Emerg Med Clin N Am 23 (2005) 1–10

History of the Development of

International Emergency Medicine
Kumar Alagappan, MD, FACEP, FAAEMa,b,*,
C. James Holliman, MD, FACEPc,d
a
Department of Emergency Medicine, Long Island Jewish Medical Center,
270-05 76th Avenue, New Hyde Park, NY 11040, USA
b
Department of Clinical Emergency Medicine, Albert Einstein College of Medicine,
1300 Morris Park Avenue, Bronx, NY 10461, USA
c
Center for International Emergency Medicine, 500 University Drive, Hershey,
PA 17033, USA
d
Department of Emergency Medicine, Penn State University, MS Hershey
Medical Center, MC 71043, P.O. Box 850, Hershey, PA, USA

International emergency medicine (EM) represents a new subspecialty,

and most of its developmental history has occurred in the last decade or so.
International EM consists of a number of different activities. These include
developing EM and EMS training programs, developing clinical EM
facilities, developing EM as a recognized specialty, charity clinical service,
staffing expatriate medical facilities, re-patriation of United States patients
from other countries, conducting exchange programs for health care
personnel, and operating travel medicine clinics. This article reviews
important milestones in the development of EM internationally; compares,
in parallel, the timelines of EM development in different countries; and
presents the general status of international EM.
There are a number of reasons for the rapidly increasing interest in
international EM over the last decade. There has been a recent awakening
by many countries that they should develop EM as a specialty [1–6]. EM in
the United States, the United Kingdom, and a few other countries has fully
matured as a specialty and thus acts as an example for EM development in
other countries [7]. The collapse of the Soviet block has opened up multiple
countries to people and new ideas (such as EM) from the outside. Multiple
international EM conferences have been launched within the past decade.

* Corresponding author. Department of Emergency Medicine, Long Island Jewish

Medical Center, 270-05 76th Avenue, New Hyde Park, NY 11040.
E-mail address: [email protected] (K. Alagappan).

0733-8627/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.emc.2004.09.013 emed.theclinics.com
2 ALAGAPPAN & HOLLIMAN

Recently, there has been greatly increased support for international

development from various national EM organization leaders [2,4,8,9].
There are also a number of reasons for recent increasing interest in
developing EM within other countries [5,6,9]. These include the general
overall medical system improvement in most countries. Also, virtually all
countries are undergoing urbanization of their populations, with a de-
mographic transition from infectious diseases to trauma and cardiorespi-
ratory diseases, which are well handled by the specialty of EM. There are
increasing outpatient visits and an increasing percentage of elderly patients
who require EM services more frequently [10–13]. There has been the
demonstrated success of EM in the United States and a few other countries,
and this has become known to people throughout the world partly from
popular television shows such as ER, Rescue 911, and Casualty. This
demonstrated success of EM has increased public expectations for EM
system improvement in many countries. In addition, increased international
travel and terrorist and other mass casualty events have contributed to the
push for EM system development in a number of countries.

Early emergency medicine system development

EM is a young specialty that has become well established and mature in
a relatively small number of countries. EM in the United States, United
Kingdom, Australia, Canada, Hong Kong, and Singapore can be regarded
as a mature specialty. Early development of the specialty in these countries
proceeded more or less in parallel, with perhaps much of the initial stimulus
coming from the United States, in which the specialty developed first.
Table 1 shows the comparative milestone years for EM development in these
countries with mature EM. Some of the years are debatable in that there
were different organizations in several of the countries involved in EM and
academic development, and in some of the countries there was not a separate
academic society but rather an academic subunit of a national society. With
maturation of EM as a specialty in these countries, a number of EM
practitioners in the early 1990s started to turn their attention to developing

Table 1
Comparative milestone years for emergency medicine development in the countries with mature
emergency medicine
United United Hong
States Kingdom Australia Canada Kong Singapore
Recognized specialty 1973 1986 1981 1980 1983 1984
National organization 1968 1967 1981 1984 1985 1993
Academic society 1970 1989 1988 1988 1994 1993
National certification 1979 1983 1986 1985 1997 1994
examination
 HISTORY OF GLOBAL EM DEVELOPMENT 3

the specialty in other countries. In 1999, an article was published in the

Annals of Emergency Medicine that proposed classification system for
determining the level of EM development in different countries [2]. This
categorization system placed countries in one of three categories: un-
derdeveloped, developing, and mature. The four different general categories
considered in this classification scheme were specialty systems, academic
EM, patient care systems, and management systems. In this classification
system, the underdeveloped category would apply to most African
countries, the developing category to some of the European and Middle
Eastern countries, and the mature category to the United States, the United
Kingdom, Canada, Australia, Hong Kong, and Singapore. Tables 2 through 5
show how this classification system, for example, could be used to describe
the development status of EM in the region of the Middle East. The use of
this categorization system allows planning and direction as to EM devel-
opment efforts within a particular country by pointing out the areas that are
deficient and require further organizational work. A goal for those interested
in international EM development is to have all countries reach the mature
stage of EM development.

