Journal Official Journal of the World Medical Association, Inc

Home , Declaration of Geneva, Thera (Caria)

ISSN 2256-0580 xxx World Medical Journal Official Journal of The World Medical Association, Inc. Nr. 3, August 2020 vol. 66

Contents

Editorial ...... 1

The WMA and the Foundations of Medical Practice ...... 2

Declaration of Geneva (1948), International Code of Medical Ethics (1949) ...... 2

Palliative Care: Free App and Tips to Improve Quality of Care ...... 9

Interview with Miguel Roberto Jorge by WMJ Editor Peteris Apinis ...... 11

What is the potential impact of the COVID-19 Pandemic on Achieving the Sustainable Development Goal of Reaching Zero Unmet Need for Contraception by 2030? ...... 13

COVID-19 Pandemic: a Possible Reversal Mechanism for Outward Medical Tourism by African Political Leaders ...... 15

COVID-19: Junior Doctors Response in Myanmar ...... 23

Emergency Care for Health Unit System Patients in Brazil ...... 25

Job Satisfaction: the Nigerian Doctor’s Story ...... 35

Critical Care Medicine in China–Solid Steps in the Past Forty Years and Future ...... 39

Obituary ...... iii World Medical Association Officers, Chairpersons and Officials

Dr . Miguel Roberto JORGE Dr . David Barbe Dr . Leonid EIDELMAN Prof . Dr . Frank Ulrich WMA President, WMA President-Elect, WMA Immediate Past-President MONTGOMERY Brazilian Medical Association American Medical Association Israeli Medical Association Chairperson of Council Rua-Sao Carlos do Pinhal 324, AMA Plaza, 330 N. Wabash, Suite 2 Twin Towers, 35 Jabotinsky St., Bundesärztekammer CEP-01333-903 Sao Paulo-SP 39300 P.O. Box 3566 Herbert-Lewin-Platz 1 (Wegelystrasse) Brazil 60611-5885 Chicago, Illinois 52136 Ramat-Gan 10623 Berlin United States Israel Germany

Dr . Otmar KLOIBER Dr . Mari MICHINAGA Dr . Ravindra Sitaram Dr . Andreas RUDKJØBING Secretary General WMA Vice-Chairperson of Council WANKHEDKAR WMA Chairperson of the Medical World Medical Association Japan Medical Association WMA Treasurer Ethics Committee 13 chemin du Levant 2-28-16 Honkomagome Indian Medical Association Danish Medical Association 01212 Ferney-Voltaire 113-8621 Bunkyo-ku, Tokyo Indraprastha Marg Kristianiagade 12 France Japan 110 002 New Delhi 2100 Copenhagen 0 India Denmark

Dr . Jung Yul PARK Dr . Osahon ENABULELE Dr . Joseph HEYMAN WMA Chairperson of the Finance WMA Chairperson of the Socio- WMA Chairperson of the Associate and Planning Committee Medical Affairs Committee Members Korean Medical Association Nigerian Medical Association 163 Middle Street Samgu B/D 7F 8F 40 Cheongpa-ro, 8 Benghazi Street, Off Addis Ababa West Newbury, Massachusetts 01985 Yongsan-gu Crescent Wuse Zone 4, FCT, United States 04373 Seoul PO Box 8829 Wuse Korea, Rep. Abuja Nigeria

www wma. .net

Official Journal of The World Medical Association

Editor in Chief Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia [email protected]

Co-Editor Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany

Assistant Editor Maira Sudraba, Velta Pozņaka; [email protected]

Journal design by Pēteris Gricenko

Layout and Artwork The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia

Publisher Medicīnas apgāds, Ltd Skolas street 3, Riga, Latvia.

ISSN: 2256-0580

Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions Editorial

Editorial

This is incomprehensible time. Covid-19 provides a serious lesson be understood that the world population is not prepared to accept for doctors, politicians and economists in the whole world. There is any longer communication restrictions. We must teach people how still much unknown about this virus. There is no experience with important it is to treat their chronic diseases – diabetes, asthma, SARS-CoV-2, but virologists and clinicians have knowledge about cardiovascular diseases, hypertension – so that the virus does not and experience with other RNA viruses. There is in-depth knowl- kill them. edge about coronaviruses in veterinary medicine. There is experience in human medicine regarding other coronaviruses, especially A key issue for the medical world will be attitudes toward newly concerning SARS and MERS. People have experience in producing created vaccines. If I was able to trust the Oxford researchers in vaccines against RNA viruses, and these vaccines are effective in moving towards a vaccine, I could not believe the news that military both human and veterinary medicine. And yet – we are not able personnel are already being vaccinated against Covid-19 in some to answer the main question: how long and persistent will the im- major post-socialist states. And indeed, we have no chance of pre- munity of people against SARC-CoV-2 be? We have only the views dicting whether we can expect long-lasting and permanent immu- and insights of the most distinguished specialists in the world, but nity of the SARS-CoV- 2 virus to vaccines. And we don’t know if sometimes these are controversial points of view. And we believe a people have cross-immunity to coronavirus. scientist or a school who, to our mind, is more persuasive or whose achievements have been acknowledged, or for example, the Nobel And in the end, we do not know how expensive, safe and effective Prize awarded. We believe high impact journals and we are used to the vaccine will be, and whether there will be enough of it for all trust them. And we also listen to information we want to believe – the people of the world, both – in rich and poor countries. The virus for example, I read articles about viruses with great interest – and does not recognize national borders. learn that the virus is self-limited, it will become less aggressive, less infectious, and people will have milder virus symptoms in the near One thing is clear. The World Medical Association should renew its future. I understand there is no convincing evidence for it, but I am cooperation with the World Veterinary Association without delay eager to believe it. and raise the concept ‘One World, One Health’ to a new level. We have zoonoses and and we will have to face zoonoses in the near We, doctors, are not protected from disinformation, and a promi- and distant future. The more the people in this world produce meat nent doctor may cause a chain reaction, when subject to disinfor- for their own consumption, the more industrial the keeping of pet mation. It is enough to come forth with exaggerated messages in animals and meat production will become. The more high-density serious non-medical news channels; and many doctors also start domestic animal farming develops, the more likely the outbreaks of believing it. It is time the World Medical Association, the largest zoonoses. Covid-19 reminded the world about hygiene and clean- and most serious forum of doctors, takes the initiative and defines liness. Maybe it is time to discuss globally modern standards for certain things. The need of staying 6 feet apart is to be repeated hygiene. every day, just as the requirement not to scream, not to sing and not to be sneezed at. The virus spreads much better indoors, and people Dr. med. h. c. Peteris Apinis, must use the opportunity to communicate more outdoors. It must Editor-in-Chief of the World Medical Journal

1 Declaration of Geneva CANADA

The WMA and the Foundations of Medical Practice . Declaration of Geneva (1948), International Code of Medical Ethics (1949)

Sean Murphy Ramona Coelho Philippe D. Violette Ewan C Goligher Timothy Lau Sheila Rutledge Harding Practising Medicine In these circumstances, it is urgent to reas- tionalize health care systems in Britain and sert that the duty to practise medicine “with the Continent. On the one hand, they wel- “with conscience conscience and dignity” includes unyielding comed the growing interest in medicine by refusal to do what one believes to be wrong governments around the world. On the oth- and dignity” even in the face of overwhelming pressure er, they worried about the consequences of Beginning with the Declaration of Ge- exerted by the state, the medico-legal estab- (as later expressed) transforming all physi- neva (the Declaration), for over 70 years lishment and even by medical leaders and cians into “Civil Servants controlled by the the World Medical Association (WMA) colleagues. That the founders of the WMA State” [13, 14]. They conceived an interna- has maintained that physicians must prac- not only supported but expected such prin- tional medical association as support for na- tise medicine with conscience and dignity cipled obstinacy is evident in the WMA’s tional associations defending practitioners [1]. On the Declaration’s 70th anniversary, early history and the development of the and patients from government demands. seven associate WMA members raised seri- Declaration, all of which remain surpris- They reminded the British health minister ous concerns about their ability to remain in ingly relevant. that physicians treat human beings, not col- medical practice if they fulfil this obligation lections of tissue, and must practise with “a by refusing to support or collaborate in the discipline of the heart that makes it difficult killing of their patients by euthanasia and Early Developments: 1945–46 to integrate [them] into the State machine” assisted suicide (EAS)[2]. [15]. A meeting of physicians from 30 coun- The physicians practise in Canada, where tries in London in June 1945 discussed While delegates were motivated to or- euthanasia and assisted suicide (EAS) the formation of an international medical ganize the WMA by concerns about the are legal, [3,4] recognized as therapeutic association [8, 9]. Some continental physi- profession-state relationship, they were also medical services by the national medical cians spoke of crimes by physicians in their deeply disturbed by physician participation association [5,6] and provided through a countries during the war [10], and over the in war crimes [8]. public health care system controlled by next 18 months the world medical commu- the state, which also regulates medical nity became increasingly aware of physician In the month following the London gath- practice and medical ethics. The national participation in crimes against humanity [8, ering, twenty German physicians were ar- government is now poised to make EAS 11, 12]. raigned in Nuremberg [13]. And the or- available for any serious and incurable ganizing committee drafted the WMA medical condition, vastly increasing the National medical association delegates re- constitution and prepared for the first number of patients legally eligible for the turning London in September 1946 were General Assembly while the Nuremberg service [7]. uneasy and ambivalent about plans to na- “Doctors Trial” was in session. Reports from

2 CANADA Declaration of Geneva

the trial resonated deeply with physicians cal oath. The WMA Council also agreed During the terrible years of occupation by a anxious about being integrated into a “State to develop an international code of medi- brutal enemy the large majority of doctors of machine” [16,17,18,19]. cal ethics, concerned that jurists reacting most of the occupied countries maintained to physician war crimes might do so if the their moral integrity, their unswerving loy- WMA did not [24,25]. alty to their patients, and their spiritual and First General Assembly: professional freedom, even at the risk of tor- War Crimes and Medicine ture and death. They thereby set a great example and vindicated the honour of their pro- (September 1947) Second & Third General Assemblies fession [19]. Physician war crimes dominated the agenda Declaration of Geneva (September 1948), According to Leo Alexander, writing a year of the first WMA General Assembly, dis- International Code of Medical Ethics later, just before the ICME was adopted, placing discussion of the profession-state (September 1949) Dutch physicians collectively demonstrated relationship. Delegates heard impassioned such heroism [28]. Steadfast refusal to do testimony from physician victims of the At the second WMA General Assembly, what one believes to be wrong was under- Third Reich and received the BMA report, delegates were presented with War Crimes stood to be central to practising medicine War Crimes and Medicine [20, 21, 22]. and Medicine: The German Betrayal and a “with conscience and dignity,” an essential Re-statement of Medical Ethics. It urged safeguard for personal and professional in- The report denounced physicians respon- the Assembly to prevent physician crimes tegrity and patients. sible for crimes against humanity as lack- against humanity by reaffirming basic Hip- ing “moral and professional conscience,” pocratic principles, which, it argued, would That was then; this is now condemning them for having allowed the be universally acceptable. Requiring medi- state to use medical knowledge and sci- cal graduates to abide by a modern version It is easy to understand this duty in rela- ence as “instruments of wanton destruction of the Hippocratic Oath would help to im- tion to refusing to comply with the mur- in the pursuit of war.” It asked the WMA press them with the fundamentals of medi- derous dictates of a totalitarian regime that to endorse the prosecution of physicians cal ethics. The suggested modern version, have been universally derided for decades. for war crimes and adopt a World Charter containing ten promises, was approved by It is more difficult to see why it should of Medicine, explicitly reaffirming medi- the Assembly and published as the Decla- apply to refusing to provide legal services cal ethics “in the spirit of the Hippocratic ration of Geneva [26]. requested by patients in a democracy. The Oath,” suggesting that medical graduation difficulty disappears once one admits that should include a promise to adhere to the The Second General Assembly also ap- both totalitarian and democratic regimes Charter [10]. proved the development of an international can make grave moral errors in law and code of medical ethics. The final version, public policy. The Assembly accepted the recommenda- which included the Declaration of Geneva, tions and approved a public apology and was approved at the Third General Assem- Events in Germany from 1920 to 1945 undertaking to be required of the German bly in 1949 [27]. demonstrate that physicians willingly en- Medical Association as a condition for listed and collaborated in the implementa- admission to the WMA. It also approved Refusing the fatal surrender of conscience tion of a biopolitical ideology thought to an oath affirming that a physician’s first be on the cutting edge of science and pro- duty is to care for a patient, “to resist any The documents make clear that what the gressive ideas. Exactly the same thing has ill treatment that may be inflicted on him” authors of the Declaration and the ICME happened elsewhere and is likely to happen and “to refuse my consent to any authority meant by practising medicine “with con- again. When it does, the medical profession that requires me to ill-treat him.” Finally, it science and dignity” was not only doing is likely to be most accommodating and appointed a committee to produce a report what one believes to be right, or only doing even anxious to participate to ensure that about war crimes [23, 24]. what one believes to be best for patients, but the state “gets it right.” refusing “to make the easy and fatal surren- Over the following year, the war crimes der of one’s conscience to the mass mind of At issue here is the freedom, integrity, dig- committee solicited forms of medical en- the totalitarian state” (18). A British physi- nity and obligations of individual physi- gagement from national associations with a cian responding to the BMA report on war cians who are convinced that the profession view to formulating an international medi- crimes commented: and the state have got it wrong, yet face

3 Declaration of Geneva CANADA

demands that they participate in activities in 1931. By 1935 sterilization laws had been Even as the Alberta court was ruling on the that they reasonably believe to be immoral adopted in Canada, Denmark, Switzerland, Alberta Eugenics Board, Alberto Fujimori or contrary to good medical practice. Germany, Norway and Sweden [36]. was mobilizing physicians in Peru for the National Program for Reproductive Health Then . . Eugenics was especially influential in Ger- and Family Planning. By the time it ended many after the First World War [37] and four years later, 200,000 to 300,000 people When the Nazi regime was installed, of- was absorbed into Nazi party policy. Since had been sterilised, most without valid con- ficials of the largest German medical as- physicians were among eugenics’ foremost sent: some forcibly, others bribed or threat- sociations “gladly” welcomed it and placed exponents, to hear Nazi policy described ened by government officials or health care themselves at its service, celebrating the as “nothing but applied biology” was es- personnel. Most victims were poor and of- intimate links of the medical profession pecially attractive to them. Hence, many ten illiterate women from indigenous ethnic with “the wisdom and aims of the State”. willingly joined the vanguard of what be- groups. The technical standard of medical Those intimate links were reflected in the came “the most ambitious and murderous care was often appalling, and numbers of law directing compulsory sterilisation of eugenics program in human history”. Their women died [50, 51, 52, 53]. those with “genetic illnesses” (including al- characteristic response was not just acqui- coholism and mental deficiency) enacted in escence, but “eager and active cooperation” The WMA’s denunciation of coercive steril- response to a petition from the associations [31,38,39]. ization came 12 years too late for Fujimori’s [29]. Physicians sterilized about 300,000 victims [54]. In the United States, Oregon persons before the war, and began killing Such eagerness was not limited to German abolished its eugenic sterilization law only the handicapped when the war began, a physicians. In 1936, the Canadian Medical in 1983, and another 20 years passed be- project supported directly and indirectly by Association Journal featured a lengthy es- fore the state acknowledged the injustice colleagues and scientists [30]. say on the superiority of the Aryan/Nordic suffered by victims sterilized according to Race by an author who, the year before, had the ethical standards of the day [55]. The Physicians were predisposed to cooperate held up Germany as a model for other na- Tuskegee Syphilis Study continued until because they were convinced of the value of tions and toasted Adolph Hitler as “a great it was exposed in 1972, the same year the eugenics. Eugenics was a widely accepted leader” [40,41]. Two years earlier it had Alberta Eugenics Board was abolished. It scientific discipline, “on the cutting edge of published a glowing report about eugenic took almost 25 years for victims to receive a science”, supported by respected scholars, sterilizations authorized by the Alberta Eu- public apology for unethical human experi- various scientific disciplines, major univer- genics Board [42]. mentation [56, 57]. sities and scholarly journals [30, 31]. The eugenics movement propagated the belief Over 44 years Alberta physicians steril- In 2012, when a generation of German that people inherited not only eye and hair ized 2,822 people at the Board’s direction physicians unconnected with the Nazi colour, but were criminals, or rich, poor, lazy, [43]. A court reviewing its operations found era admitted the enthusiastic participa- industrious, promiscuous or faithful because that it had routinely flouted the law, and, as tion of German physicians at all levels of they were “born that way” [32]. Leading sci- late as the early 1960’s, physicians had per- the profession in crimes against humanity, entists and activists campaigned to prevent formed illegal sterilizations and medically apologized, begged forgiveness, and de- the reproduction of such “defectives” by unnecessary castrations, hysterectomies, scribed what their predecessors had done contraception and sterilization of “inferior oophorectomies and biopsies of testicular “as a warning for the present and the fu- types,” including the mentally ill, physically tissue, behaviour the judge described as ture” [58]. handicapped, criminals, and certain “degen- “unlawful, offensive and outrageous”. He erate” races [33,34]. excoriated one Board geneticist for, among The warning points, in the first place, to other things, encouraging the use of persons the risk of sea changes with incalculable Eugenics was popular among the socially with Down Syndrome as “medical guinea consequences. It appears that the Ger- elite, including Winston Churchill, Herbert pigs” [44]. However, she had “no regrets,” man medical profession’s eugenic outlook Hoover and Alexander Graham Bell (35). defending her activities as “a very reasonable and interests converged with other social Eugenic societies and scientists successfully approach to a very difficult problem” [45]. and political dynamics and Hitler’s rise to lobbied for laws authorizing voluntary or Awarded the Order of Canada and other power. The convergence triggered a sud- compulsory sterilization of “defectives”, in- honours [46, 47, 48], she was eulogized in den, seismic socio-political shift that su- cluding criminals, the mentally handicapped 2014 as one of Canada’s most respected ge- percharged Nazi biopolitical ideology. The and mentally ill; 27 US states had such laws neticists (49). medical profession rapidly transformed

4 CANADA Declaration of Geneva

itself and was transformed to fulfil its new the national government allows state medi- metaphysical, philosophical and moral biopolitical responsibilities [29], and new cal regulators to compel unwilling practitio- premises that can be rationally contested possibilities suddenly materialized [59]. ners to facilitate EAS by effective referral but cannot be empirically validated. Among Carl Jung experienced this as an “earth- [65] or effective transfer of care [66], which these is the dogmatic claim that a human quake” and an “avalanche” that was sweep- even some strong supporters of the proce- being can be better off dead. In a free and ing all before it [60]. dures acknowledge to be morally equivalent democratic society, it ought to be unac- to personally killing patients [64,67,68]. ceptable to force physicians to profess this Second, the warning reminds us that mod- Courts in the province of Ontario support article of faith, or to demonstrate practical ern biopolitical ideologies are advocated this coercive policy, ruling that physicians adherence to it by killing or facilitating the worldwide by lobbyists as prominent, pow- unwilling to comply can move into fields killing of a patient. erful and influential as the eugenic enthusi- like sleep medicine, hair restoration and asts of yesteryear. dermatology [69]. Finally, there is an issue that goes to the heart of what concerned the authors of the Finally, we are warned that state collabora- Unsurprisingly, some academics recom- Declaration of Geneva. tion with the medical profession in support mend that medical schools deny admit- of faulty biopolitical ideologies is far more tance to anyone with conscientious ob- Competent patients may refuse even life- dangerous than the exercise of freedom of jections to providing whatever the state saving/sustaining interventions based en- conscience by individual physicians. Literal- considers medical treatment or health care, tirely on their subjective views of what is ly millions have suffered and died as victims including EAS [70]. Anecdotal reports beneficial, harmful, or in their best interests. of what seemed like a good idea at the time, indicate that some dissenting medical stu- Physicians ensure that patients have infor- at least in the eyes of those in positions of dents face intense pressure to conform to mation relevant to such decisions and may power and influence. the EAS biopolitical agenda, experienc- make recommendations, but they are legally ing isolation, disregard and disdain among and ethically obliged to respect patients’ in- Now . . their peers (71). violability and abide by their decision. The foundations of medical ethics and the per- The euthanasia/assisted suicide (EAS) No wonder Canadian physicians who refuse sonal integrity of physicians who disagree movement backs a biopolitical ideology to support or collaborate in killing their pa- are untouched by the patient’s decision. that is enormously popular in the developed tients feel themselves to be in the midst of a world, now entrenched in Canadian law socio-political and ethical avalanche. While competent patients can absolutely and collectively supported by the medical refuse interventions, they cannot demand profession. This has serious implications for Summing up interventions because medical decisions to the nature of medical practice. intervene are not based solely upon patients’ The historical record suggests that support demands [72]. Among other things, they Leading Canadian EAS advocates told the for physicians who refuse to kill or facilitate engage physicians as moral agents. Supreme Court of Canada that physicians the killing of their patients is justifiable on are ideal EAS practitioners because they prudential and pragmatic grounds. Tolerat- Patients request an intervention, including will agree to it only “as a last resort” [61]. ing refusal to participate in killing seems to euthanasia, because they believe it is not Indeed, they argued that “physician-assisted be a safer course than imposing an obliga- harmful, is beneficial, or is in their best in- dying” is not only “medical treatment,” but tion to kill and is certainly consistent with terests. Physicians may reasonably disagree. “at the core of health care” [62]. This must the high value EAS advocates have placed If, despite this, physicians are compelled to place killing patients at the core of the prac- on physician reluctance to kill as a primary further a patient’s request, the concepts of tice of medicine and require transformation safeguard for patients. benefit, harm and best interest become ir- of the medical profession to fulfil its role in relevant. All that remains is the demand of the new order. How far this will go remains As a matter of principle, one must dis- the patient, backed by the power of the state to be seen. tinguish what is demonstrably necessary to ensure compliance. to preserve a free and democratic society Physicians cannot currently be compelled from what may be necessary to enforce a This treats physicians as mere technicians to personally administer or prescribe lethal biopolitical ideology. The difference is sig- or state functionaries, as cogs in a state ma- drugs, though some prominent academics nificant but can be difficult to discern in an chine delivering services upon demand, not argue that should change [63,64]. However, avalanche. EAS ideology is grounded upon as responsible moral agents who, like their

