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Þ Þ Þ Þ Þ No7 No7 No7 No7 Ü Ü Ü Ü Ü July 2010
I- Lord Darzi’s interview and a comment from Dr. Mihran Nazaretyan
Dr. Mihran Nazaretyan, Armenia’s first minister of health contacted AMIC after reading the special issue of Info-Flash (May 2010), which had reprinted an interview with Lord Ara Darzi, which interested Dr. Nazaretyan very much. Info-Flash is reproducing below in its entirety the message received from Mr. Mihran Nazaretyan.
Some personal comments on the January 2010 interview made by Dr. Sonia Wartan, member of the "Great Britain Armenian Medical Association," with Lord Ara Darzi, and also attended by Dr. Seda Boghossian-Tighe and Mr. Bedo Yeghiayan.
Dear colleagues,
It was my lucky privilege to receive A SPECIAL AMIC NEWSLETTER provided by INFO-FLASH and reproducing the full text of an interview made with Lord Ara Darzi earlier this year.
As the first minister of health of the independent Republic of Armenia (1990-1991), I found this interview quite an interesting piece of information and knowledge, provided by the honourable interviewee, Lord Ara Darzi.
His vision and approaches to the common qualities and performance of health care systems within or out of the NHS are consistent with global trends in the health care system reformation, no matter how much money countries spend on health per person annually ($ US 20 to $120 in most of the developing and less developed countries to around $ US 2,500 to $ 3,500 in developed European countries and reaching up to $ US 6,500 in the USA. Source: OECD Health Data, 2008.)
Here I’d like to share some of my thoughts with the honourable interviewee since I have found his vision and concerns similar to mine:
1. I agree completely with the accentuated vision and concept of primary health care as well as, not less importantly, community care, as a cornerstone of any improvement in health, providing citizens equal access to health values, social justice, dignity, recognition and equal opportunities.
Undoubtedly, any other choices jeopardize lives of human beings and would lead to undesirable consequences and factual discrimination.
Just think about this:
• A child born today in Armenia is 5 times more likely to die before reaching one year of age and 4.7 times more likely to die before reaching the age of 5 years than a child born in the United Kingdom. If a child reaches his/her 5th birthday, he/she looks forward to a life in which he/she has a 2.6 times greater risk of contracting tuberculosis than his/her British counterpart and a mother’s likelihood of dying during pregnancy or childbirth is 4.4 times greater
*These differences we estimated based on Millennium Indicators database country profiles (UN Statistics Division: http://unstats.un.org/unsd/) – Dr. Mihran Nazaretyan
2. Dr. Darzi mentioned two important points. Firstly the function of polyclinics (that is health system institutions developed during the years when the Semashko model of health care organization was dominant in Armenia) used to share these functions with an approximate ratio of 80% of treatment services delivery and about 20% of diagnostics (most of the diagnosis, especially in complicated cases were formulated in hospital settings).
Secondly, the referral or gate-keeping function of the polyclinics was not sufficiently recognized and/or appreciated by the majority of Armenian polyclinic general practitioners.
With these two points in mind, I believe we are missing a third, not less important function, that is the "educational" mission of the polyclinics and GPs on how to protect health, live longer and enjoy a healthy life.
3. Dr. Darzi has also indicated that the statement "High Quality of Care for All" is of course a bold one, may even be idealistic, but as the Japanese say, "… the process of trying to attain quality is more important than stating you’ve reached it!".
Given current Armenian situation, with high level of economic and social corruption, mushrooming highly monopolized health care services, with catastrophic user cost, certain geographic locations having better medical care, lack of equality of access to care (only 25% of those seeking medical care in the poorest quintile receive it, compared with 51% of those in the highest income quintile; Source: World Bank 2003 (Public Expenditure Review), and where households bear the main burden of expenditures on health, the probability of delivering quality and safe services, even with spending in 2008 about 69% of the state health budget on primary care, looks pretty problematic.
One should also consider that the cost of quality of care includes also the cost of medical errors and related spending. This is a special issue which is not yet articulated at all and/or included in the national health accounts.
These are my comments.
Thank you.
I am Dr. Mihran Nazaretyan, Dr.S.M., and PhD (Hematology), M.P.H.A., former Director of the School of Health Management and Administration at the AUA (SHCMA), guest student of Honorable Sir Archie Cochrane in 1980, Cardiff, Wales, visiting professor of medical universities in CIS countries, the Imperial College London consultant-expert in health management and administration project in Bosnia and Herzegovina in 2004, currently Medical Director, Armenian Bone Marrow Donor Registry, Yerevan, Armenia
E-mail: nmihran @yahoo.com
II- Interesting news to all the readers of Info-Flash
The following news was sent to Info-Flash by Dr. Arnauld Nicogossian, Distinguished Research Professor, Director, Center of the Study of International Medical Policies and Practices, School of Public Policy, George Mason University, and Senior Editor of the Journal announced below.
