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wmj1<\/a><\/p>\n

G 20438
\nEditorial \u2013 The World Medical Journal 1954 \u2013 2004 \u2013
\nyesterday, today and tomorrow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
\nA Rational Approach To Drug Design . . . . . . . . . . . . . . . . . . . . . . . 2
\nMedical Ethics and Human Rights \u2013 Medicine, the Law and
\nMedical Ethics in a Changing Society . . . . . . . . . . . . . . . . . . . . . . . 5
\nHelsinki and the Declaration of Helsinki . . . . . . . . . . . . . . . . . . . . . 9
\nLinking moral progress to medical progress:
\nNew opportunities for the Declaration of Helsinki . . . . . . . . . . . . 11
\nWMA \u2013 \u00abGetting it Right for our Children\u00bb . . . . . . . . . . . . . . . . . 13
\nMedical Science, Professional Practice and Education \u2013
\nOrthopaedic Surgeons Are Failing To Prevent
\nOsteoporotic Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
\nRelationship Based Health Care in Six Countries . . . . . . . . . . . . . 18
\nWHO \u2013 More Research, More Resources Needed To
\nControl Expanding Global Diseases . . . . . . . . . . . . . . . . . . . . . . . . 19
\nHealth And Finance Ministers Address Need For
\nWorld-wide Increase In Health Investment . . . . . . . . . . . . . . . . . . 20
\nWHO welcomes new initiative to cut the price
\nof Aids medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
\nMaternal Deaths Disproportionately
\nHigh In Developing Countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
\nWMA \u2013 Secretary General: From the Secretary
\nGeneral’s Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
\nRegional and NMA News \u2013 Social Security is a
\nNational Security Issue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
\nHealth Reform in Germany
\n\u00absustaining or diluting social insurance?\u00bb . . . . . . . . . . . . . . . . . . . 24
\nThe South African Medical
\nAssociation’s work on the HIV\/Aids front . . . . . . . . . . . . . . . . . . . 25
\nNorwegian Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
\nU.K.: New report details the impact of smoking
\non sexual, reproductive and child health . . . . . . . . . . . . . . . . . . . . 27
\nFiji and India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
\nBook Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
\nWorld Medical Journal 1954 \u2013 2004
\nLaw and Medical Ethics in a
\nchanging society
\n\u201cGetting it right for our children\u201d
\nNews from the Regions
\nO F F I C I A L J O U R N A L O F
\nT H E W O R L D M E D I C A L A S S O C I A T I O N
\nVOL. 50 NO 1, March 2004
\n50
\nPhoto:Prof.Dr.Dr.M.Putscher
\nHIPPOKRATES
\nANDORRA
\nCol\u2019legi Oficial de Metges
\nEdifici Plaza esc. B
\nVerge del Pilar 5,
\n4art. Despatx 11, Andorra La Vella
\nTel: (376) 823 525 Fax: (376) 860 793
\nE-mail: coma@andorra.ad
\nWebsite: www.col-legidemetges.ad
\nARGENTINA
\nConfederaci\u00f3n M\u00e9dica Argentina
\nAv. Belgrano 1235
\nBuenos Aires 1093
\nTel\/Fax: (54-114) 383-8414\/5511
\nE-mail: comra@sinectis.com.ar
\nWebsite: www.comra.health.org.ar
\nAUSTRALIA
\nAustralian Medical Association
\nP.O. Box 6090
\nKingston, ACT 2604
\nTel: (61-2) 6270-5460\/Fax: -5499
\nWebsite: www.ama.com.au
\nE-mail: ama@ama.com.au
\nAUSTRIA
\n\u00d6sterreichische \u00c4rztekammer
\n(Austrian Medical Chamber)
\nWeihburggasse 10-12 – P.O. Box 213
\n1010 Wien
\nTel: (43-1) 51406-931
\nFax: (43-1) 51406-933
\nE-mail: international@aek.or.at
\nREPUBLIC OF ARMENIA
\nArmenian Medical Association
\nYerevan 375 010
\nTel: (3741) 53 48-63
\nE-mail: armainter@hotmail.com
\nAZERBAIJAN
\nAzerbaijan Medical Association
\nAZE 370001, Baku
\nTel: (994 50) 328 1888
\nFax: (994 12) 315 136
\nE-mail: Mahirs@lycos.com \/
\nazerma@hotmail.com
\nBAHAMAS
\nMedical Association of the Bahamas
\nJavon Medical Center
\nP.O. Box N999
\nNassau
\nTel: (1-242) 328 6802
\nFax: (1-242) 323 2980
\nE-mail: mabnassau@yahoo.com
\nBangladesh
\nBangladesh Medical Association
\nDhaka 1000
\nTel: (880) 2-9568714\/9562527
\nFax: (880) 2 9566060\/9562527
\nE-mail: bma@aitlbd.net.com
\nBELGIUM
\nAssociation Belge des Syndicats
\nM\u00e9dicaux
\nChauss\u00e9e de Boondael 6, bte 4
\n1050 Bruxelles
\nTel: (32-2) 644 -12 88\/Fax: -1527
\nBOLIVIA
\nColegio M\u00e9dico de Bolivia
\nCasilla 1088
\nCochabamba
\nTel\/Fax: (591-04) 523658
\nE-mail: colmedbo@supernet.com.bo
\nWebsite: www.colmedbo.org
\nBRAZIL
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nR. Sao Carlos do Pinhal 324 \u2013 Bela Vista
\nSao Paulo SP \u2013 CEP 01333-903
\nTel: (55-11) 3266 9391
\nFax: (55-11) 3266 6631
\nE-mail: presidente@amb.org.br
\nWebsite: www.amb.org.br
\nBULGARIA
\nBulgarian Medical Association
\n15, Acad. Ivan Geshov
\n1431 Sofia
\nTel: (359-2) 954 -11 69\/Fax:-1186
\nE-mail: usbls@inagency.com
\nWebsite: www.blsbg.com
\nCANADA
\nCanadian Medical Association
\nP.O. Box 8650
\n1867 Alta Vista Drive
\nOttawa, Ontario K1G 3Y6
\nTel: (1-613) 731 9331\/Fax: -1779
\nE-mail: monique.laframboise@cma.ca
\nWebsite: www.cma.ca
\nWebsite: https:\/\/www.wma.net
\nWMA Directory of National Member Medical Associations Officers, Council
\nAssociation and address\/Officers
\nWMA OFFICERS
\nOF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
\nVice-President President Immediate Past-President
\nDr. J.D.Coble Dr. J. Appleyard Dr. K. Millymaki
\nAmerican Medical Association British Medical Association Finnish Medical Association
\n515 North State St. BMA House,Tavistock Square P.O. Box 49
\nChicago, Illinois 60610, USA London WC1H 9JP, UK 00501 Helsinki, Finland
\nTreasurer Chairman of Council Vice-Chairman of Council
\nDr. K. Vilmar Dr. Y Blachar Dr. T.J. Moon
\nGerman Medical Association Israel Medical Association Korean Medical Association
\nHerbert-Lewin Strasse 1 2 Twin Towers, 35 Jabotisky St. 302-75 Ichon1-dong,Yongsan-gu,
\n50931 K\u00f6ln P.O. Box 3566, Ramat-Gan 52136 Seoul 140-721
\nSecretary General
\nDr. D. Human
\nWorld Medical Association
\nBP63, 01212 Ferney-Voltaire Cedex
\nFrance
\nTel (33) 4 50 40 75 75
\nE-mail: delon@wma.net
\nFax (33) 4 50 40 59 37
\ni see page ii
\nOFFICIAL JOURNAL OF
\nTHE WORLD MEDICAL
\nASSOCIATION
\nDr. Alan J Rowe
\nHaughley Grange Stowmarket
\nSuffolk IP 14 3 QT
\nUK
\nExecutive Editor
\nDr. Ivan M. Gillibrand
\n19 Wimblehurst Court
\nAshleigh Road
\nHorsham
\nWest Sussex RH12 2AQ
\nUK
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nOttostr. 12
\nD-50859 K\u00f6ln
\nGermany
\nBusiness Managers
\nH. Dinse, D. Weber
\n50859 K\u00f6ln
\nDieselstra\u00dfe 2
\nGermany
\nPublisher
\nTHE WORLD MEDICAL
\nASSOCIATION, INC.
\nBP 63
\n01212 Ferney-Voltaire, Ledex France
\nPublishing House
\nDeutscher \u00c4rzte-Verlag GmbH, Die-
\nselstr. 2, P. O. Box 400265, 50832 K\u00f6ln\/
\nGermany, Phone (02234) 7011-0,
\nFAX (02234) 7011-255, Postal Cheque
\nAccount: K\u00f6ln 19250-506, Bank: Com-
\nmerzbank K\u00f6ln No. 1500057, Deutsche
\nApotheker- und \u00c4rztebank,
\n50670 K\u00f6ln, No. 01513330.
\nAt present rate-card No. 3a is valid.
\nThe magazine is published quarterly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or the World
\nMedical Association.
\nSubscription fee $ 28.\u2014 per annum
\n(incl. 7% MwSt.). For members of the
\nWorld Medical Association and for As-
\nsociate members the subscription fee is
\nsettled by the membership or associate
\npayment Details of Associate Members-
\nhip may be found at the World Medical
\nAssociation website www.wma@wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nK\u00f6ln \u2014 Germany
\nISSN: 0049-8122
\nThe World Medical Journal 1954 \u2013 2004
\n\u2013 yesterday, today and tomorrow
\nThe issue is the first of the fiftieth volume of the World Medical Journal, which we celebrate
\nwith the appearance of a new style quarterly journal. Readers may not be aware that this
\njournal was not the first \u201dhouse publication\u201d of the WMA. Following the early meetings
\nstarting in 1945 which led to the setting up to the World Medical Association in 1947, a reg-
\nular publication entitled \u201dThe World Medical Association Bulletin\u201d made its first appear-
\nance in 1950. It was printed in three languages, English, French and Spanish and appeared
\nquarterly. The Bulletin of October 1953 was the last, being replaced by World Medical Jour-
\nnal in January 1954. According to the editorial of the first issue, it was renamed \u201dbecause it
\nhas become more important and deserves such a name. It also reduces the possibility
\nof confusion with other bulletins, particularly those published by other international
\nsocieties\u201d. The editorial also comments that as \u201dan official organ for a medical organ-
\nisation, (it) must reproduce the actions of that organisation\u201d. With the new style journal
\nwe intend to enlarge on this by reinstating the views from the desk of the Secretary Gener-
\nal, including reporting on the activities of the Chief Officers. There will also be informative
\nbackground articles on topical issues, some of which may be under consideration by Coun-
\ncil and its committees.
\nInformation about major problems and initiatives of National MedicalAssociations (NMAs)
\nare not only of general interest to members but may also identify issues relevant to the med-
\nical profession in other parts of the world and facilitate exchange of experiences. Therefore
\na new section \u201dRegional and N M A News\u201d will in future appear as a separate section of the
\nJournal. It is appropiate that this new section opens with a contribution from Japan, provid-
\ning an informative and thoughtful background for the Tokyo WMA General Assembly later
\nthis year.
\nArticles will be grouped in sections devoted to \u201dMedical Ethics & Human Rights\u201d, and
\n\u201dMedical Science, professional practice and education\u201d. In these sections it is our aim not to
\nduplicate the plethora of material already available in the journals dealing with scientific and
\ntechnical matters for individual medical disciplines, but to address issues which relate to the
\naims of the WMA. At the same time we will try to reflect the comment in WMJ 1(1) \u201dWhile
\ndoctors are always interested in medical economic and social problems, they also want
\nadditional items, and these must be offered to arouse and maintain interest and sup-
\nport\u201d. This will of course not preclude useful reference to, and comment on, important epi-
\ndemiological, preventive and therapeutic innovations and other issues, including WHO and
\nother relevant international agencies\u2019 initiatives and policies.
\nWith the current trends in globalisation impacting on all parts of society, this cannot be dis-
\nregarded by the medical profession, and increasingly individual physicians are recognising
\nthat these developments affect them directly or indirectly, both personally and in their indi-
\nvidual medical practice. As a non-governmental organisation comprising a membership of
\nnational medical associations, the World Medical Association is in a unique position to in-
\nfluence international opinion, both in the interests of the medical profession and of society
\nwhom it serves. The WMJ therefore aims to inform the profession and hopefully engage its
\nsupport for these WMA activities on its behalf.
\nWe hope that these changes will enhance the value and interest of the Journal as it moves
\ninto its sixth decade and beyond. Meanwhile, during this year we will include some com-
\nmentaries on the remarkable scientific and other changes which have taken place over the
\npast 50 years. In this connection it is interesting to note that in 1954 the first issue of the Jour-
\nnal reported that the Council has discussed \u201dEthical problems of Bacteriological warfare and
\n1
\nEditorial
\nHon. Editor in Chief
\nexperiments on humans\u201d, \u201dpreparation of the programme for the First World Congress on
\nMedical education\u201d, \u201drecommendations to WHO on the International Pharmacopoeia\u201d, and
\n\u201dseeking information from NMAs on Social Security\u201d. It also reported the WHO aid to six
\ncountries to produce antibiotics and insecticides \u2013 with special reference to the problem of
\nmalaria, and WHO\u2019s call for enhanced services to control Tuberculosis. Looking at the
\nmedical scene today one may well comment \u201dplus \u00e7a change, plus c\u2019est la m\u00eame chose!\u201d
\nAlan Rowe
\n2
\nEditorial
\nA Rational Approach To Drug Design
\n\u201dEssentially, health is another name for human harmony, harmony not only among our sev-
\neral parts, but also between ourselves and our environments.\u201d
\nEarle P. Scarlett
\nThe future for delivery of healthcare
\nTechnological advances, increased expectations for medicine, an ageing population and le-
\ngal, ethical and economic factors coupled with a move towards \u201devidence-based\u201d medicine
\nare all driving the rapid change in the delivery of healthcare at the start of the new millenni-
\num.
\nIn a fast-changing world, where increasing healthcare regulation co-exists with globalisation
\nof business, we encounter on a daily basis, more diversity and more uncertainty.
\nAt no other time in global history has healthcare, its benefits, its risks and its structure been
\nso frequently and so widely discussed. From the man in the street through the pressure
\ngroups and governments, everyone is talking \u201dhealthcare\u201d. The language may vary, but the
\ntopics remain the same.
\nBoth as producers and consumers as doctors, patients and healthcare providers, we face
\nhigher demands and higher expectations in targeted drug treatment.
\nOver the years, the pharmaceutical sector has had some notable successes. Antibiotics and
\nvaccines mean that many infections our parents and grandparents feared are now little more
\nthan medical curiosities. Antihypertensives, cholesterol lowering agents and other cardio-
\nvascular drugs are making considerable in-roads into the morbidity and mortality arising
\nfrom the epidemic of heart disease. In the area of osteoporosis, which often leaves sufferers
\ndisabled and debilitated, bisphosphonates are tackling the increasing problem of osteoporo-
\nsis.
\nHowever, pharmacologists cannot rest on their laurels. There is a continuing need for new
\nmedicines. But, finding innovative, more effective and safer drugs is not easy. A recent edi-
\ntorial in Nature noted that some 99.9 % of drugs either fail during development in the labo-
\nratory or during clinical trials. This attrition rate means that the cost of bringing a drug to
\nmarket is around US$ 800 million (Nature 2002). This wastage delays the launch of drugs
\nthat could potentially reduce the morbidity and mortality associated with cancers, heart dis-
\nease, osteoporosis and other common conditions.
\nSo for the last few years, pharmacologists advocated \u201drational drug discovery\u201d and \u201dratio-
\nnal drug design\u201d as ways to reduce the attrition rate, lower development costs and advance
\ndrugs to market more rapidly. \u201dRational
\ndrugs discovery is a systematic process
\nbased on screening for a particular biologi-
\ncal effect,\u201d explains Professor Philippe Van
\nder Auwera, Lifecycle Leader Roche Basel.
\n\u201dRational drug design uses our intimate
\nknowledge of the target\u2019s molecular shape
\nand structure to develop specific medi-
\ncines.\u201d Both approaches offer powerful
\nmethods for discover of new medicines.
\nTrack record
\nIn some ways, of course, drug discovery has
\nalways been rational \u2013 at least within the
\nprevailing intellectual culture. In the mid-
\neighteenth century, for example, the Rev-
\nerend Edward Stone of Chipping Norton in
\nOxfordshire, England developed a new
\ntreatment for fever. As he explained later,
\nthe idea was a rational extrapolation of the
\nprevailing scientific view that \u201dremedies lie
\nnot far from their causes\u201d. Swamps and
\nmarshes, doctors believed, caused fevers
\nand agues. Willow grows near swamps and
\nmarshes. Ergo, willow should cure fevers.
\nThe discovery that willow bark was an ef-
\nfective treatment for fever led, ultimately, to
\naspirin\u2019s development (Vane 2000) Al-
\nthough scientists no longer accept the logic,
\nStone\u2019s discovery was an example of ratio-
\nnal drug discovery within the intellectual
\nframework of the time.
\nProbably the first drug to emerge from a
\nmodern rational drug design programme
\nwas the angiotensin converting enzyme
\n(ACE) inhibitor captopril. ACE is an en-
\nzyme that cleaves an inactive precursor to
\nproduce the protein angiotensin II. This con-
\ntrols blood pressure by action of the heart,
\nblood vessels and kidneys. In the 1950s,
\nSergio Farreira, in Sao Paulo, found that the
\nBrazilian pit viper\u2019s venom contains pep-
\ntides that inhibit an enzyme that degrades
\nanother protein called bradykinin. Eventual-
\nly, researchers recognised that ACE and the
\nenzyme that degraded bradykinin were
\nidentical. One of the venom\u2019s peptides \u2013
\nteprotide \u2013 lowered blood pressure when
\ngiven to humans. Researchers from Squibb
\nidentified teprotide\u2019s active site and devel-
\noped specific inhibitors. Captopril was the
\nfirst of the ACE inhibitors to reach the mar-
\nket (Landau 1999 p 186\u2013187).
\nOn the other hand, for scientists to recognise
\nthat an idea is \u201drational\u201d, it must link logi-
\ncally to other aspects of the current knowl-
\nedge base. If not, scientists tend to dismiss
\nor ignore the idea \u2013 however rational it
\nseems in retrospect. For instance, DNA was
\nfirst discovered as a constituent of the nu-
\ncleus of living cells by the Swiss biochemist
\nFrederick Miescher in 1869, but not until
\n1953 was its true nature as the unique sub-
\nstance of heredity identified. But the intel-
\nlectual framework was not in place for other
\nbiologists to appreciate its importance be-
\nfore the pioneering work of James Watson,
\nFrancis Crick and Maurice Wilkins was
\nawarded the Nobel Prize in 1962. This was
\nbased on their model building of the con-
\nstituent DNA base pairs and Rosalind
\nFranklin\u2019s X-ray diffraction patterns of the
\nDNA double helix. Even today the proper-
\nties of the genes remain elusive, despite our
\nknowledge of the complete sequence of the
\nhuman genome, in terms of embryonic
\ngrowth, organ development and the phased
\nswitching on and off for gene sequences in
\nhuman development.
\nMendel\u2019s work lay unread for years, partly
\nbecause his findings about inherited charac-
\nteristics did not fit in the prevailing intellec-
\ntual paradigms4
\n(Sacks 1997 p. 158). More-
\nover the now well-accepted idea that viruses
\ncaused some cancers proved so controver-
\nsial that one of the concept\u2019s pioneers was
\nvirtually ostracised by some of his col-
\nleagues5
\n(Kevles 1997 p. 82\u20133).
\nSuch examples are relatively rare, however.
\nRational drug discovery and computer-aid-
\ned design are emerging as valuable means to
\ndevelop new medicines. The explosion in
\nthe number of possible drug targets arising
\nfrom, in part, genomics, gave the move to-
\nwards rational drug discovery and design
\nextra impetus.
\nAround 1,000 disease genes might be rele-
\nvant for therapeutic development by big
\nbusiness. Not all these offer direct therapeu-
\ntic targets. However, many disease genes are
\nlinked to between 5 and 10 physiological or
\npathological proteins that might offer alter-
\nnative targets. Thus, the total number of
\npossible drug targets might lie between
\n5,000 and 10,000. Drugs available in 1996
\ntargeted just 483. In other words, there are at
\nleast 10 times as many molecular targets
\nthan the pharmaceutical sector currently ex-
\nploits6
\n(Drews 2000). Screening all these us-
\ning conventional drug discovery techniques
\nwould prove impossible.
\nFortunately, rational drug discovery through
\nmolecular biology offers powerful means to
\ndevelop, prioritise and test medicines aimed
\nat these targets. For example, during rational
\ndrug discovery, researchers systematically
\nscreen compounds against the target. The
\nscreening test depends on the disease and
\ntarget. So researchers could use the strength
\nof the drugs\u2019 binding to a particular receptor
\ninvolved in blood pressure control for an an-
\ntihypertensive, or an ability to inhibit osteo-
\nclasts when screening for a drug for osteo-
\nporosis. However, all screens need to be
\nvery sensitive \u2013 so that researchers do not
\nmiss a potential drug \u2013 and also specific, to
\navoid false leads.
\nTraditionally, screening was time consum-
\ning, especially when using biological
\nscreening systems such as cells or even ani-
\nmals. In some cases, researchers had no al-
\nternative but to test every possible drug on
\nanimals. However, recent technological ad-
\nvances, in particular, high throughput
\nscreening (HTS) and laboratory robotics
\ndramatically increase productivity. Auto-
\nmated HTS can test some 10,000 possible
\ndrugs against the target each day, without
\nusing animals. Increasingly sophisticated
\ncomputer programs can prioritise the hits
\nfor further development.
\n\u201dAt first, there is a disease and a \u2018dream\u2019,
\nsuch as inhibiting osteoclasts to alleviate os-
\nteoporosis,\u201d says Professor Van der Auwera.
\n\u201dWe then identify a potential molecular tar-
\nget, such as a receptor or enzyme, based on
\nliterature and pathophysiological research.
\nIf the target can be isolated, we clone it us-
\ning genetic engineering. This allows us to
\nbuild a specific and sensitive screening as-
\nsay. But in many cases we don\u2019t know the
\ntarget. So, we have to identify the gene\u2019s
\nfunction and, if applicable, the gene prod-
\nuct, the latter using so-called proteomic ap-
\nproaches. However, identifying what the
\nproduct does in the body \u2013 a procedure
\ncalled functional genomics \u2013 can be a real
\nnightmare. But ultimately we are usually
\nable to identify a target that we can produce
\nin large quantities for high-throughput
\nscreening assays.\u201d
\nFor example, researchers developed iban-
\ndronate using a rat model that induced hy-
\npercalcemia (raised calcium levels in the
\nblood) using retinoids. This example of ra-
\ntional drug discovery uses the rise in serum
\ncalcium levels as a marker for increased os-
\nteoclast activity. In this model, bisphospho-
\nnates and other drugs targeting the osteo-
\nclasts lead to lower calcium levels compared
\nto controls. Recently, the target of a drug
\nlike ibandronate has been identified and
\ncould be used to better understand the inter-
\naction between the enzyme [fiarnesyl dis-
\nphosphate (FPP) synthase] and its specific
\ninhibitor. The enzyme activates essential in-
\ntracellular signalling proteins (\u201dintracellular
\nhormones\u201d) which regulate a variety of cell
\nprocesses important for osteoclast function.
\nWhen these signalling proteins are no
\nlonger activated, the osteoclast triggers its
\napoptosis (programmed cell death).
