JMA—President’s Speech JMA—Policies

Vol. 50 No. 2 March-April 2007

JMA—President’s Speech

JMA Activities Relating to National Health

Yoshihito KARASAWA ...................................................................................................................................... 121

JMA—Policies

The Health Care System in Japan: Current situation and future perspectives

Yoichi HOZUMI ................................................................................................................................................... 126

Doctors’ Efforts toward Appropriate Medical Waste Management in Japan

Satoshi IMAMURA .............................................................................................................................................. 130

Regarding the WMA Resolution on North Korean Nuclear Testing

Tatsuo KUROYANAGI ...................................................................................................................................... 136

Conferences and Lectures

42nd CMAAO Mid-Term Council Meeting: COUNTRY REPORTS ................................................. 137

Cambodian Medical Association ............................................................................................................ 138

Hong Kong Medical Association ............................................................................................................ 142

Indonesian Medical Association ............................................................................................................. 146

Japan Medical Association ....................................................................................................................... 148

Korean Medical Association ..................................................................................................................... 151

Macau Medical Association ..................................................................................................................... 156

Malaysian Medical Association ............................................................................................................... 157

New Zealand Medical Association ........................................................................................................ 164

Philippine Medical Association ............................................................................................................... 166

Singapore Medical Association .............................................................................................................. 168

Taiwan Medical Association ..................................................................................................................... 171

The Medical Association of Thailand .................................................................................................... 175

Sri Lanka Medical Association ................................................................................................................ 177

Research and Reviews

Differences between Japan and the U.S. in Test and Treatment Strategies inPediatrics

Takashi IGARASHI ............................................................................................................................................. 184

Local Medical Associations in Japan

Overview of the Aizuwakamatsu Medical Association

Yuzo TAKAYA ..................................................................................................................................................... 187

Perinatal Care in Crisis: Action required now

Isamu ISHIWATA ................................................................................................................................................ 190

International Medical Community

Message from the American Medical Association

William G. PLESTED III ..................................................................................................................................... 193

Medical Cooperation with Indonesia .......................................................................................................... 195

From the Editor’s Desk

Masami ISHII ......................................................................................................................................................... 196

Contents

121JMAJ, March /April 2007 — Vol. 50, No. 2

JMA—President’s Speech

JMA Activities Relating to National Health

JMAJ 50(2): 121–125, 2007

Yoshihito KARASAWA*1

security. The article’s first paragraph states that“All people shall have the right to maintain theminimum standards of wholesome and culturedliving” and Paragraph 2 clearly states the impor-tant duty of the State to “in all spheres of life...useits endeavors for the promotion and extension ofsocial welfare and security, and of public health.”

In other words, the Constitution of Japan stipu-lates that the State must fulfill its responsibilitieswith regard to social welfare, social security, andpublic health. The JMA is a core organizationinvolved in these issues and as such is vigilantlyaware that government handling of these issuesmust not stray from the Constitution’s stipulations.

In contrast, in the current social climate Isense a lack of serious and consistent principlesin approaching social welfare and social securitypolicies, even and especially amongst governmentofficials. Japan has already established a healthinsurance system that provides high-level andfunctional medical care with only a small burdenon the public, and in that sense the medical careis regarded as the core of Japan’s social securitysystem. It is precisely the maintenance and ex-pansion of this health care system that I believeis the duty of the State stated in the Constitutionof Japan.

Future Predictions for HealthExpenses

The Japanese Government has made much of howexplosively expenses for health care, the core ofJapan’s social security system, are increasing.However, investigations by the Japan MedicalAssociation Research Institute (JMARI) or theJMA think tank show that this is far from beingso. Medical care fees have been overhauled andreduced three times—in 2002, 2004, and 2006,and health care continues to be provided at these

This paper identifies the most important of thevarious issues currently facing the Japan MedicalAssociation (JMA) and provides a summary ofthe main points of each issue. I hope that this willbe helpful to the members of overseas healthorganizations in better understanding the kindsof problems occurring in the health field in Japanand what efforts the JMA is taking to resolveeach of these.

Legacy of the Koizumi Administration

Beginning in 2001 and lasting some five years, theKoizumi Administration came to a close at theend of 2006. Although born against a backgroundof overwhelming support from the general pub-lic, at the end of the day I believe the KoizumiAdministration legacy to the next generation wasa heavy burden. A typical example of this isthe more than a quadrillion yen in national andregional accumulative long-term debt. In the firstplace, I believe that when the Administrationfirst came to power it was thought imperative tosomehow halt the ever-increasing deficit. How-ever, with its enthusiasm for reforming basicfiscal revenue and expenditure, I cannot helpbut feel that the Administration attempted torebuild Japan’s economy with excessive haste,with the result that reforms lopsidedly focusedon the reduction of social security benefits.

Role of the National Government inSocial Welfare, Social Security, andPublic Health

Article 11 of the Constitution of Japan statesthat “the people shall not be prevented fromenjoying any of the fundamental human rights”,and Article 25 speaks of the people’s right to lifeand the State’s responsibility to provide social

*1 President, Japan Medical Association, Tokyo, Japan ([email protected]).

122 JMAJ, March /April 2007 — Vol. 50, No. 2

reduced fees. Predicting future medical expensesbased on this pattern, the research results showthat medical expenses in the future are unlikelyto reach an unmanageable figure; expenses willnot reach the semi-threatening high figures thatthe Ministry of Health, Labour and Welfare isclaiming. However, the role of the JMA doesnot end with our simply saying “these are thefigures”; we are now at the stage where theJMA must propose an appropriate system forproviding health care based on these figures, andclearly state how health care in Japan should besupported in the future.

Promotional Activities of the JMA

The JMA conducted a questionnaire of thepresidents and vice presidents of local medicalassociations to ascertain what they believed themost important role of the JMA to be. Theresults showed that the greatest demand was for“the JMA to clearly and properly explain ourhealth care activities to the public”; we were toldthat the JMA should provide accountability—something that I am always saying myself. Inother words, we have to boost our promotionalactivities. Other questionnaire responses included“should secure funding for health care”, “shouldpromote the disclosure of medical information”,and “should secure health care human resources”,indicating that an overwhelming number ofrespondents were of the opinion that advertisingactivities required strengthening.

Accordingly, the JMA is currently beginninga campaign to advertise the direction of the newpath the JMA has embarked upon.

Regional Databases

It is necessary for the JMA to create a detailedhealth database for each region, and it is vitalthat we recognize the importance of this. TheJMARI has been delegated this task, and theJMA intends to use the database in formulating,proposing, and then implementing health carepolicies that are acceptable to JMA members.The basic principles regarding these policies arethat they maintain public security and safety, andso the JMA intends to propose new health carepolicies along these lines.

Strategies

Another important JMA task is the creation ofstrategies for the implementation of health carepolicies. Firstly we must continue to explain ourposition to the general public by strengtheningour promotional activities as mentioned above.Secondly we must explain our position to thoseinvolved in national administration around thecountry and those in central administrative posi-tions. Thirdly we must explain our position tothe relevant administrative agencies and minis-tries, such as the Ministry of Health, Labour andWelfare; Ministry of Education, Culture, Sports,Science and Technology; Ministry of Economy,Trade and Industry; the Cabinet; and the Ministryof Finance.

I do not know how councils reporting directlyto the Cabinet—such as the Council on Fiscal andEconomic Policy and the Council on Promotionof Regulatory Reform and Privatization—havebeen functioning since the Abe Administrationcame to power, but I believe the first step in theJMA’s strategy should be to first of all explainour health policies in forums such as these.

Effectiveness (Organizational Power)

To realize these strategies, the JMA must ofcourse first of all achieve the necessary degree ofeffectiveness. It is this effectiveness, this ability torealize these policies, that is precisely the powerof the JMA as an organization, and so it is neces-sary that we cultivate this power. Of course, it is,I believe, important that the JMA makes effortsto attract the membership of as many doctorsas possible. It is therefore necessary for us tomake repeated efforts to induce in the youngergeneration of doctors a desire and willingnessto join the JMA. Here the question is what arethe merits of joining the JMA, and I believethe answer is that together we are working todevelop and implement the health care policiesof the JMA.

Accordingly, it is imperative that we striveto listen to the opinions of doctors in regionalareas and various positions—particularly hospitaldoctors, female doctors, residents, and medicalstudents—and explain the policies and activitiesof the JMA so that each may become aware ofthe enormous significance of joining the JMA.

Karasawa Y


Regarding the merits of membership, there areof course the benefits of welfare schemes fordoctors such as the JMA Pension Plan andProfessional Liability Insurance Program whichaim to accomplish community health care, butI believe the most important task for us is towork together to create health care policies andexplain to young doctors and female doctors thatthis is how a future vision of worthwhile healthcare is created.

We hope to create a pattern in which doctorssay, “OK! If that’s what the association is tryingto do, I’d like to join” and they join the JMA forthis reason. This is precisely the power of the JMA,as well as its effectiveness. In order to realizethese policies, not only the activities of our thinktank, but also the cultivation of power such as Ihave just mentioned is imperative.

Lobbying Activities

Another important issue is that there can be “nohealth policy without lobbying activities, andno medical care without health policy”. Whatwe provide to society based on our medical dis-cipline and ethics is health care. Considered inthis way, how health care is provided to the gen-eral public becomes a matter for health policy.Important are approaches to the establishment,explanation, and implementation of health carepolicies. Lobbying activities are necessary forhealth care activities to be implemented. The JMAis an academic organization and by no means areits main activities political. However, the purposeof these academic activities is to pass their resultsback to society and contribute to the improve-ment of the general public’s welfare. Accordingly,the JMA must conduct its activities within thisbroad philosophy.

Efforts Regarding Young Doctors,Hospital Doctors, and Female Doctors

Around the year 2025, the postwar baby-boomerswill have reached old age, and many are expectedto become ill. Looking at papers that have calcu-lated the number of doctors necessary to providehealth care for this great number of patients,there is expected to be a huge shortage of doctorsif matters continue as they are. Health deliverysystems for isolated and remote areas or islandsthat even now are inadequate may well collapse

if the current situation continues.Under such circumstances, there may be doctors

completing their two-year clinical training who,when considering their future options, decide thatthey would like to experience medical practice inremote or isolated areas or islands. If this is thecase, it will be necessary for public administrationto take a central role in the creation of systemsthat meet these desires in each region. It willalso be necessary to construct systems that caneffectively evaluate such doctors in the medicalfacilities where they work. I believe that only theJMA has the capacity to realize such a system.

In future, the national government is graduallytransferring authority over various aspects of thehealth care system to local government bodies.At that point, it will be an important period fordetermining what policies local medical associ-ations propose and how they interact with localgovernment bodies. The JMA intends to continueto work eagerly in the future to address theuneven distribution of doctors and trends con-cerning young doctors. Moreover, we hope to talkwith people with influence over administrativeauthorities and local government bodies as wellas people involved in national administration.The most important issue within this process iswhat kind of structure is best for hospital doctorsand female doctors.

Issues Affected by Article 21 of theMedical Practitioners Law

The JMA is making particular efforts in certainactivities that enable doctors to carry out medicaltreatment with peace of mind. Firstly, in the caseof extremely high-risk, high-difficulty treatments,there is the possibility that unforeseen accidentswill occur. In 2006, an obstetrician at a regionalhospital was suddenly arrested more than a yearafter the operation in question on charges ofprofessional negligence resulting in death andviolation of Article 21 of the Medical PractitionersLaw (failure to report an unusual death). Thepolice intervened and arrested the doctor.

If this kind of thing is going to happen, Ibelieve the shock to doctors in high-risk medicalfields will be enormous; they are sure to betruly grieved as doctors that the health care theyprovide is not valued. Even worse, such factorscould significantly influence young doctors whenthey are deciding their field of specialization.

JMA ACTIVITIES RELATING TO NATIONAL HEALTH


With regard to application of Article 21 of theMedical Practitioners Law, one change that wehope to make is to establish a structure in whichefforts of doctors are more rewarded.

No-fault Compensation Program

Another issue that the JMA is currently consider-ing is the introduction of a program of no-faultcompensation to protect doctors who provide ex-tremely difficult medical treatments. In the courseof medical treatment various problems naturallyoccur. In pregnancy and childbirth, for example,through no fault of the doctor and no fault of thepregnant woman, cerebral paralysis of the fetusoccurs during the course of pregnancy or child-birth in a certain percentage of cases. Despite thisfact, the doctor caring for such a mother andchild feels tremendous responsibility, of course,and the situation is extremely difficult for boththe parents and the child. The JMA is workingto implement a system of no-fault compensationto support people in situation such as this.

Nurse Shortage

One urgent issue is the shortage of nurses. Medicalinstitutions operate in accordance with variousnursing standards, but the situation is becomingproblematic. This is also a result of the governmenttrying to implement changes far too quickly andso now even university hospitals are scramblingto assemble adequate nursing staff. However,there needs to be thorough discussion of suchquestions as what comprises a truly good nursingsystem and what kind of nursing system shoulduniversity and large hospitals provide with asystem for the provision of community healthcare. Of course, deciding that lots more nursesneed to be trained is meaningless if there are fewyoung people interested in becoming nurses.Even with such social issues, the JMA hopes totrain many more people who are willing to makea difference in medical workplaces where safetyand trust are required and will continue to makemoves in that direction.

Hospital Beds

Another issue is a government plan to reorganizehospital beds that are allocated for long-termhospital care. The Ministry of Health, Labour and

Welfare has announced it aims to reduce thecurrent 380,000 hospital beds for medical/nurs-ing care to a final figure of 150,000 by the endof 2011, discontinuing use of some 130,000 bedsfor nursing care and a further 100,000 beds formedical care.

This is far too unexpected—an item that wasnot even mentioned in the 3rd Long-Term CareInsurance Action Plan suddenly leaped up. Theexecutive board members of JMA in charge ofnursing care are leading the JMA’s response, andit is time for us to seriously consider the reper-cussions of this decision and with the CentralSocial Insurance Medical Council and the relevantMinistry of Health, Labour and Welfare bureaudiscuss ways to ensure that medical institutionsare not seriously damaged in this plan, and moreimportantly, to ensure that people occupyinghospital beds are not forced to leave hospital,becoming so-called “nursing care refugees” or“medical care refugees”.

A New National Health Care Systemand Health Care for the Future

Lastly, the JMA is considering such what shapea new national health care system and health carefor the future should take. Under the presentsystem, special functioning hospitals are at theapex in a hierarchical health delivery system withother hospitals and clinics providing primary andsecondary health care. However, this is not whatI myself have in mind.

We have become used to health care within thehealth insurance system and health institutionsthat waits for patients, health care in which thepatient enters the health institution, presentstheir health insurance card, and are asked “Whatseems to be the trouble?” In the future, however,the conventional method of providing healthcare will be insufficient for ensuring that elderlypeople remain healthy and live longer, in otherwords, extending healthy life expectancy.

The doctors who take a central role in healthcare in the future will need to provide healthcare outside of institutions rather than “waiting”health care provided within health institutions.This should mean the beginning of home healthcare, and various community-based health careactivities which will lead to a new phase of healthcare of the commnities.

Community health care is gradually changing,

Karasawa Y


and I believe that universities will undergotremendous changes in the future. When youngdoctors have completed their two years in thenew clinical training system and think, “Now, atlast, I want to work in this field of medicine,”it is vital that the universities have systems that

will properly accept and embrace these doctors.There will also be young doctors who wish totry their hand at health care in remote areas.The JMA aims to create a system that warmlysupports and values such doctors and gives thempromise for the future.

JMA ACTIVITIES RELATING TO NATIONAL HEALTH


JMA—Policies

The Health Care System in Japan:Current situation and future perspectives*1

JMAJ 50(2): 126–129, 2007

Yoichi HOZUMI*2

Little by little, everyday living conditionsalso improved. The greatest issue for hygienicconditions was the supply of running water andmaintenance of water quality. The improvementof these secured the supply of pure water fordrinking and other domestic uses, enabling thesupply and consumption of hygienic food andclean clothing. By 1956, Japan was no longerregarded as being “postwar”, and the averagelife expectancy had grown to 63.6 for men and67.75 for women. The country entered a periodof economic expansion that saw business boom.Housing improved, and at the same time as theuse of electrical appliances such as refrigerators,washing machines, and television sets becamewidespread, so too did the use of medical equip-ment such as X-ray, electrocardiographic, andendoscopic equipment spread rapidly amongstmedical institutions, with medical technologyalso advancing rapidly. Throughout the countryeveryday living became hygienic and consider-ation to the environment improved with theinstallation of sewage systems and treatment ofwaste water, and these developments in particu-lar contributed significantly to the enterprise ofthe people.

However, as industry expanded, atmosphericpollution was caused by smoke and other pollu-tion was caused by industrial waste water; envi-ronmental pollution became a serious concern insome situations and efforts were made to rectifythese. Against this background, health manage-ment measures to prevent over-consumption ofsalt and ensure the adequate consumption ofprotein were spreading at the same time thatmedical examinations became commonly carried

Today I would like to give a general overview ofhealth care in Japan. I will also touch upon anissue of health care as an investment, which is amain theme of this scientific session.

Postwar Development

Approximately 60 years ago, Japan had just be-gun postwar reconstruction. Food was inadequateand nutritional and hygienic conditions for thegeneral public were extremely bad. The incidenceof infectious and other diseases was high inboth urban and rural areas, and life expectancyin 1947 was 50 for Japanese men and 54 forwomen. Health care in these circumstances wascompletely inadequate.

