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WorldMMeeddiiccaall JJoouurrnnaall
\nVol. No.2,June200652
\nOFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
\nG 20438
\n173rd
\nWMA
\nCouncil Meeting
\nContents
\nDeclaration of Geneva 29
\nEEddiittoorriiaall
\nHuman health resources 30
\nTrust in Physicians 31
\nDr. LEE Jong-wook 33
\nMMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
\nThe World Medical Association Declaration
\nof Tokyo 34
\nThe World Medical Association regulations
\nin times of armed conflict 35
\nWMA Declaration of Malta \u2013 A background paper
\non the ethical management of hunger strikes 36
\nFFrroomm tthhee SSeeccrreettaarryy GGeenneerraall\u2019\u2019ss DDeesskk
\n\u201cWhat do we expect from the next
\nWHO Director General?\u201d 43
\nWWMMAA
\n173rd
\nWMA Council Meeting held in Divonne 44
\nSecretary General\u2019s Report to the
\n173rd
\nWMA Council Session 49
\nWWHHOO
\nHealth workforce crisis is having a deadly impact
\non many countries\u2019 ability to fight disease and
\nimprove health 53
\nGlobal access to HIV therapy tripled in past two
\nyears, but significant challenges remain 54
\nDeveloping country access needed to existing
\nand new medicines and vaccines 56
\n00_US_02_2006.qxd 17.07.2006 13:45 Seite 1
\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 N. Arumagam Dr. Kgosi Letlape Dr. Y. D. Coble
\nMalaysian Medical Association The South African Medical Association 102 Magnolia Street
\n4th Floor MMA House P.O Box 74789 Lynnwood Ridge Neptune Beach, FL 32266
\n124 Jalan Pahang 0040 Pretoria USA
\n53000 Kuala Lumpur South Africa
\nMalaysia
\nTreasurer Chairman of Council Vice-Chairman of Council
\nProf. Dr. Dr. h.c. J. D. Hoppe Dr. Y. Blachar Dr. K. Iwasa
\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
\n01212 Ferney-Voltaire Cedex
\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: Title page: Robert Koch Institute, Berlin, Germany. Photo courtesy of Robert Koch Institute. On top: RKI aerial view
\n(Source: RKI \/ Ossenbrink). At the bottom: Foyer of the Robert Koch Institute (Source: RKI \/ Schnartendorff)
\nThis was founded as the \u201cPrussian Institute for Infections Diseases\u201d of which Koch was the Director. His name was added
\nto the title in 1912 and the Institute finally re-titled the \u201cRobert Koch Institute\u201d in 1942.
\nU2–4_WMJ_02_06.qxd 17.07.2006 13:46 Seite U2
\n29
\nOFFICIAL JOURNAL OF
\nTHE WORLD MEDICAL
\nASSOCIATION
\nHon. Editor in Chief
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSuffolk IP14 3QT
\nUK
\nCo-Editors
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
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\nUK
\nBusiness Managers
\nJ. F\u00fchrer, D. Weber
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\nGermany
\nPublisher
\nTHE WORLD MEDICAL
\nASSOCIATION, INC.
\nBP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
\nDeutscher \u00c4rzte-Verlag GmbH,
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\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. 7 %
\nMwSt.). For members of the World Medical
\nAssociation and for Associate members the
\nsubscription fee is settled by the membership
\nor associate payment. Details of Associate
\nMembership may be found at the World
\nMedical Association website www.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nK\u00f6ln \u2013 Germany
\nISSN: 0049-8122
\nDECLARATION OF GENEVA
\nAdopted by the 2nd
\nGeneral Assembly of the World Medical Association, Geneva,
\nSwitzerland, September 1948 and amended by the 22nd
\nWorld Medical Assembly,
\nSydney, Australia, August 1968 and the 35th
\nWorld Medical Assembly, Venice,
\nItaly, October 1983 and the 46th
\nWMA General Assembly, Stockholm, Sweden,
\nSeptember 1994 and editorially revised at the 170th Council Session, Divonne-les-
\nBains, France, May 2005 and the 173rd
\nCouncil Session, Divonne-les-Bains,
\nFrance, May 2006
\nAT THE TIME OF BEING ADMITTED AS A MEMBER
\nOF THE MEDICAL PROFESSION:
\nI SOLEMNLY PLEDGE to consecrate my life to the service of humanity;
\nI WILL GIVE to my teachers the respect and gratitude that is their due;
\nI WILL PRACTISE my profession with conscience and dignity;
\nTHE HEALTH OF MY PATIENT will be my first consideration;
\nI WILL RESPECT the secrets that are confided in me,
\neven after the patient has died;
\nI WILL MAINTAIN by all the means in my power, the honour and
\nthe noble traditions of the medical profession;
\nMY COLLEAGUES will be my sisters and brothers;
\nI WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic
\norigin, gender, nationality, political affiliation, race, sexual orientation, social
\nstanding or any other factor to intervene between my duty and my patient;
\nI WILL MAINTAIN the utmost respect for human life;
\nI WILL NOT USE my medical knowledge to violate human rights and
\ncivil liberties, even under threat;
\nI MAKE THESE PROMISES solemnly, freely and upon my honour.
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 29
\nEditorial
\n30
\nEditorial
\nHuman health resources
\nOver the past two years we have drawn attention to the increasing problems facing not only
\nthe medical profession but also all the health professions. These have related both to the
\nchanges and expectations of society globally and the remarkable increases in scientific
\nknowledge and technological developments which have increased the potential and actual
\nability to control and treat many diseases. At the same time the journal has reported the
\nother side of the picture, the continuing existence of poverty and the inequity in access to
\neven the most basic, let alone the more sophisticated medical advances which result from
\nit. Over the past few years these issues have been placed on the international agenda and
\nwe have witnessed increasing public acknowledgement of the need to reduce the gap
\nbetween economically successful developed countries and developed or under developing
\ncountries. This has been acknowledged by summits such as those of the G7 and individual
\ngovernmental aid programmes, by generous non-governmental donors, and by worldwide
\nfund raising movements directed towards specific major diseases or natural disasters such
\nas we have witnessed in the past few months. Nevertheless these international aid contri-
\nbutions still fall far short of the estimated need.
\nHowever attention is now being drawn to another major threat to healthcare, the relief of
\nsuffering and the reduction of morbidity and mortality from major diseases and this at a
\ntime when there is increasing concern and awareness of the risk of a new global pandem-
\nic. The WHO World Health Report 2006 launched in April 2006 is entitled \u201cWorking
\ntogether for Health\u201d(1) and marks the beginning of the WHO year of \u201cHuman Health
\nResources\u201c, to be followed by a decade of action to deal with the global shortage of health
\nworkers. This shortage applies to most groups of personnel working in the health sector and
\ncalls for a radical reappraisal of the activities of the recognised main stream health profes-
\nsions, doctors, nurses and midwives, pharmacists and dentists etc and for assessment of the
\npotential for limited training for carrying out specific tasks for some professionals and oth-
\ners, as opposed to the wider basic and specialist knowledge and skills training considered
\nessential for certain professionals to practice in health care professions.
\nWhile the report highlights the compelling and urgent need in some of the world\u2019s poorest
\ncountries, where the WHO estimates that some 57 countries (36 in Africa alone) have a
\ndeficit of 2.4 million doctors, nurses and midwives, reflecting the problems of AIDS, skills
\ndrain, rural\/urban drain etc. in addition to the factors mentioned above, developed countries
\nare also experiencing or anticipating a shortage in these professions. The latter is exempli-
\nfied by a suggestion made in a recent meeting that the anticipated needs of the USA for
\nphysicians in 2020, will be for 200,000 new doctors (half the current estimated global num-
\nber of physicians available in the year 2020).
\nIn another part of the WHO report, emphasis is also placed on the need for strong leader-
\nship – an issue which is being addressed by the World Health Professions Alliance of which
\nthe World Medical Association is a member. The late Director General Dr. LEE Jong
\nwook\u2019s opening overview of the Report referred to \u201cAcquiring critical capacities by
\nstrengthening core institutions for sound workforce development. Leadership and manage-
\nment development in health and other related sectors such as education and finance is
\nessential for strategic planning and implementation of workforce policies. Standard setting,
\naccreditation and licensing must be effectively established to improve the work of worker
\nunions, educational institutions, professional associations and civil society\u201d.
\nLater the report calls, amongst other things, for increased licensing and accreditation and
\nexamination of cost and labour efficiency of health professionals, pointing out the evidence
\nof the better rates of immunisation in the
\npopulation when using nurses rather than
\ndoctors in countries where most of the
\nimmunisations are normally given by nurs-
\nes. In this context the report cites three
\n\u201cCochrane\u201d reviews (2) of the results of
\nsubstituting nurses for doctors in primary
\ncare. These showed no difference in quality
\nof care and outcomes between appropriate-
\nly trained nurses and doctors and showed
\nthe nurses giving more health care advice.
\nWhile on the other hand nurses ordered
\nmore tests and used more other services
\nthan doctors, thus reducing cost saving. In
\nanother review of 85 randomised controlled
\ntrials, 10 of which were considered to be of
\nhigh methodological quality), while it was
\nconcluded that audit and feedback can
\nimprove professional practice. the effects
\nwere variable, \u201csmall to moderate\u201d. It con-
\ncludes \u201cresults of the trials do not provide
\nsupport for mandatory use of audit and or
\nunevaluated feedback\u201d.
\nCommenting on self-regulation, while
\nacknowledging that this can be effective
\nand that medical associations etc. can regu-
\nlate the behaviour of the profession and
\nmaintain technical competence, the report
\nstates \u201cSelf-regulation by professional asso-
\nciations is not always effective\u201c and com-
\nments on the difference between the east
\nand west. In the latter, notably Europe and
\nAmerica, \u201cthe majority of organisations are
\nat least more than 110 years old, whereas in
\nlow income countries 4 out of 10 are less
\nthan 25 years old.\u201d Even more importantly,
\nit comments on the strain on self regulation
\nresulting substantially from employers
\nincreasingly overriding it, Whilst acknowl-
\nedging this to be the case where the state is
\nthe traditional employer of health workers,
\nit points out that increasingly the previous-
\nly self-employed autonomous health work-
\ners are now working in an employer-
\nemployee situation. \u201cThe employer,
\nwhether the state, a non-governmental non-
\nprofit making organisation, financial corpo-
\nration or international organisation tends to
\nhave the most influence on professional
\nbehaviour, concluding that associations by
\nthemselves can no longer claim to provide
\ncoherent governance, in the public interest,
\nof the health workforce as a whole.\u201d This
\nacknowledges important concerns which
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 30
\nhave already been increasingly occupying
\nthe profession for some time past.
\nHowever, while the report does not specif-
\nically recommend the abolition of self- reg-
\nulation, it urges the creation (where neces-
\nsary) of the technical bodies for licensing,
\naccreditation etc. and also suggests the
\ninclusion of all stake holders in forums
\nwhich would permit interaction between all
\norganisations affecting the behaviour of
\nhealth workers and the health institutions,
\nwell illustrated in a diagram showing inter-
\naction between professional organisations,
\ninstitutional regulators and civil society
\norganisations. (3)
\nNevertheless, the report quotations above
\nreinforce the urgent need for reflection, and
\nif need be action by the medical profession
\nand its medical associations, in particular
\nthose with regulating powers. The reflec-
\ntion must take into account not only the
\nneed to adapt the functions for which the
\nspecial training of physicians is required
\nbut also the needs of the globalised society
\nin which we live.
\nThe World Health Assembly this year, in its
\ndecision addressing the problems of short-
\nage of human health resources and also the
\nchallenges of international migration of
\nhealth personnel in six recommendations in
\nits resolution (4), urged Member States to
\naffirm their commitment by:
\n\u201eGiving consideration to establishing
\nmechanisms to mitigate the adverse impact
\non developing countries of loss of health
\npersonnel through migration including
\nmeans of receiving developed countries
\nsupporting health systems, especially in
\nhuman resources development, in the coun-
\ntries of origin;
\npromoting training in accredited institu-
\ntions of a full spectrum of quality profes-
\nsionals and also community health work-
\ners, public health workers and profession-
\nals;
\npromoting training partnerships between
\nschools in industrialised developing coun-
\ntries involving faculty and student
\nexchange:
\nGuest Editorial
\n31
\nencouraging financial support by global
\nhealth partners donors etc. of health training
\ninstitutions in developing countries;
\npromoting planning teams in each country
\nfacing health-worker shortages drawing on
\nstake holders including professional bodies,
\npublic and private sectors and non-govern-
\nmental organisations to formulate compre-
\nhensive strategy for the health workforce,
\nincluding consideration of effective mecha-
\nnisms for utilisation of trained volunteers
\nusing innovative approaches to teaching in
\ndeveloped and developing countries with
\nstate-of-the-art teaching materials and con-
\ntinuing education through the innovative
\nuse for information and communications
\ntechnology.\u201c
\nIt is clear from this that the crisis in Human
\nHealth Resources is one which National
\nMedical Associations will neglect at their
\nperil and need to address, not only in their
\nown national context but also in the interna-
\ntional global context. The WMA has
\naddressed the issue of physician migration
\nand also referred to countries\u2019 bilateral
\nagreement to effect meaningful co-opera-
\ntion in health care delivery in its statement
\nof Helsinki 2003 \u201cEthical Guidelines for the
\nInternational Recruitment of Physicians.\u201d
\nHowever, the issues raised in the WHO
\nReport, the decade of action and the global
\nalliance set up to address these issues (6),
\ncall for serious consideration and leadership
\nif the profession is to influence policy ini-
\ntiatives proposed by governments to deal
\nwith this serious threat to future health care.
\nAlan Rowe
\n(1) The World Health Report 2006 \u201cWorking
\ntogether for Health\u201d, WHO Geneva
\n(2) ibid p. 138
\n(3) Ibid p. 214
\n(4) WHO,WHA59.23
\n(5) WMA statement accessible on
\nwww.wma.net
\n(6) Global Health Workforce Alliance
\nTrust in Physicians
\nAbundance of Medical Information \u2013
\nShortage of Medical Orientation
\nby Peter Atteslander, Professor emeritus, University of Augsburg,
\nDirector, INAST Research Univ., Inst. Sociology, University of Neuchatel
\nWould you trust a machine? Probably you do not. You might rely on its functioning. Trust
\nhowever has a quite clear intrinsic meaning: trust is a psychic and social process based on
\nfirm beliefs. You definitely will not trust a medical system as such but specific persons
\nplaying an important role in its institutions. It is above all the medical doctor on the daily
\nfront interacting with the patient before him that you trust, sometimes you have to trust. In
\nmany existential situations the patient lays his life in doctors\u2019 hands. He is confident about
\nthe physician\u2019s professional abilities, judgements and increasingly about medical orienta-
\ntion which only the physician is a master of. Many of us are lost before the growing amount
\nof all kinds of public health advice, leaving us over-informed but under-oriented.
\nCan one measure trust in physicians? Indeed: since many decades, numerous surveys show
\nthat medical doctors are constantly granted one of the highest prestige statuses amongst all
\nprofessions. There is no marked decline of trust in physicians, their general acceptance in
\nspite of the fact that medicine is increasingly experiencing all kinds of pressure, economic,
\nbureaucratic and stressful through the increasing velocity of medical technology develop-
\nment, inevitably leading to more specialisation. General anxieties are felt and unspecified
\ncritique finds its public. Mass media seem to be more interested in either sensationally
\nreporting cases of malfunctions in our health systems, creating wrong hopes or propagating
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 31
\nGuest Editorial
\n32
\nnew therapies not yet applicable. They fail
\nto adequate orientate the citizen.
\nNevertheless, a traditional image of doctor\u2019s
\nrole still seems to persist today. This in spite
\nof magnificent medical technologies, new
\norganization and miracles of medical prac-
\ntice. It is human empathy with the patient
\nthat the lone horse- and buggy doctor lived
\nwith centuries ago. Compared to our days,
\nhe had rather little to offer but himself and
\na handful of medicaments and instruments
\nto use.What has changed since then? Do we
\nnot still talk of the physician himself as \u2018the
\nmost efficient medicament\u2019, and of his prac-
\ntice as being an art? Until today, the interac-
\ntion between patient and doctor remains the
\nmost important source of trust.The more
\ncomplex health structures become, the more
\nimportant it is to safeguard the physician\u2019s
\nrole to offer medical and mental orientation
\nto patients. Even those expert in using the
\ninternet are essentially in danger of getting
\nlost in a labyrinth of information they are
\nunable to interpret. Since trust is a social
\nand mental process, it can neither be
\nordered, regulated or even administrated.
\nWithout orientation, patients will comply
\nless with medical prescriptions. Comp-
\nliance is amongst many other aspects pre-
\ndominantly the result of trust in the pre-
\nscriptions and advice of the physician.
\nThere are however many factors that endan-
\nger this (fortunately still persisting) com-
\nmon trust. The World Health Organisation
\n(WHO) stated long ago that governments
\nare responsible for the health of their citi-
\nzens and can only discharge that responsi-
\nbility by taking adequate measures in the
\nhealth care and social spheres. To ensure
\nfair distribution of medical services most so
\ncalled OECD-states, representing modern
\nrather wealthy societies, have introduced
\nso-called cost-moderating laws. This results
\nin wide spread fears that increased state
\nintervention will further undermine the nec-
\nessary state-free area of doctor- patient rela-
\ntions. Experience shows that more adminis-
\ntration does not in itself lead to greater con-
\ntrol over rising costs. States cannot be made
\nresponsible for individual health conditions.
\nOn the other hand it can be expected that
\nthey safeguard general policies which per-
\nmit the best possible individual medical
\nactions by all concerned. Adequate health
\ncare and social measures, however, always
\nimply greater control and planning. It is not
\nadvisable to implement too strict bureau-
\ncratic norms at the cost of impeding doctor-
\npatient relations. Individual behaviour is all
\ntoo often influenced by state action, but it
\ncannot be planned in detail, certainly not
\nwhere health is involved.
\nThe health care systems are highly com-
\nplex. Today we do not know exactly how
\nthey function. At best we still find areas
\nwhere it does not function. In future it will
\nbe impossible to satisfy every conceivable
\nneed. The total sum of individual needs as
\nexpressed, does not necessarily represent
\nthe need of a society at large on which state
\ninterventions (based on data from social
\nepidemiological surveys, that rarely meet
\nmethodological expertise), are decided.
\nGeneral expectations of the kind aroused by
\ntoo comprehensive WHO-postulates which
\ninterpret health as a state of \u201ccomplete
\nphysical, mental and social well-being and
\nnot merely the absence of illness\u201d, cannot
\nbe transposed into legally effective entitle-
\nments for the individual. The inadequacy of
\na health care system which is widely per-
\nceived today, does not in itself point to the
\ngoals which should be set.
\nThere is an increasing pressure not only to
\neconomise in healthcare systems, and also
\nto harmonize procedures independent of
\ncultural differences, leading to different
\nsocial behaviour. This provokes ever more
\nnew regulation of health reporting.
\nWarnings by many scientists have evidently
\nnot reached politicians and bureaucrats.
