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HeartBeatPAMSA

Medical Practice inthe aMericas

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IFMSAwas 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.

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.

Imprint

Editor in ChiefErick Meléndez, El Salvador

EditorsJill Stone, CanadaHelena Chapman, Dominican RepublicGénesis Cañas, El Salvador

Design/LayoutErick Meléndez, El Salvador

ProofreadingJill Stone, CanadaHelena Chapman, Dominican RepublicGénesis Cañas, El Salvador

PublisherInternational Federation ofMedical Students’ AssociationsGeneral Secretariat:IFMSA c/o WMAB.P. 6301212 Ferney-Voltaire, FrancePhone: +33 450 404 759Fax: +33 450 405 937Email: gs@ifmsa.org

Homepage: www.ifmsa.org

Contactspublications@ifmsa.org

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Content

Human rights In ourdaily practice 7

Why Health 2.0? 10

How does Peru fight TB? 13

IFMSA day fornon-communicable diseases 18

Updates from NMOs 21

Medical education in America: How similar could it be? 8

Social determinants of health in medical practice 12

Psychiatric stigma: A pending Issue 16

Publications team 22

PAMSA team 4

From our RC 6

Introduction 5

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PAMSA Team

Gabriela NolesRegional Coordinator

IFMSA - Perurcamericas@ifmsa.org

Leonel AyalaPublications and Media DAIFMSA - El Salvadorda.publications.pamsa@gmail.com

Elías OrtegaSCOME Regional AssistantIFMSA - Argentinara.scome.pamsa@gmail.com

Alhelí CalderónNMO Development DA

IFMSA - Mexicoda.nmo.pamsa@gmail.com

Mardelangel Zapata

Projects Regional AssistantAPEMH - Peru

ra.projects.pamsa@gmail.com

Ricardo ZulesSCORP Regional AssistantIFMSA - Ecuadorra.scorp.pamsa@gmail.com

Erick MeléndezSCORA Regional Assistant

IFMSA - El Salvadorra.scora.pamsa@gmail.com

Fréderic MorinSCOPE Regional Assistant

IFMSA - Quebecra.scope.pamsa@gmail.com

Roberto GarcíaSCORE Regional AssistantIFMSA - Mexicora.score.pamsa@gmail.com

Gianina CerrónSCOPH Regional Assistant

APEMH - Perura.scoph.pamsa@gmail.com

Paola AguirreSCORA Regional AssistantIFMSA - Perura.scora.pamsa@gmail.com

Javiera BrierleyNMO Development DAIFMSA - Chileda.nmo.pamsa@gmail.com

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Introduction

This magazine is an IFMSA Publication.© Portions if this magazine may be reproduced for non political, and non profit purposes mentioning the source provided.

Notice: Every case has been taken in the 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.

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.

This magazine has been made with so much love and passion, created specially for all of you as a way to acknowledge the amazing work you do in each NMO trying to improve the health of our people.

As I said in the first issue, we are related in so many ways and working together is what make us bigger and stronger, even though we have many differences in the way we act. This issue was focused on that fact: The differences in our health systems and medical practice, and how we can overcome them in order to improve the health of our region.

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.

I would like to wish the best of luck to my successor, I am sure he/she will put all the necessary effort to continue this dream from all the medical student in PAMSA, I know the HeatBeat wil only keep growing and getting 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!

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 and hopefully I will do it someday.

Thanks to everyone who sent their submission to the magazine; in the end, it was you and the quality of your work what made this magazine as good as it is now!

Finally, I want to thank my PAMSA family for showing me your love through your messages with kind words and virtual hugs. I love you so much!

Hopefully, this is not a good bye but a see you later.

Erick Meléndez.

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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

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Human rights in our daily practice

Marc-André Lavallée IFMSA-QuebecSCORP 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.

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 recognize that these human rights violations occur daily. Since “The International Declaration of Human Rights” and “The International Covenant on Economic, Social and Cultural Rights”1 state that health is a human right, it is our responsibility, as future doctors, to eliminate patient discrimination.

