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wmj201502<\/a><\/p>\n

COUNTRY
\nvol. 61
\nMedicalWorld
\nJournal
\nOfficial Journal of The World Medical Association, Inc.
\nISSN 2256-0580
\nNr. 2, July 2015
\nContents
\nThe General Assembly in Moscow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t41
\n200th
\nWMA Council Session, Oslo, April 2015. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t42
\nWMA Council Resolution on Trade Agreements and Public Health . . . . . . . . . . . . . . . . . . . . \t52
\nWorld Health Assembly Week . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t53
\nGlobal Epidemics. Industrialised Nations Must Develop Global Strategies
\nto Counter Epidemics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t57
\nWMA Roles for Climate Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t58
\nThe Art and Heart of Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t60
\nOne Health: A Concept for the 21st
\nCentury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t62
\nPros and Cons of the Over-the-counter Sales\u00a0of Antimicrobials . . . . . . . . . . . . . . . . . . . . . . . . \t64
\nMedicines Shortages: Global Problems
\nNeed Global Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t69
\nDo Ethics Need to Be Adapted to mHealth?
\nA Plea for Developing a Consistent Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t72
\nHealth Apps\u00a0\u2013 Sound and Trustworthy?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t75
\nInterview with Vytenis Andriukaitis, EU Commissioner for Health and Food Safety . . . . . . \t78
\nPosition of Israeli Medical Association in Forced Feeding Issue . . . . . . . . . . . . . . . . . . . . . . . . \t82
\n41
\nWMA News
\nEditor in Chief
\nDr.\u00a0P\u0113teris Apinis, Latvian Medical Association, Skolas street 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.lv, editorin-chief@wma.net
\nCo-Editor
\nProf. Dr.\u00a0med. Elmar Doppelfeld, Deutscher \u00c4rzte-Verlag, Dieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor
\nInese Sviesti\u0146a, wmj-editor@wma.net
\nJournal design and cover design by
\nP\u0113teris Gricenko
\nLayout and Artwork
\nLatvian Medical Publisher \u201cMedic\u012bnas apg\u0101ds\u201d, President Dr.\u00a0Maija \u0160etlere, Katr\u012bnas street 2, Riga, Latvia
\nPublisher
\nLatvian Medical Association \u201cLatvijas \u0100rstu biedr\u012bba\u201d, Skolas street 3, Riga, Latvia.
\nISSN: 2256-0580
\nDr.\u00a0Xavier DEAU
\nWMA President
\nConseil National de l\u2019Ordre des
\nM\u00e9decins (CNOM)
\n180, Blvd. Haussmann
\n75389 Paris Cedex 08
\nFrance
\nDr.\u00a0Donchun SHIN
\nWMA Chairperson of the Finance
\nand Planning Committee
\nKorean Medical Association
\n46-gil Ichon-ro
\nYongsan-gu, Seoul 140-721
\nKorea
\nProf. Dr.\u00a0Frank Ulrich
\nMONTGOMERY
\nWMA Vice-Chairperson of Council
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1 (Wegelystrasse)
\n10623 Berlin
\nGermany
\nDr.\u00a0Margaret MUNGHERERA
\nWMA Immediate Past-President
\nUganda Medical Association
\nPlot 8, 41-43 circular rd., P.O.
\nBox 29874
\nKampala
\nUganda
\nDr.\u00a0Joseph HEYMAN
\nWMA Chairperson
\nof the Associate Members 163
\nMiddle Street
\nWest Newbury, Massachusetts 01985
\nUnited States
\nDr.\u00a0Masami ISHII
\nWMA Treasurer
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nSir Michael MARMOT
\nWMA President-Elect
\nBritish Medical Association
\nBMA House,Tavistock Square
\nLondon WC1H 9JP
\nUnited Kingdom
\nDr.\u00a0Heikki P\u00c4LVE
\nWMA Chairperson of the Medical
\nEthics Committee
\nFinnish Medical Association
\nP.O. Box 49
\n00501 Helsinki
\nFinland
\nDr.\u00a0Miguel Roberto JORGE
\nWMA Chairperson of the Socio-
\nMedical Affairs Committee
\nBrazilian Medical Association
\nRua-Sao Carlos do Pinhal 324,
\nCEP-01333-903 Sao Paulo-SP
\nBrazil
\nDr.\u00a0Ardis D. HOVEN
\nWMA Chairperson of Council
\nAmerican Medical Association
\nAMA Plaza, 330 N. Wabash,
\nSuite 39300
\n60611-5885 Chikago, Illinois
\nUnited States
\nDr.\u00a0Otmar KLOIBER
\nSecretary General
\nWorld Medical Association
\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\u00a0\u2013 especially those in authored contributions\u00a0\u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\nThe General Assembly in Moscow
\nOctober 14\u201317, 2015
\nAn Invitation
\nThe World Medical Association was founded in the wake of World
\nWar II.After a two-year preparation period,27 medical associations
\nmet in Paris in September 1947 to found a new association. Since
\nthen, medical ethics and socio-medical affairs have been at the core
\nor our work and we are proud to have shaped major international
\nmedical guidelines and regulations over the past seven decades.