Japan lost approximately 1.85 million peoplein the Second World War; most cities were razedand the national wealth lost. The postwar recon-struction of Japan’s social security system pro-ceeded with the establishment of a new NationalConstitution under the powerful supervision ofthe occupational forces GHQ. The new JapaneseConstitution guaranteed fundamental humanrights for citizens in Article 11 and based on this,guaranteed citizens’ right to live in Article 25,establishing the State’s social responsibility inParagraph 2, which states that “in all spheres oflife, the State shall use its endeavors for thepromotion and extension of social welfare andsecurity, and of public health.” Amidst the harshconditions imposed by the devastation left bythe war, Japan began to rebuild, and throughthe many efforts of its citizens the society’s pro-ductive, economic, and educational conditionsbegan to gradually and steadily improve.

*1 This presentation was made at the Scientific Session on October 12, 2006 during the WMA General Assembly, Pilanesberg 2006, held inSun City, South Africa.*2 Vice President, Japan Medical Association, Tokyo, Japan ([email protected]).


out as a means of preventing diseases. Groupexaminations were held for stomach cancer andbusinesses implemented health check-ups fortheir employees. Consequently, the early diag-nosis of frequently occurring diseases and pre-ventative examinations expanded on a nationalscale, producing highly significant results. Thussince about 30 years ago, people’s nutrition hasimproved and the incidence of infectious diseaseshas decreased; in 2002 the average life expectancyfor men was 78, and for women was 85, makingJapan the world’s top country for longevity.

Features of Nature and Industry

Japan is an island nation with little flat land; 90%of the country is forest-covered mountains. Notonly is Japan a volcanic country that faces theconstant threat of massive and epicentral earth-quakes, but it also faces wind and water damageevery typhoon season. Since plentiful rainfall isbeneficial for tree growth, Japan has many fast-flowing rivers. Compared with continents, riversflow only short distances from their wellspringsto the ocean. These plentiful, clear rivers playan important role, in rice cultivation, in hydro-electric power generation, and in many otherfunctions in which water has been innovativelyutilized. Japan cannot produce oil or natural gasas energy sources and its mineral resources arealso small.

Consequently, national production in Japantends towards importing raw materials from over-seas, then manufacturing products using variousoriginal processing technologies; promotion ofhigh intelligent added value in industrial pro-duction and high computerization, as well asindustrial structuring in areas such as finance,distribution, and services is increasing more andmore, invigorating the economy. Many innov-ations have been made to production methodsfor traditional rice, fruit, and vegetable crops;developments in production technology are notonly used in domestic production but are alsospread overseas, with the export of productiontechnology now becoming an important industrythat also contributes internationally. Deep-seaand coastal fishing are two other importantindustries; the development and promotion ofinnovative fish farming technology is becomingincreasingly important as a means of securingresources. The international export of seafood

is a small industry in Japan, but it also contrib-utes greatly to the development and diffusionof technology. Since the industrial revolution,Japan’s basic policy has been to enhance theeducation system; citizens make efforts to pro-mote intelligent industry, understanding thatwe receive praise and great benefits from othercountries through the development of scienceand technology and our contributions to theinternational community.

Health Insurance System in Japan

The development of transportation facilities inJapan has enabled many people and goods to betransported anywhere within the country withinhalf a day, and information can be transmittedinstantly throughout the country.

This was a huge leap forward for emergencyand disaster medicine in Japan. With these de-velopment, from the 1950s onwards the basiccomponents necessary for providing health care—hospitals, clinics, doctors, and nurses—all ofwhich had been inadequate, gradually increasedand health care in regional areas expanded. Ahealth insurance system which operated indepen-dently for each health field continued to exist,but there continued to be a large number ofpeople who had not paid their insurance. TheJapan Medical Association recommended thatthe individual insurance systems be integratedand the entire system expanded. Eventually, in1961, the total health insurance was expandedand a universal health care system available toall citizens was introduced. Through the processof establishing this system, medical fields wereclassified broadly into four groups.

All citizens were required to join one of fourinsurance plans depending on their occupationand position: government-managed health insur-ance administered by medium and small busi-nesses; association-managed health insuranceadministered by the majority of large businesses;National Health Insurance administered by localgovernment authorities; and National HealthCooperative Insurance, also administered by thesame kind of businesses on a local level. Theestablishment of this system enabled citizens toreceive health care equally and fairly anywherein Japan, at any time and for whatever reason,for a minimal self-payment and without havingto undergo screening simply by showing their

THE HEALTH CARE SYSTEM IN JAPAN: CURRENT SITUATION AND FUTURE PERSPECTIVES


insurance card to prove they were insured. Underthis system, the medical institution providingtreatment receives the portion of paymentcovered by public funds under a reimbursementsystem known as a fee-for-service system. Thesystem operates smoothly due to the efficientfunctioning of medical fee payment fund thatcarefully checks the details of medical treatment.

Improvement of medical institution facilitiesand the implementation of this medical insurancesystem have enabled huge advances in regionalhealth care systems and provided the tremendousbenefit of care being available equally and fairlyto all citizens.

Because of differences in the history of theirestablishment and composition of member busi-nesses and organizations, each of the heath insur-ance plans has difference insurance rates. Thegovernment-managed health insurance plan isthe largest in scale and imposes public benefits inaddition to the insurance burden on employersand members.

Against this background the Japan MedicalAssociation has, as a pillar supporting the healthcare of citizens, has proactively promoted theestablishment and maintenance of this system,and with the cooperation of medical institutionnationwide, the National Health System has madea huge contribution to the health system in Japan.

With the development of the economy andindustry in Japan I have already outlined, the emer-gency medicine infrastructure and treatment ofchronic illness improved through the continuedimprovement of hygienic conditions, betternutrition, and the creation of infrastructure forthe universal and fair provision of health care.

Health Care Statistics

In 2000 and 2004, the World Health Organizationnamed Japan as a country with one of the highestlongevity rates in the world, recognizing theexcellence of Japan’s health system. Japan ranksNumber 1 in the world in a comparison of heathachievement; in 2002 longevity was again thehighest in the world, with the average life ex-pectancy for men being 78.4 and for women 85.3;and Japan also has one of the lowest infantmortality rates in the world. Japan’s excellentNational Health Insurance system is the mosteffective health insurance system of all the de-veloped countries. Since the 1970s, Japan’s GNP

has skyrocketed. With citizens’ growing healthconsciousness and medical care awareness aswell as improvements in medicine and medicaltechnology, the total cost of medical treatmentin Japan is gradually growing and managementof the health insurance system has been revisedrepeatedly.

Since 1980, the total fertility rate has droppedbelow 2.0 for a variety of reasons, and in 2005dropped to a marked low of 1.25. In a worldrapidly ageing, Japan has hurtled fastest into anaging society with fewer children.

As I have explained, medical expenses inJapan are not high compared with other devel-oped countries. Total health expenses are 7.9%of GDP, a low rank of 17 amongst the develop-ing countries. However, in 2000 Japan establisheda national Long-term Care Insurance system,administered on a municipal basis, aimed at eld-erly citizens requiring nursing care as a meansof lightening the continuously increasing cost ofhealth care for the elderly. The degree of nursingcare required is determined through screeningand nursing care services appropriate for theelderly person’s needs are provided.

Health Care as an Investment

Here I would like to touch on the theme of thissymposium—health care as an investment.

Considering the population dynamics of Japan,despite the difficulty of boosting the productive-age population, it could be possible to secure apotential working population by improving thehealth of senior citizens. Increased numbers ofelderly people capable of working would be anenormous opportunity, creating fresh consumeractivity and invigorating the economy. In otherwords, proactive health care to restore, maintain,or increase health—such as avoiding the risk ofdisease occurring through preventative medicineand the promotion of social rehabilitation andindependence through early diagnosis and treat-ment—has ample potential to increase the heathinvestment of each individual, thereby increasingthe population of potential workers, bringingabout an increase in productivity, GDP, and rev-enue from tax, and thus more stable employmentand fresh economic activity. Furthermore, healthcare is a labor-intensive industry, and so a stablesupply of workers for medical institutions willfacilitate more stable health care. Moreover, the

Hozumi Y


construction of the necessary medical facilitiescould also create a wave effect in the economy.In this way, there are certainly investment aspectsin health care, and it is vital that this is recognizedwidely by members of the general public. TheJMA is currently seeking the understanding ofthe government headed by Prime Minister Abe,newly formed in September this year, of thenecessity of promoting basic policies such as this.

JMA’s Health Reform Policies andFuture Perspectives

The JMA is proactively pursuing the followingitems as comprehensive and central policies forhealth reform, including the views just mentioned.1. Create a society able to truly rejoice at

longevity through enhanced health care andwelfare for the elderly.

2. Create a society where one can give birthwith peace of mind through the expansion ofobstetrical care and maternal and child health.

3. Create a society where children can thrive andgrow healthily through enhanced pediatriccare and school health.

4. Create a society where people can workhealthily and enthusiastically through enhancedindustrial health and workers’ compensationinsurance.

5. Create a society with as little occurrence ofdisease as possible through the promotion of

and lifestyle disease countermeasures and anti-smoking campaigns.

6. Create a society able to provide high qualitymedical care for those who are sick throughthe guarantee and enhancement of commu-nity health care and health insurance.

7. Create a society that provides an excellenthealth care system through the enhancementof community heath care centered on primarycare doctors and the promotion of coopera-tion between health services.

8. Create a society able to put medical advancesinto practice in health care through the estab-lishment of lifetime education and a medicalspecialist system.Finally, with regard to approaches to govern-

ment agencies regarding issues such as these,the JMA is campaigning to prevent corruption ofthe medical care system, including financiallymotivated proposals for medical system reform,mainly through petitions and the endorsementof Diet members who represent the position ofthe JMA in the government.

The JMA intends to continue to promote theconstruction of a foundation for communityhealth care, working with the general public toformulate and propose strategies for realizingthe establishment of a health care frameworkthat people trust, in order to create a durablesocial insurance system that safeguards the heathand welfare of Japan’s citizens.

The WMA officers and the speakers. Dr. Hozumi, the author is third left.

THE HEALTH CARE SYSTEM IN JAPAN: CURRENT SITUATION AND FUTURE PERSPECTIVES


Doctors’ Efforts toward Appropriate MedicalWaste Management in Japan*1

JMAJ 50(2): 130–135, 2007

Satoshi IMAMURA*2

This responsibility extends from when the wasteis first generated, such as in waste segregationat the medical institution, to the end, the finaldisposal of waste (Slide 4).

You may be surprised to know that, even if ourwaste is illegally disposed of by contracted wastecompany, we, as the generators of the waste, maystill have a responsibility to recover it if they failto perform their task responsibly.

Proper Disposal of Medical Waste

Regarding the fulfillment of our responsibility toproperly dispose of medical waste, let me intro-duce for you the efforts by Japanese doctors’ totreat medical waste appropriately, both in thehospital and outside of the hospital.

The first point relates to how to identify in-fectious waste in the hospital (Slide 5). We havemade guidelines for the identification of infec-tious waste, in cooperation with the governmentand the waste treatment industry.

This flowchart is the summary of the identifi-cation process (Slide 6). As you can see, there arethree steps to the flowchart, and if the targetwaste satisfies any one of the criteria, the waste isto be considered and treated as infectious waste.

After identification, the waste should be dis-carded separately as shown in Slide 7. Usually weuse several disposal boxes to conduct thoroughcontrol of waste segregation.

Slide 8 shows another example. In this case,three boxes have been used, for needles, injectionsand other matter.

Let me also introduce to you the legal criteriaconcerning containers (Slide 9). Containers should

Good afternoon, ladies and gentlemen. It is mygreat pleasure to have the opportunity to speakto you at this conference. My name is Dr. SatoshiImamura from the Japan Medical Association(JMA). Today, I would like to talk to you about“Doctors’ efforts toward appropriate medicalwaste management”.

Before talking about medical waste, let me firstintroduce our organization (Slide 2). The JMA, isan organization for physicians in Japan. The num-ber of members is about 165,000, which accountsfor 60% of the total number of physicians in Japan.

The Threat of Medical Waste andDoctors’ Responsibility

I would like to consider the issue of medical waste(Slide 3). You may be wondering, “Why shoulddoctors be concerned about medical waste?”My answer to you would be that as doctors weshould be concerned about medical waste be-cause medical waste can cause disease, which wehave a duty to prevent. As you know, medicalwaste can pose a threat to both human healthand the environment.

Needles represent a significant threat to healthcaused by medical waste. Data shows that a con-siderable number of cases of HIV, and HepatitisB and C are caused by needles. In other words, ifmedical waste is handled appropriately, such casesof these diseases could be prevented. As for theenvironmental threat, inappropriate treatment ofwaste can cause environmental pollution, such asdioxins. Though this is not only caused by doctors,as waste generators we have a responsibility totreat waste appropriately.

*1 This presentation was made at the Asia 3R Conference hosted by the Ministry of the Environment of Japan, held at the Mita ConferenceHall in Tokyo on October 30th through November 1st, 2006, and partially revised for this publication.*2 Executive Board Member, Japan Medical Association, Tokyo, Japan ([email protected]).

JMA—Policies


be strong enough so as not to be penetrable. Oneach container, a bio-hazard mark is used to leteveryone know that the box contains hazardouswaste (Slide 10). This seal comes in three differentcolors according to the different type of waste.From color of the box, then, anybody can tell whatshould be disposed of in it.

Also, each hospital should appoint a medicalwaste supervisor (Slide 11). In many cases, thehospital director holds this post. Medical wastesupervisors are responsible for medical waste man-agement and planning, and for raising awarenessamong staff. Under the Waste Management Law,only those who have enough medical knowledgeare entitled to become the supervisor.

Of course, medical waste should also be prop-erly treated after it is transferred outside of thehospital (Slide 12). Our responsibility also coversthis waste treatment. Because of the generationof dioxins and difficulty in treatment inside thehospital, medical waste should be treated outsideof the hospital under consignment contracts withwaste disposal companies.

The procedures are divided into transportation,intermediate treatment and final treatment. Ifnegligence and inappropriate treatment such asillegal dumping are detected in the actions of thewaste disposal company under the contract, theburden of cost to restore the environment to itsoriginal state is incurred by the waste generator.

Ensuring this does not occur requires the useof waste management slips, which I will talk aboutin a moment, as well as visiting the waste disposalfacilities. The best but most difficult way to solvethe problem is to appropriately select the wastedisposal companies to be engaged.

To manage waste outside of the hospital, thelaw requires the use of waste management slips.An example of these slips is shown in Slide 13.One unit contains a set of seven slips. Simplyspeaking, as you see this chart, a set of slips isalways transmitted with wastes. Each slip shouldbe returned to the medical facility after complet-ing each step of the waste treatment. Therefore,if we do not get all the slips, we can suspect apossibility of the inappropriate treatment or lossof the waste.

Another effort being made by doctors consistsof visiting and checking waste treatment facilities(Slide 14). By visiting the facilities themselves, wecan understand how our waste is being treatedoutside of the hospital.

JMA’s Activities toward AppropriateMedical Waste Management

Finally, I would like to discuss how the JMA’sactivities relate to this issue (Slide 15).

Lecturers, who include doctors, governmentofficials, and members of the waste managementindustry talk about the environmentally soundmanagement of medical waste (Slide 16). Inaddition, from 2006, the JMA will be organizingseminars to train medical waste supervisors

Another example of the activities of localmedical associations is the coordination betweenhospitals and waste disposal companies (Slide 17).For small clinics, it is difficult to find and selectan appropriate waste disposal company by them-selves. Therefore, the local medical associationshould help small clinics by building networksand providing information about waste disposalcompanies.

In addition, the JMA is developing new tech-nology aimed at the proper treatment of waste(Slide 18). An example of this is the IC chiptracing system. This system is illustrated in thetop center photo of Slide 18. By attaching theIC chip to a waste container as shown in thetop right-hand picture of Slide 18, the exact placewhere the medical waste was produced canbe traceable throughout the treatment process.This system is actually already being used in theTokyo area.

In spite of these efforts however, unfortunately,illegal dumping of medical waste still often occurs,to avoid the costs of treatment. In Slide 19, youcan see injection cylinders in the soil, whichhave been dumped. Most of the illegal dumpingis reported as being done by irresponsible wastedisposal companies.

The JMA is working in cooperation withnational and local governments against illegaldumping (Slide 20). In Japan, industries and thegovernment have established a fund to supportthe work of local governments to recover siteswhere illegal dumping has occurred, and theJMA contributes part of this fund. We think thisrepresents an important contribution to society.

Conclusion

In this presentation, I have briefly explainedthe efforts being made to treat medical waste in

DOCTORS’ EFFORTS TOWARD APPROPRIATE MEDICAL WASTE MANAGEMENT IN JAPAN


Japan. As the final message of my presentation,I would like to emphasize four points (Slide 21).First, please keep in mind that medical wastecan cause serious adverse effects to humanhealth and to the environment. In addition, fromour experience, medical wastes will increaseas industrialization progresses. Therefore, it isessential to build an appropriate treatmentsystem for medical waste. The JMA would like

to continue to share our experiences with thecountries of Asia. There is a lot that doctorscan do, and we should do it. Thank you for youattention.

Acknowledgement

Some pictures in the presentation were contributedby Ministry of the Environment of Japan and JapanIndustrial Waste Technology Center.

(Slide 2)

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Imamura S


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(Slide 14)

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(Slide 15)

(Slide 12)(Slide 11)

Imamura S


(Slide 20)

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(Slide 18)(Slide 17)



Regarding the WMA Resolution on North KoreanNuclear Testing

JMAJ 50(2): 136, 2007

Tatsuo KUROYANAGI*1

of medical professionals in Japan, which is theonly country to have experienced the destructionof atomic bombs in the cities of Hiroshima andNagasaki and the radioactive exposure fromnuclear testing suffered by Japanese fishermenat Bikini Atoll;

Moreover, the members of the JMA havetreated the pain and suffering of the victims ofthe devastating effects of the atomic bombs andare living witnesses to the radioactive destructionwrecked on the environment;

Because of these experiences, the JMA hascontinuously called for the abolition of all nu-clear testing and nuclear weapons, which directlythreaten the very survival of mankind;

The JMA officially denounced the NorthKorean nuclear testing at a press conference onOctober 11th, 2006;

For these reasons, the JMA urges that theproposed “WMA Resolution on North KoreanNuclear Testing” be adopted by the WMAGeneral Assembly.”

