Journal Official Journal of the World Medical Association, Inc

ISSN 2256-0580 COVID-19 World Medical Journal Official Journal of The World Medical Association, Inc. Nr. 2, April 2020 vol. 66

Contents

Editorial ...... 1

COVID-19: the Asian Perspective ...... 2

The Corona Virus Outbreak on South African Medical Schemes ...... 13

Reform Proceeding of Organ Donation and Transplantation System in China ...... 15

The Impact of Climate Change on Health ...... 19

Physical Activities of Doctors in Rivers State, Southern Nigeria ...... 21

Palliative Care: What, Who, When, How? ...... 25

The “Normalization” of Euthanasia in Canada: the Cautionary Tale Continues ...... 28

Appeal for Policy Promotion ...... 38

This Month Consider Indoor Air Health ...... 40

Singapore Medical Association – sixty years on ...... 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

Every day this year is to be marked as the World Doctors’ Day. Ev- patients with chronic diseases suffer worse from Covid-19 and the ery day tests the knowledge, endurance, ability and health of doctors cases are more severe. all over the world. We entreat every doctor on this planet to take care of their own Covid-19 is a podium talk for politicians and journalists, but the health at this time. If Covid-19 beats doctors, then it will beat every- front line for doctors. Politicians squander public money like their one else. Therefore, these are doctors who should be especially careful own, journalists invent catchy headlines and clusters of exclamation with distancing and disinfecting their hands, changing the cloth- marks, but doctors risk their lives and those of their loved ones. ing, washing and sterilizing it. These are doctors who need to find time for a long walk, running or cycling and breathing exercises every Several studies show that doctors are not particularly worried about day. These are doctors who need to take care of their own chronic the possibility if they themselves get sick; sacrifice is a keystone of diseases, and they should tolerate neither unstable blood sugar nor doctors’ professional ethics. Doctors fear for the lives of their be- high blood pressure. There is no more important task for National loved, especially for their parents. Medical Associations than to care for the protection and safety of doctors through their governments. Governments must provide doc- Doctors all over the world are aging together with the public. On tors with better pay, longer breaks between patient reception, longer average, doctors become specialists later than other professionals do rest time, shorter (6 minutes) communication with patients, and en- because they need a high level of training. Moreover, doctors get sure that a sick doctor is treated with the best available medicine. sick with all acute and chronic diseases just like all population. Soci- ety believes that doctors, as its most educated and wealthy members, The World Medical Association keeps track of events, collects in- keep in good health longer, they are more accurate in targeting their formation and provides advice every day. The World Medical As- own treatment, and are more committed to physical and mental ac- sociation currently cares about every doctor on this globe. Let every tivities. doctor in our world has enough strength and endurance! Let our WMA leaders have enough strength and endurance! There are some truths, which National Medical Associations should repeat to their colleagues. If possible, doctors over the age of 65 I thank Dr. KK Aggarwal, President of CMAOO, who shares the should not accept patients directly. They should fully switch to con- latest world findings on Covid-19 with me every day. sulting patients on the phone or on the Internet. Likewise, direct contacts with patients should be avoided by colleagues who are old- Dr. med. h. c. Peteris Apinis, er than 50 years, have diabetes and heart problems. Unfortunately, Editor-in-Chief of the World Medical Journal

1 COVID-19

March 31 700 cases (23%), despite preventive measures in place (CDC). COVID-19: the Asian Perspective Transmission of the virus over three months to reach the first 100,000 confirmed cases, 12 days to reach the next The disease was initially presumed to be 200,000, four days to reach 300,000, 3 days only due to wild animal-to-human trans- to reach 400,000, 2.5 days to reach 500,000, mission since the outbreak was linked to two days to reach 600,000 and two days to the Huanan Seafood Wholesale Market of reach 700,000. Wuhan. Subsequently, human-to-human transmission was confirmed [3]. Perhaps Bill Gates was prescient when he said, “The worst pandemic in modern history COVID-19 is mainly transmitted among was the Spanish flu of 1918, which killed tens humans through infected large (>5 microns of millions of people. Today, with how inter- size) droplets from coughing and/or sneez- connected the world is, it would spread faster.” ing (also speaking loudly, singing, talking (2014) face to face, shouting) and close contact with an infected person (symptomatic or The onset of the current pandemic can be asymptomatic) [3]. traced back to Wuhan, China, where a group Krishan Kumar Aggarwal of patients with viral pneumonia was report- In a retrospective multicenter study of lab- ed on 31 December 2019 [2]. These patients oratory-confirmed COVID-19 cases from We are grappling with a pandemic of mam- were categorized as “pneumonia of un- China, the median duration of viral shed- moth proportions. Coronavirus Disease known etiology” as no cause could be identi- ding was 20 days in patients who survived, (COVID-19) is spreading with a rapidity fied [3]. Subsequent investigations revealed but shedding of the virus continued until and ferocity that has caught the world un- the etiopathogen to be an unknown beta- death in fatal cases. Viral shedding was ob- aware and therefore unprepared and, more coronavirus and a new coronavirus, named served for as long as 37 days [5]. often than not, underprepared. Almost ev- 2019-nCoV, was isolated as the cause of the ery country has now reported COVID-19 viral pneumonia [2]. On February 11, the It has been suggested that mild cases and cases. The numbers are spiraling, especially disease was officially named as Coronavirus even asymptomatic persons can transmit in the European continent. Expectedly, an Disease-2019 (COVID-19) by the WHO. the infection as well [6]. atmosphere of alarm and panic now prevails worldwide. The new corona virus was found to have The virus can also be transmitted indirectly 86% genetic similarity with Severe Acute via surface fomite [7]. A new study pub- Increased globalization has made the world Respiratory Syndrome corona virus (SARS- lished online 17 March 2020 in the New more connected today; this has accelerated CoV). Hence, it was called severe acute re- England Journal of Medicine has shown the spread of the disease.. Predominantly, spiratory syndrome coronavirus 2 (SARS- that the virus can survive on surfaces even it were the travel-related cases, which have CoV-2) [4]. But unlike SARS, COVID-19 for several days [8]. The virus remained driven the pandemic in most countries [1]. has a higher transmissibility. The average viable on plastic and stainless steel for up

reproduction number (R0) of COVID-19 is to 72 hours, on copper for 4 hours and on

More than 7 lakh (700,000) persons the 3·28 and median R0 is 2·79, which is higher cardboard for up to 24 hours. On plastic world over are infected with the virus and than that of SARS [4]. surfaces, the virus exhibited a median half the global death toll will cross 45,000 with life of 6.8 hours, while on stainless steel, the current trends (current deaths + current The spread of the disease on the Diamond it was 5.6 hours. This study also suggested serious patients x 15%). Princess Cruise ship in Japan corroborates that aerosols generated in the health care the high transmissibility of the COVID-19 settings (high pressure oxygen, nebulizer, The World Health Organization (WHO) virus. On February 9, there were 20 cases intubation, forced coughing procedures) has now cautioned that the coronavirus on board; but, by the end of the quarantine may also be a possible route of transmission disease pandemic is “accelerating”. It took period, this number had increased to around of the new corona virus. The virus remained

2 COVID-19

viable in aerosols for the entire 3 hour duration of the experiment.

The CDC recommends that before disinfection, dirty surfaces should first be cleaned with soap and water.

Diluted household bleach solutions, 70% alcohol-based solutions and products con- taining hydrogen peroxide, peroxyacetic acid, sodium hypochlorite, quaternary am- monium can be used for disinfection [9].

The incubation period for COVID-19 ranges from 1–14 days, usually around 5 days (WHO). So, persons potentially exposed to the virus on a particular day will surface as cases on the 5th day. This forms the basis of testing close contacts between 5–14 days. Figure 1 . Stages of Covid-19 illness

The spectrum of the disease ranges from mild infection to critical disease. A sum- 88.7% during hospitalization), cough <300 mm Hg). Lab tests reveal transamnitis mary of a Report of 72,314 cases from the (67.8%) and diarrhea (3.8%). The most and low to normal procalcitonin. Chest im- Chinese Center for Disease Control and common finding on Chest CT was ground- aging will show an abnormal CT. Prevention shows that majority (81%) of glass opacity (56.4%); 18% patients with cases were mild (nonpneumonia and mild nonsevere disease and 3% patients with se- The hyperinflammation phase or the third pneumonia), while the disease was severe vere disease had no abnormal findings on stage is the critical stage characterized in 14% of patients (presenting as dyspnea, CT. Around 84% patients had lymphocyto- by acute respiratory distress syndrome respiratory rate ≥30/min, blood oxygen penia on admission [11]. (ARDS), systemic inflammatory response saturation ≤93%, partial pressure of arterial syndrome (SIRS) and/shock and cardiac oxygen to fraction of inspired oxygen ratio failure. The inflammatory markers (CRP, <300, and/or lung infiltrates >50% within Severity of illness IL-6, D-dimer, ferritin), troponin, NT- 24–48 hours). Five percent of patients had proBNP levels are raised and are indicative critical disease (respiratory failure, septic COVID-19 can be categorized into three of poor prognosis. shock and/or multiple organ failure) [10]. stages based on the severity of the illness: early infection, pulmonary phase and hy- Since COVID-19 is a new disease, there is The overall case-fatality rate (CFR) was re- perinflammatory phase. no specific antiviral drug for its treatment. ported to be 2.3%; CFR was higher in the Potential therapies are being explored. elderly. However, the WHO has estimated Early infection is the first stage of the ill- the global death rate for the novel corona ness. The patient has only mild constitution- In the event of any infection, the host reacts virus to be 3.4%. The CFR will also change al symptoms such as fever (>99.6º F), dry by initiating an immune response to fight in countries with high aging population, for cough, headache and diarrhea. At this stage, off the infection in the early phase (“viral instance, Italy. laboratory tests show lymphopenia and in- response phase”). In the later stages of the creased levels of PT, d-dimer and LDH. illness (“host inflammation response phase”), the host may have an exaggerated or out Clinical manifestations Undetected or untreated, the patient moves of control immune response to the trigger, into the next stage of the illness, the pul- which is the COVID-19 virus infection. Covid-19 most commonly manifests clini- monary phase. The patient develops short- This is called “cytokine storm”. At this stage, cally as fever (43.8% on admission and ness of breath and hypoxia (PaO2/FiO2 the virus is lethal and is responsible for the

3 COVID-19

critical condition of the patient and is of- Samples include nasopharyngeal and oro- of remdesivir as treatment for patients with ten fatal. Tests for inflammatory markers pharyngeal swab, or sputum and/or endo- moderate or severe COVID-19. (CRP, IL-6, D-dimer, ferritin), troponin, tracheal aspirate or bronchoalveolar lavage NT-proBNP levels can detect the presence in patients with more severe respiratory Lopinavir/ritonavir has been used for the of cytokine storm. disease. Samples should be collected with treatment of COVID-19 [18, 19]. stringent infection control precautions [13]. In a trial of adults hospitalized with severe Diagnosis The diagnosis of COVID-19 is confirmed Covid-19, time to clinical improvement was by the detection of virus RNA by reverse- comparable between patients treated with In its interim guidance for surveillance, transcription polymerase chain reaction lopinavir–ritonavir (400 mg/100 mg twice the WHO has defined criteria for suspect (RT-PCR) [13]. However, a negative result daily for 14 days plus standard care) as com- case, probable case and confirmed case as does not exclude the likelihood of the per- pared with those who were given standard follows [12]: son having the disease. Patients with nega- care alone (median, 16 days). Mortality at tive RT-PCR but high clinical suspicion 28 days was 19.2% in lopinavir-ritonavir Suspect case should undergo CT scan along with re- group, whereas it was 25% for the standard • A patient with acute respiratory illness testing for the virus [14]. A report of more care group; however, this difference was not (fever and at least one sign/symptom of than 1000 cases from China concluded that statistically significant [20]. respiratory disease, e.g., cough, shortness chest CT scan has a higher sensitivity for of breath), AND a history of travel to or diagnosis of COVID-19 as compared with In India, Central Drugs Standard Control residence in a location reporting commu- RT-PCR [15]. Organization (CDSCO), the national regu- nity transmission of the COVID-19 dis- latory body for Indian pharmaceuticals and ease during the 14 days prior to symptom medical devices, has approved the “restrict- onset; or Treatment ed use” of lopinavir-ritonavir combination • A patient with any acute respiratory ill- for treating those affected by novel corona- ness AND having been in contact with Since COVID-19 is a new disease, there is virus (nCoV). a confirmed or probable COVID-19 case no specific antiviral drug for its treatment. (see the definition of contact) in the last Potential therapies are being explored. In Thailand, oseltamivir along with lopina- 14 days prior to symptom onset; or vir and ritonavir has been used successfully. • A patient with severe acute respiratory The WHO is conducting a multi-country illness (fever and at least one sign/symp- clinical trial called the “Solidarity Trial” to Arbidol, an antiviral drug used in Russia tom of respiratory disease, e.g., cough, investigate four drugs (or their combina- and China to treat influenza, could be com- shortness of breath, AND requiring hos- tions) for the treatment of Covid-19: rem- bined with darunavir, the anti-HIV drug, pitalization) AND the absence of an al- desivir; chloroquine, hydroxychloroquine; for treating COVID-19 patients. ternative diagnosis that fully explains the combination of lopinavir and ritonavir; clinical presentation. lopinavir+ritonavir combination plus inter- The WHO does NOT recommend routine feron-beta. administration of systemic corticosteroids Probable case for the treatment of viral pneumonia outside • A suspect case with inconclusive testing Remdesivir is an investigational broad-spec- of clinical trials, unless there is an indication for COVID-19, or trum antiviral agent. It has shown encour- to do so (exacerbation of asthma or COPD, • A suspect case for whom testing could aging results in vitro for treating MERS. septic shock). Patients given steroids should not be performed for any reason. Prophylactic and therapeutic remdesivir be monitored for hyperglycemia, hyperna- improved lung function and also decreased tremia, hypokalemia, signs of adrenal insuf- Confirmed case: A person with laboratory lung viral loads and severe lung pathology in ficiency or recurrence of inflammation [21]. confirmation of the COVID-19 infection, vitro [16]. The compassionate use of remde- regardless of clinical signs and symptoms. sivir has also been reported in the first CO- Hydroxychloroquine and chloroquine have VID-19 patient diagnosed in the United also been evaluated for the treatment of All suspect cases (as per the above criteria) States with no adverse effects [17]. COVID-19 [22, 23]. should be tested for the COVID-19 virus, including other respiratory pathogens such Clinical trials in the United States and Chi- Both hydroxychloroquine and chloroquine as influenza, respiratory syncytial virus, etc. na are underway to investigate the efficacy are immunomodulatory. Of these two,

4 COVID-19

hydroxychloroquine has been found to Patients with severe COVID-19 illness also Jan . 15: Japan reported its first imported have more potent in vitro antiviral activ- had increased levels of blood interleukin case of lab-confirmed virus ity against SARS-CoV-2 suggesting that (IL)-6, high-sensitivity cardiac troponin Jan . 20: First case reported in South Korea it may be an ideal therapeutic option for I and lactate dehydrogenase (LDH) and Jan . 21: Human-to-human transmission of critically ill patients through its antiviral lymphopenia. the virus confirmed action as well as by controlling the cyto- Jan 24:. France reported the first case kine storm via its immunomodulatory Jan . 25: Australia and Malaysia reported properties [22]. Evolution of the COVID-19 their first cases pandemic: chronology Jan . 30: The WHO declared coronavirus a Results of the ongoing open‐label non‐ran- “public health emergency of international domized clinical trial “the Marseille study” of key events concern (PHEIC); India, Finland, Philip- show a strong reduction in nasopharyngeal pines reported their first cases of the new carriage of Covid-19 virus in only 3 to 6 days The COVID-19 pandemic, as it stands to- corona virus in most patients. Addition of azithromycin day, has moved through various stages since Jan . 31: First two confirmed cases of 2019- to hydroxychloroquine further augmented it first emerged from Wuhan, China, as a nCoV reported in Italy elimination of the virus. After 6 days, 100% local outbreak. The disease spread to the Feb . 5: Ten passengers on board the Dia- of patients treated with the combination of entire country within a month, despite ex- mond Princess Cruise ship docked in Yoko- hydroxychloroquine and azithromycin were treme measures adopted by China includ- hama, Japan, test positive virologicaly cured as against 57.1% patients ing a lockdown of whole cities [25]. Feb . 11: The WHO officially named the treated with hydroxychloroquine alone and disease as “COVID-19” 12.5% in the control group [24]. On March 19, China reported zero local Feb . 13: For the first time, China reported transmission rate for the first time since the clinically diagnosed cases in addition to the The National Task Force for COVID-19 pandemic began; the 34 new cases reported laboratory-confirmed cases set up by the Indian Council of Medical were imported cases. However, on March Feb . 14: Africa’s first COVID-19 case re- Research (ICMR), the apex health re- 22, after three days, China reported its first ported in Egypt search body of India, has recommended case of domestic infection. Feb . 19: First COVID-19 cases reported in hydroxychloroquine for prophylaxis of Iran SARS-CoV-2 infection for high risk pop- The number of confirmed cases worldwide Feb . 26: For the first time, more new cases ulation: has exceeded 300, 000 .The virus has now were reported from outside China than • Asymptomatic Healthcare Workers in- spread to around 200 countries . More than from China volved in the care of suspected or con- 80% of all cases are from the WHO West- Feb . 28: The WHO raised the level of glob- firmed cases of COVID-19: 400 mg ern Pacific Region and European Region . al risk to “very high” twice a day on Day 1, followed by 400 mg March 7: The global number of reported once weekly for next 7 weeks; to be taken Here is the chronology of key events as they cases crossed 100,000 with meals; have occurred. March 11: The WHO declared the corona • Asymptomatic household contacts of virus outbreak a pandemic laboratory confirmed cases: 400 mg twice Dec . 31, 2019: Cluster of cases of pneu- March 13: The WHO declared Europe a day on Day 1, followed by 400 mg once monia of unknown etiology reported from to be the new epicenter of the pandemic, weekly for next 3 weeks; to be taken with Wuhan, China with more reported cases and deaths than meals. Jan . 1, 2020: Huanan Seafood Wholesale the rest of the world combined, apart from Market in Wuhan, suspected to be the China source of the disease, closed March 15: 2,000 new coronavirus cases and Prognosis Jan . 7: China isolated a new type of corona more than 100 deaths over the last 24 hours virus as the cause, named 2019-nCoV in Spain Older age, high Sequential Organ Failure Jan . 11: First death due to the new Corona March 16: The total number of cases and Assessment (SOFA) score (a diagnostic virus reported in China deaths outside China exceeded those in marker for sepsis and septic shock) and Jan . 12: Genetic sequence of the new Co- China d‑dimer levels greater than 1 µg/L on ad- rona virus shared by China March 18: China reported no local transmission are indicative of poor prognosis and Jan . 13: Thailand reported the first case mission for the first time since the pandem- higher risk of death [5]. (lab-confirmed) outside China ic began, only imported cases; the WHO

