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wmj11<\/a><\/p>\n

WorldMMeeddiiccaall JJoouurrnnaall
\nVol. No.3,September200652
\nOFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
\nG 20438
\nContents
\nEEddiittoorriiaall
\nSun City \u2013 A chance to influence change 59
\nFirst steps towards selecting a new
\nwho Director General 60
\nMMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
\nSafeguarding Global Research on Human Subjects 60
\nA European Perspective on the Clinical Research
\nEthical Review Procedure 63
\n8th
\nWorld Congress of Bioethics, Beijing, China 65
\nA Discussion Paper on the Future of Self Care and
\nits Implications for Physicians 66
\nWWHHOO
\nMedicines, money and motivated health workers
\nare key to universal access to hiv\/aids prevention,
\ntreatment care and support 72
\nG8 commitments to infectious disease can improve
\nglobal health security 74
\nWorldwide shortage of doctors, nurses and other
\nhealth workers 74
\nwho hiv\/aids Director Outlines Progress and
\nObstacles to Achieving Universal Access
\nto aids Treatment 75
\nTop level push to tackle priorities in sexual
\nand reproductive health 76
\nwho launches new plan to confront
\nhiv-related health worker shortages 78
\nIndonesia holds avian influenza
\nexpert consultation 80
\nViet Nam eliminates maternal and
\nneonatal tetanus 80
\nwho and unicef tackle problem of lack of
\nessential medicines for children 79
\nMMeeddiiccaall SScciieennccee,, PPrrooffeessssiioonnaall PPrraaccttiiccee
\naanndd EEdduuccaattiioonn
\nImproved formula for oral rehydration salts
\nto save children\u2019s lives 81
\nNeedleless immunisations possible in the future? 82
\nNew AIDS and malaria medicines added to
\nprequalification list 82
\nMale circumcision update 82
\nRReeggiioonnaall aanndd NNMMAA NNeewwss 84
\nRReevviieewwss 86
\n00_US_03_2006.qxd 05.10.2006 17:27 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
\nCover photos: World Health Headquarters Building,Geneva. Courtesy of WHO.
\nCopyirght WHO \/ P.Virot
\n1. and 2. Main building, 3. Entrance main building
\nU2–4_WMJ_03_06.qxd 05.10.2006 16:40 Seite U2
\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_03_06.qxd 05.10.2006 16:40 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_03_06.qxd 05.10.2006 16:40 Seite U4
\n59
\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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\nGermany
\nDr. Ivan M. Gillibrand
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\nWest Sussex RH12 2AQ
\nUK
\nBusiness Managers
\nJ. F\u00fchrer, D. Weber
\n50859 K\u00f6ln
\nDieselstra\u00dfe 2
\nGermany
\nPublisher
\nTHE WORLD MEDICAL
\nASSOCIATION, INC.
\nBP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
\nDeutscher \u00c4rzte-Verlag GmbH,
\nDieselstr. 2, P. O. Box 40 02 65,
\n50832 K\u00f6ln\/Germany,
\nPhone (0 22 34) 70 11-0,
\nFax (0 22 34) 70 11-2 55,
\nPostal Cheque Account: K\u00f6ln 192 50-506,
\nBank: Commerzbank K\u00f6ln No. 1 500 057,
\nDeutsche Apotheker- und \u00c4rztebank,
\n50670 K\u00f6ln, No. 015 13330.
\nAt present rate-card No. 3 a is valid.
\nThe magazine is published quarterly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or the World
\nMedical Association.
\nSubscription fee \u20ac 22,80 per annum (incl. 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
\nThe General Assembly of the World Medical Association takes place in South Africa in
\nOctober. At a time when the continuing burden of disease, AIDS\/HIV, Malaria,
\nTuberculosis etc., inadequate resources and under-funding of need is so great (despite the
\ninternational response so far), it is thus appropriate that the Assembly is meeting in the
\nAfrican continent.
\nAlthough the agenda of the General Assembly will be much occupied with the necessary
\nupdating of WMA policy statements, including the International Code of Medical Ethics
\n(see Council meeting report in WMJ 52(2)) and possibly adopting statements on other
\nissues such as Obesity, Pandemic Influenza etc., no doubt other matters relating to major
\nhealth issues including those of the African continent will be raised during the meeting.
\nThe Scientific session will be devoted to \u201cHealth as an Investment\u201d and \u201cAdvocacy\u201d, pro-
\nviding an opportunity to examine aspects of these topics as diverse as Investment in Human
\nResources, Medical Research, Public-funded healthcare planning \u2013 not to mention the eco-
\nnomic aspects of the topic. The presentation will consider the obligations of governments
\nin the provision of basic health care, move on to aspects of Advocacy and finally address
\nthe Role of National Medical Associations in the topics addressed.
\nLooking round the world today, it is clear that health care is a major topic of discussion not
\nonly in developing countries. Developed countries, with health care \u2013 often long estab-
\nlished and well developed \u2013 are also experiencing major problems although not to the same
\ndegree. It is not without significance that in considering the economics of health, both its
\npromotion and care, governments are now trying to assess the value of investment in health
\nand how the best value for this type of investment can achieved. This situation is not with-
\nout its effect on physicians, as can be seen in the notes on news from the regions and nation-
\nal medical associations (p. 82). Disquiet is with lack of resources both financial and
\nhuman, due not only to problems associated with the economy or productivity in both
\ndeveloping and developed countries. In developing countries it can be due to emergence of
\nnew diseases or inadequate control of old ones, or by armed conflict or social unrest.
\nIn developed countries as well, governmental and healthcare system\u2019s suggested or
\nimposed changes, or dissatisfaction with the working conditions of health professionals,
\nare increasingly provoking not only disquiet and demonstrations but, in some countries,
\neven strikes.
\nIn todays world of rapid change it is not to be unexpected that change will affect the med-
\nical profession. Indeed we have addressed this problem previously in these columns.
\nHowever, it would appear that in some quarters the rapidity of change or the perceived
\ninequity of conditions, are producing considerable reactions. Not infrequently the views
\nbeing expressed are reflections of concern that proposed or imposed changes are not in the
\ninterest of the relevant population in general and patients in particular.
\nFaced with these trends, it is to be hoped that the discussions in South Africa will shine
\nsome light on the best ways in which National Medical Associations can act themselves and
\nadvise their members, both in there interest and that of the health of the people.
\nAlan Rowe
\nEditorial
\nSun City \u2013 A chance to influence change
\nWMJ_2_59-86.qxd 05.10.2006 14:05 Seite 59
\nMedical Ethics and Human Rights
\n60
\nPrinciples of Medical Research involving
\nHuman subjects from its origin in 1964 has
\nprovided the source of guidance set for
\nPhysicians worldwide. The 2000 version of
\nthe Declaration states that \u2018it is the duty of
\nthe physician to promote and safeguard the
\nhealth of the people. The physician\u2019s
\nknowledge and conscience are dedicated to
\nthe fulfillment of this duty\u201d. The
\nDeclaration also recognizes that medical
\nprogress is based on research which ulti-
\nmately must rest in part on experimentation
\ninvolving human subjects, but that consid-
\nerations related to the well being of the
\nhuman subject should take precedence over
\nthe interests of science and society.
\nThese duties and responsibilities of physi-
\ncians to their patients cannot be subsumed
\nby a research ethics committee or research
\nteam.
\nPhysicians by themselves or as members of
\nnational medical associations are unable to
\nprovide full protection to their patients and
\npopulations. They work as members of
\nresearch teams in an increasingly complex
\nenvironment. They should not work in an
\nenvironment which breaches their ethical
\nduties and obligations.
\nAwareness of these ethical issues had been
\nheightened by Claude Bernard in France in
\nthe mid-nineteen century. Personal, institu-
\ntional and national codes of practice
\nemerged over the next hundred years.
\nAn expert group, bringing together the
\nresearch community, industry and regula-
\ntors was set up by the International
\nConference on the Harmonisation of
\nTechnical Requirements for the
\nRegistration of Pharmaceuticals for Human
\nuse. (ICH) Their consolidated \u201cguidance\u201d
\non Good Clinical Practice in 1996 was
\ngleaned from their participants. This has
\nprovided a uniform standard for the
\nEuropean Union (EU), Japan and the
\nUnited States for designing, conducting,
\nrecording and reporting clinical trials on
\nhuman subjects. (ICH.GCP) In the intro-
\nduction, the Guidance states that
\n\u201cCompliance with this standard provides
\npublic assurance that their rights, safety and
\nwellbeing of trial subjects are protected
\nconsistent with the principles that have their
\nFollowing the tragic death of Dr. Lee Jong-
\nwook, the WHO Executive decided to has-
\nten the process of electing a successor.
\nNomination by Member States closed on
\n5th
\nSeptember and the list of thirteen nomi-
\nnations were announced and appear below.
\nAmongst the formidable list of candidates
\nare members and former members of WHO
\nstaff, and a former member of the WHO
\nExecutive committee
\nIt also should be noted that Dr. Lee Jong-
\nwook had only completed 3 of his 5 years of
\noffice. While this might be thought to influ-
\nence the decision in favour of an Asian can-
\ndidate and normally other UN elections
\nsuch as that of the UN Secretary General do
\nnot influence proposals, it may be that the
\npossibility in the UN Security Council that
\nthe next UN Secretary General will be
\nAsian may prove significant.
\nThe 34 members of the Executive commit-
\ntee meeting in a special session on 6-8
\nNovember and make a nomination from a
\nshort list to the World Health Assembly on
\n9th
\nNovember, who will take the final deci-
\nsion and appoint the new Director General.
\nThe list of candidates and the proposing
\nMember State are:
\nDr. Kazem Behbehani (Kuwait)
\nDr Margaret Chan (China)
\nFr. Julio Frenck (Mexico)
\nMr David A. Gunnarsson (Iceland)
\nDr. Nay Htun (Myanmar)
\nDr. Karam Karam (Syrian Arab Republic)
\nDr. Bernard Kouschner (France)
\nDr. Pascoal Manuel Mocumbi (Mozambique)
\nDr. Shigaru Omi (Japan)
\nDr. Alfredo Palacio Gonzalez (Ecuador)
\nProfessor Pekka Puska (Finland)
\nMs Elena Saigado M\u00e9dez (Spain)
\nProfessor Dr. Tomris T\u00fcrmen (Turkey)
\nFirst steps towards selecting a new
\nWHO Director General
\nWHO announces list of candidates
\nDr. James Appleyard, FRCP, Past
\nPresident of the World Medical
\nAssociation.
\nThe majority of research on human subjects
\nis now being undertaken in the \u2018developing\u2019
\nnations. This change from the established
\ncentres of clinical research in the United
\nStates, Europe and Japan has been acceler-
\nating in the recent years because of relative-
\nly low costs and the increased availability
\nof human subjects in the poorer countries.
\nMedical Ethics and Human Rights
\nSafeguarding Global Research
\non Human Subjects
\nConcerns have been raised about the vul-
\nnerability of local populations in the devel-
\noping world and whether there are suffi-
\ncient safeguards to protect them. Instances
\nof alleged abuse have been highlighted in
\nthe medical literature as well as the World\u2019s
\nPress.
\nPhysicians have a clear duty to look after
\nthe best interests of those who entrust them-
\nselves to their care. The WMA\u2019s
\nDeclaration of Helsinki on the Ethical
\nWMJ_2_59-86.qxd 05.10.2006 14:05 Seite 60
\nMedical Ethics and Human Rights
\n61
\nreceiving research support from the NIH
\ndid most of the research community appear
\nto respect the basic underlying ethical prin-
\nciples of the Belmont Report, those of
\nRespect for Persons, beneficence and jus-
\ntice. The first Director of OHRP Dr. Greg
\nKoski emphasized the requirement for
\n\u201cshared goals and shared responsibilities\u201c
\nand the need to move from \u201ca culture of
\ncompliance to a culture of conscience in
\nhuman research\u201d. His view underscores the
\nneed for the research community to inter-
\nnalize the principles of the Declaration of
\nHelsinki and the Belmont Report into their
\n\u201cconscience\u201d Dr. Melody Lin, the Deputy
\nDirector, emphasizes that the work of the
\nOHRP depends on Trust ( that is individual
\nand institutional \u2018conscience\u2019), Education
\nand Regulatory oversight \u2013 it is indeed get-
\nting this balance right that is the major chal-
\nlenge for Governments and the professions
\nand the research community.
\nThe challenge is not only to promote these
\nprinciples world wide but to ensure that
\nthere is a robust ethical research committee
\ninfrastructure globally to support the
\nincrease in research in developing countries
\nnecessary to correct the global imbalance of
\nresearch. The WHO has estimated that 90%
\nof the resources devoted to research and
\ndevelopment on medical problems are
\napplied to diseases causing less than 10% of
\nthe global suffering.
\nThe WHO published Operational
\nGuidelines for Ethics Committees review-
\ning Biomedical Research following an ini-
\ntiative by the Research and Training in
\nTropical Diseases (TDR), the World Bank
\nand the United Nations DP in 2000. The
\nSecretary General of WMA assisted in this
\ndevelopment in the International Working
\nParty, which was chaired by Francis P.
\nCrawley from Belgium.
\nA strategic Initiative for Developing
\nCapacity in Ethical review (SIDCER) was
\nlaunched under the aegis of UNICEF \/
\nUNDP \/ World Bank \/ WHO TDR in 2001.
\nThis is a network of independently estab-
\nlished regional forums for Ethical Review
\ncommittees, health researchers and invited
\npartner organisations including the WMA.
\nIt was designed to address the principle
\ngaps and challenges in ethics encountered
\norigin in the Declaration of Helsinki and
\nthat the Clinical Data are credible\u201d.
\nRevelations that financial relationships and
\nconflicts of interest had become \u2018pervasive\u2019
\nand were undermining public trust in the
\nintegrity of Science resulted in the call for
\ngreater transparency (honesty) within the
\nUS regulatory framework. The Office for
\nHuman Research Protections (OHRP) was
\nset up in 2000 from the former Office for
\nProtection from Research Risk (OPRR). It
\nreports to the Assistant Secretary of Health
\nand Human services.
\nThe National Institutes of Health [NIH] is
\nby far the largest human research funding
\nagency worldwide. To carry out its research
\nmission, nearly 10,000 universities, hospi-
\ntals and other Research Institutions in the
\nUnited States and internationally have for-
\nmal assurances with OHRP to comply with
\nthe US regulations related to human subject
\nprotection.
\nOnly when the NIH required documentation
\nof some training in research ethics and
\nhuman subject protection as a condition of
\nWMJ_2_59-86.qxd 05.10.2006 14:05 Seite 61
\nMedical Ethics and Human Rights
\n62
\nin global health research. In Dr. Vichai
\nChokevivat (Thailand), its Chairman\u2019s
\nwords \u201c the network of regional forums cre-
\nate unique opportunities for professional
\ndevelopment and learning with innovative
\napproaches to cross cultural, cross national
\nand cross regional understanding and mutu-
\nal support\u201d. Funding from different sources
\nincluding the OHRP was channeled through
\nthe WHO\/TDR. The regional fora are
\nknown by their acronyms \u2013 FERCAP
\n(Forum for Ethical Review Committees in
\nAsia and Western Pacific), the first to be set
\nup; FLACEIS (For a Latino American de
\nComits de Etica en Investigacion en Salud);
\nPABIN (Pan African Bioethics Initiative),
\nFECCIS (Forum for Ethical Committees in
\nthe Confederation of Independent States
\nand FOCUS (Forum for Ethical Review
\nBoards\/Institutional Review Boards in
\nCanada and the US.
\nThe European Forum for Good Clinical
\nPractice (EFGCP) had previously been set
\nup under the pioneering guidance of
\nProfessor Joseph Hoet and has contributed
\nto SIDCER\u2019s work.
\nSIDCER\u2019s vision was to establish systems
\nand infrastructure for the accreditation of
\nethics in Health Research and develop a
\nregister of resources and data bases of
\nethics committees and institutional review
\nboards within the countries who are mem-
\nbers of the Regional Fora.
\nMembers of the original WHO International
\nWorking Party are still very active in the
\nFora. Host governments to the Regional
\nmeetings are interested \u201cstakeholders\u201d.
\nProgress has been made in influencing
\nsome of the governments in the newly inde-
\npendent states to adopt legislation respect-
\ning human rights and human dignity upon
\nwhich the ethical principles in medical
\nresearch on human subjects depend.
\nReports from the different participating
\ncountries are presented, shared and dis-
\ncussed at the Fora Training courses are also
\narranged.
\nWhen President of the WMA I was invited
\nto give the Joseph Hoet Lecture at the
\nEFGCP, to attend FECCIS and have since
\nhad the opportunity to participate in three of
\nthe five regional fora. Such conferences are
\nboth stimulating and enjoyable for the par-
\nticipants. Often there is a feeling of
\nachievement when new recommendations
\nare made to the constituent members.
\nHowever only three Medical Research insti-
\ntutions have been accredited by SIDCER in
\n5 years \u2013 two of these in Taiwan. The
\nresearch community in Taiwan have taken
\nthe ethical issues very seriously and have
\nestablished their own Forum for
\nIndependent Review System in Taiwan \u2013
\nFIRST. National medical associations are
\nnot directly involved in the regional confer-
\nences and the most senior researchers from
\nthe countries are not invited regularly. The
\nfora are therefore not always connected
\nwith those that influence and implement
\npolicy locally. Some training may \u2018trickle
\ndown\u2019 but there must be more effective
\nways to promote and support education in
\nResearch Ethics locally.
\nIn addition to the WMA setting the ethical
\nstandards through the Declaration of
\nHelsinki, the Association needs to support
\nmeasures to implement it globally.
\nThe Declaration itself has been the subject a
\ncomprehensive study by Carlson, Boyd and
\nWebb from Edinburgh University. They
\ncomment: \u201cthere is no doubt that the
\nDeclaration of Helsinki \u2013 still less than
\n2000 words in length \u2013 is one of the most
\nsuccinct documents encapsulating the prin-
\nciples guiding research ethics in existence\u201d
\nThe World Medical Association can only be
\neffective in its promotion locally through its
\nconstituent national medical associations,
\nwho are the local custodians of the princi-
\nples in the Declaration of Helsinki. The tra-
\nditional ethical base within the national
\nmedical associations in the \u2018developing\u2019
\ncountries needs to be strengthened and sup-
\nported so they can contribute more actively
\nto the development of research within their
\ndomain and the infrastructure of research
\nethics committees. This could be achieved
\nthrough educational materials which can be
\neasily accessed. The WMA has initiated two
\nweb based courses over the last three years
\non other topics; these on-line courses allow
\ngreater access. This can be complemented
\nby materials available on CDs, as in the
\nmore remote areas access to the internet is
\nat present difficult and disproportionately
\nexpensive.