On October 10, 2006, the JMA delegation to theWMA General Assembly, Pilanesberg, SouthAfrica (Leader: Dr. Yoichi Hozumi) were greetedon their arrival in South Africa with the newsthat North Korea had gone ahead with its under-ground nuclear test. The delegation immediatelycontacted Tokyo, where it was the middle of thenight, and received the instructions of Dr. YoshihitoKarasawa, JMA President in Tokyo to present anurgent proposal to the WMA General Assemblythat the WMA pass a resolution against NorthKorea’s nuclear testing.

Accordingly, the resolution was drafted onOctober 11 and the wording adjusted in collabo-ration with the WMA secretariat, then put beforethe WMA Council Meeting as an emergencymotion on October 13. The motion was supportedby the medical associations of many countries,including the United States, and was accepted asa General Assembly resolution proposal with theunanimous approval of the entire WMA Council.

On October 14 the resolution was presented tothe General Assembly as proposed by the JMAas a WMA Council motion. As representative ofthe WMA Council, Dr. Masami Ishii, ExecutiveBoard Member of the JMA, explained the back-ground behind the decision to present the resolu-tion. The resolution was unanimously passed withthe enthusiastic support of all General Assemblyparticipants.

The content of Dr. Ishii’s statement when theresolution was being presented is as follows.

“On October 10th, 2006, North Korea an-nounced that on October 9th the country had con-ducted underground nuclear testing in defianceof the heightened global vigilance on nucleartesting and nuclear arsenal;

The JMA is the representative organization

*1 Legal Advisor, Japan Medical Association, Tokyo, Japan ([email protected]).

October 2006

WMA RESOLUTION ONNORTH KOREAN NUCLEAR TESTING

RECALLING the WMA Declaration on NuclearWeapons that was adopted at the WMA GeneralAssembly in Ottawa, Canada, in October 1998;

The WMA:

1) Denounces the North Korean nuclear testingconducted against the heightened globalvigilance on nuclear testing and arsenal;

2) Calls for the immediate abandonment of thetesting of nuclear weapons; and

3) Requests all member associations to urgetheir governments on the adverse healthconsequences of nuclear weapons.

JMA—Policies


Conferences and Lectures

Held from Fri. November 24 to Sun. 26, 2006 in Singapore, the 42nd CMAAO(Confederation of Medical Associations in Asia and Oceania) Mid-Term CouncilMeeting was attended by a total of some 50 representatives of 13 medical associ-ations (12 existing member associations and Sri Lanka, whose membership has beennewly approved). The CMAAO has a current membership of 17 associations in all.

At this mid-term council meeting, Dr. Masami Ishii, Executive Board Member ofthe JMA, was newly appointed as CMAAO Secretary-General, and it was unani-mously agreed by all the attending medical associations that the activities of theCMAAO should from now on be published in the JMA Journal.

The CMAAO holds General Assembly meetings every two years and mid-termcouncil meetings in between. Each member medical association presents a countryreport on its main activities over the previous year. The following are the countryreports presented by the 13 attending medical associations on November 25.

42nd CMAAO Mid-Term Council Meeting:COUNTRY REPORTS

Grand Copthorne Waterfront Hotel, SingaporeNovember 25, 2006

CMAAO Meeting


CAMBODIAN MEDICAL ASSOCIATION

Sau Sok KHONN*1

CMA Council in 2004–2006, –May 2007

CMA always organizes an Annual Convention(AC). The purposes are: 1) to report annual ac-tivities, 2) to develop action plan, and 3) to electnew members of the CMA Council (every two-year). As plan, AC is organized in 2006 includingelection of 8th CMA Council members, but ACis postponed due to the time constraint. Thusthe 7th CMA Council members extend theirassignments till next year.

Twenty-four members of the association tostand the 7th Council as follow:Steering committee

Prof. Sau Sok Khonn PresidentProf. Kong Kimsan MemberProf. Mom Chot Member

Executive CommitteeProf. Sea Huong DirectorProf. Touch Sareth 1st Vice-DirectorProf. Seang Tharith 2nd Vice-DirectorDr. Saint Saly Secretary GeneralDr. Kim Chhuong 1st Deputy

Secretary GeneralDr. Chou Rady 2nd Deputy

Secretary GeneralDr. Hu Bun Kim TreasurerDr. Ly Sim Cheng 1st Assistant

TreasurerDr. Iv Chhun Ros 2nd Assistant

TreasurerSub-committees

Scientific Sub-committeeDr. Kaing Sor ChiefDr. Pheav Piseth Deputy-chiefDr. Srey Sopha Member

National and International RelationSub-committee

Dr. Nguon Peng ChiefDr. Dok Chanly Deputy-chiefDr. Chhim Youth Samphy Member

Background

The Cambodian Medical Association (CMA)was created in 1994. In 1995, at the request ofthe Ministry of Health, the CMA participatedin drafting the sub decree of a Code of MedicalEthics. The CMA has played an active role inpromoting the establishment by Royal Decreein the year 2000 of the medical board. The CMAis also active in involving its leadership in dis-cussions with the Ministry of Health in order todevelop laws to regulate medical practice. Thepassing of legislation for compulsory registrationof doctors provides a critical opportunity toreview the role of CMA in relation to that ofthe Medical Board and Medical Council, andmore generally to the advancement of qualitycare in Cambodia. Additionally, the CMA plays amore active role in continuing medical education,registration and licensing and issues relating toadvocacy for quality of care.

CMA does have some successful activities,such as periodical, occasional symposia for mem-bers and an annual convention. However, in thecurrent climate the CMA now has opportunitiesto develop its role in the setting of professionalstandards, the implementation of peer supportand ethics, and in the definition of its input intomedical registration and its consequences.

CMA was accepted as a membership of theMedical Association for the South East AsianNations (MASEAN) in 1999. Moreover, CMAachieved a remarkable success in organizing the10th MASEAN Conference in Cambodia, 2001.Also CMA became a membership of the Con-federation of Medical Association in Asia andOceania (CMAAO) in September 2005.

CMA Membership: As at October 2006, thetotal membership of the Cambodian MedicalAssociation is 1,286. This represents 32.12% ofall registered medical doctors in Cambodia.

*1 President, Cambodian Medical Association, Phnom Penh, Cambodia ([email protected]).

Country Report



Social and Humanitarian Sub-committeeDr. Say Sengly ChiefDr. Ouch Dina Deputy-chiefDr. Mao Nisay Member

Medical Ethics and ProfessionalismSub-committee

Dr. Huy Kim Heng ChiefDr. Chang Keng Deputy-chiefDr. Keuth Sok Mavy Member

Main Activities of the CMA for the Year2004–2007

• 6th Cambodian National Day of Medicine andPharmacy: In collaboration with CambodiaPharmacy Association (CPA), CMA organizedthe National Day of Medicine and Pharmacyon 11–12 August 2004 in Phnom Penh. Themeof the National Day was “Medical Ethics andProfessionalism”. Seven hundred participantsfrom both CMA and CPA attended that event.

• 7th CMA Mid-Term Council Meeting: The 7thCMA Mid-Term Council Meeting held on Fri-day of June 24, 2005 in Phnom Penh, Cambodia.Objectives of the meeting were to draw conclu-sions, recommendations and lessons learned ofthe participants from 24 provinces/cities. Ac-cording to the recommendation of the AnnualConvention of CMA, the meeting revised theCMA Regulation and planning for next year.

• CMA Council organizes a monthly meeting formonitoring the CMA activities. In the last twoyears, 20 meetings were done to follow-up theCMA activities and discuss on how to improvethe activities.

• As a partnership with the Ministry of Health(MOH), CMA has been strongly involving inmonitoring and evaluating the mains activitiesof MOH; and developing the strategic planssuch as the involvement of the project of Publicand Private Mix for Tuberculosis Control byDOTS Strategy (PPM-DOTS) in the UrbanArea, Malaria Program, HIV/AIDS Program,

Mother and Child Health Program, Public medi-cal colleges and medical university, Planningfor Health Insurance and Equity Fund for thepilot areas, and developing all aspects of theHealth Regulation etc.

• 7th Cambodian National Day of Medicine andPharmacy: In collaboration with CambodiaPharmacy Association (CPA), CMA organizedthe National Day of Medicine and Pharmacyon 10–11 August 2006 in Phnom Penh. The titleand principle theme of this year’s event was“Cambodia Health Towards Globalization in theNew Millennium”. Seven hundred participantsfrom both CMA and CPA attended that event.

Relationships

• Attending the 6th International Conference“Setting Limits to Healthcare: the time is Now”on 12–13 February 2004 at the St. Francis Inter-national Center for Healthcare Ethics, USA(Prof. Sau Sok Khonn).

• Attending the International Conference onHerbal and Traditional Eastern Medicine: Analternative and Integrative Medicine to be heldon 30–31 March 2004 in Macau, China (Prof.Sau Sok Khonn/Dr. Saint Saly).

• Attending 11th MASEARN Conference, 28–31 July 2004 in Bali, Indonesia (Prof. Sau SokKhonn/Prof. Seang Tharith/Dr. Touch Sareth/Dr. Saint Saly).

• Attending the 24th CMAAO Congress & 41stCouncil Meeting, 9–11 September 2005, in Seoul,Korea (Prof. Sau Sok Khonn/Dr. Saint Saly).

• Attending 11th MASEARN Mid-Term CouncilMeeting, 16–18 November 2005, in Bangkok,Thailand (Prof. Sau Sok Khonn/Prof. SeangTharith/Dr. Touch Sareth/Dr. Saint Saly).

• Attending 1st World Medical Association Asian-Pacific Regional Conference, 10–11 September2006, in Tokyo, Japan (Prof. Sau Sok Khonn/Dr. Chi Meng Hea).


Khonn SS


HONG KONG MEDICAL ASSOCIATION

CHAN Yee-shing Alvin*1

having to pay the complainant HK$2,500. Thesettlement was supported by Medical ProtectionSociety (MPS).

We promoted the use of serving chopsticksand spoons to the public. We have raised ourconcern on air pollution in Hong Kong, influenzaprevention and control, health care reform, to-bacco control, depression detection and suicideprevention, casualties at Marathon, unregisteredvaccine and the importance of good dispensingpractice. A “Good Dispensing Practice Manual”was published and promulgated to members.We also organized skills upgrading scheme toupgrade the knowledge and skills of healthcarepersonnel who works in private clinics. To ensurea free impartial private practice environment andto protect the interest of our profession, we areconcerned with the proposal of establishing anew statutory Primary Care Registry and therevision of Medical Registration Ordinance.

To protect the interest of patients and the pub-lic, we are concerned with the lack of monitoringand regulation of medical procedures deliveredby unregistered non-medical personnel andprofit-making Health Maintenance Organizations(HMOs). We came up with a list of suggestionson how to regulate the HMOs and submittedthem to the working group under the Depart-ment of Health which looked into the regulation.Correspondence were exchanged with the Ad-ministration and the Health Services Panel ofthe Legislative Council. Meetings were held withthe Government and representatives from theInsurance Industry. The effort is continuing.

We continued our cultural and charity activ-ities. The HKMA Orchestra and HKMA Choircontinued to practise regularly and performannually for charity. The HKMA No.1 Band wasestablished last year as well to enrich the culturalmanifestation of our colleagues, and we startedestablishing our own charitable fund. To assistin organ donation, we raised fund for the Organ

With the conjoint effort of members, partners,staff and council members, Hong Kong MedicalAssociation has made significant progress in thepath of betterment for the medical and healthcareservice of Hong Kong for the year 2005–2006.Our Association continues to play an importantrole in promoting and supporting continuousmedical education. Forums and seminars havebeen organized by our Association alone or inconjunction with the other organizations. Theseeducational programmes covered a broad spec-trum of topics. We are still vigilant of infectiousdiseases that may affect every one of us. Openforums on Influenza Pandemic Preparedness forHealthcare Workers were organized in differentDistricts. We established close collaborationwith Centre for Health Protection and HospitalAuthority for control and prevention of commu-nicable diseases. We promoted vaccination forinfluenza and promulgated guidelines on the useof Tamiflu to the public and healthcare profes-sionals. Certificate Course on Advances in ChronicDisease Management and Exercise Prescriptionwere successfully carried out at our Association’sCentral Premises and United Christian Hospitalrespectively. Structured CME seminars werecontinued with Kwong Wah Hospital, QueenElizabeth Hospital and Hong Kong Sanatoriumand Hospitals. A new online CME website waslaunched at the end of last year. Apart fromeducational programmes for doctors, HKMACommunity Network has liaised with other alliedhealth professionals and provided educationalprogrammes to the patients.

The Patient Complaints Mediation Committee,set up in June 2005, had its first mediation held inone afternoon in January 2006. The mediator wasone of the qualified mediators from the HongKong Mediation Centre, and the co-mediator wasone of HKMA’s Council Members. In the end,the patient and the doctor reached an agree-ment, and a settlement was made—the doctor

*1 Council Member, Hong Kong Medical Association, Hong Kong ([email protected]).

Country Report


Donation Register. We have formed a sizabledatabase for people who are willing to donatetheir organs. We are also willing to share thisdatabase with those who need it.

Twelve Council Meetings were held last year.Members were invited to attend our council meet-ings. We participated in the 41st CMAAO CouncilMeeting held at Seoul, Korea in September 2005.We also attended the 56th World Medical Assem-bly held in Chile in October 2005 and the 56thWHO Conference in Noumea, New-Caledonia inSeptember 2005. We continued academic exchangewith Chinese Medical Association. The SeventhBeijing and Hong Kong Medical ExchangeMeeting focusing on “AIDS & Sexual Health”was successfully held in Beijing last year. Ourpresident was invited to act as Regional Advisorfor Royal College of Physicians of Ireland. Wehave published 12 monthly HKMA News and 12monthly CME Bulletins. We continued publish-ing the bimonthly Hong Kong Medical Journaljointly with Hong Kong Academy of Medicine.

Meetings have been arranged with guestsbefore our council meetings. Opinions and viewson different topics relating to medical practicein Hong Kong were exchanged at the meetings.We also completed the Doctors’ Fee Survey, theInformation Technology Survey and four otheropinion surveys. Apart from auto-reply system,we continued our collaboration with Hospital

Authority and started the Public-Private Inter-face—Electronic Patient Record Sharing PilotProject (PPI-ePR).

Our Association has been actively involvedin promoting healthy life style to the public. Weare in full support of banning smoking in closedenvironment. Apart from promoting exercise tothe public, we have organized and co-organizedsports activities for our members. These includedfamily hiking, Joint Professional Football Cup,Public Hospital Football Cup and Joint Profes-sional Golf Tournament etc. Sports night wasone of the most successful events to applaud thecontribution of our sportsmen in organizing andparticipating in these activities.

There are seven elected representatives ofHKMA in The Medical Council of Hong Kong.This is the self-governing statutory body thatregulates the profession in Hong Kong. It consistsof 28 members of which 14 were government-appointed, including 4 lay members. There are alsorepresentatives in each committee like EthicsCommittee, Education & Accreditation Commit-tee, Health Committee, Licentiate Committee,Credentials Sub-Committee of the LicentiateCommittee, Exemption Sub-Committee of theLicentiate Committee, Review Sub-Committeeof the Licentiate Committee, and PreliminaryInvestigation Committee of the Medical Council.



Chan YA


INDONESIAN MEDICAL ASSOCIATION

Ihsan OETAMA*1

• National Workshop to build the same percep-tion about the profession standard definitionrelated to medical law definition and its imple-mentation, June 2005.

• Conducted a study to anticipate the new certifi-cation, regulation, advocate system in the newmedical law, September 2005.

• Serial workshops to make a concept of medicaleducation system for primary care, October 2005

• Working together with the Indonesian Veteri-nary Association to deal with the Avian Influ-enza outbreak.

• Holding the IMA Midterm Meeting in Jakarta,December 2005, prior to the IMA Congress,which will be held in Semarang, Central Java,November 29–December 2.

International• To face the coming globalization, the IMA has

formed a team to join the Indonesian govern-ment for talks with the World Trade Organiza-tion. The team actively were joined at regionaland international event. As a team of Indo-nesian Delegation, the IMA team participatedin WTO meeting in Geneva, and also in HealthSector Working Group in CCS (CoordinatingCommittee on Service) that periodically everythree months conduct a meeting in Aseancountries, since 2004.

• The Singapore Tourism Board, in which wereincluded members of the Singapore MedicalAssociation, paid IMA a visit to seek possibil-ities of working together to provide good healthcare, if needed, for people from both countries,when they are visiting as tourists.

• One of Indonesia’s distinguished physician wasselected to be included in the World MedicalAssociation’s Caring Physician of the Worldpublication.

• Attended the Masean Council Meeting InBangkok, November 2005, where the StandingCommittee for Medical Education in Asean

*1 Chairman, International Relations, Indonesian Medical Association, Jakarta, Indonesia ([email protected]).

Since the last CMAAO Meeting in Seoul, Septem-ber 9–11, 2005, the activities of the IndonesianMedical Association, among others are:

National• Conducting monthly press conferences regard-

ing IMA’s concern for health problems thatarises and became actual topics.