\nGene expression
\nRational drug design takes a different ap-
\nproach. A gene encodes a protein. But this
\nprotein is rarely the final biologically active
\nform. Often the \u201dfirst generation\u201d gene
\nproduct undergoes considerable modifica-
\ntion in the cell\u2019s cytoplasm. Enzymes in the
\ncell may, for example, cleave the active pro-
\ntein from the precursor \u2013 as ACE does to
\nform angiotensin II. In other cases, the cell
\nadds sugars to the protein backbone. More-
\nover the allostery between the amino acids
\nin the protein means that the protein folds
\ninto a complex three-dimensional shape, to
\nachieve its biological effect.
\nEven a single acid change can dramatically
\nalter the protein\u2019s three-dimensional shape
\nand function. That is one reason why muta-
\ntions and polymorphisms, which often sub-
\ntly change the amino acid sequence, can so
\ndramatically influence the risk of develop-
\ning a particular disease.
\nSo genetically encoded differences in the vi-
\ntamin D receptor seem to influence patients\u2019
\nrisk of developing osteoporosis7
\n(for exam-
\n3
\nEditorial
\nple, Tofteng 2002). The mutation alters vita-
\nmin D\u2019s ability to bind to its receptor. As vi-
\ntamin D contributes to bone mineral density,
\nthe reduced binding ultimately weakens the
\nskeleton.
\nResearchers can grow crystals of these pro-
\nteins. By examining the way in which the
\ncrystal scatters X-rays, biologists can gain an
\ninsight into the protein\u2019s structure. A comput-
\ner can integrate these X-ray results with the
\nprotein sequence to show the shape of, for
\nexample, a receptor or an enzyme. This al-
\nlows researchers to home in on the active site
\nand design drugs that fit specifically into the
\nsite-rather like a lock and key mechanism.
\nNevertheless, validating targets can prove dif-
\nficult, especially when the lead comes from
\ngenomic rather than clinical studies. \u201dTradi-
\ntionally, we associate the target and the dis-
\nease from clinical studies. So we knew from
\nclinical and pathophysiological studies that,
\nin comparison to osteoclasts (bone forming
\ncells), overactive osteoclasts contribute to
\nlow bone mass,\u201d Professor Van der Auwera
\ncomments. \u201dHowever, genomic studies link a
\ngene to the disease. Discovering what the
\ngene\u2019s product does can be difficult. Knock-
\nout animals, which are genetically engineered
\nnot to express the gene, are fashionable and in
\nmany cases allow us to better understand the
\nlink with the disease. Nevertheless, we often
\nhave to go to phase II or even phase III clini-
\ncal studies to validate the target \u2013 which has
\nan enormous failure rate! Nevertheless, as we
\nhone our understanding of the gene\u2019s func-
\ntion, our failure rate is declining.\u201d
\nDrug discovery
\nAgainst this background, the next generation
\nof drugs for osteoporosis is likely, Professor
\nVan der Auwera believes, to emerge from ra-
\ntional drug design and discovery. \u201dMolecular
\nbiology and genomics identified many targets
\nthat either reduce resorption or increase bone
\nformation,\u201d he says. \u201dHowever, ibandronate
\nand the other anti-resorptive agents are now
\njust about as effective as they can be. Any ad-
\nvances in anti-resorptive agents are likely to
\nbe relatively minor, such as enhancing safety,
\ntolerability and convenience. The key objec-
\ntive today is finding a drug to stimulate an-
\nabolism, the formation for new bone.\u201d
\nFor example, Professor Van der Auwera notes
\nthat up to half the patients using current oral
\nbisphosphonates may stop taking the treat-
\nment within a year, which precludes any re-
\nduction in the risk of sustaining a fracture.
\n\u201dTreatment schedules such as a once a month
\ntablet, instead of weekly (52 tablets) or daily
\n(365 tablets) can make a huge difference to
\ncompliance\u201d, he comments. \u201dLikewise for
\npatients already taking lots of oral medica-
\ntion, a quarterly intravenous injection can al-
\nlow them to benefit from a very effective
\nmedicine that they would not otherwise take.\u201d
\nProfessor Van der Auwera adds that in addi-
\ntion to optimising anti-resorptive agents, an-
\nother key objective for researchers is to find
\ndrugs that stimulate the formation of new
\nbone (anabolism). \u201dIt is predictable that, at
\nleast for patients with the most severe bone
\nloss, combination or sequential therapy with
\nan anabolic drug, probably for a short period
\nsuch as 6 months, and an anti-resorptive agent
\nwill become the rule. So we need \u2018smart\u2019
\ntreatment schedules allowing the patients to
\nimprove their quality of life without the con-
\nstant reminder of their disease.\u201d
\nIn many ways, drug discovery has always
\nbeen rational. But biologist\u2019s limited under-
\nstanding of the body\u2019s complexities hindered
\nattempts to develop targeted drugs.And tradi-
\ntionally time-consuming screening slowed
\nthe development of much needed medicines.
\nToday, the genomics revolution has massive-
\nly increased biologists\u2019 understanding of the
\nnature of common diseases and identified a
\nplethora of possible targets. Fortunately, ra-
\ntional drug design and development give re-
\nsearchers the power to identify and develop
\nspecific and selective drugs that target a sin-
\ngle cell type or even a single gene product.
\nThe possibilities for new medicines tackling
\nsome of the commonest diseases seem end-
\nless.8
\nModern pharmacological
\nadvances
\nEpilepsy
\nAround 30 % of patients diagnosed with
\nepilepsy fail to respond to prescribed
\nantiepileptic drugs and continue to have
\nseizures. These refractory seizures are asso-
\nciated with increased mortality and psy-
\nchosocial morbidity and pose an enormous
\nhuman and financial burden. Notwithstand-
\ning the seriousness of the problem, remark-
\nably little attention has been paid to the bio-
\nlogical basis of refractory epilepsy. Workers
\nin the field of epilepsy-those concerned with
\nthe basic science of resistance and the
\nblood-brain barrier, and those with clinical
\nexperience of drug resistance in cancer are
\ncollaborating with a view to exploring par-
\nallels between the fields and suggesting fur-
\nther potentially profitable avenues for ex-
\nploration on drug resistance in epilepsy.
\nAgeing
\nSocial and medical developments during the
\npast century have led to a dramatic increase
\nin life expectancy. The study and under-
\nstanding of the endocrine organismic
\nchanges associated with ageing are there-
\nfore matters of urgency. Basic scientific
\nfacets and clinical aspects relevant to age-re-
\nlated changes in the multiple endocrine sys-
\ntems have been discussed. The implications
\nof therapeutic reconstitution with hormones
\nin the elderly, could be very important in the
\nfuture.
\nMucus hypersecretion in respiratory disease
\nA number of chronic respiratory diseases in-
\ncluding chronic bronchitis, asthma, cystic
\nfibrosis and bronchiectasis are characterised
\nby mucus hypersecretion and this excessive
\nmucus production can lead to a pathological
\nstate with increased risk of infection, hospi-
\ntalisation and morbidity. Despite a high and
\nincreasing prevalence and cost to healthcare
\nservices and society, this phenomenon has
\nreceived little attention until recently, prob-
\nably because of the difficulties inherent in
\nstudying its pathology. Basic scientists and
\nclinicians need to discuss recent advances
\nand their implications for the development
\nof novel, rational therapies, particularly as a
\npotential cure for CF is on the horizon.
\nAutism as a spectrum
\nTwin and family data convincingly indicate
\nthat the heritability for the underlying liabil-
\nity to autism exceeds 90 % and these studies
\npoint to a multi-factorial causation involv-
\ning an interaction among a relatively small
\nnumber of susceptibility genes. New tech-
\nniques are now available for examining the
\n4
\nEditorial
\nneurobiology of autism and imaging studies
\nhave been used to explore the contributions
\nof different brain regions. The most impor-
\ntant practical question facing medical and
\npsychological practitioners is how to help
\nchildren with autism. Data on possible psy-
\nchological or psychiatric interventions for
\nrehabilitation of children with autism need
\nto be thoroughly investigated in child pa-
\ntients in order to prove the link between
\nMMR injections, inflammatory bowel dis-
\nease and autism.
\nDesign of new drugs
\nBiological modelling and oscillatory prop-
\nerties represent fundamental approaches to
\ncollating data on gene structure and func-
\ntion. Since cell signalling systems form a
\nparticularly complicated aspect of all cellu-
\nlar function and are extremely important
\nboth in the understanding of basic cellular
\nprocesses and in the practical problems of
\nselecting targets for drugs, much work has
\nbeen devoted to integrating data on cell sig-
\nnalling into computer models. Building on
\nthese approaches, computerised models of
\nintact cells and ultimately of whole organs
\ncan be developed. Not only do computer
\nmodels aid understanding of the basic na-
\nture of biological systems, but they also
\nhelp in the design of new drugs for specific
\ndiseases.
\nThe intrinsic measurement of time in
\nbiological systems
\nThe primary hallmark of biological clocks is
\ntheir ability to entrain to environmental stim-
\nuli and the dominant, and therefore physio-
\nlogically most important, entraining stimu-
\nlus comes from environmental light cues.
\nThe classical view of the circadian system
\ndescribes it as diverse physiological rhythms
\nregulated by a centralised clock structure.
\nData coming from both vertebrate and inver-
\ntebrate systems have challenged this view,
\ndemonstrating that the circadian timing sys-
\ntem is dispersed throughout the animal and
\nthat possibly every cell contains a functional
\ncircadian clock. The mechanism of light sig-
\nnalling to the vertebrate clock, the connec-
\ntions between central and peripheral clocks,
\nthe genetics of the clock and clock proteins
\nremain to be evaluated at the molecular lev-
\nel, for example pairs of enzymes working in
\nharmony across membrane.
\n5
\nCalcium ion flux in smooth muscle
\nIon channels play a crucial role in regulating
\ndiverse cell functions in both electrically ex-
\ncitable and non-excitable cells, and have
\nbeen found in organisms ranging from
\nviruses and bacteria to plants and mammals.
\nAn increasing number of diseases (\u201dchan-
\nnellopathies\u201d) are associated with dysfunc-
\ntion of ion channels. Control of calcium ion
\nflux and compartmentalisation in terms of
\ntheoretical biology would be illuminated by
\nG the structure of channels and pores,
\nG computer simulations of channel func-
\ntion, and
\nG detailed data on potassium channels,
\nchloride and calcium channels and lig-
\nand-gated ion channels.
\nSmooth muscle contraction is crucial to
\nhealth as in, for example, blood vessels, the
\nuterus, airways and bladder and its malfunc-
\ntion can lead to serious pathological condi-
\ntions such as hypertension and pre-term
\nlabour. The calcium ion plays a central role
\nin its function, increasing in concentration
\nfor contraction and decreasing for relax-
\nation. The source of calcium is through entry
\nacross the surface membrane and release
\nfrom the sarcoplasmic reticulum (SR). How-
\never, recent data have challenged the view
\nthat the SR is simply a source and sink of
\ncalcium ions. Indeed the SR probably also
\nacts to limit contraction, via ion channel-
\nbased feedback mechanisms. There is a
\nmost important relationship between calci-
\num release and inhibition and\/or promotion
\nof contraction, the control and modulation
\nof the SR in smooth muscle, the extent to
\nwhich the SR may vary between smooth
\nmuscles and therefore potential therapeutic
\nimplications.
\nReferences
\n1. Editorial \u201cBigger isn\u2019t always better\u201c Nature
\n2002; 418: 353.
\n2. Vane JR The fight against rheumatism: from
\nwillow bark to COX-1 sparing drugs. J Physiol
\nPharmacol 2000; 51: 573\u201386.
\n3. Landau R, Achilladelis B and Scriabine A eds
\nPharmaceutical Innovation Chemical Heritage
\nPress 1999.
\n4. Sacks O Scotoma: Forgetting and neglect in sci-
\nence in Silvers RB (ed) Hidden histories of sci-
\nence Granta 1997.
\n5. Kevles DJ Pursing the unpopular in Silvers RB
\n(ed) Hiddeen histories of science Granta 1997.
\n6. Drews J Drug discovery: A historical perspec-
\ntive Science 2000; 287: 1960\u20134.
\n7. Tofteng CL, Jensen JE, Abrahamsen B, et al.
\nTwo polymorphisms in the vitamin D receptor
\ngene-association with bone mass and 5-year
\nchange in bone mass with or without hormone-
\nreplacement therapy in postmenopausal women:
\nthe Danish Osteoporosis Prevention Study. J
\nBone Miner Res 2002; 17: 1535\u201344.
\n8. Osteoporosis Care Club e-bulletin, Issue 4, pp
\n8\u201312, October 2002,
\nIvan M. Gillibrand
\nPaula Kokkonen, LL.M., Director Gener-
\nal, National Authority for Medico-legal
\nAffairs, Finland
\nAddress given at the Ceremonial Session of
\ntheWorld Medical Association, Helsinki 2003
\nFirst of all I wish to express my great plea-
\nsure for this opportunity to address such an
\ninfluential audience as represented by this
\nWMA General Assembly. You represent a
\nprofession which in well organised coun-
\ntries issues both birth and death certificates,
\nMedical Ethics & Human Rights
\nMedicine, the Law and Medical Ethics in a
\nChanging Society
\nMedical Ethics & Human Rights
\nthus controlling human life not only when
\npeople are patients, but also at the beginning
\nof life and at its end. This fact leads to dis-
\ncussion of power, responsibility, liability,
\nethics, trust and control.
\nThe medical profession has for a long time
\nbeen in the forefront of discussions on Med-
\nical Ethics. You all know very well the his-
\ntory of the WMA, established in Paris in
\n1947 due to the acts that had been revealed
\nduring the Nuremberg trials.
\nAlthough I usually present myself as a
\nlawyer who has sacrificed her life for medi-
\ncine, I have tried to bridge the two disci-
\nplines – Law and Medicine – both at home
\nand also \u00abglobally\u00bb. Thus I thought that it
\nmay be worth while drawing your attention
\nto the existence of the World Association for
\nMedical Law. The purposes of this associa-
\ntion are
\n\u2013 to encourage the study and discussion of
\nproblems concerning Medical Law and
\ntheir possible solutions, in ways that are
\nbeneficial to humanity,
\n\u2013 to promote the study and discussion of
\nnew developments in medicine and re-
\nlated sciences,
\n\u2013 to address any matters that involve is-
\nsues of Health Law.
\nThe Association was founded in Gent, Bel-
\ngium in 1967, that is twenty years later than
\nthe WMA. This is a very concrete sign that
\nthe Law usually follows behind the ethics. I
\nhope that the gap will be less than twenty
\nyears today.
\nAt the time when the Association was
\nfounded, \u00abMedical Law\u00bb was the term used.
\nThe question as to whether we should use
\nthe term \u00abHealth Law\u00bb instead has recently
\nbeen raised. This discussion reflects very
\nwell the developments in the health-care
\nfield. Modern health-care is a very complex
\nteamwork of many actors and disciplines.
\nThis is also reflected in the legislation.
\nThe development of science has created a
\nworld where we live much longer than did
\nour ancestors. Many of us who live in the so-
\ncalled developed countries have a curricu-
\nlum of diseases each of which would have
\nkilled our ancestors. There are many actors
\ninterfering in the doctor-patient relation-
\nship. One of them is society, which often
\nbears the major part, if not all of the costs of
\nhealth care. In Democracies, the modern
\nway to organise relationships between indi-
\nviduals and between citizens and society is
\nto use legislation as well as agreements.
\nEarlier, Medical Law was very much in-
\nvolved in questions like setting limits for
\n\u00abthe profession\u00bb (i. e. medical doctors),
\ndrafting legislation concerning patients with
\ncontagious diseases, involuntary care of the
\nmentally ill etc. Then came the discussion of
\nmedical negligence, and slowly after that, of
\npatients’ rights. Patients were not any more
\nconsidered as material, but they were indi-
\nviduals who had a say in their own treat-
\nment. By this time the scientific develop-
\nments in medicine had been enormous. Pa-
\ntients could in many cases be offered the
\nchoice of their own preferred treatment from
\namongst a few alternatives. This again in-
\ncreased the demand for more information in
\norder to allow patients to really make an in-
\nformed choice.
\nThe result of this, we can recognise in pa-
\ntient insurance schemes and legislation, and
\nalso legislation on patients’ rights. The Pa-
\ntients’ Rights movement can be seen as an
\nreflection of the modern discussions
\nstrengthening human rights and consumer
\nrights.
\nFrom Ethics to Law and Law
\nto Ethics
\nIn \u00abwestern societies\u00bb, a Law passed in Par-
\nliament reflects the stage of common agree-
\nment. Legislation thus consists of the ethical
\nminimum.
\nThe values documented and instructions
\ncommonly and voluntarily accepted by the
\nmembers of a given association or profession
\nare called ethical rules. The most well-known
\nof them is, as this audience knows, the Hip-
\npocratic Oath, which focussed on the rela-
\ntions between doctors and doctors vis-a-vis
\ntheir patients.
\nEthical rules drafted lately by the WMA have,
\nto my mind, approached legislation. They aim
\nat giving concrete directives in anticipation of
\nforeseeable conflicts. Like legislation, ethical
\nrules are based on facts and values. Values are
\nculturally bound and thus stand in relation to
\na given society and time. Ethical rules are of-
\nten compromises that lie on sound ethical
\ngrounds but to which reservations can be
\nmade, and from which it is possible to deviate
\nunder special circumstances.
\nEthical discussions in medicine focused first
\n(with the Hippocratic Oath) on the character-
\nistics of the doctor, and the point of departure
\nwas that a good doctors performs good deeds.
\nWider ethical discussion in medicine dates
\nback to the Nuremberg trials and the event in
\nHiroshima. It was realised that ethical discus-
\nsion in medicine and in medical research can-
\nnot be limited to the medical profession, but
\nthat society at large has the right to a dia-
\nlogue.
\nHuman dignity, autonomy and the right to
\nself-determination have been the focus of the
\ndiscussion since the Nuremberg trials. The
\nabove mentioned values have also been docu-
\nmented in many human rights texts such as
\nthe Universal Declaration of Human Rights
\n(1948), International Covenants on Econom-
\nic, Social and Cultural Rights and on Civil
\nRights (1966) and the European Convention
\non Human Rights (1959), as well as the Con-
\nvention on Bioethics of the Council of Eu-
\nrope, which is the latest of them and entered
\ninto force on December 1st 1999.
\nThe values expressed in the Human Rights
\ndocuments mentioned above are appropriate
\nfor legislation as well. In fact they are includ-
\ned in many Constitutions – not to mention oth-
\ner legislation.
\nWhy doesn’t the system work in a satisfacto-
\nry way although there are so many rules? One
\nof the reasons is probably the fact that the
\ngood principles cannot easily be found from
\nthe sources mentioned earlier. Or if they are
\nfound they need interpretation, which is not
\nvery easy even for lawyers, not to speak of
\nlay-people.
\nMedical Ethics or health-care
\nethics draws a great deal of
\nattention
\nMost of the topics discussed in the sphere of
\nmedical ethics have been discussed during
\ndecades. To these topics belong the begin-
\nning of life as well as the end of it. We have
\n6
\nMedical Ethics & Human Rights
\nbeen able to witness how insemination has
\nbeen developed into assisted reproduction
\nand surrogate motherhood. Mercy killing is
\nnot any more offered as a topic for scientific
\nmeetings, but euthanasia and terminal care,
\nas well as assisted suicide are. Dialysis has
\nbeen changed into transplantation, which has
\nbrought about a new type of scarcity discus-
\nsion. This Discussion has escaped the cabi-
\nnets where doctors used to take difficult de-
\ncisions as to who was to get dialysis and live,
\nand who was not. International declarations,
\nas well as many Constitutions secure the
\nright to health care. What does this mean in
\nthe era of priorities?
\nThe Transplantation debate has reached the
\nlevel where many countries have already for-
\nbidden the selling of human organs. Interna-
\ntional Declarations and Conventions also
\ncondemn buying and selling of organs. Yet
\nthere are actors who advocate in favour of
\ncommercial activities in this field, arguing
\nthat a poor person should not be denied the
\nright to improve his\/her standard of living by
\nselling organs to those in need. The argu-
\nmentation is that this would just be using fi-
\nnancial incentives and commercial consider-
\nations to save lives.
\nHuman cloning can be used for the develop-
\nment of tissue for transplantation, but
\n\u00abcloning\u00bb can also refer to a wide range of
\nactivities, from bringing into existence ge-
\nnetically identical individuals to pre-implan-
\ntation diagnostics. Distinctions between var-
\nious techniques need to be drawn, and their
\nacceptability has to be discussed thoroughly.
\nWhen discussing ethics and legislation, it is
\nuseful to keep in mind that theoretical dis-
\ncussion may widen our perspectives and give
\nnew ideas. It may thus enrich our thinking
\nand decision making, and will help us to
\nrecognise at least our own motives.
\nLay-people very often think that legislation
\nis an open process of fundamental thinking
\nand great elegance, as the ideal would de-
\nmand. The common truth is very different.
\nOpen, profound discussion is often either ab-
\nsent or takes place in very small circles.
\nHealth-care is an area of great common in-
\nterest. There has been, still is, and may be
\neven a growing tendency to try to increase
\nthe sphere of health-care. There is a tenden-
\ncy to try to medicalise social problems and
\nask doctors to testify more and more in mat-
\nters that are not medical, or to ask them to
\nisolate people for reasons other than med-
\nical. In our society we are to discuss for
\nwhom we are designing health-care services,
\nand what are the values of the population.
\nPressure, routine generally accepted behav-
\niour, and the atmosphere, may be used as an
\nexcuse to deviate even from the ethical prin-
\nciples accepted by ourselves. The most com-
\nmon excuse is, of course, that the patient
\ndoes not really understand his\/her own best
\ninterest. But this way of thinking brings us to
\na weak soil, both ethically and legally.
\nIn health-care we need both legislation and
\nethical rules. The aim of both is to promote
\nco-operation and minimise conflicts.As time
\npasses our values may change, and the leg-
\nislative process is often rather slow. In the
\nmeantime ethics may guide us and cast a
\nlight for the developing legislation. An ex-
\nample of ethical discussion leading to legis-
\nlation is The Finnish Law on the Status
\nand Rights of a Patient.
\nFinnish Law
\nFollowing a long-almost twenty years de-
\nbate, the Law on the Status and Rights of a
\nPatient was finally passed in the Finnish Par-
\nliament in 1992 and it entered into force on
\n1st March 1993, ten years ago.
\nIn all legislative work, the history and cul-
\ntural tradition of a country, as well as previ-
\nously existing legislation and administrative
\nsystems and structures, have to be taken into
\nconsideration. Legislation may be described
\nas a safety net. If you are going to mend the
\nnet, you have to know where the holes are.
\nThus I do not offer our law as a global solu-
\ntion applicable to all societies and problems
\na patient may ever experience in the field of
\nhealth-care.
\nOur law regulates, inter alia, the patients’
\nright to good health care, to medical care
\nand related treatment when needed; the right
\nof access to treatment, to be informed and of
\nself-determination; the status of minor pa-
\ntients; emergency treatment; powers of the
\nrepresentatives of the patient in certain situ-
\nations, and a new complaint procedure.
\nIt also establishes a Patient Ombudsman in-
\nstitution.
\nRight to care
\nEvery person who stays in Finland perma-
\nnently is entitled, without discrimination, to
\nthe health and medical care required by
\nhis\/her state of health, within the limits of
\nresources available to health care at the time
\nin question.
