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Medical Practice in the Americas


PAMSA HeartBeat


was founded in May 1951 and is run by medical students, for medical students, on a non-profit basis. IFMSA is officially recognised as a non-governmental organisation within the United Nations’ system and has official relations with the World Health Organisation. It is the international forum for medical students, and one of the largest student organisations in the world.

Imprint Editor in Chief Erick Meléndez, El Salvador Editors Jill Stone, Canada Helena Chapman, Dominican Republic Génesis Cañas, El Salvador Design/Layout Erick Meléndez, El Salvador Proofreading Jill Stone, Canada Helena Chapman, Dominican Republic Génesis Cañas, El Salvador

The mission of IFMSA



is to offer future physicians a comprehensive introduction to global health issues. Through our programs and opportunities, we develop culturally sensitive students of medicine, intent on influencing the transnational inequalities that shape the health of our planet.

International Federation of Medical Students’ Associations General Secretariat: IFMSA c/o WMA B.P. 63 01212 Ferney-Voltaire, France Phone: +33 450 404 759 Fax: +33 450 405 937 Email: Homepage:


PAMSA HeartBeat



PAMSA team




From our RC


Human rights In our daily practice


Medical education in America: How similar could it be?


Why Health 2.0?


Social determinants of health in medical practice


How does Peru fight TB?


Psychiatric stigma: A pending Issue


IFMSA day for non-communicable diseases


Updates from NMOs


Publications team


PAMSA HeartBeat

PAMSA Team Gabriela Noles

Regional Coordinator IFMSA - Peru

Javiera Brierley NMO Development DA IFMSA - Chile

Alhelí Calderón

Leonel Ayala

Mardelangel Zapata

Elías Ortega

NMO Development DA IFMSA - Mexico

Projects Regional Assistant APEMH - Peru

Publications and Media DA IFMSA - El Salvador da.publications.pamsa@gmail. com

SCOME Regional Assistant IFMSA - Argentina

Fréderic Morin

Roberto García

Gianina Cerrón

Paola Aguirre

SCOPE Regional Assistant IFMSA - Quebec

SCORE Regional Assistant IFMSA - Mexico

SCOPH Regional Assistant APEMH - Peru

SCORA Regional Assistant IFMSA - Peru

Erick Meléndez

Ricardo Zules

SCORA Regional Assistant IFMSA - El Salvador


SCORP Regional Assistant IFMSA - Ecuador PAMSA HeartBeat

Introduction Dear PAMSA family, It has been such a journey! Time went flying and here you are, reading the last issue of the HeartBeat for this year that marks the end of my term as Publications and Communications Development Assistant.

The same goes for the PAMSA team 2010-2011. Your enthusiasm and love for the work we do in IFMSA has been one of my biggest motivations to do a good job with the magazine, we could not have made it without your support. I wish I could have met you all in person This magazine has been made with so much love and and hopefully I will do it someday. passion, created specially for all of you as a way to acknowledge the amazing work you do in each NMO Thanks to everyone who sent their submission to the trying to improve the health of our people. magazine; in the end, it was you and the quality of your work what made this magazine as good as it is now! As I said in the first issue, we are related in so many ways and working together is what make us bigger and Finally, I want to thank my PAMSA family for showing me stronger, even though we have many differences in the your love through your messages with kind words and way we act. This issue was focused on that fact: The virtual hugs. I love you so much! differences in our health systems and medical practice, and how we can overcome them in order to improve Hopefully, this is not a good bye but a see you later. the health of our region. Erick Meléndez. In this issue you will find some interesting articles related to that topic which, I hope, will make you understand more about other countries. Take the good things, identify the bad ones and find new approaches to the problems we all have in the continent we share. As for the future of the magazine, I am sure that more and better things are coming in the next years. My wish is that the HeartBeat will become the written voice of the medical students in PAMSA and that every medical student will know of it and expect cheerly every issue wanting to hear from their fellow students in the Americas. This magazine is an IFMSA Publication.

© Portions if this magazine may be reproduced

I would like to wish the best of luck to my successor, I am for non political, and non profit purposes sure he/she will put all the necessary effort to continue this dream from all the medical student in PAMSA, I mentioning the source provided. know the HeatBeat wil only keep growing and getting Notice: Every case has been taken in the better! Many thanks to my wonderful Publications Team, all of them helped me in the whole proccess ever since the beggining of my term. Helena, Jill, Génesis, Sandra, Jimy and Fabrício: Thank you for everything you did! All your ideas, opinions and feedback made this magazine what it is now. You are amazing!


preparation of this document. Nevertheless, errors cannot always be avoided. IFMSA cannot accept any responsability for any liability. The opinions expressed in this magazine are those of the authors and do not necesarily reflect the views of IFMSA.

PAMSA HeartBeat

From our RC

Dear all, It is really an honor and pleasure to write to you in this third edition of the PAMSA Heartbeat, this time as Regional Coordinator for the Americas. I want to thank Erick Melendez, DA Publications 2010/2011 and his amazing team for the hard work and huge heart they have put in this edition of the PAMSA Heartbeat. The theme of this edition is Medical Practice in America and we are proud to have our members sharing with us the characteristics, determinants and feelings about the practice of medicine in their own reality. That reality that in this globalized world and common region we all share. This is sample that we not only share the culture, the aims of a better and healthy world or a common panamerican feeling, there are more other things that bring us together and remind us that we should work together and keep growing together. Enjoy the reading of this edition and don’t miss the next one. Hugs to you all, Gabriela


PAMSA HeartBeat

Human rights in our daily practice

Marc-André Lavallée IFMSA-Quebec SCORP RA 2010-11 for the Americas How often have I talked about the importance of looking beyond the disease or the patient’s social determinants? I believe that this is where human rights play a major role in our medical profession. Human rights must always be taken into consideration in our daily clinical practice to avoid injustice or inappropriate care to our patients. As future doctors, we have the responsibility to respect the actions and behavior of our patients. Discrimination “Any distinction, exclusion, restriction or preference based on [a random factor] which has the purpose or effect of nullifying or impairing the recognition, enjoyment or exercise, on an equal footing, of human rights and fundamental freedoms in the political, economic, social, cultural or any other field of public life.” - International Convention on the Elimination of All Forms of Racial Discrimination.

