Presidents' Letter - Current WONCA Europe Executive Board

Dear Colleagues

As Mehmet, your colleague, and as the  President of WONCA Europe, I can say the time in my presidency passed like a wind although a bit stronger wind than usual and shorter than a regular term. I am so proud that each of my board members always fully supported me and worked in harmony. I am happy to hand over the presidency to our very valuable and respected colleague, Prof Shlomo Vinker who has been elected by the council as the President-elect in 2019, Bratislava. With him, we have worked highly in collaboration, shared responsibility, and very properly managed the transition period. We properly made our handover in our executive board meeting on the 12th of March. The amount of work EB members have been doing is probably not easily seen from the point where you are looking but I can tell you that we achieved many goals in such a short time,  working under such a long pandemic once in a hundred years. See our revised future plan 2019-2022 which I have declared in Bratislava and you may find that here on our website. 

Those below are not all we did in the last 21 months. More achieved by collaborating and  establishing  in higher-level relations and joint production with the Organizations in Collaboration:

  1. WE signed a Memorandum of Understanding with European officials, to be represented in the Advisory Board of European Medicines Agency (EMA) Advisory board- bringing the voice of GP/FDs on new vaccines or medicines for COVID, bringing the importance of preparations for NCDs during and after covid within the WHO and with OC like European Cancer Organization, IOF, Liver diseases, Cardiovascular Diseases, and etc.
  2. WONCA Europe & WHO European Office for the Prevention and Control of Noncommunicable Diseases (NCD Office) are about to deliver a joint product, a “Manual on Brief Interventions for Noncommunicable Disease Risk Factors in Primary Healthcare”, to support member countries to implement, establish and promote brief interventions in their PHC setting.
  3. Honorary Secretary, PE and P were in the WHO Europe activities, meetings, webinars and they are now in Expert group meetings to be our voice, we celebrated the Family Doctors day, Astana Anniversary with videos, and also some other important days. We have made statements in the WHO Regional Meetings with partner organizations and with our NWs. 
  4. COVID-19 resources in our webpage targeted for use of GPs/FDs where you may find the online resources we have gathered for our members. Please prioritize any guidance from your local health authorities. But there are articles to be followed under the members’ section which you may register for free (https://www.woncaeurope.org/register)
  5. Honorary Treasurer continuously brought opportunities of projects with other Scientific or Educational organizations in Europe bringing income to maintain financial stability and positive balance (ASCEND, Peer Voice, IOF, joint consortium for the Study and Exchange of evidence from Clinical research with Euract)
  6. Created and Submitted scientific and public articles in Journals specific to what Wonca Europe does for GP/FM in Covid times (EJGP, EJFM, BMCFP, Lancet, SJPHC, News in North and South (Portugal, Sweden), published a joint paper with E.C.O. on essentials of cancer carer in PC, Work on publishing others with some of our networks. Published World Book of Family Medicine 2nd edition for Europe, free access is on WE Website.
  7. Built close relation with the MOs, and participated in the National FM/GP conferences 
  8. Organized and participated in many webinars like the WHO Lets Talk on PC, WHO-EMRO & Europe, and Imperial College Webinar on COVID in PC, WHO Europe Pandemic to Go Forward and etc.
  9. We documented the “history of WONCA Europe” for the first time, as a chronological list and also as a presentation for our students and for our partner organization, and of course for our members. You may find it here.  
  10. We recently had a pioneer virtual Europe Conference for the first time ever in WONCA history with more than 1560 participants. That is a good model for the rest of the world. The conference is as you knew organized by our MO, DEGAM, German College. A high level virtual scientific conference with so many participants is clearly a big success. And with our MO, we agreed on directly transferring all the amount of income as equal shares to our 6 Networks which supported us during these unprecedented times and took the financial risks by putting their hands under the stone together with us. DEGAM & WONCA Europe did not get income.

As some of you are aware, I have been in four WONCA Europe Executive Boards since 2010 and experienced working with many personalities. I must admit, I have never been so happy and so productive as now. I am extremely satisfied with the work we achieved together with my executive board members. Hope you may also agree. I do not think that all MOs might have been aware of the work carried out since 2019 but may have a look at the web page to see those president reports published for transparency during this period. I can tell you that respect, harmony, and elegant work is the running basis of this WONCA Europe board for the 2019-2022 term. And I believe that will be continuing.

