History of the World Allergy Organization: Two Decades Leading to World Leadership, 1990-2010
World Allergy Organization Journal volume 4, pages 231–248 (2011)
History of the World Allergy Organization: In 1951, the leaders in allergy from all over the world came together to form the International Association of Allergology and Clinical Immunology (IAACI). For the next 60 years, the allergy world converged at the IAACI triennial meetings, which became biennial in 2003. The international meetings, originally named the International Congress of Allergology and Clinical Immunology (ICACI), are now the World Allergy Congress (WAC) hosted by the World Allergy Organization (WAO). Everyone who has aspired to have worldwide recognition has played a part in IAACI-WAO. The History of the World Allergy Organization traces the global arc of the allergy field over the past 60 years. The current officers of WAO elected to focus on this rich history, inviting prominent leaders who are interested in being part of this history project to write about their time with IAACI-WAO. This series will be presented in Cancún, México as part of the XXII World Allergy Congress (December 4-8, 2011). Leading up to the Congress in Cancún, the World Allergy Organization Journal is presenting segments of the History as part of the "Notes of Allergy Watchers Series." Please enjoy.
--Michael A. Kaliner, MD
Historian and Past President (2006-2007)
World Allergy Organization
I joined the World Allergy Organization (WAO) as a member of the Board of Directors in 1988. During the time frame of 1988 to 2011, I have been at various times an At-Large Member, Vice President, Treasurer (twice), President Elect, President, and Historian. I was never Secretary General. I have also been in the "doghouse" at least once, and I thought my career with WAO (at that time the International Association of Allergy and Clinical Immunology, IAACI) was over after 1997 (more about this episode later). This 23-year span is the second longest term of office of any member of the Board of Directors of IAACI/WAO, other than Alain deWeck, who served from 1970 to 2000, a span of 30-plus years. During that period, along with my own, I have served under the presidencies of Alain deWeck, Jacques Charpin, Terumasa Miyamoto, Albert Oehling, S. Gunnar Johansson, Allen Kaplan, Carlos Baena-Cagnani, G. Walter Canonica, and Richard Lockey. I have had the fortune of attending the congresses in Jerusalem, London, Washington, DC, Montreux, Kyoto, Stockholm, Cancun, Sydney, Vancouver, Munich, Bangkok, and Buenos Aires. This compilation of the history of WAO/IAACI will be written from my memories, assisted by whatever archives I have been able to find. Following the lead of Alain deWeck, this will be a personal history, and I will add the human elements to the histories and recall stories as best I can and when they seem appropriate. I hope the human aspects of this history are enjoyable to the reader.
My first exposure to IAACI was in 1979 when I had the opportunity to give a lecture in Jerusalem for Israel Glazer at the Congress held in Israel. I had a very positive impression of the science at the meeting, loved visiting Israel, and decided to try to attend these meetings whenever possible. In fact, I have had the chance to be at every congress since 1979. I had planned to present at the 1976 congress in Buenos Aires but was not allowed to attend by my employer because of internal conflicts going on in Argentina at that time. I have seen enormous progress in every aspect of these triennial and now biannual meetings over the past 30-plus years.
Around 1984, I received a letter from Alain deWeck of Bern, Switzerland, asking if he could spend 6 months in my laboratory at the National Institutes of Health. I knew of Alain deWeck and was well aware of his notable stature in Europe. Not only was deWeck famous for his science but also he was widely acknowledged as the leading immunopolitician in Europe. He had led the IAACI, International Union of Immunologic Societies, and World Health Organization (WHO) and had started the Collegium Internationale Allergologicum, while greatly assisting in bringing the European Academy of Allergy Asthma and Clinical Immunology (EAACI) toward its current leadership position. I accepted his offer and arranged space for him for a 6-month stay. He arrived bringing his laboratory assistant with him, and we embarked on a worthwhile set of experiments relating to some complement activity.
However, as it turned out, Alain deWeck's ulterior purpose in visiting Washington, DC, was to develop the International Congress of Allergy and Clinical immunology (ICACI) as the triennial meeting sponsored by IAACI, which has planned for Washington, DC, in 1985. Both the American College of Allergy Asthma and Immunology (ACAAI) with Gil Barkin as President and the American Academy of Allergy Asthma and Immunology (AAAAI) with Leonard Bernstein as President were invited by IAACI to help organize the congress. This meeting was held on American soil in cooperation with the 2 allergy societies in the United States. However, the functional direction of the meeting was controlled by Alain deWeck with the assistance of Robert Goldstein, who was Chief of the National Institute of Allergy and Infectious Diseases extramural program, responsible for administrating research grants and other extramural activities and who functionally acted as a Co-Chair of the meeting. Allen Kaplan, who had recently left the National Institutes of Health for Stoneybrook, was the scientific advisor, and I was asked to provide general support while specifically running the social program.
For those of us taking care of allergy patients in the mid 1980s, this was a magical time. Inhaled corticosteroids were proving to be extraordinary for rhinitis and asthma. We had inhaled cromoglycate for asthma, a novel medication that had focused attention on the role of the mast cell and allergy in the pathogenesis of asthma. And, the first nonsedating antihistamines were just appearing. As the Social Program Chairman of the 1985 meeting, I was able to raise funds and hold spectacular events, such as the All-Congress event held at the Smithsonian's American History Museum, which we rented for an evening. It was a splendid setting. We had the President's Reception in the Corcoran Museum. The entire congress went to the Kennedy Center for a performance. But the highlight of the meeting was the barbeque on the National Mall. Marion-Merrell-Dow, now Sanofi-Aventis, wanted to bring Seldane, the first nonsedating H1 antihistamine, out at the meeting, and they wanted a big splash. Well, we had one. We rented the space on the National Mall just north of the Air and Space Museum, a spot now housing the National Museum of the American Indian, and rented the largest tent you can imagine. Unfortunately, it rained all week, and so you could actually splash at the event! This event is the single most memorable dinner I have attended at any meeting anywhere (and after 40 years, that includes a whole heck of a lot of meetings). The 2500 attendees were wined, dined, square-danced, and thrilled. Seldane went on to sell $billions before being replaced by Allegra.
Shortly after this meeting, Alain deWeck invited me in 1985 to participate as a special Presidential Advisor to IAACI in a very select committee, the IAACI Presidential Advisory Committee (which included K Frank Austen, Jack Pepys, Johannes Ring, AB Kay, and Andre Capron among others), and in 1988, to join the Board of Directors, where I have enjoyed the company of the leaders of allergy for the more than 2 decades. I hope that I can point out sufficient achievements to warrant such a long stay on the Board.
My memories of IAACI from 1988 through the 1990s were that the focus was nearly solely on the triennial meeting, which was really the primary purpose for the organization and its major source of income. As a federation of allergy and immunology societies, charging more than a modicum for dues was not feasible, so income from the triennial congresses determined what might be accomplished over the subsequent 3 years. Board meetings were generally only held annually, and scant communications occurred between meetings. There were no conference calls of the Board, so that the only communication occurred by mail, very little by e-mail, and mostly by face-to-face communication once a year.
The energy and commitment of the President were the major determinants of IAACI's success. He was not only President but also the Chair of the triennial congress and ran the scientific program committee as well. The congresses could be fairly small, as few as 750, or large, as many as 2000 attendees. Meeting sites were selected 6 years earlier at the triennial meeting of the House of Delegates, which is a meeting where representatives from all the member societies meet and vote on some issues of worldwide interest, such as the meeting venue. Voting in the House of Delegates was proportional to the size of membership of the society, although the smallest society (at least 30 members) had at least 1 vote, while the larger societies like the Japanese Society had 3 votes.
Many aspects of the Board itself were mysteries. It was never clear how one was selected to move from an at-large member into an officer position or how an officer was then selected to become the president. At-large membership selection for the Board of Directors was also a bit of a mystery. The past president nominated new members largely in consultation with a nominating committee composed of well-known allergists who had never served on the IAACI Board. Newly appointed members could be recycled from retiring current Board members, who might thereby spend extended periods on the Board while never becoming the president. The concept of limiting the time as a member of the Board was not considered at that time. During my early years, the core of the Board was always European, with some Eastern representation (always at least 1 person from Japan and often Australia); there was always at least 1 person from Latin America and 1 to 2 from America. The United States presented a conundrum. It was traditional to have a representative of both the ACAAI and AAAAI on the Board, but in the mid-1990s, in a rather xenophobic moment, the ACAAI decided to withdraw from the IAACI, changing their minds a few years later and reapplying for membership back into the IAACI. During that period of disengagement, no ACAAI representatives were appointed to the Board, so the AAAAI was the sole source of nominees from America.
I have distinct memories of slow Board meetings, not much ongoing activity, and what I perceived of as not much future for this society, unless there was a sea change. Allen Kaplan in his memoirs for the WAO history project described this period of IAACI as an "Old Boy's Club," and I agree with that characterization. Giving credit to where it belongs, Alain deWeck recognized the dilemma and held a retreat at the Meadowood Resort in Napa Valley after the AAAAI Annual Meeting in San Francisco in 1997, to discuss the future of IAACI. After that meeting, in large part in response to the renomination of several retiring members of the "Old Boy's Club" back onto the Board for recycling, a controversial letter written by myself was sent to the Board calling for sweeping changes. For several months after that meeting and the subsequent provocative letter, there were heated, passionate debates over the need to modernize and democratize; and in fact, several Board members eventually resigned and a new, younger Board was brought into place. The slate of officers of IAACI was shuffled a bit, and I recall some hard feelings around the Board table. At that moment, I became a persona non grata and was demoted to Second Vice President, entering the proverbial doghouse.