\nThis provision has drawn much attention
\nnow that the discussion concerning the divi-
\nsion of scarce resources has once again sur-
\nfaced. It was originally designed with the
\nnotion in mind that society has the right to
\nlimit how much and what kind of care it pro-
\nvides for its citizens. (There had at that time
\nbeen cases of Finnish citizens demanding
\nthat they be sent abroad at society’s expense
\nfor treatment which was not available in
\nFinland.)
\nThe care has to be of good quality, the pa-
\ntients’ dignity must not be violated and
\nher\/his individual needs and culture have to
\nbe taken into account as far as possible.
\nThese provisions sound perhaps like mere
\ndeclarations, but they are still important.
\nThey can be especially important in cases
\nwhere psychiatric care is required, since
\nmental patients and their relatives are, at
\nleast according to our Finnish experience,
\nvery often not capable of defending their
\nown rights.
\nPatient’s right to be informed
\nThe right to information is closely connect-
\ned to the right of self-determination, be-
\ncause the latter cannot be exercised without
\nthe former.
\nHow much information and in which form it
\nis given to patients, seems to vary between
\ncountries. The right to information has dur-
\ning the last quarter of the century, been in-
\ncreasingly emphasised in Finland.Yet, judg-
\ning from the patients’ complaints the situa-
\ntion is far from satisfactory. The law speci-
\nfies that various alternative methods of treat-
\nment and their effects have to be explained
\nto the patient. It is noteworthy that the law
\n7
\nMedical Ethics & Human Rights
\nalso gives the patient the right not to know,
\nand the \u00abtherapeutic exception\u00bb \u2013 the with-
\nholding of information from the patient in
\ncertain cases. The information to be given
\nshould be tailored to the individual patient
\nand interpreters should be used if needed.
\nPatients’ right to self-determi-
\nnation
\nWith the provision of health care, a mutual
\nunderstanding between patient and care-
\ngiver must exist. If the patient refuses a cer-
\ntain treatment or measure s\/he has to be
\ntreated according to the possibilities provid-
\ned by another medically acceptable way, in
\nmutual understanding. There had been cas-
\nes in which, for example, a terminal cancer
\npatient had refused radiation because of
\nside effects. This led to a discussion in
\nwhich the patient was threatened with de-
\nportation.
\nThere are also provisions in the law accord-
\ning to which a legal representative etc. can
\ninterpret the patient’s will. It is, however, to
\nbe emphasised that it is the patient’s will
\nwhich is decisive and not the representa-
\ntives. If the patient’s will cannot be assessed,
\nthat patient has to be given the treatment that
\ncan be considered to be in accordance with
\nhis\/her personal interests.
\nEmergency treatment
\nA patient has to be given treatment necessary
\nto ward off a hazard imperilling her\/his life
\nor health even if it is not possible to assess
\nthe patient’s will because of unconsciousness
\nor other reason. However, if the patient has
\npreviously steadfastly and competently ex-
\npressed her\/his will concerning the treatment
\ngiven to her\/him, s\/he must not be given
\ntreatment that is against her\/his will.
\nThe latter part of this section is aimed at
\nguaranteeing the patient’s right to self-de-
\ntermination. For instance, the patient’s
\nright to draft a valid \u201eliving will\u201c is based
\non this provision, as is the right of an adult
\nJehovah’s Witness to refuse a blood trans-
\nfusion even after losing consciousness \u2013
\nboth are topics constantly debated in
\nhealth care.
\nComplaints
\nA patient who is not satisfied with the health
\ncare or medical care and related treatment
\nreceived by her\/him, has the right to make a
\ncomplaint on the matter to the director re-
\nsponsible for the health care unit in ques-
\ntion. A decision on the complaint must be
\ngiven within a reasonable time after the
\nmaking of a complaint.
\nMaking a complaint does not restrict the
\nright of a patient to appeal to the authorities
\ncontrolling health care or related treatment
\nreceived by her\/him.
\nIf, once the complaint has been dealt with it
\nbecomes obvious that the care or treatment
\nof the patient my cause liability for patient
\ninjury, indemnification liability, taking legal
\naction, cancelling or restricting the right of
\nvocational practice of health care staff, or
\ntaking disciplinary proceedings, the patient
\nshall be advised as to how the matter can be
\ninitiated through a competent authority or
\norgan.
\nWhen investigating a complaint, special at-
\ntention is paid to patient safety, the equality
\nof citizens, and good service to consumers
\nof health services.
\nPatient Ombudsman
\nA Patient Ombudsman, who may also be
\ncommon for two or more units, has to be ap-
\npointed for health care units. The tasks are to
\nadvise patients on issues concerning the ap-
\nplication of the Law on Patients’ rights, to
\nhelp patients in complaints and liability
\nquestions, to inform patients of their rights,
\nand to act also for the promotion and imple-
\nmentation of patients’ rights.
\nThere are hundreds of Patient Ombudsmen
\nin Finland. The National Authority of
\nMedico-legal affairs has organised sym-
\nposia for them at the State level, and the
\nProvincial Boards at the provincial level.
\nEthics and Law
\nThe Law on Patients’ Rights is our attempt
\nin Finnish society to try to clarify and to
\nstrengthen a few of those rights of patients
\nwhich in everyday clinical practice, seem to
\nhave caused insecurity, and have resulted in
\nvarying interpretations and complaints to
\nsupervising authorities. We have tried to
\nkeep in mind that the rights of the health-
\ncare personnel and the patients ought not to
\nconflict but should be seen as complemen-
\ntary.
\nIt is obvious that we need both Ethical Rules
\nand Law. Nowadays they seem to be in in-
\nteraction. Health care professionals are very
\nconscious about the situation. Professional
\norganisations, both domestic and interna-
\ntional, draft Ethical Rules with the aim of
\nimproving quality control of the work of
\ntheir members. Yet society also drafts legis-
\nlation, as it wants to control the professions
\nand the work of professionals, and to guide
\nthem.
\nThe training and curricula of health care
\nprofessions are under reflection. I want to
\ninform you that there is a world-wide pro-
\nject under the UNESCO Chair of Medical
\nEthics, Professor Amnon Carmi, to draft a
\nuniversal curriculum for teaching medical
\nethics. The project involves more than 50
\nuniversities in different parts of the world
\nand 124 professors. The aim is to collect
\nsome 20-30 booklets dealing with living
\ncases, offering from two to three ethical so-
\nlutions. The approach is multicultural and
\naims at showing that ethics cannot be taught
\nby just giving information. Students have to
\nbe involved in discussions and trained in de-
\ncision making.
\nNew challenges are ethics, behavioural sci-
\nences, genetics and information technology.
\nThe two latter disciplines offer powerful
\ntools to be used in health care for the bene-
\nfit of humanity, but they also carry risks if
\nthey are used irresponsibly. A more compre-
\nhensive approach than today’s strictly bio-
\nmedical one towards patients is a \u00abmust\u00bb for
\nhealth care professionals in the future, if
\nthey want to be trustworthy. It is clear from
\nstatements made in public speeches that
\nethics is widely being introduced into the
\ncurricula. In addition to the ethical and the
\nbiological, other aspects of human life are
\nalso being discussed. This will no doubt
\nbring \u00abadded value\u00bb to the well being of the
\npeople.
\n8
\nMedical Ethics & Human Rights
\nThe 55th
\nGeneral Assembly of the WMA1
\ntook place in Helsinki on September 2003,
\na long-waited meeting which it was hoped
\nwould have allowed the controversies that
\narose from the latest version of the Decla-
\nration of Helsinki to settle. A final agree-
\nment in the town where the Declaration
\nhad been established for the first time in
\n1964 would give a symbolical value to the
\nevent. This paper sets out a personal view
\nof the twists and turns of the ethical dis-
\ncussion concerning the most recent ver-
\nsion.
\nThe 6th
\nedition of the Declaration of
\nHelsinki2
\nwas adopted in Edinburgh on Oc-
\ntober 7, 2000. During the debates, several
\ndelegates had asked that the adoption of
\nthis new version be postponed. They were
\nexpecting many criticism from researchers
\nand sponsors, but their warnings were soon
\nswept away, it being said that the credibili-
\nty of the WMA would be compromised if
\nthe revision (already announced for a long
\ntime) would be delayed after so many
\nyears of preparatory work.
\nNevertheless those who had argued for a
\ntime of further reflection had been right:
\nsuddenly some members of the WMA
\nraised serious objections to the previous
\nunanimously adopted version. The United
\nStates especially had rebukes from their
\nrearguard \u2013 read the FDA3
\n. The sources of
\nirritation were paragraphs 29 and 30, re-
\nspectively concerning the use of placebo,
\nand the participants’ right of access to the
\nbest-proven treatment identified by the
\nstudy.
\nThe opponents of paragraph 29 considered
\nthat studies controlled by placebo were es-
\nsential for a reliable statistical assessment
\nof the results of the trial. This is moreover
\nthe reason why the FDA recommends sys-
\ntematic control, because the methodology
\nof the scientific study is otherwise worth-
\nless, and if worthless, the research projects
\ndo not receive subsidies. By following
\nparagraph 29, institutions, including uni-
\nversities, have taken the risk of a negative
\nresponse from their Institutional Review
\nBoard4
\n, from the NIH5
\nand obviously
\nfrom the FDA. Therefore several scientific
\nprojects involving human subjects have
\nbeen interrupted and others not even start-
\ned. In the circumstances the protests are
\nunderstandable.
\nThe opponents of paragraph 30 empha-
\nsised the very poor functioning of the
\nhealthcare systems in poorly resourced na-
\ntions where most experimentation involv-
\ning human beings is carried out. This para-
\ngraph would oblige the pharmaceutical
\ncompanies to provide the participants with
\nthe best-proven treatment identified at the
\nend of the study. From the drug industry’s
\npoint of view this cannot be afforded.
\nThe academic authorities and spokesper-
\nsons of the pharmaceutical industry insist-
\ned very firmly that the Declaration of
\nHelsinki should be amended. They would
\notherwise seriously be thinking of not re-
\nferring anymore to the strong mandatory
\ncharacter of the Declaration of Helsinki.
\nSuch a boycott would mean a loss of pres-
\ntige for the WMA whose Declaration of
\nHelsinki is its pride. Basically nobody in-
\ntended to undermine the moral leadership
\nof the WMA regarding research, and cer-
\ntainly not the developing countries.
\nIn order to avert an imminent crisis the
\nWMA organised a conference in Pretoria
\non March 2001, in collaboration with the
\nEFGCP6
\nand the University of Pretoria
\nSchool of Health Systems and Public
\nHealth, which had the appearance of an
\nemergency sitting. Representatives of the
\npharmaceutical industry, of the FDA and of
\nthe NIH were numerous. In contrast the at-
\ntendance of developing countries was on
\nthe other hand very sparse, possibly be-
\ncause they were financially too weak to be
\nrepresented.
\nThe only agreement that could be reached
\nin Pretoria was that the Declaration of
\nHelsinki had to remain the most important
\nguideline in the field of research. The few
\ncountries which could hardly accept the
\nparagraphs 29 and 30 would just have to
\ncome to terms with it. However these
\n\u00abfew\u00bb countries were clearly the richer
\ncountries who persisted in protesting and
\nasking for revision. A revision of the dec-
\nlaration hardly a few months after its adop-
\ntion was politically not feasible, as it would
\nhave undoubtedly led to the view that the
\nWMA had bowed to the financial interests
\nof the rich countries.
\nTo get out of the deadlock, the Council of
\nthe WMA has simply attributed this impor-
\ntant difference of opinion to difficulties in
\ninterpretation of the controversial para-
\ngraphs, which could be easily resolved by
\nadding notes of clarification and through
\namendments if necessary. The United
\nStates agreed with the proposal that the de-
\nclaration would not be rewritten, but para-
\ngraphs 29 and 30 would be examined
\nclosely. The situation was defused!
\nA working group would examine whether
\nparagraph 29 was really an obstacle to reli-
\nable scientific research and also consider
\nthe financial implications of paragraph 30.
\nIt was felt advisable to involve in the dis-
\ncussions external representatives respected
\nfor their moral authority and expertise.
\nThus the CIOMS7
\ntook part in the debates
\ndespite engaging in rewriting its own \u00abeth-
\nical guidelines for biomedical research\u00bb8
\n.
\nThe working group decided to add a note of
\nclarification to paragraph 29 rather than
\nrewrite it. The note of clarification was
\nadopted by the 160th the Council of the
\nWMA, October 7, 2001, and is now an inte-
\ngral part of the Declaration of Helsinki.
\nThe unchanged paragraph 29 and its added
\nnote of clarification read as follows:
\n\u00abParagraph 29:
\nThe benefits, risks, burdens and effective-
\nness of a new method should be tested
\nagainst those of the best current prophylac-
\n9
\nMedical Ethics & Human Rights
\nHelsinki and the Declaration of Helsinki
\nP. G. DE ROY
\nMember of the Belgian National Council of the Order of Physicians
\ntic, diagnostic and therapeutic methods.
\nThis doesn’t exclude the use of placebo, or
\nno treatment, in studies where no proven
\nprophylactic, diagnostic or therapeutic
\nmethod exists.\u00bb
\n\u00abNote of clarification on paragraph 29 of
\nthe WMA Declaration of Helsinki
\nThe WMA hereby reaffirms its position that
\nextreme care must be taken in making use of
\na placebo-controlled trial and that in gener-
\nal this methodology should only be used in
\nthe absence of existing proven therapy.
\nHowever, a placebo-controlled trial may be
\nethically acceptable, even if proved therapy
\nis available, under the following circum-
\nstances:
\n\u2013 Where for compelling and scientifically
\nsound methodological reasons its use is
\nnecessary to determine the efficacy or
\nsafety of a prophylactic, diagnostic or
\ntherapeutic method; or
\n\u2013 Where a prophylactic, diagnostic or
\ntherapeutic method is being investigated
\nfor a minor condition and the patients
\nwho receive placebo will not be subject
\nto any additional risk of serious or irre-
\nversible harm.
\nAll other provisions of the Declaration of
\nHelsinki must be adhered to, especially the
\nneed for appropriate ethical and scientific
\nreview.\u00bb
\nCommentators judged that rather than throw
\nlight on the paragraph, this note of clarifica-
\ntion by reintroducing the use of placebo,
\ncertainly on well-defined conditions, made
\nit meaningless. Some claim that this would
\nfinally be of benefit to scientific research;
\nwhile others considered that the ethical im-
\nplications for poor countries didn’t get
\nenough attention.
\nParagraph 30:
\n\u00abAt the conclusion of the study, every pa-
\ntient entered into the study should be as-
\nsured of access to the best proven prophy-
\nlactic, diagnostic and therapeutic methods
\nidentified by the study.\u00bb
\nThis paragraph needs to be read with para-
\ngraph 19.
\nParagraph 19:
\n\u201eMedical research is only justified if there is
\na reasonable likelihood that the populations
\nin which the research is carried out stand to
\nbenefit from the results of the research.\u201c
\nBoth paragraphs deal with the sensitive sub-
\nject of experimentation on human beings in
\ndeveloping countries. Without these para-
\ngraphs, the protection of participants is vir-
\ntually non-existent.
\nThe supporters of an unchanged paragraph
\n30 recalled that the Declaration of Helsinki
\nadopted in 1964 was directly inspired by the
\nNuremberg Code. This Code refers to the
\nmandatory safeguard of participants’ rights,
\nespecially for the most vulnerable. Other in-
\nternational authorities such as the CIOMS
\nand the EGE9-10
\nalso favoured the protection
\nof population groups involved in clinical re-
\nsearch.
\nThe dispute about paragraph 30 showed a
\ngap between North and South, between
\nwealthy nations and poor nations. The re-
\nsource-poor nations consider that they have
\na right to the best-proven treatment identi-
\nfied by the study. In practice however, the
\nexperimental treatments usual cease at the
\nend of the study. The group in question for
\nwhom the only available treatment is that in
\nthe investigation, is then left on its own, with
\nno-one concerned about them.11
\nThe devel-
\noping countries invoke paragraph 30 specif-
\nically to prevent conduct which, in their
\nview, is unethical. Paragraph 30 is their last
\ndefence.
\nThe resource-rich countries say that these
\npeople would not anyway have access to
\nsome treatments. The pharmaceutical com-
\npanies are not inclined in these conditions to
\nengage in heavy financial commitments.
\nCompanies are not humanitarian aid organi-
\nsations, but are, fully prepared to sustain re-
\nsearch knowing that they will profit from
\nsome of it allthough they don’t intent to set
\nup and pay the cost of effective healthcare
\nsystems for under-resourced countries. The
\ncompanies are not satisfied with paragraphs
\n19 and 30, taking a less absolute approach to
\nthe right of participants to the best treatment
\nand its cost. An ethical declaration is not a
\nlaw and it is ultimately only mandatory to do
\none’s best to observe it. Often the researcher
\nis not able to decide which is the best treat-
\nment at the end of the research, the results of
\nwhich must be compared with others before
\nknowing which treatment is best; it can take
\ndecades before a medicine becomes avail-
\nable on the market.
\nThose who have ever heard the plea of rep-
\nresentatives of developing countries recall
\nhow distressing their message is. With dig-
\nnity, they make a distinction between their
\nfrustrations and the harm done to them with-
\nout anger, but resigned to the misfortune of
\nhaving to cope with a poor health care sys-
\ntem and a cruel lack of technology, pharma-
\nceuticals and basic welfare. For many this
\nmeans utmost poverty and reliance on char-
\nity to survive. They don’t have Social Secu-
\nrity (= the Heath Service) based on solidari-
\nty as in the wealthier countries and fre-
\nquently mentioned in the WMA.
\nVirtually everyone is convinced that these
\nwell founded concerns are justified and that
\nmany things need to be done for developing
\ncountries, but by whom it is to be done ap-
\npears much less clear. For the rich countries,
\nthis large-scale problem can’t be solved by
\nthe Declaration of Helsinki but by the local
\nauthorities. But the response is that this is
\nanother debate (in which the term \u00abcorrup-
\ntion\u00bb often appears), and in which the eco-
\nnomically weak are reduced to silence. It
\nrests with the poorer countries to interpret
\nparagraph 30 correctly. Its aim is not to make
\ndrugs available to the population of the Third
\nWorld but to protect that population from
\npossible exploitation in clinical trials.
\nIn this period of growing commercialisation
\nand globalisation, the poorer countries won-
\nder anxiously, what will be left of paragraph
\n30, their only glimmer of hope, after its clas-
\nsification by the wealthy countries.
\nThe General Assembly promised to contin-
\nue working on the problem meanwhile leav-
\ning the paragraph unchanged \u2013 hopefully for
\nnot too long, think those countries which re-
\nmember well where they buried the hatchet
\nin May 2001. Certainly the debate will con-
\ntinue \u2026
\nNo-one questions the Declaration of
\nHelsinki as being an authoritative reference
\ndocument. Its implications are ethically
\nbinding on everyone involved in scientific
\n10
\nMedical Ethics & Human Rights
\nclinical research, including both the inves-
\ntigator as sponsor on the study, and the
\nmembers of ethic committees. It is there-
\nfore satisfying that the Declaration of
\nHelsinki is often referred to in both Euro-
\npean and national law. In March 2001 in
\nPretoria, the draft European directive
\n2001\/20\/EC on \u00abthe approximation of the
\nlaws, regulations and administrative provi-
\nsions of the Members States relating to the
\nimplementation of good clinical practice in
\nthe conduct of clinical trials on medicinal
\nproducts for human use\u00bb was presented.
\nThe Assembly was very keen that the direc-
\ntive should refer to the Declaration of
\nHelsinki which would give it the force of
\nlaw, at least in the Members States of the
\nEuropean Union.
\nThe Directive was published on May 1,
\n200112
\n, and refers to the Declaration of
\nHelsinki in its preamble. But one is amazed
\nto discover that it refers to the obsolete ver-
\nsion of 1996 and not to that of 2000. Thus
\nthe last revised version with its hindering
\nprescriptions regarding to drug industry is
\nconsiderably weakened.
\nThe Member States of the European Union
\nhave to transpose the directive into their na-
\ntional legislation for May 1, 2004. Although
\nthe directive refers to the version of the De-
\nclaration of Helsinki of 1996, we hope that
\nnational legislators will take into account
\nthe last stance of the WMA thus avoiding
\n(by way of parody!) that someone consults
\nan invalidated version of the Highway Code
\nto determine his way of driving! The time
\nhas come both for WMA and for the phar-
\nmaceutical industry to decide on driving ei-
\nther on the left or on the right, in other
\nwords, to choose in favour of the rich or the
\npoor.
\nReferences:
\n1. World Medical Association
\n2. https:\/\/www.wma.net\/e\/policy\/17_e.html
\n3. Food and Drug Administration
\n4. Similar to the committees of ethics in Belgium
\n5. National Institutes of Health
\n6. European Forum on Good Clinical Practice
\n7. Council of International Organisations of Med-
\nical Sciences, www.cioms.ch
\n8. CIOMS Revised ethical guidelines for biomed-
\nical research involving human subjects. August
\n2002; ISBN 92-9036-075-5. Text available
\nonline
\n9. European Group on Ethics in Science and New
\nTechnologies;
\nhttp:\/\/europa.eu.int\/comm\/european_group_eth
\nics
\n10. Advice of February 17, 2003: Ethical aspects of
\nclinical research in developing countries; text
\navailable online
\n11. To be perfectly honest, a few remarkable excep-
\ntions must be noticed
\n12. Official Journal of the European Communities L
\n121\/34 1.5.2001
\nEditorial note:
\nFollowing the September 2003 Council
\nmeeting in Helsinki (see WMJ 49 (5\/6), 71),
\nthe working group on the Helsinki Declara-
\ntion has continued its work and following
\nthe many comments, discussions and con-
\nsultations, and will present a report to the
\nWMA Council meeting in May 2004.
\n11
\nMedical Ethics & Human Rights
\nIntroduction
\nThe Declaration of Helsinki has played a
\nseminal role in promoting protection of re-
\nsearch subjects from abuse and exploitation.
\nHowever, as medical advances have benefit-
\ned only a small proportion of the world’s
\npopulation it cannot be claimed that moral
\nprogress has matched scientific progress.
\nGiven the limited value of progress for hu-
\nmankind as a whole if its benefits are not
\nwidely shared, it is essential that scientific
\nprogress be coupled to moral progress in re-
\nsearch and in access to health care. We have
\npreviously argued that moral progress will
\nrequire more than new or refashioned decla-
\nrations, as it is people with the will and the
\ncapacity to implement the content of decla-
\nrations that are the key factor. The recent fo-
\ncus on the future of the Declaration of
\nHelsinki at the 2003 World Medical Associ-
\nation (WMA) General Assembly scientific
\nmeeting provides an opportunity to consider
\nthe potential for making moral progress
\nthrough visionary modifications to this Dec-
\nlaration.
\nLinking moral progress to medical progress:
\nNew opportunities for the Declaration
\nof Helsinki1
\nSolomon R Benatar MBChB, FRCP, Professor of Medicine, University of Cape Town
\nSummary
\nG Progress in science and medicine is
\nessential for human advancement.
\nG Ethical values are essential in direct-
\ning the application of scientific and
\nmedical advances.
\nG Moral progress requires that the bene-
\nfits of progress be shared more wide-
\nly and more equitably throughout the
\nworld.
\nG Scientific and medical progress
\nshould be inextricably linked to moral
\nprogress.