\nLarge sums have been wrongly invested
\ntrying to measure qualitative health matters
\nwith quantitative instruments. Of course
\nhealth care has material and economic
\naspects, but all other predominantly qualita-
\ntive processes cannot be measured by pure-
\nly quantitative methods. Healing.requires
\nmore than a functioning human body,and
\nthe physician more than a technician. It was
\nan illusion that the highly dynamic struc-
\ntures of the health care systems could be
\nregulated, finally controlled by simple
\nmaterial indices. It is an essential error to
\nbelieve that the role of physicians can be
\nstandardized. There is no such thing as a
\nstandard patient, just as there is no statisti-
\ncally determined average health situation.
\nBeware of statistical artefacts when dealing
\nwith sick human beings.
\nComplex systems tend to be self relevant
\nand hard to grasp. They are even harder to
\ngovern. In health systems responsibilities
\nare often nebulous and poorly defined.
\nCombined with economic restrictions and
\nbureaucratic standardisation, more and more
\nnon medically trained agents tend to restrict
\nphysicians\u2019traditional as well as prospective
\nrole. Their indispensable moral and ethical
\nidentity is thereby severely menaced.
\nThe progress of modern medicine high-
\nlights in addition another problem, which
\nmay be described as the concept of pressure
\nfor \u2018positivisation\u2019:, especially in medical
\ntechnology, surgery and pharmacology,
\nwhere the quick and obvious successes and
\nimmediate effects are so apparent, experi-
\nenced as \u201crelief\u201d and verifiable. Such pres-
\nsure for their broad and instant application
\narises that it, in turn, increases demand
\nleading to new problems of distribution,
\nboth of human resources and costs. This
\nhappens irrespective of the dangers of inter-
\nactions with other medicaments, often only
\nrecognised only later.
\nThere is growing hedonisme regarding
\nhealth: Eat the pills today, pay tomorrow,
\noften with illness !
\nThe progress in modern medicine is in
\nmany senses of the word, fantastic. One is
\ntempted to say that as in other fields of tech-
\nnology we are offered more answers than
\nwe have questions for. In medicine this
\nmeans that there are more investigation
\nalleys and more therapies at hand than we
\ncan pay for. Ethical problems are not antic-
\nipated ; adequate and fair distribution of
\nmedical services remains largely unsolved,
\nrationing wide spread. Even rationalization,
\nas the step before restricted distribution of
\nmedical services is declared, should rely on
\nsystematic, optimized action. In practice,
\nrationing often fails to meet these criteria.
\nThe discussion, as to when it is necessary to
\nomit certain therapy which has questionable
\nperspectives, has only just begun. We are
\nonly starting to comprehend that the effects
\nof modern medicine may also have impor-
\ntant societal implications.
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 32
\nEditorial
\n33
\nIllness must no longer be understood solely
\nas the dysfunction of a biological organism.
\nWe have to learn and to understand it as a
\ntypical social attitude. This changes also the
\ninteraction between physician and patient.
\nThis aspect has been largely disregarded by
\nmedicine up to now since the manifest suc-
\ncesses of modern medicine conceals this
\nweak point.
\nIllnesses which can be precisely defined in
\nscientific terms and the disorders, for which
\nclear forms of therapy exist, are increasing.
\nNobody would deny this success. Their rel-
\native importance measured against the gen-
\neral requirements placed on the medical
\nsystem, is however rapidly declining. New
\nand hard to define syndromes of illness are
\nspreading. We see modern medicine as
\nbeing caught in a dangerous trap between
\nthe growing availability of technical and
\nmedical expertise and the increasingly man-
\nifest and perceived lack of social health ori-
\nentation.
\nTrust in physicians is in principal a qualita-
\ntive property of highest importance. This
\nholds true especially when we speak of
\nhealing processes. The question is pertinent,
\nas to whether in future the precious asset of
\na free and humane doctor-patient interac-
\ntion can be safeguarded against the strong
\ninfluence of growing economization,
\nbureaucratization (above all) , in view of a
\ngrowing non steered quantitative regulation
\nin the health system.
\nOne of the leading medical social scientists
\nwrote decades ago \u201cMedicine as a social
\ninstitution has extremely broad functions.
\nNot only does medicine deal with the pre-
\nvention and treatment of pain, disease, dis-
\nability, and impairment, but it also provides
\nan acceptable excuse for relief from ordinary
\nobligations and responsibilities, and may be
\nused to justify behaviours and interventions
\nnot ordinarily tolerated by the social system
\nwithout significant sanctions. The definition
\nof illness may also be used as a mechanism
\nof social control to contain deviance, to
\nremove misfits from particular social roles,
\nor to encourage continued social functioning
\nand productive activity. Thus, the locus of
\ncontrol for medical decision making is a key
\nvariable in examining the implications of
\nmedical care for social life more generally\u201d.
\nPhysicians have rapidly to overcome the
\nmanifold effects of the further growing spe-
\ncialization. More time will be demanded for
\ninterdisciplinary actions. Managing rele-
\nvant information from different sources
\napplicable in specific cases has yet to be
\nlearned. Most important, the uniqueness
\nand intimacy in which human trust in the
\npatient-doctor relationship can only grow,
\nhas to be defended with all appropriate
\nmeans. We follow Mechanic(I)
\nin as far as
\nwe now witness the increasing velocity of
\nbureaucratisation of medicine as having the
\neffect of diluting the personal responsibility
\nof physicians, making it more likely that
\ninterests other than those of the patient will
\nprevail in the future.\u201d By segmenting
\nresponsibility for patient care, medical
\nbureaucracy relieves the physician of direct
\ncontinuing responsibility. If the patient can-
\nnot reach a physician at night or on week-
\nends, obtain responsive care, have inquiries
\nanswered or whatever, the problem is no
\nlonger focused on the failure of an individ-
\nual physician, but on the failures of the
\norganization. It is far easier for patients to
\nlocate and deal with individual failures
\nwhere responsibility is clear, than to con-
\nfront a diffuse organizational structure
\nwhere responsibility is often hazy and the
\nbuck is easily passed. To the extent that the
\nphysician knows that a patient is his or her
\ncharge, the physician feels a certain respon-
\nsibility to protect the patient\u2019s interests
\nagainst organizational roadblocks and
\nrequests that may not be fully appropriate.
\nBut when responsibility is less clear it is
\neasier to make decisions in the name of
\nother interests such as research, teaching,
\ndemonstration, or the \u201cpublic welfare,\u201d
\nwhatever that might be\u201d (p. 415).
\nTrust, as we said before, is based on firm
\nbelief. Belief in the the doctor-patient rela-
\ntionship is often nurtured by hope, even if it
\nis unrealistic and not to be granted. The
\nmore pressures of all kinds exist in this
\nhybris of health systems,. the more pressing
\nis the question of what to do. My proposi-
\ntion is that the physician has always to be in
\nthe centre of information. We forsee that
\ndoctors will depend to a greater extent on
\nother specialised experts and technical sys-
\ntems, will have to be the centre of informa-
\ntion , and will not be able to carry the per-
\nsonal full responsibility for their patients.
\nThe physician may need assistance for the
\ninterpretation of relevant data, but he alone
\nis in charge of the ultimate decisions. This
\nentitles him to ask for all means and mea-
\nsures to live up to his responsibility for the
\ngood of his patient who trusts him. It is high
\ntime that the physician\u2019s role has to be
\nwidely understood, honoured and enforced.
\nAddress for correspondence
\nProfessor Peter Atteslander
\nBellevueweg 29
\nCH 2562 Port
\nSwitzerland
\nE-Mail: peter.atteslander@bluewin.ch
\n(I)
\nDavid Mechanic, The Growth of Medical
\nTechnology and Bureaucracy: Implications for
\nMedical Care, in: Patients, Physicians, and Illness,
\nE.Gartly Jaco, London, New York, 1979, p. 415)
\nDr. LEE Jong-wook
\nWe very much regret the sudden death of the Dr. LEE Jong-
\nwook, Director General of the World Health Organisation, on
\nthe eve of the World Health Assembly. His ambitious project
\n3 by 5 to tackle HIV\/AIDS thought by many to be unrealis-
\ntic, nevertheless was a real attempt to unite agencies in a
\ncommon goal. His promotion of partnerships in dealing with
\nAIDS, Tuberculosis and Malaria, the agreement on stockpil-
\ning Tamiflu and his efforts to stimulate countries to recognise
\nthe real threat of pandemic influenza, were indications of his
\ndetermination to engage governments in the fight against the
\nthreats posed by these diseases. Dr. LEE died on 22 May 2006. He was 61.
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 33
\nMedical Ethics and Human Rights
\n34
\nPreamble
\nIt is the privilege of the physician to prac-
\ntise medicine in the service of humanity, to
\npreserve and restore bodily and mental
\nhealth without distinction as to persons, to
\ncomfort and to ease the suffering of his or
\nher patients. The utmost respect for human
\nlife is to be maintained even under threat,
\nand no use made of any medical knowl-
\nedge contrary to the laws of humanity.
\nFor the purpose of this Declaration, torture
\nis defined as the deliberate, systematic or
\nwanton infliction of physical or mental suf-
\nfering by one or more persons acting alone
\nor on the orders of any authority, to force
\nanother person to yield information, to
\nmake a confession, or for any other reason.
\nDeclaration
\n1. The physician shall not countenance,
\ncondone or participate in the practice of
\ntorture or other forms of cruel, inhuman
\nor degrading procedures, whatever the
\noffence of which the victim of such
\nprocedures is suspected, accused or
\nguilty, and whatever the victim\u2019s beliefs
\nor motives, and in all situations, includ-
\ning armed conflict and civil strife.
\n2. The physician shall not provide any
\npremises, instruments, substances or
\nknowledge to facilitate the practice of
\ntorture or other forms of cruel, inhuman
\nor degrading treatment or to diminish
\nthe ability of the victim to resist such
\ntreatment.
\n3. When providing medical assistance to
\ndetainees or prisoners who are, or who
\ncould later be, under interrogation,
\nphysicians should be particularly careful
\nto ensure the confidentiality of all per-
\nsonal medical information. A breach of
\nthe Geneva Conventions shall in any
\ncase be reported by the physician to rel-
\nevant authorities.
\nThe physician shall not use nor allow to
\nbe used, as far as he or she can, medical
\nknowledge or skills, or health informa-
\ntion specific to individuals, to facilitate
\nor otherwise aid any interrogation, legal
\nor illegal, of those individuals.
\n4. The physician shall not be present during
\nany procedure during which torture or
\nany other forms of cruel, inhuman or de-
\ngrading treatment is used or threatened.
\n5. A physician must have complete clini-
\ncal independence in deciding upon the
\ncare of a person for whom he or she is
\nmedically responsible. The physician\u2019s
\nfundamental role is to alleviate the dis-
\ntress of his or her fellow human beings,
\nand no motive, whether personal, col-
\nlective or political, shall prevail against
\nthis higher purpose.
\n6. Where a prisoner refuses nourishment
\nand is considered by the physician as
\ncapable of forming an unimpaired and
\nrational judgment concerning the con-
\nsequences of such a voluntary refusal of
\nnourishment, he or she shall not be fed
\nartificially. The decision as to the ca-
\npacity of the prisoner to form such a
\njudgment should be confirmed by at
\nleast one other independent physician.
\nThe consequences of the refusal of
\nnourishment shall be explained by the
\nphysician to the prisoner.
\n7. The World Medical Association will
\nsupport, and should encourage the in-
\nternational community, the National
\nMedical Associations and fellow physi-
\ncians to support, the physician and his
\nor her family in the face of threats or
\nreprisals resulting from a refusal to con-
\ndone the use of torture or other forms of
\ncruel, inhuman or degrading treatment.
\nThe World Medical Association Declaration of Tokyo.
\nGuidelines for Physicians Concerning Torture and other Cruel,
\nInhuman or Degrading Treatment or Punishment in Relation
\nto Detention and Imprisonment
\nAdopted by the 29th World Medical Assembly, Tokyo, Japan, October 1975,
\neditorially revised at the 170th Council Session, Divonne-les-Bains, France, May 2005
\nand the 173rd Council Session, Divonne-les-Bains, France, May 2006
\n* the latest revisions are shown underline. See also WMA Council report page 46
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 34
\nMedical Ethics and Human Rights
\n35
\n1. Medical ethics in times of armed con-
\nflict is identical to medical ethics in
\ntimes of peace, as stated in the Interna-
\ntional Code of Medical Ethics of the
\nWMA. If, in performing their profes-
\nsional duty, physicians have conflicting
\nloyalties, their primary obligation is to
\ntheir patients; in all their professional
\nactivities, physicians should adhere to
\ninternational conventions on human
\nrights, international humanitarian law
\nand WMA declarations on medical
\nethics.
\n2. The primary task of the medical profes-
\nsion is to preserve health and save life.
\nHence it is deemed unethical for physi-
\ncians to:
\na. Give advice or perform prophylac-
\ntic, diagnostic or therapeutic proce-
\ndures that are not justifiable for the
\npatient\u2019s health care.
\nb. Weaken the physical or mental
\nstrength of a human being without
\ntherapeutic justification.
\nc. Employ scientific knowledge to im-
\nperil health or destroy life.
\nd. Employ personal health information
\nto facilitate interrogation.
\ne. Condone, facilitate or participate in
\nthe practice of torture or any form of
\ncruel, inhuman or degrading treat-
\nment.
\n3. During times of armed conflict, stan-
\ndard ethical norms apply, not only in re-
\ngard to treatment but also to all other in-
\nterventions, such as research. Research
\ninvolving experimentation on human
\nsubjects is strictly forbidden on all per-
\nsons deprived of their liberty, especially
\ncivilian and military prisoners and the
\npopulation of occupied countries.
\n4. The medical duty to treat people with
\nhumanity and respect applies to all pa-
\ntients. The physician must always give
\nthe required care impartially and with-
\nout discrimination on the basis of age,
\ndisease or disability, creed, ethnic ori-
\ngin, gender, nationality, political affilia-
\ntion, race, sexual orientation, or social
\nstanding or any other similar criterion.
\n5. Governments, armed forces and others
\nin positions of power should comply
\nwith the Geneva Conventions to ensure
\nthat physicians and other health care
\nprofessionals can provide care to every-
\none in need in situations of armed con-
\nflict. This obligation includes a require-
\nment to protect health care personnel.
\n6. As in peacetime, medical confidentiali-
\nty must be preserved by the physician.
\nAlso as in peacetime, however, there
\nmay be circumstances in which a pa-
\ntient poses a significant risk to other
\npeople and physicians will need to
\nweigh their obligation to the patient
\nagainst their obligation to other individ-
\nuals threatened.
\n7. Privileges and facilities afforded to
\nphysicians and other health care profes-
\nsionals in times of armed conflict must
\nnever be used for other than health care
\npurposes.
\n8. Physicians have a clear duty to care for
\nthe sick and injured. Provision of such
\ncare should not be impeded or regarded
\nas any kind of offence. Physicians must
\nnever be prosecuted or punished for
\ncomplying with any of their ethical
\nobligations.
\n9. Physicians have a duty to press govern-
\nments and other authorities for the pro-
\nvision of the infrastructure that is a pre-
\nrequisite to health, including potable
\nwater, adequate food and shelter.
\n10.Where conflict appears to be imminent
\nand inevitable, physicians should, as far
\nas they are able, ensure that authorities
\nare planning for the repair of the public
\nhealth infrastructure in the immediate
\npost-conflict period.
\n11.In emergencies, physicians are required
\nto render immediate attention to the
\nbest of their ability. Whether civilian or
\ncombatant, the sick and wounded must
\nreceive promptly the care they need. No
\ndistinction shall be made between pa-
\ntients except those based upon clinical
\nneed.
\n12.Physicians must be granted access to
\npatients, medical facilities and equip-
\nment and the protection needed to carry
\nout their professional activities freely.
\nNecessary assistance, including unim-
\npeded passage and complete profes-
\nsional independence, must be granted.
\n13.In fulfilling their duties, physicians and
\nother health care professionals shall
\nusually be identified by internationally
\nrecognized symbols such as the Red
\nCross and Red Crescent.
\n14.Hospitals and health care facilities situ-
\nated in war regions must be respected
\nby combatants and media personnel.
\nHealth care given to the sick and
\nwounded, civilians or combatants, can-
\nnot be used for morbid publicity or pro-
\npaganda. The privacy of the sick,
\nwounded and dead must always be re-
\nspected.
\nThe World Medical Association regulations
\nin times of armed conflict
\nAdopted by the 10th
\nWorld Medical Assembly, Havana, Cuba, October 1956, edited by the 11th
\nWorld
\nMedical Assembly, Istanbul, Turkey, October 1957, amended by the 35th
\nWorld Medical Assembly,
\nVenice, Italy, October 1983 and the WMA General Assembly, Tokyo 2004, and
\neditorially revised at the 173rd
\nCouncil Session, Divonne-les-Bains, France, May 2006
\n* The latest changes in text are shown underline. See also WMA Council report page 46
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 35
\nMedical Ethics and Human Rights
\n36
\nWMA Declaration of Malta
\nA background paper on the ethical management of hunger strikes
\nThe following background paper and glos-
\nsary of terms were prepared by the British
\nMedical Association in association with the
\nrevision of the Malta Declaration currently
\nbeing considered by WMA Council and
\nNational Medical Associations.
\nSee also \u201eglossary of themes\u201c, p. 41-42.
\nIntroduction
\nPhysicians need to understand the back-
\nground to the guidance given in the World
\nMedical Association\u2019s Declaration of
\nMalta. This paper aims to set out that back-
\nground and some authentic case examples
\nare included to illustrate how complex this
\narea of practice can be. These cases are
\ntaken from field experience in widely dif-
\nfering contexts and countries. They have
\nbeen simplified and anonymised to protect
\nindividuals\u2019 confidentiality and they reflect
\nhow very different strategies may have to
\nbe adopted by physicians according to the
\ncircumstances of the case.
\nAlthough the Malta Declaration sets broad
\ninternational standards for managing hunger
\nstrikes in custodial settings, physicians still
\nneed to use their own moral judgement in
\nparticularly complex situations. To do this,
\nthey should be aware of the various different
\nforms of fasting which stem from differing
\nintentions on the protesters\u2019 part and which
\nrequire different handling. Hunger strikers\u2019
\nmotivations and their perseverance in a par-
\nticular kind of hunger strike can differ great-
\nly. Gaining their trust can be difficult but is
\ncrucial for doctors, who must be able to act
\nindependently from the detaining authori-
\nties. Physicians also need to be alert to the
\npressures which can be exerted on hunger
\nstrikers in custodial settings – not only by the
\nauthorities but also by peer group hierar-
\nchies and sometimes even by physicians
\nthemselves. For example, if doctors ask
\nhunger strikers to give advance instructions
\nat the start of a fast saying whether or not
\nthey would refuse resuscitation at a later
\nstage, it may be difficult for the hunger strik-
\ners to do anything other than refuse artificial
\nfeeding, without losing face with their peer
\ngroup. This may not be a truly valid and
\ninformed choice unless physicians can dis-
\ncuss it in private with the hunger striker.
\nPhysicians need to understand the clinical
\nand moral criteria concerning when to resus-
\ncitate a protester and when to abide by such
\na refusal of treatment. The crucial differ-
\nences between \u201cartificial\u201d and \u201cforce\u201d feed-
\ning need to be understood. Physicians also
\nneed to be aware of the symptoms and the
\nclinical physiology of the different stages of
\nfasting in order to give accurate medical
\ncounselling to patients about what to expect.
