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wmj_3_2019_WEB<\/a><\/p>\n

General Assembly Report
\nvol. 65
\nMedical
\nWorld
\nJournal
\nOfficial Journal of The World Medical Association, Inc.
\nISSN 0049-8122
\nNr. 3, November 2019
\nContents
\nEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t1
\nValedictory Address of WMA President Prof. Leonid Eidelman . . . . . . . . . . . . . . . . . . . . . . . . \t2
\nInaugural Speech of WMA President Dr. Miguel R. Jorge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t3
\nWMA 2019 General Assembly Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t6
\nWMA Statement on Sex Selection Abortion and Female Foeticide . . . . . . . . . . . . . . . . . . . . . . \t22
\nWMA Declaration on Euthanasia and Physician-Assisted Suicide . . . . . . . . . . . . . . . . . . . . . . \t22
\nWMA Declaration of Madrid on Professionally-led Regulation . . . . . . . . . . . . . . . . . . . . . . . . \t22
\nWMA Declaration on the Relation of Law and Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t23
\nWMA Declaration of Reykjavik\u00a0\u2013 Ethical Considerations Regarding the Use of Genetics
\nin Health Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t26
\nWMA Statement on Access of Women and Children to Health Care . . . . . . . . . . . . . . . . . . . . \t28
\nWMA Statement on Antimicrobial Resistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t29
\nWMA Statement on Augmented Intelligence in Medical Care . . . . . . . . . . . . . . . . . . . . . . . . . \t31
\nWMA Statement on Free Sugar Consumption and Sugar-Sweetened Beverages . . . . . . . . . . \t34
\nWMA Statement on Healthcare Information for All. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t35
\nWMA Statement on Medical Age Assessment of Unaccompanied Minor Asylum Seekers . . \t36
\nWMA Statement on Reducing Dietary Sodium Intake. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t37
\nWMA Statement on Solitary Confinement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t39
\nWMA Resolution on Legislation Against Abortion in Nicaragua. . . . . . . . . . . . . . . . . . . . . . . \t41
\nWMA Resolution on Climate Emergency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t41
\nWMA Resolution on the Revocation of Who Guidelines on Opioid Use. . . . . . . . . . . . . . . . . \t42
\nWMA Statement on Violence and Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t42
\nUnited Nations Climate Action Summit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t44
\nThe Role of Physicians in Fighting Climate Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t46
\nEditor in Chief
\nDr. P\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. med. 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. Maija \u0160etlere, Skolas street 3, Riga, Latvia
\nPublisher
\nMedic\u012bnas apg\u0101ds, Ltd
\nSkolas street 3, Riga, Latvia.
\nISSN: 2256-0580
\nDr. Miguel Roberto JORGE
\nWMA President,
\nBrazilian Medical Association
\nRua-Sao Carlos do Pinhal 324,
\nCEP-01333-903 Sao Paulo-SP
\nBrazil
\nDr. Otmar KLOIBER
\nSecretary General
\nWorld Medical Association
\n13 chemin du Levant
\n01212 Ferney-Voltaire
\nFrance
\nDr. Jung Yul PARK
\nWMA Chairperson of the Finance
\nand Planning Committee
\nKorean Medical Association
\nSamgu B\/D 7F 8F 40 Cheongpa-ro,
\nYongsan-gu
\n04373 Seoul
\nKorea, Rep.
\nDr. David Barbe
\nWMA President-Elect,
\nAmerican Medical Association
\nAMA Plaza, 330 N. Wabash, Suite
\n39300
\n60611-5885 Chicago, Illinois
\nUnited States
\nDr. Mari MICHINAGA
\nWMA Vice-Chairperson of Council
\nJapan Medical Association
\n2-28-16 Honkomagome
\n113-8621 Bunkyo-ku,Tokyo
\nJapan
\nDr. Osahon ENABULELE
\nWMA Chairperson of the Socio-
\nMedical Affairs Committee
\nNigerian Medical Association
\n8 Benghazi Street, Off Addis Ababa
\nCrescent Wuse Zone 4, FCT,
\nPO Box 8829 Wuse
\nAbuja
\nNigeria
\nDr. Leonid EIDELMAN
\nWMA Immediate Past-President
\nIsraeli Medical Association
\n2 Twin Towers, 35 Jabotinsky St.,
\nP.O. Box 3566
\n52136 Ramat-Gan
\nIsrael
\nDr. Ravindra Sitaram
\nWANKHEDKAR
\nWMA Treasurer
\nIndian Medical Association
\nIndraprastha Marg
\n110 002 New Delhi
\nIndia
\nDr. Joseph HEYMAN
\nWMA Chairperson of the Associate
\nMembers
\n163 Middle Street
\nWest Newbury, Massachusetts 01985
\nUnited States
\nProf. Dr. Frank Ulrich
\nMONTGOMERY
\nChairperson of Council
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1 (Wegelystrasse)
\n10623 Berlin
\nGermany
\nDr.\u00a0Andreas RUDKJ\u00d8BING
\nWMA Chairperson of the Medical
\nEthics Committee
\nDanish Medical Association
\nKristianiagade 12
\n2100 Copenhagen 0
\nDenmark
\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
\nEditorial
\nEditorial
\nEach doctor becomes a patient sooner or later.The opposite process
\nis possible theoretically. Consequently, sooner or later every doctor
\nstands in a patient\u2019s shoes to face everything we talk about con-
\ncerning public health. In Public Health, the emphasis is somewhat
\ndifferent. In each country Public Health focuses on slightly differ-
\nent settings as priorities. It is determined by the country itself, its
\ngeographical location, traditions, experience and medical schools.
\nHowever,globally the major challenges remain the previous ones: cli-
\nmate change, a sedentary lifestyle and overweight, smoking and alco-
\nhol abuse, malnutrition, population ageing and epidemics of chronic
\ndiseases, including oncological, cardiovascular and mental diseases.
\nAnd all this applies to both \u2013 patients and doctors.Irrespective of that,
\nin the coffee pauses of the General Assembly of the World Medical
\nAssociation, a group of delegates smoked heavily in some corner.
\nLet us be honest, relations with overweight as well might be better
\nfor our friendly global collective.
\nFor many years, I have seen one or another delegate jogging in the
\nmorning, the last time it was in Georgia; I have no need to run to-
\ngether with any of the delegates.
\nDoctors in the world differ the same way as patients do. In the
\ncountries where the situation with Public Health is better, doctors
\nare healthier. In the countries that successfully fight against smok-
\ning, doctors smoke significantly less than average population.
\nTobacco use is one of four major risk factors for non-communicable
\ndiseases. It is a huge threat to human health worldwide, and 8 mil-
\nlion people die each year, including more than 20% of cases world-
\nwide dying of cancer.
\nThe global tobacco industry\u2019s market value in 2017 was around
\n785\u00a0billion USD (excluding China). On the other hand, the global
\nloss caused by the tobacco industry to health care and productivity
\nwas 1.4 trillion USD.
\nThe tobacco industry is affecting governments and in different ways
\nis resisting tougher smoking restrictions and controls. And some-
\ntimes the doctor remains alone in the fight against smoking in their
\ncountry, among their patients and among their colleagues.
\nHow to tackle the matter of low physical activity, how to reach the
\nsituation that doctors move more, how to do more sports \u2013 at least
\nhalf an hour every day?
\nOnce, when the overweight patient came to me, I started telling
\nthem that they should start moving, and I usually asked them to go
\nto their physiotherapist twice a week, and after two months start
\ncycling, doing pilates or gymnastics, or go skiing. When I think
\nthat my obese patient will start running for half an hour tomorrow,
\nI\u00a0hear my colleagues reminding me about the knee injuries.
\nIn the world, the number of female doctors is higher than that of
\nmales. As regards sports and exercise, there is a great disproportion
\nand discrimination among men and women.
\nIn the whole world, women\u2019s and girls\u2019 sports generally receive a
\nsmaller contribution at the national level, including access to equip-
\nment,transport and training,as well as safe and efficient sports spac-
\nes and facilities. Many women are restrained from serious physical
\nactivity, they share concerns from stereotypes, the stigmatisation of
\nphysically strong women, the insecurity of the image of their body,
\nor the sense limited by physical culture.
\nGirls of pre-school and school age are physically less active; they
\nhave fewer sports available. Women\u2019s sports are less paid and less
\ntelevised as men\u2019s sports, and the gap (excluding tennis, beach vol-
\nleyball, skiing, skating, gymnastics and some more sports) is grow-
\ning.
\nIt means that doctors have to stand up for women\u2019s sports. Wom-
\nen\u2019s sports means women\u2019s health, it means caring about the health
\nof women by doctors, nurses and health professionals. Doctors
\nin the world should help to bridge the gap in physical activity
\nbetween men and women, promote women\u2019s sports and physical
\nactivity.
\nWhat to start with? Every doctor with overweight and a sedentary
\nlifestyle should start with an hour at the physiotherapist doing exer-
\ncises that involve all the muscles, all joints and ligaments in physical
\nactivity.The best vehicle for moving around is a bicycle.
\nDon\u2019t believe that anyone else will take care of you even if you\u2019re a
\ndoctor.
\nMoreover, such a unique thing as the resettlement of residents in
\nLondon to the 2012 Olympic Village with great opportunities for
\nphysical activity did not alter the sporting habits.
\nDr. med. h. c. Peteris Apinis,
\nEditor-in-Chief of the World Medical Journal
\nBACK TO CONTENTS
\n2
\nGeneral Assembly Report
\nHonorable Ilia Nakashidze,
\nProf. Lobzhanidze,
\nDistinguished guests,
\nA warm thank you to our hosts here in
\nGeorgia for your warm hospitality in this
\nwonderful city of Tbililsi.
\nMy dear friends and colleagues, It is an
\nhonour to address you here and to thank
\nyou once again for the opportunity to serve
\nyou, the World Medical Association and
\nphysicians throughout the world. I am sure
\nthat the WMA is an essential organization
\nin the modern world and should be visible,
\nactive and presented in important forums.
\nThe purpose of the WMA is to serve hu-
\nmanity by endeavoring to achieve the high-
\nest international standards in Medical Edu-
\ncation, Medical Science, Medical Art and
\nMedical Ethics, and Health Care for all
\npeople in the world.
\nSince having been inaugurated I have repre-
\nsented the WMA in different meetings.The
\nfirst one was the Global Conference on Pri-
\nmary Health Care in Astana, Kazakhstan.
\nUniversal health coverage is absolutely nec-
\nessary to achieve sustainable development
\ngoal number 3. Primary health care that
\nincludes prevention, acute and chronic care
\nis an indispensable platform for Universal
\nHealth Coverage.
\nThere are many challenges for Primary
\nHealth Care, the most important of them:
\nabsence of strong political commitment;
\ndifficulties in integration of health goals
\ninto non-health sector planning; and lack of
\nintention for physician-led teamwork.
\nDuring the meeting, it was noticeable that
\nmany participants didn\u2019t think the Primary
\nHealth Care model should have the physi-
\ncian at the helm of leadership. The confer-
\nence focused on other health care providers,
\ntraditional ones,such as,nurses,pharmacists
\nand social workers and new professions,like,
\ncommunity health workers and healthcare
\nassistants. We should continue to promote
\nthe team approach in Primary Health Care
\nand the leading role of physicians.
\nUniversal Health Coverage was one of the
\ncentral issues at the Japan Medical Asso-
\nciation Ceremony and Medical congress
\nand this was continued at The Health
\nProfessional Meeting (H20) 2019 Road
\nto Universal Health Coverage in Tokyo,
\nJapan.
\nDuring his tenure as president of the World
\nMedical Association, Dr Yoshitake Yo-
\nkokura considerably promoted UHC.
\nI also stressed the importance of physician
\nleadership during the WHO Global Coor-
\ndination Mechanism meeting on Preven-
\ntion and Control of Noncommunicable
\nDiseases in Geneva. I took the opportunity
\nto visit the WMA headquarters and express
\nmy appreciation to all the WMA staff.
\nDuring the ceremony of the German Medi-
\ncal Profession Marking the Withdrawal of
\nthe Medical Licenses of Jewish German
\nDoctors 80 years ago, I emphasized the
\nphysicians\u2019moral responsibility according to
\nthe WMA\u2019s Declaration of Geneva,recently
\nupdated due to the immense contribution
\nof the German Medical Association, which
\nstates that physicians must never use their
\nmedical knowledge to violate human rights
\nand civil liberties, even under threat.
\nAnother opportunity to stress the impor-
\ntance of the physician\u2019s professional obliga-
\ntion to the patient and the highest ethical
\nstandards was at the CPME General As-
\nsembly, where the main topic was health
\ncare in danger.
\nDuring the Swedish Medical Associa-
\ntion Annual Meeting, I learned about how
\nSwedish physicians tackle language limita-
\ntions and cultural differences when taking
\ncare of the large number of refugees.
\nThe global issue of violence in the health
\nsector that negatively impacts our ability to
\ntreat patients was addressed at the meeting
\nin Mumbai, India.The future developments
\nin medicine was in center of our meeting at
\nthe American Medical Association Head-
\nquarters. We discussed: augmented intel-
\nligence; environmental intelligence; what
\nphysicians want to know about technology;
\nhealthcare economy and what is on the ho-
\nrizon.
\nIn attempt to encourage the preparation for
\nthe future changes and the new challenges of
\na constantly evolving profession, the WMA
\nand Israeli Medical Association organised
\nthe Physician 2030 meeting, that was at-
\nValedictory Address of WMA President Prof. Leonid Eidelman,
\nOctober 2019
\nLeonid Eidelman
\nBACK TO CONTENTS
\n3
\nGeneral Assembly Report
\ntended by over 100 physicians worldwide. It
\nserved as a platform for discussions in multi-
\nple areas and dimensions of physicians\u2019activ-
\nity. Issues of the validity of models and pre-
\ndictors in health system, healthcare models
\nand medical workplace in 2030,patient-phy-
\nsician relationship,medical education-how it
\nshould be changed and technology \u2013 where it
\ncan take us, were addressed.
\nI believe that we must continue to look to
\nthe future and be prepared.
\nPhysician burnout is one of the most acute
\nchallenges of contemporary medicine and
\nendangers physicians as well as the quality of
\nhealthcare. There is a need for studying pre-
\nventive and treatment solutions.The Interna-
\ntional College of Person-Centered Medicine
\nhas decided to organize meetings on physi-
\ncian burnout and wellbeing every year.
\nDuring my presidency year, I visited many
\nphysician meetings.You can see them in my
\nreport but here I would like to give some
\nspecific examples of such meetings.
\nAt the British Medical Association Annual
\nRepresentative Meeting in Belfast, among
\nothers, there were votes on the issue of as-
\nsisted dying and the BMA\u2019s membership in
\nthe WMA.The representatives endorsed the
\ncontinued membership of the BMA in the
\nWorld Medical Association, for the oppor-
\ntunity it provides to support and influence
\nthe development of global health policy.
\nDr. Chaand Nagpaul, BMA chair of coun-
\ncil, stated the BMA\u2019s opposition to Brexit,
\ndue to potential damage to the national
\nhealth service.
\nThe other meeting was CONFEMEL the
\nSpain, Portugal, Latin American and Carib-
\nbean Medical Confederation.There were dis-
\ncussions about the specific challenges facing
\ndoctors in their respective countries, some of
\nwhich demanded the WMA intervention.We
\nsent letters to the governments of Honduras,
\nBolivia and others demanding a change of at-
\ntitude towards physicians. Another example
\nwas a letter that we sent to the Sudanese Gov-
\nernment condemning the use of lethal force
\nagainst physicians and protesters.
\nDuring the European Forum Medical As-
\nsociation annual meeting in Montenegro,
\none of the presentations was of particular
\ninterest to me, because it reflected attitude
\nof young physicians that will definitely in-
\nfluence the workforce in healthcare in the
\nyears to come.The European Junior doctors
\npresented the situation of part time em-
\nployment of junior doctors in Europe and
\nstressed the importance of this possibility to
\nthe new generation of doctors.
\nWhile attending the 34th
\nCMAAO Gener-
\nal Assembly we had the opportunity to visit
\na palliative care centre supported by the In-
\ndian Medical Association. I was much very
\nimpressed by great work undertaken by the
\nextremely dedicated staff in this facility.
\nThe climate crisis is on the agenda of the
\nWorld Medical Association. The profes-
\nsional role of physicians in the fight against
\nclimate change was suggested in our paper
\nin Fortune Journal.
\nThe greatest media attention we received
\nwas our position against the decision of the
\nInternational Association of Athletics Fed-
\neration in the case of Caster Semenya. Our
\nposition was based on strict ethical consider-
\nations, that a medical treatment is only justi-
\nfied when there is a medical need. Medical
\ntreatment for the sole purpose of altering the
\nperformance in sports is not permissible.
\nFinally, I am glad to thank two chairs of
\ncouncil I was privileged to work with, both
\nDr. Ardis Hoven and Prof. Frank-Ulrich
\nMontgomery. I am grateful to the Secretary
\nGeneral, Dr. Otmar Kloiber and his fantas-
\ntic team who have supported me through-
\nout my presidency. My deepest appreciation
\nto the leaders from more that one hundred
\ncountries that make the WMA so important
\nand so influential across the globe.I am con-
\nfident that the WMA will continue to be a
\nbeacon for doctors all over the world,to light
\nthe way in medical ethics and continue to
\nserve as a voice of doctors, as well as, sup-
\nporting NMA\u2019s and doctors in times of need.
\nI thank my predecessors and wish great success
\nto the incoming president Dr. Miguel Jorge.
\nThank You
\nDr. Miguel R. Jorge, World Medical Association 70th
\nPresident
\nInaugural Speech, 25th
\nof October 2019
\nDear Colleagues and Friends,
\nLadies and Gentlemen,
\nThank you for your presence and enduring
\nsupport to the World Medical Association.
\nIt means a lot to the physicians we repre-
\nsent and, at this particular ceremony, it also
\nmeans a lot to me.
\nThose of you familiar with the World Medi-
\ncal Association know that our constituent
\nmembers include one hundred and twelve
\nnational medical associations. I am here to-
\nday being inaugurated as the World Medi-
\ncal Association\u2019s 70th
\nPresident not by my-
\nself but representing not just my colleagues
\nfrom the Brazilian Medical Association but
\nmillions of physicians who practice in every
\ncorner of the globe.
\nMy home country, Brazil, is amongst the
\n10th
\nbiggest economies but is also amongst
\nthe 20th
\nmost unequal countries in the
\nBACK TO CONTENTS
\n4
\nGeneral Assembly Report
\nworld. And we know that wealth inequali-
\nties within a country impact social determi-
\nnants of health and consequently the health
\nstatus of its population. It is not uncommon
\nto see, in unequal countries, two realities for
\nmedical care: one with first world quality for
\nthose who have more and the other of little
\nquality\u00a0\u2013 if any\u00a0\u2013 for the underprivileged.
\nThe World Medical Association\u2019s Declara-
\ntion of Geneva states in its opening remarks
\nthat physicians pledge to dedicate their lives
\nto the service of humanity and have the
\nhealth and well being of their patients as
\ntheir first consideration. We, as physicians,
\npractice our commitment to these princi-
\nples not just when attending to our patients
\nbut also when we join our medical associa-
\ntions in their multiple activities, aiming, at
\nthe end, to raise the health status and qual-
\nity of life of the population we serve.
\nThere are many and different factors influ-
\nencing the physicians\u2019 role to promote the
\nhealth and quality of life of others, such
\nas a good and continuous medical educa-
\ntion, adequate resources and conditions for
\nwork\u00a0\u2013 particularly enough time with each
\npatient, a balanced professional and social
\nlife, and\u00a0\u2013 equally important\u00a0\u2013 to take care
\nof their own physical and mental health.
\nAs a psychiatrist, I was planning to empha-
\nsize during my Presidential term that there
\nnever will be health without mental health.
\nBut I was challenged by myself to broaden
\nmy concerns, and remind and highlight to
\nmy fellow physicians one essential compo-
\nnent of the practice of Medicine: the great
\nvalue of the physician-patient relationship.
\nIt is usually recognized that most of those
\nwho are looking to enter medical school,
\ndo so saying they want to help people in
\ntheir suffering related to illness. But studies
\nfrom different countries show that medi-
\ncal students usually are less sensitive to the
\npatient\u2019s needs as a person when finishing
\nthan they are when entering medical school.
\nWhat happened in between? One possible
\nreason is that students, during their medi-
\ncal education, are more and more exposed
\nto the biological nature of illnesses than to
\nthe social environment surrounding their
\npatients and the development of diseases.
\nThey also are not adequately taught to take
\ninto consideration the emotional aspects of
\nthose they are assisting.
\nTo those who are being trained to be a
\nmedical doctor, biology is an arena where
\nthey feel more secure and comfortable to
\nact than they do when feeling incapable of
\ndealing with people\u2019s social and psycho-
\nlogical issues. Besides that, the physicians-
\nto-be were developing defences against
\ntheir own suffering when facing different
\nforms of pain in their patients. Physi-
\ncal pain, emotional pain, social pain. And
\nthese defences reduce their sensibility to
\nothers\u2019 needs.
\nA good physician needs to be able to put
\nhim\/herself in the place of their patients,
\ntrying to feel as they feel, in order to better
\nunderstand their needs and plan to provide
\nwhat they need more. But it is not a simple
\ntask to put him\/herself in the place of a pa-
\ntient and\u00a0\u2013 at the same time\u00a0\u2013 to avoid feel-
\ning as helpless as the patient would be. In
\nmedical care, it is as essential to have empa-
\nthy as it is to be able to examine the patient
\nfrom the outside.
\nA colleague from my Department in the
\nFederal University of S\u00e3o Paulo, Dr. Julio
\nNoto (personal communication), reported
\nto me that once he heard from one of his
\nMedical Psychology students: \u201cHow can
\nI\u00a0talk to the patient if there is nothing that
\nI\u00a0can do for him due to his condition?\u201dNoto
\nconsiders that teaching Medical Psychology
\nto medical students sometimes is similar to
\nteaching someone \u201cto do nothing\u201d. There,
\ndoing nothing can correspond to cathartic
\nlistening, emotional continence, expectant
\nattitude, and even the use of countertrans-
\nference in the physician-patient relation-
\nship. A brilliant Brazilian novelist from the
\nlater 19th
\nand early 20th
\ncenturies, Machado
\nde Assis, once wrote: \u201d\u2026there are things we
\nsay better being quiet…\u201d
\nWe all hear that Medicine is both science
\nand art but, in the last decades, the prac-
\ntice of Medicine is more and more reflect-
\ning an emphasis just on its scientific nature.
\nA competent physician is not a good me-
\nchanic of the human body but someone
\nwho equally combines technical excellency
\nwith being close to their patients,respecting
\ntheir dignity, and showing them empathy
\nand compassion.
\nEvidence-based guidelines containing stan-
\ndards of care are really of great importance.
\nThey allow the organization of a fragment-
\ned physician-patient care model, as differ-
\nent physicians assisting the same patient
\nat different times can apply the same ob-
\njective scientific knowledge. But an inter-
\nesting study published in 2016 by Lauren
\nDiamond-Brown suggested that goals of
\nstandardization cannot rationalize all as-
\npects of medical practice, and policy makers
\nmust not forget the function of a positive
\nphysician-patient relationship. We have to
\nrecognize the importance of evidence-based
\nmedical practice while not forgetting that
\nthe decision-making process of care also in-
\nvolves important subjective aspects.
\nMiguel R. Jorge
\nBACK TO CONTENTS
\n5
\nGeneral Assembly Report
\nEric Cassel (2012), in his book The Na-
\nture of Healing: The Modern Practice of
\nMedicine, states that \u201cRespect for persons
\nhas helped move the idea of persons and
\nknowledge about them to a more central
\nposition in medicine. From this it follows
\nthat healers and other clinicians should
\nknow as much about persons as they know
\nabout their pathophysiology.\u201d According to
\nhim, almost nothing about people is unaf-
\nfected by sickness.
\nConcepts like this one have led to a shift of
\nmodels of care from a disease-specific mod-
\nel to patient-centered collaborative care.
\nResults from reviews of the literature con-
\nducted in 2000 by Mead and Brown and re-
\npeated in 2019 by Langberg et al. described
\nfive dimensions of a patient-centered care:
\nsharing power and responsibility, therapeu-
\ntic alliance, patient-as-person, coordinated
\ncare, and a biopsychosocial perspective.
\nEmanuel and Emanuel (1992) considered\u00a0\u2013
\nbefore the current digital era\u00a0 \u2013 that the
\nrole of physicians varies, in different mod-
\nels of physician-patient relationship, from
\na guardian to a counsellor or advisor, from
\na friend or a teacher to a technical expert.
\nNevertheless, ethical considerations about
\nthe rights of persons and the widespread ac-
\ncess to information brought by the Internet
\nto all, have a major impact on the physician-
\npatient relationship. Medical expertise con-
\ntinues to rely on the physicians\u2019 knowledge,
\nbut the decision-making process and adop-
\ntion of a treatment plan now need to include
\nand respect the patients\u2019 preferred choices.
\nTaking just diagnostic imaging and indi-
\nvidual genetic tailoring for the treatment
\nof cancers as examples of the sophisticated
\nprogress experienced by Medicine in the
\nlast few decades, as well the development
\nof telemedicine, the use of artificial intelli-
\ngence and particularly of social media, we\u00a0\u2013
\nphysicians\u00a0\u2013 have to learn how to use these
\ntools for improving the physician-patient
\nrelationship and not allow them to move us
\nfrom a focus on the patients themselves or
\nto create more difficulties in our communi-
\ncation with them.
\nAnother interesting study, from Hitchsock
\net al.(2005),involving primary care patients
\nwith multimorbidity, showed that partici-
\npants were willing to use technology for
\nmonitoring or educational purposes if it did
\nnot preclude human contact. When listen-
\ning to patients\u2019 expectations, humaneness
\nappears as equally or even more important
\nthan medical competence. So, a recommen-
\ndation of major importance is that physi-
\ncians must be focused on building trust and
\na strong therapeutic alliance early during
\nthe first visit of a patient.
\nLast November, the European Council of
\nMedical Orders supported and adhered to
\nan initiative by the Forum of the Medi-
\ncal Profession of Spain and the Portu-
\nguese Medical Association to defend and
\nstrengthen the physician-patient rela-
\ntionship by requesting its recognition by
\nUNESCO as an Intangible Cultural Heri-
\ntage of Humanity. That proposal considers
\nthe physician-patient relationship a funda-
\nmental component of health care that can
\nbe threatened by political, social, or eco-
\nnomic risks, and technological and commu-
\nnication changes, which makes it necessary
\nto protect and enhance the fundamental
\nelements of that relationship.
\nPhysicians working under difficult cir-
\ncumstances such as those in Africa, Latin
\nAmerica and Asia, often cannot do what
\nthey consider to be the best plan of action
\ndue to the scarcity of different resources.
\nBut they can accomplish at least partially
\ntheir mission if they give a little more time
\nand show empathy and attention to their
\npatients. I am sure that we can always do
\nbetter for all if we keep in mind the reason
\nwhy we chose to be physicians earlier in our
\nlives: to help those who are suffering due to
\ntheir compromised health.
\nFinally, I would like to say something about
\nmy background and this moment. My four
\ngrandparents arrived in Brazil in 1912, af-
\nter fleeing a difficult situation they were
\nfacing in their mountain villages of Leba-
\nnon. My parents were born in a small city
\nin the interior of the country and my father
\nbecame a merchant in his adult life. When
\nI was studying Medicine, his wish was to
\nsee me as a general surgeon practicing and
\nmaking my life even in a deeper part of
\nBrazil, where everything was still waiting
\nto be built.
\nBut, according to some of my colleagues
\nat the medical school, I\u00a0\u2013 in a way\u00a0\u2013 de-
\nclined to be a \u201creal\u201d physician by choosing
\nto become a psychiatrist. And, in the eyes
\nof many, the worst part of all: rather than
\nfocusing on a money driven path, I chose
\nto follow an academic career and, early in
\nmy professional life, I engaged in lifelong
\nactions for enhancing the quality of medical
\ncare provided particularly to those that are
\nmore in need.
\nAfter so many years, being here today, be-
\ncoming the 70th
\nPresident of the World
\nMedical Association was not something
\nI\u00a0ever dreamed of. It gives me great joy and
\nhappiness, even though has not been pos-
\nsible to have some of my family members
\nwith me at this moment. But, I want to spe-
\ncially thank them for their continuous and
\nenduring support.
\nI am sure that there are times when many
\nof you\u00a0\u2013 like me now\u00a0\u2013 are participating in
\nprofessional activities that divert you from
\nthe company of your family. This is a kind
\nof side effect of being a physician but\u00a0\u2013 re-
\nmember\u00a0\u2013 as I said before, a balanced pro-
\nfessional and social life is essential for tak-
\ning care of others.