5 Declaration of Geneva CANADA

patients, must form and act upon judge- Mar 10]. Available from: https://www.parl.ca/ 1004 p. Available from: http://www.loc.gov/rr/ ments about benefits and harms. It imposes Content/Bills/431/Government/C7/C7_1/ frd/Military_Law/pdf/NT_war-criminals_Vol- C7_1.PDF. I.pdf. a form of servitude that is incompatible 8. Bonah C, Schmaltz F. The reception of the 17. Mellanby K. Medical Experiments on Human with human equality, dignity and personal Nuremberg Code and its impact on medical eth- Beings in Concentration Camps in Nazi Ger- and professional integrity. ics in France: 1947-1954. In: Czech H, Druml many. BMJ [Internet].1947 Jan 25 [cited 2020 C, Weindling P, editors. Medical Ethics in the Mar 10]; 1(4490): 148-150. Available from: The authors of the Declaration and ICME 70 Years after the Nuremberg Code: 1947 to the https://www.ncbi.nlm.nih.gov/pmc/articles/ denounced such instrumentalization of Present. International Conference at the Medi- PMC2052883/pdf/brmedj03765-0026.pdf. cal University of Vienna; 2017 Mar 2-3. Central 18. Doctors on Trial. BMJ [Internet].1947 Jan 25 physicians and the medical profession in European J Med (2018) [cited 2020 Mar 10]; [cited 2020 Mar 10]; 1(4490): 143. Available the strongest terms. The precept to practise 130, S159-253. Available from: https://link. from: https://www.ncbi.nlm.nih.gov/pmc/arti- medicine with conscience and dignity im- springer.com/content/pdf/10.1007/s00508- cles/PMC2052888/pdf/brmedj037650021.pdf. poses an obligation to resist and refuse such 018-1343-y.pdf. 19. Odlum DM. World Medical Association. BMJ demands, notwithstanding overwhelming 9. Heard at Headquarters: International Rela- [Internet]. 1947 Jul 19 [cited 2020 Mar 10]; tions. BMJ [Internet]. 1945 Jun 16 [cited 2(4515): 108. Available from: https://www.ncbi. pressures exerted even in democratic soci- 2020 Feb 08]; 1(4406): S111-120. Available nlm.nih.gov/pmc/articles/PMC2055254/pdf/ eties. from: https://www.ncbi.nlm.nih.gov/pmc/ar- brmedj037380028b.pdf. ticles/PMC2057579/pdf/brmedj03889-0037. 20. World Medical Association. BMJ [Internet]. pdf#page=7 1947 Sep 27 [cited 2020 Mar 10]; 2(4525): References 10. International Relations: War Crimes. BMJ 498(500. Available from: https://www.ncbi. 1. Revised in 2017 to include, (and in accordance [Internet]. 1947 Jun 21 [cited 2020 Feb 07]; nlm.nih.gov/pmc/articles/PMC2055764/pdf/ with good medical practice. World Medical 1(4406): S131. Available from: https://www. brmedj037480028.pdf. Association. Declaration of Geneva [Internet]. ncbi.nlm.nih.gov/pmc/articles/PMC2053513/ 21. British Medical Association. Proceedings [Ferney-Voltaire, France]: World Medical Asso- pdf/brmedj03786-0043.pdf of Council, Wednesday, October 29, 1947: ciation; 2018 Jul 09 [cited 2020 Mar 10]. Avail- 11. British Medical Association. Annual Report World Medical Association. BMJ [Internet]. able from: https://www.wma.net/policiespost/ of the Council 1945-6: International Rela- 1947 Nov 08 [cited 2020 Mar 10]; 2(4531): wmadeclarationofgeneva/. tions. BMJ [Internet]. 1946 Apr 20 [cited S103-104. Available from: https://www.ncbi. 2. Leiva R, Cottle MM, Ferrier C, Harding SR, Lau 2020 Feb 10]; 1(4450): S85-86. Available from: nlm.nih.gov/pmc/articles/PMC2056019/pdf/ T, Scott JF. Euthanasia in Canada: A Caution- https://www.ncbi.nlm.nih.gov/pmc/articles/ brmedj03754-0043.pdf. ary Tale. World Med J [Internet]. 2018 Sep [cited PMC2058781/pdf/brmedj038290043.pdf. 22. Dworzeki M. “Let Us Throw the Anathema 2020 Mar 10]; 64:3 1723. Available from: https:// 12. International Medical Conference. BMJ [Inter- Against the Murderer Doctors” September 30 www.wma.net/wpcontent/uploads/2018/10/ net]. 1946 Aug 24[cited 2020 Feb 10];2(4468): 1947 [Internet]. Independence, MO: Harry S. S67-70. Available from: https://www.ncbi. Truman Library and Museum. [cited 2020 Mar WMJ_3_20181.pdf#page=19. nlm.nih.gov/pmc/articles/PMC2054062/pdf/ 10]. 4 p. Available from: https://www.truman- 3. Carter v. Canada (Attorney General), 2015 SCC brmedj037950037.pdf#page=2. library.gov/library/researchfiles/reportmarkd- 5 [Internet]. Ottawa: Supreme Court of Cana- 13. World Medical Association: General Assembly worzeckiletusthrowanathemaagainstmurderer- da; 2020 Jan 21 [cited 2020 Mar 10]. Available in London. BMJ [Internet]. 1949 Oct 22 [cited doctors. from: https://scccsc.lexum.com/scccsc/scccsc/ 2020 Mar 10]; 2(4633): S175-180. Available 23. World Medical Association. BMJ [Internet]. en/item/14637/index.do. from: https://www.ncbi.nlm.nih.gov/pmc/ar- 1947 Dec 27 [cited 2020 Mar 10]; 2(4538): 4. Criminal Code, s 222(1) [Internet]. Ottawa: ticles/PMC2051418/pdf/brmedj03647-0057. S165-166. Available from: https://www.ncbi. Minister of Justice; 2020 Jan 08 [cited 2020 pdf. nlm.nih.gov/pmc/articles/PMC2056440/pdf/ Mar 10]. Available from: https://lawslois.justice. 14. World Medical Association Constituted: Inter- brmedj037610051.pdf. gc.ca/PDF/C46.pdf#page=347. national Conference in London. BMJ [Inter- 24. Noyer F. Du syndicalisme médical de l’entredeux 5. CMA Policy: Medical Assistance in Dying [In- net]. 1946 Oct 05 [cited 2020 Mar 10]; 2(4474): guerres à la naissance de l’Association Médi- ternet]. Canadian Medical Association; 2017 503-505. Available from: https://www.ncbi. cale Mondiale: Vie et oeuvre du docteur Paul May [cited 2020 Mar 10]. Available from: htt- nlm.nih.gov/pmc/articles/PMC2057674/pdf/ CIBRIE. These Presentee pour le Diplome de ps://policybase.cma.ca/documents/policypdf/ brmedj038010027.pdf. Docteur en Medecine [Internet]. 2016 [cited PD1703.pdf. 15. Government Luncheon to World Medical As- 2020 Mar 10]. 349 p. University of Strasbourg. 6. Doctorassisted suicide a therapeutic service, sociation Delegates: Mr. Aneurin Bevin’s (In- Available from: https://dhvs.unistra.fr/filead- says Canadian Medical Association [Inter- auguration Speech. BMJ [Internet]. 1946 Oct min/uploads/websites/dhvs/Recherche/2016_ net]. CBC News; 2015 Feb 06 [cited 2020 05 [cited 2020 Mar 10]; 2(4474): 506. Avail- Noyer_Fabrice_Paul_Cibrie.pdf. Mar 10]. Available from: https://www.cbc.ca/ able from: https://www.ncbi.nlm.nih.gov/pmc/ 25. British Medical Association. Annual Repre- news/health/doctor-assisted-suicide-a-thera- articles/PMC2057674/pdf/brmedj038010027. sentative Meeting, Cambridge 1948: The Work peutic-service-says-canadian-medical-associa- pdf#page=4. of the Association. BMJ [Internet]. 1948 Jul tion-1.2947779. 16. Trials of the War Criminals before the Nuern- 03 [cited 2020 Mar 10]; 2(4565): S2. Avail- 7. Bill C-7: An Act to amend the Criminal Code berg Military Tribunals. Vol. I, The Medical able from: Available from: https://www.ncbi. (medical assistance in dying) [Internet]. Ottawa: Case [Internet]. Washington, DC: US Govern- nlm.nih.gov/pmc/articles/PMC2090189/pdf/ Parliament of Canada; 2020 Feb 24 [cited 2020 ment Printing Office; 1950 [cited 2020 Mar 10]. brmedj036840096.pdf#page=2.

6 CANADA Declaration of Geneva

26. Crimes de Guerre et Medecine (Amendment du Germany. In: Benedict S, Shields L, editors. Medical Geneticists; 2017 [cited 2020 Mar document C.2/48 tel qu(adopte par l’Assemblee Nurses and Midwives in Nazi Germany: The 10]. Available from: https://www.ccmgccgm. Generale, September 1948) La Trahison Al- “Euthanasia Programs”. New York, London: org/91members/awards/148traineeawardees. lemande et un Re-Expose de l’Ethique Medi- Routledge Taylor & Francis Group 2014. Chap- html. cale. In: Noyer F. Du syndicalisme médical de ter 2.2; 15-24. 49. Csillag R. Gifted scientist Margaret Thompson l’entredeux guerres à la naissance de l’Association 38. Lifton RJ. The Nazi Doctors: Medical Killing had a lasting impact on health care. Globe and Médicale Mondiale : Vie et oeuvre du docteur and the Psychology of Genocide. New York: Ba- Mail [Internet] 2014 Dec 14 [updated 2018 Paul CIBRIE. These Presentee pour le Diplome sic Books; 1986. 561 p. May 12] [cited 2020 Mar 10]. Available from: de Docteur en Medecine. Annex 3. [Internet]. 39. Proctor RN. Racial Hygiene: Medicine Under https://www.theglobeandmail.com/news/na- 2016 [cited 2020 Feb 10]. 349 p. University the Nazis. Cambridge, MA: Harvard University tional/giftedscientistmargaretthompsonhada- of Strasbourg. Available from: https://dhvs. Press; 1988. 414 p. lastingimpactonhealthcare/article22078694/. unistra.fr/fileadmin/uploads/websites/dhvs/ 40. Campbell CG. The Lessons of Racial His- 50. Inter-American Commission on Human Recherche/2016_Noyer_Fabrice_Paul_Cibrie. tory. Can Med Assoc J (Special Article) [In- Rights. Report No. 71/03, Petition 12.191, pdf#page=339. ternet] 1936 Jul [cited 2020 Mar 10]; 35(1): Friendly Settlement: Maria Mamérita Mes- 27. World Medical Association. BMJ [Internet]. 80-84. Available from: https://www.ncbi.nlm. tanza Chávez – Peru [Internet]. 2013 Jan [cited 1949 Oct 15 [cited 2020 Feb 08]; 2(4632): nih.gov/pmc/articles/PMC1561696/pdf/can- 2020 Mar 10]. Washington, DC: Global Health 854-855. Available from: Available from: medaj00514-0134.pdf. and Human Rights Database; Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ 41. Lombardo PA. The American Breed: Nazi Eu- https://www.globalhealthrights.org/wpcontent/ PMC2051515/pdf/brmedj036460032.pdf. genics and the Origins of the Pioneer Fund. Al- uploads/2013/01/IAComHR2003MariaMa- 28. Alexander LJ. Medical Science Under Dicta- bany Law Review [Internet]. 2002 [cited 2020 meritaMestanzaChavezv.Peru.pdf. torship. N Engl J Med 1949; 241:3947. DOI: Mar 10] 65(3):743-830. Available from: https:// 51. Inter-American Commission on Human Rights. 10.1056/NEJM194907142410201. www.academia.edu/836113/The_American_ Report No. 24/19, Petition 947-10, Report on 29. Hanauske-Abel HM. Not a slippery slope or Breed_Nazi_Eugenics_and_the_Origins_of_ Admissibility: Celia Edith Ramos Durand and sudden subversion: German medicine and Na- the_Pioneer_Fund_2002_. Family – Peru [Internet] 2019 Mar 07 [cited tional Socialism in 1933. BMJ [Internet]. 1996 42. Association notes – The Sixty-fifth Annual 2020 Mar 10]. Available from: http://www.oas. (cited 2020 Feb 9); 313:145363. Available from: Meeting of the Canadian Medical Association org/en/iachr/decisions/2019/PEAD94710EN. https://www.ncbi.nlm.nih.gov/pmc/articles/ ( June, 1934). Can Med Assoc J [Internet] 1934 docx PMC2352969/pdf/bmj005710043.pdf. Oct [cited 2020 Mar 10]; 31(4): 433-436. Avail- 52. Sastre Á. Mujeres esterilizadas en Perú: “Me 30. Friedlander H. The Origins of Nazi Genocide: able at https://www.ncbi.nlm.nih.gov/pmc/ar- ataron y vendaron, pero veía los serruchos y la From Euthanasia to the Final Solution. Chapel ticles/PMC403584/pdf/canmedaj00148-0087. sangre” [Internet]. La Razon; 2018 Apr 28 [cit- Hill and London: University of North Carolina pdf#page=3. ed 2020 Mar 10]. Available from: https://www. Press; 1995. 421 p. 43. Caufield T, Robertson G. Eugenic Policies in larazon.es/internacional/mujeresesterilizadasen- 31. Hayse MR. Recasting the West German Elites: Alberta: From the Systematic to the Systemic. perumeataronyvendaronperoveialosserruchosy- Higher Civil Servants, Business Leaders and Alberta Law Review [Internet]. 1996 [cited lasangreMJ18220914/. Physicians in Hesse Between Naziism and 2020 Mar 10]; 35(1): 59-79. Available from: 53. Peru apologizes for forced sterilizations [Inter- Democracy, 1945-1955. New York: Berghahn https://www.albertalawreview.com/index.php/ net]. UPI; 2002 Jul 24 July [cited 2020 Mar 10]. Books, 2003. 288 p. ALR/article/view/1063/1053. Available from: https://www.upi.com/Defense- 32. Gould SJ. The Mismeasure of Man. New York: 44. Muir v. Alberta, 1996 CanLII 7287 (AB QB) News/2002/07/24/Peruapologizesforforcedsteri W.W. Norton & Company; 1981. 352 p. [Internet]. Ottawa: Canadian Legal Informa- lizations/80301027529085/?ur3=1. 33. Goddard, H.H., Feeble-mindednes: Its Causes tion Institute; 2020 Feb 22 [cited 2020 Mar 10]. 54. World Medical Association. WMA Statement and Consequences. New York: MacMillan; Available from: http://canlii.ca/t/1p6lq. on Forced and Coerced Sterilization [Internet]. 1914. In: Gould SJ. The Mismeasure of Man. 45. Cairney R. “Democracy was never intended for [Ferney-Voltaire, France]: World Medical Asso- New York: W.W. Norton & Company; 1981. degenerates”: Alberta’s flirtation with eugenics ciation; 2017 Feb 20 [cited 2020 Mar 20]. Avail- 352 p. comes back to haunt it. CMAJ [Internet] 1996 able from: https://www.wma.net/policiespost/ 34. Drake MJ, Mills IW, Cranston D. On the Cheq- Sept 15 [cited 2020 Mar 10]; 155(6): 789-792 at wmastatementonforcedandcoercedsterilisation/. uered History of Vasectomy. BJU International 792. Available from: https://www.ncbi.nlm.nih. 55. Associated Press. Apology for Oregon Forced [Internet]. 2001 Dec 25 [cited 2020 Mar 10]. gov/pmc/articles/PMC1335257/. Sterilizations [Internet]. Los Angeles Times; Available from: https://onlinelibrary.wiley.com/ 46. Mrs. Margaret W. Thompson, Order of Canada, 2002 Dec 03 [cited 2020 Mar 10]. Available doi/full/10.1046/j.1464410x.1999.00206.x. Member of the Order of Canada [Internet]. Ot- from: https://www.latimes.com/archives/laxpm- 35. Benedict S. Fertile Ground for Murder. In Ben- tawa: Governor General of Canada [cited 2020 2002dec03nasterile3story.html. edict S, Shields L, editors. Nurses and Midwives Mar 10]. Available from: https://www.gg.ca/en/ 56. U.S. Public Health Service Syphilis Study at in Nazi Germany: The “Euthanasia Programs”. honours/recipients/1462897. Tuskegee – Presidential Apology: Remarks of New York, London: Routledge Taylor & Francis 47. Past Founders Award for Career Achievement the President in Apology for Study Done in Group; 2014. Chapter 2; p. 23-26. [Internet]. Kingston, ON: Canadian College Tuskegee (The White House, Office of the Press 36. Osborn F. Eugenics. In: Encyclopaedia Britan- of Medical Geneticists; 2017 [cited 2020 Mar Secretary, For Immediate Release May 16, 1997) nica. Vol. 8. Chicago: Encyclopaedia Britannica 10]. Available from: https://www.ccmgccgm. [Internet]. Washington, DC: Centers for Dis- Inc.; 1973. p. 815-817. org/80members/122founderspast.html. ease Control and Prevention; 2015 Dec 14 [cited 37. O’Donnell A, Drummond J, Simpson M, Ben- 48. Dr. Margaret Thompson Trainee Award [In- 2020 Feb 22]. Available from: https://www.cdc. edict S, Shields L. The Eugenic Movement in ternet]. Kingston, ON: Canadian College of gov/tuskegee/clintonp.htm.

7 Declaration of Geneva CANADA

57. Final Report of the Tuskegee Syphilis Study ronto: College of Physicians and Surgeons of tual and Practical Clarity in the Court of Pro- Legacy Committee – May 1996 [Internet]. Ontario; 2018 Dec [cited 2020 Feb 20]. Avail- tection. Med Law Rev [Internet]. 2016 Summer Charlottesville VA: University of Virginia; 2007 able from: https://www.cpso.on.ca/Physicians/ [cited 2020 Mar 10];24(3):396-414. Available [cited 2020 Feb 22]. Available from: http://ex- PoliciesGuidance/Policies/MedicalAssistan- from: https://academic.oup.com/medlaw/arti- hibits.hsl.virginia.edu/badblood/report/. ceinDying. cle/24/3/396/2733270. 58. Gale A. German Medical Association Finally 66. College of Physicians and Surgeons of Nova Apologizes For Atrocities Committed by Ger- Scotia. Professional Standard Regarding Medi- man Physicians Under the Nazis. Mo Med cal Assistance in Dying [Internet]. Bedford, Sean Murphy, Administrator [Internet] 2013 Nov-Dec (cited 2020 Feb 15); NS: College of Physicians and Surgeons of Protection of Conscience Project 110(6): 486–488. Available from: https://www. Canada; 2017 Oct 13 [cited 2020 Feb 20]. ncbi.nlm.nih.gov/pmc/articles/PMC6179814/. Available from: https://cpsns.ns.ca/wpcontent/ British Columbia 59. Bruns F. Turning Away from the Individual: uploads/2016/06/MedicalAssistanceinDying- Canada Medicine and Morality Under the Nazis. In: Bi- Standard.pdf. alas W, Fritze L, editors. Nazi Ideology and Eth- 67. Journal des débats (Hansard) of the Commit- Dr. Ramona Coelho, ics. Newcastle upon Tyne: Cambridge Scholars tee on Health and Social Services. 40th Legis- MDCM, CCFP Publishing; 2014. p. 211-236. lature, 1st Session (October 30, 2012 au March 60. Purrington. Carl Jung: A Rejoinder to Dr. Bally 5, 2014) Tuesday, September 17, 2013 – Vol. 43 [A response to charges of Anti-Semitism]. [In- No. 34. Special consultations and public hear- Dr. Philippe D. Violette, MSc. ternet]. Carl Jung Depth Psychology 2019 Nov ings on Bill 52, An Act respecting end-of-life MDCM, FRCSC 12 [cited 2020 Feb 19]. In: Adler G, editor, care [Internet]. Quebec City: Assemblée Na- Assistant Professor Depts. of Surgery translator, Hull RFC, editor. Collected Works of tionale du Québec; 2013 Sep 17 [cited 2020 and Health Research Methods, CG Jung. 2nd ed. Vol. 10, Civilization in Transi- Mar 10]. Available from: http://www.assnat. Evidence and Impact, tion. Bollingen Series XX. Princeton: Princeton qc.ca/en/travaux-parlementaires/commissions/ University Press. 612 p. Available from: https:// csss-40-1/journal-debats/CSSS-130917.html#_ McMaster University, Hamilton, carljungdepthpsychologysite.blog/2019/11/12/ Toc386455854. Ontario, Canada. carl-jung-rejoinder-dr-bally-response-charges- 68. Consultations & hearings on Quebec Bill 52: anti-semitism/. College of Physicians of Quebec – Dr. Charles Ewan C Goligher MD PhD 61. Supreme Court of Canada, 35591, Lee Carter, Bernard, Dr. Yves Robert, Dr. Michelle March- Assistant Professor et al. v. Attorney General of Canada, et al (Brit- and. Tuesday 17 September 2013 – Vol. 43 no. ish Columbia) (Civil) (By Leave) Webcast of 34: Collège des médecins du Québec [Internet]. Interdepartmental Division of the Hearing on 2014-10-15 [Internet]. Ot- Powell River, BC: Protection of Conscience Pro- Critical Care Medicine tawa: Supreme Court of Canada; 2018 Jan ject [cited 2020 Mar 10]. Available from: http:// University of Toronto 22 [cited 2020 Mar 10]. 00:20:02 – 00:20:40. www.consciencelaws.org/background/proce- Available from: https://www.scc-csc.ca/case- dures/assist009-001.aspx#154. Timothy Lau, MD, FRCPC dossier/info/webcastview-webdiffusionvue- 69. Christian Medical and Dental Society of Can- Distinguished Teacher, Associate eng.aspx?cas=35591&id=2014/2014-10-15-- ada v. College of Physicians and Surgeons of 35591&date=2014-10-15&fp=n&audio=n. Ontario, 2019 ONCA 393 (CanLII) [Internet] Professor, Faculty of Medicine, 62. Supreme Court of Canada, 35591, Lee Carter, Ottawa: CanLII; 2020 Jan 27 [cited 2020 Mar Department of Psychiatry, et al. v. Attorney General of Canada, et al (Brit- 10]. Available from: https://www.canlii.org/en/ Geriatrics, Royal Ottawa Hospital. ish Columbia) (Civil) (By Leave) Webcast of on/onca/doc/2019/2019onca393/2019onca393. the Hearing on 2014-10-15 [Internet]. Ot- html. Sheila Rutledge Harding, tawa: Supreme Court of Canada; 2018 Jan 22 70. Browne R. Medical schools should deny appli- [cited 2020 Mar 10]. 00:06:53 to 00:07:03, cants who object to provide abortion, assisted MD, MA, FRCPC Available from: https://www.scc-csc.ca/case- death: bioethicist [Internet]. Global News; 2019 Hematology dossier/info/webcastview-webdiffusionvue- Nov 23 [cited 2020 Mar 10]. Available from: Saskatchewan Health Authority eng.aspx?cas=35591&id=2014/2014-10-15-- https://globalnews.ca/news/6183548/medical- Professor, University of Saskatchewan 35591&date=2014-10-15&fp=n&audio=n. school-applicants-abortion-assisted-death-con- Saskatoon, Saskatchewan, Canada 63. Attaran A. The Limits of Conscientious and Re- scientious-objectors/. ligious Objection to PhysicianAssisted Dying 71. Concerned Ontario Medical Student. Com- after the Supreme Court’s Decision in Carter v ments on: “Conscience Rights Matter.” 2020 Canada. Health L Can. 2016; 36(3):86-98. Feb 27 [cited 2020 Mar 10]. In: Gandhi S. 64. Savulescu J, Schuklenk U. Doctors Have no justanoldcountrydoctor [Internet]. 2020 Feb Right to Refuse Medical Assistance in Dying, 26. Wordpress.com. Available from: https:// Abortion or Contraception. Bioethics. [Inter- justanoldcountrydoctor.com/2020/02/26/ net] 2016 Sep 22 [cited 2020 Mar 10]; 31(3): conscience-rights-matter/comment-page- 162-170. Available from: https://onlinelibrary. 1/?unapproved=664&moderation-hash=0eac7b wiley.com/doi/full/10.1111/bioe.12288. 968ac93439f9316a8bc063dc6a#comment-664. 65. College of Physicians and Surgeons of Ontario. 72. Coggon J. Mental Capacity Law, Autonomy, Medical Assistance in Dying [Internet]. To- and best Interests: An Argument for Concep-

8 CANADA Palliative Care

its icon added to the home screen of a de- Palliative Care: Free App and Tips to vice. It is also usable on a desktop computer. Improve Quality of Care After launching and reviewing usage data we realized many users were from parts of In the WHO Global Atlas Canada was rat- the world where the palliative care chal- ed as having “advanced integration of pallia- lenges and available medications may be tive care into mainstream service provision.” significantly different. Thus iPal Global was I believe this is overly generous and would born with some significant differences. say that Canada, like many other countries, suffers from lack of integration of palliative iPal Global is a downloadable app that pro- care into chronic illness care, particularly vides access to essential palliative care infor- non-cancer, and has a long way to go be- mation without requiring continuous inter- fore claiming equitable service and quality net access. The app uses the International across urban, rural and remote areas. Association for Hospice and Palliative Care (IAHPC) List of Essential Medicines for One issue raised by Canadian clinicians is Palliative Care – the most effective and safe not having palliative care symptom man- commonly available medicines throughout agement guidelines or communication tips the world. The content of the app has been on hand when seeing patients. Our pallia- reviewed and revised by clinicians working tive care program developed an app so cli- with Two Worlds Cancer Collaboration to nicians would have essential palliative care ensure its content is relevant to resource Romayne Gallagher knowledge at their fingertips. The app de- constrained countries. sign follows similar thinking formats used Based on 2011 data, the WHO Global in medicine – assess, manage, communicate, The app contains advice on when a pallia- Atlas of Palliative Care [1] was released in plan. A website-based app allows us to add tive approach to care is indicated and con- 2014 and revealed that 42% of countries content without users having to down- tains basic assessment and management of had no palliative care and 38% had only load current versions. St. Paul’s Hospital 22 symptoms, as well as managing the last pockets of service provision. That same year Foundation in Vancouver Canada funded hours of living. The app features advice for the World Health Assembly passed a reso- this development and continues to fund planning future care and decision-making. lution [2] calling for all member states to the costs of maintenance in order to keep The Communication section, is intended to develop, strengthen, and implement pallia- content free. It was launched in 2014 and improve therapeutic efficacy of communi- tive care services as part of universal health continues to be used on a regular basis by cating as well as give suggested approaches coverage. A recently published study [3] doctors, nurses, social workers and others to specific situations such as breaking bad based on 2017 country data showed the throughout North America. It is accessible news, discussing prognosis and deciding on same categories were now 24% and 7%. at ipalapp.com and can be “bookmarked” or goals of care in managing an illness. Talk

