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WorldMedical Journal
\nVol. No.1,March200652
\nOFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
\nG 20438
\nContents
\nEditorial
\nEvolution of Health Professions 1
\nEuropean Developments presage Worldwide
\nActivities 2
\nMedical Ethics and Human Rights
\nAvian influenza 3
\n\u201cCaring Physicians of the World\u201d 5
\nMedical management of hunger-strikers 5
\nThe Right to Health 6
\nMedical Science, Professional Practice
\nand Education
\nHuman Genetics and Biomedical Research 7
\nHealth Care Policy Reform \u2013 the UK National
\nHealth Service 7
\nCollaboration with the Global Health Initiative
\nof the World Economic Forum: Initiatives launched
\nto address training and education needs in TB
\nburdened countries 9
\nWMA
\nWMA General Assembly, Santiago Presidential
\nValedictory Address, Yank D. Coble 11
\nStatement on reducing the global Impact
\nof Alcohol on Health and Society 14
\nFrom the Secretary General\u2019s desk
\nWorking together for health \u2013 Human Resources
\nfor Health World Health Day 2006 16
\nWHO
\nCounterfeit medicines: the silent epidemic 17
\nCountries representing three-quarters of the
\nworld\u2019s population meet in Geneva to plan
\nthe effective implementation of the tobacco
\ncontrol treaty 18
\nWHO welcomes United Kingdom, Gates Foundation
\nfunding for global action to stop TB 19
\nWorld Cancer Day, February 2006 20
\nMedical costs push millions of people into poverty
\nacross the globe 20
\nFoundation for Innovative New Diagnostics
\nand WHO collaborate to improve diagnosis of
\nsleeping sickness 21
\nMeasles cases and deaths fall by 60% in Africa
\nsince 1999 22
\nChernobyl: the true scale of the accident 23
\nRegional and NMA News
\nIMA launches rural health plan 28
\nPhysicians speak out on prisoner forced feeding 28
\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: Karolinska Hospital, Stockholm, Sweden: photos by Veijo Mehtonen.
\nEditorial
\n1
\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
\nAshleigh Road
\nHorsham
\nWest Sussex RH12 2AQ
\nUK
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2
\nD-50859 K\u00f6ln
\nGermany
\nBusiness Managers
\nJ. F\u00fchrer, D. Weber
\n50859 K\u00f6ln
\nDieselstra\u00dfe 2
\nGermany
\nPublisher
\nTHE WORLD MEDICAL
\nASSOCIATION, INC.
\nBP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
\nDeutscher \u00c4rzte-Verlag GmbH, Die-
\nselstr. 2, P. O. Box 40 02 65, 50832 K\u00f6ln\/
\nGermany, Phone (0 22 34) 70 11-0,
\nFax (0 22 34) 70 11-2 55, Postal Cheque
\nAccount: K\u00f6ln 192 50-506, Bank: Com-
\nmerzbank K\u00f6ln No. 1 500 057, Deutsche
\nApotheker- und \u00c4rztebank,
\n50670 K\u00f6ln, No. 015 13330.
\nAt present rate-card No. 3 a is valid.
\nThe magazine is published quarterly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or the World
\nMedical Association.
\nSubscription fee \u20ac 22,80 per annum (incl.
\n7 % MwSt.). For members of the World
\nMedical Association and for Associate
\nmembers the subscription fee is settled
\nby the membership or associate payment.
\nDetails of Associate Membership may be
\nfound at the World Medical Association
\nwebsite www.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nK\u00f6ln \u2014 Germany
\nISSN: 0049-8122
\nReading the national medical association (NMA) press over the last few months there
\nappear to be a number of broad issues which appear to occupy the medical and other pro-
\nfessions. Two of these reflect major concerns in the care of patients and are related, name-
\nly Quality of Care and Patient Safety. There has been much activity in the former for many
\nyears and action in the latter has substantially increased, notably in the World Alliance for
\nPatient Safety movement of WHO. The issues involve all health professions and with
\nincreasing teamwork in health care and the huge increase in general access to information
\nand the involvement of patients in decisions about their health care, these are welcome and
\nappropriate developments.
\nAt the same time in all health professions, knowledge and roles are constantly evolving and
\nchanging, reflecting the advances in knowledge and advances in technology. In parallel
\nthere are also changes in Healthcare provision as existing national health care systems
\nreflect both changes in demography in the professions and in the population, as well as the
\neconomic and political climate in individual countries.
\nIn the past few weeks such headlines as \u201cNew healthcare role will confuse patients\u201d and
\n\u201cphysician task force confronts scope of practice legislation\u201d have appeared the press of the
\nsome national medical associations. Both of these are referring to the changes in field of
\nactivity of evolving health professions and suggestions of new ones both of which will
\nimpact on the traditional areas of practice, hitherto those of physicians. The first headline
\nquoted above refers to a proposed new type of health worker to be called by suggested titles
\nsuch as \u201cmedical care practitioner\u201d or \u201csurgical care practitioner\u201d in the United Kingdom
\nHealth Service. The second reference is to pending legislation in a number of states in the
\nUSA to formally expand the role of 20 non-medical health professions.
\nAs long ago as the early 1970s this topic was one of concern, at least in Europe, when the
\nfirst Chairs of Nursing were being established. There have been substantial developments
\nin that profession over the intervening years, accompanied by positive changes in attitudes,
\nin relationships, and the increase in teamwork referred to above. Increasing technology,
\nknowledge, training and professional co-operation have benefited both the professions and
\npatients
\nBut the apprehensions expressed above arise substantially from concerns related to some
\nhealth professionals undertaking roles for which they are much less extensively prepared as
\nthose who have undertaken the long and rigorous medical training. Whilst it is possible to
\nprovide special training for specific activities or diseases, there is concern that patient safe-
\nty could be affected. Whilst each professional has a duty to work only within their area of
\ncompetence, with the introduction of extended new roles this is causing concern It is par-
\nticularly important that where new health professionals are being introduced, patients
\nshould be aware of their professional role and the limits of their training. This certainly
\nmeans that the professional title should not be open to misinterpretation or imply in any
\nway that the competence is that of a fully qualified medical practitioner. This issue is a now
\nmatter of concern to NMAs in many countries.
\nThe role of medical and paramedical health professionals is complementary It has been so
\nfor many years, and in many countries and within countries this has substantially increased,
\nEditorial
\nEvolution of Health Professions
\nEditorial
\n2
\nwith a real feeling of partnership between
\nthe professionals. With the global crisis of
\nhuman health resources which will be the
\ntopic of WHO for this year, and for a decade
\nof action \u201cHuman Resources for Health\u201d, it
\nis vital that all the health professions work
\ntogether to ensure that maximum use is
\nmade of the potential of each profession,
\nand that roles and functions are clearly
\ndefined and adequate training provided. To
\nthis end the health professions, faced with
\nthe changing spheres of activity, need to re-
\nexamine their own scope of practice and
\nengage in active productive dialogue to
\nachieve this and ensure that the resources of
\nthe health professions are used in the best
\nway, even if this involves some change in
\ntraditional roles.
\nAlan Rowe
\nToday it is clear to everyone that telecommunications will be the new driving force for eco-
\nnomic and social systems worldwide. The paradigms of communication are currently
\nevolving at an enormous pace away from paper-based methods directly towards electronic
\nmechanisms, at all levels. This entails massive changes everywhere which can rightly be
\ncompared to the industrial revolution with all of its social and economic upheavals.
\nWhile up to now most national regulations have been dominated by regional interests, it
\ncomes as no surprise that these are becoming ever more strongly influenced by internation-
\nal aspects and interactions with foreign structures. Until today every physician practised as
\na doctor basically only within his\/her own national context. Spurred on by the increasing
\nrise in cross border traffic and telecommunications in medicine, this will no longer be the
\ncase in the foreseeable future. A World-Wide trend has been initiated.
\nThe European Community1
\nrecognized this fact and has recently adopted Directive
\n2005\/36\/EC on the Recognition of Professional Qualifications. This expressly mandates
\n\u201cthe abolition of obstacles to the free movement of persons and services\u201d and in this con-
\ntext explicitly gives each professional \u201cthe right to pursue a profession, in a self employed
\nor employed capacity, in a member state other than the one in which they have obtained
\ntheir professional qualifications\u201d.
\nIt is obvious that these regulations will also have a massive impact on the medical commu-
\nnity. However, in a separate directive, liberalising the provision of services in other mem-
\nber states, the European Parliament in February this year, voted to exclude the health sec-
\ntor. MEP\u2019s also voted to reject article 23 of the Directive, which would have given cross-
\nborder patients guarantees of reimbursement of treatment costs. The motivation can pre-
\nsumably be found in differing basic premises of the various health care systems which
\nentail major differences in health care management. In some countries enormous waiting
\nlists already dominate medical diagnostics and therapy as a last resort to curtail rising costs,
\nwhile in contrast, these services remain readily available in other countries. In this context
\n\u201chealth tourism\u201d is the last thing any nation wants to foster. However, the trend towards
\nmobility of patients and providers cannot be stopped.
\nThe technological mainstay of the secure exchange of medical data in the future will indis-
\nputably be the methods of authentification and signature as they are offered by health pro-
\nfessional cards. Only these can achieve a sufficiently high level of security as to be usable
\nHealth Professional Card
\nEuropean Developments presage
\nWorldwide Activities
\nDr. med. Christoph F-J Goetz
\nin the sensitive area of health care. In
\nrecognition of this fact many nations have
\nbegun the planning and development of
\nhealth professional cards for their own
\nmedical community.
\nIn the last years quite a number of national
\nsmart card projects with major impact were
\ninitiated worldwide. Compiled as part of a
\nTrailblazer project, the White Paper on
\n\u201cOpen Smart Card Infrastructure\u201d (OSCIE)
\ngives an excellent overview of activities in
\nEurope2
\n. With a special focus on health
\nprofessional cards the following projects
\nwere especially formative for current tech-
\nnology and trends:
\n\u2022 France (Groupement d\u2019int\u00e9r\u00eat Public,
\nCarte de Professionnel de Sant\u00e9),
\n\u2022 Germany (Heilberufsausweise f\u00fcr \u00c4rzte,
\nZahn\u00e4rzte, Apotheker und Psychothera-
\npeuten),
\n\u2022 Netherlands (NICTIZ, Nationaal ICT
\nInstituut in de Zorg) and
\n\u2022 Slovenia (Profesionalna kartica, ZZZS,
\nZavod za zdravstveno zavarovanje
\nSlovenje).
\nEarly on it was recognised that functional
\ninteroperability and widespread acceptance
\nwill be crucial for this new technology, and
\nstandardisation activities initiated.
\nIn Europe, the Technical Committee 251
\n\u201cHealth Informatics\u201d (TC 251) of the
\nComit\u00e9 Europ\u00e9en de Normalisation (CEN)
\nfocuses its activities concerning \u201cSecurity,
\nSafety and Quality\u201d in Working Group III.
\nIn the year 2000 this Group III put togeth-
\ner the first version of the European pre-
\n1
\nThe European unification started 1957 with six
\nstates. Through various expansions the European
\nCommunity now has 25 members since May 2004.
\nThese are: Austria, Belgium, Cyprus, Czech
\nRepublic, Denmark, Estonia, Finland, France,
\nGermany, Greece, Hungary, Ireland, Italy, Latvia,
\nLithuania, Luxemburg, Malta, Netherlands,
\nPoland, Portugal, Slovakia, Slovenia, Spain,
\nSweden and the United Kingdom. In addition, four
\nnations are currently also planning entry to the EC:
\nBulgaria, Croatia, Rumania and Turkey.
\n2
\nOpen Smart Card Infrastructure for Europe, White
\nPaper of the eEurope Smart Card Trailblazer 11,
\nOSCIE, Volume 1, Part 4, March 2003. Latest
\nversion of OSCIE papers are available from
\n\u201cwww.eeurope-smartcards.org\u201d and
\n\u201cwww.eurosmart.com\u201d.
\nequivalent requirements and qualifications.
\nStandardisation makes faster and easier
\ntransfer of knowledge and innovation pos-
\nsible, and thereby lowers cost and increases
\navailability. These commercial truisms also
\nhold true for medical care. It is clear that
\nthe functional interoperability of secure
\nauthentification and information transfer in
\nmedicine will be the indispensable corner-
\nstone for future applications and deserves
\nour unmitigated support.
\nDr. med. Christoph F-J Goetz
\nDirector Telemedicine
\nBavarian Administration of Statutory
\nOffice Based Physicians
\nElsenheimer Strasse 39, D-80687 Munich,
\nGermany
\nPhone: +49.89.57093-2470
\nFax: +49.89.57093-61470
\nMobile: +49.172.9544621
\nChristoph.Goetz@kvb.de
\nstandard ENV 13729 \u201cHealth informatics \u2013
\nSecure user identification \u2013 Strong authen-
\ntication using microprocessor cards\u201d. This
\nis currently undergoing revision under the
\nleadership of the author, with support of the
\nKVB (Bavarian Administration of Statutory
\nOffice Based Physicians) and the BAEK
\n(German Medical Chamber). Due to the
\nbroad range of interoperability issues fore-
\nseeable in this context, and because of
\nnational healthcare responsibilities and dif-
\nfering (or even currently non-existent) tech-
\nnical frameworks, it has been deemed nec-
\nessary to gather an up-to-date and encom-
\npassing overview of salient information
\nregarding national activities for healthcare
\nprofessional cards in the member states of
\nthe EC before starting this revision.
\nThe following aspects will be covered in
\nthis study:
\n1) Identification of institutions responsi-
\nble for planning and rollout of nation-
\nal healthcare professional cards,
\n2) identification and enumeration of
\ninvolved healthcare professions,
\n3) identification of industrial solutions
\nand product providers,
\n4) documentation of the status of current
\nplans and development,
\n5) identification of technical correspon-
\ndents for HPC queries, and finally
\n6) collection of design frameworks
\nand\/or guides of national HPC\u2019s.
\nThe output of this agenda will be a techni-
\ncal report to support ENV 13729 and it is
\nexpected (depending on the rapidity of
\nfeedback) that the work can largely be
\ncompleted within 2006. It has already been
\ndecided that the results of this European
\nreport will be shared with the correspond-
\ning Working Group 5 \u201cHealth Cards\u201d of the
\nTechnical Committee 215 \u201cHealth
\nInformatics\u201d (TC 215), which is part of the
\nInternational Standards Organization
\n(ISO), so that a world-wide overview can
\nbe expected to be available by 2007.
\nTo summarise, it is essential to recognise
\nthat in medicine, as everywhere else, stan-
\ndardisation enables the national and inter-
\nnational exchange of products and services
\nand reduces their costs by specifying
\nMedical Ethics and Human Rights
\n3
\nCurrently nobody knows exactly whether
\nwe will face a new human pandemic with a
\nmutated avian influenza virus or not. So far,
\nthe pandemic is mainly an animal disease
\nand the cases of infected human beings are
\nlinked to direct contact with infected ani-
\nmals. But if the H5N1-virus mutates into a
\nstrain which can easily pass between human
\nbeings resulting in a new human pandemic
\nwith dramatic effects, we are sure to be con-
\nfronted with serious ethical decisions, in
\naddition to huge other problems They can
\nbe anticipated and are not new \u2013 the coming
\nethical problems are well known.
\nFirst of all, a global human influenza pan-
\ndemic will bind enormous capacities in the
\nhealth care systems all over the world.
\nHighly developed medical systems in
\nwealthy countries might be able to cope
\nwith the challenges of treating an extremely
\nhigh number of sick people in a more
\nacceptable way. They might have enough
\nhuman and material resources to react in a
\nway that minimises the number of people
\ninfected and dying from the disease. But
\nmost health care systems in the world will
\nnot be able to respond adequately to the
\nincreased health care needs. They lack the
\nnecessary reserves. Their medical capaci-
\nties are already insufficient to cope with
\ntheir daily health problems, let alone to
\ncope with a new human pandemic flu. Less
\ndeveloped health care systems face two
\noptions, both of which pose serious dilem-
\nmas; they can either concentrate on fighting
\nthe new human pandemic at the expense of
\nother urgent health care needs, or they can
\nneglect the new pandemic trying to main-
\ntain the level of other health care services.
\nIn any case, the consequences will be dev-
\nastating for the people involved, the avian
\ninfluenza victims or those with other sick-
\nnesses. And the choice between these two
\noptions is a difficult one, with ethical impli-
\ncations. On the one hand the responsible
\nhealth care officials have to decide under
\nconditions of some uncertainty based on
\nvague data about the outcome of their mea-
\nsures, on the other hand they have to choose
\nthe appropriate aim of their strategy: Should
\none follow the utilitarian goal to minimize
\nthe number of fatalities, or should other
\nconsiderations govern the decisions, e.g.
\negalitarian considerations that give all indi-
\nMedical Ethics and Human Rights
\nAvian influenza: A possible new human
\npandemic with old ethical problems
\nProf. Urban Wiesing MD, PhD, Georg Marckmann MD, MPH
\nviduals an equal chance of treatment
\nregardless of the overall outcome?
\nEven well-funded health care systems will
\nbe confronted with a shortage of antiviral
\ndrugs, vaccines, hospital beds and health
\ncare professionals for the treatment of avian
\ninfluenza patients. Who should receive the
\navailable drugs, who be vaccinated first, or
\nwho get the needed hospital beds? Those
\nwho are able to pay the price \u2013 which will
\nhighly increase? Or the professionals who
\nare responsible for the public health system
\nand for the treatment of infected people?
\nShould the drug be distributed by ability to
\npay in a free market or in a regulated way
\nfor the benefit of the greatest number? The
\nanswer is dearly in favour of maximising
\nthe overall benefits. Consequently, most
\npandemic plans give priority to health care
\nworkers and other professionals who help
\nto maintain public order. Understandably, it
\nalways places a heavy burden on a physi-
\ncian to decide between two patients in the
\nabsence of capacitiesy to treat both.
\nTherefore, the World Medical Association
\nhas defined a clear priority in its \u201cStatement
\non Medical Ethics in the Event of
\nDisasters\u201d (1994) [3] When the circum-
\nstances do not allow the treatment of every
\npatient who under normal conditions could
\nbe treated, the \u201cdecision to ‘abandon an
\ninjured person’ on account of priorities dic-
\ntated by the disaster situation cannot be
\nconsidered ‘failure to come to the assistance
\nof a person in mortal danger It is justified
\nwhen it intends to save the maximum num-
\nber of victims.\u201d (3.3.e)
\nIn addition to the ethical problems of allo-
\ncating scarce resources within a health care
\nsystem, there will be even more dramatic
\nproblems regarding the distribution of
\nhealth services between health care systems.
\nIt can be expected that people in wealthy
\ncountries with highly developed medical
\nsystems will have a better chance to survive
\nthan those in low-income countries. What
\ncan be seen in the HIV pandemic will most
\nprobably also happen in a possible \u2013 and
\nhopefully never arriving \u2013 human influenza
\npandemic: the survival rates will depend on
\nthe wealth of a country, region or group of
\npeople within a certain state. Only the pure
\nchance of living in one or the other country
\nleads to tremendous differences in the prob-
\nability of surviving. A possible human
\ninfluenza pandemic will show once again
\nthe unjust distribution of health services
\naround the world.
\nAnother set of ethical issues arises from the
\nrestriction of individual rights in the inter-
\nest of the public health. During the history
\nof medicine it has always been a problem to
\nwhat extent individual rights may legiti-
\nmately be restricted to protect the health of
\nother people. Under what circumstances is
\nit permisable to put infected or other people
\nin quarantine? As long as the quarantine is
\nshort and does not reduce the survival rate
\nof those infected, most people will probably
\nagree voluntarily to quarantine. But if the
\nrestriction of individual freedom is exten-
\nsive and if the restriction leads to signifi-
\ncant financial disadvantages or even the
\nloss of a job, the ethical balancing seems
\nmore difficult. How far can the freedom of
\nmovement be restricted, in particular if peo-
\nple are not infected but live in an area in
\nwhich cases of avian influenza occurred?