Moreover, we have the power and obligation to be patient advocates so that our medical centers stop refusing any patient care to undocumented immigrants, citizens with limited financial resources or intravenous drug users.

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.

As medical students, we forget that the patient accepts our presence as part of the medical team, although he or she may refuse our physical presence during the medical history or physical exam. The final decision always belongs to the patient.

In conclusion, we must remember that our patients are humans, with their rights and their dignity. Our clinical decisions must be oriented on our patients’ health and well-being, not on our will of self-accomplishment. With this golden rule, we may become an example for our colleagues.

1. «The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. » - International Covenant on Economic, Social and Cultural Right.

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David LaPierre, MDConsider contributing to our medical education textbook – learn medicine, build your CV, and help others!

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.

Building on the lessons learned from the Bologna process in Europe and a similar movement across the Americas, a global core curriculum should be possible. From a student perspective, the IFMSA Standing Committee on Medical Education should be the association to advocate for these global curriculum standards.

Of 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.

What does this mean for medical education resources across the Americas?

Can we work together to create resources for us all to use, regardless of where we are?

The birth of SharingInHealth.caOur vision is that all medical learners meet core global curriculum standards.

Our mission is to provide freely-available medical education globally while being useful locally.

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 locally-useful 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 students, so I asked for help.

The response was overwhelming. Classmates contributed as authors. Professors and clinicians peer-reviewed our work to ensure material was accurate. Even artists started to illustrate our topics with awe-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 feedback with numerous accounts of its relevance and usefulness. We are also planning to pilot our maternal and newborn health in Canada, Uganda, and Haiti in 2012, with other countries to follow.

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

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

To learn more about this process, please visit our main page, www.SharingInHealth.ca and look under ‘how you can help’.

Currently, we are also looking for promotional representatives. If you are interested in sharing this movement with others, email contact@sharinginhealth.ca to learn more.

Contribute to freely-available, globally relevant, locally-useful medical education. Join www.sharinginhealth.ca today.

Dr. Dave LaPierre is a Family Medicine resident from the University of Western Ontario, London, Ontario, Canada and founder and chief editor of www.SharingInHealth.ca.

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

A special thanks to Julie Hebert for continuing to promote SharingInHealth.ca, most recently at the last IFMSA AM11 in Copenhagen where our movement was met with much interest and enthusiasm.

Another thanks to SCOME and IFMSA for their continued endorsement.

A final thanks to all our past, present and future readers, writers, reviewers, illustrators, and promoters – don’t stop contributing to medical education worldwide.

Reference:Collier, R. 2011. Canadian students develop mediwiki to share classroom notes with the world. CMAJ 183(11).

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

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Nicolás Allende, NOME IFMSA-ArgentinaIan Pereira, PAMSA SCOME Regional Assistant

“People don’t buy what you do, they buy why you do it”

Simon Sinek, TEDtalk at the IFMSA AM11 Health 2.0 Pre-GA

As medical students we challenge ourselves to learn so that others benefit. Limits to improving health are only for those with limited perspective. We follow what we believe in, and we believe in improving the health of our patients using everything and anything available. This should include social media.

Social media is revolutionizing healthcare today. The new technologies of social media do not equate to the impersonalization of human relationships in medicine. Instead, Facebook, twitter, blogs, podcasts, YouTube and other facets of social media have facilitated transfer of knowledge to complement clinical encounters. Physicians can easily share evidence-based knowledge to improve healthcare for their patient populations through blogs and podcasts. Cancer survivors who previously attempted to connect through email discussion groups and chat rooms now create Facebook virtual communities and wikis that enable them to quickly share information about coping strategies and build a personal support network of friends.

Health advocacy groups can now update patients on relevant health news and alerts through blog newsletters, personalized Facebook messages, and twitter and RSS feeds to smartphones. Collectively, social media can bring widely-accessible, low-cost healthcare to patients who need it worldwide and reduce the burden of disease crippling many healthcare systems. As medical students, social media should not be foreign. It is our duty to use it effectively not only to complement clinical encounters, but to improve healthcare systems worldwide. But how?

