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wmj30<\/a><\/p>\n

vol. 56
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, Inc
\nG20438
\nNr. 6, December 2010
\nDr. P\u0113teris Apinis
\nLatvian Medical Association
\nSkolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.lv
\neditorin-chief@wma.net
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSuffolk IP143QT, UK
\nProf. Dr. med. Elmar Doppelfeld
\nBachmer Str. 29-33
\nD-50931, K\u00f6ln, Germany
\nVelta Poz\u0146aka
\nwmj-editor@wma.net
\nJ\u0101nis Pavlovskis
\nThe Latvian Medical Publisher
\n\u201cMedic\u012bnas\u00a0apg\u0101ds\u201d, President Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nVolodymyr Sydoruk \u201cThe doctor came\u201d, 1970\u2019s,
\ncardboard \/ oil
\nVolodymyr Sydoruk (1925 – 1997) – Ukrainian
\npainter. Honored Artist of the Ukraine since
\n1985. Born in city Rzhishchev, Kyiv oblast. He
\ngraduated in 1938 the Kiev Art School.
\nThe World Medical Association, Inc. BP 63
\n01212 Ferney-Voltaire Cedex, France
\nDeutscher-\u00c4rzte Verlag GmbH,
\nDieselstr. 2, P.O.Box 40 02 65
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\nAdvertising rates available on request
\nThe magazine is published bi-mounthly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or
\nthe World Medical Association
\nSubscription fee \u20ac 22,80 per annum (incl.
\n7%\u00a0MwSt.). 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
\nCologne, Germany
\nISSN: 0049-8122
\nWMA President
\nThai Health Professional Alliance
\nAgainst Tobacco (THPAAT)
\nRoyal Golden Jubilee, 2 Soi
\nSoonvijai, New Petchburi Rd.
\nBangkok,Thailand
\nWMA Vice-Chairman of Council
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nWMA Chairperson of the Finance
\nand Planning Committee
\n58 Victoria Street
\nWilliamstown, VIC 3016
\nAustralia
\nWMA Immediate Past-President
\nFredericton Medical Clinic
\n1015 Regent Street Suite # 302,
\nFredericton, NB, E3B 6H5
\nCanada
\nWMA Treasurer
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1
\n10623 Berlin
\nGermany
\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
\n1380 Lasne
\nBelgium
\nWMA President-Elect
\nWMA Chairperson of the Socio-
\nMedical-Affairs Committee
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nRua Sao Carlos do Pinhal 324
\nBela Vista, CEP 01333-903
\nSao Paulo, SP
\nBrazil
\nWMA Chairperson of the Medical
\nEthics Committee
\nNorwegian Medical Association
\nP.O.Box 1152 sentrum
\n0107 Oslo
\nNorway
\nWMA Treasurer Emeritus
\nSchubertstr. 58
\n28209 Bremen
\nGermany
\nWMA Chairperson of Council
\nAmerican Medical Assn
\n515 North State Street
\nChicago, ILL 60610
\nUSA
\nWMA Secretary General
\n13 chemin du Levant
\nFrance 01212 Ferney-Voltaire
\nFrance
\n209
\nWMA News
\nDr. Wonchat Subhachaturas
\nDear Presidents and Ex. Com. of the
\nNMAs., Doctors, Colleagues and friends,
\nIt has been a great honour given to me to
\nwork for the WMA as President for the
\nyear 2010-2011 at the WMA General As-
\nsembly in Vancouver, Canada, on 15th
\n. Oc-
\ntober 2010. It has been, as well, a great hon-
\nour to the Medical Association of Thailand
\nwhich occupies only 1 vote at the meeting
\nto receive a majority one single ballot. This
\nmeant a lot to Thailand and Thai people.
\nTherefore, it is absolutely my responsibility,
\nas a doctor from a small country, in Asia,
\nto spend my all ability to shoulder this big
\njob at the global level. I do promise that I
\nwill do my best to achieve the objectives and
\ngoal of the WMA as stated. However, this
\ncould not be a reality without good cooper-
\nation and collaboration from all of you who
\nwill carry on the most parts of our profes-
\nsional responsibility to make the people at
\nevery corners of this world healthy at the
\nNational level.
\nTo achieve that goal, I propose that every
\nNMAs should break the barrier and fron-
\ntier between us. There must be no bound-
\nary in Medicine. Every NMAs should be
\nresponsible for sharing health data, health
\nproblems and bring them to the meeting
\nand congress for discussion and find out the
\nbest suitable solution. The solution that we
\nare making out of experience sharing may
\nnot be an absolute one for everywhere but at
\nleast it may be a principle standard or guide-
\nlines for our practices to fit the variable situ-
\nation and environment in each country.
\nHealth Information must be circulated to
\nall NMAs by means of various communica-
\ntions in order that we, at every part of the
\nworld, can be aware and able to prevent the
\nspreading of the communicable diseases as
\nwell as to learn from each other the best way
\nto prevent and cure the non communicable.
\nCase referring and sharing of the investiga-
\ntions using high cost technology and equip-
\nments can be done through our NMAs with
\nthe WMA Secretariat Office as a Centre of
\ncommunication and resource data bank.
\nIt is always true that doctor\u2019s rights and
\nresponsibility come together and leads to
\ngood relationship amongst the doctors and
\npatients. Medical Ethics is the most impor-
\ntant and standard of practices in Medical
\nProfession which will bring in the trustful-
\nness to all of us.
\nOne year of Presidency is not at all long, so
\nI invite and welcome all of your suggestions
\nand comments to improve and benefit our
\nWMA future development.
\nThanks and looking forwards to our close
\nrelationship.
\nKind regards,
\nWonchat Subhachaturas
\nMD, FRTCS, FICS,
\nThailand
\nPresident of the World Medical
\nAssociation 2010-2011
\n210
\nWMA news
\nPaul-\u00c9mile Cloutier
\nThe Canadian Medical Association (CMA)
\nis very proud to have been host for the re-
\ncently completed World Medical Associa-
\ntion (WMA) General Assembly meeting.
\nAlthough the meeting lasted only four days,
\nCMA staff had been busy planning and
\npreparing for it since 2006. Vancouver was
\nchosen as the host city,and I think most will
\nagree that this was a superb choice.
\nStaff from the CMA joined the WMA
\nsecretariat in Vancouver a week before the
\nmeetings began, and they were then joined
\nby delegates from 50 countries. Working
\ngroups met Oct. 12, with the General As-
\nsembly itself beginning Oct. 13.
\nOver four days, delegates discussed and
\ndebated important and topical issues of
\nconcern to the physicians of the world,
\nincluding health and the environment,
\nthe debate for which was led by Canada,
\nviolence against women and children, and
\nthe relationship between physicians and
\npharmacists. Several new policies were ad-
\nopted, and are outlined elsewhere in this is-
\nsue of the World Medical Journal.
\nI think it is safe to say that a true feeling
\nof camaraderie and consensus-building
\nemerged during this meeting, particu-
\nlarly with respect to the issue of prescrib-
\ning rights. It was very gratifying for me, as
\nCEO of the host national medical associa-
\ntion, to witness this very effective collabora-
\ntion involving physicians from all parts of
\nthe world.
\nThe camaraderie was also
\nobvious at the numerous so-
\ncial events held during the
\nmeetings, from the opening
\nreception at the Pan Pacific
\nhotel to the trip across the
\nCapilano suspension bridge
\nand the dinner atop Grouse
\nMountain.
\nI would be remiss if I did not
\nexpress the pride felt by the
\nCMA as one of our own, Dr.
\nDana Hanson, gave his vale-
\ndictory address at the end
\nof his very successful year as
\nWMA president. I would
\nalso like to thank the CMA\u2019s
\noutgoing WMA Council
\nrepresentative, Dr. Ruth Col-
\nlins-Nakai, for all of her hard
\nwork, and welcome our new
\ncouncil member, Dr. Robert
\nOuellet.
\nI would also like to give spe-
\ncial thanks to the people I
\nhave the pleasure of working with every
\nday at CMA headquarters. Over the past
\nfew years they have worked tirelessly to en-
\nsure that this meeting would be successful,
\nand I am sure you will agree that it was. In
\nparticular, I would like to thank our execu-
\ntive director of international affairs, Dr. Jeff
\nBlackmer, and his team Karen Clark,
\nJackie Chapman-Davis, Jay Remillard, Lu-
\ncie Boileau, Eve Elman, Dr. Maura Rick-
\netts, Jill Skinner and Pat Rich.
\nFinally, I would like to thank you, the del-
\negates from national medical associations
\naround the world, for your attendance at
\nthe meeting in Vancouver. Because of your
\npreparation, participation and friendship,
\nthis was a General Assembly to be remem-
\nbered.
\nPaul-\u00c9mile Cloutier,
\nSecretary General and Chief Executive Officer
\nCanadian Medical Association
\nVancouver, British Columbia
\nOctober 13-16, 2010
\n211
\nWMA news
\nThe 61st
\nannual General Assembly held at
\nThe Fairmont Hotel in Vancouver, Canada,
\nfrom October 13th
\nto 16th
\nwas attended by
\nrepresentatives from almost 50 national
\nmedical associations.
\nSpeaking at the opening of the ceremonial
\nsession on Friday October 15th
\n, His Hon-
\nour the Honourable Steven Point, Lieutenant
\nGovernor of British Columbia, said that the
\nWMA had a global vision.He welcomed the
\nrecent movement of looking back at indig-
\nenous medical knowledge and expressed his
\nopinion that it was absolutely crucial to try
\nto broaden our horizons and understanding.
\nThe work of coming together was the ques-
\ntion of our time and we had to believe that
\nwe could make a difference by doing so.
\nFollowing the Honourable Steven Point,
\nDr. Jeff Turnbull, President of the Canadian
\nMedical Association, welcomed the WMA.
\nHe said that since the WMA was founded,
\nthe world had become not only a smaller
\nplace but, unfortunately, a more fragile
\none as well. He spoke about the remark-
\nable changes in health care and revealed
\nthat the health status of Canada\u2019s poor was
\ncomparable to that of countries with a frac-
\ntion of its gross domestic product.The social
\ndeterminants of health still led to massive
\nunacceptable health inequities worldwide.
\nHe remarked that these were challenges the
\nWMA had and must continue to address.
\nHe spoke about the myriad challenges
\nCanada\u2019s physicians faced and said that,
\n\u201cWe strive to provide the best care for our
\npatients. But we face the same issues as
\nmedical professionals in other countries
\nstress, burnout and fatigue to name a few.\u201d
\nHe noted that the medical profession in
\nCanada was aging, with the average age of
\nthe Canadian physician being older than
\nthe average Canadian citizen.He concluded
\nby saying \u201cWe face having fewer physicians
\nto meet a growing need.I believe the WMA
\nmust continue to speak out for the welfare
\nof its members as they continue to serve
\ntheir patients.\u201d
\nDr. Dana Hanson, the 60th
\nPresident of the
\nWMA, followed and in his valedictory ad-
\ndress, spoke about the three E\u2019s Energize,
\nEngage, Educate. Energize the profession.
\nEngage the public and Educate govern-
\nments. \u201cIn my travels, I clearly see physi-
\ncians who entered our profession for many
\nvaried reasons but all of them, all of us, have
\nat least one common reason the vision to
\nreach out and help those around them. In
\nmedical school we were bright, young and
\naltruistic. But what we often see today are
\nphysicians who have stepped out of medical
\nschool into a world financial crisis, severe
\nphysician shortages, often a demanding,
\ncritical public, the loss of the golden age of
\nantibiotics, and the erosion of self regula-
\ntion to name just a few problems. Physi-
\ncians are often tired and disillusioned.\u201d
\nHe said an area of personal interest to him
\nhad been the resilient physician what
\ncould be learned from those who continued
\nto function in situations where others could
\nnot and, from that learning, help all of them
\ncontinue to serve.This is what he called en-
\nergizing the profession.
\nDr. Hanson called on physicians to engage
\nthe public in the battle to improve health.
\nHe said that financial crises often resulted
\nin slashed health budgets and he followed
\nwith the question \u201cBut why is there no
\nVancouver, British Columbia October 13-16, 2010
\n212
\nWMA news
\noutcry by the public that the disease burden
\nremains the same or greater?\u201d He said that
\nduring his year as President, the WMA had
\nhighlighted health and the environment\u00a0
\n\u201csomething which, regardless of causes,
\nwill touch untold millions of people in a
\nvery real and concrete way when it comes
\nto their health.\u201d But he asked why patients
\nwere so surprised when physicians pointed
\nthis out to them in clinics and hospitals.
\nThese were just two examples of where the
\nWMA had a role, in partnership with na-
\ntional medical associations, in engaging
\nthe public to realise that in order to ad-
\ndress their individual concerns they must
\nbe partners with the medical profession and
\nother healthcare professionals. He said that
\ngovernments across the world had not been
\neducated by the right people when it came
\nto heath issues. He asked why the climate
\nchange conference in Copenhagen last
\nyear had no reference to health in its final
\ndraft? Why were 80 percent of the observ-
\ners \u2018industry\u2019 based while only a handful of
\nhealthcare representatives and environmen-
\ntalists were present?
\nHe continued by asking why governments
\nalways listen to the World Bank and the
\nInternational Monetary Fund about our
\neconomic health, often to the detriment
\nof public and individual health? Why were
\nhealth systems seen as a cost centre when
\nthey had been proven to be a positive eco-
\nnomic investment? And why, with a resur-
\ngence of infectious diseases and drug resis-
\ntance, were there common drug shortages
\nand a paucity of new drug innovation?
\n\u201cPart of the answer to these vital questions
\nis that we, along with the public, have not
\neducated governments and industry. They
\nhave only heard part of the story. Yet the
\npublic and the medical profession together
\nrepresent a powerful force that no govern-
\nment could oppose.The World Medical As-
\nsociation and national medical associations
\nhave a vital role in society not just at the
\nbedside but indeed well beyond.\u201d
\nDr. Edward Hill, Chair of Council, then
\nbrought to the Assembly a recommendation
\nfrom the Council that President-Elect, Dr.
\nKetan Desai, who was not able to be present
\nin Vancouver to be installed as President, be
\nconsidered \u201cdisabled\u201d and unable to carry
\nout his duties. He proposed that Dr. Desai\u2019s
\ninauguration be suspended indefinitely.This
\nwould then require an extraordinary elec-
\ntion to elect a President for 2010\/11. The
\nrecommendation was approved. In the elec-
\ntion that followed, three candidates were
\nnominated Dr. Eva B\u00e5genholm from Swe-
\nden, Dr. Mikhail Perelman from Russia and
\nDr. Wonchat Subhachaturas from Thailand.
\nAll three candidates addressed the Assem-
\nbly and in the voting that followed,Dr. Sub-
\nhachaturas was elected on the first ballot.
\nDr. Subhachaturas, President-Elect of the
\nMedical Association of Thailand, became
\nthe first doctor from Thailand to hold the
\npost of WMA President. He is a neuro-
\nsurgeon who did his medical training in
\nBankok and worked for many years at the
\ncity\u2019s Central Hospital before moving to
\nCharoenkrung Hospital where he became
\nDirector. He was Deputy Secretary of the
\nBankok Metropolitan Administration and
\ncurrently works at the Thai Health Profes-
\nsional Alliance Against Tobacco.
\nFollowing his installation,Dr. Subhachaturas
\nspoke to the Assembly about how the medi-
\ncal profession needs to be united. He said
\nthat even though physicians spoke different
\nlanguages they were all in the same boat
\nand rowing the same direction. With good
\nwill, they could connect with one another,
\nwith the health of the people of the world
\nas their target goal.
\nAt the plenary session of the Assembly the
\nfollowing day, Dr. Jos\u00e9 Gomes do Amaral,
\nPresident of the Brazilian Medical Associa-
\ntion, was elected unopposed as WMA Pres-
\nident-Elect. He will become the third Bra-
\nzilian to become President when he takes
\nup the post at the Association\u2019s annual As-
\nsembly in Montevideo, Uruguay next year.
\n213
\nWMA news
\nDr. Gomes do Amaral is an anesthesiologist
\nand specialist in critical care in S\u00e3o Paulo,
\nwhere he works at Santa Helena Hospital.
\nHe is also Chairman of Anesthesiology and
\nCritical Care Discipline at the Surgery De-
\npartment, at Sao Paulo Federal University.
\nThe Assembly adopted the following policy
\ndocuments from the Socio-Medical Affairs
\nCommittee:
\nThe Resolution on Violence against Wom-
\nen and Girls warned that this issue had
\nbecome a worldwide institutionalised phe-
\nnomenon and a major public health crisis.
\nIn its first policy Declaration on the issue,
\nthe WMA urged physicians and their na-
\ntional medical associations to pay far greater
\nattention to the issues of female feticide, fe-
\nmale genital mutilation, forced marriages
\nand honour killings and to condemn gang
\nrape as a weapon of war and a crime against
\nhumanity.
\nDr. Ruth Collins-Nakai, Canadian Medi-
\ncal Association, who headed the WMA\u2019s
\nworkgroup on the issue, said: \u201cThese forms
\nof violence reflect the persistence of gender
\ninequalities worldwide. Physicians can be
\nthe agents of change and promote a shift of
\nmentality for the achievement of women\u2019s
\nhuman rights, their dignity and integrity.\u201d
\n(see full text p. 224)
\nThe Statement on Environmental Degrada-
\ntion and Sound Management of Chemicals
\nwarns that chemical contamination of the
\nenvironment continues to exert harmful ef-
\nfects on global public health. Dr. Hill said
\n\u201cAs we have seen from recent environmen-
\ntal disasters, the public continues to be at
\ngreat risk from chemical contamination.
\nGovernments have the primary responsibil-
\nity to protect the public\u2019s health from these
\nhazards and our job as the World Medi-
\ncal Association, on behalf of the world\u2019s
\nphysicians, is to highlight the human health
\nrisks and to recommend action.\u201d
\n(see full text p. 220)
\nThe Statement on Family Violence, which
\nrevises previous WMA policy, offers pro-
\nposals for increasing awareness and involve-
\nment among physicians, including the need
\nto oppose violent practices such as dowry
\nkillings, honour killings and the practice of
\nchild marriage
\n(see full text p. 222)
\nThe Statement on Medical Care for Refu-
\ngees, including Asylum Seekers, Refused
\nAsylum Seekers and Undocumented Mi-
\ngrants, and Internally Displaced Persons
\nwas adopted.
\n(see full text p. 226)
\nA revised Statement on the Relation-
\nship between Physicians and Pharmacists
\nin Medical Therapy was adopted after a
\nlengthy debate. At issue was a sentence in
\nthe original document that \u201cThe right to
\nprescribe medicine should be solely the re-
\nsponsibility of the physician\u201d.
\nDr. Jon Snaedal, from the Iceland Medical
\nAssociation, proposed an amendment to
\ndelete those words,arguing that it ran coun-
\nter to the collaboration the WMA engaged
\nin with other health professionals who, in
\nmany countries, also had a right to prescribe
\nunder certain circumstances.
\nBut Dr. Frank Montgomery from Germany
\nsupported the original wording which he
\nsaid was the essence of the document. \u201cWe
\nas physicians want for ourselves the right
\nand the responsibility to prescribe\u201d, he said.
\nDr. Kgose Letlape from South Africa said
\nthat if this wording was supported, in South
\n214
\nWMA news
\nAfrica it would condemn more than four hundred thousand
\npeople a year to HIV related deaths. South Africa had more than
\ntwo million people who could not access doctors and who were
\ndying unnecessarily from HIV and they were being treated by
\nprescribing nurses and other health professionals.
\nDr. Ruth Collins-Nakai from Canada said the ability to prescribe
\nshould be a competency-based decision, not an autonomy based
\ndecision.If people had the appropriate training then they had the
\nresponsibility and the obligation to prescribe.However Dr. Pedro
\nNu\u00f1es from Portugal said that prescribing was the responsibility
\nof the doctor. It would be very strange if a medical association
\nwould give up what physicians had achieved so far.
\nDr. Arie Kruseman from the Royal Dutch Medical Association,
\nsupporting the deletion of the sentence, said there was ample
\nevidence that specialist nurses, if properly trained, performed
\nequally, and in some situations, even better than doctors in their
\ntreatment of certain chronic diseases. Dr. Peter Foley from New
\nZealand said the WMA must not be seen to be just protecting
\nthe physicians. They were here for their patients and healthcare
\nwas a team delivery. Dr. Vivienne Nathanson from the British
\nMedical Association said that to deny access to healthcare to
\nmany people in many countries was so retrogressive that the
\nWMA would look back in the future with great shame.The best
\nqualified person available should be able to prescribe to people
\nin dire need of treatment.
\nThe Assembly eventually agreed to substitute the sentence \u201cThe
\nright to prescribe medicine should be solely the responsibility of
\nthe physician\u201d with \u201cThe right to prescribe medicine should be
\ncompetency based and ideally the responsibility of the physician\u201d.
\nThe revised Statement was adopted.(see full text p. 227)
\nA Resolution on Drug Prescription was then adopted setting out
\nprinciples on prescribing. (see full text p. 228)
\nThe Assembly received an oral report from the Treasurer Prof.
\nJ\u00f6rg-Dietrich Hoppe. It approved the Audited Financial State-
\nment for 2009 and adopted the Budget for 2011.
\nApplications for membership from the Mozambique Medical
\nAssociation and the Serbian Medical Chamber were approved.
\n215
\nWMA news
\nThe Assembly approved and adopted a consolidation and revision
\nof the WMA Bylaws, marking the end of a year-long task related to
\nupdating and amending outdated and repetitive documents.
\nIt was agreed that junior doctors and medical students should have
\ntheir membership fees for WMA Associate Membership waived for
\nthe first five years after graduation instead of the present three years.
\nDr.Hanson,who was instrumental in encouraging this change,said this
\nwould give junior doctors an important platform within the WMA.
\nIt was agreed that three documents Professional and Ethical Us-
\nage of Social Media, Ethical Principles for Medical Research on
\nChild Subjects and Physicians\u2019 Ethical Responsibilities regarding
\nBio Banks be r eferred to Council for discussion.