\nTo what extent may the daily living of so
\nfar uninvolved people be restricted to pre-
\nvent a human pandemic? Restrictive action
\nfor public health purposes may also include
\noverriding the right to privacy. The Council
\non Ethical and Judicial Affairs of the
\nAmerican Medical Association set up a rec-
\nommendation that tries to balance the pro-
\ntection of \u201cindividual rights of liberty and
\nself-determination\u201d and \u201cthe public health
\nrequirements\u201d. As a general rule, \u201cquaran-
\ntine and isolation should use the least
\nrestrictive measures available that will min-
\nimize negative effects on the community
\nthrough disease control, while providing
\nprotections for individual rights\u201d. [1] In
\naddition, any quarantine or isolation mea-
\nsures should be based on sound scientific
\nevidence and the people should be
\ninformed about the rationale behind the
\nrestrictive public health interventions,
\nwhich in turn will increase the likelihood
\nthat they comply voluntarily with the
\nrestraints.
\nFinally, what can be legitimately demanded
\nfrom health care workers? On the one hand,
\nhealth professionals will have an increased
\nrisk to being infected while caring for
\ninfluenza patients. On the other hand, they
\nhave the professional obligation to put the
\ninterest of their patients first and treat the
\npatients who are most in need. Certainly,
\nhealth care workers voluntarily assume a
\nspecial responsibility by choosing to
\nbecome a health professional, a responsibil-
\nity that includes increased health risks. But
\ndo they have to take any risk no matter how
\nthreatening it is? Do they have the right to
\nrefuse to treat infected patients if they are
\nnot willing to risk a life-threatening infec-
\ntion themselves? The answer remains open.
\nAt least, any available precautions should
\nbe taken to minimize the health risk for
\nhealth professionals by providing protec-
\ntive equipment, preventive immunizations
\nand preferential access to antiviral drugs if
\nthey have been infected. Still, considerable
\nhealth risks remain and so far professional
\ncodes do not provide sufficient guidance on
\nwhat can be demanded from health care
\nworkers. Even the detailed recommenda-
\ntions of the University of Toronto’s Joint
\nCentre of Bioethics remain vague on these
\ndifficult ethical issues [2]
\nHowever some procedural ethical values
\nare undisputed in open democratic soci-
\neties: The ethical choices involved in a
\nhuman pandemic of avian influenza should
\nbe discussed publicly, openly and in
\nadvance. Any measures should be based on
\nthe available scientific evidence and explic-
\nit ethical reasoning. It is better to involve
\nthe public before the crisis than during the
\ncrisis. It will increase the success of all
\nmeasures if people realize that the fight
\nagainst a pandemic flu is also their concern:
\nTheir contribution is necessary for success-
\nful interventions against the pandemic and
\nthey, as individuals, will benefit from these
\nconcerted actions. Apart from concrete
\nplans for early response and containment, a
\nbroad societal discourse about the underly-
\ning ethical choices that will have to be
\nmade is probably crucial for a successful
\nfight against a new influenza pandemic. We
\nshould rather start this public dialogue
\nsooner than later, on a national as well as on
\nan international level.
\nLiterature
\n[1] American Medical Association, Council
\non Ethical and Judicial Affairs. (2005) The
\nUse of Quarantine and Isolation as Public
\nhealth Intervention. http:\/\/www.ama
\nMedical Ethics and Human Rights
\n4
\n5
\nMedical Ethics and Human Rights
\nassn.org\/ama\/pub\/upload\/mm\/3l\/quaran-
\ntine\/57726.pdf
\n[2] University of Toronto Joint Centre for
\nBioethics, Pandemic Influenza Working
\nGroup. Stand on Guard for Thee Ethical
\nconsiderations in preparedness planning for
\npandemic influenza 2005, http:\/\/www.
\nutoronto.ca\/jcb\/home\/documents\/pandem-
\nic. pdf
\n[3] World Medical Association Statement
\non Medical Ethics in the Event of Disasters
\n(Adopted by the 46th WMA General
\nAssembly Stockholm, Sweden, September
\n1994) (https:\/\/www.wma.net\/e\/policy-
\n\/d7.htm)
\nAdress for correspondence:
\nProf. Urban Wiesing, MD PhD
\nGeorg Marckmann, MD, MPH
\nT\u00fcbingen University
\nInstitute for Ethics and History of Medicine
\nSchleichstr. 8
\nD-72076 T\u00fcbingen
\nGermany
\nEmail: urban.wiesing@uni-tuebingen.de
\n\u201cCaring Physicians of the World\u201d
\nLast year\u2019s WMA President\u2019s project was marked during the 2006 WMA meeting in
\nSantiago by the launch of the book \u201cCaring Physicians of the World\u201d. This beautifully
\nwritten and illustrated book presents the sixty five \u201cCaring Physicians of the World\u201d
\nselected by a WMA panel from the several hundred nominations made by National
\nMedical Associations
\nIn his introduction, Dr Yank Coble, while referring to the importance of individual physi-
\ncians\u2019 commitment to knowledge of medical science, its utilisation, and the observance
\nof the principles of medical ethics, stresses the primary importance of \u201cCaring\u201d with the
\nquotation \u201cI don\u2019t care how mach you know about (science and ethics) until I know how
\nmuch you care\u201d (anon). The book also quotes Sir William Osler as also quoted in the
\nbook \u201cThe most important thing is caring, so do it first, for a caring physician best
\ninspires hope and trust\u201d This quality is clearly illustrated by the description of work and
\nactivities of those whose names appear in this book
\nThe book covers a wide spectrum of individuals whose devotion and work as \u201cCaring
\nPhysicians\u201d encompasses not only their care of individuals, but also extends to \u201csocial
\nleadership on behalf of the Public Health, scientific progress, society\u2019s resources and the
\nwelfare of human kind\u201d. It includes not only some internationally recognised names but
\nmany who are little or generally recognised, whose caring qualities have been applied to
\nthose in need in all corners of the earth, both urban and remote, isolated and sometimes
\notherwise uncared for.
\nIt is little wonder that this book, honouring those chosen by their colleagues for their exem-
\nplary care, not only makes fascinating and inspiring reading, has also stimulated great
\nworldwide interest and attention. It merits reading by both doctors and their patients alike
\n(for details visit www.wma.net.)
\nDoctors around the world look to the WMA
\nfor definitive guidance on professional
\nethics. Recent controversy over the medical
\nmanagement of hunger strikes, however,
\nhas not only re-opened the issue of whether
\ndoctors can ever ethically feed protesters
\nagainst their will but highlighted the fact
\nthat the WMA has two different approaches,
\nand indeed two different policies, on the
\nissue. This is leading to some confusion and
\nneeds urgently to be addressed by the
\nWMA.
\nIt is widely recognized that the WMA\u2019s
\n1975 Declaration of Tokyo never intended
\nto provide guidance on the management of
\nhunger strikes. Its remit was the prohibition
\nof doctors\u2019 involvement in torture. It says
\nthat doctors should not resuscitate victims
\nto allow torture to continue, but also says
\nthat they should not resuscitate prisoners
\nwho fast in order to end their lives in a bid
\nto escape further torture. According to the
\nTokyo Declaration, which is now a key
\nhuman rights text, artificial feeding should
\nnot be instated \u201cwhere a prisoner refuses
\nnourishment and is considered by the physi-
\ncian to be capable of forming an unim-
\npaired and rational judgement concerning
\nthe consequences\u201d.
\nContrary to this clear prohibition on feeding
\nwhen prisoners refuse it, the WMA\u2019s 1991
\nDeclaration of Malta, ambiguously leaves
\nMedical management of hunger-strikers
\nMr. J. N. Johnson, M.D., FRCS, FRCP, FDSRCS
\nto doctors the decision on whether to artifi-
\ncially feed hunger strikers. This
\nDeclaration which deals exclusively with
\nhunger-strikes, resulted from South African
\ndoctors appealing for more detailed guid-
\nance on the subject. The Declaration elo-
\nquently raises, but fails to answer, the
\ndilemma of whether \u201csanctity of life\u201d or
\n\u201crespect of individual autonomy\u201d should be
\nthe key issue.
\nClear WMA guidance on this matter is in
\ndemand since the Malta Declaration is
\nincreasingly quoted on both sides of the
\ndebate about whether or not protesters can
\nbe force fed or artificially fed against their
\nexpressed wishes. Hunger strikes have also
\nbecome more complex in the 15 years since
\nthe Malta Declaration. Distinctions
\nbetween prisoners determined to fast to
\ndeath and those calculating to prolong their
\nprotest but ultimately survive, was blurred
\nby the Turkish hunger strikers of the 1990s.
\nThey showed that they could lengthen the
\nprotest by partial fasts. Deaths occurred,
\nbut only after extra months allowed consid-
\nerably more pressure to be put on the
\nauthorities. Collective hunger strikes, such
\nas those in Spain and Turkey, also raised
\nquestions about whether prisoners could
\nmake truly voluntary decisions in situations
\nwhere there was likely to be considerable
\npeer pressure. The WMA Declaration of
\nMalta does not provide guidance to doctors
\nfaced with such cases.
\nAnother problematic aspect of current
\nWMA guidance is that it conflates artificial
\nfeeding and forced feeding. Many would
\nargue that any medical intervention based
\non force, coercion or intimidation must be
\nclearly prohibited by the WMA. Artificial
\nfeeding without coercion can be an accept-
\nable way to defuse a hunger strike situation.
\nThe BMA is calling on the WMA to review
\nand upgrade its guidance. The guidelines
\nmust be made clearer and a background
\ndocument exploring the complex issues in
\ngreater depth is also needed. Doctors are
\nhoping that the WMA will firmly uphold its
\ncommitment to promulgating consensus
\nethics around the world.
\nMr. J. N. Johnson, M.D.,
\nFRCS, FRCP, FDSRCS
\nChairman of Council
\nBritish Medical Association
\nTavistock Square, London WC1H 9JP
\nMedical Ethics and Human Rights
\n6
\nThe Constitution of the World Health Orga-
\nnization states that the \u201cenjoyment of the
\nhighest attainable standard of health is one
\nof the fundamental rights of every human
\nbeing\u2026\u201d International statements on
\nhuman rights, such as the International
\nCovenant on Economic, Social and Cultural
\nRights and the Convention on the Rights of
\nthe Child, support the right to health and
\nrequire signatory nations to secure its obser-
\nvance.
\nDespite the widespread, although by no
\nmeans universal, acceptance of the right to
\nhealth, both its meaning and its application
\nare problematic. It cannot mean a right to be
\nhealthy, since much illness is impossible to
\nprevent or cure. Nor can it mean that indi-
\nviduals have a right to all needed health care
\nservices, since the demand for such services
\nis greater than the supply in even the
\nwealthiest countries. There seems to be gen-
\neral agreement that the right to health entails
\na minimum requirement that individuals
\nshould be protected from actions that under-
\nmine their health. There is much disagree-
\nment as to whether individuals have a fur-
\nther right to equal access to needed health
\ncare in their country or elsewhere. Some
\ncountries accept and promote this right
\nwhile in others, access to health care is large-
\nly dependent on one\u2019s financial resources.
\nEven where the right to health is accepted, it
\nis often difficult to implement because of a
\nsevere shortage of resources. This is clearly
\nthe situation in many developing countries,
\nalthough some of these countries (e.g., Sri
\nLanka) have managed to promote equitable
\naccess to their limited health care resources,
\nwith extremely positive results for the over-
\nall health status of the population.
\nIn 2000 the Committee on Economic, Social
\nand Cultural Rights, which was created to
\nmonitor the International Covenant on Eco-
\nnomic, Social and Cultural Rights, issued a
\nreport on the right to health. It interpreted
\nthis right \u201cas an inclusive right extending
\nnot only to timely and appropriate health
\ncare but also to the underlying determinants
\nof health, such as access to safe and potable
\nwater and adequate sanitation, an adequate
\nsupply of safe food, nutrition and housing,
\nhealthy occupational and environmental
\nconditions, and access to health-related edu-
\ncation and information, including on sexual
\nand reproductive health. A further important
\nThe Right to Health
\naspect is the participation of the population
\nin all health-related decision-making at the
\ncommunity, national and international lev-
\nels.\u201d According to the Committee, States
\nhave the following obligations in relation to
\nthe right to health: \u201cThe right to health, like
\nall human rights, imposes three types or
\nlevels of obligations on States parties: the
\nobligations to respect, protect and fulfil. In
\nturn, the obligation to fulfil contains oblig-
\nations to facilitate, provide and promote\u2026.
\nThe obligation to respect requires States to
\nrefrain from interfering directly or indirect-
\nly with the enjoyment of the right to health.
\nThe obligation to protect requires States to
\ntake measures that prevent third parties
\nfrom interfering with article 12 guarantees.
\nFinally, the obligation to fulfil requires
\nStates to adopt appropriate legislative,
\nadministrative, budgetary, judicial, promo-
\ntional and other measures towards the full
\nrealization of the right to health.\u201d
\nAlso in 2000 the United Nations General
\nAssembly adopted the United Nations Mil-
\nlennium Declaration that includes eight
\nMillennium Development Goals to be
\nachieved by 2015. Five of these relate to the
\nright to health: halve extreme poverty and
\nhunger, reduce under-five mortality by
\ntwo-thirds, reduce maternal mortality by
\nthree-quarters, reverse the spread of dis-
\neases, especially HIV\/AIDS and malaria,
\nand ensure environmental sustainability.
\nIn 2002 the United Nations Commission on
\nHuman Rights appointed, for a period of
\nthree years, a Special Rapporteur whose
\nmandate focuses on the right of everyone to
\nthe enjoyment of the highest attainable
\nstandard of physical and mental health. The
\nmandate was extended in 2005 for three
\nyears, and the Special Rapporteur was
\nasked, among other things, \u201cTo gather,
\nrequest, receive and exchange information
\nfrom all relevant sources, including Gov-
\nernments, intergovernmental organizations
\nand non-governmental organizations, on
\nthe realization of the right of everyone to
\nthe enjoyment of the highest attainable
\nstandard of physical and mental health.\u201d
\nMedical associations have not been particu-
\nlarly outspoken on the right to health in
\ngeneral but have tended to focus on specif-
\nic rights. The WMA’s principal documents
\nin this respect are the Declaration of Lisbon
\non the Rights of the Patient and the Declara-
\ntion of Ottawa on the Right of the Child to
\nHealth Care. In 1998 the WMA General
\nAssembly adopted a Resolution on
\nImproved Investment in Health Care that,
\nwhile not mentioning a right to health, nev-
\nertheless urged governments and intergov-
\nernmental agencies to provide the requisite
\nconditions for the exercise of this right,
\nespecially access to good quality health
\ncare.
\nReaders are invited to provide information
\non other medical association or research
\nactivities related to privacy and confiden-
\ntiality of personal health information to
\nwilliams@wma.net
\nMedical Science, Professional Practice and Education
\n7
\nThe substance of this paper was presented
\nat the WMA Santiago meeting 2005.
\nAlmost sixty years after the start of the
\nUK\u2019s National Health Service, the NHS is
\nin trouble. Despite unprecedented levels of
\ninvestment, a massive financial deficit is
\nforecast for the current year. If unit costs
\ncannot be reduced over the next two years
\nthere will be serious doubts as to whether
\nwe can sustain an NHS free at the point of
\nuse and offering comprehensive services to
\nall. That would be a tragedy.
\nHealth Care Policy Reform \u2013 the UK National
\nHealth Service
\nMr James Johnson, MD, FRCS, Chairman of Council, British
\nMedical Association.
\nThe human genome sequence, now almost
\ncomplete, is a driving force behind research,
\nfocussing on the impact of genetic differ-
\nences between people, many of which affect
\nhealth. Another key theme is how genetic
\ninformation is translated into biological
\nfunction, whether in terms of the \u2018biological
\nclock\u2019 governing cell division in tissues, or
\ngene expression in health and disease.
\nBeyond the helix
\nIt is now calculated that humans have only
\nabout 23,000 genes operating, some of
\nwhich have died out or are dying out over
\nthe course of evolution. Thus our biological
\ncomplexity is more likely to be related to
\nhow these genes are used, incorporating
\nfeedback to ensure maximum effectiveness,
\nin the solution to problems of how and
\nwhere the genes can be switched on and off
\nduring development. Many different mech-
\nanisms of gene control are being discovered
\n\u2013 indeed the higher order arrangement of
\nDNA is turning out to be particularly impor-
\ntant. For example, it has been found that the
\nDNA of active genes is not linear, as typi-
\ncally drawn in textbooks, but rather is
\nlooped, with control proteins shared
\nbetween the start and end points of the gene.
\nSuch looping of the structure is essential for
\nthe activation of the gene.
\nGene control
\nRNA interference (RNAi) is an exciting
\narea of study, as these tiny RNAs can
\nMedical Science, Professional Practice and Education
\nHuman Genetics And Biomedical Research
\nsilence genes very effectively. Generally
\nthey act by triggering a massive destruction
\nof the intermediate messenger RNA as it is
\nread from a gene. Small RNA molecules
\ncan somehow insert themselves causing
\ntightlypacked DNA to shut down its gene
\naction.
\nPremature ageing
\nDyskeratosis congenita is a devastating dis-
\nease that leads to premature ageing, bone
\nmarrow failure and cancer. Over the past
\nfew years, Professor Inderjeet Dokal and
\ncolleagues at Imperial College, London,
\nhave identified the genetic basis of this rare
\ninherited disorder. They have clarified why
\nsymptoms appear earlier in successive gen-
\nerations.
\nAffecting about one person in every million,
\nthe mutations that cause dyskeratosis con-
\ngenita disrupt telomeres the tips of the chro-
\nmosomes, rather like the plastic cap on the
\ntips of shoelaces which keep the whole
\nstructure together. When chromosomes are
\ncopied during cell division, telomeres tend
\nto get shorter, from which remaining life
\nspan can be predicted. In order to compen-
\nsate for this winding down effect, actively
\ndividing cells can synthesise the enzyme
\ntelomerase, which repairs telomeres. Indeed,
\nclose analysis of telomere structure can cal-
\nculate when a rare inherited disorder will
\nstrike. Without telomerase, the cells will go
\nthrough a certain number of divisions, as far
\nas the Hayflick Limit, and then die.
\nMutant genes, when switched on, such as
\nthat coding for telomerase, mean that chro-
\nmosome repair is faulty. Tissues with rapid-
\nly proliferating cells, such as skin, gut and
\nbone marrow, are the first to be affected.
\nThe earliest sign of accelerated wear and
\ntear is usually abnormal skin pigmentation,
\nfollowed years later by cancer, premature
\nageing and bone marrow failure, which
\noften proves fatal.
\nBut why do children\u2019s symptoms appear at
\nan earlier age than their parents? This phe-
\nnomenon is also seen in some other genetic
\ndisorders, where a 3 letter fragment of DNA
\nmultiplies in successive generations. The
\nlength of a patients telomeres show when
\nsymptoms will first emerge \u2013 the shorter the
\ntelomere, the sooner symptoms appeared.
\nIvan M. Gillibrand
\nThe NHS was founded on an assumption
\nthat once patients\u2019 \u201cneed\u201d had been satis-
\nfied, demand and costs would fall, over
\ntime. It was introduced with the promise of
\nuniversal and efficient delivery of health
\nservices. In reality, instead of demand and
\ncosts falling, there have been rising
\ndemands, costs and expectations. These are
\nglobal pressures experienced by health ser-
\nvices all over the world.
