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wmj24<\/a><\/p>\n

G 20438
\nNo. 4, December 2009
\nwma 8.indd Iwma 8.indd I 12\/4\/09 4:23:15 PM12\/4\/09 4:23:15 PM
\nEditor in Chief
\nDr. P\u0113teris Apinis
\nLatvian Medical Association
\nSkolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@nma.lv
\neditorin-chief@wma.net
\nCo-Editor
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSu\ufb00olk IP143QT, UK
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor Velta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by J\u0101nis Pavlovskis
\nLayout and Artwork
\nThe Latvian Medical Publisher
\n\u201cMedic\u012bnas apg\u0101ds\u201d, President Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nCover painting :
\nMural painting in the Cultural Administration
\nComplex of the University Campus, Caracas,
\nVenezuela. Painter: Narv\u00e1ez Francisco.
\nPhotographer: Eliseo Sierra.
\nDate of photograph 2009.
\nPublisher
\nThe World Medical Association, Inc. BP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
\nDeutscher-\u00c4rzte Verlag GmbH,
\nDieselstr. 2, P.O.Box 40 02 65
\n50832 K\u00f6ln\/Germany
\nPhone (0 22 34) 70 11-0
\nFax (0 22 34) 70 11-2 55
\nBusiness Managers J. F\u00fchrer, D. Weber
\n50859 K\u00f6ln, Dieselstr. 2, Germany
\nIBAN: DE83370100500019250506
\nBIC: PBNKDEFF
\nBank: Deutsche Apotheker- und \u00c4rztebank,
\nIBAN: DE28300606010101107410
\nBIC: DAAEDEDD
\n50670 K\u00f6ln, No. 01 011 07410
\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 Association
\nSubscription fee \u20ac 22,80 per annum (inkl. 7%
\nMwSt.). For members of the World Medical
\nAssociation and for Associate members the
\nsubscription fee is settled by the membership
\nor associate payment. Details of Associate
\nMembership may be found at the World
\nMedical Association website www.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nK\u00f6ln, Germany
\nISSN: 0049-8122
\nDr. Dana HANSON
\nWMA President
\nFredericton Medical Clinic
\n1015 Regent Street Suite # 302,
\nFredericton, NB, E3B 6H5
\nCanada
\nDr Masami ISHII
\nWMA Vice-Chairman of Council
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Mukesh HAIKERWAL
\nWMA Chairperson of the Finance
\nand Planning Committee
\n58 Victoria Street
\nWilliamstown, VIC 3016
\nAustralia
\nProf. Ketan D. Desai
\nWMA President-Elect
\nIndian Medical Association
\nIndraprastha Marg
\nNew Delhi 110 002
\nI.M.A. House
\nIndia
\nDr. J\u00f6rg-Dietrich HOPPE
\nWMA Treasurer
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1
\n10623 Berlin
\nGermany
\nDr. Guy DUMONT
\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
\n1380 Lasne
\nBelgium
\nDr. Yoram BLACHAR
\nWMA Immediate Past-President
\nIsrael Medical Assn
\n2 Twin Towers
\n35 Jabotinsky Street
\nP.O. Box 3566
\nRamat-Gan 52136
\nIsrael
\nDr. Jens Winther Jensen
\nWMA Chairperson of the Medical
\nEthics Committee
\nDanish Medical Association
\n9 Trondhjemsgade
\n2100 Copenhagen 0
\nDenmark
\nDr. Karsten VILMAR
\nWMA Treasurer Emeritus
\nSchubertstr. 58
\n28209 Bremen
\nGermany
\nDr. Edward HILL
\nWMA Chairperson of Council
\nAmerican Medical Assn
\n515 North State Street
\nChicago, ILL 60610
\nUSA
\nDr. Jos\u00e9 Luiz GOMES DO
\nAMARAL
\nWMA Chairperson of the Socio-
\nMedical-A\ufb00airs Committee
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nRua Sao Carlos do Pinhal 324
\nBela Vista, CEP 01333-903
\nSao Paulo, SP
\nBrazil
\nDr. Otmar KLOIBER
\nWMA Secretary General
\n13 chemin du Levant
\nFrance 01212 Ferney-Voltaire
\nFrance
\nWorld Medical Association O\ufb03cers, Chairpersons and O\ufb03cials
\nO\ufb03cial Journal of The World Medical Association
\nOpinions expressed in this journal \u2013 especially those in authored contributions \u2013 do not necessarily re\ufb02ect WMA policy or positions
\nwww.wma.net
\nwma 8.indd IIwma 8.indd II 12\/4\/09 4:23:24 PM12\/4\/09 4:23:24 PM
\n127
\nHealthcare and the Economic Crisis
\nEastern European countries, especially those that were formerly
\nparts of the Soviet Union, are in the midst of a serious economic
\ncrisis. The countries most signi\ufb01cantly a\ufb00ected are Lithuania, Lat-
\nvia, Romania, Bulgaria and Hungary (members of the European
\nUnion), as well as Ukraine, Moldavia and Azerbaijan. In these
\ncountries the gross national product has fallen from 10% to 25%,
\nthe national debt has increased dramatically,the unemployment rate
\nhas reached up to 20%, wages have decreased, the budget for health
\ncare and welfare have been cut, and money for heating and even
\nsubsistence is lacking in some areas.
\nAn economic crisis somewhere in the world is nothing new. In the
\nearly 1990s the economies of Eastern Europe overall dropped 32
\n% to 75% of their previous level and medical facilities were faced
\nnot only with insu\ufb03cient funds, but also with a lack of medicines
\nand bandages, while also working in out-dated facilities and with
\nimprecise laboratories. In the 1990s, during the military crisis in
\nYugoslavia and the Nagorono-Karabakh con\ufb02ict, the countries in-
\nvolved did not expend any money at all for the health care of its ci-
\nvilians. At the turn of the century the economies of the \u201cSoutheast
\nAsian tiger\u201d countries fell by more than 25%, and the health care
\nexpenditures of Thailand, Laos and Vietnam were signi\ufb01cantly re-
\nduced. But, the situation that is most analogous to the current crisis
\nin Eastern Europe occurred in Argentina and other South Ameri-
\ncan countries, whose economies collapsed at the beginning of this
\ndecade. It is interesting that almost all these countries that were
\nfaced with economic recession and decline in health expenditures
\nhave reacted to the crisis with political sensitivity.
\nTo avoid risk of o\ufb00ending colleagues in other countries,I will con\ufb01ne
\nmy comments to the situation in Latvia, though I am familiar the
\nway the crisis was handled in Lithuania, Ukraine and Byelorussia.
\nThere is a great deal of interest in crises,and how they a\ufb00ect medical
\ncare. Conferences have been held to search for solutions on how to
\nprevent economic crises from disrupting health care. For example,
\nthe conference \u201cHealth in the times of global economic crisis: im-
\nplications for the WHO European Region\u201d that was held in Oslo,
\nNorway from April 1-2, 2009 came up with recommendations for
\nEuropean countries*. The \ufb01fth recommendation stated: \u201cProtect
\ncost-e\ufb00ective public health and primary healthcare services. If
\nspending on health is reduced: a) protect spending on public health
\nprogrammes; 2) protect spending on primary health care; 3) reduce
\nspending on the least cost e\ufb00ective services. These will normally be
\nfound among the most high-technology, high-cost services in hos-
\npitals. 4) delay investment plans for high-cost facilities and promote
\nthe use of generic drugs.
\nUnfortunately,this resolution was not heard in Latvia. When health
\ncare \ufb01nancing was reduced, the \ufb01rst programmes to be cut were: 1)
\nthe Public Health Service which is the only authorized institution
\nin Latvia responsible for disease prevention and prophylaxis . We
\nare not an isolated country, and the potential spread of infectious
\ndisease could have an e\ufb00ect on others. 2) The expenditure for med-
\nical care in prisons was cut threefold – raising the prospect that our
\nprisons could become a breeding ground for resistant tuberculosis
\nin Europe. (3) Elective surgery, such as arthroplasty, cardiac valve
\nreplacement and cataract surgery was severely curtailed because of
\nlack of funding, resulting in the departure of many physicians from
\nthe Baltic countries to work in Great Britain, Scandinavia, Canada
\nand New Zealand where they can receive higher wages and bet-
\nter job security. In 1990s almost every hospital in Latvia acquired
\nnew technology, such as magnetic resonance imaging and digital
\nangiography. It was easy to make the transition to modern medicine
\nand to achieve a standard comparable to the rest of Europe – going
\nbackwards is not so easy. This year, when a true \ufb01nancial de\ufb01cit hit:
\nthe health care budget was cut by 20% in the \ufb01rst half of the year
\nand 40% in the second half. The State could no longer reimburse for
\nexpensive diagnostic methods and costly medications. It appears
\nthat it is not possible to turn back the clock: doctors would sooner
\ngo to work elsewhere than resume using cheap and ine\ufb00ective treat-
\nment methods. The plunge in doctors\u2019 salaries has led to depression
\namongst physicians and their loss of faith in the future. In Eu-
\nrope, physicians have traditionally been respected citizens and role
\nmodels. Seeing the doctors depressed spills over to the rest of the
\npopulation.
\nIt is not enough to look at the adverse e\ufb00ects of an economic crisis
\nupon the health care of a nation. We must also look at the funda-
\nmental underlying causes of the problem. In Latvia, the money for
\nhealth care is under the direct control of the politicians. The signi\ufb01-
\ncance of politicians having direct control over health care expendi-
\ntures cannot be ignored. If Latvia had introduced a self-governed
\nand contribution-\ufb01nanced social insurance system, this health care
\ndisaster might not have happened! Furthermore, the functioning
\nhealth care sector would be a stabilizing element for the economy
\ninstead of a drag on the economy. Unfortunately, in Latvia, health
\ncare has become the victim of bad politics.
\nRespected colleagues throughout the world! An economic down-
\nturn can hit any country. Latvia was not ready for these chang-
\nes. We would like others to learn from our experiences so you do
\nnot repeat our mistakes. A WMA conference focusing on how to
\nprevent, prepare for and deal with the health care problems that
\nare associated with economic crises would be an excellent way to
\nachieve this and could be organised in Latvia.
\nPeteris Apinis, MD,
\nEditor in Chief, WMJ
\nEditorial
\n* \u201cRecommendations of the meeting\u201d available at
\nhttp:\/\/www.euro.who.int\/document\/HSM\/Oslo_crisis_mtg_rec.pdf
\nwma 8.indd 127wma 8.indd 127 12\/4\/09 4:23:25 PM12\/4\/09 4:23:25 PM
\n128
\nWMA news
\nMore than 200 delegates from 46 National
\nMedical Associations (NMAs) attended
\nthe annual General Assembly held at the
\nLaLit Hotel, in New Delhi, India from
\n14-17 October 2009.
\nThe four-day event, hosted with Bollywood
\n\ufb02amboyance by the Indian Medical Associ-
\nation, was notable for the attendance of the
\nPresident of India Madam Pratibha Patil,
\nto o\ufb03cially open the Assembly, as well as
\nthe unopposed election in his own country
\nof Dr. Ketan Desai, President of the Indian
\nMedical Council, as President Elect of the
\nWMA, and the adoption of no less than 16
\nnew or revised policy statements on issues
\nranging from climate change and stem cell
\nresearch, to professionally-led regulation
\nand task shifting.
\nThe ceremonial session of the Assembly was
\naddressed by both the President of India
\nand the Health Minister Mr. Ghulam Nabi
\nAzad. In her welcome address the President
\nMadam Pratibha Patil called on the medical
\ncommunity to work for the ideal of medical
\ncare for all.
\nShe said:\u201cThe question of equitable medical
\ncare to all people is a big human and ethi-
\ncal question. In India, we are conscious of
\nthis and through policies and programmes,
\ne\ufb00orts are underway to reach populations
\nincluding those in rural areas that face the
\nhighest degree of deprivation in terms of
\nhealth facilities. All governments have re-
\nsponsibilities to take action, but global in-
\nstitutions also have a crucial role.The World
\nHealth Organization and other internation-
\nal organizations like yours are major stake-
\nholders in this endeavour. I would call on all
\nof you present here today, to contribute, to
\nfurther the cause of medical care for all.\u201d
\nUnion Health Minister, the Honourable
\nShri Gulam Nabi Azad, told the Assembly
\nabout the proposed new alternative model
\nfor medical education in his country, aimed
\nprimarily at rural health manpower. He
\npointed out that because of the concentra-
\ntion of health care professionals in urban
\nand semi-urban areas there was a huge gap
\nin availability of manpower at the grassroots
\nlevel.
\nDr. Yoram Blachar, in his valedictory ad-
\ndress as outgoing President of the WMA,
\nsaid that Association statements carried
\ngreat weight in most national and interna-
\ntional discussions on health. In recent years
\nthe WMA had taken more active roles in
\npromoting health care and had initiated or
\ntaken part in a number of projects in the
\nareas of public health, such as an internet
\ncourse on TB and the project of talking
\nbooks which enabled information to be
\nbrought to parts of the world where there
\nwas illiteracy.
\nThe WMA also had an important role in
\nadvocacy as the voice of the profession rep-
\nresenting millions of doctors around the
\nworld.The partnerships and alliances of the
\nAssociation were vital to its success.Through
\nits relationships the WMA promoted and
\ndefended the basic rights of patients and
\nphysicians, helped physicians to continu-
\nously improve their knowledge and skills,
\ndeveloped public health policy and projects
\nsuch as tobacco control and immunisation,
\nassisted with human resource planning for
\nhealth care services and encouraged democ-
\nracy building for new medical associations,
\nespecially in new or developing democra-
\ncies.
\nThe installation then took place of the new
\nWMA President for 2009-2010, Dr. Dana
\nHanson, former President of the Canadian
\nMedical Association.In his inaugural speech
\nhe criticised Governments of the world for
\npaying too little attention to the e\ufb00ects of
\nclimate change on population health and its
\nhuge impact on health services.
\n\u201cWe know that the climate a\ufb00ects local and
\nnational food supplies, air and water quality,
\nweather, economics and many other criti-
\ncal health determinants. Climate change
\nrepresents an inevitable, massive threat to
\nglobal health that will likely eclipse the ma-
\njor known pandemics as the leading cause
\nof death and disease in the 21st century. Yet
\nwhy do we hear so little or no discussion by
\nour governments of the e\ufb00ects of climate
\nchange on population health and its huge
\nimpact on health services?\u201d
\nDr. Hanson, a dermatologist from
\nFredericton, New Brunswick, said he hoped
\nthe WMA would be granted observer sta-
\ntus in Copenhagen in December when
\n192 United Nations member states will
\nmeet to create a plan of action around the
\nUN Framework Convention on Climate
\nChange.
\n\u201cThere is no other organisation that can
\nbring the message of human health protec-
\ntion and preservation \u2013 untainted by na-
\ntional political and economic agendas \u2013 to
\nthe climate change debates.There is no oth-
\nWMA General Assembly, New Delhi 2009
\nPresident of India Madam Pratibha Patil
\nwma 8.indd 128wma 8.indd 128 12\/4\/09 4:23:25 PM12\/4\/09 4:23:25 PM
\n129
\nWMA news
\ner organisation whose members view each
\nand every citizen as a cherished patient to
\nwhom we owe a professional duty and feel a
\npersonal commitment.\u201d
\nDr. Hanson said that traditionally the
\nWMA\u2019s work had focused almost exclusively
\non the development of its body of policy, as
\nit sought to promote the highest standards
\nof medical ethics,professional responsibility
\nand patient care.
\n\u201cThese standards re\ufb02ect the cumulative,
\nglobal experience and understanding of the
\nworld\u2019s physicians and constitute a rich col-
\nlection of resources for which the WMA is
\nknown among physicians and many of our
\nallied organizations. Some of our policies,
\nsuch as the Declaration of Helsinki and
\nthe Declaration of Tokyo, among others,
\nare known far beyond WMA and our close
\nfriends and, indeed, are recognised glob-
\nally as the gold standard of policy on their
\nrespective subjects.\u201d
\nHe added: \u201cI believe that our work is rel-
\nevant – indeed vital \u2013 far beyond our own
\nmembership and our historic allies and
\npartners and it is time to elevate advocacy
\nto a higher priority for the WMA. With
\nthe growth of our membership, the addition
\nof project work to our portfolio, and our
\nprofessionalised sta\ufb00 structure, the WMA
\nis now positioned to add a stronger, more
\ndynamic advocacy dimension to our work.
\nOurs is a unique advocacy voice in the world
\ntoday \u2013 that of the world\u2019s physicians \u2013 and
\nit is by activating this voice to its fullest ca-
\npacity that we will ensure WMA\u2019s vision
\nand policies are truly promoted worldwide
\nand that our expertise and experience can be
\ne\ufb00ectively accessed by those whose interests
\nintersect with our own.\u201d
\nFinally Dr.Hanson spoke of physicians\u2019own
\nwell being. \u201cAt the same time that we ad-
\nvocate for the health, safety and well-being
\nof our patients, we must also channel our
\nadvocacy e\ufb00orts in support of these quali-
\nties for ourselves and our colleagues all over
\nthe world. Poor and dangerous working en-
\nvironments, inadequate pay and overwork,
\ninstitutional and even physical violence are
\nexperienced by far too many physicians.
\nAnd while many persevere, continuing their
\ndedicated service to patients and their com-
\nmunities despite these conditions, many
\nothers move on in search of better circum-
\nstances \u2013 sometimes even leaving medicine
\nentirely for other professions.\u201d
\n\u201cI think this is a vital component of our on-
\ngoing work on health and human resources.
\nIt is a subject that is often marginalised in
\nthe international medical workforce discus-
\nsion, but we at the WMA know that it has
\na profound e\ufb00ect on physicians, patients
\nand entire health systems. The importance
\nof advocacy by the profession for our fellow
\ndoctors in this context cannot be overstated
\nand the WMA must and will continue to
\nshine a light on this endemic problem.\u201d
\nAt the plenary session of the Assembly
\nDr. Ketan Desai was elected unopposed as
\nPresident Elect of the WMA. Dr. Desai,
\nPresident of the Medical Council of India
\nand former National President of the In-
\ndian Medical Association, will take up his
\npost at the General Assembly meeting in
\nVancouver, Canada in October 2010.
\nThe Assembly, under the chairmanship of
\nDr. Edward Hill, adopted several new and
\nrevised policies, many of them the result of
\nthe Association\u2019s ongoing revision of poli-
\ncies.
\nClimate Change
\nA new Declaration was adopted \u2013 entitled
\nthe Declaration of India \u2013 setting out mea-
\nsures to bring health to the forefront of the
\nclimate change debate and to mitigate the
\nserious health risks facing the world (see full
\ntext p. 137). Dr. Ruth Collins-Nakai, from
\nthe Canadian Medical Association, who
\nchaired the WMA\u2019s climate change working
\nparty, said: \u201cWe should recognise that most
\ninitiatives, which improve the impact of cli-
\nmate change, also improve individual and
\npopulation health \u2013 that what is good for
\nthe environment is also good for health.\u201d
\nFollowing the meeting an advocacy kit was
\ncirculated to NMAs, including a factsheetDr. Ketan D. Desai
\nDr. Yoram Blachar
\nDr. Dana Hanson
\nwma 8.indd 129wma 8.indd 129 12\/4\/09 4:23:26 PM12\/4\/09 4:23:26 PM
\n130
\nWMA news
\non the impact of climate change on health
\nand a model letter to send to health minis-
\nters and to the UNFCCC national contact.
\nProfessionally-led Regulation
\nA rewritten Declaration of Madrid on Pro-
\nfessionally-led Regulation was adopted (see
\nfull text p. 140). The Declaration, a revision
\nof the 2005 Declaration on Professional
\nAutonomy and Self Regulation, resulted
\nfrom a White paper on Professionalism and
\nthe Medical Association, written by Dr. Je\ufb00
\nBlackmer from the Canadian Medical As-
\nsociation.
\nChild Health
\nThe 1998 Declaration of Ottawa on Child
\nHealth was revised and adopted to in-
\nclude new broader guidelines on improving
\nthe health of the world\u2019s children (see full
\ntex p. 140). Dr. Ruth Collins-Nakai, who
\nchaired the WMA working group on child
\nhealth, said: \u201cThe world\u2019s children are worse
\no\ufb00 today than they were two decades ago
\nand it is important that in proposing this
\nbroader policy we make physicians aware of
\njust how tenuous the status of children is in
\nthe world.\u201d
\nTask Shifting
\nA new Resolution on Task Shifting was
\nadopted, expressing a series of concerns
\nabout the global development of task shift-
\ning (see full text p. 141).
\nThe Resolution prompted lengthy debates
\nboth in Council and Assembly following
\ncriticism from several delegates that its
\ntone was too negative. However, others ar-
\ngued that this was a document relating to
\nphysicians and it was important that it was
\npublished.A call to refer back the document
\nwas defeated.
\nIran
\nIn an Emergency Resolution, National
\nMedical Associations were urged to speak
\nout in support of the rights of patients and
\nphysicians in Iran (see full text p. 143). This
\nfollowed a report from the German Medical
\nAssociation. Dr. Frank Montgomery, from
\nthe German Medical Association, said:
\n\u201cPhysicians serve people not governments.
\nThey must be able to ful\ufb01l their duties with-
\nout government harassment. Physicians will
\nnot participate in torture or degrading treat-
\nment. They are the \u201cwhistleblowers\u201d of such
\ncriminal acts committed by governments. I
\ncall upon the Iranian Government to reaf-
\n\ufb01rm the position that independent, free
\nmedicine is a cornerstone of democracy.\u201d
\nMedical Workforce
\nThe Assembly agreed to amend the 1998
\nResolution on the Medical Workforce (see
\nfull text p. 144).
\nInequalities in Health
\nA Statement was adopted calling on NMAs
\nto in\ufb02uence national policy to reduce health
\ninequalities, advocate for the abolishment
\nof \ufb01nancial barriers to obtaining needed
\nmedical care, and to advocate for equal ac-
\ncess for all to health care services irrespec-
\ntive of both geographic and economic dif-
\nferences (see full text p. 145).
\nImproved Investment in Public Health
\nWith many countries planning to cut their
\nhealth budgets as a result of the economic
\nrecession, the Assembly revised its Reso-
\nlution on Improved Investment in Public
\nHealth (see full text p. 146).
\nCon\ufb02ict of Interest and
\nCommercial Enterprises
\nA Statement on Con\ufb02ict of Interest was
\nadopted, the \ufb01rst time the WMA has is-
\nsued guidelines on physicians\u2019 behaviour on
\nissues of con\ufb02ict of interest. The guidelines
\nidentify areas where a con\ufb02ict of interest
\nmight occur during a physician\u2019s day-to-day
\npractice of medicine, and seek to assist phy-
\nsicians in resolving such con\ufb02icts in the best
\ninterests of their patients.
\nThe Association\u2019s Statement Concerning
\nthe Relationship between Physicians and
\nCommercial Enterprises was also revised
\nwith advice to physicians on receiving spon-
\nsorship or gifts when attending conferences
\nor conducting research and on their a\ufb03lia-
\ntions with commercial entities.
\nStem cell research
\nA Statement was adopted expressing sup-
\nport for stem cell research being carried out
\nwith appropriate regulation to prevent un-
\nacceptable practices.The Statement,initially
\nprepared by the Icelandic Medical Associa-
\ntion, declared that regulation according to
\nestablished ethical principles was likely to
\nalleviate public concerns, especially if asso-
\nciated with careful policing. Whenever pos-
\nsible, research should be carried out using
\nstem cells that were not of embryonic ori-
\ngin. However there would be circumstances
\nwhere only embryonic stem cells would be
\nsuitable for the research model. Research on
\nstem cells, regardless of their origin, must
\nbe carried out according to agreed ethical
\nprinciples.
\nDr. Vivienne Nathanson, from the British
\nMedical Association, who chaired the
\nWMA\u2019s stem cell working party, said: \u201cThis
\nis cutting edge science and may lead to the
\ndevelopment of new treatments for chronic
\nillnesses such as diabetes and Parkinson\u2019s,
\nwma 8.indd 130wma 8.indd 130 12\/4\/09 4:23:27 PM12\/4\/09 4:23:27 PM
\n131
\nWMA news
\nwhich would enormously lessen human suf-
\nfering. We must make sure that good, ethi-
\ncal research goes ahead, and see if we can
\nreap the bene\ufb01ts of this exciting science.\u201d
\nTelehealth
\nNew guiding principles for the use of tele-
\nhealth for the provision of health care were
\nadopted. Among the areas covered by the
\nStatement were legal responsibilities, com-
\nmunication with patients,standards of prac-
\ntice and quality of clinical care, quality indi-
\ncators, patient con\ufb01dentiality and consent.
\nNicaragua
\nAn Emergency Resolution called on the
\nNicaraguan government to repeal legisla-
\ntion criminalising abortion. It said the leg-
\nislation was having a negative impact on the
\nhealth of women in Nicaragua and could
\nresult in preventable deaths of women and
\nthe embryo or foetus. The legislation also
\nplaced physicians at risk of imprisonment if
\nthey broke this law and at risk of suspen-
\nsion from medical practice if they failed to
\nfollow government protocols, which some-
\ntimes required treatment of a pregnant
\nwoman contrary to the legislation.