We still live in a time when using cell phones and laptops can be considered rude. But times are changing. Increasingly, students across PAMSA are using social media. Most of us have Facebook. Many of us have Twitter. We post the results of workshops and lectures on Facebook, Twitter, and Youtube to complement medical education. We take more collaborative minutes with online mindmaps like Mindmeister. More importantly, we still manage to listen to our teachers, each other, and to our patients. So why not use the social media tools we already know intimately to improve our healthcare system?

This underutilization of our own knowledge prompted a few students in IFMSA to introduce to the world the SCOME IFMSA Health 2.0 Project, and its first Pre-GA Training at the 2011 AM in Copenhagen, Denmark.

Why Health 2.0?

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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.

How can you get involved today? Join IFMSA Health 2.0 on Facebook. Follow #ifmsahealth20 on twitter.Find out more at http://www.health20prega.pt.vu/ or by emailing ifmsahealth20@gmail.com

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.

AcknowledgementsThanks 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.

Correspondence should be addressed to Nicolás Allende jnallende@gmail.com

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SOCIAL DETERMINANTS OF HEALTH IN MEDICAL PRACTICE

Álvaro Mondragón-Cardona, Verónica Álzate-CarvajalASCEMCOL - 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.

References1. 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, Jimenez- Canizalez 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.

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How does Peru fight TB?

Luz del Pilar Revolledo Calizaya, IFMSA-Perú

Studies in Peru, where bone lesions have been found related to this etiology in Inca mummies, make us think that TB appears to be a disease as old as humanity itself. About the year 1882 - following the discovery of TB by Robert Kock- who gets the Nobel Prize 23 years later – begins the long process of fighting this disease; however, treatment of patients just started four decades later, when Abraham Waksman discovered streptomycin, and it soon began to be used after success in treatment during World War II. Later, paraminosalicilic acid will be introduced to this basic treatment regimen by Jorgen Lehmann; and finally isoniazid in 1952 as a result of Robitzelc’ work. Around 1952, these three drugs constitute the foundation of what will be the future therapeutic regimens.

In Peru, around 1921, the first sanatorium for the disease was built in the city of Jauja, and specific areas were established in major hospitals in the capital for these types of patients. However, in despite of the great efforts made during these decades by health professionals worldwide, the mortality rates remained extremely high: in a hundred patients, ninety died. Thus in 1940, our Ministry of Health organized the first National Plan for Tuberculosis Control, considering, among other measures, the implementation of the BGC vaccine for children under 15 years.

These measures continued until the 80’s, when the ministry faced an extremely hard situation with its organization: presenting poor methods of diagnosis and medication management and poor patients’ access to free treatment. In 1985, of 24,500 patients diagnosed with TB, only 13,000 received treatment.

In that scenario is initiated the Integrated Health Care in order to achieve what was called “Health for All”, taking into account the risks at national level, including malnutrition and tuberculosis. During this program, they emphasized the health of the mother and child in the areas of nutrition and vaccination with BCG, as well as prevention and control of TB developing the following: health education, treatment of diagnosed cases, monitorization, control and surveillance of contacts.

In the second half of 1990, it was initiated a new approach to the management of this disease in Peru, restructuring the National TB Control (NPTC), including new guidance on the regulations and procedures and introducing the important recommendations of international agencies PAHO and WHO, who provided important advice, ongoing training by highly qualified experts and recommendations in the scientific and technological field, which in short constituted a modern educational program that developed a preventive strategy during the course of that decade.

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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.

Peru, like other countries that achieved obvious results in controlling tuberculosis, received from PAHO and WHO in 1997 the award from the American Association for World Health by the success in implementing the program.

Until 2001, Peru was able to overcome the global millennium goals regarding TB control, but by 2003 there was a sustained deterioration of the activities of TB case finding, situation that was reversed for 2005.

