A blueprint for The Next Five Years
0.0.
Introduction
Since its foundation in 1960, the International Society of Nephrology (ISN) has pursued
the worldwide advancement of education, science and patient care 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 -- to improve the organization and efficiency -- a
central commission on global advancement of nephrology (COMGAN) [was established in 1994].
Currently, a third phase has been entered in which all activities have been intensified:
1) COMGAN has supported a large number of teaching programs and fact finding missions; 2)
a renal sister center program has been established; and 3) Commissions on informatics and
on clinical trials have been initiated.
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 one or two years in training. The library enhancement program reaches 218
institutions worldwide. ISN membership has soared over the past two years with over 2,500
new members, mostly in developing countries. They receive Kidney International and other
relevant forms of information. Thus far, 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 USD
from its own budget on the programs described above.
The various programs and initiatives are proving helpful in advancing renal medicine in
areas in need. Expansion into supporting similar programs within other medical
subspecialties is being explored." Kidney International, Vol 54, pp 1017-1021, 1998
COMGAN: The First Five Years -- 1994-1999
The initial experience of ISN-COMGAN has clearly verified the goals of ISN Presidents
Stewart Cameron and Robert Schrier with their respective Executive officers and Councils
in launching COMGAN under the leadership of Barry Brenner and John Dirks, with 5
Subcommission Chairs, and over 60 committee members. Numerous fact finding missions and
courses have taken place involving some 80 cities worldwide. Attendance at various
regional courses since May 1997 has been remarkable: for example, Dubai (900), Cape Town
(250), Istanbul (850), Moscow (300), Nepal (140), Nanjing (250) and Bangalore (300) alone
exceed 3000. Site visits and courses have helped to identify fellowship candidates, needs
for library and Internet involvement, expand group membership and promote sister linkages.
Most important has been the many nephrologists who now communicate frequently with COMGAN
and for whom ISN has become the highly significant catalyst to their further development
in nephrology. COMGAN has carried out its task with a modest budget of $150,000 USD per
year which has been successfully leveraged through contributions from industry and other
national and international associations. It is now timely for COMGAN to plan for the next
5 years and beyond.
MISSION 2000-2005 -- Embarking on the 21st Century
Our personal experience and widespread contacts have generated suggestions for creating
the following blueprint of expanded ISN COMGAN programs for the next 5 years, in order of
priority:
1. Promotion of Sister Center programs and Information Technology Transfer
2. Reorganisation of COMGAN
3. New Required Resources
4. Continuing nephrology courses
5. Consensus Conferences
6. Expansion of the Library Enhancement Program
7. Research in developing countries with new resources and materials
8. Greater linkages with other associations
1.0. Sister Centers
Robert Schrier's innovative leadership in establishing the sister relationship program was
forward looking and laudable. Some 135 linkages exist -- but so far only some 20 linkages
are working at an effective level. We have been asked whether the sister network should be
part of COMGAN's responsibilities and after wide discussion and reflection we believe this
to be an excellent idea. We recommend that a senior individual be added as a third
Co-Chair or Vice Chair to assume primary responsibility for oversight of the sister centre
network. As part of regular COMGAN activities subcommittee members have many opportunities
to visit sister centers in developing countries and enhance their activities and exchange
programs.
We propose that in each of our 5 subcommission areas 2 sister linkages be promoted as
model demonstration centers for a total of 10 to be built up over the next 2-3 years. They
should all be connected by Internet/e-mail through the associated offices of Dr. Kim Solez
and the Informatics Commission. These 10 demonstration linkages would serve as models of
excellence. Annually, centers would receive more regular visits, educational programs,
more comprehensive library material, frequent visits by Visiting Scholars, selected
fellowships for training and donations of equipment, supplies and pharmaceuticals as
appropriate. Inter-center clinical consultation would become common and research studies
would be greatly encouraged. Significant resources will be required to advance these model
sister relationships. We recommend that each of the 10 demonstration models receive $5,000
USD per year. We believe this sum could be augmented by various donors from corporations
and foundations. Additionally, $25,000 USD resources will be required for the remainder of
the sister program and the associated infrastructure to ensure its success. Fundraising
will be required by ISN to put together the needed resources.