9 Palliative Care CANADA

tips are placed throughout the app in ap- To win support of administrators in the their prescriptions are not filled because the propriate situations. hospital and ministry and justify requests pharmacy doesn’t have them. The pharma- for increased medication and salary support cist says they have thrown out opioids that Downloading the app requires 15 Mb you will need to show that there is an unmet expired and don’t want to do that again so of memory so it is quite modest for most need. The Lancet Commission on Palliative they don’t order them in. Working together phones. Go to the website: https://global. Care [4] calculated the world-wide serious always sorts out these issues and ongoing ipalapp.com where you will find links to health-related suffering and developed a communication is key to sorting out issues download the app to your smart phone, tab- package of resources to aid countries in de- with demand and supply. let or desktop computer. veloping their palliative care. They defined serious health-related suffering as being The United States and Canada have expe- The apps are applicable to COVID-19 as caused by illness or injury of any kind that rienced an increase in opioid-related deaths many people can suffer with shortness of could be alleviated by palliative care or pain over the past decade known as the “opioid breath if they develop Acute Respiratory management. One valuable resource is a da- crisis”. It is a complex problem, not well Distress Syndrome as a consequence of a tabase that estimates the number of patients understood by media and many healthcare severe infection. If available and appropri- needing access to palliative care and you can providers. While the focus of the “crisis” has ate, ventilation is the next step. If not avail- find your country at the database website on been on opioids and how to reduce their use able, or the person has multiple morbidities the International Association for Palliative in and out of the healthcare system, there the “Dyspnea” section under the heading Care at https://hospicecare.com/what-we-do/ has been a poisoning of the illicit opioid “Manage”. resources/global-data-platform-to-calculate- supply by synthetic opioids (fentanyl and shs-and-palliative-care-need/database/. You others), great stigma around opioid use will likely see that the estimate is greater disorder (addiction) and a lack access to Improving Palliative Care Takes than what you thought it would be and that treatment for the disorder. It is not a simple Much More than an App! is because the estimate covers those who are relationship that the more you prescribe dying from the illness as well as those living the more people are harmed. It is possible Many colleagues struggle to improve pallia- with chronic illness. to treat pain and shortness of breath and tive care capacity in their healthcare system keep abuse of these medications to as low in resource-constrained nations. It is often a Palliative care home visits have repeatedly as possible. More about this in a subsequent physician or nurse who makes it their per- shown to reduce hospital admissions and article. sonal mission to improve palliative care in costs [5, 6] which is a significant help to the their area and sacrifice a great deal of their healthcare system in any country. Reference Improving the quality of the palliative care time and energy to make that happen for 5 is available in an infographic at: https:// you offer includes the use of validated tools patients. That is not sustainable in the long www.capc.org/seminar/poster-sessions/home- for assessing symptoms and tracking func- term because of personal burnout of the in- based-palliative-care-reduces-hospital-read- tion. It promotes a standardized assessment dividual and it doesn’t change the way the missions/. Having an estimate of the need and tracks efficacy of the treatment. The system provides care. for palliative care as well as evidence that most widely used tool, available in many it reduces visits and admissions to hospital languages, is the Edmonton Symptom As- There is a greater likelihood of success in can help you to demonstrate a need for care sessment Scale [9]. The reference is online establishing change if you form a group of in the community that deals with suffering, and has a description of how to use the interested colleagues that includes nurses, improves quality of life and prevents hospi- tool to improve quality of care. The Pallia- pharmacists, social workers, other allied tal admissions. tive Performance Scale is a tool to measure professionals and administrators. Don’t for- patient function and progression of the get volunteers as no palliative care service is If you begin to treat more people’s pain illness. It is available on line at https://vic- complete without volunteers. There may be and shortness of breath you will use more toriahospice.org/how-we-can-help/clinical- already people in the community who do vis- opioids. Opioids remain the medication tools/ and has been widely translated. With its to sick people and they can be invaluable of first choice for moderate to severe pain training these tools could be used by vol- in understanding the barriers to accessing and shortness of breath due to advanced unteers checking up on patients at home care and may even have workable solutions. illness of any cause [7, 8]. My experience with serious illness to determine if a visit by has been that if doctors don’t use opioids, the healthcare professional is needed. This Establishing who and how many people hospital and community pharmacists don’t means that the doctor/nurse save their visits need palliative care is an essential first step. stock them. If you talk to doctors, they say for those who most need their help.

10 COVID-19

Getting more education in palliative care References 7. Bruera E Paice J. Cancer Pain Management: for your team is challenging as online cours- 1. WHO The Worldwide Hospice Palliative Care Safe and Effective Use of Opioids American Society of Clinical Oncology Educational Book es do not have the evidence [10] to show Alliance. Global atlas of palliative care at the end of life. World Health Organization and The 2015 :35, e593-e599 Accessed at: https://ascop- that they improve palliative care practice. Worldwide Hospice Palliative Care Alliance, ubs.org/doi/10.14694/EdBook_AM.2015.35. Participation in the learning such as a jour- Geneva2014 e593 on March 22, 2020 nal club that reviews clinical articles regu- 2. WHO Strengthening of palliative care as a 8. Ekström M, Abernethy A, Currow D. The man- larly may improve practice but the evidence component of comprehensive care throughout agement of chronic breathlessness in patients the life course. World Health Organization, Ge- with advanced and terminal illness BMJ 2015; is not there yet. Additionally, case review 349 :g7617 of patients, especially when the symptoms neva2014 3. Clark D, Baur N, Clelland D, Garrald E, 9. Hui D, Bruera E. The Edmonton Symptom As- were not well controlled or the death was López-Fidalgo J, Connor S, Centeno C. Map- sessment System 25 Years Later: Past, Present, not well managed is essential. What tends ping Levels of Palliative Care Development in and Future Developments. J Pain Symptom to stick with physicians is experiential 198 Countries: The Situation in 2017. Journal of Manage. 2017; 53(3): 630–643. doi: 10.1016/j. jpainsymman.2016.10.370 Full article access learning where they encounter a clinical Pain and Symptom Management 2020; 59(4): 794-807 https//doi.org/10.1016/j.jpainsym- at: https://www.ncbi.nlm.nih.gov/pmc/articles/ situation (e.g. neuropathic pain) and seek PMC5337174/ evidence for its management. That is where man.2019.11.009. 4. Knaul F, Farmer P, Krakauer E, De Lima L, 10. Hughes S, Preston NJ, Payne SA. Online learning in palliative care: does it improve practice? the app and some supplemental reading of Bhadelia A, Kwete X et al. Alleviating the ac- Eur J Palliat Care. 2016;23(5): 236–9. medical literature can boost your practice. cess abyss in palliative care and pain relief—an imperative of universal health coverage: The Most healthcare providers find palliative Lancet Commission report. THE LAN- Romayne Gallagher MD, care work meaningful and rewarding. If CET 2018; 391, (10128): 1391-1454 Ac- CCFP(PC), FCFP cessed at: https://www.thelancet.com/journals/ burnout occurs it is usually due to the frus- lancet/article/PIIS0140-6736(17)32513-8/ Department of Family and tration and challenges of doing this work fulltext#articleInformation on March 22, 2020 Community Medicine “off the side of your desk” or not being able 5. Elnadry, Jeanne. Home-Based Palliative Care Providence Health Care to get the resources you need to do this Reduces Hospital Readmissions. Journal of Pain Clinical Professor, Division of work in a sustainable way (salary, necessary and Symptom Management, Volume 53, Issue Palliative Care, UBC medications, support from colleagues etc…) 2, 428 – 429 1081 Burrard St. 6. Akhtar S, Srinivasan V, Weisse C, DiSorbo P. If you have a team you can share experienc- Characterizing the Financial Value of In-Home Vancouver, BC, Canada es and potential solutions as well as provide Palliative Care for Patients, Payers, and Hospi- V6Z 1Y6 emotional support to each other. Self-care tals. American Journal of Hospice and Palliative tips are on the global app under self-care. Medicine 2020; 33(3): 196-200 Email: [email protected]

Interview with Miguel Roberto Jorge by WMJ Editor Peteris Apinis

Brazil is one of the countries where Covid–19 we are also experiencing a political crisis, has spread very widely. How are you in this with a polarized country and a President difficult time? How are Brazilian doctors these who is against the recommendations from days? specialists on how to face the COVID-19 pandemic. Physicians, nurses and other We see that the situation worsens day by health personnel are trying to do their best day. We have the second highest number of to help those affected by the virus, but there cases and soon will also rank second as to is shortage of specialized people at public the number of deaths. And we know that hospitals, lack of PPE, lack of reliable data the current numbers are undercounted. Be- (only seriously ill patients are tested) and sides this sanitary crisis, we had some years specialists are stigmatized by people in fear of a crisis in economy and, unfortunately, of being infected. Miguel Roberto Jorge

11 COVID-19

As I understand, you contact your fellow col- months in comparison with an endless situ- helping patients. Public campaigns are im- leagues, doctors around the world, almost every ation. As I have said before, we are observ- portant to educate people. day. What is the mood among our friends – the ing anxiety, depression and other emotional leaders of National Medical Associations? reactions to the pandemic and the associ- From the experience of China and Italy, we ated quarantine. That situation is also con- know that doctors are really exposed to the There is an enormous mobilization of medi- tributing to decreasing physical activity and disease, as it is very common to get sick with cal leaders around the world in order to the consumption of non-healthy food, gain- Covid–19. Most doctors are very afraid of get- overcome all sort of obstacles to have effi- ing weight and potentially triggering some ting sick, mainly because they can take the disease cient and safe working conditions. I am par- health problems. Sleep disorders have also home to their parents, relatives. The worrying ticularly following the group of NMAs that been observed. about a potential disease can be very serious. belong to CONFEMEL (Confederation of Medical Entities of Ibero Latin America) It is known that isolation and confinement in Can doctors in the world feel protected from the and CMAAO (Confederation of Medical very small spaces can lead to domestic violence illness and feel more or less safe? Associations in Asia and Oceania). Despite and aggression. Isn’t the world threatened by a the difficulties, they are doing their work and wave of violence as a response to lasting isola- Governments and health managers have the trying to build efficacy with great enthusiasm. tion? responsibility to offer good and safe working conditions to doctors and health work- We know you as a distinguished psychiatrist, Confinement of people in not large spaces ers at the frontline. Adequate personal pro- professor and a long-term specialist of the that create difficulties to have privacy or for tective equipment needs to be fully available World Health Organization. As a special- a long period of time is associated with ris- and services need to take into account the ist of such a kind, I must ask you, hasn’t the ing tensions among them, increase of irrita- required sufficient number of personnel so Covid–19 pandemic caused a very large out- bility, and potentially causing verbal and/or as not to expose one another to a bigger risk break of mental diseases in the world, defined physical aggression. Some couples can even of being infected. Time off between shifts by fear, ignorance, worry, the loss of loved ones? experience a serious marital crisis. and breaks during shifts also contribute to rest and focus when returning to work. The COVID-19 pandemic and the needed World experience has shown that in difficult confinement at home brought out a series of times like these people tend to pour out their From the experience of China and Italy, we mental health problems as well as new cases discontent and aggression on relatives, doctors know that doctors who face a large number of or worsening of previous mental disorders. and pharmacists. Doctors around the world severely ill Covid–19 patients daily are forced Anxiety and different types of fears are often become victims of negative feelings, not to make very difficult decisions – which patients common reactions when facing the possi- only verbally, but they are attacked also physi- should be assisted to. Are doctors psychologically bility of infection and also after some weeks cally. What can we do to make doctors feel safe supported and what can the World Medical As- of quarantine. Depression and alcohol abuse at such a moment of tension? sociation, National Medical Associations and are problems affecting the vulnerable ones. Governments do to maintain the psychological The loss of someone close, economic loss or We see reports about people applauding health of doctors? becoming unemployed are factors contrib- health professionals and also reports about uting to emotional distress. violence against them. As regards safety, Even before the COVID-19 outbreak, there people need to be informed in what difficult were reports about increasing burnout among There are many interesting articles in world lit- situations professionals at the pandemic’s physicians, particularly among those in erature that solitude and isolation reduces non- frontline are, risking their lives to save oth- training or with few years of practice. Good specific immunity, increases the risk of neurologi- ers. Physicians, nurses and other members and safe working conditions protect physical and endocrinological diseases. Many people of the health team also experience fears of cians from psychological problems but even in the world now live more or less in isolation, being infected, to infect their relatives at in rich countries there are situations where quarantining. Doesn’t loneliness and isolation home, to die or not being able to save many they have to choose between patients – those lead to depression, anxiety, and other psycho- patients they attend to. They are people like who will be placed in an Intensive Care Unit logical changes? Can these psychological chang- any other. When someone attacks health or not or have access to a ventilator. National es become a cause for psychosomatic diseases? professionals, usually it is because of a Medical Associations and their specialized wrong idea about getting infected from be- societies are developing guidelines with al- We have to be careful when considering ing in their presence. And if a health worker gorithms to help physicians be less subjective isolation or loneliness for a period of some is attacked, it will be one less at the frontline in their decision making and consequently

12 COVID-19

experience less psychological stress in that In the world, not only doctors and patients have Your final remarks? undesirable situation. conversations in Zoom, Skype or over the telephone, but also the relationship between doc- I believe that the most important thing that Covid–19 has produced fantastic developments tors, their mutual advice and communication the COVID-19 outbreak brought to us was in science and research. Every day there is new is remote. Do we not lose much of the human the astonishing awareness of how unequal research, new lessons, new information. There has communication qualities? Don’t our doctors lose is the world we live in. We discussed in the never been so much contradictory information professional ties? Maybe we need psychotherapy previous questions situations that can be about one topic. How do doctors feel about this for the all-global medical community? more applicable to privileged people but we information flow and how to adapt to it? must think about those who live in low and Different forms of telemedicine and the middle income countries and even in the There is an enormous effort from scientists utility of remote work are tested during the outskirts of cities or urban areas of rich coun- worldwide to know better this new coronavi- situation the world is experiencing since the tries. Think about those who do not have ac- rus and the pathophysiology of COVID-19. outbreak that started in China. I am sure that cess to health services or have limited and The world is anxious for a vaccine to prevent it will affect the work of everybody and our difficult access to not too good quality medi- new cases and the right medication to treat the work as physicians as well. As a psychiatrist cal services. At this particular time, during disease. Moreover, there are lots of researches and psychotherapist, I do not believe that a the current pandemic, while I am here, in my being done to study human behavior during virtual consultation will give us all we can small but comfortable apartment, answering the current pandemic and trying to figure out have when in the physical presence of our questions, typing on my computer, there are how habits will change after the COVID-19 patients. Unfortunately, sometimes physical millions of people fighting to survive in this outbreak. Unfortunately, good research takes examination is replaced by labs and images, difficult situation. There are cultures were time to achieve results that will last and not be and the patient as a person loses importance philanthropy is not rare and I do not know contradicted by another research. And doctors to the signs and symptoms they present. Evi- about every country but I have never seen know it better than anyone not familiar with dence based diagnosis and treatment are of people being mobilized to do something or the development of science. What is impor- great importance but the human contact is to donate a considerable amount of money tant – science was not properly considered or an essential aspect of the practice of medi- to the underprivileged as nowadays in my even rejected before this pandemic and now cine. Telemedicine can be a wonderful tool to country, Brazil. I hope and wish that such we see people more interested and recogniz- complement the possibilities of an encounter attitudes will increase and reach every corner ing the importance of science development. between a physician and their patient. of the world.

What is the potential impact of the COVID-19 Pandemic on Achieving the Sustainable Development Goal of Reaching Zero Unmet Need for Contraception by 2030? The World Health Organization is re- The Nairobi Summit on ICPD+25 held in tions related to COVID-19 could have vast porting this June 2020, that there are over November 2019 had a major theme, Reach- consequences for the sexual and reproduc- 6 million cases globally of COVID-19 ing Zero Unmet Need for Family Planning tive rights and health of women and girls, with over 380,000 deaths and the human by 2030. At that time, in Developing coun- a new analysis by UNFPA and partners cost of this pandemic could be extraordi- tries 214 million women did not have access shows. The pandemic will undermine efforts nary [1]. It is important to shine a lens on to modern contraception and thus, become to end gender-based violence and limit the the potential impact of the pandemic on pregnant as young adolescents, often while progress of ending gender-based violence by Women’s Health Issues and the Sustain- they are still in school. There still exists a 2030 [2]. For every 3 months the lockdown able Development Goal of reaching Zero disparity in contraceptive use between the continues, assuming high levels of disrup- Unmet Need for Contraception by 2030. high and middle-low countries, even within tion, up to 2 million women may be unable Unplanned teenage pregnancy is a global African countries, and between the higher to use modern contraception. Significant health issue, a women’s health issue, and a and lower income quintiles within coun- levels of lockdown-related disruption over human rights issue. tries. The economic and physical disrup- 3 months could leave 47 million women in

13 COVID-19

Bev Johnson Padmini Murthy Deborah Bateson Marion Okoh-Owusu low- and middle-income countries unable borders and production of some contracep- Medical Women’s International Association to use modern contraceptives, leading to a tives have been disrupted. It is essential to (MWIA): Teenage Pregnancy Task Force projected 7 million additional unintended ensure supply chains of contraceptive prod- pregnancies [2]. In the most severe scenario, ucts so that there is unimpeded flow from with significant service disruptions lasting manufacturer to the patient. FP2020 has cre- References for a full year, 51 million women would be ated a platform to ensure information from 1. WHO Coronavirus Disease (COVID-19) unable to use modern contraceptives, re- global experts about family planning [4]. Dashboard. [Internet]. 2020 [cited 4 June 2020]. Available from: https://covid19.who.int/ sulting in 15 million unintended pregnan- 2. Impact of the COVID-19 Pandemic on Fam- cies [2]. During the past 4-5 months, the Key action points to consider maintenance of ily Planning and Ending Gender-based Vio- COVID-19, a highly infectious virus that essential Family Planning services during the lence, Female Genital Mutilation and Child we do not have a vaccine for yet, has spread COVID-19 pandemic have been published Marriage. [Internet]. 2020 [cited 4 June 2020]. to every corner of the world. by the International Federation of Obstetrics Available from: https://www.unfpa.org/resources/impact-covid-19-pandemic-family- and Gynecology [5]. These include an urgent planning-and-ending-gender-based-violence- Dr. Natalia Kanem, Executive Director need to use points of care such as postpar- female-genital of the United Nations Population Fund tum and prenatal visits for providing educa- 3. New UNFPA projections predict calamitous (UNFPA) stated “This new data shows the tion and access to long acting reversible con- impact on women’s health as COVID-19 pan- catastrophic impact that COVID-19 could traceptive (LARC) options. Also, self-care demic continues. [Internet]. 2020 [cited 28 soon have on women and girls globally. The family planning methods which include self April 2020]. Available from: https://www. unfpa.org/press/new-unfpa-projections-pre- pandemic is deepening inequalities, and mil- injectables, condoms and vaginal rings which dict-calamitous-impact-womens-health-covid- lions more women and girls now risk losing can be supplied to women are important. 19-pandemic-continues the ability to plan their families and protect Implementation of telemedicine using mo- 4. FP2020 COVID-19 & Family Planning. [Inter- their bodies and their health,” said Dr. Na- bile phones and social media can be used for net]. 2020 [cited 4 June 2020]. Available from: talia Kanem, UNFPA Executive Director. both information and access to supplies [5] http://familyplanning2020.org/covid-19 5. Contraception and Family Planning. Federation “Women’s reproductive health and rights Adolescents are particularly vulnerable in the of International Gynaecology and Obstetrics. must be safeguarded at all costs. The services pandemic as they may have restricted ability [Internet]. 2020 [cited 4 June 2020]. Available must continue; the supplies must be deliv- to seek services away from home but there from: https://www.figo.org/covid-19-contracep- ered; and the vulnerable must be protected are opportunities to remove some barriers to tion-family-planning and supported [3].” Some clinics may not care with use of telemedicine. have the Personal Protective Equipment Dr. Bev Johnson (PPE) to protect themselves or the patients Contraception is a human right for adoles- E-mail: [email protected]; and staff illness may impact service provi- cent girls, and healthy families are by choice, Dr. Padmini Murthy sion. Staff will need to focus on COVID-19 The impact of the COVID-19 Pandemic E-mail: [email protected]; patient care and may not have the resources on Family Planning requires a collaborative Dr. Deborah Bateson to provide contraceptive advice and services. and novel approach so that we can continue E-mail: [email protected]; The function of supply chains in some coun- to strive towards Zero Unmet Need for Dr. Marion Okoh-Owusu tries has been disrupted with the closure of Contraception by 2030. E-mail: [email protected]

14 NIGERIA COVID-19

COVID-19 Pandemic: a Possible Reversal Mechanism for Outward Medical Tourism by African Political Leaders of their healthcare systems, some African Chinese authorities [3], it has spread be- political leaders prefer to seek medical care yond China to many other countries of abroad, outside their respective countries. the world. This trend of regional and con- However, with the outbreak of Coronavi- tinental spread, as well as the increase in the rus disease (COVID-19) in China and its number of cases, informed WHO’s declara- subsequent spread to other regions of the tion of the disease as a Public Health Emer- world, including Africa, most parts of the gency of International Concern (PHEIC) world have been on lockdown with closures on January 30, 2020 [4], and as a Pandemic of international airports, land and sea bor- on 11th March, 2020 [5]. As at Sunday, 14th ders. June, 2020, over 200 countries have been affected by COVID-19, with 7,948,001 Apart from the COVID-19 pandemic ex- persons confirmed to have COVID-19 and posing the long-standing challenges and 434, 097 deaths recorded, globally [6]. Af- fragility of African healthcare systems, it rica recorded her first case of COVID-19 in has severely limited the opportunity to seek Egypt on the 14th of February, 2020 [7], and medical care abroad, with African political as at Sunday, 14th June, 2020, over 50 Af- leaders and elites left with no choice but to rican countries have been affected by CO- Osahon Enabulele seek healthcare in their home countries. VID-19, with a total of 233, 732 persons confirmed to have COVID-19 and 6, 253 Medical Tourism is the process of people While it may be premature to tell if this deaths recorded [8]. travelling to another country, across inter- switch to the utilization of local health national borders and outside their country facilities by African political leaders will Coronavirus disease (COVID-19) is spread of residence, for the purpose of obtaining remain a permanent feature in the post- through respiratory droplets from infected medical care, which may include the full COVID-19 era, this article is aimed at individuals (especially when they cough or range of medical services such as preventive, reviewing the impact of outward medical sneeze), aerosols, and contact with infected promotive, curative and rehabilitative ser- tourism by Africa’s political leaders and the objects and surfaces [9]. It is characterized vices. Importantly, it includes the range of likelihood of the COVID-19 pandemic by symptoms such as fever, cough, sore socio-economic activities undertaken by an serving as a reversal mechanism, with a pro- throat, difficulty with breathing/short- individual or group of persons in the process jection into the post-COVID-19 era. ness of breath, myalgia, anosmia, fatigue, of accessing medical care/health care ser- as well as complications such as acute re- vices outside his/her country of residence. Funding: This research/paper did not respiratory distress, septic shock, metabolic These activities, which are usually undertak- ceive any specific grant from funding agen- acidosis, bleeding and coagulation dysfunc- en after completion of the primary medical cies in the public, commercial, or not-for- tion [10]. There is currently no approved procedure, could include leisure and busi- profit sectors. drug treatment or vaccine for the disease ness activities in the destination country. [11]. Therefore, Infection Prevention and The global community is currently con- Control measures and other public health Outward Medical tourism, particularly po- fronted with the challenge of containing interventions such as respiratory and hand litical health tourism by African political coronavirus disease (COVID-19) caused by hygiene, social distancing, use of face mask, leaders, has been a major challenge con- a novel strain of coronavirus, called SARS- public lockdown, risk communication, etc. fronting the African continent, with health- COV-2 [1]. The disease first came to public have been the mainstay of containment ef- care systems in most of the African conti- attention following the outbreak of an acute forts [12]. This has resulted in movement nent left undeveloped, at huge cost to the respiratory illness in Wuhan City, Hubei restrictions, including stoppage of interna- health of African people and the economy province of China in December 2019 [2]. tional, national and local travels, closure of of the African continent. Instead of invest- Since the outbreak was reported to the international and domestic airports, closure ing required resources in the development World Health Organization (WHO) by of land and sea borders, closure of schools