Privacy and dignity “[Privacy is] respect for the autonomy of individuals, and limits on the power of both state and private organizations to intrude on that autonomy.” - The Preamble to the Australian Privacy Charter “Dignity is concerned with how people feel, think and behave in relation to the worth or value of themselves and others. To treat someone with dignity is to treat them as being of worth, in a way that is respectful of them as valued individuals.” - Royal College of Nursing Privacy and dignity are human rights that are frequently violated in daily clinical practice. We must consider our actions when we are around our patients. Privacy, which includes patient confidentiality, means that we cannot divulge information about our patient to any other individual, whether in private or public settings. For example, we should complete our patient’s medical history in a private room so that other people cannot hear our interview and discussion of intimate details. In addition, dignity means that we should treat every patient with respect. For example, in our pre-operative preparations, we do not need to completely uncover the patient when the cardiac surgical intervention only requires access to the thorax. We must always remember that our patients enter the unfamiliar environment of a medical center due to illness or preventive health check-up, so we must recognize their anxiety and promote respect in their privacy and dignity in the health setting.

We discriminate when we consider that two individuals have different human rights, where we may use age, gender, origin, socioeconomic status or another factor to impede the full enjoyment of fundamental rights. Discrimination may be strictly defined as preventing an individual from having health care access because he or she is an undocumented immigrant, resides in an aboriginal community, does not have the financial resources, or utilizes non-traditional hygiene practices. As medical students, we forget that the patient accepts our presence as part of the medical team, although he As medical students, we recognize that these human or she may refuse our physical presence during the rights violations occur daily. Since “The International medical history or physical exam. The final decision Declaration of Human Rights” and “The International always belongs to the patient. Covenant on Economic, Social and Cultural Rights”1 state that health is a human right, it is our responsibility, In conclusion, we must remember that our patients are as future doctors, to eliminate patient discrimination. humans, with their rights and their dignity. Our clinical decisions must be oriented on our patients’ health and Moreover, we have the power and obligation to be well-being, not on our will of self-accomplishment. With patient advocates so that our medical centers stop this golden rule, we may become an example for our refusing any patient care to undocumented immigrants, colleagues. citizens with limited financial resources or intravenous 1. «The States Parties to the present Covenant recognize the right of everyone to drug users. the enjoyment of the highest attainable standard of physical and mental health. » International Covenant on Economic, Social and Cultural Right.


PAMSA HeartBeat

Medical Education in the Americas: How similar could it be?

David LaPierre, MD The birth of Consider contributing to our medical education textbook Our vision is that all medical learners meet core global – learn medicine, build your CV, and help others! curriculum standards. Our mission is to provide freely-available medical education globally while being useful locally. Just how different are health and disease amongst different countries? Do the causes of chest pain, the steps of delivering a baby, or the diagnoses of pneumonia, vary depending on where we are located? Global travel and immigration mean diseases like malaria previously only in certain countries are now relevant to doctors worldwide. An increasing number of medical students, residents, and physicians also desire to train, volunteer, and work abroad. To be competent healthcare practitioners in these settings, we are required to recognize and understand presentations of global diseases that may not be common at home. In addition to adequate pre-departure training, global core curriculum standards for medical education should exist containing these global considerations, regardless of where medical studies are taking place.

This is accomplished through globally-relevant topics from maternal and newborn health to pre-departure training, while providing country-specific cases allowing learners to apply their newfound knowledge locally (Fig 1).

Figure 1: Globally relevant content applied through locallyuseful cases.

I began this project in 2006 as a medical student by bringing my computer to class and typing up my notes. I soon realized that this project could be helpful to other Building on the lessons learned from the Bologna process students, so I asked for help. in Europe and a similar movement across the Americas, a global core curriculum should be possible. From a The response was overwhelming. Classmates student perspective, the IFMSA Standing Committee contributed as authors. Professors and clinicians peeron Medical Education should be the association to reviewed our work to ensure material was accurate. advocate for these global curriculum standards. Even artists started to illustrate our topics with aweOf course, treating malaria or any other disease will depend on the context. For example, a patient with malaria will have a different experience living in a city like Toronto versus the remote mountains of Haiti. This means that while medical learners will be covering the same material as their peers around the world, in order to be useful, the curriculum will need to be understood according to the specifics of the local healthcare system, geography, culture, and available resources.

inspiring images. Since then, our resources have grown rapidly. We are endorsed by IFMSA, the Canadian Federation of Medical Students (CFMS), and numerous other medical associations. People are even writing about us including the Canadian Medical Association Journal1.

Where do We Go from Here? Our on-the-ground evaluations of our material in countries such as Haiti have already provided promising What does this mean for medical education resources feedback with numerous accounts of its relevance and across the Americas? usefulness. We are also planning to pilot our maternal and newborn health in Canada, Uganda, and Haiti in Can we work together to create resources for us all to 2012, with other countries to follow. use, regardless of where we are? 8

PAMSA HeartBeat

Medical Education in the Americas: How similar could it be?

Whether you want to improve medical education worldwide, your own knowledge, or add a publication to your CV, has something for you.

Acknowledgements: Thanks to Ian Pereira, PAMSA SCOME Regional Assistant, for his continuous support of SharingInHealth. ca and kindly reviewing this article.

To learn more about this process, please visit our main A special thanks to Julie Hebert for continuing to promote page, and look under ‘how, most recently at the last IFMSA AM11 in Copenhagen where our movement was met you can help’. with much interest and enthusiasm. Currently, we are also looking for promotional representatives. If you are interested in sharing this Another thanks to SCOME and IFMSA for their continued movement with others, email contact@sharinginhealth. endorsement. ca to learn more. A final thanks to all our past, present and future readers, Contribute to freely-available, globally relevant, locally- writers, reviewers, illustrators, and promoters – don’t useful medical education. Join stop contributing to medical education worldwide. today. Reference: Dr. Dave LaPierre is a Family Medicine resident Collier, R. 2011. Canadian students develop mediwiki to from the University of Western Ontario, London, share classroom notes with the world. CMAJ 183(11). Ontario, Canada and founder and chief editor of


PAMSA HeartBeat

Why Health 2.0?