Current executive board members are, as it should be, thinking only of the organization's benefit, not their own career or not their own colleges' benefit. They keep working well to do their best, both in this pandemic period and also for after this period when hard times end in Europe. Even under such an unprecedented pandemic period seen once in a hundred years, they’ve worked, produced, supported members, preserved funds, and even put on it with several educational engagements.

The EB has a different composition than all previous boards. A well-balanced one for the geographical, socio-cultural diversity of European regions is a remarkable specification. But also this is a highly scientific board according to my personal research at least compared with all other EBs I have worked in the last 11 years. All of the executive board members in this term, except the young doctor member, due to young age, all have the title of Professor in GP/FM, an academic and scientific identity. When checking through the Clarivate Analytics Web of Science with its Citation Reports feature, the “average h-index” of all 8 board members is over 16 (ranging from 5 to 33, even including all of the eight). Looking at only the number of papers in the web of a science core collection for the eight EB members, I found an average of 70,25 core papers per EB member, while they have been cited an average 1096.25 times, by 984.5 citing articles, again on average. One may agree or not, but I think these numbers additionally reflect the productivity of executive board members as also scientific authors based on their publication and citation records. Of course, being scientific in decisions, or thoughts is not an art or not an inheritance. That is something “learnable” by all family physicians, general practitioners. Of course no need for being a scientific author, or to have the title of Professor to be elected to the executive board. The absence of a good h-index is nothing to do with good policy-making skills or good governance experiences. But this is an additional feature your executives have, showing that they have a scientific way in their actions, and thoughts in addition to their good personalities, and governance experiences.  Hence those high-level academic profiles mean for me that the board member has already proven their own capability, and already took a respected place before coming on the board to work only on behalf of WONCA Europe. Not for creating their own carrier. 

For sure it is a very difficult period which shall not be compared with any period in WONCA history. My friends, I am really honored to have my name on that medallion like the names of all Presidents “since 1959” in the GP/FM journey of Europe, and I am happy to be a leader even in such a hard period. News: Presidents' Letter - History of FM/GP in Europe and WONCA Europe 

I appreciate my board members, and to you for your support, and especially to those MOs and those colleagues who have sent their very positive feedback. As one of the well-known names in Europe told me, one may realize how hard this board worked only after seeing the reports on our website, and observe the huge list of work done in such a short period of time. 

With such a long work background and having several experiences in several boards, knowing who is who and what will be good to focus on in the future, and searching for good practices for the GP/FM in Europe, I will continue to work for and follow closely WONCA and will keep advocating the best interest of our MOs and yours.

Part 2: What have we done as WONCA Europe during this pandemic period?

In the meantime what my executive board members and I realized? Please see the website and published reports for the answer.

