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WorldMedical Journal
\nVol. No.4,December200551
\nOFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
\nG 20438
\nwma Santiago
\nGeneral Assembly \u2013 Reports
\nContents
\nEditorial
\n2005 \u2013 a Lesson: \u201cHumanity\u2019s need for Care\u201d 85
\nMedical Ethics and Human Rights
\nSponsorship Guidelines 86
\nEnhancing the WMA Declarations
\non Human Rights 86
\nMedical Science, Professional Practice
\nand Education
\nHealth Care System Reform in Japan 88
\nThe U.S. Health System: A Question of Access 90
\nWMA
\nAssembly Ceremonial Session, Santiago 2005 93
\nGeneral Assembly, Santiago 2005 94
\n171th WMA Council Session 95
\nResolution on Avian Influenza 97
\nStatement on Genetics and Medicine 98
\nStatement on Drug Substitution 100
\nStatement on Medical Liability Reform 101
\nGeneral Assembly Associates\u2019 Meeting 102
\nBeyond statements and resolutions \u2013 Working
\nat the WMA Secretariat in Ferney-Voltaire 103
\nFrom the Secretary General\u2019s desk
\n\u201cDon\u2019t forget the others\u201d 104
\nWHO
\nFAO\/OIE\/WB\/WHO Meeting on Avian Influenza
\nand Human Pandemic Influenza 105
\nMassive international effort stops polio epidemic
\nacross 10 West and Central African countries 107
\nTelemedicine via Satellite 108
\nRegional and NMA News
\nEuropean Region 108
\nLatin America and the Caribbean 109
\nKorean Medical Association 109
\nLetters to the Editor 110
\nReview 111
\nWebsite: https:\/\/www.wma.net
\nWMA Directory of National Member Medical Associations Officers and Council
\nAssociation and address\/Officers
\nWMA OFFICERS
\nOF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
\ni see page ii
\nPresident-Elect President Immediate Past-President
\nDr K. Letlape Dr Y. D. Coble Dr J. Appleyard
\nSouth African Med. Assn. 102 Magnolia Street Thimble Hall
\nP.O. Box 74789 Neptune Beach, FL 32266 108 Blean Common
\nLynnwood Ridge 0040 USA Blean, Nr Canterbury
\nPretoria 0153 Kent, CT2 9JJ
\nSouth Africa Great Britain
\nTreasurer Chairman of Council Vice-Chairman of Council
\nProf. Dr. Dr. h.c. J. D. Hoppe Dr Y. Blachar Dr N. Hashimoto
\nBundes\u00e4rztekammer Israel Medical Association Japan Medical Association
\nHerbert-Lewin-Platz 1 2 Twin Towers 2-28-16 Honkomagome
\n10623 Berlin 35 Jabotisky Street Bunkyo-ku
\nGermany P.O. Box 3566 Tokyo 113-8621
\nRamat-Gan 52136 Japan
\nIsrael
\nSecretary General
\nDr O. Kloiber
\nWorld Medical Association
\nBP 63
\nFrance
\nANDORRA S
\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 S
\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 E
\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 E
\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 E
\nArmenian Medical Association
\nP.O. Box 143, Yerevan 375 010
\nTel: (3741) 53 58-63
\nFax: (3741) 53 48 79
\nE-mail:info@armeda.am
\nWebsite: www.armeda.am
\nAZERBAIJAN E
\nAzerbaijan Medical Association
\n5 Sona Velikham Str.
\nAZE 370001, Baku
\nTel: (994 50) 328 1888
\nFax: (994 12) 315 136
\nE-mail: Mahirs@lycos.com \/
\nazerma@hotmail.com
\nBAHAMAS E
\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 E
\nBangladesh Medical Association
\nB.M.A House
\n15\/2 Topkhana Road,
\nDhaka 1000
\nTel: (880) 2-9568714\/9562527
\nFax: (880) 2-9566060\/9568714
\nE-mail: bma@aitlbd.net
\nBELGIUM F
\nAssociation Belge des Syndicats
\nM\u00e9dicaux
\nChauss\u00e9e de Boondael 6, bte 4
\n1050 Bruxelles
\nTel: (32-2) 644-12 88\/Fax: -1527
\nE-mail: absym.bras@euronet.be
\nWebsite: www.absym-bras.be
\nBOLIVIA S
\nColegio M\u00e9dico de Bolivia
\nCasilla 1088
\nCochabamba
\nTel\/Fax: (591-04) 523658
\nE-mail: colmedbo_oru@hotmail.com
\nWebsite: www.colmedbo.org
\nBRAZIL E
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nR. Sao Carlos do Pinhal 324 \u2013 Bela Vista
\nSao Paulo SP \u2013 CEP 01333-903
\nTel: (55-11) 317868 00
\nFax: (55-11) 317868 31
\nE-mail: presidente@amb.org.br
\nWebsite: www.amb.org.br
\nBULGARIA E
\nBulgarian Medical Association
\n15, Acad. Ivan Geshov Blvd.
\n1431 Sofia
\nTel: (359-2) 954 -11 26\/Fax:-1186
\nE-mail: usbls@inagency.com
\nWebsite: www.blsbg.com
\nCANADA E
\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
\nCHILE S
\nColegio M\u00e9dico de Chile
\nEsmeralda 678 – Casilla 639
\nSantiago
\nTel: (56-2) 4277800
\nFax: (56-2) 6330940 \/ 6336732
\nE-mail: sectecni@colegiomedico.c
\nWebsite: www.colegiomedico.cl
\nTitlepage: Semmelweis Hospital. Prof. I. Semmelweis worked in this hospital, later named after him,
\nwhen he left Vienna after the initial rejection of his ideas about the transmission of infection.
\nEditorial
\n2005 \u2013 a Lesson: \u201cHumanity\u2019s need for Care\u201d
\nThe editorial in the September issue was entitled \u201cBackwards to the future?\u201d. As this year
\ndraws to its close it is natural to look back over the past 12 months and to consider where
\nwe are and where we are going.
\nInternationally there has been much activity in the health field tackling long standing dis-
\nease problems, as such HIV\/AIDS and Malaria. Preventive policies such as basic immuni-
\nsation, the provision of impregnated mosquito nets continue to reduce morbidity and save
\nmany lives, when the resources available permit their use and provision. Despite the ef-
\nforts to eliminate poliomyelitis major efforts are still needed to deal with the threat of sud-
\nden outbreaks requiring rapid large scale immunisation programmes, and the declaration
\nby WHO of Tuberculosis in Africa as an emergency, both highlight the need for constant
\nvigilance and continuing action. At the same time the underlying problem of poverty in
\nmany parts of the underdeveloped, the developing and even the so-called developed
\nworld, appear as far as ever from solution although the global summit meetings may assist.
\nAll this has been complicated by natural disasters, such as those arising in Southeast
\nAsia, Pakistan and even in such a highly developed and affluent country as the USA, and
\nmade sudden demands on health care resources both in terms of materials and skilled per-
\nsonnel.
\nAttention has been focused not only on the global shortage of healthcare personnel but
\nalso on training and retention of physician policies in the face of developments such as
\nthe \u201cskills drain\u201d phenomenon. Health Services Reform remains a high priority in many
\ncountries and, both at national and international levels, continues to exercise those re-
\nsponsible \u2013 health professionals, administrators and politicians \u2013 as to how to proceed, at
\nwhat cost and at what speed change can or should be effected.
\nAll of the above are having major impacts on many health professionals, including the
\nphysicians. Long standing traditions of practice are being abandoned in the efforts to
\nmeet the huge demands both of deprived populations and of those in more fortunate cir-
\ncumstances, in a rapidly changing society where speed of access to knowledge and scien-
\ntific developments are leading to new expectations.
\nPositive developments, increasing scientific knowledge, proven healthcare reform poli-
\ncies are of course to be welcomed, and the physicians, like others, should be prepared to
\nadapt their professional style of practice appropriately \u2013 points we have sought to empha-
\nsise in these columns. The changes are, however, often very radical. Reform of the basic
\nmedical curriculum, the changing role of individual health professionals and professional
\nworking practices are not easy to adapt to the speed which some politicians consider pos-
\nsible. Adequate consultation and co-operation on all sides is essential to achieve them.
\nOne thing however remains constant regardless of the problems and issues mentioned
\nabove, it is the continuing need for care and relief of humanity\u2019s sick and suffering. This,
\nthe medical profession clearly responded to the crises of the past year. Through the many
\nchallenges which it will continue to face, this must remain at the centre of all its activity
\nin the future.
\nAlan Rowe
\nEditorial
\n85
\nOFFICIAL JOURNAL OF
\nTHE WORLD MEDICAL
\nASSOCIATION
\nHon. Editor in Chief
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSuffolk IP14 3QT
\nUK
\nCo-Editors
\nDr. Ivan M. Gillibrand
\n19 Wimblehurst Court
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\nUK
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\nTHE WORLD MEDICAL
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\nAt present rate-card No. 3 a is valid.
\nThe magazine is published quarterly.
\nSubscriptions will be accepted by
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\nSubscription fee \u20ac 22,80 per annum (incl.
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\nISSN: 0049-8122
\nEditorial note: Please accept our apologies that unfortunately, due to technical problems,
\nit has not been possible to include all the reports of the Santiago WMA meeting in this is-
\nsue. The rest will appear in the next issue.
\nNMAs and financial relationships with all
\noutside organisations needed to be consid-
\nered Dr. Appleyard (Immediate Past
\nPresident) made the point that in any \u2018rela-
\ntionship\u2019 there was potential for \u2018influence\u2019
\nboth ways, The WMA was not a passive
\npartner and we should never compromise
\nour own internationally accepted ethical
\nstandards, we should rather use any part-
\nnership \u2018platform\u2019 to promote them. Dr. H
\nMiyazaki (Japan) emphasised the impor-
\ntance of transparency in all our financial
\narrangements Dr. Kloiber, the Secretary
\nGeneral, said that specific guidance had
\nbeen developed for sponsorship by com-
\nmercial, governmental and charitable part-
\nnerships for specific projects or pieces of
\nwork which were consistent with existing
\nWMA policies. He was advised by the
\nSponsorship Advisory Committee, which
\nreviewed all potential developments. Dr.
\nKloiber said that he personally had been
\none of the greatest critics of commercial
\nsponsorship. In response to the question
\nabout how much existing sponsors had
\nattempted to \u2018influence\u2019 the WMA, he said
\nhe had not experienced any attempt to
\ninfluence the association whatsoever. Dr.
\nKloiber felt that a Work Group could iden-
\ntify the concerns expressed and review the
\nexisting guidelines
\nThe committee agreed unanimously to rec-
\nommend \u201cThat Council establish a Work
\nGroup consisting of the Chairs of the
\nMedical Ethics and Finance and Planning
\nCommittees, to review the WMA Corporate
\nRelationship Guidelines\u201d. This was subse-
\nquently AGREED by Council. \u25a0
\nThis issue was discussed during the meet-
\ning of the WMA Ethics Committee in
\nSantiago. We feel it to be of sufficient gen-
\neral interest to include in the Journal.
\n(The following report is based on notes
\nkindly provided by Dr. Appleyard to whom
\nwe are most grateful. Edit.)
\nDr. Bagenholm introduced the issue of the
\nacceptance by the WMA of commercial
\nsponsorship funding. She indicated that the
\ncurrent financial situation for the WMA
\nwas difficult in that membership dues did
\nnot cover the WMA\u2019s expenses. Some
\nmember organisations had approached her
\nwith their concerns that the WMA had
\nbecome dependent on financial sponsor-
\nship from the pharmaceutical industry for
\nmany of its activities. Posing the question
\nas to why such industries want to sponsor
\nour activities, she said they became
\ninvolved so that they could influence us. If
\nthe WMA was thought to be influenced by
\nthe pharmaceutical industry, it would loose
\nits credibility. Dr. Bagenholm, recognized
\nthat there were guidelines agreed by the
\nCouncil for such sponsorship, but felt that
\nthey needed to be revisited to consider
\nwhether it is ethical to receive sponsorship,
\nfrom the pharmaceutical industry and what
\nwould be the financial implications. The
\ndelegate from Denmark agreed that the eth-
\nical and financial aspects should be recon-
\nsidered and suggested a small group com-
\nprising the Chair of Ethics and the Chair of
\nFinance and Planning be set up who could
\nreceive information about how NMAs are
\ncoping with these problems in their own
\ncountries. (This was subsequently
\napproved by Council.) He felt that the
\nWMA mission was to foster the indepen-
\ndence of the profession and set the highest
\npossible ethical standards for physicians
\nworldwide. Ethics and Human Rights were
\nfundamental to our profession. National
\nMedical Associations founded the WMA
\nwith these issues foremost in their minds
\nMedical Ethics and Human Rights
\n86
\nand we are only as strong as the individual
\ncomponents of the \u2018chain\u2019 of our member-
\nship associations.
\nJon Snaedal, (Iceland) Icelandic Medical
\nAssociation and former chair of Ethics
\nagreed that the WMA needed to be finan-
\ncially \u2018autonomous\u2019 and should not rely on
\nother sources of finance. If we were seen to
\nbe influenced by our Sponsors the WMA
\nwould cease to be respected.
\nDr. Johnson (UK) agreed that the ideal
\nwould be that the WMA was self funding.
\nWith the cost of all the activities at
\nInternational level with all our partners this
\nwas not possible and he asked what was the
\nevidence of the WMA being influenced by
\nthe current sponsors Dr. Kgnosi Letlape,
\nPresident Elect, told the meeting that there
\nwere different issues in different countries,
\nIn South Africa the main influence on the
\nProfession was that of Government and he
\nfelt that Industry was much more under-
\nstanding of the importance of the indepen-
\ndence of the Profession. Without their part-
\nnership and support, the Association would
\nnot be able to function the way it does as an
\nadvocate for its members. Ms. Wapner
\n(Israel) said that where there were matters
\nof ethics and finance, ethics was preemi-
\nnent. She recognized the concerns raised.
\nAny change in standards should apply to all
\nMedical Ethics and Human Rights
\nSponsorship Guidelines
\nThe WMA was founded in 1947 to attempt
\nto ensure that never again would doctors be
\ncomplicit in human rights abuses. The \u201cbig
\nthree\u201d WMA declarations \u2013 Geneva,
\nHelsinki and Tokyo \u2013 aim to raise ethical
\nstandards globally, and to protect the rights
\nof the vulnerable. Despite these carefully
\ndrafted words stories of medical involve-
\nment in human rights abuses still emerge.
\nCurrent draft amendments to the Declara-
\ntions of Tokyo and Geneva and to the Regu-
\nlations in Times of Armed Conflict are the
\nlatest attempt to fortify this global consen-
\nsus.
\nEnhancing the WMA Declarations
\non Human Rights
\nV. Nathanson
\nMedical Ethics and Human Rights
\n87
\nThe sad fact is that prisoners are subjected
\nto human rights abuses \u2013 both torture and
\ncruel inhuman and degrading treatment in
\nvery many countries. Involvement by doc-
\ntors, when it occurs, is often a part of the
\nprocess; doctors resuscitate the torture sur-
\nvivor so that he or she can be tortured
\nagain. They certify fitness for harsh inter-
\nrogations and for frankly abusive practices.
\nThey falsify death certificates or other key
\nparts of medical and legal records. At the
\nsame time other doctors are putting them-
\nselves at risk in decrying the torturers, doc-
\numenting abuse, giving evidence in courts,
\nopposing systematic and episodic practices
\nthat put people at risk of abuse and using
\nmedical knowledge and expertise to protect
\nthe vulnerable and challenge the abusers.
\nAllegations have emerged from a variety of
\nsources about the abuse of prisoners in Abu
\nGhraib and in Guantanamo Bay.1
\nWhile no
\ncases have been brought against doctors
\nthere are stories in circulation of doctor in-
\nvolvement that would, if true, amount to se-
\nrious ethical failures. While these are not
\nthe only places where such medical abuses
\nare alleged they are important as they high-
\nlight apparent weaknesses in current WMA
\npolicy. The BMA has led a WMA Council
\nworking group that has prepared amend-
\nments to existing policy that will, we be-
\nlieve, strengthen the appropriate prohibi-
\ntions.2
\nOne issue that has arisen in relation to
\nthese allegations as well as to those from
\nsome other countries, is that medical
\nrecords are being provided to interrogators
\nto aid in targeting of harsh interrogation or
\ntorture. Although the Declaration of Tokyo
\nis read by most people as disallowing this
\npractice, it does not currently say so ex-
\nplicitly. In too many countries physicians\u2019
\nnotes, recorded to help their patients and to
\ninform other health care workers about
\ntheir findings and treatment plans, are in-
\nstead used to undermine the safety and se-
\ncurity of the individual. Some physicians
\nappear willing to hand over such notes, or
\neven to help the prison authorities use
\nmedical information to devise a pro-
\ngramme that will undermine the mental or
\nphysical health of a detainee. They argue
\nthat as the code is silent on the prohibition,
\nit does not in fact exist. 3
\nFor that reason an amendment has been
\nsuggested to make this prohibition explicit.
\nThis will not only strengthen the hand of
\nthose doctors who refuse to hand over
\nrecords to prison authorities, but it may also
\nhelp doctors who work for agencies visiting
\nprisons and detention centres as part of the
\nchecks and balances system of international
\nregulation, including the Red Cross, the
\nUNHCHR, Amnesty International and
\nMSF. This specific amendment has also
\nbeen repeated in the Regulations in Times
\nof Armed Conflict, to make doubly certain
\nthat this prohibition exists regardless of cur-
\nrent political and security circumstances.
\nThe carefully constructed language of
\nWMA declarations and regulations can also
\nbecome obscure over time as common lan-
\nguage usage changes. This is why the sug-
\ngestions for amendments include removing
\nthe concept that physicians\u2019 consciences
\nshould be their guides and its replacement
\nwith a requirement to adhere to internation-
\nal conventions on human rights, interna-
\ntional humanitarian law and WMA declara-
\ntions on medical ethics. The international
\nlaws are easily found; they are the Geneva
\nConventions and associated protocols of
\nwhich the ICRC acts as guardian. \u201cThe oth-
\ner laws and conventions are available on-
\nline from the UN or the WMA itself.\u201d All
\nare clear; torture is prohibited, and we each
\nhave an absolute right not to be subjected to
\nsuch treatment.
\nSo are these changes a response to as yet
\nunproven allegations about Abu Ghraib and
\nGuantanamo Bay? No; not only to these,
\nbut also to similar allegations to similar
\nabuses in many places
\nMany associations reading these changes
\nmay wonder if they are necessary. I believe
\nthat they are; the number of reportsAmnesty
\nand others can produce of medical involve-
\nment in abuse makes change and reinforce-
\nment of high norms essential. They give us,
\nas doctors, a chance to rededicate ourselves
\nto stopping abuse by doctors, or medical
\ncomplicity. They give us a chance to ap-
\nplaud those colleagues who stick their heads
\nabove the parapet, putting themselves at risk
\nby adhering to the highest standards. They
\ngive us an opportunity to condemn those we
\nthink unworthy of their medical licences.
\nThey can act as a call to arms for all of us to
\ndefend vulnerable people around the world.
\nIn short; they are an opportunity for the
\nWMAto reassert its core reason for existing.
\nProf. Vivienne Nathanson
\nDirector of Professional Services
\nBritish Medical Association
\nvnathanson@bma.org
\n1 See, for example, Lewis NA. Red Cross finds
\ndetainee abuse in Guantanamo. New York
\nTimes, Nov 30, 2004: A1. Okie S. Glimpses of
\nGuantanamo \u2013 medical ethics and the war on
\nterror. NEJM 353;24 15 Dec 05.
\n2 See WMA paper MEC\/Misc\/Dec2005
\n3 Bloche G, Marks J. When Doctors go to War.
\nNEJM 352:3-6 6 Jan 05
\n4 http:\/\/www.icrc.org\/Web\/Eng\/siteeng0.nsf\/
\nhtml\/genevaconventions.
\n5 https:\/\/www.wma.net. \u25a0
\nNurses and Physicians Welcome Libyan Court\u2019s Decision
\nto Reverse Death Sentences
\nThe International Council of Nurses and the World Medical Association have welcomed the decision of
\nLibya\u2019s Supreme Court to reverse the death sentences and order a retrial for five Bulgarian nurses and
\na Palestinian doctor, accused of deliberately infecting more than 400 children with AIDS. The supreme
\ncourt has quashed the sentences and accepted the appeal against the lower court ruling on both sub-
\nstance and procedure. Prosecutors agreed with defence lawyers that there were \u201cirregularities\u201d in the
\narrests and interrogations of the accused. Expert evidence that the cause was probably poor hygiene at
\nthe hospital appeared to have been ignored. Indeed, infections were believed to have occurred before
\nthe accused started work at the hospital, and continued after their arrests.