\n(Such advice can be found in the \u2018Course for
\nprison doctors\u2019, chapter 5, by the World
\nMedical Association, Norwegian Medical
\nAssociation and International Committee of
\nthe Red Cross at http:\/\/lupin-nma.net).
\nHealth professionals often act as mediators
\nbetween patients, authorities and other peo-
\nple such as patients\u2019families. They can be in
\na position to facilitate face-saving opportu-
\nnities which could bring the hunger strike to
\nan end for the benefit of all involved. This
\npaper seeks to help them do that.
\nDefinition of \u201chunger strike\u201d
\nAs explained in the glossary, a \u201chunger
\nstrike\u201d involves food refusal as a form of
\nprotest or demand. Such fasting is particu-
\nlarly undertaken by people in custodial set-
\ntings who lack alternative means to gain
\nattention and bring pressure to bear to
\nobtain some goal. Short-term rejection of
\nfood rarely gives rise to ethical dilemmas as
\nhealth is generally not permanently dam-
\naged as long as fluids are accepted. It is
\nimportant, however, for physicians to have
\na clear frame of reference on how to define
\na serious \u201chunger strike\u201d.
\nExcluded here are short-lived fasts which
\npeter out within 72 hours. If hunger strikers
\ncontinue to refuse both nutrition and hydra-
\ntion for more than 48 hours, however, they
\nrisk significant harm. Dry fasting without
\nany fluid intake which persists for more
\nthan a few days would fall within the defin-
\nition of \u201chunger strike\u201d used here but, fortu-
\nnately, this is rare. As the body cannot sur-
\nvive more than a few days without fluid,
\ndeath would occur within the first week
\nwhich, from the protesters\u2019 perspective, is
\ntoo short a period for negotiation to be
\neffective. In short, the term \u201chunger strike\u201d
\nas discussed here refers to protest fasting
\nwithout any intake of food but with inges-
\ntion of adequate quantities of water.
\nIn the first days of fasting, the body uses its
\nstores of glycogen in the liver and muscles.
\nKetosis occurs and is discernible clinically
\non the breath or by laboratory test in the
\nurine. It subdues the voracious sensation of
\nhunger experienced during the first days of
\nfasting. It can be argued that total fasting
\n(taking water only) for longer than 48 – 72
\nhours is the clearest definition on metabolic
\ngrounds for the term \u201chunger strike\u201d.
\nGlycogen stores are exhausted by about day
\n10-14 and certain amino acids take over as
\nthe substrate for gluconeogenesis. Muscle,
\nincluding heart muscle is gradually lost.
\nClose medical monitoring is recommended
\nafter a weight loss of 10% in lean healthy
\nindividuals and major problems arise at a
\nweight loss of about 18%. Hunger strikers
\nneed to be aware that dehydration is a risk
\nas they lose their sensations of hunger and
\nthirst.
\n1. The medical duty to establish
\ncompetence and motivation
\nAssessing patient competence and gaining
\nan understanding of the purpose of the fast
\nis crucial for physicians. Good communica-
\ntion and trust are essential here. Fasting as a
\nsymptom or manifestation of a psychiatric
\ndisorder such as anorexia or depression
\nrequires a totally different approach, so
\nassessing patients\u2019 mental health must be a
\nfirst step for physicians. People suffering
\nfrom any serious psychiatric or mental dis-
\norder likely to undermine their judgement
\nneed medical attention for their disorder
\nand cannot be permitted to fast in a way that
\ndamages their health. Fasting for religious
\nreasons should also not be confused with
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 36
\nMedical Ethics and Human Rights
\n37
\nprotest fasting but should be respected. It is
\ngenerally not health threatening and does
\nnot raise dilemmas when undertaken by an
\notherwise healthy person.
\nTwo main categories of individuals embark
\non hunger strikes with quite different inten-
\ntions and motivation. In potentially coercive
\ncontexts, (which include any situation of
\ndetention) it is important for physicians
\nalways to determine for themselves what are
\nthe exact motives for refusing nourishment.
\nSome food refusers fast to gain publicity to
\nachieve their goal, but have no intention of
\npermanently damaging their health. Their
\ngoal may seem relatively petty or it may
\ninvolve reasons of principle. As they do not
\nwish to die, these protesters often agree to
\nartificial feeding being provided at some
\nstage and may actually request medical
\nassistance in monitoring their fast. Those
\nwho repeatedly make this type of protest
\ncan come to be seen as exercising a form of
\nblackmail by the authorities, who then let
\nstrikes continue to test protesters\u2019 resolve.
\nPhysicians need to clarify privately with
\nprotesters, at regular intervals, how far they
\nare willing to go and when they expect and
\ndesire medical interventions to be made to
\nprevent lasting harm to their health.
\nThe other very different category consists
\nof what might be seen as very determined
\nhunger strikers who are not prepared to
\nback down unless their goal is actually
\nattained. Individually or in groups, they
\nmay differ in their mode of fasting but they
\nshare a determination to risk their health or
\ntheir lives for a cause. Political hunger
\nstrikers often fall into this category. Unlike
\nthe food refusers who rely on medical help
\nto prevent serious harm, this category of
\nprotesters often mistrust physicians, whom
\nthey see as belonging to the detaining sys-
\ntem. Such protesters pose a serious chal-
\nlenge to medical ethics, as their willingness
\nto take fasting to the extreme inevitably
\nraises difficult questions about whether and
\nwhen to intervene and the thorny ethical
\nquestion of whether feeding contrary to
\npatients\u2019 expressed wish can ever be justi-
\nfied. In this paper, we have rejected the term
\n\u201cdeath fast\u201d which is sometimes used to
\ndescribe a determined hunger strike. The
\nterm is unfortunate in that it appears to
\nassume death is the inevitable outcome. By
\nperceiving death as the objective of the fast,
\nopportunities for constructive dialogue may
\nbe lost from the outset. It is seen by the
\nauthorities as establishing an unacceptable
\nultimatum with no leeway for discussion.
\nThis can deter doctors from even attempting
\nto mediate.
\n2. The medical duty to attempt to
\nestablish \u201cvoluntariness\u201d
\n\u201cVoluntary total fasting\u201d is a term often
\nused, but fasts in detention are seldom total.
\nMost protesters accept fluids and some-
\ntimes the rejection of food too is less than
\ntotal. Participation can also be more
\ncoerced than voluntary, particularly in long
\ncollective hunger strikes. The authorities
\nmay want to stop protests by finding accept-
\nable compromises but pressures may come
\ninadvertently from staff, such as guards,
\nwhose taunts and derision of protesters can
\nlead to a hardening of positions. Detainees
\nmay also suffer coercion from peer groups
\nin subtle as well as obvious ways. These
\noften complex situations can lead to the
\npoint where it becomes virtually impossible
\nfor a protester to cease fasting voluntarily.
\nThe informed and voluntary nature of indi-
\nviduals\u2019 food refusal are key aspects that
\nphysicians need to ascertain once mental
\ncompetence has been established.
\nPhysicians must do their utmost to speak to
\neach patient privately, out of earshot of all
\nother people but with an interpreter if nec-
\nessary. It is important that interpreters are
\nnot connected with the detaining authorities
\nor the patient\u2019s peer group and that they are
\naware of the confidentiality expected of
\nthem. Those orchestrating collective hunger
\nstrikes are often reluctant to allow such
\ntalks, as this undermines their authority.
\nThis is possibly the most complex situation
\nto deal with in determining whether hunger
\nstrikers are indeed genuine volunteers. The
\nsubsequent extent to which medical confi-
\ndentiality can be guaranteed in custodial
\nsettings needs to be discussed with the
\npatient. Physicians should do everything in
\ntheir power to engage in frank discussion
\nwith patients and gain their trust. Where
\nprotesters appear to be fasting under duress,
\na solution may be to separate those individ-
\nuals in hospital on a medical pretext, there-
\nby extracting them from the influence of
\nothers and allowing them, if they agree, to
\nresume nourishment on medical grounds.
\nPressure may still come from relatives or
\nthe media. Families often alert the media,
\nhoping this will heighten the pressure on the
\nauthorities to make concessions but it can
\nalso increase pressure on the protester not to
\ngive way.
\nPhysicians sometimes cannot gain the trust
\nof patients. In such situations, it may be
\npossible to bring in an external physician
\nunconnected with the detaining authority or
\none nominated by the patient to ascertain
\nwhether the fast is truly voluntary. If the
\n\u201cvoluntariness\u201d of the decision appears to
\nbe established, protestors\u2019 decisions should
\nbe respected. It is likely that some cases of
\ncoercion go undetected, even if all reason-
\nable precautions are taken, but in the
\nabsence of evidence to that effect, physi-
\ncians must listen to and abide by what
\npatients say.
\nPhysicians can discuss with patients the
\nflaws or lack of logic in their expressed
\nwishes without exercising undue pressure.
\nExperience shows that particularly in high-
\nly political hunger strikes, decision-making
\nis far from simple. There may be situations
\nwhere physicians need to challenge the
\npatient rather than accept that person\u2019s
\nviews at face value. It is here that the impor-
\ntance of trust and the confidentiality of the
\nindividual interview become of paramount
\nimportance. There are cases in which physi-
\ncians, confronted with an apparently fanati-
\ncal hunger striker, can use their position of
\ntrust and medical authority to try to bring
\nthe protestor to reason.
\nCase example 1 \u2013 Difficulties of establish-
\ning a hunger striker\u2019s real wishes
\nA physician, visiting a collective hunger
\nstrike involving many politically motivated
\nprisoners, listened carefully to the story of a
\nfemale protestor. She had suffered many
\nhardships, including rape and the loss of
\nfamily members. She was barely 20 years
\nold and appeared politically motivated
\nalmost to the point of fanaticism. Her inten-
\ntion, she said, was to fast unto death to
\nprotest against oppression. The physician
\ndecided to test her determination as he was
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\nMedical Ethics and Human Rights
\n38
\nnot convinced her words reflected her real
\nwishes. He took a firm stance, arguing that
\nher apparent choice to die seemed wrong
\nafter all she had already endured and sur-
\nvived. In his view, her decision was ill
\nthought out and he said that, as a doctor, he
\nwas unwilling to let her waste her life but
\nwanted her to reconsider. The young woman
\nwas shocked as nobody \u2013 not even she her-
\nself – had questioned her intention previous-
\nly. She burst into tears but, on reflection,
\nagreed that she did not want to die. As they
\ntalked, the doctor\u2019s careful reasoning and
\nanalysis of her situation helped her to iden-
\ntify her real wishes. The conversation
\nbetween them was kept confidential but the
\nwoman agreed to accept nourishment which
\nwas given on a medical pretext to avoid
\npressure being brought to bear upon her by
\nher peer group. The doctor\u2019s willingness to
\nprobe deeper than the woman\u2019s superficial
\nstatements allowed him to test whether her
\nstatements really were an autonomous
\nexpression of her views. Her readiness to
\nhear his arguments made the hunger striker
\nre-evaluate her intentions and realize that
\nshe had suppressed her true feelings. The
\nexample shows how complex such issues
\ncan be and the risks of accepting an individ-
\nual\u2019s views without any question.
\n3. The duty to provide accurate
\ninformation to patients
\nPhysicians need to explain to each protester
\nthe implications of fasting for that person.
\nThis entails first taking a detailed medical
\nhistory and conducting an examination so
\nthat existing medical conditions are identi-
\nfied and discussed. They should objectively
\nwarn patients who suffer from ailments that
\nare incompatible with prolonged fasting,
\nnot to embark on a hunger strike or to
\nrestrict themselves to a limited form of fast-
\ning. Conditions such as diabetes, gastritis,
\ngastric or duodenal ulcer and many meta-
\nbolic diseases are contra-indications to total
\nfasting. Only if fully informed, can protest-
\ners make a truly voluntary and informed
\ndecision on whether to embark on a hunger
\nstrike. They only have a chance of obtaining
\ntheir goals if there is enough time for the
\nauthorities under pressure to react. The like-
\nly duration of their fast is therefore of para-
\nmount importance to hunger strikers, espe-
\ncially if they have difficulties in making
\ntheir plight known to those outside who can
\ntry to exercise influence. It will be essential
\nfor hunger strikers to know as accurately as
\npossible how long they personally could
\nfast. The fatal outcomes of total fasting
\nwere first documented during the 1980 and
\n1981 hunger strikes in Northern Ireland
\nwhere death generally occurred between 55
\nand 75 days. Similar experiences have con-
\nfirmed this wide time bracket. The three-
\nweek interval is due to differences in initial
\nphysical constitution and individual adapta-
\ntion. It is not possible to predict any time
\nspan more precisely. Protesters need to be
\nadvised that death occurs some time after
\nsix full weeks of fasting and survival after
\nten weeks of total fasting is practically
\nimpossible. They also need to know that in
\nthe final clinical stages of fasting, they will
\nno longer be capable of discernment and
\nneed to make clear in advance what they
\nexpect physicians to do for them then.
\n4. The duty to give counselling
\nMedical counselling may often be a key ele-
\nment in determining the duration of a
\nhunger strike. Physicians often find that
\nsome patients do not believe them, even
\nwhen they try to give objective counselling.
\nSome people who are detained understand-
\nably mistrust physicians, whom they see as
\nworking for the authorities. Doctors can
\nhave a difficult task convincing hunger-
\nstrikers that they are acting on their behalf,
\npartly because in many cases doctors are
\nunable to show that they are neutral. In such
\nsituations, there is a role for outside physi-
\ncians, not only to give medical advice, but
\nalso to act as neutral intermediaries in nego-
\ntiations with the authorities. Doctors are
\noften able to play a crucial role, but only if
\nthey obtain the trust of the patient. In some
\ncases, transferring a hunger striker to hospi-
\ntal on the pretext of performing further tests
\nmay serve a humanitarian purpose, allow-
\ning the protester to resume nourishment on
\nthe doctor\u2019s orders. Detainees, however,
\nconfide in the physician only if they are
\nconvinced that medical confidentiality will
\nbe respected. The element of trust is here
\nall-important.
\nTo give accurate advice and counselling,
\nphysicians need to clarify the type of
\nhunger strike that will occur. Most so-called
\n\u201ctotal fasts\u201d involve protesters accepting
\nwater but abstaining from all foodstuffs.
\nDifferent cultures, however, have different
\nnotions of how fasting should be defined.
\nSalt (either NaCl alone or a combination of
\nminerals) is often added to the water and
\npossibly sugar or other sweet substances
\nsuch as honey. Some cultures define fasting
\nin terms of abstaining from solid food (sub-
\nstances that need to be chewed) or from
\nfood that is cooked or heated. They may
\ndiscount the ingestion of milk, honey or
\neven nutrients such as eggs but the duration
\nof the fast remains the crucial element.
\nPhysicians need to make clear to hunger
\nstrikers that non-total or partial strikes, if
\nprolonged, lead to death but at a much later
\nstage than a total fast.
\nSome forms of partial fasting are consid-
\nered as \u201ccheating\u201d by the authorities. This
\ncan lead to controversy about the serious-
\nness of the protest. Prolongation of the peri-
\nod for potential negotiation, however, is
\noften beneficial to the final outcome and
\nhelps avoid deaths. Therefore physicians
\ncan find themselves in an apparently
\ncounter-intuitive situation. They may see
\nmore advantages in terms of life-saving
\nopportunities in a longer hunger strike
\nwhich allows more time for negotiation
\nrather than a short fast which is more
\nrestrictive in terms of what can be ingested
\nand therefore more lethal. Physicians need
\nto avoid implying to protesters or the
\nauthorities that non-total fasting is not seri-
\nous or lacks credibility. They should not
\nchallenge partial hunger strikers on the non-
\ntotal quality of their protest fast. Physicians
\nneed to understand that partial fasting for a
\nlengthy period of time can be a legitimate
\nform of protest which could provide more
\ntime to find a face-saving solution for all
\ninvolved and thus be instrumental in avoid-
\ning fatal outcomes. They must not, howev-
\ner, let themselves be manipulated by either
\nthe authorities or the hunger strikers.
\nPhysicians must not give erroneous clinical
\ntestimony or advice. Prison doctors, for
\nexample, have been known to threaten
\nhunger strikers with grave medical sequelae
\nthat are fictitious. In one example, doctors
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\nMedical Ethics and Human Rights
\n39
\ntold hunger strikers that fasting caused
\nimpotence, with the sole purpose of fright-
\nening them into giving up their fasting. This
\nsort of action is completely unethical and
\nundermines any trust that hunger strikers
\nmay have in the medical profession.
\n5. The duty to maintain confidentiality
\nThe duty of confidentiality is as strong in
\ncustodial situations as in the community. It
\nis never an absolute requirement in either
\ncontext if serious harm would result from
\nnon-disclosure and physicians need to make
\nan evaluation about where the best balance
\nlies. In situations where physicians are
\nunable to maintain some aspects of a
\npatient\u2019s confidentiality, this should ideally
\nbe made clear at the start of the consulta-
\ntion. Wherever possible, however, physi-
\ncians should respect patient confidentiality
\nas the maintenance of trust depends upon it.
\nThis applies to non-medical information
\ngiven to physicians by patients. For exam-
\nple, physicians interviewing hunger strikers
\nmight learn the names of the ringleaders of
\nthe protest, but they would lose patients\u2019
\ntrust and may put them at risk of reprisals if
\nthey disclosed that information to the
\nauthorities.
\nCase example 2 \u2013 Challenges in maintain-
\ning confidentiality
\nIn a collective hunger strike, the physician
\nrealised that the hunger strikers needed to
\nprolong their protest to allow time for the
\nnegotiation of their goals but none wished
\nactually to risk their lives. As the protest
\nwas the focus of media attention, however,
\nthey could not be seen to be lacking in com-
\nmitment and so while ostensibly refusing
\nnormal food, they privately agreed with the
\ndoctor to accept some nutrition and hydra-
\ntion intravenously. The physician main-
\ntained the trust and confidentiality of the
\nprisoners by not disclosing the full situation
\nto the prison authorities who, recognising
\nthat normal food was still being rejected,
\neventually threatened to end the strike by
\nforce feeding. The physician intervened and
\nexplained that he had the situation under
\ncontrol without force. Both sides in the
\nprotest were engaged in a drama where nei-
\nther was willing to be seen to concede. The
\ndoctor\u2019s ability to agree privately with the
\nprisoners to provide artificial feeding
\nallowed time for both sides to reach an
\nacceptable compromise without publicly
\nlosing face.
\nHunger strikers also need to be aware that
\nrequiring a doctor to maintain their confi-
\ndentiality can in some cases have potential
\ndisadvantages for them. Such aspects need
\nto be discussed at an early stage.