5 COVID-19

launched multi-country SOLIDARITY India Model firmed cases; patients are discharged only Trial to compare untested treatments after evidence of chest radiographic clear- March 19: The number of confirmed cases 1117 active cases and 32 deaths at the time ance and viral clearance in the respiratory worldwide exceeded 200,000; Italy (3405 of writing this article samples (after two specimens test negative deaths) overtook China (3249 deaths) for for the virus within 24 hours). the number of deaths related to corona vi- India is currently in the early third stage of rus, making it the world’s deadliest centre of the epidemic, most confirmed cases have a ICMR’s National Institute of Virology has the outbreak history of travel to corona-affected coun- isolated the COVID-19 virus strain mak- March 22: India attempted the largest study tries and their close contacts. There is no ing India the 5th country to do so. The other on the role of over 5% population (critical evidence of widespread community trans- four countries are China, Japan, Thailand mass) on social behaviours by observing mission yet in India. A sentinel surveillance and the United States of America. self-restriction based ‘shelter in home’, a initiated by ICMR found no positive sam- 14‑hour restriction at home with mass clap- ples in H1N1 negative viral pneumonias. The Ministry of Health & Family Welfare ping for 5 minutes at 5pm as an alternative The survey tested 826 samples of people has invoked the Epidemic Disease Act, 1897 to forced lockdown. suffering from severe acute respiratory in- (Section 2) so that all advisories issued are fection (SARI)/influenza like illnesses at enforceable; the Disaster Management Act 51 sites by 15 March 2020 [26]. to ensure price regulation and availability COVID-19: Measures of masks, hand sanitizers and gloves, and adopted by CMAAO India issued a travel advisory as early as Jan- the Essential Commodities Act to regulate uary 17 and has been regularly updating the production, quality, distribution, etc. of face countries travel advisories keeping with the evolving masks and hand sanitizers and to ensure situation. Screening of air travellers has been their availability at reasonable prices or un- CMAAO is a Confederation of Medical ongoing since January 18. All existing visas der MRP. Associations in Asia and Oceania. It has (except for diplomatic, official, UN/Interna- national medical associations (NMAs) of tional Organizations, employment, project Other public health measures include creat- 19 countries as its members. Since it was visas) have been suspended until 15 April ing mass awareness about preventive mea- first established in 1956, the objective of 2020. All international commercial passen- sures (social distancing, hand washing,), CMAAO activities as stated in its consti- ger flights have been banned from 22 March closing of all educational institutions, mu- tution has been to promote academic ex- 2020 till April 14. All domestic travel too has seums, swimming pools, malls and theatres change and cultivate ties of friendship be- been put on hold until March 31. (except for grocery, vegetables and chemist tween member medical associations. shops); work from home (except those work- Countrywide regular surveillance was ing in emergency/essential services); all citi- Many Asian countries have been able to initiated for all travel-related and their zens above 65 and children below 10 years contain the disease to some extent, unlike close contacts, including those having fe- have been advised to remain at home. Europe and the USA, where cases are spi- ver, cough or breathlessness. India has been ralling and a slowdown seems inconceivable. carrying out “need-based testing”, i.e., testing suspected cases with history of travel South Korea Model Strategies like mass testing, timely alerts to areas with active transmission and their and advisories, effective screening and sur- close contacts. However, the government 9786 cases with 162 deaths veillance have been crucial in the efforts to has revised its testing policy: “All hospital- contain the spread of the virus. However, ized patients with severe acute respiratory With 4212 confirmed cases, up to March 2, this is not the time to be complacent; it is illness (fever and cough and/or shortness of South Korea was next only to China, which the time to exercise patience, be cautious breath) will now be tested for COVID-19 had 80,026 confirmed cases at that time and not let up the constant vigil. infection. And, all asymptomatic direct [27]. and high-risk contacts of a confirmed case We first issued a CMAAO Alert on CO- should be tested once between day 5 and Still, South Korea has slowed down its rate VID-19 on January 8, even as it was still day 14 of coming in contact”. of infection; from a peak of 851 new cases a mysterious lung infection in China. Since per day on March 3, the number of new then CMAAO has been creating awareness The Ministry of Health & Family Welfare cases has declined to 64 cases per day, as on about the disease every day. of India has a discharge policy for con- March 23 [28].

6 COVID-19

The reason for this success has been its test- suspected of infection and order them to cases that did not fit the prescribed case ing policy of “Trace, Test and Treat” . In- undergo diagnosis and treatment. A “Clus- definition [32], aggressive contact tracing stead of putting entire cities under a lock- ter Response Section” was formed to quick- and quarantine of close contacts of con- down or implementing punitive measures, ly identify and contain small-scale clusters firmed cases, travel advisories and entry South Korea put in place an extensive mass of COVID-19 infections before they turn restrictions, as well as public education testing program to quickly identify hotspots into large-scale ones [31]. helped to contain the epidemic in the to further prevent transmission and initi- country [33]. All events and gatherings ate early intervention (contact tracing and Japan initially made an error of cohort quar- with 250 or more participants had been quarantine) and treatment [29]. antine for 3700 people on the Diamond suspended. ship mixing people of all ages together South Korea has randomly tested more for 14 days and ending up with 712 posi- Singapore also defined punitive actions than 270,000 people (amounting to more tive cases and 8 deaths. Cohort quarantine (fine of up to $10,000 or up to six months than 5200 tests per million population); should have been high risk vs low risk co- in prison) against those who violate their this number is higher than in any other hort quarantine [31]. quarantine or give a false account of their country [29]. Under this program, around travel history. 12,000–15,000 people are tested daily and the system is capable of carrying out 20,000 Singapore Model Singapore had zero healthcare infection tests a day [30]. Drive-through testing rate due to its policy of liberal distribu- centres and mobile alerts about those who 926 cases with only 3 deaths tion of masks at every hospital reception, tested positive for the virus have further ex- N95 masks by health care providers and AI panded the testing capacity. Singapore acted early on in the pandemic rooms for all positive cases. and constituted a Multi-Ministry Task Besides travel restrictions, other preventive Force before a case was detected to provide measures such as social distancing, use of central coordination during the crisis [32]. Taiwan Model masks, hand washing, allowing people to work remotely, avoiding mass gatherings Besides temperature screening of all trav- 322 cases with 5 deaths (attending online religious services instead) ellers from Wuhan, all physicians had also have helped the country to reduce the num- been warned by the Health Ministry to Taiwan created a data source (also accessible ber of infected cases [29]. identify any patient with pneumonia and a to health professionals) by integrating the recent travel history to Wuhan, almost right national health insurance database with im- from the time when the outbreak was first migration and customs database to identify Japan Model reported from Wuhan [33]. As a result, Sin- persons at high risk based on their travel gapore was able to expedite case detection. history and clinical symptoms. Patients 1953 cases and 56 deaths Doctors were also allowed to test patients if with severe respiratory symptoms who had they suspected them to be infected, based tested negative for influenza were retested Japan initially focused on containment of on clinical judgment or epidemiological for COVID-19 [34]. the epidemic, but after the COVID-19 out- reasons [32]. break on the Diamond Princess Cruise ship, QR code scanning and online reporting of the focus shifted to a prevention and treat- More than 800 Public Health Preparedness travel history and health symptoms were ment policy in anticipation of community Clinics (PHPCs) were activated to treat re- used to stratify risk categories of travellers: spread within the country. spiratory infections at the primary care level the low risk group was given a health dec- [32]. laration border pass through SMS on their The new coronavirus was designated as an phones; persons in the higher risk group “infectious disease” under the Infectious Singapore has a testing capacity of 2200 were put into home quarantine and moni- Diseases Control Law, which allowed the tests daily for a population of 5.7 million tored through cell phones to ensure compli- government to order infected patients to [32]. Tests are free for all, including visitors ance with the quarantine [34]. undergo hospitalization. COVID-19 was to the country. also classified as a “quarantinable infectious The government has also imposed fines for disease” under the Quarantine Act, which Other public health measures, which in- hoarding, spread of misinformation and allows the government to quarantine people cluded enhanced surveillance to identify breach of quarantine.

7 COVID-19

Malaysia Model VID-19 and increasing the total number of transmission, reduce the number of cases cases to 114 from 82 [36]. More and more and contain the epidemic. 2766 cases with 43 deaths clusters are testing positive for the virus, indicating a super spreader. Social distancing with no emotional dis- I was in Malaysia on January 18 when we tancing, i.e., maintaining a distance of at had the first interaction with MMA re- Thailand has a dedicated national pandemic least 1 m (3 feet) from other people or self- garding Corona Virus. Same day, I had a influenza preparedness plan, which is in the quarantine or self-isolation; working from meeting with the Myanmar Medical Asso- process of updating. All educational insti- home; virtual meetings; closure of schools; ciation, Thailand Medical Association and tutions, entertainment outlets have been limiting the size or canceling public gath- China Medical Association regarding the closed. erings; regular handwashing with soap and same. water; respiratory hygiene, cough etiquette Air travellers have been segregated into or building hygiene are potential mitigation Malaysia is now experiencing widespread three risk groups, based on the origin of strategies, which can be implemented when ongoing transmission of the COVID-19 their flight: Disease Infected Zones (man- a chain of transmission is not known. virus. datory 14-day self-quarantine, health forms at check-in certifying that they are not at Instead of moving from containment to Malaysia has been under a nation-wide risk of COVID-19), countries with ongo- mitigation, adopting a combination of con- lock-down (except for essential services) ing local transmission (home-based 14-day tainment and mitigation measures may slow since March 18 with the growing num- quarantine, report symptoms to officials) the disease spread. ber of corona cases. All persons arriving in and other destinations (precautions such as Malaysia mandatorily undergo check for wearing masks, avoiding mass gatherings Flattening the epidemic curve, instead of symptoms of corona. All air travellers are and crowds). allowing a steep curve (illustrating an ex- issued Health Alert Cards indicating their ponential increase in the number of cases), health status, which must be kept for the slows the transmission of the COVID-19 next 14 days. Flattening the curve: virus so there are fewer cases and also fewer Decontaminate, wash hands deaths; enough resources are available and The Ministry of Health has identified 48 patients are able to access the critical care hospitals for coronavirus screening includ- and maintain social they need. While a flatter curve may pro- ing 26 referral hospitals to manage coro- distancing long the epidemic, it relieves the overbur- navirus suspected and positive cases. Con- dened healthcare system, where demand tacts of positive cases are being tracked Countries are engaged in efforts to control surpasses capacity, for instance, not enough by the Malaysian Epidemiology Bureau. the ongoing pandemic, but there seems to hospital beds, ventilators, etc. Italy is expe- Asymptomatic cases are put under home be no foreseeable end to this. The inevitable riencing this at present. quarantine, while symptomatic persons are question is whether we will be able to stop hospitalized for testing and monitoring as or delay the peak and rapid spread of the To control the COVID-19 pandemic, the persons under investigations [35]. disease. aim should be to flatten the curve and delay the peak. Addressing the media on March 11, WHO Thailand Model Director-General Dr Tedros Adhanom Results of a latest mathematical model Ghebreyesus said, “This is the first pandemic study conducted by ICMR show that 1651 cases with 10 deaths caused by a coronavirus. And we have never adopting social distancing as a preventive before seen a pandemic that can be controlled, measure will flatten the curve. If strictly fol- The situation has begun to change since at the same time… We cannot say this loudly lowed, this will reduce the expected number mid-March, when health officials reported enough, or clearly enough, or often enough: all of cases by 62% and the peak number of a few large clusters of infections in Bang- countries can still change the course of this pan- cases by 89% [37]. kok. demic.” To achieve this: Thailand recorded a spike in the number of Identification and isolation of cases along • Clean and decontaminate surfaces, wash cases for the first time on March 15, with with rapid tracing and quarantine of con- hands and stay away from people with fe- 32 new cases of laboratory-confirmed CO- tacts may break the identified chains of ver and cough.

8 COVID-19

• Using 1 : 1 isolation method kit will help ment. Communication is crucial for sharing the world. In the event of any outbreak or stop the formation of clusters. information. There are lessons to be learnt public health crisis, we can share our health • Avoid handshakes and elbow greet; the from the ways different countries have models besides knowledge and experiences of traditional Indian greeting Namaste and managed the situation. a similar situation.” bowing is the best greeting in these times. • Maintain social distancing of one feet When I took over as President of CMAAO For the first time (March 19), since the pan- with others on 5 September 2019, at the CMAAO demic first began, China reported zero local General Assembly in Goa, India, in my transmission rate suggesting that it may be address I said, “As an organization, we too possible to control the disease, although it Conclusion share several public health challenges such as had a new case of local transmission 3 days vector-borne diseases such as dengue, malaria; later. COVID-19 is hitherto an unknown disease air pollution; communicable and non-com- caused by an unknown virus. Information municable diseases (NCDs); antimicrobial To achieve this, there needs to be a strategic about this disease is still evolving. There are resistance (AMR); tobacco use; HIV/AIDS, shift in our approach to tackle the pandem- still several questions unanswered. What to name a few. Violence against doctors and ic; instead of moving from containment to will be the fate of the virus? Will CO- inequity in health are few other issues that are mitigation in a stepwise manner, it may be VID-19 become an endemic disease? And a concern. Attaining universal health cover- prudent to combine containment and miti- many more. age, which is affordable, accessible, available, gation measures. appropriate and accountable, still remains a Preparedness and capacity building are distant goal for many of us. All these have a Could COVID-19 be the Disease X men- keys to averting such pandemics in times bearing on the socioeconomic progress of our tioned by the WHO in 2018 in its list of to come. A robust surveillance system is the countries. Therefore, it becomes our collective eight priority diseases? We do not know yet. basis of preparedness for any epidemic. It is responsibility to make certain that these is- also important to strengthen public health sues are prioritized. Some of these issues are Still, now we cannot afford to be compla- care systems for optimum utilization of re- global concerns and we should try to solve cent as the window of opportunity may be sources and facilitate research and develop- them as a family and set an example for too small in any such future events.

Appendix Coronary artery disease patients most at risk [CAD 10.5%, Diabe- tes 7.3%, COPD 6.3%, Hypertension 6%, Cancer 5.6%, no pre–existing disease (0.9%) Three Cs of managing a new disease Health care provider infection: China 3.8%; 0.3% deaths. Singa- First Case – index or the primary (Stage 1) pore: nil First Cluster of “person to person” transmission (Stage 2) Deaths: 10% in Iran (under reporting) First evidence of Community spread (surface to person transmis- South Korea: (0.6%) doing more tests in mild cases sion) Affects all sexes but predominately males: 56% Age: 87% (30–79), 10% (<20), 3% (>80)

COVID-19: A snapshot Mean time to symptoms: 5 days Mean time to pneumonia: 9 days Causes mild illness in 82%, severe illness in 15%, critical illness in 3% Mean time to death: 14 days Mean time to CT changes: 4 days

Death rate: males 2.8% females 1.7% Reproductive number R0 3–4 (flu 1.2, SARS 2) Death: 3.4% (March 3) Epidemic doubling time: 7.5 days Deaths: 15% serious cases Doubling time in Korea: 1 day probably due to the super spreader Deaths: 71% with comorbidity Tripling time in Korea: 3 days 71% deaths are in patients with comorbidity due to cytokine Positivity rate (%): UK 0.2, Italy 5, France 2.2, Austria 0.6, storm. [72,314 Chinese cases, largest patient–based study, JAMA) USA 3.1

9 COVID-19

Origin: Probably from bats (mammal; central hosts), snakes and • Semen: We do not know yet for the new corona virus (in patients pangolins (intermediate hosts); possible animal sources of COV- infected with Ebola, the virus may persist for months in the testes ID-19 not yet been confirmed or eyes even after recovery and can infect others and keep the epidemic going). Spread: large droplets; predominately from people having LRTI • Sexual transmission like Ebola and Zika infected cases: No evi- Precautions: standard droplet for the public and close contacts; air dence yet. borne for healthcare workers dealing with secretions • Goods from affected areas: People receiving packages from affected areas are not at risk. Incubation period: 2–14 days • Pipes: Ventilation systems connect one room to another. There Mean Incubation period: 5.2 days has been previous concern that the coronavirus can spread through pipes. Recovery time 2 weeks (mild cases); 4–6 weeks (severe cases) • Stress: Stress and anxiety are known to suppress the immune Case fatality: 80 + 14.8% system, making people more susceptible to contracting the virus. Case fatality: 70–79 = 8% • Patients without symptoms: Both SARS-CoV and Case fatality 60–69: = 3.6% MERS-CoV infect intrapulmonary epithelial cells more than Case Fatality 50–59: = 1.3% the cells of the upper airways. Consequently, transmission oc- Case fatality 40–49: 0.4% curs primarily from patients with recognized illness and not Case fatality 10–39: 0.2% from patients with mild, nonspecific signs. Though NEJM has Case fatality <9 years: nil reported a case of COVID-19 infection acquired outside Asia when the transmission of mild cases appears to have occurred during the incubation period in the index patient but the same Transmission has been challenged now. • Fabric, carpet, and other soft surfaces: Currently, there is no evi- • Corona beer: It has nothing to do with coronavirus. It is a brand dence. of beer. • Hard surfaces: Doorknobs, likely to survive for just a few hours • Minimal risk in a plane: Window seat. (WHO). • Airports more at risk: Pipes, AC, International travelers, close • Non-porous surface 1–2 days and porous surface 8–12 hours. surface contact; wear gloves when in doubt. • Casual exposure: Human to human contact requires prolonged • All TV panelists: Wear disposable earphones. contact (possibly 10 minutes or more) within 3 to 6 feet. • Currency notes: The central banking authorities of China are disinfecting cash to stop the spread. Formula of C • Biometric attendance: Suspended in India. • Kissing: Scenes banned in movies in China. France cut back on la Corona; COVID; CHINA Pneumonia (early name); CONTAIN- bise, the custom of greeting with kisses, or air kisses, on the cheeks. MENT policy; break CHAIN of transmission; 1st Case; 1st Cluster; • Breath analyzer tests for alcohol: Kerala (India) exempted air 1st Community spread; new Case; avoid COHORT of CLOSE crews. CONTACTS; CAP price of essential items; CONTACT trac- • Public gatherings: The affected countries have banned death ing; CARE of the elderly; CONVINCE patients to wear surgi- rituals, people gatherings. cal masks; COUGH not to be ignored; CDC guidelines; avoid • Uncovered eyes: The transmission is through the mucous mem- CHAOS; CHLOROQUINE can be tried; COLOR CODING brane contamination. One case got infected even when using a (Red, Yellow, Green); stay CONNECTED with updates; know gown, but eyes were not covered. COUNTRIES not affected; CRITICAL cases; no CONTACT • Eating meat, fish or chicken:It’s not a food-borne illness but policy; CHECK list of hospitals; CHECK points (all port entries); a respiratory illness. It cannot occur by eating any food or meat. COLLECTIVE action; CONTROLLED measures; CONDOM However, it is always advised not to touch raw meat, eat raw meat (no evidence that it protects); CONGENITAL (no evidence of or eat partially cooked meat to prevent meat-related food borne congenital Covid-19); CLEARING of antigen; COMPLAIN illnesses. Eating fish and chicken is safe. (Section 270 of Indian Penal Code [IPC]); do not CRTICISE; • Eating snakes or drinking bat soups: Eating wild animals cannot CALM during illness; COMMUNICATION is the key; COM- cause it. Handling their secretions can cause it. MITMENT of government; CAD patients are the highest risk; • Handling wild animals or their meat: Yes, if their secretions are CHILDREN are less likely to die; COLD blooded animals are not handled by the animal handlers. the source; CLAIM of insurance should not be cancelled.