Albert Oehling was President at the time and Gunnar Johansson was President Elect. Gunnar Johansson understood the issues, as did Rick Iber of Executive Director Incorporated (EDI) (the WAO Secretariat housed in Milwaukee). Rick and I had worked on the post-Meadowood provocative letter together, recognizing that it was certain to cause an upheaval. When Gunnar Johansson became President, he called for a retreat to be held at a seaside venue in Sweden in 1998. Rick Iber's partner in EDI was Kay Whalen, now the President of EDI, which is still the WAO Secretariat, and one of the true assets of WAO. With the help of Rick and Kay, a facilitator was hired who presided over the meeting, leading to progressive discussions and a revolutionary, unifying and exhilarating new direction for the old IAACI. Attending this session were the members of the Board, which had become decidedly younger after the 1997 upheaval. In a brilliant 2day session, we decided to focus IAACI as a global federation of allergy societies, changing our name to the World Allergy Organization (WAO). It was universally felt that WAO should be much more than the host of a triennial meeting, and objectives for education, research, and training were identified.
The frequency of the Congress meeting was moved from triennial to biennial and eventually was renamed the World Allergy Congress; the tenure of the officers were adjusted to a 2-year duration; the goals of WAO beyond having a scientific meeting were established; and the current structure of WAO was initiated. The bylaws were laboriously redesigned (a continual activity) under the guidance of Richard Lockey and have continued to evolve thereafter. The length of time one can serve as a member of the Board was defined, leading to the opportunity for more countries to be represented on the Board. WAO has emerged as a democratic organization, with representatives chosen in equal distribution from a worldwide pool, with consideration for the need to represent small and large allergy societies. The method for electing officers and their progress through the various elected positions was defined, and democratic transparent elections both to become a member of the Board and to become an officer became the mode. Rotation of the biannual meeting around the globe assured the opportunity for all interested societies to host this important meeting. Recent meetings have taken place in Australia, Canada, Mexico, Sweden, Thailand, Germany, and Argentina. We soon shall return to Mexico, go to Italy and Korea, and perhaps the United States.
In the period when an urgent need to revitalize IAACI into a power for the world of allergy was recognized, from Meadowood 1997 through the ensuing 13 years, WAO has come into being and is now firmly established as the worldwide voice of allergy. Not only have the 35,000 plus allergists benefited but also the hundreds of millions of allergy sufferers have benefited even more. WAO does so much more than host a scientific congress. The needs of the allergy sufferer and the means to provide care for these patients is the paramount driving force of WAO, and the organization has grown into itself in such a manner that this former "Old Boy's Club" is now a modern, forceful, powerful advocate of impressive power and focus.
What a change, what an improvement, what an achievement!
1988-1997: The End of the "OLD BOY'S CLUB"
After the extraordinarily successful (scientifically and socially) meeting in Washington, DC, in 1985, the congress moved back to Europe and was held in Montreux, Switzerland. Jacques Charpin was the President of IAACI when I joined the Board in 1988. However, Jacques Charpin was ill, and Alain deWeck ran the triennial Congress, and he did so in a unique and personal fashion. He enlisted students from the university to assist him, so we had many charming young people running around the congress halls, doing everything that one would hire a professional organizing company to do these days. In this manner, Alain deWeck saved money and kept the meeting quite personal. The science of the meeting was excellent, as it always is, and the social program memorable, especially the dinners organized in nearby Swiss castles. About 3500 attended the meeting and nearly $200,000 in profit was achieved.
During this period, the Board focused on the upcoming meetings and had little interest in outside activities. Other than the congress in Montreux, the major outside achievements were the publication of Allergy and Clinical Immunology News, edited by Alain deWeck. Jacques Charpin became progressively more ill during his tenure and had to resign in 1990. Albert Oehling was named acting president in 1990.
Terumasa Miyamoto became the president of IAACI in 1991 after having organized the congress in Kyoto the same year. The congress in Kyoto was a sound success both scientifically and financially. It was during this period that IAACI, for the first time, became involved in sponsoring educational meetings in conjunction with member societies, in addition to the triennial Congress. Taking advantage of some excess income, IAACI elected to create a Seminars and Conferences Program, which I initiated and Chaired, utilizing $40,000 per year to organize and host up to 2 conferences per year at WAO Member Society meetings. This initiative was the first time that IAACI assisted its member societies in enhancing their educational programs and is the forerunner of the GLORIA (Global Resources in Allergy) and Seminars and Conferences programs that followed later in the decade. At the same time, under the driving force of Alain deWeck and Jacques Charpin, IAACI published an international membership directory that allowed allergists worldwide to locate other allergists for purposes such as referring patients who were changing locations. This monumental work helped place IAACI in the center of the allergy world and was extremely useful.
During this Board of Directors meeting in 1991, the principle that WAO would take 12% of all registration fees from the triennial Congress was established and has been kept in place for essentially all congresses since then, until the World Allergy Congress in Buenos Aires in 2009.
The congress in Kyoto was attended by 2500 delegates from 52 countries. My clearest memory, other than the sushi, was the park just near the conference hotel. Each morning I would join literally hundreds of absolutely quiet Japanese people on a walk/jog around a beautiful garden and lake. Even though the weather was wet, the number of Japanese exercising was always huge, and the quiet, despite the numbers of people walking/running together, was eerie. No boom boxes, no yelling, no rowdy children, just beauty and peacefulness.
After a time of preparation, the WAO Conferences Committee sponsored a meeting in Argentina, which although considered quite successful educationally, was very costly. We recognized that sponsoring conferences, in addition to the triennial meeting, required ironclad constraints. The major contribution of this program to the development of IAACI was that it opened up the opportunity for member societies to be directly supported by IAACI, and it gave IAACI a presence other than the triennial meeting. I recall that all communications took place by mail and that it literally took months for any consensus to be achieved. Thus, the pace of activities in 1988 to 1994 seems so slow by today's perspective, but it was unavoidable based upon the communications systems in place at the time.
In 1993, recognizing the need to move outside of the restricted objectives of the old IAACI, Alain deWeck and Rick Iber developed the Perspectives in Allergy Program (POA), sponsored by Marion-Merrell Dow. This program was designed to place seminars focused on allergy or clinical immunology at nonallergy meetings as a way to teach nonallergists some of the principles of allergy. In addition, symposia were also held within major European allergy meetings. As a European program, the advisory committee was entirely European. An ambitious program of seminars was created and the time had come for IAACI to move outside of itself.
Thus, in this short period, 2 programs were developed by the IAACI that increased its worldwide presence and have been the starting point for future developments. While Terumasa Miyamoto was then the President and he fully supported these programs, Alain deWeck was the consistent driving force behind them and Rick Iber of the Secretariat provided much of the creativity and funding prowess. The POA program got off to an impressive start, with meetings in Florence, Jerusalem, Stockholm, Berlin, and Austria.
The 1994 congress in Stockholm was an important turning point for IAACI. The meeting was conducted in conjunction with EAACI, had a very large attendance (4700 paid participants plus 1400 others), and led to the eventual presidency of Gunnar Johansson (1997-2000), who rightfully deserves much credit for the revitalization of IAACI and the creation of WAO (Figure 1). The congress in Stockholm was a success in every respect, including a $300,000 profit. As a result, IAACI became much more widely recognized as a global power in allergy.
The congress in Stockholm was held during glorious spring weather, in a near-perfect setting, by a welcoming host. WAO and EAACI advertised the meeting extensively and I was certain that hundreds of Americans would attend the meeting. After all, it was held in June in an inviting country and surely Americans would flock to Sweden when the chance was provided. In my certainty, I assured Gunnar Johansson that 600 Americans would attend his congress. To my disappointment, registration from the United States was small (about 200), and Gunnar Johansson always asks me about the missing 400 Americans. I still do not know where they are! Had they attended, they would have enjoyed the wonderful science, the splendid countryside, a wonderful All-Congress event at the city park, Skoda, and the hospitality of one of the warmest countries in Europe. Too bad!
After the congress, about 50 of us traveled to Helsinki and St Petersburg for a week, where we experienced continuing medical education lectures presented on the bus returning to the hotel, the absence of Allen Kaplan who got misplaced outside the Hermitage, the rescue of Marcia Fireman (Phil Fireman's wife) from some marauding gypsies, and the reality of an authentic Soviet hotel, where the towels were more than 20 years old and truly threadbare. Despite their age, these towels were valuable to the hotel, and when my family tried to check out, a towel missing from my children's room meant that we could not leave. Amazingly, this relic was discovered in time for us to check out, but I still wonder what might have happened if the towel had not turned up.
WAO is a federation of national and regional allergy, asthma, and immunology societies. It is the allergy societies that belong to the organization, not the individuals. Dues are paid by the societies and are derived from whatever sources of income the societies have in place. The dues to belong to IAACI/WAO had been fixed since 1951 at 2 Swiss francs per member. In 1994, there were about 25,000 allergists worldwide, and thus the dues yielded about $40,000 per year. The budget for expenses during the year the congress takes place was in the order of $3,000,000. This imbalance between budget and income was dangerously out of balance, as any untoward event could lead to bankruptcy. After a long and arduous debate, first in the Board of Directors and then at the House of Delegates, it was agreed to increase the dues to 5 Swiss francs per member. Anyone reading this document will recognize that this is still a paltry amount, but the painful discussion leading to this increase in dues remains vividly in my memory, as it underlines some of the major perplexing issues any international society faces as it grows.
