JMA—President’s Speech JMA Activities Conferences and Lectures

JMA—President’s Speech

Policy Address

Yoshihito KARASAWA ...................................................................................................................................... 1

JMA Activities

School Health Activities in Japan

Takeo UCHIDA .................................................................................................................................................... 5

Conferences and Lectures

The 25th CMAAO Congress and the 43rd Council Meeting:COUNTRY REPORTS .................................................................................................................................... 12

Hong Kong Medical Association ............................................................................................................ 13

Indonesian Medical Association ............................................................................................................. 19

Japan Medical Association ....................................................................................................................... 22

Korean Medical Association ..................................................................................................................... 24

New Zealand Medical Association ........................................................................................................ 29

Singapore Medical Association .............................................................................................................. 31

Taiwan Medical Association ..................................................................................................................... 36

Research and Reviews

Body Donation: An act of love supporting anatomy education

Tatsuo SAKAI ....................................................................................................................................................... 39

From the Japanese Association of Medical Sciences

Simultaneous and Rapid Detection of Causative Pathogens in Community-acquiredPneumonia by Real-time PCR (1167)

Kimiko UBUKATA .............................................................................................................................................. 46

Local Medical Associations in Japan

Working towards an “Open Medical Association”

Hideki ADACHI, Hiroshi OYABU................................................................................................................... 51

Infant Healthcare Activities of the Mie Medical Association

Masahiko KATO ................................................................................................................................................... 53

Vol. 51 No. 1 January-February 2008

Contents

International Medical Community

The Danish Society for Patient Safety—Operation Life Campaign

Jens Winther JENSEN .......................................................................................................................................... 56

New Zealand’s World-leading No-fault Accident Compensation Scheme

Peter FOLEY ......................................................................................................................................................... 58

From the Editor’s DeskMasami ISHII ......................................................................................................................................................... 61

1JMAJ, January /February 2008 — Vol. 51, No. 1

JMA—President’s Speech

Policy Address*1

JMAJ 51(1): 1–4, 2008

Yoshihito KARASAWA*2

Survey of Attitudes towards the JMA

Considering this political climate, between Octo-ber 2006 and March 2007 the JMA conducted asurvey of more than 1,000 members of the generalpublic on their attitudes towards the JMA in whichawareness of the Association surveyed beforeand 6 months after the broadcast of televisioncommercials for the JMA were compared.

The survey found that 15.6% of respondentswere “interested” in JMA activities directly beforethe commercial broadcasts, compared with 18.9%6 months later—an increase of more than 3 points.Similarly, the percentage of respondents whosaid they “held expectations” for JMA activitiesrose more than 3 points, from 19.3% before thebroadcasts to 22.9% 6 months later. Over the6-month television advertising campaign, interestin and expectations for JMA activities rose, if notdramatically, certainly steadily.

In contrast, JMA awareness was high (95%)both before and after the commercial broadcast,but in reality members of the general publicknow little about the actual activities of the JMA.

Looking at the junior high school civics text-book and the high school textbook on ModernSociety, the JMA is given as an example of a lobbygroup. Although the expression “lobby groups”does not necessarily express a negative meaning,the JMA is an association that proactively con-tributes proposals for social security policies,particularly in the fields of medicine, health, andwelfare, as well as collaborates with the govern-ment, strives to prevent disease, with schooldoctors providing support in schools and indus-trial doctors providing support in companies.

*1 This is an English version of the policy address originally delivered in Japanese by Dr. Yoshihito Karasawa at the 117th Extraordinary GeneralAssembly of the JMA House of Delegates held in Tokyo, October 28, 2007.*2 President, Japan Medical Association, Tokyo, Japan ([email protected]).

Recent Political Climate

It has been one-and-a-half years since the currentleadership came to office, and I would like toexpress my heartfelt thanks for their understand-ing and support of the JMA’s operation andvarious activities during this time.

Beginning with the nationwide local electionsheld at the start of the year, 2007 has been a yearof many elections, and this year’s Upper Houseelections were decisive in determining the direc-tion of future public policy. This election resultedin a dramatic decrease in the number of parliamen-tary seats held by the ruling Liberal DemocraticParty, with the opposition gaining control of theUpper House.

Over the process of several elections, the dangerof collapse in regions throughout the country ofcommunity healthcare and various other systemsaffecting people’s everyday living and livelihoods,hitherto overlooked in national policies, washighlighted; disparities between regional areasnationwide grew even greater, and the anxietyand distrust of the general public increased. Thenational government’s hasty course of structuralreform of recent years prioritizing public financehas placed tremendous strain on national health-care and other aspects of people’s everyday livingand livelihoods. In the future it will be even moreimportant to promote the formulation of policiesfrom the perspective of the general public, pro-viding a sense of security in everyday life, andthis, as well as policy turnaround, is becoming amajor proposition.

2 JMAJ, January /February 2008 — Vol. 51, No. 1

Karasawa Y

There is a need to increase the general public’sawareness that the JMA is an organization thatis deeply involved in healthcare-related activitiesin the community.

The Endangered State of the UniversalHealthcare System

The Michael Moore film, “Sicko” has been recentlyscreened in Japan. That this film portrays theplight of some 150 million Americans who haveprivate medical insurance—and not the 45 millionAmericans that are uninsured—provides impor-tant talking points for discussing the direction ofhealthcare in Japan.

Japan’s universal healthcare system is todayfacing a tremendous crisis, and I would like tobriefly discuss below five points that have emergedas characteristics of this crisis.

Firstly, the number of medical institutionsunable to provide childbirth services has increasedrapidly on a nationwide basis, causing tremen-dous anxiety for many women. In 1996 therewere 3,991 medical facilities providing birthingservices, but 10 years later, in 2006, this figure haddropped some 27% to 2,933. Even amongst facili-ties claiming to have a “Department of Obstet-rics and Gynecology,” in reality there are nowsome that only provide gynecology services.

Behind this drop is not only the decrease inobstetricians due to harsh working conditionsbut also the increase in cases of criminal actionbeing taken against doctors when accidents haveoccurred during childbirth. Consequently, thenumber of hospitals that do not provide child-birth services has increased and the number ofmedical interns desiring to become obstetricianshas decreased dramatically.

As part of the JMA’s response to this problem,we proposed the establishment of a system of ano-fault compensation system which looks likelyto be realized. Under this system, we hope to pro-pel medicine towards a situation where womencan give birth with peace of mind.

Secondly, there is a dearth of pediatriciansin emergency pediatric care. More than half ofthe patients who are seen at emergency medicalcenters at night or on weekends are children.With the extreme shortage of hospital pediatri-cians, the situation arises in which a doctor goeson night duty after working a full day of routineduties, deals with the nighttime emergency cases,

then goes straight back to their daytime dutieswithout catching one wink of sleep. Such casesare by no means rare. This situation has led tohospitals throughout the country closing theirpediatrics department. In 1996, 35.2% of hospi-tals had pediatrics departments, but by 2006 thisfigure had dropped some 6 points to 29.2%. Nor-mally this would be a problem for the nationalgovernment and local government bodies toresolve, but local medical associations are insome areas taking a central role in proactivelyproviding emergency pediatric services by sharingthe nighttime work during a certain timeframeamongst local medical institutions and doctors.The extremely harsh working conditions forhospital pediatricians is unimaginable, and theJMA has marked it as an urgent issue which wewill work to resolve through further cooperationwith local medical associations.

Thirdly, there is concern about people dyingsolitary deaths. Japanese society has aged veryrapidly over the past several years and the num-ber of households exclusively comprising old oldpeople is increasing. In 2005, 33.2% of old oldpeople—one in three—lived in households com-prising only elderly people, and consequentlysolitary deaths are becoming a huge social prob-lem. Under such circumstances, the Ministry ofHealth, Labour and Welfare plans, in the name of“Reorganization of Long Stay Beds,” to reducethe number of hospital beds from the current380,000 beds to 150,000 by 2012, the reasongiven being to prevent “social hospitalization” byelderly people.

However, surveys conducted by the JMA ofthe conditions for hospitalized patients foundthat there was also significant numbers of gastrictubal feeding and sputum aspiration patients;objectively considering the situations of patientswho, in addition to whole-body management,must be hospitalized in order to adequately carefor, some 250,000 long-stay beds will be still berequired in 2012. The expulsion of such patientsfrom hospitals would create a massive number of“medical refugees” and “nursing care refugees.”

The JMA is firmly opposed to the widespreadreduction of long-stay beds. In order to avoid anysudden changes, regardless of whether the patientis being treated at home or in a medical facility,changes must be considered gradually, beginningwith the making of thorough preparations. More-over, patients hospitalized and in hospital beds


would not necessarily prefer to be treated andcared for in their own home.

Fourthly, there is the issue of healthcare expen-diture standards in Japan. The World HealthOrganization (WHO) has ranked Japan’s health-care achievement as the highest in the world.However, Japan’s healthcare expenditure/GDPratio was ranked 22nd amongst the 30 developednations who are members of the Organisationfor Economic Co-operation and Development(OECD) according to 2004 figures. The averageratio for the 30 developed countries was 8.9%,with a ratio of 8.0% for Japan. That one of theworld’s economic powers has such extremely lowhealthcare expenditure compared with othercountries is demonstrated by these official figures.

Fifthly, there is an absolute dearth of doctorsin Japan. Looking at the number of doctors inJapan per 1,000 head of population, the averagefor OECD member countries is 3.1 whereas forJapan it is 2.0. The same figure for France is 3.4,for Germany 3.4, and for the United States 2.4,placing Japan in last place amongst the group ofmember countries with per capita GDPs abovethe OECD average. In addition to the overalldearth of doctors, there are severe disparitiesbetween cities and regional areas. The reasonfor this is the weakening of the doctor dispatchfunction of university hospital departments stem-ming from the introduction of the new doctorclinical training system which began in April2004. Demand for doctors far exceeds supply,and consequently interns are concentrated incity hospitals with good facilities and trainingprograms or hospitals that pay high wages, evenif temporarily.

Japan’s healthcare achievement is the highestin the world in part because of the high diligenceand health awareness of the general public, butthe fact that the healthcare system is supportedby the self-sacrificing care provided by doctors,nurses, and other healthcare professionals shouldbe re-acknowledged and appreciated.

Finance-led Healthcare ExpenditureRestraint Policies

“Healthcare collapse” is fundamentally the resultof the national government’s healthcare expen-diture restraint policies and began after the

collapse of Japan’s bubble economy. However,the problem became most pronounced from thetime of the Koizumi Administration’s “structuralreform with nothing sacred” policy, which took alarge axe to social security areas.

Over the past 5 years, between 2001 and 2006,in contrast to the natural increase of necessarysocial security expenditure (paid by the govern-ment), some 3.3 trillion yen (28.7 US dollars)*3

in national treasury payments was lost. The natu-ral increase in healthcare expenditure—said tobe 2–3% annually—is the increase in expendi-ture due to advances in medicine and healthcare.In fact, 70% of the vanished 3.3 trillion yen ofsocial security expenditure has been achievedby the curbing of healthcare and nursing careexpenditure to the point where has becomedifficult to provide “costs for safety,” let alone“costs for peace of mind.” As if to demonstratethis, medical institutions have been going bank-rupt at the worst pace ever this year. If thisrestraint on healthcare expenditure continuesfor another 5 years, 12 trillion yen (104 billion USdollars) in national treasury payments will be cutfrom social security expenditure, bringing thetotal loss of healthcare expenditure to approxi-mately 8 trillion yen (69.6 billion US dollars).

Curbing of healthcare expenditure is aimed atcurbing benefit expenditure, and is thrown backat the general public in the form of increases inpatient charges. Moreover, ensuring the supply ofdoctors, nurses, and other medical professionalswill become difficult, leading to excessive over-work and the reduction of time for each patientto be treated individually, all of which would behighly detrimental to the general public.

Amongst members of committees such as theCouncil on Economic and Fiscal Policy and theCouncil for the Promotion of Regulatory Reformare some who are considering introducing insur-ance exemptions and mixture of public insuranceand private payment in order to reduce the burdenon the national government. However, this wouldmake it very difficult to maintain the equity ofhealthcare in Japan.

We do not advocate that medical expenditureshould match that of the United States but insteadpropose that a healthcare expenditure scale com-mensurate with national and economic power beachieved and that regional systems for providing

POLICY ADDRESS

*3 1 US dollar�115 yen.


healthcare be enhanced. This would be a first steptowards enabling those people whose efforts con-tributed to Japan’s economic growth and thosewho have health anxieties and their families tolive their lives with peace of mind.

Government in Japan in recent years hasseemed to focus entirely on economic and fiscalmanagement and, cursed by an ever-increasinggovernment bonds outstanding, has been preoc-cupied solely with fiscal revenue and expenditure.

Maintaining Steady RegionalHealthcare Systems

The nation’s greatest assets are its people. Thefirst responsibility of the national government isto secure the country and the lives and propertyof its citizens, protecting the everyday lives of thepeople, and maintaining a society that enablesthe people to live enriched lives and local com-munities that are safe and enable trust. The keyto this is the construction of a rich lifestyle foun-dation that looks ahead and that focuses on thesmallest structural units of society—the house-hold and the family.

Unless the national wealth contributes ad-equately and effectively to the welfare of thepeople, it would be completely impossible toconstruct the basis for a 100 year of the nation.

As society ages and the birth rate decreases, wemust avoid increasing the burden on regions,exacerbating disparities between regions, andspreading anxiety.

Now is precisely the time we need to reaffirmthe section of Article 25 of the Japanese Consti-tution that sets out the right to life and security ofthe people and the nation’s social mission. Nowis the time to explain to and gain the understand-ing of the general public regarding the difficultynow being faced in maintaining regional health-care systems for the safety and security of thatregion, as well as the fact that this is an importantperiod for formulating policies that maintain andstrengthen the universal healthcare system.

Following the publication of our “Grand Design2007—General Outline—,” the JMA has pub-lished “Grand Design 2007—Specific Views—”as its sequel. The JMA aims to further strengthenthe universal healthcare system so that membersof the general public are universally able to receivegood quality and highly satisfactory healthcare.To achieve this, from the standpoint of protect-ing the lives and health of the people, we willproactively make proposals to the governmentfrom the same perspective as members of thegeneral public, while promptly and proactivelyworking to resolve issues that the Associationshould respond to.

Karasawa Y


JMA Policies

School Health Activities in Japan

JMAJ 51(1): 5–11, 2008

Takeo UCHIDA*1

AbstractThe Japanese school health system can be traced back to the promulgation of the school system in 1872, whenits major aim was to implement measures to prevent schools from serving as a medium for the transmission ofprevalent infectious diseases such as smallpox and cholera. In 1898, an imperial ordinance was issued to placeschool doctors in public schools. Since then, school doctors have played a central role in school healthcare. Inmore recent years, we have seen rapid changes in social and living environments, and these changes have beenaccompanied by a wide spectrum of new health issues including mental health problems and the onset of lifestyle-related diseases at younger ages. The cooperation of specialists from a variety of medical fields as well as healtheducation and health management that provides a firm basis for lifelong health in schoolchildren are necessaryand will become an integral part of the role assigned to school doctors in the future.