\nIt was reported that a working group would be set up to examine
\norgan procurement, including the issues of transplantation from ex-
\necuted prisoners, the commercialisation of organ transplants, pre-
\nsumed and other systems of consent and related issues.
\nThe Council\u2019s detailed report to the Assembly about significant de-
\nvelopments during the year referred to the WMA\u2019s involvement in
\nthe WHO global action plan on noncommunicable diseases and ac-
\ntivities to progress the WHO Framework Convention on Tobacco
\nControl.The Association had also been involved in the global strat-
\negy to reduce the harmful use of alcohol.
\nOn the multi drug resistant tuberculosis project, as part of the Lilly
\nMDR-TB partnership, the TB refresher course for physicians had
\nbeen launched during the General Assembly in 2009 in Delhi. The
\npurpose of the course was to set the baseline for basic knowledge on
\nthe subject, with the existing Multi-Drug Resistant TB course pro-
\nviding more advanced knowledge.The TB refresher course had been
\nnominated by the United States Center of Disease Control as an edu-
\ncational highlight and had received an award.Over time,both courses
\nwould be translated into different languages. The Georgian Medical
\nAssociation had offered to translate the TB refresher course for free.
\nTo increase the outreach of itsTB and MDRTB educational activities,
\nthe WMA had held a train-the-trainer course in TB and MDR-TB
\n216
\nWMA news
\nin China, based on the existing training ma-
\nterials from the courses held in South Africa
\nand India. In April 2010, the WMA and
\nthe Chinese Medical Association organised
\na third workshop in Hangshuang with the
\nhelp of the Chinese Thoracic Society. Thirty
\nleaders of TB hospitals from all over China
\ntook part in the training.The government and
\nthe provincial health department honoured
\nthe activities of the WMA and the Chinese
\nMedical Association.
\nThe WHO had developed a policy on ethics
\nin the TB Setting, and launched the policy
\nduring a conference and workshop in Ath-
\nens in May this year.The WMA was invited
\nto address the issues related to health pro-
\nfessionals in the policy and Dr. Jeff Blackmer
\nfrom the Canadian Medical Association of-
\nfered to draft this part of the policy, which
\naddressed the duty to treat and the risks and
\nobligations to patients.The WMA, together
\nwith the International Council of Nurses,
\nInternational Hospital Federation and Inter-
\nnational Committee of the Red Cross,and in
\nclose cooperation with the WHO, organised
\nan inter-professional workshop on Health
\nCare Worker Safety and Infection Control
\nin the Context of Drug Resistant TB in Be-
\nnin in September. Forty-eight physicians,
\nnurses, managers and laboratory technicians
\nfrom Benin,Burkina Faso,Mali,Ivory Coast,
\nGuinea and Senegal discussed the infection
\ncontrol measures in their hospitals and the
\nchallenges to improve the situation and de-
\nveloped ten recommendations for their TB
\nhospitals.
\nOn counterfeit medical products, the
\nWMA and the members of the World
\nHealth Professions Alliance had developed
\nthe \u201cBe Aware\u201d toolkit for health profes-
\nsionals and patients to increase awareness of
\nthis topic and provide practical advice for
\nactions to take in case of a suspected coun-
\nterfeit medical products. Workshops were
\nbeing organized.
\nA WMA workgroup on health and the en-
\nvironment, established in 2008, had been
\ninvolved in the global United Nations
\nFramework Convention on Climate Change
\nand the Association had been involved in ac-
\ntion to reduce the global burden of mercury
\nand the management of chemicals.
\nThe WMA had continued its close involve-
\nment in the Positive Practice Environment
\nCampaign, a global five-year campaign
\nspearheaded by the World Health Profes-
\nsions Alliance that aimed to ensure high-
\nquality health workplaces for quality care.
\nThe first activities on a country level started
\nin Uganda, Morocco and Zambia. National
\nresearchers conducted studies about the
\nworking conditions of health profession-
\nals in these countries and during two-day
\nworkshops, national and local health pro-
\nfessionals, governments and researchers
\ndeveloped an action plan to improve the
\nworking conditions of health professionals.
\nThe Association had also been involved
\nwith the UN Millennium Development
\nGoals, in workplace violence in the health
\nsector, patient safety and with the Inter-
\nnational Rehabilitation Council for Tor-
\nture Victims. It had also participated as a
\nmember of steering groups in two projects
\ncommissioned by the European Union on
\nthe mobility and migration of health pro-
\nfessionals.
\nThe Caring Physicians of the World proj-
\nect had continued with further leadership
\ncourses organised by the INSEAD Business
\nSchool. The courses had been made possible
\nby an unrestricted educational grant provid-
\ned by Pfizer, Inc. During the year, Books of
\nHope, with the support of Pfizer, the Chi-
\nnese Center of Disease Control, the Chinese
\nMedical Doctors Association, the Chinese
\nAssociation on Tobacco Control and the
\nWMA presented a speaking book on the
\ndangers of smoking.It targeted a low literacy
\ncommunity that had experienced significant
\nincreases in smoking rates over the last de-
\ncades,yet could not benefit from much of the
\nwritten informational products on tobacco
\ncessation and the dangers of smoking.
\n217
\nWMA news
\nThe WMA had campaigned on behalf of
\nphysicians in distress worldwide.
\nIt had sent an appeal to the President of Su-
\ndan for the release of six Sudanese doctors
\narrested and detained without charge for
\ntheir activities as members of the Doctors\u2019
\nStrike Committee calling for better pay and
\nworking conditions for doctors in Sudan.
\nWMA members were invited to act in sup-
\nport of these doctors, for their immediate
\nrelease and the assurance that they were not
\nbeing tortured. The six doctors were subse-
\nquently released.
\nThe WMA also wrote to the Iranian au-
\nthorities concerning the cases of Dr. Arash
\nAlaei and Dr. Kamiar Alaei who were sen-
\ntenced to six and three years\u2019 imprisonment
\nrespectively, for \u2018cooperating with an enemy
\ngovernment\u2019. But despite strong calls from
\nthe international medical and scientific
\ncommunity, the brothers remained in jail,
\nmore than two years after their arrest. The
\nWMA considers them prisoners of con-
\nscience, as they appear to have been impris-
\noned solely in relation to their work with
\ninternational and specifically US insti-
\ntutions in the field of HIV and AIDS pre-
\nvention and treatment.
\nThe WPHA had celebrated its 10th anni-
\nversary during the year and the four main
\nhealth professions-physicians, nurses, phar-
\nmacists and dentists had now been joined
\nby the World Confederation for Physical
\nTherapy. Together they had shown that
\nworking in collaboration instead of along
\nparallel tracks, benefited both patients and
\nhealth care systems. The WHPA amplified
\nthe policy and advocacy messages of mem-
\nber organisations and facilitated coherence
\nand synergy among the messages of nation-
\nal member organisations.
\nThe WHPA had established an expert
\nworking group on collaborative practice to
\nsearch for best practice models of collabora-
\ntive practice in different health care settings
\nand different regions, to advocate for these
\nexamples among WHPA members, and to
\nencourage national or regional organiza-
\ntions to replicate these models.
\nIn the session set aside for representatives to
\nreport on any issue of interest to the Assem-
\nbly, Dr. Cecil Wilson, President of the Ameri-
\ncan Medical Association, spoke about health
\ncare reform in the US. He said that not since
\nthe creation of Medicare providing insur-
\nance for senior citizens in 1965 had America
\nwitnessed such sweeping legislation.The Af-
\nfordable Care Act set out to boldly reform
\nthe American healthcare system to increase
\naccess for millions,reform insurance industry
\npractices and place new emphasis on qual-
\nity and prevention, all while reducing cost.
\nIt remained to be seen whether all the items
\ncould be achieved. But it was already clear
\nthat the right goals were in place and over the
\ncoming months and years the AMA would
\nremain involved every step of the way. They
\nwould push to correct those items the law got
\nwrong, improve those it got right and tackle
\nthose it failed to address.
\nDr. Rudolf Henke, a member of the Medi-
\ncal Council in Germany, talked about phy-
\nsicians\u2019 employment contracts in Germany
\nand serious concerns relating to interference
\nin physicians\u2019 union representation.
\nDr. Douglas Leon Natera from the Venezu-
\nela reported on the freezing of doctors\u2019con-
\ntracts in his country. This had led to 45 per
\ncent of doctors leaving their hospitals, 25
\npercent going into private practice and 15
\npercent to other health care professions.
\nNow thousands of new \u201ccommunity doc-
\ntors\u201d were being educated with lower stan-
\ndards, which would create huge problems
\nnot only for the profession but for patients.
\nEarlier in the week the scientific session
\nwas held on the theme of \u201cHealth and the
\n218
\nWMA news
\nEnvironment\u201d and the keynote speaker was
\nProfessor Sir Michael Marmot, professor of
\nEpidemiology and Public Health at Uni-
\nversity College, London. He spoke about
\nthe 40 year difference in life expectancy
\nbetween different countries and between
\ndifferent regions in the same country. Envi-
\nronment was one reason, but social and eco-
\nnomic factors were another. He compared
\nthe 28 year difference in the life expectancy
\nfor men living in Glasgow, Scotland with
\nthe life expectancy of men in India which
\nis eight years longer than the life expectancy
\nof men in the poorest parts of Glasgow.
\nExplaining why he was an evidence based
\noptimist about the future, he said that be-
\ning rich was not a necessity for a country to
\nimprove life expectancy. Costa Rica had a
\nrelatively low income but remarkably good
\nhealth. It had abolished its military in 1948
\nand put the money into education, social
\nprotection, clean water and health care.
\nNow life expectancy there was the same as
\nin the United Kingdom, yet their gross na-
\ntional income was one third of that in the
\nUK.
\nHis conclusion was: \u201cIf we put fairness at
\nthe heart of all decision-making, health
\nwould improve and health inequities would
\ndiminish\u201d.
\nDr. Diego Bassani, an epidemiologist from
\nthe University of Toronto, spoke about the
\nhuge problem of indoor air quality in de-
\nveloping countries. He presented data on
\nthe effect of using solid fuels inside houses
\nand said people did not realise how low the
\nquality of air was inside the homes of most
\npeople in the world.
\nDr. Dongchun Shin,chair of the Department
\nof Preventive Medicine at Yonsei Univer-
\nsity College of Medicine in Seoul, Korea,
\nspoke about the strategic approach to in-
\nternational chemical management and said
\nthat environmental toxic chemical exposure
\nwas now ubiquitous in our everyday life.
\nHe warned that the world was facing a big
\nenvironmental disaster which he referred to
\nas chemical warfare. Dr. Peter Orris, Chief
\nof the Occupational and Environmental
\nMedicine Clinical Service at the Univer-
\nsity of Illinois at Chicago Medical Center,
\nspoke about the current status of knowledge
\non mercury toxicity and its phasing out in
\nhealth care.
\nDr. Alan Abelsohn, a family physician in
\nToronto, addressed the meeting about the
\nhealth impact of climate change. He talked
\nabout the science of climate change, and the
\ndirect health effects from extreme weather
\nevents which would become more evident.
\nThe indirect effects would include more air
\npollution, air allergens and an increase in
\nvector borne diseases. He said that rather
\nthan bringing new diseases, climate change
\nwould change the distribution of diseases.
\nDr. Lawrence Frank, Bombardier Chair-
\nholder in Sustainable Transportation at
\nthe University of British Columbia, spoke
\nabout the health impact of community de-
\nsign,focused around travel patterns.Dr. Ray
\nCopes, Director of Environmental and Oc-
\ncupational Health at the Ontario Agency
\nfor Health Protection and Promotion in
\nToronto, spoke about adaptive measures
\nat local and regional levels to mitigate the
\nhealth impact of climate change
\nThe last two speakers were Dr. Kue Young,
\nProfessor and TransCanada Pipelines
\nChair in the Dalla Lana School of Public
\nHealth at the University of Toronto, who
\nspoke about Health and Environment in
\nCircumpolar Indigenous Peoples, and Dr.
\nRobin Walker, Vice-President, Medicine at
\nthe IWK Health Centre in Halifax, Nova
\nScotia and a Professor of Paediatrics at Dal-
\nhousie University, who spoke about Child
\nhealth and the environment.
\nThe 2011 WMA General Assembly will be
\nheld in Montevideo, Uruguay from October
\n12 to 15.
\n219
\nWMA news
\nEarlier in the week, a number of issues
\nwere raised during the committee meetings,
\nwhich included:
\nMedical Ethics Committee
\nDr. Torunn Janbu, Chair of the Medical
\nEthics Committee, reported that a docu-
\nment on end-of-life palliative care was be-
\ning prepared by a working group for con-
\nsideration at the next meeting in Sydney,
\nAustralia.
\nDr. Ramin Parsa-Parsi, from Germany, re-
\nported on the workgroup\u2019s progress on de-
\nveloping a proposal for revising paragraph
\n32 of the Declaration of Helsinki. At the
\nexpert conference in Sao Paulo earlier in
\nthe year, the question arose regarding pla-
\ncebo research use in resource poor settings.
\nDr. Parsa-Parsi said another international
\nexpert conference led by the WMA would
\nbe required to resolve this and to develop
\na proposal for a new wording of paragraph
\n32. He recommended holding a conference
\nin the summer of 2011, which Council later
\napproved.
\nAn oral report was received from the
\nworkgroup considering guidance to na-
\ntional medical associations on how best to
\nuse the Declaration of Tokyo, which ad-
\ndresses physician participation in torture.
\nDr. Vivienne Nathanson from the British
\nMedical Association said this was one of
\nthe WMA\u2019s Declarations that was cited
\ninternationally and it was important for
\nnational medical associations to have guid-
\nance on how to respond to allegations of
\nviolations of patients\u2019 health rights and
\nphysicians\u2019 professional ethics in custo-
\ndial settings. A draft document would be
\ncirculated to NMAs for consideration at
\nthe next meeting.
\nSocio-Medical Affairs Committee
\nIt was agreed to circulate for comment revi-
\nsions to the WMA Declaration on Prison
\nConditions and the Spread of Tuberculosis
\nand Other Communicable Diseases.
\nIt was agreed to circulate for comment a state-
\nment on the Global Burden of Chronic Dis-
\nease for consideration at the next meeting.
\nThe Israel Medical Association presented a
\ndraft statement on Violence in the Health
\nWorkplace, arguing that it was a big prob-
\nlem in many countries and yet the WMA
\nhad no policy on the subject. It was agreed
\nto circulate the document to NMAs for
\ncomment and consideration at the next
\nmeeting.
\nThe committee recommended that a work-
\ngroup be set up to consider the social de-
\nterminants of health. Sir Michael Marmot,
\nPresident of the British Medical Associa-
\ntion, presented a draft paper arguing that
\nthe inequalities of the health of the public
\nshould be a core con-
\ncern of the medical
\nprofession and of the
\nWMA.The recommen-
\ndation was approved by
\nthe Council.
\nMr. Nigel Duncan,
\nPublic Relations
\nConsultant, WMA
\n220
\nWMA news
\nThis Statement focuses on one important aspect of environmental
\ndegradation, which is environmental contamination by harmful do-
\nmestic and industrial substances. It emphasizes the harmful chemi-
\ncal contribution to environmental degradation and physicians\u2019 role
\nin promoting sound management of chemicals as part of sustainable
\ndevelopment, especially in the healthcare environment.
\nMost chemicals to which humans are exposed come from indus-
\ntrial sources and include, food additives, household consumer and
\ncosmetic products, agrochemicals, and other substances (drugs;
\ndietary supplements) used for therapeutic purposes.\u00a0 Recently, at-
\ntention has been concentrated on the effects of human engineered
\n(or synthetic) chemicals on the environment, including specific
\nindustrial or agrochemicals and on new patterns of distribution of
\nnatural substances due to human activity.\u00a0 As the number of such
\ncompounds has multiplied, governments and international orga-
\nnizations have begun to develop a more comprehensive approach
\nto their safe regulation.
\nWhile governments have the primary responsibility for establishing
\na framework to protect the public\u2019s health from chemical hazards,
\nthe World Medical Association, on behalf of its members, empha-
\nsizes the need to highlight the human health risks and make recom-
\nmendations for further action.
\nDuring the last half-century, the use of chemical pesticides and
\nfertilizers dominated agricultural practice and manufacturing in-
\ndustries rapidly expanded their use of synthetic chemicals in the
\nproduction of consumer and industrial goods.1
\n\u00a0\u00a0\u00a0 The greatest con-
\ncern relates to chemicals,which persist in the environment,have low
\nrates of degradation, bio-accumulate in human and animal tissue
\n(concentrating as they move up the food chain), and which have
\nsignificant harmful impacts on human health and the environment
\n(particularly at low concentrations).2
\nSome naturally occurring met-
\nals including lead, mercury, and cadmium have industrial sources
\nand are also of concern.\u00a0\u00a0 Advances in environmental health research
\nincluding environmental and human sampling and measuring
\ntechniques, and better information about the potential of low dose
\nhuman health effects have helped to underscore emerging concerns.
\nHealth effects from chemical emissions can be direct (occurring as
\nan immediate effect of the emission) or indirect. Indirect health ef-
\nfects are caused by the emissions\u2019effects on water, air and food qual-
\nity as well as the alterations in regional and global systems, such as
\nred tide in many oceans, and the ozone layer and the climate, to
\nwhich the emissions may contribute.
\nThe model of regulation of chemicals varies widely both within and
\nbetween countries, from voluntary controls to statutory legislation.\u00a0\u00a0
\nIt is important that all countries move to a coherent, standardized
\nnational legislated approach to regulatory control.\u00a0 Furthermore,
\ninternational regulations must be coherent such that developing
\ncountries will not be forced by economic circumstances to circum-
\nvent potentially weak national regulations.\u00a0 An example of a leg-
\nislative framework can be found at http:\/\/ec.europa.eu\/environment\/
\nchemicals\/index.htm.
\nSynthetic chemicals include all substances that are produced by, or
\nresult from, human activities including industrial and household
\nchemicals, fertilizers, pesticides, chemicals contained in products
\nand in wastes, prescription\u00a0 and over-the-counter drug products
\nand dietary supplements, and unintentionally produced byproducts
\nof industrial processes or incineration, like dioxins.\u00a0 Furthermore,
\nnanomaterials, in some circumstances, can be regulated by synthetic
\nchemicals regulations but in other cases, may need explicit regula-
\ntion.
\nSeveral notable agreements on chemicals exist.These were prompt-
\ned by the first United Nations Conference on the Human Envi-
\nronment declaration in 1972 (Stockholm) on the discharge of toxic
\nsubstances into the environment.3
\nThese agreements include the
\n1989 Basel Convention to control\/prevent trans-boundary move-
\nments of hazardous wastes, the 1992 Rio Declaration on Envi-
\nronment and Development, the 1998 Rotterdam Convention on
\ninformed consent and shipment of hazardous substances, and the
\n2001 Stockholm Convention on Persistent Organic Pollutants.4 5 6
\nIt should be noted that little information is available on the efficacy
\nof the controls.
\nWorldwide hazardous environmental contamination persists de-
\nspite these agreements, making a more comprehensive approach
\n221
\nWMA news
\nto chemicals essential. Reasons for ongoing contamination include
\npersistence of companies, absolute lack of controls in some coun-
\ntries, lack of awareness of the potential hazards, inability to apply
\nthe precautionary principle, non-adherence to the various conven-
\ntions and treaties and lack of political will.\u00a0 The Strategic Approach
\nto International Chemicals Management (SAICM) was adopted in
\nDubai, on February 6, 2006 by delegates from over 100 govern-
\nments and representatives of civil society.\u00a0 This is a voluntary global
\nplan of action designed to assure the sound management of chemi-
\ncals throughout their life cycle so that, by 2020, chemicals are used
\nand produced in ways that minimize significant adverse effects on
\nhuman health and the environment.\u00a0 The SAICM addresses both
\nagricultural and industrial chemicals, covers all stages of the chemi-
\ncal life cycle of manufacture, use and disposal, and includes chemi-
\ncals in products and in wastes.7
\nDespite these national and international initiatives, chemical con-
\ntamination of the environment due to inadequately controlled
\nchemical production and usage continues to exert harmful effects
\non global public health.\u00a0 Evidence linking some chemicals to some
\nhealth issues is strong,but there is not evidence for all chemicals,es-
\npecially newer or nano materials, particularly at low doses over long
\nperiods of time.\u00a0 Physicians and the healthcare sector are frequently
\nrequired to make decisions concerning individual patient and the
\npublic as a whole based on existing data.\u00a0 Physicians therefore cau-
\ntion that they, too, have a significant role to play in closing the gap
\nbetween policy formation and chemicals management and in reduc-
\ning risks to human health.
\nNational Medical Associations (NMAs) advocate for legisla-
\ntion that reduces chemical pollution, reduces human exposure
\nto chemicals, detects and monitors harmful chemicals in both
\nhumans and the environment, and mitigates the health effects
\nof toxic exposures with special attention to vulnerability during
\npregnancy and early childhood.
\nNMAs urge their governments to support international efforts
\nto restrict chemical pollution through safe management, or phase
\nout and safer substitution when unmanageable (e.g. asbestos),
\nwith particular attention to developed countries aiding develop-
\ning countries to achieve a safe environment and good health for
\nall.
\nNMAs facilitate better communication between government
\nministries\/departments responsible for the environment and pub-
\nlic health.
\nPhysicians and their medical associations advocate for environ-
\nmental protection, disclosure of product constituents, sustainable
\ndevelopment, and green chemistry within their communities,
\ncountries and regions.
\nPhysicians and their medical associations should support the
\nphase out of mercury and persistent bioaccumulative and toxic
\nchemicals in health care devices and products.
\nPhysicians and their medical associations should support legisla-
\ntion to require an environmental and health impact assessment
\nprior to the introduction of a new chemical or a new industrial
\nfacility.
\nPhysicians should encourage the publication of evidence of the
\neffects of different chemicals and dosages on human health and
\nthe environment.\u00a0 These publications should be accessible inter-
\nnationally and readily available to media, non-governmental or-
\nganizations (NGOs) and concerned citizens locally.
