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wmj17<\/a><\/p>\n

Hon. Editor in Chief
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSu\ufb00olk IP143QT
\nUK
\nEditor in Chief
\nDr.P\u0113teris Apinis
\nLatvian Medical Association
\nSkolas iela 3,
\nRiga, Latvia
\nPhone +371 67 220 661
\npeteris@nma.lv
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte- Verlag
\nDieselstr.2
\nD-50859 K\u00f6ln
\nGermany
\nAssistant Editor
\nDr. Ilze H\u0101znere,
\nPilso\u0146u iela 13, Riga, Latvia
\nilzehaz@inbox.lv
\nJournal design by J\u0101nis Pavlovskis
\nCover design by Ilze Ozola
\nCover painting \u201ePhysician and
\nApothecary\u201d by Miervaldis Polis
\n(Pauls Stradin Museum
\nof the History of Medicine)
\nBussiness Managers
\nJ. F\u00fchrer, D. Weber
\n50859 K\u00f6ln
\nDieselstr. 2
\nGermany
\nPublisher
\nThe World Medical
\nAssociation, Inc.
\nBP 63
\n01212 Ferney- Voltaire Cedex, France
\nPublishing House
\nThe Latvian Medical Publisher
\n\u201eMedic\u012bnas apg\u0101ds\u201d,
\nPresident, Dr. Maija \u0160etlere,
\nHospit\u0101\u013cu iela 55, Riga, Latvia
\nDeutscher \u2013 \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
\nSpecial thanks to Bertram Zarins, MD,
\nprofessor of Massachusets General
\nHospital (Boston, USA) for his
\ncontribution and help preparing the WMJ
\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
\nthe World Medical
\nAssociation
\nSubscription fee \u20ac 22,80 per year
\n(incl. 7% MwSt.). For members of the
\nWorld Medical Association and for
\nAssociate members the subscription fee
\nis settled by the membership or associate
\npayment. Details of Associate Membership
\nmay be found at the World Medical
\nAssociatiobn website www.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nK\u00f6ln-Germany
\nISSN: 0049-8122
\nDr. Jon SNAEDAL
\nPresident
\n(Iceland)
\nDr. Edward HILL
\nChairperson of Council
\n(USA)
\nDr. Otmar KLOIBER
\nSecretary-General
\n(Germany)
\nDr. Yoram BLACHAR
\nPresident-Elect
\n(Israel)
\nDr. Nachiappan ARUMUGAM
\nImmediate Past-President
\n(Malaysia)
\nDr. Kazuo IWASA
\nVice-Chairperson of Council
\n(Japan)
\nDr. Eva N. BAGENHOLM
\nChairperson of the Medical Ethics
\nCommittee
\n(Sweden)
\nDr. Mukesh HIKERWAL
\nChairperson of the Finance and Planning
\nCommittee
\n(Australia)
\nDr. J.L. GOMES DO AMARAL
\nChairperson of the Socio-Medical A\ufb00airs
\nCommittee
\n(Brazil)
\nDr. J\u00f6rg-Dietrich HOPPE
\nTreasurer
\n(Germany)
\nDr. Andr\u00e9 WYNEN
\nSecretary-General Emeritus
\n(Belgium)
\nDr. Karsten VILMAR
\nTreasurer Emeritus
\n(Germany)
\nDr. Guy DUMONT
\nChairperson of the Associate Members
\n(Belgium)
\nO\ufb03cial Journal Of The World Medical Association
\nWorld Medical Associations O\ufb03cers
\nwww.wma.net
\n1
\nIt is a great honor to address you as the new editor of the World
\nMedical Journal. The World Medical Journal re\ufb02ects the thoughts
\nand ideas of physicians from all parts of the world. I invite you to
\nnot only read the Journal, but to be a part of the Journal by \ufb01lling
\nit with your manuscripts, illustrations, reviews and opinions. Your
\ncontributions are the heart and soul of the Journal.
\nFirst, I would like to take this opportunity to thank Dr. Alan Rowe
\nand pay special tribute to his longstanding Editorship of the World
\nMedical Journal. Dr. Rowe\u2019s global perspective of medicine, strong
\nsense of ethics, wisdom and brilliant literary skills have shaped this
\nJournal into a truly outstanding publication. His tireless e\ufb00orts have
\nleft a unique impact on the global medical community and I will do
\nmy best to continue the work he has begun. We are truly grateful to
\nDr. Rowe for his long-standing and altruistic work.
\nAs the new editor, I will have the opportunity to communicate with
\nleaders of medical associations from all parts of the world.However,
\nI will do more than speak to the leaders of our member organiza-
\ntions. I will encourage these organizations to use our Journal as a
\nmeans of expressing their views and the concerns of their mem-
\nbers. The national medical organizations in small and developing
\ncountries may not have the resources to pay dues and attend WMA
\nmeetings and conferences. However, they are in our brotherhood \u2013
\ngens una sumus. I will work with medical organizations in all coun-
\ntries to engage their active participation in our Journal.
\nI will also work directly with physicians throughout the world to try
\nto make the WMJ more personal.I would like to see the Journal be-
\ncome a voice for our colleagues in all countries. Of course, in order
\nto converse with someone,it is best to be able to see the person\u2019s face
\nand to look him or her in the eyes. Global organizations can rarely
\ndo this, so I will try to do the next best thing. I will ask you to write
\nabout who you are, what you feel and what you think. What urgent
\nissues do you face? What are the pressing medical needs in your
\ncountry? We will continue our discussions of social, medical, and
\nethical issues on national and international levels, but also expand
\nthe discussions to the personal physician level.
\nEvery country has unique medical problems,but often similar issues
\nexist elsewhere. For example, in Latvia we currently face the predic-
\nament that the government is reluctant to increase the excise-tax for
\ntobacco. Cigarettes can be bought cheaply in Latvia and many tour-
\nists come from other countries in order to buy large quantities of
\ncigarettes.The low price of cigarettes also a\ufb00ects the Latvian people
\nbecause there is little \ufb01nancial incentive to stop smoking. The Lat-
\nvian Medical Association has taken a stand against smoking and has
\nurged the government to ban smoking while driving. I would like
\nto know more about your experiences in the struggle to eliminate
\nsmoking.
\nI will also ask you to write about your national medical association,
\norganizations and your personal experiences. Each story may be an
\netude, opus, or masterpiece. I would like you to send me pictures so
\nthat along with your publication we can show who you are. This is
\na good way to get to know one another. Physicians from Somalia
\nand Vietnam have already answered my \ufb01rst call.Thank you! In our
\nvery next edition we would like to have stories from many other
\ncountries and their medical organizations. Please don\u2019t hesitate to
\ncommunicate with me.
\nAs Editor of the WMJ, I will communicate with editors of medical
\njournals in countries throughout the world. Large countries with
\nthousands of physicians have multiple weekly and monthly medical
\njournals which are readily available. Many journals are supported by
\nadvertising and are provided free of charge to every physician. On
\nthe other hand, in small countries where the health-care budget is
\nconstrained, scanty journals are published infrequently and often
\nare not accessible to every physician. Most of these medical journals
\nare edited by physicians who are well aware of the problems facing
\nphysicians and patients in their own country. I will pay particular
\nattention to physician editors and communications from smaller
\ncountries to help highlight local issues. This may help \ufb01nd common
\nsolutions. I will work to provide a forum for a global perspective on
\nissues that are important to all.
\nThe World Medical Journal is a global publication and as such I
\nplan to dedicate each issue to one of our member countries. The
\ncover will depict a symbol or work of art from that country. As you
\ncan see, I have taken the Editor\u2019s prerogative and begun with my
\ncountry, Latvia. Our cover shows a panoramic view of Riga, the
\ncapital of Latvia and a painting \u201ePhysician and Apothecary\u201dpainted
\nby Latvian artist, Miervaldis Polis.The painting depicts the medical
\nenvironment of Riga in the 15th
\ncentury.Our next cover will be from
\nNorway and the following from Somalia.
\nDear colleagues! Thank you for allowing me to serve as your editor.
\nPlease join me in working to improve our common bond: the World
\nMedical Journal.
\nDear colleagues throughout the world!
\nSincerely yours \u2013
\nP\u0113teris Apinis, M.D.
\nPresident of the Latvian Medical Association,
\nEditor-in-Chief of the World Medical Journal
\n2
\nMost countries of the world experience a
\nshortage of health professionals.This has led
\nto migration \u2013 more or less \u2013 along a wealth
\nor payment gradient from East to West,
\nfrom North to South. Countries like the
\nUnited States Canada or the Scandinavian
\ncountries are now long time net importers
\nof physicians and other health professionals
\n(graph 1),while countries in Asia,like India,
\nChina and the Philippines as well as Sub-
\nSahara African countries are net providers
\nof physicians (graph 2). A third group lies
\nin the middle: immigration and emigration
\nare strong and in a few cases even balanced
\nlike Germany, the United Kingdom or the
\nCzech Republic.
\nWhile the rich countries report shortages
\nespecially in rural practice, countries in
\nSub-Sahara Africa are factually depleted
\nfrom physicians. Comparing the density of
\nphysicians in counties of Sub-Sahara Africa
\nto the density in Europe or North America
\nmakes it clear that the rich countries suf-
\nfer from a relative, if not a luxury problem,
\nwhen compared to the poorest countries in
\nthe world. But does that mean they don\u2019t
\nhave to worry?
\nIndeed the shortage of physicians espe-
\ncially in the European Countries and North
\nAmerica is harmless only on the \ufb01rst look.
\nInternally the undersupply of health ser-
\nvices can produce severe tension within the
\ncountries and regions. But more important,
\nalthough the relative numbers of physicians
\nin demand is comparatively low,it translates
\ninto a high absolute number on a global
\nscale. This produces a pull to the physicians
\nin poorer countries. What we \ufb01nd is a sig-
\nni\ufb01cant percentage of physicians trained in
\nAfrica or Asia showing up to work in the
\nUnited States, Canada, West and Central
\nEurope. The relative shortage of physicians
\nin the rich countries leads to an absolute
\nde\ufb01cit in the poor countries.
\nHowever special migration is by far not the
\nonly problem as money is not the only driv-
\ning force. When we look to the reasons for
\nmigration (see graph 3) we \ufb01nd remunera-
\ntion as the \ufb01rst argument, but closely fol-
\nlowed by a group of other reasons, which
\ncan be summarized under working and
\nliving conditions. And indeed some migra-
\ntions streams e.g. from Germany to Scan-
\ndinavia are not being driven by money, but
\nby chances for a better and more satisfying
\nwork environment, more time for patient
\ncare, more time for the family.
\nThe quantitatively biggest loss to the
\nwork force in Central Europe occurs be-
\ncause of its demographic shift combined
\nwith a set of recent health reforms that
\nare driving the traditionally long work-
\ning physicians into early retirement. Loss
\nof professional autonomy, clinical inde-
\npendence, a ridiculous and still growing
\namount of bureaucracy and financial dis-
\nincentives make many physicians to give
\nup early, if they are not young enough to
\ngo away.
\nCounteracting this by just producing more
\nphysicians doesn\u2019t work either. Germany
\nproduces more physicians than it need. Yet
\nduring the last decade not only the dropout
\nrate of medical students increased dramati-
\ncally, even worse, successful graduates don\u2019t
\nshow up in clinical practice. More than a
\n\ufb01fth of those completing medicine either
\nseek directly positions abroad or go to other
\nprofessions.
\nWhat can be an answer: The rich health
\ncare systems developed three strategies that
\ncan be summarized under the terms
\n\u2022 Hotlines: don\u2019t provide care \u2013 just talk
\nabout it! Certainly people in western
\ncountries want to be served immediate-
\nly, hotlines are a demand of our times.
\nBut they are also used to keep patients
\naway from their physicians.
\n\u2022 Rationing: pretending that higher qual-
\nity requires concentration. Disinvest-
\nment strategies usually come with ar-
\nguments of quality. Services have to be
\nconcentrated to get higher numbers and
\nmore pro\ufb01ciency, drugs have to be in-
\ntensively tested and evaluated over and
\nover again. Sometimes these arguments
\nare true, sometimes this is nothing but a
\nhidden rationing.
\n\u2022 Substitution: \u201cYou don\u2019t need a physi-
\ncian!\u201d More and more medical tasks
\nare shifted to nurses, midwives, phar-
\nmacists and other health professionals.
\nIndeed many automated and standard-
\nized procedures can be done by others
\nthan physicians and delegation may be
\na reasonable way to discharge physician.
\nIn a number of cases even complex pro-
\ncedures can be done by specially trained
\nnurses or other professionals. However,
\nwhat we currently see in charging nurse
\npractitioners, pharmacists and others is
\nnothing else but to downgrade primary
\ncare to a non-professional, because of
\nnon \u2013 educated level.
\nFrom the Secretary General\u2019s desk
\nThe global Shortage of Health Professionals must concern all of us
\nDr. Otmar Kloiber
\nSecretary-General
\n(Germany)
\n3
\nTo a certain extend it works. People feel sa-
\ntis\ufb01ed, because they are immediately taken
\ncare of. What they don\u2019t realize is that do-
\ning just something often is not enough and
\nsometimes even dangerous.
\nWhen we turn our look to the poorest coun-
\ntries of the world, it becomes clear that the
\nsubstitution of physician and often nurse
\ncapacity is unavoidable. With physician\/
\npopulation ratios as low a 1\/50000 there
\nis no way that physicians will be available
\nfor all medical services.Task shifting, as the
\nWHO calls the provision of medical and
\nnursing services by laypersons, is necessary.
\nHowever, as clear as a necessary and un-
\navoidable emergency measure WHO wants
\nto call it \ufb01rst class care.
\nLaypersons can be trained and guided to
\nvaluable and often high quality care. The
\nbest example of that is the Red Cross\/Red
\nCrescent workforce,which for most of it is a
\nvoluntary lay structure.They do undoubted-
\nly a terri\ufb01c job.However,they are embedded
\nin a well-structured organization providing
\ncontinuous training, guidance, support and
\nsupervision and most of all they work with
\nclear and strict limits.
\nFor some speci\ufb01c tasks this may be pos-
\nsible and actually is already being deployed
\nin several countries. Often with speci\ufb01c
\nprograms and limited to certain tasks. Un-
\nfortunately people in those countries don\u2019t
\nonly get the diseases for which there are
\nprograms i.e. for HIV\/AIDS, tuberculosis,
\nmalaria and river blindness, they get all the
\nother problems people get: heart infarcts,
\nmental disorders, rheumatism, injuries and
\nso on. How lay community workers should
\nprovide a \ufb01rst class care for all those illness-
\nes and injuries probably will remain a secret.
\nBut worse: If not combined with measures
\nto invest and strengthen the remaining pro-
\nfessional workforce Task Shifting will even
\ndrive out the last health professionals.
\nOf course all those programs are supposed
\nto be evaluated. But in the past those evalu-
\nations have served as justi\ufb01cations tools
\nlooking to exactly what they wanted to
\nsee. No doubt, as long as there is external
\nmoney for a task-shifting project on HIV\/
\nAIDS care you will see a decline of mor-
\ntality from AIDS. But what happens to all
\nthe other medical needs that can\u2019t no longer
\nbe served. What happens to the surround-
\ning communities, which may have nothing
\nleft? How sustainable will be a non-paid lay
\nforce when outside support will be gone?
\nNow, we already see a huge problem in
\nrise of Multi-Drug-Resistant Tuberculosis
\n(MDR-TB) and even worse Extended-
\nDrug-Resistant TB (XDR-TB). And as a
\nWHO o\ufb03cer correctly analysed: XDR-TB
\nis nothing else than badly managed MDR-
\nTB, and MDR-TB is nothing else than
\nbadly managed TB. This gives us a glimpse
\npreview on what may happen with resis-
\ntance development to anti-retroviral drugs
\nin non-professionally structured treatment
\nprograms.
\nHealth care is highly depending on hope
\nand trust. For patients and those who work
\nin the system. If hope and trust is missing,
\ndevelopment will not happen. The health
\ncare systems of many countries of this
\nworld are living proof of this. Task shifting
\nwithout strengthening the existing health
\nprofessional workforce will down-spiral the
\nhealth care systems of the poorest countries
\neven more leading to the exodus of even the
\nlast health professionals.
\nGraph1:The health care systems of the richnations are strongly depending on immigrant physicians.
\n(World Health Report 2006)
\nGraph 2: Many African countries have lost signi\ufb01cant parts of their workforce to the rich countries
\nof the world. (World Health Report 2006)
\n4
\nUnfortunately, the rich countries installing
\nthe programs for task shifting in the poor
\ncountries are at the same time the magnets
\nfor migrant physicians. Bringing the work-
\nforce situation of the rich countries in order,
\nwhich means in the \ufb01rst place improving
\nthe work and life conditions for the health
\nprofessionals is a necessary prerequisite to
\nhelp the health care systems of the poor
\ncountries of this world.
\nTraining su\ufb03cient numbers of health pro-
\nfessionals, but also providing well enough
\nwork and living conditions for them is an
\nurgent demand in rich and poor countries.
\nAnd just because of the strong attraction
\nthe rich countries produce, \ufb01xing their
\nworkforce problem is no luxury item but a
\nquestion of survival for many nations.
\nBetween the yearly sessions of the World
\nHealth Assembly, the \u201cExecutive Board\u201d
\nis the highest steering body of the World
\nHealth Organisation (WHO). From Janu-
\nary 21st
\nto 26th
\n, 2008 it met in Geneva for
\nits 122nd
\nsession. The Executive Board
\ndealt with many technical and health mat-
\nters ranging from the pandemic in\ufb02uenza
\npreparedness, or the Poliomyelitis to the
\nstrategies to reduce the harmful use of al-
\ncohol and the monitoring of health-related
\nMillennium Development Goals1
\n. Some of
\nwhich the Health Professions, admitted as
\nobservers to the Session, took a common
\nstand on.The board recognized the interna-
\ntional discussion about climate change and
\niterated on its e\ufb00ects on human health.
\nDeveloping e\ufb00ective health responses to
\nclimate changes
\nOf particular interest is the resolution on cli-
\nmate change and health that was adopted by
\n1 The working documents and adopted resolution of
\nWHO Executive Board can be downloaded from:
\nhttp:\/\/www.who.int\/gb\/
\nthe Board for submission to the World Health
\nAssembly. The resolution namely recognizes
\nthat \u201cthe scienti\ufb01c evidence of the e\ufb00ect of
\nthe increase in atmospheric greenhouse gases,
\nand of the potential consequences for human
\nhealth, has considerably strengthened\u201d2
\nand
\nthat \u201creinforcing health systems to enable
\nthem to deal with both gradual changes and
\nsudden shocks is a fundamental priority in
\nterms of addressing the direct and indirect ef-
\nfects of climate change for health\u201d3
\n.
\nThe Board therefore recommends the World
\nHealth Assembly to take several actions,
\nsuch as for WHO Director General to draw
\nto the attention of the public and policy-
\nmakers of the serious risk of climate change
\nto global health security and to the achieve-
\nment of the health-related Millennium De-
\nvelopment Goals, and, to work with appro-
\npriate UN organisations and other agencies
\nin order to develop capacity to assess the
\nrisks from climate change for human health
\nand to implement e\ufb00ective responses. Dr
\n2 Preamble, indent 6
\n3 Preamble, last indent
\nMargaret Chan, the Director General of
\nWHO, is also encouraged to consult Mem-
\nber States on the preparation of a work plan
\nfor scaling up WHO\u2019s technical support to
\nMember States in that area.
\nVoicing health professions\u2019 concerns to
\nthe Executive Board
\nThe World Medical Association\u2019s secretariat
\nfollowed closely the Board session and took
\nan active role together with the other part-
\nners in the World Heath Professional Al-
\nliance4
\nThe WHPA is a unique alliance of
\ndentists, nurses, pharmacists and physicians
\naddressing global health issues and striving to
\nhelp deliver cost e\ufb00ective quality health care
\nworldwide. The World Medical Association
\nrepresents the physicians in this Alliance.
\nThe WHPA identi\ufb01ed three key themes out
\nof the WHO Board agenda, on which it
\n4 FDI World Dental Federation, International Council
\nof Nurses, International Pharmaceutical Federation,
\nand the World Medical Association – http:\/\/www.
