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\"\"<\/a><\/p>\n

vol. 64
\nMedical
\nWorld
\nJournal
\nOfficial Journal of The World Medical Association, Inc.
\nISSN 2256-0580
\nNr. 2, August 2018
\nContents
\nEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t1
\n209th
\nWMA Council Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t2
\nWMA Council Resolution on the Prohibition of Nuclear Weapons . . . . . . . . . . . . . . . . . . . . . \t13
\nEnd of Life Seminars. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t13
\nJunior Doctors Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t14
\nWorld Health Professions Alliance Regulation Conference 2018 . . . . . . . . . . . . . . . . . . . . . . . \t15
\nWorld Health Assembly Side Events \u2013 May\u00a02018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t18
\nIntellectual Property: who owns the right to good health?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t20
\nPhysicians\u2019 Role in the Management and Leadership of Health Care . . . . . . . . . . . . . . . . . . . . \t22
\nPolicy Analysis Ottawa Declaration on Child Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t25
\nCMA Thousand Talents Cultivation Program for County Hospitals . . . . . . . . . . . . . . . . . . . . \t28
\nUniversal Medical Esperanto Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t30
\nCompetence Drift in Professional Practice: a\u00a0Psychological Perspective . . . . . . . . . . . . . . . . . \t33
\nWorkforce of Healthcare Professionals in\u00a0Rural Nigeria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t36
\nInternational Congress on Medical Ethics, a Risk Worth Taking? . . . . . . . . . . . . . . . . . . . . . . \t38
\nMulti-Media Educational Tool Created to Help Children Cope with Cancer. . . . . . . . . . . . . \t40
\nEditor in Chief
\nDr.\u00a0P\u0113teris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.lv, editorin-chief@wma.net
\nCo-Editor
\nProf. Dr.\u00a0med. Elmar Doppelfeld, Deutscher \u00c4rzte-Verlag, Dieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor
\nMaira Sudraba, Velta Poz\u0146aka; lma@arstubiedriba.lv
\nJournal design by
\nP\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher, \u201cMedic\u012bnas apg\u0101ds\u201d, President Dr.\u00a0Maija \u0160etlere, Skolas street 3, Riga, Latvia
\nPublisher
\nThe Latvian Medical Association, \u201cLatvijas \u0100rstu biedr\u012bba\u201d,
\nSkolas street 3, Riga, Latvia.
\nISSN: 2256-0580
\nDr.\u00a0Yoshitake YOKOKURA
\nWMA President
\nJapan Medical Association
\n2-28-16 Honkomagome
\n113-8621 Bunkyo-ku,
\nTokyo, Japan
\nDr.\u00a0Ren\u00e9 H\u00c9MAN
\nWMA Chairperson of the Finance
\nand Planning Committee
\nP.O. Box 20051
\n3502 LB, Utrecht
\nNetherlands
\nProf. Dr.\u00a0Frank Ulrich
\nMONTGOMERY
\nWMA Vice-Chairperson of Council
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1 (Wegelystrasse)
\n10623 Berlin
\nGermany
\nDr.\u00a0Ketan DESAI
\nWMA Immediate Past-President
\nIndian Medical Association
\nIndraprastha Marg
\n110 002 New Delhi
\nIndia
\nDr.\u00a0Joseph HEYMAN
\nWMA Chairperson
\nof the Associate Members
\n163 Middle Street
\nWest Newbury, Massachusetts 01985
\nUnited States
\nDr.\u00a0Andrew DEARDEN
\nWMA Treasurer
\nBritish Medical Association
\nBMA House,Tavistock Square
\nLondon WC1H 9JP
\nUnited Kingdom
\nDr.\u00a0Leonid EIDELMAN
\nWMA President-Elect
\nIsraeli Medical Association
\n2 Twin Towers, 35 Jabotinsky St.,
\nP.O. Box 3566
\n52136 Ramat-Gan
\nIsrael
\nDr.\u00a0Heidi STENSMYREN
\nWMA Chairperson of the Medical
\nEthics Committee
\nSwedish Medical Association
\n(Villagatan 5) P.O. Box 5610
\nSE \u2013 114 86 Stockholm
\nSweden
\nDr.\u00a0Miguel Roberto JORGE
\nWMA Chairperson of the Socio-
\nMedical Affairs Committee
\nBrazilian Medical Association
\nRua-Sao Carlos do Pinhal 324,
\nCEP-01333-903 Sao Paulo-SP
\nBrazil
\nDr.\u00a0Ardis D. HOVEN
\nWMA Chairperson of Council
\nAmerican Medical Association
\nAMA Plaza, 330 N. Wabash,
\nSuite 39300
\n60611-5885 Chicago, Illinois
\nUnited States
\nDr.\u00a0Otmar KLOIBER
\nSecretary General
\nWorld Medical Association
\n13 chemin du Levant
\n01212 Ferney-Voltaire
\nFrance
\nWorld Medical Association Officers, Chairpersons and Officials
\nOfficial Journal of The World Medical Association
\nOpinions expressed in this journal\u00a0\u2013 especially those in authored contributions\u00a0\u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\n1
\nBACK TO CONTENTS
\nEditorial
\nEditorial
\nRegular reviewing of rigid assumptions is the prime task of the 21st
\ncentury medicine. Undoubtedly, first and foremost it refers to medi-
\ncations and it is vital to assess anew whether the particular medica-
\ntion is appropriate for the specific illness or syndrome or the risks
\nmight exceed the expected result; is it really so that polypragmasia\u00a0\u2013
\nadministration of 6\u201310 medications to a patient at the same time\u00a0\u2013
\nis the best practice for concurrent treatment of several diseases.
\nIt would be purposeful to revise the indications of any medication at
\nleast once in ten years. It would be even better if it were done with-
\nout involving the pharmaceutical industry. It should be investigated
\non what grounds using of a certain medication or applying some
\ndiagnostic or manipulative treatment has been refused now. Quite
\noften it is because a new, more effective medication has entered the
\nmarket, but we are unaware of its real side effects and long-term
\nimpact in a ten year period.
\nTreatment is vital, however, not the most important part of health
\ncare\u00a0\u2013 there is also prevention,diagnostics,treatment and rehabilita-
\ntion. Still, treatment includes not only the use of medications, but
\nalso physical medicine (heat, electricity), surgery, psychotherapeutic
\ntreatment, radiation therapy and non-traditional methods of treat-
\nment.
\nDuring the last 30 years the role of physical therapy and surgery has
\ndiminished due to new medications.
\nIt would also be wise to reconsider an evidence-based opinion that
\nhas been formulated as a result of serious research. For example,
\nanti-bacterial therapy was developed on the basis of definite find-
\nings and it treated easily different infectious diseases. Today, when
\nwe understand that the microbiome is an important part of human
\nphysiology and how it is damaged by antibacterial therapy, it is sen-
\nsible to review our considerations about treating not so serious and
\nalso very serious infectious diseases.
\nIt is time to review the physician-pharmacist relationship on a global
\nscale. There is a strong tendency in the world to associate medicine
\nwith doctors, but the pharmaceutical industry\u00a0\u2013 with pharmacists
\nand druggists. Doctors are often blamed publicly as soon as any-
\nthing has been done wrong either by the nurse or nurse assistant or
\nhospital registrar. Pharmacists are made responsible for medications
\nbeing expensive,for prescribing them too much and that quite often
\nmedicine seems to be an appendix to the pharmaceutical industry.
\nCivil service and politics have largely promoted pharmacy to take
\nthe lead position on a global scale.Under the auspices of civil service
\nthe usage of medications is focused on in guidelines, recommenda-
\ntions and funded health care.There is extensive and fruitful research
\nworldwide about the beneficial effect of movement (walks, train-
\nings) on the progress in treatment, but in the prepared documents it
\nis substituted by bed regime and a handful of tablets because politi-
\ncians and financiers are unable to calculate the costs of indirect care,
\ntreatment of psychosomatic disorders, holistic treatment (and even
\nmore incapable of calculating the cost of non-conventional medi-
\ncine).
\nPoliticians and civil servants are incapable of understanding science;
\nthey cannot perceive man as a whole and they demand to treat a
\nspecific illness, not a patient, moreover, they demand to treat, but
\nnot to heal. Globalization associates with the consumer philosophy
\nwhich propagates two slogans\u00a0\u2013 \u201cthe more medications, the better
\nyour health\u201d and \u201cexpensive medicine is better than cheap medi-
\ncine\u201d. The consumer philosophy leads to the situation when a sick
\nman is equated with a broken car.The greatest lobbyists of the con-
\nsumer philosophy are rich people\u00a0\u2013 politicians and civil servants as
\nthey always manage to get public or insurance funds to pay for the
\nhealth care services they have received.
\nThus, polypragmasia and bureaucracy poison medicine globally.The
\nonly remedy against this policy and red-tapism is regular revising of
\nthe long-standing assumptions. The World Medical Association is
\nthe structure which is capable of undertaking the leadership in these
\nactivities and, moreover, it will be obliged to do it.
\nDr. med. h. c. Peteris Apinis,
\nEditor-in-Chief of the World Medical Journal,
\nPresident of the Latvian Medical Association
\n2
\nWMA Council Session
\nThe 209th
\nWMA Council meeting was held
\nat the Radisson Blu Latvija Conference &
\nSpa Hotel from April 26\u201328 in the year of
\nLatvia\u2019s 100th
\nanniversary.Around 150 dele-
\ngates from 40 national medic al associations
\nattended.
\nTHURSDAY APRIL 26
\nCouncil
\nThe proceedings were opened by Dr.\u00a0Ardis
\nHoven, Chair of the WMA, who thanked
\nthe Latvian Medical Association for their
\nhospitality. She spoke about the importance
\nof everybody participating in the meeting
\nand listening to one another.
\nPresident\u2019s Report
\nDr.\u00a0 Yoshitake Yokokura, in his Presiden-
\ntial report, reported on his activities in the
\npast six months and his mission to advance
\nthe initiative of Universal Health Cover-
\nage (UHC), as well as to strengthen health
\nsystems around the world. He referred
\nto the various meetings he had attended.
\nThese included the 2017 Global Health
\nForum in November 2017 hosted by the
\nTaiwan Health Ministry and Foreign Af-
\nfairs, and the UHC Forum 2017 held in
\nTokyo in December organized by the Jap-
\nanese Government, World Bank, United
\nNations, WHO and UNICEF. One of the
\nhighlights of the latter meeting was the
\nagreement between the WMA and WHO
\nto agree an official Memorandum of Un-
\nderstanding on collaboration for establish-
\ning the UHC on a global level and for the
\nstrengthening of disaster preparedness.
\nThis Memorandum was signed in Gene-
\nva on April 5 and he believed this agree-
\nment was a milestone and would further
\nenhance the presence of the WMA in the
\nglobal community.
\nSecretary General\u2019s Report
\nDr.\u00a0 Otmar Kloiber, Secretary General,
\ntabled a detailed written report, setting
\nout the Secretariat\u2019s activities since the last
\nmeeting. In his oral report he said that since
\nthe Chicago Assembly further end of life
\nseminars had been held at the Vatican in
\nRome and in Abuja, Nigeria, and a session
\nwith the Arab Medical Union had been ad-
\ndressed by Dr.\u00a0Hoven.
\nChair\u2019s Report
\nDr.\u00a0Ardis Hoven, in her written report for
\nCouncil, mentioned that in writing a fore-
\nword on Women\u2019s Health in Global Per-
\nspective, she was reminded of the barriers
\nto health care and clinical needs that con-
\nstituted threats to adequate health care for
\nwomen. With increasing migrant streams
\ncaused by war, climate change and econom-
\nic disruption, women had become targets
\nof abuse, violence and deprivation. She said
\ngender based health disparities intensified
\nthe need for the WMA\u2019s role in the Social
\nDeterminants of Health globally.
\n\u201cAs leaders in medicine, we have the op-
\nportunity and the responsibility to lay aside
\nour politics and concentrate on the needs of
\npatients and our health care colleagues. As
\nwe enjoy the hospitality of Riga, I encour-
\nage honest dialogue around what we might
\nconsider difficult topics. Respect for, and
\nencouraging, the minority opinion will be
\nvery desirable. We are diverse in many ways
\nand we must celebrate that diversity\u201d.
\nEmergency Resolution
\nAn emergency resolution on nuclear weap-
\nons was submitted for debate by the Japan
\nMedical Association and the International
\nPhysicians for the Prevention of Nuclear
\nWar. The Council agreed that this should
\nbe considered by the Socio Medical Affairs
\nCommittee.
\nThe Council meeting was adjourned.
\nFinance and Planning
\nCommittee
\nDr. Ren\u00e9 H\u00e9man (Netherlands) took the
\nchair.
\nFinancial Statements for 2016 and 2017
\nDr.\u00a0Andrew Dearden,the Treasurer,gave an
\noral report on the Association\u2019s financial ac-
\ncounts and interim statement. He said there
\nwere no surprises, but several very good
\nmessages. They had finished 2017 with a
\nsurplus, their equity was good, expenses
\nwere well regulated and membership dues
\nhad increased. These achievements allowed
\nthe Association to increase workload as
\nnecessary. In short, the Association\u2019s financ-
\nes were in a good position.
\nThe committee recommended that the
\nCouncil approve the interim Financial
\nStatement for 2017, as well as the report on
\nMembership Dues Payments for 2018
\nWMA Strategic Plan
\nDr.\u00a0Kloiber gave an oral report on the As-
\nsociation\u2019s draft Strategic Plan, explaining
\nthat it was being separated into two parts\u00a0\u2013
\none reflecting the principles upon which the
\nplan was based and a second part articulat-
\ning an action plan. The revised draft would
\nbe reported to the Council in October in
\nReykjavik.
\n209th
\nWMA Council Session,
\n26\u201328 April, 2018, Riga
\n3
\nBACK TO CONTENTS
\nWMA Council Session
\nWMA Statutory Meetings
\nThe Committee considered arrangements
\nfor future WMA Statutory Meetings and
\nheard about offers from three Constituent
\nMembers to host the 2020 General Assem-
\nbly\u00a0\u2013 the Rwanda Medical Association to
\nhost in Kigali, the British Medical Asso-
\nciation to host in London and the Consejo
\nGeneral de Colegios M\u00e9dicos de Espa\u00f1a to
\nhost in Cordova.
\nThe Conseil National de l\u2019Ordre des M\u00e9de-
\ncins (France) also presented an invitation to
\nhost the 2022 Council Session in Paris.
\nThe Committee recommended to Coun-
\ncil that the 218th
\nCouncil session be held
\nfrom 22\u201324 April 2021, that the 72nd
\nGen-
\neral Assembly be held from 13\u201316 October
\n2021 and that the 221st
\nCouncil session be
\nheld from 7\u20139 April 2022.
\nIt recommended that the invitations from
\nRwanda, the UK, and Spain be postponed
\nto the next Council session in Reykjavik and
\nthat the invitation from CNOM France for
\nParis to host the 221st
\nCouncil Session in
\nApril 2022 be accepted.
\nWMA Special Meetings
\nThe Committee received an oral report
\nfrom the Secretary General, about several
\nforthcoming events:
\n\u2022\t Ethics Conference, Reykjavik, 2\u20134 Octo-
\nber 2018: This year\u2019s scientific session at
\nthe General Assembly would be integrated
\non the second day of the three-day Ethics
\nconference and this could be a model for
\nfuture meetings. Dr.\u00a0Sn\u00e6dal (Iceland) said
\nthe programme would include the Decla-
\nration of Helsinki, the Declaration of Lis-
\nbon, the Declaration of Taipei and other
\ncore WMA policies. External participants
\nwould be invited to join the discussions.
\n\u2022\t UNESCO World conference: This meet-
\ning would be held in Israel, 27\u201329 No-
\nvember 2018.
\n\u2022\t World Health Assembly, 21\u201326 May
\n2018. The WMA was planning multiple
\nside events during the WHA.
\n\u2022\t The World Health Professions Alliance
\nRegulation conference would be held before
\nthe WHA, 19\u201320 May 2018 in Geneva.
\nAssociate Membership
\nDr.\u00a0 Joe Heyman, Chair of the Associate
\nMembers, said that at the end their meet-
\ning in Chicago, 85 members had joined a
\nGoogle group set up to debate online draft
\npolicy documents. He told the committee
\nthat they now had around 200 members in
\nwhat had become a very active group.
\nDr.\u00a0Kloiber thanked Dr.\u00a0Heyman for his ef-
\nforts managing the online group. He said it
\nwas a very lively group, involved in a very
\nhigh quality discussion about draft policies.
\nJunior Doctors Network
\nDr.\u00a0 Caline Mattar, Chair of the Junior
\nDoctors Network, reported on the group\u2019s
\nwork on antimicrobial resistance, UHC and
\nhealth workers. They had held a one-day
\nmeeting in Latvia that included a capacity
\nbuilding and a leadership workshop attend-
\ned by some NMAs.
\nIn her written report, she said that there
\nwas now an active group of junior doctors
\nin Latin America and new members from
\nthe Eastern Mediterranean were joining the
\nNetwork.
\nPast Presidents and Chairs
\nof Council Network
\nDr.\u00a0Jon Sn\u00e6dal (Iceland) gave a report on the
\ngroup\u2019s activities. He thought the title of the
\ngroup was rather cumbersome and suggested
\nthat perhaps it might be renamed the Senate
\nor the House of Lords of the WMA! He told
\nthe committee that the group had started en-
\ngaging in the dialogue related to the 40th
\nan-
\nniversary of Alma-Ata Declaration.
\nGovernance Review
\nDr.\u00a0Mark Porter, Chair of the Review Com-
\nmittee,gave an oral report.He reminded del-
\negates that the committee had been set up to
\nreceive and review proposals for new business
\nand to assist in considering items for con-
\nsideration. The committee had made a good
\nstart in helping to improve Council business.
\nNominating Process
\nA proposal to introduce a self-declaration
\nstatement to the nominating process for
\nWMA Presidency was discussed. It was
\nexplained that this would be an additional
\nlayer of governance.
\nTheCommitteeagreedtorecommendthatthe
\nproposal should be circulated for comment.
\nWorld Medical Journal
\nIn his written report,the editor in chief of the
\nJournal, Dr.\u00a0Peteris Apinis, said the Journal
\nturned 64 this year and much had changed
\nduring this time. He thanked those who had
\nassisted him since he took over the editorship
\nin 2008. He said the Journal was essentially
\na newsletter meant for the leaders of medical
\nassociations all over the world,to inform them
\nabout key events, documents, movements and
\nthe direction in which the WMA was going.
\nThe Journal was published four times a year
\nand for the past two years had also been pub-
\nlishing in digital form,with printed copies go-
\ning to the world\u2019s leading libraries.
\nPublic Relations
\nThe Committee was told that after the Gen-
\neral Assembly in Chicago last year, there was
\nvery strong international publicity, including
\n4
\nWMA Council Session
\non social media, generated by the revision of
\nthe Declaration of Geneva and its immediate
\npublication in the Journal of the American
\nMedical Association. Ms Magda Mihaila,
\nWMA Communications and Information
\nManager,was now coordinating social media
\non Twitter and Facebook. There had been a
\nhighly successful social media campaign dur-
\ning the early part of 2018 in support of the
\narrested Turkish doctors.
\nSocio Medical Affairs
\nCommittee
\nDr. Miguel Roberto Jorge (Brazil) took the
\nchair.
\nHealth and Migration
\nDr.\u00a0 Poonam Dhavan, Migration Health
\nProgramme Coordinator at the Internation-
\nal Organisation for Migration, gave an oral
\nreport about the work of her organisation.
\nShe emphasized the critical role of health
\nfor migrant populations and referred to the
\nincreasing development of international
\npolicies on migration. She spoke about the
\nimportance of the role of health profession-
\nals in providing care to all migrants in need,
\nin line with medical ethics principles. She
\nconcluded by expressing her organisation\u2019s
\naspiration to collaborate with the WMA in
\nthe area of health and migration.
\nMonitoring Report
\nDr.\u00a0Kloiber reported on the new Memoran-
\ndum of Understanding between the WMA
\nand the World Health Organisation signed
\nin April between Dr.\u00a0 Tedros Adhanom
\nGhebreyesus,WHO Director-General, and
\nWMA President Dr.\u00a0 Yoshitake Yokokura.
\nThe Memorandum identified four areas for
\nthe organisations to focus on\u00a0\u2013 fostering the
\ndevelopment of Universal Health Coverage
\nwith specific attention on the role of physi-
\ncians, strengthening the world health work-
\nforce, inequalities in health and emergency
\npreparedness. Dr.\u00a0Kloiber said that as a re-
\nsult of the agreement the WMA would have
\nto deliver more on how physicians were in-
\nvolved in these processes. One example was
\nthe situation facing African countries of
\ndoctors being imported from Cuba. He said
\nhe had already started by bringing together
\nvarious NMAs to discuss this issue.
\nHealth and Environment
\nThe Co-Chair of the Environment Caucus,
\nDr.\u00a0Lujain Al-Qodmani (Kuwait), reported
\non the meeting the Caucus had held the pre-
\nvious day.It had discussed the opportunity to
\nreview and analyze the WMA\u2019s existing envi-
\nronmental policies to make them more con-
\ncise, coherent and current and had decided
\nto set up an informal working group to look
\nat those policies and make recommendations
\nto the Council. The Caucus had also agreed
\nto set up a green mailing list to facilitate and
\npromote exchange of information within the
\nWMA membership on issues related specifi-
\ncally to health and the environment.The list
\nwould be open to any NMA members and
\ninterested Associate members.
\nPlastic Bags, Ecological Issues &
\nEnvironmental Degradation
\nThe Committee considered a proposed revi-
\nsion of the WMA Statement on Environ-
\nmental Degradation and Sound Manage-
\nment of Chemicals, originally submitted
\nby the Latvian Medical Association. It was
\nargued that the current policy should be
\nwidened to include plastic pollution.
\nThe Committee agreed to recommend that
\nthe draft revision should be circulated to
\nconstituent members for comment.
\nMedical Tourism
\nThe committee considered the proposed
\nWMA Statement on Medical Tourism.
\nDelegates were reminded that the paper
\nwas first brought to the committee two
\nyears ago by the Israel Medical Association.
\nConcerns were raised then about parts of
\nthe document and the new proposed State-
\nment was a revised version, taking into ac-
\ncount those concerns. The argument of the
\nIsraeli Medial Association was that at the
\nmoment this activity was going on and the
\nWMA did not have a firm policy or any
\nregulations.
\nDuring the debate that followed, several
\nmembers expressed continuing concerns
\nabout the definition of medical tourism and
\nthought that the word \u201ctourism\u201d suggested
\nsomething leisurely,when,what it was really
\nabout was cross border medical treatment.
\nDelegates agreed several amendments.
\nOne called on governments to consider all
\nthe implications of medical tourism to the
\nhealthcare system of a country by develop-
\ning comprehensive, coordinated national
\nprotocols and legislation. Another, relating
\nto confidentiality, made it clear that inter-
\npreters, and other administrative staff with
\naccess to health information of the medical
\ntourist should sign confidentiality agree-
\nments.
\nThe committee recommended that the pro-
\nposed Statement, as amended, be approved
\nby the Council and forwarded to the Gen-
\neral Assembly for adoption.
\nGender Equality in Medicine
\nThe Israel Medical Association submitted
\na revised Statement on Women in Medi-
\ncine. An earlier draft had been debated,
\namended and circulated among members
\nfor comment. The committee was told that
\nthe revised paper attempted to bring to-
\ngether physicians from different parts of the
\nworld, with different cultures and different
\nwork environments. An attempt had been
\nmade to address all the concerns raised.The
\nchallenge was that in one part of the world,
\nparticularly northern Europe, they were
\n5
\nBACK TO CONTENTS
\nWMA Council Session
\ndealing with a quite equal society, where it
\nmight be problematic to talk about special
\nconcerns for women. However, there were
\nother parts of the world where there was no
\nequality in the medical workplace and no
\nequal opportunities.These countries needed
\nmore protection to encourage employers to
\nallow women to achieve their true potential
\nin medicine.
\nA lengthy debate followed, with several
\namendments being put forward and debated.
\nThe committee agreed to change the title of
\nthe document from \u201cWomen in Medicine\u201d
\nto \u201cGender Equality in Medicine\u201d.
\nThe issues of flexible working hours and
\nwork-life balance were debated. One pro-
\nposal, to encourage employers to ensure
\nwomen were able to access all their rights
\nand entitlements, and to ensure that men
\nhad equal opportunities to take parental
\nleave, was rejected.
\nDelegates debated whether or not to in-
\nclude a reference to female physicians fac-
\ning significant levels of mental illness and
\nsuicide. Some delegates questioned the ac-
\ncuracy of the reference, and many speakers
\nsaid that suicide and mental illness affected
\nboth women and men. The committee de-
\ncided to omit any reference to this issue.
\nThe committee then approved the whole
\ndocument as amended.