• IMA now becomes an active body in healthscreening and medical check-up for candidatesparticipating in elections, be it in provinces ordistricts, as well as for central government.

• Holding National Workshops to restructurethe system of Continuing Medical Education/Continuing Professional Development in linewith the implementation of the new Law ofMedical Practice.

• Actively socializing the new Law of MedicalPractice, since enacted October 2004.

• Assisting the government and the society toenhance sanitation environment to controlDHF spreading in Jakarta, October 2004.

• Proactive in handling/facing tsunami disasterthrough special effort to lead some non gov-ernment association or other professional asso-ciation. The government recognizes the IMAeffort through MOU between IMA and MoHin which the government gives authority toIMA to coordinate medical personnel supportplaced at Aceh during the emergency phase,between December 2004 and April 2005.

• During the Yogya earthquake, and immedi-ately followed by the Pangandaran tsunami,the IMA helped coordinate medical and per-sonnel support by several volunteer foreignmedical associations. Among others, The KoreanMedical Association was never absent in help-ing Indonesia, through the IMA, whereverthere is a natural disaster happening.

• Holding a National Workshop about The Fam-ily Medicine Concept in The New NationalHealth System, February 2005.

Country Report


Countries were formed.• Attended the 1st World Medical Association

Asia Pacific Regional Meeting in Tokyo,September 2006.

• Attended the Masean Congress in KualaLumpur, November 9–11, 2006, where theMasean Presidency were handed over fromIndonesia to Malaysia.

INDONESIAN MEDICAL ASSOCIATION


JAPAN MEDICAL ASSOCIATION

Kazuo IWASA*1

*1 Vice-Chair, World Medical Association. Vice-President, Japan Medical Association, Tokyo, Japan ([email protected]).

Of the international activities in which the JapanMedical Association has participated this pastyear, I would particularly like to report on the1st WMA Asian-Pacific Regional Conferencewhich was hosted jointly by the WMA and JMAin Tokyo on September 10 and 11.

Today I would like to briefly present an over-view of the significance and achievements of thisconference.

The conference was organized jointly by theWMA and JMA supported by the Pfizer Founda-tion Initiative. The main theme, proposed by theJMA, was “Disaster Preparedness and Responseto Infectious Diseases.”

The conference was attended by approximately50 representatives of national medical associ-ations in the Asian-Pacific region, mainly fromCMAAO and MASEAN, and lively discussionswere observed. Opening the conference was akeynote speech by Dr. Shigeru Omi, RegionalDirector of the WHO Regional Office for theWestern Pacific, who spoke in detail about thesituation at the time of the SARS outbreak andresponses to it. One of Japan’s leading seismolo-gists spoke about mechanisms for the occurrenceof earthquakes and tsunami. The topics dealtwith were on a broad rage of issues including theacute phase following a disaster, the risk manage-ment of infectious diseases and the activities ofa rescue team from the Korean Medical Associ-ation in the areas devastated in the Indian OceanTsunami. For medical specialists, the conferenceproved to be deeply significant and meaningful.

Both earthquakes and tsunami are unpredict-able. The possibility of their occurring is high inthe Asian-Pacific region and tremendous damageis anticipated. There is an urgent need for us phy-sicians to work together across national bound-aries to minimize the spread of damage, disaster,and infection. Human lives are equally valuable,

regardless of nationality, race, politics, religion,or disparities in wealth.

As long ago as 460 BC, Hippocrates swore anoath that is now the basic philosophy of all medi-cal profession. As one who had been granted theability to practice medicine, Hippocrates sworeto serve humanity throughout his entire life.

As medical profession, it is our duty to treatour colleagues as brothers and sisters and treatour patients equally without regard to race, reli-gion, nationality, or social position. We must actand work in cooperation in accordance with theDeclaration of Geneva (1948), which was createdbased on the philosophy of Hippocrates.

To coincide with this timely conference, theJMA also independently held a special publiclecture open to the general public and rescueand disaster prevention organizers for regionsthroughout Japan on the same theme and thesame day as the conference. It was attended byapproximately 700 people.

This regional conference was the first of itskind in the Asian region, and I am certain that allthe participants fully understood the significanceof this event. As one of the hosts of this confer-ence, the JMA also published a full-page articleon the conference in the International HeraldTribune of October 7. For your reference I havebrought a copy of the newspaper with me if youwould care to see the article.

In future, the JMA intends to further strengthenits cooperative framework through the exchangeof information, particularly with the CMAAOand WMA, providing forums for the discussionof serious problems such as those discussed atthe conference and fulfilling our responsibilitiesas medical profession.

That concludes my introduction of one of therecent activities of the JMA.

Country Report


JAPAN MEDICAL ASSOCIATION


Iwasa K


KOREAN MEDICAL ASSOCIATION

Dong Chun SHIN*1

Healthcare Policy Issues in Korea

Government’s plan for reducing medical feeThe Korean government announced its plan forreducing medical fees in May this year, featuringtransfer of medicine registration system to becovered by National Health Insurance (NHI) fromnegative system to positive system. Currently,all medicines including those newly-invented inKorea are automatically eligible for NHI regis-tration except for some medicines designated asnon-benefit items by the Government (negativesystem). When a positive system is introduced,only “cost-effective (pharmaco-economic)” medi-cine on the basis of clinical efficiency and safetywill remain on the registration list. This bringsforth controversy and confusion in the medicalfield and each association concerned such as theKorea Pharmaceutical Manufacturers Associationand the Korean Pharmaceutical Association (KPA)have taken different stances. Pharmaceuticalmanufacturers take a strong opposition to thisplan, arguing that it is too early to carry out theplan under the circumstances where standards toassess pharmaco-economic level of a medicineare not established and there is a lack in qualifiedmanpower and data for assessment. It will alsoplace additional burden on the manufacturersto outsource research for the assessment, whichwould eventually lead to the decreased inventionof new medicines, according to the manufacturers.

Meanwhile, the KPA agrees with the Govern-ment on the necessity of a positive system basedon the grounds that it will solve the problem ofdrug inventory caused by frequent changes indoctor’s prescriptions.

The KMA requested that the Korean govern-ment take a careful approach, as the plan mightharm physician’s autonomy in prescription andlimit patient’s right to the best treatment.

This issue has been drawn into a even morecontroversial whirlpool linked with other separateissues such as the scandal about manipulatingbio-equivalency test results, bilateral talks fora Free Trade Agreement between Korea andthe US and so on. Nevertheless, the governmentsticks to its stance of implementing this planwithin this year. The KMA will continue to keepa close eye on its proceeding and make effortsfor establishing reasonable and fair standardsof pharmaco-economic assessment.

Launch of Resident’s Labor UnionThe first physician’s labor union came into exist-ence in Korea. The Korea Intern Resident Asso-ciation had submitted an application to establishthe Resident’s Labor Union and finally got thegreen light from the Ministry of Labor in July.Resident’s Labor Union aims to achieve bettertraining conditions for interns and residents inhospitals. As a labor union, it has a legal right toengage in labor actions including strikes.

Decline of Obstetrics & GynecologyLike many other countries, Korea is sufferingsignificantly from the dwindling birth rate. Theall-time-low birth rate of Korea (1.02 baby perwoman) began to take a toll on medical field,especially on Ob & Gyn part. In the past, Ob& Gyn enjoyed the highest popularity amongphysicians in training in terms of specialty selec-tion but now it is on the brink of falling downinto “specialties in need of support for fostering”.Medical trainees who apply for “specialties inneed of support for fostering” will receive train-ing subsidy as a way to promote relatively un-popular specialties suffering from lack of trainees.

Free provision of essential vaccinationsThe National Assembly passed the bill to provideessential vaccinations for all infants under age six

*1 Executive Board Member, Korean Medical Association. Professor, Department of Preventive Medicine, Yonsei University, Seoul, Korea([email protected]).

Country Report


Shin DC

in all clinics. This bill will come into effect fromnext year on. However this bill refers to increasein tobacco tax as its financial resources, so it willface some financial problems if the increase intobacco isn’t followed.

Pressure to price down IressaThe Government made a decision to lower theprice of Iressa in response to the strong requestof the NGO, “Health Network”. “Health Net-work” is asserting that the price of Iressa is tooexpensive while its clinical efficiency has not beenfully proven. The manufacturer of Iressa apposedto the decision and filed a lawsuit against theGovernment, saying the decision infringes uponthe company’s legal rights.

KMA’s Public Affairs

Community ActivitiesThe KMA has actively taken part in public healthpromotion and in other activities to come closerto the public. With the launch of the new execu-tive board on May 2006, led by the PresidentDong Ik Jhang, serving the community will con-tinuously be placed high on its agenda. As a partof these efforts, the Public Health Committeewas organized as a special committee in June.It has nine sub-specialty committees under itsumbrella. Sub-specialty committees have beenorganized by top experts in their respective fieldsincluding allergy/atopy, food safety, cancer,metabolic syndrome, environment, anti-tobaccocommittee and so forth. They are taking the leadin producing guidelines for both physicians andpatients against certain diseases. It also has themission of delivering the most reliable informa-tion to the public in the event of controversy suchas outbreak of mass food-poisoning in schools,where people often get confused with an over-flow of different views. The committee also aimsto summit recommendations to the Governmentin its policy making process for better operationof national health system as a way of deliveringvoices from the forefront of healthcare.

Medical Aid Activities abroadWith the help of Indonesian Medical Association,the KMA sent the Korean Emergency MedicalAid Team (KEMAT) to Indonesia on June 1,2006, just five days after the quake hit Indonesia.This was the second joint relief activity of the two

associations following to the joint activity for theinjured in Tsunami disaster in January 2005. Theteam was composed of 1 orthopedic surgeon, 1cardiovascular surgeon, 2 general surgeons, 1 GP,4 nurses, 4 administrative staff, 2 reporters and 3interpreters and they set their base camp at theHappyland Hospital in Yogyakarta. This hospitalis run by a Korean businessman and his Indo-nesian wife who is a medical doctor. The KEMATdivided its team members into three units, oneproviding medical cares at the base camp and theothers mobilizing into remote areas, where handsof medical professionals have not yet reached out.The KEMAT treated approximately 600 patients(150 patients a day on average) for four days.

Other than this emergency medical aid activi-ties, the KMA accomplished “Humanity medicalmarch along the Silk Road” in collaboration withthe Busan metropolitan government and providedprimary healthcare to people in Kazakhstan, Kyr-gyzstan, Vladivostok and the autonomous districtof Urumiqi, where access to healthcare is limited.

Gearing up for 2008 WMA General AssemblyThe KMA has been approved as the hostingNMA of 2008 World Medical Association (WMA)General Assembly in 2004 WMA Tokyo GeneralAssembly. With the assembly only two years away,KMA launched the organizing committee inSeptember to get down to preparation on details.The committee is spearheaded by Dr. T.J. Moon,the Honorary President of KMA and Dr. D.I.Jhang, the President of KMA and consists ofmembers reflecting diversified voices of medicalfield including Korean Medical Women’s Asso-ciation and Korean Academy of Medical Sciences.The diversity in committee members will lead theAssembly to a success both in public promotionand academic achievement. The committee isnow pooling their wisdom to select the theme forthe scientific session of the assembly and plansto submit the draft to the next WMA CouncilMeeting in Berlin in May 2007. The date of the2008 WMA General Assembly has been decidedto be October 15–18, 2008 at the 2006 GeneralAssembly held in South Africa last month.

Bridges to the successful centennialanniversaryThe KMA hosted various events in the frame-work of promoting the celebration of KMA’s cen-tennial anniversary in 2008. At a charity fashion


independence movement. This symposium is thefirst of its kind and considered to have contrib-uted to the vitalization of the field of physicianhistory. In addition, the KMA is preparing a full-blown scientific program to highlight the rapidimprovement of medical technologies and infra-structures in Korea for the last century.

show held in January, 50 women physicians fromvarious generation volunteered to be models ofthe show and won applause from audience andthe media. In August, a special symposium washeld in memory of the National IndependenceDay (August 15), which traces the lives of threephysicians who devoted themselves to Korea’s



Shin DC


MACAU MEDICAL ASSOCIATION

Nai Chi CHAN*1

*1 Director, Macau Association of Medical Practitioners. President, Macau Society of Hematology and Oncology, Macau ([email protected]).

Country Report


MALAYSIAN MEDICAL ASSOCIATION

P. VYTHILINGAM*1

Chairman, Private Practitioners’ Society (PPS)Dato’ Dr N.K.S. Tharmaseelan

Chairman, Section Concerning House Officers,Medical Officers & Specialists (SCHOMOS)

Dr. S. VasanWe have two Sections in our Association;

namely, the Section Concerning House Officers,Medical Officers & Specialists (SCHOMOS) andthe Private Practitioners’ Section (PPS).

There are six Societies—Public Health Society,Society of Sports Medicine, Society of Occupatio-nal and Environmental Medicine, Ophthalmolo-gical Society, MMA Physicians for the Preventionof Nuclear War and Society of MMA MedicalStudents.

We also have 30 Committees and MMA isrepresented in 33 external bodies—governmentand non-governmental organizations (NGOs).

Membership

As at 31st December 2005, the total membershipof the Malaysian Medical Association stands at12,030 (excluding students of 3,614), out of which3,798 members are classified as ‘Archives’. Thus,the MMA represents only 52.10% (8,232 benefitsmembers), when compared to 15,800 registeredmedical practitioners in the country.

As of September 2006, the MMA membershipstands at 13,601.

Liaison with Government Agencies

Ministry of HealthThe MMA had attended various meetings with theMinistry of Health during the 2005/2006 term.Some of the significant meetings are as follows.Section Concerning HouseOfficers, MedicalOfficers and Specialists’ (SCHOMOS) IssuesOn 16th December 2005, the SCHOMOS ExCowas invited to meet the Chief Secretary of theMinistry of Health, Dato’ Dr. Hj Mohd Nasir b.

Objectives of the Malaysian MedicalAssociation

• To promote and maintain the honour andinterest of the profession of Medicine in allits branches and in every one of its segmentsand help to sustain the professional standardsof medical ethics.

• To serve as a vehicle of the integrated voiceof the whole profession and all or each of itssegments both in relation to its own special prob-lems and in relation to educating and directingpublic opinion on the problems of public healthas affecting the community at large.

• To participate in the conduct of medical educa-tion, as may be as appropriate.

• To promote social, cultural and charitable ac-tivities in building a united Malaysian nation.

Council, Executive Committee, Sections,Societies, Committees and Representativesof the Malaysian Medical Association

The MMA Council consists of the following keyoffice-bearers who are also members of the Execu-tive Committee; as well as 19 branch representa-tives from the 13 states in Malaysia.President

Datuk Dr. Teoh Siang ChinImmediate Past President

Datuk Dr. N. ArumugamPresident-Elect

Dato’ Dr. Khoo Kah LinHonorary General Secretary

Dr. Mary Suma CardosaHonorary General Treasurer

Dr. P. VythilingamHonorary Deputy Secretary

Dr. Kuljit SinghHonorary Deputy Secretary

Dr. George Fernandez

*1 Honorary General Treasurer, Malaysian Medical Association, Kuala Lumpur, Malaysia ([email protected]).

Country Report


Vythilingam P

Ashraf and among the issues discussed were jobvacancies—availability and allocation, promotionfor Specialist Medical Officers, implementationof CPD Committee, full paying patient and thenational health financing scheme, the Ministryof Health paid attention towards disabled doc-tors or those suffering from chronic illnesses, theproblems of Medical Officers who pursued exter-nal degree programs such as FRCS, MRCP andMRCOG, allocation of allowance for OverseasProfessional Medicine Conference, doctors whohad served for at least 10 years in the Ministryof Health to be provided with medical facilitiesfor themselves and their family when they retireor resign from the government and finally, allow-ance for Public Health Officers when the countryis hit by infectious disease problem.Private Practitioners’ Section (PPS) issuesA meeting was held between the MMA and theEconomic Planning Unit (EPU) on the ForeignMedical Examination of Foreign Workers(FOMEMA) on 11 August 2005. Among the mainissues discussed were financial issues, generalissues such as verification of foreign workers,payment, standard operating procedures, quotaand untrue statements as well as operations, e.g.GPs—group practice and in-house clinics andx-ray facilities and Radiologists.

Liaison with Non-GovernmentalOrganizations

MMA-Direct Access Affinity ProgrammeDirect Access was first conceived in 1995 as adivision of Southern

Bank Berhad and is Malaysia’s first 24-hourtrue direct banking service provider, meetingcustomers’ needs for an effective and convenientalternative banking in place of conventional branchbanking. As the country’s premier direct bank,Direct Access offers a complete and extensiverange of personal banking products and servicessuch as current account, savings account, fixeddeposit, overdraft facilities, personal loans, homemortgages and credit cards via remote channelssuch as telephone, fax, mail, ATM and PC.

Soon after Direct Access’s establishment, theMMA entered into an affinity programme withthe financial organization. With this programme,the MMA members enjoyed preferential bankrates for most of the 1990s, albeit these privilegesare now also offered by other banks, which offer

similar banking facilities, including “free” creditcards.Group multiple benefits schemeThis scheme was launched in the year 2002 and isunderwritten by Great Eastern Life Assurance(M) Bhd. The scheme offers a very comprehen-sive protection with attractive premium refundat retirement. The scheme is open to all MMAmembers, their spouses and children and pro-vides coverage against death, disabilities and also36 critical illnesses. The special features of thescheme is that same level of premium for all ages,the premium of this scheme is much cheaper thanan individual policy in the market, memberscan participate in this scheme until the age of65 and double the amount of coverage if deathor disabilities are due to accidental causes. Themembers can terminate the policy at anytime andthe minimum guaranteed surrender value is 35%of the total premiums contributed.Other insurance packagesThere are also other insurance packages speciallytailored for the members of the MMA such as thespecial clinic insurance package covering all theclinic insurance needs under one policy, motorinsurance scheme and doctors personal protectorinsurance scheme (personal accident policy).