  1. We have signed a memorandum of understanding with the European Medicines Agency (EMA), WONCA Europe, UEMO, and EFPC in 2019. 
  2. Made keynote on essentials in PC for cancer care, in ECCO 2019 European Cancer Summit, 12-14 September 2019 Brussels, Belgium
  3. We have attended as an expert to the WHO Region retreat meetings, EMA advisory board, E.C.O network meetings, and regional meetings with partner organizations.
  4. We have created a Wonca Europe COVID-19 resources page targeted for use of GPs/FDs where you may find the online resources we have gathered for our members. Please prioritize any guidance from your local health authorities. But there are articles to be followed under the members’ section which you may register for free (https://www.woncaeurope.org/register )
  5. We created an Obituaries Section on our Web: We are aware that there are unfortunately more colleagues whom we lost to the COVID-19 pandemic. If you know someone who you want to remember or pay tribute to, please add an obituary on the top of this heart-breaking page using a "Submit an Obituary" button: https://www.woncaeurope.org/m/obituaries 
  6. On June 4th together with WHO Europe, we organized a joint webinar open to Family Doctors and other PHC experts, to discuss the vital role of the family physician for a better and stronger PHC in times of COVID-19 and other health threats. The participation of our members and member colleges was very high. This was a unique opportunity not easy to repeat. If you were not able to join or want to watch it again, you may find the sessions recording on our youtube channel https://www.youtube.com/c/WONCAEurope 
  7. The World Book of Family Medicine - WONCA Europe Edition; Published on the occasion of the 25th Anniversary of WONCA Europe Berlin, December 2020. You must be registered on the Wonca Europe website to download this book from this link. “Registration is free of charge”.
  8. WHO Europe’s "Let's Talk Primary Health Care" talk show focusing on priority setting of primary health care services during the COVID-19 pandemic seeking practical experiences from both policy and practice hosted by M Jakab, Head of Office, WHO European, Centre for Primary Health Care, and speakers Prof Mehmet UNGAN, President of WONCA Europe, Dr S VAINIOMÄKI, GP & Deputy Chief Physician, Turku Welfare Division, Finland, Dr Toni Dedau, Senior Expert of the WHO, European Center for Primary, Health Care, Dr Pia Vracko Senior Advisor, National Public Health, Institute, Slovenia, 24 February 2021, https://euro-who.zoom.us/webinar/register/WN_UmvZplqcQx-RwhijpFQc0Q?timezone_id=Europe%2FAmsterdam 
  9. On 29 March we have participated in to firts of those 5 WHO Retreats for the EURO Country Presence Review, as a member of the “stakeholders” group and contributed in WHO Country Presence Review: How can WHO enhance its presence and increase its relevance for all its Member States? G Director Dr Hans Kluge opens these meeting where core WHO, country and advisor stakeholder groups like WONCA Europe, discuss. Other prescheduled advisory meetings are as follows; future Advisory Group retreats: May 27-28, 09:00-12:00, July 6-7, 09:00-12:00, Aug 25-26, 09:00-12:00 and Oct 6-7, 09:00-12:00 CET.
  10. We have joined to EMA public meeting update to EU citizens about the continued assessment, approval and safety monitoring of COVID-19 vaccines, and their expected impact at community level. Covering COVID-19 vaccines approved in the EU and those currently under review; post-authorisation activities, including emerging safety data since EU authorisation of the first COVID-19 vaccines; ongoing work to address new variants; the expected impact of COVID-19 vaccination on our society; transparency and the publication of clinical data for COVID-19 vaccines.https://www.ema.europa.eu/en/events/public-stakeholder-meeting-approval-safety-monitoring-impact-covid-19-vaccines-eu  26 March 2021. 
  11. We organized a joint a webinar with WHO-EMRO region, Imperial College London
  12. We have published a joint paper with European Cancer Organization on essentials of cancer carer in PC 
  13. We realized meetings with organizations in collaboration like ECCO, EMA, UEMO, EFPC, meetings for new training activities, 
  14. WONCA Europe Statement for 70th session of the WHO Regional Committee for Europe; “Digital Health & Telemedicine in PC Addressing also Inequity in Rural Health”, 
  15. We supported the WHO World Patient Safety Day 2020 for health professionals,
  16. Created Scientific Article telling the regional fight in Balkans: Struggle with COVID-19: A Cross-border View; 
  17. I have made an Interview article in Scandinavian Journal of General Practice,
  18. WONCA Europe Presidential letters to MOs on COVID, 
  19. Family Doctors Day 19th May celebration with a short video, a script where the whole EB taking place by one message in our native languages to our colleagues keeping all of us motivated in this very challenging pandemic period, 
  20. On-line training program on COVID-19 management. 
  21. WONCA Europe joint the consortium created by International Society for the Study and Exchange of evidence from Clinical research And Medical experience (ISSECAM) and European Academy of Teachers in General Practice/Family Medicine (EURACT),
  22. We have worked on contractual issues like Conferences in Amsterdam and London,
  23.  We all joined Webinars in series of the COVID, all around Europe
  24. At least once a month EB online meetings continued online.
  25. WONCA Europe conferences had roughly from 1500 to 5000 participants each year, and Berlin conference had 1560 participants for the main program while 161 to VdGM preconference. This may be considered the largest virtual conference up to now in this level for WONCA worldwide. A virtual conference for WONCA Europe is for the first time ever in our history (https://www.woncaeurope.org/news/view/after-family-doctors-europe-2020-virtual-conference