\nProfessional Autonomy of Physicians
\nClarisse Delorme, the WMA\u2019s Advocacy
\nAdviser, explained that as part of the As-
\nsociation\u2019s annual policy review process, the
\nCouncil had decided that the Statement
\non Professional Responsibility for standards
\nof Medical Care be rescinded and archived,
\nand that the Declaration of Seoul on Pro-
\nfessional Autonomy and Clinical Indepen-
\ndence and the Declaration of Madrid on
\nProfessionally-led Regulation be merged in
\na single document. Sections could then be
\nincorporated into that merged document
\nfrom the Statement on Professional Responsi-
\nbility for standards of Medical Care.However,
\nthe Council later reversed its decision and
\ndecided that the Declarations of Seoul and
\nMadrid be kept separate and revised indi-
\nvidually to incorporate the relevant missing
\nsections from the Statement on Professional
\nResponsibility for standards of Medical Care,
\nwhich would then be rescinded and ar-
\nchived.
\nDuring a debate on the Declaration of
\nSeoul, the issue was raised of other profes-
\nsions, particularly in Africa, moving into
\nareas traditionally undertaken by physi-
\ncians. It was argued that the document did
\nnot satisfactorily address this. Dr.\u00a0 Kloiber
\nresponded by saying that other professions
\nwere in fact trying to occupy parts of the
\nphysician\u2019s traditional scope of practice. In
\nsome places there might be a good reason
\nfor this, but in general it was a problem.
\nThere was a big problem in different health
\ncare systems with the density of health
\nprofessions. There were parts of the world
\nwhere there was no physician and patients
\nhad to rely on health care workers or nurses.
\nDr.\u00a0Kloiber said current WMA documents
\ndid not address this situation and he had
\nbeen asked by the Executive Committee to
\nlook into this issue and build alliances with
\nother groups, such as WoNCA.
\nThe committee went on to recommend to
\nthe Council that the revised Declaration
\nof Seoul be approved and forwarded to the
\nAssembly for adoption.
\nDeclaration of Madrid on on
\nProfessionally-led Regulation
\nThe committee then considered the revised
\nDeclaration of Madrid on Professionally-
\nled Regulation. Members pointed out that
\nmany countries no longer had professional-
\nly-led regulation, having moved to statutory
\nregulation. However, it was pointed out that
\nin a recent WMA survey of members,it was
\nshown that 46 countries had professionally-
\nled regulation.
\nAfter a brief debate the committee decided
\nto recommend to the Council that the re-
\nvised Declaration be recirculated among
\nmembers for comment.
\nSustainable Development
\nThe Japan Medical Association introduced
\na proposed Statement on Sustainable De-
\nvelopment. It was explained that two years
\nago it had been decided to set up a working
\ngroup on sustainable development with the
\nmandate to develop a proposal for a WMA
\npolicy on the topic and to define a proposed
\nstrategy for sustainable development at in-
\nternational and national level. The Council
\nmeeting in Chicago decided to circulate the
\ndocument among members for comments.
\nThe committee recommended that the re-
\nvised Statement be approved and forwarded
\nto the Assembly for adoption.
\nAvian and Pandemic Influenza
\nA proposed revision of the WMA State-
\nment on Avian and Pandemic Influenza was
\nconsidered. Delegates were reminded it had
\nbeen decided that this Statement should
\nundergo a minor revision under the 10-year
\nreview process. Concerns had been raised
\nabout the scientific content of an early revi-
\nsion of the document. Those concerns had
\nnow been addressed. The committee agreed
\nto amend the document to say that a new
\npandemic virus could develop if a human
\nbecame simultaneously infected with avian
\nand human influenza viruses, resulting in
\ngene swapping and a new virus strain for
\nwhich there may be no immunity.
\nThe committee recommended that the
\nwhole document as amended should be ap-
\nproved by the Council and forwarded to the
\nAssembly for adoption.
\n6
\nWMA Council Session
\nNuclear Weapons
\nA revised Statement on Nuclear Weapons
\nwas presented jointly by the Japan Medical
\nAssociation and the International Physi-
\ncians for the Prevention of Nuclear War.
\nDr.\u00a0 Bj\u00f8rn Hilt, chair of board of the
\nIPPNW, said there were two important
\namendments to the previous WMA State-
\nment on nuclear weapons. The first was the
\nso-called modernization of nuclear weap-
\nons. Nuclear weapon states wanted to use
\na perverse amount of money to modernize
\ntheir nuclear arsenals They wanted to use
\ntrillions of US dollars, pounds and roubles
\nto modernize their nuclear weapons and to
\nkeep them for infinity. This meant making
\nthese weapons more usable and this was
\nvery dangerous and disturbing.
\nThe other amendment was that 122 UN
\nmembers on July 7 last year adopted the
\ntext of the Treaty on Nuclear Weapons.The
\nsecretariat of the WMA, ICN and IPPNW
\nhad published a joint statement in Septem-
\nber. But to make this statement the official
\npolicy of the WMA it needed the approval
\nof the Council. They had a common inter-
\nest to use this new window of opportunity
\nof the Treaty to educate the public and for
\nWMA members to put pressure on their
\nown governments.
\nHe said that critics of the Treaty argued that
\nthe Treaty as such would not eliminate a
\nsingle nuclear weapon. But once the Treaty
\nhad been ratified by 50 states it would en-
\nter into force and become international law.
\nThat would strengthen the legal and moral
\npressure on nuclear states to fulfil their ex-
\nisting obligations according to the non-pro-
\nliferation Treaty to negotiate for the elimi-
\nnation of all nuclear weapons. Dr.\u00a0Hilt said
\nthey could still prevent another catastrophe
\nof nuclear weapons happening.
\nDelegates agreed several minor amend-
\nments to the Statement and the committee
\nagreed to recommend to the Council that
\nthe Statement be forwarded to the General
\nAssembly for adoption.
\nThe committee also agreed the emergency
\nresolution on nuclear weapons and recom-
\nmended to the Council that it be approved.
\nMaternal and Child Health
\nThe Japanese Medical Association pre-
\nsented a proposed Statement on the De-
\nvelopment and Promotion of a Maternal
\nand Child Health Handbook. The State-
\nment was based on a booklet developed by
\nthe Japanese Medical Association in 1948.
\nThe committee was told that the booklet
\nhad contributed to improved health for
\nthe mother and child in Japan. Today there
\nwere 40 different versions of the handbook
\nin various countries.There was also an elec-
\ntronic format. The Japanese Medical Asso-
\nciation said the WMA should be collabo-
\nrating on this with the WHO, and NMAs
\nshould help in developing and promoting
\nthe handbook globally.
\nThe Committee agreed to recommend to
\nCouncil that the booklet be circulated to
\nconstituent members for comment.
\nPseudoscience
\nA proposed Declaration on Pseudoscience,
\nPseudotherapies, intrusion and sects in the
\nfield of health was submitted by the Spanish
\nMedical Association. It argued that there
\nwas concern over the proliferation of these
\npractices with their negative consequences.
\nThere was a whole group of disciplines of
\npseudo practices intruding on the medi-
\ncal profession and trying to trespass on the
\nscope of conventional scientific based medi-
\ncine. But in most countries there was no
\nregulatory framework.
\nThe committee recommended that the doc-
\nument be circulated to constituent members
\nfor comment.
\nLatvian Reception
\nDuring an evening reception, hosted by the
\nLatvian Medical Association for all WMA
\ndelegates, Dr.\u00a0Ilze Aizsilniece, Vice Presi-
\ndent of the LVA, welcomed the WMA, and
\ntalking about the changing weather in Riga
\nand the change in democracy that had oc-
\ncurred in her country.
\n\u2018Nuclear weapons, detention of medical
\ndoctors for expressing publicly their con-
\ncerns about the impact of war on humans\u2019
\nhealth, autonomy of the medical profession,
\nthe way the research is conducted: these are
\nonly a few of problems discussed during the
\n209th
\nCouncil of the WMA.
\n\u2018Maybe someone will say that medical
\ndoctors should not be concerned about
\nsuch matters, they should only focus on
\nclinical practice and research. I want to
\noppose.
\n\u2018I lived in a country where travel to another
\ncountry was a dream. We needed special
\npermission from authorities to cross the
\nborder. Only books approved by the author-
\nities were available. Reading other books
\nwas a very dangerous. I lived in a country
\nwhere people not agreeing with the system
\nwere imprisoned in psychiatric hospitals.
\nCan you be a good medical doctor in such
\nsituation? Can you follow the principles
\nof medical ethics in such circumstances?
\nI\u00a0doubt it.
\n\u2018I would like to take this opportunity to
\nthank the World Medical Association for
\nthe courage to tackle inconvenient topics, to
\ntake action in support of the national medi-
\ncal associations, to discuss internationally
\nthe problems related to environment and
\nother factors affecting human health.
\n\u2018I do believe that working together we
\ncan make this planet peaceful and healthy.
\nThank you for the work you are doing ev-
\nery day at the national and international
\nlevel\u2019
\n7
\nBACK TO CONTENTS
\nWMA Council Session
\nFRIDAY APRIL 28
\nSocio Medical Affairs
\nCommittee (continued)
\nClassification of Documents
\nNine policies that were 10 years old were
\nconsidered for review:
\n–
\n– The Committee recommended that the
\nfollowing documents should undergo a
\nmajor revision:
\n–
\n– Resolution on the Access of Women
\nand Children to Health Care and the
\nRole of Women in the Medical Profes-
\nsion
\n–
\n– Statement on Reducing Dietary So-
\ndium Intake
\n–
\n– Statement on Resistance to Antimicro-
\nbial Drugs
\n–
\n– Statement on Violence and Health
\n–
\n– The following Statements should un-
\ndergo a minor revision
\n–
\n– Resolution on Collaboration Between
\nHuman and Veterinary Medicine
\n–
\n– Statement on Reducing the Global
\nBurden of Mercury
\n–
\n– The following documents should be
\nrescinded
\n–
\n– Resolution on Poppies for Medicine
\nProject for Afghanistan
\n–
\n– Resolution on Economic Crisis: Impli-
\ncations for Health
\n–
\n– The following policy should be reaf-
\nfirmed
\n–
\n– Resolution Supporting the Ottawa
\nConvention on the Prohibition of
\nthe Use, Stockpiling, Production, and
\nTransfer of Anti-Personnel Mines and
\non Their Destruction
\nDisaster Preparedness
\nThe Japanese Medical Association sub-
\nmitted a paper on disaster medicine and
\nraised the issue of whether the WMA
\nshould establish a network for disaster
\nmedicine.
\nThe paper argued that the time had come for
\nWMA to establish such a disaster-response
\nand assistance scheme on the global level.
\nThis would involve the WMA in bringing
\ntogether UN agencies, international or-
\nganizations, governments, military forces,
\nNGOs and others to work for disaster relief
\nin a bilateral manner. Medical association
\nmembers in each country would actively
\nparticipate in such a network.
\nThe Committee agreed to recommend that
\nthe proposal to set up a WMA Network on
\nDisaster Medicine be approved by Council
\nand forwarded to the General Assembly for
\nadoption.
\nArtificial Intelligence
\nThe American Medical Association pre-
\nsented a white paper on Artificial\/Aug-
\nmented Intelligence and Considerations for
\nUse of Health Care. The paper asked how
\nthe WMA should position itself on this is-
\nsue. Computing power had a broad impact
\nin many areas of life and would have a great
\nimpact on medicine. This could be posi-
\ntive, but there needed to be a dialogue with
\nother stakeholders. Clinical decision mak-
\ning could be enhanced by this, not replaced
\nby it. However, there were downsides, for
\ninstance on liability issues and protection
\nof health data. The AMA said it would be
\ndiscussing this topic at its meeting in June
\nand might return with proposals at a future
\nWMA meeting.
\nAutonomy of Doctor\u2019s work
\nThe Finnish Medical Association made
\na presentation to the Committee on ethi-
\ncal guidelines it had drawn up to support
\ndoctors acting in unclear situations. The
\nguidelines were thought necessary because
\nit was felt that professional autonomy was
\nnot clear to all doctors and particularly to
\njunior doctors. Yet the pressure on the pro-
\nfession was very strong,from politicians,the
\nmedia, patients and the pharmaceutical in-
\ndustry. So the Finnish Medical Association
\nhad collected what it called \u201c10 Command-
\nments\u201d from WMA policy documents and
\nits own policies to help doctors understand
\nwhat their obligations were.
\nMedical Ethics Committee
\nDr.\u00a0 Heidi Stensmyren (Sweden) took the
\nchair.
\nDr.\u00a0 Kloiber, the Secretary General, high-
\nlighted two important emerging issues
\nthat impacted on the medical profession.
\nThe first was artificial\/augmented intelli-
\ngence. In many countries ethical questions
\nwere being discussed.The WMA needed to
\nhave an ethical position on this and would
\nbe helped by knowing more about what
\nNMAs were doing in this area.
\nThe second issue was nano-technology,
\nwhere more questions were being asked. It
\nwas being widely introduced in many ar-
\neas of our lives, and regulatory authorities
\nwith whom the WMA worked were already
\nworking on these issues. This would have
\nregulatory consequence and there would
\nbe ethical ramifications. The WMA should
\nlook into this and he invited NMAs to
\nshare their work with the Association.
\nFinally, he said that the Pontifical Acad-
\nemy for Life had issued a White Paper on
\nGlobal Palliative Care Advocacy, and the
\nWMA had been invited to participate in
\nthis process.
\nTurkey
\nThe Committee heard a report on the situ-
\nation in Turkey and, in particular, how it
\naffected the Turkish Medical Association.
\nThey were reminded that the Turkish Med-
\nical Association had no ties to any Govern-
\nment bodies and received no financial sup-
\nport from Government. It had authority to
\n8
\ntake disciplinary action over violations of
\nprofessional conduct and was on the side
\nof prioritising disadvantageous groups and
\nthe oppressed. It also tried to keep channels
\nof dialogue open with the government. On
\nJanuary 24,after Turkish armed forces start-
\ned a military campaign in Afrin, the Turk-
\nish Medical Association had issued a press
\nrelease saying that war was a public health
\nproblem. After this press release, Turkish
\nauthorities accused the TMA of assisting
\nterrorists. A criminal complaint was filed
\nagainst TMA leaders for making propa-
\nganda in favour of a terrorist organisation.
\nThe Ministry of Health filed another law
\nsuit saying that the TMA engaged in activi-
\nties incompatible with its mandate. Central
\ncommittee members of the TMA were
\nthen detained for a week. Delegates were
\ntold that the TMA had fulfilled the pro-
\nfessional duty of physicians and the WMA
\nand NMAs around world had responded in
\nsupport.
\nDr.\u00a0Kloiber said the WMA had organised a
\nhighly successful social media campaign in
\ndefence of the TMA.
\nIstanbul Protocol
\nClarisse Delorme, WMA Advocacy Advi-
\nsor, reported that the WMA had been in-
\nvited to participate in the development of
\na supplement to the Manual on Effective
\nInvestigation and Documentation of Tor-
\nture and Other Cruel, Inhuman or Degrad-
\ning Treatment or Punishment, commonly
\ncalled the Istanbul Protocol.
\nTherapeutic Abortion
\nAs part of the annual policy review process,
\nthe Committee continued its revision of the
\nWMA Declaration on Therapeutic Abor-
\ntion. It considered a draft document that
\nhad been circulated among members, and
\nreceived an oral report from the workgroup
\nset up to work on the document.
\nIn the debate that followed it was argued
\nthat it should be made clear in the preamble
\nwhat this document was not about. It was
\nproposed that the following wording be
\nadded: \u201cThis Declaration does not include
\nor imply any views on termination of preg-
\nnancy carried out for any reason other than
\nmedical indication\u201d. This wording was ap-
\nproved.
\nIt was also suggested that the document
\nshould be renamed WMA Statement on
\nMedically-Indicated Termination of Preg-
\nnancy.This was also approved.
\nAfter a further debate, during which other
\namendments were approved, the Commit-
\ntee recommended that the Statement, as
\namended, be approved by Council and for-
\nwarded to the General Assembly for adop-
\ntion.
\nEthics of Telemedicine
\nThe revised WMA Statement on the Ethics
\nof Telemedicine was considered. It had been
\nagreed that the document should undergo
\na major revision and the South African
\nMedical Association volunteered to under-
\ntake that work. The document before the
\ncommittee explained that telemedicine was
\nthe practice of medicine over a distance, in
\nwhich interventions, diagnoses, therapeu-
\ntic decisions, and subsequent treatment
\nrecommendations were based on patient
\ndata, documents and other information
\ntransmitted through telecommunication
\nsystems. The committee was told that the
\ndocument addressed a number of issues,
\nincluding cross border regulation. However,
\nthe Statement as revised still highlighted
\nthe importance of face to face medicine and
\ndoctors\u2019 autonomy in their responsibilities
\nin telemedicine.
\nA brief debate followed about the phrase in
\nthe document that \u201cthe patient-physician
\nrelationship must be based on a prior per-
\nsonal examination\u201d. The committee agreed
\nthat this should be amended, along with
\nother changes.
\nThe committee then recommended that the
\nproposed Statement, as amended, be ap-
\nproved by the Council and forwarded to the
\nGeneral Assembly for adoption.
\nFleeing Physicians
\nThe committee considered the proposed re-
\nvision of the WMA Statement on Licensing
\nof Physicians Fleeing Prosecution for Seri-
\nous Criminal Offences. During the debate
\nthat followed, a number of questions were
\nraised. It was explained that this document
\nwas about physicians fleeing prosecution.
\nBut what was meant by serious offences?
\nSome people talked about serious allega-
\ntions, some about offences and some about
\ncrimes. Should they be talking about phy-
\nsicians who had not yet been prosecuted?
\nAnd what was meant by serious offences?
\nShould it be up to the host country to de-
\ncide?
\nThe committee approved one amendment,
\nmaking it clear that physicians who had
\nbeen convicted of serious criminal offenc-
\nes, in particular of genocide, war crimes or
\ncrimes against humanity,should be denied a
\nlicence to practice medicine elsewhere.
\nHowever, speakers argued that further con-
\nsideration should be given to the definition
\nof serious or outrageous offences and it was
\nagreed to recommend to Council that the
\ndocument be recirculated to members for
\ncomment.
\nEnd of Life Questions
\nThe committee heard reports about the four
\nregional end of life conferences that had
\nbeen held around the world, as part of the
\nWMA\u2019s review of its policy on physician as-
\nsisted suicide and euthanasia. Four written
\nreports were submitted (see p. 13) and oral
\nWMA Council Session
\n9
\nBACK TO CONTENTS
\nreports were also given about the discus-
\nsions in Nigeria and in Rome.
\nDr.\u00a0Kloiber explained that this issue would
\nbe brought back into an international dis-
\ncussion to be started in Reykjavik at the
\nmedical ethics conference before the Gen-
\neral Assembly in October.
\nA brief debate took place about how to
\nreconcile current WMA policy that eutha-
\nnasia was unethical with the fact that in
\nsome countries euthanasia was now legal.
\nThe committee was told that there would
\nbe ample time to discuss this matter fur-
\nther at the medical ethics conference in
\nReykjavik.
\nThe Canadian Medical Association gave
\nnotice that together with the Royal Dutch
\nMedical Association it would be bringing a
\ndraft revised paper for consideration in Oc-
\ntober, to see if they could accommodate all
\nthe divergent views among members.
\nDr.\u00a0Kloiber said that one message he took
\nfrom the regional conferences was that
\nthere was a very strong need for the WMA
\nto look again at its policies relating to end-
\ning futile treatment, respecting patient will
\nand the use of living wills, as well as pallia-
\ntive care.
\nGenetics and Medicine
\nThe Danish Medical Association proposed
\nthat the WMA initiate a major revision of
\nits Statement on Genetics and Medicine.
\nThe main reason for this was that the cur-
\nrent version of the Statement did not deal
\nsufficiently with the ethical issues that
\narose through the development and use
\nof next-generation sequencing in person-
\nalized medicine. It was proposed that a
\nworking group be set up to carry out the
\nrevision.
\nThe committee agreed to recommend to
\nCouncil that a major revision take place and
\nthat a working group be set up to do this,
\nwith the aim of producing a revised State-
\nment to be considered by the meeting in
\nReykjavik.
\nBiosimilar Medicinal Products
\nThe Israeli Medical Association proposed a
\nStatement on Biosimilar Medicinal Prod-
\nucts. Delegates were told that biological
\npharmaceuticals had been around for some
\ntime. This had allowed new methods of
\ntreatment, but these were extremely costly
\nand were hard to access. The high pricing
\nwas because of the complexity of manu-
\nfacturing and production, but also because
\nthese pharmaceuticals were under patent.
\nNow some of these patents were starting to
\nexpire. This would reduce prices consider-
\nably, allowing more patients and countries
\nto access these therapies. But identical ac-
\ntive substances could not be created because
\nthere might be a difference in the dosages.
\nThe challenge was to know when a drug was
\na biosimilar or not. In Europe biosimilars
\nhad been regulated since 2005. In the US
\nthey had only allowed this in 2015. In Israel
\nthey were not allowing it, but difficult regu-
\nlatory issues were involved. One of the ethi-
\ncal challenges to be faced was that insurers,
\nemployers and maybe governments might
\nbe inclined to encourage or demand phy-
\nsicians to switch to biosimilars because of
\nlower prices, posing a risk to patients. It was
\ntherefore thought important for the WMA
\nto have some guidance on this issue.
\nThe committee agreed to recommend to
\nCouncil that the proposed Statement be
\ncirculated to members for comment.
\nClassification of 2008 Policies
\nThe committee recommended that the
\nResolution on Physician Participation in
\nCapital Punishment and the Resolution on
\nthe Prohibition of Physician Participation
\nin Capital Punishment be merged.
\nIt also recommended to Council that the
\nResolution on the Responsibility of Physi-
\ncians in the Denunciation of Acts of Torture
\nor Cruel,Inhuman or Degrading Treatment
\nof Which They are Aware should undergo a
\nmajor revision and that a workgroup be set
\nup to undertake this.
\nThe committee recommended that the In-
\nternational Code of Medical Ethics should
\nundergo a long-term major revision and
\nthat a working group be set up to undertake
\nthis.
\nFemale Foeticide
\nThe committee was informed that the Swiss
\nMedical Association, with the support of
\nthe Swedish Medical Association, would
\nsubmit a revision of the WMA Resolution
\non Female Foeticide at the General Assem-
\nbly in Reykjavik in October.
\nSATURDAY APRIL 29
\nCouncil (continued)
\nDr.\u00a0 Hoven took the chair for the recon-
\nvened meeting of the Council and delegates
\nstood to recite the Physicians\u2019 Pledge.
\nThe Council considered reports from the
\nthree committees that had met on the pre-
\nvious two days.
\nReport of the Medical
\nEthics Committee
\nMedically-Indicated
\nTermination of Pregnancy
\nA proposal was put forward to amend the
\nproposed Declaration to add to the pre-
\namble the words: \u201cThe medical profession
\nretains its respect for all human life, born
\nand unborn\u201d. However, after a brief debate,
\nWMA Council Session
\n10
\nthe proposed amendment was defeated,
\nand the Council agreed that the Declara-
\ntion as submitted should be approved and
\nforwarded to the General Assembly for
\nadoption.
\nTelemedicine
\nThe Council agreed to forward to the Gen-
\neral Assembly the Statement on the Ethics
\nof Telemedicine.
\nFleeing Physicians
\nThe Council agreed to recirculate the pro-
\nposed Statement on Licensing of Physicians
\nFleeing Prosecution for Serious Criminal
\nOffences for comment.
\nGenetics and Medicine
\nThe Council agreed to set up a work group
\nto develop a Statement on Genetics and
\nMedicine and to circulate the document
\nfor comment, with the aim of producing a
\nrevised Statement to be considered by the
\nmeeting in Reykjavik.
\nBiosimilar Medicinal Products
\nThe Council agreed to circulate the pro-
\nposed Statement on Biosimilar Medicinal
\nProducts for comment.
\nClassification of Documents
\nThe Council agreed:
\n\u2022\t that the Resolution on Physician Partici-
\npation in Capital Punishment be merged
\nwith the WMA Resolution to Reaffirm
\nthe WMA\u2019s Prohibition of Physician Par-
\nticipation in Capital Punishment, which
\nwill constitute a minor revision as there is
\nno change to the content of either docu-
\nment
\n\u2022\t that the resolution on the Responsibility
\nof Physicians in the Denunciation of Acts
\nof Torture or Cruel, Inhuman or Degrad-
\ning Treatment of Which They are Aware
\nundergo a major revision
\n\u2022\t that a workgroup be set up to undertake
\na long term major review of the Interna-
\ntional Code of Medical Ethics
\nReport of the Finance and
\nPlanning Committee
\nFinancial Statement
\nThe Council approved the interim Financial
\nStatement for 2017.