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 reactions and hypersensitivity, loss of visual acuity and blindness, even going so far as hepatitis frequent toxic effect, nephrotoxicity and ototoxicity, in addition to the emergence resistance.

Before starting treatment, every TB case should be evaluated for initial bacteriological status, history of previous treatment, disease location, and disease severity and prognosis.

How does Peru fight TB?

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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).

On the other hand, the BCG vaccine, developed by Calmette and Guérin 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

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.

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Octavio Garaycochea Mendoza Del SolarAPEMH - Perú

‘’When life itself seems lunatic, who knows where madness lies? Perhaps to be too practical is madness. To surrender dreams—this may be madness. To seek treasure where there is only trash. Too much sanity may be madness. And maddest of all, to see life as it is and not as it should be’’ – Don Quixote, The Man of La Mancha.

Following Quixote’s reflection on insanity, how should the life be of a human being who carries a mental disease? Shouldn’t it be without discrimination? Without stigmatization? The meaning of stigma is defined as a mark of disgrace associated with a particular circumstance, quality, or person. Nowadays, many people hold negative stereotypes against those with mental illnesses, to be mark as ‘’mentally ill’’ carries internal and external consequences, such as lower self-esteem, social exclusion and discrimination.

Suppose that one day a friend of yours came up to tell you that his sister has been hospitalized because of a severe urinary tract infection, how different your reaction would be if he would tell you that the reason of why she is being hospitalize is because she is going through a severe depression, or an episode of acute psychosis. Like your friend’s sister, you could be one in four people that will experience a mental health disorder during their lifetime (1), and you might be a victim of unfair prejudices.

Psychiatric illnesses take place in all types of societies and it is not only a disorder influenced by biology; it is also influenced by culture, and therefore, the way it is managed is culturally determined. And how do societies label mental patients? Are they dangerous, volatile, shameful, lazy, weak, unstable, depended, irrational, and incurable among others?

There have been several investigations and reviews of the psychiatric stigma throughout history; Western societies have always linked ideas of morality and virtue with health and reason. Early Christian societies added symbols of the demonic, the morally perverse, the promiscuous, and the sinful to this cultural picture of madness (2).

There is much evidence pointing to banishment, condemnation, and forms of incarceration being applied to those insane persons who were chronically ill, poor, isolated and hence marginal. Later on, insanity came to be associated with the countryside, the wilderness, making mental patients less likely to be part of a city and their culture.

Today the media plays an important role in the perpetuation of psychiatric stigma, for the people who have little direct experience with psychiatric illness. The media is most often the source for the language, concepts and images of psychiatry. Wilson et al have studied 128 children’s television programmes of these, 46% referred to mental illness using derogatory terms such as nuts, bananas, twisted, wacko, freak and others (3). But it’s not only the children’s television programmes, in a survey of families of mentally ill and their perceptions of what causes stigma, 86.6% blamed popular movies about mentally ill killers (4).

Psychiatric patients do not only carry a heavy burden of social perception, but this stigma has negative consequences on the detection and treatment of their mental illness. More than forty negative consequences of stigma have been identified including discrimination in housing, education, employment and increased feelings of hopelessness and loneliness (5). The result is that many people suffering from mental illnesses are reluctant to seek help, less likely to cooperate with treatment, and they are slower in recovering their self-esteem and confidence.

Nevertheless, this negative attitude towards mental illness it is not only shown by the community, but doctors and medical students can also share their negative opinions about psychiatric illnesses, especially those with schizophrenia and substance addiction (6). There have been reports that stigmatization in healthcare workers leads to a different attitude for the patient, seen as ‘’less likeable’’ (7) and most of us wouldn’t be surprise to hear that mental health services and research are relatively underfunded worldwide (8). Consequently the stigmatization in healthcare workers is a very important issue, but where does it begin? In my view, it is during the Psychiatric rotation of a medical student when this negative attitude starts to grow.

Psychiatric Stigma: A pending Issue

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Psychiatric Stigma: A pending Issue

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?