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What is Coranxiety? 10. Total expected number of cases 11. Italy scenario: 978/million population (0.1% of the population) Anxiety about falling ill and dying; avoiding or not approaching 12. China scenario: 56/million population healthcare facilities due to fear of becoming infected during care; 13. Switzerland scenario: 1000/population fear of losing livelihood; fear of not being able to work during iso- 14. Average scenario: 46 per million population lation; fear of being dismissed from work if found positive; fear of 15. Average scenario India: 50 per million population being socially excluded; fear of getting put into quarantine; fear of 16. Expected number of cases after seven days being separated from loved ones and caregivers due to quarantine; 17. Number of cases today x 2 (doubling time 7 days, normal refusal to take care of unaccompanied or separated minors; refusal spreader) to take care of people with disabilities or elderly because of their 18. Number of cases x 6 (doubling time 2days, super spreader) high-risk nature; feeling of helplessness; feeling of boredom; feel- 19. Number of cases expected in the community: We can look at ing of depression due to being isolated; stigmatization of positive the number of deaths occurring in a five-day period, and esti- infection; possible anger and aggression against government; un- mate the number of infections required to generate these deaths necessary approaching the courts; possible mistrust on informa- based on a 3.3 per cent fatality rate. tion provided by government; relapses of mental illness in already 20. Finally, we can compare that to the number of new cases actu- mentally-ill patients; overstress on people to cover work of infected ally detected in the five-day period 17 days earlier to give us an colleagues; quarantined for 14 days and insufficient or incomplete estimate of the proportion of actual cases that were detected 17 information leading to myths and fake news. days ago. 21. This can then give us an estimate of the total number of cases, confirmed and unconfirmed. Precautions for general public 22. Lockdown effect: reduction in cases after average incubation • Strict self-quarantine if sick with flu-like illness: 2 weeks. period ( 5 days) • Wash your hands often and for at least 20 seconds with soap and 23. Lockdown effect in reduction in deaths: on day 14 (time of water or use an alcohol-based hand sanitizer. death) • Avoid touching: eyes, nose, and mouth with unwashed hands. 24. Requirement for ventilators on day 9: 3% of the number of • Avoid close contact: stay at a distance of 3-6 feet from people who new cases detected are sick with cough or breathlessness. 25. Requirement for future oxygen on day 7: 15% of total cases • Cover your cough or sneeze with a tissue, then throw the tissue detected today in the trash. 26. Number of people which can be managed at home care: 80% • Clean and disinfect frequently touched objects and surfaces. of number of cases today 27. Requirement for ventilators: 3% of the number of cases today Which masks should be used by health 28. Requirement for oxygen beds today: 15% of total cases today care providers and patients? 29. Match the curve to see where you are going • For patients and close contacts: surgical 3-layered masks: • For healthcare providers when handling respiratory secretions: N95 masks

COVID Models to Know Future Numbers 1. Case fatality rate: Number of deaths/Number of cases 2. 5 pm 23 March: 14924/345289 = 4.32% 3. Correct formula: CFR = deaths at day .x/cases at day .x-{T} (where T = average time period from case confirmation to death, which is 14 days) 4. Deaths on 23 March: 14924 5. Cases 14 days before 10 March: 114381 6. Correct CFR = 14924/114381= 13% 7. Deaths in symptomatic cases = 1-2% 8. Number of deaths X 100 = expected number of symptomatic cases 9. Symptomatic cases x 50 = number of asymptomatic cases

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fection in Korea: the application of lopinavir/ri- lances: The epidemiological characteristics of an 60. 2020 coronavirus pandemic in Japan. Available tonavir for the treatment of COVID-19 infected outbreak of 2019 novel Coronavirus Diseases at: https://en.wikipedia.org/wiki/2020_corona- pneumonia monitored by quantitative RT-PCR. (COVID-19) — China, 2020. China CDC virus_pandemic_in_Japan. J Korean Med Sci. 2020; 35(6):e79. Weekly. 2020;2(8):113-22. 61. Lee VJ, Chiew CJ, Khong WX. Interrupting 49. Cao B, Wang Y, Wen D, Liu W, Wang J, Fan G, 55. ICMR Initiated Sentinel Surveillance to detect transmission of COVID-19: lessons from con- et al. A trial of lopinavir-ritonavir in adults hos- community transmission of COVID-19, ICMR tainment efforts in Singapore. J Travel Med. pitalized with severe Covid-19. N Engl J Med. Press release, March 19, 2020. 2020 Mar 13. pii: taaa039. doi: 10.1093/jtm/ 2020 Mar 18. 56. Korean Society of Infectious Diseases; Korean taaa039. [Epub ahead of print] 50. Clinical management of severe acute respiratory Society of Pediatric Infectious Diseases; Ko- 62. Wong JEL, Leo YS, Tan CC. COVID-19 in infection (SARI) when COVID-19 disease is rean Society of Epidemiology; Korean Society Singapore-Current experience: critical global suspected. Interim guidance, WHO, March 13, for Antimicrobial Therapy; Korean Society for issues that require attention and action. JAMA. 2020. Healthcare-associated Infection Control and 2020 Feb 20. doi: 10.1001/jama.2020.2467. 51. Yao X, Ye F, Zhang M, Cui C, Huang B, Niu Prevention; Korea Centers for Disease Control [Epub ahead of print] P, et al. In Vitro Antiviral Activity and Projec- and Prevention. Report on the Epidemiological 63. Wang CJ, Ng CY, Brook RH. Response to tion of Optimized Dosing Design of Hydroxy- Features of Coronavirus Disease 2019 (COV- COVID-19 in Taiwan: Big Data Analytics, New chloroquine for the Treatment of Severe Acute ID-19) Outbreak in the Republic of Korea from Technology, and Proactive Testing. JAMA. 2020 Mar 3. doi: 10.1001/jama.2020.3151. [Epub Respiratory Syndrome Coronavirus 2 (SARS- January 19 to March 2, 2020. J Korean Med Sci. ahead of print] CoV-2). Clin Infect Dis. 2020 Mar 9. 2020 Mar 16; 35(10):e112. 64. Duddu P. Coronavirus in Malaysia: COVID-19 52. Gao J, Tian Z, Yang X. Breakthrough: Chloro- 57. https://www.worldometers.info/coronavirus/ outbreak, measures and impact. MARCH 23, quine phosphate has shown apparent efficacy in country/south-korea/. 2020. Available at: https://www.pharmaceutical- treatment of COVID-19 associated pneumonia 58. Coronavirus cases have dropped sharply in technology.com/features/coronavirus-affected- in clinical studies. Biosci Trends. 2020 Feb 19. South Korea. What’s the secret to its success? countries-malaysia-covid-19-outbreak-meas- 53. Gautret et al. (2020) Hydroxychloroquine and March 17, 2020, Available at: https://www.sci- ures-tourism-economy-impact/ azithromycin as a treatment of COVID‐19: encemag.org/news/2020/03/coronavirus-cases- results of an open‐label non‐randomized clini- have-dropped-sharply-south-korea-whats-se-

cal trial. International Journal of Antimicro- cret-its-success. bial Agents – In Press 17 March 2020 – DOI : 59. What the U.S. needs to do today to follow South Dr. Krishan Kumar Aggarwal 10.1016/j.ijantimicag.2020.105949. Korea’s model for fighting Coronavirus. Avail- President CMAAO & Heart 54. The Novel Coronavirus Pneumonia Emergency able at: https://time.com/5804899/u-s-corona- Care Foundation of India Response Epidemiology Team. Vital Surveil- virus-needs-follow-s-korea/. Past President Indian Medical Association

The Corona Virus Outbreak on South African Medical Schemes

Maninie Molatseli Michael Mncedisi Willie Sipho Kabane Clarence Mini

The economic impact of pandemics is be- travel and unlimited access to media tech- marily driven not by mortality or morbidity coming more potent and widespread as a nologies often fuel contagion of both the figures but mostly by the behavioral changes result of greater human and economic con- disease and the fear surrounding it. Interest- as people, businesses and governments seeks nectedness. Transnational supply chains, ingly, the impact of infectious disease is pri- to avoid infection or isolate infected persons

13 COVID-19

volatile financial markets as a result of the virus outbreak are likely to negatively impact investment returns in this asset class. This is further exacerbated by the prevail- ing domestic recession conditions after two consecutive quarters of negative economic growth in the region of 0.8 and 1.4 percent respectively (Stats SA, 2020). Other asset classes, like local government bonds and money market/bank deposits may also be affected, however the overall impact on the investments of medical aids is largely unknown and likely on the downside.

References 1. Jonas O. (2014). Pandemic risk. Washington, DC: World Bank. 2. World Bank (2014). The economic impact of the 2014 Ebola epidemic: Short and medium term estimates for West Africa. Washington, DC: World Bank. Figure 1 . MSCI (market cap weighted stock market index) trends and associated disease 3. IMF: Virus outbreak will slow global economic outbreaks. Source: Charles Schwab Factset data as of 1/21/2020 growth this year. Available online: https://www. aljazeera.com/ajimpact/imf-virus-outbreak-slow- global-economic-growth-year-200305013321840. or populations. Estimates provided by the nancial market woes have been felt on the html. Accessed: 03/03/2020. World Bank indicate that the economic Johannesburg Stock Exchange. China is not 4. Will the Coronavirus Outbreak Lead to a Mar- impact of a severe pandemic can be in the only the biggest importer of South African ket Breakdown? Available online: https://www. region of five percent of global GDP ( Jo- raw mineral exports; it is also a global leader schwab.com/resource-center/insights/content/ nas, 2014). While this may seem overstated, in the production and value addition of fin- will-virus-outbreak-lead-to-market-breakdown. Accessed: 03/03/2020. the recent Ebola outbreak in West Africa ished products destined for South Africa. 5. Stats SA (2020). GDP in the fourth quar- resulted in cumulative losses of 10 percent ter of 2019 decreased by 1,4%. [Press release]. of GDP between 2014 and 2015 with an The impact on the medical schemes in- 03/03/2020. infection rate of less than one percent of the dustry is likely twofold. On the one hand, Ms. Maninie Molatseli, region’s population (World Bank, 2014). medical schemes invest their reserves in Senior Researcher: Policy, Research viable investment instruments to counter and Monitoring Unit Aside from the productivity losses experi- the impact of medical aid inflation, so they enced due to pandemics, financial markets are exposed to the current financial market Mr. Michael Mncedisi Willie, are also adversely affected as a result of a downturn. On the other hand, any hint of General Manager Research & Monitoring, slowdown in trade, disruption of supply a weakness in South Africa’s public health Council for Medical Schemes, South Africa chains or perceived health systems risks. The surveillance and detection system will likely E-mail: [email protected] current outbreak of the Corona virus in Chi- result in public panic and cause a rise in na, which contributes about 16 percent to claims for health consultations or hospital- Dr. Sipho Kabane, the global economy, has accelerated fears of izations by members. CE and Registrar, Council a global economic slowdown or an outright for Medical Schemes, recession (IMF, 2020). Global stock markets In terms of investments, medical schemes South Africa have experienced losses since the outbreak; are only allowed to allocate a maximum of E-mail: [email protected] however, trends of past disease outbreaks 40 percent of their reserves to equities as and the global stock market performance per Regulation 29 and 30 of the Medical Dr. Clarence Mini, show a subdued impact overtime (Charles Schemes Act in order to reduce exposure Chairman of Council, Council Schwab, 2020). South Africa currently has to high risk asset classes. The impact of the for Medical Schemes, one reported case of the virus, but the fi- forecasted global economic slowdown and South Africa E-mail: [email protected]

14 Organ Donation

transplant practice, the Chinese Medical Reform Proceeding of Organ Donation and Association developed serial clinical norms and guidelines about transplantation, A to- Transplantation System in China tal of 23 guidelines, covered aspects like complications diagnosis, prevention and tation system, develop voluntary, no-paid treatment, had been published and com- organ donation by citizens at the World piled in The clinical guideline for organ trans- Health Organization (WHO) High-level plantation (2010 version). At same times, meeting on health held in Philippines [2]. the clinical practice regulations of kidney, The development and construction phase liver, heart and lung were also developed started, and the reform proceeding to es- and formed a book on organ transplant clini- tablish a legal and standardized system for cal technique norms (2010 version) [6, 7]. organ transplantation began in China. The The application of this clinical norms and reform was initiated with promotion of the guidelines did improve the standardization legislation in the field of organ transplan- and medical quality of the organ transplantation in 2007, the State Council of China tation practice in China. promulgated the Regulations on Human Or- gan Transplantation [3], which was imple- With the strengthening of the legal frame- mented nationwide in May 2007. The ad- work surrounding organ transplantation, ministrative matters involved in the process deceased organ donation was explored in of human organ transplantation were stipu- a three-year pilot program since 2010 [8], lated. It was reiterated in the regulations and then was officially promoted nation- Bingyi Shi that organ transplantation in China must wide on February 25, 2013. The organ Pro- comply with the WHO guidelines on hu- curement Organizations (OPOs) and or- The first kidney transplantation in China man organ transplantation and the interna- gan donation offices were then established was performed in 1960, which symbolized tional medical norms. In order to criminal- in various transplant medical institutions. the start of transplantation exploration in ize organ trafficking, the Amendment (VIII) According to China’s socioeconomic de- China [1]. To facilitate understood, the or- to The Criminal Law was promulgated in velopment level and cultural background, gan transplantation development in China 2011, making it punishable under criminal the Red Cross Society of China (RCSC) could be divided into in three phases: the law, and the legal framework in the field of was introduced to participate in propa- initial exploration phase (1960–2005), de- transplantation was strengthened [4]. The ganda, coordinate, and witness in organ velopment and construction phase (2005– Law of The Red Cross Society of the Peo- donation as a third party [9]. The China 2015) and scientific standardization phase ple’s Republic of China was revised in May Organ Donation Administrative Center (2015–). During the initial exploration 2017 [5], and it clearly stipulated that or- (CODAC) was set up to take charge in phase, all activities related to organ dona- gan donation should be promoted and that the work related to human organ donation tion and transplantation were explored humanitarian relief mechanisms should be and promote the concept of organ dona- Although a few cases of transplant with explored by charities. tion. An efficient and professional team organs donated after citizen’s death has of organ donation coordinator is need to been performed, executed prisoners were According to the regulations, the former promote the deceased organ donation, and the main source of organs donors. Neither Ministry of Health of china reviewed it was organized and trained by CODAC norms and guidelines nor registration sys- and approved organ transplant hospitals since 2011.So far, 34 training courses have tem were present in this period, as experi- in 2008, thereby reducing the number of been held, and 2,516 professional coor- ences accumulating and technique matu- transplant-qualified medical institutions dinators have been trained and certified. rating, guidelines and regulations was in from >600 to 164 (in 2008), the hospitals The coordinators are affirmed by inspec- urgent need to safeguard the scientific and were scrutinized and regulated strictly ev- tion, qualification, and certification every health development. ery year from then on. In the same year, year to ensure strict implementation of the a registration system for liver and kidney certification systems. This has gradually Huang Jiefu, the vice minister of the Min- transplant recipients was established, the established an efficient and professional istry of Health, pledged that China would medical quality of the transplant hospitals countrywide coordinator team, which has promote the reform of the organ transplan- was monitored. To standardize the clinical become the main force on the organ dona-

15 Organ Donation

tion front. Organ donation involves social, As coordinators are growing and matur- rate rose to 4.53 (from 0.03 at the begin- religious, ethical, political, legal, etc. To ing with the construction and improve- ning of the pilot in 2010), thereby laying a better promote the deceased organ dona- ment of the organ donation system, the solid foundation for high-speed develop- tion, a unique deceased donor classification number of voluntary deceased organ dona- ment of organ donation and transplantation system with three categories has been in- tion has been increasing year by year, and (Figure 1) [16]. More patients benefit from novatively proposed [9]. Meanwhile, the gradually occupying an important part of transplant surgery with the promotion of criteria and clinical norms for brain death transplant organs [14]. Based on these facts, deceased organ donation. The quantity of determination have been developed and The National Human Organ Donation and solid organ transplantation was rapidly es- updated, and the latest version (including Transplantation Commission (NHODT) calating, a total of 20,201 organ transplants adult and child version, respectively) was announced that executed prisoner organ were performed in 2018 (Figure 2). With revised in 2013 [10, 11], and the national donation should be terminated from Janu- the rapid increasing of the quantity of the “Brain Injury Evaluation Quality Control ary 1, 2015. From then on, citizen organ solid organ transplantation recently, China Center” set in Xuanwu hospital is approved donation has become the only legitimate now turns to pursue quality management for training and certifying physicians and source of transplantable organ in Chi- and improvement in the transplantation surgeons qualified to declare brain death. na [15]. field [16]. At present, the development tar- A total of 3,643 professionals qualified in gets of organ transplantation is undergo- brain death determination were trained After 10 years of arduous reform, a fair, ing a transition from fast growth of quan- from 2013 to 2019, who covered all regions transparent, and open climate of volun- tity and scale to promoting improvement of in the mainland China. They are certified to tary citizen organ donation movement has quality. China has set up organ transplant create suitable conditions for organ dona- gradually formed across the society. Organ quality control centers based on the original tion based on brain death. In recent years, donation reached 6,302 cases in China transplant recipient clinical data registra- China has also explored and introduced mainland in 2018. The number of organ tion systems in 2016, who are responsible regulations and mechanisms beneficial for donors ranked second worldwide, and the for the national medical quality monitor- organ donation and transplantation. For per-million-population (pmp) donation ing, supervision and inspection of specific example, the former National Health and Family Planning Commission, Ministry of Public Security, Ministry of Transport, China Civil Aviation Administration, Chi- na Railway Corporation and RCSC jointly established a green channel mechanism for organ transportation to ensure smooth transfer of donated organs in 2016 [12].