\nSo, once again, on behalf of millions of phy-
\nsicians worldwide and of those they serve,
\nI want to recognize your efforts and dedi-
\ncation, ultimately aiming to provide better
\nhealth to all.
\nThank you!
\nBACK TO CONTENTS
\n6
\nGeneral Assembly Report
\nWednesday October 23
\nAt the invitation of the Georgian Medical
\nAssociation, delegates from more than 50
\nNational Medical Associations and constit-
\nuent member associations met at the Shera-
\nton Grand Tbilisi Metechi Palace.
\nCouncil
\nDr. Frank Ulrich Montgomery, Chair of
\nCouncil, opened the 213th
\nCouncil session,
\nwelcoming delegates to Tbilisi.
\nDr. Otmar Kloiber, the Secretary General,
\nintroduced several new Council members
\nand gave apologies for absence.
\nPresident\u2019s Report
\nDr. Leonid Eidelman presented his written
\nand oral report about his work as President
\nduring 2018\/19. He said he had stated at
\nthe start of his Presidency that he would
\nlike to devote his tenure to evaluating future
\nchallenges faced by physicians throughout
\nthe world, as well as promoting prepared-
\nness. This he had done at the many meet-
\nings he had spoken at and attended. Among
\nthem was the \u2018Physician 2030\u2019 meeting in
\nHerzliya, Israel in May, which addressed
\nhealthcare models and the medical work-
\nplace in 2030. He had also attended many
\nnational medical association meetings.
\nSecretary General\u2019s Report
\nDr. Kloiber said that a comprehensive writ-
\nten report had been submitted to the As-
\nsembly on the work of the Council over the
\npreceding six months.
\nEmergency Resolutions
\nTwo emergency resolutions were submitted
\nfor consideration.
\nOpioids
\nThe first Proposed Emergency Resolution
\non the Revocation of WHO Guidelines
\non Opioid Use concerned the decision by
\nthe World Health Organisation to abruptly
\nwithdraw its guidelines on controlled medi-
\ncines. The Council was told that this had
\nmade it much more difficult for patients
\nsuffering pain to get access to opioids. The
\nemergency resolution called on the WHO
\nto reinstate its guidelines urgently until they
\nwere replaced by new or amended ones.
\nThe Council agreed that this was a matter of
\nurgency and the Resolution should be sent to
\nthe Social Affairs Committee for discussion.
\nClimate Emergency
\nA second proposed Resolution on Climate
\nEmergency was submitted by the Brit-
\nish Medical Association. The Council was
\ntold that the resolution followed the recent
\nUnited Nations summit on climate change
\nwhich recognised that controlling climate
\nchange was necessary for achieving sig-
\nnificant health gains. In order to take full
\nadvantage of this political momentum now,
\nthe BMA said it was proposing this reso-
\nlution to help co-ordinated action globally
\nthrough the voice of doctors. The summit
\nwas instrumental in galvanizing support
\nfrom the private sector and securing na-
\ntional commitment. Radical change was
\nneeded. Climate action was an opportunity
\nand a call to action to fundamentally trans-
\nform economies, systems of production and
\ntrade. It was an issue that went far beyond
\nthe environment to affect every aspect of
\nsociety and development, and climate ac-
\ntion was necessary for achieving the sus-
\ntainable development goals and controlling
\ndisease. The WMA was in a unique posi-
\ntion, as the voice of doctors, to ensure that
\nthe significant implications for health that
\nclimate change posed were recognised and
\nappropriately mitigated.
\nThe Council agreed that this was also an
\nemergency and the Resolution should be
\ndiscussed in the Social Affairs Commit-
\ntee.
\nChair\u2019s Report
\nDr. Montgomery, in his written report,
\nsaid that since his election in Santiago in
\nApril many big health issues had \u2018stormed
\nover\u2019 them\u00a0 \u2013 Universal Health Coverage,
\nEbola returning to Africa, and the measles
\nreturning in many countries, either due to
\npeople having no access to vaccines, or to
\nthe shameful fact that a growing vaccine
\nhesitancy in richer societies had led to a loss
\nof immunity.There was also climate change,
\nwith heatwaves in Europe, typhoons and
\nhurricanes in tropical and subtropical re-
\ngions, and the dangerous melting of polar
\nice on both sides of the planet This was cast-
\ning long shadows over the future of their
\nchildren\u2019s generation.
\nWMA 2019 General Assembly Report
\nTbilisi, Georgia October 23\u201326
\nNigel Duncan
\nBACK TO CONTENTS
\n7
\nGeneral Assembly Report
\nThe Council meeting was then adjourned
\nuntil Friday.
\nFinance and Planning Committee
\nDr. Jung Yul Park (South Korea) took the
\nchair and called the committee to order.
\nFinancial Statement for 2018
\nThe committee considered the Audited Fi-
\nnancial Statement for 2018. The Treasurer,
\nDr. Ravindra Sitaram Wankhedkar, stated
\nthat the WMA finished 2018 with a sur-
\nplus and he thanked the secretariat, which
\nregulated, monitored and controlled the ex-
\npenses.
\nThe committee agreed that the Statement
\nbe approved by the Council and forwarded
\nto the General Assembly for approval and
\nadoption.
\nBudget
\nThe committee considered the proposed
\nWMA Budget for 2020 vs. the actual 2018
\nExpenditures. The Treasurer noted the ex-
\ncess of income over expenses.
\nThe committee recommended that the pro-
\nposed Budget for 2020 be approved by the
\nCouncil and forwarded to the General As-
\nsembly for adoption.
\nMembership Dues Payments and Arrears
\nThe committee received the report on
\nmembership dues payments for 2019 to be
\nforwarded to the General Assembly for in-
\nformation.
\nIt also considered the report on member-
\nship dues arrears and the proposed dues in-
\ncrease for 2020.
\nThe committee received dues categories for
\n2020 to be forwarded to the General As-
\nsembly for information.
\nWMA Strategic Plan
\nDr. Kloiber reported that the Strategic Plan
\nfor 2020-2025 had been forwarded to the
\nGeneral Assembly for a decision. Some
\nof the items in the strategic plan, such as
\nUniversal Health Coverage, had already
\nbeen taken up for action as described in the
\nCouncil Report.
\nWMA Statutory Meetings
\nThe committee considered planning and ar-
\nrangements for future WMA Meetings.
\nIt recommended that the Council with-
\ndraw its recommendation to hold the
\n224th
\nCouncil Session in 2023 in Baku,
\nAzerbaijan, because of visa problems and
\nthe membership status of the Azerbaijan
\nMedical Association. It recommended
\nthat the venue be switched to Nairobi, Ke-
\nnya.
\nWMA Special Meetings
\nDr. Kloiber gave an oral report about the
\nfollowing meetings planned in 2020:
\n\u2022\t International Conference on Bioethics in
\nPhiladelphia, 18-21 June 2020
\n\u2022\t UNESCO Bioethics Conference in Por-
\nto, 11-14 May 2020
\n\u2022\t International Code of Medical Ethics
\nRegional Conferences
\n–
\n– East Mediterranean Region in Kuwait,
\n6-7 February 2020
\n–
\n– Latin American Region in Sao Paulo,
\n5-6 March 2020
\n–
\n– Further regional conferences were
\nplanned for the second half of the
\nyear
\n\u2022\t Global Forum on Vaccination in Vatican,
\n4-5 May 2020
\nReview Committee
\nThe committee received an oral report from
\nthe Chair of the Review Committee, Ms
\nRobin Menes. She reported that the man-
\ndate of the committee as a pilot project had
\nbeen extended through to April 2020. She
\nhoped that this committee could be estab-
\nlished as a permanent fixture.
\nDr. Montgomery thanked Ms Menes for
\nher contributions and hard work during her
\nterm.Since this meeting was her last, he ap-
\npointed Ms Mervi Kattelus (Finnish Medi-
\ncal Association) in her place.
\nCouncil Resolutions
\nThe committee considered the proposed
\nclassification of old council resolutions.
\nIt recommended that the following Council
\nresolutions be revised for the next meeting
\nin Porto, April 2020 for forwarding to the
\nGeneral Assembly:
\n\u2022\t Trade Agreements and Public Health
\n\u2022\t Threats to Professional Autonomy and Self-
\nRegulation in Turkey
\n\u2022\t Support of Dr Serdar K\u00fcni
\nThe proposal to revise the Resolution on
\nObserver Status for Taiwan to the World
\nHealth Organisation and Inclusion as
\nParticipating Party to the International
\nHealth Regulations prompted opposi-
\ntion from the Chinese Medical Associa-
\ntion. The CMA said the UN General As-
\nsembly and World Health Assembly had
\nprovided legal foundation for the WHO
\nto follow the One-China Policy and con-
\nfirmed the legal status of Taiwan as part
\nof the Chinese Territory to participate in
\nthe WHA. The mainland had consistent-
\nly attached great importance to the health
\nand welfare of compatriots in the Taiwan
\nregion. Taiwan region\u2019s participation in
\nglobal health affairs, including WHO
\ntechnical activities and information ac-
\ncess, was unimpeded. But the CMA\u2019s
\nmotion to withdraw the proposal was not
\nseconded.
\nA further proposal on how to deal with the
\nCouncil Resolution on Organ Donation in
\nChina also led to criticism from the Chinese
\nMedical Association.
\nBACK TO CONTENTS
\n8
\nGeneral Assembly Report
\nDr. Kloiber reported that the WMA had
\nstrict policy that organs from executed pris-
\noners must not be used for organ transplan-
\ntation. They had learned that in 2015 there
\nwas a change in the legal situation in China
\nand that it was planned to phase out trans-
\nplantation.The WMA was not in a position
\nto do any research or fact-finding missions
\nto discover what was now happening. The
\nChinese Medical Association had written
\nto say there had been significant change and
\nthe use of organs from executed prisoners
\nno longer took place.
\nThe Chinese Medical Association appealed
\nto the committee to withdraw the proposal
\nto revise the resolution. Since July 2015
\nChina had completely stopped using or-
\ngans from executed prisoners.Therefore, the
\nresolution was already irrelevant.
\nAt the suggestion of the Chair of Council,
\nthe committee agreed to forward this issue
\nto the Medical Ethics Committee for con-
\nsideration in Porto. Law and Ethics see p.\u00a023.
\nThe committee agreed to recommend that
\nthe Council Resolution on the Relation of Law
\nand Ethics be approved by the Council as a
\nDeclaration and be forwarded to the Gen-
\neral Assembly for adoption.
\nIt was agreed that the following Council
\nresolutions be filed for no further action:
\n\u2022\t Legislation Banning Smoking in Public
\nPlaces
\n\u2022\t Supporting the Preservation of Internation-
\nal Standards of Medical Neutrality
\n\u2022\t Prohibition of Physician Participation in
\nTorture
\n\u2022\t Autonomy of Professional Orders in West
\nAfrica
\n\u2022\t Professor Cyril Karabus
\n\u2022\t Prohibition of Nuclear Weapons
\n\u2022\t Danger in Health Care in Syria and Bah-
\nrain
\nOn the final policy on Syria, Dr. Kloiber ex-
\nplained that work continued on monitoring
\nthe situation in Syria.
\nSocio-Medical Affairs Committee
\nDr. Osahon Enabulele (Nigeria) took the
\nchair and called the committee to order.
\nDr. Kloiber, in his monitoring report, spoke
\nabout events related to physicians in primary
\nhealth care.The WMA had been working on
\na study about this issue,in the light of the fact
\nthat major funding donor groups in develop-
\ning countries tended to be critical about the
\nrole and availability of physicians in primary
\nhealth care. The WMA had worries about
\nvarious studies that set out to support the
\nreplacement of physicians by nurse practitio-
\nners, but did not prove this. He had asked
\nNMAs to send in evidence on the situation
\nrelating to the substitution, replacement
\nand delegation of the role of physicians. He
\nthanked those NMAs that had done so and
\na WMA report would soon be available to
\ncounteract arguments from other professions
\nand international organisations. This would
\nnot be a document against any other health
\nprofession.Modern health care was based on
\na team approach. But at the same time there
\nhad to be clearly defined roles,
\nNetwork on Disaster Medicine
\nAn oral report was given by the Japan Med-
\nical Association
\non the initiative to set up a World Platform
\nfor Disaster Medicine involving the WMA,
\nWHO and other United Nations agencies,
\ngovernments, NGOs, academic institutions,
\nenterprises and public service organisations.
\nGiven the increasing number of natural di-
\nsasters related to climate change, such as
\nthe typhoon \u2018Hagibis\u2019 earlier in October in
\nJapan, the need to develop a robust interna-
\ntional framework for emergency medicine
\nwas becoming urgent.
\nPseudoscience and Pseudotherapies in the Field
\nof Health
\nThe chair of the workgroup from the Span-
\nish Medical Association presented a pro-
\nposed Declaration on Pseudoscience and
\nPseudotherapies in the Field of Health. He
\nexplained that this was not a declaration
\nagainst traditional medicine nor against
\nindigenous medicine. It was a commitment
\nto scientific proven methods to quality of
\nmedical care, medical values, and profes-
\nsional good practice. It was against intru-
\nsion and in favour of patient safety. He pro-
\nposed that the document should be sent to
\nthe Assembly for adoption.
\nThis led to a debate, during which several
\ndelegates said this was a very topical is-
\nsue, but argued that more time was needed
\nto consider the various amendments that
\nhad been suggested by NMAs. References
\nwere made to pseudoscientific journals in
\nthe United States and Europe and to fake
\nnews.
\nThe committee recommended that the pro-
\nposed Declaration be recirculated with the
\nsuggested amendments and that further
\ndiscussion be postponed until the next com-
\nmittee meeting in Porto.
\nViolence and Health
\nThe committee considered the proposed
\nrevision of the WMA Statement on Vio-
\nlence and Health submitted by the Nigerian
\nMedical Association.
\nAfter a brief debate, during which two edi-
\ntorial amendments were agreed, the com-
\nmittee decided to recommend that the
\nStatement, as amended, be approved by the
\nCouncil and forwarded to the General As-
\nsembly for adoption.
\nMedical Liability and Defensive Medicine
\nThe Israel Medical Association introduced
\na proposed revision to the WMA State-
\nment on Medical Liability. The document
\nentitled, Medical Liability Reform and De-
\nfensive Medicine, defined defensive medi-
\ncine as \u2018the practice of ordering medical
\ntests, procedures, or consultations of doubt-
\nBACK TO CONTENTS
\n9
\nGeneral Assembly Report
\nful clinical value in order to protect the pre-
\nscribing physician from malpractice suits.\u2019
\nIn the brief debate that followed, several
\nspeakers argued that that further consid-
\neration should be given to the paper. One
\nspeaker argued that it focused on personal
\nphysician culpability,when the vast majority
\nof errors that occurred were about systems.
\nHad the WMA ever looked at whether na-
\ntions that had no fault compensation had
\nless defensive practice than nations which
\nhad personal liability? Dr. Kloiber replied
\nthat the WMA did not have such informa-
\ntion, but it was very important and perti-
\nnent.
\nThe committee decided to recommend that
\nthe document be recirculated to NMAs for
\ncomment.
\nDeclaration of Ottawa on Child Health
\nThe committee considered a proposed ma-
\njor revision of the WMA Declaration of
\nOttawa on Child Health submitted by the
\nSouth African Medical Association. The
\npaper emphasised the importance for chil-
\ndren to grow up in an environment where
\nthey could strive. Delegates were told that
\nthe health and prosperity of a nation were
\nmeasured by the state of their health and
\neducation systems. That started with chil-
\ndren. If children could fulfil their potential
\nthere would be a lot less poverty across the
\nworld.
\nThe committee recommended that in view
\nof the number of amendments submitted
\nthe document should be recirculated to
\nNMAs for comment.
\nInequalities in Health
\nA proposed revision of the WMA Decla-
\nration of Oslo on social determinants of
\nhealth was presented by the Swedish Medi-
\ncal Association. The meeting was reminded
\nthat this involved a major revision of the
\n2009 Statement on Inequalities in Health
\nstatement, integrating relevant parts of the
\nStatement in the Declaration of Oslo on Social
\nDeterminants of Health. This new consoli-
\ndated policy on social determinants would
\nrefer to Universal Health Coverage and the
\nSustainable Development Goals, especially
\non ensuring ensure healthy lives and pro-
\nmoting well-being for all ages and the SDG
\non reducing inequality within and among
\ncountries. The Statement on Inequalities in
\nhealth would then be rescinded.
\nThe committee recommended that the re-
\nvised Declaration be recirculated to NMAs
\nfor comments.
\nUse of Telehealth for the Provision of Health
\nCare
\nAs part of the 10-year revision process, the
\nIndian Medical Association proposed a
\nmajor revision of the WMA Statement on
\nGuiding Principles for the Use ofTelehealth
\nfor the Provision of Health Care.This com-
\nbined the Statements on Telemedicine and
\nMobile Health.
\nIn a brief debate, it was pointed out that
\nthere was nothing in the paper about in-
\nequalities, yet telemedicine should reduce
\ninequalities. It was also argued that there
\nshould be more about safety and efficacy.
\nThe committee recommended that the doc-
\nument be recirculated to NMAs for com-
\nments.
\nLegislation Against Abortion in Nicaragua
\nA proposed revision of the WMA Resolu-
\ntion on the Legislation Against Abortion in
\nNicaragua was submitted following com-
\nments at the last meeting that there was a
\nneed for a more global document.The Reso-
\nlution had been amended to broadly address
\nthe threats to women\u2019s reproductive health
\ncare and the criminalization of reproductive
\nhealth care provided by physicians that was
\noccurring globally. It called on the Nicara-
\nguan Government to repeal its penal code
\ncriminalising abortion and to develop in its
\nplace legislation promoting and protecting
\nwomen\u2019s human rights. An amendment was
\nagreed, inserting a reference to the need for
\nmedical confidentiality.
\nThe committee recommended that the
\ndocument, as amended, be approved by the
\nCouncil and forwarded to the General As-
\nsembly for adoption.
\nRights of Patients and Physicians in the Is-
\nlamic Republic of Iran
\nAt the last Council meeting in April, it was
\ndecided that the Resolution Supporting the
\nRights of Patients and Physicians in the
\nIslamic Republic of Iran should undergo a
\nmajor revision, but there was no volunteer
\nto undertake the revision.
\nThe committee recommended that the Ku-
\nwait Medical Association be appointed as
\nrapporteur for the revision of the Resolu-
\ntion.
\nContinuous Quality Improvement in Health
\nCare
\nA minor revision was proposed to the
\nWMA Declaration on Guidelines for Con-
\ntinuous Quality Improvement in Health
\nCare, including references to new WMA
\npolicies.
\nThe committee recommended that the
\ndocument be approved by the Council and
\nforwarded to the General Assembly for in-
\nformation.
\nRelationship between Physicians and Com-
\nmercial Enterprises
\nA proposal was submitted for a minor revi-
\nsion to the WMA Statement Concerning
\nthe Relationship between Physicians and
\nCommercial Enterprises.
\nSeveral speakers said this was a major
\nproblem. In the United States commercial
\nBACK TO CONTENTS
\n10
\nGeneral Assembly Report
\n\u00ad
\nrelationships were changing rapidly, with
\nprivate equity and other commercial enti-
\nties purchasing medical practices.
\nThe committee recommended that the
\ndocument be approved by the Council and
\nforwarded to the General Assembly for in-
\nformation.
\nHypertension and Cardiovascular Disease
\nThe American Medical Association pre-
\nsented a proposed Statement on Hyper-
\ntension and Cardiovascular Disease as a
\nbasis for further discussion. The State-
\nment called for national governments to
\nrecognize hypertension as the single most
\nimportant risk factor for cardiovascular
\ndisease and death and said that hyperten-
\nsion control should be declared a national
\nhealth priority.
\nThe committee recommended that the doc-
\nument be circulated for comment.
\nProtecting the Future Generation\u2019s Right to
\nLive in a Healthy Environment
\nA proposed Resolution on Protecting the
\nFuture Generation\u2019s Right to Live in a
\nHealthy Environment was submitted by the
\nTurkish Medical Association.
\nThe committee recommended that the doc-
\nument be circulated for comment.
\nClimate Emergency
\nThe British Medical Association presented
\nits emergency resolution on climate change,
\ncalling on the WMA to declare a climate
\nemergency and for the international health
\ncommunity to join doctors\u2019 mobilisation on
\nthe issue.
\nSeveral speakers said the resolution should
\nbe stronger, and a number of amendments
\nwere proposed. The committee agreed that
\nthe resolution should be simplified and that
\nproposed amendments should be consid-
\nered as part of the discussion on the pre-
\nvious document on Protecting the Future
\nGeneration\u2019s Right to Live in a Healthy
\nEnvironment.
\nSeveral amendments were agreed to sim-
\nplify the resolution.
\nThe committee recommended that the
\nresolution, as amended, be approved by the
\nCouncil and forwarded to the General As-
\nsembly for adoption.
\nOpioid use
\nThe committee considered the second
\nemergency resolution on the Revocation of
\nthe WHO Guidelines on Opioid Use. The
\nSecretary General said this represented a
\ncall to the WHO to rectify the situation and
\nto do so transparently.
\nThe committee recommended that the reso-
\nlution be approved by the Council and for-
\nwarded to the General Assembly for adop-
\ntion.
\nMedical Ethics Committee
\nDr. Andreas Rudkjoebind (Denmark) took
\nthe chair and called the committee to order.
\nMonitoring Report
\nThe Secretary General, in his monitoring
\nreport, informed the committee in rela-
\ntion to the Declaration of Helsinki that
\nthe secretariat was interested in collecting
\ninformation from NMAs related to medi-
\ncal experimentation, and the development
\nof clinical testing. He was interested in ex-
\namples of good practice and challenges, as
\nwell as trends or changes observed.
\nGenetics and Medicine
\nThe Iceland Medical Association presented
\na proposed revision of the WMA Declara-
\ntion of Reykjavik on Ethical Consideration
\nRegarding the Use of Genetics in Medicine.
\nThe committee was told there had been
\nrapid changes in this field and the revised
\ndocument set out updated guidance on the
\nuse of genetics and genetic testing in health
\ncare.
\nThe committee recommended that the pro-
\nposed revision be approved by the Council
\nand forwarded to the General Assembly for
\nadoption.
\nInternational Code of Medical Ethics
\nThe committee received an oral report
\nfrom the Chair of the workgroup, Dr. Ra-
\nmin Parsa-Parsi (German Medical Asso-
\nciation). He presented an update on the
\nworkgroup\u2019s progress and a timeline of the
\nICoME revision process for the coming
\nmonths. He said regional expert meetings
\nhad been scheduled for 2020, starting with
\nKuwait (6-7 February) and Brazil (5-6
\nMarch).
\nThe oral report was received.The committee
\nagreed that the proposed revision process be
\napproved so that the workgroup could pro-
\nceed with the regional expert meetings. It
\nwas also agreed that the preliminary draft of
\nthe International Code of Medical Ethics
\nbe shared to serve as a basis for discussion
\nin the regional meetings.
\nReproductive Technologies
\nThe chair of the workgroup from the South
\nAfrican Medical Association gave an oral
\nreport on a proposed revision of the WMA
\nStatement on Reproductive Technologies
\nand said that further work was needed on
\nmany important issues. The workgroup
\nhad coordinated with the workgroup on
\ngenetics, as there were some reproduction-
\nrelated aspects that could be considered for
\nincorporation in this paper. The workgroup
\nwould prepare a list of priority issues and
\na proposed revision was planned to be sub-
\nmitted to the next Council meeting in April
\n2020.
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\n11
\nGeneral Assembly Report
\nDocumentation of Torture
\nThe committee received an oral report
\nfrom the Chair of the workgroup. It was
\nexplained that a new draft was not being
\nconsidered as the workgroup was seeking to
\nfind a balance between ethical obligations
\nto report and denounce torture without be-
\ning too demanding. A proposed revised ver-
\nsion of the Resolution on the Responsibility
\nof\u00a0 Physicians in the Documentation and
\nDenunciation of Acts of Torture and\u00a0 Ill-
\ntreatment was planned to be submitted to
\nthe next Council meeting in April 2020.
\nEuthanasia and Physician Assisted Suicide
\nThe proposed revision of the WMA State-
\nment Euthanasia and Physician Assisted
\nSuicide was presented by the German
\nMedical Association. The committee was
\nreminded that the draft compromise docu-
\nment was intended to replace the WMA
\nResolution on Euthanasia, the Declaration
\non Euthanasia and the Statement on Physi-
\ncian Assisted Suicide.
\nThis led to the first of three lengthy debates
\nheld during the meeting on the issue of eu-
\nthanasia and physician assisted suicide.
\nA number of speakers argued against
\nchanging current WMA policy. Concern
\nwas expressed about the attempt to com-
\npromise. It was argued that this was erod-
\ning ethics and was the beginning of the
\nend for an ethical stance. It would become
\na slippery slope.
\nOthers supported the draft document, say-
\ning that it was right to remove the policy
\ncondemning doctors who participated in
\neuthanasia in those countries where it was
\nlegal.
\nSeveral amendments were proposed. The
\nfirst referred to the opening paragraph of the
\ndocument which stated: \u2018For the purpose of
\nthis declaration, euthanasia is defined as the
\nvoluntary act of a physician deliberately ad-
\nministering a lethal substance or carrying
\nout an intervention to cause the death of
\na patient with decision-making capacity at
\nthe patient\u2019s own voluntary request.\u2019
\nAn amendment was proposed to delete the
\nwords \u2018the voluntary act of.\u2019 It was argued
\nthat by including these words it ruled out
\ndealing with physicians being forced to par-
\nticipate in euthanasia. The amendment was
\nagreed.
\nA further debate took place about the sen-
\ntence which read: \u2018It is not the role of the
\nphysician to participate in euthanasia or
\ndeliberately enable a patient to end his or
\nher own life.\u2019 It was felt that the already
\nexpressed opposition to physician assisted
\nsuicide and euthanasia was strong and clear
\nand should not be confused. Others argued
\nthat this was taking policy backwards and
\nsome wanted to add that it was contrary to
\nmedical ethics.
\nAn amendment to delete the sentence was
\nagreed.
\nThe committee recommended that the
\ndocument, as amended, be forwarded to the
\nCouncil for adoption by the Assembly. It
\nalso recommended that the WMA Resolu-
\ntion on Euthanasia, the WMA Declaration
\non Euthanasia, and the WMA Statement
\non Physician-Assisted Suicide be rescinded
\nand archived.
\nDuring the whole debate on this issue, no
\ndelegate spoke in favour of physician as-
\nsisted suicide and\/or euthanasia
\nAction on the WMA Physician\u2019s Pledge
\nThe Associate Members proposed a revi-
\nsion of the WMA Statement on Action to
\nStimulate use of the Physicians\u2019 Pledge of
\nthe Declaration of Geneva, by making the
\nwording less prescriptive. They proposed
\nusing the word \u2019encourage\u2019 rather than
\n\u2018require\u2019 the pledge to be used at medical
\nmeetings.
\nAfter speakers said that this change was not
\nnecessary, the proposal to amend the State-
\nment was rejected.
\nSolitary Confinement
\nThe committee considered a proposed revi-
\nsion of the WMA Statement on Solitary
\nConfinement submitted by the British
\nMedical Association. This advised physi-
\ncians not to participate in the decision-
\nmaking process resulting in the solitary
\nconfinement of prisoners. The BMA talked
\nabout the need to exclude children and
\nyoung people from this practice.
\nThe committee recommended that the pro-
\nposed revision be approved by the Council
\nand forwarded to the General Assembly for
\nadoption.
\nPhysicians Treating Relatives and Friends
\nThe South African Medical Association
\npresented a proposed revision of the WMA
\nStatement on Physicians Treating Relatives
\nand Friends, stating that wherever possible,
\nphysicians should avoid providing medical
\ntreatment to family.
\nSpeakers argued that the document ad-
\ndressed an important issue but needed fur-
\nther consideration and editing.
\nThe committee recommended that the pro-
\nposed revision be recirculated for comments.
\nPhysician Patient Relationship
\nThe committee received an oral report
\nfrom the Chair of the workgroup from the
\nSpanish Medical Association. The commit-
\ntee was told that a revised Declaration was
\nplanned to be submitted to the Council ses-
\nsion in Porto in April 2020.
\nEthics in Sports Medicine
\nA proposed revision of the Council Reso-
\nlution on Ethics in Sports Medicine was
\nBACK TO CONTENTS
\n12
\nGeneral Assembly Report
\nsubmitted by the South African Medical
\nAssociation. This was largely related to the
\nissue of the gender rules for classifying fe-
\nmale athletes issued by the International
\nAssociation of Athletics Federation.
\nSpeakers argued that this issue had been
\nwell publicised following the last meeting.
\nHowever, there was a need for more general
\npolicy to be drawn up.