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 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, 97-119.

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

18 PAMSA HeartBeat

Nilofer Khan Habibullah (AMSA-USA)On behalf of Think Global Initiative Project and the Small Working Group on NCDs

• Non-communicable diseases (NCDs) – which include diabetes, cardiovascular disease, cancer and chronic respiratory disease – cause 60 % of all deaths globally (35 million) each year. The Moscow Ministerial Declaration revealed that this figure will jump to 75% by 2030.

• 4 out of 5 deaths occur in low- and middle-income countries.

• NCDs share the common risk factors of tobacco use, unhealthy diet and physical inactivity.

• NCDs only receive 0.9% of health official development assistance (ODA).

• NCDs are a major cause of poverty, a barrier to economic development, and a neglected global emergency.

Courtesy MDGs and NCDs Factsheet: The NCD Alliance1

A latest report concludes that the best way to ensure access to health care for NCDs patients will be to fully integrate national Disease Management Programs (DMPs) into the primary care sector (Chronic Disease Management Matrix 2010, NIVEL 2011). On May 13, 2010, the United Nations, led by Caribbean Community (CARICOM) member states, voted unanimously for the United Nations’ (UN) Resolution 64/265 to hold a UN High-Level Summit on NCDs in September 2011. This will be the second time that a health issue has been brought to the global agenda on the UN High-Level Summit.

In line with the IFMSA’s commitment pledged on its Policy Statement on the NCDs for ‘promoting increased youth involvement in the global NCDs movement by advocating for youth-oriented NCDs awareness programs within local communities, interaction forums at medical schools, grassroots organizing, and (to some extent) lobbying decision-makers; to mobilize young health professionals in-training to contribute to NCDs control....’, and interventions proposed during the NCDs discussions at the 64th World Health Assembly (May 2011), the IFMSA recently held it’s first-ever Day for Non-communicable disease, observed on September 19, 2011, which also commemorated the first day of the UN Summit on NCDs.

What was the NCD Day about and how did we act? Read on….

Why the IFMSA Day for NCDs? Aims and objectivesMember States at the 63rd WHO World Health Assembly reviewed progress achieved during the first two years in implementing the Action Plan for the Global Strategy on the Prevention and Control of Non-communicable Diseases2.

Successful approaches included3:• implementing interventions aimed at monitoring

NCDs and their contributing factors;• addressing risk factors and determinants supported

by effective mechanisms of inter-sectoral action; and• improving health care for people with NCDs through

health system strengthening.

However, one short-coming noted was the unremarkable progress made towards building sustainable institutional capacity to tackle NCDs in developing countries3.

To address the need for young health advocates to contribute to the growing global NCDs movement in building such capacities, the aim of the IFMSA Day for NCD was to mobilize medical student members to dispel healthy lifestyle awareness while promoting preventative measures. This would highlight the danger posed by the four shared risk factors for NCDs, including tobacco use, physical inactivity, unhealthy diets and the harmful use of alcohol.

The Think Global team and the Small Working Group on NCDs composed a toolkit with ready-to-use Powerpoint presentations and guide-sheets for organizing fun walks, press conferences, and declaring a Policy Statement on NCDs- to name a few.

How did NMOs act?To observe the IFMSA Day for NCDs, NMOs across the world, from 37 countries, observed coordinated action by organizing awareness drives for the general public and school children. NMOs also held peer-education sessions with fellow medical students to discuss NCDs in context of the social determinants of health, Millennium Development Goals (MDGs), and sustainable health.

IFMSA Day for Non-communicable Diseases

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IFMSA Day for Non-communicable Diseases

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.

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.

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

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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!

Please submit your questions and comments to the Think Global Coordinator at thinkglobal@ifmsa.org or write to me at Nilo.metalrex@gmail.com. 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!

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),

building up youth movement towards the UN High-level 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 thinkglobal@ifmsa.org or Facebook at IFMSA’s Think Global Initiative Project.