  26. We have documented the history of WONCA Europe chronological list and also as a pp presentation for our students and for our partner organization and of course for our members. In 1995 the organization became a region in WONCA, and was renamed as WONCA Europe. The names of all Presidents “since 1959” are on the medallion of the president which is transferred in between the Presidents during the handover ceremony. You may have a look at GP/FM history in WHO region Europe https://www.woncaeurope.org/news/view/history-of-fm-gp-in-europe-and-wonca-europe 
  27. Educational Activity: Who Is at Risk of Fracture? Clues to Early Detection in Postmenopausal Women ( http://www.peervoice.com/FNS980 )
  28. Wonca Europe has recently partnered with ASCEND to review and endorse some which is a CME-accredited programme designed to improve the care of people living with diabetes and obesity worldwide. Led by an international faculty, ASCEND provides practical, independent content about diabetes and weight management for FDs/GPs content tailored to primary care https://www.woncaeurope.org/news/view/wonca-europe-newsletter-may-2020-happy-world-family-doctor-day%21 
  29. Advisory and contract issues for the editor of EJGP continued, and the publisher part is almost finalized. We now have a stronger Journal talking in Impact Factor. In June, the journal received an impact factor of 2.478 and moved up in the ranking of primary health care journals to #7/19; and 54/165 in the category Medicine, General & Internal. The acceptance rate is not more than 15% as we see. The prioritization of the topics and a representative geographical distribution of accepted articles in line with a Wonca Europe Journal is something we are discussing. Editorial is successful and thanks to them. We want to share a very good news with you all: the EJGP’s new IF = 2,478; and EJGP has moved up in the ranking of primary health care journals to #7/19,  Contract with T&F is in 2021
  30. WONCA Europe/UEMO/EFPC- for EMA 7th Feb:  We noted the unequal acquisition of vaccines with rich countries buying many millions of doses (far more than their population would need), a strong recommendation to EMA to support COVAX and equitable distribution of Covid-19 vaccines. AMR: Regularly develop guidelines. Wrote a paper on two topics to EMA.
  31. European Cancer Organisation (E.C.O.) and the World Organization of Family Doctors (WONCA Europe) announce a new partnership agreement for joint working. From implementing more effective cancer prevention strategies, to achieving earlier detection of cancer. From ensuring an enhanced environment for follow-up and survivorship care to cancer patients, to better management of comorbidities. The achievement of Europe’s vision of quality cancer care requires Family Doctors (FDs/GPs) and community physicians to be a central part of implementation conversation. The new collaboration agreement between E.C.O. and WONCA Europe; ‘Essential Requirements for Quality Cancer: Primary Care’. The agreement is to work together in taking forward advocacy actions during 2021 related to Quality Cancer Care, cancer prevention, early detection of cancer and the cancer comorbidities challenge in EU, and WHO as well.https://www.woncaeurope.org/news/view/primary-care-and-cancer-care-a-new-partnership-commitment-by-e-c-o-and-wonca-europe 
  32. ECO and WONCA Europe are working together on “Time To Act strapline: Don’t let Covid-19 stop you from tackling Cancer '' with other stakeholders.
  33. I am pleased to inform you that the WONCA Europe & WHO European Office for the Prevention and Control of Noncommunicable Diseases (NCD Office) are currently working on a “Manual on Brief Interventions for Noncommunicable Disease Risk Factors in Primary Healthcare”, to support member countries to implement, establish and promote brief interventions in their PHC setting. The Manual focuses on the main NCDs risk factors which are smoking, alcohol, unhealthy nutrition, and physical inactivity. Manuel content is almost finalized but currently. The NCD Office and the WONCA Europe are running an online survey among HCPs of different specialties followed by a series of short interviews with them to get detailed insights regarding this matter. The invitations are sent to five Member Organizations of WONCA Europe, Dutch, Romanian, Italian, French, Hungarian colleges. That is a piece where we will be happy to provide all our MOs in close future. The interviews are planned to be conducted in April/May; the working language is English. The interviews will be held on the Zoom platform. During the interview, an audio recording will be made, which will be used exclusively for the subsequent analysis of the data obtained, and will not be shared with the third parties.
  34. WONCA Europe EB worked on ICPC-3 coding and evaluated the coding through liaisons and reported to the world about some concerns on the shift to 3rd version from 2nd version, ICPC-2. As Wonca Europe is not the owner of the product we concluded that we are not a part of the decision whether to approve the 3rd version or not but provide a report to the World to let them conclude. We paid around fifty thousand Euro to the consortium last term and decided not to continue with it. 
  35. We have had financial success thinking that there is no conference income nowadays due to pandemic. We have focused on educational activities (virtual), and collaboration with other organizations, we asked partly exempting regular payments of some of our Networks, EJGP and we cut the costs of social media facilitator, web, and etc, besides getting a valuable support from Slovenian MO and Department in Ljubljana exempting part of the cost of our office. And we arranged to give back the exempted amount of our scientiƟfic NWs through the educational and scientific work income to WE. We started almost under the reserve fund, and now we are over that and financial sustainability is maintained through intense scientific work of the Board members.