History of international organizations’ involvement in international

emergency medicine development
A number of organizations have been involved in international EM
(Box 1). Following is a brief description of the history of international
involvement by each of these organizations.
The International Federation for EM (IFEM) represents a consortium of
national EM organizations and was founded by the American College of
Emergency Physicians (ACEP), the British Association of Accident and
Emergency Medicine, the Australasian College of Emergency Medicine
(ACEM), and the Canadian Association of Emergency Physicians (CAEP)
in 1989. After an initial meeting in London in 1986, this group of four
organizations has conducted an international conference on EM every other
year. A pattern was set up to rotate the ICEM conference every other year
from the United Kingdom to Australia to Canada to the United States.

Table 2
Comparison of emergency medicine specialty systems
Country class
Underdeveloped Developing Mature Middle East countries
National EM organization No Yes Yes Some
EM residency training No Yes Yes Some
EM board certification No Yes/no Yes No
Official specialty status No Yes Yes Some
Abbreviation: EM, emergency medicine.
4 ALAGAPPAN & HOLLIMAN

Table 3
Comparison of academic emergency medicine features
Country class
Underdeveloped Developing Mature Middle East countries
Specialty journal No Yes/no Yes Some
Research No Yes/no Yes Limited clinical
Databases No No Yes No
EM subspecialty training No No Yes No

These ICEM conferences have been successful at generating collaboration

and networking between physicians interested in international EM de-
velopment. Most of the conferences have had 1000 or more registrants.
IFEM extended membership to other national EM organizations in 1998.
Current members of the IFEM and the year the organization joined are:
ACEP 1989, BAEM 1989, CAEP 1989, ACEM 1989, Hong Kong 1998,
Mexico 1999, China 1999, Korea 2000, Czech Republic 2000, Taiwan
2000, Singapore 2000, Israel 2000, Turkey 2002, Poland 2002, Netherlands
2002, South Africa 2002, Spain 2002, Ireland 2002, and Argentina 2003. The
IFEM is developing policy statements on international health issues and an
international core curriculum for EM. The organization is expected to vote
to open up the host site for the ICEM to countries other than the original
four founders starting in the year 2010. The IFEM consortium represents
probably the most active, broad-based, international organization dealing
with international EM development issues.
For a number of years, ACEP did not have much active involvement in
international EM except for its participation in the IFEM. In the late 1990s,
the ACEP leadership started to directly support a number of EM activities
[7]. ACEP members started a Section on International EM in 1998, which
quickly became the second largest section within ACEP and currently has

Table 4
Comparison of patient care systems
Country class Middle East
Underdeveloped Developing Mature countries
Emergency Housestaff, other Some EM All EM residency GPs, some
physicians doctors residency trained residency
trained trained
Emergency Other specialty EM physician EM-certified Some EM
department physician
director
Prehospital care Private car, taxi BLS or EMT Paramedic or Varies
ambulance doctor by area
Transfer system No No Yes No
Trauma system No No Yes No
Abbreviations: BLS, basic life support; EM, emergency medicine; EMT, emergency medical
technician.
 HISTORY OF GLOBAL EM DEVELOPMENT 5

Table 5
Comparison of management systems
Country class
Underdeveloped Developing Mature Middle East countries
Quality assurance programs No No Yes No
Peer review programs No No Yes No
Specialty CME required No Yes/no Yes No
Abbreviation: CME, continuing medical education.

about 500 members. The ACEP leadership formed a task force on

international EM that developed a long-term plan for further ACEP
support of international EM efforts. In the mid to late 1990s, the Annals of
Emergency Medicine published a series of articles describing EM de-
velopment in different countries. ACEP leaders have recently become
increasingly active with other countries’ EM organizations, and it is
expected that ACEP will soon start a process for formally endorsing other
international EM conferences.
SAEM had an international committee from 1991 to 1996 and then
changed the committee to an International EM Interest Group [14]. This
quickly became the largest interest group within SAEM. The members of
the interest group developed a reference database on international EM
rotations and fellowship programs, which was converted to a Web-based
electronic format at Boston University and transferred to the ACEP Web
site as a result of a section grant award from ACEP, where it is maintained
and updated. Members of the SAEM International Interest Group
published a series of articles that provided the academic underpinning and
literature basis for organized international EM development efforts [4].