Armenian physicians’ and researchers’ articles are welcome. For further or detailed information, please write to Dr. Nicogossian, anicogoss@cox.net You may also visit this website (given below): http://www.psocommons.org/wmhp/ for information.
"I'm delighted to send you information regarding the World Medical and Health Policy Journal.
The Journal is dedicated to the trans-disciplinary study of politics, policy, medicine, and public health. We hope that it will contribute to the improvement of global health by providing evidence based knowledge for health and medical policy decisions.
By bringing a policy perspective to medical practice, the Journal will help readers navigate the often tangled world of regulations, liability, standards of care, and deepen awareness of ethics, practices, politics and the socio-economic context in which they are created. By translating empirical evidence into policy, the Journal also will help policymakers design programs to improve health outcomes, with special attention to the proper allocation of scarce resources.
Below are potential topics of interest to the general readership:
1- Social cost of smoking
2- Literacy for women and minorities
3- Public health and regional conflicts
4- Health Impacts of international trafficking and violence against minorities and health care workers
5- Malnutrition and obesity
6- Access to health care
7- Communicating risks: lessons learned from disasters and pandemics
8- Emergency preparedness and response: politics and policies
9- Medical infrastructure(including health care workers) protection and continuity of operations: policies and practice guidelines
10- Antibiotic stewardship and management of emerging infection
11- Principles of scarce resource allocation and priority setting in medicine
The above topics were distilled from last year’s survey conducted by George Mason University and the World Medical Association."
The Journal can be viewed at: http://www.psocommons.org/wmhp/
III- A useful "dialogue" between Dr. Armen Yuri Gasparyan and Info-Flash
A few weeks ago, Dr. Armen Y. Gasparyan sent a message to Info-Flash describing a recent experience he had in the editorial room of the famous Medical Review Lancet. As the content of the message was both "intriguing" and interesting, I asked Dr. Gasparyan what was the reason for sending me his message and would he be willing to elaborate a little bit more about his experience. Dr. Gasparyan who is an Associate Professor of Medicine (Armenia), a Postdoctoral Clinical Research Fellow (UK), member of numerous editorial boards of medical journals, including of the World Association of Medical Editors and of the European Association of Science Editors, agreed. Info-Flash reprints below the edited versions of both messages.
"Yesterday,
for the first time in my academic career, I attended editors’ weekly meeting
and video conference at the Lancet office in London. It was a
unique opportunity to upgrade knowledge in medical journalism, to gain new
experience and share my own thoughts on possible prospects of international
collaboration.
Manuscripts,
which passed the peer-review and received positive comments, were open for
discussion by all the editors of this prestigious journal. It was quite interesting
to know that each manuscript, even recommended for publication by all referees,
needs approval and comments from the editors and from a biostatistician.
The
peer-review often criticized for its bias due to conflict of interest and other
subjective reasons, does work well in this oldest general medical journal.
Disclosure of any type of conflict of interest lies behind objective
commenting, which may increase, to some extent, quality of a submission.
Needless
to say that the majority of submissions to Lancet are of high
quality in the first instance, and the few manuscripts passing the peer-review
are indeed pearls of scientific work flow.
I
had the chance to discuss issues of scientific misconduct, fraud, poor-quality
submissions, and submissions with 'negative' results with fewer chances to be
published. I also presented my views on how new and small journals can improve
the quality of their publications by taking good example from Lancet.
The journal publishes results of large trials, extensive narrative reviews with
elements of systematic review or pure systematic reviews, news items,
editorials on urgent public health and clinical medicine issues. Each published
item has a great potential impact which, to some extent, can be measured by citations.
The institute of peer-reviewers is based on a huge network of experts from
around the world, including Armenia. Most devoted reviewers, especially
those with numerous reviewer comments, are incentivized for their
time and efforts. Incentives for reviewers include free subscription to the
journal and books published by the Publisher.
The
Lancet editors are members of the World Association of Medical
Editors and European Association of Science Editors. The journal itself joined
the Committee of Publication Ethics and other organizations responsible for
high standards in biomedical publications. Most medical libraries worldwide are
subscribers of this prestigious journal and have it on display for
visitors.
Though it may sound as a bias, I always consider publications of the Lancet for citations and recommend the same to my colleagues. The journal, a source of evidence-based and unbiased information, has been and will be a guiding star for many generations of physicians and biomedical scientists from around the globe."
