Since its foundation in 1960, the International Society of
Nephrology (ISN) has pursued the worldwide advancement of education, science and
patientcare in nephrology. This goal was achieved by means of the
Society’s journal and the organization of international congresses and symposia. In order
to better reach its colleagues and patients in economically less developed countries, the
ISN expanded its activities as of 1980 by a large number of specific programs aimed at
these regions.
The first phase of activities included teaching
programs, fellowship and visiting scholar programs and the provision of travel grants to
enhance accessibility to the ISN congresses. A second phase consisted of
the creation of a library enhancement program, a commission on acute renal failure and –
in order to improve the organization and efficiency – a central commission on global
advancement of nephrology (COMGAN). Currently, a third phase has been
entered in which all activities have been intensified under the guidance of COMGAN,
supported by a large number of teaching programs and fact finding missions; by
establishing a renal sister program, and by starting commissions on informatics and on
clinical trials.
As a result, the ISN has reached most parts of the
world, previously deprived of contact with renal science and renal patient care. The
fellowship program now counts 160 fellows, who spend 1 or 2 years in training; the library
enhancement program reaches 218 institutions worldwide; ISN membership has soared over the
past 2 years with over 2,500 new members, mostly in the developing countries, receiving
Kidney International and other relevant forms of information; 135 pairs of renal units in
developing and developed countries have been linked for support on a more continuous
basis; ISN-sponsored congresses, symposia, and courses are being held in increasing
numbers in the developing world. In many of its activities, the ISN closely collaborates
with sister organizations, which also contribute financially. In total, the ISN spends
annually over 1 million US$ from its own budget on the programs described above.
In conclusion, the various programs and initiatives
are proving helpful in advancing renal medicine in areas in need. Similar programs in
other medical subspecialties may be equally beneficial and gratifying and possibilities
for further expansion in this direction are being explored.
The article below outlines the history of the ISN and its
activities. It was written by Jan J. Weening, Barry M. Brenner, John H. Dirks and Robert
W. Schrier and published in Kidney International Vol. 54 (1998), pp 1017-1021. Detailed information on the ISN’s programs and activities can be found
by pressing the respective buttons on the left side of your screen.
The International Society Experience
If a society is in part judged by the ways it treats its least
advantaged citizens, it might also be appropriate to consider how our health professions
reach out to those whose medical needs are largely unmet. This is most apparent in
developing countries where economic factors and education are limiting. The
term developing countries is in common usage to refer to nations and regions
where economic advancement often lags behind cultural and even biomedical development, as
in the Peoples Republic of China where traditional Chinese medicine has been
practised successfully for several millennia. Efforts to correct these deficiencies are
obviously necessary. In this regard whereas many medical organizations are international
in scope, their membership is typically derived from Western countries and their focus is
concerned more with scientific interchange than raising health care standards for those in
greatest need.
Does an international medical society have an obligation to bring
about improvements in its own field of medicine in less privileged countries? The
International Society of Nephrology (ISN) feels this obligation most strongly and has
taken the opportunity during this favourable time of globalization to assist in the
education of physicians and other caregivers treating those afflicted with kidney disease.
The purpose of this article is to describe the ISNs outreach programs, in part to
motivate other societies to undertake similar humanitarian initiatives.
The ISN was founded in 1960 by eminent leaders in the field to
provide its membership with programs and services that elevate the standards of education,
research and patient care in nephrology on a worldwide basis. To fulfill this mission the
ISN acts as an international forum on nephrology and provides a variety of educational
services to nephrologists and those in related disciplines. Over the years, the Society
expanded to a membership in 1995 of over 6,500 members. To that time members came
predominantly from North America, Western Europe and Japan. Due to an aggressive campaign
beginning in 1995 to actively recruit members from the developing world using promotional
strategies described below, membership on 1 January 1998 has increased to 8,715 .