\nCase example 3 – Challenges in maintaining
\nconfidentiality
\nA political prisoner on hunger strike com-
\nplained to a visiting physician that he had
\nbeen forcibly fed while semi-conscious con-
\ntrary to his verbal advance instructions. The
\nprisoner wished to register a formal com-
\nplaint. Having listened carefully to the pris-
\noner\u2019s story, however, the doctor had doubts
\nas to whether the prisoner had indeed been
\nfed against his will since although semi-
\ncomatose, he was a strong man who could
\nhave exhibited some signs of resistance. In
\nfact the prisoner had made no effort to resist
\nand later, in private, he confided in the
\nphysician that he was relieved to have been
\nresuscitated but that these facts had to be
\nkept confidential both from other prisoners
\nand from the prison authorities. The doctor,
\ntherefore, was obliged to continue the pre-
\ntence of taking the complaint seriously but
\nin cases such as this, physicians also need to
\nexplain to hunger strikers the risks of such a
\ndeception since in future situations, it would
\nbe assumed that the hunger strikers did not
\nwant to be resuscitated unless they had
\nmade their real views plain. A hunger strik-
\ner in this situation would have a particular-
\nly difficult dilemma if asked to sign a formal
\nadvance directive refusing future resuscita-
\ntion since this would either force him to
\nexpose his real views or it would mean that
\nhe risked being allowed to die in future if
\nevidence were lacking of his real feelings. In
\nthis case, as a last resort, the confidentiality
\nof the prisoner\u2019s discussion with the visiting
\nphysician could arguably be breached to
\navoid that harm but this would really need to
\nbe discussed in advance with him.
\n6. The advantages and disadvantages of
\ncommunicating with families
\nFamilies may support detainees\u2019 fasting or
\ntry to get the authorities to intervene to save
\nthe prisoner\u2019s life regardless of that individ-
\nual\u2019s views. Given, however, that people in
\ncustodial settings often have only limited
\nways of making their own genuine views
\nknown, physicians attending them can find
\nit useful to communicate with their rela-
\ntives. Direct contact with them may provide
\ncrucial background information allowing
\nthem to make the best decision. Cases also
\narise where physicians find themselves at
\nodds with a family demanding intervention
\nwhich the patient refuses. In many coun-
\ntries, the family of a prisoner on hunger
\nstrike has the legal right to require medical
\nintervention. While keeping this in mind,
\nphysicians should never forget that their
\nprimary professional commitment is to the
\npatient. Where families support the hunger
\nstriker or openly lobby for media attention,
\nthe authorities may be reluctant to allow
\nfamily visits and physicians may have an
\nimportant role as intermediary. Although
\npressures on hunger strikers should obvi-
\nously be kept to a minimum, this should not
\nbe an excuse to suppress family visits.
\n7. Is there a duty to act as mediator?
\nThe role of mediator is outside physicians\u2019
\nobligations in most circumstances but in the
\ncontext of hunger strikes, they can be par-
\nticularly influential in saving life if they are
\nwilling to do so and have the trust of both
\nsides. They also need an objective view of
\nthe true situation. They may then be in a
\nposition to negotiate and possibly obtain
\nconcessions from both sides. They have to
\ndecide from the start, however, whether
\nthey can act as a medical intermediary
\nbetween hunger strikers and the authorities
\nand if they cannot, they need to make that
\nclear to patients and not pretend to play the
\nrole. Prison doctors are likely to be in a
\nprivileged position if they have the trust of
\nthe prisoners and the confidence of the
\nprison authorities. If hunger strikers trust
\nand confide in them, physicians are able to
\nevaluate how urgent is the need for media-
\ntion. Most hunger strikers desperately want
\nto find a way out of the confrontation and
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\nMedical Ethics and Human Rights
\n40
\noften stop fasting if they obtain some minor
\nform of concession from the authorities. In
\nsuch cases physicians may be in the best posi-
\ntion to negotiate some compromise between
\nthe two parties. When the demands of hunger
\nstrikers are very obviously out of reach,
\nprison doctors must not fall into the trap of
\npretending otherwise or insinuating that a
\nsolution is achievable through mediation.
\nThey should make clear that they are outside
\nthe negotiations but the crucial role of provid-
\ning accurate information to patients about
\ntheir medical condition should continue.
\n8. The duty to remain objective and inde-
\npendent
\nMedicalisation of hunger strikes often
\noccurs and can threaten physicians\u2019 ability
\nto act independently. Local law may require
\nmedical monitoring of the hunger strike and
\nthe status of a particular hunger striker can
\nalso influence the attention given to that
\nperson. Physicians may have to balance
\nobjective medical observations with prag-
\nmatic face-saving situations, in order to buy
\ntime for essential negotiations to produce
\nresults. They must avoid pandering to any
\nparticular interest group by giving medical
\ninformation or advice that is scientifically
\nquestionable or inaccurate.
\nPhysicians working for prison administra-
\ntions or other detaining authorities some-
\ntimes cannot be really independent. Even if
\nthey are fully aware of the ethical implica-
\ntions of a terminal hunger strike, without
\nexternal support they are often powerless to
\noppose administrative decisions imposed
\non them by the authorities. Medical associ-
\nations have a duty to inform physicians of
\ninternational ethical guidelines that should
\nbe respected at all times and to provide sup-
\nport for them. Independent physicians ide-
\nally should be permitted to counsel hunger
\nstrikers in the interest of all involved and in
\norder to try to avoid any fatal outcome.
\nSome countries do allow this, and these
\nphysicians\u2019 independent status ensures their
\ncredibility as acceptable intermediaries for
\nall parties concerned.
\n9. Management of medical conditions
\nduring a hunger strike
\nThe WMA\u2019s training module on prison
\nhealth care contains a detailed account of
\nthe clinical stages undergone by hunger
\nstrikers between the first days of fasting and
\nthe final stage between 45 to 75 days later
\nwhen death occurs from cardiovascular col-
\nlapse or severe arrhythmias. As well as the
\nphysical aspects, physicians need to be
\naware of patients\u2019 mental and psychological
\ndisruptions. Refusal to take sustenance
\nleads to a clinical syndrome that resembles,
\nbut is not equivalent to starvation. In the lat-
\nter case, body depletion is a dragged-out
\nprocess, with little caloric intake, but still
\nminimum absorption of vital elements such
\nas vitamins or proteins. It is this intake that
\ndifferentiates total fasting in a hunger strike
\nsituation (taking just water) with starvation
\nin concentration camps. Among the symp-
\ntoms experienced by long term hunger
\nstrikers are significant gaps in memory and
\ninability to concentrate. They live for the
\nmoment. Total fasting forces the body to
\nfind substitute sources of glucose, essential
\nfor providing energy, to the brain in partic-
\nular. Lack of calorie intake disrupts the
\nusual pathways, and complex mechanisms
\nkick in to replace the external energy
\nsource. The body begins to digest itself,
\nbreaking down the various tissues so as to
\nhave a constant supply of glucose. If the
\nfasting leads to medical complications, it is
\nthe duty of physicians to do more than
\nmerely take notes and monitor vital signs.
\nThere is need for them to enter into a seri-
\nous discussion with each hunger striker. It
\ncannot be stressed enough that the privacy
\nof the medical consultation is of paramount
\nimportance, so as to avoid any meddling or
\ncoercion, from any side, and for physicians
\nto be able to play their role.
\n10. Artificial feeding, force-feeding and
\nresuscitation
\nIt is important that physicians understand
\nthe moral and practical distinctions between
\nforcible feeding, artificial feeding and
\nresuscitation. The WMA Malta Declaration
\ngives some leeway to the treating physician,
\nwho should have the final word in deciding
\nwhat is best for the patient, all factors being
\ntaken into consideration. Force-feeding,
\nhowever, is out of the question. If the pro-
\ntester\u2019s intent is to extend the fasting as
\nlong as possible, there should be advance
\ndiscussion between the physician and
\nhunger striker to clarify the expectations on
\neither side. In particular, physicians need to
\nbe clear what actions they have patient con-
\nsent for once the fasting has clouded the
\npatient\u2019s mind and coherent communication
\nbecomes impossible. Physicians must dis-
\ncuss the crucial issue of artificial feeding
\nand resuscitation before that stage. In some
\ncountries, patients\u2019 known wishes dictate
\nwhat the physician does after consciousness
\nis lost. In others, this is not an option and
\nphysicians may be prosecuted if they fail to
\nintervene to save the hunger striker\u2019s life.
\nPhysicians need to know clearly what atti-
\ntude to adopt and also make this clear to the
\nhunger striker, so that they can reach a deci-
\nsion in common. If, for personal reasons,
\nphysicians cannot accept the patient\u2019s deci-
\nsion, they should say so and step aside so
\nthat another physician can act according to
\nthe informed decision of the hunger striker.
\nArtificial feeding should not involve coer-
\ncion. It may be prescribed by a physician or
\nbe imposed by a judicial authority. This
\noccurs usually at a stage when the hunger
\nstriker is no longer fully conscious and too
\nweak to express a view. Artificial feeding
\ninvolves administering nutriments and liq-
\nuids parenterally or through a naso-gastric
\ntube. Even when physicians agree to respect
\npatients\u2019 advance refusals, some circum-
\nstances may justify a decision to resuscitate
\nor artificially feed a hunger striker who has
\nlost competence. A justification would be
\nfor example, that the situation has changed
\nafter the patient lost awareness so that the
\nadvance refusal may be considered inap-
\nplicable to the new scenario. If, however,
\nwhen competence is regained, the hunger
\nstriker persists in the refusal of feeding or
\ntreatment, the physician should allow the
\nperson to die in dignity, without repeated
\nresuscitations.
\nPhysicians should never condone or partic-
\nipate in forcible feeding or any other
\nenforced measures which may amount to
\ncruel, inhuman and degrading treatment.
\nWhen hunger strikes have a political com-
\nponent, the authority in charge may decide
\nto end them by force and order the forcible
\nartificial feeding of protesters. This may be
\ndecided very early on in the fasting, when
\nthere is no actual medical need to adminis-
\nter nutrition. It should be realized in this
\ncontinue on p. 42
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\nMedical Ethics and Human Rights
\n41
\nDeclaration of Malta
\nGlossary
\nTo be read in conjunction with the background discussion paper on management of hunger strikes.
\nAdvance instructions\/advance directive
\nMentally competent patients can give consent or refusal in advance for future medical
\ninterventions, in order for their wishes to be known if later mental impairment leaves them
\nunable to express a view. Advance instructions are a useful indicator of an individual\u2019s
\nviews but only if the person making them is aware of the implications and not pressured
\nto make a certain choice. These criteria can be hard to meet in custodial settings but are
\nnot invariably absent. Physicians need to be aware that at the start of hunger strikes, there
\ncan be pressure for hunger strikers to prove that their intentions are serious which may
\npush them into making an ill-considered advance refusal of resuscitation. Where possible,
\nphysicians need to discuss this privately with hunger strikers and ascertain their real inten-
\ntion. Some advance instructions truly reflect the individual\u2019s wishes but others do not.
\nPhysicians need to assess the evidence. Advance instructions can be written or verbal but
\nhave no value if made under duress. They may also be invalid if the situation has under-
\ngone significant change since the individual lost competence and it is no longer what he
\nor she expected it to be. (See WMA statement on advance directives, Helsinki 2003).
\nArtificial feeding
\nAlthough often seen as synonymous, artificial feeding is not the same as forcible feeding.
\nAll force-feeding is artificial but not all artificial feeding is forced. Artificial feeding in
\nhunger strikes can be a solution for hunger strikers who do not want to endanger their
\nhealth but who refuse to take nourishment normally for reasons of their own. Artificial
\nfeeding is acceptable if hunger strikers make known their agreement to it by any means or,
\nif incompetent, they have not refused it in advance.
\nForce feeding
\nForce feeding not acceptable. It involves use of force and physical restraints to immobilise
\nthe hunger striker. Although described as life saving, it is sometimes implemented as a
\ncoercive measure to break a hunger strike
\nAutonomy
\nPhysicians should respect patients\u2019 autonomy by not overriding their voluntary, informed
\nand competent decisions. In the case of hunger strikes, this means physicians should
\nrespect patients\u2019 refusal of feeding. It is important for physicians to explain accurately to
\nhunger strikers the potential health impact of prolonged fasting and to advise them on how
\nto minimise the harmful consequences by for example, increasing fluid and vitamin
\nintake. Consent and refusal are invalid if the result of coercion. Autonomy is one of four
\nkey principles that are frequently portrayed as core to modern medical ethics.
\nBeneficence & Non-maleficence
\nThe duty to benefit (beneficence) and not harm (non-maleficence) are also part of the four
\nkey principles but need to be interpreted holistically. Imposing treatment in the face of
\nvalid patient refusal is seen as a harm not a benefit. In custodial settings, this raises ques-
\ntions about whether prisoners or detainees can make such free choices.
\nBest interests
\nPhysicians are morally obliged to act in patients\u2019 best interests but this does not mean pro-
\nlonging life at all costs. An assessment of best interests must be a balance between seek-
\ning the best medical outcome and a consideration of the patient\u2019s own views, values and
\npreferences. Physicians do not act in patients\u2019 best interests by overriding patients\u2019 strong-
\nly held wishes.
\nConfidentiality
\nAll patients, including detainees, have rights of confidentiality but these are not absolute
\nrights. Consent to disclosure should generally be sought from competent individuals.
\nInformation about incapacitated individuals can be disclosed if it is in their best interests.
\nFor all patients, disclosure is also permitted if it prevents serious harm to others. In hunger
\nstrikes, information about the patients\u2019 views and medical condition should be shared
\namong health professionals providing care. Information can be given to other people such
\nas relatives and lawyers with hunger strikers\u2019 consent.
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 41
\nMedical Ethics and Human Rights
\n42
\nrespect that the authorities often have spe-
\ncific agendas when ordering doctors to arti-
\nficially feed (or force-feed) hunger strikers.
\nWhile claiming to want to save lives, some
\ncoercive authorities clearly intend to repress
\nthe principle of protest. For example, the
\nauthority may decide to force-feed hunger
\nstrikers after two weeks of fasting, when
\nthere is no immediate medical need to inter-
\nvene. It may also be decided to feed prison-
\ners who resist by brute force, tying down
\ntheir limbs and forcibly inserting a naso-
\ngastric tube. This coercion is what defines
\nforce-feeding. It is not necessarily carried
\nout by medical staff but may involve med-
\nical orderlies if doctors refuse.
\nCase example 4
\nIn a collective hunger strike, the degree of
\ncommitment to the fast varied considerably
\namong the hunger strikers. It was clear to
\nthe visiting physician that some prisoners
\nwere absolutely determined to fast until
\nthey died. These prisoners not only refused
\nall nourishment and drank only water but
\nthey resisted all attempts to provide nutri-
\ntion by naso-gastric tube. If tubes were
\ninserted against their will, they used them
\nto suck out any nourishment that had gone
\ninto their stomach. Other prisoners in the
\nsame strike however, told the doctor pri-
\nvately that they were willing to accept an
\nintravenous line or naso-gastric tube as
\nlong as they could maintain the pretence
\npublicly that these interventions were done
\nagainst their will. Since all the prisoners
\nwere saying publicly that they were unwill-
\ning to be artificially fed (even though pri-
\nvately some were saying the opposite), the
\nfirst task for the doctor was to separate the
\nConfidentiality
\nAll patients, including detainees, have rights of confidentiality but these are not absolute
\nrights. Consent to disclosure should generally be sought from competent individuals.
\nInformation about incapacitated individuals can be disclosed if it is in their best interests.
\nFor all patients, disclosure is also permitted if it prevents serious harm to others. In hunger
\nstrikes, information about the patients\u2019views and medical condition should be shared among
\nhealth professionals providing care. Information can be given to other people such as rela-
\ntives and lawyers with hunger strikers\u2019 consent.
\nDual loyalties
\nPhysicians supervising the management of hunger strikers often have contractual duties and
\nobligations to other agencies, such as prison authorities. The WMA strongly emphasises that
\nmedicine is a privilege that invariably carries certain responsibilities. All medically quali-
\nfied individuals must demonstrate the professional duties of beneficence and non-malefi-
\ncence even when they have dual loyalties and even if their work does not involve the actu-
\nal provision of care. This means that all people who have been trained as care givers have
\nthe same ethical duties of care givers even when not employed to provide care.
\nEating\/fasting
\nGood communication depends on all parties understanding common terms in the same way.
\nDifferent cultures have very differing views on what constitutes fasting or accepting nutri-
\ntion. This is addressed in the WMA background paper and also in chapter 5 of the WMA\u2019s
\nInternet course for prison doctors on www.lupin.nma.net.
\nHunger strike and \u201eVoluntary Total
\nFasting\u201c
\nRefusing nutrition takes different forms. The terms \u201chunger strike\u201d and \u201cvoluntary total fast-
\ning\u201c are sometimes used inter-changeably even though fasting may be neither voluntary nor
\ntotal. The\u201d voluntariness\u201d of the individual\u2019s decision is a key issue for physicians in assess-
\ning whether to abide by it.
\nPartial or short-term food refusal rarely raises ethical dilemmas. The most accepted defini-
\ntion of a hunger strike is total fasting (taking only water) for over 48-72 hours. Salt, miner-
\nals or sugar may be added to water. Dry fasting where all nutrition and hydration are refused
\nis uncommon and leads to death within a week. A hunger strike is not equivalent to suicide.
\nIndividuals who embark on hunger strikes aim to achieve goals important to them but gen-
\nerally hope and intend to survive.
\nJustice
\nJustice is another of the commonly cited four key principles of medical ethics. In this con-
\ntext, it is the requirement for physicians to treat hunger strikers fairly, by listening to their
\nviews and trying to minimise undue coercion from any source.
\nPhysician\/physician assistant
\nThe WMA primarily addresses its guidance to physicians but in the context of hunger strike
\nmanagement, other health professionals are likely to be involved and should be encouraged
\nto abide by the Malta Declaration. Professional guidance for other groups such as nurses and
\nparamedics, for example, generally reflects the same principles.
\nUndue pressure\/coersion
\nInforming hunger strikers of the implications of their decisions and encouraging them to
\nreflect are essential and do not constitute undue pressure. Attempting to dissuade them from
\nfasting by threats, including the threat of forcible feeding, is not acceptable.
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 42
\nFrom the Secretary Gerneral\u2019s desk
\n43
\nprisoners from each other without in any
\nway indicating that some were willingly
\naccepting nutrition. Eventually, however, it
\nwas bound to become clear which prisoners
\nwere determined to fast to death since the
\nphysician recognised that it would be
\nunethical to force feed those who were gen-
\nuinely resistant. He hoped that by separat-
\ning them, each of the prisoners would have
\nsome opportunity to reconsider their deci-
\nsion away from the influence of the peer
\ngroup in a situation of privacy. For those
\nwho maintained their fast, their decisions
\nwere respected.
\n11. Gaining support from professional
\nassociations
\nPhysicians can themselves in difficult situa-
\ntions if they want to comply with the inter-
\nnational guidelines which are in conflict
\nwith local legislation. They may face the
\ndilemma of whether to do everything to
\nsave a person\u2019s life or respect the right of
\nindividuals to dispose of their bodies as
\nthey please. This question is often further
\ncomplicated by religious or legal issues.
\nLocal law may require physicians to inter-
\nvene, even against their will, if a hunger
\nstriker\u2019s life is at stake. On the other hand,
\ninternational ethics guidelines focus on the
\nrights of individuals to determine what is
\ndone to them. Where individual rights are
\nrespected, hunger strikers have a chance to
\nhave their decisions respected. Physicians
\nencountering difficult dilemmas should
\nappeal to their national associations or
\ndirectly to the World Medical Association
\nfor guidance and support. It may also some-
\ntimes be necessary to have help from a per-
\nceived neutral organization, such as doctors
\nfrom the ICRC (International Committee of
\nthe Red Cross), Council of Europe CPT
\n(Committee for Prevention of Torture and
\nInhuman Degrading Treatment and
\nPunishment) or similar organizations.