15 COVID-19 NIGERIA

and offices, and prohibition of mass gather- Though there is currently no universally nologies and cancer diagnostic facilities), ings [13]. agreed definition of medical tourism [19], political instability and insecurity in the it is sometimes simply defined as the pro- source country, availability of the required Covid-19 has had great impact on many cess of people travelling to another coun- expertise/highly skilled medical person- countries. Indeed, the health, socio-eco- try, across international borders and outside nel in the destination country, ambience of nomic, political and cultural implications of their country of residence, for the purpose the health facilities and receptiveness of the COVID-19 have been quite evident. Even of obtaining medical care [19, 20]. This may health personnel, etc [21, 22]. In the case countries with well-developed healthcare include the full range of medical services, in- of Africa, Nigeria inclusive, it sometimes systems have had their healthcare systems cluding preventive, promotive, curative and also includes the absurd such as inordinate seriously challenged and overwhelmed by rehabilitative services [19]. This simplified quest for government estacodes by some COVID-19 [14]. The lives and livelihoods definition may however not truly reflect the political and public office holders, poor -po of the people have been grossly affected important factor of tourism associated with litical commitment to the development of by the shutting down of the economy and these foreign medical travels [21]. There- the health system and health of the citizens, people’s sources of livelihood/income. It fore, to better appreciate its significance, it and official secrecy [21]. Indeed, some elites, has been estimated that half a billion more may be better defined as the range of socio- public and political office holders see it as people in the world could be pushed into economic activities undertaken by an indi- a status symbol, even when such medical poverty as governments shut down entire vidual or group of persons in the process of conditions or medical care needs can be sat- economies to manage the spread of the vi- accessing medical care/ health care services isfactorily attended to in Africa [21]. This rus [15]. COVID-19 has enthroned a “new outside his/her country of residence. These notwithstanding, it is important to note normal” and way of life, with various cop- activities, which are usually undertaken af- that there are Africans who genuinely travel ing strategies developed to cope with the ter completion of the primary medical pro- abroad to access quality healthcare services effects of COVID-19, including new ways cedure, could include leisure and business and technologies (such as heart surgeries of living and conduct of human affairs and activities in the destination country [21]. and oncological treatments) which may transactions, increased local production of not be readily available in most of Africa’s essential commodities and human needs, Medical Tourism is usually classed into healthcare facilities [21]. increased utilization of local, homegrown Outward Medical Tourism (when it in- resources and facilities, etc [16]. These im- volves travel for medical care outside one’s plications are more glaring in most of the country of residence) and Inward/In-bound Outward Medical Tourism by developing countries of the world, includ- Medical Tourism (when it involves travel Africa’s Political Leaders ing the African continent where most of for medical care within one’s country of the countries have fragile economies, in- residence) [21]. It is well known that rather than invest- stitutions, and fragile health care systems ing resources in the sustained development [17, 18]. Aside from the patients, there are sev- of their healthcare systems, some African eral stakeholders currently involved in the political leaders and public office holders multi-billion dollars medical tourism mar- utilize public resources to undertake fre- Impact of COVID-19 ket. These include the healthcare providers, quent travels abroad to receive medical care, Pandemic on Outward medical tourism agents, insurance and trav- sometimes for medical conditions that can el agencies, national governments, etc [21]. be readily managed in their respective coun- Medical Tourism tries [21, 23, 24]. The common destination Reasons for Outward Medical Tourism countries for African political leaders and What is Medical Tourism? elites include India, United States, United There are various reasons for outward medi- Kingdom, United Arab Emirates, Germany, Medical tourism as a concept has been cal tourism (foreign medical travels) by in- Turkey, Thailand, and Israel. practiced for centuries in Africa and other dividuals and groups. These include better parts of the world. However, the emergence quality of health infrastructure and health- Aside from the huge loss to their country’s of technology and globalization, as well as care services in the destination country, re- healthcare systems and economies, some the involvement of political leaders, govern- duced cost of healthcare services in the des- of these African political leaders have un- ments, and the corporate world, has accel- tination country, lack of access to required fortunately kicked the bucket either in the erated its transformation and significance health care and diagnostic services in the course of obtaining foreign medical care in over the decades. source country (such as reproductive tech- the destination countries, or shortly after

16 NIGERIA COVID-19

returning to their home countries. Some to meet up with the 2001 Abuja declaration led to continuous emigration of medical have also had to spend upwards of 4months of African Heads of Government (signed doctors and other healthcare professionals in the destination countries, at great loss over 18 years ago) in which they pledged to to countries in the developed parts of the to the governance/political leadership and allocate a minimum of 15% of their annual world with better economic climate and economy of their countries [24]. budgets to the health sector [24, 26, 27]. more enabling health care environments, Whereas Africa currently (as at Sunday, such as United States of America, United In the words of Professor Khama Rogo of June 14, 2020) constitutes about 16.72% of Kingdom, Canada, United Arab Emirates, the World Bank, much as Africa is heavily the global population [28], and bears about Germany, etc [35, 36]. resource constrained, a lot of money is spent 24% of the global disease burden [29], pub- on treatment abroad that could have instead lic health spending in Africa is reported to helped develop capacity locally. Africa, ac- be 1% of global health spending [30, 31], Consequences of Outward cording to Prof. Khama Rogo, is exporting with the average public expenditure on Medical Tourism on African money and patients to the East, especially health in the African region put at 10% of Healthcare Systems India, which has largely contributed to a total public spending [32]. flourishing private health sector at the ex- There have been several consequences of pense of Africa’s. Prof. Rogo went further This state of poor financial investment in outbound/outward medical tourism by Af- to state that 25% of the passenger loads on African healthcare systems has led to poor rican political leaders and elites in the pre- major airlines such as Kenya Airways and and fragile health infrastructure, equipment COVID-19 era. One of such consequences Ethiopian Airlines, are medical tourists and diagnostic facilities, poor investment is the huge outflow of foreign exchange from Africa to foreign countries [25]. in research, poor emergency preparedness (capital flight) to other countries outside and response to epidemics, as well as a se- Africa, in the course of accessing foreign The unceasing trend of outward medical rious dearth in human resource for health, medical facilities, healthcare services and tourism by African political leaders in the amongst other challenges [33, 34]. technologies that ought to be available lo- pre-COVID-19 era is a reflection of their cally in Africa. poor priority for the health of their citizens. 2. Dearth of Human Resource for Health. It is also a strong reflection of their unsat- In 2016 alone, Africa is reported to have isfactory level of political commitment to A very significant factor in the develop- lost over $6 billion from outward medical the development and utilization of health ment of healthcare systems is the Human tourism [37]. Indeed, it is important to note facilities/systems within their respective Resource for Health, comprised largely of that there are some African countries whose countries. physicians, nurses, pharmacists and other economic loss (country wise) to outward allied health professionals/health workers. medical tourism exceeds $1billion. This is Amongst several enablers of health sys- These professionals play a significant role more so as each foreign medical trip typi- tem development are two critical enablers, in the provision of the much-needed access cally cost an average of $20,000–$40, 000 which clearly depict the poor priority for to quality, effective and efficient health care per individual traveler, with each traveler health and unsatisfactory level of political services. usually accompanied, most of the time [21]. commitment to the development of health- In the case of foreign medical travels by Af- care systems by most African political lead- Currently, there is a global crisis of avail- rican political leaders, the expenditures are ers/governments, viz: ability of human resource for health, re- even more, on account of the fact that they flected in the acute and chronic shortages usually travel with outlandish entourages/ 1. Inadequate Government Health Financ- of health care workers in most countries of horde of aides and in expensive chartered ing and Budgetary allocations. the world. This crisis is even worse off in the jets which sometimes incur huge parking African continent, which though accounts costs in the destination countries. For in- One of the major factors that has blighted for about 24% of the global disease bur- stance, in the year 2013, Nigeria alone, lost African health systems is inadequate health den, only boast of about 3% of the global over $1billion to capital flight from outward financing and budgetary allocations to the health work force [29]. Notwithstanding medical tourism [21, 23, 38, 39]. health sector by most African governments. the globally acknowledged significance of This is coupled with the injudicious utiliza- the human resource for health, most Afri- The unfortunate trend of frequent foreign tion of even the insufficient funds allocated can countries hardly accord this component medical travels by African political leaders to the health sector. An evidence of this is of the healthcare system serious consider- in the pre-COVID-19 era has also led to the the fact that many African countries are yet ation and importance, an attitude that has sustained de-marketing of the healthcare

17 COVID-19 NIGERIA

systems of their respective countries [21]. to health system development in the post- the following expectations, amongst others, This has been at great loss to the econo- COVID-19 era. in the post-COVID-19 era: mies of African countries with tremendous negative knock-on effects on the healthcare Interestingly, COVID-19 has indubita- (1) Improved healthcare financing and systems of African countries, with most of bly compelled most governments in Af- level of political commitment by African them left in very fragile states. rica with poor priority for health, to have political leaders to the health of African a rethink about their commitment to their people and the development of African The fragile and deteriorated state of health healthcare systems, particularly with the healthcare systems . facilities in most African countries has over grim reality that COVID-19 is no respecter time led to loss of confidence in the avail- of social class, age, gender or race, and the With the grim realities thrown up by the able local health facilities, thus promoting fact that the opportunity for foreign medi- COVID-19 pandemic, it is expected that Af- outward medical tourism for the average cal travels does not currently exist. Truly, rican political leaders will step up their level African citizen. African governments have been compelled of political commitment to the health of Af- by COVID-19 to make the kind of invest- rican people, through more sincere commit- The emergence of COVID-19 on African ments in the healthcare system that they ment to the protection of their health rights soil on the 14th of February 2020 [7], has may ordinarily not have made in the pre- and sustained development of the healthcare only exposed further, the fragility of most COVID-19 era; a fact that is evident when systems in their respective countries. It is ex- African healthcare systems. The current their current responses to the COVID-19 pected that they will continually appreciate COVID-19 pandemic revealed that most pandemic is compared with their responses the significant nexus between investments African healthcare systems lacked enough to other epidemic and endemic diseases in healthcare, and the productivity and eco- capacity to respond to COVID-19 as was like Malaria, Lassa fever, Tuberculosis, nomic prosperity/wealth of their respective evident by the insufficient numbers of suit- and Cholera, some of which have caused countries and people. They need to appreci- able isolation centers and inadequate hu- more deaths in the African continent than ate the imperative of making greater invest- man resource for health, as well as the in- COVID-19. ments in the health of African people, health sufficient diagnostic capacity to screen and system development and quality healthcare detect COVID-19 [40]. Before the first These COVID-19 induced investments service provision, particularly through im- recorded case in Africa on the 14th of Feb- have led to the development of new health proved budgetary allocations to the health ruary, 2020, most of the African countries infrastructure and equipment, including sector, in line with the 2001 Abuja declara- had very limited number of Laboratories to Isolation centres and Infectious Disease tion of African Heads of Government [26]. process confirmatory tests for COVID-19 Hospitals, the upgrade of existing ones, pur- [40]. In Nigeria (the most populous country chase of diagnostic machines, recruitment (2) Reversal and restriction of Outward in Africa), for example, as at the 27th of Feb- and motivation of healthcare personnel, Medical Tourism by African political ruary 2020 when the country recorded her encouragement of local production of some leaders . first case of COVID-19, there were only 5 essential commodities like Ventilators, Face diagnostic laboratories (4 public and 1 pri- masks, and Personal Protective Equipment The first real step towards limiting or -re vate) for test confirmation of COVID-19. (PPEs), amongst other initiatives to contain versing outward medical tourism in the This was to serve a Nigerian population of COVID-19 in Africa. African continent, particularly the frequent over 200 million people resident in the 36 foreign medical travels by African political States of Nigeria and the Federal Capital This notwithstanding, it remains to be seen leaders, is the recommitment of African po- territory, Abuja [41]. if these investments and commitment to litical leaders and governments at all levels, emergency preparedness and response, as to quality healthcare development and the well as health system development, will be health of their citizens. This is the first real Expectations in the Post- sustained in the post-COVID-19 era. This step towards limiting the huge loss of for- COVID-19 Era author hopes that it will no longer be “busi- eign exchange from Africa and ploughing ness as usual” in the post-COVID-19 era, back the saved resources to the development With the deficits in African healthcare sys- and that African governments will emplace of the healthcare systems in the African tems exposed by the COVID-19 pandemic, an effective and focused strategic develop- continent, on a sustainable basis. there are lots of expectations by African ment plan that incorporates effective per- people, particularly in terms of African formance monitoring and evaluation (in the Interestingly, one obvious effect of the political leaders recommitting themselves short, medium and long-term), to address COVID-19 pandemic is the fact that it

18 NIGERIA COVID-19

has apparently conditioned African peo- adequate number and distribution of well of the pandemic. This is particularly on ac- ple, particularly the African political lead- skilled and motivated health workforce. count of the report that over 80% of cases of ers and elites, with a penchant for foreign For African healthcare systems to make the COVID-19 affected individuals are in the medical travels, to stay back home to utilize needed progress in the post-COVID-19 mild category [42]. The primary healthcare the healthcare facilities and systems in their era, there is urgent need for African gov- system is therefore well suited for the man- respective countries to resolve their health- ernments to pay greater attention and care agement of these mild cases, thus removing care needs. Instructively, since COVID-19 for their human resource for health. They some burden from the higher levels of the arrived in Africa, various political leaders must develop a focused, strategic, dynamic healthcare system. This is also of particular have come down with the disease. How- and robust Human Resource for Health relevance in Africa where home manage- ever, unlike what was the case in the pre- Development plan; one that takes cogni- ment of mild cases of COVID-19 may be COVID-19 era where they could easily zance of the need for sustained produc- challenging because of the multiple number travel abroad to resolve their medical chal- tion of sufficient numbers of quality and of occupants that generally characterizes lenges, the option of foreign medical travel competent physicians and other healthcare each African household. has been virtually blotted by the restrictions professionals, as well as their recruitment and challenges imposed by the COVID-19 and retention in Africa. Unfortunately, most African countries can- pandemic. The main choice available to not boast of having a robust and effective them has been to use the healthcare facili- They must pay attention to the push and Primary health care and referral system, ties that are available in-country. This may pull factors that influence the emigration of hence the overburdening of the secondary be seen as a positive effect of COVID-19, physicians and other healthcare personnel and tertiary levels of care in the manage- particularly when viewed against the hu- from the African region. This will particu- ment of individuals with COVID-19. mongous capital flight out of the various larly require the institution of motivational countries in Africa on account of outward mechanisms, incentives and competitive Arising from the foregoing, it is expected medical tourism/foreign medical travels, wages, training and retraining of health- that African governments will invest more with grave consequences for the economies care personnel, better conditions of service in the strengthening of the Primary health- and healthcare systems of African countries. and enabling work/practice environments care system, but without relegating their infor healthcare personnel, improved security vestments in the development of the other It is therefore expected that this trend of re- and safety of healthcare personnel, as well levels of the African healthcare system. versal of outward medical tourism along with as schemes for turning brain drain to brain Along with this is the need for strengthen- the associated reversal of capital flight will be gain. ing of the referral system, and the national sustained and consolidated upon in the post- system in general, in a way that improves COVID-19 era. A critical factor in the real- (4) Improved Quality of Health Infra- confidence in the system by communities ization of this objective is the commitment structure and Technologies . and consumers of care. of African political and public office holders to leadership by example through their utili- It is expected that African governments will (6) Development of the Private health zation of health facilities in their respective make greater commitments to the sustained sector . communities and countries, rather than in- provision of quality health infrastructure, dulging in frequent foreign medical trips for technologies and equipment, along with It is not in doubt that most patients first their healthcare needs. The positive knock-on the development of a maintenance policy visit private healthcare facilities in an at- effect on the confidence of their citizens (Af- to guarantee continuous upgrade of existing tempt to get solutions to their healthcare rican people) in utilizing health facilities in health infrastructure, diagnostic facilities needs. It is therefore imperative that in their communities and countries, along with and technologies, in the post-COVID-19 advancing progress in the African health- the growth and development of the health- era. care system, the sustained development and care system, cannot be over-emphasized. quality regulation of the African private (5) Development of the Primary Health- healthcare sector must be given priority (3) Sincere development and effective care System . consideration. The private healthcare sector management of the Human Resource for and private healthcare providers should not Health . One of the realities of the COVID-19 be seen as competitors but as great partners pandemic is that the existence of a robust in the quest for enthronement of robust, ef- A critical element needed for health sys- primary healthcare system is a significant fective and efficient healthcare systems. This tem development is the presence of an factor in the containment and management will require the blurring of old concepts

19 COVID-19 NIGERIA

and ideological frameworks, and modifica- lots of talents, initiatives and energies, governance. To enthrone good governance tion of health seeking behaviours in Africa, which need to be harnessed and developed of African healthcare systems, and good to enable the private healthcare sector get for the progress of the African continent governance in general, it is important that the required significant support. This can be and its healthcare system. In this regard, it the perspectives and needs of the governed in the form of sustained grants and single- should no longer be fashionable in the post- (citizens) are given due digit (very minimal) interest loans extended COVID-19 era for African governments to to private healthcare providers in the post- sustain the practice of importing most of consideration. It is therefore fundamental COVID-19 era, the institution of a Health Africa’s healthcare requirements, including that African citizens are empowered to play and Hospital/Health system Development drugs and vaccines. Indeed, time has come their expected roles more responsibly and Intervention Fund (HHDIF) and strength- for African countries to be self-sufficient in courageously, in the post-COVID-19 era. ening of beneficial and productive Public- drug and vaccine production. It is therefore This is especially as it is expected that in Private-Partnership arrangements. All these expected that the post-COVID-19 era will the post-COVID-19 era, African citizens will help guarantee the development of an witness more commitment by African gov- will consistently and courageously demand effective, efficient and responsive private ernments to sustained efforts at supporting accountability and transparency from their healthcare sector, to complement the pub- and boosting local drug manufacturing and African political leaders (and managers of lic healthcare sector in the delivery of ac- vaccine production, on a sustainable basis. the healthcare system) at all levels. It is also cessible and quality healthcare to African expected that African citizens will consis- people. (9) Research, Data and ICT/Health Man- tently demand for sustained development of agement Information System the healthcare system, as well as the unre- (7) Strengthening the Quality Regulatory pressed expression of their health rights (in- and Clinical Governance Framework . It is important for African governments to cluding their right to access quality health significantly invest in Research develop- care), particularly as enshrined in the con- For real progress to be made by African ment and innovations so as to improve the stitution of the World Health Organization healthcare systems in the post-COVID-19 quantum and quality of research and inno- [43] and other declarative International in- era, African governments must pay particu- vations in African healthcare systems. struments such as the Universal Declaration lar attention to the quality component of of Human Rights [44]. their healthcare systems. This will require It is also necessary to promote the effective the enthronement of clinical governance and ethical management of data and the It is the author’s considered view that for frameworks at all levels, with the develop- Health Management Information architec- sustained commitment to the expected ment of quality, ethical and safety frame- ture by African countries, to aid more pro- post-COVID-19 healthcare reforms and works and protocols/practice guidelines. ductive data deployment for development of expression of the health rights of African Additionally, there is need to support and the healthcare system, and improvement of citizens, it is imperative for African coun- empower the health professional regulatory the health and well-being of African people. tries without an existing National Legal bodies meant to enforce quality standards in The dazzling opportunities and avenues cre- framework for health, to consciously de- the health sector. ated by the Information, Communication velop one, with the inputs of the citizens, and Technology (ICT)/Digital age, should professional health associations, Civil Soci- There is no doubt that sustained implemen- be explored to advance equitable, afford- ety Organizations (CSOs), and other stake- tation and adherence to clinical governance able, quality and ethical access to healthcare holders in the health sector, incorporated. protocols, safety and quality standards/ services and commodities. This will particu- The Legal framework for health should regulatory frameworks, will improve the larly be of benefit to African people residing contain provisions that guarantee the sus- quality accreditation of healthcare facilities in rural and hard-to-reach communities. tained development, growth and regulation in the African region, and the people’s con- of the healthcare system, including the obli- fidence in African healthcare systems. (10) Legal framework for health/Regula- gations and commitment of government to tions restricting use of public resources this objective. It should importantly contain (8) Self-sufficiency in Pharmaceutics and for Outward Medical Tourism by Public protective provisions for the health rights Vaccine production and Political Office Holders, and -Em of African citizens, including their right to powerment of the Citizens . hold their leaders to account, particularly as The challenges thrown up by the it concerns the development of the health- COVID-19 pandemic revealed once again An empowered citizenry is a necessary care system and expression of their health that, the African continent is imbued with ingredient for the advancement of good rights.