After the last Berlin 2020 Conference, the next Europe Conference is virtual by Amsterdam in July 2021, and this time there is considerably a shorter interval, a little more or less than 6 months after Berlin and 6 months before the already postponed Abu Dhabi World Conference and Council.

Hope you have health and be safe in the coming months, and looking forward to hugging you all in one of those face to face meetings in 2022.

Part 3.  What happened with GP/FM in Europe during this pandemic?

To say the last word first, the “FDs made the difference”, looking at the health systems of the countries in Europe. 

This continuing pandemic, since the end of 2019, harmed almost all of Europe. In recent years we have been headed by the World Health Organization (WHO) to work more on non-communicable diseases (NCDs) and on increasing health literacy. For some politicians and governments, it sounded like we were able to control communicable diseases (CDs) so we turned to NCDs. But with this unprecedented pandemic, we immediately turned years back in history and tried to get lessons from the influenza pandemics this continent faced a hundred years ago. That was showing us once more how important it that countries have working preparedness plans for CDs.  

There is an "infodemic" associated with the COVID-19 pandemic, meaning in short for "information epidemic", a phenomenon that portrays the rapid spread and amplification of vast amounts of valid and invalid information on the internet or through other communication technologies like visual media. The term has not been used much in the scientific literature before 2020. Since the beginning of the COVID-19 pandemic, both the production and consumption of information have increased rapidly and significantly. I am not blaming real scientists, I am valuing and putting them out of my criticism as they are real values who save lives with their science, talk evidence-based, and act firmly getting our trust. On the other hand, there appeared some characters in the media causing “infodemic”. We have been living with so many new faces appearing on our TV screens, on social media with their questionable knowledge, showman attitudes, and colorful presentations, regarded as authors, sometimes as if they are talking on a soccer game, sometimes correct, sometimes irresponsibly not.  Under the influence of their infodemic, we have been finding our long-term patients on the other side of the phone asking several unclear or unanswered questions, hesitations for treatments, vaccine hesitancy, etc, increasing our workload.  Think how unfortunate the WHO health literacy work delayed, how the WHO delayed in integrating public health into primary health care services. The WHO stressed that infodemic is a serious threat to public health, public action, social cohesion, and the political landscape as a whole. On the individual level, the infodemic creates confusion among recipients of information, specifically about the identification of reliable information. In the current pandemic, this constitutes a global scientific challenge. And furthermore, such infodemic created a very heavy additional workload on FDs, while trying to fight against the virus at the same time also spending energy on correcting such wrong information on the public mind. 

 Infectious disease took a major role in the wide spectrum of health problems the WHO mentioned. The health care systems have been the focus of attention all over Europe and the world. Spotlights are now on Family Doctors (FDs/GPs), who stand on the front line of the fight against the virus

The more successful in this fight were those having more FM & primary health care (PHC) in their health system. That is the main lesson with this pandemic for all governments to take. We also saw that governments have to support and invest more in FM & PHC as the FDs and PHC is the real “backbone” in all health systems. Hospital ICU care is no doubt very important, paramount but without a good PHC, none of the health systems is sustainable by only relying on the number and capacity of hospitals. Integration of public health to FM and PHC is another step to be taken after having a firm backbone. Dr. Hans Kluge, Director of the WHO Europe answered my question in our recent WONCA Europe conference held virtually from Berlin where I asked what would be the 3 key achievable goals for us in the following months. He answered that we have to work on directly linking and partnering with Hospital and Primary Health Care as equally balanced partners in a health system. That is based on evidence in health system research.

