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wmj201302<\/a><\/p>\n

COUNTRY
\n\u2022 194th
\nWMA Council Session \u2013 Bali
\n\u2022 Protective Provisions for Research Participants
\nvol. 59
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 2, April 2013
\nEditor in Chief
\nDr. P\u0113teris Apinis
\nLatvian Medical Association
\nSkolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.lv
\neditorin-chief@wma.net
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor
\nVelta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by
\nP\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher
\n\u201cMedic\u012bnas apg\u0101ds\u201d,
\nPresident Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nCover painting:
\nEnglish physician vaccinating his son\/sculpture
\nby Edward Jenner\/vintage illustration from
\nMeyers Konversations-Lexik on 1897
\nPublisher
\nThe World Medical Association, Inc. BP 63
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\nPrinted by
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\nISSN: 0049-8122
\nDr. Cecil B. WILSON
\nWMA President
\nAmerican Medical Association
\n515 North State Street
\n60654 Chicago, Illinois
\nUnited States
\nDr. Leonid EIDELMAN
\nWMA Chairperson of the Finance
\nand Planning Committee
\nIsrael Medical Asociation
\n2 Twin Towers, 35 Jabotinsky St.
\nP.O.Box 3566, Ramat-Gan 52136
\nIsrael
\nDr. Masami ISHII
\nWMA Vice-Chairman of Council
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Jos\u00e9 Luiz
\nGOMES DO AMARAL
\nWMA Immediate Past-President
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nRua Sao Carlos do Pinhal 324
\nBela Vista, CEP 01333-903
\nSao Paulo, SP Brazil
\nSir Michael MARMOT
\nWMA Chairperson of the Socio-
\nMedical-Affairs Committee
\nBritish Medical Association
\nBMA House,Tavistock Square
\nLondon WC1H 9JP
\nUnited Kingdom
\nDr. Guy DUMONT
\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
\n1380 Lasne
\nBelgium
\nDr. Margaret MUNGHERERA
\nWMA President-Elect
\nUganda Medical Association
\nPlot 8, 41-43 circular rd., P.O. Box
\n29874
\nKampala
\nUganda
\nDr. Heikki P\u00c4LVE
\nWMA Chairperson of the Medical
\nEthics Committee
\nFinnish Medical Association
\nP.O. Box 49
\n00501 Helsinki
\nFinland
\nDr.Frank Ulrich MONTGOMERY
\nWMA Treasurer
\nHerbert-Lewin-Platz 1
\n(Wegelystrasse)
\n10623 Berlin
\nGermany
\nDr. Mukesh HAIKERWAL
\nWMA Chairperson of Council
\n58 Victoria Street
\nWilliamstown, VIC 3016
\nAustralia
\nDr. Otmar KLOIBER
\nWMA Secretary General
\n13 chemin du Levant
\n01212 Ferney-Voltaire
\nFrance
\nWorld Medical Association Officers, Chairpersons and Officials
\nOfficial Journal of the World Medical Association
\nOpinions expressed in this journal \u2013 especially those in authored contributions \u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\n41
\nWMA news
\nIt has been a great privilege for me over
\nthe past five months to represent the
\nWorld Medical Association as your presi-
\ndent.
\nI have found the responsibility sobering,
\nthe experience fascinating and the oppor-
\ntunity personally rewarding.
\nIn my inaugural address at the General As-
\nsembly last October in Bangkok I shared
\nwith you the message that I would carry
\nin my travels around the world on behalf
\nof the WMA.
\nThat message consisted of three parts:
\n1. The moral imperative of ethics in medi-
\ncine
\n2. The challenge of noncommunicable dis-
\neases and their Siamese twins, the social
\ndeterminants of health
\n3. The threat of climate change
\nThat message has gone with me as I have traveled to four continents,
\nTo twelve countries and
\nFifteen cities within those countries for a total of
\nSixteen meetings and conferences in the past five months.
\nThe countries visited include the US, Canada, Taiwan, South Af-
\nrica, Israel, Egypt, Singapore, China, Japan, Nepal, England and
\nLatvia.
\nI would be remiss if I did not express my appreciation to the medi-
\ncal associations and others in each of those countries, many of
\nwhich are here in this room today, for their warm hospitality to
\nme and their expressions of support for the World Medical As-
\nsociation.
\nThank you all.
\nPosted on the web last week is a list of all the events in which I have
\nparticipated with a brief description of each.
\nIn addition, following the meeting in Bangkok I started a presi-
\ndent\u2019s blog titled \u201cAround the World with WMA President Cecil
\nWilson, MD\u201d. The blog site is accessible from the WMA home
\npage at www.wma.net. These blogs total 38 to date, almost two a
\nweek.
\nIn them I have chronicled each of the events in which I have par-
\nticipated.
\nThey have also dealt with other issues of
\nimportance to the WMA.
\nEach event in which I have participated
\nhas warranted at least one blog and there
\nare some for which I wrote two \u2013 \u201ctwo blog
\nmeetings\u201d \u2013 if you will.
\nI will not describe each visit today in detail,
\nbut I would like to highlight some of the
\nthemes that were a part of the meetings and
\nwere only some among the many issues that
\ncaught my attention.
\nI will conclude with some observations
\nabout the WMA based on my experience in
\nthis office to date.
\nThe themes include:
\n\u2022 NCDs and the social determinants of
\nhealth,
\n\u2022 Violence in the health sector,
\n\u2022 Revision of the Declaration of Helsinki,
\n\u2022 Medical students and junior doctors
\n\u2022 Leadership training for physicians.
\nFirst, the social determinants of health.
\nTwo weeks ago at a conference in London organized by our Chair of
\nthe Socio-Medical Committee, Sir Michael Marmot, a new report
\nwas presented, \u201cWorking for Health Equity: The Role of Health
\nProfessionals in the Social Determinants of Health.
\nThis report from the University College of London, Institute of
\nHealth Equity addresses what medical professionals can do to ad-
\ndress this problem.
\nTwenty-one national professional organizations participated in the
\nreport.
\nProof that when Sir Michael calls, people say yes.
\nI provided an international perspective based on WMA policy.
\nAnd Dr. Anna Reid, President of the Canadian Medical Associa-
\ntion reported on a simultaneously released Canadian study based
\non a survey of Canadian physicians titled \u201cPhysicians and Health
\nEquity Opportunities in Practice\u201d.
\nAt the Taiwan Health Forum held in Taipei in November Dr.Wen-
\nTa Chiu, Minister of Health emphasized the importance of the so-
\ncial determinants of health.
\nDr. Chiu is credited with leadership in passing a bike helmet law in
\nTaiwan a number of years ago.
\nPresident\u2019s Report
\nWorld Medical Association Cecil B. Wilson, MD, MACP April 4, 2013 Bali, Indonesia
\nCecil B. Wilson
\n42
\nWMA news
\nDuring the time since passage of the law the number of people in
\nTaiwan has increased, the number of motor bikes has increased ex-
\nponentially and likewise the number of accidents.
\nHowever the number of deaths has decreased or at least remained
\nrelatively stable.
\nSince head injuries are the primary cause of deaths from bike acci-
\ndents, this social determinant of health has been addressed in large
\npart by the helmet law.
\nEstimates are this law saves approximately 4000 lives a year in Tai-
\nwan.
\nAt the annual scientific conference in Beijing in January Dr. Chen
\nZhu, President of the Chinese Medical Association and Minister of
\nHealth for China reported on the status of health system reform in
\nChina and the influence of social determinants of health.
\nDr. Zhu commented positively on my remarks to the conference
\nabout the importance of governments recognizing that all policy
\nhas health effects \u2013 that we should think not just about one min-
\nister of health but all ministers should be considered health min-
\nisters.
\nAt the All Nepal Medical Conference in Kathmandu in March, Dr.
\nRam Baran Yadav, President of Nepal and a physician, described
\nthe threat of earthquakes in Nepal where buildings lack structural
\nintegrity.
\nHe highlighted the increasing burden of communicable disease
\nwith its strains on the health care infrastructure.
\nHe reported on the high incidence of accidents in a developing
\ncountry with roads in a poor state of repair, the absence of street
\nlights and only a few traffic lights in Kathmandu a city of roughly
\nthree million people where vehicles, bikes and pedestrians all share
\nthe same roadways.
\nAll social determinants of health.
\nNext is the issue of violence in the health sector:
\nLast October Chair of Council Dr. Mukesh Haikerwal, Dr. Dana
\nHanson, former WMA president and I attended the third inter-
\nnational conference on violence in the health sector in Vancouver,
\nCanada.
\nDr. Haikerwal gave the opening keynote speech.
\nThe evidence that this is a major problem of epidemic proportions
\nwas illustrated by the attendance of 482 health care workers from 43
\ncountries who presented 189 papers documenting violence against
\nhealth professionals in their countries.
\nAn additional aspect of this problem is the increase in violence
\nagainst health care professionals and facilities in areas of armed
\ncombat.
\nThe WMA is working with the ICRC\/Red Crescent Society on
\nthe Health Care in Danger Initiative seeking to develop ways to
\ndecrease the danger of violence in these circumstances.
\nVivienne Nathanson of the British Medical Association and I were
\nin Cairo, Egypt in December participating in one of the regional
\nconferences to seek advice from those actually working in the field.
\nThe meeting included 70 physicians from areas of armed conflict in
\nEgypt, Libya, Syria, Yemen, Kenya, Pakistan and Afghanistan.
\nThese true heroes of medicine described in dispassionate profes-
\nsional detail the work they are doing and measures that can help
\ndecrease danger based on their experience.
\nIn February I spoke to the Syrian American Medical Society
\n(SAMS) Conference in Clearwater, Florida in the US and de-
\nscribed the WMA\u2019s work with the ICRC and our publically call-
\ning on President Assad of Syria to protect health care workers and
\nfacilities.
\nSAMS is involved in a major effort to provide medical relief to
\nwounded Syrian citizens in Turkey, in border refugee camps and
\ninside Syria.
\nOf their 10 chapters nationwide, over 100 volunteer physicians to
\ndate have traveled across the Turkish border to reach field hospi-
\ntals.
\nOnce there, these doctors treat hundreds of casualties while under
\nthe constant threat of attacks by Syrian military artillery and air-
\nstrikes.
\nSAMS has established eleven hospitals in Syria, supported twenty-
\nfive already existing medical facilities, and has appropriated over
\n$2\u00a0million to specific relief projects since April 2012.
\nIn the area of ethics, it was my privilege to attend and present open-
\ning remarks at the two expert conferences our workgroup on the
\nDeclaration of Helsinki has held since we met in Bangkok.
\nI was impressed by the quality of the conferences and the input
\nreceived.
\nI believe the work group was similarly impressed and apprecia-
\ntive.
\nI was also impressed by the hospitality and arrangements of our host
\ncountries \u2013 the South African Medical Association hosting the con-
\nference in Cape Town, South Africa in December and the Japanese
\nMedical Association (JMA) serving as host for the conference in
\nTokyo in February.
\nThank you both.
\nSome of you may know, others not, that at the conference in Tokyo
\nI gave my opening remarks in Japanese.
\nDr. Yoshitake Yokokura, JMA President, and Dr. Massami Ishii,
\nvice chair of the WMA Council were kind in complimenting me
\non my efforts.
\nIn fact when I asked Dr. Yokokura how I had done he said \u201cper-
\nfect!\u201d
\nYokokura san, Ishii san, thank you very much for your most gener-
\nous assessment of my performance.
\nDoomo Arrigato Gozaimasu.
\nNow to medical students.
\nThe WMA is a strong supporter of medical students through the In-
\nternational Federation of Medical Student Associations (IFMSA).
\n43
\nWMA news
\nIn March I gave the opening speech to their annual meeting held in
\nBaltimore, Maryland in the United States.
\nI focused on optimism about the future of the profession tempered
\nby an understanding of the major challenges we face.
\nDuring the conference I led a president\u2019s session on conflicts of
\ninterest physicians face particularly in their interaction with com-
\nmercial interests.
\nI also spoke to the alumni section and Junior Doctors group on
\nworldwide health care systems and the future of medicine.
\nThe group meeting in Baltimore, the medical student association, is
\nmost favorably impressed with the support of the WMA and eager
\nto continue a positive relationship.
\nNext is leadership training:
\nThe INSEAD\/WMA sponsored weeklong leadership-training
\ncourse was held this year in January in Singapore.
\nOur Secretary General Otmar Kloiber, Dr. Yank Coble, former
\nWMA President, Leah Wapner, Secretary General Israeli Medical
\nAssociation and I participated in the course along with the faculty
\nof INSEAD.
\n32 medical association leaders from 20 countries were enrolled in
\nthis course, which began initially in 2006.
\nA superb faculty and an enthusiastic, engaged group of physician
\nleaders highlighted the week.
\nThis effort to provide leadership training for physicians is truly a star
\nin the WMA crown.
\nOver the years I have had the opportunity to attend similar
\ncourses in premier institutions in my country \u2013 Kellogg Business
\nSchool in Chicago, Harvard Kennedy School of Government in
\nMassachusetts and Stanford University School of Business in
\nCalifornia.
\nI can say based on my experiences, and in comparison, that the
\nWMA course in Singapore is the gold standard.
\nI would recommend WMA member associations take advantage
\nof this outstanding opportunity for their rising leaders to receive
\ntraining.
\nLet me conclude with some thoughts based on my initial experi-
\nences as your president.
\nThe WMA has a powerful positive message to share with the
\nworld.
\nIt is a message based being a voice for ethics, good health policy and
\nseeking to support physicians to achieve the best of health care for
\npatients around the world.
\nWe are speaking out on matters of importance.
\nWe are pointing out violations of health related human rights \u2013 vio-
\nlations against health care workers and patients.
\nWe are fortunate to have a professional, creative, energetic staff led
\nby our Secretary General Otmar Kloiber.
\nMy thanks to them for what they do and for their support of my ef-
\nforts over the past months, especially facilitating work on the presi-
\ndent\u2019s blog.
\nNigel Duncan, our communications director, is working diligently
\nand creatively moving into social media to expand communication
\nof our message to the world.
\nThose around the world who know of the WMA\u2019s work and interact
\nwith us appear to hold the WMA in high regard.
\nFor those around the world who do not know the WMA, just our
\nname the World Medical Association suggests to them an organiza-
\ntion of importance.
\nAfter all, we are not just another medical association.
\nWe are The World Medical Association.
\nThat being said, organizations thrive and endure if they continue
\nto grow.
\nOur resources are limited and as everyone in this room knows,come
\nprimarily from dues income.
\nTherefore it is important in preserving those resources that our
\nmember organizations, which provide the dues income, are aware of
\nthe importance of the WMA.
\nAnd it is incumbent on us as leaders to keep our associations aware
\nso that they continue to support the WMA.
\nThe achievements of the WMA, which are considerable, are ac-
\ncomplished with extremely limited resources for an organization so
\nimportant to world medicine.
\nIt is a credit to our staff that they are able to achieve so much given
\nthe limited resources.
\nGoing forward I believe the existing dues income structure is in-
\nadequate to support the significant role the WMA should play in
\nrepresenting the medical profession on the world stage.
\nI understand that we have struggled for a number of years with how
\nto increase income while remaining true to the ethical principles
\nthat are the foundation of this association.
\nHowever,I believe it is important for us to continue to look for ways
\nto expand the power of our voice by increasing our interaction with
\nother international organizations \u2013 and by finding more resources
\n(translation \u2013 more money).
\nThank you for the opportunity to share this report with you.
\n44
\nWMA news
\nHonorable Governor of Bali,
\nChairman of the World Medical Association,
\nChairman of the Indonesian Medical Asso-
\nciation,
\nHead of the Agency for Development of Hu-
\nman Resources for Health
\nMinistry of Health, Indonesia
\nHead of the Provincial Health Services of
\nBali,
\nMembers of the World Medical Association
\nCouncil,
\nDistinguished Guests,
\nLadies and Gentlemen.
\nIt is a great pleasure for me be here with
\nyou at the opening of this important 194th
\nWorld Medical Association Council Ses-
\nsion. Let me extend my warm welcome
\nto all participants who have travelled here
\nfrom the four corners of the world to join this meeting today.
\nI am impressed that your organization includes representation
\nfrom north and south, from east and west and, happily, reflecting
\nthe make up of the modern medical profession, I see both men
\nand women.
\nI would like to thank the World Medical Association for orga-
\nnizing this council session in Bali. Although some of you may
\nhave visited here before, I am sure you will agree this is always
\na good place to revive the body and renew the soul. I have never
\nheard anyone complain when they had reason to come back to
\nthis beautiful island.Let me also extend thanks to the Organizing
\nCommittee and the partners who have worked so hard to make
\nthis event a success.
\nThe values and practices which were identified as important in
\n1947 when your organization was founded are just as crucial to-
\nday as they were then. Innovation in medicine enables doctors to
\nextend life and cure more patients than ever before. If, however,
\nthis is done without reference to the highest professional and
\nethical standards we are all placed at risk \u2013 patients, practitio-
\nners, the health systems within which we practice. Doctors looses
\ntouch with their limitations, patients become merely \u201cobjects of
\nconcern\u201d, and health services loose the
\nhuman touch.
\nAs we gather here today,what are some of
\nthe most significant changes in our field?
\nDiseases like leprosy used to need life-
\nlong treatment, while today they can be
\ncured in a year. Many cancers are also
\ncurable,while a decade ago the number of
\npeople with even a five year survival rate
\nwas limited. Now we find \u201ccancer survi-
\nvors\u201d leading full, independent, normal
\nlives. Advances in diagnostic technology,
\nlikewise, contribute to improved health
\noutcomes and make outreach of diagno-
\nsis to new patients possible. Disease can
\nbe identified and treated far earlier than
\nwas possible formerly and telemedicine
\ncan make diagnosis and consultation possible for patients who
\nwithout such technology would have been altogether unreached
\nand unserved.
\nThese rapid advances of technology in medical care combined
\nwith revolutions in communications and information present us
\nwith both opportunity and challenge. Health outcomes can with-
\nout doubt be improved but almost without exception these in-
\nnovations are costly and beyond the reach of many, perhaps most,
\nof our people.To meet this challenge some governments have de-
\nveloped national health financing schemes which increase acces-
\nsibility of service while distributing health costs more equitably.
\nSuch health insurance systems have generally proved extremely
\neffective.
\nWhile changes have been taking place relative to medical tech-
\nnology there have also been epidemiological changes across the
\nglobe. Many communicable diseases have become curable result-
\ning in steadily increasing life expectancy. At the same time there
\nhas also been an increase in prevalence of non communicable
\ndiseases many of which are particularly dependent on advanced
\ntechnology for diagnosis and treatment. This, in turn, has con-
\ntributed to increasing health care costs, leading many countries to
\nOpening Speech by H.\u00a0E. Dr. Nafsiah Mboi, Md, Pediatrician,
\nMPH Minister of Health of the Republic of Indonesia at the 194th
\nWorld Medical Association Council Session
\nNafsiah Mboi
\n45
\nWMA news
\nmore careful evaluation of the effectiveness, structure, and equita-
\nbility of their health expenditures.
\nIn fact, in most situations technological advances account for the
\nbulk of health care costs, now. Responsible management of health
\ncare systems requires good cost benefit analysis to assure that ben-
\nefits to health outcomes justify the costs. Calculations are compli-
\ncated, nonetheless, it is clear that correct and equitable use of new
\ntechnologies has contributed to reductions in mortality, increases
\nin longevity, improvements in quality of life, and reductions in
\nproductivity losses resulting from ill health.
\nThe objectives of the World Medical Association are attuned to
\nassisting physicians in learning to be sensitive, skilled, and con-
\nsistent in making such decisions. This commitment is reflected
\nin your programs to \u201cachieve the highest international standards
\nrelated to Medical Education, Medical Science, Medical Art,
\nMedical Ethics, and Health Care for all people in the world.\u201d
\nI take this opportunity to call upon the WMA to encourage phy-
\nsicians around the globe, including those in Indonesia, to remain
\nfaithful to the highest professional standards of service to their
\npatients as they evaluate and utilize technology. At the same time
\nI would underscore that no cost benefit analysis of treatment is
\ncomplete without due attention to the issue of equity in the provi-
\nsion of health services.
\nI would like to comment on the issue of Human Resources for
\nHealth or HRH. In Indonesia, one of the main challenges to im-
\nproving our health services has been related to the inadequate sup-
\nply and uneven distribution of trained health care personnel to
\nmeet the needs of our widely scattered people. The Government
\nof Indonesia has used various approaches to increase the number
\nof health workers, improved the range and quality of their skills,
\nand to achieve their more equitable distribution across the country.
\nIn the early 2000s management of health services was decentral-
\nization in Indonesia. While in some parts of the country the im-
\nportance of Human Resources for Health was well recognized by
\nlocal government, in other areas it was not regarded as a priority
\nissue. Local budget allocations were uneven in this field, and in
\nsome cases were extremely low.
\nIn 2008, to increase the availability of specialist care in more
\nremote areas, the Ministry of Health established a scholarship
\nprogram to support education of medical specialists. Upon grad-
\nuation, scholarship awardees have a service obligation (twice as
\nlong as their residential education) in areas lacking appropriate
\nspecialists. At the end of 2012, a total of 4,311 doctors had been
\ngranted the scholarships. 320 had already graduated. Although
\nthis program has gotten off to a good start, there is concern that
\nthis approach may only meet the needs temporarily,because at the
\nend of their term of service, if they wish, these specialists will be
\nfree to move to other posts.
\nBefore closing, let me comment briefly on the importance of the
\nwork of WMA. I believe that collaboration among WMA mem-
\nbers is important, especially working together and information
\nsharing to tackle common health problems of developing coun-
\ntries, such as malnutrition, and infant and maternal mortality.
\nAdditionally, many of us experience a \u201cbrain drain\u201d with various
\nfaces \u2013 the movement of doctors from short assignments in rural
\nareas to settle in the city, from the public service to the private
\nsector, and from their low paying home country to higher paying
\nservice abroad. Finally, as provision of health care is increasingly
\ndriven by market forces and international boundaries become
\nmore opened, physicians in some countries find themselves at a
\ndisadvantage competing with externally funded health care pro-
\nviders and facilities which are part of the evolving global health
\ncare market.
\nThis is a comparatively new issue and one I believe is of consider-
\nable long term importance. I urge the World Medical Association
\nto engage itself and its members in exploring this important issue.
\nThe global market is here to stay and will undoubtedly expand
\nbut it is important that as medical practitioners and health care
\nproviders we not jump into the world market and sell our souls to
\nthe highest bidder.
\nI would argue that we are a service-based profession and should
\nfight hard to remain so. We should not loose our identity in the
\nsearch for a bigger profit. Likewise, the countries that are most
\nlikely to be targets of new international medical enterprise need
\nadvice and support in considering how to respond to this new
\nchallenge.This is a challenge calling for national and international
\nreflection and cooperation if we are to protect our profession and
\nthe rights and the well being of our patients. I believe that only
\nwith collaboration between developed and developing countries,
\nbetween \u201csending\u201d and \u201creceiving\u201d countries, between techni-
\ncal and ethical specialists will we be able to influence the global
\nhealth market and better serve the global family.
\nWe need doctors whose of obsession is the best interest of the
\npatient, still inspired by the principle \u201cprimum non nocere\u201d that is
\nto say \u201cfirst, do no harm\u201d. As it is mentioned the Hippocratic Oath:
\n\u201cI will use treatment to help the sick according to my ability and
\njudgment, but will never use it to injure or wrong them.\u201d
\nNow, with rising education the world around and information
\ntechnology available to all, patients are no longer passive. Doctors
\n46
\nWMA news
\nhave to be prepared to answer difficult questions from the pa-
\ntients, often to work more with them, not just issue instructions!.
\nImprovement in the quality of doctors \u2013 their technical knowl-
\nedge and skills as well as professionalism, commitment to ser-
\nvice, and perhaps strengthening of human skills \u2013 should begin
\nin medical education. Teachers in medical school are role models
\nfor doctors and, in their knowledge and manner they train their
\nstudents. I thank you WMA, therefore, for your attention to the
\nimportant field of medical education.
\nIn closing, let me repeat my thanks to the WMA for organiz-
\ning this meeting and for bringing it to Indonesia. We are pleased
\nto host your gathering and have high hopes for your discussions.
\nMay you have fruitful deliberations and a pleasant stay in this
\nisland paradise called Bali.
\nFinally, asking the Grace of God The Almighty, on our delibera-
\ntions, I declare the 194th
\nWorld Medical Association Council Ses-
\nsion officially open.