A scientific allocation system through which the organs donated could be allocated fairly and transparently is key characteristics to the scientific and ethical transplant system. The China Organ Transplant Response System (COTRS) was developed and put into operation in 2011, by which advanced international experience was referred to for determining the allocation priority. The Management Regulations for Acquisition and Distribution of Human Donor Organs (Trial) was issued in August 2013 as based on the experience with operation of COTRS [13]. It is mandatory that all donor organs must Figure 1 . Counts of Deceased Donor, Living Donor and PMP, 2015–2018. PMP was be allocated through the COTRS thereby calculated with the deceased donor. The Figure and data were obtained from ensuring that the processes are just, open, the Report on Organ Transplantation Development in China (2015–1018), and and traceable. authorized by the China Organ Transplantation Development Foundation

16 Organ Donation

Figure 2 . Counts of Transplantation Surgeries in China, 2015–2018. A: kidney Transplantation performed in china, and the annual growth rate calculated with the deceased donor Transplantation. B: Liver Transplantation performed in china, and the annual growth rate calculated with the deceased donor Transplantation. C: Heart Transplantation performed in china, and the annual growth rate. D: Lung Transplantation performed in china, and the annual growth rate. All the data were obtained from the Report on Organ Transplantation Development in China (2015–1018), and authorized by the China Organ Transplantation Development Foundation transplant programs. The exploration of transplantation. The establishment of stan- [20–22]. The publication of guidelines and the quality improvement program began in dardized diagnosis and treatment system norms effectively improves the standard- 2017 by the Kidney Transplantation Qual- was led by the Chinese Medical Associa- ization of organ transplant diagnosis and ity Control Center of National Health tion, which organize the experts from Chi- treatment, and does promote the quality commission [17], and it was introduced to nese Society of Organ Transplantation to improvement of clinical care. other transplantation program in the 2019 update and revise the clinical guideline and Annual Congress of Chinese Society of clinical norms for transplantation. Clini- The organ donation and transplantation Organ Transplantation [18]. The Chinese cal Guideline For Organ Transplantation in system in China was constructed with organ transplantation quality improvement China (2017 version) has been published in long-term support and assistance of the program would establish statistic models 2018, it has referred the latest clinical evi- international transplant community. Since based on clinical outcomes data of the Chi- dence and incorporated with the local ex- 2006, many international transplantation nese recipients to set up scientific medical perience about the Chinese patient clinical experts have visited China to provide as- quality evaluation methods, and through characteristics, a total of 27 guidelines had sistance and guidance [8]. A jointly China- refining of clinical practices guideline and been revised or establish [19]. The updating European Union (EU) education program norms to promotion standardized diagnosis and revising of the clinical norms has been named “knowledge Transfer and Leader- and treatment procedures, thereby to pro- ongoing since 2018, 57 clinical practice ship in Organ Donation, from Europe to motion the quality improvement in organ norms have been completed and published China (KeTLOD)” has been carried out

17 Organ Donation

since 2016. These efforts greatly increased with the criteria of WHO. It also provided sion). Beijing: People’s Military Medical House, awareness of organ donation among Chi- the world transplant community with the 2010. 8. Huang J, Millis MJ, Mao Y, Millis AM, Sang X, nese society [23, 24]. Since 2015, the China “Chinese experience.” China will actively Zhong S. A pilot programme of organ donation has invited international experts to person- promote international exchanges and coop- after cardiac death in China. Lancet 2012; 379 ally witness the whole organ donation pro- eration in the cause of organ donation and (9818): 862-865. cesses to confirm the facts. The organ dona- transplantation in the field of humanities 9. Huang J, Wang H, Fan ST, Zhao B, Zhang Z, tion work is transparent and open in China, and health organ among countries along Hao L, et al. The National Program for De- and leaves a deep impression on the visiting “The Belt and Road,” thereby jointly ad- ceased Organ Donation in China. Transplanta- tion 2013; 96 (1): 5-9. experts. It has also prompted experts skepti- dressing problems and challenges in human 10. Brain Injury Evaluation Quality Control Centre cal of the organ transplantation process to development [30]. of National Health and Family Planning Com- acknowledge the construction and reform mission. Criteria and practical guidance for de- of the organ transplantation system [2, 25]. We will make unremitting efforts to build termination of brain death in adults (BQCC ver- The United Nations and the Vatican Pon- a perfect organ donation and transplanta- sion). Chin J Neurosurg 2013; 46 (9): 637-640. 11. Brain Injury Evaluation Quality Control Centre tifical Academy of Sciences jointly held a tion system that is consistent with the ethics of National Health and Family Planning Com- conference on “Ethics in Action” in March and criteria of the WHO, thereby actively mission. Criteria and practical guidance for de- 2018 [26, 27]. For the first time, Huang promoting international cooperation of termination of brain death in children (BQCC Jiefu introduced the experience with organ “The Belt and Road” organ donation and version). Chin J Pediatr 2014; 52 (10): 756-759. transplantation reform and its practice to transplantation, presenting the image of a 12. National Health and Family Planning Commis- the world. It was referred to as the “China responsible political power to the interna- sion, Ministry of Public Security, Ministry of Transport, China Civil Aviation Administration, model” and well received by the participat- tional community, and making our due con- China Railway Corporation, China Red Cross ing experts [28]. it was concluded that the tribution to the construction of the “human Federation. Notice on Establishing a Green organ donation and transplantation reform destiny community”. Channel for Human Organ Donation2016. experience in China may be adopted as a Last accessed on 2020 February 20th. Available reference for countries with similar social from:http://www.nhc.gov.cn/xxgk/pages/view- document.jsp?dispatchDate=&staticUrl=/yzygj/ and cultural backgrounds and socioeco- References s3585/201605/206fb7d1c0014c48bd6a76b8f15 1. Guo Y, Yang J. Overview of Renal Graft. China nomic development status [26, 29]. 5c935.shtml&wenhao=%E5%9B%BD%E5%8 Meical News 2003; 18 (3): 18-19. D%AB%E5%8C%BB%E5%8F%91%E3%80% 2. Huang J, Wang H, Zheng S, Liu Y, Feng H. The fourth China – International Confer- 942016%E3%80%9518%E5%8F%B7&utitle= Advances in China’s Organ Transplantation %E5%85%B3%E4%BA%8E%E5%BB%BA%E ence on Organ Donation – ‘The Belt and Achieved with the Guidance of Law. Chin Med Road’ Organ Donation International Co- 7%AB%8B%E4%BA%BA%E4%BD%93%E6 J (Engl) 2015; 128 (2): 143-146. %8D%90%E7%8C%AE%E5%99%A8%E5% operation Development Forum was held in 3. Chinese Ministry of Health. Regulation on hu- AE%98%E8%BD%AC%E8%BF%90%E7%B Kunming, Yunnan, from December 6, 2019, man organ transplantation2007. Last accessed on B%BF%E8%89%B2%E9%80%9A%E9%81%9 to December 8, 2019 [30]. Representatives 2020 Februay 20th. Available from:http://www. 3%E7%9A%84%E9%80%9A%E7%9F%A5&t gov.cn/zwgk/2007-04/06/content_574120.htm. from WHO, the International Associa- opictype=&topic=&publishedOrg=%E5%8C% 4. National People’s Congress of the People’s tion of Organ Transplantation (TTS), and BB%E6%94%BF%E5%8C%BB%E7%AE%A Republic of China. Amendment (VIII) to the 1%E5%B1%80&indexNum=000013610/2016- transplant associations from 62 countries Criminal Law of the People’s Republic of Chi- 00090&manuscriptId=206fb7d1c0014c48bd6a across all continents attended the forum. na2011. Last accessed on 2020 February 20th. 76b8f155c935. Experts at the conference praised China’s Available from:https://www.cecc.gov/resources/ 13. National Health and Family Planning Commis- achievements in organ donation and trans- legal-provisions/eighth-amendment-to-the- sion of the People’s Republic of China. Notice of plantation reform, and they affirmed the criminal-law-of-the-peoples-republic-of-china. the Interim Provisions on Human Organ Pro- 5. National People’s Congress of the People’s Re- important role of the “Chinese Experience” curement and Allocation2013. Last accessed on public of China. Amended Law of the People’s 2020 February 20th. Available from:http://www. in the construction of the transplant system. Republic of China on the Red Cross Soci- nhc.gov.cn/yzygj/s3585u/201308/8f4ca932129 The forum follows the principles of “exten- ety2017. Last accessed on 2020 February 20th. 84722b51c4684569e9917.shtml. sive consultation, joint contribution, and Available from:http://www.npc.gov.cn/npc/xin- 14. Zhang Q. They gave their word, and more. shared benefits.” The Kunming Consensus wen/2017-02/24/content_2008112.htm. Global Times.2016. Last accessed on 2020 Feb- on International Cooperation Development 6. Chinese Medical Association. The Clinical ruary 20th. Available from:http://www.global- Guideline for Organ Transplantation(2010 times.cn/content/1001281.shtml. of ‘The Belt and Road’ Organ Donation and version). Beijing: People’s Medical Publishing 15. Guo Y. The “Chinese Mode” of organ donation Transplantation was issued. 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18 Climate Change

16. China Organ Transplantation Development 23. Jiang W, Ye Q, Li L, Sun X, Feng G, Liu Y, et Last accessed on 2020 February 20. Available Foundation. Report on Organ Transplantation al. 115.8: Developing the educational pathway from:https://news.cgtn.com/news/2019-12-08/ Development in China(2015-1018). Beijing: for organ donation in China: international-joint China-s-effort-in-organ-donation-and-trans- 2019 November 2019. Report No. training program to increase organ donation plant-applauded-amid-rumors-Mg2f9aG1X2/ 17. Shi B, Liu Z. Kidney transplantation: from qual- rate. Transplantation 2019; 103 (11S): S5-S6. index.html. ity control to quality improvement plan. Chinese 24. Marti M, Chloe B, Entela K, Melania I, Wenshi 1, 2 Journal of Transplantation (Electronic Edition) J, Marco Z, et al. 330.4: Knowledge transfer and Bingyi Shi , 2018; 12 (03): 7-11. leadership in organ donation from Europe to Bingyi Shi, M.D, Chairman of Chinese 18. Shi B, Liu Z. To Construct of quality improve- China: KeTLOD project. Transplantation 2019; Society of Organ Transplantation ment proram system and to promote the transi- 103 (11S): S71. of Chinese Medical association. tion development of organ transplantation. Or- 25. Danovitch GM, Delmonico FL. A path of hope gan Transplantation 2020; 10 (1): 1-7. for organ transplantation in China? Nephrol The honorary Dean of the PLA Organ th 19. Chinese Society of Organ Transplanta- Dial Transplant 2015; 30 (9): 1413-1414. Transplant Institute, The 8 Medical tion of Chinese Medical Association. Clini- 26. China Daily. China to share organ transplant Centre of Chinese PLA General cal Guideline For Organ Transplantation In expertise2018. Last accessed on 2020 Febru- Hospital, Beijing 100091, China China. Beijing: People’s Medical Publishing ary 20th. Available from:http://usa.chinadaily. E-mail: [email protected] House(PMPH), 2018. com.cn/a/201805/26/WS5b097ed3a31001b-

20. Chinese Society of Organ Transplantation of 82571c7c7.html. 1, 2 Chinese Medical Association. Procedures and 27. Fan L. China’s organ transplant reforms win Zhijia Liu , regulations for organ donation after the death of recognition. Global Times.2018. Last accessed E-mail: [email protected] Chinese citizens. Organ Transplantation 2019; on 2020 Ferbruary 20th. Available from: http:// 10 (2): 122-127. www.globaltimes.cn/content/1106029.shtml. Tao Yu 1, 2, 21. Chinese Society of Organ Transplantation of 28. Guo Y. The “Chinese Mode” of organ donation E-mail: [email protected] Chinese Medical Association. Clinical technical and transplantation: moving towards the center operation specification of small bowel transplan- stage of the world. 2018; 1 tation. Chin J Organ Transplant 2019; 40 (10): 29. China Global Television Network. World Chinese Society 580-590. Health Assembly: Tackling global issues of or- of Organ Transplantation 22. Chinese Society of Organ Transplantation gan donation and transplantation2018. Last ac- th of Chinese Medical Association, of Chinese Medical Association. Technical cessed on 2020 February 20 . Available from: Beijing 100091, China; specification for preoperative evaluation and https://news.cgtn.com/news/334d444f3145446

preparation of heart transplantation recipients 4776c6d636a4e6e62684a4856/share_p.html. 2 th in China (2019 edition). Chinese Journal of 30. Yang J, Zhang K. China’s effort in organ do- Organ Transplant Institute, The 8 Transplantation (Electronic Edition) 2019; 13 nation and transplant applauded amid ru- Medical Centre of Chinese PLA General (1): 1-7. mors. China Global Television Network.2019. Hospital, Beijing 100091, China

The Impact of Climate Change on Health A question of survival

Climate is a decisive social factor in basic programmes, in addition to preparation and health. The climate system is fundamental response programmes for emergencies that for life as a safe climate is needed to sus- may occur. tain health, for which reason climate change is a direct threat to health. It is also one of Climate change is the global variation in humanity’s greatest challenges and protect- the Earth’s climate, mainly owed to human ing the climate and environment is syn- activity through greenhouse gases that al- onymous with protecting health. To achieve ter the atmosphere’s composition, causing this objective, swift, efficient mitigation and global warming with detrimental effects adaptation strategies that improve health in many areas of the planet and with spe- and reduce health vulnerability must be cific consequences for global health. The implemented. These should incorporate latter is a priority for public health as it climate change and its risks within health may become progressively worse, creating José Ramón Huerta Blanco

19 Climate Change

a world health crisis throughout the 21st According to the WHO, one in four deaths Climate change is a health emergency, an im- century. Being aware of this, preventing it in the world is owed to environmental fac- mense crisis for humanity that is at a tipping as far as possible, and acting to diminish tors and it warns that the impact of climate point. It destroys the economy and health and temper its consequences are obliga- change will be particularly serious in chil- (and even health advances achieved over tions for all of mankind, and the medical dren, old people, pregnant women, people time), thus reducing life expectancy. Con- profession in particular given its responsi- with chronic diseases in general, and es- sequently, it constitutes a global challenge bility and commitment to caring for hu- pecially those affected by respiratory and given its repercussions, which are difficult to man health. cardiovascular diseases, considering that reverse, and its impact on health results. Time diseases sensitive to the climate are among is short when it comes to stopping global According to the World Meteorologi- the most lethal. For these reasons, the cru- warming and protecting health, therefore, cal Organisation (WMO) and the World cial impact of climate change on health and our life model must be redefined to become Health Organisation (WHO), at present life must be emphasised. Although it is a more sustainable and healthier because when climate change makes a significant contri- recognised fact, it appears to be of second- the climate changes, life also changes. bution to increasing the global burden of ary importance when it should be a priority. premature deaths and illnesses worldwide, In this battle against the clock, public especially in terms of cardiovascular, respi- Climate change is a global issue that re- health systems must be strengthened so ratory, allergic, digestive and neurological quires solidarity and collaboration on all as to improve their health response capac- diseases. In addition, it alters the distribu- aspects, with a comprehensive approach ity and ability to adapt to climate change. tion of numerous infectious diseases, caus- covering prevention, mitigation, adapta- Funding must be increased to bolster pri- ing continuous changes in some vectors tion to its consequences, and research in mary health care (along with community that expand important illnesses (malaria, all areas to reduce its impact on health. initiatives and risk prevention responses), yellow fever, zika virus, chikungunya virus, Via their National Medical Associations reduce greenhouse gases that cause global dengue fever, among others). It affects agri- (NMAs), doctors must take climate change warming, control vectors, protect environ- culture, food, air and water with disastrous into consideration and actively participate mental health, and monitor the diseases cli- consequences for people’s health and qual- in devising policies and initiatives that re- mate change causes. Research in all areas of ity of life. Climate change will heighten duce its consequences on health, participat- health affected by climate change must be inequality in health, especially in more vul- ing in the field of education in particular encouraged in order to pinpoint solutions nerable countries and populations who will to raise professional and social awareness and ameliorate the health consequences suffer more from its consequences. of the importance of the environment and for people and communities, strengthen climate change on people’s health as well as monitoring systems for the diseases caused Climate change is an important risk fac- community health. Environmental educa- or altered as a result of climate change, and tor for health given its repercussions that tion constitutes a form of training in values make the medical community’s voice heard impact many relevant aspects, ranging and, in order to fight climate change and as a significant party in the climate debate from extreme events like torrential rains, improve its impact on health, doctors and such that climate change’s impact on health floods, droughts, hurricanes, tornadoes, their professional organisations (as well as is treated with the importance it requires. heat waves and cold snaps, to alterations in the entire health industry) must strive to The WMA must also join these efforts to the distribution of water and food. These uphold and introduce new values in addi- promote better environmental manage- threaten food safety and cause diarrhoea tion to an ethical and moral facet to address ment in addition to improved management along with other problems, such as air pol- the issue. of water, farming, and industrial resources lution, changes in pollination and ultravio- as well as ecosystems. It must also call for let radiation, resulting in increased diseases The World Medical Association (WMA) responsibility and professional commit- and deaths. Other consequences include and NMAs must act as the frontline when ments in relation to a healthy environment exoduses with mass emigration and cli- defending against the health issues related given that doctors, when protecting life and mate refugees in a panorama that could act to climate change. They must also lead doc- health, have an ethical and professional duty as the trigger for armed conflicts, poverty, tors so they may help people to adapt to to protect the environment and report inci- hunger, and changes to oceans and fishing, its consequences, fight against the diseases dents of environmental abuse that may be with fewer glaciers and more droughts that linked to climate change, and collaborate potentially dangerous to health or life. threaten the entire rural environment and with governments and other organisations agriculture, altering ecosystems and biodi- to tackle, mitigate and adapt to the effects José Ramón Huerta Blanco. M.D. versity. climate change has on health. Spanish Medical Council

20 Public Health

Physical Activities of Doctors in Rivers State, Southern Nigeria

Dabota Yvonne Buowari Hope Ilanye Bellgam Obelebra Adebiyi Ufuoma Edewor Vetty Agala

Globally, sedentary lifestyle has been a pub- with little concern of its importance on the of their work. Advices are given by the lic health burden [1, 2]. More people are role it plays on physical fitness [11]. healthcare workers are usually held in high becoming sedentary due to modernization, esteem as most hospital clients and patients westernization and civilization, as well as When physical activity is planned, it is exer- will perceive that the healthcare worker as a the advancement in technology. There have cise, that is structured and it is used for the role model in health matters and maintain- been more devises invented that helps relief improvement of health for the maintenance ing healthy lifestyle [3, 10, 24]. Hence this manual labour and some of these newly de- of physical fitness [10]. Healthy lifestyle in- study investigates physical activity amongst veloped household gargets that makes life volves physical activity [12]. Different forms medical doctors in Rivers State, Southern easier and expends less energy in operating of physical activity have different intensities; Nigeria. them. These are making people to be less hence the World Health Organization rec- physically active. In public health, physical ommends that the activity should be done inactivity has become an important research in episodes of at least ten minutes for it to Method topic [3]. Many people are becoming physi- be beneficial to cardiorespiratory health [8]. cally inactive in the changing world [4]. There are several benefits of physical activity This is a cross-sectional descriptive study Worldwide, one in four adults is physically [13] as it is important for staying healthy [7, conducted during the 2018 annual general inactive [5]. Movement of the human body 14, 15]. It helps in the prevention of diseases meeting and scientific conference of the is linked to physical activity as the human as physical inactivity is a risk factor of most Rivers State Branch of the Nigerian Medi- beings are designed for it. Physical activity non-communicable diseases such as hyper- cal Association. Respondents were medical is necessary for maintaining physical and tension, obesity, cardiovascular diseases, cor- doctors and dentists and participation was mental wellbeing. onary heart disease, type 2 diabetes mellitus, voluntary. A questionnaire was administered osteoporosis, colon cancer, depression, anxi- to the research respondents. The question- Physical activity can be defined as any ety, improves physical fitness and strength naire included questions related to demo- movement of the body produced by the [3, 5, 7–9, 11, 12, 16–19]. The fourth leading graphics and the short form of the Inter- skeletal muscles that result in the expendi- risk factor for mortality is physical inactivity national Physical Activity Questionnaire ture of energy [6]. Physical activity involves as globally about 3.2 million persons die be- (IPAQ-SF). The International Physical all forms of activities which can be chores cause they are physically inactive [8]. There Activity Questionnaire is a valid and reliable done within and outside the home, activities is an increase in the number of people that instrument for measuring physical activity of daily living and also recreational activi- are becoming physically inactive worldwide which has been tested in different popula- ties [7, 8]. Examples of physical activity are [8, 20, 21]. Therefore in global health, physi- tions worldwide [1, 25–30]. The short form brisk walking, cycling, swimming, running, cal inactivity has become a burden [5, 9, which was used in this study is a recall of dancing, shopping, exercise, jogging and ac- 22, 23]. Healthcare professionals including physical activity of moderate and vigorous tive sports [5, 7–10]. Being physical active medical doctors are involved in counsel- activity and walking and sitting in the past has some health benefits but they are done ling their clients and patients in the course seven days and comprises of seven ques-