\nA number of courses are already available
\nin the USA and Europe. It would be possi-
\nble for the WMA to develop with suitable
\npartners web-based courses which could be
\nintegrated with Regional and National
\nstrategies. One potential partner could be
\nthe Collaborative Institutional Training
\nInitiative (CITI) together with international
\nfunding agencies involved in planning
\nresearch in the developing world, such as
\nthe Gates Foundation, the Welcome Trust,
\nthe pharmaceutical industry, non-govern-
\nmental organizations, and national
\nGovernments themselves.
\nCITI was formed by a small group of physi-
\ncians, bio-ethicists, institutional review
\nboard chairs and scientists from nine inde-
\npendent academic institutions in the USA,
\nincluding the university of Miami,
\nDartmouth College, the University of
\nWashington and the Children\u2019s Hospital,
\nBoston. The universities pooled their
\nresources to meet the requirements of the
\nUS Department of Health and Human
\nServices (DHHS) that all investigators and
\nkey personal in human subject research
\nmust complete training in human subject
\nprotection by October 1st
\n2000. The CITI
\nprogramme has been devised by the multi-
\ndisciplinary research community itself and
\nis independent of any US National
\nRegulatory Body.
\nCourses have been developed covering
\nBiomedical Research including Good
\nClinical Practice and Social and
\nBehavioural Research with quality controls.
\nAn International Group has been formed
\nwithin CITI which includes input from the
\nCaribbean, SE Asia and the Middle East.
\nThough the underlying ethical principles
\nneed to be the same worldwide, the local
\ncontext and culture are important.
\nInternational Courses are being developed
\non a pilot basis for individual countries.
\nResearch institutions in the poorer nations
\nare already finding even the current more
\nUS-centric CITI courses helpful.
\nSuch a collaborative approach would allow
\nthe creation of sound international educa-
\ntional materials leading to accreditation and
\ncontinuing professional development with
\nquality standards shared with those in the
\nUS, Europe and Japan. In short a truly glob-
\nWMJ_2_59-86.qxd 05.10.2006 14:05 Seite 62
\nMedical Ethics and Human Rights
\n63
\nal research ethics network. Enhanced train-
\ning will give more confidence to those
\nfunding and sponsoring clinical research.
\nProfessions are the rightful custodians of
\ntheir body of knowledge. In medicine this
\nmeans a continuing duty to expand that
\nknowledge base in the interest of patients
\nwith new therapies and new procedures and
\nensuring that the best evidence is available
\nfor effective management of disease and
\ndisorders internationally. A sound research
\nethics infrastructure should encourage a
\ngreater increase in the clinical research in
\nthe developing world necessary to reduce
\nthe overwhelming burden of disease due to
\nAIDS, Malaria, and Tuberculosis in the
\npoorer nations.
\nThe WMA with other key stakeholders
\ncould build on their recognized standards of
\nmedical research ethics to influence their
\npractical implementation and to reduce the
\nserious research \u2018gap\u2019 between the rich and
\nthe poor nations. The resultant improve-
\nment in the health of the nations from qual-
\nity research will have major economic ben-
\nefits by enabling nations to prosper, rather
\nthan perpetuate their cycles of poverty and
\nmalnutrition.
\nIt will be a long, hard and continuing
\nprocess but one that could well make a
\nmajor contribution to protection of patients
\nin research worldwide.
\nJames Appleyard, Thimble Hall, Blean, 109
\nBlean Common,Canterbury, CT2 9JJ, UK
\nReferences
\n1. Declaration of Helsinki 2000 World Medical
\nAssociation
\n2. International Conference on Harmonisation of
\nTechnical Requirements for the Registration
\nof Pharmaceuticals for Human use (ICH) Note
\nfor Guidance on Good Clinical Practice
\n(CPMP\/ICH\/135)
\n3. Koski G Research, Regulations and
\nResponsibility. Emory Law Journal 52 403-
\n416 2003
\n4. Forum for Institutional Review
\nBoards\/Research Ethics Boards in Canada and
\nthe United States October 2003
\n5. Operational Guidelines for Ethics Committees
\nthat review Biomedical Research W.H.O.
\nGeneva 2000 TDR\/PRD\/ETHICS\/2000al
\n6. Chokevival V. A Global Strategy to promote
\nEthical Health Research. Strategic Initiative
\nfor Developing Capacity in Ethical Review.
\nScince and Development Network 2004
\nwww.scidevnet\/ms\/sidcer
\n7.Global Forum for Health Research 10\/90
\nReport 2003-2004 P.O. Box 2100 Geneva
\n8. Carlson, Boyd and Webb Brit J Clin
\nPharmacology 2004 57.6 695)
\n9. Braunschweiger P and Hansen K
\nCollaborative Institutional Training Initiative
\nReport of Developers Meeting April 2006
\ncal (research) practice where they had not
\nalready done so and, particularly, to estab-
\nlish research ethics committees. For some
\nmember states these had, in practice, been
\nin operation for many years, but in others
\nthe ethical review procedure for clinical tri-
\nals was vestigial and, for them, the imple-
\nmentation of this Directive presented a
\nnumber of problems.
\nThe European Forum for Good Clinical
\nPractice (EFGCP) is a not-for-profit organ-
\nisation, based in Brussels, which exists to
\npromote, in its widest sense, and across the
\nboard, uniformly high standards for the
\nconduct of clinical research. It is a confus-
\ning convention that, throughout the clinical
\nresearch community, the word \u2018research\u2019
\nhas been dropped from the phrase \u2018good
\nclinical research practice\u2019, but that is what
\n\u2018good clinical practice\u2019 (GCP) means, cer-
\ntainly in the context of this article.
\nOne of the key features of the strategy of
\nthe European Forum for Good Clinical
\nPractice (EFGCP) has always been to pro-
\nmote European values and principles in
\nethics across the EU member states and in
\ninternational research. The standards
\nagainst which this should be achieved were,
\nby general agreement, set out by the
\nDeclaration of Helsinki of the World
\nMedical Association2
\n, the International
\nConference on Harmonisation (ICH)
\nprocess as it applied to good clinical prac-
\ntice (GCP)3
\nand, as far as Europe is con-
\ncerned, were included within the Clinical
\nTrials Directive1. All these important policy
\ndocuments included reference to the struc-
\nture and function of independent ethics
\ncommittees established to provide the ethi-
\ncal review of all clinical trial protocols.
\nEFGCP operates through conferences,
\nworkshops and working parties and it was
\nthe EFGCP Ethics Working Party that felt
\nthat the advent of the Clinical Trials
\nDirective presented a golden opportunity to
\nascertain exactly how this extremely impor-
\ntant Directive, which was drafted to ensure
\nthat clinical trials throughout Europe were
\nall conducted to the same high standard
\nhaving been subjected to a proper ethical
\nreview, had in practice been interpreted in
\neach of the 25 member states. We felt that
\nA major challenge that exists for each of
\nthe, now 25, member states in the European
\nUnion is how to adopt a Directive whilst
\nstill retaining all the national characteristics
\nwithin the particular field that is to be cov-
\nered by that Directive*. On the other hand,
\nthe adoption of a European Directive can
\nprovide a good opportunity to alter, or even
\nA European Perspective on the Clinical
\nResearch Ethical Review Procedure
\nDr. Frank Wells, Co-chairman of EFGPC Ethics Working Party
\nabandon, national characteristics that have
\nbecome outdated or are inappropriate or
\nirrelevant.
\nOne such Directive, known as the Clinical
\nTrials Directive, was introduced in 2001
\n(20\/2001\/EC)1
\n, which required member
\nstates to adopt the principles of good clini-
\nWMJ_2_59-86.qxd 05.10.2006 14:05 Seite 63
\nMedical Ethics and Human Rights
\n64
\nreporting on the structure and function of
\nresearch ethics committees in every mem-
\nber state was important, given that such a
\nreview had not been conducted previously
\nby anyone else and that nobody seemed to
\nknow what was happening outside their
\nown country in this regard.
\nWe were particularly mindful that one of
\nthe functions of EFGCP is to observe the
\nmethods by which member states fulfil the
\nvarious Directives of the European
\nCommission that affect the conduct of clin-
\nical research to GCP standards. Thus it was
\nin early 2005 that the EFGCP Ethics
\nWorking Party recognised that the ethical
\nreview processes in the various member
\nstates varied widely and that, in the context
\nof multi-national research, it was not easy
\nto be sure that ethical review had been con-
\nsistent across the whole of Europe. The
\nWorking Party even wondered whether the
\ndifferences between operational policies in
\nthe various member states might interfere
\nwith the aims of the Directives.
\nFurthermore, whereas a sponsor could be
\nreasonably confident that it understood the
\nethical review process that operated in the
\nmember states in which it regularly con-
\nducted research, it was sometimes difficult
\nto gain access to the ethical review process
\nin other member states in which it might
\nwish to conduct research in the future.
\nA subgroup of the EFGCP Ethics Working
\nParty was established, specifically to ascer-
\ntain in detail exactly what were the struc-
\ntures and functions of research ethics com-
\nmittees across the 25 member states of the
\nEU. The nine members of the subgroup
\ncame from eight different member states,
\nwhich made it easy for us to share the work
\nthat had to be done. In practice, we
\nacknowledged that Luxembourg relied
\nwholly on Belgian legislation in this regard,
\nand, because much clinical research
\nemanates from, or is conducted within,
\nSwitzerland and Norway, we took a prag-
\nmatic decision to add these two countries to
\nour project.
\nThe differences we discovered were wide-
\nspread. For example, roughly half the mem-
\nber states specify that an application should
\nbe made to an ethics committee by the
\nsponsor, whereas the other half specify that
\nit should be made by the chief investigator.
\nAnother example revealed the different
\nmethods by which a single opinion is
\nobtained for a multi-site application within
\nany given member state: some countries
\ndesignate which committee out of several,
\nwhereas others only have one committee for
\nthe whole country anyway. The most strik-
\ning differences arose in the areas of training
\nfor members of research ethics committees
\nand of quality assurance, assessment and
\naccreditation of such committees.
\nWe were particularly interested in the inde-
\npendence of research ethics committees
\n(RECs). For some time there has been con-
\ncern within the research ethics community
\nthat the equivalent bodies to RECs in the
\nUSA are institutional review boards (IRBs)
\nwhich, by definition, cannot be truly inde-
\npendent as they are based on specific, usu-
\nally academic, institutions. In general, we
\nfound that RECs in Europe are constituted
\nin such a way as to ensure that the indepen-
\ndence of committees and of individual
\nmembers is safeguarded, but there were
\nsome member sates that clearly followed
\nthe institution-based model. However,
\nwhere appropriate safeguards are in place,
\neven institutional review boards can
\ndemonstrate that they operate independent-
\nly; but such safeguards are not always there.
\nIt is therefore important that bodies such as
\nthe WMA and EFGCP strive to ensure that
\nany committee conducting ethical reviews
\nof research projects involving human sub-
\njects is truly independent in its constitution
\nand in its decision-making processes.
\nEFGCP hopes that this report4
\n, which will
\nbe published in January 2007, will be of
\npractical use to sponsors, investigators, reg-
\nulators and those that have responsibility
\nfor setting research ethics committees up
\nand subsequently approving them. The
\nreport could not have been produced with-
\nout the invaluable help and co-operation
\nprovided by the many persons within the
\nmember states who have provided informa-
\ntion that has been gathered together.
\nFinally, the development of the research
\nethical review process in Europe is
\ninevitably in a state of flux. Recent entrants
\ninto the EU have clearly striven to achieve
\nthe requirements of the Directive and of its
\nrecent companion on GCP (2005\/28\/EC)5
\n.
\nNew candidates for EU membership,
\nnotably Bulgaria and Romania, have yet to
\ndemonstrate their adoption of these
\nDirectives but no doubt they will. Even
\nwithin well-established member states we
\nfound that the detail of how ethical review
\nwas actually being conducted was constant-
\nly changing. However, by referring to the
\nrelevant websites for the various countries,
\nreaders will be able to check for themselves
\nthe exact situation pertaining at any given
\ntime. The challenge of safeguarding
\nresearch subjects is a highly responsible one
\nfor research ethics committees throughout
\nthe world. Our awareness of the importance
\nof this challenge should go some way
\ntowards ensuring that the highest possible
\nstandards of clinical research practice are
\nattained.
\nReferences
\n1. European Commission. Clinical Trials
\nDirective (2001\/20\/EC) Brussels, 2001.
\n2. World Medical Association. Declaration of
\nHelsinki. Haughley, 2004
\n3. International Conference on Harmonisation.
\nGood Clinical Practice (E6). IFPMA, Geneva,
\n1996.
\n4. EFGCP. Structure and Function of Research
\nEthics Committees. Intl Jl Pharm Med, 2007
\n(in print).
\n5. European Commission. GCP Directive
\n(2005\/28\/EC) Brussels, 2005.
\n* A Directive is a form of European Legislative
\ninstrument which is binding as to the effect to
\nbe achieved but permits the Member State to
\nchoose the form and method of legislative
\nimplementation.
\nFrank Wells
\nCorrespondence to:
\nOld Hadleigh, London Rd., Capel St.
\nMary, Suffolk IP9 2JJ,U
\nWMJ_2_59-86.qxd 05.10.2006 14:05 Seite 64
\nMedical Ethics and Human Rights
\n65
\ntions and relatively little opportunity for
\ndiscussion. The presentations dealt with
\nthe following aspects of the topic: an
\nupdate onAIDS vaccine research, which is
\nnot very promising; design issues in
\nHIV\/AIDS clinical trials, including stan-
\ndards of care (para. 30 of the Declaration
\nof Helsinki was cited favourably);
\ninformed consent: from theory to practice
\n(it was noted that the practice in China is
\nfar from adequate); risks and benefits to
\nparticipants and communities; meaningful
\nstakeholder consultation and community
\nadvisory boards; and vulnerable groups.
\nThe three other pre-conference workshops
\ndealt with public health ethics and control
\nof emerging contagious diseases, stem-cell
\nresearch, and human enhancement (physi-
\ncal, cognitive, life-extending, etc.).
\nThe opening Plenary session featured the
\nfollowing presentations:
\n\u2022 The British philosopher, Onora O\u2019Neill,
\nspoke on informed consent, the topic of
\nher forthcoming book. She contended that
\nthe requirement that consent be explicit
\nand specific, which is found in the Decla-
\nration of Helsinki and many laws and reg-
\nulations, is impossible to fulfil. Her justifi-
\ncation of consent procedures would see
\nthem not as securing individual autonomy,
\nbut as a way by which research subjects
\ncan waive standard obligations \u2013 such as
\nobligations not to injure, coerce or deceive
\n\u2013 in limited ways in particular circum-
\nstances
\n\u2022 In his response, Dan Wikler of Harvard
\ncriticized her position and pointed out that
\nthe Nuremberg Declaration was developed
\nin the context of the Cold War, when West-
\nerners considered it necessary to promote
\nrespect for the individual over against the
\ncollective. He contended that research
\nabuses have usually been the result of
\nracism, not of the subordination of the
\nindividual to the collective.
\n\u2022 Sang-yong Song of the Korean Academy
\nof Science and Technology gave a detailed
\naccount of the Korean stem cell research
\nscandal involving Hwang Woo-suk,
\nincluding the cultural and commercial fac-
\ntors that prepared the ground for such mis-
\nconduct and the failure of the political
\nauthorities and the media to learn from the
\ndisaster. He noted that there had been ear-
\nly and consistent ethical opposition to
\nHwang Woo-suk\u2019s research in Korea. In
\nhis response, Chingli Hu from Shanghai
\nnoted that there are similar problems in
\nChina but that the Chinese have become
\nmore vigilant.
\n\u2022 Florencia Luna of Argentina spoke about
\nvulnerability, powerlessness and exclusion
\nin research, particularly regarding women.
\nIn discussing the problematic status of
\nreproductive rights in her country, she
\nposed the question, how can bioethics be
\ncontext sensitive when context seems
\ninsensitive? She criticized a recent tenden-
\ncy in bioethics to downplay the concept of
\n\u2018vulnerability\u2019.
\nOther plenary sessions dealt with health
\ncare reform in China, ethical lessons from
\nUnit 731\u2019s human experiments, access to
\nlife-saving drugs, and experiences and
\nlessons in emergent public health issues:
\nfrom SARS to avian flu.
\nMost of the conference timetable was
\ndevoted to 64 concurrent sessions on a wide
\nvariety of topics which, amongst others,
\nincluded the following:
\n\u2022 \u201cMedical professionalism\u201d \u2013 this consist-
\ned of four short presentations on why pro-
\nfessionalism cannot be assessed, profes-
\nsionalism in psychiatry, enhancing profes-
\nsionalism in Taiwan following the SARS
\noutbreak, and fostering patient autonomy.
\n\u2022 \u201cSex ratio at birth imbalance\u201d \u2013 this
\nfocussed on China but included compar-
\nisons with other countries where there is
\nno such imbalance, the question being
\nwhether the ethics of pre-natal sex selec-
\ntion are universal or country-specific.
\n\u2022 \u201cEthical issues in pandemic avian influen-
\nza\u201d \u2013 this included presentations on Chi-
\nThis biennial conference of the Internatio-
\nnal Association of Bioethics attracted
\napproximately 600 participants, including
\nover 200 Chinese scholars and students. It
\nwas held concurrently with the 6th
\nInterna-
\ntional Congress on Feminist Approaches to
\nBioethics and consisted of two days of pre-
\nconference workshops and four days of ple-
\nnary and simultaneous sessions.
\nThere were five preconference
\nworkshops of which I was
\nable to attend two which were
\nall day sessions:
\n\u201cBioethics and Human Rights: Working
\nTogether for Global Health\u201d \u2013 this was
\norganized by three Harvard University
\nunits. Their premise was that there has been
\nrelatively little communication or other
\ninteraction between these two academic and
\norganizational fields and that this should be
\nchanged. The main presenter, Steven Marks,
\na human rights specialist at Harvard and
\neditor of a recent book, Health and Human
\nRights: Basic International Documents
\n(which includes 6 WMA statements). He
\ndescribed in some detail the similarities and
\ndifferences between bioethics and human
\nrights: both cover many of the same issues
\nbut human rights tends to be more general
\nwhile bioethics deals with specific details of
\nthe implementation of rights. Both combine
\naspirations and current realities. The rest of
\nthe workshop was devoted to a free-ranging
\ndiscussion of the topic from many points of
\nview and ended with reactions to a proposed
\nHarvard graduate programme on bioethics
\nand human rights.
\n\u2022 \u201cEthical Issues in AIDS Vaccine
\nResearch\u201d \u2013 This was a tightly structured
\nsession with numerous formal presenta-
\nConference Report
\n8th
\nWorld Congress of Bioethics,
\n4-9 August 2006, Beijing, China
\nJohn R. Williams, Ph. D, Head of Ethics Department, WMA
\nWMJ_2_59-86.qxd 05.10.2006 14:05 Seite 65
\nDiscussion Paper
\n66
\nna\u2019s planning, the WHO\u2019s project, and dif-
\nferent scenarios for distributing scarce
\nresources such as Tamiflu. Dan Wikler
\nmade an interesting observation that dur-
\ning the 1918-19 influenza pandemic, the
\nannual number of deaths from TB in the
\nU.S.A. decreased by almost the same
\namount as the increase in deaths from the
\n\u2018flu.