\n1 Based on a presentation at the WMA General
\nAssembly in Helsinki in September 2003
\nDiscussion
\nMoral progress in research on human sub-
\njects since the infamous Nazi human exper-
\niments, is evident in many activities. These
\ninclude the development of many codes,
\nguidelines and procedures for research
\nethics that aim to protect research subjects
\nfrom harm and exploitation, and the increas-
\ning attention being paid by scientists and
\nothers to the requirements for ethical re-
\nsearch. Expansion of international collabo-
\nrative research has prompted generous fund-
\ning from the US National Institutes of
\nHealth’s Fogarty International Centre for
\npromotion of capacity building in research
\nethics in developing countries.1
\nHowever, there is a wide gap between scien-
\ntific\/medical progress and moral progress in
\nmedical research and practice. This is stark-
\nly evident from widening disparities in
\nhealth, longevity and health care and in the
\nexpenditure on medical research. Indeed
\nquestions must be raised about the moral
\ncredibility of a medical research endeavour
\nin which 90 % of US$ 73 billion is spent on
\ndiseases that cause 10 % global burden of
\ndisease (10 : 90 gap),ii
\nand only 16 of the
\n1393 new drugs marketed from 1975-1999
\nwere for tropical diseases or tuberculosis.iii
\nDealing with such moral challenges requires
\nthat in addition to preserving and enhancing
\ncommitment to long-standing values in re-
\nsearch ethics (Box 2), several new values be
\nbuilt into the research endeavour (Box 3).
\nIn evaluating the research enterprise and
\npossible future changes to the Declaration of
\nHelsinki from a moral perspective, a critical
\nquestion that could be asked is what the pri-
\norities of the World Medical Association
\n(WMA) and its Declaration should be. That
\nis, whose agenda should the WMA be ad-
\ndressing through the Declaration? Choices
\ninclude the pharmaceutical industry; med-
\nical associations in North America and Eu-
\nrope; the US Federal Drug Administration;
\nresearchers in privileged countries; the
\nhealth of those who already have the
\nprospect of long lives; the health of those dy-
\ning prematurely from preventable diseases,
\nor the health of all people at a global level.
\nGiven the widening disparities in health
\nglobally,iv
\nand the presumption that the
\nhealth of all people globally is the concern of
\nthe WMA, it is suggested that incorporation
\nof new ethical values in research (Box 3) into
\nthe Declaration of Helsinki could enhance
\nthe \u00abmoral capital\u00bb of the Declaration. This
\nin turn may lead to reduction in disparities in
\nhealth and medical research.
\nSuggested Changes to the
\nDeclaration of Helsinki
\nAn appropriate preamble to the declaration
\ncould sensitise research workers to imbalance
\nin the research agenda.
\n\u00abSpectacular developments in science, tech-
\nnology and medical practice have transformed
\nhealth care and improved the lives of many.
\nDespite such progress millions of people live
\nin degrading poverty with little access to
\nhealth care and are denied even basic medical
\ntreatments. Because improving the potential
\nfor good health for a greater proportion of the
\nworld’s population is one of the most pressing
\nmoral problems of our time, research should
\nincreasingly be directed towards diseases that
\nafflict poor and marginalised people. Those
\nundertaking research in developing countries
\nshould also have some understanding of and
\nbe sensitive to the social, economic and politi-
\ncal milieu that frames the context in which
\nsuch research is undertaken. Lessons learned
\nfrom research should be made more equitably
\navailable world wide and used to improve re-
\nlationships between host and sponsoring
\ncountries, as part of the endeavour to improve
\nhealth globally.\u00bb
\nThe declaration states that medical research
\ninvolving human subjects must conform to
\ngenerally accepted scientific principles, and
\nbe based on a thorough knowledge of the
\nscientific literature. An accompanying state-
\nment should indicate that all such research
\nshould conform to accepted ethical princi-
\nples, be based on a thorough knowledge of
\nthe research ethics literature, and that med-
\nical research involving human subjects
\nshould be conducted by scientifically quali-
\nfied persons with knowledge of research
\nethics.
\nIt should also be explicitly stated that exploita-
\ntion of subjects, or their use as means to the
\nends of others, must be avoided by ensuring
\nthat the research is of relevance to the individ-
\nuals participating in the research as well as to
\ntheir communities. The balance of benefits and
\nburdens of research should be fairly distrib-
\nuted with due consideration of the benefits that
\ncould accrue to sponsors in the long term, and
\nto ensuring that studies are not done with the
\nintention of spending as little as possible on
\ncare of research subjects and the communities
\n12
\nMedical Ethics & Human Rights
\nBox 2. Long-standing
\nethical values in research
\nethics
\nG Do not harm
\nG Minimisation of risk
\nG Protection of the vulnerable
\nG Respect for dignity of patients\/sub-
\njects
\nG Informed consent
\nG Protection of confidentiality
\nG Freedom to withdraw
\nG Justice
\nG Compensation for injury
\nG Appropriate remuneration for
\nparticipation
\nBox 3. Newer ethical values
\nin research ethics
\nG Justice
\nG Fair access to participation in re-
\nsearch studies
\nG Fairness in distribution of harms\/ben-
\nefits – long term as well as short-term
\nG Non-Exploitation of the vulnerable
\nG Coupling the research endeavour to
\nimprovements in health care through
\npartnerships and improves overall
\nstandards of care in research
\nG Relevance of research to local needs
\n– the importance of context
\nG Narrowing the 10 : 90 gap by re-
\nshaping the research agenda
\nG Cultural and linguistic sensitivity
\nin obtaining informed consent
\nG Solidarity and interdependence –
\nacknowledging and facing global
\nthreats
\nG Addressing deteriorating global
\nhealth
\nG Focusing on re-emerging and new
\ninfectious diseases
\nG Global health information equity
\nin which they live, when large profits may re-
\nsult from the research.
\nCare should be taken that research does not in-
\nappropriately deflect local human or material
\nresources away from the health care system in
\nthe host country towards research projects,
\nthus more deeply entrenching existing dispari-
\nties. Priors evaluation by a local committee or
\ngoverning body should include consideration
\nof whether study findings can, and will be in-
\ncorporated into the local health care system.
\nInformed consent should be obtained in the
\nlanguage spoken by the research subject and
\nwith insight into, and respect for the subject’s
\nculture.
\nAt the conclusion of the study, every patient
\nshould receive interventions identified as ben-
\neficial by the study, or access to other appro-
\npriate care. This is particularly important for
\npatients with serious conditions for whom ces-
\nsation of the study intervention could have se-
\nvere consequences. Research in developing
\ncountries should be linked to a broader notion
\nof standard of care, to capacity building in
\nhealth care, and to economic and educational
\nempowerment that could benefit delivery of
\nhealth care specifically, and progress general-
\nly, in the host country. Some of these issues are
\nbeing addressed in an expanding discourse on
\nresearch ethics and much remains to be
\ndone.v vi vii viii ix
\nConclusions
\nDisparities in global health pose the greatest
\npotential security risk to the lives of all people
\nin the world.x
\nWe are challenged to recognise
\nthis risk and to take appropriate action. To
\nparaphrase Virchow \u00abhealth is political and
\npopulation health is politics writ large\u00bb. Re-
\nsearch is also political and it does not take
\nplace in a vacuum.
\nScientific progress must be coupled to moral
\nprogress, and in particular in relation to social
\njustice. The Helsinki Declaration has the po-
\ntential to stimulate moral progress in research.
\nSuch progress, if made, will be reflected in re-
\nductions in health inequity, and in improve-
\nments in population health.
\nAcknowledgement. I thank Peter Singer for construc-
\ntive comments.
\n13
\nWMA
\nWorld Medical Association
\nPresidential Address of Dr. James Apple-
\nyard to the General Assembly of the World
\nMedical Association, Helsinki, September
\n2004
\n\u201dThe level of civilisation attained by any so-
\nciety will be determined by the attention it
\nhas paid to the welfare of its children.\u201d Pro-
\nfessor Billy Andrews (1964)
\nThe continuing challenge facing the World
\nMedical Association is to maintain and pro-
\nmote the professional values that underpin
\nmedical practice world-wide. At the 90th
\nbirthday celebrations of our hosts the
\nFinnish Medical Association entitled \u201dpro
\nhumanitate\u201d, the Emeritus Archbishop of
\nHelsinki encouraged physicians to reaffirm
\nour shared values so that they became \u201din-
\nternalised\u201d as our professional conscience.
\nOur conscience should become our compass
\nin the everyday practice of medicine and for
\nour role as leaders and teachers in the field
\nof healthcare.
\nThe Hippocratic tradition recognises our re-
\nsponsibility to respect the individual
\n\u201drights\u201d of those who entrust themselves to
\nour care. This respect for our patients, nur-
\ntured by our profession in the patient\/physi-
\ncian relationship, is fundamental for the sur-
\nvival and development of communities and
\nnations.
\nThe standards we set in our WMA Declara-
\ntions are important safeguards for our pa-
\ntients. The Declarations of Geneva(1),
\nHelsinki (2) and Tokyo (3) in particular re-
\nestablished ourselves as a trustworthy ethi-
\ncal profession after the horrors of World
\nWar 2. More recently we have established
\nessential standards for the care of children
\nworld-wide in the Declaration of Ottawa on
\nthe \u201dRight of a Child to healthcare\u201d(4)
\nChildren are a country\u2019s most valuable re-
\nsource. Poverty and the denial of children\u2019s
\nrights have devastating effects on our chil-
\ndrens\u2019survival. The World Health Organisa-
\nReferences
\ni Singer PA, Benatar S R. Beyond Helsinki: a vision
\nfor global health ethics. Brit. Med. J. 2001; 322:
\n747-8
\nii Commission on Health Research for Development.
\nHealth Research: Essential link to equity in devel-
\nopment. OUP. Oxford. 1990.
\niii Trouiller P, Olliaro P, Torreele E, Orbinski J, Laing
\nR, Ford N. Drug development for neglected dis-
\neases: a deficient market and a public health fail-
\nure. Lancet. 2002; 359: 2188-94 4
\niv Benatar S R. Some reflections and recommenda-
\ntions on research ethics in developing countries.
\nSocial Science & Medicine. 2002; 54 : 1131-41
\n&1147-48
\nv Benatar S R, Singer P A. A new look at interna-
\ntional research ethics. Brit Med J 2000; 321: 824-
\n26
\nvi Lo B, Bayer R. Establishing ethical trials for treat-
\nment and prevention of AIDS in developing coun-
\ntries. Brit Med J 2003; 327: 337-9
\nvii Berkley S. Thorny issues in the ethics ofAIDS vac-
\ncine trials. Lancet 2003; 362: 992.
\nviii Fitzgerald D, Pape J W, Wasserheit J N, Counts G
\nW, Corey L. Provision of treatment in HIV-1 vac-
\ncine trials in developing countries. Lancet 2003;
\n362: 993-4
\nix Tucker T, Slack C. Not if but how? Caring for HIV-
\n1 vaccine trial participants in South Africa. Lancet
\n2003; 362: 995.
\nx Benatar S R. The coming catastrophe in interna-
\ntional health: an analogy with lung cancer. Interna-
\ntional Journ 2001; LV1 (4)611-631
\nAddress for correspondence
\nBioethics Centre,
\nDepartment of Medicine
\nUniversity of Cape Town
\nJ Floor, Old Main Building
\nGroote Schuur Hospital
\nObservatory
\n7925 Cape
\nSouth Africa
\nTel +27 +21 406 6115
\nFax +27 +21 448 6815
\nEmail sbenatar@uctgshl.uct.ac.za
\n\u201dGetting it Right for our Children\u201d
\ntion\u2019s Commission on Macro-economics
\nand Health has recognised that substantially
\nimproved health outcomes are a pre-requi-
\nsite if developing countries are to break out
\nof the cycle of poverty.(5) Healthy children
\nbecome healthy, more productive adults and
\nremain healthier in their old age.
\nA study of the \u201dValue of Children\u201d was con-
\nducted in nine countries comparing parents\u2019
\nmotivation for child bearing.(6) It was found
\nthat in less developed countries where chil-
\ndren were conceived to be \u201dused\u201d for eco-
\nnomic reasons, there was a relatively high
\nfertility rate. In more affluent countries
\nwhere children were conceived as loved in-
\ndividuals in what was termed their \u201dpsycho-
\nlogical value\u201d, there was a lower fertility
\nrate. With improvement in health and educa-
\ntion, less children will die and less
\nchildren will be conceived.
\nUNICEF publish international com-
\nparative tables of the under five mor-
\ntality rate per 1,000 births.(7) This is
\na remarkably sensitive indicator of
\nhow individual nations \u201dvalue\u201d their
\nchildren. Top of the list with the low-
\nest mortality rate is Sweden, which
\nhas only around 3 children dying un-
\nder five year of age per 1,000 births
\n(Table 1). Bottom of the world list is
\nSierra Leone with 316 children per
\n1,000 dying under the age of five
\nyears (Table 2). That country is \u201dsac-
\nrificing\u201d nearly one third of its
\nyoung children. The difference be-
\ntween the top and bottom nations is
\n100 fold. This differential reflects
\nthat widening gap between the
\n\u201drich\u201d and \u201dpoor\u201d nations which is
\nunsustainable for clear humanitari-
\nan, health and economic reasons.
\nJust how sensitive this \u201dindex\u201d is to
\nthe \u201dpolitical\u201d factors of a nation can
\nbe seen in table 3. With a very simi-
\nlar birth rate and gross national in-
\ncome per capita to Tanzania, Uganda
\nhas \u201dsaved\u201d the lives of some
\n50,000 children under five in 2001
\nas compared to the rate in 1990.
\nNeighbouring Tanzania however
\nmade no real progress. Likewise
\nover the same ten year period, the devastat-
\ning deterioration in the survival of children
\nunder five in Iraq contrasts dramatically
\nwith neighbouring Iran. The additional
\nloss of around 20,000 children under five
\nin Zimbabwe as compared to ten years ago
\nwill have very serious consequences for
\nthe future of that country.
\nThough the difference in the Gross Nation-
\nal Income per capita in US$ between the
\ntop and bottom ten nations in the UNICEF
\nlist is enormous, the correlation between
\nhow rich a country is and how much it in-
\nvests in its children is variable. For in-
\nstance Cuba has had half the gross nation-
\nal income per capita of Iraq but they are
\nranked 42nd, whereas Iraq has fallen to
\n162nd of the 195 nations in the world
\nwhich are recognised by the WHO
\n(Table 4). Slovenia (6th) has an under five
\nmortality rate of only 5 with a GNI of
\n9,780 US$, which is significantly above
\nthe United Kingdom (31st) with a GNI of
\nwell over twice as much!
\nThe major causes of the under 5 mortality
\nworld-wide are diarrhoea, malnutrition,
\nmalaria, measles, HIV\/AIDS and Pul-
\nmonary Tuberculosis. Each of these condi-
\ntions is easily preventable and treated. In-
\ndeed the World Bank has estimated that if
\nthe burden of infectious disease were lifted
\nfrom the developing world, the gap be-
\ntween the richest 20 and poorest 20 nations
\nwould largely be bridged.(17)
\nSo what action can national medical asso-
\nciations take to effect change? Their mem-
\nbers are involved in and affected by all as-
\npects of these problems. There needs to be
\nboth the central political will to make
\nchanges as well as an effective local infra-
\n14
\nWMA
\nCountry Value Rank Gross National
\nIncome per capita
\nUS$
\nSweden 3 1 25,400
\nSingapore 4 2 24,740
\nNorway 4 35,530
\nIceland 4 28,880
\nDenmark 4 31,090
\nSlovenia 5 6 9,780
\nMonaco n\/a
\nMalta 9,120
\nLuxembourg 5 41,770
\nKorea 5 9,4000
\nTable 1 \u2013 Under 5-year mortality \u2013 Top 10
\nCountry Value Gross National
\nIncome per capita
\nUS$
\nSierra Leone 316 140
\nNiger 265 170
\nAngola 260 500
\nAfghanistan 257 250
\nLiberia 235 490
\nMali 231 210
\nSomalia 225 120
\nGinea Bissan 211 160
\nCongo 205 700
\nZambia 202 320
\nTable 2 \u2013 Under 5-year mortality \u2013 10 na-
\ntions with highest rates per 1,000 births
\nCountry Value Rank Gross National
\nIncome per capita
\nUS$
\nJapan 5 11 35,990
\nGreece 5 11,780
\nGermany 5 23,700
\nFinland 5 23,940
\nCzech 5 5,270
\nAustria 5 23,940
\nSwitzerland 5 36,970
\nSpain 5 14,860
\nSan Marino 6 19 n\/a
\nPortugal 6 10.670
\nCountry Value Rank Gross National
\nIncome per capita
\nUS$
\nIsrael 6 24 16,710
\nUnited Kingdom 7 31 24,230
\nUnited States 8 34 34,870
\nCuba 9 42 1,170
\nKuwait 10 43 18,070
\nOcc. Palestine 24 80 1,350
\nChina 39 110 890
\nIran 42 114 1,750
\nZimbabwe 123 156 480
\nIraq 133 162 2,170
\nTable 3 \u2013 Selected countries \u2013 under 5-year
\nMortality ranking and GNI
\nstructure in which changes can be made.
\nThis requires advocacy with professional
\nand allied partners, and the setting of prior-
\nities for action.
\nWater and Sanitation
\nAbout 1,2 billion people world-wide lack
\naccess to safe drinking water and 2,4 billion
\nlack adequate sanitation, giving rise to dis-
\neases such as diarrhoea, cholera and tra-
\nchoma. In poor countries it has been esti-
\nmated that at any one time, about half the ur-
\nban population is suffering from one or
\nmore of the diseases associated with the lack
\nof water and proper sanitation.(8) The inci-
\ndence of diarrhoea can be reduced by near-
\nly a quarter and the number of deaths by
\nclose to 2\/3rds, through improvements in
\nsafe water supply with sanitation and hy-
\ngiene. The cost of realising universal access
\nto health, water sanitation and education,
\nwas estimated by the United Nations and the
\nWorld Bank in 1995 to be an additional
\n70\u201380 billion dollars per year. The World
\nleaders can and must afford this. The Ugan-
\ndan Medical Association has made \u201dsanita-
\ntion\u201d their theme for the coming year.(9)
\nThe Japan Medical Association is leading
\nthe WMA\u2019s current initiative on key issues
\nconcerning water world-wide.
\nMalnutrition
\nMore than half the deaths of children in the
\nworld under the age of five are associated
\nwith malnutrition. The number of malnour-
\nished children in sub-Saharan Africa has in-
\ncreased over the last ten years. Malnutrition
\nis a cause as well as a consequence of pover-
\nty. Despite the high profile and the work of
\na large number of non-governmental organ-
\nisations, the essential infrastructure has not
\nbeen properly developed to relieve this to-
\ntally preventable burden.
\nArmed Conflict
\nMore children have suffered from armed
\nconflicts and violence in the last ten years
\nthan in any other comparable period in his-
\ntory.(8) Ethnic conflicts and civil wars have
\ncome in the wake of the \u201dcold war\u201d. Con-
\nflicts killed 2 million children in the \u201890s.
\nThey left large numbers of children disabled
\nand psychologically scarred. Violence
\nbreeds violence! Children have been dis-
\nplaced, placed in unsanitary conditions with
\npoor or absent social infrastructure, and
\nwith no system of justice. There are 35 mil-
\nlion displaced persons and refugees world-
\nwide, 80 % are women and children. This is
\na severe indictment on the responsibilities of
\nsome nations\u2019 leaders and the ineffective-
\nness of the United Nations to resolve inter-
\nnational conflicts.
\nAbuse, Neglect and
\nExploitation
\nIn the wake of armed conflict, poverty and a
\nculture of violence, children are increasing-
\nly becoming victims of abuse, neglect and
\nexploitation. It has been estimated that there
\nmay be as many as 35 million child victims
\nof child prostitution, sex tourism and child
\n\u201dslavery\u201d. One form of gross breach of hu-
\nman rights affecting young girls is female
\ngenital mutilation. The WMA believe that
\nthis practice is completely unethical.(18)Yet
\nin the UK where the practice is outlawed, it
\nis widely alleged that FGM continues to be
\npractised in private hospitals.(10) Girls are
\nalso being sent abroad to those countries
\nwhere the operation is allowed. Physicians
\nhave a duty to do all in their power to expose
\nunethical practice and try and prevent all
\nforms of child abuse.
\nSmoking
\nMore than five million children alive today
\nwill die prematurely of smoking related dis-
\neases.(11) Recent studies have revealed that
\nin Bangladesh as a result of marketing by
\nthe tobacco industry, family members are
\nspending money on cigarettes rather than on
\nfood for their children, even to the extent of
\ncausing malnutrition.(12) It is crucial that
\nthe tobacco \u201depidemic\u201d that has swept the
\nwestern world causing such a toll of respira-
\ntory, cardio-vascular and neurological dis-
\nease, is not inflicted on the poor nations al-
\nready bearing an intolerable and financially
\noverwhelming burden of disease by the mar-
\nketing practices of a selfish and unscrupu-
\nlous tobacco industry. Cigarette Companies
\nspend more then US$ 11,22 billion on pro-
\nmoting their products. It is well known that
\n15
\nWMA
\nTable 4 \u2013 Rate of progress
\nCountry Gross Under 5 Under 5 Annual Change
\nNational mortality mortality births
\nIncome per 1,000 per 1,000 1000\u2019s in
\nper capita births births 2001
\nUS$ 1990 2001
\nTanzania 270 163 165 1,393 2,786 +
\nUganda 280 165 124 1,222 50,000 +
\nZimbabwe 480 80 123 459 20,000 \u2013
\nSouth Africa 2,900 60 71 1,105 12,155 \u2013
\nIran 1,750 72 42 1592 47,600 +
\nIraq 2170 50 133 823 66,840 \u2013
\nOcc. Palestine 1350 40 24 132 2,112 +
\nIsrael 16,710 12 6 126 756 +
\nAfghanistan 250 260 257 1,078 3,234 +
\nRwanda 220 178 183 320 1,600 \u2013
\nRussian
\nFederation 1,750 21 21 1,230 \u2013 0 \u2013
\nRomania 1,170 32 21 233 2,330 +
\nchildren are more susceptible to cigarette ad-
\nvertising than adults. To quote Philip Morris:
\n\u201dToday\u2019s teenager is tomorrows regular cus-
\ntomer, and the overwhelming majority of
\nsmokers first begin to smoke in their teens.
\nThe smoking pattern of teenagers is particu-
\nlarly important to Philip Morris.\u201d National
\nmedical associations need to advocate in the
\nstrongest possible terms for their country to
\nsign up to the UN Framework Convention on
\nTobacco Control (13) which will provide
\ntheir fellow citizens with some protection
\nfrom the predicted tobacco epidemic.
\nHIV\/AIDS
\nThe HIV\/AIDS pandemic is a global disas-
\nter. There are 10.4 AIDS orphans, 95 % of
\nwhom live in Sub-Saharan Africa. In chil-
\ndren under five years, it has been predicted
\nthat the virus will cause 2\/3rds of deaths in
\nBotswana and half the deaths in Zimbabwe
\nand South Africa. In Uganda of the
\n100,000 people suitable for anti-retroviral
\ntherapy, only 10,000 can be afforded the
\ntreatment.(14)
\nMedicines, Resources and
\nResponsibilities
\nThe affordability of medications is a key issue
\nin the battle against infectious diseases in
\npoor nations. The development of life saving
\ndrugs is however largely subject to market
\nforces. Those nations with the highest burden
\nof disease have the smallest financial market.