Given the early geographic representation of members it is hardly
surprising that initial educational programs were designed for those with a rather
advanced understanding of nephrology operating in highly developed academic and clinical
centres. For example, triennial scientific congresses dealing with state of the art
concepts and practices were held within these same highly developed geographic areas and
were targeted almost exclusively for this sophisticated audience. Likewise, diffusion of
scientific and clinical research and updates on society affairs occurred via the
Societys journal Kidney International, the exemplary journal in the field,
whose distribution was largely coincident with this membership and their affiliated,
well-stocked libraries.
Likewise, the Societys third major ongoing educational
initiative, its Forefront Conferences held twice each year, have been concerned with
contemporary topics in basic sciences related to nephrology, with interest and attendance
dominated by experts from North America, Europe, Japan and Australasia.
Yet, ISNs leadership has long been aware that for those
afflicted with chronic renal disease, death from uremia is an inevitable consequence for
more than 80% of the world population. By contrast, intensive renal replacement therapy is
almost universal in much of North America, Europe and Japan. This disparity is largely a
function, not of lack of interest or potential availability of trained caregivers, but
rather of limited financial resources, few qualified personnel and relative lack of action
by local and regional health policy makers.
Furthermore, in many parts of the world acute renal failure (ARF) is
inadequately diagnosed and treated, causing death from what would otherwise be a
potentially reversible condition. To this should be added the untoward clinical burden
derived from unrecognized or inadequately treated hypertension, urinary tract infections,
systemic infectious diseases, diabetes mellitus, nephrolithiasis and a host of
developmental and acquired renal and urological diseases.
ISN
INITIATIVES TO ENHANCE NEPHROLOGY WORLDWIDE – PHASE 1
To address these inequities, the ISN launched its outreach programs
with the following four initiatives.
Since 1980 six ISN Presidents have each allocated $40,000 USD to
support major teaching programs in a specific underdeveloped region in Central and South
America, Africa, Asia and Central and Eastern Europe. In several instances these teaching
programs led the regions leadership in nephrology to establish a regional society. A
vibrant example is the African Association of Nephrology (AFRAN) which now encompasses all
of Africa and whose biennial meetings attract more than 400 physician registrants.
This program, established in 1985, has granted 160 fellowship awards
to young physicians from the developing world to train for periods of one to two years in
academic renal centres in North America, Western Europe, Japan and Australia. This program
is by far the most costly educational program of the ISN, currently in excess of $600,000
annually. A recent survey indicates that over 80% of the fellows return to their home
countries upon completion of their training, the majority to positions in local academic
centres with subsequent impact on clinical care and teaching.
The Society believes that bilateral exchange of more senior
physicians and scientists between developed and developing centres is an essential
mechanism for accelerating the pace of progress in areas in need of further advancement in
nephrology. The typical visiting scholar from a developed region possesses specialized
skills such as expertise in continuous ambulatory peritoneal dialysis (CAPD), renal
immuno-pathology and clinical epidemiology and spends 1 to 3 months interacting with local
physicians, nurses and technicians. Coming from a developing region the typical physician
is relatively senior in age and experience but lacks training in such modalities as renal
biopsy, renal ultrasonography, hemodialysis, CAPD, or other essential skills.
To increase accessibility to its programs, the ISN began providing
travel grants to both the ISN international congresses and ISN Forefront conferences.
Approximately half of these travel grants are reserved specifically for young physicians
and scientists from developing countries. Past ISN fellows have received special
consideration in order to ensure their continued education.
After these initial programs were established and deemed highly
successful, the Society voted to support several additional programs, including the
Library Enhancement Program, to establish a Commission on Acute Renal Failure and to hold
some of its now biennial congresses in the developing world.
Library
Enhancement Program and Educational Material
In recognition of the fact that many libraries in developing
countries are poorly stocked, the ISN undertook, in conjunction with Blackwell Science, to
support 218 institutions worldwide with free subscriptions to Kidney International,
and to donate current nephrological textbooks as they become available. While the focus
has been on nephrology, material has been provided for other disciplines as well. In
addition to the Library Enhancement Program, the ISN prepares and distributes a variety of
teaching materials, including extensive renal histopathology and hypertension slide sets
to each library. A near term goal of the Society is to help developing centres to acquire
multimedia personal computers so as to rely on CD-ROM technology for more efficient and
less costly distribution of educational materials.