\nICN and WMA call for a speedy retrial that will consider the evidence presented by international
\nexperts and liberate the health professionals.
\nJapan is experiencing a lowering of the
\nbirth rate and an aging of the population. In
\n1985, population from 0 to 4-year-old
\naccounted for 6.2% of the total population.
\nIn 2004, the figure declined to 4.5%. On the
\nother hand, the elderly over 65 years old
\naccounted for 10.3% of the total population
\nin 1985 and increased to 19.5% in 2004. As
\nthis indicates, the population structure is
\nrapidly changing. In the current year, 2005,
\npopulation aged 4 years old or below is
\n4.5% of the total population, and this figure
\nis estimated to decrease to 3.6% in 2025.
\nPeople aged 65 years or over, however,
\naccount for 19.9% of the total population in
\nthe current year, 2005, and this is estimated
\nto increase to 28.7% in 2025. These trends
\nof declining birth rate and aging population
\nare expected to continue at an even more
\naccelerated rate in the future. This situation,
\ncombined with the deteriorated financial
\nbasis of the nation, is calling for social
\nsecurity reform. Health care system reform
\nis currently underway to keep the system
\nsustainable in the future, supported by bal-
\nanced economic and fiscal foundation.
\nThe government proposes a basic policy
\nplan for health care system reform. It is
\nnecessary to radically change all parts of
\nthe health care system, while taking into
\naccount changes in the medical environ-
\nment, the rapidly declining birth rate and
\naging population, and the current stagnant
\neconomy, as well as advances in medical
\ntechnologies and shifts in the public\u2019s atti-
\ntude. It is also essential to reform the health
\ncare system, health care delivery system,
\nmedical fee programme, and the health
\ninsurance system. In other words, a health
\nsystem that meets the demands of the
\nchanging environment is required. In addi-
\ntion to the basic points for reform, the gov-
\nernment also proposes the following
\nimprovement, They are, the importance of
\nrespecting the patients\u2019 point of view, pro-
\nmotion of disclosure of health information,
\nreestablishment of safe and assured health
\ncare, provision of quality and efficient
\nhealth care, establishment of a health care
\ndelivery system of high quality and effi-
\nciency, separation of roles between medical
\ninstitutions for more focused and efficient
\nmedical services, ensuring necessary health
\nservices in communities, cultivation of
\nhuman resource in health care and improve-
\nment of their quality, improvement of the
\nstructural basis for health care, and the
\nimprovement of the foundation for health
\ncare to support lives in the 21st century.
\nHowever, the government is pushing poli-
\ncies to \u201ccontain health costs\u201d to \u201censure
\nappropriate health costs\u201d because of wors-
\nening national finances. It is trying to intro-
\nduce the total budget system of health care
\ncosts as well as controlling the increasing
\ncosts to suppress the growth of social secu-
\nrity costs lower than the economic growth.
\nWhat is needed for health care from the
\ngeneral public is improved quality and safe-
\nty of health care. From the government\u2019s
\npoint of view, however, it is containment of
\nhealth costs. The problem may be how well
\nthe medical profession can meet these
\nneeds. The Japan Medical Association
\n(JMA) advocates that it is fundamentally
\nnecessary to ensure the health insurance
\nsystem which permits every citizen to
\nequally receive health services with an
\ninsurance card, anytime and anywhere,
\nwhich may be most characteristic of
\nJapan\u2019s health system.
\nThe JMA considers that all the people have
\na right to lead a healthy life, and enhance-
\nment of social security for this purpose is
\nan obligation of the government. Health
\ncare is an asset for the public good, and
\ndevelopment of the foundation of the health
\ncare system is the responsibility of the
\nnation. The government should not fit
\nMedical Science, Professional Practice and Education
\n88
\nhealth care to the economy. The economy
\nshould be fitted to health care. To secure
\nquality health care and provide safe health
\nservices, financial resources to cover the
\nhealth costs are necessary. We maintain
\nthat the policies to contain health costs
\nsurely lead to lowered quality of health
\ncare and may block the promotion of safer
\nmedical services.
\nIn relation to the health status of Japan,
\naccording to the report by WHO, Japan
\nretains the longest average life expectancy
\nin the world. As for the health care costs,
\nwhen total health care costs are compared
\nwith GDP, Japan has the 17th lowest health
\ncare cost among the OECD countries.
\nFurthermore, in comparison with other
\ncountries for health achievement, Japan
\nranked No. 1 in life expectancy and in
\noverall rating of health achievement.
\nJapan\u2019s health insurance system is an
\nexcellent system with high performance at
\nlow cost.
\nLooking at the trends of national health
\ncare expenditure and live expectancy, the
\ngrowth of expenditure and average life
\nexpectancy for females, is in proportion. Of
\ncourse, there are other factors such as
\nadvances in medical technologies and
\nincrease disease in the elderly. However,
\nthe increase in expenditure is obviously
\nlinked and corresponds with the growth of
\naverage life expectancy. The containment
\nof health expenditure could, therefore,
\nshorten life expectancy.
\nThe financial resources of Japan\u2019s health
\ncosts consist of public expenditure (taxes),
\npremium from employers and the insured,
\nand patient cost sharing. From 1990 to
\n2002, the percentage of public expenditure
\nshowed little changes. As for the premi-
\nums, the burden on the employers
\ndecreased, while the percentage of patient
\ncost sharing increased. This is because of
\nthe increase in the patient\u2019s co-payment for
\nmedical services from 20% to 30% after
\nApril 2003 and the establishment of the
\nfixed amount of payment by the elderly
\nwhich started in October 2002. In Japan, a
\nlimit is set for patients\u2019 co-payment at
\n72,300 yen (approximately 650 US dollars)
\nfor the general public, except for low-
\nincome earners. However, the government
\nMedical Science, Professional Practice and Education
\nHealth Care System Reform in Japan
\nHideki Miyazaki, MD, Ph.D
\nVice President, Japan Medical Association
\nPresented at WMA Scientific Session, Santiago
\nhas been taking policies to increase the
\ncosts to be paid by the patient in the past
\nfew years. It is contrary to the principles of
\ninsurance when you consider that the
\ninsured who pays the premiums to be cov-
\nered by the insurance has to pay extra costs
\nto receive health services.
\nThere is a large gap between the employ-
\nee\u2019s pension insurance rate and the health
\ninsurance rate. This partly accounts for the
\ndeficit of the health costs. The health insur-
\nance rate has hardly changed since 1980. In
\n2003, the employee\u2019s pension insurance
\nrate dropped because premiums were
\ncharged for total remuneration, including
\nbonuses. The insurance rate up to the year
\n2018 has been set by law. However, there is
\nno policy to increase the health insurance
\nrate further and when compared with the
\nemployee\u2019s pension, it is undervalued. The
\nhealth insurance rate, if increased, will help
\nto secure resources for the health costs.
\nJapan\u2019s national contribution ratio which is
\nthe ratio of tax burden and social security
\nburden has been showing around 37% for
\nthe past 18 years which is very low. In the
\ngovernment\u2019s policy, the rate should be
\nsuppressed below 50% at the highest, but it
\nis already at a low level, compared with
\nother developed countries.
\nThe comparison of the ratio of national
\nhealth expenditures to GDP, and the break-
\ndown of public and private spending in
\nmajor countries, suggests that health costs
\nin Japan need an increase of 1 to 2% of pub-
\nlic spending to GDP when compared with
\nSweden, France, and Germany. From this
\npoint of view, the government should allo-
\ncate more of its money on health care areas.
\nI have just explained the current situation in
\nJapan. The problem in the health care sys-
\ntem reform to be discussed here is that the
\nnumber of insurers in Japan is extraordinar-
\nily large when compared with health care
\ninsurance systems of other countries. In the
\nRevised Health Insurance Act enacted 2
\nyears ago, integration and unification of
\ndifferent kinds of insurances is one of the
\nitems to be studied in the future.
\nIn 2004, the number of insurers managed
\nby the national government is 1, while
\nthose managed by health insurance soci-
\neties is 1,674 and those managed by sea-
\nmen\u2019s insurance is 1. As for the mutual aid
\ninsurance, the number of insurers managed
\nby the national government employees
\nmutual aid associations is 23; those man-
\naged by local government employees mutu-
\nal aid associations is 54; those managed by
\nprivate school teachers & employees mutu-
\nal aid is 1. As for national health insurance,
\nthe number of insurers managed by munic-
\nipalities is 3,224 and those managed by
\nassociations is 166. The total number of
\ninsurers is 5,144 with the total of insured
\npersons being 94,248,000.
\nCurrently there is a discussion to integrate
\nand reorganize the insurers in each prefec-
\nture, and it is suggested firstly to integrate
\nthose managed by municipalities and by
\nnational government.
\nThe Japan Medical Association is propos-
\ning basic policies for the health care system
\nreform.
\nWe firstly and strongly advocate for main-
\ntaining the universal health insurance sys-
\ntem. We are also suggesting the creation of
\nnew Medical Insurance System for the
\nElderly to address public concerns. The
\nsystem with the national government as
\ninsurer would cover only those aged 75
\nyears and older. However, the system will
\nbe managed by the local government after a
\ncertain period of time. We are proposing for
\nthe financial sources of this system special;
\n10% of the contribution from the patient,
\n10% from insurance premiums, with\u2013con-
\nsideration for low-income earners, and 80%
\nfrom public expenses and national mutual
\nassistance such as consumption tax and cig-
\narettes tax. If a health insurance system is
\nseen as a part of social security system, it is
\nnecessary to increase public funding or tax
\nto meet its need for financial sources.
\nCompared to other in major countries, the
\nprice of cigarettes is the lowest for Japan
\nand it is necessary to discuss various relat-
\ned matters including a consumption tax
\nscheme and a proposal for an earmarked tax
\nfor health car.
\nA rise in cigarette prices may be the most
\nefficient measures to cut the number of
\nsmokers. We are proposing to utilize the
\nincreased tax for financial resources for
\nhealth care.
\nHealth care should not be regulated by age.
\nThis is natural when you think about char-
\nacteristics of the elderly and their potential
\ndiseases. The Medical Insurance System for
\nthe Elderly will be based on self-help, and
\nmutual and public assistance. The health
\ninsurance system in Japan provides benefits
\nin kind sufficiently to meet people\u2019s needs
\nfor health care. In Japan, the Long-term
\nCare Insurance System was established for
\nthose aged over 40 years of age in 2000,
\nwhich provides cash benefits to support
\nlong-term or nursing care. The fund comes
\nfrom the premiums and public spending.
\nThe level of nursing care required is divid-
\ned into 5 levels, each having a set quota. We
\ndistinguish between a long-term or nursing
\ncare and medical care. And necessary
\narrangements are being made between the
\ntwo areas of care. Therefore, the Long-term
\nCare Insurance System, which provides
\ncash benefits, and the health insurance sys-
\ntem cannot be integrated. Control of the
\ngrowth rate of health costs based on the
\neconomic indicators such as GDP should
\nnot be permitted because it disturbs neces-
\nsary and safe health care.
\nTo enhance the level of health services for
\nthe elderly, it is important to promote pre-
\nventative measures against lifestyle-related
\ndiseases to keep the elderly healthy. Co-pay-
\nment by patients should be decreased and
\nshould not exceed the current level. The
\ngovernment should extend the retirement
\nage of workers to 65 years of age. All retired
\nemployees should join the National Health
\nInsurance which provides benefits which
\nwill be covered by patients\u2019 co-payment,
\npremiums and mutual assistance between
\nemployee\u2019s health insurance systems.
\nThe government managed health insurance
\nsystem has been enlarged by the Social
\nInsurance Agency and been establishing
\nand managing hospitals. Retired bureau-
\ncrats of the Health, Labour and Welfare
\nMinistry have been obtaining jobs at these
\nhospitals. A reform is going to abolish these
\nhospitals.
\nAs for the health care delivery system, in a
\ncomparison of the average number of visits
\nper person per year in major countries, it is
\nMedical Science, Professional Practice and Education
\n89
\n21 higher times in Japan, the highest figure.
\nHowever, health cost per one visit in Japan
\ncompared with other countries in 63 US dol-
\nlars, which is very low. To sum it up, it can
\nbe said that health cost in Japan is very low.
\nIn an international comparison of the health
\ncare delivery system in 1998, the number of
\nbeds per 1,000 people was high at 13.1 in
\nJapan, while the number of physicians per
\n100 beds was low at 12.5. Furthermore, the
\nnumber of nursing staff per 100 beds was
\nalso low at 43.5, with the longest average
\nnumber of hospital stays being 31.8. The
\nrate of outpatient visits stand at 16.0. This
\nreveals the facts that in Japan the people
\nhave many opportunities to visit any kind
\nof medical institutions under the universal
\nhealth insurance, the period of hospital stay
\nis long, and a patient is attended by a small
\nnumber of physicians and nursing staff.
\nTo shorten the hospital stay, we are trying
\nto review the organizational problems relat-
\ned to the inpatient settings, health care
\ndelivery system, and the revision of the
\nmedical fees. The Japan Medical Asso-
\nciation is making its utmost efforts to main-
\ntain the universal health insurance which
\nJapan is proud of, to provide necessary and
\nsafer health care services for all the nation
\nof Japan. \u25a0
\nMedical Science, Professional Practice and Education
\n90
\nI am delighted to be here today on behalf of
\nthe American Medical Association. My
\nvisit with you continues a decades-long tra-
\ndition of mutual friendship and support.
\nAnd our friendship, now and in the future,
\nis even more vital than it has been in the
\npast. Together, we face potential pandemics
\nand terrorist threats. Public health chal-
\nlenges from tsunamis, hurricanes, earth-
\nquakes and floods. We are subject to eco-
\nnomic and political decisions made far
\naway that have immediate impact in our
\ncommunities \u2013 that affect access to care and
\nquality of care for our patients. More than
\nothers, perhaps, we recognize that disease
\nand discord, that epidemics and terrorists,
\nalike, respect no boundaries.
\nWe also know that knowledge and our
\nmutual caring for our patients know no
\nboundaries, either. No boundaries and no
\nlimits. In such a world, cooperation among
\nour associations and within the WMA is
\nmore important that ever. I shines like a bea-
\ncon \u2013 a model for ethical behavior for all
\nother professions and associations. Today,
\nas we discuss the strenghts and weaknesses
\nof our nations\u2019 health care systems, we can
\nlearn from each other. Identify the best prac-
\ntices \u2013 and the worst pitfalls. And steer our-
\nselves toward a better, healthier world
\ntomorrow.
\nThe Uninsured
\nThis is something the American Medical
\nAssociation is trying to deal with in my
\nhomeland, the United States.
\nThere, medical care is financed and deliv-
\nered through both public and private
\nmeans. Persons over the age of 65 are cov-
\nered under the Medicare program, adminis-
\ntered by our national federal government.
\nThe economically disadvantaged are eligi-
\nble for Medicaid, administered on the state
\nlevel with partial federal funding.
\nMost American workers get their health
\ninsurance through their employers, a prac-
\ntice that started during World War II, when
\nwages were controlled. Health insurance
\nemerged as a way to enhance benefits for
\nworkers who couldn\u2019t get salary increases.
\nFor some people, this patchwork system
\nworks well. For those with access, the U.S.
\noffers what I believe is the highest quality
\ncare in the world, despite our significant
\ndelivery and systems problems.
\nBut for others, it barely functions, if at all.
\nFor instance, there are almost 46 million
\nAmericans who have no health insurance.
\nThat\u2019s about 15 percent of our population \u2013
\na national disgrace.
\nThe employer-based system of health
\ninsurance is showing signs of weakness.
\nMore than 80 percent of the uninsured \u2013 36
\nmillion of them \u2013 work or are members of
\nworking families. They hold down jobs and
\ndraw a paycheck. For them, living without
\nhealth insurance has terrible consequences
\nfor health and economic well-being. They
\nlive sicker and die younger. Often, they
\ndelay seeking help until they are suffering
\nfrom a more advanced stage of disease \u2013
\nwhen treatment is often more expensive \u2013
\nand less effective.
\nBut it takes a toll on more than the individ-
\nual. It extracts a heavy cost on our society
\nin terms of reduced employment and pro-
\nductivity, and the flood of uninsured into
\nemergency departments and free clinics has
\na price tag, too.
\nIn 2004, American taxpayers spent 35 bil-
\nlion U.S. dollars from uncompensated,
\npublicly-funded care. That\u2019s $4 million per
\nhour every day. And this number doesn\u2019t
\ntake into account the additional billions of
\ndollars spent on privately given care,
\nincluding uncompensated care by physi-
\ncians.
\nManaged Care Concentration
\nSo the question is, how do we in the United
\nStates repair our system? It is flawed, and
\nfails to give coverage to enough people.
\nOne of the most severe issues, not only
\nwith those who have no health insurance,
\nbut for all American patients, is continuity
\nof care \u2013 the patient-physician relationship.
\nThat relationship has been under siege in
\nrecent decades in the U.S.
\nIn my practice, I\u2019ve seen some of my
\npatients for many years. I know their med-
\nical histories. I can follow up on old prob-
\nlems or see subtle changes that a stranger
\nThe U.S. Health System:
\nA Question of Access
\nPresented at the World Medical Association Scientific Session, Santiago
\nJ. Edward Hill, MD, President American Medical Association
\nMedical Science, Professional Practice and Education
\n91
\nmight not. In these circumstances, a patient
\nfeels comfortable \u2013 and is better able to ask
\nquestions and communicate.
\nThis patient-physician relationship is the
\ncornerstone of medicine. A healthy and
\ncontinuous relationship with a physician
\ncan lower costs by getting a patient access
\nto the health care system at an earlier stage
\nof a disease.
\nBut with the spread of privately run man-
\naged care in the U.S., this continuity has
\nbeen disrupted. Patients often move from
\nphysician to physician \u2013 when their
\nemployers change health plans \u2013 or when
\ntheir physician decides not to contract with
\na given insurer.
\nPerhaps it is because with some of the more
\nabusive insurers \u2013 physicians are paid less
\nto see more patients and work longer hours.
\nIt is clear that a more competitive insurance
\nlandscape would help protect the quality of
\nmedical care \u2013 and ultimately lower costs
\nfor consumers.
\nWhat we have structured is a cost-based
\ncare system \u2013 while we should be offering a
\ncare-based cost system. We need to put
\ndecisions about health care coverage \u2013 back
\nwhere they belong: in the hands of patients
\n\u2013 and their physicians.
\nIn the United States, a handful of giant
\nhealth insurance companies dominate the
\nmarket. It makes it difficult for an individ-
\nual physician to negotiate patient care
\nissues with what are essentially monopo-
\nlies.
\nManaged care organizations have consoli-
\ndated at a record pace in the United States,
\nwith more than 350 mergers and acquisi-
\ntions in one five-year span.
\nThe AMA is working to redress this imbal-
\nance.
\nWe believe regulators should start looking
\nmore closely at the behavior of the health
\ninsurance industry. Also that physicians
\nshould be able to negotiate more effective-
\nly with large health insurance companies.
\nBecause when the health care market land-
\nscape is dominated by just a few giant com-
\npanies, it forces physicians to accept unfair
\ncontracts which can have serious implica-
\ntions for patient care.
\nSingle-Payer Not the Answer
\nSome would argue that the solution to the
\nproblem of the uninsured would be to adopt
\na single-payer national health insurance
\nplan. Most of you in this room practice
\nunder such a system, in one form or anoth-
\ner.
\nProponents of such a system are passionate
\nand vocal. But we at the American Medical
\nAssociation respectfully disagree. We
\nbelieve a single-payer system in the United
\nStates would:
\n\u2022 Require physicians to negotiate a bind-
\ning fee schedule;
\n\u2022 Discourage hospital expansions and
\ncapital purchases;
\n\u2022 Eliminate the health insurance industry,
\neliminating institutional memory and
\nhundreds of thousands of jobs;
\n\u2022 Force employers to transfer money ear-
\nmarked for health benefits to a national
\nhealth insurance program.
\n\u2022 And discourage the innovation that has
\ndriven medical advances and innova-
\ntions in the United States over the past
\ncentury.
\nTo us, this runs counter to freedom, choice,
\nand private enterprise, qualities ingrained in
\nthe American psyche, and which fuel
\nAmerican society.
\nSuch a system would be exponentially
\nmore difficult to manage in the United
\nStates than it is almost elsewhere, because
\nwe have a \u201cmelting pot\u201d society with a
\nremarkably diverse and diffuse character. It
\nmakes our country especially resistant to
\none-size-fits-all solutions imposed from
\nabove.