\nThe UK\u2019s NHS is an experiment in health
\nreform. Almost every conceivable lever has
\nbeen pulled to try to influence the system,
\nfor example by reducing waiting times and
\nincreasing quality. Although when elected
\nin 1997 the Labour Party was critical of an
\ninternal market created by the previous
\n(Conservative) government, it is interesting
\nthat after seven years in office, the Labour
\ngovernment has recreated the basic model
\nand returned to incentives as the main
\nmodel of reform.
\nRecent NHS reforms have included a pledge
\nto increase the numbers of health profes-
\nsionals, including doctors, and the moderni-
\nsation of the infrastructure and services. The
\nnumber of medical school places has been
\nincreased and we are attracting more doc-
\ntors from other parts of the European Union
\nand elsewhere. Nevertheless there are still
\nshortages in some specialities and in some
\nbranches of the profession such as general
\npractice. It\u2019s also true that in general prac-
\ntice the majority of the extra doctors recruit-
\ned elect to work less than full time and
\nchoose portfolio careers.
\nImprovements in NHS infrastructure have
\nbeen largely secured via the Private
\nFinance Initiative (PFI) using private sec-
\ntor money to build and staff new hospitals
\nwhich are then leased back to the NHS for
\na limited period, typically 30 or 35 years.
\nCritics of PFI , and they are vociferous, say
\nthis is a very expensive way of accessing
\nmoney and while it saves on capital costs it
\nleaves Hospital Trusts with a heavy debt
\nburden for many years. On the more posi-
\ntive side, clinicians have welcomed the
\nchance to move from outdated, deficient,
\nhospital buildings to modern purpose-
\ndesigned ones, albeit often with fewer beds.
\nIt isn\u2019t just NHS buildings which are old
\nfashioned and in need of modernisation.
\nHospitals in particular have been slow to
\ntake advantage of new technology, and in
\nGeneral Practice, a multiplicity of IT sys-
\ntems mean that we still have not got the
\nability to transfer patient records between
\npractices electronically \u2013 let alone between
\nhospital and GP.
\nTo combat all this, the government has
\ncommissioned a National Programme for
\nIT for the NHS (NPfIT) run by Connecting
\nfor Health. The initial budget for the NPfIT
\nproject was \u00a36 billion sterling but commen-
\ntators predict this will be substantially
\nexceeded. Described as the world\u2019s largest
\ncivil computer programme, NPfIT includes
\na national care records system to provide a
\ncentral database for the electronic health
\nrecords of 50 million patients. It also
\nincludes \u201cChoose and Book\u201d, a software
\nsystem to allow people to select hospital
\nappointments from a choice of dates and
\nlocations when they are referred to sec-
\nondary care by their GP. Suffice to say there
\nhave been problems implementing the sys-
\ntems and neither is fully operational.
\nThe British Medical Association has criti-
\ncised the IT project for failing to engage
\nwith clinicians from the start. Quite late on,
\nthe Department of Health appointed clinical
\nadvisors who have been helpful, but by the
\ntime they came on board a great many doc-
\ntors felt alienated.
\nIn terms of other NHS Reforms, clinical
\ngovernance was tightened and a raft of bod-
\nies brought in to implement it and to sup-
\nport learning activities. These included the
\nModernisation Agency, the National
\nPatient Safety Agency and the short-lived
\nNHS University. Hierarchical reforms to
\nthe NHS include setting national standards
\nand targets, inspection and regulation from
\nthe centre, published information on perfor-
\nmance and other central interventions.
\nThe National Institute for Clinical Excel-
\nlence (NICE), was set up to examine new
\ndrugs and treatment to determine whether
\nthey should be available on the NHS.
\nNational Service Frameworks emerged to
\ndirect clinicians towards best treatments for
\ncertain conditions, and the Healthcare
\nCommission (formerly CHI, the Commi-
\nssion for Health Improvement) is an inde-
\npendent organisation which inspects health
\nservices. Its duties include giving local
\nTrusts and NHS bodies a rating to reflect
\ntheir performance. Initially this was a star
\nrating system which my Association has
\ncondemned as far too crude to offer any
\nuseful information to patients or to the
\nNHS. The star ratings are being replaced by
\nnew measures which will separately look at
\na Trusts\u2019 financial management.
\nThese Healthcare Commission ratings are
\nimportant to NHS hospitals seeking to
\nbecome Foundation Hospitals, which are
\nfree from the normal constraints under
\nwhich the majority of NHS Trusts operate.
\nOnly three star Trusts are eligible to apply
\nfor Foundation status.
\nAs incentives to drive these changes to the
\nNHS, the Government has introduced choice
\nand commissioning policies. Patient choice
\nis to drive the reform agenda, with people
\ngiven more say in how when and where
\nthey access treatments. Money will follow
\nthe patient\u2019s journey through the NHS and
\nthis will be effected via Payment by
\nResults. A fixed national tariff will be
\npayable to NHS providers \u2013 including the
\ngrowing number of independent sector
\norganisations providing NHS care \u2013 for
\neach treatment. At present only Foundation
\nTrusts are covered by Payment by Results
\nbut the intention is for all NHS hospitals to
\noperate under the system from April 2006.
\nAt the same time the government wants to
\ntake the role of commissioning services
\naway from local NHS bodies and hand it to
\nother commissioners, notably general prac-
\ntitioners under a scheme called Practice
\nBased Commissioning. The hope is that by
\ngiving clinicians the commissioning role,
\ncosts will be constrained and more patients
\nwill be treated nearer to home in a commu-
\nnity setting, rather than in expensive acute
\nhospitals and other secondary care.
\nSo far, take up on Practice Based Commi-
\nssioning has been patchy and somewhat
\nlukewarm. Potential commissioners are
\ndubious about assuming the role in the face
\nof large-scale deficits in local NHS bud-
\ngets. Payment by Results has the potential
\nto attract even more care into the hospital
\nsector, driving up NHS costs, and the gov-
\nernment clearly hopes that Practice Based
\nCommissioning with contain that.
\nMedical Science, Professional Practice and Education
\n8
\nKey Changes in the UK
\nIn future the NHS will have less emphasis
\non the state\u2019s role as provider and more as
\na purchaser of care. It will be less directive
\nof local services and act more as a regula-
\ntor, setting the framework for a competitive
\nmarket in the provision of healthcare.
\nWe will see greater devolvement of man-
\nagerial responsibility, while retaining cen-
\ntral direction through the use of financial
\nincentives and quality standards.
\nMost importantly there will be plurality of
\nprovision with health care delivered by
\nboth public and private sectors, still free at
\nthe point of use. Independent Sector
\nTreatment Centres have been introduced in
\nsecondary care to bring down waiting times
\nand lists, amid many concerns among NHS
\nstaff that their introduction risks destabilis-
\ning existing hospitals which train staff and
\nprovide round the clock NHS care in all its
\naspects.
\nGeneral Practice is also changing. A new
\ncontract for GPs introduced in 2004 con-
\ntains a Quality and Outcomes Framework
\nrewarding GPs according to the quality of
\nservices they provide. General practice is
\nnow said to have \u201cover-delivered\u201d causing
\nthe contract to cost more than the govern-
\nment expected. GPs are able to point to the
\nhigh quality care they provide for patients.
\nNevertheless a national shortage of GPs
\nmeans that some areas are \u201cunder-doc-
\ntored\u201d. The government is opening up the
\nservice to commercial providers for the
\nfirst time. It is providing wider access with
\nwalk-in centres and plans to bring more
\ncare out of hospitals closer to patients\u2019
\nhomes.
\nThere is an ideological debate taking place
\nin the UK over whether the \u201csocialised\u201d
\nmodel of healthcare is being dismantled
\nand the NHS privatised. The financing of
\nUK healthcare has not changed. The gov-
\nernment pledges that money will continue
\nto come from general taxation. We are
\nexperiencing a privatisation of provision.
\nThe change is in provision and delivery of
\nUK healthcare
\nDoctors see threats and opportunities in
\nthis \u2013 more providers means a choice of
\nemployers and while there is a shortage of
\ndoctors, more freedom to move around.
\nThe future picture of health policy is uncer-
\ntain, but incentives ensure that service pro-
\nvision will change radically.
\nThe NHS has seen a huge increase in fund-
\ning in the past five years so that by 2007\/08
\nit will have risen to approach 10% of total
\nGDP. Britain will by then be spending on
\nhealth sums comparable to other countries
\nof the Western world, with the exception of
\nthe USA. Certainly in recent years we have
\nseen a marked change in the proportion of
\nGDP we spend on health. Five years into
\nthis investment, people are questioning
\nwhether there has been commensurate
\nimprovement.
\nPeople ask where has the money gone.
\nRectifying the legacy of historic under-
\nfunding has absorbed some of it. New tech-
\nnology and new buildings account for
\nmore. New contracts for NHS staff account
\nfor half of the resources, and incentives to
\nreach government targets have swallowed
\nup an appreciable amount.
\nDespite higher numbers of doctors, the UK
\nis still relatively low in the league table of
\npractising physicians per 1000 population.
\nFew westernised countries have lower
\nratios than the UK. Yet we face increasing
\npressures on the NHS resulting from an
\nincrease in the number of elderly people in
\nthe population, many of whom will have
\nmultiple morbidity.
\nChallenges for policy makers
\nThe Finance Ministry and the Department
\nof Health have two key priorities. They
\nmust enhance productivity and they must
\nincrease self management of care. The first,
\nthey plan to tackle by changing service pro-
\nvision and patterns of working within the
\nNHS. Their approach to increasing self
\nmanagement of care is through giving
\npatients greater choice of care pathways
\noutside hospital.
\nThe current level of NHS investment
\ngrowth will cease in 2008 and we will
\nreturn to the relative low annual increases
\nof around 2.5%. If the system is not work-
\ning well by then, people will question
\nwhether a \u201cfree-at-the-point-of-use\u201d model
\nis sustainable. We have two years left to
\nsort out the financial problems and demon-
\nstrate that the NHS can work.
\nMr James Johnson
\nM.D., FRCS, FRCP, FDSRCS
\nChairman of Council,
\nBritish Medical Association
\nTavistock Square, London, WC1H 9JP
\nMedical Science, Professional Practice and Education
\n9
\nNobel Peace Laureates and representa-
\ntives of 20 million health care providers
\ncall on governments to fund the scale up
\nof human resources needed to fight TB
\nGENEVA, 21 March 2006 \u2013 Nobel Peace
\nLaureates Archbishop Desmond Tutu and
\nBetty Williams joined forces with global
\nhealthcare organizations representing more
\nthan 20 million health care providers in
\nhighlighting the need to provide the neces-
\nsary human resources to fight the growing
\nTB threat in high burden countries. They
\ncalled on governments to immediately com-
\nmit to fund, train and scale-up the health
\ncare workforce to combat TB and help pre-
\nvent 5 000 daily deaths from this curable
\ndisease. At this special event, Eli Lilly &
\nCompany and six leading global health and
\nrelief organizations launched a number of
\nCollaboration with the Global Health Initiative
\nof the World Economic Forum: Initiatives
\nlaunched to address training and education
\nneeds in TB burdened countries
\ninitiatives to tackle the human resources
\ncrisis in TB treatment.
\nThough 90% of the world\u2019s population live
\nin countries that have adopted the interna-
\ntionally recommended strategy for control-
\nling TB, an adequately trained health care
\nworkforce is required to fully implement
\ncontrol programmes and save an additional
\n14 million lives over the next ten years.
\nAccording to the Stop TB Partnership, it is
\nestimated that US$250 million is needed
\nevery year to provide technical assistance to
\ncountries to provide the training and
\nstrengthening of TB control services to mil-
\nlions of care providers.
\nTo address this, the International Council of
\nNurses (ICN), the International Hospital
\nFederation (IHF), and the World Medical
\nAssociation (WMA) their new on-site and
\ndistance learning TB training programmes
\nfor nurses, hospital managers, doctors and
\nlaboratory technicians, which are being
\nrolled-out in the high-burden countries. The
\nWorld Economic Forum and the
\nInternational Federation of the Red Cross
\nand Red Crescent Societies outlined their
\nnew programs to introduce TB prevention
\nand treatment into the workplace and com-
\nmunities, so that workers and families can
\nbe diagnosed correctly and the social stig-
\nma of the disease reduced.
\nThis event follows the announcement of the
\nGlobal Plan to Stop TB 2006-2015 at the
\nAnnual Meeting of the World Economic
\nForum in Davos, and aims to raise aware-
\nness of the urgent need to expand and
\nstrengthen human resources to deliver the
\nGlobal Plan. Tuberculosis is re-emerging as
\na serious global health threat that causes 9
\nmillion new cases and 2 million deaths
\nevery year. Of these new cases, 400 000 are
\nof increasingly virulent drugresistant
\nstrains (MDR-TB), which are often
\nspawned by improper or incomplete treat-
\nment of normal TB. In several countries of
\nEastern Europe and Central Asia, MDR-TB
\nhas increased to 15 % of new cases, while
\nin several African countries with high HIV
\nprevalence, rates of TB have tripled.
\nAccording to the WHO, fewer than 1 in 50
\npeople who develop MDR-TB currently
\nhave access to effective treatment and the
\nvast majority die.
\nArchbishop Tutu, speaking from his per-
\nsonal experience with TB, said \u201cI urge the
\nG8, governments of TB burdened countries,
\nand international donors to address this gap
\nin funding for human resources urgently.\u201d
\nThe Archbishop, who contracted the dis-
\nease as a child in South Africa, continued
\n\u201cWithout well-trained health care providers
\nin the field we cannot possibly combat this
\ncurable disease which kills so many so
\nneedlessly, and the Global Plan will fail.
\nFourteen million lives can be saved and 50
\nmillion people treated in the next 10 years
\nif we address this crisis now and ramp-up
\ntraining and education in high burden coun-
\ntries.\u201d
\nEli Lilly and Company has committed $70
\nmillion to a ground breaking global partner-
\nship to fight multi-drug resistant tuberculo-
\nsis (Lilly MDR-TB Partnership**). Rich
\nPilnik, Lilly President of Europe, Africa,
\nMiddle East and CIS, comments: \u201cThe suc-
\ncessful treatment and prevention of this
\nsilent killer is above all dependent on suffi-
\ncient well trained, mobilized and motivated
\nhealth providers, particularly for multi-drug
\nresistant tuberculosis. As some of the pro-
\ngrams launched today show, we are begin-
\nning to build the defences, but now we need
\nto fight this war with welltrained profes-
\nsionals.\u201d
\n* High burden countries (the top 22
\nranked by number of new TB cases)
\ninclude: Afghanistan, Bangladesh,
\nBrazil, Cambodia, China, DR Congo,
\nEthiopia, India, Indonesia, Kenya,
\nMozambique, Myanmar, Nigeria,
\nPakistan, Philippines, Russian
\nFederation, South Africa, Tanzania,
\nThailand, Uganda, Viet Nam, Zimbabwe.
\n** The Lilly MDR-TB Partnership is a
\npublic-private initiative led by Eli Lilly
\n& Company to address the expanding
\ncrisis of multi-drug resistant tuberculo-
\nsis (MDR-TB) The partnership is pursu-
\ning a comprehensive strategy to fight
\nMDR-TB through increasing drug sup-
\nply and discounting prices, providing
\ntraining in prevention, treatment, and
\nsurveillance, and sharing drug manufac-
\nturing technology with nations most at
\nrisk. For further information www.lil-
\nlymdr-tb.com.
\nWorld Economic Forum
\nAs part of its Global Health initiative
\nlaunched in January 2002, the World
\nEconomic Forum (WEF) has developed a
\nunique TB Awareness Workplace Toolkit.
\nThe toolkit, consisting of educational mate-
\nrials, awareness programs, and suggested
\nprevention techniques for teaching in the
\nworkplace, will help employees, and com-
\npany health-care staff better understand
\nsymptoms of TB and seek timely diagnosis
\nand care.
\nThe International Council of Nurses
\n(ICN), the International Hospital
\nFederation (IHF) and the World Medical
\nAssociation (WMA), have all produced
\ntraining programmes which include detect-
\ning, planning and implementation of treat-
\nment for both TB and MDR-TB.
\nHeroki Minami, President of ICN stated
\n\u201cNurses are usually and often the only
\nhealth care professionals to see a person
\nwith TB or MDR-TB, particularly in strug-
\ngling health systems in developing coun-
\ntries where we are seeing TB re-emerging
\ndramatically.\u201d
\nThe Director General of the IHF (Per-
\nGunnar Svensson, said, \u201cIt is vital to recog-
\nnise that there is a need to include managers
\nof hospitals and health services in planning
\nand implementation of disease prevention
\nand control systems. Ignorance and non-
\ninvolvement\/exclusion can lead to adoption
\nand implementation of counter-productive
\ndecisions and actions\u201d
\nATB Distance-learning course is being pre-
\npared by the WMA, whose manual is being
\nconverted into a web-based course by the
\nNorwegian Medical Association for WMA,
\nand will provide Continuing Medical
\nEducation (CME) accreditation. While
\nfocusing on the quality of clinical care
\nneeded to treat tuberculosis Dr. Otmar
\nKloiber, Secretary-General of the WMA,
\nrecognising the fundamental causes of this
\ndisease and other global pandemics, said
\n\u201cTuberculosis is a disease that is strongly
\nrelated to social circumstances and living
\nconditions\u201d and explained \u201cTo improve the
\neconomic situation of the affected popula-
\ntions must be a central aim of any develop-
\nment, in other words: Fight Poverty\u201d.
\nMedical Science, Professional Practice and Education
\n10
\nWMA
\n11
\nI am honored to be here, to share my per-
\nspective on some of the World Medical
\nAssociation\u2019s initiatives this past year.
\nWhat was accomplished where we\u2019ve made
\nprogress and the work yet to be done.
\nAmong you, I see many familiar faces. Old
\nfriends and new. I am proud to be associat-
\ned with all of you, who care so much for
\nyour patients, practice medicine with such
\npassion and who work so hard to live out
\nand uphold the ethics of our profession.
\nAs WMA president, I tried to be true to that
\nmission. We want medical care everywhere
\nto be the best care anywhere. We promote
\nthe highest standards of medical education,
\nethics and science. And we expect the same
\nfrom the other players in our respective
\nhealth care systems \u2013 be they in the private
\nor public sectors.
\nAnd we have to expect something from our
\npatients, as well.
\nWe cannot speak too much, or too often, of
\nthe paramount importance of individual
\nhealth. It has been said that \u201cHe who has
\nhealth, has hope. And he who has hope, has
\neverything.\u201d
\nIn the last century, a mere instant in the
\ntimeline of human history, the rapid
\nadvance of medical progress and innova-
\ntions in care has supplied that hope for
\nthousands of millions of people in need.
\nHerophilus, a physician in ancient Greece,
\nsaid \u201cWhen health is absent, wisdom cannot
\nreveal itself, art cannot manifest, strength
\ncannot fight, wealth becomes useless, and
\nintelligence cannot be applied.\u201d
\nYou cannot put a price tag on hope, but
\nresearchers have placed a value on the eco-
\nnomic return of investments in better health,
\nhigher quality medical care and medical
\nresearch. It tells us the wealth of nations
\ndepends on the health of nations. And it is
\nwe, as physicians, who are the instruments
\nused to fulfill those hopes, address those
\nneeds and meet those expectations.
\nThe Canadian physician Sir William Osler,
\nwho was a philosopher as much as he was a
\ndoctor, described the heart and soul of what
\nwe do more than 100 years ago, no matter
\nwhere we live. \u201cThe practice of medicine is
\nan art, not a trade; a calling, not a business;
\na calling in which your heart will be exer-
\ncised equally with your head. Often the best
\npart of your work will have nothing to do
\nwith potions and powders, but with the
\nexercise of an influence of the strong upon
\nthe weak, of the righteous upon the wicked,
\nof the wise upon the foolish.\u201d
\nIt was just these sort of ethical issues that
\nled to the founding of the World Medical
\nAssociation in 1947. It\u2019s stated purpose: \u201dto
\nserve humanity by endeavoring to achieve
\nthe highest international standards in med-
\nical education, medical science, medical art,
\nand medical ethics and health care for all
\npeople of the world\u201d.