References1. The NCD Alliance: The MDGs and NCDs coversheet. 2010.

Available from http://www.ncdalliance.org/sites/default/files/rfiles/The%20Millennium%20Development%20Goals%20and%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: http://whqlibdoc.who.int/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://www.who.int/mediacentre/news/releases/2010/wha_closes_20100521/en/index.html (accessed 22 May 2011).

21 PAMSA HeartBeat

Updates from NMOs

Maria Jose Navarrete DättwylerProud-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 SCOME, SCORA and SCOPH with new projects and more independent lines of action. Also this year, we opened two committees (SCOPE and SCORP). That made us realize that we have to work on our structure, as it gets bigger and more diverse.

• We are about to hold our TOM3 and who would imagine that we could talk about such things as “policy statements” or “transnational projects”? certainly this is a surprise for us, and things are getting more exiting each day!.

• Last year at the AM Montreal 10’ (the zero, in our timeline), we were just two delegates, very lost and overwhelmed. And this year, with 9 delegates during the RM Cochabamba 11’ and 5 delegates at the AM Denmark 11’ , we feel very proud (and much oriented) to say that we know how IFMSA works, we feel confident, and we are ready to transmit it to our whole country. RM Peru 12’ … wait for us.

Thanks to our team, to the hopes and fears (soundtrack [on]), to the will and hope that we can do whatever we want if we trust ourselves and eachother. This is how we work and this is how we want to show the world that you can achive, you can learn, you can change! just feed your dreams with a nice amount of team friendship and teamwork.

There is a lot to tell, and much more to feel, but don’t pause the movie because IFMSA-Argentina is still getting stronger and you won’t have to wait much longer to see it bloom!

Yassen TcholakovIFMSA-Québec

In IFMSA-Québec, we are just coming back from vacation; indeed, pre-clinical students have a few months off of medical school during the summer. Many use that time to work, do research, to travel or just to relax. However, IFMSA-Québec’s newly elected national team for the next year keeps on working to prepare everything for the great year to come. Indeed, many things are going to happen right after the start of school in August/September: we will have national trainings for all our peer education projects; the national congress is coming up. Furthermore, local coordinators for all the committees will be chosen very soon after the start of school. Finally, our National GA will take place at the beginning of October, it will last one day, but it will be followed by a full day of training for all the elected and nominated officials. This second day is something that will take place for the first time in IFMSA-Québec and we are very excited about it, hopefully it will have a very positive impact. I will be able to share more about it soon I hope.

Other interesting things that we are working on is trying to get membership in the Canadian commission for UNESCO, formalizing our relationship with the organizations that sponsor many of the students that go to GAs and RMs, and the reconstruction of the pre-GA/pre-RM training for IFMSA-Québec delegates. Looking forward to see all of you soon.

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Publications Team

Jill Stone, CFMS - CanadaRandom fact: I’ve been on dives with sharks, but am ridiculously afraid of jellyfishFavourite 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 - PerúRandom 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! :DA 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 - PerúRandom fact: I love being a girlFavourite superhero: Sailor JupiterSomeone in PAMSA I’d kiss: PalmyA message for PAMSA: I LOVE YOU!

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!).

23 PAMSA HeartBeat

Helena Chapman, Dominican RepublicRandom fact: I often dance salsa in my sleepFavourite superhero: Robin HoodSomeone 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.

Publications Team

Génesis Cañas, IFMSA - El SalvadorRandom 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!”

Erick Meléndez, IFMSA - El SalvadorRandom fact: My first kiss was with someone from PAMSA (not from my NMO)

Favourite superhero: RogueSomeone 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!

www.ifmsa.orgmedical students worldwide

Algeria (Le Souk)Argentina (IFMSA-Argentina)

Armenia (AMSP)Australia (AMSA)

Austria (AMSA)Azerbaijan (AzerMDS)

Bahrain (IFMSA-BH)Bangladesh (BMSS)

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)

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)

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)

Mali (APS)Belgium (BeMSA)

Tanzania (TAMSA)