Professional Indemnity InsuranceMedical protection societyMMA had several fruitful meetings with theMPS representatives during the year 2005. Oneof the highlights of these meetings was the sign-ing of the MoU on 21st March 2005. The MoUwas revised to provide for a fixed rate of commis-sion across the board for each member.

On 26th September 2006, the MMA in col-laboration with MPS launched the MMA Pro-fessional Medical Indemnity Insurance schemefor Medical Officers. This is to create awarenessof clinical risk management as well as encouragethese officers to practice with medical indemnitycover. This package brings a convenient solutionto assist the transition from medical students tomedical officers. As a member of the MMA, thisprofessional association looks after their welfareand has various working committees on specificprofessional issues. We want to ensure that thedevelopment of a doctor’s career is based onstrong foundations of knowledge and awarenessof patient safety.

The main benefit of the plan is that it is applic-


able across all disciplines and all kinds of hospitalor primary care practice. If there is a problem,all the medical officer need to do is to dial theMPS helpline for advice. Together with DirectAccess of the Southern Bank Group, the MMAmembership will afford them a pre-approvedfree-for-life credit card to simplify payments.Malaysian medical indemnity insuranceAON Insurance Brokers (M) Sdn Bhd took overthe management of this scheme on 26th January2001. The membership count at the time of takeover was only 700 members.

AON Insurance Brokers had carried out aseries of advertisements in our in-house publica-tion, the Berita MMA, MMA Annual Reportsand MMA Branches souvenir programme books.Road shows had also been conducted in theStates of Penang, Kedah, Malacca and Kelantan.They had been able to increase the membershipcount to 2,300 as of 31st December 2005 with apremium base of around RM3 million.

International Affairs

Medical Associations of South East AsianNations (MASEAN)

The 11th MASEAN Mid-Term Council Meetingwas held on 16th to 18th November 2005 at theChalerm Prabarani Building, Medical Associ-ation of Thailand, Bangkok.

The MMA was represented by the ImmediatePast President, Honorary General Secretary andtwo of the Honorary Deputy Secretaries.

Two papers were presented—country reportand a paper on “The Medical Role in MassiveDisaster”.

Confederation of Medical Associations inAsia and Oceania (CMAAO)The 24th CMAAO Congress and the 41st Coun-cil Meeting was held on 9th to 11th September2005 at the JW Marriott Hotel in Seoul, Korea. Itwas hosted by the Korean Medical Association.

The MMA was represented by the Presidentand the Honorary General Treasurer. Two paperswere presented—country report and a paper onthe status of “National Health Financing Schemein Malaysia”.

Two important events took place—the instal-lation of the 27th President of CMAAO, Dr. JaeJung Kim from Korea and secondly, the 7th TaroTakemi Memorial Oration was delivered by Dr.

Tai Yoon Moon. The topic was on “Progress andProblems of Health Insurance Program in Korea”.

World Medical Association (WMA)The 56th WMA General Assembly was held on12th–15th December 2005 at the Hyatt RegencyHotel, Santiago, Chile.

The MMA was represented by the Presidentand the Immediate Past President.

Datuk Dr. N. Arumugam, Immediate Past Presi-dent was elected as the President-Elect of theWMA after defeating nominees from Hungaryand Belgium over two rounds of close voting bydelegates from the national medical associations.He assumed his post of President of the WMAat the recently held WMA General Assembly inSun City, South Africa on 13th October 2006.

The publication “Caring Physicians of theWorld” was the central theme during Dr. YankCoble’s term as President from 2004–2005. TheMMA nominated Dato’ Dr. T.P. Devaraj as aninspirational role model for Malaysia and hewas one of the 65 physicians selected from 55members countries of the WMA (which has 84national medical associations as its members)and featured in this book.

MMA Aid and Study Mission to Sri LankaThis mission was organized by the MMA and theSchool of Medicine, University Malaysia Sabahand supported by the Hospital Mesra Padang,Sabah Medical Centre, Wong Kwok Group andthe Sabah Psychiatry Welfare Body.

The world’s most powerful earthquake in morethan 40 years struck deep under the Indian Oceanon 26th December 2004, triggering massive tsu-namis that obliterated cities, seaside communitiesand holiday resorts, killing tens of thousands ofpeople in a dozen countries.

The objective of the mission was to provideaid—24 boxes of clothes, medicines and toys.Secondly, to conduct a study and finally, it was afact finding mission to learn about the communityand NGO interventions.

The location was the coastal belt of Vadamarachiin the Jaffna Peninsula, Mullaitivu in Vanni andBatticola (Ampara). The team coordinator wasthe current President of MMA.

Some of the activities during this period whichwere implemented by the taskforce were to createawareness and providing education, needs assess-ment to determine the developing long-term



consequences of the disaster, to promote accessto existing services, to ensure quality of psycho-logical interventions provided, community work,additional training on specialized topics, to coor-dinate plans and networking as well as to createawareness on the needs of special groups.

Seminars Conducted by the MMA

Ethics Day 2005This event was organized by the Ethics Commit-tee of the MMA and it was commemorated on2nd October 2005. The aim of the celebrationwas to ensure that the ethics and its practiceremained in the forefront of the association’sactivities. As essay competition was held for themedical students from all the local universities,both private and public. The title of the essaycompetition was: “Current Ethical Dilemmas—Problems and Solutions”.

This year, the Ethics Day was on 18th Septem-ber 2006 and in conjunction with this Day, againan essay competition had been organized butthis time round it is for the medical students aswell as doctors.

8th Scientific Conference for GeneralPractitionersThis conference was organized by the MMAPenang Branch and was held from 16th to 18th Sep-tember 2005 at the City Bayview Hotel, Penang.The target groups were doctors in primary careand a total of 200 participants registered for thisconference. The areas covered included psychia-try, diabetes mellitus and obesity, hypertension,obstetrics & gynaecology, neurology, surgical pro-cedures and CPR.

This conference has been conducted annuallysince 1998. This year, the conference was held on8th–10th September 2006.

4th National Adolescent Health SymposiumThis symposium was organized by the AdolescentHealth Committee of the MMA and co-organizedby the Ministry of Health, Sabah State HealthDepartment, Federation of Family PlanningAssociations, Malaysia, Hospital Mesra, Sabahand the Malaysian Paediatric Association.

It was held on 18th and 19th March 2006 withthe theme “Adolescent Health the Way Forward”.The main objective was to bring together all stake-holders of adolescent health to discuss issues

related to adolescent health. It also aimed toincrease and improve awareness among healthcare providers, parents and youths on the im-portance of adolescent health in Malaysia.

The Society on Occupational Medicine(SOEM) Annual Seminar MedicalEmergency Preparedness in IndustryThis seminar was organized by the SOEM incollaboration with the Ministry of Health andDepartment of Occupational Safety and Health(DOSH). It was held on 4th March 2006.

Among the topics presented were MedicalEmergency Preparedness in Industry, Role ofOccupational Health Professionals in MedicalEmergency Preparedness, Industry MedicalEmergency Preparedness—are we ready?

Second Regional Conferenceon Occupational Health (RCOH)This conference was held on 7th to 9th April 2006.

The target group were Occupational HealthPhysicians, Occupational Health Doctors, MedicalPractitioners/Specialists, Allied Health CareProfessionals (Nurses, Medical Assistants, HealthInspectors, etc), medical students, IndustrialHygienists, Safety Health Officers and HumanResource Personnel.

‘Health and Flying’ SeminarThis event was organized by the SOEM and theRoyal Malaysian Air Force (RMAF).

It was held on 25th February 2006 and amongthe topics presented were on Introduction toAviation Medicine, Aviation Physiology andPsychology, Medication and Flying, MedicalEvacuation and Certifying Passengers Fitnessfor Air Travel.

MMA SCHOMOS Workshop onEmpowerment of the Medical Professionin the New MillenniumThis Workshop was organized by SCHOMOSMMA. It was held on 5th to 7th January 2006.

This workshop marked a milestone in theMMA’s continual efforts to address the quality ofcare in the public health care sector. Fifty doctorsrepresenting all the States and specialties wasinvited to address issues of access and equity forthe patients in the public sector.

The objective of the workshop was to retainskilled and development of motivated doctors

Vythilingam P


in the Ministry of Health. The maintenance ofhigh standards and improving quality health caredepends on structured career development andimproving satisfaction. The doctors examined indetail our national health care system againstthe background of regional and global trends.The discussions were very analytical of thefactors that contribute to the retention of thevaluable and experienced doctors.

The MMA presented the final working paperof the recommendations of the workshop to theHonorable Minister of Health Malaysia on 19thJanuary 2006.

14th International Union Against SexuallyTransmitted Infections (IUSTI) Asia-PacificConferenceThis international conference was held on 27th to30th July 2006 in Kuala Lumpur. It was hostedjointly by the Academy of Family Physicians ofMalaysia and the MMA in collaboration with theMinistry of Health, Malaysia.

In line with the theme “STI : Challenges andStrategies”, the programme highlighted thecontrol of sexually transmitted infections (STI)including HIV/AIDS, with special reference toregional cultural practices and economic con-straints. Besides the scientific presentations on

recent advancements, there were also workshopsand interactive sessions of interest to physiciansin both hospital and private practice, publichealth experts and other healthcare professionals,as well as members of organizations concernedwith the impact of STI/HIV on the society.

About 250 participants attended this conference.

Conclusion

Overall, it was yet another active year for the 46thMMA Council especially the key office-bearerswho had many meetings to attend with the Min-istry of Health and other external organizationsto help solve problems faced by the profession.

The Committees, Societies and Branches ofthe MMA were equally active participating in thevarious activities, meetings and courses whichbenefits the community at large.

The Sections of the MMA were also busyhaving meetings with the various external organ-izations to resolve problems faced by theirrespective members. The Branches continueddiligently with their activities, especially CPDand community activities. The main focus byBranches was to recruit more new membersand some Branches had done very well in thisrecruitment drive.



Vythilingam P


NEW ZEALAND MEDICAL ASSOCIATION

Ross BOSWELL*1

ments for laboratory services. In the most seriouscase, three of New Zealand largest’s DHBs (inAuckland) rejected their well-established highly-respected laboratory provider in favour of a start-up company with no staff, premises or equipment.This decision is currently being challenged incourt. Since September 2004 the NZMA hasbeen warning of the outcomes of the lack of anational policy framework for DHB laboratoryreviews, and has called on the Minister of Healthto urgently address this issue.

Medical registration in New Zealand is con-trolled by the Health Practitioners CompetenceAssurance Act 2003, which brought together allregistered health practitioners (such as doctors,nurses, dentists, midwives and physiotherapists)under the same registration, competency anddisciplinary procedures. The Act has the primaryaim of protecting the public. Of great concern tothe NZMA is the fact that although the Act per-mits regulations to be made which would allowfor elected members to the Medical Council ofNew Zealand (MCNZ), to date, the Minister ofHealth has not done so. For the MCNZ to workeffectively it must have the respect and confi-dence of the profession, and that will not happenwhile there are no directly elected members.

The medical workforce in New Zealand con-tinues to be under extreme stress. The high feesand resulting debt levels incurred by medicalstudents in training lead to many newly-qualifiedNew Zealand doctors seeking higher-paid pos-itions overseas. Campaigning by the NZMA,along with the New Zealand Medical Students’Association, has resulted in the Governmentagreeing to reduce the student debt burden(including the debt of medical students/juniordoctors). Many of New Zealand’s practising doc-tors trained elsewhere in the world—currentlyone-third are from overseas countries.

Doctor shortages in some regions and notablyin rural areas continue to place extra demands

*1 Chairman, New Zealand Medical Association, Wellington, New Zealand ([email protected]).

New Zealand’s health sector has been radicallytransformed over the past decade and a half.Successive governments with different perspec-tives and ideologies have made huge structuralchanges. The current Labour-led Government,headed by Prime Minister Helen Clark, is nowone year into its third three-year term, and is in aphase of consolidation rather than implementingnew initiatives.

Over the past 15 years democratically-electedregional hospital boards have operated, beenabolished and replaced by commercial companies,and then re-introduced. New Zealand now has21 District Health Boards (DHBs) which areresponsible for providing government-fundedhealth care for the population in their region.DHBs focus on planning and delivering healthservices, running hospitals, overseeing primaryhealth care services and delivering some publichealth programmes.

Adequacy of funding at District Health Boardlevel is a continuing concern, with some runningcontinual deficits and/or cutting services to meetbudget constraints. Earlier this year the Govern-ment decreed that no-one must be on a publicwaiting list for specialist assessment or surgeryfor more than six months. The outcome? Thou-sands of New Zealanders have been removedfrom waiting lists and referred back to theirGeneral Practitioners, to widespread outrage inthe community and medical profession.

Care in the private secondary health sector isavailable to those with health insurance or themeans to pay. More than 50% of elective surgerytakes place in the private sector, as funding re-straints and restricted waiting lists mean only themost urgent cases get priority in public hospitals.

A major issue which came to a head in 2006has been the reviews of laboratory services beingcarried out by DHBs. Individual DHBs aroundNew Zealand have been reviewing and, in somecases, making changes to their contractual arrange-

Country Report


on the profession. Specialities such as obstetrics,psychiatry and general practice are particularlyshort. After a report from the Health WorkforceAdvisory Committee, the Government has es-tablished a Workforce Taskforce to advise ofsolutions to workforce problems. This taskforceis currently examining the issue of medical edu-cation and models of medical training.

Six years ago the Government released itsPrimary Health Care Strategy, based on capitatedfunding to general practices which enrol theirpatients as members of a Primary Health Organ-isation (PHO). This was the biggest shake-upof the primary health sector for half a century.PHOs receive public funding through DistrictHealth Boards. The Government has progres-sively rolled out increased funding to more agegroups, until now just the 25–44 year olds do notreceive any public subsidy.

The New Zealand Medical Association sup-ported the broad proposals of the PrimaryHealth Care Strategy as having the potential toimprove the health of New Zealanders and theiraccess to primary health services. We have foughthard to retain the principle that GPs be able toset their own fees, and charge a co-payment ifnecessary (as the government funding does notcover the entire cost of visiting a GP). However,inroads have been made into this basic principle,often because some GPs have themselves abdi-cated this right in order to receive extra funding.

The NZMA has been involved with changesto maternity care this year. The Ministry of Healthhas proposed changes to the way maternity ser-vices are delivered, many of which the NZMAhas rejected as unworkable. While New Zealandhas a world-class maternity system, problemsstill exist, particularly in rural and provincialareas and with shortages of practitioners.

The NZMA continues to publish the NewZealand Medical Journal, which has been onlineonly since 2002. The NZMJ is the premier scientificmedical journal for the profession in New Zealand,and continues to publish well regarded researchon a wide variety of medical topics.

The NZMA provides the Code of Ethics forthe profession in New Zealand, and will be review-ing its Code next year.

The NZMA works closely with the NZ MedicalStudents’ Association, recognizing that students

are the future of the profession. The NZMA alsohas a Doctors-in-Training Council, which repre-sents the interests of junior doctors and medicalstudent members.

Other NZMA initiatives include:• Around 50 submissions on a wide variety of

issues, including organ donation, smokefreeenvironments, obesity, epidemic preparedness,and direct-to-consumer advertising of pre-scription medicines.

• Promoting the message that people shouldn’ttake Benzylpiperazine-based party pills.

• Adopting a policy on obesity, a growing issuewhich can lead to serious health problems.

• Adopting a policy on alcohol use, which willbe used to inform NZMA’s work regarding theimpact of alcohol on individuals and society.

• Issuing a resource—“Beginners guide to indus-trial action” in light of a planned junior doctorstrike.Government public health initiatives in the

past year include:• The majority of the under-20 population have

been immunized against meningococcal dis-ease type B. The vaccine has been speciallydeveloped for New Zealand conditions and isadministered through general practices andschools.

• Planning has taken place for the possibility of abird flu pandemic. The NZMA has written itsown resource about pandemic planning aimedat doctors who employ staff.

• The Government launched a $67 million healthylifestyles package for young New Zealanders,which aims to help young people improve theirnutrition and be more active.It has been another busy and challenging

year for the NZMA. We place a high value onadvocacy for the health of the population andsupport for professional conditions. Continuingliaison with health sector policy makers, repre-sentation on consultative bodies, preparation ofsubmissions on health-related legislation and ad-vocacy about the introduction of new initiativescontinue to keep members actively engaged inimproving health care for all New Zealanders.We continue to work closely with other medicalorganisations both within the country and at aninternational level.

NEW ZEALAND MEDICAL ASSOCIATION


*1 President, Philippine Medical Association, Manila, Philippines ([email protected]).

PHILIPPINE MEDICAL ASSOCIATION

Jose Asa SABILI*1

Country Report


PHILIPPINE MEDICAL ASSOCIATION


SINGAPORE MEDICAL ASSOCIATION

Raymond CHUA Swee Boon*1

*1 Honorary Secretary, Singapore Medical Association, Singapore ([email protected]).

Country Report


SINGAPORE MEDICAL ASSOCIATION


Chua R


TAIWAN MEDICAL ASSOCIATION

Nan-Her WU*1

The Health Affairs Journal and ABC News bothreported the achievement of Taiwan health insur-ance system in 2003. Many other countries havetaken Taiwan’s health care system as a modelsystem. Up to July of 2005, 21 countries cameto Taiwan to discover the secret of our nationalhealth insurance system, including the UnitedStates, Belgium, Canada, France, Germany...etc.