To deal with such a wide variety of issues, the JMA has introduced a three-pillar policy, i.e., the JMA SchoolHealth Committee, school doctor training sessions, and national conventions of school health providers andschool doctors. Currently, the JMA is working with the national government and other relevant organizations onvarious approaches, holding training sessions which are intended to spread of the knowledge required by schooldoctors. In order to make good use of the know-how regarding school health activities in Japan and to improvethe level of health in developing countries, a joint international project was implemented in Nepal and hasproduced excellent results. It is hoped that Japan will make greater contributions to global health through effortssuch as these.

Key words School health, School doctor, School Health Law, Health education, Global health

Before the end of World War II, the systemwas called the school hygiene system, but it waslater known as the school health system. Therewas also a transition in the activities requiredto maintain school health from the periods ofMeiji (1868–1912) to Taisho (1912–1926), Showa(1926–1989), and Heisei (1989–).

This paper outlines the background and pro-cess of establishment of the school health systemin Japan, discusses new issues of school healthcurrently occurring in the school system, andintroduces activities being carried out by JMA tosolve such issues.

The School System and the SchoolDoctor System in Japan

An outline of the current Japanese school systemwill be given below because it is necessary to

*1 Executive Board Member, Japan Medical Association, Tokyo, Japan ([email protected]).

Introduction

The Japanese school health system was establishedat about the same time as the modern Japaneseeducational system and thus has a history of morethan a century. In the middle of the 19th century(1866), Dr. Hermann Cohn, professor of Ophthal-mology at the University of Breslau, Germany,proposed allocating doctors to schools to pro-vide inspection and guidance in the hygienic andenvironmental conditions of the school, sincethe incidence of myopia was particularly highamong school attendees. Consequently, the needfor management and guidance of hygiene inschools was advocated in Europe at the time.Following the European lead, Japan formulated asystem to manage the health of children in schooland to facilitate their growth and development.


Uchida T

understand the system that underlies schoolhealth in Japan.

The current Japanese school system has beenin place since 1947, when the School EducationLaw was enacted. The current system is a 6-3-3-4system that comprises 6 years of elementaryschool, 3 years of junior high school, 3 years ofsenior high school, and 4 years of university. Thissystem is a consistent single-track system thatbasically offers the same curriculum to every child.The education of children is classified as preschool,primary/secondary, and higher education.

Preschool education is provided to childrenprior to school age at child-care centers or kin-dergartens, although attendance at such facilitiesis not obligatory. Primary and secondary educa-tion are compulsory in Japan. Children who are6 years old as of April 1 enter an elementaryschool as first graders who then receive 9 years ofeducation in an elementary school (6 years) anda junior high school (3 years). The school yearbegins in April and consists of 3 terms, each fol-lowed by a break in summer, winter, and spring,respectively. Under the current system of com-pulsory education in elementary and junior highschools, tuition and textbooks in public elemen-tary and junior high schools are free of charge.Those who have completed the 9 years of com-pulsory education and have passed the entranceexamination can enter a senior high school. Seniorhigh schools provide 3-year courses designedfor general education, technical education, or acombination of general and technical education.After senior high school, students can go on tohigher education, primarily in universities or jun-ior colleges. These organizations provide higherand more specialized education. The term is 4years in universities and 2 years in junior colleges.Beyond these schools, graduate schools are avail-able (2 years for a master’s course and 3 years fora doctoral course).

School health is defined as “health educationand health management in school” in No. 12,Article 4 of the Establishment Law of the Min-istry of Education, Culture, Sports, Science andTechnology (MEXT). In addition, in Article 1,Chapter 1 of the School Health Law, the purposeof formulating the School Health Law is specifiedas follows: to prescribe necessary matters relatingto health and safety management in school, topromote maintenance and enhancement of thehealth of schoolchildren and students, as well

as infants and school personnel, and to therebyfacilitate smooth implementation of school edu-cation and securement of its achievements. Article16 of this law regulates that schools shall haveschool doctors, providing a legal basis for theirpresence. “School” here is any of the schoolsprescribed in Article 1 of the School EducationLaw, i.e., elementary, junior high, senior high, andsecondary schools; universities; specialized voca-tional high schools; schools for the blind, deaf,and handicapped; and kindergartens. In principle,school doctors are present at any stage of educa-tion under the school system in Japan. Accordingto the School Basic Survey (fiscal 2006) con-ducted by MEXT, there are 22,878 elementaryschools (including public and private) in Japan,and 22,420 (98%) of them have school doctors.A total of 59,006 doctors are serving as schooldoctors for elementary schools, accounting for2.6 doctors per school. Results of statistics aresimilar for junior high and senior high schools.Thus, it is apparent that the school doctor systemis functioning as a nationwide system.

The board of education of each local govern-ment is responsible for implementing schoolhealth administration in public schools. Amongprivate schools, the section governing privateschools in the clerical department of the prefec-tural government is responsible. The status of theschool doctor in a public school corresponds tothat of part-time school personnel. In most cases,local medical association members perform theactivities of school doctors as part of communitymedicine.

Developmental History of the SchoolHealth System

Development in the pre-war periodAs was mentioned at the beginning, the Japaneseschool health system has a long history that canbe traced back to the promulgation of the schoolsystem in 1872, the fifth year of the Meiji period(1868–1912), with the major aim of taking mea-sures to prevent schools from serving as a meansof transmission of prevalent infectious diseasessuch as smallpox and cholera.

The initial measure related to school environ-mental health in the school health system was theallocation of a contract investigator of schoolhygiene issues, Michiyoshi Mishima, of the Minis-try of Education in 1891. Mishima conducted an


investigation of the situation of school hygienein various parts of the country, and the resultsof the investigation were reflected in variouspolicies regarding school hygiene. School doctorswere first adopted as contractual doctors in theKojimachi area of Tokyo in 1894. In 1896, theMinistry of Education set up a school hygieneadvisory committee to develop the school hygienesystem, choosing the school doctor system as thesubject of discussion. In 1898, an imperial ordi-nance was issued to place school doctors in publicschools. At that time, “school doctor’s job regula-tions” were issued to officially stipulate the posi-tion of school doctor. This allocation of schooldoctors to public schools throughout the countrywas the first such case in the world. The duties ofschool doctors at that time included inspection ofclasses at least once per month, observing fornine hygiene items (Table 1), and offering out-side advice as a supervisor. In addition, schooldoctors were in charge of physical examinationsas specified by the “schoolchildren and studentsphysical examination rules,” which prescribedthat the physical examination of children be per-formed in April and October every year andinclude 11 items: height, weight, chest circum-ference, spinal column, physique, visual acuity,eye disease, hearing acuity, ear disease, teeth, andother diseases. The provision of therapy was notincluded in the duties of school doctors.

However, in the Taisho period (1912–1926),the school environment itself was improved, andthe rate of enrollment of school-age children

increased, resulting in attendance by more chil-dren with diseases and physically weak children,thereby increasing the need for management ofschoolchildren’s health. In addition to the morepassive measures, it was considered necessary totake measures aimed at the maintenance andenhancement of health, including improvementsin nutrition, physical training, fragile habitus, etc.As a result, the school doctor’s job regulationswere amended in 1920. The amendment stipu-lated matters related to the supervision and careof sick, weak, or mentally retarded children,thereby expanding the conventional duties con-cerning environmental hygiene and physicalexamination. For example, school doctors wererequired to advise in matters of school attend-ance by affected children and provide guidanceas to how to deal with such children. Since thisnew role was imposed on school doctors, addi-tional staff members were required to serve asassistants of school doctors in the schools and toplay a major part in the practical work of super-vising and caring for children, and, consequently,the number of school nurses increased dramati-cally. School nurses were adopted first in GifuPrefecture in the main island of Japan in 1905.They were placed initially to carry out eye wash-ing procedures to cope with the concern existingat that time. In the late 1890s to early 1990s, therewere major epidemics of trachoma in Japancausing many pupils and students to be absentfrom school for long periods of time, creating aproblem from the educational standpoint.

In the Showa period (1926–1989), tuberculosisbecame a national affliction and was regarded asa serious social problem, and the need for pre-vention in the adolescent stage was advocated.As a result, special classes for the care of physi-cally weak or scrofulous children were formedin various schools around the country. To screenfor tuberculosis, intracutaneous tuberculin test-ing, roentgenography, and bacteriologic exami-nation were performed for schoolchildren, andcare classes were formed for tuberculin-positivechildren and those with suspected tuberculosis,to provide extensive health guidance.

As wartime approached, improvement of thehealth status and strength of schoolchildren wasregarded as an important theme and attracted agreat deal of attention. The priority of the schoolhealth policies rapidly changed from the formertherapeutic measures to preventive medicine and

SCHOOL HEALTH ACTIVITIES IN JAPAN

Table 1 Role of school doctors as prescribed bythe school doctor’s job regulations (1898)

1. Quality of air ventilation

2. Adequacy of lighting

3. Adequacy of desk and chair

4. Distance from the chalk board to the front row and tothe backmost row

5. Presence/absence of fireplace, and distancebetween the fireplace and the nearest seat

6. Room temperature

7. Hygienic adequacy of books, wall charts, and chalkboards

8. Status of school cleaning procedures

9. Adequacy of water for medical use and issuesrelated to environmental hygiene


training.The major role of school doctors in the Meiji

period was the management and guidance ofschool environmental hygiene. From the Taishoto early Showa period, school doctors played acentral role in healthcare at school. At any rate, itis clear that school doctors played a central rolein school health (hygiene) from the Meiji periodto the prewar period.

Development in the post-war periodAfter the war, the school doctor system was leg-islated by the School Health Law, establishedin 1958. Although the Basic Education Law andthe School Education Law were promulgatedin 1947, after the war, there were no regulationsregarding school doctors until the establishmentof the School Health Law. Article 16 of theSchool Health Law prescribes that schools shallhave school doctors, and that school doctors beengaged in technical and guidance activities inrelation to specialized issues of health manage-ment. According to Article 23 of the EnforcementRegulations of the School Health Law, the dutiesof a school doctor are classified into 9 categories(Table 2).

As prescribed in Article 2 of the EnforcementOrder of the School Health Law, children readyfor school receive a health examination consist-ing of the following items: 1) nutritional status,2) presence/absence of disease and abnormalityof the spinal column and thorax, 3) visual andhearing acuity, 4) presence/absence of diseaseand abnormality of the eye, 5) presence/absenceof otorhinopharyngeal disease and skin disease,6) presence/absence of dental and oral diseaseand abnormality, 7) presence/absence of otherdisease and abnormality. From this, it would seemnatural that three doctors, i.e., an internist (orpediatrician), ophthalmologist, and otorhinolaryn-gologist, would be in charge of a school. How-ever, as mentioned previously, there are no legalregulations as to the specialties of school doctors.

Major health issues found in schoolchildren atthe time the School Health Law was establishedincluded parasitic infection, trachoma, tubercu-losis or other infectious diseases, and decayedteeth. In coping with these issues, school healthactivities achieved significant results throughhealth screenings based on the School HealthLaw. However, in more recent years, we haveseen rapid changes in social and living environ-ments due to urbanization, declining birthrate, anincreasing proportion of the elderly, informati-zation, and internationalization. These changeshave been accompanied by a wide spectrum ofnew health issues including bullying, schoolavoidance, allergic diseases, problematic sexualbehavior and drug abuse, emerging or reemerg-ing infectious diseases, diseases and disorders ofthe motor apparatus due to excessive exerciseand sports, onset of lifestyle-related diseases atyounger ages, and so on. Thus, the field of schoolhealth is in need of new strategies.

School Health Measures Related tothe Activities of the Japan MedicalAssociation (JMA)

The mission of the JMA aims at the enhance-ment of medical ethics, advancement of medicaleducation, overall progress of medicine and relatedsciences, continuing education, and other activi-ties. Major activities of this organization includemedical policy decisions, dealing with variousbioethical issues, scholarly activities, promotionof medical services, healthcare and welfare, pro-motion of international cooperation, and public

Table 2 Duties of school doctors as prescribed byArticle 23 of the Enforcement Regulationsof the School Health Law (1958)

1. Participating in school health planning

2. Providing necessary guidance and advice in coop-eration with school pharmacists in the maintenanceand improvement of school environmental hygiene

3. Being engaged in the health checks of schoolchil-dren, students, and infants

4. Being engaged in the preventive treatment ofdiseases and in health guidance

5. Being engaged in health counseling

6. Providing necessary guidance and advice as tothe prevention of contagious diseases, andproviding preventive treatment of contagiousdiseases and food poisoning in schools

7. Providing first-aid treatment by request from theprincipal

8. Being engaged in health examinations of childrenready for school and school personnel as requestedby municipal education boards or the school founder

9. Providing guidance about professional issuesconcerning health management in schools asneeded

Uchida T


relations. School health activities are categorizedunder the promotion of medical services, health-care, and welfare.

To promote school health activities, the JMAhas introduced a three-pillar policy, i.e., the schoolhealth committee, school doctor training sessions,and national conventions of school health pro-viders and school doctors.

The school health committee consists of localmedical association board members in chargeof school health (representatives of respectiveblocks), representatives of various medical fields(internal medicine, ophthalmology, otorhinolaryn-gology, psychiatry, obstetrics and gynecology,orthopedics, dermatology), representatives of theJapanese Society of School Health, and academicexperts on particular learning and experience inschool health (particularly matters of school doc-tors). This committee discusses problems on thebasis of an understanding of the current status ofschool health, proposals or suggestions for solu-tions to problems, school doctor training sessions(described below), planning and operation ofnational conventions of school health providersand school doctors, and issuance of reports tobiennial inquiries from the president of the JMAconcerning future perspectives and other issuesof school health (Table 3). In response to recentreports, the JMA set up the following targets:1) shifting from health management by schoolhealth screening toward health education, 2) hav-ing a school health committee at every school,3) implementing health education through healthcounseling, 4) ensuring the participation of variousspecialists (particularly from psychiatry, obstetricsand gynecology, orthopedics, and dermatology)

as school doctors in addition to the more com-mon internists, ophthalmologists, and otorhino-laryngologists. Currently, the JMA is workingwith the national government and other relevantorganizations in various approaches to fulfillthese targets.

School doctor training sessions are held annu-ally by the JMA, and, with support from the Japa-nese Society of School Health, with the aim ofimproving the quality of school doctors. Trainingsessions are intended for the spread of knowl-edge necessary for school doctors in pursuingtheir duties and provide opportunities to discussvarious issues and formulate new measures andpolicies. In addition, the JMA issued “A Guidefor School Doctors” in 2004 to make school doc-tor activities more effective in practice and tofurther enrich them.

National congresses relating to school healthand attended by school doctors are held by theJMA. As a place for study that includes discus-sions by school doctors on a national scale, thecongresses have been held in various parts ofJapan since the first congress in Akita Prefecturein 1970, in cooperation with the regional medicalassociation in charge.