\nThe AMA believes that by implementing a
\nsingle-payer system, the United States
\nwould be trading one set of problems for
\nanother.
\n\u2022 We would see long, detrimental waits
\nfor care and the rationing of care.
\n\u2022 We would be slow to adopt new tech-
\nnology and maintain facilities.
\n\u2022 We would be bound by price controls,
\nwhich eventually drive up costs;
\n\u2022 And it would create a gigantic bureau-
\ncracy that interferes with clinical deci-
\nsion making.
\nWould a single-payer system save us
\nmoney? We don\u2019t think so. We believe that
\nsuch a conclusion is rooted in faulty and
\nincomplete comparisons of administrative
\ncosts between the United States and coun-
\ntries that offer a single-payer system.
\nIt has long been recognized that public
\ninsurance imposes a variety of costs on
\npatients, including excessive wait times, a
\nproliferation of short visits, and lack of
\naccess to certain services and procedures.
\nIn June 2003, the Chairman of the British
\nMedical Association characterized the
\nU.K.\u2019s single-payer health care system as:
\n\u201cThe stifling of innovation by excessive,
\nintrusive audit \u2026 the shackling of doctors
\nby prescribing guidelines, referral guide-
\nlines and protocols \u2026 the suffocation of
\nprofessional responsibility by target-setting
\nand production-line values that leave little
\nroom for the professional judgment of indi-
\nvidual doctors or the needs of individual
\npatients.\u201d So say a physician with long,
\nfirst-hand experience with a single-payer
\nhealth system.
\nWe have to recognize that nothing worth-
\nwhile \u2013 comes without a price. The fact is
\nthat effective prices play a role in the provi-
\nsion of, and access to, services in any health
\ncare system, not just market-based systems.
\nIn the final analysis, consumers clearly pay,
\nin one way or another \u2013 regardless of the
\nsystem.
\nAny system that offers access to care with-
\nout direct charges to consumers generates
\ndemand for care that exceeds what can be
\ndelivered. Ultimately, there is no guarantee
\nthat even medically urgent services will be
\navailable when needed.
\nThe AMA has a viable solution \u2013 one that
\ndoes not limit the universe of choices and
\nthat does not dictate a single-payer system
\nas the only path toward universal health
\ncoverage.
\nMedical Science, Professional Practice and Education
\n92
\nAMA Plan for the Uninsured
\nThe AMA has long advocated that every
\nAmerican should have health insurance and
\nthus access to medical care. We\u2019ve been
\nworking with other major players on the
\nAmerican health care scene to raise the pro-
\nfile of this issue \u2013 and to remind the public
\nof its urgency. We believe the country will
\nseriously address this issue eventually.
\nAs Winston Churchill once said,
\n\u201cAmericans can always be counted on to do
\nthe right thing \u2026 after they have exhausted
\nall other possibilities\u201d.
\nThe American Medical Association believe
\nwe have a plan that would expand health
\ninsurance coverage in our country. We think
\nit\u2019s the right thing to do.
\nThe plan is simple:
\n\u2022 Give people money to buy their own
\nhealth care coverage.
\n\u2022 Give wealthy people less money. Give
\nmore to poor people.
\nThe AMA plan has three pillars \u2013 tax cred-
\nits, individual ownership and selection of
\nplans, and regulatory reform.
\nThe most central point to understand \u2013 is
\nthe system of tax credits. Under the AMA
\nplan, all workers would get a tax credit
\nlarge enough to ensure they could purchase
\naffordable coverage. The tax credit would
\nbe inversely related to income. This means
\nthat the people with the lowest incomes \u2013
\nthose most likely to be uninsured \u2013 would
\nget the biggest subsidy. The tax credits
\nwould be refundable, so families that owe
\nlittle or no taxes would still get a credit.
\nFinally, the credits would be available in
\nadvance, so that families who can\u2019t afford
\nmonthly premiums don\u2019t have to wait for a
\nyear-end refund to bye coverage.
\nWhat\u2019s more, Americans could choose and
\npurchase a health care plan that fits their
\nneeds.
\nAt present, of those companies that offer
\nhealth care coverage only one in six offers
\na choice of more than one plan. Under the
\nAMA insurance proposal, employees could
\nchoose to get coverage through their
\nemployers or not.
\nThis would empower people. Allow them to
\ndo what federal government employees,
\nincluding members of our U.S. Congress,
\ncan do today. That is to choose from a wide
\narray of plans. This in turn, would create
\ncompetition and vibrant health insurance
\nmarkets.
\nFinally, our plans for regulatory reform
\nwould also bring sanity and reason to the
\ncurrent maze of market regulations for
\nhealth insurance.
\nCurrently, some regulations aimed at pro-
\ntecting high-risk individuals have the unin-
\ntended consequence of a driving up the
\nnumber of people who are insured.
\nWe aim to create a more sensible regulato-
\nry system. A system that gives incentives to
\npatients to purchase coverage before they
\nget sick. And that gives incentives to insur-
\ners to cover high-risk individuals. Overall,
\nour plan to expand health care coverage and
\nchoice \u2013 would get 94 percent of Americans
\ncovered. This is just one example of how
\nwe could improve market regulations for
\nhealth insurance and get more people cov-
\nered in the process.
\nThese kind of market-based approaches for
\nreform in the United States are already
\nshowing promise. The removal of some
\nmandates, for example, has made possible a
\nnew kind of plan that combines high
\ndeductible insurance with health savings
\naccounts \u2013 HSAs. These accounts allow
\nconsumers to use tax free dollars to pay for
\nout of pocket health care costs, or to roll
\nthose dollars over. Nationwide, more than
\none million people have already signed up
\nfor HSAs. And the best part is that the sta-
\ntistics show that about one-third of them
\nwere previously uninsured. [U.S. Chamber
\nof Commerce].
\nCan groups like families of the develop-
\nmentally and mentally disabled benefit
\nfrom these kinds of market-driven reforms,
\ntoo? We think so. That\u2019s why we endorse
\nthe concept of a tax-exempt medical trust to
\nprovide for the long-term health care needs
\nof disabled family members. And we think
\nthis concept should be linked to our overall
\nplan to finance health care for all
\nAmericans. [H-165.893]
\nThere\u2019s no reason that anyone should be left
\nout of the picture (when it comes to creat-
\ning a system driven by choice), that has the
\npotential to increase quality of life and
\nreduce costs for all patients.
\nThe AMA\u2019s plan of action is a good one. If
\nenacted nationally, it could give more than
\n94 percent of Americans health coverage.
\nIt is an idea with powerful support. During
\nthe most recent U.S. presidential campaign,
\nthe candidates from both major political
\nparties endorsed the general concept of
\nusing tax credits for individuals to purchase
\nhealth care coverage. However, given cur-
\nrent government budget challenges, we
\nknow it\u2019s unlikely that our plan will be
\nenacted nationally soon. That\u2019s way we are
\nwilling to support an incremental approach.
\nFor example, we would like to see pilot
\nprograms on local government levels to try
\nout our reforms. Such pilot programs could
\nfocus on particularly vulnerable popula-
\ntions such as a low-income people, chil-
\ndren, or the chronically ill. Pilot programs
\nhave the added benefit of allowing policy-
\nmakers to guide future decisions through
\nactual data an experience and letting them
\nsee how the AMA plan could work on a
\nnational scale.
\nAn editorial from one of America\u2019s leading
\nnewspaper, The Detroit News said, \u201cThe
\nAMA is offering a credible blueprint for
\nfundamental health care reform. It deserves
\na hearing in Congress.\u201d We agree.
\nBut we know that this won\u2019t be easy. That\u2019s
\nwhy our leadership is bringing our ideas to
\na group called the Search for Common
\nGround. This group has all the major play-
\ners and associations in health care \u2013
\nemployers, health plans, physicians and
\nmany more. The one thing we have in com-
\nmon is that we\u2019re all frustrated that 45 mil-
\nlion Americans are uninsured and 10 to 15
\nmillion more are underinsured. The mission
\nof this group? To cover as many people as
\npossible as soon as possible through non-
\ngovernmental solutions. Together, we can
\nget coverage for the millions of Americans
\nwho lack it and we can maintain the integri-
\nty and quality of American medicine in the
\nprocess.
\nWMA
\n93
\nConclusion
\nOne thing is certain \u2013 whatever insurance
\nplan we arrive at will be a uniquely
\nAmerican system, with uniquely American
\ncharacteristics. Yet perhaps we can show
\nthe world a different approach to providing
\nhealth coverage to everyone in our commu-
\nnities \u2013 and our countries.
\nWe have a motto in the American Medical
\nAssociation that goes like this:
\n\u201cTogether we are stronger.\u201d
\nIt sounds self-evident, but it is a powerful
\nidea.
\nWorking together \u2013 in meetings just like
\nthis \u2013 we all become stronger.
\nOur profession becomes stronger. We learn
\nfrom each other. We find out more about what
\nworks in medicine \u2013 and what doesn\u2019t. And
\nwe reinforce the foundation of science, ethics,
\ncaring and compassion that supports all we
\ndo. Through our work our patients are better
\noff. No matter what our health care system.
\nNo matter what our country. The commitment
\nof the world\u2019s physician to their patients is
\none thing that doesn\u2019t need reform. \u25a0
\nThe ceremony was opened by the President,
\nDr. Yank D. Coble Jr., who warmly thanked
\nthe Chilean Medical Association and its
\nleaders for the excellent arrangements and
\nthe warmth and hospitality which had been
\nshown to the participants. He then called on
\nDr. Juan Luis Castro, President of the
\nChilean Medical Association, to address the
\nAssembly.
\nDr. Castro in welcoming the Assembly, said
\nthat the Chilean Medical Association was a
\nvoluntary organisation with 20000 mem-
\nbers. Speaking about the problems of the
\nprofession in Chile, he referred both to the
\nneed to improve salaries (stating that on
\nqualification earnings were about $ 300
\nand after five years might reach $30000),
\nbut stressed that a major problem was that
\nof lawsuits and liability He mentioned that
\nthese resulted in about 180 trials a year and
\nspoke of the pioneering experience in Latin
\nAmerica of creating the Foundation for
\nLegal Assistance (FALMED) to manage
\nlawsuits against the physicians and avoid
\nincreases in insurance costs. Another
\nimportant achievement was the restoration
\nof ethical defence for the Association. At a
\ntime when many countries were undergoing
\nprocesses of health reform, Chile was no
\nexception. There, physicians are witnessing
\nchanges which will impact greatly on the
\nmedical profession and its relations with
\npatients.
\nThanking him Dr. Coble then introduced Dr.
\nPedro Garcia, the Chilean Minister of
\nHealth, who addressed the Assembly. He
\nwelcomed delegates and referred to the
\nimportance of the profession meeting to dis-
\ncuss problems. As a doctor himself and as a
\npolitician he was, of course, interested in the
\nchallenges facing society. Referring to the
\ncomplexity of the geography of Chile he
\nsaid this posed many problems for health
\ncare, but there was a long history of health
\ncare in the country and they still looked to
\nphysicians to keep up with new develop-
\nments in scientific knowledge and health
\ncare. In his view it was there was need for
\npoliticians and physicians to work together
\nto solve these problems and he was there-
\nfore particularly delighted that the WMA
\nhad chosen to meet in Chile. He congratulat-
\ned all the bodies responsible for the organi-
\nsation of the meeting, in particular, the
\nChilean Medical Association. He pointed
\nout that 80% of Chilean doctors were mem-
\nbers of the CMA, of which he had been one
\nfor many years. He hoped that delegates
\nwould be able to get some idea of the
\nChilean Health Reforms and also that they
\nwould see something of the country during
\ntheir visit. He would be happy to respond to
\nany questions and he closed by wishing the
\nWMA a very successful conference.
\nDr. Blachar, the Chair of Council, paid a
\ntribute to Dr. Yank Coble for his outstand-
\ning services during his Presidential term of
\noffice and invested him with the Past
\nPresident\u2019s medal following which Dr.
\nCoble gave his valedictory address (This
\nwill appear in WMJ 52 (1))
\nDr. Blachar then introduced the new
\nPresident Dr. Kgosi Letlape and invited him
\nto take the oath of office. Following this,
\nDr. Blachar invested him with the
\nPresident\u2019s Badge of Office and invited him
\nto address the meeting (see Inaugural
\nPresidential Address p. 94).
\nDr. Blachar after thanking the speakers for
\ntheir addresses and once again the members
\nof the Chilean Medical Association for invit-
\ning the WMA to hold its General Assembly
\nin Santiago, adjourned the meeting. \u25a0
\nWMA
\nWMA Assembly Ceremonial Session, Santiago 2005
\nWMA
\n94
\nHonourable Minister of Health Dr. Pedro
\nGarcia, Dr. Castro, the President of the
\nChilean Medical Association, Honoured
\nGuests, Ladies and Gentlemen
\nThank you for the privilege you have given
\nme to serve as President of the World
\nMedical Association. I assume this role on
\nbehalf of all physicians on earth, but please
\nindulge me as I single out particularly my
\nbrothers and sisters of Africa.
\nI would firstly like to congratulate Dr. Yank
\nCoble on an extraordinary Presidency.
\nThrough his Presidential initiative of
\n\u201cCaring Physicians of the World\u201d, he has
\nmanaged to re-establish the fundamental
\nvalues of medicine\u2013caring, ethics and sci-
\nence. Together with the book on caring
\nphysicians, he has succeeded in making us
\nfeel good about being doctors again\u2013so
\nYank, thank you again for your leadership,
\ndedication and commitment to our profes-
\nsion. I find it a humbling experience to fol-
\nlow him as President and hope that I will be
\nable to rise to the occasion.
\nAn old Israeli saying states that you have to
\nlook back to where you have come from, to
\nbetter see where you are heading. Looking
\nback over the last few years, it is gratifying
\nto note that the WMA has unquestionably
\ngrown into the representative voice of
\nphysicians. The World Health Organi-
\nzation, World Bank and other UN agencies
\nturn to the WMA if they need to hear the
\nviews of physicians. Through our alliance
\nwith the International Council of Nurses,
\nInternational Pharmaceutical Federation
\nand the World Dental Federation we have
\nalso been able to make major break-
\nthroughs in the field of public health.
\nWithin the WMA there have also been very
\npositive developments. Our role as the cus-
\ntodians of medical ethics has been rein-
\nforces by the successful revision of the
\nDeclaration of Helsinki and the launch of
\nthe WMA Ethics Manual. The impact of
\nthe manual has been immediate and very
\nfront line physicians. In addition, the
\nWMA called for Taiwan to be included in
\nthe WHO surveillance and response net-
\nwork, as they are a separate health entity,
\nnot receiving any funding or assistance
\nfrom China. Here we are in 2005, with
\navian flu posing as a possible disaster of a
\nproportion we have not seen since the
\nSpanish Flu epidemic in 1918, when mil-
\nlions died. Yet we do not have a fully func-
\ntional network where the physicians and
\nmedical associations are directly linked to
\nWHO. The gab in the global public health
\nnetwork, Taiwan, a country with 23 million
\ncitizens, has not been yet addressed. If
\navian flu is transmitted from China to
\nTaiwan, as had happened with SARS, there
\nare still no formal channels open between
\nWHO and Taiwan to exchange technical
\ndata and provide help. Clearly we need to
\nbe more vocal and active as social leaders
\nto make sure that all measures can be taken
\nto include all the peoples of the world in
\npreparing for health disasters.
\nThe UN Commanding Officer in Rwanda
\nGeneral Dallaire said that after shaking
\nhands with the devil in Rwanda he knows
\nthere is a God. Noting that SARS never
\ncame to Africa in 2003 I have also come to
\nknow fully that God is there for all of us.
\nI offer you another story from my own con-
\ntinent. Last year the fundamentalist gover-
\nnor of Nigeria\u2019s Kano State halted all polio
\nimmunisation efforts because of alleged
\nand unsubstantiated claims that it was part
\nof a plot to sterilize Muslim girls. By the
\ntime he relented, polio hat spread to 12
\nAfrican countries that had previously been
\nfreed of the disease, thereby dramatically
\nsetting back global eradication efforts and
\nforcing the rest of the world to continue
\nvaccination programmes\u2013another classic
\nexample of where politics ruled over health
\nimperatives. Where were we, the physi-
\ncians of the world, in preventing this kind
\nof disaster? We can and should prevent this
\nfrom happening again!
\nIn Northern Europe over the last year,
\nphysicians have expressed their severe dis-
\nsatisfaction with the new trend of rationing
\nof care, ever increasing paper work, work
\nhours and diminishing remuneration. This
\nled to protest actions in France, Germany
\nWMA General Assembly, Santiago 2005
\nInaugural Presidential Address
\nDr. T. K. S. Letlape
\nsignificant. From its publication in January
\nthis year, it has now already been distrib-
\nuted worldwide and translated into at least
\n12 languages.
\nThe WMA\u2019s recent contributions in health
\nrelated human rights have also been wel-
\ncomed by my compatriots from Africa. We
\ncannot encourage the WMA enough to help
\nphysicians to be involved as the advocates
\nand protectors of patients and the vulnera-
\nble groups in society. It will be part of my
\nPresidential plan to help push forward our
\nhealth-related human rights agenda.
\nI see the future role of the WMA as more
\nand more that of social leaders, in addition
\nto our role as the leaders of the health care
\nteams. I would like to tell you three stories
\nfrom the North, South and East to illustrate
\nthis point.
\nIn the East we currently have an outbreak
\nof avian flu. You will remember that in
\n2003 the world endured the SARS epidem-
\nic, where hundreds of patients died in
\nChina, Taiwan, Singapore and Canada. At
\nthe Time the WMA argued strongly for the
\nestablishment of a global surveillance and
\nresponse network which would include
\nWMA
\n95
\nand Belgium. As governments find it diffi-
\ncult to fund health care services (from the
\npatients\u2019 own money), rationing has
\nincreasingly been used to balance accounts.
\nThis has placed great pressure on the
\npatient-physician relationship and physi-
\ncian autonomy. In September Belgian doc-
\ntors protested against a proposed new gov-
\nernment policy, whereby the Ministry of
\nHealth could intervene whenever the coun-
\ntry\u2019s health insurance budget goes into
\ndeficit, effectively being able to exclude
\nfinancial benefits for certain types of diag-
\nnosis or treatment. What is in fact happen-
\ning is that health care is being dumped
\ndown to the lowest common denominator
\nof cost. Even more importantly, rationing is
\nslowly destroying the art and professional
\npractice of medicine, the patient-physician
\nrelationship and patient access to all treat-
\nment options. Physicians are expected to
\nact as administrative clerks and accoun-
\ntants and their professional role downgrad-
\ned to select the least expensive, not the best
\navailable, treatment for their patients.
\nThis trend of political considerations deny-
\ning our patients the best possible health
\ncare services is unacceptable. We cannot
\nallow politics to stand in the way of effec-
\ntive handling of epidemics or disasters
\naffecting both national and international
\nlevels. It highlights the fact that physicians
\nneed to become more effective in shaping
\nthe health policy environment, rather than
\nbe shaped by it.
\nAs I mentioned before, the last WMA
\nPresidency very effectively re-affirmed the
\nfundamental values of medicine. During
\nmy term as President, I would like to place
\nthe focus on patient-centred medical care.
\nAs physicians we can draw encouragement
\nfrom the fact that patients still regard us as
\nthe most trusted source of health informa-
\ntion, but as communicators we can do
\nmuch better. Patients are overawed with the
\ninformation they can now source from the
\ninternet, but recent reports show that physi-
\ncians still don\u2019t communicate effectively
\nenough with their patients. During my term
\nI hope that we can revisit out policy on
\npatient information and communication
\nand develop a training manual on the sub-
\nject, as we have done so successfully for
\nethics and human rights. We must remem-
\nber always that our responsibilities come
\nbefore our rights.
\nWe have two themes in the vision of the
\nWorld Medical Association, these are ethics
\nand access. Whilst we have been in the
\nforefront on ethics, there is still a lot to be
\ndone on access. We have collective respon-
\nsibility globally to ensure access to basic
\nhealthcare for all citizens of the word. The
\nMillennium Development Goals are being
\nrolled back and those that are needing help
\nare not necessarily receiving it. Globally,
\nhealthcare is being under-funded and physi-
\ncian autonomy is interfered with, thus
\nundermining patients` rights. Doctors need
\nto work together with civil society to create
\na safer world that can fund health care
\nappropriately.
\nI come from South Africa, the epicentre of
\nthe HIV and AIDS epidemic. Therefore I
\nwould like to close with an impassioned
\nplea for the WMA and all its members to
\nfully taken on the responsibility of combat-
\ning HIV. This is still a growing disease,
\nwhere the role physicians can and should
\nplay has not been optimized. This is espe-
\ncially true for our role in prevention. So far
\nonly a limited number of full scale preven-
\ntion efforts have been developed with effec-
\ntively target \u201cat risk\u201d populations, the infra-
\nstructure of health systems, societal atti-
\ntudes and individual beliefs and motiva-
\ntions.