Nicolás Allende, NOME IFMSA-Argentina Ian Pereira, PAMSA SCOME Regional Assistant

Health advocacy groups can now update patients on relevant health news and alerts through blog newsletters, personalized Facebook messages, and twitter and “People don’t buy what you do, they buy why you RSS feeds to smartphones. Collectively, social media do it” can bring widely-accessible, low-cost healthcare to Simon Sinek, TEDtalk at the IFMSA AM11 Health 2.0 patients who need it worldwide and reduce the burden Pre-GA of disease crippling many healthcare systems. As medical students, social media should not be foreign. As medical students we challenge ourselves to learn so It is our duty to use it effectively not only to complement that others benefit. Limits to improving health are only clinical encounters, but to improve healthcare systems for those with limited perspective. We follow what we worldwide. But how? believe in, and we believe in improving the health of our patients using everything and anything available. This We still live in a time when using cell phones and laptops should include social media. can be considered rude. But times are changing. Increasingly, students across PAMSA are using social Social media is revolutionizing healthcare today. The media. Most of us have Facebook. Many of us have new technologies of social media do not equate to the Twitter. We post the results of workshops and lectures impersonalization of human relationships in medicine. on Facebook, Twitter, and Youtube to complement Instead, Facebook, twitter, blogs, podcasts, YouTube medical education. We take more collaborative minutes and other facets of social media have facilitated transfer with online mindmaps like Mindmeister. More importantly, of knowledge to complement clinical encounters. we still manage to listen to our teachers, each other, and Physicians can easily share evidence-based knowledge to our patients. So why not use the social media tools to improve healthcare for their patient populations through we already know intimately to improve our healthcare blogs and podcasts. Cancer survivors who previously system? attempted to connect through email discussion groups and chat rooms now create Facebook virtual This underutilization of our own knowledge prompted communities and wikis that enable them to quickly share a few students in IFMSA to introduce to the world the information about coping strategies and build a personal SCOME IFMSA Health 2.0 Project, and its first Pre-GA support network of friends. Training at the 2011 AM in Copenhagen, Denmark. 10

PAMSA HeartBeat

Why Health 2.0? Through inspirational TEDtalks and informative videos on useful websites we showed you how much you already knew about social media and how to use it effectively. We used Small Working Groups and Open Spaces Technology to share ideas, pushing your creativity to its limits, and then showed you how to push farther using tools like MindMeister. We then showed you the not-so-distant future: medical applications for portable computers, online patient communities, and portable diagnostic devices all being developed today with student input. For social media, the possibilities to positively impact patient care are endless. As medical students and future doctors already informed and involved, it is up to us to help make these possibilities a reality.

Stay tuned for Health 2.0 in other SCOME Projects, workshops, and trainings including E-Medicine and Medical Technology. A warning before you ride: Health 2.0 may cause one or more of the following symptoms: severe geekiness, sore eyes, sore shoulders from typing, awesomeness, new friendships, realized idealism, and improvement in healthcare. Acknowledgements Thanks to the creators of the IFMSA PreGA Health 2.0 Charlotte Holm-Hanson, Cj Kaduru, Eric Suero, Miguel Cabral, Nassima Dzair, and Salmaan Sana for their input and ongoing work. And of course, thanks to all the participants and supporters that have made Health 2.0 a reality. Health and the future? Challenge accepted.

How can you get involved today? Join IFMSA Health 2.0 on Facebook. Correspondence should be addressed to Nicolรกs Follow #ifmsahealth20 on twitter. Find out more at or by Allende emailing


PAMSA HeartBeat

SOCIAL DETERMINANTS OF HEALTH IN MEDICAL PRACTICE Álvaro Mondragón-Cardona, Verónica Álzate-Carvajal ASCEMCOL - Colombia Health Professionals are influenced by a number of factors which affect the medical practice. The institutional and national policies, the social, environmental and personal determinants significatnly impact each patient’s care that will be assisted in the future. In this context it is vital to consider these determinants as influencers in the health- disease process of the people; without setting them aside while automatically starting to search for isolated signs and symptoms that could be related according to the wide medical theories, forgetting the patient as a set of complex situations that determine their health-disease process. The health determinants have been an object of study for different researchers all around the word, whom have been trying to establish the relationship between the extrinsic and intrinsic factors of each subject and the health-disease process. It has been questioned if the differences in basic sanitation, natural variable, biological variable, behaviour are considered determinant factors in the health-disease continuum, this particular theory postulates that the social inequalities originate all the determinants. Equality can be analyzed from many perspectives, however, in topics related to health there are two defining factors: insurances and the overall financial model of health. These two operating factors represent the political side of the distribution of resources, together they can define the characteristics of a health care system. In developing countries the social differences are remarkable. Much of the population lives in adverse conditions that favor the emergence of infectious diseases, chronic diseases and even oncological diseases. These social problems are only exacerbated by the difference in health care quality and the accessibility to these services As it was mention in the beginning, the socio-economical, cultural and environmental conditions affect each and every health determinant. In this sense, the non-availability of health services, poor access, lack of economics resources, and low level of education, among other key factors, adversely affect the health of the population. The Millennium Development Goals recognize the interdependence between health and social condition and offer a chance to promote sanitation policies that tackles the social root of unjust and evitable human suffer.


Figure 1. The Main Determinants of Health.

For this purpose the “Commission on Social Determinants of Health (CSDH)” was created, to lead the processes in the management and the understanding of the importance of social determinants of health. To understand the health-disease process is absolutely necessary to consider the social determinants. This concept is not new. Since its creation in 1948 the World Health Organization (WHO) has recognized the social determinants as indispensables objectives for health care and promotion, sadly these considerations are frequently forgotten in the current medical practice. This article is an invitation to never forget the social factors that define the health in our patients. We must have in mind that many pathological processes that we face everyday could be caused, exacerbated or promoted by these factors. References

1. Organización Mundial de la Salud. Comisión sobre factores determinantes de salud. Acción Sobre Los Factores Sociales Determinantes De La Salud: Aprender De Las Experiencias Anteriores. 2005. 2. San Pedro A, Souza-Santos R, Sabroza P, Chagastelles and Oliveira, Rosely Magalhães. Las Condiciones de Producción y Reproducción de Dengue Local: estudio de Itaipú, Región Oceánica de Niterói, Rio de Janeiro, Brasil. Cad. Saúde Pública [online]. 2009, vol.25, n.9. 1937-1946 3. Labonte, R. Health Systems Governance for Health Equity: Critical Reflections.Rev. salud pública [online]. 2010, vol.12, suppl.1 4. Cardona-Arias J. Representaciones sociales de calidad de vida relacionada con la salud en personas con VIH/SIDA, Medellín, Colombia. Rev. salud pública [online]. 2010, vol.12, n.5 5. Sojo A. Condiciones para el acceso universal a la salud en América Latina: derechos sociales, protección social y restricciones financieras y políticas. Ciênc. saúde coletiva [online]. 2011, vol.16, n.6 6. Campo C, Mondragón-Cardona A, Moreno-Gutierrez Pa, JimenezCanizalez C, Tobon-García D, Martinez J. Identificación de factores de riesgo cardiovascular a través del campamento universitario Multidisciplinario de investigación y servicios CUMIS. Acta Cient Estud. 8(3). 2010.