\n\u2022 \u201cEthical Lessons from Unit 731\u2019s Human
\nExperiments\u201d \u2013 Takashi Tsuchiya from
\nOsaka gave a detailed account of the
\nJapanese biological weapons programme
\nin Manchuria and elsewhere. He noted that
\nfollowing W.W. II the U.S. did not investi-
\ngate medical crimes of the Japanese but
\nsought the data to use against the U.S.S.R.
\nThe Soviets did conduct some trials but
\nboth the Japanese and the Americans cov-
\nered up the atrocities. The first Japanese
\nexpos\u00e9 was in 1981 but only in the 1990s
\ndid the crimes become known outside
\nJapan. The Japanese medical profession
\nconsiders the subject taboo.
\n\u2022 Another session on \u201cProfessionalism in
\nMedicine\u201d was chaired by David Rothman
\nof Columbia University. He dealt with the
\ncurrent challenges to professionalism,
\nincluding conflicts of interest, weak self-
\nregulation, medical errors, lack of civic
\nengagement, patient use of the Internet
\nand overwork. There were two presenta-
\ntions of surveys of American physicians\u2019
\nattitudes towards professional and ethical
\nissues and one on professionalism among
\nChinese physicians.
\n\u2022 \u201cFrom SARS to Avian Flu in China\u201d \u2013 a
\npresentation by Guang Zeng, Chief Epi-
\ndemiologist, Center for Disease Preven-
\ntion and Control. SARS caused Chinese
\npoliticians to become concerned with pub-
\nlic health for the first time and to begin to
\novercome the tradition of secrecy and cov-
\ner-up with regard to health-related prob-
\nlems. There is a better surveillance and
\nreporting system now, although decentral-
\nization poses obstacles.
\n\u2022 \u201cBioethics Without Borders\u201d \u2013 this con-
\nsisted of presentations on the ethics activi-
\nties of the WMA, WHO, UNESCO and
\nthe European Commission.
\nSeveral other concurrent sessions focussed
\non China, including a Germany-China
\nForum on ethical and legal issues in end-of-
\nlife care, emerging health and environmen-
\ntal issues facing China, a France-China
\nForum on stem cell research, a Japan-China
\nForum on \u201cIs human dignity or human right
\nprinciple sustainable for a future Asian soci-
\nety?\u201d, ethical issues in new rural coopera-
\ntive medical care programs of Mainland
\nChina, and Confucianism and bioethics.
\nNone of the presentation abstracts men-
\ntioned the retrieval of organs from executed
\nprisoners for transplantation although three
\nof them discussed the sale of organs and
\ncompensation of donors.
\nThe next World Congress of Bioethics will
\ntake place in Croatia in 2008.
\n(Clearly the selfcare aspect of healthcare,
\nboth in the context of self management of
\nminor illness and the selfcare aspect of col-
\nlaborative care by the affected individual in
\npartnership with caring health profession-
\nals such as doctors and nurses etc., is
\nimportant to both patient and health profes-
\nsionals. The following discussion paper is
\nparticularly timely also in the context of the
\nglobal shortage of healthcare professionals,
\nwhich is currently the focus of WHO\u2019s
\ndecade of action. Comments on this will be
\nwelcomed in these columns \u2013 edit)
\nThis discussion paper is the first product of
\na project that has been initiated by represen-
\ntatives of the World Medical Association
\n(WMA) and the World Self-Medication
\nIndustry (WSMI), although it does not nec-
\nessarily reflect the official policy of either
\norganization. Its goal is to identify the
\npotential impacts and implications for
\nphysicians of the increasing prevalence of
\nself care. Following on from this, there will
\nbe an opportunity to consider \u2018tools\u2019 by
\nwhich physicians may be better equipped to
\nsupport and deal with patient self care.
\nThe discussion paper is structured as fol-
\nlows:
\n\u2022 Introduction \u2013 purpose, scope, defini-
\ntions;
\n\u2022 Section 1 \u2013 Current trends regarding self
\ncare (social, economic, technological,
\netc.);
\n\u2022 Section 2 \u2013 Implications for physicians;
\n\u2022 Conclusion;
\n\u2022 Select bibliography.
\nIntroduction
\nThe topic of this project is very broad.
\nMoreover, there has been relatively little
\nattention paid to it by health professionals,
\npolicy makers, academics and industry.
\nAlthough it would benefit from a well-fund-
\ned, large-scale study, the scope of this pro-
\nject is much more modest. It will review
\nsome of the recent developments on the
\nsubject of self care and identify the major
\nfactors that are likely to have an impact on
\nphysicians. The general approach of the
\nproject is deliberately towards a broader,
\nover-arching view that will be useful in
\nguiding future activities, rather than an
\nexpert focused study.
\nThe basic methodology of the project will
\nbe to pull together and synthesise available
\ninformation rather than undertake original
\nresearch. Since it is likely that \u2018gaps\u2019 in
\nFROM PATIENT TO SELF CARER:
\nA Discussion Paper on the Future of Self Care
\nand its Implications for Physicians
\nDavid E. Webber Ph.D., General Secretaery Self Medication
\nIndustry. John R. Williams Ph.D., Head of Ethics Department,
\nWorld Medical Association
\nWMJ_2_59-86.qxd 05.10.2006 14:05 Seite 66
\nDiscussion Paper
\n67
\nknowledge will be identified that will lead
\nto the possibility of commissioning
\nresearch; such opportunities will be consid-
\nered as they arise.
\nThe following working definitions of key
\nterms are proposed for the purposes of the
\nproject:
\nHealth \u2013 An indicator of physical, mental,
\nemotional and\/or spiritual well-being, char-
\nacterized in part by an absence of illness (a
\nsubjective experience) and disease (a patho-
\nlogical abnormality) that enable one to pur-
\nsue major life goals and to function in per-
\nsonal, social and work contexts.
\nWellness \u2013 Another term for health that
\nemphasizes measures, such as a healthy
\ndiet, exercise and self-care decisions, that
\npromote health and prevent illness. This
\nincludes reducing the risk of chronic dis-
\nease, preventing injuries, banishing envi-
\nronmental and safety hazards from home
\nand workplace, and eliminating unneces-
\nsary trips to the hospital.
\nHealth care \u2013 Any activity that has as its
\nprimary objective the improvement, main-
\ntenance or support of physical, mental,
\nemotional and spiritual well-being, as char-
\nacterized by the absence of illness and dis-
\nease.
\nSelf care \u2013 The care taken by individuals
\ntowards their own health and well being,
\nincluding the care extended to their family
\nmembers and others.
\nIn practice self care includes the actions
\npeople take to stay fit and maintain good
\nphysical and mental health; meet social and
\npsychological needs; prevent illness or acci-
\ndents; avoid unnecessary risks; care and self
\nmedicate for minor ailments and long-term
\nconditions; and maintain health and well
\nbeing after an acute illness or discharge
\nfrom hospital.
\nPatient \u2013 The traditional term for a person
\nreceiving health care. Although the term has
\nevolved away from the passivity that is its
\nroot meaning towards a more active role for
\nthe person in decisions concerning his or
\nher health care, it probably does not fully
\nexpress the emphasis on self care that is the
\nfocus of this report.
\nThe future \u2013 The horizon for this report is
\n3-10 years. Further than that it becomes
\nextremely difficult to predict and plan,
\ngiven the rapid pace of technological and
\nsocial change.
\nSection 1 \u2013 Current trends
\nregarding self care
\n\u2022 What is self care?
\nSelf care is the care taken by individuals
\ntowards their own health and well being,
\nincluding the care extended to their family
\nmembers and others.
\nIn practice, self care includes the actions
\npeople take to stay fit and maintain good
\nphysical and mental health; meet social and
\npsychological needs; prevent illness or acci-
\ndents; avoid unnecessary risks; care and self
\nmedicate for minor ailments and long-term
\nconditions; and maintain health and well
\nbeing after an acute illness or discharge
\nfrom hospital.
\nThis is a substantial and broad set of activi-
\nties that may be further detailed; today\u2019s
\nunderstanding of self care involves:
\n\u2022 Healthy choices that encourage the
\nmaintenance of health and the preven-
\ntion of illness, including good nutrition
\nand appropriate levels of physical activi-
\nty;
\n\u2022 Avoidance of risk factors such as unsafe
\nsex, tobacco smoking and environmental
\nhazards;
\n\u2022 Self recognition of symptoms, screening
\nand assessing these in partnership with a
\nhealthcare professional, when necessary;
\n\u2022 Self management that includes being
\nable to handle the symptoms of disease
\neither alone or in partnership with
\nhealthcare professionals or other people
\nwith the same condition;
\n\u2022 Self treatment involving responsible use
\nof medication, both OTC and prescrip-
\ntion (but specifically excluding ‘self pre-
\nscription’).
\nIn practice, the definition and understand-
\ning of self care have evolved significantly
\nover the last 25 years and are likely to
\nevolve still further. An early narrow defini-
\ntion of self care was simply the lay behav-
\nioural response to illness, in contrast to pro-
\nfessional care (Dean 1989). Until 1980 self
\ncare and self medication were not high pri-
\nority issues in country health policies or for
\nthe World Health Organisation (WHO)
\n(Levin 1990). During the early 1980s self
\ncare was conceptualised as a part of
\nlifestyle, with WHO being the initial cata-
\nlyst for this perspective. By 1990 self care
\nwas already being identified as one of the
\nmegatrends in the health care sector
\n(Bezold 1990). Self care started to be seen
\nmore broadly as actions that people do to
\nimprove their health and well-being within
\nthe context of everyday life. Thus in 1998
\nWHO stated:
\nSelf care is what people do for themselves to
\nestablish and maintain health, prevent and
\ndeal with illness. It is a broad concept
\nencompassing hygiene (general and per-
\nsonal), nutrition (type and quality of food
\neaten), lifestyle (sporting activities, leisure
\netc), environmental factors (living condi-
\ntions, social habits etc), socioeconomic fac-
\ntors (income level, cultural beliefs etc) and
\nself-medication. (WHO 1998)
\nMore recently this definition has been
\nexpanded to include a focus on risk factors
\nand risk factor avoidance (WHO 2002) and
\na more explicit and better defined expres-
\nsion of the role of physical activity (beyond
\n\u2018sporting activity, leisure, etc.\u2019) in maintain-
\ning health.
\nAnother important understanding today is
\nthat self care may be exercised alone (e.g.
\ntreating a mild headache) or in collabora-
\ntion with professional care. In other words,
\nself care presents an important opportunity
\nfor the healthcare professional in a support-
\ning role, guiding and advising the self care
\nmanager. For the present discussion this
\nrole (sometimes called \u2018collaborative care\u2019)
\nshould be underlined: self care should not
\nmean absence of healthcare professional
\ninvolvement.
\nOf course, seeking professional care can
\nalso be the result of a self-determined self
\ncare decision-making process. In effect the
\nrole of the patient in symptom recognition
\nand even minor ailment diagnosis is also
\nexpanding. In future, self care may more
\nWMJ_2_59-86.qxd 05.10.2006 14:05 Seite 67
\nDiscussion Paper
\n68
\nexplicitly involve family and friends, as
\nwell as community-level activities.
\n\u2022 The self care continuum
\nThe fact that the majority of symptoms and
\ncomplaints are treated by self care has been
\ndescribed as an \u201ciceberg\u201d (Verbrugge &
\nAscione 1987). The small part of the ice-
\nberg that is above the water represents the
\ncases seen by health professionals and the
\nlarge unseen part under the water represents
\ncases treated via different self care prac-
\ntices. Overall, an estimated 70% to 95% of
\nall illnesses are managed without the inter-
\nvention of a physician (Dean 1981, Coons
\n& McGhan 1988, Segal & Goldstein 1989,
\nVulcovic & Nichter 1997).
\nIn terms of episodes and hours, most health
\ncare in daily life is self-evidently self care.
\nIf, for illustrative purposes, a person has 3
\nhours contact with a healthcare profession-
\nal each year, they in reality undertake self
\ncare for the remaining 8757 hours of the
\nyear. They do this by using the advice given
\nby professionals during the 3 hours contact,
\nor by using knowledge and skills gained
\nfrom a variety of sources. There are many
\nopportunities to improve on this self care,
\nand physicians can play a leading role in
\nsupporting and encouraging more appropri-
\nate self care across the whole spectrum of
\ncare, to the advantage of healthcare profes-
\nsionals and particularly to people them-
\nselves.
\nAn alternative visualisation is of health care
\non a continuum (see Fig. 1) ranging from
\n100% self care (e.g. brushing teeth regular-
\nly) to 100% professional care (e.g. neuro-
\nsurgery). In between these two extremes is
\nshared care where individuals or families
\npartner with practitioners in the care of the
\nindividual; practitioners include physicians,
\nnurses, allied health professionals, social
\nworkers and pharmacists. This is a more
\nuseful image than the iceberg since it shows
\nthat supporting self care has always been
\npart of good practice, especially for allied
\nhealth professionals, nurses and pharma-
\ncists. Further, it shows that the dividing
\nlines between self care, collaborative care
\nand professional care are not necessarily
\nfixed, but can depend on a variety of indi-
\nvidual and social factors.
\n\u2022 The (re)-emergence of self care
\nAt a simplistic level it is a fact that through-
\nout most of human history, self care was the
\nnorm and the only available form of health
\ncare for the majority of the population. With
\nthe industrialisation of societies and the
\nincrease in knowledge and specialisation of
\nthe last 300 years has come the develop-
\nment of \u2013 and wider access to \u2013 medical
\nprofessional help. But fundamentally, self
\ncare is not a new invention so much as the
\nprevious norm.
\nToday self care is being positively driven by
\na number of powerful forces and trends.
\nThese include the following:
\n\u2022 Many developing countries are starting
\nto experience the disease transitions that
\ncome with improved economic perfor-
\nmance. This includes a shift away from
\ncommunicable diseases such as TB and
\nmalaria to non-communicable diseases.
\nToday’s reality is that, globally, the
\ngreatest causes of avoidable death in the
\nworld are not HIV\/AIDS or TB but car-
\ndiovascular disease, cancer and respira-
\ntory diseases. If disease burden is con-
\nsidered, neuropsychiatric disorders and
\ninjuries should be added to this list.
\n(World Health Report 2005). The epi-
\ndemiological shift in disease patterns
\nfrom acute to chronic morbidity results
\nin the need to move from \u2018curative\u2019 to
\n\u2018chronic\u2019 care. Self care is particularly
\nimportant for patients living with chron-
\nic diseases and the term \u2018self manage-
\nment\u2019 is sometimes used here.
\n\u2022 Improved scientific and medical under-
\nstanding of the causes of health and ill-
\nness shows where self care can most
\nappropriately be deployed (WHO 2002).
\nIncreased knowledge about the effects of
\nlifestyles on health is playing a part. As
\nexpressed by one set of authors: \u201cIt is
\nestimated that by 2020 two-thirds of the
\nglobal burden of disease will be attribut-
\nable to chronic non-communicable dis-
\neases, most of them strongly associated
\nwith diet. The nutrition transition
\ntowards refined foods, foods of animal
\norigin and increased fats plays a major
\nrole in the current global epidemics of
\nobesity, diabetes and cardiovascular dis-
\neases, among other non-communicable
\nconditions. Sedentary lifestyles and the
\nuse of tobacco are also significant risk
\nfactors\u201d (Chopra et al 2002).
\n\u2022 Putting this another way, increasingly
\nthe fundamental causes of disease are
\nbeing understood and it is seen that
\nmany represent a failure of prevention
\nrather than an inevitability of life.
\nFigure 1. The healthcare continuum
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 68
\nDiscussion Paper
\n69
\nAlthough controversial, there is now a
\ngood body of evidence to show that per-
\nsons with better health habits survive
\nlonger, and in such persons, disability is
\npostponed and compressed into fewer
\nyears at the end of life (Vita et al 1998).
\nWith ageing populations this has sub-
\nstantial implications on the design of
\nhealth care systems of the future, and for
\nthe self care sector. A new balance
\nbetween disease prevention + wellness
\nmanagement vs. downstream disease
\ntreatment needs to be struck.
\n\u2022 Society is ever-changing. People around
\nthe world are better educated and want
\nmore information, choice and control
\nover their lives and this is no different
\nfor health. The public\u2019s attitude to look-
\ning after their own health is beginning to
\nchange. There is a shift towards indepen-
\ndence and a range of personalised
\noptions for provider agencies. Surveys in
\nmany countries consistently indicate that
\nmany patients and the public have the
\nincreasing sense that health, and health-
\ncare in general, is something with rights
\nattached to it and want more support for
\nself care.
\n\u2022 There is an increasing amount of infor-
\nmation available to people on all aspects
\nof self care and self medication, in print-
\ned form in books and articles, and
\nthrough the Internet. Some of this is of
\nhigh quality; some of lesser quality.
\n\u2022 As part of the consumer movement,
\ngroups representing patients have
\nbecome more prominent in recent years.
\nFor example, the International Alliance
\nof Patient’s Organisations (IAPO) has
\nbeen formed and has expanded rapidly.
\nIAPO has produced a \u2018Declaration on
\nPatient-Centred Healthcare\u2019 that
\nincludes patient information and
\ninvolvement in health policy as key prin-
\nciples (IAPO 2006). Patient-focused
\norganisations such as the Picker Institute
\nare publishing studies on topics such as
\n\u2018patient-centred medical professional-
\nism\u2019 (Askham & Chisholm 2006).
\n\u2022 Economic constraints, always a major
\nconsideration in much of the world, are
\nincreasingly a key factor in the most
\ndeveloped countries as the cost of tech-
\nnologies (medicines and other high-tech
\ninterventions) continues to rise.
\nGovernments and payers are looking
\nafresh at all means of containing health
\ncare costs. Encouraging people to take
\nmore responsibility for their own health
\nthrough self care is seen as an important
\npotential opportunity to achieve a double
\neffect of better health at lower cost.
\nIn summary, a complex mix of drivers has
\ncombined to give impetus to the movement
\nfor self care. At the same time, there are
\nsubstantial hurdles or barriers to be over-
\ncome before self care can make its full con-
\ntribution to human health.
\n\u2022 The case for encouraging self care
\nThe potential opportunity in self care is well
\nexpressed in the UK Department of Health’s
\npublication: \u201cSelf Care \u2013 A Real Choice\u201d
\n(2005):
\nResearch shows that supporting self care
\ncan improve health outcomes, increase
\npatient satisfaction and help in deploying
\nthe biggest collaborative resource available
\nto the NHS [National Health Service] and
\nsocial care \u2013 patients and the public.