\nBehind its founding was a sad fact of life \u2013
\nthat the same rapid advances in medical
\ntechnology and innovations in care that has
\nbrought hope to millions could be twisted to
\nbring suffering to millions if conducted in
\nan ethical vacuum.
\nSince 1947, time and again, we\u2019ve seen the
\nimportance of National Medical Asso-
\nciations acting in their role as nongovern-
\nmental organizations, acting together as the
\nvanguard for medical ethics. We saw it in
\nthe aftermath of World War II, and we saw
\nit during the dictatorship in Iraq.
\nAs our world becomes smaller with more
\nintertwined interests, so also, the medical
\nassociations of the world need to tighten
\ntheir mutual bonds.
\nIn this global village, we need to support
\neach other. We need to provide a balance to
\na politics of scarcity that views medical care
\nand medical professions not as a value to be
\ncherished and protected but as a cost to be
\ncut, and controlled.
\nIt was in that spirit that I approached my
\nterm as president.
\nAs you know, we sometimes cannot accom-
\nplish everything that we wish for in our
\norganization. But while our finances may be
\nlimited, our imaginations are not, nor need
\nour influence or example.
\nWhen I assumed the WMA presidency, my
\ngoal was to continue to communicate the
\nunique, enduring traditions and values of
\nthe medical profession \u2013 that is caring,
\nethics and science. These three values are
\nshared by physicians throughout the
\nworld.
\nAs physicians we are committed to science
\nand the life-long process of learning. It
\ngives us a unique authority and perspective.
\nEthics compel us to put the interests of the
\npatient or the public health first.
\nCaring, as Osler said, \u201cis the most important
\nthing \u2013 so do it first. For it is the caring
\nphysician who most inspires hope and trust.\u201d
\nThese traditions enable physicians to pro-
\nvide value, hope and trust to patients and
\nsociety. They make us powerful advocates
\nfor our patients, our profession and the pub-
\nlic\u2019s health. They give us a common lan-
\nguage of action and behavior. They are, in
\nshort, what unify us.
\nI wanted to let the world know about the
\ngood work we do as an organization \u2013 and
\nthe great work done by physicians around
\nthe world. To remind people that there\u2019s a
\nhuman face on the concept \u2013 on the act \u2013 of
\nhealing. That science, ethics and caring
\naren\u2019t just words but a way of life.
\nWMA
\nWMA General Assembly, Santiago Presidential
\nValedictory Address, Yank D. Coble,
\nMD, MACP, MACE, October 14, 2005
\n\u201cApology: We apologise for the misprint in
\nWMJ 51(4) which, in the report of the Associ-
\nates\u2019 meeting, referred to a paper by the late
\nDr. Doppelfeld. We are pleased to report that
\nDr. Doppelfeld recovered from his spell in
\nhospital and we very much regret any distress
\nthis may have caused\u201d.
\nTo me, that idea is represented in the Caring
\nPhysicians of the World Initiative.
\nWith the help of the Pfizer Medical
\nHumanities Initiative (PMHI) team, led by
\nDirector Mike Magee, we decided to pro-
\nduce a publication profiling physicians
\namong those nominated by National
\nMedical Associations around the world.
\nThese are physicians who carry on the tra-
\ndition of caring ethics and science while
\npracticing or teaching medicine in an array
\nof circumstances, some difficult, some dan-
\ngerous, all of them a challenge. And all the
\nwhile, they give of themselves in service to
\npatients or students.
\nOur national medical associations were
\ninterested, but assembling this book would
\nrequire a lot of resources, including trips to
\noften remote locations to photograph this
\ninternational array of physicians and learn
\ntheir stories. Again, the PMHI Team
\nstepped forward with generous support. At
\nthe same time, they left all decisions on
\nselection, writing and editing to us. We pre-
\nsented the idea at WMA gatherings
\nthroughout 2004, and in November of that
\nyear, requests for nominations were sent to
\nnational associations.
\nWe asked for rapid response so we could
\ncomplete the publication within one year
\nand launch the book during the WMA
\nAnnual meeting in Santiago, Chile in
\nOctober, 2005.
\nThe response was overwhelming. Within
\ntwo months, 55 national associations nomi-
\nnated more than 200 physicians. We heard
\nnot only from members, but from NMAs
\nthat were not yet members. We also received
\nnominations from people outside the med-
\nical professions, particularly for physicians
\nwho performed so admirably following the
\nSouth Asian tsunami of December, 2004.
\nOf the 200 nominees, 65 physicians were
\nselected, interviewed, photographed in their
\nhome environments and profiled.
\nPhysicians such as Valentin Pokrovsky, a
\nleading expert on AIDS and the first person
\nin Russia to describe HIV-infection and
\nAIDS;
\nOtar Toidze, a neurologist and epileptolo-
\ngist who became a Member of Parliament
\nin Georgia;
\nEmily Chan, President of the Hong Kong
\nsection of Medecins Sans Frontieres;
\nNanshan Zhong, China\u2019s top expert on
\nSevere Acute Respiratory Syndrome, who
\nplayed such a vital role in the SARS epi-
\ndemic in 2002;
\nBenito Atienza of the Philippines, who cre-
\nated the Child Community Health Workers
\nFoundation;
\nHoang Dinh Cau, who is the chairman of
\nthe Committee for Investigation of the
\nConsequences of Chemicals Used in the
\nVietnam War;
\nMamphela Ramphele, who was imprisoned
\nfor her anti-apartheid political activities,
\nand went on to become the first black
\nwoman Vice Chancellor at a South African
\nUniversity and then a managing director of
\nthe World Bank.
\nAnd John Awoonor-Williams from Ghana,
\nwho works in one of the remotest areas of
\nthe world as the only doctor serving a vast
\narea.
\nHeroes all, immortalized not just in their
\nwork, but now in words and pictures, as well.
\nWe made our deadline. The book cleared
\ncustoms in Santiago less than 24 hours
\nbefore our scheduled launch two days ago,
\nOctober 12, 2005.
\nWhen we unveiled \u201cCaring Physicians of
\nthe World,\u201d the event was attended by more
\nthan 200 people .and we presented the first
\nvolumes to our hosts, the Chilean Medical
\nAssociation and their nominee profiled in
\nthe book.
\nA separate web site was linked to the WMA
\nweb site and described in detail the purpose
\nbehind the book \u2013 how it came to be pub-
\nlished \u2013 and why we believe it\u2019s an important
\nglimpse into the lives of physicians the world
\nover. All nominees and all National Medical
\nAssociations have received the \u201cCaring
\nPhysicians of the World\u201d book. Some of you
\nhave used the book in press conferences and
\nmeetings with government officials and relat-
\ned health professions and organizations.
\nMore than 250 copies of the book were dis-
\ntributed to health and medical leaders in
\nGeneva at the World Health Organization
\nand other groups. In the United States,
\ncopies have been distributed widely among
\nthe leadership of the American Medical
\nAssociation and the leadership of national
\nmedical specialty associations, state med-
\nical associations, health related organiza-
\ntions, and government agencies.
\nIf you want to read some positive reviews
\nand widespread publicity, type the words
\n\u201cCaring Physicians of the World\u201d into a
\nGoogle search.
\nAll of this \u2013 the extraordinary expressions of
\ngratitude by the nominees – and by their
\nassociations, families and friends, suggest
\nthat physicians appreciate this sort of recog-
\nnition. For some, it is what helps them perse-
\nvere through often difficult circumstances.
\nNMA response has been equally gratifying.
\nTwo of the largest NMAs in terms of physi-
\ncian numbers, who are WMA members but
\nwere inactive and non dues paying for sev-
\neral years, nominated physicians for inclu-
\nsion, subsequently paid dues, and request-
\ned presentation of the book at an annual
\nmeeting.
\nThe WHO has requested that the \u201cCaring
\nPhysicians of the World\u201d book be presented
\non April 7 during World Health Day and
\npresented to press conferences in London
\nor Lusaka. For our part, the WMA will hold
\na press conference for the Ministers of
\nHealth of all nations participating in the
\nWHA in Geneva in May 2006. We\u2019ll be
\nshowing off the book and making sure that
\nthe WHO delegations get a copy. Beyond
\nthat, plans are in the works to distribute the
\nbook to English language medical schools,
\nand we\u2019re seeking new venues to get this
\nmessage out.
\n\u201cThe Caring Physicians of the World,\u201d
\nthrough photographs and words, conveys a
\ncompelling story about the impact of med-
\nical professionals on their communities and
\ntheir countries. I am confident that it will
\ncontinue to be a useful resource and refer-
\nence for our organization and for those
\norganizations we engage.
\nNMA Survey & CPWI: Out-
\nreach and Regional Meetings
\nBut this book was only one way the World
\nMedical Association is opening its lines of
\ncommunication.
\nWMA
\n12
\nIn the summer of 2004 the WMA complet-
\ned a survey of its member associations that
\nrevealed that we share many of the same
\nconcerns and needs, such as diminished
\naccess to quality, safe, affordable medical
\ncare, limited patient choice, reduction of
\nprofessional prestige, and appropriate
\nautonomy and compensation. These are
\nproblems for our profession that cross all
\nnational and cultural borders.
\nKnowing this helps the WMA better
\napproach our priorities and communicate
\nbetter with our member national associa-
\ntions. It also helps us communicate better
\nwith outside organizations, and the public.
\nOutreach
\nOur Caring Physicians of the World out-
\nreach effort is striving to re-introduce the
\nWMA to those national medical associa-
\ntions that have been inactive.
\nThis included the associations from two of
\nthe most populous nations on the planet.
\nIn the space of a single one-year period, we
\nhad four meetings with the Chinese
\nMedical Association and other medical
\ngroups there \u2013 including the Shanghai First
\nWorld Medical Summit and the Shanghai
\nMedical University.
\nThe World Medical Association\u2019s Caring
\nPhysicians of the World initiative also
\nreached out to India \u2013 I spoke in February
\nto the Indian Medical Association and
\nMedical Council of India in Delhi, and
\naddressed officials of their association
\nagain in December.
\nThe initiative\u2019s outreach support also gave
\nthe new Secretary General and President the
\nopportunity to visit jointly with NMAs, a
\nkey representation benefit that would have
\nbeen otherwise impossible.These included
\nthe annual meeting of the American Medical
\nAssociation, the inaugural ceremony of the
\nCanadian Medical Association, the
\nConfederation of Latin American Nations
\nand the Caribbean (CONFEMEL) in Costa
\nRica, the Israel Medical Association, the
\nSouth African Medical Association, and the
\nThailand Medical Association. We carried
\nour message of the Caring Physicians of the
\nworld as well to the Hungarian Medical
\nAssociation, the Taiwan Medical
\nAssociation, the Colegio Medico de Mexico,
\nthe Portuguese Medical Association, and the
\nBritish Medical Association.
\nThe WMA took part in the WHO Executive
\nBoard meetings in January and March,
\n2005, which focused on the tsunami res-
\nponse effort; and also participated in the
\nWHO strategic workgroup on Diet, Fitness
\nand Health.
\nThe WMA also reached out to the World
\nHealth Assembly (WHA) in May.
\nOther events of note include:
\n\u2022 Keynoting of the WMA World Oceans
\nForum November, 2004 in New York;
\n\u2022 Chairing the WMA Ethics Manual
\nlaunch in Geneva, Switzerland in
\nJanuary, 2005 (the ethics manual has
\nalready been translated into more than a
\nhalf-dozen languages);
\n\u2022 Addressing the World Bank Forum on
\nCounterfeit Drugs;
\n\u2022 Meetings with the World Bank leader-
\nship on Global response to AIDS,
\nTuberculosis and Malaria;
\n\u2022 Participation in formation meetings of
\nthe Iraqi Physicians Society and the
\nProject Hope Basra, at the Iraq Pediatric
\nHospital;
\n\u2022 And addressing the US DHHS\/DOD
\nForum on disaster response for tsunami
\neffected countries.
\nRegional Meetings
\nThe third component of the CPWI, stimu-
\nlated by NMA response to our WMA ques-
\ntionnaire the summer of 2004, was the
\nestablishment of WMA\/CPW Regional
\nMeetings of NMAs around the world These
\nmeetings enable WMA to listen and learn
\nhow to best serve their membership and
\nadvocate on behalf of patients and the pro-
\nfession, enhance exchange of information
\nbetween WMA and NMAs, and among
\nNMAs in regions, and enhance NMA\u2019s
\neffectiveness and growth.
\nThe concerns expressed by NMAs reflected
\nthe concerns of Physicians worldwide:
\ndiminishing access to safe, affordable med-
\nical care; limited patient choice; erosion of
\nprofessional prestige, and appropriate
\nautonomy and compensations.
\nThe first regional meeting was among Sub-
\nSaharan NMAs in Johannesburg, South
\nAfrica in January 2005. The second highly
\nsuccessful regional meeting was among
\nLatin American NMAs here in Santiago
\nfour days ago.
\nRegional meetings are planned for South
\nEast Asian NMAs in November in Bang-
\nkok, European NMAs in Prague in
\nDecember 2005, and North American
\nNMAs in Florida March 2006.
\nEach of these regions and each of these
\norganizations have different needs and
\ninterests and capabilities. Each can teach us
\nsomething new about the practice and value
\nof medicine. Each can tell us more about
\nwhy it is so important \u2013 to rally around the
\nbanner of science, ethics and caring.
\nScience, Ethics and Caring
\nThese are the three enduring traditions.
\nScience \u2013 ethics \u2013 caring.
\nWe see these exemplified in the 65 of our
\ncolleagues profiled in the \u201cCaring Phy-
\nsicians of the World\u201d book. We see it prac-
\nticed by physicians everywhere.
\nThey are what make us effective advocates
\nfor patients and for our profession, no mat-
\nter where we live. They give us an anchor \u2013
\na sense of permanence \u2013 in an imperfect
\nand transitory world of political upheavals,
\npolicy shifts and spasms of public opinion.
\nGet involved \u2013 become an activist in nation-
\nal and international organizations that affect
\nyour patients and your calling. That way,
\nyou make an impact as an individual and as
\npart of chorus of powerful voices, singing as
\none. A voice that makes entities in govern-
\nment and industry which may seem distant
\nand unresponsive, sit up and take notice.
\nAlso to learn what we do, what we stand for
\nand the values we embrace. All in the ser-
\nvice of our patients and the public health.
\nWe are the global face of medicine. We
\nshare a commitment to the best science \u2013 to
\ncaring and compassion \u2013 and to the highest
\nethical standards. We are by now familiar
\nwith those profiled as Caring Physicians of
\nthe World what they do every day to change
\nthe course of health care in their communi-
\nties and in their countries.
\nOur challenge, each and every one of us , is
\nto effect that change wherever we may live.
\nBecause all of us are the \u201cCaring Physicians
\nof the World.\u201d
\nWMA
\n13
\nWMA
\n14
\nPreamble
\n1. Alcohol use is deeply embedded in
\nmany societies. Overall, 4% of the
\nglobal burden of disease is attributable
\nto alcohol, which accounts for about
\nas much death and disability globally
\nas tobacco or hypertension. Overall,
\nthere are causal relationships between
\nalcohol consumption and more than
\n60 types of disease and injury includ-
\ning traffic fatalities. Alcohol con-
\nsumption is the leading risk factor for
\ndisease burden in low mortality devel-
\noping countries and the third largest
\nrisk factor in developed countries.
\nBeyond the numerous chronic and
\nacute health effects, alcohol use is
\nassociated with widespread social,
\nmental and emotional consequences.
\nThe global burden related to alcohol
\nconsumption, both in terms of morbid-
\nity and mortality, is considerable.
\n2. Alcohol-related problems are the
\nresult of a complex interplay between
\nindividual use of alcoholic beverages
\nand the surrounding cultural, econom-
\nic, physical environment, political and
\nsocial contexts.
\n3. Alcohol cannot be considered an ordi-
\nnary beverage or consumer commodi-
\nty since it is a drug that causes sub-
\nstantial medical, psychological and
\nsocial harm by means of physical tox-
\nicity, intoxication and dependence.
\nThere is increasing evidence that
\ngenetic vulnerability to alcohol depen-
\ndence is a risk factor for some individ-
\nuals. Fetal alcohol syndrome and fetal
\nalcohol effects, preventable causes of
\nmental retardation, may result from
\nalcohol consumption during pregnan-
\ncy. Growing scientific evidence has
\ndemonstrated the harmful effects of
\nconsumption prior to adulthood on the
\nbrains, mental, cognitive and social
\nfunctioning of youth and increased
\nlikelihood of adult alcohol depen-
\ndence and alcohol related problems
\namong those who drink before full
\nphysiological maturity. Regular alco-
\nhol consumption and binge drinking
\nin adolescents can negatively affect
\nschool performance, increase partici-
\npation in crime and adversely affect
\nsexual performance and behaviour.
\n4. Alcohol advertising and promotion is
\nrapidly expanding throughout the
\nworld and is increasingly sophisticat-
\ned and carefully targeted, including to
\nyouth. It is aimed to attract, influence,
\nand recruit new generations of poten-
\ntial drinkers despite industry codes of
\nself-regulation that are widely ignored
\nand often not enforced.
\n5. Effective alcohol social policy can put
\ninto place measures that control the
\nsupply of alcohol and\/or affect popu-
\nlation-wide demand for alcohol bever-
\nages. Comprehensive policies address
\nlegal measures to: control supply and
\ndemand, control access to alcohol (by
\nage, location and time), provide public
\neducation and treatment for those who
\nneed assistance, levy taxation to affect
\nprices and to pay for problems gener-
\nated by consumption, and harm-reduc-
\ntion strategies to limit alcohol-related
\nproblems such as impaired driving
\nand domestic violence.
\n6. Alcohol problems are highly correlat-
\ned with per capita consumption so that
\nreductions of use can lead to decreas-
\nes in alcohol problems. Because alco-
\nhol is an economic commodity, alco-
\nhol beverage sales are sensitive to
\nprices, i.e., as prices increase, demand
\ndeclines, and visa versa. Price can be
\ninfluenced through taxation and effec-
\ntive penalties for inappropriate sales
\nand promotion activities. Such policy
\nmeasures affect even heavy drinkers,
\nand they are particularly effective
\namong young people.
\n7. Heavy drinkers and those with alco-
\nhol-related problems or alcohol
\ndependence cause a significant share
\nof the problems resulting from con-
\nsumption. However, in most coun-
\ntries, the majority of alcohol-related
\nproblems in a population are associat-
\ned with harmful or hazardous drinking
\nby non-dependent \u2018social\u2019 drinkers,
\nparticularly when intoxicated. This is
\nparticularly a problem of young peo-
\nple in many regions of the world who
\ndrink with the intent of becoming
\nintoxicated.
\n8. Although research has found some
\nlimited positive health effects of low
\nlevels of alcohol consumption in some
\npopulations, this must be weighed
\nagainst potential harms from con-
\nsumption in those same populations as
\nwell as in population as a whole.
\n9. Thus, population-based approaches
\nthat affect the social drinking environ-
\nment and the availability of alcoholic
\nbeverages are more effective than
\nindividual approaches (such as educa-
\ntion) for preventing alcohol related
\nproblems and illness. Alcohol policies
\nthat affect drinking patterns by limit-
\ning access and by discouraging drink-
\ning by young people through setting a
\nminimum legal purchasing age are
\nespecially likely to reduce harms.