\nRemember, prevention in HIV and AIDS is
\nABCD, the four letters of the alphabet col-
\nlectively and in the proper sequence; selec-
\ntive application of the alphabet is hazardous
\nto the health of the people.
\nWe need to ensure that our doctors are
\ntrained appropriately to fulfil the role that
\nthey play as leaders and healers. Medical
\nschools train them to be great healers; we
\nneed to find a way to appropriately train
\nthem to be great leaders too. We need a pro-
\ngramme to assist National Medical
\nAssociations to get doctors to be good lead-
\ners as well. I will dedicate my years as pres-
\nident to realise this objective as a follow-on
\nto caring physicians, so that we can emulate
\nthose caring physicians and truly put our
\npatients first.
\nThere are three things to remember:
\n1. Health is political even for doctors but
\nwe will be non-partisan and engage
\nothers, as opposed to confronting them.
\n2. Health is a foundation for peace not a
\nbridge, for as we saw in the aftermath of
\nKatrina, bridges were swept away but
\nthe foundations remained.
\n3. A quote from Nelson Mandela: \u201cAfter
\nclimbing a great hill, one finds that
\nthere are many more hills to climb.\u201d
\nHaving seen the hills and mountains of
\nChile, I wonder if Mr. Mandela ever lived
\nin Chile!
\nI would like to end by thanking our hosts,
\nthe Chilean Medical Association for their
\nunforgettable warmth and hospitality dur-
\ning this Assembly. We are inviting you all
\nto our Assembly in South Africa next year
\nwhere we will try to emulate them. \u25a0
\n(We are particularly indebted to Dr.
\nAppleyard for his background notes on this
\nmeeting. Ed.)
\nThe 171th Council meeting took place in
\nSantiago, Chile on 14th October 2005.
\nThe meeting was opened by the Chairman,
\nDr. Blachar who called on the Secretary
\nGeneral to give his report.
\nSecretary General\u2019s Report
\nDr. Otmar Kloiber thanked the President,
\nDr. Yank Coble, for his dedication and for
\nthe \u2018added value\u2019 he had given to the Asso-
\nciation through the \u201cCaring Physicians of
\nthe World\u201d initiative. The resulting book
\nprovides insight into how our physician
\n171th WMA Council Session
\nWMA
\n96
\ncolleagues throughout the world serve their
\npatients under conditions that are often hard
\nto accept. The initiative had also supported
\nconferences in different parts of the world.
\nDr. Kloiber also thanked all NMAs for their
\nresponse to the disaster caused by the
\nTsunami and mentioned that money was
\nstill being collected. He expressed his grat-
\nitude to specific NMAs for their support, in
\nparticular for the staff time provided by the
\nAMA, in particular to Sharon Ostrowski
\nand Robin Menes, to the BMA, which
\nthrough Dr. Vivienne Nathanson provided
\nsupport for Work Groups, the Canadian
\nMedical Association and Dr. Bill Thould
\nfor the Business Development Group, the
\nGerman Medical Association especially for
\nDr. Parsa-Parsi\u2019s secondment, Ms Leah
\nWapner and the Israeli Medical Asso-
\nciation, also to the Norwegian Medical
\nAssociation for the online courses.
\nTurning to restructuring of WMA Office
\nTeam, he reported that since the last meeting
\nof Council Ms. Emma Viaud, a member of
\nStaff, had left the office. Dr. Parsi had been
\nseconded to the office for three months and
\nhad, among other items, worked on the
\ndevelopment of the TB Course, Outreach to
\nArab Countries, and on the Regional Office
\nfor Africa in SAMA.
\nThe Prison Medical Course had now been
\ntranslated into Spanish and is available on a
\nCD-Rom.
\nDr. Kloiber appealed to all NMAs to assist
\nthe Office in Ferney Voltaire by making
\navailable secondments for one of their staff
\nto work at the WMA for three months until
\nanother member of staff has been employed
\nIt was felt that this could provide a valuable
\neducational opportunity for NMAs\u2019 junior
\nmedical staff.
\nDr. Kloiber thanked Johnson and Johnson
\nfor their continuing support of the Ethics
\nUnit and the production of the Ethics
\nManual and to the South African, Australian
\nand Norwegian MA\u2019s for their work on the
\nTB project.
\nFollowing the successful completion of the
\nimplementation of the Istanbul Project in
\nfive nations with the ICRT, the work will be
\nextended to other countries through a fur-
\nther grant from the European Commission.
\nDr. Kloiber reported that the FDI had now
\njoined the World Health Professions Alli-
\nance. At a very successful WHPA Reception
\non Patient Safety held at the same time as
\nthe World Health Assembly. Sir Liam
\nDonaldson, Chairman of the World Alliance
\nfor Patient Safety, gave the keynote address.
\nA joint seminar will be held next year on
\nthree topics, the Reporting of Medical
\nErrors, Counterfeit Medicines and on
\nHuman Resources for Health.
\nTurning to finance and organisation, Dr.
\nKloiber told Council that his first priority
\nfollowing his appointment was to ensure
\nsound financial governance. In this he had
\nhad great support from Mr Adi H\u00e4llmayr
\nand Dr. Karsten Vilmar, the Treasurer
\nEmeritus. He had had to apply the brakes to
\ngive an emergency stop to expenditure.
\nStating that his main concern was to know
\nhow much of the WMA could be used for
\nadvocacy he commented that the WMA had
\nestablished a high reputation internationally
\nand its opinion was increasingly being
\nsought for its professional expertise.
\nConcerning Forced Sterilizations, since the
\nlast Council meeting Dr. Kloiber had been
\nin correspondence with the Slovak Medical
\nAssociation about allegations that some
\nPhysicians in Slovakia had been involved
\nin forced sterilisations (an illegal practice in
\nthat country). The Slovak Medical Asso-
\nciation had investigated these allegations
\nwith the Slovakian Government. The Board
\nof the Slovakian Medical Association had
\nwritten, stating that the allegations could
\nnot be confirmed and that none of the mem-
\nbers of the Slovakian Medical Association
\nhad been involved.
\nDr. Kloiber reported that since the last
\nCouncil Session he had attended meetings
\nof the AMA, BMA, Norwegian MA and
\nCuban Medical Association. He valued
\nthese personal contacts and by participating
\nin the meetings had a greater understanding
\nof local issues. Further visits to other NMAs
\nwill be undertaken next year.
\nDues
\nThe Revision of the Dues system as proposed
\nby the Treasure Emeritus was considered.
\nDr. Plested (AMA) asked if the full implica-
\ntions of the proposed changes had been
\nexplored and whether some NMAs would
\nuse this schedule as an opportunity to reduce
\ntheir dues. Dr. Kloiber replied that he antici-
\npated that the changes would be cost neutral.
\nThe NMA\u2019s from poorer nations would be
\nable to receive more votes in proportion to
\ntheir subscriptions and become more
\ninvolved in the activities of the WMA. The
\nlower cost would encourage non members
\nfrom poorer nations to join. He emphasised
\nthat there would be no change in the dues
\npaid by the larger and richer NMA\u2019s, who
\nprovide 85% of the WMAs dues revenue.
\nAfter Dr. Johnson (BMA) agreed that the
\nrecommendations had to be taken as a \u2018pack-
\nage\u2019, the revised dues system wasAGREED.
\nSponsorship
\nDr. Plested (AMA) proposed that the speci-
\nfication for new Sponsorship projects should
\nbe reassessed to ensure robust projections for
\nanticipated Income and Expenditure. He
\nmoved a motion, seconded by Dr. Nelson
\n(USA),\u2018that the Secretary General work
\nwithin the existing guidelines to maximise
\nnon-dues income\u201c. This was AGREED.
\nMedical Ethics Committee
\nReport
\nThis was presented by the Chairman, Dr.
\nBagenholm.
\nMinor Revisions of Declarations etc.
\nThe Declaration of Lisbon, as revised, was
\napproved.
\nIt was agreed that a work group be convened
\nby the AMA with the BMA to integrate
\nNMA comments on the \u2018Statement of
\nEthical Issues concerning patients with
\nMental Illness\u2019, which was re-classified as
\nrequiring major revision.
\nMajor Revisions of Declarations etc.
\nIt was resolved that all the Documents clas-
\nsified as requiring major revisions be
\nreferred to NMA\u2019s for comment.
\nConcerning the Policy Review of the
\nDeclarations of Geneva, of Tokyo, and the
\nRegulations in Times of Armed Conflict, Dr.
\nNathanson gave an oral report on her pro-
\nWMA
\n97
\nposals to amend these statements. It was
\nAGREED that the proposals of the BMAs
\nconvened Work Group be circulated to
\nNMA\u2019s.
\nSponsorship Guidelines
\nDr. Bagenholm reported on the discussion
\nwithin her committee on the principle of
\naccepting sponsorship It was AGREED that
\nCouncil establish a Working Group of the
\nChairs of Ethics and of Finance and
\nPlanning Committees, to review the WMA\u2019s
\nCorporate relationship Guidelines (see page
\n86 for fuller account of the discussion).
\nSocio-Medical Affairs
\nCommittee Report
\nDr. Haddad in presenting his report, intro-
\nduced for the first time a Consent Calendar
\nfor the Recommendations of his Committee.
\nThis procedure involves the presentation of
\nall the Recommendations from the
\nCommittee together as one recommenda-
\ntion, with the option that any member of
\nCouncil could request the withdrawal of any
\nspecific recommendation, for further debate.
\nThe report was for the first time presented
\nas a consent calendar, which meant that all
\nrecommendations that were not challenged
\n(extracted) were then voted for en bloc and
\napproved.
\nDr. Plested suggested the extraction of para
\n2.2.1, the Proposed Statement on Reducing
\nthe Global impact of Alcohol. This enabled
\nhim to speak in favour of the document
\nemphasising the point made within it of the
\nnecessity for a Strategic Framework similar
\nto the one on Tobacco, following this the
\nstatement was agreed unanimously (the
\nAlcohol Statement will appear in the next
\nissue of WMJ).
\nSkills Drain
\nThe BMA had prepared two background
\npapers on the Healthcare Skills Drain from
\nDeveloping Countries.These will be distrib-
\nuted to NMA\u2019s for information.
\nFinance and Planning
\nCommittee
\nDr. John Nelson presented his report of the
\nmeeting of the committee. All the recom-
\nmendations were adopted without further
\ndebate including the revised dues structure.
\n(see also Dues above)
\nOther Business
\nRecommendations on Business Develop-
\nment and on Non-dues income were agreed
\n(see above!).
\nDisaster Planning
\nIt was AGREED that a Work Group be
\nestablished to consider the preventive mea-
\nsures and contingencies necessary for
\nDisaster Planning including the possible
\nAsian Flu pandemic. The Canadian, South
\nAfrican, German and American MA\u2019s will
\ncontribute to this.
\nPreventing Chronic Diseases
\nDr. Appleyard (IPP) referred to his report to
\nCouncil in May concerning the WHO initia-
\ntive on Preventing Chronic Diseases and
\nstressed the importance of the major finan-
\ncial burden this would place on developing
\ncountries. WHO was launching the initia-
\ntive at the end of October and it would be
\nappropriate for the WMA to identify itself
\nwith this important preventive venture. In
\nview of the time constraints he suggested a
\nspecial Council Resolution:
\n\u201eThe WMA (Council) welcomes the
\nWHO Report on \u201cPreventing Chronic
\nDiseases, a vital investment, and recom-
\nmends that all NMA\u2019s work with health
\nprofessional organisations, interested
\nstakeholders and their Governments, to
\nprevent and relieve the increasing burden
\nof chronic disease.
\nThis was formally proposed by Dr. Haddad
\nand seconded by Dr. Wu.
\nDr. Kloiber raised concerns about the finan-
\ncial impact saying that he had no capacity to
\nattend the launch later in the month.
\nAfter further debate to which Dr. Appleyard
\nreplied, reading out for translation purposes
\na brief background paper he had prepared,
\nthe Council Resolution was AGREED nem
\ncon, with the caveat that there would be no
\nadditional cost incurred.
\n(full WHO report is accessible at
\nwww.who.int\/chp\/chronic_disease_report\/
\noverview_en.pdf)
\nExecutive Committee
\nDr. John Nelson raised a question about the
\ncomposition of the Executive Committee,
\nexpressing concern at the exclusion of the
\nthree Presidents as non-voting members.
\nPresidents were elected from the General
\nAssembly representing all the NMAs, not
\njust those larger NMA\u2019s who had \u2018bought\u2019
\nseats on the Council with their larger
\ndeclared membership. Dr. Kloiber said that
\nhe was bound by the last decision of Council
\nthat only the voting members of Council
\nwould be included on the executive. These
\nhad been specified as the Chair of Council,
\nDeputy Chair, and the Chair of the three
\nCommittees. The Executive committee had
\nalready decided to revisit the issue again. \u25a0
\nThe World Medical Association recog-
\nnizes the potential global morbidity and
\nmortality as a result of the H5N1 strain of
\navian flu. This possibility increases with
\nevery passing day as more countries find
\ninfected birds in their territories. The
\nWMA will work with member NMAs, the
\nWHO and other stakeholders to track the
\nprogress of the disease and propose the
\nnecessary measures to minimize its
\nimpact on the global human population.
\nThe WMA also urges governments to
\nengage with NMAs to prepare for the pos-
\nsibility of a pandemic.
\nThe World Medical Association Resolution on
\nAvian Influenza
\nAdopted by the WMA General Assembly, Santiago 2005
\nWMA
\n98
\nPreamble
\n1. In recent years, the field of genetics has
\nundergone rapid change and development.
\nThe areas of gene therapy and genetic
\nengineering and the development of new
\ntechnology have presented possibilities
\ninconceivable only decades ago.
\n2. The Human Genome Project opened new
\nspheres of research. Its applications also
\nproved useful to clinical care by allowing
\nphysicians to utilize knowledge of the
\nhuman genome in order to diagnose future
\ndisease, as well as to individualize drug
\ntherapy (pharmacogenomics).
\n3. Because of this, genetics has become an
\nintegral part of primary care medicine.
\nWhereas at one time, medical genetics
\nwas devoted to the study of relatively rare
\ngenetic disorders, the Human Genome
\nProject has established a genetic contribu-
\ntion to a variety of common diseases. It is
\ntherefore incumbent upon all physicians
\nto have a working knowledge of the field.
\n4. Genetics is an area of medicine with enor-
\nmous medical, social, ethical and legal
\nimplications. The WMA has developed
\nthis statement in order to address some of
\nthese concerns and provide guidance to
\nphysicians. These guidelines should be
\nupdated in accordance with developments
\nin the field of genetics.
\nMajor Issues:
\nGenetic Testing
\n5. The identification of disease-related genes
\nhas led to an increase in the number of
\navailable genetic tests that detect disease
\nor an individual’s risk of disease. As the
\nnumber and types of such tests and the
\ndiseases they detect increases, there is
\nconcern about the reliability and limita-
\ntions of such tests, as well as the implica-
\ntions of testing and disclosure. The ability
\nof physicians to interpret test results and
\ncounsel their patients has also been chal-
\nlenged by the proliferation of knowledge.
\n6. Genetic testing may be undergone prior to
\nmarriage or childbearing to detect the
\npresence of carrier genes that might affect
\nthe health of future offspring. Physicians
\nshould actively inform those from popula-
\ntions with high incidence of certain genet-
\nic diseases about the possibility of pre-
\nmarital and pre-pregnancy testing, and
\ngenetic counseling should be made avail-
\nable to those individuals or couples who
\nare considering such testing.
\n7. Genetic counseling and testing during
\npregnancy should be offered as an option.
\nIn cases where no medical intervention is
\npossible following diagnosis, this should
\nbe explained to the couple prior to their
\ndecision to test.
\n8. In recent years, with the advent of IVF,
\ngenetic testing has been extended to pre-
\nimplantation genetic diagnosis of embryos
\n(PGD). This can be a useful tool in cases
\nwhere a couple has a high chance of con-
\nceiving a child with genetic disease.
\n9. Since the purpose of medicine is to treat,
\nin cases where no sickness or disability is
\ninvolved genetic screening should not be
\nemployed as a means of producing chil-
\ndren with pre-determined characteristics.
\nFor example, genetic screening should not
\nbe used to enable sex selection unless
\nthere is a gender-based illness involved.
\nSimilarly, physicians should not counte-
\nnance the use of such screening to pro-
\nmote non-health related personal attribut-
\nes.
\n10. Genetic testing should be done only with
\ninformed consent of the individual or
\nhis\/her legal guardian. Genetic testing for
\npredisposition to disease should be per-
\nformed only on consenting adults, unless
\nthere is treatment available for the condi-
\ntion and the test results would facilitate
\nearlier instigation of this treatment.
\n11. Valid consent to genetic testing should
\ninclude the following factors:
\na. The limitations of genetic testing,
\nincluding the fact that the presence of a
\nspecific gene may denote predisposi-
\ntion to disease rather than the disease
\nitself and does not definitively predict
\nthe likelihood of developing a certain
\ndisease, particularly in multi-factorial
\ndisorders.
\nb. The fact that a disease may manifest
\nitself in one of several forms and in
\nvarying degrees
\nc. Information about the nature and pre-
\ndictability of information received
\nfrom the tests.
\nd. The benefits of testing including the
\nrelief of uncertainty and the ability to
\nmake informed choices, including the
\npossible need to increase or reduce reg-
\nular screenings and checkups, and to
\nimplement risk reduction measures
\ne. The implications of a positive result
\nand the prevention, screening and\/or
\ntreatment possibilities.
\nf. The possible implications for the fami-
\nly members of the patient involved.
\n12. In the case of a positive test result that
\nmay have implications for third parties
\nsuch as close relatives, the individual test-
\ned should be encouraged to discuss the
\nresults of the test with such third parties.
\nIn cases where not disclosing the results
\ninvolves a direct and imminent threat to
\nthe life or health of an individual, the
\nphysician may reveal the results to such
\nthird parties, but should usually discuss
\nthis with the patient first. If the physician
\nhas access to an ethics committee, it is
\nThe World Medical Association Statement on Genetics and Medicine
\nAdopted by the WMA General Assembly, Santiago 2005
\nWMA
\n99
\npreferable to consult such a committee
\nprior to revealing results to third parties.
\nGenetic Counseling
\n13. Genetic counseling is generally offered
\nprior to marriage or conception, in order
\nto predict the likelihood of conceiving an
\naffected child, during pregnancy, in order
\nto determine the condition of the fetus, or
\nto an adult, in order to determine suscepti-
\nbility to a certain disease.
\n14. Individuals at higher risk for conceiving a
\nchild with a specific disease should be
\noffered genetic counseling prior to con-
\nception or during pregnancy. In addition,
\nadults at higher risk for various diseases
\nsuch as cancer, mental illness or neuro-
\ndegenerative diseases in which the risk
\ncan be tested for, should be made aware of
\nthe availability of genetic counseling.
\n15. Because of the scientific complexity
\ninvolved in genetic testing as well as the
\npractical and emotional implications of
\nthe results, the WMA sees great impor-
\ntance in educating and training medical
\nstudents and physicians in genetic coun-
\nseling, particularly counseling related to
\npre-symptomatic diagnosis of disease.
\nIndependent genetic counselors also have
\nan important role to play. The WMA
\nacknowledges that there can be very com-
\nplex situations requiring the involvement
\nof medical genetics specialists.
\n16. In all cases where genetic counseling is
\noffered, it should be non-directive and
\nprotect the individual’s right not to be test-
\ned.
\n17. In cases of counseling prior to or during
\npregnancy, the prospective parents should
\nbe given information to provide the basis
\nfor an informed decision regarding child-
\nbearing, but should not be influenced by
\nthe physicians’ personal views in this mat-
\nter and physicians should be careful not to
\nsubstitute their own moral judgment for
\nthat of the prospective parents. In cases
\nwhere a physician is morally opposed to
\ncontraception or abortion, he\/she may
\nchoose not to provide these services but
\nshould alert prospective parents that a
\npotential genetic problem exists and make
\nnote of the option of contraception or
\nabortion as well as treatment alternatives,
\nrelevant genetic tests, and the availabili-
\nty of genetic counseling.
\nConfidentiality of results
\n18. Like all medical records, the results of
\ngenetic testing should be kept strictly con-
\nfidential, and should not be revealed to
\noutside parties without the consent of the
\nindividual tested. Third parties to whom
\nresults may in certain circumstances be
\nreleased are identified in paragraph 12.