\nHelping people self care represents an
\nexciting opportunity and challenge for the
\nNHS and social care services to empower
\npatients to take more control over their
\nlives.
\nMany individual peer-reviewed studies
\nhave shown that there are a variety of
\npotential benefits that can be achieved by
\nencouraging self care. Some examples are
\nas follows:
\n\u2022 Reduction in general practitioner consul-
\ntations. Professors Blenkinsopp and
\nNoyce from Keele and Manchester
\nUniversities in the UK collected data on
\nGP consultations for 12 ailments: consti-
\npation, cough, diarrhoea, dyspepsia, ear-
\nache, hay fever, headache, head lice,
\nnasal symptoms, sore throat, temperature
\nand vaginal thrush. The proportion of GP
\nconsultations for these ailments was
\n8.9% representing about 11 consulta-
\ntions per GP per week. Almost 40% of
\nconsultations for these ailments were
\ntransferred to pharmacy management,
\nwith the implication that future recur-
\nrence could be similarly managed with-
\nout the need for further consultation
\n(Blenkinsopp & Noyce 2002).
\n\u2022 Dr. Martin Lipsky of Northwestern
\nUniversity Medical School in Chicago
\nand colleagues showed in a study that
\navailability of over-the-counter clotrima-
\nzole for the treatment of candidal vagini-
\ntis led to a 15% decline in the number of
\nvaginitis visits. The decrease in physi-
\ncian visits resulted in approximately $45
\nmillion in direct cost savings and anoth-
\ner $18.75 million in indirect savings by
\nreducing time lost from work (Lipsky et
\nal 2000).
\n\u2022 In Canada, a study by Mullet showed
\nthat people\u2019s intent to use emergency
\nservices decreased from 30.5% to 13.4%
\nafter advice from a health support line.
\nCompliance with self care advice was
\n84%. Some patients still visited doctors
\nfor reassurance that they had done the
\nright thing but self-reported doctor visits
\nwere reduced (Mullet 2000).
\n\u2022 In Shanghai China, Fu et al. evaluated
\nthe effectiveness of a chronic disease
\nself-management programme in the form
\nof a lay-lead teaching course and guide-
\nbook. The study found that, compared
\nwith controls, patients who received this
\nhad significant improvement in amount
\nof exercise undertaken, cognitive symp-
\ntom management, self-efficacy in symp-
\ntom management, and self-efficacy in
\ndisease management (Fu et al. 2003).
\n\u2022 In the UK, emergency hormonal contra-
\nception (EHC) became available over
\nthe counter from pharmacies in 2001 for
\nwomen aged 16 and over. This change
\nwas welcomed by emergency physicians
\nand there were anecdotal reports of
\nfewer requests for EHC at accident and
\nemergency departments. Kerins et al
\n(2004) undertook a study to see if these
\nanecdotal reports were true, reviewing
\npatient records from two emergency
\ndepartments. They showed a 52% reduc-
\ntion in the number of women attending
\nfor EHC between 2000 and 2001.
\n\u2022 In a project commencing in 1995,
\nHealthwise, a US based non-profit orga-
\nnization, initiated the Healthwise
\nCommunities Project: distributing
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\nDiscussion Paper
\n70
\n143,000 copies of a handbook on 180
\ncommon ailments and how to care for
\nthem, plus a telephone nurse advice
\nhelpline. Three years after the pro-
\ngramme launch, an estimated $7.5 to
\n21.5 million was saved in unnecessary
\nhealth care costs. More recently a similar
\ninitiative reported a reduction in unnec-
\nessary visits to the doctor of 23% and of
\n15% in unnecessary visits to emergency
\nroom services, and 16% of employees
\nsaving a sick day from work (see
\nhttp:\/\/www.healthwise.org\/a_communi-
\nties.aspx).
\n\u2022 A workplace health education pro-
\ngramme aimed at reducing unnecessary
\noutpatient visits was designed by Lorig
\net al. A total of 5,200 employees attend-
\ned a presentation, received self-help
\nbooks, and completed self-administered
\nquestionnaires. The study found that a
\nminimal cost, self-care workplace inter-
\nvention can reduce outpatient visits by
\nimportant magnitudes \u2013 up to 17% or 2.0
\nvisits per household per year (Lorig et al
\n1985).
\nBased on these and other studies the poten-
\ntial benefits may be summarised as:
\n\u2022 Reducing time spent in seeing a general
\npractice physician for minor or trivial
\nailments, giving physicians more time
\nfor more important cases.
\n\u2022 Reduction in the number of unnecessary
\nvisits to accident and emergency depart-
\nments, again saving the time of these
\nhard-pressed services.
\n\u2022 Increased motivation for patients and for
\nhealthy people in maintaining or improv-
\ning their well being.
\nIt is important to emphasise that none of
\nthese examples excludes healthcare profes-
\nsionals; indeed their full involvement helps
\nensure the success of self care schemes. An
\nimportant point must, however, be made. In
\nmany poor countries the reality is of oblig-
\natory self care due to the absence of basic
\nhealthcare facilities. Obligatory self care is
\nprevalent in the least developed countries
\nand can be most unfortunate when it is a
\nforced substitute for essential medical inter-
\nventions. On the other hand, in many devel-
\noped countries, the reverse is true \u2013 insuffi-
\ncient self care and over-dependency on the
\nhealth care system gives a major opportuni-
\nty to encourage self care in these countries.
\nIn both situations there are significant ques-
\ntions about the appropriate levels of self
\ncare for a country, given the particular cir-
\ncumstances, and around approaches for
\nintegrating self care into the mainstream
\nhealth care systems.
\nSection 2 \u2013 Implications for
\nphysicians
\nEvery person has the right to health educa-
\ntion that will assist him\/her in making
\ninformed choices about personal health and
\nabout the available health services. The
\neducation should include information about
\nhealthy lifestyles and about methods of pre-
\nvention and early detection of illnesses. The
\npersonal responsibility of everybody for
\nhis\/her own health should be stressed.
\nPhysicians have an obligation to partici-
\npate actively in educational efforts (WMA
\nDeclaration of Lisbon on the Rights of the
\nPatient).
\nAs described above, self care is already
\nwidely practised in many parts of the world
\nand this is likely to increase.
\nPhysicians and medical associations may be
\nsceptical of some of the claims of self care
\nadvocates, especially regarding the finan-
\ncial savings that can result from the expan-
\nsion of self care (e.g., the reduction in hos-
\npital admissions). For one thing, these
\nadvocates may underestimate the role of
\nuncertainty in symptom analysis, especially
\nwhen the analysis is performed by someone
\nwith no medical training. It is often only
\nafter an examination by a physician that it is
\nevident that the patient’s condition is self-
\nlimiting and can be dealt with by self care.
\nConversely, attempts to provide self care
\nfor some conditions can result in serious,
\nand costly, complications because a physi-
\ncian was not consulted in time.
\nNevertheless, physicians and medical asso-
\nciations should welcome the self care
\nmovement. There are both ethical and prac-
\ntical reasons for this:
\n\u2022 Physician support of appropriate self
\ncare is in keeping with the shift to shared
\ndecision making in the patient-physician
\nrelationship that has been occurring in
\nmany parts of the world during the past
\nhalf-century. This shift is reflected in the
\npolicy statements of the World Medical
\nAssociation. For example, the
\nDeclaration of Lisbon on the Rights of
\nthe Patient states, \u201cThe patient has the
\nright to self-determination, to make free
\ndecisions regarding himself\/herself. The
\nphysician will inform the patient of the
\nconsequences of his\/her decisions.\u201d
\n\u2022 Although self care deprives physicians
\nof certain functions that they are accus-
\ntomed to perform, it also frees them from
\nroutine, relatively unskilled, tasks and
\nallows them to focus on more interesting
\nand challenging ones. This is especially
\nappropriate in areas where there is a
\nshortage of physicians.
\nPhysician involvement in self care is noth-
\ning new. They have always encouraged
\npatients to adopt practices that are con-
\nducive to good health, e.g., a balanced diet,
\nmoderate exercise and, more recently, absti-
\nnence from tobacco, and most of the med-
\nications prescribed by physicians are
\nadministered by the patients themselves or
\ntheir family members. The current self care
\nmovement requires an evolution, rather
\nthan a revolution, in the role of the physi-
\ncian. The principal elements of this evolv-
\ning role are the following:
\n\u2022 Learning about self care \u2013 Just as physi-
\ncians have to maintain their clinical
\nknowledge and skills, so also do they
\nneed to be aware of developments in
\npatient expectations and requirements
\nfor self care, as well as the resources
\navailable for this purpose. Whereas at
\none time physicians had a virtual
\nmonopoly on medical knowledge, now
\nthere are many other sources \u2013 the
\nInternet, the media (articles and adver-
\ntisements), WHO, governments, patient
\norganizations, pharmacies, health food
\nstores, etc. Much valuable information is
\navailable from these sources, but there is
\na great deal of misinformation as well.
\nPhysicians need to have some familiari-
\nty with these sources in order to direct
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 70
\nDiscussion Paper
\n71
\npatients towards those that are reputable
\nand away from the others.
\n\u2022 Listening to patients \u2013 Patients differ
\ngreatly in their understanding of and
\ncapacity for self care. Some will ask for
\na physician’s help in learning how to care
\nfor themselves while others will expect
\nthe physician to take care of them. Only
\nby careful questioning and listening to
\ntheir answers can the physician know the
\nextent to which they are able to exercise
\nself care.
\n\u2022 Encouraging and teaching patients how
\nto care for themselves and when to seek
\nexpert advice \u2013 Self care is vastly more
\ncomplex than it was a few decades ago
\nwhen its main form was taking medica-
\ntion as prescribed by a physician.
\nNowadays there are multiple regimes of
\npharmaceutical products, medical
\ndevices, monitors and exercises avail-
\nable for a great variety of conditions,
\nboth acute and chronic. The choice of the
\nmost appropriate regime for a particular
\npatient and instruction for its use can be
\na significant task for a physician, espe-
\ncially when there are intellectual, lin-
\nguistic or cultural barriers. Self-medica-
\ntion is an important aspect of self care.
\nThe World Medical Association
\nStatement on Self-Medication (www.
\nwma.net\/e\/policy\/s7.htm) provides guid-
\nance to physicians and patients on the
\nfollowing topics: the distinction between
\nprescription and non-prescription med-
\nication and potential interactions
\nbetween the two; the roles and responsi-
\nbilities of patients, physicians, drug
\nmanufacturers, pharmacists and govern-
\nments; and the promotion and marketing
\nof self-medication products.
\n\u2022 Monitoring patient self care \u2013 In order to
\nprovide optimal care, physicians need to
\nknow what self care measures, such as
\nnon-prescription medication and health
\nfoods, are being used by the patient. If
\nthey are inappropriate, the physician
\nshould so inform the patient.
\n\u2022 Developing and maintaining skill in
\nmotivating behaviour change in patients
\n\u2013 Many self care measures, for example,
\nsmoking cessation and dieting, require
\nsignificant will power on the part of
\npatients to overcome long-established
\nhabits or addictions. There is a large
\nbody of evidence-based literature on
\nhow physicians can best assist such
\nbehaviour changes (www.tcsg.org\/tobac-
\nco\/cessation\/biblio\/medical_01.pdf), and
\nfamiliarity with this literature is an
\nimportant step in developing the skill
\nrequired to help patients with this aspect
\nof self care. Also important for patient
\nmotivation is physician role modelling
\nof healthy behaviour.
\n\u2022 Collaborating with other health profes-
\nsionals (nurses, pharmacists, social
\nworkers, etc.) \u2013 Just as self care requires
\ncollaboration between patients and
\nphysicians, so too are other health pro-
\nfessionals involved. For various reasons,
\npatients receive more education in self
\ncare from these others than they do from
\nphysicians, but physicians need to know
\nwhat patients are being told and whether
\nthey are following the advice they
\nreceive from these sources. Ideally self
\ncare will be part of collaborative care
\ninvolving good communication among
\nall those who deal with the patient.
\nFor self care to enter the mainstream of
\nmedical practice, certain system changes
\nare required:
\n\u2022 As noted above, education and advice
\nregarding self care can be very time con-
\nsuming, and many physician remunera-
\ntion plans do not provide adequate com-
\npensation for this work, even though it
\ncan provide significant cost savings to
\nhealth care systems. Medical associa-
\ntions should develop evidence-based
\narguments to convince the appropriate
\nfunding authorities to correct this imbal-
\nance.
\n\u2022 Medical school curricula need to prepare
\nfuture physicians to deal with self care,
\nwhich will include instruction in the
\nknowledge and skills listed above.
\nContinuing medical education pro-
\ngrammes on this subject should also be
\ndeveloped.
\n\u2022 Medical associations should collaborate
\nwith patient self help and support groups
\nto develop programs and resources that
\npromote a proper balance between self
\ncare and professional care.
\nConclusion
\nAs stated at the beginning of this document,
\nits purpose is to identify the potential
\nimpacts and implications for physicians of
\nthe increasing prevalence of self care. The
\nWMA and WSMI welcome comments on
\nthis paper, including suggestions for next
\nsteps. Please send your comments by email
\nto Dr. David Webber, Director-General,
\nWSMI, dwebber@wsmi.org and Dr. John
\nWilliams, Director of Ethics, WMA,
\nwilliams@wma.net.
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\nological issues in self-care research. Soc Sci Med
\n29 1989 117-23.
\nElo J, Myllykangas M. Perceived symptoms and
\naction taking. J. Soc Med 23 1986 28-38.
\nFu, D, Fu, H, P McGowan, Shen Y et al.
\nImplementation and quantitative evaluation of
\nchronic disease self-management programme in
\nshanghai, China: randomized controlled trial.
\nBulletin of the World Health Organisation 81
\n2003 174-182.
\nHealth Canada: Supporting Self-Care: The
\nContribution of Nurses and Physicians — An
\nExploratory Study, 1997 (www.hc-
\nsc.gc.ca\/hppb\/healthcare\/pubs\/selfcare\/index.ht
\nml)
\nHealth Canada: Supporting Self-Care:
\nPerspectives of Nurses and Physician Educators,
\n1997 (www.hc-sc.gc.ca\/hppb\/
\nhealthcare\/pubs\/selfcare98\/maintoc.htm)
\nHedvall M-B. Towards a research programme for
\nself-medication. J Soc Adm Pharm 7 1990 156-
\n63.
\nInternational Alliance of Patients’ Organizations
\n(IAPO). Declaration on Patient-Centred
\nHealthcare, 2006. (http:\/\/www.patientsorganiza-
\ntions.org\/showarticle.pl?id=697)
\nKerins M, Maguire E, Fahey DK, Glucksman A.
\nEmergency contraception. Has over the counter
\navailability reduced attendance at emergency
\ndepartments? Emerg J Med 21 2004 67-68.
\nLenker S, Lorig K, Gallager D. Reasons for the
\nlack of association between changes in health
\nbehaviour and improved health status: An
\nexplanatory study. Patient Education and
\nCounseling 6 1984 69-72.
\nLevin L.S. Reorienting perspectives on self-med-
\nication. J. Soc Adm Pharm 7 1990 164-9
\nLipsky M.S., T. Waters, L.K. Sharp. Impact of
\nVaginal Antifungal Products on Utilization of
\nHealth Care Services: Evidence from Physician
\nVisits. J. Am. Board Fam. Pract. 13 2000 178-
\n182.
\nLorig, KR, Kraines, RG, Brown BW, Richardson
\nN. A Workplace Health Education Program That
\nReduces Outpatient Visits. Med Care 23 1985
\n1044-1054.
\nLorig KR, Holman, HR. Self-Management
\nEducation: History, Definition, Outcomes, and
\nMechanisms. Ann Behav Med 26 2003 1-7.
\nMullet, J. Partnerships for Better Health: a self
\ncare pilot project. British Columbia. Ministry of
\nHealth. ISBN 0-7726-4258-3. Available on
\nhttp:\/\/www.health.gov.bc.ca\/cpa\/publications\/ev
\nalfin.pdf.
\nPolgar S. Evolution and the ills of mankind. In
\nHorizons of Anthropology, Sol Tax, ed. Chicago:
\nAldine, 1964.
\nSchleidt M et al. Chem. Senses 13 1988 279-93.
\nSegall A, Goldstein J. Exploring the correlates of
\nself-provided health care behaviour. Soc Sci Med
\n29 1989 153-61.
\nSihvo, S. Utilization and appropriateness of self-
\nmedication in Finland. Academic Dissertation,
\nUniversity of Helsinki, Medical Faculty,
\nDepartment of Public Health and National
\nResearch and Development Centre for Welfare
\nand Health, Health and Social Services, Helsinki
\n2000.
\nUK Department of Health. Self Care – A Real
\nChoice http:\/\/www.dh.gov.uk\/SelfCare (January
\n2005)
\nUlrich, RS Science 224 1984 420-1.
\n18 AUGUST 2006 | TORONTO \u2013 Dr.
\nAnders Nordstr\u00f6m, Acting Director-
\nGeneral of the World Health Organization
\ntold delegates at the XVIth International
\nAIDS Conference that \u201cdrastic measures\u201d
\nwere required to ensure there are enough
\nhealth workers available to deliver univer-
\nsal access to HIV\/AIDS prevention, treat-
\nment, care and support by 2010. He also
\nwelcoming the broad consensus at the con-
\nference that a comprehensive response to
\nHIV\/AIDS was essential. Speaking at the
\nclosing session, Dr Nordstr\u00f6m stressed that
\n\u201cmoney, medicines and a motivated, skilled
\nworkforce\u201d were key to delivering universal
\naccess.
\nHe underscored that the funds available for
\nHIV\/AIDS globally were growing, but, so
\nwere the needs. \u201cWorldwide, resources for
\nHIV\/AIDS have increased to over US$
\n8 billion a year, but estimated need in low-
\nand middle-income countries is US$ 15 bil-
\nlion this year, and that will grow to US$ 22
\nbillion in 2008. \u201cThat widening gap must be
\nfilled, and commitment sustained. It calls
\nWHO
\nMedicines, money and motivated health work-
\ners are key to universal access to HIV\/AIDS
\nprevention, treatment care and support
\nA \u201cborderless society for health\u201d necessary to make greater
\ninroads: WHO Acting Director-General
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 72
\nWHO
\n73
\nenced the HIV\/AIDS landscape. He paid
\ntribute to Dr Lee Jong-Wook, WHO’s for-
\nmer Director-General, and his role in forc-
\ning a shift in approach and attitude to access
\nto treatment. \u201cThis is demonstrated through
\na ten-fold increase in people on treatment in
\nsub-Saharan Africa,\u201d he said. \u201cBut the chal-
\nlenges in that region also illustrate what still
\nneeds to be done. Seventy per cent of the
\nglobal unmet need for treatment is in
\nAfrica.\u201d
\nHe stressed that drug pricing was still an
\nissue \u2013 to ensure that both first-line and sec-
\nond-line treatments were affordable. \u201cThere
\nis growing momentum for innovation,
\nresearch and addressing intellectual proper-
\nty issues to ensure maximum access to new
\nproducts that save lives.