\nPhysicians and their medical associations advocate for the de-
\nvelopment of effective and safe systems to collect and dispose of
\npharmaceuticals that are not consumed.
\nPhysicians and their medical associations should support efforts
\nto rehabilitate or clean areas of environmental degradation based
\non a \u201cpolluter pays\u201d and precautionary principles and ensure that
\nmoving forward, such principles are built into legislation.
\nThe WMA, NMAs and physicians should urge governments to
\ncollaborate within and between departments to ensure coherent
\nregulations are developed.
\nSupports the goals of the Strategic Approach to International
\nChemicals Management (SAICM), which promotes best prac-
\ntices in the handling of chemicals by utilizing safer substitution,
\nwaste reduction, sustainable non-toxic building, recycling, as well
\nas safe and sustainable waste handling in the health care sector.\u00a0
\nCautions that these chemical practices must be coordinated with
\nefforts to reduce green house gas emissions from health care to
\nmitigate its contribution to global warming.
\nUrges physicians, medical associations and countries to work
\ncollaboratively to develop systems for event alerts to ensure that
\nhealth care systems and physicians are aware of high-risk indus-
\ntrial accidents as they occur, and receive timely accurate informa-
\ntion regarding the management of these emergencies.
\nUrges local, national and international organizations to focus on
\nsustainable production, safer substitution, green safe jobs, and
\nconsultation with the health care community to ensure that dam-
\naging health impacts of development are anticipated and mini-
\nmized.
\nEmphasizes the importance of the safe disposal of pharmaceuti-
\ncals as one aspect of health care\u2019s responsibility and the need for
\n222
\nWMA news
\ncollaborative work in developing best practice models to reduce
\nthis part of the chemical waste problem.
\nEncourages environmental classification of pharmaceuticals in
\norder to stimulate prescription of environmentally less harmful
\npharmaceuticals.
\nEncourages ongoing outcomes research on the impact of regu-
\nlations and monitoring of chemicals on human health and the
\nenvironment.
\nWork to reduce toxic medical waste and exposures within their
\nprofessional settings as part of the World Health Professional Al-
\nliance\u2019s campaign for Positive Practice Environments.
\nWork to provide information on the health impacts associated
\nwith exposure to toxic chemicals, how to reduce patient exposure
\nto specific agents and encourage behaviours that improve overall
\nhealth.
\nInform patients about the importance of safe disposal of pharma-
\nceuticals that are not consumed.
\nWork with others to help address the gaps in research regarding
\nthe environment and health (i.e., patterns and burden of disease
\nattributed to environmental degradation; community and house-
\nhold impacts of industrial chemicals; the most vulnerable popula-
\ntions and protections for such populations).
\nPhysicians and their professional associations assist in building
\nprofessional and public awareness of the importance of the envi-
\nronment and global chemical pollutants on personal health.
\nNational Medical Associations (NMAs) and physician profes-
\nsional associations develop tools for physicians to help assess their
\npatients\u2019 risk from chemical exposures.
\nPhysicians and their professional associations develop locally
\nappropriate continuing medical education on the clinical signs,
\ndiagnosis and treatment of diseases that are introduced into com-
\nmunities as a result of chemical pollution and exacerbated by cli-
\nmate change.
\nEnvironmental health and occupational medicine should become
\na core theme in medical education.\u00a0 Medical schools should en-
\ncourage in the training of sufficient specialists in environmental
\nhealth and occupational medicine.
\n1. Wiser G, Center for International Environmental Law, UNEP Forum,
\nSept. 2005
\n2. http:\/\/www.unep.org\/hazardoussubstances\/Introduction\/tabid\/258\/lan-
\nguage\/en-US\/Default.aspx
\n3. http:\/\/www.unep.org\/Documents.Multilingual\/Default.asp?DocumentID
\n=97&ArticleID=1503&l=en
\n4. http:\/\/www.unep.org\/Documents.Multilingual\/Default.asp?DocumentID
\n=78&ArticleID=1163
\n5. Wiser G, Center for International Environmental Law, UNEP Forum,
\nSept. 2005
\n6. http:\/\/chm.pops.int\/Convention\/tabid\/54\/language\/en-US\/Default.aspx
\n7. http:\/\/www.chem.unep.ch\/saicm\/SAICM%20texts\/SAICM%20docu-
\nments.htm
\nAdopted by the 48th
\nGeneral Assembly Somerset West, Republic of
\nSouth Africa, October 1996, editorially revised at the 174th
\nCouncil
\nSession, Pilanesberg, South Africa, October 2006 and amended by
\nthe WMA General Assembly, Vancouver, Canada, October 2010
\nRecalling the World Medical Association Declaration of Hong
\nKong on the Abuse of the Elderly and the World Medical Associa-
\ntion Statement on Child Abuse and Neglect, and profoundly con-
\ncerned with violence as a public health issue, the World Medical
\nAssociation calls upon National Medical Associations to intensify
\nand broaden their efforts to address the universal problem of family
\nviolence.
\nFamily violence is a term applied to physical and\/or emotional
\nmistreatment of a person by someone in an intimate relationship
\nwith the victim. The term includes domestic violence (sometimes
\nreferred to as partner,spouse,or wife battering),child physical abuse
\nand neglect, child sexual abuse, maltreatment of older people, and
\nmany cases of sexual assault. Family violence can be found in every
\ncountry in the world, cutting across gender and all racial, ethnic,
\nreligious and socio-economic lines. Although case definitions vary
\nfrom culture to culture, family violence represents a major public
\nhealth problem by virtue of the many deaths, injuries, and adverse
\npsychological consequences that it causes. The physical and emo-
\ntional harm may represent chronic or even lifetime disabilities for
\nmany victims. Family violence is associated with increased risk of
\ndepression, anxiety, substance abuse, and self-injurious behaviour,
\nincluding suicide.Victims often become perpetrators or become in-
\nvolved in violent relationships later on. Although the focus of this
\ndocument is the welfare of the victim, the needs of the perpetrator
\nshould not be overlooked.
\nAlthough the causes of family violence are complex, a number of
\ncontributing factors are known. These include poverty, unemploy-
\nment, other exogenous stresses, attitudes of acceptance of violence
\nfor dispute resolution, substance abuse (particularly alcohol),
\nrigid gender roles, poor parenting skills, ambiguous family roles,
\n223
\nWMA news
\nunrealistic expectations of other family members, interpersonal
\nconflicts within the family, actual or perceived physical or psycho-
\nlogical vulnerability of victims by perpetrators, perpetrator pre-
\noccupation with power and control, and familial social isolation,
\namong others.
\nThere is a growing awareness of the need to think about and take
\naction against family violence in a unified way, rather than focusing
\non the particular type of victim or community affected. In many
\nfamilies where partner battering occurs, for example, there may be
\nabuse of children and\/or of older people as well, often carried out by
\na single perpetrator. In addition, there is substantial evidence that
\nchildren who are victimized or who witness violence against oth-
\ners in the family are later at increased risk as adolescents or adults
\nof being re-victimized and\/or becoming perpetrators of violence
\nthemselves. Finally, more recent data suggest that victims of family
\nviolence are more likely to become perpetrators of violence against
\nnon-intimates as well. All of this suggests that each instance of
\nfamily violence may have implications not only for further family
\nviolence, but also for the broader spread of violence throughout a
\nsociety.
\nPhysicians and NMAs should oppose violent practices such as dow-
\nry killings and honour killings.
\nPhysicians and NMAs should oppose the practice of child marriage.
\nPhysicians have important roles to play in the prevention and treat-
\nment of family violence. Of course they will manage injuries, ill-
\nnesses,and psychiatric problems deriving from the abuse.The thera-
\npeutic relationships physicians have with patients may allow victims
\nto confide in them about current or past victimization. Physicians
\nshould inquire about violence routinely, as well as when they see
\nparticular clinical presentations that may be associated with abuse.
\nThey can help patients to find methods of achieving safety and ac-
\ncess to community resources that will allow protection and\/or inter-
\nvention in the abusive relationship.They can educate patients about
\nthe progression and adverse consequences of family violence, stress
\nmanagement and availability of relevant mental health treatment,
\nand parenting skills as ways of preventing the violence before it oc-
\ncurs. Finally, physicians as citizens and as community leaders and
\nmedical experts can become involved in local and national activities
\ndesigned to decrease family violence.
\nPhysicians recognise that victims of violence may find it difficult
\nto trust their physician at first. Physicians must be prepared to de-
\nvelop a trusting relationship with their patient over time until s\/he
\nis ready to accept advice, help and intervention.
\nThe World Medical Association recommends that National Medi-
\ncal Associations adopt the following guidelines for physicians:
\nAll physicians should receive adequate training in the medical,
\nsociological, psychological and preventive aspects of all types of
\nfamily violence. This would include medical school training in
\nthe general principles, specialty-specific information during post-
\ngraduate training, and continuing medical education about family
\nviolence.Trainees must receive adequate instruction in the role of
\ngender, power and other issues of family dynamics in contribut-
\ning to family violence. The training should also include adequate
\ncollecting of evidence, documentation and reporting in cases of
\nabuse.
\nPhysicians should know how to take an appropriate and culturally
\nsensitive history of current and past victimization.
\nPhysicians should routinely consider and be sensitive to signs in-
\ndicating the need for further evaluations about current or past
\nvictimization as part of their general health screen or in response
\nto suggestive clinical findings.
\nPhysicians should be encouraged to provide pocket cards, book-
\nlets, videotapes, and\/or other educational materials in reception
\nrooms and emergency departments to offer patients general in-
\nformation about family violence as well as to inform them about
\nlocal help and services.
\nPhysicians should be aware of social, community and other ser-
\nvices of use to victims of violence, and refer to and use these rou-
\ntinely.
\nPhysicians have the obligation to consider reporting to appro-
\npriate protection services suspected violence against children and
\nother family members without legal capacity.
\nPhysicians should be acutely aware of the need for maintaining
\nconfidentiality in cases of family violence.
\nPhysicians should be encouraged to participate in coordinated
\ncommunity activities that seek to reduce the amount and impact
\nof family violence.
\nPhysicians should be encouraged to develop non-judgemental
\nattitudes toward those involved in family violence so their
\nability to influence victims, survivors and perpetrators is en-
\nhanced. For example, the behaviour should be judged but not
\nthe person.
\nNational Medical Associations should encourage and facili-
\ntate coordination of action against family violence between and
\namong components of the health care system,criminal justice sys-
\ntems, law enforcement authorities, family and juvenile courts, and
\nvictims\u2019 services organizations. They should also support public
\nawareness and community education.
\nNational Medical Associations should encourage and facilitate
\nresearch to understand the prevalence, risk factors, outcomes and
\noptimal care for victims of family violence.
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\nWMA news
\nViolence is a worldwide, institutionalised phenomenon, and a com-
\nplex issue, which includes many manifestations.\u00a0 The nature of the
\nviolence experienced by victims is at least partly dependent upon
\nthe social, cultural, political and economic contexts within which
\nthe victims and their abusers live.\u00a0 Some violence is deliberate, sys-
\ntematic and widespread while others will experience it in covert cir-
\ncumstances; this is especially true of domestic violence in settings
\nwhere women enjoy legislated equal and protected rights to those of
\nmen but culturally still have an increased likelihood of experiencing
\nlife-threatening domestic violence.
\nThere is clear evidence in most countries that men can be and are
\noften the victims of violence, including intimate partner violence.\u00a0
\nThey are also statistically far more likely to be the victims of random
\nviolence on the streets.\u00a0 Research shows that while men frequently
\nexperience such events, they are not associated with systemic abuse
\nin terms of denial of rights, which makes the experience of women
\nso much worse in many cultures.Nothing in this paper suggests that
\nviolence against men including boys should be condoned.\u00a0 Actions
\nto protect women and girls are likely to reduce everyone\u2019s experience
\nof violence.
\nDefinitions of violence vary (see footnote), but it is essential that the
\nvarious forms violence may take are recognised by policy makers.\u00a0
\nViolence against women and girls includes violence within the family,
\nwithin the community and violence perpetrated by (or condoned by)
\nthe state.\u00a0 Many excuses are given for violence generally and spe-
\ncifically; in cultural and societal terms these include tradition, beliefs,
\ncustoms, values and religion. Although rarely cited the traditional
\npower differential between men and women is also a major cause.
\nWithin the family and domestic settings violence includes the de-
\nnial of rights and freedoms enjoyed by boys and men.\u00a0 This includes
\nfemale feticide and infanticide, systematic and deliberate neglect of
\ngirls, including poor nutrition and denial of educational opportuni-
\nties1
\nas well as direct physical, psychological and sexual violence.\u00a0
\nSpecific cultural practices that harm women, including female
\ngenital mutilation, forced marriages, dowry attacks and so-called
\n\u201chonour\u201d killings are all practices that may occur within the family
\nsetting.
\nWithin society, attitudes towards rape, sexual abuse and harass-
\nment,intimidation at work or in education,modern slavery,traffick-
\ning and forced prostitution, are all forms of violence condoned by
\nsome societies. One extreme form of such violence is sexual violence
\nused as a weapon of war. In several recent conflicts (e.g. the Balkans,
\nRwanda) rape was both associated with ethnic cleansing and spe-
\ncifically, in some cases, used to introduce widespread AIDS into a
\ncommunity.\u00a0The ICRC has examined this issue, and recognises that
\nsexual violence of this sort may be commonly perpetrated against
\nwomen and girls.2
\n\u00a0\u00a0
\nSexual violence or the threat of it can also be used against men, but
\nculturally, women are more vulnerable and more likely to be targeted.\u00a0
\nCurrent conflicts are not based upon battles fought in far away places,
\nbut are increasingly concentrated around dense centres of population
\nincreasing the exposure of women to soldiers and armed groups. In
\nwar and in immediate post-conflict situations, societal fabric can col-
\nlapse, making women increasingly vulnerable to group attacks.
\nLack of economic independence, and of basic education, also mean
\nthat women who survive abuse are more likely to be or to become
\nmore dependent upon the state or society and less able to support
\nthemselves and contribute to that society. Biologically and behav-
\niourally, women are likely to outlive men; denial of the opportu-
\nnity to be economically independent leaves society with a cohort of
\nolder, economically dependent women.
\nAll these forms of violence may be condoned by the state, or it may
\nremain silent on them, refusing to condemn or act against them.\u00a0
\nIn some cases the state may legislate to allow violent practices (for
\nexample rape within marriage) and itself become a perpetrator.
\nAll human beings enjoy certain fundamental human rights; the
\nexamples listed above of violence against women and girls involve
\ndenial of many of those rights, and each abuse can be examined
\nagainst the UN convention on human rights\u00a0 (and for children the
\nConvention on the Rights of the Child).3
\n\u00a0
\nIn health terms, the denial of rights and the violence itself have
\nhealth consequences to the girls and women and to the society of
\nwhich they are a part.\u00a0 In addition to the specific and direct physical
\nand health consequences, the general way in which girls and women
\nare treated can lead to an excess of mental health problems; suicide
\nis the second leading cause of premature death in women.
\nThe direct health consequence of the violence depends upon the na-
\nture of the act. Female genital mutilation for example may kill the
\nwoman at the time of infliction, may lead to difficulty in voiding the
\nbody of waste products including those of menses,and will give rise to
\ndifficulties in childbearing. It also reinforces the ideological concept
\nof women as the possessions of men (on its own,a form of abuse) who
\n225
\nWMA news
\ncontrol their sexuality. Gang rape or other forms of sexual violence
\nmay result in long-term gynaecological, urological and intestinal
\ndifficulties including the development of fistulae and incontinence,
\nwhich further diminishes societal support for the abused female.
\nThe short and long term mental health consequences of violence
\nmay severely influence later wellbeing, enjoyment of life, function in
\nsociety and the ability to provide appropriate care for dependants.
\nGathering evidence is an important role for doctors.\u00a0 Currently
\nmany countries do not have mandatory registration of all births,
\nmaking evidence about infanticide or the effects of neglect difficult
\nto document.\u00a0 Equally, some countries allow marriage at any age,
\nexposing girls to the high risks associated with childbearing before
\ntheir own bodies are fully mature, let alone the mental health risks
\ninvolved.\u00a0 The health consequences of such policies and their rela-
\ntionship to other health costs must be better documented.
\nDenial of good nutritional opportunities leads to generations of
\nwomen with poorer health, poorer growth and development leading
\nto women who are less fit to survive pregnancy and childbirth or to
\nrear their families.\u00a0 Denial of educational opportunities leads to poor-
\ner health for all the family members; good education is a major factor
\nin the mother providing optimal care for all her family. In addition to
\nbeing wrong in and of itself, violence against women is also socially
\nand economically damaging to the family and to society.\u00a0 There are
\ndirect and indirect economic consequences to violence against women
\nthat are far greater than the direct health sector costs.
\nThe costs and consequences of violence, including neglect, against
\nwomen have been reported in many fora including by WHO4
\n.The
\nhealth consequences to the women, their children and thus to soci-
\nety are clear and need to be made explicit to policy makers.
\nThe WMA has a number of policies on violence including the
\nWMA Statement on Violence and Health and the WMA State-
\nment on Family Violence.\u00a0This current (Statement\/resolution\/ dec-
\nlaration) brings some of these policies together with a coordinated
\nset of action points for the WMA,NMAs and individual physicians.
\nAs most human beings look first for the advantages to themselves,their
\nfamilies and their societies in enabling change, making the benefits of
\nchange obvious from the beginning creates a \u201cwin:win\u201dsolution. Con-
\ncentrating first on the health aspects,for women,their children,and the
\nbroad family is therefore a useful way to enter the debate.
\nDoctors have a unique insight into the combined effects upon well-
\nbeing of social, cultural, economic and political environments.\u00a0 If all
\npersons are to achieve health and wellbeing, all these factors need
\nto operate positively.\u00a0 The holistic view from doctors can be used to
\ninfluence society and politicians. Gaining societal support for im-
\nproving the rights, freedom and status of women is essential.
\nAsserts that violence is not only about physical, psychological and
\nsexual violence but includes abuses such as harmful cultural and
\ntraditional practices, and actions such as complicity in trafficking
\nof women, and is a major public health crisis.
\nRecognizes the linkage between better education and other rights
\nfor women with family and societal health and wellbeing and
\nemphasizes that equality in civil liberties and human rights is a
\nhealth issue.
\nWill prepare briefing and advocacy materials for NMAs to use
\nwith national governments and intergovernmental groups ad-
\ndressing the health and wellbeing implications of discrimination
\nagainst women and girls, including adolescents.This material will
\ninclude relevant references about the impact of violence on family
\nwellbeing and on societal financial sustainability
\nWill work with others to prepare and distribute to physicians and
\nother health workers briefing and advocacy materials dealing with
\nharmful traditional and cultural practices, including female geni-
\ntal mutilation, dowry, and honour killings, and emphasizing the
\nhealth impact as well as the violations of human rights.
\nPrepare practical examples of the impact of violence and strate-
\ngies for reducing it, such as consensus guidelines that are based
\nupon the best available evidence.
\nWill advocate at WHO, other UN agencies and elsewhere for
\nending discrimination and violence against women.
\nWill work with others to prepare templates of educational ma-
\nterials for use by individual practitioners for documenting and
\nreporting individual cases of abuse.
\nEncourages others to develop free educational materials online to
\nprovide guidance to front line health care workers on abuse and
\nits effects, and on prevention strategies.
\nEncourage legislation that classifies gang rape used as a weapon
\nof war as a crime against humanity that is eligible for litigation
\nthrough the jurisdiction of the International Criminal Court sys-
\ntem.
\nUse and promote the available materials on preventing and treat-
\ning the consequences of violence against women and girls and act
\nas advocates within their own country.
\nSeek to ensure that those devising and delivering education to
\ndoctors and other health care workers are aware of the likelihood
\nof exposure to violence, its consequences, and the evidence on
\n226
\nWMA news
\npreventative strategies that work, and place appropriate emphasis
\non this in undergraduate, graduate and continuing education of
\nhealth care workers.
\nRecognise the importance of more complete reporting of the
\nsequelae of violence and encourage the development of training
\nthat emphasises violence awareness and prevention, in addition to
\nusing better reporting and research into incidence, prevalence and
\nhealth impact of all forms of violence.
\nEncourage medical journals to publish more of the research on
\nthe complex interactions in this area, thus keeping it in the pro-
\nfessions\u2019awareness and contributing to the development of a solid
\nresearch base and ongoing documentation of types and incidence
\nof violence.
\nEncourage medical journals to consider publishing theme issues
\non violence including neglect of women and girls.
\nAdvocate for universal registration of births, and a higher age
\nlimit for marriage.
\nAdvocate for effective implementation of universal human rights.
\nAdvocate for parental education and support on the care, nurtur-
\ning, development, education and protection of children, especially
\ngirls.
\nAdvocate for the monitoring of statistics on children, including
\nboth positive and negative indicators of health and well-being,
\nand social determinants of health.
\nAdvocate for legislation against specific harmful practices includ-
\ning female feticide, female genital mutilation, forced marriage,
\nand corporal punishment.
\nAdvocate for the criminalisation of rape in all circumstances in-
\ncluding within marriage.
\nCondemn the use of gang rape as a weapon of war and work with
\nothers to document and report it.
\nAdvocate for the development of research data on the impact of
\nviolence and neglect upon primary and secondary victims and
\nupon society, and for increased funding for such research.
\nAdvocate for the protection of those who speak out against abuse,
\nincluding physicians and other health workers.
\nUse the material developed for their education to better inform
\nthemselves about the effects of abuse and the successful strategies
\nfor prevention.
\nProvide health care and protection to children, (especially in
\ntimes of crisis) and document and report all cases of violence
\nagainst children, taking care to safeguard the patient\u2019s privacy as
\nmuch as possible.
\nTreat and reverse, where possible, the complications and adverse
\neffects of female genital mutilation and refer the patient for social
\nsupport services.
\nOppose the publication or broadcast of victims\u2019 names, addresses
\nor likenesses without the explicit permission of the victim.