\n19. Physicians should support the passage of
\nlaws guaranteeing that no individual shall
\nbe discriminated against on the basis of
\ngenetic makeup in the fields of human
\nrights, employment and insurance.
\nGene therapy and genetic research
\n20.Gene therapy represents a combination
\nof techniques used to correct defective
\ngenes that cause disease, especially in the
\nfields of oncology, hematology and
\nimmune disorders. Gene therapy is not
\nyet an active current therapy but is still in
\na stage of clinical investigation.
\nHowever, with the continued develop-
\nment of this field, it should proceed
\naccording to the following guidelines:
\na. Gene therapy performed in a research
\ncontext should conform to the require-
\nments of the Declaration of Helsinki
\nwhile therapy performed in a treatment
\ncontext should conform to standards of
\nmedical practice and professional
\nresponsibility.
\nb. Informed consent should always be
\nobtained from the patient undergoing
\nthe therapy. This informed consent
\nshould include disclosure of the risks of
\ngene therapy, including the fact that the
\npatient may have to undergo multiple
\nrounds of gene therapy, the risk of an
\nimmune response, and the potential
\nproblems arising from the use of viral
\nvectors.
\nc. Gene therapy should only be undertak-
\nen after a careful analysis of the risks
\nand benefits involved and an evaluation
\nof the perceived effectiveness of the
\ntherapy, as compared to the risks, side
\neffects, availability and effectiveness of
\nother treatments.
\n21. It is currently possible to undertake
\nscreening of an embryo in order to pro-
\nvide stem cell or other therapies for an
\nexisting sibling with a genetic disorder.
\nThis may be considered acceptable med-
\nical practice where no evidence exists that
\nthe embryo is being created exclusively
\nfor this purpose.
\n22. Genetic discoveries should be shared as
\nmuch as possible between countries, so as
\nto benefit humankind and reduce duplica-
\ntion of research and the risk inherent in
\nresearch in this area.
\n23. In the case of genetic research performed
\non large, defined population groups,
\nefforts should be made to avoid potential
\nstigmatization.
\nCloning
\n24. Recent developments in science have led
\nto the cloning of a mammal and raise the
\npossibility of such cloning techniques
\nbeing used in humans.
\n25. Cloning includes both therapeutic clon-
\ning, namely the cloning of individual stem
\ncells in order to produce a healthy copy of
\na diseased tissue or organ for transplant,
\nand reproductive cloning, namely the
\ncloning of an existing mammal to produce
\na duplicate of such mammal. The WMA
\ncurrently opposes reproductive cloning,
\nand in many countries it is considered to
\npose more of an ethical problem than ther-
\napeutic cloning.
\n26. Physicians should act in accordance with
\nthe codes of medical ethics in their coun-
\ntries regarding the use of cloning and be
\nmindful of the law governing this activity.
\nWMA
\n100
\nIntroduction
\n1. The prescription of a drug represents
\nthe culmination of a careful delibera-
\ntive process between physician and
\npatient aimed at the prevention, amelio-
\nration or cure of a disease or problem.
\nThis deliberative process requires that
\nthe physician evaluate a variety of sci-
\nentific and other data including costs
\nand make an individualized choice of
\ntherapy for the patient. Sometimes,
\nhowever, a pharmacist is required to
\nsubstitute a different drug for the one
\nprescribed by the physician. The World
\nMedical Association has serious con-
\ncerns about this practice.
\n2. Drug substitution can take two forms:
\ngeneric substitution and therapeutic
\nsubstitution.
\n3. In generic substitution, a generic drug
\nis substituted for a brand name drug.
\nHowever, both drugs have the same
\nactive chemical ingredient, same
\ndosage strength, and same dosage
\nform.
\n4. Therapeutic substitution occurs when a
\npharmacist substitutes a chemically dif-
\nferent drug for the drug that the physi-
\ncian prescribed. The drug substituted
\nby the pharmacist belongs to the same
\npharmacologic class and\/or to the same
\ntherapeutic class. However since the
\ntwo drugs have different chemical
\nstructures, adverse outcomes for the
\npatient can occur.
\n5. The respective roles of physicians and
\npharmacists in serving the patient’s
\nneed for optimal drug therapy are out-
\nlined in the WMA Statement on the
\nWorking Relationship between
\nPhysicians and Pharmacists in
\nMedicinal Therapy.
\n6. The physician should be assured by
\nnational regulatory authorities of the
\nbioequivalence and the chemical and
\ntherapeutic equivalence of prescription
\ndrug products from both multiple and
\nsingle sources. Quality assurance pro-
\ncedures should be in place to ensure
\ntheir lot-to-lot bioequivalence and their
\nchemical and therapeutic equivalence.
\n7. Many considerations should be
\naddressed before prescribing the drug
\nof choice for a particular indication in
\nany given patient. Drug therapy should
\nbe individualized based on a complete
\nclinical patient history, current physical
\nfindings, all relevant laboratory data,
\nand psychosocial factors. Once these
\nprimary considerations are met, the
\nphysician should then consider com-
\nparative costs of similar drug products
\navailable to best serve the patient’s
\nneeds. The physician should select the
\ntype and quantity of drug product that
\nhe or she considers to be in the best
\nmedical and financial interest of the
\npatient.
\n8. Once the patient gives his or her con-
\nsent to the drug selected, that drug
\nshould not be changed without the con-
\nsent of the patient and his or her physi-
\ncian. Failure to follow this principle
\ncan result in harm to patients. On
\nbehalf of patients and physicians alike,
\nNational Medical Associations should
\ndo everything possible to ensure the
\nimplementation of the following rec-
\nommendations:
\nRecommendations
\n9. Physicians should become familiar
\nwith specific laws and\/or regulations
\ngoverning drug substitution where they
\npractise.
\n10.Pharmacists should be required to dis-
\npense the exact chemical, dose, and
\ndosage form prescribed by the physi-
\ncian. Once medication has been pre-
\nscribed and begun, no drug substitution
\nshould be made without the prescribing
\nphysician’s permission.
\n11.If substitution of a drug product occurs,
\nthe physician should carefully monitor
\nand adjust the dose to ensure therapeu-
\ntic equivalence of the drug products.
\n12.If drug substitution leads to serious
\nadverse drug reaction or therapeutic
\nfailure, the physician should document
\nthis finding and report it to appropriate
\ndrug regulatory authorities.
\n13.National Medical Associations should
\nregularly monitor drug substitution
\nissues and keep their members advised
\non developments that have special rele-
\nvance for patient care. Collection and
\nevaluation of information reports on
\nsignificant developments in this area is
\nencouraged.
\n14.Appropriate drug regulatory bodies
\nshould evaluate and ensure the bioe-
\nquivalence and the chemical and thera-
\npeutic equivalence of all similar drug
\nproducts, whether generic or brand-
\nname, in order to ensure safe and effec-
\ntive treatment.
\n15.National Medical Associations should
\noppose any action to restrict the free-
\ndom and the responsibility of the physi-
\ncian to prescribe in the best medical
\nand financial interest of the patient.
\n16.National Medical Associations should
\nurge national regulatory authorities to
\ndeclare therapeutic substitution illegal,
\nunless such substitution has the imme-
\ndiate prior consent of the prescribing
\nphysician.
\nThe World Medical Association Statement on Drug Substitution
\nAdopted by the WMA General Assembly, Santiago 2005
\nWMA
\n101
\n1. A culture of litigation is growing around
\nthe world that is adversely affecting the
\npractice of medicine and eroding the
\navailability and quality of health care
\nservices. Some National Medical
\nAssociations report a medical liability
\ncrisis whereby the lawsuit culture is
\nincreasing health care costs, restraining
\naccess to health care services, and hin-
\ndering efforts to improve patient safety
\nand quality. In other countries, medical
\nliability claims are less rampant, but
\nNational Medical Associations in those
\ncountries should be alert to the issues
\nand circumstances that could result in
\nan increase in the frequency and severi-
\nty of medical liability claims brought
\nagainst physicians.
\n2. Medical liability claims have greatly
\nincreased health care costs, diverting
\nscarce health care resources to the legal
\nsystem and away from direct patient
\ncare, research, and physician training.
\nThe lawsuit culture has also blurred the
\ndistinction between negligence and
\nunavoidable adverse outcomes, often
\nresulting in a random determination of
\nthe standard of care. This has led to the
\nbroad perception that anyone can sue
\nfor almost anything, betting on a chance
\nto win a big award. Such a culture
\nbreeds cynicism and distrust in both the
\nmedical and legal systems with damag-
\ning consequences to the patient-physi-
\ncian relationship.
\n3. In adopting this Statement, the World
\nMedical Association makes an urgent
\ncall to all National Medical
\nAssociations to demand the establish-
\nment of a reliable system of medical
\njustice in their respective countries.
\nLegal systems should ensure that
\npatients are protected against harmful
\npractices, physicians are protected
\nagainst unmeritorious lawsuits, and
\n\u201cstandard of care\u201d determinations are
\nconsistent and reliable, so that all par-
\nties know where they stand.
\n4. In this Statement the World Medical
\nAssociation wishes to inform National
\nMedical Associations of some of the
\nfacts and issues related to medical lia-
\nbility claims. The laws and legal sys-
\ntems in each country, as well as the
\nsocial traditions and the economic con-
\nditions of the country, will affect the rel-
\nevance of some portions of this
\nStatement to each National Medical
\nAssociation but do not detract from the
\nfundamental importance of such a
\nStatement.
\n5. An increase in the frequency and sever-
\nity of medical liability claims may
\nresult, in part, from one or more of the
\nfollowing circumstances:
\na. Increases in medical knowledge and
\nmedical technology that have
\nenabled physicians to accomplish
\nmedical feats that were not possible
\nin the past, but that involve consider-
\nable risks in many instances.
\nb. Pressures on physicians by private
\nmanaged care organizations or gov-
\nernment-managed health care sys-
\ntems to limit the costs of medical
\ncare.
\nc. Confusing the right to access to
\nhealth care, which is attainable, with
\nthe right to achieve and maintain
\nhealth, which cannot be guaranteed.
\nd. The role of the media in fostering
\nmistrust of physicians by questioning
\ntheir ability, knowledge, behaviour,
\nand management of patients, and by
\nprompting patients to submit com-
\nplaints against physicians.
\n6. A distinction must be made between
\nharm caused by medical negligence and
\nan untoward result occurring in the
\ncourse of medical care and treatment
\nthat is not the fault of the physician.
\na. Injury caused by negligence is the
\ndirect result of the physician’s failure
\nto conform to the standard of care for
\ntreatment of the patient’s condition,
\nor the physician’s lack of skill in pro-
\nviding care to the patient.
\nb. An untoward result is an injury
\noccurring in the course of medical
\ntreatment that was not the result of
\nany lack of skill or knowledge on the
\npart of the treating physician, and for
\nwhich the physician should not bear
\nany liability.
\n7. Compensation for patients suffering a
\nmedical injury should be determined
\ndifferently for medical liability claims
\nthan for the untoward results that occur
\nduring medical care and treatment,
\nunless there is an alternative system in
\nplace such as a no-fault system or alter-
\nnate resolution system.
\na. Where an untoward result occurs
\nwithout fault on the part of the physi-
\ncian, each country must determine if
\nthe patient should be compensated
\nfor the injuries suffered, and if so, the
\nsource from which the funds will be
\npaid. The economic conditions of the
\ncountry will determine if such soli-
\ndarity funds are available to compen-
\nsate the patient without being at the
\nexpense of the physician.
\nb. The laws of each jurisdiction should
\nprovide the procedures for deciding
\nThe World Medical Association Statement on Medical Liability Reform
\nAdopted by the WMA General Assembly, Santiago 2005
\nWMA
\n102
\nliability for medical liability claims
\nand for determining the amount of
\ncompensation owed to the patient in
\nthose cases where negligence is
\nproven.
\n8. National Medical Associations should
\nconsider some or all of the following
\nactivities in an effort to provide fair and
\nequitable treatment for both physicians
\nand patients:
\na. Establish public education programs
\non the risks inherent in some of the
\nnew advances in treatment modali-
\nties and surgery, and professional
\neducation programs on the need for
\nobtaining the patient’s informed con-
\nsent to such treatment and surgery.
\nb. Implement public advocacy pro-
\ngrams to demonstrate the problems
\nin medicine and health care delivery
\nresulting from strict cost contain-
\nment limitations.
\nc. Enhance the level and quality of
\nmedical education for all physicians,
\nincluding improved clinical training
\nexperiences.
\nd. Develop and participate in programs
\nfor physicians to improve the quality
\nof medical care and treatment.
\ne. Develop appropriate policy positions
\non remedial training for physicians
\nfound to be deficient in knowledge
\nor skills, including policy positions
\non limiting the physician’s medical
\npractice until the deficiencies are
\ncorrected.
\nf. Inform the public and government of
\nthe dangers that various manifesta-
\ntions of defensive medicine may
\npose (the multiplication of medical
\nacts or, on the contrary, the absten-
\ntion of the physicians, the disaffec-
\ntion of young physicians for certain
\nhigher risk specialties or the reluc-
\ntance by physicians or hospitals to
\ntreat higher-risk patients).
\ng. Educate the public on the possible
\noccurrence of injuries during med-
\nical treatment that are not the result
\nof physician negligence, and estab-
\nlish simple procedures to allow
\npatients to receive explanations in
\nthe case of adverse events and to be
\ninformed of the steps that must be
\ntaken to obtain compensation, if
\navailable.
\nh. Advocate for legal protection for
\nphysicians when patients are injured
\nby untoward results not caused by
\nany negligence, and participate in
\ndecisions relating to the advisability
\nof providing compensation for
\npatients injured during medical treat-
\nment without any negligence.
\ni. Participate in the development of the
\nlaws and procedures applicable to
\nmedical liability claims.
\nj. Develop active opposition to merit-
\nless or frivolous claims and to con-
\ntingency billing by lawyers.
\nk. Explore innovative alternative dis-
\npute resolution procedures for han-
\ndling medical liability claims, such
\nas arbitration, rather than court pro-
\nceedings.
\nl. Encourage self-insurance by physi-
\ncians against medical liability
\nclaims, paid by the practitioners
\nthemselves or by the employer if the
\nphysician is employed.
\nm.Encourage the development of vol-
\nuntary, confidential, and legally pro-
\ntected systems for reporting unto-
\nward outcomes or medical errors for
\nthe purpose of analysis and for mak-
\ning recommendations on reducing
\nuntoward outcomes and improving
\npatient safety and health care quality.
\nn. Advocate against the increasing
\ncriminalization or penal liability of
\nmedical acts by the courts.
\nDr. G Dumont was re-elected Chair and the
\nminutes of the meeting in Tokyo 2004 were
\napproved.
\nArising from the minutes, Dr. Kloiber, the
\nSecretary General, reported that, following
\nlast year\u2019s resolution in connection with
\nforced sterilisation of women in the Slovak
\nRepublic, he had written to the Slovak
\nMedical Association. The Slovak Ministry
\nof Health had investigated the allegation
\nwith the Medical Association. The allega-
\ntions were found to have no foundation.
\nThe Slovak Medical Association had writ-
\nten to WMA stating that no member of the
\nSMA had been involved in this practice
\nwhich was illegal in the Slovak Republic.
\nGeneral Assembly Associates\u2019 Meeting,
\nSantiago 2005
\nThe Secretary General, reporting on the total
\nnumbers of Associate Members commented
\nthat he was reviewing the role of Associate
\nMembers in the future, pointing out that the
\nInternational Dental Federation\u2019s associate
\nmembers played a more proactive role.
\nResponding to a proposal by Dr. Mont-
\ngomery, the longest serving member present
\nat the meeting, that the meeting be disband-
\ned, Dr. Appleyard opposing this ,said that
\nthe Associate\u2019s meeting had produced some
\nhelpful statements, citing the two which
\nwere on the agenda as examples. Junior doc-
\ntors were keen to form a group within WMA
\nWMA
\n103
\nand he referred to IFMSA members being
\neligible for free associate membership of
\nWMA for three years after graduation. Dr.
\nKloiber confirming this, pointed out that res-
\nolutions of theAssociates\u2019meeting were sent
\nto the General Assembly, although Council
\ntended to consider them first.
\nAfter an extensive debate it was agreed that
\nthe Secretary General would report back on
\nhis deliberation.
\nDr. Montgomery proposed, seconded by Dr.
\nNelson, that Assembly business be consid-
\nered next on the agenda. Although this was
\nopposed by Dr. Fransblau, the motion was
\nadopted by a large majority.
\nThe meeting then elected Drs. Montgomery
\nand Smoak as representatives at the General
\nAssembly.
\nThe meeting then considered a resolution on
\nMedical Assistance in Air Travel submitted
\nby the late Dr. Odenbach, presented on his
\nbehalf by Dr. Kloiber. This was supported
\nby Dr. Montgomery. Dr. Appleyard felt that
\nthe issue of liability in circumstances where
\nhumanitarian help was offered was impor-
\ntant and proposed that the motion be
\nreferred to Council in the first instance. The
\nproposal was seconded by Dr. Montgomery
\nand the Resolution was adopted.
\nA second proposed Resolution on Child
\nSafety in Air travel, was introduced by Dr.
\nKloiber, expressing concern that adequate
\nsafety systems for babies and small chil-
\ndren had not been implemented. After some
\ndiscussion the Resolution was passed unan-
\nimously. \u25a0
\nThe author of the following note spent three
\nmonths in the WMA Office this year and
\nwrites about the experience and what it
\noffers.
\nThe voice of the World Medical Association
\nis considered as the opinion of millions of
\nphysicians from every region of the world.
\nIts function has always been to constitute a
\nfree, open forum for the frank discussion of
\nmatters related to medical ethics, medical
\neducation, and socio-medical affairs. With
\nits declarations and statements it has con-
\ntributed significantly to national and inter-
\nnational debates. Approved by its General
\nAssembly, WMA documents guide national
\nmedical associations, health care, govern-
\nments, non-governmental organisations and
\nUnited Nations agencies.
\nThe World Medical Association has also,
\nhowever, always been involved in many
\nother activities beyond statements and reso-
\nlutions. A number of global projects and
\nprogrammes are continuously initiated,
\nsupported or conducted by the WMA.
\nThese activities might not be as visible and
\nwell known to the health care community
\nand the general public.
\nWho is doing all the work?
\nPeople might assume that a few tens of
\nhighly specialized staff members work
\ninexorably in the high-tech offices of a
\nlarge WMA headquarters. The WMA must
\nsurely work with heavy administration and
\nstaff budgets?
\nIn truth, for reasons of economy, and in
\norder to operate within the vicinity of
\nGeneva-based international organizations
\nlike the WHO and other UN agencies, the
\nInternational Red Cross and international
\nassociations, the WMA Secretariat was
\ntransferred in 1975 from New York to its
\npresent location in Ferney-Voltaire, France
\nclose to Geneva.
\nMembership of the World Medical
\nAssociation is voluntary and its budget is
\nfunded from membership fees from nation-
\nal medical associations. Hence, funds are
\nlimited and vary significantly. The WMA
\nhas been a marvel in managing projects,
\nprogrammes and its meetings and assem-
\nblies with extremely small budgets. Its
\nSecretariat operates with a small permanent
\nstaff only, but manages to accomplish an
\nimpressive amount of work.
\nThe WMA would certainly be interested to
\ncommit itself to even more projects and
\nactivities. However, more manpower
\nwould be necessary. One way to increase
\ncapacities at WMA is its programme for
\nhealth care professionals to spend three to
\nsix months at the WMA Secretariat in
\nFerney-Voltaire. National medical associa-
\ntions may use this opportunity to send a
\nstaff-member for a short-term \u201ctraining\u201d at
\nthe WMA Secretariat.
\nThere is certainly no better way to get to
\nknow the work of the WMA and experi-
\nence the job environment of a truly interna-
\ntional organization.
\nIt is a win-win-situation
\nFellows are able to dive into \u201ehands on\u201c
\nwork from the very first day. Apart from
\nsome routine work which clearly helps to
\nunderstand the every-day work of an inter-
\nnational organization, Fellows have the
\nchance to take on the management of indi-
\nvidual projects. Fellows routinely interact
\nwith senior health care experts from the
\nvarious health care organisations and work
\nself-responsibly and independently.
\nFor example, this summer the WMA start-
\ned a project to develop an online course for
\nphysicians on multi-drug-resistant tubercu-
\nBeyond statements and resolutions \u2013 Working
\nat the WMA Secretariat in Ferney-Voltaire
\nDr. Ramin Parsa-Parsi, MD, MPH, German Medical Association
\nWMA
\n104
\nlosis (MDR-TB). The WMA had previous-
\nly developed a similar programme for
\nphysicians in prisons. This training course
\nis being developed to train physicians to
\nmore effectively diagnose, prevent and
\ntreat MDR-TB. The WMA is collaborating
\nwith the South African Medical
\nAssociation and its Foundation for
\nProfessional Development on this project.