Commission on
Acute Renal Failure (ARF)
Outbreaks of acute renal failure due to epidemic illnesses or
natural catastrophes such as earthquakes place a great burden on local medical resources.
When these emergencies occur in a less prepared environment, loss of life from potentially
reversible causes is usually severe. To assist regions lacking organization and resources
for such contingencies, the Society has established a Commission on Acute Renal Failure
which includes a Disaster Task Force consisting of a worldwide network of experts in the
management of patients with acute renal failure. The disaster Task Force was created after
the severe earthquake in Armenia in 1988, to coordinate nephrological assistance for the
future. Both in North America and Europe the Task Force has organised intervention teams
to provide dialysis assistance when needed. The Task Force recently convened a Pan African
demonstration workshop in Nairobi on invasive and non-invasive treatment modalities in
patients with forms of acute renal failure commonly encountered in the tropics, e.g. snake
bites, massive hemolysis, obstetrical complications, trauma and sepsis. The Task Force
also intervened in humanitarian assistance during the cholera epidemic in Central Africa,
the epidemic of toxic ARF in Haiti and the recent earthquake in Turkey.
Congresses in the
Developing World
Whereas previous congresses of the Society have been held mainly in
well developed regions of the world, the Society has decided to shift to venues closer to
areas in need. Accordingly, the next congress will be held in Buenos Aires, Argentina,
from May 2-6, 1999, organised in conjunction with the regional nephrology society.
Commission for the
Global Advancement of Nephrology (COMGAN)
In order to more efficiently manage, monitor and plan the
aforementioned programs the Society has begun to amalgamate these various initiatives
under a single administrative structure designated the ISN Commission on Global
Advancement of Nephrology (COMGAN), which led to the third phase of ISN initiatives.
COMGAN is led by two senior nephrologists who oversee five working
subcommittees representing Africa, Asia, Central and South America, Eastern and Central
Europe, the Commonwealth of Independent States (former Soviet Union) and Middle East, each
with seven or more members. Progress has been substantial in all targeted areas with
respect to short courses and fact finding missions. Attendance at the various courses in
most instances has exceeded expectations. When on site, the committee members promote new
membership, hear clinical and research presentations and encourage Fellowship and Visiting
Scholar applications from a multitude of young and more senior physicians respectively.
Libraries likely to benefit from the Library Enhancement Program are identified. In many
of the short courses the ISN has benefitted from partnerships with other organizations
including the European Society of Pediatric Nephrology, the European Renal Association,
the American Society of Nephrology, the Society of Latin American Nephrology and
Hypertension, the Asian Pacific Society of Nephrology and the World Council on Renal Care
representing dialysis technicians, dieticians, renal nurses and social workers. These
organizations have provided speakers with needed areas of expertise and have fully
defrayed their travel and per diem expenses incurred in course participation.
During several fact finding missions to developing countries, it
became readily evident that the relatively meagre monthly income of local physicians does
not allow payment of the Societys annual dues (currently $120 USD/yr). To solve this
problem, ISN designed a novel and effective solution: the concept of joint membership. By
having up to 10 individuals in a local area join together to raise a total annual fee of
$100 USD, membership is granted to each participant, with all rights and privileges of
full membership. A single copy of the Societys journal, Kidney International,
accompanies this joint membership for shared use by the new members. In this way, the
Society recovers its publication and shipping costs and reaches up to 10 new colleagues
per joint membership. This discounted annual fee is offered to potential members only in
developing countries, defined as those with per capita incomes below $10,000 per year as
compiled by the World Bank. In the span of just 2 years, 779 new regular members and 1,770
new joint members from developing countries have joined the ISN. For example, 20 or more
new members have been enrolled from each of the following previously poorly represented
countries: Argentina, Brazil, Bulgaria, Croatia, Czech Republic, Egypt, Hungary, India,
Latvia, Lithuania, P.R.China, Poland, Rumania, Russia, Thailand, Turkey and Uruguay.