\nIndeed only 10 % of the global health re-
\nsearch is devoted to conditions that account
\nfor 90 % of the global disease burden \u2013 the so
\ncalled 10\/90 dis-equilibrium. Of the 1393
\nnew chemical entities developed between
\n1975 and 1999, only 1\/3rd were truly \u201dbreak-
\nthrough\u201d drugs and only 16 were for tropical
\ndiseases, TB and AIDS. All these 16 drugs
\nwere developed with \u201dpublic sector\u201d sup-
\nport.(15)
\nThere are seriously disabling and life threat-
\nening diseases, mainly affecting the poor in
\ndeveloping countries, that may be considered
\nas \u201dneglected diseases\u201d, where treatment op-
\ntions are inadequate or simply do not exist.
\nThese include Malaria \u2013 causing over a mil-
\nlion deaths \u2013 and Tuberculosis, over 2 million
\ndeaths each year, HIV\/AIDS which result in
\nsome 3 million deaths each year, and visceral
\nLeishmaniasis which affects some 12 million
\npeople world-wide. InAfrica,Asia andAmer-
\nica 146 million are affected by Trachoma and
\nin 6 million this has caused blindness. Like-
\nwise Onchocercosis affects 18 million with
\nnearly a third of a million blinded. The agen-
\ncies active in the field of drugs for the \u201dne-
\nglected diseases\u201d include the WHO\/World
\nBank\u2019s Tropical Disease Research Unit, the
\nGlobal Alliances for \u201dTB\u201d and \u201dVaccines and
\nImmunisations\u201d, Medicines for Malaria and
\nthe International AIDS Vaccine Initiative. But
\nall these entities with the few others involved
\nonly have a combined budget of around
\n100 million dollars a year.(15) It is only a
\nfraction of the reported cost of up to US$
\n800 million that it takes the pharmaceutical
\nindustry to develop a single new drug. In or-
\nder to restore a proper balance to the current
\n10\/90 dis-equilibrium, it is essential that Gov-
\nernments of all nations, global industries,
\nacademia, universities and the non-govern-
\nment organisations involved, urgently start
\nfocusing on these neglected diseases. Nation-
\nal medical associations need to encourage
\nand foster academic partnerships between
\nuniversities and academic centres in the rich
\nand poor countries which could provide a
\nvaluable research network world-wide.(16)
\nThe modern pestilences due to HIV, Ebola
\nVirus and more recently SARS have arisen
\nin the aftermath of conflict and\/or in areas of
\ngreat poverty. When faced with a greater
\nrisk of dying and the serious financial con-
\nsequences of the SARS epidemic, it was re-
\nmarkable that in the \u201drich\u201d world the com-
\nbined resourcefulness of humans and human
\nresources were mobilised, commercial com-
\npetition set aside and the causative organism
\nof SARS, its genetic sequence, likely mode
\nof transmission and some possible therapeu-
\ntic agents identified within a very short time.
\nIf the same energy could be sustained to re-
\nsolve the burden of infectious diseases in the
\npoor countries, great strides would be made
\nin relieving the widening inequalities in the
\nhealth and wealth of nations.
\nFuture Progress
\nThere are clear and well trodden paths to
\nprogress. These require children to be at the
\ncentre of each nation\u2019s thoughts for their fu-
\nture, and governments need to examine the
\nimpact of all their policies on the health of
\nchildren. The World Medical Association has
\nbuilt on the foundations of the UN Declaration
\nof the Rights of the Child in the WMA Decla-
\nration of Ottawa on the Right of a Child to
\nHealthcare.(4) National Medical Associations
\nwith others need to use these standards as a
\nmeasurement of progress to achieve improved
\nhealthcare for, and the health of children.
\nThe World Summit for Children\u2019s \u201dPlan of
\nAction\u201d in 1990 called on Government to
\nprepare their own national programmes, in
\norder to implement their World Summit com-
\nmitments on children. It is the will to incor-
\nporate the needs of children into each nation\u2019s
\nmainstream developmental thinking together
\nwith a robust local infrastructure that will
\nproduce results. Local communities often
\nstruggle to meet the needs of children without
\na fair share of the country\u2019s resources. In the
\n1990s, the World Health Organisation\u2019s 20\/20
\ninitiative was based on the premise that an av-
\nerage of 20 % of the national budget in devel-
\noping countries and 20 % of the Official De-
\nvelopmental Assistance (ODA), would be
\nsufficient to achieve universal access to basic
\nsocial and health services. Most countries
\ncontinue to seriously under invest in these ba-
\nsic social and health services for children,
\nwith only 12\u201314 % of the national budget and
\nonly 11 % of the ODA being allocated to
\nthese basic services.
\nDeveloping countries spent on average more
\non defence than on either basic education or
\nbasic healthcare.(8) Levels of defence spend-
\ning by developed countries were about
\n10 times the level of spending allocated to in-
\nternational development. Yet the increasing
\ngap between the rich and poor nations has
\nbeen shown to foster violence and terrorism
\nand to promote conflict. This vicious circle
\ncan and must be broken.(17)
\nPhysicians individually and collectively
\nthrough their national medical associations,
\nare strong advocates for the health needs of
\ntheir local communities and nations. Medical
\nstudents and young doctors in the rich coun-
\ntries need to experience the health facilities of
\nthe \u201dpoor\u201d countries first hand as an elective
\nand as part of their postgraduate training.
\nSuch experience will change their lives. In
\nturn their work and their advocacy will
\nchange the lives of those currently over-
\n16
\nWMA
\nwhelmed by the burden of disease. The final
\nthought I leave with them is a quote from Nel-
\nson Mandella and Graca Machel:
\n\u201dWe cannot waste our precious children.
\nNot another one. Not another day. It is long
\npast the time for us to act on their behalf.\u201d
\nReferences
\n1. Declaration of Geneva 1948 World MedicalAsso-
\nciation.
\n2. Declaration of Helsinki 1964 Recommendations
\nguiding physicians in biomedical research involv-
\ning human subjects. (Revised 2000) World Med-
\nical Association.
\n3. Declaration of Tokyo 1975 Guidelines for med-
\nical doctors concerning Torture. World Medical
\nAssociation.
\n4. Declaration of Ottawa 1998 The Right of a Child
\nto Health Care.
\n5. WHO 2001 Report of the Commission on Macro-
\neconomics and Health WHO Geneva.
\n6. Kagitcibasi Cigdem The Value of Children. Inter-
\nnational Child Health Vol. 9 1 Jan 1998.
\n7. The State of the 3 Worlds Children 2003
\nUNICEF.
\n8. We the Children: End of decade review of the fol-
\nlow up to the World Summit for children. Report
\nof Secretary General 2001 United Nations Gener-
\nal Assembly.
\n9. Margaret Mungherera Presidential Address
\nUganda Medical Association Scientific Meeting
\nKabale Uganda 2003.
\n10. Joint Committee on Human Rights 10th Report to
\nthe Houses of Lords and Commons. UK 2002.
\n11. National Centre for Tobacco Free Kids 2002.
\n12. GM Leung, L-M Ho, T-H Lam \u201cThe economic
\nburden of environmental tobacco smoke in the
\nfirst year of life\u201d Arch Dis Child Vol. 88 9 Sept
\n2003.
\n13. United Nations Framework Convention on Tobac-
\nco Control WHO 2003.
\n14. Okongo Bernard \u201cDevelopment of Resistance to
\nARVs\u201d Ugandan Medical Association Scientific
\nMeeting, Kabale 2003.
\n15. Patrice Trouiller et al. \u201cDrug Development for
\nNeglected Diseases\u201d. Lancet Vol. 359 June 22,
\n2002.
\n16. Weatherall David Leading Article BMJ 2003
\nVol. 327 20th Dec. 1415\u20131416.
\n17. Poverty and Health OECD World Health Organi-
\nsation 2003.
\n18. Statement on Condemnation of Female genital
\nMutilation. Budapest 1993 World Medical Asso-
\nciation.
\n17
\nMedical Science, Professional Practice and Education
\nA multinational study of orthopaedic surge-
\nons has found that in as much as 95 % of ca-
\nses, orthopaedists fail to investigate osteo-
\nporosis as a cause of the fracture and are in-
\nconsistent in offering specific treatment or
\nreferrals.
\nFull results of the study co-sponsored by the
\nBone and Joint Decade and the International
\nOsteoporosis Foundation (IOF), were pre-
\nsented by Dr Karsten Dreinh\u00f6fer, Ulm Uni-
\nversity Hospital, Germany on October 15th
\nduring the first global 24-hour eLecture con-
\nference on musculoskeletal disorders, orga-
\nnised by the Bone and Joint Decade for the
\nmedical community and in recognition of
\nWorld Osteoporosis Day, October 20th.
\nUntil recently, the only fractures considered
\nto be osteoporotic in nature were spinal
\nwedge, hip and wrist fractures as these cau-
\nsed the majority of problems for patients
\nand hospitals. \u201dHowever, it is now clear that
\nfractures of the pelvis, ankle, knee and
\nshoulder, as well as fractures of the clavicle
\nshould all be treated as osteoporotic fractu-
\nres,\u201d said Dr Karsten Dreinh\u00f6fer.
\n\u201dAll orthopaedic surgeons who treat midd-
\nle-aged and elderly patients with fractures
\nhave a duty to consider and institute mecha-
\nnisms for preventing future fractures. This
\ncan be done by instituting protocols for the
\nscreening, identification and treatment of
\nthose who have sustained a fracture\u201d, he
\nsaid.
\nStudies show that 50 % of women and 30 %
\nof men will experience an osteoporotic frac-
\nture in their lifetime and a prior fracture in-
\ncreases the risk of subsequent fracture as
\nmuch as five-fold. Osteoporotic fractures
\nare associated with increased morbidity and
\nmortality: 50 % of hip fracture patients will
\nhave long-term disability, and 25 % will re-
\nquire long-time nursing home care. With the
\npopulation ageing world-wide, the number
\nof fragility fractures is expected to increase
\ndramatically over the next few years.
\nA multinational survey involving 3,500 or-
\nthopaedic surgeons from France, Germany,
\nItaly, Spain, the UK and New Zealand was
\nconducted earlier in 2003 to determine the
\nscope of the problem and areas for improve-
\nment. The results revealed striking examples
\nof ineffective care of osteoporosis:
\nG Fifty percent of orthopaedic surgeons
\npractising today received little or no
\ntraining in osteoporosis.
\nG Only roughly one in four orthopaedic
\nsurgeons in France and the UK feel
\nknowledgeable about managing the dis-
\nease in their patients.
\nG Only in Germany are the majority of
\nfracture patients referred for a bone den-
\nsity test; in the UK, this figure is as low
\nas 16 %.
\nG Only half of the orthopaedic surgeons in
\nSouthern Europe know about the impor-
\ntance of external risk factors for hip frac-
\ntures (cataracts, poor lighting, pathway
\nobstacles, poor balance).
\nG In four of the countries surveyed, more
\nthan half of the surgeons have not heard
\nabout their national osteoporosis patient
\nsociety.
\n\u201dSince orthopaedic surgeons are often the
\nfirst and only physicians to see fracture pa-
\ntients, they are in a unique position to iden-
\ntify untreated cases of osteoporosis, and as
\nsuch reduce the risk of subsequent fracture,\u201d
\nsaid Professor Olof Johnell, International
\nOsteoporosis Foundation, who led the de-
\nvelopment of guidelines for orthopaedic
\nsurgeons to identify and treat osteoporosis.
\nHe cautioned, \u201dIt is important to act at the
\ntime of fracture. It is the responsibility of or-
\nthopaedic surgeons to investigate whether
\nosteoporosis is the underlying cause.\u201d
\nOsteoporosis is a condition that affects peo-
\nple of all ethnic and cultural groups from
\naround the world. Although there is no cure
\nfor osteoporosis, there are treatments and
\nlifestyle changes such as regular exercise that
\ncan stop further bone loss and reduce the risk
\nMedical Science, Professional Practice and Education
\nOrthopaedic Surgeons Are Failing To Prevent
\nOsteoporotic Fractures
\nof fractures. For example, a recent study in
\nChina by Professor Kai Ming Chan, shows
\nthat regular tai chi chuan exercises can delay
\nbone loss in postmenopausal women.
\nBackground
\nThe Bone and Joint Action Week,
\nOctober 12\u201320th 2003
\nAs a highlight of the Bone and Joint Decade
\nAction Week, leading authorities in the mus-
\nculoskeletal field presented a 24-hour series
\nof eLectures via webcast. Subjects ranged
\nfrom prevention, to state-of-the-art treatment
\nand from how to best teach musculoskeletal
\ndisorders to the best biological approaches.
\nThe Action Week was a major driving force
\nfor prevention and advocacy and included:
\nWorld Arthritis Day (Oct 12th), World Spine
\nDay (Oct 16th), World Trauma Day (Oct 17th)
\nand World Osteoporosis Day (Oct 20th).
\nLaunched in January 2000, the Bone and
\nJoint Decade is an NGO, headquartered in
\nSweden. Its mission is to advance under-
\nstanding of musculoskeletal disorders
\nworld-wide through research, and to im-
\nprove the quality of life for those affected by
\nthese disorders. The Bone and Joint Decade
\nis supported by National Action Networks,
\nprofessional medical societies, patient advo-
\ncacy groups, governments, industry and re-
\nsearchers who are to effect change. The
\nBone and Joint Decade is delighted to have
\nthe personal and active support of Kofi An-
\nnan, Secretary-General of the UN, the WHO
\nand the World Bank.
\nThe Bone and Joint Decade encompasses
\ndiseases associated with musculoskeletal
\ndisorders such as joint diseases, osteoporo-
\nsis, osteoarthritis, rheumatoid arthritis, low
\nback pain, spinal disorders, severe trauma to
\nthe extremities, crippling diseases and defor-
\nmities in children.
\nFor more information and a copy of the os-
\nteoporosis guidelines, see: The Bone & Joint
\nDecade: http:\/\/www.boneandjointdecade.org
\nand: International Osteoporosis Foundation:
\nhttp:\/\/www.osteofound.org.
\n18
\nMedical Science, Professional Practice and Education
\nA comparative study of patient and
\nphysicians’ perceptions world-wide
\nThe following is an abstract summary of
\nthis study carried out and presented at
\nthe Helsinki General Assembly, Septem-
\nber 2003 by Dr. Mike Mcgee, WMA, Fel-
\nlow in Humanities 2003 The full text can
\nbe obtained from the author*
\nContext of study
\nA number of forces have transformed the
\npractice of medicine in the past two decades.
\nEvidence suggests that these forces are im-
\npacting on both patients and physicians and
\non their relationship with each other.
\nObjectives
\nTo simultaneously survey patients’ and
\nphysicians’ perceptions of their relationship
\nwith each other in six countries on four
\ncontinents.
\nDesign and Setting
\nPatients and physicians were simultaneous-
\nly studied in six countries using nationally
\nrepresentative telephone surveys between
\nJuly 22, 2002 and October 13, 2002. 2506
\ninterviews were conducted on patients (63
\n% response rate) and 1201 interviews were
\nconducted on physicians (58 % response
\nrate) using a random digit dialing (RDD)
\nmethodology.
\nParticipants
\nPatients had to be at least 21 years of age.
\nPhysicians had to be general practitioners
\nand in practice for five or more years.
\nMain Outcome Measures
\nRelative importance of patient-physician re-
\nlationships compared to other critical rela-
\ntionships in society. Type of relationship as
\ndefined by patients and physicians. Levels
\nof patient empowerment and self-manage-
\nment of care. Actual and ideal performance
\nratings in 5 dimensions in the humanistic
\ndomain (compassion, trust, understanding,
\npatience, listening) and 5 dimensions in the
\naccess domain (access to physician, time
\nwith physician, appointment scheduling,
\nchoice of treatment, choice of specialists).
\nResults
\nThe patient-physician relationship ranked
\nsecond in importance only to family rela-
\ntionships in all countries studied. Physicians
\nwere the leading source of health informa-
\ntion, the most trusted source, and the source
\nmost likely to instigate positive behavioural
\nchange in patients in all countries studied.
\nAll countries agree that authoritarian pater-
\nnalistic relationships between physicians
\nand patients are relatively uncommon today.
\nThese relationships are being replaced by
\nmutual partnerships or advisor models. Pa-
\ntients and physicians in all countries foresee
\nfuture movement toward partnership and
\nteam based models. Compared to 10 years
\nago, most patients in all countries believe
\nthey ask more questions, make more choic-
\nes, actively evaluate benefit and risk, and
\ntake better care of their own health. Patients’
\nconfidence in managing their own health is
\nvery high in all countries except Japan.
\nPhysician confidence in patients self-man-
\nagement is lower than patients scoring in
\nfive of the six countries. In general, all co-
\nhorts rate physician humanistic perfor-
\nmance higher than access performance.
\nPhysicians in all countries rate their ideal
\nhumanistic performance higher than do pa-
\ntients. In contrast, physicians in the United
\nKingdom and Germany rate their ideal ac-
\ncess performance lower than the patients’
\nexpectation for ideal access performance. In
\nactual performance both in humanistic and
\naccess domains, physicians score them-
\nselves higher than do patients in 8 of the 10
\ndimensions. Patients and physicians scoring
\nof opportunities for improvement is relative-
\nly well aligned in five of the six countries
\nstudied. The greatest variance in opportuni-
\nRelationship Based Health Care in Six Countries
\nty scores between patient and physician ex-
\nists in the United Kingdom in both humanis-
\ntic domain (17 % difference) and access do-
\nmain (26 % difference) and in Germany ac-
\ncess domain (19 % difference), with patients
\nseeing more opportunity than do physicians.
\nConclusions
\nThe findings indicate a fundamental shift in
\nthe patient-physician relationship away
\nfrom an authoritarian and paternalistic mod-
\nel and toward partnership and team based
\napproaches. Patients are significantly more
\nconfident and empowered than they were
\nten years ago. Physician confidence in pa-
\ntient self-management is more modest. Pa-
\ntients possess high confidence in physicians
\nbut also demonstrate higher expectations for
\nideal physician performance and higher ex-
\npectations for improvement along five di-
\nmensions of humanistic care and five di-
\nmensions of access to care. The ability to
\nalign expectations of patients and physi-
\ncians, and meet commonly held objectives,
\nwill be increasingly important in assuring
\nthe future health of this critically important
\nsocietal relationship.
\n* Mike Magee, Pfizer Medical Humanities
\nInitiative, 235 East 42nd
\nSt, New York NY
\n10017
\n19
\nWorld Health Organisation
\nWorld Health Organisation
\nMore Research, More Resources Needed To
\nControl Expanding Global Diseases
\nDr. Lee Jong-wook, WHO Director General
\nin his introduction to the World Health Re-
\nport 2003, writes \u201eToday\u2019s global health sit-
\nuation raises urgent questions about justice.
\nIn some parts of the world there is a contin-
\nued expectation of longer and more com-
\nfortable life, while in many others there is
\ndespair over the failure to control disease al-
\nthough the means to do so exist.
\nThis contrast is starkly evident in lack of ac-
\ncess to HIV\/AIDS treatment, which led me,
\nearlier this year, to declare a global health
\nemergency. WHO decided to take this rare
\nmeasure after evaluating the global situation
\nand finding that only 5 % of those in the de-
\nveloping world who require antiretrovirals
\n(ARVs) are getting them. In sub-Saharan
\nAfrica, only 50,000 of the 4 million people
\nin need have access toARVs. This spells cat-
\nastrophe, not only for the societies hardest
\nhit but for the world as a whole. Our first
\nstep to respond to this crisis must be to reach
\n\u201d3 by 5\u201d \u2013 3 million people in developing
\ncountries on antiretrovirals by 2005. Major
\ndisparities also exist in areas such as child
\nmortality. Of the more than 10 million chil-
\ndren under 5 years old who die every year,
\nalmost all are in developing countries.
\nA world marked by such inequities is in very
\nserious trouble. We have to find ways to
\nunite our strengths as a global community to
\nshape a healthier future. This report on the
\nworld\u2019s health, my first since taking office,
\ngives some initial indications of how to do it.
\nThe message (running through the report) is
\nthat progress in health, including rapid and
\nsustainable expansion of emergency treat-
\nments, depends on viable national and local
\nhealth systems. Scaling up ARV therapy in
\nresource-poor settings has to be done in such
\na way as to strengthen health systems based
\non primary health care. In most countries,
\nthere will be only small and short-lived ad-
\nvances towards acceptable standards of
\nhealth without the development of health
\ncare systems which are strong enough to re-
\nspond the current challenges.
\nTo lend impetus to this process WHO is now
\nmaking results in countries its main objec-
\ntive. Effective action to improve population
\nhealth is possible in every country but it
\ntakes local knowledge and strength to turn
\nthat possibility into reality. We have learnt
\nthis through successes such as controlling
\nthe SARS epidemic and major advances in
\nthe polio eradication campaign, and we have
\nlearnt it through setbacks as well, such as
\ncontinuing rise of AIDS, TB and malaria.
\nAll of these lessons have prepared us for the
\ntask ahead.
\nTwenty-five years ago, the Declaration of
\nAlma-Ata challenged the world to embrace
\nthe principles of primary health care as the
\nway to overcome gross health inequalities
\nbetween and within countries. \u201dHealth for
\nall\u201d became the slogan for a movement. It
\nwas not just an ideal but an organizing prin-
\nciple: everybody needs and is entitled to the
\nhighest possible standard of health. The
\nprinciples defined at that time remain indis-
\npensable for a coherent vision of global
\nhealth. Turning that vision into reality calls
\nfor clarity both on the possibilities and on
\nthe obstacles that have slowed and in some
\ncases reversed progress towards meeting the
\nhealth needs of all people. This entails work-
\ning with countries \u2013 especially those most in
\nneed \u2013 not only to confront health crises, but
\nto construct sustainable and equitable health
\nsystems.
\nI urge the global health community to set its
\nsights on bold objectives. All countries of the
\nworld have pledged to reach the Millenium
\nDevelopment Goals set at the United Nations
\nSummit in 2000. These include ambitious tar-
\ngets for nutrition, maternal and child health,
\ninfectious disease control, and access to essen-
\ntial medicines. With this support we have a real
\nopportunity now to make progress that will
\nmean longer, healthier lives for millions for
\npeople, turn despair into realistic hope, and lay
\nthe foundations for improved health for gener-
\nations to come.
\nTo reach our goals, increased resource
\ncommitments and intensified collabora-
\ntion among partners will be required. The
\n[…] report describes the challenges we
\nface and points the way for a united re-
\nsponse from WHO and the global health
\ncommunity.\u201c
\nGeneva
\nOctober 2003
\nWHO welcomes new
\ninitiative to cut the
\nprice of AIDS
\nmedicines
\n20
\nWorld Health Organisation
\nPoverty
\nHealth And Finance Ministers Address Need
\nFor World-wide Increase In Health Investment
\nGeneva \u2013 Ministers of Health, Finance and
\nPlanning from 40 developing countries
\ncame together with development partners at
\nWHO headquarters from 29 to 30 October
\nto address the need to significantly increase
\ninvestments in health. This is the first time
\nthat the World Health Organisation has host-
\ned a meeting so widely attended by non-
\nhealth officials, underlining the urgency of
\nbuilding national capacity to absorb in-
\ncreased health funding.
\n\u201dThis meeting signifies real political commit-
\nment from the highest levels of government
\nand donor representatives. Let us capitalize on
\nthis unique opportunity to regognize health as
\na critical investment and together develop a
\ncommon understanding of how countries and
\ntheir partners can transform these commit-
\nments into immediate actions. We must
\nchoose to make equitable and efficient health
\ninvestments a reality,\u201d said WHO Director-
\nGeneral Dr Lee Jong-wook.