Health care expenditure in Taiwan accountedfor 6.3% of GDP in 2003, compare to an averageof 8% in other OECD countries and 14% in theUnited States. The health care expenditure perperson was US$819, US$5,569 and US$2,306 inTaiwan, the United States and OECD countriesrespectively in 2003. This is an obvious evidencethat the health care professionals provide highquality health care services with very low payment.However, the health care system has faced aconstructional unbalance between the insurancepremium and medical payment since July of 1998and the financial insufficiency has reached NT$58 billion. By using the global budget system, thisfinancial burden has been shifted to the healthcare industry. For example, the BNHI retrieved30% of medical payment it made to health careinstitutions in 2004 and 2005. This has seriousimpact on health care institutions’ operation.

The purpose of national health insurancesystem is to provide quality health services andto promote people’s health. Taiwan MedicalAssociation will focus on the advocacy of thehealth insurance system reform, establishing apremium adjusting mechanism, avoiding healthcare resource consuming and increasing servicequality to create a comprehensive and holistichealth care environment.

Donating US$50,000 to Assist theEstablishment of WMA AfricanRegional Office

WMA has devoted itself to the establishment of

Promoting Medical Ethics Aggressively

“Medical care without boarders, human rightswithout ethnics.” Patient rights and medicalethics have become key issues internationally inthe 21st century along with the changing in theawareness of human rights, patient-physicianrelationship and medical technology. Physician’sethical responsibility is not limited to serve thecommunity or country, it has become a globalhealth issue.

WMA came up with the resolution to addmedical ethics to the curriculum for medicalstudents based on the WFME resolution in 1999.WMA also published its first medical ethics aux-iliary material—Medical Ethics Manual in 2005.

In response to WMA’s long term promotionon the central value of medical ethics, TMAacquired the authority to translate the MedicalEthics Manual into Chinese version and launchedits published on the National Doctor’s Day inNovember of 2005 in Taiwan. One copy hadbeen distributed to every physician in the nationin order to promote the professional “diseasecuring” technique to “human-being caring” level.Taiwan is one of the few pilot countries who haddone this with the hope to foster selfless-mindedphysicians, to provide priceless medical servicesto patients, to fulfill the duties as a member of theworld health community and to put patients-firstas the true value in the daily practice. This is alsothe most updated central value of medical carethat the WMA has proposed in the 21st century.

Health Care System in Taiwan

Since the implementation of national health in-surance system in 1995, the survey shows thatmore than 70% of people in Taiwan are satisfiedwith its remarkable medical care for all, eliminat-ing medical care access and care for the minors.

*1 President, Taiwan Medical Association, Taipei, Taiwan, ROC ([email protected]).

Country Report


Wu NH

reference libraries in different regions in order toassist country members to monitor and preventcommunicable diseases periodically. Besides, italso provides help to its member countries toidentify those viruses and bacteria that are stillunknown in recent years in order to prevent theoutbreak of new epidemics.

In response to the call from WMA, TMAdonated US$50,000 to the South African MedicalAssociation to help with the establishment of a

new office in African region which is to addresson the prevention and treatment of AIDS/HIV,tuberculosis, malaria, cholera, Avian Flu...etc. tofulfill our duties as a member of the global healthsociety and to carry out the spirit of medicalcare cross boarders. We are willing to providenecessary manpower support on the project andto share Taiwan’s successful experience andaccomplishment in Public Health.


TAIWAN MEDICAL ASSOCIATION


Wu NH


THE MEDICAL ASSOCIATION OF THAILAND

Wonchat SUBHACHATURAS*1

President of the Thai Medical CouncilPresident of Royal Colleges of SurgeonsPresident of Royal Colleges of PhysiciansPresident of Royal Colleges of AnesthesiologistsPresident of Royal Colleges of Obstetricians

& GynaecologistsPresident of Royal Colleges of PediatriciansPresident of Royal Colleges of OphthalmologistsPresident of Royal Colleges of PathologistsPresident of Royal Colleges of RadiologistsPresident of Royal Colleges of OtolaryngologistsPresident of Royal Colleges of PsychiatristsPresident of Royal Colleges Orthopaedic SurgeonsPresident of Royal Colleges PhysiatristsPresident of College of Family PhysiciansPresident of Women Medical Association

Membership:As at September 2005, The Total membership ofthe Medical Association of Thailand (MAT) at17,168 This represented 60% of all registeredpractitioners in Thailand.

The Activities in the years 2005–2006 are asfollows.

Activities to continue medical educationand research in the medical area• Organize Scientific Meeting twice a year

- At Bangkok in January 29th, 2006- Provincial Scientific meeting and general

assembly usually we organized in October everyyear. This year, we organized at Chiang-RaiProvince on October 5–7, 2006.

• Providing five Scholarships. for Thai Physicianwho work outside Bangkok to extend theirstudies aboard for three months. One scholar-ship for one to two years research study.

• Providing Research grant for Thai doctors whoseresearch project is accepted by the Committee.This year we have five awardees.

• Organize special lecture to continue MedicalEducation for members two times in April andJune 2005.

The Administrative Committee is composed of34 Council members. In which generally have amonthly meeting and set up 15 sub committees towork in different function.

Office Bearers and Councilors of MAT 2006–2007President

Air Vice Marshal Dr. Apichart KoysukloPresident Elect

Dr. Aurchat kanjanapitakVice-President

Assoc. Prof. Dr. Prasert SarnvivadSecretary General

Pol. Maj. Gen. Dr. Jongjate AojanepongTreasurer

Maj. Gen. Dr. Nopadol Wora-UraiHouse Master

Group Captain Dr. Paisai ChantarapitakPublication

Prof. Dr. Sukhit PhaosavasdiWelfare Section

Group Captain Dr. Tenehtsak WudhapitakMedical Education

Prof. Dr. Somkiat WattanasirichaigoonEthics

Dr. Sawat TakerngdejScientific Section

Prof. Dr. Teerachai ChantarojanasiriSpecial Affair

Prof. Dr. Sriprasit BoonvisutGroup Captain Dr. Karun Kengsakul

International RelationDr. Wonchat Subhachaturas

Public RelationGroup Captain Dr. Paisai Chantarapitak

RegistrationAssoc. Prof. Dr. Saranatra Waikakul

Member of CouncilDr. Varaphan Unachak (Rep. From North)Dr. Kamol Veeraprdist (Rep. From South)Dr. Vithya Jarupoonphol (Rep. From East)Dr. Pinit Hirunyachote (Rep. From Central)

*1 International Relation, The Medical Association of Thailand, Bangkok, Thailand ([email protected]).

Country Report


Medical ethics activities• Publication of two new books “Ethics in the

Medicine” and “Medical Ethic: Collecting casesin five years published in Thai and Englisheditions for local and international distribution.

• Special Lecture for doctors in Private Hospital.• Special Lecture in topic of Ethic for Medical

student.• Continue publish column about medical ethics

in the Journal of Medical Association.

The activities of supporting and servicingto members of the association• Publish Publication of the Journal of Medical

Association of Thailand, distributed monthly toall member of the Association and major Library.

• Up-date and review the member registration.• Serve and accommodate the member in using

medical club house.• Publish Publication of the newsletter of the

Medical Association of Thailand, distributed toall members monthly.

• Set up the project to help the members whohave legal problems from their medical prac-tice over 24 hours.

• Organize the “Post Congress Tour” for 150members to observe public health in Bruneiduring 18–22 October, 2006.

International activities• 26–27 May, 2006; attended “Singapore Medical

Association Annual Dinner 2006”, at RegentHotel, Singapore.

• 1–4 June, 2006; attended 46th Annual GeneralMeeting of Malaysian Medical Association, Bayview Beach Resort, Penang.

• 25–29 June, 2006; attended “BMA’s 2006 AnnualRepresentative Meeting” in Belfast. 30 June, 2006attended “Improving Health in the developingworld at BMA House, London, UK.

• 10–11 September, 2006 attended “1st WorldMedical Association Asian Pacific Regional”,Four Seasons Hotel, Tokyo, Japan.

• 10–15 October, 2006; attend “57th GeneralAssembly of WMA” Sun City, South Africa

• 10–12 September, 2005; Medical Association of

South East Asia Nations (MASEAN)—12thMASEAN Conference, Awana Genting High-lands Golf & Country Resort, Malaysia.

• Confederation of Medical Association in Asiaand Oceania (CMAAO)—The 42nd Mid-termCouncil Meeting, Grand Copthorne WaterfrontHotel, Singapore.

National activities• Founded the Committee of doctors composed

of three Parties. Ministry of Public Health,The Medical Association of Thailand, MedicalCouncil, for supporting each others.

• Take part in The Council of Scientific andTechnological Associations of Thailand as oneof association member.

Special activities• Publication of three books in Thai.

- His Majesty the King and Medicine in Thai-land.

- King’s Mother and Medicine.- The Crown Price and his support in Medicine.

• Organized “The Medical Association of ThailandHealthy Family Walk-Run” on 26 June, 2005.

• Organized Charity Golf Tournament for Win-ning His Royal Highness Crown Prince MahaVajiralongkorn Cup. on 27 June, 2005.

• Support Thai Culture by many projects fromSubcommittee for Thai Art and Culture.

• Donate B30 Million and two statues of LordBuddha to the King of Thailand on September29, 2006.

Future plan in 2006–2007Four major areas will be strengthened• Improving the efficiency of connection of MAT

to public and other related organizations bothlocally and internationally.

• Supporting protection of Medical Profession aswell as Medical ethics through Medical studentsand site visits.

• Supporting Medical education, trainings andresearches

• Magnifying the services to member througheducation, social, public understanding andlegal supports.

Subhachaturas W


meetings and Guest Lectures held in Colombo,and Quarterly Regional Meetings held in prov-inces outside Colombo.The Association functions through its ExpertCommittees• Communicable Diseases• Drugs• Ethics• Ethical Review• Food and Nutraceuticals• Getting Research into Practice• Health Care Waste Management• Health management• Media• Medical Education• National Health Policy• Non Communicable Diseases• Prevention of Motor Traffic Accidents• Snake Bite• Tobacco Alcohol and Substance Abuse• Tsunami Disaster Relief• Women’s Health

The SLMA has taken the responsibility offormulating National Guidelines on various im-portant topics. These committees have formulatedseveral such Guidelines namely Management ofLipid Disorders, Communication Skills and Coun-selling Skills, Management of Asthma, Code ofPractice for Assisted Reproductive Technologies,Advocacy Document for prevention of Type IIDiabetes, and Management of Snake Bite.

I would like to high light some of the note-worthy activities of the Expert Committees in thepast year.

Communicable Diseases CommitteeCommunicable Diseases Committee has con-ducted Seminars on Avian Influenza, HIV/AIDSand Varicella.

Three Seminars on Tuberculosis have been held,in Colombo, in Matara in the Southern Provinceand Chilaw in the North Western Province, in

SRI LANKA MEDICAL ASSOCIATION

Suriyakanthie AMARASEKERA F.R.C.A*1

*1 President, Sri Lanka Medical Association, Colombo, Sri Lanka ([email protected]).

The Sri Lanka Medical Association (SLMA) isthe premier professional association in Sri Lanka,which brings together medical practitioners of allgrades and all branches of medicine. The SLMAis the oldest medical organization in Australasiaand South East Asia, with a proud history datingfrom 1887. At its inception it was called the CeylonBranch of the British Medical Association. In1951 it evolved into the Ceylon Medical Asso-ciation and in 1972, when Sri Lanka became aRepublic, the name was changed to Sri LankaMedical Association.

The office of the SLMA is situated at “WijeramaHouse” on Wijerama Mawata Colombo 7, abeautiful Victorian building, named after Dr.E.M. Wijerama, a distinguished past presidentof the SLMA who donated his residence to theassociation.

At present the total membership of the SLMAis 2,216 which is rather disappointing, consideringthat there are approximately 20,000 registeredmedical practitioners in Sri Lanka today.

The Annual Scientific Sessions are held inMarch every year and provides a forum for themembers to present their research and furthertheir professional and academic development.The 119th ASS were held from the 22nd to 25thMarch 2006 and was attended by 449 Delegates.The Chief Guest at the Sessions was Dame DiedrieHine, the President of the BMA and there were33 Foreign and 45 Local Guest speakers. Theprogram included 16 Symposia, 6 Plenary and10 Guest Lectures, 3 Workshops and 2 Orations.There were also 47 Free Papers and 36 PosterPresentations of original research done by ourmembers.

The lower key “Foundation Sessions” arescheduled to be held from 16th to 18th Novem-ber. The program will consist mainly of Symposiawith four Guest Lectures and two Orations

In addition to these, the educational programof the association includes Monthly Clinical

Country Report


Amarasekera S

collaboration with the National Program on Tuber-culosis and Control of Chest Diseases, to sensitizemedical staff of General and Base Hospitals.

A booklet on Congenital Syphilis has beenprinted and distributed to all primary health careinstitutions and is available on demand to anyhealth care personnel.

Committee on DrugsA booklet on Antibiotic Guidelines to advisemedical specialists, grade medical officers andfamily physicians on the appropriate use of anti-microbial agents is being prepared.

The Committee is also involved in developinga National Medicinal Drugs Policy in collabora-tion with the Ministry of Health and the WHO.

Continuing Professional DevelopmentCommitteeHaving successfully launched a pilot project intwo Districts outside Colombo, the committeeplans to conduct this program island wide. Stepsare being taken to raise the necessary funds fromthe Ministry of Health & WHO.

Ethics CommitteeEthical issues such as unethical broadcast drugadvertising, broadcast publicity by doctors, pre-vention of medical negligence, inadequate timespent on consultation, and updating the SLMADeclaration of Health which spells out thepatients rights were taken up for discussion anddisseminated to the membership by the monthlyNews Letter.

Health Care Waste ManagementThis committee has been successful in urging thegovernment to implement the National HealthCare Waste Policy that had been drawn up in 2001.

Health ManagementA Consultation on “Balancing the requirementand supply of Doctors” was conducted with thecollaboration of the WHO. The proceedings arenow in print and will act as a policy documentfor the Ministry of Health.

A Career guidance Seminar for young doctorswas conducted with participation by SpecialistColleges and Associations.

National Health PolicyThough there have been several health policy

documents, strategic frameworks, task forcedocuments and master plans, there has been afailure of implementation of accepted policiesin a systematic manner and poor monitoring ofprogress. Further, the SLMA recognises the factthat the health needs of a nation are in a continu-ous state of flux and needs frequent evaluationand reprioritization of policies and action as wasdemonstrated in the Tsunami disaster.

This committee has drawn up a Document inwhich the main thrust is on Equity of distributionof health care, inclusive of vulnerable groups,Internally Displaced Persons, and Victims ofDisaster, Investing more on preventive services,Enhancement of primary care leading to anational scheme of general practice and referralsystem, combating malnutrition, and efficientmanagement of human and financial resources.The document contains General DirectionalPolicies from which Operational Policies shouldflow and it has been presented to the Ministry ofHealth and all the Political Party Leaders.

MediaHigh quality Medical Journalism is being en-couraged by awarding the “Excellence in HealthJournalism” prizes to the best selected article inSinhala, Tamil and English, the three languagesused in Sri Lanka. A Seminar was also held forskills development in Health Science Communi-cation and Career Guidance Seminar for pro-spective Health and Science Journalists.

Medical EducationA CME Bulletin is published bimonthly and dis-tributed free of charge. The articles are presentedin the distant education format, and provides auseful update for primary care physicians andgeneral practitioners. Readers who return answersto the MCQ’s in the CME Bulletin are entitledto certificate of CME participation.

A Training of Trainers programme in Coun-selling Skills is being planned. It is intended toproduce a DVD of ideal counselling sessions, tobe given to trainers who in turn will use them totrain other doctors in their respective institutions.

Non Communicable DiseasesThe committee has published an advocacy docu-ment for the prevention of Type II Diabetes inSri Lanka.

There are an estimated 1M diabetics and


another 1M with pre diabetes in Sri Lanka andthis figure is expected to double by 2025. In orderto battle this pandemic a Diabetic Task Forcehas been set up The main activity of this commit-tee has been to increase the public awarenessof diabetes and prevention of diabetes andcardiovascular disease amongst school childrenand the youth of our country, through a series ofWorkshops, Seminars, Radio and TV programsand using the printed media, posters stickers,and slogans. The Health Education Bureau andthe National Institute of Education have been,involved to institute curriculum changes in schoolsand universities. The activities will culminatewith the “Diabetic Walk” which is scheduledfor the 19th of November at which children from25 schools in Colombo, University students,medically related professional organizations,diabetic patients from the diabetic associationof Sri Lanka and members of the public areexpected to participate.

Prevention of Motor Traffic AccidentsEfforts are being continued to legislate the wear-ing of seat belts. Implementation of fixing reflectorsin bicycle pedals and use of luminous paint orstickers to mark elevated areas and obstacleshas been done in various parts of the country incollaboration with the Police Department andthe Department of Motor Traffic.

Snake BiteThe Guidelines in management of Snake bitehave been made available in a CD.

Tobacco, Alcohol and Substance AbusePrevention of smoking has been promoted inthe School Science day program throughoutthe island with the collaboration of the Ministryof Health and the Sri Lanka Association forthe Advancement of Science.

Tsunami Disaster ReliefThe generous donation of the CMAAO hasenabled the SLMA to launch a joint CMAAO/SLMA Scholarship scheme for children whohave lost one or both parents in the Tsunamidisaster of 26th December 2004. We hope to usethe interest generated by investing the donationto generate sufficient funds to award 25 childrena sum of Rs. 2,000/—monthly till they completetheir education or leave school If funds permitwe hope to give an extra sum of money to pur-chase school books, uniforms and shoes at thebeginning of each year.