\nThe WMA is also collaborating with the
\nWHO and several national medical associ-
\nations in order to produce a state-of-the art
\nand universally accessible product. The
\nNorwegian Medical Association is trans-
\nforming the material into the online format
\nand the German Medical Association is
\nhelping with logistic support. The manage-
\nment and the coordination of the entire pro-
\nject is performed by WMA staff. Although
\nthe coordination of all stakeholders and
\ninternational experts can be challenging,
\nhelping to make this project happen is a
\ntruly exciting and rewarding task. The final
\nproduct will be an important contribution
\nto the global fight against MDR-TB.
\nFor another project the WMA collaborates
\nwith the International Rehabilitation
\nCouncil for Torture Victims (IRCT) on a
\nEuropean Union sponsored project. Using
\nthe \u201cIstanbul Protocol\u201d as a manual, physi-
\ncians are trained in effective investigation
\nand documentation of torture and other
\ncruel, inhuman or degrading treatment or
\npunishment. The training seminars were
\ncompleted in five pilot countries: Morocco,
\nMexico, Uganda, Sri Lanka and Georgia.
\nWMA experts participated in coordination
\nand evaluation meetings and attended
\npreparatory missions and training semi-
\nnars. The WMA particularly fostered the
\nidentification process with national med-
\nical associations and used its special exper-
\ntise in medical ethics during seminars.
\nAlso, the collaboration with other organiza-
\ntions, local authorities and consultants has
\nbeen helpful and important in the process.
\nThe continuation of the project with a new
\nphase is projected to run over a three-year
\nperiod and will most probably start by
\nJanuary 2006. The new project will include
\na consolidation of activities in the five cur-
\nrent project countries and initiate activities
\nin five new countries. Furthermore it will
\nsupport capacity-building activities for
\nrehabilitation centres and strengthen the
\ncollaboration between centres and local
\nhuman rights organizations. The IRCT and
\nthe WMA have a formal partnership in this
\nproject with shared responsibilities. The
\ncollaboration has been extremely good.
\nRegular contact and discussions on key
\nissues helped ensuring a coordinated and
\nefficient process.
\nApplications are welcome
\nBeing involved in the work of various dif-
\nferent projects, fellows will experience the
\nentire spectrum of health care services and
\nsystems. Furthermore, regular communica-
\ntion with representatives of national med-
\nical associations, including new and future
\nWMA members, helps understanding the
\ndifferences and similarities of physician
\norganizations worldwide. Also helping to
\nprepare Council meetings and the Annual
\nGeneral Assembly is indeed rewarding. In
\nshort: Working at the WMA Secretariat is a
\nunique experience.
\nNational Medical Associations who are
\ninterested in the fellowship programme
\nmay contact the WMA Secretariat in
\nFerney-Voltaire. Interested parties may also
\ncontact previous fellows for more detailed
\ninformation.
\nPlease contact:
\nDr. Ramin Parsa-Parsi
\nPhone: 030\/ 4004 56-366
\nThe World Medical Association
\n13, ch. du Levant
\nCIB – B\u00e2timent A
\n01210 Ferney-Voltaire
\nFrance
\nPhone: +33 4 50 40 75 75
\nFax: +33 4 50 40 59 37
\ne-mail: wma@wma.net \u25a0
\nWhile currently the whole world seems to
\nworry about the prisoners in Guant\u00e1namo
\nBay those incarcerated in the other prisons
\nof Cuba seem to be forgotten. Men and
\nwomen asking for nothing but freedom,
\nwho are not involved in terrorism, war or
\noppression, are being held as prisoners of
\nconscience permanently or repeatedly,
\nsome for decades. Many of them have not
\nsurvived the special treatment by the Cuban
\ngovernment and others possibly will die.
\nWhile for many of us Cuba may be seen as
\na cheap Caribbean holiday resort, for those
\nliving there the paradise may have some
\ndark spots. For more than forty years Cuba
\nhas been under communist dictatorship.
\nWhat has been overcome in most of the for-
\nmer communist countries in Europe, terror,
\nintimidation, oppression, and prosecution
\nof those who want freedom, still lives in
\nCuba.
\nThe \u201cCuban Spring 2003\u201d stands for an
\naggressive \u201ccleaning-up\u201d campaign which
\nthe communists carried out in Cuba: As far
\nas it is known in the free world, 75 persons
\nwere sentenced to long prison terms of up
\nto 28 years. The way they are treated is sim-
\nilar for totalitarian regimes. Methods
\ninclude imprisonment far away from their
\nfamilies, placment together with violent
\ncriminals, intimidation of family members
\nand reduced allowances for visits. Left
\nwithout sufficient food some loose weight
\nrapidly, and food and medicine brought by
\nrelatives has been taken away.
\nThe World Medical Association has repeat-
\nedly remembered the fate of Cuban
\nPhysicians. They are outstanding col-
\nFrom the Secretary General\u2019s desk
\n\u201cDon\u2019t forget the others\u201d
\nWHO
\n105
\nleagues fighting for the freedom of the
\nCuban People and for the freedom of med-
\nicine in their country. What they currently
\nget is hell on earth. Six of them are known
\nto us, they and their families and friends
\ndeserve our attention as examples of all
\nthose who pay a high price in the struggle
\nfor freedom. The following information has
\nbeen compiled from various sources:
\nDr. OSCAR EL\u00cdAS BISCET, 44 years old,
\na specialist in internal medicine, is the pres-
\nident of the unofficial Lawton Human
\nRights Foundation. He has been detained
\nmore than two dozen times, charged with
\n\u2018insult to the symbols of the homeland,\u2019
\n\u2018public disorder,\u2019 and \u2018incitement to com-
\nmit an offence\u2019. Dr. Biscet has been kept in
\nspecial punishment cells for refusing to
\ncarry out disciplinary measures. Before
\nSpring 2003 when Dr. Biscet was arrested
\nlast, he had already been in prison for 3
\nyears. Now in December 2005 it adds up to
\n6 years.
\nTo discourage visits by his family he was
\ntemporarily imprisoned in Prison Kilo 8 in
\nthe province of Pinar del Rio, sharing a cell
\nwith twelve other prisoners. He has been
\nsentenced to 25 years in prison.
\nDR. MARCELO CANO RODR\u00cdGUEZ, 41
\nyears old, is National Coordinator of the
\nunofficial Cuban Independent Medical
\nAssociation, an association of medical pro-
\nfessionals around the island. For not
\nrespecting the prison rules for criminals Dr.
\nCano has not been allowed to see the sun
\nfor 10 month. Dr. Cano has been sentenced
\nto 18 years in prison.
\nDR. JOS\u00c9 LUIS GARC\u00cdA PANEQUE,
\naged 39, is a plastic surgeon and a member
\nof the Cuban Independent Medical
\nAssociation. He has worked as a journalist,
\nas director of the independent news agency
\nLibertad and member of the independent
\nJournalists\u2019 Society. Dr. Paneque\u2019s weight
\nhas dropped from 86 to 48 kg and he is
\npresently in the infirmary of \u201cLas Mangas\u201d
\nPrison in Bayamo. His health continues to
\nbe critical. His wife is currently being
\nthreatened with imminent mob attacks
\nagainst their home Dr. Paneque was sen-
\ntenced to 24 years in prison.
\nDR. LUIS MIL\u00c1N FERN\u00c1NDEZ, 36 year
\nold, is a member of the Cuban Medical
\nAssociation. In June 2001 he and his wife,
\nLisandra Lafitta, also a doctor, signed a
\ndocument called \u2018Manifiesto 2001,\u2019 calling
\namong other measures for recognition of
\nfundamental freedoms in Cuba. Together
\nwith other health professionals they carried
\nout a one-day hunger strike to call attention
\nto the medical situation of detainees and
\nother issues. Although without emotional or
\nmental problems, he is now confined with
\nmental patients in the psychiatric ward of
\nthe Prison of Boniato, in the province of
\nSantiago de Cuba. Dr. Mil\u00e1n Fern\u00e1ndez,
\nhad been sentenced to 13 years in prison.
\nALFREDO MANUEL PULIDO L\u00d3PEZ,
\naged 45, graduated in 1983 in the specialty
\nof Stomatology, and Dentistry. He practiced
\nuntil 1998, when he was fired from his job
\nfor joining the Christian Liberation
\nMovement. In 2001 he joined the unofficial
\nnews agency El Mayor in Camag\u00fcey for
\nwhich he worked as journalist. Incarcerated
\nin the Maximum Security Prison Kilo 7 his
\nhealth is rapidly deteriorating. He is not
\nonly suffering from severe migraine, but
\nhas also experienced several hypoglycemic
\nepisodes. Instead of providing treatment he
\nhas been threatened that he gets a psychi-
\natric evaluation to find out the sources of
\nhis headaches. Dr. Pulido L\u00f3pez has been
\nsentenced to 14 years in prison.
\nRICARDO ENRIQUE SILVA GUAL, 32,
\nphysician and member of the Christian
\nLiberation Movement like Dr. Pulido
\nL\u00f3pez. Dr. Siva Gual suffering from glau-
\ncoma. Dr. Silva Guall has been sentenced to
\n10 years in prison.
\nSources:
\nCoalition of Cuban-American
\nWomen\/LAIDA CARRO.
\nJoseito76@aol.com.
\nHuman rights first
\nhttp:\/\/action.humanrightsfirst.org\/cam-
\npaign\/Biscet
\nAmnesty International
\nhttp:\/\/web.amnesty.org\/library\/Index\/ENG
\nAMR250022005
\nInternationale Gesellschaft f\u00fcr
\nMenschenrechte
\nhttp:\/\/www.igfm.de
\nMedicina Cubana
\nhttp:\/\/medicinacubana.blogspot.com\/2005_
\n09_01_medicinacubana_archive.html
\nFor further information monitor our web-
\nsite: www.wma.net \u25a0
\nGeneva, Switzerland, 9 November 2005.
\n\u201cThank you for making this a remarkable
\nand productive meeting. The world has
\nbeen watching and listening as, over these
\nthree days, the scale of the challenges has
\nemerged. The international solidarity to
\nconfront these threats is clear. The urgency
\nof acting now is felt by us all. Precise rec-
\nommendations for action have emerged.
\nEqually, precise offers of help and support
\nhave been put forward, by both developing
\nand industrialized countries.
\nI will now review the central points that
\nhave come out of the meeting. Next I will
\noutline an integrated programme of action
\nwhich responds to the issues raised.
\n1. Minimizing the threat at source to both
\nanimal and human populations through
\nrapid reduction of the viral burden of
\nWHO
\nFAO\/OIE\/WB\/WHO Meeting on Avian
\nInfluenza and Human Pandemic Influenza
\nClosing remarks of Dr. LEE Jong Wook, D.G., WHO
\nWHO
\n106
\nH5N1 is essential. This entails timely
\nnotification of outbreaks in birds, poul-
\ntry culling and vaccination as indicated,
\nincluding \u201ebackyard\u201c flocks, and provi-
\nsion of appropriate compensation for
\nfarmers.
\n2. \u201cEarly warning\u201d and surveillance sys-
\ntems for animal and human influenza are
\ncritical to effective response. The current
\nwindow of opportunity to intervene is
\nmeasured in days. Transparent and
\nimmediate reporting is essential.
\n3. The introduction of avian infection with
\nH5N1 to other countries is predicted,
\nfollowing the patterns of migratory
\nbirds, and as a result of production sys-
\ntems and market practices. Other strains
\nof avian flu are also an ongoing and
\nemerging threat and must be monitored.
\nStrengthened veterinary services are a
\ncrucial aspect of detection and response.
\nOpen sharing of virus samples is essen-
\ntial. Quality assured animal vaccines
\nproduced to international standards
\nshould be used in healthy poultry when
\nappropriate.
\n4. At present many governments are not
\nready to cope with outbreaks, still less a
\npandemic. Preparedness is vital in every
\ncountry, in every Region. Integrated
\ncountry plans will build on and strength-
\nen existing systems and mechanisms.
\nThey will be comprehensive, costed, and
\nevaluated. Response mechanisms should
\nbe rehearsed through simulation exercis-
\nes. These plans will include protection of
\nvulnerable groups such as children,
\nrefugees and displaced populations.
\n5. Resources needed to slow down or con-
\ntain the emergence of a pandemic are
\ninsufficient. Supplies of antiviral drugs
\ncurrently do not meet potential demand.
\nIssues remain of equitable access to
\nmedicines and deployment of stockpiles.
\n6. A universal non-specific pandemic vac-
\ncine may be the ultimate protective solu-
\ntion for human influenza. \u201eSmart\u201c solu-
\ntions are being investigated. Issues of
\ntechnology transfer, resolution of licens-
\ning and regulatory obstacles, sustained
\nuse of good manufacturing practices and
\npre-qualification are under discussion.
\nPredictable, increased orders for season-
\nal flu vaccine will support greater manu-
\nfacturing capacity, including in develop-
\ning countries.
\n7. Communications. The recent series of
\nhigh-level meetings on avian influenza
\nand human pandemic influenza have
\nsuccessfully created a shared agenda.
\nThe public needs clear, regular, reliable
\ninformation. Civil society, nongovern-
\nmental organizations and other commu-
\nnity groups must be involved.
\n8. A rich array of resources is potentially
\navailable to support government and
\ninstitutional efforts. Countries that have
\nsuccessfully controlled outbreaks of
\navian influenza are prepared to help oth-
\ners.
\n9. Mechanisms for donor support are in
\nplace. There is broad commitment to
\nminimize transaction costs of interna-
\ntional support through alignment and
\nharmonization. International support to
\ncountry plans should supplement nation-
\nal resources, as well as existing donor
\nresources, and should target resource-
\npoor countries.
\n10.Investments are urgently needed at
\nnational level \u2013 potentially reaching 1
\nbillion dollars over the next three years.
\nAn additional 35 million dollars is need-
\ned immediately to support high priority
\nactions by technical agencies at the glob-
\nal level over the next six months.
\nThe 10 points I have outlined need detailed
\nand concrete actions. This meeting has
\nidentified a series of integrated actions
\nthat will start straight away.
\n1. Support the development of integrated
\nnational plans for avian influenza con-
\ntrol and human pandemic influenza pre-
\nparedness and response.
\n2. Assist countries in aggressive control of
\navian influenza in birds, and deepen the
\nunderstanding of the role of wild birds in
\nvirus transmission.
\n3. Nominate \u201erapid response\u201c teams of
\nexperts to support epidemiological field
\ninvestigations.
\n4. Strengthen country and regional capacity
\nin surveillance, laboratory diagnosis,
\nand alert and response systems.
\n5. Expand the network of influenza labora-
\ntories, with regional collaborative sys-
\ntems for access to reference laboratories.
\n6. Establish and integrate multi-country
\nnetworks for the control or prevention of
\nanimal trans-boundary diseases, and
\nregional support units as established in
\nthe Global Framework for the
\nProgressive Control of Trans-boundary
\nAnimal Diseases.
\n7. Expand the global antiviral stockpile,
\nand prepare standard operating practices
\nfor its rapid deployment to achieve early
\ncontainment.
\n8. Assess the needs and strengthen veteri-
\nnary infrastructure in line with OIE stan-
\ndards.
\n9. Map out a global strategy and work plan
\nfor coordinating antiviral and influenza
\nvaccine research and development, and
\nfor increasing production capacity and
\nequitable access.
\n10.Put forward proposals to the WHO
\nExecutive Board at its 117th meeting for
\nimmediate voluntary compliance with
\nrelevant articles of the International
\nHealth Regulations 2005.
\n11.Finalize detailed costing of country
\nplans and the regional and global
\nrequirements to support them, in prepa-
\nration for the January pledging meeting
\nto be hosted by the Government of
\nChina.
\n12.Finalize a coordination framework
\nbuilding on existing mechanisms at the
\ncountry level, and at the global level,
\nbuilding on international best practices.
\nThis is a challenging agenda which will
\nrequire all our best efforts.\u201d \u25a0
\nWHO
\n107
\nPublic health experts have confirmed that a
\npolio epidemic in ten countries in west and
\ncentral Africa \u2013 Benin, Burkina Faso,
\nCameroon, Central African Republic, Chad,
\nC\u00f4te d\u2019Ivoire, Ghana, Guinea, Mali and
\nTogo \u2013 has been successfully stopped. The
\nepidemic has paralysed nearly 200 children
\nfor life since mid-2003, but no new cases
\nhave been reported in these countries since
\nearly June. At the same time, polio eradica-
\ntion efforts are intensifying in Nigeria,
\nwhere extensive disease transmission con-
\ntinues, as part of a mass polio campaign
\nacross 28 African countries beginning today.
\nEmergency efforts to stop the epidemic had
\nbeen launched under the auspices of the
\nAfrican Union (AU), and largely underwrit-
\nten through US$ 135 million in emergency
\nfunding from the European Commission
\n(EC), Canada and Sweden. The ten coun-
\ntries, which had previously been polio-free,
\nparticipated in a series of mass immunisation
\ndrives across 23 countries, reaching as many
\nas 100 million children with multiple doses
\nof polio vaccine over the last 18 months.
\nSpeaking on behalf of donors, European
\nCommissioner for Development and
\nHumanitarian Aid, Mr Louis Michel, said:
\n\u201eThe reversal of these epidemics is precise-
\nly what EC development objectives are all
\nabout. Such a rapid return on development
\ninvestment is good for Africa, good for
\ndonors, and most importantly, good for the
\nchildren of Africa.\u201c
\nExperts cautioned, however, that ongoing
\ndisease transmission in remaining endemic
\nareas continues to pose a risk of more out-
\nbreaks across the region. To minimise this
\nrisk, 28 African countries \u2013 including the
\nten countries which have stopped their epi-
\ndemics \u2013 today launched the first element
\nof a \u2018maintenance\u2019 programme to sustain
\nthis progress, with an additional series of
\nsynchronized immunisation activities to
\nreach more than 100 million children with
\npolio vaccine in November and December.
\nThe \u2018maintenance\u2019 programme is part of a
\nfour-pronged strategy to protect the US$ 4
\nbillion invested globally since the 1988
\nlaunch of the Global Polio Eradication
\nInitiative. The other elements of the strate-
\ngy include: strengthening routine immuni-
\nsation at country level in close collabora-
\ntion with the Global Alliance for Vaccines
\nand Immunisation (GAVI) and through the
\nnew Global Immunisation Vision and
\nStrategy (GIVS); increasing surveillance
\nsensitivity and outbreak response capacity,
\nand increasing both the number and quality
\nof polio campaigns in the remaining
\nendemic areas, particularly in Nigeria.
\nThe Nigerian government has signalled
\nstrong commitments to further strengthen-
\ning its polio eradication programme. With
\nvirus now beaten back to the north of the
\ncountry, efforts are focusing on re-deploy-
\ning support staff to the northern states dur-
\ning the upcoming immunisation campaigns.
\nTo succeed, however, Nigeria needs the
\nongoing support of the international com-
\nmunity to ensure every child is reached
\nthroughout the country with polio vaccine.
\nKey to success is ensuring the necessary
\nfunds continue to be made available. A US$
\n200 million funding gap for 2006 must
\nurgently be filled, US$ 75 million of which
\nis needed by December, to ensure activities
\nin the first quarter of next year can proceed.
\nUnderlining the urgency of closing the
\nfunding gap, late arrival of funds may com-
\npromise the quality of the immunisation
\ncampaigns in some countries.
\nTo support Nigeria and west and central
\nAfrica in polio eradication efforts, Rotary
\nInternational is also gearing up its support
\nto the region. \u201eRotary club members from
\nacross North America, Europe and Asia are
\njoining fellow Rotarians in Africa to partic-
\nipate in the polio campaigns,\u201c commented
\nCarl-Wilhelm Stenhammar, President of
\nRotary International. \u201eAt Rotary, we are
\ncommitted to doing everything we can to
\nsupport Africa in their polio eradication
\nefforts\u201c.Rotary International and its 1.2
\nmillion volunteers worldwide have been
\nintegral to the global eradicate of polio.
\nCollectively, Rotarians have committed
\nwell over US$ 600 million to the effort, and
\ncontributed countless volunteer hours dur-
\ning immunization campaigns.
\nThe polio eradication coalition includes
\ngovernments of countries affected by polio;
\nprivate sector foundations (e.g. United
\nNations Foundation, Bill & Melinda Gates
\nFoundation); development banks (e.g. the
\nWorld Bank); donor governments (e.g.