\nThe World Medical Association Statement on reducing the global
\nImpact of Alcohol on Health and Society
\nAdopted by the WMA General Assembly, Santiago 2005
\nWMA
\n15
\nLaws to reduce permitted blood alco-
\nhol levels for drivers and to control
\nthe number of sales outlets have been
\neffective in lowering alcohol prob-
\nlems.
\n10. In recent years some constraints on the
\nproduction, mass marketing and pat-
\nterns of consumption of alcohol have
\nbeen weakened and have resulted in
\nincreased availability and accessibility
\nof alcoholic beverages and changes in
\ndrinking patterns across the world.
\nThis has created a global health prob-
\nlem that urgently requires governmen-
\ntal, citizen, medical and health care
\nintervention.
\nRecommendations
\nThe WMA urges National Medical
\nAssociations and all physicians to take the
\nfollowing actions to help reduce the
\nimpact of alcohol on health and society:
\n11. Advocate for comprehensive national
\npolicies that
\na. incorporate measures to educate the
\npublic about the dangers of haz-
\nardous and unhealthy use of alcohol
\n(from risky amounts through depen-
\ndence), including, but not limited to,
\neducation programs targeted specif-
\nically at youth;
\nb. create legal interventions that focus
\nprimarily on treating or provide evi-
\ndence-based legal sanctions that
\ndeter those who place themselves or
\nothers at risk, and
\nc. put in place regulatory and other
\nenvironmental supports that pro-
\nmote the health of the population as
\na whole.
\n12. Promote national and sub-national
\npolicies that follow \u2018best practices\u2019
\nfrom the developed countries that with
\nappropriate modification may also be
\neffective in developing nations. These
\nmay include setting of a minimum
\nlegal purchase age, restricted sales
\npolicies, restricting hours or days of
\nsale and the number of sales outlets,
\nincreasing alcohol taxes, and imple-
\nmenting effective countermeasures for
\nalcohol impaired driving (such as low-
\nered blood alcohol concentration lim-
\nits for driving, active enforcement of
\ntraffic safety measures, random breath
\ntesting, and legal and medical inter-
\nventions for repeat intoxicated dri-
\nvers).
\n13. Be aware of and counter non-evi-
\ndence-based alcohol control strategies
\npromoted by the alcohol industry or
\ntheir social aspect organizations.
\n14. Restrict the promotion, advertising
\nand provision of alcohol to youth so
\nthat youth can grow up with fewer
\nsocial pressures to consume alcohol.
\nSupport the creation of an independent
\nmonitoring capability that assures that
\nalcohol advertising conforms to the
\ncontent and exposure guidelines
\ndescribed in alcohol industry self-reg-
\nulation codes.
\n15. Work collaboratively with national
\nand local medical societies, specialty
\nmedical organizations, concerned
\nsocial, religious and economic groups
\n(including governmental, scientific,
\nprofessional, nongovernmental and
\nvoluntary bodies, the private sector,
\nand civil society) to:
\na. reduce harmful use of alcohol, espe-
\ncially among young people and
\npregnant women, in the workplace,
\nand when driving;
\nb. increase the likelihood that every-
\none will be free of pressures to con-
\nsume alcohol and free from the
\nharmful and unhealthy effects of
\ndrinking by others; and
\nc. promote evidence-based prevention
\nstrategies in schools.
\n16. Undertake to
\na. screen patients for alcohol use dis-
\norders and at-risk drinking, or
\narrange to have screening conducted
\nsystematically by qualified person-
\nnel using evidence-based screening
\ntools that can be used in clinical
\npractice;
\nb. promote self-screening \/ mass
\nscreening with questionnaires that
\ncould then select those needing to
\nbe seen by a provider for assess-
\nment;
\nc. provide brief interventions to moti-
\nvate high-risk drinkers to moderate
\ntheir consumption; and
\nd. provide specialized treatment, in-
\ncluding use of evidence-based phar-
\nmaceuticals, and rehabilitation for
\nalcohol-dependent individuals and
\nassistance to their families.
\n17. Encourage physicians to facilitate epi-
\ndemiologic and health service data
\ncollection on the impact of alcohol.
\n18. Promote consideration of a Frame-
\nwork Convention on Alcohol Control
\nsimilar to that of the WHO Framework
\nConvention on Tobacco Control that
\ntook effect on February 27, 2005.
\n19. Furthermore, in order to protect cur-
\nrent and future alcohol control mea-
\nsures, advocate for consideration of
\nalcohol as an extra-ordinary commod-
\nity and that measures affecting the
\nsupply, distribution, sale, advertising,
\npromotion or investment in alcoholic
\nbeverages be excluded from interna-
\ntional trade agreements.
\nyoung physicians has been suggested.
\nBonding means to oblige a person to pro-
\nvide a service in return e,g, for the educa-
\ntion they have received. Bonding could also
\nbe seen as part of a social contract, when
\nphysicians return a service for the state paid
\neducation they received. However there are
\nmany problems with bonding other than
\nthat young workers or college graduate stu-
\ndents are not being paid. One could argue
\nthat the return has already been made, it is
\ntheir commitment to study and not receive
\na salary for that work. Also, each nation
\nthat believes in equality before the law
\nwould have to demand the same bonding
\nfrom every other student as well.
\nYet good examples of voluntary bonding
\nexist and bonding can serve to guarantee a
\nworkforce. For those who promise to serve
\nin certain areas, special benefits or prefer-
\nential treatment could be awarded. But that
\nonly works if there are focal shortfalls, e.g.
\nin a certain rural area or in the military.
\nWhen there is a general shortage of physi-
\ncians, voluntary bonding is meaningless. In
\nthese cases a better payment and better
\nworking conditions would be the straight-
\nforward approach.
\nThere is a decreasing willingness to accept
\n36 hours shifts, there is a demand for
\nparental leave and there is a higher demand
\nfor more private time in general. To blame
\nthis trend on a feminisation of medicine is
\nshortsighted. It is true that medicine is no
\nlonger a male domain. In many countries
\nthe majority of graduates now are female
\nand new gender mix reaches the workplace.
\nBut a suggestion that women go off the job
\nbecause they marry and have children and
\ntherefore reduce the workforce, is far too
\neasy.
\nThirty years ago the typical physician was
\nmale and provided the single income of the
\nfamily. He would work 150 to 200 % of
\nwhat was a normal workload and (in the
\nwestern world) would receive a decent
\nincome after specialization. Today physi-
\ncians, male and female, are in relationships
\nwith spouses who have their own profes-
\nsional life. Burdens are to be shared
\nbetween equal partners, nor do young
\nphysicians do, or want to have. The same
\nwork load as their predecessors regardless
\nof whether they are male or female.
\n\u201cWork-life balance\u201d is a phrase that our
\nslave-like profession is slowly learning to
\nrecognize. Although senior physicians
\noften see it as a kind of mutiny, those who
\nare asking for more private time and rea-
\nsonable working hours, are only asking for
\nwhat other professions see as their natural
\nright since decades.
\nThe traditional expectation of a good
\nincome in a late part of our professional life
\nhas for a long time led us to often tolerate
\ninadequate payment and unacceptable
\nworking conditions, Often to the extent
\nthat the average salary of a young physician
\nis lower than that of a factory worker. And
\nwith the increasing tendency of employers
\nto be unwilling or able to pay for over-
\nhours worked, the misery does not start, but
\nbecomes visible.
\nGrave as are the failures of governments,
\npoliticians, insurances, managed care orga-
\nnizations, hospital owners and other out-
\nsiders in regulating the health care labour
\nmarket, we have to acknowledge that we
\nmade mistakes ourselves. There are certain
\nmyths and misunderstandings we have to
\nclarify ourselves:
\n1. A good physician is always available.
\nPhysicians have the same physiology as
\nother humans. There is a point when an
\noverworked person doing a danger-
\nprone work becomes a danger him or
\nherself. That is what every physician
\nwould tell an employer. It\u2019s now time to
\ntell it our employers. And when we
\nindeed believe in the equality of men
\nand women, and when we indeed value
\nthe family, we have to change the med-
\nical work place now.
\n2. The more experience you get \u2013 the more
\nyou learn \u2013 that is wishful thinking. One
\ncan have a lot of experience and still
\nmake everything wrong. Learning is pri-
\nmarily not a question of quantity but of
\nFrom the Secretary Gerneral\u2019s desk
\n16
\nAs WHO invites governments and institu-
\ntions to celebrate World Health Day 2006
\nunder the theme \u201eWorking together for
\nhealth\u201c, the people working in health care
\nin many countries of this world may have
\nthe feeling that there is not very much to
\ncelebrate. Actually there is rather a ques-
\ntion, \u201cWhere to go?\u201d and the answer has
\nalready been given: \u201cfrom East to West and
\nfrom South to North\u201d. The migration of
\nhealth professionals is soaring and clearly
\nfollows an economic gradient from poor
\ncountries to rich countries. While in Europe
\nthe migration from East to West is partly
\ncompensated by an oversupply of physi-
\ncians in East and Central Europe, and the
\nbrain drain from African countries in partic-
\nular, reaches catastrophic dimensions.
\nBut to believe that money is the only dri-
\nving force for health professionals to
\nmigrate falls short of reality. There are
\nmany other reasons that make physicians
\n(and other health professions) go or stay.
\nWorking conditions, amongst them the
\navailability of material local items that lead
\nto a decision whether to go or to stay. The
\nenvironment in which the physician and his
\nor her family have to live certainly is anoth-
\ner. However, cross border migration is not
\nthe only move that is possible. Young physi-
\ncians leave medicine and search other fields
\nof work in their country, sometimes imme-
\ndiately after passing their final exams.
\nEstablished physicians retire early or they
\nsimply discover that there is \u201clife beyond
\nmedicine\u201d and decide to reduce their work-
\nload at the expense of a lower income.
\nCountries with an emigration of physicians
\nhave to try very hard to do whatever they
\ncan to offer better conditions to physicians
\n(and other health professions) and their
\nfamilies, if they wish to retain them. The
\nexpenses of educating physicians alone
\nshould make it a necessity for all countries
\nto retain as many of the physicians they
\nhave trained as is possible. Bonding of
\nFrom the Secretary General\u2019s desk
\nWorking together for health \u2013 Human
\nResources for Health World Health Day 2006
\nquality. Burying young physicians under
\nwork does not mean that they learn a lot
\n\u2013 unless you take frustration as a learn-
\ning experience. Those senior physicians
\nwho believe that their assistants or
\ninterns only learn when working long
\nhours, have probably missed the most
\nimportant lesson of their life, namely
\nhow to teach.
\n3. It is similar with our (specialist) educa-
\ntion. Whatever is new in medicine sim-
\nply adds up to medical education. Every
\none of us knows examples of things we
\nlearnt as being essential at the beginning
\nof our professional career, (some of
\nwhich were outdated even before we fin-
\nished formal education). With an ever
\nfaster evolving knowledge, the exten-
\nsion of training duration is exactly the
\nwrong strategy. Instead of prolonging
\nour basic and specialist training ever
\nmore, we would be better off to reduce
\nthese periods and admit that we have to
\nundergo (structured) education as part of
\nour professional development for our
\nwhole lifetime.
\n4. Those responsible for the working con-
\nditions of physicians are often physi-
\ncians themselves. Sometimes they are
\nreacting to a miserable shortage of
\nresources management, truly earning the
\ntitle of a disaster. We are in no position
\nto blame them. But often senior physi-
\ncians simply exploit young doctors for
\ntheir own profit The more hierachical
\nthe organizational structure is the more
\nthis becomes a danger. The exploitation
\nof physicians by senior physicians is not
\nacceptable.
\n5. We don\u2019t talk about money. That is fine
\n\u2013 as long as you have enough of it. In
\nmany countries of this world physicians
\nare underpaid, absolutely and in relation
\nto the general population. More and
\nmore often this happens in the western
\nworld as well. Whoever thinks that a
\nhighly valuable service can be delivered
\nfor token payment lives an illusion.
\nWaiting lists, \u201cunder the table pay-
\nments\u201d and emigration, are the immedi-
\nate answer. Whoever organizes such a
\nsystem betrays both the physicians and
\nthe patients. Being silent about this is a
\nshame.
\nSir William Osler said: \u201eThe most impor-
\ntant thing is caring, so do it first, for the car-
\ning physician best inspires hope and trust.\u201c
\nLet\u2019s do our part, to give our young col-
\nleagues a chance to care.
\nWHO
\n17
\nThe World Health Organization (WHO)
\ncalls for immediate concrete action against
\nthe growing epidemic of counterfeit medi-
\ncines. In a bid to accelerate the war on fake
\ndrugs, the agency pushed for stronger glob-
\nal cooperation, political commitment and
\ncreative solutions at a meeting in Rome
\n16 \u2013 18 February, 2006.
\nWHO aims to create a global task force
\ninvolving all major interested parties. The
\ntask force will focus on legislation and law
\nenforcement, trade, risk communications
\nand innovative technology solutions,
\nincluding public-private initiatives for
\napplying new technologies to the detection
\nof counterfeits and technology transfer to
\ndeveloping countries.
\nThe counterfeiting of medicines is present
\nin all countries and is thought to represent
\n10% of the global medicines trade.
\nParticularly insidious, counterfeit medi-
\ncines dupe sick people into believing they
\nWHO
\nCounterfeit medicines: the silent epidemic
\nWHO convenes stakeholders to find global solutions to a growing
\nhealth threat
\nare taking something which will make
\nthem well, when it may instead make them
\nsicker or even kill them.
\n\u201ePeople don\u2019t die from carrying a fake
\nhandbag or wearing a fake t-shirt. They can
\ndie from taking a counterfeit medicine,\u201d
\nsays Howard Zucker, Assistant Director
\nGeneral for Health Technology and
\nPharmaceuticals at WHO. \u201cInternational
\npolice action against the factories and dis-
\ntribution networks should be as uncompro-
\nmising as that applied to the pursuit of nar-
\ncotic smuggling.\u201d
\nCounterfeit medicines are part of the
\nbroader phenomenon of substandard phar-
\nmaceuticals. The difference is that they are
\ndeliberately and fraudulently mislabelled
\nwith respect to identity and\/or source.
\nThese products mostly have no therapeutic
\nbenefit; they can cause drug resistance and
\ndeath.
\nTrade in counterfeits is extremely lucrative,
\nthus making it more attractive to criminal
\nnetworks. A report released by the Centre
\nfor Medicines in the Public Interest, in the
\nUnited States, projects counterfeit drug
\nsales to reach US$ 75 billion in 2010, a
\n92 % increase from 2005.
\nThe presence of fake drugs is more preva-
\nlent in countries with weak drug regulation
\ncontrol and enforcement. However, no sin-
\ngle country is immune to the problem.
\nReports from the pharmaceutical industry
\nand governments clearly indicate that the
\nmethods and channels used by counterfeit-
\ners are becoming more sophisticated, mak-
\ning detection more difficult. Measures for
\ncombating counterfeit medicines so far
\nhave included support to under-resourced
\ndrug regulatory authorities; simple, easily
\ninterpretable and cheap markers of authen-
\nticity such as barcoding; transnational sur-
\nveillance for fake and substandard drugs;
\nand education of patients, healthcare work-
\ners, and pharmacists.
\n\u201cThese measures need to be intensified,\u201d
\nadds Dr Zucker. \u201cCountries should think
\nabout ways to make the necessary techno-
\nlogical, legislative and financial adjust-
\nments as quickly as possible to guarantee
\nthe availability of quality assured essential
\ndrugs.\u201d
\nWHO would also like to see more develop-
\nments in the areas of innovative high and
\nlow tech solutions for prevention at the
\nmanufacturing stage and for detection in
\nthe distribution chain.
\nSimple, inexpensive methods to identify
\nfakes can be effective. For example, simple
\ncolorimetric assays developed for
\nartemisinins have been used successfully to
\nidentify fake artesunate antimalarials.
\nWHO set up the world\u2019s first web-based
\nsystem for tracking the activities of drug
\ncheats in the Western Pacific Region in
\n2005. The Rapid Alert System (RAS) com-
\nmunications network transmits reports on
\nthe distribution of counterfeit medicines to
\nthe relevant authorities for them to take
\nrapid countermeasures. That system should
\nbe expanded to include all regions.
\nRadio frequency identification (RFID) and
\nmore sophisticated technologies for prod-
\nuct tracking within supply chain manage-
\nment systems are being experimented with
\nin some countries. Means must be sought to
\nmake these more sophisticated tools avail-
\nable and workable in developing countries.
\nInformation on fake drug identity and dis-
\ntribution needs to be shared nationally and
\ninternationally between government drug
\nregulatory authorities, customs and police
\norganizations, pharmaceutical companies,
\nnon-governmental organizations, and con-
\nsumer groups. Risk communications,
\ninvolving the media, should be practised to
\nraise public awareness.
\nThe Rome conference was hosted by the
\nItalian Pharmaceutical Agency (AIFA) and
\nItalian Cooperation, and organized with the
\nsupport of the International Federation of
\nPharmaceutical Manufacturers &
\nAssociations (IFPMA) and the German
\nGovernment. Participants in the conference
\nincluded experts from national govern-
\nments and regulatory authorities, industry,
\nintergovernmental organizations, and con-
\nsumer and patient groups.
\nContact:
\nDaniela Bagozzi
\nTelephone: + 41 22 791 45 44
\nMobile phone: + 41 794 75 5490
\nE-mail: bagozzid@who.int
\nWHO
\n18
\nCountries around the world are taking
\neffective measures to curb tobacco use,
\nincluding strong legislation, graphic warn-
\ning labels and advertising bans. These posi-
\ntive changes reinforce the commitment
\nmade by the more than 110 countries who
\nmet to decide on the detailed implementa-
\ntion of the World Health Organization
\nFramework Convention on Tobacco
\nControl (WHO FCTC).
\nAt the opening of the first session of the
\nConference of the Parties (COP) to the
\nWHO Framework Convention on Tobacco
\nControl, in Geneva \/Feb 6\u201317m, 2006) Dr
\nLEE Jong-wook, WHO Director General
\nsaid.
\n\u201cOne hundred and twenty one countries are
\nnow contracting parties to the Convention.
\nOf these, 110 are here today, with full pow-
\ners of participation. You represent nearly
\nthree quarters of the world\u2019s population.
\nYou represent nations at all levels of income
\nand all stages of development. In this pow-
\nerful gathering, we have three of the five
\ntop tobacco-leaf exporting countries, and
\nfour of the five top cigarette-exporting
\ncountries. This group of countries repre-
\nsents 69% of the world\u2019s cigarette con-
\nsumption. It might seem astonishing that
\nthis group is also preparing to put into
\naction the roadmap for countries to control
\ntobacco. But this group has already changed
\nhistory.
\nWhen the process began there was some
\nscepticism over its success. The sceptics
\nwere wrong.
\nYou are driving change forward. To name
\nsome examples: India has introduced com-
\nprehensive tobacco advertising bans.
\nAustralia, Brazil, Canada, Singapore and
\nThailand have introduced highly visible
\ngraphic warnings on cigarette packets. The
\nEuropean Union is on its way to doing the
\nCountries representing three-quarters of the
\nworld\u2019s population meet in Geneva to plan
\nthe effective implementation of the tobacco
\ncontrol treaty
\nsame. In Ireland, Norway, and now in
\nSpain, smoking has been banned in indoor
\npublic places. These, and other similar
\nsteps, will result in a major reduction in
\ntobacco deaths.
\nNew York State passed a smoking ban. It
\ntermed this act its \u201cstrongest public health
\npolicy ever\u201d. Ironically, now it\u2019s said that
\nthe only place you can smoke with impuni-
\nty in New York City is the United Nations
\nBuilding.
\nBoth Ann Veneman and I have said that this
\nis wrong. Smoking should be banned in all
\nUN premises. Also, cigarette sales should
\nbe banned in all United Nations premises.