\nOf course, physicians have had many other interest groups both
\nbefore and since, but the WMA became, and still is, an advocacy
\ngroup striving to make the best health care possible for all,including
\nthrough health education, prevention, rehabilitation and palliative
\ntherapy, aside from curative care and public health.
\nOver past years, aspects of human rights and social determinants
\nhave become more prominent and important for the work of the
\nassociation.The spectrum we deal with stretches from equitable ac-
\ncess to treatment through to issues of human rights violations in
\nmedicine right up to the challenge of preserving medical neutrality.
\nWe are now working more closely than ever on human rights issues
\nwith partners like the International Committee of the Red Cross,
\nAmnesty International and Physicians for Human Rights, to name
\njust a few.
\nWe support member associations in making their case for the ethi-
\ncal practice of our profession, we call upon governments to allow
\nphysicians to perform properly and we advise on how to stay within
\nthe rules. We are searching deeper for the causes behind the causes
\nof diseases, and we often find very simple mechanisms that deter-
\nmine our health and our chances of dealing with disease.
\nThe WMA has become a strong voice for physicians and their pa-
\ntients worldwide and we need to stay that way: able to raise ques-
\ntions, willing to find answers, and able to speak out. We invite our
\nmembers \u2013 Constituent and Associate Members \u2013 to join us in
\nMoscow from 14\u201317 October for the Council Session and the 2015
\nGeneral Assembly. Please register on our website now. We need ev-
\nery single one of you!
\nhttps:\/\/www.wma.net\/en\/50events\/10statutorymeetings\/13ga_2015\/
\nindex.html
\nDr. Otmar Kloiber
\nWMA Secretary General
\nBACK TO CONTENTS
\n42 43
\nWMA News WMA News
\nEmergency Resolution
\nA proposal was put forward by the British Medical Association that
\nthe meeting should consider an urgent Resolution about the several
\ntrade agreements being negotiated throughout the world and their
\nimpact on the provision of health. The Council accepted this as an
\nurgent matter which should be discussed in committee.The Council
\nthen adjourned for the committee meetings.
\nFinance and Planning Committee
\nDr.\u00a0Dongchun Shin (Korean Medical Association) was elected un-
\nopposed as Chair of the Committee. The Committee received a re-
\nport on membership dues payments and on the Financial Statement
\nfor 2014.The Committee approved the document as an interim fi-
\nnancial statement. A debate took place on a new dues structure.
\nAlcohol Session
\nThe Committee meeting then adjourned to hear two invited speak-
\ners talking about the alcohol policy in Norway. Mr \u00d8ystein Bakke,
\nSenior Adviser, FORUT, Campaign for Development and Solidar-
\nity and Secretary of the Global Alcohol Policy Alliance,spoke about
\nNorway\u2019s 40 years of experience with a ban on alcohol advertising.
\nHe said that increasing amounts of evidence showed that alcohol ad-
\nvertising and other marketing efforts had an impact on consumption.
\nMarketing was a dominant feature of the global alcohol trade, and
\ndrinks companies spent massively towards \u201cinvestments in the brands\u201d.
\nAdvertising and marketing had the strongest impact on young people,
\nspeeding up onset of drinking and increasing the amount consumed by
\nthose who already drank.The alcohol industry looked for new markets
\nas the traditional markets of the West were becoming less profitable.In
\nthese emerging markets in Africa and Asia, marketing was effective in
\nrecruiting new consumers from the non-drinking population.
\nThe alcohol industry\u2019s response to calls for marketing regulations
\nwas \u201cself-regulation\u201d. This approach to alcohol marketing had gen-
\nerally been deemed ineffective by several studies, but the alcohol
\nproducers and their so called \u201csocial aspects organizations\u201d still re-
\nferred to this as the best way forward.
\nHe said that, marketing restrictions existed in many countries
\naround the world and not only in Norway. Almost 50 countries had
\na total ban on alcohol advertising on national television in 2012,
\nwhile another 50 had some sort of partial restriction on TV adver-
\ntising. That added up to about half the world\u2019s countries. Advertis-
\ning bans were effective measures,particularly in reducing the impact
\non underage and young consumers.