Recommendation: That COMGAN assumes responsibility for the sisters
program, that a third senior individual be appointed as Co-Chair or Vice Chair to oversee
the sister centre network, that COMGAN develop a pilot study for up to 2 model sister
linkages in each of the 5 subcommission areas over the next 2-3 years, and that the
necessary resources be provided to promote this program.
2.0. Reorganisation of COMGAN
The current system of two COMGAN Co-Chairs with 5 regional Subcommissions has worked
reasonably well. We appreciate the commitment of so many members and thank those who are
completing their terms. We also appreciate the appointment of new members affirming
increased regional representation. More recently we have observed that with the growth and
intensification of the program a subregional structure may be required so as to reduce
extremely large geographic subcommissions to more workable regional units. A subregional
structure could involve 3 or more individuals for each subregion. eg. South Asia 3-5;
China 3-5, Indonesia-Phillippines 3-5, etc. The Subcommission Chairs and the overall
Co-Chairs of COMGAN would act as coordinators for the subregional approach and current
members would be more specifically assigned to their subregions.
Subregions could be visualized as follows:
Africa -- subdivided into Northern, Western,
Eastern and Southern Africa regions
Asia subdivided into: South Asia South East
Asia China Indonesia-Phillippines
CIS-Middle East subdivided into:
CIS --
Russia - Belarus
Ukraine - Moldova
Caucasus
Central Asia
Middle East --
Gulf Countries
Iran
Eastern & Central Europe subdivided
into:
Baltic Countries
Balkan Countries
Central Europe
Turkey
Latin America subdivided into:
Mexico
Central America
Caribbean
Northern & Southern South America
Recommendation: That the Co-Chairs be charged with the responsibility of
reorganising COMGAN to meet the needs of expanding programs in geographic areas by
creating more efficient smaller regional units and involving more ISN members in the
programs therein.
3.0. Resources
New resources would need to be added to COMGAN's budget to carry out its current programs,
support its newly recommended programs and promote model demonstration sister
relationships. New programs of Consensus Conferences, Library Expansion and Research
Development (Items 5.0 -- 7.0) would need additional support. The new programs, beginning
with enhanced sister center support, can be incrementally developed with an increased
budget for COMGAN. However, ISN Executive should consider a capital campaign to raise up
to $10 million USD over the next 3 years from pharmaceutical companies, medical equipment
suppliers, publishers, computer hardware and software firms, foundations, and other
governmental and non-governmental agencies to develop resources for these new initiatives.
A select committee should be appointed to implement and oversee this fundraising campaign
drawn from senior ISN leadership as well as government and industry. The challenge for the
leadership of ISN and COMGAN will be to develop the strategies for fundraising and its
implementation that bring about the Mission 2000-2005.
Recommendation: That ISN Executive, Council and COMGAN establish a
capital fundraising campaign of up to $10 million USD to ensure the accomplishment of
Mission 2000-2005. A committee of ISN leaders as well as representatives from industry and
government should be invited to implement and oversee this fundraising campaign.
4.0. Continuing Nephrology Courses
and Site Visits
We believe that the highly successful regional courses should be enhanced -- not only as
major broad updates but as "hands-on" workshops and specialty courses. The
ability of ISN to bring its most talented and articulate experts to the remote regions of
the world is highly appreciated. Much CME has already been done -- eg. ISN Updates in
Istanbul, histopathology course in Senegal and ultrasonography course in Czech Republic.
While maintaining current programs we recommend more workshops eg. prevention strategies,
technical skills, renal pathology, CAPD. We plan a number of niche courses eg. renal
pathology, and intend to broaden these efforts and are taking steps to evaluate CME
endeavours. In association with the Informatics Commission, we intend to offer more
educational material via electronic interactive media. Strengthening regional and national
nephrology education programs may well become ISN's major educational arm in addition to
our biennial international Congresses.