\n\u201cWe need ideas to turn into new drugs and
\ndiagnostics that strengthen our ability to
\nsafely treat infants and children as well as
\nadults. We also need a vaccine and a micro-
\nbicide.\u201d
\n\u201cUniversal access must include access to a
\nskilled and motivated health worker,\u201d said
\nDr Nordstr\u00f6m. \u201cNo improvement in financ-
\ning or medical products can make a lasting
\ndifference in people’s lives until the crisis in
\nthe health workforce is solved.\u201d
\nfor more than traditional international
\ndevelopment assistance.\u201d
\nDr Nordstr\u00f6m praised recent initiatives
\naimed at providing sustainable financing
\nmechanisms, such as the UNITAID initia-
\ntive of France, Brazil, Chile, Norway and
\nthe United Kingdom, which uses a levy on
\nairline taxes to channel new money to HIV
\nwork. He also noted that new potential
\nmechanisms \u2013 such as advance market com-
\nmitments \u2013 could provide incentives for
\nresearch and development into new medi-
\ncines and vaccines. He stressed that devel-
\noped countries, including the G8, must live
\nup to their financial and political HIV\/AIDS
\ncommitments, and that national govern-
\nments must also spend more on health
\ndomestically, and make HIV\/AIDS a fund-
\ning priority.
\nMedicines \u2013 access to drugs
\nremains critical
\nDr Nordstr\u00f6m noted that \u201c3 by 5\u201d \u2013 the
\nWHO and UNAIDS initiative to expand
\naccess to antiretroviral treatment to 3 mil-
\nlion people in low- and middle-income
\ncountries by the end of 2005 \u2013 had influ-
\nWithout health workers, uni-
\nversal access not possible
\nHe called for \u201cdrastic measures\u201d to urgent-
\nly strengthen the workforce. WHO\u2019s new
\n\u2018Treat, Train, Retain\u2019 plan, launched at the
\nconference, (see below) also demonstrates
\nhow ensuring prevention and treatment for
\nhealth workers in a supportive work envi-
\nronment can help improve working condi-
\ntions, and critically, keep staff healthy and
\nmotivated.
\nA health system also depends on stronger
\ninformation and surveillance systems,
\nlogistics and distribution systems \u2013 all areas
\nthat WHO is helping national governments
\nto address, he said.
\nDr Nordstr\u00f6m asked delegates to make uni-
\nversal access possible through \u201ca borderless
\nsociety for health. One that embraces all
\nwho can make a difference, from political
\nleaders, scientists, health workers to young
\npeople, persons living with HIV, the poor,
\nsex workers, injection drug users, people in
\nprisons.\u201d
\nStrengthening prevention
\nDr. Nordstr\u00f6m also stressed the need for a
\nstrong gender perspective to ensure that
\nboth women and men have equal opportuni-
\nties.
\nFinally, Dr. Nordstr\u00f6m told delegates that,
\nalong with treatment, care and support,
\nrenewed attention must be paid to the pre-
\nvention of HIV.
\n\u201cToo many resources \u2013 time, energy and
\nmoney \u2013 have been wasted on the debate
\nover whether prevention or treatment
\nshould be the priority. At this conference we
\nhave come to a clearer understanding that it
\nis not a case of doing one or the other.
\nMillions have died through lack of both.\u201d
\nWHO’s contribution to achieving universal
\naccess to HIV prevention, treatment, care
\nand support focuses on five strategic direc-
\ntions: scaling up HIV testing and coun-
\nselling; maximizing the health sector\u2019s role
\nin prevention; scaling up treatment, care
\nand support; strengthening health systems
\nand investing in strategic information.
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 73
\nWHO
\n74
\nImmunization Financing Facility, and
\nthe France\/Chile\/Brazil\/Norway plan to
\nfund HIV\/TB and malaria drugs through
\nairline ticket taxes are very promising.
\nThe 12-page health outcome document
\nincludes G8 country\u2019s commitments to:
\nstrengthen the global network for surveil-
\nlance and monitoring; increase global pre-
\nparedness for a human influenza pandemic;
\ncombat HIV\/AIDS, tuberculosis and malar-
\nia; eradicate polio; make progress on
\nmeasles and other vaccine-preventable dis-
\neases; ensure access to prevention, treat-
\nment and care including through research,
\nthe use of Trade-Related Aspects of
\nIntellectual Property Rights (TRIPS) flexi-
\nbilities and also strengthened health sys-
\ntems; and to address the health conse-
\nquences of natural and man-made disasters.
\nThe Russian Federation carried on the G8
\ntradition of supporting polio eradication and
\nmade a specific funding pledge for polio
\neradication, committing US$18 million to
\nthe programme, as did the United Kingdom
\nin Gleneagles in 2005.
\nST PETERSBURG \u2013 At their July meeting
\nGroup of Eight vowed to improve the ways
\nin which the world cooperates on surveil-
\nlance for infectious diseases, including
\nimproving transparency by all countries in
\nsharing information. The G8 also commit-
\nted to continued support to fight
\nHIV\/AIDS, tuberculosis, malaria, and to
\neradication of polio. Dr. Anders Nordstr\u00f6m,
\nacting Director-General of the WHO said
\n\u201eToday the G8 spoke together on the essen-
\ntial need to tackle infectious diseases,
\nbecause of their health, social, security and
\neconomic impacts\u201d, \u201eThe commitments are
\ndetailed and specific, and represent another
\nstep forward in G8 leadership on public
\nhealth.\u201d
\nDr. Nordstr\u00f6m led a senior WHO team at
\nthe Summit to contribute to discussions on
\ninfectious disease and he addressed G8
\nleaders, in the presence of the Heads of
\nState or Governments of Brazil, China,
\nCongo, Finland, India, Kazakhstan, Mexico
\nSouth Africa and invited UN leaders. He
\nunderscored priorities for infectious dis-
\nease, including the need to:
\n\u2022 Sustain the political and financial
\nmomentum for scaling up against the
\nmajor infectious diseases and basic
\nhealth services: HIV, tuberculosis,
\nmalaria, polio and immunization.
\n\u2022 Manage new disease outbreaks and
\nthreats \u2013 including a potential pandemic
\ninfluenza outbreak.
\n\u2022 Improve access to existing and new
\ndrugs and vaccines though expanded
\nmarkets and increased affordability.
\n\u2022 Ensure there are enough motivated
\nhealth workers in health centres and hos-
\npitals and address the current four-mil-
\nlion health worker shortage. The biggest
\nshortages are in the poorest countries
\nwhere the need is greatest.
\n\u2022 Invest in innovative financing. The
\nUnited Kingdom\u2019s support for the
\nG8 commitments to infectious disease can
\nimprove global health security
\nGeneva \u2013 A new global partnership that
\nwill strive to address the worldwide short-
\nage of nurses, doctors, midwives and other
\nhealth workers has been launched. The
\nGlobal Health Workforce Alliance will
\ndraw together and mobilize key stakehold-
\ners engaged in global health to help coun-
\ntries improve the way they plan for, educate
\nand employ health workers. Its secretariat
\nwill be hosted by the World Health
\nOrganization.
\nResponding to the call by African Heads of
\nState, the G-8 and the World Health
\nAssembly for urgent solutions to the health
\nworkforce crisis, the Alliance will seek
\npractical approaches to urgent problems
\nsuch as improving working conditions for
\nhealth professionals and reaching more
\neffective agreements to manage their migra-
\ntion. It will also serve as an international
\ninformation hub and monitoring body.
\nThe Alliance will start an ambitious pro-
\ngramme \u2013 the Fast Track Training Initiative
\n\u2013 aimed at achieving a rapid increase in the
\nnumber of qualified health workers in coun-
\ntries experiencing shortages. The initiative
\nwill work towards that goal through five
\nstrategies:
\n\u2022 Mobilizing direct financial support for
\nhealth training institutions, through a
\nmodel similar to that of the Education for
\nAll Fast Track Initiative \u2013 a global part-
\nnership between donor and developing
\ncountries to ensure accelerated progress
\ntowards the Millennium Development
\nGoal of universal primary education;
\n\u2022 Training partnerships between schools in
\nindustrialized and developing countries
\ninvolving exchanges of faculty and stu-
\ndents, with the aim of improving the edu-
\ncation of doctors, nurses, midwives and
\nparaprofessional health workers, and
\ntraining more of them now;
\n\u2022 Nurturing a new generation of academic
\nleaders in developing countries with the
\nsupport of experts in the clinical, public
\nhealth and managerial sciences from
\naround the world;
\n\u2022 Developing innovative approaches to
\nteaching in developing countries with
\nstate-of-the art teaching materials and
\ncontinuing education through information
\nand communications technology;
\n\u2022 Assistance with the creation of planning
\nteams in each country facing health work-
\nGlobal Health
\nWorldwide shortage of doctors, nurses and
\nother health workers
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 74
\nWHO
\n75
\ner shortages, drawing on the top leader-
\nship of the major schools, whose task will
\nbe to develop a comprehensive national
\nhealth workforce strategy.
\nFifty-seven countries, 36 of which are in
\nsub-Saharan Africa, have severe shortages
\nof health workers. More than four million
\nadditional doctors, nurses, midwives, man-
\nagers and public health workers are urgent-
\nly needed to fill this gap. An adequate
\nhealth workforce is defined by WHO as at
\nleast 2.3 well-trained health care providers
\navailable per 1000 people and balanced in
\nsuch a way as to reach 80% of the popula-
\ntion or more with skilled birth attendance
\nand childhood immunization.
\n\u201cThe inadequacy of the health workforce in
\nmany developing countries is a major obsta-
\ncle to providing essential life-saving health
\nservices to millions of people who lack
\naccess now,\u201d said Dr Timothy Evans, WHO
\nAssistant Director-General. \u201cCoordinated
\naction to address this crisis at the global
\nlevel, in regions and within countries must
\nbegin now.\u201d
\nThe Alliance will seek to spur country
\naction implementing the ten-year health
\nworkforce plan set forth in The world health
\nreport 2006: Working together for health.
\nThe Report calls for national leadership to
\nurgently formulate and implement country
\nstrategies for the health workforce, with
\nbacking by international assistance.
\n\u201cThe Global Health Workforce Alliance
\nwill bring together all the stakeholders
\nneeded to move forward on this plan with a
\nview to sharing evidence-based practices
\ncountries can follow to expand their work-
\nforces and make them more effective,\u201d said
\nDr Lincoln Chen, WHO Special Envoy for
\nHuman Resources for Health and Chair of
\nthe Alliance\u2019s Board.
\nThe initial partners of the Alliance include
\nthe Bill & Melinda Gates Foundation, the
\nCanadian International Development
\nAgency, the European Commission, the
\nGlobal Alliance for Vaccines and
\nImmunization, the Global Equity Initiative
\nat Harvard University, the International
\nCouncil of Nurses, the New Partnership for
\nAfrica\u2019s Development, the Norwegian
\nAgency for Development Cooperation, the
\nMinistry of Public Health, Thailand,
\nPhysicians for Human Rights, the World
\nBank and WHO. Its executive director, Dr
\nFrancis Omaswa, is the former Director
\nGeneral of Health Services of Uganda.
\nThe Government of Norway has donated
\nUS$ 3.5 million towards the Alliance\u2019s
\noperations during its first year. Seed money
\nfor its start-up was donated by the govern-
\nments of Canada, Ireland and Sweden.
\n16 AUGUST 2006 | TORONTO \u2013
\nAddressing a plenary session of the XVI
\nInternational AIDS Conference, WHO
\nHIV\/AIDS Director Dr Kevin De Cock
\nreported that the number of people receiv-
\ning HIV antiretroviral therapy in sub-
\nSaharan Africa has surpassed 1 million for
\nthe first time, a ten-fold increase in treat-
\nment access in the region since December
\n2003.
\nIn low- and middle-income countries, just
\nover 1.6 million persons were receiving
\nantiretroviral therapy at the end of June
\n2006, a 24 percent increase over the 1.3
\nmillion who had access to the drugs in
\nDecember 2005, and four times the 400,000
\npeople receiving treatment in these coun-
\ntries in December 2003. Ninety-five percent
\nof people living with HIV\/AIDS today live
\nin the developing world.
\nWhile WHO and UNAIDS reported signifi-
\ncant increases in treatment access in several
\nregions of the world, Dr De Cock empha-
\nsized that there is considerable work ahead
\nto reach the G-8 and UN-endorsed goal of
\nproviding as close as possible to universal
\naccess to HIV prevention programmes,
\ntreatment, care and support by 2010. In his
\nremarks today. He also laid out WHO’s
\nvision for continuing to expand HIV treat-
\nment access, calling for new action to over-
\ncome barriers that, if unaddressed, will slow
\nthe rate of expansion in access to HIV treat-
\nment in the future.
\n\u201cThe combined efforts of donors, affected
\nnations, UN agencies and public health
\nauthorities are providing substantial, ongo-
\ning increases in access to lifesaving HIV
\ntreatment,\u201d commented Dr De Cock. \u201cYet,
\nin many ways we are still at the beginning
\nof this effort. We have reached just one-
\nquarter of the people in need in low and
\nmiddle-income countries, and the number
\nof those who need treatment will continue
\nto grow. Our efforts to overcome the obsta-
\ncles to treatment access must grow even
\nfaster.\u201d
\nOf the 38.6 million persons living with HIV
\nglobally, approximately 6.8 million people
\nliving in low- and middle-income countries
\nrequire antiretroviral therapy now, meaning
\nthat about 24 percent of people in need
\nworldwide were receiving antiretroviral
\ntherapy by end-June 2006. Coverage by
\nregion varied, from five percent in North
\nAfrica and the Middle East and 13 percent
\nin Eastern Europe and Central Asia to 75
\nper cent in Latin America and the
\nCaribbean. Sixty-three percent of persons
\non antiretroviral therapy in low- and mid-
\nWHO Reports from XVI International Aids Conference
\nWHO HIV\/AIDS Director Outlines Progress
\nand Obstacles to Achieving Universal Access
\nto AIDS Treatment
\nHIV treatment access reaches over 1 million in sub-Saharan
\nAfrica, WHO reports
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 75
\nGENEVA \u2013 Leaders of the World Health
\nOrganization (WHO) and UNFPA, the
\nUnited Nations Population Fund, are coor-
\ndinating action to reverse the global trend of
\ndeteriorating levels of sexual and reproduc-
\ntive health and reduce the adverse impact on
\nmothers, babies and young people.
\nWHO
\n76
\ndle-income countries today are African,
\ncompared with 25 percent in late 2003.
\nAlthough sub-Saharan Africa has the great-
\nest number of people on treatment, and the
\nsecond-highest rate of treatment coverage
\namong those who need it, the region still
\naccounts for 70 percent of the global unmet
\ntreatment need.
\nIn addition to expenditures by countries
\nthemselves, treatment scale-up has been
\nfunded through the U.S. President’s
\nEmergency Plan for AIDS Relief; the
\nGlobal Fund to Fight AIDS, Tuberculosis,
\nand Malaria; the World Bank; other bilater-
\nal donors, and pharmaceutical companies
\nthrough contributions such as the
\nAccelerating Access Initiative. In general,
\nprogress has been greatest in countries
\nreceiving specific assistance from these ini-
\ntiatives.
\nIncreasing Equitable Access
\nSpeaking on efforts to ensure equitable
\naccess to treatment among all people who
\nneed it, Dr De Cock reported that current
\ndata do not indicate any systematic bias
\nagainst women in treatment access, with the
\nproportion of female ART recipients corre-
\nsponding closely to, and in some cases
\nexceeding, the proportion of people infect-
\ned.
\nHowever, other inequities are clear. While
\nan estimated 800,000 children below the
\nage of 15 require antiretroviral therapy,
\nonly about 60,000 to 100,000 are estimated
\nto be receiving it. One in 7 people dying of
\nHIV-related illness worldwide is a child
\nunder 15 years of age, a fact that is largely
\ndue to the failure to scale up programmes
\nfor the prevention of mother-to-child trans-
\nmission of HIV and to prevent HIV infec-
\ntion in young women, noted Dr De Cock.
\nDespite the successes of such countries as
\nBrazil, Thailand, and Botswana, only about
\nsix percent of HIV-positive pregnant
\nwomen globally are currently benefiting
\nfrom antiretroviral prophylaxis to help pre-
\nvent HIV transmission in childbirth. In con-
\ntrast, pediatric HIV disease has been virtu-
\nally eliminated in the industrialized world.
\nPeople who contracted HIV through inject-
\ning drug use are also not receiving equitable
\naccess to treatment. In Eastern Europe and
\nCentral Asia, injecting drug users, a major-
\nity of them men, account for over 70 per
\ncent of HIV-infected persons, but only
\nabout a quarter of treatment recipients.
\nDr De Cock encouraged delegates at the
\nmeeting to evaluate treatment efforts not
\nonly based on the number of patients
\nreceiving care, but on the quality of treat-
\nment outcomes as well. Noting that most
\npatients in developing country treatment
\nprogrammes present with late-stage disease,
\nhe emphasized that improving treatment
\noutcomes will require both diagnosing HIV
\nand starting treatment earlier.
\n\u201cA three-and-a half times higher death rate
\nafter one year of therapy in HIV-infected
\ncitizens of resource-poor countries com-
\npared with Europeans and North Americans
\nshould not be viewed as acceptable, and we
\nmust commit to change it,\u201d said Dr De
\nCock. \u201cThese priorities are not radical new
\ninsights but they do require altered commit-
\nment to saving human life.\u201d
\nMoving Towards Universal
\nAccess
\nLooking forward, Dr De Cock outlined five
\nstrategic directions, each of which repre-
\nsents a critical area where the health sector
\nmust lead if countries are to make progress
\ntowards achieving universal access, and on
\nwhich WHO will focus its technical assis-
\ntance. These include:
\n\u2022 expanding HIV testing and counselling;
\n\u2022 maximizing prevention opportunities in
\nhealth care settings;
\n\u2022 increasing access to treatment and care;
\n\u2022 strengthening health systems; and
\n\u2022 investing in strategic information.
\nWhile stressing that prevention, treatment
\nand care are inextricably linked, Dr. De
\nCock called for an increased emphasis on
\nprevention efforts where HIV transmission
\nis most intense. He also emphasized the
\nneed to be guided by science when deter-
\nmining the effectiveness of prevention
\ninterventions.
\nReviewing lessons learned from the \u201c3 by
\n5\u201d effort to rapidly scale up access to HIV
\ntreatment, Dr. De Cock cited the frailty
\nof health systems \u2013 including human
\nresources, physical infrastructure, laborato-
\nry capacity, procurement and supply sys-
\ntems, and fiscal management \u2013 as the key
\nobstacle to widescale provision of HIV ser-
\nvices, and called for the elevation of health
\nsystems strengthening among global politi-
\ncal priorities. Dr. De Cock also cited the
\nreliability and availability of strategic infor-
\nmation, including epidemiology and sur-
\nveillance, monitoring and evaluation, and
\noperational research as essential in monitor-
\ning progress towards universal access.