\nThe second speaker,Lilly Sofie Ottesen,Deputy Director General of
\nthe Unit for Alcohol and Illicit Drugs Policy at Norway\u2019s \u00adMinistry
\nof Health and Care Services Department of Public Health, spoke
\nabout 40 years\u2019 experience of the alcohol ban in Norway. She said
\nthe ban, which was introduced in 1975, was very strict and probably
\nthe most comprehensive in Europe. It covered all the media and
\nall expressions associated with alcoholic beverages. Phrases such as
\n\u2018happy hour\u2019 and \u2018a cold one\u2019 were even covered, as well as the mere
\nuse of a neutral picture of a beverage and alcohol sponsorships such
\nas beer brands on football shirts and on boards at sport venues.
\nThe aim of the ban was twofold\u00a0\u2013 to reduce directly the demand and
\nthereby the consumption and harm of alcohol, and secondly to re-
\ninforce the effect of other alcohol policy measures and to contribute
\nto the support for the alcohol policy as a whole.
\nAddressing the question of whether the ban was working,Ms \u00a0Ottesen\u00ad
\nreplied that it was. Alcohol consumption in Norway was low com-
\npared to the rest of Europe and there was evidence to back up the
\nassumption that the ban reinforced other alcohol measures. Public
\nsupport for the ban had grown in recent years. There had been chal-
\nlenges to the ban from the alcohol industry,but there was now a broad
\npolitical consensus that Norway should keep the ban.
\nShe concluded: \u2018We believe that it is important to maintain a strict
\nand media neutral advertising ban. We do not see any threats to
\nthe ban as such, but as there will always be changes in society, com-
\nmunications and industry, and we must make sure that the ban and
\nits exceptions adapts to these changes. This, along with an efficient
\ncontrol and sanction system, is important to safeguard the support
\nfor the ban also in the years to come.\u2019
\nFinance and Planning Committee (resumed)
\nWMA Strategic Plan
\nThe Secretary General spoke about the WMA\u2019s strategic alliances
\nand highlighted a number of activities implemented according to its
\nstrategic plan. These included organising another Regulation Con-
\nference with the World Health Professions Alliance in May 2016.
\nThere would be a Global One Health Conference with the World
\nVeterinarian Association on 21\u201322 May in Madrid with an agenda
\nconcerning issues relating to both professions. There would be a
\nUNESCO Bioethics Conference from October 20\u201322 in Naples at
\nwhich the WMA would be organising two sessions and the WMA
\nwas now participating in the World Federation of Medical Educa-
\ntion as a voting member.
\nBusiness Development
\nA report was given on the Business Development Group\u2019s work
\nand the issue of finding external sources of funding. The Group had
\nworked on the first principle that the core work of the WMA had to
\nbe funded by membership subscriptions. The question was whether
\nother activities, such as educational activities, should be funded in
\nsome way by external sources. The meeting agreed that the Group
\nshould prepare a paper on the issue and come back to the Committee.
\nThe 200th
\nWMA Council meeting, was held at the Hotel Bristol in Oslo,
\nNorway. The meeting was opened by the Secretary General Dr.\u00a0Otmar
\nKloiber, who began by reminding delegates that this was a confidential
\nmeeting and that tweeting should not take place. There were no apolo-
\ngies for absence. He welcomed three new members of Council, Dr.\u00a0Heidi
\nStensmyren from Sweden, Prof. Rutger Jan Van Der Gaag from the
\nNetherlands and Dr.\u00a0Carlos Jorge Janez from Argentina. He also wel-
\ncomed delegates from more than 35 national medical associations, Past
\nPresidents, observers and guests and in particular the return of one of the
\nWMA\u2019s founding members, the Italian Medical Association.
\nCouncil
\nElections and Appointments
\nThe Council began with an election for Chair of Council.Two nomi-
\nnations were received\u00a0\u2013 from the sitting Chair Dr.\u00a0Mukesh Haik-
\nerwal (Australian Medical Association) and from Dr.\u00a0Ardis Hoven
\n(American Medical Association). Both candidates briefly addressed
\nthe meeting. Dr.\u00a0 Haikerwal, a former President of the Australian
\nMedical Association, spoke about his achievements as a leader of the
\nmedical profession throughout his career and talked about his vision
\nfor the future of the WMA to build on his work of the past four years.