Of course, there have been ongoing risks and challenges that pandemic presents to FDs in daily practice, and of course, we will have more suffering. What makes us sad is, not the whole population feels as responsible as healthcare professionals. Increasing violence towards health professionals, mainly including GPs/FDs, legal problems demotivating PC service providers, poor self-care, poor respect in some PC settings sadly ending with thousands of “falling stars”. The FD is a star but modest, touchable, visible, and extremely careful for its community, a very valuable one. Now we are losing stars one by one, and still putting ourselves in front lines fighting in these pandemic waves. At the beginning of the outbreak, many of them have paid the highest sacrifice with their lives in the fight against the global pandemic. As WONCA Europe we are carrying photos or names of those stars in Europe so that the memory lives with us forever. (https://www.woncaeurope.org/m/obituaries) . We are all saddened by the loss of all those FDs, Health Care Professionals, and of course also millions of patients all around the world. I wish their souls to be in peace. I wish their families the power to live with this. The governments shall see the fact that those are all occupational deaths. At the end of 2020, there have been more than 300000 deaths, reported to WHO Europe, for our region, and the average daily increase is 11,6% showing an incline. Most of the cases are from Turkey,  Russia, Spain, France, UK, Italy, and Germany until now according to the WHO data. They have to see that we are not endless.

As said earlier, FDs were the first to arrive and will likely be the last to come out when this pandemic is over. Some of the families of these doctors actually are having difficulties not only psychologically but also financially in this world. The united call for the further need for encouragement and motivation succeeded to add extra payments for the PC health workers in some of our member countries. The European Public Service Union (EPSU) website published the round-up of COVID-19 bonuses in July 2020. Depending on this already 4 months old information Portuguese, Netherlands, Germany, Belgium, Austria, Wale/UK, Bulgaria, Czech Republic, Sweden were providing somehow an additional payment in a non-standard way and to some PHC workers.  None of those so-called bonuses were enough when thinking of the actual risk. The pandemic progressed and a second wave a third wave, mutation effect occurred terribly hitting nowadays, and may even be stronger.  Our MOs started to talk about occupational work-related disease coverage and pointed out the social security funds or additional supportive fund coverage. Citizens of low GDP countries are not being supported as much as high GDP countries in Europe. It is obvious to all of us that the European Region has marked diversity and is full of inequalities also for primary health care professionals. While in some low-populated areas with less density, family physicians are safe in their practice, many others practicing in dense and/or large populations are in a serious struggle for survival in a  pit called as COVID-19 pandemic. It looks like we do have many differences in core values and whole life experiences. I do not want to mention any discrepancies and I am not criticizing governments as they were giving different values to FDs but somehow it seems like the Southern & Northern, Eastern & Western, and central parts of Europe are all affected in this pandemic differently. Health Systems Researches shall illuminate different health and governance (PHC) responses in these regions in this pandemic which occurs once in a hundred years. In certain  circumstances,  COVID-19  can be regarded as an  “occupational  (work-related) disease”. An “occupational disease” is any disease contracted primarily as a result of exposure to risk factors arising from work activity. “Work-related diseases” have multiple causes, where factors in the work environment may play a role, together with other risk factors, in the development of such diseases.  I think all our MOs shall work for and welcome recognition of COVID-19 as an occupational disease. The FOA sees it as a huge victory that COVID-19 is now recognized as an occupational disease and has also welcomed the fact that the process of proving infection has been relaxed. The dependent family members (e.g. spouses and children) of those FDs who die from COVID-19 contracted in the course of work-related activities should be entitled to cash benefits or compensation, as well as to a funeral grant or benefit. Although not nice to include such a sharp sentence here, I am finding it necessary to be considered as this kind of pandemics and hazards will probably always be our problem in our families.Professionals working in the health sector can benefit from recognition. An example of this working recognition from France is under two simple conditions: Their contamination with Covid-19 took place in the course of their work; Their contamination with Covid-19 has resulted in a serious respiratory disease with the use of oxygen therapy or any other form of respiratory assistance. Those sad subjects shall be worded in the WONCA Europe council also. If something will be realized, we are the ones who should ask for changes. Who shall do that for us? We are responsible to our population but also to our families, children. As the WONCA Europe with its MOs, and members of MOs it is clear that a need exists to work on legal, ethical, deontological sides and set fair criteria creating studies. In order to make the research/evidence-based decision.