\nThe 1997 Declaration on Guidelines for
\nContinuous Quality Improvement in
\nHealth Care was revised as part of the
\nWMA\u2019s review of policy documents and
\namendments were also made to the 1999
\nStatement on Patenting of Medical Proce-
\ndures,which was renamed the Statement on
\nMedical Process Patents, and to the 2005
\nStatement on Genetics and Medicine.
\nHuman Rights
\nMs. Clarisse Delorme, the WMA\u2019s advoca-
\ncy advisor, and Dr. Herman Reyes, from the
\nInternational Committee for the Red Cross,
\ngave a presentation to the Assembly about
\nthe role of physicians in the prevention of
\ntorture and ill treatment in places of deten-
\ntion. They spoke about the Optional Proto-
\ncol to the UN Convention against Torture
\nand how national medical associations had
\nan important role in monitoring the Na-
\ntional Prevention Mechanisms where they
\nhad been set up in their countries.
\nDr. Otmar Kloiber, secretary general of
\nthe WMA, said this was not a problem for
\nother countries. It was a problem for all
\ncountries.
\nAssociates
\nThe Associate Members meeting debated
\na report from Dr. Masami Ishii, Chair of
\nthe Work Group on Reform of Associate
\nMembership. It was agreed that proposals
\nfor increasing the merits of membership
\nshould be circulated for further discussion.
\nNew Member
\nThe Assembly approved an application for
\nmembership from the Society of Medical
\nDoctors in Malawi.
\nOther Business
\nThe Assembly adopted the audited Finan-
\ncial Statement for the year ended December
\n2008 and adopted the Budget for 2010.
\nOpen Session
\nDuring the \u201copen session\u201d, giving delegates
\nan opportunity to present any profession-
\nspeci\ufb01c problem, policy or project they be-
\nlieved the WMA should know about, the
\nmeeting heard from several NMA repre-
\nsentatives.
\nDr.Cecil Wilson,from the American Medi-
\ncal Association, reported on the controversy
\nsurrounding America\u2019s health care reform
\nproposals. He said the AMA was proud of
\nthe health care that was provided to the citi-
\nzens of the US and proud of the country\u2019s
\ndedicated physicians. The problem was that
\nthat health care was not universal. Some
\n46 million Americans or 16 per cent of the
\npopulation did not have health insurance.
\nThe AMA was committed to health care
\nreform and was working very closely with
\nPresident Obama and with Members of
\nCongress on proposals for reform,but it was
\nnot an easy task. He added that the AMA
\nshared the concern about the vitriolic tone
\nof the debate and had called for calm.
\nScienti\ufb01c session
\nThe theme of the scienti\ufb01c session was
\n\u201cMulti-Drug Resistant Tuberculosis and
\nLessons Learned from this Epidemic.\u201d Ex-
\nperts from across the world spoke about
\nguidelines for treatment and infection con-
\ntrol, with a particular emphasis on the expe-
\nrience in India.
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\n132
\nWMA news
\nAt the same time, the WMA launched a
\nnew online refresher course for physicians,
\nproviding basic clinical care information for
\nTB including the latest diagnostics, treat-
\nment and information about multidrug-
\nresistant TB. The new course was written
\nfor the WMA by the New Jersey Medical
\nSchool Global Tuberculosis Institute, USA.
\nIt incorporates key strategies of interna-
\ntionally accepted strategies for management
\nand control of TB, will link to the WMA\u2019s
\nMDR-TB course which has been running
\nfor the past two years.
\nDr. Julia Seyer, medical adviser at the
\nWMA, said: \u201cWhen we started an online
\nmultidrug-resistant tuberculosis (MDR-
\nTB) training course in 2006, we discovered
\nthat many physicians were missing the most
\nbasic knowledge about normal TB. With
\nthe disappearance of the disease from large
\nparts of the world, many physicians from
\nthe developed world had never even seen
\na case of TB and had no basic training in
\ndiagnosing and treating what is a prevent-
\nable disease. Now that TB has re-emerged
\nas a serious global disease, it is vital that
\nphysicians around the world regain the ba-
\nsic knowledge they once had. The course
\nwill be useful in developing countries,where
\nthe majority of TB cases are, and will serve
\nas a refresher of what physicians may have
\nlearned some time ago.\u201d
\nThe course is free of charge and can be used
\nby physicians in private practice, as well
\nas in the public. Physicians will be able to
\nreceive credits for completing the course
\nas part of their continuing medical educa-
\ntion programme. Although the course is
\navailable only in English at the moment,
\nit will be translated into Spanish, French,
\nRussian and Chinese.The new course is be-
\ning \ufb01nanced by an unrestricted educational
\ngrant by the Lilly MDR-TB Partnership,
\nwhich comprises several other organisations
\nworking together to improve tuberculosis
\ncontrol worldwide.
\nSecretary General\u2019s Report
\nDr. Otmar Kloiber reported on signi\ufb01cant
\nactivities and developments during the year.
\nA train-the-trainer course in MDR-TB
\nhad been developed to create champions in
\nthe \ufb01eld of TB on a local level. Physicians
\nwho were experts in TB received training
\nin adult learning and accelerated learning
\nprinciples in order to better teach their col-
\nleagues. The \ufb01rst of a series of workshops
\ntook place in Pretoria, South Africa in
\nNovember 2008 in co-operation with the
\nFoundation of Professional Development.
\nA further workshop was due to take place
\nin New Delhi before the Assembly together
\nwith the Indian Medical Association.
\nThe WHO was in the process of developing
\na policy on ethics in the TB setting, with
\na goal for its adoption at the World Health
\nAssembly in 2010. The WMA was invited
\nto address the issues related to health pro-
\nfessionals in the policy.
\nGiven the already critical shortage of health
\nproviders and generally weak health sys-
\ntems in the regions most a\ufb00ected by XDR-
\nTB and MDR-TB, anxiety about safety in
\nthe health care environment ran high and
\ncould dissuade health providers from ac-
\ncepting assignments in these settings. A set
\nof inter-professional workshops on health
\ncare worker safety in the context of drug
\nresistant TB in low and middle-income
\ncountries addressed TB infection protec-
\ntion with the objective of identifying good
\npractices, implementing joint recommenda-
\ntions for facilities and health workers and
\nestablishing a working group with a plan of
\naction to communicate the identi\ufb01ed prac-
\ntices and recommendations. The WMA,
\nin collaboration with the South African
\nMedical Association and the ICN, IHF
\nand ICRC, organised the \ufb01rst workshop
\nin Cape Town South Africa in November
\n2007. The second one took place together
\nwith the Brazilian Medical Association in
\nRio De Janeiro, Brazil in March 2009, and
\nthe third one was in Durban, South Africa
\nin June 2009.
\nThe WMA joined the implementation pro-
\ncess of the WHO Framework Convention
\non Tobacco Control (FCTC) http:\/\/www.
\nwho.int\/tobacco\/framework\/en\/, the interna-
\ntional treaty that condemned tobacco as an
\naddictive substance,imposed bans on adver-
\ntising and promotion of tobacco, and reaf-
\n\ufb01rmed the right of all people to the highest
\nstandard of health. The \ufb01rst international
\ntreaty negotiated under the auspices of the
\nWHO, the FCTC entered into force in
\n2005 and was the most widely embraced
\ntreaty in UN history, with 168 signatories
\nand 154 rati\ufb01cations to date.
\nWHO FCTC held its Third Conference of
\nthe Parties COP3 in Durban from in No-
\nvember 2008 to discuss articles of the treaty
\nand receive reports of the working groups
\ncreated for speci\ufb01c articles. The WMA was
\na member of the working groups on Article
\n12 – Education, Communication, Training
\nand Public Awareness and Article 14: Mea-
\nsures Concerning Tobacco Dependence and
\nCessation.
\nThe WMA continued its close involve-
\nment in the Positive Practice Environ-
\nment Campaign (PPE). This global \ufb01ve-
\nyear campaign – spearheaded by WHPA
\nmembers together with the World Con-
\nfederation for Physical Therapy and the In-
\nternational Hospital Federation – aimed to
\nensure high-quality healthcare workplaces
\nworldwide. The appointment last March of
\nwma 8.indd 132wma 8.indd 132 12\/4\/09 4:23:29 PM12\/4\/09 4:23:29 PM
\n133
\nWMA news
\na full-time coordinator,in charge of running
\nthe campaign on behalf of the organisation
\nmembers, allowed the PPE to kick o\ufb00 in
\nthree selected countries: Uganda, Morocco
\nand Zambia.Taiwan would also be involved
\nin the PPE as a self-funded country. With
\nthe support of the PPE coordinator, health
\nprofessionals\u2019 organisations from the select-
\ned countries were in the process of setting
\nup national structures (national coordinator
\nand steering committee) for the running of
\nthe campaign.
\nAt the invitation of the Iceland Medical As-
\nsociation and WMA Past president, Dr. Jon
\nSnaedal, the World Medical Association
\nconvened a Seminar on Human Resources
\nfor Health and the Future of Health Care
\nfrom in March, 2009. The seminar was an
\ne\ufb00ort to bring together stakeholders from a
\nrange of health professions to focus on these
\nissues and help WMA de\ufb01ne some policy
\npriorities in its approach to the subject. The
\n\ufb01nal report of the event included ideas to
\nfacilitate WMA policy development in this
\narea.The WMA Advocacy Working Group
\nwas considering these proposals and explor-
\ning follow-up opportunities, such as map-
\nping relevant work and research undertaken
\non task shifting.
\nIn early March, the WMA was invited to
\ntake part in the planning process of the
\nnext Conference on Workplace Violence
\nin the Health Sector, scheduled to take
\nplace from 27-29 October 2010 in Amster-
\ndam. The event is supported by the Glo-
\nbal Health Workforce Alliance (GHWA),
\nWHO, International Labour Organisation
\n(ILO), the International Council of Nurses
\n(ICN), Public Services International (PSI)
\nand other relevant health organisations.
\nThe WHO was developing guidelines on
\nretention strategies for health profession-
\nals in rural areas, which should be adopted
\nat the World Health Assembly 2010. The
\nobjective was to ensure access to health
\ncare for people living in rural areas, thus
\nimproving the health outcomes, including
\nthose outlined in the Millennium Develop-
\nment Goals (MDGs).The guidelines would
\nbe based on three pillars: educational and
\nregulatory incentives, monetary incentives
\nand management, environment and social
\nsupport.The WMA,as the secretariat of the
\nWorld Health Professions Alliance, was a
\nmember of the core expert group develop-
\ning the guidelines.
\nWMA sta\ufb00, Dr. Julia Seyer, as secretariat
\nof the WHPA, had been invited to join an
\nindependent merit review panel organised
\nby the Global Health Research Initiative.
\nThe panel would review research propos-
\nals submitted in response to a competition
\nlaunched in January 2009 by the \u201cAfrica
\nHealth Systems Initiative Support to Af-
\nrican Research Partnerships\u201d program
\n(AHSI-RES). AHSI-RES was a 5-year
\nresearch program (2008-2013) that formed
\none component of the Africa Health Sys-
\ntem Initiative (AHSI) supported by the Ca-
\nnadian International Development Agency
\n(CIDA). AHSI was a 10-year initiative
\nfocused on strengthening national-level
\nhealth strategies and architecture, ensur-
\ning appropriate human resources for health,
\nstrengthening front-line service delivery,
\nand building stronger health information
\nsystems – all with special attention to equity
\nconsiderations.
\nThe WMA participated as a member of the
\nsteering group in the Mobility of Health
\nProfessionals research project. The objec-
\ntive of the project was to assess the current
\ntrends of mobility of health professionals to,
\nfrom, and within the European Union, in-
\ncluding their reasons for moving. Research
\nwould also be conducted in non-European
\nsending and receiving countries, although
\nthe focus lay on the EU.
\nIn January 2011 the Global Health Work-
\nforce Alliance is organising the 2nd Global
\nForum on Human Resources in Health
\n(HRH) in Thailand. The WMA is part
\nof the thematic focus committee for this
\nevent. In a \ufb01rst meeting, two main themes
\nis proposed: improving quantity and quality
\nof health workforce for equitable access to
\nprimary health care within a robust health
\nsystem and \ufb01nancing HRH in the light of
\nthe global \ufb01nancial crisis.
\nCounterfeit medicines were drugs manu-
\nfactured below established standards of
\nsafety, quality and e\ufb03cacy and therefore
\nrisked causing ill health and killing thou-
\nsands of people every year. Experts esti-
\nmated that 10 per cent of medicines around
\nthe world could be counterfeit. The phe-
\nnomenon had grown in recent years due
\nto increasing sophistication of counterfeit-
\ning methods and the increasing amount of
\nmerchandise crossing borders. At the last
\nExecutive Board Meeting of the WHO in
\nJanuary 2009, the report and draft resolu-
\ntion on counterfeit medical products were
\n\u201cSpeeking book\u201d opening
\nwma 8.indd 133wma 8.indd 133 12\/4\/09 4:23:29 PM12\/4\/09 4:23:29 PM
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\ndiscussed and all member states stressed
\nthe importance of protecting public health
\nagainst risks caused by counterfeit medica-
\ntions. An intense debate took place on the
\nde\ufb01nition of counterfeits versus substand-
\nard medicines. So far WHO has focused
\non counterfeits while largely ignoring the
\nbroader – and more politically sensitive –
\ncategory of substandard drugs.
\nThe World Health Report from 2008
\n\u201cPrimary Health Care \u2013 Now More Than
\nEver\u201d- critically assessed the way that
\nhealth care was organised, \ufb01nanced, and
\ndelivered in rich and poor countries around
\nthe world. The WHO report documented
\nthe failures and shortcomings over the last
\ndecades that had left the health status of dif-
\nferent populations, both within and among
\ncountries, dangerously out of balance. The
\nreport urged the importance of an holistic
\nhealth care approach where primary health
\ncare played an important role as a facilitator
\nbetween prevention, secondary and tertiary
\ncare.The report focused health care systems
\non four pillars: universal coverage, people-
\ncentred health care, leadership reform to
\nmake health authorities more accountable
\nand to promote and protect public health in
\ngeneral.
\nThe Executive Board of the WHO in
\nJanuary 2009 discussed a draft resolution
\non primary health care, including health
\ncare system strengthening. On behalf of
\nthe World Health Professions Alliance,
\nthe WMA made a public statement dur-
\ning the Executive Board session. Further
\ndebate took place during the World Health
\nAssembly in May 2009. The WHO invited
\nthe WMA to take part in a global consul-
\ntation on the contribution of health pro-
\nfessions to primary health care and the
\nglobal health agenda in June 2009. As one
\nof the outcomes the WHO was develop-
\ning implementation guidelines to support
\ngovernments in setting up primary health
\ncare teams in a holistic health care system,
\nwhich would be sent out soon for comments.
\nThe WHO saw physicians as a strong pillar
\nin this approach and was pleased to work
\nclosely with WMA.
\nIn May 2008, the World Health Assembly
\nadopted a resolution requiring the WHO to
\nintensify its work to curb the harmful use
\nof alcohol. Members States called on the
\nWHO to develop a global strategy for this
\npurpose. The resolution also requested the
\nWHO Director-General to consult with
\nintergovernmental organisations, health
\nprofessionals, nongovernmental organisa-
\ntions, and economic operators regarding
\nways in which they could contribute to re-
\nducing the harmful use of alcohol. In line
\nwith the WMA Statement on Reducing
\nthe Global Impact of Alcohol on Health
\nand Society, the WMA secretariat moni-
\ntored the drafting process of the WHO
\nstrategy, informed WMA members on a
\nregular basis of relevant developments in
\nthis area and had developed contacts with
\nrelevant WHO o\ufb03cials and civil society or-
\nganisations to collaborate in the process.
\nIn October 2008, the WMA Advocacy
\nAdvisor, Ms. Clarisse Delorme, moderated
\nan NGO brie\ufb01ng on reducing the glo-
\nbal harm caused by alcohol, organised by
\nGAPA (Global Alcohol Policy Alliance).
\nThe objectives of the brie\ufb01ng were to un-
\nderstand the WHO process related to the
\nstrategy, to begin discussions on substantive
\nand political proposals to promote an ef-
\nfective, evidence-based global strategy, and,
\n\ufb01nally, to develop further working relations
\nbetween civil society actors involved in this
\narea.
\nIn November 2008, Dr. Kloiber, and Ms.
\nDelorme, participated in the WHO round-
\ntable meeting with representatives of
\nNGOs and health professionals on ways
\nthey could contribute to reducing harmful
\nuse of alcohol. This was an opportunity to
\nraise,amongst others issues,the WMA\u2019s de-
\nsire that medical associations and individual
\nphysicians be fully involved in the WHO
\nstrategy on alcohol.
\nThe World Medical Association had
\ndeveloped, together with the Geneva Social
\nObservatory, a Workplace Strategy on Di-
\nabetes and Wellness. This was a guideline
\nfor employers and employees to educate and
\nraise awareness about diabetes, and provide
\nexamples of healthier lifestyles during work.
\nThe aim was to mitigate the ill e\ufb00ects of
\ndiabetes on personal health, workplace pro-
\nductivity, and health care costs.
\nThe WMA Workgroup on Health and
\nthe Environment, chaired by the Canadian
\nMedical Association, was established in the
\nsummer of 2008. For 2009, the workgroup
\nagreed to focus its attention on health and
\nclimate change,in view of the global United
\nNations conference on this topic in Co-
\npenhagen in December 2009. In 2010, the
\nworkgroup would focus on environmental
\ndegradation and the built environment.
\nFollowing the adoption by the 2008 General
\nAssembly of the WMA Statement on Re-
\nducing the Global Burden of Mercury, the
\nWMA joined the UNEP Global Mercury
\nPartnership to contribute to the partner-
\nship goal to protect human health and the
\nglobal environment from the release of
\nmercury and its compounds.
\nDuring the reporting period, the WMA
\nsecretariat launched several lobbying ac-
\ntions, based on information from Amnesty
\ninternational, to support physicians in dis-
\ntress worldwide:
\nTwo Egyptian doctors, Raouf Amin al-\u2022
\nArabi and Shawqi Abd Rabbuh, were
\nsentenced to 15 and 20 years in prison
\nwma 8.indd 134wma 8.indd 134 12\/4\/09 4:23:30 PM12\/4\/09 4:23:30 PM
\n135
\nWMA news
\nand 1500 and 1700 lashes respectively in
\nSaudi Arabia for having facilitated the
\naddiction of a patient to morphine after
\nprescribing the medicine for her pain
\nrelief following an accident (December
\n2008). The WMA sent letters calling on
\nthe authorities of Saudi Arabia to review
\nthe case or send it for retrial and to ensure
\nthat any such procedures were undertaken
\nin accordance with international fair trial
\nstandards.
\nDr. Arash Alaei and Kamiar Alaei (Re-\u2022
\npublic of Iran) were sentenced to six and
\nthree years of imprisonment respectively
\nfor \u201cco-operating with an enemy govern-
\nment\u201d, speci\ufb01cally with US institutions
\nin the \ufb01eld of HIV & AIDS prevention
\nand treatment (January 2009). In letters
\nto the Iranian authorities, the WMA ex-
\npressed its serious concerns on the pro-
\nceedings falling far short of international
\nstandards for fair trial and asked for the
\nimmediate release of the two physicians,
\nas their imprisonment appeared to be po-
\nlitically motivated.
\nThree government employed doctors,\u2022
\nDr.T.Sathiyamoorthy,Dr.T.Varatharajah
\nand Dr. Shanmugarajah, who had been
\nworking in the con\ufb02ict zone in northeast-
\nern Sri Lanka until 15 May 2009, were
\nheld under emergency regulations by the
\nSri Lankan government for providing
\n\u201cfalse information\u201c to foreign journalists.
\nAt the end of May, the WMA sent letters
\nurging the Sri Lankan authorities to give
\nto the three doctors immediate and unre-
\nstricted access to lawyers of their choice
\nand that they be promptly brought before
\nan independent court. Access to medical
\ntreatment and permission for family visits
\nwere also required. They were released on
\nthe 24 August 2009, but with restricted
\nliberty, required to report regularly to the
\nauthorities. Amnesty International con-
\ntinued to have serious concerns, given the
\nunclear process for their bail and possible
\nongoing trial. The WMA Secretariat was
\nin regular contact with Amnesty and was
\nready to take further actions, if appropri-
\nate.
\nThe WMA also intervened on behalf of
\nMajid Movahedi who was sentenced last
\nMarch in Iran to be blinded in both eyes
\nwith acid \u2013 a process that would involve
\nmedical professionals. Recalling its \ufb01rm
\nopposition to punishments that constitute
\ncruel, inhuman and degrading treatment
\namounting to torture, WMA emphasised
\nin letters to Iran authorities that, according
\nto international medical standards, it was
\nunacceptable to involve physicians in this
\ninhuman and degrading treatment.
\nThe WMA was actively involved in
\ndeveloping the \u201cRight to Health as a
\nBridge to Peace in the Middle East\u201d joint
\nseminar, which was due to take place in
\nOctober 2009 in Turkey. The seminar was
\nbeing organised by the International Fed-
\neration of Health and Human Rights Or-
\nganisations (IFHHRO), the Norwegian
\nMedical Association (NMA), the Human
\nRights Foundation of Turkey (HRFT), the
\nTurkish Medical Association (TMA) and
\nthe WMA.The objectives of the meeting are
\nto discuss what role the medical profession
\ncan play in securing equal access to health
\ncare for the population and to facilitate the
\ncommunication among health professionals
\nin the participating nations.
\nThe WMA maintained regular contact with
\nAnand Grover, the UN Special Rappor-
\nteur on Health in order to increase the role
\nof health professionals in the promotion of
\nthe human rights to the highest attainable
\nstandard of health.
\nIn August 2008, Clarisse Delorme, WMA
\nadvocacy advisor, was elected as indepen-
\ndent expert on the Council of the Interna-
\ntional Rehabilitation Council for Torture
\nVictims (IRCT) 2009-2012.
\nIn September 2009, the WMA secretariat
\ntogether with the Danish Medical Asso-
\nciation contacted the Danish permanent
\nRepresentative in Geneva to discuss po-
\ntential follow-up from the resolution on
\nthe Role and Responsibility of Medical
\nand other Health Personnel in Relation
\nto Torture, adopted by the Human Rights
\nCouncil last March at its 10th session.
\nBased on their concerns that the resolu-
\ntion adopted did not include references to
\nWMA core policies in this area, nor did it
\nhighlight the positive role of physicians and
\nother health personnel in preventing and
\ncondemning torture and other inhuman
\ntreatments, the WMA and DMA suggest-
\ned that the Permanent Representative work
\nwith the Danish government on a further
\nresolution highlighting the positive role of
\nphysicians and other health personnel in
\npreventing and condemning torture and
\nother inhuman treatments.
\nIn August 2008, the Commission on Social
\nDeterminants of Health published its \ufb01nal
\nreport \u201cClosing the Gap in a Generation \u2013
\nHealth Equity through Action on the Social
\nDeterminants of Health\u201d. In this 200-page
\nreport, the Commission addressed global
\nhealth through social determinants, i.e.,
\nthe structural determinants and conditions
\nof daily life responsible for a major part of
\nhealth inequities among and within coun-
\ntries, and proposes a new global agenda for
\nhealth equity.
\nOn the occasion of the 124th
\nsession of
\nWHO Executive Board (January 2009),
\nthe WMA \u2013 on behalf of the World Health
\nProfessions Alliance (WHPA) – presented
\na statement on this report, with a focus on
\nthe health workforce. In this statement, the
\nWHPA welcomed the recommendation
\ndirected at national governments and do-
\nwma 8.indd 135wma 8.indd 135 12\/4\/09 4:23:30 PM12\/4\/09 4:23:30 PM
\n136
\nWMA news
\nnors to \u201cincrease investment in medical and
\nhealth personnel\u201d, but regretted that the
\nreport in general does not give more atten-
\ntion to health professionals as key players in
\naddressing the social determinants of health
\nand to the inequalities health professionals
\nface in their daily work.
\nClinical research involving human subjects
\nhad proliferated in developing countries in
\nthe recent past, increasing concerns about
\nethical and legal implications of misconduct
\nand violations of subjects\u2019human rights and
\nwelfare due to inadequate scienti\ufb01c and
\nethical review of protocols or as a result
\nof poor or absent drug regulatory systems.
\nThe WMA was invited to the international
\nRound Table – Biomedical Research in
\nDeveloping Countries: the Promotion of
\nEthics, Human Rights and Justice – to
\ncompare and exchange expertise and expe-
\nriences between national and international
\ninstitutions, on the issue of protection of
\nhuman participants in biomedical research.
\nParticipants stressed the importance of
\nbuilding capacity in biomedical ethics re-
\nviews in developing countries by supporting
\neducation and training curricula of health
\nprofessionals and community health work-
\ners, in order to facilitate the creation of in-
\nstitutional Research Ethics Committees.
\nThe Caring Physicians of the World
\n(CPW) Initiative (Leadership Course)
\nbegan with the Caring Physicians of the
\nWorld book, published in October 2005
\nin English and in Spanish in March 2007.
\nRegional conferences were held in Latin
\nAmerica, Asia-Paci\ufb01c and Africa regions.