\nwhpa.org\/
\nGraph 3: Payment is an important reason for health professionals to migrate, but working and
\nliving conditions are likewise important. (World Health Report 2006)
\nWHO Executive Board, 122nd
\nsession, 21\u2013 26 January 2008
\n5
\naddressed the Executive Board with joint
\nstatements.
\n\u2022 Female genital mutilation, a severe vio-
\nlation of women\u2019s human rights
\nIn its statement, the Alliance welcomes the
\nreport by WHO secretariat on female geni-
\ntal mutilation (FGM), noting the slow rate of
\ndecline of these practices,and praises the draft
\nresolution submitted to the Board for adop-
\ntion.Because of its serious detrimental impact
\non the physical and mental health of women
\nand girls,female genital mutilation is a matter
\nof deep concern to health professionals. The
\nWHPA therefore urges Medical and Nursing
\nAssociations, and invites the support of other
\nhealth professions associations, to develop
\neducational programs that would:
\n\u2022 Include adequate information on the
\nacute dangers of female genital mutila-
\ntion for women and girls;
\n\u2022 Raise awareness on such practices as
\na severe violation of women\u2019s human
\nrights that physicians or other health
\nprofessionals should never practice un-
\nder any circumstances,
\n\u2022 Encourage physicians and nurses to in-
\nform women, men and children about
\nFGM and discourage them from per-
\nforming or promoting such practices.
\nIn the end \u2013the members of the Executive
\nBoard could not \ufb01nd a compromise on sev-
\neral controversial amendments put forward
\nby the US delegation.The text will therefore
\nbe submitted \u2013 in its current version – to the
\nWorld Health Assembly in May.
\nOn the 6th
\nof February, in a statement to
\nmark the international day of zero tolerance
\nto FGM,the WMA repeated its strong con-
\ndemnation of this practice and expressed se-
\nrious concern about the increasing tendency
\nfor female genital mutilation to be carried
\nout by medical personnel.
\n\u2022 Addressing the health of migrants from
\na human rights\u2019 perspective
\nWhile welcoming the initiative from
\nWHO secretariat in this area, the WHPA
\nemphasizes in its statement some key issues
\nthat should be addressed by the Board in its
\nresolution:
\n\u2022 The legal status of migrants, whether
\ndocumented or undocumented, consti-
\ntutes an important health determinant.
\nAlthough all migrants are exposed to the
\nparticular trauma of the migration process,
\nthe situation is even more acute for un-
\ndocumented migrants in particular when
\naccessing health care. In addition, the Al-
\nliance deplores the practice in some des-
\ntination countries whereby health profes-
\nsionals are encouraged or even constrained
\nto denounce or give personal details to the
\nauthorities on undocumented migrants.
\nThis blatantly violates the fundamental
\nprinciple of patient con\ufb01dentiality, threat-
\nens the patient\/health care professional re-
\nlationship and, inappropriately, introduces
\nlaw enforcement responsibilities within
\nhealth professionals\u2019scope of practice.
\n\u2022 Children of undocumented migrants
\nstart their lives disadvantaged because
\nthey may not be registered at birth. The
\nWHPA is deeply concerned that unreg-
\nistered and undocumented children face
\nexclusion from access to health services,
\nsuch as immunization, and to schooling
\n\u2022 The Alliance deplores as well the dis-
\ncrimination often faced by migrant
\nhealth professionals in accessing social
\nand health services in receiving coun-
\ntries. Other forms of discriminations
\ninclude lower pay, job insecurity, less
\nfavourable assignments and heavier
\nworkload. Health professions organiza-
\ntions therefore support a code of ethical
\nrecruitment, including a focus on equal
\nopportunity, and its full implementation
\nby employers and other authorities.
\n\u2022 The WHPA emphasizes that the resolu-
\ntion should address the particular needs
\nof migrant women. Many are particu-
\nlarly exposed to gender-based violence
\nand other forms of abuse, due to their
\nprecarious economic, social and legal
\nstatus. They encounter di\ufb03culties in ac-
\ncessing health care, including sexual and
\nreproductive health services, leading \u2013
\namongst other things – to inadequate
\nantenatal care, high rate of stillborn
\nchildren and a higher incidence of un-
\nplanned pregnancies amongst the mi-
\ngrant communities.
\nIn conclusion of the statement, the Alliance
\nrecommends that the countries facing migra-
\ntionchallengesdevelopcomprehensivehuman
\nrights impact assessments and monitoring
\nmechanisms that take into consideration the
\nright of all migrants, women and men, to the
\nhighest attainable standard of health, regard-
\nless of their legal or social status.
\n\u2022 The strengthening of e\ufb03cient health
\nsystems as a key determinant of inter-
\nnational migration of health personnel
\nThe health professions readdressed the chal-
\nlenges resulting from international migration
\nof health personnel and is pleased to note that
\nsince its foundation,the Global Health Work-
\nforce Alliance5
\nhas developed into a facilitating
\nbody that drives and shapes the global agenda
\nin this context. However, despite major e\ufb00ort,
\nthe realities of health personnel migration
\nhave not yet changed signi\ufb01cantly.Reminding
\nthat migration is a symptom of a disfunctional
\nhealth system, the World Health Professions
\nAlliance stresses the urgent need to translate
\ninternational policies, guidelines and codes
\ninto tangible national action, as much as shar-
\ning of best practices and successes.It calls upon
\nall governments, WHO and other stakehold-
\ners to seriously address the strengthening of
\nfunctional health systems, as well as the rein-
\nforcement of infrastructures and training ca-
\npacity of countries worldwide in order to reach
\nthe goal of self-su\ufb03ciency in health human
\nresources.
\n5 The Global Health Workforce Alliance is a partner-
\nship dedicated to identifying and implementing solu-
\ntions to the health workforce crisis. It brings together
\na variety of actors, including national governments,
\ncivil society, finance institutions, workers, international
\nagencies, academic institutions and professional as-
\nsociations.The Alliance is hosted and administered by
\nWHO – http:\/\/www.who.int\/workforcealliance\/en\/
\n6
\nNon-communicable diseases are not the
\nbeloved children of public health. Although
\nWHO deals with them now for a long
\ntime they never have gotten the clear and
\nprogrammatic approach infectious diseases
\nhave received.This,of course,has something
\nto do with the clear aetiology of infectious
\ndiseases. Second traditional public health
\nwas heavily focused to infectious diseases
\nas the leverage for public or political action
\nwas impediment, while it seemed that non-
\ncommunicable diseases where a matter of
\nfate or personal behaviour.
\nHowever, huge progress has been made
\nwhen looking on non-communicable diseas-
\nes from the risk side. Analyzing factors that
\nlead to non-communicable diseases is an
\nestablished and successful strategy. Starting
\nwith the work of Bernardino Ramazzini in-
\naugurating occupational and environmental
\nmedicine more than 200 years ago coming
\nto the multinational Frame Work Conven-
\ntion on Tobacco Control as the most recent
\nmajor achievement e\ufb00ective and often very
\ncheap methods have been found to combat
\na large number of non-communicable dis-
\neases and injuries.
\nRisk factors are a key to combating non-
\ncommunicable diseases: The draft action
\nplan especially stresses tobacco use, un-
\nhealthy diet, physical inactivity, and the
\nharmful use of alcohol. But looking to the
\npoorest countries of the world childhood
\nand maternal underweight, high blood
\npressure, unsafe water, indoor smoke from
\nsolid fuels, illicit drug use, tra\ufb03c related
\ninjuries, environmental and occupational
\nrisks, unsafe health care practices, abuse,
\nviolence, poverty and poor housing are cer-
\ntainly likewise important and preventable
\nrisk factors for non-communicable diseases
\nand injuries.
\nThe overall purpose of the draft action plan
\nis to
\n\u2022 \u201cmap the emerging epidemics of non-
\ncommunicable diseases and analysing
\ntheir technical, social, economic, behav-
\nioural and political determinants [\u2026]
\n\u2022 reduce the level of exposure of individu-
\nals and populations to the common risk
\nfactors for non-communicable diseases
\n[\u2026] and
\n\u2022 strengthen health care for people with
\nnon-communicable diseases [\u2026]\u201d
\nThe new draft action plan develops 5 ob-
\njectives (see box) each with action items for
\nmember states, the WHO secretariat and
\ninternational partners. For each of those
\naction items deliverable as indicators for
\nsuccessful implementation are de\ufb01ned. The
\nplan de\ufb01nes its purpose on one hand as to
\n\u201cprovide an overall direction\u201d for all non-
\ncommunicable diseases many of which are
\nchronic and high burden diseases.
\nOn the other hand, it lists four of them
\nnamely: cardiovascular disease, cancer,
\nchronic respiratory disease, and diabetes
\nmaking the largest contribution to mortality
\nin the majority of low- and middle-income
\ncountries and it delineates the program
\nagainst conditions like blindness, deafness,
\noral diseases, certain genetic diseases, and
\nother diseases of a chronic nature, includ-
\ning some communicable diseases. The rela-
\ntion of the action plan to other important
\nchronic and non-communicable disease
\ngroups like muscular-skeletal diseases or
\nmental diseases is not mentioned.
\nThis may by just a matter of language and in-
\nclusion.This may be vague by purpose \u2013 not
\nto exclude any options or for other reasons
\ne.g. not to produce any con\ufb02ict with other
\nprograms. However, clarity would help and
\nthat starts with the title: What does \u201ccon-
\ntrol\u201d of non-communicable diseases mean?
\nDoes it mean to \u201cin\ufb02uence\u201d, \u201crestrain\u201d or
\n\u201cmanage\u201d them, or does it only mean to
\n\u201cmonitor\u201d them? The ambiguity is resolved
\nonly to some extent by the objectives and
\nmeasures described. This gives some indi-
\ncation of what can be meant by \u201ccontrol\u201d.
\nThe document would win considerably if
\nthe ambiguous term would be replaced with
\na more clear and precise one, or at least it
\nwould have to be de\ufb01ned.
\nBut scepticism may remain, because \u2013 and
\nthat is most worrying \u2013 none of the \u201cperfor-
\nmance indicators\u201d measures the quality and
\naccessibility of care for patients with non-
\ncommunicable diseases.Instead,numbers of
\nmeeting,administrational units and budgets
\nare measured. All very important, but what
\ndo they mean, if nothing changes in real
\nhealth care? WHO may be reminded from
\nNon-communicable diseases are in the focus
\nof a new WHO action plan
\nObjectives of the \u201cWHO draft action plan for the prevention and control of non-com-
\nmunicable diseases\u201d
\n\u2022 To raise awareness of non-communicable diseases and advocate for their prevention
\nand control
\n\u2022 To establish or strengthen, as appropriate, national policies and plans for the preven-
\ntion and control of non-communicable diseases
\n\u2022 To promote speci\ufb01c measures and interventions to reduce the main shared risk fac-
\ntors for non-communicable diseases: tobacco use, unhealthy diets, physical inactivity
\nand harmful use of alcohol
\n\u2022 To promote research for the prevention and control of non-communicable diseases
\n\u2022 To promote partnerships for the prevention and control of non-communicable dis-
\neases
\n\u2022 To establish systems for tracking global progress in the prevention and control of
\nnon-communicable diseases
\n7
\nAdopted by the 44th World Medical Assembly,Marbella,
\nSpain,September 1992 and amended by theWMA Gen-
\neral Assembly in Copenhagen, Denmark, October 2007
\nPreamble
\nGiven growing environmental awareness
\nand knowledge of the impact of noise on
\nhealth, the psyche, performance and well-
\nbeing, the \ufb01ght against environmental noise
\nis becoming increasingly important. The
\nWorld Health Organization (WHO) de-
\nscribes noise as the principal environmental
\nnuisance in industrial nations.
\nNoise a\ufb00ects people in various ways. Its ef-
\nfects relate to hearing, the vegetative nervous
\nsystem, the psyche, spoken communication,
\nsleep and performance. Since noise acts as
\na stressor, an increased burden on the body
\nleads to higher energy consumption and
\ngreater wear. It is thus suspected that noise
\ncan primarily favour diseases in which stress
\nplays a contributory role, such as cardiovas-
\ncular diseases, which can then be manifested
\nin the form of hypertension, myocardial in-
\nfarction, angina pectoris, or even apoplexy.
\nThe e\ufb00ects in the psychosocial \ufb01eld are
\nlikewise dramatic. The stress caused by en-
\nvironmental noise – particularly road tra\ufb03c
\nnoise – is a central concern, not only in the
\nindustrial nations, but increasingly also in
\nthe developing countries.
\nOwing to the continuous and massive
\ngrowth of tra\ufb03c volumes, both on the roads
\nand in the air, the stress caused by environ-
\nmental noise has increased steadily in terms
\nof both its duration and the area a\ufb00ected.
\nDamage to hearing caused by leisure-time
\nnoise is also of growing concern. The most
\ncommon source of noise in this context is
\nmusic, to which the ear is exposed by di\ufb00e-
\nrent audio media at di\ufb00erent places (portable
\nmusic players, stereo systems, discotheques,
\nconcerts). The risk of su\ufb00ering hearing
\ndamage is underestimated by most people,
\nor even consciously denied. The greatest is-
\nsue (or aspect) lies in creating awareness of
\nthe problem in the high-risk group – which
\ngenerally means young people. In this res-
\npect, the legislature is called upon to inter-
\nvene and reduce the potential for damage
\nby introducing sound level limiters in audio
\nplayback units and maximum permissible
\nsound levels at music events, or by banning
\nchildren\u2019s toys that are excessively loud or
\nproduce excessive noise levels.
\nIn keeping with its socio-medical commit-
\nment, the World Medical Association is is-
\nsuing a statement on the problem of noise
\npollution with the aim of making a contri-
\nbution to the \ufb01ght against environmental
\nnoise through more extensive information
\nand more acute awareness.
\ntime to time that it is the World\u2019s Health
\nOrganization and not only the World\u2019s
\nPublic Health Organization. This is more
\nthan just a play with words; people su\ufb00er-
\ning from non-communicable diseases will
\nbe able to tell the di\ufb00erence.
\nThe \u201cDraft WHO action plan for the pre-
\nvention and control of non-communicable
\ndiseases\u201c is an important document for
\nthe further development of regional and
\nnational health policies aimed to control
\nand prevent non-communicable diseases
\nas leading causes of deaths and burden of
\ndiseases. Just working on the reduction of
\nthe mentioned risk factors should lead to a
\nmeasurable reduction of non-communicab-
\nle diseases. And hopefully it will not only
\nprevent a large number of cases but also en-
\nhance availability, quality and accessibility
\nof care for patients with non-communicable
\ndiseases.
\nThe \u201cWHO draft action plan for the pre-
\nvention and control of non-communicable
\ndiseases\u201d
\n(WHO Document EB 122\/9) can be
\ndownloaded from:
\nhttp:\/\/www.who.int\/gb\/ebwha\/pdf_\ufb01les\/
\nEB122\/B122_9-en.pdf
\nWMA Statement on Noise Pollution
\nRecommendations
\nThe World Medical Association calls upon the National Medical Associations to:
\n1. Inform the public,especially persons a\ufb00ected by environmental noise,as well as policy and deci-
\nsion makers, of the dangers of noise pollution.
\n2. Call upon ministers of transport and urban planners to develop alternative concepts that are
\ncapable of countering the growing level of environmental noise pollution.
\n3. Advocate appropriate statutory regulations for combating environmental noise pollution.
\n4. Support enforcement of noise pollution legislation and monitor the e\ufb00ectiveness of control
\nmeasures.
\n5. Inform young people of the risks associated with listening to excessively loud music,such as that
\nwhich emanates,for example,from portable music players,use of stereo systems with earphones,
\naudio systems in cars, and attendance at rock concerts and discotheques.
\n6. Prompt the educational authorities to inform pupils at an early stage regarding the e\ufb00ects of
\nnoise on people, how stress due to environmental noise can be counteracted, the role of the in-
\ndividual in contributing to noise pollution, and the risks associated with listening to excessively
\nloud music.
\n7. Provide information about risks of damage to hearing that arise in the private sector as a result
\nof working with power tools or operating excessively loud motor vehicles.
\n8. Emphasize to those individuals who are exposed to excessive levels of noise in the workplace the
\nimportance of protecting themselves against irreducible noise.
\n9. Call upon the persons responsible for occupational safety and health in businesses to take fur-
\nther action to reduce noise emission, in order to ensure protection of the health of employees at
\nthe workplace.
\n8
\nSerious concern about the increasing ten-
\ndency for female genital mutilation
\n(FGM) to be carried out by medical person-
\nnel has been expressed by the World Medi-
\ncal Association. In a statement to mark the
\ninternational day of zero tolerance to FGM
\ntomorrow (Feb 6), the WMA repeats its
\nstrong condemnation of this practice that
\nit says constitutes a severe form of violence
\nagainst women.
\nDr. Jon Snaedal, President of the WMA,
\nsaid a recent World Health Organisation
\nreport indicated that \u2018the rate of progress
\ntowards a signi\ufb01cant decline in the practice
\nis slow\u2019, although the practice was interna-
\ntionally recognised as a violation of human
\nrights and many countries had put in place
\npolicies and legislations to ban it.
\nHe added: \u2018Because of its serious detri-
\nmental impact on the physical and mental
\nhealth of women and girls, female genital
\nmutilation is a matter of deep concern to
\nphysicians. We are particularly worried to
\nnote the increasing practice of female geni-
\ntal mutilation by medical personnel. This is
\nin contradiction with our code of ethics, as
\nthese practices violate the human rights of
\nwomen and girls. The WMA is totally op-
\nposed to this \u201cmedicalization\u201d of FGM \u2018.
\nDr. Snaedal called for all physicians and
\nother health professionals to mobilise ac-
\ntively to stop these \ufb02agrant forms of vio-
\nlence against women.
\nIn 1993, the WMA adopted a statement on
\nfemale genital mutilation condemning such
\npractices as a form of oppression of women.
\nIn 2005 it strengthened its opposition, urg-
\ning national medical association to develop
\neducational programmes for physicians,
\nwhich would:
\n\u2022 Include adequate information on the
\nacute dangers of Female Genital Muti-
\nlations for women and girls;
\n\u2022 Raise awareness on such practices as a
\nviolation of women\u2019s human rights that
\nphysicians or other health professionals
\nshould never practice under any circum-
\nstances,
\n\u2022 Encourage physicians to inform wom-
\nen, men and children about FGM and
\ndiscourage them from performing or
\npromoting such practices.
\nFor further information please contact:
\nDr. Otmar Kloiber
\nWMA Secretary General
\nNigel Duncan
\nWMA Public Relations Consultant
\nnduncan@ndcommunications.co.uk
\nwebsite: www.wma.net
\nPhysicians Call For Zero Tolerance to Female
\nGenital Mutilation Across The World
\nThe World Medical Association Statement on Female Genital Mutilation
\nAdopted by the 45th World Medical Assembly, Budapest, Hungary, October 1993 and edi-
\ntorially revised at the 170th Council Session, Divonne-les-Bains, France, May 2005
\nPreamble
\nFemale genital mutilation (FGM) is a common practice in over thirty countries. In many
\nother countries the problem has arisen more recently due to the presence of ethnic groups
\nfrom countries in which FGM is common practice, including immigrants and refugees who
\n\ufb02ed from hunger and war.
\nBecause of its impact on the physical and mental health of women and children, FGM is a
\nmatter of concern to physicians.Physicians worldwide are confronted with the e\ufb00ects of this
\ntraditional practice. Sometimes they are asked to perform this mutilating procedure.
\nThere are various forms of FGM. It can be a primary circumcision for young girls, usually
\nbetween 5 and 12 years of age,or a secondary circumcision,e.g.,after childbirth.The extent of
\na primary circumcision may vary: from an incision in the foreskin of the clitoris up to a phara-
\nonic circumcision or in\ufb01bulation removing the clitoris and labia minora and stitching up the
\nlabia majora so that only a minimal opening remains to allow for urine and menstrual blood.
\nRegardless of the extent of the circumcision, FGM a\ufb00ects the health of women and girls.
\nResearch evidence shows the grave permanent damage to health. Acute complications
\nof FGM are: hemorrhage, infections, bleeding of adjacent organs, and excruciating pain.
\nLong-term complications include severe scarring, chronic infections, urologic and obstetric
\ncomplications, and psychological and social problems. FGM has serious consequences for
\nsexuality and how it is experienced.There is a multiplicity of complications during childbirth
\nincluding expulsion disturbances, formation of \ufb01stulae, ruptures and incontinence.