\nAustralia, Austria, Belgium, Canada, Den-
\nmark, Finland, France, Germany, Ireland,
\nItaly, Japan, Luxembourg, Malaysia,
\nMonaco, the Netherlands, New Zealand,
\nNorway, Oman, Portugal, Qatar, the Rus-
\nsian Federation, Spain, Sweden, United
\nArab Emirates, the United Kingdom and
\nthe United States of America); the
\nEuropean Commission; humanitarian and
\nnongovernmental organizations (e.g. the
\nInternational Red Cross and Red Crescent
\nsocieties) and corporate partners (e.g.
\nSanofi Pasteur, De Beers, Wyeth).
\nVolunteers in developing countries also
\nplay a key role; 20 million have participat-
\ned in mass immunization campaigns.
\nSince 1988, global eradication efforts have
\nreduced the number of polio cases by more
\nthan 99%, from 350,000 annually to 1,469
\ncases in 2005 (as of 1 November). Six coun-
\ntries remain polio endemic (Nigeria, India,
\nPakistan, Afghanistan, Niger and Egypt),
\nhowever poliovirus continues to spread to
\npreviously polio-free countries. In total, 11
\npreviously polio-free countries have been
\nre-infected in late 2004 and 2005 (Somalia,
\nIndonesia, Yemen, Angola, Ethiopia, Chad,
\nSudan, Mali, Eritrea, Cameroon and Nepal).
\nFor more information contact:
\nSona Bari Oliver Rosenbauer
\nTelephone: +41 22 791 1476
\nTelephone: +41 22 791 383
\nEmail: baris@who.int
\nint Email: rosenbauero@who.int
\n1
\nBenin, Burkina Faso, Cameroon, Cape Verde,
\nCentralAfrican Republic, Chad, C\u00f4te d\u2019Ivoire,
\nthe Democratic Republic of the Congo,
\nDjibouti, Equatorial Guinea, Eritrea, Ethiopia,
\nGabon, Gambia, Ghana, Guinea, Guinea-
\nBissau, Kenya, Liberia, Mali, Mauritania,
\nNiger, Nigeria, Senegal, Sierra Leone,
\nSomalia, Sudan and Togo. \u25a0
\nMassive international effort stops polio epidemic
\nacross 10 West and Central African countries
\nRegional and NMA News
\n108
\nThese projects will be implemented by
\nESA with the technical assistance of WHO.
\nNowadays, the use of satellite-based Infor-
\nmation and Communications Technologies
\n(ICT) for telemedicine is progressing from
\nthe scouting phase towards a more stable and
\noperational profile, where integration into
\nexisting healthcare systems and the attain-
\nment of self-sustainability is increasingly
\nbecoming an essential condition for success.
\nIn this frame, the European Space Agency
\nin line with the recommendations of the
\nTelemedicine Working Group (ref.
\n\u2018Opportunities and Challenges of eHealth
\nand Telemedicine via Satellite\u2019, European
\nJournal of Medical Research, vol.10, 2005,
\nhttp:\/\/telecom.esa.int\/telecom\/media\/docu-
\nment\/Scientific%5FPublication%5FESA%
\n5F Telemed.041222.final.pdf) is issuing
\nthree invitations to tender to demonstrate
\nthe exploitation of Satcom in Telemedicine
\nand validate the associated sustainability
\nthrough a user driven approach.
\nThe ultimate goal of this action is to pave
\nthe way for a European Telemedicine via
\nSatellite Programme of direct benefit for
\nthe Health community and which will be
\ndeveloped in close consultation with WHO.
\nThe three invitations to tender are focused
\non the following thematic areas:
\nHealth Early Warning
\nThe activity on Health Early Warning will
\nbe aimed at the integration, deployment and
\nvalidation of a Satcom based system devot-
\ned to gathering data from the field to predict
\ncommunicable disease diffusion patterns
\nand associated risks of outbreak. The sys-
\ntem will also provide a fast and resilient
\nway to distribute, over geographical areas
\nearly warning and information to the popu-
\nlation to facilitate the establishment of ade-
\nquate protective measures to safeguard the
\npopulation\u2019s health. The system will be con-
\nceived, in particular, to face healthcare con-
\nsequences of catastrophic events.
\nInterconnectivity for Health-
\ncare Services and
\nProfessional Medical
\nEducation bridging
\nCommunities in Eastern and
\nWestern Europe
\nThe activity of Interconnectivity for
\nHealthcare Services and Professional
\nMedical Education bridging Communities
\nin Eastern and Western Europe will estab-
\nlish a pilot exploitation period and validate
\nthe associated sustainability of the devel-
\noped satellite based service supporting
\nremote medical consultation and healthcare
\nprofessional education and collaboration
\nbetween two medical systems, one in a
\nremote areas of Eastern Europe, and the
\nother in a Western European country.
\nManagement of Medical
\nEmergency for Commercial
\nAviation
\nThe activity of Management of Medical
\nEmergency for Commercial Aviation will
\nbe aimed to develop, integrate and validate
\nin an operational environment a telemedi-
\ncine service to support diagnosis from on-
\nboard civil aircrafts. The system will pro-
\nvide interactive multimedia data exchange
\nbetween aircraft and ground based medical
\ncenters to support decisions, in cases of
\nmedical emergency, on whether to go for a
\nflight diversion and which actions to take
\non board.
\nThe details of these three invitations to
\ntender are available at the following URL
\naddress: ftp:\/\/ftp.estec.esa.int\/pub\/telemedi \u25a0
\nA number of meetings in the European re-
\ngion relating to health issues are of interest
\nat both regional and international levels. In
\nan interesting development in 1994 an ini-
\ntiative supported by the Catalan government
\nand the European Union in a conference
\nsought to explore health care and healthcare
\nproblems in the Mediterranean region. Enti-
\ntled Euromed Health Forum (Euromed
\nSalud) the outcome was the Declaration of
\nBarcelona (1994) urging co-operation in the
\nhealthcare field between all the countries
\nbordering on the Mediterranean Sea, includ-
\ning those on the north coast of Africa, and at
\nthe eastern end of the Sea. In November of
\nthis year the tenth anniversary of this was
\ncelebrated with a further highly successful
\nForum in Barcelona. It explored such areas
\nas health policy development, the use of
\ntelemedicine and the regulation and licens-
\ning of healthcare physicians and other work-
\ners. A further declaration was issued ex-
\npressing the view of the Forum that these di-
\nalogues should continue and that a further
\nmeeting take place in two years time. This
\ninitiative to dialogue and explore positive
\ncollaboration represents a potentially inter-
\nesting development in collaboration in the
\nHealth sector between the northern side of
\nthe Mediterranean (mostly European Union
\ncountries), those at the eastern end, and on
\nthe north African coast.
\nFor more than 20 years there has been an an-
\nnual meeting under the title of Europe
\nBlanche under the aegis of the Institut des
\nSciences de la Sant\u00e9 (Paris), to discuss a
\nspecific major health or health professional
\nproblem. These have included such topics as
\nEurope and Medicines, Continuing medical
\neducation, The Therapeutic Revolution etc.
\nThese meeting have provided an important
\nforum at which leading figures with an in-
\nterest in health including researchers, physi-
\ncians, healthcare providers and organisers,
\neconomists, ministers and other politicians
\nTelemedicine via Satellite: An opportunity to
\ndevelop Satcom based sustainable services
\nRegional and NMA News
\nEuropean Region
\nRegional and NMA News
\n109
\nand other relevant persons in society have
\nbeen able to meet and discuss issues during a
\ntwo day meeting. The enlargement of the
\nEuropean Community to 25 has introduced
\nnew considerations into the discussions.
\nThis year the meeting was held in the Bu-
\ndapest, capital of one of the new members of
\nthe EU, the topic for discussion was \u201cLiving
\nLonger but Healthier Lives\u201d exploring how
\nto achieve health gains in the Elderly of the
\nEuropean Union. At these meetings the Se-
\nnior and Junior Europe and Medicine Prizes
\nare awarded.
\nFinally, at a meeting organised by WMAand
\nthe Caring Physicians of the World Net-
\nwork, leaders of national medical associa-
\ntions in the European Region of the World
\nMedical Association met in Prague in No-
\nvember to discuss two major issues. Presen-
\ntations were given by WHO and other ex-
\nperts on the two topics of discussion. The
\nfirst was on the \u201cSkills Drain\u201d among physi-
\ncians and what actions NMAs can take. The
\nsecond topic was Human Avian Influenza
\nwhen the meeting considered what actions
\ncan be done by NMAs in collaboration with
\nother institutions to prepare for a potential
\npandemic. The presentations and discus-
\nsions were both lively and productive. \u25a0
\nUnder the aegis of the Caring Physicians of
\nthe World Initiative, members of the General
\nAssembly of CONFERMEL met with repre-
\nsentatives of WMA to discuss issues of im-
\nportance to the medical profession, Health
\nPolicy and reform of the Health Sector, the
\nnew role of physicians in society and how
\nNMAs can meet the emerging needs of their
\nmembers at a meeting held on 10th October
\nprior to the WMA Assembly. A manifesto
\nwas issued in the name of the 12 countries
\npresent, Argentina, Bolivia, Brasil, Costa
\nRica Ecuador, Honduras, Mexico, Nicaragua,
\nPanama, Peru, Venezuela and Uruguay. It re-
\nferred to the difficult situation in these coun-
\ntries such as poverty and unfairness which
\ncontinue, despite some advances in growth
\nindices. In particular reference was made to
\nthe consequent nutritional deficiencies, lack
\nof sanitation ,drinking water and the high
\nprevalence of malaria, dengue AIDS and tu-
\nberculosis. Concern was expressed that the
\nprocesses of reform and modernisation of the
\nhealth sector in these countries promoted pri-
\nvatisation of the public sector, deepening the
\ninequities without substantial improvement
\nin the quality of life and excluding large seg-
\nments of the population from health care.
\nPointing out that reform and modernisation
\nof the Health sector needs the participation
\nof representative organisations of health
\nprofessionals attention was drawn to the
\n\u201cThe 2nd KEMAT team arrived in Abbot-
\ntabad in the morning of October 22 and
\ntook over all the tasks frorn the 1 team
\nwithout any reservatinn. As many yo physi-
\ncians have joined the 2nd team, mostly
\ncomposed by staff of Asian Medical Center
\nin Seoul, the camp was full of energy and
\nvibrancy. Lawrnaker Mr. Seok Hyun Lee,
\nthe Chairperson of Health and Welfare
\nCommittee of Korean National Assembly,
\nalso joined this team and supported all the
\ncommitment and hard work of all the Kore-
\nan medical teams and rescue teams dis-
\npatched to the quake-hit-areas taking a
\nfield assessment from Abbottabad via Bal-
\nakot to Muzaffarabad. Over ten Korean
\nNGO`s are taking part in voluntary medical
\nwork in Patika, Balakot, Muzaffarabad,
\nBatagram and Abbottabad.
\nCases of scabies are continuously on the
\nrise and many people, especially children,
\nare still in need of long-term medical atten-
\ntion after being amputated. Dr. Irfan Khat-
\ntak, general surgeon of Ayub Medical Com-
\nplex and coordinator of voluntary medical
\nwork said that they need medical equip-
\nment such as DERMATOSE or MESHER
\nto take care of these patients. Drugs for
\nanesthesia are also needed. Moreover, men-
\ntal shocks they are going through also
\nshould be brought under delicate treatment.
\nOperation Rooms of Ayub Medical Com-
\nplex, once shut down of additional collapse
\nare now functioning little by little. The 2nd
\nKEMAT conduction five major surgeries
\nincluding skin graft for open fractures, K-
\nWire Reconstruction Operation and
\nPROSTALAC at operation rooms in coop-
\neration of Pakistani doctors.
\nIn Balakot mobile clinic, considerable
\nnumbers of patients are suffering from diar-
\nrhea and de-hydration. Scabies is a major
\nconcern here, too. The 2nd team has treated
\ntotal 2,810 patients (2,485 at Ayuh Medical
\nCenter, and 325 in Balakot mobile clinic).
\nLatin America and the Caribbean lack of priority given by governments in re-
\nsource allocation to the health care systems
\nwhich among others affects quality of care
\nand the rights of physicians and other
\nhealth personnel. The manifesto denounced
\nthe indiscriminate creation of medical
\nschools without social necessity, and the
\ncreation of non-medical careers permitting
\nthe illegal practice of medicine.
\nExpressing concern about inequitable com-
\nmercial agreements relating to intellectual
\nproperty and pharmaceuticals which limit ac-
\ncess of citizens to drugs, and disregarding
\nWTO agreements, the manifesto ends by reit-
\nerating the professional organisations’ commit-
\nment to the supervision of the quality of med-
\nical care and the autoregulation of the profes-
\nsion through obligatory membership of a col-
\nlege in accordance with national legislation. \u25a0
\nKorean Medical Association
\nActivity Report of the KMA Medical Team in to quake-affected
\nareas in Pakistan
\n(Extract from this interesting report. Ed.)
\nLetters
\n110
\nReplacing the tasks of the 2nd team, the 3rd
\nKEMAT team, composed of six doctors,
\nfive nurses, one pharmacist, one policeman
\nand two administrative staff, arrived in Ab-
\nbottabad on October 29. The 3rd team spe-
\ncially is composed by the staff of National
\nPolice Hospital.
\nDue to the huge difference of temperatures
\nbetween day and night, the number of pa-
\ntients coming down with the ART (Acute
\nRespiratory Infections) continues to inerease.
\nAt Ayub Medical Complex, quake-related
\nemergency patients have decreased promi-
\nnently, compared to the situation of two
\nweeks ago and more and more patients with
\nchronic diseases come to see a doctor and
\nwant to get medicines for their diseases.
\nHowever patients in need of minor surgery
\ndressing, cast and suturing still an average
\n70\u201380 people a day.
\nMore equipment and efforts are necessary
\nto be put prevention of epidemics. Al-
\nthough KEMAT is carrying out some pre-
\nvention steps using a smoke disinfector,
\nmore organized projects should be urgently
\narranged and carried out.
\nIn Balakot mobile clinic, cases of diarrhea
\nskin diseases like scabies, and ARI are still
\ntopping the list and many patients needing
\nto get their dressing renewed, or need to get
\ncare after ampulation keep visiting the mo-
\nbile clinic.
\nThe 3rd team has treated 3,395 patients all to-
\ngether (2,353 at Ayub Medical Complex and
\n1,040 at mobile clinic in Balakot), making
\nthe total number of patients through the ac-
\ntivities of KEMAT is 7,505 approximately.
\nEnding its voluntary medical works, the
\nKEMAT donated medicines (anti-scabies
\ndrugs, antibiotics, fluids, etc.) and medical
\nsupplies left from their activities to the
\nAyub Medical Complex and some medi-
\ncines to the Good Samaritan Hospital run
\nby Korean missionaries in Pakistan.
\nContact info of Korean Medical Associa-
\ntion Medical Team (KEMAT; KMA Emer-
\ngency Medical Assistance Team):
\nMs Yoonsun Park, Chief of Strategie Plan-
\nning Team, KMA:
\n+822 794 2474 (ext. 120) (oftice) \/ +82 11
\n792 6908 (mobile phone) \u25a0
\nSir,
\nFirst let me introduce myself: I am a
\nPaediatric Surgeon, former Head of the
\nDepartment of Surgery of the main
\nLisboa\u2019s Children\u2019s Hospital and also a for-
\nmer President of the WMA (more than 20
\nyears ago \u2013 1981\/1983).
\nSecondly I would like to congratulate you
\nand your co-workers for the excellent qual-
\nity of the \u201cWorld Medical Journal\u201d, which I
\nread always with great interest.
\nFinally I have to make a short comment on
\nyour article \u201cSaving the lives of Siamese
\nTwins\u201d [WMJ 51(2) 30-31, 2005].
\nMy experience started in 1978 and stems
\nfrom 7, fully and personally operated pairs,
\nwith 9 survivors and 5 deaths (in one pair
\none child was already dead on arrival,
\nanother died of \u201cmalignant hyperthermia\u201d
\nafter separation had already been per-
\nformed, and the remaining one patient
\ndying 1 month post-operatively, with peri-
\ntonitis due to a leak in an intestinal anasto-
\nmoses). Lisboa and its Hospital D.
\nEstefania, are not as fashionable and well-
\nknown worldwide, as the Hospital for Sick
\nChildren, (GOS), in London\u2026!
\nMy longest operation, with \u201ctotal\u201d recon-
\nstruction of omphaloischiopagus twins
\n(boys, of which one had to remain a girl,
\ndue to only one existing penis) took 13.30
\nhours, because, taking into account the
\ntraining I received in England (GOS and
\nAlder Hey), I was able to conduct the whole
\noperation, in both twins, from \u201ctop to bot-
\ntom\u201d (and not having, at my side, several
\nsub-specialist, working in succession, in the
\nAmerican Style). Also skin expanders
\nproved unnecessary, after adequate iliac
\nosteotomies.
\nThe 7 survivors lead totally normal lives,
\nand the 2 latest ones have only minor prob-
\nlems and lead also, practically, normal
\nlives. The liver is usually the least problem,
\nwith no significant haemorrhagic danger, as
\nnormally a reasonable noticeable demarca-
\ntion exists between the 2 individual seg-
\nments. The most difficult problem, for a
\ngood functional and aesthetic outcome, is
\nassociated with the urinary tract, followed
\nby the intestines. Osteotomies in the iliac
\nbones usually do away with the need to use
\npreviously insert skin expanders.
\nIn my opinion liver transplantation is not a
\nprimary factor in the treatment of Siamese
\ntwins, and its progress, no matter how
\ndesirable it certainly is, will not benefit
\nthese children (at least directly). Good
\nanaesthesia and intensive care (including
\nnurses), are the real issues, apart from
\nsurgery itself. No matter how well a sur-
\ngeon works, if anaesthesia and intensive
\ncare are not also as good, the result may be
\ndisastrous. In fact, the only really inopera-
\nble Siamese twins are those with a \u201ccom-
\nmon heart\u201d, and in which, the existing heart
\nand major vessels, cannot be useful for any
\nof them (so malformed they are\u2026).
\nAs Horsley once said, \u201cA beautiful opera-
\ntion that ends with the death of the patient
\nis not satisfactory surgery\u201d.
\nFinally I believe it is completely wrong and
\na real pity, to abort Siamese twins, found at
\nroutine echographies (as well as some
\napparently major malformations), as mod-
\nern Paediatric Surgery is able to correct
\nthem (allowing those human beings, to lead
\nnormal, useful and happy lives). That
\nshould, I feel, be the main message to pro-
\nmote!
\nUnfortunately abortion is what we find in
\nthe \u201cso-called\u201d developed countries. Most
\noperated Siamese twins come from devel-
\noping countries, where echography is not
\ncurrently available and the diagnosis is
\nmade only after birth!
\nYours sincerely
\nProf. Dr. Antonio Gentil Martins
\nRua de Campolide 166-G
\nLisbon 1070-096 PORTUGAL
\nEmail: agentilmartins@netcabo.pt \u25a0
\nLetters to the Editor
\nSaving the Lives of Siamese Twins
\nReview
\n111
\nSir,
\nWith regards to your article about \u2018Spray-
\non Skin Grafts\u2019. I think this technique and
\nother similar techniques involving the cul-
\nture of skin stem cells still has a long way
\nto go before they can be used for burns
\ninvolving the full thickness of the skin. I am
\nnot familiar with the technology used at
\nEast Grinstead but I suspect it may have
\nbeen rather over hyped. Just this week there
\nhas been an article in the Lancet from a
\nFrench group using foetal skin cells which
\ngrow rapidly and are incorporated into a
\ncollagen matrix which have been used suc-
\ncessfully in a small number of patients but
\nit is really a biological dressing which is
\nreplaced by host tissue. The use of cultured
\nskin cells obviously is attractive particular-
\nly now that the stem cells of the skin can
\nnow be identified and grown quite rapidly
\nbut this still provided a very thin layer
\nwhich would not be adequate to replace a
\nfull thickness burn following excision of
\nthe scar.
\nHowever, this is an important area of devel-
\nopment and many groups around the world
\nare working on the culture of cells of the skin
\nand particularly the stem cells of the epider-
\nmis and without question in due course suc-
\ncessful clinical applications will be devel-
\noped that would allow permanent replace-
\nment without scarring. This then would be
\nperhaps suitable in reconstruction of the face.