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tions [26, 31–33] The International Physi- Results Table 1 . Social demographic characteristics cal Activity Questionnaire was developed of the respondents in 1998 [27]. Data extracted from the In- One hundred and six doctors participated ternational Physical Activity Questionnaire in this study; only 102 questionnaires were Frequency Percentage Variable short form was analyzed using the scoring filled completely while four questionnaires (n) (%) protocol of the instrument [34]. The Meta- where incomplete therefore they were not Age (n=102) bolic Equivalent Task was obtained from the included in the study. Table 1 shows the 26 25.5 21–30 Years International Physical Activity Question- social demographics characteristics of the naire scoring protocol and the total Meta- respondents while table 2 shows the re- 31–40 Years 49 48 bolic Equivalent Task (MET) calculated. spondents place of work. Most 77 (80%) of 41–50 Years 18 17.6 One Metabolic Equivalent Task was the en- the respondents worked in a government 51–60 Years 4 3.9 ergy that would be expended at rest and this owned hospital. Table 3 shows the number is approximately 3.5 ml O2 kg-1min-1 in of days that is spent on physical activities. 61–70 Years 4 3.9 adults [16, 35, 36] or 20 mlmin of oxygen is Table 4 shows physical activities of respon- 71–80 Years 1 1 used up in an average 70 kg adult [16]. There dents using the metabolic equivalent task. Sex (n=102) is a rise in the amount of oxygen consumed The highest physical activity was conducted where an increase in the intensity of the ac- by 43 (42.16%) moderate physical activ- Males 34 33.3 tivity hence the mean equivalent increase ity, 40 (39.22%) low physical activity and Females 68 66.7 with the intensity of physical activity [16]. 19 (18.63%). Table 4 shows the time spent Marital sta- on various activities. tus (n=102) The values of MET assigned to sitting, walking, moderate and vigorous physical ac- Measurement of physical activity is com- Separated 2 2 tivity intensity by the international physical plex as it can be measured directly or Single 35 33.3 activity questionnaire protocol are [28, 30]: indirectly using self-reported question- Married 66 64.7 • Walking: 3.3 MET naires [4]. There are different methods of • Moderate physical activity: 4.0 MET measuring physical activity. Questionnaires Rank • Vigorous physical activity: 8.0 MET is the most commonly used and valuable (n=100) House of- method [3]. Doctors spend a lot of time 14 14 For each activity as calculated by multiply- sitting down as they have to sit down tak- ficer ing the number of minutes the activity was ing history from their patients except those Senior carried out by the number of days and the involved in surgeries or procedures in which House of- 1 1 constant assigned to that activity. The cal- they have to stand. According to the World ficer culated MET was compared with the stan- Health Organization adults should have Registrar 22 22 dard MET 150 minutes of moderate physical activity Senior Reg- 9 9 per week or 75 minutes of activity of vigor- istrar Using the MET, physical activity was cat- ous intensity daily [8, 20]. Using the MET Consultant 11 11 egorized into low, moderate and high physi- 43 (42.16%) had moderate physical activity cal activity as shown below [1, 2]: and 19 (18.63%) high physical activity. It Professor 2 2 MET – min- shows that some doctors are physically in- Medical of- Category 23 23 utes/week active. Activities les that ten minutes were ficer Low physical activity: <600 not included in the study. Senior Moderate physical Medical Of- 12 12 ≥600 to <3000 Doctors are involved in the counselling activity: ficer and educating patients on been physically High physical activity: ≥3000 Principal active to help prevent some non-commu- Medical of- 2 2 The MET – min-per week = : MET level X nicable diseases in which physical inactiv- ficer events per week. ity is a risk factor [2, 37, 38]. The result of Chief medi- this study is in contrast to the study con- 3 3 cal officer Activities lasting less than 10 minutes are ducted among healthcare professionals in not counted [36]. South-West Nigeria where only 20.8% met Retired 1 1

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Table 2 . Place of work of the respondents Table 4 . Time spent on various activities amongst the respondents Frequency Percentage (n=102) Variable (n) (%) Variable Frequency (n) Percent (%) Hospital Ownership (n=96) Time spent on Vigorous activities (minutes) Military Hospital 1 1 <= 60 94 92.2 91–120 4 3.9 Company hospital 3 3.1 121–150 1 1.0 Non-Governmental Organization 3 3.1 151+ 3 2.9 Private 12 12.5 Government 77 80.2 Time spent on moderate vigorous activities (minutes) Type of public facility (n=71) <= 60 91 89.2 General hospital 2 2.8 61–200 8 7.8 Management staff 4 5.6 201–340 1 1.0 341+ 2 2.0 Specialist hospital 9 12.7

Primary health care 11 15.5 Time spent Walking (minutes) University teaching hospital 45 63.4 <= 60 85 83.3 Department (n=92) 61–220 8 7.8 No Department 26 28.3 221–380 6 5.9 Community Medicine 9 9.8 381+ 3 2.9 Total 102 100.0 Family Medicine 6 6.5

Hematology 3 3.3 Time spent sitting (minutes) Internal medicine 7 7.6 <= 60 53 52.0 Obstetrics and Gynaecology 19 20.7 61–440 31 30.4 Surgery 4 4.3 441–820 14 13.7 Paediatrics 3 3.3 821+ 4 3.9

Others 17 18.5 Time spent sleeping (hours) <= 3.0 73 71.6 3.1–6.0 18 17.6 6.1–9.0 7 6.9 9.1+ 4 3.9 Table 3 . Physical activity category Physical category Metabolic equivalent task Time spent watching TV (Hours) Low <600 MET 40 (39.22%) <= 3.0 73 71.6 Moderate >600–3000 43 (42.16%) 3.1–6.0 18 17.6 High >3000 19 (18.63%) 6.1–9.0 7 6.9 Total 102 (100%) 9.1+ 4 3.9

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the recommendation for physical activity. 5. Boopathirajam R, Raveendran A, Agyalusamy 18. Rhodes RE, Janseen I, Bredin SSD, Warbur- Though this study included all cadres of P. Study on practice of physical activity among ton DER, Bauman A. Physical activity: health healthcare workers, it did not specify the medical interns in a private medical college impact, prevalence correlates and interventions. hospital in Chennai. Inter J Comm Med Public Psychol Health. 2017, 32 (8), 942-975. different categories of healthcare profes- Health. 2019, 6 (5), 1-5. 19. Oyeyemi AL, Oyeyemi HY, Adegoke BO, Oy- sionals [24]. The long hours spent at the 6. World Health Organization. Global strategy on etoke FO, Aliyu HN, Aliyu SU, Rufai AA. The workplace and the sedentary nature of diet, physical activity and health. www.who.int Short International Physical Activity Ques- medical work are some of the causes of low assessed January 2020. tionnaire: cross cultural adaptation, validation physical activity among healthcare workers 7. Kruk J. Physical activity and health. Asian Pa- and reliability of the Hausa language version in including doctors [24]. cific J Cancer Prevention. 209, 10, 721-728. Nigeria. BMC Med Res Methos. 2011, 11, 156. 8. World Health Organization. Physical activity www.biomedcentral.com/1471-2288/11/156 Physical inactivity is a risk factor for most fact sheet no 385, 2014. www.who.int assessed 20. Akarolo-Anthony SN, Adebamowo CA. Preva- January 2020. lence and correlates of leisure-time physical ac- non-communicable diseases which are life 9. Miles L. Physical activity and health. Bri Nutr tivity among Nigerians. BMC Public Health. threatening and causes morbidity, mortality Foundation Bull. 2007, 32, 314-363. 2014, 14:29. www.biomedcentral.com/1471- and end organ damage. Doctors who know 10. Adegboyega JA. Physical activity and exercise 2458/14/529 all about the benefits of physical activity are behaviour of senior academics and administra- 21. Craig CL, Marshall AL, Sjnostrom M, Bau- also physically inactive even though they tive staff of tertiary institutions in Ondo State, man AE, Booth ML, Ainsworth BE, Pratt M, contribute so much to health education ad- Nigeria. Inter J Educ Res. 2015, 3 (2), 189-202. Ekelundu et al. International Physical Activity vising their clients and patients to increase 11. Oyeyemi AY, Usman RB, Oyeyemi AL. A sur- Questionnaire: 12-country reliability and valid- their physical activity and decrease physical vey of disposition of physicians towards physi- ity. Med Sci Sports Exer. 2003, 1381-1395. cal activity promotion at two tertiary hospitals 22. Pratt M, Norris J, Lobelo F, Ronx L, Wang G. inactivity. in North-Western Nigeria. Ann Ibd Pg Med. The cost of physical activity: moving into the 2016, 14 (2), 74-80. 21st century. Bri J Sports Med. 2014, 48, 171- 12. Al-Asousi M, El-Sabban F. Physical activity 173. Limitation among preclinical medical students at the Uni- 23. Momton JS, Ferment P, Khan K, Poirer P, versity of Malaya, Malaysia. J Nutritional Health Fowles J, Wells GD, Frankorich RJ. Physical ac- Since this study was conducted during a Food Sci. 2016. www.symbiosisonline.org as- tivity prescription: a critical opportunity to ad- scientific and annual general meeting of the sessed 2020. dress a modifiable risk factor for the prevention Rivers State branch of the Nigerian Medi- 13. Weissblueth E. Short Hebrew international and management of chronic disease: a position physical activity questionnaire: reliability and statement by the Canadian Academy of Sports cal Association, only doctors that attended validity. Baltic J Health Physical Activity. 2015, and Exercise Medicine. Bri J Sports Med. 2016, the meeting participated in the study hence 7 (1), 7-13. 6,1-6. doi.10:1136/bjsports.2016-696291. the results may not reflect the true physical 14. Kumar H, Ramakrishnan N, Chandrashekar 24. Wuala SO, Sekoni AO, Olamoyegun MA, activity of doctors in Rivers State, Nigeria as M, Kodihdl A, Jayaramegowda AK, Kadian M, Akanbi MA, Sadirr AA, Ayankogbe OO. Self- doctors that did not attend the meeting did Chauhan V. A cross-sectional study on patterns, reported physical activity among health care not participate in the study. motivating factors and barriers for physical ac- professionals in South-West Nigeria. Nig J Clin tivity among undergraduate medial students. In- Pract. 2018, 18 (6), 790-795. ter J Med Public Health. 2014, 41 (4), 413-416. 25. Hagstromer M, Oka P, Sjostrom M. The In- 15. Wennlof AH, Hagstromer M, Olsson L. The ternational Physical Activity Questionnaire References international physical activity questionnaire (IPAQ): a study of concurrent and construct 1. International Physical Activity Questionnaire. modified for the elderly: aspects of validity and validly. Public Health Nutrit. 9(6), 755-762. www.ipaq.ki.se assessed January 2020. feasibility. Public Health Nutri. 2010, 13 (11), doi.10.1079/PHN.2-58598. 2. Hadimani CP, Kulkarni SS, Matt AK, Javali SB. 26. Lee PH, McDowell L, Leung Ham TM, Pattern of physical activity and its correlation 1847-1854. with gender, body mass index among medical 16. Polito A, Intorr F, Ciarapica D, Barnabas L, Stewart SM. Performance of the International students. Inter J Comm Med Public Health. Tagliabue A, Ferraris C, Zaccaria M. Physical Physical Activity Questionnaire (Short Form) in 2018, 5 (6), 2296-2300. activity assessment in an Italian adult popula- subgroups of the Hong Kong Chinese popula- 3. Metcalf KM, Baquero BI, Gracia MLC, Francis tion using the international physical activity tion. Inter J Behavioral Nutr Physical Activity. SL, Janz KF, Laroche HH, Sewell DK. Calibra- questionnaire. Obes Res Open J. 2016, 4 (1). 2011.8.81. www.ijbnja.org/contents/811/81 as- tion of the Global Physical Activity Questionnaire doi.10.17140/OROJ-4-127. sessed january 2020. to accelorometry measured physical activity and 17. Bolarinde SO, Olagbegi OM, Daniel EO, 27. Lee PH, MacFarlane DJ, Ham TH, Stewart sedentary behaviour. BMC Public Health, 2018, Akinnbola B. Knowledge, attitude and practice SM. Validity of the International Physical Ac- 18.412. doi.org/10.1186/51/2889-018-5310-3. of physical activity among health professionals tivity Questionnaire Short Form (IPAQ-SF): a 4. Alricsson M. Physical activity why and how. in a Nigerian tertiary health institution. South systematic review. Inter J Behavior Nutr Physi- J Biosafety Health Educ. 2013:1.4. doi. Am J Public Health. 2015, 3 (2). www.research- cal Activity. 2011. 8. 115. www.ijbnpa.org/con- Org/10.4172/2332-0893.1000e/11. gate.net/publication/283496898 tent/18/1/15 assessed january 2020.

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28. Adeniyi AF, Ogwumike OO, John-Chu CG, physical activity in chronic fatigue syndrome? Dr. Dabota Yvonne Buowari, Fasanmade AA, Adeleya JO. Links among mo- Disability Rehabilitation. 2010, 1-8. Department of Accident and tivation, socio-demographic characteristics and 34. Guidelines for data processing and analysis of Emergency, University of Port Harcourt physical activity level among a group of Nigerian the International Physical Activity Question- Teaching Hospital, Nigeria patients with type 2 diabetes. J Med Biomed Sci. naire (IPAQ) short and long forms. www.ipaq. 2013, 2(2), 8-16. ki.se/scoringpdf E-mail: [email protected] 29. Kim Y, Park L, Kang M. Convergent validity of 35. American College of Sports Medicine. Position the International Physical Activity Question- stand. The recommended quantity and quality of Dr. Hope Ilanye Bellgam, naire (IPAQ): meta-analysis. Public Health Nu- exercise for developing and maintaining cardi- Department of Internal Medicine, Care of tri. 2012, 16(3), 440-452. orespiratory and muscular fitness and flexibil- Elderly Persons Unit, University of Port 30. Wolin KY, Heil DP, Askew S, Mathews CE, Ben- ity in healthy adults. Medicine and Science in Harcourt Teaching Hospital, Nigeria nett GG. Validation of the international physical Sports and Exercise. 1998, 30, 975-91. activity questionnaire-short form among Blacks. J 36. Forde C. Scoring International Physical Activity Dr. Obelebra Adebiyi, Physical Activity Health. 2008, 5, 746-760. Questionnaire (IPAQ). Trinity College of Dub- 31. Nang EEK, Ngunjiri SAG, Wu Y, Salim A, Tai lin. The University of Dublin exercise, prescrip- Medical Women’s Association of Nigeria, ES, Lee J, Dam RMV. Validity of the Interna- tion for the prevention and treatment of disease. Rivers State Branch, Port Harcourt, Nigeria tional Physical Activity Questionnaire and the 37. Nomton JS, Ferment P, Khan K, Poirere P, Singapore prospective study program physical ac- Fowles J, Well GD, Frankorich RI. Physical ac- Dr. Ufuoma Edewor, tivity questionnaire in a multiethnic urban Asian tivity prescription: a critical opportunity to ad- Medical Women’s Association of Nigeria, population. BMC Med Res Meth. 2011.11.141. dress a modifiable risk factors for the prevention Rivers State Branch, Port Harcourt, Nigeria www.biomedcentral.com/1471-288/11/141. and management of chronic disease: a position 32. Tran DV, Lee AH, Au TB, Nguyen CT, Hoang statement by the Canadian Academy of Sport Dr. Vetty Agala, DV. Reliability and validity of the International and Exercise Medicine. Bri J Sports Med. 2016, Medical Women’s Association of Nigeria, Physical Activity Questionnaire-Short Form for 6, 1-16. doi.10.1136/bjsports.2016-696291 older adults in Vietnam. Health Promotion J 38. Brannan M, Bernardotto M, Clarke N, Varney J. Rivers State Branch, Port Harcourt, Australia. 2013, 24, 126-131. Moving healthcare professionals – a whole sys- Department of Community Medicine, 33. Meeus M, Eupen IV, Willems J, Kos D, Nijs J. tem approach to embed physical activity in clini- University of Port Harcourt Teaching Is the International Physical Activity Question- cal practice. BMC Med Educ. 2019, 19, 84. doi. Hospital, Rivers State Ministry of naire – short form (IPAQ-SF) valid for assessing org/10.1/86/s/2909-019.1517y Health, Port Harcourt, Nigeria

Palliative Care: What, Who, When, How?* In other words, humane care for human beings, not mechanical care for human *Based on a lecture on October 24, 2019, at the World Medical Association General Assembly, Tbilisi, Georgia machines. However, shifting from cure-ori- What and who? ented care to palliative care requires a transition by all involved – clinicians, patient Fifty years ago, palliative care was largely lim- and family: an acceptance that cure is not ited to comfort care at the end of life, and was possible and a re-focusing on comfort [2], mainly provided in very few free-standing and an avoidance of ‘therapeutic obstinacy’ hospices. Since then the scope of palliative not prolonging death and suffering by fu- care has expanded considerably and probably tile resuscitative interventions when death can best described as ‘care beyond cure’. It is: is clearly inevitable and relatively imminent. • holistic: addressing physical, psychological, social/family, and spiritual/existential In 2014, the World Health Assembly called concerns on all health services to provide palliative • focused on quality of life, but can be provided care within the context of universal health in tandem with life-prolonging treatments coverage [3]. Thus, palliative care should be • based on need, not limited by diagnosis integrated into primary health care in the or prognosis community, with back-up from specialist • applicable across all age groups palliative care – as with other medical spe- • ideally provided by a multidisciplinary cialties [4]. Centres of excellence, particu- Robert Twycross healthcare team [1]. larly in tertiary care and university hospitals,

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are necessary for the care of patients and to the hospital – with significant financial Palliative care should be seen as a partner- family with complex needs, and for training savings being made. ship between experts. In relation to the dis- both generalists and specialists. In practice, ease process, the clinicians are the experts most of such centres care for patients with There is also a tendency for palliative care to but, in relation to the impact of the illness, end-stage disease, most commonly cancer, fill the gaps in existing provision for long- the experts are the patient and family. It is with their services embracing outpatients, term (continuing) care. For example, in the vital to recognize this because, through lis- inpatients, ward consultations, day care, UK, many palliative care services in the 1980s tening to their story and their problems, the home care support, and even more intensive and 1990s established lymphoedema clinics, patient and family begin to shift from be- round-the-clock ‘hospice at home’ in the fi- caring for those with congenital lymphoede- ing passive victims to empowered persons. nal few days, as well as bereavement support ma as well as patients with cancer (cured or An important first step is to let the patient if necessary. end-stage). In Moldova, the Angelus Hos- set the agenda, for example, by asking them pice in the capital Chisinau is the only ser- what is troubling them the most, or what When should family practitioners and other vice in the country offering ostomy care; and, they hope will come out of the consultation. hospital specialists refer to a specialist pal- in Moscow, long-term inpatient post-stroke liative care service? In the USA, the Ameri- and long-term inpatient ventilation care has In recent decades, much has been written can Society of Clinical Oncology suggests been integrated into palliative care. about ‘person-centred care’. However, in prac- that referral should be considered for any tice much of it is about moving from a pater- patient with metastatic cancer and/or high nalistic ‘covenantal’ relationship between pa- symptom burden [5]. Other specialties will How? tient and carer to a commodified ‘contractual’ need to make their own criteria for referral. one – akin to a typical business relationship However, having a list of ‘Red Alerts’ could According to a systematic review, in relation of client and contractor. In practice this tends allow more timely referral, for example: to palliative care, the top four priorities for to downgrade the professional to a techni- • pain not responding to your analgesia patients and families are: cian, and often leaves the patient uncertain of • nausea/vomiting not responding to anti- • effective communication, shared deci- the best way forward. For partnership, a ‘cov- emetics sion-making enantal’ (but non-paternalistic) relationship • inoperable bowel obstruction • expert care is required [7]. Empathy, the cognitive abil- • constipation not responding to routine • respectful and compassionate care ity to imagine what someone else is feeling, measures • trust and confidence in clinicians [6]. is essential. Empathy is enhanced by listening • breathlessness at rest to people’s stories. For those not often caring • insomnia/nocturnal distress Three of these four priorities relate to cli- for palliative patients, reading stories can sub- • anyone expressing distress that they are nician–patient/family relationships. Rela- stitute for personal clinical experience [8, 9]. dying tionships are built on trust. Thus, the basic • anyone you think is dying badly. question for the professional carer must Susan Block, an American psycho-oncolo- surely be: what can we do to increase trust? gist, has listed what she regards as impor- In the UK and possibly elsewhere, there is A doctor in her mid-30s with end-stage tant to know when talking to someone with a shift towards ‘pro-active’ palliative care: ovarian cancer wrote, ‘Introductions [make] advanced disease: instead of waiting for a referral, all admis- a human connection… They begin thera- • What do you understand about your ill- sions over the previous 24 hours are scru- peutic relationships and can instantly build ness? tinized from the hospital’s master-list. trust in difficult circumstances’. She began • What are your concerns about the future? Likely palliative care patients are visited by a campaign for all those working within • If your health were to get worse, what the Support Team whether in a temporary health services called ‘Hello, my name is…’ would you want to do in the time that’s left? ‘holding’ ward or an Intensive Care Unit. In because she knew from hard experience (as • What trade-offs are you willing to make? addition there are regular pro-active visits I do too!) how dehumanizing it is when • How much suffering are you prepared to to Oncology and Renal Departments, and someone by-passes this common courtesy accept in order to gain added time? other specialist wards depending on local and just says what they have come to do. • Who do you want to make decisions for arrangements. This results in many patients Thus, all health professionals (and support you if you cannot [10]? being transferred more swiftly to the pallia- staff) should begin by introducing them- tive care inpatient unit or discharged home selves by name, and wear a clearly visible Holistic care takes time. Data from a sys- with a care package in place. It is of value and easily readable badge stating the per- tematic review show that the median length not only to the patients concerned but also son’s name and position. of the initial consultation is 55 minutes