\nThe committee noted that the WMA Decla-
\nration on Principles of Health Care for Sports
\nMedicine was scheduled to be revised next
\nApril as part of the annual policy review
\nprocess. This revision would provide an op-
\nportunity to incorporate the main policy el-
\nements of the proposed Council Resolution
\non Ethics in Sports Medicine into the re-
\nvised Declaration in an effort to consolidate
\nWMA policy.
\nThe committee decided not to approve
\nthe revised Resolution, but to circulate the
\ndocument and a paper from the American
\nMedical Association, and to work on an-
\nother more general statement on ethics and
\nsports medicine.
\nEmbryonic Stem Cell Research
\nThe committee considered a major revi-
\nsion of the WMA Statement on Embry-
\nonic Stem Cell Research submitted by the
\nAmerican Medical Association and recom-
\nmended that the document be circulated for
\ncomments.
\nDeclaration of Geneva
\nA proposed revision of the WMA Declara-
\ntion of Geneva was submitted by the Brit-
\nish Medical Association. It suggested add-
\ning one sentence to the Declaration: \u2018I shall
\nstrive to practise fairly and justly through-
\nout my professional life\u2019.
\nThe committee welcomed the proposal as
\na positive one and noted that it was being
\nactively examined as part of the current re-
\nvision process of the International Code of
\nMedical Ethics. The issue was also consid-
\nered during the most recent revision process
\nof the Declaration of Geneva and would be
\nkept in mind for the next revision.
\nThe committee recommended that the pro-
\nposed revision be rejected.
\nWMA Human Rights
\nClarisse Delorme, WMA Advocacy Advi-
\nsor, referred to the relevant human rights
\nsection of the Report of the Council to the
\nWMA General Assembly.
\nThursday October 24
\nAssociate Members Group
\nThe meeting was called to order by the
\nChair Dr. Joseph Heyman.
\nMembership
\nDr. Heyman reported that there were 613
\nAssociate Members from Japan, 775 other
\nmembers, 31 life members, 192 junior doc-
\ntors and 96 medical students.
\nJunior Doctors\u2019 Network
\nDr. Audrey Fontaine, newly elected Chair
\nof the JDN, reported on the Network\u2019s ac-
\ntivities since the last Associate Members
\nmeeting in October 2018. Membership had
\nincreased considerably due to increasing
\nsupport from the Constituent Members.
\nThe JDN\u2019s participation in the World
\nHealth Assembly meeting had produced
\nreports on the various issues discussed,
\nnamely health workforce, universal health
\ncoverage, health emergencies, air pollution
\nand antimicrobial resistance.
\nDr. Fontaine thanked all those who had
\nsupported the JDN. She introduced the
\nnew JDN leadership team and reminded
\nthe meeting that 2020 would mark the 10th
\nanniversary of the Network, an event which
\nwould be marked with special activities.
\nPast Presidents and Chairs of Council Net-
\nwork
\nDr. Jon Snaedal reported on the activities
\nof the Network. He spoke about Dr Yoram
\nBlachar\u2019s continued liaison with the UNES-
\nCO World Conference on Bioethics, Medi-
\ncal Ethics and Health Law, which was last
\nheld in Jerusalem,Israel,from 27-29 Novem-
\nber 2018. Dr Mukesh Haikerwal was con-
\ntinuing to raise the WMA\u2019s profile in social
\nmedia networks.He had attended the Health
\nProfessional Meeting (H20)\u00a0\u2013 The Road to
\nUniversal Health Coverage, as a keynote
\nspeaker, in June 2019, in Tokyo, Japan.
\nDr. Snaedal expressed his regret on the
\npassing of Dr J. Blahos from the Czech Re-
\npublic.
\nDr. Heyman reported that the Associates
\nnow had a lively Google group of 228 mem-
\nbers
\nAccess to Surgery and Anesthesia Care
\nThe JDN presented a proposed Statement
\non Access to Surgery and Anesthesia Care.
\nIt was agreed to send this to the General
\nAssembly for consideration.
\nScientific Session on \u201cPalliative
\ncare\u00a0\u2013 For the implementation
\nof international standards
\nof palliative care
\nZaza Bokhua, Vice-Minister of Ministry of
\nInternally Displaced Persons from the Oc-
\ncupied Territories, Labor, Health and Social
\nAffairs of Georgia welcomed delegates.
\nThe first speaker, Professor Robert
\nTwycross, Emeritus Clinical Reader in Pal-
\nliative Medicine from Oxford, UK entitled
\nhis speech \u2018Palliative Care: What, Who,
\nBACK TO CONTENTS
\n13
\nGeneral Assembly Report
\nWhen, and How?\u2019 He spoke about the his-
\ntory of the hospice movement and the way
\nin which palliative care had broadened out.
\nHe said palliative care focused on quality of
\nlife, and was based on need, not limited by
\ndiagnosis or prognosis. It was care beyond
\ncure. He said patients\u2019 top four priorities
\nwere expert care, effective communication
\nand shared decision-making, respectful and
\ncompassionate care, and trust and confi-
\ndence in clinicians.
\nProfessor Julia Downing,Chief Executive of
\nthe International Children\u2019s Palliative Care
\nNetwork (ICPCN),King\u2019s College London,
\nspoke on \u2018Palliative care for children\u2019 and
\nparticularly in Uganda where she works.She
\nsaid the ICPCN was the global network of
\nindividuals and organisations working to-
\ngether to reach the estimated 21 million
\nchildren with life-limiting conditions and
\nlife-threatening illnesses. Yet only five per
\ncent of them had any access to palliative
\ncare. The Network believed that all children
\nand young people and their families had
\nthe right of access to palliative care and this
\nshould begin at diagnosis until bereavement.
\nDr. Fiona Rawlinson (Johansen), Director
\nof the Cardiff University School of Medi-
\ncine Centre for Medical Education, Col-
\nlege of Biomedical and Life Sciences in the
\nUK talked about \u2018Postgraduate education
\nprogrammes\u00a0\u2013 correct planning and imple-
\nmentation.\u2019 She said that there needed to be
\nundergraduate palliative care training for
\nall.Palliative care was something that would
\naffect everybody. But there were not enough
\nhealth care professionals with expertise in
\nthe area. Palliative care needed to be includ-
\ned as an integral part of ongoing education
\nand training to care providers. She went on
\nto talk about what should be taught and the
\ncore competencies needed.
\nProfessor Xavier Gomez-Batiste, Professor
\nof Palliative Care at the Faculty of Medicine,
\nUniversity of Vic, Catalonia entitled his
\nspeech \u2018Adapting palliative care programs to
\nadvanced chronic care epidemics\u2019. He spoke
\nabout how to extend palliative care to non-
\ncancer patients, and about \u2019the tsunami of
\nneeds\u2019they were facing in Catalonia.
\nThe next speaker was Professor Julia Verne,
\nHead of Clinical Epidemiology, at Public
\nHealth England\u2019s National End of Life
\nCare Intelligence Network, who spoke on
\n\u2018Using a Human Rights approach to evalu-
\nate Palliative and End of Life Care in Eng-
\nland.\u2019 She said that a human rights frame-
\nwork was useful to judge the progress of
\nimplementation of comprehensive palliative
\nand end of life care. Human rights legisla-
\ntion could also be a useful adjunct to the ar-
\nguments made for implementing palliative
\nand end of life care to relieve suffering and
\nrespect the dignity of human beings.
\n\u2018Palliative Care Development Globally and
\nin Post-Soviet Countries\u2019 was the subject of
\nthe next speaker, Professor Stephen Con-
\nnor, Executive Director of the Worldwide
\nHospice Palliative Care Alliance. He spoke
\nabout palliative care development in the
\nformer Soviet Republics. He talked of the
\nglobal need for palliative care and looked at
\nthe impact of palliative care on the cost of
\nhealth care.The challenge for the future was
\nhow to integrate specialised palliative care
\ninto existing healthcare delivery structures
\nand primary care, to get better continuity of
\ncare and more community involvement and
\nownership.
\nDr. Katalin Muzsbek, Medical Director of
\nthe Hungarian Hospice Foundation, talk-
\ned about \u2018Psychological issues in palliative
\ncare\u2019. Cancer, death and dying were still ta-
\nboos subjects in eastern European countries.
\nAdvanced cancer and incurability caused
\nfear,distress and depression.Therefore,early
\nrecognition and treatment of psychological
\nsymptoms were crucial, and the education
\nof professionals and the public were of great
\nimportance.
\nProfessor Ging-Long Wang, Adjunct Clini-
\ncal Professor of Psychiatry National Yang-
\nMing University School of Medicine, Tai-
\npei, Taiwan talked about the integration of
\npsycho-oncology services and palliative care
\nin Taiwan. The aim was to improve quality
\nof care for all patients and families in every
\nstage of their medical care. There was satis-
\nfactory coverage in the stage of diagnosis and
\ncurative treatment and at end of life. They
\nhad tried to extend psycho-oncology services
\nto all cancer patients and palliative care to
\nall patients in stage 4 disease who needed it.
\n\u2018Care development across Europe: les-
\nsons from the Atlas 2013-Atlas 2019\u2019 was
\nthe title of the speech by Professor Carlos
\nCenteno, Professor, Palliative Medicine and
\nSymptom Control Faculty of Medicine,
\nUniversity of Navarra, Spain. He said that
\nlittle by little palliative care was becoming
\nthe conscience and responsibility of society.
\nVolunteers and the community were play-
\ning a leading role in many countries. He
\nsaid that society involvement would be the
\nkey to the future.
\nDr. Eduardo Garralda, from the University
\nof Navarra, Spain talked about the current
\nstatus of palliative care development in
\nGeorgia in comparison with benchmark-
\ning countries. He looked at socio economic
\ndata. Globally there were 60 million people
\nneeding palliative care, with 44,000 people
\nin Georgia in need. He compared Geor-
\ngia\u2019s palliative care services to neighbouring
\ncountries. There was a low use of opioids,
\nbelow the European average. He said that
\nthe situation in Georgia had slightly im-
\nproved recently, but coverage was still insuf-
\nficient and there was still a need to focus on
\naccess to medicines and speciality services.
\nFriday October 25
\nResumed Council Session. Medical
\nEthics Committee Report
\nWith the exception of the issue of physi-
\ncian-assisted suicide,the Council passed the
\nfull report of the Medical Ethics Commit-
\ntee.
\nBACK TO CONTENTS
\n14
\nGeneral Assembly Report
\nThis included forwarding to the General
\nAssembly for adoption the Declaration of
\nReykjavik on Ethical Consideration Re-
\ngarding the Use of Genetics in Medicine
\nand the revised Statement on Solitary Con-
\nfinement.
\nIt also agreed to circulate for comment the
\nStatement on Physicians Treating Relatives
\nand Friends and the Statement on Embry-
\nonic Stem Cell Research.
\nIt agreed that the revision of the Interna-
\ntional Code of Medical Ethics should con-
\ntinue with a draft proposal being shared at
\nregional expert meetings.
\nDeclaration on Euthanasia and Physician-
\nAssisted Suicide (see p. 22)
\nOn the proposed Declaration on Euthana-
\nsia and Physician-Assisted Suicide,a further
\ndebate took place, when several delegates
\ncalled for the document to be recirculated
\nand for further debate to be postponed until
\nthe next meeting in Porto in April. It was
\npointed out that the proposed Declaration
\ndid not mention either palliative care or
\nmental health of children. However, there
\nwas opposition to any delay, and in a vote
\nthe committee rejected a motion to recircu-
\nlate the document.
\nThe committee then approved the Declara-
\ntion for forwarding to the General Assem-
\nbly for adoption.
\nSocio-Medical Affairs Report
\nWith the exception of three items, the re-
\nport from the
\nSocio- Medical Affairs Committee was ap-
\nproved.
\nIt was agreed that the following documents
\nbe forwarded to the General Assembly for
\nadoption:
\nViolence and Health, Legislation Against
\nAbortion in Nicaragua, Climate Emergen-
\ncy and Opioid Use.
\nIt was agreed that the following documents
\nbe circulated for comment\u00a0\u2013 Pseudoscience
\nand Pseudotherapies in the Field of Health,
\nMedical Liability & Defensive Medicine,
\nChild Health,Inequalities in Health,Use of
\nTelehealth for the Provision of Health Care,
\nHypertension and Cardiovascular Disease,
\nand Protecting the Future Generation\u2019s
\nRight to Live in a Healthy Environment
\nContinuous Quality Improvement
\nAn amendment was proposed by the Brit-
\nish Medical Association to add a new para-
\ngraph to the proposed revision of\u00a0the\u00a0WMA
\nDeclaration on Guidelines for Continuous
\nQuality Improvement in Healthcare. The
\nparagraph read: \u2018Healthcare professionals
\nand institutions should systematically re-
\ncord and reflect on adverse incidents and
\nmedical error for the purposes of learning
\nand quality improvement. This should oc-
\ncur in an environment of trust (and confi-
\ndentiality when appropriate) and to actively
\navoid a blame culture.\u2019
\nThe amendment was accepted and the
\nCouncil agreed that the document as
\namended should be forwarded to the Gen-
\neral Assembly for adoption.
\nRelationship Between Physicians and Com-
\nmercial Enterprises
\nThe American Medical Association sug-
\ngested recirculating the proposed revi-
\nsion of\u00a0the WMA Statement Concerning
\nthe Relationship Between Physicians and
\nCommercial Enterprises. It was argued
\nthat significant changes were occurring in
\nrelations between physicians, hospitals and
\nother economic institutions, such as private
\nequity groups, venture capital and insurance
\ncompanies. This required more discussion
\non the policy.
\nA motion to recirculate the document was
\nagreed.
\nClimate Emergency (see p. 41)
\nThe British Medical Association proposed
\nan amendment to add to its emergency
\nresolution the sentence: \u2018The WMA and
\nits constituent members and the interna-
\ntional health community must acknowledge
\nthe environmental footprint of the global
\nhealthcare sector, and act to reduce waste
\nand prevent pollution to ensure healthcare
\nsustainability.\u2018
\nThe amendment was supported and the
\nCouncil agreed to forward the Resolution,
\nas amended, to the General Assembly for
\nadoption.
\nFinance and Planning
\nCommittee Report
\nThe Council approved the report from the
\nFinance and Planning Committee, includ-
\ning the Audited Financial Statement for
\n2018 and the proposed Budget for 2020,
\nboth of which were forwarded to the Gen-
\neral Assembly for adoption.
\nThe Council agreed to withdraw the rec-
\nommendation on the venue for the 224th
\nCouncil Session in 2023 in Baku, Azer-
\nbaijan, and approve Nairobi, Kenya, as
\nthe venue for the 224th
\nCouncil Session in
\n2023.
\nThe Council agreed the proposed Classifi-
\ncation of Old Council Resolutions as rec-
\nommended by the committee.
\nAssociates Members
\nA report was presented from the Chair of
\nthe Associate Members, Dr. Joseph Hey-
\nman. He said the membership had become
\nmuch more efficient,engaged and meaning-
\nful.
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\n15
\nGeneral Assembly Report
\nTwo webinars were being planned, on social
\ndeterminants of health and on the Interna-
\ntional Code of Medical Ethics.
\nPast President and Chairs Network
\nDr. Jon Snaedal said the Network had been
\nactive with past Presidents and Chairs act-
\ning individually on behalf of the WMA.
\nJunior Doctors Network
\nA report on the work of the Network was
\npresented by the Chair. A growing number
\nof junior doctors had been attracted to the
\nNetwork and plans were being prepared to
\ncelebrate the 10th
\nanniversary of the Net-
\nwork next year.
\nWorld Medical Journal
\nThe Editor referred to his written report,
\nwhich stressed that the Journal was his-
\ntorical evidence which enabled them to re-
\nmember all presidents, key members of the
\nCouncil, chairs of committees and opin-
\nion leaders. His task was to collate, as far
\nas possible, everything that WMA leaders
\nthought, did and wrote. He said he would
\nlike to see more activity from the leaders of
\nnational medical associations writing about
\nsocial determinants, public health and med-
\nical ethics.
\nPublic Relations
\nThe meeting heard a report on public re-
\nlations and the need to publicise the vari-
\nous policy statements to be adopted by the
\nGeneral Assembly. Press releases and social
\nmedia were used to achieve this. However,
\nnational medical associations could also
\nhelp by issuing their own press releases and
\ncontacting their own governments about
\nnew policy statements.
\nEnvironment Caucus
\nAn oral report was presented on the Envi-
\nronment Caucus which had met the previ-
\nous day. The Caucus had heard about the
\nresults of the recent UN Climate Action
\nSummit. It was now preparing for the next
\nclimate conference COP 25 in December
\nwhere the WMA would be co-hosting a
\nglobal climate and health summit. Consid-
\neration was being given to having sustain-
\nable climate for WMA meetings and how
\nWMA delegates would promote and sup-
\nport green conduct at international meet-
\nings, reducing WMA delegates\u2019 contribu-
\ntions to climate change.
\nAdvocacy and Communications Panel
\nThe Chair of the Advocacy and Commu-
\nnications Advisory Panel, Dr. Angelique
\nCoetzee gave an oral report. She referred to
\na small survey of NMAs that had been car-
\nried out about communications and advo-
\ncacy, which emphasised the importance of
\nthe WMA website and e mail communica-
\ntion with the office in France. At a meeting
\nof the Panel earlier in the week there had
\nbeen a discussion about the need to support
\nsmaller NMAs, possibly by having larger
\nNMAs in the region acting as mentors,how
\nto foster media visibility by reaching the
\nunreached, the role of social media and the
\npossibility of having open consultation on
\nkey issues under consideration .
\nGeneral Assembly Ceremonial Session
\nThe Ceremonial Session was called to order
\nby the WMA President, Dr. Leonid Eidel-
\nman
\nFollowing welcoming speeches, delegates
\nstood to recite the Declaration of Geneva.
\nA Roll Call and Introduction of Delegates
\nand Observers was carried out by the Secre-
\ntary General, Dr. Otmar Kloiber
\nThe Chair of the WMA Council Dr.Mont-
\ngomery then paid tribute to the outgoing
\nPresident Dr. Eidelman and thanked him
\nfor his work during his Presidential year.He
\nsaid he had highlighted the issue of physi-
\ncians of the future, questioning how they
\nwere going to carry out their profession in
\nthe years to come. And he had never forgot-
\nten patients during his work.
\nDr.Eidelman then delivered his Valedictory
\nAddress.
\nDr. Miguel Roberto Jorge, then took the
\noath of office as President of the WMA
\nfor 2019\/20. He was officially installed as
\nPresident and presented with the Presiden-
\ntial Medal.
\nDr. Jorge then gave his Inaugural Address.
\nThe Assembly then adjourned.
\nSaturday October 26
\nGeneral Assembly Plenary Session
\nThe day began with a brief orientation
\nsession, when the Chair of Council Dr.
\nMontgomery explained to delegates the
\nprocedure of the Assembly. He reminded
\ndelegates that any vote on changing ethical
\npolicy required a three-quarters majority.
\nHe then called the Assembly to order.
\nCredentials Committee
\nThe Credentials Committee reported that
\nthere were 52 WMA constituent members
\npresent and registered, with a total number
\nof 145 votes. A three-quarters majority was
\n109. A two-thirds majority, required for
\nchanging the bylaws, would be 97 votes.
\nElection of President for 2020-2021
\nThe first item on the agenda was the elec-
\ntion of a President for 2020-21.
\nThe only nomination was that of Dr. David
\nBarbe, former President of the American
\nMedical Association. Dr. Barbe was elected
\nunopposed as President-elect.
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\n16
\nGeneral Assembly Report
\nHe thanked the meeting for its support
\nwith these words:
\n\u2018Our physician colleagues and our patients
\ndepend on our wisdom and leadership to
\nmake healthcare better. Only by relying
\non strong core principles can we adapt to
\nthe changes and seize the opportunities
\nthat face us. I promise I will rely on WMA
\npolicy and our core values of promoting hu-
\nman rights, ethical medical practice and the
\nprimacy of the patient physician relation-
\nship to make decisions and statements that
\nreflect the will of this Assembly.
\n\u2018The WMA will continue to form partner-
\nships and collaborative efforts to accomplish
\nour many strategic objectives. But most of
\nall, critical to our success, will be your ac-
\ntive participation. So I sincerely hope you
\nwill join me in boldly moving the WMA
\nforward into the future, while at same time
\nupholding our best ideals from past and as
\nalways providing the best patient care for
\nthe patients that we serve.\u2019
\nUniversal Health Coverage
\nAn oral report was given by Dr. Yoshitake
\nYokokura, Past President of the WMA and
\nPresident of the Japan Medical Association.
\nHe talked about the WMA\u2019s engagement
\non the issue of universal health coverage.He
\nreported on the UHC Forum held in De-
\ncember 2017 in Tokyo, which had adopted
\nthe Memorandum of Tokyo \u2018Affirming
\nhealth for all\u2019 and about the Memorandum
\nof Understanding signed with the World
\nHealth Organisation.
\nHe had participated in the United Nations
\nHigh Level meeting in New York in Sep-
\ntember where world leaders adopted a high-
\nlevel declaration.
\nReport of the Council
\nThe Assembly approved the written report
\nfrom Council that had been tabled.
\nThe Assembly then considered actions rec-
\nommended by the Council from the Medi-
\ncal Ethics Committee.
\nFemale Foeticide (see p. 22)
\nDr.J\u00fcrg Schlup (Switzerland) presented the
\nproposed Revision of the WMA Statement
\non Female Foeticide. He said the policy
\nhad been amended to add the following
\nsentence: \u2018The WMA holds that sex selec-
\ntion abortion for reasons of gender prefer-
\nence is discriminatory, where it is solely
\ndue to parental preference and where there
\nare no health implications for the foetus or
\nthe woman.\u2019 He said the goal was to avoid
\nfemale foeticide with all its social conse-
\nquences.
\nThe Assembly agreed to adopt the revised
\nStatement.
\nGenetics in Medicine (see p. 26)
\nDr. Reynir Arngrimsson (Iceland) present-
\ned the Declaration of Reykjavik\u00a0\u2013 Ethical
\nConsideration Regarding the Use of Ge-
\nnetics in Medicine. He said the Declara-
\ntion was a response to the rapid progress
\ntaking place with genetics in medicine and
\nthe need to put ethical considerations at the
\nforefront of these developments.
\nThe Assembly agreed to adopt the Declara-
\ntion.
\nSolitary Confinement (see p. 39)
\nThe proposed revision of the WMA State-
\nment on Solitary Confinement was present-
\ned by Dr.Chaand Nagpaul (British Medical
\nAssociation).
\nThe Assembly agreed to adopt the State-
\nment.
\nThe Assembly then moved on to consider
\nactions recommended by the Council from
\nthe Socio-Medical Affairs Committee.
\nDeclaration of Madrid on Professionally-led
\nRegulation (see p. 22)
\nDr. Nagpaul presented the proposed revi-
\nsion of the WMA Declaration of Madrid
\non Professionally-led Regulation
\nThe Assembly agreed to adopt the Declara-
\ntion.
\nAntimicrobial Resistance (see p. 29)
\nDr. Nagpaul also introduced the proposed
\nrevision of the WMA Statement on Anti-
\nmicrobial Resistance. He said this was an
\nissue of huge importance and was central to
\nthe work of the WMA globally.
\nThe Assembly agreed to adopt the State-
\nment.
\nReducing Dietary Sodium Intake (see p. 37)
\nTh South African Medical Association pre-
\nsented the proposed revision of the WMA
\nStatement on Reducing Dietary Sodium
\nIntake, recognising the prevalence of hyper-
\ntension associated with sodium intake.
\nThe Assembly agreed to adopt the Statement.
\nSugar (see p. 34)
\nThe proposed WMA Statement on Free Sug-
\nar Consumption and Sugar-sweetened Bev-
\nerages was introduced by Dr. Lujain Alqod-
\nmani (Kuwait Medical Association). She said
\nthat given the rise of NCDs and child health
\nobesity and nutritional challenges all over the
\nworld,it was important for the WMA to have
\na strong statement on the issue.
\nThe Assembly agreed to adopt the State-
\nment.
\nHealthcare Information for All (see p. 35)
\nDr. Nagpaul introduced the proposed
\nWMA Statement on Healthcare Informa-
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\n17
\nGeneral Assembly Report
\ntion for All. He said it was well recognised
\nthat a lack of access to health care informa-
\ntion was a major contributor to morbidity
\nand mortality, especially in low and middle
\nincome countries and also among vulner-
\nable groups. He said this was a really im-
\nportant statement because it was essentially
\nabout equity, empowerment and allowing
\nevery single citizen to fulfil their fullest po-
\ntential in achieving their maximum health.
\nThe Assembly agreed to adopt the State-
\nment.
\nAccess of Women and Children to Health Care
\n(see p. 28)
\nLeah Wapner (Israel) presented the pro-
\nposed WMA Statement on Access of
\nWomen and Children to Health Care.
\nThe Assembly agreed to adopt the State-
\nment.
\nAugmented Intelligence (see p. 31)
\nDr. Patrice Harris (American Medical As-
\nsociation) presented the proposed WMA
\nStatement on Augmented Intelligence in
\nMedical Care. She said the AMA had pro-
\nposed this because machine learning tech-
\nnology innovation was going to continue to
\nimpact on how they cared for their patients.
\nIt was important for NMAs to be educated
\non the issue.
\nThe Assembly agreed to adopt the State-
\nment.
\nMedical Age Assessment of Unaccompanied
\nMinor Asylum Seekers (see p. 36)
\nDr. Ramin Parsa-Parsi (German Medi-
\ncal Association) introduced the proposed
\nWMA Statement on Medical Age Assess-
\nment of Unaccompanied Minor Asylum
\nSeekers. He said the document emerged
\nfrom what was perceived to be an exception-
\nally pressing and timely matter, namely the
\nmethods employed to assess the age of un-
\naccompanied minor asylum seekers for the
\npurposes of determining their legal status in
\nthe country in which they were seeking asy-
\nlum. Given the global implications of this
\nissue, it was important that physicians the
\nworld over were given guidance for dealing
\nwith cases they were called upon to perform
\nmedical age assessments.
\nDr. Marit Hermansen (Norway) referred
\nto the WMA statement earlier in the year
\non new eligibility regulations for classifying
\nfemale athletes which said \u2018It is in general
\nconsidered as unethical for physicians to
\nprescribe treatment for excessive endoge-
\nnous testosterone\u00a0if the condition is not rec-
\nognized as pathological\u2019 and went on to call
\non physicians to refuse to perform any test
\nor administer any treatment or medicine
\nwhich was not in accordance with medi-
\ncal ethics. In that case, she said, the WMA
\nwas opposing treatment for non-medical
\nreasons. Radiological examination without
\nmedical indication or examination that in-
\nfringed on the dignity and privacy of asylum
\nseekers,that was genital examination,was in
\nthe same category.
\nSo she proposed inserting in the asylum
\nseekers Statement a new paragraph saying
\n\u2018The WMA advises doctors not to partici-
\npate in the age assessment of minor asylum
\nseekers in all cases but where it is demon-
\nstrably of interest of the individual.\u2019
\nDr. Andreas Rudkjoebin (Denmark) spoke
\nagainst the amendment. He said it was not
\nconsistent with an earlier paragraph in the
\nStatement which stated that the patient
\nmust be informed that the procedure was
\nnot done to provide health care. In addi-
\ntion, the Statement already referred to any
\ninfringement of dignity and privacy.
\nIn a vote, the amendment was rejected.
\nThe Assembly then agreed to adopt the
\nStatement.
\nThe Assembly agreed that the WMA Resolu-
\ntion on Improved Investment in Public Health
\nbe rescinded and archived.
\nViolence and Health (see p. 42)
\nThe Nigerian Medical Association intro-
\nduced the proposed revision of the WMA
\nStatement on Violence and Health.
\nThe meeting was told that this covered all
\nforms of violence at the work place and
\nagainst physicians. The Assembly agreed to
\nadopt the Statement.
\nAbortion in Nicaragua (see p. 41)
\nDr. Gustavo Grecco (Uruguay) proposed
\nthe revised Resolution on Legislation
\nAgainst Abortion in Nicaragua
\nThe Assembly agreed to adopt the revised
\nResolution.
\nClimate Emergency (see p. 41)
\nDr. Helena Mc Keown (British Medical
\nAssociation) introduced the emergency
\nResolution on Climate Emergency. She
\nsaid she recognised the previous work un-
\ndertaken by the WMA on this issue,but the
\nBMA believed it was time to express the
\nview that action on climate change should
\nbe accelerated.
\nThe Assembly agreed to adopt the emer-
\ngency Resolution.
\nOpioid Use (see p. 42)
\nDr. Ravindra Wankhedkar (India) intro-
\nduced the emergency Resolution on the
\nRevocation of WHO Guidelines on Opi-
\noid Use. He said the resolution had been
\nintroduced because the WHO, without
\nany discussion with any stakeholder, had
\nrescinded its guidelines on opioids, causing
\na lot of difficulties for health care providers
\nand patients.