\nNoting that only about 10 percent of people
\nliving with HIV in sub-Saharan Africa
\nknow their HIV status, Dr. De Cock added
\nthat WHO is working with UNAIDS to
\nevaluate how countries are implementing
\nHIV testing and counseling. A consultative
\nprocess is under way to develop operational
\nguidelines to help countries expand access
\nto provider-initiated testing and counseling
\nin health care settings, with a view to
\nincreasing uptake of treatment and preven-
\ntion particularly in high prevalence coun-
\ntries. The guidelines will be issued later this
\nyear.
\nTop level push to tackle priorities in sexual and
\nreproductive health
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 76
\nWHO
\n77
\nimproving maternal health and reducing
\nperinatal death. Yet, in developing countries
\nand those in transition, an estimated 200
\nmillion women lack access to family plan-
\nning.\u201d
\nIn addition, in some cultures, three million
\ngirls and young women are subjected each
\nyear to genital mutilation\/cutting which, in
\nrecent studies by WHO, has been shown to
\nsignificantly increase the risk of death and
\nserious injury for newborn babies and their
\nmothers around childbirth.
\nFollowing a high-level meeting on Friday,
\nthe leaders agreed the agencies will coordi-
\nnate action in countries to ensure pro-
\ngrammes are more effective and account-
\nable for results.The aim is to scale-up work
\nto put a number of global proposals and ini-
\ntiatives into action in countries: The Global
\nReproductive Health Strategy, endorsed by
\nthe World Health Assembly, a 2005
\nResolution on achieving internationally
\nagreed health-related development goals,
\nincluding those contained in the
\nMillennium Declaration, another on work-
\ning towards universal coverage of maternal,
\nnewborn and child health interventions, and
\nthis year’s World Health Assembly
\nResolution agreeing to the Global Strategy
\nto tackle sexually transmitted infections.
\nA communiqu\u00e9 issued at the end of the
\nmeeting identified a number of priority
\nareas including:
\n\u2022 A coordinated action plan to implement
\nthe Global STI Prevention and Control
\nStrategy;
\n\u2022 Support to countries to increase skilled
\nhealth attendants in target countries;
\n\u2022 Coordinated workplans on improving
\nreproductive, maternal, newborn and ado-
\nlescent health;
\n\u2022 \u201cOne framework\u201d plans for the 16 African
\ncountries covered by the strategic frame-
\nwork just completed by the UN agencies;
\n\u2022 Advocacy for inclusion of sexual and
\nreproductive health in national economic
\nplanning such as Poverty Reduction
\nStrategies (PRSPs);
\n\u2022 Strengthening the linkages between HIV
\nand sexual and reproductive health
\nthrough coordinated action in HIV pre-
\nvention, care and treatment;
\n\u2022 Joint training of country teams on the
\nprocess for planning and working together
\nat country level and joint competency
\nreviews;
\n\u2022 Coordinated work in countries addressing:
\n\u2022 Female genital mutilation\/cutting
\n\u2022 Obstetric fistula
\n\u2022 Violence against women, including in
\nemergencies
\n\u2022 A pilot programme in two countries to
\nintroduce the Human Papilloma Virus
\n(HPV) vaccine
\n\u2022 Human resources for health.
\n\u2022 The key is to make practical plans in order
\nto implement these strategies,\u201d says Ms
\nObaid. \u201cWe are faced with an urgent need
\nto increase investment in sexual and
\nreproductive health to ensure access to
\nquality reproductive health services,
\nincluding youth-friendly services, and to
\nlink HIV\/AIDS and STI prevention with
\nreproductive health services and vice
\nversa.\u201d
\n\u2022 Country support and advocacy are going
\nto be vital elements for any successful
\nattempt to reduce the impact of poor sex-
\nual and reproductive health,\u201d says Dr
\nNordstr\u00f6m. \u201cEvidence shows that invest-
\nments in and access to sexual and repro-
\nductive health, including family planning,
\nare essential to breaking the cycle of
\npoverty. This then frees national and
\nhousehold resources for investments in
\nhealth, nutrition, and education, promot-
\ning economic growth with tangible
\nreturns.\u201d
\nFor further information please contact:
\nChristopher Powell, WHO
\nTelephone: +41 791 2888
\nMobile: +41 79 217 3425
\nEmail:powellc@who.int
\nOmar Gharzeddine, UNFPA
\nTelephone: +1 212 297 5028
\nEmail:gharzeddine@unfpa.org
\nGlobally, inadequate sexual and reproduc-
\ntive health services have resulted in mater-
\nnal deaths and rising numbers of sexually
\ntransmitted infections (STIs), particularly in
\ndeveloping countries. WHO estimates that
\n340 million new cases of sexually transmit-
\nted bacterial infections, such as chlamydia
\nand gonorrhoea occur annually in people
\naged 15 \u2013 49, many untreated because of
\nlack of access to services. In addition, mil-
\nlions of cases of viral infection, including
\nHIV, occur every year. The sexually trans-
\nmitted human papilloma virus (HPV) infec-
\ntion is closely associated with cervical can-
\ncer, which is diagnosed in more than 490
\n000 women and causes 240 000 deaths
\nevery year. Around eight million women
\nwho become pregnant each year suffer life-
\nthreatening complications as a result of
\nSTI’s and poor sexual health. Annually, an
\nestimated 529 000 women, almost all in
\ndeveloping countries, die during pregnancy
\nand childbirth from largely preventable
\ncauses.
\n\u201cThere is a really worrying rise in the num-
\nber and severity of sexually transmitted
\ninfections,\u201d says Dr Anders Nordstr\u00f6m,
\nActing Director-General, WHO. \u201cBut the
\nconsequences of poor sexual and reproduc-
\ntive health go well beyond Sexually
\nTransmissible Infections. They lead directly
\nto completely preventable illness and death.
\nIt is unacceptable today for a woman to die
\nin childbirth, or for a person to become HIV
\npositive for lack of information and
\nresources.\u201d
\nYoung people are particularly vulnerable.
\nMore than 100 million curable sexually
\ntransmitted infections occur each year and a
\nsignificant proportion of the 4.1 million
\nnew HIV infections occur among 15-to-24
\nyear olds. In sexually active adolescents
\n(aged 10-19 years), sexual and reproductive
\nhealth problems include early pregnancy,
\nunsafe abortion, STIs including HIV, and
\nsexual coercion and violence. \u201cIt is clear
\nthat the Millennium Development Goals 5
\nand 4 to reduce mother and child deaths by
\n2015 cannot be achieved without investing
\nin sexual and reproductive health,\u201d says Ms
\nThoraya Ahmed Obaid, Executive Director,
\nUNFPA. \u201cFor example, averting unintended
\npregnancy and reducing unmet need for
\nfamily planning are key interventions in
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 77
\nWHO
\n78
\nleading to a lack of health workers trained
\nto prevent and treat AIDS. In addition,
\nmany health workers trained in developing
\nworld health systems leave their jobs (or
\ncountries) for better-paying jobs in wealthy
\ncountries, in bigger cities, or in non-govern-
\nmental organizations (NGOs).
\n\u201cWHO has a unique role to play in helping
\ncountries mount an effective, comprehen-
\nsive and sustainable response to the AIDS
\nepidemic,\u201d said Dr. Anarfi Asamoa-Baah,
\nAssistant Director-General of WHO. \u201cThe
\nshortage of health workers is devastating
\npublic health systems, particularly in the
\ndeveloping world, and it is one of the most
\nsignificant challenges we face in preventing
\nand treating HIV. WHO is launching \u2018Treat,
\nTrain, Retain\u2019 to confront this crisis.\u201d
\nDr Sigrun Mogedal, the Norwegian govern-
\nment\u2019s Ambassador for HIV\/AIDS said
\n\u201cWHO\u2019s \u2018Treat, Train, Retain\u2019 plan pro-
\nvides a much-needed boost to national
\nhealth systems that will have an impact far
\nbeyond HIV\/AIDS. By increasing the num-
\nber of well-trained, healthy and motivated
\nhealth workers, the plan will provide signif-
\nicant benefit to health systems generally.\u201d
\nThe \u2018Treat, Train, Retain\u2019 plan will be
\nimplemented under the umbrella of the
\nGlobal Health Workforce Alliance, hosted
\nby WHO, which was established in May
\n2006 and is a partnership of governments,
\naid agencies, civil society groups and mul-
\ntilateral organizations.
\n\u201c’Treat, Train, Retain\u2019 draws on the growing
\nbody of evidence and experience of what
\nworks in improving the performance of the
\nhealth workforce,\u201d said Dr Francis
\nOmaswa, Executive Director of the Global
\nHealth Workforce Alliance. \u201cIt will acceler-
\nate the adoption of best practices on critical
\nissues like the increased roles and responsi-
\nbilities of community health workers in
\ncombating HIV\/AIDS and promoting better
\nhealth at household and community level.\u201d
\n\u2018Treat, Train, Retain\u2019 will focus on those
\ncountries most severely affected by
\nHIV\/AIDS, and incorporates a menu of
\noptions that countries can adapt to their spe-
\ncific needs. WHO estimates that it will cost
\na minimum of US$7.2 billion over the next
\nfive years to implement the plan in the 60
\ncountries with the highest HIV burden, and
\nit could cost substantially more \u2013 up to
\nUS$14 billion. This corresponds to an annu-
\nal per capita cost of approximately US$0.60
\nin the countries concerned, or between two
\nand five percent of the levels of health
\nexpenditure typically found in low-income
\ncountries.
\n\u2018Treat\u2019
\nAlthough health workers are at the frontline
\nof national HIV\/AIDS programmes, they
\noften do not have adequate access to
\nHIV\/AIDS services themselves. The \u2018Treat\u2019
\ncomponent of the plan represents a full
\npackage of HIV\/AIDS prevention, treat-
\nment and care services that should be made
\navailable to health workers on a priority
\nbasis and tailored specifically to their
\nneeds. These include:
\n\u2022 Specially designed awareness and anti-
\nstigma and discrimination campaigns
\n\u2022 Testing and counselling services
\n\u2022 Priority access to antiretroviral treatment
\nfor health workers and their families
\n\u2022 Protection from HIV transmission in the
\nhealth care environment, including
\naccess to post-exposure prophylaxis
\n\u2018Train\u2019
\nThe \u2018Train\u2019 aspect involves strategies for
\ncountries to expand the numbers of new
\nhealth workers and maximize the efficiency
\nof the existing workforce. These include:
\n\u2022 Recruiting and training additional health
\nworkers
\n\u2022 Shifting tasks from more- to less-spe-
\ncialised health workers (e.g., from spe-
\ncialists to physicians, physicians to nurs-
\nes, and nurses to community health
\nworkers and lay providers including peo-
\nple living with HIV)
\nTORONTO \u2013 The World Health
\nOrganization (WHO), in collaboration with
\nthe International Labour Organization and
\nthe International Organization for
\nMigration, announced the launch of a coor-
\ndinated global plan to address a major and
\noften overlooked barrier to preventing and
\ntreating HIV\/AIDS namely the severe
\nshortage of health workers, particularly in
\ndeveloping nations.
\nCalled \u2018Treat, Train, Retain\u2019, the plan is an
\nimportant component of WHO’s overall
\nefforts to strengthen human resources for
\nhealth and to promote comprehensive
\nnational strategies for human resource
\ndevelopment across different disease pro-
\ngrammes. The plan is also part of WHO\u2019s
\nwork to promote universal access to
\nHIV\/AIDS services. Through its HIV\/AIDS
\nProgramme, WHO is playing a central role
\nin making the goal of universal access a
\nreality.
\nFifty-seven countries, mostly in sub-
\nSaharan Africa and Asia (particularly
\nBangladesh, India, and Indonesia) face crip-
\npling shortages of health workers. WHO
\nestimates that more than four million health
\nworkers are needed to fill the gap. Sub-
\nSaharan Africa faces the greatest chal-
\nlenges. With 11 percent of the world\u2019s pop-
\nulation and almost 64 percent of all people
\nliving with HIV, the region has only 3 per-
\ncent of the world’s health workers. Globally,
\nhealth workers are also concentrated in
\nurban areas, leaving shortages in rural
\nareas.
\nIn sub-Saharan Africa and elsewhere, the
\nHIV\/AIDS epidemic is contributing to
\nhealth worker shortages. HIV\/AIDS is an
\nemerging source of mortality, loss of pro-
\nductivity and demoralisation among health
\nworkers. HIV\/AIDS has also changed the
\nway young people view health work, mak-
\ning it a less desirable career choice and
\nWHO launches new plan to confront
\nHIV-related health worker shortages
\nCrisis in human resources for health poses significant obstacle to
\nglobal HIV\/AIDS prevention and treatment
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 78
\nWHO and UNICEF
\n79
\n\u2022 Increasing the number of graduates by
\nimproving and expanding pre-service
\ntraining in medical and nursing schools,
\nand incorporating AIDS-specific training
\n\u2022 Providing in-service training to health
\nworkers already in the health system to
\nempower and better equip them with the
\nskills needed to more effectively care for
\npatients living with HIV\/AIDS
\n\u2018Retain\u2019
\n\u2018Retain\u2019 relates to a set of interventions to
\nhelp ensure that countries are able to keep
\nexisting workers employed in the health
\nsystem. These include:
\n\u2022 Instituting policy changes, codes of prac-
\ntice and ethical guidelines to minimize
\nmigration of health workers from low-
\nincome countries to developed countries.
\n\u2022 Diminishing the draw of private-sector
\nand NGO HIV\/AIDS programmes on
\nworkers in public health systems.
\n\u2022 Improving the quality of the workplace
\nenvironment, including establishing
\noccupational health and safety proce-
\ndures, reducing the risk of contracting
\nHIV and other blood-borne diseases and
\naddressing workplace issues such as
\nstress and burnout.
\n\u2022 Supporting staff and families with HIV
\nby guaranteeing job security, prohibiting
\ndiscrimination, providing social benefits
\nand adjusting work demands.
\n\u2022 Providing financial incentives, as well as
\nnon-financial incentives such as career
\nand training opportunities, transport and
\nHIV treatment access for family mem-
\nbers.
\nWHO\u2019s Priority Action Steps
\nTo ensure the success of \u2018Treat, Train,
\nRetain\u2019, WHO has identified the following
\npriority action steps:
\n\u2022 Establish a special steering committee
\nthat will advocate for the \u2018Treat, Train,
\nRetain\u2019 plan, guide the implementation
\nof its activities, and monitor progress.
\n\u2022 Provide guidance and technical assis-
\ntance to national governments for the
\nimplementation of the activities outlined
\nin the \u2018Treat, Train, Retain\u2019 plan.
\n\u2022 Promote global recognition of the health
\nworkforce as a \u2018vulnerable group\u2019, with
\ncampaigns targeted specifically to the
\nwell-being of health workers within the
\ncontext of the HIV epidemic.
\n\u2022 Design and facilitate the implementation
\nof a global agenda on task shifting to
\nexpedite the world\u2019s response to the
\nhuman resource crisis.
\n\u2022 Advocate for financial incentives to
\nretain health workers and research
\npotential options for non-financial incen-
\ntives.
\nThe first international Expert Consultation
\non Paediatric Essential Medicines, jointly
\nheld by the World Health Organization
\n(WHO) and the United Nation’s Children’s
\nFund (UNICEF), has delivered a plan to
\nboost access to essential medicines for chil-
\ndren.
\nDr Howard Zucker, Assistant-Director
\nGeneral at WHO said \u201cChildren are often
\nhailed as the hope and future of humanity,
\nbut they don’t benefit enough from pharma-
\nceutical research and technologyToo often,
\nthe right medicines for children, in the right
\ndosages and formulations are missing from
\nthe spectrum of available treatment options.
\nWHO and UNICEF will work quickly with
\npartners to change this.\u201d
\nTen million children die every year, many
\nof them from diarrhoea, HIV\/AIDS, malar-
\nia, respiratory tract infection or pneumonia.
\nEffective interventions – classified on
\nWHO’s list of essential medicines – exist for
\nthese illnesses but there’s a lack of knowl-
\nedge of how best to use these medicines in
\nchildren, and a lack of paediatric formula-
\ntions of them.
\nDuring two days of intensive discussion
\nheld 9-10 August at WHO’s headquarters in
\nGeneva, a mix of more than 20 developed
\nand developing countries, NGO’s including
\nM\u00e9decins Sans Fronti\u00e8res, regulatory agen-
\ncies, UNICEF and WHO staff prioritized a
\nlong-needed approach to overall paediatric
\ncare.
\nA top priority resulting from the meeting is
\nto dramatically expand access to much
\nneeded child-focused formulations such as
\nfixed dose combinations (several pills in
\none), crucial for children’s correct use of
\nmedicines and treatment adherence. The
\nplan also calls for the improvement of med-
\nicines and prescribing guidelines address-
\ning the entire range of infant and child care
\nneeds. Priorities include respiratory infec-
\ntions, neonatal care, palliative care for end
\nstage AIDS, for HIV\/TB co-infection and
\nfor other opportunistic infections, and
\nimproved electronic access to the latest
\nWHO drug information.
\nThe WHO Expert Consultation warned that
\nwithout a model of best practice guidelines
\nand paediatric formulations, and a buy-in at
\nnational levels right down to local care cen-
\ntres, then children – who in many countries
\nmake up half of the population – will contin-
\nue to be considered as therapeutic orphans.
\n\u201cFor example, it is worrying to see so very
\nfew medicines suitable for children in
\nresource-poor settings where there is enor-
\nmous need. For these children, we must
\naddress cost issues and ensure the right
\nmedicine formulations exist\u201d, said Dr Hans
\nHogerzeil, WHO’s Director for Medicines
\nPolicy and Standards. \u201cThe expert consulta-
\ntion was unanimous in its support for
\nurgent, specific actions, which will signifi-
\ncantly improve the chances for children to
\naccess the right medicines.\u201d
\nWHO and UNICEF tackle problem of lack of
\nessential medicines for children
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 79
\nWHO
\n80
\nAccording to Hanne Bak Pedersen, Senior
\nAdviser Pharmaceutical Policy, UNICEF
\nSupply Division, \u201cUNICEF is concerned
\nthat children’s access to medicines is very
\nlow in many resource limited settings.
\nFurthermore, there is a lack of availability
\nof several paediatric formulations. Based on
\nthe work of this new project and WHO clin-
\nical recommendations, UNICEF Supply
\nDivision will strengthen and expand the
\ndialogue with industry on paediatric formu-
\nlations for HIV\/AIDS to promote the devel-
\nopment of the missing medicines for chil-
\ndren.\u201d
\nHigh priority will be placed on ensuring a
\nholistic approach to child care and treat-
\nment, including addressing quality of life
\nissues such as producing painless remedies
\nover injections, better tasting medications
\nand investigating new mini tablet presenta-
\ntions.