\nAfter all, the people who are smoking in
\nthe UN building sometimes are the repre-
\nsentatives of the same Member States who
\nhave signed up to the Framework
\nConvention. But it can be hard to put agree-
\nments into practice. We will all face this.
\nWhen we know that, in an Irish pub a
\nsmoking ban can really work, then we
\nknow that anything is possible.
\nSmoking is an advance contract. Those
\nwho smoke don\u2019t pay now, but will do so
\n30 to 40 years later, when their health fails.
\nThey pay with lung cancer, with obstruc-
\ntive airways disorders, with cardiovascular
\ndiseases. One in two smokers pays with
\ntheir life. We have to help them stop smok-
\ning. We have to prevent them from starting.
\nThis convention is something that we all
\ncommitted to. Its provisions are bold. They
\nare based on knowledge of what is effec-
\ntive.
\nWe will make it work.\u201d
\nThe COP is the governing body of the
\nTreaty. It serves as the authority to oversee,
\nmonitor and evaluate progress of the Treaty,
\nin order to reduce tobacco consumption and
\ntobacco-related deaths globally.
\n\u2022 To allow the Conference of the Parties to
\nassess progress made by countries in
\nimplementing the measures required by
\nthe Treaty through a pilot reporting
\nquestionnaire agreed by the Parties dur-
\ning the Conference.
\n\u2022 To establish an ad-hoc group of experts
\nthat will study economically viable
\nalternatives to tobacco growing and pro-
\nduction, with a view to making recom-
\nmendations on diversification initiatives
\nfor those countries whose economies
\ndepend heavily on tobacco production.
\nThe President of the Conference,
\nAmbassador Juan Martabit from Chile said,
\n\u201cThe urgency of the problem of tobacco use
\nis shared by all of us, and the commitment
\nfrom countries and civil society to take
\naction is very strong. I felt the positive spir-
\nit throughout the Conference, which clearly
\ncontributed to its success, helping countries
\nto reach consensus quickly on the basic
\nissues, so we can concentrate our efforts in
\nthe implementation. I am confident we are
\non track to save millions of lives in the near
\nfuture thanks to this Treaty.\u201d
\nMore information about the first session of
\nthe COP, including day to day overview,
\ndocuments and presentations: www.who.
\nint\/tobacco\/fctc\/cop\/en\/index.html
\nConcrete measures included in the Treaty
\ncould help save 200 million lives by the
\nyear 2050 if a progressive 50% reduction in
\nuptake and consumption rates is achieved.
\nMany measures in the WHO FCTC have
\ndeadlines and clear guidelines. For exam-
\nple, from the Treaty\u2019s entry into force,
\ncountries have three years to enforce health
\nwarnings on tobacco products, and five
\nyears to implement comprehensive bans on
\ntobacco advertising, promotion and spon-
\nsorship.
\nOther measures, such as those regarding
\nillicit trade or cross-border advertising,
\nhave not yet been detailed in the Treaty.
\nThe COP could decide to develop protocols
\nand specific guidelines and requirements
\nfor countries to implement these measures.
\nIn February 2007, the first Contracting
\nParties will submit to the COP initial
\nreports on their progress, specifying what
\nactions they have taken to implement the
\ntobacco control measures established in the
\nTreaty. \u201cThis is a crucial time for people
\nsuffering the consequences of tobacco
\nuse,\u201d said Dr Yumiko Mochizuki-
\nKobayashi, Director of the WHO Tobacco
\nFree Initiative. \u201cTobacco is still the top pre-
\nventable cause of death. The goal is to see
\nit fall from that position in our
\nlifetime.With continued commitment from
\nMember States, we will achieve that goal.\u201d
\nThe conference having adopted the follow-
\ning decisions:
\n\u2022 To establish the permanent secretariat of
\nthe Treaty within the World Health
\nOrganization, located in Geneva.
\nDelegates agreed on a budget of US$ 8
\nmillion for its functioning during the
\nnext two years. Parties agreed to fund it
\nthrough voluntary assessed contribu-
\ntions.
\n\u2022 To create working groups that will begin
\ndevelopment of protocols (legally bind-
\ning instruments) in the areas of cross-
\nborder advertising and illicit trade. To
\nhelp countries establish smoke-free
\nplaces and effective ways of regulating
\ntobacco products, Parties agreed to
\ndevelop guidelines (non-binding instru-
\nments).
\nWHO
\n19
\nThe World Health Organization welcomed
\nthe announcement by the United Kingdom
\ngovernment that it will give \u00a341.7 million
\n(US$ 74 million) to help fight tuberculosis
\n(TB) in India and by the Bill and Melinda
\nGates Foundation that it will triple funding
\nfor tuberculosis to more than US$ 900 mil-
\nlion by 2015.
\nAnnouncement of the two funding commit-
\nments follows publication of the Global Plan
\nto Stop Tuberculosis which sets out the steps
\nthat are needed to tackle the global tubercu-
\nlosis epidemic. Two million people die of
\nTB every year and eight million become
\ninfected. The plan, prepared by the Stop
\nTuberculosis Partnership, calls for global
\nspending on tuberculosis to triple over the
\nnext ten years to increase access to tubercu-
\nlosis control programmes and accelerate
\nresearch on new tools to fight the disease.
\nStop TB
\nWHO welcomes United Kingdom, Gates
\nFoundation funding for global action to stop
\ntuberculosis
\nNew tools to fight the disease
\n\u201eThis funding from the UK government
\nand from the Gates Foundation shows real,
\nlong-term commitment to the global effort
\nto stop tuberculosis,\u201c said Dr LEE Jong-
\nwook, WHO Director-General. \u201cThe glob-
\nal TB action plan shows clearly what must
\nbe done to tackle the burden of TB. We
\nmust now act urgently to raise all the funds
\nneeded to put the plan into action.\u201c
\nKey objectives of the plan include improv-
\ning access to treatment in order to prevent
\n14 million deaths and provide treatment to
\n50 million people; developing and distrib-
\nuting new drugs and a new, safe and afford-
\nable vaccine; and developing new efficient,
\neffective and affordable diagnostic tests.
\nWHO is a partner in the Stop TB Partner-
\nship, which was established in 2000. The
\npartnership secretariat is hosted by WHO
\nin Geneva.
\nWHO
\n20
\nCancer is a leading cause of death globally:
\nan estimated 7.6 million people died of can-
\ncer in 2005 and 84 million people will die in
\nthe next 10 years if action is not taken. The
\nWorld Health Organization (WHO) has pro-
\nposed a global goal of reducing chronic dis-
\nease death rates by 2% per annum from
\n2006 to 2015.
\nMore than 70% of all cancer deaths occur in
\nlow- and middle-income countries, where
\nresources available for prevention, diagno-
\nsis and treatment of cancer are limited or
\nnonexistent. Tobacco use alone accounts for
\nsome 1.5 million cancer deaths per year.
\nWHO is actively responding to these rising
\nlevels of cancer. A World Health Assembly
\nresolution adopted in May 2005 called on
\nWHO and its Member States to take urgent
\naction to prevent and control cancer. As a
\nresult, WHO has been developing a Global
\nCancer Strategy and the coming year will
\nsee the publication of \u201cCancer Control:
\nKnowledge into Action \u2013 WHO Guide for
\nEffective Programmes\u201c, a series of six mod-
\nules aimed at supporting Member States to
\ndevelop strategies to improve prevention,
\ntreatment and care of cancer patients.
\n\u201cWe must, first and foremost, address the
\ntremendous inequalities between developed
\nand developing countries in terms of cancer
\nprevention, treatment and care,\u201c said Dr
\nCatherine Le Gal\u00e8s-Camus, Assistant
\nDirector-General for Noncommunicable
\nDiseases and Mental Health. \u201dDespite our
\nknowledge that many cases are avoidable,
\nor curable when detected early and treated
\naccording to best evidence, sadly for many
\npeople tumours are detected too late and
\nadequate treatment is not available.
\nFurthermore, the quality of life of many
\npatients with cancer can be improved sub-
\nstantially by pain control and palliative
\ncare.\u201c
\nIt is estimated that over 40% of all cancer
\ncan be prevented. However, dramatic
\nincreases in risk factors such as tobacco use
\nand obesity are contributing to the rise in
\ncancer rates, particularly in low- and mid-
\ndle-income countries. A rapidly changing
\nglobal environment due to globalization of
\nmarkets and urbanization is leading to ris-
\ning consumption of processed foods high in
\nfats, sugars and salt, as well as tobacco
\nproducts; declining consumption of fruit
\nand vegetables; and more sedentary activi-
\nty levels. As a consequence the burden
\n(incidence) of cancer and other chronic dis-
\neases is increasing. Other preventable risk
\nfactors include many environmental car-
\ncinogens and infections caused by Hepatitis
\nB Virus and Human Papilloma Virus.
\nWHO is taking significant measures to pre-
\nvent cancer and other chronic diseases. A
\nkey achievement has been the entry into
\nforce this past year of the first-ever WHO
\nglobal health treaty. The WHO Framework
\nConvention on Tobacco Control (WHO
\nFCTC), is a major step towards the goal of
\nreducing tobacco use, which is the leading
\npreventable cause of cancer. Additionally,
\nthe Global Strategy on Diet, Physical
\nActivity and Health has provided a multi-
\nsectoral approach to reducing key risk fac-
\ntors for cancer and other chronic diseases.
\nThe Programme on Chemical Safety is a
\nworldwide WHO-guided network aimed at
\nreducing exposure to carcinogens, and
\nimmunization programmes against hepati-
\ntis are part of WHO global immunization
\nstrategies.
\nTo improve early detection, treatment and
\ncare of cancer patients, WHO\u2019s
\nInternational Agency for Research on
\nCancer (IARC) is providing the scientific
\nevidence for cancer causes and mechanisms
\nof cancer development as well as develop-
\ning strategies for early detection of cancer.
\nMoreover, WHO acts in partnership with a
\nrange of major stakeholders in cancer con-
\ntrol, including other UN organizations such
\nas the International Atomic Energy Agency
\n(IAEA), NGOs such as the International
\nUnion Against Cancer (UICC) and many
\nnational cancer institutes.
\nWHO advocates an integrated approach to
\nprevention, treatment and care for all lead-
\ning chronic diseases. Integrated approaches
\nthat combine cancer prevention, diagnosis,
\nmanagement with that for heart disease,
\nstroke, diabetes and other chronic diseases
\nare necessary because the diseases share
\ncommon risk factors (tobacco use,
\nunhealthy diet and physical inactivity) and
\nrequire similar responses from the health
\nsystem. Tthe integrated approach is best for
\nprevention and treatment, it is also cost-
\neffective. It is outlined in the recently
\nreleased report, \u201ePreventing chronic dis-
\neases: a vital investment\u201c.
\nFor more information contact:
\nDr JoAnne Epping-Jordan
\nSenior Programme Adviser
\nDepartment of Chronic Diseases and
\nHealth Promotion
\nWHO\/Geneva
\nTelephone: +41 22 791 46 46
\nE-mail: eppingj@who.int
\nWorld Cancer Day, February 2006:
\nGlobal action to avert 8 million cancer-related
\ndeaths by 2015
\nBerlin\/Geneva \u2013 Each year 100 million peo-
\nple slide into poverty as a result of medical
\ncare payments. Another 150 million people
\nare forced to spend nearly half their incomes
\non medical expenses. That is because in many
\ncountries people have no access to social
\nhealth protection \u2013 affordable health insur-
\nance or government-funded health services.
\nSocial Healthcare
\nMedical costs push millions of people into
\npoverty across the globe
\nParadoxically, people in the world\u2019s poor-
\nest countries contribute relatively more for
\nhealth care than those in wealthy industrial-
\nized nations. In Germany, for example,
\nwhere the average GDP per capita is
\nUS$ 32 860 and almost everyone has social
\nhealth protection, 10% of all medical
\nexpenses nationwide are borne by house-
\nholds. In the Democratic Republic of the
\nCongo, by contrast, where GDP per capita
\nis only US$ 120 and where social health
\nprotection is scant, about 70% of the
\nmoney spent on medical care is paid direct-
\nly by households.
\nExperts from some 40 countries met in
\nBerlin at a conference convened by the
\nDeutsche Gesellschaft f\u00fcr Technische
\nZusammenarbeit GmbH (GTZ), the
\nGerman Federal Ministry for Economic
\nCooperation and Development, the
\nInternational Labour Office (ILO) and the
\nWorld Health Organization and laid out
\nstrategies that they and their partners can
\nundertake to prevent such catastrophes.
\n\u201cSocial health protection is feasible even in
\nthe developing world, but it has not got the
\nattention it deserves. Countries must begin
\nnow to craft well-organized schemes, and
\ninternational donors will have to help. It
\ntakes years to put such a scheme into place,
\nbut if we start now, by 2015 \u2013 the target for
\nthe Millennium Development Goals \u2013 we
\ncould be well on the way to protecting peo-
\nple worldwide through equitable health
\nfinancing,\u201d said Dr Timothy Evans, WHO
\nAssistant Director-General for Evidence
\nand Information for Policy.
\nIn low-income countries, it would take an
\naverage of about US$ 35 per person per
\nyear to finance a social health protection
\nscheme able to provide basic health ser-
\nvices, of which US$ 15 to US$ 25 would
\nhave to come from international donors.
\nSocial health protection can do more than
\nshield people against poverty \u2013 it can also
\nsave lives. \u201cAt least 1.3 billion people
\nworldwide lack access to the most basic
\nhealthcare. Often it is because they cannot
\nafford it. As a result, millions become very
\nsick or die every year from preventable or
\ncurable medical conditions said Dr.
\nR\u00fcdiger Krech, Head of Social Protection
\nWHO
\n21
\nin the Division Health, Education, and
\nSocial Protection at GTZ.
\n\u201cSocial health protection is not only a key
\ntool in making health care accessible to all
\nand to free millions of people from poverty.
\nIt is also an investment in health, productiv-
\nity and development \u2013 an investment that is
\na prerequisite for international competitive-
\nness\u201d, said Assane Diop, Executive
\nDirector of the ILO.
\nHaving to pay for medical treatment can
\ncause a farmer to lose his herd or a family
\nto lose its business. The Chinwubas and
\ntheir five children used to live comfortably
\nin Abakpa, Kenya from the earnings of a
\nsmall building supply shop they owned.
\nWhen Gloria needed an emergency
\nCesarean section they were suddenly faced
\nwith medical bills of US$ 200 \u2013 more than
\ntheir usual earnings for a four-month peri-
\nod. Unable to pay the entire bill, Amos had
\nto give his motorbike as a safety deposit to
\nthe hospital. Without it, he was unable to
\ncollect material from the wholesaler, and
\nhis business came to standstill. He had to
\npull the children out of school, because
\nthere was no money to pay for fees and uni-
\nforms; and the family is now subsisting on
\none meal a day.
\nAnumber of low-income countries \u2013 includ-
\ning Ghana, Rwanda and Senegal \u2013 have
\nalready experimented with innovative ways
\nof protecting people against the financial
\nrisks of ill health. Drawing on those experi-
\nences, the GTZ, ILO and WHO are offering
\ndirect technical assistance to countries seek-
\ning to develop social health protection
\nplans.
\nThe Foundation for Innovative New
\nDiagnostics (FIND) and the World Health
\nOrganization (WHO), with a grant from the
\nBill & Melinda Gates Foundation, today
\nannounced that they will begin work on the
\ndevelopment and evaluation of new diag-
\nnostic tests for human African trypanosomi-
\nasis (HAT) also known as sleeping sickness.
\nAfrican sleeping sickness, a major public
\nhealth threat in sub-Saharan Africa, spreads
\namong people bitten by the tsetse fly and is
\nfatal unless treated. Because early-stage
\ninfection produces few symptoms, it is
\nthought that only 10% of patients with the
\ndisease are accurately diagnosed. FIND and
\nthe World Health Organization will collabo-
\nrate in seeking to identify, test and imple-
\nment diagnostics that will increase the like-
\nlihood of early detection of HAT and the
\nopportunity for treatment.
\nFoundation for Innovative New Diagnostics
\nand WHO collaborate to improve diagnosis
\nof sleeping sickness
\n\u201cThe spread of human African trypanoso-
\nmiasis has reached epidemic proportions in
\nregions of Africa. There is clearly a great
\nneed for a simple, accurate and cost-effec-
\ntive way to diagnose this disease so that it
\ncan be better treated and controlled,\u201d said
\nDr Giorgio Roscigno, CEO of FIND.
\n\u201cFIND is committed to identifying and
\nimplementing diagnostics for infectious
\ndiseases, and we look forward to securing
\npartnerships and initiating field testing.\u201d
\n\u201cExisting diagnostics for sleeping sickness
\nare difficult to implement in remote, impov-
\nerished settings,\u201d said Dr Jean Jannin and Dr
\nPere Simarro, from the Neglected Tropical
\nDiseases Control Department of the World
\nHealth Organization. \u201cWe look forward to
\nworking with FIND to advance new diag-
\nnostic tests that could revolutionize human
\nAfrican trypanosomiasis control.\u201d
\n\u201cDeveloping point-of-care tests to direct
\nsleeping sickness treatment will greatly
\nsimplify patient care, allowing for early
\ncase detection, simpler and safer treatment,
\nand higher rates of cure that will improve
\ndisease management and could lead to the
\nelimination of the disease as a public health
\nproblem,\u201d said Thomas Brewer, M.D.,
\nsenior programme officer, Infectious
\nDiseases division, Global Health
\nProgramme, at the Gates Foundation.
\nCurrently, diagnosis of sleeping sickness is
\nmade by serologic examinations followed
\nby microscopy, which is laborious, insensi-
\ntive and costly. FIND\u2019s and WHO\u2019s efforts
\nwill be focused on developing tools that
\nwill be simple to use and effective in the
\nremote field conditions that exist where it
\nis most prevalent. In addition to developing
\nappropriate diagnostic technologies, the
\nobjectives of the programme include estab-
\nlishing field research sites for clinical stud-
\nies and evaluating prototype products.
\nAbout FIND
\nThe Foundation for Innovative New
\nDiagnostics (FIND) was launched at the
\nWorld Health Assembly in May 2003 as a
\nnon-profit Swiss foundation based in
\nGeneva. Its purpose is to support and pro-
\nmote the health of people in developing
\ncountries by sponsoring the development
\nand introduction of new but affordable diag-
\nnostic products for infectious diseases.
\nFIND currently has established collabora-
\ntions with a number of leading public and
\nprivate organizations for the development
\nof diagnostics for tuberculosis. For more
\ninformation, please visit www.finddiagnos-
\ntics.org
\nFor more information contact:
\nDr Jean Jannin
\nDepartment of Control of Neglected
\nTropical Diseases
\nWorld Health Organization
\nTelephone: +41 22 791 3779
\nE-mail: janninj@who.int
\nDr Giorgio Roscigno
\nCEO FIND
\nTelephone: +41 22 710 0590
\nE-mail:
\ngiorgio.roscigno@finddiagnotics.org
\nWHO
\n22
\nTed Turner Announces $20 million
\nCommitment from UN Foundation to
\nMeasles Initiative Over the Next Four
\nYears
\nThe Measles Initiative partners gathered in a
\nTIME Magazine Global Health Summit in
\nNew York this week to announce that tremen-
\ndous progress has been made in Africa in the
\nfight against measles. Largely due to the tech-
\nnical and financial support of the Measles
\nInitiative and commitment from African gov-
\nernments, more than 200 million children in
\nAfrica have been vaccinated against measles
\nand one million lives have been saved since
\n1999. Measles cases and deaths have dropped
\nby 60%, thanks to improvements in routine
\nand supplementary immunization activities in
\nAfrica. The founding partners of the Measles
\nInitiative are the American Red Cross, UN
\nFoundation, World Health Organization,
\nUNICEF and Centers for Disease Control and
\nPrevention.