\nFrom the Secretary General\u2019s Desk
\n\u201cWhat do we expect from the next WHO Director General?\u201d
\nOn the day he was supposed to open the 59th
\nWorld Health Assembly on May 22nd
\nthis
\nyear, the Director General of the World
\nHealth Organization (WHO) tragically died
\nfollowing a sudden illness. The World
\nHealth Assembly decided to hold an extra-
\nordinary session later this year to determine
\nthe next Director General (DG).
\nDr. Lee was committed to give more power
\nto the regional organizations of WHO.
\nCertainly all health care is local and coming
\ncloser to place of need was logical and nec-
\nessary. He headed a difficult institution,
\nbecause a political organisation is struggling
\nbetween opposing political interests, increas-
\ning challenges for health and an always inad-
\nequa te budget. This task is like squaring a
\nthe circle \u2013 there is no final solution.
\nGeneva is the home of the Red Cross, the
\nUnited Nations Commission on Human
\nRights, the first assembly place of a supra-
\nnational organization preceding the United
\nNations. The Conventions regulating mini-
\nmal human behavior in wars have the name
\nof this city and what ever is connected with
\nit has the bonus of being of high moral
\nstanding. But that is an illusion. The WHO
\nis a good example of an institution which
\nmany people believe it to be a moral author-
\nity for health care. Something it never was,
\nand most likely never will be.
\nThe organization was build right in the mid-
\ndle of a political minefield between the east
\nand the west. In times of cold war it was one
\nof the green tables where leaders of the
\npolitical blocks could meet and discuss,
\nwithout pretending to like each other. The
\nold demarcation lines have gone. In time of
\nglobalisation, trade determines the rules.
\nBut the borders and frontiers are not gone.
\nThey are now more complex, sometimes
\ninvisible and often blurry. Players in the
\nglobalisation game often don\u2019t know
\nwhether they are friends or foes. And all
\nmay be different tomorrow. The problem is:
\n\u201cthe old mines are still hot\u201d.
\nThe WHO is a governmental organization
\nand it is only as good as the governments it
\nrepresents. No government of this world is
\nmade of Saints, no government is without
\nmistakes, yet many deserve our respect. But
\nmany others have no democratic back-
\nground \u2013 they are not elected leaders of
\ntheir people. Many governments of this
\nworld deny their people basic rights, the
\nfreedom of speech, the right to work, the
\nright to move, the right to build coalitions.
\nMany governments deny their people even
\nthe right to live, they torture and abuse their
\nown people. Yet they sit in the World Health
\nAssembly, the highest deliberative body of
\nthe WHO.
\nWHO has driven many health campaigns:
\nThe fight against small pox and polio are
\nwonderful success stories, much of it Dr.
\nLee\u2019s achievement. The WHO works suc-
\ncessfully on tobacco control and fights
\ntuberculosis world wide, it has programmes
\non injury prevention and disaster relief, it
\nsupports medical reference centres and pro-
\nvides administrative guidance for the recog-
\nnition of education and training. In other
\nwords there are many, many things the
\nWHO has to be praised for. If it wasn\u2019t
\nthere, we would have to build it.
\nBut then it is a political organisation with
\nthe parameters described above, excluding
\nmany people from cooperation just for
\npolitical reasons: Taiwan is a good example
\nof this. Its basis of work are the decisions of
\nthe World Health Assembly and reports,
\nfacts and figures provided by the countries
\n\u2013 or better their governments. How much
\ndo we trust reports from countries without
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 43
\nWMA
\n44
\nfree press, without the freedom of expres-
\nsion? Large parts of the WHO work are ide-
\nologically biased, they are neither the
\nreflection of high morals nor of good sci-
\nence but just of political powers.
\nWhoever goes there to be the new DG has
\nan uphill battle before him. Organisational
\nreform like with the rest of the UN-
\nInstitutions is urgently needed. So what can
\nwe realistically expect? The political prob-
\nlems will remain. However, a re-focusing
\non true health issues and a closer coopera-
\ntion with the health care community would
\nbe a good start. There is a strong alliance
\nout there for health care, but WHO is going
\nin another direction. The revitalization of
\nbare-foot-doctor concepts in the recent dis-
\ncussion on \u201chuman resources for health\u201d is
\njust one example of the misled attempts to
\ntackle one of the worst current problems in
\nglobal health care: the global shortage of
\nhealth professionals.
\nTo take out politics will be the biggest politi-
\ncal challenge for the new DG. To orient WHO
\ntowards health and not political problems will
\nhelp to shift resources in the right direction.
\nMore transparency to and cooperation with
\nthe health community is high on our wish list.
\nAt WHO many people work as staff and as
\nvolunteers who care for health. They
\ndeserve our cooperation and support. They
\nalso deserve a powerful DG who is able to
\nfree their way. WHO doesn\u2019t need a com-
\npromise candidate, it needs a strong and
\ncourageous leader. WHO needs a leader
\nwho knows that the Organization is there to
\nserve the people of the world \u2013 and govern-
\nments only if they do exactly the same.
\nWMA
\n173rd
\nWMA Council Meeting held in Divonne
\nThe 173rd
\nCouncil met in Divonne les Bain,
\nFrance 18-20th
\nMay 2006 under the chair-
\nmanship of Dr. Yoram Blachar.
\nAfter welcoming new members the first
\nitem of business was to elect a new Vice
\nChairman to replace Dr. Hashimoto, who
\nhad resigned. Following nomination
\nDr. K. Iwasa (Japan) was elected as Vice-
\nChairman of Council.
\nFollowing the approval of the
\nminutes of the 171st
\nand 172nd
\nmeetings, the President, Dr.
\nKgnosi Letlape reported on his
\nactivities since the last meeting.
\nHe had just visited Finland
\nwhere he participated in a very
\nproductive WHO meeting on
\n\u201cHealth as a bridge for Peace\u201d.
\nTurning to Africa he reported
\nthat the establishment of an
\nAfrican Regional meeting was
\nprogressing very well. This
\nshould be formalised at a meeting in July
\nand it was anticipated that it would meet
\nlater in the year. HIV\/AIDS remained a
\nmajor problem and he felt that actions of
\nWMA needed to become more open in this
\narea. Priorities were preventing the exten-
\nsion of HIV\/AIDS and increasing access to
\ntreatment. In this connection he stressed
\nthat the unavailability of medicines was
\naggravated by problems with patent sys-
\ntems.
\nHe was also concerned about those infec-
\ntious diseases which were not adequately
\ncovered and welcomed the role of the
\nHealth Protection Agency He was very dis-
\nturbed by the lack of disaster plans and
\npreparations still in many countries. NMAs
\ncould assist with these, but there was a lack
\nof appropriate mechanisms for mobilisation
\nof the profession.
\nOn a different note he stressed
\nthe need for coordination of
\nthose health professionals who
\nrapidly respond to the need for
\nassistance in major disasters.
\nHe paid a special tribute to Dr.
\nYank Coble for his work in
\ninspiring the \u201cCaring Physicians
\nof the World\u201d project, especially
\nin promoting and supporting
\nregional meetings. These had
\npermitted real dialogues on major issues
\nrelating to medicine.
\nHe felt that WMA needed to become more
\nengaged in policy decisions in the health-
\nfield, particularly with WHO. It also needed
\nto promote leadership within the profession.
\nConcluding by referring again to the prob-
\nlems of Africa he said that while the \u201c3 in
\n5\u201d initiative was a most welcome one,
\nunfortuntely the target was not being
\nachieved. Only 1.3 of the three million tar-
\nget had been achieved by the programme.
\nAt the same time he paid tribute to the work
\nof the catholic missions who quietly got on
\nwith work providing care, particularly in
\nthe most remote areas.They were one of the
\nbiggest providers of help globally and in
\nAfrica provided 10% of the aid for
\nHIV\/AIDS care.
\nThe Secretary General invited to speak to
\nhis written report, (see 49 for the full
\nreport), said that the first part concerned
\nthe Caring Physicians of the World
\nInitiatative and it was appropriate there-
\nfore that Dr. Yank Coble should present
\nthis.
\nDr. Coble, referring to the World Medical
\nJournal (WMJ 2006, 52, (1), 11) said that
\nthe start of this project was in Helsinki. The
\nbook had been launched in Santiago, had
\nbeen sent to NMAs and will go to all
\nMinistries of Health. It had been distrib-
\nuted to Ministers in Bangkok, Taiwan,
\nIndia, to the President of the United States
\nof America and also to many international
\nbodies. The programme had been expanded
\nthrough regional meetings in Johannisburg,
\nBangkok, Prague, North and South
\nAmerica. He was delighted that these meet-
\ning provided firm evidence that people
\nwould agree on the enduring traditions of
\nCaring, Ethics and Science in medicine.
\nDr. K. Iwasa
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\nWMA
\n45
\nThe Secretary General, Dr. Otmar Kloiber,
\nexpressed his pleasure at being part of these
\nactivities which also increased the visibility
\nof the WMA, especially for those members
\nwho cannot get to global meetings such as
\nthose of the Council and the General
\nAssembly. Returning to his report he said that
\nmuch of the work had concentrated on gover-
\nnance, statutory reform, finance and balanc-
\ning the budget. Referring to problems of get-
\nting NMA subscriptions, he reminded NMAs
\nof the need to pay both in time, and in full.
\nThere had been continuing discussion on
\nfinance and partnerships and he pointed out
\nthat engagement in new activites could not
\nbe done without forming partnerships.
\nTurning to the World Health Professions\u2019
\nAlliance (WHPA), he reported that cooper-
\nation had been very positive, although pos-
\nsible points of critical discussion had still to
\nbe faced by the Alliance, such as shared
\ncompetences and the limits of each profes-
\nsion. The Alliance was in agreement that the
\nWorld Health Report (WHR) on the work
\nforce was distorted. There was an emphasis
\nin this WHO report on training lay people,
\nbut while some of this emphasis had been
\nmodified during the preparation of the
\nreport, there were still statements about self
\nregulation and a preference for a \u201ccommand
\nand control\u201d style. The so called \u201cGlobal
\nAlliance for the Workforce for Health\u201d had
\nprepared its work without the Health
\nProfessions. The WHPA had asked for a dis-
\ncussion on the World Health Report with
\nthe Director General. As it was not possible
\nto see him about their concerns before
\nWorld Health Day, the Health Professions
\nOrganizations did not participate in this.
\nThere was a need to cope with the problem
\nof representation at WHO. This would be a
\ncore part of the strategic development of the
\nWMA.
\nBoth Dr. Blachar and Dr. Letlape concurred
\nin their concern that the WHR possibly
\ndowngrades the profession.
\nDr. Blachar thanked Dr. Kloiber, in particu-
\nlar for his work in taking over WMA at a
\ndifficult time and in fulfilling the Council\u2019s
\nexpectations.
\nIn response to a question about the obliga-
\ntion of the Chinese Medical Association to
\ninclude a member of the government
\namongst the senior officers of the
\nAssociation, Dr Coble observed that at the
\ntime of the SARS epidemic, the Vice
\nPresident of the Chinese Medical
\nAssociation was a Minister, the executive
\nVice President and executive staff were
\npolitically determined.
\nCouncil then adjourned for the Meeting of
\nthe
\nFinance and Planning
\nCommittee
\nThis meeting was opened by the Chairman,
\nDr. John Nelson and the minutes of the last
\nmeeting in Santiago were approved.
\nDues
\nThe committee considered various reports
\nconcerning NMAs\u2019 dues and actual dues
\npayment; also the status of council mem-
\nbers and officers during their term of office
\nin the event of irregularities in payment of
\ndues by their NMA. Legal counsel con-
\nfirmed that NMAs who are represented on
\nCouncil are required to pay their dues on
\nschedule, or have a written agreement with
\nthe Secretary General that they will be reg-
\nularised before the General Assembly. The
\nSecretary General outlined the process of
\ndealing with non dues payment, a process
\nwhich now leads to the termination of sin-
\ngle membership.
\nFinancial statement 2005
\nAfter further discussion on the issue of non
\ndues payment, the committee considered
\nthe financial statement for 2005, presented
\nby Mr. Adi H\u00e4allmayr who gave a particu-
\nlarly clear transparent presentation of the
\nsituation. The Council noted the remarkable
\nachievement of \u201cturn round\u201d in the financial
\nposition which had taken place, achieving a
\nbalanced budget for the first time in years.
\nThis was thought to be impossible in the
\nspace of a year and the Secretary General
\nwas congratulated on this achievement.
\nThis, Dr. Kloiber reported had been largely
\ndue to strict budgetary constraints on activ-
\nities and a number of other factors which
\nwere included in Mr H\u00e4allmayr\u2019s report.
\nIn response to a question as to whether this
\nimprovement was sustainable, the Secretary
\nGeneral responded positively, but only if
\nthe WMA confined itself to its Core busi-
\nness. Any extra activity would call for extra
\nfinancing. Concerning any advantage to be
\ngained by moving from Ferney Voltaire to
\nGeneva, he referred to a relevant study cur-
\nrently being undertaken by the World
\nDental Federation.
\nThe committee recommended that the pre-
\nliminary financial statement for 2005 be
\napproved, also by council later.
\nGovernance changes
\nThe Finance and Planning Committee dealt
\nwith the Governance changes that had been
\ndeveloped over the last year. These recom-
\nmended changes in the Bye laws including
\na limitation of the terms of officers to a
\nmaximum time of six years, during which a
\ncouncil member could hold a specific func-
\ntion. Furthermore the Executive Committee
\nconsisting of the chairpersons of Council,
\nthe Committees and the Treasurer, was
\nenlarged to include the President as a non-
\nvoting member. The executive committee
\nwill serve at the request of the Council
\nChair and will advise the Chair of Council,
\nCouncil and the Secretary General. The
\namendments to the Bye-Laws were recom-
\nmended for approval and submission to the
\nGeneral Assembly. This was subsequently
\napproved by Council.
\nBusiness development Group
\nAn oral report from the Business develop-
\nment Group was considered. Eight options
\nwere identified and the group sought to
\nidentify two for initial consideration. A sur-
\nvey of the views of participants present at
\nthe council meeting on the options was dis-
\ntributed.
\nStrategic Plan
\nThe Secretary General presented the
\nStrategic Plan for 2006-2010. He comment-
\ned that during the Caring Physicians of the
\nWorld Initiative and the Strategic survey
\nthey had learnt that there was a need for
\nclear advocacy work called for by most
\nNMAs, an issue which was also discussed
\nin parallel by the Business Group. Referring
\nto the document he indicated that before the
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 45
\nWMA
\n46
\ncommittee there were three areas reflecting
\nNMAs needs, namely, Ethics Guidance
\nincluding Social- Medical Questions,
\nAdvocacy Representation and Service and
\nOutreach.
\nDr. Kloiber said that outreach services
\nneeded to be developed, as did Advocacy.
\nThe Ethics Unit needed to be strengthened
\nand this was the way forward to maintain
\nthe high reputation of WMA, as exempli-
\nfied by Helsinki, Geneva and Tokyo. He
\npaid tribute to the outstanding work of Dr.
\nJohn Williams both in the unit and his other
\ncontributions in the representational work.
\nSpeaking generally about ethics, he felt that
\nmore attention needed to be given to begin-
\nning and end of life issues, many of which
\nmay not lead easily to consensus agree-
\nments. Issues of cloning, of stem cells and
\nof the use of modern technology and its
\nproblems need equal attention. We also
\nhave our own problems. NMAs should be
\nchallenged to report back if WMA guidance
\nwas not acceptable. Prison Medicine and
\nmulti-drug resistant tuberculosis need to be
\ntackled. Awareness of the problems of
\nyoung physicians and young students must
\nbe strengthened and WMA needs to advo-
\ncate for them. Referring to the importance
\nof the location of the Office near to Geneva,
\nhe outlined the opportunities this provided
\nfor discussions with the UN, WHO, ILO,
\nthe Commission on Human Rights etc..
\nThere was however some limit on how
\nmuch the Secretary General and Dr.
\nWilliams could do. Asking NMAs to sit in
\non some meetings was difficult as meetings
\nwere often at short notice and air fares cost-
\nly. Nevertheless in order to avoid lost
\nopportunities, there is a need for more
\ninvolvement of NMAs.
\nServices and support to NMAs also need to
\nbe strengthened. In this connection he was
\nglad to respond to NMAs who ask for help,
\nbut this had to be within the limits imposed
\nby shortage of staff.
\nThe services to individual associate mem-
\nbers need to be broadened. The web portal
\nand other projects should to be part of the
\noutreach to associates. The benefits of asso-
\nciate membership need to be strengthened
\nbeyond receipt of the WMJ and insurance.
\nThe Journal now has a new image, is now
\nmore orientated to WMA work and offers a
\nplatform for discussion.
\nDr. Haddad welcomed the Secretary
\nGeneral\u2019s plan. The three areas highlighted
\nwere absolutely right and should be used to
\nbuild upon. He agreed with the emphasis on
\nAdvocacy, but more resources were needed.
\nThe committee recommended that the Chair
\nof the committee and the Secretary General
\nconvene a working party to develop an
\nimplementation plan proposing specific
\nobjectives, deliverables and time tables,
\nwith cost estimates for the actions proposed
\nin the Strategic Plan.
\nIn further discussion the committee consid-
\nered the financial implications of expanding
\nthe advocacy role, the manpower needs to
\ndevelop the Ethics Unit, to deal with
\nDocumentation and the development of the
\nwww portal etc.
\nFuture General Assemblies
\nThe arrangements for the 2006 WMA
\nGeneral Assembly in South Africa were
\nreported. The Danish Medical Association
\nproposed \u201cHealth Care Information
\nTechnology\u201d as the theme of the Scientific
\nSession in Copenhagen in 2007, but the
\nfinal decision on the theme would be for the
\n2006 General Assembly to decide.
\nAssociate members
\nThe report on Associate membership was
\nreceived.
\nPublic relations
\nThe Committee received the report of the
\nPublic Relations consultant and thanked
\nMr. Nigel Duncan for his work.
\nWorld Medical Journal
\nThe committee received the report of the
\nEditor of the World Medical Journal and the
\nHon Editor stressed that a successor had not
\nyet been identified. The Chair recognised
\nthe need to identify a successor to Dr. Alan
\nRowe soon and thanked him for his consid-
\nerable efforts.
\nThe Ethics Committee
\nDr. Eva Bagenholm, opening the meeting
\nwelcomed new members, following which
\nthe minutes of the last meeting in Santiago
\n2006 were approved.
\nEthics Unit
\nDr. Williams, who will be leaving the
\nWMA Ethics Unit at the end of the year,
\npresenting the report of the Ethics Unit,
\ninformed the committee that the Ethics
\nManual had now been translated into
\nMacedonian, Albanian, Taiwanese, Indo-
\nnesian and Chinese, French and Spanish. It
\nwas hoped to produce the manual as a CD
\nROM in three languages. The Bulgarians
\nhad also offered to translate it, bringing the
\ntotal translations to 19 languages. An on-
\nline version in Norwegian will soon be
\navailable as well as Arabic, if funds are
\navailable.