\nYours sincerely
\nSir Peter Morris AC FRS FRCS
\nHead, Centre for Evidence in Transplan-
\ntation,
\nEmeritus Professor, University of Oxford,
\nHonorary Professor, University of London
\nThe Royal College of Surgeons of England
\n35-43 Lincoln\u2019s Inn Fields,
\nLondon WC2A 3PE
\nwww.rcseng.ac.uk \u25a0
\nEthics of Research and Treatment in
\nDeveloping Countries
\nFran\u00e7ois and Emmanuel Hirsch, editors
\nCollection Espace \u00e9thique
\nParis, Librairie Vuibert, 2005
\n14.50 Euro
\nISBN 2 7117 7278 0
\nWhen the World Medical Association
\nundertook the latest revision of the
\nDeclaration of Helsinki in 1997, it encoun-
\ntered issues in the application of ethics to
\nmedical research in developing countries
\nthat had not arisen previously. The most
\ncontroversial articles in the 2000 version of
\nthe Declaration are precisely those that
\naddress these issues, namely, paragraph 29
\nthat deals with the comparator to be used in
\na clinical trial, and paragraphs 19 and 30
\nthat specify the obligations of researchers
\nand research sponsors to those who serve as
\nresearch subjects.
\nThese same issues have been considered in
\nother international statements on research
\nethics such as the 2001 National Bioethics
\nAdvisory Commission (U.S.A.) report,
\nEthical and Policy Issues in International
\nResearch: Clinical Trials in Developing
\nCountries, the 2002 Council for International
\nOrganizations of Medical Sciences (CIOMS)
\nInternational Ethical Guidelines for
\nBiomedical Research Involving Human
\nSubjects, the 2002 Nuffield Council (U.K.)
\nreport, The Ethics of Research Related to
\nHealthcare in Developing Countries and its
\n2005 follow-up discussion paper with the
\nsame title, and the 2003 European Group on
\nEthics in Science and New Technologies
\nOpinion #17 on the Ethical Aspects of
\nClinical Research in Developing Countries.
\nAs the 2005 Nuffield Council discussion
\npaper explains, these documents do not agree
\non many of the key issues in research in
\ndeveloping countries.
\nIn October 2002, a conference was held in
\nParis to discuss these issues with particular
\nreference to the francophone countries of
\nAfrica. The proceedings of this conference
\nare the subject of this review. Many of the
\ncontributors areAfrican and they do not hes-
\nitate to criticise the dominant \u2018Western\u2019 par-
\nadigm of medical research as it is applied in
\ntheir countries.
\nTwo sets of essays set out the context for
\nthe presentations that follow. The first deals
\nwith the principles of human rights and
\nmedical research, and the second describes
\nthe methodology of clinical trials and relat-
\ned ethical issues.
\nThe major part of the book consists of
\nseven substantial essays on African
\napproaches to biomedical research, each of
\nwhich points out shortcomings in the appli-
\ncation of \u2018Western\u2019 research methodology
\nin Africa. According to Godfrey B. Tangwa,
\nthis methodology is based on a worldview
\nthat is quite alien to Africans, for whom
\n\u201cmetaphysical concepts, ethics, customs,
\nlaws and taboos form a unique ensem-
\nble\u2026\u201d (p. 57). Whereas Western approach-
\nes display an excess of epistemological
\nconfidence, bordering on arrogance and
\noften resulting in imprudence, \u201cthe princi-
\npal value underlying African worldvisions
\nand concepts is its epistemological humility
\nand respectful prudence\u2026\u201d (p. 60). Certain
\nAdvancing Surgical Standards \u2013 Stem Cells
\nReview
\n\u00c9thique de la recherch\u00e9 et des soins dans les pays en d\u00e9veloppement
\nReview
\n112
\nethical principles of great importance in
\nWestern society, such as the confidentiality
\nof personal information, must be applied
\ndifferently in Africa where the family and
\nthe community, not the autonomous indi-
\nvidual, are the fundamental social units.
\nThe widespread suspicion of Western
\nresearchers and the revelations of racist
\nmedical research in apartheid-era South
\nAfrica, have provided fertile ground for the
\nspread of conspiracy theories regarding the
\norigin and treatment of diseases such as
\nHIV\/AIDS. The rationing of medical treat-
\nment by ability to pay rather than by need is
\ncontrary to the African view of healthcare
\nas a service, not a commodity. To illustrate
\nthe Western attitude to Africa, Tangwa pro-
\nvides a case study of a medical researcher
\nin Cameroon who developed a promising
\napproach to a vaccine for HIV but was
\nunable to get funding from any of the
\nWestern research agencies because it did
\nnot fit their paradigm of medical research.
\nAn important concept in both medical
\nresearch and medical treatment is \u2018quality\u2019.
\nIn his article, Jean-Godefroy Bidima raises
\nmany questions regarding how this concept
\napplies in Africa \u2013 quality of what, quality
\nfor whom, and how should it be measured
\n(pp. 80-83). He goes on to discuss why the
\nWestern concept of informed consent is
\ninapplicable in much of Africa: \u201cIn certain
\nAfrican cultures one does not express a
\nrefusal to someone in authority. One
\nexpresses a refusal by not carrying out an
\norder that has been given, but formally one
\nagrees in order that the authority does not
\nlose face. The caregiver is an authority, and
\nwhen a sick African gives consent, what
\ndoes that signify? An agreement or simple
\npoliteness?\u201d (p. 85)
\nThe African understanding of clinical trials
\n(\u2018essais th\u00e9rapeutiques\u2019) is explored by
\nAss\u00e9tou Isma\u00ebla Derme in relation to pro-
\nposed treatments for malaria. As with other
\nailments, malaria is considered to be not
\njust a physical affliction but a result of
\nupsetting the relationships of natural and
\nsupernatural forces. Healing therefore
\nrequires spiritual as well as physical mea-
\nsures. Research on the prevention and treat-
\nment of malaria is complicated by the mul-
\ntiple local terms used for the different phas-
\nes of this illness. Researchers must take all
\nthese factors into account when undertak-
\ning projects in Africa.
\nIn the Ivory Coast, according to Lazare
\nMarcelin Poame, the concept of free and
\ninformed consent to medical research or
\ntreatment is largely unknown. Physicians
\nare the experts and the patient is expected,
\nand expects, to follow their orders.
\nMoreover, busy physicians simply do not
\nhave the time required to present all their
\npatients with the information necessary for
\ninformed consent. Where consent is sought,
\nit is usually from the family rather than the
\nindividual patient. Despite all these obsta-
\ncles, Poame believes that the practice of
\ninformed consent is achievable in the Ivory
\nCoast and offers concrete suggestions for
\nmoving in this direction.
\nA French social scientist, Christophe
\nPerrey, reports on a research project on
\ninformed consent conducted in the Ivory
\nCoast in which 57 women were interviewed
\nabout their understanding of clinical trials,
\nincluding the meaning of placebo. Despite
\nexplanations, it turned out that none of the
\nwomen could explain what a placebo is and
\nthey all were convinced that they had
\nreceived the experimental drug. Other chal-
\nlenges to informed consent were different
\nunderstandings and terminology for the
\nsymptoms and causes of diseases, the diffi-
\nculty of getting spousal consent for a
\nwoman\u2019s participation in the trial, and
\nrumours about toxicity of the proposed
\nintervention. If the principle of informed
\nconsent is to be implemented in such set-
\ntings, much more work is needed on its
\npedagogy.
\nIn May 2002 the French National Agency
\nfor AIDS Research published a Charter of
\nEthics for Research in Developing
\nCountries that addresses many of the issues
\nraised at this conference. In presenting the
\nCharter, Brigitte Bazin noted some of the
\ndifficulties in its implementation, including
\nthe absence of ethics regulations and com-
\nmittees in many developing countries, the
\nlack of resources for those ethics commit-
\ntees that do exist, and the inability of non-
\nprofit agencies to provide continuing care
\nto participants in research as required by the
\nDeclaration of Helsinki.
\nIn the final contribution from Africa,
\nPatrice Emmanuel Mbo Abenoyap provides
\na perspective on these issues from African
\ntheology. Africans live simultaneously in
\ntwo worlds: the visible one of humans and
\nfinite creatures and the invisible one of
\nenergies and powers. In the former, individ-
\nuals are subordinate to the community; in
\nthe latter, they are subordinate to supernat-
\nural forces. Both relationships challenge the
\nWestern concept of individual autonomy
\nand the related principle of informed con-
\nsent. Moreover, the fact that one\u2019s family is
\noften the only source of funds for one\u2019s
\nmedical treatment entails that the family
\nhas a legitimate role to play in the consent
\nprocess.
\nTo complete the list of issues that need to be
\nconsidered in relation to the ethics of
\nresearch in developing countries, the edi-
\ntors included as an annex a summary of dis-
\ncussions that took place in Paris in January
\n2001 and that presumably inspired the con-
\nference that led to this book. The additional
\nissues mentioned include the following: the
\nright to health, global disparities, lack of
\ndemocracy in some developing countries,
\nthe needs of migrants, corruption (a two-
\nway process, involving corrupters as well
\nas corruptees), taboos, and learning from
\ndeveloping countries.
\nNone of the issues, problems and chal-
\nlenges raised in this book admits of easy
\nanswers. However, they must first be recog-
\nnized, and the authors have provided a
\nvaluable service in pointing out both theo-
\nretical and practical difficulties in the appli-
\ncation of international standards of research
\nethics in developing countries. The sugges-
\ntions they make for improving the situation
\nare worthy of further consideration, but as
\nthe authors would be the first to admit,
\nmuch more needs to be done. All those
\nresponsible for international research ethics
\nshould follow the example of the editors of
\nthis book in seeking meaningful involve-
\nment of developing country representatives
\nin both the review of policies and in the
\ndesign and implementation of research
\nstudies.
\nJohn R. Williams, Ph.D.
\nDirector of Ethics
\nWorld Medical Association \u25a0
\nCHINA E
\nChinese Medical Association
\n42 Dongsi Xidajie
\nBeijing 100710
\nTel: (86-10) 6524 9989
\nFax: (86-10) 6512 3754
\nE-mail: suyumu@cma.org.cn
\nWebsite: www.chinamed.com.cn
\nCOLOMBIA S
\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 F
\nOrdre des M\u00e9decins du Zaire
\nB.P. 4922
\nKinshasa \u2013 Gombe
\nTel: (242-12) 24589\/
\nFax (Pr\u00e9sidente): (242) 8846574
\nCOSTA RICA S
\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 E
\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 E
\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
\nCUBA S
\nColegio M\u00e9dico Cubano Libre
\nP.O. Box 141016
\n717 Ponce de Leon Boulevard
\nCoral Gables, FL 33114-1016
\nUnited States
\nTel: (1-305) 446 9902\/445 1429
\nFax: (1-305) 4459310
\nDENMARK E
\nDanish Medical Association
\n9 Trondhjemsgade
\n2100 Copenhagen 0
\nTel: (45) 35 44 -82 29\/Fax:-8505
\nE-mail: er@dadl.dk
\nWebsite: www.laegeforeningen.dk
\nDOMINICAN REPUBLIC S
\nAsociaci\u00f3n M\u00e9dica Dominicana
\nCalle Paseo de los Medicos
\nEsquina Modesto Diaz Zona
\nUniversitaria
\nSanto Domingo
\nTel: (1809) 533-4602\/533-4686\/
\n533-8700
\nFax: (1809) 535 7337
\nE-mail: asoc.medica@codetel.net.do
\nECUADOR S
\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: fdmedec@andinanet.net
\nEGYPT E
\nEgyptian Medical Association
\n\u201eDar El Hekmah\u201c
\n42, Kasr El-Eini Street
\nCairo
\nTel: (20-2) 3543406
\nEL SALVADOR, C.A S
\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
\nmarnuca@hotmail.com
\nESTONIA E
\nEstonian Medical Association (EsMA)
\nPepleri 32
\n51010 Tartu
\nTel\/Fax (372) 7420429
\nE-mail: eal@arstideliit.ee
\nWebsite: www.arstideliit.ee
\nETHIOPIA E
\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 E
\nFiji Medical Association
\n2nd Fl. Narsey\u2019s Bldg, Renwick Road
\nG.P.O. Box 1116
\nSuva
\nTel: (679) 315388
\nFax: (679) 387671
\nE-mail: fijimedassoc@connect.com.fj
\nFINLAND E
\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 F
\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 E
\nGeorgian Medical Association
\n7 Asatiani Street
\n380077 Tbilisi
\nTel: (995 32) 398686 \/ Fax: -398083
\nE-mail: Gma@posta.ge
\nGERMANY E
\nBundes\u00e4rztekammer
\n(German Medical Association)
\nHerbert-Lewin-Platz 1
\n10623 Berlin
\nTel: (49-30) 400-456 363\/Fax: -384
\nE-mail: renate.vonhoff-winter@baek.de
\nWebsite: www.bundesaerztekammer.de
\nGHANA E
\nGhana Medical Association
\nP.O. Box 1596
\nAccra
\nTel: (233-21) 670-510\/Fax: -511
\nE-mail: gma@ghana.com
\nHAITI, W.I. F
\nAssociation M\u00e9dicale Haitienne
\n1\u00e8re
\nAv. du Travail #33 \u2013 Bois Verna
\nPort-au-Prince
\nTel: (509) 245-2060
\nFax: (509) 245-6323
\nE-mail: amh@amhhaiti.net
\nWebsite: www.amhhaiti.net
\nHONG KONG E
\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 E
\nAssociation of Hungarian Medical
\nSocieties (MOTESZ)
\nN\u00e1dor u. 36
\n1443 Budapest, PO.Box 145
\nTel: (36-1) 312 3807 \u2013 311 6687
\nFax: (36-1) 383-7918
\nE-mail: motesz@motesz.hu
\nWebsite: www.motesz.hu
\nICELAND E
\nIcelandic Medical Association
\nHlidasmari 8
\n200 K\u00f3pavogur
\nTel: (354) 8640478
\nFax: (354) 5644106
\nE-mail: icemed@icemed.is
\nINDIA E
\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 E
\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 E
\nIrish Medical Organisation
\n10 Fitzwilliam Place
\nDublin 2
\nTel: (353-1) 676-7273
\nFax: (353-1) 6612758\/6682168
\nWebsite: www.imo.ie
\nISRAEL E
\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 E
\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 F
\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 E
\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 E
\nKuwait Medical Association
\nP.O. Box 1202
\nSafat 13013
\nTel: (965) 5333278, 5317971
\nFax: (965) 5333276
\nE-mail: aks.shatti@kma.org.kw
\nLATVIA E
\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 E
\nLiechtensteinischer \u00c4rztekammer
\nPostfach 52
\n9490 Vaduz
\nTel: (423) 231-1690
\nFax: (423) 231-1691
\nE-mail: office@aerztekammer.li
\nWebsite: www.aerzte-net.li
\nLITHUANIA E
\nLithuanian Medical Association
\nLiubarto Str. 2
\n2004 Vilnius
\nTel\/Fax: (370-5) 2731400
\nE-mail: lgs@takas.lt
\nLUXEMBOURG F
\nAssociation des M\u00e9decins et
\nM\u00e9decins Dentistes du Grand-
\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
\nAssociation and address\/Officers
\nii
\nAssociation and address\/Officers
\niii
\nMACEDONIA E
\nMacedonian Medical Association
\nDame Gruev St. 3
\nP.O. Box 174
\n91000 Skopje
\nTel\/Fax: (389-91) 232577
\nMALAYSIA E
\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 E
\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 S
\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 E
\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 E
\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: www.knmg.nl
\nNEW ZEALAND E
\nNew Zealand Medical Association
\nP.O. Box 156
\nWellington 1
\nTel: (64-4) 472-4741
\nFax: (64-4) 471 0838
\nE-mail: nzma@nzma.org.nz
\nWebsite: www.nzma.org.nz
\nNIGERIA E
\nNigerian Medical Association
\n74, Adeniyi Jones Avenue Ikeja
\nP.O. Box 1108, Marina
\nLagos
\nTel: (234-1) 480 1569,
\nFax: (234-1) 493 6854
\nE-mail: info@nigeriannma.org
\nWebsite: www.nigeriannma.org
\nNORWAY E
\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 S
\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 S
\nColegio M\u00e9dico del Per\u00fa
\nMalec\u00f3n Armend\u00e1riz N\u00b0 791
\nMiraflores, Lima
\nTel: (51-1) 241 75 72
\nFax: (51-1) 242 3917
\nE-mail: decano@colmedi.org.pe
\nWebsite: www.colmed.org.pe
\nPHILIPPINES E
\nPhilippine Medical Association
\nPMA Bldg, North Avenue
\nQuezon City
\nTel: (63-2) 929-63 66\/Fax: -6951
\nE-mail: pmasec1@edsamail.com.ph
\nPOLAND E
\nPolish Medical Association
\nAl. Ujazdowskie 24, 00-478 Warszawa
\nTel\/Fax: (48-22) 628 86 99
\nPORTUGAL E
\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@omsul.com
\nWebsite: www.ordemdosmedicos.pt
\nROMANIA F
\nRomanian Medical Association
\nStr. Ionel Perlea, nr 10
\nSect. 1, Bucarest, cod 70754
\nTel: (40-1) 6141071
\nFax: (40-1) 3121357
\nE-mail: AMR@itcnet.ro
\nWebsite: www.cdi.pub.ro\/CDI\/
\nParteneri\/AMR_main.htm
\nRUSSIA E
\nRussian Medical Society
\nUdaltsova Street 85
\n121099 Moscow
\nTel: (7-095)932-83-02
\nE-mail: rusmed@rusmed.rmt.ru
\ninfo@russmed.com
\nSINGAPORE E
\nSingapore Medical Association
\nAlumni Medical Centre, Level 2
\n2 College Road, 169850 Singapore
\nTel: (65) 6223 1264
\nFax: (65) 6224 7827
\nE-Mail: sma@sma.org.sg
\nSLOVAK REPUBLIC E
\nSlovak Medical Association
\nLegionarska 4
\n81322 Bratislava
\nTel: (421-2) 554 24 015
\nFax: (421-2) 554 223 63
\nE-mail: secretarysma@ba.telecom.sk
\nSLOVENIA E
\nSlovenian Medical Association
\nKomenskega 4, 61001 Ljubljana
\nTel: (386-61) 323 469
\nFax: (386-61) 301 955
\nSOUTH AFRICA E
\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 S
\nConsejo General de Colegios M\u00e9dicos
\nPlaza de las Cortes 11, Madrid 28014
\nTel: (34-91) 431 7780
\nFax: (34-91) 431 9620
\nE-mail: internacional1@cgcom.es
\nSWEDEN E
\nSwedish Medical Association
\n(Villagatan 5)
\nP.O. Box 5610, SE – 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 F
\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
\nTAIWAN E
\nTaiwan Medical Association
\n9F No 29 Sec1
\nAn-Ho Road
\nTaipei
\nDeputy Secretary General
\nTel: (886-2) 2752-7286
\nFax: (886-2) 2771-8392
\nE-mail: intl@med-assn.org.tw
\nTHAILAND E
\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 F
\nConseil National de l\u2019Ordre
\ndes M\u00e9decins de Tunisie
\n16, rue de Touraine
\n1082 Tunis Cit\u00e9 Jardins
\nTel: (216-71) 792 736\/799 041
\nFax: (216-71) 788 729
\nE-mail: ordremed.na@planet.tn
\nTURKEY E
\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 E
\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 E
\nBritish Medical Association
\nBMA House, Tavistock Square
\nLondon WC1H 9JP
\nTel: (44-207) 387-4499
\nFax: (44- 207) 383-6710
\nE-mail: vivn@bma.org.uk
\nWebsite: www.bma.org.uk
\nUNITED STATES OF AMERICA E
\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 S
\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 F
\nAssociazione Medica del Vaticano
\nStato della Citta del Vaticano 00120
\nTel: (39-06) 6983552
\nFax: (39-06) 69885364
\nE-mail: servizi.sanitari@scv.va
\nVENEZUELA S
\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
\nE-mail: info@saludgmv.org
\nVIETNAM E
\nVietnam General Association
\nof Medicine and Pharmacy (VGAMP)
\n68A Ba Trieu-Street
\nHoau Kiem district
\nHanoi
\nTel: (84) 4 943 9323
\nFax: (84) 4 943 9323
\nZIMBABWE E
\nZimbabwe Medical Association
\nP.O. Box 3671
\nHarare
\nTel: (263-4) 791\/553
\nFax: (263-4) 791561
\nE-mail: zima@healthnet.zw<\/p>\n"},"caption":{"rendered":"

wmj8 WorldMedical Journal Vol. No.4,December200551 OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC. G 20438 wma Santiago General Assembly \u2013 Reports Contents Editorial 2005 \u2013 a Lesson: \u201cHumanity\u2019s need for Care\u201d 85 Medical Ethics and Human Rights Sponsorship Guidelines 86 Enhancing the WMA Declarations on Human Rights 86 Medical Science, Professional Practice and Education Health […]<\/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\/wmj8.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3540"}],"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=3540"}]}}