20 NIGERIA COVID-19

Additionally, the Legal framework for demand for their health rights to access References health should, amongst other provi- health care facilities and services compa- 1. World Health Organization. Q&A on Corona- sions, contain provisions restricting the rable to those in the developed countries viruses (COVID-19). Retrieved from https:// www.who.int/emergencies/diseases/novel-cor- use of public/tax payers’ resources for the of the world. African people must stand onavirus-2019/question-and-answers-hub/q-a- sponsorship of foreign medical travels by against the use of their commonwealth/ detail/q-a-coronaviruses. Accessed June 8, 2020. African political and public office hold- public resources or tax payers’ resources for 2. World Health Organization. WHO Timeline- ers. Necessary criteria should however financing foreign medical travels by Afri- COVID-19. Retrieved from https://www.who. be established for exceptional cases that can political and public office holders. They int/news-room/detail/27-04-2020-who-timeline---covid-19. Accessed June 8, 2020. may be considered for sponsorship. For must insist that African political and public 3. Carlos WG, Dela Cruz CS, Cao B, Pasnick S, instance, where a Medical Board of Ex- office holders utilize healthcare facilities Jamil S. Novel Wuhan (2019-nCoV) Coronavi- perts have conclusively determined that and services in their various countries, ex- rus. Am J Respir Crit Care Med. 2020; 201(4): a medical condition cannot be handled cept for cases where it is proven by a team 7-8. Doi:10.1164/rccm.2014P7. by healthcare facilities in the country, of indigenous medical experts that facilities 4. World Health Organization. COVID-19 Pub- or where the required experts/expertise, for managing such medical conditions are lic Health Emergency of International Con- cern (PHEIC) Global research and innovation health technologies or diagnostic services unavailable in their countries. forum. Retrieved from https://www.who.int/ are unavailable in the country, an approval publications/m/item/covid-19-public-health- could be considered in these instances, but The citizens’ decision to vote for their lead- emergency-of-international-concern-(pheic)- with a proviso that such identified gaps be ers during electoral contestations should be global-research-and-innovation-forum. Accessed filled by the relevant authorities/govern- predicated on the ability of such candidates June 8, 2020. 5. World Health Organization. WHO Director- ment with a specified period. These sug- to make significant commitments in their General’s opening remarks at the media briefing gested restrictions are without prejudice electoral manifestos, to health system de- on COVID-19-11 March, 2020. Retrieved from to the fundamental right of such politi- velopment, the citizens’ health and health https://www.who.int/dg/speeches/detail/who- cal and public office holders to use their rights. director-general-s-opening-remarks-at-the- private resources to access healthcare ser- media-briefing-on-covid-19---11-march-2020. Accessed June 8, 2020. vices and technologies wherever they may For countries without a Legal framework 6. Worldometer. Latest updates. Learn more so wish. for health, the citizens should demand for about Worldometer’s Covid-19 data. Re- its enactment, with significant provisions trieved from https://www.worldometers.info/ protecting and promoting their health coronavirus/#countries. Accessed June 07, 2020. Conclusion rights incorporated. Above all, African 7. Nkengasong JN, Mankoula W. Looming threat people should consistently demand for of COVID-19 infection in Africa: act collectively, and fast. Lancet. 2020; 395: 841-42. While the new spirit of commitment to the good governance, transparency and ac- 8. Africa Centres for Disease Control and Preven- development of African healthcare systems countability from their leaders. tion. Coronavirus Disease 2019 (COVID-19). by African political leaders during the cur- Latest updates on the Covid-19 crisis from Af- rent COVID-19 pandemic is commend- If these and other progressive steps are rica CDC. Retrieved from https://africacdc.org/ able, the big question remains whether this taken, the African continent may yet see covid-19/. 9. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong new spirit of healthcare investment and brighter days ahead for African people and Y, et al. Early transmission dynamics in Wuhan, commitment is going to be sustained in the African healthcare systems. China, of novel coronavirus: Implications for vi- post-COVID-19 era or not. Will it be one rus origins and receptor binding. Lancet 2020; of sustained sincere commitment or an- Indeed, the author is convinced that with 395 (10224):565-574. other flash in the pan, as was the case dur- the commitment of African political and 10. Zhong B-L, Luo W, Li H-M, Zhang Q-Q, Liu X-G, Li W-T, et al. Knowledge, attitudes, and ing and after the ravaging scourge of Ebola public office holders to leadership by -ex practices towards COVID-19 among Chinese Viral Hemorrhagic Disease and other pre- ample, with commitment to good gover- residents during the rapid rise period of the vious epidemics that ravaged the African nance and transparency frameworks, with COVID-19 outbreak: a quick online cross-sec- continent? political stability and political will, backed tional survey. Int J Biol Sci. 2020;16(10):1745- by the support of all Africans, the trend of 52. While it may be difficult to immediately outward medical tourism, particularly as it 11. World Health Organization. Coronavirus: Overview. Retrieved from: https://www.who. resolve these questions, one critical fac- concerns frequent foreign medical travels int/health-topics/coronavirus#tab=tab_1. Ac- tor needed to ensure that African political by African political leaders, may be sub- cessed June 7, 2020. leaders/Governments do not turn back to stantially reversed in the post-COVID-19 12. Li JY, You Z, Wang Q, Zhou ZJ, Qiu Y, Luo their old ways is the Citizens’ capacity to era. R,et al. The Epidemic of 2019-novel-coronavi-

21 COVID-19 NIGERIA

rus (2019-nCov) Pneumonia and Insights for ment officials.” https://qz.com/africa/1208275/ Retrieved from https://dailytimes.ng/brain- Emerging Infectious Diseases in the Future.Mi- nigerian-lawmakers-to-limit-foreign-medical- drain-migration-of-nigerian-doctors-abroad- crobes Infect. 2020; 22(2):80-85. doi:10.1016/j. trips-for-government-officials/. Accessed June worrisome-cmd/. Accessed June 8, 2020. micinf.2020.02.002. 8, 2020. 36. Enabulele, Osahon. 2017. “Curbing the Mas- 13. Nairametrics. COVID-19: President imposes 24. CNN. Africa’s Leaders forced to confront health- sive Brain drain in the Nigerian Health Sector: Lockdown on Lagos, Ogun, FCT. Retrieved care systems they neglected for years. Retrieved Restructuring as the Solution.’’ Presented at the from https://nairametrics.com/2020/03/31/cov- from https://edition.cnn.com/2020/04/10/afri- opening ceremony of the 2017 Annual General id-19-president-imposes-lockdown-on-lagos- ca/african-leaders-healthcare-coronavirus-intl/ Meeting (AGM) and Scientific Conference of ogun-fct/. Accessed June 8, 2020. index.html. Accessed June14, 2020. the Association of Resident Doctors, Univer- 14. MEDECINS SANS FRONTIERES. Cov- 25. IMTJ. Africa Spends $1billion a year on out- sity of Ilorin Teaching Hospital (UITH). Ilorin, id-19 pandemic brings new challenges to well- bound Medical Tourism. Retrieved from https:// Kwara State, Nigeria. developed healthcare systems. Retrieved from www.imtj.com/news/africa-spends-1-billion- 37. Africa’s health tourism Presidents [Travel]. Re- https://www.msf.org/new-approach-public- year-outbound-medical-tourism/. Accessed trieved from https://youtu.be/dj7HHttmsYQ. health-big-change-needed-fight-covid-19. Ac- June 14, 2020. Accessed June14, 2020. cessed on June 8, 2020. 26. World Health Organization. 2011. “Health 38. THISDAY NEWS. Ehanire: Nigeria Loses 15. OXFAM. Half A Billion People Could Be systems. The Abuja Declaration: Ten Years on.” Over $1bn Annually to Medical Tourism. Re- Pushed Into Poverty By Covid-19. Retrieved Retrieved from https://www.who.int/healthsys- trieved from https://www.thisdaylive.com/ from https://www.oxfamamerica.org/press/ tems/publications/abuja_declaration/en/. Ac- index.php/2018/05/20/ehanire-nigeria-loses- over-1bn-annually-to-medical-tourism/. Ac- half-billion-people-could-be-pushed-poverty- cessed June 8, 2020. cessed June 8, 2020. covid-19/. Accessed June 07, 2020. 27. Sambo LG, Kirigia JM, Orem JN. Health fi- 39. BBC News. 2016. “Nigeria’s Buhari ‘broke 16. United Nations. Coronavirus. A new normal: nancing in the African Region: 2000-2009 promise to end medical tourism.”Retrieved from UN lays out road map to lift economies and save data analysis. Int Arch Med. 2013;6:10. https://www.bbc.com/news/business-36468154. jobs after Covid-19. Retrieved from https://www. doi:10.1188/1755-7682-6-10. Accessed June 8, 2020. un.org/africarenewal/news/coronavirus/new- 28. Worldometer. Africa Population. Retrieved from 40. BBC NEWS. Coronavirus: Are African coun- normal-un-lays-out-roadmap-lift-economies- https://www.worldometers.info/world-popula- tries struggling to increase testing? Retrieved and-save-jobs-after-covid-19. Accessed June 7, tion/africa-population/. Accessed June 14, 2020. from https://www.bbc.com/news/world-afri- 2020. 29. Francis SC, Roger IG, Jack W, Mary W, Eric ca-52478344. Accessed June 8, 2020. 17. Scientific American. The Special Challenge of PG. 2010. “Developing Health Workforce Ca- 41. Reliefweb. Nigeria. Expanding COVID-19 tests Fighting COVID-19 in Africa. Retrieved from pacity in Africa.” Science, 330(6009): 1324- in Africa’s most populous nation. Retrieved from https://blogs.scientificamerican.com/observa- 1325. doi: 10.1126/science.1199930. https://reliefweb.int/report/nigeria/expanding- tions/the-special-challenge-of-fighting-covid- 30. World Health Organization. Global Spending covid-19-tests-africa-s-most-populous-nation. 19-in-africa/. Accessed June 7, 2020. on Health: A World in Transition. Retrieved Accessed June 8, 2020. 18. KUJENGA AMANI. Covid-19 Responses from https://www.who.int/health_financing/ 42. MEDICALNEWSTODAY. Coronavirus: 81% in Africa: Implications for Peace, Security, and documents/health-expenditure-report-2019. of cases are ‘mild,’ study says. Retrieved from Public Health. Retrieved from https://kujenga- pdf?ua=1. Accessed on June 8, 2020. https://www.medicalnewstoday.com/articles/ amani.ssrc.org/2020/04/30/covid-19-respons- 31. BROOKINGS Closing Africa’s health financ- coronavirus-81-of-cases-are-mild-study-says. es-in-africa-implications-for-peace-securi- ing gap. Retrieved from https://www.brook- Accessed June 8, 2020. ty-and-public-health/. Accessed June 7, 2020. ings.edu/blog/future-development/2019/03/01/ 43. World Health Organization. Constitution. Re- 19. World Health Organization. Medical Tourism. closing-africas-health-financing-gap/. Accessed trieved from https://www.who.int/about/who- Retrieved from https://www.who.int/global_ June 14, 2020. we-are/constitution. Accessed June14, 2020. health_histories/seminars/kelley_presentation_ 32. World Health Organization. Public Financ- 44. United Nations. Universal Declaration of Hu- medical_tourism.pdf. Accessed June 7, 2020. ing for Health in Africa: From Abuja to the man Rights. Retrieved from https://www. 20. Centers for Disease Control and Prevention. SDGs.Retrieved from https://apps.who.int/iris/ un.org/en/universal-declaration-human-rights/. Medical Tourism: Getting Medical Care in An- bitstream/handle/10665/249527/WHO-HIS- Accessed June14, 2020. other Country. Retrieved from https://wwwnc. HGF-Tech.Report-16.2-eng.pdf;jsessionid=E6 cdc.gov/travel/page/medical-tourism. Accessed AFF68F738AF596C39B84AD875A94A9?seq Dr. Osahon Enabulele, June 7, 2020. uence=1. Accessed on June 8, 2020. President, Commonwealth 21. Enabulele, Osahon. 2017. “Medical Tourism: 33. Enabulele, Osahon. 2015. “The Nigerian Health Medical Association. The implications for an unhealthy economy.” Sector: Burning issues and the way forward.” Chair, Socio-Medical Affairs Committee, Presented at the opening ceremony of the 2017 Presented at the 2015 Annual General Meeting World Medical Association. Annual General Meeting (AGM) of Delta and Scientific Conference of Edo State branch State branch of Nigerian Medical Association of Nigerian Medical Association. Irrua, Edo Past President, Nigerian Medical (NMA). Abraka, Delta State, Nigeria. State, Nigeria. Association (2012-2014). 22. Hanefeld J, Lunt N, Smith R, Horsfall D. Why 34. Enabulele, Osahon. 2018. “Healthcare delivery Coordinator, Coalition of African National do medical tourists travel to where they do? the in Nigeria”. Presented at the opening ceremony Medical Associations (CANMA). role of networks in determining medical travel. of the 2018 Week & Symposium of Health Chief Consultant Family Physician, Soc Sci Med 2015;124:356–63.doi:10.1016/j. Writers Association of Nigeria (HEWAN), La- socscimed.2014.05.016. gos, Lagos State, Nigeria. University of Benin Teaching Hospital. 23. Quartz Africa. 2018. “Nigeria’s lawmakers 35. Dailytimes. 2019. “Brain drain: Migration of want to limit medical trips abroad for govern- Nigerian doctors abroad worrisome-CMD.” E-mail: [email protected]

22 MYANMAR COVID-19

downs of buildings and streets with con- COVID-19: Junior Doctors Response firmed cases, “Stay at Home” programs, de facto curfews, and mandatory quaran- in Myanmar tines for travellers [5]. The need for the most accurate, latest information on self- demic. There was a significant reduction protection is critical. The junior doctors in surgical activity – elective operating and took part in mask campaign, hand washing some outpatients were cancelled. Given campaign, and strict stay at home & social the discrepancy in the workload between distancing. specialties and COVID 19 dedicated hospitals, the junior doctors across the spe- In this pandemic, millions of Myanmar cialties had re-organized as part of the people lack basic information about how to COVID-19 response. These doctors have keep themselves and their communities safe generic skills that can be used anywhere. and well. The misinformation and disinfor- They voluntarily took park in hospitals mation is overwhelming all over the coun- designed for treating COVID-19 cases try. People started panicking, calling health to help their colleagues in these hospi- care centres for more information. There are tals. As Myanmar is one of the developing many people who give advice, quoting from countries, there are shortages of personal books that don’t exist, deliberate wrong and protective equipment in hospitals and re- misleading translation of text and things that serving this equipment for doctors who are never evidence based and never tested. are involved in the direct care and treat- There were also a lot of rumours circulating, Osahon Enabulele ment of patients. A junior doctor across including through social media channels, the country has been fundraising for es- which spreads faster than the infection and The outbreak of COVID-19 started as a sential protective gears for their hospitals. or disease. Failing to address their informa- cluster of pneumonia in China, reported The well-wishers from Myanmar and those tion and communication needs will prevent in other Asian countries, Europe, Africa working overseas generously have donated the pandemic response from being as ef- and America. COVID-19 has devastated ventilators, monitors and personal protec- fective as we all need it to be. In efforts to the lives and livelihoods of communities tive equipment, foods directly to hospitals speed up the prevention, containment and globally as they grapple with such an un- in need and to the government [3, 4]. treatment of the COVID-19 disease, the precedented crisis [1]. The State Counsel- national COVID-19 call centre was estab- lor played a key and prominent role in the A thousands of brave junior doctors who lished by MOHS with the help from com- government’s response, heading two newly are working in established committees, using social media, private sectors and hosting televised virtual meetings en- have signed up as gaging with health care workers, officials, volunteers doctors volunteers, and union representatives [2]. for MMA and MMA also communicates and cooper- other local health ates with the Government Response Plan services to keep all for reacting to the epidemic of COVID. safe from the vi- A significant contribution comes from ju- rus. National and nior doctors who have made an immense regional govern- amount of voluntary commitment stepping ments have rolled into new roles to support their colleagues in out increasingly a range of positions in this time of uncer- stringent social tainties. distancing measures to mitigate It is clear that many junior doctors in the pandemic’s Myanmar are working frontline across the spread, including government hospitals fighting the pan- localized lock-

23 COVID-19 MYANMAR

munications operators. Junior doctors from depending on the requirement and avail- covid-19-national-volunteer-steering-unit [Ac- cessed 11 Jul. 2020]. MMA voluntarily joined their hands to the able services for the whole period of 21 7. Global New Light Of Myanmar. (2020). COV- staff from the Medical Research Depart- days. They will also have to live at specific ID-19 Call Centre opens daily. [online] Available ment to provide free of charge live consulta- places for the 7-day recreation [10]. Ju- at: https://www.globalnewlightofmyanmar.com/ tion for information about disease preven- nior doctors from MMA provide training covid-19-call-centre-opens-daily/[Accessed 11 tion and how to access medical treatment to course to these volunteers, which includes Jul. 2020]. 8. Lynn, K.Y. 2020. Fever clinics: the first line of an estimated 60 million mobile subscribers the topics of public communications, defence against COVID-19. Frontier Myanmar. in Myanmar [6, 7]. counselling, taking care of vulnerable pop- https://frontiermyanmar.net/en/fever-clinics- ulation, practical use of PPE, safe disposal the-first-line-of-defence-against-covid-19 The fever clinic in Myanmar serves a front- of hazardous material and environmental 12 July 2020. line role to test patients for COVID-19 cleaning all over the country. In addition, 9. www.who.int. (n.d.). Accelerating a safe and ef- and, if necessary, to send them to the near- junior doctors working in private sector fective COVID-19 vaccine. [online] Available at: https://www.who.int/emergencies/diseases/ est public hospital for further tests. The fe- stepping forward as quarantine site doc- novel-coronavirus-2019/global-research-on- ver clinics are run by collaborative effort of tors to early detection, and prompt man- novel-coronavirus-2019-ncov/accelerating-a- junior doctors and MMA to relieve pressure agement of the patients [11]. safe-and-effective-covid-19-vaccine. on the under-staffed and under-resourced 10. Khin, A. (n.d.). Volunteer Invitation to COVID-19 hospitals and health care system, to reduce To conclude, having such enthusiastic and National Volunteer Steering Unit. [online] Minis- try Of Information. Available at: https://www. infection in primary care doctors and re- selfless junior doctors from public and pri- moi.gov.mm/moi:eng/?q=news/13/05/2020/id- duce nosocomial infection transmission of vate sector in Myanmar has further boosted 21645 [Accessed 12 Jul. 2020]. patients in hospitals. With the help of well- for other junior doctors participation and 11. Thit, M. (2020).ToT course conducted for wishers, doctors in fever clinics are well help the country to flatten the curve at this COVID-19 volunteers - Global New Light Of My- equipped with level 2 PPE for screening of time of greatest need. anmar. [online] www.globalnewlightofmyanmar. com. Available at: https://www.globalnewlightof- COVID-19 and diagnosis and treatment of myanmar.com/tot-course-conducted-for-covid- other aetiology and proper referral to hospi- 19-volunteers/ [Accessed 11 Jul. 2020]. tals throughout the country [8]. References 1. www.mohs.gov.mm. (n.d.). Coronavirus Disease Currently, there are no effective medicines 2019 (COVID-19) Situation Reports (Myanmar). Wunna Tun, [online] Available at: https://mohs.gov.mm/ or vaccines available to treat or prevent page/9575 [Accessed 11 Jul. 2020a]. MBBS, MD, COVID-19. (9) Early implementation of 2. Kyaw, W. (2020). Myanmar and COVID-19. Fellow in Medical Education quarantine and its combination with other [online] thediplomat.com. Available at: https:// Founder, Myanmar Medical public health measures may reduce spread thediplomat.com/2020/05/myanmar-and-cov- Associaton, Young Doctor Society of the disease. For this reason, restrictive id-19/. Past Communication Director, JDN, WMA public health measures such as social dis- 3. YPO. (2020). Responding to COVID-19 in Conflict-Ridden Myanmar. [online] Available tancing, and quarantine have been used to at: https://www.ypo.org/2020/06/responding- reduce transmission of the virus. The Com- to-covid-19-in-conflict-ridden-myanmar/ [Ac- munity Based Facility Quarantine play cessed 11 Jul. 2020]. major role for containment of COVID-19 4. www.mohs.gov.mm. (n.d.). COVID-19 (Coro- spread. Those who had close contacts with navirus Disease 2019) Acute Respiratory Disease. the COVID-19 positive patients and the [online] Available at: https://www.mohs.gov. mm/Main/content/publication/2019-ncov [Ac- peopled travelling from foreign countries cessed 11 Jul. 2020b]. need to take part in this program. Despite 5. Nan, L. (2020). Timeline: Myanmar’s Govern- no symptoms, they need to stay under sur- ment Responses to the COVID-19 Pandemic. [on- veillance for a total of 28 days during incu- line] The Irrawaddy. Available at: https://www. bation period – 21 days facility quarantine irrawaddy.com/specials/myanmar-covid-19/ and the 7- day home quarantine. Those in timeline-myanmars-government-responses-to- the-covid-19-pandemic.html [Accessed 11 Jul. community based facility quarantine will 2020]. require assistance of well-trained volun- 6. MDN - Myanmar DigitalNews. (n.d.). Invita- teers. For the specific process and period, tion for Volunteer COVID-19 National Volunteer the volunteers will have to perform their Steering Unit. [online] Available at: https:// daily duties in inner circle or outer circle www.mdn.gov.mm/en/invitation-volunteer-

24 BRAZIL Emergency Health

A systematic approach to emergency care – Emergency Care for Health Unit System centred on acuity-based triage, early recognition and resuscitation, and simple initial Patients in Brazil management and referral – has been shown to decrease the mortality associated with a range of medical and surgical conditions. Despite the substantial positive impact emergency care can have, however, many low- and middle-income countries (LMICs) lack the fundamentals of organized emergency care: basic pre-hospital care and transport, a dedicated area and standards for hospital-based emergency care, and a core of nonrotating providers trained in the care of emergencies and assigned to the emergency unit. These gaps are reflected in wide global discrepancies in outcomes across the range of emergency conditions [2].

Although severe global discrepancies exist in outcomes from emergency conditions, both these modelling estimates and direct Lincoln Ferreira Wanderley Bernardo evidence suggest that emergency care has the potential to narrow this gap dramatical- Introduction digestive tract, dizziness, fainting, acute ap- ly. Powerful examples of feasible life-saving pendicitis, acute pancreatitis, drug and food emergency care interventions in LMICs In Brazil, one of the health care priorities poisoning, urination disorders and deliv- may include: organizing low-cost pre-hos- is emergency care. As everywhere, there are ery/parturition [1]. pital systems with a dramatic decrease in challenges related to the models of care that all-condition or in road-traffic mortality; accompany population growth, increase in Emergency care has been defined by vari- designating an area for emergency care of health problems and aging. The spectrum ous attributes, such as time-to-care provi- all critical patients at a third-level hospital of patients seen in emergency medical situ- sion and acuity of the condition addressed. transformed care and halved mortality; re- ations is generally associated with increased Common definitions include care delivered structuring a hospital intake area to create risks of undesirable outcomes, and obvi- within minutes or hours and care for con- a dedicated emergency care area and initi- ously greater than in chronic or subacute ditions that require rapid intervention to ating formal triage associated with halved conditions. And despite the population avoid death or disability or for which delays inpatient mortality and a reduction in the differences between the different parts of of hours can worsen prognosis or render care proportion of deaths occurring within the world, this is very common among all less effective. People in need of care may ac- 24 hours; timely simple interventions (flu- and thus the frequency of the character- cess the system at many points, including by ids, antibiotics, and clinical monitoring) istics of these patients: upper respiratory activating the pre-hospital system, by visit- within the first six hours of hospitalization tract infection, cough, pharyngitis, tonsil- ing a primary health centre, or by presenting in adults with serious infection reduced litis, myocardial infarction, angina pecto- directly to a hospital-based emergency unit; mortality; in rural area improved access to ris, coronary heart disease, lower respira- providers at every level of the health system emergency obstetric care halved the risk tory tract infection, bronchitis, pneumonia, deliver emergency care, whether or not they of maternal mortality and reduced the risk acute hyperthermia, acute abdominal pain, have the dedicated training and resources to among women with hemorrhage; the intro- stroke, cerebral hemorrhage, cerebral apo- do so effectively. Frontline emergency care duction of standardized resuscitation pro- plexy, fracture and contusion, stomachache may involve early recognition and initial tocols reduced hospital length of stay and and gastroenteritis, vomiting, diarrhea, he- resuscitation for dangerous conditions fol- all-cause mortality among injured patients; matochezia, bloody stool, urinary calculi, lowed by transfer for definitive care or may short course trainings in trauma manage- renal colic, hypertension, hemorrhage of encompass definitive therapy [2]. ment associated with reduced mortality in

25 Emergency Health BRAZIL

injured patient with no significant increase whether public or private, and which pre- Urgency and Emergency in resource usage; the use of pulse oximetry, scribes to every citizen the following rights: Care Network (RUE) [4, 5] combined with current guidelines for recog- orderly access to organized health systems; nition of severe illness, has the potential to adequate and effective treatment for their The organization of the RUE has the pur- avert deaths per year [2]. problem; humane, welcoming and free from pose of articulating and integrating all any discrimination treatment; care that re- health equipment aiming to expand and Evidence from around the world shows spects their person, their values and their qualify humanized and integral access to that emergency care is an effective means rights; treatment conducted in an appro- users in urgent/emergency situations in of saving lives, and evidence from LMICs priate manner; the commitment of health health services in an agile and timely man- suggests that feasible and simple steps to managers so that the above principles are ner. Its components and interfaces are the improve emergency care could rapidly im- adhered to. following: the basic health units (patients prove outcomes and reduce global dispari- in need of observation in urgent/emergen- ties in outcomes [2]. cy cases in the period of operation of the The Brazilian Urgency and unit, articulated and connected to the other It is then possible to reflect on relevant Emergency Program [4, 5] services of the emergency care network for Brazilian and global aspects in medical later transport and referral); the Emergency emergency to assist decision making by the The analysis of the rules that regulate the Care Units (UPAs) and other services open leaders regarding priority actions to reduce National Emergency Care Policy shows 24 hours a day; the Emergency Medical the risk of these patients who face acute that – in a context of increased demand, Service (SAMU/192); hospital doors for and potentially serious situations. The chal- overload of care at hospital doors as a result emergency care; rear wards and intensive lenges are enormous, but they have many of the increase in accidents, violence and care units; and home care. experiences that point in an apolitical and chronic diseases and insufficiency of the -ba technical-scientific direction. sic network – attention to emergency care in The principles of this network are guided by Brazil was centred on hospital care, on the expanding access, with acceptance, to acute implementation of the Centres for Medical cases and in all points of care; articulation The Unified Health System Regulation of Urgencies and the Mobile and integration between points of care, with in Brazil (SUS) [3] Emergency Care Service (SAMU) in large primary care as the centre of communica- capitals as an auxiliary line to the hospital tion; risk rating; regionalization of health The Brazilian Unified Health System door. However, the recent implementation and territorial action; institutionalization (Sistema Único de Saúde, known by the ac- of Emergency Care Units (UPAs 24hs) in- of the practice of monitoring and evalu- ronym SUS) is one of the largest and most duces even more the urgencies inserted in a ation through process, performance and complex public health systems in the world care network, tuned in the national policy of result indicators; promotion, coordination and includes primary, medium and high forming regional networks. and execution of strategic projects to meet complexities, urgency and emergency ser- collective health needs of an urgent and vices, hospital care, epidemiological surveil- However, among the various barriers to transitory nature, resulting from situations lance actions and services, sanitary and en- the implementation of this policy are: the of imminent danger, public calamities and vironmental and pharmaceutical assistance. fragmented nature of assistance with the accidents with multiple victims; qualifi- The conceptual principles of SUS are Uni- logic of the market; the insufficient supply cation of urgent and emergency hospital versalization, Equity and Integrality. The of beds; the public financing; the relation- doors and of care for critically ill patients organizational principles are Regionaliza- ship and inequality between private opera- through qualification of intensive care units; tion and Hierarchization, Decentralization tors and the philanthropic network due to organization and expansion of clinical rear and Single Command, and Popular Par- technological requirements and the con- beds; creation of inpatient long-term care ticipation. These responsibilities are shared centration of this market in the richest and units (UCP) and specialized long-term between the Union (Ministry of Health of most developed regional headquarters. In care hospitals (HCP); qualification of care Brazil), States (State Health Departments) addition, the number of doctors in Brazil is through the organization of cardiovascular, and Municipalities (Municipal Health permeated by profound inequalities, related cerebrovascular and traumatological care Departments). The Charter of Rights of to geographical distribution, unbalance be- lines; definition of home care organized Health Users contains the six basic prin- tween the public and private health sectors, through multidisciplinary home care teams ciples of citizenship that ensure the Bra- and the lack of professional specialization, (EMAD) and multidisciplinary support zilian dignified entry into health systems, including the emergency specialty. teams (EMAP).