\nAssess for risk of family violence in the context of taking a routine
\nsocial history.
\nBe alert to the association between current alcohol or drug depen-
\ndence among women and a history of abuse.
\nSupport colleagues who become personally involved in work to
\nend abuse.
\nWork to establish the necessary relationship of trust with abused
\nwomen and children including respect for confidentiality.
\nSupport global and local action to better understand the health con-
\nsequences both of abuse and of the denial of rights, and advocate for
\nincreased services for victims.
\nReferences
\n1. At first glance neglect does not seem to equate with violence.\u00a0 But the accept-
\nance of neglect and the lesser rights given to women and girls are major factors
\nin reinforcing an acceptance of causal and systematic violence.\u00a0In that it denies
\nbasic rights,many would classify neglect as a form of violence in and of itself.
\n2. Rape is considered to be a method of warfare when armed forces or groups
\nuse it to torture, injure, extract information, degrade, displace, intimidate,
\npunish or simply to destroy the fabric of the community, The mere threat
\nof sexual violence can cause entire communities to flee their homes.\u00a0 from
\nWomen and War, ICRC 2008
\n3. Women\u2019s Health and Human Rights: the Promotion and Protection of
\nWomen\u2019s Health through International Human Rights Law.\u00a0 Rebecca
\nCook.\u00a0 Presented at the 1999 Adapting to Change Core Course
\n4. Women and Health: Today\u2019s Evidence, Tomorrow\u2019s Agenda. WHO No-
\nvember 2009. ISBN 978 92 4 156385 7
\nAdopted by the 50th
\nWorld Medical Assembly Ottawa, Canada,
\nOctober 1998, reaffirmed by the WMA General Assembly, Seoul,
\nKorea, October 2008 and amended by the WMA General Assem-
\nbly, Vancouver, Canada, October 2010
\nInternational and civil conflicts as well as poverty and hunger re-
\nsult in large numbers of refugees, including asylum seekers, refused
\nasylum seekers and undocumented migrants, as well as internally
\ndisplaced persons (IDPs) in all regions.These persons are among the
\nmost vulnerable in society.
\nInternational codes of human rights and medical ethics, includ-
\ning the WMA Declaration of Lisbon on the Rights of the Patient,
\n227
\nWMA news
\ndeclare that all people are entitled without discrimination to appro-
\npriate medical care. However, national legislation varies and is often
\nnot in accordance with this important principle.
\nPhysicians have a duty to provide appropriate medical care regard-
\nless of the civil or political status of the patient, and governments
\nshould not deny patients the right to receive such care, nor should
\nthey interfere with physicians\u2019obligation to administer treatment on
\nthe basis of clinical need alone.
\nPhysicians cannot be compelled to participate in any punitive or
\njudicial action involving refugees, including asylum seekers, refused
\nasylum seekers and undocumented migrants, or IDPs or to admin-
\nister any non-medically justified diagnostic measure or treatment,
\nsuch as sedatives to facilitate easy deportation from the country or
\nrelocation.
\nPhysicians must be allowed adequate time and sufficient resources
\nto assess the physical and psychological condition of refugees who
\nare seeking asylum.
\nNational Medical Associations and physicians should actively sup-
\nport and promote the right of all people to receive medical care on
\nthe basis of clinical need alone and speak out against legislation and
\npractices that are in opposition to this fundamental right.
\nAdopted by the 51st
\nWorld Medical Assembly Tel Aviv, Israel, Oc-
\ntober 1999 and amended by the WMA General Assembly,Vancou-
\nver, Canada, October 2010
\nThe goal of pharmacological treatment is to improve patients\u2019health
\nand quality of life. Optimal pharmacological treatment should be
\nsafe, effective and efficient. There should be equity of access to this
\nkind of treatment and an accurate and up-to-date information base
\nthat meets the needs of patients and practitioners.
\nPharmacological treatment has become increasingly complex, often
\nrequiring the input of a multi-disciplinary team to administer and
\nmonitor the chosen therapy. In the hospital setting the inclusion of
\na clinical pharmacist in such a team is increasingly common and
\nhelpful. The right to prescribe medicine should be competency
\nbased and ideally the responsibility of the physician.
\nPhysicians and pharmacists have complementary and supportive
\nresponsibilities in achieving the goal of providing optimal pharma-
\ncological treatment.This requires communication, respect, trust and
\nmutual recognition of each other\u2019s professional competence. Access
\nby both physicians and pharmacists to the same accurate and up-to-
\ndate information base is important to avoid providing patients with
\nconflicting information.
\nPhysicians and pharmacists must provide quality service to their
\npatients and ensure safe use of drugs. Therefore collaboration be-
\ntween these professions is imperative, including with respect to the
\ndevelopment of training and in terms of information sharing with
\none another and with patients. It is necessary to keep an open and
\ncontinued dialogue between physicians\u2019 and pharmacists\u2019 represen-
\ntative organizations in order to define each profession\u2019s respective
\nfunctions and promote the optimal use of drugs within a framework
\nof transparency and cooperation, all in the best interests of patients.
\nDiagnosing diseases on the basis of the physician\u2019s education and
\nspecialized skills and competence.
\nAssessing the need for pharmacological treatment and prescribing
\nthe corresponding medicines in consultation with patients, pharma-
\ncists and other health care professionals, when appropriate.
\nProviding information to patients about diagnosis, indications and
\ntreatment goals, as well as action, benefits, risks and potential side ef-
\nfects of pharmacological treatment.In the case of off-label prescriptions
\nthe patient must be informed about the character of the prescription.
\nMonitoring and assessing response to pharmacological treatment,
\nprogress toward therapeutic goals, and, as necessary, revising the
\ntherapeutic plan in collaboration with pharmacists, other health
\nprofessionals and, when appropriate, caregivers.
\nProviding and sharing information in relation to pharmacological
\ntreatment with other health care practitioners.
\nLeading the multi-disciplinary team of health professionals respon-
\nsible for managing complex pharmacological treatment.
\nMaintaining adequate records for each patient, according to the
\nneed for therapy and in compliance with legislation respecting con-
\nfidentiality and protecting the patient\u2019s data.
\n228
\nWMA news
\nWhere practically possible, actively participating in establishing
\nelectronic drug delivery systems within their workplace and sup-
\nporting those systems with their professional knowledge.
\nMaintaining a high level of knowledge of pharmacological treat-
\nment through continuing professional development.
\nEnsuring safe procurement and storage of medicines that the physi-
\ncian is required to supply or permitted to dispense.
\nReviewing prescription orders to identify interactions, allergic reac-
\ntions, contra-indications and therapeutic duplications.
\nReporting adverse reactions to medicines to health authorities, in
\naccordance with national legislation.
\nMonitoring and limiting, where appropriate, prescriptions of medi-
\ncations that may have addictive properties.
\nDocumenting adverse reactions to medicines in the patient\u2019s medi-
\ncal record.
\nEnsuring safe procurement, adequate storage and dispensing of
\nmedicines in compliance with the relevant regulations.
\nProviding information to patients, which may include the informa-
\ntion leaflet, name of the medicine, its purpose, potential interactions
\nand side effects, as well as correct usage and storage.
\nReviewing prescription orders to identify interactions, allergic re-
\nactions, contra-indications and therapeutic duplications. Concerns
\nshould be discussed with the prescribing physician but the phar-
\nmacist should not change the prescription without consulting the
\nprescriber.
\nDiscussing medicine-related problems or concerns with regard to
\nthe prescribed medicines when appropriate and when requested by
\nthe patient.
\nAdvising patients, when appropriate, on the selection and the use of
\nnon-prescription medicines and the patient\u2019s management of minor
\nsymptoms or ailments. Where self-medication is not appropriate,
\nadvising patients to consult their physician for diagnosis and treat-
\nment.
\nParticipating in multi-disciplinary teams concerning complex phar-
\nmacological treatment in collaboration with physicians and other
\nhealth care providers, typically in a hospital setting.
\nReporting adverse reactions to medicines to the prescribing physi-
\ncian and to health authorities in accordance with national legisla-
\ntion.
\nProviding and sharing general as well as specific medicine-related in-
\nformation and advice with the public and health care practitioners.
\nMaintaining a high level of knowledge of pharmacological treat-
\nment through continuing professional development.
\nThe patient will best be served when pharmacists and physicians
\ncollaborate, recognizing and respecting each other\u2019s roles, to ensure
\nthat medicines are used safely and appropriately to achieve the best
\noutcome for the patient\u2019s health.
\nAdopted by the WMA General Assembly, Vancouver, Canada, Oc-
\ntober 2010
\nFrom the beginning of their studies and throughout their profes-
\nsional careers, doctors acquire the knowledge, training and compe-
\ntence required to treat their patients with the utmost skill and care.
\nPhysicians determine the most accurate diagnosis and the most ef-
\nfective treatment to cure illness, or alleviate its effects, taking into
\nconsideration the overall condition of the patient.
\nPharmaceutical products are often an essential part of the treatment
\napproach.\u00a0 In order to make the right decisions in accordance with
\nthe ethical and professional principles of medical practice, the doc-
\ntor must have a thorough knowledge and understanding of the prin-
\nciples of pharmacology and possible interactions among different
\ndrugs and their effects on the health of the patient.
\nThe prescribing of medication is a significant clinical intervention,
\nwhich should be preceded by multiple, integrated processes to as-
\nsess the patient and determine the correct clinical diagnosis. These
\nprocesses include:
\nTaking a history of the current condition and past medical his-
\ntory;
\nThe ability to make differential diagnosis;
\nUnderstanding any multiple chronic and complex illnesses in-
\nvolved;
\n229
\nWMA news
\nTaking a history of the medications currently being administered
\nsuccessfully or previously withdrawn and also being aware of pos-
\nsible interactions.
\nInappropriate drug prescription without proper knowledge and accu-
\nrate diagnosis may cause serious adverse effects on the patient\u2019s health.
\nIn view of the possible serious consequences that may result from an
\ninappropriate therapeutic decision, the WMA affirms the following
\nprinciples on high quality treatment and ensuring patient safety:
\nPrescription of drugs should be based on a correct diagnosis of the
\npatient\u2019s condition and should be performed by those who have suc-
\ncessfully completed a curriculum on disease mechanisms, diagnostic
\nmethods and medical treatment of the condition in question.
\nPrescriptions issued by physicians are vital for ensuring patient safe-
\nty, which in turn is critical for maintaining the relationship of trust
\nbetween patients and their physicians.
\nAlthough nurses and other healthcare workers cooperate in the
\noverall treatment of patients, the physician is the best qualified in-
\ndividuals to prescribe independently. In some countries, laws may
\nallow for other professionals to prescribe drugs under specific cir-
\ncumstances, generally with extra training and education and most
\noften under medical supervision. In all cases, the responsibility for
\nthe patient\u2019s treatment must remain with the physician. Each coun-
\ntry\u2019s medical system should ensure the protection of public interest
\nand safety in the diagnosis and treatment of patients. If a system
\nfails to comply with this basic framework due to social, economical
\nor other compelling reasons, it should make every effort to improve
\nthe situation and to protect the safety of the patients.
\nThe World Medical Association added its
\nsupport to worldwide calls for an immedi-
\nate inquiry into allegations that more than
\n700 women, men and children were raped
\nwhen Angola recently expelled thousands
\nof people back to the Democratic Republic
\nof Congo. These atrocities add to the wide-
\nspread and systematic nature of rape and
\nother human rights violations in the Congo
\nby rebels. More than 8,000 women were
\nraped during fighting in 2009, the UN says.
\nIn a statement to mark the international day
\nfortheeliminationofviolenceagainstwomen
\n(http:\/\/ndcommunications.hosted.phplist.com\/
\nlists\/lt.php?id=N0RSBk8BBkgMU1Q%3D,
\nthe WMA\u201ds chair Dr. Edward Hill said:
\n\u201eThe appalling allegations of rape in the
\nCongo are a grim reminder that violence
\nagainst women has become a systematic
\nweapon of war. This is only the latest in a
\ncatalogue of similar atrocities in various
\nparts of the world. As the WMA declared
\nin its Statement last month this is a major
\npublic health issue and one on which physi-
\ncians are calling for absolute zero tolerance.
\n\u201eToday we are calling in the strongest possi-
\nble terms for the perpetrators of these rapes
\nto be prosecuted for their crimes. We urge
\nall national medical associations to remind
\ntheir members to pay far greater attention
\nto these unacceptable violations of the most
\nbasic women\u201ds human rights.
\n\u201ePhysicians are in a position to document
\nand report all cases of violence against
\nwomen that come to their attention and I
\nwould urge them to do so. We must also
\nseek to protect those who speak out against
\nabuse,including physicians and other health
\nprofessionals.\u201d
\nDr. Nkelani Matondo Norine, from the
\nOrder of Physicians of the Democratic
\nRepublic of Congo, said that the situation
\nof abused women in the Congo was criti-
\ncal and required urgent attention from the
\ninternational community and all organiza-
\ntions working for peace and human rights.
\nMass rape had become a weapon of destruc-
\ntion, much used by the enemy and many
\nphysicians were now working for women
\nvictims in the area, including Dr. Denis
\nMukwege of the Panzi Hospital in Bukavu\/
\nSouth Kivu, specializing in the reconstitu-
\ntion of vaginas, which has already operated
\non more than mutilated 20,000 women.
\nShe added: \u201eIn my political struggle
\nagainst violence towards women, I al-
\nways explain the disastrous consequences
\nof sexual assault. It can cause lesions that
\ncan have grave consequences in the long
\nrun, such as frigidity and sterility. Sexually
\ntransmissible diseases, such as HIV, and
\nunwanted pregnancies are other common
\nconsequences.
\n\u201ePsychologically, women feel diminished
\nand humiliated and without proper support
\nfrom a psychology specialist, they fall into
\na deep depression. Socially, many women
\nare abandoned by their husbands because of
\nrape. Towards their children, they feel hu-
\nmiliated, in particular those violated in the
\npresence of her children\u201d.
\nDr. Nkelani said: \u201cthe WMA and its mem-
\nbers should put pressure on the UN to take
\nappropriate action towards the Congolese
\nauthorities.\u201d
\n230
\nWMA news
\nCancun The \u201cCancun Climate and
\nHealth Statement\u201d launched 6th
\nDecember,
\n2010, Health Day at COP 16 [1], calls on
\nnegotiators to consider the \u201creal costs\u201d of
\nclimate change and the benefits of strong
\naction by taking the human health dimen-
\nsion into account.
\nEndorsed by the World Medical Associa-
\ntion [2], the International Council of Nurs-
\nes and other global health organizations
\nrepresenting millions of health profession-
\nals worldwide [3], the Cancun Climate and
\nHealth Statement calls on the negotiators
\nto \u201ctake into account the significant hu-
\nman health dimensions of the climate crisis
\nalong with the health benefits of climate
\nchange mitigation and adaptation policies.\u201d
\nDr. Michael Wilks from the Standing
\nCommittee of European Doctors (CPME)
\n[4] in announcing the Statement during a
\nmeeting of the World Health Organization
\n[5] says: \u201cOverwhelming evidence exists
\nthat reducing greenhouse gases benefits not
\njust health but countries\u2019 economies. These
\n\u201cco-benefits\u201d provide all those attending
\nCancun with a powerful and unifying new
\nnarrative – reducing greenhouse gases is
\ngood for your health, and for your budget.\u201d
\nOne regional example of these co-benefits
\nis recent research published by the Health
\nand Environment Alliance and Health Care
\nWithout Harm Europe. It shows that up to
\nan additional 30.5 billion Euros of public
\nhealth benefits could be achieved each year by
\n2020 if the European Union adopted a policy
\nof 30% domestic cuts in greenhouse gas emis-
\nsions (instead of the current 20% target) [6].
\nBut negotiators in Cancun are barely men-
\ntioning this health dividend to the climate
\ntalks. \u201cNegotiations seem focused on fi-
\nnancial rather than human costs of climate
\nchange,\u201d says Professor Hugh Montgom-
\nery, University College London. \u201cWe want
\nthem to take into account the fact that,
\nquite aside from any benefits from avert-
\ning climate change, strong data show that
\nlow-carbon living brings with it enormous
\nbenefits to health (less cancer, heart and
\nrespiratory disease, dementia, diabetes, de-
\npressive illness) and with that comes huge
\nsavings in healthcare costs. These health
\ngains could substantially offset the costs
\nof mitigation and urgently need to be fac-
\ntored in\u201d [7].
\n\u201cMonetary estimates of public health sav-
\nings do not just apply to Europe: a re-
\ncent independent scientific report shows
\nthat such health and financial gains apply
\nworldwide, and especially to countries such
\nas India and China\u201d [8]. \u201cWe want the even
\ngreater benefits for health in countries and
\nregions other than Europe to be taken into
\naccount by governments and acted upon. It
\nis high time for governments to realize that
\nreducing greenhouse gas emissions will im-
\nprove human health and save them money.
\nToday – Health Day at COP 16 – we plan to
\ntake this message to delegates,\u201d says Pendo
\nMaro, Senior Climate Change and Energy
\nPolicy Advisor,Health Care Without Harm
\nEurope (HCWH Europe) and Health and
\nEnvironment Alliance (HEAL).
\nDr. Pendo Maro, Health Care With-
\nout Harm Europe (HCWH Europe)
\nand Health and Environment Alliance
\n(HEAL), pendo.maro@hcwh.org\u00a0 or pen-
\ndo@env-health.org. Mobile phone: + 32
\n495 281 494(in Cancun)
\nDr. Michael Wilks, Standing Committee
\nof European Doctors, MWilks@bma.org.
\nuk. Mobile phone: + 44 7870 674490(in
\nCancun)
\nProf. Hugh Montgomery, University
\nCollege London, h.montgomery@ucl.
\nac.uk \u00a0Mobile phone: +44 7981 654 009
\n1. Health Day at COP 16 has been organized
\nto bring the health community together to
\nhighlight the benefits for public health of
\nstrong climate change to delegates. Doctors
\nand health experts believe that this is a crucial
\nargument for why we need to work towards a
\nglobal agreement.
\n2. The World Medical Association is a credited
\nobserver at the UNFCCC talks. The Decem-
\nber issue of its Journal will feature climate
\nchange. See WMA website.
\n3. The Cancun Climate and Health Statement
\nis signed by ten organizations: Climate and
\nHealth Council, International Federation of
\nMedical Students\u2019 Associations, Health and
\nEnvironment Alliance, Health Care Without
\nHarm, International Council of Nurses, In-
\nternational Society of Doctors for the Envi-
\nronment, Physicians for Social Responsibility,
\nStanding Committee of European Doctors,
\nWorld Federation of Public Health Associa-
\ntions, and World Medical Association. It has
\nalso been endorsed by Richard Horton,Editor,
\nThe Lancet, and Fiona Godlee, Editor, Brit-
\nish Medical Journal. It is available in English,
\nFrench and Spanish.
\n4. Dr. Michael Wilks, Climate Advisor and
\nImmediate Past President of the Standing
\nCommittee of European Doctors (CPME)
\nis part of the Health and Environment Al-
\nliance\/Health Care Without Harm Europe
\ndelegation in Cancun. CPME represents 27
\nmedical associations with approximately 1.5
\nmillion members in Europe. Other mem-
\nbers are Pendo Maro (see above), Prof Hugh
\nMontgomery, University College Lon-
\ndon, UK and Walter Vernon (HCWH US
\nBoard), San Francisco, USA. More about
\nthem at HEAL website and at HCWH
\nwebsite. The delegation is working closely
\nwith other groups in Cancun including In-
\nternational Federation of Medical Students\u2019
\nAssociations (IFMSA) and Nurses Across
\nthe Borders (Nigeria).
\n5. The Cancun Climate and Health Statement
\nwill be announced by Dr Wilks at a World
\nHealth Organization and World Food
\nProgramme \u201cside event\u201d called \u201cImprov-
\ning resilience to protect human health and
\nwelfare from the adverse affects of climate
\nSource: http:\/\/www.noharm.org\/global\/news_hcwh\/2010\/dec\/hcwh2010-12-06a.php\u00a0\u00a0
\n231
\nMedical and socio-medical affairs
\nchange\u201d to be held on Monday, 6 December
\nfrom 13.20 to 14.40 (Mexico time, minus
\n6 \u00a0GMT).
\n6. \u201cActing Now for better health, A 30% reduc-
\ntion target for EU climate policy\u201d, HEAL and
\nHCWH Europe, Brussels, September 2010.
\n7. Prof. Montgomery was one of the lead authors
\ninvolved in The Lancet Series, Health and
\nClimate Change, November 2009. One study
\nshowed that lower carbon policies in Lon-
\ndon and New Delhi associated more \u201cactive
\ntransport\u201d (walking and cycling), more public
\ntransport and reduced use of private cars could
\nproduce measurable benefits for heart disease,
\ncerebro-vascular disease, dementia, breast can-
\ncer,lung cancer,colon cancer,diabetes,and de-
\npression. It was called \u201cPublic health benefits
\nof strategies to reduce greenhouse gas emis-
\nsions: urban land transport.\u201d
\n8. Inter Academy Medical Panel, 2010, State-
\nment on the health co-benefits of policies to
\ntackle Climate Change (from Haines A, et al.
\n(2009). Public health benefits of strategies to
\nreduce greenhouse-gas emissions: overview
\nand implications for policy makers. The Lan-
\ncet. doi:10.1016\/S0140-6736(09)61759-1.)
\nAchieving final agreement on the draft Di-
\nrective on Patients\u2019 Rights in Cross-Border
\nHealthcare in the next few months will
\nbe an important step forward in codify-
\ning patients\u2019 rights in European law. While
\nthe draft Directive as it stands today is not
\nperfect with some remaining gaps and de-
\ntails that need to be worked out in its key
\naspects the recommendation of the Euro-
\npean Parliament has the broad support of
\npatients and the health community.