\nThe CPW Project was extended to in-
\nclude a leadership course organised by the
\nINSEAD Business School in Fontaineb-
\nleau, France, in December 2007, in which
\n32 medical leaders from a wide range of
\ncountries participated. The second Leader-
\nship Course was held at the same place in
\nDecember 2008 for one-week with 30 par-
\nticipants, with continued successful results
\nand positive feedback.The third Leadership
\nCourse at the INSEAD Business School
\nwould be held in Singapore, 8-13 February
\n2010. The curriculum included training in
\ndecision-making, policy work, negotiating
\nand coalition building, intercultural rela-
\ntions and media relations. The courses were
\nmade possible by an unrestricted education-
\nal grant provided by P\ufb01zer, Inc.
\nThe World Health Professions Alliance
\nwas now a decade old. The context within
\nwhich it was working had evolved with its
\ncontinued development, and so had the or-
\nganisations that made up the alliance. The
\nWHPA had revised its strategy and priori-
\nties for the next few years and would focus
\nmainly on human resources in health, pa-
\ntient safety, public health, counterfeit medi-
\ncal products and human rights in health.
\nThe World Federation for Medical Edu-
\ncation (WFME) brought together medical
\nfaculties and the profession. During recent
\nyears it had focused on describing global
\nstandards for basic and post-graduate edu-
\ncation of physicians, as well as for Continu-
\ning Professional Development. The WMA
\nGeneral Assembly, Tokyo 2004 endorsed
\nthese standards.
\nCurrently, the WFME worked on encour-
\naging and supporting countries and medical
\nschools to further develop, or to improve,
\ntheir accreditation. Although not itself an
\naccrediting body, the WFME – together
\nwith WHO – strongly supported the use of
\naccreditation as a method of documenting
\nand improving the quality of education and
\nachieving comparability in the international
\narena.
\nBased on a mutual agreement with the
\nWHO, the WFME together with the Uni-
\nversity of Copenhagen (which hosted the
\nWFME o\ufb03ce), had taken over from WHO
\nHeadquarter the register of institutions
\nfor higher education in health care. The
\nWFME now developed this register in an
\nonline database called Avicenna Directories,
\nwhich would not only list the institutions as
\nnamed by their governments, but also pro-
\nvide information about their accreditation
\nstatus and the accrediting body.
\nIn January 2009, the WMA signed a con-
\ntract with DGN Services to develop and
\ninstall a new web portal for the WMA.The
\nnew web portal, launched in October 2009,
\nwould provide the platform for co-operation
\nwith the members of WMA, allow online
\npayments for meetings, books and associate
\nmembership dues, and, most of all, it would
\nfacilitate more timely presentation of con-
\ntent on the public website.
\nSpeaking book on clinical trials
\nOne of the fringe events of the Assembly
\nwas an evening presentation of an Indian
\nperspective of the WMA\u2019s Speaking Book
\non Clinical Trials, aimed at patients and
\ntheir relatives who do not read and write
\nsu\ufb03ciently well to understand what a clini-
\ncal trial is for and how it works.Representa-
\ntives from the WMA, the Indian Medical
\nAssociation, the Indian Council of Medical
\nResearch and P\ufb01zer,spoke about the launch
\nof the English-Hindi books and Ms. Zane
\nWilson,from Books of Hope and the South
\nAfrican Depression and Anxiety Group,
\nspoke movingly about the developments of
\nthe project.
\nWMA Public Relations Consultant
\nMr. Nigel Duncan
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\nDeclaration of Delhi on Health
\nand Climate Change
\nAdopted by the WMA General Assembly,
\nNew Delhi, India, October 2009
\nPREAMBLE
\nThe purpose of this document is to provide a response by the WMA
\non behalf of its members to the challenges imposed on health and
\nhealthcare systems by climate change.
\nAlthough governments and international organizations have
\nthe main responsibility for creating regulations and legislation to
\nmitigate the e\ufb00ects of climate change and to help their populations
\nadapt to it, the World Medical Association, on behalf of its national
\nmedical association members and their physician members, feels an
\nobligation to highlight the health consequences of climate change
\nand to suggest solutions.The 4th Assessment Report of the Interna-
\ntional Panel on Climate Change (IPCC) contains a full chapter on
\nhuman health impacts (AR4 Chapter 8 Human Health*
\n), includ-
\ning a range of possibilities regarding the potential e\ufb00ects of climate
\nchange. The following introduction includes the most likely e\ufb00ects
\nof climate change from the IPCC report.
\nINTRODUCTION
\nThe response of world leaders to the impact that humans are having
\non climate and the environment will permanently alter the livability
\nof this planet.
\n1. The UN International Panel on Climate Change (IPCC) states
\n\u201cEven the minimum predicted shifts in climate for the 21st century
\nare likely to be signi\ufb01cant and disruptive\u201d.**
\n1.1 The minimum warming forecast for the next 100 years is more
\nthan twice the 0.6\u00b0 C increase that has occurred since 1900.
\n1.2 Extra-tropical storm tracks are projected to move toward the
\npoles, with consequent changes in wind, precipitation, and tem-
\nperature patterns.
\n1.3 Sea levels have already risen by 10 to 20 cm over pre-industrial
\naverages, and will continue to rise due to the time scales associ-
\nated with climate processes and feedbacks.
\n* Confalonieri, U., B. Menne, R. Akhtar, K.L. Ebi, M. Hauengue, R.S. Kovats,
\nB. Revich and A. Woodward, 2007: Human health. Climate Change 2007:
\nImpacts, Adaptation and Vulnerability. Contribution of Working Group II to
\nthe Fourth Assessment Report of the Intergovernmental Panel on Climate
\nChange, M.L. Parry, O.F. Canziani, J.P. Palutikof, P.J. van der Linden and C.E.
\nHanson, Eds., Cambridge University Press, Cambridge, UK, 391-431.
\n** United Nations Framework Convention on Climate Change. http:\/\/unfccc.
\nint\/2860.php downloaded 1 September 2008
\n1.4 Projections point to continued snow cover contraction, and
\nwidespread increases in thaw depth over most permafrost re-
\ngions, now including Antarctica.
\n1.5 A future of more severe storms and \ufb02oods along the world’s
\nincreasingly crowded coastlines is likely.
\n1.6 Increases in the amounts of precipitation in high latitudes and
\nprecipitation decreases in most sub-tropical land regions are
\npredicted.
\n1.7 Regional \/ local e\ufb00ects may di\ufb00er but a reduction in potential
\ncrop yields is expected in most tropical \/ sub-tropical regions \u2013
\ncausing further disruptions in global food supply.
\n1.8 Salt-water intrusion from rising sea levels will reduce the quality
\nand quantity of freshwater supplies, and seawater will become
\nmore acidic from dissolved CO2.
\n1.9 As many as 25% of mammals and 12% of birds may become ex-
\ntinct within the next few decades. Warmer conditions are alter-
\ning the ecosystem and human development is blocking threat-
\nened species from migrating.
\n1.10 Higher temperatures will expand the range of some vector-
\nborne diseases, such as malaria, which already kills 1 million
\npeople annually, mostly children.
\n2. The IPCC authors begin with a review of the evidence and pro-
\nvide the following information (con\ufb01dence levels as determined by
\nIPCC in brackets):
\n2.1 Climate change currently contributes to the global burden of
\ndisease and premature deaths (very high con\ufb01dence). At this
\nearly stage the e\ufb00ects are small but are projected to progressively
\nincrease in all countries and regions.
\n2.2 Emerging evidence of climate change e\ufb00ects on human health
\nshows that climate change has (con\ufb01dence levels in brackets):
\n2.2.1 Altered the distribution of some infectious disease vectors
\n(medium);
\n2.2.2 Altered the seasonal distribution of some allergenic pollen
\nspecies (high);
\n2.2.3 Increased heat wave related deaths (medium).
\n3. In their thorough review, the IPCC authors\u2019 project climate
\nchange related human health impacts as follows (con\ufb01dence levels
\nin brackets):
\n3.1 Increased malnutrition and consequent disorders, including
\nthose relating to child growth and development (high).
\n3.2 Increased numbers of people su\ufb00ering from death, disease
\nand injury from heat waves, \ufb02oods, storms, \ufb01res and droughts
\n(high).
\n3.3 Continued change in the range of some infectious disease vec-
\ntors (high).
\n3.4 Mixed e\ufb00ects on malaria; in some places the geographical range
\nwill contract, elsewhere the geographical range will expand and
\nthe transmission season may be changed (very high).
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\n3.5 Increased burden of diarrheal diseases (medium).
\n3.6 Increased cardio-respiratory morbidity and mortality associated
\nwith ground-level ozone (high).
\n3.7 Increased numbers of people at risk of dengue (low).
\n3.8 Social and health inequalities due to possible deserti\ufb01cation,
\nnatural disasters, changes in agriculture, feeding and water pol-
\nicy which will have consequences on both human health and
\nhuman resources in health.
\n4. The authors note that climate change could bring some bene\ufb01ts
\nto health, including fewer deaths from cold, although these will be
\noutweighed by the negative e\ufb00ects of rising temperatures world-
\nwide, especially in developing countries (high con\ufb01dence).
\n5.The WMA notes that climate change is likely to amplify inequali-
\nties in health and other existing problems within and between coun-
\ntries.
\n6.Early research suggests that mitigation of the e\ufb00ects of climate change
\nmay have a link with prevention such that mitigation might have signi\ufb01-
\ncant health bene\ufb01ts for both individuals and populations*
\nSTATEMENT
\nGiven the consequences of global climate change on the health of
\npeople throughout the world, the World Medical Association, on
\nbehalf of its national medical association members and their physi-
\ncian members supports and commits to the following actions:
\n1. ADVOCACY to Combat Global Warming
\n1.1 The World Medical Association and National Medical Associa-
\ntions urge national governments to recognize the serious con-
\nsequences for health as a result of climate change and therefore
\nto strive for an intergovernmental agreement in Copenhagen in
\nDecember 2009 with the following components:
\n1.1.1 speci\ufb01c goals for reductions of climate altering emissions
\n(mitigation);
\n1.1.2 a mechanism to minimize the harms and health inequalities
\nthat are globally associated with climate change (adaptation);
\n1.1.3 because climate change will exaggerate health disparities,
\nWMA recommends that resources transferred to developing
\n* In the context of this paper, Mitigation describes the actions to
\nreduce human e\ufb00ects on the climate system: principally strategies
\nto reduce greenhouse gas emissions (analogous to primary preven-
\ntion) while Adaptation is understood to refer to the adjustment in
\nnatural or human systems taken in response to actual or expected
\nclimate stimuli or their e\ufb00ects, and that moderate harm or exploit
\nbene\ufb01cial opportunities (analogous to secondary prevention). (See
\nWHO EB122\/4, Jan 08)
\ncountries for climate change must include designated funds
\nto support the strengthening of health systems.
\n1.2 As a profession, physicians & their medical associations will
\nencourage advocacy for environmental protection, reduction of
\ngreen house gas production, sustainable development and green
\nadaptation practices within their communities, countries\/re-
\ngions, especially for the right of safe water & sewage disposal
\nfor all.
\n1.3 As professionals, physicians are encouraged to act within their
\nprofessional settings (clinics, hospitals, laboratories etc.) to re-
\nduce the environmental impact of medical activities, & to de-
\nvelop environmentally sustainable professional settings.
\n1.4 As individuals, physicians will be encouraged to act to minimize
\ntheir impact on the environment, reduce their carbon footprint
\nand encourage those around them to do so.
\n2. LEADERSHIP: Help people to mitigate
\nclimate damage & adapt to climate change
\n2.1 Support the Millennium Development Goals and commit to
\nwork to attain them.
\n2.2 Support and implement the principles outlined in the WHO
\nCommission on the Social Determinants of Health report,
\nClosing the Gap in a Generation and in the World Health As-
\nsembly Resolution on climate change and health and work with
\nWHO and others to ensure implementation of the recommen-
\ndations.
\n2.3 Work to create resilience within health systems to ensure that all
\nhealth care providers are able to adapt and can fully utilize their
\ncapacity to provide care to those in need.
\n2.4 Urge local, national and international organizations focused on
\nadaptation, mitigation, and development to involve physicians
\nand the healthcare community to ensure that unanticipated
\nhealth impacts of development are minimized, while opportu-
\nnities for health promotion are maximized.
\n2.5 Work to improve the ability of patients to adapt to climate
\nchange and catastrophic weather events by:
\n2.5.1 encouraging health behaviors that improve overall health;
\n2.5.2 creating targeted programs designed to address speci\ufb01c
\nexposures;
\n2.5.3 providing health promotion information and education on
\nself-management of the symptoms of climate-associated ill-
\nness.
\n3. EDUCATION & CAPACITY BUILDING:
\n3.1 Build professional awareness of the importance of the environ-
\nment and global climate change to personal, community and
\nsocietal health, and recognize that universal equitable education
\nimproves health capacity for all.
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\n3.2 Physicians have obligations for the health and health care of
\nindividual patients. Collectively, through their national medical
\nassociations, and through WMA they also have obligations and
\nresponsibilities for the health of all people.
\n3.3 Work with others to educate the general public about the im-
\nportant e\ufb00ects of climate change on health and the need to both
\nmitigate climate change and adapt to its e\ufb00ects.
\n3.4 Add or strengthen routine health training on environmental
\nhealth\/medicine and public health for all students in health re-
\nlated disciplines.
\n3.5 The WMA and NMAs should develop concrete actionable
\nplans\/practical steps as tools for physicians to adopt in their
\npractices; health authorities and governments should do the
\nsame for hospitals and other health facilities.
\n3.6 Incorporate tools such as a patient environmental impact assess-
\nment and encourage physicians to evaluate their patients and
\ntheir families for risk from the environment and global climate
\nchange.
\n3.7 Advocate that governments undertake community climate
\nchange health impact assessments, widely disseminate the re-
\nsults, and incorporate the results into planning for mitigation
\nand adaptation.
\n3.8 Encourage recruitment of physicians for work in public health
\nand all roles in emergency planning & response to extreme cli-
\nmate change, including the training of other physicians.
\n3.9 Urge colleges and universities to develop locally appropriate
\ncontinuing medical and public health education on the clinical
\nsigns, diagnosis and treatment of new diseases that are intro-
\nduced into communities as a result of climate change, and on
\nthe management of long-term anxiety and depression that often
\naccompany experiences of disasters.
\n3.10 Urge governments to provide training for climate-change-re-
\nlated emergency response to physicians, particularly those living
\nin relatively isolated regions.
\n3.11 Work with policy makers on the development of concrete ac-
\ntions to be taken to prevent or reduce the health impact of cli-
\nmate-related emissions,in particular those initiatives,which will
\nalso improve the general health of the population. This would
\ninclude initiatives to stop the privatization of water.
\n4. SURVEILLANCE AND RESEARCH:
\n4.1 Work with others, including governments, to address the gaps
\nin research regarding climate change and health by undertaking
\nstudies to:
\n4.1.1 describe the patterns of disease that are attributed to cli-
\nmate change, including the impacts of climate change on
\ncommunities and households;
\n4.1.2 quantify and model the burden of disease that will be
\ncaused by global climate change;
\n4.1.3 describe the e\ufb00ects of poorly treated wastewater used for
\nirrigation and
\n4.1.4 describe the most vulnerable populations, the particular
\nhealth impacts of climate change on vulnerable populations,
\n& possible new protections for such populations.
\n4.2 Advocate for the collection of vital statistics and the removal of
\nbarriers to the registration of births & deaths, in recognition of
\nthe special vulnerability of some populations.
\n4.3 Report diseases that emerge in conjunction with global climate
\nchange, and participate in \ufb01eld investigations, as with outbreaks
\nof infectious diseases.
\n4.4 Support and participate in the development or expansion of sur-
\nveillance systems to include diseases caused by global climate
\nchange.
\n4.5 WMA will and encourages all NMAs to collaborate in the col-
\nlection and sharing of local or regional health information with-
\nin and between countries in order to encourage the adoption of
\nbest practices and proven strategies
\n5. COLLABORATION: Prepare for climate emergencies
\n5.1 Collaborate with governments, NGOs and other health profes-
\nsionals to develop knowledge about the best ways to mitigate
\nclimate change, including those adaptive and mitigation strate-
\ngies that will result in improved health.
\n5.2 Encourage governments to incorporate national medical as-
\nsociations & physicians into country & community emergency
\nplanning & response.
\n5.3 Work to ensure integration of physicians into the plans of civil
\nsociety, governments, public health authorities, international
\nNGOs and WHO.
\n5.4 Encourage WHO and countries of the World Medical Assem-
\nbly to review the International Health Regulations and Plan-
\nning for Pandemic In\ufb02uenza and obtain the perspective of clini-
\ncians in community practice to ensure that there are appropriate
\nresponses by practicing physicians to emergency alerts, and to
\nmake recommendations regarding the most appropriate educa-
\ntion, and tools for physicians and other healthcare workers.
\n5.5 Call upon governments to strengthen public health systems in
\norder to improve the capacity of communities to adapt to cli-
\nmate change.
\n5.6 Prepare physicians, physicians\u2019o\ufb03ces, clinics, hospitals and oth-
\ner health care facilities for the infrastructure disruptions that
\naccompany major emergencies, in particular by planning in ad-
\nvance the delivery of services during times of such disruptions.
\n5.7 Urge physicians, medical associations and governments to work
\ncollaboratively to develop systems for event alerts in order to
\nensure that health care systems and physicians are aware of
\nclimate-related events as they unfold, and receive timely accu-
\nrate information regarding the management of emerging health
\nevents.
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\n5.8 Call upon governments to plan for environmental refugees
\nwithin their countries.
\n5.9 In collaboration with WHO,produce locally adapted fact sheets
\non climate change for national medical associations, physicians,
\nand other health professionals.
\n5.10 WMA will work with others to identify funding for speci\ufb01c re-
\nsearch programs on mitigation and adaptation related to health,
\nand the sharing of information\/research within and between
\ncountries and jurisdictions.
\nDeclaration of Madrid on
\nProfessionally-led Regulation
\nAdopted by the WMA General Assembly,
\nNew Delhi, India, October 2009
\nThe collective action by the medical profession seeking for the1.
\nbene\ufb01t of patients, in assuming responsibility for implement-
\ning a system of professionally-led regulation will enhance and
\nassure the individual physician’s right to treat patients without
\ninterference, based on his or her best clinical judgment. There-
\nfore, the WMA urges the national medical associations and all
\nphysicians to take the following actions.
\nPhysicians have been granted by society a high degree of profes-2.
\nsional autonomy and clinical independence, whereby they are
\nable to make recommendations based on the best interests of
\ntheir patients without undue outside in\ufb02uence.
\nAs a corollary to the right of professional autonomy and clinical3.
\nindependence,the medical profession has a continuing responsi-
\nbility to be self-regulating. Ultimate control and decision-mak-
\ning authority must rest with physicians, based on their speci\ufb01c
\nmedical training, knowledge, experience and expertise
\nPhysicians in each country are urged to establish, maintain and4.
\nactively participate in a legitimate system of professionally-led
\nregulation. This dedication is to ultimately assure full clinical
\nindependence in patient care decisions.
\nTo avoid being in\ufb02uenced by the inherent potential con\ufb02icts of5.
\ninterest that will arise from assuming both representational and
\nregulatory duties, National Medical Associations must do their
\nutmost to promote and support the concept of professionally-
\nled regulation amongst their membership and the public.
\nAny system of professionally-led regulation must ensure6.
\na) the quality of the care provided to patients,
\nb) the competence of the physician providing that care and
\nc) the professional conduct of physician.
\nTo ensure the patient quality continuing care, physicians must
\nparticipate actively in the process of Continuing Professional
\nDevelopment in order to update and maintain their clinical
\nknowledge, skills and competence.
\nThe professional conduct of physicians must always be within7.
\nthe bounds of the Code of Ethics governing physicians in each
\ncountry. National Medical Associations must promote profes-
\nsional and ethical conduct among physicians for the bene\ufb01t of
\ntheir patients. Ethical violations must be promptly recognized
\nand reported. The physicians who have erred must be appropri-
\nately disciplined and where possible be rehabilitated.
\nNational Medical Associations are urged to assist each other in8.
\ncoping with new and developing problems, including potential
\ninappropriate threats to professionally-led regulation.The ongo-
\ning exchange of information and experiences between National
\nMedical Associations is essential for the bene\ufb01t of patients.
\nAn e\ufb00ective and responsible system of professionally-led regu-9.
\nlation by the medical profession in each country must not be
\nself serving or internally protective of the profession, and the
\nprocess must be fair, reasonable and su\ufb03ciently transparent to
\nensure this. National Medical Associations should assist their
\nmembers in understanding that self-regulation cannot only be
\nperceived as being protective of physicians, but must maintain
\nthe safety, support and con\ufb01dence of the general public as well
\nas the honour of the profession itself.
\nDeclaration of Ottawa
\non Child Health
\nAdopted by the 50th World Medical Assembly, Ottawa,
\nCanada, October 1998 and amended by the WMA
\nGeneral Assembly, New Delhi, India, October 2009
\nPREAMBLE
\nScience has now proven that to reach their potential, children need
\nto grow up in a place where they can thrive \u2013 spiritually,emotionally,
\nmentally, physically and intellectually*
\n. That place must have four
\nfundamental elements:
\na safe and secure environment;\u2022
\nthe opportunity for optimal growth and development;\u2022
\nhealth services when needed; and\u2022
\nmonitoring & research for evidence-based continual improve-\u2022
\nment into the future**
\n.
\n* Irwin LG, Siddiqi A, Hertzman C. \u201cEarly Child Development: A Power-
\nful Equalizer. Final Report\u201d. World Health Organization Commission on the
\nSocial Determinants of Health June 2007.
\n** WHO Commission on Social Determinants of Health (Closing the Gap in a
\nGeneration) 2008
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\nPhysicians know that the future of our world depends on our chil-
\ndren: their education, their employability, their productivity, their
\ninnovation, and their love and care for one another and for this
\nplanet. Early childhood experiences strongly in\ufb02uence future de-
\nvelopment including basic learning, school success, economic par-
\nticipation, social citizenry, and health3
\n. In most situations, parents
\nand caregivers alone cannot provide strong nurturing environ-
\nments without help from local, regional, national and international
\norganizations.***
\nPhysicians therefore join with parents, and with
\nworld leaders to advocate for healthy children.
\nThe principles of this Declaration apply to all children in the world
\nfrom birth to 18 years of age, regardless of race, age, ethnicity, na-
\ntionality, political a\ufb03liation, creed, language, gender, disease or dis-
\nability, physical ability, mental ability, sexual orientation, cultural
\nhistory, life experience or the social standing of the child or her\/his
\nparents or legal guardian. In all countries of the world, regardless of
\nresources, meeting these principles should be a priority for parents,
\ncommunities and governments. The United Nations Convention
\non the Rights of Children (1989) sets out the wider rights of all
\nchildren and young people, but those rights cannot exist without
\nhealth.
\nGENERAL PRINCIPLES
\n1. A place with a safe and secure environment includes:
\nClean water, air and soil;\u2022
\nProtection from injury, exploitation, discrimination and from tra-\u2022
\nditional practices prejudicial to the health of the child, and
\nHealthy families, homes and communities.\u2022
\n2. A place where a child can have good health and development
\no\ufb00ers:
\nPrenatal and maternal care for the best possible health at birth;\u2022
\nNutrition for proper growth, development and long-term health;\u2022
\nEarly learning opportunities and high quality care at home and\u2022
\nin the community;
\nOpportunities and encouragement for physical activity;\u2022
\n*** Canadian Charter for Child and Youth Health
\nA\ufb00ordable & accessible high quality primary & secondary educa-\u2022
\ntion.
\n3. A full range of health resources available to all means:
\nThe best interests of the child shall be the primary consideration\u2022
\nin the provision of health care;
\nThose caring for children shall have the special training and skills\u2022
\nnecessary to enable them to respond appropriately to the medical,
\nphysical, emotional and developmental needs of children & their
\nfamilies;
\nBasic health care including health promotion, recommended im-\u2022
\nmunization, drugs & dental health;
\nMental health care and prompt referral to intervention when\u2022
\nproblems identi\ufb01ed;
\nPriority access to drugs for life- or limb-threatening conditions\u2022
\nfor all mothers and children;
\nHospitalization only if the care and treatment required cannot be\u2022
\nprovided at home, in the community or on an outpatient basis;
\nAccess to specialty diagnostic and treatment services when need-\u2022
\ned;
\nRehabilitation services and supports within community;\u2022
\nPain management and care and prevention (or minimization) of\u2022
\nsu\ufb00ering;
\nInformed consent is necessary before initiating any diagnostic,\u2022
\ntherapeutic, rehabilitative, or research procedure on a child. In
\nthe majority of cases, the consent shall be obtained from the
\nparent(s) or legal guardian, or in some cases, by extended family,
\nalthough the wishes of a competent child should be taken into
\naccount before consent is given.