\nFuture Meetings
\nIt agreed the following dates for future
\nmeetings:
\n\u2022\t the 218th
\nCouncil session to be held from
\n22\u201324 April 2021
\n\u2022\t the 72nd
\nGeneral Assembly to be held
\nfrom 13\u201316 October 2021
\n\u2022\t the 221st
\nCouncil session to be held from
\n7\u20139 April 2022
\n\u2022\t that no additional invitations be accepted
\nfor the 2020 General Assembly, 2021
\nCouncil Session, and 2023 Council Ses-
\nsion and General Assembly, and that the
\ndecision regarding the existing invita-
\ntions from Rwanda, the UK, and Spain
\nbe postponed to the next Council session
\nin Reykjavik.
\n\u2022\t the invitation from CNOM France to
\nhost the 221st
\nCouncil Session in Paris in
\nApril 2022 be accepted.
\nNominating process for
\nWMA Presidency
\nThe Council agreed that the proposal to
\nintroduce a self-declaration statement to
\nthe nominating process for WMA Presi-
\ndency be circulated to members for com-
\nment and for further discussion at the next
\nmeeting.
\nReport of the Socio-Medical
\nAffairs Committee
\nPlastic Bags, Ecological
\nIssues & Environmental
\nDegradation
\nThe Council agreed to circulate for com-
\nment the proposed Statement on Environ-
\nmental Degradation and Sound Manage-
\nment of Chemicals
\nPolicies for Adoption
\nThe Council agreed that the following doc-
\numents be approved and forwarded to the
\nGeneral Assembly for adoption:
\n–
\n– Statement on Medical Tourism
\n–
\n– Statement on Gender Equality in
\nMedicine
\n–
\n– Declaration of Seoul on Professional Au-
\ntonomy and Clinical Independence
\n–
\n– Statement on Sustainable Develop-
\nment
\n–
\n– Statement on Avian and Pandemic In-
\nfluenza
\n–
\n– Statement on Nuclear Weapons
\nEmergency Resolution
\nIt was agreed that the proposed emergency
\nResolution on the Prohibition of Nuclear
\nWeapons be approved for immediate release
\n(see p. 13).
\nDocuments to be Circulated
\nThe Council agreed that three documents
\nbe circulated among members for com-
\nments:
\n–
\n– Declaration of Madrid on Professionally-
\nled Regulation
\nWMA Council Session
\n11
\nBACK TO CONTENTS
\n–
\n– Statement on the Development and
\nPromotion of a Maternal and Child
\nHealth Handbook
\n–
\n– Declaration on Pseudoscience, Pseudo
\ntherapies, Intrusion and Sects in the
\nfield of health
\nClassification of Documents
\nThe Council agreed that the following poli-
\ncies should undergo major revision:
\n–
\n– Resolution on Access of Women and
\nChildren to Health Care and the Role
\nof Women in the Medical Profession
\n–
\n– Statement on Reducing Dietary So-
\ndium Intake
\n–
\n– Statement on Resistance to Antimicro-
\nbial Drugs
\n–
\n– Statement on Violence and Health
\nIt was agreed that the Resolution on Col-
\nlaboration Between Human and Veterinary
\nMedicine and the Statement on Reducing
\nthe Global Burden of Mercury be reaffirmed
\nwith minor revision and that the Resolution
\nSupporting the Ottawa Convention on the
\nProhibition of the Use,Stockpiling,Produc-
\ntion, and Transfer of Anti-Personnel Mines
\nand on Their Destruction be reaffirmed.
\nFinally, it was agreed that the Resolu-
\ntions on Poppies for Medicine Project for
\nAfghanistan and on the Economic Crisis:
\nImplications for Health be rescinded and
\narchived.
\nDisaster Medicine
\nThe Council agreed that the proposal to set
\nup a WMA Network on Disaster Medicine
\nbe approved.
\nAdvocacy Panel
\nDr.\u00a0 Ashok Paul, Chair of the Advocacy
\nPanel, presented an oral report from the
\ngroup. He said that despite the fact that the
\nWMA had a very small permanent staff,
\nthe Association had a fairly wide reach and
\nhigh brand name recognition, well above
\nwhat might be expected based on size
\nalone. He said the prime focus of increasing
\nthe WMA\u2019s visibility, reach and influence
\nshould be concentrated on NMAs. He sug-
\ngested that briefings should be arranged for
\nnew participants to WMA meetings to in-
\nform them about available WMA resources.
\nAnother way to raise the Association\u2019s pro-
\nfile would be to consider relaxing the rule
\nthat matters under discussion should not be
\ndiscussed in public fora. And he said that
\nthere could be more engagement with non-
\nmember NMAs.
\nWorld Health Organisation
\nThe Council heard reports on the WMA\u2019s
\nwork with the WHO on a number of is-
\nsues, including supporting the development
\nof Universal Health Coverage, engagement
\non the health workforce and emergency
\npreparedness.
\nThe 71st
\nWorld Health Assembly, in May,
\nwas due to discuss two high level meetings
\non NCDs and TB arranged for later in the
\nyear.
\nTogether with the other health professions
\nin the World Health Professions Alliance,
\nthe WMA was holding the 5th Regulation
\nConference. And there was also due to be a
\nside event during the World Health Assem-
\nbly on the 100th anniversary of the Spanish
\nflu outbreak.
\nThe WMA would be sponsoring a lunch-
\ntime event during the week on Healthcare
\nin Danger and the issue of strengthening
\nnational frameworks for the protection of
\nhealth care.
\nDr.\u00a0Kloiber then spoke about some of the
\npolitical undercurrents currently going on
\nabout the 40th
\nanniversary of the Alma Ata
\nDeclaration. This Declaration had put the
\nfocus on primary care and this had led to
\nHealth for All for 2000.But the Declaration
\nhad had only a limited success. However, a
\n2008 report on primary care had emphasised
\nthe value of primary care as the core part of
\ncomprehensive health care and the necessity
\nfor family physicians as part of it.
\nHe said there was a clear role for the physi-
\ncian as a leading part of the primary care
\nteam. But in a further document that was
\ncurrently being discussed as part of the fol-
\nlow up to Alma Ata, the focus had been put
\non other health professionals and not on
\nfamily physicians. There was a strong trend
\nto change the scope of practice towards
\nnurse specialists and pharmacists, not only
\nconcerning prescribing rights, but also to
\nbe the first point of contact in primary care
\nprovision. This was something about which
\nthe WMA was extremely critical. Howev-
\ner, it was no longer enough to simply say
\n\u201cno\u201d to this development. The WMA had
\nto have scientific evidence. So it was now
\nbuilding a coalition of organisations with
\nthe same views and was looking for what
\nevidence there was to support its case on
\nfamily physicians. It was important that
\nthose NMAs that had already done work
\non scope of practice came forward with the
\nnecessary material to help the WMA\u2019s case.
\nDr.\u00a0 Kloiber\u2019s report led to a lengthy and
\nwide-ranging debate, that turned out to be
\none of the most important discussions of
\nthe meeting.
\nSpeakers from Israel, Denmark, India and
\nSouth Africa were among those who sup-
\nported Dr.\u00a0 Kloiber and reported about
\nsimilar pressures in their countries. In Isra-
\nel, these pressures were leading to tensions
\nbetween physicians and nurses. There was
\nagreement that the WMA needed to work
\non its arguments about the importance
\nof family physicians. It needed to counter
\nthe argument that nurse practitioners were
\nmore cost effective. Some speakers talked
\nabout patients preferring to see family phy-
\nsicians, while others referred to the risk to
\nWMA Council Session
\n12
\npatient safety and quality of care by moving
\naway from family physicians. What was re-
\nquired was less complexity in delivering pri-
\nmary care, not more complexity from more
\nindependent contractors.
\nIt was reported that in India this issue was
\na huge problem.Thousands of medical cen-
\ntres were being opened by the Government,
\nmanned by non-doctors. The medical pro-
\nfession was fighting this, but it needed evi-
\ndence to bring the community onside.
\nIt was argued that this was essentially a
\npolitical problem, in part caused by a lack
\nof doctors, encouraging other professions
\nto trespass on the medical profession. In
\nFrance they referred not to doctors but to
\nhealth professionals. One speaker said doc-
\ntors should not talk about delegating tasks
\nto nurses, but about collaborating with
\nnurses.
\nSeveral speakers said there was a need to
\nrecognise that the delivery of health care
\nhad changed with time and the role of doc-
\ntors was changing as well. This required
\nthinking about who was the most appro-
\npriate person to deliver a particular type of
\ncare.But it was also said that patients would
\nalways need medical practitioners and non-
\nmedical practitioners should be augmenting
\nphysicians\u2019 job and not replacing them.
\nSpeakers from Brazil, France, Britain, Ger-
\nmany, Canada and Malaysia, all referred to
\nsimilar problems in their own countries.
\nThere was general agreement that this was
\nan extremely important issue and that the
\nWMA needed to engage with governments
\nas well as with the community as a whole.
\nThe Council approved a proposal for the
\nsecretariat to prepare urgently an advocacy
\nplan for the Council Executive on how to
\nrespond to this issue.
\nThe meeting ended with a round of thanks
\nfrom Dr.\u00a0Kloiber for all those who had con-
\ntributed towards a highly successful meet-
\ning.
\nMr. Nigel Duncan,
\nPublic Relations Consultant, WMA
\nE-mail: nduncan@ndcommunications.co.uk
\nWMA Council Session
\n13
\nBACK TO CONTENTS
\nWMA Council Resolution
\non the Prohibition of Nuclear
\nWeapons
\nAdopted by the 209th
\nSession of the Council, Riga, April 2018
\nThe duties of physicians are to preserve life and safeguard the
\nhealth of the patient and to dedicate themselves to the service of
\nhumanity.
\nConcerned about current global discussions on nuclear proliferation
\nand given the catastrophic consequences of these weapons on hu-
\nman health and the environment, the World Medical Association
\n(WMA) and its Constituent Members consider that they have a re-
\nsponsibility to work for the elimination of nuclear weapons world-
\nwide.
\nThe WMA is deeply concerned by plans to retain indefinitely and
\nmodernize nuclear arsenals; the absence of progress in nuclear
\ndisarmament by nuclear-armed states; and the growing threat of
\nnuclear war.
\nThe WMA welcomes the Treaty on the Prohibition of Nuclear
\nWeapons, and joins with others in the international community,
\nincluding the Red Cross and Red Crescent movement, Interna-
\ntional Physicians for the Prevention of Nuclear War, the Interna-
\ntional Campaign to Abolish Nuclear Weapons, and a large majority
\nof UN member states. Consistent with our mission as physicians,
\nthe WMA calls on all states to promptly sign, ratify or accede to,
\nand faithfully implement the Treaty on the Prohibition of Nuclear
\nWeapons;
\nEmphasizing the devastating long-term health consequences, the
\nWMA and its Constituent Members urge governments to work
\nimmediately to prohibit and eliminate nuclear weapons.
\nEnd of Life Seminars
\nThe Socio Medical Affairs Committee received reports about the
\nfour end of life conferences that had been held in Latin America,
\nAsia, Europe and Africa, as part of the WMA\u2019s review of its policy
\non physician assisted suicide. Four written reports were submitted
\nand oral reports were also given on each conference. A summary of
\nthe written reports follows.
\nBrazil Symposium
\nA written report was submitted by the Brazilian Medical Associa-
\ntion about the Symposium it hosted in Rio de Janeiro in March
\n2017. This referred to the advances in medicine as well as the in-
\ncrease in life expectancy which had led to times of suffering, useless
\ntreatments and the solitude of patients. Against this background,
\npalliative care must be a right or at least an attainable service for all
\npatients.The report spoke about the need to protect patients\u2019dignity
\nand added \u2018if the doctor is prepared not only to cure but also to kill,
\nthe ethics of medical practice and the trust that the patient must
\nhave in his doctor will be very battered\u2019.
\nThe report referred to the pressure that some patients might face if
\neuthanasia was allowed and the fact that the request for euthanasia
\nmight be reduced by improved training of professionals in palliative
\ncare. It said societies should be aware of the \u2018slippery slope\u2019 risks of
\nlegislation allowing euthanasia.
\nIt concluded: \u2018The sick at the end of life need a helping hand not to
\nprecipitate their death, nor to prolong their agony with the thera-
\npeutic obstinacy,but to be with them and relieve their suffering with
\npalliative care while their death arrives\u2019.
\nJapan Symposium
\nThe meeting on End-of-Life Questions in Japan was held on Sep-
\ntember 14 and 15,2017,with the participation of the Confederation
\nof Medical Associations in Asia and Oceania members,the Chinese
\nMedical Association and the Israel Medical Association. A report,
\nprepared by Professor Tatsuo Kuroyanagi,the legal adviser of the Ja-
\npan Medical Association, said the main purpose of the symposium
\nwas to investigate different opinions that existed among the WMA
\nAsia-Pacific members and their home countries\/jurisdictions with
\nregard to the three WMA policies, namely WMA Declaration on
\nEuthanasia, WMA Statement on Physician-Assisted Suicide, and
\nWMA Resolution on Euthanasia.
\nA questionnaire survey was sent to 21 NMAs, and 19 submitted
\ntheir answers. At the symposium, 17 NMAs presented their reports
\nby further elaborating or partially modifying their answers. At the
\nmeeting NMAs were divided into four groups based on the simi-
\nlarities in legal systems and religions.
\nBased on the survey and the group discussions,all of the NMAs op-
\nposed euthanasia and physician assisted suicide.With the exception
\nof Australia and New Zealand, there was no significant desire in the
\ncivil society of the Asia\/Oceania region to discuss the concept of eu-
\nthanasia and PAS. However, all the NMAs supported the creation
\nof Advanced Directives and advanced care planning with physicians
\nfor the terminally-ill patients.
\nWMA Council Session
\n14
\nRome Symposium
\nThe WMA together with the German Medical Association and the
\nPontifical Academy for Life organized a two-day Conference at the
\nVatican\u2019s Aula Vecchia del Sinodo on 16 and 17 November 2017.
\nThe meeting was attended by around 150 participants, including
\nWMA leaders and members, experts in palliative care, ethicists,
\nlawyers and religious leaders. The presentations and the views ex-
\npressed covered the full spectrum of opinion.
\nIn an address prepared by Pope Francis and read by Cardinal Pe-
\nter Turkson, the Pope said it was clear that not adopting, or else
\nsuspending, disproportionate measures, meant avoiding overzealous
\ntreatment. From an ethical standpoint, this was completely differ-
\nent from euthanasia, which was always wrong, in that the intent of
\neuthanasia was to end life and cause death.
\nThroughout the meeting, proponents of right-to-die policies empha-
\nsised that their intention was to protect physicians in their own coun-
\ntries who are acting within the law,not to change or influence policies
\nin other countries. They based their arguments on the concepts of
\npatient self-determination, dignity and compassion. Those who were
\nopposed to euthanasia and PAS, representing the majority of attend-
\nees, rejected these procedures as being diametrically opposed to the
\nethical principles of medicine and expressed concern that they could
\nlead to misuse or abuse, e.g. in the case of mentally or psychologically
\nincapacitated people. They also expressed concern that these proce-
\ndures could cause damage to the complete trust which characterises
\nthe patient-physician relationship or lead to social pressure for the
\nelderly or those with chronic illness to end their lives.
\nThe majority of attendees ultimately advocated for the retention of
\nthe existing policies of the WMA on euthanasia and PAS.
\nBut participants were united in their support for high-quality, ac-
\ncessible palliative care and their belief that PAS and euthanasia
\nshould never be seen as a cost-saving measure.
\nNigeria Symposium
\nThe African Symposium was hosted by the Nigerian Medical As-
\nsociation in Abuja, Nigeria on February 1 and 2 2018.
\nAttendees included Presidents and delegates of National Medi-
\ncal Associations from Nigeria, Zambia, Kenya, South Africa, Cote
\nD\u2019Ivoire and Botswana.
\nAmong the resolutions at the conclusion of the meeting were that
\nNMAs in Africa are unanimously opposed to euthanasia and physi-
\ncian assisted suicide in any form. They supported policies and leg-
\nislations permitting and strengthening palliative care. There was a
\nneed for improved political will and commitment to palliative care
\nby African Governments. There was agreement on the need to ori-
\nentate governments, policy makers and the public on the impor-
\ntance and availability of palliative care.
\nAnd there was great need for the strengthening of African health-
\ncare systems, universal health coverage, improved budgetary alloca-
\ntion to health, and integration of palliative care and other chronic
\nmedical conditions into the health care financing\/health insurance
\nschemes of African countries.
\nJunior Doctors Meeting
\nThe Junior Doctors Network held a meeting prior to the 209th
\nWMA Council Meeting. This brought together 20 young doctors
\nfrom across the world to discuss issues important to the WMA\u2019s
\nwork and to gain skills important for their work and future roles
\nas health leaders. The event served as an opportunity to meet with
\na\u00a0number of Latvian junior doctors as well a representative from the
\nEuropean Junior Doctors Association.
\nThe day started with a meeting with the WMA leadership\u00a0\u2013 Dr.\u00a0Yo-
\nshitake Yokokura, WMA President, Dr.\u00a0Ardis Hoven, WMA Chair
\nof Council, and Dr.\u00a0Otmar Kloiber, WMA Secretary General. There
\nwere discussions on leadership within the WMA and within National
\nMedical Associations,as well as current issues important to the WMA.
\nThe morning session included important internal work for the
\nJDN reviewing the proposed terms of reference for JDN Working
\nGroups, and a discussion on the structure of JDN meetings and ap-
\nproaches to membership of the network.
\nConcluding the morning, a scientific workshop on climate change
\npolicy and health summarized WMA work in this field at the inter-
\nnational level It highlighted future opportunities for JDN involve-
\nment and familiarized participants with how national commitments
\nare defined. This allowed them to reflect how they could contrib-
\nute to the implementation of the WMA Declaration of Delhi on
\nHealth and Climate Change in their own contexts.
\nDuring the afternoon, selected JDN working groups were discussed
\nwith important advances made with respect to planning the work of
\nthe recently created group on Working Conditions. Finally, for the
\nfirst time at any JDN meeting, there was a leadership training sec-
\ntion, led by two external speakers, Drs Paul Jones and Greg Radu.
\nThis elaborated on different leadership theories and their applica-
\ntion in the healthcare context.
\nYassen Tcholakov
\nJDN Socio-Medical Affairs Officer
\nWMA Council Session
\n15
\nBACK TO CONTENTS
\nThe Fifth World Health Professions Regu-
\nlation Conference was held at the Crowne
\nPlaza Hotel, Geneva on May 19 and 20.
\nAn audience of almost 150 attended from
\n36 countries.They included members of the
\nfive professions that make up the World
\nHealth Professions Alliance\u00a0 \u2013 physicians,
\nnurses, pharmacists, dentists and physical
\ntherapists, as well as a number of econo-
\nmists and regulators. Over the two days,
\n20 expert speakers addressed the theme of
\nthe conference, \u2018Facing challenges to acting
\nin the public interest\u2019, and engaged in high
\nlevel debates with participants.
\nDr.\u00a0Ardis Hoven, Chair of the WMA, who
\nchaired the first day\u2019s debates, said in ad-
\nvance of the conference, that regulation of
\nthe health professions was increasingly per-
\nceived as an economic issue or as a question
\nof power.Some professionals saw regulation
\nas a means to limit their professional free-
\ndom. Others, such as insurers and managed
\ncare companies, viewed it as an unwelcome
\nexpense, since obeying rules costs time and
\nmoney.
\n\u2018Regulation necessarily means … setting
\nlimits and demanding checks and balances,\u2019
\nshe said. \u2018Striking a balance between per-
\nsonal choices … and obligations towards
\nsafety, highest quality and equity is difficult
\nand requires justification\u2019. Dr.\u00a0Hoven added
\n\u2018Standards can help to provide a level play-
\ning field for all involved, including both fair
\nand appropriate processes\u2019.
\nThe first session of the conference looked
\nat the barriers to implementing regulatory
\nstandards. Dr.\u00a0 Hoven said such barriers
\nincluded political and commercial interfer-
\nence, inadequate understanding of profes-
\nsional autonomy and regulation and a high
\ndegree of resistance to change.
\nThree speakers addressed different aspects
\nof professional autonomy and regulation.
\nProfessor Zubin Austen, Professor of the
\nKoffler Chair in Management at the Uni-
\nversity of Toronto, spoke about setting
\nstandards and how these could be got right.
\nHe gave a history of the word \u2019competence\u2019
\nand looked at what competency assessment
\nmodels had been tried\u00a0 \u2013 including the se-
\ncret shopper methodology involving actors
\ndisguised as patients visiting clinicians. He
\nemphasised the importance, when creating
\nassessment models, of getting \u2018buy in\u2019 from
\nboth the public and the profession.
\nAndrew Gray, from South Africa, vice Presi-
\ndent of the International Pharmaceutical
\nFederation, talked about autonomy, with ref-
\nerence to the WMA\u2019s Declaration of Seoul
\non Professional Autonomy and Clinical In-
\ndependence. He said that as the working en-
\nvironment had changed for many health pro-
\nfessionals, so professional autonomy had also
\nbeen seen as under threat, or at least subject
\nto change. On the positive side, collaborative
\npractice had blurred the boundaries between
\nprofessions and between professionals.How-
\never, health professionals needed to guard
\nagainst the negative consequence of dual and
\ndivided loyalties.
\nDavid Benton, CEO at the National
\nCouncil of State Boards of Nursing, asked
\nwho regulated the regulators. He said there
\nwas currently a lot of critical commentary
\nabout regulation. However, it was right that
\nregulators should be held to account, and
\nthey were already being held to account in
\nvarious ways. But which of the ways was
\neffective and had the biggest impact\u00a0\u2013 the
\nexternal ones or the self imposed ones? The
\nformal processes or the informal processes?
\nHe concluded that they needed to get bet-
\nter in managing the performance of regula-
\ntors.
\nDuring the following panel discussion, par-
\nticipants debated whether there was too
\nstrong an alignment between the professions
\nand the regulators. It was said that regulators
\nin many parts of the world were enriched by
\ntheir interaction with the professions. More
\nthan one speaker warned about the risk of
\npoliticians leaning on regulators.
\nAn example of the barriers to implementing
\nthe right standards was given by Dr.\u00a0Andrew
\nWetende, President of the Kenyan Dental
\nAssociation, who spoke about Kenya\u2019s ex-
\nperience with the Minamata Convention on
\nMercury, the international treaty designed to
\nprotect human health and the environment
\nfrom the releases of mercury and mercury
\ncompounds. Barriers to success in imple-
\nmenting this included lack of resources and
\ninvolvement of key stakeholders, profession-
\nals who refused to embrace the regulations
\nand a lack of operational guidelines.
\nDr.\u00a0 Barry Dolman, President of the In-
\nternational Society of Dental Regulators,
\nWorld Health Professions Alliance Regulation Conference 2018
\nGeneva 19\u201320 May
\nNigel Duncan
\nWMA News
\n16
\nWMA News
\nfrom Montreal, talked about the impor-
\ntance of regulation to ensure evidence-
\nbased care. He spoke about four trends
\nimpacting regulation\u00a0\u2013 from governments,
\nthe new patient, social media and disrup-
\ntive technology.
\nHe said new patients were more educated,
\nlooking at ways where they wanted to direct
\ntreatment rather than relying on physicians
\nand others. They had now trained patients
\nto find their own answers.
\nHe said that regulators also had no ability to
\ncontrol social media information.They were
\nfacing catch up and were powerless to stop
\nthis this phenomenon. But hopefully they
\ncould moderate its impact.
\nAgnes Waudo, a director of Emory Uni-
\nversity Kenya Projects, continued on the
\ntheme of barriers to implementation of
\nregulatory standards as they affected Africa.
\nThese included a lack of resources to sup-
\nport implementation and enforcement, a
\nlack of capacity building, political influence
\nsubverting standards, conflicting mandates
\nand non-compliance. Finally, there was the
\nproblem of the shortage of health work-
\nforce.
\nDuring the panel discussion, Dr.\u00a0 Mark
\nSonderup from the South African Medical
\nAssociation, said that in South Africa the
\nmedical profession felt isolated from regula-
\ntors. He asked what role regulators should
\nhave in the world of social media, where
\nprofessionals were pushing out information.
\nThe answer he received was that there was a
\nmajor role for regulators to play.
\nDr.\u00a0 Otmar Kloiber, Secretary General of
\nthe WMA, said that in his view people
\nwere turning more and more to regulators
\nto ask questions and get advice. He said
\nthat almost half of the WMA\u2019s national
\nmedical association members were also
\nregulators. He questioned the perception
\nthat physician regulators were less tough
\non the profession and thought the oppo-
\nsite might be the case and that they were in
\nfact tougher. He also said that the profes-
\nsion was not lagging behind governments
\non the issue of regulation. It was ahead of
\ngovernments in thinking about regulation.
\nHe was particularly critical of governments
\nthat blamed the health profession when
\nthings went wrong because of a failure of
\nthe legal system, adding to applause \u2018We
\nare not the sheriffs\u2019.
\nThe second day\u2019s proceedings opened with
\na warning that the health professions were
\nfacing many challenges on regulation.