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Dr. Gasparyan (right) with a
colleague in the office of Lancet
"The reason of sending my impressions is to share it with Armenian colleagues worldwide through the AMIC newsletter. Lancet is a well-known source of evidence-based medical information, with long-standing publishing traditions. Its first issue was published back in 1823 and at that time covered entirely surgical topics. All its issues are now safely preserved at the Journal's library. Today's Lancet publishes results of multi-national trials, which translate into guidelines for treatment of numerous diseases; it also publishes medical news, public health reports from around the globe, biographies of scientists and health care leaders who revolutionized medical practice in the UK and elsewhere. Actually, it is now registered as a newspaper, and this is why it combines purely scientific articles with news items. The Journal is archived, listed and indexed in numerous leading catalogues, digital libraries and indexing systems. Its impact and citation rate are outstanding.
As a physician, researcher, editor, member of numerous small and large Journals and author of scientific articles, I've been long interested in upgrading my experience in medical writing and publishing, and I was really fortunate to be offered such a unique chance to join editorial team of the Journal, at least for a short time, to learn and to discuss possibilities of future collaboration. As an editor of a new general medical Journal, I was particularly impressed by the editorial independence and openness and the flexibility and objectivity of the referee comments. No doubt, most general medical Journals in any corner of the world may greatly benefit of learning from Lancet example. Having mentioned that, I should also acknowledge the fact that the Journal is well-funded and can even allow covering expenses for the peer-review.
Of course, as an Armenian, I am also interested in publications of my compatriots on issues of global and national concern. To the best of my knowledge, in past 2-3 decades, there have been 10 publications by Lord Ara Darzi (former health minister of the UK) and his colleagues. Most recent notorious editorials of Prof. Darzi were about reforms in National Health Service, medical education and training in the UK (Darzi A. What next for the NHS? Lancet. 2007; 370(9596):1400-1. Darzi A, Kibasi T. Could the UK lead the world in medical education and training? Lancet, 2009; 373(9681):2095-6.).
There were also a few papers authored by Armenians, including the following most remarkable report from the Ministry of Health of Soviet Armenia: Autier P, Férir MC, Hairapetien A, Alexanian A, Agoudjian V, Schmets G, Dallemagne G, Leva MN, Pinel J. Drug supply in the aftermath of the 1988 Armenian earthquake. Lancet, 1990; 335(8702):1388-90.
Hopefully, many other publications by Armenian scholars will be published in the Lancet and cover issues of national and international concern such as current state of medical research and education, familial Mediterranean fever in Armenian cohorts of patients, medical geography, etc. Hope also that one day biographies of devoted Armenian scientists, who made groundbreaking discoveries or improved health care practice anywhere in the world, will appear on pages of this Journal."
IV- The Commencement Speech given by Dr. Haroutioun Armenian
The following speech was given on June 9, 2010, by Dr. Haroutioun Armenian, President of the American University of Armenia, (Professor Emeritus, Johns Hopkins University) at the Commencement ceremony of the Faculty of Medicine of the Yerevan State University.
"Rector Professor Gohar Kaylian, Dear Faculty Colleagues, Dear Graduates and families
It is a great honor for me to be asked to be the Commencement speaker of this prestigious Medical University.
It is interesting that the ceremony we are having today is called Commencement. The word commencement means a beginning, a start.
This is a new beginning in your careers or professional life. This is a new beginning in a more responsible pattern of life. There are many transitions that you have to make from a role as student. There are new expectations that you have to respond to all around you.
Others have dealt with this topic that a graduation is a start and not an end.
However, something that is not emphasized is that a commencement is about new beginnings in EDUCATION. Recently, Universities have emphasized their role in what is called LIFE LONG LEARNING: the emphasis on a process that allows the individual to continuously upgrade herself or himself in order to face the challenges of a dynamic world where change is the rule that has very few exceptions. I hope that during your education here you have learned the need for lifelong learning.
Many of the countries around the world including Armenia are making the claim that their future is in building knowledge societies. Knowledge is a fascinating human phenomenon.
The most revolutionary philosopher of science of the 20th century, Sir Karl Popper described human knowledge "as ‘the greatest miracle in the universe’. …What is extraordinary about knowledge is that it proposes the existence of objects, events or states of affairs that exceed our sense experiences."