\n4. Research****
\n& monitoring for continual improvement includes:
\nAll infants will be o\ufb03cially registered within one month of birth;\u2022
\nAll children will be treated with dignity and respect;\u2022
\nQuality care is ensured through on-going monitoring of services,\u2022
\nincluding collection of data, and evaluation of outcomes;
\nChildren will share in the bene\ufb01ts from scienti\ufb01c research rel-\u2022
\nevant to their needs;
\nThe privacy of a child patient will be respected.\u2022
\n**** Proposed WMA statement on ethical principles for medical research on child
\nsubjects
\nWMA Resolution on Task
\nShifting from the Medical
\nProfession
\nAdopted by the WMA General Assembly,
\nNew Delhi, India, October 2009
\nIn health care, the term \u00abTask Shifting\u00bb is used to describe a situa-
\ntion where a task normally performed by a physician is transferred
\nto a health professional with a di\ufb00erent or lower level of education
\nand training, or to a person speci\ufb01cally trained to perform a limited
\ntask only, without having a formal health education. Task shifting
\noccurs both in countries facing shortages of physicians and those
\nnot facing shortages.
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\nA major factor leading to task shifting is the shortage of quali\ufb01ed
\nworkers resulting from migration or other factors. In countries facing
\na critical shortage of physicians, task shifting may be used to train al-
\nternate health care workers or laypersons to perform tasks generally
\nconsidered to be within the purview of the medical profession. The
\nrationale behind the transferring of these tasks is that the alternative
\nwould be no service to those in need. In such countries, task shifting
\nis aimed at improving the health of extremely vulnerable populations,
\nmostly to address current shortages of healthcare professionals or tackle
\nspeci\ufb01c health issues such as HIV. In countries with the most extreme
\nshortage of physicians, new cadres of health care workers have been
\nestablished. However, those persons taking over physicians’ tasks lack
\nthe broad education and training of physicians and must perform their
\ntasks according to protocols, but without the knowledge, experience
\nand professional judgement required to make proper decisions when
\ncomplications arise or other deviations occur.This may be appropriate
\nin countries where the alternative to task shifting is no care at all but
\nshould not be extended to countries with di\ufb00erent circumstances.
\nIn countries not facing a critical shortage of physicians,task shifting
\nmay occur for various reasons: social, economic, and professional,
\nsometimes under the guise of e\ufb03ciency, savings or other unproven
\nclaims. It may be spurred, or, conversely, impeded, by professions
\nseeking to expand or protect their traditional domain. It may be
\ninitiated by health authorities, by alternate health care workers and
\nsometimes by physicians themselves. It may be facilitated by the
\nadvancement of medical technology, which standardizes the perfor-
\nmance and interpretation of certain tasks, therefore allowing them
\nto be performed by non-physicians or technical assistants instead of
\nphysicians. This has typically been done in close collaboration with
\nthe medical profession. However, it must be recognized that medi-
\ncine can never be viewed solely as a technical discipline.
\nTask shifting may occur within an already existing medical team,
\nresulting in a reshu\ufb04ing of the roles and functions performed by the
\nmembers of such a team. It may also create new types of personnel
\nwhose function is to assist other health professionals, speci\ufb01cally
\nphysicians, as well as personnel trained to independently perform
\nspeci\ufb01c tasks.
\nAlthough task shifting may be useful in certain situations, and may
\nsometimes improve the level of patient care,it carries with it signi\ufb01-
\ncant risks. First and foremost among these is the risk of decreased
\nquality of patient care,particularly if medical judgment and decision
\nmaking is transferred. In addition to the fact that the patient may
\nbe cared for by a lesser trained health care worker, there are speci\ufb01c
\nquality issues involved, including reduced patient-physician contact,
\nfragmented and ine\ufb03cient service, lack of proper follow up, incor-
\nrect diagnosis and treatment and inability to deal with complica-
\ntions.
\nIn addition, task shifting which deploys assistive personnel may ac-
\ntually increase the demand on physicians. Physicians will have in-
\ncreasing responsibilities as trainers and supervisors, diverting scarce
\ntime from their many other tasks such as direct patient care. They
\nmay also have increased professional and\/or legal responsibility for
\nthe care given by health care workers under their supervision.
\nThe World Medical Association expresses particular apprehension
\nover the fact that task shifting is often initiated by health authori-
\nties, without consultation with physicians and their professional
\nrepresentative associations.
\nRECOMMENDATIONS
\nTherefore, the World Medical Association recommends the follow-
\ning guidelines:
\n1. Quality and continuity of care and patient safety must never be
\ncompromised and should be the basis for all reforms and legisla-
\ntion dealing with task shifting.
\n2. When tasks are shifted away from physicians, physicians and
\ntheir professional representative associations should be con-
\nsulted and closely involved from the beginning in all aspects
\nconcerning the implementation of task shifting,especially in the
\nreform of legislations and regulations. Physicians might them-
\nselves consider initiating and training a new cadre of assistants
\nunder their supervision and in accordance with principles of
\nsafety and proper patient care.
\n3. Quality assurance standards and treatment protocols must be
\nde\ufb01ned, developed and supervised by physicians. Credential-
\ning systems should be devised and implemented alongside the
\nimplementation of task shifting in order to ensure quality of
\ncare.Tasks that should be performed only by physicians must be
\nclearly de\ufb01ned. Speci\ufb01cally, the role of diagnosis and prescrib-
\ning should be carefully studied.
\n4. In countries with a critical shortage of physicians, task shifting
\nshould be viewed as an interim strategy with a clearly formulat-
\ned exit strategy. However, where conditions in a speci\ufb01c country
\nmake it likely that it will be implemented for the longer term, a
\nstrategy of sustainability must be implemented.
\n5. Task shifting should not replace the development of sustain-
\nable, fully functioning health care systems. Assistive workers
\nshould not be employed at the expense of unemployed and un-
\nderemployed health care professionals.Task shifting also should
\nnot replace the education and training of physicians and other
\nhealth care professionals. The aspiration should be to train and
\nemploy more skilled workers rather than shifting tasks to less
\nskilled workers.
\n6. Task shifting should not be undertaken or viewed solely as a cost
\nsaving measure as the economic bene\ufb01ts of task shifting remain
\nunsubstantiated and because cost driven measures are unlikely
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\nWMA news
\nto produce quality results in the best interest of patients. Cred-
\nible analysis of the economic bene\ufb01ts of task shifting should be
\nconducted in order to measure health outcomes, cost e\ufb00ective-
\nness and productivity.
\n7. Task shifting should be complemented with incentives for the
\nretention of health professionals such as an increase of health
\nprofessionals’ salaries and improvement of working conditions.
\n8. The reasons underlying the need for task shifting di\ufb00er from
\ncountry to country and therefore solutions appropriate for one
\ncountry cannot be automatically adopted by others.
\n9. The e\ufb00ect of task shifting on the overall functioning of health
\nsystems remains unclear. Assessments should be made of the
\nimpact of task shifting on patient and health outcomes as well
\nas on e\ufb03ciency and e\ufb00ectiveness of health care delivery. In par-
\nticular, when task shifting occurs in response to speci\ufb01c health
\nissues, such as HIV, regular assessment and monitoring should
\nbe conducted of the entire health system. Such work is essential
\nin order to ensure that these programs are improving the health
\nof patients.
\n10. Task shifting must be studied and assessed independently and
\nnot under the auspices of those designated to perform or \ufb01nance
\ntask shifting measures.
\n11.Task shifting is only one response to the health workforce short-
\nage. Other methods, such as collaborative practice or a team\/
\npartner approach, should be developed in parallel and viewed
\nas the gold standard. Task shifting should not replace the de-
\nvelopment of mutually supportive, interactive health care teams,
\ncoordinated by a physician, where each member can make his or
\nher unique contribution to the care being provided.
\n12. In order for collaborative practice to succeed, training in lead-
\nership and teamwork must be improved. There must also be
\na clear understanding of what each person is trained for and
\ncapable of doing, clear understanding of responsibilities and a
\nde\ufb01ned, uniformly accepted use of terminology.
\n13.Task shifting should be preceded by a systematic review, analysis
\nand discussion of the potential needs, costs and bene\ufb01ts. It
\nshould not be instituted solely as a reaction to other develop-
\nments in the health care system.
\n14.Research must be conducted in order to identify successful train-
\ning models. Work will need to be aligned to various models cur-
\nrently in existence. Research should also focus on the collection
\nand sharing of information, evidence and outcomes. Research
\nand analysis must be comprehensive and physicians must be part
\nof the process.
\n15. When appropriate, National Medical Associations should col-
\nlaborate with associations of other health care professionals in
\nsetting the framework for task shifting. The WMA shall con-
\nsider establishing a framework for the sharing of information
\non this topic where members can discuss developments in their
\ncountries and their e\ufb00ects on patient care and outcomes.
\nWMA Emergency Resolution
\nsupporting the Rights of Patients
\nand Physicians in the Islamic
\nRepublic of Iran
\nAdopted by the WMA General Assembly,
\nNew Delhi, India, October 2009
\nWHEREAS,
\nPhysicians in the Islamic Republic of Iran have reported:
\nUnsettling practices of injured persons being taken to prisons, with-
\nout adequate medical treatment or the consensus of the attending
\nphysicians;
\nPhysicians being hindered from treating patients;
\nConcern about the veracity of documentation related to the death of
\npatients and physicians being forced to clinically inaccurate docu-
\nmentation; and
\nCorpses and badly injured political and religious prisoners who
\nwere admitted to hospitals with signs of brutal torture, including
\nsexual abuse.
\nTHEREFORE, the World Medical Association
\n1. Rea\ufb03rms its Declaration of Lisbon: Declaration on the Rights
\nof the Patient, which states that whenever legislation, government
\naction or any other administration or institution denies patients the
\nright to medical care, physicians should pursue appropriate means
\nto assure or to restore it.
\n2. Rea\ufb03rms its Declaration of Hamburg: Declaration Concern-
\ning Support for Medical Doctors Refusing to Participate in, or to
\nCondone, the Use of Torture or Other Forms of Cruel, Inhuman
\nor Degrading Treatment, which encourages doctors to honor their
\ncommitment as physicians to serve humanity and to resist any pres-
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\nWMA news
\nsure to act contrary to the ethical principles governing their dedica-
\ntion to this task.
\n3. Rea\ufb03rms its Declaration of Tokyo: Guidelines for Physicians
\nConcerning Torture and other Cruel,Inhuman or Degrading Treat-
\nment or Punishment in Relation to Detention and Imprisonment,
\nwhich:
\nprohibits physicians from participating in, or even being present\u2022
\nduring the practice of torture or other forms of cruel or inhuman
\nor degrading procedures;
\nrequires that physicians maintain utmost respect for human life\u2022
\neven under threat, and prohibits them from using any medical
\nknowledge contrary to the laws of humanity.
\n4. Rea\ufb03rms its Resolution on the Responsibility of Physicians in
\nthe Documentation and Denunciation of Acts of Torture or Cruel
\nor Inhuman or Degrading Treatment; which states that physicians
\nshould attempt to:
\nensure that detainees or victims of torture or cruelty or mistreat-\u2022
\nment have access to immediate and independent health care;
\nensure that physicians include assessment and documentation of\u2022
\nsymptoms of torture or ill-treatment in the medical records us-
\ning the necessary procedural safeguards to prevent endangering
\ndetainees.
\n5. Refers to the WMA International Code of Medical Ethics,
\nwhich states that physicians shall be dedicated to providing com-
\npetent medical service in full professional and moral independence,
\nwith compassion and respect for human dignity.
\n6. Urges the government of the Islamic Republic of Iran to respect
\nthe International Code of Medical Ethics and the standards in-
\ncluded in the aforementioned declarations to which physicians are
\ncommitted.
\n7. Urges National Medical Associations to speak out in support of
\nthis resolution.
\nWMA Resolution on Medical
\nWorkforce
\nAdopted by the 50th World Medical Assembly, Ottawa,
\nCanada, October 1998 and amended by the WMA
\nGeneral Assembly, New Delhi, India, October 2009
\nPREAMBLE
\nThe health of our countries depends upon keeping the population
\nhealthy. Health care is a key right of individuals.This care is depen-
\ndent upon access to highly-trained medical and other healthcare
\nprofessionals. Well-functioning health care systems depend upon
\nthese su\ufb03cient human resources. Comprehensive and extensive
\nplanning on a national level is required in order to ensure that a
\ncountry has a medical workforce in all \ufb01elds of medicine that meets
\nthe present and future health needs of the entire population of that
\ncountry.
\nThere are currently signi\ufb01cant shortages in the area of health hu-
\nman resources. These shortages are present in all countries but are
\nespecially pronounced in developing countries where health human
\nresources are more limited.
\nThe problem is made more severe by the fact that many countries
\nhave not invested adequately in the education, training, recruitment
\nand retention of their medical workforce. The ageing population in
\ndeveloped countries has also been re\ufb02ected by an ageing medical
\nworkforce. Many developed countries address their medical work-
\nforce shortages by employing health care professionals from devel-
\noping countries to bolster their own health care systems.
\nThe migration of health care professionals from developing coun-
\ntries to developed countries has,over the past ten years,impaired the
\nperformance of health systems in developing countries. Economic
\nrealities of insu\ufb03cient investments in health care and inadequate
\nfacilities and support for health care professionals have continued to
\nbe responsible for this migration.
\nThe World Health Organization has recognized that the crisis of
\nhealth workforce shortages is impeding the provision of essential,
\nlife-saving interventions.It has therefore established structures such
\nas the Global Health Workforce Alliance, a partnership dedicated
\nto identifying and implementing solutions to the health workforce
\nproblems. The WHO is promoting the development of a cadre of
\nmedical\/clinical assistants who propose to join the medical work-
\nforce to partially address these shortages.
\nRECOMMENDATIONS
\nRecognizing that health care systems require adequate numbers of
\nquali\ufb01ed and competent health care professionals, the World Medi-
\ncal Association asks all National Medical Associations to partici-
\npate and be active in addressing these requirements and to:
\n1. Call on their respective governments to allocate su\ufb03cient \ufb01nan-
\ncial resources for the education, training, development, recruitment
\nand retention of physicians to meet the medical needs of the entire
\npopulation in their countries.
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\n2. Call on their respective governments to ensure that the educa-
\ntion, training and development of healthcare professionals meets
\nthe highest possible standards including:
\nThe training and development of medical\/clinical assistants where\u2022
\nthis is applicable and appropriate and
\nEnsuring clear de\ufb01nitions of scope of practice and conditions for\u2022
\nadequate support and supervision.
\n3. Call on governments to ensure that appropriate ratios are main-
\ntained between population and the medical workforce at all levels,
\nincluding mechanisms to address reduced access to care in rural and
\nremote areas, based on accepted international norms and standards
\nwhere these are available.
\n4. Take measures to attract and support individuals within their
\ncountries to enter the medical profession and also call on their re-
\nspective governments to take such action.
\n5. Actively advocate for programs that will ensure the retention of
\nphysicians within their respective countries and ensure governments\u2019
\nrecognition of this need.
\n6.Call on governments to improve the health care working environ-
\nment (including access to appropriate facilities, equipment, treat-
\nment modalities and professional support), physician remuneration,
\nphysician living environment and career development of the medi-
\ncal workforce at all levels.
\n7. Advocate for the development of transparent memoranda of un-
\nderstanding between countries where migration of trained health
\ncare professionals is an issue of concern and enlist where possible the
\nNMA of origin and receiving NMA\u2019s to support these physicians.
\nWMA Statement on
\nInequalities in Health
\nAdopted by the WMA General Assembly,
\nNew Delhi, India, October 2009
\nPREAMBLE
\nFor over 150 years, the existence of health inequality has been ac-
\nknowledged worldwide. The recently published Final Report of the
\nWHO Commission on Social Determinants of Health has high-
\nlighted the critical importance of health equity to the health, econ-
\nomy and social cohesiveness of all countries. It is clear that while
\nthere are major di\ufb00erences between countries,especially between the
\ndeveloping and developed countries, there are also substantial dis-
\nparities within countries with respect to various measures of socio-
\neconomic and cultural diversity. Disparities in health can be de\ufb01ned
\nas either disparities in access to healthcare, disparities in quality of
\ncare received, or both.The di\ufb00erences manifest themselves in a wide
\nvariety of health measures, such as life expectancy, infant mortality,
\nand childhood mortality. Particularly disturbing is evidence of the
\ngradual and ongoing widening of speci\ufb01c disparities.
\nAt the core of this issue is the healthcare provided by physicians.
\nNational medical associations should take an active role in combat-
\ning social and health inequalities in order to allow their physician
\nmembers the ability to provide equal, quality service to all.
\nThe Role of the Health Care System
\nWhile the major causes of health disparities lie in the socio-eco-
\nnomic and cultural diversity of population groups, there is a very
\nsigni\ufb01cant role for the health care system in their prevention and
\nreduction.This role can be summarized as follows:
\nTo prevent the health e\ufb00ects of socio-economic and cultural in-\u2022
\nequality and inequity \u2013 especially by health promotion and dis-
\nease prevention activities (Primary Prevention)
\nTo Identify, treat and reduce existing health inequality, e.g. early\u2022
\ndiagnosis of disease,quality management of chronic disease,reha-
\nbilitation (Secondary and Tertiary Prevention).
\nRECOMMENDATIONS
\nThe members of the medical profession, faced with treating the re-
\nsults of this inequity, have a major responsibility and call on their
\nnational medical associations to:
\n1. Recognize the importance of health inequality and the need to
\nin\ufb02uence national policy and action for its prevention and re-
\nduction
\n2. Identify the social and cultural risk factors to which patients and
\nfamilies are exposed and to plan clinical activities (diagnostic
\nand treatment) to counter their consequences.
\n3. Advocate for the abolishment of \ufb01nancial barriers to obtaining
\nneeded medical care.
\n4. Advocate for equal access for all to health care services irrespec-
\ntive of geographic, social, age, gender, religious, ethnic and eco-
\nnomic di\ufb00erences or sexual orientation.
\n5. Require the inclusion of health inequality studies (including the
\nscope, severity, causes, health, economic and social implications)
\nas well as the provision of cultural competence tools, at all lev-
\nels of academic medical training, including further training for
\nthose already in clinical practice.
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\nWMA Resolution on Improved
\nInvestment in Public Health
\nAdopted by the 50th World Medical Assembly, Ottawa,
\nCanada, October 1998 and amended by the WMA
\nGeneral Assembly, New Delhi, India, October 2009
\nINTRODUCTION
\nEach country should have a health system with enough resources to
\nattend to the needs of its population. However today, many coun-
\ntries across the world are su\ufb00ering wide inequities and inequalities
\nin health care and this is causing problems of access to health servic-
\nes for the poorer segments of society [the weak or underprivileged].
\nThe situation is especially serious in low-income countries.
\nThe international community has attempted to improve the situ-
\nation. The 20\/20 initiative of 1995, the 1996 Initiative for Heavily
\nIndebted Poor Countries (HIPC), and Objectives for Millennium
\n2000 Development (MDGs) are all initiatives aimed at reducing
\npoverty and dealing with poor health, inequities and inequalities
\nbetween the sexes, education, insu\ufb03cient access to drinking water
\nand environmental contamination.
\nThe objectives are formed as an agreement with acknowledgement
\nof the contributions which developed countries can make, in the
\nshape of trade relations, development assistance, reduction of the
\nburden of debt, improving access to essential medication and the
\ntransfer of technology. Three of the eight objectives are directly re-
\nlated to health, which has a considerable in\ufb02uence on various other
\nobjectives that interact to support each of the others within a struc-
\ntural framework,these are designed to increase human development
\nglobally. The eight Millennium Development Objectives (MDO)
\nforesee a development vision based on health and education, thus
\na\ufb03rming that development does not only refer (allude) to economic
\ngrowth.
\nVarious reports from the World Health Organization have un-
\nderlined the opportunities and skills [or techniques] which are
\ncurrently involved in bringing about signi\ufb01cant improvements in
\nhealth, as well as helping to reduce poverty and encourage growth.
\nAdditionally, the reports highlight the fact that it is of fundamental
\nimportance to reduce limitations on human resources, in order to
\nincrease the achievements of the public health system, a situation
\nwhich requires urgent attention. These limitations are related to
\nwork, training and payment conditions, and play a substantial role
\nin determining capacity for sustained growth of access to health
\nservices.
\nRECOMMENDATIONS
\nThe World Medical Association urges National Medical Associa-
\ntions to:
\n1. Advocate that their governments should adhere to and promote
\nthe proposals to increase investment in the health sector; and to
\nadhere to and promote initiatives to reduce the debt burden for the
\npoorest countries on the planet.
\n2. Advocate [defend] the inclusion of public health factors in all
\n\ufb01elds of policy provision, since health is mostly determined by fac-
\ntors that are external to the area of healthcare, for example, housing
\nand education. [Health is not only medicine, it also depends on liv-
\ning standards].
\n3. Encourage and support countries in the planning and implemen-
\ntation of investment plans,which invest in health for the poor; guar-
\nantee that more resources be used for health in general, with greater
\ne\ufb03ciency and impact; and reduce limitations for the most e\ufb00ective
\nuse of the additional investments.
\n4. Maintain vigilance to ensure that the investment plans focus
\nmaximum attention on generating capacity, that they promote lead-
\nership skills and promote incentives to retain and place quali\ufb01ed
\npersonnel, whilst it is taken into consideration that the limitations
\nin relation to the previous matter currently constitute the greatest
\nobstacle for progress.
\n5. Urge international \ufb01nancial institutions and other important
\ndonors to: i) Adopt the necessary measures to help the countries
\nthat have already organised mechanisms to prepare their investment
\nplans, and provide assistance to those countries that have begun to
\ntake the necessary steps, with the support and participation of the
\ninternational community; ii) Help countries to obtain funds to de-
\nvelop and implement their investment plans; iii) Continue provid-
\ning technical assistance to the countries for their plans.
\n6. Exchange information in order to coordinate e\ufb00orts to change
\npolicies in these areas.
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\n\u201cSpeaking Books\u201d launched at the World
\nMedical Association AGM in New Delhi
\nIn a joint collaboration, the WMA togeth-
\ner with P\ufb01zer, and South African NGO
\nSADAG (The South African Depression
\nand Anxiety Group) launched the next two
\nbooks in their ongoing series of \u201cSpeaking
\nBooks\u201d for vulnerable communities.
\nThe \u201cSpeaking Books\u201d \ufb01rst launched in
\nSouth Africa for rural and least served
\ncommunities are to help patients gain a ba-
\nsic understanding of clinical trials that they
\nmay choose to participate in.The \ufb01rst in this
\nseries was \ufb01eld tested in South Africa at
\nTB, and HIV and AIDS facilities. Patients
\noverwhelmingly gained a better under-
\nstanding of their rights and responsibilities,
\nwith results indicating that:
\n93% of patients understood that they\u2022
\nwould be told how long to take the medi-
\ncine or vaccination and the duration of
\nthe trial;
\n91% understood that they would be al-\u2022
\nlowed to stop the trial at anytime;
\n91% were aware that they must tell their\u2022
\ndoctor about other medications they were
\ntaking;
\n100% knew both that they had rights\u2022
\nwhen participating and that their infor-
\nmation would be private.
\nThis hard backed book with 16 pages of
\nculturally appropriate illustrations, has a re-
\ncorded soundtrack, so that with the push of
\na button, each page can be read, heard and
\nviewed simultaneously. Each book is cus-
\ntomized to meet the needs of the local com-
\nmunity, recorded in the required language
\nand read by a well known local personality
\nThe \ufb01rst \u201cSpeaking Book\u201d in South Africa
\nwas as a result of the collaboration between
\nthe South African Medical Association,
\nThe Steve Biko Centre for Bioethics, the
\nWorld Medical Association and sponsored
\nby P\ufb01zer in the interests of patient educa-
\ntion.This \u201cSpeaking Book\u201d was produced to
\nsupport the principles of the Declaration of
\nHelsinki in promoting Good Clinical Prac-
\ntice and protecting the human rights, safety,
\nand well-being of clinical trial participants.
\nAccording to Dr. Soeren Rasmussen, Se-
\nnior Director for P\ufb01zer Inc and responsible
\nfor implementing P\ufb01zer’s \u201cSpeaking Book\u201d
\nprogram, \u201cThere is a need for informing
\npeople with limited literacy skills on how
\nclinical trials work,and by using the \u201cSpeak-
\ning Book\u201d it has made it possible for us to
\ndeliver simple messages that will be seen
\nread, heard and understood. We \ufb01rst intro-
\nduced the \u201cSpeaking Books\u201d with WMA
\nfor Africa, followed by India in Hindi and
\nTelugu,and now the next in our series being
\nan anti-smoking \u201cSpeaking Book\u201d recorded
\nin Mandarin focusing on Chinese youth\u201d
\n\u201cSpeaking Books\u201denable patients with little or
\nno literacy skills to understand critical health
\ncare messages and to take them home to share
\nwith their families so that the clinical trial
\nconcept is fully understood by all. The sound
\ntracks are read by local celebrities and in the
\nlanguage of choice for that community. By
\nbeing battery operated even the most isolated
\nand remote community can be reached with
\nthis innovative cost e\ufb00ective tool.
\nIn India the \ufb01rst ever dual language \u201cSpeak-
\ning Book\u201dwas distributed using both Hindi
\nand Telugu for use by clinics, trial centres
\nand hospitals. One clinical trial sister com-
\nmented that, \u201cThe book is a great idea to
\nsend home with each person. Sometimes
\npeople forget things you have said to them.