\nThe meeting was told that today\u2019s skills
\nand culture needed to change to be fit for
\n\u00ad
\ntomorrow.The professions were standing on
\nshifting sands.
\nDr.\u00a0 Jacques de Haller, President of the
\nStanding Committee of European Doctors
\n(CPME), in his presentation, spoke about
\nglobal standards and how much local adap-
\ntation was needed. The medical profession
\nwas a profession that loved to travel,to learn
\nand to practice. It needed to travel. But al-
\nthough it was a truly global profession,there
\nwas no global regulation or global rules with
\nlegal effect about the health professions.
\nHe spoke about the situation in Europe,
\nwhere there were some supra-national
\nregulations. The Professional Qualifications
\nDirective set rules about what was to be
\nrecognised by different member countries.
\nIt dealt with rules for temporary mobility,
\nintroduced a system of mutual recognition
\nof diplomas and defined minimum edu-
\ncational requirements, although it did not
\nharmonise education requirements.
\nA survey carried out by the CPME showed
\nthat regulations to practice and the imple-
\nmentation of regulations to practice were
\ndifferent in each country. His conclusion
\nwas that although the global profession
\ndid not have global regulation, it probably
\ndid not need it because the current systems
\nworked well. They shared a common goal,
\nproviding safe and high quality care.
\nHe said it was commonly thought that a
\ndoctor should be \u2018the same\u2019 anywhere. How-
\never, such a concept, if considered desirable,
\ncould only be achieved with bottom up edu-
\ncational initiatives by the medical profession
\nitself and sharing best regulatory practice ex-
\namples, enabling regulators to select require-
\nments best suited to their local needs.
\nLuke Slawomirski, an OECD economist,
\ndelivered a presentation on patient re-
\nported outcome measurements. These were
\nbased on the question \u2018What was the goal
\nof health care?\u2019. If it was to improve the
\nwellbeing of individuals and society, health
\nsystems knew very little about whether or
\nnot they were successful in this endeavour.
\nHe spoke about how the OECD was mea-
\nsuring health outcomes. There was an in-
\nformation gap they were trying to fill and
\ncollecting patient reported indicators would
\nimprove policy and practice.
\nEmmanuel Jo,Manager Analytics at Health
\nWorkforce New Zealand Ministry of
\nHealth said big data analysis improved care
\nand patient safety. We were now living in a
\nbig data environment with electronic health
\nrecords, electronic human resources data,
\nregistration data for regulated health work-
\ners and claims data. He talked about how
\nanalytics were now being used in New Zea-
\nland, in both primary and secondary care.
\nDr.\u00a0Margot Skinner, vice President of the
\nWorld Confederation for Physical Therapy,
\ntalked about her experiences of the Trans-
\nTasman Mutual Recognition Arrangement
\nthat had allowed health professionals in
\nAustralia and New Zealand to practise in
\neither country without the need for further
\nstudy or assessment. The agreement en-
\nabled each country\u2019s professional workforce
\nto come from a bigger pool. Professionals
\nwere also able to undertake courses and post
\ngraduate qualifications without the usual
\nbarriers. The arrangements had generally
\nworked well for Australia and New Zealand
\nbecause the two countries had similar stan-
\ndards for health and wellbeing.
\n17
\nBACK TO CONTENTS
\nWMA News
\n\u2018The bigger challenge is for countries where
\nstandards for education of health profes-
\nsionals are not the same\u2019, she said.
\nIn the panel discussion that followed there
\nwas a lively discussion, when one partici-
\npant asked whether regulation had lost its
\nidentity. Panellists were quick to emphasise
\nthe importance of the patient in the process.
\nThe primary purpose of regulation, it was
\nsaid, was to secure protection for the public,
\nto ensure that practice did meet require-
\nments. Regulators had to be effective, effi-
\ncient and ethical.But there was a big danger
\nwhen regulation lost the human touch.
\nThe last session of the conference looked at
\ncontinuing professional development, what
\nit meant and how it served patients. This
\nled to a debate about whether measure-
\nments and accreditation were useful tools.
\nDr.\u00a0 Kloiber said it was political pressure
\nthat had driven medical associations and
\nregulators to accreditation.
\nOne of the final panel discussions related to
\nthe WHPA\u2019s slogan \u2018Teaming up for better
\nhealth\u2019. What did it mean? Panellists said
\nthis had to start within the professions. Key
\nplayers needed to team up, and this was
\nhappening. But Janet Grant, an educational
\npsychologist, said that the evidence on inter
\nprofessional education was not good. The
\nevidence was it was a waste of time unless
\nteams learned together in practice.
\nDr.\u00a0 Kloiber said that in a lot of circum-
\nstances a non-team approach to learning
\nwas not constructive.
\nHe explained that the phrase started with
\nthe global organisations working together
\nas the WHPA. He said the five health pro-
\nfessions were not far apart in what they had
\nto say. But each group on its own was not
\nbeing heard. So they had come together as
\nthe WHPA , as they thought they could
\ncontribute to better health.They could pro-
\nduce more together than apart, and he had
\nnot seen any evidence to the contrary.
\nThe conference ended with a closing sum-
\nmary from Ema Paulino, Interim CEO of
\nthe International Pharmaceutical Federa-
\ntion. She reminded the meeting that these
\nWHPA conferences aimed to shape the fu-
\nture of health professional regulation within
\nthe context of global health systems via
\nmulti-disciplinary and multi-stakeholder
\napproaches. She said that regulation should
\nbe an enabler and a facilitator of the practice
\nof all healthcare professionals, with a prime
\nobjective of ensuring the safety of the deliv-
\nery of healthcare services.
\n\u2018Too often, there is a lack of knowledge
\nabout systems of regulations and only a few
\ncomparisons are available to describe such
\nsystems internationally. We observed that
\nalthough globalization is rapidly advancing
\nin all spheres of human endeavour, regula-
\ntory systems controlling the health profes-
\nsions are very disparate.\u2019
\nShe said the conference had illustrated that
\nhealth professional regulation faced many
\nchallenges in a world characterised by po-
\nlitical, social, economic and technologi-
\ncal change. Widespread reform of health
\nprofessional regulation reflected policy
\ninitiatives by many governments to ensure
\nsustainable, efficient and effective health
\nservice delivery. But what were the implica-
\ntions, and how did they ensure the public\u2019s
\nbest interests were met?
\n\u2018Health professional regulation is high on
\nthe global agenda. Increasing numbers of
\ntrade agreements, a push for greater har-
\nmonisation and ease of mobility, economic
\npressures, privatisation and corporatisation
\nof health and education services and health
\nhuman resource challenges are all impacting
\nthe regulatory environment globally.\u2019
\nShe said these trends would influence the
\nshape of regulation. The conference had
\nnoted that public scrutiny of professional
\nwork was higher than ever and that the de-
\nsign,implementation and execution of com-
\npetence assessment were essential. Speakers
\nhad emphasised that the central element of
\nprofessional autonomy was the assurance
\nthat individual healthcare professionals had
\nthe freedom to exercise professional judg-
\nment in the care and treatment of patients
\nwithout undue influence by outside parties
\nor individuals.
\nThe conference had agreed that professions
\nevolved and that regulations, standards and
\nassessment schemes should follow.They had
\ntalked about safety, quality and compliance
\nto benefit patients, communities and popu-
\nlations and how right-touch regulation was
\ntargeted, transparent, agile, accountable,
\nconsistent and proportionate. They had
\nconsidered migration challenges, whether
\nadaptation to local needs was necessary,
\nand how new ways of looking at perfor-
\nmance and population data was changing
\nthe health landscape and how regulators
\nensured patient safety and quality of care.
\nFinally, on supporting the quality of life-
\nlong learning, Ema Paulino said that dif-
\nferent views had been presented on what
\nconstituted the roles and responsibilities of
\nregulators associated with continuing pro-
\nfessional development, and how they could
\nultimately ensure competency in a sector
\nwhere information asymmetry was preva-
\nlent.
\n\u2018I believe we can conclude by stressing
\nthe importance of collaboration amongst
\nhealthcare professionals, the true value of
\nworking together in practice for the benefit
\nof the patient. This can also be enhanced
\nand translated from us looking at regula-
\ntory systems together, in these forums. In
\naddition, I believe we can also conclude that
\nthere is a significant advantage of looking
\nat regulation from an interprofessional per-
\nspective, given that similar challenges are
\nmet by the various professions throughout
\nthe world.\u2019
\nMr. Nigel Duncan,
\nPublic Relations Consultant, WMA
\nE-mail: nduncan@ndcommunications.co.uk
\n18
\nWorld Health Assembly
\nDuring the week of the World Health As-
\nsembly in May, Geneva was hive of activ-
\nity, with breakfast meetings, lunchtime side
\nevents and evening conferences.WMA lead-
\ners were involved in a large number of these
\nevents. Among them were the following.
\nInternational Symposium on
\nUniversal Health Coverage
\nOn Tuesday May 22, the second day of the
\nAssembly, the WMA, together with the
\nTaiwan Medical Association, hosted the
\nInternational Symposium on Universal
\nHealth Coverage.
\nThe packed meeting was addressed by both
\nthe President and the Chair of the WMA.
\nDr.\u00a0 Yoshitake Yokokura, President of the
\nWMA and President of the Japan Medical
\nAssociation, spoke about borderless-ness in
\na world of globalization. He said the cross-
\nborder unity of physicians worldwide was
\nincreasingly important to prepare for the
\nspread of infectious diseases and the occur-
\nrence of natural disasters.
\n\u2018The WMA is concerned about the eco-
\nnomic and social influence of the preva-
\nlence of rapidly expanding NCDs. The
\nWMA also recognizes the importance of
\nmeasures to be taken beyond the fields and
\ndepartments at the national and global
\n\u00adlevels.\u2019
\nHe said the new Memorandum of Under-
\nstanding with the WHO aimed to promote
\nUHC and strengthen the emergency di-
\nsaster preparedness and he added that the
\nmedical profession should return to the ba-
\nsis of health care, create a healthy longevity
\nsociety, and continue to support it.
\n\u2018I am convinced that the system which leads
\nJapan\u2019s aging society, unprecedented in the
\nworld, to \u201cthe society of peace of mind\u201d
\nshould be also supported by the \u201cUniversal
\nhealth insurance\u201d.I think that it is ideal that
\nbecause of extended healthy life expectancy,
\nthe elderly people can help to create a basis
\nof the nation as \u201cthe people who support
\na society\u201d. In this sense, the significance
\nof promoting UHC is extremely high to
\nrealize such a society. As President of the
\nWMA, I\u00a0 am determined to make utmost
\nefforts toward global promotion of the
\nUHC.\u2019
\nDr.\u00a0Ardis Hoven, Chair of the WMA, said
\nthe concept of UHC was very close to the
\nideas of the WMA. She said there was ma-
\njor inequality in health in the world and
\nthose regions with the highest need\u00a0\u2013 south
\neast Asia and Africa\u00a0\u2013 had the lowest share
\nof the health work force. It was the same
\nwith resources, which were mainly available
\nin regions with a moderate or low burden of
\ndisease. This inequality was reflected in the
\nlife expectancy at birth. And all these in-
\nequalities existed within countries, whether
\nthey were affluent or not.
\nDr.\u00a0 Hoven referred to the WMA\u2019s policy
\non patients\u2019 rights and UHC with its state-
\nment that every person was entitled, with-
\nout discrimination, to appropriate medical
\ncare.The WMA was firmly of the view that
\nevery patient should have a chance to be
\nseen by a physician. But there was a clear
\ndisparity between countries in the numbers
\nof physicians per thousand people, and this
\nhad to be recognized. So the WMA had
\npolicy that where countries had a critical
\nshortage of physicians, task shifting should
\nbe viewed as an interim strategy. But task
\nshifting should not replace the development
\nof sustainable, fully functioning health care
\nsystems. If they wanted to achieve equitable
\naccess to care, political action was necessary.
\nDr.\u00a0 Hoven concluded with these words:
\n\u2018To make Universal Health Coverage a re-
\nality will require huge investments. It will
\nrequire investments in people and, let me
\nemphasize, this includes the education of
\nphysicians. It will require investment in fa-
\ncilities, in safety, and quality. But there is no
\ndoubt that these investments will pay off\u00a0\u2013
\nfor healthier living, for a better society and
\nform a stronger economy\u2019.
\nA recorded video message was sent to the
\nmeeting by Ms Tsai Ing-wen, President of
\nTaiwan. She said that Universal Health
\nCoverage was the most unifying theme in
\nglobal health. She talked about Taiwan\u2019s in-
\ntroduction of National Health Insurance in
\n1995, under which all nationals, regardless
\nof gender, age or wealth were equally cov-
\nered for their whole life.The NHI premium
\naccounted for less than five per cent of the
\nindividual monthly pay roll and the total na-
\ntional health care expenditure was less than
\nseven per cent of GDP.The scheme was very
\ncomprehensive, covering everything from
\nthe common cold to organ transplants. The
\npublic satisfaction approval rate was recently
\nfound to be 85 per cent. The scheme safe-
\nguarded not only people\u2019s access to health
\ncare, but also ensured financial protection.
\nEver since the implementation of NHI, no-
\none had gone broke because of medical bills.
\nThe scheme was a model to achieve UHC
\nand she said she believed Taiwan\u2019s experi-
\nence could serve as a paradigm for the world.
\nStrengthening National
\nFrameworks for the
\nProtection of Health Care
\nThe following day, the WMA was one of
\nthe coordinating organisations for an ICRC
\nHealth Care in Danger event.The meeting\u2019s
\ntheme was \u2018Strengthening National Frame-
\nworks for the Protection of Health Care\u2019.
\nWorld Health Assembly Side Events \u2013
\nMay\u00a02018
\n19
\nBACK TO CONTENTS
\nWorld Health Assembly
\nThe two-hour forum was hosted by Maciej
\nPolkowski, ICRC Head of the HCiD Ini-
\ntiative, who emphasised how important this
\nproject was for the ICRC.
\nTwo keynote speakers outlined the scale
\nof the problem of violence. Dr.\u00a0Esperanza
\nMartinez, Head of Health at the ICRC\u2019s
\nHealth Unit, spoke about the consequences
\nof attacks on hospital and health profession-
\nals, and said the problem was not confined
\nto war zones. However, he said there was
\nnow a very strong community of concern
\nwith a common voice that was going to be
\nheard. Raphael Gorgea, Deputy Director of
\nOperations from M\u00e9decins Sans Fronti\u00e8res,
\ntalked about the attacks that had been made
\non MSF hospitals and staff, and the impact
\nthis had had on patients and the delivery of
\nhealth care. Among the ways to combat this
\nwas to advocate for the respect of interna-
\ntional law and to promote health care as a
\ncommon good.
\nThe meeting went on to hear speakers from
\nthree countries\u00a0 \u2013 Nigeria, Pakistan and
\nPeru\u00a0\u2013 about how the problem of violence
\nagainst the health sector was being tackled.
\nThis ranged from round table talks to en-
\ngage all those involved to practical interven-
\ntions for raising awareness locally, improved
\nreporting of incidents, policies of zero tol-
\nerance and crowd control measures. The
\nmeeting concluded with general agreement
\nthat health care was a common good, that it
\ncould not be taken as a given and that it had
\nto be promoted.
\n100 Years After the
\nSpanish Flu Pandemic
\nThe third event, on Wednesday May 23,
\nwas held to mark the 100th anniversary of
\nthe Spanish Flu Pandemic and was hosted
\nby the WMA, the International Federation
\nof Red Cross and Red Crescent Societies
\n(IFRC) and the International Federation of
\nPharmaceutical Manufacturers & Associa-
\ntions (IFPMA).
\nThe event was opened by Thomas Cueni,
\nDirector General of the IFPMA, who said
\nit was estimated that Spanish flu killed more
\npeople in 24 weeks than Aids had killed in
\n24 years. In fact, the pandemic killed up to
\n100 million people,more people than all the
\nwars of the 20th
\ncentury combined. In 1918
\nthis amounted to nearly five per cent of the
\nworld\u2019s population. It served as a poignant
\nreminder of the importance of preparedness.
\nIf a highly contagious and lethal pathogen
\nlike the 1918 influenza were to take hold
\ntoday, nearly 33 million people worldwide
\nwould die in just six months. More than
\never they were exposed to new biological
\nthreats, many of them yet undiscovered.
\nHe said that in today\u2019s extremely inter-
\nconnected world, with people travelling at
\nunprecedented rates, global health security
\nhad never been more fragile or more urgent.
\nPrevious epidemics had shown that when the
\nglobal health community came together,they
\nwere able to tackle infectious diseases.Going
\nforward, they needed to design and imple-
\nment pro-active preparedness, to further im-
\nprove their capacity to prevent and control
\nunpredictable disease outbreaks. Sample and
\ndata sharing were key and he said they all
\nrecognized the importance of the WHO\u2019s
\nglobal influenza surveillance system.
\nThe first of two keynote speakers was Alex
\nAzar, US Secretary of Health and Human
\nServices, who said that at the time of the
\noutbreak of Spanish flu, the United States
\nand the world were ill-prepared to combat
\na pandemic. Influenza viruses had not yet
\nbeen discovered, there were no vaccines to
\nprevent infection and no medicines to treat
\nit, and the field of public health was in its
\ninfancy.
\n\u2018Today, influenza pandemics remain one of
\nour top infectious disease threats. We have
\na growing set of increasingly advanced tools
\nto detect the emergence of a new strain of
\ninfluenza virus domestically and abroad,
\nbut much work remains to be done. When
\nit comes to the threat of pandemic flu, as
\nwell as other infectious threats, prepared-
\nness cannot be confined within borders.The
\nworld must work together to focus on the
\nprevention and mitigation of pandemics
\nthat pay no mind to borders and focus the
\nwork of institutions like the World Health
\nOrganization on that threat.\u2019
\nHe said the Trump Administration strong-
\nly supported the Global Health Security
\nAgenda to prevent, detect and respond to
\ninfectious disease threats in collaboration
\nwith their partner countries. It also sup-
\nported reforms to the WHO to ensure that
\nfuture epidemics were handled more effec-
\ntively than Ebola was.He outlined the work
\nof the Centers for Disease Control and Pre-
\nvention in building global flu surveillance
\nnetworks with partner countries that helped
\nto detect and respond to new and known
\ninfluenza viruses. And he talked about the
\nway in which the US was putting in place
\npreparedness plans for responding in the
\nevent of a flu pandemic.
\nThe country\u2019s vaccine manufacturing capac-
\nity had increased ten-fold since the 2000s.
\nAt the same time they had worked to reduce
\nthe time it took to develop a new flu vac-
\ncine in the event of a pandemic and they
\nhad invested in research toward a universal
\nflu vaccine.
\nMr. Azar concluded with these words: \u2018The
\nworld has come a long way since 1918, but
\nwe are still vulnerable, not just to the flu but
\na range of infectious threats. The United
\nStates will continue to work with our part-
\nners around the globe to build preparedness
\nfor these threats and to strengthen our pre-
\nparedness at home.
\nInfectious diseases remain a serious threat,
\nbut with the right level of cooperation and
\nfocus, we can look forward to marking
\nmany more World Health Days before we
\nsee another pandemic like the Spanish flu\u2019.
\nThe second keynote speaker was Elhadj As
\nSy, Secretary General of the International
\n20
\nIntellectual Property Rights
\nThe 71st
\nWorld Health Assembly (WHA),
\nwhich represents the highest decision-
\nmaking body of the World Health Organ-
\nisation (WHO), took place in Geneva this
\nMay. The World Medical Association was
\nrepresented by a diverse delegation of both
\nmembers of the Junior Doctors Networks
\nand representatives from National Medical
\nAssociations working under the coordina-
\ntion of the WMA Secretariat. Amongst
\nthe many issues followed by the WMA, an
\ninherently contentious part of the WHA
\nagenda was the review of the global strat-
\negy and plan of action (GSPoA) on public
\nhealth, innovation and intellectual proper-
\nty1
\n. Indeed, the potential barriers of medi-
\n1\u2002
\nWorld Health Organization. \u201cGlobal Strategy
\nand Plan of Action on Public Health, Innova-
\ntion and Intellectual Property\u201d 2011. Available
\nat: http:\/\/www.who.int\/phi\/publications\/Global_
\nStrategy_Plan_Action.pdf
\ncines costs and procurement are central ele-
\nments for achieving the ambitious goals of
\nthe SDGs Agenda by 2030 especially at this
\nWHA focused on Universal Health Cov-
\nerage. While these negotiations have taken
\nplace over previous decades, progress has
\nbeen slow and there is still a long way to go
\nbefore accomplishing the vision behind the
\nwork on access to medicines.
\nDiscussion around intellectual property
\nand access to medicines have been taking
\nplace at WHO ever since the adoption of
\nThe Agreement on Trade-Related Aspects
\nof Intellectual Property Rights (TRIPS)
\nagreement in 1994. Being party to this
\ntreaty was mandatory for participation in
\nFederation of Red Cross and Red Crescent
\nSocieties. He said that over the last few
\nyears the world had experienced a number
\nof epidemics, including Ebola, which had
\nkilled around 11,000 people in three west
\nAfrican countries. He asked if they were
\nreally ready and prepared for another epi-
\ndemic or pandemic. Had they learned the
\nlessons of the first Ebola outbreak? He said
\nit did not matter how far away outbreaks
\noccurred, adding \u2018They are only one hand
\nshake away from many of us. They are only
\none plane ride away for many of us\u2019.
\nHe said there were many factors involved
\nin determining the levels of vulnerability in
\nepidemics. But none of them would be safe
\nuntil all of them were safe. The only way to
\ncontain these epidemics and outbreaks was
\nwhere they were happening, right in the
\ncommunities. They needed international
\nregulations and preventive measures, but
\nthey also needed to make the necessary
\ninvestment in those areas where these out-
\nbreaks were occurring.Too often they had to
\nreturn to the same communities to respond
\nto the same outbreaks. He emphasized how
\nimportant it was to get the acceptance of lo-
\ncal communities to take preventive action.
\nPartnerships were essential and health sys-
\ntem strengthening was vital.
\nThere was then a panel discussion conducted
\nby the moderator, ex-BBC journalist Claire
\nDoole. The panel consisted of Dr.\u00a0 Ardis
\nHoven, Chair of the WMA, Dr.\u00a0 Marie
\nMazur, Vice President of Response Solu-
\ntions at Seqirus, Dr.\u00a0Sylvie Briand, Direc-
\ntor of Infectious Hazards Management at
\nthe WHO and Dr.\u00a0Julie Hall, Chief of Staff
\nfrom the Office of the Secretary General at
\nthe IFRC.The first querstioin the panellists
\nwere asked was whether the world was pre-
\npared for another pandemic. Dr.\u00a0Hoven re-
\nplied bluntly \u2018No\u2019. She and the other panel-
\nlists agreed that there was much more work
\nto be done.
\nThey went on to talk about vaccines.
\nDr.\u00a0Hoven spoke about the scepticism sur-
\nrounding vaccines, saying that the challenge
\nwas to counter the reluctance to accept im-
\nmunisation of any kind. They had barriers
\nto confront. There was information going
\nround that was not scientific and that was
\ndiscouraging individuals from being immu-
\nnized. So they had to have systems in place
\nthat accelerated the way people could get
\nimmunized. She said that when physicians
\nsaid they had been immunized, it was much
\nmore likely that their patients and families
\nwould be immunized. She also spoke about
\nthe WMA\u2019s influenza campaign which had
\nbeen running for five years in partnership
\nwith others.
\nIn a discussion about Ebola, Dr.\u00a0 Hoven
\nstressed the importance of strengthening
\nhealth care systems and addressing the work
\nforce issue. \u2018If we don\u2019t have people to take
\ncare of people, it all falls apart\u2019, she said.The
\nEbola outbreak of two years ago had illus-
\ntrated cracks in the health infrastructure.
\nOn a more general issue, she added that
\nhealth care professions and their national
\norganisations should be \u2018looped in\u2019 with
\ngovernments, so that they were part of the
\nplanning work that needed to be done, not
\njust when there was an emergency, but on
\nan everyday basis. She also said that there
\nshould be a removal of barriers between
\nagencies in order to communicate better.
\nThey had to remove the silos of information
\nand knowledge between them.
\nAs the meeting ended,the moderator Claire
\nDoole tweeted: \u2018I had great panelists\u00a0\u2013 so
\nrare to have an all woman panel! They were
\na joy to moderate\u00a0\u2013 succinct clear and com-
\npelling\u00a0\u2013 the perfect panelists\u2019.
\nMr. Nigel Duncan,
\nPublic Relations Consultant, WMA
\nE-mail: nduncan@ndcommunications.co.uk
\nIntellectual Property: who owns the right to
\ngood health?