"The objects of knowledge transcend their sensory basis. Or, to put it in another way, knowledge transcends the body or organism. The mystery of is that it is effective as a guide to action, even though it has only the loosest connection with immediate experience." Raymond Tallis, "The mystery and the paradox of scientific medicine" Clinical Medicine 2008; 8: 75-78
Thus, a Knowledge Society:
-Is a society where the intellectual product is pre-eminent over the material
-Is a society where creativity and innovation is encouraged over sensory pleasure
-Is where spirituality is enhanced because of the intellectual and creative experiences of the individual.
One of the first things I hope you have learned about medical education is that your education is not about making more money. If that was your objective then attending a business school would probably have been more profitable.
In a speech in 1890, titled End of Century Education, Krikor Zohrab, our great writer and professional par excellence, who was one of the first victims of the genocide of 1915, stated:
"Education is learning for moral and intellectual development and not for monetary gain."
Over the past couple of years, the World has been living through one of the most serious economic crises in recent history. The big lesson to learn from this and similar crises is that material wealth is so fragile and can be built and/or destroyed based on greed, emotions, perceptions and impressions. We need to strive not just for material wealth preservation but preservation of intellectual wealth in society and strong societies are those that prioritize intellectual wealth more than material ones.
Within an hour or so you will be called health professionals. But what is a professional?
Some years ago I discovered an article by one of my medical school professors of the American University of Beirut - Dr. John Racy. In that article he defined a profession as:
"a socially sanctioned activity whose primary object is the well-being of others above the professional’s personal gain." A profession is much more than a job; it is an identity where the giving supersedes and precedes the gain. A profession also uses well defined paradigms or common approaches for practice. All definitions of the word profession emphasize the need for specialized knowledge, academic preparation, as well as an altruistic spirit.
What about being a medical professional in your lifetime?
The great historian of medicine, Henry Siegerist, has stated that one of the problems of medicine through the ages has been that technology has always outpaced sociology. We have new knowledge and technology that takes decades and sometimes centuries to make it part of our social fabric. For example, although we had the technology of smallpox vaccination for almost 200 years we could not eradicate the disease because we did not have a good social and epidemiologic strategy. Today, we are in need of sociology more than additional technology. Sociology in professional life is in the context of its uses and its practice within the framework of health services. Dealing with more complex problems like cancer and cardiovascular diseases demands more difficult socio-cultural strategies than what we used for smallpox. Without its social dimension, professional practice loses its soul. We need to discover not an overarching set of technologies but an overarching set of social strategies to deal with disease in human populations. Over the past five years I have been concerned with the concept of dignity and its relationship to health. Two of my students have done their thesis research on this topic one in Palestinian refugees and another one compared dignity scores in Armenian refugees. In both studies we have been able to demonstrate a relationship between the sense of dignity of the individual and their health status.
The ultimate objective of our aggregate effort as human being is achieving dignity. In the health professions, we aim at helping the individual and the group in improving their dignity. It is what ultimately every profession aims at.
We agree that human beings are not just a collection of cells or molecules but also have spirituality that binds the molecules and cells with an integrative purpose and the resultant direction. Thus, in every culture and with every individual there is this search for dignity that elevates us out of our biological complexity.
As the great French scientist and philosopher
Theillard De Chardin says, "In the final analysis, the questions of why
bad things happen to good people transmutes itself into some very different
questions, no longer asking why something happened, but asking how we will
respond, what we intend to do now that it happened."
"We are not human beings having a spiritual experience. We are spiritual beings having a human experience."
Our primary role as physicians is strengthening the sense of dignity of people who turn to us for help by all the means that are available to us.
I hope you never look at others with disdain. Your diploma today does not give you the right for arrogance. Humility and simplicity will always make you better appreciated and more effective and more dignified for your patients. The only time you can look down on people is when you are helping them to get up.
As I look at your future professional life I can project an optimistic and a pessimistic scenario.
The pessimistic scenario is one where your focus of attention is your own selves. As individuals, you are striving at making money at all cost and in the fastest way possible. Considering the relative economic difficulties in Armenia and the countries you come from, this frame of mind will lead you to getting out of your country and you will contribute to the process of diasporization in the West.
The optimistic scenario is about investment in the future of your country. Investing in your country is an expression of confidence in your being an Armenian, an Iranian, Syrian, Indian, Lebanese or whatever nationality you belong to. If you make the commitment of investing yourself in your country first, then you will have the wonderful opportunity to use all the problem solving skills that you have learned in this university, and tackle head on the adverse situations that you are facing. Whether it was through the twelve years of the civil war in Lebanon that my wife Sona and I have lived through, whether it was during the terrible earthquake of 1988 in Armenia, or through the difficulties that we went through with our daughter’s leukemia and death, we have always thought of transforming an adverse situation into a positive experience. The positive experience of social responsibility and scientific or artistic creativity is what has given us the inner strength to face our difficulties. I wish you have that positive experience hopefully without any major ordeals.