The beginning stage of the response against the pandemic has varied across European countries. Some shock periods due to the unawareness of family doctors, lack of guidelines, lack of tests for differential diagnosis, lack of PPE and etc. FDs had to rely on what their governments provided, and on the diverse information published in many medical journals publishing even without a good review process almost a year-long about transmission, infectivity, survival of the virus, factors facilitating a severe infection, and others [3].  There have been several steps in the approach used by the guidelines for FDS. Classical patient consultation by family doctors was not possible in most of Europe, instead of many FDs used phone interviews and worked in triage in referrals to hospitals. In Europe many FDs worked without any testing available. Direct contact with patients frequently ended with self-infection. The experience of how COVID-19 behaved was through a very expensive direct observation, paid by many lives of FDs in return, sadly. Later laboratory tests and imaging started in assessing the severity of patients. Point-of-care testing implanted in work in some countries. In many countries, all available medical treatments were used only in hospitalized patients, but for some countries, those isolated house patients were also provided some medical treatment through the family doctors’ information hub and work. Finding the contacts and isolation was a major task of the FDs and the Primary Health Care professionals who worked hard and showed great teamwork in PHC. Since last December in many countries vaccination has started, and in the vast majority of them the FDs, and practices were once more on the front lines. Some countries used a set up out of FD practices, some used mixed methods like community centers, vaccine centers, hospitals, and all FDs providing a fast and well-planned vaccination process to cover the main part of the population in a short time starting with the riskiest groups. Some countries like Israel succeeded in inoculating a very high percentage of the population in a very short time. Some started very fast but due to vaccine unequal distribution, or timely availability, or due to financial problems interrupted, although temporarily. 

FDs saw that the Vaccines certainly were distributed unequally among countries. Although they may be under pressure to get as much vaccine administered as quickly as possible, as WONCA Europe president stated in our website on behalf of our executive board and as we have informed those European Official bodies like in WHO Europe, like in EMA, the vaccine industry and those defining policy in the WHO-Europe region, cannot and must not leave equity behind. A limited supply of vaccines needed to reach a really large number of individuals so it was predictable in WHO-Europe countries; We, therefore, need an Agency which is strong enough and which can lead the equity process. Europe relatively has better infrastructure compared with many other regions, should be able to generate at least weekly data to see who is being vaccinated so that countries can be flexible and adjust their plans to improve uptake. There was not enough attention to a shared mission, shared vision, and shared sacrifice in the European region, but the PC in Europe should not shy away from the hard work and hard choices to enable equitable distribution of the Covid-19 vaccine.

As FDs, we are warning that NCDs will explode and be a larger problem. During all these, the follow-up for NCDs, care of those people with warning signs all delayed and we feel we are probably looking at an iceberg. After the pandemic, we are afraid to face the burden of the NCDs. Now we have been familiar with the mutant virus types which are complicating the fight against the virus and returning the normalization studies back to isolations and lockdowns.  We are faced with cycles that consume the FD workforce, who have been working non-stop as a frontier in all stages of the fight since the beginning. 

Telemedicine was put into practice by default in Europe with this pandemic, although lack of good regulations in some countries. What we had in hand at the beginning was a definition by the WHO. We have seen the rapid adoption of both patients and providers during the pandemic. Of course, there are still problems to be solved like reimbursement, more user-friendly telemedicine technologies, infrastructure problem particularly in remote rural areas, legal and ethical potential problems experienced during this period, lack of traditional patient consultations in the training of FDs and medical students, and the threat of replacing regular services in FM, usually by governments. The traditional telephone consultation used by family doctors widely. FDs practiced not only patient interviews by a secure video meeting, and the use of remote advanced technology, but also for physical examination and vital signs monitoring. Digital remote examination tools, such as the digital stethoscope and otoscope were used in a very restricted proportion of FDs sometimes complementary for video telemedicine solutions. But, some prior studies concluded that phone consultations might be used restricted like for follow-up. Problems like difficult communication, absence of physical examination, lack of comprehensive approach are pointed out in some articles.  Remote consultations mainly were for prescribing. Over and sometimes miss prescribing were some observations reported by some of the FDs. Those are probably indicating a need for some measures to be worked on in order not to harm.