\nThe 194th
\nCouncil Session,held at the Laguna
\nResort and Spa, Nusa Dua, Bali, Indonesia
\n(April 4\u20136) was opened wiseth a speech of
\nwelcome from Indonesia\u2019s Minister of Health
\nMadame Nafsiah Mboi,a paediatrician.
\nCouncil
\nFollowing the speech, which was warmly
\nreceived, the Council went into formal ses-
\nsion and Dr. Mukesh Haikerwal (Australia)
\nwas re-elected Chair, Dr. Masai Ishii (Ja-
\npan) was re-elected Vice-Chair and Prof.
\nFrank-Ulrich Montgomery (Germany) was
\nre-elected Treasurer.All three were re-elect-
\ned unopposed.
\nDr.Wilson then gave his Presidential report
\non his activities since his inauguration in
\nBangkok in October 2013. He said he had
\ntravelled to four continents with his three-
\nfold message on ethics in medicine,the chal-
\nlenge of non-communicable diseases and
\nthe social determinants of health, and on
\nclimate change. He had attended 16 meet-
\nings in 12 countries and 15 cities. He spoke
\nabout his twice-weekly President\u2019s blog on
\nthe WMA website which had detailed these
\ntrips. He said the WMA had a powerful
\npositive message to share with the world. It
\nwas a message based on a voice for ethics,
\ngood health policy and seeking to support
\nphysicians to achieve the best of health care
\nfor patients around the world. The WMA
\nwas speaking out on matters of importance,
\npointing out violations of health-related
\nhuman rights, violations against health care
\nworkers and patients. But the organisation\u2019s
\nachievements were accomplished with ex-
\ntremely limited resources and he thought
\nit was very important for the WMA to in-
\ncrease its inter-action with other organisa-
\ntions and to find more resources.
\nDr. Otmar Kloiber, Secretary General, in
\nhis oral report elaborated on the secretar-
\niat\u2019s activities as set out in his written re-
\nport (see page 54). He detailed the actions
\ntaken in support of the 2012\u201315 strategic
\nplan and the 20 strategic initiatives set out
\nin the plan. He spoke about partnerships
\nand collaboration with other organisation,
\nas well as the activities of the Junior Doc-
\ntors Network, the Business Development
\nGroup and the potential for the growth of
\nthe organisation.
\nDr. Haikerwal reported on his many visits
\naround the globe during his chairmanship
\nand praised the work of the WMA secre-
\ntariat.
\nThe Council then heard arguments why two
\nemergency Resolutions should be discussed
\nat the meeting as matters of urgency.
\nThe first was a Resolution proposed by
\nthe American Medical Association on the
\nCriminalisation of Medical Practice. It was
\nargued that three developments had made
\nthis a matter of urgency \u2013 the case of Pro-
\nfessor Cyril Karabus, who had faced man-
\nslaughter charges in the United Arab Emir-
\nates, reports that more than 400 physicians
\nwere under arrest in Syria for giving care to
\nwounded combatants and state legislatures
\nin the USA that were proposing to force
\ndoctors to do procedures without medical
\nindications.
\nThe second Resolution, proposed by the
\nSouth African Medical Association, re-
\nlated specifically to the case of Professor
\nKarabus who had been acquitted of all
\ncharges against him concerning the death
\nof a child under his care, but faced an ap-
\npeal against the acquittal by the prosecut-
\ning authorities.The South Africans wanted
\nthe WMA to send a strong message to the
\ngovernment in the UAE that this was not
\nacceptable.
\nThe Council decided that both Resolutions
\nwere urgent and should be debated, as well
\nas a third motion on Patient Safety and
\nStandardisation in Medical Practice pre-
\nsented jointly by the Conseil National de
\nl\u2019Ordre des M\u00e9decins France, the Consejo
\nGeneral de Colegios M\u00e9dicos de Espa\u00f1a
\nand the German Medical Association.
\n194th
\nWMA Council Session.
\nGeneral Report
\nBali, Indonesia (April 4\u20136, 2013)
\n47
\nWMA news
\nSocio Medical Affairs Committee
\nSir Michael Marmot (British Medical As-
\nsociation) was re-elected unopposed as
\nChair of the Socio-Medical Affairs Com-
\nmittee.
\nProfessor Karabus
\nThe emergency Resolution on the case of
\nProfessor Karabus was formally proposed
\nto thecCommittee by the South African
\nMedical Association. The Resolution ex-
\npressed concern that Professor Karabus re-
\nmained on bail in the United Arab Emir-
\nates despite being absolved of all charges
\nagainst him. It stated that he was being
\ntreated in a manner which failed to meet
\ninternational fair trial standards and that
\nhe should be allowed to return home im-
\nmediately. But the South African delegates
\nargued for stronger measures than those
\noutlined in the Resolutio, such as sanctions
\nagainst the UAE. When the committee
\nvoted for the Resolution to be sent to the
\nCouncil, the South Africans declined to
\nsupport it.
\nLater in the meeting the South Afri-
\ncan Medical Association returned with
\nan amended Resolution, adding that the
\nCouncil should publish an advisory notice
\nin the World Medical Journal and on the
\nWMA website to note the working condi-
\ntions in the United Arab Emirates and en-
\ncourage NMAs to publish similar advisories
\nin their publications.
\nThis was agreed on and thecCommittee rec-
\nommended the Resolution to the Council.
\nChair\u2019s Report
\nIn his opening words, Sir Michael Marmot
\nreported on the development of the post-
\n48
\nWMA news
\n2015 Millennium Development Goals
\nagenda. He said the British Prime Minis-
\nter was co-chairing the global planning ac-
\ntivities. Sir Michael said he had made the
\ncase that the health-related MDGs should
\ninclude health equity that covered not only
\naverages for countries, but the unequal dis-
\ntribution of health and disease within coun-
\ntries. The United Nations Development
\nProgramme was the lead UN agency. Sir
\nMichael said he had made the case to the
\nUNDP that their policies and activities re-
\nlated to the development were,in fact,social
\ndeterminants of health. A similar approach
\nhad been made to UNICEF. He also wel-
\ncomed the recent four-year plan of activi-
\nties adopted by the Canadian Medical As-
\nsociation, which included actions on social
\ndeterminants of health and health equity,
\nas a good example of concrete action that
\nmedical associations could do in the area of
\nsocial determinants.
\nViolence Against Women and Girls
\nThe British Medical Association reported
\nthat it would submit written proposals to
\nthe committee on implementing the WMA
\nResolution on Violence against Women.
\nSir Michael said it was important for the
\nWMA to take a strong stand on this issue
\nfollowing a number of high profile cases
\nof violence against women and girls. The
\nBMA said its proposals could include on-
\nline learning courses for doctors on the topi,
\nand developing co-operation with relevant
\npartner, such as the International Federa-
\ntion of Gynaecology and Obstetrics.
\nHealth Databases
\nDr. Jon Snaedal (Iceland), Chair of the
\nWorkgroup on Health Databases, present-
\ned a proposed Declaration to the commit-
\ntee on The Ethical Considerations Regard-
\ning Health Databases. He said this was not
\na final document but only information and
\nhe invited thecCommittee members to send
\ntheir comments to the group. The aim was
\nto present the final text to the committee
\nat the General Assembly meeting in Brazil
\nin October. It was agreed to refer the paper
\nto the Medical Ethics Committee for con-
\nsideration.
\nRight to Reparation of Victims of Torture
\nThe committee considered a proposed
\nStatement from the Danish Medical As-
\nsociation on The Right to Reparation of
\nVictims of Torture. The paper noted with
\ngrave concern the continued use of torture
\nthroughout the world and said doctors had
\na critical role to play in the reparation pro-
\ncess of victims of torture. During a brief
\ndebate it was argued that the definition of
\nreparation needed further consideration.
\nThe committee decided to recommend to
\nthe Council that the document be circu-
\nlated to NMAs for comment.
\nStandardisation in Medical Practice and Pa-
\ntient Safety
\nA proposed Resolution on Standardisa-
\ntion in Medical Practice and Patient Safety
\nwas put forward jointly by the Conseil Na-
\ntional de l\u2019Ordre des M\u00e9decins France, the
\nConsejo General de Colegios M\u00e9dicos de
\nEspa\u00f1a and the German Medical Associa-
\ntion. It was explained that the Resolution
\nwas tabled to enable the WMA to react to
\nplans currently under way in the European
\nUnion to allow the European Community
\nof Standardisation to set standards in med-
\nical practice in the fields of aesthetic sur-
\ngery services. This would cover procedures
\nas well as post-graduate education and
\nwould open the door to similar efforts in
\nother medical fields. The concern was that
\nthis move might be followed in other parts
\nof the world. The three NMAs proposing
\nthe Resolution wanted to send a clear mes-
\nsage that allowing industrial standardisa-
\ntion bodies that did not have the required
\nprofessional, medical, ethical or technical
\ncompetenc, to set standards in medical
\npractice could have negative implications
\nfor patient safety.
\nFollowing a debate, it was decided to defer
\nfurther consideration and amend the Reso-
\nlution to make it shorter and punchier.
\nWhen the shortened amended Resolution
\nwas later presented, the committee agreed it
\nshould be sent to the Council for approval
\nand then forwarded to the Assembly for
\nadoption.
\nHuman Papillomavirus Vaccination
\nThe American Medical Association report-
\ned that it had set up an internal working
\ngroup with a view to developing a policy on
\nHPV which would be submitted at the next
\nCouncil meeting in October.
\nFungal Disease Diagnosis and Management
\nThe Brazilian Medical Association pro-
\nduced a proposed Statement on Fungal
\nDisease Diagnosis and Management giv-
\ning guidance to NMAs and physicians on
\nhow they should be involved in providing
\ndiagnostic tests and prescribing antifungal
\ntherapy most effectively.
\nAfter a brief debate it was agreed to rec-
\nommend that work should continue on the
\ndocument and afterwards to be circulated to
\nNMAs for comment.
\nCriminalisation of Medical Practice
\nAn emergency Resolution on the Criminal-
\nisation of Medical Practice was presented
\nby the American Medical Association. This
\nurged that NMAs should oppose criminal-
\nizing medical judgment. But the following
\nconcern by some delegates that the Reso-
\nlution might give the impression doctors
\nshould be above the law, an amended para-
\ngraph was proposed making it clear that
\ndoctors who committed criminal acts unre-
\nlated to patient care must remain as liable
\nto sanctions as all other members of society.
\nThis provoked a lengthy debate about crim-
\ninal intent and how incompetent doctors
\nwho committed errors should be dealt with.
\n49
\nWMA news
\nThe committee eventually recommended
\nthat the amended Resolution should be
\nsent to the Council for approval and then
\nforwarded to the Assembly for adoption as
\npolicy.
\nClassification of 2003 Policies
\nUnder the rules stating that policies that
\nare 10 years old should come up for revi-
\nsion, it was decided that the Statement on
\nthe Ethical Guidelines for Recruitment of
\nPhysicians and the Resolution on the Non-
\nCommercialization of Human Reproduc-
\ntive Material should undergo major revision.
\nThe committee agreed that the Resolu-
\ntion on SARS (Severe Acute Respiratory
\nSyndrome) be rescindet and NMAs be in-
\nvited to come forward with a new policy on
\nchronic respiratory diseases.
\nHealth and the Environment
\nDr.\u00a0D.C.Shin (Korea) reported on a meet-
\ning of the Association\u2019s environment cau-
\ncus that had taken place earlier in the da,
\nwhere participants had discussed the global
\nmercury treaty recently signe, as well as the
\noutcome of the Doha United Nations sum-
\nmit on climate change. The caucus had also
\ndiscussed the results of a WMA survey of
\nthe NMA activity in the field of environ-
\nment. It was agreed to recommend that the
\nwork of the caucus should continue.
\nWMA Advocacy
\nPaul-Emile Cloutier (Canada), Chair of the
\nAdvocacy Advisory Group, reported on the
\nactivities of the group and said that it was
\nproposing to develop an advocacy plan in
\nrelation to the Declaration of Helsinki.This
\nwould emphasise the WMA\u2019s ownership of
\nthe document.
\nHe said that as part of developing tools for
\nthe benefit of NMAs, the group was willing
\nto organise an advocacy training session at a
\nfuture Assembly meeting.
\nCollaboration between the Stakeholders and
\nthe Pharmaceutical Industry
\nThe Secretary General informed thecCom-
\nmittee about a collaborative project between
\nthe stakeholders and the pharmaceutical in-
\ndustry on the ways of dealing with common
\nissues relating to sponsorship of research,
\nsupport and gifts. This was a draft Joint
\nFramework on Collaboration between the
\npharmaceutical industry, healthcare pro-
\nfessionals, medical institutions and patient
\norganizations. The plan was for the docu-
\nment to be published later in the year on
\na common website, although a common
\npolicy was not the intention. Dr. Kloiber
\nemphasised that this did not constitute
\na new policy since the Framework docu-
\nmentdcontained common existing policies
\nof all participants. This could then be used
\nas a toolkit for others wanting to develop
\nthe policy.
\nAfter a brief debate the committee agreed
\nthat the item be referred to the Council for
\nfurther consideration.
\nCouncil
\nProfessor Karabus
\nThe Council reconvened to consider the
\namended Resolution on Professor Karabus
\nand it was agreed on (see page 59).
\nMedical Ethics Committee
\nDr. Heikki Palve (Finnish Medical Asso-
\nciation) was elected unopposed as Chair of
\nthe Medical Ethics Committee, succeeding
\nDr. Torunn Janbu (Norway) who stepped
\ndown after three years.
\nDeclaration of Helsinki
\nDr. Ramin Parsa-Parsi (Germany), Chair of
\nthe Workgroup revising the Declaration of
\nHelsinki, reported that considerable prog-
\nress had been made, with essential input on
\nthe part of the expert conferences held in
\nSouth Africa and Japan. The Cape Town
\nconference was attended by 76 delegates
\nfrom 22 countries, while in Tokyo 135 del-
\negates from 23 countries participated.
\nProfessor Urban Wiesing, adviser to the
\nWorkgroup, reported on the key issues dis-
\ncussed at these meetings \u2013 the structure of
\nthe Declaration, vulnerable groups, post-
\nstudy arrangements, research ethics com-
\nmittees, compensation, bio-banks and the
\nfrequency of revisions. He said that a gen-
\neral consensus had been reached, except on
\nthe final two points.
\nDr. Parsa-Parsi presented a preliminary
\ndraft revision which he hoped the com-
\nmittee would recommend to be posted on
\nthe WMA website for a two-month con-
\nsultation with NMAs and the public. This
\nwould last from mid-April to mid-June. At
\nthe end of this period, in August, a meet-
\ning would be held in Washingtontto assess
\nall the comments and a further revised ver-
\nsion of the Declaration would be presented
\nto the committee at its meeting in Brazil in
\nOctober. If approved, the document would
\nbe forwarded to the Council with a view
\nto submitting to the General Assembly in
\nBrazil for adoption.
\nDr. Jeff Blackmer (Canada) presented the
\nrevised document, explaining paragraph by
\nparagraph the proposed changed.
\nAfter further debate and unsuccessful moves
\nto amend the draft document, the commit-
\ntee agreed to recommend to the Council
\nthat the document should be posted on the
\nWMA website for public consultation and
\ncomments from NMAs.
\nPerson Centered Medicine
\nThecCommittee considered a proposed
\nrevision of the WMA Statement on Per-
\nson Centered Medicine. Dr. Jon Snaedal
\n(Iceland) said the paper was intended for
\n50
\nWMA news
\nphysicians to have some kind of definition
\nof the core issue and to support the WMA
\nin the initiative it had been working on
\nfor the last five years. The committee rec-
\nommended that a Workgroup be set up to
\ncomplete this work.
\nEuthanasia
\nThe committee considered a minor revision
\nto update the WMA Resolution on Eu-
\nthanasia. This prompted Dr. Van der Gaag
\n(Royal Dutch Medical Association) to say
\nthat he coult support neither the revision
\nnor the Resolution. He said that since 2002
\nthe Netherlands had been one of the few
\ncountries where euthanasia and physician-
\nassisted suicide had been regulated by law
\nunder strict conditions. Therefore his Asso-
\nciation could not and would not support the
\nResolution in its present form. It would not
\ntell the doctors in his country that it consid-
\nered euthanasia to be unethica, nor would it
\ncondemn doctors who performed euthana-
\nsia. He called on the Council to reconsider
\nthe revision of the Resolution and work on
\nrephrasing it respecting the different views
\non this subject.
\nThe committee Chair said that should they
\nwish the Royal Dutch Medical Association
\ncould submit a new policy proposal. How-
\never, the committee agreed to approve the
\nminor revision.
\nUse of the Death Penalty
\nThe committee considered a proposal for
\nthe WMA to support the United Nations
\nGeneral Assembly Resolution calling for a
\nmoratorium on the use of the death penalty.
\nThis led to an extensive debate about wheth-
\ner the WMA should take a position on the
\ndeath penalty, with delegates expressing op-
\nposing views. It was argued that this should
\nbe a matter for individual physicians and
\nthat by supporting a moratorium it might
\nbe demonstrated that the WMA was siding
\nwith those physicians and NMAs who were
\nopposed to the death penalty.
\nHowever, at the conclusion of the debate
\nthe committee voted overwhelmingly to
\nrecommend to the Council that the WMA
\nshould support a moratorium.
\nWomen\u2019s Right to Health Care
\nThe South African Medical Association
\npresented a proposed revision to the WMA
\nResolution on Women\u2019s Rights to Health-
\ncare and how that related to Mothed-to-
\nChildnTransmission of HIn. It was agreed
\nto recommend to the Council that this
\nshould be circulated to NMAs for com-
\nment.
\nHuman Rights
\nClarisse Delorme, WMA advocacy adviser,
\nhighlighted some of the Association\u2019s ac-
\ntivities on human rights in recent months,
\nincluding its work on palliative care with
\nHuman Rights Watch and the Healthcare
\nin Danger initiative of the International
\nCommittee of the Red Cross.
\nShe said that in March representatives
\nof ten Medical Associations from Arabic
\ncountries had met in Amman to discuss the
\nprovision of health care in detention places.
\nThe regional conference had been orga-
\nnized by the ICR, in collaboration with the
\nWMA.The meeting focused on the specific
\nhealth needs of prisoner, as well as the role
\nof NMAs and the WMA in co-operating to
\nimprove the situation in prisons.
\nThe Secretary General, who attended the
\nconference, reported in more detail on the
\ndiscussionk that had taken place during the
\nevent.He emphasized the positive outcome,
\nnotably the strong interest expressed by Ar-
\nabic medical associations about the WMA
\nand their possible willingness to join the
\nAssociation.
\nEuropean Union Clinical Trials Directive
\nProfessor Andr\u00e9 Herchuelz (Association
\nBelge des Syndicats M\u00e9dicaux) reported
\non current developments in the EU with
\nregard to the revision of the Clinical Trials
\nDirective and its implications for the Dec-
\nlaration of Helsinki. Dr. Kloiber responded
\nby referring to the WMA\u2019s activities on this
\nissue. He said he was in contact with the
\ncompetent EU Committee Rapporteur.
\nFinanceand Planning
\nCommittee
\nDr. Leonid Eidelman (Israel) was re-elect-
\ned unopposed as Chair of the Finance and
\nPlanning Committee.
\nMembership Dues Payments
\nThe committee received a report on Mem-
\nbership Dues Payments for 2013 and an
\noral report from Mr Adi H\u00e4llmayr, Finan-
\ncial Advisor, on Dues Arrears.
\nFinancial Statement
\nMr. H\u00e4llmayr provided a detailed explana-
\ntion of the pre-audited interim Financial
\nStatement for 2012. ThecCommittee was
\npleased with the favourable financial situa-
\ntion and recommended that the Statement
\nbe approved.
\nBusiness Development
\nAn oral report was given by Mr. Tony
\nBourne (British Medical Association),
\nChair of Business Development Group,
\nabout the work of the group. He spoke
\nabout the WMA roundtable initiative and
\nplans for the year ahead. Twelve organisa-
\ntions had expressed an interest in being
\ninvolved in the roundtable. These organisa-
\ntions would now be approached and it was
\nhoped to hold the first introductory meet-
\ning later in the year.
\nHe also spoke of potential new initiatives
\nbeing considere, which would be self-
\nfinancing and enable the WMA capacity
\nbuilding.
\n51
\nWMA news
\nWMA Meetings
\nThere was a discussion about the dates for
\nthe Council meeting in Tokyo in the Spring
\nof 2014, about holding the 2015 Spring
\nmeeting in St. Petersburg and about the
\nmeetings in 2016 being held in Buenos Ai-
\nres in April 2016 and in Taipei, Taiwan in
\nOctober 2016.
\nThe committee recommended that further
\nconsideration be given to these venues.
\nThe South African Medical Association
\nproposed the theme of the scientific session
\nat the General Assembly in Durban, South
\nAfrica, 8\u201311 October 2014 be the subject
\nof \u2018Universal Access to Healthcare after
\nMDGs\u2019.
\n50th
\nAnniversary of the Declaration of Hel-
\nsinki
\nThe Committee received an oral report
\nfrom the Workgroup on the 50th
\nAnniver-
\nsary of the Declaration of Helsinki in 2014.
\nDr. Eidelman reported that the main event
\nwould be held in Helsinki in November
\n2014, possibly at the place where the origi-
\n52
\nWMA news
\nnal Declaration was adopted 50 years ago.
\nThe Workgroup was encouraging NMAs
\nto organise events on regional and national
\nlevel. Moreover, a book was being written
\nabout the Declaration for publication in
\n2014.
\nDisaster Preparedness and Medical Response
\nThe Committee received an oral report of
\nthe Workgroup on Disaster Preparedness
\nand Medical Response. On behalf of Dr.
\nMiguel Jorge, the Chair of the Workgroup,
\nDr. Nivio Moreira (Brazil) summarised the
\nresult of a survey of NMAs about their di-
\nsaster preparedness and medical responses.
\nOf those that replied, most had experi-
\nenced disasters in recent years and almost
\nall had plans to cope with them. Most of
\nthe NMAs had been involved in assisting
\npeople affected by disasters. Few offered
\ngeneral training courses for physicians on
\ndisaster issues and few also offered some
\nbasic medical guidance to the general pub-
\nlic on how to behave when facing a disaster.
\nBut most had systems for mobilizing physi-
\ncians and other health care personnel in the
\nevent of a disaster.
\nThe Workgroup recommended that the
\nsurvey should be updated in two or three
\nyears and the findings should be posted on
\nthe WMA website and be shared among
\nNMAs.
\nThe committee recommended that the
\nCouncil approve the Workgroup\u2019s recom-
\nmendations.
\nAssociate Membership
\nIt was reported that the total number of
\nAssociate Members whose annual sub-
\nscriptions had been paid was 832. In ad-
\ndition members of the International Fed-
\neration of Medical Student Associations
\nwould be granted Associate Membership
\non graduation as physicians for a period of
\nfive years and no membership fee would be
\ncharged.
\nPast Presidents Network
\nDr. Dana Hanson (Canada), Past President
\nof the WMA, reported on the proposal and
\nterms of reference foraPast Presidents and
\nChairs of Council Network. He said this
\nlargely virtual network would be very useful
\nfor the WMA to tap into the expertise of
\nthe past officers in any projects that would
\nbe of assistance.
\nThe committee recommended that the
\nCouncil approve the establishment and the
\nterms of reference for the Network.
\nJunior Doctors Network
\nAn oral report on the activities of the Junior
\nDoctors Network was given by the Chair of
\nthe Network, Thorsten Hornung (Germa-
\nny).He reminded the meeting that the Net-
\nwork was a forum for experience-sharing
\nand discussion among younger members
\nof the Association. The Network had been
\nliaising with other junior doctor groups
\naround the world. Its projects included a
\nwhite paper on physicians\u2019 wellbeing to be
\npresented in Brazil, a policy paper on the
\nethical aspects of global health education
\nand an environmental scan of post-graduate
\nmedical education examining conditions
\nfor junior doctors in training in countries
\naround the world. A questionnaire was be-
\ning prepared.
\nHe said that the Network was currently dis-
\ncussing the definition of a junior doctor and
\nat the moment was considering basing this
\non a number of years after graduation, such
\nas eight to 10 years.