Women’s HealthA seminar on Domestic Violence was held in thecourse of this year. The journal of the SLMA theCeylon Medical Journal is published quarterlyby Elsevier. It has the distinction of being theonly Indexed Journal published in Sri Lanka.In keeping with the requirements laid down bythe International Committee of Medical JournalEditors, the SLMA is in the process of setting upa Sri Lanka Clinical Trials Registry.

The SLMA has also launched a web sitewww.slma.lk opening our doors to the world.



Amarasekera S


Research and Reviews

Differences between Japan and the U.S. in Testand Treatment Strategies in Pediatrics

JMAJ 50(2): 184–186, 2007

Takashi IGARASHI*1

AbstractThe differences between Japan and the U.S. regarding the treatment strategies in pediatrics are discussed. InJapan, serum CRP measurement is considered an important screening test for serious bacterial infection andevaluating the effectiveness of treatment, antibiotics are used frequently for bacterial gastrointestinal infection,and theophylline is administered often to children with bronchitis or bronchial asthma. Theophylline is also givento children with asthmatoid bronchitis. On the other hand, these tests and therapies are not frequntly used in theU.S. These are preferred in Japan based on the physicians’ experience and wishful thinking.

Key words Pediatrics in Japan and the U.S., CRP, Antibiotics, Bacterial gastrointestinal infection,Theophylline

it is generally understood as a marker for inflam-matory response. I am not going to argue againstthis understanding, but more exactly, it shouldbe considered as a protein that is called to actionas a result of tissue damage. When tissue damagebrings cells into direct contact with blood, the nu-clei and DNA in such cells are quickly opsonizedand processed in the reticuloendothelial system.Many Japanese physicians measure serum CRPas a marker for inflammatory response withoutrecognizing the meaning of the important bio-logical roles of CRP.

On the other hand, physicians in the U.S. do notmeasure CRP as frequently as in Japan. There areseveral reasons discouraging the measurement ofCRP in patients with infection. Even in the caseof bacterial infection, serum CRP is not elevatedmuch in the early stage of infection. A patientwith high fever due to bacterial brain abscessdoes not show elevated serum CRP because thepresence of the blood-brain barrier prevents thetransmission of the CRP production stimulus tothe liver. Serum CRP may be elevated even in thecase of viral infection, because EB virus, adeno-

*1 Professor and Chairperson, Pediatrics, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan ([email protected]).This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol.134, No.12, 2006,pages 2391–2393).

Introduction

Each country has a distinct style in the practiceof health care and medical sciences reflecting thetradition of the country. Japan has come throughmore than 130 years since the introduction ofWestern medicine and experienced strong influ-ence of the U.S. medicine after the World War II.Despite this fact, there are several importantdifferences between Japan and the U.S. in thetest and treatment policies regarding the clinicalfindings and diseases in children.

The Use of Serum CRP

The first difference is the inclination of Japanesepediatricians toward the use of serum CRP (C-reactive protein) measurement in estimating thecause and evaluating the severity of infections.1

CRP was first recognized as the protein producedin the liver binded to and precipitated pneumoccalC-polysaccharide.

While CRP has various physiological functions,


virus, and some other viruses cause tissue dam-age. Hence, serum CRP by itself is not a definitivemeans for discriminating bacterial infection fromviral infection. Because of these reasons, Ameri-can physicians use blood cultures more frequentlythan Japanese physicians when serious bacterialinfection is suspected, in particular when thefocus of infection is not identified. This attitudeof American physicians seems to reflect theirphilosophy of placing more emphasis on evidence.Recently, serum CRP is measured in the U.S.for research purposes. For example, obesity isconsidered a condition involving chronic inflam-mation, and this theory is supported by the smallincrease in blood CRP in obese persons.

The Use of Antibiotics for BacterialGastroenteritis

The second peculiarity of Japanese practice is theuse of antibiotics for bacterial gastroenteritis.

All physicians in Japan and in the U.S. knowthat enterohemorrhagic E. coli such as O157:H7is the causative agent of bacterial gastroenteritisoccurring frequently in the period from Juneto September. When a child is presented withdiarrhea followed by bloody stool in summer,Japanese physicians use an antibiotic therapytypically with fosfomycin after a stool culture isdone. A report from Japan demonstrated that theuse of fosfomycin within 3 days after the onsetof diarrhea was effective for the prevention ofhemolytic uremic syndrome (HUS) secondary toenterohemorrhagic E. coli infection in a studycomparing the groups with and without the useof fosfomycin. However, American physiciansdo not use antibiotics except for severe cases.To begin with, fosfomycin is not commerciallyavailable in the U.S. It should be noted that evenin Japan, antibiotics are not given to patientswith gastroenteritis, if Salmonella is consideredto be the causative bacteria.

It is generally believed in the U.S. that there isno evidence that the use of antibiotics improvesthe course of bacterial gastroenteritis. On the finalday of the international conference on verotoxin-producing E. coli (VTEC) in Washington DC, 1999,bacteriologists and pediatricians form Japan andthe U.S. held a one-day conference sponsoredby the Ministry of Health and Welfare. Thisconference only underscored the disagreementof opinions concerning the use of antibiotics.

Bacteriologists from Japan alone argued for theusefulness of antibiotics. The report of the effect-iveness of early fosfomycin therapy has not beena subject of serious consideration in the U.S.,because it was not a controlled study.

Furthermore, the common opinion of pedia-tricians in the U.S. is represented by the reportfrom Seattle2 claiming that the use of antibioticsincreases the risk of HUS. Although the result ofthis study was statistically significant and shouldbe respected, it should be interpreted with cautionbecause the study might have been biased by twofacts: the patients who received antibiotics weremuch fewer than those who did not and the HUSoccurrence rate was much higher than that inJapan. We need to see some more evidence beforeconcluding that antibiotics are detrimental, butexperience in Japan has also shown that the earlyuse of antibiotics cannot always prevent severeHUS. When Verotoxin has been absorbed fromthe small intestines before the onset of diarrheain VTEC infection, it is impossible to preventencephalopathy and nephropathy by the earlyuse of highly bactericidal antibiotics.

The Use of Theophylline for Bronchitisand Bronchial Asthma

The third point is the use of theophylline forbronchitis and bronchial asthma.3

Formerly in the U.S., the round-the-clock (RTC)therapy with theophylline was used commonlyfor the prevention of acute bronchial asthmain children, but this therapy is rarely used at thepresent. Theophylline is also going out of usefor the treatment of acute bronchial asthma. Thischange reflects the facts that the effectivenessof inhaled steroids for the prevention of acutebronchial asthma was proved, several new drugsfor the treatment of acute bronchial asthma weredeveloped, and the risk of theophylline intoxica-tion has become widely known to people. As aresult, the convenient kit for the bedside measure-ment of blood theophylline is no longer producedin the U.S. In the U.S., relatively inexpensivetheophylline is regarded as an antiasthmatic drugfor developing countries.

In Japan, the 2005 version of the guidelines forthe treatment of bronchial asthma (“Japanese Pedi-atric Guideline for the Treatment and Managementof Asthma 2005” [JPGL 2005]) was published bythe Japanese Society of Pediatric Allergy and

DIFFERENCES BETWEEN JAPAN AND THE U.S. IN TEST AND TREATMENT STRATEGIES IN PEDIATRICS


Clinical Immunology. The new version advisesincreased caution regarding the use of theophyl-line for the treatment of acute bronchial asthma.However, theophylline is still used in Japan, oftenon an outpatient basis, not only for bronchialasthma but also for bronchiolitis, bronchitis, andasthmatoid bronchitis in children.

The margin between the therapeutic rangeand the toxic range of theophylline is small, andtheophylline intoxication may occur unless theblood level is monitored. There also have beencases of younger children developing so-calledtheophylline-associated convulsions, in whichserious convulsions take place even when theblood level is lower than the toxic range. Convul-sions due to theophylline intoxication and convul-sions associated with the nontoxic blood levelsof theophylline are often refractory, respondingpoorly to anticonvulsants and persisting for along time. Such convulsions frequently leave after-effects such as central nervous system (CNS)damages.

Recently, there have been an increasing num-ber of lawsuits in Japan concerning the cases inwhich high blood levels of theophylline causedconvulsions and CNS aftereffects. In most cases,the disputes have been settled through reconcili-ation. Japanese pediatricians should recognizethe fact that the court often acknowledges thefault on the side of medical providers.

The decreased rate of theophylline metabol-ism during fever may cause the elevation of theblood level to reach the toxic range. To preventCNS damages due to theophylline intoxicationand those due to theophylline-associated enceph-alopathy, pediatricians should basically avoid theuse of theophylline for bronchiolitis, bronchitis,and asthmatoid bronchitis in children under theage of 5. If theophylline must be prescribed, par-ents should be fully informed about potentialside effects of theophylline and consent shouldbe obtained. Revision of the current indicationsfor theophylline is also needed regarding the factthat they include asthmatoid bronchitis.

References

1. Papaevangelou V, Papassotrioul I, Sakou I, et al. Evaluation ofa quick test for C-reactive protein in a pediatric Emergencydepartment. Scand J Clin Lab Invest. 2006;66:717–721.

2. Chandler WL, Jelacic S, Boster D, et al. Prothrombotic coagula-tion abnormalities preceding the hemolytic uremic syndrome.

New Engl J Med. 2002;346:23–32.3. Seddon P, Bara A, Ducharme FM, Lasserson TJ. Oral xanthines

as maintenance treatment for asthma in children. CochraneDatabase Sys Rev. 2006 Jan 25; CD002885

Igarashi T



Overview of the Aizuwakamatsu MedicalAssociation

JMAJ 50(2): 187–189, 2007

Yuzo TAKAYA*1

monthly or semimonthly meetings for continuingmedical education. Although the Ekiyuukai wasa voluntary organization, it served as a body todecide the activities of the association.

Following the promulgation of the new con-stitution of Japan, the Aizuwakamatsu MedicalAssociation was reorganized as a corporate bodyon November 1, 1947 in concert with other medi-cal associations in Japan.

Aizu Is Closely United

There are four local medical associations in theAizu area: Aizuwakamatsu, Kitakata, Ryonuma-gun, and Minamiaizu-gun. A liaison councilcombining these medical associations was setup within this author’s generation. The councilmeets whenever needed to discuss whatevertopics necessary. Respecting the opinions ofneighboring medical associations, the councilunifies their opinions and communicates them tothe prefectural medical association to facilitatethe exchange of information.

Aizuwakamatsu City is in the Aizu region, thewestern part of Fukushima Prefecture. The cityis renowned for its Tsurugajo Castle, besiegedduring the Boshin Civil War in 1868. To the eastof the city are magnificent Bandai Mountainand Inawashiro Lake, the birthplace of the out-standing medical scientist, Hideyo Noguchi. Thenatural beauty of the Urabandai area is alsonoteworthy. The city abounds with cultural assets,such as the historically important remains ofEnichiji Temple founded by the great priest,Tokuichi, and Shojoji Temple housing invaluableBuddhist statues.

“You must not do what you must not do”has long been the spirit of Aizu, which strictlygoverned the acts of young clansmen attendingthe Nisshinkan school. Adhering to this spirit,Masayoshi Ito (1913–1994), a statesman fromthis area, refused to take office as prime minister,when he considered the governing party’s reformpolicy as useless as “changing the cover of a bookwithout changing the content.” The climate andculture of the Aizu region as glimpsed here hashad considerable influence over the origin anddevelopment of the Aizuwakamatsu MedicalAssociation.

Establishment of the MedicalAssociation

Like most local medical associations in Japan, theAizuwakamatsu Medical Association was firstestablished on April 4, 1906 under the MedicalPractitioners Law (Law No. 47). Its antecedent,called the Ekiyuukai, had been formed by doc-tors in Aizuwakamatsu in 1886. The doctors held

*1 Vice President, Fukushima Medical Association, Aizuwakamatsu, Japan ([email protected]).This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol.134, No.10, 2006,pages 1952–1953).

Tokyo

Fukushima

Pop. 2.1mil.Area 13,800km2


Hospital-Clinic, Clinic-Clinic, andHospital-Hospital Collaboration

In Aizuwakamatsu City, there are two hospitalswith more than 1,000 beds, a prefectural hospitalwith 401 beds, and a private hospital with 435beds (including a psychiatric ward). The age ofcompetition among hospitals has ended, andeach hospital is now offering its own distinctivefeatures, striving to strengthen cooperation withclinics to encourage referrals from clinics tohospitals and from hospitals to clinics.

The driving force behind this movement isprovided by the presence of Hatsukakai, a groupof doctors from all parts of Aizu which wasformed in January 1983 under the motto of “Noacademic cliques, no seniority. All that countsis personality and specialty.” Starting from amembership of eight doctors, this group grad-ually attracted more and more doctors, not onlygeneral practitioners but also department chiefsand managers of hospitals. Today, 22 years afterits establishment, it has as many as 136 members.We are confident that the relationship amongdirectly acquainted members has been effectivein removing much of the hesitation in writingreferral letters. The monthly meeting of generalpractitioners and hospital doctors, consisting oflectures and presentations followed by a recep-tion, has helped the development of hospital-clinic, clinic-clinic, and hospital-hospital collab-oration. This group has been instrumental inimplementing model projects for hospital-cliniccollaboration, the family doctor system, andregional health care collaboration promoted bythe Japan Medical Association. Every memberof the medical associations in Aizu is directlyexperiencing the importance of hospital-cliniccollaboration and its role in the enrichment ofcommunity health care.

The School Doctor and PreschoolDoctor Committee

In former days, the assignment of school doctorswas hereditary in the sense that each positionwas handed down from the predecessor to thesuccessor, but a committee now appoints schooldoctors impartially, and the new system has wonthe confidence of members.

Meetings of school doctors and nurse teachers

and seminars for preschool doctors and preschoolteachers are held annually. With the participationof schoolmasters, dentists, and pharmacists, theseactivities are contributing to the improvement ofthe health of children and students. The seminarsof preschool doctors and preschool teachersare held to address common problems such asinfection control measures (e.g., when studentswith infection should refrain from attendingschool and when they may return to school).Because of this, a large proportion of preschoolteachers attend these meetings, and we have hadto limit the number of participants from eachpreschool.

Holiday and Nighttime EmergencyMedical Services

The shortage of pediatricians is a serious prob-lem nationwide. An emergency child patient takento the emergency room of a large hospital is notlikely to be treated by a specialist pediatrician.Although citizens need specialist pediatricians,this need is hard to satisfy. Furthermore, theconcentration of pediatricians in university hos-pitals is aggravating the shortage of pediatriciansespecially at clinics. Those working in hospitalsare fatigued from overwork.

The Aizuwakamatsu Medical Association hasreorganized holiday and nighttime emergencymedical services to include pediatrics, in additionto internal medicine and surgery, so that threegroups of doctors are available on holidays, al-though the number of doctors is still insufficient.Nighttime emergency centers are staffed withpediatricians on holidays (Sundays and publicholidays) and with doctors trained in pediatricson weekdays. Two years from the introduction ofthis system, the number of pediatric patients isincreasing steadily, reflecting the growing aware-ness among citizens.

Promotion of Maternal and Child Health

We have been making efforts to improve socialservices and negotiating with relevant authoritiesto make changes in response to the needs ofcitizens, such as the in-kind payment of medicalbenefits for infants, the raising of the age limit tosix, and the direct payment of the Lump SumBirth Allowance from the municipal governmentto hospitals. While wide-area standardization of

Takaya Y


individual (as opposed to mass) vaccination hasnot been implemented on a prefectural basis, weare calling for the cooperation of municipalitiesto achieve standardization, at least in the Aizuregion.

Publication of the Journal of theAizuwakamatsu Medical Association

The Journal of the Aizuwakamatsu MedicalAssociation has been issued since April 1965. Asof 2006, 500 journal numbers have been issuedwithout any interruption. Under the motto of“Written by all, read by all” the journal has beenpublished by the joint efforts of the four medicalassociations, and the monthly editorial meetingsprovide wonderful opportunities for interaction.

The Aizu Society of Medicine

The Aizu Society of Medicine evolved from astudy group formed by members of medical asso-ciations in the Aizu region. The first lecture meet-

OVERVIEW OF THE AIZUWAKAMATSU MEDICAL ASSOCIATION

ing in 1933 was held to commemorate Dr. HideyoNoguchi, who passed on a few years before. Sincethen, a lecture meeting inviting two distinguishedspeakers from various fields has been held everyyear, and is attended by a large audience, of notonly practitioners and hospital doctors but alsodentists, pharmacists, and nurses.

Conclusion

The most serious problem at present is relatedto prefectural hospitals, which have become in-dependent corporations under Local Public En-terprise Law and have a tremendous cumulativedeficit. They must be revived through the processof closing down and consolidation, and finding away to survive in the regional community as gen-eral hospitals. All members of the AizuwakamatsuMedical Association are working together towardthe enrichment and development of regionalhealth care, striving to be doctors who are loved,trusted, and respected by citizens.