\nWith the book they can listen over and over
\nagain until they understand fully\u201d.
\nDeveloped by a small South African mental
\nhealth NGO, these \u201cSpeaking Books\u201d have
\nnow been distributed globally in 14 lan-
\nguages and on 35 health care topics. www.
\nbooksofhope.com
\nThe \u201cSpeaking Book\u201d delivers important
\nhealth information to low-literacy commu-
\nnities.Available free of charge,each book fo-
\ncuses on a single subject, such as a particular
\ndisease \u2013 or a healthcare assistance program.
\nThis book explains clinical trials to potential
\nparticipants including goals, possible risks,
\nand patient rights and responsibilities.
\nHealthcare practitioners request the free
\n\u201cSpeaking Books\u201dand give them to their pa-
\ntients. Patients considering participation can
\ntake the books home and share them with
\nfriends, family, and community members.
\nAfter spending a week with the book in
\ntheir homes, community members who had
\nnever taken part in a clinical trial shared
\ntheir experiences:
\n\u201cI like the explanation about clinical tri-\u2022
\nals. It is clear and understandable\u201d
\n\u201cI liked the voice… and all the informa-\u2022
\ntion given. It was really great\u201d
\n\u201cI liked how the talking book encourages\u2022
\nreading\u201d
\nDr. Brian M. Julius (bj@booksofhope.com)
\nHindi \u2013 English bilingual \u201cSpeaking Book\u201d
\nMs. Yoonsun Park
\nMs. Anne-Marie Delage
\nwma 8.indd 147wma 8.indd 147 12\/4\/09 4:23:35 PM12\/4\/09 4:23:35 PM
\n148
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nDong-Chun Shin
\nIntroduction
\nThe world\u2019s greatest health concern in the
\n21st
\ncentury is global warming. Warnings
\nagainst the dangers of future climate change
\nare heralded by every newspaper. Average
\nglobal temperature has increased by 0.74 \u00b0C
\nwith a span of 0.56-0.92 \u00b0C over the past
\ncentury, which has resulted in numerous
\nproblems such as increasing rainfall, melt-
\ning glaciers and \ufb02ooding of low-lying areas
\naround the equator. Decrease in crop yield
\nand higher frequency of nature disasters
\nand communicable diseases also threaten
\nmankind. Many countries have tried to re-
\nduce greenhouse gas emission. Even the US
\nHouse of Representatives drafted a clean
\nenergy legislation called the American
\nClean Energy and Security Act, also known
\nas the \u201cWaxman-Markey Bill\u201d on 26, June
\n2009.
\nClimate change threatens to stall economic
\ndevelopment in Asia and Oceania and en-
\ndangers the health and safety of its vast
\npopulation. Climate change causes temper-
\nature, wind and precipitation to vary, with
\nprofound e\ufb00ects on natural systems. This,
\nin turn, has e\ufb00ects on the health, safety and
\nlivelihoods of people \u2013 especially the dis-
\nadvantaged. Nowhere in the world are as
\nmany people a\ufb00ected by climate change as
\nin Asia and Oceania.
\nClimate change will intensify typhoons,
\ndroughts, heat waves, landslides and other
\nnatural hazards in a region which already
\nsu\ufb00ers from more natural disasters than any
\nother part of the world. During the last de-
\ncade,Bangladesh,India,the Philippines and
\nViet Nam have topped the list of countries
\nfacing serious climate risks. The cumulative
\nlosses due to natural disasters have averaged
\nnearly $20 billion over the same period.
\nFuture warming will cause an increase of
\nsea-levels, warmer ocean temperatures and
\nhigher sea water acidity, leading to greater
\ncoastal erosion and threatening the health
\nof marine ecosystems.
\nClimate Change in Asia and Oceania
\nAsia is the most populous continent in the
\nworld. Marine and coastal ecosystems in
\nAsia are likely to be a\ufb00ected by sea-level ris-
\nes and temperature increases.Future climate
\nchange is likely to a\ufb00ect agriculture and ag-
\ngravate the risk of food and water short-
\nages by amplifying climate variability and
\naccelerating glaciers melting [1]. From the
\nHimalayas, which provide water to a billion
\npeople, to the coastal areas of Bangladesh,
\nSouth Asian countries must prepare against
\nthe impact of global warming. A moder-
\nate rise in temperatures could cause seri-
\nous changes to the environment in South
\nAsia [2]. A large number of deaths from
\nheat waves have been reported in India [3]
\nand Siberia [4]. An endemic morbidity and
\nmortality of diarrheal disease, closely asso-
\nciated with poverty and hygiene, also have
\nbeen reported in South Asia [5].
\nFigure 1.
\nHimalaya Glacier and Asian rivers
\nMost Asian countries have already realised
\ntheir own risk related with climate change,
\nbut not all of them are prepared against
\nit. Some leading countries have developed
\ne\ufb00orts for reducing greenhouse gas emis-
\nsions and have even started to support other
\ncountries in Asia. For example, CarboEast-
\nAsia (China, Japan and Korea) copes with
\nclimate change by developing measure-
\nments, theory and modelling that helps
\nquantify and understand the global warm-
\ning mechanism [6].
\nIn December 1993, Korea joined the
\nUNFCCC.It is currently classi\ufb01ed as a non-
\nAnnex I (industrialized countries) and II
\n(developed countries) country and therefore,
\nhas no obligation to reduce emissions during
\nthe \ufb01rst commitment period (2008-2012).
\nHowever, after the \ufb01rst commitment period,
\nthe international demand for Korean\u2019s par-
\nticipation in the international e\ufb00orts to tack-
\nle global warming will be even stronger [7].
\nChina is also a developing country and
\ndoes not have an international obligation to
\ncut emissions. But, in the 2007 G8 meet-
\ning in Germany, the Chinese government
\nunveiled its \ufb01rst national plan for climate
\nchange. This plan contained China’s aim to
\nreduce energy use by a \ufb01fth before 2010 and
\nto increase the amount of renewable energy
\nproduction [8].
\nImpact of climate change in Asia and Oceania
\nregion and challenges ahead
\nwma 8.indd 148wma 8.indd 148 12\/4\/09 4:23:35 PM12\/4\/09 4:23:35 PM
\n149
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nJapan has provided training in developing
\ncountries and has promoted monitoring,
\nanalysing and interpreting of observational
\ndata, as well as sharing climate change data
\nin the Asia-Paci\ufb01c region with other gov-
\nernments [9].
\nThe Oceania region ranges from the lush
\ntropical rainforests of Indonesia to the inte-
\nrior deserts of Australia. Climate is strongly
\nin\ufb02uenced by the ocean and El Ni\u00f1o. Small
\nisland states and the coastal regions \u2013 where
\nmost of the population is concentrated \u2013 are
\nhighlyvulnerabletoincreasingcoastal\ufb02ood-
\ning and erosion due to a rising sea level.The
\nrecent increase in ocean temperatures has
\ndamaged many of the region\u2019s spectacular
\ncoral reefs, one of the world\u2019s most diverse
\necosystems.
\nExtreme temperatures have contributed to
\nthe deaths of some 1100 people aged over 65
\neach year in 10 Australian and 2 New Zea-
\nland cities.The projected rise in temperature
\nfor the next 50 years is predicted to result in
\na substantial increase in heat-related deaths
\nin all the cities studied, in the absence of
\nadaptive measures. Temperate cities show
\nhigher rates of deaths due to heat than trop-
\nical cities. Global warming is projected to
\nreduce the number of cold winter days and
\na few cities may actually experience fewer
\nannual deaths in the short-term due to this.
\nIn the medium to long-term,however,these
\nhealth gains would be greatly outweighed
\nby additional heat-related deaths.
\nExtreme rainfall events are expected to in-
\ncrease in almost all Australian states and
\nterritories by 2020. Annual \ufb02ood-related
\ndeaths and injuries may also increase by
\nup to 240 %, depending on the region. The
\nsituation by 2050 is mixed. As the climate
\nchanges, parts of Australia are projected to
\nhave substantially less rainfall, and in these
\nplaces the risk of \ufb02ooding is predicted to
\nlessen. Most parts of the country, however,
\nare still predicted to be at far greater risk
\nof \ufb02ood-related deaths and injuries than at
\npresent.
\nThe \u201cmalaria receptive zone\u201d may expand
\nsouthwards, to include regional towns like
\nRockhampton, Gladstone and Bundaberg.
\nHowever, in the foreseeable future malaria
\nitself is not a direct threat to Australia under
\nclimate change, as long as a high priority is
\nplaced on prevention via the maintenance
\nand extension of public health and local
\ngovernment infrastructure.
\nWarmer temperatures and stronger rainfall
\nvariability are predicted to increase the in-
\ntensity and frequency of food-borne and
\nwater-borne diseases. Successful adaptation
\nto the projected climate changes will require
\nthe upgrading of sewerage systems and safer
\nfood production and storage processes. Due
\nto their poor living conditions and limited
\naccess to public services, Aboriginal people
\nliving in remote arid communities will be
\nexposed to increased risk. The annual num-
\nber of diarrheal admissions among Aborigi-
\nnal children living in the central Australian
\nregion is predicted to increase by 10 % by
\n2050.
\nThe number of people exposed to \ufb02ood-
\ning due to sea-level rise in Australia and
\nNew Zealand is predicted to approximately
\ndouble in the next 50 years, although abso-
\nlute numbers would still be low. For the rest
\nof the Paci\ufb01c region, however, the number
\nof people who experience \ufb02ooding by the
\n2050s could increase by a factor of more
\nthan 50 to between 60,000 and 90,000 in an
\naverage year. As well as the impact of \ufb02ood-
\ning on settlements, the impact of sea-level
\nrise on freshwater quality and quantity is
\nlikely to be a critical threat to Paci\ufb01c Island
\nhealth and welfare.
\nThe \ufb01rst detectable changes in human
\nhealth may well be alterations in the geo-
\ngraphic range and seasonality of certain
\nvector-borne infectious diseases. Summer-
\ntime food-borne infections (e.g. salmo-
\nnellosis) may show longer-lasting annual
\npeaks. The public health consequences of
\nthe disturbance of natural and managed
\nfood-producing systems, of rising sea-levels
\nand of population displacement for reasons
\nof physical hazard, land loss, economic dis-
\nruption and civil strife may not become evi-
\ndent for several decades.
\nReducing the total level of greenhouse gas
\nemissions is a primary preventive health
\nstrategy.Because the current levels of green-
\nhouse gases will continue to in\ufb02uence the
\nclimate over the next several hundred years,
\nTable 1. General statistics in Asia by year 2005
\n* Sources
\nArea\/Population: UN Statistics Division \/\u2022 \u201cwww.nationmaster.com\u201d
\nAverage temperature\/Annual precipitation: World Meteorological Organization\u2022
\nCO\u2022 2
\nemission: UN Statistics Division \/ IPCC AR4 report
\nGross National Income: The World Bank\u2022
\nwma 8.indd 149wma 8.indd 149 12\/4\/09 4:23:36 PM12\/4\/09 4:23:36 PM
\n150
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\ngreater research e\ufb00ort must be devoted to
\nhow humans can adapt to these changes.
\nThe health impacts of climate change will
\nbe strongly in\ufb02uenced by the extent and rate
\nof warming, as well as local environmental
\nconditions and social behaviours and the
\nrange of social, technological, institutional,
\nand behavioural adaptations taken to reduce
\nthe threats.
\nSome individuals and communities will
\nlack the resources required for adequate
\nresponse. Remote Aboriginal communi-
\nties, low income households, the elderly and
\nmany Paci\ufb01c Island countries will be most
\nvulnerable [14].
\nClimate Change and Human Health
\nWe can see some of the health e\ufb00ects that
\nmay lie ahead if extreme weather events
\ncontinue to increase. Heat waves like the
\none that hit Chicago in 1995, killing some
\n750 people and hospitalising thousands,
\nhave become more common. Hot, humid
\nnights, which have become more frequent
\nwith global warming, magnify the e\ufb00ects.
\nThe 2003 European heat wave \u2013 involving
\ntemperatures that were 18\u00b0F (10\u00b0C) above
\nthe 30-year average,with no relief at night \u2013
\nkilled 21,000 to 35,000 people in \ufb01ve coun-
\ntries.
\nBut even more subtle, gradual climatic
\nchange can quietly damage human health.
\nDuring the past two decades,the prevalence
\nof asthma in the United States has qua-
\ndrupled, in part because of climate-related
\nfactors. For Caribbean islanders, respiratory
\nirritants are carried by dust clouds from
\nAfrica’s expanding deserts and then swept
\nacross the Atlantic by trade winds accelerat-
\ned by the widening pressure gradients over
\nwarming oceans. Increased levels of plant
\npollen and soil fungi may also be involved.
\nWhen ragweed grows in conditions with
\ntwice the ambient level of carbon dioxide,
\nthe stalks sprout 10 percent taller and pro-
\nduce 60 percent more pollen. Elevated car-
\nbon dioxide levels also promote the growth
\nand sporulation of some soil fungi. Diesel
\nparticles deliver these aeroallergens deeper
\ninto our alveoli and present them to im-
\nmune cells along the way.
\nMosquitoes, which can carry many diseases,
\nare very sensitive to temperature changes.
\nWarming of their environment \u2013 within
\ntheir viable range \u2013 boosts their rates of re-
\nproduction and the number of blood meals
\nthey take, prolongs their breeding season,
\nand shortens the maturation period for the
\nmicrobes they disperse. In highland regions,
\nas permafrost thaws and glaciers retreat,
\nmosquitoes and plant communities are mi-
\ngrating to higher ground.
\nExtremely wet weather may bring its own
\nshare of ills. Floods are frequently followed
\nby disease clusters: downpours can drive
\nrodents from burrows, deposit mosquito-
\nbreeding sites, foster fungus growth in
\nhouses, and \ufb02ush pathogens, nutrients, and
\nchemicals into waterways. Milwaukee’s
\ncryptosporidium outbreak, for instance, ac-
\ncompanied the 1993 \ufb02oods of the Missis-
\nsippi River and norovirus and toxins spread
\nin Katrina’s wake. Major coastal storms
\ncan also trigger harmful algal blooms (\u201cred
\ntides\u201d), which can be toxic, help to create
\nhypoxic \u201cdead zones\u201d in gulfs and bays and
\nharbour pathogens.
\nProlonged droughts, for their part, can
\nweaken trees’ defences against infestations
\nand promote wild\ufb01res, which can cause in-
\njuries, burns, respiratory illness, and deaths.
\nShifting weather patterns are jeopardising
\nwater quality and quantity in many coun-
\ntries, where groundwater systems are al-
\nready being overdrawn and underfed. Most
\nmontane ice \ufb01elds are predicted to disap-
\npear during this century \u2013 removing a pri-
\nmary source of water for humans, livestock,
\nand agriculture in some parts of the world.
\nAnd many habitats are not faring well.
\nCoastal zones, for example, are in trouble:
\ncoral reefs are su\ufb00ering from warming-
\ninduced \u00abbleaching,\u00bb excess waste, physical
\ndamage, over\ufb01shing, and fungal and bacte-
\nrial diseases. Reefs provide a bu\ufb00er against
\nstorms and groundwater salinisation and
\no\ufb00er protection for \ufb01sh,the primary protein
\nsource for many inhabitants of island na-
\ntions. One reef resident, the cone snail, pro-
\nduces a peptide that is 1000 times as potent
\nas morphine and that is not addictive. We
\nmay never know what other potential treat-
\nments will be lost as reefs deteriorate.
\nClimate Change and In\ufb02uenza
\nClimate change would almost certainly al-
\nter bird migration, in\ufb02uence the AI virus
\ntransmission cycle and directly a\ufb00ect virus
\nsurvival outside the host [12].Some say that
\nTable 2. General statistics in Oceania by year 2005
\n* Sources
\nArea\/Population: UN Statistics Division \/\u2022 \u201cwww.nationmaster.com\u201d
\nAverage temperature\/Annual precipitation: World Meteorological Organization\u2022
\nCO\u2022 2
\nemission: UN Statistics Division \/ IPCC AR4 report
\nGross National Income: The World Bank\u2022
\nwma 8.indd 150wma 8.indd 150 12\/4\/09 4:23:36 PM12\/4\/09 4:23:36 PM
\n151
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nswine \ufb02u (H1N1) and climate change are
\ninextricably related [13]. Tropical Africa
\nis not the only area where deadly viruses
\nhave recently emerged. In South-East Asia,
\nsevere epidemics of dengue hemorrhagic
\nfever started in 1954 and \ufb02u pandemics
\nhave originated from China such as the
\nAsian \ufb02u (H2N2) in 1957, the Hong-Kong
\n\ufb02u (H3N2) in 1968, and the Russian \ufb02u
\n(H1N1) in 1977. However, it is especially
\nduring the last ten years that very danger-
\nous viruses for mankind have repeatedly de-
\nveloped in Asia.The evolution of these viral
\ndiseases was probably not directly a\ufb00ected
\nby climate change, but we cannot simply
\npass over this pattern.
\nMitigation: Black Carbon
\nThe Annex I & II Parties and other coun-
\ntries that have more developed technology
\nand research circumstances must co-operate
\nwith developing countries to reduce the
\ndamage from climate change. We all need
\nto focus on the newly emerging issues, such
\nas new greenhouse gas pollutants other than
\nclassic sources and pandemic health e\ufb00ects
\nampli\ufb01ed by climate change.
\nGreenhouse causing gases in the Earth’s
\natmosphere are SO2
\n, water vapour, (about
\n80%) and carbon dioxide. But nowadays,
\ngreater interest is being directed towards
\nblack carbon and aerosol. It is reported that
\na strong radiative heating e\ufb00ect was caused
\nwhen black carbon (BC) was mixed in at-
\nmospheric aerosols [11]. And black carbon
\nis estimated to be the second largest con-
\ntributor to global warming following car-
\nbon dioxide. Today, the majority of black
\ncarbon emissions from developing coun-
\ntries in South Asia are from biofuel cook-
\ning, whereas in East Asia, coal combustion
\nfor residential and industrial uses plays a
\nlarger role. Regulating black carbon emis-
\nsions from diesel engines or local emission
\nsources presents a signi\ufb01cant opportunity to
\nreduce black carbon\u2019s global warming im-
\npact.
\nFuture Adaptation
\nConsidering the magnitude of potential
\nimpacts, greater e\ufb00orts need to be devoted
\nto building climate resilience in sectors and
\nclimate-proo\ufb01ng infrastructure of at-risk
\nareas. The impact of climate change may
\nundermine the long-term development of
\nmany countries. The poorest people in the
\npoorest countries are likely to su\ufb00er most.
\nClimate change is not the only issue on the
\nglobal agenda, but it requires our greatest
\npersonal and regional attention and com-
\nmitment.
\nReferences
\nClimate Change 2007: impacts, adaptation and vulner-1.
\nability : working group II to the 4th assessment report of
\nthe intergovernmental panel on climate change. [Docu-
\nment on the Internet] [cited 2009 October 7].Available
\nfrom: http:\/\/www.ipcc.ch\/publications_and_data\/publi-
\ncations_ipcc_fourth_assessment_report_wg2_report_im-
\npacts_adaptation_and_vulnerability.htm.
\nUnderstanding and responding to climate change in de-2.
\nveloping Asia. Asian Development Bank, 2009. [Docu-
\nment on the Internet] [cited 2009 October 7]. Available
\nfrom: http:\/\/www.adb.org\/Documents\/Books\/Climate-
\nChange-Dev-Asia\/default.asp.
\nLal M. Global climate change: India\u2019s monsoon and its3.
\nvariability: \ufb01nal report under \u201cCountry Studies Vulner-
\nability and Adaptation\u201d. 2002 September. 58 p.
\nZolotov PA. Human physiological functions and public4.
\nhealth ultra-continental climate. In: Proceedings of intl.
\nconf. on Climate Change and Public Health; 2004 Apr
\n5-6; Moscow, Russia. Moscow: Russian Academy of Sci-
\nences, 2004. p. 212-22.
\nCheckley W, Epstein LD, Gilman RH, Figueroa D, Cama5.
\nRI,Patz JA,Black RE.E\ufb00ect of El Ni\u00f1o and ambient tem-
\nperature on hospital admissions for diarrhoeal diseases in
\nPeruvian children. Lancet. 2000 Feb 5; 355 (9202): 442-
\n50.
\nA3 Foresight Program CarboEastAsia [homepage on the6.
\nInternet] [cited 2009 October 7]. Available from: http:\/\/
\nwww.carboeastasia.org.
\nClimate Change Information website [homepage on the7.
\nInternet] [cited 2009 October 7]. Available from: http:\/\/
\nwww.gihoo.or.kr.
\nNational Development and Reform Commision (NDRC)8.
\n[homepage on the Internet] [cited 2009 October 7].Avail-
\nable from: http:\/\/en.ndrc.gov.cn.
\nMinistry of Foreign A\ufb00airs of Japan [homepage on the9.
\nInternet] [cited 2009 October 7]. Available from: http:\/\/
\nwww.mofa.go.jp.
\nClimate Change 2007: synthesis report: summary for10.
\npolicymakers: IPCC Plenary XXVII; 2007 Nov 12-
\n17;Valencia, Spain [document on the Internet] [cited
\n2009 October 7]. Available from http:\/\/www.ipcc.ch\/pdf\/
\nassessment-report\/ar4\/syr\/ar4_syr_spm.pdf.
\nJacobson MZ. Strong radiative heating due to the mixing11.
\nstate of black carbon in atmospheric aerosols. Nature. 2001
\nFeb 8; 409 (6821): 695-7.
\nGilbert M, Slingenbergh J, Xiao X. Climate change and12.
\navian in\ufb02uenza. Rev Sci Tech. 2008 Aug;27(2):459-66.
\nMawle A. Swine \ufb02u and climate change are inextricably13.
\nrelated. Voice of the public health movement [document
\non the Internet] [cited 2009 October 7]. Available from
\nhttp:\/\/www.ukpha.org.uk\/news-and-press\/press-releases.
\naspx.
\nMcMichael A, Woodru\ufb00 R, Whetton P, Hennessy K,14.
\nNicholls N, Hales S, Woodward A, Kjellstrom T. Human
\nhealth and climate change in Oceania : a risk assessment:
\n2002. [Document on the Internet] [cited 2009 October
\n7]. Available from http:\/\/nceph.anu.edu.au\/Sta\ufb00_Stu-
\ndents\/Sta\ufb00_pdf_papers\/Rosalie_Woodru\ufb00\/Health_Cli-
\nmate_Change_Impact_Assessment_2002.pdf.
\nEpstein PR. Climate change and human health. N Engl15.
\nJ Med. 2005 Oct 6; 353 (14): 1433-6. Available from :
\nhttp:\/\/content.nejm.org\/cgi\/content\/full\/353\/14\/1433.
\nDong-Chun Shin, MD, PhD
\nChair, Executive Committee
\nof International A\ufb00airs,
\nKorean Medical Association
\nProfessor, Dept. of Preventive Medicine,
\nYonsei University College of Medicine
\nClimate
\nchange
\nEnviron-
\nmental
\nconditions
\nSocial conditions
\n(\u201eupstream\u201ddeterminants
\nof health)
\nDirect Exposure
\n(temperature
\nprecipitation,
\nsea level rise,
\nextreme events)
\nIndirect Exposure
\n(change in water, air
\nand food quality, vector
\necology, ecosystems,
\nagriculture, industry
\nand settlements)
\nSocial &
\neconomic
\ndisruption
\nHealth
\nSystem
\nconditions
\nHealth
\nimpacts
\nSource: IPCC 2007
\n*
\nModifying in\ufb02uence*
\nFigure 2. Climate Change and Health Impact Pathways
\nwma 8.indd 151wma 8.indd 151 12\/4\/09 4:23:36 PM12\/4\/09 4:23:36 PM
\n152
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nAs the rates of lifestyle and stress-related
\nillness increase worldwide, the Anthropedia
\nFoundation (APF) advances the Science of
\nWell-Being and o\ufb00ers solutions to foster
\nhealth and happiness that are adapted to
\nthe 21st century. APF is a non-pro\ufb01t orga-
\nnization that promotes well-being through
\nhealth and education initiatives, and is ded-
\nicated to empowering individuals of all ages
\nto reach their fullest potential for physical,
\nmental, and social well-being. Anthrope-
\ndia is led by an institute of professionals
\nfrom the \ufb01elds of medicine, psychology, art,
\neducation, and public health. Members of
\nthe Anthropedia Institute examine e\ufb00ec-
\ntive and scienti\ufb01cally based practices from
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\nInstitute, the foundation creates resources
\nthat teach people ways to cultivate healthy
\nlifestyles, psychological resilience, character
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\nto achieving and sustaining well-being.