Albert Oehling became president in 1994 for the second time-he had presided as acting president at the end of Jacques Charpin's term, when he became ill and had to resign (Figure 2). During his term, the Seminars and Conferences Committee hosted meetings in South Africa, Hong Kong (leading to the creation of the Hong Kong Allergy Society), and Poland. At this time, pharmaceutical companies were beginning to recognize how partnering with IAACI could be helpful in educating physicians about allergies and their treatment, and the incredible value IAACI offered. Astra Pharmaceuticals became our second partner committing to a 3-year program, "Global Aspects of Allergy and Immunology." Unfortunately, this program only lasted 1 year before Astra withdrew support, as the company initiated a very restrictive policy on asthma education, which still exists to this day.
In 1996, the ACAAI withdrew their membership from IAACI. This abrupt withdrawal occurred at the same time that the number of new societies trying to join IAACI was blossoming, so withdrawal by a major society was rather shocking to everyone. The ACAAI representative to the Board at that time was Bud Bardana from Oregon, and he was not aware that ACAAI had intended to withdraw, nor could he explain the reasons. The stated reason was that the increased dues of 3 Swiss francs per member would cost more that the perceived benefits received by the society. At that time, there were 34 member societies, and about 10 additional societies were considering joining IAACI. The total cost of dues worldwide in 1995 was $76,000 and the share that ACAAI had been expected to pay was about $8,000; the AAAAI was paying $18,000 at the same time.
In 1997, ACAAI reversed their decision and reapplied for IAACI membership. In that same year, 13 societies applied to become new members, underlining the growing importance of IAACI in the world of allergy. Nonetheless, the damage to the ACAAI had been done and in this period, only the AAAAI was represented on the IAACI Board.
As for IAACI's outside activities, a new program was initiated sponsored by Rhone Poulenc Rorer entitled the World Allergy Forum (WAF) (Figure 3). The purpose of this program was to present "state of the art forums" at allergy meetings. Between the years of 1997 and 1998, 8 programs were developed. The WAF has continued since 1994, the funding has changed from Rhone Poulenc Rorer to Novartis, and it is still called the World Allergy Forum. The WAF has sponsored sessions at both the AAAAI and EAACI continuously for 17 years and is the longest running educational program of IAACI/ WAO. On years where there has been sufficient funding, WAF has added programs at the ACAAI and other venues as well.
The POA program lost funding briefly in 1996 but was renewed by Hoechst Marion Roussel (now Sanofi-Aventis) for 1997-1998, and several programs were presented. The Seminars and Conferences committee elected not to develop any programs in 1997 but resumed operations in 1998.
Following the Executive Committee meeting held in conjunction with the AAAAI meeting in San Francisco in February 1997, a retreat was held at Meadowood in Napa Valley, CA. This retreat led to a paper referred to by Alain deWeck as the Meadowood Manifesto, which was directed at the future of allergy.
Shortly thereafter, another "manifesto" was created by me, with the silent support of Rick Iber, addressing the need of IAACI to change its image and direction and to enlist younger, more vital, more energetic leaders interested in expanding the IAACI to its potential. This letter was sent to WAO President Albert Oehling but was also copied to the Board. I recall a huge uproar after this note was received and digested. There were a flurry of notes, some condemnations, and a few approvals. However, several established Board members elected not to continue past 1997, and the opportunity to revitalize the Board ensued. The period between March 1997 and the congress in Cancun later that year was full of behind-the-scenes discussions and decisions. I recall one well-respected Board member stating that he preferred to have older, more mature Board members because they had already fulfilled their ambitions. While this position has merit, the need to make IAACI more democratic, with a broader world representation and a more involved and vital leadership outweighed this argument. I believe that the 1997 letter actually precipitated the events that occurred in 1998 that have revitalized WAO. Rereading it 15 years later, I recognize that the impudence and emotion that led to that letter were well-meaning and effective, but this was an incredible bomb to lob into the laps of a staid and reserved group of otherwise well-meaning allergy leaders. I think is likely that all is well that ends well. But, I wonder how I would have reacted had I been the current president.
The triennial meeting in 1997 was held in Cancun, Mexico. For the first time, there was quite substantial pharmaceutical sponsorship, representing an income of about $1,600,000. The scientific program was developed nearly exclusively by the President and Chairman of the meeting, Albert Oehling. Despite asking for very limited input from his Scientific Program Committee, he created a creditable scientific program. The organization of the meeting was run internally by EDI, and they did an excellent job. The social aspects of the meeting were delightful, and Cancun was a huge success. More than 6500 attended the meeting and a huge profit of $600,000 was realized--this represents the single largest profit made by IAACI from any meeting to that time.
1998-2000: The End of IAACI-The Start of WAO
On the heels of a very successful meeting in Cancun, and with more money in the bank than ever before, the leaders of IAACI could look internally and decide if the time was ripe for change. Remember that we had just completed an extremely challenging period, when the "Old Boy's Club" had been challenged publically by a prominent executive committee member, and there had been resignations and internal changes that followed shortly thereafter. With Gunnar Johansson as an imaginative and courageous president, the time for serious consideration of the future of IAACI came into sharp focus. During a 2-day period in late August 1998, the following leaders met and changed the future of IAACI into the World Allergy Organization: Gunnar Johansson, Michael Kaliner, Carlos Baena-Cagnani, Allen Kaplan, Albert Oehling, Johannes Ring, Robert Davies, Francois-Bernard Michel, Mitsuro Adachi, G. Walter Canonica, Connie Katelaris, Richard Lockey, Joao de Mello, Joaquin Sastre, and Daniel Vervloet, along with Rick Iber and Karen Henley from the Secretariat.
The end result of this retreat was to change the entire focus of the organization and to take the name World Allergy Organization. As you might imagine, there was a huge discussion about discarding the old IAACI name and also not claiming clinical immunology in the title. If you review the history of IAACI written by Alain deWeck as part of this project, you will see that the basic immunologists had already removed themselves from IAACI, and clinical immunology had become integrated into many organ-based specialties. Thus, it was more a recognition that WAO represented allergy as its core constituency and that clinical immunology was part of WAO much as it is part of dermatology, rheumatology, nephrology, transplantation, and the like. But the decision to focus on allergy and to represent the allergist and the huge segment of the population suffering from allergy was a giant step forward and moved the organization toward a true global power more than any other decision.
A plan to transition from the name IAACI to WAO over several years was created with a gradual phasing out of the IAACI name. The vision of WAO was to optimize allergy care worldwide. The organization would exist to build a global alliance of allergy and immunology societies to advance excellence in clinical care, research, education, and training. Five areas of focus were identified: education, communication, global recommendations, cooperation and research, and training. Plans to institute these changes were put into place from 1998 to 1999.
It is difficult to describe the excitement of this retreat. The setting was the Grand Hotel Saltsjobaden, the site at which the great racing yachts of Sweden are housed. The weather was bright, the atmosphere was exciting, and the creativity could be felt. We all knew we were creating something of value, and for me, years of frustration were finally coming to an end. This was going to be something into which you could put your heart and soul, and the benefits would be immense. One very pleasant memory from the weekend was taking a huge walk for several hours with Richard Lockey, during which we smoked Cuban cigars (which he provided, being from Tampa) and planned the revision of the bylaws. Subsequently, he and I, along with others, worked and reworked the constitution and bylaws again and again over the next 10 years; and there are still ambiguities, but it is a democratic transparent document that allows a growing and increasingly more vital global organization to grow and succeed.
As noted throughout this report, WAO's initiatives and commitments to support its member societies was ever-growing and was perceived to have the second largest impact on the world's perception of WAO after the triennial meeting. To better support this outreach programming, the Seminars and Conferences Committee restructured and began to provide select speakers to member society meetings on an application driven basis. With this change, between 4 and 8 speakers were sent each year to allergy meetings throughout the world, with each speaker solely sponsored by WAO. During 1998 to 1999, this program sponsored lectures in Australia, Great Britain, Korea, Norway, Turkey, Argentina, Ecuador, Hungary, and Italy (Figure 4).
The WAF program continued to provide 2 or 3 seminars at other allergy meetings, largely in Europe and the United States. The seminars were held in San Francisco, Rhodes, Cancun, Maui, Hawaii, Washington, DC, Birmingham, the United Kingdom, Manila, and the Philippines, during 1997 and 1998. The POA program sponsored meetings in Lisbon, Berlin, Cancun, Paris, Cordoba, and Vienna during 1997 and 1998. Thus, these outreach programs were having a major effect on the world of allergy during this transitional period and further raising the awareness of IAACI/WAO.
Gunnar Johansson created a new program GLORIA-Global Resources in Allergy (Figure 5). This new program was to be unique. To better arm our constituents to teach allergy to others, GLORIA would include a lecture (for example on allergic rhinitis) at a national allergy meeting, then the speaker would meet with the local allergists, review the slides, and provide them with copies of the slides that they could use to give subsequent lectures either to allergists or family doctors. Thus, this was a 2-tiered outreach program-from WAO to its member societies and then from a society to local medical doctors.