In order to make good use of the know-howregarding school health activities in Japan and toimprove the level of health in developing coun-tries, a project in international cooperation, the“JMA School and Community Health Project,”was begun in 1992 in Nepal, one of the develop-ing countries, and has continued for 12 years. Theproject was adopted as the prototype of the cur-rent pediatric health policy in Nepal, and hasearned a decoration conferred by the king ofNepal as the result of its valuable achievements.

Current Problems and FuturePerspectives in School Health

As mentioned previously, because of rapidchanges in society and lifestyle, Japanese school-children have a wide spectrum of new healthissues including mental heath matters such asbullying and school avoidance, allergic disease,problematic sexual behavior and drug abuse,emerging or reemerging infectious diseases,diseases and disorders of the motor apparatusdue to excessive exercise and sports, young ageof onset of lifestyle-related diseases, and so on.Thus, the field of school health is in need of new

Table 3 Matters under deliberation in the SchoolHealth Committee of the Japan MedicalAssociation during the past decade

1. School doctor as it ought to be in the new century(July 1998)

2. The modality of health education and measuresfor its promotion in the activities of school doctors(July 2000)

3. Practice of school doctor activities and means of itsexpansion (July 2002)

4. Practice of health education by school doctors(September 2004)

5. Lifetime health and school health (September 2006)



strategies. JMA considers the school doctorsystem comprising the three major specialties ofinternal medicine, ophthalmology, and otorhino-laryngology no longer suitable for dealing withsuch a wide variety of issues, and has indicatedthe need for specialists from psychiatry, obstetricsand gynecology, orthopedics, and dermatologyto attend to the aforementioned issues and toparticipate in school health activities as schooldoctors.

Since 2002, the JMA, particularly the SchoolHealth Committee, has discussed the issues ofcooperation and support of doctors from variousspecialties, and a JMA model project—the prac-tice research project on school health activitiesby doctors of various specialties—was conductedin Chiba, Kanagawa, and Osaka Prefectures in2003 and 2004. This project was further extended

to Hokkaido, Mie, and Okinawa Prefectures thefollowing year. Based on the results of thisproject, the JMA requested MEXT to expandit to a nationwide model project. As a result,the school regional health cooperation project(Fig. 1) was launched by the Japanese govern-ment in 2004 as a national program to cover all47 prefectures. Through this program, specialistsof psychiatry, obstetrics and gynecology, ortho-pedics, dermatology, and other medical fields aresent to individual schools to provide health coun-seling, educational training programs for parentsand school personnel, and other services. Recog-nizing the importance of this program, the JMAhas suggested to MEXT on all possible occasionsthat the program be perpetuated and expanded.As a result, a more extensive cooperative regionalprogram for protecting children’s health has

Uchida T

Fig. 1 School regional health cooperation project (launched in 2004)

Establishing a liaison council�Examples of constitutive members of the liaison council� Medical associations, dental associations, pharmaceutical associations, society of certified clinical psychologists, public health centers, children's consultation offices, people of experience or academic standing, etc.

Project requests from MEXT

Prefectural education boards

Subjects of discussion in the liaison council ▫ System of cooperation of the school and

local health authorities ▫ Production of the list of cooperative

medical specialists, etc. ▫ Implementation of joint training sessions

with local health organizations ▫ Office procedures, etc.

Applicatio

n

Request for dispatch

Medical andother specialists:

Psychiatrists,Dermatologists,Ob-gyns,Child guidancespecialists, Publichealth nurses, etc.

Schoolchildren and students,school personnel, guardians

Participation inhealth counselingand health education

Dispatchingmedical specialists,etc.

Guidance at health counseling sessions for schoolchildren and guardians; Participation in classwork, e.g., practical first aid as part of special school activities; Guidance in training sessions to deal with mental and physical health issues for school personnel; Counseling by medical specialists (telephone, facsimile, e-mail, etc.); and other activities

Regional bodiesconcerned:

Medical associations,Clinics / hospitals, Public health centers,Children’s counselingoffices, etc.


expanded to a total of 111 areas, comprising 2areas each of 47 prefectures and 1 area eachof 17 government-decreed cities was includedin the estimate of national budget requests forfiscal 2008. To achieve smooth operation of thisprogram in various parts of the country in thefuture, the following will be needed: various effortsincluding reinforced cooperation of local medicalassociations and boards of education, develop-ment of health education materials and applica-tion of information technology by the JMA andprefectural medical associations, and creatingteams of specialists on a regional basis throughthe cooperation of specialists from a variety ofmedical fields. The JMA has high expectationsthat the various issues emerging in school healthin Japan will lead to solutions through theseactive efforts.

On the other hand, the probability of deathfrom any of the three major causes—malignantneoplasm, cardiac disease, and cerebrovasculardisease—exceeds 50% in Japan for both males andfemales of any age. One-third of national health-care expenditures are used for the treatmentof these lifestyle-related diseases. Consideringthe enormous economic loss from lifestyle-related diseases in individuals and society, rapidand radical actions are called for. Measures ofsecondary prevention alone, such as early detec-tion by health screenings and early treatment,are not sufficient to deal with these problemsadequately. Thus, increasing importance is beingplaced on primary prevention centering on life-style modification. As a practical strategy, it isimportant that children learn and practice propereating habits, engage in physical activity, andestablish good sleep habits in order to have awell-balanced lifestyle that leads to the preven-tion of lifestyle-related diseases. It seems that

health education and health management willprovide a firm basis of lifelong health in school-children and will become an integral part of therole assigned to school doctors in the future.

Concluding Remarks

As described above, one of the foundations ofnational public health has been the establishmentof school health in Japan. These efforts haveled to today’s high health standards and long-living society, results which the JMA has madesignificant contributions to attain. Sharing itslong experience in the school health area, theJMA also launched a school/community healthproject in Nepal and achieved great success indecreasing the mortality of children. Recognizingthe achievements of the JMA’s activities in Nepal,the Nepalese government established a conceptof “School Health” to be jointly supported by theMinistries of Health and Education. This is thestarting point for increasing health standards inthat country. The development and improvementof school health in developing countries wouldproduce great benefits of the people of thesecountries.

The JMA intends to do its best not only toimprove the quality of school health in Japan,but also to make substantial contributions to thepromotion of global health activities. As a long-standing member of the World Medical Asso-ciation (WMA) and one of the founders of theConfederation of Medical Associations of Asiaand Oceania (CMAAO), the JMA has a highresponsibility to make efforts in this area. It is ourhope that the experience of Japan and the JMAdescribed in this article will provide suggestionsfor the efficient development of school healthactivities in other nations.



Conferences and Lectures

The 25th CMAAO Congress and the 43rd Council Meeting:COUNTRY REPORTS

Hotel Royal Cliff Beach and Resort, Pattaya, ThailandNovember 18–20, 2007

The 25th CMAAO (Confederation of Medical Associations in Asia and Oceania)Congress and the 43rd Council Meeting was held from November 18 (Sun.) to 20(Tue.), 2007, in Thailand. This issue of the JMAJ features the country reports of sevenNMAs presented during the Country Report session on November 19 in which eachmember NMA reported its major activities over the past year.

This year’s congress was attended by some 50 representatives of 13 member NMAs.With the re-admittance of the Sri Lanka Medical Association officially decided,CMAAO now has a membership of 17 medical associations. CMAAO was foundedin 1965 with a membership of 10 medical associations, but substantive activity beganat the 1st CMAAO Congress held in Tokyo, Japan, in 1959. For this reason, this year’scongress considered plans for events celebrating the confederation’s 50th anniversaryin 2008/2009 as well as invigoration of confederation activities.

Decisions made concerning CMAAO operations included newly appointing alegal advisor to provide support for legal aspects of future confederation activities;revising the Constitution and Bylaws to renew and strengthen organization; andmaking efforts to recruit those NMAs that are members of MASEAN (MedicalAssociation of South East Asian Nations) but not yet of CMAAO.

At the Opening Ceremony held on November 19, Professor Dr. Somsri Pausawasdi(Immediate Past President, The Medical Association of Thailand) was installed asthe 28th President of the CMAAO (term: 2 years; 2007–2009) and presented with theCMAAO Presidential Medal by out-going President Dr. Jae Jung Kim of KoreanMedical Association.

The symposium held on November 20 on the theme “Arts and Science of HealthyLongevity” will be featured in the JMAJ 51(2).

Handover of a Presidential Medal


HONG KONG MEDICAL ASSOCIATION

CHAN Yee-shing Alvin*1

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

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Chan YA




Chan YA




Chan YA


INDONESIAN MEDICAL ASSOCIATION

Ihsan OETAMA*1

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

Country Report


Oetama I


INDONESIAN MEDICAL ASSOCIATION


JAPAN MEDICAL ASSOCIATION

Kazuo IWASA*1

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

Grand Design 2007 Published by theJMA

The JMA recently published a policy analysisdocument titled “Grand Design 2007” based onthe discussions with the JMA Research Institutestudy group on the future of Japanese healthcare.This grand design lays the analytical foundationsfor state finances overall in order to give directionto the reconstruction of the health insurancesystem and discusses total analysis of nationalfinance to see how healthcare as the core of socialsecurity should be treated in the future. Based onthese two pillars, we are trying to evaluate thecurrent healthcare provision system to find mostappropriate way of how the environment toensure quality healthcare should be providedand discuss the most appropriate way of the costsharing by the Japanese people for healthcare. Ofthese, the general statement will be published inEnglish translation in the JMA Journal of theJapan Medical Association in installments, andwe encourage you to read it.

The 27th General Assembly of theJapan Medical Congress

The General Assembly of the Japan MedicalCongress met in Osaka in April 2007. Its themeswere “life, people, and dream,” and 25,000 peopleattended it. The General Assembly meets onceevery 4 years. Its first meeting was in 1902, andthis year was its 27th meeting. The GeneralAssembly now has a tradition of over 100 years.During the period of this General Assembly,the officers of the Korean Medical Associationin charge of scientific affairs visited Japan andconducted an exchange of opinions with JMAofficers including myself.

JMA Research Institute Celebrates 10thAnniversary

This year the JMA Research Institute, the JMAthink tank, celebrates the 10th anniversary ofits foundation, and an event was held in Aprilto mark the occasion. Dr. Michael Reich, TaroTakemi Professor of International Health at theHarvard School of Public Health, and Mr. KeizoTakemi, then Vice Minister of Health, Laborand Welfare, joined Dr. Yoshihito Karasawa,President of JMA for a panel discussion onhealthcare. People interested will also find thiscontent published in the JMA Journal.

WMA Medical Ethics Manual

In 1999 the WMA reached agreement to publishits own medical ethics manual, and the Englishversion was accordingly completed in 2005.Individual national medical associations have beenpreparing translations of this English version intheir own national languages and distributingthem at a national level to people involved withhealthcare and legal affairs. The Japanese versionis the 13th produced. Copies were donated to the160,000 members in Japan and to all currentmedical school students. We understand that itis widely used as a textbook in ethics trainingprovided to clinic and hospital staff in Japan.

Indonesia Tsunami Recovery SupportProject

The JMA collected over 60 million yen or500,000 US$ in donations for Indonesia to assistwith recovery from the 2005 Indian Ocean earth-quake and allocated this sum through the AsianMedical Doctors Association or AMDA towardsthe establishment of a healthcare center in thesuburbs of Jogjakarta, Indonesia. Dr. Ishii, as

Country Report


CMAAO Secretary General, visited Indonesialast March in order to exchange memorandum

of understanding with the Indonesian HealthMinistry and the Indonesia Medical Association.

JAPAN MEDICAL ASSOCIATION


KOREAN MEDICAL ASSOCIATION

Dong Chun SHIN*1

Government’s Plan to Develop ‘MedicalIndustry’ and Revision of Medical Law

In 2005, the Korean government launched itsstrategic plan to develop the medical sectorinto a core future industry in Korea and hascontinued with follow-up measures to supportthe plan. The measures include diversificationof for-profit-business of hospitals, establishmentM&A procedures for hospitals, developmentof high-tech medical industry complexes andpromotion of private health insurance. Thesemeasures require institutional support in theform of an all-out revision of the Korean MedicalLaw, which was last revised 30 years ago. KMAagrees in principal to the government’s directionof active medical area promotion but at thesame time emphasizes that measures to preventnegative impact on underprivileged people shouldcome first. KMA also expresses concern that thegovernment’s plan is focused only on the hospital-level and doesn’t include strategies to strengthenfinancial structures of clinic-level medical services.Moreover, the plan cannot become fundamentalmeasures because it fails to address issues suchas improvement of regulations, review of under-estimated physician fee and increase of socialhealth insurance contributions. Regarding theproposed bill of the Medical Law revision, KMAclearly opposes it, as some provisions impose tooheavy legal obligations on physicians and someraise serious concern by expanding the scopeof practice by non-physician professionals. Forinstance, the bill stipulated that the obligation toexplain to patients is a ‘legal duty.’ The KMA’sposition is that this obligation is considered a‘moral obligation’ of physicians and should bedealt in the area of medical ethics. The bill alsodrafted a new stipulation banning on false keepingof medical records. False keeping of medical

records can be dealt with within the concept of“fraud” on the current criminal law and recklessestablishment of another penal stipulation mayresult in overuse of administrative disposition.KMA is planning to further keep a keen eyeon the proceedings of the bill and continue toexpress its stance to the government.

Criticism on Government’s Plan toEnforce Generic Prescribing

The government announced the plan to urgephysicians to issue generic prescribing as a wayof reducing health expenditure. One of thebiggest cost increases in Korean health care isprescription medications. On average, medica-tions accounted for over 30% of the total healthinsurance expenditure in 2005. KMA warned thegovernment that rushed enforcement of genericprescribing without proper infrastructure andstringent institutional requirement to ensure thesafety and quality of generics would harmpeople’s health. It was found in 2006 that somebioequivalence test results of generics werefabricated by the inspecting institutions. As aresult, their marketing approvals were cancelled.The Korea Food and Drug Administration(KFDA) is currently re-inspecting the bioequiva-lence of generics previously approved. However,notwithstanding this circumstance and KMA’sconcern, the government went ahead with a pilotprogram of generic prescription starting with theNational Medical Center (NMC) in September2007. Another concern of KMA is generic sub-stitution. Generic substitution may underminethe relationship between doctors and patients.Doctors face difficulties in treating patients,because changes in medication can influencecompliance with the course of treatment. Duringthe first 2 months of the pilot program, only 29 %of the patients subject to generic prescribing

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

Country Report


have been actually prescribed by generic names.KMA believes this low rate of compliance is aclear reflection of the concerns Korean physi-cians have about this new approach. KMA willcontinue to monitor the re-inspection processof KFDA to ensure the safety and quality ofgenerics and keep members and the publicinformed about the risk of hasty enforcement.