\nCooperative Relations
\nDr. Kloiber reminded the committee that
\nthe Council had approved three academic
\norganisations to be the WMA Cooperating
\nCenters from 2013\u20132015 \u2013 the Center for
\nthe Study of International Medical Policies
\nand Practices, George-Mason-University,
\nFairfax, Virginia, on microbial resistance
\nand the development of public health
\npolicy; the Center for Global Health and
\nMedical Diplomacy, University of North
\nFlorida, on MedicallLeadership and Medi-
\ncal Diplomacy; and the Institute of Eth-
\nics and History of Medicin,: University of
\nT\u00fcbingen. He proposed a further Center,
\nthe Institut de droit de la sant\u00e9, Universit\u00e9
\nde Neuch\u00e2tel, Switzerland. The committee
\nrecommended this to the Council.
\nDeath of Dr. Perelman
\nDr. Leonid Mikhailov (Russia) informed
\nthe committee of the recent death of
\nDr.\u00a0Perelman, former President of the Rus-
\nsian Medical Society and a prominent tho-
\nracic surgeon.
\nCouncil
\nThe Council then reconvened.
\nDr. Ketan Desai
\nDr. Ajay Kumar (India) said the Indian
\nMedical Association had submitted an ap-
\nplication to the Council for Dr.Ketan Desai
\nto be installed as President of the WMA.
\nHe reminded the meeting that in 2009
\nDr.\u00a0Ketan\u00a0Desai was elected President Elect
\nof the WMA. But in 2010 he was arrested
\nin India on charges that he had used his
\noffice as President of the Medical Council
\nof India for personal gain. As a result the
\nWMA Assembly decided to suspend his
\nPresidency indefinitely. Dr.\u00a0Desai said that
\nthe charges facing Dr.Ketan Desai had now
\nbeen dropped and he should be allowed to
\nbe reinstalled as the WMA President.
\nDr. Haikerwal replied that the relevant pa-
\npers would be studied and the application
\nwould be considered.
\nThe Council later requested the execu-
\ntive committee and Chair to ensure that
\ndue diligence takes place before pro-
\nceeding.
\n53
\nWMA news
\nThe Council then considered reports from
\nthree Committees, approving the follow-
\ning
\nFrom the Medical Ethics Committed:
\n\u2022 a public consultation process on the re-
\nvised draft of the Declaration of Helsinki
\nand a further meeting in Washington to
\nreview the comments received;
\n\u2022 a new Workgroup on person centred
\nmedicine to complete work on a revised
\nStatement;
\n\u2022 a minor revision to the Resolution on Eu-
\nthanasia;
\n\u2022 a circulation to NMAs of the proposed
\nrevision of the Resolution on Women\u2019s
\nRight to Healthcare and how that re-
\nlates to Mother and Child HIV Infec-
\ntion;
\n\u2022 a Statement supporting the UN mora-
\ntorium on the use of the death penalty
\nwhich should be forwarded to the Gen-
\neral Assembly for adoption.
\nFrom the Finance and Planning Commit-
\nted:
\n\u2022 the interim 2012 Financial Statement;
\n\u2022 referring future meeting venues and dates
\nto the executivec Committee for further
\nconsideration;
\n\u2022 an on-going survey relating to NMA di-
\nsaster preparedness and medical response;
\n\u2022 the establishment of Past Presidents and
\nChairs of the Council Network;
\n\u2022 the renewals and appointments of the
\nWMA Cooperating Centers.
\nFrom the Socio-Medical Affairs Commit-
\nted:
\n\u2022 the referral to the Medical Ethics Com-
\nmittee of the proposed Declaration
\non Ethical Considerations Regarding
\nHealth Databases;
\n\u2022 the circulation to NMAs of the proposed
\nStatement on the Right to Reparation of
\nVictims of Torture;
\n\u2022 the Resolution on Standardisation in
\nMedical Practice and Patient Safety (see
\npage 59);
\n\u2022 the circulation to NMAs of a revised pa-
\nper on fungal disease diagnosis and man-
\nagement.
\nThe Council heard oral reports on outreach
\nactivities.
\nThe Editor-in-Chief of the World Medical
\nJournal,Dr.P\u0113teris Apinis,said he was plan-
\nning to produce six issues in 2013. He said
\nthe content of the Journal must be created
\nby physicians from all over the world and
\narticles were mainly related to four issues:
\nnews of the WMA and national medical as-
\nsociations, medical ethics, self- governance
\nand public health.The aim was to include at
\nleast one contribution from each continent
\nin every Journal. The concept of the WMJ
\nwas based on the assumption that, although
\nall people were different,they all had a lot in
\ncommon. The problems and situations they
\nhad to deal with were the same, especially
\nin the domain of medical ethics and public
\nhealth.
\nDuring further debate, the Council raised
\nno objection to continuing the collaborative
\nproject between the stakeholders and the
\npharmaceutical industry, as reported earlier
\nby the Secretary General.
\nWorld Health Assembly
\nClarisse Delorme reported on issues due to
\nbe discussed at this year\u2019s World Health As-
\nsembly. One related the targets and moni-
\ntoring framework concerning non-commu-
\nnicable diseases. She said that one positive
\nmove had been the inclusion of a mental
\nhealth action plan in the discussions. Other
\nissues were health workforce, Millennium
\nDevelopment Goals and social determi-
\nnants of health.
\nCriminalisation of Medical Practice
\nA further debate took place in the Coun-
\ncil on the Resolution on Criminalisation of
\nMedical Practice, when amendments were
\nproposed to deal with the issue of criminal
\nintent and negligence. The Council eventu-
\nally agreed to approve the Resolution for
\nforwarding it to the General Assembly for
\nconsideration (see page 58). In the vote Can-
\nada, Finland and France abstained.
\nThe meeting ended with thanks to the In-
\ndonesian Medical Association for hosting
\nthe event.
\nMr. Nigel Duncan,
\nPublic Relations Consultant, WMA
\n54
\nWMA news
\nSecretary General\u2019s Report
\nPolicy & Advocacy
\nNon-Communicable Diseases
\nNCDs have emerged as one of the most
\nimportant topics on the public health
\nagenda. The WHO is developing a
\n2013\u20132020 Global Action Plan for the
\nPrevention and Control of NCDs. The
\nWMA\u2019s main criticism of the new plan
\nand the monitoring framework is that it
\nfocuses only on adults and adolescents.
\nYet it is during childhood when many
\nlifelong habits are developed and which
\nare difficult to change later in life. Many
\ncountries emphasized at the last WHO
\nExecutive Board meeting the importance
\nof health care system strengthening, uni-
\nversal access and the link to social deter-
\nminants of health as the right approach in
\nthe fight of NCDS. A revised draft of the
\n2013\u20132020 Action Plan was opened for
\ncomment in February and was discussed
\nin March with NGOs. The WMA will advocate for a holistic
\nhealth care approach, avoiding a silo-style disease-specific ap-
\nproach and considering the social determinants of health.
\nTogether with our partners at the WHPA, the WMA participated
\nin the development of the NCD toolkit to assess the risk level in
\nlifestyle behaviours and bio measures in the form of NCD indica-
\ntors. We are also setting up an independent project together with
\nSir Michael Marmot (British Medical Association) and his team
\nto develop a common set of Social Determinants of Health and
\nNCD indicators.
\nMulti Drug Resistant Tuberculosis Project
\nIn March, the WMA launched the revised MDR-TB online
\ncourse.We now have a complete set of TB and MDR-TB courses
\nas online versions, printed formats and CDs.The printed courses
\nhave been translated into Azeri, Chinese, French, Georgian, Rus-
\nsian Spanish and other languages may follow. All courses can be
\naccessed free of charge via the WMA webpage. The printed TB
\nrefresher course and the new MDR-TB course were nominated
\nby the United States Center for Disease Control (CDC) as an
\neducational highlight and received an award. The WMA is col-
\nlaborating with the WHO to develop the MDR-TB course as
\nan application for tablet computers, especially for low-cost 10-
\ninch devices running on Android, which are increasingly used in
\nlow-income countries.The app will be accessible from the Google
\nand iPhone app webpage and, once downloaded, will be self-
\ncontained and able to run offline without an internet connection.
\nTobacco Project
\nThe WMA is involved in the implemen-
\ntation process of the WHO Framework
\nConvention on Tobacco Control that con-
\ndemns tobacco as an addictive substance,
\nimposes bans on advertising and promo-
\ntion of tobacco, and reaffirms the right
\nof all people to the highest standard of
\nhealth.The WMA will cooperate with the
\npublic private partnership \u201cQuitNowTXT
\nprogram\u201d to develop an evidence-based
\ndiffusion of health information for to-
\nbacco cessation via mobile phones to reach
\npeople at risk from preventable NCDs.
\nAlcohol
\nIn May 2010, the World Health Assem-
\nbly endorsed the Global Strategy to Re-
\nduce the Harmful Use of Alcohol. The Strategy provides a port-
\nfolio of policy options and interventions for implementation at a
\nnational level with the goal of reducing the harmful use of alco-
\nhol worldwide.The successful implementation of the strategy re-
\nquires concerted action by countries, effective global governance,
\nand appropriate engagement of all relevant stakeholders, includ-
\ning health actors. In line with the WMA Statement on Reducing
\nthe Global Impact of Alcohol on Health and Society, the WMA
\nSecretariat monitors progress to ensure that medical associations
\nat the national and global levels continue to be engaged in imple-
\nmentation.
\nCounterfeit Medical Products
\nThe WMA and the members of the World Health Professions
\nAlliance WHPA stepped up their activities on counterfeit medi-
\ncal issues and developed an Anti-Counterfeit campaign with an
\neducational grant from Pfizer Inc. and Eli Lilly. The basis of the
\ncampaign is the \u2018Be Aware\u2019 toolkit for health professionals and
\npatients to increase awareness of this topic and provide practi-
\ncal advice for actions to take in case of a suspected counterfeit
\nmedical product.The WHPA organised several regional WHPA
\nCounterfeit Medical Products workshops to implement the
\ntoolkit.
\nOtmar Kloiber
\n55
\nWMA news
\nClimate change
\nThe WMA continues to be involved in the UN Climate Change
\nnegotiations. Due to its UN observer status to the Convention,
\nthe WMA Secretariat can facilitate the participation of medi-
\ncal associations interested in the various official meetings taking
\nplace in this framework. The WMA takes part in an informal
\nconsultation group set up by the WHO, which brings together
\ncivil society actors working on health and environmental issues.
\nThe goal of the group is to facilitate the exchange of information
\nwith regard to the UN meetings and coordinate potential joint
\napproaches. In this context, the WMA signed the Doha Dec-
\nlaration on Climate, Health and Wellbeing that was adopted by
\nhealth and medical associations from around the world on the
\noccasion of the Climate Change Summit in Doha (COP 18 \u2013
\nDecember 2012). The Declaration calls for the protection and
\npromotion of health to be made the one of the central priorities
\nof global and national policy responses to climate change.
\nMercury
\nThe WMA has been a member of the UNEP Global Mercury Part-
\nnership (Mercury product) since December 2008 in order to con-
\ntribute to the partnership goal of protecting human health and the
\nglobal environment from the release of mercury and its compounds.
\nThis engagement is based on the WMA Statement on Reducing the
\nGlobal Burden of Mercury (Seoul,2008).Since June 2010,Dr.Peter
\nOrris has been attending the successive negotiating sessions of the
\nUNEP (UN Environment Programme) for a legally binding instru-
\nment on mercury, and brought forward the WMA\u2019s recommenda-
\ntions from its 2008 Resolution on Mercury.The Mercury Treaty was
\nfinally adopted in January 2013 in Geneva.The Treaty sets a phase-
\nout date of 2020 for most mercury containing products \u2013 including
\nthermometers and blood pressure devices, and calls for the phase-
\ndown of dental amalgam.This aspect of the treaty is a major victory
\nfor all who have worked for mercury-free health care.
\nChemicals
\nIn December 2009, the WMA joined the Strategic Approach to
\nInternational Chemicals Management (SAICM) of the Chemicals
\nBranch of the United Nations Environment Programme (UNEP),
\nwhich aims to develop a strategy for strengthening the engagement
\nof the health sector in the implementation of the Strategic Approach.
\nIn consultation with the WHO, Prof. Shin (Korean Medical As-
\nsociation) has represented the WMA at several SAICM meetings,
\nbringing forward the WMA Statement on Environmental Degra-
\ndation and Sound Management of Chemicals (adopted in October
\n2010 in Vancouver). In September 2012, the WMA, together with
\nthe World Federation of Public Health Associations, the Govern-
\nment of Slovenia and the WHO,organised a side event on the topic
\nin the context of the third session of the International Conference
\non Chemicals Management, held in Nairobi in September 2012.
\nSocial Determinants of Health
\nThe Rio Political Declaration on Social Determinants of Health
\nproduced at the World Conference on Social Determinants of
\nHealth in Rio, Brazil, in October 2011, identifies five action areas
\nfor health to engage in to address the social determinants of health.
\nOne of these action areas emphasizes the role of the health sector
\nin reducing health inequities. Within this framework, the WMA
\nand the International Federation of Medical Students Associations
\n(IFMSA) organised in May 2012 a side-event during the World
\nHealth Assembly in Geneva, with the support of the UK delega-
\ntion. Participants discussed concrete ways for the health sector to
\nimplement the Rio Declaration and engage in reducing health in-
\nequities.The issue of medical education and training of health pro-
\nfessionals regarding SDH was raised several times and there was a
\ngeneral agreement that efforts should focus on this matter.
\nMillennium Development Goals
\nAs the 2015 target date for the MDGs approaches, there is lively
\ndebate on the contents and form of the post-2015 agenda. This
\ndebate raises important questions about how progress in improv-
\ning human health should be reflected in any future set of goals,
\ntargets and indicators. At the start of the 2013 UN General As-
\nsembly there will be a high level summit to review progress and
\nmap out a forward-looking agenda. In preparation, the UN De-
\nvelopment Group (chaired by the United Nations Development
\nProgramme \u2013 UNDP) is leading a series of national and global
\nthematic discussion on key issues: inequalities, population, health,
\neducation, economic growth and employment, conflict and fra-
\ngility, governance, environmental sustainability, and food security
\nand nutrition. The aim is to involve a broad range of stakehold-
\ners to discuss the options for a post-2015 framework.The WMA
\nsubmitted a proposal and will continue to advocate that health
\nand health care systems are important drivers for the economies
\nand for securing social stability and development.
\nHealth Systems
\nGeneral
\nImmunization rates against influenza among our profession re-
\nmain worryingly low. Therefore we developed an advocacy and
\nawareness campaign with support from IFPMA on immunisa-
\ntion for influenza. The campaign started with a survey of the
\n56
\nWMA news
\nactivity level of our nation members on influenza immunisation
\nand, in a second step, we will develop material for our members
\nand individual physicians emphasizing the emotional benefits
\nof receiving immunisation. As part of this campaign, this year\u2019s
\nWMA luncheon during the World Health Assembly will be on
\n\u2018Immunisation with a focus on influenza\u2019. This event will give us
\nthe possibility to highlight our new WMA policy on Immunisa-
\ntion as well.
\nPerson Centered Medicine
\nTogether with the World Psychiatric Association (WPA), the
\nWorld Organization of Family Doctors, the World Health Orga-
\nnization, the International Association of Patient Organizations
\nand many other partners, the WMA will hold for the fifth time
\nthe Conference on Person Centered Medicine in Geneva in May
\n2013.The concept of person centered cedicine embodies the prin-
\nciples of patient-centered medicine, but goes far beyond this and
\nbetter reflects the entire spectrum of medicine where we as physi-
\ncians not only deal with the \u201cpatient-hood\u201d of person, but respect
\nthe individual with his or her entire personality and in the context
\nof his or her personal life.
\nHealth Workforce
\nThird Global Forum on Human Resources for Health (GHWA).
\nHuman resources for health (HRH) challenges are in many coun-
\ntries the single largest impediment to scaling up access to health
\nservices and to achieving the health-related Millennium Develop-
\nment Goals (MDGs) and universal health coverage. Along with
\nthe revised strategy of GHWA the theme for the forum will be
\n\u201cHuman Resources for Health: Foundation for Universal Health
\nCoverage and the Post-2015 Development Agenda\u201d and will
\nbe held in November in Brazil. Participation is only possible by
\ninvitation. WMA advocates that the voice of physicians will be
\nreflected in the program and as a result Dr. Julia Tainijoki-Seyer
\nwas invited to take part in the forum working group to define the
\nprogram. The WHO has developed the Guidelines on Reten-
\ntion Strategies for Health Professionals in Rural Areas, with the
\nWMA taking part in the drafting process.The guidelines are based
\non three pillars: educational and regulatory incentives, monetary
\nincentives and management, and environment and social support.
\nWorkplace Violence in the Health Sector
\nThe 3rd
\nConference on Workplace Violence in the Health Sector
\ntook place in October 2012 in Vancouver.The WMA was a mem-
\nber of the planning committee. Dr. Mukesh Haikerwal, Chair of
\nCouncil, opened the conference with a keynote speech. It was a
\ngood opportunity to present the WMA policy on Violence in the
\nHealth Sector that was adopted in Bangkok last October, and to
\nbring forward more strongly the physicians\u2019 perspective in the de-
\nbate.The next Conference is scheduled for October 2014 in the US.
\nEducation & Research
\nThe World Federation for Medical Education (WFME) has
\nstarted a discussion process on the future role of the physician.
\nBeginning with an expert panel in March that included represen-
\ntatives from academia, the WHO, the WMA and international
\nand regional organizations for medical education, the WFME
\nrolled out a debate.The WMA participated as a member of steer-
\ning groups in two projects commissioned by the European Union
\non the Mobility and Migration of Health Professionals. One
\nproject was led by the European Health Care Management As-
\nsociation, and the other by the Research Institute of the German
\nHartmann Bund, a private physicians\u2019 organization. The general
\nobjective of the research projects is to assess the current trends
\nof mobility and migration of health professionals to, from, and
\nwithin the European Union, including their reasons for moving.
\nPatient Safety
\nThe WHO stepped up its commitment to patient safety and de-
\nfined it as a major global priority in health care. To deliver safe
\nhealth care, clinicians require training in the discipline of patient
\nsafety, which includes an understanding of the nature of medi-
\ncal error, how clinicians themselves can work in ways that reduce
\nthe risk of harm to patients, techniques for learning from errors
\nand how clinicians can harness quality improvement methods to
\nimprove patient safety in their own organizations. The WHO
\nrevised the existing Patient Safety Curriculum Guide for medi-
\ncal schools and transformed it into a Multi-professional Patient
\nSafety Curriculum Guide. The WMA was a member of the re-
\nviewing committee for the multi-professional guidelines.
\nCaring Physicians of the World Leadership Course
\nThe CPW Project began with the Caring Physicians of the World
\nbook, published in English in October 2005 and in Spanish in
\nMarch 2007, which is now available in html and pdf. Some hard-
\ncopies (English and Spanish) are still available at the WMA of-
\nfice upon request. Please visit the WMA website (http:\/\/www.
\nwma.net\/en\/30publications\/60cpwbook\/index.html) to access to the
\nelectronic versions and to order the hardcopies. The CPW Proj-
\nect was extended to include a leadership course organized by the
\nINSEAD Business School in Fontainebleau, France in Decem-
\nber 2007. The fifth course was held at the INSEAD campus in
\nSingapore in January 2013.The courses were made possible by an
\nunrestricted educational grant provided by Bayer HealthCare and
\n57
\nWMA news
\nPfizer, Inc. This work, including the preparation and evaluation
\nof the course, is supported by the WMA cooperating center, the
\nCenter for Global Health and Medical Diplomacy at the Univer-
\nsity of North Florida.
\nHealth Politics
\nThe WMA has intervened three times on health politics matters
\nat the request of member associations:
\nIn Slovakia,the government declared a state of emergency in hos-
\npitals in order to stop protests and industrial action by physicians
\nfighting for better working conditions and against the privatisa-
\ntion of public hospitals. In consultation with the Slovak Medi-
\ncal Association, the WMA wrote to the Prime Minister and the
\nPresident of the Republic to call for proper working conditions
\nand fair payment.
\nIn Poland, physicians were made liable for managing the reim-
\nbursement entitlements of the insured. Everyone in Poland is
\ninsured under a state insurance scheme which gives various en-
\ntitlements for reimbursement. These different entitlements were
\nat least in part non-transparent to the physicians, who should not
\nbe held liable for wrongly assigning reimbursement statuses for
\ndrugs on prescription.Together with the Polish Chamber of Phy-
\nsicians and Dentist, the WMA protested against this measure,
\nwhich was later revoked.
\nAt the end of 2011, the Turkish Government removed key func-
\ntions, such as the supervision of physicians and the regulation of
\npost-graduate education, from the Turkish Medical Association
\nand other self-governing institutions. Together with the Turkish
\nMedical Association, the WMA staged public events in Ankara
\nand Istanbul in April 2012 to fight for retaining these critical
\nrights of physician self-governance.
\nHuman Rights
\nZimbabwe
\nIn November 2012, the International Rehabilitation Council for
\nTorture Victims drew our attention to the case of its member
\ncentre \u2013 the Counselling Services Unit, Zimbabwe \u2013 which faces
\nongoing legal harassment of its staff, with three staff arrested
\nand in detention. The WMA wrote a letter to the authorities of
\nZimbabwe, expressing its concerns regarding the procedures fall-
\ning short of international standards for fair trial, as well as the
\nviolation of the confidentiality principle towards patients by the
\nsecurity forces during the raid. The staff was finally granted bail.
\nTurkey
\nOn 12 September 2012, around 60 prisoners began a hunger
\nstrike in seven prisons across Turkey as a protest against the au-
\nthorities\u2019 longstanding refusal to allow Kurdistan Workers\u2019 Party
\n(PKK) leader Abdullah \u00d6calan to meet with his lawyers and to
\ndemand the provision of education in the Kurdish language.
\nAccording to Amnesty, prison doctors were routinely refusing
\nto conduct medical examinations of the hunger strikers. In No-
\nvember, the Turkish Medical Association drew the attention of
\nthe WMA to the gravity of the situation. The WMA wrote a
\nletter to the Turkish authorities to support TMA\u2019s call to form
\nboards composed of independent and experienced physicians to
\nvisit hunger strikers and check their health status. The WMA
\nalso asked for an assurance that no punitive measures were taken
\nagainst prisoners on hunger strike and that the absolute prohibi-
\ntion of torture and other forms of ill treatment was upheld.Under
\nincreasing national and international pressure, the Turkish au-
\nthorities took measures to improve the situation of the prisoners.
\nUnited Arab Emirates
\nWMA secretariat has sent letters to the United Arab Emirates\u2019
\nauthorities expressing its concerns about the arrest of Professor
\nCyril Karabus. He was arrested whilst transiting through Dubai
\nfrom UK to South Africa and was held responsible for the death
\nof a child (member of the royal family) in 2002 when he worked
\nthere of WMA on the precarious health situation of Prof. Kara-
\nbus. A range of questions \u2013 regarding the legal proceeding and
\nguarantees for a fair trial \u2013 were also asked to the Minister of
\nJustice.
\nProtection of health professionals in areas of armed-conflicts
\nLast January, the WMA joined a group of 18 NGOs, initiated by
\nthe Safeguarding Health in Conflict coalition to co-sign a letter
\nto WHO Director General Margaret Chan expressing alarm at
\nthe recent spate of attacks on health workers in Pakistan.
\nICRC Campaign \u201cHealth Care in Danger\u201d
\nThe framework of the International Committee of the Red Cross
\n4-year campaign \u201cHealthcare in Danger\u201d,in which the WMA is a
\npartner, was launched during the summer 2011. A series of work-
\nshops took place on specific themes, each designed to come up
\nwith practical measures to enhance the protection of health-care
\nproviders and beneficiaries in armed conflicts and other emergen-
\ncies.The WMA participated in the workshop entitled \u201cThe secu-
\nrity and delivery of effective and impartial health care in armed
\n58
\nWMA news
\nconflict and other situations of violence\u201d that took place in Lon-
\ndon in April 2012. It was organised by the ICRC, the British Red
\nCross Society, the British Medical Association and the WMA.
\nCooperation with International Rehabilitation Council for Torture
\nVictims
\nAs an elected member of the Executive Committee of the IRCT,
\nClarisse Delorme attended the Executive Committee and Coun-
\ncil meetings that took place last November in Budapest. A new
\nround of elections took place. Ms Delorme was re-elected as
\nan independent expert for a new mandate of three years in the
\nCouncil and the Executive Committee.
\nEthics
\nDeclaration of Helsinki
\nInOctober2011,theCounciloftheWorldMedicalAssociationdecid-
\nedtoembarkonanewprocessofrevisingtheDeclarationofHelsinki.
\nA workgroup was subsequently formed with the mandate to present
\na revised wording of the Declaration to the Ethics Committee.The
\nrevision process was accompanied by a series of expert conferences.