PAMSA HeartBeat

How does Peru fight TB? Luz del Pilar Revolledo Calizaya, IFMSA-Perú

These measures continued until the 80’s, when the ministry faced an extremely hard situation with its Studies in Peru, where bone lesions have been found organization: presenting poor methods of diagnosis and related to this etiology in Inca mummies, make us think medication management and poor patients’ access to that TB appears to be a disease as old as humanity free treatment. In 1985, of 24,500 patients diagnosed itself. About the year 1882 - following the discovery with TB, only 13,000 received treatment. of TB by Robert Kock- who gets the Nobel Prize 23 years later – begins the long process of fighting this In that scenario is initiated the Integrated Health Care disease; however, treatment of patients just started four in order to achieve what was called “Health for All”, decades later, when Abraham Waksman discovered taking into account the risks at national level, including streptomycin, and it soon began to be used after success malnutrition and tuberculosis. During this program, they in treatment during World War II. Later, paraminosalicilic emphasized the health of the mother and child in the acid will be introduced to this basic treatment regimen areas of nutrition and vaccination with BCG, as well as by Jorgen Lehmann; and finally isoniazid in 1952 as prevention and control of TB developing the following: a result of Robitzelc’ work. Around 1952, these three health education, treatment of diagnosed cases, drugs constitute the foundation of what will be the future monitorization, control and surveillance of contacts. therapeutic regimens. In the second half of 1990, it was initiated a new In Peru, around 1921, the first sanatorium for the approach to the management of this disease in Peru, disease was built in the city of Jauja, and specific restructuring the National TB Control (NPTC), including areas were established in major hospitals in the capital new guidance on the regulations and procedures for these types of patients. However, in despite of the and introducing the important recommendations of great efforts made during these decades by health international agencies PAHO and WHO, who provided professionals worldwide, the mortality rates remained important advice, ongoing training by highly qualified extremely high: in a hundred patients, ninety died. Thus experts and recommendations in the scientific and in 1940, our Ministry of Health organized the first National technological field, which in short constituted a modern Plan for Tuberculosis Control, considering, among other educational program that developed a preventive measures, the implementation of the BGC vaccine for strategy during the course of that decade. children under 15 years.


PAMSA HeartBeat

How does Peru fight TB?

Later, the Health Ministry, through the National TB Control Program (NPTC), now National Health Strategy for Prevention and Control of Tuberculosis (ESN-PCT), decided to implement the DOTS strategy (Directly Observed Treatment Short Course) which is the WHO recommended strategy for TB control to be highly cost effective, considering its main components government’s commitment to ensure the necessary resources to control Tuberculosis, through the regular supply of drugs and laboratory supplies in all health services, organization in the detection, diagnosis and treatment of cases, timely information system for registering and tracking patients through their healing, and, after training, supervision and evaluation. The implementation of the DOTS strategy has been carried out to date on all services of the ministry health network, which has helped to reduce the incidence of tuberculosis in all its forms. The therapeutic efficacy described in range of 99% and average recovery rate reaches 92.1%, demonstrating that the implementation of DOTS leads to higher cure rates.

In absolute numbers in 2007 were diagnosed with TB 34.860 (in all its forms). The distribution of these TB cases is not consistent across the country, showing significant concentrations associated with the characteristics of urban development where living areas of highest concentration of poverty close to those of greater economic development. These figures are similar to those found in the following years, which would be reflected in the Strategic Multisectorial Plan Response to TB, with an eye toward 2019, in which there are considered as targets early and sensitive diagnosis of TB, MDR TB and XDR TB, prevention and treatment, and likewise give people moral, social and economic development necessary to sustain and complete the treatment. In Peru, essential drugs most used by the NTP (National Tuberculosis Control) are isoniazid, rifampin, pyrazinamide, streptomycin and ethambutol.

There are, however, several adverse reactions to the use of these medications, which range from fever, or allergic Peru, like other countries that achieved obvious results reactions and hypersensitivity, loss of visual acuity and in controlling tuberculosis, received from PAHO and blindness, even going so far as hepatitis frequent toxic WHO in 1997 the award from the American Association effect, nephrotoxicity and ototoxicity, in addition to the for World Health by the success in implementing the emergence resistance. program. Before starting treatment, every TB case should be Until 2001, Peru was able to overcome the global evaluated for initial bacteriological status, history of millennium goals regarding TB control, but by 2003 previous treatment, disease location, and disease there was a sustained deterioration of the activities of TB severity and prognosis. case finding, situation that was reversed for 2005.


PAMSA HeartBeat

How does Peru fight TB? The identification of different categories of patients leads to the use of different treatment regimens for new patients with bacteriologically positive and severe extrapulmonary forms, previously treated patients with bacteriologically positive (as relapses and dropouts recovered) and new patients paucibacillary and extrapulmonary forms less severe. Incorrect use of TB drugs may cause the presence of some MDR-TB cases; that means the presence of bacilli resistant to at least isoniazid and rifampicin. These cases may help to decrease the effectiveness of treatment regimens for new and previously treated patients. Therefore, it is necessary to establish other categories of patients for different schemes, such as patients who fail to outline the primary and who have entered the NTCP as new cases, patients who fail to secondary schema and have entered the NTCP as cases of relapse or recovered dropouts, or patients who fail to re schedule - standardized treatment for MDR-TB. The association between HIV / AIDS-TB reported in 2007 represents 2.49% of the overall morbidity due to tuberculosis. High mortality in coinfected patients is likely due to complications associated with AIDS or a delayed diagnosis of tuberculosis. In the coinfection of TB and HIV, we must integrate as much as possible the control of TB and HIV care to synergize. Interventions that have proven highly effective in establishing the immunological capacity and therefore reduce the incidence of opportunistic infections and tuberculosis in general are: actions to control tuberculosis, and appropriate early treatment of TB cases, provision of chemoprophylaxis in HIV-infected patients and on the other measures for the control of HIV as the concierge, performing diagnostic tests and the introduction of antiretroviral therapy (TARGA).

severe forms of disease such as miliary tuberculosis and meningitis. Studies of BCG applied in the neonatal period suggest a good protection. In summary major efforts to control tuberculosis are being developed in the country. However, it is essential to improve and strengthen existing guidelines, incorporating broader criteria with concerned to health. It is necessary to meet the challenges established by the drug resistance, the coinfection HIV - TB, deaths from tuberculosis and areas of high epidemiological risk of transmission. There is no doubt that a comprehensive care approach would be the most appropriate way to address the problem. This opportunity will amplify the response of the authorities, professional excellence in case management, equity and access to resources, as well as respect for human rights of people and all those aspects that are involved with the current situation of the disease in our country. This improvement must be one of our goals. Peru, as well as many other countries, deserves to be TB free. We can work it out.