Not only was the concept of GLORIA unique, so was the idea of sponsorship. Pharmaceutical companies were asked to contribute a relatively small amount ($45,000 per company), and multiple companies were enlisted to sponsor the program. We gave equal credit to each sponsor, and then opened up GLORIA to WAO Member Societies. The initial lectures were allergic rhinitis and allergic conjunctivitis. Over the next 10 years, lectures were prepared and posted for downloading on the WAO Web site http://www.worldallergy.org, covering these additional topics: Allergic emergencies, immunotherapy, treatment of severe asthma, food allergy, angioedema, anaphylaxis, diagnosis of IgE sensitization, chronic rhinosinusitis and nasal polyposis, drug allergy, and urticaria. These slides have been downloaded by thousands of allergists and presented to countless physicians worldwide; many have been translated into Spanish. By any account, the GLORIA program has been an immense success.
By 1999, the priorities of IAACI/WAO were coming into focus: improve the triennial, now biennial, meeting, rewrite the constitution, develop global recommendations, develop cooperative relationships with other global organizations as well as with WAO Member Societies, and help develop a fellowship program. Each area of focus developed short, mid, and long-range goals. The strategic statements for each area of focus were resolved, as below.
Education: Provide state-of-the-art continuing medical education for members and member societies through the biennial congress and provide educational opportunities for other medical professions outside of the allergy-related specialties to achieve optimal allergy care worldwide and direct and support patient education and advocacy.
Communications: Improve communications with member societies, develop communication strategies for all initiatives, and utilize external communication for enhanced public relations, medical relations, and nonmember communications.
Global recommendations: Develop and endorse guidelines and develop strong relations with associations such as the World Health Organization.
Cooperation: Develop partnerships with member societies, other national and international societies, industrial sponsors, and patient groups.
Research and training: Support and promote advocacy for research in allergy and immunology globally and nationally, define and promote the roles of the specialist and subspecialist, and support training of future allergists.
One of the most concrete reflections of the new WAO initiatives was the development of the Web site, http://www.worldallergy.org. It was envisioned that the Web site could be the clearinghouse for international statements, position papers, and global recommendations. The plan was to have both professional and patient-oriented portions of the Web site. Initially, the Web site was called the Global Allergy Information Network (GAIN) and was sponsored by Aventis.
A move to develop a World Allergy Awareness Day was begun. Originally, it was conceived to be a partnership with the WHO, and it always was based upon a central leadership (WAO) assisting a global outreach (the national societies that constitute WAO). World Allergy Awareness Day was to be a professional and patient cooperative action. The first event was held in Sydney, Australia, during the XVII International Congress of Allergy Asthma and Immunology in Sydney in October 2000. The timing was to be determined by each allergy society, using the timing that worked best for each geographical region. Working with the WHO turned out to be problematic, and without going into detail, did not develop. The idea of a World Allergy Day continued for the last decade, with no generally agreed upon plan. Individually, countries sporadically developed their own plans in association with the WAO initiative, with some degree of local success. In 2010, the WAO Communications Council, with Marek Kowalski as Chair, proposed to the Board the concept of World Allergy Week, to be held at the same time each year and independent of any congresses (Figure 6). I have high hopes that the new plan will be more successful at a global level.
The congress in Sydney in 2000 had extremely bright spots, but unrelated to the Congress itself, this was a time for some low memories as well. The bright events included an excellent, extremely well-organized meeting with first-rate science and a chance to meet many scientists from the eastern world. Connie Katelaris and her colleagues did an amazing job. Sydney was a wonderful city, full of interesting things to do, and very welcoming. The social program was excellent, and everyone left the meeting elated. This congress was highly successful financially with a net income of above $300,000.
The disturbing issues dealt with the Secretariat and a sad disappointing exit by our friend and advisor Rick Iber, who resigned from EDI and his role as Executive Director of IAACI abruptly just before the Congress, and left IAACI in some disarray. I recall sitting as the Treasurer at the Board's presentation to the House of Delegates realizing that I did not have a financial report that I could present. I had been Treasurer for 6 years and certainly knew our financial status, but as mentioned earlier, we were in a bit of a tough time, and I wanted to give an accurate report, not an estimate; and those numbers just were not available. So, for the first time in my professional life, I was forced to report to my peers that I could not give a report, but that as soon as numbers became available, we would share them with the member societies. As it turns out, we were financially secure, with enough revenue from a number of our outreach programs that we were solvent and have remained so ever since. But, I would rate this moment in my memory as my low point professionally. This disarray at the end of Gunnar Johansson's term as the president was unfortunate, but we soon recovered. Allen Kaplan became the president in 2001, the last president to serve a 3-year term (Figure 7).
It was at the congress in Sydney in 2000 that the House of Delegates reviewed and approved the overall concepts generated at the retreat held in 1998. Thus, officially, IAACI became WAO in 2000. Approval to radically change the bylaws was given, and the overall concepts engendered by the retreat were approved. The location and timing of the congress that would follow the next one in Vancouver (2003) was chosen to be Munich in 2005 in conjunction with EAACI and the German Allergy Society. Because of the change in timing to a 2-year cycle, the House of Delegates also selected the 2007 location of Bangkok in Thailand. It was at this congress that there was recognition of the enormous contributions that Alain deWeck had made to IAACI/WAO and to world of allergy and immunology. After a 30-year stint on the Executive Committee of IAACI, and after having effectively led the organization for much of this time, it was fitting that he received a universal standing recognition for his achievements.
2000-2003: Solidifying Progress in The New WAO
Allen Kaplan had been on the WAO Board since 1991, had previously been the president of the AAAAI, and knew how to run a large organization. The WAO Secretariat at EDI regained its footing quickly, placing Gail Bast as the Executive Director. As always, Kay Whalen was the quiet power behind the scene, being ready and capable to make certain that WAO always remained stable. Kay Whalen has been the major hidden asset of EDI since the very beginning of the relationship with IAACI/WAO. She has guided Don McNeil, Rick Iber, Sally Kolf, Gail Bast, Denise Lemke, Stan Mandarich, Karen Henley Davies, and Charu Malik with balancing the intricacies of an international organization and the ever-changing personalities of the officers.
The XVIII International Congress on Allergy and Clinical Immunology in 2003 was planned for Vancouver, Canada, with Estelle Simons and Michael Kaliner assisting Allen Kaplan; many of the outreach programs (WAF, GAIN) were working well; and GLORIA was about to begin. It was a time to make certain that WAO was ready to become a world power and to be certain that we did not overreach. Allen Kaplan's solid imperturbable personality and an abundance of careful planning were a perfect follow-up to the dynamic but sometimes chaotic period that had proceeded.
Connie Katelaris, with the active support of Allen Kaplan, initiated a new program with a unique concept: WAO would foster developing allergy societies with the Emerging Societies Program (ESP) (Figure 8). We recognized in retrospect that the meetings we had organized in several countries during the mid 1990s had turned out to be instrumental in assisting these countries toward developing an allergy society and eventually joining WAO. The ESP plan was to identify countries with fledgling societies and to invite them to meet with other regional fledgling societies along with leaders from WAO to provide information and support to help them develop into independent allergy societies. The first ESP took place in Seoul, South Korea, in conjunction with the annual meeting of the Asia Pacific Allergy Asthma and Clinical Immunology (APAACI) meeting in 2002. This ESP meeting, and essentially all subsequent meetings, was cosponsored by WAO and ACAAI. ESP has continued from 2001 through 2011, with a string of educational programs in many developing parts of the world and has led to the emergence of dozens of new allergy societies, which have subsequently contributed to WAO. From the start of this program, ACAAI has remained an active partner with WAO, providing both educational and financial support.
The Web site http://www.worldallergy.org was originally called GAIN (the Global Allergy Information Network) and was sponsored by Aventis Pharmaceuticals and subsequently by Novartis. Novartis has remained the sponsor for most of the decade, and without their support, the task of building a first rate Web site would have been more challenging. Novartis has been advised by Keith Allen, who started with Aventis/Rhone Poulenc Rorer and has remained the most stalwart of all the supporters of WAO through the years. Keith initially advised Aventis to work with WAO with educational programs and the Web site (GAIN), and after moving to Novartis has maintained constant support from this company both for the Web site and for WAF, the longest running of all the WAO outreach programs.
It needs to be noted that Aventis (now Sanofi-Aventis) was an early and major sponsor of WAO, largely due to the support of Greg Lund, who still remains today actively advising various pharmaceutical companies and who continues to support WAO with new programming. TEVA Pharmaceuticals is currently sponsoring a special program on small airways diseases, which was brought to WAO by Greg Lund and is providing state-of-the-art lectures throughout the world on this topic. Much of the success of WAO over the past decade is due to imaginative outreach programs, many of which have received pharmaceutical support, and much of the credit for this critical sponsorship has to be given to individuals like Greg Lund and Keith Allen.
Internally, the plan to strengthen the organization of WAO involved creating 5 councils: education, communications, research, specialty and training, and congress organization. Each of these councils was empowered to create initiatives that supported WAO and world allergy.
The Communications Council was initially directed by Richard Lockey, and it took over responsibility for the Web site and the journal (Allergy and Clinical Immunology International), which is addressed more fully in Alain deWeck's comments.
Two important papers were created by WAO from 2002 to 2004. The first was the "Prevention of Allergy and Allergic Asthma (PAAA)," which was initially proposed to be a joint venture with WAO and WHO but in the end was a WAO project, which was provided to WHO. The editors of PAAA were Gunnar Johansson and Tari Haahtela, and the chapters were written by a cast of internationally recognized experts. This document was published as an editorial summary in time for the congress in Vancouver in 2003, and it was widely recognized as an important document. The full document came out as a book in 2004. The topic is so important that there is current consideration for WAO to create a revision and update of this topic http://www.worldallergy.org/professional/who_paa2003.pdf.