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\n18
\nGeneral Assembly Report
\nThe Assembly agreed to adopt the emer-
\ngency Resolution.
\nThe Assembly then referred back to the re-
\nport from the Medical Ethics Committee
\nto discuss one additional item.
\nPhysician-Assisted Suicide
\nOn a motion to adopt the proposed Dec-
\nlaration on Euthanasia and Physician-As-
\nsisted Suicide as amended by the Council,
\nDr. Ramin Parsa-Parsi (Germany) said that
\ndiscussions had been continuing for some
\ntime about merging three WMA policies
\ninto a new document. Following further
\ncollaboration, he proposed an amendment
\nadding wording at the beginning of the
\ndocument to read: \u2018The WMA reiterates
\nits strong commitment to the principles of
\nmedical ethics and that utmost respect has
\nto be maintained for human life. Therefore,
\nthe WMA is firmly opposed to euthanasia
\nand physician-assisted suicide.\u2019
\nThis led to a lengthy debate, with speakers
\narguing for and against the amendment.
\nDr. Helena McKeown (British Medical
\nAssociation) supported the amendment.
\nShe said the BMA was concerned by the
\nshortcomings in current and applied care
\nand was working to ensure that those cared
\nfor at home had access to needed pain re-
\nlief at any time during the day or night.
\nThe BMA did not believe that physician
\nassisted suicide should be made legal in
\nBritain. It did not believe either voluntary
\nor involuntary euthanasia should be legal-
\nised. The BMA was currently polling its
\nmembers on the position of the BMA and
\nneutrality.
\nProf. Pablo Requena Meana (Vatican
\nMedical Association) said the draft policy
\nsubmitted was not a bad document. But
\nwithout doubt it weakened the WMA\u2019s
\nposition on euthanasia. He said it would
\nnot be appropriate to adopt this document
\nbecause many countries were discussing
\nlaws on euthanasia and it might give the
\nimpression that the WMA in some way
\nrecognised this social pressure and had low-
\nered its standards on this issue. The Vatican
\nMedical Association was not in a position
\nto adopt this document if it did not include
\nat the beginning a reference saying that eu-
\nthanasia and physician assisted suicide were
\ncontrary to medical ethics.
\nProf. Yang Yang (Chinese Medical Asso-
\nciation) supported adopting the document,
\nbut Dr. Kgosi Letlape, a Past President of
\nthe WMA, said that current WMA policy
\nwas a beacon of medical ethics. He argued
\nagainst adopting a document that might
\ngive governments that did not want to pro-
\nvide health services an option of allowing
\ncitizens to die that might have tacit support
\nfrom the WMA.
\nHe received support from the New Zea-
\nland and Romanian Medical Associations.
\nDelegates heard that New Zealand was
\ngoing through a big social debate on phy-
\nsician-assisted suicide at the moment and
\nthe medical association there had used the
\nWMA\u2019s strong policy position. Dr. Gheor-
\nghe Borcean (Rumania) asked the meeting
\nto consider what message it wanted to send
\nthe world and whether it would still be rep-
\nresentative of the profession.
\nDr. Yoshitake Yokokura (Japan) said that
\nin Japan and in Asia there were very strong
\nreligious conceptions about death and eu-
\nthanasia. Two years ago, a symposium had
\nbeen held in Japan on this issue, and Asian
\ncountries were unanimously against the
\nidea of euthanasia. The other day the state-
\nrun broadcaster in Japan had reported on
\na lady who had travelled to Switzerland to
\nreceive physician-assisted suicide because
\nshe could not do so in Japan. Since then in
\nJapan this topic had attracted much atten-
\ntion. Under such circumstances it was high
\ntime the WMA came out with a very clear
\nmessage that it was opposed to euthanasia
\nand physician-assisted suicide. Physicians
\nshould not be forced into being any part of
\nthat. He therefore suggested that the pro-
\nposed Declaration be adopted.
\nDr. Jaques de Haller, an Associate Member
\nfrom Switzerland
\nand former President of the Standing Com-
\nmittee of European Doctors, thanked the
\nGermans for their compromise document.
\nIt reaffirmed the position of the majority of
\nmembers of the WMA,being firmly against
\neuthanasia and physician assisted-suicide.
\nAt same time it avoided stigmatising col-
\nleagues in different situations. This was a
\npositive point. He said the document fos-
\ntered respect and reconciliation and they
\nshould be thankful for it.
\nDr. Barbara McAneny (American Medi-
\ncal Association) said that ethics over time
\ndid change.The document carefully defined
\neuthanasia and physician-assisted suicide as
\ntwo very different things. She said she was
\na cancer doctor and had been present at the
\nend of life for many patients.The cancer,not
\nthe patient decided when that patient would
\ndie. The only thing the patient had in their
\ncontrol was the manner and the comfort of
\ntheir passing. The WMA had decided that
\nwith palliative care and terminal sedation
\nit was acceptable for her to sedate a patent
\nin the last two hours of their life. But two
\nhours was different from two weeks. There
\nwas a grey zone of what was acceptable and
\nwhat it meant to relieve pain and suffering
\nat the end of life. She said she supported
\nthe amendment because the words allowed
\nphysicians to use their own judgement.
\nProf. Zion Hagay (Israel) said he fully sup-
\nported palliative care but not euthanasia. It
\nwas against his ethics.It was also against the
\nposition of the Israeli medical ethics com-
\nmittee which was against euthanasia.There-
\nfore, he would vote against the proposed
\nDeclaration and the amendment.
\nThe Brazilian Medical Association said
\nit would support the document, while Dr.
\nSerafin Romero (Spain) said it was im-
\nBACK TO CONTENTS
\n19
\nGeneral Assembly Report
\nportant to reach a consensus. He said that
\nthey should all made clear that everyone
\nwas against euthanasia. Dr. Gana Baskaran
\nNadason, President of the Malaysian Medi-
\ncal Association, said his association strongly
\nopposed euthanasia. Physicians were sup-
\nposed to save life, not to take away life.
\nDr. Francis Faduyile (Nigeria) said that at
\nthe regional meeting held in Africa two
\nyears it was agreed that euthanasia and phy-
\nsician-assisted suicide were unethical and
\nthey should go the way of palliative care.
\nThe physician pledge stated that physicians
\nwould maintain the utmost respect for hu-
\nman life. In Nigeria, they believed that any
\nphysician who participated in euthanasia or
\nphysician-assisted death was actually un-
\nethical. He said he wanted to plead with
\ncolleagues they should state that the WMA
\nreiterated its strong commitment to the
\nprinciple of medical ethics. He proposed a
\nfurther amendment to add the words \u2018The
\nWMA considers involvement in physician-
\nassisted suicide and euthanasia as being un-
\nethical\u2019.
\nDiscussion then focused on the Nigerian
\namendment, which was seconded. Dr. Jac-
\nqueline Kitula (Kenya) said that medical
\nethics was their bedrock. The amendment
\nwould be in line with this. In Kenya eutha-
\nnasia and physician-assisted suicide were
\nnot permissible. But any statement that be-
\ngan to waiver might open up a leeway for
\ngovernments to deliver a cheaper way to take
\ncare of those who were chronically ill. She
\ntherefore supported issuing a strong state-
\nment as set out in the Nigerian amendment.
\nAfter further debate, a vote was taken and
\nthe Nigerian amendment was defeated by
\n84 votes to 36 with 17 abstentions.
\nThe debate then continued on the original
\namendment from the German Medical As-
\nsociation.
\nDr.Tony Bartone (Australia) said that society
\nchanged and ethics evolved. He did not be-
\nlieve the language of the amendment and the
\nproposed Declaration weakened the position
\nof the WMA.The AMA had a firm position
\non euthanasia and physician-assisted suicide.
\nHe read one sentence from the AMA policy
\n\u2018The AMA believes doctors should not be
\ninvolved in interventions that have as their
\nprimary intent the ending of a person\u2019s life.
\nThis does not include the discontinuation of
\ntreatment of no medical benefit\u2019. He said in
\nAustralia some of the states had started the
\nprocess of allowing the legalisation of vol-
\nuntary assisted dying. He said he did not
\nbelieve there was anything in the proposed
\nDeclaration that lessened the opposition to
\neuthanasia and physician-assisted suicide.
\nHe would therefore be voting in favour.
\nDr. Jean-Francois Rault (France) said that
\nthe French Medical Association was op-
\nposed to active euthanasia and assisted sui-
\ncide. Like many colleagues, he was pleased
\nthat a compromise text had been found in
\nwhich all opinions could be reflected. Fur-
\nther support came from speakers from the
\nHungarian and Indian Medical Associa-
\ntions, both of whom welcomed the strength
\nof the document.
\nBefore the next vote was taken, Dr. Andy
\nGurman, an Associate Member, asked for
\nclarification about how abstaining votes
\nwould be treated as part of the rule for
\nthree-quarters or two-thirds majorities.
\nThis led to an examination of the bylaws
\nand a ruling from the Chair that in the As-
\nsembly abstentions counted.
\nA vote then took place on the original
\namendment to add at the start of the docu-
\nment two sentences: \u2018The WMA reiterates
\nits strong commitment to the principles of
\nmedical ethics and that utmost respect has
\nto be maintained for human life. Therefore,
\nthe WMA is firmly opposed to euthanasia
\nand physician-assisted suicide.\u2019
\nThe amendment was carried by 115 votes to
\n0, with 12 abstentions.
\nThe debate continued on the proposed Dec-
\nlaration, as amended.
\nThe Ghana Medical Association proposed
\nadding the words \u2018No physician should
\nparticipate in euthanasia or assisted suicide
\nwhether voluntary or under compulsion,
\nnor should any physician make, refer deci-
\nsions to this end even if obliged or coerced.\u2019
\nBut the proposal failed to find a seconder.
\nBefore the final vote on whether to adopt
\nthe final Declaration as amended, Leah
\nWapner (Israel) said that voting on this did
\nnot mean that participating in euthanasia or
\nassisted suicide was unethical. It was clear
\nthat what they were going to vote on was
\nweaker than what they were saying before,
\nthat it was unethical. She said they needed
\nto reach a consensus on this,but she thought
\nthere were large parts of the room that felt
\nvery uncomfortable with the document.
\nDr. Kenji Matsubara (Japan) said the pro-
\nposed Declaration was a softening of the
\nWMA\u2019s policy and he proposed an amend-
\nment to add the words \u2018Euthanasia and
\nphysician-assisted suicide are not compat-
\nible with medical ethics.\u2019
\nThe amendment was defeated by 70 votes to
\n45 with 21 abstentions.
\nIn a final vote to adopt the amended Dec-
\nlaration, which required a three-quarters
\nmajority, 110 voted for, 10 against with four
\nabstentions.
\nThe Declaration was adopted and the As-
\nsembly agreed to rescind three previous
\nWMA policy statements.
\nDeclaration of Geneva
\nProf. Raanan Gillon, President of the Brit-
\nish Medical Association, returned to the is-
\nsue of revising the Declaration of Geneva
\nby adding the words \u2018I shall strive to practise
\nfairly and justly\u2019, an amendment that failed
\nto find a seconder earlier in the week. He
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\n20
\nGeneral Assembly Report
\nsaid he should have sought a seconder for
\nhis motion before proposing it and he in-
\nvited those who supported it to contact him
\nso that the matter could be raised again at
\nthe next meeting.
\nReport of the Treasurer
\nThe Treasurer, Dr. Ravindra Sitaram
\nWankhedkar gave a comprehensive report
\non the financial statement for 2018. He said
\nthere was a surplus, and expenses were well
\nregulated, monitored and controlled.
\nMembership dues had increased and the
\nAssociation had a low risk investment strat-
\negy. It relied heavily on membership sub-
\nscriptions for its income.
\nHe said the volume, structure and quality of
\nthe finances were solid,and savings were safe.
\nHe reported detailed expenditure and in-
\ncome statistics.
\nThe Audited Financial Statement for the
\nyear ending 31 December 2018 was ap-
\nproved.
\nDr. Wankhedkar then presented the pro-
\nposed Budget for 2020 and the Report on
\nMembership Dues Payments for 2019.
\nBoth reports were adopted.
\nThe Assembly received for information the
\nWMA Dues Categories 2020.
\nThe Assembly approved the proposed Dues
\nIncrease starting in 2021.
\nFuture Meetings
\nThe Assembly agreed that the 224th
\nCouncil
\nSession in 2023 be held in Nairobi, Kenya.
\nLaw and Ethics (see p. 23)
\nThe Assembly adopted the 2003 Resolution
\non Law and Ethics as a Declaration.
\nThe Assembly received for information the
\nlist of policy documents to be rescinded.
\nScientific Session 2020
\nThe Assembly agreed that \u2018Transplants and
\ndonation\/organ trafficking: International
\nscenario\u2019 be the theme of the Scientific Ses-
\nsion of the 71st
\nGeneral Assembly, in Cor-
\ndoba 2020.
\nGeneral Assembly 2023
\nThe Assembly agreed that 4-7 October
\n2023 be the dates for the 74th
\nGeneral As-
\nsembly in Kigali, Rwanda.
\nMembership
\nThe application for membership from Doc-
\ntors 4 Doctors, Seychelles was approved.
\nStrategic Plan 2020-25
\nThe draft WMA Strategic Plan 2020-2025
\nwas approved.
\nAssociate Members
\nDr. Audrey Fontaine gave a report of the
\nAssociate Members meeting and proposed
\na Statement on Access to Surgery and An-
\nesthesia Care, which she said had been very
\nmuch neglected in the objectives towards
\nuniversal health coverage. She said it was
\nimportant to have a position on this.
\nThe Assembly agreed to send the document
\nto Council for consideration.
\nPresentations from International Organisa-
\ntions
\nDr. Patricia Turner, President-Elect of the
\nWorld Veterinary Association, spoke about
\ncollaboration between the WMA and the
\nWVA. She gave a brief history of the WVA
\nand its structure.The Association represent-
\ned more than half a million members and
\nput great emphasis on public health.
\nShe talked about the ongoing African swine
\nfever, which was highly infectious and was
\nspreading throughout south east Asia. This
\nwas a massive animal welfare issue.
\nThere had been an increased feminisation in
\nveterinary practice and a change in work-
\ning practices, such as increased technology
\nand the use of telemedicine. She referred to
\nthe issue of antimicrobial misuse and spoke
\nabout the health benefits of keeping pets.
\nFinally, Dr. Turner talked about the collab-
\noration between the WVA and the WMA
\nthat had been going on since 2012. This
\nhad involved joint press releases and host-
\ning joint conferences. It was bringing to-
\ngether the strength of the two professions,
\ncapitalising on their joint knowledge base
\nfor educating people about issues impact-
\ning humans, animals and the environment
\nand applying pressure on governments and
\nnon-governmental organisations.The WVA
\nhighly valued this partnership.
\nIstanbul Protocol
\nMariam Jishkariani from the Rehabilitation
\nCentre for Victims of Torture spoke about
\nrevisions to the Istanbul Protocol for the
\ninvestigation and documentation of torture
\nin relation to the various WMA policies on
\nthe issue.
\nWMA Open Session
\nThis session gave delegates an opportunity
\nto present to the Assembly any profession-
\nspecific problem, policy or project they
\nbelieved the WMA should know about or
\nhelp address.
\nBritish Medical Association
\nDr. Helena McKeown spoke about plans
\nfor the WMA Council meeting in Porto.
\nThe BMA had presented its climate emer-
\ngency resolution this week and she thought
\nit was time they looked to extend this to at-
\ntendees at the Porto meeting to try to use
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\nGeneral Assembly Report
\na green travel plan and reduce air travel. If
\nthey were not able to reduce air travel, she
\nwould suggest they should be trying to off-
\nset their carbon. She would like to see the
\nPorto conference be as green as possible,
\nwith the use of single use plastic, recycle
\nbins and the avoidance of generating waste.
\nVenezuela Medical Association
\nDr. Douglas Leon-Natera, President of the
\nVenezuelan Medical Association, said they
\nwere fighting for the health of the Venezue-
\nlan people because the Government was ne-
\nglecting it.There was no way that physicians
\ncould provide the health service that was
\nrequired, save lives and provide medicines.
\nRegrettably, patients were paying the price
\nfor this. Physicians could not do anything
\nto stop the diseases that were killing people.
\nThere was no epidemiological data available
\nto allow them to do their job. The medical
\nprofession was doing its best, but many of
\nthem were fleeing the country as it was not
\nsafe and they were not being paid. Inflation
\nwas rampant,4,500 per cent this year,and as
\na result people could not live. The situation
\nwas a terrible crisis and he wanted the world
\nto be aware of this.
\nUruguay Medical Association
\nDr. Gustavo Grecco also spoke about the
\nsituation that the medical communities in
\nLatin America were facing. At the moment
\nthey had countries with different political
\nsituations from both the left and the right
\nthat were suffering from a dilapidation of
\nhealth services.
\nIn Chile there was a serious situation, in
\nVenezuela the situation was terrible, in
\nHonduras doctors were being persecuted
\ntrying to protect the health of their people.
\nIn Nicaragua doctors were suffering from
\nviolence and being forced not to help op-
\nponents of the regime.
\nHe said the World Health Organisation
\nwas fighting for universal health coverage,
\nbut in his region many countries were actu-
\nally going in the wrong direction
\nBangladesh Medical Association
\nDr. Ehteshamul Huq Choudhury said that
\nin his country doctors were also being as-
\nsaulted by miscreants and patients\u2019 relatives.
\nThe police and law enforcement authorities
\ntook the side of the miscreants. In India one
\ndoctor had died. He would like to urge the
\nAssembly to take a decision that govern-
\nments should be asked to formulate a law
\nto protect doctors in their working environ-
\nments.
\nThe Chair of Council, Dr. Montgomery,
\nsaid this was a very important issue and was
\nalso a problem in Germany, where legisla-
\ntion was being discussed to protect physi-
\ncians and other health care workers from
\nassaults by patients.
\nThe Assembly ended with a presentation
\nto the outgoing President of the WMA,
\nDr. Leonid Eidelman, and a short film of
\nCordoba, the venue for the next Assembly
\nin 2020.
\nThe Chair of Council then brought the
\nAssembly to a close, after a very successful
\nweek.
\nMr. Nigel Duncan
\nPublic Relation Consultant,
\nWMA
\nE-mail: nduncan@ndcommunications.co.uk
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\nGeneral Assembly Report
\nWMA Statement on Sex Selection
\nAbortion and Female Foeticide
\nAdopted by the 53rd
\nWMA General Assembly, Washington, DC, USA,
\nOctober 2002, reaffirmed by the 191st
\nWMA Council Session, Prague,
\nCzech Republic, April 2012 And revised by the 70th
\nWMA General As-
\nsembly, Tbilisi, Georgia, October 2019
\nThe WMA is gravely concerned that female foeticide and sex selec-
\ntion abortion is commonly practiced in certain countries.
\nThe WMA denounces female foeticide and sex selection abortion as
\na totally unacceptable example form of gender discrimination.
\nThe WMA holds that sex selection abortion for reasons of gender
\npreference is discriminatory, where it is solely due to parental pref-
\nerence and where there are no health implications for the foetus or
\nthe woman.
\nThe World Medical Association calls on National Medical Associa-
\ntions:
\n\u2022\t To denounce the practice of female foeticide and the use of sex
\nselection abortion for gender preference and;
\n\u2022\t To advise their governments accordingly.
\nWMA Declaration on Euthanasia
\nand Physician-Assisted Suicide
\nAdopted by the 70th
\nWMA General Assembly, Tbilisi, Georgia, October
\n2019
\nThe WMA reiterates its strong commitment to the principles of
\nmedical ethics and that utmost respect has to be maintained for hu-
\nman life. Therefore, the WMA is firmly opposed to euthanasia and
\nphysician-assisted suicide.
\nFor the purpose of this declaration, euthanasia is defined as a physi-
\ncian deliberately administering a lethal substance or carrying out an
\nintervention to cause the death of a patient with decision-making
\ncapacity at the patient\u2019s own voluntary request. Physician-assisted
\nsuicide refers to cases in which, at the voluntary request of a patient
\nwith decision-making capacity, a physician deliberately enables a
\npatient to end his or her own life by prescribing or providing medi-
\ncal substances with the intent to bring about death.
\nNo physician should be forced to participate in euthanasia or as-
\nsisted suicide, nor should any physician be obliged to make referral
\ndecisions to this end.
\nSeparately, the physician who respects the basic right of the patient
\nto decline medical treatment does not act unethically in forgoing or
\nwithholding unwanted care, even if respecting such a wish results in
\nthe death of the patient.
\nWMA Declaration of Madrid on
\nProfessionally-led Regulation
\nAdopted by the 60th
\nWMA General Assembly, New Delhi, India, October
\n2009 and revised by the 70th
\nWMA General Assembly, Tbilisi, Georgia,
\nOctober 2019
\nThe WMA reaffirms the Declaration of Seoul on professional autono-
\nmy and clinical independence of physicians.
\nThe medical profession must play a central role in regulating the
\nconduct and professional activities of its members, ensuring that
\ntheir professional practice is in the best interests of citizens.
\nThe regulation of the medical profession plays an essential role in
\nensuring and maintaining public confidence in the standards of care
\nand of behaviour that they can expect from medical professionals.
\nThat regulation requires very strong independent professional in-
\nvolvement.
\nPhysicians aspire to the development or maintenance of systems
\nof regulation that will best protect the highest possible stan-
\ndards of care for all patients. Professionally led models can pro-
\nvide an environment that enhances and assures the individual
\nphysician\u2019s right to treat patients without interference, based on
\nhis or her best clinical judgment. Therefore, the WMA urges its
\nconstituent members and all physicians to work with regulatory
\nbodies and take appropriate actions to ensure effective systems
\nare in place. These actions should be informed by the following
\nprinciples:
\n1.\t Physicians are accorded a high degree of professional autono-
\nmy and clinical independence, whereby they are able to make
\nrecommendations based on their knowledge and experience,
\nclinical evidence and their holistic understanding of the patient
\nincluding his\/her best interests without undue or inappropriate
\noutside influence. This is expounded in more detail in the Dec-
\nlaration of Seoul.
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\nGeneral Assembly Report
\n2.\t The regulation of the profession must be proportionate and
\nfacilitative and not be burdensome, and be based on a model
\nthat applies to every physician equally and that protects and
\nbenefits patients and is based upon an ethical code. The plan-
\nning and delivery of all types of health care is based upon an
\nethical model and current evidence-based medical knowledge
\nby which all physicians are governed. This is a core element of
\nprofessionalism and protects patients. Physicians are best quali-
\nfied to judge the actions of their peers against such normative
\nstandards, bearing in mind relevant local circumstances.
\n3.\t The medical profession has a continuing responsibility to be
\nstrongly involved in regulation or self-regulating. Ultimate con-
\ntrol and decision-making authority must include physicians,
\nbased on their specific medical training, knowledge, experience
\nand expertise. In countries where Professionally led regulation is
\nin place physicians must ensure that this retains the confidence
\nof the public. In countries that have a mixed regulation system
\nphysicians must seek to ensure that it maintains professional
\nand public confidence.
\n4.\t Physicians in each country are urged to consider establishing,
\nmaintaining and actively participating in a proportionate, fair,
\nrigorous and transparent system of professionally-led regulation.
\nSuch systems are intended to balance physicians\u2019 rights to exer-
\ncise medical judgment freely with the obligation to do so wisely
\nand temperately.
\n5.\t National Medical Associations must do their utmost to promote
\nand support the concept of well-informed and effective regula-
\ntion amongst their membership and the public. To ensure that
\nany potential conflicts of interest between their representative
\nand regulatory roles are avoided they must ensure separation of
\nthe two processes and pay rigorous attention to a transparent
\nand fair system of regulation that will assure the public of its
\nindependence and fairness.
\n6.\t Any system of professionally-led regulation must enhance and
\nensure:
\n–
\n– the delivery of high quality safe and competent healthcare to
\npatients,
\n–
\n– the competence of the physician providing that care
\n–
\n– the professional, including ethical, conduct of all physicians
\n–
\n– the protection of society and the rights of patients
\n–
\n– the promotion of trust and confidence of patients,their families
\nand the public
\n–
\n– the quality assurance of the regulation system
\n–
\n– the maintenance of trust by patients and society
\n–
\n– the development of solutions to potential conflicts of interest
\n–
\n– a commitment to wide professional responsibilities
\n7.\t To ensure that the patient is offered quality continuing care,
\nphysicians should participate actively in the process of Continu-
\ning Professional Development, including reflective practice, in
\norder to update and maintain their clinical knowledge,skills and
\ncompetence. Employers and management have a responsibility
\nto enable physicians to meet this requirement.
\n8.\t The professional conduct of physicians must always be within
\nthe bounds of the Code of Ethics governing physicians in each
\ncountry. National Medical Associations must promote profes-
\nsional and ethical conduct among physicians for the benefit of
\npatients,and ethical violations must be promptly recognized, re-
\nported to the relevant regulatory authority and acted upon.Phy-
\nsicians are obligated to intervene in a timely manner to ensure
\nthat impaired colleagues do not put patients or colleagues at risk
\nand receive appropriate assistance from a physician health pro-
\ngram or appropriate training enabling a return to active practice.
\n9.\t The regulatory body should, when the judicial or quasi-judicial
\nprocesses are complete,and assuming that a case is found against
\nthe physician, publish their findings and include details of the
\nremedial action taken. Lessons learned from every case should,
\nto the extent possible,be extracted and used in professional edu-
\ncation processes. The regulation process should ensure that the
\nincorporation of such lessons is, as far as possible, seamless.
\n10.\tNational Medical Associations are urged to assist each other in
\ncoping with new and developing challenges including potential
\nthreats to professionally-led regulation. The ongoing exchange
\nof information and experiences between National Medical As-
\nsociations is essential for the benefit of patients.
\n11.\tWhatever judicial or regulatory process a country has estab-
\nlished, any judgment on a physician\u2019s professional conduct or
\nperformance must incorporate evaluation by the physician\u2019s pro-
\nfessional peers who,by their training,knowledge and experience,
\nunderstand the complexity of the medical issues involved.
\n12.\tAn effective and responsible system of professionally-led regu-
\nlation must not be self-serving or internally protective of the
\nprofession. National Medical Associations should assist their
\nmembers in understanding that professionally-led regulation, in
\ncountries where that system exists,must maintain the safety,sup-
\nport and confidence of the general public,including their health-
\nrelated rights, as well as the honour of the profession itself.
\nWMA Declaration on the
\nRelation of Law and Ethics
\nAdopted by the 164th
\nWMA Council Session,Divonne-les-Bains,France,
\nMay 2003 and adopted as a Declaration by the 70th WMA General As-
\nsembly, Tbilisi, Georgia, October 2019
\nEthical Values and legal principles are usually closely related, but
\nethical obligations typically exceed legal duties. In some cases, the
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\nGeneral Assembly Report
\nlaw mandates unethical conduct.The fact that a physician has com-
\nplied with the law does not necessarily mean that the physician
\nacted ethically.
\nWhen law is in conflict with medical ethics, physicians should work
\nto change the law. In circumstances of such conflict, ethical respon-
\nsibilities supersede legal obligations.
\nWMA Declaration of Reykjavik\u00a0\u2013
\nEthical Considerations Regarding
\nthe Use of Genetics in Health Care
\nAdopted by the 56th
\nWMA General Assembly, Santiago, Chile, October
\n2005, Revised by the 60th
\nWMA General Assembly, New Delhi, India,
\nOctober 2009 and by the 70th
\nWMA General Assembly,Tbilisi, Georgia,
\nOctober 2019
\nPreamble
\nGenetics contributes to the growing understanding of the causes,
\ndevelopments, classifications and treatments of diseases. The use
\nof genetics is increasing, moving from the identification of mono-
\ngenic diseases and use in cancer treatment towards predicting risks
\nof multifactorial diseases and manipulation of individual genes. In
\nthese ways,the use of genetics does and increasingly will create great
\nvalue at an individual as well as at a societal level. However, the use
\nof genetic information about individuals also raises issues concern-
\ning confidentiality, privacy and the risk of psychological distress,
\nstigmatization, and discrimination.
\nThis declaration provides recommendations for the use of medical
\ngenetics that respects the ethical challenges that such use entails. It
\nis primarily aimed at the use of genetics in the provision of health
\ncare.The collection,storage and use of genetic data beyond the indi-
\nvidual care of patients should adhere to the principles put forward in
\nthe WMA Declaration of Taipei on Ethical Considerations regard-
\ning Health Databases and Biobanks.The use of genetics in medical
\nresearch involving human subjects, including research on identifi-
\nable human material and data, should adhere to the principles put
\nforward in the WMA Declaration of Helsinki Ethical Principles
\nfor Medical Research Involving Human Subjects.