Controversies over a Bill on MedicalMalpractice Law

The National Assembly Sub-committee on Legis-lation passed a draft bill on Medical MalpracticeLaw in August 2007, imposing the burden provingno-fault on physicians. Efforts to legislate aMedical Malpractice Law have existed for 20years in Korea, but an agreement was neverreached due to its strong ramifications on thebehavior of physicians, the quality of medicalservices and thus on the entire health caresystem. The 2007 draft bill reflected opinionsof civil groups to a great extent in the followingcontroversial issues: 1) imposing the burden ofproving no-fault on physicians and 2) changingarbitration to a voluntary process. (Medicalmalpractice arbitration committee will be estab-lished, but whether to bring individual cases tothe committee depends on patients’ decisions.This means that patients can file a lawsuit withoutgoing through an arbitration process)

KMA expressed clear opposition to this draftbill. Imposing the burden of proving no-fault onphysicians will result in passive and defensivemedical treatment and avoidance of specialtieswhich involve a high possibility of medicalmalpractice among trainee for residency.

This bill failed to be submitted to the plenarysession of the National Assembly and wasautomatically annulled with the end of the termof the National Assembly this year. However,the lawmaker who proposed this bill is expectedto introduce the bill again next year. KMA willcontinue to make clear its stance and concerns onthe bill to lawmakers and the public. It plans todraft a separate bill which defines the burden ofproving no-faults based on general principles andmaintains an obligatory process of arbitration.

Preparation for 2008 WMA GeneralAssembly

The KMA will host the 2008 World MedicalAssociation (WMA) General Assembly in Seoulnext year (The Shilla Hotel) from October as apart of celebrating its centennial anniversary.With the assembly only one year away, KMAis pulling an all-out effort for the successfulhosting. Promotional materials (video, posterand leaflet) were presented at the 2007 WMACopenhagen General Assembly held last month,which attracted participants’ attention fromvarious countries. At the assembly, the proposedtheme for the scientific session “Health andHuman Rights” was approved. The preparationcommittee is now working on a detailed programand inviting renowned speakers for each session.A photo exhibition displaying the history ofKMA and medical societies is planned in parallelwith the Assembly. It will become an opportunityto look back on the traces of the medicaldevelopment in the last century and to set futurepriorities and strategies for the next century.



Shin DC




Shin DC


NEW ZEALAND MEDICAL ASSOCIATION

Peter FOLEY*1

the most urgent cases get priority in publichospitals. A major issue has been the removal ofsubsidies, in some regions, for patients of privatespecialists who require laboratory tests. TheNZMA believes this is inequitable and unfairboth to the patients and private specialists.

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 concernto the NZMA is the fact that although the Actpermits regulations to be made which wouldallow for elected members to the Medical Councilof New Zealand (MCNZ), to date, the Ministerof Health has not done so. For the MCNZ towork effectively it must have the respect andconfidence of the profession, and that will nothappen while there are no directly electedmembers.

The medical workforce in New Zealandcontinues to be under extreme stress. The highfees and resulting debt levels incurred by medicalstudents in training lead to many newly-qualifiedNew Zealand doctors seeking higher-paid posi-tions overseas. Other problems include:• Increasing demand• Ageing workforce• Doctor dissatisfaction and morale leading to

retention issues• Insufficient medical student places (self-

sufficiency is needed)• Student debt• Long lead time to train doctors• Generational changes in work-life balance ex-

pectations• Inappropriate reliance on overseas trained

doctors (OTDs)Many of New Zealand’s practising doctors

*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 now 2years into its third 3-year term, and is in a phaseof consolidation rather than implementing newinitiatives. This Government now faces a strongchallenge from the main Opposition party, whichis leading in the polls.

Over the past 15 years democratically-electedregional hospital boards have been set up, abol-ished 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. The continuing inability ofmany DHBs to meet their commitments in respectof patient access to secondary and tertiaryservices continues to be of great concern. This isparticularly so in relation to first appointmentwith specialists, and the long waiting times formany elective procedures. The situation is furthercomplicated by the returning of many patientsfrom hospital waiting lists to the care of their GP.This lack of timely access to the care they needcauses great distress to many New Zealandersand their families.

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 fundingrestraints and restricted waiting lists mean only

Country Report


trained elsewhere in the world—currently 42%are from overseas countries. Doctor shortages insome regions and notably in rural areas continueto place extra demands on the profession.Specialities such as obstetrics, psychiatry andgeneral practice are particularly short. TheGovernment has established a Medical TrainingBoard to find solutions to workforce problems.The NZMA has long called for a comprehensivestrategic plan for the medical workforce whichwill address both the short and long term needfor medical practitioners in New Zealand.

Seven years ago the Government releasedits Primary Health Care Strategy, based oncapitated funding to general practices whichenrol their patients as members of a PrimaryHealth Organisation (PHO). PHOs receive publicfunding through District Health Boards. This wasthe biggest shake-up of the primary health sectorfor half a century.

The New Zealand Medical Associationsupported the broad proposals of the PrimaryHealth Care Strategy as having the potential toimprove the health of New Zealanders and theiraccess to primary health services. The Governmenthas progressively rolled out increased fundingto all age groups, which has enabled patient co-payments to be reduced. We have fought hard toretain the principle that GPs be able to set theirown fees, and charge a co-payment if necessary(as the government funding does not cover theentire cost of visiting a GP). The control of GPfees is shaping up to be a major election issue.

The NZMA continues to publish the NewZealand Medical Journal, which has been onlineonly since 2002. The NZMJ is the premierscientific medical journal for the profession inNew Zealand, and continues to publish wellregarded research on a wide variety of medicaltopics.

The NZMA provides the Code of Ethics forthe profession in New Zealand, and has beenreviewing the Code this year.

The NZMA works closely with the NZMedical Students’ Association, recognising thatstudents are the future of the profession. TheNZMA also has a Doctors-in-Training Council,which represents the interests of junior doctorsand medical student members.

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

issues.• Running a successful Trainee Forum, with

participation from registrars from many of theMedical Colleges.

• The establishment of a Leadership Fund tosupport participation in leadership activities.

• Settling the largest multi-employer collectiveemployment agreement ever to be negotiated inNew Zealand (representing GPs as employersof practice nurses).

• Launching a new publication—the NZMJDigest.

• Producing a member resource on the CommerceAct, to enable medical practitioners to developan understanding of competition law andpractise safely within the confines of the law.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 andadvocacy 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.

Foley P


SINGAPORE MEDICAL ASSOCIATION

Yik Voon LEE*1

*1 Honorary Treasurer, 48th Council, Singapore Medical Association, Singapore ([email protected]).

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Lee YV




Lee YV




TAIWAN MEDICAL ASSOCIATION

Ming-Been LEE*1

Striving for Medical ReconstructionFund

The increase of aging population, numbersqualify for serious injury and the introduction ofnew medical technologies have all contribute tothe annual 8–10% medical expenditure growthrate. The financial difficulty is extremely urgent.However, the Bureau of National Health Insur-ance has strengthened its control over healthcare facilities. The model it uses to control thepayment system contradicts with market mecha-nism and has led to a twisted and restrainedfuture for the health care development.

In 2005, the health care expenditure countedfor 6.16% of GDP in Taiwan. This is significantlylow compare to 8% in OECD countries and15.3% in the U.S.A. There is no doubt thatTaiwan is offering high quality health careservices with insufficient resource. Nevertheless,health care facilities face a discounted paymentsystem. This will danger the health care systemif it induces the health care facilities to collapseand the providers to break down.

In order to maintain the health service quality,improve peoples’ habit of accessing health careservices and health care system default, hold thepublic health system together, assure patients’right to access health care services, we havebeen striving for the government to budgetingthe “medical reconstruction fund” for 2 years.The main purpose is to add the budget to theunbalanced global budget payment system. Thepremier has finally agreed our appeal for 50billion dollars “medical reconstruction fund”budget in September of 2007.

Insurance Certification—IC card

Taiwan introduced National Health Insurance in1995. With the need of informationize, insurance

Installment of Taiwan MedicalAssociation’s New President andExecutives

Taiwan Medical Association held the presidentialelection at the first Representative Congress ofthe 8th term in May of 2007. Dr. Ming-Been Leewon majority votes from the representatives andcouncils and was installed as the new presidentof Taiwan Medical Association. In order toundertake our responsibilities as a member ofthe global society, Dr. Lee stresses his desireto strengthen the communication with othermedical associations and to share Taiwan’smedical system and experience through frequentinteractions.

Taiwan Medical Association WasAwarded the 2006 Excellent NationalProfessional Organization by Ministryof the Interior

In order to strengthen the function and structure,and enhance the development of professionalorganizations, Ministry of the Interior in Taiwanhosted an “Excellent National ProfessionalOrganization” performance screening. TaiwanMedical Association stood out from among 7,800organizations and was awarded by the Ministerof the Interior for the following reasons: Aggres-sively participate in cooperative plan hosted bythe Department of Health and WMA activities;undertake physician clinics global budget task;build global informational network; assist in phy-sicians’ national insurance enrollment, paymentand brochures’ edition; establish medical dedica-tion award to cite for physicians’ exceptionaldistribution to the health care industry; assistDOH in drawing up “Patient Safety Guidelines”as a reference to patients and families.

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

Country Report


certification evolved from paper into IC cardin 2004 and the first stage registration anduploading was implemented at the same time.In order to increase the accuracy of medicalinformation, reduce the consumption of medicalresources, monitor health care facilities thatpatients access and assist in the implementationof various prevention measures, the Bureau ofNational Health Insurance in Taiwan adopted adisciplinary and rewarding method to requesthealth care facilities to cooperate with secondstage registration and uploading in 2007. Themain contents include primary and secondarydiagnosis, medication, physician orders, fees...etc.However, Taiwan Medical Association continuesto negotiate with Department of Health and theBureau of National Health Insurance not toforce the implementation by using disciplinaryway due to the suspection from different facetssuch as: facilities’ settlement, ability to handleinformation and the doubt of service quality,ethics, privacy, legal and practical operation. Weare still continuing our talks with other partiesin order to reduce the impact this has caused tohealth care facilities.

Taiwan Medical Association Signed aMemorandum of Understanding withthe Argentina Medical Association

Taiwan Medical Association signed a bilateral

Avian Flu cooperative memorandum of Under-standing with Dr. Jorge Carlos Janez, Presidentof the Argentina Medical Association, in Aprilof 2007 based on the standpoint of “diseaseswithout borders.” The main purpose is to bringNGO’s participation in international epidemicprevention into play through both organizations’interaction and cooperation with the hopeto assist people and government from bothcountries to completely prevent avian flu fromhappening again.

Taiwan Medical Association’sRepresentative Made a Keynote Speechin 2007 World Medical Assembly

Dr. Heng-Shuen Chen from the Taiwan MedicalAssociation was invited to be the speaker of2007 World Medical Assembly Scientific Sessionon the topic “e-Health Solutions for Systems inDevelopment.”

Dr. Chen gave a detail introduction onTaiwan’s medical technology, such as IC card,telemedicine, the development and research intelemedicine in recent years, and how to combineother information systems to promote healthcare quality...etc.

TAIWAN MEDICAL ASSOCIATION


Lee MB


Research and Reviews

Body Donation: An act of love supportinganatomy education

JMAJ 51(1): 39–45, 2008

Tatsuo SAKAI*1

AbstractCadavers for anatomical dissection in Japan are supplied totally by body donation. At present, 210,000 personshave been registered for body donation and donation of 77,000 bodies has been conducted. The supply isgenerally sufficient. To extend the spirit of love associated with body donation, Tokushi Kaibo Zenkoku Rengokai[National Confederation of Anatomy Body Donation] conducts PR activities using publications and lecture meet-ings. A distinct feature of body donation in Japan is the fact that the ashes after dissection are returned to thefamilies of body donors. This practice reflects the strong attachment of Japanese people to the remains ofdeceased relatives. In Western countries, the ashes are not usually returned to the families, and donated bodiesare used for various purposes, such as the study of human body damage in car crash experiments and thepreparation of anatomical specimens for exhibitions. Japanese laws place restrictions on cadaver dissection withrespect to place, instructors, purposes, and courtesy, and strictly limit the use of cadavers for purposes other thanthe education of medical students. Medical students in Japan perform dissection with deep understanding of thegoodwill of body donors and the feelings of their families. This fact contributes tremendously to the effectivenessof ethical education.

Key words Medical education, Cadaver dissection, Body donation, International comparison

work in the dissection course and the personalityof their anatomy professors.

Decades ago, the bodies used for cadaverdissection were mostly those of persons thathad died from sickness without relatives. Atpresent, almost all bodies for cadaver dissectionare donated. Body donation is the act of givingaway one’s body after death without any condi-tions or rewards for the sake of education andresearch in medicine. When a body is donated, ittakes 2 to 3 years before dissection is performed,cremation is done, and ashes are returned tothe family.

Rumors were once circulated that body dona-tion was rewarded with money or favoritism inthe provision of medical services at hospitals. Ido not deny the possibility that some universitystaff might have provided some benefits at their

*1 Professor, Department of Anatomy, School of Medicine, Juntendo University, 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.136, No.3, 2007,pages 541–547).

Introduction

Every year, a large number of students areadmitted to the medical and dental faculties ofcolleges and universities in Japan, and experiencecadaver dissection. The number of students ina year exceeds 10,000, approximately 8,000 inmedicine and 2,500 in dentistry, and the numberof donated bodies used in the dissection coursesfor them is approximately 3,500.1,2 The cadaverdissection course is the gateway to a medicalcareer for almost all students aspiring to workin medicine, and the source of precious memoriesthat are the first to be recalled when they laterlook back on their student days. Probably most ofthe 270,000 physicians in Japan dearly remembertheir school days with recollections of their hard


Sakai T

discretion in the 50-year history of body dona-tion. However, present day body donation hasnothing to do with such provision of benefits.Body donors are wholeheartedly glad that theirbodies will serve the progress of medicine afterdeath. Taking the gratuitous love of body donors,students learn human anatomy and start their firststeps towards becoming fully trained physicians.3

This article, outlining the distinctive featuresand present state of anatomy education and thebody donation movement in Japan, calls forfurther understanding and support of all peopleengaged in medicine.

Present State of Anatomy Education

With the rapid progress of medicine, medicaleducation has been undergoing incessant drasticchanges. As compared with the times when I wasa student about 30 years ago and when I startedto teach at Juntendo University about 15 yearsago, medical students nowadays need to learnmuch more in the same length of 6 years.

For effective learning, textbooks and referencebooks have been improved to be more userfriendly and direct, and the use of Power Pointduring lectures now helps the delivery of suffi-cient knowledge in a compact timetable. Themeans to increase the learning ability of medicalstudents have also been introduced, such as earlystart of experience-based learning and small-group tutorial classes. To standardize medicaleducation, the core curriculum was developed in2001, and the Computer Based Testing (CBT) formeasuring the achievement of medical studentsin Japan was introduced in December 2005. Inthe context of continuing change in medical edu-cation, the position of cadaver dissection requiresconstant revision.

The number of hours allocated to cadaver dis-section and lectures in anatomy has decreasedconsiderably. However, it always remains truethat cadaver dissection is the core part of edu-cation in anatomy, and anatomy provides thefoundation for the entire medical education. Thegreatness of the mental and physical burdensassociated with dissecting human bodies alsoremains unchanged. As medical education hasbecome more and more standardized andefficient, the role of the cadaver dissection coursehas become even more important. It provides aprecious occasion for students to be confronted

with the human body. The body of a person lyingin front of them means various things for theperson, for the family, and for physicians. Withsuch thoughts in mind, students excavate nerves,blood vessels, organs, muscles, and other struc-tures, and explore the mechanisms supportingthe human body.