\nPolicy review
\nThe committee then considered proposed
\nchanges to policy and NMAs comments on
\nthem.
\nThe Declarations of Geneva, of Tokyo and
\nthe Regulations in Times of Armed Conflict
\nwhich had undergone minor revision (see
\npages 29, 34, 35 for the revised texts), were
\nrecommended for approval and were later
\napproved by council.
\nThe committee then considered policies
\nclassified as requiring major amendment.
\nIn the list of amended documents recom-
\nmended for approval (see list below),
\nnotable points raised included the removal
\nof Human Tissue from the proposed revised
\nStatement on Human Organ Donation and
\nTransplantation. This was requested in
\norder to distinguish between organs and tis-
\nsues, which were subject to different legal
\ntreatment in European Community legisla-
\ntion. The German Medical association
\nagreed to develop a new proposal for a
\nstatement on Human Tissue Donation.
\nOther amendments to the original text were
\nadopted.
\nThe proposed revision of the International
\nCode of Medical Ethics led to considerable
\ndiscussion which substantially focused as
\nmuch on the concepts underlying proposed
\nphrasing, as on individual words. After
\nagreement on some word changes, it was
\nagreed that a new working group would fur-
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 46
\nWMA
\n47
\nther consider the revision, the group to be
\nled by the Icelandic Medical Association
\nand includes members from the Medical
\nAssociations of Canada, Israel, Slovakia
\nand the United Kingdom.
\nAfter some discussion of the 1996 Policy
\nStatement on Weapons and their relation to
\nLife and Health Issues which had been rec-
\nommended for minor revision, following
\nNMAs\u2019 expression of views, it was agreed
\nthat the BMA would do a revision for con-
\nsideration at the next meeting.
\nConcerning those WMA policies undergo-
\ning major revision the committee recom-
\nmended and, with some changes in the
\nDeclaration of Oslo, the Council later
\napproved the following:
\n\u2022 That the Proposed Revision of the
\nInternational Code of Medical Ethics be
\nassigned to a new working group led by
\nthe Icelandic Medical Association and
\nincluding the NMAs from Canada,
\nIsrael, Slovakia and the United
\nKingdom;
\nthe Proposed WMA Statement on
\nHIV\/AIDS and the Medical Profession
\nbe approved and forwarded to the 2006
\nGeneral Assembly for adoption and that
\nthe
\nInterim Statement on AIDS, Statement on
\nthe Professional Responsibility of
\nPhysicians in Treating AIDS Patients,
\nand the Statement on Issues Raised by
\nthe HIV Epidemic be rescinded and
\narchived.
\n\u2022 That the Proposed Revision of the
\nDeclaration of Venice on Terminal
\nIllness be approved and forwarded to the
\n2006 General Assembly for adoption and
\nthat the Statement on the Care of
\nPatients with Severe Chronic Pain in
\nTerminal Illness be rescinded and
\narchived;
\nthe Proposed Revision of the Statement
\non Human Organ Donation and
\nTransplantation, as revised, be approved
\nand forwarded to the 2006 General
\nAssembly for adoption;
\nthe Proposed Revision of the Statement
\non Ethical Issues Concerning Patients
\nwith Mental Illness, as revised be
\napproved and forwarded to the 2006
\nGeneral Assembly for adoption;
\nthe Proposed Revision of the
\nDeclaration of Sydney on the
\nDetermination of Death and the
\nRecovery of Organs as re-titled, be
\napproved and forwarded to the 2006
\nGeneral Assembly for adoption;
\nthe Proposed Revision of the Declaration
\nof Oslo on Therapeutic Abortion, as
\nrevised and amended by Council, be
\napproved and forwarded to the 2006
\nGeneral Assembly for adoption;
\nthe Proposed Statement on Assisted
\nReproductive Technologies be approved
\nand forwarded to the 2006 General
\nAssembly for adoption; and that the
\nStatement on In-vitro Fertilisation and
\nEmbryo Transplantation and the
\nStatement on Ethical Aspects of
\nEmbryonic Reduction be rescinded and
\narchived.
\n\u2022 That the Proposed Revision of the
\nStatement on Animal Use in Biomedical
\nResearch be approved and forwarded to
\nthe 2006 General Assembly for adop-
\ntion;
\nthe Proposed Revision of the Statement
\non Medical Ethics in the Event of
\nDisasters, as revised be approved and
\nforwarded to the 2006 General Assembly
\nfor adoption;
\nthe Proposed Revision of the Statement
\non Child Abuse and Neglect, as revised,
\nbe approved and forwarded to the 2006
\nGeneral Assembly for adoption;
\nthe Proposed Revision of the Statement
\non Patient Advocacy and Confiden-
\ntiality, be approved and forwarded to the
\n2006 General Assembly for adoption;
\nand
\nthe Statement on Foetal Tissue Trans-
\nplantation be rescinded and archived.
\n\u2022 That the Proposed Revision of the
\nDeclaration of Malta on Hunger Strikers
\nbe referred to NMAs for comment, along
\nwith a background paper and glossary of
\nterms prepared by the BMA.(see pxxx)
\nThe recommendations were later app-
\nroved by council.
\nHuman Rights
\nThe Secretary General reporting on Human
\nRights matters, said that the CD ROM
\nCourse for Prison Doctors was completed in
\nEnglish and Spanish, Mr. Hernan Reyes
\n(ICRC) added that the French version was
\nvirtually complete and the CD ROM would
\nthen be in English, French and Spanish. Dr.
\nTerje Vigen (Norway) stated that a Chinese
\nversion was under discussion. Dr. Kloiber
\nresuming his report reminded the commit-
\ntee of WMA\u2019s participation in the teaching
\nproject in relation to the Istanbul Protocol.
\nThe number of countries who would permit
\nthis to take place was unfortunately limited.
\nSpeaking of problems which had come to
\nthe WMA, he spoke first about Guantanamo
\nBay. The American Medical Associations in
\ntheir discussions with the USA government
\nhad made WMA policy on this issue very
\nclear and the AMA continued to be very
\nhelpful.
\nReferring to Cuba he reminded the commit-
\ntee that two years ago doctors were impris-
\noned for speaking among other issues about
\nproblems of health care and of preferential
\ntreatment for some parts of the population.
\nThe WMA had appealed for better condi-
\ntions and for the release of those doctors
\nimprisoned. Dr. Parsa-Parsi had attended a
\nmeeting on Medical Apartheid in Cuba
\nwhich was held in Germany. Dr. Parsa-Parsi
\nsaid that medical care was available for
\nTourists and High Officials in reasonable
\nconditions but there were few facilities for
\nthe rest of the population. There was a high
\nabortion rate in the absence of birth control,
\nespecially amongst the younger population.
\nHe also spoke of the suffering of doctors
\nimprisoned in inhuman conditions whose
\nfamilies had evidence of their bad physical
\nstate. Dr. Kloiber urged NMAs to pick up
\nthis issue and support these doctors.
\nChina
\nThe Secretary General then addressed the
\nsubject of China. He reminded the commit-
\ntee that they had asked him to write to the
\nChinese Medical Association about the har-
\nvesting of organs from executed Chinese
\nprisoners. This matter had already been dis-
\ncussed at a time when China applied to be a
\nmember of WMA in 1997. Last year the
\nTimes newspaper had reported that the
\nDeputy Minister of Health admitted that
\nthis activity had taken place but stated that
\nregulations would deal with this.
\nNevertheless advertisements still appeared
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 47
\nWMA
\n48
\nfrom hospitals offering kidney transplants
\nobtained from this source. Since then there
\nhave been reports that Chinese doctors have
\nparticipated in removing organs from exe-
\ncuted prisoners, and allegations have even
\nbeen made that vivisection is taking place.
\nThe Secretary General wrote to the Chinese
\nMedical Association as instructed and had
\nhad no reply. Likewise there had been no
\nreply to a second letter in December 2005,
\nrequesting that the association confirm its
\nsupport of WMA policy on this matter as
\nfor all other policies, in accordance with the
\nWMA conditions of membership.
\nIn view of the consistent failure to reply not
\nonly to letters but also to e-mails and faxes
\netc, the Council now had to consider further
\naction.
\nIn the ensuing discussion, speakers sought
\nclarification that the policy referred to was
\nthat prisoners were in no position to give
\ninformed consent and that physicians
\nshould not participate when organs were
\nremoved from prisoners after execution.
\nThis was confirmed and it was further indi-
\ncated that China was a fully paid up mem-
\nber of WMA in 2004.
\nFollowing extensive discussions during
\nwhich very deep concern was widely
\nexpressed, it was proposed and agreed that
\nthe secretariat prepare a document with all
\nthe evidence of these practices, for informa-
\ntion and use by NMAs. The following
\nResolution was later adopted unanimous-
\nly by the Council after further discussion.
\nThe committee also recommended and
\ncouncil later approved:
\n\u201cThat the Secretary General forward the
\nResolution on Organ donation in China to the
\nChinese Medical Association with a letter
\nexpressing the council\u2019s grave concerns. The
\nletter will indicate that the Council had dis-
\ncussed future possible actions with respect to
\nthe Chinese Medical Association in the event
\nthat it did not respond to WMA with an
\nexpress condemnation of this practice and its
\nsupport of WMA policy on this issue.\u201d
\nTaiwan
\nThe committee also reviewed its concerns
\nabout WHO denial of participation of
\nTaiwan in the World Health Assembly and
\nother technical meetings and adopted the
\nfollowing recommendation which Council
\nlater endorsed:
\n\u201cThat the WMA issue a press release reaf-
\nfirming its position on the status of Taiwan
\nas an observer at the World Health
\nAssembly, the importance of the meaning-
\nful participation of Taiwan in technical
\nmeetings of the World Health Organisation
\nand urging that Taiwan\u2019s status and partici-
\npation not be hindered by excessive bureau-
\ncratic or administrative requirements.\u201c
\nSocio-Medical Committee
\nThe Socio-Medical Affairs committee met
\nunder the Chairmanship of Dr. Henry
\nHaddad and approved the minutes of the
\nmeeting in Santiago 2006.
\nPolicy Revision
\nThe committee proceeded to consider com-
\nments from NMAs on policies requiring
\nmajor revision, using the consent agenda
\nprocedure (the final recommendations of
\nthe committee are set out below). Under this
\nprocedure, which agrees all items other than
\nthose identified by committee members as
\nindicating a need for discussion, following
\nshort discussion, the Statement on Medical
\nEducation was approved, as was that on
\nAdolescent Suicide and Traffic Injury.
\nThere was some discussion on the Role of
\nPhysicians in Environmental Issues in
\nwhich the importance of the environment in
\ndisease was stressed It was pointed out that
\nthe European Union had addressed this
\ntopic, but that this was ,of course, a world-
\nwide issue. The document was drawn up in
\n1997 and it was suggested that the docu-
\nment needed to be expanded. It was recom-
\nmended that a working group be established
\n(see below)
\nThe committee\u2019s recommendations, later
\nagreed by Council, were
\n\u2022 That the Proposed Statement on Medical
\nEducation be approved and forwarded to
\nthe 2006 General Assembly for adop-
\ntion;
\nthe Fifth World Conference on Medical
\nEducation and the Declaration of
\nRancho Mirage on Medical Education
\nbe rescinded and archived;
\nthe Proposed Revision of the Statement
\non Adolescent Suicide, (as revised), be
\napproved and forwarded to the 2006
\nGeneral Assembly for adoption;
\nthe Proposed Revision of the Statement
\non Traffic Injury, as revised be approved
\nand forwarded to the 2006 General
\nAssembly for adoption.
\n\u2022 That a Working Group be established to
\naddress the topic of the Role of
\nPhysicians in Environmental Issues.
\n\u2022 The Working Group, composed of the
\nNMAs from France, Brazil, South Africa
\nand the United States, will review all of
\nthe proposed documents developed to
\ndate on this subject.
\n\u2022 That the Proposed Revision of the
\nStatement on Health Promotion be
\nreferred to NMAs for comment;
\nthe Proposed Revision of the Statement
\non Injury Control be referred to NMAs
\nfor comment;
\nCouncil Resolution on Organ
\nDonation in China
\nWhereas, the WMA Statement on Human
\nOrgan and Tissue Donation and Transplanta-
\ntion stresses the importance of free and
\ninformed choice in organ donation, and
\nWhereas, the statement explicitly states that
\nprisoners and other individuals in custody are
\nnot in a position to give consent freely, and
\ntherefore their organs must not be used for
\ntransplantation, and
\nWhereas, there have been reports of Chinese
\nprisoners being executed and their organs har-
\nvested for donation,
\nTherefore, the WMAreiterates its position that
\norgan donation be achieved through the free
\nand informed consent of the potential donor.
\nThe WMA demands that the Chinese Medical
\nAssociation condemn any practice in violation
\nof these ethical principles and basic human
\nrights and ensure that Chinese doctors are not
\ninvolved in the removal or transplantation of
\norgans from executed Chinese prisoners.
\nThe WMA demands that China immediately
\ncease the practice of using prisoners as organ
\ndonors. 20.05.06
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\nWMA
\n49
\nthe Proposed Revision of the Statement
\non Access to Health Care be referred to
\nNMAs for comment;
\nthe Proposed Revision of the Statement
\non the Twelve Principles of Provision of
\nHealth Care in Any National Health
\nCare System be referred to NMAs for
\ncomment;
\nthe Proposed Statement on the
\nResponsibilities of Physicians in
\nPreventing and Treating Opiate and
\nPsychotropic Drug Abuse be referred to
\nNMAs for comment and
\nthe Proposed Revision of the Statement
\non Alcohol and Road Safety be referred
\nto NMAs for comment.
\nAfter considering NMAs\u2019 suggestions for
\nclassifying the five Socio-Medical Affairs
\npolicies adopted in 1996 the committee rec-
\nommended and Council later agreed
\n\u2022 that the Statement on Family Planning
\nand the Right of a Woman to
\nContraception undergo major revision
\nby the British Medical Association and
\nthe Statement on Resistance to
\nAntimicrobial Drugs undergo major
\nrevision by the American Medical
\nAssociation;
\n\u2022 That the Declaration on Family Violence
\nand the Statement on Professional
\nResponsibility for Standards of Medical
\nCare undergo minor revision.
\n\u2022 That the Resolution concerning Dr.
\nRadovan Karadzic be rescinded and
\narchived.
\nTuberculosis
\nDuring the consideration of NMAs\u2019 com-
\nments on a proposed Statement on
\nTuberculosis, the committee proposed that
\nthe Resolution on Tuberculosis as revised,
\nbe approved and forwarded to the 2006
\nGeneral Assembly for adoption and that the
\n1997 Statement on Drug treatment of
\nTuberculosis be rescinded and archived.
\nThis was subsequently agreed by Council
\nIn an oral report by the Secretariat on
\nprogress in the development of the on-line
\ncourse on the treatment of drug-resistant
\nTB, reference was made to the success of
\nthe Geneva Press conference, that a chapter
\non Tuberculosis in prisons had been added
\nby ICRC, that the text material would be
\ntested in South Africa and then be translat-
\ned into other languages.
\nMedical Assistance in Air Travel
\nThere was considerable discussion on a
\nResolution, originally proposed in the
\nAssociates\u2019 meeting, on Medical Assistance
\nin Air Travel. The Secretary General point-
\ned out that this dealt with the problems and
\nthe risk of physicians\u2019 liability when
\nresponding to calls for medical assistance in
\nthe air. He considered that this needed to be
\nregulated internationally. While in some
\nlegislation there was a limit on the financial
\nliability in these circumstances, a speaker
\ncalled for the enactment of legislation to
\nprovide immunity from liability action to
\nthose physicians who provide emergency
\nassistance in in-flight incidents. A further
\nspeaker pointed out that the request for
\nassistance came from the airline and it
\ncould be that the Aviation Authority should
\naccept the liability. It was also suggested
\nthat the Airlines should regard the doctor as
\nan employee in these circumstances.
\nSeveral speakers observed that there could
\nbe no immunity from criminal liability and
\na suggestion was made that in the absence
\nof immunity from legal liability, airlines
\nmust \u201caccept all legal and financial conse-
\nquences of asking for assistance\u201d.
\nDr Kloiber said that there were differences
\nin legal responsibilities in different coun-
\ntries. After amendment, the committee rec-
\nommended \u201cthat the Resolution on Medical
\nassistance in Air Travel, as revised, be rec-
\nommended for approval and forwarding to
\nthe 2006 General Assembly for adoption.
\nThis was subsequently approved by
\nCouncil.
\nDiscussion of a proposed Resolution on
\nChild Safety in Airline Travel was deferred,
\npending a review of this topic by the
\nGerman Medical Association
\nAvian and Pandemic Influenza
\nFinally, the committee recommended that in
\nview of the importance and urgency of this
\nissue:
\n\u201cThe Proposed WMA Resolution on Avian
\nand Pandemic Influenza, be sent without
\ndelay to NMAs, and that NMAs be urged to
\nuse the recommendations in the document
\nin their policy and advocacy activities, in
\nadvance of further consideration of this
\ntopic at the 2006 General Assembly\u201d.
\nFurther Council discussion
\nIn addition to the decisions of Council in
\nthe second part of its meeting set out above,
\nthe Russian Medical Society made a state-
\nment about the situation of physicians in
\nRussia clarifying that the Pirogov
\nConferences were called by the Health
\nMinister. They were not meetings of
\nNational Medical Associations. The
\nChairman of Council took note of this.
\nSecretary General\u2019s Report
\nto the 173rd
\nWMA Council Session
\n(October 2005 \u2013 April 2006)
\nConsolidation
\nThe year 2005 was determined by the seri-
\nous financial situation of the WMA. The
\nyears before the operation of the WMA
\nended with deficits, thus consuming signif-
\nicant parts of its assets. It therefore was the
\nfirst priority to maintain strict control over
\nthe WMA finances. This has been success-
\nfully achieved by
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\nWMA
\n50
\n\u2022 Consulting with the executive treasurer,
\nwho immediately reorganized our
\ninvestments and cash management and
\nthereby stopped financial losses.
\n\u2022 Quarterly financial reports, allowing bet-
\nter control over the financial and eco-
\nnomic situation.
\n\u2022 Priority setting: The World Medical
\nAssociation has been involved in a vari-
\nety of fields which certainly are related
\nto medicine and the work of physicians,
\nhowever we were not able to provide a
\nuseful and sustainable service. Those
\nactivities were terminated or reduced
\nand will only be revived, if an idealistic
\nor material net value can be obtained for
\nthe association or its members.
\n\u2022 Reviewing contracts and business rela-
\ntions. We examined all contracts for
\nnecessity and price-worthiness. In many
\ncases we achieved better prices for the
\nsame service or better service for the
\nsame price. We reduced spending for
\ntravel and representational expenses to
\nan absolute minimum.
\n\u2022 Outsourcing. After the resignation of our
\nFrench translator the position has not
\nbeen refilled. French translations are
\nnow being done by an outside translator
\nat lower cost to the association with no
\nloss in quality and speed.
\n\u2022 Application of rules. Consulting with the
\nexecutive committee, the financial offi-
\ncers or the Sponsorship advisory com-
\nmittee leed to clear governance and
\nfinancially sustainable partnerships and
\nsponsorship arrangements, thus reducing
\nthe risk of financially non-sustainable
\nengagements or ethically questionable
\nliaisons.