\nDr.\u00a0Hoven, Immediate Past President of the American Medical As-
\nsociation, spoke of the great opportunity the WMA had to influence
\nmedical practice and global health, and the complex and far reaching
\nchallenges facing the Association\u00a0\u2013 shrinking resources, complicated
\nand difficult practice environments, shifting government regulations
\nand dangerous working conditions. The WMA\u2019s current work spoke
\nto its impact and credibility. She said she valued consensus and the
\nWMA\u2019s diversity and she would work to increase the Association\u2019s
\nvisibility and strengthen its voice. In the vote, Dr.\u00a0Hoven was elected
\nand immediately took the Chair,thanking the Council for its support
\nand in particular thanking Dr.\u00a0Haikerwal for his work as Chair.
\nProf. Dr.\u00a0 Frank Ulrich Montgomery (German Medical Associa-
\ntion) was elected unopposed as Vice-Chair to succeed Dr.\u00a0Masami
\nIshii and Dr.\u00a0Ishii (Japan Medical Association) was elected unop-
\nposed as Treasurer to succeed Dr.\u00a0Montgomery.
\nThe Council approved the membership of the Council committees
\nand approved the names of their advisers.
\nPresident\u2019s Report
\nThe President Dr.\u00a0Xavier Deau gave an interim report on his activities
\nsince his inauguration in Durban last year.He referred to the work on
\nthe Health Care in Danger project and the H20 Health Summit in
\nMelbourne,where it was concluded that health was a wise investment
\nand an economic driver in society for the creation of employment.
\nHe also spoke about WMA\u2019s role on the issue of climate change, the
\nimportance of the issue of the Social Determinants of Health and the
\nsuccessful revision of the Declaration of Helsinki.
\nSecretary General\u2019s Report
\nDr.\u00a0Kloiber had presented a lengthy written report to Council about
\nthe secretariat\u2019s activities. In his oral report he highlighted two
\n\u00adissues to illustrate the WMA\u2019s influence and impact.
\nThe Association had received an invitation from the United States
\nDefence Health Board to advise the US Defence Secretary and the
\nUS military on issues relating to health and the military. The WMA
\nwas invited to take part in a session on medical ethics. Past Presi-
\ndent Dr.\u00a0Cecil Wilson represented the WMA at this meeting and the
\nBoard came out with 16 recommendations. Dr.\u00a0Kloiber then quoted
\nfrom a letter from the Vice Chair of the US Senate Committee on
\nIntelligence, Senator Dianne Feinstein, to the US Defence Secretary
\nreferring to the WMA\u2019s Declaration of Malta on the issue of ending
\nthe forced feeding of detainees at Guantanamo Bay.
\nThe second development illustrating the WMA\u2019s impact related to
\nthe issue of scheduling the drug Ketamine some weeks ago by the
\nUnited Nations Commission on Narcotic Drugs. The WMA had
\nasked its members to argue against this scheduling as many people
\nwould have suffered from the absence of the drug. Eventually it was
\ndecided to postpone the decision for a year and Dr.\u00a0Kloiber thanked
\nthose NMAs who had lobbied on this issue.
\nDr.\u00a0Margaret Mungherera, the Immediate Past President, said that
\nthe largest threat to global health were the African health systems,
\nbut there was not enough attention being paid to this. She said the
\nWMA needed to keep this issue on the agenda. The WMA had
\ndone a lot of work to reduce the deafening silence of NMAs in
\n\u00adAfrica on this issue, but it had a moral authority to do more and
\ncould not afford to sit back.
\nChair\u2019s Report
\nIn his report, Dr.\u00a0Haikerwal reported on the WMA\u2019s increased foot-
\nprint on the global health map.He referred to the first \u201cH20+\u201dHealth
\nSummit in Melbourne, adjacent to the G20 World Leader\u2019s Summit.
\nHe said ethical guidance and ensuring access to health and healthcare
\nremained core and key. He and the WMA\u2019s leaders continued to re-
\nmind people that health was a core component of a successful fair and
\njust society,that health was a wise investment and that health brought
\nhuman, political and economic dividends. Physicians were part of the
\nsolution in health and healthcare research planning implementation.
\n200th
\nWMA Council Session, Oslo, April 2015
\nBACK TO CONTENTS
\n44 45
\nWMA News WMA News
\nFuture Meetings
\nThe Committee considered the planning and arrangements for fu-
\nture WMA statutory meetings. The Taiwan Medical Association
\nsuggested that at the Assembly meeting in Taipei in October 2016
\nthe scientific session should be on \u2018Healthcare System Sustainabil-
\nity\u2019 with two sessions, the first on \u2018Health System Performance\u2019 and
\nthe second session on \u2018eHealth\u2019.This was agreed.