\n\u201cThis is a major public health achievement,\u201d
\nsaid Dr. LEE Jong-wook, WHO Director-
\nGeneral. \u201eIt is the result of the hard work and
\ndedication of the governments of priority
\ncountries with high measles deaths and all our
\nMeasles Initiative partners to achieve a com-
\nmon goal \u2013 to reduce measles deaths. Let us
\ncontinue to build on this momentum.\u201c
\nMeasles is one of the leading vaccine-pre-
\nventable childhood killers in the world. In
\n2003, more than 500,000 people \u2013 470,000 of
\nthem children under age 5 \u2013 died from the
\ndisease. Half of these deaths were in Africa
\nalone. A safe and highly effective vaccine has
\nbeen available for over forty years, and it
\ncosts less than US $1 to protect a child
\nagainst measles. Despite this, millions of chil-
\ndren still remain at risk from measles.
\nUNICEF Executive Director Ann M.
\nVeneman said that the Initiative\u2019s extraordi-
\nnary success against measles has brought the
\nworld closer to reaching the Millennium
\nDevelopment Goal (MDG) on child mortali-
\nty. The results in Africa can now be replicat-
\ned in Asia, the region that accounts for more
\nthan 180,000 deaths worldwide.
\n\u201cThe Measles Initiative and other investments
\nin immunization not only save lives, they
\nbuild economies,\u201d said Bo Stenson of the
\nGlobal Alliance for Vaccines and
\nImmunization (GAVI). \u201cIn fact, a new study
\nout of the Harvard School of Public Health
\ndemonstrates that in the past, development
\nexperts have generally underestimated the
\neconomic value of immunization. Investing
\nin the health of children is not only the com-
\npassionate thing to do, it is the smart thing to
\ndo and will pay off for future generations in
\ntheir educational attainment, labor productiv-
\nity, income and savings.\u201d
\nNext steps for the Measles Initiative include
\nadditional \u2018follow-up\u2019 vaccination campaigns
\nin Africa, expanding vaccination campaigns
\ninto Asia and continuing the successful \u201cinte-
\ngrated child health campaigns\u201d in which
\nhealth workers provide not only measles vac-
\ncines, but also insecticide-treated bed-nets
\n(for malaria prevention), vitamin A, de-
\nworming medication, and polio vaccines.
\nLaunched in February 2001, the Measles
\nInitiative (www.measlesinitiative.org) is a
\npartnership formed to reduce and control
\nmeasles deaths. The Initiative is led by the
\nUnited Nations Foundation, American Red
\nCross, Centers for Disease Control and
\nPrevention, UNICEF and the World Health
\nOrganization. The Measles Initiative (MI)
\nbases its success on its far-reaching partner-
\nship between public and private institutions,
\nincluding key players such as the International
\nFederation of Red Cross and Red Crescent
\nSocieties, the Canadian International
\nDevelopment Agency (CIDA), Becton,
\nDickinson and Company, The Bill and Melinda
\nGates Foundation, the Church of Jesus Christ
\nand Latter Day Saints, Becton, Dickinson and
\nCompany (BD), the Global Alliance for
\nVaccines and Immunization (GAVI) and coun-
\ntries and governments affected by measles.
\nWhile the Measles Initiative is focused in
\nAfrica where the majority of measles-related
\ndeaths occur, partners also work on a wide-
\nrange of health initiatives around the world,
\nincluding measles control and other vaccina-
\ntion services outside of Africa.
\nMeasles cases and deaths fall
\nby 60% in Africa since 1999
\nWHO
\n23
\nGeneva, 5 September 2005 – A total of up
\nto 4000 people could eventually die of radi-
\nation exposure from the Chernobyl nuclear
\npower plant (NPP) accident nearly 20 years
\nago, an international team of more than 100
\nscientists has concluded.
\nAs of mid-2005, however, fewer than 50
\ndeaths had been directly attributed to radia-
\ntion from the disaster, almost all being high-
\nly exposed rescue workers, many who died
\nwithin months of the accident but others
\nwho died as late as 2004.
\nThe new numbers are presented in a land-
\nmark digest report, \u201cChernobyl\u2019s Legacy:
\nHealth, Environmental and Socio-Eco-
\nnomic Impacts,\u201d just released by the
\nChernobyl Forum. The digest, based on a
\nthree-volume, 600-page report and incorpo-
\nrating the work of hundreds of scientists,
\neconomists and health experts, assesses the
\n20-year impact of the largest nuclear acci-
\ndent in history. The Forum is made up of 8
\nUN specialized agencies, including the
\nInternational Atomic Energy Agency
\n(IAEA), World Health Organization
\n(WHO), United Nations Development
\nProgramme (UNDP), Food and Agriculture
\nOrganization (FAO), United Nations
\nEnvironment Programme (UNEP), United
\nNations Office for the Coordination of
\nHumanitarian Affairs (UN-OCHA), United
\nNations Scientific Committee on the Effects
\nof Atomic Radiation (UNSCEAR), and the
\nWorld Bank, as well as the governments of
\nBelarus, the Russian Federation and
\nUkraine.
\n\u201cThis compilation of the latest research can
\nhelp to settle the outstanding questions
\nabout how much death, disease and eco-
\nnomic fallout really resulted from the
\nChernobyl accident,\u201d explains Dr. Burton
\nBennett, chairman of the Chernobyl Forum
\nand an authority on radiation effects. \u201cThe
\ngovernments of the three most-affected
\ncountries have realized that they need to
\nfind a clear way forward, and that progress
\nmust be based on a sound consensus about
\nenvironmental, health and economic conse-
\nquences and some good advice and support
\nfrom the international community.\u201d
\nBennett continued: \u201cThis was a very serious
\naccident with major health consequences,
\nespecially for thousands of workers
\nexposed in the early days who received very
\nhigh radiation doses, and for the thousands
\nmore stricken with thyroid cancer. By and
\nlarge, however, we have not found profound
\nnegative health impacts to the rest of the
\npopulation in surrounding areas, nor have
\nwe found widespread contamination that
\nwould continue to pose a substantial threat
\nto human health, within a few exceptional,
\nrestricted areas.\u201d
\nThe Forum\u2019s report aims to help the affect-
\ned countries understand the true scale of the
\naccident\u2019s consequences and also suggests
\nways the governments of Belarus, the
\nRussian Federation and Ukraine might
\naddress major economic and social prob-
\nlems stemming from the accident. Members
\nof the Forum, including representatives of
\nthe three governments, met on September 6
\nand 7 in Vienna at an unprecedented gather-
\ning of the world\u2019s experts on Chernobyl,
\nradiation effects and protection, to consider
\nthese findings and recommendations.
\nMajor study findings
\nDozens of important findings are included
\nin the massive report:
\n\u2022 Approximately 1000 on-site reactor staff
\nand emergency workers were heavily
\nexposed to high-level radiation on the first
\nday of the accident; among the more than
\n200,000 emergency and recovery opera-
\ntion workers exposed during the period
\nfrom 1986-1987, an estimated 2,200 radi-
\nation-caused deaths can be expected dur-
\ning their lifetime.
\n\u2022 An estimated five million people current-
\nly live in areas of Belarus, Russia and
\nUkraine that are contaminated with
\nradionuclides due to the accident; about
\n100 000 of them live in areas classified in
\nthe past by government authorities as
\nareas of \u201cstrict control\u201d. The existing
\n\u201czoning\u201d definitions need to be revisited
\nand relaxed in the light of these new find-
\nings.
\n\u2022 About 4,000 cases of thyroid cancer,
\nmainly in children and adolescents at the
\ntime of the accident, have resulted from
\nthe accident\u2019s contamination and at least
\nnine children died of thyroid cancer; how-
\never the survival rate among such cancer
\nvictims, judging from experience in
\nBelarus, has been almost 99%.
\n\u2022 Most emergency workers and people liv-
\ning in contaminated areas received rela-
\ntively low whole body radiation doses,
\ncomparable to natural background levels.
\nAs a consequence, no evidence or likeli-
\nhood of decreased fertility among the
\naffected population has been found, nor
\nhas there been any evidence of increases
\nin congenital malformations that can be
\nattributed to radiation exposure.
\n\u2022 Poverty, \u201clifestyle\u201d diseases now rampant
\nin the former Soviet Union and mental
\nhealth problems pose a far greater threat
\nto local communities than does radiation
\nexposure.
\n\u2022 Relocation proved a \u201cdeeply traumatic
\nexperience\u201d for some 350,000 people
\nmoved out of the affected areas. Although
\n116 000 were moved from the most heav-
\nily impacted area immediately after the
\naccident, later relocations did little to
\nreduce radiation exposure.
\n\u2022 Persistent myths and misperceptions
\nabout the threat of radiation have resulted
\nin \u201cparalyzing fatalism\u201d among residents
\nof affected areas.
\n\u2022 Ambitious rehabilitation and social bene-
\nfit programmes started by the former
\nSoviet Union, and continued by Belarus,
\nRussia and Ukraine, need reformulation
\nChernobyl: the true scale of the accident
\n20 years later a UN report provides definitive answers and ways to
\nrepair lives
\ndue to changes in radiation conditions,
\npoor targeting and funding shortages.
\n\u2022 Structural elements of the sarcophagus
\nbuilt to contain the damaged reactor have
\ndegraded, posing a risk of collapse and
\nthe release of radioactive dust;
\n\u2022 A comprehensive plan to dispose of tons
\nof high-level radioactive waste at and
\naround the Chernobyl NPP site, in accor-
\ndance with current safety standards, has
\nyet to be defined.
\nAlongside radiation-induced deaths and
\ndiseases, the report labels the mental health
\nimpact of Chernobyl as \u201cthe largest public
\nhealth problem created by the accident\u201d and
\npartially attributes this damaging psycho-
\nlogical impact to a lack of accurate infor-
\nmation. These problems manifest as nega-
\ntive self-assessments of health, belief in a
\nshortened life expectancy, lack of initiative,
\nand dependency on assistance from the
\nstate.
\n\u201cTwo decades after the Chernobyl accident,
\nresidents in the affected areas still lack the
\ninformation they need to lead the healthy
\nand productive lives that are possible,\u201d
\nexplains Louisa Vinton, Chernobyl focal
\npoint at the UNDP. \u201cWe are advising our
\npartner governments that they must reach
\npeople with accurate information, not only
\nabout how to live safely in regions of low-
\nlevel contamination, but also about leading
\nhealthy lifestyles and creating new liveli-
\nhoods.\u201d But, says Dr. Michael Repacholi,
\nManager of WHO\u2019s Radiation Programme,
\n\u201cthe sum total of the Chernobyl Forum is a
\nreassuring message.\u201d
\nHe explains that there have been 4,000
\ncases of thyroid cancer, mainly in children,
\nbut that except for nine deaths, all of them
\nhave recovered. \u201cOtherwise, the team of
\ninternational experts found no evidence for
\nany increases in the incidence of leukemia
\nand cancer among affected residents.\u201c
\nThe international experts have estimated
\nthat radiation could cause up to about 4000
\neventual deaths among the higher-exposed
\nChernobyl populations, i.e., emergency
\nworkers from 1986-1987, evacuees and res-
\nidents of the most contaminated areas. This
\nnumber contains both the known radiation-
\ninduced cancer and leukaemia deaths and a
\nstatistical prediction, based on estimates of
\nthe radiation doses received by these popu-
\nlations. As about quarter of people die from
\nspontaneous cancer not caused by
\nChernobyl radiation, the radiation-induced
\nincrease of only about 3% will be difficult
\nto observe. However, in the most exposed
\ncohorts of emergency and recovery opera-
\ntion workers some increase of particular
\ncancer forms (e.g., leukemia) in particular
\ntime periods has already been observed.
\nThe predictions use six decades of scientif-
\nic experience with the effects of such doses,
\nexplained Repacholi.
\nRepacholi concludes that \u201cthe health effects
\nof the accident are potentially horrific, but
\nwhen they are added them up using validat-
\ned conclusions from good science, the pub-
\nlic health effects are not nearly as substan-
\ntial as at first feared.\u201d
\nThe report\u2019s estimate for the eventual num-
\nber of deaths is far lower than earlier, well-
\npublicized speculations that radiation expo-
\nsure would claim tens of thousands of lives.
\nBut the 4,000 figure is not far different from
\nestimates made in 1986 by Soviet scientists,
\naccording to Dr. Mikhail Balonov, a radia-
\ntion expert with the International Atomic
\nEnergy Agency in Vienna, who was a scien-
\ntist in the former Soviet Union at the time
\nof the accident.
\nAs for environmental impact, the reports
\nare also reassuring, for the scientific assess-
\nments show that, except for the still closed
\nhighly contaminated 30 kilometre area sur-
\nrounding the reactor, and some closed lakes
\nand restricted forests, radiation levels have
\nmostly returned to acceptable levels. \u201cIn
\nmost areas the problems are economic and
\npsychological, not health or environmen-
\ntal,\u201d reports Balonov, the scientific secre-
\ntary of the Chernobyl Forum effort who has
\nbeen involved with Chernobyl recovery
\nsince the disaster occurred.
\nRecommendations
\nRecommendations call for focussing assis-
\ntance efforts on highly contaminated areas
\nand redesigning government programmes
\nto help those genuinely in need. Suggested
\nchanges would shift programmes away
\nfrom those that foster \u201cdependency\u201d and a
\n\u201cvictim\u201d mentality, and replacing them with
\ninitiatives that encourage opportunity, sup-
\nport local development, and give people
\nconfidence in their futures.
\nIn the health area, the Forum report calls for
\ncontinued close monitoring of workers who
\nrecovered from Acute Radiation Syndrome
\n(ARS) and other highly exposed emergency
\npersonnel. The Report also calls for
\nfocussed screening of children exposed to
\nradioiodine for thyroid cancer and highly
\nexposed clean-up workers for non-thyroid
\ncancers. However, existing screening pro-
\ngrammes should be evaluated for cost-
\neffectiveness, since the incidence of sponta-
\nneous thyroid cancers is increasing signifi-
\ncantly as the target population ages.
\nMoreover, high quality cancer registries
\nneed continuing government support.
\nIn the environmental realm, the Report calls
\nfor long term monitoring of caesium and
\nstrontium radionuclides to assess human
\nexposure and food contamination and to
\nanalyse the impacts of remedial actions and
\nradiation-reduction countermeasures.
\nBetter information needs to be provided to
\nthe public about the persistence of radioac-
\ntive contamination in certain food products
\nand about food preparation methods that
\nreduce radionuclide intake. Restrictions on
\nharvesting of some wild food products are
\nstill needed in some areas.
\nAlso in the realm of protecting the environ-
\nment, the Report calls for an \u201cintegrated
\nwaste management programme for the
\nShelter, the Chernobyl NPP site and the
\nExclusion Zone\u201d to ensure application of
\nconsistent management and capacity for all
\ntypes of radioactive waste. Waste storage
\nand disposal must be dealt with in a com-
\nprehensive manner across the entire
\nExclusion Zone, according to the Report.
\nIn areas where human exposure is not high,
\nno remediation needs to be done, points out
\nBalonov. \u201cIf we do not expect health or
\nenvironmental effects, we should not waste
\nresources and effort on low priority, low
\ncontamination areas,\u201d he explains. \u201cWe
\nneed to focus our efforts and resources on
\nreal problems.\u201d
\nWHO
\n24
\nOne key recommendation addresses the
\nfact that large parts of the population, espe-
\ncially in rural areas, still lack accurate
\ninformation and emphasizes the need to
\nfind better ways both to inform the public
\nand to overcome the lack of credibility that
\nhampered previous efforts. Even though
\naccurate information has been available for
\nyears, either it has not reached those who
\nneed it or people do not trust and accept the
\ninformation and do not act upon it, accord-
\ning to the Report.
\nThis recommendation calls for targeting
\ninformation to specific audiences, including
\ncommunity leaders and health care work-
\ners, along with a broader strategy that pro-
\nmotes healthy lifestyles as well as informa-
\ntion about how to reduce internal and exter-
\nnal radiation exposures and address the
\nmain causes of disease and mortality.
\nIn the socioeconomic sphere, the Report
\nrecommends a new development approach
\nthat helps individuals to \u201ctake control of
\ntheir own lives and communities to take
\ncontrol of their own futures.\u201d The
\nGovernments, the Report states, must
\nstreamline and refocus Chernobyl pro-
\ngrammes through more targeted benefits,
\nelimination of unnecessary benefits to peo-
\nple in less contaminated areas, improving
\nprimary health care, support for safe food
\nproduction techniques, and encouragement
\nfor investment and private sector develop-
\nment, including small and medium-size
\nenterprises.
\nNotes Vinton, \u201cThe most important need is
\nfor accurate information on healthy
\nlifestyles, together with better regulations
\nto promote small, rural businesses. Poverty
\nis the real danger. We need to take steps to
\nempower people.\u201d
\nAnswers to Longstanding
\nQuestions
\nHow much radiation were people exposed
\nto as a result of the accident?
\nWith the exception of on-site reactor staff
\nand emergency workers exposed on 26
\nApril, most recovery operation workers and
\nthose living in contaminated territories
\nreceived relatively low whole body radia-
\ntion doses, comparable to background radi-
\nation levels and lower than the average
\ndoses received by residents in some parts of
\nthe world having high natural background
\nradiation levels.
\nFor the majority of the five million people
\nliving in the contaminated areas, exposures
\nare within the recommended dose limit for
\nthe general public, though about 100,000
\nresidents still receive more. Remediation of
\nthose areas and application of some agricul-
\ntural countermeasures continues. Further
\nreduction of exposure levels will be slow,
\nbut most exposure from the accident has
\nalready occurred.
\nHow many people died and how many
\nmore are likely to die in the future?
\nThe total number of deaths already attribut-
\nable to Chernobyl or expected in the future
\nover the lifetime of emergency workers and
\nlocal residents in the most contaminated
\nareas is estimated to be about 4,000. This
\nincludes some 50 emergency workers who
\ndied of acute radiation syndrome and nine
\nchildren who died of thyroid cancer, and an
\nestimated total of 3,940 deaths from radia-
\ntion-induced cancer and leukemia among
\nthe 200,000 emergency workers from 1986-
\n1987, 116,000 evacuees and 270,000 resi-
\ndents of the most contaminated areas (total
\nabout 600,000). These three major cohorts
\nwere subjected to higher doses of radiation
\namongst all the people exposed to
\nChernobyl radiation.
\nThe estimated 4,000 casualties may occur
\nduring the lifetime of about 600,000 people
\nunder consideration. As about quarter of
\nthem will eventually die from spontaneous
\ncancer not caused by Chernobyl radiation,
\nthe radiation-induced increase of about 3%
\nwill be difficult to observe. However, in the
\nmost highly exposed cohorts of emergency
\nand recovery operation workers, some
\nincrease in particular cancers (e.g.,
\nleukemia) has already been observed.
\nConfusion about the impact has arisen
\nowing to the fact that thousands of people
\nin the affected areas have died of natural
\ncauses. Also, widespread expectations of ill
\nhealth and a tendency to attribute all health
\nproblems to radiation exposure have led
\nlocal residents to assume that Chernobyl
\nrelated fatalities were much higher than
\nthey actually were.
\nWhat diseases have already occurred or
\nmight occur in the future?
\nResidents who ate food contaminated with
\nradioactive iodine in the days immediately
\nafter the accident received relatively high
\ndoses to the thyroid gland. This was espe-
\ncially true of children who drank milk from
\ncows who had eaten contaminated grass.
\nSince iodine concentrates in the thyroid
\ngland, this was a major cause of the high
\nincidence of thyroid cancer in children.