\nThe WMA and the University of T\u00fcbingen organised a satel-
\nlite meeting during the 11th
\nWorld Congress of Bioethics in
\nRotterdam in June 2012 during which international speakers
\nfrom a wide range of scientific disciplines were invited to pres-
\nent their views on the future of the Declaration. In addition, a
\ncall for comments was sent out to all WMA members, and se-
\nlected international organisations were invited to submit their
\nsuggestions for topics requiring revision. In December 2012
\nthe WMA together with the South African Medical Associa-
\ntion staged the first open expert conference on the revision of
\nthe Declaration of Helsinki in Cape Town South Africa. A sec-
\nond conference was held in Tokyo in February. A public con-
\nsultation on the revision process is envisioned for spring 2013.
\nWorld Health Professions Alliance
\nHealth Improvement Card
\nTogether with other members of the WHPA, the WMA launched
\nthe WHPA NCD campaign in May 2011. At the core of the
\ncampaign is the WHPA Health Improvement Card, a simple,
\nuniversal educational tool that will allow everyone to assess and
\nrecord his or her lifestyle\/behavioural and biometric risk fac-
\ntors. The objective of the project is to develop a tool that can be
\nused in all health care settings throughout the world that 1) in-
\ncreases awareness of the individual responsibility of each person
\nfor their health, and 2) serves as an advocacy tool for improved
\nhealth care systems. The NCD health Improvement Card is
\ntranslated into French, Spanish and Portuguese. An online ver-
\nsion of the toolkit is now available on the WHPA webpage. 2012
\nsaw the second phase start with a pilot study in South Africa.
\nCounterfeit Medical Products
\nFor the past four years, the WMA together with the other health
\nprofessionals of WHPA have engaged in an anti-counterfeit
\nmedical products campaign to protect public health. This year
\nthe WHPA\u2019s activity is to involve national members and national
\nstudent organisation through an offer of small grants of $2500\u2013
\n6000. Each grant application required at least two national asso-
\nciations of different health professions in the same country. In the
\nfirst round of applications the following were selected as recipi-
\nents: Ethiopia, Lesotho, Rwanda and the Philippines.The second
\nround of selection is still taking place.
\nDr. Otmar Kloiber,
\nSecretary General
\nPreamble
\nDoctors who commit criminal acts which are not part of patient
\ncare must remain as liable to sanctions as all other members of so-
\nciety. Serious abuses of medical practice must be subject to sanc-
\ntions, usually through professional regulatory processes.
\nNumerous attempts are made by governments to control physi-
\ncians\u2019 practice of medicine at local, regional and national levels
\nworldwide. Physicians have seen attempts to:
\n\u2022 Prevent medically indicated procedures;
\n\u2022 Mandate medical procedures that are not indicated; and
\n\u2022 Mandate certain drug prescribing practices.
\nWMA Council Resolution on Criminalisation of Medical Practice
\nAdopted by the 194th
\nWMA Council Session, Bali, April 2013
\n59
\nWMA news
\nThe World Medical Association is extremely concerned that
\nProfessor Cyril Karabus, a retired paediatric oncologist remains
\nremanded on bail in the UAE despite a long and slow judicial
\nprocess, which has absolved him of all the charges against him.
\nThe WMA notes that the expert medical panel, appointed by the
\ncourt to advise it whether there was any evidence against Professor
\nKarabus, has advised the judge that Professor Karabus has no case
\nto answer. Consequently the judge dismissed all charges and a rul-
\ning of not guilty was given.It also notes with concern that the pros-
\necutors have indicated they will appeal the courts ruling meaning
\nthat Professor Karabus needs to remain in the UAE indefinitely.
\nGiven the findings of the medical panel, the WMA believes that
\nProfessor Karabus is being treated in a manner, which fails to
\nmeet international fair trial standards and should be allowed to
\nreturn home immediately.
\nIn light of the above experience, the WMA will publish an ad-
\nvisory notice in the WMJ and on the WMA website to advise
\ndoctors thinking of working in the UAE to note the working con-
\nditions and the legal risks of employment there. The WMA will
\nencourage member NMAs to publish similar advisory notices in
\ntheir national publications.
\nEnsuring patient safety and quality of care is at the core of medi-
\ncal practice. For patients, a high level of performance can be a
\nmatter of life or death. Therefore, guidance and standardisation
\nin healthcare must be based on solid medical evidence and has
\nto take ethical considerations into account. Currently, trends in
\nthe European Union can be observed to introduce standards in
\nclinical, medical care developed by non-medical standardisation
\nbodies, which neither have the necessary professional ethical and
\ntechnical competencies nor a public mandate.
\nThe WMA has major concerns about such tendencies which are
\nlikely to reduce the quality of care offered, and calls upon govern-
\nments and other institutions not to leave standardisation of medi-
\ncal care up to non-medical self-selected bodies.
\nWMA Council Resolution on Standardisation in Medical
\nPractice and Patient Safety
\nAdopted by the 194th
\nWMA Council Session, Bali, April 2013
\nCriminal penalties have been imposed on physicians for vari-
\nous aspects of medical practice, including medical errors, despite
\nthe availability of adequate non-criminal redress. Criminalizing
\nmedical decision making is a disservice to patients. In times of
\nwar and civil strife, there have also been attempts to criminalize
\ncompassionate medical care to those injured as a result of these
\nconflicts.
\nRecommendations
\nTherefore, the WMA recommends that its members:
\n\u2022 Oppose government intrusions into the practice of medicine
\nand in healthcare decision making, including the government\u2019s
\nability to define appropriate medical practice through imposi-
\ntion of criminal penalties.
\n\u2022 Oppose criminalizing medical judgment.
\n\u2022 Oppose criminalizing healthcare decisions, including physician
\nvariance from guidelines and standards.
\n\u2022 Oppose criminalizing medical care provided to patients injured
\nin civil conflicts.
\n\u2022 Implement action plans to alert opinion leaders, elected offi-
\ncials and the media about the detrimental effects on healthcare
\nthat result from criminalizing healthcare decision making.
\n\u2022 Support the principles set forth in the WMA\u2019s Declaration of
\nMadrid on Professional Autonomy and Self-Regulation.
\n\u2022 Support the guidance set forth in the WMA\u2019s Regulations in
\nTimes of Armed Conflict and Other Situations of Violence.
\nWMA Council Resolution on Professor Karabus
\nAdopted by the 194th
\nWMA Council Session, Bali, April 2013
\n60
\nPrison Health
\nPast Practices and Controversies
\nThis second section examines specific hun-
\nger strikes from the recent past, to discuss
\nthe pitfalls and stumbling points encoun-
\ntered by both custodial and medical au-
\nthorities. As will been seen, a conflictual
\nsituation develops mainly because the non-
\nmedical, custodial authorities decide to
\nstop the protest by ordering the physician
\nintervene. In some cases this may be out of
\ngenuine concern that the fasting prisoner(s)
\nmay come to harm. In our experience,
\nhowever, it more often is simply to ensure
\ntaking all precautions so that no prisoner
\n\u201ckills him\/herself.\u201dAs a determined hunger
\nstriker is hardly likely to simply accept an
\n\u201corder\u201d from the physician to resume eat-
\ning, the doctor is then instructed to feed
\nthe fasting prisoner against his\/her will, i.e.
\nforce-feed.
\nThe examples chosen are from different
\ncountries, different contexts. What is im-
\nportant is the phenomenon that each ex-
\nample illustrates. This is neither intended
\nto be an analysis in any way of the underly-
\ning political situation, nor to justify either
\nside in positions taken regarding the rea-
\nson for the hunger strikes. The aim is to
\nshow how these hunger strikes have been
\nhandled, or (mostly) mishandled, and to
\nreview briefly the decisions taken and why
\nthey were taken. Hence it is not important
\nto identify the specific case and country,
\nwith the obvious exceptions of the well-
\npublicized cases of Guant\u00e1namo Bay and
\nNorthern Ireland (N.I.). All examples are
\nbased on personal field experience or that
\nof close colleagues.
\nEthical Background:
\nthe Evolution of
\n\u201cWMA Malta\u201d
\nThe Northern Ireland hunger strikes in
\n1980 and 1981 took place in the context
\nof \u201cthe Troubles\u201d in Ulster, at a time when
\nthere were mass arrests of I.R.A. militants
\nand accusations of brutality and worsened
\nby the public order forces. Some years be-
\nfore, to avoid any medical involvement in
\ninterrogations and other such activities
\nthe British Medical Association had ap-
\nproached the WMA, so a clear position be
\ntaken regarding medical participation in
\nsuch non-medical activities. (At one point,
\nthe British authorities had suggested that
\nphysicians sit in on interrogations to see
\nthere was \u201cfair play\u201d\u2026). The WMA issued
\nits declaration of Tokyo in 1975 against the
\nparticipation of doctors in any form of tor-
\nture. In this Declaration, one of the Articles
\n(originally \u201c5\u201d, now in the revised 2006 ver-
\nsion, \u201c6\u201d) mentioned hunger strikers, stipu-
\nlating:
\n\u201cWhere a prisoner refuses nourishment and is
\nconsidered by the physician as capable of form-
\ning an unimpaired and rational judgment
\nconcerning the consequences of such a voluntary
\nrefusal of nourishment, he or she shall not be
\nfed artificially. The decision as to the capacity
\nof the prisoner to form such a judgment should
\nbe confirmed by at least one other independent
\nphysician. The consequences of the refusal of
\nnourishment shall be explained by the physician
\nto the prisoner.\u201d
\nFew doctors know why this clause is includ-
\ned in what is essentially a declaration on
\nnon-physician participation in torture. The
\nreason1
\nrelates to situations that may occur
\nwhere torture is taking place. If a prisoner
\nbeing tortured decides to protest against
\nhis plight by refusing to eat, the physician
\nshould not be obliged to administer nour-
\nishment against the prisoner\u2019s will, and
\nthereby effectively revive him for more tor-
\nture. This was the reason for the inclusion
\nof this article in the Tokyo declaration. The
\nwording \u201cartificially fed\u201d, instead of \u201cforci-
\nbly fed\u201dwas an imprecise choice of wording,
\nas \u201cartificially\u201d clearly does not convey that
\nit was feeding against the prisoner\u2019s will
\nthat was prescribed. It also implied not to
\nresuscitate an unconscious prisoner, victim
\nof torture, even without force being used, so
\nas to send him back for more.
\nDuring the hunger strikes in N.I. in 1980
\nand 1981, force-feeding was not performed.
\nThe UK doctors never envisaged the pos-
\nsibility \u201cthat there be any circumstances
\nwhere the due process of law would require
\na physician to force-feed anybody against
\n1 Reyes H., Luebeck; op. cit.
\nPhysicians and Hunger Strikes in Prison: Confrontation,
\nManipulation, Medicalization and Medical Ethics (part 2) (part 1 vol. 59 N 1)
\nHern\u00e1n Reyes George J. AnnasScott Allen
\n61
\nPrison Health
\ntheir will.\u201d1
\nA clear position for the uphold-
\ning of patient autonomy was taken by the
\nU.K. during the hunger strikes in Northern
\nIreland. Respecting autonomy came with a
\nprice.Ten deaths resulted before the prison-
\ners broke off their strike, and the authori-
\nties quietly gave in to some of the prisoners\u2019
\ndemands.
\nAfter these dramatic events in Ulster, it
\nwas awhile before there were any such de-
\ntermined protests leading to loss of life.
\nMany hunger strikes took place during the
\nnext 15 years, in the Middle East, in Latin
\nAmerica and elsewhere, but never led to
\nany showdowns as in Northern Ireland.
\nProtest fasting in most of these contexts,
\nwithout wanting to minimize neither the
\nprisoners\u2019 sincerity nor their grievances,
\nnever went \u201cdown to the wire\u201d. In South
\nAfrica, however, in the 1980s, there were
\n\u201cmore serious\u201d hunger strikes. This led the
\nSouth African doctors to seek further guid-
\nance from the WMA, about hunger strikes
\nper se, and as a result, a new declaration, ex-
\nclusively on hunger strikes in custody, was
\ndrafted and passed by the World Medi-
\ncal Assembly in Malta in 1991 (hereafter
\n\u201cMalta 1991\u201d).This new document defined
\nthe different forms of fasting, the role of
\nthe doctor in monitoring the patient, and
\nmentioned the effects of \u201cterminal\u201d hunger
\nstrikes.
\nWhile \u201cMalta 1991\u201d mentioned artificial
\nfeeding, still it did not explicitly forbid
\nforce-feeding. At the time, forcible treat-
\nment was not an issue, and hence was not
\nconsidered as a problem. After the deadly
\nmistake,occurring during a hunger strike in
\nthe Middle East in the early 1980s, which
\nresulted in the death of two prisoners who
\nwere forcibly fed \u2013 liquid nutrients being
\nerroneously introduced into the windpipe
\nrather than the oesophagus \u2013 force-feeding,
\nalready rare, had practically disappeared.
\n1 Written statement to the author by a former sen-
\nior medical officer who was involved at the time
\nin the Irish hunger strikes.
\nThe hunger strikes in Turkey in the late 90s
\nled to an unprecedented number of deaths.
\nAt least 60\u201370 prisoners, and also many
\nfamily members fasting outside the prison,
\ndied.The deaths from fasting occurred after
\nperiods of time well beyond the \u201c72 days\u201d,
\nwhich implied they had not been \u201ctotally
\nfasting\u201d, and so died from prolonged, not
\nacute, malnutrition. This was a completely
\ndifferent situation from that of the 1981
\nIrish Hunger Strikes. The Turkish hunger
\nstrikes and the way they were ultimately
\n\u201cmanaged\u201d by the authorities and by the
\nprisoners are a complex issue, well beyond
\nany detailed discussion here. The point to
\nbe stressed is that there was no question of
\nany forcible feeding, the confrontation be-
\ning of a very different complexity. It was
\nthe Turkish strikes that triggered the revi-
\nsion of \u201cMalta 1991\u201d2
\nat the WMA. Ini-
\ntially, the new draft was intended to refer
\nessentially to the confrontation in Turkey.
\nHowever, as the revision was taking place
\nand being debated within the WMA, the
\nequally serious situation at Guant\u00e1namo
\nBay was taken into consideration. The use
\nof systematic force-feeding at Guant\u00e1namo
\nBay led to a review of the ethical issues in-
\nvolved,and to reaffirming patient autonomy
\nover just beneficence at any cost. This was
\nthe main reason for the WMA considerably
\nstrengthening the condemnation of force-
\nfeeding, distinguishing it this time clearly
\nfrom voluntary artificial feeding3
\n. The new
\n\u201cMalta 2006\u201d was revised and passed by the
\nWorld Medical Assembly in South Africa
\nin 2006.
\nThe Controversy Around
\nForce-feeding
\nThe situation at Guant\u00e1namo Bay (Gtmo)
\nhas been widely documented in the press
\n2 Reyes, H. Force-Feeding and Coercion: No Physi-
\ncian Complicity. In: Virtual Mentor, American
\nMedical Association Journal of Ethics, October
\n2007, Vol. 9, No 10, pp 703-708.
\n3 WMJ; op. cit.; Glossary
\nsince 2001, and there is now a large amount
\nof information accessible to the public.
\nForce-feeding at Gtmo is now well docu-
\nmented in many articles in prestigious
\njournals, and on countless websites4
\n. Force-
\nfeeding was implemented there by physi-
\ncians, and may still be at the time of this
\npublication. This constitutes a violation of
\nthe principles set down by \u201cMalta 2006\u201d,
\nand constitutes an example of medical
\ncomplicity in what the WMA has defined
\nas inhuman and degrading treatment. The
\nWMA\u2019s firm position against force-feeding
\nis explained in detail in the Background
\npaper5
\naccompanying the revised 2006 ver-
\nsion of \u201cMalta\u201d. Article 13 of \u201cMalta 2006\u201d
\nstates:
\n\u201cForcible feeding is never ethically accept-
\nable.Even if intended to benefit,feeding ac-
\ncompanied by threats, coercion, force or use
\nof physical restraints is a form of inhuman
\nand degrading treatment. \u2026\u201d
\nPhysicians now should unequivocally know
\nthat it is their ethical duty not to participate
\nin, nor condone, any such coercive proce-
\ndures. Guant\u00e1namo Bay is a typical exam-
\nple of \u201cmedicalization\u201d being implemented
\nas the \u201csolution\u201d to a problem the custodial
\nauthorities \u2013 in this case the military —
\ncannot accept. The term used, \u201casymmetric
\nwarfare\u201d6
\nbrings to light a fundamental con-
\ntradiction in the response to hunger strikes
\nin the Guant\u00e1namo context. On the one
\nhand,medical intervention by force-feeding
\nis \u201cjustified\u201das necessary to provide humane
\nmedical treatment to prisoners, to save their
\nlives. On the other hand, hunger strikes
\nbeing described as a new type of \u201cwarfare\u201d
\ncannot have a \u201cmedical\u201d solution. It is ei-
\nther suppression, by any and all means pos-
\nsible, of an act of warfare, or it is\u00a0providing
\n4 http:\/\/www.nytimes.com\/2006\/02\/22\/interna-
\ntional\/middleeast\/22gitmo.html?scp=1&sq=Force-
\nFeeding%20at%20Guant%E1namo%20Is%20
\nNow%20Acknowledged&st=cse
\n5 WMJ; op. cit.
\n6 Annas G.J., op. cit.
\n62
\nPrison Health
\nhumane treatment \u2013 one cannot have it
\nboth ways!
\nTwo arguments for feeding hunger strik-
\ners even against their will have been given
\nby the military authorities responsible for
\nGtmo. The first argument is that force-
\nfeeding has had to be implemented to \u201csave
\nlives\u201d. This statement is fallacious, as the
\nfeeding was being administered very early
\non, after a maximum of 10-15 days of to-
\ntal fasting. As has been shown, at this stage
\nthere is no risk of dying from fasting.When
\npressed with this reasoning, the custodial
\nauthorities have switched their argument
\nto being \u201cnot to save lives, but to save their
\nhealth\u201d. This is again a fallacious argument,
\nvaguely disguising the real intent, which is
\nto break the protest, indeed to suppress the
\n\u201casymetrical warfare\u201d.
\nThere have been rare cases of hunger strikers
\ndying very early on in their protest fasting.
\nOne of the ten 1981 N.I. hunger strikers,
\nMartin Hurson, died after 46 days, from a
\ncomplication that apparently did not allow
\nhim to ingest water. A recent 2012 case of a
\nCalifornia prisoner on hunger strike, dying
\nafter one week\u201d1
\nis still being medically in-
\nvestigated, but the death was most certainly
\nnot due to the fasting alone.
\nThe second argument issued by the mili-
\ntary authorities for intervention has been
\nthat the vast majority of internees at Gtmo
\n\u201caccept\u201d in fact being thus fed, meaning
\nthey do not struggle and fight against in-
\nsertion of the naso-gastric tube, \u201cbecause
\nthey do not want to die\u201d. If this were to
\nbe the case, i.e. voluntary acceptance of
\nthe feeding, it would not constitute force-
\nfeeding, but artificial feeding. The latter, as
\nhas been stated, is not a transgression of
\nethics as by definition it implies voluntary
\nacceptance of medical intervention from
\nthe hunger striker.
\n1 http:\/\/rt.com\/usa\/news\/california-hunger-strike-
\ngomez-187\/
\nThis argumentation nonetheless warrants
\nfurther scrutiny. One of the higher authori-
\nties in the military command has stated
\nthat at Gtmo they have been \u201cstrapping
\nsome of the detainees (sic) into restraint
\nchairs to force-feed them and isolate them
\nfrom one another after finding that some
\nwere deliberately vomiting or siphoning
\nout the liquid they had been fed\u201d2
\n. This is
\nalso the reason naso-gastric tubes have not
\nbeen left in place, as they can indeed be
\nused to empty the nutrients introduced into
\nthe stomach by a hunger striker not want-
\ning to receive food. The point is obvious:
\nthe fact that restraint is \u201cnecessary\u201d proves
\nthat the administration of nutrients is not
\naccepted voluntarily, and hence constitutes
\nforce-feeding.
\nThis being said, one must look beyond this
\nfirst stage,as force-feeding has been the sys-
\ntematic policy at Gtmo3
\nfor many years now,
\nand not merely an exceptional intervention.
\nThe military authority quoted earlier ad-
\nmitted that \u201c\u2026commanders (had) decided
\nto try to make life less comfortable for the
\nhunger strikers, and that the measures were
\nseen as successful. \u2026 Pretty soon it wasn\u2019t
\nconvenient, and they [the hunger strikers]
\ndecided it wasn\u2019t worth it,\u201d \u2026 \u201cA lot of the
\ndetainees said: \u2018I don\u2019t want to put up with
\nthis. [resisting force and the restraint chair]
\nThis is too much of a hassle.\u201d
\nIt is thus deliberately misleading to ascer-
\ntain that the feeding implemented at Gtmo
\nis not coercive because a hunger striker
\ngives up protesting and struggling. Know-
\ning that he cannot prevail against the physi-
\ncians charged with feeding him, a hunger
\nstriker may even renounce resisting at all.
\nSeeing fellow hunger strikers being forced
\nto submit to the naso-gastric feeding and
\n2 http:\/\/www.nytimes.com\/2006\/02\/22\/interna-
\ntional\/middleeast\/22gitmo.html?scp=1&sq=Force-
\nFeeding%20at%20Guant%E1namo%20Is%20
\nNow%20Acknowledged&st=cse op. cit.
\n3 Annas G.J; op. cit. and others
\nthe restraint chair may be enough to dis-
\ncourage any resistance.
\nIn this respect, \u201cMalta 2006\u201d specifically
\nstates, in the same Article 13:
\n\u201dEqually unacceptable is the forced feeding of
\nsome detainees in order to intimidate or coerce
\nother hunger strikers to stop fasting.\u201d
\nThe whole discussion around the policy of
\nforce-feeding hunger striking internees at
\nGtmo thus centers on this flouting of the
\nclear prohibition for physicians to partici-
\npate in inhuman and degrading treatment.
\nMuch has been debated regarding the is-
\nsue of whether force-feeding qualifies as a
\nform of torture.The WMA does not use the
\nterm torture, but declare force-feeding as
\n\u201cinhuman and degrading treatment\u201d, mak-
\ning it a violation of Common Article 3 of
\nthe Geneva Conventions of 1949, which
\ncondemn \u201ccruel, humiliating and degrad-
\ning treatments\u201d. Repeated force-feedings
\ncan only make the situation more degrading
\nand inhuman. However, legally speaking, as
\nthere is no clear intent \u201cto inflict pain\u201d, the
\njuridical definition or torture according to
\nthe UN 1984 Convention against Torture
\nwould arguably not be met. The distinc-
\ntion here between \u201cinhuman and degrading
\ntreatment\u201d and \u201ctorture\u201d is not the point \u2013
\nforce-feeding is a violation of medical ethics
\nunder any circumstances.
\nIndeed, in many non-military settings, the
\nforce-feeding is not only legally permissible,
\nit is actually ordered by the courts. Court
\norders do not invalidate the professional
\nobligation of the physician to act within the
\nbounds of medical ethics. While such con-
\nflicts are notoriously challenging for indi-
\nvidual physicians, violations of professional
\nethics greatly undermine the integrity and
\nautonomy of the medical profession and
\nmay have profound consequences on the fu-
\nture efficacy of the profession. As a practical
\nmatter, they have the immediate impact of
\ndamaging the ability of professional col-
\nleagues and future physicians to establish
\n63
\nPrison Health
\ntrust with fellow prisoner patients; and as
\nwe have said, without trust, medicine can-
\nnot be practiced.
\nIn Guant\u00e1namo Bay, restraint chairs ac-
\ncompanied by threats and muscular
\ninterventions,were used, and any recalci-
\ntrant to the feeding thus made to comply.
\nThis situation of coercion, the force-feed-
\ning, was maintained for weeks, months and
\nmore on fasting detainees.The WMA Dec-
\nlaration of Malta qualifies \u201cforce-feeding\u201d
\nunequivocally as \u201ca form of cruel, inhuman
\ntreatment\u201d \u2013 but this refers to a \u201cone-shot\u201d
\nforce-feeding.The WMA never envisaged a
\nsituation whereby repeated force-feedings
\nwould be applied to the same individu-
\nals over such long periods of time. There is
\nno historical precedent for hunger strikes
\nlasting over five years and \u201cmanaged\u201d with
\ninhumane and unethical practices in this
\ncoercive way1
\n. There may be one exception
\nto this, Irom Chanu Sharmila of India who
\nhas been on a hunger strike for more than
\na decade. It could arguably be necessary to
\nnow submit to the WMA the question of
\nhow long-term and repeated force-feedings
\nshould be qualified.