The second document, "Revised Nomenclature for Allergy for Global Use: Report of the Nomenclature Review Committee of the World Allergy Organization, October 2003," was an initiative to clarify allergy nomenclature spearheaded by Gunnar Johansson. This simple but straightforward document addressed some of the strange allergy phrases that were being used at the time, "pseudoallergic" and "anaphylactoid", for example, and to make a simple scientifically based set of suggestions for accurate nomenclature http://www.sciencedirect.com/science/article/pii/S0091674904009303.
The congress in Vancouver in 2003 was chaired by Allen Kaplan with Estelle Simons and Michael Kaliner as the organizers. The planning and organization of the meeting was done transparently, with regular input from the Board and the Scientific Program Committee. The congress was held in September 2003 as a joint venture with the Canadian Allergy Society and in cooperation with both the AAAAI and ACAAI. As always, the Congress was a resounding scientific success. For the first time, a relatively large contingent from the United States attended the congress, but the total attendance was disappointing. The attendance had been projected at over 3000 but only 2250 attended, a number affected by worldwide concerns over severe acute respiratory syndrome (SARS), which was endemic in parts of Canada, as well as the newly appreciated threats of world terrorism that had began after the destruction of the Twin Towers in New York City on September 11, 2001. Nonetheless, the meeting yielded a profit of over $800,000 (the largest profit ever generated by WAO) and was considered a solid scientific success. The social programs were interesting and well attended, and Vancouver turned out to be a good host city for international events. The issues of SARS and 9/11 underscore the difficulties in relying on international meetings for essential income.
Overall, Allen Kaplan's tenure as WAO President solidified the gains achieved over the preceding transitional years and led to a solid beginning for WAO, as it emerged from the IAACI beginnings. During 2000 to 2003, our Executive Director was Denise Lemke. Carlos Baena-Cagnani became the president of WAO in September 2003 after the congress in Vancouver and served until November 2005. The Executive Director from EDI during this time was Stan Mandarich. The World Allergy Congress was now an every other year event, and it was to be held in June 2005 in Munich in partnership with the German Society for Allergology and Clinical Immunology and EAACI. Johannes Ring was the Co-Chair (representing Germany) along with Carlos Baena-Cagnani and Anthony Frew (from EAACI).
Carlos Baena-Cagnani started his presidency with several clear-stated goals (Figure 9). He wanted to explore individual memberships for allergists in WAO, start a junior member's group, and enhance WAO's relationship with the WHO. The question of individual members of WAO had been explored from the onset of IAACI more than 50 years earlier. The charter of WAO precludes individual members to prevent WAO from competing with its member societies for both members and dues. Thus, after discussions and a careful review of this topic, it was agreed that membership in WAO is for societies only. The junior member idea has been discussed for a decade, and only now, with the launch of the WAO Junior Members Group in March 2011, has the concept become a reality http://www.worldallergy.org/juniormembers. The concept is now to offer incentives to young allergists to participate in WAO as a way to start a lifelong habit of keeping WAO on the agenda, not to make them individual members.
During this time frame, Richard Lockey started a bi-monthly electronic newsletter, WAO News and Notes, to be sent to all WAO members for whom we had an e-mail address. Richard Lockey's concept was to have WAO News and Notes simultaneously translated into several languages to make it more accessible to the readership. Use of the e-mail method allowed WAO to communicate with 35,000 allergists worldwide, saved considerable money, and allowed for instantaneous communication. The WAO News and Notes newsletters were an immediate success. In fact, this communication was so successful that it went from every other month to monthly, and we now have an e-mail communication every 2 weeks, with the WAO Reviews (of the current literature) newsletter alternating with the WAO News and Notes mailings. Richard Lockey enlisted the support of a committed group of editors who have donated their time to translate the electronic newsletters into 8 or more languages. The success of the WAO News and Notes subsequently had a major effect on WAO's journal, leading the organization to launch an electronic journal in 2008 (much more about the journal and its trials and tribulations later).
In 1992, there were 35 member societies within WAO. By 2004, there were 70 members, including affiliate and other nonvoting members. This increase in membership reflects the rapid growth of WAO during the decade from 2000 to 2010. At the end of the decade, there were 85 member societies. Around this time, led by Carlos Baena-Cagnani and Walter Canonica, WAO began to host meetings with member societies at major international meetings, such as EAACI and AAAAI. These 2-hour sessions-"Member Society Forums"-were immediately successful, gave an opportunity to enhance communications with WAO Member Societies and gave the societies a new mechanism for feedback. These Member Society Forums have continued from 1994 to the present and have proven to be a valuable communications tool.
One area where WAO had always had an interest but for which little had been done was sponsorship of research fellowships. During 2004 to 2006, in part based upon sufficient funds being in the bank as an offshoot of the financially successful congress in Vancouver in 2003, a trial of WAO funded research fellowships was tried. Two offerings were developed: A limited 2- to 6-week rotation to a research laboratory to learn a new technique and a 2-year fellowship as a research fellow by a young applicant to an established laboratory. Both of these initiatives were successful, but it was clear that at this point, WAO was probably not the right body to administer and supervise research funding. Both of these funding ideas have merit and are needed by the community, but there was no continuity of funding, the Board turned over too quickly, and the WAO Secretariat required a lot of time to supervise recipients and sponsors. Thus, while in the best of worlds, WAO would like to offer research funding, in the real world, our experience was that other organizations can do this sort of initiative far better than WAO. This may, however, change with the new initiative to develop WAO Collaborative Centers of Excellence, which is in planning in 2011.
In 2005, in conjunction with the congress in Munich, WAO renamed the biannual meeting, the World Allergy Congress (WAC). The Congress had been known for decades as the International Congress of Allergology and Clinical Immunology (ICACI), the World Allergy Organization Congress, and now WAC-this is the name that will remain from now on, as it is simple and states exactly what the congress is.
The outreach programs of GLORIA, GAIN, and WAF continued growing and improving throughout this period. GLORIA was the most vulnerable program, as it required multiple sponsors for its continuation. There were 8 original cosponsors of GLORIA in 2001, but by 2005, there were just 3. The problems were that sponsors wanted a program they could say was their own and to support lectures that directly related to a product-related interest on their commercial side. Despite trying to make GLORIA more attractive to sponsors, the pharmaceutical support dwindled. To instill new life in the program, we created a new initiative, an American version of GLORIA. This project was cosponsored by the ACAAI, who provided the Continuing Medical Education (CME). The "US GLORIA" was immediately successful, and 6-10 programs per year were sponsored at regional, state, and local allergy societies between 1995 and 2010.
Unfortunately, the whole world of pharmaceutical support changed in the time frame of 2008 to 2010. Markedly increased overview was imposed on the pharmaceutical industry by programs of the US Food and Drug Administration (FDA) that were created to be restrictive rather than supportive. Congressional interest in medical education led by Iowa's Senator Grassely focused on apparent excessive "giveaways," but overlooked the important education provided by the industry to physicians. The influence of these oversight initiatives generated extreme caution by the pharmaceutical companies and led to a significant and rapid reduction in educational funding. Programs such as GLORIA and many pharmaceutical-sponsored education programs at national meetings, including the WAC, were curtailed. This reduction in sponsoring medical education is the classic example of cutting off one's nose to spite the face. Everyone has suffered. There is far less education available to the physician, and no funds are available for patient education. Physicians can no longer attend sponsored CME meetings where a general topic can be addressed (such as asthma or anaphylaxis), as the industry will now only sponsor promotional talks, which require the use of internally approved slides and a restricted discussion of an FDA-approved product kept within the package insert. I believe that within a few years, pharmaceutical companies will once again realize that education of physicians about best practices is by far the most efficient way to introduce a product into a prescribing physician's treatment plans. I wonder if the FDA and its European counterpart will have the insight to create room for educational programs that are more useful than the current promotional talks. I have no hope that Senator Grassley will ever see how his pressure on the US Congress and FDA has hurt the very industry he has tried to support, but senators come and go, so his time will end eventually.
Getting back to GLORIA, this excellent program has educated tens of thousands of physicians about the best practices of allergy, and it is still running in a more limited fashion with the hope that funding might again increase once the pharmaceutical industry realizes this program's immense value.
By mid 1995, the Specialty and Training Council had completed a survey of the adequacy of the provision of allergy services worldwide and had confirmed that the number of allergy-trained physicians was woefully short of the number needed. This survey was published in Allergy and Clinical Immunology International. However, the Specialty and Training Council, led by John Warner, Sergio Del Giacco, and myself, recognized that many countries were shifting allergy care to nonallergy specialists who had an overlapping interest in allergy but who were not sufficiently trained in allergy (such as dermatology, ear, nose, and throat [ENT], gastroenterology) or to primary care physicians who often or mostly had received no specialized training in allergy. This council took several actions of critical long-term consequence. Starting in 1995 and continuing through to the current council, this group has created several WAO position papers designed to define the specialty, the training required to adequately care for patients with allergic and immunologic disease, and the need for to train adequate numbers of allergists to provide care for the hundreds of millions of allergy sufferers.
These papers include the following:
Del Giacco S, Rosenwasser LJ, Crisci CD, et al. What is an allergist? A Position Statement of the WAO Specialty and Training Council. World Allergy Organ J. 2008;1:19-20.