\nExisting biomedical approaches to illness
\nprevention and treatment often fail to ad-
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\nperson\u2019s body, mind, and social context [1, 2,
\n3]. Furthermore, healthcare systems world-
\nwide are limited in their ability to provide
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\nprofessionals with tools to apply a compre-
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\nas a complement to therapy. Anthropedia\u2019s
\nKnow Yourself series is a step-by-step course
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\nto mental and physical well-being that is
\nbased on the latest research in psychiatry,
\npsychology, neuroscience, and mind-body
\nhealth, including studies on self-aware-
\nness, personality, positive thought, and life
\nsatisfaction. Speci\ufb01cally, the series builds on
\nthe research and clinical work of C. Robert
\nCloninger, MD [4]. Supplemental materi-
\nals for each part of Know Yourself, including
\nsummaries and exercises are also available
\non Anthropedia\u2019s website (www.anthrope-
\ndia.org).The Know Yourself series is received
\nwell by individuals and is successfully used
\nin schools, criminal rehabilitation, medical
\ntreatments, and therapy settings.
\nAPF also develops and provides evalua-
\ntion tools for professionals and individu-
\nals to gain insight into a person\u2019s sense of
\nwell-being, emotional outlook, and higher
\ncognitive processes via temperament and
\ncharacter measurements, as well as through
\npositive and negative emotion inventories,
\nand life satisfaction scales. The presence of
\npositive emotions,as well as a persons\u2019ability
\nto be resourceful, purposeful, goal directed,
\ncontrolled, and aware of one\u2019s psychological
\nattachments and dependences, are strong
\npositive predictors of health [4]. The Tem-
\nperament and Character Inventory (TCI) is
\nthe most advanced and comprehensive test
\nof personality available to date. Designed by
\nC. Robert Cloninger MD, the TCI identi-
\n\ufb01es the intensity of and the relationships
\nbetween the seven basic personality dimen-
\nsions of temperament and character, which
\ninteract to create the unique personality of
\nan individual [5]. The TCI provides a pro-
\n\ufb01le that can help people understand them-
\nselves or another person, such as their child,
\nspouse, friend, or anyone else they know
\nwell. Low Self-Directedness is a strong in-
\ndicator of vulnerability to major depressive
\ndisorders [6]. High Self-Directedness is
\nalso a predictor of rapid and stable response
\nto both antidepressants and CBT [7].
\nWhen a patient or health care professional
\nhas a more complete understanding of a
\nperson\u2019s unique character and temperament
\ntraits, and how they help or hinder a per-
\nAnthropedia\u2019s initiatives to
\npromote person centered care
\nSita Kedia Lauren E. Munsch
\nwma 8.indd 152wma 8.indd 152 12\/4\/09 4:23:37 PM12\/4\/09 4:23:37 PM
\n153
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nson\u2019s experience of well-being, they can take
\na more personalized and targeted approach
\nto treatment. APF has worked to make this
\ntest available through our website for both
\nindividual and professional use,as well as for
\nclinicians interested in using the test for re-
\nsearch.The TCI is a validated assessment in
\nboth adolescents and adults o\ufb00ered in sev-
\neral languages [8, 9]. Quantitative scoring
\nof the pro\ufb01les allows comparison to other
\npeople. It also allows for predictions about
\nsituations that are di\ufb03cult or stressful, and
\nways of dealing with those di\ufb03culties.
\nAnthropedia\u2019s initiatives promote person-
\ncentered care by providing professionals
\nwith tools to learn more about their pa-
\ntients, and by increasing the availability
\nof educational resources that teach ways
\nto develop and sustain physical and men-
\ntal health. For more information about
\nthe Anthropedia Foundation please visit
\nwww.anthropedia.org.
\nReferences:
\n1. Mezzich, J.E. and I.M. Salloum, Clinical complexity and
\nperson-centered integrative diagnosis. World Psychiatry,
\n2008. 7(1): 1-2.
\n2. Mezzich, J.E., Positive health: conceptual place, dimen-
\nsions and implications. Psychopathology, 2005. 38(4):
\n177-9.
\n3. Mezzich, J.E., Psychiatry for the Person: articulating
\nmedicine’s science and humanism.World Psychiatry,2007.
\n6(2): 65-7.
\n4. Herrman, H., R. Moodie, and S. SR, Mental Health Pro-
\nmotion, in International Encyclopedia of Public Health,
\nK. Heggenhougen and S. Quah, Editors. 2008, Anademic
\nPress: San Diego.
\n5. Cloninger,C.R.,Feeling Good:The Science of Well Being.
\n2004, New York: Oxford University Press.
\n6. Farmer,A.,et al.,A sib-pair study of the Temperament and
\nCharacter Inventory scales in major depression. Arch Gen
\nPsychiatry, 2003. 60(5): 490-6.
\n7. Cloninger, C.R., A practical way to diagnosis personality
\ndisorder: a proposal. J Pers Disord, 2000. 14(2): 99-108.
\n8. Cloninger, C.R., D.M. Svrakic, and T.R. Przybeck, A psy-
\nchobiological model of temperament and character. Arch
\nGen Psychiatry, 1993. 50(12): 975-90.
\n9. Lyoo, I.K., et al., The reliability and validity of the junior
\ntemperament and character inventory. Compr Psychiatry,
\n2004. 45(2): 121-8.
\nSita Kedia, MD, Lauren E. Munsch, MD
\nNeil Pakenham-Walsh
\nEvery day, tens of thousands of children,
\nwomen and men die needlessly for want of
\nsimple, low-cost interventions – interven-
\ntions that are often already locally available.
\nA major contributing factor is that the mother,
\nfamily caregiver or health worker does not have
\naccess to the information and knowledge they
\nneed, when they need it, to make appropriate
\ndecisions and save lives. For example:
\n8 in 10 caregivers\u2022 in developing coun-
\ntries do not know the two key symptoms of
\nchildhood pneumonia \u2013 fast and di\ufb03cult
\nbreathing \u2013 which indicate the need for
\nurgent treatment[1] (only 20% of chil-
\ndren with pneumonia receive antibiotics
\ndespite wide availability,and 2 million die
\neach year);
\n4 in 10 mothers\u2022 in India believed that
\nthey should withhold \ufb02uids if their baby
\ndevelops diarrhoea (worldwide, 1.8 mil-
\nlion children die every year from dehy-
\ndration due to diarrhoea)[2];
\n3 in 4 hospital doctors\u2022 responsible for
\nsick children in district hospitals in Ban-
\ngladesh, Dominican Republic, Ethiopia,
\nIndonesia, Philippines, Tanzania, and
\nUganda had poor basic knowledge of com-
\nmon killers such as childhood pneumonia,
\nsevere malnutrition, and sepsis[3];
\n4 in 10 general practitioners\u2022 in Pakistan
\nused tranquilisers as their standard treat-
\nment for hypertension[4].
\nHIFA2015 is a rapidly growing campaign
\nand knowledge network with more than
\n2900 professionals from 150 countries
\nworldwide – healthcare providers, librarians,
\npublishers, researchers, policymakers and
\nothers committed to improve health care.
\nEvery day, members exchange ideas, expe-
\nrience and expertise on ways to enhance
\nthe availability of relevant, reliable health-
\ncare information in low-income countries.
\nLack of access to healthcare information
\nis a hidden killer
\nHealthcare Information For All by 2015
\nBy 2015, people will no longer be dying for lack of knowledge
\nwma 8.indd 153wma 8.indd 153 12\/4\/09 4:23:37 PM12\/4\/09 4:23:37 PM
\n154
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nOur common goal: By 2015, every person
\nworldwide will have access to an informed
\nhealthcare provider \u2013 people will no longer be
\ndying for lack of knowledge.
\nTogether, we are building a specialised web-
\nbased tool,the HIFA2015 Knowledge Base.
\nThis harnesses the collective experience and
\nexpertise of HIFA2015 members as a basis
\nfor a better understanding of the informa-
\ntion needs of di\ufb00erent groups of healthcare
\nprovider in di\ufb00erent contexts, and ways of
\nmeeting those needs. A prototype is avail-
\nable at www.hifa2015.org\/knowledge-base.
\n\u201cHIFA2015 is needed as a global forum
\nwhich provides space for professionals
\nfrom all parts of the world to exchange
\nviews and share knowledge.\u201d Dr Najeeb
\nAl-Shorbaji, Director of Knowledge
\nManagement and Sharing, World Health
\nOrganization, HIFA2015 Foundation
\nDocument 2008
\nThe HIFA2015 Knowledge Base will pro-
\nvide the evidence we need to persuade gov-
\nernments and funding agencies to commit
\npolitical and \ufb01nancial support for diverse
\ne\ufb00orts to improve availability and use of
\nhealthcare information, especially where it
\nis most needed. For too long, the informa-
\ntion needs of healthcare providers in low-
\nincome settings have been neglected.
\nEach year the campaign includes a focus
\non a particular cadre of healthcare provider.
\nIn 2008 the focus was on health students
\n(medical, nursing, midwifery and allied
\nhealth). The HIFA 2009 Challenge is ad-
\ndressing the information needs of nurses
\nand midwives, in collaboration with the
\nBritish Medical Association, Global Al-
\nliance for Nursing and Midwifery, Inter-
\nnational Council of Nurses, International
\nConfederation of Midwives, Royal Col-
\nlege of Midwives, Royal College of Nurses,
\nWHO and others. In 2010 the HIFA2015
\nmembership will turn its attention to Com-
\nmunity Health Workers.
\nThe HIFA2015 members have evolved the
\ncampaign strategy (see Figure).The strategy
\nfocuses on improving interdisciplinary com-
\nmunication (HIFA2015 and CHILD2015
\nforums),understanding (HIFA2015 knowl-
\nedge base) and advocacy (see \ufb01gure, above
\ndotted line). These are the three pillars of
\nthe campaign, providing an enabling envi-
\nronment to support and inform independent
\nhealth information activities by HIFA2015
\nmembers and others.
\nHIFA2015 Forums
\nUnderstanding AdvocacyCommunication
\nHIFA2015 Knowledge Base
\nHealthcare Information for All
\nPromote evidence-
\nbased solutions
\nStrengthened, independent action by
\nHIFA 2015 members and others
\nBetter health information production and delivery world
\nwide, based on:
\n\u2022 better und understanding of information needs
\nand barriers, and how to address them
\n\u2022 more sharing of experience and expertise,
\nand lessons learned
\n\u2022 increased investment in evidence-based,
\ncost-effective solution
\nFigure: The HIFA2015 Campaign strategy and how it assists HIFA2015 members and others to
\nachieve our common goal.
\nUpper section: HIFA2015. All stakeholders are invited to use and contribute to the HIFA2015
\nForums and HIFA2015 Knowledge Base. HIFA2015 members share experience and build an
\nunderstanding of information needs and barriers, and how to meet them.This in turn provides the
\nevidence base needed to identify and promote cost-e\ufb00ective solutions.
\nLower section: Independent action by HIFA2015 members and others. HIFA2015 members rep-
\nresent thousands of organisations that produce, exchange and deliver health information. These
\norganisations bene\ufb01t from their participation in the HIFA2015 Forums and Knowledge-Base.
\nTheir collective impact is increased, leading progressively to Healthcare Information For All by
\n2015, a future where people are no longer dying for lack of knowledge.
\nwma 8.indd 154wma 8.indd 154 12\/4\/09 4:23:37 PM12\/4\/09 4:23:37 PM
\n155
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nHIFA2015 is administered by the Global
\nHealthcare Information Network (www.
\nghi-net.org), assisted by the HIFA2015
\nSteering Group, three Working Groups
\n(HIFA Challenge; Knowledge Base; Fund-
\nraising & Marketing), an International
\nExpert Advisory Panel, and dozens of HI-
\nFA2015 volunteers.
\nOver 70 leading health and development
\norganisations have o\ufb03cially committed to
\nwork together towards the HIFA2015 goal.
\nExamples are shown below.
\nHIFA2015 Supporting Organisations\u2022
\n(2009 funders in bold)
\nAssociation for Health Information and\u2022
\nLibraries in Africa
\nBioMed Central\u2022
\nBook Aid International\u2022
\nBritish Medical Association\u2022
\neIFL\u2022
\nEuropean Association of Senior Hospital\u2022
\nPhysicians
\nEuropean Federation of Salaried Doctors\u2022
\nFaculty of Public Health (UK)\u2022
\nHesperian Foundation\u2022
\nINCLEN\u2022
\nInstitution of Engineering and Technol-\u2022
\nogy
\nInternational Council of Nurses\u2022
\nInternational Federation of Medical Stu-\u2022
\ndents\u2019 Associations
\nInternational Medical Corps\u2022
\nLondon School of Hygiene and Tropical\u2022
\nMedicine
\nMedical Library Association\u2022
\nMedsin\u2022
\nPartnerships in Health Information\u2022
\nRoyal College of Midwives\u2022
\nRoyal College of Nursing\u2022
\nRoyal College of Obstetricians and Gy-\u2022
\nnaecologists
\nStanding Committee of European Doc-\u2022
\ntors
\nTeaching-Aids at Low Cost\u2022
\nTropical Health and Education Trust\u2022
\nWHO African Regional O\ufb03ce Library\u2022
\nOn 19th November 2009, in Maputo, Mo-
\nzambique, we are launching HIFA2015-
\nPortuguese in collaboration with the ePOR-
\nTUGU\u00caSe network, hosted at WHO
\nheadquarters. In 2010 we hope to launch
\nHIF2015 in French, with other languages
\nto follow.
\nThe HIFA2015 campaign strategy is cur-
\nrently only 20% funded, with thanks to the
\nBritish Medical Association, Royal College
\nof Midwives and Royal College of Nursing.
\nThis means that we are far from reaching
\nour full potential. We welcome additional
\no\ufb00ers of funding and in-kind support to
\nenable us to achieve our goal.
\nWe also invite all readers to join the cam-
\npaign as individuals. To \ufb01nd out more, and
\nto contribute your expertise to our e\ufb00orts,
\nplease visit our website: www.hifa2015.org.
\nReferences
\n1. Wardlaw T et al. Pneumonia: the leading killer of
\nchildren. Lancet 2006;368:1048-50
\n2. Wadhwani N. An integrated approach to reduce
\nchildhood mortality and morbidity due to diarrhoea
\nand dehydration. http:\/\/hetv.org\/india\/mh\/plan\/
\nhetvplan.pdf
\n3. Nolan T et al. Quality of hospital care for seri-
\nously ill children in less-developed countries. Lancet
\n2001;357(9250):106-10
\n4. Jafar TH et al. General practitioners\u2019 approach to
\nhypertension in urban Pakistan: disturbing trends in
\npractice. Circulation 2005;111(10):1278-83.
\nDr. Neil Pakenham-Walsh,
\nHIFA2015 Coordinator
\nThe Medical Women\u2019s International As-
\nsociation has been in existence since 1919,
\nwhen it was founded in New York city by a
\ngroup of medical women from around the
\nworld. Dr. Esther Pohl Lovejoy was its \ufb01rst
\npresident.
\nAs a non-political, non-sectarian and non-
\npro\ufb01t association of medical women repre-
\nsenting women physicians from all \ufb01ve con-
\ntinents, the Medical Women\u2019s International
\nAssociation\u2019s objectives are:
\nTo o\ufb00er women in medicine the oppor-\u2022
\ntunity to meet, network and discuss issues
\nconcerning the health and well-being of
\nhumanity.
\nTo promote the general interest of women\u2022
\nin medicine by developing cooperation,
\nfriendship and understanding without
\nregard to race, religion or political views.
\nTo overcome gender-related di\ufb00erences\u2022
\nin health and healthcare between women
\nand men, girls and boys throughout the
\nworld.
\nThe Medical Women\u2019s International
\nAssociation (MWIA)
\nShelley Ross
\nwma 8.indd 155wma 8.indd 155 12\/4\/09 4:23:38 PM12\/4\/09 4:23:38 PM
\n156
\nInternational, Regional and NMA news
\nTo overcome gender-related inequalities\u2022
\nwithin the medical profession.
\nTo promote health for all throughout the\u2022
\nworld with particular interest in women,
\nhealth and development.
\nThe Association is composed of eight geo-
\ngraphical regions:Northern Europe,Central
\nEurope, Southern Europe, North America,
\nLatin America, Near East and Africa, Cen-
\ntral Asia and Western Paci\ufb01c. Each region
\nis represented on the Executive Committee
\nby its regional Vice-President. The Presi-
\ndent, President-Elect, Treasurer, Secretary-
\nGeneral and the Vice-Presidents are elected
\nby the members for a term of three years.
\nThe MWIA Secretariat in Burnaby, Cana-
\nda,coordinates the interests and activities of
\nthe Organization.
\nDr. Atsuko Heshiki is the current President
\nand Dr. Shelley Ross is the Secretary-Gen-
\neral.
\nEvery three years, the MWIA holds an in-
\nternational meeting. The last meeting was in
\nAccra,Ghana,in 2007 and the next meeting
\nwill be in Munster, Germany, in July, 2010.
\nThe theme of the 2010 conference will be
\n\u201cGlobalisation in Medicine – Challenges and
\nOpportunities,\u201d with a focus on four sub-
\ntopics: Gender Strategies, Addiction, Epi-
\ndemic Plagues and Nutrition. Please visit
\nthe website at www.mwia2010.net and
\nplan to join us.
\nMWIA has advocated on numerous for
\ngender and health issues for many years.
\nMWIA wrote a Training Manual on Gen-
\nder Mainstreaming in Health for physicians
\nand helped the World Health Organiza-
\ntion Department of Gender Women and
\nHealth develop their gender training mod-
\nules. MWIA\u2019s manual can be accessed on
\nthe webpage at www.mwia.net. Numer-
\nous workshops on gender and health have
\nbeen held at regional and national meetings.
\nMWIA has also written a Training Manual
\non Adolescent Sexuality, which can be ac-
\ncessed on the website.
\nMWIA has been on the forefront of work
\non female genital mutilation,with one of our
\nmembers from Sierra Leone having written
\na book back in the 1980\u2019s on the topic and
\nappearing in the Danish \ufb01lm entitled The
\nSilent Pain. MWIA participated recently in
\na large meeting organized by the WHO on
\nthis subject in Kenya.
\nIn many countries, women physicians have
\nbeen instrumental in developing govern-
\nment-funded programs for prevention
\nof cervical cancer by the use of the HPV
\nvaccines, early detection and treatment.
\nMWIA was represented in October in Lu-
\nsaka, Zambia, at a meeting of cervical can-
\ncer prevention and treatment strategies.
\nMWIA has recently partnered with the
\nInternational Osteoporosis Foundation
\nto make women aware that osteoporosis
\nis a silent killer. MWIA participated in a
\nsurvey conducted in Europe, Mexico and
\nCanada to assess the public\u2019s perception
\nof the osteoporotic woman. Much to the
\nsurprise of physicians, this is no longer as-
\nsumed to be a disease of the old and frail,
\nbut one that a\ufb00ects women who are active
\nand who want to be in charge of their lives.
\nA second survey was done to see if mothers
\nand daughters were aware of the dangers of
\nosteoporosis.
\nWith an increasingly large proportion of
\nwomen in medical schools, MWIA has
\nsought to ensure the training of women
\nin leadership roles to ensure that medicine
\ncontinues to have signi\ufb01cant in\ufb02uence on
\npolicy decisions in the health \ufb01eld. MWIA
\nfeels that medicine must not be allowed to
\nbecome a Pink Collar Profession.
\nMWIA is active in primary health care de-
\nlivery, with several of its members on the
\nfront lines of delivering health care in vari-
\nous areas around the world.
\nIn Calcutta, the West Bengal Branch of
\nMWIA runs a Mission Hospital. Dona-
\ntions are always welcome, as the physicians
\nvolunteer their time at the hospital.
\nMWIA is pleased to attend the annual
\nmeetings of the World Medical Association
\nas an observer. MWIA would be pleased
\nto partner with the World Medical Associa-
\ntion in projects of mutual interest.
\nShelley Ross, MD, Secretary-General, MWIA
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\n157
\nInternational, Regional and NMA news
\nIntroduction
\nThe declaration of a national health emer-
\ngency in any country in the world is a de-
\ncision that is adopted by the authorities in
\nthe face of unexpected or unusual events
\nthat produce a situation that is considered
\na public health emergency [1] of national or
\ninternational concern. These diverse events
\ngo from natural disasters,armed con\ufb02icts,to
\ndisease outbreaks or potentially pathogenic
\nevents that constitute a threat to the public
\nhealth of a country and of other States.
\nThis type of declaration is usually accom-
\npanied by decisions of a legal and admin-
\nistrative nature, that allow the authorities
\nto adopt dispositions that, amongst other
\nthings, temporarily restrict liberties, as in
\nthe case of quarantines, and\/or temporar-
\nily eliminate certain requisites demanded of
\nthe national public administrations for the
\nacquisition of the goods and services neces-
\nsary to protect the health of the population
\na\ufb00ected by the events that produced the
\nemergency.
\nThe case we are concerned with, the decla-
\nration of emergency recently announced by
\nthe President of the Bolivarian Republic of
\nVenezuela, Hugo Chavez [2], is sui generis.
\nOn one hand, it is not the result of an un-
\nexpected or unusual event of a kind that is
\nfrequently invoked to adopt such a decision;
\non the other hand, it is not supported by
\nany administrative act. Other kinds of facts
\nare clearly at play here, and revealing their
\nmeaning is the purpose of this article,which
\ndraws heavily on an open letter addressed to
\nPresident Chavez by Venezuelan ex-Minis-
\nters of Health Blas Bruni Celli, Jose Felix
\nOletta, Rafael Orihuela, Pablo Pulido and
\nCarlos Walter.
\nThe announcement of the emergency dec-
\nlaration and a question that warrants a
\ndi\ufb00erent response
\n\u201cIn the social area, we have an emergency at
\nthis time: health. Let us state that we are all in
\na state of emergency (\u2026) Two thousand Barrio
\nAdentro*
\nprimary health care units have been
\nclosed. What happened there? We have all been
\nnegligent\u201d [3]. In this wars was this declara-
\ntion of emergency announced to the Ven-
\nezuelans in an extended Cabinet Meeting
\nheld on 19 September.
\nVenezuelans were surprised that President
\nChavez asked himself \u201cWhat happened
\nthere?\u201d The president seems to have forgot-
\nten that both he and the Cuban Govern-
\nment decided to start a progressive transfer
\nof 4500 Cuban doctors from Venezuela to
\nBolivia by 2006?
\nSince 2007, various studies as well as state-
\nments [4, 5] by the users of the parallel sys-
\ntem of Barrio Adentro, have shown serious
\nproblems in access and quality of services.
\nThis dissatisfaction worsened when the per-
\nsonnel were reduced upon being transferred
\n(without explanation to the Venezuelan
\npeople) to other countries.
\nOf the 8000 buildings scheduled to be built
\nas popular clinics for the Barrio Adentro I
\nnetwork only 2000 have been built, and in
\nthe clinics and attention sites that are op-
\nerative,the tasks of primary health attention
\n* Barrio Adentro (BA) I is the name that the Ven-
\nezuelan government uses to designate a network of
\nprimary attention in a health system that is parallel
\nto the conventional one, that began operating in
\n2003.This system is managed by the Cuban Medi-
\ncal Mission in Venezuela outside the rectory of the
\nMinistry of Health.
\nhad to be limited. In addition, many of the
\n\u201ccooperantes\u201d or Cuban health profession-
\nals or technicians were moved to work at
\nthe \u201cComprehensive Diagnostic Centres\u201d**
\n.
\nVery soon the provision of services was
\ndiscontinuous and irregular, the hours of
\noperation were reduced and many modules
\nclosed their doors. This resulted in discom-
\nfort and frustration among the users and
\namong those that in good faith accepted to
\nget involved in health activities. Finally, the
\ninfrastructure has deteriorated due to lack
\nof maintenance and use.
\nIt seems that President Chavez has not
\nfound out that on January 2008, the Presi-
\ndent of The Metropolitan College of Phy-
\nsicians and representative of the National
\nBolivarian Physicians Front stated: \u201cUnfor-
\ntunately, I have to admit that the wonderful
\nplan of Barrio Adentro has collapsed. The cen-
\ntres have been transformed into simple points
\nof reception. The constitutional goal has not
\nbeen met\u201d [6].
\nThe abandonment of the 2000 Barrio Aden-
\ntro centres to which the President referred
\nis not the only problem this system faces.
\nBarrio Adentro generated a new network
\nwithin the public subsystem, which deep-
\nened and broadened the segmentation and
\nfragmentation of the Venezuelan health sys-
\ntem. These characteristics were some of the
\n\ufb02aws that the Ministry of Health and Social
\nDevelopment (today the Ministry of Popu-
\nlar Power for Health) pointed out about the
\nhealth system existing in the country before
\n1999, and that needed to be corrected [7].
\nFrom a technical, administrative, and man-
\nagerial perspective, Barrio Adentro was
\nnever integrated into the Public Health
\nSystem; on the contrary, it was a critical fac-
\ntor in debilitating the existing system. At
\nthe same time, this system did not achieve
\n** The Comprehensive Diagnostic Centers are part
\nof the medical assistance establishments that con-
\nstitute the network for secondary attention in the
\nparallel health system managed by the Cuban
\nMedical Mission in Venezuela.
\nA strange form of declaring a health
\nemergency:
\nthe case of Venezuela
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\n158
\nInternational, Regional and NMA news
\nthe expected coverage. Even though Bar-
\nrio Adentro increased the coverage of the
\nprimary care level, in practice it duplicated
\nthe existing coverage. The question is, how
\ne\ufb03cient, e\ufb00ective and sustainable has this
\npolicy been? How much has it contributed
\nto reduce the regional inequities in terms of
\ncoverage? In addition, there has never been
\nenough information to evaluate the results,
\nnor transparency in the management and
\nrendering of accounts by those who have led
\nand managed this parallel health system.