Box 1. Organizations involved in international EM development

The American Academy of Emergency Medicine (AAEM)
American Academy for Emergency Medicine in India (AAEMI)
The American College of Emergency Physicians (ACEP)
The Asian Society for Emergency Medicine
The European Society for Emergency Medicine (EuSEM)
Emergency International (EI)
The International Federation for EM (IFEM)
International Medical Corps (IMC)
Medecins sans Frontieres [Doctors without Borders] (MSF)
The Pan-Arab Society of Trauma and Emergency Medicine
The Society for Academic Emergency Medicine (SAEM)
The World Association for Disaster and Emergency Medicine
(WADEM)
6 ALAGAPPAN & HOLLIMAN

These articles included recommended curricula for international observa-

tional EM fellowships and international fellowship programs for United
States EM residency graduates [7,15]. In addition, a listing all of the
references published up to that time on international EM was compiled.
Additional articles on methods for operation and evaluation of interna-
tional EM projects and how to plan and develop EM at the national level in
other countries were published [16–18]. The SAEM International Interest
Group has conducted business meetings at the annual meetings of ACEP
and SAEM since 1993 and has stimulated interest in international work
among United States medical students and EM residents. SAEM also
sponsored joint meetings with the UK Faculty of A&E Medicine in 1990,
1993, and 1998 and with the European Society of Emergency Medicine in
San Marino in 1998. The members of the SAEM International interest
group are active in promoting international EM research projects.
The World Association for Disaster and Emergency Medicine
(WADEM) was founded in 1976 as the ‘‘Club of Mainz.’’ The WADEM
has conducted an international conference every 2 years since 1987 in a
variety of locations across the globe [19]. The next conference for WADEM
will be in 2005 in Edinburgh, Scotland. This organization has been con-
cerned mainly with disaster medicine and not as much with EM system
development. Many of the WADEM members are physicians from non-
emergency medicine specialties. Prehospital and Disaster Medicine is the
official journal of this organization and has published a number of articles
related to international EM work.
The American Academy of Emergency Medicine (AAEM) has had an
international committee since 2000. The AAEM co-sponsored the First
Mediterranean Congress on EM in Stresa, Italy in September 2001 and the
Second Mediterranean Congress in Sitges, Spain, September 14 through 17,
2003. This conference attracted over 1000 EM physicians from 80 countries.
The European Society of Emergency Medicine and the AAEM have co-
sponsored the European Society of Emergency Medicine Congresses, with
the last one being in Slovenia in September of 2002 and the next one
scheduled for Leuven, Belgium in 2005. The AAEM has been actively
encouraging its members to undertake international EM work.
The European Society for Emergency Medicine (EuSEM) was founded at
the IFEM conference in London in 1994. This organization conducted The
First European Congress in Emergency Medicine in San Marino in 1998,
which was widely attended. The EuSEM dropped out of sponsoring the
second Congress, which was held in Wroclaw, Poland, in the year 2000 but
resumed at the Congress in Slovenia in September 2002. The EuSEM co-
conducted the Mediterranean Congress of EM in 2001 and 2003. The
EuSEM has published The European Journal of Emergency Medicine since
1994 and published the important Manifesto for Emergency Medicine in
Europe, which defines the needed structure for EM in the European
countries. The EuSEM has started to develop recommendations for the
 HISTORY OF GLOBAL EM DEVELOPMENT 7

standardization of training and certification in EM for the European

countries. The EuSEM supports the disaster medicine training center and
degree program in San Marino, Italy. The EuSEM has struggled to increase
its membership and currently has a membership of about 200.
The Asian Society of EM was founded in 1998 and has conducted
multinational conferences in Singapore in 1999, Taiwan in 2001, and Hong
Kong in 2003. The Asian Society is starting to develop curriculum
recommendations and exchange programs for the Asian countries. EM
has become well developed in a number of the Asian countries, including
Hong Kong, Singapore, Korea, Taiwan, The Peoples Republic of China,
and the Philippines.
Emergency International (EI), originally named ‘‘The Society for the
International Advancement of Emergency Medical Care,’’ started in the late
1980s. Early on this organization mainly conducted medical tours but
developed into a grass roots organization devoted to assisting EM
development in other countries. The organization had a number of
regional-based projects, most prominently in China, The Middle East,
and Latin America. EI conducted business meetings at the annual meetings
of ACEP and SAEM regularly, but in the last several years EI has developed
significant financial problems. The organization has not had any recent
major development activities.
The International Medical Corps (IMC) was started by Dr. Bob Simon of
Cook County Hospital in Chicago in the 1980s to provide medical care for
Afghan refugees. The organization has been active in promoting refugee
relief work in a number of different countries and in developing training
programs for rural health care personnel [20].
Doctors without Borders (Medicines Sans Frontieres, MSF) is devoted
mainly to international refugee relief work. MSF was dominated by French
nonemergency physicians until the mid-1990s, when it started to use more
EM physicians. MSF received the Noble Peace Prize in 1999 for its work in
the Balkans and in Africa. IMC and MSF are active and interested in
recruiting emergency physicians as volunteer and as paid workers [21].
The Center for International EMS was founded in 1991 by Elco Dykstra.
This organization was originally headquartered in Wiesbaden, Germany
and then in the Netherlands. The organization conducted a series of EM
conferences that provided significant networking opportunities for emer-
gency physicians from multiple countries. These conferences were entitled
the Pan European Conferences on EMS. The first was conducted in
Budapest, Hungary in 1992 and then Abano Terme, Italy 1994, Prague The
Czech Republic in 1996, and Opatija, Croatia in 1998. The Center developed
some financial problems and dissolved after being unable to organize
a conference in Turkey in 2000.
The Pan Arab Society of Trauma and Emergency Medicine was founded
in 2002 and is currently headquartered in Doha, Qatar. This organization
conducted the Qatar International Trauma and Emergency Medicine
8 ALAGAPPAN & HOLLIMAN