\nLessons from Guant\u00e1namo
\nAt Gtmo force-feeding was accordingly
\nmade mandatory. It was the Secretary of
\nDefence who specifically decided that the
\ndecision was a military one, to be made by
\nthe non-medical camp commander,but that
\nwould be implemented by physicians2 3
\n.
\n1 Polgreen, L. In India, 11-Year Hunger Strike over
\nMilitary Violence is Waged in Shadows. In: New
\nYork Times, September 11, 2011, 5. Annas G.J.
\npersonal communication.
\n2 Annas, G.J. Military Medical Ethics \u2013 Physician
\nfirst, last, always. In: N Engl J Med 2008; 359;
\n1087-90
\n3 Rubenstein, L.S., Annas, G,J, Medical Ethics at
\nGuant\u00e1namo Bay Detention Centre and in the US
\nMilitary: a time for Reform In: Lancet 2009, 374;
\n353-55
\n\u201cThe use of physicians to aggressively break
\na prison hunger strike raises complex medi-
\ncal ethical and legal issues that have been the
\nsubject of international debate for decades.\u201d4
\nIt is a perverse medicalization of the issue,
\nimposing a medical act on an unwilling pa-
\ntient, thus taking the physician away from
\nthe role of medical intermediary. The issue
\nbecame so politicized that the most senior
\nphysician in the Pentagon at the time con-
\ntradicted his base commander on the issue
\nof the hunger strikers being suicidal5
\nand
\nsuggesting that the case of hunger strikers
\nat Guant\u00e1namo was like the Terri Schiavo
\ncase6
\n.\u201cThere is a moral question. Do you al-
\nlow a person to commit suicide? Or do you
\ntake steps to protect their health and pre-
\nserve their life?7
\n\u201d The order was then given
\nspecifically requiring military physicians to
\nperform an act in direct violation of medi-
\ncal ethics.
\nAnother recent case in Switzerland illus-
\ntrates this point. The heated arguments
\nbetween the judiciary, adamant to \u201cbreak\u201d
\na well-known hunger striker by having the
\ndoctors force-feed him, and the physicians,
\nrefusing to comply citing the support of
\ntheir Medical Association, even though
\nthe decision to force-feed was (surprising-
\nly) sustained by the Swiss Federal Tribunal
\n(the equivalent in the US to the Supreme
\nCourt) led to a stand-off. In the end, the
\nphysicians stood their ground and firmly
\nrefused to give in to any judicial authority
\nthat flouted medical ethics, be it the high-
\nest Tribunal in the land.8
\nThey were right
\nin doing so, and the judiciary was wrong
\n4 Annas G.J. op. cit. Footnote 10
\n5 Wei M., Brendel J.W., op. cit.
\n6 Media Roundtable with Department of Defense
\nAssistant Secretary for Health Affairs William
\nWinkenwerder, News Transcript, June 7, 2006
\navailable at: http:\/\/www.defenselink.mil\/tran-
\nscripts\/transcript.aspx?transcriptID=33
\n7 Annas G.J., op. cit.
\n8 Editorial by Dr. Jacques de Haller, President of
\nthe Swiss Medical Association (FMH); Bulletin
\ndes M\u00e9decins Suisses, September 2010, N\u00b0 39.
\nto try to get physicians to violate medical
\nethics, including the clear directives on
\nhunger strikes of the World Medical As-
\nsociation9
\n.
\nIt is this abuse of the medical role of prison
\nauthorities and even the judiciary that has
\nled to serious confrontations. Unfortunate-
\nly, the spotlight has been turned more and
\nmore onto the extreme violation of medical
\nethics in the case of hunger strikes \u2013 force-
\nfeeding \u2013 neglecting almost totally the real
\nrole of physicians. This real role of doctors
\nhas been discussed earlier and it will be fur-
\nther addressed later on.
\nThe US military authorities do not dis-
\npute that force-feeding violates medical
\nethics, but insist that physicians follow
\norders because force-feeding is necessary
\nfor national security reasons. National se-
\ncurity, not the prevention of \u201cself-harm\u201d, is
\nthe real issue. Physicians at Gtmo, mainly
\nNavy reservists, have complied with or-
\nders, although it is possible that any physi-
\ncian not willing to do so may have been
\ndirected elsewhere. In Switzerland, eighty
\nprominent physicians signed a petition re-
\nsisting such \u201corders\u201dfrom the highest court
\nin the land, the Federal Tribunal10
\n, and the
\norder was revoked.
\nThe Conflict that Needn\u2019t Be
\nGuant\u00e1namo Bay has been merely the
\nmost visible example of \u201cmedicalization\u201d of
\nthe controversy around hunger strikes, in
\nthe media spotlight because of the char-
\nacteristics of the place and its inmates.
\nSuch \u201cmedicalization\u201d occurs, however,
\nto a lesser degree, in prisons everywhere.
\nThe custodial authorities\u2019 first and utmost
\npriority is maintaining security and \u201cpeace
\nand quiet\u201d. A prisoner who protests by
\nfasting, by definition will do it \u201cnoisily\u201d, to
\nattract as much attention as s\/he can, and
\n9 \u201cMalta 2006\u201d, op. cit.
\n10 de Haller J., op. cit.
\n64
\nPrison Health
\nget as much support as possible from all
\nsides. A hunger striker is seen therefore as
\na trouble-maker, a \u201chostage taker\u201d as has
\nbeen mentioned.The tendency to \u201chave the
\ndoctor\u201d solve the problem is not limited to
\nGtmo.
\nHunger strikes elsewhere have had similar,
\nthough mostly attenuated, complications.
\nA case in point was a collective hunger
\nstrike in a Latin American country, where
\nan ICRC physician played a key role in
\nfinding a solution. By speaking to the pris-
\noners both collectively and individually, it
\nbecame clear that none of them wanted to
\ndie, but all wanted their protest to continue
\nand make as much \u201cnoise\u201d as possible. The
\ndoctor could thus persuade the hunger
\nstrikers to accept intravenous lines and the
\nadministration of vitamins and nutrients.
\nThe prisoners continued proclaiming they
\nwere still \u201con hunger strike\u201d. The physician
\nplayed his role of intermediary discreetly,
\nrefusing to comment publicly on whether
\nthe hunger strike was \u201creally genuine\u201d.
\nHad he made any public statements, this
\nwould have been seen by the hunger strik-
\ners as a betrayal of trust, possibly leading
\nto a breakdown in the process of recon-
\nciliation. It was finally a representative of
\nthe Church who brought about a peaceful
\nresolution.
\nOther recent examples in the Middle East
\nhave proven again that if the physician
\nplays his or her role of discreet, trusted
\nmedical intermediary, there will be no
\nneed for any force to be considered. The
\nhunger striker not wanting to die may be
\npersuaded to accept medical help in ex-
\nchange for some face-saving \u201cconcession\u201d
\nfor example. Or he may accept transferral
\nto hospital so as to be able to \u201cblame the
\nprison doctor\u201d for having to refrain from
\npursuing the protest fast.The prison doctor
\nmust be ready to shoulder this blame, hav-
\ning the interest of the patient as a priority.
\nFurthermore, it will allow for smoothing
\nthe conflictual situation between the cus-
\ntodial authorities and the protestors.
\nThus, there need be no conflict once all par-
\nties agree that a solution has to be found so
\nas not to endanger anyone\u2019s life.
\nAllowing the Prisoner
\nOne Last Chance
\nThe debate on respecting autonomy, and
\nnot imposing treatment on hunger strik-
\ners is most often a moot point. The hunger
\nstrikers at Guant\u00e1namo Bay were force-
\nfed early, and it will never be known how
\nmany of them could have been coaxed out
\nof their collective strike had the doctors
\nbeen able to have an independent role of
\nmedical intermediary. Some well meaning
\nvoices have intransigently supported re-
\nspect at all times of, for example, any writ-
\nten instructions, calling the (exceptional)
\nhunger striker who goes \u201call the way\u201d, to
\nbe respected.
\nThis is certainly the policy that was applied
\nto the Northern Ireland hunger strikers.
\nHowever, a recent personal example will
\nillustrate exactly the contrary, and still be
\nin accordance with the guidance in \u201cMalta
\n2006\u201d.
\nIn a hunger strike in Transcaucasia, the
\nprison doctor took it upon himself to resus-
\ncitate a vociferous political hunger striker
\nwho had reached the confusional phase late
\nin total fasting. This was, in fact, contrary
\nto the hunger striker\u2019s written instructions.
\nOn the face of it, this case would seem to be
\na violation of medical ethics by the prison
\ndoctor.
\nSome time later, this same prisoner pro-
\ntested about the prison doctor\u2019s actions
\nto one of the authors of this paper. When
\nquestioned as to why he had gone against
\nthe hunger striker\u2019s written decision not to
\nbe resuscitated, the local doctor explained
\nthat he came from the same region as the
\nhunger striker. \u201cIn his heart\u201d, he said, he
\nknew the patient would not want to die, so
\nhe intervened once the prisoner was no lon-
\nger alert and aware of what was happening.
\nThis prison doctor did well in doing so. As
\nthe hunger striker confessed to the author,
\nhe was actually delighted to find himself
\nalive and well \u2013 but he did not want either
\nthe authorities or the prison doctor to know
\nthis! This example may be uncommon, but
\nit is not atypical of the ambivalence there is
\nin many cases.
\nPrisoners begin a hunger strike often not
\nreally knowing what they get into. As shall
\nbe discussed further on, some will \u201cpaint
\nthemselves into a corner\u201dat some point, and
\nmay not know how to back off. It is here the
\ndoctor can play an important role. Force-
\nfeeding will not be an issue, since this type
\nof hunger striker does not want to harm
\nhimself. In the privacy of the medical con-
\nsultation, away from any outside peer pres-
\nsure, the physician often easily convinces
\nthe hesitating protester to accept artificial
\nfeeding. As to the ethical guidelines, it is
\nimportant to understand that \u201cMalta 2006\u201d
\nspecifically allows such leeway to the treat-
\ning physician who knows the patient, and
\nshould thus have the final word in deciding
\nwhat is best1
\n. Article 10 reads:
\n\u201cIf no discussion with the individual is pos-
\nsible and no advance instructions exist, phy-
\nsicians have to act in what they judge to be
\nthe person\u2019s best interests. This means consid-
\nering the hunger strikers\u2019 previously expressed
\nwishes, their personal and cultural values as
\nwell as their physical health. In the absence of
\nany evidence of hunger strikers\u2019 former wish-
\nes, physicians should decide whether or not to
\nprovide feeding, without interference from
\nthird parties.\u201d
\nThe prison doctor who thus ignored the
\nTranscaucasian hunger strikers\u2019 written in-
\nstructions thus took the risk of erring by
\ngoing against the expressed will of the pris-
\noner \u2013 but in fact he ended up taking the
\nright decision. The physician retained the
\nproper authority to exercise judgment, in
\n1 WMJ; op cit. 10. Artificial feeding, force-feeding
\nand resuscitation; p. 40
\n65
\nPrison Health
\ngood faith, in assessing the patients\u2019will in a
\ndifficult clinical situation.
\n\u201cMalta 2006\u201d allows for error. If the Trans-
\ncaucasian prisoner had torn away his in-
\ntravenous lines and naso-gastric tube upon
\nrevival, then the prison doctor would have
\nbeen justified in not interfering a second
\ntime.This will be discussed in the final point
\nbefore reaching a conclusion.
\nVolunteer or Volunteered ?
\nThe common denominator to all problem-
\natic hunger strikes is the clash between
\nmedical and non-medical authorities.How-
\never, this should not distract the physician
\nfrom other possible conflicts which will di-
\nrectly influence the ethical management of
\nthe hunger strikers.
\nA prisoner who decides to protest by fast-
\ning must do so voluntarily. As it has been
\nmentioned, some voices object to anything
\nbeing truly voluntary in a custodial setting,
\nreferring to the overall control exerted by
\nthe custodial authorities. Different pressure
\non the hunger striker has also been exert-
\ned, which in some contexts can be potent
\nenough to force the hunger striker to pursue
\nthe protest that the individual would have
\nbroken off.It is here that the physician has a
\nduty to identify such a case.
\nBy making sure every hunger striker is seen
\nand interviewed in the privacy of the medi-
\ncal consultation, the physician has a good
\nchance of establishing sufficient trust to be
\nable to know what the situation is. All too
\noften, when many prisoners are all on strike
\ntogether, they are kept in an open ward to-
\ngether. In such conditions it is easy for a
\n\u201cleader\u201d, identifiable or not, to exert pres-
\nsure on the others to pursue a hunger strike
\nall may not be in agreement with. To avoid
\nthis type of peer coercion, the physician
\nmust insist on seeing each hunger striker
\nindividually. If the hunger strikers initially
\nrefuse (possibly again because of peer pres-
\nsure), the excuse of doing a \u201cmedical ex-
\namination in private\u201d usually gets them to
\nconsent.
\nConcerns about how to examine \u201chundreds
\nof prisoners\u201d individually should not be a
\nmajor issue, as \u201cmass hunger strikes\u201d usu-
\nally fade out after a few weeks, reducing the
\nnumber down to the real and problematic
\ncases. As will be developed in the recom-
\nmendations and in contexts where this is
\nfeasible, hunger strikers should be kept in
\nseparate rooms \u2013 but not in isolation. To
\nabsolutely separate them and leave them
\nincommunicado will be in most cases seen
\nas a repressive measure,required by the phy-
\nsician to boot, and will not encourage the
\nprisoners to trust the doctor.
\nExperience from many contexts has shown
\nthat many hunger strikers will, in the pri-
\nvacy of the consultation, even plead with
\nthe physician to help in getting away from
\npeer coercion, or from a threatening leader-
\nship. If the physician can convey the mes-
\nsage that s\/he is there not to stop the strike,
\nbut to help the individual hunger striker,
\nmore than half the battle is won. It is then
\na question of finding a solution. This may
\nentail transfer to the medical ward, for \u201cfur-
\nther exams\u201d, or for \u201ctreatment of a medical
\ncondition\u201d. A form of \u201creverse medicaliza-
\ntion\u201d can be evoked here, the physician tak-
\ning upon him\/herself to give the individual
\na way out. This may be so as to merely \u201cnot
\nlose face\u201d, important in many contexts. Or
\nit may be to extract from reprisals a hun-
\nger striker who has \u201cvolunteered\u201d to protest
\nway beyond the length of time he may have
\nenvisaged initially.The result \u2013 medical care
\nbeing provided \u2013 is the same as for the food
\nrefuser, but in the refuser\u2019s case it is clear
\nfrom the start that the fasting is limited and
\nto be under full medical control. It cannot
\nbe stressed sufficiently here the need for the
\nphysician to be able to convey to the hunger
\nstrikers that s\/he is \u201con their side\u201d, meaning
\nto provide care and empathy and whatever
\nassistance is needed, and not as an agent of
\nthe custodial authorities.
\nManipulators and Manipulated
\nThe imposition on medical staff by judges,
\ntribunals or other custodial authorities of
\norders to perform the task of force-feeding
\n\u201crecalcitrant\u201d hunger strikers, knowing full
\nwell or ignoring that this is contrary to
\nthe doctors\u2019 ethical principles, is a form of
\nmanipulation. Physicians should never let
\nthemselves be manipulated this way, what-
\never the authority evokes, be it judicial or
\nmilitary. Even in situations of \u201cdual loyal-
\nties\u201d, whereby physicians owe loyalty to, for
\nexample, the Prison Service, or the Armed
\nForces, the bottom line must always be re-
\nspect for their ethical principles1
\n.Physicians
\nare first and foremost responsible to their
\npatients2 3
\n, and they have the full support
\nof the World Medical Association behind
\nthem in this.
\nThere is a different form of manipulation
\nthat physicians also should avoid.Individual
\nor groups of hunger strikers may also seek
\nto \u201cuse\u201d the doctor. Recent cases of what
\none may call \u201cproblematic hunger strikes\u201d,
\ni.e. going beyond a mere couple of weeks,
\nin politically charged contexts, have given
\nrise to such behaviour.A hunger striker may
\ntell the physician in confidence that for sure
\nhe neither does want to die nor endanger
\nhis health. While accepting assistance in
\nthe form of an intravenous line or possibly
\neven nutritional intake in the discretion of
\nthe medical consultation, the hunger striker
\ntries to manipulate the doctor, for example,
\ninsisting he makes a public statement to the
\npress, or blatantly lies to his superiors in the
\nprison.This is unacceptable when it is obvi-
\nously a form of manipulation of the physi-
\ncian, trying to get him to collaborate with
\nthe protest. The physician has to remain on
\nneutral ground, and thus retain credibility
\n1 Reyes, H. Medical ethics subject to national law:
\nShould doctors always comply? In: Medische Neu-
\ntraliteit; Jaargang 51, 8 November 1996 MC NR
\n45; pp. 1456\/1459
\n2 Annas G.J. op. cit.
\n3 Allen S., Reyes H.; op. cit.
\n66
\nPrison Health
\non all sides. While there is not need to be
\nspecific, towards the press for example, on
\n\u201cwhat type of treatment\u201d is being given,
\nthe physician should not lie about it. To his
\nimmediate superiors he should explain his
\nsituation of intermediary, and not let them
\nmanipulate the situation either.
\nIn another highly publicized hunger strike
\nin Europe, a determined prisoner, who to-
\ntally fasting lost more than 20 kilos but
\nwho knew exactly what he was doing, man-
\naged to manipulate into believing he was
\nsteadfast in his resolve not only the custo-
\ndial authorities, but also the medical staff.
\nThe custodial authorities, in this case both
\nprison and judicial, ordered the prisoner to
\nbe force-fed. The physicians refused, evok-
\ning the ethical principles in \u201cMalta 2006\u201d.
\nThe nurses, however, took pity on the \u201cpoor
\nold man\u201d1
\nand persuaded him (sic) to accept
\na naso-gastric tube. The hunger striker as-
\ncertained that if he were attached, he would
\nyank it out. However, he then proceeded to
\nhelp the nurses attach him.
\nThis case was widely commented on and
\neven went visually into the media. It is now
\nclear that the prisoner had no intention of
\nstarving himself to death, but manipulated
\nthe authorities into ordering him force-fed;
\nmanipulated the medical staff into attach-
\ning him down, while accepting in fact the
\nnaso-gastric feeding; and even manipulated
\nan outside higher authority into believing
\nhe had been force-fed. Once he obtained
\nwhat he wanted, he quickly stopped fasting
\nand walked out of custody a free man.
\nIt is most important for physicians to main-
\ntain the high moral ground here, and refuse
\nmanipulation from any side. In the above-
\nmentioned case most of them refused to
\nhave anything to do with the prisoner, but
\nsome \u2013 and the nursing staff \u2013 were tricked
\ninto playing his game.It is essential the phy-
\nsician not let him\/herself be manipulated by
\n1 An authentic quote to the author from the inter-
\nviewed medical staff\u2026
\nany side.Only this way a constructive medi-
\ncal role will be possible and hopefully calm
\ndown the situation and avoid coming to an
\nimpasse.
\nPainting Hunger Strikers
\nOut of Their Corner
\nIt was mentioned in the introduction to this
\npaper that the hunger striker was some-
\ntimes \u201cforgotten\u201d in the heated controver-
\nsies between the custodial authorities and
\nthe medical profession. Such confronta-
\ntions, and their often very public \u201cventila-
\ntion\u201d in the media, put the hunger striker
\n\u201con the spot\u201d, or more to the point, \u201cin the
\nspotlight\u201d. A lone hunger striker may all of
\na sudden find he has become a \u201cstar\u201d, talked
\nabout, held up as a \u201cvictim\u201d or \u201cmartyr\u201d as
\nthe case may be. From a hostage taker hold-
\ning himself hostage, he effectively becomes
\na real one of the situation. Any \u201csupport\u201d
\nfrom outside or from the same media, may
\nhave the contra-productive effect of \u201cpaint-
\ning the hunger striker into a corner\u201d. Find-
\ning oneself with the \u201cstar\u201d or \u201cmartyr\u201d status
\nmakes it very difficult to back out of a more
\nand more difficult situation. Abandoning
\nthe hunger strike becomes impossible, even
\nin exchange for lesser concessions that glad-
\nly might have been accepted initially. The
\nhunger striker may fear the taunts from the
\nprison guards if he now backs down; or the
\nshaming of his family; or the reproaches of
\nhis fellow inmates who will fell \u201clet down\u201d\u2026
\nThe hunger striker may thus feel obliged to
\nfast beyond whatever limit he initially may
\nhave had in mind.
\nWhen the individual hunger striker, or
\ngroup of resolute hunger strikers, gets into
\nsuch a \u201cshowdown\u201d position with the au-
\nthorities,pushed by their new notoriety into
\nradical positions they may have not initially
\nintended to take, it may seem too late to
\nfind a useful alternative to impasse. How-
\never, even in the most politicised situations,
\nletting the situation deteriorate and become
\nconfrontational is not inevitable.
\nThe physician still can play a crucial role in
\nfinding a way out. It is important for the
\nphysician not to medicalize just any form
\nof fasting during the first 72 hours, other-
\nwise the precious time will be wasted on
\nfutile cases. The custodial authorities may
\ncertainly consult the doctor about a spe-
\ncific prisoner \u2013 to know whether there is
\na medical condition that would put him in
\ndanger very early on. As mentioned above,
\nit is to be avoided to have the physician rush
\nto each hunger striker\u2019s bedside before 72
\nhours. After this period of time, the physi-
\ncian can plan how to manage each situation,
\nand first and foremost reaffirm a relation-
\nship of trust as soon as s\/he can. The phy-
\nsician should proceed without fanfare, and
\nmost of all without pressure from any side,
\neither from the custodial authorities or from
\nthe prisoner(s).
\nThe Ultimate Goal:
\nPreserving Human Dignity
\nA final point need be made here. It should
\nbe sufficiently clear that hunger strikers very
\nrarely go to a final fatal conclusion. Those
\nthat do often fall into the \u201cpainted into the
\ncorner\u201d category, i.e. a situation of impasse,
\ncreated by those who have left the situa-
\ntion get out of hand. The Northern Ireland
\nstrikes were an exception, and no one can
\naccuse the physicians of not having done all
\nthey possibly could to defuse a highly po-
\nliticized situation. That hunger strike, like
\nthose embarked on by Mahatma Ghandi,
\nhad there been no concessions in his case,
\nended in fatalities. Such rare terminations
\nof the ultimate way for prisoners to protest
\nare rare, and it has been shown that they
\ncan be avoided in the majority of cases.
\nHowever, force-feeding is not a solution,
\nas it imposes refused medical treatment on
\nthe individual, from a non-medical author-
\nity, making the physician an accomplice of
\nwrong-doing, if inhuman and degrading
\ntreatment. As already said, \u201cMalta 2006\u201d
\nclearly states that force-feeding is never
\njustified. A competent hunger striker can-
\n67
\nPrison Health
\nnot be coerced, even were it to save his or
\nher life.
\nArticle 11 of \u201cMalta 2006\u201d states:
\n\u201cIf, after resuscitation and having regained
\ntheir mental faculties, hunger strikers continue
\nto reiterate their intention to fast, that decision
\nshould be respected. It is ethical to allow a de-
\ntermined hunger striker to die in dignity rather
\nthan submit that person to repeated interven-
\ntions against his or her will.\u201d
\nThis clause applies to cases where a prisoner
\nmay have been forced to sign such instruc-
\ntions under duress, in a repressive or dicta-
\ntorial prison system for example. However,
\nin a more normal situation, it also applies
\nto those cases, such as the above mentioned
\nCaucasian one, where the prison doctor has
\ngiven a terminal hunger striker \u201cone last
\nchance\u201d. As has been said, this is admis-
\nsible if the doctor who has been following
\nthe patient, and knows him, has the firm
\nconviction there is good reason to believe
\nthe hunger striker really does not want to
\ndie. If the physician has in good faith mis-
\njudged the situation, he cannot be accused
\nof unethical behaviour. What would not
\nbe admissible, it would be the physician\u2019s
\ncomplicity with the coercive custodial au-
\nthorities to play the game of allowing de-
\nliberate deterioration of the hunger striker\u2019s
\nmental state through total fasting. In such a
\ncase, once the hunger striker was in a con-
\nfused state and no longer able to make an
\ninformed decision, s\/he would be in fact
\n\u201cforce-fed, evoking the lack of resistance
\nto such feeding. To thus justify \u201cartificial\u201d
\nfeeding (sic!), and then start over all again
\nonce the prisoner was resuscitated, is totally
\nunacceptable.This type of situation actually
\noccurred in the 1970s, in a North African
\ncountry, several hunger striking prison-
\ners submitted to what was assimilated to
\na \u201cyo-yo\u201d situation, which ended up last-
\ning for some two years. \u201cMalta\u201d specifically
\nsays that a truly determined hunger striker
\nshould be allowed, if all ethical attempts to
\nreverse his or her decision have failed, \u201cto
\ndie in dignity.\u201d
\nWay Forward: How to
\nExtricate Physicians
\n(and their ethics) from the
\nImbroglio and Possibly
\nContribute to a Solution
\nHow can the confrontational situations
\nmentioned above be avoided? The authors
\nof this paper are convinced the \u201cWay For-
\nward\u201d that has been mentioned, specifically
\ninvolving physicians, will work for the great
\nmajority of hunger strikers. It may not in
\nthe most extreme situations, but such cases
\nare truly exceptional.