Normalization of using available smartphones in between the physicians and patients opened a new but unhealthy track for 24 hours communication and changed the main function of the doctor-patient relationship of family medicine.  In remote areas, telemedicine may improve access to equitable health, but also raise a concern in FDs’ minds if it may lead to a decline in motivation to invest significant resources in rural infrastructure.

FDs faced many concerns for their own safety, health and worried about the lives of their relatives and patients. As patients are contagious before symptoms appear, or even totally asymptomatic during the whole illness period makes a threat tools. Working overcapacity is a problem.   Lack of adequate PPE and medical information were also facts [14] In many countries, retired family doctors supported the work, although mostly in triage and not in direct contact with the patient. Depression and other mental disorders amongst family doctors were apparent but also not well handled in some countries. Work-related psychological pressure, emotional burnout, and somatic symptoms were mentioned [18]. In daily practice, we are faced with FDs feeling lack of energy, detachment, irritability, poor decisions having negative impacts on interpersonal relationships. Depression and substance use or abuse disorder for the doctors may be a potential problem if this pandemic is longer. Students or Family doctors early in their career need to be monitored by the mentors as they may have more workload than older colleagues. There is a published article in the World Book of Family Medicine 2020 edition, showing the positive effect of a high internal locus of control and people-centered consultations on burnout. 

Integration of Public Health (PH) into Family Medicine/General Practice approaches to the COVID 19 pandemic interlock with individual clinical care, prevention, and health education, as well as structural measures. Some PH challenges have emerged and loaded on the shoulders of the FDs for example tracing and testing of persons with COVID 19 contact, tracing and management, dealing with the adverse effects, for example, on mental health, violence in households/families. Certain vulnerable populations (i.e. people with disabilities, or in insecure housing conditions) may be impacted more significantly by COVID-19. WHO provides advice on adjusting PHSM while managing the risk of resurgence. Economic factors, security-related factors, human rights, food security, and public sentiment should also be considered. There are four domains that should be evaluated

  1. Epidemiology - Is the epidemic controlled?  
  2. Health system - Is the health system able to cope with a resurgence of COVID-19 cases that may arise after adapting some measures?
  3. Public Health Surveillance - Is the public health surveillance system able to detect and manage the cases and their contacts, and identify a resurgence of cases? 
  4. Adverse effects – Is there a need to address the harmful effects of COVID-19 measures, and which PH/PHSM measures are necessary to alleviate these?

All COVID-19 related measures should be informed by this assessment and available evidence: In the context of the COVID-19 pandemic, finding, testing, and isolating cases, contact tracing, and quarantine remain core public health measures through all stages of the response. Models combining quarantine with other measures including school closures, travel restrictions, and social distancing demonstrated a larger reduction of new cases, transmissions, and deaths than individual measures alone.  Although still limited, the best available evidence consistently supports social distancing as an effective means of reducing transmission and delaying spread. WHO announced standard operating procedures to prevent the transmission of COVID-19 in the workplaces.  A well-known potential threat is underserviced patients with NCDs. Regular services for the patients by FDs should be a priority in order to reduce the burden after the Pandemic when the dust settles down. 

In medical schools, the traditional face-to-face clinical classes were replaced by virtual education.  There are some worries in our MOs that the quality of the graduates may be negatively affected but also the need for new physicians in the system requires continuing the clinical years in some relatively mixed or hybrid methods mainly through distance education. Those trainers and Professors in he medicine started to use technologies although some were not happy with that and needed much more effort to adopt [40].

Looking at the research arena in the COVID-19 period one may see that the FDs were not able to answer by research outcome for many questions, and there were a restricted number of studies representing the primary care setting they work in, and also not many about the disease and prevention. In many member countries, researcher FDs were not able to conduct research as they were all in the frontlines, and in some, it was not possible to reach central data for research talking for Primary Care. 

Mehmet Ungan
WONCA Europe President