\nFor all these reasons, the dismantling of
\nBarrio Adentro is not a \u201chealth emergency\u201d.
\nIt is a fact known for over three years by the
\nPresident, the health authorities and most
\nVenezuelans, a fact that adds to other ills of
\nthe national health system. We regret that
\nthe President accepts it as true only when
\nthe Cuban Government corroborates this
\ninformation. It would have been enough
\nfor him to listen to the Venezuelan people,
\nthose who support him, those who support-
\ned him, and those who do not agree with
\nhis administration, but particularly, to those
\npeople with scant resources that bene\ufb01ted
\nfrom Barrio Adentro and who now feel de-
\nceived and cheated.
\nResponsibilities of the announced
\nabandonment
\nThe responsibility of the President in this
\nmatter is not transferable. He cannot trans-
\nfer blame to the rest of his Cabinet, his
\ngovernors and his mayors. He and he alone
\nis responsible for having delegated to a for-
\neign government, the Cuban Government,
\nthrough the Cuban Medical Mission, the
\nmanagement, supervision and evaluation of
\nthis Parallel Health System.
\nHow can the President explain to the coun-
\ntry that in January 2008 in his Annual Mes-
\nsage to the Nation [8], he stated that 6531
\nprimary health centres were in operation and
\nseven months later, he said 2000 had been
\nabandoned? How can he explain that on 25
\nJanuary 2006, at the height of Barrio Aden-
\ntro, 21 745 Cuban health \u201ccooperantes\u201d were
\nworking, and now with 24 000 \u201ccooperantes\u201d,
\n2000 health centres have been closed?
\nIt is the duty of the President and of the
\nState Controller Agencies to promptly or-
\nder investigations to establish responsibili-
\nties in the neglect and abandonment of Bar-
\nrio Adentro Mission that gave rise to the
\naforementioned declaration of emergency,
\nand what share of the responsibility belongs
\nto the Cuban Government.
\nA wrong answer
\nThe solution is not to bring more Cuban
\ndoctors and students to join those already
\nhere, and who are not showing results in
\nimproving the health care in our Nation.
\nThis will only compound the errors and will
\ndelay the actions to start a systematic ap-
\nproach to improve the Venezuelan health
\ncare system.
\nAfter 10 years in power, President Chavez
\ndoes not seem to realise that the severe
\nproblems of the Venezuelan health care
\nsystem are not limited to the appalling
\nneglect of Barrio Adentro. During this
\ndecade of President Chavez\u2019s government,
\nmany critical health system functions were
\nabandoned, deteriorated or improvised. De-
\nbilitating policies, such as reorienting the
\nobjectives of health campaigns, fragment-
\ning,segmenting and centralising health care
\nservices have produced inequity and exclu-
\nsion, in addition to reducing the coverage
\nand the quality of health care. Never before
\nhas so much money been spent in health,
\nin a disorganised, uncontrollable, and non-
\ntransparent way. And never before have the
\nresults, as measured by health indicators,
\nbeen so poor.
\nFundamental health programs do not show
\nresults, epidemiological surveillance is weak
\nand the capacity to respond to endemic dis-
\neases,epidemics,emerging and re-emerging
\ndiseases is poor and ine\ufb03cient.There are no
\nintegrated plans against new social health
\nthreats such as violence, drug addiction and
\nproblems arising from population explosion.
\nEnvironmental sanitation and the quality
\nof housing is poor. Public hospitals are in
\nruins, Venezuelan mothers are giving birth
\non the street, health information has been
\narbitrarily restricted, all of which weaken
\nthe response capacity of the system. In ad-
\ndition, there is a deliberate policy to destroy
\nthe national health manpower, which has
\nmorally damaged the health workers and
\ntheir families.
\nTo make matters worse, in these past 10
\nyears of President Chavez and his ruling
\nparty in government, despite having an am-
\nple majority in the National Assembly, he
\nhas been unable to foster a broad debate to
\napprove health legislation that would con-
\ntribute to make the right to health an e\ufb00ec-
\ntive right for all Venezuelans.
\nThe critical social reality
\nThe problems related to the health sector af-
\nfect other social policy areas, which in turn
\ndecisively a\ufb00ect the health of the popula-
\ntion and their quality of life.
\nWe are deeply concerned that the political
\nenvironment, the democratic shift towards
\nan authoritarian regime, the fragile social
\npeace, the loss of civil liberties and the re-
\nUnsanitary conditions near an aban-
\ndoned popular clinic in the \u201cEl Hediondito\u201d
\n(The Stinky) neighborhood
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\n159
\nInternational, Regional and NMA news
\ncently approved unconstitutional laws that
\nimpose a national model stamped with the
\npersonal ideology of President Chavez,have
\nall advanced simultaneously with repres-
\nsion and threats to the freedom of speech.
\nThe increasingly unsatis\ufb01ed social demands
\nstimulate con\ufb02ict and have contributed to a
\ndisrupted social dialog, particularly with the
\npublic authorities. These conditions fertil-
\nise the way towards greater poverty, deeper
\ncon\ufb02icts, greater insecurity, more exclusion,
\nless health, fewer opportunities for produc-
\ntive work and less development.
\nThus, it is critical to enable a space for so-
\ncial dialogue in order to reach fundamental
\nagreements. Amongst these, health is a crit-
\nical condition for equitable development,
\nand this value is the best drive in combating
\nexclusion and poverty.
\nThe necessary correction
\nThe Venezuelan health system has serious
\nde\ufb01ciencies. Improving them requires mak-
\ning political decisions sustained by sound
\ntechnical and scienti\ufb01c criteria. This is a
\nhard reality for all Venezuelans, a reality
\nfrom which we cannot escape. A shared
\ndestiny forces us to humbly o\ufb00er wise and
\ntimely responses.
\nThe construction of Venezuela requires
\ntolerance, respect for personal dignity, will-
\ningness to a civilised understanding within
\nour society that cannot continue oscillating
\nbetween extremes of endless and fruitless
\nconfrontation, and indi\ufb00erence or social
\nautism, driven by hatred, resentment and
\nthoughtlessness.There is still time to rectify,
\nto invoke more freedom and more democ-
\nracy, and in this way call on all Venezuelans
\nto share the dream of a more just and better
\ncountry.
\nReferences
\n1. Organizaci\u00f3n Mundial de la Salud (2006). Regla-
\nmento Sanitario Internacional 2005, Ediciones de la
\nOMS, Ginebra, Suiza.
\n2. Ch\u00e1vez declara en emergencia sistema de salud.
\nAvalaible from: http:\/\/www.eud.com\/2009\/09\/19\/
\npol_ava_chavez-declara-en-em_19A2760687.
\nshtml
\n3. Ch\u00e1vez declar\u00f3 en emergencia la salud en Ven-
\nezuela. Avalaible from: http:\/\/www.eluniversal.
\ncom.ve\/2009\/09\/20\/pol_art_chavez-declaro-en-
\nem_1574464.shtml
\n4. Rachel Jones, Hugo Chavez’s health-care programme
\nmisses its goals. Lancet. 2008 Jun; 371( 9629):
\n1988.
\n5. Aceptaci\u00f3n de Barrio Adentro descendi\u00f3 pero
\nsigue alta. Avalaible from: http:\/\/www.guia.com.
\nve\/noti\/50545\/aceptacion-de-barrio-adentro-de-
\nscendio-pero-sigue-alta
\n6. Fernando Bianco: \u00abLa misi\u00f3n Barrio Adentro se
\nvino abajo\u00bb. Avalaible from: http:\/\/www.aporrea.
\norg\/misiones\/n108067.html
\n7. Organizaci\u00f3n Panamericana de la Salud -OPS
\n(2006). Barrio Adentro: derecho a la salud e inclusi\u00f3n
\nsocial en Venezuela, Caracas, Venezuela
\n8. Mensaje Anual a la Naci\u00f3n del Presidente de la
\nRep\u00fablica. Avalaible from: www.abn.info.ve\/
\nmensaje_anual_2009.doc
\nCarlos Walter V.
\nEx-Minister of Health of the
\nBolivarian Republic of Venezuela
\nEx- Institutional Development Advisor of
\nthe Pan American Health Organization
\nDirector of the Centre for Development
\nStudies (CENDES) of the Central
\nUniversity of Venezuela.
\nCaracas. Venezuela
\nPoster on the wall of a fully operating popu-
\nlar clinic with a list of materials requested of
\nthe community:broom; syringes 5cc, 3cc; white
\nsheets of paper; staplers; magic markers; toilet
\npaper; soap powdered and bathroom; Clorox
\nand masking tape.
\nInside an abandoned popular clinic
\nIMA\u2019s Dedication to TB Care
\nIMA started perhaps India\u2019s \ufb01rst Public Pri-
\nvate Mix (PPM) project by joining hands
\nwith the Central TB Division (CTD) to
\naid their Revised National Tuberculosis
\nControl Program (RNTCP) using DOTS
\nfunded by GFATM through our IMA-
\nGFATM-RNTCP-PPM Project and with
\nM\/s. Eli Lilly in a separate project.We have
\nsensitised 25 080 private practitioners (PPs)
\nand trained 3334 of them in providing ser-
\nvices through 1585 DOT centres in various
\nStates of the country. It is planned to be ex-
\ntended to whole of the country soon.
\nIEC material prepared by us has been cir-
\nculated to all the members for awareness of
\nthe disease and its control and cure among
\nthe masses.Spreading awareness among our
\nown members is a regular feature through
\nthe mouthpiece of the Association \u2013 The
\nJournal of IMA. A regular news bulletin
\nhighlighting the activities of the project is
\nbeing mailed to all the members to incul-
\ncate a feeling of belonging in them for con-
\ntrol of the disease.
\nAlso, an Indian Medical Professional Asso-
\nciations\u2019 Coalition Against TB (IMPACT)
\nhas been formed consisting of 10 specialist
\nAssociations other than IMA to promote
\nIndian Medical Association:
\nbrief report of all projects
\nwma 8.indd 159wma 8.indd 159 12\/4\/09 4:23:39 PM12\/4\/09 4:23:39 PM
\n160
\nInternational, Regional and NMA news
\ntreatment of TB by PPs on the guidelines
\nof International Standards for TB Care
\n(ISTC). Endorsements are being received
\nfrom these Associations.
\nStop Sex Selection
\nTaking serious note of the falling sex ratio
\nin the country, IMA has taken sex selection
\nprohibition as one of its most important
\nactivities. Therefore, IMA started a project
\non sex selection \u201cCadre of IMA Volunteers
\nstrengthened and capacities built for medi-
\ncal community to prevent sex selection\u201dwith
\nUNFPA with a goal to prevent sex selection
\nprocedures by stopping the unethical prac-
\ntice of intra-uterine gender determination
\nby members of the medical profession and
\nthereby help to restore the natural child sex
\nratio.
\nA National Mentoring Group to Stop
\nSex Selection consisting of 7 permanent
\nmembers meets quarterly to plan and de-
\nvise strategies for proper implementation
\nof the project. Federation of Obstetric and
\nGynaecological Societies of India (FOGSI)
\nand Indian Radiological and Imaging As-
\nsociation (IRIA) are being involved in this
\nactivity.
\n50 eminent members of the Association
\nknown for their dedication against sex se-
\nlective procedures have been nominated as
\nIMA Ambassadors Against Sex Selection
\n(IAASS).They have been sensitised through
\nworkshops and are working for achieving
\nthe aims of the project. Guidelines have
\nbeen formulated and issued to them for for-
\nmation and working of the Doctors Against
\nSex Selection (DASS) forums at district
\nlevels.
\nThese Ambassadors share their experiences
\non a regular basis through an IMA e-Group.
\nThis helps all of them to plan their strategy
\nand gear up beforehand in their endeavour.
\nContraceptive Updates and
\nSafe Abortion Techniques
\nBeing of the view that India\u2019s current con-
\ntraceptive prevalence rate is just 48.2 %
\nand unprotected sex and contraceptive ac-
\ncidents account for nearly 13% of unwanted
\nand unplanned pregnancies, the IMA, in
\npartnership with the Ministry of Health &
\nFamily Welfare, planned and successfully
\norganised many programmes for sensitisa-
\ntion of the society and also its own members
\nabout the various methods of contraception.
\nMore than 2000 IMA members have been
\ntrained and sensitised to organise sessions in
\ntheir area on the use of contraception. IMA
\nFamily Welfare programme has included
\nemergency contraception and unsafe abor-
\ntions as an integral part of the programme.
\nMany sessions have been organised in vari-
\nous IMA Family Welfare activities.
\nIMA also partnered with UNFPA and has
\norganised a Resource Persons\u2019Workshop on
\n\u201cContraceptive Updates and Safe Abortion
\nTechniques\u201d which was attended by doctors
\nfrom some States of India. These trained
\ndoctors will be conducting total 150 district
\nworkshops in these \ufb01ve States and will fur-
\nther train more doctors. We expect to train
\nnearly 5000 private practitioners in these
\nStates in Family Welfare activities.
\nOne more project by the Ministry of
\nHealth and Family Welfare wherein we will
\nbe organising sensitisation and awareness
\nWorkshop on IMA-GFATM-RNTCP-PPM
\nProject (a project on TB)
\nMaster Trainers Workshop on Avian Flu
\nRegional Workshop on \u201cStop Sex Selection \u2013
\nDoctors can make a di\ufb00erence\u201d
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\n161
\nInternational, Regional and NMA news
\nprogramme on the various modes of avail-
\nable contraceptives and their use in most of
\nthe States is on the anvil. Further we will
\nidentify members who will be interested in
\ntaking up training in No Scalpel Vasectomy
\n(N.S.V) and Laparoscopic Sterilization in
\nnear future.
\nPharmaco Vigilance and Drug Safety
\nThe e\ufb03cacy and safety of a new drug are
\ngenerally studied on a few thousand care-
\nfully selected and followed up trial subjects.
\nTherefore, only very frequent adverse reac-
\ntions are observed during its clinical devel-
\nopment. Once, the medicine is placed on
\nthe market and the population is exposed,
\nits actual safety pro\ufb01le is known. To iden-
\ntify and tackle these risks, the new adverse
\nreactions should be reported immediately
\nas a contribution to an incomplete safety
\npro\ufb01le.
\nAn IMA Pharmaco Vigilance cell was
\nformed at IMA HQs, IMA House, New
\nDelhi with an Advisory committee to mon-
\nitor and report such adverse reactions ob-
\nserved by the members of the Association
\nto the competent authorities and related
\norganisations. Nearly 1200 members from
\nall States have been trained and sensitised
\nin the need and procedure of Adverse Drug
\nReporting (ADR) \/ Adverse Event (AE)
\nreporting through various sessions during
\nevents of IMA at National, State and Dis-
\ntrict levels.
\nAn ADR \/ AE reporting form has been
\ncirculated amongst members of IMA on
\nwhich reports of ADR\/AE are being sent
\nto us by them.
\nAao Gaon Chalen Project
\n\u201cIndia lives in villages\u201d. However, due to
\nvarious socio-economic and other reasons,
\nthe basic healthcare needs of these citizens
\nof the country cannot be looked after due to
\nthe poor facilities available to them.
\nTherefore, IMA considered its \ufb01rst duty to
\ncater to the healthcare needs of the masses
\nliving in these villages. Hence, it was decid-
\ned that every State and local branch of IMA
\nwill adopt villages in their area of jurisdic-
\ntion to provide medical facilities to them at
\ntheir doorstep.
\nUnder the project implementation plan,cre-
\nation of health awareness (general health &
\nhygiene, adolescent health, FP, MCH care
\nespecially ANC & anaemia, gender sensiti-
\nzation, quackery, sex determination, female
\ninfanticide etc.) plays a pivotal role. This is
\ndone through Puppet shows; Nukkad nat-
\naks, School health talks; essay & painting
\ncompetitions, debates in schools and col-
\nleges, social meetings involving pradhans,
\ngram sabha members, community leaders
\nand religious leaders.
\nWe have been quite successful in achieving
\nour expected outcomes from this project.
\nSwine Flu
\nDespite of the e\ufb00orts of the Government to
\ncontrol the spread of Swine Flu,it has taken
\nthe form of an epidemic in our country.
\nIMA has already sensitised all its members
\nabout the Swine Flu epidemic and issued
\nguidelines through its News Letter. General
\npublic has been informed and sensitised about
\nthe methods to prevent the Swine Flu. An
\nInformation Cell at IMA HQs. is working
\nround the clock to respond to various queries
\nof general public and our members.
\nTobacco De-addiction and Control
\nIdentifying tobacco as a giant killer with 5.4
\nmillion global and around 10 lakhs Indian
\ntobacco related deaths, IMA undertook a
\nnationwide campaign against tobacco. To
\nsensitise health providers about the dangers
\nof tobacco products and generate awareness
\non tobacco related health issues, IMA or-
\nganised Public rallies, workshops and lec-
\ntures on Tobacco Control & De-addiction
\non 31 May 2009 all over the country on
\n\u201cWorld No Tobacco Day\u201d.
\nBlood Donation
\nVoluntary blood donation is one of IMA\u2019s
\nregular activities with IMA running its own
\nstate-of-art blood banks all over the country
\nto cater to the needs of patients.
\nDr. Dharam Prakash, Hon. Secretary General
\nIndian Medical Association
\nBlood Donation camps are being organized
\nfrom time to time by IMA Branches
\nLaparascopic sterilization campNo Tobacco Day Rally organized by various
\nIMA Branches all over the country
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\nInternational, Regional and NMA news
\nTaking into consideration a recent o\ufb03cial pub-
\nlication, we provide a brief overview of the
\nUruguayan health system in the mid-2000s
\nand the main measures adopted within the
\nframework of this change, organising it around
\nseven issue.
\nJulio Trostchansky
\nAccording to the classic indicators of mor-
\ntality, the health situation in Uruguay has
\nbeen comparable to that in various devel-
\noped countries. However, upon observation
\nof its historical evolution, we maintain that
\nthere has been a severe stagnation in regard
\nto health indicators, particularly those that
\nare more speci\ufb01c and closely related to the
\ntransitional model. Up until a few decades
\nago, Uruguay was among the top coun-
\ntries in the Americas for the good results
\nobtained in the health of its population, al-
\nthough the fact that it failed to follow the
\ndynamics created by several countries in the
\nregion resulted in slowdown of progress in
\nthe \ufb01eld.
\nIt is said that the health system failed to re-
\nspond to the needs of the Uruguayan popu-
\nlation. Demographical, epidemiological and
\nsocial transformations that took place ulti-
\nmately de\ufb01ne a new needs pro\ufb01le. Increase
\nin life expectancy and decrease in fertility
\nare re\ufb02ected in an aged population, where
\nchronic degenerative conditions prevail. In
\naddition to this, a strong process of eco-
\nnomic and social inequality experienced in
\nthe past decades caused a large sector of
\nsociety to fall below the poverty line. As a
\nmatter of fact, it is in these sectors, deprived
\nof protection, where the highest child mor-
\ntality rates are found.
\n1. From the point of view of the organisa-
\ntion of the health care services,it is said that
\nthe main problems are grounded on the ex-
\nistence of two service providers\u2019sub-systems
\nthat were fragmented and had no connec-
\ntion with one another, unequal in terms of
\ncitizen access to them and showing no signs
\nof being complementary. In particular, the
\nState\u2019s main provider remained as an entity
\nthat had no relation with the Ministry of
\nHealth, and thus acted sti\ufb04y, evidencing
\nconfusion with other tasks carried out by
\nthe Ministry.
\nAccording to o\ufb03cial publications, sec-
\ntoral measures were geared towards creat-
\ning a national integrated health system, by
\nstrengthening the connection between sub-
\nsectors, favouring greater equality based on
\nthe strong contribution of resources and
\nstrengthening the main public health care
\ncentre, thus aiming to improve access of
\nmore vulnerable sectors of population and
\nto encourage complementary bonds be-
\ntween sub-sectors. The State\u2019s main health
\ncare services provider is decentralised, and
\nthrough the reinforcement of \ufb01nancial re-
\nsources, priority was given to the salaries of
\nphysicians, which increased substantially.
\nThe latter is probably the most relevant
\nchange in terms of human resources, an
\naspect that has not been prioritised in the
\nagenda for change.
\n2. Likewise, only employees from the for-
\nmal private sector \u2013 without including their
\nrelatives \u2013 were covered by a social health
\ninsurance they paid for together with their
\nemployers via their payroll, it being only
\npossible for them to choose their health
\ncare services provider from among private
\nmedical institutions and later on losing
\ntheir right to choose and the said health in-
\nsurance coverage upon retirement.
\nThe new system is said to have a combined
\nnature in terms of the service providers,
\nincluding private and public institutions
\nacting within the framework of a comple-
\nmentary and competitive regime, giving a
\nchance to those insured to choose between
\npublic and private institutions.
\nAt the same time, the rest of the population
\nhad access to health care services under dif-
\nferent modalities, ranging from individuals
\npaying for services out of their own pockets
\nto free services being funded by taxes col-
\nlected by the State for indigents or people
\nlacking enough resources, or else provided
\nby means of a combination of \ufb01nancing
\nmodalities for speci\ufb01c sectors of the popula-
\ntion, as for instance, the military and police.
\nAs to relatives, they are speci\ufb01cally included
\nin the social insurance health coverage,chil-
\ndren are immediately covered, and as from
\n2010 spouses will be included according to
\nthe regulations in force.The system consists
\nin making social insurance into a universal
\ncoverage plan that provides for a graded
\nadmission of citizens to the system that is
\nfunded by the national insurance, turning it
\ninto a life insurance, since insurance rights
\nsurvive upon the bene\ufb01ciaries retirement.
\n3. The price reimbursed to providers of
\nhealth care centres who ensured and ren-
\ndered health care services was regulated by
\na single monthly payment by the State. In
\nthis way, the social sickness insurance and
\na large portion of the remaining population
\npaid their insurance via this system,ignoring
\nthe risk associated with the covered popula-
\ntion and the expected cost di\ufb00erential, thus
\nweakening the sustainability of the health
\ncare service system itself. Simultaneously,
\nChanges in the Uruguayan health system
\nwma 8.indd 162wma 8.indd 162 12\/4\/09 4:23:42 PM12\/4\/09 4:23:42 PM
\n163
\nInternational, Regional and NMA news
\nthe price of important supplies was under
\nno regulation whatsoever.
\nFrom the point of view of payment to health
\ncare centres, the national health insurance
\npays according to risk \u2013 even partially, as a
\nstage in the transition process – as distinct
\nfrom single payment reimbursement.
\nPrior to the process of change, a distortion
\nin the price of co-payments grew stronger
\n(care-order payments, medicine tickets
\nand multiple diagnose and treatment tech-
\nniques), evolving from a way to regulate de-
\nmand \u2013 under State provisions \u2013 into a way
\nto fund the private health care system, and
\nthus creating great barriers for the access of
\nusers.
\nThanks to modi\ufb01cations introduced into the
\nsystem, the prices of a number of medicine
\ntickets controlled by the State were mainly
\nbrought down, although they still hinder
\naccess to consumption by a large portion of
\nusers.
\nHigh-cost non-frequent techniques, gen-
\nerally associated to high-technology, are
\ncovered by the so-called National Resource
\nFund, a combined fund (public and private)
\nand reimbursement system \u2013 according to
\ndi\ufb00erent modalities \u2013 for highly specialised
\nmedical institutions.
\n4. It is believed that the system portrays a
\nhealth care model that fails to emphasise
\nstrategies for primary health care services,
\nand is instead eminently a therapeutic, hos-
\npital-cantered model.
\nThe o\ufb03cial document suggests the transfor-
\nmation of the advanced health care model
\nbased on the implementation of strategies
\nfor primary health care services, according
\nto regulations that encourage these strate-
\ngies and additional payments associated
\nwith achieving health care goals that need
\nto be carried out by the \ufb01rst level of assis-
\ntance.
\n5. The document further explains that the
\nadministration and control system is weak-
\nened in the di\ufb00erent tasks required, there
\nbeing no management contracts or incen-
\ntive programs based on goal accomplish-
\nment (health\/economic-\ufb01nancial goals).
\nAt the o\ufb03cial level, the change process is
\nto provide the system with a real adminis-
\ntrative and control policy, mainly by means
\nof the execution of management contracts
\nand their enforcement and sanctions frame-
\nwork, whereby institutions providing health
\ncare services commit to ful\ufb01l the health
\nprograms de\ufb01ned as priority programs.
\n6. The quality and quantity of services that
\nthe whole structure commits to render was
\nnot clearly de\ufb01ned.
\nMinisterial authorities reassure that the sys-
\ntem has managed to level the quality and
\nquantity of bene\ufb01ts by means of the speci\ufb01c
\nde\ufb01nition of the national integrated health
\nsystem that becomes an explicit guarantee
\nwhose enforcement can be demanded from
\nthe health authorities.
\n7. Finally, reference is made to the fact that
\nhistorically there has been no social partici-
\npation in the running of systems or institu-
\ntional management.