26 BRAZIL Emergency Health

Mobile Emergency which must operate 24 hours a day, every the service to spontaneous and/ or refer- Service (SAMU) [4, 5] day of the week, and compose an organized enced demand from other points of care of network of attention to urgencies and emer- less complexity in the care of patients in ur- It is the component of the urgency and gencies, with pacts and flows previously de- gent or emergency situations; ensuring sup- emergency care network that aims to order fined, with the objective of guaranteeing the port for medium to high complexity care, the flow of assistance and provide early care reception of patients, intervening in their offering diagnostic procedures, clinical rear and adequate, fast and resolving transport clinical condition and against referring beds, Extended Care beds and ICU beds; to victims affected by health problems of a them to other points of care, to primary or reinforcing the guarantee of hospital care in clinical, surgical, gynecological-obstetric, specialized care services or to hospitaliza- the priority lines: traumatology, cardiovas- traumatic and psychiatric nature through tion, providing continuity of treatment with cular and cerebrovascular. the sending of manned vehicles by a trained positive impact on the population’s individ- team, accessed by the number 192 and acti- ual and collective health. vated by an Emergency Regulation Centre, Pre-hospital Emergency reducing morbidity and mortality. SAMU However, there are some limitations in its Medicine is fundamental in the rapid assistance and implementation, such as: the fragmenta- transportation of victims of exogenous in- tion between the sectors involved, due to Pre-hospital care is emergency medical care toxication, serious burns, mistreatment, the presence of several instances of coor- given to patients before arrival in hospital suicide attempts, accidents/traumas, cases dination, without articulation with each after activation of emergency medical ser- of drowning, electric shock, accidents with other; little interference in the formulation vices. It traditionally incorporated a breadth dangerous products and in cases of hyper- of municipal networks and, therefore, in of care from bystander resuscitation to tensive crises, cardiorespiratory problems, the choice of the location and size of the statutory emergency medical services treat- labour in which there is a risk of death for UPAs; the municipalities stop allocating ment and transfer. New concepts of care the mother and/or the fetus, as well as in the the resources that are needed by the UPAs including community paramedicine, novel inter-hospital transfer of patients at risk of to philanthropic hospitals; the activation of roles such as emergency care practitioners, death. The mobile units for emergency care emergency units without the proper hospi- and physician delivered pre-hospital emer- can be basic terrestrial life support (USB), tal backup; and the impossibility of regu- gency medicine are re-defining the scope of advanced terrestrial life support (USA), lating the totality of beds in regional and pre-hospital care. For severely ill or injured aeromedical and rapid intervention vehicle teaching hospitals. patients, acting quickly in the pre-hospital (VIR), varying the composition of the teams period is crucial with decisions and inter- in each unit. The emergency medical regula- ventions greatly affecting outcomes. Pre- tion centre is an integral part of SAMU 192, Hospital Component of the hospital clinicians should be generalists defined as a physical structure with the per- Emergency Care Network [7] with a broad understanding of medical, formance of medical professionals, auxiliary surgical, and trauma pathologies, who will telephone operators for medical regulation It is the qualified service of the Emergency often work from locally developed standard and radio operators trained in the regula- Hospital Entrance Doors, the rear clini- operating procedures, but who are able to tion of telephone calls that require guidance cal wards, the long-term care beds and the revert to core principles. Pre-hospital emer- and/ or emergency care through a classifica- Intensive Care Unit Beds belonging to the gency medicine consists of not only clinical tion and prioritization of urgent care needs, Emergency Care Network. The Hospital care, but also logistics, rescue competencies, in addition to ordering the effective flow Component is part of the Emergency Care and scene management skills (especially of referrals and against referrals within the Network. The Hospital Component must in major incidents, which have their own Health Care Network. be integrated and articulated with the oth- set of management principles). Tradition- er components belonging to the Urgency ally, research into the hyper-acute phase and Emergency Network: Health Promo- (the first hour) of disease has been difficult, The Emergency Care tion, Prevention and Surveillance; Primary largely because physicians are rarely pres- Units (UPAs 24h) [4–6] Health Care; SAMU 192; Stabilization ent and issues of consent, transport expedi- Room; SUS National Health Force; UPA ency, and resourcing of research. However, The 24-hour emergency care units are struc- 24h and the set of 24h emergency services the pre-hospital phase is acknowledged as a tures of intermediate complexity between and Home Care. The organization of the crucial period, when irreversible pathology the basic health units (UBS), family health Hospital Component of the Urgency and and secondary injury to neuronal and car- units (USF) and the hospital network, Emergency Care Network aims to qualify diac tissue can be prevented [8].

27 Emergency Health BRAZIL

When pre-hospital emergency personnel parison is hampered by differences in case viders. Pre-hospital care is very minimal, and reach an injured person, two types of strategic mix and the organization of emergency med- the EMS system is still a new concept. In an evaluations are performed to determine the ical services. Future research should strive to emergency room of a hospital only 9.9% pa- patient’s needs: a diagnostic analytical deci- design studies that enable appropriate control tients arrived in ambulance, whereas 53.6% sion-making process and an interpretation of baseline confounding and obtain follow- came in a taxi, 11.4% came by private vehicle, of the patient’s needs based on their health up data for the proportion of patients who die 13.5% came by bus, 5.4% came by bike, and status. Depending on severity, the transfer in the pre-hospital setting [10]. the rest 6.2% came by other modes of trans- time to a care facility differs; however, al- portation. Police are always the first person most all emergency patients are transferred Pre-hospital care has evolved dramatically to be asked for help in case of road traffic -ac to an appropriate care hospital regardless of during the past decades from being a basic cidents. Ambulance services are operated by condition severity. In general, the three tasks transport facility into offering advanced pa- not just government but multiple trusts, non- of emergency teams involve arriving at the tient care on scene and during transportation. profitable organizations, and also almost all scene, providing fast and effective treatment, In recent years, much focus has been placed private hospitals. Most of the ambulances and transferring the patient to the hospital. on the utilization and effect of pre-hospital have no formal paramedics and are not able Generally, pre-hospital emergencies are char- resources underlining the need for research to accommodate any medical equipment. acterized by judgment and decision making and system performance evaluations. The These ambulances carry pediatric and adult in uncertain situations. Physicians and pre- pre-hospital organizations are responsible patients, and even those who require a ven- hospital specialists must make advanced de- for the care and treatment on scene and dur- tilator. The general population lacks proper cisions and evaluate and treat patients with ing transportation until the patient reaches knowledge and information about hospitals various symptoms. Clinical decision support the hospital. Helicopter Emergency Service and health care. Most of the time patients systems help users make decisions by using (HEMS) acts as a supplement to ground land up in the wrong hospital where the available resources, thus promoting effective EMS (ambulances and nurse- or physician- service for a particular disease or condition decision-making and optimal medical emer- staffed rapid response vehicles). The HEMS is not available. They are further referred to gency care. Clinical decision support systems is organized and staffed by a consultant- another hospital causing loss of critical time in pre-hospital emergency care result in bet- level anaesthesiologist, a pilot and a specially period increasing morbidity and mortality ter triage of patients, reduced pre-hospital trained paramedic and operating 24 h/day, 7 of the patient. Most of the private hospitals time, facilitate mass gathering management, days a week. Most parts of the country can have their own ambulance and are also re- optimize resources, increase diagnostic accu- be reached within 30 min. The decision to sponsible for their function and maintenance. racy, improve patient outcomes, and enhance dispatch a helicopter is taken by the medi- The patient is charged by these hospitals for the quality of pre-hospital care [9]. cal dispatchers who are healthcare profes- their use of services. Charge usually depends sionals (specially trained nurses, ambulance on the amount of distance covered which Physician treatment was associated with in- technicians and paramedics) handling medi- is similar or more than the cab service. A creased survival in patients with out-of-hos- cal emergency calls from the public dialling non-profitable private organized ambulance pital cardiac arrest and patients with severe the emergency phone number 112. Technical service system (NAS) was established and trauma; in the latter group, the result was dispatchers trained in logistics undertake the began its service of pre-hospital emergency based on more limited evidence. The success actual dispatch. The HEMS undertakes both care. It provides pre-hospital medical care by rate of pre-hospital endotracheal intubation primary critical care missions (request from emergency medical technicians (EMTs) who (ETI) has improved over the years, but ETI citizens through emergency calls and crew undergo 3 months training. These EMTs by physicians is still associated with higher request from ambulances and rapid response provide variety of medical interventions in- success rates than intubation by paramedics. vehicles on scene) and time critical second- cluding BLS, ALS, splinting fractures, brac- In patients with severe traumatic brain injury, ary missions (inter-facility transfers). Fur- ing spinal cord injuries bleeding control, air- intubation by paramedics who were not well thermore, the HEMS also provides pre-hos- way management, and starting IV fluids for skilled to do so markedly increased mortal- pital care and transport for less ill or injured patients in shock. It also has helicopter-based ity. Current evidence is hinting at a benefit of patients located on islands not connected by emergency services (HEMS). Lack of medi- physicians in selected aspects of pre-hospital road to the mainland [11]. cal personnel and equipment has reduced its emergency services, including treatment of efficiency below its potency. The fragmented patients with out-of-hospital cardiac arrest Developing integrated emergency medi- system, high demand–low supply, inequity and critically ill or injured patients in need of cal services in a low-income country can be with the service, and low quality of the repre-hospital intubation. Evidence is, however, referred to as “the neglect model” where no sponders are major problems associated with limited by confounding and bias, and com- rules and regulations exist about service pro- the EMS. Although the HEMS rescue has

28 BRAZIL Emergency Health

boosted the system, it still does not have its standing EDs, however, face their fair share satellite FrEDs had significantly higher own proper air ambulance which is more of criticism. Many individuals worry that visit volume in general but did not experi- spacious than a helicopter and can accom- patients are mistaking freestanding EDs for ence shorter wait times or length of visit if modate more people required for rescue. The cheaper urgent care centres, that freestand- located in large metropolitan areas. The en- HEMS often resulted in over triage leading ing EDs may be misleading patients about try of FrEDs did not help relieve congestion to higher financial burden and workload at their insurance network status, and that in nearby hospitals in major metropolitan trauma centres. Patients with minor injuries these facilities may be exacerbating increas- areas. By offering more treatment options make the majority of transport accounting ing medical costs. to patients, FrEDs are associated with infor unnecessary larger funding requirements. creased usage of emergency services [14]. The HEMS are expensive and its misuse can According to American College of Emer- have a great deal of financial burden to a poor gency Physicians (ACEP), facilities should be country [22]. available to the public 24 hours a day, 7 days Patient-centred Access a week, 365 days per year; be staffed by quali- to Health Care fied emergency physicians; have adequate Quality of Emergency Care staffing by qualified medical and nursing per- Access is central to the performance of sonnel to meet the written emergency proce- health care systems around the world. There The organization of acute care can be im- dures and needs anticipated by the facility; al- are five dimensions of accessibility: 1) approved by strengthening the primary care ways be staffed by a registered nurse currently proachability; 2) acceptability; 3) availabil- and community systems by improving ac- certified in advanced cardiac life support and ity and accommodation; 4) affordability; cess closer to home, increasing the acces- pediatric advanced life support; have policies 5) appropriateness. And five corresponding sibility of General Practitioner (GP) and and procedures in place to transfer patients abilities of population interact with the di- optimizing the use of out of office hours in need of a higher level of care to appropri- mensions of accessibility to generate access: GP services. The system can improve ambu- ate facilities; and have the same standards the ability 1) to perceive; 2) to seek; 3) to latory care to reduce pressure on in-patient as hospital-based EDs for quality improve- reach; 4) to pay; and 5) to engage [15]. beds and improve patient experience, rather ment, medical leadership, medical directors, than the more traditional models of out-pa- credentials, and referral policies. In most Emergency Department (ED) crowding has tient care. Ambulatory emergency care can metrics, freestanding EDs perform as well as been identified as a major issue in health provide an appropriate support to primary if not better than hospital based EDs, with services research. Access block, leading to care when escalation is needed, and reduce some significant exceptions. Freestanding prolonged ED length of stay (EDLoS) for the use of the inpatient bed base, thereby EDs tended to have higher patient satisfac- admitted patients has been associated with facilitating more treatment of acute illnesses tion rates compared with hospital based EDs. ED overcrowding. Adverse effects associated from a community setting [12]. The wait times, treatment times, and time to with delays in ED have included: increased pain medication administration for long bone mortality and morbidity, delayed pain relief, fractures were similar between freestanding longer hospital stays, increased aggression Freestanding Emergency EDs and hospital based EDs. Freestanding and delayed ambulance offloads with poorer Departments EDs had shorter lengths of stays, lower hos- response times. The National Emergency Ac- pital admission rates, and lower radiograph cess Target (NEAT) policy was implement- Freestanding emergency departments and ECG use. They found similar usage rates ed to increase ED flow. The policy stated that (EDs) are changing the landscape of emer- for ultrasonography, computed tomography, 90% of patients presenting to EDs were to gency care in the United States and are and laboratory testing compared with that be admitted, transferred or discharged within being considered around the world. These for hospital based EDs. Although this may 4 hours. After the NEAT introduction, ED facilities provide emergency care to patients indicate better care, it may also just reflect the length of stay ≤4 h increased and access while remaining physically distinct from a lower acuity level of patients presenting at block decreased. Short-stay admissions in- hospital, unlike a traditional hospital-based freestanding EDs [13]. creased. Unplanned ED re-attendances did ED. These facilities may help alleviate the not change significantly. ED presentations stress faced by the emergency care system Hospital ED visits, wait times, length of continued to increase over time in all juris- and may help address crowding at tradition- visit for discharged patients were not asso- dictions. There showed significant improve- al hospital based EDs and improve access to ciated with the number of competitor Free- ments in time-based measures. Significant care. They may be able to improve access to standing Emergency Departments (FrEDs) increases in short-stay admissions suggest care for trauma patients in rural areas. Free- in the local market. Hospitals that opened a strategic change in ED process associated

29 Emergency Health BRAZIL

with the NEAT implementation. Rates of of mobility. The availability (desired services urgent care for patients within the first hour unplanned ED re-attendances and those available) and accommodation (ability to after symptom onset can drastically decrease leaving at their own risk showed no evidence reach desired services) and affordability morbidity and mortality outcomes. Having for adverse effects from NEAT [16]. (ability to pay for the services) of emergency trained EMS providers interact with labour- transport depends on the physical and geo- ing women before they reach the healthcare graphic infrastructure of the environment facility, expedites the woman’s access to ob- Maternal Emergency Health (road conditions, traffic rules, season/weath- stetric care, and consequentially, improves er, etc.). It is during this second phase of the her (and the fetus’) chances of survival. The An access framework for integrating emer- delay model that EMS competes with taxis second approach to EC interventions in gency medicine with maternal health to re- and other commercial vehicles that are per- this phase should focus on in-hospital care, duce the burden of maternal mortality can ceived to be more expeditious and less costly. with the creation and training of Emergency be divided in three components or phases: Critics cite that even though ambulances are Medicine providers who are adept at prop- underutilized, levying a fee for ambulance erly triaging patients, and skilfully trained to Phase I: Seeking care-approachability and use will further delay care for the most vul- deliver appropriate life-saving interventions. acceptability within access, approachability nerable. Measureable outcomes for EC in- Deliveries necessitating analgesia, forceps (the ability to perceive that EC services are terventions in this phase should incorporate or vacuum extraction, and cesarean section required) and acceptability (the ability to seek ambulance response time (the time it takes should be triaged from lower-risk pregnan- EC services) are part of the care-seeking at- for ambulances to arrive on-scene), on-scene cies with less maternal and/or fetal distress. tributes of the first delay in maternal health time (time spent on scene, preparing the Emergency and labour wards should be well theory. The individual has to subjectively labouring woman for transport) and arrival equipped and appropriately staffed to deliver decide that they require emergency care and time (duration of time spent transporting the care needed in various emergency situa- treatment based on a set of personal health the woman to the healthcare facility). Other tions, so challenging obstetric cases are dealt beliefs, their health literacy, trust, and expec- outcomes could include number of ambu- with appropriately. Subpar outcomes in the tations of the healthcare system. However, lance dispatches and dispatch types. third delay heavily influence the cyclical na- their ability to seek the desired services de- ture of the entire Three Delays model. Thus, pends on if they have the personal autonomy Phase III: Receiving care-appropriateness; measurable benchmarks in this phase of the to seek the care, they perceive they need. Au- appropriateness is subjective, and denotes framework should correlate EMS and EM tonomy is determined by a set of norms and the fit between services rendered, the pa- training programs with in-hospital interven- expectations that are attributed to individuals tient’s needs, and their expectations. Addi- tions and maternal mortality metrics to en- in a given society. The community should be tionally, appropriateness is highly dependent sure that there is a “fit” between the needs educated about EMS operations and the life- on outcome. In maternal health, survival of and expectations of the target population, sustaining benefits of using ambulance ser- both mother and fetus is perhaps the greatest and the services rendered by both pre- and vices over taxis and other traditional modes motivator for encouraging labouring moth- in-hospital providers [17]. of transport. Education curricula should ers to deliver in-hospital, where the staff is cover how ambulances are alerted (toll free expected to be trained to manage labour numbers), qualifications and training of EMS complications and other obstetric emergen- Pediatric Emergency Care providers, types of life sustaining care for ma- cies. Reducing the time to in-hospital in- ternal and other emergencies provided on terventions is crucial to patient survival, and Differences in emergency care for children ambulances versus commercial vehicles, etc. expeditious services rendered by skilled and exist between general and pediatric emergen- Barriers to approachability and acceptability well-equipped EC providers can drastically cy departments (EDs). Some pediatric qual- will be unique to each community, based on reduce in-hospital maternal mortality. EC ity measures are available but are not routine- their distinct social structures and cultural be- interventions in this phase of the integrated ly employed nationwide. We sought to create liefs. A community that perceives EMS to be model should take a two-pronged approach. a short list of applied measures that would approachable, acceptable and “normal” would The first approach should focus on bridg- provide a starting point for EDs to measure (increasingly) initiate EMS services. ing the care gap in the pre-hospital context. pediatric emergency care quality and to com- This would involve training EMS providers pare care between general and pediatric EDs Phase II: Reaching care-availability and ac- paramedics and Emergency Medical Tech- for these measures. Previously reported lists commodation, affordability once emergency nicians (EMTs) to cater to labouring moth- comprising 465 pediatric emergency care care is initiated, the ability to reach the de- ers in the field, before they get to hospital. quality measures were reconciled. Perfor- sired services is often determined by issues The “golden hour” shows that expediting mance was better in pediatric EDs for three

30 BRAZIL Emergency Health

of seven condition-specific measures, includ- tients were attended, averaging 5.3 per day, programs, care was provided exclusively ing antibiotics for viral infections, chest X- and 1289 (67.0%) patients were managed in by general practice physicians (GPs); sub- rays for asthma, and topical anesthesia for the community. The service was estimated sequently, care has been provided through wound closures. Performance was similar for to deliver a reduction of 868 inpatient bed mutually exclusive shifts allocated between four of seven condition-specific measures: days and generate a net economic benefit of GPs and EM trainees. Patients seeking computed tomography for head trauma, ste- £530 107. The PRU model provides com- Emergency Centre (EC) care during pre- roids for asthma, steroids for croup, and oral munity emergency medical care and early training and post-training were assessed. rehydration for dehydration. Compared with patient contact with a senior clinical de- Pre-training EC mortality was 6.3%, while pediatric EDs, general EDs discharged and cision-maker. It engages with community that of post-training – 1.2%. Pre-training transferred higher proportions of children, providers in order to manage 67.0% of pa- overall hospital mortality was 12.2% while had shorter lengths of stay, and sent patients tients in the community. The PRU offers an that of post-training – 8.2% [23]. home with fewer prescriptions. General effective model of community emergency EDs obtained fewer pain scores for injured medicine and helps to integrate local emer- Emergency Medicine is a relatively recent children. Pediatric EDs had a lower propor- gency and community providers [20]. medical specialty. Currently, Emergency tion of pediatric visits in which patients left Medicine is a primary medical specialty in against medical advice. General and pediat- Emergency care is under pressure, with de- nineteen member states of the European ric EDs had similar rates of mortality, left mand continuing to increase across the emer- Union (EU)/ European Economic Area without being seen, incomplete vital signs, gency care system. Significant staffing short- and a supra-specialty in two EU countries. labs in non-acute patients, and similar num- ages coupled with rising demand may have One of the main functions of the European bers of medications given per patient [18]. implications for the quality of care and safety Core Curriculum for Emergency Medicine of patients. One solution to this may be to is to define the specialty by spelling out the concentrate resources on fewer sites by clos- core concepts that underlie its distinctive- Emergency Physician-Based ing some of these EDs or suspending services ness and by listing the competences that Intensive Care Unit overnight. In recent years a small number of can be expected of specialists in Emer- EDs have been closed or downgraded to a gency Medicine. A shared understanding of To provide a prompt and optimal inten- less acute facility, reportedly due to reasons of what Emergency Medicine represents as a sive care to critically ill patients visiting our inadequate staffing and safety implications. specialty, common training goals, training emergency department (ED), a specific type For residents in the areas affected by closure, standards and exit examination are intend- of emergency intensive care unit (EICU) journey time to the nearest ED increased, but ed to promote the development of the spe- managed by emergency physician (EP) inno statistically reliable evidence of a change cialty throughout Europe and skills transfer tensivists was established. The ED-ICU in- in overall mortality following reorganiza- across national borders. The European So- terval for the EICU group was significantly tion of ED care was found. There was some ciety for Emergency Medicine (EUSEM) shorter than that for the other ICUs group. evidence to suggest that there was a small incorporates 30 European national societ- The ICU mortality and hospital mortality of increase in case fatality, an indicator of the ies of Emergency Medicine with more than the EICU group were not inferior to those ‘risk of death’, but this may have arisen due 14,000 medical members. The European of the other ICUs group. The EICU run by to changes in hospital admissions. We found Core Curriculum for Emergency Medicine EP intensivists reduced the time interval no evidence that reorganization of emer- lists the core competences in Emergency from ED arrival to ICU transfer without gency care was associated with a change in Medicine, namely: the ability to triage and altering hospital mortality [19]. population mortality in the five areas studied. resuscitate patients; the symptoms, signs Further research should establish the eco- and situations Emergency Physicians (EPs) nomic consequences and impact on patient should be able to address; the conditions Community Emergency experience and neighbouring hospitals [21]. EPs should be able to recognize and ini- Medicine tially manage; the procedures EPs should be able to carry out and investigations they Background and objectives. International Emergency Training and should be able to interpret; the ability to and national health policies advocate great- Physician Quality make judicious decisions regarding further er integration of emergency and community investigations and treatments; professional care. The Physician Response Unit (PRU) An Emergency Medicine post-gradu- competences EPs should master. Most sub- responds to 999 calls ‘taking the Emergency ate program was initiated, followed by a sections feature introductory paragraphs Department to the patient’, when 1924 pa- residency-training program. Prior to the that describe the inclusion criteria the lists