At Juntendo University, students of the schoolof medicine attend the dissection course fromlate October to early February in the secondyear. The moment when students meet the bodyto be dissected is full of tension. Each body on thetable is a person, who has lived a life of severaldecades, and is lying there because he or shewanted to. Everybody in the dissection coursesilently prays for the souls of body donors (Fig. 1).

However, once the covering cloth is removed,and a knife cuts the skin to reveal the interior ofthe body, the body instantly becomes a cadaver.During the 4 months that follow, students arebusy identifying and removing each and everystructure constituting the human body—muscles,blood vessels, nerves, thoracic and abdominalorgans, etc. They realize that the body of a personis an assembly of tangible objects. The experienceof doing this using their own hands is invaluable.On the other hand, students are fully aware thatthe structures taken out of the cadaver are some-thing more than physical objects. This is becausethey have met the body as a person with dignity,and because they themselves have changed it toan object of science called a cadaver.

On the other hand, body donors are proud

Fig. 1 The first day of the cadaver dissection course inJuntendo University School of Medicine

Before meeting the bodies, all attendants pray silently for thesouls of body donors.


BODY DONATION: AN ACT OF LOVE SUPPORTING ANATOMY EDUCATION

of being body donors and find fulfillment in con-tributing to society. The late Mr. Akira Nawa,former President of “Shiraume-Kai” society ofbody donors to Juntendo University, used tosay that he was taking good care of his body sothat he could better serve medical students. Thebody donors to Juntendo University gather at thegeneral meeting of Shiraume-Kai, held everyyear in the fall. Juntendo considers this meetingas an important occasion for expressing thanksto body donors, and the meeting is incorporatedin the curriculum of second year students, whoperform cadaver dissection. All second year stu-dents cooperate in the operation of the meetingas volunteers. They sit around the same tables withbody donors and have conversation. Throughthis direct interaction, body donors are reassuredof their roles in helping the development ofmedicine, and students understand the profoundmeaning of being allowed to dissect donatedbodies. Thus, body donors are helping the growthof medical students, and medical students aregiving a sense of fulfillment to body donors. Iquote the following words by a student.

When I was in front of the body, I wasintimidated by the presence called death. I felt

as if my heart was squeezed tight. Probablybecause I had seen the death of my grand-father, I was going to be overwhelmed by theseriousness of the meaning of death. Promptedby my mentor, I took up the knife, which feltheavy. I hesitated, because of the doubt that itmight be wrong to cut into a body that shouldbe respected, and a complete stranger like Imight not be allowed to touch the body in sucha way.

Encouraged by the serious undertaking ofmy mentors and friends, I was able to completethe course. However, I have not forgotten theanxiety and discontent I felt in the beginning.

As time passed, I came to realize thethoughts of body donors and their familieswho agreed on body donation. I am sure thattheir decisions were the result of their strongwill, as well as much emotional conflict. I feltsincere gratitude for their goodwill. I wishedI could bow in front of body donors in lifeand thank them and their families. As this wasno longer possible, I thought the only thingI could do for them was to continue study-ing with respect and thankfulness. (From thespeech by Ms. Asako Nishino, the representa-tive of students, at the ceremony of returning

(Compiled from Tokushi Kaibo Zenkoku Rengokai: The State of Body Donation, List of Associations 2006.)

Fig. 2 Number of persons registered for body donation and number of body donations conducted, compiled fromdata for donor associations

(Persons)

(Year)

200,000

Number of persons registered for body donationNumber of body donations conducted

150,000

100,000

50,000

0

1969

200070 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 91 92 93 94 95 96 97 98 9990 01 02 03 04 05


ashes of body donors for systemic anatomy,Juntendo University, 2006.)

Physicians do not often recollect the experienceof cadaver dissection in their student days. Despitethe fact that the dissection course had much to dowith the development of their professional viewson humanity and life, few consciously ask howthey changed through this experience. A rareexception is the novel “Igakusei” [A Medical Stu-dent]4 written by Mr. Keishi Nagi in 1993. Thisnovel describes the growth of a medical studentwith a vivid narrative of the memories of the dis-section course.

Literary works featuring the thoughts of bodydonors seem to be even scarcer. The novel“Bizan”5 by Mr. Masashi Sada is the story of awoman who donates her body and the daughterof the woman. Their thoughts on body donationare given a substantial weight in this novel.

The Present Day Body DonationMovement

Tokushi Kaibo Zenkoku Rengokai [NationalConfederation of Anatomy Body Donation] isthe organization formed by universities perform-ing cadaver dissection and body donor asso-ciations in Japan. In cooperation with NihonTokushi Kentai Kyokai [Japan Body DonationAssociation], the Confederation performs out-reach activities to promote the significance ofbody donation. It was established in 1971 againstthe background of a serious shortage of cadaversfor medical education, and has been makingactive efforts to influence the government andvarious organizations.

Starting from 1982, body donors are presentedwith letters of thanks from the Minister of Edu-cation, Science and Culture (present Ministerof Education, Culture, Sports, Science and Tech-nology). The Law Concerning Body Donationfor Medical and Dental Education (the BodyDonation Law) was enacted and enforced in1983. From this time, body donation becamewidely recognized in society, and the number ofpersons registered for body donation increasedrapidly (Fig. 2). As of the end of March 2006,the accumulated number of persons registeredfor donation reached 210,605, and donation of77,645 bodies has been realized.1 At present, thebodies for cadaver dissection courses in medical

and dental faculties are almost completely sup-plied by body donation, and many universitiesare restricting or declining new registration forbody donation.

After attaining the goal of securing a sufficientnumber of bodies, the body donation movementat present has two important issues that need tobe addressed.

One is the realization of more enrichedanatomy education through body donation. Inother words, the goal is the qualitative improve-ment of body donation and anatomy education.To this end, the Federation is issuing variousPR materials and distributing them to anatomydepartments and body donor associations acrossJapan. Collections of writings by body donorsand students performing cadaver dissection,entitled “Kaibogaku he no Shotai” [Introductionto Anatomy], are produced every year. (In 2006,the 26th volume of body donors’ writings andthe 28th volume of students’ writings were pub-lished.)6 Another yearly publication is “TokushiKentai” [Goodwill Body Donation] distributedat the general meeting of the Federation. (No. 48was published in 2006.) A manual for personsdealing with the practical aspects of body dona-tion, entitled “Kentai no Tadashii Rikai noTameni” [For Correct Understanding of BodyDonation] (called the Body Donation Manualfor short),7 and an informative document forpersons wishing to register for body donation,entitled “Kentai Toha” [What Is Body Donation](called the Leaflet for short), are always availableon request.

The second issue is how we should permit thepractice or observation of cadaver dissection inthe anatomy education of co-medical students.The anatomy departments of most universitiesin Japan accept students from many co-medicaltraining schools and they allow them to observecadaver dissection without hands-on involvementin dissection. Many nursing schools operated bymunicipalities, medical associations, and hospi-tals are relying on the observation of cadaverdissection at anatomy departments of nearby uni-versities. Through such observation of cadaverdissection, co-medical students gain first-handexperience on the internal structure of the humanbody and develop a sense of reverence towardsthe human body, similarly to the case of medicalstudents performing cadaver dissection. Specialistsin vocations involving direct contact with the

Sakai T


body of patients, such as physiotherapists andoccupational therapists, are required to havedeep understanding of human anatomy. Forthis reason, some institutions including nationaluniversities offer cadaver dissection courses forco-medical students including actual dissectionusing knives and forceps.

The legal basis for cadaver dissection per-formed by medical students is the Law Concern-ing Cadaver Dissection and Preservation enactedin 1949. It stipulates that dissection must beconducted in appropriate places (in anatomy dis-section rooms), with instruction by appropriateteachers (by professors and associate professorsin anatomy), and for appropriate purposes (toserve for medical and dental education). Inaddition, the Law demands that bodies must behandled respectfully. Although the expression isabstract, the ethical issue of the respect of aperson’s body is addressed as a crucial matter. Atpresent, the observation and practice of cadaverdissection for co-medical education are conductedunder the responsibility of professors in anatomy,respecting the spirit of the Law ConcerningCadaver Dissection and Preservation and withinsocially acceptable ethical boundaries.

Distinct Features of Anatomy Educationand Body Donation Movement in Japan

Body donors provide their bodies after deathwithout any conditions or rewards, and studentsgratefully use their bodies without inconvenientlimitations. Although this is taken for grantedin Japan, situations in other countries differcompletely. In the United States and Europeancountries, the almost overabundant number ofbodies is supplied through body donation, andthe donated bodies are used for various purposes.The ashes after dissection are usually not returnedto the families of the body donors.

Particularly in the United States, the uses ofbodies extend widely beyond the scope of ordi-nary medical education. While an advantage isthe possibility of the study of clinical anatomyusing fresh frozen bodies, bodies are also used forvarious non-medical uses that are not imaginablein Japan. For example, bodies are reported tohave been used in car crash experiments examin-ing the damage to the human body for the pur-pose of improving safety devices on automobiles,and in experiments examining the impact of

bullets and bombs on the human body for thepurpose of improving protective body armors.8,9

In addition, a person managing the body dona-tion program at the University of California LosAngeles was arrested for smuggling cadaversin 2004.

In Germany, restrictions on cadaver dissectionare relatively weak. Private laboratories acceptmany donated bodies and produce plastinatedspecimens from them. These are presented at theexhibition called BODY WORLDS in variouscountries. Displaying cadavers arranged in variousposes, such as riding a horse and playing chess,this exhibition has been the focus of much contro-versy. The German Anatomical Society has offi-cially issued a statement against this exhibition.10

China has no system of body donation, andmedical students are unable to perform neces-sary cadaver dissection. Chinese students visitingJapan often admire the excellent cadaver dissec-tion courses in Japan. On the other hand, thereare workshops producing plastinated specimensin various locations in China. Although the ori-gins of the cadavers are unknown, many anatomi-cal specimens produced at such workshops areexported. Commercial-based human anatomyexhibitions using Chinese-made specimens areheld in Japan and Korea, attracting many visitors.

In Taiwan, a body donation movement wascommenced by Tzu Chi Medical School (presentTzu Chi University) operated by a Buddhistfoundation. However, the shortage of cadaversstill remains unsolved.

Body donation in Japan is an excellent prac-tice that has no counterparts in the world. Wehave an ideal education environment, in whichstudents can perform dissection using the abun-dant supply of cadavers filled with the love ofbody donors and their families. This is the fruit ofthe efforts made by body donors and universitypersonnel that have supported the body dona-tion movement, as well as the understanding andsupport of the public. Anatomists in Japan arealso fully responding to such efforts. While anato-mists in the United States and Europe tend tofocus on biological study and stay away fromeducation in anatomy, those in Japan are keep-ing the balance between education and researchand accomplishing considerable achievements inboth aspects.

While plastinated specimens have great edu-cational value, importation of plastinated speci-



mens produced in other countries can be a formof cadaver trade unless certain restraints are used.It is difficult to produce plastinated specimens inJapan, because body donors are not ready toagree on such use of their bodies.

Towards the Future of AnatomyEducation and the Body DonationMovement

Even if body donation and anatomy education inpresent day Japan are praiseworthy, there aremany difficult problems to be solved for the future.The support and understanding of the medicalcommunity and the public are still required.

The first problem is the scarcity of younganatomists who are to support the education andresearch in anatomy. This problem is not uniqueto anatomy, but is shared by all fields of basicmedical sciences. However, the training of anato-mists is not a matter of learning techniques frommanuals, and it depends more heavily on theaccumulation of experience than that in otherfields. In operating a cadaver dissection course,one need not only perform dissection in thedissection lab, but must also deal with variousdelicate tasks, such as communicating with per-sons registering for body donation, respondingto the family and receiving the body, applyingpreservative treatment to the body, conductingmemorial services and body donors’ meetings,and returning the ashes to families. Experience isalso important in such peripheral tasks.

The second problem is the rapid destabiliza-tion of the education and research environmentat universities, which is further complicating thesituation. The working budget is compressed, andresearchers are encouraged to acquire competi-tive research funds. The conversion of public andnational universities to independent administra-tive institutions also resulted in the tighteningof the budget. It is virtually impossible to takethe first step of a research program using auniversity’s own research funds.

Much of the time and labor of anatomists arespent on education in the cadaver dissectioncourse, leaving very little for research. In addi-tion, although anatomical studies are quoted inother works over a long period of time and theirinfluence is widespread, they are disadvantagedin terms of the impact factor and the effectivenessin raising research funds. There is a clearly grow-

ing tendency that the appointment of new profes-sors is made based on the volume of researchachievements and the ability to raise researchfunds. In the present environment, researchers inbasic medical sciences are hard pressed to produceimmediate results in research, giving up educa-tion. This is a result of the competitive principleworking only in the aspect of research achieve-ments, which are easy to evaluate objectively. Onthe other hand, objective evaluation is difficult inthe aspect of education, including the characterdevelopment of medical students. In the face ofthis reality, anatomists supporting anatomy edu-cation are increasingly becoming wary of makingefforts.

The third problem in anatomy education isthe presence of many risks, which are insepara-bly related to educational effects. Preventionof infection from bodies before preservativetreatment, protection of students and teachingstaff against the health hazard of formalin fromcadavers, emotional conflicts with body donorsand their families, judgment about cadaver dis-section courses for co-medical students, impru-dent comments on cadaver dissection incitedby mass media, and many other issues need tobe addressed. Precautions are used to preventeach of these, but measures to minimize damageafter the occurrence of an accident must also beprovided.

Above all, it is important that all people in theuniversity recognize the significance of cadaverdissection and the many risks associated withit, understand the mental and physical effortsmade by the anatomy staff and the time spentby them, and provide mental and physical sup-port to anatomy education. Without being cyni-cal, I would say that the largest challenge foranatomists at present might be obtaining theunderstanding and cooperation of the universityadministration.

Concluding Remarks

Finally, I would like to add a few words aboutthe body donation movement. Tokushi KaiboZenkoku Rengokai has been supported by coop-eration from the national government, variousassociations in medicine and dentistry, localgovernments, and other organizations. At thegeneral meeting held every year, speeches aregiven by the President of the Japanese Medical

Sakai T


References

1. Tokushi Kaibo Zenkoku Rengokai. The State of Body Donation,List of Universities 2006. (in Japanese)

2. Tokushi Kaibo Zenkoku Rengokai. The State of Body Donation,List of Associations 2006. (in Japanese)

3. Sakai T. Jintai Kaibo no Subete—Kaibogaku he no Shotai[Cadaver Dissection—An Introduction to Anatomy]. Tokyo:Nippon Jitsugyo Publishing; 1998. (in Japanese)

4. Nagi K. Igakusei [A Medical Student]. Tokyo: Bungeishunju Ltd.;1993. (in Japanese)

5. Sada M. Bizan. Tokyo: Gentosha; 2004. (in Japanese)6. Tokushi Kaibo Zenkoku Rengokai, ed. Kaibogaku he no Shotai

[An Introduction to Anatomy] 2006. Tokyo: Nihon Tokushi Kentai

Association and the President of the MedicalAssociation in the area. Nihon Tokushi KentaiKyokai receives a subsidy from the JapaneseMedical Association every year. For 20 years, theNippon Foundation provided an extraordinarysum of subsidy, as much as 100 million yen(870,000 US dollars) in total, but partly due to thefinancial condition of the Nippon Foundation,this grant was terminated ending with the pay-ment in 2005. As a result, our PR materials thathave been distributed free of charge now need tobe purchased at cost.