\nThis meeting comes nearly two years after
\nthe launch of the 2001 Report of the Com-
\nmission on Macroeconomics and Health
\n(CMH), which recommends that by 2007,
\ndonors should increase assistance for health
\nto US$ 27 billion. The Commission also
\ncalls for more budgetary resources for pub-
\nlic health from both developed and develop-
\ning countries, and more political and organ-
\nisational effort than has been seen in the past
\ndecades to achieve real improvements in
\nhealth.
\nTwo years on, the world still has not shown
\ndetermination in increase investment in
\nhealth to the levels needed to measurably
\nimpact major diseases that affect the world\u2019s
\npoor. A recent study* has shown that the to-
\ntal development assistance for health from
\nmajor selected sources increased by US$
\n1.6 billion, from an average of US$ 6.1 bil-
\nlion (1997\u20131999) to US$ 7.7 billion (2001).
\nMost of the increase in funding was allocat-
\ned to fighting HIV\/AIDS in sub-Saharan
\nAfrica. Although these recent increases in
\nassistance for health are encouraging, they
\nstill fall short of meeting real needs.
\n\u201dOn taking office, I declared the target of
\n\u20183 by 5\u2019 \u2013 to have 3 million people with AIDS
\nin developing countries on treatment with an-
\ntiretrovirals by the end of 2005. Only 300,000
\nare on treatment at the moment. To achieve
\n\u20183 by 5\u2019 and other health priorities we need
\nconsiderably more funds than those currently
\navailable. If we don\u2019t increase resources for
\nhealth and target these resources to activities
\nthat will have the greatest impact, we stand to
\nlose millions of men, women and children to
\ndisease. This also means trapping individuals
\nand families in poverty and disillusionment,\u201d
\nsaid Dr Lee.
\nDuring the meeting, the combined work of
\ncountries, WHO and partners was to devel-
\nop concrete plans for increased health in-
\nvestment in countries. Continued global
\nleadership and follow-up from the develop-
\nment community, combined with inter-min-
\nisterial collaboration is needed: first, to in-
\ncrease resources for health from domestic
\nresources, debt relief and development as-
\nsistance for health, and second to eliminate
\nhealth system and institutional constraints,
\nenabling greater absorption of increased re-
\nsources. This will be critical for pursuing
\ncountry action to reach the \u20183 by 5\u2019 and oth-
\ner health targets.
\n\u201dWe need country-specific blueprints for
\nmaking real increases in health investment.
\nDeveloping countries and their partners
\nneed to collectively and quickly do much
\nmore, for health and global stability. This
\nmeeting can identify ways to make this hap-
\npen,\u201d added Dr Lee.
\nNational Macroeconomics and Health activ-
\nities are ongoing in the countries participat-
\ning in the Consultation: From Africa: Ango-
\nla, Botswana, Congo, Ethiopia, Ghana,
\nKenya, Malawi, Mozambique, Nigeria,
\nRwanda, Senegal, South Africa, Uganda,
\nUnited Republic of Tanzania. From the
\nAmericans: Argentina, Brazil, Mexico,
\nNicaragua, Peru and the Caribbean Com-
\nmunity including Haiti. From the Eastern
\nMediterranean: Djibouti, Iran (Islamic Re-
\npublic of), Jordan, Pakistan, Sudan, Yemen.
\nFrom Europe: Azerbaijan and Estonia.
\nFrom South East Asia: Bangladesh, Bhutan,
\nIndia, Indonesia, Myanmar, Nepal, Sri Lan-
\nka and Thailand. From the Western Pacific:
\nCambodia, China, Philippines and Viet
\nNam.
\n* Development
\nAssistance for health (DAH): Recent Trends and
\nresource Allocation Dr. Catherine Michaud, Senior
\nReserach Associate, Harvard Center for Population
\nand Development Studies
\nGeneva \u2013 The World Health Organisation
\nhas welcomed a new initiative to further cut
\nthe price of AIDS medicines in developing
\ncountries. WHO also underlined the impor-
\ntance of speedy delivery and distribution, as
\nwell as effective treatment and care to en-
\nsure equitable access to treatment around
\nthe world.
\nIn New York, the William J. Clinton Foun-
\ndation announced that it had reached agree-
\nment with some manufacturers to cut the
\nprice of AIDS medicines in half.
\n\u201dProviding AIDS treatment to those who
\nmost urgently need it in poor countries is the
\nmost urgent health challenge the world
\nfaces,\u201d said the WHO Director-General, Dr
\nLEE Jong-wook. \u201dWHO welcomes this
\nClinton Foundation initiative and all private
\nand public sector efforts that will both re-
\nduce the price of AIDS medicines and en-
\nsure their availability to the people who
\nmost urgently need them.\u201d
\nWHO and its partners are fully committed
\nto delivering antiretroviral therapy to three
\n21
\nWorld Health Organisation
\nmillion people in developing countries by
\nthe end of 2005, the \u201d3 by 5\u201d target. To do
\nthis, WHO is leading emergency response
\nteams to assist developing countries in in-
\ncreasing the availability of treatment for
\npeople with AIDS, developing simplified
\ntreatment guidelines, building an AIDS
\ndrugs and diagnostics facility, and ensuring
\nthe widespread availability of training for
\nhealth staff and volunteers.
\n\u201dFurther price reductions are vital for coun-
\ntries to be able to provide treatment to those
\nwho need it,\u201d said Dr Paulo Teixeira, Direc-
\ntor of the HIV\/AIDS Department at WHO.
\n\u201dBut lower price medicines alone will not
\ndeliver treatment. Improving the ability of
\ncountries to deliver the medicines, building
\nstronger health systems and training more
\nhealth workers are also vital if we are to
\nreach the \u20183 by 5\u2019 target.\u201d
\nMaternal mortality
\nMaternal Deaths Disproportionately High In
\nDeveloping Countries
\nAfrican women are 175 times more likely to
\ndie in childbirth than women in developed
\nregions of the world
\nGeneva \u2013 New findings on maternal mortal-
\nity by WHO, UNICEF and UNFPA show
\nthat a woman living in Sub-Saharan Africa
\nhas a 1 in 16 chance of dying in pregnancy
\nor childbirth. This compares with a 1 in
\n2,800 risk for a woman from a developed re-
\ngion. These findings are contained in a new
\nglobal report on maternal mortality released
\nonline by the three agencies at.
\nwww.who.int\/……..
\nOf the estimated 529,000 maternal deaths in
\n2000, 95 % occurred in Africa and Asia,
\nwhile only 4 % (22,000) occurred in Latin
\nAmerica and the Caribbean, and less than
\none percent (2,500) in the more developed
\nregions of the world.
\nExperience from successful maternal health
\nprograms let show that much of this death
\nand suffering could be avoided if all women
\nhad the assistance of a skilled health worker
\nduring pregnancy and delivery, and access to
\nemergency medical care when complica-
\ntions arise.
\n\u201dMany women deliver their children alone
\nor with family members or other untrained
\nattendants who lack the skills to deal with
\ncomplications during delivery,\u201d said Dr LEE
\nJong-wook, Director-General of WHO.
\n\u201dSkilled attendants are vital because they
\ncan recognise and prevent medical crises
\nand provide or refer for life-saving care
\nwhen complications arise. They also provide
\nmothers with basic information about care
\nfor themselves and their children before and
\nafter giving birth.\u201d
\nReducing maternal mortality is a key factor
\nin ensuring that all children, especially in
\nthe world\u2019s poorest countries, survive and
\nthrive through adolescence.
\n\u201dThese new estimates indicate an unaccept-
\nably high number of women dying in child-
\nbirth and an urgent need for increased access
\nto emergency obstetric care, especially in sub-
\nSaharan Africa,\u201d said UNICEF Executive Di-
\nrector Carol Bellamy. \u201dThe widespread provi-
\nsion of emergency obstetric care is essential if
\nwe want to reduce maternal deaths.\u201d
\nThe maternal mortality ratio, was estimated
\nto be 400 per 100,000 live births globally in
\n2000. By region, it was highest in Africa
\n(830), followed by Asia \u2013 excluding Japan
\n(330), Oceania \u2013 excluding Australia and
\nNew Zealand (240), Latin America and the
\nCaribbean (190) and the developed countries
\n(20).
\nWorldwide, 13 developing countries ac-
\ncounted for 70 % of all maternal deaths. The
\nhighest number occurred in India where
\n136,000 women died, followed by Nigeria
\nwhere there were 37,000 deaths.
\nIn 2000, world leaders agreed to reduce ma-
\nternal mortality by three-quarters by 2015,
\nas part of the Millenium Development Goals
\n(MDGs). Tracking progress remains diffi-
\ncult, except where comprehensive registra-
\ntion of deaths, including causes of death, ex-
\nists. For this reason, the use of indicators
\nsuch as the proportion of women who have a
\nskilled attendant at delivery is essential to
\ntrack change.
\nThe use of skilled attendants at delivery in
\ndeveloping countries increased between
\nWHO\/UNICEF\/UNFPA Estimates of number of maternal
\ndeaths, lifetime risk and maternal mortality ratio,
\nby MDG regions, for the year 2000
\nNumber of Lifetime risk of Maternal
\nmaternal deaths* maternal deaths: mortality ratio
\n1 in: (maternal deaths
\nper 100,000 livebirths)MDG region
\nWorld 529,000 74 400
\nDeveloped regions \u00b2 2,500 2,800 20
\nEurope 1,700 2,400 24
\nDeveloping regions 527,000 61 440
\nAfrica 251,000 20 830
\nNorthern Africa 4,600 210 130
\nSub-Saharan Africa 247,000 16 920
\nLatin America and the Caribbean 22,000 160 190
\nAsia 253,000 94 330
\nEastern Asia 11,000 840 55
\nSouth-central Asia 207,000 46 520
\nSouth-eastern Asia 25,000 140 210
\nWestern Asia 9,800 120 19
\nOceania 530 83 240
\n* includes Canada, United States of America, Japan, Australia and New Zealand.
\n22
\nWMA Secretary General
\n1990 and 2000 from 42 to 52 %, suggesting
\na potential decrease in maternal deaths.
\nFindings show the greatest improvements in
\nSouth East Asia and Northern Africa and the
\nslowest change in sub-SaharanAfrica, which
\nwent from 40 % in 1990 to 43 % in 2000.
\nMost maternal deaths and disability occur as
\nthe result of one or more of three delays: a
\ndelay in recognising complications; a delay
\nin reaching a medical facility; or a delay in
\nreceiving good quality care. Efforts to ad-
\ndress these delays are essential in order to
\nsave the lives of mothers and babies.
\nEducation on family planning and the provi-
\nsion of family planning services of high
\nquality can also make a difference.
\nAs the focal agencies within the United Na-
\ntions systems for the health of women and
\nchildren, WHO, UNICEF and UNFPA
\npledge to enhance \u2013 both individually and
\njointly in collaboration with their partners \u2013
\ntheir efforts in assisting countries strengthen
\ntheir maternal health programs.
\nFor further information contact: Chris Powell, Com-
\nmunications Advisor; Family and Community
\nHealth, WHO, Geneva, Email: powelle @who.int
\nWMA Secretary General
\nFrom the Secretary General\u2019s Desk
\nIt is fascinating to look back on the history
\nof the World Medical Association (WMA)
\nin this historic 50th edition of the World Me-
\ndical Journal (WMJ). The roots of the WMA
\nare described in an article of the British Me-
\ndical Journal on October 5, 1946, where it
\nwas reported that physician\u2019s leaders had
\nmet to discuss the establishment of the
\nWorld Medical Association (WMA). This
\nAssociation would \u201dpromote closer ties bet-
\nween National Medical Associations, study
\nthe problems which confront the medical
\nprofession throughout the world, organise
\nthe exchange of information and establish
\nrelations with the World Health Organisati-
\non and present the views of the profession\u201d.
\nSubsequently the WMA was formally esta-
\nblished on September 18, 1947, and has gro-
\nwn into a formidable organisation. What I
\nfind most appealing of the work of National
\nMedical Associations and the WMA is its
\ndual purpose \u2013 serving the profession, but
\nalways making sure that the best interest of
\nthe patient remains our first consideration.
\nThis is one reason why medical leaders are
\noften, as it should be, gifted social leaders.
\nAs the WMJ turns a new page and embarks
\non a new style, format and list of contents,
\nwe stand on the shoulders of these medical
\nand social giants of the past and present to
\nbuild an even greater WMA, the global re-
\npresentative body for physicians. We con-
\ngratulate and wish Dr. Alan Rowe, our new
\nWMJ Editor-in-Chief and his team all of the
\nvery best in this worthy endeavour.
\nMuch has been done to promote the medical
\nprofession since the WMA General Assem-
\nbly last met in Helsinki during September
\n2003:
\nWorking against torture
\nThe WMA, in partnership with the Interna-
\ntional Council for the Rehabilitation of Tor-
\nture Victims (IRCT), has developed a suc-
\ncessful project to help train physicians in the
\ndetection, documentation and treatment of
\ntorture victims, using the so-called \u201dIstanbul
\nProtocol\u201d. Funded by the European Union,
\nthe partnership has now completed the first
\nphase of establishing links and building trai-
\nning centres in five pilot countries (Georgia,
\nMorocco, Mexico, Uganda and Sri Lanka).
\nOne of the highlights over the last few
\nmonths has been the determined efforts by
\nDr. Yoram Blachar, WMA Chair of Council
\n(and President of the Israel Medical Asso-
\nciation) to help establish these centres as he
\nundertook the trip to Sri Lanka on behalf of
\nthe WMA;
\nFight against SARS
\nThe Canadian Medical Association was par-
\nticularly effective in helping their members
\nunderstand and combat the SARS virus
\nwhen it hit that country during 2003. Buil-
\nding on the CMA example and following a
\nresolution by the WMA General Assembly,
\nthe CMA and WMA are now preparing a
\nnew policy on NMA preparedness for epide-
\nmics. The WMA has been negotiating with
\nWHO to develop a more effective communi-
\ncation channel and network to provide in-
\nformation and resources to NMAs and their
\nmembers in times of epidemics such as
\nSARS or the current Avian Flu;
\nRussian Medical Society
\n(RMS) comes of age
\nIt took the WMA four years of persistent
\nand often difficult negotiations to identify
\nand help develop a National Medical Asso-
\nciation in Russia. When the Russian Medi-
\ncal Society was admitted as member to the
\nWMA in 2002, it was a historic moment,
\nlong overdue. In this process, Dr Leonid
\nMikhailov, RMS Secretary General, deser-
\nves credit for his committed efforts to forge
\ntogether medical groups in Russia and build
\nlinks with the international community.
\nRussia has such vast intellectual riches that
\na world body simply cannot afford to grow
\nwithout the Russian medical leadership. Du-
\nring February 2004, this was strengthened
\neven more when one of the fathers of Russi-
\nan medicine, Prof. Valerie Pokrovsky, was
\nelected as President of the RMS for the next
\nyear. Prof. Pokrovsky is also the President of
\nthe prestigiousAcademy of Russian Medici-
\nne and is thus in a very good position to fur-
\nther strengthen the uniting role of the RMS
\nin the Russian medical profession;
\nAdvocacy at the WHO
\nNever before in the history of the WMA have
\nthere been a stronger links and more colla-
\nborative work between the WMA and WHO.
\nDuring the annual meetings of WHO, WMA
\nleaders regularly present the views of the
\nprofession in a concise and forthright man-
\nner. Most recently the Chair of Council, Dr
\nBlachar represented the WMA views on
\nhealth promotion and healthy lifestyles at the
\nWHO Executive Board Meeting during Ja-
\nnuary 2004. Other examples of collaboration
\nover the last 6 years include:
\n23
\nRegional and NMA News
\nG The WMA has been a forceful partner
\nand supporter of the Framework Conven-
\ntion on Tobacco Control
\nG Leadership of health professional groups
\nin the World No Tobacco Day 1999
\nG Development of a policy on safe injec-
\ntions as part of the Safe Injection Global
\nNetwork
\nG Development of a policy on Violence and
\nHealth
\nG Survey on Human Resources for Health
\nG Inclusion of the WMA in the GlobalAlert
\nand Response Network for the combat of
\ncommunicable diseases and now the de-
\nvelopment of a more comprehensive net-
\nwork to respond more rapidly and effec-
\ntively against diseases such as SARS.
\nEven though it is reassuring that progress
\nhas been made, much still needs to be done.
\nThe WMA has as one of its stated objectives
\nthat every nation in the world should be re-
\npresented in its membership. This ideal has
\nnot yet been achieved. Furthermore, the
\nWMA Council has set some priorities for
\naction over the next few years. The organi-
\nsation will focus on medical ethics, health
\nrelated human rights, the development of a
\ndatabase of physician and NMA informati-
\non, and to be the foremost central advocate
\nfor the medical profession, especially at the
\nlevel of WHO and other United Nations
\nagencies. At the Secretariat, we are very ex-
\ncited about this growth of enthusiasm and
\nenergy in the organisation, and hope that all
\nphysicians and NMAs will unite and help
\nbuild the WMA into a truly world class as-
\nsociation. We owe this to our dual constitu-
\nencies, our patients and our colleagues in the
\nmedical profession, the noblest profession
\non earth.
\nRegional and NMA News
\nSocial Security is a National Security Issue
\nEitaka Tsuboi, MD President, Japan Medical Association
\nThe time for government intervention is
\nwhen the national security of its citizens is
\nthreatened. That is why the national popula-
\nce pays taxes to enable their national leaders
\nto deal with national crises. If the Japanese
\ngovernment does not adequately address na-
\ntional security or the social security of its
\npeople, our country may undergo the expe-
\nrience of total national dysfunction.
\nTo rescue Japan from this kind of crisis situa-
\ntion, it is vitally important for the government
\nto pursue a national policy that will provide
\nJapanese citizens with a sense of security. Fo-
\nstering a national sense of security, removes
\napprehensions about the future and creates an
\natmosphere of social pace. A sense of securi-
\nty must be restored, in other words, national
\nsecurity must be definitely promised.
\nThis must be regarded as a national task that is
\na segment of the overall national security stra-
\ntegy without diminishing social security as a
\nsafety net. The ultimate goal of social securi-
\nty is employment, i. e., the ability of individu-
\nal citizens to contribute confidently to buil-
\nding society and the economy in good mental
\nand physical health through gainful employm-
\nent. What supports employment is health care,
\nlong-term care, education, pension, employm-
\nent insurance and livelihood protection \u2013
\ncomponents of the social security system.
\nThe ability to work is developed through edu-
\ncation, while national securityprotects our
\nlives through health care. Employment insur-
\nance provides assistance in the unfortunate
\nevent we become unemployed. Livelihood in-
\nsurance provides assistance when we experi-
\nence permanent unemployment. Pension is re-
\nmuneration for yielding our job to a younger
\nperson. Pensions help us maintain our liveli-
\nhood in our twilight years as we prepare for
\ndeath. Long-term care helps us through our fi-
\nnal stage of life. The social security system is
\nour common social capital that supports the
\ncycle of transitions in our lives. The govern-
\nment has an obligation to permanently en-
\nhance this common social capital.
\nSocial security is a dynamic system that is
\nconstantly evolving to enable us to live and
\nwork in prosperity. In terms of the health
\ncare sector, social security has evolved in
\ntandem with the era of infectious diseases in
\nthe aftermath of the war, followed by the era
\nof lifestyle related diseases, the current era
\nof medical care for the elderly and the fu-
\nture era of preventive medical care. Japan
\nhas become a nation with the world\u2019s
\nlongest life expectancy and the lowest in-
\nfant mortality rate. Although individual is-
\nsues remain, the fact that the entire nation
\nfunctions quietly on a system that guaran-
\ntees these living standards for its people has
\nraised Japan\u2019s national worth and has con-
\ntributed to high quality human resources.
\nThis social security system is a paramount
\ntask that maintains and strengthens national
\nstability. As common social capital, social
\nsecurity must be strategically invested to
\nachieve the combined components of health
\ncare, long-term care, pension, education,
\nemployment and others. Based on this fun-
\ndamental recognition of the social security
\nsystem, those of us who have been entrust-
\ned with the country\u2019s health care must fulfil
\nthe following three responsibilities.
\n1) Recognise that the universal national
\nhealth insurance is national security.
\nStrongly demand that the government
\nsubstantiate, improve and strengthen the
\nnational health insurance system.
\n2) Secure that individual rights of citizens
\nto have access to physicians at all time
\nand in all areas throughout the country,
\nin order to guarantee the equality of life.
\n3) Individual payments of medical expens-
\nes are required under the prevent sys-
\ntem. However they should be limited to
\na 20 % maximum of the medical cost. In
\nfuture, individual payments should be
\ncompletely abolished.
\nPhysicians should continue to advocate
\nthis responsibility while enduring the criti-
\ncism and disapproval of market principle
\nsupporters.
\nSubstantiating, improving and strengthen-
\ning health care is a welcome means of main-
\ntaining and increasing the health of the na-
\ntional populace. But as we pursue the bene-
\nfits that are derived from this process and
\nthose stemming from the introduction of ad-
\n24
\nRegional and NMA News
\nvanced medical technology, there is always
\nthe risk that medical ethics will be aban-
\ndoned.
\nAt the time of my inauguration as the 52nd
\npresident of the WMA in Edinburgh, 2000,
\nI discussed the subject of \u201dchannelling the
\nabundant benefits of advanced medical
\ntechnology\u201d. The JMA submitted a pro-
\nposed declaration on this issue, and \u201dthe
\nWMA Declaration on Medical Ethics and
\nAdvanced Medical Technology\u201d was adopt-
\ned by the WMA General Assembly, Wash-
\nington 2002.
\nA scientific session on the theme, \u201dAdvanced
\nMedical Technology and Medical Ethics\u201d and
\n\u201dThe Internet and Health Care\u201d, is planned for
\nthe WMA General Assembly, Tokyo 2004,
\nand many successful developments are antici-
\npated. It is hoped that the medical profession,
\nwhich has been entrusted with the control of
\nadvanced medical technology and cutting-
\nedge information technology in the 21st cen-
\ntury, will raise its awareness about its respon-
\nsibility of overseeing humanity\u2019s health based
\non a code of medical ethics that is the essence
\nof all medical practice.
\nI look forward to the contribution of your
\nwisdom and the participation of all WMA
\nmember associations of the WMA Tokyo
\nGeneral Assembly.
\nThe German Health Care System (social in-
\nsurance system) has been financed on the
\nbasis of contributions linked to wages and
\nsalaries. For many years now Co-payments
\nhave also been a feature of the system but
\nthese were only set at a symbolic level.
\nIn a major reform act the government coali-
\ntion with support of the opposition Christian
\nDemocrats have introduced multiple
\nchanges in the Statutory Health Insurance
\n(Gesetzliche Krankenversicherung). The
\nchanges are of considerable concern to Ger-
\nman doctors but will be of interest to others
\nwhose health care systems are based on this
\ntype of social insurance.
\nThe major aim is the reduction of expendi-
\nture. As the financing of the SHI is based on
\ncontributions linked to wages and salaries,
\nincreasing cost for health insurance is being
\nseen as an economic burden to the export
\norientated German industry. The following
\nnote indicates some of the major concerns
\nabout the changes in the SHI.