On the other hand, the BCG vaccine, developed by Calmette and GuĂŠrin and included in the Expanded Programme on Immunization of WHO in most countries since 1974, is widely used today, accepting that can prevent endogenous reinfection and prevent the spread of tuberculosis infection, and therefore reduce the 15

PAMSA HeartBeat

Psychiatric Stigma: A pending Issue

Octavio Garaycochea Mendoza Del Solar APEMH - Perú

There is much evidence pointing to banishment, condemnation, and forms of incarceration being applied to those insane persons who were chronically ill, poor, ‘’When life itself seems lunatic, who knows where isolated and hence marginal. Later on, insanity came madness lies? Perhaps to be too practical is to be associated with the countryside, the wilderness, madness. To surrender dreams—this may be making mental patients less likely to be part of a city and madness. To seek treasure where there is only trash. their culture. Too much sanity may be madness. And maddest of all, to see life as it is and not as it should be’’ Today the media plays an important role in the – Don Quixote, The Man of La Mancha. perpetuation of psychiatric stigma, for the people who have little direct experience with psychiatric illness. Following Quixote’s reflection on insanity, how should The media is most often the source for the language, the life be of a human being who carries a mental concepts and images of psychiatry. Wilson et al have disease? Shouldn’t it be without discrimination? Without studied 128 children’s television programmes of these, stigmatization? The meaning of stigma is defined 46% referred to mental illness using derogatory terms as a mark of disgrace associated with a particular such as nuts, bananas, twisted, wacko, freak and circumstance, quality, or person. Nowadays, many others (3). But it’s not only the children’s television people hold negative stereotypes against those with programmes, in a survey of families of mentally ill and mental illnesses, to be mark as ‘’mentally ill’’ carries their perceptions of what causes stigma, 86.6% blamed internal and external consequences, such as lower self- popular movies about mentally ill killers (4). esteem, social exclusion and discrimination. Psychiatric patients do not only carry a heavy burden Suppose that one day a friend of yours came up to tell of social perception, but this stigma has negative you that his sister has been hospitalized because of a consequences on the detection and treatment of their severe urinary tract infection, how different your reaction mental illness. More than forty negative consequences would be if he would tell you that the reason of why she of stigma have been identified including discrimination in is being hospitalize is because she is going through a housing, education, employment and increased feelings severe depression, or an episode of acute psychosis. of hopelessness and loneliness (5). The result is that Like your friend’s sister, you could be one in four people many people suffering from mental illnesses are reluctant that will experience a mental health disorder during their to seek help, less likely to cooperate with treatment, lifetime (1), and you might be a victim of unfair prejudices. and they are slower in recovering their self-esteem and confidence. Psychiatric illnesses take place in all types of societies and it is not only a disorder influenced by biology; it is Nevertheless, this negative attitude towards mental also influenced by culture, and therefore, the way it is illness it is not only shown by the community, but managed is culturally determined. And how do societies doctors and medical students can also share their label mental patients? Are they dangerous, volatile, negative opinions about psychiatric illnesses, especially shameful, lazy, weak, unstable, depended, irrational, those with schizophrenia and substance addiction (6). and incurable among others? There have been reports that stigmatization in healthcare workers leads to a different attitude for the patient, seen There have been several investigations and reviews as ‘’less likeable’’ (7) and most of us wouldn’t be surprise of the psychiatric stigma throughout history; Western to hear that mental health services and research are societies have always linked ideas of morality and virtue relatively underfunded worldwide (8). Consequently the with health and reason. Early Christian societies added stigmatization in healthcare workers is a very important symbols of the demonic, the morally perverse, the issue, but where does it begin? In my view, it is during promiscuous, and the sinful to this cultural picture of the Psychiatric rotation of a medical student when this madness (2). negative attitude starts to grow. 16

PAMSA HeartBeat

Psychiatric Stigma: A pending Issue

Challenging people who use disrespectful language or jokes about mental health? Mentioning a successful actress or a prize-winning author with a mental illness? Yes, we could if we think that this should decrease the stigmatization among us, starting the change locally. There have been good results using educational campaigns; culturally-sensitive and comprehensive, but not only limited in the community. There are results suggesting that attitudes towards mental illness could be changed favorably in a one-hour educational program for medical students (9). Knowing that people with mental illness suffer as much from other people’s responses and expectations as from the symptoms of the illness itself, we need to remember as well that living in the community does not mean being part of the community. The treatment of psychiatric patients should be more than focusing on a dopamine receptor, it should include quality of life indices and the feeling of being part of a community. It’s time to get moving and leave the stigmatization behind. Remembering Ghandi’s phrase, it’s time to be the change we want to see in the world. Bibliography

In most countries when a medical student rotates in psychiatry he\she does so at a Psychiatric Hospital, and nearly all of them are public hospitals where most of the patients are chronic, so that’s the idea that he\she gets of a psychiatric illness: an elderly patient with severe dyskinesia. What can be done? Some good examples of what can be done are seen in the United Kingdom, Canada and New Zealand. They have created multi-faceted, long-term, financially suitable and anti-discrimination/social inclusion programs (Time to Change, Opening minds, Like Minds – Like Mine) to face this issue, but unfortunately very few countries have these kinds of programs. What about the rest of the countries? The change must start in healthcare workers, especially students; we need to consider our own awareness and attitudes. Where do we start? By saying chronic imbalance in serotonin levels rather than depression? 17