\nThis was the strong message from stake-
\nholders the High-Level Roundtable organ-
\nised by the European Patients\u2019Forum under
\nthe patronage of the Belgian EU Presi-
\ndency, ahead of the Council\u2019s debate on the
\ndraft Directive on 6 December 2010, and
\nin anticipation of the draft Directive\u2019s Sec-
\nond Reading in the European Parliament
\nin mid-January 2011. Indeed, some of the
\nparticipants were involved in the trialogue
\nmeeting that was to take place on the eve-
\nning of 1 December.
\nIn the words of , Commis-
\nsioner for Health and Consumers, the mo-
\nmentum achieved so far in the negotiations
\nmeans that \u201ctime is of the essence\u201d, and
\nflexibility is needed to reach agreement.
\nHowever, Mr Dalli reiterated that his guid-
\ning principle is \u201cpatients first\u201d, so while the
\nBelgian Presidency and the EP can count
\non the European Commission\u2019s support in
\nfinding acceptable compromise solutions,
\n\u201cwe should not lose sight of the proposed
\nDirective\u2019s original purpose: to clarify pa-
\ntients\u2019 rights to access safe and good quality
\ntreatment across borders,and be reimbursed
\nfor it.\u201d
\nIn the course of the day, most of the high-
\nlevel participants at the Roundtable con-
\ntributed their views as stakeholders. In ad-
\ndition to the Health Commissioner, they
\nincluded members of the European Parlia-
\nment, Commission officials, representatives
\nof the Belgian Presidency and the Perma-
\nnent Representations of Sweden, Denmark,
\nRomania plus the Swiss negotiating team,
\nas well as leaders of stakeholder organisa-
\ntions (nurses, doctors, community phar-
\nmacists, hospital, health managers, medical
\nspecialists, the pharmaceutical industry and
\nmedical devices industry).
\n, Head of the Belgian Na-
\ntional Institute Health & Disability Insur-
\nance (NIHDI) stressed that the Belgian
\nPresidency\u2019s approach to the Directive was
\nnot a simple application of the EU\u2019s internal
\nmarket rules, but a sector-specific approach
\non the basis of high quality, equity and
\nuniversality in healthcare. \u201cThe Directive
\nwill create a momentum beneficial to all
\npatients, not just the one or two percent of
\npatients that would need to travel abroad\u201d,
\nhe said. He also emphasised that the de-
\nbate is not just about general principles, but
\nabout practical issues that affect patients\u2019
\nlives and which therefore require solutions
\nto be found.
\n, the Rap-
\nporteur on the draft Directive, said that
\nMEPs want to reassure the Council that the
\npurpose of the Directive is not to promote
\nhealth tourism or facilitate cross-border ac-
\ntivity by healthcare providers what is vi-
\ntally important is that it offers patients the
\nopportunity to access healthcare that is not
\navailable to them in their own countries. In
\nthis context,she regretted the \u201clack of ambi-
\ntion\u201dshown by some Member States, which
\nseem willing to accept a continuation of the
\ncurrent system of patients seeking recourse
\nto the courts in defence of their rights.
\naddressed
\nthe wider topic of health inequalities. She
\nstressed the importance of addressing the
\nexisting health inequalities across the Euro-
\npean Union, and linked the Directive to the
\nongoing work by the Commission and the
\nParliament, including the health inequali-
\nties report now being discussed within the
\nENVI Committee. It is crucial to uphold
\nthe right of all patients to access good qual-
\nity healthcare in their own countries, par-
\nticularly in the context of the current eco-
\nnomic climate. She finally highlighted that
\nthe Directive should be seen as a first step,
\nwhich should later serve to promote a wider
\napproach of public health initiatives at EU
\nlevel.
\n232
\nMedical and socio-medical affairs
\nManchester, UK – Bioanalysis announced
\nthat Stephen Holman (Michael Barber
\nCentre for Mass Spectrometry Manches-
\nter Interdisciplinary Biocentre (MIB), The
\nUniversity of Manchester) has been award-
\ned the Young Investigator of the Year title
\nby the international editorial board of the
\nmonthly journal Bioanalysis.
\nOver the course of 2009\/2010, the profiles
\nof 8 international bioanalysts were featured
\nin the journal, nominated by their supervi-
\nsors. Each Young Investigators was given the
\nopportunity to highlight their bioanalytical
\nwork to date, discuss their future career aspi-
\nrations and give their thoughts on the future
\nrevolution of the field of bioanalysis.
\nThe Young Investigator of the Year award
\nhas been awarded by the international edi-
\ntorial advisory board of Bioanalysis in rec-
\nognition of the achievements of a young
\nbioanalysts at an early stage of their career.
\nAt the end of the year, votes were cast by
\nthe international editorial advisory panel to
\nselect the winner.
\nBrian Booth, US FDA, Senior Editor
\nsaid: \u201cWhen we launched Bioanalysis, we
\nthought of beginning a regular Young In-
\nvestigator segment to highlight the devel-
\nopment and talents of the youngest genera-
\ntion in this field. They represent the future
\nof this science, and there are very few ven-
\nues to demonstrate their skills and potential.
\nThe purpose of this award is to stimulate
\nthese young people and provide some small
\nOther key issues identified by various con-
\ntributors included the following:
\nThe importance of safety and quality of
\nhealthcare is recognised by all. There ap-
\npears to be agreement in principle on
\nMember State cooperation in this area,
\nalthough there is disagreement about the
\nexact mechanisms to ensure safety and
\nimprove quality.Mr Dalli said: \u201cI am con-
\nfident that once adopted, this Directive
\nwill pave the way towards a convergence
\nof standards in this area.\u201d
\nFrom the patients\u2019perspective,upfront pay-
\nment, reimbursement and prior authorisation
\nremain crucial. In order to ensure equity,
\nand to prevent new inequalities emerg-
\ning, a workable system must be found to
\navoid individual patients having to shoul-
\nder the financial burden of cross-border
\nhealthcare. Mrs Grosset\u00eate emphasised
\nthat \u201cmoney must not be a form of dis-
\ncrimination\u201d.There is strong support from
\npatients\u2019 organisations echoed among
\nMEPs for developing a system to handle
\ncross-border payments directly. Establish-
\ning national channels for accessible, clear
\nand reliable information for patients is a
\ncrucial component of the process.
\nFrom the perspective of patients with rare
\ndiseases, obtaining an accurate, timely diag-
\nnosis is pivotal point in the delivery of care.
\nA compromise that enables cross- border
\nsolutions for rare diseases patients to access
\nto diagnosis in the first instance, will be an
\nacceptable starting point. It is also crucial
\nthat prior authorization be given by special-
\nist physicians familiar with rare diseases and
\ntheir complexities.A clear procedure should
\nbe established for such cases.
\nThe importance of eHealth to patient safety
\nand continuity of care, and its role in the
\nfuture sustainability of health systems was
\nmentioned by several contributors, while
\nthe challenges of achieving interoperabil-
\nity and working cross-border prescrip-
\ntions were also acknowledged. Speakers
\nfelt that those Member States with the
\nmost advanced systems should promote
\nthe sharing of information and best prac-
\ntices. However, as the area is still contro-
\nversial, any eventual compromise is likely
\nto be a partial solution, on which further
\ncooperation may be built in future.
\nThe role of health professionals, and the
\nsharing of practitioner information across
\nMember States to improve patient safety
\nwere touched upon, as were the practical
\nimplications of cross-border healthcare
\nfor other actors, such as health managers
\nand administrators.
\nOnce the Directive comes into force, there
\nwill be much work involved in its imple-
\nmentation and its eventual review. The
\nreal-life impact of the Directive on patients
\nand all the other parties will only become
\nclear as it is implemented across the EU.
\nThe involvement of all relevant stakeholders,
\nincluding patients\u2019 organisations, in this
\nprocess will be key to its success.
\nIn his summing up at the end of the day,
\n, EPF President
\nstressed the importance of keeping the
\nprinciples of equity and solidarity at the
\ncentre of the draft Directive: \u201cAt heart, the
\nDirective is, after all, about people the pa-
\ntients, who need equitable access to good
\nquality healthcare. We as EPF, and through
\nour member organisations and allies all over
\nEurope, are committed to playing the part
\nof a proactive and constructive partner in
\nthis ongoing process, and we look forward
\nto working together with the Institutions,
\nand with all stakeholders to make the Di-
\nrective the best it can be.\u201d
\nA full report of the High-Level Roundtable
\nwill be prepared and disseminated to all par-
\nticipants and stakeholders in the next days.
\nFor more information please contact:
\nKaisa Immonen-Charalambous
\nPolicy Officer
\nEuropean Patients\u2019 Forum 65, rue
\nBelliard, 1040 Brussels Tel:+3222802334
\nFax:\u00a0+3222311447
\nWebsite: www.eu-patient.eu
\nNicola Bedlington, Director
\n233
\nNMA news
\nMarija Vavlukis
\nFrom September 30th
\nthrough October 2nd
\n,
\nthe Macedonian Medical Chamber hosted
\nthe 17th
\nSymposium of Medical Cham-
\nbers of the Central and Eastern European
\nCountries – ZEVA.
\nThe central theme of the meeting was \u201cpa-
\ntient safety and quality in medicine\u201d. Issues
\nconcerning self-governance and self-regula-
\ntion in medicine were also main topics. The
\nSymposium was attended by 39 participants
\nfrom delegations of 17 European countries.
\nMembers of the Assembly, the Executive
\nBoard and members of bodies of the Medi-
\ncal Chamber of Macedonia, as well as rep-
\nresentatives of the Macedonian Medical
\nAssociation, the Ministry of Health and
\nvarious NGOs were in attendance.
\nThe meeting began on September 30th
\nwith a reception organized by the Medical
\nChamber. Opening ceremonies were prop-
\nerly commenced with opening remarks by
\nthe President of the Macedonian Medical
\nChamber – Vladimir Borozanov. He wished
\na warm welcome to all guests and partici-
\npants. Welcome and wishes for successful
\nwork on behalf of The Ministry of Health
\nwere delivered by Deputy Minister, Vladi-
\nmir Popovski.
\nThe meeting was enriched by lectures and
\ndiscussions,especially on topics discussed by
\nDr. Dana Hanson, President of the World
\nMedical Association, Dr. Otmar Kloiber,
\nSecretary General of the World Medical
\nAssociation, and Dr. Konstanty Radzivill
\nPresident of the Standing Committee of
\nreward for their efforts. Stephen Holman
\nwas selected this year (among some very
\nstiff competition) because of his involve-
\nment in some innovative research, and we
\nanticipate much more from him in the fu-
\nture. Congratulations Stephen!\u201d*
\nStephen Holman commented; \u201cI was very
\nsurprised, but also very honoured and hum-
\nbled, to be bestowed the award of Young In-
\nvestigator of the Year 2010.\u201d He went on to
\nsay,\u201cThe award will provide a significant boost
\nto my CV given that it is a truly international
\nprize; the list of nominees spanned several
\ncontinents, as did the selection committee
\nwho decided upon the eventual awardee. The
\njournal is quickly becoming established in the
\nfield of Bioanalysis, and to be associated with
\nit as the first recipient of the Young Investiga-
\ntor award is a great privilege.\u201d
\nIn addition, Stephen\u2019s original profile\/
\nnomination can be found here: http:\/\/
\nwww.future-science.com\/doi\/abs\/10.4155\/
\nbio.09.45
\nStephen was nominated for the award by
\nDr Pat Wright (Pfizer UK) whilst studying
\nfor his PhD at the University of Southamp-
\nton. Pat said: \u201cStephen has shown himself
\nto be an exceptional advocate for bioanalysis
\nand an outstanding researcher. He quickly
\nadapted his skills to the requirements of his
\nPhD project, acquiring an understanding of
\nmass spectrometry to which even more ex-
\nperienced practitioners would aspire. With-
\nin 18 months, he published his first paper,
\nwith a second being recently accepted for
\npublication, and he has presented his work
\nat a number of meetings. In September
\n2008, he received the Michael Barber award
\nfor the best student oral presentation at the
\nBritish Mass Spectrometry Society confer-
\nence in York, which attests to his enthusi-
\nastic delivery as well as the high standard
\nof his science. His outstanding work and
\nposition in his peer group was further rec-
\nognized when he won the poster prize com-
\npetition, held at the end of the second year
\nof PhD study at the School of Chemistry,
\nUniversity of Southampton. Stephen has
\nexpanded his project to a self-initiated and
\nexciting area that is not only of extreme rel-
\nevance to metabolite identification, but also
\nincreases fundamental knowledge of gas-
\nphase ion chemistry within the collision cell
\nof a mass spectrometer.\u201d
\nStephen receives a complementary 1-year
\nprint and online subscription to Bioanalysis
\nand the next paper he submits to Bioanaly-
\nsis will be highlighted as \u201cYoung Investiga-
\ntor of the Year 2010\u201dand made free-to-view
\npermanently, which we hope will further
\nboost his research career.
\nBioanalysis is now accepting nominations
\nfor Young Investigator 2011. They should
\nbe under the age of 30, including Masters
\nand Doctorate students, Post doctorate re-
\nsearchers and those working in industry. If
\nyou wish to nominate a Young Investigator,
\nplease contact the Commissioning Editor at:
\nr.devooght-johnson@future-science.com.
\n* The views expressed are those of the author and do not
\nreflect official policy of the FDA. No official endorse-
\nment by the FDA is intended or should be inferred.
\n234
\nNMA news
\nEuropean Doctors.Rich and interesting de-
\nbate sparked wide interest among the par-
\nticipants, who stressed that the meeting in
\nSkopje opened new horizons in the opera-
\ntion of medical associations.
\n, gave
\nhis speech about medical regulation and
\nself-government At the beginning of his
\nspeech he spoke about self-regulation and
\nself -governance in professional organiza-
\ntions and associations. He remarked that
\nself-regulation in an association is a bal-
\nance between professional and public func-
\ntions. If the activities of the association are
\ndominated by public offices, membership
\nin such associations is compulsory, but if
\ndominated by professional functions, mem-
\nbership is optional. He pointed out that, in
\ndemocratic societies, self-regulation means
\na healthy distribution of power, protecting
\nthe freedom of vulnerable groups and those
\nwho serve them. It was noted that the chal-
\nlenges of these organizations are:
\nCompetence,
\nQuality,
\nBehavior (without the involvement of
\ncriminal activities), and
\nProviding high quality health care for all.
\nIn regard to patients and patient relation-
\nships, it is important to remember that
\npatients are not customers or consumers
\nand healthcare professionals are not only
\nproviders of healthcare services. Self-man-
\nagement in healthcare is much more than
\nself-regulation; it involves a contract with
\nsociety, and often represents more effort
\nthan a privilege. Self-regulation is a factor
\nthat provides quality care for all.
\nspoke
\nabout the system to ensure patient safety
\nfrom the German perspective. Elaborating
\non the German experience, she concluded
\nthat patient safety must be an integral part
\nof all institutions involved in healthcare,
\nthrough good communication and coop-
\neration, measures that to some degree have
\nbeen implemented in daily routine practice.
\nThese measures should, in the future, be
\navailable to every healthcare professional
\nand be emphasized as the role of experts
\nand boards of arbitration in terms of pre-
\nvention of adverse incidents and promotion
\nof increased professionalism. Identification
\nand implementation of quality indicators to
\nensure the safety of procedures and patient
\nsafety must be based on scientific research,
\nby which an authoritarian system will be re-
\nplaced by a system of learning from errors.
\n, shared Austrian ex-
\nperiences on the measures and activities un-
\ndertaken by Austrian institutional systems
\nto improve patient safety. The focus was on
\nthe experiences of utilizing an electronic
\ndatabase for patients, particularly in relation
\nto the prescribing of drugs by doctors and
\npharmacists, and the possibility of interac-
\ntions especially in select patient subgroups,
\nsuch as the elderly and patients with mul-
\ntiple diseases. He underlined that improv-
\ning care for patients must be accompanied
\nby appropriate legislation. Dr. Bretenhaler
\nalso explained the Medical CIRS project
\nfor anonymous reporting of critical inci-
\ndents, and the learning system based on this
\nby health professionals with the support of
\nhealth authorities.
\nProf. Borozanov- President of Macedonian
\nMedical Chamber and host of the meeting,
\ngave his introductory lecture about actual
\nsituations in the area of patient safety and
\nquality in healthcare in Macedonia. At the
\nbeginning he stressed the necessity of con-
\nsistent terminology in the area of medical
\n235
\nNMA news
\nerror. It was reemphasized that despite
\nwell-documented cases of unsafe care in de-
\nveloped countries, we are lacking the load-
\nbearing unsafe medical care in countries in
\ntransition and developing countries, where
\nlimited resources, technology and infra-
\nstructure contribute to increase this burden.
\nIn our field, we need considerable political
\nwill and cooperation from all stakeholders in
\nthe to improve the education of health pro-
\nfessionals in the field of patient safety, and
\nto stimulate research projects in this area,
\nwhich ultimately will result in improved
\nquality of treatment. Required related sys-
\ntems for documenting and disseminating at
\nthe national level will result in linking the
\ninstitutions of the system horizontally and
\nvertically, including the private and public
\nsectors, based on the principle of fairness
\nand impartiality. What is now a reality in
\nour country is that we have established ev-
\nidence-based standards in patients\u2019 medical
\ntreatment beginning in 2006, but we lack
\nfeedback on their implementation. A par-
\nticularly prominent project is the introduc-
\ntion of the electronic medical card, however,
\nwe cannot yet speak on the effectiveness of
\nan integrated medical information system.
\nPatient safety depends on many elements.
\nDoctor-patient confrontations are absolute-
\nly an undesirable situation. The improve-
\nment of the working environment of medi-
\ncal professionals is critical to providing a
\nhealthy work environment.That way we will
\nminimize the role of the human factor as a
\ncause of medical errors. In order to improve
\npatient safety by 2008, a law was introduced
\nto protect patients rights and manuals dis-
\ntributed to facilitate its implementation.
\nDespite numerous systems for reporting
\ncases of unsafe treatment, available data
\nis insufficient. There were less than 100
\nreported cases in the last eighteen months
\nto state authorities, primarily to the Insti-
\ntute of Public Health and state inspection.
\nThis practice shows that patients, or their
\nfamilies, often complain or report cases of
\nunsafe care, not in the system, but at less
\nappropriate places (in the electronic media,
\nto the Minister of Health in person, to the
\ndirectors of health facilities, and rarely in
\nthe Medical Chamber). Work is needed in
\nthis area to ensure one comprehensive sys-
\ntem for reporting medical errors.
\nDuring the meeting, representatives of med-
\nical associations presented their experiences
\nin their work and the problems they face in
\nrealizing the goals and tasks through their
\nnational reports. Six national reports were
\npresented from five countries from the re-
\ngion (Serbia,Slovakia,Croatia,Romania and
\nCanton Sarajevo – Bosnia and Herzegovina).
\nSpeaking on the experiences of the Serbian
\nChamber, the President of the Medical As-
\nsociation of Serbia presented the legisla-
\ntion on which it operates, including some
\nof their problems . Prominence in the re-
\nport was given to the policy for prescription
\ndrugs. It was emphasized that it prescribing
\nis restricted only to general practitioners,
\nand specialists can only prescribe drugs in
\nrare, specific cases. However, despite this
\nabsurd situation Serbian doctors do not for-
\nget their ethical principles. In the second
\npart of the report, the president addressed
\nthe status of medical professionals. It was
\nnoted that only 37.6% of physicians are sat-
\nisfied with the availability and equipment
\nat work, only 19.2% are satisfied with their
\nearnings,and over 60% are satisfied with the
\nchoice of profession.
\nThe report from the Medical Association in
\nSlovakia largely concerned the identifica-
\ntion of general common interests in relation
\nto:
\nImprovement of medical care;
\nIncreased patient safety;
\nGreater satisfaction of all stakeholders in
\nthe system.
\nMeasures that can achieve these objectives
\nare: improving the relationship in the re-
\nlational triangle of doctors-patients-health
\ninstitutions,improving relations with health
\ninsurance funds, the quality of medical care
\nand ways of payment for medical care pro-
\nvided, and the intellectual efforts and op-
\nportunities for the public.
\nThe Romanian delegation presented two
\nnational reports. In the first report atten-
\ntion was given to the relationship between
\nthe historical evolution and current situ-
\nation in order to present the situation in
\ntheir country and organization, as well as
\ndifficulties in the initiation and continua-
\ntion of reforms. Significant observations in
\nthe report were:
\nThe medical profession in Romania is not
\ntreated as a craft but as a liberal profes-
\nsion;
\nThe healthcare system focuses on each
\npatient individually;
\nRestrictions on the role of the legisla-
\ntor in establishing general conditions in
\nhealthcare policies is recommended, as
\nwell as limiting the misuse of the medi-
\ncal profession. It was pointed out that se-
\ncurity and protection of the patient as an
\nindividual is not only the responsibility of
\nhealth authorities.
\nidentified two central
\nguidelines aimed toward the Chamber:
\nThe Chamber represents a guarantee for
\nhigh standard of medical profession and
\nethics.
\nFor physicians, the Chamber is an insti-
\ntution through which they are represent-
\ned in society, administration and politics.
\nThe Chamber has a legal background and
\na multitude of functions including: the de-
\nvelopment of professional ethics and super-
\nvision of the profession, the supervision of
\npostgraduate education, continuing medical
\neducation, licenses and registration, arbitra-
\ntion, and quality assurance of healthcare
\n236
\nNMA news
\nservices.The Chamber defends the econom-
\nic interests of doctors at all levels, including
\nworking conditions,represents medical pro-
\nfessionals to the media and political enti-
\nties, and, although often in limited capacity,
\ncan participate if called upon in legal proj-
\nects and other regulatory matters, providing
\nits expert opinion if asked in court or parlia-
\nmentary bodies.
\nThere are other, social functions of the
\nChamber as well, for example, an initiative
\nfor additional pension insurance intended
\nsolely for the medical profession so that
\nthey can provide welfare to members in
\nneed.
\nDr. Kulenovik gave a comprehensive de-
\nscription of the Medical Chamber of Bos-
\nnia and Herzegovina, and the problems
\nfaced by the chambers within the country.
\nThe assertion of his speech was that the
\nquality of medical care also depends on
\nthe condition of medical professionals.