\nEven with the least drastic version of circumcision, complications and functional conse-
\nquences can occur, including the loss of all capacity for orgasm.
\nThere are various reasons to explain the existence and continuation of the practice of FGM:
\ncustom, tradition (preserving virginity of young girls and limiting the sexual expression of
\nwomen) and social reasons.These reasons do not justify the considerable damages to health.
\nNone of the major religions supports this practice.The current medical opinion is that FGM
\nis detrimental to the physical and mental health of girls and women. FGM is seen by many
\nas a form of oppression of women.
\nBy and large there is a strong tendency to condemn FGM more overtly:
\n– There are active campaigns against the practice in Africa. Many African women leaders
\nas well as African heads of state have issued strong statements against the practice.
\n– International agencies such as the World Health Organization, the United Nations
\nCommission on Human Rights and UNICEF have recommended that speci\ufb01c measures
\nbe aimed at the eradication of FGM.
\n– Governments in several countries have developed legislation, such as prohibiting FGM
\nin their criminal codes.
\nRecommendations
\n1. Taking into account the psychological needs and \u2018cultural identity\u2019of the people involved,
\nphysicians should inform women, men and children about FGM and discourage them
\nfrom performing or promoting FGM. Physicians should integrate health promotion and
\ncounselling against FGM into their work.
\n2. As a consequence,physicians should have adequate information and support for doing so.
\nEducational programmes concerning FGM should be expanded and\/or developed.
\n3. National Medical Associations should stimulate public and professional awareness of the
\ndamaging e\ufb00ects of FGM.
\n4. National Medical Associations should stimulate governmental action in preventing the
\npractice of FGM.
\n5. National Medical Associations should cooperate in organising an appropriate preventive
\nand legal strategy when a child is at risk of undergoing FGM.
\nConclusion
\nThe World Medical Association condemns the practice of genital mutilation including the
\ncircumcision of women and girls and condemns the participation of physicians in such prac-
\ntices.
\n9
\nInformed Consent \u2013 Recent Developments
\nProfessor Andreas Spickho\ufb00, LLD
\nFaculty of Law, Department of Medical and
\nHealth Law
\nUniversity of Regensburg
\nIntroduction
\nThe principle that any medical intervention,
\neven if it serves the patient\u2019s health, needs
\nhis informed consent is in accordance with
\nthe international standard of medical ethics
\nand medical jurisprudence: salus et voluntas
\naegroti suprema lex.Generally the therapeu-
\ntic intervention is seen as a physical injury,
\njusti\ufb01ed only by the patient\u2019s consent which
\nmeans with regard to the practitioner\u2019s li-
\nability that the physician in charge of the
\ntreatment has the burden of proof for the
\npatient\u2019s informed consent.1
\nIn the past decades this principle has been
\nconstantly put into practice by the jurisdic-
\ntion. This has happened particularly with
\nregard to the application of new and more
\nunusual methods,above all in the domain of
\nmedical research. Seen thus, it is question-
\nable whether minors, unconscious persons
\nor such persons whose self-determination
\nis restricted are capable of consent. Increas-
\n1 Gerfried Fischer; Hans Lilie, \u00c4rztliche Verantwortung
\nim europ\u00e4ischen Rechtsvergleich, 1999; Christian von
\nBar, Gemeineurop\u00e4isches Deliktsrecht, Bd. II, 1999,
\nRn. 299.
\ningly it is considered doubtful if and to what
\nextent an \u201copen consent\u201d is at all possible.
\nNew or unusual methods
\nIn the more recent past the German Federal
\nHigh Court of Justice (Bundesgerichtshof)
\nhas on several occasions given its opinion
\non the problem of employing new and unu-
\nsual methods of medical treatment. It must,
\nhowever, be emphasized that the particular
\ndecisions in question did in no case concern
\nclinical tests. So the rules for clinical re-
\nsearch were not to be applied unreservedly.
\nThe \ufb01rst decision dealt with the insertion of
\na new hip-joint in a computer-aided opera-
\ntion (the so-called \u201cRobodoc\u201d). In the pro-
\ncess of the operation certain nerves of the
\nfemale patient were damaged which led to
\nan impaired function of the legs and feet.
\nThe Federal High Court of Justice pointed
\nout that the employment of a new method
\nof treatment is only permitted if after care-
\nful consideration of the expected advantages
\nof this method and its possible disadvan-
\ntages compared with the standard treat-
\nment, the application of the new method is
\njusti\ufb01ed. Should that be the case, a mistake
\nof treatment is excluded because the physi-
\ncian\u2019s freedom of choice as to the method
\nof treatment has priority. But in respect of
\nthe patient\u2019s right of self-determination,
\nthe patient has to be informed of alterna-
\ntive methods of treatment if, with regard to
\na speci\ufb01c medical therapy several equally
\ne\ufb00ective, and in a given case pertinent
\nmethods are available, though this might
\ncause other physical strains or other risks,
\nbut also other chances of success to the pa-
\ntient. With respect to standard treatments,
\nthe patient need not be informed in general
\nabout the occurrence of unknown compli-
\ncations.They might in a particular case even
\nworry him unnecessarily. This is di\ufb00erent
\nin the case of new methods of operations
\nwhich (as for instance Robodocs) have been
\nonly clinically tested abroad for a few years
\n(in the USA). But in the above mentioned
\ncase the claim against the doctor was dis-
\nmissed, as with the nerve damage a risk had
\nmaterialised about which the plainti\ufb00 had
\nbeen thoroughly instructed, even if only in
\nconnection with the established method of
\noperation.2
\nA further decision of the Federal High
\nCourt of Justice dealt with an attempt at
\nhealing by a treatment with a drug deve-
\nloped in the USA and licensed only when
\nthe treatment had been already applied.The
\nmedicine was meant for the treatment of
\nepilepsy and caused irreparable eye damage
\nto the patient. At the time of the treatment
\nit was licensed neither in the USA nor in
\nGermany but in some European Countries.
\nA clinical test in progress conducted by the
\ndefendant physicians, in which the plainti\ufb00
\nwas not included, was undergoing phase III
\ntrials. The physicians knew that the medi-
\ncal product had not yet been examined for
\ndisturbances of eye functions in humans.
\nTherefore periodic,say for instance monthly
\ncontrols, of the strength of vision were indi-
\ncated.The plainti\ufb00 did notice that his power
\nof vision was impaired. But the medication
\nwas continued all the same and was stopped
\nonly several weeks later. In this case the
\nFederal High Court recognised the liability
\nof the physicians. It held that an individual
\nattempt at healing with a medicine which
\nhad still to be licensed was not forbidden,
\nbut that the physicians were under the obli-
\ngation to control the treatment continually,
\nand particularly with regard to possible eye
\ndamages.Thus the omission of the necessary
\nobservation constituted a fault. The causa-
\ntion of the fault for the damages was even
\npresumed since the Federal High Court
\nassumed a serious fault in treatment, for in
\nan attempt at healing a special standard of
\ncare has to be adopted, which reduces the
\nrequirements necessary for the a\ufb03rmation
\nof a serious fault of treatment. Furthermore,
\nthe Federal High Court assumed insu\ufb03-
\n2 Bundesgerichtshof, 13.6.2006, VI ZR 323\/04, Sam-
\nmlung des Bundesgerichtshofs in Zivilsachen Band
\n168, S. 103; aus der Literatur dazu Christian Katzen-
\nmeier, Neue Juristische Wochenschrift 2006 Seite
\n2738; Benedikt Buchner, Versicherungsrecht 2006, Seite
\n1460.
\n10
\ncient information, because the patient had
\nnot been told that the medical product had
\nnot yet been licensed and that therefore un-
\nknown risks might arise. In such a case it
\ncould not possibly be presumed that the pa-
\ntient, when informed of the circumstances,
\nwould have given his consent to the treat-
\nment with a non-licensed medication.3
\nThethirddecisionoftheFederalHighCourt
\ndealt likewise with a \ufb01rst time-administra-
\ntion of a medication with a view to testing
\nits e\ufb00ects. The female patient was treated
\nin a university hospital for arrhythmia with
\nthe medical drug Cordarex (Amiodaron).
\nDuring the treatment her circulation ceased
\nto function, which caused a permanent da-
\nmage to the brain. The Federal High Court
\nruled that the information given to the pa-
\ntient had been insu\ufb03cient. Though, in the
\nopinion of the lower court the danger of a
\ncardiac arrest was greater with the standard
\nmedication than with the new medication,
\nthe patient had to be informed that the new
\nmedication might likewise lead to a cardiac
\narrest. The Federal High Court has expli-
\ncitly underlined that having regard to the
\nright of self-determination,.the patient has
\nto be informed already before the \ufb01rst ad-
\nministration of a medication. Therefore, the
\nFederal High Court rejected the opinion of
\nthe lower court which declared that the ap-
\nplication of a new medication was tempo-
\nrarily admissible for an initial test in order
\nto show if the medical drug is e\ufb00ective at
\nall.The argument of the patient\u2019s hypotheti-
\ncal consent was also rejected by the Federal
\nHigh Court of Justice since the new medi-
\ncation was not meant as a treatment with
\na view to prolongation of life, but only for
\nreducing the pain of the patient. In such
\ncases a hypothetical consent can only be
\npresumed with great reserve.4
\nThe subject of the most recent decision of
\nthe Federal High Court was again the ap-
\n3 Bundesgerichtshof, 27.3.2007, VI ZR 55\/05, Sam-
\nmlung des Bundesgerichtshofs in Zivilsachen, Band
\n172, Seite 1; dazu Dieter Hart, Medizinrecht 2007,
\nSeite 631; Christian Katzenmeier, Juristenzeitung 2007,
\nSeite 1108.
\n4 Bundesgerichtshof, 17.4.2007, VI ZR 108\/06, Versich-
\nerungsrecht 2007, Seite 999.
\nplication of an outside method which was
\nnew at the time the treatment took place
\nand which was scienti\ufb01cally disputed – sci-
\nenti\ufb01c evaluations with statistical relevance
\nas to the e\ufb03caciousness of the therapy were
\nlacking. In the present case a slipped disc
\nwas treated with a so-called Racz-catheter.
\nThis method consists in injecting several
\nmedical drugs (a \u201ccocktail\u201d) into the spinal
\nchannel with the aid of an epidural catheter.
\nAt the end of this procedure, the patient
\nwas in great pain. The physician prescribed
\nby telephone an additional dose of pain-
\nkillers. When the pain still recurred he pre-
\nscribed, again by telephone, a withdrawal of
\nthe catheter of one centimetre. This caused
\nthe pain to diminish, but with an aftermath
\nof bladder and intestine trouble. Firstly, the
\nFederal High Court underlined again the
\nphysician\u2019s freedom of treatment: The phy-
\nsician was not bound to apply in any case
\nthe surest therapeutic method. But a greater
\nrisk had to be justi\ufb01ed objectively by a spe-
\ncial situation in a concrete case, or else by
\na more favourable healing prognosis.There-
\nfore the Federal High Court of Justice took
\nthe view that the present case constituted
\nan error of treatment. At all events, as se-
\nvere pain connected with the new method
\nof treatment occurred, an augmented care
\nand a detailed medical examination were
\nindicated. Under the given circumstances,
\nand even in taking also into consideration
\nthat the patient was medically treated in the
\nhospital, the physician could by no means
\nbe allowed to give his instructions solely by
\ntelephone, but was bound to examine the
\npatient personally. In addition, the physi-
\ncian was liable in the matter of insu\ufb03cient
\nconsent, for the patient had not been in-
\nformed that the projected intervention was
\nnot yet a standard medical procedure and
\nthat its e\ufb00ectiveness was not yet statistically
\ncon\ufb01rmed. Again the Federal High Court
\nof Justice rejected the appeal of the physi-
\ncian based on a hypothetical consent. It is
\nenough if the patient a\ufb03rms that he would
\nnot have consented to a new medical treat-
\nment outside the medical standards.5
\n5 Bundesgerichtshof, 22.5.2007, VI ZR 35\/06, Neue
\nJuristische Wochenschrift 2007, Seite 2774.
\nInformed Consent and
\nMedical Research
\nNaturally, the above extends also to con-
\ntrolled clinical studies. The existing regula-
\ntions at the level of international standard
\nlaw (Declaration of Helsinki), at the level
\nof the European Community Directives
\n(Good Clinical Practice [GCP] Direc-
\ntive) and at the European level at large (the
\nBiomedicine Convention together with the
\nadditional protocols) are in harmony with
\nthese principles,or at least do not contradict
\nthem.
\nIt is important in this context to broach
\nanother subject which has likewise turned
\nup in a more recent decision of the German
\nFederal High Court.The Court looked into
\nthe matter of a unit of blood from a donor.
\nIn connection with this donation of blood
\nof the patient, a policeman, the injection
\ncaused trauma to the nerve of the epidermis
\non his forearm. This brought on permanent
\npain. A complete recovery is more or less
\nimprobable. That the patient had been in-
\nformed in writing of the slight possibility
\nof a damage to the nerve was not enough.
\nThe Federal High Court of Justice did not
\ngo into the question of whether a mere in-
\nformation in writing in connection with a
\ndonation of blood was su\ufb03cient. The fact
\nseems to be that the patient has also to be
\ninformed of the risks verbally. Considering
\nthe serious consequences, the information
\nwhich the patient received was at all events
\nnot enough. Especially in a case where a
\npatient consents to an intervention from
\naltruistic motives, a particularly straightfor-
\nward and clear information is distinctly in-
\ndicated, because the patient does not pro\ufb01t
\npersonally from the intervention.6
\nThese
\nprinciples are important in connection with
\nmedical research, for the decision of the
\nFederal High Court makes it clear that the
\ninformation given to patients in cases of ex-
\nperiments pro\ufb01ting others have to be more
\n6 Bundesgerichtshof, 15.3.2006, VI ZR 279\/04; Sam-
\nmlung des Bundesgerichtshofs in Zivilsachen, Band
\n166, Seite 336; dazu Andreas Spickhoff, Neue Juristische
\nWochenschrift 2006, 2075; Horst Hasskarl, Pharma
\nRecht 2006, Seite 311.
\n11
\nthorough than in cases of scienti\ufb01c experi-
\nments which are undertaken for the bene\ufb01t
\nof the patient himself.
\nOpen Consent
\nThere is another question which presents it-
\nself in connection with medically controlled
\nresearch namely, if a possibility exists for
\nconsent to be given in view of future sci-
\nenti\ufb01c use of the relevant biological human
\nmaterial to establish a collection of cells,tis-
\nsues etc. for future scienti\ufb01c use. This ques-
\ntion is causing controversy in discussion. It
\nshould, however, with the agreement of the
\nprevious National Ethic Council in Germa-
\nny (Nationaler Ethikrat) and a recommen-
\ndation of the Council of Ministers of the
\nEuropean Council concerning the research
\nwith biological human material, be an-
\nswered in the a\ufb03rmative. Nevertheless, the
\nspecial provisions as to data protection of a
\ngiven country in which the research is car-
\nried out have to be respected. The next step
\nis to inform the patient about the advantag-
\nes and disadvantages of the \u201canonymising\u201d
\nor \u201cpseudonymising\u201d of the relevant tissue.
\nFinally, examples of typical \ufb01elds of appli-
\ncation for a possible research in connection
\nwith a given material should be made plain
\nto the patient. In addition to the appropri-
\nate printed form the information should be
\ngiven verbally, since the printed forms of
\ninformation are subject to the severe regu-
\nlations controlling the general terms and
\nconditions of trade. If all of these condi-
\ntions are complied with, a general consent
\nin the form of an \u201copen consent\u201d should be
\nconsidered admissible. It has to be seen that
\nit is even thought feasible for the patient to
\nwaive his right of information.7
\nThis follows
\nfrom the patient\u2019s autonomy. Therefore, the
\nopinion which states that an \u201copen consent\u201d
\nwas not e\ufb00ective cannot be agreed to.8
\nThe
\npatient\u2019s health in particular is not endan-
\ngered by such an open consent.
\n7 Erwin Deutsch; Andreas Spickhoff, Medizinrecht, 8.
\nAuflage 2008, Rn. 247; Andreas Spickhoff, in: Theodor
\nSoergel, B\u00fcrgerliches Gesetzbuch, Schuldrecht, Band
\n10, 13. Auflage 2005, \u00a7 823, Anhang I: Arzthaftung-
\nsrecht, Rn. 184.
\n8 Anders aber Adolf Laufs, Arztrecht, 5. Auflage 1993,
\nRn. 207.
\nMinors, Unconscious persons,
\npersons incapable of consent
\nResearch in connection with minors or
\nadults incapable of consent presents a spe-
\ncial problem. The GCP-Directive distin-
\nguishes in this instance between minors and
\nadults. In an urgency it is permissible to at-
\ntend to a patient by presuming his consent
\nif, according to the state of investigation of
\nthe medical science or other methods of re-
\nsearch, no su\ufb03cient results from the clinical
\nexamination of persons capable of consent
\nare to be expected, and if, according to the
\nknowledge of medical science, the applica-
\ntion of the medical product still to be tested
\nis indicated to save the life of the person in
\nquestion, to restore his health or to alleviate
\nhis pains. Finally, such researches must be
\ndirectly related to a life-endangering con-
\ndition or a condition of extreme feebleness
\nof the patient and the clinical examination
\nmust be as far as possible free from stress
\nor other foreseeable risks. A group bene\ufb01t
\nalone – as in the case of minors – is not
\nsu\ufb03cient. In the case of minors, however,
\na group bene\ufb01t is enough if the research
\nincludes only a minimal risk or a minimal
\nstress for the minor.It is hardly understand-
\nable why under these additional require-
\nments, a comparable research cannot be
\ncarried out where adults who are incapable
\nof consent are concerned.
\nAnother problem has to do with art. 5 of
\nthe GCP-Directive, (in the form of its in-
\ncorporation into national law). According
\nto the wording of the directive, a treatment
\nwhich cannot be delayed in order to save a
\ngiven person\u2019s life, to restore his health or
\nto alleviate his pains is possible even within
\nthe bounds of the clinical research, when in
\nan emergency a consent cannot be obtained.
\nThis, it is true, applies only to the treat-
\nment of adults capable of consent and not
\nto minors or adults incapable of consent.
\nThe said principle should be nevertheless
\napplied analogously to persons permanently
\nincapable of consent or to minors, insofar as
\nthe patient\u2019s presumed opinion is in favour
\nof his participation in the research project,
\nand insofar as a legal representative can in
\na matter of urgency not be reached, and in-
\nsofar as the experiment can bene\ufb01t the pa-
\ntient directly. Otherwise a whole group of
\npatients might be excluded from possible
\ntherapeutic experiments in cases where the
\nappointment of a legal representative before
\nthe beginning of the experiment is not pos-
\nsible.9
\nThe already mentioned unequal treatment
\nof minors and adults incapable of consent
\ncan be found also in the German jurisdic-
\ntion.The Federal High Court of Justice is,at
\nleast where the medical practitioner\u2019s liabili-
\nty is concerned,of the opinion that even mi-
\nnors who have entered into their 16th
\nyear
\nhave only a right of veto against the consent
\nof their legal representatives, their parents.
\nThe other way round, this means that mi-
\nnors cannot alone give an e\ufb00ective consent,
\neven when they are quite capable of under-
\nstanding. The Federal High Court decided
\nin this sense in the case of a female (minor)
\npatient who had undergone an operation on
\nthe spinal column that caused a paraplegia.
\nFortunately, she \ufb01nally was awarded dam-
\nages for having been insu\ufb03ciently informed
\nsince she had neither given her consent, nor
\nbeen informed at all.10
\nIt would be the right
\ncourse of action, if the minor\u2019s decision
\nalone would count.The jurisdiction does not
\nrule otherwise in cases of adults incapable
\nof consent. Even if an adult is incapable of
\nconsent his wishes with regard to the deci-
\nsion about the treatment are respected up to
\nthe limit of a serious risk to his health, and
\nthis applies equally to his refusal of consent
\nand to his demand for treatment.11
\n9 Erwin Deutsch, Neue Juristische Wochenschrift 2001,
\nSeite 3361 (3363); Andreas Spickhoff, Medizinrecht
\n2006, Seite 707 (710).