1. World Health Organization: Mental health: New understanding new hope. In The World Health Report Geneva, WHO; 2001. 2. Fabrega, H. (1991a) The culture and history of psychiatric stigma in early modern and modern Western societies: a review of recent literature. Comprehensive Psychiatry, 32, 97119. 3. Wilson, C., Nairn, R., Coverdale, J. et al (2000) How mental illness is portrayed in children’s television. A prospective study. British Journal of Psychiatry, 176, 440 -443. 4. Wahl 0, Harman C. Family views of stigma. Schizophrenia Bull 1989;15:131-9 5. Byrne, P. (1997) Psychiatric stigma: past, passing and to come. Journal of the Royal Society of Medicine, 90, 618 6. Mukherjee R, Wijetunge M, Surgenor T. The stigmatisation of psychiatric illness: the attitudes of medical students and doctors in a London teaching hospital. Psychiat Bull 2002;26:178–81 7. Fleming, J. & Szmukler, G. I. (1992) Attitudes of medical professionals towards patients with eating disorders. Australian and New Zealand Journal of Psychiatry, 26, 436 8. Sartorius N. Stigma: what can psychiatrists do about it? Lancet 1998;352: 1058-9. 9. Mino, Y., Yasuda, N., Tsuda, T. and Shimodera, S. (2001), Effects of a one-hour educational program on medical students’ attitudes to mental illness. Psychiatry and Clinical Neurosciences, 55: 501–507. doi: 10.1046/j.1440-1819.2001.00896.x

PAMSA HeartBeat

IFMSA Day for Non-communicable Diseases

What was the NCD Day about and how did we act? Nilofer Khan Habibullah (AMSA-USA) On behalf of Think Global Initiative Project and the Read on…. Small Working Group on NCDs Why the IFMSA Day for NCDs? • Non-communicable diseases (NCDs) – which Aims and objectives include diabetes, cardiovascular disease, cancer Member States at the 63rd WHO World Health Assembly and chronic respiratory disease – cause 60 % reviewed progress achieved during the first two years of all deaths globally (35 million) each year. The in implementing the Action Plan for the Global Strategy Moscow Ministerial Declaration revealed that on the Prevention and Control of Non-communicable Diseases2. this figure will jump to 75% by 2030. • 4 out of 5 deaths occur in low- and middleincome countries. Successful approaches included3: • NCDs share the common risk factors of tobacco • implementing interventions aimed at monitoring use, unhealthy diet and physical inactivity. NCDs and their contributing factors; • NCDs only receive 0.9% of health official • addressing risk factors and determinants supported development assistance (ODA). by effective mechanisms of inter-sectoral action; and • NCDs are a major cause of poverty, a barrier to • improving health care for people with NCDs through economic development, and a neglected global health system strengthening. emergency. Courtesy MDGs and NCDs Factsheet: The NCD Alliance1 However, one short-coming noted was the unremarkable progress made towards building sustainable institutional A latest report concludes that the best way to ensure capacity to tackle NCDs in developing countries3. access to health care for NCDs patients will be to fully integrate national Disease Management Programs To address the need for young health advocates to (DMPs) into the primary care sector (Chronic Disease contribute to the growing global NCDs movement in Management Matrix 2010, NIVEL 2011). On May 13, building such capacities, the aim of the IFMSA Day for 2010, the United Nations, led by Caribbean Community NCD was to mobilize medical student members to dispel (CARICOM) member states, voted unanimously for the healthy lifestyle awareness while promoting preventative United Nations’ (UN) Resolution 64/265 to hold a UN measures. This would highlight the danger posed by High-Level Summit on NCDs in September 2011. This the four shared risk factors for NCDs, including tobacco will be the second time that a health issue has been use, physical inactivity, unhealthy diets and the harmful brought to the global agenda on the UN High-Level use of alcohol. Summit. The Think Global team and the Small Working Group on In line with the IFMSA’s commitment pledged on its Policy NCDs composed a toolkit with ready-to-use Powerpoint Statement on the NCDs for ‘promoting increased youth presentations and guide-sheets for organizing fun walks, involvement in the global NCDs movement by advocating press conferences, and declaring a Policy Statement on for youth-oriented NCDs awareness programs within NCDs- to name a few. local communities, interaction forums at medical schools, grassroots organizing, and (to some extent) lobbying How did NMOs act? decision-makers; to mobilize young health professionals To observe the IFMSA Day for NCDs, NMOs across the in-training to contribute to NCDs control....’, and world, from 37 countries, observed coordinated action interventions proposed during the NCDs discussions at by organizing awareness drives for the general public the 64th World Health Assembly (May 2011), the IFMSA and school children. NMOs also held peer-education recently held it’s first-ever Day for Non-communicable sessions with fellow medical students to discuss NCDs disease, observed on September 19, 2011, which also in context of the social determinants of health, Millennium commemorated the first day of the UN Summit on NCDs. Development Goals (MDGs), and sustainable health. 18

PAMSA HeartBeat

IFMSA Day for Non-communicable Diseases

Image Courtesy: Beaglehole R,Bonita R,Horton R,et al.Priority Actions for the Non-communicable Disease Crisis.Lancet 2011;377: 1438-47

In general, NMO activities on the NCD Day ran under the following tracks: 1. Training medical students: including workshops, training sessions or roundtable discussions. 2. Outreach to the general public and advocacy on awareness and prevention activities: Public screening or NCD educational presentations at local town hall or public landmarks, media events such as press conferences on NCDs, declaring a Policy Statement, etc, and hosting on-campus lunch talks with local NCD experts. 19

3. Educating school students by raising awareness and other appropriate interventions: Screening Powerpoint lectures intended for early adolescents promoting healthy eating and physical activity. Booklets were also distributed. NCD Day is done, what’s next? After the event and completion of reporting procedures, participating NMOs will contribute towards a compilation of a “go-to” resource of NCDs advocacy tools and materials. PAMSA HeartBeat

By acting locally, you made an impact on NCDs globally!