\nThe conclusion was that efforts should be
\ndirected towards activities to improve the
\nmaterial and financial wellbeing of medical
\nprofessionals.To achieve these goals, cham-
\nbers have to act together with the unions in
\na measure of solidarity when approaching
\ngovernment institutions. Government in-
\nstitutions should bear in mind that the best
\nway to express respect for the medical pro-
\nfession is through material rewards and a
\nmore dignified presentation of the medical
\nprofession in society.
\nThe title of the report of the Croatian
\nMedical Chamber was \u201cbetween doc-
\ntors and objective needs and real op-
\nportunities as a result of organization-
\nal, legal and technological resources\u201d.
\nThe first part of the report was the presen-
\ntation of the historical development of the
\nChamber\u2019s organization in Croatia from
\n1913 until today. The report followed with
\nthe presentation of current activities, such
\nas preparing and maintaining the Register
\nof doctors, the process of licensing, supervi-
\nsion and oversight of the work of doctors,
\nthe determination of basic working condi-
\ntions and prices of services of private doc-
\ntors.. Among other things discussed was the
\nprominent cooperation with educational
\ninstitutions in the country and the super-
\nvision and evaluation of continuing profes-
\nsional training of doctors in Croatia. The
\nCroatian Chamber has the prominent role
\nin cooperation with the Croatian Health
\nInsurance Institute in proposing the basics
\nof the health network as well as suggestions,
\nopinions and expert opinions in this area.
\nThe President of the Chamber is a member
\nof the Croatian parliamentary Committee
\non Health and the Board of Directors of
\nthe Agency for quality and accreditation.
\nRegarding patients\u2019 rights, this body un-
\nconditionally supports their needs, guaran-
\nteeing quality and accessibility to healthcare
\ninstitutions, protecting their rights before
\nthe decisions of healthcare administrations,
\nand sanctioning doctors.
\nDr. Radziwill spoke about current EU poli-
\ncies and activities of this the CPME.This is
\nan organization of 27 European countries
\nand other specialized European medical
\nassociations. The purpose of this organiza-
\ntion is to promote high standards in medi-
\ncal practice for all residents of Europe. He
\nstressed the need for further development
\nof electronic databases in healthcare sys-
\ntems and for their availability and a stan-
\ndardization of communication. In terms
\nof patient safety, he noted that the CPME
\ncontributes actively in order to complete the
\nproject EUNetPaS, especially in the field of
\neducation, training and manuals. He also
\ncited other problems in healthcare policy
\nrelated to the field of patient safety.
\nDr. Vurhe shared the German experience
\non the evaluation of postgraduate education
\nof residents. Analysis of evaluation that spe-
\ncializing doctors made about the quality of
\ntheir education is the basis for recommen-
\ndations provided by the German Associa-
\ntion, and refers to postgraduate education.
\nNamely, it is recommended that reports of
\nany specialist training center be analyzed by
\nspecialists and residents together.Individual
\nresults should be published if necessary, and
\npositive and negative impacts on specialist
\ntraining should be clearly stated. Emphasis
\non the importance of clear feedback should
\nbe made which would motivate participants
\nto be involved in projects of this kind in
\nfuture. According to the findings that Dr.
\nVurhe presented for this project, it is evi-
\ndent that residents exhibit little interest in
\nparticipating in the evaluation of educators
\nand training programs in such a manner
\n(electronic).Those who expressed interest in
\nparticipating in the project have expressed
\ntheir dissatisfaction with the workload in-
\nvolved in their practice, bureaucratic proce-
\ndures, and time pressure and overtime work.
\nPrecisely because of these considerations, a
\nclear need for open discussion about these
\nproblems was expressed,in order to improve
\noperational models.
\nDr. Georgievska-Ismail addressed the pro-
\ncess of continuing medical education or-
\nganized within the activities of the Mace-
\ndonian Medical Chamber. CME is a tool
\nthat covers the gap between current and
\n237
\nClimate change
\noptimal medical care. She stays current
\nwith healthcare law according to which
\ndoctors are bound by CME. Successfully
\nperformed, CME is the basis for renewal
\nof medical licenses, an activity that has
\nbeen legitimately transferred to the Medi-
\ncal Chamber. The current organization
\nof CME is based on global principles for
\nits performance, but the observations are
\nthat its impact on professional practice
\nis moderate. This is important because of
\nthe introduction of the process of moving
\nfrom CME to CPD. Continuous profes-
\nsional development is a range of educa-
\ntional activities through which healthcare
\nprofessionals maintain and develop their
\ncapacity to practice safely, effectively and
\nlegally within their practice. In her speech,
\nDr. Georgievska-Ismail stressed the dif-
\nferences between CME and CPD, and
\nsuggested ways to implement CPD. Her
\nmain suggestion: There should be a process
\nof learning based on practical work (prac-
\ntice), which can be implemented through
\nfour major levels of CPD: identifying areas
\nof improvement, engaged learning, apply-
\ning new knowledge and skills in practice
\nand control of improvement. She then
\nshe addressed the major obstacles in the
\nimplementation of CPD: lack of knowl-
\nedge about the usefulness of education,
\nlack of time, resources and opportunities,
\nthe wrong timing and type of educational
\nactivities, lack of wider choice of learning
\nand professional conservatism. What is
\nexpected as a benefit of regular CPD is
\nwell-designed educational activities, phy-
\nsician satisfaction, change in knowledge
\nand behavior and improved medical care
\nto patients.
\nThe main conclusions and recommenda-
\ntions from this ZEVA meeting will be
\nmerged into one declaration mainly de-
\nsigned for countries and governments
\nfrom the ZEVA region. The main idea: it
\nis necessary to change the widely accepted
\nperception of unsafe medical care as a doc-
\ntor\u2019s (medical personnel) error.\u00a0\u00a0It is of es-
\nsential importance to identify patient safety
\nincidents as a result of a system-wide error.
\nThe declaration will soon be distributed to
\nall professional associations of the member
\nstates of the ZEVA region. The host of the
\nnext – XVIII ZEVA Symposium in Sep-
\ntember next year will be the Polish Cham-
\nber of Physicians and Dentists.
\nMarija Vavlukis MD, PhD
\nUniversity Clinic for Cardiology, Macedonia
\ne-mail: marija.vavlukis@gmail.com
\nIt is high time for doctors everywhere to
\nstand up and be counted on the impact of
\nclimate change on health.
\nThe phenomenon of human-induced global
\nclimate change can no longer be refuted [1].
\nWithout any doubt, climate change will hit
\npublic health and health services very hard.
\nLast year, the world\u2019s foremost medi-
\ncal journal, the Lancet described climate
\nchange as the greatest potential threat to
\npublic health in the 21st
\ncentury. It said that
\nclimate change will have devastating effects
\non human health as a result of changing
\npatterns of disease, heat waves, reduced wa-
\nter and food security, and because extreme
\nweather events, such as hurricanes, cyclones
\nand storm surges, will result in flooding and
\ndirect injury [2].
\nWith catastrophes like Haiti or Pakistan in
\nthe news, no-one finds it difficult to imag-
\nine the pressure on medical staff from ex-
\ntreme weather, especially in an era of ever
\ntightening health budgets.
\nThe Standing Committee of European
\nDoctors, Health and Environment Alliance
\nMichael Wilks Genon Jensen Anja Leetz
\n238
\nClimate change
\n(HEAL) and Health Care Without Harm
\n(HCWH) are currently in Cancun, Mexico
\nwhere the latest round of climate change ne-
\ngotiations is taking place. We are convinced
\nthat the leadership of health professionals
\n– with its high moral standing – is vital to
\npersuade governments about the urgency of
\nstrong climate change policy. Acting now
\nwill save lives and reduce health care and
\nother costs for governments.
\nFortunately, we have a positive message
\nto help us convince governments in Can-
\ncun. Research shows that stronger climate
\nchange policy would bring almost immedi-
\nate public health benefits. This is because
\nsome policies aimed at mitigating climate
\nchange have the effect of reducing air pollu-
\ntion and therefore improving health.
\nThe so-called \u201cco-benefits\u201d of climate
\nchange are entirely separate from the poten-
\ntial health benefits associated with combat-
\ning global warming.The co-benefits, or side
\neffects of climate change policy, take place
\nbecause as falls in greenhouse gases occur
\nso do air pollutants such as fine particles,
\nnitrogen oxides and sulphur dioxide. Since
\nexposure to air pollutants is associated with
\nmany deaths and substantial morbidity, re-
\nducing greenhouse gases as part of climate
\nchange policy has the effect of improving
\npublic health.
\nA recent report published by the Health
\nand Environment Alliance and Health Care
\nWithout Harm
\nEurope quantifies
\nthese benefits for
\ncountries of the
\nEuropean Union.
\nIt estimates that up
\nto 30.5 billion Eu-
\nros of public health
\nbenefits could be
\nachieved within
\nthe EU per year by
\n2020 if the Euro-
\npean Union adopt-
\ned a policy of 30%
\ncuts in greenhouse
\ngas emissions[3].
\nThe health benefits associated with stronger
\nclimate change policy in EU countries are
\nmainly due to a reduction in the number
\nof anticipated respiratory and cardiac cases
\nassociated with exposure to air pollution.
\nThese benefits begin almost immediately
\nthe policies are introduced. By 2020 for a
\n30% domestic cut in greenhouse gas emis-
\nsions, 140,385 fewer years of life would be
\nlost and 13 million fewer days of restricted
\nactivity could be avoided for those with re-
\nspiratory problems.In addition,there would
\nbe 1.2 million fewer days when people
\nwould need to use respiratory medication
\nand 142,000 fewer consultations for upper
\nrespiratory problems and asthma during the
\nyear 2020 [3].
\nIn countries with severely polluted major
\ncities, the benefits for health are likely to
\neven greater. For example, a study in air-
\npolluted Mexico City shows that reducing
\nboth ozone and PM10 (a type of Particu-
\nlate Matter that contributes to air pollution)
\nby just 10% would result in 33,287 fewer
\nemergency room visits in 2010, 4,188 fewer
\nhospital admissions for respiratory distress
\nand 266 fewer infant deaths a year due to
\ncleaner air.This is estimated to result in po-
\ntential savings of US\u00a0$760\u00a0million a year [4].
\nSimilar health co-benefits from cli-
\nmate change policy occur when carbon
\nemissions from private vehicles are the
\ntarget. Studies from New Delhi and Lon-
\ndon published in the Lancet medical jour-
\nnal have shown how lower carbon policies
\nassociated with more public transport,
\nless use of private cars and more \u201cactive
\ntransport\u201d (walking and cycling) would
\nbenefit health. Measurable benefits were
\nrecorded for ischaemic heart disease,
\ncerebro-vascular disease, dementia, breast
\ncancer, lung cancer, colon cancer, diabetes,
\nand depression [5].
\nThe World Medical Association has al-
\nready urged doctors to help steer political
\nthinking on climate change. In his valedic-
\ntory speech as President at the WMA\u2019s an-
\nnual assembly in Vancouver in October, Dr
\nDana Hanson voiced his conviction that
\nthe\u00a0 World Medical Association, national
\nmedical associations and the public should
\nbegin educating governments and indus-
\ntry on the vital issue of health and climate
\nchange [6].
\nBoth WMA and the Standing Committee
\nof European Doctors have position state-
\nments for members to use in writing and
\nspeaking to politicians and policy makers
\n[7], and WMA has recently sent a letter to
\nall members urging them to write to their
\nenvironment ministers.Floods in Venice
\nCopenhagen, December 2009
\n239
\nHealth financing
\nNational medical association around the
\nworld should join these efforts if the worst
\nperils of climate change are to be avoided.
\nWhen doctors speak up publicly, govern-
\nments listen. The moral standing of doctors
\nwithin society creates a powerful force. We
\nurge you to turn your attention to treating
\nour ailing planet earth.
\nFor more information – and to let us know
\nabout your efforts – please contact Dr Pendo
\nMaro, Health Care Without Harm Europe
\n(HCWH Europe) and Health and Envi-
\nronment Alliance (HEAL) at pendo@env-
\nhealth.org or pendo.maro@hcwh.org
\n1. Climate Change 2007: synthesis report. Sum-
\nmary for policy makers. Intergovernmental
\nPanel on Climate Change (IPCC-AR-4), p.2.
\n2. Managing the health effects of climate change,
\nThe Lancet Series, Health and Climate
\nChange, November 2009.
\n3. \u201cAct Now for better health, A 30% reduction
\ntarget for EU climate policy\u201d, HEAL and
\nHCWHE, Brussels, September 2010.
\n4. Taking Control of Air Pollution in Mexico
\nCity, http:\/\/www.idrc.ca\/en\/ev-31594-201-1-
\nDO_TOPIC.html.
\n5. The Lancet Series, Health and Climate
\nChange, November 2009, \u201cPublic health ben-
\nefits of strategies to reduce greenhouse gas
\nemissions: urban land transport.
\n6. WMA press release, October 2010.
\n7. \u201cGlobal Warming and Health\u201d (CPME
\n2009\/021 EN\/FR final).
\nDr. Michael Wilks, Climate Advisor and
\nExecutive Committee member, Standing
\nCommittee of European Doctors;
\nGenon Jensen, Executive Director, Health
\nand Environment Alliance (HEAL);
\nAnja Leetz, Executive Director,
\nHealth Care Without Harm
\nMarkus Schneider
\nSeveral countries have made serious cuts in
\npublic health expenditures during the current
\nperiod and expect more in the near future to
\ncope with budget deficits and increased pub-
\nlic debts caused by the current world financial
\ncrises. Sustainability serves in this context as
\na general principle to guide fiscal policy, how-
\never \u201csustainability\u201d is a buzzword defined
\ndifferently around the world and,perhaps,has
\nbeen universally accepted and used simply be-
\ncause it seems to be immediately understand-
\nable. Subsequent to the Brundtland Report
\n(1987) at least the following definition is gen-
\nerally agreed: Sustainable development meets
\nthe needs of the present without compromis-
\ning the ability of future generations to meet
\ntheir own needs[1]. A sustainable health sys-
\ntem is one in which the scale and the structure
\nof the state\u2019s activities are such that the health
\nneeds of the current generation for high qual-
\nity effective health services may be met with-
\nout compromising the ability of future gen-
\nerations to meet their needs. No wonder that
\nsustainability compilation is the domain of
\ngenerational accounts, focusing on fiscal gaps
\nin the long-run [2]. But the long-term view
\nis not suited to deal with the tremendous fis-
\ncal imbalances in the short-term and will not
\nprovide the appropriate remedy for healthcare
\nsystem development in the short-term.
\nShort-term and long-term fiscal gaps of
\nthe general government have to be dis-
\ntinguished from the financial sustainabil-
\nity of the healthcare system as part of the
\neconomy. Fiscal stability in the short-term
\nrelates to the need for public revenue and
\npublic expenditure on healthcare to be in
\nequilibrium within an economic cycle (say
\nfive years). Financial sustainability is a
\nbroader concept embracing the idea that to-
\ntal (public and private) income and expen-
\nditure on the healthcare system should be
\nin equilibrium in the mid-term (say twenty
\nyears).Several instruments have been devel-
\noped to deal with the long-term stability of
\nsocial and private insurance programs these
\ninstruments are not appropriate to manage
\nthe immediate burden of fiscal shocks that
\ncan overwhelm the financial capacity of a
\ncountry, (e.g. in the cases of Greece and
\nLatvia).
\nObviously, concepts and measurements are
\ncritical to sustainability. Sustainability rep-
\nresents a process rather than a static quality.
\nIndicators of sustainability must therefore
\ncapture this movement over time, or capac-
\nity for continuity. But how do we measure
\nsustainability? By definition a fiscal im-
\nbalance exists if government expenditures
\nexceed tax revenues in a particular period.
\nThis fiscal imbalance of a particular period
\nis called the budget deficit. Since the bud-
\nget deficit adds to the national debt, the
\nbudget deficit represents the increase in the
\nPresentation given at the WMA conference of \u201cFinancial crisis and its implications for
\nhealth care\u201d, Riga, September, 10-11th
\n2010
\n240
\nHealth financing
\npublic debt from one year to the next. In
\nthe same way the deficit of health insurance
\nadds to health insurance debts.
\nWhat is the problem with deficits? It is the
\nrelated interest payment. The increased
\ndebt raises the government\u2019s interest spend-
\ning and decreases the government\u2019s ability
\nto spend the revenues for other purposes.
\nFor example, suppose the total public deficit
\nwas 100% of the GDP, with an interest rate
\nof 5%. If the governments ratio of the GDP
\nwas 30%, then the government would have
\nto spend one sixth of its budget on interest
\npayments alone. That is above the financial
\ncapabilities of the public health expendi-
\ntures for Latvia and several other countries.
\nAny increase in public debt would further
\nraise interest payments, thereby reducing
\nthe government\u2019s available funds for health-
\ncare,education,security,and other purposes.
\nObviously, such a policy is not sustainable
\nin the long-run. So, the question remains,
\nwhat to do in the short-run?
\nThe assessment of both short-term and
\nlong-term sustainability of public finances
\nis a multifaceted issue and there is not a
\nunique indicator that provides a clear re-
\nsponse to what extent a country\u2019s public
\nfinances are sustainable in the long-term.
\nHence, the European Commission and the
\nCouncil assess long-term sustainability of
\npublic finances by using both quantitative
\nindicators and qualitative information so
\nthat the determinants affecting the long-
\nrun state of public finances in the Member
\nStates are reflected [3].
\nFocusing on the inter-temporal balance of
\nthe public budget, the S1 indicator shows
\nthe durable adjustment required to reach
\na target debt below 60% of GDP in 2060,
\nas defined in the European Stability and
\nGrowth Pact for EU public finance. The
\nS2 indicator shows the durable adjustment
\nrequired to fulfil the infinite horizon inter-
\ntemporal budget constraints, which states
\nthat the present value of government pur-
\nchases and net debts cannot be larger than
\nthe present net value of government reve-
\nnues. In the EU as a whole and in the Euro
\narea, the sustainability gap is estimated
\nabout 2% of GDP according to the S1 in-
\ndicator and about 3% of GDP according to
\nthe S2 indicator [4]. Unsurprisingly, there
\nare large variations by countries, strongly
\ndepending on the current debt position.The
\ncontribution of health and long-term care
\nto this stability gap is roughly the same as
\nthe additional liabilities of the pension sys-
\ntems [5].
\nWhile constraints and indexation rules for
\npublic pension systems policies are imple-
\nmented in many countries, the rules for
\nhealthcare are rather opaque. As a result,
\ngovernments can more easily cut healthcare
\nexpenditures than public pensions if reve-
\nnues are falling. Following the experience of
\nthe Great Depression, governments should
\ncounter-balance sudden drops in private
\ndemand. In fact, pro-cyclical cuts of public
\nexpenditure, especially health care, have a
\ntendency to aggravate the economic crisis
\ninstead of alleviat it [6].
\nCounter-cyclical fiscal policy should be a
\nshort-term economic policy. A short-term
\nindicator of financial need of the health
\nsector is Medicare\u2019s sustainable growth
\nrate mechanism, which limits payments for
\nphysicians\u2019 services. Cumulative Medicare
\nspending on physicians\u2019 services is sup-
\nposed to follow a target path that depends
\non the rates of growth in physicians\u2019 costs,
\nMedicare enrolment, and real GDP per
\nperson. That system is currently projected
\nto reduce the growth of payments to phy-
\nsicians. However, growth rates of public
\nhealth care will be positive and not nega-
\ntive, as discussed in Latvia and other Cen-
\ntral and Eastern European countries. Even
\nin the long-run, in the United States, the
\nCongressional Budget Office (CBO) has
\nanticipated in its last projection that, de-
\nspite financial crises, spending for Medicare
\nwill expand faster than the economy. As a
\nresult, by the end of the decade, outlays for
\nMedicare are projected to total $929 billion
\n(4.0 percent of GDP), compared with $519
\nbillion (3.5 percent of GDP) this year [7].
\nThe conclusion is that there are similarities,
\nbut also different views on the concept of
\nsustainability and its measurement. While
\ndemographic impacts are generally consid-
\nered rather low, institutional structures and
\ndeficit spending are assessed differently by
\ncountries, experts, and politicians. Under
\nthe perspective of public finance,many poli-
\nticians see health care rather as a cost factor
\nthan as an investment in human capital and
\nconsequently a factor of economic growth.
\nIt is worth the effort to analyse the argu-
\nment for budget cuts in healthcare in great-
\ner detail, as the projections neither consider
\ndevelopments in the past nor health re-
\nforms in the future. Clearly, the pressure
\non healthcare expenditure will be reduced
\nby the compression of morbidity and de-
\ncreasing prevalence in rates of acute and
\nchronic diseases (decline in chronic diseas-
\nes) [8]. On the other hand, the pressure on
\nhealthcare expenditure will be increased by
\nrelatively higher labour intensity and lower
\nproductivity growth in the service economy,
\nwhich leads to relative health care prices
\nabove GDP prices or the so-called \u201cBau-
\nmol\u2019s cost disease\u201d [9]. Further pressure
\ncomes from the medical-technical devel-
\nopment and consumer behaviour. But, the
\nexpenditure side is only one component of
\nthe government\u2019s accounts. What happens
\non the revenue side? The prerequisite of a
\nhealthy labour workforce is a healthy popu-
\nlation which is therefore crucial to sustain-
\nable revenue development. Independence of
\nhealthcare financing from the general bud-
\nget and willingness to pay are other factors
\nof sustainable revenue development. Insti-
\ntutional factors that affect financial stability
\nof health financing are the mode of revenue
\ncollection income-independent premiums,
\nincome related contributions, and taxes,
\nthe allocation of risks to public and private
\nschemes, the organisation of purchasing of
\n241
\nHealth financing
\nproviders (single versus multi-pipes), and
\nthe contracting and payment of provider
\n(framework versus selective contracts, capi-
\ntation versus fee-for-service) [10]. Premi-
\nums for health insurance have an advantage
\nbecause they are not directly related to fluc-
\ntuation, but they do need to be counterbal-
\nanced by equity measures. The need to bal-
\nance increasing needs for healthcare and
\nscarce public resources is present among
\neconomic and healthcare policy makers in
\nall countries. Many instruments have been
\ndeveloped to assess the benefits and costs
\nof medical technologies at the micro-level,
\nhowever, at the macro-level comprehensible
\nmodels to guide policy for the governance
\nof the health care budget do not exist.