\nThis Declaration should be read as a whole and each of its constitu-
\nent paragraphs should be applied with consideration of all other rel-
\nevant paragraphs. The declaration should be updated in accordance
\nwith developments in the field of genetics.
\nGenetic information has characteristics that are ethically significant.
\nIndividually, these characteristics can also be found in other types of
\nhealth care information. However, the combination of these charac-
\nteristics makes genetic information particularly sensitive. This sensi-
\ntivity \u2013 combined with the intense interest in genetic information
\nfrom many different stakeholders \u2013 underscores the importance of
\nrespecting the fundamental principles of medical ethics, particularly
\nthe patient\u2019s right to autonomy, confidentiality, privacy and benefit in
\nrelation to generating, storing, using or sharing genetic information.
\nCentral among the ethically significant characteristics are:
\n\u2022\t Genetic information is identifying for an individual.
\n\u2022\t Genetic analysis can generate extensive and detailed information
\nabout an
\n\u2022\t Genetic analysis may generate additional findings.
\n\u2022\t The full significance of the information generated by genetic
\nanalysis is not yet known.
\n\u2022\t Genetic information about an individual cannot be fully anony-
\nmized, and de-identified genetic information may be re-identi-
\nfied.
\n\u2022\t Genetic data contains information not only about the individual
\nwho has undergone testing, but also about individuals who are
\ngenetically related to the tested individual.
\n\u2022\t Genetic testing of one individual may entail that the phycisian
\nasks for access to health care information about \u2013 or genetic test-
\ning of \u2013 genetically related persons (family members).
\nEthical principles
\n1. Benefit
\nGenetic testing in the context of healthcare provision should pri-
\nmarily be done for the benefit of the patient being tested.
\n2. Relevance
\nGenetics test should not be wider in scope than what is relevant for
\nthe purpose of the test.
\n3. Informed consent
\na.Genetic testing should only be done with the informed consent of
\nthe individual or his\/her legal guardian. Genetic testing for predis-
\nposition to disease should be performed on children only if there are
\nclear clinical indications and being aware of the test results would be
\nin the best interests of the child.
\nb. The consent process must include providing the patient with un-
\nderstandable, accurate and adequate information about the follow-
\ning:
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\nGeneral Assembly Report
\n\u2022\t The purpose, nature and benefits of the test.
\n\u2022\t The risks, burdens and limitations of the test.
\n\u2022\t The nature and significance of the information to be generated
\nby the test.
\n\u2022\t The procedures for return of results including additional findings
\nand future discoveries.
\n\u2022\t The options for responding to the results, including possible
\ntreatments.
\n\u2022\t How, where, and for how long the test results, data and biological
\nsamples will be stored, and who can gain access to current and
\nfuture results.
\n\u2022\t The possible secondary uses of the information generated by the
\ntest
\n\u2022\t The measures protecting confidentiality, privacy and autonomy,
\nincluding data security measures
\n\u2022\t The procedures for managing results that have implications for
\ngenetically related persons
\n\u2022\t When applicable,commercial use and benefit sharing,intellectual
\nproperty issues and the transfer of data or material to third par-
\nties.
\n4. Additional findings (secondary and incidental findings)
\na. A genetic test may generate additional findings that are not related
\nto the primary purpose of the test, also referred to as secondary or
\nincidental findings. Procedures for handling such findings should be
\ndetermined before the test, and information about these procedures
\nshould be communicated to the patient as part of the consent process.
\nb. The principles for managing additional findings must include
\nconsideration for:
\n\u2022\t The patient\u2019s preferences regarding the management of additional
\nfindings.
\n\u2022\t The significance of the additional findings for the patient\u2019s health
\nand other interests.
\n\u2022\t The significance of the findings for the health and other interests
\nof persons who are genetically related to the patient.
\n\u2022\t The scientific validity of the additional findings.
\n\u2022\t The strengths of the evidence for the correlation between the ad-
\nditional findings and health related risks for the patient.
\n\u2022\t The degree to which the additional findings are actionable, medi-
\ncally or otherwise.
\n5. Genetic counselling
\na. Appropriate genetic counselling should always be offered when
\ngenetic tests or genetics-based treatments are offered or performed
\nand for the interpretation of results. Counselling should enable the
\npatient to make informed decisions according to their own values
\nand interests. Counselling must not be biased by the personal values
\nof the counsellor. The individual\u2019s right not to be tested should be
\nprotected, and if the individual has been tested, there should be no
\nobligation for the individual to act on the results of the test.
\nb. Medical students and physicians should receive education and
\ntraining in genetic counselling, particularly counselling related to
\npre-symptomatic diagnosis of disease.
\n6. Confidentiality
\nLike all medical records, information from genetic testing or ge-
\nnetic therapy must be kept strictly confidential and must not be
\nrevealed to third parties in identifiable form without the consent of
\nthe individual tested. Third parties, to whom results may in certain
\ncircumstances be released, are identified in paragraph 15.
\n7. Informing third parties
\nIn the case of a test result that may have implications for third par-
\nties such as close relatives, the individual tested should be encour-
\naged to discuss the results of the test with such third parties.In cases
\nwhere not disclosing the results involves an expected harm that is
\nserious and unavoidable except by disclosure, and clearly greater
\nthan the harm likely to result from disclosure, the physician may re-
\nveal necessary information to such third parties without the consent
\nof the patient but should usually discuss this with the patient first.
\nIf the physician has access to an ethics committee, it is preferable
\nto consult such a committee prior to revealing information to third
\nparties.
\n8. Data protection
\nThe collection, storage and use of genetic data requires the highest
\nlevel of data protection.
\n9. Discrimination
\nNo individual or group must be discriminated against in any way
\nbased on genetic makeup, including the fields of human rights,
\nemployment and insurance. This protection should apply to those
\nindividuals who have undergone genetic testing or genetic therapy
\nas well as those individuals about whom genetic information can
\nbe inferred. Particular care should be taken to protect vulnerable
\nindividuals and groups.
\n10. Cost of testing
\nThe decision to include genetic analysis as part of medical care can
\nintroduce significant cost for the patient and the health care system.
\nTherefore, such a decision should always be based on the expecta-
\ntion that the costs of the analysis are justified by the benefits for the
\npatient.
\n11. Reliability and limitations
\na. The identification of disease-related genes has led to an increase
\nin the number of available genetic tests, analyses and treatments.
\nAs the number, types and complexity of these increase, great care
\nmust be taken to ensure their reliability, accuracy and quality and to
\ninform patients about their limitations.
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\nGeneral Assembly Report
\nb.The benefit of a genetic test for an individual may depend on the
\navailability of information about the relevant background popula-
\ntion. Medical professionals should be aware of the scope and the
\nlimitations of genetic background data and health information
\nstored in databases used in providing clinical genetic testing ser-
\nvices.
\n12. Direct-to-consumer tests
\nIf genetic tests are offered directly to consumers for medical pur-
\nposes, they must meet the same technical, professional, legal and
\nethical standards as tests offered by certified laboratories and must
\nbe in accordance with the recommendations put forward in this
\nstatement. In particular, providers of direct-to-consumer tests must
\nprovide understandable, accurate and adequate information about
\nthe reliability and limitations of their services.
\n13. Clinical use of data from research
\nFor research projects that involve genetic testing,and where the par-
\nticipant can be identified,the research participant must be informed
\nabout the possibility of findings that indicate a serious threat to the
\nhealth of the participant. If there are such findings, the participant
\nshould be offered a referral to genetic counseling and appropriate
\nmedical intervention.
\n14. Gene therapy and editing
\nGene therapy and editing represents a combination of techniques
\nused to manipulate disease related genes. The use of these tech-
\nniques should adhere to the following guidelines:
\n\u2022\t The use of gene therapy and somatic genome editing should con-
\nform to standards of medical ethics and professional responsibility.
\n\u2022\t Patient autonomy should be respected,and informed consent should
\nalways be obtained. This informed consent process should include
\ndisclosure of the risks of gene therapy and editing, including the
\nfact that the patient may have to undergo multiple rounds of gene
\ntherapy, the risk of an immune response, the potential problems
\narising from the use of viral vectors and off-target genome effects.
\n\u2022\t Gene therapy and editing should only be undertaken after a care-
\nful analysis of the risks and benefits involved and an evaluation
\nof the perceived effectiveness of the therapy, as compared to the
\nrisks,side effects,availability and effectiveness of other treatments.
\n\u2022\t Gene editing of germline cells has scientifically unresolved risks
\nand should not be clinically applied. This does not preclude test-
\ning gene editing or other similar research.
\n15. Cloning
\nCloning includes both therapeutic cloning, namely the cloning of
\nindividual stem cells to produce a healthy copy of a diseased tissue
\nor organ for transplant, and reproductive cloning, namely the clon-
\ning of an existing human to produce a genetic duplicate of that hu-
\nman.The WMA opposes reproductive cloning of humans.
\nWMA Statement on Access of
\nWomen and Children to Health
\nCare
\nAdopted by the 49th
\nWMA General Assembly, Hamburg, Germany, No-
\nvember 1997 and revised by the 59th
\nWMA General Assembly, Seoul,
\nKorea, October 2008 and by the 70th
\nWMA General Assembly, Tbilisi,
\nGeorgia, October 2019
\nPreamble
\nFor centuries, women and girls worldwide have suffered from gen-
\nder inequality and an uneven balance of power between men and
\nwomen. Historically based gender bias has led to women and girls
\nbeing restricted in their access to, inter alia, employment, education
\nand health care. Gender inequality may lead to health risks, subop-
\ntimal health behaviors and inferior health outcomes for women and
\ngirls1
\n1.
\nIn addition, in some countries, female doctors and nurses have been
\nprevented from, or face barriers to practicing their profession due to
\nreligious and\/or cultural convictions, or discrimination based on the
\nintersecting grounds of sex and religion\/ethnicity. A lack of gender
\nrepresentation and diversity within the medical profession may lead
\nto female patients and their children not having equitable access to
\nhealth care.
\nGender is a social determinant of health and health problems may
\nmanifest themselves differently in men and women.There is a need
\nto address the differences in health and health care between men
\nand women, including both the biological and socio-cultural di-
\nmensions.
\nDiscrimination against girls and women damages their health ex-
\npectation. For example, the education of girls positively affects their
\nhealth and well-being as adults.Education also improves the chanc-
\nes of their children surviving infancy and contributes to the overall
\nwell-being of their families. Conversely, secondary discrimination
\ndue to social, religious and cultural practices \u2013 which diminishes
\nwomen\u2019s freedom to make decisions for themselves and to access
\nemployment and healthcare opportunities \u2013 has a negative impact
\non health expectation.
\n1\u2002
\nMen et al, \u201cGender as a social determinant of health: Gender analysis of the
\nhealth sector in Cambodia in Cambodia\u201d.World Conference on Social Deter-
\nminants of Health. World Health Organization. October 2011.
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\nGeneral Assembly Report
\nThe WMA has several policies that focus on women and children\u2019s
\nhealth. They include: WMA Resolution on Women\u2019s Rights to Health
\nCare and How That Relates to the Prevention of Mother-to-Child HIV
\nInfection, WMA Resolution on Violence against Women and Girls and
\nWMA Declaration of Ottawa on Child Health.This statement stresses
\nthe importance of equal access to health care and the effects of dis-
\ncrimination against women and children.
\nRecommendations
\nTherefore, the World Medical Association urges its constituent
\nmembers to:
\n\u2022\t Categorically condemn violations of the basic human rights of
\nwomen and children, including violations stemming from social,
\npolitical, religious, economic and cultural practices;
\n\u2022\t Insist on the rights of all women and children to full and adequate
\nmedical care,especially where religious,social and cultural restric-
\ntions or discrimination may hinder access to such medical care;
\n\u2022\t Advocate for parity of health insurance premiums and coverage to
\nensure that women\u2019s access to care is not impeded by prohibitively
\nhigh expenses;
\n\u2022\t Promote the provision of pre-conception, prenatal and maternal
\ncare, and post-natal care including immunization, nutrition for
\nproper growth and health-care development for children;
\n\u2022\t Ensure universal access to sexual and reproductive health;
\n\u2022\t Promote women\u2019s and children\u2019s health as human rights;
\n\u2022\t Advocate for educational, employment and economic opportuni-
\nties for women and for their access to information about health-
\ncare and health services;
\n\u2022\t Work towards the achievement of the human right to equality of
\nopportunity and equality of treatment, regardless of gender.
\nWMA Statement on
\nAntimicrobial Resistance
\nAdopted by the 48th
\nWMA General Assembly, Somerset West, South Afri-
\nca, October 1996 and revised by the 59th
\nWMA General Assembly, Seoul,
\nKorea, October 2008 and by the 70th
\nWMA General Assembly, Tbilisi,
\nGeorgia, October 2019
\nPreamble
\nAMR is a growing threat to global public health that transcends
\nnational boundaries and socioeconomic divisions. AMR affects hu-
\nman, animal and environmental health. It is a multi-faceted prob-
\nlem of crisis proportions with significant economic, health, and hu-
\nman implications.
\nAddressing the threat of antimicrobial resistance is a fundamental
\nglobal health priority, and the responsibility of all countries.
\nAntimicrobial drugs form an essential component of modern medi-
\ncine, ensuring that complex procedures, such as surgery and chemo-
\ntherapy, can be performed with lower risk.
\nAMR threatens the effective prevention and treatment of an in-
\ncreasing range of infections caused by bacteria, parasites, viruses and
\nfungi.
\nAMR occurs when microorganisms develop the ability to resist the
\nactions of antimicrobial drugs (such as antibiotics, antifungals, anti-
\nvirals, antimalarials, and anthelmintics).
\nInfections caused by bacteria that are resistant to multiple classes of
\nantibiotic are increasingly being documented.
\nWhile AMR is a natural evolutionary phenomenon, it is exacer-
\nbated by the overuse and misuse of antimicrobials in medicine, as
\nwell as in veterinary practice and agriculture,and can be exacerbated
\nwhen antimicrobials are given as growth promoters in animals or
\nused to prevent diseases in healthy animals.
\nThe emergence and spread of AMR is further enhanced by lack of
\naccess to effective drugs, access to antibiotics \u201cover the counter\u201d in
\nsome countries, the availability of substandard and falsified prod-
\nucts, misuse of antibiotics in food production, increased global trav-
\nel, medical tourism and trade, and the poor application of infection
\ncontrol measures.
\nAnother major cause of AMR is the release of antibiotics into the
\nenvironment. This can occur as either as a result of poor manufac-
\nturing practices, the improper disposal of unused medication, hu-
\nman and animal excretion, and the inadequate disposal of human
\nand animal corpses.
\nIn many countries, particularly in low-and middle-income coun-
\ntries, access to effective antimicrobials as well as complementary
\ntechnologies including vaccines and diagnostics continues to re-
\nmain a significant challenge, furthering AMR.
\nThe ramifications of resistance manifest themselves not just in the
\nimpact on human health, but also in potentially heavy economic
\ncosts. The World Health Organization (WHO) has warned that
\nresistance has reached alarming levels in many parts of the world,
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\nGeneral Assembly Report
\nand that a continued increase in resistance could lead to 10 million
\npeople dying per year and a reduction of 2-3.5% in global gross
\ndomestic product by 2050.
\nAt the rate at which resistance is growing globally, it poses a sig-
\nnificant threat to successfully achieving the UN Sustainable De-
\nvelopment Goals and undermines efforts to reduce health inequali-
\nties. Without harmonized and coordinated cross-sector action on a
\nglobal, scale, the world is heading towards a post-antibiotic era in
\nwhich common infections and minor injuries can once again kill.
\nAMR has reached great prominence at the highest political levels
\nincluding the UN General Assembly, and the agenda of the G7 and
\nG20.
\nThere is a need for an effective \u2018one health\u2019 approach to minimize
\nunnecessary or inappropriate use of antimicrobials and to prevent
\nand control the transmission of existing resistance. A \u2018one health\u2019
\napproach recognizes that action is required across human medicine,
\nveterinary practice and agriculture.
\nRecommendations
\n1. Global
\na. The primary prevention of community and healthcare associated
\ninfections is necessary to reduce the demand for antibiotics. Ad-
\ndressing the social determinants of infectious disease, such as poor
\nliving conditions and sanitation, will have co-benefits of reducing
\nhealth inequalities and tackling AMR.
\nb. Nations have varying resources available to combat antimicrobial
\nresistance, and must cooperate with the WHO, Food and Agricul-
\nture Organization and World Organization for Animal Health that
\nsupport the WHO Global Action Plan on AMR which provides
\nthe framework for national action plans.
\nc. The World Medical Association and its constituent members
\nshould advocate for:
\n\u2022\t investment in the surveillance of drug resistant infections across
\nhuman health, veterinary medicine, agriculture, fishing industry,
\nand food production, and international cooperation for data-
\nsharing procedures to improve global responses;
\n\u2022\t the WHO and other UN agencies should examine the role of
\ninternational travel and trade agreements on the development of
\nantimicrobial resistance, and promote measures in those agree-
\nments to act as safeguards against the globalisation of drug resis-
\ntant pathogens in our food supply;
\n\u2022\t the WHO should continue to encourage the use of Trade Related
\nAspects of Intellectual Property Rights (TRIPS) flexibilities to
\nhelp ensure affordable access to quality medicines and oppose the
\nproliferation of \u2018TRIPS-plus\u2019provisions within trade agreements,
\nwhich restrict the use of TRIPS flexibilities and limit their ef-
\nfectiveness;
\n\u2022\t the widespread application of verifiable technology such as track-
\nand-trace systems to ensure the authenticity of pharmaceutical
\nproducts;
\n\u2022\t equitable access to, and appropriate use of, existing and new
\nquality-assured antimicrobial medicines. This requires effectively
\napplying the Access, Watch and Reserve lists of the WHO Es-
\nsential Medicines program. For the WHO global action plan and
\nnational action plans to be effective, access to health facilities,
\nhealth care professionals, veterinarians, knowledge, education and
\ninformation are vital;
\n\u2022\t greater use of vaccinations which will reduce the burden of in-
\nfectious disease, reducing the need for antibiotics and therefore
\nlimiting the emergence of resistance;
\n\u2022\t for global health organisations and governments to scale up their
\naction and coordination in promoting appropriate antibiotic use
\nand work together to reduce AMR using a One Health approach,
\nwhich recognises that human,animal and environmental health is
\ninextricably linked. to reduce the spread of resistance.
\nd. The World Medical Association and its constituent members
\nshould encourage their governments to:
\n\u2022\t fund more basic and applied research directed toward the devel-
\nopment of innovative antimicrobial agents, diagnostic tools and
\nvaccines (innovative antimicrobial vaccines), and on the appropri-
\nate and safe use of such therapeutic tools;
\n\u2022\t ensure parity between financial and technical resources towards
\nthe development of innovative antimicrobial medicines, vaccines,
\nand diagnostics as well as innovative infection control and pre-
\nvention methods across human health, veterinary, and agricultural
\nsectors;
\n\u2022\t support Research and Development efforts for novel antimi-
\ncrobial agents, vaccines, and rapid diagnostic methods that are
\nneeds-driven and guided by the principles outlined in the UN
\nDeclaration on AMR, adopted in September 2016, including af-
\nfordability, effectiveness, efficiency, and equity [1];
\n\u2022\t initiate regulatory measures to control the environmental pollu-
\ntion that allows the spread of antibiotic- resistant genes across
\nsoil, water and air;
\n\u2022\t educate a sufficient number of clinical infectious disease special-
\nists in every country, which is a fundamental requirement for
\ntackling antimicrobial resistance and hospital-acquired infections.
\n2. National
\na. National medical associations should urge their governments to:
\n\u2022\t require that antimicrobial agents be available only through a pre-
\nscription provided by healthcare professionals and\/or veterinary
\nprofessionals and dispersed or sold by professionals;
\n\u2022\t to initiate national campaigns to raise awareness among the public
\nof the harmful consequences of overuse and misuse of antibiotics.
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\nGeneral Assembly Report
\nThis should be supported through the introduction of national
\ntargets to raise public awareness;
\n\u2022\t to support professional societies, civil society, and healthcare de-
\nlivery systems to pilot and adopt proven behaviour change strate-
\ngies to ensure appropriate use of antibiotics;
\n\u2022\t to ensure access to appropriate and fit-for-purpose point-of-care
\ndiagnostics in hospitals and clinics to support decision making
\nand prevent inappropriate prescribing of antibiotic;
\n\u2022\t to mandate the collection of data on antibiotic use, prescriptions,
\nprices, resistance patterns, and trade in both the healthcare and
\nagricultural sectors.This data should be made publicly accessible;
\n\u2022\t promote effective programs of antimicrobial stewardship and
\ntraining on the appropriate use of antimicrobials agents, and in-
\nfection control;
\n\u2022\t actively pursue the development of a national surveillance system
\nfor the provision of antimicrobials and for antimicrobial resis-
\ntance.Data from this system should be linked with or contributed
\nto the WHO\u2019s global surveillance network;
\n\u2022\t monitoring of antimicrobial use in food producing animals must
\nbe sufficiently granular to ensure accountability.
\nb. National medical associations should:
\n\u2022\t encourage medical schools and continuing medical education
\nprograms to renew their efforts to educate physicians, who can in
\nturn inform their patients, about the appropriate use of antimi-
\ncrobial agents and appropriate infection control practices, includ-
\ning antibiotic use in the outpatient setting;
\n\u2022\t support the education of their members in areas of AMR, includ-
\ning antimicrobial stewardship, rational use of antimicrobials, and
\ninfection control measures including hand hygiene;
\n\u2022\t advocate for the publishing and communication of local informa-
\ntion relating to resistance patterns, clinical guidelines and recom-
\nmended treatment options for physicians;
\n\u2022\t in collaboration with veterinary authorities, encourage their gov-
\nernments to introduce regulations to reduce the use of antimi-
\ncrobials in agriculture, in particular food producing animals, in-
\ncluding restrictions on the routine use of antimicrobials for both
\nprophylaxis and growth promotion, and on the use of classes of
\nantimicrobial that are critically important in human medicine;
\n\u2022\t support regulation that prevents conflicts of interest among vet-
\nerinarians, such as roles where veterinarians both prescribe and
\nsell antibiotics;
\n\u2022\t consider the use of social media to educate and promote the prop-
\ner use and disposal of antibiotic medications;
\n\u2022\t encourage parents to comply with the national recommended immu-
\nnization schedules for children.Adults should also have easy access to
\nvaccines against influenza and pneumococcal infections among others.
\n3. Local
\na. Health professionals and health systems have a vital role in pre-
\nserving antimicrobial medicines.
\nb. Physicians should:
\n\u2022\t have access to high-quality and reliable, evidence-based informa-
\ntion free of conflict of interest and actively participate in and lead
\nantimicrobial stewardship programs in their hospitals, clinics and
\ncommunities to optimise antibiotic use;
\n\u2022\t raise awareness amongst their patients about antimicrobial ther-
\napy, its risks and benefits, the importance of adherence with the
\nprescribed regimen, infection prevention practices, and the prob-
\nlem of AMR;
\n\u2022\t promote and ensure adherence hygiene measures (especially hand
\nhygiene) and other infection prevention practices.
\nWMA Statement on Augmented
\nIntelligence in Medical Care
\nAdopted by the 70th
\nWMA General Assembly, Tbilisi, Georgia, October
\n2019
\nPreamble
\nArtificial Intelligence (AI) is the ability of a machine to simulate in-
\ntelligent behavior,a quality that enables an entity to function appro-
\npriately and with foresight in its environment. The term AI covers
\na range of methods, techniques and systems. Common examples of
\nAI systems include, but are not limited to, natural language process-
\ning (NLP), computer vision and machine learning. In health care,
\nas in other sectors, AI solutions may include a combination of these
\nsystems and methods.
\n(Note: A glossary of terms appears as an appendix to this statement.)
\nIn health care, a more appropriate term is \u201caugmented intelligence\u201d,
\nan alternative conceptualization that more accurately reflects the
\npurpose of such systems because they are intended to coexist with
\nhuman decision-making [1]. Therefore, in the remainder of this
\nstatement, AI refers to augmented intelligence.
\nAn AI system utilizing machine learning employs an algorithm
\nprogrammed to learn (\u201clearner algorithm\u201d) from data referred to as
\n\u201ctraining data.\u201dThe learner algorithm will then automatically adjust
\nthe machine learning model based on the training data. A \u201ccontinu-
\nous learning system\u201d updates the model without human oversight
\nas new data is presented, whereas \u201clocked learners\u201d will not auto-
\nmatically update the model with new data. In health care, it is im-
\nportant to know whether the learner algorithm is eventually locked
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\nGeneral Assembly Report
\nor whether the learner algorithm continues to learn once deployed
\ninto clinical practice in order to assess the systems for quality, safety,
\nand bias. Being able to trace the source of training data is critical
\nto understanding the risk associated with applying a health care AI
\nsystem to individuals whose personal characteristics are significantly
\ndifferent than those in the training data set.
\nHealth care AI generally describes methods, tools and solutions
\nwhose applications are focused on health care settings and patient
\ncare. In addition to clinical applications, there are many other appli-
\ncations of AI systems in health care including business operations,
\nresearch, health care administration, and population health.
\nThe concepts of AI and machine learning have quickly become at-
\ntractive to health care organizations, but there is often no clear defi-
\nnition of terminology used.Many see AI as a technological panacea;
\nhowever,realizing the promise of AI may have its challenges,since it
\nmight be hampered by evolving regulatory oversight to ensure safety
\nand clinical efficacy, lack of widely accepted standards, liability is-
\nsues, need for clear laws and regulations governing data uses, and a
\nlack of shared understanding of terminology and definitions.
\nSome of the most promising uses for health care AI systems include
\npredictive analytics, precision medicine, diagnostic imaging of dis-
\neases, and clinical decision support. Development in these areas is
\nunderway, and investments in AI have grown over the past several
\nyears [2]. Currently, health care AI systems have started to provide
\nvalue in the realm of pattern recognition, NLP, and deep learning.
\nMachine learning systems are designed to identify data errors with-
\nout perpetuating them. However, health care AI systems do not re-
\nplace the need for the patient-physician relationship. Such systems
\naugment physician-provided medical care and do not replace it.
\nHealth care AI systems must be, transparent, reproducible, and be
\ntrusted by both health care providers and patients. Systems must
\nfocus on users\u2019 needs. Usability should be tested by participants
\nwho reflect similar needs and practice patterns of the end user, and
\nsystems must work effectively with people. Physicians will be more
\nlikely to accept AI systems that can be integrated into or improve
\ntheir existing practice patterns, and also improve patient care.
\nOpportunities
\nHealth care AI can offer a transformative set of tools to physicians
\nand patients and has the potential to make health care safer and more
\nefficient. By automating hospital and office processes, physician pro-
\nductivity would improve.The use of data mining to produce accurate
\nuseful data at the right time may improve electronic health records.
\nand access to relevant patient information.Results of data mining may
\nalso provide evidence for trends that may serve to inform resource al-
\nlocation and utilization decisions. New insights into diagnosis and
\nbest practices for treatment may be produced because of analyzing all
\nknown data about a patient. The potential also exists to improve the
\npatient experience, patient safety, and treatment adherence.
\nApplications of health care AI to medical education include con-
\ntinuing medical education, training simulations, learning assistance,
\ncoaching for medical students and residents,and may provide objec-
\ntive assessment tools to evaluate competencies. These applications
\nwould help customize the medical education experience and facili-
\ntate independent individual or group learning.
\nThere are a number of stakeholders and policy makers involved in
\nshaping the evolution of AI in health care besides physicians.These
\ninclude medical associations, businesses, governments, and those in
\nthe technology industry. Physicians have an unprecedented oppor-
\ntunity to positively inform and influence the discussions and debates
\ncurrently taking place around AI. Physicians should proactively en-
\ngage in these conversations in order to ensure that their perspectives
\nare heard and incorporated into this rapidly developing technology.
\nChallenges
\nDevelopers and regulators of health care AI systems must ensure
\nproper disclosure and note the benefits, limitations, and scope of
\nappropriate use of such systems. In turn, physicians will need to
\nunderstand AI methods and systems in order to rely upon clinical
\nrecommendations. Instruction in the opportunities and limitations
\nof health care AI systems must take place both with medical stu-
\ndents and practicing physicians, as physician involvement is critical
\nto successful evolution of the field. AI systems must always adhere
\nto professional values and ethics of the medical profession.
\nProtecting confidentiality,control and ownership of patient data is a
\ncentral tenet of the patient-physician relationship. Anonymization
\nof data does not provide enough protection to a patient\u2019s informa-
\ntion when machine-learning algorithms can identify an individual
\nfrom among large complex data sets when provided with as few as
\nthree data points, which could put patient data privacy at risk. Cur-
\nrent expectations patients have for confidentiality of their personal
\ninformation must be addressed, and new models that include con-
\nsent and data stewardship developed. Viable technical solutions to
\nmitigate these risks are being explored and will be critical to wide-
\nspread adoption of health care AI systems.