COMGAN wishes to involve an even greater number of ISN members in this educational
campaign. When an ISN member goes abroad for another purpose we want to encourage them
also to be ambassadors of ISN, promoting its purposes and assisting in fundraising, etc.
Fact finding missions to nephrology centres occurring in preparation for and associated
with regional-national meetings have played an instrumental role in helping us understand
local issues and in grasping the strengths and resource constraints of a centre in the
developing lands. Strong relationships are then developed which lead to regular
communication with Co-Chairs and Subcommittee Chairs. It also facilitates presentation of
membership, fellowship, sister relationships, library and educational material.
Recommendation: That ISN continue to maintain regional and national
educational courses in conjunction with regional associations and industry and to focus
more on teaching in workshops and education via electronic information technology, as well
as enlisting its membership in a broad educational and fundraising campaign worldwide.
5.0. ISN Consensus Conferences
We have identified a need for consensus conferences based on what we and our colleagues
have learned during site visits and various courses. ISN's Forefronts Conferences have
served an invaluable role in promoting basic science in nephrology. There is an equal need
at a global level for ISN COMGAN to implement consensus conferences in order to facilitate
discussion of clinically relevant topics. The organization of such conferences would need
to be developed. Up-to-date Informatics for on-going discussion would be a critical
building block for the conferences. Each consensus conference would have specific goals
and targets for future outcomes.
A. Prevention of Chronic Renal Disease. The
global burden of chronic renal disease requiring renal replacement therapy is rising
sharply and the costs, even in developed nations, will become staggering. Strategies for
preventing and delaying progression of renal disease especially due to hypertension and
diabetes mellitus are now available. We believe ISN should establish guidelines and
algorithms that can be implemented in various international settings by primary care
physicians, public health officials and other health professionals and caregivers
including nephrologists. Linkages should be established with international aid agencies
such as WHO and national health authorities. It is noteworthy that no other international
medical organization is addressing issues such as hypertension and diabetes mellitus and
this is a most appropriate and timely agenda for ISN.
B. Aboriginal Renal Disease: It is now well
established that End Stage Renal Disease has a substantially greater prevalence in the
aboriginal populations in North America, Australia and Oceania, South America and Africa
-- principally due to higher incidence of diabetes mellitus and hypertension. Low birth
weight is a significant marker of future increased prevalence. ISN can play a leadership
role in bringing together physicians and public health officials to develop global
strategies and implementation measures to reduce the horrendous ESRD incidence in the
first peoples.
C. Costs of Renal Care: Our experience
repeatedly has indicated that the high cost of renal care is a major global deterrent to
adequate treatment of ESRD. There is a need for active discussion of strategies to reduce
costs and to make treatment more readily available. A forum to bring together all
decision-makers on a regular basis will create new directions for meeting these issues.
D. Training Guidelines: We have had many
requests for training guidelines for nephrology. While North American guidelines may be
ideal, reasonable compromises must be worked out for many nations. A consensus conference
repeated from time to time is needed to discuss and identify suitable and regionally
sensitive guidelines for training nephrologists. A universally crafted and accepted ISN
standard for training would be a major contribution to the quality of nephrology education
and care world wide.
E. Ethics of Transplantation: Much recent
work has been done by individual transplant units but ISN should also take on this
responsibility as regards best ethical guidelines for renal transplantation with other
transplantation societies. The ethical landscape is constantly changing and rigorous
discussion and reflection is needed to create a widely accepted standard for renal
transplantation crafted through ISN-led dialogue.
Recommendation: That ISN COMGAN initiate a program of ISN consensus
conferences on vital issues such as prevention of renal disease, aboriginal renal disease,
costs of renal care, guidelines for nephrology training, ethics of transplantation and
others as appropriate. ISN consensus conferences will be a highly visible and prestigious
platform for discussion and debate and would need to be suitably published and transmitted
by Information Technology and by ISN's leaders. Additional resources will be required for
organisation and operational costs of such meetings.