\nIn many countries the healthcare economy
\nis the largest industry. There is a paradigm
\nshift from healthcare as cost factor toward
\nhealth as growth factor. The impact of the
\nhealth economy on the general economy
\nand public finance system can be simu-
\nlated by healthcare satellite accounts inte-
\ngrated into the national accounts. A sat-
\nellite account captures all of the economic
\nactivities of the health economy. A study
\nof Germany\u2019s health economy has shown
\na considerable export surplus, a large share
\nof the overall economy\u2019s total workforce, a
\nmarked predominance of service industry, a
\nhigh share of value added, and significant
\nspillover effects into other industries. The
\nHealth-Input-Output-Table makes it pos-
\nsible to exhibit the supply for health com-
\nmodities in consistent differentiation from
\nthe supply of the overall economy. The
\nabove mentioned study for the German
\nMinistry of Economics and Technology
\nconfirms the strong link between the health
\neconomy and overall economy [11].
\nOne particular question of cost contain-
\nment measures is the impact on final de-
\nmand in healthcare and the economy as a
\nwhole. How do cuts of public healthcare
\nexpenditures affect economic growth. The
\ncompilation of production multipliers by
\nthe so-called \u201cLeontief Inverse\u201d shows
\nvariations of these multipliers for different
\nbranches of the health economy between
\n1.47 and 2.38. On average, a reduction of
\npublic health expenditures by 1% will lead
\nto further indirect and induced reductions
\nof the output by in total 1.8%. As a result
\nnegative consequence can be expected from
\ncuts of public health expenditures, not only
\nfor patients and health professionals, but
\nalso for the economy as a whole.
\nHealth expenditures contribute in manifold
\nways to economic development. Health
\nimpacts of economic growth take place over
\nseveral channels [12]:
\nThe labour force becomes more produc-
\ntive and can generate higher income
\nthanks to improved health;
\nImproved health gives people a longer
\nworking life an imperative in our aging
\nand childless society;
\nFewer days are lost to ill health\/disability
\nand early retirement;
\nImproved health and a longer working
\nlife increase the return on investing more
\nin education and helps raise productivity;
\nImproved health extends people\u2019s
\nhealthy-life expectancy.This fuels a high-
\ner savings rate and thus creates funds for
\nfurther investment.
\nFinally, a stable health sector contributes to
\nthe stabilization of the whole business cycle
\nand contributes to the functioning of the
\nlabour markets.
\nMany studies have confirmed the positive cor-
\nrelation between health and growth. Suhrke et
\nal. 2005 examined 65 studies about the con-
\nnection of health in the most diverse develop-
\nments and their economic effects. The review
\nconfirmed that the health of the population
\nis a crucial factor for personal income and the
\neconomic growth. In economic growth mod-
\nels,economic growth rises with the productiv-
\nity of both health generation and the human
\ncapital accumulation process. Furthermore,
\nimprovements in health raise longevity,which
\nwill increase savings (for retirement) and
\nhence facilitate investment, and the occur-
\nrence of a demographic dividend that creates
\nan increase in the population of working age
\n[14]. There is also an indirect link, similar to
\nthe impact of education,on economic growth.
\nInvestments in health, together with invest-
\nments in education, determine the number of
\neffective labour-services relative to the physi-
\ncal units of labour available that represent po-
\ntential labour services.
\nCertainly,there are limits of the contribution
\nof the subsidised health economy to econom-
\nic growth and productivity across the whole
\neconomy [15]. Oversupply and over-medi-
\ncalisation may harm both economic growth
\nand the health of the population. Taking into
\nconsideration the overall development of the
\nhealth economy and its impact on society,
\nreliable indicators about the performance of
\nhealth economy are crucial for both health-
\ncare and economic policy. The contribution
\nof the health economy to gross value added,
\nemployment, and economic growth can be
\nverified in the framework of health satellite
\naccounts. Additionally, both the contribu-
\ntion to growth and the labour force in the
\nhealth economy can be compared to other
\nbranches of the overall economy. Moreover,
\nthe limits of the national accounts regarding
\nthe welfare of the nation (beyond GDP) are
\ntaken into account.
\nThe direction of sustainable development
\nis based on the sector view, viewed across
\nHealth impacts
\nSource: BASYS, adapted from WHO 2008. [13]
\n242
\nHealth financing
\nsectors,and fiscal feedback. From the sector
\nperspective, the increase of efficiency within
\nthe healthcare system, fiscal discipline, and
\nrevenue raising (e.g. via complementary in-
\nsurance) contribute to sustainable develop-
\nment. Across sectors, economies of scope
\nby a holistic approach can contribute to
\nsustainable development. Links between
\nmedical care and the extended health sec-
\ntor (e.g. health tourism, sport, and wellness)
\nand reduction of risk factors have to be
\nconsidered in the assessment of the health
\neconomy. Health risks can be reduced by
\nprimary prevention and human capital
\nas growth factors can be strengthened by
\nhealth education. The inclusion of coverage
\nfor the whole population and equity issues
\nare essential in considering such a broad
\nperspective.
\nFrom the view point of fiscal stability, the
\nfiscal feed back of cuts or expansions of
\nhealthcare expenditures are of particular
\ninterest. In most countries healthcare is
\nheavily subsidised. Therefore, the indirect
\nand induced effects on the overall economy
\nand public finance and the feedback have to
\nbe compiled to make a proper assessment
\nof healthcare expenditure cuts. More-
\nover, self-financing of the health economy
\nand independence from the public budget
\nshould be checked by both social and pri-
\nvate health insurance systems and private fi-
\nnancing mechanisms while at the same time
\nbalancing access to care.
\nSecuring the safety net of the healthcare
\nsystem is an imperative in the short-run. It
\ntakes generations to develop a healthcare
\nsystem, train and educate health profession-
\nals and implement governance and contract
\nstructures. Therefore, avoid pro-cyclical
\ncuts of public health system expenditures
\nbecause of large impacts on employment
\nand value added; governments should sus-
\ntain healthcare expenditures despite finan-
\ncial crisis; Avoid healthcare bubbles – prices
\nof health insurance policies or health infra-
\nstructure investments rising to a level that
\nappears to be unsustainable and well above
\nthe assets\u2019 value as determined by economic
\nfundamentals.
\nReforms of the healthcare system within a
\ncountry are always embedded in a specific
\ninstitutional environment and value system
\nwhich has been developed over several gener-
\nations. Although constraints differ by coun-
\ntries\u2019 productivity, development is a must for
\nhealthcare, independent of the system, and a
\nprerequisite for sustainable financing. Strat-
\negies for productivity development might
\nbuild on the experience of the industrial side
\nof the health economy and on the results of
\nhealthcare system comparisons. If the crises
\nof public finance continue, further measures
\nshould be taken under consideration of the
\nimpact on the supply side and health of the
\npopulation. Independently, tradeoffs be-
\ntween different types of investments in hu-
\nman capital have to be considered:
\nThe well-being of future generations will
\ndepend not only upon how much stock of
\nexhaustible resources we leave to them but
\nalso how much we devote to the constitu-
\ntion of human capital, essentially through
\nexpenditure on education, research, and
\nhealth.
\nAll industrial countries invest a substantial
\nproportion of national income in human
\ncapital development. Taking into account
\nboth public and private sources of funds,
\nOECD countries had spent 16.8% of their
\nGross Domestic Product, on average in
\n2006, on human capital. In many Central
\nand eastern European Countries, as well as
\nin less advanced countries, the investment
\nin human capital is far below this level.
\nThe following conclusions of sustainable
\nhealth financing have been drawn:
\nIn the short-term, governments should sus-
\ntain healthcare expenditures despite finan-
\ncial crises (public deficit financing) because
\nof the strong economic impact of the health
\neconomy on the whole economy and em-
\nployment;
\nCutting resources of healthcare systems is
\nnot a likely solution for financial sustain-
\nability, rather the focus should be on effi-
\nciency and equity;
\nUnderstand healthcare as an investment
\nin human capital: long-term fiscal policies
\nhave to optimize both health and human
\ncapital development (education, R&D, and
\nhealth expenditures);
\nDevelop international consensus about rel-
\nevant indicators of financial sustainability of
\npublic healthcare expenditures and policies;
\ninstall an international learning process about
\nbest practises in economic and financial crisis.
\n1. Brundtland G.H. Our Common Future, Re-
\nport of the World Commission on Environ-
\nment and Development. Published as Annex
\nto General Assembly document A\/42\/427.
\nDevelopment and International Co-opera-
\ntion: Environment August 2. 1987. Retrieved,
\n2007.11.14.
\n2. Auerbach H., Gokhale J., Kotlikoff L.J. Gen-
\nerational Accounting: A Meaningful Way to
\nEvaluate Fiscal Policy. Journal of Economic
\nPerspectives, vol. 8, 1994: 73-94.
\n3. European Commission. Public Finances in
\nEMU, European Economy 4\/2010, Economic
\nand Financial Affairs, Brussels, 2010.
\n4. European Commission. Sustainability Report
\n2009. EUROPEAN ECONOMY 9\/2009,
\nBrussels
\n5. European Commission.The 2009 Ageing Re-
\nport: economic and budgetary projections for
\nthe EU-27 Member States (2008-2060). Joint
\nReport prepared by the European Commis-
\nsion (DG ECFIN) and the Economic Policy
\nCommittee (AWG).
\n6. Weisbrot, Mark, Rebecca Ray, Jake Johnston,
\nJose Antonio Cordero and Juan Antonio
\nMontecino. IMF-Supported Macroeconomic
\nPolicies and the World Recession: A Look at
\nForty-One Borrowing Countries. Center for
\nEconomic and Policy Research Briefing Pa-
\nper, October. http:\/\/www.cepr.net\/documents\/
\npublications\/imf-2009-10.pdf.
\n7. Congressional Budget Office.The Budget and
\nEconomic Outlook: An update, The Congress
\nof the United States, August 2010: p.20.
\n243
\nNMA news
\n8. Fogel R.W. Forecasting the cost of U.S.
\nHealth Care in 2040. NBER Working Paper
\nNo. 14361. September 2008. JEL No. I11.
\n9. Baumol W. J. Productivity policy and the ser-
\nvice sector. Inman R. P. (ed.): Managing the
\nService Economy: Prospects and Problems.
\nCambridge University Press. Cambridge
\n1985: 301-317.
\n10. Henke K.-D., Schrey\u00f6gg J. Towards sustain-
\nable health care systems: Strategies in health
\ninsurance schemes in France, Germany, Japan
\nand the Netherlands A comparative study
\nTechnical University of Berlin, Department
\nfor Public Finance and Health Economics and
\nDepartment for Health Care Management,
\nWorking paper, 23. March 2004.
\n11. Ministry of Economics and Technology
\n(BMWi). Towards a German Health Sat-
\nellite Account. November 2009. http:\/\/
\nwww.bmwi.de\/BMWi\/Navigation\/Service\/
\npublikationen,did=320754.html and BASYS.
\nFoundations, methodology, and selected re-
\nsults of a Satellite Account for the German
\nhealth economy, 2005. Working paper. June
\n2010. http:\/\/www.basys.de\/aktuelles\/gsk-en.
\npdf.
\n12. 12 Suhrke, M. et al. The Contribution of
\nHealth to the Economy in the European Un-
\nion, European Commission, Health & Con-
\nsumer Protection Directorate-General. 2005.
\n13. 13 WHO (2008). The contribution of regions
\nto health and wealth. Technical report for the
\nWHO European Ministerial Conference on
\nHealth Systems: \u201cHealth Systems, Health and
\nWealth\u201d, Tallinn, Estonia, 2527 June 2008,
\nRegions for Health Network in Europe.
\n14. 14 Bloom D.E, Canning D. and J. Sevilla.The
\nDemographic Dividend: A New Perspective
\non the Economic Consequences of Population
\nChange. Santa Monica. 2003.
\n15. 15 Zon van A.H., Muysken J. Health as a
\nPrincipal Determinant of Economic Growth.
\nMERIT-Infonomics Research Memorandum
\nseries, 2003-021, Maastricht University.
\nMarkus Schneider, BASYS,
\nConsulting Company for
\nApplied Systems Research
\ne-mail: ms@basys.de
\nCecil B. Wilson
\nMy thanks to the House of Delegates, my
\ncolleagues, my friends, and my family for
\nwhat is truly the greatest honor of my life
\nin medicine.
\nSome of you know my story of growing
\nup in South Georgia, the son of a Meth-
\nodist minister. And in the tradition of the
\nitinerant ministry, moving every few years\u00a0
\nfrom town to town and church to church
\nthroughout the state. And I recall how,
\nwhen my brothers and I would head out the
\ndoor to go to school,our fathert he Rev.Dr.
\nWilsonw ould admonish us: \u201cRemember,
\nyou represent the whole family. Act accord-
\ningly.\u201d That simple statement of purpose
\nhas guided me through college, medical
\nschool, my service in the U.S. Navy as a
\nflight surgeon, and my professional career
\nand personal life in Florida.
\nIt guides me today, and it will continue to
\nguide me tomorrow, when I head out the
\ndoor to tour this country on behalf of the
\nAmerican Medical Association.
\nMy commitment to you is that now as in
\nthe past I will remember that I represent
\nthe whole family of medicine. And I will act
\naccordingly.
\nLife is about opportunities and responsibili-
\nties.And nowhere are these found in greater
\nmeasure than in the calling we have chosen
\nthe profession of medicine. As physicians
\nwe have the opportunity to heal, and the re-
\nsponsibility to do no harm.We have the op-
\nportunity to care for those who are ill, and
\nthe responsibility to deliver the best care
\npossible. And at this historic time, we have
\nthe opportunity to assure that our country\u2019s
\nhealthcare system bears the imprimatur of
\nphysicians, and we have the responsibility
\nto bring to that task a voice that is clear,firm
\nand constructive.
\nIn thinking about what I was going to say
\nthis evening, I turned to my love of sailing
\nan attraction to the sea and ships sealed
\nduring my service in the Navy.
\nAmong the joys of living in Florida are
\nthe proximity to the ocean and access to
\nsailboats preferably, someone else\u2019s. I\u2019ve
\nlearned that off the coast, the waters are
\nsometimes shallow and the winds variable.
\nRunning aground, being whipped by gales,
\nor becoming becalmed are all part of the
\nexperience. I recall one sailing trip from St.
\nPetersburg across Florida Bay toward Key
\nWest. In early evening, we strayed from the
\nchannel and ran aground in the middle of
\nthe bay an 850-square mile body of water.
\nTo get off the reef,we tried hoisting our sails
\nand lowering them; we cranked the auxil-
\niary engine; we put out an anchor and tried
\nto winch ourselves off. Nothing worked.We
\n244
\nNMA news
\neven tried to rock the boat off the entire
\ncrew running from one side to the other
\nfrom port to starboard and back, and from
\nbow to stern and back. By the way, did I say
\nthe crew was all doctors? Fortunately, this
\nwas in the days before You Tube or else we
\nmay have gone \u201cviral.\u201d
\nDuring this exercise in futility we dislodged
\nthe dingy, which then drifted away. One of
\nthe crew dove in, swam to it, and climbed
\nin only to discover there were no oars. The
\ndingy, with him in it, was being blown out
\nto sea. Another member of the crew dove
\nin carrying oars and swam to the drifting
\ndingy. Two hours later, two very exhausted
\nsailors came back. Six hours later a rising
\ntide helped free us from the reef, and we
\ncould continue our trip.
\nThis reminds me a bit of our journey toward
\nhealth system reform. Embarked upon with
\na plan of action, at times diverted off course,
\nat times becalmed but ultimately the
\ncountry reached its destination. In talking
\nwith AMA members around the country, I
\nfound most physicians did not dispute the
\ncore principles of health system reform.
\nRather, physicians disagreed on the in-
\nterpretation of those principles and the
\nstrategy and tactics used to advance re-
\nform. Some did not like how we plotted our
\ncourse, unfurled our sails and set our speed.
\nOthers sought a different destination. All
\nwere sincere in their views.
\nTo me,these reforms are a long overdue first
\nstep a first step toward a better health
\ncare system in this country. This legislation
\nis not perfect, but it makes medical care
\nmore accessible and coverage more reliable
\nfor millions. It makes insurance companies
\nmore accountable. It strengthens wellness
\nand prevention. These are no small things.
\nBut it\u2019s easy to lose sight of what\u2019s good
\namid the finger-pointing, partisanship and
\njust plain anger that marked this debate.
\nIt\u2019s been said that: \u201cHonest criticism is hard
\nto take especially when it comes from a
\nrelative, a friend, a colleague, an acquain-
\ntance or a stranger. Did I leave anyone out?\u201d
\nI know too well that there are fences to
\nmend, assurances to make, and wounds to
\nheal.I am also well aware that if we dwell on
\nthe past, we risk running aground.
\nOur energies are better spent making health
\nsystem reform the best it can be for physi-
\ncians and patients. Now more than ever we
\nneed to focus on what\u2019s best for our profes-
\nsion and act accordingly. Of course that\u2019s
\neasier said than done. This is a complicated
\nsystem, with many stakeholders involved.
\nAnd it\u2019s also complex work that we do every
\nday. Sometimes we forget that.
\nThink about it:
\nPhysicians must choose from among more
\nthan 60,000 diagnoses; 11,000 surgical pro-
\ncedures; and at least 4,000 different drugs.
\nThe pressures on physicians are intense.
\nAnd we welcome that responsibility. But we
\nalso have to recognize that we can do even
\nbetter. All of us can do betterfr om govern-
\nment officials, to insurers to patients. Well
\nTonight, the doctor is in. That\u2019s me. And
\nI would like to offer some prescriptions for
\nour ailing health care system.
\nLet me start with four of the biggest chal-
\nlenges we face to make health system re-
\nform a success:
\nmedical liability,
\nskyrocketing costs,
\ninefficiencies in health care delivery, and
\nMedicare underpayment.
\nFirst, medical liability.
\nStudies tell us that today 75 per cent of
\nAmerican physicians are forced to prac-
\ntice defensive medicine to order tests or
\nprocedures more out of a need to protect
\nagainst possible litigation, than to improve
\npatient care.This drains as much as 126 bil-
\nlion dollars out of the health care system an-
\nnually. The health system reform legislation
\nacknowledges this problem but it does not
\ngo far enough to solve it.Ultimately,caps on
\nnon-economic damages are the gold stan-
\ndard for successful medical liability reform.
\nThey\u2019ve worked for more than a generation
\nin California, and they are also working to-
\nday in Texas, Louisiana and other states.
\nMy prescription: Caps. Caps are AMA pol-
\nicy. Caps are the only prescription proven
\nto work.
\nIn addition, we need to explore alternative
\nreforms, such as health courts, administra-
\ntive compensation systems, early offer mod-
\nels and \u201csafe harbors\u201d for physicians who
\nfollow best practices.
\nNext, cost.
\nIf nothing changes, by 2020 America will
\nspend 4.4 trillion dollars a year on health
\ncare. Let me put this in perspective. That
\nmeans a family of four that makes 80 thou-
\nsand a year would spend a fourth of their
\nincome on health care. That\u2019s not sustain-
\nable.
\nMy prescription:
\nWe need a comprehensive plan for contain-
\ning costs and getting the most out of our
\nhealth care dollars. If we don\u2019t, reform will
\nfail.
\nThe AMA has identified four broad strate-
\ngies to contain costs:
\nreduce the burden of preventable disease;
\nmake the delivery of care more efficient;
\nreduce nonclinical costs that don\u2019t con-
\ntribute to patient care; and
\npromote value-based decision-making
\nat all levels.
\nLet me next focus for a moment on one of
\nthe accomplices of soaring costs inefficient
\ndelivery of care.
\nFrom fragmentation of care to a lack of
\navailable comparative effective research
\n245
\nNMA news
\ndata, the current system is plagued by inef-
\nficiencies. Some services are over-utilized,
\nothers are under-underutilized.
\nMy prescription: Focus on making sure pa-
\ntients get the right care at the right time, at
\nthe right place.
\nThis means:
\nimproving coordination of care;
\nusing more services that address cost and
\nprevention; and
\nmaking available more research to help
\nphysicians make the best decisions pos-
\nsible.
\nAnother challenge is all too familiar
\nthe Medicare reimbursement crisis. Be-
\ncause of the senseless payment formula,
\nthe SGR, physicians are threatened with
\ncuts. Year after year. And year after year,
\nthe costs of providing care and running an
\noffice continue to rise. The disparity be-
\ntween actual expenses and what Medicare
\npays are, to use an expression familiar in
\nFlorida, like the open jaws of an alligator.
\nAnd they\u2019re ready to snap shut on access
\nfor our seniors.
\nMy prescription: Scrap the SGR. Toss it
\noverboard. Feed it to that gator, instead.
\nReplace it with a payment structure that re-
\nflects the true costs of providing care in the
\n21st
\ncentury. We also need new approaches
\nto physician payment that are rooted in the
\nreality of how medical care is provided. For
\nexample, Medicare should encourage better
\ndisease management, which is especially im-
\nportant for seniors in need of chronic care.
\nNow, improving our system is not just about
\ntackling the important issues. It\u2019s also about
\nfulfilling our responsibilities as stakeholders.
\nIt\u2019s been said that Socrates was a teacher
\nwho went around giving everyone advice
\nso they poisoned him.
\nSo despite this great personal risk, and well
\naware of the aphorism that \u201cfools rush in
\nwhere angels fear to tread\u201d I would now
\nlike to offer some prescriptions to each of
\nthe major stakeholders in our health care
\nsystem.
\nStarting with the private sector.
\nTo America\u2019s health plans, insurance com-
\npanies, pharmaceuticals and device manu-
\nfacturers:
\nYou have a special responsibility to the
\nhealth care system. Your products and ser-
\nvices, like ours, directly affect patients\u2019 lives
\nand health. This isn\u2019t as simple as offering a
\nchoice of toothpaste or cell phone.