\nData structure, and integrity are major challenges that need to be
\naddressed when designing health care AI systems. The data sets on
\nwhich machine learning systems are trained are created by humans
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\nGeneral Assembly Report
\nand may reflect bias and contain errors. Because of this, these data
\nsets will normalize errors and the biases inherent in their data sets.
\nMinorities may be disadvantaged because there is less data available
\nabout minority populations. Another design consideration is how a
\nmodel will be evaluated for accuracy and involves very careful analy-
\nsis of the training data set and its relationship to the data set used to
\nevaluate the algorithms.
\nLiability concerns present significant challenges to adoption. As ex-
\nisting and new oversight models develop health care AI systems, the
\ndevelopers of such systems will typically have the most knowledge of
\nrisks and be best positioned to mitigate the risk.As a result,develop-
\ners of health care AI systems and those who mandate use of such
\nsystems must be accountable and liable for adverse events resulting
\nfrom malfunction(s) or inaccuracy in output. Physicians are often
\nfrustrated with the usability of electronic health records.Systems de-
\nsigned to support team-based care and other workflow patterns but
\noften fall short. In addition to human factors in the design and de-
\nvelopment of health care AI systems, significant consideration must
\nbe given to appropriate system deployment. Not every system can be
\ndeployed to every setting due to data source variations.
\nWork is already underway to advance governance and oversight of
\nhealth care AI, including standards for medical care, intellectual
\nproperty rights, certification procedures or government regulation,
\nand ethical and legal considerations.
\nRecommendations
\n1.That the WMA:
\n–
\n– Recognize the potential for improving patient outcomes and
\nphysicians\u2019 professional satisfaction through the use of health
\ncare AI, provided they conform to the principles of medical
\nethics, confidentiality of patient data, and non-discrimination.
\n–
\n– Support the process of setting priorities for health care AI.
\n–
\n– Encourage the review of medical curricula and educational op-
\nportunities for patients, physicians, medical students, health
\nadministrators and other health care professionals to promote
\ngreater understanding of the many aspects, both positive and
\nnegative, of health care AI.
\n2.The WMA urges its member organizations to:
\n–
\n– Find opportunities to bring the practicing physician\u2019s perspec-
\ntive to the development, design, validation and implementation
\nof health care AI.
\n–
\n– Advocate for direct physician involvement in the development
\nand management of health care AI and appropriate govern-
\nment and professional oversight for safe, effective, equitable,
\nethical, and accessible AI products and services.
\n–
\n– Advocate that all healthcare AI systems be transparent, repro-
\nducible,and be trusted by both health care providers and patients.
\n–
\n– Advocate for the primacy of the patient-physician relationship
\nwhen developing and implementing health care AI systems.
\nAppendix
\nGlossary of Terms Used in Health
\nCare Augmented Intelligence
\nAlgorithm is a set of detailed,ordered instructions that are followed
\nby a computer to solve a mathematical problem or to complete a
\ncomputer process.
\nArtificial intelligence consists of a host of computational methods
\nused to produce systems that perform tasks which exhibit intelligent
\nbehavior that is indistinguishable from human behavior.
\nAugmented intelligence (AI) is a conceptualization of artificial intel-
\nligence that focuses on artificial intelligence\u2019s assistive role, emphasiz-
\ning that its design enhances human intelligence rather than replaces it.
\nComputer vision is an interdisciplinary scientific field that deals
\nwith how computers can be made to gain high-level understanding
\nfrom digital images or videos and seeks to automate tasks that the
\nhuman visual system can do.
\nData mining is an interdisciplinary subfield of computer science
\nand statistics whose overall goal is to extract information (with in-
\ntelligent methods) from a data set and transform the information
\ninto a comprehensible structure for further use.
\nMachine learning (ML) is the scientific study of algorithms and sta-
\ntistical models that computer systems use to effectively perform spe-
\ncific tasks with minimal human interaction and without using explicit
\ninstructions, by learning from data and identification of patterns.
\nNatural language processing (NLP) is a subfield of computer sci-
\nence, information engineering, and artificial intelligence concerned
\nwith the interactions between computers and human (natural) lan-
\nguages, in particular how to program computers to process and ana-
\nlyze large amounts of natural language data.
\nTraining data is used to train an algorithm; it generally consists of a
\ncertain percentage of an overall dataset along with a testing set. As a
\nrule, the better the training data, the better the algorithm performs.
\nOnce an algorithm is trained on a training set, it\u2019s usually evaluated
\non a test set. The training set should be labelled or enriched to in-
\ncrease an algorithm\u2019s confidence and accuracy.
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\nGeneral Assembly Report
\nReferences:
\n1.\t For purposes of this statement, the term \u201chealth care AI\u201dwill be used to refer
\nto systems that augment, not replace, the work of clinicians.
\n2.\t CB Insights. The Race for AI: Google, Baidu, Intel, Apple in a Rush to Grab Ar-
\ntificial Intelligence Startups. https:\/\/www.cbinsights.com\/research\/top-acquirers-
\nai-startups-ma-timeline\/.
\nWMA Statement on Free
\nSugar Consumption and Sugar-
\nSweetened Beverages
\nAdopted by the 70th
\nWMA General Assembly, Tbilisi, Georgia, October
\n2019
\nPreamble
\nNon-communicable diseases (NCDs) are the leading causes of
\ndeath worldwide. Every year 40 million people die from NCDs\u00a0[1].
\nThe most common causes of these diseases are poorly balanced diet
\nand physical inactivity. A high level of free sugar consumption has
\nbeen associated with NCDs because of its association with obesity
\nand poor dietary quality.
\nAccording to the World Health Organization (WHO), free sugar
\nis sugar that is added to foods and beverages by the manufacturer,
\ncook or consumer that results in excess energy intake which in turn
\nmay lead to parallel changes in body weight.
\nWHO defines free sugar as \u2018all sugars that are added during food
\nmanufacturing and preparation as well as sugars that are naturally
\npresent in honey, syrups, fruit juices, and fruit concentrates.\u2019
\nSugar has become widely available and its global consumption has
\ngrown from about 130 to 178 million tonnes over the last decade.
\nExcess free sugar intake,particularly in the form of sugar-sweetened
\nbeverages, threatens the nutrient quality of the diet by contribut-
\ning to the overall energy density but without adding specific nutri-
\nents. This can lead to unhealthy weight gain and increases the risk
\nof dental disease, obesity and NCDs. Sugar-sweetened beverages
\nare defined as all types of beverages containing free sugars (include
\nmonosaccharides and disaccharide) including soft drinks, fruit\/veg-
\netables juices and drinks, liquid and powder concentrates, flavored
\nwater, energy and sports drinks, ready-to-drink tea, ready-to-drink
\ncoffee and flavored milk drinks.
\nThe World Health Organization recommends reducing sugar in-
\ntake to a level that comprises 5% of total energy intake (that is
\naround 6 teaspoons per day) and not to exceed 10% of total energy
\nintake\u00a0[2].
\nThe price elasticity of sugar-sweetened beverages according to a
\nmeta-analysis published in USA, is \u20131.21. This means that for each
\n10% increase in the price of sugar-sweetened beverages, there is a
\n\u201312.1% decrease in consumption. Successful examples of price elas-
\nticity were seen in Mexico as the consumption of sugar-sweetened
\nbeverages decreased after imposing the sugar tax.
\nData and experience from across the world demonstrate that a tax
\non sugar works best as part of a comprehensive set of interventions
\nto address obesity and related chronic diseases. Such interventions
\ninclude food advertising regulations, food labelling, educational
\ncampaigns, and subsidy on healthy foods.
\nRecommendations
\n3.\t The World Medical Association (WMA) and its constituent
\nmembers should:
\n–
\n– call upon the national governments to reduce the affordabil-
\nity of free sugar and sugar-sweetened beverages through sugar
\ntaxation. The tax revenue collected should be used for health
\npromotion and public health preventive programs aimed at re-
\nducing obesity and NCDs in their countries;
\n–
\n– encourage food manufacturers to clearly label sugar, if present,
\nin their products and urge governments to mandate such label-
\ning;
\n–
\n– urge governments to strictly regulate the advertising of sugar
\ncontaining food and beverages targeted especially at children;
\n–
\n– urge national governments to restrict availability of sugar-
\nsweetened beverages and products that are highly concentrated
\nwith free sugar from educational and healthcare institutions
\nand replace with healthier alternatives.
\n4.\t Constituent members of the WMA and their physician mem-
\nbers should work with national stakeholders to:
\n–
\n– advocate for healthy sustainable food with limited free sugar
\nintake that is less than 5% of total energy intake;
\n–
\n– encourage nutrition education and skills programs toward pre-
\nparing healthy meals from foods without added sugar;
\n–
\n– initiate and\/or support campaigns focused on healthy diets to
\nreduce sugars intake;
\n–
\n– advocate for an inter-sectoral, multidisciplinary and compre-
\nhensive approach to reducing free sugar intake.
\nReferences
\n1.\t http:\/\/www.who.int\/fr\/news-room\/fact-sheets\/detail\/noncommunicable-diseases
\n2.\t WHO Guideline: Sugars Intake for Adults and Children 2015
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\n35
\nGeneral Assembly Report
\nWMA Statement on Healthcare
\nInformation for All
\nAdopted by the 70th
\nWMA General Assembly, Tbilisi, Georgia, October
\n2019
\nPreamble
\nThe WHO constitution states that \u201cthe extension to all people of
\nthe benefits of medical, psychological and related knowledge is es-
\nsential to the fullest attainment of health\u201d. Access to relevant, reli-
\nable, unbiased, up-to-date and evidence-based healthcare informa-
\ntion is crucial for the public, patients and health personnel for every
\naspect of health, including (but not limited to) health education,
\ninformed choice, professional development, safety and efficacy of
\nhealth services, and public health policy.
\nLack of access to healthcare information is a major contributor
\nto morbidity and mortality, especially in low- and middle-income
\ncountries, and among vulnerable groups in all countries.
\nHealthcare information is only useful if it is relevant, appropriate,
\ntimely,updated,understandable and accurate.It covers a broad spec-
\ntrum of issues and refers to diseases, treatments, services, as well as
\nthe promotion and preservation of health.
\nHealth literacy is a key factor in understanding how health services
\nwork and how to use them. Health professionals need access to
\nadequate training and support to communicate with patients with
\nlow health literacy or with those who have difficulty understanding
\nhealthcare information, for example because of a disability.
\nGlobally, thousands of children and adults die needlessly because
\nthey do not receive basic life-saving interventions. Some interven-
\ntions may be available locally but are simply not provided due to
\nindecision, delays, misdiagnosis and incorrect treatment. Failure to
\nprovide basic life-saving interventions more commonly affects those
\nwho are socioeconomically disadvantaged.
\nIn the case of children with acute diarrhea, for example, the wide-
\nspread misconception among parents that they should withhold
\nfluids, and among health workers that they should give antibiotics
\nrather than oral rehydration, contributes to thousands of unneces-
\nsary deaths every day worldwide.
\nGovernments have a moral obligation to ensure that the public,
\npatients and health workers have access to the healthcare informa-
\ntion they need to protect their own health and the health of those
\nfor whom they are responsible. This obligation includes providing
\nadequate education, in form and content, to identify and use such
\ninformation effectively.
\nThe public, patients and healthcare workers need easy, reliable ac-
\ncess to evidence-based, relevant healthcare information as part of
\na learning process throughout the life-course to enhance under-
\nstanding, and to make informed and conscious decisions about
\ntheir health, healthcare options and the health care they receive.
\nThese groups need information in the right language, and in a
\nformat and technical level that is understandable to them, with
\nrelevant services signposted as appropriate. This should take into
\naccount the characteristics, customs and beliefs of the popula-
\ntion to which it is directed, and a feedback process should be
\nestablished. The public, patients and families need information
\nthat is appropriate to their specific context and situation, which
\nmay change over time. They need guidance on when and how to
\nmake important health decisions, which are usually best made
\nwhen there is time to consider, understand and discuss the issue
\nat hand.
\nMeeting the information needs of the public, patients and health-
\ncare providers is a prerequisite for the realisation of quality univer-
\nsal health coverage and the UN Sustainable Development Goals
\n(SDGs).\u201d UN SDG Target 3.8 on universal health coverage spe-
\ncifically aims to deliver \u2018quality essential health-care services and
\naccess to safe, effective, quality and affordable essential medicines
\nand vaccines for all\u2019. Achieving this requires empowerment of the
\npublic and patients, as well as health workers, with the healthcare
\ninformation they need to recognize and assume their rights and re-
\nsponsibilities to access, use and provide appropriate services and to
\nprevent, diagnose and manage disease.
\nThe development and availability of evidence-based,relevant health-
\ncare information depends on the integrity of the global healthcare
\ninformation system. This system comprises researchers, publishers,
\nsystematic reviewers, producers of end-user content (including aca-
\ndemic publishers, health education, journalists and others), infor-
\nmation professionals, policymakers, frontline health professionals
\nand patient representatives, among others.
\nRecommendations
\nRecognizing this, the World Medical Association and its constitu-
\nent members on behalf of their physician members,will support and
\ncommit to the following actions:
\n1.\t Promote initiatives to improve access to timely, current, evi-
\ndence-based healthcare information for health professionals,
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\nGeneral Assembly Report
\npatients and the public to support appropriate decision-making,
\nlifestyle changes, care-seeking behaviour and improved quality
\nof care \u2013 thereby upholding the right to health.
\n2.\t Promote standards of good practice and ethics to be met by in-
\nformation providers, guaranteeing reliable and quality informa-
\ntion that is produced with the participation of physicians, other
\nhealth professionals, and patient representatives.
\n3.\t Support research to identify enablers and barriers to the avail-
\nability of healthcare information, including how to improve the
\nproduction and dissemination of evidence-based information
\nfor the public, patients and health professionals, and measures
\nto increase health literacy and the ability to find and interpret
\nsuch information.
\n4.\t Ensure that health professionals have access to evidence-based
\ninformation on diagnosis and treatment of diseases, including
\nunbiased information on medicines. Particular attention should
\nbe paid to those working in primary care in low- and middle-
\nincome countries.
\n5.\t Combat myths and misinformation around healthcare through
\nvalidated scientific and clinical evidence, and by urging the me-
\ndia to report responsibly on health issues.This includes the study
\nof health-related beliefs stemming from cultural or sociological
\ndifferences.This will improve the effectiveness of health promo-
\ntion activities and allow the dissemination of healthcare infor-
\nmation to be adequately targeted to different segments of the
\npopulation.
\n6.\t Urge governments to recognize their moral obligation to take
\nmeasures to improve the availability and use of evidence-based
\nhealthcare information.This includes:
\n–
\n– resources to select, compile, integrate and channel scientifically
\nvalidated information and knowledge. This should be adapted
\nto target various different recipients;
\n–
\n– measures to increase availability of healthcare information for
\nhealthcare workers and patients at health centres;
\n–
\n– leveraging modern communication technology and social me-
\ndia;
\n–
\n– policies that support efforts to increase the availability and use
\nof reliable healthcare information.
\n7.\t Urge governments to provide the political and financial sup-
\nport needed for \u2018WHO\u2019s function to ensure access to authori-
\ntative and strategic information on matters that affect peoples\u2019
\nhealth\u2019, based on the WHO General Programme of Work
\n2019-23.
\nWMA Statement on Medical Age
\nAssessment of Unaccompanied
\nMinor Asylum Seekers
\nAdopted by the 70th
\nWMA General Assembly, Tbilisi, Georgia, October
\n2019
\nPreamble
\nPopulation displacement resulting from war, violence or persecu-
\ntion has wide-ranging implications for the entire global community.
\nRefugees \u2013 that is, individuals who have been forced to flee their
\nrespective countries of origin for these reasons \u2013 generally must
\nundergo rigorous procedures for determining their legal status ac-
\ncording to the national legislation of the country in which they are
\nseeking asylum.
\nAn increasing number of refugees fall under the category of unac-
\ncompanied minors, which are defined as people under the age of 18
\nwho have been separated from or who have fled their countries of
\norigin without their families. In light of their unique vulnerability,
\nunaccompanied minor refugees are eligible for special protections,
\nas outlined in the United Nations\u2019 Convention on the Rights of the
\nChild, which states that the best interests of the child must be the
\nprimary consideration in all stages of the displacement cycle.
\nGiven the differences in how adults and unaccompanied minors are
\nprocessed and protected when seeking asylum, recipient countries
\nhave an interest in verifying the age of applicants outside the context
\nof criminal proceedings. However, some asylum seekers either do
\nnot have access to documentation confirming their age or originate
\nfrom countries in which there is no central birth registry. In cases
\nwhere there is doubt as to whether an asylum seeker is a child or an
\nadult, e.g. if the authenticity of available documentation is called
\ninto question or if there is reason to believe the applicant\u2019s physical
\nappearance suggests a discrepancy between the reported age and the
\nactual age, the competent authorities may resort to medical and\/or
\nnon-medical methods for assessing the applicant\u2019s age.
\nMedical age assessments carried out by medical professionals may
\ntake the form of X-ray scans of the jaw, hand or wrist; CT scans
\nof the collarbone; MRI scans of the knee; or the examination of
\nsecondary sex characteristics to determine the applicant\u2019s stage of
\npuberty.However,ethical concerns have been raised about these and
\nother forms of examination, as they can potentially endanger the
\nhealth of those being examined and violate the privacy and dig-
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\nGeneral Assembly Report
\nnity of young people who may already be severely traumatized.\u00a0[1]
\nFurthermore, there is conflicting evidence about the accuracy and
\nreliability of the available methods of medical age assessment,which
\nmay generate significant margins of error. [2] For example, some
\navailable studies do not appear to take into account potential delays
\nin skeletal maturation caused by malnutrition, which is just one fac-
\ntor that could translate into a risk of age misclassification among
\nasylum seekers. [3] Comparative assessments are further impeded
\nby a lack of standard images from certain world regions and limited
\nrepresentation in age assessment reference data, much of which was
\ncompiled on the basis of European and North American popula-
\ntions. [4] An imprecise assessment of an individual\u2019s age can have
\nfar-reaching administrative, ethical, psychological and other signifi-
\ncant consequences, including potential breaches of children\u2019s rights.
\nThe following recommendations apply explicitly and exclusively to
\ncases outside the context of the criminal justice system.
\nRecommendations
\n1.\t The WMA recognizes that there is sometimes a need to assess
\nthe age of asylum seekers to ensure that all unaccompanied mi-
\nnors receive the protections afforded them under international
\nand national law.
\n2.\t The WMA recommends that medical age assessments only be
\ncarried out in exceptional cases and only after all non-medical
\nmethods have been exhausted.The WMA recognizes that non-
\nmedical methods, e.g. questioning children about traumatic
\nevents, may also have a negative impact and must therefore be
\ncarried out with great care. Each case must be evaluated care-
\nfully based on the totality of circumstances and the preponder-
\nance of available evidence.
\n3.\t The WMA asserts that,in cases where medical age assessment is
\nunavoidable, the health and safety and dignity of the young asy-
\nlum seeker must be the highest priority. Physical examinations
\nmust be carried out by a qualified physician with appropriate
\npediatric examination experience in accordance with the highest
\nmedical and ethical standards, in observance of the principles of
\nproportionality, in adherence to the standards of prior informed
\nconsent and with consideration of cultural and religious sensi-
\ntivities and potential language barriers. The asylum seeker must
\nalways be made aware that the examination is carried out as part
\nof the age assessment procedure and not to provide healthcare.
\n4.\t The WMA underscores that any medical methods that could
\ninvolve a health risk for the applicant, e.g. radiological exami-
\nnations without medical indication, or that infringe upon the
\ndignity or privacy of an already potentially traumatized asylum
\nseeker, e.g. genital examinations, must be avoided.
\n5.\t The WMA stresses that medical certificates indicating the re-
\nsults of medical age assessment examinations should include in-
\nformation concerning the accuracy and reliability of the meth-
\nods used and the relevant margins of error.
\n6.\t The WMA urges constituent members to develop or promote
\nthe development of internationally accepted interdisciplinary
\nguidelines which outline the scientific basis, as well as ethical
\nand legal or regulatory principles of medical age assessment of
\nasylum seekers, including the potential health risks and psycho-
\nlogical impact of specific procedures.
\n7.\t The WMA emphasizes that, in cases where doubts regarding
\nthe age of an asylum seeker cannot be resolved or confirmed
\nwith absolute certainty, any remaining uncertainty should be in-
\nterpreted in favor of the asylum seeker.
\nReferences:
\n1.\t Zentrale Ethikkommission der Bundes\u00e4rztekammer (2016): Stellungnahme
\n\u201cMedizinische Alterssch\u00e4tzung bei unbegleiteten jungen Fl\u00fcchtlingen.
\nDeutsches \u00c4rzteblatt 2016; A1-A6.\/German Medical Association\u2019s Central
\nEthics Committee: Statement on Medical Age Assessment of Unaccompa-
\nnied Minor Refugees.
\n2.\t Separated Children in Europe Programme (2012): Position Paper on Age
\nAssessment in the Context of Separated Children in Europe. Online http:\/\/
\nwww.separated-children-europe-programme.org\/separated_children\/good_prac-
\ntice\/index.html. Last accessed 03.07.2018.
\n3.\t Sauer PJJ, Nicholson A, Neubauer D, On behalf of the Advocacy and Ethics
\nGroup of the European Academy of Paediatrics (2016): Age determination
\nin asylum seekers: physicians should not be implicated. European Journal of
\nPediatrics 175, (3): 299-303.
\n4.\t Aynsley-Green et al. (2012): Medical, statistical, ethical and human rights
\nconsiderations in the assessment of age in children and young people subject
\nto immigration control. British Medical Bulletin 2012; 102: 39.
\nWMA Statement on Reducing
\nDietary Sodium Intake
\nAdopted by the 59th
\nWMA General Assembly, Seoul, Korea, October
\n2008 and amended by the 70th
\nWMA General Assembly, Tbilisi, Geor-
\ngia, October 2019
\nPreamble
\nDietary table salt is an ionic compound comprising of sodium chlo-
\nride, which is 40% sodium (Na+
\n) and 60% chloride (Cl\u2013
\n). There is
\noverwhelming evidence that excessive sodium intake is a risk factor
\nfor the development, or worsening of hypertension, which is one
\nof the main cardiovascular risk factors. Hypertension may also be
\nan independent risk factor for cardiovascular diseases as well as all-
\ncause mortality. The effect of dietary sodium on blood pressure is
\ninfluenced by various demographic factors such as age and ethnicity.
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\nGeneral Assembly Report
\nSalt intake is also a risk factor for gastric cancer [1].
\nThe World Health Organization (WHO) recommends that average
\ndaily sodium consumption in adults (\u226516 years of age) should be less
\nthan 2000 mg (5 g salt). For children (2\u201315 years of age), the adult
\nintake limit of 2 g\/day sodium should be adjusted downward based
\non the energy requirements of children relative to those of adults [2].
\nThe majority of the world\u2019s population consumes too much sodi-
\num \u2013 3.95 (3.89\u20134.01) g\/day, equivalent to table salt level of 10.06
\n(9.88\u201310.21) g\/day.These consumption levels are far above the rec-
\nommended limit [3].
\nThe main source of sodium is dietary consumption, 90% of it in the
\nform of salt [4], as added salt during cooking or eating, or in pro-
\ncessed foods such as canned soups, condiments, commercial meals,
\nbaking soda, processed meats (such as ham, bacon, bologna), cheese,
\nsnacks, and instant noodles, among others. In higher-income coun-
\ntries sodium added during food processing can be as high as 75%-
\n80% of total salt intake [5].
\nThe Global Action Plan for the Prevention and Control of Non-
\nCommunicable Disease (NCDs) 2013-2020 is made up of 9 global
\ntargets, including a 30 % relative reduction in mean population in-
\ntake of sodium. The WHO has created the S.H.A.K.E technical
\npackage to assist Member States with the development, implemen-
\ntation and monitoring of salt reduction strategies.
\nThe WHO recognises that while salt reduction is recommended
\nglobally, there is concern that iodine deficiency disorders (IDD)
\nmay re-emerge as iodized salt is the main vehicle for dietary iodine
\nintake through fortification.Therefore the WHO, in recognition of
\nthe importance of both sodium reduction and iodine fortification,
\nurges that efforts of the two programs be coordinated [6].
\nSubstantial overall benefits can result from even small reductions in
\nthe population\u2019s blood pressure. Population-wide efforts to reduce
\ndietary sodium intake are a cost-effective way to reduce overall hy-
\npertension levels and subsequent cardiovascular disease. Evidence
\nshows that keeping sodium consumption within the reference level
\ncould prevent an estimated premature 2.5 million deaths each year
\nglobally [7].
\nRecommendations
\nWMA and its Constituent Members should:
\n1.\t Urge governments to recognise that salt consumption is a seri-
\nous public health problem and prioritise prevention as an equi-
\ntable, cost effective and lifesaving population-wide approach to
\naddress high sodium intake and the associated high burden of
\ncardiovascular diseases.
\n2.\t Work in cooperation with national and international health
\norganisations to educate consumers from childhood about the
\neffects of excessive sodium intake on hypertension and cardio-
\nvascular disease, the benefits of long-term reductions in sodium
\nintake, and about the dietary sources of salt\/sodium and how
\nthese can be reduced.
\n3.\t Urge the governments and other stakeholders work together to
\nachieve the targets set in the Global Action Plan for the Preven-
\ntion and Control of NCDs 2013-2020.
\n4.\t Recognise the critical role of the food processing and food ser-
\nvices industry in reducing dietary sodium, and support regu-
\nlatory efforts involving mandatory targets in food processing,
\nsodium content of foodstuffs, and clear labelling. Food reformu-
\nlation efforts must target food products that are most commonly
\nconsumed in the population.
\nConstituent members of WMA should:
\n1.\t Encourage their governments strictly to enforce laws regulating
\nthe sodium content in processed foods.
\n2.\t Embrace a multi stakeholder approach in working towards re-
\nducing the consumption of excessive sodium by the population,
\nincluding active promotion of physician awareness regarding the
\neffects of excessive dietary sodium.
\n3.\t Recognise that sodium reduction and salt iodization programmes
\nneed to be compatible and support sodium reduction strategies
\nthat do not compromise dietary iodine content,orincrease or wors-
\nen iodine deficiency disorders, especially in low income settings.
\n4.\t Contribute to making the public aware of the potential conse-
\nquences of low iodine levels as a result of restricted iodized salt
\nintake.
\n5.\t Encourage their members to contribute to scientific research on
\nsodium reduction strategies.
\n6.\t Encourage the initiation of food labeling, media campaigns and
\npopulation-wide policies such as mandatory reformulation to
\nachieve larger reductions in population-wide salt consumption
\nthan individually focused interventions.
\nIndividual physicians should:
\n1.\t Counsel patients about the major sources of sodium in their di-
\nets and how to reduce sodium intake, including reducing the
\namount of salt used in cooking at home, use of salt substitutes,
\nand addressing any relevant local practices and beliefs that con-
\ntribute to high sodium intake.
\nReferences:
\n1.\t World Cancer Research Fund\/American Institute for Cancer Research.
\nFood, Nutrition, Physical Activity, and the Prevention of Cancer: a Global
\nPerspective. Washington DC: AICR, 2007
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\nGeneral Assembly Report
\n2.\t Guideline: Sodium intake for adults and children. Geneva, World Health
\nOrganization (WHO), 2012.
\n3.\t Mozaffarian, Dariush, Fahimi, Saman, Singh, Gitanjali M., Micha, Renata,
\nKhatibzadeh, Shahab, Engell, Rebecca E., Lim, Stephen, Danaei, Goodarz,
\nEzzati, Majid and Powles, John (2014) Global sodium consumption and
\ndeath from cardiovascular causes. New England Journal of Medicine, 371 7:
\n624-634. doi:10.1056\/NEJMoa1304127
\n4.\t J. He, N.R.C. Campbell, G.A. MacGregor. Reducing salt intake to prevent
\nhypertension and cardiovascular disease. Rev. Panam. Salud Publica, 32 (4)
\n(2012), pp. 293-300
\n5.\t World Health Organization Regional Office for Europe Mapping salt re-
\nduction initiatives in the WHO European Region (Web. 10 May 2014.)
\nhttp:\/\/www.euro.who.int\/__data\/assets\/pdf_file\/0009\/186462\/Mapping-
\nsalt-reduction-initiatives-in-the-WHO-European-Region.pdf (2013)
\n6.\t Salt reduction and iodine fortification strategies in public health. 2014.