\nCo-payments
\nCo-payments have existed for many years
\nbut only on a symbolic level. Now they have
\nbeen raised significantly and can in some in-
\nstances reach 100 %, including prescribed
\n\u201dOver-the-Counter\u201d-Drugs (OTC), trans-
\nportation costs, and many remedies includ-
\ning glasses. For hospital stays the co-pay-
\nment has been raised from 9 Euros for a
\nmaximum of 14 days per year, to 10 Euros
\nfor 28 days per year. A 10 Euro co-payment
\nis required for the first consultation with a
\nphysician in each quarter. If another physi-
\ncian is consulted without referral by a Gen-
\neral practitioner, an additional co-payment
\nis applied. It is thought that this will reduce
\nthe common \u201ddoctor hopping\u201d in Germany.
\nA limit of 2 % of annual income has been set
\non the yearly sum of co-payments for which
\nparticipants are responsible. If co-payments
\nexceed this value the excess is covered. For
\nserious chronically ill patients (needing at
\nleast one physician consultation per quarter)
\nthe capping operates a 1 % of income. Cer-
\ntain exceptions much more rigid than in the
\npast may however be set in the future.
\nWhilst in the past Pharmacists income de-
\npended in part on a percentage payment based
\non the cost of drugs, this has been replaced by
\na fixed pharmacy charge of 8.10 Euro. Where-
\nas this has resulted in an increase in price for
\nlow-cost prescribed drugs, it has reduced the
\ncost of the higher priced ones.
\nThe introduction of these co-payments is
\nhighly criticised by consumer organisations
\nand unions. Due to unclear wording in the
\nlaw and lack of regulations at the time of im-
\nplementation, many problems and argu-
\nments occurred.
\nSick funds may provide some relief to their
\nmembers by offering the use of internet
\npharmacies, which was previously prohibit-
\ned, or of enrolment in a primary care model
\nin which the insured would agree always to
\nconsult a GP first.
\nDefinition of Basket
\nA common body of the sick funds, physi-
\ncians and hospitals, will define the services
\nand treatment that can be rendered under
\nSHI. In the past this covered only ambulato-
\nry treatment, but now also includes the hos-
\npital sector. The decisions have to be based
\non evidence, thus giving Health Technology
\nAssessment and EBM a strong boost. In ad-
\ndition a patients\u2019 representative has been in-
\nstalled (Bundesbeand is to be heard before
\ndecisions will be taken). Furthermore the
\nself-government of sick funds and providers
\nhas to introduce a new institute for quality
\nmatters. (The initial plan to copy the British
\nNational Institute for Clinical Excellence
\nwas not followed.)
\nSelective contracting \u2013 new provider types
\nWhile until now contracts between the sick
\nfunds and the ambulatory physicians only ex-
\nisted as group contracts negotiated between
\nthe \u201dumbrella\u201d organisations of the sick funds
\nand the association of the office based physi-
\ncians (Kassen\u00e4rztliche Vereinigung \u2013 KV) (a
\nstatutory body with obligatory membership),
\nsick funds are now permitted to make con-
\ntracts with physicians and groups of physi-
\ncians directly on a limited basis. One percent
\nof the budget for ambulatory treatment is to
\nbe set aside for such new types of contracts,
\nwhose number is planned to be increased in
\nthe future. At the same time new types of am-
\nbulatory institutions owned by third parties
\nwill be eligible to provide ambulatory treat-
\nments. Hospital emergency rooms, which in
\nthe past have been strictly limited to use for
\nHealth Reform in Germany \u201dsustaining or
\ndiluting social insurance?\u201d
\nDr. Otmar Kloiber, German Medical Association
\nThe South African Medical Association
\n(SAMA) has for years been the association
\ntaking doctors forward and into the future.
\nAs an Association with many social res-
\nponsibilities, we have dedicated ourselves
\nto fighting the HIV\/Aids scourge.
\nIn July 2001, SAMA criticised the govern-
\nment for their lack of direction in rolling
\nout an HIV programme, and called on go-
\nvernment to provide antiretroviral treat-
\nment (ART) to SouthAfricans in the public
\nsector. SAMA Chairperson, Dr Kgosi Let-
\nlape, said South Africa was the only coun-
\ntry in the world where there was no policy
\nfor the treatment of HIV.
\nA year later SAMA praised government
\nfor the provision of Nevirapine for the pre-
\nvention of mother-to-child transmission of
\nHIV. Dr Anant Chetty, then Chairperson of
\nSAMA\u2019s Human Rights, Law and Ethics
\nCommittee, emphasising that doctors need
\nnot be afraid to prescribe HIV\/Aids drugs,
\nsaid \u201dDoctor\u2019s ethical and moral rights are
\nprotected in our constitution, their clinical
\nindependence is fully supported by the
\nHealth Professions Council of SA and in-
\nternationally by world health organisati-
\nons.\u201d
\nYet, still adamant that a treatment pro-
\ngramme was necessary, SAMA met with
\nthe Minister of Health in August 2002. In
\ndiscussions with the Minister, Dr Manto
\nTshabalala-Msimang, SAMA re-cemented
\nits views that an HIV\/Aids treatment po-
\nlicy that includes the provision ofART was
\nessential to slow down the impact of
\nHIV\/Aids in South Africa. Following the
\nunsuccessful meeting with the Department
\nof Health, SAMA continued to persevere
\nin its efforts to facilitate treatment for peo-
\nple living with Aids, irrespective of the go-
\nvernment\u2019s position of not providing ART.
\nAfter the meeting Letlape stated, \u201dWe have
\nnot changed our position, and neither has
\nthe Department of Health. But both parties
\nare committed to further dialogue, and we
\nwill continue urging the department to re-
\nview its stance on makingART available in
\nthe public sector. Unfortunately time is not
\non our side. We would like to see the im-
\nplementation of pilot projects for
\n25
\nRegional and NMA News
\nemergency cases, will also be eligible to pro-
\nvide ambulatory services.
\nCommentary:
\nThe reform brings back some of the birth
\ndefects of the SHI, namely the high burden
\nfor the sick and a market (financial interest)
\ndriven system for the relations between sick
\nfunds and physicians.
\nIn the beginning of the SHI, the sick funds
\nonly paid compensation for lost income.
\nOver time it became more and more evident
\nthat it is better to care for the medical treat-
\nment in a comprehensive way, including fi-
\nnancial protection. Access to care is limited
\nby high co-payments. However, while one
\nmight correctly argue that contributing an
\nextra 1 or 2 % of income is not very much,
\nit hits especially the seriously ill patients.
\nOften they already have only a very small
\nincome because of their disease or handi-
\ncap. 1 or 2 % percent may be above what
\nthey can afford – just the money they can\u2019t
\ndecide about. Taking this away may have ef-
\nfects on compliance.
\nIn the beginning of the SHI it took more
\nthan 30 years to understand that selective
\ncontracting of physicians leads to a suppres-
\nsion of the provider side by powerful sick
\nfunds. Finally after years of strikes and
\nfights the situation was resolved, as it was
\nordered by government and later by law, that
\ncontracts could only be made with the trade
\nunion of ambulatory physicians. The union
\nwas later transformed into a statutory body
\nwith obligatory membership for all physici-
\nans who wished to treat patients insured un-
\nder SHI in ambulatory settings. Also, in or-
\nder to avoid Sick Funds circumventing this
\nmutual bargaining, they were not permitted
\nto have their own establishment for ambula-
\ntory treatment or to contract with third par-
\nties. This gave enormous stability and pre-
\nvented competition for prices.
\nThe new regulation shifts the provision of
\nambulatory care towards a commodity bu-
\nsiness, as it will put financial considerations
\nbefore medical ones. The same is true for
\npermitting third parties e. g. commercial
\nentities, to open ambulatory treatment faci-
\nlities competing with established specialists
\nand GPs.
\nAlthough there have never been formally
\nmandated patient representatives in Ger-
\nmany, the patient\u2019s voice has always been
\neffective. If not, public movements resulted
\nin change, and the courts decided very often
\nin favour of patients and continuously ex-
\ntended benefits for patients. The underlying
\nnotion was that neither sick funds nor provi-
\nders in their contractual relationship should
\nbe able to deprive patients of benefits. Now,
\nwith a formally installed patient representa-
\ntive included in the procedures, the argu-
\nment that decisions were taken without par-
\nticipation of patients may no longer be ap-
\nplicable. This may lead to more effective li-
\nmitation of the basket than in the past. In-
\ndeed the introduction of a patient represen-
\ntative may in the end do just this: limiting
\npatient claims. In the context of the overall
\naim of the reform, namely limiting health
\ncare expenditure, this of course would be a
\nsuccess but at what cost to be principle of
\nequity in providing for the needs of the sick
\nThe South African Medical Association\u2019s work
\non the HIV\/Aids front
\n26
\nRegional and NMA News
\nHIV\/Aids treatment in all provinces as a
\nmatter of urgency, and will pursue all possi-
\nbilities towards facilitating treatment
\nthrough efforts with other organisations.\u201d
\nMeanwhile, SAMA joined forces with the
\nTreatment Action Campaign and the Nelson
\nMandela Foundation to strengthen its positi-
\non in the fight against the disease.
\nSAMA has over the years used all means ne-
\ncessary to inform its members, and patients,
\non the right to treatment of HIV. SAMA has
\nreiterated the profession\u2019s commitment to
\nthe alleviation of the HIV pandemic by all
\nmeans possible, and affirmed its strong sup-
\nport for the fundamental rights of medical
\npractitioners to clinical independence and
\nautonomy. This includes the right to treat
\npatients without undue influence, pressure
\nor victimisation from employers or govern-
\nment institutions.
\nThe Association then adopted a set of guide-
\nlines, \u201dHIV Human Rights and Ethical Gui-
\ndelines\u201d which informed members how to
\ndeal with the management of HIV. Members
\nwere kept informed of rulings by the Labour
\nCourt regarding HIV through our Human
\nRights, Law and Ethics Unit, and adopted a
\ndocument on \u201dDoctors\u2019 and Patients\u2019 Rights
\nand Responsibilities\u201d. What makes this do-
\ncument unique, is that it translates the hu-
\nman rights found in the South African Con-
\nstitution into real-life situations affecting
\ndoctors and patients. A second distinctive
\nfeature is the inclusion of responsibilities or
\nduties. For example, every doctor has the
\nright to life, which includes the right not to
\nbe placed in disproportional life-threatening
\nsituations. But every doctor has the duty to
\nprotect life, within the confines of patient
\nautonomy and decision-making power. On
\nthe other hand, patients have the right to
\nhave their lives protected by means of the
\nbenefits of medicine when available, and
\nwhen they so wish. However, patients also
\nhave the duty to ensure that their illness or
\nincapacity does not endanger the lives of
\nothers.
\nSAMA has always stressed the fact that its
\nmembers were fighting the pandemic in
\ntheir everyday work. \u201dMedical practitioners
\nare under an ethical duty to act in the best in-
\nterest of their patients, who form an excep-
\ntionally vulnerable group in South Africa
\nsociety,\u201d said Dr Chetty.
\nDoctors\u2019 clinical independence came under
\nfire with the von Mollendorff case. Dr Thys
\nvon Mollendorff was dismissed for treating
\nHIV-positive patients. SAMA worked close-
\nly with the Greater Nelspruit Intervention
\nProgramme (GRIP) and the Aids Law Pro-
\nject to see that the case was concluded for
\nthe positive. Letlape referred to the dismis-
\nsal of Dr von Mollendorff as an example in
\nwhich doctors\u2019 responsibility to their pati-
\nents was severely disrupted, which was in
\ndirect contrast with the rights of individuals
\nwhich are entrenched in the constitution. He
\nemphasised that urgent discussion with go-
\nvernment was needed to look at the principle
\nof interference in the profession\u2019s obligati-
\nons and duties on a broad scale. \u201dWe need
\nguidelines and rules to stimulate and nurtu-
\nre private public interface,\u201d Letlape said.
\nSAMA continued to reiterate the profes-
\nsion\u2019s right to clinical independence and au-
\ntonomy. Letlape referred to the 38th World
\nMedical Assembly (WMA) in 1986 when
\nthe WMA unambiguously denounced politi-
\ncal interference in health care delivery.
\n\u201dPhysicians must have the professional fre-
\nedom to care for their patients without inter-
\nference. The exercise of the physician\u2019s pro-
\nfessional judgement and discretion in ma-
\nking clinical and ethical decisions in the
\ncare and treatment of patients must be pre-
\nserved and protected.\u201d The Association
\nmade it clear that it would continue to assist
\nand support doctors who acted in the best in-
\nterest of patients and their rights to access to
\nhealth care.
\nLater Amnesty International (A.I.) urged the
\nMinister of Health to put a stop to the haras-
\nsment of health care professionals and other
\nservice providers in Mpumalanga Province,
\nto end discrimination against women in
\nneed and to uphold professional ethics.
\nA.I.\u2019s involvement in this issue started in
\nNovember 2001 when renewed action was
\ntaken against Dr von Mollendorff for his in-
\nvolvement in GRIP, which offered counsel-
\nling and treatment to rape survivors. Accor-
\nding to A.I., its correspondence with the re-
\nlevant authorities requesting information on
\nthe issue remained unanswered.
\nAs part of awareness campaigns the Junior
\nDoctors\u2019Association of SA (Judasa), an af-
\nfiliate group of SAMA, created the Black
\nArmband Campaign to show solidarity with
\nHIV\/Aids victims. Judasa emphasised that
\ntheir campaign was not an attack on govern-
\nment, but rather an offer to assist in any go-
\nvernment action aimed at fighting the
\nHIV\/Aids pandemic. As part of the cam-
\npaign, junior doctors intended to keep
\nthorough records of patients they saw dying
\nof HIV. The records would then be sent to
\nthe relevant authorities, to share with gover-
\nnment what junior doctors\u2019 experienced in
\ndealing with the HIV\/Aids pandemic every
\nday.
\nAwareness campaigns continued with
\nSAMA closely watching the development of
\nthe country\u2019s HIV\/Aids programme.
\nOn December 1, 2002 SAMA launched the
\nTshepang Treatment Programme, named af-
\nter baby Tshepang who had been savagely
\nraped and was put back together by caring
\ndoctors.
\nNearly a year later the Association\u2019s dream
\ncame true \u2013 supplying ART to people living
\nwith HIV. On December 1, 2003, World
\nAids Day, SAMA launched an ART treat-
\nment programme at the GF Jooste Hospital
\nin the Western Cape. The Association plans
\nto gather more financial support from the
\nrole-players in the industry, and eventually
\nhave two treatment sites in every province.
\nSAMA\u2019s Foundation for Professional Deve-
\nlopment (FPD), the educational arm of
\nSAMA, has developed an HIV management
\ncourse for doctors and other health person-
\nnel. To date they have trained 3,500 health
\ncare professionals in South Africa, and also
\ntrain health workers in Africa.
\nSAMA\u2019s motto is \u201dUniting doctors for the
\nhealth of the nation,\u201d and we plan to do just
\nso. KL\/TS
\n27
\nRegional and NMA News
\nHealth care for prisoners: human rights
\nand ethical dilemmas for doctors working
\nin prison – a web-based course for health
\ncare personnel working in prison
\nIn 2001 the Norwegian Medical Association
\ntook the initiative to develop a web-based
\ncourse on Human rights and ethics for prison
\ndoctors. Various associations and organisa-
\ntions have contributed to this course, and
\nWorld Medical Association will be the main
\nprovider.
\nDoctors working in prisons face problems
\nthat are different from the problems encoun-
\ntered by doctors working with the ordinary
\npopulation. Prison doctors must be able to
\nprovide adequate health care in the special
\nenvironments to be found in prisons, and en-
\nsure that this practice does not conflict with
\ninternational human rights and ethical stan-
\ndards.
\nIn many countries education of prison doc-
\ntors is a priority area. Many doctors do not
\neven have access to international conventions
\nand rules regulating the health care service
\nfor prisoners. We are aware that many doctors
\nknow about human rights violations, but do
\nnot know how to deal with them in an ade-
\nquate way. We hope this course will con-
\ntribute to meeting some of the needs for more
\nknowledge and skills in human rights and
\nmedical ethics felt by many prison doctors.
\nThe objectives of the course are to present
\nrelevant international statements regulating
\nmedical treatment of prisoners, and to raise
\nprison doctor’s awareness of their role in var-
\nious areas of conflicting interests between the
\nprisoner (patient) and the prison administra-
\ntion, e. g. during hunger strikes; the patient’s
\nright to confidentiality; certifying prisoners
\nfor special punishment etc.
\nThe course will be accessible to everyone with
\nan Internet connection. Doctors and other
\nhealth personnel working in prison can take the
\ncourse at their own pace and whenever they
\nwant. Participants do not have to complete the
\nwhole course in one go. The course is divided
\ninto lessons and the system remembers which
\nlessons the participant has completed.
\nNo course fee will be charged for those who
\nwish to complete the course. When it is fin-
\nished we will apply for approval at European
\nAccreditation Council for CME.
\nThis course is sponsored by The Norwegian
\nMinistry of Foreign Affairs. The authors and
\neditors have contributed without receiving
\nany fees.
\nA preliminary version of the course is acces-
\nsible at http:\/\/www.lupin-nma.net\/b.m.
\nA new report from the British Medical Asso-
\nciation presents a disturbing picture of the ef-
\nfects of smoking on sexual, reproductive and
\nchild health – and demands national and inter-
\nnational action to tackle the issue. Smoking
\nand Reproductive Life, a joint publication of
\nthe BMA board of Science and Education and
\nthe BMA-funded Tobacco Control Resource
\nCentre, is the first focused overview of its
\nkind.
\nThe picture that emerges is disturbing. Smo-
\nking harms sexual and reproductive health in
\nboth men and women. Its damaging effects
\nare seen throughout reproductive life – from
\npuberty, through young adulthood and into
\nmiddle age. Smoking can compromise the ca-
\npacity to have a family, and parental smoking
\ncan have long-term and serious consequences
\nfor child health. Exposure to second-hand
\nsmoke is a risk during pregnancy, and harms
\ninfants and children.
\nThe peer-reviewed report draws together ma-
\nterial from more than 200 reference sources,
\nincluding expert evaluations by the US Sur-
\ngeon General and the World Health Organi-
\nsation, as well as more recent original rese-
\narch. Among the effects linked to active smo-
\nking are impotence, sperm damage, delayed
\nconception, infertility. increased risk of ecto-
\npic pregnancy and miscarriage. damage to
\nthe foetus, low birthweight, placental compli-
\ncations, premature birth. Smoking is also a
\ncause of early menopause, and increases the
\nrisk of malignant cervical cancer up to three
\nfold.
\nThe effects of passive smoking are also high-
\nlighted. Non-smoking women exposed to
\nother people\u2019s tobacco smoke during preg-
\nnancy have lighter babies. and are at increa-
\nsed risk of having a low birth-weight baby.
\nEven relatively low-level exposure has a sig-
\nnificant effect. In children, secondhand smo-
\nke is a cause of cot death, and increases the
\nrisk of respiratory illness and middle ear in-
\nfection. It can cause asthma, and exacerbates
\nattacks in those already affected.
\nThe good news is that giving up smoking re-
\nduces or eliminates many of the risks to re-
\nproductive life and health. In contrast to much
\nof the excess risk of death associated with
\nsmoking, much of the b\u00fcrden of smoking on
\nreproductive life falls in younger adults, befo-
\nre age 40. In coming years. this b\u00fcrden looks
\nset to increase: smoking rates look set to triple
\namong women in the next generation, and
\nmore than half the world\u2019s children are expo-
\nsed to secondhand smoke.
\nThe report frames smoking as an important
\nconsideration in sexual, reproductive and
\nchild health. It makes recommendations to re-
\nduce the burden of sexual, reproductive and
\nchildhood ill health caused by tobacco. inclu-
\nding recommendations for research, healthca-
\nre professionals and public policy.
\nThe full report is available from the Tobacco
\nControl Resource Centre website:
\nhttp:\/\/www.tobacco-control.org. For further
\ninformation, contact: tcrc@bma.org.uk.
\nNorwegian Medical Association
\nU.K.
\nNew report details the impact of smoking on
\nsexual, reproductive and child health
\n28
\nReviews
\nThe WHO Bulletin WHO Bull. 82\/2 reports
\nconcern that legislative delays are slowing
\ndown the progress of continuing medical ed-
\nucation in India. \u201dThe Medical Council has
\nbeen campaigning for CME to be made
\ncompulsory\u201d and has \u201dproposed a draft
\namendment to a law that would standardise
\nmedical practice across the country while
\nmaking sure that it is up to date with the lat-
\nest medical developments\u201d.
\nThe Fiji MedicalAssociation is seeking re-
\nvision of the Medical Act and is also en-
\ncountering problems in generating politi-
\ncal will to provide legislative time. The
\nkey issues are to bring the licensing re-
\nquirements into line with global trends in
\n2004, to introduce obligatory CME as a
\ncondition for renewal of registration and to
\nupdate professional disciplinary proce-
\ndures. The Fiji Medical Association has
\nalso joined the Fiji Human Rights Com-
\nmission to become actively involved in as-
\nsessment of treatment of persons in cus-
\ntody.
\nFiji and India
\nLicensing and Regulation
\nBook Review
\nMedical Ethics Today: The BMA\u2019s handbook
\nof ethics and law (2nd
\nedition). British Med-
\nical Association Ethics Department. Pp. xxv,
\n882, London, BMJ Books, 2004, \u00a3 60.00
\nIn 1993 the BMA published Medical Ethics
\nToday: Its Practice and Philosophy, which
\nwas the fifth in a series of handbooks on
\nethics dating back to 1980. Now, a decade
\nlater, a revised version of the 1993 edition
\nhas appeared. Its greatly increased bulk,
\nmore than twice that of its predecessor, is
\nlargely due to the addition of legal issues that
\nwere formerly treated in a separate BMA
\npublication, Rights and Responsibilities of
\nDoctors. Indeed, the title of the present vol-
\nume is somewhat inaccurate, since the law
\nreceives at least as much consideration as
\ndoes ethics.
\nUnlike the 1993 edition, the authorship and
\nstatus of this book is unclear. The front cov-
\ner assigns authorship to the BMA Ethics De-
\npartment whereas on p. xxiii the book is re-
\nferred to as a publication from the BMA\u2019s
\nMedical Ethics Committee. The text fre-
\nquently speaks in the name of the BMA (\u201dIn
\nthe BMA\u2019s view \u2026,\u201d, \u201dthe BMA believes
\n\u2026,\u201d, \u201dBMA advice is that \u2026,\u201d etc.) but it is
\nseldom evident what type of approval any
\nparticular statement has received within the
\nBMA.
\nThe book comprises an introduction and
\n21 chapters on topics ranging from the doc-
\ntor-patient relationship to public health and
\nfrom assisted reproduction to responsibilities
\nafter a patient\u2019s death. Each chapter includes
\na statement of relevant principles, detailed
\ntreatments of the chapter subtopics with
\nsummaries of the main points, abstracts of
\npertinent legal cases, and extensive endnotes.
\nThe chapters are generally quite comprehen-
\nsive in their treatment of the issues, as least
\ninsofar as they affect doctors in the UK.
\nThere are very few citations of publications
\nfrom other countries.
\nLike the 1993 edition, the aim of this book is
\nto produce a working tool for doctors rather
\nthan a philosophical treatise: \u201dSince doctors
\ntend to need a quick and workable solution
\nfor an immediate case, the guidance focuses
\non practical responses to these common
\nquestions, but this process inevitably brings
\nin reference to philosophy and law\u201d (p. 2).