The body donation movement and anatomyeducation are the foundation of the high level ofethics developed through medical education in

Japan. I sincerely ask all people in universitiesand medical institutions for their further under-standing and support of the body donation move-ment and anatomy education.

<Contact Related to Body Donation>Tokushi Kaibo Zenkoku Rengokai andNihon Tokushi Kentai KyokaiRoom #404, Famil Nishi-shinjuku,3-3-23 Nishi-shinjuku, Shinjuku-ku,Tokyo 160-0023, JapanPhone: +81-3-3345-8498, Fax: +81-3-3349-1244Website: http://www.kentai.or.jp/E-mail: [email protected]

Kyokai; 2006. (in Japanese)7. “Kentai” Editing Committee, Tokushi Kaibo Zenkoku Rengokai

ed. Kentai no Tadashii Rikai no Tameni [For the Correct Under-standing of Body Donation]. Tokyo: Nihon Tokushi KentaiKyokai; 2002. (in Japanese)

8. Andrews L, Nelkin D. Body Bazaar: The Market for HumanTissue in the Biotechnology Age. New York: Crown Publishers;2001.

9. Roach M. STIFF: The Curious Lives of Human Cadavers. London:Norton; 2003.

10. Christ B, Drenckhahn D, Funk R, et al. Statement der AnatomischeGesellschaft. Ann Anat. 2004;186:193–194.



From the Japanese Association of Medical Sciences

*1 Laboratory of Molecular Epidemiology for Infectious Agents, Kitasato Institute for Life Sciences, Kitasato University, Tokyo, Japan([email protected]).

Simultaneous and Rapid Detection of CausativePathogens in Community-acquired Pneumoniaby Real-time PCR (1167)

JMAJ 51(1): 46–50, 2008

Kimiko UBUKATA*1

The Japanese Association for Infectious Diseases

Introduction

Community-acquired pneumonia (CAP) is still amajor threat to individuals, especially children andcompromised hosts such as senior citizens andpeople with underlying chronic diseases. The maincausative pathogens in CAP are Streptococcuspneumoniae, Haemophilus influenzae and Myco-plasma pneumoniae, but the rates change accord-ing to age and the underlying disease.1,2 Recently,Chlamydophila pneumoniae and Legionellapneumophila have frequently been identified ascausative pathogens of CAP.3–5 In clinical prac-tice, empirical chemotherapy with broad spec-trum antibiotics must be started based on clinicalsymptoms, chest X-rays, and clinical examina-tions, considering the severity of the symptoms.

On the other hand, the increase of resistantstrains in the CAP pathogens is a worldwide healthproblem.6 One effective measure to prevent thenew emergence of resistant bacteria is to use onlythe sufficient quantity of the most appropriateantibiotics to eliminate target pathogens. We havedeveloped a method to simultaneously identifythe six pathogens in CAP by real-time PCR withhigh sensitivity and specificity, thus reducinganalysis time and improving cost performance,toward the goal of the rapid and precise detec-tion of causative agents.7

In this paper, I will describe an outline of thenew identification system using real-time PCRassay for six CAP pathogens, S. pneumoniae,H. influenzae, M. pneumoniae, C. pneumoniae,L. pneumophila, and Streptococcus pyogenes.

Methods

Extraction of DNA from clinical samplesSamples of nasopharyngeal and sputum frompediatric and adult patients who were diagnosedwith CAP at their first visit to a hospital, werecollected after obtaining informed consent frompatients themselves or from their family members.

Firstly, the samples were suspended in 1.5 mlof PPLO broth and centrifuged at 2,000�g for5 min at 4°C to collect bacterial cells, togetherwith epithelial and polymorphonuclear leuko-cyte cells. The supernatant was discarded, andthe harvested pellet was resuspended in 150�l ofDNase- and RNase-free H2O. All DNA sampleswere extracted using EXTRAGEN II kit. Theprocess of DNA extraction was completed in 20minutes.

Identification of pathogens by real-time PCRThe six sets of bacterial specific primers andmolecular beacon (MB) probes used in this real-time PCR have been reported by us.7 Theseprimers and MB probes were designed on appro-priate genes for each pathogen; the lytA genewas selected for S. pneumoniae, the mip and 16SrRNA genes for L. pneumophila, the slo and 16SrRNA genes for S. pyogenes, and the 16S rRNAgene for the other three pathogens were selectedas a target, respectively.

As shown in Fig. 1, all of the MB probes werelabeled with a fluorescent reporter, 6-carboxy-fluorescein (FAM) at the 5’-end, and labeled witha black hole quencher 1 (BHQ-1) at the 3’-end.


The reporters and quenchers were connected tostem structure with short oligonucleotides. Thecentral region of about 20 bp, which is shown as aloop, corresponds to the sequences of each targetgene. The color development of FAM occurredby an attachment of the oligonucreotides to cor-respondent sequences of single stranded DNA atthe denature stage.

The overall protocol of real-time PCR assayconstructed by us is shown in Fig. 2. Reactionmixtures corresponding to six CAP pathogenswere employed in six wells of one strip. After theaddition of a 2�l DNA extraction to the six wells,the strip was placed on the real-time PCR instru-

ment (Thermal cycler Dice, TP800, TAKARABIO INC.), and DNA amplification was immedi-ately started at 40 cycles of PCR with conditionsat 95°C for 15 sec, at 50°C for 30 sec, and at 75°Cfor 30 sec per cycle, followed by 95°C for 30 sec.The results for every one cycle of the PCR weredisplayed on the screen of a personal computerconnected to a PCR instrument. All processes inthis protocol were completed in 1.5 hours.

Results

Sensitivity and specificity of real-time PCRThe Ct (threshold cycle) value for a positive

12

34

56

Sample

1. S. pneumoniae2. H. influenzae3. S. pyogenes4. M. pneumoniae5. C. pneumoniae6. L. pneumophila

lytA gene16S rRNA geneslo and 16S rRNA genes16S rRNA gene16S rRNA genemip and 16S rRNA gene

1.5 ml PPLO broth

Report

Centrifuge5,000 rpm

(5 min)

Real-time PCR(60 min)

Apply of DNAsample into wellfilled with PCR

reaction mixture(5 min)

DNA extractionwith Extragen II ®

(20 min)

Fig. 2 Protocols of six pathogens detection from CAP samples by real-time PCR

Molecular beacon probe

Stem structure

DNA amplification and color development

Sense primer Reverse primer

FAM (5’ end) Quencher (3’ end)QF

QF

Loop (20–23 bp)

Fig. 1 Principle of real-time PCR using a molecular beacon probe

RAPID DETECTION OF PATHOGENS IN PATIENTS WITH CAP BY REAL-TIME PCR


result was defined as the point at which thehorizontal threshold line was crossed. The sensi-tivities of PCR assay for six CAP pathogenswere high, from 2 copies for S. pneumoniae to 18

copies for S. pyogenes per reaction tube. The cor-relation coefficient between Ct and bacterial cellcounts was high from r�0.9970 of S. pyogenes tor�0.9992 of S. pneumoniae.

M. pneumoniae

S. pneumoniae

22,000

Flu

ores

cenc

e (d

R)

20,000

18,000

Cycles

Amplification Plots

16,000

14,000

12,000

10,000

8,000

6,000

4,000

2,000

0

2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40

Findings on admission• Fever: 38°C and over• Oral antibiotics prescribed: �-lactam• WBC: 6,890/�l• CRP: 14.1 mg/dL• Chest X-ray: segmental pneumonia• Severe cough

Fig. 3 PC screen after real-time PCR assay for sputum from adult patient with CAP

(A) Pediatrics (n�117)

AbbreviationsS. pn: S. pneumoniaeH. inf: H. influenzaeM. pn: M. pneumoniaeC. pn: C. pneumoniaeS. pyog: S. pyogenesL. pn: L. pneumophila

S. pn30.0%

S. pn25.0%

H. inf18.0%

H. inf7.7%

M. pn7.0%

M. pn9.6%

Unknown10.0%

Unknown44.2%

S. pn�H. inf28.0%

S. pn�H. inf3.8%

S. pn�M. pn4.0%

S. pn�M. pn3.8%

H. inf�M. pn1.0%

H. inf�M. pn1.9%

H. inf�C. pn1.0%

L. pn1.9%

S. pn�H. inf�M. pn1.0%

S. pyog1.9%

(B) Adults (n�50)

Fig. 4 Bacterial pathogens identified by real-time PCR in pediatric and adult patients with CAP

Ubukata K


The specificity of the six MB probe and primersets were examined against 27 gram-positive and-negative microorganisms selected from labo-ratory stock cultures as amplification negativecontrols. From those organisms, no non-specificpositive results were obtained.

Application of real-time PCR for clinicalsamplesFigure 3 shows the result of sputum collectedfrom a typical CAP case in a young female adult.She was diagnosed with segmental pneumonia,having a severe cough, and hospitalized. ThePCR results displayed on the PC screen suggesteda mixed infection of M. pneumoniae and S. pneu-moniae. Based on these results, medical treatmentwas conducted by combination chemotherapy.

Figure 4 shows the results of real-time PCRapplied to pediatric patients (A) and adults (B)with CAP. The sensitivity and specificity of real-time PCR assay for S. pneumoniae, H. influenzae,S. pyogenes, and M. pneumoniae for 150 clinicalsamples was determined, comparing them withthe results of conventional culture. Both the rela-tive sensitivity and the specificity of this PCR wasover 90% for all six pathogens.

Culture assay of C. pneumoniae has not beenperformed routinely in clinical laboratories, buthas instead been determined by the antibody titerin acute phase and the convalescence phase. In allof C. pneumoniae cases identified serologically,the real-time PCR gave positive results.

Although the culture for sputum was negative,L. pneumophila pneumonia was identified by PCRin the case of an adult patient. Later, L. pneumo-phila serogroup 5 was actually detected in thewater from the patient’s bathroom.

Discussion

One of the measures to decrease healthcare costsand to improve benefit for patients with bacterialinfection is to identify the causative pathogensrapidly and precisely, thus enabling the mostappropriate antibiotic to be selected at the begin-ning of hospitalization. In the case of patientswho were treated by antibiotics prior to hospital-ization, the culture method may sometimes givefalse-negative results.

By real-time PCR molecular assay, it is possibleto detect microorganisms with high sensitivityand specificity,8–10 even if bacteria have beendamaged by the antibiotics pretreatment. Basi-cally, the simultaneous detection of the mainCAP pathogens described here is desirable forrapid diagnosis of CAP and for the selection ofthe appropriate antibiotics.

To determine causative pathogens, sputum hasbeen employed in the case of adults. However,expectoration is impossible for infants and chil-dren. Alternatively, nasopharyngeal secretionsare readily obtainable from children with respi-ratory tract infections (RTIs), but the test resultsmust be analyzed carefully because healthy chil-dren also carry S. pneumoniae and H. influenzaein nasopharyngeal secretions.11

Our data demonstrates that real-time PCR withpathogen-specific MB can detect microorganismsin a few hours, and thus by this assay it is possibleto assess the time course of empirical chemo-therapy, thus supporting infection management.

Finally, we also expect that the real-time PCRtechnique described here could be expanded intoa multiplex real-time PCR to detect several RTIcausative viruses as a general diagnostic methodfor lower RTIs in the near future.

References

1. McAvin JC, Reilly PA, Roudabush RM, et al. Sensitive andspecific method for rapid identification of Streptococcus pneu-moniae using real-time Fluorescence PCR. J Clin Microbiol.2001;39:3446–3451.

2. Schneeberger PM, Dorigo-Zetsma JW, van der Zee A, van BonM, van Opstal JL. Diagnosis of atypical pathogens in patientshospitalized with community-acquired respiratory infection.Scand J Infect Dis. 2004;36:269–273.

3. File TM Jr, Tan JS, Plouffe JF. The role of atypical pathogens:Mycoplasma pneumoniae, Chlamydia pneumoniae, andLegionella pneumophila in respiratory infection. Infect Dis ClinNorth Am. 1998;12:569–592.

4. Templeton KE, Scheltinga SA, Sillekens P, et al. Developmentand clinical evaluation of an internally controlled, single-tubemultiplex real-time PCR assay for detection of Legionellapneumophila and other Legionella species. J Clin Microbiol.2003;41:4016–4021.

5. Welti M, Jaton K, Altwegg M, Sahli R, Wenger A, Bille J. Devel-opment of a multiplex real-time quantitative PCR assay to detectChlamydia pneumoniae, Legionella pneumophila and Myco-plasma pneumoniae in respiratory tract secretions. DiagnMicrobiol Infect Dis. 2003;45:85–95.

6. Morozumi M, Hasegawa K, Kobayashi R, et al. Emergenceof macrolide-resistant Mycoplasma pneumoniae with a 23S

RAPID DETECTION OF PATHOGENS IN PATIENTS WITH CAP BY REAL-TIME PCR


rRNA gene mutation. Antimicrob Agents Chemother. 2005;49:2302–2306.

7. Morozumi M, Nakayama E, Iwata S, et al. Simultaneous detectionof pathogens in clinical samples from patients with community-acquired pneumonia by real-time PCR with pathogen-specificmolecular beacon probes. J Clin Microbiol. 2006;44:1440–1446.

8. Hardick J, Maldeis N, Theodore M, et al. Real-time PCR forChlamydia pneumoniae utilizing the Roche LightCycler and a16S rRNA gene target. J Mol Diagn. 2004;6:132–136.

9. Loens K, Ieven M, Ursi D, et al. Detection of Mycoplasma

pneumoniae by real-time nucleic acid sequence-based amplifi-cation. J Clin Microbiol. 2003;41:4448–4450.

10. van Haeften R, Palladino S, Kay I, Keil T, Heath C, Waterer GW.A quantitative LightCycler PCR to detect Streptococcuspneumoniae in blood and CSF. Diagn Microbial Infect Dis.2003;47:407–414.

11. Greiner O, Day PJ, Bosshard PP, Imeri F, Altwegg M, Nadal D.Quantitative detection of Streptococcus pneumoniae in naso-pharyngeal secretions by real-time PCR. J Clin Microbiol. 2001;39:3129–3134.

Ubukata K



*1 Vice-President, Kyoto Medical Association, Kyoto, Japan ([email protected]).*2 Board Member, Kyoto Medical Association, Kyoto, Japan.*3 “Mixed Medical Services” means that the services are paid partly by health insurance and partly by other sources.This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol.136, No.3, 2007,pages 552–553).