6.0. Library Enhancement Program
ISN's program of library enhancement, ably run by the Treasurer's office, has been of
great assistance to developing centres. Our feedback and experience is that the Library
Enhancement program needs to be greatly expanded. The knowledge base of many centers is
still impoverished and unrestricted access to a variety of journals and textbooks and
electronic educational materials like CD-ROMs is urgently required. A close working
relationship with the Commission on Informatics will be necessary as library material
becomes increasingly electronic. A review of resources needed to obtain and ship the
relevant educational material is required.
Recommendation: That the current Library Enhancement program be greatly
expanded and resources developed to accomplish this goal. A close working relationship
with the Commission on Informatics should be established.
7.0. Global Research Development
There are unique opportunities for epidemiological research where "western"
expertise can be applied to local problems. For example, the recent site visit to Cuba
indicated an opportunity to work with the well developed Cuban public and primary health
care system to do epidemiological and interventional therapeutic studies. Special training
of epidemiologists for nephrology research is part of such an initiative and access to a
cadre of experienced epidemiologists is needed. The Commission on Clinical Trails and
Informatics would also be involved. ISN through COMGAN should develop a program to define
research needs and opportunities in various regions and to develop funds for such studies.
NIH-type RFA's could be developed by ISN to invite specific themes for active research.
Recommendation: That ISN assess research needs, opportunities and
implementation strategies in developing countries and identify the necessary resources
required.
8.0. Linkages With Associations
COMGAN has linked for specific courses with EDTA/ERA, ESPN, ASN, WCRC and many national
and regional organisations. We recognize the substantial partnership with NKF in the USA
with the ISN Informatics Commission for Cybernephrology. We propose that these
associations be greatly extended and formalized. They should fall into 2 categories:
A. Nephrology Associations
ISN as the international nephrology society should maintain and extend its primary
leadership. COMGAN is very gratified with its close and effective relationship with
several health professional societies such as the World Council of Renal Care (WCRC).
Working partnerships should be actively fostered and cooperation in courses and activities
be directed to the appropriate geographical regions (as with Asia-Pacific Society,
Nephrol, ASN, ERA, AFRAN etc.). Specific meetings need to occur regularly with partner
societies to maximize further joint opportunities and to avoid duplication.
B. Medical Specialty Societies
ISN has set a global example as to how an international society can positively impact on
its specialty nephrology. It has made a unique contribution especially in the breadth of
its agenda and the full global nature of its interactions. Opportunities arise to partner
with associations such as the International Societies of Hypertension, Urology and
Pediatrics that closely fit with the ISN COMGAN mission eg. multi-dimensional ICU course
on the Management of a Surgical Patient; setting standards for blood pressure control,
etc. Very important is setting a priority for pediatric nephrology care as 50% of the
population in developing countries are under 16 years of age.
Further, ISN's experience should be used to foster other international specialty societies
to develop global programs eg. Cardiology, gastroenterology, hematology, oncology etc. in
order to augment the international forefront of volunteer assistance from developed and
privileged nations and associations to regions that are less developed and
under-resourced.
Recommendation: That ISN-COMGAN in consultation with the ISN Executive,
develop effective partnerships with regional and national nephrology associations and also
with other medical subspecialty societies for the purposes of further augmenting the
global care of patients and education of health care professionals.
Summary -- Mission 2000-2005
We present to the ISN Executive and Council a report entitled "Mission 2000-2005: A
Blueprint For The Next Five Years" to further extend ISN's global humanitarian
effort. We emphasize the following in order of priority:
1. Increase the availability of Information
Technology for sister centers and establish a model demonstration program of 10 intensive
model sister relationships
2. Reorganisation of COMGAN Committee Structure to fulfil Mission
2000-2005
3. Development of increased resources and an ISN capital fundraising
campaign
4. Further Continuing Nephrology Education Courses, Workshops and Site
Visits
5. ISN Consensus Conferences
6. Expansion of the Library Enhancement Program
7. Research on Unique Problems in the Developing World
8. Linkage and partnership with other medical associations
Submitted by:
John Dirks, MD, Co-Chair, ISN COMGAN
Barry M. Brenner, MD, Co-Chair, ISN COMGAN
May 2, 1999
Last update: December 22, 2001