\n10 Bundesgerichtshof, 10.10.2006, VI ZR 74\/05, Neue
\nJuristische Wochenschrift 2007, Seite 217.
\n11 Andreas Spickhoff, in: Theodor Soergel, B\u00fcrgerliches
\nGesetzbuch, Schuldrecht 10, 13. Auflage 2005, \u00a7 823
\nAnhang I: Arzthaftungsrecht, Rn. 108.
\n12
\nThe Danish Medical Association dates back
\na hundred and \ufb01fty years and celebrated its
\nBirthday in 2007 amongst other initiatives
\nby inviting the World Medical Association
\nto Copenhagen to have its General Assem-
\nbly in the autumn winds and sunshine of
\nCopenhagen City Centre.
\nThe following is a portrait of an association
\nwhich has survived a 150 years of di\ufb00erent
\nregimes and of in\ufb02uence on health policy
\nmaking in Denmark but without direct ac-
\ncess to write the health laws that govern a
\npublic health care system.
\nThe DMA is an umbrella organisation
\nwhich seeks to in\ufb02uence the development
\nof health and social policy and render visible
\nthe interest of the medical profession. Fur-
\nthermore the DMA coordinates and unites
\nthe opinions of the four associations that
\nconstitute the Danish Medical Association.
\n95 % of all doctors working in Denmark are
\nmembers of the organisation.
\nThe Danish Medical Association
\n(policy making body)
\nThe Danish Association of Junior Doctors
\nThe Danish Association of
\nMedical Specialists
\nThe Danish Organisation of
\nMedical Practitioners
\nThe highest authority of the DMA is the
\nassembly of representatives which meets an-
\nnually. The representatives are appointed by
\nthe above mentioned organisations accord-
\ning to the number of members.The Assem-
\nbly of Representatives decides the general
\npolicy of the DMA, the budget, approve
\nthe accounts and elect the president and the
\ncouncil. The Assembly of representatives
\nalso elects the DMA arbitration committee,
\nthe medical ethics board and the Commit-
\ntee of Preventive Medicine.
\nThe DMA council is responsible for the day
\nto day leadership of the DMA. It consists of
\na chairman and six members, two each rep-
\nresenting the three negotiating organsations.
\nThe Council points out a number of stand-
\ning and temporary committees and working
\ngroups in order to attend to the various sub-
\njects that the organisation has to deal with.
\nServices
\nAs most professional organisations the
\nDMA provides services to its members. In
\nthe legal department, the lawyers give ad-
\nvice on patient complaints, the handling of
\ncriminal cases, duty on con\ufb01dentiality, ac-
\ncess to health information, medical ethics
\ndisputes and the overall regulation in the
\n\ufb01eld of health care.
\nTraining
\nThe DMA o\ufb00ers a great variety of train-
\ning. Mostly one day short courses in various
\n\ufb01elds and courses for trade union represen-
\ntatives. Through the DMA Committee on
\ntraining and research the DMA in\ufb02uences
\nthe medical and specialist training.
\nMedical bulletin
\nThe DMA arranges public meetings on
\nvarious subjects and o\ufb00ers a medical bul-
\nletin with important news on research and
\ndebate on a weekly basis.
\nWorking environment
\nThe DMA seeks to improve the working
\nconditions for Doctors and through in\ufb02u-
\nencing the legislation and cooperation with
\nother health professionals.The DMA Com-
\nmittee for Doctor\u00b4s Occupational environ-
\nment especially focuses on inter-collegial
\nrelations and collegial spirit.
\nCooperation with
\npharmaceutical companies
\nThe DMA has established a cooperation with
\nthe umbrella body of the pharmaceutical com-
\npanies and other stake holders in order to de-
\nvelop common independent information on
\npharmaceuticals. Furthermore the DMA has
\nmade an agreement with the pharmaceutical
\ncompanies and the association of pharmacists
\nin order to regulate the question of sponsor-
\nships from the industry towards doctors to
\nensure independence of all parties.
\nEthics
\nThe DMA has a strong engagement in
\nethical matters. The DMA Medical Ethics
\nCommittee has a consultation part and it is
\nalso independently creating policies on the
\ncontemporary ethical dilemmas, both with
\nregard to the special problems relating to
\nimmigration and the use of new technol-
\nogy.
\nPortrait of a key player
\nThe Danish Medical Association through 150 years
\nDr.Jens Winther Jensen, the President of
\nDanish Medical Association, Dr.Otmar
\nKloiber and Dr. Nachiappan Arumugam
\n13
\nOrganisation and membership
\nThe Norwegian Medical Association
\n(NMA), was founded in 1886 as the profes-
\nsional association and trade union for Nor-
\nwegian physicians. Membership is volun-
\ntary, and approximately 96 % of Norwegian
\nphysicians are members. The main aims of
\nthe Association are to protect the profes-
\nsional, social and \ufb01nancial interests of its
\nmembers, to promote their interests in mat-
\nters concerning medical education, profes-
\nsional development and scienti\ufb01c activities,
\nand to advance the quality of the Norwe-
\ngian health care system.
\nSome main bodies of the Norwegian
\nMedical Association:
\nAnnual Representative Meeting (ARM) is
\nthe chief decision-making body and elects
\nthe Central Board of 9 members, including
\nthe president and vice-president. The elec-
\ntion period for the board is two years. ARM
\nalso elect the The Medical Ethics Commit-
\ntee (chairperson: Trond Markestad)
\nThe secretariat
\nThe secretariat has \ufb01ve departments: Dep.
\nof medical education, Dep.of information
\nand health policy, Dep.of \ufb01nance and ad-
\nministration, Medical journal and Dep.of
\nnegotiation and legal section. The number
\nof full-time sta\ufb00 members is 130.
\nThe role of The Norwegian
\nMedical Association
\nThe Norwegian Medical Association
\n(NMA) is the only nationwide association
\nfor doctors in Norway. NMA has two main
\nresponsibilities:
\n1 Negotiating salaries and working condi-
\ntions for the members
\n2 Taking care of the members professional
\nand scienti\ufb01c interests
\nThe medical association consists of 19 local
\nbranches, 7 occupational branches and 44
\nspecialty branches.
\nThe local branches represent the 19 coun-
\nties.
\nThe seven occupational branches organise
\nmembers that share occupational interests:
\njunior doctors, consultants, GPs, research-
\ners, occupational health doctors, private
\npracticing specialists and public health
\ndoctors. The occupational branches are ne-
\ngotiating salaries and working conditions,
\nwhile the specialty branches take care of the
\nprofessional activities like education,quality
\nimprovement etc.
\nNMA has its own,independent research in-
\nstitute that among other things do research
\non doctors\u2019 health and well being.
\nSome data about Norway
\nNorway has a population of 4 525 000 and
\nis situated in the northern part of Europe
\nand has borders to Sweden, Finland and
\nRussia.
\nPublic health services are \ufb01nanced by taxa-
\ntion and are designed to be equally acces-
\nsible to all residents, independent of social
\nstatus. With its 220 000 employees, the
\npublic health sector is one of the largest sec-
\ntors in Norwegian society.
\nThe public health system is under the juris-
\ndiction of the Ministry of Health and Care
\nservices, which is responsible for devising
\nand monitoring national health policy. Res-
\nponsibility for provision of services is de-
\ncentralized to the municipal and regional
\nlevel. The municipalities are in charge of
\nproviding primary health services such as
\ngeneral practitioner, while the \ufb01ve Health
\nregions provide the more specialized medi-
\ncal services, such as hospital care. Just a few
\nnumber of authorized private hospitals and
\nhealth services have been established in ad-
\ndition to the public facilities.
\nThe numbers of doctors, inclusive students
\nand retired doctors, are about 25 000. In
\nrelation to inhabitants we have among the
\nhighest number of doctors in Europe, in
\n2007 the ratio was one doctor per 244 in-
\nhabitants.
\nThe Norwegian Medical Association
\nThe president of The Norwegian Medical
\nAssociation, dr.med., Torunn Janbu and
\nsecretary general Terje Vigen.
\n14
\nThe Committee on Human Rights; since
\nthe early 1990s, the NMA has run human
\nrights programmes in Turkey, the former
\nYugoslavia and now in China. These activi-
\nties are funded mainly by The Norwegian
\nMinistry of Foreign A\ufb00aires.In cooperation
\nwith WMA, The International Red Cross
\nand Amnesty International the association
\nhas published, on the web, free of charge, a
\ncourse for prison doctors.
\nThe Journal of The Norwegian Medical
\nAssociation is issued every second week
\nand are in charge of the web-site www.lege-
\nforeningen.no.
\nPost-graduate medical education
\nThere are 44 recognised medical specialties
\nin Norway of which eight are subspecialties
\nunder internal medicine and \ufb01ve are sub-
\nspecialties under general surgery. The ma-
\njority of the specialties relate to health ser-
\nvices in institutions (hospitals). Specialties
\nin primary health care are family medicine,
\ncommunity medicine, and occupational
\nmedicine.
\nHealth politics
\nThe NMA is involved in many of the activi-
\nties run by the health authorities through
\nappointing members to participate in dif-
\nferent task groups, and also by meetings
\nwith the political parties inthe Parliament.
\nO\ufb03cers President Torunn Janbu, vice-
\npresident B\u00e5rd Lilleeng, and secretary ge-
\nneral Terje Vigen.
\nContact information;
\nThe Norwegian Medical Association
\nPb 1152 Sentrum,
\nNO 0107 Oslo
\n+ 47 23 10 90 00 fax + 47 23 10 90 10
\nwww.legeforeningen.no
\nThe ethics committees of the Nordic medi-
\ncal associations have a long tradition of
\nmeeting every two years to discuss current
\nissues in medical ethics. The venue of these
\ninformal gatherings rotates between the \ufb01ve
\ncountries (Denmark, Finland, Iceland, Nor-
\nway or Sweden).
\nIn September 2007 the meeting was host-
\ned by the Finnish Medical Association in
\nNauvo, a peaceful seaside resort in south-
\nwestern Finland. There were altogether 37
\nparticipants, mostly practicing physicians
\nwho are also members of the ethics com-
\nmittees.
\nThree themes of discussion at the meeting
\nwere chosen beforehand. They were
\n– Medical ethics of physicians working in
\nleadership or administrative tasks
\n– Ethics of stem cell research
\n– Liability issues in telemedicine.
\nEach of the themes was \ufb01rst introduced in a
\nplenary setting, then discussed in depth by a
\nworking group of about ten participants and
\n\ufb01nally reported back to the plenary. This
\nmethod proved to be useful as everyone got
\na chance to concentrate on the issue closest
\nto their heart and at the same time com-
\nment and re\ufb02ect on the two other subjects.
\nMedical ethics of physicians
\nworking in leadership or
\nadministrative tasks
\nThis theme was introduced by Dr. Thomas
\nLind\u00e9n from Sweden. Ethical rules as such
\nare of course applicable to all doctors, but
\nthe question is whether they di\ufb00er (and
\nhow) when a doctor is also working as a
\nleader. Lind\u00e9n presented the general ethi-
\ncal guidelines of the Swedish Medical As-
\nsociation and highlighted the points where
\nproblems might arise.
\nIn the discussion that followed it was con-
\ncluded that all the ethical rules also apply
\nto doctors in leadership positions. Special
\nchallenges exist however.These include pri-
\noritisation when resources are limited, the
\nbene\ufb01ts of one patient versus those of many
\nJoint Medical Ethics Re\ufb02ections
\nof the Nordic Countries
\n15
\npatients, loyalty con\ufb02icts and also potential
\ncon\ufb02icts related to economic pro\ufb01t.
\nOrganisations should facilitate physicians
\nin leadership or managerial positions to be
\nable to follow high ethical standards. This
\ncould be done by facilitating the knowledge
\nof ethics as well as ethical discussions and
\nre\ufb02ections at the workplaces. Also non-
\nphysician-leaders and managers should be
\nincluded in these processes.
\nEthics of stem cell research
\nThe meeting was honoured to have the cur-
\nrent president of the WMA,Dr Jon Snaedal,
\nas a member of the Icelandic delegation. He
\nintroduced the subject of stem cell research.
\nThe working group focused on the speci\ufb01c
\nquestions of using human embryonic stem
\ncells. It presented three statements and ar-
\ngued for and against them.
\nThe \ufb01rst statement was that production of
\nembryonic stem cells solely for research
\npurposes should be prohibited. Arguments
\nspeaking for this are the invasiveness of the
\nprocedure and potential harm caused by it
\nas well as possible uncontrolled commer-
\ncialisation. Using extra embryonic cells cre-
\nated in fertility treatments is therefore a less
\nrisky alternative.On the other hand reliance
\non these extra cells only may lead to double
\nmoral in their collection if and when re-
\nsearch on embryonic stem cells is accepted.
\nThe second statement argued that produc-
\ntion and selection of embryos for therapeu-
\ntic purposes is acceptable if it is performed
\nunder close supervision by an independent
\nauthority and based on individual risk-
\nbene\ufb01t estimation. This statement can be
\ndefended by the utility for the sick child,
\nwhich may be major (while the harm to
\nthe selected sibling must be small). Help-
\ning one sibling does not prohibit the parents
\nfrom loving the other also as an individual.
\nMany western societies already have em-
\npirical evidence of tolerance from case ex-
\namples. Points against this are the di\ufb03culty
\nof preventing social strains on and between
\nthe children. The therapies using selected
\nsiblings are still experimental and medical
\nrisks therefore unknown. It can also create
\nas slippery slope towards mass production
\nof embryos.
\nThethirdstatementwasthatcloningofgenes
\nor genomes into stem cells for reproductive
\npurposes is ethically unacceptable.Points for
\nthe statement are that the procedures are
\nbiologically uncertain and may have unfore-
\nseen consequences, they may create a \u201dslip-
\npery slope\u201d to genetic engineering for cos-
\nmetic or sport purposes and genetic copying
\nof human beings involves unknown social
\nand human risks. Arguments against the
\nstatement include the possibility of cloning
\nto provide an alternative to using embryonic
\ncells genetically identical cell lines without
\nreproductive purposes. Cloning healthy so-
\nmatic genes to reproductive cells also mir-
\nrors the selective abortion of severe disease
\ngenes (which is already performed today).
\nLiability issues in telemedicine
\nThe introduction to the theme on behalf
\nof the Danish delegation was given by Dr
\nMogens Skadborg. He emphasized that as
\nfar as ethics is concerned, telemedicine does
\nnot di\ufb00er from any other kind of medical
\npractice. It is simply a new way of treating
\npatients and requires technical expertise in
\n\ufb01elds other than medicine.
\nTheir group discussion centred around three
\nissues: who is responsible for the quality and
\nresults of the treatment, who has (or should
\nget) access to patient records and why and
\nwhat are the e\ufb00ects to the patient-doctor
\nrelationship.
\nThe discussion produced some further con-
\nclusions. Ethics does not di\ufb00er between
\ndi\ufb00erent formats of consultation, but face-
\nto-face contact is still the preferred way.
\nAccurate documentation of advice is impor-
\ntant. Communication may be less e\ufb00ective
\nand relevant information not received when
\nthere is no physical presence. Reliable iden-
\nti\ufb01cation may also cause problems. There-
\nfore risks and bene\ufb01ts of using telemedicine
\nmust always be balanced.
\nThe new tools o\ufb00er new ways of informing
\npatients of their health status and treatment.
\nPatients however may have di\ufb00erent capa-
\nbilities of understanding that information.
\nMisuse of information must be prevented
\nand the trust of patients maintained.
\nIn addition to the lively discussions on eth-
\nics the participants enjoyed each other\u2019s
\ncompany on a cruise in the surrounding ar-
\nchipelago and a traditional Finnish smoke
\nsauna. An excursion into the history of
\nmedical ethics was also made at the island
\nof Seili, which was a hospital for lepers
\n1619-1785 and a then mental institution up
\nto 1962.
\nThe next meeting on medical ethics in the
\nNordic countries will be hosted by the Dan-
\nish Medical Association in 2009.
\nJukka Siukosaari
\nInternational A\ufb00airs O\ufb03cer and secretary of
\nthe Medical Ethics Committee
\nFinnish Medical Association
\n16
\nAs far back as before the World War II, the
\nmedical men in Independent Lithuania had
\nto solve the important health care problems.
\nEven then, the society was formed which act-
\ned for the good of Lithuanian doctors.During
\nthe years of soviet occupation, the society was
\nclosed and only after more than 50 years its
\nactivities have been restored. The Lithuanian
\nMedical Association (subsequently,the LMA)
\nis an independently acting trade union, a vol-
\nunteer organization bringing together 80% of
\nLithuanian medical doctors and defending
\ntheir professional, labour, economic and social
\nrights and interests.Founded in October 1924,
\nthe LMA operated until 1940.After regaining
\nindependence in 1989, the sixth congress re-
\nestablished the LMA.
\nIn 2004, the 12th congress of the LMA
\nelected prof. Liutauras Labanauskas presi-
\ndent of the association for a third term, Lo-
\nreta Le\u0161\u010dinskien\u0117 and Virginija Luk\u0161ien\u0117
\nas vice presidents, and Asta Grigali\u016bnien\u0117
\nas secretary. Standing commissions of the
\nLMA are those of professional ethics, \ufb01-
\nnance, law and the primary level of health
\ncare. Other commissions are non-standing
\nand are normally established to solve some
\nspeci\ufb01c issues. The LMA represents the
\nprofessional interests of its members in their
\nrelationship with employers and other legal
\nand natural entities. It concludes collective
\nemployment contracts and other agree-
\nments with employers and controls their
\nimplementation.The association also analy-
\nses salaries of medical doctors and submits
\nremuneration proposals. The LMA strives
\nto obtain higher salaries for medical doc-
\ntors. As a result of implementation of this
\nobjective, on 3 May 2005 the LMA signed
\nan agreement with the Government \u201cOn
\nthe increase of salaries for medical doctors\u201d.
\nIn accordance with the 2001 agreement
\nwith the Ministry of Health and Vilnius and
\nKaunas Medical Universities, the LMA ac-
\ntively participates in the professional training
\nof medical doctors. The training is \ufb01nanced
\nby the Ministry of Health and performed by
\nVilnius and Kaunas Medical Universities with
\nthe LMA as a coordinator of the process.
\nIn 2006-2007, the LMA successfully im-
\nplemented a project to strengthen social
\npartnership. For example, the project \u201cThe
\ndevelopment of social partnership in the
\nLithuanian health care system\u201d. The key
\naim of the project is to develop social part-
\nnership among the equal partners of health
\ncare system. As a result of cooperation
\namong the Ministry of Health, the Asso-
\nciation of Representative O\ufb03ces of Ethical
\nPharmaceutical Manufacturers, the Asso-
\nciation of Pharmaceutical Manufacturers,
\nand the LMA, the project \u201cFairer treatment
\nwith pharmaceuticals\u201dhas been implement-
\ned. Company Transparency International
\nLithuania is performing social research
\naiming at a more transparent relationship
\nbetween the pharmaceutical industry and
\nmedical doctors. The LMA is a partner of
\nthe \u201cGood mood programme\u201dimplemented
\nby the private company AstraZeneca and
\naimed at reducing the stress experienced by
\nboth medical personnel and patients. To-
\ngether with the TV program Sveikatos ABC
\n(Health ABC) hosted by the TV channel
\nLNK, the LMA has been implementing a
\nsocial project called \u201cThank you, doctor\u201d.
\nThe LMA actively cooperates with other
\nprofessional unions and associations, inter-
\nnational organizations of medical doctors
\nabroad, as well as participates in the prepa-
\nration and implementation of international
\nprograms. The LMA is a member of the
\nWMA (the World Medical Association)
\nand the CPME (the Standing Commit-
\ntee of European Doctors). In May 2006, a
\njoint conference with other specialist soci-
\neties discussed membership in the UEMS
\n(European Union of Medical Specialists).
\nThis would allow the LMA together with
\nother specialist unions to confer on pro-
\nfessional problems of medical specialists
\non the highest level. The problems include
\ninternship, post-graduate studies, quali\ufb01ca-
\ntion training, and life-long learning.