Conference in Doha in 2002, which had over 800 attendees. The

organization conducted a second international EM conference in Doha
April 7 through 11, 2004. The organization has published The Middle
Eastern Journal of Emergency Medicine since 2001, and some of its members
have conducted active regional training programs in modular EM courses in
Doha for the last several years.
The American Academy for Emergency Medicine in India (AAEMI) was
founded in 2001. The AAEMI represents a group focused on helping EM
develop in a single country (India). The organization has cosponsored
international conferences in India since 2002 with the Society for EM in
India [22]. These are among the few internationally located conferences that
have been awarded Category I CME credit. The next conference was
conducted in Mumbai, India in November 2004. AAEMI has several
committees working on projects related to international research, EMS
development in India, and standardized curriculum recommendations for
EM training.

Status of emergency medicine in different countries

Countries that have national EM organizations and annual EM
conferences include the United States, the United Kingdom, Canada,
Australia, Hong Kong, Singapore, Korea, China, Taiwan, Mexico,
Argentina, Chile, Spain, Croatia, Turkey, Poland, Israel, India, Czech
Republic, Hungary, Slovenia, and Italy. Countries that have national EM
organizations but less regular EM conferences include Iceland, Estonia,
Costa Rica, Romania, Brazil, Jordan, Belgium, Philippines, Sweden, and
South Africa. The following countries have started EM residency training
programs: Nicaragua in 1998, South Korea in 1993, China in 1995, Taiwan
in 1994, Estonia in 1999, Israel in 2001, Bulgaria in 1999, Costa Rica in
1994, Turkey in 1994, Jordan in 1996, Hungary in 1992, Bosnia in 1996, and
Belgium in 1990. Other countries with EM residency programs in
development include Italy, Netherlands, Sweden, Romania, Philippines,
Poland, Czech Republic, Oman, Saudi Arabia, India, Ireland, Mexico,
Chile, Guatemala, Colombia, Iran, Egypt, and Qatar. The following
countries publish EM journals: the United States, the United Kingdom,
Australia, Korea, China, Hong Kong, Taiwan, Turkey, Qatar, Israel, Czech
Republic, Poland, and India.
Several United States universities have developed international EM
fellowship programs for graduates of United States EM residencies [23] (see
the article by Anderson et al elsewhere in this issue). These programs are
designed to provide academic career training for United States EM
residency graduates who want to make international EM a major focus of
their career. Current programs and their start year are as follows: Loma
Linda University in 1994; University of Illinois in 1996; John Hopkins
University in 1997; Harvard University in 1999; George Washington
 HISTORY OF GLOBAL EM DEVELOPMENT 9

University in 2001; New York University (Bellevue) in 2002; Rush

University, Cook County in 2004; and North Shore-LIJ in 2004. Some
universities in the United States have developed international EM fellowship
programs for physicians from other countries. These programs are designed
mainly to provide faculty development for physicians from other countries
who want to start EM programs in their own country [8]. These programs
include Penn State University, Loma Linda University, George Washington
University, Harvard University, Stanford University, and University of
Oregon. United States institutions with an active interest in international
EM are Penn State University, George Washington University, Harvard
University, Johns Hopkins University, Loma Linda University, University
of New Mexico, University of Oregon, Bellevue Hospital, Long Island
Jewish Medical Center, Mt. Sinai Medical Center, Emory University,
Stanford University, University of Illinois, Boston University, University of
Pittsburgh, University of Massachusetts, Yale University, and University of
California, Irvine.

Summary
A future challenge for international EM development is expanding the
specialty to Africa, where it is non-existent. Another goal for international
EM development is to assist in the peace process in the Middle East. There is
increasing need for good EM development throughout the world. De-
velopment of international EM has been rapid, with most of the spread of
development occurring in the last 10 years. There is great opportunity and
reward for students, residents, and EM physicians to further promote and
develop EM internationally.

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