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(range 20–120) [11]. The median time Drugs for persistent symptoms should be Holistic care is generally best provided by devoted to symptom management was prescribed regularly on a prophylactic (‘by a multidisciplinary team. The ‘nuclear’ team 20 minutes (range 0–75); coping 15 min- the clock’) basis; the use of drugs only ‘as comprises a doctor and a nurse. To these utes (range 0–78); understanding 10 min- needed’ is the cause of much needless dis- can be added a physiotherapist, occupa- utes (range 0–35). However, giving this tress. For some symptoms, management tional therapist, social worker, chaplain, time initially results in better care – and may mostly be helping the patient (and clinical psychologist, liaison psychiatrist, may well save time in the long-term. family) accept the irreversible physical limi- and even music and art therapists. Volun- tations of advanced progressive disease, for teers are vital. Depending on their abilities, example anorexia, weakness and fatigue. they can do a wide range of tasks along- Expert Care: symptom side the professional staff. In addition, their management Monitoring is crucial. Patients vary and it is presence conveys the message to the patient not always possible to predict the optimum that they are still a valued member of the Palliative care is generally ‘low-tech’ but dose of opioids, laxatives, and psychotropic community. always ‘high-skill’. The general principles drugs. Particularly initially, doses may need underlying symptom management can be to be adjusted upwards (and sometimes summarized in the mnemonic ‘EEMMA’: downwards). Adverse (side) effects may Incompatible Values • Evaluation: diagnosis of each symptom jeopardize patient compliance. Attention before treatment to detail is important at every stage, and is Regrettably, there are many factors that • Explanation: explanation to the patient equally important in relation to the non- work against the provision and delivery of before treatment physical aspects of care. All symptoms are palliative care – and not only financial ones. • Management: individualized treatment exacerbated by anxiety and fear. There will always be the need to contend • Monitoring: continuing review of the im- with the ‘distaste’ many health professionals pact of treatment feel when confronted with end-stage dis- • Attention to detail: no unwarranted as- Death-accepting, but ease, and a reluctance to change the focus sumptions. Also Life-enhancing of care from disease control to comfort. Linked with this is the inability of many To a large extent, evaluation is based on ‘Add life to days even when it is no longer professionals to engage sensitively and probability and pattern recognition [12]. possible to add days to life’ is a central tenet skillfully in discussions about impending Symptoms may be caused by treatment, de- of palliative care. An emphasis on ‘doing’ death. bility or a concurrent second disorder rather rather than ‘being done to’ helps the patient than the primary disorder. Symptoms are to live and die with their self-respect main- Further, the underlying values of most often caused by multiple factors; pain can tained. In many cases, gentle and imagina- healthcare systems are incompatible with occur at several sites have distinct causes. tive encouragement is all that is needed to compassion and caring. The values of the Explanation by the doctor of the causes of a entice a patient into an activity that leaves system tend to be competition, rational- symptom can do much to reduce its psycho- him with an increased sense of well-being. ization, productivity, efficiency, and even logical impact on the sufferer (‘The doctor The concept of living with cancer (or other profit [15]. Healthcare has been ‘industri- understands what is going on…’). advanced progressive disease) until death alized’ and there is little room for holistic comes is still foreign to many patients and care. All too often this leads to emotional Management falls into three categories: their families, and to many professionals as exhaustion and cynicism in the profes- correct the correctable, non-drug measures, well. Indeed, many terminally ill patients, sional carers. Thus, the long-term challenge and drugs. By adopting a multimodal ap- although capable of a greater degree of ac- of providing high quality palliative care proach, it is generally possible to obtain tivity and independence, are unnecessarily should not be under-estimated. It requires considerable, if not complete, relief. A list restricted by well-meaning relatives. resilience, determination, high level clinical of 20 relatively inexpensive essential drugs skills, undergirded by the attitude verbal- is contained in the report of the Lancet ized by Cicely Saunders, the founder of the Commission on Global Access to Pallia- Multidisciplinary Teamwork modern hospice and palliative care: tive Care [13] and updated guidelines for and Community Involvement ‘You matter because you are you. You matter to the management of cancer pain in adults the last moment of your life, and we will do all and adolescents have been published by ‘Teamwork is the fuel that allows ordinary we can, not only to help you die peacefully, but the World Health Organization [14]. people to achieve extraordinary results.’ to live until you die.’

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References Standard Oncology Care. J Clin Oncol, 2012; tation in patients with metastatic nonsmall cell 1. Pastrana T, Junger S, Ostgathe C, Elsner F & 30: 880-887. lung cancer. J Pall Med, 2011; 14: 459–464. Radbruch L. A matter of definition: key ele- 6. Virdun C, Luckett T, Davidson PM & Phillips 12. Twycross R. Factors involved in difficult-to- ments identified in a discourse analysis of defi- J. Dying in the hospital setting: a systrmatic re- manage pain. lnd J Pall Care, 2004; 10(2):21-32. nitions of palliative care. Pall Med, 2008; 22: view of quantitative studies identifying the ele- 13. Knaul FM, Farmer PE, Krakauer EL, De Lima 222-232. ments of end-of-life care that patients and their L, Bhadelia A, Kwete XJ et al. Alleviating the 2. Meeker MA, McGinley JM & Jezewski MA. families rank as being most important. Pall Med, access abyss in palliative care and pain relief: Metasynthesis: dying adults’ transition process 2015; 29: 774-796. an imperative of universal health coverage: the from cure-focused to comfort-focused care. J 7. Beach MC, Inui T & the Relationship-Cen- Lancet Commission report. Lancet, 2018; 391: Adv Nurs, 2019; 75: 2059-2071. tered Care Research Network. Relationship- 1391-1454 (Panel 2). http://dx.doi.org/10.1016/ 3. World Health Assembly. Strengthening of pal- centered care: a constructive reframing. J Gen S0140-6736(17)32513-8ing the n alliative care liative care as a component of integrated treat- Intern Med, 2006; 21: S3-8. 14. World Health Organization. WHO guidelines ment throughout the life course. 67th World 8. Byock I. Dying Well: peace and possibilities at for the pharmacological and radiotherapeutic Health Assembly, 2014. the end of life. Riverside Books, New York, 1997. management of cancer pain in adults and ado- 4. Gomez-Batiste X & Connor S. Building Inte- pp. 299. lescents. WHO: ISBN 978 92 4 155039 0 (avail- grated Palliative Care Programs and Services. 9. Mannix K. With the End in Mind: how to live able on-line). Worldwide Hospice and Palliative Care Alli- and die well. William Collins, London, 2017. pp. 15. Youngson R & Blennerhassett M. Humanising ance, 2017. https://www.thewhpca.org/resources 342. healthcare. Brit Med J, 2016; 355: 466–467. 5. Smith TJ, Temin S, Alesi ER, Abernethy AP, 10. Block S. in: Gawande Atul. Being Mortal: ill- Balboni TA, Basch EM, Ferrell BR, Loscalzo M, ness, medicine and what matters in the end. Pro- Robert Twycross DM Oxon, FRCP Lond. Meier DE, Paice JA, Peppercorn JM, Somerfield file Books, London. 2014, pp. 182-183. M, Stovall E & Von Roenn JH. American So- 11. Jacobsen J, Jackson V, Dahlin C, Greer J, Perez- Emeritus Clinical Reader in Palliative ciety of Clinical Oncology Provisional Clinical Cruz P, Billings JA, Pirl W & Temel J. Compo- Medicine, Oxford University, UK Opinion: The Integration of Palliative Care into nents of early outpatient palliative care consul- E-mail: [email protected]

The “Normalization” of Euthanasia in Canada: the Cautionary Tale Continues

Leonie Herx Margaret Cottle John Scott

In June 2016, Canada legalized euthanasia was published in this journal summarizing reaffirmed its opposition to euthanasia and and assisted suicide, which legislators re- the early impacts of legalized euthanasia on assisted suicide [2]. We propose in this ar- ferred to collectively as “Medical Assistance Canadian medicine [1]. In October 2019, ticle to update colleagues around the globe in Dying” (MAiD). In Sept 2018, an article the World Medical Association (WMA) on consequences of the rapid expansion and

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cultural normalization of the practice of in- more rapidly than other permissive jurisdic- is committed to expanding the legislation tentional termination of life in Canada. tions over a similar initial time period, and and, on February 24, 2020, tabled a new bill that our rates are quickly approaching cur- in Parliament to respond to the Truchon This paper will balance recent portrayals in rent rates in the Netherlands and Belgium, case ruling to remove the requirement for the popular and medical media that imply where euthanasia has been legal for almost RFND [18]. In the near future, euthanasia only a positive impact as a result of the intro- 20 years. in Canada will almost certainly be open to duction of euthanasia into Canada’s health any person who feels their suffering cannot system [3–4]. Evidence will be presented to be addressed except through intentional demonstrate that there are significant nega- Expansion of Euthanasia termination of life. As mandated by the tive and dangerous consequences of this Practice and Legislative 2016 legislation, the Canadian government radical shift for medicine, and particularly is continuing to explore the additional in- for palliative medicine. These include the Changes clusion of those with mental health issues widening and loosening of already ambigu- as a primary diagnosis, “mature minors” (i.e. ous eligibility criteria, the lack of adequate In addition to the increasing numbers of children), and euthanasia by advance direc- and appropriate safeguards, the erosion of cases, there is also an expanding range of tive (for those who may lose decisional ca- conscience protection for health care pro- indications approved for euthanasia. In four pacity at some point in the future) as part of fessionals, and the failure of adequate over- years, Canada has moved from approving a parliamentary review expected to begin by sight, review and prosecution for non-com- euthanasia for so-called “exceptional” cases June 2020 [19]. pliance with the legislation. Indeed, what to euthanasia being treated as a normalized, we have seen over the past four years is that almost routine, option for death. Even those who support euthanasia in some “the slope has in fact proved every bit as circumstances are voicing concerns over slippery as the critics had warned” [5]. We Ongoing court challenges to legislative re- the rapid expansion of the procedure in also seek to reaffirm the vision of the physi- quirements for euthanasia have resulted in Canada, and a problematic lack of proper, cian’s role “to cure sometimes, to relieve of- its approval for individuals with chronic ill- robust analysis of its utilization [20]. Many ten and to comfort always.” nesses such as osteoarthritis, dementia, and who care for citizens with mental health physical disability [9, 10, 11, 12]. Media issues are extremely concerned, not only reports point to less restrictive interpreta- that psychiatric conditions may be consid- How Many People Undergo tions of eligibility criteria by assessors and ered “irremediable” by some, but also that Euthanasia in Canada? providers of euthanasia without interven- if psychiatric indications are permitted as tion from the courts [13, 14]. These prec- the sole reason for euthanasia, these pa- In just under four years, the number of edent-setting cases have produced what tients could possibly have euthanasia per- euthanasia deaths has rapidly increased in euthanasia providers themselves call “not an formed almost immediately, whereas the Canada. New statistics released by the fed- expansion of our law” but “a maturing of the wait time can be years for specialized, life- eral government on February 24, 2020, show understanding of what we’re doing” [12]. saving psychiatric interventions and care that 13,000 people have died by euthanasia This, in turn, has led providers to approve [21]. The lack of access to psychiatric care since the legalization of the practice, which cases they would not have previously ap- in Canada is also putting patients who are represents approximately 2% of all deaths proved due to earlier fears of criminal pros- facing an end of life diagnosis in an even in Canada. The government estimated ecution [15]. Although reports of criminal more dire situation [22], given the high that there were 5,444 deaths in 2019 and code and regulatory body violations have risk for suicide in this population [23, 24]. 4,438 deaths in 2018 from euthanasia [6]. been well documented [16, 17], no charges In comparison, Statistics Canada reported have ever been laid. Euthanasia deaths are now serving as a 1,922 deaths in motor vehicle accidents for growing source of organ and tissue dona- 2018, the latest year for which statistics are In September 2019, a Quebec Superior tions in Canada [25]. Unlike other coun- available [7]. Euthanasia proponents argue Court ruling on the Truchon case [11] tries, Canada is the first jurisdiction to allow that the Canadian death rate should stabi- struck down a central euthanasia criterion non-patient-initiated discussion of organ lize at a level comparable to other jurisdic- for “reasonably foreseeable natural death” donation for those approved for euthana- tions with equivalent legislation, such as (RFND) which may soon open up eutha- sia. In other jurisdictions where euthanasia the Netherlands where euthanasia now ac- nasia to those with chronic conditions, dis- is legalized, including the Netherlands and counts for 4.9% of deaths [8]. However, it abilities and mental health issues as a pri- Belgium, only patient-initiated organ do- is troubling that Canada’s rate has increased mary diagnosis. The Federal Government nation discussion is allowed, while in some

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jurisdictions, including Switzerland and recommends, “if the adults surrounding the end of life criterion (RFND) means that some U.S. states, subsequent organ donation them normalize MAID [sic], so will the disability-related suffering, largely caused is not possible following assisted suicide. children” [29]. Medical literature regarding by lack of support and societal inequality, Having the potential to alleviate the suffer- children, death and grieving was used to ex- justifies the termination of a person’s life. ing of another person in need or to leave a trapolate approaches to the euthanasia con- When the legislation is amended, this will legacy appears to be a powerful motivator text. Tip #5 states that these conversations effectively enshrine in Canadian law the in the decision for organ donation as part can easily be had with children as young as principle that a person’s life can be ended of death by euthanasia [25]. One individual four years old. Tip #6 suggests that eutha- based on disability alone, further stigmatiz- who donated her organs after euthanasia nasia providers should offer to show your ing and devaluing the lives of those living stated, “I thought the knowledge of having equipment (syringes, stethoscope, IV sup- with disabilities. full autonomy by way of MAiD was com- plies). For example: “I have a tray with the forting, but, when the possibility of organ things I will use to help your loved one die. Disability advocates continue to express donation was added to it, the sense of elation These include medications and syringes. alarm at the evolving situation in Canada, is the only appropriate word for me.” [25]. I am going to leave them on the table and if and Catherine Frazee (former Human Given that most requests for euthanasia you would like to take a look you can. I will Rights Commissioner in Ontario and re- are due to existential suffering, in particular stand beside the table and you can ask me tired professor in Disability Studies) points feeling a burden to others and loss of mean- any questions” [29]. to the hidden message being conveyed by ing and purpose in life [26], the potential government, that “expanding medically as- “good” of organ donation may be a persua- sisted death so that it is not only for those sive incentive for some who may otherwise Euthanasia Due to Lack of who are dying, but also, exclusively, for those not have chosen to hasten their death. Access to Care or Lack of who have some illness, disease or disability, makes us a ‘special case’ for ending a difficult Euthanasia providers are now making rec- Perceived Quality of Life life. This categorically sends one and only ommendations to add drugs (e.g., potassi- one message: we are not needed. Whatever um chloride) to the existing regimen which Examples are mounting of Canadians re- gifts we bring to the world, gifts of mind will cause rapid cessation of cardiac activity questing euthanasia because of lack of access and heart and body, are not of such value and reduce the potential for ischemic dam- to care, such as long-term care or disability that Canada will fight for us to live” [36]. age to organs to be transplanted. The ratio- supports [30, 31]. A significant number of nale for the change is that it “allows organs reports have documented cases in which in- International attention was garnered last to be donated in the best condition possible” dividuals have been told by health care pro- year when the UN’s Special Rapporteur on [27]. Questions are also being raised about fessionals and others to consider euthanasia the Rights of Persons with Disabilities trav- starting organ procurement processes prior as an “answer” to a perceived poor quality of eled to Canada in the spring of 2019. In her to death being determined which would life or a lack of health care resources to meet end-of-mission statement, Ms. Devandas- also allow organs to be donated in “the best their needs. Motivation for these decisions Aguilar stated that she is “extremely con- condition possible” [28]. There are a number and suggestions appears to include the cost cerned about the implementation of the of difficult issues that arise when consider- of care or specialized supports [32, 33]. legislation on medical assistance in dying ing organ donation in these circumstances, from a disability perspective…” and she including conscientious objection of team Following the Quebec Superior Court rul- urged Canada to do more to “…ensure that members involved in transplantation, the ing on the Truchon case [11], over seventy persons with disabilities do not request as- “dead donor” rule, and informing potential Canadian disability allied organizations sistive [sic] dying simply because of the ab- recipients of the source of the organs to be came together out of concern for the equal- sence of community-based alternatives and transplanted. ity rights of vulnerable Canadians, and palliative care” [37]. signed an open letter asking the federal gov- More evidence of the normalization of eu- ernment to appeal the court ruling to the thanasia can be seen in the recent set of tips Supreme Court of Canada [34]. A similar “Safeguards” for Euthanasia published on how to prepare children for a open letter [35], urging an appeal in the euthanasia death of a loved one. The author, same case, was signed by over 350 physi- The Supreme Court of Canada, in the case Co-Chair of the Ontario College of Family cians from all specialties across Canada. No of Carter v. Canada (2015), that originally Physicians Palliative/End of Life Care and appeal was made. These disability experts led to the decriminalization and subsequent MAiD Collaborative Mentoring Network, and physicians argued that the removal of legalization of euthanasia, stated that a