\nFor many issues the practical response is rel-
\natively unproblematic, since the legislators,
\nthe courts or the General Medical Council
\nhave already reached a conclusion and the
\nbook states categorically that \u201dit is \u2026 neces-
\nsary to ensure that the action proposed is not
\ncontrary to law or to guidance issued by the
\nGMC\u201d (p. 10).
\nOther issues are not so clear-cut because the
\nlaw and the GMC are silent or inconclusive.
\nHowever, as with the unproblematic issues,
\nthe book encourages doctors to look for ex-
\nternal advice rather than deciding on their
\nown how to deal with the situation. The guid-
\nance provided by the book on these issues is
\nderived from previous BMA statements, re-
\nports from various organisations, the ethics
\nand legal literature, and especially standards
\nof good clinical practice. Indeed, much of the
\nguidance is neither ethical nor legal but
\nrather descriptive of social and organisation-
\nal factors that doctors need to take into ac-
\ncount in their everyday practice. And when
\nthe guidance is specifically ethical, it is
\nsometimes formulated in prescriptive terms
\nwithout any ethical reasoning, for example,
\n\u201ddoctors with a conscientious objection to
\nproviding contraceptive advice or treatment
\nhave an ethical duty to refer their patients
\npromptly to another practitioner or family
\nplanning service\u201d (p. 233).
\nWhere ethical dilemmas occur for which
\nthere is no explicit legal or regulatory re-
\nquirement, the book recommends that the
\nBMA Ethics Department and\/or the medical
\nindemnity bodies be consulted. However, in
\nthese circumstances the book frequently also
\nrecommends that doctors seek legal advice.
\nThe reader is entitled to question the value of
\nthis approach, since legal opinions can and
\ndo differ greatly, especially when the law is
\nunclear, and seeking such advice is both
\ntime-consuming and costly. Clinical ethics
\ncommittees, which in other countries have
\nproved useful for dealing with ethical dilem-
\nmas, are mentioned only in connection with
\nassisted reproduction.
\nDespite the book\u2019s massive size, there are
\nseveral topics that would have merited more
\nextensive treatment. These include alloca-
\ntion\/rationing of health care resources, par-
\nticularly the role of the individual doctor; the
\nparticipation of doctors in medical research,
\nincluding their qualifications, compensation
\nand responsibility for ethical committee re-
\nview; the relationship of doctors and com-
\nmercial organisations, especially pharmaceu-
\ntical companies; multicultural health care;
\nand ethics education in medical schools.
\nDoctors in the UK will find this book to be a
\nuseful reference for a great variety of clinical,
\nprofessional and public policy issues. Since
\nso much of the book is devoted to British law,
\nhowever, it has limited applicability in other
\ncountries.
\nA CD-ROM version of the book, with a
\nhandy search feature, is included at no extra
\ncost or can be purchased separately. Updates
\non the issues covered in the book are to be
\nprovided on the BMA Ethics web site.
\nJohn R. Williams
\nDirector of Ethics
\nWorld Medical Association
\nFerney-Voltaire, France
\nCHILE
\nColegio M\u00e9dico de Chile
\nEsmeralda 678 – Casilla 639
\nSantiago
\nTel: (56-2) 4277800
\nFax: (56-2) 6330940 \/ 6336732
\nE-mail: sectecni@colegiomedico.cl
\nWebsite: www.colegiomedico.cl
\nVicepresidente
\nCHINA
\nChinese Medical Association
\n42 Dongsi Xidajie
\nBeijing 100710
\nTel: (86-10) 6513 4885
\nFax: (86-10) 6512 3754
\nE-mail: cmafrd@public3.bta.net.cn
\nCOLOMBIA
\nFederaci\u00f3n M\u00e9dica Colombiana
\nCalle 72 – N\u00b0 6-44, Piso 11
\nSantaf\u00e9 de Bogot\u00e1, D.E.
\nTel: (57-1) 211 0208
\nTel\/Fax: (57-1) 212 6082
\nE-mail: federacionmedicacol@
\nhotmail.com
\nDEMOCRATIC REP. OF CONGO
\nOrdre des M\u00e9decins du Zaire
\nB.P. 4922
\nKinshasa \u2013 Gombe
\nTel: (242-12) 24589\/
\nFax (secr.Gen): (242) 8846574
\nCOSTA RICA
\nUni\u00f3n M\u00e9dica Nacional
\nApartado 5920-1000
\nSan Jos\u00e9
\nTel: (506) 290-5490
\nFax: (506) 231 7373
\nE-mail: unmedica@sol.racsa.co.cr
\nCROATIA
\nCroatian Medical Association
\nSubiceva 9
\n10000 Zagreb
\nTel: (385-1) 46 93 300
\nFax: (385-1) 46 55 066
\nE-mail: orlic@mamef.mef.hr
\nCZECH REPUBLIC
\nCzech Medical Association .
\nJ.E. Purkyne
\nSokolsk\u00e1 31 – P.O. Box 88
\n120 26 Prague 2
\nTel: (420-2) 242 66 201\/202\/203\/204
\nFax: (420-2) 242 66 212 \/ 96 18 18 69
\nE-mail: czma@cls.cz
\nWebsite: www.cls.cz
\nUNITED STATES
\nColegio M\u00e9dico Cubano Libre
\nP.O. Box 141016
\nCoral Gables, FL 33114-1016
\nTel: (1-305) 446 9902\/445 1429
\nFax: (1-305) 4459310
\nDENMARK
\nDanish Medical Association
\n9 Trondhjemsgade
\n2100 Copenhagen 0
\nTel: (45) 35 44 -82 29\/Fax:-8505
\nE-mail: dadl@dadl.dk
\nWebsite: www.laegeforeningen.dk
\nDOMINICAN REPUBLIC
\nAsociaci\u00f3n M\u00e9dica Dominicana
\nCalle Paseo de los Medicos
\nEsquina Modesto Diaz Zona
\nUniversitaria
\nSanto Domingo
\nTel: (1809) 533-4602\/533-4686
\n\/533-8700
\nFax: (1809) 535 7337
\nE-mail: asoc.medica@codetel.net.do
\nECUADOR
\nFederaci\u00f3n M\u00e9dica Ecuatoriana
\nV.M. Rend\u00f3n 923 \u2013 2 do.Piso Of. 201
\nP.O. Box 09-01-9848
\nGuayaquil
\nTel\/Fax: (593) 4 562569
\nE-mail: fedmedec@andinanet.net
\nEGYPT
\nEgyptian Medical Association
\n\u201eDar El Hekmah\u201c
\n42, Kasr El-Eini Street
\nCairo
\nTel: (20-2) 3543406
\nEL SALVADOR, C.A
\nColegio M\u00e9dico de El Salvador
\nFinal Pasaje N\u00b0 10
\nColonia Miramonte
\nSan Salvador
\nTel: (503) 260-1111, 260-1112\/
\nFax: -0324
\nE-mail: comcolmed@telesal.net
\nETHIOPIA
\nEthiopian Medical Association
\nP.O. Box 2179
\nAddis Ababa
\nTel: (251-1) 158174
\nFax: (251-1) 533742
\nE-mail: ema.emj@telecom.net.et \/
\nema@eth.healthnet.org
\nFIJI ISLANDS
\nFiji Medical Association
\n2nd Fl. Narsey\u2019s Bldg, Renwick Road
\nG.P.O. Box 1116
\nSuva
\nTel: (679) \u2013315388
\nFax: (679) 387671
\nE-mail: fijimedassoc@connect.com.fi
\nFINLAND
\nFinnish Medical Association
\nP.O. Box 49
\n00501 Helsinki
\nTel: (358-9) 3930 826\/Fax-794
\nTelex: 125336 sll sf
\nE-mail: fma@fimnet.fi
\nWebsite: www.medassoc.fi
\nFRANCE
\nAssociation M\u00e9dicale Fran\u00e7aise
\n180, Blvd. Haussmann
\n75389 Paris Cedex 08
\nTel: (33) 1 53 89 32 41
\nFax: (33) 1 53 89 33 44
\nE-mail: cnom-international@
\ncn.medecin.fr
\nGEORGIA
\nGeorgian Medical Association
\n7 Asatiani Street
\n380077 Tbilisi
\nTel: (995 32) 39868 \/ Fax: -398083
\nE-mail: Gma@posta.ge
\nGERMANY
\nBundes\u00e4rztekammer
\n(German Medical Association)
\nHerbert-Lewin-Strasse 1
\n50931 K\u00f6ln
\nTel: (49-221) 400-4360\/Fax: -4384
\nTeletex: 2211315 – BAK
\nE-mail:auslandsdienst@baek.de
\nWebsite: www.bundesaerztekammer.de
\nGHANA
\nGhana Medical Association
\nP.O. Box 1596
\nAccra
\nTel: (233-21) 670-510\/Fax: -511
\nE-mail: gma@ghana.com
\nHAITI, W.I.
\nAssociation M\u00e9dicale Haitienne
\n1\u00e8re
\nAv. du Travail #33 \u2013 Bois Verna
\nPort-au-Prince
\nTel: (509) 245-2060\/511-0253
\nFax: (509) 223-9885
\nE-mail: amh@acn2..net
\nWebsite: www.amhhaiti.org
\nHONG KONG
\nHong Kong Medical Association, China
\nDuke of Windsor Building, 5th Floor
\n15 Hennessy Road
\nTel: (852) 2527-8285
\nFax: (852) 2865-0943
\nE-mail: hkma@hkma.org
\nWebsite: www.hkma.org
\nHUNGARY
\nAssociation of Hungarian Medical
\nSocieties (MOTESZ)
\nN\u00e1dor u. 36
\n1443 Budapest, PO.Box 145
\nGeneral Director
\nTel: (36-1) 312 3807 \u2013 311 6687
\nFax: (36-1) 383-7918
\nE-mail: motesz@motesz.hu
\nWebsite: www.motesz.hu
\nICELAND
\nIcelandic Medical Association
\nHlidasmari 8
\n200 K\u00f3pavogur
\nTel: (354) 5 864 0478
\nFax: (354) 5 644106
\nE-mail: icemed@icemed.is
\nINDIA
\nIndian Medical Association
\nIndraprastha Marg
\nNew Delhi 110 002
\nTel: (91-11) 337009\/3378819\/3378680
\nFax: (91-11) 3379178\/3379470
\nE-mail: inmedici@vsnl.com \/
\ninmedici@ndb.vsnl.com
\nINDONESIA
\nIndonesian Medical Association
\nJalan Dr Sam Ratulangie N\u00b0 29
\nJakarta 10350
\nTel: (62-21) 3150679
\nFax: (62-21) 390 0473\/3154 091
\nE-mail: pbidi@idola.net.id
\nIRELAND
\nIrish Medical Organisation
\n10 Fitzwilliam Place
\nDublin 2
\nTel: (353-1) 676-7273
\nFax: (353-1) 6612758\/6682168
\nWebsite: www.imo.ie
\nISRAEL
\nIsrael Medical Association
\n2 Twin Towers, 35 Jabotinsky St.
\nP.O. Box 3566, Ramat-Gan 52136
\nTel: (972-3) 6100444 \/ 424
\nFax: (972-3) 5751616 \/ 5753303
\nE-mail: estish@ima.org.il
\nWebsite: www.ima.org.il
\nJAPAN
\nJapan Medical Association
\n2-28-16 Honkomagome, Bunkyo-ku
\nTokyo 113-8621
\nTel: (81-3) 3946 2121\/3942 6489
\nFax: (81-3) 3946 6295
\nE-mail: jmaintl@po.med.or.jp
\nKAZAKHSTAN
\nAssociation of Medical Doctors
\nof Kazakhstan
\n117\/1 Kazybek bi St.,
\nAlmaty
\nTel: (3272) 62 -43 01 \/ -92 92
\nFax: -3606
\nE-mail: sadykova-aizhan@yahoo.com
\nREP. OF KOREA
\nKorean Medical Association
\n302-75 Ichon 1-dong, Yongsan-gu
\nSeoul 140-721
\nTel: (82-2) 794 2474
\nFax: (82-2) 793 9190
\nE-mail: intl@kma.org
\nWebsite: www.kma.org
\nKUWAIT
\nKuwait Medical Association
\nP.O. Box 1202
\nSafat 13013
\nTel: (965) 5333278, 5317971
\nFax: (965) 5333276
\nE-mail: aks.shatti@kma.org.kw
\nLATVIA
\nLatvian Physicians Association
\nSkolas Str. 3
\nRiga
\n1010 Latvia
\nTel: (371-7) 22 06 61; 22 06 57
\nFax: (371-7) 22 06 57
\nE-mail: lab@parks.lv
\nLIECHTENSTEIN
\nLiechtensteinischer \u00c4rzteverein
\nPostfach 52
\n9490 Vaduz
\nTel: (423) 232 -3440
\nFax: (423) 232 3455
\nWebsite: www.aerzte-net.li
\nLITHUANIA
\nLithuanian Medical Association
\nLiubarto 2
\n2004 Vilnius
\nTel\/Fax: (370-5) 2731400
\nE-mail: lgs@takas.lt
\nLUXEMBOURG
\nAssociation des M\u00e9decins et
\nM\u00e9decins Dentistes du Grand-
\nAssociation and address\/Officers
\nii
\nAssociation and address\/Officers
\nDuch\u00e9 de Luxembourg
\n29, rue de Vianden
\n2680 Luxembourg
\nTel: (352) 44 40 331
\nFax: (352) 45 83 49
\nE-mail: secretariat@ammd.lu
\nWebsite: www.ammd.lu
\nMACEDONIA
\nMacedonian Medical Association
\nDame Gruev St. 3
\nP.O. Box 174
\n91000 Skopje
\nTel\/Fax: (389-91) 232577
\nMALAYSIA
\nMalaysian Medical Association
\n4th Floor, MMA House
\n124 Jalan Pahang
\n53000 Kuala Lumpur
\nTel: (60-3) 40418972\/40411375
\nFax: (60-3) 40418187\/40434444
\nE-mail: mma@tm.net.my
\nWebsite: http:\/\/www.mma.org.my
\nMALTA
\nMedical Association of Malta
\nThe Professional Centre
\nSliema Road, Gzira GZR 06
\nTel: (356) 21312888
\nFax: (356) 21331713
\nE-mail: mfpb@maltanet.net
\nWebsite: www.mam.org.mt
\nMEXICO
\nColegio Medico de Mexico
\nFenacome
\nHidalgo 1828 Pte. Cons. 410
\nColonia Obispado C.P. 64060
\nMonterrey, Nuevo L\u00e9on
\nTel\/Fax: (52-8) 348-41-55
\nE-mail: fenacomemexico@usa.net
\nWebsite: www.fenacome.org
\nNEPAL
\nNepal Medical Association
\nSiddhi Sadan, Post Box 189
\nExhibition Road
\nKatmandu
\nTel: (977 1) 225860, 231825
\nFax: (977 1) 225300
\nE-mail: nma@healthnet.org.np
\nNETHERLANDS
\nRoyal Dutch Medical Association
\nP.O. Box 20051
\n3502 LB Utrecht
\nTel: (31-30) 28 23-267\/Fax-318
\nE-mail: j.bouwman@fed.knmg.nl
\nWebsite: http:\/\/www.knmg.nl
\nNEW ZEALAND
\nNew Zealand Medical Association
\nP.O. Box 156
\nWellington 1
\nTel: (64-4) 472 \u20134741\/ Fax-0838
\nFax: (64-4) 471 0838
\nE-mail: nzma@nzma.org.nz
\nWebsite: www.nzma.org.nz
\nNIGERIA
\nNigerian Medical Association
\n74, Adeniyi Jones Avenue Ikeja
\nP.O. Box 1108, Marina
\nLagos
\nTel: (234-1) 497 7262,
\nFax: (234-1) 585 1432 (ext 2197)
\nE-mail: nigeriannma@hotmail.com
\nNORWAY
\nNorwegian Medical Association
\nP.O.Box 1152 sentrum
\n0107 Oslo
\nTel: (47) 23 10 -90 00\/Fax: -9010
\nE-mail: ellen.pettersen@
\nlegeforeningen.no
\nWebsite: www.legeforeningen.no
\nPANAMA
\nAsociaci\u00f3n M\u00e9dica Nacional
\nde la Rep\u00fablica de Panam\u00e1
\nApartado Postal 2020
\nPanam\u00e1 1
\nTel: (507) 263 7622 \/263-7758
\nFax: (507) 223 1462
\nFax modem: (507) 223-5555
\nE-mail: amenalpa@sinfo.net
\nPERU
\nColegio M\u00e9dico del Per\u00fa
\nMalec\u00f3n Armend\u00e1riz N\u00b0 791
\nMiraflores
\nLima
\nTel: (51-1) 241 75 72
\nFax: (51-1) 242 3917
\nE-mail: decano@colmedi.org.pe
\nWebsite: www.colmed.org.pe
\nPHILIPPINES
\nPhilippine Medical Association
\nPMA Bldg, North Avenue
\nQuezon City
\nTel: (63-2) 929-63 66\/Fax: -6951
\nE-mail: pmasec1@edsamail.com.ph
\nPOLAND
\nPolish Medical Association
\nAl. Ujazdowskie 24
\n00-478 Warszawa
\nTel: (48-22) 628 86 99
\nFax: (48-22) 628 86 99
\nPORTUGAL
\nOrdem dos M\u00e9dicos
\nAv. Almirante Gago Coutinho, 151
\n1749-084 Lisbon
\nTel: (351-21) 842 71 00\/842 71 11
\nFax: (351-21) 842 71 99
\nE-mail: ordemmedicos@mail.telepac.pt
\n\/ intl.omcne@netcabo.pt
\nWebsite: www.ordemdosmedicos.pt
\nROMANIA
\nRomanian Medical Association
\nStr. Progresului 10
\nSect. 1, Bucarest, cod 70754
\nTel: (40-1) 6141071
\nFax: (40-1) 3121357
\nE-mail: amr@amr.sfos.ro
\nWebsite: www.cdi.pub.ro\/CDI\/
\nParteneri\/AMR_main.htm
\nRUSSIA
\nRussian Medical Society
\n34, Build. 1, Novy Arbat
\n121099 Moscow
\nTel: (7-095)205-7371
\nFax: (7-095) 205-3293
\nE-mail: rusmed@rusmed.rmt.ru
\nSLOVAK REPUBLIC
\nSlovak Medical Association
\nLegionarska 4
\n81322 Bratislavia
\nTel: (421-2) 554 24 015
\nFax: (421-2) 554 223 63
\nE-mail: secretarysma@ba.telecom.sk
\nSLOVENIA
\nSlovenian Medical Association
\nKomenskega 4
\n61001 Ljubljana
\nTel: (386-61) 323 469
\nFax: (386-61) 301 955
\nSOUTH AFRICA
\nThe South African Medical Association
\nP.O. Box 74789, Lynnwood Rydge
\n0040 Pretoria
\nTel: (27-12) 481 2036\/7
\nFax: (27-12) 481 2058
\nE-mail: liliang@samedical.org
\nWebsite: www.samedical.org
\nSPAIN
\nConsejo General de Colegios
\nOficiales de M\u00e9dicos
\nVillanueva 11
\nMadrid 28001
\nTel: (34-91) 4317780
\nFax: (34-91) 5764388
\nE-mail: internacional1@cgcom.org
\nSWEDEN
\nSwedish Medical Association
\n(Villagatan 5)
\nP.O. Box 5610
\nSE – 114 86 Stockholm
\nTel: (46-8) 790 33 00
\nFax: (46-8) 20 57 18
\nE-mail: info@slf.se
\nWebsite: www.lakarforbundet.se
\nSWITZERLAND
\nF\u00e9d\u00e9ration des M\u00e9decins Suisses
\nElfenstrasse 18 \u2013 POB 293
\n3000 Berne 16
\nTel: (41-31) 359 \u20131111\/Fax: -1112
\nE-mail: fmh@hin.ch
\nWebsite: www.fmh.ch\/ww\/fr\/pub\/fmh\/
\nhistoire_fmh.htm
\nTAIWAN
\nChinese Medical Association – Taipei
\n201, Shih-pai Rd., Sec. 2
\nP.O. Box 3043
\nTaipei 11217
\nTel: (886-2) 2871-2121, ext 7358
\nFax: (886-2) 28741097
\nE-mail: cma@vghtpe.gov.tw
\nTHAILAND
\nMedical Association of Thailand
\n2 Soi Soonvijai
\nNew Petchburi Road
\nBangkok 10320
\nTel: (66-2) 314 4333\/318-8170
\nFax: (66-2) 314 6305
\nE-mail: math@loxinfo.co.th
\nWebsite: http:\/\/www.medassocthai.org\/
\nindex.htm.
\nTUNISIA
\nConseil National de l\u2019Ordre
\ndes M\u00e9decins de Tunisie
\n16, rue de Touraine
\n1082 Tunis Cit\u00e9 Jardins
\nTel: (216-1) 792 736\/799 041
\nFax: (216-1) 788 729
\nE-mail: ordremed.na@planet.tn
\nTURKEY
\nTurkish Medical Association
\nGMK Bulvary,.
\nPehit Danip Tunalygil Sok. N\u00b0 2 Kat 4
\nMaltepe
\nAnkara
\nTel: (90-312) 231 \u20133179\/Fax: -1952
\nE-mail: Ttb@ttb.org.tr
\nUGANDA
\nUganda Medical Association
\nPlot 8, 41-43 circular rd.
\nP.O. Box 29874
\nKampala
\nTel: (256) 41 32 1795
\nFax: (256) 41 34 5597
\nE-mail: myers28@hotmail.com
\nUNITED KINGDOM
\nBritish Medical Association
\nBMA House, Tavistock Square
\nLondon WC1H 9JP
\nTel: (44-207) 387-4499
\nFax: (44- 207) 383-6711
\nE-mail: vivn@bma.org.uk
\nWebsite: www.bma.org.uk
\nUNITED STATES OF AMERICA
\nAmerican Medical Association
\n515 North State Street
\nChicago, Illinois 60610
\nTel: (1-312) 464 5040
\nFax: (1-312) 464 5973
\nWebsite: http:\/\/www.ama-assn.org
\nURUGUAY
\nSindicato M\u00e9dico del Uruguay
\nBulevar Artigas 1515
\nCP 11200 Montevideo
\nTel: (598-2) 401 47 01
\nFax: (598-2) 409 16 03
\nE-mail: secretaria@smu.org.uy
\nVATICAN STATE
\nAssociazione Medica del Vaticano
\nStato della Citta del Vaticano 00120
\nTel: (39-06) 6983552
\nFax: (39-06) 69885364
\nVENEZUELA
\nFederacion M\u00e9dica Venezolana
\nAvenida Orinoco
\nTorre Federacion M\u00e9dica Venezolana
\nUrbanizacion Las Mercedes
\nCaracas
\nTel: (58-2) 9934547
\nFax: (58-2) 9932890
\nWebsite: www.saludfmv.org and
\ninfo@saludgmv.org
\nZIMBABWE
\nZimbabwe Medical Association
\nP.O. Box 3671
\nHarare
\nTel: (263-4) 791\/553
\nFax: (263-4) 791561
\nE-mail: zima@healthnet.zw
\niii<\/p>\n"},"caption":{"rendered":"

wmj1 G 20438 Editorial \u2013 The World Medical Journal 1954 \u2013 2004 \u2013 yesterday, today and tomorrow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 A Rational Approach To Drug Design . . […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":940,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/wmj1.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3519"}],"collection":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media"}],"about":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/types\/attachment"}],"author":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/comments?post=3519"}]}}