31 Emergency Health BRAZIL

are based on and the level of competence where appropriate; When prescribing an in- are able to deal with these problems, such as expected of Emergency Physicians [25]. tervention, make an effort to ensure that the internists and geriatricians, and generalists patient is capable of accomplishing what is with the ability to coordinate care for these Bringing value, balance and humanity to recommended; Tailor discharge instructions complex patients, such as Emergency Phy- the emergency department determine a list and follow-up recommendations to the in- sicians and acute physicians. A way to reach of quality physician attitudes: (1) ‘The quix- dividual patient; Be an advocate [26]. this broader expertise and treat patients in otic search for certainty’ describes the all too a holistic way, is assuring superspecialism common attempt by clinicians to find the Components of Emergency Medicine: we instead of subspecialism for at least inter- last few patients who may be in danger even always help the sick; work tirelessly with nists. Superspecialism requires persisting though an evaluation has shown that risk colleagues to provide universal high-quality interest in areas beyond the subspecialty is minimal. Along with this fear of missing care to those in need every second of every and willingness to practice medicine in a even a single patient with a serious problem, day; from a fractured ankle to a cardiac ar- patient-oriented way, in contrast to sub- most clinicians have been taught to believe rest, arterial lines to shoulder relocations specialism which focuses on a specific area (incorrectly) that ‘tests’ are more ‘objective’ and from sick children to the frail, comorbid of interest leading to treatment of a disease than clinical judgement and, thus, that do- elderly the breadth of our practice is stag- rather than treating a patient. Therefore, a ing more is ‘safer’ and more ‘evidence based’. gering; be and are ready to respond at a mo- proportion of all medical specialists should Even if there is some small benefit in find- ment’s notice to a new more pressing need change their attitude and adapt their training the few cases that would otherwise be or a change in circumstance; implement- ing and daily practice to superspecialism, missed after routine evaluation (in most cas- ing evidence-based medicine and shaping which will match the demand of the future es based on clinical gestalt alone), this fails future practice; moving into understanding case mix. To improve the organisation of to consider the diminishing returns that in- the theory of how we think and make deci- health care, we believe that doctors need to evitably occur as we endeavour to lower the sions, meta-cognition and clinical reasoning; be visible medical leaders and participate in miss rate from ‘too many’ to ‘a few’ to ‘rarely’ recognition of staff well-being and working the organisation of care. Doctors should use to ‘never’. More importantly, when further to improve our system of safety alert high- their experience and medical knowledge to testing is done in a population of patients lighting the need for staff to take adequate establish the best acute care working with who can be classified as minimal risk, based breaks; adoption of new technology; change patients and introduce changes in the or- on gestalt, this almost cannot fail to cause even further as new solutions, including ar- ganisation in concert with the managers. more harm than benefit – even if the tests tificial intelligence and immersive technolo- Medical leadership is considered to play an themselves are ‘non-invasive – because of gies, evolve from research environments; free important role in improving organizational the downstream consequences of false posi- open access medical education; democratiz- performance, including quality of care, pa- tives, ‘incidentalomas’ and overdiagnosis; (2) ing and spreading clinical knowledge [27]. tient safety and cost-efficient care [28]. Medical care is not the sole, or even the most important, determinant of health outcomes. The roles of emergency physicians and acute Social determinants – including, but not physicians should be clear and complement- Innovation limited to, food insecurity, homelessness and ing which may be reached by more uniform addiction – are profoundly important to the staffing. Given the increased complexity of Clinician-led design for optimizing flow for health of a great many patients; Avoid fur- care, experienced consultants need to be an Emergency Department: ther testing beyond history, physical exam, present at the ED, providing optimal care 1. Pivot nurse: Standard triage and regis- clinical gestalt and ECG in patients who are pathways, training junior doctors and im- tration is inefficient, delays care and is at minimal risk of an acute coronary syn- proving timely and right decision-making of low value to the patient. Alternative drome (ACS); Avoid further testing beyond and patient flow. It has been shown that systems such as a pivot or ‘quick-look’ history, physical exam and clinical gestalt in presence of consultants at the ED, beside nurse are validated and are now estab- patients who are at minimal risk of pulmo- Emergency Physicians, leads to a shorter lished; this nurse greets the patient and nary embolus (PE); Be judicious with the Length of Stay and higher patient satisfac- rapidly acquires limited critical infor- use of imaging, especially advanced imaging, tion. In both countries the ageing popula- mation including the chief complaint. in trauma patients; Avoid routine laboratory tion has led to a changing case mix at the Following triage category decision, the testing; Consider non-medical reasons for a ED with an increased amount of multimor- patient is escorted to one of several patient’s presentation to the ED; Tailor the bid patients with polypharmacy. As a result, ‘tracks’ in ED; intensity of care to the goals of the patient; ED presentations are becoming increas- 2. Advanced split-flow system: The track Employ shared decision-making (SDM) ingly complex. This requires specialists who system is designed to increase efficiency,

32 BRAZIL Emergency Health

reduce clinical risk, increase patient sat- larger diverse geographic area with greater terms have been used to describe efforts and isfaction and reduce those leaving ED possibilities for clinical investigation. Al- strategies to speed a change in evidence- prior to treatment or after treatment though infrastructure burdens for research based practice, such as: implementation sci- commences: Core Track; Mid Track; must still be shared between the centralized ence, knowledge translation, research trans- Fast and Super Track; Paediatric Track resources and the clinical sites, the support lation and others. In contrast to traditional (except children requiring resuscitation) of the broader SIREN network promises to clinical research, implementation science [29]. expand the field for future research studies. generally aims to understand and change In summary, through a strong collaborative health professional behaviour to promote Evolution of the Strategies to Innovate research network, SIREN offers the oppor- evidence uptake as opposed to attempt- Emergency Care Clinical Trials Network tunity to significantly enhance emergency ing to change patient behaviour. There are (SIREN) offers an efficient mechanism for care research, with the aim of improvement now theoretical frameworks and evolving conducting large trials in emergency care in patient outcomes [30]. evidence providing guidance how to change research. SIREN has successfully submit- clinician behaviour and, specifically, emerg- ted several grant applications for trials, and Large-scale quality and performance mea- ing evidence on how to achieve this in the several other trials are in various stages of surement across unaffiliated hospitals is an emergency setting [32]. development. All sponsored trials within important strategy to drive practice change. SIREN will significantly benefit from the The Michigan Emergency Department Today we have many kinds of possible ac- leadership of experienced researchers with Improvement Collaborative (MEDIC) is a tions in the field of emergency care, varying established track records of success and a unique physician-led partnership supported from education to structural, but all of them strong culture of cooperation within the by a major third-party payer. Member sites that produce proves of efficacy do not use network. Another major aim of SIREN will contribute electronic health record data and an adaptation process or an old structure be furthering innovation in trial design, fo- trained abstractors add supplementary data of care. Everybody that look to emergency cusing on adaptive trials and registry-based for eligible cases. Quality measures include like a individualized and specialized type of methods. Registry based studies would computed tomography (CT) appropriate- care, innovate and are based in a really ca- make use of relationships between the SI- ness for minor head injury, using the Cana- pacitation process of the emergency teams, REN Clinical Coordinating Centre with dian CT Head Rule for adults and Pediatric with evidence based protocols and with a other groups, such as the American College Emergency Care Applied Network rules for new flow and decentralized interconnected of Surgeons Committee on Trauma and children; chest radiograph use for children network that are capable to give an atten- the American Heart Association, for use with asthma, bronchiolitis, and croup; and tion adequate, ethical, equitable and effec- of larger nationwide databases for analysis. diagnostic yield of CTs for suspected pul- tive in the point of care. Another strength of SIREN – it has al- monary embolism. Baseline performance lowed access and feedback from the Data was established with statistical process con- and Clinical Coordinating Centres, and it trol charts. Overall baseline performance References is hoped that it will facilitate increased ap- included the following: 40.9% of adult pa- 1. Chen SX, Fan K, Leung LP. Epidemiological plications. SIREN is an ideal place where tients with minor head injury had appro- characteristics and disease spectrum of emergency investigators can seek input from both the priate CTs, 10.3% of pediatric minor head patients in two cities in China: Hong Kong and Shenzhen. World J Emerg Med. 2020; 11(1):48- Clinical and Data Coordinating Centres to injury cases exhibited CT overuse, 38.1% of 53. doi: 10.5847/wjem.j.1920-8642.2020.01.007. increase chances for successful funding of pediatric patients with a respiratory condi- PMID: 31893003. large grants that seek complex adaptive de- tion received a chest radiograph, and 8.7% 2. Reynolds TA, Sawe H, Rubiano AM, Shin SD, signs outside of the scope of most clinicians. of pulmonary embolism CT results were Wallis L, Mock CN. Strengthening Health Sys- SIREN offers a unique and exciting oppor- positive. Performance varied greatly, with tems to Provide Emergency Care. In: Jamison DT, Gelband H, Horton S, Jha P, Laxminarayan tunity to advance the clinical trial enterprise demonstrated opportunity for improve- R, Mock CN, Nugent R, editors. Disease Con- by creating a culture of studying clinical trial ment. MEDIC provides a robust platform trol Priorities: Improving Health and Reducing methodology and processes. These investi- for emergency physician engagement across Poverty. 3rd ed. Washington (DC): The Interna- gations may enhance the overall conduct of ED practice settings to improve care and is tional Bank for Reconstruction and Develop- clinical trials, thereby leading to important a model for other states [31]. ment/ The World Bank; 2017 Nov 27. Ch. 13. developments in emergency care research. PMID: 30212151. 3. Sistema Único de Saúde (SUS): estrutura, For individual research sites, engagement New research findings may not lead to princípios e como funciona. Available at: https:// with the SIREN network offers the po- change in practice, or a change at the front www.saude.gov.br/sistema-unico-de-saude. Ac- tential for expanding enrolment sites to a line may be delayed by years. A number of cessed on 22 February 2020.

33 Emergency Health BRAZIL

4. Os hospitais e a Rede de Atenção às Urgências e 6. doi: 10.1016/j.ajem.2019.05.020. PMID: pdf/European_Core_Curriculum_for_EM_ Emergências: desafios. Available at: http://www. 31126669. Version_1.2_April_2017_final_version.pdf. Ac- conass.org.br/consensus/os-hospitais-e-rede- 15. Levesque JF, Harris MF, Russell G. Patient-cen- cessed on 23 February 2020. de-atencao-urgencias-e-emergencias desafios/. tred access to health care: conceptualizing access 25. Khattab E, Sabbagh A, Aljerian N, Binsalleeh Accessed on 22 February 2020. at the interface of health systems and popula- H, Almulhim M, Alqahtani A, et al. Emergency 5. Manual Instrutivo da Rede de Atenção às Urgên- tions. Int J Equity Health 2013; 12: 18. doi: medicine in Saudi Arabia: a century of progress cias e Emergências no Sistema Único de Saúde 10.1186/1475-9276-12-18. PMID: 23496984. and a bright vision for the future. Int J Emerg (SUS). Available at: http://bvsms.saude.gov.br/ 16. Forero R, Man N, McCarthy S, Richardson D, Med 2019; 12: 16. doi: 10.1186/s12245-019- bvs/publicacoes/manual_instrutivo_rede_at- Mohsin M, Toloo GS, et al. Impact of the Na- 0232-0. PMID: 31286863. enção_urgências.pdf. Accessed on 22 February tional Emergency Access Target policy on emer- 26. Dorsett M, Cooper RJ, Taira BR, Wilkes E, 2020. gency departments’ performance: A time-trend Hoffman JR. Bringing value, balance and human- 6. Rede de atenço as urgencias e emergencias: analysis for New South Wales, Australian Capi- ity to the emergency department: The Right Care avaliaço da implantaço e do desempenho das tal Territory and Queensland. Emerg Med Aus- Top 10 for emergency medicine. Emerg Med J unidades de pronto atendimento (UPAS). Avail- tralas 2019; 31: 253-261. doi: 10.1111/1742- 2019. pii: emermed-2019-209031. doi: 10.1136/ 6723.13142. PMID: 30043403. able at: https://www.conass.org.br/biblioteca/ emermed-2019-209031. PMID: 31874920. 17. Anto-Ocrah M, Cushman J, Sanders M, De Ver pdf/Conass_ Documenta_28.pdf. Accessed on 27. Reynard C, Oliver G, Hassan T, Body R. Dye T. A woman’s worth: an access framework 22 February 2020. Emergency Medicine: let’s feed the good wolf. for integrating emergency medicine with ma- 7. Componente Hospitalar da Rede de Atenção às Emerg Med J 2020; 37: 52-53. doi: 10.1136/ ternal health to reduce the burden of maternal Urgências. Available at: https://www.saude.gov. emermed-2019-208924. PMID: 31685680. br/saude-de-a-z/componente-hospitalar-da- mortality in sub-Saharan Africa. BMC Emerg Med 2020; 20: 3. doi: 10.1186/s12873-020- 28. Kremers MNT, Nanayakkara PWB, Levi M, rede-de-atencao-as-urgencias. Accessed on 22 Bell D, Haak HR. Strengths and weaknesses of February 2020. 0300-z. PMID: 31931748. 18. Michelson KA, Lyons TW, Hudgins JD, Levy JA, the acute care systems in the United Kingdom 8. Wilson MH, Habig K, Wright C, Hughes and the Netherlands: what can we learn from A, Davies G, Imray CH. Pre-hospital emer- Monuteaux MC, Finkelstein JA, et al. Use of a National Database to Assess Pediatric Emergency each other? BMC Emerg Med 2019; 19: 40. doi: gency medicine. Lancet 2015; 386: 2526-34. 10.1186/s12873-019-0257-y. PMID: 31349797. doi: 10.1016/S0140-6736(15)00985-X. PMID: Care Across United States Emergency Depart- ments. Acad Emerg Med 2018; 25: 1355-1364. 29. Keogh S. Clinician-led design for optimising 26738719. doi: 10.1111/acem.13489. PMID: 29858524. flow: Seizing the opportunity for a new-build 9. Bashiri A, Alizadeh Savareh B, Ghazisaee- 19. Jeong H, Jung YS, Suh GJ, Kwon WY, Kim KS, Australian Emergency Department. Emerg Med di M. Promotion of prehospital emergency Kim T, et al. Emergency physician-based inten- Australas 2020. doi: 10.1111/1742-6723.13464. care through clinical decision support sys- sive care unit for critically ill patients visiting PMID: 31958893. tems: opportunities and challenges. Clin Exp emergency department. Am J Emerg Med 2019. 30. Beam DM, Brown J, Kaji AH, Lagina A, Levy Emerg Med 2019; 6: 288-296. doi: 10.15441/ pii: S0735-6757(19)30605-9. doi: 10.1016/j. PD, Maher PJ, et al. Evolution of the Strategies ceem.18.032. PMID: 31910499. ajem.2019.09.021. PMID: 31785978. to Innovate Emergency Care Clinical Trials Net- 10. Valentin G, Jensen LG. What is the impact of 20. Joy T, Ramage L, Mitchinson S, Kirby O, Green- work (SIREN). Ann Emerg Med 2020; 75: 400- physicians in prehospital treatment for patients halgh R, Goodsman D, et al. Community emer- 407. doi: 10.1016/j.annemergmed.2019.07.029. in need of acute critical care? – An overview of gency medicine: taking the ED to the patient: a PMID: 31668572. reviews. Int J Technol Assess Health Care 2019; 12-month observational analysis of activity and 31. Kocher KE, Arora R, Bassin BS, Benjamin LS, 35: 27-35. doi: 10.1017/S0266462318003616. impact of a physician response unit. Emerg Med Bolton M, Dennis BJ, et al. Baseline Perfor- PMID: 30722802. J 2019. pii: emermed-2018-208394. doi: 10.1136/ mance of Real-World Clinical Practice Within 11. Alstrup K, Petersen JAK, Barfod C, Knudsen emermed-2018-208394. PMID: 31857371. a Statewide Emergency Medicine Quality Net- L, Rognås L, et al. The Danish helicopter emer- 21. Knowles E, Shephard N, Stone T, Mason SM, work: The Michigan Emergency Department gency medical service database: high quality data Nicholl J. The impact of closing emergency Improvement Collaborative (MEDIC). Ann with great potential. Scand J Trauma Resusc departments on mortality in emergencies: an Emerg Med 2020; 75: 192-205. doi: 10.1016/j. Emerg Med 2019; 27: 38. doi: 10.1186/s13049- observational study. Emerg Med J 2019; 36: 019-0615-5. PMID: 30953564. annemergmed.2019.04.033. PMID: 31256906. 645-651. doi: 10.1136/emermed-2018-208146. 32. Tavender E, Babl FE, Middleton S. Review 12. Kremers MNT, Nanayakkara PWB, Levi M, PMID: 31591092. Bell D, Haak HR. Strengths and weaknesses of article: A primer for clinical researchers in the 22. Bhandari D, Yadav NK. Developing integrated emergency department: Part VIII. Implementa- the acute care systems in the United Kingdom emergency medical services in a low-income tion science: An introduction. Emerg Med Aus- and the Netherlands: what can we learn from country like Nepal: a concept paper. Int J Emerg tralas 2019; 31: 332-338. doi: 10.1111/1742- each other? BMC Emerg Med 2019; 19: 40. doi: Med 2020; 13: 7. doi: 10.1186/s12245-020- 6723.13296. PMID: 31016861. 10.1186/s12873-019-0257-y. PMID: 31349797. 0268-1. PMID: 32028893. 13. Alexander AJ, Dark C. Freestanding Emergency 23. Aluisio AR, Barry MA, Martin KD, Mban- Lincoln Ferreira, Departments: What Is Their Role in Emergency jumucyo G, Mutabazi ZA, Karim N, et al. Care? Ann Emerg Med 2019; 74: 325-331. doi: Impact of emergency medicine training im- President of the 10.1016/j.annemergmed.2019.03.018. PMID: plementation on mortality outcomes in Kigali, Brazilian Medical Association 31182317. Rwanda: An interrupted time-series study. Afr 14. Xu Y, Ho V. Freestanding emergency depart- J Emerg Med 2019; 9: 14-20. doi: 10.1016/j. ments in Texas do not alleviate congestion in afjem.2018.10.002. PMID: 30873346. Wanderley Bernardo, hospital-based emergency departments. Am J 24. European core curriculum for emergency medi- Coordinator of Guidelines Program of Emerg Med 2019. pii: S0735-6757(19)30331- cine. Available at: https://eusem.org/images/ the Brazilian Medical Association

34 NIGERIA Health Care

in a tertiary hospital in the capital of India, Job Satisfaction: the Nigerian Doctor’s Story there was a positive relationship between the dissatisfaction with the job and the average number of work hours per day and expected to serve selflessly and emphasis also the number of night shifts per month is on patient care [1,8]. Therefore, it is im- [15]. Various researches have revealed that portant that doctors are satisfied with their there is a positive association between the job as it will affect the doctor-patient rela- health of staff and job satisfaction as staff tionship [9]. The job satisfaction of doctors who are not satisfied with their job tend is also necessary to promote commitment to be frequently absent from work due to and loyalty to healthcare delivery, effective, ill health [12]. In another study conducted service provision and more importantly in a government hospital in eastern India, preventing migration of doctors to other younger doctors and those in medical spe- countries [6]. cialties that require spending more time in the hospital were dissatisfied with their job compared to doctors of an older age group Definition of Job Satisfaction and those working in non-clinical specialties. In this study increasing age was found Job satisfaction has been defined by several to be associated with a higher level of job scholars. It can be defined as the extent or satisfaction [9]. degree to which an employee likes their job Dabota Yvonne Buowari [3, 4, 8–11]. Job satisfaction is related to the In a study conducted among health workers attitudes of an employee to their job [5]. It in Zaria, Northern Nigeria, job stress, op- Introduction also represents both the positive and nega- portunities for training and the salaries were tive feelings about the job and also the ful- the determinants of job satisfaction among Job satisfaction affects the entire satisfac- fillment gotten from the job [3, 12]. Hence doctors [12]. tion with life and it is an indicator of the job satisfaction is a very crucial element for situation at the workplace [1, 2]. It does an effective performance of the health care not refer to the medical sphere but to other sector [13]. Consequences of Job professions as well. Worldwide, chief ex- Satisfaction of Doctors ecutives including Chief Medical Directors and Medical Directors face the problem of Factors Affecting Job Users of healthcare facilities i.e. patients ensuring job satisfaction for their employees Satisfaction of Doctors and hospital clients are the ones who suf- [3–5]. Human resources are the priority for fer if a doctor has job dissatisfaction. This is quality in healthcare [4]. This involves cad- There are some factors that affect job sat- because job satisfaction affects job perfor- res of healthcare workers, medical doctors isfaction. Some of them are related to the mance and the quality of healthcare service and junior doctors inclusive. Hence, doctors individual or the hospital management. rendered [2, 14–16]. High level of job satis- need to be satisfied with their job in order to The attitude towards job satisfaction results faction among junior doctors at a Sudanese carry out their duties effectively as a doctor from three areas which are specific job fac- hospital impacted positively on the quality who is dissatisfied with the job will get tired tors, individual characteristics and group of the healthcare services and patient’s sat- out [2]. The training to become a doctor is relationships outside the job [5]. These isfaction [4]. Low job satisfaction predicts expensive, challenging, long and demanding factors include job security, interaction the intention to leave the job as doctors [6]. Doctors should enjoy and be satisfied with other health workers and colleagues, who are dissatisfied with their job may be with their job as training takes a long time. finance incentives which include salaries considering leaving the job for elsewhere, Moreover during the period of medical and allowances, the number of work days, either to another hospital or migrating to a training, physicians are expected to deprive supervision, conditions of service, conflict developed country as shown in a study con- themselves of sleep and leisure. They are and conflict resolution, age, sex, years of ducted in South-East Nigeria [13]. It has encouraged to disregard their needs when employment, opportunities for training and been proved that job dissatisfaction leads practicing [7]. In most parts of the world, career advancement [3, 5, 9, 14–15]. In a to migration of doctors as seen in a study Nigeria including, doctors in hospitals are study conducted among doctors working conducted in Zaria, Northern Nigeria [12].