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“carefully designed and monitored system current and proposed initial amendments or health care provider [18]. There is also a of safeguards” would limit risks to vulner- to the euthanasia legislation in Canada (re- reasonable concern that the blanket misap- able persons [38]. The safeguards in the sponse to the Truchon case) do not permit plication of the so-called “duty to inform” subsequent 2016 legislation [39] include euthanasia for psychiatric reasons alone, this may soon suggest to all physicians that they a mandatory ten-day reflection period be- indication is under formal review [19] and are required to offer euthanasia as an option tween the request and the euthanasia pro- there is considerable public pressure for its in every serious illness. If this is the case, cedure, the independent nature of the two legalization from those who wish to see this it will be impossible for physicians to avoid eligibility assessors, the requirement for expansion [43]. the appearance, if not the reality, of coercion decisional capacity of the patient at the for vulnerable patients who may already time of the request and at the time of the We also note that it is difficult, even in feel they are a burden to others. Even sup- procedure, protection against coercion by person, to determine decisional capacity porters of euthanasia have already acknowl- requiring two independent witnesses, and a or possible coercion, especially if a case is edged there is no reliable way to measure rigorous system of monitoring and review. complicated. In Canada, both telemedicine coercion [46]. (video) and telephone (voice) are allowed Currently, the ten-day reflection period is to be used for euthanasia assessments. De- Concerned Canadians continue to work often waived, and the newly proposed leg- termination of a person’s decisional capac- together to address the issue of safety for islation would formally repeal this require- ity is not straightforward and may require vulnerable citizens. The Vulnerable Persons ment [18]. In one cohort study of euthanasia advanced skills and tools [44], but there are Standard (VPS), initially developed in re- deaths in Ontario, 26% of euthanasia deaths no formal requirements for training to as- sponse to the Carter v. Canada decision, had the ten-day reflection period expedited sess decisional capacity and no requirement is an internationally recognized evidence- [40]. In Quebec, it has been reported that for psychiatric consultation in complex based framework “that provides clear and 60% of euthanasia cases had the ten-day re- cases. Many physician colleagues, ourselves comprehensive guidance to law-makers flection period waived and, of these cases, included, report personal experiences with by identifying the safeguards necessary to 48% did not meet the criminal code criteria patients who, in their opinion, lacked deci- protect vulnerable persons within a regu- for removal (i.e., imminent risk of death or sional capacity at the time of the euthanasia latory environment that permits medical- imminent loss of decisional capacity) and assessment and/or at the time of the pro- assistance in dying” [47]. The VPS was 26% had no documented reason for waiving cedure, and still received euthanasia even developed by a large body of advisors with the reflection period [41]. though formal documented concerns had expertise in medicine, ethics, law, public been raised with the euthanasia providers. policy and the needs of vulnerable persons. Compliance reports from Quebec have also Despite the fact that the VPS has received documented concerns about the “indepen- Monitoring requirements include only basic strong, broad-based, continuing support, it dent nature” of assessors [17]. In our per- demographic information and are reviewed has been completely ignored by every level sonal experience, the assessors are in reality in retrospect [45]. Information about race, of government. not always independent. Assessors are often education, socioeconomic status, and lan- colleagues belonging to a small community guage abilities is not collected, and there is It is also important to note that, during the of providers who practice euthanasia. The no direct oversight or mechanism to stop legalization process, access to palliative care second assessor can see the first assessor’s the procedure if red flags are raised. was positioned as a “safeguard” for euthana- report prior to seeing the patient or writ- sia. However, in reality, less than 30% of Ca- ing their own report. There are also no data A group representing euthanasia provid- nadians have access to any form of palliative about how often a second assessor disagrees ers, the Canadian Association of MAiD care and less than 15% have access to spe- with a first assessor, or how many different Assessors and Providers (CAMAP) has cialized palliative care [48]. Many, including assessors an individual seeks out, since there been calling for the abandonment of the Shariff and Gingerich, have questioned if is no limit to the number of assessments that requirement for two independent witnesses euthanasia can truly be an informed choice can be obtained. An individual patient only (established to ensure protection against co- if there is no meaningful access to palliative needs two approved assessments. A study ercion). They contend that this requirement care [49]. from Belgium, which deals with euthanasia is a bureaucratic frustration that blocks for psychiatric reasons, suggested that 24% patient access. New legislation proposes Although economic considerations may of cases involved disagreement amongst to reduce the number of witnesses to one not currently be driving the normalization consultants, highlighting the challenge of and would make it legal for that witness to and expansion of euthanasia in Canada, it discordant assessments [42]. Although the be the patient’s paid personal care worker cannot be denied that the procedure is sig-

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nificantly cheaper than rigorous, traditional National Canadian palliative care orga- Euthanasia proponents continue to co-opt palliative care. The financial savings of eu- nizations have expressed concern that the vocabulary and tools of palliative care thanasia for the health care system in Cana- this confusion and conflation of eutha- to create a new discipline of “end of life da have already been reported [50] and with nasia and palliative care perpetuates the medicine” with a radically different phi- an aging demographic and diminishing fis- myth that palliative care hastens death losophy, intention and approach that em- cal resources, the option to save money in and that misconception may prevent pa- braces hastened death as the “most beautiful this way may become increasingly accept- tients from seeking timely palliative care death” [3]. Under this banner of “end of life able to health care decision makers. interventions which improve quality of care,” existing palliative care resources are life and, in some cases, enable people to being used in some jurisdictions to provide live longer [60]. The Canadian Society euthanasia, effectively reducing already lim- Confusion Between Palliative of Palliative Care Physicians has stated ited resources for palliative care. This is the Care and Euthanasia that “patients and families must be able case in Ontario where, in some regions, the to trust that the principles of palliative community Hospice Palliative Care Nurse Another ongoing issue is the confusion care remain focused on effective symp- Practitioners were given the additional role and conflation of euthanasia with palliative tom management and psychological, so- of providing euthanasia [62–63]. The as- care. The use of the euphemistic terminol- cial, and spiritual interventions to help sessment for and provision of euthanasia by ogy of Medical Assistance in Dying to refer people live as well as they can until their physicians in Ontario are billed to the Min- to euthanasia in Canada has exacerbated this natural death.” [53]. istry of Health using palliative care billing confusion in both the public and health care codes, despite the objections of palliative spheres. Canadian palliative care organiza- Dr. Balfour Mount, the “father” of palliative care physicians [64]. The very distinct and tions have argued against the use of such care in Canada, recently stated that disparate goals and procedures followed by language, affirming that palliative care pro- euthanasia teams and palliative care teams vides support or “assistance» in dying to help Canadian legislation utilizes the euphe- make it reasonable and advisable to separate people live as fully as possible until their nat- mism ‘medical assistance in dying’ (MAiD) the two practices. This separation should be ural death, but does not intentionally hasten to define euthanasia/assisted suicide and accepted without acrimony or contention as death [51]. This assertion is also supported that language has caused confusion con- it is in the best interests of patients, their by the longstanding World Health Organi- cerning its distinction from Palliative Care. families and the teams themselves. zation definition of palliative care [52]. For over four decades, Palliative Care has been providing expert medical management The impact of normalized euthanasia on In spite of clear and repeated distinctions to assist and support those who are dying our day-to-day clinical work in palliative made by national palliative care organiza- without hastening death or administering a care has been profound. When someone tions and the Canadian Medical Associa- lethal dose of drugs to end life. The MAiD expresses a desire to die or a desire for has- tion [53–56], there are ongoing efforts by euphemism confuses and causes fear in our tened death (for example, “I just want this some euthanasia providers to incorporate patients and the general public regarding to be over…”), there can now be a knee-jerk euthanasia within the scope of practice of the practice of Palliative Care and the na- reaction to consult the euthanasia team as palliative care, and to co-opt palliative care ture of Palliative Medicine [61]. a first response and neglect what palliative language to describe their euthanasia prac- care has to offer. Until now, the standard of tice, “as one of the many items in the pal- care has been to engage the patient in seri- liative care basket” [57, 58]. Linking the Impact on Palliative Care ous dialogue, to try to understand the nature two practices in this way misleads other of their suffering and grief expression more health care professionals and the public re- The 2016 Federal legislation positioned eu- fully, and to determine what supports might garding palliative care. The 2019 Canadian thanasia (MAiD) as a health care right un- be helpful. In palliative care, it is universally Guideline for Parkinson Disease is a recent der the Canada Health Act, and so it must accepted that expressing a desire to die and example [59]. Palliative care was commend- be publicly funded and accessible to all Ca- talking about hastening death are most of- ably presented as one of the five key recom- nadians [39]. Palliative care, however, is not ten normal expressions of grief, loss and mendations for the approach to care for afforded such status and there is no similar coming to terms with one’s mortality in the persons with Parkinson Disease. However, requirement for it to be funded and accessi- face of a life-threatening condition. Such ex- euthanasia (as “MAiD“) was listed directly ble to Canadians. This is highly inequitable pressions of distress need to be explored and under the banner of palliative care support since almost 98% of deaths in Canada are supported with skilled palliative care inter- and was the only specific measure listed! not through euthanasia [6]. ventions to better understand the nature of

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the suffering and how to address this, and/or thanasia without ever having a proper trial Hospices and faith-based institutions are to accompany the person in their suffering. of excellent palliative care, even where it is criticized for “blocking access” to euthana- There are many holistic, dignity-conserving available. A Quebec study found that in pa- sia, even where access is documented to be palliative care interventions such as Dignity tients requesting euthanasia, 32% of those excellent [68]. Therapy [65], developed by renowned Cana- who received a palliative care consultation dian palliative care psychiatrist Dr. Harvey had it requested less than seven days be- Chochinov, which are aimed at restoring fore euthanasia provision and another 25% Protection of Conscience purpose, meaning, and reframing hope in of palliative care consults were requested for Physicians the face of the losses that accompany life- the day of or the day after the euthana- threatening illnesses. Such therapies help a sia request [41]. With the removal of the Participation in euthanasia is also a great person and their loved ones to focus on liv- ten-day reflection period from euthanasia concern for physicians who are profession- ing, even while dying, and provide support request to delivery of the procedure in the ally and/or morally opposed to it. Some to accompany people on their journey, so proposed revision for euthanasia legislation physician regulatory bodies require partici- they do not feel abandoned or alone. [18], the reality of a meaningful palliative pation via a mandatory referral for eutha- care consultation seems even less likely. nasia by physicians unwilling to provide the There is no mandatory palliative care con- procedure themselves. For some physicians, sultation prior to euthanasia. The only re- Downar et al (2020) state that 74% of eu- such an obligation makes them complicit quirement is that a patient is aware of all thanasia cases in Ontario had palliative care in an act they find not clinically indicated, options for care (informed of all means to involved, however, the reporting measures unethical, or immoral. This happens in relieve suffering, including palliative care). used during the study period do not allow Ontario, Canada’s largest province, where Awareness is not the same thing as mean- for a detailed evaluation of the quality of the College of Physicians and Surgeons of ingful access, and what a person understands medical care provided, including palliative Ontario has mandated such an “effective palliative care to be may influence the per- care, as it is not within the legislated re- referral” requirement [69]. Physicians who son’s understanding of what palliative care quirements for oversight by the Office of decline to do this could face disciplinary ac- has to offer. The Chief Coroner of Ontario, the Chief Coroner to review or collect this tion such as the loss of the license to practice who receives all reports of euthanasia cases information [66]. It is thus not possible medicine. The Ontario courts have agreed in the province, has identified that it is very to delineate or evaluate either the quality that the requirement for referral violates difficult to evaluate the quality/suitability of or quantity of palliative care involvement, the conscience/religious rights of physicians the palliative care being offered to patients when it occurred in relation to the request (which are protected under the Canadian who receive euthanasia [66]. Our own per- for euthanasia (the study only documented Charter of Rights and Freedoms) but justi- sonal experience is that many patients and that there was involvement at the time of fies the referral requirement to “ensure ac- health care professionals, including some request), which palliative care team mem- cess» to euthanasia for patients, despite no euthanasia providers, do not fully under- ber provided it (e.g. physician, nurse, or documented lack of access in Ontario [70]. stand palliative care and its extensive array social worker, etc.) or whether there was This is the very first time in Canada that the of therapeutic interventions. any meaningful involvement by a specialist burden of ensuring access to other parts of palliative care team. A number of detailed the health care system has rested on the in- It is also our experience that, although pal- responses outlining the significant problems dividual physician. liative care teams offer to provide ongoing with the conclusions made in this paper palliative care for patients who request a eu- have already been published online [40]. As previously discussed, euthanasia pro- thanasia death, a number of these patients ponents are now suggesting that doctors reject palliative care involvement. These Strong lobbies are pushing for euthanasia to must introduce euthanasia as an option to patients often refuse many of the medica- be available in every palliative care unit and all potentially eligible patients as a so-called tions offered for optimizing symptom man- hospice in the country [67]. In many areas, “duty to inform” [71]. However, in no other agement, citing fear that the medications euthanasia is required to be provided in all clinical situations are physicians required to will cause them to lose decisional capacity settings of care in order to avoid the with- discuss all potential options and procedures and therefore their eligibility to receive eu- drawal of public funding. Hospice societies if they determine that those options are not thanasia. Tragically and paradoxically, this who fundraise to build the buildings and medically indicated [72–74]. may result in the last days of life await- co-support the day-to-day costs of special- ing a euthanasia death being more highly ized hospice care are also being mandated Some euthanasia providers are now re- symptomatic, and patients may have eu- to provide euthanasia on site or face closure. fusing to become the “Most Responsible

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Physician” (MRP) via a transfer of care solely on the principle of autonomy as justi- experience should not lead to discourage- prior to or during the euthanasia procedure. fication for euthanasia [77]. But, in Canada, ment but should instead inspire a reaffir- One of the authors on this paper has direct- the delivery of euthanasia is anything but an mation of the commitment to traditional, ly experienced this at their local hospital. autonomous act. By design, it involves one whole-person medicine. Patients, loved Personal written communications have also or more other individuals. Many individu- ones, clinicians, and even society in gen- reported this practice happening at other als and health care and community services eral are all deeply enriched when palliative hospitals across Canada. In addition, some commonly participate in each death, some- teams use our expertise to show compas- euthanasia providers are refusing to accept times against their better judgment and sion through excellent clinical care in an patient transfers from palliative care units possibly even against their will. on-going, committed relationship with and hospices. These strategies profoundly each patient, no matter how difficult the damage collegiality and may force physi- While palliative care has so far been on the circumstances or how complicated the is- cians unwilling to collaborate in euthanasia forefront of the euthanasia experience, the sues. Suffering — pain, fear, loss of control, (professionally or morally) into an ethical coming expansion of the legislation that will sense of burden—is not solved by hastened crisis, compelling them either to remain the allow euthanasia for suffering due to any ill- death, but by this excellent care, delivered MRP, formally approving euthanasia and ness, condition or disability, will have a much in a community and a society that honours responsible for all aspects of care for the broader impact on physicians from all medi- and protects our most vulnerable citizens at patient and family, or to refuse to approve cal disciplines, as well as on other health care the most difficult times in their lives. Eu- it and face contrived accusations of having professionals. There will be very few areas thanasia is not the panacea that proponents obstructed patient access. of medicine that euthanasia does not touch. promise. Its legalization and subsequent rapid normalization have had serious nega- Palliative care clinicians have a high level of In less than four years since the legalization tive effects on Canadian medicine and on burnout [75–76], and the perceived lack of of euthanasia in Canada we have witnessed Canadian society as a whole. We urge the control over the scope of practice and forced • rapid increase in rate of death by euthana- WMA and our colleagues around the world participation in something that goes against sia (now estimated to be 2% of all deaths to look beyond the simplistic media reports their convictions about the very core of their and expected to rise further) – a rate of and to monitor developments in Canada vocation may be contributing to increas- growth over 3 years that has surpassed all carefully and wisely before making any ing moral distress and moral injury. This is other permissive jurisdictions changes in their own country’s legal frame- reflected in colleagues who come to us on a • the loosening of eligibility criteria by asses- work for medical practice. daily basis to share experiences of repeated sors and courts and the weakening of safe- distress from euthanasia cases. Even col- guard mechanisms in existing legislation leagues who support euthanasia in some cir- • the imminent expansion of euthana- References cumstances have reported experiencing this sia through legislative revision, despite 1. Leiva R, Cottle M, Ferrier C, Rutledge Hard- serious distress at times. Moral distress and strong opposition from citizens in the ing S, Lau T, McQuiston T, et al. Euthanasia in Canada: a cautionary tale. WMJ 2018 Oct; 64 moral injury manifest as early retirements, disability community, mental health pro- (3):17-23 [cited 2020 Feb 29]. Available from: leaves of absence, and career changes by phy- fessionals, palliative care clinicians and Available from: https://www.wma.net/wp-con- sicians who will no longer provide palliative public policy leaders tent/uploads/2018/10/WMJ_3_2018-1.pdf care due to the expectation that euthanasia is • the failure of federal and provincial gov- 2. World Medical Association. WMA Declaration included in the scope of practice. Additional ernments to designate palliative care as a on Euthanasia and Physician-Assisted Suicide moral distress is experienced by some pallia- right and to provide access to palliative [Internet]. 2019 Nov 13 [cited 2020 Feb 29]. tive care leaders when health region admin- care that is at least as robust as access to Available from: https://www.wma.net/policies- post/declaration-on-euthanasia-and-physician- istrators arbitrarily put euthanasia admin- euthanasia assisted-suicide/ istration and oversight into the “end of life • the confusion and conflation of palliative 3. Buchman S. Why I decided to provide assisted care” portfolio. The probable loss of palliative care with euthanasia; and dying: it is truly patient centred care. BMJ. 2019 care physicians from the workforce at a time • the erosion of conscience protection for Jan 30;364:l412. when even more clinicians are needed is in physicians and other health care profes- 4. Smith R. Learning from Canada about assisted part a direct consequence of such stressful sionals leading to coerced participation dying. BMJ Blogs [Internet] 2020 Jan [cited 2020 Feb 29]. Available from: https://blogs.bmj. situations and heavy-handed measures. and demoralization. com/bmj/2020/01/22/richard-smith-learning- from-canada-about-assisted-dying/ Proponents of euthanasia use the phrase These formidable challenges faced by physi- 5. Coyne A. Globe and Mail [Internet]. 2020 Jan “my life, my death, my choice,” which calls cians and patients in our difficult Canadian 17 [cited 2020 Feb 29]. Available from: https://