\nhttp:\/\/www.who.int\/nutrition\/publications\/publichealth_saltreduc_iodine_
\nfortification\/en\/
\n7.\t McLaren L, Sumar N, Barberio AM, Trieu K, Lorenzetti DL, Tarasuk V,
\nWebster J, Campbell NRC.Population-level interventions in government
\njurisdictions for dietary sodium reduction. Cochrane Database of System-
\natic Reviews 2016, Issue 9. Art. No.: CD010166.DOI: 10.1002\/14651858.
\nCD010166.pub2.
\nWMA Statement on Solitary
\nConfinement
\nAdopted by the 65th
\nWMA General Assembly, Durban, South Africa,
\nOctober 2014 and amended by the 70th
\nWMA General Assembly,Tbilisi,
\nGeorgia, October 2019
\nPreamble
\n1.\t In many countries, a substantial number of prisoners are held in
\nsolitary confinement. Solitary confinement is a form of confine-
\nment used in detention settings where individuals are separated
\nfrom the general detained population and held alone in a sepa-
\nrate cell or room for upwards of 22 hours a day. Jurisdictions
\nmay use a range of different terms to refer to the process (such
\nas segregation, separation, isolation or removal from associa-
\ntion) and the conditions and environment can vary from place
\nto place. However, it may be defined or implemented, solitary
\nconfinement is characterised by complete social isolation; a lack
\nof meaningful contact; and reduced activity and environmental
\nstimuli. Some countries have strict provisions on how long and
\nhow often prisoners can be kept in solitary confinement, but
\nmany countries lack clear rules on this.
\n2.\t Solitary confinement can be distinguished from other brief inter-
\nventions when individuals must be separated as an immediate re-
\nsponse to violent or disruptive behaviour or where a person must
\nbe isolated to protect themselves or others. These interventions
\nshould take place in a non-solitary confinement environment.
\n3.\t The reasons for the use of solitary confinement vary in different
\njurisdictions and it can be used at various stages of the criminal
\njustice process. It may be used as a disciplinary measure for the
\nmaintenance of order or security; as an administrative measure,for
\nthe purposes of investigation or questioning; as a preventive mea-
\nsure against future harm (either to the individual or to others); or it
\nmay be the consequence of a restrictive regime that limits contact
\nwith others. It can be imposed for hours to days or even years.
\nMedical impacts of solitary confinement
\n4.\t People react to isolation in different ways.For a significant num-
\nber of prisoners, solitary confinement has been documented to
\ncause serious psychological, psychiatric, and sometimes physi-
\nological effects. These include insomnia, confusion, hallucina-
\ntions, psychosis, and aggravation of pre-existing health prob-
\nlems. Solitary confinement is also associated with a high rate of
\nsuicidal behaviour. Negative health effects can occur after only
\na few days and may in some cases persist when isolation ends.
\n5.\t Certain populations are particularly vulnerable to the negative
\nhealth effects of solitary confinement. Persons with psychotic
\ndisorders, major depression, or post-traumatic stress disorder
\nor people with severe personality disorders may find isolation
\nunbearable and suffer considerable health harms. Solitary con-
\nfinement may complicate treating such individuals and their
\nassociated health problems successfully later in the prison en-
\nvironment or when they are released back into the community.
\nPrisoners with physical disabilities or other medical conditions
\noften have their conditions aggravated,not only as a result of the
\nphysical conditions of isolation, but also as the particular health
\nrequirements linked to their disability or condition are often not
\naccommodated.
\n6.\t For children and young people, who are in the crucial stages of
\ndeveloping socially, psychologically, and neurologically, there are
\nserious risks of solitary confinement causing long-term mental
\nand physical harm.A growing international consensus about the
\nharms of solitary confinement on children and young people has
\nresulted in some jurisdictions abolishing the practice completely.
\nInternational norms on solitary confinement
\n7.\t The increasing documentation on the harmful impact of solitary
\nconfinement on the health of prisoners led to the development of
\na range of international norms and recommendations seeking to
\nmitigate the use and the harmful effect of solitary confinement.
\n8.\t The United Nations Standard Minimum Rules for the Treat-
\nment of Prisoners (SMR) were first adopted in 1957, and re-
\nvised in 2015 as the Nelson Mandela Rules unanimously adopted
\nby the United Nations Assembly. The SMR constitute the key
\ninternational framework for the treatment of prisoners.
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\nGeneral Assembly Report
\n9.\t Other international standards and recommendations, such as
\nthe United Nations Rules for theTreatment of Women Prisoners and
\nNon-Custodial Sanctions for Women Offenders (the Bangkok Rules),
\nthe United Nations Rules for the Protection of Juveniles Deprived
\nof their Liberty and the observations of the Special Rapporteur
\non Torture and Other Cruel, Inhuman or Degrading Treatment or
\nPunishment, support and complete the Nelson Mandela Rules.
\n10.\tThe misuse of solitary confinement can include indefinite or pro-
\nlonged solitary confinement (defined as a period of solitary con-
\nfinement in excess of 15 days), but can also include corporal or
\ncollective punishment, the reduction of a prisoner\u2019s diet or drink-
\ning water,or the placement of a prisoner in a dark or constantly lit
\ncell. Misuse of solitary confinement in these ways can constitute
\na form of torture or ill-treatment and as such must be prohibited
\nin line with international human rights law and medical ethics.
\n11.\tThe WMA and its members reiterate their firm and long-stand-
\ning position condemning any forms of torture and other cruel,
\ninhuman or degrading treatment or punishment and reaffirm
\nthe basic principle that doctors should never participate in or
\ncondone torture or other cruel,inhuman or degrading treatment.
\nRecommendations
\n12.\tGiven the harmful impact of solitary confinement,which can on
\noccasion result in a form of torture or ill-treatment, the WMA
\nand its members call for the implementation of the Nelson
\nMandela Rules and other associated international standards and
\nrecommendations, with a view to protect the human rights and
\nthe dignity of the prisoners.
\n13.\tThe WMA and its members emphasize in particular the respect
\nof the following principles:
\n14.\tIn light of the serious consequences solitary confinement can
\nhave on physical and mental health (including an increased risk
\nof suicide or self-harm), it should be imposed only in exception-
\nal cases as a last resort and subject to independent review, and
\nfor the shortest period of time possible.The authority imposing
\nthe solitary confinement must be acting in line with clear rules
\nand regulations as to its use.
\n15.\tAll decisions on solitary confinement must be transparent and
\nregulated by law. The use of solitary confinement should be
\ntime-limited by law. The detainee should be informed of the
\nduration of the isolation, and the period of duration should be
\ndetermined before the measure takes place. Prisoners subject to
\nsolitary confinement should have a right of appeal.
\n16.\tSolitary confinement should not exceed a time period of 15 con-
\nsecutive days. Releasing the prisoner from solitary confinement
\nfor a very limited period of time, with the intention that the
\nindividual will be placed in solitary confinement immediately
\nagain to get around the rules on length of stay must also be
\nprohibited.
\nProhibitions of the use of solitary confinement
\n17.\tThe indefinite or prolonged solitary confinement should be pro-
\nhibited as amounting to torture or other cruel, inhuman or de-
\ngrading treatment or punishment [1].
\n18.\tSolitary confinement should be prohibited for children and
\nyoung people (as defined by domestic law), pregnant women,
\nwomen up to six months post-partum, women with infants
\nand breastfeeding mothers as well as for prisoners with mental
\nhealth problems given that isolation often results in severe exac-
\nerbation of pre-existing mental health conditions.
\n19.\tThe use of solitary confinement should be prohibited in the case
\nof prisoners with physical disabilities or other medical conditions
\nwhere their conditions would be exacerbated by such measures.
\n20.\tWhere children and young people must be separated, in order
\nto ensure their safety or the safety of others, this should be car-
\nried out in a non-solitary confinement setting with adequate re-
\nsources to meet their needs, including ensuring regular human
\ncontact and purposeful activity.
\nConditions of solitary confinement
\n21.\tThe human dignity of prisoners confined in isolation must al-
\nways be respected.
\n22.\tPrisoners in isolation should be allowed a reasonable amount of
\nmeaningful regular human contact, activity, and environmental
\nstimuli, including daily outside exercise. As with all prisoners,
\nthey must not be subjected to extreme physically and\/or men-
\ntally taxing conditions.
\n23.\tPrisoners who have been in solitary confinement should have an
\nadjustment period,including a medical examination,before they
\nare released from prison.This must never extend their period of
\nincarceration.
\nRole of physician
\n24.\tThe physician\u2019s role is to protect, advocate for, and improve pris-
\noners\u2019 physical and mental health, not to inflict punishment.
\nTherefore, physicians should never participate in any part of the
\ndecision-making process resulting in solitary confinement,which
\nincludes declaring an individual as \u201cfit\u201dto withstand solitary con-
\nfinement or participating in any way in its administration. This
\ndoes not prevent physicians from carrying out regular visits to
\nthose in solitary confinement to assess health and provide care
\nand treatment where necessary, or from raising concerns where
\nthey identify a deterioration in an individual\u2019s health.
\n25.\tThe provision of medical care should take place upon medical
\nneed or the request of the prisoner. Physicians should be guar-
\nanteed daily access to prisoners in solitary confinement, upon
\ntheir own initiative. More frequent access should be granted if
\nphysicians deem this to be necessary.
\n26.\tPhysicians working in prisons must be able to practice with
\ncomplete clinical independence from the prison administration.
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\nGeneral Assembly Report
\nIn order to maintain that independence, physicians working in
\nprisons should be employed and managed by a body separate
\nfrom the prison or criminal justice system.
\n27.\tPhysicians should only provide drugs or treatment that are
\nmedically necessary and should never prescribe drugs or treat-
\nment with the intention of enabling a longer period of solitary
\nconfinement.
\n28.\tHealthcare should always be provided in a setting that respects
\nthe privacy and dignity of prisoners. Physicians working in the
\nprison setting are bound by the sample codes and principles of
\nmedical ethics as they would be in any other setting.
\n29.\tPhysicians should report any concerns about the impact soli-
\ntary confinement is having on the health and wellbeing of an
\nindividual prisoner to those responsible for reviewing solitary
\nconfinement decisions. If necessary, they should make a clear
\nrecommendation that the person be removed from solitary con-
\nfinement, and this recommendation should be respected and
\nacted upon by the prison authorities.
\n30.\tPhysicians have a duty to consider the conditions in solitary
\nconfinement and to raise concerns with the authorities if they
\nbelieve that they are unacceptable or might amount to inhumane
\nor degrading treatment. There should be clear mechanisms in
\nplace in each system to allow physicians to report such concerns.
\nReference.
\n1.\t Rule 43 SMR
\nWMA Resolution on Legislation
\nAgainst Abortion in Nicaragua
\nAdopted by the 60th
\nWMA General Assembly, New Delhi, India, October
\n2009, and amended by the 70th
\nWMA General Assembly, Tbilisi, Geor-
\ngia, October 2019
\nWhereas
\nIn 2006, Nicaragua adopted a penal code that criminalises abortion
\nin all circumstances, including any medical treatment of a pregnant
\nwoman which results in the death of or injury to an embryo or fetus.
\nAccording to the UN Population Fund (UNFPA), despite improve-
\nment of national sexual and reproductive health indicators, Nica-
\nragua continues to have one of the highest teenage pregnancy and
\nmaternal mortality rates in the Americas region, in particular in
\nlower income rural population groups.
\nThis legislation:
\n\u2022\t Has a negative impact on the health of women in Nicaragua re-
\nsulting in preventable deaths of women and the embryo or fetus
\nthey are carrying.
\n\u2022\t Places physicians at risk of imprisonment if they carry out abor-
\ntions, even to save a pregnant woman\u2019s life, unless they follow the
\nNicaraguan Ministry of Health\u2019s (MINSA) 2006 Obstetric Pro-
\ntocols designed for high emergency care alone.
\n\u2022\t Requires physicians to report to police, women and girls for sus-
\npected abortions, in breach of their duty of confidentiality to-
\nwards patients and placing them in a conflict between the law
\nand medical ethics.
\nThe WMA Statement on Medically-IndicatedTermination of Pregnancy\u00ad
\n(October 2018) provides that: \u201cNational laws, norms, standards, and
\nclinical practice related to termination of pregnancy should promote and
\nprotect women\u2019s health, dignity and their human rights, voluntary in-
\nformed consent, and autonomy in decision-making, confidentiality and
\nprivacy. National medical associations should advocate that national
\nhealth policy upholds these principles.\u201d
\nThe WMA reiterates its Resolution on Criminalisation of Medical
\nPractice (October 2013) recommending that its members \u201coppose
\ngovernment intrusions into the practice of medicine and in healthcare
\ndecision making, including the government\u2019s ability to define appropriate
\nmedical practice through imposition of criminal penalties.\u201d
\nTHEREFORE,the World Medical Association and its constituent
\nmembers urge the Nicaraguan government to repeal its penal code
\ncriminalizing abortion and develop in its place a legislation that
\npromotes and protects women\u2019s human rights, dignity and health,
\nincluding adequate access to reproductive healthcare, and that al-
\nlows physicians to perform their duties in line with medical ethics
\nand particularly medical confidentiality.
\nWMA Resolution on Climate
\nEmergency
\nAdopted by the 70th
\nWMA General Assembly,Tbilisi,Georgia,October 2019
\nHealth professionals have an important role in advocating to protect
\nthe health of citizens around the world,and therefore have a respon-
\nsibility to demand greater action on climate change.
\nThe UN summit on climate action that took place in September
\n2019 further demonstrated the growing recognition that climate
\nBACK TO CONTENTS
\n42
\nGeneral Assembly Report
\nchange action must be accelerated, with many countries making
\ncommitments to achieving net zero emissions by 2050 and others
\ncommitting to boost national action plans by 2020.
\nThere is emerging consensus within the medical profession globally
\nthat action on climate change must be accelerated.
\nThe WMA and its constituent members and the international
\nhealth community:
\n\u2022\t declare a climate emergency and call the international health
\ncommunity to join their mobilisation;
\n\u2022\t commit to advocate to protect the health of citizens across the
\nglobe in relation to climate change;
\n\u2022\t urge national government to rapidly work to deliver carbon neu-
\ntrality by 2030, so as to minimise the life-threatening impacts of
\nclimate change on health;
\n\u2022\t must acknowledge the environmental footprint of the global
\nhealthcare sector,and act to reduce waste and prevent pollution to
\nensure healthcare sustainability.
\nWMA Resolution on the
\nRevocation of Who Guidelines
\non Opioid Use
\nAdopted by the 70th
\nWMA General Assembly, Tbilisi, Georgia, October
\n2019
\nThe World Medical Association expresses concern about the abrupt
\ndiscontinuation of WHO 2011 guidance \u201cEnsuring balance in na-
\ntional policies on controlled substances: Guidance for availability and ac-
\ncessibility of controlled medicines\u201d, as well as its 2012 \u201cWHO guidelines
\non the pharmacological treatment of persisting pain in children with
\nmedical illnesses\u201d.
\nThis revocation, which took place last Summer without consulting
\nthe medical community, will deprive many physicians of support
\nand regulation in countries without related national legislation, thus
\nendangering their medically justified use of such substances. Ulti-
\nmately, suffering patients will not have access to proper medication.
\nThe WMA notes that the withdrawal was decided unilaterally,with-
\nout providing any supporting evidence and without including any
\nreplacement or substitution. Moreover, the discontinued guidelines
\nwere fully removed from WHO online publications portal, thus im-
\npeding the ability of physicians to justify and validate retrospectively
\nthe use of controlled substances,exposing them potentially to crimi-
\nnal prosecution.
\nWithout further information, the WMA considers it necessary to
\nreinstate the mentioned guidelines until they are replaced by new or
\namended ones.
\nThe WMA demands the adherence to the principle of evidence-
\nbased development of treatment guidelines. This should apply to
\nthe definition, amendment and discontinuation of such guidance in
\naddition to the application of a precautionary principle. Evidence
\nsupporting the revocation of the opioid-guidelines must be pub-
\nlished and made available for scientific scrutiny.
\nThe WMA welcomes the efforts to assemble a new team of experts
\nand strongly recommends an open and transparent process, includ-
\ning a reliable mechanism to ensure the disqualification of experts
\nwith conflicts of interest.
\nWMA Statement on Violence
\nand Health
\nAdopted by the 54th
\nWMA General Assembly, Helsinki, Finland, Sptem-
\nber 2003 and reaffirmed by the 59th
\nWMA General Assembly, Seoul,
\nKorea, October 2008 and revised by the 70th WMA General Assembly,
\nTbilisi, Georgia, October 2019
\nPreamble
\nViolence is defined as \u201cthe intentional use of physical force or pow-
\ner, threatened or actual, against oneself, or against a group or com-
\nmunity that either results in or has a high likelihood of resulting in
\ninjury, death, psychological harm, maldevelopment or deprivation.\u2019\u2019
\nViolence is multi-dimensional, has multiple driving factors, and can
\nbe physical,sexual,psychological or exerted through acts of depriva-
\ntion or neglect.
\nThe World Medical Association (WMA) has developed policies
\ncondemning different forms of violence.These include statements on
\nViolence Against Women and Girls, Family Violence, Child Abuse
\nand Neglect, Abuse of the Elderly, Adolescent Suicide, Violence in
\nthe Health Sector by Patients and those close to them,Protection of
\nHealth Care Workers in Situation of Violence, WMA Declaration
\non Alcohol and the WMA Statement on Armed-Conflicts.
\nBACK TO CONTENTS
\n43
\nGeneral Assembly Report
\nViolence is a manifestation of the health, socio-economic, policy,
\nlegal, and political conditions of a country. It occurs in all social
\nclasses and is strongly associated with leadership failure and poor
\ngovernance, and social determinants such as unemployment, pov-
\nerty, health and gender inequality, and poor access to educational
\nopportunities.
\nDespite regional and country-wide disparities in the scale and bur-
\nden of violence, along with the under reporting of data, it is evident
\nthat violence results in fatal and non-fatal consequences. These in-
\nclude the devastation of individual, family, and community life, as
\nwell as disruption of the social,economic,and political development
\nof nations.
\nViolence impacts the economy because of increased health and ad-
\nministrative expenditures by the criminal justice, law enforcement,
\nand social welfare systems. It also has negative impact on a nation\u2019s
\nproductivity because of a loss in human capital and the productivity
\nof the workforce.
\nImpact on Health
\nThe effects of violence on health vary and can be life-long. Health
\nconsequences include physical disability, depression, post-traumatic
\nstress disorder and other mental health challenges, unwanted preg-
\nnancies, miscarriages, and sexually transmitted infections.
\nBehavioral risk factors such as substance use, which can give rise to
\nviolent behaviour, are also risk factors for cancer, cardiovascular and
\ncerebrovascular diseases.
\nDirect victims of violence are prone to traumatizing experienc-
\nes such as physical, sexual and psychological abuse, and may be
\nunwilling or unable to disclose or report their experiences to ap-
\npropriate authorities due to shame, cultural taboo, fear of societal
\nstigma or reprisal, and the justice system\u2019s undue delay in dispens-
\ning justice.
\nIn institutions such as healthcare facilities, violence is often in-
\nterpersonal in nature, and may be perpetrated against patients by
\nhealthcare workers, or against health care workers by patients and
\ntheir caregivers, or among healthcare personnel in the form of bul-
\nlying, intimidation, and harassment.
\nAdditionally, healthcare professionals and healthcare facilities are
\nincreasingly subjected to violent attacks. Such violence and targeted
\nattacks on healthcare facilities, healthcare personnel, and the sick
\nand wounded are in direct breach of medical ethics, international
\nhumanitarian and human rights laws.
\nThough many countries are increasingly accepting the need to insti-
\ntute violence prevention programs in their respective jurisdictions,
\nthe field of violence prevention and management still faces many
\nchallenges. Challenges include inadequate or non-existent report-
\ning of data, inadequate investment in violence prevention programs
\nand support services for victims of violence, and failure to enforce
\nexisting laws against violence, including measures to restrict access
\nto alcohol.
\nRecognizing that violence remains a significant public health chal-
\nlenge which is multi-dimensional and preventable in nature, and af-
\nfirming the pre-eminent role of physicians as role models,and in the
\ncare and support of victims of violence, the WMA commits itself to
\nact against this global scourge.
\nRecommendations
\nWMA encourages its constituent members to:
\n1.\t Educate and advise political and public office holders at all levels
\nof government with appropriate and adequate knowledge and
\nscientific evidence on the benefits of investing more resources in
\nviolence prevention.
\n2.\t Advocate for and support good governance based on the rule of
\nlaw, transparency, and accountability.
\n3.\t Conduct and support effective media campaigns to inform and
\nraise the public\u2019s awareness on the burden and consequences of
\nviolence and the need to prevent it.
\n4.\t Raise public awareness of international laws, norms, and ethical
\ncodes that mandate the protection of healthcare workers and
\nfacilities in times of peace and conflict.
\n5.\t Advocate for and promote the inclusion of courses on violence
\nand its prevention in academic curricula,including those for un-
\ndergraduate and postgraduate medical training and Continuing
\nMedical Education (CME).
\n6.\t Consider organizing capacity building and CME programs for
\nphysicians on violence prevention, caring for victims of violence,
\nemergency preparedness and response, and early recognition of
\nsigns of interpersonal and sexual violence.
\nThe WMA urges governments to:
\n1.\t Work towards achieving a zero-tolerance for violence, through
\nprevention programs, establishment of violence prevention and
\nvictim support clinics, establishment of safe domestic violence
\nshelters,increased public and private investment in public safety,
\nsecurity, and strengthening of health and educational institu-
\ntions.
\n2.\t Encourage collaborative action on violence prevention, with in-
\ntegrated violence prevention and victim support in health care
\ninstitutions.
\nBACK TO CONTENTS
\n44
\nClimate Changes
\n3.\t Promote social justice and equity by eliminating inequities and
\ninequalities that may create the conditions for violence.
\n4.\t Focus on addressing social determinants of health through
\nthe creation and improvement of socio-economic, educational
\nand health infrastructure and opportunities, and elimination
\nof adverse and oppressive cultural attitudes and practices and
\nall forms of inequality or discrimination on the basis of gender,
\ncreed, ethnic origin, nationality, political affiliation, race, sexual
\norientation, social standing, disease or disability.
\n5.\t Secure the enactment and enforcement of policies and laws on
\nviolence prevention, protection and support of victims of vio-
\nlence, and punishment of offenders.
\n6.\t Strengthen institutions concerned with public safety and security.
\n7.\t Develop policies and enforce legislations that regulate access to
\nalcohol.
\n8.\t Develop and implement effective legal frameworks that protect
\nindividuals and entities that deliver healthcare. Such frame-
\nworks should guarantee the protection of physicians and other
\nhealthcare professionals, as well as the free and safe access of
\nhealthcare personnel and patients to health care facilities.
\n9.\t Support comprehensive research studies on the nature and
\ncharacter of the various forms of violence, including the effec-
\ntiveness of response strategies, to assist them in the preparation
\nand implementation of policies, laws and strategies on violence
\nprevention, protection and support of victims, and punishment
\nof perpetrators.
\n10.
\nInitiate and foster multi-stakeholder involvement and col-
\nlaboration among relevant bodies and organizations at global,
\nnational, state and local levels, in the development, implemen-
\ntation and promotion of violence prevention and management
\nstrategies, including engagement of traditional, religious, and
\npolitical leaders.
\n11.
\nDevelop robust multi-sectoral partnerships at local, state and
\nnational levels with violence prevention made a priority concern
\nin all government ministries,including health,education,labour,
\nand defense ministries.
\n12.
\nInstitute a Safe Care Initiative that guarantees the safety and
\nsecurity of physicians and other healthcare workers, patients,
\nhealthcare facilities, and the uninterrupted delivery of health-
\ncare services in times of peace and conflict.
\n13.\tThe initiative should include the following components:
\n–
\n– Routine violence risk audit.
\n–
\n– Efficient and effective violence surveillance and reporting
\nmechanisms.
\n–
\n– Transparent and timely investigation of all reported cases of
\nviolence.
\n–
\n– A system for protecting patients and healthcare personnel who
\nreport cases of violence.
\n–
\n– Legal support for physicians and other healthcare workers sub-
\njected to violence in the workplace.
\n–
\n– Establishment of security posts in healthcare facilities as
\ndeemed necessary.
\n–
\n– Financial coverage for injured medical personnel and other
\nhealthcare workers.
\n–
\n– Compensated time off for injured medical personnel and other
\nhealthcare workers.
\nThe United Nations Climate Action Sum-
\nmit was held in New York at UN Headquar-
\nters on 21\u201322 September 2019. This week-
\nend prefaced the high-level meetings by
\nheads of state and government officials from
\naround the world that started on 23 Sep-
\ntember. Representatives from governmental
\nand non-governmental organizations from
\naround the world attended. World Medical
\nAssociation was represented at the Climate
\nAction Summit by Dr.Mike Kalmus-Eliasz
\nfrom the Junior Doctors Network and Dr.
\nYoshitake Yokokura, past president of the
\nWMA. Additionally, a few other WMA
\nmembers were present representing other
\norganizations at the coalition meetings pre-
\nceding the summit. I was present as a rep-
\nresentative of Physicians for Social Respon-
\nsibility (PSR), the United States chapter of
\nInternational Physicians for the Prevention
\nof Nuclear War (IPPNW). PSR has two
\nprimary national aims \u2013 the prevention of
\nnuclear war and climate change.
\nOne of the tracks was on air pollution, en-
\ntitled, \u201cClimate Action for Health: Cut
\nEmissions, Clean our Air, and Save Lives\u201d
\nmoderated by Lucia Ruiz Ostoic, the Min-
\nister of Environment for Peru. There was
\nalso a special appearance, speech, and plea
\nby Dr. Tedros Ghebreyesus, Director-Gen-
\neral of the World Health Organization. Ankush K. Bansal
\nUnited Nations Climate Action Summit
\nBACK TO CONTENTS
\n45
\nClimate Changes
\nAn informative and sobering presentation,a
\ncall to action, was given by Dr. Arvind Ku-
\nmar, a leading pulmonologist in New Delhi,
\nIndia. New Delhi has one of the highest
\nlevels of air pollution globally, a fact that
\nI\u00a0can personally attest to, with PM2.5 levels
\nconsistently many times over the maximum
\nsafe limit. In 2018, the average PM2.5 lev-
\nel was 14.3 times over the safe limit. This
\nwas equivalent to smoking 6.5 cigarettes
\nper day. In fact, a teenager living his\/her
\nwhole life in the Delhi Metropolitan Area
\n(DMA) had the level of pollution and par-
\nticulate matter in his\/her lungs as a lifelong
\nsmoker, even if this teenager never smoked
\na single cigarette. Furthermore, from 1988
\nto 2018, the rate of lung cancer among
\nnon-smokers in the DMA rose from 10%
\nto 50%, with the average age of diagnosis
\ndropping from 50\u201360 to 30\u201340, even fac-
\ntoring in earlier diagnosis during this same
\ntime period, and increase in diagnosis in
\nwomen rising from almost non-existent to
\n40%. The sobering statistic for populations
\nis that based on previous studies, breath-
\ning polluted air was equivalent to smoking
\nat a rate of 22\u00a0mcg\/m3
\nof pollutants, equal
\nto 1 cigarette. This included newborns and
\nchildren which has been found to result in
\nneuroinflammation and reduced cognitive
\ndevelopment. In adults, it increases the risk
\nof stroke by at least 5 times.Additionally,air
\npollution results in infertility, miscarriage,
\npreterm and low-birth-weight infants, and
\ncongenital abnormalities. Up to 7 million
\npremature deaths per year worldwide have
\nbeen attributed to air pollution according to
\nthe WHO. This is the reason that reducing
\nair pollution and mitigating its effects is so
\ncritical and emergent.
\nLeaders from government and non-govern-
\nmental organizations then provided exam-
\nples of solutions, trials, and collaborations
\nto tackle this. While the DMA may be one
\nof the most extreme examples in the world,
\nair pollution affects all of us. The mayors of
\nAccra and Seville; the Ministers of Health,
\nEnvironment\/Climate, or Energy from the
\nUnited Arab Emirates, Finland, and Nor-
\nway; the European Union Commissioner
\nfor Environment; and the Directors of
\nHealthcare Without Harm and the Clean
\nAir Fund made presentations on work be-
\ning done. Cities in Spain and in South
\nAmerica are working together to reduce
\nair pollution by redesigning cities through
\ndecentralization of services, increasing bi-
\ncycle and pedestrian lanes with improve-
\nment in access to social, occupational, and
\nretail services through decentralization.