Kaliner MA, Del Giacco S, Crisci CD, et al; on behalf of the WAO Specialty and Training Council. Requirements for physician competencies in allergy: key clinical competencies appropriate for the care of patients with allergic or immunologic diseases: a position statement of the World Allergy Organization. World Allergy Organ J. 2008;1:42-46.
Potter PC, Warner JO, Pawankar RS, et al; for the WAO Specialty and Training Council. Recommendations for competency in allergy training for undergraduates qualifying as medical practitioners: a World Allergy Organization Position Paper. World Allergy Organ J. 2009;2:150-189.
Warner JO, Kaliner MA, Crisci CD, et al. Allergy practice worldwide: a report by the World Allergy Organization Specialty and Training Council. Allergy Clin Immunol Int. 2006;18:4-10 and International Arch Allergy Immunol. 2006;139:166-174.
All of these papers are accessible at http://www.worldallergy.org.
The development of these position papers opened up a new way for WAO to influence the world of allergy. A system designed to promote the development of global position papers to the world of allergy was developed. Papers considered warranting designation as a position paper of WAO were initially developed and written by a committee selected by WAO and after internal review were published provisionally. Each WAO Member Society in the world was subsequently invited to comment upon and add suggestions to the text. The suggestions were reviewed and the text reconciled. Finally, each society was asked to approve the paper, which was initially published in the World Allergy Organization Journal. Each allergy society was finally requested to republish these important statements in their own society journals in their native languages. Thus, the plan was for WAO to act as the global initiator and clearinghouse of position statements that are created to address global problems and to have the weight of the entire world body of allergy behind them. This process is still evolving. In 2011, WAO, EAACI and AAAAI agreed to work together to summarize existing global guidelines and are discussing ways to create global statements of importance in concert by these 3 organizations.
Over the past 5 years, WAO has published an impressive series of position papers, each of great importance to the specialty and ranging from immunotherapy to milk allergy to anaphylaxis. These publications are accessible via the WAO Web site, http://www.worldallergy.org, under WAO publications http://www.worldallergy.org/publications/.
Simons FER, Ardusso LRF, Bilò MB, et al. World Allergy Organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J. 2010;4:13-37; February 2011.
Fiocchi A, Brozek J, Schünemann H, et al. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines. World Allergy Organ J. 2010;3:57-161.
Fiocchi A, Brozek J, Schünemann H, et al. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines. Pediatr Allergy Immunol.2010;21(suppl 21): 1-125.
Canonica GW, Bousquet J, Casale T, et al. Sublingual immunotherapy: World Allergy Organization Position Paper 2009. World Allergy Organ J. 2009; 2:223-281.
Potter PC, Warner JO, Pawankar RS, et al; for the WAO Specialty and Training Council. Recommendations for competency in allergy training for undergraduates qualifying as medical practitioners: A World Allergy Organization Position Paper. World Allergy Organ J. 2009;2:150-189.
Kemp SF, Lockey RF, Simons FER; on behalf of the World Allergy Organization ad hoc committee on epinephrine in anaphylaxis. Epinephrine: the drug of choice for anaphylaxis. A Statement of the World Allergy Organization. Allergy. 2008;63:1061-1070 and World Allergy Organ J. 2008;1:S18-S26.
Pawankar RS, Baena-Cagnani CE, Bousquet J, et al. State of World Allergy Report 2008: allergy and chronic respiratory diseases. World Allergy Organ J. 2008;1:S1-S17.
Del Giacco S, Rosenwasser LJ, Crisci CD, et al. What is an allergist? A Position Statement of the WAO Specialty and Training Council. World Allergy Organ J. 2008;1:19-20.
Kaliner MA, Del Giacco S, Crisci CD, et al; on behalf of the WAO Specialty and Training Council. Requirements for physician competencies in allergy: key clinical competencies appropriate for the care of patients with allergic or immunologic diseases: a Position Statement of the World Allergy Organization. World Allergy Organ J. 2008;1:42-46.
Canonica GW, Baena-Cagnani CE, Bousquet J, et al. Recommendations for standardization of clinical trials with allergen specific immunotherapy for respiratory allergy: a statement of a World Allergy Organization (WAO) taskforce. Allergy. 2007;62:317-324.
The congress in 2005 in Munich by all standards was excellent. It was unusually hot in Munich in June 2005, and we learned that few German hotels had functional air-conditioning. I recall looking out my hotel window and inadvertently seeing much more of the leadership of the world of allergy than was seemly (through doors left open to try to cool the incredibly hot rooms). The meeting was exceptionally well attended, with more than 5000 attending-a record for WAO and for EAACI at the time. With 3 societies (WAO, EAACI, and the German Society of Allergology and Clinical Immunology) contributing to the program, the meeting was very strong scientifically and had wonderful venues for the social program.
Two more anecdotes: The awards ceremony was held at a magnificent palace in absolutely beautiful rooms. However, there was no air-conditioning, and I recall presenting a very special award to Barry Kay while drenched in sweat and not wearing either a coat or a tie. In Europe, such informality, especially in a royal palace, is unheard of! But, boy was it HOT!
The highlight of the meeting was the opera created by Johannes Ring. He had served long and well on the WAO Board. He was a Vice President, became the founding editor of the newly launched World Allergy Organization Journal, and was the Chair of the annual meeting in 2005 from the German Society for Allergology and Clinical Immunology. Johannes Ring is the rarely encountered "renaissance" man, an astute academician, allergist-dermatologist, historian, and semiprofessional composer of operas. I first knew of his talent at writing operas when 10 years earlier he had written an homage to Alain deWeck, performed on a bus while we drove through The Netherlands. The coup d'état in Munich was his opera on allergy based upon Dante's Inferno, written by Johannes Ring and performed by his professional colleagues in Munich. I treasure the recording of the performance and marvel at his talents and those of his colleagues. Of all of my memories of memorable moments in WAO history over the past 40 years, this one achieves a topmost tier.
All in all, it was a wonderful meeting and a fitting end to Carlos Baena-Cagnani's tenure as president. Traditionally, the WAO president's term ends after his congress and the new president assumes responsibility on the last day of the congress. I was to follow him as the next president and was looking forward to assuming the role. However, such was not to be the case. At the Board meeting in the spring of 2005 just prior to the Munich Congress, Richard Lockey ate lunch at a table apart from my own. Richard Lockey is a wonderful Board member, fully capable of making rapid and decisive decisions and knowledgeable about how Boards operate. Well, after this particular lunch, he immediately made a motion to have the tenure of the president run from January 1 of the year following our biennial Congress until December 31 of the next year. For me, it cut 6 months from my possible term of presidency to what is now the usual 2-year term as determined by the calendar rather than the dates of the congress. In every way, the decision to change the dates was correct, but I have made it a policy to eat lunch with Richard Lockey at every Board meeting since, just so I know what he might have up his sleeve.
Carlos Baena-Cagnani was an energetic WAO president who took it upon himself to represent WAO in all corners of the world. Some travel is a prerequisite of representing WAO. He represented us well and everywhere. As such, he became our diplomat and probably personally won us as many friends as could be achieved in a 2-year period. I have always recognized that Carlos Baena-Cagnani has more best friends than anyone I have ever met. He is welcome throughout the world because of his pleasant nature, charming personality, and personal energy. Let me share one anecdote about him: I arrived at a Board meeting having been able to upgrade to business class because I had some (very limited) status with this one airline. Lanny Rosenwasser flew on the same flight, but in first class, as he was a 100,000-mile traveler. While getting our luggage, Walter Canonica (who was President Elect at the time) arrived, and he related that he was a 100,000-mile traveler with 2 airline systems. Finally, Carlos Baena-Cagnani came sauntering over, having flown in the co-pilot's seat, stating that he had 100,000-mile status with 3 separate airline systems. My hat is off to him. I appreciate that he has earned the respect of allergists throughout the world and that WAO has benefited from his energy and willingness to be our world diplomat.
2005-2010: Progress Abounds, WAO Ascends, The World of Allergy Benefits
My tenure as WAO President began in November 2005 and ran until December 31, 2007 (Figure 10). By this time, I had officially been part of WAO since 1998, knew the organization inside and out, and had previously directed a large organization by being president of the AAAAI in 1995-1996. The WAO Executive Director, Stanley Mandarich, who performed admirably while supporting Carlos Baena-Cagnani during his presidency, decided to relocate. I was especially privileged to be asked to work with Charu Malik, a wonderful, astute, diplomatic (a skill in which I am woefully deficient), reliable, hardworking, and fun Executive Director. Charu and I had a wonderful partnership during and after these 2 years. She embodies the qualities that EDI provides to WAO: a dependable colleague who always is supportive but steps up when an error is about to be made. All the officers of WAO are volunteers who give up their time and energy for the worthy purpose of assisting the world of allergy. Our EDI colleagues are paid professionals who provide the 24/7 support that a thriving organization requires. Charu Malik, Executive Director, along with Karen Henley Davies, Global Projects Director, and Kay Whalen, Consulting Partner, have earned the respect of all the members of WAO, and we are indebted to them and to EDI.
I laid out my agenda for these 2 years in an editorial published in Allergy and Clinical Immunology International (ACII) in 2006 (Kaliner MA. A new direction for WAO and ACII-JWAO. Journal of the World Allergy Organization. 2006:18). The following several paragraphs outline what was proposed in 2005 and will be followed in more detail by what actually occurred. The plan was to maintain 3 overall principles: partnership, cooperation, and recognition. As a federation of allergy societies, the leadership of WAO was committed to partnering with member societies whenever possible, cooperating with each other to strengthen each society and always recognizing the skills and contributions that each partner brings to any shared agenda.