\nAll physicians want to preserve life. They
\nshould do so respecting the dignity and
\nrights of their patients,and respect for med-
\nical ethics will automatically follow.
\nOur analysis leads us to conclude there are
\nmany ways that physicians can act, consis-
\ntent with medical ethics, to develop a true
\ndoctor-patient relationship with hunger-
\nstrikers. It is also critical that the custo-
\ndial authorities do not act to undermine
\nthe fragile trust between the doctor and
\nthe patient for in doing so, they deprive
\nthemselves of the easiest solutions to the
\nconflict. Positive and trusting therapeu-
\ntic relationships will ultimately result in a
\nreasonable outcome for all involved in the
\nvast majority of cases. It must be recalled
\nthat hunger strikes, if they are to work, can
\nonly do so over a span of time. The key to
\nfinding a way out of the imbroglio is for
\nthe custodial authorities to realize that
\na hunger strike is not an emergency, let
\nalone a medical emergency. If the physi-
\ncians have done their job of excluding any
\npotential cases with concurrent medical
\nproblems, there is no need for panic. There
\nis at least a full month before reaching the
\nstage when medical symptoms may begin
\nto cloud the issue. These full four weeks
\nare unfortunately seldom used to look for
\na solution. Instead, the custodial authori-
\nties tend to crack down from a viewpoint
\nof mere \u201cprinciple\u201d (\u201cNobody kills himself
\nin my prison!\u201d) that is when the spotlights
\nturn on and confrontations begin.
\nRigid standard operating procedures
\n(SOP\u2019s) which decree that hunger strikers
\nshall be force-fed already during the sec-
\nond or third week of fasting supposedly \u201cto
\nsave their lives\u201d are unethical nonsense and
\nprecisely what is to be avoided. A healthy
\nyoung adult with no concurrent medical
\nproblems can usually go for a month tak-
\ning only sufficient amounts of water, and
\nhave no serious health issue. The timeframe
\npresented in this paper clearly shows that
\nno serious medical complications of fasting
\nwill occur during this first month, leaving
\nample time for the physician to play a more
\nuseful role than merely monitoring blood
\ntests, weights and blood pressures.
\nParamount during this period is the mean-
\ningful discussion between the physician
\nand the hunger striker. This whole concept
\nof a constructive way forward is based on
\nthe physician-patient relationship. The pro-
\nposed solutions and suggestions that follow
\nhave all to be seen from this perspective.
\nTo be continued…
\nDr. Hern\u00e1n Reyes,
\nMD, Medical coordinator for the
\nInternational Committee of the Red Cross,
\nspecializing in medical and ethical aspects
\nof Human Rights, Prison Health, and in
\nthe field of MDR TB in prisons. Observer
\nfor the ICRC on issues of medical ethics.
\nProf. George J. Annas,
\nChair of the Department of Health
\nLaw, Bioethics & Human Rights of
\nBoston University School of Public
\nHealth; Prof. Boston University School
\nof Medicine, and School of Law.
\nScott A. Allen, MD, FACP, School of
\nMedicine,University of California, Riverside
\nE-mail: manzikert@gmail.com
\n68
\nCouncil of Europe
\nThe Council of Europe, which, as an inde-
\npendent institution, may not be confused
\nwith the European Union, was established
\nin 1949 for the promotion of human rights
\nand democracy on the basis of its Conven-
\ntion for the Protection of Human Rights
\nand Fundamental Freedoms of 4 No-
\nvember 1950 [1]. This Intergovernmental
\nBody, composed of 47 Member States and
\n5 Observer States (Canada, the Holy See,
\nJapan, Mexico and the USA) and repre-
\nsenting about 800 million of citizens aims
\nat harmonizing the European legislation
\nby using Conventions and Additional
\nProtocols to these Conventions. Conven-
\ntions and Protocols are treaties, and it is
\nup to the decision of the Member States
\nto incorportae them into their national law
\nby signature and ratification. The develop-
\nment of modern biomedicine, in particu-
\nlar the in-vitro-fertilisation of man, gave
\na reason to the Council to pay more at-
\ntention to the application of biology and
\nmedicine on man. To achieve the aim a
\nStanding Committee, the Steering Com-
\nmittee on Bioethics (CDBI), was estab-
\nlished which is the author of all provisions
\nin that field. It was clear from the begin-
\nning that the common good of protection
\nof human dignity, autonomy, beneficence
\nand justice should be in the focus.
\nClassification of
\nProvisions and Reasons
\nfor Legal Instruments
\nProvisions for the protection of research
\nparticipants are commonly classified as le-
\ngal instruments and other provisions, of-
\nten addressed as \u201csoft law\u201d. There are few
\nlegal instruments. Meanwhile there are
\nrecognised treaties like the Oviedo Con-
\nvention (Council of Europe, 1997) and its
\nadditional Protocol concerning biomedical
\nresearch, as well as Directive 2001\/20\/EC
\n(2001) [2] of the European Union.The Di-
\nrective is applicable only to drug research.
\nMost States regulate biomedical research,
\nat least drug research, by national law. It
\nseems that there is a big number of \u201cother
\nprovisions\u201d. The most important texts, at
\nleast in the view of the author, are the Dec-
\nlaration of Helsinki [3], the International
\nGuidelines of CIOMS [4] and the UNES-
\nCO Universal Declaration on Bioethics on
\nHuman Rights [5]. The national codes of
\ndeontology, e.g. for physicians, and other
\nprofessional codes are to be mentioned as
\nparts of \u201csoft law\u201d. Soft law may be incor-
\nporated into national binding law by the
\ndecision of the State. At least in the past,
\nsoft law played an important role in the
\nprotection of research participants. There-
\nfore a question may arise about the need
\nof its replacing by legally binding instru-
\nments. In this context the relation between
\nethics and law may be reflected upon. In
\nmodern states ethical principles are more
\nand more adopted by legislation with the
\npurpose to find regulations acceptable to
\nall citizens. Free and informed consent can
\nbe considered important, e.g.,based on the
\ndoctrine of autonomy, in Germany pre-
\ndominantly linked to Immanuel Kant, the
\nGerman law system requires this consent
\nsince 1887 for medical interventions and
\nsince 1900 for participation in research.
\nIn the past decades, particularly since the
\nend of the Second World War, protection
\nof human rights and fundamental freedoms
\nis mainly a responsibility of the States and
\nit has been accepted and laid down in sev-
\neral International Conventions. In line with
\nthese internationally based provisions the
\nStates are asked to regulate the respective
\nfields concerning these rights by the instru-
\nments under their supervision and respon-
\nsibility. Soft law has no sufficient protective
\nforce in these fields. Law is a necessary in-
\nstrument for the harmonization of interests,
\neven contradictory ones, of different groups
\nof society. No group should be entitled to
\nimpose its specific positions, even with the
\nbest intention, on other groups. Legal in-
\nstruments, usually a result of compromise,
\nare binding for all groups concerned. They
\ngive the frame for the application of soft
\nlaw, a frame which might be used, but never
\nbroken.
\nSystem of Protective
\nProvisions of the
\nCouncil of Europe
\nThe system of protective provisions of the
\nCouncil of Europe in the field of biomedi-
\ncal research is composed by legally binding
\ninstruments and other provisions (see Box)
\nProtective Provisions for Research
\nParticipants1
\n1 Presented at the Expert Conference on the Revision of the Declaration of Helsinki, 28 February \u2013 1 March 2013,Tokyo
\nElmar Doppelfeld
\nClinical Research
\n69
\nClinical Research
\nThese protective provisions address re-
\nsearchers of all disciplines and are not re-
\nstricted to one group, e.g. physicians. The
\nOviedo Convention [6] contains the basic
\nprinciples for the application of biology
\nand medicine on human beings covering
\nthe whole field of health. A specific chap-
\nter on biomedical research entails the basic
\nprinciples which apply, in the context with
\nother provisions of the Convention, for the
\nprotection of research participants. These
\nprinciples became legally binding in the 29
\nMember States of the Council which rati-
\nfied this treaty. The Convention gives the
\nframework for the elaboration of a specific
\nprotocol concerning biomedical research
\n[7], in fact, a treaty that enters into legal
\nforce by ratification.
\nMoreover, the Committee of Ministers
\nadopted a recommendation for research
\nusing biological material of human origin
\n[8].This recommendation, even not a le-
\ngal instrument, influences the practice of
\nscientific use of those materials, as well as
\nare the first steps to regulate this field. The
\nrecommendation, currently under revision,
\noutlines important provisions for biobanks.
\nThe provisions need to be implemented in
\nactual protection of research participants.
\nDue to the important role of Research Eth-
\nics Committees (RECs) the Steering Com-
\nmittee adopted guidelines for Committee
\nmembers [9] that may help with capacity
\nbuilding.
\nFundamental Principles
\nof Protection
\nResearch involving human beings is carried
\nout for the potential benefit of the person
\nconcerned or for the benefit of others or to
\nenhance knowledge. The relation between
\nthe rights of the individual and the inter-
\nests of society must be clarified.The Oviedo
\nConvention (Article 2) states that the in-
\nterests and the welfare of the human being
\n\u201cshall prevail over the sole interest of society
\nor science\u201d. This provision underlines the
\nprimacy of the human being without mak-
\ning it an absolute priority. The word \u201csole\u201d
\nindicates that individual rights and interests
\nof society may be balanced to develop syn-
\nergy.
\nFreedom of research is a basic provision
\nalso for scientific projects in the field of
\nbiology and medicine. The Convention
\nsupports this freedom (Article 15), but
\nemphasizes clearly that this freedom is
\nsubject to the protective prescriptions of
\nthe Convention and of other legal provi-
\nsions ensuring the protection of the hu-
\nman being. This article clearly stipulates
\nthat research must not be carried out
\nwithout limitations.
\nIt is generally accepted that the quality of
\na scientific project is one of the main pro-
\nvisions to justify ethically the exposure
\nof human beings to research related risks.
\nArticle 8 of the Research Protocol provides
\nfor scientific justification, general criteria of
\nscientific quality and relevant professional
\nstandards. Moreover, supervision of an ap-
\npropriately qualified researcher is required.
\nThe Article is a rare example of legal defini-
\ntion of the quality of research.
\nRisk and Benefit
\nThe legal wording of this principle is as
\nfollows: \u201cNo risks and burdens to the par-
\nticipant disproportionate to its potential
\nbenefits\u201d \u2013 the well known postulate of a
\nproportion between risk and benefit. This
\nproportion is adapted to specific kinds of
\nresearch. In research without a potential
\ndirect benefit for the participant, e.g. re-
\nsearch on healthy volunteers, no more than
\nacceptable risk and acceptable burden is al-
\nlowed. It is the obligation of the competent
\nethic committee to assess the acceptance.
\nIn research with a potential direct benefit
\nfor the participant, e.g. patients suffering
\nfrom a specific disease for which a drug
\ntreatment is tested, risk and burden may
\nnot be disproportionate to the expected
\nbenefit
\nThe risk\/benefit relation plays a specific role
\nin research on persons not able to consent,
\ne.g. minors, victims of traffic accidents or
\npatients suffering from dementia.
\nIf research is carried out with the expec-
\ntation of a potential direct benefit for
\nthe participants, the above mentioned
\nproportion of risk, burden and benefit
\nmay take place. If such a potential direct
\nbenefit is not expected, research on per-
\nsons not able to consent may be carried
\nout in compliance with other provisions
\nonly if the project does not entail more
\nthan minimal risk and minimal burden.
\nIntroduced in 1997 by the Oviedo Con-
\nvention these limitations of \u201cminimal risk
\nand minimal burden\u201d (both must be met)
\nhave been later incorporated in national
\nor soft law. (Main sources: Articles 16,17,
\nOviedo Convention; Article 6, Research
\nProtocol)
\nFree and Informed Consent
\nFree and informed consent is the absolute
\nprecondition for participation in a research
\nproject. A valid consent can be given only
\nLegally binding instruments
\n\u2022 Convention for the Protection of
\nHuman Rights and Dignity of the
\nHuman Being with regard to the Ap-
\nplication of Biology and Medicine:
\nConvention on Human Rights and
\nBiomedicine (Oviedo Convention)
\n\u2022 Additional Protocol to the Conven-
\ntion on Human Rights and Bio-
\nmedicine concerning Biomedical
\nResearch
\nOther provisions
\n\u2022 Recommendation Rec(2006) 4 of the
\nCommittee of Ministers to member
\nstates on research on biological ma-
\nterials of human origin
\n\u2022 Guide for Members of Research
\nEthics Committees
\n70
\non the basis of full information on the
\nproject given to the invited participant in
\na wording understandable for him or her.
\nConsent may be given freely without any
\nundue influence or coercion. Consent may
\nbe refused or withdrawn in the course of
\nthe research project. No discrimination, in
\nparticular no withdrawal of healthcare, may
\noccur as a consequence of such a refusal or
\nwithdrawal. It is one of the main respon-
\nsibilities of ethics committees to supervise
\nthe conditions for free and informed con-
\nsent.
\nProtection of Persons
\nUndergoing Research
\nA precondition for involving persons in
\nmedical research is the lack of alternatives
\nof comparable effectiveness to research on
\nhumans. The risk\/benefit proportion has
\nbeen assessed as acceptable.The approval by
\na competent body has been given after an
\nindependent examination of the scientific
\nmerit, including assessment of the impor-
\ntance of the aim of the research, and after
\nmultidisciplinary review of the ethical ac-
\nceptability. The ethical review has to pre-
\ncede any approval of a competent body as
\nprovided by national law. In addition to the
\ninformation on the research project partici-
\npants shall be informed on their rights and
\nthe safeguards prescribed by law for their
\nprotection
\nFree and informed consent or, in case of
\nresearch on persons not able to consent,
\nauthorization by the legal representative
\nmust be given expressly and specifically;
\nand it must be documented. Consent and
\nauthorization may be refused or withdrawn
\nat any time. It is clear that \u201cspecific con-
\nsent\u201d only applies to specific research proj-
\nects. This provision is applied to research
\nusing human materials to \u201copen consent\u201d
\n(Recommendation [8]). Article 16 of the
\nOviedo Convention contains the protec-
\ntive provisions that recur in other relevant
\nprovisions.
\nResearch on Persons
\nUnable to Consent
\nResearch on persons unable to consent is a
\nworld wide ethical and legal problem, spe-
\ncifically in research without a potential di-
\nrect benefit for the person. The provisions
\nof the Council introduce a proposal for a
\nsolution, accepted in many States. Scientific
\nquality must be ensured, research on the
\nenvisaged group of persons has to be justi-
\nfied.Research which could be performed on
\npersons able to consent is excluded. If there
\nis an expected benefit for participants, the
\nrisk may be assessed in view of this benefit.
\nResearch without such a potential direct
\nbenefit may only be performed if protective
\nprovisions prescribed by law are applicable.
\nOnly minimal risk and minimal burden are
\nacceptable1
\n.
\nThe authorization by the legal representa-
\ntive according to national law is needed
\nto include into research persons unable to
\nconsent. The representative receives full
\ninformation on the research projects. The
\nrepresented person participates in the au-
\nthorization procedure proportionally to his\/
\nher maturity and understanding.Any objec-
\ntion has to be respected.The best interest of
\nthe represented person is the decision line.
\nRefusal or withdrawal of the authorisation
\nis possible at any time without any form
\nof discrimination against the represented
\n1 Minimal risk and minimal burden are rather new
\nterms. Thereis a legal definiton in Article 17 of
\nthe Research Protocol.:\u201dArticle 17 \u2013 Research
\nwith minimal risk and minimal burden
\n\u2022 For the purposes of this Protocol it is deemed
\nthat the research bears a minimal risk if, hav-
\ning regard to the nature and scale of the inter-
\nvention, it is to be expected that it will result,
\nat the most, in a very slight and temporary
\nnegative impact on the health of the person
\nconcerned.
\n\u2022 It is deemed that it bears a minimal burden if
\nit is to be expected that the discomfort will be,
\nat the most, temporary and very slight for the
\nperson concerned. In assessing the burden for
\nan individual,a person enjoying the special con-
\nfidence of the person concerned shall assess the
\nburden where appropriate.\u201d
\nperson. The legal representative should not
\nhave any financial or other interest. (Sourc-
\nes: Article 17, Oviedo Convention; Chap-
\nter\u00a0V, Research Protocol).
\nResearch in Specific Situations
\nThe provisions of the Council of Europe
\nare extended to research fields that are not
\ncovered by other texts, at least not in detail.
\na) Research during pregnancy or breast-
\nfeeding
\nResearch without a potential direct benefit
\nfor the pregnant woman, or for her embryo,
\nfoetus or child after birth, are only admit-
\nted if there is expected a contribution to the
\nbenefit of that group and if comparable re-
\nsearch cannot be carried out on women who
\nare not pregnant.Minimal risk and minimal
\nburden are the absolute limitations.
\nb) Research on persons deprived of liberty
\nFor safeguarding human rights in research
\non this group protective provisions by law
\nare required. Research without a poten-
\ntial direct benefit may be only carried out
\nif comparable research on persons not de-
\nprived of liberty is not possible and if a
\ncontribution to the benefit of that group is
\nexpected. Again minimal risk and minimal
\nburden are the limiting conditions.
\nFor research with a potential direct benefit
\non pregnant women and on persons de-
\nprived of liberty the relevant provisions of
\nthe legal instruments apply.
\nc) Research in clinical emergency situations
\nAgain for safeguarding human rights in this
\nvery specific field of research, which is un-
\ntil now rarely regulated, the permission and
\nthe determination of protective additional
\nconditions by law are required.These provi-
\nsions should define research in emergency
\nas a situation when a person is not in a state
\nClinical Research
\n71
\nto give consent, and when because of the
\nurgency of the situation, it is impossible to
\nobtain in a sufficiently timely manner the
\nauthorisation from the legal representative
\nor an authority or a person or a body to be
\ncalled upon to give authorization and when
\nresearch of comparable effectiveness cannot
\nbe carried out on persons in non-emergency
\nsituations.
\nMoreover, specific provisions are compul-
\nsory. The project has been approved as \u201cre-
\nsearch in emergency situations\u201dby the com-
\npetent body. This approval may be given in
\nline with the relevant articles of the research
\nprotocol, e.g. only after assessment of the
\nscientific quality and after ethical review.
\nExpressed objections, if known, shall be re-
\nspected. For research with a potential direct
\nbenefit the risk\/benefit assessment takes
\nplace. A research project without a potential
\ndirect benefit for the participant is limited
\nby minimal risk and minimal burden. In-
\nformation to the person involved or to the
\nlegal representative is given as soon as it is
\npossible to ask for consent or authorization
\nfor continued participation. This procedure
\nis considered as postponed consent\/autho-
\nrization and not as a waiver of consent\/au-
\nthorization. (Source: Chapter VI, Research
\nProtocol).
\nResponsibility of Ethics
\nCommittees
\nThe world wide accepted principle of inde-
\npendent examination of research projects
\nby Research Ethics Committees (REC) is
\ncodified. Every research project should be
\nsubmitted for independent examination
\nof its ethical acceptability to a REC. In
\ntransnational projects this examination is
\nrequired in each State in which the project
\nor parts of it are performed. Depending on
\nnational law the scope of the examination
\nmay be restricted to ethical acceptability
\nor extended including the scientific quality
\nand conformity with law. The protection of
\ndignity, rights, safety and well-being of re-
\nsearch participants are listed as purpose of
\nthe examination.The composition of RECs
\nis mostly regulated by national law. How-
\never, the appropriate range of expertise and
\nexperience adequately reflecting profession-
\nal and lay views are the basic principles.The
\nindependence of the REC must be guaran-
\nteed. The harmonization of information for
\nRECs plays a major role in enabling these
\ncommittees to decide on a similar basis.The
\nitems for this information are listed in the
\nAppendix to the Research Protocol. And
\nas already stated above: any approval of a
\nresearch project by an authority, if required
\nby national law, is appropriate only after the
\nexamination by a REC! (Sources: Article
\n16, Oviedo Convention; Chapter III, Re-
\nsearch Protocol).
\nSafety, Supervision
\nand Duty of Care
\nIn research risk and burden should be mi-
\nnimised in proportion to the scientific aims.
\nMinimisation may not be confused with
\nminimal risk and minimal burden men-
\ntioned above, which are absolute limita-
\ntions. A qualified clinical professional shall
\nbe in supervision. The assessment of health
\nstatus prior to inclusion in research with
\nparticular considerations on participants in
\nthe reproductive stage of life may be done
\non the basis of patients\u2019 files or by a spe-
\ncific assessment. Necessary preventive, di-
\nagnostic or therapeutic procedures may not
\nbe delayed or abandoned in favour of the
\nresearch project. Control groups shall be
\nassured of proven methods of prevention,
\ndiagnosis or treatment. The use of placebo
\nis accepted when no methods of proven
\neffectiveness are known or if withdrawal
\nor withholding of such methods does not
\npresent an unacceptable risk or burden.
\nA re-examination of a project is justified
\nin the light of scientific developments or
\nevents arising in the course of the research.
\nA decision to discontinue or to change the
\nresearch project may be the result of this
\nre-examination. In line with this procedure
\nit may be necessary to inform the research
\nparticipants or their representatives of the
\ndevelopments or events.An additional con-
\nsent or authorisation for participation can
\nbe proven as appropriate. The information
\nof the competent body of the reasons for
\nany premature termination of a research
\nproject serves as a help to prevent similar
\nprojects if appropriate. (Source: Chapter
\nVII, Research Protocol).
\nIf results of the research can be of rel-
\nevance to the current or future health or
\nquality of life of research participants, this
\ninformation must be offered to them.\u201cThat
\nshall be done within a framework of health
\ncare or counselling. In communication of
\nsuch information, due care must be taken
\nin order to protect confidentiality and to
\nrespect any wish of a participant not to
\nreceive such information\u201d. (Article 27, Re-
\nsearch Protocol).
\nConfidentiality and
\nRight to Information
\nData collected during biomedical research
\nshould be protected as confidential data.
\nLegal provisions to prohibit inappropriate
\ndisclosure of information submitted to an
\nEthics Committee should be introduced to
\nprevent any misuse of this information.
\nThe right to information for research par-
\nticipants is often questioned by researchers
\nand physicians in view of \u201cthe best for the
\nperson concerned\u201d. However, the provisions
\nof the Council of Europe underline the
\nright to know any information on health
\ncollected in the research project and the
\nright not to know (Article 10, Oviedo Con-
\nvention).This states clearly that researchers,
\nincluding physicians, are obliged to inform
\nthe person concerned and to respect any
\nwish not to be informed. The right not to
\nknow may only be suspended by law. Per-
\nsonal information outside the health field
\nmay be given in conformity with the na-
\ntional law on data protection.