Tochigi

Kyoto

Pop. 2.6mil.Area 4,600km2

Tokyo

Working towards an “Open Medical Association”

JMAJ 51(1): 51–52, 2008

Hideki ADACHI,*1 Hiroshi OYABU*2

The Future Course of Japanese Healthcare withthe Ban Lifted on Mixed Medical Services,*3”with a presentation by rakugo performer NankoKatsura and a panel discussion, in November2004, (2) “Our Common Interest in the Futureof Japanese Healthcare, Health Insurance andWelfare: From Child-rearing to Long-term Care,”with lectures and information booths, in June2005, (3) “The Japanese Healthcare System GoingForward 2005: What We Can Do for You, WhatYou Can Do for Your Loved Ones,” with dra-matic sketches and a panel discussion featuringformer Minister of Health, Labor and WelfareChikara Sakaguchi, Asahi Shimbun journalistHiroyuki Ota and Kyoto Medical AssociationVice-President Katsutoshi Tachiiri, in December2005, and (4) “Sea Change in Medicine, HealthInsurance and Welfare: Your Health Crisis!Autumn Campaign,” with dramatic sketches,information booths, live broadcasting on KBSKyoto Radio and interviews, in October 2006.

We also conducted two signature drives,gathering 79,632 signatures in October andNovember 2004 in the “Signature Drive to Save

Under the Previous President Aburaya the KyotoMedical Association has, in particular since 2002,conducted a range of activities with the sloganof An Open Medical Association. What thissignified was releasing information widely toAssociation members to provoke discussion andpromote the sharing of a stronger awarenessof the various problems involved in healthcare,and also maintaining an attitude of keeping thepublic, both patients receiving care and theirfamilies, informed of and engaged in healthcarepolicy and the current state of healthcare.

Since April 2006 we have developed thispolicy further under President Mori and areworking to bolster it. We report here on activitiesconducted recently and activities we are planningfor the future.

Kyoto Healthcare Promotion Council

The Kyoto Healthcare Promotion Council waslaunched in October 2004 at the instigation of theKyoto Medical Association and with the partici-pation of 24 groups, including healthcare groups,patients’ organizations and the Kyoto Federationof Senior Citizens’ Club. As of April 2007,the Council’s membership has reached 31 suchgroups. The Council periodically meets to discussissues in such fields as the healthcare system, thesystem of healthcare provision and the systemof nursing care provision, including specificexamples from the field. The issues that occasion-ally emerge from these discussions have beenraised at community meetings and featured insignature drives.

These community meetings include (1) “TheJapanese Healthcare System Going Forward 2004:


Adachi H, Oyabu H

the Universal Medical Care Insurance System: InOpposition to Lifting the Ban on Mixed MedicalServices” and 295,729 signatures in Novemberand December 2005 in the “Citizens Movementto Save the Universal Medical Care InsuranceSystem: A Rebuttal of Proposals for StructuralReform of the Healthcare System.” The 2004experience in the first signature drive proved apositive advantage in the second signature drivein 2005, as the efforts of the members of the KyotoMedical Association, who are the driving forcebehind Council campaigns, garnered over threetimes as many signatures as in the first outing.

A Circle Town of Rakugo PerformerTomaru Katsura “Everyone’s Health,Kyoto” Programming on KBS KyotoRadio

As part of our efforts to bolster publicityactivities under the new Mori leadership, inthe first week of April 2007 we began providing10-minute weekly spot programming for a regularSaturday radio program. We hope to use this1-year opportunity to make the citizens of Kyotoaware of our misgivings and proposals concerningsuch areas as the medical associations, thehealthcare system, long-term care insurance,healthcare and pharmaceuticals. We plan toinclude healthcare counseling and long-termcare counseling features and to offer advice andexchanges of views on these issues in a way thatlocal citizens can engage with.

Kyoto Medical Association “MedicalSafety Symposium”

Medical safety measures will be a prominentaspect of restoring and enhancing trust in health-care amidst the healthcare environment of recentyears, and the provision of safe and high-qualityhealthcare is a pressing task for us now. Inorder to meet this challenge, the Kyoto MedicalAssociation has established the Medical SafetyMeasures Committee, which has now held numer-ous discussions. Since 2003 it has held MedicalSafety symposium and created opportunities forcitizens and representatives of the healthcareprofessions to engage each other on the questionof “Create a new environment for patient safety.”

One hundred fifty persons attended the first

symposium in February 2004 to hear such panel-ists as attorneys, representatives of citizens groups,and the Board Member of the Kyoto MedicalAssociation, representing the medical profession,speak from their various standpoints on thecentral theme of “The Role of the Patient, theRole of the Physician: Create a new environmentfor patient safety” followed by a panel discussion.

Two hundred eighty persons attended thesecond symposium in February 2005 to hearpanelists speak on the topic of “Create a newenvironment for patient safety 2005” followedby a panel discussion that included nursingand pharmacist representatives in a co-medicalapproach, with the hope of bringing patients andphysicians together in a culture of medical safety.For its part, the Kyoto Medical Associationadvocated “Seven Must-do’s for All Physicians.”

Some 300 persons attended the third sympo-sium in February 2006 to consider patient-doctorcommunications in the context of the theme,“The Patient’s Say, the Physician’s Say: InPromotion of Mutual Understanding.” Notingthe great importance of medical safety of patient-doctor communication and informed consent,Professor Suguru Sato of the Literature Depart-ment of Doshisha University spoke from theperspective of psychology on “Communicationon the Medical Front Lines: A PsychologicalPerspective.” This was followed by the presen-tation of dramatic sketches on the theme ofcommunication and a panel discussion.

Two hundred sixty persons attended the fourthsymposium in February 2007 to hear a paneldiscussion on “Patient-Doctor Communication:Informed Consent as the Bridge to Trust” amongYoshiko Tsujimoto representing the non-profitorganization Consumer Organization for Medi-cine & Law, a member of the Kyoto Shimbuneditorial board representing the mass media, andmedical safety administrators and Medical SafetyMeasures Committee physicians representing themedical profession.

It is the objective of the Kyoto Medical Asso-ciation to eliminate discord and misunderstandingin building relationships of collaboration, ratherthan confrontation, between patients and health-care professionals and to build relationships oftrust between the citizens of Kyoto and membersof the Kyoto Medical Association, while pro-moting deeper understanding between them.


Infant Healthcare Activities of the Mie MedicalAssociation

JMAJ 51(1): 53–55, 2008

Masahiko KATO*1


*1 Vice-President, Mie Medical Association, Mie, Japan ([email protected]).This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol.136, No.1, 2007,pages 130–131).

Tochigi

Mie

Pop. 1.9mil.Area 5,800km2

Tokyo

knowledge of infant healthcare and made atten-dance a requirement for gaining qualificationas an examining physician. During the 10 yearssince this practice began, the workshops wereconsolidated into one location several years agowith the objective of giving the workshop contentfuller substance and the attendance obligationhas itself been relaxed, but it is now mandatoryfor examining physicians to attend meetings ofthe infant physical examination committee intheir local medical associations. (Absentees arerequired to submit a written case report.)

Fourteen city-level medical associationsthroughout Mie prefecture have establishedinfant physical examination committees, whichgenerally meet every month or every othermonth. They are deeply involved in regionalinfant healthcare through clinical conferences,follow-up guidance on children aged 1.5 yearsand through the review of the full scope of infanthealthcare. The challenge we currently face isthe provision of support to local committeeswhere a dearth of leadership has resulted ininactivity.

Infant healthcare activities conducted by the MieMedical Association consist of three programs:maternal and child healthcare, infant physicalexaminations and medical attention provided atkindergartens and daycare centers. As the infantexamination program has the longest history ofthe three and is well-established as a Mie MedicalAssociation process among our members, thispaper will focus on this examination programwhile also outlining activities in the other twoprograms in recent years.

The Mie Medical Association Process ina Physical Examination Framework forInfants Aged 4 Months and 10 Months

Mie prefecture has long performed physicalexaminations, fully funded at public expense(costs borne at the municipal and village level)and performed on an individual basis, for infantsaged 4 months and 10 months. The commissionis set annually at an informal meeting of theMie Medical Association, municipal and villagerepresentatives and the prefectural government,basically according to the criteria originally estab-lished when the national government declared ita grant program. The commission is set throughthis process, with attention to changes in medicalfees made with revision of medical fee scheduleand to needs of medical practitioners in the areasof obstetrics and pediatrics.

In order to improve the qualifications ofexamining physicians, we held physical exam-ination workshops at five locations within Mieprefecture with the aims of attendants learningthe Mie Medical Association process and gaining


Kato M

Overhaul of the “Maternal and ChildHealthcare Guidebook (with antenatalconsultation certificate and 4-monthand 10-month infant consultationcertificates)”

In 2006 the Mie Medical Association InfantPhysical Examination Subcommittee (chairedby Hitoshi Ochiai, with Vice Chair NorikoYamakawa) conducted studies of the adoptionrate of the current examination checklist, com-paring infant physical examinations at 18 monthsand at 3 1/2 years, in two model local areasand made revisions to the examination checklistin view of the changing objectives of theseexaminations. At the same time, the committeereplaced the Yes/No question about anxietyover child-rearing with a new detailed ques-tionnaire, the “Mother’s Interview Sheet,” to befilled out by mothers. In 2007 preparations areunderway to implement these revisions throughMie prefecture.

Medical Attention Provided toKindergartens and Daycare Centers

As part of preschool health activities, in 2005 theMie Medical Association Preschool MedicineSubcommittee (formerly chaired by Takashi Kato,currently chaired by Machiko Isachi) drafted aChild Development Record Sheet (download-able from the Mie Medical Association website athttp://www.mie.med.or.jp/hp/ishi/nyuyouji/kiroku/index.html) for tracking children’s psychologicaldevelopment and early detection of strain inchild-rearing, which is now employed in physicalexaminations. All parents and guardians areasked to fill out this sheet twice a year priorto physical examinations, and it is then used byphysicians and children’s nurses and has cometo be rather highly regarded on the ground.We now hope that it will also contribute toearly assistance for children diagnosed with milddevelopmental disorders and assigned to specialassistance education.

With a view to generating greater activity inpreschool medical programs, in 2006 we begandrafting the “Mie Prefecture Preschool MedicalPrograms Manual” and in 2007 plan to distributeit to preschool doctors, physicians and the rele-vant bodies involved in preschool medicine.

Further promotion of preschool healthcareprograms will require a Mie Medical Associationmanual expressing an efficient activities policy.This will likely require no less than a forum fordiscussion, with medical association leadership,that includes all the relevant bodies involved,overcoming differences among the competentauthorities.

Neonatal Auditory Screening Program

Currently over 50% of medical institutions thatperform deliveries in Mie prefecture performneonatal auditory screening. Although we desig-nate medical institutions to perform completeexaminations, much work remains to be donewith respect to screening methodologies andprovisions for children requiring examinations.In 2003 we launched a Neonatal AuditoryScreening Commission (chaired by MasahikoKubo) within the Mie Medical AssociationMaternal and Child Healthcare Committee andnow aim to involve governmental authorities inpromoting the program. At present, such opera-tions as regular workshops, the collection andmanagement of screening data, and governmentaltieups (the government-led “Study Group ona Prefectural Framework for Early Treatmentof Hearing-Impaired Children”) are only justunderway, and there is much work to do in termsof, for example, the standardization of screeningprocedures, early treatment of hearing-impairedchildren and establishment of a framework forearly support.

Prenatal Visitation Program

Prenatal visitation programs are currently under-way in two areas in Mie prefecture (one of theseas of 2005) and idle in one other area. At present,the chief concern is that whether the programwill continue in these two areas must necessarilydepend on whether strong leadership is in place.

In 2005 the Mie Perinatal Healthcare Guid-ance Programs Review Commission (chairedby Hitoshi Ochiai) was launched within theMie Medical Association Maternal and ChildHealthcare Committee as a subcommittee topromote prenatal visitation programs. The sub-committee membership is comprised of repre-sentatives of the Mie Medical Association,representatives of the obstetrics and gynecology


INFANT HEALTHCARE ACTIVITIES OF THE MIE MEDICAL ASSOCIATION

association, representatives of the pediatriciansassociation and representatives from the prefec-tural government, and its activities are fundedby the small fund that the first three thereof setaside annually to promote the program.

This remains a difficult undertaking, but weintend to draw on the Oita Medical Associationprocedures while working towards establishingour own Mie Medical Association procedures.



The Danish Society for Patient Safety—Operation Life Campaign

JMAJ 51(1): 56–57, 2008

Jens Winther JENSEN*1

educational tools to enable health care personnelto deal with issues of patient safety in their dailywork.

Reporting Unintended Occurrences

One of the main goals of the Danish Society forPatient Safety was to ensure that knowledge onmistakes and system failures are reported andused as a learning tool to improve patient safetyand minimize harm to the patients.

In 2005 the Danish Parliament passed a law onreporting system failures and other unintendedoccurrences in the hospital sector. The reportingis currently done anonymously from the locallevel to the central level of administration andthe law ensures, that health care personnel is notheld accountable for the mistakes that they mighthave made in the treatment or the care of thepatient. The principle of “no-blame” is introducedto ensure that by far most of the incidents areactually reported. The aim of the law is to catego-rize and develop guidelines in areas that haveproven difficult for the health care personnel tomanage. So far the work has resulted in guidelinesfrom the National Board of Health in differentareas such as administration of medicine, preven-tion of patients falling while in care of the hospital,prevention of burns subsequent to the use of alco-hol for disinfection prior to operations etc. Equallyimportant however are the local initiatives to fol-low up on the reported data and ensure changesin procedures locally where changes are indi-cated. A vast number of changes have been madelocally since the reporting began.

At the moment the Danish Ministry of theInterior and Health is preparing to enlarge thescope of the law so that it will cover the primary

*1 President of the Danish Medical Association, Copenhagen, Denmark ([email protected]).

Introduction

For some years the Danish Society for PatientSafety has been very active in setting the agendafor the work on patient safety in Denmark.The Danish Society for Patient Safety is a privateorganization which was founded on the initiativeof a group of people who after years in the hos-pital system realized that something drastic hadto be done in the field of patient safety. TheDanish Society for Patient Safety was founded inDecember 2001. The Board of the Danish Societyfor Patient Safety has a broad representation ofthe Danish Regions who are owners of the hospi-tals, the Danish municipalities who recently havebeen given a role to play in prevention of dis-ease and rehabilitation of patients, health careprofessionals, pharmacists, the medical industry,research institutions and last but not least—thepatients.

The Danish Medical Association currentlyholds the position of vice-chair to the Board whichis chaired by the Danish Regions. To support theactivities of the Danish Society for Patient Safety,the Board has engaged a secretariat with a staffof about 12 people. A large amount of funding forthe activities is provided by a private insurancecompany and other funding is received throughmembership dues.