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69. Medical Assistance in Dying [Internet]. Col- Queen’s University Paola Diadori, Bryan Dias, Marisa Derman, lege of Physicians and Surgeon of Ontario. 2016 Kingston, Ontario, Canada Jane Dobson, Ugo Dodd, Anne Doig, [cited 2020 Feb 29]. Available from: https:// www.cpso.on.ca/Physicians/Policies-Guidance/ Christopher J. Doig , Rosaria Domenicone, Policies/Medical-Assistance-in-Dying#Policy Margaret Cottle MD CCFP (PC) David P. D’Souza, Ed Dubland, Sherif Emil, 70. Ontario Superior Court of Justice Divisional Assistant Professor, Division Duncan Etches, Hao Ian Anita Fan, Court. The Christian Medical and Dental Society of Palliative Care Elizabeth Feeley, Theodore Karl Fenske, of Canada v. College of Physicians and Surgeons Faculty of Medicine, University Natasha Fernandes, Nisha Fernandes, of Ontario, 2018 ONSC 579 (CanLII) [Inter- net]. 2018 Jan 31 [cited 2020 Feb 29]. Available of British Columbia Catherine Ferrier, Michael Fielden, from: https://www.canlii.org/en/on/onscdc/doc/ Vancouver, British Columbia, Canada Alanna Fitzpatrick, George M. Francis, 2018/2018onsc579/2018onsc579.pdf Geoff Friderichs, Remedios T. Fu, 71. The Canadian Association of MAiD Asses- John F. Scott MD MDiv Abraham Fuks, Romayne Gallagher, sors and Providers. Key Messages: End of Life Associate Professor, Division Dominique Garrel, Stan P. George, Care and Medical Assistance in Dying [Inter- of Palliative Care, Gabriella Gobbi, Pamela Gold, net]. 2020 Feb [cited 2020 Feb 29]. Available from: https://camapcanada.ca/wp-content/up- Department of Medicine, Ewan Goligher, Rudy Hamm, loads/2020/02/FINAL-Key-Messages-EOL- University of Ottawa Sheila Rutledge Harding, Pippa Hawley, Care-and-MAiD.pdf Ottawa, Ontario, Canada David Henderson, Amy Hendricks, 72. Williams JR. Law catching up with ethics. Neil Hilliard, Zoltan Horvath, Ann Hoskin- CMAJ [Internet]. 2020 Feb 3 [cited 2020 Feb Mott, Lawrence F. Jardine, Andre Jakubow, 29]; 192(5): E123. Available from: https://www. cmaj.ca/content/192/5/E123 Will Johnston, Stephanie M. Kafie, 73. Downar J, Close E, Sibbald R. Do physicians Acknowledgements Ebru Kaya, Lynn Kealey, Timothy J. Kelton, require consent to withhold CPR that they de- and Endorsements Nuala Kenny, Anthony Kerigan, termine to be nonbeneficial? CMAJ [Internet]. Pongrac Kocsis, Michelle Korvemaker, 2019 Nov 25 [cited 2020 Feb 29]; 191(47): The authors want to express our deepest Tim Kostamo, Jaro Kotalik, Judith Kwok, E1289-E1290. Available from: https://www. cmaj.ca/content/191/47/E1289 thanks to our dear colleagues for their in- Joseph M.C. Lam, Jim Lane, Michael Lane, 74. Ontario Superior Court of Justice Wawrzyniak sights, edits and support. Tim Lau, Mireille Lecours, Keith Lee, v. Livingstone, 2019 ONSC 4900 (CanLII) [In- Renata Leong, Andrea Loewen, ternet). 2019 Aug 20 [cited 2020 Feb 29]. Avail- The article has been explicitly endorsed by David Loewen, Constant H. Leung, able from: https://www.canlii.org/en/on/onsc/ the following Canadian physicians: Iris Liu, Cindy Lou, Karen MacDonald, doc/2019/2019onsc4900/2019onsc4900.html Maria MacDonald, Jean-Noel Mahy, 75. Kamal AH, Bull JH, Wolf SP, Swetz KM, Shanafelt TD, Ast K, et al. Prevalence and Pre- Balfour M Mount, OC, OQ, Lauren M. Mai, Giuseppe Maiolo, dictors of Burnout Among Hospice and Pallia- MD, FRCSC, LLD Karen Mason, Loraine Mazzella, tive Care Clinicians in the U.S. J Pain Symptom Canadian Pioneer in Palliative Care and Brandon McIlmoyle, John R. McLeod, Manage. 2016 Apr; 51 (4): 690-696. Founding Director of Palliative Care, McGill Terence McQuiston, Amy Megyesi, 76. Reddy S, Yennu S, Tanco KC, Anderson AE, & McGill Programs in Whole Person Care Randy Montag, Alisha Montes, Jose Morais, Guzman D, Williams JL, et al. Frequency of burn-out among palliative care physicians partici- Emeritus Professor of Medicine, Louis Morissette, David Neima, pating in continuing medical education. Journal McGill University, Nicholas Newman, Natalia Novosedlik, of Clinical Oncology 2019; 37:31_suppl, 77. Montreal, Quebec, Canada Michael J. Passmore, John Patrick, 77. Wesley Smith. My Life, My Death, My Choice Cameron W. Pierce, Jose Pereira, [Internet]. 2010 Aug 5 [cited 2020 Feb 29]. Avail- Rebecca Adams, Lubomir Alexov, Francois Primeau, Mimitha Puthuparampil, able from: https://www.discovery.org/a/15141/ Tommy Aumond-Beaupre, Stephanie Austin, Geoffrey Purdell-Lewis, Roger Roberge, Jason Bailey, Pascal Bastien, Cameron Ross, Christopher J. Ryan, Authors’ Affiliations Thomas Bouchard, Ralf Buhrmann, Paul Saba, Rafael Sumalinog, Luke Savage, Myra Butler, Julia Cataudella, Kevin Sclater, Valerie Schulz, Elvira Smuts, (Institutional affiliation are provided for Joseph Cavanagh, Cyril Chan, Beverly Spring, Nathan Stefani, identification purposes only and do not im- David Chan, Sherry Chan, Srini Chary, Sephora Tang, Philippe Violette, Lucas Vivas, ply endorsement by the institution) Martin Chasen, Luke Chen, Riley Chen- Lilian Lee Yan Vivas, Esther Warkentin, Mack, Sylvia Cheng, Samantha Chittick, James Warkentin, Eric Wasylenko, Leonie Herx MD PhD CCFP (PC) FCFP Joyce Choi, Eileen Cochien, Ramona Coelho, Richard Welsh, Kiely Williams, Ryan Wilson, Chair, Division of Palliative Medicine Alana Cormier, Robin W. Cottle, Maria Wolfs, Artur Wozniak, Paul Yong, Associate Professor, Department of Medicine Rita Dahlke, Julie E. Dermarkar, Roman Zyla, Nathan Schneidereit

37 Medical Ethics

as well. They perceive the WMA’s position Appeal for Policy Promotion as merely conservative, and the WMA as a milieu in which Hippocrates is strug- To our President gling to catch up to the twenty-first century. Personally, I think they are tragically and I counsel against it when the subject arises. mistaken. I think there are good reasons for Rather, I try to discover the reasons underlying physicians to abstain from euthanasia, and my patient’s request, in order to see how I can that these reasons are just as pressing to- ethically help them with these.) In conversa- day as they were twenty-four centuries ago. tion with them, I have found it very helpful I gather that suicide assistance did occur in to point out that the World Medical Asso- the Greece of Hippocrates’ day, but we have ciation has repeatedly stated that physician no evidence that he or his disciples were involvement in euthanasia is unethical, and political reformers. Rather, their position that since the WMA has over 100 con- seems to have been that suicide assistance stituent national medical associations, we in was not their role, that it was inconsistent Canada are “the odd man out” of the world- with medical care. As in Hippocrates’ day, wide medical profession. there are reasons for the medical profession to abstain from euthanasia that apply In light of the continuing creep of euthana- no matter whether the larger society wants sia in the Western World, I feel an urgency it. While there are reasonable concerns that to present to you a proposal to promote the the option of euthanasia in our clinical work WMA’s wise policy and ethics statements harms the doctor-patient relationship, I be- Terence McQuiston on the subject. I believe we need to ac- lieve there are also reasons for concern that tively promote the WMA policy not only euthanasia in the health care system harms Dear colleagues, I was a co-author of the ar- in countries such as my own whose medical society as a whole. ticle Euthanasia in Canada – a Cautionary associations have already succumbed to the Tale, published in the World Medical As- euthanasia activists, but also in other coun- I would therefore submit for the WMA’s sociation Journal September 2018, Vol. 64 tries where cultural and political pressures consideration the following as reasons that #3 pp. 17-23, although today I am writing are mounting to make euthanasia both legal society, even if it has decided to approve eu- only on my own behalf. and expected of the medical profession. The thanasia for its citizens, should not delegate WMA’s existing policy statements prohib- the adjudication or execution of euthanasia I am writing to you to plead for a fresh iting euthanasia are valuable, but would be requests to its physicians. start by the WMA leadership to promote more effective if the reasons for them were the WMA’s vision of medical care without explained. If explained, I think that the euthanasia. WMA’s policy could have much more trac- Euthanasia in the Health Care System tion in Western countries. Even if Society has Decided that it To this end, I believe that in addition to Wants Euthanasia, why Should it Keep maintaining its prohibition of euthanasia by its Health Care Workers, Especially physicians, the WMA needs now to explain Why do we say that euthanasia its Physicians, out of Euthanasia? publicly its reasons for this, and these rea- by physicians is unethical? sons need to be on the WMA website along First – Magistrates would do a better job with a prominent display of the policy. Regrettably, when I searched through than physicians in adjudicating euthanasia the WMA website’s policies and archives applications. My patients live in retirement residences I found nothing on this question. The re- and therefore include many who think action of many people, especially the well- Unless society decides to legalize euthanasia about euthanasia for themselves now that in educated, if they hear about the WMA’s on demand, any legalization of euthanasia Canada it is legal, increasingly frequent, and policy will be to say, “That’s interesting, but will try to define some restrictions on the increasingly seen as normal in the health why does the WMA say that?” The WMA’s practice. Therefore, as a practical necessity care system and in society in general. (I per- reasons are not obvious to them, and that the legislation will need to construct an ap- sonally never suggest euthanasia to a patient, is so with many of my medical colleagues plication process and to appoint someone to

38 Medical Ethics

adjudicate the applications. So far all eutha- A – The presence of euthanasia in the health already seeing this in Canada, with physi- nasia laws in whatever jurisdiction have as- care system erodes public confidence in cians leaving palliative care, and difficulties signed the job of adjudication to physicians. the health care system, especially in its phy- in recruiting new medical graduates for pal- However, I would contend that physicians sicians, that they can be trusted to care in liative care. are a poor choice for this role. It involves all circumstances, and never to harm. We legal decision-making, which is different have seen evidence of this problem in the Perhaps you know of other reasons why from clinical decision-making. We, phy- Dutch experience. Indeed, this came out at physicians should not involve themselves in sicians, are trained for and experienced in the WMA General Assembly in Reykjavik, euthanasia. Unfortunately, although our eth- the latter, but not the former. There are no where it was reported that Dutch patients ics code includes “the utmost respect for human medical indications for euthanasia. Eutha- receiving health care in Germany often car- life”, I don’t think this consideration will reso- nasia is not at its base a medical act. Rather, ry cards saying, “I do not wish to be killed.” nate strongly in our increasingly secular West- it uses simple medical technology to ac- In a fiduciary doctor-patient relationship, ern societies, but perhaps you are aware of other complish a non-medical end. Euthanasia is the patient’s trust in the physician is vital to reasons that might resonate with them. a new activity for our societies and needs to the relationship’s optimum function. How be framed uniquely, distinct from all other can patients receive maximum benefit from activities such as health care. their doctors if they don’t trust them not to Euthanasia in Society as a Whole kill them? is this a Public Health Issue? Predictably we are seeing a great variation Should the WMA Address it as in physicians’ responses to euthanasia ap- B – The presence of euthanasia in the health Such that in the Public Square? plication. This variation looks arbitrary to care system impairs the morale of health the public, so it breeds disrespect for the law care providers including, but not limited So far, I have written only about euthana- and emboldens both patients and physi- to, physicians and nurses. We are human sia’s effects on the health care system. cians to skirt the law. beings, not robots. Quality clinical care necessitates a caring, personal relationship However, it can be argued that euthanasia is In 2009, the Human Rights Committee of between care-giver and patient. To kill our also a public health issue (People do die from the United Nations Covenant on Civil and patient necessitates a certain hardening of it), and the WMA quite properly involves Political Rights investigated Dutch eutha- ourselves to cope with this horrible real- itself in other public health issues. nasia practice and expressed concern “at the ity. Such hardening cannot be restricted to extent of euthanasia and assisted suicides the immediate euthanasia act. In our clini- Does the presence of euthanasia in a so- ...... a physician can terminate a patient’s cal work with other suffering or “hopeless” ciety’s culture result in significantly more life without any independent review by a patients we will inevitably be weighing in deaths than the euthanasia advocates origi- judge or magistrate to guarantee that this our minds the question of whether killing nally anticipated or advocated for? Have we decision was not the subject of undue influ- the patient would be in their best interest. “let a genie out of its bottle” in the words ence or misapprehension.” Evidently, they It is very difficult to be continually mov- of the Dutch Ethics Professor Theo Boer? did not consider review by a second physi- ing between the vision of classical medical That is certainly what has been happening cian to be an adequate safeguard. care (to cure sometimes, relieve often, and in Canada, and in the Netherlands also, console always) and the idea of killing this I think. To quote from the then Professor Second – Execution of approved euthanasia person. It’s like continually shifting our car’s of medical ethics at the Free University of applications does not need a physician. gears back and forth, between forward and Amsterdam, Dr. Henk Jochemsen, in an reverse. This severely grinds the gears. It cre- open letter to Canadians in 2010 when our Instead, other individuals can be licensed ates too much stress in us to cope with, so parliament was first considering legalizing to perform euthanasia. The knowledge and we have to reduce the gear-shifting. We can euthanasia, “the practice of euthanasia in skill set needed to kill someone painlessly is do this either by suppressing the “reverse” to the Netherlands is changing the doctor-pa- remarkably simple. A High School gradu- euthanasia, thus failing our society in its de- tient relationship and the attitudes of soci- ate could easily be trained for this in two to sire for euthanasia, or else by restraining the ety toward the severely disabled, elderly, and four weeks. “forward”, namely our professional calling terminally ill.” I see similar changes now oc- to give of ourselves to the maximum care curring in Canada. Third – The effectiveness of the health care for patients in dire circumstances. Society system suffers when euthanasia is intro- will therefore suffer in the quality of care it It should not come as a surprise that the duced in it. gets from its physicians. Anecdotally I am presence of euthanasia in a society’s culture

39 Green Doctor

will result in people being euthanized be- WMA be saying in the public square about If we really want credibility for our eutha- cause they are sick, disabled, elderly, men- the effects of euthanasia in the broader cul- nasia policy with physicians in the West, tally ill, or in the last phase of their lives (i.e., ture of society, as an issue of public health? let alone adherence to it, we must “unpack” “terminally ill”). Requests for euthanasia The WMA has worldwide prestige. Its it. (Perhaps the WMA Workgroups on the from our patients and their families don’t messages become part of the cultural brew Patient-Physician Relationship and on the In- arise only from dispassionate philosophy and can make a difference. People still do ternational Code of Medical Ethics could work about end-of-life questions, but also from a listen to what they hear their doctors say- on this.) number of extra-rational factors including ing. However, such a statement would need suffering in many forms (physical, men- to be supported by more data than I have Please also form a committee to look into tal, and social – they’re lonely), fear of the ready access to. Drawing from our networks, the public health ramifications of eu- future, shame (“I’m just a burden to my who can supply us with the necessary stud- thanasia, and develop an adequately re- family”), and existential despair (“My life ies and statistics on the WMA approach, as searched statement on this matter . (Sooner has no meaning anymore.”) As euthanasia you work on a statement about the ramifi- rather than later – the need is urgent.) becomes more public and commonplace in cations of euthanasia on public health? society, cultural pressure to conform to its Terence McQuiston M.D. ideology will inevitably increase. I plead with the WMA’s leadership to con- Associate Member, WMA sider what I have written. Toronto, Canada Let us not imagine that we of the WMA will succeed on the battlefront of medical Please elaborate publicly your reasons for ethics while ignoring this issue of public declaring euthanasia by physicians to be health. Therefore I ask, what should the unethical .

This Month Consider Indoor Air Health

Most of us are spending more time indoors org/go-green-at-home-to-prevent-asthma- our communities for the health threats of this month. Many people do not know that breathing-problems/. There’s also a link to a climate change. Ask your clinic or office the air inside is usually dirtier than the air free waiting room poster on this topic. manager to register: https://www.MyGreen- outside, contributing to asthma and other Doctor.org/. pulmonary complaints. The World Medi- My Green Doctor is a free membership cal Association’s My Green Doctor pro- benefit from the World Medical Associa- If you are a leader in your national medical gram has a short guide to help your patients tion that is saving clinics and offices money association, please add this message to your improve indoor air quality, “Go Green at as they adopt wise environmental practices organization’s newsletter so that your doc- Home to Prevent Asthma and Breathing and share these ideas with their patients. tors can enjoy this free membership benefit. Problems” (Reading Time: five minutes). Hundreds of offices use My Green Doc- To receive this e-newsletter announcement You might print copies to share with your tor. It adds just five minutes to each regular in a language other than English, simply office colleagues and for the waiting room, office staff meeting. My Green Doctor ex- contact My Green Doctor’s Editor: tsack8@ or consider emailing it to all of your pa- plains what to say and do at each meeting gmail.com. tients, either as a PDF (we provide the file) so there is nothing for the office manager or as a link: https://www.mygreendoctor. to study or prepare. This is how we prepare

40 NMA News

in the next generation of medical doctors. Singapore Medical Association – sixty years on Inaugurated in 1963, the SMA Lectureship is a prestigious annual lecture delivered by gations versus rising a distinguished speaker on medical ethics healthcare costs, and and related topics that are pertinent in the increasing demand day. The 2018 SMA Lectureship was de- that doctors follow livered by A/Prof Yeoh Khay Guan (Dean guidelines of care of Yong Loo Lin School of Medicine, Na- versus being liable tional University of Singapore and Deputy for medical incom- Chief Executive of National University petence. Till today, Health System) on “The Future of Medi- CMEP constantly cal Education”. The lecture explored the engages with the implications of shifting trends in Singapore current generation of healthcare and its impact on medical educa- doctors to promote tion. The event drew an audience of more the art and science than 150, comprising doctors, educators, Benny Loo Lee Yik Voon of medical ethics and medical students, even A-Level students medical practice, as and their parents. The 2017 SMA National Singapore Medical Association (SMA) well as their application, for the betterment Medical Students’ Convention provided an has been the voice of the medical profes- of patient care and public health in the con- opportunity for students of all three local sion in Singapore since its establishment in text of changing social norms. medical schools to come together for a day 1959, representing the majority of medical of learning and networking. Through the practitioners in both the public and pri- The global epidemic of Severe Acute Re- discussion of important issues pertinent to vate sectors. The objectives of SMA include spiratory Syndrome (SARS) in 2003 tested medical education, the convention sought fostering and maintaining the honour, in- Singapore’s healthcare preparedness in out- to provide clarity on students’ roles as fu- terest and unity of the medical profession break management. The sudden and swift ture doctors in an evolving medical training as a whole. This is in conjunction with ac- spread of the virus, which we had little and practice landscape. In its first run, A/ quainting the government and regulatory knowledge of at that time, almost paralysed Prof. Benjamin Ong (Director of Medical bodies with the policies and attitudes of the community healthcare services – Gen- Services, Ministry of Health) delivered the the profession. SMA has participated in eral Practitioners (GP) did not have enough keynote address “The Future of Singapore numerous consultations with various minis- N95 masks. In response to members’ feed- Healthcare and What It Means to Medical tries and government organisations to voice back on the difficulties in obtaining the Students Today”. members’ opinions on matters such as the N95 masks, SMA purchased 5,000 pieces National Electronic Health Records, the of N95 masks from the Singapore General Celebrating our 60th anniversary this year, Healthcare Services Bill, telemedicine and Hospital and sold them to the GPs. Due to SMA will continue to work towards being the local residency training programme. the overwhelming response, all 5,000 pieces a stronger representative voice of the medi- were sold out on the same day. SMA subse- cal profession in Singapore – for doctors, for SMA plays a key role in professional de- quently sought support from the Ministry patients. velopment through the setting up of Cen- of Health and received a second shipment tre for Medical Ethics and Professionalism of 5,000 pieces of N95 masks, which were Acknowledgement: (CMEP) in 2000. CMEP hopes to provide sold to the GP clinics who were unable We would like to thank Dr Tan Yia Swam doctors with a platform for life-long learning to obtain masks earlier. This collaborated (1st Vice President), Dr Daniel Lee (2nd Vice in the area of medical ethics, professionalism move provided GPs with protection from President), Ms Sylvia Thay and Ms Jo-Ann and health law. This was driven by the change the deadly virus and hence allowed them to Teo (SMA News Team) for their assistance in medical landscape in the late 1990s, when continue the care of their patients safely. and support towards the writing of this article. there was a move from social capital-based healthcare financing towards economic SMA strongly believes in investing in the Dr. Benny Loo – Honorary Assistant capital-based healthcare financing. This future of healthcare and the recent SMA Secretary (60th SMA Council) transition posed challenges of answering Lectureship and the National Medical Stu- Dr. Lee Yik Voon – President healthcare problems with innovative investi- dents’ Convention are evident of our support (60th SMA Council) COVID-19