\nClinical Research
\n72
\nPrimary Care TANZANIA
\nBackground: The worldwide prevalence of
\nhypertension in established market economy
\ncountries was estimated to be 37.4% for males
\nand 37.2% for females. The prevalence of hy-
\npertension in Tanzania ranged between 30
\nand 57% (<20% aware of their hypertension,\n<10% compliant). The purpose of our study is\nto identify the frequency of hypertension in our\nsample population, looking at gender differ-\nences, rate of previous diagnosis, compliance to\nmedication in relation to socio-economic sta-\ntus, and diet.\nMethods: A cross-sectional population based\nsurvey to calculate the frequency of hyperten-\nsion in a primary care clinic.\nResults: Satisfactory data was available on\n198 patients (98.0%), 160 (85.0%) were fe-\nmales. The mean age of the population was\n37.8years. Frequency of patients suffering from\nhypertension was 44.9% (89 patients), confi-\ndence intervals 95% (CI 95%) 38.0\u201351.9%.\n19 patients (9.6%, CI 95% 3.8\u201315.4%) were\ndiagnosed with malignant hypertension. 62\npatients (69.7%, CI 95% 60.1\u201374.2%) were\nincidence cases while 27 patients (30.3%, CI\n95% 20.8\u201339.9%) were prevalence. Only\n6\u00a0persons (22.2%) were compliant to the pre-\nviously prescribed medication and only 2 of\nFrequency of Hypertension in a Primary Care\nSetting in Buza,Tanzania\nTo improve transparency of research a re-\nport or a summary should be submitted to\nthe Ethics Committee or to the competent\nbody after termination of the project. Con-\nclusions of the research should be avail-\nable to the participants within a reasonable\ntime on request. Unfortunately it was not\npossible to introduce a stringent provision\nconcerning publication of the results. As a\ncompromise appropriate measures of the\nresearcher to make public the results of the\nresearch in a reasonable time has been ac-\ncepted (Source: Chapter VIII, Research\nProtocol).\nThe protective provisions of the Council of\nEurope seem to be very detailed. However,\nit was aimed at addressing all the ethical\nand legal problems known at the moment\nof their adoption.The provisions enter more\nand more into legal force binding all re-\nsearchers, including physicians.They are the\nlegal framework to follow soft law which, as\nsuch,does not permit to neglect any of these\nprovisions.\nReferences\n1. Convention for the Protection of Human Rights\nand Fundamental Freedoms of 4 November\n1950, Council of Europe, CETS N: 005\n2. DIRECTIVE 2011\/20\/EC OF THE EU-\nROPEAN PARLIAMENT AND OF THE\nCOUNCIL of 4 April 2001on the approxima-\ntion of the laws, regulations and administrative\nprovisions of the Member States relating to the\nimplementation of good clinical practice in the\nconduct of clinical trials on medicinal products\nfor human use, Official Journal of the European\nCommunities, 1.5.2001, L 121\/34\n3. DECLARATION OF HELSINKI Ethical\nPrinciples for Medical Research Involving Hu-\nman Subjects, 2008, wma@wma.net\n4. Council for International Organizations of\nMedical Sciences (CIOMS), International Eth-\nical Guidelines for Biomedical Research Involv-\ning Human Subjects, Geneva 2002\n5. Universal Declaration on Bioethics an Human\nRights, UNESCO, 2005\n6. Convention for the Protection of Human Rights\nand Dignity of the Human Being with regard\nto the Application of Biology and Medicine:\nConvention on Human Rights and Biomedi-\ncine, Oviedo, 4.IV.1997, European Treaty Serie,\nN. 164\n7. Additional Protocol to the Convention on Hu-\nman Rights and Biomedicine concerning Bio-\nmedical Research, Strasbourg, 25.I.2005, Coun-\ncil of Europe Treaty Serie, N. 195\n8. Recommendation Rec(2006)4 of the Commit-\ntee of Ministers to member states on research on\nbiological materials of human origin (Adopted\nby the Committee of Ministers on 15 March\n2006). Strasbourg, www.Health and Bioethics \u2013\nCouncil of Europe\n9. Guide for Members of Research Ethics Com-\nmittees (Adopted by the Steering Committee\non Bioethics on 3 December 2010), Strasbourg,\nwww.Health and Bioethics \u2013 Council of Eu-\nrope\nProf. Elmar Doppelfeld, MD\nChair of the Working Group\n\u201cBiomedical Research\u201d, Committee on\nBioethics (DH-BIO),Chair (2005\u20132007)\nof the \u201cSteering Committee\non Bioethics (CDBI)\u201d\nCouncil of Europe\nChair (1994\u20132012) of the Permanent\nWorking Party of Research Ethics\nCommittees in Germany\nE-mail: elmar-doppelfeld@t-online.de\nDaphne Gatt Nigel CamilleriSteven Micallef Eynaud\n73\nPrimary CareTANZANIA\nthese (7.4%) had their blood pressure controlled\n(blood pressure <140\/90\u00a0mmHg).\nConclusion: Prevalence of hypertension\n(44.9%) in the population was significantly\nhigher than that calculated for the market\neconomy countries (37.3%). However, it fell\nwithin the range of previous reported stud-\nies (30\u201357%). No significant differences were\nfound between males and females, though a\nstatistical link was found to lowest and highest\nsocio-economic states and diet.\nAwareness and management of hypertension is\na much needed public health service in Tanza-\nnia and one that is cheap, easy and would result\nin greatly improved quality of life.\nBackground\nHypertension (HT) is defined by the World\nHealth Organisation as a persistent raised\narterial blood pressure (BP) of over 140\/90\nmm Hg. HT is the main risk factor for con-\ngestive heart failure and is of great social\nand economic importance because of its\nhigh prevalence, mortality and impact on\nyoung, economically active individuals [1].\nA systematic review calculated the preva-\nlence of HT in established market economy\ncountries to be 37.4% in males and 37.2%\nin females. The prevalence of HT varied\ngreatly around the world, with the lowest\nprevalence being in rural India (3.4% in\nmen and 6.8% in women) and the high-\nest prevalence in Poland (68.9% in men\nand 72.5% in women). Control of HT (BP\n<140\/90 mmHg while on antihypertensive\nmedication) varied from 5.4% in Korea to\n58% in Barbados [2].\nA study that focused on the prevalence of\nHT in the United States, Canada and 6\nEuropean countries found it to be 28% in\nthe North American countries and 44%\nin the European countries[3]. In a self re-\nported study carried out in the US, overall\ntwo-thirds of the population were aware\nof their diagnosis (69%) and a majority of\nthese (53% to 79%) were taking prescribed\nmedication [4]. Another study analysing\ncompliance rates in three Central European\ncountries reported 53.5% as compliant and\n46.5% as non-compliant [5].\nThe causes of heart failure in Africans re-\nmain largely non-ischemic. Hypertensive\nheart disease complications occur more\nfrequently in Africans than in Europeans\nand North Americans, and the majority\nof affected patients are younger. [6] It is a\ngrowing problem in African communities\nof low socio-economic demographics. [7]\nTanzania is an East African country with a\npopulation of 38,329,000, and an estimated\ngrowth rate of 2%. Population distribution\nis extremely uneven, varying from 1 person\nper sq km to 134 per sq km, with over 80%\nof the population being rural. GDP per\ncapita stands at $1,416. [8] Whilst infec-\ntious disease continues to pose a relentless\nthreat to life throughout impoverished re-\ngions on the continent, numerous studies\ncarried out in Africa have brought to light\nthe emerging problem of non-communi-\ncable disease, in particular cardiovascular\ndisease. [9]\nAnother study carried out in Tanzania re-\nported the prevalence of HT as 30% in men\nand 26.8% in women in Ilala (urban area),\nand 32% in men and 31.5% in women in\nShari (rural area). In both areas, just under\n20% of hypertensive subjects were aware of\ntheir diagnosis,approximately 10% reported\nreceiving treatment, and less than 1% had\na controlled BP. [10] A different study fo-\ncused on gender-related differences in car-\ndiovascular disease risk factors and their\ncorrelates in an urban area in Tanzania.\nThey reported a higher prevalence of HT\n(57%) and severe HT (30%) in the popu-\nlation. Women had more than three-fold\ngreater odds of having metabolic syndrome\ncompared to male counterparts. In contrast,\nfemale participants had 50% lower odds\nof having hypertension, compared to men.\n[11]\nA similar trend was noticed in other East\nAfrican countries. A study in Addis Ababa,\nEthiopia found the prevalence to be 31.5%\namong males and 28.9% among females.\n[12] A study in Nakuru, Kenya found the\noverall prevalence of HT to be 50.1%. [13]\nIn Mozambique, the prevalence of HT was\nfound to be 35.7% among men and 31.2%\namong women. Of those receiving anti-\nhypertensive treatment, only 42.9% of the\nwomen and 28.7% of the men were well\ncontrolled. [14]\nOther studies carried out on the African\ncontinent showed a varying prevalence of\nHT. Studies carried out in Algeria (North\nAfrica) showed that the prevalence of HT\nranged between 32.7% and 44%. Of those\ntreated, only 25% were well controlled. [15]\nIn South Africa, a study concluded that HT\nwas independently related to age, obesity\nand urbanization. Only 16% of those on\ntreatment were controlled. [16] In central\nGhana (West Africa), the overall preva-\nlence of HT was found to be 28.7% in men\nandwomen, and was higher in semi-urban\nvillages (32.9%) than in rural villages (24%).\n[17]\nThe location for our study was Buza, a slum\nin the outskirts of Dar es Salaam. This area\nis among those of the lowest socioeconomic\nstatus\u2019 (SES) in the region. The aim of this\nstudy was to identify the frequency of hy-\npertension in our sample population, look-\ning specifically at gender differences, the\nrate of previous diagnosis, compliance to\nmedication in relation to socio-economic\nstatus, and diet. To date we believe it is the\nfirst study of this kind to be done in the area.\nMethods\nStudy design:\nThe study design was a cross-sectional\npopulation based survey to calculate the\nfrequency of hypertension in a primary care\nmedical clinic.\n74\nThe setting was an urban suburb of an over-\nall low socio-economic area, named Buza,\nDar Es Salam,Tanzania.\nThe Inclusion criteria included any adult\n(n=202) of ages 18 and older, any gender\nor social class who attended this clinic for\nany medical reason or even for a basic medi-\ncal check\u2013up between the 19th\nJuly and 6th\naugust 2010. Thus the cohort of people in-\ncluded in our study ranged from being very\nunwell and requiring referralor admission to\nhospital, to those who had simply just heard\nof this new clinic were passing by and asked\nfor a medical review. This reduced any pos-\nsible selection and observation bias.\nExclusion criteria:\nAll patients under the age of 18 years were\nexcluded from our study for statistical pur-\nposes. This is not to say that those with a\nhigher risk of suffering from hypertension\nwho were under 18 years of age did not have\ntheir blood pressure checked.\nAnalysis:\nEvery person attending the clinic had their\nblood pressure assessed by one of the staff\nworking at reception. If the patient was\nfound to be hypertensive this would be re-\ncorded in the patient\u2019s case notes (repeated\ntwice or more), and then reviewed, treated\nand followed up by the doctors working in\nthe clinic.\nEvery patient attending the clinic had a full\nhistory taken by a doctor. Those previously\ndiagnosed with hypertension, were asked\nwhether they were prescribed and taking\nany anti-hypertensives or dietary precau-\ntions. Their blood pressure was monitored\non subsequent follow-ups and recorded.\nData Protection:\nAll patients reviewed at this clinic gave in-\nformed consent for their blood pressure to\nbe checked.Any person who refused to have\nthis parameter assessed was not negatively\nor positively affected by the treatment re-\nceived here. All data collected was anony-\nmous and confidential.\nStatistics:\nAll data collected were input into Microsoft\nExcel and analysed using SPSS. P values\nwere calculated using Fisher\u2019s Exact test.\nConfidence intervals were calculated using\nstandard formulae for rates.Gender and age\nspecific direct standardisation of data was\ncarried out.\nResults:\nThe cohort consisted of 202 people. Satis-\nfactory data was available on 198 patients\n(98.0%),160 (85.0%) of whom were females\nand 38 (15%) were males.The mean age for\nthe population studied was 37.8years. The\nages ranged from 18 to 88 years.\nPrevalence:\nThe frequency of patients in our population\nsuffering from hypertension (blood pres-\nsure\u00a0 = or >140\/or 90 mmHg) was 44.9%
\n(89 patients), confidence intervals 95% (CI
\n95%) 38.0\u201351.9%. Of these 20 (52.6% of
\nthe male cohort) CI 95% 36.8\u201368.5% were
\nmales and 69 (43.1%, CI 95% 35.5\u201350.8)
\npersons of our cohort were females. There
\nwas no statistical significance between the
\ntwo gender groups (P=0.365).
\n19 (9.6%, CI 95% 3.8\u201315.4%) patients were
\ndiagnosed with malignant hypertension,
\n25 (12.6%, CI 95% 6.1\u201319.1%) patients
\nsuffered from stage 2 hypertension (BP
\n>160\/>100mm) and 31 (15.7%, CI 95%
\n8.6\u201322.8%) of these patients were diag-
\nnosed with stage 1 HT (BP >140\u2013159\/90\u2013
\n99). For more details, see table: 1
\n62 patients (69.7%, CI 95% 60.1\u201374.2%)
\nwere incidence cases as they received the
\ndiagnosis of hypertension for the first time
\nin their lives.
\n27 patients (30.3%, CI 95% 20.8\u201339.9%)
\nfrom the cohort had previously received a
\ndiagnosis for hypertension. Of these pa-
\ntients, only 6 (22.2%) were compliant to
\nthe prescribed medication and, following
\na blood pressure examination in this clinic,
\nit was noticed that only two persons (7.4%)
\nhad their blood pressure controlled. (mean-
\ning blood pressure <140\/90\u00a0mmHg).\nOutcome of patients receiving treatment in the\nBuza clinic:\nOf the 89 patients diagnosed with hyper-\ntension, 83 (93.3%) patients received some\nform of treatment. 20 (22.1%) patients re-\nceived advice on how to live a healthy life-\nstyle.This included diet and exercise.\n63 (87.9%) patients who attended the clinic\nwere treated for hypertension with medica-\ntion. Of these, 22 (34.9%) patients did not\nTable 1. Sample population of varying grades of severity of hypertension\nn= Percentage %\nBlood pressure within normal range 68 34.3 (Cl 95% 25.1\u201343.7)\nPre-hypertensive 120\u2013139\/80\u201389 43 21.7 (Cl 95% 16.6\u201329.3)\nStage 1 hypertension 140\u2013159 of >90\u201399 31 15.7 (Cl 95% 8.6\u201322.8)
\nStage 1 hypertension >160 or >100 25 12.6 (Cl 95% 6.1\u201319.1)
\nMalignant hypertension >180\/110 19 9.6 (Cl 95% 3.8\u201315.4)
\nBlood pressure >130\/80 and suffering from DM, Kid-
\nney disease or CVS disease
\n6 3.0 (Cl 95% 0.6\u20136.3)
\nIsolated hypertension >140 but <90 6 3.0 (Cl 95% 0.6\u20136.3)\nTotal 198 100\nPrimary Care TANZANIA\n75\nturn up for their follow up appointment so\nwere never reviewed at the clinic again.\nOf those who did turn up for their follow up\nreviews,26 (41.3%) were found to have con-\ntrolled blood pressure. Another 10 (15.9%)\npatients who attended the clinic attained\npartial control of their hypertension, whilst\n3 (4.8%) other patients who had some im-\nprovement in their blood pressure recorded\nand were still referred on to a specialist, for\nfurther advice. Only 2 (3.2%) patients had\nno improvement in blood pressure recorded\nby the end of the study period and these too\nwere referred for specialist advice.\nAge:\nWhen looking at the changes in frequency\nof hypertension with age, statistical signifi-\ncance P<0.001 is found in females. From\nthe results one notices a stark increase in\nfrequency of hypertension from the 35\u201344\nyear age group (33.3%) to the 45\u201354 year\nage group (65.5%) and keeps increasing\ngradually after that.\nThis sudden change in not observed within\nthe male cohort of the study (P0.149), in-\nstead a constant but gradual increase with\nage is noticed. In this cohort the males over\n75 years (n=2) were all hypertensive. Then\nagain one must take into account the small\nsample size for men.\nSocio-economic status:\nThis study looked further into whether there\nwas a significant link between socio eco-\nnomic status and hypertension. Though the\nP value for a difference in socio-economic\nstatus and hypertension was not statistically\nsignificant (P=0.156), the difference in fre-\nquency for those placed in social class one\n[hypertensive: 6 (35.3%), non-hypertensive:\n11 (64.7%)] and five [(Hypertensive: 5\n(33.3%) non-hypertensive: 10 (66.7%)] was\nremarkable.The difference seen in the other\nsocial classes is not as remarkable, further\ndetails may be found in table 3.\nNon medical\ntreatment of\nhypertension,\n22.0%\nBlood pressure\ncontrolled by\nmedication, 43.0%\nPartial control of\nblood pressure,\n15.9%\nPartial control\nof BP, referred to\nspecialist, 4.3%\nNo improvement in\nBP, referred to\nspecialist, 3.2%\nLost to follow up,\n28.0%\nFigure 1. Outcome of patients who received treatment in clinic\nTable 2. BP = N (BP within normal range), HT (hypertensive) Hypertension by gender and age\nAge\nTotal\n<25 25\u201334 35\u201344 45\u201354 55\u201364 64\u201374 75+\nMales\nBP = N 3 6 1 3 3 2 0 18\n60.0% 85.7% 50.0% 60.0% 37.5% 22.2% 0% 47.4%\nHT 2 1 1 2 5 7 2 20\n40.0% 14.3% 50.0% 40.0% 62.5% 77.8% 100.0% 52.6%\nTotal 5 7 2 5 8 9 2 38\n100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%\nFemales\nBP = N 12 34 24 10 5 4 2 91\n85.7% 75.6% 66.7% 34.5% 31.3% 30.8% 28.6% 56.9%\nHT 2 11 12 19 11 9 5 69\n14.3% 24.4% 33.3% 65.5% 68.8% 69.2% 71.4% 43.1%\nTotal 14 45 36 29 16 13 7 160\n100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%\nTable 3. BP = N (BP within normal range), HT (Hypertensive) Hypertension according to\nsocio-economic status\nSocio economic status\nTotal\n1 (very poor) 2 (poor) 3 (avarage) 4 (above avarage) 5 (rich)\nBP = N 6 68 22 8 5 109\n35.3% 58.6% 61.1% 57.1% 33.3% 55.1%\nHT 11 48 14 6 10 89\n64.7% 41.4% 38.9% 42.9% 66.7% 44.9%\nPrimary CareTANZANIA\n76\nDiscussion\nThe prevalence of HT (44.9%) in the popu-\nlation from Buza included in this study was\nsignificantly higher than that calculated\nfor the market economy countries (37.3%)\n[2]. However, the prevalence of HT in our\ntarget population was found to be within\nthe range of previous reported studies (30\u2013\n57%) carried out in Tanzania, [10], [11].\nOnce again similar results are reported in\nother East African countries (28% to 50%)\n[8], [11], [13] and to other African coun-\ntries (28.7% to 44%) [6], [7], [9]. One rea-\nson for such differences could be explained\nby some studies reporting examined results\nwhereas others use patient reported BP re-\nsults.\nThere is no real statistical significance be-\ntween males and females. Statistical signifi-\ncance was found when using age standard-\nization for females (P<0.001). It was also\nobserved that between the 35\u201344 and 45\u2013\n54 year age group the prevalence in women\ndoubled from 33% to 66%. One can hy-\npothesise that most probably almost 100%\nof the women in menopause were suffering\nfrom HT. This is further substantiated by\nthe increase in frequency of HT with age.\nIn males this was not statistically significant\n(P=0.149) though this could be due to the\nsmall male sample. As found in other stud-\nies carried out around the world, therate of\nHT in males increases proportionally with\nage. [18]\nThe results in our study highlight another\nrisk factor associated with HT\u00a0 \u2013 low so-\ncioeconomic status (SES). [19] However,\nresults from our study have taken this asso-\nciation a step further and reported another\npeak in HT with the high SES group. In\nBuza being of higher SES means having a\nstaple diet of things such as fried chicken\nand chips, thus bringing to light the prob-\nable association of HT to diet.This was also\nfound in other studies. [20]\nLess than a third of our patients were aware\nthat they were suffering from high blood\npressure, as found in a parallel study (20%)\ncarried out in other cities in Tanzania. [10]\nThis is markedly lower than awareness re-\nported by studies carried out in the US\n(69%) and Europe (53%) [4],[5].This high-\nlights another important fact that awareness\nand availability of clinics to manage HT\nmay help increase compliance. Another im-\nportant finding in our study highlights the\nfact that over 9% of the target population\nhad malignant hypertension,a life threaten-\ning condition which people were living with\nundiagnosed and, thus, untreated.\nThe compliance rate in our study was found\nto be slightly higher (22.2%) to that carried\nout in another study in Africa (10%) [10].\nWe believe that this may simply be due to\nsmaller sample size (n=198) than the other\nstudy (n=1600).\nAnother important finding consistent with\nprevious studies is that less than 8% of the\ncohort in Buza had their HT treated ad-\nequately (BP <140\/90) [14], [15], [16]. The\nresults of this study show that a clinic open\nfor only 3 weeks was able to get the BP of\n41.4% within normal range and improve\nthe BP for 16% of patients, meaning that\nsuch a life threatening disease can be eas-\nily and cheaply managed by increasing the\navailability of such clinics.\nStrengths and limitations\nof the study\nThe results from our study report only ex-\namined BP as opposed to self-reported,\nthus reducing a recall bias. The population\nsample in this study did not only include\npatients who were ill but also those who at-\ntended the clinic for a check up, thus reduc-\ning a selection bias. All patients had their\nBP checked at least twice, and most were\nreviewed for follow up more than once.\nLimitations of this study include a relatively\nsmall sample size, thus representativeness\nof the target population is questioned and\npatients were only followed up for a short\nwhile, so a longer longitudinal study is rec-\nommended.\nConclusion\nThe prevalence of HT is expected to rise\nsubstantially in sub-Saharan Africa, so the\nauthors call for population-based studies\nand registries of the epidemiology of HT\nPoland, 2005\nIndia, 2005\nMozambique, 2009\nNakuru, Kenya, 2010\nAddis Ababa, Ethiopia, 2009\nShara, Tanzania, 2000\nIliala, Tanzania, 2000\nBuza, Tanzania, 2010\nMarket economy countries, 2005\n0 604020 80\nMales %\nFemales %\nFigure 2. International prevalence of hypertension\nPrimary Care TANZANIA\n77\nin the African population. The provision\nof awareness campaigns and more clinics\navailable for assessment and management\nof HT in the health services in Tanzania is\nstrongly recommended. As reported in this\nstudy this cheap provision of service yield\nquick positive results, thus improving the\noverall quality of life of the people living in\nTanzania.\nOther studies carried out worldwide found\nthat more than half of respondents took\naction following the receipt of advice. [17]\nThus the authors believe that this simple\nmeasure will have a highly positive effect on\nthe people living in this country.\nConflict of Interest:\nThe authors declare they have no conflict of\ninterest and this data has not been submit-\nted for publication anywhere else.\nAuthors contribution:\nAll authors have contributed equally to the\nwork in this study and agree with the publi-\ncation of this document.\nDr. Daphne Gatt: contributed to the litera-\nture search, writing up of the background\nand managed the overall work of the manu-\nscript.\nDr. Steve ME: contributed to the literature\nsearch, writing up of discussion and refer-\nences.\nDr. Nigel Camilleri: Came up with the re-\nsearch question, was involved in the writing\nup of the methodology and results and su-\npervised the work.\nAcknowledgements\nWe would like to thank Dr. Neville Calleja\nfor his constant support and advice provid-\ning a public health perspective to the study\nand with carrying out the statistics needed\nfor this study.\nReferences\n1. Chockalingam AA, Norman RC, Fodor JG.\nWorldwide epidemic of hypertension.Can Jour\nCardiol. 2006 May; 22(7): 553\u2013555.\n2. earney PM, Whelton M, Reynolds K, et al.\nWorldwide prevalence of hypertension: a sys-\ntematic review. J Hypertens. 2004 Jan;22(1):21-4.\n3. Wolf-Maier K, Cooper RS, Banegas JR, et\nal. Hypertension prevalence and blood pres-\nsure levels in 6 European countries, Canada,\nand the United States. JAMA. 2003 May\n14;289(18):2420-2.\n4. Valderrama AL, Tong X, Ayala C, Keenan NL.\net al. Prevalence of self-reported hypertension,\nadvice received from health care profession-\nals, and actions taken to reduce blood pressure\namong US adults, HealthStyles, 2008. J ClinHy-\npertens (Greenwich). 2010 Oct;12(10):784-92.\n5. George J. Fodora, Marian Kotreca, KingaBac-\nskaia, et al Is interview a reliable method to ver-\nify the compliance with antihypertensive ther-\napy? An international central-European study.\nJournal of Hypertension 2005, 23:1261\u20131266.\n6. Gombet T, Steichen O, Plouin PF. Hypertensive\ndisease in subjects born in sub-Saharan Africa\nor in Europe referred to a hypertension unit: a\ncross-sectional study. Bull AcadNatl Med. 2007\nNov;191(8):1745-54.\n7. Bunker CH, Okoro FI, Markovic N, et al. Rela-\ntionship of hypertension to socioeconomic sta-\ntus in a west African population. Ethn Health.\n1996 Mar;1(1):33-45.\n8. The Tanzania Demographic and Health Survey\n(TDHS) 2004-05. June 2005.\n9. Unwin N, Agyemang C, Allotey P, et al. Tack-\nling Africa\u2019s chronic disease burden: from the lo-\ncal to the global. Global Health. 2010 Apr 19;6:5.