\nSeveral recent studies suggest a slight
\nincrease in the incidence of leukemia
\namong emergency workers, but not in chil-
\ndren or adult residents of contaminated
\nareas. A slight increase in solid cancers and
\npossibly circulatory system diseases was
\nnoted, but needs to be evaluated further
\nbecause of the possible indirect influence of
\nsuch factors as smoking, alcohol, stress and
\nunhealthy lifestyle.
\nHave there been or will there be any
\ninherited or reproductive effects?
\nBecause of the relatively low doses to resi-
\ndents of contaminated territories, no evi-
\ndence or likelihood of decreased fertility
\nhas been seen among males or females.
\nAlso, because the doses were so low, there
\nwas no evidence of any effect on the num-
\nber of stillbirths, adverse pregnancy out-
\ncomes, delivery complications or overall
\nhealth of children. A modest but steady
\nincrease in reported congenital malforma-
\ntions in both contaminated and uncontami-
\nnated areas of Belarus appears related to
\nbetter reporting, not radiation.
\nDid the trauma of rapid relocation cause
\npersistent psychological or mental health
\nproblems?
\nStress symptoms, depression, anxiety and
\nmedically unexplained physical symptoms
\nhave been reported, including self-per-
\nceived poor health. The designation of the
\naffected population as \u201cvictims\u201d rather than
\n\u201csurvivors\u201d has led them to perceive them-
\nselves as helpless, weak and lacking control
\nover their future. This, in turn, has led either
\nto over cautious behavior and exaggerated
\nhealth concerns, or to reckless conduct,
\nWHO
\n25
\nsuch as consumption of mushrooms, berries
\nand game from areas still designated as
\nhighly contaminated, overuse of alcohol
\nand tobacco, and unprotected promiscuous
\nsexual activity.
\nWhat was the environmental impact?
\nEcosystems affected by Chernobyl have
\nbeen studied and monitored extensively for
\nthe past two decades. Major releases of
\nradionuclides continued for ten days and
\ncontaminated more than 200,000 square
\nkilometres of Europe. The extent of deposi-
\ntion varied depending on whether it was
\nraining when contaminated air masses
\npassed.
\nMost of the strontium and plutonium iso-
\ntopes were deposited within 100 kilometres
\nof the damaged reactor. Radioactive iodine,
\nof great concern after the accident, has a
\nshort half-life, and has now decayed away.
\nStrontium and caesium, with a longer half
\nlife of 30 years, persist and will remain a
\nconcern for decades to come. Although plu-
\ntonium isotopes and americium 241 will
\npersist perhaps for thousands of years, their
\ncontribution to human exposure is low.
\nWhat is the scope of urban conta-
\nmination?
\nOpen surfaces, such as roads, lawns and
\nroofs, were most heavily contaminated.
\nResidents of Pripyat, the city nearest to
\nChernobyl, were quickly evacuated, reduc-
\ning their potential exposure to radioactive
\nmaterials. Wind, rain and human activity
\nhas reduced surface contamination, but led
\nto secondary contamination of sewage and
\nsludge systems. Radiation in air above set-
\ntled areas returned to background levels,
\nthough levels remain higher where soils
\nhave remained undisturbed.
\nHow contaminated are agricultural
\nareas?
\nWeathering, physical decay, migration of
\nradionuclides down the soil and reductions
\nin bioavailability have led to a significant
\nreduction in the transfer of radionuclides to
\nplants and animals. Radioactive iodine,
\nrapidly absorbed from grasses and animal
\nfeed into milk, was an early concern and
\nelevated levels were seen in some parts of
\nthe former Soviet Union and Southern
\nEurope, but, given the nuclide\u2019s short half
\nlife, this concern abated quickly. Currently
\nand for the long term, radiocaesium, pre-
\nsent in milk, meat and some plant foods,
\nremains the most significant concern for
\ninternal human exposure, but, with the
\nexception of a few areas, concentrations fall
\nwithin safe levels.
\nWhat is the extent of forest conta-
\nmination?
\nFollowing the accident, animals and vege-
\ntation in forest and mountain areas had high
\nabsorption of radiocaesium, with persistent
\nhigh levels in mushrooms, berries and
\ngame. Because exposure from agricultural
\nproducts has declined, the relative impor-
\ntance of exposure from forest products has
\nincreased and will only decline as radioac-
\ntive materials migrate downward into the
\nsoil and slowly decay. The high transfer of
\nradiocaesium from lichen to reindeer meat
\nto humans was seen in the Arctic and sub-
\nArctic areas, with high contamination of
\nreindeer meat in Finland, Norway, Russia,
\nand Sweden. The concerned governments
\nimposed some restrictions on hunting,
\nincluding scheduling hunting season when
\nanimals have lower meat contamination.
\nHow contaminated are the aquatic
\nsystems?
\nContamination of surface waters through-
\nout much of Europe declined quickly
\nthrough dilution, physical decay, and
\nabsorption of radionuclides in bed sedi-
\nments and catchment soils. Because of
\nbioaccumulation in the aquatic food chain,
\nthough, elevated concentrations of radio-
\ncaesium were found in fish from lakes as
\nfar away as Germany and Scandinavia.
\nComparable levels of radiostrontium,
\nwhich concentrates in fish bone, not in
\nmuscle, were not significant for humans.
\nLevels in fish and waters are currently low,
\nexcept in areas with \u201cclosed\u201d lakes with no
\noutflowing streams. In those lakes, levels of
\nradiocaesium in fish will remain high for
\ndecades and, therefore, restrictions on fish-
\ning there should be maintained.
\nWhat environmental countermeasures
\nand remediation have been taken?
\nThe most effective early agricultural coun-
\ntermeasure was removing contaminated
\npasture grasses from animal diets and mon-
\nitoring milk for radiation levels. Treatment
\nof land for fodder crops, clean feeding and
\nuse of Cs-binders (that prevented the trans-
\nfer of radiocaesium from fodder to milk)
\nled to large reductions in contamination and
\npermitted agriculture to continue, though
\nsome increase in radionuclide content of
\nplant and animal products has been mea-
\nsured since the mid-1990s when economic
\nproblems forced a cutback in treatments.
\nSome agricultural lands in the three coun-
\ntries have been taken out of use until reme-
\ndiation is undertaken.
\nA number of measures applied to forests in
\naffected countries and in Scandinavia have
\nreduced human exposure, including restric-
\ntions on access to forest areas, on harvest-
\ning of food products such as game, berries
\nand mushrooms, and on the public collec-
\ntion of firewood, along with changes in
\nhunting to avoid consumption of game
\nmeat where seasonal levels of radiocaesium
\nmay be high. Low income levels in some
\nareas cause local residents to disregard
\nthese rules.
\nWhat were radiation-induced effects on
\nplants and animals?
\nIncreased mortality of coniferous plants,
\nsoil invertebrates and mammals and repro-
\nductive losses in plants and animals were
\nseen in high exposure areas up to a distance
\nof 20-30 kilometres. Outside that zone, no
\nacute radiation-induced effects have been
\nreported. With reductions of exposure lev-
\nels, biological populations have been recov-
\nering, though the genetic effects of radia-
\ntion were seen in both somatic and germ
\ncells of plants and animals. Prohibiting
\nagricultural and industrial activities in the
\nexclusion zone permitted many plant and
\nanimal populations to expand and created,
\nparadoxically, \u201ca unique sanctuary for bio-
\ndiversity.\u201d
\nDoes dismantlement of the Shelter and
\nmanagement of radioactive waste pose
\nfurther environmental problems?
\nThe protective shelter was erected quickly,
\nwhich led to some imperfections in the
\nshelter itself and did not permit gathering
\ncomplete data on the stability of the dam-
\naged unit. Also, some structural parts of the
\nWHO
\n26
\nshelter have corroded in the past two
\ndecades. The main potential hazard posed by
\nthe shelter is the possible collapse of its top
\nstructures and the release of radioactive dust.
\nStrengthening those unstable structures has
\nbeen performed recently, and construction
\nof a New Safe Confinement covering the
\nexisting shelter that should serve for more
\nthan 100 years, starts in the near future. The
\nnew cover will allow dismantlement of the
\ncurrent shelter, removal of the radioactive
\nfuel mass from the damaged unit and, even-
\ntually, decommissioning of the damaged
\nreactor.
\nA comprehensive strategy still has to be
\ndeveloped for dealing with the high level
\nand long-lived radioactive waste from past
\nremediation activities. Much of this waste
\nwas placed in temporary storage in trench-
\nes and landfills that do not meet current
\nwaste safety requirements.
\nWhat was the economic cost?
\nBecause of policies in place at the time of
\nthe explosion and the inflation and econom-
\nic disruptions that followed the break-up of
\nthe Soviet Union, precise costs have been
\nimpossible to calculate. A variety of esti-
\nmates from the 1990s placed the costs over
\ntwo decades at hundreds of billions of dol-
\nlars. These costs included direct damage,
\nexpenditures related to recovery and miti-
\ngation, resettlement of people, social pro-
\ntection and health care for the affected pop-
\nulation, research on environment, health
\nand the production of clean food, radiation
\nmonitoring, as well as indirect losses due to
\nremoving agricultural lands and forests
\nfrom use and the closing of agriculture and
\nindustrial facilities, and such additional
\ncosts as cancellation of the nuclear power
\nprogram in Belarus and the additional costs
\nof energy from the loss of power from
\nChernobyl. The costs have created a huge
\ndrain on the budgets of the three countries
\ninvolved.
\nWhat were the main consequences for the
\nlocal economy?
\nAgriculture was hardest hit, with 784,320
\nhectares taken from production. Timber
\nproduction was halted in 694,200 hectares
\nof forest. Remediation made \u201cclean food\u201d
\nproduction possible in many areas but led to
\nhigher costs in the form of fertilizers, addi-
\ntives and special cultivation processes.
\nEven where farming is safe, the stigma
\nassociated with Chernobyl caused market-
\ning problems and led to falling revenues,
\ndeclining production and the closure of
\nsome facilities. Combined with disruptions
\ndue to the collapse of the Soviet Union,
\nrecession, and new market mechanisms, the
\nregion\u2019s economy suffered, resulting in
\nlower living standards, unemployment and
\nincreased poverty. All agricultural areas,
\nwhether affected by radiation or not, proved
\nvulnerable.
\nPoverty is especially acute in affected
\nareas. Wages for agricultural workers tend
\nto be low and employment outside of agri-
\nculture is limited. Many skilled and educat-
\ned workers, especially younger workers,
\nleft the region. Also, the business environ-
\nment discourages entrepreneurial ventures
\nand private investment is low.
\nWhat impact did Chernobyl and the after-
\nmath have on local communities?
\nMore than 350,000 people have been relo-
\ncated away from the most severely contam-
\ninated areas, 116,000 of them immediately
\nafter the accident. Even when people were
\ncompensated for losses, given free houses
\nand a choice of resettlement location, the
\nexperience was traumatic and left many
\nwith no employment and a belief that they
\nhave no place in society. Surveys show that
\nthose who remained or returned to their
\nhomes coped better with the aftermath than
\nthose who were resettled. Tensions
\nbetween new and old residents of resettle-
\nment villages also contributed to the
\nostracism felt by the newcomers. The
\ndemographic structure of the affected areas
\nbecame skewed since many skilled, edu-
\ncated and entrepreneurial workers, often
\nyounger, left the areas leaving behind an
\nolder population with few of the skills
\nneeded for economic recovery.
\nThe older population has meant that deaths
\nexceed births, which reinforces the percep-
\ntion that these areas are dangerous places
\nto live. Even when pay is high, schools,
\nhospitals and other essential public ser-
\nvices are short of qualified specialists.
\nWhat has been the impact on individuals?
\nAccording to the Forum\u2019s report on health,
\n\u201cthe mental health impact of Chernobyl is
\nthe largest public health problem unleashed
\nby the accident to date.\u201d People in the
\naffected areas report negative assessments
\nof their health and well-being, coupled
\nwith an exaggerated sense of the danger to
\ntheir health from radiation exposure and a
\nbelief in a shorter life expectancy. Anxiety
\nover the health effects of radiation shows
\nno signs of diminishing and may even be
\nspreading. Life expectancy has been
\ndeclining across the former Soviet Union,
\ndue to cardiovascular disease, injuries and
\npoisoning, and not radiation-related illness.
\nHow have governments responded?
\nThe resettlement and rehabilitation pro-
\ngrams launched in Soviet conditions
\nproved unsustainable after 1991 and fund-
\ning for projects declined, leaving many
\nprojects unfinished and abandoned and
\nmany of the promised benefits under fund-
\ned. Also, benefits were offered to broad
\ncategories of \u201cChernobyl victims\u201d that
\nexpanded to seven million now receiving
\nor eligible for pensions, special allowances
\nand health benefits, including free holidays
\nand guaranteed allowances. Chernobyl
\nbenefits deprive other areas of public
\nspending of resources, but scaling down
\nbenefits or targeting only high-risk groups
\nis unpopular and presents political prob-
\nlems.
\nGiven significant reduction of radiation
\nlevels during past twenty years, govern-
\nments need to revisit the classification of
\ncontaminated zones. Many areas previous-
\nly considered to be at risk are in fact safe
\nfor habitation and cultivation. Current
\ndelineations are far more restrictive than
\ndemonstrated radiation levels can justify.
\nThe report identifies the need to sharpen
\npriorities and streamline the programmes
\nto target the most needy, noting that reallo-
\ncating resources is likely to face \u201cstrong
\nresistance from vested interests\u201c. One sug-
\ngestion calls for a \u201cbuy out\u201d of the entitle-
\nment to benefits in return for lump sum
\nstart-up financing for small businesses.
\nWHO
\n27
\nRegional and NMA News
\n28
\nThe Indian Medical Association (IMA) has
\nundetaken an ambitious project \u201cAao gaon
\nchalen\u201d to shoulder the responsibility of
\nproviding positive health to every village in
\nthe country. The project will enable medical
\nprofessionals to develop a vision and under-
\ntake innovations to improve rural health as
\nenvisaged in the national health policy.
\nThe project which was launched off by
\nUnion Textile Minister Shankarsingh
\nVaghela at a village in Mehsana District
\nentails a new scheme where IMA members
\nwill adopt a most vulnerable village accord-
\ning to prevalent major health problems.
\nThe first step of its kind by the IMA, in the
\nworld, aims to target the 75% of the popu-
\nlation which lives in the villages and also
\nthe popular myth in the public mind that
\ndoctors do not want to serve in rural areas.
\n\u201cUnder this project each state unit of IMA
\nwill adopt 5 villages to begin with and
\nundertake promotive health camps free of
\ncost. The idea is to slowly make the exist-
\ning healthcare available in every nook and
\ncorner of India\u201d, said Dr. Kedan Desai,
\nChairman of the project.
\nThe major emphasis will be on the control
\nof epidemics and endemics, maternal and
\nchild health, geriatric care and adolscent
\nhealth. \u201cThe IMA with its reach and dedica-
\ntion can make a big difference to the rural
\nhealth scenario and this step from the med-
\nical fraternity will amount to a giant leap for
\nthe whole country\u201d, Dr. Desai added.
\n\u201cEmphasis will be laid on increasing orien-
\ntation of health professionals towards the
\nneeds of rural population and provide pri-
\nmary care to them on a regular basis at their
\ndoorsteps\u201d. Said Dr. Vinay Aggarwal,
\nSecretary General, IMA.
\nThe Soul of India lies in the villages\u2026
\nAlmost 75% of our population lives in vil-
\nlages but 75% of the country\u2019s health infra-
\nstructure is concentrated in cities. Most of
\nthe villages still fall short of health man-
\npower and infrastructure. The popular myth
\nin the public mind is that doctors do not
\nwant to serve in rural areas.
\nThe villages are unaware of the progress the
\nmedical profession has made and the inher-
\nent potential of qualified and dedicated doc-
\ntor. They accept all diseases as part of their
\ndestiny. This, coupled with poverty-gener-
\nated helplessness, adds to considerable
\nmorbidity and mortality. IMA with its vari-
\nous branches can take the lead in this direc-
\ntion.
\nAao Ganon Chalen: Advent of a new era in
\nrural health
\nIMA has undertaken this ambitious project
\nto shoulder the responsibility of the provi-
\nsion of positive health to every village in
\nthe country. The project will enable medical
\nprofessionals to develop a vision and under-
\ntake innovations to improve rural health as
\nenvisaged in the national health policy.
\nUnder the project, the members of IMA will
\nbe adopting the most vulnerable villages
\naccording to prevalent major public health
\nproblems. Major emphasis will be on the
\ncontrol of epidemics and endemics, mater-
\nnal and child health, geriatric care and ado-
\nlescent health.
\nWhat the project will achieve
\n\u2022 Orientation of professionals to village
\nhealth
\n\u2022 Health awareness generation
\n\u2022 Provision and strengthening of promo-
\ntive, preventive, curative and rehabilita-
\ntive services
\n\u2022 Community involvement and participa-
\ntion in health care
\n\u2022 Public \/ private partnership in rural
\nhealth care
\n\u2022 Co-ordination to strengthen referral link-
\nages in the health care delivery system
\n\u2022 An improved image of IMA and the
\nmedical profession
\nProposed activities
\nHealth awareness activities
\n\u2022 Community health meetings
\n\u2022 Debates, posters and painting competi-
\ntions in schools
\n\u2022 Puppets shows and magic shows
\n\u2022 Nukkad nataks
\nMedical and surgical facilities
\n\u2022 Health camps providing multi-discipli-
\nnary care
\n\u2022 Special clinics for expectant mothers,
\nchildren and elderly people
\n\u2022 Cataract \/ sterilization camps
\n\u2022 Immunization services
\n\u2022 Adolescent guidance and counseling ser-
\nvices
\n\u2022 Family welfare services
\n\u2022 Cancer detection clinics
\nRehabilitation services
\n\u2022 Distribution of wheel chairs, artificial
\nlimbs and other required services to
\nhandicapped people. …amongst a host of
\nother welfare activites.
\nhttp:\/\/www.imanational.com\/AaoGaon.asp
\naccessed on 28\/2\/06
\nIndian Medical Association
\nAao Gaon Chalen \u2013 IMA launches rural
\nhealth plan
\nPhysicians speak out on prisoner forced feeding \u2013 the American
\nMedical Association speaks out.
\nAs reported in American Medical News, the American Medical Association (AMA) has given pub-
\nlicity to its condemnation of physician participation in prisoners\u2019 forced feeding It stresses, in an
\neditorial written by Dr. Duane M Cady (chair of AMA\u2019s Board of Trustees) passed to news outlets,
\nthe AMA\u2019s endorsement of the WMA Declaration of Tokyo, quoting \u201cwhere a prisoner refuses nour-
\nishment and is considered by the physician as capable of forming an unimpaired, rational judgement
\nconcerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed
\nartificially\u201d. The AMA has met the Department of Defence over the past years raising its concerns,
\n\u201cand to offer to provide them with relevant policies and expertise, with the goal of ensuring that US
\npolicies in detainee treatment comport with ethical standards of medicine\u2026\u201d
\nThe U.S.government defends its policy \u201cWe\u2019re trying to preserve life\u201d a spokeswoman of the
\nDefence Dept. is reported as saying. (American Medical News 49, 13)
\nThe AMA House of Delegates has asked the Council on Ethical and Judicial Affairs to develop clear
\nguidelines for physician participation in prisoner and detainee interrogations. (American Medical
\nNews 48, 13)
\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":"

wmj9 WorldMedical Journal Vol. No.1,March200652 OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC. G 20438 Contents Editorial Evolution of Health Professions 1 European Developments presage Worldwide Activities 2 Medical Ethics and Human Rights Avian influenza 3 \u201cCaring Physicians of the World\u201d 5 Medical management of hunger-strikers 5 The Right to Health 6 Medical Science, Professional […]<\/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\/wmj9.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3543"}],"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=3543"}]}}