\n21
\nBACK TO CONTENTS
\nIntellectual Property Rights
\nYassen Tcholakov Lisa Murphy
\nthe World Trade Organization (WTO)
\nand thus countries were inherently forced
\nto adhere to it. TRIPS set down regulation
\non Intellectual Property (IP) into the inter-
\nnational trading system, which has namely
\nimpacted access to newly developed medi-
\ncines. While TRIPS contains provision for
\na number of flexibility mechanisms2
\n(in-
\ncluding patent exceptions, compulsory li-
\ncensing and limits on data protection) their
\nuse has been rare. Indeed, countries who
\nhave utilised them have had to face politi-
\ncal pressure and retaliatory action. In that
\ncontext, the WHO proposed the GSPoA in
\n2008 which was fully adopted in 2009.This
\nyear marks the 10th
\nanniversary of GSPoA\u2019s
\ncreation, and member states were reflective
\non what had been achieved.
\nThe GSPoA focuses on the 8 elements:
\n\u2022\t prioritizing research and development
\nneeds;
\n\u2022\t promoting research and development;
\n\u2022\t building and improving innovative capac-
\nity;
\n\u2022\t transfer of technology;
\n2\u2002
\nNicol D. Owoeye O.\u201cUsing TRIPS flexibilities
\nto facilitate access to medicines\u201d WHO Bulletin.
\nApril 2013.Available at: http:\/\/www.who.int\/bul-
\nletin\/volumes\/91\/7\/12-115865\/en\/
\n\u2022\t application and management of intellec-
\ntual property to contribute to innovation
\nand promote public health;
\n\u2022\t improving delivery and access;
\n\u2022\t promoting sustainable financing mecha-
\nnisms;
\n\u2022\t establishing and monitoring reporting
\nsystems.3
\nThis GSPoA review4
\nhighlighted the slow
\nand uneven progress in the various areas
\nof work and some of the funding gaps. It\u2019s
\nrecommendations include WHO support
\nfor member states to utilise the aforemen-
\ntioned TRIPS flexibilities1
\n, increased trans-
\nparency in the pricing of medicines, and the
\nstrengthening of non-profit based innova-
\ntion models through delinkage5
\n(the process
\n3\u2002
\nWorld Health Organization.\u201cThe Global Strat-
\negy and Plan of Action on Public Health, In-
\nnovation and Intellectual Property\u201d. Available at:
\nhttp:\/\/www.who.int\/phi\/implementation\/phi_glob-
\nstat_action\/en\/
\n4\u2002
\nWorld Health Organization. \u201cOverall pro-
\ngramme review of the global strategy and plan
\nof action on public health, innovation and intel-
\nlectual property\u201d November 2017. Available at:
\nhttp:\/\/www.who.int\/medicines\/areas\/policy\/GSPA-
\nPHI3011rev.pdf?ua=1
\n5\u2002
\nLove J. \u201cInside Views: Delinkage Of R&D
\nCosts From Product Prices\u201d Intellectual \u00ad
\nProperty
\nthrough which pharmaceutical research is
\nfinanced through means other than medi-
\ncation sales).
\nHowever the review neglected some im-
\nportant issues, such as the creation of a
\nresearch and development (R&D) treaty.
\nMany members expressed frustration dur-
\ning WHA with the lack of progress on
\nimplementation and funding for this area of
\nwork. The current finance gaps are largely
\na reflection of WHO\u2019s wider funding chal-
\nlenges, with a large proportion of its money
\nfirmly earmarked according to donor inter-
\nests. During these R&D discussions there
\nwas a noticeable equatorial difference in
\nopinion. While the global south empha-
\nsized the importance of WHO facilitat-
\ning the use of TRIPS flexibilities and new
\nnon-profit based innovation models, the
\nnorth focused on patent driven innovation.
\nThere were calls from many low and middle
\nincome countries for international coopera-
\ntion and financing to increase their R&D
\ncapacities, with support sought from WHO
\nfor country led action.
\nMany member states from within the
\nhigh income bracket endorsed the estab-
\nlishment of public-private partnerships as
\nkey to driving creation of quality medi-
\ncines. There was also push back against the
\nGSPoA\u2019s recommendations for transpar-
\nency of research and development costs,
\nwhich is a crucial measure for preventing
\nindustry manipulation of drug costs and
\nensuring fair medicine pricing.This, along-
\nside a move to a fixed price model for med-
\nicines from a market driven system, could
\ngreatly enhance medicines availability and
\nprocurement. The perceived threat to prof-
\nits for the pharmaceutical industry make
\nthose recommendations contentious. The
\nquestion of how much implementation the
\nWHO will be able to drive has yet to be
\nanswered.
\nWatch. September 2016. Available at: http:\/\/
\nwww.ip-watch.org\/2016\/09\/15\/delinkage-of-rd-
\ncosts-from-product-prices\/
\n22
\nHealth Care
\nOn the agenda item on the GSPoA review,
\nthe WMA presented a statement support-
\ning opening the GSPoA to newer essential
\nhealth products, encompassing medicines,
\nvaccines, diagnostics or biologicals and to
\ncall for intellectual property which serve the
\npeople and contribute to sustainable devel-
\nopment.6
\nAdditionally, the WMA also de-
\nlivered an intervention on a different agen-
\nda item calling for the WHO to help with
\nfilling the gap in the current R&D system
\nand address global challenges such as anti-
\n6\u2002
\nWorld Medical Association. \u201c71st World Health
\nAssembly 11.6 Global strategy and plan of action
\non public health,innovation and intellectual prop-
\nerty\u201d May 2018. Available at: https:\/\/www.wma.
\nnet\/wp-content\/uploads\/2018\/05\/11.6-WHA71-
\nGlobal-strategy-public-health-innovation-and-
\nintellectual-property-WMA.pdf
\nmicrobial resistance and the lack of effective
\ntreatment for dementia.7
\nNow that the review panel for priority ac-
\ntions have identified a number of key ob-
\njectives8
\nto be achieved by 2022, it remains
\nto be seen what achievements the global
\nhealth community will be celebrating in
\n5\u00a0years time.In a globalized economy,inter-
\n7\u2002
\nWorld Medical Association. \u201c71st World Health
\nAssembly 11.5 Addressing the global shortage of,
\nand access to, medicines and vaccines\u201d May 2018.
\nAvailable at: https:\/\/www.wma.net\/wp-content\/
\nuploads\/2018\/05\/WMA-11.5-access-to-medicine.
\npdf
\n8\u2002
\nWorld Health Organization. \u201cGlobal strategy
\nand plan of action on public health, innovation
\nand intellectual property\u201d March 2018. Avail-
\nable at: http:\/\/apps.who.int\/gb\/ebwha\/pdf_files\/
\nWHA71\/A71_13-en.pdf
\nnational law, including intellectual property
\nregulations, should always serve the people.
\nIf it fails to do so, the global community has
\na moral obligation to redress its mistakes.
\nThe current IP system has failed to deliver
\non its promises and it is unjustified to award
\ncorporations the privileges of a monopoly
\nat the expense of the wellbeing of millions
\nwho still lack access to essential medica-
\ntions.
\nYassen Tcholakov, MD MIH CCFP,
\nMcGill University (Canada)
\nLisa Murphy, MBChB BSc, Barts
\nand The London NHS Trust
\nE-mail: yassentch@gmail.com
\nThe Demographic Challenge
\nLong-term forecasts on demographics are
\nsimilar in most rich welfare states, in the
\nsense that as populations are ageing and
\nwealth is increasing, more and better health
\ncare is demanded. Since many countries
\nfinance health care largely through taxes,
\nfinding solutions to finance the welfare
\nwill put the public systems under pressure.
\nAs the workforce will consist of a smaller
\npart of the population, either taxes or out-
\nof-pocket payments will have to increase,
\nthe quantity or quality of publicly delivered
\nhealth care will have to decrease, or a com-
\nbination of the above. Any solution that
\nsimplifies the equation and releases some
\nof the pressure on the health care system
\nshould be taken into consideration. The
\nSwedish Medical Association sees physi-
\ncians taking a more active role in the leader-
\nship of health care as crucial in making the
\nhealth care more efficient.
\nThe scarce resources would most likely be
\nused more efficiently if the decisions on
\nresource allocations were always based on
\nthe medical and clinical knowledge about
\nwhat creates the most substantial impact on
\nhealth outcomes.
\nIn 2017 the Swedish Medical Associa-
\ntion commissioned a report on physicians\u2019
\nengagement in leadership in health care,
\nand the effects thereof. The report, Physi-
\ncians\u2019 role in the management and leadership
\nof health care1
\n, examined the published sci-
\nentific literature and found several positive
\neffects of getting more medical doctors to
\nengage in leadership.
\nThe report found, among other things, that
\nphysician leadership can improve hospital
\nperformance in terms of quality of care,
\n1\u2002
\nPhysicians\u2019 role in the management and lead-
\nership of health care. A scoping review.
\nStockholm,February 2017. Mairi Savage, MPH
\nPamela Mazzocato, PhD Carl Savage, PhD Mats
\nBrommels, MD, PhD, Professor
\nPhysicians\u2019 Role in the Management and Leadership of
\nHealth Care
\nHeidi Stensmyren
\nSWEDEN
\n23
\nBACK TO CONTENTS
\nHealth Care
\nmanagement of financial resources and staff
\nsatisfaction. All these factors are vital to
\nmeet the increasing demands of heath care
\nfor a long time to come.
\nThe report also identified some mechanisms
\nthat seem to have a role in mediating the
\npositive relationship between physician
\nleadership and performance outcomes. For
\ninstance,having a medical background gives
\nphysician leaders increased credibility com-
\npared to managers without medical train-
\ning. Clinical knowledge seems also to be
\nessential for improved decision making.The
\nknowledge acquired from a long medical
\neducation and years of working experience
\nis obviously helpful for creating an under-
\nstanding between different levels of man-
\nagement and performance.
\nWhile the quality of medical decisions im-
\nproves, the risk of complications decreases,
\nand costs are lowered. This might explain
\nwhy there are indications that financial re-
\nsources are managed in a better way when
\nphysicians are assuming a managing role.
\nFew doctors in management
\nWhy then, aren\u2019t physicians more engaged
\nin management? One reason could be that
\nmost physicians already make a good earn-
\ning.The financial gain from taking on more
\nresponsibility does not often add up to the
\namount of workload from managerial tasks.
\nA managing role in health care is associated
\nwith a lot of responsibility and potential ex-
\npressions of dissatisfaction from both em-
\nployees and superiors. This is of course the
\ncase in most sectors, but certainly no less in
\nthe medical profession where decisions are
\nliterally about life and death.
\nIn contrast, for nurses in Sweden, the wage
\ndifference between being a regular employ-
\nee and a manager can be much larger, which
\npartly could explain why many nurses are
\nkeener on engaging in management. Still,
\naccording to the Swedish Medical Asso-
\nPicture 1
\nPicture 2
\nSWEDEN
\n24
\nciation it should be the genuine interest for
\nleadership and management, not financial
\nbenefits, that should motivate doctors to
\npursue a career in leadership and manage-
\nment in health care. If medical doctors, de-
\nspite being interested, choose not to seek
\nthe managerial roles, it will benefit no one
\nin the health care system.
\nVirtuous and vicious cycles
\nPicture 1 shows a possible virtuous cycle
\nthat can arise from better physician leader-
\nship.Medical doctors as leaders and manag-
\ners create a culture and an atmosphere that
\ninvites and engages staff to participate in
\nimproving health care. The catalyst in such
\na process is not obvious but formal recruit-
\nment as a starting point is probably where
\npolicy makers can influence the process.
\nFormal recruitment can lead to positive as-
\npects in the leadership, such as creating a
\nbroader recruitment base. It may very well
\nbe the case that persons who would not have
\nconsidered becoming a leader can be made
\naware of the opportunity if the process is
\nformal, and if the responsible for human re-
\nsources actively seek out to those individu-
\nals. Since there is no reason to expect that
\npersons who previously haven\u00b4t considered
\nleadership are less likely to be successful at
\nit, such actions are likely to lead to better
\nmanagement in the long run.
\nThese positive effects can hopefully be self-
\nsustaining, giving a positive spiral upwards.
\nOn the other hand, picture 2 illustrates the
\noutcome if the recruitment process is done
\ninformally.
\nInformal recruitment can lead to a narrow
\nbase of recruitment, placing wrong persons
\nin important management positions. Such
\ndiscrepancy in the workplace is likely to lead
\nto internal conflicts and impaired commu-
\nnication between the managerial level and
\nemployees.
\nThus,it is obvious how important it is to en-
\ngage the right persons in management and
\nto make sure that recruitment is formal and
\norganised.
\nStrong leadership for
\nimproved communication
\nAn aspect that is sometimes overlooked is
\nthe leadership as a link from health care
\npolicies to delivering good health care. In
\nthis context, it means that effective leader-
\nship easily can communicate the intentions
\nof upper-level decision makers to floor-level
\nstaffers. If the economic incentives points in
\na certain direction, but solutions to accom-
\nplish these incentives are perceived to be
\ntechnical or difficult to understand, a leader
\nwith good understanding of the whole sys-
\ntem can create an atmosphere of commit-
\nment among the staff. For this to hold, the
\neconomic incentives must of course steer
\ntowards improving health outcomes.
\nPolicies for improved leadership
\nEven after finding good and promising
\nleaders for management, the process is not
\nnearly completed.There is a need for support
\nthroughout the career, and learning leader-
\nship skills must begin already in the early
\nstages of education. Mandatory courses in
\nleadership in medical schools are important
\nin order to establish a culture where medi-
\ncal professionals are encouraged to consider
\nmaking a managerial career in addition to a
\nclinical career. Better possibilities to com-
\nbine clinical and managerial positions are
\nimportant, not only to make management
\nmore attractive but to strengthen the con-
\nnection between staff and managerial levels.
\nSuch courses can include both traditional
\nleadership education and more hands-on
\nprocedures such as catastrophe simulation,
\ndepending on the focus.
\nPutting it all together
\nTo insure a sustainable programme for ef-
\nfective management and leadership in
\nhealth care all the steps in different levels
\nmust be connected.
\n\u2022\t Medical schools must supply the basic
\nfoundation of leadership knowledge
\n\u2022\t Incentives must be in place for enough
\nphysicians to pursue this alternative ca-
\nreer
\n\u2022\t Recruitment processes must aim to find
\nthe most suitable candidates
\n\u2022\t Support in place for those who choose to
\nbecome managers.
\nIf all these factors are in place there is rea-
\nson to believe that physicians\u2019 leadership
\nwill provide better use of the resources in
\nhealthcare.
\nHeidi Stensmyren, MD
\nPresident of the Swedish Medical Association
\nChairperson of the WMA
\nMedical Ethics Committee
\nE-mail: ordforande@slf.se
\nHealth Care SWEDEN
\n25
\nBACK TO CONTENTS
\nChild Health
\n1.\u2002Introduction
\nThe World Medical Association (WMA)
\nOttawa Declaration was adopted by 50th
\nWMA Assembly October 1998 and later
\nsubstantially revised by the 60th
\nWMA As-
\nsembly October 20091
\n, According to the
\nWMA revision cycle, the document is up
\nfor revision next year. This analysis pro-
\nvides an overview of the development of
\nthe declaration, its elements and their oc-
\ncurrence in the original and the amended
\nversion.
\nThe Declaration of Ottawa originally aimed
\nat improving the rights of children to health
\ncare2
\nthroughout the world. In this article
\nwe analyze and compare the above two doc-
\n1\u2002
\nWorld medical association, published 22nd
\n.
\nMarch. 2017, https:\/\/www.wma.net\/policies-post\/
\nwma-declaration-of-ottawa-on-child-health\/
\n2\u2002
\nSee World Medical Association Web page
\npublished 20.October.1998, https:\/\/www.wma.
\nnet\/news-post\/declaration-of-ottawa-on-the-right-
\nof-the-child-to-health-care\/
\numents looking for the new points added in
\nthe new version and the important points
\nleft out while amending as well as points to
\nemphasize on.
\n2.\u2002Analysis
\nThe initiative, entitled the Declaration of
\nOttawa, was building on the WMA Dec-
\nlaration of Lisbon on the Rights of the Pa-
\ntient (1981) and the 1989 United Nations
\nConvention on the Rights of the Child.
\nAmong other rights3
\n, the Declaration of
\nOttawa stated that:
\n\u2022\t Parents whose children are admitted to
\nhospital should, wherever possible, be
\nprovided with appropriate accommoda-
\ntion in or near the hospital at minimal or
\nno cost. In addition parents should be al-
\nlowed time off work without prejudice to
\ntheir continued employment;
\n3\u2002
\nUNICEF. convention on the rights of the child ,
\nNew York, 20 November 1989.
\n\u2022\t parents,guardians or children of sufficient
\nmaturity should be free to change their
\nphysician or to seek a second opinion;
\n\u2022\t the wishes of children should be taken into
\naccount in decisions involving their care;
\n\u2022\t a competent child patient, their par-
\nents or guardians should be entitled to
\nwithhold consent to any procedure or
\ntherapy;
\n\u2022\t the child patient is entitled to be fully in-
\nformed about their medical condition.
\nDr. James Appleyard himself Pediatrician
\nwho was the President of WMA by then,
\nsaid at the time \u201cthat the Ottawa Declara-
\ntion provides an international bench mark
\nfor children\u2019s health care and a bench mark
\nthat many governments fail to reach.
\nThis bench mark will empower national
\nmedical associations throughout the world
\nto persuade their governments to value
\ntheir children and improve the health of the
\nworld\u2019s children\u201d4
\n.
\nDr. Appleyard continued \u201cThe rights of
\nchildren to health care need to be at the
\ncentre of our health policies and investment
\nin the health care of children is the most
\ncost effective measure for any government
\nto take\u201d4
\n.
\nThe amended Ottawa Declaration of 2009
\nsent a clear demand towards governments,
\ncare providers, communities and parents
\nregarding their responsibilities by asking
\nthem to have the Ottawa principles ful-
\nfilled without any constraints. However,
\nwith the revision of 2009, the WMA split
\nthe content of the original document as
\nwell as additional, new items and informa-
\ntion into two documents: The revised policy
\ndocument5
\n, the (then) new Declaration of
\n4\u2002
\nWorld Medical Association, pub 20 October
\n1998, https:\/\/www.wma.net\/news-post\/decla-
\nration-of-ottawa-on-the-right-of-the-child-to-
\nhealth-care\/
\n5\u2002https:\/\/www.wma.net\/policies-post\/wma-declara-
\ntion-of-ottawa-on-child-health\/
\nPolicy Analysis Ottawa Declaration
\non Child Health
\nElicien Ishimwe Otmar Kloiber
\n26
\nChild Health
\n\u00ad
\nOttawa and a background document6
\n, giv-
\ning explanation to the policy revision, but
\nnot being part of the policy.
\nIn addition, the amended Ottawa declara-
\ntion7
\nstated clearly seven new important
\nprinciples, which are:
\n1.\t Clean water, air and soil with a safe en-
\nvironment
\n2.\t Protection from injury,exploitation,dis-
\ncrimination
\n3.\t Health Families, homes and communi-
\nties
\n4.\t Healthy Nutrition
\n5.\t Early Learning opportunities
\n6.\t Availability of drugs & immunization and
\n7.\t Research
\nHowever, there are other Principles which
\nhave been left out from the original Ottawa
\ndeclaration such as,
\n1. Child abuse which could have been a du-
\nplication to the WMA Statement on Child
\nAbuse and Neglect revised by 68th
\nWMA as-
\nsembly of 2017:There it is noted that the wel-
\nfare of children is of paramount importance
\nand that child abuse in all its forms8
\nis one of
\nthe most destructive manifestations of fam-
\nily violence. Moreover the United Nations
\nconvention on the rights (1989) of a child in
\nits article 9,19 and 39 state that all forms of
\nchild abuse should be taken into consider-
\nation by states parties to prevent them9
\n.
\n6\u2002
\nh t t p s : \/ \/ w w w . w m a . n e t \/ w p – c o n t e n t \/
\nuploads\/2017\/02\/Background_Ottawa_
\nDeclaration-Oct2009.pdf
\n7\u2002
\nSee WMA, Current policies. 2017 https:\/\/www.
\nwma.net\/policies-post\/wma-declaration-of-ottawa-
\non-child-health\/
\n8\u2002
\nWMA statement on child abuse and neglect,
\n15th
\nOctober 2017
\nhttps:\/\/www.wma.net\/policies-post\/wma-
\nstatement-on-child-abuse-and-neglect\/
\n9\u2002
\nAdopted and opened for signature, ratification
\nand accession by General Assembly resolution
\n44\/25 of 20 November 1989, available at:
\nhttp:\/\/www.ohchr.org\/EN\/ProfessionalInterest\/
\nPages\/CRC.aspx
\nThe amended policy mentions \u201cprotection
\nfrom the child\u2019s exploitation\u201dhowever given
\nthe definition of the UNHCR in the report
\nentitled \u201caction for the rights of children\u201d
\nUNHCR10
\ndefines abuse as \u201cthe process
\nof making bad or improper use, or violat-
\ning or injuring, or to take bad advantage of,
\nor maltreat, the person,\u201d while exploitation
\nliterally means \u201cusing for one\u2019s own profit or
\nfor selfish purposes\u201d10
\n.
\nChild abuse includes the physical, emo-
\ntional, or sexual mistreatment of a child, or
\nthe neglect of a child, in the context of a
\nrelationship of responsibility, trust or power,
\nresulting in actual or potential harm to the
\nchild\u2019s physical and emotional health, sur-
\nvival and development11
\n.
\nExploitation of a child on the other hand
\nrefers to the use of the child in work or
\nother activities for the benefit of others and
\nto the detriment of the child\u2019s physical or
\nmental health, development, and education.
\nExploitation includes, but is not limited to,
\nchild labor and child prostitution; therefore
\nchild abuse should be one the principles not
\nbe left out8
\n.
\nDuring Human Rights Council 2018, pre-
\nsenting her report, Ms. Santos Pais said
\nthat half of the world\u2019s countries had ad-
\nopted a comprehensive policy agenda on
\nviolence against children. Nevertheless,
\nhalf of the world\u2019s children experienced
\nviolence. Children were disciplined by
\nviolent means, bullied, sexually assaulted
\nin their circle of trust, groomed online,
\nand abused in detention centers. The 2030
\nAgenda provided a historic opportunity
\nto end violence12
\n. In 2019 there would be
\nan in-depth review of goal 16, including
\n10\u2002
\nUNHCR report \u201caction for the rights of chil-
\ndren\u201d ttp:\/\/www.unhcr.org\/3bb825cd2.pdf
\n11\u2002
\nUNHCR, Critical issues Abuse and Ex-
\nploitation. March 1999, http:\/\/www.unhcr.
\norg\/3bb81aea4.pdf
\n12\u2002
\nhttp:\/\/srsg.violenceagainstchildren.org\/page\/1229
\ntarget 16.2 to end all forms of violence
\nagainst children.
\n2.Religious assistance: this principle is also
\nin the original document13
\nwhile amending,
\nit was left behind. However, The Declara-
\ntion of Lisbon states clearly that one has the
\nright to receive or to decline spiritual and
\nmoral comfort including the help of a min-
\nister of his\/her chosen religion14
\n.
\n3. Freedom of choice: This principle is not
\nmentioned in the amended policy5
\nas well
\nalthough in the background document of
\nthe amended policy it no longer part of the
\npolicy.
\n4. Emergency Consent: The original docu-
\nments explain that if the child is uncon-
\nscious, or otherwise incapable of giving
\nconsent, and a parent or legally entitled
\nrepresentative is not available, but a medical
\nintervention is needed urgently,then specif-
\nic consent to the intervention may be pre-
\nsumed, unless it is obvious and beyond any
\nreasonable doubt on the basis of a previous
\nfirm expression or conviction that consent
\nwould be refused in particular situation; it is
\nnot stated in the new polic13
\n.
\nThe UN convention on the rights of child15
\ndeems the \u201cthe right to develop a healthy
\nattachment to a parent, legal guardian, or
\ncaregiver\u201d as necessary for its social and
\nemotional wellbeing. And finally and in dif-
\nference to the UN convention children with
\n13\u2002
\nworld medical association. declaration of Ot-
\ntawa on the right of the child to health care,
\nadopted by the 50th
\nWMA general assembly Ot-
\ntawa, Canada, October 1998, https:\/\/www.wma.