Most importantly, we hope that that the NCD Day reiterated that reducing NCD numbers is within our reach and largely a preventative public health issue, while making students realize the need and importance of integrating NCD prevention and control concepts as part of standard medical education curricula, thereby, setting an impetus for other sustainable youth-driven healthy lifestyle programs and efforts on NCDs within the IFMSA. Furthermore, there will be on-going efforts to continue the NCDs movement beyond the IFMSA Day on NCDs, by addressing the social determinants of health aspects on the NCDs, as part of the SWG on Health Inequity’s Week of Global Action on the Social Determinants of Health (WOA-SDH, October 17-23, 2011) and the upcoming pre-Regional Meeting workshop for PAMSA. Stay tuned!

building up youth movement towards the UN Highlevel summit on NCDs with the IFMSA Day for NCDs, sustainable health, working with the Global Health Education Consortium (GHEC) on its global health guidebook, and forging partnerships with the WHO’s Global Health Workforce Alliance. We have integrated many aspects of these areas in order to emphasize the linkages between different factors affecting the same diseases and the underlying causes. Think Global has also partnered with different IFMSA projects and Officials, such as the SWG on Social Determinants of Health, SWG on NCDs, Healthy Planet International, LO Public Health, SCOPH, Projects Director and LO WHO. The Think Global team can be contacted at or Facebook at IFMSA’s Think Global Initiative Project. References

Please submit your questions and comments to the Think Global Coordinator at or write to me at Please feel free to contact us and follow us on our Facebook page, IFMSA’s Think Global Initiative Project. The costs for NCD priority interventions are likely to remain small, but lack adequate action. As the largest medical student organization in the world, the IFMSA reaffirms its commitment to mitigate the global threat of encroaching NCD numbers. With the IFMSA Day for NCDs, we hope to channel medical student efforts to push NCDs in the limelight on all local, national and global levels, while energizing our biggest asset to be effective NCDs advocates: our 1.3 million medical students worldwide. As health professionals, we have an obligation to improve the health of our global citizens. Join us in our efforts in keeping this promise!

1. The NCD Alliance: The MDGs and NCDs coversheet. 2010. Available from rfiles/The%20Millennium%20Development%20Goals%20 and%20NCDs.rar (accessed 15 April 2011). 2. 2008-2013 Action plan for the global strategy on the prevention and control of non-communicable diseases. World Health Organization. 2009. Available from: publications/2009/9789241597418_eng.pdf (accessed 15 April 2011). 3. Sixty-third assembly closes after passing multiple resolutions. World Health Organization. 2010. Available from: http:// closes_20100521/en/index.html (accessed 22 May 2011).

The Think Global Initiative is IFMSA’s flagship Global Health project with a broad area of work. The affiliation with IFMSA’s standing committees allows this project to have an incredible horizontal approach to Global Health. Some of our focus areas for the past months have been related to advocating for updated global health education in standard Medical Curricula (supported by a UNESCO grant),


PAMSA HeartBeat

Updates from NMOs Maria Jose Navarrete Dättwyler Proud-President of IFMSA-Argentina Have you seen a “time-lapse” movie of a growing plant? I cannot think of a better way to describe and picture how IFMSA-Argentina has been developing. It is a great honor for all of us to see that the dream, one year ago has taken place into our realities. So let me sum-up this 11’ for you: • We had our first NGA, the very first time that we worked with an OC and organized an event. It was great, a lot to do and a lot to learn. Our new EB was chosen, not many changes but many new goals. • We have been trying to give a better shape to Yassen Tcholakov SCOME, SCORA and SCOPH with new projects IFMSA-Québec and more independent lines of action. Also this year, we opened two committees (SCOPE and SCORP). In IFMSA-Québec, we are just coming back from That made us realize that we have to work on our vacation; indeed, pre-clinical students have a few structure, as it gets bigger and more diverse. months off of medical school during the summer. Many • We are about to hold our TOM3 and who would use that time to work, do research, to travel or just to imagine that we could talk about such things as relax. However, IFMSA-Québec’s newly elected national “policy statements” or “transnational projects”? team for the next year keeps on working to prepare certainly this is a surprise for us, and things are everything for the great year to come. Indeed, many getting more exiting each day!. things are going to happen right after the start of school • Last year at the AM Montreal 10’ (the zero, in our in August/September: we will have national trainings for timeline), we were just two delegates, very lost and all our peer education projects; the national congress overwhelmed. And this year, with 9 delegates during is coming up. Furthermore, local coordinators for all the the RM Cochabamba 11’ and 5 delegates at the committees will be chosen very soon after the start of AM Denmark 11’ , we feel very proud (and much school. Finally, our National GA will take place at the oriented) to say that we know how IFMSA works, we beginning of October, it will last one day, but it will be feel confident, and we are ready to transmit it to our followed by a full day of training for all the elected and whole country. RM Peru 12’ … wait for us. nominated officials. This second day is something that will take place for the first time in IFMSA-Québec and Thanks to our team, to the hopes and fears (soundtrack we are very excited about it, hopefully it will have a very [on]), to the will and hope that we can do whatever we positive impact. I will be able to share more about it soon want if we trust ourselves and eachother. This is how I hope. we work and this is how we want to show the world that you can achive, you can learn, you can change! just Other interesting things that we are working on is feed your dreams with a nice amount of team friendship trying to get membership in the Canadian commission and teamwork. for UNESCO, formalizing our relationship with the organizations that sponsor many of the students that go There is a lot to tell, and much more to feel, but don’t to GAs and RMs, and the reconstruction of the pre-GA/ pause the movie because IFMSA-Argentina is still getting pre-RM training for IFMSA-Québec delegates. Looking stronger and you won’t have to wait much longer to see forward to see all of you soon. it bloom! 21

PAMSA HeartBeat

Publications Team These guys are AMAZING! They were the ones who brought you the great three first issues of the HeartBeat and they put all of their love and passion for PAMSA doing it. I have no words to tell how grateful I am for their ideas, opinions, comments, thoughts and help through the process of making the PAMSA magazine a reality. I love them so much! Get to know a little bit about them and what makes them special (and what makes me special too!).

Jill Stone, CFMS - Canada

Random fact: I’ve been on dives with sharks, but am ridiculously afraid of jellyfish Favourite superhero: Can’t deny it. Batman is hot. Someone in PAMSA I’d kiss: Besides my significant other....? Erick: because he’s the “ruler of the people” and whips us into shape. (But only in virtual xoxo’s) A message for PAMSA: Do not argue with an idiot. He will drag you down to his level and beat you with experience. Take life lightly, and don’t sweat the small stuff. :)

Jimy Campana, IFMSA - Perú

Random fact: 100% fact... doesn´t exist such a thing. Favourite superhero: Iron Man... I bet no one else can listen his favorite music while is kickin asses. I mean... Who needs an iPod when u have that suit? Someone in PAMSA I’d kiss: There is someone but you won´t know her name! :D A message for PAMSA: All of you are amazing people! I can´t wait until see u in the RM... but in the meanwhile keep rockin, PAMSA!