\nSix years ago, based on the experience of
\nforeign countries, the LMA initiated civil li-
\nability insurance for medical doctors (natu-
\nral entities) that was successfully adopted in
\nLithuania. Currently, the LMA is initiating
\nadoption of voluntary (additional) health
\ninsurance in Lithuania. Head of the LMA
\nSecretariat Aist\u0117 Sivakovait\u0117 is involved in
\nanalyzing information from state and local
\ngovernment bodies, coordinating the activity
\nof the association on representation in labor
\ngroups, and preparation of the laws and legal
\nacts.She also coordinates international coope-
\nration and publishing activities of the LMA.
\nThe LMA publishes the bi-weekly maga-
\nzine Gydytoj\u0173 \u017einios (Medical News) and,
\ntogether with Vilnius and Kaunas Medical
\nUniversities,the magazine Medicina (Medi-
\ncine). One-o\ufb00 publications such as Lietuvos
\ngydytoj\u0173 s\u0105junga (The Lithuanian Medical
\nAssociation), Lietuvos gydytojai (Doctors
\nof Lithuania), and a collection of laws for
\ndoctors and administrators. In 2007, the as-
\nsessment of the situation in the world and
\nLithuania and the desire to help doctors
\nwho face challenges in their professional
\nactivities prompted publication of the book
\nMedical Ethics Manual by the LMA in co-
\noperation with the ethics committee of the
\nWorld Medical Association (WMA) and
\nthe Lithuanian Bioethics Committee.
\nThe Lithuanian Medical Association
\nand its Priorities
\nLMA vice president Loreta Le\u0161\u010dinskiene,
\nLMA president prof. Liutauras Labanauskas,
\nLMA vicepresident Virginija Luk\u0161ien\u0117, LMA
\nSecretary General Asta Grigali\u016bnien\u0117
\n17
\nGeneral Information about the State
\nThe Republic of Belarus is situated in the
\ncentre of Europe. The shortest transport
\ncommunications connecting the CIS coun-
\ntries and Western Europe countries run
\nthrough its territory. Belarus has common
\nborder lines with Poland, the Baltic states,
\nRussia and the Ukraine.
\nThe territory of the republic comprises
\n207 000 square kilometers, its population is
\nabout 10 million people, with 70% living in
\nthe cities. Nearly one-\ufb01fth of the population
\nresides in Minsk, the capital of Belarus. Ac-
\ncording to its administrative division there are
\nsix regions in the republic. The o\ufb03cial lan-
\nguages are Belarusian and Russian.The most
\ncommon languages for business communica-
\ntion are Russian, English and German.
\nThe Republic of Belarus is a unitary demo-
\ncratic social legal state and recognizes the
\npriority of conventional principles of the
\ninternational law.
\nThe state power is conducted on the basis
\nof its division into legislative, executive and
\nlegal. Belarus is a presidential republic. The
\nPresident of the Republic of Belarus is the
\nhead of the state, the guarantor of the Con-
\nstitution, the rights and liberties of an indi-
\nvidual and a citizen. The legislative body of
\npower is the Parliament consisting of two
\nchambers. The executive power is run by
\nthe Government \u2013 the Soviet of Ministers,
\nwhich is the central organ of power. Local
\npower and self-government are carried out
\nthrough local executive and administrative
\norgans, self-government organs, referen-
\ndums, etc.
\nBelarus is one of the economically deve-
\nloped CIS states. Industry comprises about
\none-third of the national output volume.
\nThe most developed branches of industry
\nare motor-car industry, tractor construction
\nand agricultural engineering, machine-tool
\nand bearing construction, electrotechni-
\ncal industry, oil extraction and processing,
\nsynthetic \ufb01bres production, mineral ferti-
\nlizers production, pharmaceutical industry,
\nproduction of building materials, light and
\nfood industry.
\nGovernmental Support
\nof the Health Care
\nThe state system makes the basis of the
\nhealth care and is \ufb01nanced from state bud-
\nget (4,5% of gross national output).The sys-
\ntem of social standards has been developed
\nfor health care, which includes the norms
\nfor covering health care expenses from the
\nbudget for 1 citizen per year. This \ufb02attens
\nthe disproportion while distributing the re-
\nsources over the regions of the republic.
\nThe policy for developing paid medical ser-
\nvices is aimed both at allocating additional
\nmeans for health care development, and
\ncontrolling the substitution of free medical
\nservices by paid ones, since the latter are not
\nvitally important.
\nDevelopment of the
\nHealth Care System
\nThe programme of social and economic
\ndevelopment for 2006-2010 provides in-
\ncreased access and quality of health care for
\nall population based on:
\n\u2022 introducing up-to-date medical tech-
\nnologies and creating scienti\ufb01c and
\npractical centres;
\n\u2022 reconstructing the system for providing
\nhealth care including the redistribution
\nof the resources from in-patient to out-
\npatient medical care, developing medi-
\ncal and social care and general medical
\npractice;
\n\u2022 improving the system of social stan-
\ndards, as well as territorial programmes
\nof guaranteed state health care;
\n\u2022 enlarging access to e\ufb00ective, safe and
\nhigh quality medicines, creating the
\ncomplex programme for providing some
\ncategories of citizens with medicines;
\n\u2022 improving the management and qual-
\nity control, standardizing medical tech-
\nnologies, working out prevention and
\nrehabilitation technologies.
\nThe development and the implementation
\nof standards for medical information sys-
\ntems, advanced medical technologies, tele-
\nmedicine including, large computerization
\nof medical institutions, creating local elec-
\ntronic computing systems,introducing elec-
\ntronic patients\u2019 medical charts are planned.
\nThere are more than 40 000 doctors and
\nabout 109 000 nurses, more than 150 sana-
\ntorium and prophylactic establishments and
\n1700 treatment and prophylactic institutions.
\nMedical sta\ufb00 is trained at 4 medical univer-
\nsities, 17 colleges, at the Belarusian Medical
\nAcademy of Post-Graduate Education and
\nsome centers for advanced training and im-
\nproving the quali\ufb01cation of the nursing sta\ufb00.
\nThe reform of health care system is in prog-
\nress, with the state budget \ufb01nancing being
\nfollowed.The positive dynamics of the basic
\nindices is seen. These are increase of birth
\nrate, decrease of infant and mother mortal-
\nity rate, postoperative lethality, morbidity
\nThe Republic of Belarus and its
\nHealth Care System in Brief
\nIn the photo V.I. Zharko, Minister of Health,
\nRepublic of Belarus; V.N. Lektorov, Deputy
\nChairman of the Commission for Social
\nProtection, Chamber of Representatives of
\nthe National Assembly, Republic of Belarus,
\nChairman of the Belarusian Association of
\nPhysicians.
\n18
\nHistory of the Ukrainian Medical Associa-
\ntion (UMA) \u2013 in Ukrainian language: Vse-
\nUkrainske Likarske Tovarystvo (VULT)
\nwas founded in 1910, but its activities were
\ninterrupted by the Soviet Communist re-
\ngime.
\nIn 1990 on June 30, in Kyiv the First Con-
\ngress of Ukrainian Medical Association
\nwas held, which renewed the organization
\ninterrupted during the Soviet period. On
\nAugust 17, 1990 in the 3-rd Congress of
\nthe WFUMA the UMA was accepted to
\nthe World Federation of Ukrainian\u2019s Medi-
\ncal Associations (WFUMA). Later on the
\nUMA was involved in:
\n– In 1991,May 24-30,in Ivano-Frankivsk
\nthe 1-st Congress of Medical Associa-
\ntions for Ukrainians from Europe was
\nheld;
\n– In 1992, February 24, the UMA was
\nregistered by the Ministry of Justice of
\nUkraine (No.209).
\n– In 1992,November 7,in Uzhghorod the
\n2-nd Congress of UMA and scienti\ufb01c
\nconference \u201cNatural factors in sanatori-
\num-resort treatment\u201d took place;
\n– In 1995,April 28,in Kyiv the 3-rd Con-
\ngress of UMA and scienti\ufb01c conference
\n\u00abHistory of Ukrainian medicine\u00bb were
\nheld;
\n– In 1997, May 17, in Kyiv the scienti\ufb01c
\nconference on the problems of organiza-
\ntion of public health and 4-th Congress
\nof UMA were organized.
\n– In 1999, May 28-29, in Kyiv the 5-th
\nCongress of the UMA and scienti\ufb01c
\nconference \u201cPrimary medical healthcare
\nand family medicine\u201d were arranged.
\n– In 2001, May 18-19, in Chernivci in the
\nBukovina Medical Academy the 6-th
\nCongress of the UMA was held;
\n– In 2002, January 25-26, in Kyiv the
\nscienti\ufb01c conference of the UMA \u201cThe
\nsystem of public health of Ukraine and
\nthe ways of reforms\u201d took place;
\n– In 2003, May 16-17, in Ternopil the
\n7-th Congress of the UMA gathered.
\n– In 2005 on April 21-22, in Ivano-
\nFrankivsk the 8-th Congress of the
\nUMA dedicated to the 15th Anniver-
\nsary of re-establishment of the UMA
\n(1990-2005) in modern independent
\nUkraine was held;
\n– In 2008 on May 10-12, in Vinnycja the
\n9-th Congress of the UMA took place.
\nDuring the Congress the President of
\nthe UMA \u2013 Dr.Oleg Musii,the Honou-
\nrary President (Previous President of the
\nUMA) Dr.Ljubomyr Pyrih, the Chair-
\nman of Board of UMA Dr.Stanislav Ne-
\nchaiv and the Board of UMA (includes
\n33 people) were elected.
\nThe total number of the members of the
\nUkrainian Medical Association \u2013 around to
\n20 000 physicians from 25 regions (oblast)
\nof Ukraine. The number of physicians in
\nUkraine is about 200 000 persons. At this
\ntime the UMA is a non-governmental and
\nnon-pro\ufb01t public organization. There is in-
\ndividual and collective membership in the
\nUMA. The individual members are physi-
\ncians by education. The collective members
\nare medical organizations of narrow special-
\nists, scientists etc.
\nThe UMA publishes a periodical of the
\nUMA \u201cThe Ukrainian Medical News\u201d
\njournal. It was founded in 1918 and re-
\nnewed again in 1997. Besides apart from
\nthis UMA publishes articles and interviews
\nin di\ufb00erent journals and newspapers in
\nUkraine and abroad.
\nfrom common infectious diseases. Great
\nattention is payed to the modernization and
\nre-equipment of all treatment institutions.
\nMedical modalities are planned to corre-
\nspond to European standards by 2010.
\nPublic Organizations in the
\nHealth Care System
\nThere are 32 medical public organizations
\nincluding the multipro\ufb01le Belarusian As-
\nsociation of Physicians, founded in Febru-
\nary 1992. During its history, it contributed
\nto developing the draft of new legislation for
\nmedicine, as well as concepts and plans for
\nevolving medical system, working out Medi-
\ncal Ethics Code.In 2007,the new agreement
\non cooperation with the Ministry of Health
\nwas signed. Currently, the re-registration of
\nfellows and structural units is under way, the
\nplans for further evolution are being made.
\nSome Basic Indices in 2007
\nBirth rate, mortality rate, infant mortal-
\nity rate 10,7\u2030; 13,7\u2030; 5,2\u2030. Number
\nof medical visits per 1 inhabitant per year
\n12,7 (including 1,5 in dentistry). Number
\nof hospital beds per 10 000 of the popula-
\ntion 105,5. Number of admissions to the
\nhospital per 1000 274 individuals. Average
\nhospital stay 11,7 days per 1000 live births.
\nThe following information sources have
\nbeen used:
\nhttp:\/\/www.president.gov.by\/
\nhttp:\/\/medicine.belmapo.by\/
\nhttp:\/\/minzdrav.by\/
\nThe Ukrainian Medical Association
\nis going to Europe
\nPart of the Board of UMA with our
\ninternational partners.
\n19
\nFinancing of the UMA consists of:
\n– membership dues 5%
\n– income from publications in the journal
\nof the UMA – 20%
\n– income from participating in various
\ngrant projects – 10%
\n– income from the participants of congress-
\nes,conferences,seminars etc.- 10%
\n– income from \ufb01rms-sponsors, exhibitors
\nin the UMA congresses, conferences,
\nseminars etc. – 45%
\nIn Ukraine the UMA takes part in the ac-
\ntivities of Public Council of the Ministry of
\nHealth of Ukraine and in Advisory Council
\nof the Committee of Health of the Parlia-
\nment of Ukraine.The UMA also cooperates
\nwith the Ukrainian Medical Law Asso-
\nciation and the Ukrainian organization of
\nprotection of the patients rights \u00abHealth of
\nPeople\u00bb.
\nIn Ukraine, the system of public health
\nis under the control and regulation of the
\ngovernment. During the two last years the
\nUMA has been writting and submiting to
\nthe Parliament of Ukraine the Draft Law
\n\u201cAbout medical self-government\u201d (The Eu-
\nropean model of public health) for intro-
\nduction in Ukraine.Today the promotion of
\nthis law is one of the basic activities of the
\nUMA.In the international arena since 1990
\nthe UMA is a member of the World Fed-
\neration of Ukrainian\u2019s Medical Associations
\n(WFUMA). The WFUMA includes the
\nmedical associations of Ukrainians from 14
\ncountries around the world. In addition, the
\nUMA has close contacts with many medi-
\ncal associations in other countries, \ufb01rst of
\nall with the German Medical Association
\n(Bundes\u00e4rztekammer), the Finnish Medical
\nAssociation (Suomen L\u00e4\u00e4k\u00e4riliitto), and the
\nPolish Medical Association (Naczelna Izba
\nLekarska).
\nAmong strategic objectives at an interna-
\ntional level for the UMA is entering the
\nleading international medical organiza-
\ntions like the World Medical Association
\n(WMA), European Forum of Medical As-
\nsociations (EFMA\/WHO), the Standing
\nCommittee of European Doctors (SCED\/
\nCPME), etc. It is decided that introduction
\nof the World achievments of Medicare in
\nUkraine is utmost important to the citizens
\nof our country. The importance of health
\nmanagement in Ukraine through introduc-
\ntion of medical self-government and medi-
\ncal ethics is also on UMA agenda for to-
\nday Entry into the WMA,SCED\/CPME,
\nEFMA\/WHO will enable us to learn the
\nprinciples represented in declarations and
\ndecisions accepted on the World Medical
\nAssemblies and Forums of these organiza-
\ntions and introduction of these principles
\nin Ukraine.
\nMission of the UMA is:
\n– to promote the prestige of doctors in
\nsociety through the observance by them
\nthe highest standards of professional-
\nism, medical ethics and education in
\nserving for health bene\ufb01ts to all Ukrai-
\nnian people;
\n– to provide a high-quality medicare;
\n– to help medical doctors in their in\ufb02u-
\nence, participation and adaptation to
\nchanges in the system of public health;
\nAims and objectives of the association:
\n– Assistance to protect and strengthen the
\nhealth of people in Ukraine, development
\nof national medical sciences, participation
\nin discussing medical questions,assistance
\nfor professional growth of medical em-
\nployees, their legal and social protection,
\nsatisfaction of legitimate social, economic,
\ncreative or other general interests.
\nThe main tasks of UMA are:
\n– to assist in moral, cultural and national
\nrenaissance of Ukrainian physicians and
\nall people of Ukraine;
\n– to increase the state and public signi\ufb01-
\ncanceofphysician\u2019sprofession;assistance
\nwith the renaissance of its authority and
\nprestige; assistance in the improvement
\nof level and qualities of medical service
\nto all levels of population;
\n– to assist in growth of the professional
\nlevel of Ukrainian physicians to interna-
\ntional standards, by increase of quali\ufb01-
\ncation and practical skills; improvement
\nof medical education; development of
\ncreative potential and realization of the
\nright of everyone for intellectual work
\nand its results;
\n– to assist the formation of priority direc-
\ntions of a medical science; organize and
\nparticipate in implementation of scien-
\nti\ufb01c researches of medicine and public
\nhealth; introduction of such achieve-
\nments in practice;
\n– to protect the interests of members of
\nUMA in institutions of the government
\nand state control, public organizations,
\ncourt and o\ufb03ce of the public prosecu-
\ntor; assistance to ensure the legal pro-
\ntection of their civil rights, professional,
\nsocial and economic interests.
\nBesides in the Ukrainian Medical Asso-
\nciation (UMA) there are many societies of
\nnarrow specialties and subspecialties for ex-
\nample: cardiology, surgery, neurology, cardio
\nsurgery, plastically surgery, pediatric, oph-
\nthalmology, neurosurgery, pediatric oph-
\nthalmology, nephrology, sexology, internal
\nmedicine, radiology, gastroenterology, oto-
\nlaryngology, hematology, dermatology, ger-
\nontology, urology, family medicine, oncol-
\nogy and etc. A physician at the same time
\ncan be a member of various such societies.
\nTheir basic activities are scienti\ufb01c researche,
\nimprovement of quali\ufb01cation and training
\nmedical doctors in their specialties. A part
\nof such narrow professional societies are also
\ncollective members of our Ukrainian Medi-
\ncal Association. Besides in Odessa (the one
\nof the 25 regions of Ukraine) the Society of
\nUkrainian Doctors was established with the
\naim to embrace the whole Ukraine. Unfor-
\ntunately, it incorporated only the Odessa
\nregion. For all the time of its existence, not
\nbeing able to expand, to our regret the Soci-
\nety practically has halted its activity. There
\nis also a trade union of medical workers in
\nUkraine. It has remained since the times
\nof Soviet Union. Its members are doctors,
\nnurses, junior nurses; hospital attendants,
\nparamedics and all other people who works
\nin medical institutions. Competence of this
\ntrade union mainly is the treatment of so-
\ncial issues..
\n20
\nTheBulgarianMedicalAssociation(BuMA)
\nwas established one hundred and six years
\nago, and is therefore among the oldest pro-
\nfessional organizations of physicians in Eu-
\nrope. During the period of socialist regime,
\nhowever, it ceased to exist and was restored
\nin 1991 by a group of enthusiasts. At that
\ntime membership was voluntary and the
\nfunctions of the Association were rather
\nlimited. But the situation changed quickly
\nand in 1998, thanks to a strong lobby, an
\nact was adopted for the professional asso-
\nciations of medical doctors and dentists in
\nBulgaria, which regulated its functions and
\nwas practically a legal recognition of the ex-
\nistence of the BuMA. Membership became
\nmandatory which enabled better control
\nto be exercised on health service quality as
\nwell as the rights of the physicians to be de-
\nfended.
\nAs a lawful representative of the physicians,
\nthe BuMA won am important victory \u2013 the
\nright to be a party to the negotiation process
\nof determining the budget of the National
\nHealth Insurance Fund (NHIF) and fund
\nallocation. From the very beginning the As-
\nsociation aimed at procuring the necessary
\nresources for improvement of healthcare
\nquality. Regretfully recently the NHIF did
\nnot seem to be willing to cooperate in that
\nrespect as a consequence of which in 2006
\nand in 2007 no framework contracts were
\nsigned. This resulted in disregard of the
\nrights of patients and physicians and deteri-
\noration of the healthcare system as a whole.
\nDespite the di\ufb03cult situation in which it is
\nfunctioning, the Bulgarian Medical Associ-
\nation makes e\ufb00orts to ensure very good level
\nof health services through providing incen-
\ntives for the continuous medical education
\nand professional development of physicians.
\nIt developed a credit system and undertook
\ncrediting of di\ufb00erent forms of CME.
\nThe BuMA pays much attention to the
\nethical issues of the profession. That is why,
\nbesides adopting its own Code of Medical
\nEthics, it acquaints the Bulgarian physi-
\ncians with documents of international sig-
\nni\ufb01cance in this \ufb01eld, such as the Medical
\nEthics Manual of the WMA, which is not
\nonly a convenient tool for solving practical
\nproblems, but also brings about uni\ufb01cation
\nof standards and criteria in di\ufb00erent coun-
\ntries. It was a privilege for the Bulgarian
\nphysicians to have this Manual presented
\npersonally by its author, Prof. John Wil-
\nliams, at a meeting held in Bulgaria in Sep-
\ntember, 2006.
\nFrom its restoration the organization real-
\nized the signi\ufb01cance of international rela-
\ntions and the need to share ideas. That is
\nwhy two years after it resumed its activi-
\nties the BuMA joined the big family of the
\nWMA, and during the last few years be-
\ncame full member of a number of European
\norganizations of physicians. This was done
\nfor the purpose of exchange of experience
\nwhich enables \ufb01nding better solutions to
\nproblems.