35 Health Care NIGERIA

There is a positive association between job dictor of job stress [7]. This was also seen 6. Surman G, Lambert TW, Goldacre M. Doc- satisfaction and employee absenteeism as in another Nigerian study conducted in tors enjoyment of their work and satisfaction with time available for leisure: UK time when the job satisfaction is high, absentee- Sokoto, northern Nigeria [17]. This may be trend questionnaire-based study. Postgradu- ism is low and vice versa [3]. Oche et al in due to the stressful nature of the residency ate Medical Journal. 2016. doi.10.1336/post- their study in Sokoto, Northern Nigeria, training program [17, 21]. Job stress has an gradmedj-2015-133743 revealed that was a high rate of absentee- impact on the health of the doctor and their 7. Adeolu JO, Yussuf OB, Popoola OH. Prevalence ism noticed among resident doctors because ability to cope with the demands associated and correlates of job stress among junior doctors they were not satisfied with their job [17]. with their job [16]. in the University College hospital, Ibadan. An- nals of Ibadan Postgraduate Medicine. 2016, 14 Therefore it can be seen that the impact of (2), 92-98. dissatisfaction of a physician with the job One of the best ways to strengthen the Ni- 8. Kolo ES. Job satisfaction among healthcare is overwhelming. Various researches con- gerian weak healthcare sector is the devel- workers in a tertiary Centre in Kano, North ducted in the developing countries which opment of human capacity and identifica- Western Nigeria. Nigerian Journal of Basic and are low resource settings and developed tion of factors affecting the job satisfaction Clinical Sciences. 2018, 15, 87-91. 9. Bhattacherjee S, Ray K, Roy JK, Mukherjee A, countries have shown a difference in job of healthcare professionals including doc- Roy H, Data S. Job satisfaction among doctors satisfaction [9]. tors [8, 12]. Several reforms and policies of a government medical college and hospital, have been developed in Nigeria to address Eastern India. Nepal Journal of Epidemiology. the challenges in the healthcare system but 2016, 6(3), 595-602. the creation of a desirable workplace en- 10. Yongu TW, Hondoaver U, Danen PT. Emotion- Job Satisfaction Of Doctors al intelligence and job satisfaction as predictors vironment which will eventually lead to a of organizational commitment among resident Several studies have been conducted world- higher rate of job satisfaction has received doctors at Benue State University Teaching wide on job satisfaction amongst doctors but little or no attention. Hospital, Makurdi. African Journal of Social Is- few specifically about junior doctors. Some sues, 2018, 21 (3), 61-76. of these studies were done in conjunction 11. Omalase CO, Seidu MA, Omalase BO, Ag- with other healthcare workers. High rate of borubere DE. Job satisfaction amongst Nigerian Conclusion ophthalmologists: an exploratory study. Libyan job dissatisfaction is seen among Nigerian Journal of Medicine. 2010, 5, 46-69. doctors compared to their counterparts in Job satisfaction of healthcare workers es- 12. Butawa NN, Sule AG, Omole VN, Yere JK, Europe and North America [18]. Job satis- pecially doctors is necessary for the quality Dogo M, Gyuro J. Assessment of job satisfac- faction brings a lot of benefits [8]. The job healthcare delivery as this will help reduce tion among health workers in a tertiary hospital satisfaction of doctors is beneficial for the the current brain drain and migration of in Zaria, Northern Nigeria. Savannah Journal of Medical Research and Practice. 2013, 2 (2), patient/client and the physician [19]. Doc- doctors to countries with better work envi- 54-62. tors derive their satisfaction from their work ronments. 13. Ogbuabor DS, Okoronkwo L, Uzochukwu B, but may not be happy with their work envi- Onwujekwe O. Determinants of job satisfac- ronment [2]. Some doctors may not be hap- tion and retention of public sector health worker py with their jobs because of long working References in South East Nigeria. International Journal of 1. Anuradha PM. Impact of work-life balance on Medical Health Development. 2016, 2 (2), 27-39. hours, overwork and heavy workload due to 14. Gedam SR, Babar V, Bahhulkar S. Study of understaffing [15] and this affects the atti- job satisfaction of women doctors. Problems and Perspectives in Management. 2016, 14(2), job satisfaction and stress among doctors from tude of the doctors towards their colleagues, doi.2016.07 tertiary care institute rural region of Cen- coworkers, patients and clients [14] as well 2. Madaan N. Job satisfaction among doctors in a tral India. International Archives of Addic- as this affects the way they carry out their tertiary care teaching hospital. Jk Science. 2008, tion Research and Medicine. 2018, 4 (1), doi. duties [16,20]. 10(2), 81-83. org/10.23937/2474-3631/15/0026 3. Aziri B. job satisfaction: a literature review. 15. Kaur S, Sharma R, Talwar R, Verma A, Singh Management Research and Practice. 2011, 3(4), A. A study of job satisfaction and work environ- In an Indian study, 59.6% of doctors satis- 77-86. ment perception among doctors in a tertiary fied with their job [9]. In a Nigerian study 4. Suliman AA, Eltom M, Elmadhoun WM, Noor hospital in Delhi. Indian Journal of Medical 58 doctors were studied under four do- SK, Almobarak AO, Osman MM, Awadalla H, Sciences. 2009, 63 (4), 139-144. mains, namely, the hospital management, Ahmed MH. Factors affecting job satisfaction 16. Meinam M, Behara BK. Job satisfaction of doc- among junior doctors working at teaching hos- tors in government hospitals in Manipur: a soci- hospital facilities, healthcare providers as ological study. Journal of Humanities and Social well as pay and benefits, and there was a pitals in River Nile State, Sudan. Journal of Pub- lic Health and Emergency. 2017, 1, 1-6. www. sciences. 2015, 20 (5), 22-24. low rate of job satisfaction [20]. In a study jphe-amegroups.com assessed 2019. 17. Oche MO, Oladigbolu R, Ango JT, Okafogu conducted among junior doctors in Ibadan, 5. Mishra PK. Job satisfaction. Journal of Humani- N, Ango U. Work absenteeism amongst health- Western Nigeria job satisfaction was a pre- ties and Social Sciences. 2013, 14 (5), 45-54. care workers in a tertiary health institutions in

36 Organ Donation

Sokoto, Nigeria. Journal of Advances in Medi- cians job satisfaction in their begin, mid and end faction among resident doctors in Nigeria: any cine and Medical Research, 2018, 26 (2), 1-9. career stage. Journal of Hospital Administration. justification for a change in training policy. Jour- doi.10.9734/JAMMR/2018/40467 2017, 6 (1), 1-9. nal of Clinical Sciences. 2018, 15, 32-40. 18. Ofili AN, Asurzu MC, Isah EC, Ogbeide O. Job 20. Olutayo FM, Dahiru T, Danburam A, Salwau satisfaction and psychological health of doctors FK. Job satisfaction among doctors and nurses: a at the University of Benin Teaching Hospital. case study of Federal Medical Centre, Yola, Nige- Dabota Yvoone Buowari, Occupational Medicine. 2004, 54(4), 400-403. ria. International Journal of Community Medi- Ibinye Avenue, Behind Genesis Fastfood, Doi.10.1093/occmed/kqh081 cine and Public Health. 2016, 3 (6), 1640-1647. Woji, Port Harcourt, 19. Jongbloed LJS, Sehonrock-Adema J, Borleffs 21. Ogunnubi OP, Ojo TM, Oyelohumu MA, Ola- Nigeria JCC, Stewart RE, Cohen-Schotanus J. physi- gunju AT, Tshuma N. stress and training satis- E-mail: [email protected]

Comment: Reform of Transplantation in China We have engaged in research and writing into organ transplant Dr. Shi was interviewed for a TV documentary titled “Davids’ Re- abuse in China since 2006 and have come to the conclusion, as have port Re-examined” produced by Phoenix TV and broadcast in Oc- others after us, that prisoners of conscience have been and are being tober 2007.4 We are the Davids of the documentary title. killed in China in large numbers for their organs. The primary victims are practitioners of the spiritually based set of exercises Falun Some of the questions asked of Dr. Shi in the TV interview and his Gong and Uyghurs.1 answers are these: “Question: We recently saw a report produced by two Canadian One focus of our research has been official Chinese government independent investigators. It quotes your statement that by 2005 statistics on transplant volumes. We have attempted to determine if China had conducted some 90,000 transplants. They include these statistics are accurate and what the sources of these volumes 60,000 such operations from 2000 and [to] 2005 which is a period are. Shi Bingyi, the author of the article “Reform Proceeding of when the Falun Gong was suppressed. This shows a numerical in- Organ Donation and Transplantation System in China” published crease. Under what conditions did you say this? in the World Medical Journal of April 2020, has in the past been Answer: I didn’t make such a statement because I have no quoted in Chinese publications as providing statistical information knowledge of these figures. I have not made [a] detailed inves- on transplant volumes and then denied he has done so. tigation about the subject. Therefore I have no figures to show how many were carried out and in which year. So I could not An article posted on Health Paper Net in March 2006 contained have said this. this statement: “Professor Shi said that in the past 10 years, organ transplantation Question: Although you have not revealed concrete figures, do the in China had grown rapidly; the types of transplant operations figures in the report match the reality? that can be performed were very wide, ranging from kidney, liver, Answer: I don’t think that these figures are correct as the report heart, pancreas, lung, bone marrow, cornea; so far, there had been shows they were calculated on the basis of phone calls to hospitals. over 90,000 transplants completed country-wide;”2 They asked for figures from those hospitals in the names of families of patients. In an interview with Science Times in May 2007, Dr. Shi said: “The number of organ transplants in China reached a historic peak Question: You have read the report. Have you ventured to clarify in 2006, in which nearly 20,000 cases of organ transplants were figures the report says you produced? performed.” 3 Answer: Yes I did. Because I am a soldier what I did was to lodge a protest through legal channels. I sent the protest to the Ministry of Health through the Department of Health of the PLA General 1 See https://seraphimeditions.com/portfolio-posts/bloody-harvest/ Logistics Department. I made it clear in the protest that I never https://endtransplantabuse.org/; http://www.david-kilgour.com/ said what is attributed to me. 2 https://web.archive.org/web/20060826070646/http://www. transplantation.org.cn/html/200603/394.html 3 http://web.archive.org/web/2010*/news.sciencenet.cn/html/showsbnews1. 4 http://web.archive.org/web/20140816105904/http://www.facts. aspx?id=182075 org.cn/Reports/World/200710/26/t20071026_779607.htm

37 Organ Donation

... As noted, the Phoenix TV interview was October 2007. So, Dr. Shi Question: Some other figures contained in the report say some was saying during this TV interview that he did not say something Chinese hospital websites advertised to say donors could be found which, at the very moment of his denial, was posted on the internet in two weeks in China. In other countries, the waiting period may as something he said. last more than one year. How do you explain the difference? Answer: I can tell you the fact that some people have waited for If one looks at the translation of the original Chinese Health Pa- three or four years in our hospital. The number of those who have to per Net of March 2006 article which the Google Chrome browser wait for over one year absolutely exceeds 200.” generates, the sentence which contains the 90,000 figure disappears, not just in the English translation, but in all of the many language Manfred Nowak, the then United Nations Rapporteur on Torture, translations we have examined. Yet, the number 9 appears in the asked the Government of China to explain the discrepancy between original Chinese paragraph, as one can plainly see. volume of organ transplants and volume of identified sources, rely- ing, in part, in our report and its reference to the article of March If one saves the original Chinese language article as PDF through a 2006 quoting Dr. Shi. The Chinese government, in a response sent printing option, convert the PDF to Word, through an optical char- to the Rapporteurs by letter dated March 19, 2007 and published in acter recognition app which can recognize Chinese characters, and the report of Professor Nowak to the UN Human Rights Council then put this Word text into Google translate, the sentence with the dated February 19, 2008, stated that 90,000 figure appears in the translation. The phrase with the figure “Professor Shi Bingyi expressly clarified that on no occasion had he 90,000 in Google translate is this: “More than 90,000 cases were made such a statement or given figures of this kind, and these al- transplanted last year”. legations and the related figures are pure fabrication.”5 Because of translations we have had done of the original by per- Dr. Shi, MD and Li-Ping Chen wrote in the issue of the Journal of sons proficient in Chinese, a better translation would be “More the American Medical Association in November 2011: than 90,000 cases were transplanted so far” or “More than 90,000 “Dr Trey and colleagues mention that in 2005, transplant figures cases were transplanted up to last year“ or “More than 90,000 cases peaked with 20 000 transplants. However, as organ transplant were transplanted last year to date” or “More than 90,000 cases were specialists, we and our colleagues have never heard of this many transplanted by last year”. As for the 20,000 figure in the Science transplants per year in China”6 Times article, that remains in the translation of the original Chi- nese Science Times article of May 2007 which the Google Chrome Dr. Shi then, in four instances, professed ignorance of something browser generates. about which his earlier statements show that he knew – the 20,000 and 90,000 figures and our research on the mass killing through Given this history, the article “Reform Proceeding of Organ Dona- forced organ extraction of practitioners of the spiritually based set tion and Transplantation System in China” should be approached of exercises Falun Gong. with caution. Anything Dr. Shi writes about organ transplantation reform in China needs to be independently verified. Neither the article in Health Paper Net nor the article in Science Times nor the Phoenix TV interview are available any more on the Sincerely yours, internet on their original websites. They are available only because they have been archived through a web crawler, the Wayback Ma- chine. David Matas

The Wayback Machine captured the Health Paper Net March 2006 David Kilgour article first on August 26, 2006. The last capture was August 7, 2008. The next web crawler capture of the URL after that date, on June 20, 2009, reports that the page could not be found.

5 https://documentsddsny.un.org/doc/UNDOC/GEN/G08/106/97/PDF/ G0810697.pdf?OpenElement 6 November 2, 2011 Volume 306 number 17 page 1864

38 CHINA Critical Care Medicine

special support from the National Natural Critical Care Medicine in China–Solid Steps Science Foundation of the Ministry of Sci- ence and Technology. In 2017, critical care in the Past Forty Years and Future medicine was one of the four key support directions for the 15 billion ‘National Proj- intensity, high risk working, the team of crit- ect to improve the diagnosis and treatment ical care medicine was not only the leader of critical diseases’. Nowadays, in China, of the clinical front line, they also summa- critical care medicine is the preferred major rized and published very valuable Clinical for emergency treatment of major disasters research results about the novel coronavirus and a showcase for modern hospitals. pneumonia, what’s more they wrote the Diagnosis and Treatment Protocol for CO- The results of three national ICU surveys in VID-19 Critical Cases and Severe Critical 2006, 2011 and 2015 showed that the num- Cases, which guided frontline doctors treat- ber of ICUs in China increased from more ing critical patients all over the country. The than 1,000 to nearly 4,000 [1]. The num- battle of the novel coronavirus pneumonia ber of intensivists in China has increased to has again witnessed the importance and 63,605, and the number of ICU nurses has prospects of critical care medicine for the increased to over 100,000 [1]. The propor- people in China and all over the world. tion of ICUs in third-grade class-A hospitals increased significantly. The ratio of -in tensivist to bed and the ratio of nurse to bed Discipline Construction also increased significantly [1]. The growth Xiang-Dong Guan rate and range indicate that China’s criti- Compared with western countries, the cal care medicine develops rapidly and has Novel coronavirus pneumonia is highly in- development of critical care medicine in abundant reserves. According to the data fectious and can cause patients to develop China started later but rapidly. In 1970s from the three national surveys of ICU, at acute respiratory failure and multiple organ and1980s, few intensive care units were es- the beginning of the establishment of the system dysfunction or even death. To con- tablished in China mainland. In 1990, the CSCCM, only about 30% of the ICUs in trol the epidemic and spread of the virus, the Ministry of Health of The People’s Repub- China were subordinate to the ICU depart- government of China has taken the most lic of China started to include the establishment. With the unremitting efforts of the stringent isolation and control measures. ment of ICU as one of the key evaluations CSCCM, nearly 66% of the ICUs in China All provinces and cities across the country of hospital accreditation. Since then ICU had been included in the ICU department have responded to the call of the country. constructions all around the country were management by 2015, which indicates the 0n January 29, 2020, The Chinese Society in full swing. In 1997, the Committee of rapid development of the ICU department of Critical Care Medicine of The Chinese Critical Care Medicine of Chinese Patho- in China [1]. Medical Association (CMA-CSCCM), The physiological Society was established. On Chinese Society of Pathophysiology and March 18, 2005, Chinese Society of Criti- The Chinese Medical Doctor Association, cal Care Medicine (CSCCM) was founded Quality and Staffing issued a joint call for the colleagues of criti- in Beijing. On July 4, 2008, The Standard- Improvement cal care medicine in China to fight together ization Administration of the State Council in danger. As we always said, where there is approved critical care medicine as a second- For the development of critical care medi- the need to save lives, there will be intensive level discipline (320.58). In 2009, Intensive cine, we tried further strengthen the dis- care doctors. Medical teams from all over Care Unit (ICU), a national key clinical cipline standardization construction and the country which were consisted of more specialty construction project of the Min- management, and build the discipline con- than 40000 medical staffs rushed to Wuhan istry of Health, became the only specialty struction platform of critical care medi- and Hubei to fight. Among them, more than covering all provinces in China. In 2010, cine. On this platform, multidisciplinary 19000 medical staffs were from departments the intermediate and senior promotion as- integration and innovation can be realized of critical care medicine. The total number sessment of critical care medicine was in- which promised the effective diagnosis and was more than 10% of the critical care pro- cluded in the National Examination of the treatment and finally reduce the mortality. fessionals all over the country. In such a high Ministry of Health. In 2013, ICU received With the unremitting efforts of the chap-

39 Critical Care Medicine CHINA

ter, critical care medicine was finally listed concepts of Critical Care Medicine from greatly promoted the development of inter- in the national best Specialty ranking list in the Society of Critical Care Medicine of national cooperation in critical care medi- 2016 (evaluated by the Hospital Manage- the United States to the local critical care cine in China. ment Research Institute of Fudan Univer- society was introduced since 2016. sity), which is of great significance to the promotion of the influence of critical care Challenges and Opportunities medicine. In April 2015, the CSCCM was International Influence in the Future awarded the title of Outstanding Specialist Chapter of the CMA at the commendation Over the past 10 years, the communication While reviewing the great achievements of conference for the 100th anniversary of the between Chinese critical care medicine and critical care medicine in the past 40 years, establishment of the CMA, which is the the international community has been in- we must be soberly aware of the problems recognition of the work by the CMA. creasingly close, and the depth and breadth and challenges in the development of the have been expanding. The voice of Chinese discipline. The development of the discipline of criti- critical care medicine has been increasingly cal care medicine needs to be based on appearing on the stage of important inter- clinical work and scientific research, which national academic congresses at different The Number of Icu Beds is Still cannot be separated from each other. More levels. Unable to Meet the Demand than 180 scientific researches of critical care medicine were funded by the National During the 2018 Chinese critical care According to the results of the national sur- Natural Science Foundation of China in medicine society annual conference, the vey of ICU beds, the ratio of ICU to hos- 2018 alone. In 2018, more than 430 articles society held the launching ceremony of pital beds increased from 1.49% in 2011 to related to critical care medicine in China “the Belt and Road initiative” in the spirit 1.7% in 2015[1], but still failed to meet the were published in foreign journals related of friendly cooperation. The heads of criti- national minimum standard (2%-8%) [2]. to critical care. According to the prelimi- cal care medical academic groups from 16 In 2010, the ratio of ICU to hospital beds nary statistics of the top five journals re- countries along “the Belt and Road ini- in the United States has reached 13.4% [3]. lated to critical care, such as INTENSIVE tiative” were warmly welcomed to attend CARE MEDICINE, CRITICAL CARE this annual meeting. Up to now, more MEDICINE,CRITICAL CARE and so than 20 countries and regions have signed Challenges of Discipline on, more than 121 research articles were “the Belt and Road initiative” Agreement Construction presented by Chinese authors. These voices with the CSCCM which promoted the will certainly represent China’s critical care integration of CSCCM with the interna- It is necessary to gradually improve the medicine and resound through the critical tional community. ‘Peri-Critical Care Medicine’ discipline care medicine field in the world. system of ‘early warning, prevention, organ In 2018, a special session in Chinese was support and long-term prognosis’. There is The key to resolve the shortage of human held on the 31st Annual European Confer- still a need to improve and strengthen the resources is not only to increase the staff ence on Critical Care Medicine. Professors treatment of pre-hospital critical transport, numbers but also to improve their capabili- of critical care medicine from China were in-hospital critical rapid response team, ties (15). 5C was initiated in 2009, which invited to give keynote speeches. These critical care and life support, and post-criti- devotes to equipping intensivists with pro- achievements show that Chinese experts cal quality of life management. fessional knowledge and skills in mainland in critical care medicine are playing an in- China. So far, 120 training sessions have creasingly important roles in promoting been held, with a total of 24,202 students the development of critical care medicine Challenges of Informatization and 208 teachers. It has been held in 31 around the world. Construction provinces, autonomous regions and municipalities, and is “the only continuing In recent years, international communica- No information, no modernization. Critical education quality project”of 88 specialized tion boards have been set up in the annual care informatization isolated island is a cur- chapters of the CMA. In order to further academic conferences of critical care medi- rent phenomenon in China. With the top- improve the professional knowledge and cine in China (such as the annual academic level design and support at the national level, skills of intensivists, the Multiprofessional conferences of CMA-CSCCM). This inno- it is imperative to establish a national online Critical Care Review Course and current vative international communications have database of critical care medicine in China.

40 Talent Training connotation of critical care medicine, which References greatly promotes the sustainable develop- 1. Wu JF, Pei F, Ouyang B, et al. Critical Care Re- Critically ill patients should be managed by ment of critical care medicine. Therefore, sources in Guangdong Province of China: Three Surveys from 2005 to 2015. Crit Care Med. skilled intensivists with the most special- multi-disciplinary integration and innova- 2017;45(12): e1218-e1225. ized training in critical care, not by physi- tion are needed to complement each other. 2. Rhodes A, Ferdinande P, Flaatten H, et al: The cians who only receive other specialized Interdisciplinary integration and innova- variability of critical care bed numbers in Eu- training to qualify for ‘standardized training’ tion are not only the needs of the overall rope. Intensive Care Med 2012; 38:1647–1653 and then perform treatment at the bedside development of critical care medicine, but 3. Halpern NA, Goldman DA, Tan KS, et al: Trends in critical care beds and use among pop- of the ICU. It is an urgent and critical prob- also an important symbol of the develop- ulation groups and medicare and medicaid ben- lem to establish a unified and standardized ment of modern medicine. efciaries in the United States: 2000-2010. Crit talent training system for critical medical Care Med 2016; 44:1490–1499 staff. In July 2020, Critical care medicine Critical care medicine is about to enter the was included in the national resident train- third decade of the 21st century, a decade ing system which will promote the reserva- of opportunity and possibility, a decade of Xiang-Dong Guan, Ph.D., MD tion of professionals and development of great times. With a clear discipline devel- Zi-Meng Liu, MD the discipline. opment plan, clear development ideas, and Department of Critical Care adherence to integration and innovation, Medicine, The First Affiliated critical care medicine will surely stand at Hospital, Sun Yat-sen University. Integration and Innovation the forefront of modern medicine in the fu- President of Chinese Society ture, have a better tomorrow, and make the of Critical Care Medicine of The development of modern medicine has greatest contribution to modern medicine Chinese Medical Association put forward higher requirements for the and human health. E-mail: [email protected]

Obituary In 1967 Dr Moon entered politics to devote his life to the good of society. He ran for election to the national legislative and was Tai Joon Moon, MD, PhD elected in his hometown at the age of 39. He was subsequently re- 14 January 1928–11 March 2020 elected four times, with his main focus and activities being around the enhancement of community health. He served as chair of the Tai Joon Moon was born in 1928 in Youngdeok City, north Gyong- National Assembly, chair of the National Assembly’s Commerce sang Province, South Korea. He graduated from the Seoul National Committee, a member of the Democratic Republican Party, and University School of Medicine in 1950, just one month before the chair of the Gyungbuk Provincial Party. Korean War broke out, during which he served as a surgeon on the frontline. Shortly after the war ended in 1954, he continued his After 14 years in the Korean National Assembly, he was elected studies at the Thomas Jefferson Graduate School of Medicine, Phil- as President of the Korean Medical Association (KMA) and re- adelphia, USA, where he completed his residency in neurosurgery elected three times, serving with the KMA until 1988. Following on and neurology to become a neurosurgeon. He returned to Korea in from his 9-year presidency of the KMA, he was appointed as Min- 1957 and started teaching at the department of surgery at the Yon- ister of Health and Welfare for 8 months. During his term, Korea sei University Severance Hospital. In 1961 he was the main con- implemented National Health Insurance, which covered the entire tributor in establishing the department of neurosurgery, which until population. He continued to serve the KMA as President Emeritus, then had been part of the neurology department, as an independent especially in the area of international relations. department. He was a founding member of the Korean Neurosur- gery Society and served as its President from 1968–1969. Tai Joon His leadership skills were extended to an affiliated regional orga- Moon received his Ph.D. in Medicine from the Nihon University nization of the WMA, namely the Confederation of Medical As- in Tokyo, Japan in 1969. Among the honours that were bestowed sociations in Asia and Oceania (CMAAO), as its President between on him were an Honorary Doctorate in Science from Chungbuk 1981-1983, and subsequently as Senior Advisor until recent years. University in Korea in 1986, and an Honorary Law Degree from He made a remarkable impact in strengthening the Asian voice on Thomas Jefferson University in 1987. the global stage.

III xxx

Inauguration at the 37th World Medical Assembly, Brussels in 1985 180th WMA Council Session during the 59th WMA General Assembly, (left: Tai Joon Moon, right: J. J. Coury) Seoul in 2008

The World Medical Association’s (WMA) members elected Tai Joon Moon as their President in 1984 and he was inaugurated in 1985 at the WMA General Assembly in Brussels, Belgium. Remaining committed to the WMA, he was later elected as Vice-Chair of Council from 1995 to 2005. We all have special memories of the WMA General Assembly in Seoul in 2008 and his tireless work as Chairperson of the organizing committee to make it one of the most successful meetings of the WMA. Right up until his final WMA meeting in Vancouver in 2010 he displayed outstanding leadership and charisma, especially in the midst of critical debates. We knew him as an Elder Statesman who, in his wisdom, was able to reconcile the different ideas within the WMA. His charisma gave him great influence even without any formal authority. Assembly dinner with his wife Mrs Young Boo CHO at the 59th WMA General Assembly, Seoul in 2008 We, together with our colleagues in Korea, the Asia and Pa- cific regions and globally, remember him as a great mentor. tional relations will be remembered as an everlasting footprint. Dr. Moon is not with us any longer, but the life he devoted to He is deeply missed. the health of people and society through politics and interna- Sunny Park, Otmar Kloiber