Sandra Tang, APEMH - Perú Random fact: I love being a girl Favourite superhero: Sailor Jupiter Someone in PAMSA I’d kiss: Palmy A message for PAMSA: I LOVE YOU!


PAMSA HeartBeat

Publications Team Erick Meléndez, IFMSA - El Salvador

Random fact: My first kiss was with someone from PAMSA (not from my NMO) Favourite superhero: Rogue Someone in PAMSA I’d kiss: Oh so many people! Coti, Geni, Fio, Y... oops! A message for PAMSA: I love you guys! Keep strong and working as a family, but always having fun when doing it!

Helena Chapman, Dominican Republic

Random fact: I often dance salsa in my sleep Favourite superhero: Robin Hood Someone in PAMSA I’d kiss: Any guy with a smile and passion to improve health! A message for PAMSA: Our PAMSA collaborations are successfully based on the following formula: Dedicated teamwork + Enthusiasm = Community health. Dissecting these variables, we find that teamwork shows that we should “Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has” (Margaret Mead) and enthusiasm reflects that “Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around” (Leo Buscaglia). Community health is the sum of these variables and provides evidence of our passion in medicine and public health across the Americas.

Génesis Cañas, IFMSA - El Salvador

Random fact: 1)By raising your legs slowly and laying on your back, you can’t sink in quicksand; 2)Coconuts kill more people in the world than sharks do; 3)Alfred Hitchcock didn’t have a belly button! Favourite superhero: Lelouch Lamperouge (a misunderstood hero!) Someone in PAMSA I’d kiss: Well, there is this DA publications who is incredibly cute (as in puppy cute!), even though he is a dork! A message for PAMSA: Helen Keller once said “Many persons have a wrong idea of what constitutes true happiness. It is not attained through self-gratification but through fidelity to a worthy purpose”, well, I can not think of a more worthy purpose than to devote your life to serve those who needs us the most. As med students we have a huge responsability, and that leads to tiring and stressful times that makes you wonder about your sanity. However, it is because we are Med Students that we are part of this amazing PAMSA family, so I can’t help but to think “It’s all worth it!”


PAMSA HeartBeat

Algeria (Le Souk) Argentina (IFMSA-Argentina) Armenia (AMSP) Australia (AMSA) Austria (AMSA) Azerbaijan (AzerMDS) Bahrain (IFMSA-BH) Bangladesh (BMSS) Belgium (BeMSA) Bolivia (IFMSA Bolivia) Bosnia and Herzegovina (BoHeMSA) Bosnia and Herzegovina - Rep. of Srpska (SaMSIC) Brazil (DENEM) Brazil (IFMSA Brazil) Bulgaria (AMSB) Burkina Faso (AEM) Burundi (ABEM) Canada (CFMS) Canada-Quebec (IFMSA-Quebec) Catalonia - Spain (AECS) Chile (IFMSA-Chile) China (IFMSA-China) Colombia (ASCEMCOL) Costa Rica (ACEM) Croatia (CroMSIC) Czech Republic (IFMSA CZ) Denmark (IMCC) Ecuador (IFMSA-Ecuador) Egypt (EMSA) Egypt (IFMSA-Egypt) El Salvador (IFMSA El Salvador) Estonia (EstMSA) Ethiopia (EMSA) Finland (FiMSIC) France (ANEMF) Georgia (GYMU) Germany (BVMD) Ghana (FGMSA) Greece (HelMSIC) Grenada (IFMSA-Grenada) Hong Kong (AMSAHK) Hungary (HuMSIRC) Iceland (IMSIC) Indonesia (CIMSA-ISMKI) Iran (IFMSA-Iran) Israel (FIMS) Italy (SISM) Jamaica (JAMSA) Japan (IFMSA-Japan) Jordan (IFMSA-Jo) Kenya (MSAKE) Korea (KMSA) Kurdistan - Iraq (IFMSA-Kurdistan/Iraq)

Kuwait (KuMSA) Kyrgyzstan (MSPA Kyrgyzstan) Latvia (LaMSA Latvia) Lebanon (LeMSIC) Libya (LMSA) Lithuania (LiMSA) Luxembourg (ALEM) Malaysia (SMAMMS) Mali (APS) Malta (MMSA) Mexico (IFMSA-Mexico) Mongolia (MMLA) Montenegro (MoMSIC Montenegro) Mozambique (IFMSA-Mozambique) Nepal (NMSS) New Zealand (NZMSA) Nigeria (NiMSA) Norway (NMSA) Oman (SQU-MSG) Pakistan (IFMSA-Pakistan) Palestine (IFMSA-Palestine) Panama (IFMSA-Panama) Paraguay (IFMSA-Paraguay) Peru (APEMH) Peru (IFMSA Peru) Philippines (AMSA-Philippines) Poland (IFMSA-Poland) Portugal (PorMSIC) Romania (FASMR) Russian Federation (HCCM) Rwanda (MEDSAR) Saudi Arabia (IFMSA-Saudi Arabia) Serbia (IFMSA-Serbia) Slovakia (SloMSA) Slovenia (SloMSIC) South Africa (SAMSA) Spain (IFMSA-Spain) Sudan (MedSIN-Sudan) Sweden (IFMSA-Sweden) Switzerland (SwiMSA) Taiwan (IFMSA-Taiwan) Tanzania (TAMSA) Tatarstan-Russia (TaMSA-Tatarstan) Thailand (IFMSA-Thailand) The former Yugoslav Republic of Macedonia (MMSA-Macedonia) The Netherlands (IFMSA-The Netherlands) Tunisia (ASSOCIA-MED) Turkey (TurkMSIC) Uganda (FUMSA) United Arab Emirates (EMSS) United Kingdom of Great Britain and Northern Ireland (Medsin-UK) United States of America (AMSA-USA) Venezuela (FEVESOCEM) medical students worldwide

PAMSA HeartBeat Medical Practice in the Americas  

3rd edition of the PAMSA magazine. Titled "Medical Practice in the Americas", it focus on the differences between heatlh systems in the PAMS...

PAMSA HeartBeat Medical Practice in the Americas  

3rd edition of the PAMSA magazine. Titled "Medical Practice in the Americas", it focus on the differences between heatlh systems in the PAMS...