\nThe strict application of these methods
\nhelped to achieve a balanced budget for
\n2005 much earlier than anticipated.
\nHowever, this does not mean that the WMA
\nis in a financially comfortable situation:
\n\u2022 The income from dues is still unstable.
\nAgain in 2006 some major dues did not
\ncome in time or as agreed, some did not
\ncome in full.
\n\u2022 Some member associations pay only
\nnominal dues, some because clearly their
\nfinancial situation does not allow other,
\nsome which have obviously other rea-
\nsons.
\n\u2022 Even with a complete income from dues
\nthis would not allow extra activities,
\nwhich increase our visibility, presence at
\ninternational organization or own activi-
\nties providing service to our members or
\nthe general public.
\n\u2022 Revenue from sponsorship is problemat-
\nic as it may produce dependency we do
\nnot wish and as it is of course in the
\nhands of a partner whether to engage or
\nnot.
\n\u2022 With the opening of the borders between
\nSwitzerland and the European Union
\nconsumer prices and labour costs adapt-
\ned to the level of the dominating Swiss
\nneighborhood,.the once very cheap
\nFrench area \u201cPays de Gex\u201d west of
\nGeneva has become one of the most
\nexpensive areas in Europe.
\nCaring Physicians of the
\nWorld Initiative
\nPrior to our General Assembly in Santiago
\nde Chile, October 2006 we organized a
\nregional conference with the Latin
\nAmerican Confederation of Medical
\nAssociations CONFEMEL in Santiago on
\n10\/11 October 2006 and we publicly
\nlaunched the Caring Physicians of the
\nWorld-Book on October 12th
\n. Since then the
\ndistribution of the Caring Physicians of the
\nWorld-Book has continued and its reception
\nis overwhelmingly positive. We have not
\nreceived a single negative comment on the
\nbook, but a great deal of support and inter-
\nest in it.
\nThe campaign is about values, dedication
\nand pride and upholding our traditions of
\ncaring, ethics and science. At the same time
\nin our conferences we are addressing the
\ncurrent needs of the member associations
\non a very practical level. With own confer-
\nences in Europe and North America and the
\nparticipation of WMA leaders in regional or
\nnational meetings in various places, we are
\ncontinuing the CPW campaign.
\nRegional Leadership
\nConferences
\nLatin America
\nTogether with the Confederation of Medical
\nAssociations in Latin-America CON-
\nFEMEL the World Medical Association
\nheld a regional conference prior to our
\nGeneral Assembly in Santiago de Chile,
\nOctober 9th
\nand 10th
\n. The Cooperation with
\nCONFEMEL allowed us to meet not only
\nwith our regional member associations, but
\nalso other medical associations which exist
\neither in parallel with our members in some
\nof the countries or which are from countries
\nhaving no association with WMA member
\nstatus. The conference dealt with issues of
\nhealth system reform and continuing pro-
\nfessional development.
\nEurope
\nThe heads of the European Medical
\nAssociations in the WMA met in Prague,
\nDecember 9th
\nand 10th
\n. The leadership sem-
\ninar focused on:
\n\u2022 Health and Human Resources, analysing
\nthe global trends of migration from south
\nto north and in the European region from
\neast to west. In general the migration fol-
\nlows an economic gradient from poorer
\nto richer countries, from less favorable to
\nbetter working conditions. Concerning
\nthe situation in Africa it was noted that
\nfor many countries there, the loss of
\nhealth professionals is catastrophic. In
\nsome of the European countries it
\nalready leads to a significant shortage of
\nprofessionals endangering continuation
\nof care especially in rural areas.
\nAmong the factors that make profession-
\nals migrate are not only payment issues
\nbut also too high workloads, inadequate
\nworking circumstances and overburden-
\ning democracies. In European countries
\nthe loss by migration into other countries
\nis even exceeded by loss to other occu-
\npations of young physicians and the
\nchoosing of early retirement by estab-
\nlished physicians.
\n\u2022 In Germany, Belgium and France, strikes
\nand demonstrations of doctors were the
\napparent signs of a deep dissatisfaction
\nwith the conditions doctors have to work
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 50
\nWMA
\n51
\nunder in many European Countries. A
\npresentation on the perception of the cur-
\nrent protest actions taken by doctors
\nespecially in Belgium and Germany
\nshowed an overwhelming support by the
\npublic for the strikes and demonstrations
\nof the doctors.
\n\u2022 A second session dealt with pandemic
\npreparedness and the threat of the avian
\nflu outbreak turning into a human pan-
\ndemic. Although in all of the countries
\nrepresented pandemic plans were
\nalready prepared or under preparation,
\nthe overall preparedness was not seen to
\nbe sufficient. Questions of management,
\nresource allocation but also preventive
\nstrategies remained still open. The repre-
\nsented leadership felt it necessary that
\nthe National Medical Associations
\nshould be more strongly involved in the
\ndiscussion of and preparation for a pos-
\nsible pandemic. Finding a fine line and
\nappropriate risk communication that on
\nthe one hand explains the threats and
\nnecessity for preparation, but on the
\nother hand does not trigger panic, seems
\nto be the challenge in which the organi-
\nsations of physicians can help most.
\nIt was mentioned by some of those present
\nthat regional conferences like the one in
\nPrague would offer possibilities for partici-
\npation
\nNorth Americas
\nLeaders of the Canadian, American and
\nMexican Medical Associations met on
\nAmelia Island, Florida, March 24th
\nand 25th
\nto discuss \u2013 for the first time in this group \u2013
\nemerging health topics for the region with
\nleading experts from academic institutions
\nand the industry.
\n\u2022 The development of the profession, its
\nnew challenges through rapid changes in
\ntechnology, demography and patient
\ndemands meet in North America with a
\nsharp deficit of health professionals.
\nCurrently the health care markets in
\nCanada and the United States are the
\nstrongest magnets for health profession-
\nals. This stimulates a global migration as
\nit has been described in our preceeding
\nEuropean conference (see above). New
\ntechnologies but also better planning for
\nthe health work force may counteract the
\nproblems of human resources.
\n\u2022 For many years now counterfeit drugs
\nhave been observed and registered as a
\nserious threat to the developing nations.
\nHowever the notion that this is a prob-
\nlem of developing countries is a mistake.
\nCounterfeit drugs probably occur in all
\ncountries, certainly in the rich countries
\nof the northern hemisphere. This poses
\nmultiple dangers:
\n\u2022 Counterfeits are theft of intellectual
\nproperty. They reduce the return on
\ninvestments others have made and
\nreduce the resources for new develop-
\nments.
\n\u2022 Counterfeits are of uncontrolled qual-
\nity. They may or may not contain the
\nactive substance, they may or may not
\nbe dosed correctly, they may or may
\nnot carry other poisonous substances,
\nand they may deteriorate faster than
\ndescribed on the package
\n\u2022 Counterfeits destroy trust. The occur-
\nrence of counterfeits severely endan-
\ngers patients\u2019 compliance.
\nIt will be challenge for us to help to
\ndetect counterfeits (by just considering
\nthem), but at the same time not to dimin-
\nish the compliance of our patients.
\n\u2022 Although North America has been
\nspared from infection with the avian
\ninfluenza virus H5N1, the threat of a
\nglobal health pandemic exists for the
\nAmericas as for any other region in the
\nworld. Although our knowledge about
\nthe pandemic development and the med-
\nication options, both those for prevention
\n(vaccines), therapy (anti-virals) and the
\ntreatment of opportunistic infections
\n(antibiotics) have strongly improved, the
\nrisk has grown as well. A century ago
\npandemic spread was somewhat limited
\nby the slowness and low density of trans-
\nportation. At that time traveling around
\nthe world took weeks, but now it takes
\nonly hours and before a serious virus
\nmay be diagnosed, it most likely to have
\nalready landed on another continent. Our
\nawareness of this threat has to be
\nincreased and our resources, communi-
\ncations structures and our regulations,
\nhave to be tested in the preparedness for
\na global pandemic.
\nThe three North American Medical
\nAssociations agreed to work on a common
\naction plan.
\nWorld Health Professions
\nAlliance (WHPA)
\n(www.whpa.org)
\nIn 1999 the International Council of Nurses
\n(www.icn.ch), the International Pharma-
\nceutical Federation (FIP) (www.fip.org) and
\nthe WMA founded the World Health
\nProfessions Alliance. The alliance aims are
\nto foster the cooperation of the professional
\norganizations and to augment our advocacy
\nwork with the international organizations,
\nespecially the WHO and the public. Last
\nyear the World Dental Federation (FDI)
\n(www.fdiworldental.org) joined the alli-
\nance.
\nSince its inauguration the WHPA has taken
\nan active role in the anti-tobacco initiative,
\nin the fight to protect human rights, the
\nrecognition of the HIV\/AIDS pandemic and
\nagainst discrimination of the mentally ill. It
\npromoted awareness on issues such as
\nantimicrobial resistance, nutrition and
\nhealth care for the elderly. The WHPA has
\nengaged in leadership issues and has often
\novercome objections of officials who prefer
\nto speak with a \u201csingle\u201d health profession.
\nDuring the last year WHPA has cooperated
\nwith the International Alliance of Patient
\nOrganisations, IAPO (www.iapo.org). On
\nthe occasion of its second annual meeting in
\nFebruary 2006 the WMA President, Dr.
\nKgosi Letlape, represented the World
\nHealth Professions Alliance and spoke on
\ntheir behalf on patient safety.
\nThe WHPA serves as a platform for various
\ndiscussions and initiatives in health care.
\n\u2022 it cooperates closely with the WHO and
\nthe Industry to combat counterfeit drugs
\nand materials,
\n\u2022 it develops guidelines for the compe-
\ntence of international health care consul-
\ntants,
\n\u2022 it discusses overlapping educational
\nissues and
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 51
\nWMA
\n52
\n\u2022 it serves as a common platform on health
\nprofessional issues with WHO.
\nThe latter point has led to a personal discus-
\nsion with the Director General of WHO, Dr.
\nLee Jong-wook. Dr. Lee met with the
\nSecretaries of the four WHPA Associations
\non April 3rd
\n, 2006. In the meeting the
\nAssociations documented their interest and
\nneed for a closer relationship with WHO
\nand their preparedness for a stronger coop-
\neration especially on human resource relat-
\ned issues. The secretaries\u2019 expressed their
\nopinion that there is a need to further dis-
\ncuss some aspects of the World Health
\nReport 2006 in common. It was agreed that
\nthe relative status of the health professions
\nassociations be revised and that common
\nwork on human resources issues with a
\nfocus on regulation should start as soon as
\npossible. We were not able to achieve a sig-
\nnificant role in the \u201cAlliance for the work-
\nforce for health\u201d under preparation by
\nWHO.
\nThe WHPA Leadership
\nSymposium
\nIn May 2004 the WHPA staged its first
\nWHPA leadership symposium. The sympo-
\nsium aimed to strengthen the bond and
\nencourage collaboration between the three
\nhealth professions at the country level.
\nThe second biennial WHPA Leaders\u2019Forum
\nwill be held on May 20-21, 2006 in Geneva,
\nSwitzerland. The main focus of this forum
\nis patient safety, highlighting the critical
\nrole of health professionals. Daniel Ford of
\nthe National Patient Safety Foundation
\nPatient and Family Advisory Council will
\nlead a discussion on building blame-free,
\nresponsible health care environments. The
\nways in which health professionals can
\ncombat counterfeit medicines will also be
\ndiscussed, along with the importance of
\nhealth professionals working together.
\nThe European Forum of
\nMedical Associations and
\nWHO (EFMA)
\nBudapest 21-22 April 2006
\nThe EFMA is a common forum of Medical
\nAssociations of the WHO-Region \u201cEurope\u201d
\nand the WHO EURO in Copenhagen.
\nAlthough existing now for nearly a quarter
\nof a century WHO has lost interest in the
\nForum during the last years under the lead-
\nership of the current director, Dr. Marc
\nDanzon in the year 2000. This year the
\ndeputy director of WHO EURO, Dr. Nata
\nMenabde, joined the Forum in lieu of the
\nRegional Director who was unable to attend
\nbecause of illness. This was the first partic-
\nipation of WHO leadership since the year
\n2000.
\nThe current leadership made it clear that the
\nsupport formerly given to this Forum could
\nnot be reestablished. However, the WHO
\noffered partnerships for the establishment
\nof common projects.
\nThe Forum discussed among others topics
\n\u2022 National patients\u2019 records databases, and
\nstressing the importance of having the
\nusers of these systems, patients and
\nhealth professional included in the plan-
\nning of the systems.
\n\u2022 Collaboration between the medical pro-
\nfession and the pharmaceutical industry,
\nincluding the guidance given by the
\nStanding Committee of European
\nDoctors (CPME).
\n\u2022 Threats to health and pandemic pre-
\nparedness
\n\u2022 Patient safety and \u201cno blame\u201d approach-
\nes were discussed using the example of
\nthe legally regulated blame free report-
\ning system in Denmark, and
\n\u2022 Health policy reforms in Europe. The
\nForum received reports on the current sit-
\nuation in Albania, Germany, Kazakhstan,
\nCroatia, United Kingdom, Byelorussia
\nand Azerbaijan. It was apparent that in
\nmost of the countries the governments,
\nwhile on one hand talking about more
\ncompetition, on the other they are more
\nand more regulating the health care sys-
\ntems directly and by that doing just the
\nopposite of what they are preaching.
\nProfessional autonomy and self-regula-
\ntion are under pressure. A presentation on
\nthe perception of the current industrial
\nactions taken by doctors especially in
\nBelgium (last year) and Germany (ongo-
\ning) showed an overwhelming support by
\nthe public for the strikes and demonstra-
\ntions of the doctors.
\nOther national or regional
\nmeetings
\nWMA officers or the Secretary General
\nattended national meetings of the following
\nWMA member associations or their region-
\nal groups:
\n\u2022 Colegio M\u00e9dico de M\u00e9xico
\n\u2022 Indian Medical Association
\n\u2022 Medical Associations of the South East
\nAsian Nations (MASEAN)
\n\u2022 Standing Committee of European
\nDoctors (CPME),
\nOn-line Course on treatment
\nof multi-drug resistant tuber-
\nculosis (MDR-TB)
\nFollowing the success of the online course
\nfor prison medicine,WMA decided to trans-
\nlate the new WHO guidelines for the treat-
\nment of multi-drug-resistant tuberculosis
\ninto a course that would help doctors who
\ntreat patients with MDR-TB. The guide-
\nlines were finally published with a consid-
\nerable delay in the fall of last year.
\nThe development of an online course on the
\ntreatment of multi-drug-resistant tuberculo-
\nsis has been nearly completed. The final
\nproduct will be launched in mid-June. The
\nproject is a cooperation with the Foundation
\nfor Professional Development of the South
\nAfrican Medical Association and the
\nNorwegian Medical Association. It was
\nmade possible by a grant from Eli Lilly, Inc.
\nAssignment to regions
\nThe Indonesian Medical Association has
\nbeen reassigned to the Pacific Region on
\ntheir own request. This assignment is effec-
\ntive from the beginning of 2006.
\nThe new member, the Singapore Medical
\nAssociation, has been assigned to the
\nPacific Region.
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 52
\nWHO
\n53
\nnational sources, as well as from interna-
\ntional development partners. The Report
\nrecommends that of all new donor funds for
\nhealth, 50% should be dedicated to
\nstrengthening health systems, of which 50%
\nshould be dedicated specifically to training,
\nretaining and sustaining the health work-
\nforce.
\nAt least 1.3 billion people worldwide lack
\naccess to the most basic healthcare, often
\nbecause there is no health worker. The
\nshortage is global, but the burden is greatest
\nin countries overwhelmed by poverty and
\ndisease where these health workers are
\nneeded most. Shortages are most severe in
\nsub-Saharan Africa, which has 11% of the
\nworld’s population and 24% of the global
\nburden of disease but only 3% of the
\nworld’s health workers.
\nThe Report calls for prompt and innovative
\ninitiatives to improve efficiency. For exam-
\nple, HIV\/AIDS, TB and other priority dis-
\nease programmes have implemented ways
\nfor health workers with limited formal
\ntraining to successfully carry out specific
\nhealth tasks. These experiences should be
\ndrawn upon to develop national health
\nworkforce strategies.
\nThe World Health Report recommends that
\nin order to achieve the goal of getting \u201cthe
\nright workers with the right skills in the
\nright place doing the right things,\u201c countries
\nshould develop plans that include the fol-
\nlowing:
\n\u2022 Acting now for workforce productivity:
\nbetter working conditions for health work-
\ners, improved safety, better access to treat-
\nment and care;
\n\u2022 Anticipating what lies ahead: a well-
\ndeveloped plan to train the health work-
\nforce of the future;
\n\u2022 Acquiring critical capacity: workforce
\nplanning; development of leadership and
\nmanagement; standard setting, accredita-
\ntion and licensing as drivers for quality
\nimprovement.
\nBeyond the national strategies the report
\nurges global cooperation:
\n\u2022 Joint investment in research and informa-
\ntion systems;
\nWHO
\nHealth workforce crisis is having a deadly
\nimpact on many countries\u2019 ability to fight
\ndisease and improve health
\nWorld Health Report outlines need for more investment in health workforce to
\nimprove working conditions, revitalize training institutions and anticipate future
\nchallenges
\nGENEVA\/LUSAKA\/LONDON \u2013 A serious
\nshortage of health workers in 57 countries is
\nimpairing provision of essential, life-saving
\ninterventions such as childhood immuniza-
\ntion, safe pregnancy and delivery services
\nfor mothers, and access to treatment for
\nHIV\/AIDS, malaria and tuberculosis. This
\nshortage, combined with a lack of training
\nand knowledge, is also a major obstacle for
\nhealth systems as they attempt to respond
\neffectively to chronic diseases, avian
\ninfluenza and other health challenges,
\naccording to The World Health Report 2006
\n– Working together for health, published by
\nthe World Health Organization.
\nMore than four million additional doctors,
\nnurses, midwives, managers and public
\nhealth workers are urgently needed to fill
\nthe gap in these 57 countries, 36 of which
\nare in sub-Saharan Africa, says the Report,
\nwhich is highlighted by events in many
\ncities around the world to mark World
\nHealth Day. Every country needs to
\nimprove the way it plans for, educates and
\nemploys the doctors, nurses and support
\nstaff who make up the health workforce and
\nprovide them with better working condi-
\ntions, it concludes.
\n\u201cThe global population is growing, but the
\nnumber of health workers is stagnating or
\neven falling in many of the places where
\nthey are needed most,\u201c said WHO Director-
\nGeneral Dr LEE Jong-wook. \u201cAcross the
\ndeveloping world, health workers face eco-
\nnomic hardship, deteriorating infrastructure
\nand social unrest. In many countries, the
\nHIV\/AIDS epidemic has also destroyed the
\nhealth and lives of health workers.\u201c
\nThe World Health Report sets out a 10-year
\nplan to address the crisis. It calls for nation-
\nal leadership to urgently formulate and
\nimplement country strategies for the health
\nworkforce. These need to be backed by
\ninternational donor assistance.