Perinatal Care in Crisis: Action required now

JMAJ 50(2): 190–192, 2007

Isamu ISHIWATA*1

according to function and the establishmentof inter-institution cooperation and networksbased on the classification)

3. Submission of a proposal for the creation ofan extensive system of cooperation betweengovernment bodies, across administrativedistrict boundaries (2001)

4. Establishment of a “Study Group on Com-prehensively Improving the Perinatal CareSystem” within the Ibaraki Prefectural Gov-ernment Health and Welfare Department (in2003, attended by the President of the IbarakiAssociation of Obstetricians & Gynecologists)

5. Establishment of the “Ibaraki PrefecturePerinatal Care Council” within the IbarakiPrefectural Government Health and WelfareDepartment (in 2005, attended by the Vice-President of the Ibaraki Medical Associationand the President of the Ibaraki Associationof Obstetricians & Gynecologists)

6. Submission of a proposal regarding the issueof nurses performing vaginal examinations(2003)

7. Survey of actual conditions for medical insti-tutions providing obstetrics and gynecological

A marked decline in the number of perinatal(birth) care facilities nationwide is creatinganxiety amongst local residents and becoming asocial issue in Japan. The Japanese governmenthas set the goal of assuring safe and comfortablepregnancy and birth as an aim of its “HealthyParents and Children 21” campaign. With the rapiddecrease in the number of perinatal facilities,however, this government aim is far from beingrealized, creating anxiety amongst citizens andcasting a dark shadow over national efforts toreverse the declining birthrate.

Perinatal medicine is facing a critical situation,but the severity of the crisis varies from region toregion. This is not a problem that can be resolvedby the Japan Association of Obstetricians &Gynecologists alone, but must be addressedcomprehensively in all medical fields in conjunc-tion with emergency medical care.

Together with the Ibaraki Association ofObstetricians & Gynecologists and the IbarakiPediatricians’ Association, the Ibaraki MedicalAssociation not only senses impending crisis withthe current situation threatening the collapse ofperinatal care, but also is working to encouragethe government to implement reform.

Ibaraki Medical Association EffortsRegarding Perinatal Care

1. Twice-yearly meetings held with the IbarakiPrefectural Government Health and WelfareDepartment for open and frank exchange ofopinions.

2. Realization in 1983 of the perinatal careregionalization concept (the improvement ofregional medical care through the classificationof medical institutions from primary to tertiary

*1 Executive Board Member in charge of Maternal and Child Health, Ibaraki Medical Association, Mito, Japan ([email protected]).This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol.134, No.11, 2006,pages 2186–2187).

Ibaraki

Pop. 3mil.Area 6,100km2

Tokyo


care (2005)8. Explanation of the critical situation facing

perinatal care to the Ibaraki Prefecture PressClub (2005)

9. Submission of petitions to the Governor ofIbaraki Prefecture requesting the creation ofan environment enabling certain nurses toperform vaginal examinations, conduct of asurvey of the midwife shortage, increasing thenumber of trained midwives, and securing ofperinatal (birth) facilities in the north of theprefecture (there were only two such facilitiesin the broad northern region which comprisesone-third of the prefecture’s area) (2005)

10. Informal meeting held with Ibaraki Prefec-ture’s Assembly members responsible forwelfare (2005)

11. The Governor decided that in 2006 the capa-city of prefectural midwife training facilitieswould be increased to 15 students (7 maturestudents) and would be further raised to 20in 2007.

Current Situation in Ibaraki Prefecture

Over the past 10 years and in particular in thepast 3 years, Ibaraki Prefecture has experienceda marked drop in the number of perinatal (birth)facilities. Compared with a 2.8% decrease in thebirthrate in the 10 years between 1995 (27,517births) to 2004 (26,751 births), there has beena decrease of 22% in the number of perinatalfacilities (97 to 76) over the same period—a muchhigher figure than the national attrition rate.1. The average age of obstetricians/gynecologists

in general practice is over 64 years old and,with their successors avoiding specializationin obstetrics/gynecology, they have little choicebut to eventually close their practices.

2. Twice, in 2002 and 2004, following notificationissued by the Nursing Division, Health PolicyBureau, Ministry of Health and Welfare (pro-hibition of vaginal examinations by nursesunder the direction of doctors at medical careinstitutions), birth services at perinatal (birth)care facilities with insufficient midwives onstaff were withdrawn.

3. With the withdrawal of obstetricians gyneco-logists in postgraduate clinical training fromuniversity-affiliated hospitals, one after theother medical care facilities have had to closedown birth services. The number of hospitals

providing birth services has declined (37 hospi-tals in Ibaraki Prefecture providing birth ser-vices in 1995; by 2004 the figure had droppedto 32. In 2005 another 4 and in 2006 another2 hospitals planned to ceased birth services).

4. In 30 years, the overall number of doctors hasincreased by 196% but the number of obste-tricians/gynecologists has fallen to 82%.

5. Looking at where midwives are employed inIbaraki Prefecture, 219 work in the obstetrics/gynecology departments of hospitals and 70work at birth clinics. Of the Ibaraki-trainedmidwives who graduated in the three yearsfrom 2001 to 2003, 24 found employment athospitals within Ibaraki Prefecture, 20 foundemployment at hospitals in other prefectures,and none found employment at clinics. Clearly,if nothing continues to be done about the issueof nurses performing vaginal examinations,the situation will become very grave indeed.The Ministry of Health, Labour and Welfare

“Committee to Consider the Health Nurse,Midwife, and Nurse Law with the Aim of Assur-ing Medical Safety” (attended by the President ofthe Ibaraki Association of Obstetricians & Gyne-cologists) debated “The Duties of Nurses inObstetrics”, but no resolution was reached onwhether or not to lift the ban on nurses perform-ing partial vaginal examinations (measurementof cervical dilation and/or engagement of baby’shead), and it was decided to continue to investi-gate this issue.

Future Efforts

What we need to do right now is work from thestandpoint of local residents to create as quicklyas possible an environment that enables womenin regional areas to give birth safely and withoutanxiety in their own communities. This means, atthe very least, ensuring that the number of peri-natal (birth) facilities does not decrease furtherat the prefectural level. To enable this, it is imper-ative that government approval be given to a sys-tem of nurse cooperation in pelvic examinationsunder the guidance and responsibility of doctors(experienced nurses performing measurementsof cervical dilation and/or engagement of baby’shead) at perinatal (birth) facilities where there isa shortage of midwives, at least until sufficientmidwife numbers can be secured.

With regard to improvement of the perinatal

PERINATAL CARE IN CRISIS: ACTION REQUIRED NOW


medical care system, the Ibaraki Medical Asso-ciation as a whole is working to encourage thegovernment to implement changes. In order tosecure a supply of doctors in regional areas, itis imperative that (1) regional quotas be estab-lished in medical school examinations (alreadyestablished in such medical schools as SapporoMed. Univ., Shiga Univ. of Med. Science, WakayamaMed. College, Fukushima Med. College, SagaMed. School, and Shinshu Univ., School of Med.);(2) a scholarship system be introduced for medi-cal students aiming to specialize in the fields inwhich there is already a shortage of doctors thatis expected to continue in the future—obstetrics/gynecology, pediatrics, and anesthesiology; and(3) places at midwife training facilities be increasedand mature student quotas be established.

Moreover, it is vital that Ibaraki prefectureresidents understand the issues facing obstetri-cal/gynecological care. To ensure the happinessof the residents of our prefecture, the IbarakiMedical Association intends to focus on activitiesfrom the standpoint of residents, and on beingan open, familiar presence from which residentsfeel they can seek advice. In the past, we haveheld numerous public forums, and in 2004 thisAssociation took the initiative in establishingwith other medical care-related organizations theIbaraki Council for the Promotion of MedicalCare with that aim of protecting and preserving

medical care. On December 13, 2005 a publicforum was held as part of the “Ibaraki Citizen’sMeeting to Protect the Universal Health Insur-ance System: Right Now, Your Life Expectancyis about to be Shortened”.

The number of perinatal (birth) care facilitieshas not declined because of a reduction in thenumber of hospitals but because a decrease in thenumber of obstetricians and gynecologists andan absolute shortage of midwives has forced suchfacilities to close. The number of obstetriciansand gynecologists has not decreased becausethe number of births has decreased; if workingconditions were improved, medical fees com-mensurate with work assured, an environmentcreated in which trouble would rarely occur(such as introduction of a no-fault compensationprogram), and young doctors shown in concreteterms the appeal of obstetrics/gynecology, thenthe number of obstetricians and gynecologistsis sure to increase. Efforts by medical associ-ations to encourage the government to implementreforms will become more and more importantin future. Today, amidst resident’s anxiety anddissatisfaction with perinatal care as it stands, theIbaraki Medical Association intends to strive toexplain to residents the current situation facingperinatal medicine and gain their understandingas well as to work together with residents towardsimprovement.

Ishiwata I



Message from the American Medical Association

JMAJ 50(2): 193–194, 2007

William G. PLESTED III*1

mins and other economic goods and services thatproduce health living.

From a public policy point of view, all of thisgood news is a mixed blessing. Gallons of ink andtons of newsprint have been expended in publicdiscussion over the “graying” of society.

The debate centers on a totally private systemof health care versus a totally public one. This, tome, is a false dichotomy, faulty logic which is an“either-or” approach when, in reality, the success-ful model appears to be “both.” The AmericanMedical Association continues to work towardmaking public-private partnership become a moreand more effective solution.

Health insurance is a case in point. Federalresources pay 45% of the U.S. healthcare bill.Private insurance picks up the rest. Most recently,we are working out a public-private solution tothe problems of uninsured Americans, lookingat ways of making insurance affordable for thosewith the means to buy their own coverage, andways of providing government funds to thosewithout the means.

And, as is true in Japan as well as the UnitedStates, too many citizens each day make un-healthy lifestyle choices that add up to enormouscosts to society at large. A survey of estimates ofthe health care costs, lost wages, lost productivity,lost investment and other societal costs providesthis grim picture:

Violence in America drains $300 billion fromthe economy each year;Drug and alcohol abuse, $246 billion;Traffic accidents, $150 billion;Work-related accidents, $171 billion;Tobacco, $202 billion;Obesity, $102 billion.And, there are no estimates readily available

for teen pregnancy, sexually transmitted diseaseand suicides, though intuitively one understands

It is an honor and a distinct privilege to writesome of my thoughts for your consideration.

The profession of medicine is truly the firstglobal profession. Bacteria and viruses respectno national boundaries. Epidemics do not requirepassports. And treatments that are effective inOsaka, Japan, are equally effective in Omaha,Nebraska.

Today, there are two socio-economic tsunamiscommon to both our professional lives and ourprofession’s future. I’m talking about demographicand technologic forces that are bearing down onboth Japan and the United States. And both areproducts of our past successes.

The fact that life expectancy for your 127.5million residents is 81.25 and for our 300 millionis 77.8 years underscores the fact that we are allliving longer. The fact that the worldwide life ex-pectancy is but 64.77 years points up the successesour profession has bestowed on our respectivenations.

Medicine in both countries has brought moreyears of life. But medicine in both countries hasbrought more life to years, not only keepingpeople alive but giving them previously unheardof good health.

Free from the ravages of old age, our seniorcitizens have a literal second chance to enjoyfamily and friends, to travel, to engage in allmanner of activities their grandparents neverknew, had they lived that long.

The twin economic miracles in both ourcountries means your average resident’s shareof Gross Domestic Product is $33,100 (US) andours, $43,500—again an economic statistic with-out historic precedent. The worldwide average is$10,000. Our economic success, in turn, meansour neighbors have more funds with which topurchase a healthy lifestyle—not only medicalcare when needed but also the foodstuffs, vita-

*1 President, American Medical Association, Chicago, USA ([email protected]).


there are significant costs involved.Now, these estimates come from a variety of

sources using a variety of methods to calculatethe amounts. Neither the AMA nor I can vouchfor their accuracy or validity. But the enormity ofthe issue is obvious even before factoring in theheartbreak and disruption of countless lives.

I would be interested in learning if compa-rable estimates are available in Japan. I suspectthe relative enormity of the problems are as greatfor you as they are for us in America.

The problems we wrestle with the United Statesare, I believe, common to every country in the21st century.

Add to these problems the threats of terrorism,of pandemics and of severe weather and natural

Plested WG

disasters and we have to conclude the globe issmall but the common problems, enormous.

In the past, physicians in Japan and the UnitedStates have forged incalculable numbers of links,of shared professional concerns and solutions.It is even more vital in the 21st century that wereinforce those bonds, look for new and moreproductive public-private solutions and extendthe breadth and depth of research.

We need to do so not so much from profes-sional interest, though that would be reasonenough. Rather, we need to do so for our patients,the men, women and children who look to us forhealing, for health, for hope.

I, for one, look forward to closer, richer,deeper collaboration in the days to come.



Medical Cooperationwith Indonesia

Banguntapan 3rd Health Center, Yogyakarata, Indonesia

The following is a Congratulatory Messagedelivered by Dr. Masami Ishii, Executive BoardMember of the Japan Medical Association andSecretary General of CMAAO on the Openingand Endowment Ceremony of the Banguntapan3rd Health Center, Yogyakarata, Indonesia onMarch 10, 2007. This health center was financiallysupported by the JMA.

Greetings

Distinguished guests, ladies and gentlemen,

On behalf of the Japan Medical Association, it is an honor for me to say a few words on theoccasion of the Opening and Endowment Ceremony for the Banguntapan 3rd Health Center.

Let me begin by offering my deepest sympathies for the victims of the Central Java Earth-quake that occurred in May 2006 as well as expressing my deepest condolences to the familiesand friends of those who were lost. I would also like to express my heartfelt respect andadmiration for all those who were able to make such strong efforts towards recovery afterexperiencing such devastation.

Directly following the Central Java Earthquake last year, the Japan Medical Associationbegan to collect donations and quite a lot of donations were received from local medicalassociations throughout Japan. Of the total amount collected, 36.6 million yen, or about 300thousand US dollars was provided to support the activities of AMDA (Association of MedicalDoctors of Asia) and this Health Center was constructed based on this donation.

Japan is one of the most earthquake-prone countries in the world. Most notably, more than6,000 lives were lost in the Great Hanshin-Awaji Earthquake of 1995, and all the members ofJMA had been driven to extend their utmost efforts from its humanitarian standpoint to helpthe victims damaged by the Java Central Earthquake. As an academic organization, we believeone mission of the Japan Medical Association is to contribute to the advancement of medicine,and in particular that we should strive to improve health care irrespective of national bound-aries or race, which is stated in the Declaration of Geneva of the World Medical Association.The construction of this Health Center with the cooperation of the AMDA reflects thisphilosophy of the JMA as well as the enthusiasm of the local people here.

This center is exchanging hands today, and it is my great hope that it will be used to greateffect. We have asked the Indonesian Medical Association to provide technical advice asrequired, as we would be grateful for support to enable the stable operation of the center.

I hope from my heart that the construction of this Health Center will lead to furtherimprovement and promotion of health of the people in Indonesia. I also strongly believe thatour cooperative activities devoted to the establishment of this center will ensure much deeperfriendship between our two nations in the future.

Thank you very much.


Appreciation of the JMA JournalOn the occasion of the publication of the JMAJournal Vol.50 No.1, which features the 1st WMAAsian-Pacific Regional Conference held in Tokyoon September, 2007, I received congratulatoryletters from Dr. Yank Coble, Chair of CaringPhysicians of the World Initiative, and Dr. OtmarKloiber, Secretary General of the WMA, express-ing their appreciation for the efforts of the JMAin supplying Japanese and overseas physicianswith their own high-class journal for 50 years andproducing an excellent proceedings of the WMAmeeting, and also saying that this journal volumewill serve as a very high standard for the future.

It is a great honor for me to receive such wordsof encouragement. To improve the contents ofthis journal, I always welcome the frank opinionsfrom our readers.

Publication of a Japanese version of the“Medical Ethics Manual” of the WMAThe manual of the WMA was published in 2005and has been translated into 12 languages. TheJMA has also made efforts to publish a Japaneseversion which will soon be ready for distributionto all JMA members—around 160,000 in total.This version will be also presented to all themedical students in Japan. The publication of thismanual is sure to be highly appreciated becauseit presents a kind of global standard for medicalethics with which healthcare professionals canlearn how to cope with any problems which mayarise in daily clinical settings.

The 27th Medical Congress of JapanThe Japanese Association of Medical Sciencesheld its General Congress in Osaka in early Aprilof this year. More than 25,000 participants regis-tered for this congress and the total number ofattendees at the event reached about 200,000.During the congress period, the Korean MedicalAssociation delegation visited this big meetingto gain information about its organizational andlogistical aspects. The JMA officers and KMA dele-gation exchanged opinions about health problemsand enjoyed the cherry blossoms in full bloom.

Masami ISHII, Secretary General, CMAAO. Executive BoardMember, Japan Medical Association, Tokyo, Japan([email protected]).

Visiting IndonesiaI visited Indonesia in early March of this year.As seen on page 195, the JMA made a financialdonation to Indonesia to assist in the country’srecovery from the tsunami it suffered in 2006.The money was collected from JMA members.Using this donation, the JMA built a healthcenter near Yogyakarta on Java Island throughthe AMDA (Association of Medical Doctors inAsia) in early March of this year.

During this visit I met with Dr. Idris and Dr.Oetama, President and International Director, re-spectively, of the Indonesian Medical Association(IMA) as well as officers of the Health Ministry.It was also agreed between the IMA and JMAthat the IMA would provide technical assistancefor the activities of the health center. The JMAhighly appreciates this offer of cooperation.

During my stay in Indonesia, I also heardabout a “lotus land” which is said to exist some-where in Indonesia, with moderate temperaturesall the year round and an abundance of all kindsof foods including rice, fruits and vegetables. Afascinating country!

My overall impression was that the first steptoward raising the basic level of healthcare in Indo-nesia as a whole is the effective use of abundantnatural resources. I hope that the joint efforts ofthe Indonesian Medical Association and otherhealth related public organizations will contrib-ute to the further development of Indonesia.

Discussion at the office of the Indonesian Medical Associ-ation. From Left: President Idris and Dr. Oetama of theIMA. From right: Dr. Ishii, JMA and Dr. Suganami, Directorof AMDA.

From the Editor’s Desk

JMA—President’s Speech JMA—Policies

Documents

Transcript of JMA—President’s Speech JMA—Policies