\nnet\/policies-post\/wma-declaration-of-ottawa-on-
\nchild-health
\n14\u2002
\nWMA declaration of Lisbon on the rights of
\nthe patient. 2015, https:\/\/www.wma.net\/policies-
\npost\/wma-declaration-of-lisbon-on-the-rights-of-
\nthe-patient\/
\n15\u2002http:\/\/www.ohchr.org\/en\/professionalinterest\/
\npages\/crc.aspx
\n27
\nBACK TO CONTENTS
\nChild Health
\nTable 1. Summary of the comparison of the original and amended policy
\nNo Item Old Policy New Policy
\nBackground document of the
\nnew policy
\n1 Clean water, air and soil Left out Present
\nChildren shall have access to
\nthe mentioned items adequately
\nand environments free of toxins
\nand microbes known to harm
\n2 Protection from injury, exploitation, discrimination Left out Present Mentioned
\n3 Child Abuse Present Left out
\nItem was pointed out as a sub
\nline of the previous item
\n4 Health Families, homes and communities Left out Present Mentioned
\n5 Best Possible Health at Birth Present Present Mentioned
\n6 Health nutrition Left out Present Mentioned
\n7 Early Learning Left out Present Mentioned
\n8 Physical Activity Present Present Mentioned
\n9 Education Present Present Mentioned
\n10 Eradicate traditional practices prejudicial to health of the child Present Left out Present under the item No 2
\n11 Health Resources Available to All
\nPresent but renamed
\nas Quality of care
\nPresent Mentioned
\n12 Drugs & immunization Left out Present Mentioned
\n13
\nHospitalization Present
\nPresent with follow-
\ning details missing
\nPresent with all the details
\n1. A child should be admitted to hospital only if the care
\ncannot be provided at home
\nPresent present
\n2. A child in the hospital should be provided a suitable
\nenvironment
\nPresent Left out
\n3. Every effort should be made to allow a child admitted to
\nbe accompanied
\nPresent Left out
\n4. A child should be allowed as much outside contact and
\nvisiting as possible
\nPresent Left out
\n13
\n5. With relevant age a mother should not be denied the
\nopportunity to breastfeed except if there is a medical
\ncontraindication
\nPresent Left out
\nPresent with all the details
\n6. A child should be afforded every opportunity and facility
\nappropriate to play, recreation and continue Education
\nPresent Left out
\n14 Rehabilitation
\nMentioned in the
\ngeneral principal
\nPresent Mentioned
\n15 Freedom of choice Present Left out Mentioned in the background
\n16 Dignity of the Patient Present Present Mentioned in the background
\n17 Access to Information Present Left out Mentioned
\n18 Consent Present Present Mentioned
\n19 Confidentiality Present Present Mentioned
\n20 Research Left out Present Mentioned
\n21 Freedom of choice Present Left out Present
\n22 No discrimination of any kind Present Present Present
\n23
\nEmergency Consent (child unconscious and no guardian
\navailable)
\nPresent Left out Left out
\n24 Health Education Present Left out Mentioned
\n25 Religious, assistance Present Left out Mentioned
\nNote that the background document is not part of the policy.
\n28
\nHealth Care
\nAs a social organization of science and
\ntechnology on the national level, the Chi-
\nnese Medical Association (CMA) responds
\nactively to the task and requirements of
\nhealth poverty alleviation put forward by
\nthe Chinese government, attaches great im-
\nportance to the health poverty alleviation
\nwork, and gives full play to its advantages
\nof having extensive connections with vari-
\nous industries and with all walks of life, as
\nwell as to the advantages of the experts and
\nthe active roles of scientific and technologi-
\ncal communities in poverty alleviation work.
\nWith a view to boosting the development of
\nmedical and health services in China\u2019s pov-
\nerty-stricken areas, CMA\u2019s health poverty
\nalleviation leading group thoroughly carries
\nout the essence of poverty alleviation docu-
\nments adopted at the 19th
\nNational Con-
\ngress of the Communist Party of China, re-
\nduces or exempts registration fees through
\nacademic conferences for doctors in China\u2019s
\nwest region, at the grassroots level and in
\npoverty-stricken areas, grants transporta-
\ntion and accommodation subsidies to grass-
\nroots doctors, intensively patronizes clinical
\nscientific research projects of west region,
\ndonates much-needed materials such as
\nmedical equipment to impoverished regions
\nand counties and medical periodicals to
\ngrassroots hospitals, and launches activities
\nsuch as CMA Thousand Talents Cultiva-
\ntion Program for county hospitals, etc.
\nAs a typical case of the health poverty al-
\nleviation work conducted by CMA, the
\nThousand Talents Cultivation Program for
\ncounty hospitals (abbreviated to \u201cThou-
\nsand Talents Program\u201d) adopts approaches
\nof \u201cgoing down to grassroots to offer help\u201d
\nand \u201cushering in grassroots medical staffs
\nfor training\u201d to improve grassroots doctors\u2019
\nabilities in diagnosis and medical treatment
\nand to favour the health of impoverished
\nmasses.The following is the brief.
\nwith disability were not given much atten-
\ntion in this policy.
\n3.\u2002Conclusion and
\nRecommendation
\nAs expected there are many similarities be-
\ntween the original Declaration of Ottawa
\non Child Health in 1998 and the amended
\npolicy of the 60th
\nWMA assembly in 2009.
\nBoth list items to be considered for the good
\nof child health, however, in the new policy
\nwhich is currently being used as guidance to
\nphysicians worldwide is lacking some im-
\nportant principles. Some have been lost in
\nthe revision,some moved to the background
\ndocument (which is not part of the policy)
\nand some were not mentioned in the origi-
\nnal and the revised version.
\nThe child health was at the center of the
\nUnited Nation Millennium Development
\nGoals (MDGs)16
\nand it is still a of the pri-
\nority in Sustainable Development Goal 3
\nwhich emphasizes among others the re-
\nduction of child mortality. Child health
\ngoes beyond SDG 3 to SDG4 (child needs
\na healthy diet), SDG5 (be free of any dis-
\ncrimination or violence) and SDG6 (clean
\nwater and hygiene)17
\n. The above highlights
\nthe critical importance of collaboration and
\ncoordinated action across multisector to
\nachieve improvement in chil health. There-
\n16\u2002
\nUnited Nations, MDG4 at: http:\/\/www.un.org\/
\nmillenniumgoals\/pdf\/Goal_4_fs.pdf
\n17\u2002
\nUnited Nations, Sustainable Development
\nGoals, 2017 available at: https:\/\/www.un.org\/
\nsustainabledevelopment\/sustainable-development-
\ngoals\/
\nfore The Ottawa Declaration is one of the
\nkey documents together with the Declara-
\ntion of Oslo on the Social Determinants
\nof Health to guide actions, regulations and
\nattitudes to improve the rights of children
\nto health and health care throughout the
\nworld. Under the light of the fulfillment of
\nthe United Nations\u2019s Sustainable Develop-
\nment goals the revision of the Ottawa Dec-
\nlaration deserves highest attention.
\nElicien Ishimwe,
\nMedical Doctor,
\nMinistry of Health, Rwanda
\nE-mail\u00a0: ielicien@gmail.com
\nOtmar Kloiber,
\nGeneral Secretary,
\nWorld Medical Association
\nE-mail: otmar.kloiber@wma.net
\nKeqin Rao Yongmao Jiang Weili Zhao
\nCMA Thousand Talents Cultivation
\nProgram for County Hospitals
\nCHINA
\n29
\nBACK TO CONTENTS
\nHealth Care
\nI. Going Down to
\nGrassroots to Offer Help\u00a0\u2013
\nPopularization of Medical
\nSciences and Technologies
\nIn 2017, the \u201cThousand Talents Program\u201d
\ninvited a total of 223 experts (205 associate
\nseniors or higher and 18 PhDs) to popu-
\nlarize sciences and technologies in 7 prov-
\ninces, 13 prefecture-level municipalities,
\n13\u00a0 counties and 34 hospitals, with ward-
\nround teaching, surgery teaching and gra-
\ntuitous treatment for the rank and file serv-
\ning as a platform for study, communication
\nand sharing among grassroots doctors. In
\nthis way, the \u201cThousand Talents Program\u201d
\nset up a bridge of partnership between
\ngrassroots hospitals and major hospitals.
\n8 events conducted in the year attracted a
\ntotal of 4914 participators, with 4800 cop-
\nies of data compilations issued gratuitously
\nand downloads of the electronic version
\nreaching 7149.
\nIn addition, some CMA branches secured
\nfunds from other sources or used their own
\nfunds to conduct special training courses
\nmuch needed by grassroots units or pover-
\nty-stricken areas. In 2017, CMA\u2019s pathol-
\nogy branch conducted the \u201cWest Bound\u201d
\npathology training course in 2017 to teach
\n165 trainees gratuitously; the anaesthesiol-
\nogy branch offered the clinical anaesthesia
\nguide training course; and the paediatrics
\nbranch launched the 11th
\nPaediatricians\u2019
\nLecture Tour in West China, etc.
\nII. Ushering in Grassroots
\nMedical Staffs for Training\u00a0\u2013
\nFurther Education and Training
\nfor Grassroots Doctors
\nIn 2017, CMA organized two batches of
\ncore-member doctors totalling 207 from
\ncounty hospitals in 10 provinces to receive
\na 5-month professional training at 37 pro-
\nvincial Class-A tertiary comprehensive hos-
\npitals with a view to improving their abili-
\nties in standard diagnosis and treatment of
\ncommon and frequent diseases, which pro-
\nvided a personnel support for reducing the
\nreferral rates from counties.
\n10 provinces, including Guizhou, Sichuan,
\nGansu, Qinghai, Jiangxi, Shaanxi, Hubei,
\nYunnan, Henan and Hunan, were chosen
\nfor the pilot project. The provinces were
\na linked aggregation of destitute areas as
\nlisted by Poverty Relief Office of the State
\nCouncil, highlighting the requirement of
\nimproving health conditions for poverty-
\nstricken areas.
\nThe trainees came from 177 hospitals,
\n91.7% of which were county hospitals or
\nhospitals at the county level (trainees from
\nimpoverished counties made up 32.27%,
\nand those from poor cities accounted for
\n7.73%) while 5.8% were prefecture-level
\nhospitals. The trainees were all honoured
\nwith the professional title of attending doc-
\ntor or higher and had an educational back-
\nground of college degree or above. Two-
\nthirds of the trainees were less than 40 years
\nold and signed the letter of commitment to
\npromise return to their original units after
\ntraining to serve continuously at the grass-
\nroots level. The pilot project accorded with
\nthe sanitation and health work guideline of
\nthe new era and observed the \u201cEnhancing
\nGrassroots\u201dspirit stressed in the medical re-
\nform and complied with the requirements
\nof establishing and perfecting the mecha-
\nnism for conducting further education
\namong grassroots health workers as well
\nas training among core-member doctors of
\ncounty hospitals as are put forward in the
\nNational Health and Family PlanningTalents
\nDevelopment Plan for the 13th
\nFive-Year Plan
\nand the National Health and Family Plan-
\nning Professionals Training Plan for the 13th
\nFive-Year Plan.
\nThe training related to 12 specialties, of
\nwhich 76% were about gynaecology and
\nobstetrics, paediatrics, intensive care medi-
\ncine, emergency medicine, anaesthesiology,
\npsychiatric medicine, etc., which are much-
\nneeded specialties underscored in the Na-
\ntional Health and Family Planning Talents
\nDevelopment Plan for the 13th Five-Year
\nPlan.
\nTo ensure the quality of the further educa-
\ntion and training, CMA signed entrusted
\norientation training agreements with the
\nsaid 37 Class-A tertiary comprehensive
\nhospitals and appropriated training funds
\ndirectly to the hospitals to entrust them to
\ncultivate the trainees and issue qualification
\ncertificates to the eligible after the training.
\nApart from entrusting provincial medi-
\ncal associations to guide and appraise the
\ntraining work in their provinces, CMA also
\norganized a supervising team composed of
\n10\u00a0famous experts in paediatrics,gynaecolo-
\ngy,intensive care medicine,ultrasonic medi-
\ncine and medical pedagogy to launch inten-
\nsified inspections from Sep. 21st
\nthrough
\n22nd
\n, 2017 in Sichuan where trainees were
\nrelatively concentrated. The experts went to
\nSichuan Maternal and Child Health Hos-
\npital and Chengdu First People\u2019s Hospital,
\nwhere they made on-site inspection over
\nthe implementation of the training system
\nby the hospitals. In the meantime, the ex-
\nperts offered ward-round guidance and
\nconducted case discussion and academic
\nlectures, etc. CMA also invited representa-
\ntives of medical associations of other 9 pilot
\nprovinces to constitute a research group to
\nwatch live demonstrations and make work
\ndiscussions to enhance the implementation
\nof the training quality requirements and the
\noverall progress in the provinces.
\nCMA has formulated its \u201c2018\u20132020 Work
\nPlan for Health Poverty Alleviation Proj-
\nects\u201d. In the future, CMA will conduct its
\nhealth poverty alleviation work more ac-
\ncurately, give more play to its advantages,
\nadhere to the problem-oriented and de-
\nmand-oriented principles, improve its par-
\nticipation and input efficiency and effective-
\nness in poverty alleviation work, and make
\nits due contributions to the construction of
\na \u201cHealth China\u201d.
\nCHINA
\n30
\nMedical Esperanto
\nEsperanto
\nLudwik Lejzer Zamenhof (1859\u20131917),
\na Polish ophthalmologist, descendant of
\na family of language teachers, published
\nhis first book about the international lan-
\nguage after years of diligent preparation in
\n1887\u00a0[1]. He did so under the pseudonym
\nDoctor Esperanto\u00a0\u2013 the doctor who hopes,
\nand Esperanto was soon adopted as the
\nname of the constructed language itself.
\nEsperanto,Bridge of Words [2],was designed
\nto be easily learned in much less time than
\nethnic languages. Word roots are taken
\nfrom European languages; so many learners
\nwill recognize them. There are no irregular
\nforms, and an appropriate word can easily
\nbe created from a known stem by using a
\nlogical set of prefixes and suffixes. Given
\nits regularity, no exceptions, language pro-
\nficiency in Esperanto can be achieved via
\nthe internet or smartphone app. There is a
\nwell-established method of teaching Espe-
\nranto to groups of people who do not have a
\nlanguage in common, the so called Czech-
\nmethod [3].
\nBackground Information:
\nA brief introduction to the
\nChinese Medical Association
\nThe Chinese Medical Association (CMA)
\nis a non-profit national academic organi-
\nzation in China. It is an important social
\nforce in the development of medical science
\nand technology and a linkage between the
\ngovernment and the medical professionals.
\nEstablished in 1915, the CMA now has
\n88\u00a0specialty societies and 667,000 members
\nin China.
\nMajor Functions of the CMA include: de-
\nveloping domestic and international medi-
\ncal academic exchange activities; discover-
\ning, recommending and cultivating medical
\ntalents; editing and publishing 184 medical
\nand popular science journals including print
\nand electronic, books and over 2,000 audio-
\nvisual products; carrying out continuing
\nmedical education projects and training
\nspecialists; implementing medical project
\nevaluation and review and as well as science
\nand technology decision-making demon-
\nstration; selecting and presenting awards for
\noutstanding achievements in medical sci-
\nence and technology; promoting transfor-
\nmation and practical application of medical
\nresearch results; disseminating medical and
\nhealth knowledge for the general public; or-
\nganizing technical appraisement on medi-
\ncal malpractice and AEFI (Adverse Events
\nFollowing Immunization); undertaking the
\nfunctions and missions entrusted by the
\ngovernment, and relaying suggestions and
\nrequests from the medical professionals to
\nthe government.
\nThe current 25th
\nCMA council was elected
\nin December 2015, with HAN Qide and
\nCHEN Zhu as CMA Honorary Presi-
\ndents, ZHONG Nanshan and BA Denian
\nas CMA Consultant, and MA Xiaowei as
\nCMA President. The Vice President and
\nSecretary General is Dr. RAO Keqin.
\nKeqin Rao, Vice President & Secretary
\nGeneral, Chinese Medical Association
\nYongmao Jiang, Director, Dept. of
\nInternational Relations & Publishing
\nHouse, Chinese Medical Association
\nWeili Zhao, Program Manager,
\nDept. of International Relations,
\nChinese Medical Association
\nE-mail: cmazhaoweili@163.com
\nUniversal Medical Esperanto Association
\n31
\nBACK TO CONTENTS
\nMedical Esperanto
\nAccording to reasonable estimates, there are
\nabout 2 million Esperanto speakers today
\n[4]. They are well connected via interna-
\ntional networks and the Universal Esperan-
\nto Association (UEA),founded in 1908,has
\na network of 1669 delegates in 102\u00a0coun-
\ntries [5]. The traditional close connection
\nof Esperanto speakers is enhanced by the
\ninternet and there is a Smartphone app that
\nlocates nearby Esperanto speakers [6].
\nThe UNESCO resolution of Montevideo in
\n1954 (Resolution IV. 4. 422-4224) recom-
\nmended that the Director-General of UNES-
\nCO follow current developments in the use of
\nEsperanto.In 1977,the Director-General vis-
\nited the World Esperanto Congress in Reyk-
\njav\u00edk,Iceland,and in 1985 UNESCO passed a
\nresolution recommending that member coun-
\ntries encourage the teaching of Esperanto.
\nIn the 130 years of its history, Esperanto has
\nproduced a rich culture and extensive,diverse
\nliterature. The language is pleasantly sound-
\ning and can express intricate thoughts and
\nfeelings with structural simplicity. Its exten-
\nsive literature includes poetry, novels, history,
\nscience, including dramas and films original-
\nly produced in Esperanto. The language has
\nproved to be suitable for scientific exchange
\nas well. The Red Cross supported the use of
\nEsperanto in its humanitarian missions [7].
\nBrief History of the Universal
\nMedical Esperanto Association
\nDoctor Ludwig Zamenhof was followed by
\nmany other physician-pioneers in the bur-
\ngeoning Esperanto movement. At the 4th
\nEsperanto World Congress, 1908, Wilhelm
\nR\u00f3bin, a Polish doctor, proposed a medical
\nassociation, subsequently founded as the
\nTutmonda Esperantista Kuracista Asocio
\n(TEKA: Worldwide Association of Espe-
\nranto-speaking Physicians). R\u00f3bin edited
\nthe medical Esperanto journal Kuracisto
\n(Physician) and gained the support of sev-
\neral influential opinion leaders.
\nR\u00f3bin also helped prepare the Encyclopaedia
\nof Esperanto and was an important figure in
\nhis country. As early as 1893 in Warsaw he
\nfounded one of the first Esperanto groups.
\nThe first president of TEKA was Dr. Henri
\nDor (1835\u20131912), a famous Swiss oph-
\nthalmologist. He spoke eleven languages
\nfluently and propagated Esperanto among
\nscientists. The first yearbook of TEKA was
\npublished in 1909 with a preface by Za-
\nmenhof himself. It contained the addresses
\nof 19 national delegates, 41 representatives
\nin big cities and 428 members.
\nDuring the great international medical con-
\ngress in Budapest (1910) TEKA organized
\na successful Esperanto session. World War
\nI considerably disrupted the activities of
\nTEKA, but by 1923 they were effectively
\nresumed. Hungarian
\ncolleagues took the
\ninitiative (Kalocsay,
\nMezei, S\u00f3s, and later
\nBulyovszky). Other
\nnotables included
\nProf. Dr. Odo Bu-
\njwid (1857\u20131942),
\na Polish bacteri-
\nologist who studied
\nwith Koch in Berlin
\n(1885) and Pasteur
\nin Paris (1886), an
\nhonorary member of
\nTEKA since 1927.
\nProf.Dr.J.Vanverts,a French gynaecologist,
\nwas editor-in-chief of the Internacia Medic-
\nina Revuo (International Medical Review)
\nfor many years. This journal has been pub-
\nlished in Esperanto from 1923 on.
\nDr. Paul Kempeneers (1895\u20131979), a Bel-
\ngian physician, orthopaedic surgeon, worked
\nselflessly forTEKA as a chief secretary.Max-
\nimilian Blassberg, a Polish doctor (1875\u2013
\n1939), was an outstanding activist in the
\nmedical Esperanto movement and president
\nof TEKA for two years. An important mile-
\nstone was the first comprehensive Esperanto
\nDictionary of Medical Technical Terms, edited
\nby Maurice Briquet (1865\u20131953), a French
\nphysician, in 1932. Briquet was also the edi-
\ntor of the TEKA-Review for several years.
\nAfter World War II, the centre of Espe-
\nranto medical activities shifted to Japan. Dr.
\nSuzuki, professor at the University of Tiba,
\nbecame the editor of the Review. Before
\nand after the 40th World Congress of Espe-
\nranto (1955) the Japanese gynaecologist and
\nEsperantist Dr. Hideo Shinoda presented
\nhis recently developed surgical techniques
\nin the United States and several European
\ncountries; Esperanto was used for interpre-
\ntation. Following the proposal of Dr. Shi-
\nnoda at the World Congress of Esperanto
\nin 1961, TEKA members unanimously de-
\ncided to change the name of the association
\nto Universala Medicina Esperanto Asocio
\n(UMEA, Universal Medical Esperanto
\nChristoph Klawe
\nParticipants of the TEKA founding convention in 1908
\n32
\n\u00ad
\nAssociation).UMEA subsequently was lead
\nby Japanese professors Hideo Yagi, Masao
\nSuzuki, Hideo Shinoda and Seiji Kato.
\nThe Hungarian physician Imre Ferenczy took
\nover the presidency from Seiji Kato in 1984
\nand, in office until 2012, substantially shaped
\nthe character of the association [8]. The
\nCzech Dr. Eva Kopecna had served as presi-
\ndent of the UMEA for two years, when the
\nauthor of these lines succeeded her and the
\nhead office was transferred to Trier,Germany.
\nMedical International Review
\nUMEA started publishing its own journal
\nin 1923. It contained medical research and
\ncase reports written entirely in Esperanto.In
\n1964 the journal was renamed Medicina In-
\nternacia Revuo (MIR, Medical International
\nReview). After moving from Budapest to
\nLille and Tiba,from 1994 on,MIR has been
\npublished in Krakow, Poland, in print and as
\nan open access biannual journal [9].
\nAs the number of authors able to submit
\nworthy articles in Esperanto has diminished
\nover the years due to the changing fate of
\nthe Esperanto movement itself, the editors
\ndecided to accept articles in other languages
\nas well. If the article is not in Esperanto, the
\neditors either provide an abstract in Espe-
\nranto or, on demand, translate the whole
\narticle. With his language policy MIR can
\ngive a voice to those who lack access to the
\nEnglish speaking medical community.
\nIn December 2015, MIR was included in
\nthe list of scientific B-journals according to
\nthe ranking system of the Polish Ministry
\nof Science and Higher Education. Publica-
\ntions in B-journals are acknowledged for
\nthe academic careers of Polish scientists
\n[10]. MIR is not listed in the indexes of
\nthe US National Library of Medicine or
\nScopus, not so much because of the lack of
\nquality but because the peculiar language
\npolicy did not seem appealing to the re-
\nviewers. The contents of MIR can easily be
\nfound, however, in Google Scholar.
\nThe Universal Medical
\nEsperanto Association today
\nUMEA now has members in 19 countries
\nand special chapters of general medicine,
\nrehabilitation, neurology, ophthalmology,
\npsychiatry, psychotherapy, endocrinology,
\npaediatrics, cardiology, infectious diseases,
\nphysiotherapy, Traditional Chinese Medi-
\ncine, neuropsychology, pharmacology, even
\nveterinary medicine, and the traditional
\nJapanese massage technique Yumeiho.
\nSince 1977 UMEA has held a conference
\nof Esperanto speaking physicians every sec-
\nond year (IMEK, Internacia Medicinista
\nEsperanto-Konferenco), which usually at-
\ntracts 30\u2013200 participants, and less formal
\ninternational Skype-conferences for Espe-
\nranto speaking doctors now and then.
\nUMEA honors outstanding protagonists in
\nthe sphere of Esperanto in medicine with the
\nprestigious UMEA-
\nShinoda-Award.
\nUMEA uses the
\nTwitter-account @
\nUMEAeo to be ac-
\ntive in social media.
\nUMEA can support
\nall who need to estab-
\nlish a common means
\nof communication in
\nmultinational groups
\nrapidly, as may happen with humanitarian
\ncrises.
\nUMEA continually proves that Espe-
\nranto can be effectively used in medicine.
\nThanks to excellent networking between
\ninternational Esperanto speakers, UMEA
\ncan effectively convey important medi-
\ncal information to the Esperanto speaking
\ncommunity, as happened on the occasion of
\nthe Ebola and Zika epidemics. UMEA has
\nready access to the estimated two million
\nEsperanto speakers and is willing to sup-
\nport such international health organizations
\nas WMA and WHO.
\nReferences
\n1.\t Zamenhof L L. Internationale Sprache. Vorrede
\nund vollst\u00e4ndiges Lehrbuch. Warschau: Ge-
\nbethner et Wolff; 1887
\n2.\t Schor E. A Bridge of Words. New York: Metro-
\npolitan Books, Henry Holt and Company; 2016
\n3.\t Internacia Esperanto-Instituto, editors. Baza
\nCseh-Kurso kun metodikaj konsiloj. Den Haag:
\nInternacia Esperanto-Instituto; 1992
\n4.\t Wandel A. How many people speak Esperanto?
\nOr: Esperanto on the web Interdisciplinary
\nDescription of Complex Systems, 2015;13 (2),
\n318-321.
\n5.\t Universala Esperanto Asocio, editors. Jarlibro
\n2017, 109-249.