\nThe BuMA has welcomed di\ufb00erent initia-
\ntives of the WMA which we believe are im-
\nportant for preservation of the good tradi-
\ntions of the profession.Bulgarian physicians
\nwere nominated for the WMA publication
\nCaring Physicians of the World.We all owe
\nwell deserved respect and recognition for
\nphysicians who are fully devoted to their
\nmission and serve as an example of high
\nethical standards and humanity in practi-
\ncing the profession.
\nLooking back to the years after the resto-
\nration of the BuMA – almost two decades
\nnow, and taking into account its achieve-
\nments, one may say that the organization
\nis going in the right direction, because the
\nAssociation is heading to a future where no
\nboundaries would exist both for the patients
\nand for the physicians and everyone would
\nhave access to high quality healthcare, re-
\ngardless of where they live. But this might
\nonly happen if the professionals could make
\nthe governments understand that health-
\ncare is and should be regarded as a priority
\nissue. Otherwise total collapse of the system
\nmight occur due to lack of medical person-
\nnel as we are living in a very dynamic and
\nmobile world and this problem is already
\nvery familiar in some parts of the globe.
\nDr. Andrey Kehayov
\nPresident
\nDr. Plamen Demirov
\nSecretary General
\nThe Bulgarian Medical Association
\n21
\nDear Colleagues,
\nOne of my proposals as president
\nin 2000 of the WMA was to estab-
\nlish the regional o\ufb03ces of WMA
\nin di\ufb00erent parts of the world.
\nThe rationale of this proposal was
\nto take into consideration di\ufb00er-
\nences which exist among regions
\nof the world in health care, medical
\neducation, medical ethics, medical
\npolicy, management, human right
\nissues etc. The WMA as a non-
\ngovernmental body may directly
\ncontact individual NMAs and
\nget valid information about their
\nhealth care systems in di\ufb00erent regions. Another output of the ac-
\ntivities of the regional o\ufb03ces is the increased visibility of the WMA
\nin individual regions giving them an occasion to more detailed dis-
\ncussions on the WMA documents, which could be tailored to their
\nspeci\ufb01c conditions.
\nThe role of the regional o\ufb03ces seems to me even more advantages
\nat present when the World Health Professional Alliance unites the
\nWMA, World Dental Federation (FDI), International Pharmaceu-
\ntical Federation (FIP) and International Council of Nurses (ICN)
\nbringing together more than 23 million health care professionals
\nworldwide. (The WHPI should consider accepting also the World
\nFederation of Medical Education) with the secretariat recently tak-
\nen over by the secretariat of WMA.
\nThe Regional o\ufb03ce for Central and East European countries was
\nfounded in 2000 and hosted already 4 meetings. At the last one in
\nPrague in December 2006 also other European NMAs were present
\nincluding the general secretary and the president of the WMA.The
\nprogram of the meeting included actual health care issues as avian
\nin\ufb02uence, smoking and nutrition in respective regions.
\nThe CzMA proposes to revitalize the activities of the regional o\ufb03c-
\nes and establish the regional o\ufb03ces of WHPA, perhaps in Prague.
\nWith kind regards,
\nProfessor Jaroslav C MD.,DSc.
\nPresident, Czech Medical Association
\nFormer president, WMA
\nOur Association is a voluntary and in-
\ndependent organization of medical doc-
\ntors, pharmacists and other workers in the
\nhealthcare service and related \ufb01elds in the
\nCzech Republic.
\nThe number of our members has been grad-
\nually rising since 1989 when the CzMA be-
\ncame a democratic institution with demo-
\ncratically elected president and council. The
\nmembers of the CzMA are a\ufb03liated on the
\nbasis of their specialities in individual scien-
\nti\ufb01c societies. In larger cities the doctors or-
\nganize the local medical clubs.104 scienti\ufb01c
\nsocietes and 40 local medical organizations
\nare currently working within CzMA. Both
\nCzech citizens and foreigners may become
\nmembers of the CzMA. Medical doctors
\nand associated health workers represent 90
\np. cent of all health personnel in the repub-
\nlic.
\nThe history of the CzMA dates from the
\nmiddle of the 19th century and is closely
\nlinked with propagators of national Czech
\nmedical science. Their main representative
\nwas Jan Evangelista Purkyn\u011b (1787-1869),
\na world renowned scientist in physiology.
\nHis name thus gives prestige to the title of
\nour Association. By associating ourselves
\nwith this great personality we wish to ex-
\npress that we are continuing the traditions
\nof the humane and scienti\ufb01c legacy.The aim
\nof J. E. Purkyn\u011b and his colleagues was,
\nabove all, the development and propagation
\nof knowledge of medical sciences and relat-
\ned \ufb01elds and their application in healthcare
\nfor people. These fundamental aims remain
\nunchanged to the present time.
\nThe CZMA is involved in postgraduate and
\ncontinuing medical education in almost all
\n\ufb01elds of medicine, in organizing national
\nand international congresses, symposia,
\ncourse etc.
\nThe CzMA has also close relations with Eu-
\nropean and medical associations worldwide.
\nOf these the most important is the World
\nMedical Association (WMA), the Forum
\nof European Medical Associations within
\nWHO, the Council for the International
\nOrganization of Medical Sciences within
\nWHO (CIOMS).
\nThanks to the reputation of our Associa-
\ntion, the CzMA also awards honours and
\nprizes which are received with the respect
\nthey deserve.
\nThe Czech Medical Association
\nJ. E. Purkyn\u011b (CzMA).
\n22
\nThe Austrian Medical Chamber is the statu-
\ntory professional organization of all doctors
\npractising in Austria. We represent approxi-
\nmately 38 000 doctors – working either in
\na self-employed, or in an employed capac-
\nity. On the one hand, the Austrian Medi-
\ncal Chamber represents their professional,
\nsocial and economic interests, on the other
\nit constitutes the competent national author-
\nity for Austrian doctors. The responsibilities
\nof the Chamber comprise, besides others,
\nthe following areas: involvement in medical
\ntraining, continuing medical education and
\nprofessional development, quality assurance
\nin continuing medical education and medi-
\ncal practice, the conclusion of contracts with
\nsocial insurance institutions and of collective
\nagreements,admission to and administration
\nof the medical register,recognition of foreign
\nmedical diplomas, execution of disciplinary
\nlegislation and arbitration.
\nThe Austrian Medical Chamber deals with
\na variety of issues at national and interna-
\ntional level.The reform of the medical train-
\ning system and a recent governmental plan
\nto restructure the Austrian health system are
\nsome of the current issues at the national
\nlevel. At the international level, the Medi-
\ncal Chamber is mainly concerned by Euro-
\npean Union issues such as the migration of
\ndoctors, the Working Time Directive, the
\nHealth Services Directive, eHealth, etc.
\nIn Austria, the medical training system is
\nstructured as follows: after having completed
\n6-year medical studies, doctors must engage
\nin a 3-year medical training as a general
\npractitioner or a 6-year medical training as
\na specialist in order to obtain their licence to
\npractice. Due to a lack of training positions
\nin Austria, many doctors migrate to other
\nEU-countries for training purposes. At pres-
\nent, there are concrete plans for a reform of
\nthe training system and the introduction of
\na one year post-gradual training programme,
\nafter which doctors will be awarded their
\nlicence to practice. Besides, general practice
\nwill become a specialty with 5 years of practi-
\ncal training after the \ufb01rst, basic year. In 2007,
\nAustria also underwent some changes in the
\ntraining regulations introducing 3 new spe-
\ncialties: cardiac surgery, thoracic surgery and
\nchild and adolescent psychiatry.
\nThe Austrian Medical Chamber is very con-
\ncerned about the above-mentioned govern-
\nmental plans to restructure the health system.
\nDespite Austria was awarded the top position
\nintherankingofconsumer-friendlyhealthsys-
\ntems in Europe (European Health Consumer
\nIndex 2007), the Health Ministry tried to in-
\ntroduce what the Austrian Medical Chamber
\nquali\ufb01es as a nationalisation and centralisation
\nof healthcare,i.e.transfer of the Austrian Med-
\nical Chamber\u2019s competence of decision on the
\nnumber of contracts with social security bod-
\nies to the ministry, introduction of guidelines
\non the treatment of patients by the ministry,
\ncontrol of the ministry over quality assurance,
\netc. For that reason the president of the Aus-
\ntrian Medical Chamber, Dr. Walter Dorner,
\nmet with the Health Minister, and a declara-
\ntion of intention was signed, con\ufb01rming that
\nthere will be no reform of the health system
\nbefore a discussion with the Medical Chamber
\nhas taken place. In addition, the Austrian and
\nthe regional medical chambers called upon all
\nAustrian doctors to inform their patients on
\nthe dangers of the initial plans of the govern-
\nment.For this purpose,a so-called information
\nday was organised on November 8th, 2007 in
\nmedical practices all over Austria. Unfortu-
\nnately,some of the concerns raised by the med-
\nical body proved later not to have been taken
\ninto account.Therefore, the Austrian Medical
\nChamber is still monitoring very carefully the
\nnext steps of the government.
\nFrom the international point of view, the
\nAustrian Medical Chamber is very active and
\nthus a member of di\ufb00erent European and in-
\nternational organisations such as the WMA,
\nCPME, EFMA\/WHO, FEMS, UEMS,
\netc. Migration of doctors within the EU is
\nalso an important issue. As described earlier,
\nAustria is soon to adapt its system so as to en-
\nable an even smoother migration of Austrian
\ndoctors. The Austrian Medical Chamber is
\nalso in close contact with Germany and has
\nrecently concluded a friendship treaty with
\nthe German federal state of Saxony aiming to
\npromote bilateral mobility of doctors. Friend-
\nship treaties with other German states are to
\nfollow. This initiative is also supported by the
\nEuropean Union in the framework of the life
\nlong learning initiative.
\nThe Austrian Medical Chamber
\nVice-President Harald Mayer, President Walter Dorner, Vice-President Artur Wechselberger,
\nVice-President G\u00fcnther Wawrowsky. Photo: Alfred Habitzl.
\n23
\nLiberal practice,which for physicians means
\nclinical independence in selecting the best
\ntherapy for patients, seems to be a disrup-
\ntive factor in a system of increasingly state-
\ncontrolled health management in Germany.
\nBut physicians are demonstrating a new
\ndegree of solidarity, and the German Medi-
\ncal Association is \ufb01ghting \ufb01ercely for the
\nfreedom and independence of the medi-
\ncal profession and the provision of the best
\nmedical services available for patients.
\nThe Federation of the German Chambers of
\nPhysicians(\u201cGermanMedicalAssociation\u201d-
\nGMA) was founded in 1947 as the working
\ngroup of the West German Chambers of
\nPhysicians. Today, all 17 State Chambers
\nof Physicians are represented by the GMA.
\nMembership in a Chamber of Physicians is
\nobligatory; the GMA represents all 413,696
\nphysicians, of whom 314,912 are practising
\n(2007) – about 48% in the inpatient sector
\nand 44% in the outpatient sector1
\n. As part
\nof the statutorily regulated system of self-
\ngovernment of the medical profession, the
\nChambers of Physicians are responsible for
\nsafeguarding the professional interests of
\n1 National Association of Statutory Health Insurance
\nPhysicians, Department 4.1 (Need Related Planning,
\nFederal Registry of Physicians and Data Exchange)
\nthe physician community and exercise the
\nsovereign task of registering and supervising
\nphysicians.They regulate and promote post-
\ngraduate medical education and continuing
\nmedical education and ensure the high ethi-
\ncal and scienti\ufb01c standards of doctors.
\nThe elected presidents of all 17 State
\nChambers become members of the GMA
\nCouncil, which convenes every month for
\nan all-day meeting at the GMA\u2019s headquar-
\nters in Berlin. The GMA mediates the ex-
\nchange of opinions and activities between
\nthe State Chambers, mutually coordinating
\ntheir goals and working towards the most
\nuniform possible regulation of all activities
\nin the di\ufb00erent regions.The 17 State Cham-
\nbers send a total of 250 delegates to the an-
\nnual Medical Assembly, which serves as the
\n\u201cparliament\u201d of the physicians in Germany.
\nThe Assembly elaborates and adopts regu-
\nlations regarding the professional code of
\nconduct and postgraduate medical educa-
\ntion curricula, passes changes in the statutes
\nof the GMA and agrees on o\ufb03cial positions
\non health policy issues. It establishes per-
\nmanent or temporary committees to deal
\nwith individual subject areas and ongoing
\nquestions. The Assembly also elects the
\nPresident and two Vice-Presidents of the
\nGerman Medical Association. Prof. J\u00f6rg-
\nDietrich Hoppe was re-elected as President
\nfor another four-year term at last year\u2019s
\nMedical Assembly. Dr. Cornelia Goesmann
\nand Dr.Frank-Ulrich Montgomery are cur-
\nrently serving as Vice-Presidents.
\nWith a population of 82.3 million, Ger-
\nmany has about 3.8 practicing physicians
\nper 1,000 residents (2007)*. Although the
\nnumber of medical school graduates has re-
\nmained relatively constant in recent years, it
\nseems that a serious shortage of physicians
\nwill become a major issue in the near future.
\nIn 2006, more than 2,500 mostly young
\nphysicians left the country for better salary
\nand improved working conditions abroad*.
\nIn addition, many medical school graduates
\nchose to work in other, better-paid indus-
\ntries. Although Germany records a relative-
\nly high number of physicians immigrating
\nfrom abroad, many more physicians will be
\nretiring in the next few years. As a result,
\nthe provision of medical care may be jeop-
\nardised, especially in rural areas.
\nOne of the tasks of the GMA is to respond
\nto the needs of the high number of migrat-
\ning physicians. Another task is maintaining
\ncontacts with other national medical asso-
\nciations and international healthcare organi-
\nsations worldwide. On behalf of Germany\u2019s
\nphysicians, the GMA collaborates with the
\nStanding Committee of European Doctors
\n(CPME) and has been an active member
\nof the World Medical Association (WMA)
\nsince 1951,where two GMA representatives
\nare currently serving on the Council of the
\nWMA. The GMA continuously supports
\nthe WMA\u2019s various activities, and GMA
\nsta\ufb00 is actively involved in several WMA
\nworking groups, task forces and a number of
\nprojects, most recently the MDR-TB online
\ncourse for physicians. The publishing house
\nof the GMA\u2019s weekly \u201cDeutsches \u00c4rzteblatt\u201d
\njournal has been serving as the publisher of
\nthe World Medical Journal for many years.
\nDr. Ramin Parsa-Parsi, MD, MPH
\nHead of the Department for
\nInternational A\ufb00airs
\nThe German Medical Association
\nFighting \ufb01ercely for the freedom and independence of the medical profession
\nProf.Dr.Dr.h.c. J\u00f6rg-Dietrich Hoppe
\nProf.Dr.Dr.h.c.Dr.Karsten Vilmar,Treasurer
\nEmeritus of WMA
\n24
\nThe Georgian Medical Association (GMA)
\nisthedoctors\u2019independent,professionalorga-
\nnization established to look after the profes-
\nsional needs of Georgian Physicians. GMA
\nwas established in 1989 and is considered
\nas the \ufb01rst professional non-governmental
\norganization in the country.The GMA rep-
\nresents doctors in all \ufb01elds of medicine all
\nover the country. The GMA is the voice for
\ndoctors, residents and medical students \u2013 in
\nconstant contact with relevant national au-
\nthorities.The Georgian Medical Association
\nplays an active role in the opinion-forming
\nprocess in relation to health policy in society,
\nand in legislative procedures.
\nThe mission of Georgian Medical Associa-
\ntion is to serve and unite the physicians in
\nthe country, for the highest achievable stan-
\ndards of health care; to promote the art and
\nscience of medicine and the improvement
\nof the public health.GMA works for and by
\nthe medical doctors. In addition, the one of
\nthe important directions of activities are the
\npatients\u2019 rights, quality of care and patients\u2019
\nsafety.
\nGMA Membership is voluntary based. The
\ntypes of membership include: individual,
\ncollective, junior and honorary members.
\nMore than 50 professional \ufb01eld associations,
\nworking in di\ufb00erent branches of medicine
\nare the collective members of the GMA.
\nThus, the Georgian Medical Association
\nrepresents the umbrella organization for the
\nmedical profession and organized medicine
\nin the country.
\nThe GMA is governed by the General As-
\nsembly (GA), which is the highest legisla-
\ntive and decision making representative
\nbody. General Assembly elects the GMA
\nBoard of Directors and giving the creden-
\ntial to this structure for governing the asso-
\nciation between the periods of the GA.The
\nBoard of Directors includes the leaders of
\nGMA: President, Vice-President, Secretary
\nGeneral and heads of committees. Geor-
\ngian Medical Association represents the
\nGeorgian Medical Profession on European
\n(European Forum of Medical Associations
\nand the WHO) and International (World
\nMedical Association) levels.
\nThe relations with the Parliamentary Com-
\nmittee on Health care are developing ra-
\npidly and fruitfully. We are often invited
\nby the parliamentary committee for Health
\nCare to participate in discussions on health
\ncare legislation and initiatives. During the
\nyears we have submitted several proposals to
\nthe Parliament to strength the protection of
\nphysicians\u2019 legal, social and professional in-
\nterests. Georgian Medical Association ini-
\ntiated the preparation of amendments and
\nadditions to the Georgian Law of Medical
\nActivities. The GMA requested to add to
\nthe Law the additional chapter (94-1) on
\nLegal Safeguards of Physicians. The GMA
\npresidium discussed the amendments and
\nsubmitted the document to the Health Care
\nCommittee of the Parliament. Another im-
\nportant direction of our activities is the rela-
\ntionship with the O\ufb03ce of Georgian Public
\nDefender. We are participating in joint task
\nforce for elaboration of the amendments
\nand changes in the Georgian Law of Pa-
\ntients\u2019 Rights.
\nThe Georgian Medical Association is ac-
\nquiring more and more important functions
\nin health care sector of the country. The as-
\nsociation closely cooperates with the Minis-
\ntry of Health, Labor and Social A\ufb00airs and
\nState Medical Regulation Agency.Based on
\nthis cooperation, GMA is carrying out the
\nfollowing activities:
\nMedical Education: The members of the
\nGMA in association with the Tbilisi State
\nMedical University elaborated the Post-
\ngraduate Curricula in several medical spe-
\ncialties.
\nProfessional Liability: The physicians\u2019
\nrights were widely violated several months
\nago. The complaints of the patients (one
\nyear ago) in most of the cases were the back-
\nground for professional or even criminal li-
\nThe Georgian Medical Association
\n25
\nability of practitioners.The GMA expressed
\nits concern and strong position against this
\ntrend. GMA raised this issue in Health
\nCare Committee of the Parliament. The
\nnegotiations with the ministry of Health,
\nLabor and Social a\ufb00airs \ufb01nished success-
\nfully.The GMA was delegated the privilege
\nto appoint professional medical experts for
\ninvestigation and review of medical records.
\nNowadays, any professional complaints
\nagainst the physicians are forwarded to the
\nGMA and the decision of the Licensing
\nBoard now is based on alove conclusions.
\nAs a result, the physicians now are more
\nprotected and professional issues are solved
\nonly by professionals.
\nProfessional Standards: The GMA started
\nelaboration of the document about the Pro-
\nfessional Framework of medical special-
\nties. A part of the documents are already
\nsubmitted to the Ministry of Health. As
\na result, the ministry reviewed existing
\nstandards and started amendments. The
\nGMA is continuing the work on National
\nGuidelines on Good Medical Practice. We
\nstrongly believe that mentioned document
\nwill improve the relations between the state
\nand medical professionals. The members
\nof the GMA, together with the di\ufb00erent
\nprofessional associations are very active in
\nelaboration of the National Medical Guide-
\nlines and Protocols. Recently,The Georgian
\nMedical Association, in association with
\nthe Georgian Association of Surgeons
\nelaborated the guidelines for management
\nof surgical emergencies in clinical practice
\nfor 4 diseases.
\nLicensing and Certi\ufb01cation of Physicians:
\nThe Georgian Medical Association is ac-
\ntively involved in the process of the Licens-
\ning and Accreditation of the Physicians.
\nRecent times, GMA was invited by the
\nministry of health to carry out the techni-
\ncal and organizational support of the exams.