Specific plans in 2005 were to develop the leadership role of WAO by creating position papers that assist allergists worldwide. It was during this period that the "Definition of an Allergist" and the "Key Competencies" papers listed earlier were created and published worldwide; these position papers defined the specialty and detailed the necessary skills and training that are required to care for allergy patients. The start of a number of fruitful programs that came into full development over the next 6 years were initiated, including the 3 part series on anaphylaxis, which has recently led to an authoritative and extremely useful position paper on anaphylaxis, headed by Estelle Simons.
The GLORIA program and the Seminars and Conferences program were further developed and strengthened. The American GLORIA program was developed and launched, with more than 40 lectures delivered over the next few years. WAF and other outreach programs were strengthened, as one way to reduce WAO's dependency on the income from the biennial meeting. It was recognized that one cannot predict the next SARS or Twin Towers disaster. Holding international meetings is wrought with potential pitfalls; witness the current upheaval in the Middle East and the earthquake and tsunami in Japan early in 2011. Unpredictable geopolitical events are capable of destroying the most well-planned meeting. The plan developed in 2005 was to establish a network of partnerships with global pharmaceutical companies, and to a large extent, WAO was successful during that time frame. As mentioned earlier, however, the world of pharmaceutical funding and interactions between pharmaceutical companies and professional associations has changed dramatically, and we are currently back to largely depending on income generated by our biannual meeting and a newly created interim meeting initially held in Dubai, United Arab Emirates, in December 2010. Richard Lockey, with the active assistance of Ruby Pawankar, has developed this new concept, and the first interim meeting was very successful. More about this new development later.
During this period, support of the Emerging Societies Program, in cooperation with the ACAAI, was strengthened, and the number of ESP events expanded to 1-2 per year. The WAO News and Notes electronic newsletter was increased in frequency to monthly, and a set of discussions about the creation of a new journal was initiated. The WAC in 2007 was held in Bangkok, Thailand, and was developed adhering to the principles of welcoming partners from the various allergy communities (Figure 11). All in all, a challenging set of plans was started, and this was a period when WAO grew and strengthened considerably.
There were many individual areas of WAO that were expanded and strengthened during these years, but the most demanding and possibly the most important was the development of a new WAO-owned journal, the World Allergy Organization Journal. WAO had several publications spanning a several decade period, but none had been consistently successful, either scientifically or financially. In every instance, WAO did not own the journal and had limited responsibility for the direction and financial issues related to these journals. Allergy and Clinical Immunology News, or ACIN (later Allergy and Clinical Immunology International) was developed by Alain deWeck, who was the initial editor. ACIN was designed to be a newsletter and was very readable and quite an enjoyable magazine, but it was not scientifically competitive. Attempts to get this journal into PubMed were unsuccessful. The journal eventually became the Journal of the World Allergy Organization, but this conversion was also scientifically unsuccessful. Over the years, WAO had worked closely with Hogrefe and Huber to develop a viable journal, but in the period from 2005 to 2006, after a series of long and difficult discussions, WAO decided to part from Hogrefe and Huber and establish its own journal. The concept of the new journal was electronic, with rapid publication, an excellent editorial board, a recognized publisher (Lippincott Williams & Wilkins), and to be provided free to the readership. The World Allergy Organization Journal has been promoted primarily through the WAO e-mail list and all WAO meetings and mailings. The first editor was Johannes Ring, and he has been succeeded by Lanny Rosenwasser. An initial attempt to get accepted by PubMed has not been successful but attempts are still proceeding. The first few years of the World Allergy Organization Journal have been promising, with some very good articles-both scientific reviews and innovative new science-being published. The initial costs are still affordable to WAO, provided that there is a glimmer of success, as judged by readership, citation index, and acceptance in PubMed.
The WAC held in Bangkok in December 2007 was successful in a number of ways. The attendance was good (4200 attendees from nearly 100 countries), the meeting was profitable ($260,000), and both the social and scientific aspects were excellent. The meeting was developed following the principles of WAO interactions with its partners. The Asthma, Allergy and Immunology Society of Thailand, headed by Pakit Vichyanond, was involved in every decision and directed the social aspects of the meeting. Pakit Vichyanond was an excellent host who represented the Eastern world of allergy with grace and discretion. Pakit was a pleasure to work with, and he made certain that there was an excellent representation from Eastern speakers at the program. The scientific program committee was headed by him, Anthony Frew, and Lanny Rosenwasser, supported by Carlos Baena-Cagnani and Walter Canonica. There were joint sessions cohosted with AAAAI, ACAAI, and EAACI. These sessions were part of focused "bookends" to anchor both the first and last days of the meeting. There was an aggressive movement to showcase each member society by permitting "sister society sessions" where WAO Member Societies individually or in combinations of societies could sponsor a session, and about 20 such society-sponsored sessions took place at the meeting. There was a World Allergy Day held during the congress, and an opportunity for member societies to have an exhibit in the main portion of the registration area in a world allergy village format. In partnership with Schering, APAACI and EAACI, and a record number of travel grants were given to nearly 100 young allergists. As part of the program, training programs from around the world were given the opportunity to compete with one another in an ongoing "Allergy Quiz," which ran throughout the entire meeting. Thus, the congress in Thailand was innovative, entertaining, and completely successful. As always, the science presented at the meeting was a leading edge, the Thai settings were stupendous, and the social program was memorable. I will always treasure the feeling of being brought into the opening ceremony on a palanquin carried by sturdy Thai men, led by beautiful Thai women. Then, Pakit Vichyanond and I struck a large gong to officially open the meeting (Figure 12). All in all, Thailand proved to be a most hospitable host, Pakit Vichyanond and the Asthma, Allergy and Immunology Society of Thailand were gracious partners, and those allergists who attended the meeting enjoyed themselves very well.
As a part of the promotion of WAC 2007, WAO held its interim Board of Directors meeting in Korea in 2006, and most members of the Board presented lectures as part of the annual meeting of the Korean Academy of Allergy, Asthma and Clinical Immunology. Thus, WAO held its Board meeting in conjunction with the Academy's annual meeting as a way to support that society. Just prior to our visit to Korea, several Board members also presented at the annual meeting of the Japanese Society of Allergology. The idea to use the Board to support member society meetings was novel and hopefully will be continued into the future. In 2004 and 2007, WAO Board members also supported our Affiliate Member, Interasma, at their meetings in Bilbao, Spain, and Monaco, Monte Carlo. Thus, WAO has also supported other organizations with lecturers. Along these same lines, the WAF program is part of the AAAAI and EAACI annual programs with occasional presentations at the ACAAI. The GLORIA lectures and the Seminars and Conferences presentations always enhance WAO Member Society meetings. These commitments reflect WAO's continual effort to enhance the education of allergists worldwide.
During 2006, an agreement was made between WAO and AAAAI to develop an extensive series of lectures on all aspects of applied immunology and allergy and make them available on the Web through both the AAAAI and WAO Web sites. This extensive and excellent immunology series is now online and provides an opportunity for worldwide education. Parts of this program have been translated into Japanese and Spanish.
WAO began an ambitious project focused on anaphylaxis in 2007, headed by Estelle Simons. This program followed up on an earlier survey, which had identified the dismally poor availability of injectable epinephrine in many countries. Under the excellent leadership of Estelle Simons, 2 additional surveys have been conducted and published, demonstrating an improvement in the availability of allergy services worldwide. These studies have highlighted the importance of a proper diagnosis of anaphylaxis and its rapid treatment. As a follow-up, a major WAO Position Paper on anaphylaxis and a separate paper on the early use of epinephrine in anaphylaxis have been published. This initiative was initially sponsored by UCB.
During these 2 years, WAO solidified its position in the world of allergy, continued its immense commitment to global education in allergy (GLORIA-both international and US, Seminars and Conferences, WAF), held a very successful congress in Thailand, supported its member societies with several extremely important position papers designed to strengthen the position of allergy in each country, and started a new electronic journal. From my perspective as the president, this was a very satisfying experience. The Board of Directors of WAO with whom I worked included Walter Canonica, Jean Bousquet, Ruby Pawankar, Richard Lockey, and Carlos Baena-Cagnani, supported by Charu Malik, Karen Henley, Katie Vande Zande, Jennie Smazik, Kate Kirchner, and Kay Whalen from the Secretariat. I was extremely fortunate to have such an accomplished Board with which to work, and the achievements accomplished during that period reflect enormous hard work and commitment (Figure 13).
Walter Canonica became president at the completion of WAC 2007 in Thailand (Figure 14). As an esteemed scientist with a worldwide reputation, and a powerful supporting group in Genoa, Italy, he brought many skills to the organization. One of his initial decisions was to strengthen the WAO Mission Statement: WAO'smission is to be a global alliance and advocate in the field of allergy, advancing excellence in clinical care through education, research, and training as a world-wide alliance of allergy and clinical immunology societies.
Walter Canonica extended WAO's usual committees and councils with the development of a number of "special committees," as a way to involve more allergists in the WAO and as a way to develop new initiatives. Thus, the usual WAO committee structure consisting of audit and finance, awards, bylaws, communication council, congress council, credentials, education council, emerging societies, ethics, GLORIA, research council, specialty, and training council, and WAF was extended to include allergy diagnosis, anaphylaxis, ARIA-GARD-WHO, asthma, clinical trials, evidence-based medicine, food allergy, immunotherapy, and impact of climate change. I believe that Walter Canonica knew that not every special committee would be functional, nor that all of them would survive his tenure, but if some committees generated useful initiatives, that would suffice.