\n10. Edwards R, Unwin N, Mugusi F, et al. Hy-\npertension prevalence and care in an urban\nand rural area of Tanzania. J Hypertens. 2000\nFeb;18(2):145-52.\n11. Njelekela MA, Mpembeni R, Muhihi A, et\nal.Gender-related differences in the prevalence\nof cardiovascular disease risk factors and their\ncorrelates in urban Tanzania. BMC Cardiovasc\nDisord. 2009 Jul 17;9:30\n12. Tesfaye F, Byass P, Wall S. Population based\nprevalence of high blood pressure among adults\nin Addis Ababa: uncovering a silent epidemic.\nBMC CardiovascDisord. 2009 Aug 23;9:39.\n13. Mathenge W, Foster A, Kuper H. Urbanization,\nethnicity and cardiovascular risk in a population\nin transition in Nakuru, Kenya: a population-\nbased survey. BMC Public Health. 2010 Sep\n22;10:569.\n14. Damasceno A, Azevedo A, Silva-Matos C, et\nal. Hypertension Prevalence, Awareness, Treat-\nment, and Control in Mozambique. Urban\/\nRural Gap During Epidemiological Transition.\nHypertension. 2009;54:77.\n15. Temmar M, Labat C, Benkhedda S, et al.\nPrevalence and determinants of hyperten-\nsion in the Algerian Sahara. J Hypertens. 2007\nNov;25(11):2218-26.\n16. Steyn K, Fourie J, Lombard C, Katzenellenbo-\ngen J, et al. Hypertension in the black commu-\nnity of the Cape Peninsula, South Africa. East\nAfr Med J. 1996 Nov;73(11):758-63.\n17. Francesco PC, Frank B, Sally LE, et al. Preva-\nlence, Detection, Management, and Control of\nHypertension in Ashanti, West Africa. Hyper-\ntension.2004;43:1017.\n18. Joan H. Skurnick, MordechayAladjem, Abra-\nham Aviv. Sex Differences in Pulse Pressure\nTrends with Age Are Cross-Cultural. Hyperten-\nsion. 2010;55:40-47\n19. Grotto I, Huerta M, Sharabi Y. Hypertension\nand socioeconomic status.CurrOpinCardiol.\n2008 Jul;23(4):335-9.\n20. John P. Forman, Meir J. Stampfer, Gary C.\nCurhan. Diet and lifestyle risk factors associated\nwith incident hypertension in women.JAMA.\n2009 July 22; 302(4): 401\u2013411.\nSteven Micallef Eynaud,\nMater Dei Hospital\nTal-Qroqq, Msida, Malta\nNigel Camilleri\nUON, University of Newcastle\nCorresponding author:\nDr. Daphne Gatt MD\nMater Dei Hospital\nTal-Qroqq, Msida, Malta\n32, Triq il-Konventwali\nQawra SPB1133\nMalta, Europe\nE-mail: daphnegatt@gmail.com\nPrimary CareTANZANIA\n78\nEnvironment and Health\nEuropean coal-fired power plants are caus-\ning 18,200 premature deaths and serious\nillnesses that cost the population up to \u20ac43\nbillion each year, say health experts in a new\nreport entitled The Unpaid Health Bill\u2014\nHow coal power plants make us sick.\nThe Health and Environment Alliance\n(HEAL) also expresses concerns that dirty\nemissions from coal are contributing to cli-\nmate change, which itself will create more\ncostly public health problems-especially\namongst the most vulnerable groups-the\nyoung and elderly. Despite this double\nthreat, the use of coal as an energy source is\nnow on the rise in Europe.\nCoal use is projected to rise worldwide\nthroughout 2013 which is, ironically, the\nEU\u2019s designated Year of Air. Health experts\nat HEAL are now urging governments to\nput a stop to building new coal plants in\nEurope and abandon coal altogether by\n2040. If the share of coal in power gen-\neration is not brought down over the next\ndecades, Europe will put in jeopardy its cli-\nmate target for 2050.\nIn October 2011, over 500 health and secu-\nrity experts, including medical associations,\nleading medical research institutes and pub-\nlic health organisations, called on govern-\nments to ban the building of new coal-fired\npower plants without Carbon Capture and\nStorage (CCS) technology,and to phase out\nthe operation of existing coal-fired plants,\nstarting with lignite plants due to their most\nharmful effects on health.\nLast year at the UN climate talks, medical\norganisations petitioned negotiators at the\ninternational climate talks in Doha, Qatar\n(http:\/\/dohadeclaration.weebly.com\/index.\nhtml) to recognise that worldwide millions\nof deaths each year have been linked to air\npollution that occurs as a result of burning\ncoal. The World Medical Association was\namong the top medical group signatories to\nthe so-called Doha Declaration on Climate,\nHealth and Wellbeing. Dr. Cecil Wilson,\nPresident of the WMA, said he was ex-\ntremely worried about the slow progress in\ninternational negotiations and called on the\nworld\u2019s leaders to recognise the impact on\nhealth from climate change.\nAs the \u201cfirst ever economic assessment of\nthe health costs associated with air pollu-\ntion from coal power plants in Europe\u201d, this\nreport highlights evidence on how exposure\nto air pollutants affects the lungs, heart and\nnervous system. Effects include chronic\nrespiratory diseases, such as chronic bron-\nchitis, emphysema and lung cancer; and\ncardiovascular diseases, such as myocardial\ninfarctions, congestive heart failure, isch-\nemic heart disease and heart arrhythmias.\nAcute effects include respiratory symptoms,\nsuch as chest tightness and coughing, as\nwell as exacerbated asthma attacks.\nChildren, older people and patients with an\nunderlying condition are more susceptible to\nthese effects. Children are particularly sus-\nceptible to air pollutants,in part because they\nbreathe more air in relation to their body\nweight and spend more time outside,but also\ndue to the immaturity of their immune and\nenzyme systems and their still-developing\nairways. In addition, coal power plants are\nthe largest source for mercury emissions in\nEurope, a heavy metal that is well known to\naffect brain development in children. A re-\ncent study put the price tag of this mercury\nexposure at about \u20ac9 billion per year.\nThe report draws on the work of medi-\ncal and health groups in the US, Australia\nand elsewhere around the world.The inten-\ntion is that the report will stimulate further\nengagement of doctors and other health\ngroups around the issue of coal and health,\nespecially in countries where coal burning\nis a major contributor to poor air quality. In\ncoming months, the Standing Committee\nof European Doctors (CPME), which has\n27 members representing medical doctors\nin EU countries,will be raising awareness of\nthe risks of coal burning as part of its work\nunderlining the importance of cleaner air.\nMedical professionals are powerful advo-\ncates for better policy to protect health.\nMedical doctor and German Member of\nthe European Parliament, Peter Liese has\nalready indicated his support for the report.\nHe says he recognises coal as both an im-\nmediate and a long-term threat to public\nhealth because of its contribution to climate\nchange.\nHEAL will be running a Health and\nCoal educational and advocacy campaign\nthroughout Europe, with national launches\nplanned in Germany and Poland in close\ncollaboration with medical experts, asthma\ngroups and local experts. Expertise and tes-\ntimonies from doctors and others in the\nhealth community are key to our success,\nand we invite you to join the collective ef-\nforts to prevent chronic disease and suffer-\ning from coal power pollution.\nThis article is adapted from one which\nappeared on the blog of the Collabora-\ntive on Health and Environment (CHE)\nhttp:\/\/ourhealthandenvironment.wordpress.\ncom\/2013\/03\/07\/778\/\nHEAL\u2019s vision is a healthy planet for\nhealthier people in Europe and beyond. We\nshow how environmental action can bring\ndown rates of asthma,obesity,diabetes,can-\ncer and infertility working closely with our\nmembers in more than 26 countries.\nG\u00e9non Jensen\nExecutive Director, Health and\nEnvironment Alliance (HEAL) ,\nCoordinator of CHE\u2019s Climate Change\nand Health Working Group.\nRevealed: Coal\u2019s Unpaid Health\u00a0Bill\n79\nRegional and NMA news\nThe Human Factors in Crisis and Disas-\nters Thematic Conference to be held in\nMelbourne, Australia from 30 September\nto 2 October 2013 will focus on issues of\ngreat relevance to us all.\nDisasters and crises impact globally and lo-\ncally, affecting diverse human populations,\nand the resources that sustain them. Disas-\nters by their very nature may overwhelm\ncommunities and their capacity to respond,\nwith mass death and damage, as we have\nseen across the world with tsunamis, earth-\nquakes, hurricanes and cyclones, floods and\nfamine, fire and pollution as after the vol-\ncanic eruption. The mass natural disasters\nof recent times have also lead to population\ndisplacement, huge economic loss and bur-\nden. Disasters of disease, such as pandem-\nics of influenza and virulent infections are\nalso a challenge and threat, requiring global\ncollaborations. Disasters that are human\ncaused, particularly those of violence, lead\nto profound human damage \u2013 not only by\ndeath, fear and threat, but also in the ongo-\ning vulnerabilities and further violence that\nmay be generated.\nThis conference will present global themes\nand the human factors and resources that\nare challenges worldwide. Dr. Judy Kurian-\nsky will present on these themes from the\nglobal perspective looking at the United\nNations and the multiple global agencies\nthat work together to mitigate disasters and\ntheir impact; for instance the collaboration\nfollowing the Japanese earthquake, tsunami\nand nuclear incident; and the Haiti hurri-\ncane.\nVulnerable groups require specific focus\nand particularly children, as she will dis-\ncuss, as will others, including Professor\nBrett McDermott and also those dealing\nwith children who are war affected refugees,\ndisplaced and dislocated from family and\nhome. Threats and disasters, including nu-\nclear accidents such as Chernobyl, hazards\nof Fukushima, collective trauma and the\ndiverse crisis they bring; as do disaster trau-\nmas and mental health consequences; are all\nconsidered. Institutional aid and collabora-\ntions, through to the needs of the elderly,\ndisabled and vulnerable, all come into these\nchallenging fields.There is the need for rec-\nognition of practical needs such as clean\nwater, food, shelter and support for human\nengagement, families and communities that\nhelp the healing processes.\nDealing with the threat and consequence of\nmass violence is a challenge in all societies,\nwhether they are \u2018home-grown\u2019 or associ-\nated with potential external attack, such as\nterrorism. Professor Lars Weisaeth, from\nNorway will lead this component of the\nconference, building on his diverse experi-\nence in Europe and beyond. He will dis-\ncuss the bombing and subsequent shooting\nof young people in Norway and its mental\nhealth and social implications then and into\nthe future. Others will present on the short\nand long term consequences of terrorism,\nespecially how this relates to mental health\nand social well-being. War and conflict also\nhave both short and long term consequenc-\nes particularly for those displaced from\nhome and community, from families and\nplace. Refugees, veterans and others face\nongoing threat, uncertainties and loss, with\nlittle support. As well as their resilience and\nsurvival strength they continue to have pro-\nfound vulnerabilities.\nEven in the face of human induced death,\nthe \u2018good\u2019 in people remains a powerful fac-\ntor that supports people and gives them the\ncourage and hope that helps people to go\nforward into the future.\nMany forms of care and support are needed\nin crises and disaster. Medical experts from\naround the world will make a major contri-\nbution at this meting, led by Dr. Mukesh\nHaikerwal, Chair of the Council of the\nWorld Medical Association and his col-\nleagues from USA, Japan and elsewhere,\nincluding Australia. How we all work to-\ngether to address the effect of disasters and\ncrisis,our health and mental health,requires\na recognition and linkage across disciplines\nand expertise. Systems of response facilitat-\ning such linkages are critical and require\nglobal policy and adaptation to national\nrequirements. Professor Chris Bagley, who\nleads Australian disaster health response\nwill present on Australian systems in the\nAll Hazard Framework of National Col-\nlaboration. His colleagues will also con-\ntribute, addressing the defence component\nof response, and health and mental health\nprograms to mitigate impact.\nIT systems and resources contribute in ma-\njor and rapidly developing ways, from pre-\nvention through to longer term recovery,\nfrom warning to psychological first aid and\nresilience. Glenn Wightwick will lead this\ncomponent with colleagues addressing the\nmultiple chances and opportunities that can\nassist in such crises and their consequences.\nFrom climate change to conflict, from tsu-\nnami to terrorism, from global epidemics\nto nuclear hazard, crises and disasters are\nrelevant to us all. They can bring death and\ndestruction, love and loss, courage and fear.\nLike so many aspects of life, we do best\nwhen we invest in the future, as well as look\nafter the present, and accept the past, as it\nhas been what we know and will use for the\nfuture preparation and planning, but learn-\ning while we do so. The human factors that\nflow throughout this important meeting\nrecognize the suffering that may occur, but\nfocuses on the courage, strength, resilience,\ncompassion, connectedness and care. The\nhealing and hope that will help us go for-\nward, to the future.\nProfessor Beverley Raphael\nProfessor of Psychiatry and Addiction\nMedicine, Australian National University\nand Professor of Population Mental Health\nand Disasters, University of Western Sydney\nMass Catastrophe: dealing with crises and\ndisasters now and in the future\n80\nThe New Zealand Medical Association is\nsaddened to learn of the death of Dr. Peter\nFoley, Chair of the NZMA for an historic\ntwo terms from 2007 until 2011.\nFollowing in his father\u2019s footsteps,Dr.\u00a0Foley\npractised as a GP in Napier for over 25\nyears, after graduating from Otago Univer-\nsity in 1981. He became president of the\nNZMA\u2019s Hawke\u2019s Bay division in 1999,was\nan inaugural member of the NZMA\u2019s Gen-\neral Practice Council (GPC) in 1998, and\nthen served two terms as Chair of the GPC\nbefore moving to chair the wider organisa-\ntion. He was also the initial Chair of the\nGeneral Practice Leaders Forum (GPLF).\nDr. Foley\u2019s particular contribution was\nin General Practice. He was at the fore-\nfront of the General Practice effort to seek\nmeaningful engagement with the Govern-\nment and its agencies during the debate\nover General Practice fees. The efforts of\nthe initial GPLF team, led by Dr. Foley,\nresulted in effect involvement for General\nPractice in the contracting process, and in\na successful outcome\u00a0\u2013 an achievement that\nwas recognised when he was awarded the\nNZMA\u2019s highest honour, the Chairman\u2019s\nAward, in 2006 and an NZMA Fellowship\nin 2011. Further recognition followed \u2013 last\nyear Dr.\u00a0 Foley received the Member NZ\nOrder of Merit for his services to health,\nwhich was presented in a special ceremony\nlast month by Governor-General Sir Jerry\nMateparae.\nAfter ending his term with the NZMA,\nDr. Foley continued his active role in the\nhealth sector with roles as Chief Medical\nOfficer for primary care in the Hawkes Bay\nand Deputy Chair for the Health Quality\nand Safety Commission. He also headed\nthe independent panel that reviewed health\nservices in Queenstown and the surround-\ning area.\n\u201cPete recognised that our health system\nrequires the profession\u2019s strong guidance\nand in striving to do this he researched\nthe issues, engaged in consultation and\nworked towards achieving consensus,\u201d says\nDr.\u00a0Ockelford. \u201cIn his time as GPC Chair\nand NZMA Chair, he cultivated strong re-\nlationships within the medical profession,\nthe Government and wider health sector.\nHe was always a loyal NZMA member, and\nheld a strong belief in the NZMA\u2019s ability\nto make a difference, and have significant\ninfluence. He consistently promoted the\nhallmarks of the NZMA \u2013 its pan-profes-\nsionalism, its ability to represent all sectors\nof the profession and its willingness to en-\ngage with all sectors within health.\nIn Memoriam\nIn Memoriam Dr. Peter Foley\nIt has been a joy to have known,worked and\nrelaxed with Pete over at least ten years.\nPete was well known, highly respected\naround and warmly welcomed around the\nWorld in the World Medical Association\nfamily and in CMAAO (Confederation of\nMedical Associations of Asia & Oceania).\nOver the years we met across the World and\nin Australia and in his beloved New Zea-\nland of which he would wax lyrical about\nwithout drawing breath! He taught us as\nChair of the GP Council and later of the\nNZ Medical Association the skills energy\nand tenacity not to mention charm needed\nto work with and influence governments\nand lead the profession whilst achieving\nresults and not compromising his patients,\nprofession or himself.\nPete was a passionate advocate for General\nPractice and quality health care and for the\nrights of all to that health care he personally\nprovided to the people of Napier. Interna-\ntionally he was equally forthright for the\nrights of physicians and the key role they\nplay in the health of individuals and na-\ntions and the need to maintain high moral,\nethical and professional standards set by the\nprofession.\nTireless, diligent and dedicated to his pro-\nfession though he was, he would always\nremember the support and love and devo-\ntion for those at home who supported him\nin his endeavours on the road or \u201cup in the\nair\u201d of whom he spoke with great passion\nand pride.\nThe world has benefited from having Peter\nFoley as a champion for its health, I and\nnumerous of his friends and colleagues are\nthe richer for having had him in our lives.\nFarewell my dear friend! Keep smiling at us\nfrom where you rest \u2013 in peace.\nDr. Mukesh Haikerwal AO\nChair of Council, WMA\nAustralian Medical Association\nThe IRCT and Restart Center are holding a global conference on the\nright to rehabilitation for torture victims. The conference takes place\non 27\u201328 June 2013 in Beirut, Lebanon. We hope that you will be\nable to participate in this exciting global event which will provide a\nplatform for discussion between key stakeholders in the torture reha-\nbilitation movement on the right to rehabilitation for torture victims.\nThe conference will explore in detail the way rehabilitation is pro-\nvided to torture victims and it will consider how States can be en-\ncouraged to strengthen their implementation efforts in providing\nholistic and victim-centred rehabilitation services and the neces-\nsary funding to torture victims.The four interlinked themes of the\nconference will provide a platform to share good practice examples\nin models for the delivery and funding of rehabilitation and explore\nways in which rehabilitation services and other key stakeholders\ncan assess and evaluate the services provided in their national con-\ntext. Linked to this is a need to focus on the immediate situation\nin the MENA region which faces particular challenges with regard\nto the provision of rehabilitation services to torture victims. The\nconference will draw on the experience from rehabilitation centres\nworldwide as well as representatives from academia, governments,\ninter-governmental organisations and civil society.\nRegistration is free but required \u2013 please fill in the online registra-\ntion form at www.irct.org\/conference2013. Please note places are\nlimited.\nThe conference programme and information on the venue and\nnearby accommodation are available on the website.\nFor more details, please contact Rachel Towers (rto@irct.org) or\nDalal Khawaja (dalal@restartcenter.com).\nGlobal Conference on the Right to Rehabilitation for Torture Victims\nCongress Topics: Person-centered medical education, Person-\ncentered interdisciplinary training in medicine and healthcare,\nPatients and family education, Stakeholders in health education,\nStudents-centered health education, Art in health education.\nClinical topics: Primary care, Pediatrics, Geriatric medicine,\nMental health, Internal medicine, Cardiovascular Cancer, Cir-\nculatory disorders, Respiratory disorders, Obesity, Diabetes, Pain\nmanagement and palliative medicine.\nPublic health topics: Prevention, Health promotion, Services,\nPolicies.\nCongress Participants: physicians, nurses psychologists, social\nworkers, pharmacists, dentists, policy makers and other health\nprofessionals (including students), educators and other interested\nscholars, representatives of patients and their families, advocates,\nindustry, person-centered public health.\nPresentation Formats: lectures, symposia, workshops, brief oral\npresentations and poster presentations.\nDeadlines: For abstracts: July 1st\n, 2013; For early registration:\nSeptember 1st\n, 2013.\nCongress Committee: Juan E.Mezzich (president),Jon Snaedal,\nChris van Weel,Michel Botbol,Ihsan Salloum,Tesfamicael Ghe-\nbrehiwet, Veljko \u0110or\u0111evi\u0107, Marijana Bra\u0161, Lovorka Brajkovi\u0107.\nTechnical secretariat: Penta Ltd, PCO, Address: I. Kr\u0161njavoga\n25, 10 000 Zagreb, Croatia.\nPhone: (+385 1) 462 8615, Fax: (385 1) 4555 3284,\nWeb: www.penta-zagreb.hr,\nE-mail: ana.jurasic@penta-zagreb.hr\nZagreb \u2013 the capital of Croatia, is deeply rooted in rich Central\nEuropean culture. In it lives the legacy of Prof. Andrija \u0160tampar,\nthe president of the first WHO World Health Assembly and a\npioneer of person-centered public health. Zagreb is waiting for\nyou with its thousand fascinating faces, ready to make you feel\nat home.\nFor more information, as well as for registration\nand abstract forms, please visit the Congress website:\nwww.ICPCMzagreb2013.com\n1st\nInternational Congress of the International College\nof Person-centered Medicine\nWhole Person in Health Education and Training. November 7\u201310, 2013 Westin Hotel, Zagreb Croatia\nIV\nContents\nA two-month public consultation on the\nWorld Medical Association\u2019s Declaration of\nHelsinki on medical research involving hu-\nman subjects began today (Monday) with\nthe posting of a revised version of the Dec-\nlaration on the WMA website.\nThe public and the WMA\u2019s 102 national\nmedical association members are being in-\nvited to comment on the proposed changes\nwhich have been drawn up following an\n18-month process of deliberation. A WMA\nworkgroup has held comprehensive discus-\nsions and three expert conferences to help it\ndraft the changes.\nIn an explanatory note on the WMA web-\nsite, the workgroup states that the proposed\nchanges provide for more protection for\nvulnerable groups and all participants by\nincluding the issue of compensation, more\nprecise and specific requirements for post-\nstudy arrangements and a more systematic\napproach to the use of placebos. In addition\nthe workgroup states that the revised text\nmaintains the unique character and length\nof the Declaration. It also provides better\nreadability by reorganising and restructur-\ning the document with sub headings.\nFor details of the major changes, people\nshould refer to the WMA website.\nAll experts and stakeholders have been in-\nvited to submit comments to the WMA\nsecretariat no later than 15 June 2013.\nThe workgroup will then produce a fi-\nnal revised draft to be considered by the\nWMA\u2019s ethics committee and Council at\ntheir meetings in Fortaleza, Brazil in Oc-\ntober 2013 when a decision will be taken\nwhether to forward the document to the\nWMA Assembly at the same meeting for\nadoption.\nThedocumentforpublicconsultationmaybe\ndownloaded here http:\/\/ndcommunications.\nhosted.phplist.com\/lists\/lt.php?id=N0RSBgZP\nAAQMGVUGBg%3D%3D\nwww wma.net\nPublic Consultation Opens on WMA Helsinki Declaration\nPresident\u2019s Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41\nOpening Speech by H.\u00a0E. Dr. Nafsiah Mboi . . . . . . . . . . . 44\n194th\nWMA Council Session. General Report . . . . . . . . . . 46\nSecretary General\u2019s Report . . . . . . . . . . . . . . . . . . . . . . . . . 54\nWMA Council Resolution on Criminalisation\nof Medical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58\nWMA Council Resolution on Standardisation\nin Medical Practice and Patient Safety . . . . . . . . . . . . . . . . 59\nWMA Council Resolution on Professor Karabus . . . . . . . . 59\nPhysicians and Hunger Strikes in Prison: Confrontation,\nManipulation, Medicalization and Medical Ethics . . . . . . . . 60\nProtective Provisions for Research Participants . . . . . . . . . 68\nFrequency of Hypertension in a Primary Care Setting\nin Buza,Tanzania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72\nRevealed: Coal\u2019s Unpaid Health\u00a0Bill . . . . . . . . . . . . . . . . . 78\nMass Catastrophe: dealing with crises and disasters\nnow and in the future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79\nIn Memoriam Dr. Peter Foley . . . . . . . . . . . . . . . . . . . . . . 80\n\n<\/p>\n"},"caption":{"rendered":"

wmj201302 COUNTRY \u2022 194th WMA Council Session \u2013 Bali \u2022 Protective Provisions for Research Participants vol. 59 MedicalWorld Journal Official Journal of the World Medical Association, INC G20438 Nr. 2, April 2013 Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 661 peteris@arstubiedriba.lv editorin-chief@wma.net Co-Editor Prof. […]<\/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\/wmj201302.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3648"}],"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=3648"}]}}