\nInfectious diseases and complications of
\npregnancy and delivery cause at least 10
\nmillion deaths each year. Better access to
\nhealth workers could prevent many of those
\ndeaths. There is clear evidence that as the
\nratio of health workers to population
\nincreases, so in turn does infant, child and
\nmaternal survival.
\n\u201cNot enough health workers are being
\ntrained or recruited where they are most
\nneeded, and increasing numbers are joining
\na brain drain of qualified professionals who
\nare migrating to better-paid jobs in richer
\ncountries, whether those countries are near
\nneighbours or wealthy industrialized
\nnations. Such countries are likely to attract
\neven more foreign staff because of their
\nageing populations, who will need more
\nlong-term, chronic care,\u201c said WHO
\nAssistant Director-General Dr Timothy
\nEvans.
\nTo tackle this crisis, more direct investment
\nin the training and support of health work-
\ners is needed now. Initial costs will be for
\nthe training of more health workers. As they
\ngraduate and enter the workforce, funds
\nwill be needed to pay their salaries. Health
\nbudgets will have to increase by at least
\nUS$10 per person per year in the 57 coun-
\ntries with severe shortages to educate and
\npay the salaries of the four million health
\nworkers needed to fill the gap. To meet that
\ntarget within 20 years is an ambitious but
\nreasonable goal, the Report concludes.
\nFinancing this gap will require significant,
\ndedicated and predictable funding from
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 53
\nWHO
\n54
\n\u2022 Agreements on ethical recruitment of and
\nworking conditions for migrant health
\nworkers and international planning on the
\nhealth workforce for humanitarian emer-
\ngencies or global health threats such as an
\ninfluenza pandemic;
\n\u2022 Commitment from donor countries to
\nassist crisis countries with their efforts to
\nimprove and support the health workforce.
\nfor example that the number of treatment
\nsites in Malawi increased from three in
\nearly 2003 to 60, and in Zambia increased
\nfrom three to more than 110 facilities in just
\nover two years.
\nGlobally, 18 developing countries met the \u201c3
\nby 5\u201d target of providing treatment to at least
\nhalf of those in need by the end of 2005, and
\nare now concentrating their efforts on mov-
\ning towards universal access to treatment.
\nWhile other countries fell short of this target,
\nlessons learned in expanding treatment
\naccess and overcoming critical weaknesses
\nin health systems are informing new initia-
\ntives to further scale-up HIV prevention,
\ntreatment and care services. Increased avail-
\nability of ART averted an estimated 250 000
\nto 350 000 premature deaths in the develop-
\ning world in 2005 alone.
\nLaunched by WHO and UNAIDS on World
\nAIDS Day, 1 December 2003, \u201c3 by 5\u201c
\naimed to provide treatment to 3 million peo-
\nple in low- and middle-income countries by
\nthe end of 2005. This ambitious target was
\nbased on a 2001 analysis of what could be
\naccomplished with an optimal combination
\nof funding, technical capacity building,
\nhealth systems strengthening and political
\nwill and cooperation. The initiative con-
\nfirmed that HIV treatment can be delivered
\neffectively in a wide variety of health sys-
\ntems, including those in poor countries and
\nrural settings, and that large-scale ART
\naccess is both achievable and increasingly
\naffordable.
\nBetween 2003 and 2005, global expenditure
\non AIDS increased from US$ 4.7 billion to
\nan estimated US$ 8.3 billion. Significant
\nproportions of this funding were provided
\nby the US President\u2019s Emergency Plan for
\nAIDS Relief, the Global Fund to Fight
\nAIDS, TB and Malaria and the World Bank.
\nDuring the same period, the price of first-
\nline treatment decreased by between 37%
\nand 53%, depending on the regimen used.
\nProgress: Treatment Access
\nby Region
\nBetween end-2003 and 2005, HIV treat-
\nment access expanded in every region of the
\nworld. Sub-Saharan Africa and East, South
\nGlobal Access to HIV Therapy Tripled in Past
\nTwo Years, But Significant Challenges Remain
\n1.3 Million People Now Receiving Treatment in Low- and Middle-income
\nCountries; Sub-Saharan Africa Leads in Treatment Scale-up. Lessons learned
\nin \u201c3 by 5\u201d should guide efforts to move towards Universal Access to Treatment
\nby 2010
\nGENEVA, 28 MARCH 2006 \u2013 A new
\nreport by the World Health Organization
\nand the Joint United Nations Programme on
\nHIV\/AIDS (UNAIDS) shows that the num-
\nber of people on HIV antiretroviral treat-
\nment (ART) in low- and middle-income
\ncountries more than tripled to 1.3 million in
\nDecember 2005 from 400 000 in December
\n2003. Charting the final progress of the \u201c3
\nby 5\u201c strategy to expand access to HIV ther-
\napy in the developing world, the report also
\nsays that the lessons learned in the last two
\nyears provide a foundation for global efforts
\nnow underway to provide universal access
\nto HIV treatment by 2010.
\nProgress in treatment scale-up, while sub-
\nstantial, was less than initially hoped. The
\nreport notes, however, that treatment access
\nexpanded in every region of the world dur-
\ning the \u201c3 by 5\u201d initiative, with approxi-
\nmately 50 000 additional people beginning
\nART every month in the past year. Sub-
\nSaharan Africa, the region most severely
\nimpacted, led the scale-up effort, with the
\nnumber of people receiving HIV treatment
\nthere increasing more than eight-fold to 810
\n000 from 100 000 in the two-year period.
\nBy the end of 2005, more than half of all
\npeople receiving HIV treatment in low- and
\nmiddle-income countries resided in sub-
\nSaharan Africa, up from one-quarter two
\nyears earlier.
\n\u201cTwo years ago, political support and
\nresources for the rapid scale-up of HIV
\ntreatment were very limited,\u201d said WHO
\nDirector-General, Dr LEE Jong-wook.
\n\u201cToday \u201c3 by 5\u201c has helped to mobilize
\npolitical and financial commitment to
\nachieving much broader access to treatment.
\nThis fundamental change in expectations is
\ntransforming our hopes of tackling not just
\nHIV\/AIDS, but other diseases as well.\u201d
\nIn July 2005, the G8 nations endorsed a
\ngoal of working with WHO and UNAIDS
\nto develop an essential package of HIV pre-
\nvention, treatment and care, with the aim of
\nmoving as close as possible to universal
\naccess to treatment by 2010, a target subse-
\nquently endorsed by the United Nations
\nGeneral Assembly in September 2005. The
\nnew WHO\/UNAIDS report outlines a num-
\nber of steps that must be taken to continue
\nand expand treatment scale-up toward
\nachieving this goal.
\nSubstantial increases in HIV
\ntreatment access
\nCountries in every region of the world made
\nsubstantial gains during the \u201c3 by 5\u201d period
\nin closing the gap between those in need of
\ntreatment and those receiving it. The num-
\nber of public sector treatment sites in low-
\nand middle-income countries increased
\nfrom fewer than 500 providing ART to
\nmore than 5100 operational treatment sites
\nby the end of 2005. A recent survey showed
\nWMJ_2_29-58.qxd 17.07.2006 13:35 Seite 54
\nWHO
\n55
\nand Southeast Asia, the regions most heavi-
\nly affected by the epidemic, achieved the
\nmost rapid and sustained progress.
\n\u2022 More than 810 000 people in sub-Saharan
\nAfrica, or 17% of those in need of ART,
\nhad accessed treatment by the end of
\n2005. Well over half the people on ART in
\nthe developing world live in this region.
\nThis substantial increase in ART availabil-
\nity in sub-Saharan Africa occurred despite
\nconsiderable regional challenges: the
\nregion is home to over 20 of the world\u2019s
\n25 poorest countries, and suffers a short-
\nage of some 1 million professional health
\nworkers, with an additional 20 000 trained
\nstaff lost each year to emigration.
\n\u2022 East, South and Southeast Asia recorded
\nsignificant gains in ART access from end-
\n2003 (70 000 people) to 2005 (180 000
\npeople), with coverage in the region
\nexpanding more than 75% in 2005.
\nThailand was a major driver of this
\nincrease, particularly during 2004 and the
\nfirst half of 2005.
\n\u2022 Latin America and the Caribbean, with
\nmore than 315 000 people on ART (up
\nfrom 210 000 at the end of 2003), is pro-
\nviding treatment to approximately 68% of
\nits population in need \u2013 the highest cover-
\nage of any region in the developing world.
\nThirteen countries in this region provide
\ntreatment to more than half of the popula-
\ntion in need.
\n\u2022 Despite gains in overall numbers on treat-
\nment, ART access in low- and middle-
\nincome countries in Eastern Europe,
\nCentral Asia, the Middle East and North
\nAfrica was lower than in other regions,
\nwith just 21 000 people in Eastern Europe
\nand Central Asia and 4000 in the Middle
\nEast and North Africa receiving treatment
\nas compared to 15 000 and 1000 respec-
\ntively at the end of 2003. Virtually all
\ncountries in these regions are experienc-
\ning low-level epidemics that involve diffi-
\ncult-to-reach populations such as injecting
\ndrug users (IDUs) and sex workers.
\nReaching Women, Children
\nand Vulnerable Populations
\nWhile the new report found no systematic
\nbias against women in ART access, rates of
\ncoverage for women varied. In some coun-
\ntries, more women receive treatment; in
\nothers, more men. One notable area of con-
\ncern is access to therapy to prevent mother-
\nto-child HIV transmission, which remains
\nunacceptably low. Between 2003 and 2005,
\nfewer than 10% of HIV-positive pregnant
\nwomen received antiretroviral prophylaxis
\nbefore or during childbirth. As a result,
\n1800 infants were born with HIV every day.
\nEach year, over 570 000 children under the
\nage of 15 die of AIDS, most having
\nacquired HIV from their mothers. In 2005,
\n660 000 children under the age of 15 were
\nin need of immediate ART, representing
\nmore than 10% of unmet global need. Nine
\nout of ten children needing treatment live in
\nsub-Saharan Africa.
\nWhile an estimated 36 000 injecting drug
\nusers (IDUs) were receiving ART by the
\nend of 2005, more than 80% (30 000) of
\nthese are in Brazil. The remaining 6000
\npatients were distributed among 45 other
\ncountries. These figures suggest a large
\nunmet need, particularly in Eastern Europe
\nand Central Asia, where IDUs represent
\n70% of HIV cases, but just 24% of patients
\ncurrently on treatment.
\n\u201cMisinformation about the disease and stig-
\nma against people living with HIV still
\nhamper prevention, care and treatment
\nefforts everywhere,\u201d said Dr Peter Piot,
\nUNAIDS Executive Director. \u201cIf we are to
\nget ahead of the AIDS epidemic, we must
\ntackle stigma, ensure that the available
\nfunds are spent effectively to scale-up HIV
\nprevention, care and treatment pro-
\ngrammes, and mobilize more resources.\u201d
\nMoving toward universal
\naccess
\nWhile important advances in HIV treatment
\naccess have been achieved in the past two
\nyears, the report also acknowledges that,
\ndespite the efforts of many partners and sig-
\nnificant funding from a number of donors,
\nthe \u201c3 by 5\u201c strategy fell short of its ambi-
\ntions. Obstacles to scaling up HIV treatment
\nand prevention highlighted in the report
\ninclude poorly harmonized partnerships;
\nconstraints on the procurement and supply
\nof drugs, diagnostics and other commodi-
\nties; strained human resources capacity and
\nother critical weaknesses in health systems;
\ndifficulties in ensuring equitable access;
\nand lack of standardized systems for the
\nmanagement of programmes and monitor-
\ning progress.
\n\u201cThe past two years have provided a wealth
\nof experience and information on which we
\nmust now continue to build,\u201d said Kevin De
\nCock, Director, HIV\/AIDS Department at
\nthe World Health Organization. \u201cWe intend
\nto utilize this knowledge to focus future
\nefforts on overcoming persistent challenges
\nand obstacles. It is particularly important
\nthat scaling-up HIV prevention, treatment
\nand care services contributes to strengthen-
\ning of health systems overall.\u201d
\nA number of lessons learned in treatment
\nscale-up efforts and outlined in the new
\nreport provide a valuable roadmap for
\nefforts to achieve universal access to treat-
\nment. Among these are:
\n\u2022 The positive impact of targets in creating
\nand sustaining momentum for action and
\nin increasing accountability among stake-
\nholders. A key element of the \u201c3 by 5\u201d
\nstrategy was developing bold country-
\nlevel targets that encouraged national gov-
\nernments to expand capacity beyond what
\nwas previously considered possible.
\nMoving forward, targets for treatment
\nmust be complemented by achievable tar-
\ngets for other elements of a comprehen-
\nsive response to AIDS, including preven-
\ntion and mitigating impact.
\n\u2022 The need to strengthen health systems.
\nBuilding universal access to HIV treat-
\nment will require significant ongoing
\nefforts to re-build, reinforce and expand
\nunder-staffed and under-funded health
\ncare systems that are already severely
\nchallenged in many countries.
\n\u2022 Promoting a ‘public health approach’ to
\nhealth care delivery that emphasizes ser-
\nvice decentralization, community mobili-
\nsation and education, team-based
\napproaches and the delegation of routine
\ntasks to trained nurses and health workers.
\nThe approach also promotes use of mech-
\nanisms to ensure the consistency and qual-
\nity of supplies of drugs and diagnostics as
\nWMJ_2_29-58.qxd 17.07.2006 13:36 Seite 55
\nWHO
\n56
\nwell as the routine offer of voluntary test-
\ning and counselling to increase knowledge
\nof HIV status in settings where there is
\nhigh HIV prevalence.
\n\u2022 The ongoing need to intensify prevention
\nefforts and to integrate prevention and
\ntreatment scale-up, using all effective
\napproaches and paying particular attention
\nto the needs of vulnerable groups.
\nEpidemiological modelling consistently
\nshows that more deaths can be averted
\nwith a comprehensive response including
\nboth prevention and treatment, than by
\nfocusing on treatment or prevention alone.
\n\u2022 The need for substantial increases in
\nresources and sustainable financing.
\nUNAIDS estimates that the gap between
\navailable resources and those needed is
\nUS$18 billion for the period 2005-2007,
\nand that at least US$22 billion per year
\nwill be needed by 2008 to fund compre-
\nhensive national HIV prevention, treat-
\nment and care programmes.
\n\u2022 Long-term donor commitments are essen-
\ntial to ensuring sustainable treatment
\nscale-up, as placing large numbers of peo-
\nple on ART is impractical for many coun-
\ntries without firm funding. The report
\nencourages the use of innovative financ-
\ning mechanisms to fund increased
\nresources for AIDS. These include a pro-
\nposal by France to introduce an airline sol-
\nidarity contribution and the UK\u2019s
\nInternational Finance Facility, which aims
\nto \u201cfront-load\u201d additional funds leveraged
\nfrom international capital markets to make
\nthem immediately available for sustain-
\nable investments that support the achieve-
\nment of the Millennium Development
\nGoals.
\nThe new report emphasizes that WHO and
\nUNAIDS will continue to build upon these
\nlessons learned, as well as on the priorities,
\nstrategies and partnerships of \u201c3 by 5\u201c in
\naccelerating the AIDS response. UNAIDS
\nis currently facilitating the development of
\nnationally agreed plans and targets to move
\ntowards universal access to HIV preven-
\ntion, treatment, care and support. WHO’s
\ncontribution to realizing the goal of univer-
\nsal access will be based on a set of priority
\ninterventions in the following five strategic
\ndirections known to be able to significantly
\ninfluence the epidemic in different epidemi-
\nological contexts:
\n– enabling people to know their HIV status
\nthrough HIV testing and counselling;
\n– accelerating the scale-up of treatment and
\ncare;
\n– maximizing the health sector’s contribu-
\ntion to HIV prevention;
\n– investing in strategic information to guide
\na more effective response; and
\n– strengthening and expanding health sys-
\ntems.
\nIntellectual property rights,
\nInnovation and Public Health Commission
\nDeveloping country access needed to existing
\nand new medicines and vaccines
\nGENEVA. The independent Commission
\non Intellectual Property Rights, Innovation
\nand Public Health has presented its report to
\nthe World Health Organization. The report
\nrecommends key actions needed to ensure
\nthat poor people in developing countries
\nhave access to existing and new products to
\ndiagnose, treat and prevent the diseases
\nwhich most affect them.
\nOver half of the people in the poorest parts
\nof Africa and Asia lack regular access to
\nexisting essential medicines because they
\ncannot afford them, or because the health
\nsystem in their country is too weak. Apart
\nfrom access to existing medicines, some
\nhealth products specifically for diseases
\nwhich disproportionately affect developing
\ncountries are simply not developed at all
\ndue to the lack of a sustainable market. The
\nrelationship between intellectual property
\nrights, innovation and public health has
\nbeen at the heart of debate on these issues.
\nThe report of the Commission: \u201cPublic
\nHealth, Innovation and Intellectual Property
\nRights\u201c is the result of two years’ analysis
\nof how governments, industry, scientists,
\ninternational law and financing mecha-
\nnisms can work best to overcome the chal-
\nlenges.
\n\u201cThere is now global momentum to address
\nthese issues, and we have a unique opportu-
\nnity to build on this. There is more aware-
\nness, more money potentially available,
\nmore utilization of scientific capacity in
\ndeveloping countries and new institutions
\nsuch as public\u2013private partnerships. The
\nCommission report is clear that we must
\nbuild on all of these to ensure that poor peo-
\nple in developing countries have sustainable
\naccess to the medicines, vaccines and diag-
\nnostics they need now, and critically, in the
\nfuture. The report maps out the ways this
\ncan be done,\u201c said Mme Ruth Dreifuss, the
\nChair of the Commission.
\nThe report was commissioned by the World
\nHealth Assembly and WHO’s Director-
\nGeneral, Dr LEE Jong-wook, established
\nthe Commission on Intellectual Property
\nRights, Innovation and Public Health in
\nFebruary 2004 meeting first in April (as
\nreported in WMJ 50(2), 50).
\n\u201cWe are grateful to the Commissioners for
\nundertaking this difficult task. With this
\nreport, the Commission has built a solid
\nfoundation from which countries can move
\nforward. I encourage all countries to give
\nserious consideration to their role in
\naddressing these critical issues,\u201c said Dr
\nLEE Jong-wook, today as Mme Dreifuss
\npresented the report, which contains more
\nthan 50 recommendations which serve as a
\nroad map for tackling the issues in different
\ncountry settings. The report after considera-
\ntion by the Executive Board, goes to the
\nWorld Health Assembly. (see next issue)
\nWMJ_2_29-58.qxd 17.07.2006 13:36 Seite 56
\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
\nU2–4_WMJ_02_06.qxd 17.07.2006 13:46 Seite U3
\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
\nU2–4_WMJ_02_06.qxd 17.07.2006 13:46 Seite U4<\/p>\n"},"caption":{"rendered":"

wmj10 WorldMMeeddiiccaall JJoouurrnnaall Vol. No.2,June200652 OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC. G 20438 173rd WMA Council Meeting Contents Declaration of Geneva 29 EEddiittoorriiaall Human health resources 30 Trust in Physicians 31 Dr. LEE Jong-wook 33 MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss The World Medical Association Declaration of Tokyo 34 The World Medical Association regulations […]<\/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\/wmj10.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3546"}],"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=3546"}]}}