\nEmphasis will also be placed on consider-
\ning the climate zone requirements linked to
\ndistribution and use whenever new product
\nformulations are made. For example, chew-
\nable or soluble powders are preferred over
\nsyrups as they do not require refrigeration
\nand are less bulky to transport.
\nThe plan will immediately be sent to coun-
\ntries for feedback on how best to implement
\nthe recommendations at the local level. In
\naddition, WHO will consider several chil-
\ndren’s medicines for inclusion in the WHO
\nEssential Medicines List in March 2007.
\nFor more information contact:
\nDr Suzanne Hill
\nMedical Officer
\nWHO
\nTelephone: +41 22 791 35 22
\nMobile phone: +41 79 815 79 21
\nE-mail: hills@who.int
\nPersahabatan Hospital, U.S. Centers for
\nDiseases Control and Prevention, France\u2019s
\nEpicentre, Hong Kong University,
\nNAMRU-2 laboratory and Japan\u2019s National
\nInstitute for Infectious Diseases.
\nIndonesia became the focus of international
\nattention last month when the largest cluster
\nof human H5N1 cases was identified. The
\noutbreak involved eight members of a sin-
\ngle family in Kubu Sembelang village,
\nKaro District, of North Sumatra. Samples
\nconfirmed the presence of the virus in seven
\nmembers of the family, and it is presumed
\nthat the initial case was also infected with
\nH5N1. Seven of the eight family members
\ndied. The outbreak was considered con-
\ntrolled on June 12, three weeks after the
\ndeath of the last case with no new cases
\nreported.
\nThe H5N1 virus is considered firmly
\nentrenched in poultry throughout much of
\nIndonesia, and this widespread presence of
\nthe virus has resulted in a significant num-
\nber of human cases. This year alone,
\nIndonesia has reported more than 33 cases
\nwith 27 deaths. Unless this situation is
\nurgently addressed, sporadic human cases
\nare likely and human-to-human transmis-
\nsion is possible.
\nResults from the expert consultation were
\nprovided to Komnas FBPI on Friday, 23
\nJune.
\n\u201cIndonesia\u2019s Ministry of Health has already
\ndemonstrated a great degree of transparency
\nand collaboration since the first case
\nappeared last year,\u201d said Dr. Paul Gully, a
\nsenior advisor for communicable diseases at
\nthe World Health Organization. \u201cIndonesia
\nhas quickly acknowledged all cases pub-
\nlicly, teamed up with WHO for rapid field
\ninvestigations, and provided virus isolates
\nto the WHO H5 Reference Laboratory
\nNetwork to enable monitoring of the evolu-
\ntion of the H5N1 virus. With this consulta-
\ntion, Indonesia is taking another step to
\nassess how best to protect the health of its
\npeople. The results will certainly be of great
\nimportance to all worldwide, who are eye-
\ning the risk of the next pandemic.\u201d
\nThis consultation brought together experts
\nfrom Indonesia\u2019s Ministries of Health and
\nof Agriculture, with those from the World
\nHealth Organization, the Food and
\nAgriculture Organization, UNICEF and
\nexperts from Airlangga University
\nSurabaya, Udayana University Bali,
\nJune 2006 \u2013 The continuing avian influenza
\noutbreak in Indonesia, involving both
\nhumans and animals, was the focus of a
\nthree-day international consultation starting
\nin Jakarta.
\nOn 13 June, Indonesia\u2019s National
\nCommittee for Avian Influenza Control and
\nPandemic Influenza Preparedness, known
\nas Komnas FBPI, asked the World Health
\nOrganization and other UN agencies to
\n\u201curgently convene\u201d an international consul-
\ntation of experts to:
\n\u2022 Review the status of the H5N1 virus in
\nhumans and animals
\n\u2022 Provide recommendations to control the
\nvirus in both animals and humans
\n\u2022 Review lessons learned for rapid response
\nand containment, and
\n\u2022 Provide an authoritative risk assessment
\nof avian influenza in Indonesia in both
\nhuman and animals.
\nH5N1 Virus
\nIndonesia holds avian influenza expert
\nconsultation
\nHanoi\/Manila\/Bankok\/Geneva \u2013 Viet
\nNam has eliminated maternal and neonatal
\ntetanus as a public health problem. The dis-
\nease, that kills tens of thousands of newborn
\neach year, most of them in developing
\ncountries, is often called the \u201csilent killer\u201d
\nbecause many newborn affected by it die at
\nViet Nam eliminates
\nmaternal and
\nneonatal tetanus
\nIn a joint news release the Ministry of
\nHealth of the Socialist Republic of Viet
\nNam, the World Health Organization
\nand the United Nations Children’s
\nFund (UNICEF) announced that.
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 80
\nMedical Science, Professional Practice and Education
\n81
\nhome in very remote and poor communities
\nwhere both the births and the deaths go
\nunreported.
\n\u00abWe congratulate the Government of Viet
\nNam on achieving this critical goal for chil-
\ndren and women. This accomplishment
\ndemonstrates that life-saving vaccines can
\nbe delivered to even the poorest and most
\nmarginalized communities,\u201d said Anupama
\nRao Singh, Regional Director of UNICEF
\nfor East Asia and the Pacific. \u00abUNICEF
\nremains committed to working with all part-
\nners to target and invest more in maternal
\nand child health services to reach the most
\nvulnerable.\u00bb
\nA survey conducted by UNICEF, WHO and
\nthe Government of Viet Nam in three of
\nVietnam’s disadvantaged districts \u2014 Bao
\nYen and Bao Thang in Lao Cai Province,
\nand Phuoc Long in Binh Phuoc Province \u2014
\nshowed less than one neonatal tetanus death
\nper 1000 live births. If neonatal tetanus is
\nshown to be eliminated in the most under-
\nserved and poorest performing areas, it is
\nconsidered as having been eliminated in
\nbetter performing areas.
\n\u00abThese excellent results mark a major
\nachievement by a country that used to have
\na high incidence of neonatal tetanus. All
\ncountries in the WHO Western Pacific
\nRegion have made progress towards neona-
\ntal tetanus elimination. Viet Nam has shown
\nthat government commitment, hard work
\nand partnerships lead to results. We are
\nhopeful that several other countries in the
\nregion will soon follow Viet Nam’s exam-
\nple,\u00bb said Dr Shigeru Omi, WHO Regional
\nDirector for the Western Pacific. Five coun-
\ntries in the Western Pacific have yet to reach
\nthe elimination goal of one case per 1000
\nlive births at district level.
\n\u00abMore than ten years of accelerated immu-
\nnization activities targeting women in high-
\nrisk districts of the country and pregnant
\nwomen, are paying off and we will make
\nevery effort to sustain this progress against
\na disease that kills but which can be pre-
\nvented,\u00bb said Professor Tran Thi Trung
\nChien, Minister of Health, Viet Nam.
\nIn the 1980s, in Vietnam there were approx-
\nimately ten neonatal deaths due to tetanus
\nper 1000 live births. Some 20,000 Viet-
\nnamese babies died annually of tetanus
\nbefore the age of one month. Since 1991,
\nTT vaccine has been routinely given to
\npregnant women throughout Viet Nam
\nthrough its Expanded Programme on
\nImmunization resulting in a high vaccina-
\ntion coverage rate; accelerated activities
\nbegan in 1993.
\nIn 2000, 58 countries in the world had yet to
\neliminate maternal and neonatal tetanus.
\nVietnam is the ninth country and first East
\nAsian country within the priority country
\ngroup that has been assessed and validated
\nas having eliminated these diseases. The
\nother eight are Eritrea, Malawi, Namibia,
\nNepal, Rwanda,South Africa, Togo and
\nZimbabwe. Major contributors of financial
\nand technical support to maternal and
\nneonatal elimination efforts in Viet Nam
\ninclude: the Bill & Melinda Gates
\nFoundation, Beckton & Dickinson (a med-
\nical technology company), the government
\nof Japan, AusAid, US Fund for UNICEF,
\nUNICEF and WHO.
\nThe next Communication from the
\nWMA Secretary General will appear in
\nthe December issue, which will contain
\na report on the WMA General Assembly
\nin South Africa.
\nThe World Health Organization (WHO) and
\nUNICEF today announced a new formula
\nfor the manufacture of Oral Rehydration
\nSalts (ORS). The new formula will better
\ncombat acute diarrhoeal disease and
\nadvance the Millennium Development Goal
\nof reducing child mortality by two-thirds
\nbefore 2015.
\nDiarrhoea is currently the second leading
\ncause of child deaths and kills 1.9 million
\nyoung children every year, mostly from
\ndehydration.
\nThe latest improved ORS formula contains
\nless glucose and sodium (245 mOsm\/l com-
\npared with the previous 311 mOsm\/l). The
\nlower concentration of the new formula
\nallows for quicker absorption of fluids,
\nreducing the need for intravenous fluids and
\nmaking it easier to treat children with acute
\nnon-cholera diarrhoea without hospitaliza-
\ntion.
\nORS use is the simplest, most effective and
\ncheapest way to keep children alive during
\nsevere episodes of diarrhoea. The ORS
\nsolution is absorbed in the small intestine,
\nthus replacing the water and electrolytes
\nlost. WHO provides the only updated inter-
\nnational quality specifications for this for-
\nmula and UNICEF is a leading supplier of
\nORS to poor countries. WHO and UNICEF
\nhave jointly issued guidance for the produc-
\ntion of the new ORS.
\nWHO and UNICEF recommend that coun-
\ntries manufacture and use the new ORS in
\nplace of the previous formula. WHO and
\nUNICEF will help national authorities
\ndevelop manufacturing guidelines and pro-
\ncedures for the new formula. Establishing
\nthe local production of ORS will be a key
\nstep to ensure countries can meet their own
\nneeds in controlling diarrhoeal disease.
\nAccording to UNICEF and WHO, oral
\nrehydration therapy should be combined
\nwith guidance on appropriate feeding prac-
\ntices. Provision of zinc supplements (20 mg
\nof zinc per day for 10 to 14 days) and con-
\ntinued breastfeeding during acute episodes
\nof diarrhoea protect against dehydration and
\nreduces protein and calorie consumption to
\nhave the greatest impact on reducing diar-
\nrhoea and malnutrition in children.
\nMedical Science, Professional Practice and Education
\nImproved formula for oral rehydration salts
\nto save children\u2019s lives
\nImproved formula means better treatment for life-threatening
\ndiarrhoeal dehydration
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 81
\nMedical Science, Professional Practice and Education
\n82
\nThe revised monograph for the new ORS
\nformula will be published in the fourth edi-
\ntion of The International Pharmacopoeia. It
\nis also available on the WHO website.
\nAdditional information on diarrhoea can be
\nfound on UNICEF’s Facts for Life website
\nand on the WHO Child and Adolescent
\nHealth web site: http:\/\/www.who.int\/medi-
\ncines\/publications\/pharmacopoeia\/ors
\nDetailed recommendations concerning the
\nprovision and production of ORS are pro-
\nvided in a revised joint WHO\/UNICEF
\npublication, ‘Oral Rehydration Salts:
\nProduction of the New ORS’:
\nhttp:\/\/www.who.int\/child-adolescent-
\nhealth\/publications\/CHILD_HEALTH\/WH
\nO_FCH_CAH_06.1.htm
\nThe antimalarial, artemotil, manufactured
\nby ARTECEF BV, is a parenteral (non-oral)
\nartemisinin preparation intended for the
\ntreatment of severe malaria, such as cere-
\nbral malaria, which may cause a lowered
\ndegree of consciousness and thus preclude
\noral intake of medicines. Malaria leads to
\nmore than one million deaths yearly, of
\nwhich over 75% occur in African children
\nunder 5 years of age infected with the cere-
\nbral form of the illness.
\nProducts newly listed:
\n\u2022 Efavirenz, 50mg Hard Capsule, Merck
\nSharp & Dohme BV, The Netherlands
\n\u2022 Efavirenz, 200mg Hard Capsule, Merck
\nSharp & Dohme BV, The Netherlands
\n\u2022 Tenofovir, 300mg Tablets, Gilead
\nSciences, Inc., United States
\n\u2022 Artemotil, 50mg\/ml solution for injection,
\nARTECEF BV, Germany
\n\u2022 Artemotil, 150mg\/ml solution for injec-
\ntion, ARTECEF BV, Germany
\nThree new antiretrovirals and two anti-
\nmalarials have been added to the World
\nHealth Organization’s list of prequalified
\nmedicines. Tenofovir and efavirenz (in two
\ndifferent strengths) and artemotil (also in
\ntwo different strengths) are crucial products
\nfor the treatment of HIV\/AIDS and malaria
\nrespectively and will considerably boost the
\nchoice of therapy in resource-poor coun-
\ntries.
\nTenofovir, produced by Gilead Sciences,
\nInc. was recommended in WHO’s 2003
\nAIDS treatment guidelines mainly as an
\noption for the second-line treatment of
\nAIDS. In 2006, its use will be expanded to
\nfirst-line treatment.
\nThe second antiretroviral is efavirenz, man-
\nufactured by Merck Sharp and Dohme BV.
\nThis product is one of the medicines recom-
\nmended by WHO for first-line treatment
\nand is a preferential drug in treatment pro-
\ngrammes for patients with HIV\/tuberculosis
\nco-infection.
\nNew AIDS and malaria medicines added to
\nprequalification list
\nNeedleless immuni-
\nsations possible in
\nthe future?
\nA new approach to
\nan old problem.
\nReuter. A press release from a British
\nPharmaceutical Conference in Man-
\nchester reports research carried out at the
\nSchool of Pharmacy at University of
\nLondon has found a means of applying
\nlow-frequency ultrasound to the skin
\ncoupled with a product which makes the
\nskin more permeable. Vaccines then
\napplied to the skin in liquid form are then
\neasily absorbed. Researchers tested the
\ntetanus vaccines on mice and rats and
\nwill now proceed to trials on human skin.
\nThe leader of the research, Afendi
\nDahian, commenting on the potential for
\nremoving the problems associated with
\nneedle delivery is reported as saying
\n\u201cNeedle usage can spread blood-borne
\ndiseases if someone is accidently pricked
\nwith a needle or if a needle is reused.
\nAlso you need a doctor or trained nurse
\nto administer a vaccine using a needle.\u201d
\nHe hoped that a hand-held,low frequency
\nultrasound could be developed for use in
\nhospitals and clinics.
\nMale circumcision update: Ongoing clinical
\ntrials are key to validating the link between
\nmale circumcision and protection against HIV
\ninfection
\nAs trials continue, UN agencies work to ensure that current male
\ncircumcision practices are safe
\n17 AUGUST 2006 | TORONTO \u2013 In June
\n2006, the US National Institutes of Health
\nannounced that, following an interim
\nreview, two ongoing trials in Uganda and
\nKenya examining the link between male
\ncircumcision and the risk of acquisition of
\nHIV infection in men should be continued.
\nThe trials are scheduled to end in July 2007
\nand September 2007 respectively. Data
\nfrom these studies will be important in val-
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 82
\nMedical Science, Professional Practice and Education
\n83
\nidating findings reported in July 2005 from
\nthe Orange Farm Intervention Trial in South
\nAfrica, funded by the French Agence
\nNationale de Recherches sur le SIDA
\n(ANRS), which showed a reduction of 60%
\nor more in the risk of acquiring HIV infec-
\ntion among circumcised men.
\nThe interim data from the ongoing Uganda
\nand Kenya trials were reviewed in June
\n2006 by the Data and Safety Monitoring
\nBoard (DSMB), which recommended that
\nthe studies continue on the grounds that
\nthere were not yet enough data to draw firm
\nconclusions. The DSMB further proposed
\nthat an additional interim analysis of data
\nfrom the two studies take place within the
\nnext year. \u201cThe results of the two ongoing
\ntrials will help clarify the relationship
\nbetween male circumcision and risk of HIV
\nin differing contexts, which is key to deter-
\nmining the reproducibility and application
\nof the Orange Farm findings,\u201d noted Dr
\nKevin De Cock, Director, WHO HIV\/AIDS
\nDepartment. \u201cWhile we await these impor-
\ntant results, UN partners and others are
\nworking to provide coordinated guidance
\nand support to countries to help improve the
\nsafety of current male circumcision prac-
\ntices.\u201d
\nAn additional trial assessing the impact of
\nmale circumcision on the risk of HIV trans-
\nmission to female partners, led by
\nresearchers at Johns Hopkins University, is
\ncurrently under way in Uganda with results
\nexpected in late 2007. The effect of male
\ncircumcision on reducing the risk of HIV
\ntransmission among men who have sex with
\nmen has been studied but has not been the
\nsubject of a trial.
\nGUIDANCE AND SUPPORT
\nEFFORTS NOW UNDER-
\nWAY
\nWHO, UNFPA, UNICEF and the UNAIDS
\nSecretariat emphasize that their current pol-
\nicy position has not changed and that they
\ndo not currently recommend the promotion
\nof male circumcision for HIV prevention
\npurposes. However, the UN recognizes the
\nimportance of anticipating and preparing
\nfor possible increased demand for circumci-
\nsion if the current trials confirm the protec-
\ntive effect of the practice. Recent mathe-
\nmatical modelling based on an assumed
\nreduction of HIV transmission of 60% in
\ncircumcised men suggests that, if this level
\nof protection is indeed confirmed and if
\nmale circumcision were widely practised,
\nthe number of HIV-related infections and
\ndeaths could be considerably reduced over a
\ntwenty-year period in sub-Saharan Africa.
\nCountries currently considering how to
\nimprove the safety of current services will
\nneed to ensure that male circumcision is
\nimplemented by appropriately trained prac-
\ntitioners with adequate equipment in
\nhygienic settings, and with close follow-up
\nand post-operative care. Countries should
\nensure that the procedure is being per-
\nformed under conditions of informed con-
\nsent, confidentiality, and counselling tai-
\nlored to the individual, emphasizing the
\ncontinuing need for multiple HIV preven-
\ntion measures.
\n\u201cEven if further trials show a lower risk of
\nHIV infection in circumcised men, male cir-
\ncumcision will not provide complete pro-
\ntection against HIV infection,\u201d said
\nCatherine Hankins, Chief Scientific
\nAdviser, UNAIDS. \u201cCircumcised men can
\nstill contract HIV and pass it to their part-
\nners. If male circumcision is proven to be
\neffective, it must be considered as just one
\nelement of a comprehensive HIV preven-
\ntion package that includes correct and con-
\nsistent use of condoms, reductions in the
\nnumber of sexual partners, delaying onset
\nof sexual relations, and voluntary and con-
\nfidential counselling and HIV testing to
\nknow one’s HIV serostatus. Just as combi-
\nnation treatment is more effective than sin-
\ngle drug therapy for people with HIV, com-
\nbination prevention is more effective than
\nreliance on a single HIV prevention
\nmethod.\u201d
\nSince the reporting of the Orange Farm
\nstudy findings, the UNAIDS Secretariat,
\nWHO, UNFPA, UNICEF, the World Bank
\nand other partners have been working
\ntogether to develop a range of guidance
\ndocuments and practical materials for coun-
\ntries or institutions that choose to improve
\nthe safety of and\/or scale up male circumci-
\nsion services, now or in the future.