\n6.\t Wikipedia. https:\/\/en.m.wikipedia.org\/wiki\/Amikumu
\n7.\t The Esperantist Movement\u2019s humanitarian ac-
\ntivities in the two World Wars and its relation-
\nship with the International Red Cross. https:\/\/
\nwww.icrc.org\/eng\/resources\/documents\/article\/
\nother\/57jn53.htm
\n8.\t Ferenczy I: Esperanto kaj medicino. In: Blanke
\nD, Lins U, editors. La arto labori kune. Rotter-
\ndam: Universala Esperanto-Asocio; 2012.
\n9.\t Homepage of the Journal of UMEA. http:\/\/in-
\nterrev.com\/mir\/index.php\/mir
\n10.\tJournal Ranking of the Polish Ministry of Educa-
\ntion.http:\/\/www.nauka.gov.pl\/g2\/oryginal\/2015_
\n12\/6a011a7e5df2bc88abdea880d7f3a863.pdf
\nDr. Christoph Klawe,
\nPresident of the Universal Medical
\nEsperanto-Association
\nDepartment of Neurology
\nand Neurophysiology
\nHospital of the Brothers of Charity, Germany
\nE-mail: umea@uea.org
\nParticipants of the 20th
\nIMEK, Nitra, Slovakia, 2016
\nMedical Esperanto
\n33
\nBACK TO CONTENTS
\nProfessional Competence
\nBackground
\nAcross the health professions, there is sig-
\nnificant interest in maintenance of com-
\npetence [1]. It is an issue for regulators,
\npractitioners, educators, employers, policy
\nmakers\u00a0\u2013 and most of all, for the patients
\nwho rely upon the knowledge and skills of
\ntheir care providers [1, 2, 3 ]. While there
\nare no universally applicable definitions for
\n\u201ccompetence\u201d, most stakeholders agree that
\nfacets of competence include an ability to
\nremain up-to-date with developments in
\none\u2019s profession, and a fitness-to-practice
\nat a level commensurate with one\u2019s peers
\n[3, 4]. In attempt to systematize thinking
\nabout competence many regulators and ed-
\nucators have turned to the use of standards
\nof practice or competence statements as a
\nvehicle for articulating a profession\u2019s base-
\nline minimum competence expectations of
\npractitioners in the field [5]. In many ju-
\nrisdictions, there are requirements in place
\nfor practitioners to complete a minimum
\nnumber of continuing education hours
\nor units each year as a proxy measure for
\ndemonstrating maintenance of competence
\nin the field (despite the fact that there is
\nno compelling evidence supporting this
\napproach as an effective tool for this pur-
\npose) [4. 5]. The measurement of compe-
\ntence through standardized metrics (such
\nas the use of objective structured clinical
\nexaminations or well-constructed multiple
\nchoice questions) has become a mainstay
\nof professional education and regulation\u00a0\u2013
\nyet concerns exists as to whether the time,
\neffort and money invested in these ap-
\nproaches actually supports maintenance of
\ncompetence or simply encourages practi-
\ntioners to jump through regulatory hoops
\non a semi-regular basis [4, 5, 6]. In some
\nfields, there is increasing use of self- and
\npeer-assessment models, triangulated with
\npractitioner-specific outcomes data that
\nhave shown promising results in terms of
\nprofessional development; this \u201c360 degree
\nreview\u201d approach may be effective, but is
\nlogistically cumbersome and very costly,
\nlimiting its applicability in most health care
\nprofessions [7, 8].
\nFraming Competence
\nHistorically, our understanding of compe-
\ntence has been as a binary: one is EITHER
\ncompetent or incompetent. Only these two
\nstates exist, and practitioners must dem-
\nonstrate they belong to the former, rather
\nthan the latter, category [9]. Measurement
\nof competence through standardized test-
\ning further reinforces this binary view of
\ncompetence: one either \u201cpasses\u201d tests or
\n\u201cmeets\u201d standards, or one \u201cfails\u201d them or
\n\u201cfalls below\u201d standards [6]. While such
\nbinary thinking may be marginally more
\nacceptable within an educational context
\nin which students are proving their bona
\nfides, it becomes problematic when applied
\nto practitioners who may have had years
\nor decades of experience delivering care to
\npatients and communities. A binary model
\nwhen applied to an experienced practitio-
\nner suggests there is a bright line between
\nthe two states of \u201ccompetent\u201d and \u201cincom-
\npetent\u201dthat may be confidently articulated,
\nmeasured, and defended.
\nHodges and Lingard, quoting Burke, have
\nnoted that \u201cevery way of seeing is also a
\nway of not seeing\u201d [6]. If we define prac-
\nticing physicians and other health care
\nprofessionals using binary terms such as
\n\u201ccompetent and \u201cincompetent\u201d what are
\nthe consequences, and what opportunities
\nmay we be missing? From the perspective
\nof most practitioners, competence is not an
\neither-or phenomenon, and labelling it as
\nsuch can be profoundly counterproductive
\nin motivating individuals to maintain and
\nenhance their professional skills over a life
\ntime of practice. Simply put, how can we
\nunderstand the process by which a physi-
\ncian\u00a0\u2013 who has worked hard her whole life
\nto first gain entry to a highly competitive
\nmedical school, who then sacrificed greatly
\nto get through the gruelling 8\u201310 years of
\nundergraduate and post-graduate education
\nand training, and then who chooses to take
\none of the most demanding jobs in soci-
\nety\u00a0\u2013 would allow herself to become incom-
\npetent? Framing competence as a binary
\nsuggests this physician made bad choices
\nand decisions that led to her current state\u2026
\nand most of what we understand about
\nhuman psychology and motivation sug-
\ngests that this simply does not make sense.
\nThe vast majority of physicians are smart,
\nwell-intentioned, caring individuals who
\nselected this profession to apply their skills
\nand talents in a way that would help their
\nsocieties and communities. By what process
\nwould such smart, well-intentioned, caring
\nindividuals \u201callow\u201d themselves to become
\nincompetent? And does the threat of being
\nlabelled incompetent, the use of standard-
\nized testing mechanisms, or the require-
\nment for compulsory continuing education
\nactually change an individual\u2019s choices and
\nbehaviours?
\nZubin Austin
\nCompetence Drift in Professional Practice:
\na\u00a0Psychological Perspective
\nCANADA
\n34
\nProfessional Competence
\nAlternatives to either-or
\nmodels of competence
\nRecently, there has been interest in \u201csee-
\ning\u201d competence in a different way\u00a0\u2013 not as
\na psychometric or measurement issue, but
\ninstead as a psychological issue reflective of
\nlived human experience [6, 9]. While there
\nis an abundance of literature examining the
\nreliability and validity of competence assess-
\nment instruments and approaches (5)(6)(9),
\nthere is very limited literature examining the
\nexperiences of physicians who have failed:
\nindividuals who have been labelled by their
\nprofession as \u201cincompetent\u201d or who have
\nhad their registrations suspended or revoked.
\nHow did these smart, well-intentioned and
\ncaring individuals end up this way? Beyond
\ncaricatures of predatory individuals or sub-
\nstance-abuse problems, how does one move
\nfrom competence to incompetence without
\nfirst drifting through an intermediary state (a
\nmiddle ground) of being somewhat compe-
\ntent? And what is in place to support indi-
\nviduals who (for whatever reason) find them-
\nselves in this intermediary state to help them
\nregain their fullest competence?
\nCompetence Drift in the
\nHealth Professions
\nRecently, we published a study examining
\nthe psychological dimensions of competence
\nwithin the context of another profession\u00a0 \u2013
\npharmacy [10].This study explored the lived
\nexperiences and deterioration experienced
\nby pharmacists who had been labelled by
\ntheir regulatory body as \u201cincompetent\u201d.
\nLongitudinal interviews [11,\u00a012] with these
\nindividuals highlighted that, from their per-
\nspective, competence is not a binary: they
\ndid not wake up one day and suddenly find
\nthemselves incompetent, nor did they (for
\nthe most part) maliciously or intentionally
\nchoose to become incompetent. Instead, for
\nparticipants in this study, the voyage from
\ncompetence to incompetence was character-
\nized as a slow drift, a series of imperceptibly
\nsmall problems which over time became im-
\npossible for them to address by themselves.
\nWhile in some cases, incompetence was the
\nresult of wilful decisions (e.g. choosing to
\ndefraud an insurance plan), the majority of
\nparticipants were labelled as incompetent be-
\ncause of their performance on a compulsory,
\nstandardized assessment that was part of the
\nannual registration\/licensure renewal process
\nfor pharmacists. These practitioners\u00a0\u2013 with a
\nmean of 26 years clinical experience (range of
\n9\u201333 years) were deemed psychometrically
\nincompetent due to their performance on a
\nrequired and standardized objective struc-
\ntured clinical examination and a case-based
\nmultiple choice test [13], not because of a
\ncomplaint or disciplinary procedure.
\nThe competence drift experienced by these
\nindividuals had several important char-
\nacteristics. First, there were demographic
\nfactors that may highlight who is a risk for
\ncompetence drift: those in practice 25 years
\nor more, those who worked in sole practice
\nsettings without benefit of peers, and those
\nwho were internationally educated (i.e. re-
\nceived their formative education and clini-
\ncal training outside the United States or
\nCanada) appeared to have a higher risk for
\nbeing labelled incompetent by their regula-
\ntory body [10,13].Second,the vast majority
\nof these individuals had no prior history of
\ncomplaints or disciplinary issues with the
\nregulator; their competence drift was only
\nidentified through the test that was admin-
\nistered as a compulsory requirement as part
\nof an annual license\/registration renewal
\nprocess [13]. Third\u00a0\u2013 and perhaps most rel-
\nevant\u00a0\u2013 all of the individuals interviewed for
\nthis study highlighted the impact of pro-
\nfessional isolation on deterioration of their
\nskills,even though the majority of them had
\ncomplied with relevant continuing educa-
\ntion or other requirements.
\nA common denominator for participants in
\nthis study was the notion of isolation and
\ndisengagement from their profession. Those
\nwho were internationally educated individu-
\nals noted that they never felt they truly \u201cfit
\nin\u201d the professional community as they were,
\nfrom the start of their careers, outsiders to
\nthe schools and pre-existing professional and
\nalumni networks that characterize profes-
\nsional life. Those who worked in sole-prac-
\ntitioner settings noted that they were in the
\nunenviable position of never actually seeing
\na peer do their job, and never having the op-
\nportunity to actually benchmark themselves
\nagainst a colleague. Those who had been in
\npractice 25 years or longer noted how much
\nthe foundations of practice had changed in
\nthose years, particularly society\u2019s and pa-
\ntient\u2019s expectations of what a professional
\nis and should be\u00a0\u2013 the professional was no
\nlonger a trusted expert, but instead simply a
\nvehicle to do whatever the patient wanted (as
\nopposed to actually needed).
\nThe Psychological Dimensions
\nof Competence Drift
\nCompetence does not switch on and off
\nquickly\u00a0\u2013 instead, participants in this study
\nreported increasing anxiety, decreasing self-
\nconfidence,and diminishing interest in their
\njob as a slow-and-steady precursor to finally
\nbeing labelled incompetent by their regula-
\ntor. With professional isolation, there was
\nno obvious person they could ask for help,
\nwithout disclosing their deficits. Without
\na person or organization to reach out to,
\nthese individuals felt further marginalized
\nand disengaged from their profession. This
\nstudy highlighted that competence drift
\nmay be a decade`s long process or deterio-
\nration, one with early warning signs that, if
\naddressed, perhaps could have led to a dif-
\nferent outcome for these individuals.Rather
\nthan \u201csee\u201d competence as a binary defined
\nby psychometric properties related to tests
\nand assessment methods, if we view com-
\npetence as a psychological process in which
\nindividuals are unconsciously decoupling
\nfrom their professional community, perhaps
\nthere are opportunities to prevent this drift
\nfrom becoming permanent.
\nAcross all participants interviewed, a com-
\nmon theme emerged: disengagement as
\nCANADA
\n35
\nBACK TO CONTENTS
\nProfessional Competence
\nthe root cause of competence drift [14, 15].
\nA\u00a0psychological unfettering from one\u2019s pro-
\nfession, one\u2019s professional colleagues and
\ncommunity and ultimately one\u2019s patients
\nwere characteristics shared by all those who
\nwere ultimately found to be incompetent.
\nImportantly, for most of these individu-
\nals there was no actual documented harm
\ncause to patients: there were no complaints,
\nno discipline or legal cases, and no evidence
\nthat they had done anything wrong. Yet
\nwhen it came time to actually \u201cprove\u201d con-
\ntinuing competence using psychometric
\nstandardized tests, they were unable to do
\nso. Interestingly, after the fact, most of the
\nparticipants admitted they\u2019d known for years
\nthey were sub- or incompetent, but were so
\npsychologically disengaged by this point
\nthey had insufficient energy to overcome
\nthe inertia of simply carrying on doing what
\nthey\u2019d always done.Many participants noted
\nthat bureaucratic regulatory requirements\u00a0\u2013
\nranging from compulsory continuing educa-
\ntion attendance to maintenance of a learn-
\ning portfolio, to completion of standardized
\ncompetence assessment tests\u00a0\u2013 all contrib-
\nuted to this competence drift, as they were
\nseen as simply hurdles to be cleared and not
\nvaluable opportunities to reengage profes-
\nsionally with their field or their community.
\nWhile this study in one profession may
\nhave limited direct applicability to other
\nfields because of the unique way in which
\n\u201cincompetence\u201d was measured and defined,
\nthere may be lessons that could be of rel-
\nevance to all health care professions. First,
\ncompetence is not an either-or state,it is not
\na binary. Competence is a continuum and
\ncompetence drift is a years- or decades-long
\nprocess. Along this continuum there may
\nbe warning indicators and red flags\u00a0 \u2013 for
\nexample, demographic risk factors; rather
\nthan focus on maintenance of competence
\nas a series of proxy requirements (e.g. com-
\npulsory continuing education), we would be
\nadvised to focus on these early warning in-
\ndicators and intervene in a supportive way
\nsooner.Second,a core feature of competence
\ndrift appears to be disengagement\u00a0 \u2013 from
\ncolleagues, from the profession itself, and
\nultimately from patients. Psychological dis-
\nengagement deprives an individual of the
\nenergy and motivation required to actually
\naddress competence drift on his\/her own.
\nAt a certain point, a disengaged individual
\nsimply cannot see the problem or help him\/
\nherself and will require some external sup-
\nport to see them through to a more positive
\noutcome. Unfortunately, after graduation
\nand registration as a health care professional,
\nthere are few opportunities for a practitioner
\nin competence drift to actually reach out to
\nfind such help; to whom can a disengaged,
\ndisconnected physician turn if s\/he sus-
\npects s\/he is experiencing competence drift?
\nRegulators are not to be trusted due to their
\nobligations to protect the public; disengaged
\nindividuals likely do not have peers or con-
\nfidantes within the profession they can turn
\nto and admit the need for help [15]. Con-
\ntinuing education has been demonstrated
\nto have very limited value (if any) in lead-
\ning to practice change. Third, psychological
\ndisengagement becomes a vicious down-
\nward spiral [15]; as competence continues
\nto deteriorate, disengagement becomes even
\nmore of a survival and coping mechanism.
\nFourth\u00a0 \u2013 and perhaps most importantly\u00a0 \u2013
\nthis vicious downward spiral is rarely if
\never a conscious choice or decision made by
\nthe practitioner, and it may accelerate over
\ntime, making it even more difficult to stop
\nthe descent. Fifth, our current practices and
\napproaches within medical regulation and
\neducation\u00a0 \u2013 while well-intentioned\u00a0 \u2013 may
\nactually be paradoxically contributing to this
\ndownward spiral. In the name of public pro-
\ntection, we may be using concepts, tools and
\napproaches that actually further irritate, iso-
\nlate, and ultimately disengage practitioners
\nfrom their profession. For example, fram-
\ning competence as a binary concept (as we
\ncurrently do) deprives practitioners of a vo-
\ncabulary to describe their lived experience of
\ncompetence drift. Requiring practitioners to
\n\u201cprove\u201d they are competent may not actually
\nimprove practice and enhance competence
\nif it is interpreted as simply a hoop to be
\njumped through and bureaucratic require-
\nment enforced by those who do not realize
\nhow challenging day-to-day patient facing
\nwork actually is in today\u2019s environment.
\nConclusions
\nWe need to \u201csee\u201d competence in a different
\nway, one that is more psychologically nu-
\nanced and recognizes that physicians and
\nother health care professionals are actually
\nlike all other human beings. By seeing com-
\npetence as a continuum,not a binary, and by
\nrecognizing that the psychological energy
\nrequired to maintain competence comes
\nfrom engagement with one\u2019s profession, not
\nmandatory continuing education, we may
\nhave opportunities to prevent small prob-
\nlems from becoming bigger ones. When
\nwe see competence drift as a psychological,
\nrather than psychometric, issue, new oppor-
\ntunities open for providing support and re-
\nmediation in a more targeted and more nur-
\nturing manner. Psychological engagement
\nin one\u2019s profession\u00a0 \u2013 a feeling of positive,
\nenergized connection to colleagues,the field
\nitself, and the patients we serve [15]\u00a0\u2013 needs
\nto be researched further as an inoculation
\nto competence drift. In so doing, perhaps
\nwe will find alternative ways to intervene
\nin competence drift before small problems
\nbecome big ones.
\nReferences
\n1.\t Epstein R and Hundert E. Defining and as-
\nsessing professional competence (review). J Am
\nMed Assoc. 2002;287(2): 226\u2013236.
\n2.\t Ibrahim J. Continuing professional develop-
\nment: a burden lacking educational outcomes
\nor a marker of professionalism? Med Educ.
\n2015;49(3):240-242.
\n3.\t Kane M.The assessment of professional compe-
\ntence, Eval Health Prof. 1992;15 (2):163-182.
\n4.\t Kogan J, Holmboe E and Hauer K.Tools for di-
\nrect observation and assessment of clinical skills
\nof medical trainees: a systematic review. JAMA
\n2009;302(12):1316-1326.
\n5.\t Accreditation Council for Graduate Medical
\nEducation (ACGME) and American Board
\nof Medical Specialties (ABMS).\u00a0 Toolbox
\nof Assessment Methods v1.1 \u2013 September
\n2000.\u00a0 Accessed at:\u00a0 \u00a0 https:\/\/www.slideshare.
\nCANADA
\n36
\nHealth Care
\nHealthcare is essential in the growth of any
\ncountry though with its challenges. This article
\nexamines healthcare services and workforce in
\nrural communities in Nigeria. This is a review
\narticle. Search for previous articles written on
\nhealth care in rural Nigeria was done using
\nGoogle, PubMed and Medline to search for
\narticles on healthcare in rural areas, develop-
\ning countries and Nigeria. There is dearth of
\nhealth care in Nigerian rural areas due to lack
\nof career opportunities, lack of basic amenities,
\nlack of training opportunities and fate in tra-
\nditional medicine.
\nHealth is the most significant ingredient
\nto life [1] and the quality of health in any
\nstate or country is the fundamental right of
\nits citizens [2].This means that a healthy na-
\ntion is made up of healthy citizens. In Ni-
\ngeria a large percentage of the population
\nreside in rural communities hence they are
\nalso entitled to good healthcare facilities [3].
\nProviding equitable access to healthcare be-
\ncomes an indispensable imperative to achiev-
\ning wellbeing [4] . Compared to inhabitants
\nin Nigerian urban areas, people that dwell in
\nrural and remote areas experience a lower life
\nexpectancy and poor health status [5]. Gen-
\nerally, Nigeria has a high population density
\nbut a weak healthcare system [6]. Therefore,
\naccess to healthcare should be near to where
\nthe people live as much as possible [7]. The
\nhealth sector is labour intensive as it requires
\ndifferent professionals and precise applica-
\ntion of knowledge to deliver quality service
\n[8]. Good public health is vital in any coun-
\ntry not only for the purpose of maintaining a
\nhealthy populace but also as a matter of na-
\ntional security [1].
\nHealthcare in Nigeria
\nHealthcare in Nigeria is provided by both
\nthe government and private health facilities
\nthough some individuals still practice tradi-
\ntional medicine in the use of herbs and oth-
\ner traditional materials. The practitioners
\nof this traditional medicine are herbalists,
\ntraditional bone setters, traditional birth at-
\ntendants, spiritualists and faith healers. The
\nspiritualist and faith healers use religion and
\nconduct sacrifices as part of administering
\ntraditional healthcare to people that patron-
\nize them. In Nigeria today, the provision of
\nhealthcare facilities seems to be at low ebb
\nas many Nigerians are vulnerably exposed to
\ndeath [1]. The healthcare facilities in Nige-
\nria are three-tier,the primary,secondary and
\ntertiary healthcare facilities [9].The primary
\nhealthcare centres and health posts provide
\nprimary health care services, the general,
\ndistrict and cottage hospitals provide sec-
\nondary healthcare services while the teach-
\ning hospitals, federal medical centres and
\nspecialists\u2019hospitals provide tertiary health-
\ncare services [9]. The tertiary health care
\nproviders receive referrals from the primary
\nand secondary healthcare providers.
\nWorkforce of Healthcare Professionals
\nin\u00a0Rural Nigeria
\nBuowari, Dabota Yvonne
\nnet\/pedgishih\/toolbox-of-acgme-assessment-
\nmethods\u00a0on August 8 2018.
\n6.\t Hodges B and Lingard L, (Eds.) (2012). The
\nQuestion of Competence: Reconsidering Medi-
\ncal Education in the Twenty-first century. ILR
\nPress; Ithaca NY.
\n7.\t Sargeant J, Mann K, Sinclair D, van der Vleuten
\nC and J. Metsemarkers J. Challenges in multi-
\nsource feedback: intended and unintended out-
\ncomes. Med Educ. 2008; 42 (10): 1107-1113.
\n8.\t Smither J, London M and Reilly R. Does per-
\nformance improve following multisource feed-
\nback? A theoretical model, meta-analysis, and
\nreview of empirical findings, Person Psychol.
\n2005; 58:33-66.
\n9.\t Eva K and Regehr G. \u201cI\u2019ll never play professional
\nfootball\u201d and other fallacies of self-assessment, J
\nContinuing Educ Health Prof.2008;28 (1):14\u201319.
\n10.\tAustin Z and Gregory PAM. The role of disen-
\ngagement in the psychology of competence drift.
\nRes Social Admin Pharm 2018 Feb 27.Accessed
\nat: https:\/\/www.sciencedirect.com\/science\/arti-
\ncle\/pii\/S1551741117307775?via%3Dihub
\n11.\tKratochwill T and Levin J (2014). Single-case
\nIntervention Research: Methodological and
\nStatistical Advances. American Psychological
\nAssociation Press.
\n12.\tKratochwill T and Levin J. Enhancing the sci-
\nentific credibility of single-case intervention
\nresearch: randomization to the rescue. Psychol
\nMeth. 2010; 15 (2): 124\u2013144.
\n13.\tAustin Z, Marini A, Croteau D and Violato C.
\nAssessment of pharmacists\u2019 patient care compe-
\ntencies: validity evidence from Ontario (Cana-
\nda\u2019s) quality assurance and peer review process.
\nPharm Educ. 2004;4 (1);23\u201332.
\n14.\tCsikszentmihalyi M (2008). Flow: The Psychol-
\nogy of Optimal Experience. Harper Perennial
\nModern Classics New York NY.
\n15.\tSchon D (1983). The Reflective Practitioner:
\nHow Professionals Think in Action. Basic Books
\nNew York NY.
\nZubin Austin, BScPhm, MBA,
\nMISc, PhD, FCAHS
\nProfessor and Koffler Chair in Management,
\nLeslie Dan Faculty of Pharmacy,
\nUniversity of Toronto Canada
\nPaul AM Gregory, BA, MLS
\nResearch Associate, Leslie Dan Faculty of
\nPharmacy, University of Toronto Canada
\nNIGERIA
\n37
\nBACK TO CONTENTS
\nHealth Care
\nThe Nigerian government has made nu-
\nmerous great efforts in providing health-
\ncare facilities for its citizens especially in
\nthe establishment of primary healthcare
\ncentres in Nigerian rural communities [10].
\nThe private hospitals are usually expensive
\nand mostly located in the urban areas hence
\nindividuals use their digression to choose
\nwhich health facility they wish to receive
\nhealthcare.
\nIn a study conducted in rural communi-
\nties in Kogi State, Nigeria, results from
\nthe study suggested that distance to im-
\nproved health facilities and the total costs
\nof seeking healthcare needs to be reduced
\nto enhance accessibility to improved health
\nservices by various socioeconomic groups
\n[10]. Many countries are striving to keep
\npace with healthcare delivery because the
\nsustainability and viability of any country\u2019s
\neconomic and social growth depends on the
\nhealthcare sector as a nation of sick people
\nwould certainly not live up to its basic re-
\nsponsibilities [1].