Moreover, new members now represent countries previously totally unrepresented, e.g. Zaire
and Zimbabwe.
The success of the aforementioned programs has encouraged many
clinician and scientist members of the ISN to join this international effort through
direct personal participation. Such enthusiasm is especially gratifying when one takes
into consideration the enormous financial cost to the Society of underwriting these
various programs. By promoting the idea of having established renal centres adopting less
developed programs, the basis for self-sustaining and long-term linkages is made possible.
To this end, the Renal Sister Centre Program was established by the Society in early 1996.
Today more than 135 firm linkages have been formalized. In these linked centres the more
developed program is underwriting the costs of exchange of faculties and trainees, and is
providing surplus laboratory and clinical supplies and equipment such as dialysis
machines, flame photometers, personal computers, and FAX machines. In the months and years
ahead we are confident that these linkages will stimulate joint clinical research, the
formation of epidemiological databases, and even joint laboratory investigation.
In 1997, a task force was established to develop an international
network for clinical trials in nephrology by the ISN and other supranational societies of
nephrology. This initiative will be evaluated in 1999 and is projected to result in an
important adjunct to further enhance the standard of clinical nephrology and the training
in clinical epidemiology.
The fellowship program is by far the most costly with 26 fellows
currently deriving an annual stipend of $22,500 USD each. The newly established COMGAN has
a current annual budget of $125,000 USD, with each subcommittee receiving an operating
budget of $15,000 per year. Although the latter is insufficient to defray travel and per
diem expenses for workshop speakers and for fact finding delegations, generous financial
assistance has usually been provided by industry. In no instance have speakers or
delegates received honoraria. Income to defray the 1996 annual budget for all ISN
humanitarian programs, totalling $1,000,000 USD, is derived primarily from membership
dues, income from ISN ownership of its journal, return on investment, corporate grants and
gifts and generous donations from other national and regional nephrological societies. For
example, several ISN fellowships are supported by the American Society of Nephrology, the
British National Kidney Research Fund and Japanese industry. Overhead costs are less than
8% of the total budget.
The ISN is committed to continuing support of developing centres
until they come mature to the point where they in turn can assist others around them. In
addition, ISN has established an Informatics Commision to foster better
communication between renal centres via the World Wide Web. Presently the Commission is
providing information technology including hard and software worldwide. This will enhance
access to scientific publications, educational programs, and clinical consultation with
recognized experts and their staffs.
The question is often asked why bring specialty medicine to
the less developed world? There are obvious and powerful reasons to give priority to
basic shortcomings in population health, such as preventive immunization against
communicable diseases and infant and maternal mortality, to name just two critical
problems. Needless to say, initiatives addressing such serious public health problems must
be actively pursued by the involved countries and global aid agencies. However, in most
developing countries the range of human illness includes a rapidly growing incidence of
western diseases such as hypertension and stroke, coronary artery disease,
diabetes mellitus and renal failure. An increasing number of citizens in developing
countries so afflicted deserve to receive specialty care in their own country. The ISN
believes it can make a significant contribution in its area of expertise while
realistically tailoring its programs to what can be specifically achieved in different
countries. In the long run we can only assist each nation in developing its own
independent programs so that future renal care and the training of professional staff can
be done within regional boundaries.
The initiatives described in this report are proving helpful to
addressing needs in renal medicine in the developing world. But patients afflicted with
renal disease also suffer from many other causes of acute and chronic illness.
Deficiencies in clinical care apply as readily for these diseases as we have found for
renal diseases, thereby necessitating that similar educational programs be launched by
other international medical organizations. Many of the problems and solutions described
herein will likely be faced by colleagues mounting international programs in these other
specialties. The ISN has found its experiences in the developing world to be
extraordinarily gratifying, strongly supported by its leadership and enthusiastically
endorsed by its members. We call on our colleagues in other specialist societies to extend
their knowledge and experience to colleagues in geographical areas in need. The ISN
envisions a gathering with the leadership of other international organizations to extend
the range of medical expertise available to those in need in the developing world.