\nFurthermore, some cities are utilizing pol-
\nlution sensors with less expensive versions
\nbeing developed so that the population can
\nbe notified accordingly. While these mea-
\nsures will result in some improvement in lo-
\ncal pollution levels and future city planning\/
\ndevelopment, the causes of air pollution on
\na larger scale need to be addressed fully and
\nurgently. Here, the national ministers pro-
\nvided examples of how their governments
\nare committed to solutions. However, no
\nspecific examples beyond voluntary interna-
\ntional agreements were provided. Partially
\nbecause of this, the Clean Air Fund was
\ncreated and was formally introduced to the
\nworld in the subsequent days at the United
\nNations to bring awareness and encourage
\npressure on governments to act.
\nIt is of note that recent research has shown
\nthat air pollution, particularly among the
\nwealthiest nations, is increasing, contrary to
\nwhat scientific consensus strongly recom-
\nmends occur as soon as possible. For ex-
\nample, in the United States, in 2018, there
\nwere an additional 10,000 deaths attributed
\nto air pollution, specifically PM2.5 pollu-
\ntion, compared to 2 years prior. This was
\nafter a decline to almost half from 2000 lev-
\nels. Even if the increase in wildfires in the
\nwestern United States during the preceding
\n3 years were considered, the rise in air pol-
\nlution would continue.
\nTherefore, as physicians of the world who
\nencounter the effects of climate change
\nregularly, including air pollution, it is our
\nresponsibility to advocate for our patients\u2019
\nhealth to our respective governments.
\nDecentralization, pedestrian and bicycle-
\nfriendly cities, and pollution sensors are
\na start but even as the mayors and minis-
\nters present at the Summit stated, it is not
\nenough or comprehensive.
\nThe Environmental Caucus at the World
\nMedical Association meets during the
\ncouncil sessions and is open to all WMA
\nmembers. The Caucus discusses measures
\nbeing taken in participant\u2019s respective coun-
\ntries, news from recent international meet-
\nings, upcoming meeting announcements,
\nand drafts documents for the Council to
\nconsider regarding the environment and
\nclimate change.
\nAnkush K. Bansal, MD, FACP,
\nFACPM, SFHM
\nAssociate Member and Representative to the
\nGeneral Assembly \u2013 World Medical Association
\nBoard Member \u2013 Florida Chapter,
\nPhysicians for Social Responsibility
\nCo-Chair and Co-Founder \u2013 Florida
\nClinicians for Climate Action
\nCo-Chair and Co-Founder \u2013 Palm Beach
\nChapter, Climate Reality Project
\nUnited States of Americav
\nBACK TO CONTENTS
\n46
\nClimate Changes
\nIn 1958,a team of researchers installed their
\nequipment on the top of the Mauna Loa,
\none of the five volcanoes on the island of
\nHawaii.Led by Charles David Keeling,they
\nstarted monitoring the level of atmospheric
\nCO\u2082 concentration. Since then, the verdict
\nis unequivocal: the CO\u2082 concentration in
\nthe atmosphere is consistently increasing
\nfrom year to year. This is now known as the
\nKeeling curve.
\nAt that time, only a handful of individuals
\nwere starting to worry about climate change.
\nHowever, greenhouse gases (GHGs) have
\nincreased in such a way that effects of cli-
\nmate change have already started being
\nfelt by people around the globe, increasing
\nas consistently as the Keeling curve. What
\nwas once a scientific matter is now a public
\nhealth matter.
\nClimate change has been called the great-
\nest threat to global health in the 21st cen-
\ntury [1]. We could lose decades of global
\nhealth advancement [2] and face about 250
\n000 additional deaths each year between
\n2030 and 2050 [3]. This article aims to
\nexplain key impacts of climate change on
\nhealth and what physicians can do about
\nit, specifically focusing on the global pro-
\ntest movements that have started occurring
\nglobally.
\nHealth Impacts of
\nClimate Change
\nHeat waves
\n\u201cJuly has re-written climate history, with
\ndozens of new temperature records at local,
\nnational and global level,\u201d recently com-
\nmented Petteri Taalas, Secretary-General
\nof the World Meteorological Organization
\n[4]. Indeed, many cities in Europe saw their
\nthermometers reach temperatures as high as
\n45\u00a0\u00baC in July.
\nEach decade since the 1980s has been hot-
\nter than the previous [5]. We expect that
\nhot days and nights will be warmer and
\nmore frequent and that periods of intense
\nheat will occur more frequently and will be
\nlonger in parts of Europe, Asia, the Ameri-
\ncas and Australia [6]. This will affect the
\nhealth of our communities, particularly the
\nmost vulnerable (older populations, people
\nliving with chronic diseases, such as cardio-
\nvascular,respiratory or renal diseases,people
\ndealing with psychiatric issues and people
\nliving in urban areas, particularly those in
\nneighborhoods with lower socioeconomic
\nstatus). According to the 2018 report of The
\nLancet countdown on health and climate
\nchange, there were 18 million more heat
\nwave exposure affecting vulnerable people
\nin 2017 than in 2016, and over 157 mil-
\nlion more than the 2000s baseline [7]. The
\nhealthcare system and its workers must be
\nready to address the challenges related to
\nthis important exposure.
\nAir pollution
\nClimate change and air pollution are closely
\nrelated, both driven by fossil fuel burning,
\nand because of the impact of the former
\non the latter. Indeed, climate change could
\nworsen air quality with increased levels of
\ntropospheric ozone, a lengthened pollen
\nseason and an increased number of forest
\nwildfires [8].
\nFor example, in urban areas, tropospheric
\nozone can increase in response to high tem-
\nperatures. It is hence predicted that there
\nwould be more ozone-related mortality
\nwith a global warming of 2 \u00baC than with
\nwarming of 1.5 \u00baC [9].
\nCurrently, over 90% of the urban popula-
\ntion of the world breathes air containing
\nlevels of outdoor air pollutants that exceed
\nWHO\u2019s guidelines [10].This can contribute
\nto strokes, ischaemic heart disease, chronic
\nobstructive pulmonary disease and lung
\ncancer. Estimates say that 7 million people
\ndie each year from outdoor and indoor air
\npollution; one in eight deaths annually [11].
\nReducing fossil fuel burning would have
\nan impact on both climate change and air
\npollution-related diseases.
\nAnne-Sara Briand Alice McGushin Claudel P\u00e9trin-Desrosiers Amro Aglan
\nThe Role of Physicians in Fighting Climate Change
\nYassen Tcholakov
\nBACK TO CONTENTS
\n47
\nClimate Changes
\nExtreme weather events
\nIn November last year, the state of Cali-
\nfornia had to deal with the Camp Fire,
\nthe largest and the deadliest wildfire in its
\nhistory as 153,336 acres were progressively
\nburned [12]. 85 people died, many were in-
\njured, and the smoke from the fire caused
\nwidespread air pollution. A few weeks later,
\na United States report underlined that cli-
\nmate change would increase the quantity of
\nwildfires and their size in the country [13].
\nGlobally, from 1979 to 2013, fire seasons
\nhave lengthened in time by almost 19% and
\nacross 25.3% of the vegetated surface of the
\nEarth [14]. Forest fires are expected to con-
\ntinue to increase in many parts of the world
\nbecause of climate change [15].
\nThis increase is also observed in other ex-
\ntreme weather events (EWE): droughts,
\nheavy rains, violent tropical cyclones and
\nfloods [16]. While EWE cause direct im-
\npacts such as trauma and increases in diar-
\nrheal diseases, many people also experience
\nstress and serious mental health consequenc-
\nes. For example, among a population sample
\naffected by Hurricane Katrina, suicide and
\nsuicidal ideation more than doubled, one
\nin six people met the diagnostic criteria for
\npost-traumatic stress disorder (PTSD), and
\n49% of people living in an affected area de-
\nveloped an anxiety or mood disorder such as
\ndepression [17]. With a changing climate,
\nwe will have to face the added stress from
\nincreased EWE on the healthcare system.
\nInfectious diseases
\nThe National Institute of Public Health of
\nQuebec in Canada is currently working on
\na public education campaign on Lyme\u2019s dis-
\nease. This disease, transmitted by a tick, has
\nbeen in Quebec for only a few years, but it
\nis now constantly gaining ground with the
\nclimate becoming more favorable [18].This
\nis the case for many vector-borne diseases
\naround the world that will cover new areas
\nas the climate change. Aedes aegypti and Ae-
\ndes albopictus are two kinds of mosquitoes
\nthat can transmit viruses like dengue,yellow
\nfever, chikungunya and zika. It is expected
\nthat the geographical distribution of these
\nmosquitoes will grow with climate change,
\nbut also that their ability to act as a vector
\nand transmit diseases will increase [19].
\nThe case of malaria is particularly worrisome.
\nThe WHO predicts that climate change
\ncould result in 60,000 additional malaria
\ndeaths by 2030, even with improvements in
\nour control methods [20]. During the next
\ncentury, the geographical reach of malaria
\nand the period of transmission could both
\nincrease, exposing ever-growing numbers of
\npeople to this deadly disease [21].
\nIt is also predicted that climate change will
\nincrease morbidity and mortality from vari-
\nous diarrheal illnesses such as vibrio cholera
\ncases which have been linked to high tem-
\nperatures and heavy rainfalls [22, 23].
\nThese changes in the pattern of infectious
\ndiseases related to climate change will need
\nto be dealt with globally and are in certain
\ncases linked to global health security.
\nFood security
\nA recent analysis from the World Resources
\nInstitute, identified that nearly a quarter of
\nthe world\u2019s population, in just 17 countries,
\nare in severe water shortage [24]. At this
\nmoment, drinking water levels are decreas-
\ning; food yields from ocean are waning; and
\ncrops yields are declining as they are im-
\npacted by rising temperatures and extreme
\nweather events. Climate stress represents
\n62.5% of all stressors accelerating soil deg-
\nradation in Africa [25]. All aspects of food
\nsecurity could be affected by climate change
\naccording to the IPCC [26].The progress of
\nrecent decades in the fight to end hunger in
\ndeveloping countries and the access to food
\nglobally are at stake.
\nClimate change could push 3 to 16 mil-
\nlion people into extreme poverty [27] and it
\ncould force people to flee their homes in or-
\nder to survive. The Red Cross believes that
\nenvironmental crises are already generat-
\ning more refugee flows than armed conflict
\n[28]. In 2010, more than 42 million people
\nworldwide were displaced due to sudden
\nnatural disasters, and it is that 90% of those
\nwere due to climate change [29].
\nThe Role of Physicians
\nClimate change is already affecting the
\nhealth of people around the world and its
\nimpacts are expected to grow. Even if all
\nemissions of greenhouse gas (GHG) were
\nreduced to zero tomorrow,we would still feel
\nthe impact, due to the effects of the cumu-
\nlative GHG emissions [30]. As physicians
\ncaring for the health of our communities, we
\nhave a role to play in fighting climate change.
\nThe Canadian Association of Physicians for
\nthe Environment dedicated an entire chapter
\nof its Climate Change Toolkit for Health Pro-
\nfessionals as to what we can do [31].
\nPhysicians hold a privileged position in so-
\nciety as trusted health authorities. We can
\nbe powerful messengers, informing our pa-
\ntients and the public about the health im-
\npacts of climate change and give ideas for
\naction. We also have a responsibility to en-
\nsure that the health co-benefits of environ-
\nmental policies are well understood by the
\npublic and by policymakers.
\nEngaged doctors can, for example, carry
\nmessages on a wide range of health benefits
\nthat result from \u201chealthy transport\u201dmeasures
\nsuch as active transport (walking and cy-
\ncling) and better urban planning based upon
\nlow-emissions public transport systems.
\nPhysical activity from walking and cycling
\ncan help prevent heart disease, type 2\u00a0diabe-
\ntes,and some obesity-related risks.Increased
\nuse of non-vehicular transport also leads to
\nlower rates of traffic injuries and less noise
\npollution. Active transport systems along
\nwith better urban land use can help improve
\nhealthcare access for vulnerable groups, en-
\nhancing health equity [32].
\nBACK TO CONTENTS
\n48
\nClimate Changes
\nWe can also help our hospitals and clinics
\nto adapt to climate change, making sure we
\nare prepared, and contribute to making the
\nhealthcare system greener. Indeed, GHG
\nemissions from the health sector are grow-
\ning and currently represent 5 to 8% of the
\ntotal emissions in high-income countries
\n[33]. Many solutions exist, and physicians
\ncan help implement them. According to a
\nnew report published by Healthcare With-
\nout Harm, if the global healthcare system
\nwas a country, it would be the fifth largest
\nemitter on the planet [32]. Physicians are
\nwell placed to initiate changes in their insti-
\ntution and to reduce greenhouse gas emis-
\nsions from the healthcare sector.
\nThis is also true at an international level. The
\ninvolvement of the health community dur-
\ning the previous UN Framework Convention
\non Climate Change Conferences of Par-
\nties (COPs) have led to the insertion of \u201cthe
\nright to health\u201din the Paris Agreement.It was
\nspecified that \u201cparties should,when taking ac-
\ntion to address climate change, respect, pro-
\nmote and consider their respective obligations
\non the right to health\u201d[34]. At the COP24, a
\ncall to action on climate and health was issued
\nby organizations representing over 5 million
\ndoctors, nurses and health professionals in
\nover 120 countries [35]. By pushing govern-
\nments to meet the targets of the Paris Agree-
\nment, we could save over one million lives a
\nyear from air pollution alone by 2050 [36].
\nClimate Health Education
\nClimate change has various and serious
\nimplications for human health and as such
\nare of fundamental relevance to future and
\ncurrent doctors [37]. Since July 2017, the
\naccreditation process of the Association of
\nFaculties of Medicine of Canada (AFMC)
\nrequires all medical schools to have a social
\naccountability mandate. Social accountabil-
\nity has been defined by the World Health
\nOrganization as \u201cthe obligation to direct
\ntheir education, research and service activi-
\nties towards addressing the priority health
\nconcerns of the community, region, and\/or
\nnation they have a mandate to serve\u201d [38].
\nAdditionally,ASPIRE,an international pro-
\ngram that recognises excellence in medical
\neducation, has now outlined specific criteria
\non environmental accountability, including
\nthe obligation for medical schools to ensure
\nthey actively develop, promote, and protect
\nenvironmentally sustainable solutions to ad-
\ndress the health concerns of the community,
\nregion, and the nation they serve [39].
\nHowever, there is a worrisome gap in educa-
\ntion of medical students and health profes-
\nsionals on this topic, leaving healthcare pro-
\nfessionals with insufficient knowledge and
\nskills to address climate change.As an exam-
\nple,presently,there is no climate change cur-
\nriculum within any Canadian medical school
\nprograms [40]. The preliminary results from
\na survey done by the Canadian Federation
\nof Medical Students (CFMS) suggest that
\nstudents are concerned about the health
\nimpacts of climate change and believe their
\ncurrent teaching is insufficient [41].A survey
\ndone by the Qu\u00e9bec National Public Health
\nInstitute (INSPQ) in 2016 has also shown
\nthat 65% of family physicians in the province
\nbelieved they lacked the required training on
\nclimate change and health issues [42].
\nThe Canadian Medical Association
\n(CMA), the Canadian Association of Phy-
\nsicians for the Environment (CAPE) and
\nThe Lancet have unanimously recommended
\nthat climate change be integrated into all
\nmedical and health science curricula [43].
\nThey argue that a well-trained workforce
\nis required to respond to the enormous
\nchallenges posed by climate change. The
\nInternational Federation of Medical Stu-
\ndents Associations (IFMSA), the world\u2019s
\nlargest and oldest medical students\u2019 group,
\nrepresenting over 1.3 million medical stu-
\ndents in 123 countries,is also advocating for
\nthe inclusion of climate change in medical
\ncurricula around the world [44]. The Fed-
\neration has collaborated with the World
\nHealth Organization (WHO) and the
\nUnited Nations Framework Convention on
\nClimate Change (UNFCCC) to create a
\nmanual for future health professionals [45].
\nThere is an urgent need to integrate climate
\nchange related issues within the medical
\ncurricula. Medical teachers can play a cru-
\ncial role in supporting their respective facul-
\nties to develop such curricula.
\nGlobal Protest Movements
\nSchool strikes for the climate is a move-
\nment started by Greta Thunberg, a student,
\nwho, on 20 August 2018, stopped attend-
\ning school until the Swedish elections three
\nweeks later calling for more action on cli-
\nmate change from Swedish politicians [46].
\nThe strikes then continued every Friday and
\nwere given the name Fridays for Future as
\nstudents from all parts of the world joined
\nin the movement [47]. Through 2018 and
\n2019, the global protest movements have
\nincreased in size and diversity of popula-
\ntions reached with more than 4500 climate
\nstrikes taking place in over 150 countries
\nduring the month of September 2019 [48]
\nand bringing the estimated total number of
\npeople to an impressive 6 million [49]. This
\nis estimated to have been the largest global
\nprotest movement [50].
\nDoctors and healthcare professionals have
\nbeen joining the protest movement, lending
\ntheir voices and those of their patients suffer-
\ning from the consequences of climate change
\nto support increase action on this emergency
\n[51, 52]. Organizations such as Doctors for
\nExtinction Rebellion have also formed and
\nare calling for three simple things: telling the
\ntruth, acting now; and going beyond politics
\nto create a citizens\u2019assembly [53, 54].
\nClimate change poses a threat to people\u2019s
\nhealth now and in the future.It is one of the
\nmost defining issues on which the genera-
\ntions that currently have the power to act
\nwill be judged by their successors. Knowing
\nthat each degree of warming will have a sig-
\nnificant impact on the health of our patients
\nand of people around the world, addressing
\nBACK TO CONTENTS
\nClimate Changes
\nclimate change might be the most powerful
\nway we can improve health. Doctors around
\nthe world have a role to play in the political
\ndecisions that will shape our environment.
\nAs Rudolf Virchow said: \u201cMedicine is a so-
\ncial science and politics is nothing else but
\nmedicine on a large scale.\u201d
\nReferences
\n1.\t Costello, Anthony, et al. (2009). Managing the
\nHealth Effects of Climate Change. The Lancet, vol.
\n373, no. 9676, pp. 1693\u20131733., doi:10.1016\/s0140-
\n6736(09)60935-1
\n2.\t World Health Organization. (2018). Global Re-
\nport on Health and Climate Change. Geneva,
\nSwitzerland. p.10
\n3.\t Ibid., p.24
\n4.\t World Meteorological Organization. (2019). July
\nmatched, and maybe broke, the record for the hot-
\ntest month since analysis began. Retrieved 4 Sep-
\ntember 2019, from https:\/\/public.wmo.int\/en\/media\/
\nnews\/july-matched-and-maybe-broke-record-hottest-
\nmonth-analysis-began.
\n5.\t Be\u0301langer, D., Gosselin, P., Bustinza, R., & Cam-
\npagna, C. (2019). Changements climatiques et
\nsante\u0301. Pr\u00e9venir, soigner et s\u2019adapter, p.25
\n6.\t Ibid., p.33
\n7.\t Watts et al. (2018). The 2018 report of the Lancet
\nCountdown on health and climate change: Shap-
\ning the health of nations for centuries to come. The
\nLancet 392(10163): 2479\u20132514.
\n8.\t Perrotta, Kim. (2019). Climate Change Toolkit for
\nHealth Professionals. Produced by the Canadian
\nAssociation of Physicians for the Environment
\n(CAPE). p.34-35.
\n9.\t Ibid.
\n10.\t World Health Organization, op. cit., p.16
\n11.\tIbid., p.8
\n12.\tCalifornia Department of Forestry and Fire
\nProtection (2019). Camp Fire. Retrieved Sep-
\ntember 4th 2019 from : https:\/\/fire.ca.gov\/
\nincident\/?incident=75dafe80-f18a-4a4a-9a37-
\n4b564c5f6014
\n13.\tMelillo, Jerry M., Terese (T.C.) Richmond, and
\nGary W. Yohe, Eds. (2014). Climate Change Im-
\npacts in the United States: The Third National Cli-
\nmate Assessment. U.S. Global Change Research
\nProgram, 841 pp. doi:10.7930\/J0Z31WJ2.
\n14.\tBe\u0301langer, D., Gosselin, P., Bustinza, R., & Cam-
\npagna, C, op. cit., p.35
\n15.\tPerrotta, Kim, op. cit., p.35
\n16.\tIbid., p.12
\n17.\tKessler, R., Galea, S., Gruber, M., Sampson, N.,
\nUrsano, R., & Wessely, S. (2008). Trends in men-
\ntal illness and suicidality after Hurricane Katrina.
\nMolecular Psychiatry, 13, 374\u2013384.
\n18.\tIbid., p.38
\n19.\tWatts, Nick, et al.(2018). \u201cThe 2018 Report of
\nThe Lancet Countdown on Health and Climate
\nChange: Shaping the Health of Nations for Cen-
\nturies to Come.\u201dThe Lancet, vol. 392, no. 10163, pp.
\n2479\u20132514., doi:10.1016\/s0140-6736(18)32594-
\n7.
\n20.\tWorld Health Organization. (2014). Quantitative
\nrisk assessment of the effects of climate change on
\nselected causes of death, 2030s and 2050s. World
\nHealth Organization. https:\/\/apps.who.int\/iris\/
\nhandle\/10665\/134014
\n21.\tR\u00e9f source? Perrotta, Kim, op. cit., p.38
\n22.\tPerrotta, Kim, op. cit., p.37.
\n23.\tBe\u0301langer, D., Gosselin, P., Bustinza, R., & Cam-
\npagna, C, op. cit., p.118.
\n24.\tWorld Resources Institute. (2019). RELEASE:
\nUpdated Global Water Risk Atlas Reveals Top
\nWater-Stressed Countries and States. Retrieved
\non September 4th 2019, from https:\/\/www.wri.
\norg\/news\/2019\/08\/release-updated-global-water-
\nrisk-atlas-reveals-top-water-stressed-countries-
\nand-states
\n25.\tUN Convention to Combat Desertification. (2014).
\nDesertification.The invisible frontline. 20p.
\n26.\tBe\u0301langer, D., Gosselin, P., Bustinza, R., & Cam-
\npagna, C, op. cit., p.165.
\n27.\tPerrotta, Kim, op. cit., p.39
\n28.\tRich, N. (2019). Losing earth: A recent history,
\np.13
\n29.\tBe\u0301langer, D., Gosselin, P., Bustinza, R., & Cam-
\npagna, C, op. cit., p.162.
\n30.\tWorld Health Organization, op. cit., p.24
\n31.\tPerrotta, Kim, op. cit., Module 8.
\n32.\tWorld Health Organization (2011). In the green
\neconomy: health co-benefit of climate change mit-
\nigation \u2013 transport sector
\n33.\thttps:\/\/noharm-uscanada.org\/ClimateFootprintRe-
\nport
\n34.\tWorld Health Organization, op. cit., p.10
\n35.\tIbid., p.8
\n36.\tIbid., p.27
\n37.\tMaxwell, J., & Blashki, G. (2016).Teaching About
\nClimate Change in Medical Education: An Op-
\nportunity.\u00a0Journal of public health research,\u00a05(1), 673.
\ndoi:10.4081\/jphr.2016.673
\n38.\tBoelen, Charles,\u00a0Heck, Jeffery E\u00a0&\u00a0World Health
\nOrganization. Division of Development of Human
\nResources for Health.\u00a0(1995).\u00a0Defining and meas-
\nuring the social accountability of medical schools\/
\nCharles Boelen and Jeffery E. Heck.\u00a0World Health
\nOrganization.\u00a0 https:\/\/apps.who.int\/iris\/han-
\ndle\/10665\/59441
\n39.\tPearson, David, Walpole, Sarah & Barna,
\nStefi.\u00a0 (2015).\u00a0 Challenges to professional-
\nism: Social accountability and global environ-
\nmental change,\u00a0 Medical Teacher,\u00a0 37:9,\u00a0 825-
\n830,\u00a0DOI:\u00a010.3109\/0142159X.2015.1044955
\n40.\tVogel,Lauren.(2019).Whyaren\u2019tmoredoctorstalk-
\ning about climate change? CMAJ,\u00a0191\u00a0(13)\u00a0E375-
\nE376;\u00a0DOI:\u00a010.1503\/cmaj.109-5731
\n41.\tMercer, C. (2019). Medical students call for more
\neducation on climate change.\u00a0 Canadian Medi-
\ncal Association Journal,\u00a0 191(10), E291-E292. doi:
\n10.1503\/cmaj.109-5717
\n42.\tValois, P., Blouin, P., Ouellet, C., Renaud, J., B\u00e9-
\nlanger, D., & Gosselin, P. (2016). The Health Im-
\npacts of Climate Change.\u00a0 Journal Of Continuing
\nEducation In The Health Professions,\u00a036(3), 218-225.
\ndoi: 10.1097\/ceh.0000000000000084
\n43.\thttps:\/\/www.cma.ca\/sites\/default\/files\/pdf\/Tools%20
\n%26%20resources\/2018-lancet-countdown-policy-
\nbrief-canada.pdf
\n44.\tIFMSA. (2018). IFMSA Policy Climate
\nChange and Health. Retrieved on November
\n2nd 2019, from: https:\/\/ifmsa.org\/wp-content\/
\nuploads\/2018\/09\/GS_AM2018_Policy_Climate-
\nChange-and-Health_final.pdf
\n45.\tIFMSA (2016). IFMSA Training Manual on
\nClimate & Health. Retrieved on November 2nd
\n2019, from: https:\/\/ifmsa.org\/wp-content\/up-
\nloads\/2017\/03\/Final-IFMSA-Climate-and-health-
\ntraining-Manual-2016.pdf
\n46.\tGessen, Masha. (2018).The Fifteen-Year-Old Cli-
\nmate Activist Who Is Demanding a New Kind of
\nPolitics. The New Yorker. Retrieved on November
\n2nd 2019, from : https:\/\/www.newyorker.com\/news\/
\nour-columnists\/the-fifteen-year-old-climate-activist-
\nwho-is-demanding-a-new-kind-of-politics
\n47.\tCarrington, Damian. (2018). Our leaders are like
\nchildren,\u2019 school strike founder tells climate sum-
\nmit. The Guardian. Retrieved on November 2nd
\n2019, from : https:\/\/www.theguardian.com\/envi-
\nronment\/2018\/dec\/04\/leaders-like-children-school-
\nstrike-founder-greta-thunberg-tells-un-climate-
\nsummit
\n48.\tMilman, Oliver. (2019). US to stage its largest ever
\nclimate strike: \u2018Somebody must sound the alarm\u2019.
\nThe Guardian. Retrieved on November 2nd 2019,
\nfrom : https:\/\/www.theguardian.com\/world\/2019\/
\nsep\/20\/climate-strikes-us-students-greta-thunberg
\n49.\tTaylor, M., Watts, J., Bartlett, J. (2019). Climate
\ncrisis: 6 million people join latest wave of global
\nprotests. The Guardian. Retrieved on November 2nd
\n2019, from : https:\/\/www.theguardian.com\/environ-
\nment\/2019\/sep\/27\/climate-crisis-6-million-people-
\njoin-latest-wave-of-worldwide-protests
\n50.\tLaville, S., Watts, J. (2019). Across the globe, mil-
\nlions join biggest climate protest ever. The Guardian.
\nRetrieved on November 2nd 2019, from: https:\/\/
\nwww.theguardian.com\/environment\/2019\/sep\/21\/
\nacross-the-globe-millions-join-biggest-climate-protest-
\never
\n51.\tMatthew, Taylor. (2019). Doctors call for nonvio-
\nlent direct action over climate crisis. The Guardian.
\nRetrieved on November 2nd 2019, from : http:\/\/
\ntheguardian.com\/environment\/2019\/jun\/27\/doctors-
\ncall-for-nonviolent-direct-action-over-climate-crisis
\n52.\tLecomte, Anne Marie. (2019). Des m\u00e9decins
\nmettent en garde contre la menace climatique sur
\nla sant\u00e9. Radio-Canada. Retrieved on November
\n2nd 2019, from : https:\/\/ici.radio-canada.ca\/nou-
\nvelle\/1165785\/protection-environnement-sante-pub-
\nlique-quebec-canada-changement-climatique
\n53.\thttps:\/\/www.doctorsforxr.com\/
\n54.\tHorton,R.(2019).Offline: Extinction or rebellion?
\nThe Lancet, 394(10205), 1216. doi: 10.1016\/s0140-
\n6736(19)32260-3.
\nAnne-Sara Briand, Resident in Public
\nHealth and Preventive Medicine,
\nUniversity of Montreal, Canada
\nAlice McGushin, University College
\nLondon, United Kingdom.
\nClaudel P\u00e9trin-Desrosiers, Resident in Family
\nMedicine, University of Montreal, Canada
\nAmro Aglan, Medical intern,
\nTanta University, Egypt
\nYassen Tcholakov, Resident in Public
\nHealth and Preventive Medicine,
\nMcGill University, Canada
\nBACK TO CONTENTS
\nIV
\nGeneral Assembly Report
\nBACK TO CONTENTS<\/p>\n"},"caption":{"rendered":"

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