\nHealthcare Professionals
\nin Nigeria
\nThe healthcare workforce is made up of
\nhealth workers which include all the people
\ninvolved in the promotion, protection or
\nimprovement of the health of the popula-
\ntion which play a very important role in
\nachieving an effective healthcare delivery
\nsystem [11] The healthcare system requires
\na large number of health workers [8] to ad-
\ndress the health needs such as the doctors,
\nnurses, laboratory scientists, physiothera-
\npists, medical technologists, medical tech-
\nnicians and others. The healthcare work-
\nforce is an important guide and indicator
\nof the strength of the health system and
\nalso the quality of healthcare in a coun-
\ntry. Though there is shortage of healthcare
\nworkers in Nigeria [11], there is too much
\nconcentration of medical personnel in the
\nurban areas than in the rural communities
\n[2]. Generally graduates both in medical
\nand non-medical professions prefer to work
\nin the urban cities [7] where there are better
\namenities such as pipe borne water, electric-
\nity, telecommunication, career advancement
\nopportunities, good schools, accommoda-
\ntion and communication problems if they
\ndo not understand the local language.
\nTherefore retention of healthcare workers in
\nthese rural communities is a challenge [13].
\nThe inadequacy of medical doctors, nurses
\nand midwives across Nigeria in 2016\u20132030
\nis not likely to change and this would not
\nlikely affect the health indicators over the
\nsame period since healthcare workers force
\nplay a critical role in strengthening health
\nsystem of any country [11].
\nHealthcare in Rural
\nAreas in Nigeria
\nA healthy country is a wealthy country as
\nits citizens are useful resources that will
\nbe involved in useful investments in order
\nto move the nation to greater heights [1].
\nMost rural Nigerian communities do not
\nhave access to healthcare. Sometimes there
\nare health facilities either primary or sec-
\nondary healthcare facilities but the service
\nis not utilized by the inhabitants. There are
\ndifferent reasons for this. While primary
\nhealthcare centres (PHC) are relatively
\nuniformly distributed throughout the local
\ngovernment areas (LGA) in Nigeria, the
\nrural people tend to underuse the service
\n[2]. The availability of basic health services
\nprovided by the primary healthcare centres
\nespecially to rural areas in a country might
\nbe used as a yardstick to measure the extent
\nof its level of development of healthcare [2].
\nAdequate and equitable distribution of
\nhealthcare facilities in rural areas is critical
\nto human capital development [10]. Before
\nthe establishment of these health facilities,
\nmost residents in Nigerian rural settlements
\ndepended on traditional health services, but
\npresently there exists a variety of healthcare
\nservices in Nigeria [14]. Though the pri-
\nmary healthcare centres were established in
\nboth rural and urban areas in Nigeria with
\nthe intention of equity and easy access re-
\ngrettably the rural populations in Nigeria
\nare seriously underserved when compared
\nwith their urban counterparts [2].Therefore
\nthe government should encourage public-
\nprivate partnership in healthcare delivery at
\naffordable prices to people residing in rural
\nareas as is done in the urban areas, as this
\nwould be achieved through the provision of
\nbasic infrastructure such as accessible roads,
\nelectricity etc [10].
\nChallenges of Healthcare
\nin Rural Nigeria
\nThere are challenges facing health care de-
\nlivery in rural areas. A large percentage of
\nthe Nigerian population living in rural ar-
\neas have been affected with several diseases
\nwith deleterious consequences both on their
\nhealth and finance [3] due to the shortage
\nof healthcare workers in rural areas. There
\nare many challenges to healthcare in Nige-
\nrian rural communities.
\n1.\t Lack of good roads and other means of
\ntransportation to the health facility:
\nThis transportation problem is a signifi-
\ncant problem in the management of pri-
\nmary healthcare centres [2]. In order to
\novercome the barrier of distance to the
\nutilization of healthcare facilities in the
\nrural communities, government should
\nestablish the primary health centres in
\nthe core rural areas close to where the
\npeople live.
\n2.\t Lack of training for healthcare work-
\ners: There is lack of training most times
\navailable to healthcare professionals
\nworking in rural areas compared to
\nthose working in the urban for instance
\nthere is no continuous medical educa-
\ntion\/continuous professional develop-
\nment for medical doctors in the rural
\nareas and this is a prerequisite for the
\nrenewal of medical doctors and dentists
\npractising licence by the Medical Den-
\ntal and Medical Council of Nigeria. Ac-
\nademic isolation has been identified as
\nNIGERIA
\n38
\nMedical Ethics
\nIntroduction
\nThe Icelandic Medical Association was one
\nof the 27 founding members of the WMA
\nin 1947 but in October this year the first
\nconstituent WMA meeting will be held in
\nIceland. The venue of the General Assem-
\nbly is the extraordinary music and confer-
\nence centre Harpa by the harbour in cen-
\ntral Reykjavik. For the first time, a two and
\na half day conference on medical ethics is
\nplanned replacing the traditional scientific
\nday. It has been a challenge to organize a
\nconference in parallel with the obligatory
\nmeetings of the assembly. The last day is
\nspecifically organized around the central
\nissues of the WMA, based on some of its
\nmost important policies such as the Decla-
\nration of Geneva and the Helsinki Decla-
\nration. We are hoping for good attendance,
\nnot only by the delegates of the assembly
\nbut by all those working on medical eth-
\nics in the respective medical associations
\nas well as others that are interested in fol-
\nlowing the dialogue inside the WMA on
\nmedical ethics.
\none of the factors that discourage doc-
\ntors from working in underdeveloped
\nareas.Training deficiencies is a restrain-
\ning factor that needs to be addressed to
\nenable medical practitioners to deliver
\nequitable and quality service in district
\nand cottage hospitals which are located
\nin rural areas [12].
\n3.\t Lack of basic infrastructure in Nige-
\nrian rural areas: There is lack of basic
\ninfrastructure in the rural communities.
\nThis discourages healthcare workers
\nfrom staying at their duty posts when
\nposted to the primary healthcare centres
\nand other district, cottage and general
\nhospitals located in rural areas. These
\ninclude lack of electricity, telecom-
\nmunication services, social amenities
\nand schools for their children. Poorly
\nequipped and managed hospitals, in-
\nappropriate training and an excessive
\nworkload are significant contributors to
\npoor healthcare facilities in rural areas
\n[15]. Better healthcare in the Nigerian
\nrural communities could be achieved
\nthrough the provision of basic infra-
\nstructure such as accessible roads, elec-
\ntricity, water, schools and essential drugs
\n[10].
\nHealthcare is very important to both resi-
\ndents of urban and rural areas. There is
\nshortage of healthcare workers in develop-
\ning countries with Nigeria inclusive. Most
\nof the healthcare workers in Nigeria are
\nconcentrated in the urban communities
\nwhere there are better amenities and career
\nopportunities.There is need for government
\nto tackle the challenges facing both the de-
\nlivery of healthcare services and healthcare
\nprofessionals in the rural areas in order to
\nencourage all cadres of health workers to
\ndevelop interest in working in rural areas.
\nReferences
\n1.\t Eme OI, Uche AO, Uche IB. Building a solid
\nhealthcare system in Nigeria: challenges and
\nprospects.Acad J Inter Stud,2014,3 (6),501-510.
\n2.\t Abdulraheem IS, Olapipo AR, Amodu MO.
\nPrimary healthcare services in Nigeria: critical
\nissues and strategies for enhancing the use by
\nthe rural communities. J Pub Health Epid, 2012,
\n4 (11), 5-13.
\n3.\t Udoudo MGM, Umoh GS. Can government
\ndeliver quality rural healthcare? Empirics on
\nmalaria prevention and control in Nigeria. Asian
\nJ Econ Modelling, 2016, 4 (2), 70-81.
\n4.\t Omogbadegun Z. Development of a framework
\nfor collaborative healthcare services delivery. In-
\nter J Adv Comp Sci Apli, 2013, XXX(No XXX),
\n1-9, www.ijacsa.thesai.org accessed 2018.
\n5.\t Strasser R, Kam SM, Regalado SM. Rural
\nhealthcare access and policy in developing coun-
\ntries. Annual Rev Pub Health, 2016, 37, 395-
\n412, www.annualreviews.org
\n6.\t Okoli U, Eze-Ajoku E, Oludipe M, Spiek-
\ner N, Ekezie W, Ohiri K. Improving qual-
\nity of care in primary healthcare facilities
\nin rural Nigeria: successes and challenges.
\nHealth Serv Res Manag Epid, 2016, 1-6, doi.
\n10.1177\/2333392816662581
\n7.\t O\u2019Connor B, Bagg W. Encouragers and dis-
\ncouragers affecting medical graduate\u2019s choice of
\nregional and rural practice locations. Rural Re-
\nmote Health,2017,17,4247,doi org\/10.226051\/
\nRRH4242
\n8.\t Adindu A, Asuquo A. Training human resource
\nfor 21st
\ncentury Nigerian health sector. Global J
\nHum Res Manag, 2013, 1 (3), 1-11.
\n9.\t Udoh U, Uyanga J. Housing conditions and
\nhealth in rural Nigeria: a study of Akwa Ibom
\nState. Res Hum Soc Sci, 2013, 3 (18), 34-42,
\nwww.iiste.org accessed 2018.
\n10.\tAwoyemi TT, Obayelu OA, Opaluwa HI. Effect
\nof distance on utilization of healthcare services
\nin rural Kogi State, Nigeria. J Hum Ecol, 2011,
\n35 (1), 1-9.
\n11.\tAdebayo O, Labiran A, Emerenini CF, Omoruji
\nL. Health workforce for 2016-2030: will Nigeria
\nhave enough? Inter J Innovative Healthcare Res,
\n2016, 4 (1), 9-16.
\n12.\tOkoli U, Mohammed SA, Ejecka C, Oshin T,
\nOkigbo A, Ekezie W. Strengthening primary
\nhealthcare services in rural Nigeria: the poten-
\ntial of using midwives as skilled birth attendants.
\nHealth Systems Policy Res, 2016, 3 (2), 18, 1-7.
\n13.\tObembe TA, Osungbade KO, Olumide EA,
\nIbrahim CM, Fawole OI. Staffing situation of
\nprimary healthcare facilities in federal capital
\nterritory Nigeria: implication for attention and
\nretention policies. Afr J Soc Manag Sci, 2014,
\n5 (2), 84-90.
\n14.\tEfe SI. Healthcare problem and management in
\nNigeria. J Geo Reg Plan, 2013, 6(6), 244-254.
\n15.\tDe Villiers MR, De Villiers PJP. Doctors views
\nof working conditions in rural hospitals in the
\nWestern Cape. SA Fam Pract, 2004, 46 (3), 21-
\n26.
\nDr. Buowari, Dabota Yvonne,
\nRiverine Community Medical
\nCentre, Port Harcourt, Nigeria.
\nE-mail: dabotabuowari@yahoo.com
\nInternational Congress on Medical Ethics,
\na\u00a0Risk Worth Taking?
\n39
\nBACK TO CONTENTS
\nMedical Ethics
\nThe medical ethics
\nconference (MEC)
\nAt the opening of the conference, WMA
\npresident Yokokura and the Health Minis-
\nter of Iceland will address the participants
\nin addition to the president of the Icelandic
\nMedical Association and the President of
\nthe conference. Following the opening cer-
\nemony, the Secretary General of WMA, Dr.
\nOtmar Kloiber will give an overview of the
\nhistory of the WMA. As the conference is
\nnot only for delegates to the Assembly, this
\nis a very good opportunity to inform of the
\nactivities of the WMA through the decades
\nsince its foundation 71 years ago and the
\nimpact it has had.
\nGenerally, there are two parallel sessions,
\nmost of them organized with a specific
\ntheme, i.e. invited symposia. In addition,
\nthere are two sessions with free oral presen-
\ntations. The general rule for a symposium
\nis three presentations at 20 minutes each
\nand 30 minutes of discussion. This is rather
\nunusual but it has to be pointed out that
\nthis is not a classical scientific conference,
\nrather a forum for dialogue and discussions.
\nTherefore an ample time for discussions is
\nplanned for in each symposium. Another
\npoint worth mentioning is that the last day
\nis specific for the topics that are central to
\nthe WMA even though all other topics are
\nimportant in one way or another.This is the
\nclassical scientific day of a WMA General
\nAssembly as it has been practiced for de-
\ncades. The central policy documents of the
\nWMA such as the Declaration of Geneva
\n(DoG), the International Code of Medical
\nEthics (ICME), the Declaration of Hel-
\nsinki (DoH) and the Declaration of Taipei
\n(DoT) will be discussed. Some of them
\nhave recently been revised (DoG and DoT)
\nbut others are in a starting phase of the next
\nrevision (if so decided) such as the ICME
\nthat is very linked to DoG.The most known
\npolicy of WMA, the DoH was revised in
\n2013. There are now some ideas of changes
\nthat will be discussed at the conference. It
\nremains to be seen if this will lead to a new
\nround of revision, it is up to the formal bod-
\nies of WMA to decide.
\nThe only social event that is planned for
\nthe participants is the reception at the City
\nHall,an event that is for both the MEC and
\nthe GA. In addition our travel agency, the
\nIceland Travel is organizing many tours for
\nthe participants.
\nThe web site of the conference is www.
\nmedicalethicsiceland.is
\nA Facebook page has been created: www.
\nfacebook.com\/events\/33292879056658
\nThe General Assembly (GA)
\nThe GA will have the usual format, which
\nis not necessary to describe for the read-
\ners of the WMJ. Every location is however
\nunique and so it is in Iceland. This is the
\nmost northern capital in the world and the
\nweather can be unpredictable. It will most
\nlikely be around 10\u00b0C and hopefully, the
\nwindy season has not begun but that varies
\nfrom one year to the next. There might be
\nopportunities to see the Northern lights as
\nthe autumn is the best time but the visibility
\nneeds to be good.The main hotel is not ad-
\njacent to the venue and thus transportation
\nis provided for. There will be a city tour for
\nthe accompanying persons on Thursday and
\nthe classical half-day tour for all the partici-
\npants is scheduled on Friday. On that tour,
\nthe GA members and their accompanying
\npersons will visit Thingvellir,the area for the
\noldest parliament in the world, established
\nthe year 930 and on going since then apart
\nfrom 45 years in the early eighteen century.
\nIt is also a very interesting geological area
\nas it is the most visible rift on land between
\nEurope and America. The dinner will take
\nplace in a replica of the oldest type of houses
\nin the country that were built by the settlers
\nin the 8th
\ncentury.
\nTo take a risk
\nThe Icelandic Medical Association is cel-
\nebrating its 100 years anniversary in 2018.
\nThere are many special events organized
\nthrough the year celebrating the profession,
\nnot only for its work and its contribution
\nto society but also for other contributions
\nsuch as in music and literature as some doc-
\ntors have been quite influential in these ar-
\neas. The GA and the MEC in October is
\nhowever the biggest event. There are some
\nrisks taken by organizing the conference.
\nFirst of all, it is to some extent parallel to
\nthe GA and that creates some difficulties
\nand has been criticised. Another risk is on
\nthe finances. The Association is taken full
\nfinancial responsibility for the event even
\nthough WMA will contribute with speak-
\ners and other support.As there is ever grow-
\ning competition regarding conferences and
\nas this is the first time an international con-
\nference focusing purely on medical ethics is
\norganized, it is obvious that the organizers
\ncould not count on good attendance. The
\nAssociation is however in good standing
\nand the event will take place and hopefully
\nbe memorable for all of us.
\nJon Snaedal,
\nPresident of the International
\nConference on Medical Ethics
\n2.-4. October 2018
\nReykjavik, Iceland
\nJon Snaedal
\n40
\nPublic Health
\nMaking sense of what a cancer diagno-
\nsis means is monumental for anyone. How
\nmuch more complicated and unbearable for
\nlow literacy patients and children who really
\ndon\u2019t understand their diagnosis or what is
\nhappening to them? Globally, the absence of
\nsuitable health educational material, particu-
\nlarly for those whose home language is not
\nEnglish, severely aggravates misunderstand-
\ning and treatment non-compliance.
\nThe Speaking Book\u00ae is a multi-media edu-
\ncational tool developed specifically to deliv-
\ner critical health information to vulnerable
\npatients and communities in an interactive,
\nnon-threatening and culturally appropriate
\nway. Using 16 audio buttons that follow the
\nwritten text of each page of the Book allows
\nthe patient to follow the book and listen to
\nthe messages,if they are unable or unwilling
\nto read.
\nSpeaking Books\u00ae has just launched a
\nbrand new book\u00a0\u2013 \u201cChildren Coping with
\nCancer\u201d\u00a0\u2013 created for children in paediat-
\nric oncology wards in the USA. Written in
\nEnglish and Spanish, this ground-breaking
\nBook was developed with the input and
\nassistance from a number of paediatric on-
\ncologists; is endorsed by the WMA, funded
\nby Pfizer, and has the support of the Rotary
\nClub of Hilton Head. Together with Pfizer
\nand Rotary Clubs in the USA,the Speaking
\nBook\u00ae Children Coping with Cancer will be
\ndistributed in all children\u2019s cancer centres and
\nhospitals free of charge whilst stocks last.
\n\u201cIn addition\u201d, according to Brian Julius,The
\nPresident and Founder of Speaking Books\u00ae,
\n\u201cwe have included on the back page a list of
\nreally useful resources for parents and care
\ngivers to contact for cancer related ques-
\ntions, financial and emotional support\u201d
\nThe two narrators of the Book, Cade Kris-
\ncunas (11) and EfrainTinoco (10) are mem-
\nbers of The Rotary Club of Hilton Head\u2019s
\n\u201cEarly Act Programme\u201d for young Rotar-
\nians. Together their narration of this Book
\nin English and Spanish delivers a message
\nof hope and courage to children with cancer.
\nWith a push of a button, children in oncol-
\nogy wards (and their families) can listen to
\nDavid telling his story about being a child
\nwith cancer; can learn about cancer; and can
\nbe entertained and distracted.
\nDavid provides an understanding and re-
\nlatable voice for children. \u201cI had cancer too.
\nI\u00a0am here to keep you company while you\u2019re
\nin the hospital. I know you might be scared
\nor in pain now.\u201d He explains, in an easy to
\nunderstand way,what cancer is and how chil-
\ndren can cope. In writing the Book, research
\nshowed that many children with cancer and
\nother life-threatening illnesses feel they are to
\nblame for being sick or that their illness is a
\npunishment. David emphasises that cancer is
\nan illness.\u201cYou cannot catch it from someone
\nand you cannot make anyone else sick. You
\ndid not get cancer because you were naughty
\nor because you did something wrong.\u201d
\nFrom counting flowers, to finding the
\nsquirrel hiding in the garden, to drawing
\npictures, David and Children Coping With
\nCancer distracts sick kids from the pain of
\ntreatment.The Speaking Book\u00ae is colourful
\nand interactive. David chats naturally with
\nhis young audience and helps them feel less
\nlonely and afraid.
\nChildhood cancers are very different in na-
\nture, cause and treatment to adult cancers.
\nWhile generally childhood cancers tend to
\nrespond better to treatments that adult can-
\ncers, they require specialist paediatric treat-
\nment by a paediatric oncologist. The occur-
\nrence of childhood cancer is significantly
\nless than that of adult cancer.To develop the
\nexpertise required, the medical team needs
\nto see a large number of patients. This has
\nMulti-Media Educational Tool Created to
\nHelp Children Cope with Cancer
\nBrian Julius
\nIII
\nBACK TO CONTENTS
\nPublic Health
\nled to childhood cancers worldwide being
\ntreated mostly in public sector hospitals.
\nWhile the expertise is generally in a pub-
\nlic hospital, often there is insufficient time
\nto devote to each patient. There are wait-
\ning lists and busy staff and the environment
\ncan be all the more overwhelming for a
\nchild and for a family who may not speak
\nEnglish. It is for this reason that Children
\nCoping with Cancer was created as a dual-
\nlanguage English\/Spanish Book.
\nDavid explains what cancer is in a way that
\nis engaging and comprehensible. He asks
\nhis listeners to copy a picture in the Book
\nas quickly as they can. It isn\u2019t quite right\u2026
\n\u201cWhen we grow, our cells and DNA split
\ninto two and make a copy of each other like
\nthe copy of your picture. Kids grow really
\nfast and sometimes the copy isn\u2019t the way
\nit should be. That\u2019s what cancer is.\u201d He ex-
\nplains that there are different types of can-
\ncer and that it can start in any part of the
\nbody. Cancer can spread but it is always
\nnamed for the place where it starts.
\nThrough the
\nBook, David ex-
\nplains the treat-
\nment teams to
\nthe child. He
\nreaches out to
\neach listener, en-
\ncouraging them
\nto trust their
\nteams and all the tests and procedures.\u201cYou
\nhave a lot of different people on your team
\nto make sure that you will get well.\u201d One
\nof the strengths of the Speaking Book\u00ae is
\nthat it answers questions that may not be
\nable to be asked. Many patients who use the
\nSpeaking Book\u00ae feel like their doctor is al-
\nways with them, answering their questions,
\nand reinforcing healthy treatment compli-
\nance. For children with cancer, and for their
\nfamilies, having a reassuring expert at the
\ntouch of a button is incredibly powerful.
\nDavid will tell you the same advice,will play
\nthe same games, and share the same secrets
\nwith you every time you press the button.
\nFor people trying to grasp a diagnosis of
\ncancer, this reassurance is comforting, edu-
\ncational and empowering.
\n\u201cOur experience with all Speaking Books\u00ae
\nhas always been so positive, and we know
\nthis latest book will go a long way to help
\nreduce Children\u2019s Fears and improve their
\nunderstanding of Cancer, that it is not
\ncatching, was not their fault, and that they
\nare being looked after by wonderful people
\ndedicated to their treatment.\u201d Says Marc
\nChioda, Medical Director, Pfizer Oncology.\u00a0
\nEach child is different. Some worry. Others
\nget upset or become quiet, afraid, or defiant.
\nSome express their feelings in words, others
\nin actions.Children Coping with Cancer offers
\nall children,across age groups,to express how
\nthey feel and connect with another child in
\na safe space. In the absence of fact, children
\nuse their imaginations to make up answers to
\nunanswered questions. Answering questions
\nhonestly can be extremely challenging for
\nfamilies who don\u2019t have the language capac-
\nity to really grasp what is happening to their
\nchild. The Speaking Book\u00ae is dual language
\nfor exactly this reason.
\nDavid (Cade Kriscunas and Efrain Tinoco)
\nare honest with their listeners that treat-
\nment may hurt; that they may feel scared
\nand sick. They also have words of wisdom
\nfor their young listeners\u2026 \u201cWe know that
\nyou want to be brave and strong and not cry
\nor show how you feel. I used to try and pre-
\ntend I was fine but I learned that being re-
\nally brave means telling other people when
\nyou feel weak or sick.\u201d
\nIt is in this spirit that this Speaking Book\u00ae
\nis dedicated to Dr. Jack Watters, former
\nPfizer Vice President and Fellow and Trust-
\nee of both the New York Academy of Med-
\nicine, and Help Aged International who
\npassed away on June 30th
\n2015 from Cancer.
\nHe was an invaluable supporter for public
\nhealth care and a tireless advocate of health
\ncare education. He did so much to promote
\nhealth care education to the most vulner-
\nable communities, and is sorely missed.
\nSpeaking Books\u00ae have been developed in
\nmore than 40 languages for distribution
\nin over 30 countries worldwide. Child-
\nhood cancer is certainly not limited to the
\nUSA. While this Book has been created,
\nwith Pfizer,the WMA and the Rotary Club
\nHilton Head, for childhood cancer centres
\nacross the United States of America, it is
\nthe aim to offer this Book to children and
\nfamilies across the globe.
\nBrian Julius
\nSpeaking Books, Hilton Head, USA
\nWebsite: www.speakingbooks.com
\nE-mail: bj@speakingbooks.com
\nIV<\/p>\n"},"caption":{"rendered":"

vol. 64 Medical World Journal Official Journal of The World Medical Association, Inc. ISSN 2256-0580 Nr. 2, August 2018 Contents Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{"sizes":{"thumbnail":{"file":"WMJ_2_2018-pdf-110x150.jpg","width":110,"height":150,"mime_type":"image\/jpeg","source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2018\/09\/WMJ_2_2018-pdf-110x150.jpg"},"medium":{"file":"WMJ_2_2018-pdf-220x300.jpg","width":220,"height":300,"mime_type":"image\/jpeg","source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2018\/09\/WMJ_2_2018-pdf-220x300.jpg"},"large":{"file":"WMJ_2_2018-pdf-750x1024.jpg","width":750,"height":1024,"mime_type":"image\/jpeg","source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2018\/09\/WMJ_2_2018-pdf-750x1024.jpg"},"full":{"file":"WMJ_2_2018-pdf.jpg","width":1033,"height":1411,"mime_type":"application\/pdf","source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2018\/09\/WMJ_2_2018-pdf.jpg"}}},"post":940,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2018\/09\/WMJ_2_2018.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/11366"}],"collection":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media"}],"about":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/types\/attachment"}],"author":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/users\/17"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/comments?post=11366"}]}}