Both the GLORIA and the Seminars and Conferences committees were active through 2008, with multiple programs throughout the world and in the United States. The Web site http://www.worldallergy.org continued to thrive with tens of thousands of visitors, an active carefully selected international editorial board; online learning and CME modules; interactive modules on food allergy, parotitis, and angioedema; a series of interviews with world experts on a range of topics including (for example) Marek Kowalski on Aspirin Exacerbated Respiratory Disease (AERD), Thomas Casale on omalizumab, and Estelle Simons on epinephrine, and a host of others; and an online allergic diseases resource center where numerous educational synopses are posted. The Web site was developed by Chief Editor, Richard Lockey with support by many WAO members, the Web Editorial Board, and the WAO Secretariat. The current Editor-in-Chief is Juan Carlos Ivancevich.
During 2006 and 2007, the Emerging Societies Program had held meetings in Buenos Aires, Malaysia, Mexico, China, and Bangkok; and in 2008, a major meeting was held for Latin America in Venezuela. Ruby Pawankar raised the possibility of having an ESP meeting in Dubai in 2009 and also a World Allergy Training School (WATS), as a part of the Middle East-Asia Allergy Asthma Immunology Congress, and the Board decided to support this idea. Both the ESP and the WATS in 2009 went extremely well. I have already mentioned the change in pharmaceutical funding that developed in 2008-2009. WAO recognized that GLORIA and other programs were not attracting the funding awarded in earlier years and was forced to restrict its budget to have sufficient funding for essential programs. In fact, only 2 GLORIA presentations and 2 Seminars and Conferences speakers were funded in 2009. Richard Lockey and Ruby Pawankar initiated a proposal for an interim meeting, held in the year between the biannual congresses, with the initial meeting in Dubai, as a way to help bridge the financial gap. There were some Board members who were concerned that an interim meeting might strain the Board, the Secretariat support, and the pharmaceutical sponsors, but in the end, Richard Lockey was given the chance to move forward to explore this idea. He developed a proposal to hold a meeting focused on asthma and its comorbidities as a way to attract not only the usual allergy community but also primary care physicians who deal with a broader spectrum of diseases.
As a leading scientist in the development of sublingual immunotherapy, Walter Canonica proposed to gather the world's allergy societies and to develop a position statement on the study of sublingual immunotherapy (SLIT). This meeting was cohosted by most major allergy societies, such as EAACI and AAAAI, and directed by Walter Canonica, and it led to a publication summarizing the state of the art of sublingual immunotherapy that also details the methods by which SLIT and subcutaneous immunotherapy could be properly studied as a way to make European and US studies more compatible. "Sublingual Immunotherapy: World Allergy Organization Position Paper 2009" was published in the World Allergy Organization Journal, while an accompanying Rostrum article, "Recommendations for appropriate sublingual immunotherapy trials" was published in the Journal of Allergy and Clinical Immunology.
The Food Allergy Special Committee, headed by Alessandro Fiocchi, developed an important paper on cow's milk allergy, published in the World Allergy Organization Journal: "World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines."
Finally, a major endeavor was the development of a WAO White Book on Allergy, headed by Ruby Pawankar, and supported by Stephen Holgate, Richard Lockey, and Walter Canonica (all 4 as editors) plus the WAO Board and a worldwide group of allergists. This White Book succinctly summarizes the state of the art of allergy and is designed as a way to influence government decision makers when considering distribution of funds among various medical specialties. This project took 2 years to finalize, but it is an extremely important publication, and it is available to anyone on http://www.worldallergy.org. The White Book emphasizes the importance of the specialty of allergy, the need for enhanced medical teaching of allergic diseases, and the necessity to provide specialized treatment for the tens of millions of allergy sufferers worldwide.
In 2009, the Specialty and Training Council produced another position paper on Undergraduate Training in Allergy: "Recommendations for Competency in Allergy Training for Undergraduates Qualifying as Medical Practitioners: A World Allergy Organization Position Paper," and was published in World Allergy Organization Journal and is also available on http://www.worldallergy.org.
By 2010, the membership in WAO had grown to 83 member societies. ESP meetings were held in Dubai, Warsaw, and Vietnam.
The culmination of Walter Canonica's presidency was the WAC in Buenos Aires (WAC 2009), chaired by his close friend Carlos Baena-Cagnani. This was the second meeting in Argentina; the first was held in 1979 and was a financial disaster. The second Buenos Aires meeting was quite successful, with more than 5000 attending, excellent science, and an altogether pleasant experience. Unfortunately, this meeting was also a financial disaster, with a net profit of less than $100,000. It is hard to explain the reasons why a well-attended meeting could be nonprofitable, and even from a clear retrospective analysis, it is still not clear what happened. Certainly, Argentina turned out to be quite expensive, the social programs were outstanding but were far too expensive, and the government taxed the revenue despite promises that they would not. The primary lesson learned was that WAO cannot allow meetings to proceed without ironclad control of all expenditures and total control of all the finances. Having said that, I believe that these lessons were learned and that they will be instituted henceforth. WAC 2009 in Buenos Aires was a lovely meeting and won WAO many worldwide admirers and supporters.
2010 And the Future. Toward Providing Expert Care for Millions of Patients Worldwide
Richard Lockey became president on January 1, 2010, recognizing that WAC 2009 in Buenos Aires had left him with markedly depleted funds for his 2-year term (Figure 15). He, and the Executive Committee, decided to move forward with an interim meeting late in 2010 focused on diseases, which overlap and influence the course of asthma. Dubai, United Arab Emirates, was the site, and the meeting was focused on the Middle East. About 1400 attended the meeting, which was run on a very tight budget and with adequate pharmaceutical support. The meeting was extremely successful from the scientific and financial aspects with a profit of more than $300,000. The credit for this successful meeting goes to Richard Lockey, Ruby Pawankar, and the rest of the Board of Directors. The drive, organizational skills, and foresight to create such a meeting define the type of leadership now in control of WAO. The organization is being run in an extremely transparent democratic fashion, with multiple Board members having responsibility for multiple aspects of the organization. When I think back 2 decades to the "Old Boy's Club" that existed until 2000, compared with the dynamic global structure currently in place, I feel extremely pleased that the world of allergy is being led by this organization. Richard Lockey joins the group of outstanding leaders who have left a permanent imprint on the organization. He has been the driving force behind the constitution and the Web site, and he has impacted WAO's finances repeatedly. He has insisted on a democratic structure, run with the highest standards of ethics, and has asked everyone to contribute their time and energy. He will have the chance to contribute his own chapter to this history, but my expectation is that he will be much too modest to describe his achievements in the terms I have chosen.
In 2012-2013, the president will be Ruby Pawankar, an Indian, based in Japan. She joined the WAO Board in January 2001 and has served as Treasurer and President-Elect. She will run the 2nd WAO International Scientific Conference in India, December 2012. As WAO President, she will co-chair with EAACI President Cezmi Akdis the World Allergy Congress in June 2013 to be held jointly with the EAACI Congress in Italy. Lanny Rosenwasser will be president in 2014-2015, and he will chair the Congress in 2015 in South Korea. The venue for the Congress in 2017 will be chosen during WAC 2011 in Cancun.
As I look at the activity currently being invested in WAO and the world of allergy, I cannot but be impressed with the scope of activity underway. All aspects of allergy are being explored, with research papers, position statements, congresses, lectures, webinars, and the like providing the world with great opportunities for education. The Web site continues to grow and strengthen under the leadership of Juan Carlos Ivancevich. The World Allergy Organization Journal is being run by Lanny Rosenasser with the assistance of a worldwide selection of allergy leaders. The WAC 2011 in Cancun is headed by Richard Lockey, but Thomas Casale is organizing the program.
I see activity for WAO from many Europeans, Africans, Asians, North Americans, and Latin Americans. The diversity of those actively participating is exactly what we had in mind in 1998 when the IAACI retreat in Sweden took place. That such an exhilarating achievement has been created, has taken roots, and has developed in this decade of activity is breathtaking. From those of us who have been privileged to watch WAO develop, to those of you who will participate in an even stronger organization in the future, we all must recognize that the hundreds of millions of allergy and asthma sufferers are the real beneficiaries of this work. The medical specialty of allergy has been strengthened by WAO, but it is the patients who will benefit. Patients who already have access to well-trained specialists will find these physicians better trained and those patients whose access will be available only because WAO laid the groundwork for their physicians to receive training in allergy may not understand the role WAO played but will benefit by the availability of a specialist specifically trained to treat them. It is the commitment to global education, to convincing governments that allergy needs to be supported and fostered, and the seminal work of developing allergy societies that exemplifies what WAO has and will contribute to the world of allergy.
For me, my small contributions to WAO and the world of allergy have been the highlights of a successful career. It has been my privilege to work with giants such as de Alain deWeck, Jack Pepys, Terumasa Miyamoto, Gunnar Johansson, Allen Kaplan, Walter Canonica, Richard Lockey, Stephen Holgate, Marek Kowalski, and so many others. It is easy to see how the time and energy devoted to WAO have led to achievements not otherwise possible and to encourage others to invest their time and skills to future achievements.
The authors have no funding to disclose.
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Kaliner, M.A. History of the World Allergy Organization: Two Decades Leading to World Leadership, 1990-2010. World Allergy Organ J 4, 231–248 (2011). https://doi.org/10.1097/WOX.0b013e31823ba552