\nChanges suggest the incorporation of social
\nparticipation as a system and institutional
\nguideline. In this way, the participation of
\nusers and workers of the National Integrated
\nHealth System is strongly encouraged at the
\nmacro level of the National Health Council,
\nand at the micro level of institutions provid-
\ning health care services. Private institutions
\nwill do it by means of Counselling Consult-
\ning Councils, and public institutions will
\nrely on the participation of the board of the
\nmain health care services centre.
\nEc. Luis Lazarov, Executive
\nCommittee Consultant;
\nDr. Julio Trostchansky, MD, President
\nSINDICATO M\u00c9DICO del URUGUAY;
\nAlarico Rodr\u00edguez, MD, Head
\nof Foreign Relations
\nHealth Care Without Harm (HCWH)
\nand the Health and Environment Alli-
\nance (HEAL) are working with the World
\nHealth Organisation (WHO) to launch
\na new platform, the Prescription for a
\nHealthy Planet.
\nWhy you should care
\nClimate change a\ufb00ects health, the environ-
\nment and economy \u2013 but the health com-
\nmunity will be picking up the tab as the
\nhealth impacts of climate change begin
\nmaking themselves felt.
\nYet health is largely missing in climate
\nchange discussions.
\nThe health community holds an in\ufb02uential
\nposition in society and in policy-making. If
\nits voice were heard then climate initiatives
\nwould be signi\ufb01cantly stronger and more
\nhealth-friendly.
\nPlease join our e\ufb00orts to bring health to cli-
\nmate change negotiations
\nEndorse the Prescription\u2022
\nPromote the Prescription in National\u2022
\nMedical Association publications and
\nelsewhere
\nJoin us in Barcelona for the global launch\u2022
\nof the Prescription and Network
\nPrescription for a Healthy Planet
\nwma 8.indd 163wma 8.indd 163 12\/4\/09 4:23:43 PM12\/4\/09 4:23:43 PM
\n164
\nInternational, Regional and NMA news
\nThe problem
\nThere is increasingly powerful scienti\ufb01c evi-
\ndence that climate change is not only a real-
\nity now but is threatening to become a far
\nmore destructive phenomenon much more
\nquickly than even recently predicted.
\nOne of the most disturbing implications of
\nclimate change is its potentially dramatic
\nimpact on human health around the world.
\nAs the Lancet Commission report says:\u201cthe
\ne\ufb00ects of climate change on health will af-
\nfect most populations in the next decades
\nand put the lives and well-being of billions
\nof people at increased risk.\u201d
\nOverall, the health impacts of climate
\nchange will be disproportionately felt by the
\nmost vulnerable populations \u2013 the poor, the
\nvery young, the elderly and the medically
\nin\ufb01rm.
\nThe World Health Organization predicts that
\nclimate change will lead to a series of signi\ufb01-
\ncant health impacts, including: higher levels of
\nsome air pollutants and concomitant increased
\nrespiratory disease; the spread of diseases such
\nas cholera, malaria, dengue and other infec-
\ntious diseases; the compromising of agricul-
\ntural production and food security in some of
\nthe least developed countries leading to greater
\nmalnutrition; an increase in extreme weather
\nevents like \ufb02oods and droughts with dramatic
\nimpacts especially on the health of people liv-
\ning in coastal communities.
\nThe health sector on the front lines
\nHealthcare providers and public health
\npractitioners will be on the front lines,
\nconfronting and adapting to this changing
\nlandscape and shifting burden of disease.
\nSuch adaptation will come at a cost: the
\nmore severe the health-related symptoms
\nof climate change, the greater the outlay of
\n\ufb01nancial and human resources that will be
\nrequired to treat them.
\nThe health sector itself also makes a signi\ufb01-
\ncant contribution to the problem of climate
\nchange. Healthcare is a major consumer of
\nenergy, water, computers, chemicals, phar-
\nmaceuticals, food and other resources. This
\nconsumption leaves a signi\ufb01cant climate
\nfootprint.
\nA leadership role
\nPrecisely because the healthcare sector\u2019s cli-
\nmate impact is so far-reaching, it must play
\na leadership role in developing and model-
\nling solutions for the rest of society.
\nMany healthcare institutions are already
\nemploying a diversity of cost-e\ufb00ective cli-
\nmate-mitigation measures including energy
\ne\ufb03ciency,on-site alternative energy genera-
\ntion, green building design and construc-
\ntion, along with more climate-friendly pro-
\ncurement, transportation, food, waste and
\nwater-use policies.
\nDone correctly, these e\ufb00orts to reduce our
\nclimate footprint and to move healthcare
\ntoward carbon neutrality will also create
\nmajor bene\ufb01ts for public health. The extent
\nof these bene\ufb01ts is only gradually becoming
\nknown.
\nReducing our reliance on fossil fuels and
\nmoving toward clean, renewable energy can
\nhave the added bene\ufb01t of reducing local
\npollution generated by the combustion of
\ncoal, oil and gas. This in turn would reduce
\nthe number of respiratory illnesses related
\nto such energy consumption, thereby im-
\nproving public health. Visionary action to
\nmitigate climate change now will go a long
\nway toward avoiding major health challeng-
\nes in the future.
\nThe Prescription for a Healthy Planet, if
\nimplemented, would both help mitigate
\nclimate change\u2019s most severe impacts while
\nensuring major bene\ufb01ts to society by pro-
\ntecting public health.
\nA prescription for a healthy planet
\nProtectPublicHealth:\u2022 Take into account
\nthe signi\ufb01cant human health dimensions
\nof the climate crisis along with the health
\nbene\ufb01ts of climate change mitigation
\npolicies. In conjunction with this, a por-
\ntion of climate mitigation and adaptation
\nfunds should be targeted for the health
\nsector.This is needed to ensure evidence
\nof the health impacts of climate change
\nis continuously updated and brought to
\npolicy makers, so that the health sector
\ncan adapt to the health impacts of cli-
\nmate change while reducing its own cli-
\nmate footprint.To assure a strong voice in
\nthe debate, the health sector should also
\nbe adequately represented on all national
\ndelegations to Copenhagen.
\nTransition to Clean Energy:\u2022 A viable
\naccord must promote solutions to the cli-
\nmate crisis that move away from coal, oil,
\ngas,nuclear power,waste incineration and
\nfossil-fuel-intensive agriculture. The Co-
\npenhagen treaty should foster energy ef-
\n\ufb01ciency as well as clean, renewable energy
\nthat improves public health by reducing
\nboth local and global pollution.
\nReduce Emissions:\u2022 In order to protect
\nhuman and environmental health, the
\nworld\u2019s governments must take urgent
\naction to drastically reduce world-wide
\nemissions by 2050. Over the next decade,
\ndeveloped countries must signi\ufb01cantly
\nreduce their greenhouse gas emissions
\nbelow 1990 levels. Developing countries
\nmust also commit to stabilizing and re-
\nducing their emissions.
\nFinance Global Action:\u2022 A fair and eq-
\nuitable agreement in Copenhagen should
\nalso provide new and additional resources
\nfor developing countries to reduce their
\nclimate footprint and adapt to the im-
\npacts of climate change.
\nwma 8.indd 164wma 8.indd 164 12\/4\/09 4:23:43 PM12\/4\/09 4:23:43 PM
\n165
\nInternational, Regional and NMA news
\nReducing the health sector\u2019s
\nclimate footprint
\nAs health professionals and representa-
\ntives of major healthcare and public health
\ninstitutions and associations, we pledge to
\naggressively address climate change in our
\nsector and to promote health-friendly cli-
\nmate policy in all sectors.
\nWe will work together as part of a global
\nnetwork to conduct research, share infor-
\nmation and strategies to reduce our climate
\nfootprint,adapt our health systems and pro-
\nmote policies for mitigating climate change
\nthat also achieve signi\ufb01cant bene\ufb01ts for
\npublic health.
\nUltimately it is up to the leaders of the world
\nto establish a forward thinking framework
\nthat transcends immediate political pre-
\nrogatives to adequately confront this loom-
\ning threat. Therefore we are calling on all
\nworld leaders to take a strong and vision-
\nary stand in the Copenhagen negotiations
\nin December, as well as in the national and
\ninternational policy debates that ensue, by
\nfollowing this simple and clear Prescription
\nfor a Healthy Planet.
\nThe clock is ticking. The time for action is
\nnow.
\nFor more information about signing up
\nPlease contact Dr. Pendo Maro, Senior Cli-
\nmate Policy Advisor to HCWH Europe
\nand HEAL: pendo@env-health.org
\nWebsite: www.climateandhealthcare.org
\nDr. Regina M. Benjamin, former board
\nmember of the American Medical Associa-
\ntion (AMA) and Chair of the AMA Council
\nof Ethical and Judicial a\ufb00airs was appointed
\nto the position of United States Surgeon
\nGeneral on October 29, 2009. U.S. Dept. of
\nHealth and Human Services Secretary Kath-
\nleen Sebelius announced the con\ufb01rmation,
\nnoting that Dr. Benjamin\u2019s \u201cdeep knowledge
\nand strong medical skills, her commitment
\nto her patients, and her ability to inspire the
\npeople she interacts with every day will serve
\nher well as Surgeon General.\u201d
\nDr. Benjamin is founder and CEO of the
\nBayou La Batre Rural Health Clinic in Bay-
\nou La Batre, Alabama, whose mission is to
\nprovide \u201cHealth Care with Dignity\u201d to the
\nimpoverished residents of Bayou La Batre.
\nBorn in 1956, Dr. Benjamin attended Xavier
\nUniversity in New Orleans, and was a mem-
\nber of the second class of Morehouse School
\nof Medicine. She received her MD degree
\nfrom the University of Alabama Birmingham,
\nand completed her residency in family prac-
\ntice at the Medical Center of Central Georgia.
\nShe returned to her home region of Bayou La
\nBatre (a small shrimping village along the gulf
\ncoast of Alabama) to establish a solo medical
\npractice. After several years moonlighting in
\nemergency rooms and nursing homes to sus-
\ntain her practice open, mean while obtaining
\nan MBA fromTulane, Dr.Benjamin convert-
\ned her medical o\ufb03ce into a small rural health
\nclinic dedicated to serving the large indigent
\npopulation in her community.
\nDr. Benjamin is a member of the National
\nAcademy of Science’s Institute of Medicine,
\na Diplomat of the American Board of Fam-
\nily Practice, and a Fellow of the American
\nAcademy of Family Physicians. She is the
\nimmediate past-chair of the Federation of
\nState Medical Boards of the United States,
\nand was a Kellogg National Fellow and a
\nRockefeller Next Generation Leader. Con-
\nsistent with her strong social conscience,
\nDr. Benjamin spent time doing missionary
\nwork in Honduras.
\nIn 1995 she was elected to the AMA Board
\nof Trustees, the \ufb01rst physician under age 40
\nand the \ufb01rst African-American woman to
\nbe elected. She also served as President of
\nthe AMA Education and Research Foun-
\ndation (AMA-ERF). In 2002 she became
\nPresident of the Medical Association State
\nof Alabama, the \ufb01rst African American fe-
\nmale president of a State Medical Society in
\nthe United States.
\nDr. Benjamin\u2019s extraordinary accomplish-
\nments and commitment to her medical
\nprofession have won international recogni-
\ntion. Dr. Benjamin was previously named
\nby Time Magazine as one of the \u201cNation\u2019s
\n50 Future Leaders Age 40 and Under.\u201d She
\nwas also featured in a New York Times article,
\nRegina M. Benjamin, MD, MBA,
\nUnited States Surgeon General
\nwma 8.indd 165wma 8.indd 165 12\/4\/09 4:23:43 PM12\/4\/09 4:23:43 PM
\n166
\nInternational, Regional and NMA news
\nThe CPME celebrated its 50th
\nAnniversary
\nin Winchester (United-Kingdom,the home
\ntown of Dr. Wilks the CPME President)
\non October 23rd
\nand 24th
\n2009. 4 past Presi-
\ndents and the current President thanked all
\nthose people that played a role in the past
\n50 years.
\nDr. Alan Rowe is currently retracing the
\nhistory of CPME in the context of EU- and
\ninternational health policy. In the introduc-
\ntion he gave of this upcoming description of
\n50 years CPME he concluded that CPME
\ncan be proud of its accomplishments.
\nThis CPME anniversary meeting was also
\ndirected towards the future. The Gen-
\neral Assembly envisaged, and adopted, a
\nchange in its functioning.: From 2010, the 4
\nCPME subcommittees will be replaced by
\nworking groups, dedicated to speci\ufb01c policy
\ntopics. Along with an increased use of elec-
\ntronic communication instead of face-to-
\nface meetings, this shift will allow a more
\n\ufb02exible and cost-e\ufb00ective decision-making
\nprocess.
\nAt the Winchester meeting the following
\npolicies were adopted:
\n\u201cUse of Health Related Genetic In-
\nformation outside the Health Service\u201d
\n(http:\/\/cpme.dyndns.org:591\/adopted\/2009\/
\nCPME_AD_Brd_241009_170_f inal_
\nEN.pdfCP)
\nME calls national governments to enact
\nlegislation which should prohibit the use of
\nhealth related genetic information outside
\nthe area of direct patient care and health
\nservice, such as for insurance or pension
\nfunds purposes.
\n\u201cVitamin D nutritional policy in Europe\u201d
\n(http:\/\/cpme.dyndns.org:591\/adopted\/2009\/
\nCPME_AD_Brd_241009_179_f inal_
\nEN.pdf)
\nCPME believes Vitamin D supplementa-
\ntion (600-800 IU D3) and a good calcium
\nintake (about or above 1 g\/d) should be
\nconsidered (especially) for elderly people.
\nCPME calls on the EU Institutions to in-
\nclude vitamin D de\ufb01ciency in the health
\nagenda.
\nPrescription for a Healthy Planet
\nCPME co-signed the Prescription for a
\nHealthy Planet, calling for better represen-
\ntation of the health sector into the negotia-
\ntions, which must lead to a strong, binding
\nCopenhagen Treaty that promotes a healthy
\nclimate.
\nCPME Response to the Commission
\nproposal for Council Recommendation
\non Patient Safety (http:\/\/cpme.dyndns.
\norg:591\/adopted\/2009\/CPME_AD_
\nEC_160909_075_\ufb01nal_EN.pdf)
\nCPME welcomes the European Commis-
\nsion\u2019s proposal,which recognizes the urgency
\nof joint actions with regard to patient safety.
\nCPME welcomes the recommendation that
\nMember States establish reporting systems
\nthat are fair, open and non punitive. In ad-
\ndition, CPME urges the Council to give due
\nconsideration to the future organization of
\nEU patient safety work and to the creation
\nof a European Center for Patient Safety.
\nLisette Tiddens-Engwirda, Secretary General
\nStanding Commitee of European Doctors \u2013 50
\n\u201cAngel in a White Coat,\u201d as \u201cPerson of the
\nWeek\u201d on ABC’s World News Tonight with
\nPeter Jennings, as \u201cWoman of the Year\u201d by
\nCBS This Morning, and in People Magazine.
\nShe was featured on the December 1999
\ncover of Clarity Magazine, and on the Janu-
\nary 2003 cover of Reader’s Digest. Dr. Ben-
\njamin received the Nelson Mandela Award
\nfor Health and Human Rights in 1998. She
\nreceived the 2000 National Caring Award
\nwhich was inspired by Mother Teresa,as well
\nas the papal honor Pro Ecclesia et Ponti\ufb01ce
\nfrom Pope Benedict XVI.She is also a recent
\nrecipient of the MacArthur Genius Award.
\nPresident Barack Obama praised Dr. Ben-
\njamin\u2019s dedication to providing health care
\nfor her rural community in the face of ad-
\nversity, naming her a \u201crelentless promoter
\nof prevention and wellness programs\u201d who
\n\u201crepresents what’s best about health care
\nin America — doctors and nurses who give
\nand care and sacri\ufb01ce for the sake of their
\npatients\u201d. Dr. Benjamin explained that as
\nSurgeon General she hopes \u201cto be Ameri-
\nca’s doctor, America’s family physician\u201d and
\nshe promised to \u201ccommunicate directly with
\nthe American people to help guide them
\nthrough whatever changes may come with
\nhealth care reform\u201d.
\nDr. Benjamin is worthy of recognition
\namong the World Medical Association\u2019s
\nCaring Physicians of the World. She too, ex-
\nempli\ufb01es the three enduring traditions of
\nthe medical profession, caring, ethics and
\nscience, which inspire hope and trust.
\nYank D. Coble, MD. Director and
\nDistinguished Professor Center for Global
\nHealth and Medical Diplomacy
\nwma 8.indd 166wma 8.indd 166 12\/4\/09 4:23:44 PM12\/4\/09 4:23:44 PM
\n167
\nInternational, Regional and NMA news
\nA delegation of doctors from Malawi vis-
\nited Berlin at the beginning of September.
\nIn just under a week, three Malawian doc-
\ntors were given an insight into the German
\nhealth sector and the system of medical self-
\nadministration. They had accepted an invi-
\ntation from the German Medical Associa-
\ntion (Bundes\u00e4rztekammer \u2013 B\u00c4K) and the
\nGerman Agency for Technical Cooperation
\n(Gesellschaft f\u00fcr Technische Zusammenar-
\nbeit \u2013 GTZ).
\nDr. Douglas Lungu is 43 years old, a surgeon
\nand Director of the Presbyterian Hospital in
\nLilongwe, the capital of Malawi. Dr. Bridget
\nMsolomba (26) and Dr. Andrew Likaka (29)
\nboth work in hospitals as general practitio-
\nners. The three doctors represent Malawi’s
\n\u201cSociety for Medical Doctors\u201d(SMD),which
\nwas only founded in 2008.
\nThe visit focused on various players in the
\nGerman health system, such as the German
\nMedical Association and the German As-
\nsociation of Hospital Doctors (\u201cMarburger
\nBund\u201d).
\nThe guests from Malawi gathered numerous
\nideas and suggestions that they said would
\nhelp them promote the development of their
\nmedical organisation. They explained that
\nthey had set up their organisation only re-
\ncently because there were very few doctors
\nworking in Malawi. In statistical terms, an
\nestimated 64 000 inhabitants are served by
\none doctor. Accordingly, there are roughly
\n200 practising doctors in Malawi with its
\npopulation of 13 million,and a single univer-
\nsity has to cover the demand for junior medi-
\ncal sta\ufb00. To guarantee at least a minimum of
\nhealthcare, graduates in medicine have to
\nagree to work in their home country for two
\nyears after completing their studies.
\nMedical care is free of charge for patients
\nin Malawi. At the same time, the country is
\nfacing massive \ufb01nancial challenges, particu-
\nlarly in the health sector: infant mortality is
\nin the region of eight percent of all births,
\nthe high AIDS rate of 11.9 percent of the
\ntotal population causes serious problems,and
\nthe average life expectancy is just 46 years.
\nAlthough the doctors and medical assistants
\nmake a major e\ufb00ort to e\ufb00ectively counter-
\nact the numerous problems in the healthcare
\nsector, the available budget needs to be util-
\nised more e\ufb03ciently in practice. In the view
\nof the doctors from Malawi, however, the
\ndistributed structure of the healthcare sys-
\ntem is in principle sensible and will continue
\nto be viable in the future.
\nGeneral practitioners like Dr. Likaka and
\nDr. Msolomba are most in demand, because
\nbroad-based knowledge is needed in a hos-
\npital. \u201cIf you’re not familiar with a disease,
\nyou look up the treatment in a textbook,\u201d
\nsaid Dr. Lungu, describing the pragmatic
\napproach of his hospital doctors. What the
\nthree are very knowledgeable about, is tropi-
\ncal medicine. Given the wealth of tropical
\ndiseases that are the daily bread of Malawian
\ndoctors, colleagues from abroad were always
\namazed, they said with a grin. Consequently,
\nit would be interesting and instructive for
\ninternational doctors to spend some time
\nworking at a tropical hospital in Malawi.
\n\u201cAs far as the equipment of the hospitals is
\nconcerned, the main thing missing is beds,\u201d
\nsaid Dr. Lungu. In addition to which, how-
\never, the quality of the products they could
\na\ufb00ord often left a lot to be desired. For that
\nreason, they would very much like to equip
\ntheir hospitals with sturdy, second-hand
\nbeds from Europe, for example \u2013 if the funds
\nfor the transport were available.
\nThe three Malawian doctors subsequently
\nexperienced what the equipment of a Ger-
\nman hospital can look like during a tour
\nof the eye clinic of the Charit\u00e9 hospital in
\nBerlin. The one-and-a-half-hour visit intro-
\nduced them to the procedures for dealing
\nwith eye patients. Senior physician Dr. Mir-
\niam Doblhofer not only explained the ex-
\namination and treatment methods, but also
\ndemonstrated the work\ufb02ows in patient ad-
\nministration, from admission and the course
\nof the operation, all the way to collaboration
\nwith other specialist clinics.
\nThe exchange between the representatives
\nof the Malawian and German medical com-
\nmunities was a \ufb01rst step towards closer co-
\noperation. Although the conditions under
\nwhich doctors work around the globe appear
\nto be very di\ufb00erent on the surface, it can be
\nseen time and again that all doctors have to
\ncontend with many very similar problems.
\nUnfortunately, their wish to engage in their
\ncurative activity often has to take a back seat
\nto political, bureaucratic or \ufb01nancial targets.
\nIn this respect, closer contacts help to fur-
\nther strengthen the self-image of the medical
\ncommunity worldwide.
\nTherefore, the World Medical Association
\nreceived the SMD from Malawi as a new
\nmember at this year’s General Assembly in
\nDelhi\/India. Although the new association
\njoining the WMA is only small, its dedicat-
\ned members will no doubt help to strengthen
\nthe medical community, especially in Africa.
\nMore information on the \u201cSociety for Medi-
\ncal Doctors\u201d in Malawi can be found on the
\nwebsite at www.smdmalawi.org.
\nJohanna Janotta, Marburger Bund;
\nDomen Podnar, German Medical Association
\nAverage of one doctor per 64 000 inhabitants
\nMedical delegation from Malawi as guests of the German medical community
\nFrom left to right: Armin Ehl (Secretary
\nGeneral of Marburger Bund), Johanna
\nJanotta (Marburger Bund), Domen Podnar
\n(GMA), Dr. Andrew Likaka (SMD),
\nElisabeth Jibikilayi (GMA), Dr. Douglas
\nLungu (President of SMD), Dr. Bidget
\nMsolomba (SMD)
\nwma 8.indd 167wma 8.indd 167 12\/4\/09 4:23:44 PM12\/4\/09 4:23:44 PM
\nWMA news
\nWMA General Assembly, New Delhi 2009 . . . . . . . . . . . . . . 128
\nDeclaration of Delhi on Health and Climate Change. . . . . . . 137
\nDeclaration of Madrid on Professionally-led Regulation . . . . 140
\nDeclaration of Ottawa on Child Health . . . . . . . . . . . . . . . . . 140
\nWMA Resolution on Task Shifting
\nfrom the Medical Profession . . . . . . . . . . . . . . . . . . . . . . . . . . 141
\nWMA Emergency Resolution supporting the Rights
\nof Patients and Physicians in the Islamic Republic of Iran . . . 143
\nWMA Resolution on Medical Workforce. . . . . . . . . . . . . . . . 144
\nWMA Statement on Inequalities in Health . . . . . . . . . . . . . . 145
\nWMA Resolution on Improved Investment in Public Health 146
\nHindi \u2013 English bilingual \u201cSpeaking Book\u201d. . . . . . . . . . . . . . . 147
\nImpact of climate change in Asia and
\nOceania region and challenges ahead . . . . . . . . . . . . . . . . . . . 148
\nAnthropedia\u2019s initiatives to promote person centered care. . . . 152
\nLack of access to healthcare information is a hidden killer . . . 153
\nThe Medical Women\u2019s International Association (MWIA) . . 155
\nA strange form of declaring a health emergency:
\nthe case of Venezuela. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
\nIndian Medical Association:brief report of all projects . . . . . . 159
\nChanges in the Uruguayan health system . . . . . . . . . . . . . . . . 162
\nPrescription for a Healthy Planet . . . . . . . . . . . . . . . . . . . . . . 163
\nRegina M. Benjamin, MD, MBA,
\nUnited States Surgeon General. . . . . . . . . . . . . . . . . . . . . . . . 165
\nStanding Commitee of European Doctors \u2013 50 . . . . . . . . . . . 166
\nAverage of one doctor per 64 000 inhabitants. . . . . . . . . . . . . 167
\nContents
\nWMA General Assembly, New Delhi 2009
\nwma 8.indd 168wma 8.indd 168 12\/4\/09 4:23:44 PM12\/4\/09 4:23:44 PM<\/p>\n"},"caption":{"rendered":"

wmj24 G 20438 No. 4, December 2009 wma 8.indd Iwma 8.indd I 12\/4\/09 4:23:15 PM12\/4\/09 4:23:15 PM Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 661 peteris@nma.lv editorin-chief@wma.net Co-Editor Dr. Alan J. Rowe Haughley Grange, Stowmarket Su\ufb00olk IP143QT, UK Co-Editor Prof. Dr. med. Elmar Doppelfeld […]<\/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\/wmj24.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3588"}],"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=3588"}]}}