\nThe persons recommended by the GMA
\nare appointed as a Chairs and Members of
\nthe Examination Commissions. The GMA
\nleaders are chairing the examination com-
\nmission for the GP Licensing process, as
\nwell as the Appellation Commissions. The
\nexamination tests are to be renewed before
\neach examination session. The GMA in
\ncollaboration with the professional medi-
\ncal associations are making the mentioned
\nupdates and amendments.
\nMedical-SocialExpertise:GeorgianMedi-
\ncal Association and the experts from GMA,
\nare providing the training cycles for the sta\ufb00
\nresponsible for provision of Social-Medical
\nExpertise to decide about the matter and
\ndegree of disability (mental and physical).
\nRightofPhysicians: Georgian Medical As-
\nsociation is supporting its members, as well
\nas non-member physicians in case of medi-
\ncal litigation. GMA representatives are at-
\ntending the judiciary processes and submit-
\nting the professional conclusions in favor of
\nmedical doctors if the association believes
\nthat the doctor is deserving support. GMA
\ntries to make the evident border between
\nthe medical error and medical crime. We
\nstrongly believe that the physicians should
\nnot be sentenced by the criminal courts for
\nmedical errors!
\nEthical Standards: One of the most im-
\nportant directions of the GMA\u2019s activities is
\nthe development of Code of Medical Eth-
\nics. The Code is obligatory for the GMA
\nmembers.
\nHuman Rights: Georgian Medical As-
\nsociation, in close partnership with lo-
\ncal organizations (RCT\/EMPATHY and
\nARTICLE 42) developed and successfully
\ncompleted the Istanbul Protocol Develop-
\nment Project (1 and 2 phase 2003-2007).
\nThe international partners of the project
\nwere: WMA, Physicians for the Human
\nRights \u2013 USA, Human Rights Founda-
\ntion \u2013 Turkey,Redress and the International
\nRehabilitation Council of Torture Victims
\n(Denmark).In the Frames of the Project,15
\nmedical professional was prepared and cer-
\nti\ufb01ed as an international expert in e\ufb00ective
\nmedical investigation and documentation of
\ntorture victims. The physicians prepared by
\nthe project now are used as trainers in other
\ncountries of the world.
\nUndergraduate Medical Education Stan-
\ndards: GMA is working now on the under-
\ngraduate medical education curricula. The
\nstandards should be based on recommen-
\ndation of the World Federation of Medical
\nEducation \/ WHO. All the Quality Assur-
\nance tools are emphasized. In this respect,
\nthe GMA has the close partnership with
\nTbilisi State Medical University. Tbilisi
\nState Medical University is kindly o\ufb00ering
\nthe o\ufb03ce space for GMA during the past
\nyears up today.
\nForeign Medical Graduated: According
\nto the Georgian Law on Medical Activi-
\nties, any foreign graduate, applying for the
\nworking License of the physician in Geor-
\ngia should be recommended by the profes-
\nsional association. Recent years, more and
\nmore foreign graduates are applying us for
\nrecommendation. GMA is reviewing the
\napplications and after the \ufb01nal interview is
\ngiving or declining the recommendations.
\nGeorgian Law on Medical Activities stipu-
\nlates that any incoming foreign practitioner
\nshould have a temporary license for tempo-
\nrary work permit in the country. Georgian
\nMedical Association is active also in this
\ndirection. In this respect our obligation is to
\n\ufb01nd and collect the data about the clinical
\ncompetence of the incoming physician and
\nrecommend them to the Licensing Board
\nfor granting the temporary working license.
\nRegulatory Boards: The leaders of the
\nGeorgian Medical Association, according
\nto the local legislation are invited to work in
\ndi\ufb00erent health care regulatory boards, such
\nas: State Licensing Board of Medical Per-
\nsonnel; The Board of Postgraduate Medical
\nEducation and CPD; National Bioethical
\nCouncil.
\nAbovementioned activities carried out by
\nGMA is positively re\ufb02ects on physicians
\nprofessional environment and conditions.
\nDr. Levan Labauri M.D., Ph.D.
\nSecretary General, Georgian
\nMedical Association
\n26
\nThe Israeli Medical Association (IMA) is
\nan independent professional organization,
\nadvocating for the rights of physicians and
\npatients throughout Israel. Established in
\n1912, 36 years before the founding of the
\nState of Israel,the IMA has been con\ufb01rmed
\nby the courts as the representative body of
\nphysicians in Israel. Although membership
\nis on a voluntary basis, 94% of physicians in
\nIsrael are members of the IMA. The IMA
\nalso includes within its ranks 155 scien-
\nti\ufb01c associations, societies and workgroups.
\nThe IMA is responsible for setting profes-
\nsional norms and ensuring high standards
\nof medicine along with ethical behavior and
\nprofessional integrity.It also strives to secure
\nthe physician\u2019s status, rights and autonomy.
\nIn recent years, the IMA has expanded its
\nfunction to take a greater role in shaping
\nnational health policy, in\ufb02uencing the legis-
\nlative process, and promoting public health
\nand quality assurance.
\nThe IMA has recently been involved in seve-
\nral key processes intended to improve the
\nsituation of both the individual physician as
\nwell as the state of health care in Israel.
\nIn July 2000, the IMA agreed on behalf of
\nall publicly employed physicians to give up
\nthe right to strike for ten years in exchange
\nfor mandatory arbitration. The arbitration
\nprocess only began in 2005 and continues
\ntoday. The arbitrators are expected to ar-
\nrive at a \ufb01nal decision within the coming
\nmonths.
\nThe IMA\u2019s list of demands include an ad-
\nditional salary of approximately 32% (for
\npublic doctors), accounting for a physician\u2019s
\novertime work when calculating his\/her ba-
\nsic salary, a solution to the shortage of pro-
\nfessionals in certain specialties, allocation of
\ntime and remuneration for those physicians
\nwho participate in CME\/CPD and increas-
\ning pension pay from 70 to 85% of a physi-
\ncian\u2019s basic salary.
\nAnother recent development which the
\nIMA initiated was the establishment of
\nthe Public Forum to Update the Basket
\nof Health Services. This public forum was
\nformed when the Ministry of Health\u2019s ad-
\nvisory committee on the yearly basket of
\nhealth services reduced the amount of phy-
\nsician and patient advocates allowed to serve
\non the committee. The Forum included
\nexperts in ethics and health economics, pa-
\ntient advocates, public representatives, and
\nclergy members. As a result of the estab-
\nlishment of this alternative committee, the
\nIsraeli Medical Association was successful
\nat expanding the amount of resources com-
\nmitted to the basket of health services from
\n250 million New Israeli Shekels to 400
\nmillion New Israeli Shekels. Additionally,
\nthe alternative committee\u2019s establishment
\ncaused a ripple e\ufb00ect on the Ministry of
\nHealth\u2019s advisory committee, resulting in
\nmore transparent procedures, hearings that
\nincluded patient testimony,the allowance of
\ncriticism from the media, and the opening
\nof an advisory committee website.
\nOn the international front, the IMA has
\nbeen an active member of the World Medi-
\ncal Association for many years, drafting and
\ncontributing to statements and declarations
\nand providing representation to several com-
\nmittees. Dr. Yoram Blachar, current WMA
\nPresident-Elect, has served as chairman of
\nthe Socio-Medical A\ufb00airs Committee and
\nthe Finance and Planning Committee, in
\naddition to two consecutive terms as Chair-
\nman of Council. Adv. Leah Wapner assists
\nwith legal counsel to the WMA and Adv.
\nMalke Borow serves as an advisory member
\nof the Medical Ethics Committee.
\nCurrently, the IMA serves as a member of
\nthe workgroup on stem cells, and a member
\nof the workgroup on clinical trials involving
\nchildren, as well as leading the workgroup
\non task shifting, which will result in the
\ndrafting of a statement on the topic. Addi-
\ntionally, the IMA is at work on a number of
\nother draft statements on di\ufb00erent topics.
\nOne of Dr. Yoram Blachar\u2019s goals for his
\nupcoming presidency at the WMA is to in-
\ncrease the WMA\u2019s Arab member constitu-
\nency. During his term as President-Elect,
\nDr. Blachar has already made contacts with
\nvarious heads of NMAs of Arab countries
\ncurrently not members of the WMA. Dr.
\nBlachar will continue with these recruitment
\ne\ufb00orts during his upcoming presidency.
\nThe Israeli Medical Association
\nAdv. Leah WapnerDr. Yoram Blachar,
\nPresident\u2013Elect of WMA
\n27
\nThe Estonian Medical Association (EMA)
\nis a voluntary nongovernmental organisa-
\ntion representing the interests of Estonian
\ndoctors. The EMA was founded on Febru-
\nary 28 1921 as an Association of Estonian
\nMedical Societies, dismissed in year 1940
\nby Soviet regime, and refounded on June
\n11, 1988 as a National Medical Association.
\nEMA has the functions of trade union since
\n1992.
\nThe main objectives of The Estonian Medi-
\ncal Association are to unite the physicians,
\ndevelop and elaborate health policy,medical
\nculture and ethics in Estonia as well as re-
\npresent and protect the professional inter-
\nests and rights of the members of the EMA.
\nThe EMA participates in the elaboration of
\nthe legislation concerning health and is rep-
\nresented in a number of organizations and
\ncommissions coordinating health care.
\nMore than 70 % of Estonian doctors belong
\nto Estonian Medical Association. Besides
\nregional medical associations also the Esto-
\nnian Junior Doctors\u2019 Association belongs to
\nthe EMA.
\nDr. Andres Kork- a general surgeon at the
\nWest Tallinn Central Hospital has held the
\npost of the president of association since
\n2002. The General Assembly is the highest
\ndecision-making body that is summoned
\nonce a year in November. The Council pre-
\nsides the EMA in the recesses.The Council
\nis comprised of the president, Board mem-
\nbers and the representatives of the regional
\nassociations. The Board is the organ of the
\nexecutive-organizational administration of
\nthe EMA.
\nThe EMA publishes its journal,the Estonian
\nMedical Journal (www.eestiarst.ee), which
\nalso contains original research reports. De-
\nspite the fact that the number of people
\nspeaking Estonian is fairly low, EMA has
\nmade the best e\ufb00orts to translate most of
\nthe medical terms int Estonian and keep
\nthe language medically useful.
\nInternational relations
\nThe Estonian Medical Association is a full
\nmember of the major medical organizations
\nin Europe: the Standing Committee of Eu-
\nropean Doctors (CPME) and the European
\nUnion of Medical Specialists (UEMS). Es-
\ntonian Junior Doctors\u2019 Association (EJDA)
\nis a full member of the Permanent Working
\nGroup of European Doctors (PWG).EMA
\nhas joined World Medical Association in
\nyear 2004.
\nEMA and WMA
\nThere is no doubt that the World Medical
\nAssociation is one of the most in\ufb02uential
\nmedical organizations worldwide. As Esto-
\nnians have experienced the soviet political
\nsystem which did not comply with the ba-
\nsic human rights and democracy we highly
\nvalue the \ufb01rm standpoint WMA has always
\nhad in these key questions.
\nLast year the EMA in conjunction with the
\nMedical School of Tartu University pub-
\nlished the Estonian version of the WMA
\nMedical Ethics Manual. Now every medi-
\ncal student will receive his or her own copy
\nof the WMA ethics manual when having
\nethics classes. Besides being a very clear and
\nconcise handbook of ethics, I believe that
\nmany students will realize with the help of
\nthat book, that the work and ethical stan-
\ndards of doctors is very similar in various
\ncountries.
\nVallo Volke MD, PhD
\nBoard member of Estonian Medical
\nAssociation
\nThe Estonian Medical Association and WMA
\n28
\nOutline of the JMA
\nThe Japan Medical Association (JMA) was
\n\ufb01rst established in 1916 and took on its
\npresent form following the Second World
\nWar in 1947. Membership comprises mem-
\nbers of Japan\u2019s 47 local medical associations.
\nAs an academic organization,the JMA aims
\nto promote policies that ensure the health
\nof the general public and the autonomy of
\nmedical professionals through the formula-
\ntion of national medical policies. Member-
\nship is voluntary, and currently numbers
\n165,000 (as of December 2007), which is
\n60% of the number of physicians in nation-
\nwide (approx. 270,000). Of these, approx.
\n85,000 are clinic physicians and 80,000 are
\nhospital-based physicians.
\nAssociation a\ufb00airs and important matters
\nmust be decided by the JMA Board; the
\nhighest decision-maiking organ is the Gen-
\neral Assembly of House of Delegates. The
\nSecretariat comprises 226 sta\ufb00 (as of Decem-
\nber 2007) and the Secretary General must be
\na quali\ufb01ed physician (Tables 1 and 2).
\nTwo WMA Presidents
\nThe JMA has provided by two WMA Presi-
\ndents,Dr.Taro Takemi and Dr.Eitaka Tsuboi.
\nDr. Taro Takemi served as President of the
\nJMA for 25 consecutive years, from 1957
\nuntil 1982. In 1975, he was appointed as
\nthe 29th WMA President and the WMA
\nGeneral Assembly was held in Tokyo in the
\nsame year.Early in his research e\ufb00orts on the
\ntheme of \u201cthe development and distribution
\nof medical resources\u201d, Dr. Takemi foresaw
\nthat Japanese healthcare would in the fu-
\nture become intertwined with global health
\nin the future. Dr. Takemi also took part in
\nthe establishment of the Confederation of
\nMedical Associations in Asia and Oceania
\n(CMAAO) in 1956, a major aim of which
\nwas to gather together of the voices of Asian
\nphysicians and to deliver them to the WMA
\nfor discussion. CMAAO membership now
\ncomprises the national medical associations
\nof 17 countries, with the confederation car-
\nrying out various activities in order to raise
\nhealth standards for the people of the region
\nthrough the promotion of exchange between
\nphysicians and information exchange.
\nDr. Takemi also founded the Takemi Pro-
\ngram in International Health at the Har-
\nvard School of Public Health in Boston in
\n1983 with the aim of providing opportu-
\nnities for health professionals, particularly
\nthose in developing countries, to futher
\nimprove their skills. Even now, the program
\nrecruits approximately 10 researchers from
\nall around the world every year. Those who
\nhave completed the program are known as
\n\u201cTakemi Fellows\u201dand they play central roles
\nin healthcare all over the world.
\nDr. Eitaka Tsuboi served as JMA President
\nfrom 1996 to 2004; in 2000,he was appoint-
\ned as the 52nd WMA President and the
\nWMA General Assembly was held again
\nin Tokyo in 2004 after a break of 25 years.
\nDr. Tsuboi was tireless in his international
\ncontributions, such as the implementation
\nof health programs in developing countries.
\nIn 1997, the Japan Medical Association
\nResearch Institute (JMARI) was estab-
\nlished as a Think Tank for supporting the
\n\u201cDevelopment of Health Care Policies for
\nthe Japanese People\u201d promoted by the JMA
\nthrough research activities, information
\ngathering, and survey analysis. The JMA
\nincorporates the results of JMARI research
\ninto its policy proposals and on occasion
\npresents these directly to political party re-
\nviews as \u201cMedical Workplace-led Policies\u201d,
\nThe International Activities of
\nthe JMA and the WMA
\nTable 1. Organization of the JMA
\n1. Membership is voluntary.
\n2. There are 165,000 members (out of
\n270,000 physicians in Japan).
\n3. The highest organ is the General
\nAssembly of House of Delegates.
\n4. The JMA Board serves as actual
\ndecision-maker.
\n5. Secretariat of 226 people works
\nto implement the decision of the
\nboard.
\nTable 2. Secretariat of the JMA
\n1. Number of sta\ufb00: 226; 185 are full-
\ntime.
\n2. Three departments and 20 divisions.
\nThe International Division has
\n5 sta\ufb00.
\n2. JMA Research Institute: est. in 1997
\n3. Top is Secretary General (MD).
\n4. O\ufb03ce hours: 9:30 to 17:30; Monday
\nto Friday.
\nCMAAO Congress in Pattaya, 2007
\n29
\nLong tradition
\nThe Viet Nam Medical Association (VMA)
\nwas established more than half a century
\nago, in 1955, and since then has brought
\nmedical doctors and pharmacists together
\nunder the mission of uni\ufb01cation for the de-
\nvelopment of Viet Nam and to improve the
\nquality of heath care for all, with a focus on
\nindependence and medical ethics.
\nDuring the development of the VMA,some
\nspecialties,including pharmacists,tradition-
\nal medical doctors and acupuncture doctors,
\nlobbied to create independent associations
\nfor each of these professions. Based on the
\nprinciples of voluntarism,the Exco of VMA
\nagreed with this request to split these pro-
\nfessional groups into specialty associations
\nas well as incorporate a number of new as-
\nsociations under the VMA umbrella. Now
\nthe VMA has 43 national specialties and 63
\nprovincial Medical Associations, as well as
\nthe Viet Nam Nurses Association and the
\nViet Nam Midwives Association.
\nSince its establishment, the Presidents of
\nthe VMA have been symbols of Viet Nam
\nintellects, both in general and especially
\nwithin the medical sector. Two of them
\nhave been chosen as the namesakes for two
\nstreets of the capital city HaNoi.
\nTransparency
\nThe VMA concentrates on publishing
\nMedical Journals. Four of the journals were
\nestablished \ufb01fty years ago, a further journal
\nThe Viet Nam Medical Association (VMA)
\nas opposed to bureaucracy-led or \ufb01nancially
\nled policy proposals.
\nCurrent and Future
\nInternational Activities
\nThe current executive of the JMA regards
\ncommunity healthcare in Japan as a part of
\nglobal health and has carried out activities
\nwith an emphasis on international coop-
\neration. The JMA Journal, o\ufb03cial English
\njournal of JMA, together with its English
\nwebsite, introduces major activities of the
\nJMA including those of local medical as-
\nsociations, such as health policies, advocacy
\npolicies, analysis of health systems, reports
\nof Takemi fellows and conferences and lec-
\ntures. It also publishes international topics
\ncontributed by WMA and CMAAO re-
\nlated to physicians. This journal is a com-
\nprehensive one introducing JMA activities
\nfrom the global perspective.
\nThree of the current WMA council mem-
\nbers are from the JMA, and thus policy do-
\ncuments adopted by the WMA are always
\nreported to the JMA Board.Important doc-
\numents such as the Declaration of Geneva,
\nDeclaration of Helsinki, and Declaration
\nof Lisbon are used as necessary as reference
\nmaterials in JMA Ethics Committee and
\nPatient Safety Committee discussions. In
\nthe spring of 2007, 220,000 copies of the
\nJapanese version of the \u201cWMA Medical
\nEthics Manual\u201d were published and not
\nonly distributed to all JMA members, but
\nalso given to 45,000 medical students at 80
\nmedical colleges nationwide as part of the
\nJMA\u2019s support for medical education.
\nInformation is also actively exchanged with
\nindividual national medical associations
\nthroughout the world. A broad range of
\ninformation from both around Japan and
\nfrom overseas is necessary for resolving
\nvarious health issues faced in Japan and
\ninternational community as well, but over-
\nseas information obtained from the inter-
\nnet does not always meet our requirements.
\nAn international network centered on the
\nWMA and CMAAO would be an extreme-
\nly e\ufb00ective means for medical associations
\nto e\ufb03ciently acquire accurate and wide
\nscope of information from overseas. In ad-
\ndition to expressing our heartfelt gratitude
\nto the responsible o\ufb03cers in the NMAs that
\ncooperate regularly with the JMA, we hope
\nthat this type of cooperation in exchanging
\ninformation among NMAs will be main-
\ntained in the future.
\nMasami Ishi, MD
\nExecutive Board Member, Japan
\nMedical Association
\nCouncil Member, World Medical Association
\nMASEAN 12th Midterm Meeting Council Hanoi Vietnam 10. November 2007. Delegates
\nfrom: Indonesian Medical Association, Medical Association of Lao PDR, Malaysian Medical
\nAssociation, Myanmar Medical Association, Philippines Medical Association, Singapore Medical
\nAssociation, Medical Association of Thailand, Vietnam Medical Association, Ministry of Health,
\nBrunei Bandar Seri Begawan
\n30
\nBy all the historical accounts, the 4th
\nof Janu-
\nary 1958 was a signi\ufb01cant de\ufb01ning moment
\nfor the future of the medical profession in
\nGhana. In many ways, the signi\ufb01cance of
\nthat achievement was not without drama of
\nits own, deeply steeped in the rich colonial
\nand political ethos of the time.