The assignment of the Danish Society forPatient Safety is to ensure that the issue of patientsafety remains a top priority on the agenda ofpoliticians, the Danish Regions and the hospitalmanagement and to gather and distribute infor-mation on patient safety. Furthermore the assign-ment is to instigate and participate in projectsand work shops on patient safety and to develop


care sector (General Practitioners and nurseryhomes) as well as the hospital sector. The new lawis expected to be passed in the beginning of 2008and is expected to be based on the same prin-ciples of “no-blame” reporting and follow upinitiatives as the current legislation.

Operation Life

On 16 April 2007, the Danish Society for PatientSafety launched a campaign referred to as “Opera-tion Life” (www.operationlife.dk). The targetgroup of the campaign includes all Danish hospi-tals and the goal is to prevent deaths through theimplementation of six interventions to improvepatient care.

BackgroundIn the United States, the renowned Institute forHealthcare Improvement (IHI) has successfullycompleted a national campaign known as “100klives Campaign,” in which more than 3,000 par-ticipating hospitals, through the implementationof six evidence-based interventions, have esti-mated prevented deaths of 122,300 patients in18 months. In the UK and Canada, similar cam-paigns are being instituted based on the sameclinical interventions. Operation Life is inspiredby both the British “Safer Patient Initiative”started by Health Foundation and the Canadian“Safer Healthcare Now!” carried out by Cana-dian Patient Safety Institute, but in particularIHI’s “100,000 Lives Campaign” has been asource of inspiration.

The six clinical interventions of the campaign1. Rapid Response Teams to patients showing

evidence of deterioration2. Preventing adverse drug events by reconciling

patient medications at every transition pointin care

3. Preventing ventilator-associated pneumonia4. Correct treatment of acute myocardial infarc-

tion5. Preventing central line infections6. Correct treatment of sepsis, blood infections

The interventions have been studied by anexpert panel of Danish physicians and nurses andhave been adjusted to comply with Danish guide-lines and standards.

The campaign is open to hospitals that wish tojoin, and registration can be made at any time.

There are no restrictions as to the type and num-ber of interventions the hospitals may choose toimplement.

The goals of Operation Life• prevent 3,000 deaths• make sure that all regions are represented in

the campaign from the start• make sure that 75% of the patients in somatic

hospitals are covered by the campaign once thecampaign is closed.

MeasuresCampaign results are measured in terms of num-ber of prevented deaths and using an obligatoryindicator for each intervention package. The goalof the campaign is to prevent deaths and thisshould be evidenced by monitoring the develop-ment (decline) in the national mortality rates atDanish hospitals in absolute figures. Mortalityrates must be collected on a national and regionallevel. The mortality rates registered during thecampaign period will be measured up against ahospital standardised mortality ratio.

Training programmesSupport is provided to the participants during theimplementation phase, for instance in the form of“kick-off packages” (clinical guidelines, etc.) foreach intervention, data collection and outcomefollow-up, establishment of network and activitiesfor sharing experience. Also a training programmeusing the “breakthrough method” is provided assupport for implementation and quality improve-ment. The participating hospitals may appoint anumber of teams consisting of 3–4 persons whoare to undertake implementation at their ownhospital, as well as training in the “breakthroughmethod” in a number of workshops. Instructortraining in the breakthrough method is alsoprovided.

Future Perspectives

The Danish Medical Association will work toimprove patient safety and will therefore continueto support the activities of the Danish Society forPatient Safety to the benefit of the patients.

If you wish to learn more about the campaign in prog-ress, please contact: Project manager Bodil Bjerg,tlf. 36 32 60 17, mail: [email protected]

THE DANISH SOCIETY FOR PATIENT SAFETY—OPERATION LIFE CAMPAIGN



New Zealand’s World-leading No-fault AccidentCompensation Scheme

JMAJ 51(1): 58–60, 2008

Peter FOLEY*1

scheme became universally known as “ACC.”The legal structure was later changed to a Corpo-ration without disturbance of the acronym.

The Woodhouse Commission proposed fivegeneral principles:• community responsibility;• comprehensive entitlement;• complete rehabilitation;• real compensation;• administrative efficiency.

Writing retrospectively in 1999 after 25 yearsof its operation, Sir Owen enlarged on some ofthe underlying rationale for the proposals thatled to the ACC scheme. As he describes it, thepre-existing system of compensation was expen-sive in legal costs, slow in operation with manyclaims taking 5 years or more to be determined,and capricious in that similar injuries sufferedunder similar circumstances might produce vastlydifferent financial outcomes. The outcome wasa scheme that then seemed, and still does seemto many outsiders, radical. The right to sue fordamages for the tort of negligence causing injurywas removed, and in return injury would be com-pensated regardless of fault, including fault of theinjured.

One of the early cases causing public outragewas the compensation of an inexpert safe-blowerwho misjudged the explosion and injured hishands. The acceptance of his claim was inevitable—consider the inequity that might result if thosebreaking the law were to be refused compensation:Suppose, for example, the case of a man drivingthe wrong way down a one-way street (and so incommission of an illegal act), and a workman onan adjacent high-rise building site dropping anuntethered tool on his car and causing seriousinjury. He would be unable to sue, since that right

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

New Zealand is unique in a number of respects,and one which is of interest to the internationalmedical community is our no-fault accident com-pensation legislation.

Prior to 1974, New Zealand had a regime simi-lar to most other countries. Citizens who sufferedthe tort of injury caused by the action or negligenceof some other person or company could sue fordamages, and receive financial compensation forthe injury. Amounts awarded in New Zealandnever reached the dizzy heights seen in someplaces, but were assessed as compensation forpain, suffering, loss of function and loss of income.Employers were required to insure against injuryto their employees; motor vehicle owners wererequired to carry third-party personal insurance(paid at time of vehicle registration), and publicbodies and corporations generally insured againstthe possibility of damages awarded against thembecause of some injury traceable to their actionsor inactions.

Some of the undesirable features of this tort-based workers compensation scheme includedthe propensity of some workers who had sufferedan injury at sport or recreation at the weekendto limp along to work on Monday morning, andsuffer an “accident” at work, and claim compen-sation for the injury. Another was the secondarygain from exaggerating the effects of compensat-able injury.

The 1966 Royal Commission on Worker’sCompensation, chaired by the Rt Hon Sir OwenWoodhouse, proposed what amounted to sweep-ing reforms. Its implementation was the 1972Accident Compensation Act which came intoforce in 1974 and which, with some tinkering,has been with us ever since. Initially there wasan Accident Compensation Commission, and the


was abolished by the ACC legislation, but byvirtue of a relatively minor transgression, deniedrelief.

One of the most radical aspects of the pro-posal was that ACC would be principally fundedby levies on employers, but injuries occurringoutside the workplace would also be covered.Sir Owen explains this aspect of the scheme byshowing that in the case of an employer carryingworkman’s insurance and paying premiums forthat insurance, the cost of those premiums isloaded onto the products of the enterprise andtherefore constitutes a tax on all of us. This wasviewed as an aspect of community responsibilityfor injury at work that should then be extendedto injury in other circumstances. The outcomewas a proposal that the community should com-pensate for injury, regardless of the location andcircumstances of the injury.

Writing in Health Affairs journal, HarknessFellow Dr Marie Bismark and Health and Dis-ability Commissioner Ron Paterson state that fourmain factors have contributed to the system’saffordability. First, New Zealanders benefit froma strong social security system. Injured patients,like everyone else, receive free hospital care andsubsidized pharmaceuticals. (Yet per capita healthspending was only US$1,886 in 2003, comparedwith US$5,635 in the United States.) Thus, NewZealand’s public health and welfare systemscover many of the damages that would be at issuein a U.S. medical malpractice claim, leaving theACC with a much smaller compensation burden.Second, compensation awards are generally lowerand more consistent than under a malpracticeequivalent. Third, the New Zealand experiencesuggests that even under such a system (whichincludes a legal duty of open disclosure), mostentitled patients never seek compensation, andmany may be unaware that they have even suf-fered an adverse event. And finally, the NewZealand system does not incur large legal andadministrative costs. The system has been verycost-effective, with administrative costs absorbingonly 10% of the ACC’s expenditures comparedwith 50–60% among malpractice systems in othercountries.1

Separate and independent processes are avail-able for responding to patients’ non-monetaryinterests (such as the desire for an apology, anexplanation, or corrective action to prevent harmto future patients). In particular, the Health and

Disability Commissioner resolves complaints byadvocacy, investigation, or mediation.2

One of the anomalies in the first 30 years ofthe scheme was its handling of complications andundesirable outcomes of medical treatment. Ifthe provider of care were at fault, then this wasan injury and was compensated. If it were a rareoccurrence, for which the provider was not atfault (expected in fewer than 1% of cases) then itwas a medical mishap, and compensated. If it didnot meet either of these criteria, then it was notcompensated. This always seemed anomalous ina no-fault scheme.

A review carried out in 2003 found that therequirement to establish fault impacted on healthprofessionals by creating an overly blaming culture(rather than a culture of learning from mistakes)—by focusing too much on the actions of indi-vidual health professionals, and by making healthprofessionals uneasy about participating in themedical misadventure claims process for fear ofthe repercussions, particularly from inter-agencyreporting. The consequences of this included lessfocus on the patient’s injury, less focus on theprevention of similar injuries, confusion over theCorporation’s role, and opportunities to learn(and therefore improve) safety being limited.3

The New Zealand Medical Association(NZMA) had advocated for, and strongly sup-ported, the amendment that came into force inApril 2005 redefining all such occurrences as“treatment injury,” and compensating regardlessof perceived fault. That provides a much moreequitable outcome for patients, and helps to avoidthe adversarial situation that could previouslyarise where a patient was required to assert negli-gence on the part of the doctor in order to receivecompensation.

There has, however, been some resiling fromthe original principles. The initial position wasthat the full costs of the accident would be met.The level of funding for care has been restricted,and most patients now find that they must makea co-payment for many items of assessment andtreatment. There is a reasonable argument tomake that this is not in keeping with the socialcontract inherent in the scheme, in that the rightto gain compensation for costs has been removedand these costs should be met in full.

It remains an anomaly that in New Zealandaccident, but not illness, is compensated. In theWoodhouse report, the principle of community

NEW ZEALAND’S WORLD-LEADING NO-FAULT ACCIDENT COMPENSATION SCHEME


responsibility is stated thus:Just as modern society benefits from productivework of its citizens, so should society acceptresponsibility for those willing to work but pre-vented from doing so by physical incapacity.

It is by no means clear why this should apply toaccident but not to illness. There may be “con-tributory negligence” in both circumstances, andthere is an inherent randomness in both circum-stances. For example, ACC will pay compensationto someone who cannot work due to havingorgans damaged in a car crash, but the same levelof compensation may not be available if theysuffer organ damage through illness. This is anettle that has apparently been too daunting forsuccessive governments to grasp.

However, the deficiencies of New Zealand’sACC system are small compared to its advan-tages (see Table 1). One of those will have beenbrought home to New Zealand doctors by thecollapse in 2004 of the Australian medical indem-nity system, brought down by huge claims andhuge settlements. Because such claims cannot bemade in New Zealand, our medical indemnitysubscriptions are considerably lower than thoseof most comparable countries. This does not makeNew Zealand doctors more careless, although itmay make us less risk-averse and more willingto deal with uncertainty of outcome. That is oneof the strengths of our medical system—NewZealand doctors are still prepared to exerciseclinical judgement, whereas it seems that ourcolleagues in some other jurisdictions have hadmuch of that beaten out of them.

References

1. Bismark M, Paterson R. No-fault compensation In New Zealand:Harmonizing injury compensation, provider accountability, andpatient safety. Health Affairs. 2006;25:278–283.

2. Bismark M. Compensation and complaints in New Zealand.BMJ. 2006;332:1095.

3. Accident Compensation Corporation. Review of ACC MedicalMisadventure: Consultation Document. Wellington: ACC; 2003(quoted in: Coates J and Smith K. Reform of ACC Medical Mis-adventure. NZ Med J. 2004. Vol.117 No.1201).

Acknowledgements

Dr. Foley wishes to thank former NZMA ChairmanDr. Ross Boswell for his input.

Table 1 Facts and statistics about AccidentCompensation Commission (ACC)

According to the ACC, the scheme:

• provides cover for injuries, no matter who is at fault

• eliminates the slow, costly and wasteful process ofusing the courts for each injury

• reduces personal, physical and emotional sufferingby providing timely care and rehabilitation that getspeople back to work or independence as soon aspossible

• minimises personal financial loss by paying weeklyearnings compensation to injured people who are offwork

• focuses on reducing the causes of these problems—the circumstances that lead to accidents at work, athome, on the road and elsewhere.

In 2005/2006 more than 1.2 million people had injuriestreated by their local GP and paid for by ACC, with ACCpaying for over 2.3 million visits. ACC funded NZ$24.3million in dental treatments and $154.5 million in hos-pital treatments. ACC funded 2.6 million physiotherapistvisits, 2.4 million visits to other treatment providers and250,000 rehabilitation services. Rehabilitation rates arehigh: 66% of people return to work after 3 months, 84%after 6 months and 93% after a year. Injury prevention isa primary focus of ACC’s work, with campaigns focusedon safety at work, at home, on the road and playing sports.

(Source: ACC website—www.acc.co.nz)

Foley P


NMAs also viewed white animals as a lucky omen,as we do in Japan.

The congress produced fruitful discussions.Agreement was also reached to make efforts toincrease the number of participating NMAs. Asthe Secretary General of CMAAO, I would liketo, with the JMA, facilitate closer communicationbetween CMAAO members using the associa-tion website and journal. All the topics discussedat the congress will appear in this and next issueof the JMAJ.

Masami ISHII, Executive Board Member, Japan Medical Association( [email protected]), Secretary General, Confederation ofMedical Associations in Asia and Oceania (CMAAO), CouncilMember, World Medical Association.

The 25th CMAAO Congress in Pattaya,ThailandThe Confederation of Medical Associations inAsia and Oceania (CMAAO) congress was heldwith 50 participants from 13 national medicalassociations (NMAs) at the Hotel Royal CliffBeach and Resort in Pattaya, Thailand, from 18to 20 November, 2007. CMAAO is a confedera-tion with a long tradition over nearly half acentury and consists of 16 medical associationsfrom various countries in the Asia and Oceaniaregion—17 now that approval has been given forthe Sri Lanka Medical Association to rejoin.These NMAs collaborate on specific issues, andeach presents a report of its activities during theyear at the annual meeting.

A general congress and mid-term councilmeeting are held every 2 years alternatively. Themain theme of the symposium held during thisyear’s congress was “Arts and Science of HealthyLongevity,” which has become one of the mainissues in healthcare in this region and reflects aglobal trend.

The congress venue was a luxurious hotelby the sea with several big convention halls forevents and other facilities, as well as its own beach.The hotel was surrounded by lush greenery andtropical flowers which were frequently visited bybirds. I discovered a couple of white squirrelsplaying in the forest near the hotel one morning. Itwas interesting to learn that people from different

From the Editor’s Desk

Sunrise viewed from Royal Cliff Beach, Pattaya

Documents

JMA—President’s Speech JMA Activities Conferences and Lectures