\nMy prescription: Always remember you are
\nmore than just businesses. Keep your business
\npractices transparent and keep the needs
\nof your customers our patients foremost
\nwhen you develop products and policy. To
\nour leaders in government, especially those
\nin elected offices such as Congress.
\nWe are ill-served by partisan bickering
\namid a toxic atmosphere that poisons efforts
\nto work together.Turning every policy deci-
\nsion even suggestion into a 30-second
\nattack ad damages our democracy.
\nThe prescription: Develop legislation that
\nserves us well. Move beyond the partisan
\nfight. Seek accommodation or at least un-
\nderstanding across political divides. Tol-
\nerate differences of opinion. Do the job for
\nwhich you were elected!
\nAbove all remember that you represent the
\ninterests of the nation. Act accordingly.
\nTo my fellow physicians: This has been a
\nchallenging year, and on an issue as complex
\nas health system reform it is inevitable that
\ndifferences of opinion will arise. Remember,
\nthe common ground we share is vast what
\ndivides us is not.
\nThomas Jefferson once said: \u201cNot every dif-
\nference of opinion is a difference of principle.\u201d
\nMy prescription:
\nSupport the AMA, support all your medi-
\ncal associations they are the only way to
\nfocus light on the goals of our profession,
\nthe challenges we face, and our efforts to
\nbetter serve our patients. Do not let others
\ndivide us.
\nGet involved. Make a difference.
\nTo our medical students and residents
\nthose who are now learning what this call-
\ning entails You are embarking on your
\ncareers at an historic time.
\nRemember: the issues we face are not just
\nchallenges they also are opportunities.
\nRemember too that the system itself may
\nneed fixing, the tradition of excellence in
\nthis country is as strong as ever. American
\nphysicians are world leaders in medical
\nknowledge, technical skills and cutting-
\nedge care. And most important, remember
\nthat the profession you have chosen is in-
\ncredibly rewarding. To heal, to comfort, to
\nrelieve pain to be trusted with this most
\nsensitive part of your patients\u2019 lives is a
\ngreat privilege. And after more than 30
\nyears of practice, I can honestly say that the
\nsense of gratification I get from helping pa-
\ntients now is just as strong as it was when
\nI first started out some years ago.
\nMy prescription for you:
\nListen to your patients; they will tell you
\ntheir problems. And sometimes their di-
\nagnoses as well. And join the AMA. Join
\norganized medicine. Influence the policies
\nthat affect your education and how to pay
\nfor it. Influence the policies that affect your
\nfuture profession. Add your voice.
\nTo businesses remember that investing in
\nthe health of your employees today, can lead
\nto significant savings in the long run. And
\nit\u2019s not just a matter of offering insurance.It\u2019s
\nalso a matter of fostering healthier lifestyles.
\n246
\nNMA news
\nMy prescription: Take an interest in the
\nhealth of your employees. If they smoke,
\nhelp them quit. Provide a gym membership
\nor better yet, a gym. Replace some of the
\ncandy bars and snacks in the vending ma-
\nchine with healthier options.
\nThe rewards aren\u2019t just physical.They\u2019re also
\nfinancial.Healthier employees mean less in-
\ncidence of obesity, diabetes, cancer, and the
\ncostly chronic care that goes with it.
\nAnd this brings me to patients. To them
\nto you:
\nMy prescription: Take responsibility for the
\nkind of care you receive. Empower and edu-
\ncate yourself as a patient.
\nMake important health decisions now
\nsuch as insuring your family, choosing a
\npersonal physician, and documenting your
\nwishes about end-of-life care.
\nMost common diseases are preventable.Chal-
\nlenge yourself to adopt healthier behaviors.
\nYour well-being is your biggest asset. Don\u2019t
\nwaste it.Your loved ones will thank you.
\nNow I\u2019m going to break a cardinal rule of
\nmedicine and issue one final prescription
\nfor myself.
\nAs president of the American Medical As-
\nsociation, I promise to do what I can to
\nmend the divisions within our ranks. Isaac
\nNewton observed: \u201cWe build too many
\nwalls and not enough bridges.\u201d I plan to
\nheed those words a nd act accordingly.
\nOne way I plan to do this is through regular
\nconference calls or other means to speak with
\nAMA members. The goal will be in part to
\nupdate you on the latest developments, but
\nprimarily, to hear from you your thoughts,
\nsuggestions, questions and concerns.
\nThis will be interactive. A two-way conver-
\nsation to openly and honestly communicate
\nwith each other.
\nI\u2019m not just going to talk – I\u2019m going to lis-
\nten.
\nWe will let you know the details soon.
\nThese communications will be a way to ad-
\ndress the here and now.
\nUltimately, history will judge whether the
\ndecisions made during this historic and tur-
\nbulent time were the right ones.
\nBut I can assure you that these decisions
\nwere rooted in principle, not expedience.
\nFor a better health care system not a bro-
\nken status quo. In the interests of our pa-
\ntients not just ourselves.
\nWe did not control events. But neither did
\nevents control us. We plotted a course, un-
\nfurled our sails, and journeyed on, tempest
\ntossed but hands on the wheel. We helped
\ndetermine our own fate.The alternative was
\nto have it determined for us.
\nEarlier, I spoke of a lesson learned on the
\nsea and from it. Let me offer a second,
\nabout a race from Daytona Beach to Ber-
\nmuda. The third day out featured sunny,
\ncloudless skies, moderate temperature,
\na strong breeze blue water sailing at
\nits best. We were making 16 knots on a
\ndownwind tack with all sails flying. Crest-
\ning large waves, then plowing into troughs
\nas water broke across the bow. Even as we
\nreveled in perfect conditions, the captain
\nnoted that the breeze had picked up and
\nthat we should take in some of the sails.
\nBut among the crew, there was much sec-
\nond-guessing. We were, after all, \u201cexperi-
\nenced\u201dsailors.We\u2019d taken the Coast Guard
\ncourses. We\u2019d learned celestial navigation.
\nWe\u2019d sailed around Florida on a serious
\nrecreational basis. We knew better. By the
\nway did I say the crew was all doctors?
\nThis \u201cdiscussion\u201d was interrupted by a loud
\npow!! blasting from the bow. We looked up
\nto find that a sail had blown out, shredded
\nby the strong winds.
\nLessons learned.
\nA cruise to Bermuda that reminds us that
\neven when the sailing is smooth and the sun
\nis shining, prudence dictates we check the
\nwind, check the sea, check our sails, expect
\nchanges and prepare for them. And maybe
\nmaybe it tells us that no single one of us
\nhas all the answers. If we fail to plan if we
\nlet outside forces plot our course and set our
\nspeed, we will ultimately drift, powerless
\nwithout direction or purpose.
\nThat is why the AMA kept our hand on the
\nwheel during the storms of the reform de-
\nbate. Now, we face a defining moment for
\norganized medicine and the AMA. This is
\nnot just a challenge, but a tremendous op-
\nportunity. Let\u2019s work together to bridge the
\nlegitimate differences that exist between us.
\nAnd let\u2019s keep in mind that we\u2019re in this
\nboat together.
\nThe poet Ella Wilcox wrote:
\nOne ship sails East,
\nAnd another West,
\nBy the self-same winds that blow,
\nTis the set of the sails
\nAnd not the gales,
\nThat tell the way we go.
\nLike the winds of the sea
\nAre the waves of time,
\nAs we journey along through life,
\nTis the set of the soul,
\nThat determines the goal,
\nAnd not the calm or the strife.
\nTis the set of the soul. We are the family
\nof medicine. We represent our patients. We
\nmust set our souls and the course together.
\nBecause together we are stronger.Thank you.
\nCecil B. Wilson, MD, American
\nMedical Association, President
\n247
\nNMA news, Education
\nArmin Ehl
\nCurrently the employed doctors in Ger-
\nmany and their trade union, the Marburger
\nBund,face a very serious problem.The Mar-
\nburger Bund is the association of the em-
\nployed doctors in Germany and their trade
\nunion as well. It was founded in 1947 and
\norganizes 108,000 doctors. In 2006 the first
\ncollective agreements especially for doctors
\nwere signed after a strike period of 14 weeks
\nat the university hospitals and another 7
\nweeks at the communal hospitals.
\nIn July 2010 the Federal Labour Court
\nruled that the working conditions in one
\nenterprise can be defined by multiple col-
\nlective agreements covering different groups
\nof workers (nurses, auxiliary staff, doctors).
\nWith this judgement the Federal Labour
\nCourt changed its previous interpretation
\nand confirmed the lawfulness of general
\npractice in Germany.
\nSoon afterwards the German Federation
\nof Employer Associations (BDA) together
\nwith the Confederation of German Trade
\nUnions (DGB) started to lobby the Ger-
\nman Government in order to change the
\nexisting law. In their opinion the collective
\nagreement of the trade union with most
\nmembers in the enterprise should have pre-
\ncedence over all other collective agreements.
\nThey argue that otherwise the enterprises
\nwould face too many strikes (they talk about
\n\u201cEnglische Verh\u00e4ltnisse\u201d) and as a result the
\neconomy in general would suffer. The los-
\ners would be the employees which decided
\nto organise their interests in specialist trade
\nunions (doctors, pilots, train drivers, air-
\ntraffic controllers). Among other things
\nspecialist trade unions would be at risk to
\nforfeit their right to strike.
\nThe Marburger Bund points out that an
\nalteration of the labour law as pursued by
\nthe BDA and the DGB will not only be
\nundemocratic but also violates the Basic
\n(Constitutional) Law of the Federal Re-
\npublic of Germany (Article 9 (3): Freedom
\nof Association).We do everything we can to
\nconvince the government to respect the lat-
\nest judgement of the Federal Labour Court
\nand leave the law unchanged.Together with
\nother specialist trade unions the Marburger
\nBund started the campaign \u201cSave the Free-
\ndom of Association\u201d (www.rettet-die-ko-
\nalitionsfreiheit.de). With this campaign we
\nwant to make the general public aware of
\nthe problem. We also asked our members to
\nwrite to the members of the Parliament and
\nlet them know their opinion.
\nArmin Ehl,
\nMarburger Bund Bundesverband
\nThe International Federation of Medical
\nStudents\u2019Associations (IFMSA), one of the
\nlargest international student organizations
\nin the global medical community, aims to
\nserve medical students all over the world.
\nCurrently, the IFMSA represents 1.2 mil-
\nlion medical students through its 102 na-
\ntional member organizations.
\nThe IFMSA is an independent, non-polit-
\nical organization, founded in 1951, and is
\nofficially recognized as a Non Governmental
\nOrganization (NGO) within the United Na-
\ntions\u2019 and recognized by the World Health
\nOrganization as the International Forum for
\nmedical students. The IFMSA aims to offer
\nmedical students a comprehensive introduc-
\ntion to global health issues. This is done by
\nour exchanges with more than 11.000 ex-
\nchanges taking place per year. It is the largest
\nstudent-run exchange program in the world,
\nand operates through our work in the fields
\nof medical education, reproductive health,
\nhuman rights and public health.
\nThe IFMSA\u2019s Standing Committee on
\nMedical Education strives to improve medi-
\ncal education worldwide.In order to achieve
\nthis goal, members from all national orga-
\nnizations share their experiences and train
\neach other, organize projects and advocate
\nfor the improvement of their curricula.
\nTwice a year, 800 IFMSA members come
\ntogether to educate one another on issues
\nregarding global health.During these meet-
\nings, specific sessions focusing on medical
\neducation are organized for members of the
\nStanding Committee on Medical Educa-
\ntion. Also, workshops called the Medical
\n248
\nEducation
\nEducation Development International
\nKit Training (MEDIK-T) are organized
\nto give students the necessary knowledge
\nand skills to work with their faculties to re-
\nstructure and improve their own education.
\nThese peer-to-peer trainings utilize various
\nteaching methods on a wide range of topics
\n(e.g. adult learning theory and curriculum
\ndevelopment), with additional support from
\nexpert teachers.
\nIn between meetings, students make use of
\na Wiki-based online platform[1]
\nand mail-
\ning lists to stay in touch, follow-up on work
\ndone during meetings and share ideas for
\nfurther improvement and new projects.
\nThe IFMSA organizes projects on local, na-
\ntional and international levels. The aim of
\nthe projects of our Standing Committee are
\nto provide medical students with additional
\ninformation concerning global health and to
\nmake them aware of the role they can play in
\ntheir own education. Examples include elec-
\ntive courses on tropical medicine and inter-
\nnational health[2
\n]and online databases where
\ninformation about curricula and residency
\nsystems of many countries can be found [3]
\n.
\nAnother important aspect of our work is
\nadvocacy. The IFMSA aims to empower
\nmedical students and improve participa-
\ntion in their medical education either as
\nstudent-teachers or student-representatives.
\nWith our work we emphasize the important
\nrole medical students play in the improve-
\nment of their education.
\nIn 2004, medical students were the first
\nstakeholders to issue a statement on The
\nBologna Process; the effort to harmonize
\nEuropean higher education. This state-
\nment[4]
\nwas the result of a series of meet-
\nings organized by medical student repre-
\nsentatives. Over the years that followed, we
\nhave evaluated the implementation of The
\nBologna Process in Medicine and consid-
\nered constructive approaches to European
\npolicy. In our work, we emphasized the stu-
\ndent\u2019s role and responsibility as an impor-
\ntant stakeholder of The Bologna Process in
\nMedicine [5, 6]
\n.
\nWe have written an outcome-based core
\ncurriculum identifying nine domains with
\n76 learning outcomes for graduates of Eu-
\nropean medical schools. The \u201cEuropean
\nCore Curriculum the Students\u2019 Perspective\u201d
\nexpresses the medical students\u2019 opinion on
\nwhich abilities, knowledge and attitudes
\nstudents of medical schools in Europe
\nshould have gained upon graduation. This
\ncore curriculum has served as a framework
\nin numerous countries, and can be adjusted
\nfor specific national and local needs[6]
\n.
\nOur statements are used for lobbying uni-
\nversity leadership, national professional
\nbodies or governments and relevant inter-
\nnational organizations. Representatives of
\nIFMSA are members of the executive board
\nof the World Federation for Medical Edu-
\ncation (WFME) and AMEE. They pres-
\nent outcomes of our work during executive
\nmeetings and raise awareness of the student
\npoint of view. In addition, our members
\naim to present our views at scientific con-
\nferences and in peer-reviewed journals [7, 8]
\n.
\nThe work of the Standing Committee on
\nMedical Education of IFMSA aims to im-
\nprove medical education worldwide. We
\nenable students to share their experiences
\nand empower them to train each other. We
\norganize projects in 102 countries world-
\nwide and advocate for the improvement of
\nmedical education through our network of
\nstudents.The outcomes of our work are dis-
\nseminated through our professional partner
\norganizations, and by presenting at confer-
\nences and meetings. We also intend to pub-
\nlish our work in journals, such as the World
\nMedical Journal, to broaden our sphere of
\ninfluence.
\n1. www.ifmsa.org\/scome\/wiki
\n2. Duvivier RJ, Brouwer EE, Weggemans M.
\nMedical Education in Global Health: Stu-
\ndent Initiatives in the Netherlands. Med
\nEduc.2010;44(5):528-9.
\n3. http:\/\/residency-database.helmsic.gr\/
\n4. Onur O, Westbye HJ, Kovac K. The Bologna
\ndeclaration and medical education: a policy
\nstatement for the medical students of Europe.
\nMed Teach. 2005;27(1):83-5.
\nMargot Weggemans Robbert Duvivier
\n249
\nThe mobility of health professionals is of
\ncrucial importance from the point of view
\nof the sustainability of health care sys-
\ntems in member states of the EU. One of
\nthe recommendations of the Green Paper
\non the migration of the health workforce
\nis to establish an EU-wide data collection
\nsystem to monitor flow of health workers.
\nMonitoring and analysis of the changes and
\ntrends can only be based on valid, reliable
\nand comparable data. One of the objectives
\nof the Prometheus project (Health Profes-
\nsionals\u2019 Mobility in the EU Study) was to
\ncollect valid and reliable data on health
\nprofessionals\u2019 migration particularly of Eu-
\nropean countries, but also of countries out-
\nside Europe. International data collection
\nhas never been done before. Comparative
\nanalysis was carried out using a set of stan-
\ndardized health workforce indicators.
\nThe main aim of the Health Prometheus
\nProject was to prepare the establishment
\nof an EU-wide health professionals\u2019 migra-
\ntion monitoring system (observatory) to
\nsupport both EU and national decision-
\nmaking in this area. The project aimed to
\nobtain an overview about the current situ-
\nation and the changes, which took place in
\nthe last decade, in Europe. Moreover, it was
\nbased on the available routine data, various
\nreports and grey literature from a network
\nof participating countries and provides an
\ninitial mapping of the scale and nature of
\nmobility for all EU countries by different
\nprofessional cadres.The Prometheus Project
\nalso included and differentiated mobility of
\nhealth professionals from 3rd
\n(i.e. non EU)
\ncountries. The findings and experiences re-
\ngarding the sources, the quality and
\nthe comparability of the available data,
\ngathered together in the frame of this
\nproject is used to assess the feasibility
\nof a sustainable data collection system
\non the migration of health profession-
\nals, as the future target.
\nThe Health Prometheus Project is
\nan FP7 supported research project
\n(the research leading to these results
\nhas received funding from the Euro-
\npean Community\u2019s Seventh Frame-
\nwork Programme ([FP7\/2007-2013]
\n[FP7\/2007-2011]) under grant agreement
\nn\u00b0 [223383]) led by the European Health
\nManagement Association and the WHO
\nEuropean Observatory on Health Systems
\nand Policies. There
\nwere eleven partner
\ninstitutions from eight
\ncountries. Semmel-
\nweis University, Health
\nServices Management
\nTraining Centre, Hun-
\ngary was responsible
\nfor data collection and
\nanalyses.
\nThe next figure shows
\nthe participating
\ncountries in the Pro-
\nmetheus Project.There
\nwere project partners (conceptual contribu-
\ntion, data collection and case study), coun-
\ntry correspondents (data collection and case
\nstudy) and country informants (only data
\ncollection). Regarding Australia, Canada,
\nNew Zealand, Norway and the USA we
\nhave collected the data from country experts
\nor online-access websites.
\nMembers of Semmelweis
\nTeam: Mikl\u00f3s\u00a0Sz\u00f3cska MD,
\nP\u00e9ter \u00a0Ga\u00e1l \u00a0MD, Edmond Girasek,
\nEszter Kov\u00e1cs, Edit Eke MD
\nMedical and socio-medical affairs
\n5. Duvivier RJ Hilgers J, Davaris N, Rodriguez
\nMu\u00f1oz D. Implementation of the Bologna
\nTwo-Cycle System in Medical Education
\nthe Student\u2019s View. Med Teach. 2009;31:376-
\n7.
\n6. Duvivier RJ, Weggemans M. Joint issue
\nTMO\/ZMA: Reply from International
\nMedical Students. GMS Z Med Ausbild.
\n2010;27(3):Doc40.
\n7. IFMSA, EMSA, Hilgers J, De Roos P. Eu-
\nropean Core Curriculum The students\u2019 per-
\nspective. Med Teach. 2006;29:270-5.
\n8. Duvivier RJ, Mansouri M, Iemmi D, Ru-
\nkavina S. Migrants and the Rigth to
\nHealth: The Students\u2019 Perspective. Lancet
\n2010;375(9712):376.
\nMargot Weggemans, Liaison Officer for
\nMedical Education issues 2010-2011
\nRobbert Duvivier, Liaison Officer for
\nMedical Education issues 2008-2010
\n250
\nWMA news
\nMessage from the President
\nof the World\u00a0Medical Association . . . . . . . . . . . . . . . . . . . . . . 209
\nThe World Medical Association General Assembly. . . . . . . . . 210
\nThe World Medical Association General Assembly. . . . . . . . . 211
\nStatement on Environmental Degradation
\nand Sound Management of Chemicals . . . . . . . . . . . . . . . . . . 220
\nStatement on Family Violence . . . . . . . . . . . . . . . . . . . . . . . . . 222
\nStatement on the Relationship between
\nPhysicians and Pharmacists in Medicinal Therapy . . . . . . . . . . 227
\nResolution on Drug Prescription . . . . . . . . . . . . . . . . . . . . . . . 228
\nWorld Physicians Call for Inquiry into Congo Rapes . . . . . . . 229
\nHealth Day at COP16 – Doctors Say:
\nDon\u2019t Forget the Health Dividend . . . . . . . . . . . . . . . . . . . . . . 230
\nTime is of the Essence to Achieve
\na Solution on Patients\u2019 Rights. . . . . . . . . . . . . . . . . . . . . . . . . . 231
\nStephen Holman awarded Bioanalysis:
\nYoung Investigator 2010. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
\nPatient Safety and Quality in Medicine
\nPermanent Obligation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
\nClimate Change: Governments Need to
\nHear from Medical Professionals . . . . . . . . . . . . . . . . . . . . . . . 237
\nSustainable Health Financing . . . . . . . . . . . . . . . . . . . . . . . . . 239
\nA Prescription for America\u2019s Health Care System . . . . . . . . . . 243
\nFreedom of Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
\nStudents Striving to Improve Medical Education
\nExperiences from International Perspective . . . . . . . . . . . . . . . 247
\nHealth Professionals\u2019 Mobility
\nPresentation of a Research Project . . . . . . . . . . . . . . . . . . . . . . 249<\/p>\n"},"caption":{"rendered":"

wmj30 vol. 56 MedicalWorld Journal Official Journal of the World Medical Association, Inc G20438 Nr. 6, December 2010 Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 661 peteris@arstubiedriba.lv editorin-chief@wma.net Dr. Alan J. Rowe Haughley Grange, Stowmarket Suffolk IP143QT, UK Prof. Dr. med. Elmar Doppelfeld Bachmer Str. 29-33 D-50931, […]<\/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\/wmj30.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3609"}],"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=3609"}]}}