\nThe UN Work Plan on Male Circumcision,
\nwhich was developed with financial support
\nfrom the US National Institutes of Health,
\nthe UNAIDS Secretariat, the ANRS and the
\nBill & Melinda Gates Foundation, includes
\nthe development of technical guidance as
\nwell as survey methodologies that can help
\ncountries to determine their needs and
\ncapacity to enhance services, and help track
\nimplementation and changes in sexual
\nbehaviour. As part of the UN plan, a number
\nof country stakeholder meetings are also
\nbeing organized to help countries assess the
\ncurrent status of male circumcision includ-
\ning human rights, ethical and cultural
\naspects, evaluate clinical capacity, and
\ndefine knowledge gaps.
\nWhile this programme and policy work is
\nongoing, some high HIV prevalence coun-
\ntries are already working to improve the
\nsafety of current male circumcision prac-
\ntices and some are considering whether and
\nhow to offer male circumcision in an HIV
\nprevention context. UN agencies emphasize
\nthat the final results of the ongoing trials
\nwill be essential to determining the efficacy
\nof circumcision in preventing HIV infection
\nin men in differing social and cultural set-
\ntings. Once the findings of these trials have
\nbeen announced and reviewed in 2007,
\nWHO, the UNAIDS Secretariat and their
\npartners will define specific policy and pro-
\ngramming recommendations.
\nFor more information contact:
\nWHO
\nAnne Winter
\nTelephone: +41 79 440 6011
\nE-mail: wintera@who.int
\nCathy Bartley
\nTelephone: +44 7958 561 671
\nE-mail: cathy.bartley@ukonline.co.uk
\nIqbal Nandra
\nTelephone: +41 22 791 5589
\nMobile Phone: +41 79 509 0622
\nE-mail: nandrai@who.int
\nTunga Namjilsuren
\nTelephone: +41 22 791 1073
\nE-mail: namjilsurent@who.int
\nUNAIDS
\nSophie Barton-Knott
\nTelephone: +41 22 791 1697
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 83
\nRegional and NMA News
\n84
\nMobile Phone: +41 79 472 7917
\nE-mail: bartonknotts@unaids.org
\nUNICEF
\nGerrit Beger
\nTelephone: +1 212 326 7116
\nMobile Phone: +1 646 764 0200
\nE-mail: gbeger@unicef.org
\nUNFPA
\nPatricia Leidl
\nTelephone: +1 212 297 5088
\nMobile Phone: +1 917 535 9508
\nE-mail: leidl@unfpa.org
\nresource issues in the health field remain a
\nkey CMA priority.
\n(see CMAJ Sept,2006-175(6))
\nGermany
\nThere have been a series of demonstrations
\nand strikes in the hospital sector over the
\npast few months. These have recently been
\nsettled and a report on these actions will
\nappear in the next issue of WMJ
\nThe Exopharm newsletter (www.exophar-
\nmde\/newsletter) also reports concern about
\nan initial draft proposal in the context of
\nhealth reform in Germany. It proposes radi-
\ncal changes in the provision of medication
\nunder the health insurance system.
\nFrance
\nINPADHUE (trade union of practitioners
\nqualified outside the European Union),fol-
\nlowing two strikes of emergency care
\nphysicians earlier this year which sought to
\nfurther their demand for the same working
\nconditions and remuneration as their French
\ncolleagues, further demonstrations in Paris
\nhave now taken place in Paris.. They are
\nseeking a re-opening of negotiations on the
\nlegislation governing doctors with foreign
\nqualifications working in France and have
\nthreatened further actions if their request is
\nnot met. According to the report these
\nactions have been going on for two years.
\nAmerica
\nSubsequent to the Annual Meeting of the
\nAmerican Medical Association, AMA News
\nreports that delegates voted to press Congress
\nto make it quicker and easier for foreign doc-
\ntors to obtain visas to work and stay in the
\nUSA,. Also reported is the adoption of new
\nethical policy placing an obligation on physi-
\ncians to disclose all relevant information to
\ntheir patients, making \u201c therapeutic privilege
\n\u201d no longer acceptable, as it creates a conflict
\nbetween the physician\u2019s obligation to pro-
\nmote patients\u2019well-being and respect for their
\nautonomy by communicating truthfully\u201d. The
\nopinion states that if patients ask to be not
\nThe following report gives some indication
\nof activities or problems exercising the
\nmedical professional organisations or issues
\naddressed in NMA publications since the
\nlast Regional and NMA news.
\nGeneral
\nDiffering problems of migrant physicians
\ncontinue to exercise both groups of
\nmigrants and members of the profession in
\nthe host country. Apart from the global con-
\ncern about shortage of physicians as part of
\nthe growing shortage of healthcare workers
\ngenerally and the moral problem of recruit-
\ning from countries already undersupplied
\nwith physicians, there are dilemmas arising
\nfrom political decisions by governments to
\nsolve this problem. In certain countries of
\nboth North and South America there have
\nbeen actions- in one case to the advantage
\nto the migrant if not to his country of origin.
\nIn the particular host country express con-
\ncern is about tolerance of unlicensed prac-
\ntice by migrant physicians from a specific
\ncountry the nature of whose training cannot
\nbe challenged. In another country a court
\nhas pronounced illegal immigration regula-
\ntions concerned with the period of service
\nin a deprived area recognised as qualifying
\nfor a \u201cnational interest\u201d waiver in respect of
\nobtaining a permanent visa approval.
\nIn the European Union, professional con-
\ncerns of migrant physicians qualified out-
\nside the European Union about inequity in
\nworking conditions between medically
\nqualified EU nationals and Non-EU migrant
\nphysicians, has not only led to demonstra-
\ntions but also to the threat of strikes.
\nDemonstrations have also taken place in
\none war- torn country in the Middle East
\nwhere physicians have not been paid for six
\nmonths
\nCanada
\nMuch of Canadian Medical Association\u2019s
\nAnnual meeting was dominated by the rela-
\ntionship between public and private medi-
\ncine. Delegates voted on more than 20
\nmotions concerning the relationship
\nbetween the public and private sectors,
\napproving a motion to request the govern-
\nment to remove bans preventing physicians
\npractising in both sectors but in addition
\nrequested the CMA to develop a code of
\nconduct for doctors who do this, which
\nwould balance professional autonomy with
\nsocial responsibility The meeting voted
\nagainst the establishing of health insurance
\nservices which would lead to a parallel pri-
\nvate system. The Retiring President Ruth
\nCollins-Nakai left no doubt that Canadian
\nMDs \u201ccontinue to support the principle that
\naccess to care mist be based on need, not
\nability to pay\u201d. The new President, Dr.
\nColin McMillan made clear that human
\nRegional and NMA News
\nThe medical profession: the scene across
\nthe world
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 84
\nReview
\n85
\ninformed or a proxy told this should be
\nrespected. Other adopted policy includes that
\nstating that the public soliciting of organs
\nfrom living donors is ethically acceptable
\nunder certain conditions including the provi-
\nso that it does not unreasonably disadvantage
\nothers on the organ waiting list. The policy
\nadopted is intended to help guide doctors
\nthrough the issues study of which will contin-
\nue. (see http:\/ww.ama-assn.org\/ama\/pub\/cat-
\negory\/16450.html).
\nAMA news also reports the formation of a
\nCouncil on Physician and Nurse supply.
\nThis is part of the Consortium for
\nWorkforce Research Policy, a joint pro-
\ngramme of Pennsylvania\u2019s School of
\nMedicine, School of Nursing and the
\nLeonard Davis Institute of Health
\nEconomics and will monitor and address
\nthe problems of what many say is a growing
\nshortage of physicians and nurses across the
\nUSA. Interestingly there is also a report
\nthat following a five year study by a work-
\nforce of the Massachusetts Medical Society
\nthere is a shortage of primary care physi-
\ncians in Massachusetts .The report \u201c2006
\nPhysician Workforce Study\u201d also refers to
\nsevere to critical shortages of specialists in
\nsome other disciplines.
\nUnited Kingdom
\nFollowing a debate and resolution at the
\nAnnual Meeting of the BMA (ARM), the
\nAssociation is engaged in formulating
\nviews on the future of health service pro-
\nvision in the UK. In addition it is consulting
\nits members in preparing its response to the
\nproposals of the Report \u201cGood Doctors:
\nSafer Patients \u2013 proposals to strengthen the
\nsystem to assure and improve the perfor-
\nmance of doctors and to protect the safety
\nof patients\u201d. This report by the Chief
\nMedical Officer contains radical proposals
\nconcerning the regulation of the profession
\nand changes in the functions of the General
\nMedical Council, the regulating body, some
\nof which have caused grave concern to the
\nmedical profession. In particular, the pro-
\nposals to remove responsibility for the
\noverview of medical education and are
\nthought to be a retrograde step. Following
\nthe ARM a well attended meeting entitled
\n\u201cImproving health in the developing world:
\nwhat can national medical associations
\ndo?\u201d, was attended by a number of repre-
\nsentatives of National Medical
\nAssociations and many others from bodies
\nwith an interest with these problems. The
\nconference was held under the BMA\u2019s
\nStrategic Grant Agreement with the
\nDepartment for International Development.
\nSpeakers in the opening session included
\nProfessor Paul Hunt, UN Special
\nRapporteur on the Right to Health and in
\nthe afternoon Mr Gareth Thomas, UK
\nParliamentary Under-Secretary of State for
\nInternational Development The final ses-
\nsion was opened by Dr Kgnosi Letlape,
\nPresident of the WMA, followed by formal
\npresentations from two NMA speakers.
\nThere were very lively discussions after
\neach session, and Dr. Edwin Borman,
\nChairman of the BMA International
\nCommittee, summing up and suggesting an
\nagenda for co-operation, emphasised the
\nkey challenge for NMAs to develop
\nAdvocacy; that the Right to Health and
\nother principles of human rights provided a
\ngood basis for dialogue with governments;
\nand the importance above all of
\nPartnerships with others to achieve policies
\nto improve the health of the poor and the
\nassociated social problems.
\nSpeaking of Public Health he referred to the
\nchallenges and problems of population
\ngroups and Public Health, also to the need
\nfor healthcare systems to be fit for purpose
\nif, for example, the health-related MDGs
\nwere to be achieved in relation to specific
\npopulations and the burdens imposed by
\n\u201cneglected diseases\u201d addressed. He finally
\nstressed the importance of Collaboration, a
\npure form of which was the Links move-
\nment, a system enabling health profession-
\nals in developed and developing countries
\nto work together to regenerate health sys-
\ntems.
\nIn the glorious setting of Cape Town, South
\nAfrica, at the recently-opened Institute of
\nInfectious Disease and Molecular Medicine
\nof the University\u2019s Faculty of Health
\nSciences, the Novartis Foundation held a
\nsymposium on the highly-relevant topic of
\nInnate immunity to pulmonary infection.
\nLung infection is a major cause of morbidi-
\nty and death in developing, as well as devel-
\noped countries. In South Africa, there is an
\nexplosive combined epidemic of Tuber-
\nculosis and HIV, but also a great deal of
\ninfection in adults and children by other
\nmicro organisms, including pyogenic bacte-
\nria such as S. pneumoniae and H. influen-
\nzae, viruses such as influenza and respirato-
\nry syncytial virus (RSV) and fungal agents
\nsuch as Pneumocvstis carinii and
\nCryptococcus, (nosocomial, 2 immunodefi-
\nciency and primary). In addition, there is an
\nincreasing incidence of asthma, associated
\nwith urbanization. All of this occurs against
\nan historical background of occupational
\nlung disease in miners (silico-anthracosis
\nand asbestosis) and environmental factors
\nassociated with a rural lifestyle. While TB
\nand AIDS are receiving increasing attention
\nand attracting international research effort,
\nscientific studies of other aspects of lung
\ninfection, many treatable or preventable, are
\nrelatively neglected
\nThe subject of innate immunity has moved
\ntowards the centre of immunology and is
\nkey to the pathogenesis of and vaccination
\nstrategies for infectious diseases. Whilst
\nmuch has been learnt with regard to cellular
\nand molecular mechanisms of innate resis-
\ntance to infection, this has still received lit-
\ntle application to human diseases The lung
\nBook review
\nInnate Immunity to Pulmonary Infection
\nChair; Siamon Gordon, Sir William Dunn
\nSchool of Pathology, University of Oxford, UK
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 85
\nReview
\n86
\nis a key target for environmental pathogens,
\nas well as for opportunistic infection, and
\ncould be a fertile source of cells and clini-
\ncal\/pathological materials to investigate dis-
\nease in a genetically varied population.
\nGenetic as well as environmental factors
\nwhich determine the outcome of infection
\nare still poorly understood.
\nAutumn meetings
\nAMA-CMA International Conference
\non Physician Health, Ottawa, Ontario,
\nCanada 30 November – 2 December,
\n2006
\nFurther information: cma.ca\/physician-
\nhealth
\nThe Institute of Medical Law,
\nInternational Conference \u201cGlobal Safety
\nand Rights in Healthcare\u201d Hospital
\nPhuket, Bangkok, Thailand, 13 -15
\nDecember 2006.
\nFurther information: ww.imrab.se\/phuket
\nDevolution: a map of divergence in the
\nNHS -Smith T. & Babbington E in BMA
\nHealth Policy Review Summer 2006 BMA.
\nISSN 1750-0885
\nIn this article, it is interesting to note that
\nthe Devolution of powers to Scotland,
\nWales and (eventually) to Northern Ireland
\nshows signs of divergence in the way in
\nwhich national policies are developing,
\nwhich raise questions as to whether the
\nNational Health Service in the United
\nKingdom hitherto regarded by some as
\nmonolithic, can be so described in the
\nfuture. As this article in the summer issue of
\nHealth Policy Review from the British
\nMedical Association\u2019s Health Policy and
\nEconomic Research Unit comments, while
\nsuperficially it could be argued that the
\naims in England are the same as those in
\nScotland and not dissimilar to those in
\nWales and Northern Ireland (all wishing to
\nstreamline the acute sector and provide
\nmore care in the community and broad
\ncommonalities in broad policy objectives
\nacross the UK), these aims are being pur-
\nsued within different political and contexts
\nand political communities.
\nThis is succinctly illustrated in the reference
\nto a note by Scott Greer (1). Commenting
\non Scottish policy direction, and referring
\nto its broad tone of professionalism, trust in
\nprofessionals running the system and lack
\nNHS Healthcare system in UK shows divergence
\nfollowing Devolution in the Four Kingdoms
\nneed for them to position themselves in
\nrelation to the four different strategic direc-
\ntion in which policies are moving. Finally
\nin a section entitled \u201cDifferent working
\nenvironments for doctors\u201d in the context of
\nthe strategic directions and organisational
\ncontext, they address the question \u201cto what
\nextent does the NHS remain a national
\nhealth service?\u201d and consider the implica-
\ntions for doctors in the four countries.
\nThis fascinating article will be of consider-
\nable interest to both policy makers and
\nphysicians in both developing and devel-
\noped countries who are in the process of, or
\nconsidering, health policy change. It will
\nprove an eye-opener to those who have
\nhitherto observed the huge organisation of
\nthe UK National Health Service and its rel-
\natively uniform policy direction with both
\nadmiration and scepticism. Reading about
\nthese trends following devolution in the UK
\nis well worth the effort and to be widely
\ncommended.
\nOther articles in this issue of the review
\ninclude the problems of management of
\nlong-term conditions in a system under
\nreform, the reality of choice in the political
\ncontext of health and the role of quality in
\nNHS productivity, providing a most valu-
\nable thought provoking resource.
\n(1) Greer S (2004) The politics of health-policy
\ndivergence in Adams J & Scheumueker K
\nDevolution in practice in 2006: public policy dif-
\nferences in the UK. Newcastle upon Tyne: Ippr
\nNorth.
\nW.M.A. MEDICAL ETHICS MANUAL
\nThe Bulgarian Medical Association have
\nrecently translated the Medical Ethics Manual
\ninto Bulgarian and it will be made available to
\nall first year medical students in Bulgaria. The
\nEthics Manual is now available in 13 lan-
\nguages. Further information about availability
\nwma@wma.net
\nof trust in, \u201cor even antipathy towards the
\nmarkets and managers \u2013 who have been
\ncalled in, in increasing numbers, to reform
\nthe English NHS\u201d he continues \u2013 \u201cunder the
\nslogan partnership, Scotland has restored its
\nplanning capacity and sharply reduced the
\nrole of managers while eliminating the pur-
\nchaser-provider divide and the market
\nmanipulating policies that English policy
\nmakers use to try and create competition\u201d.
\nIt is further illustrated by Smith and
\nBabbingtons\u2019comment on Wales (where the
\nHealth and Social Care (Wales) Act 2003
\nprovided powers to take forward policies in
\nNHS healthcare etc.) \u2013 \u201cmuch more so than
\nin England or Scotland, policy is concerned
\nwith health rather than healthcare and there
\nis a greater emphasis on public health.
\nPolitical rhetoric has been directed against
\nthe causes of ill-health in society with less
\nattention played to the management of the
\nsystem\u201d.
\nIn this article in BMA Health Policy and
\nEconomic Research Review published by
\nthe BMA (but not necessarily reflecting
\nBMA policy), in a section entitled
\n\u201cStrategic direction\u201d, Scott Greer (1) is
\nquoted as having given labels to three dis-
\ntinct approaches: England characterised by
\nmarkets and management: the Scotland by
\nnew professionalism \u2013 focused on clinical
\nmanagement: Wales as being primarily
\n\u201clocalist\u201d: Northern Ireland is labelled
\nUneventful management\u201d but the authors
\ncomment that while this is beginning to
\nchange it is the least changed of the four
\ncountries.
\nAfter concentrating on the political, philo-
\nsophical and policy divergences behind the
\ndivergences in the NHS, the authors analyse
\nsome of the implications for doctors work-
\ning in the United Kingdom, dealing with the
\nWMJ_2_59-86.qxd 05.10.2006 14:06 Seite 86<\/p>\n"},"caption":{"rendered":"

wmj11 WorldMMeeddiiccaall JJoouurrnnaall Vol. No.3,September200652 OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC. G 20438 Contents EEddiittoorriiaall Sun City \u2013 A chance to influence change 59 First steps towards selecting a new who Director General 60 MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss Safeguarding Global Research on Human Subjects 60 A European Perspective on the Clinical Research […]<\/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\/wmj11.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3549"}],"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=3549"}]}}