\nMind you, 1958 was the year after Ghana,
\nthe \ufb01rst country south of the Sahara had
\nachieved its independence. Kwame Nkrumah
\nthe Osagyefo was busily stamping the Gha-
\nnaian seal on all National emblems, monu-
\nments and organizations. Above all perhaps,
\nhe was also breaking off the shackles of
\ncolonialism from the minds of the recently
\ncolonized. The year was also interesting for
\nkeen observers of the medical scene not
\nleast because it witnessed the co-existence
\nof two bodies which could neither be said to
\nbe serious rivals and yet not exactly comple-
\nmentary of each other\u2019s activities. Within
\nthis politically charged context, there had
\nexisted 25 years back in 1933, an organiza-
\ntion of mainly African medical practitioners
\nwhose main purpose according to celebrated
\nmedical historian, Prof Stephen Addae was
\nto \u201cact as a vehicle for redressing grievances
\nof African medical of\ufb01cers in government
\nemployment.\u201d It had Dr. F. V. Nanka-Bruce
\nas its \ufb01rst President and Spokesman and was
\nof\ufb01cially known as the Gold Coast Medical
\nPractitioners Union.
\nBut it was a beginning.
\nThe second more powerful group of doc-
\ntors was formed in January 1953 and was
\nknown as the Ghana Branch of the Brit-
\nish Medical Association. Mind you, in
\nthe Gold Coast, the interests of medical
\npractitioners were advanced by the parent
\nBritish Medical Association whose branch
\nit was. With an African government taking
\nup the reigns of leadership in 1951, it must
\nhave felt increasingly anachronistic to look
\nback to Great Britain for leadership. Be-
\ning better connected and grouping a larger
\nbody of doctors, this second group was
\nmore vibrant.
\nIn fact in the words of Prof Addae, \u201cthe re-
\ncords indicate that the Branch Association
\nwas a very active body\u2026It quickly established
\na good working relationship with the new Af-
\nrican government and was soon recognized
\nas the negotiating body for the medical pro-
\nfession in the country. It participated in the
\nnew Ministry of Health\u2019s plans for setting up
\na Medical and Dental Board and amending
\nthe existing Medical and Dental Practitioners
\nOrdinance. Political goodwill prevailed.\u201d This
\nBranch was led \ufb01rst by Dr. F. V. Nanka-Bruce
\nof the initial Practitioners Union whose brief
\ntenure was followed by the election of anoth-
\ner African, Dr. C. E. Reindorf following the
\nformer\u2019s sudden death after only \ufb01ve months
\nin of\ufb01ce.
\nTheoretically therefore, by 1958 when the
\nGhana Medical Association was formed, we
\nhad these two bodies championing the cause
\nof doctors in modern Ghana. Increasingly
\nhowever, according to the late Dr. M. A Bar-
\nnor, third GMA President in his book A Socio-
\nMedical Adventure in Ghana, debate had long
\nbeen on-going as to how to transform the
\nBranch organization as the Gold Coast itself
\nbegan in 2007 and 30 journals belong to na-
\ntional specialties.
\nInternational relations
\nThe VMA was accepted fully as member of
\nthe South East Medical Association (Mase-
\nan) and have hosted two Masean meetings
\nin Ha Noi .
\nIn addition, we have good relationships
\nwith the UK and USA Medical Associa-
\ntions as well as excellent linkages with the
\nWorld Medical Association.
\nVMA will advocate a comprehensive policy
\napproach against Hepatitis B, supported
\nby Bristol Squich Meyer. In addition, Path-
\n\ufb01nder International will provide a project of
\ncapacity building for VMA in three years,
\nstarting from 2008.
\nConsultant for MOH
\nVMA has been actively involved as a con-
\nsultant for MOH, especially on policy and
\nhealth system structure and organization.
\nThe VMA now conducts monthly meet-
\nings with the Minister of Health to ensure a
\nregular dialogue on key issues.
\nVMA will continue to promote a prior-
\nity focus on improvements in the mental
\nhealth of mothers and infants in collabora-
\ntion with the Research and Training Centre
\nfor Community Development (RTCCD), a
\nlocal NGO with remerkable skills and abili-
\nties in this area.
\nSome ideas on further
\nactivities of WMA.
\nThe 21 century is the Century of Knowl-
\nedge and globalisation is on the way to be-
\ning realized. The WMA must be the key
\nassociation to provide continuing education
\nas well as communication on the key health
\nissues throughout the world. However the
\nmajority of medical associations are not in a
\nposition to make large payments, therefore
\nfree membership is necessary to ensure that
\nthe collaboration between organizations
\nas well as knowledge dissemination by the
\nWMA continues.The VMA hopes that the
\nWMA will have the innovation to realize
\nthis noble task.
\nPham Song
\nPresident of VMA .
\nThe Ghana Medical Association
\n50 years of health advocacy, policy dialogue and welfare
\n31
\nmoved from a colonial status to an indepen-
\ndent nation.
\nNow, this is where the plot thickens for within
\nless than a year of his return to Ghana after
\nhis studies in America and Canada, one Dr.
\nSchandorf in partnership with a few others
\nachieved what others had only been debating
\nfor years. In Dr. Barnor\u2019s opinion, Dr. J. A.
\nSchandorf whom he described as a \u201cmedi-
\ncal entrepreneur\u201d and who was later elected
\nthe second president of the Ghana Medical
\nAssociation was not controversial in what he
\nset out to do.
\n\u201cIt was the way he went about doing it-which
\nwas the right way-but which people thought
\nwas controversial\u201d, observes Dr. Barnor.
\nAnd just what did our second president do?
\nOnce again, we defer to the \ufb01rst hand ac-
\ncount of second general secretary and third
\npresident, Dr. Barnor.
\n\u201cOne day in 1958, there was a news\ufb02ash in
\nthe \u2018Daily Graphic\u2019 newspaper. The newspa-
\nper announcement indicated that a newly ar-
\nrived doctor and a medical entrepreneur from
\nthe United States, Dr. J. A Schandorf had an-
\nnounced he was going to launch a \u2018Ghana
\nMedical Association\u2019 which would be recog-
\nnized by government and would also be the
\nmouthpiece of the profession in the country.
\nThe ceremony was to be performed by the
\nPrime Minister, Dr. Kwame Nkrumah\u201d
\nFrom all indications, Schandorf was strate-
\ngic if not radical. As an American-trained
\ndoctor, he had been denied registration in
\nEngland when he tried. He, therefore must
\nhave had his motivation for wanting a Ghana
\nMedical Association that was not a branch of
\nthe British Medical Association. Secondly, he
\nhad a personal relationship with the Prime
\nMinister with whom he had attended Lincoln
\nUniversity in the United States. Thirdly, he
\nmanaged to rope in other heavy weights like
\nDr. C. E. Reindorf, Chairman of the Gold
\nCoast Branch of the British Medical Associa-
\ntion and Dr. W.A.C Nanka-Bruce, one time
\nSecretary of the original Gold Coast Medical
\nPractitioners Union.
\nAnd so it happened that on the 4th of Janu-
\nary 1958 at 5 pm in the Arden Hall of the
\nAmbassador Hotel, Prime Minister Kwame
\nNkrumah duly launched the GMA after
\nstating \u201chow pleased he was that the Ghana
\nMedical Association was going to be formed,
\nand that that would mean a strong body of
\ndoctors would from then on exist to help
\nboth the government and the medical pro-
\nfession itself.The Prime Minister also added
\nthat \u2018from now on, the Ghana Medical As-
\nsociation is the only organization of doctors
\nmy government is prepared to recognize\u2019.
\nGrowing Pains
\nIn the immediate aftermath of its formation,
\nthe GMA had to deal with issues of estab-
\nlishing the credibility of this \ufb01rst professional
\nbody including popularizing it among doctors
\nand the general public, securing funding for its
\nactivities and contributing to the larger health
\nagenda of the newly independent nation. And
\nso it was that a new Executive was elected led
\nby Prof Charles Odamtten Easmon as First
\nPresident and Dr. F. T Sai as his Secretary with
\nthe latter being later succeeded by Dr M. A.
\nBarnor on his departure to the United King-
\ndom for further studies in Internal Medicine.
\nAs early as July 1959, Divisions of the GMA
\nbegan to be set up in various parts of the coun-
\ntry with Ashanti-Brong Ahafo being the \ufb01rst
\nDivision. This Division, an amalgamation of
\ndoctors from two Regions was led by Dr. Evans
\nAnfom who would later become the 5th GMA
\nPresident. This was followed almost immedi-
\nately the following month by the inauguration
\nof the Western Division which incorporated
\nthe Western and Central Divisions. To quote Dr.
\nM. A Barnor, \u201cthis was a momentous occasion,
\nexhibited by the rapidity with which almost all
\ndoctors in the region-private and government
\nmedical of\ufb01cers without exception \u2013 in no
\ntime became active, enthusiastic and pioneering
\nmembers. It was a timely development and Dr.
\nA. A. Akiwumi of Ef\ufb01a-Nkwanta Hospital was
\nelected the \ufb01rst Chairman of the Western Divi-
\nsion of the Ghana Medical Association.\u201d
\nThe Eastern Division was to follow, curiously
\nwith its administrative base in the Greater
\nAccra Region with Dr. R.H.O Bannerman as
\nChairman. Then came the Northern Divi-
\nsion comprising all three Northern Regions
\nin 1973 and then \ufb01nally Volta came. Today,
\nof course, the Association consists of ten
\nDivisions whose Chairmen together with
\nrepresentatives each of the Ghana Dental
\nAssociation, Society of Private Medical and
\nDental Practitioners and Junior Doctors and
\nthe seven elected members of the National
\nExecutive Committee constitute the National
\nExecutive Council, the highest decision ma-
\nking body, second only to the authority of the
\nAnnual General Meeting.
\nEven at that early stage, the GMA quickly
\nstarted organizing public lectures on health
\neducation, nutrition and hygiene in Accra, a
\ntradition which it has maintained till date as its
\ncontribution to health education and policy di-
\nalogue. Today also, beyond the organization of
\nAnnual Public lectures, the GMA has sourced
\nfunding and is very advanced in its attempts to
\npublish public lectures on Hypertension and
\nRoad Traf\ufb01c Accidents etc as Supplementary
\nReaders for Children in Ghana.
\nAs part of its growing efforts, the Ghana
\nMedical Association sought and gained inter-
\nnational recognition when in 1959, it applied
\nfor and was granted membership of the World
\nMedical Association followed in May 1960 by
\naf\ufb01liation to the British Medical Association
\n(BMA). Two years later, following a proposal
\nfrom the BMA, the GMA would signi\ufb01cantly
\nco-sponsor the conversion of the \u2018British
\nCommonwealth Medical Conference\u2019 into the
\nCommonwealth Medical Association.
\nToday it is indeed a source of great pride to
\nthe Ghana Medical Association to have Prof
\nAgyeman Badu Akosa, himself a Past Presi-
\ndent ascend to the high of\ufb01ce of President
\nof the Commonwealth Medical Association
\nfrom 2005-2007. Having completed his ten-
\nure, he has been succeeded on the Executive
\nby Past GMA General Secretary Dr. Ohen-
\neba Danso who is the current Secretary of
\nthe Commonwealth Medical Association.
\nSodzi Sodzi-Tettey
\n32
\nSomalia Republic is situated in the horn of
\nAfrica. Its land is estimated to be 638,000 sq.
\nkm.,and its coastline extends 3,330 km.Ethi-
\nopia borders it in the west,Kenya in the south,
\nthe Indian Ocean in the east, in addition to
\nthe Red Sea and the Republic of Djibouti in
\nthe north (Fig 3.1).The population of Soma-
\nlia is estimated to be 10.8 million (2003); the
\ncapital city is Mogadishu with 2.5 million in-
\nhabitants. Somalia is divided into 18 regions.
\nMajor climatic factors are a year-round hot
\nweather,seasonal monsoon winds,and irregu-
\nlar rainfall with recurring droughts.
\nIntermittent civil wars have been a fact of
\nlife in Somalia since 1977 with much ca-
\nsualties and famine. One of the world\u2019s
\nleast developed countries, Somalia has few
\nresources with much of the economy be-
\ning devastated by the civil war. Agriculture
\nis the most important sector, with livestock
\naccounting for about 40% of GDP and
\nabout 65% of export earnings.
\nSomali Medical Association. Aims:
\n\u2022 To represent the Somali medical doc-
\ntors and advocate for their rights.
\n\u2022 To provide continued medical educa-
\ntion to its own members.
\n\u2022 To implement medical relief projects
\nEstablishment:
\n\u2022 Was founded in 1961, with the \ufb01rst 4
\nnewly quali\ufb01ed medical doctors Founded
\nin 1961 with the \ufb01rst 4 Somali doctors.
\n\u2022 Grew in number and quality, and in
\n1990 the members were 1142.
\n\u2022 Ceased to work in 1991, due to civil war
\nin the country.
\n\u2022 A lot of its members \ufb02ed the country
\nCurrent SMA:
\n\u2022 Re-established in 2000 by 143 doctors
\nin Mogadishu.
\n\u2022 The current number is 481 working
\nthroughout the country.
\n\u2022 Member of the World Medical Asso-
\nciation and Arab Medical Union
\n\u2022 Applied to become a FIMA member
\n\u2022 In late 2006 the Transitional federal
\ngovernment relocated to the capital city,
\nMogadishu with the support of Ethio-
\npian troops.
\n\u2022 In early 2007 a local armed insurgency
\nagainst the Ethiopian army presence
\nstarted all over south-central Somalia.
\n\u2022 This caused a lot of internal and inter-
\nnational displacement of the local popu-
\nlation, including the medical doctors.
\n\u2022 There are only two major hospitals
\nworking at the moment, down from 15
\nhospitals in 2006.
\nStructure of SMA
\n\u2022 General assembly: Held every two
\nyears, where all members are eligible to
\nparticipate and elect the executive com-
\nmittee.
\n\u2022 Executive committee: Is elected for a
\nperiod of two years, and it is composed
\nof 10 members, including the Chair-
\nman, Deputy chairman, Treasurer and
\nheads of di\ufb00erent subcommittees
\n\u2022 Subcommittees: We have subcommit-
\ntee on ethics, medical defense, interna-
\ntional relations, training and research,
\nsocial a\ufb00airs, public health etc.
\nDr. Abdirisak A Dalmar
\nMD MScOphth PhD
\nChairman
\nSomali Medical Association
\nThe Somali Medical Association
\nTable 1:
\nSelected demographic and economic
\ncharacteristics in Somalia
\nDemographic
\nIndicators
\nYear Value
\nPopulation 2004 10.8 million*
\nPopulation
\nGrowth Rate
\n2000 3.41%
\nAge Structure: 2000
\n0-14 years: 44%
\n15-64 years: 53%
\n65 years and over: 3%
\nLife Expectancy
\nat Birth
\n2000
\nTotal population:
\n46.2 years
\nmale: 44.7 years
\nfemale: 47.9 years
\nTotal Fertility
\nRate
\n2000
\n7.18 children born\/
\nwoman
\nBirth Rate 2000
\n47.7 births\/1,000
\npopulation
\nDeath Rate 2000
\n18.69 deaths\/1,000
\npopulation
\nInfant Mortality
\nRate
\n2000
\n125.77 deaths\/1,000
\nlive births
\nLiteracy (de\ufb01ni-
\ntion: age 15 and
\nover can read and
\nwrite)
\n1990
\ntotal population: 24%
\nmale: 36%
\nfemale: 14%
\nPer Capita
\nIncome
\n$600
\n* This estimate was derived from an official
\ncensus taken in 1975 by the Somali Govern-
\nment; population counting in Somalia is
\ncomplicated by the large number of nomads
\nand by refugee movements in response to fam-
\nine and clan warfare.
\nTable 2:
\nSelected health indicators in Somalia
\nHealth Indicators Year Value
\nPhysician Per 10,000 Population 1997 0.4
\nDentists Per 10,000 Population 1997 0.02
\nPharmacists Per 10,000 Popula-
\ntion
\n1997 0.01
\nNursing and Midwifery Person-
\nnel Per 10,000 Population
\n1997 2
\nHospital Beds Per 10,000
\nPopulation
\n1997 4.2
\nHouseholds with Access to Lo-
\ncal Health Facilities (%)
\n2003 72.2
\nPopulation with Access to Safe
\nDrinking Water (%)
\n1999 23.1
\nPopulation with Adequate
\nExcreta Disposal Facilities
\n1999 48.5
\nDr. Abdirisak A Dalmar
\nThe WMA Statement on Family Planning
\nand the Right of a Woman to Contraception
\nContents
\nEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
\nFrom the Secretary General\u2019s desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
\nWHO Executive Board, 122nd
\nsession, 21\u2013 26 January 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
\nNon-communicable diseases are in the focus of a new WHO action plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
\nWMA Statement on Noise Pollution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
\nPhysicians Call For Zero Tolerance to Female Genital Mutilation Across The World . . . . . . . . . . . . . . . . . . . . . . . . . . 8
\nInformed Consent \u2013 Recent Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
\nPortrait of a key player . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
\nThe Norwegian Medical Association. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
\nJoint Medical Ethics Re\ufb02ections of the Nordic Countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
\nThe Lithuanian Medical Association and its Priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
\nThe Republic of Belarus and its Health Care System in Brief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
\nThe Ukrainian Medical Association is going to Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
\nThe Bulgarian Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
\nThe Czech Medical Association J. E. Purkyn\u011b (CzMA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
\nThe Austrian Medical Chamber . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
\nThe German Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
\nThe Georgian Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
\nThe Israeli Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
\nThe Estonian Medical Association and WMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
\nThe International Activities of the JMA and the WMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
\nThe Viet Nam Medical Association (VMA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
\nThe Ghana Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
\nThe Somali Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
\nThe WMA Statement on Family Planning and the Right of a Woman to Contraception . . . . . . . . . . . . . . . . . . . . . . . .33
\nAdopted by the 48th
\nGeneral Assembly, Somerset
\nWest, Republic of South Africa, October
\n1996 and amended by the General Assembly,
\nCopenhagen, Denmark, October 2007
\nThe WMA recognizes that unwanted preg-
\nnancies and pregnancies that are too closely
\nspaced can have a serious adverse e\ufb00ect on
\nthe health of a woman and of her children.
\nThese adverse e\ufb00ects can include the prema-
\nture deaths of women. Existing children in
\nthe family can also su\ufb00er starvation, neglect
\nor abandonment resulting in their death or
\nimpaired health, when families are unable
\nto provide for all their children. Social func-
\ntioning and the ability to reach their full
\npotential can also be impaired.
\nThe WMA recognizes the bene\ufb01ts for
\nwomen who are able to control their fer-
\ntility. They should be helped to make such
\nchoices themselves, as well as in discussion
\nwith their partners. The ability to do so by
\nchoice and not chance is a principal compo-
\nnent of women\u2019s physical and mental health
\nand social well being.
\nAccess to adequate fertility control meth-
\nods is not universal; many of the poorest
\nwomen in the world have the least access.
\nKnowledge about how their bodies work,
\ninformation on how to control their fer-
\ntility and the materials necessary to make
\nthose choices are universal and basic human
\nrights for all women.
\nThe role of family planning and secure ac-
\ncess to appropriate methods is recognized
\nin the 5th Millennium Development goal
\nas a major factor promoting maternal and
\nchild health.
\nThe WMA recommends that National
\nMedical Associations:
\nPromote family planning education by
\nworking with governments, NGOs and
\nothers to provide secure and high-quality
\nservices and assistance
\nAttempt to ensure that such information,
\nmaterials, products and services are avail-
\nable without regard to nationality, creed,
\nrace, religion or socioeconomic status.<\/p>\n"},"caption":{"rendered":"

wmj17 Hon. Editor in Chief Dr. Alan J. Rowe Haughley Grange, Stowmarket Su\ufb00olk IP143QT UK Editor in Chief Dr.P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 661 peteris@nma.lv Co-Editor Prof. Dr. med. Elmar Doppelfeld Deutscher \u00c4rzte- Verlag Dieselstr.2 D-50859 K\u00f6ln Germany Assistant Editor Dr. Ilze H\u0101znere, Pilso\u0146u iela 13, […]<\/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\/wmj17.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3567"}],"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=3567"}]}}