As I go around the world I am more impressed by what is common between people rather than what is different. Never accept that a new idea does not work here in Armenia or in your country. In order to make such a statement you have to test your idea first! You have to adapt, you have to use your problem solving skills to make your new idea relevant to the environment within which it needs to be practiced. This is true whether you are implementing your new idea in Armenia, in Russia or in the United States.
During this talk I have given you a lot of advice by me and others. You may ask yourself whether I myself implement all the advice I give. That is probably something you should ask yourselves every time you advise another patient/human being.
I want to emphasize the following one more time before you get your diplomas. These are things I and my wife Sona do and experience every day. It is essential that if you are going to be the civilized and model physicians of the 21st century then you need to make the appropriate life style changes if you are not doing it already:
1- If you are smokers, stop smoking! In this day and age it is impossible for me to accept that we still have physicians who smoke cigarettes.
2- Do not wait for your diagnosis of hypertension or myocardial infarction or colon cancer before taking up a daily leisure time exercise routine as part of your busy schedules.
3- As relatively economically prosperous professionals you are exposed to an abundance of food. Enjoy your food for the taste of it rather than for filling your belly with all those heavy calories.
4- Your more senior 50,000 colleagues who participated as subjects in the Physicians’ Health Study have taught us taking an aspirin every other day will decrease our risk of myocardial infarction by 30%.
As I said earlier last week from this podium twentieth century medicine had its major emphasis on prevention of diseases, 21st century medicine will be the century where we build health. What we call Salutogenesis. This is a different philosophy and needs a different set of approaches. I hope that we see all of you having a role in building healthy individuals and communities in addition to treating disease and preventing it.
At the end of my talk I would like to read one of my favorite poems that I translated from Armenian to English. This poem was written in 1921 by the leading Armenian futurist Gara Darvish who lived in Tbilisi much of his short life and died in prison persecuted by the Stalin regime.
To Youth
By Gara Darvish
First and foremost be a human being. Being a human being is the finest of the arts. Being human is the most difficult but yet the easiest thing. A man is the person who sees the human in man. A man likes to see his fellow man being fortunate.
A man shares half his loaf with his fellow men. A man worships justice, truth and the rights. A man will pull-up the weak, will embrace the fallen, and help him stand up. You and we are the creators of both evil and good. Love and let your childlike love be your punishment.
Love and the lyrical smile are stronger than the canons, the powder, the battleships and the tanks. It is the word friend that conquers and not the armies. The armies will destroy the boundaries and the walls separating people But love will unite people Unite them in love and only in love.
This poet is with you and has nothing but love to breath, He has no other words for you but love.
Tbilisi, May 1921.
Congratulations and welcome to the great family of health professionals. I hope we will be working together soon to build the communities of the future and we will be there together at the front lines in the good and the bad days.
V- What is AMIC?
The Armenian Medical International Committee (AMIC) was created 20 years ago. It is an umbrella organization that unites and promotes Armenian medical associations throughout the Diaspora, creating thus a large network through which information and data are exchanged.
AMIC organizes Armenian Medical Congresses. So far ten have been held in different cities of the Diaspora, the latest being the one held in New York from July 1 to July 4, 2009. In 2007, the "Second International Medical Congress of Armenia" organized by Armenia, was held in Yerevan (June 28 to June 30). The third one is being organized in summer of 2011.
Since 1998 AMIC has published an online newsletter which is sent free of charge to all Armenian Health Care Professionals. If you are a health care professional and are interested in receiving Info-Flash, please send us your email address (aida@amic.ca). To all those who already receive the Info, please do not forget to send us your new e-mail address when you change it. Info-Flash is posted on GROONG, but with a different format, and often with less data and graphics, due to GROONG’s rules. To receive it individually in full size and content, please contact AMIC office (aida@amic.ca). For further information, visit our website: www.amic.ca
As of 2005, AMIC in collaboration with Regimedia, publishes a scientific journal, the "Armenian Medical Review". The fourth issue is out. To subscribe please contact aida@amic.ca or visit www.amic-review.com
Useful information to remember: You can send free of charge from wherever you are located, medical equipment/medicine through the services of the United Armenian Fund: Contact: U.A.F. President Mr. Harout Sassounian (sassoun@pacbell.net)
Armenian Medical International Committee (AMIC) 2340 Chemin Lucerne, Suite 30 Ville Mont-Royal, Qc., Canada H3R 2J8 Ph: 514- 739-8950 Email: amic@amic.ca Skype: amic112