\nThe Secretary General reported that as in previous years, a WMA
\nluncheon in Geneva would again be held during the WHO World
\nHealth Assembly period.The main theme this year would be public
\nhealth issues, including health and investments. Dr.\u00a0Haikerwal re-
\nported that a second H20+ Health Summit was also being planned
\nfollowing the success of the Melbourne meeting.
\nAssociate Members
\nThe Committee received an oral report from the Chair of the As-
\nsociate Members, Dr.\u00a0Joe Heyman. He informed the Committee
\nof his plans to draw more commitment from individual associate
\nmembers by promoting membership through introducing life mem-
\nbership. An international conference call was planned for May and
\nhe also spoke about holding regional, on-site meetings when statu-
\ntory meetings were held and linking up with the Junior Doctors
\nNetwork and the Past Presidents and Chairs of Council Network.
\nJunior Doctors Network
\nThe Chair of the Junior Doctors Network,Dr.\u00a0Ahmet Murt,gave an
\noral report on the JDN\u2019s activities. Among the current topics it was
\nworking on were physicians\u2019 wellbeing, medical work force, medical
\neducation, Ebola and social media.
\nPast Presidents and Chairs of Council Network
\nDelegates received a written report on the activities of the Past Presi-
\ndents and Chairs of Council Network. Dr.\u00a0Cecil Wilson had repre-
\nsented the WMA at the U.S. Defence Health Board Subcommittee
\nMeeting in February, Prof. Dr.\u00a0Jos\u00e9 Luiz Gomes do Amaral had given
\nexpert advice on the possible scheduling of Ketamine as a narcotic drug
\nand Dr.\u00a0Dana Hanson was presenting a paper entitled,\u201cGlobal Physi-
\ncian Resilience: The Role of Social Context to the European Associa-
\ntion for Physician Health\u201din Barcelona in April. Dr.\u00a0Jon Snaedal gave
\nan oral report and said the activities of the Network were increasing.
\nWorld Medical Journal
\nThe WMJ Editor, Dr.\u00a0Peteris Apinis, in his oral report, said the
\ntransition producing a digital edition of the Journal had been com-
\nplicated. Four issues had been scheduled for this year and the first
\ndigital edition would be published within days.
\nPublic Relations
\nThe WMA\u2019s Public Relations Consultant, Mr. Nigel Duncan, spoke
\nabout the importance of social media and the advantages this pre-
\nsented for the WMA. He said there was a need for some guidelines
\nand rules for a more efficient and productive use of social media.
\nIFMSA Memorandum of Understanding
\nDr.\u00a0 Kloiber reported on a new Memorandum of Understanding
\nwith the International Federation of Medical Students Associa-
\ntions. Dr.\u00a0Agostinho de Sousa, President of IFMSA, explained that
\nIFMSA had been cooperating with the WMA since the 1960s,
\nand that the official MoU would facilitate future collaboration. The
\nCommittee agreed to recommend to the Council to accept the new
\nMemorandum of Understanding.
\nInternship and Secondment
\nThe Committee received an oral report from the Secretary General
\non internships and secondment to the WMA. He reported that two
\nbioethics students from the University of Pennsylvania and medical
\nstudents from the IFMSA had been interning at the WMA Secre-
\ntariat in Ferney Voltaire annually. He asked NMAs to consider sec-
\nondment for intensive contact with the WMA for mutual benefit.
\nViolence Against Doctors
\nThe meeting heard a report from the Indian Medical Association
\nabout increasing incidents of assaults on doctors by patients in India.
\nDr.\u00a0Kloiber\u00adagreed that this was a very pressing issue that had arisen in
\ncountries around the globe. He had received reports in recent months
\nfrom every continent,from Asia,Eastern Europe and from Latin Amer-
\nica.The WMA had recently issued a press release about the case of a sur-
\ngeon murdered in a Boston hospital in the USA.There had also been a
\nrecent case in Germany.He added that this was a second line of violence
\nin addition to the violence taking place in areas of armed conflict,about
\nwhich the WMA was working with the International Committee of the
\nRed Cross. He told the meeting that the WMA would need to step up
\nits work on violence against doctors not connected with armed conflict.
\nSocio-Medical Affairs Committee
\nElections
\nThe proceedings began with a contested election for Chair of the
\nCommittee, following the decision of President Elect Sir Michael
\nMarmot to stand down. Two candidates were nominated, Prof.
\nMiguel Roberto Jorge (Brazilian Medical Association) and Dr.\u00a0An-
\ndr\u00e9 Bernard (Canadian Medical Association).After both candidates
\naddressed the meeting,the Committee elected Prof.Jorge,Associate
\nProfessor of Psychiatry and Chair of the Research Ethics Commit-
\ntee, at the Federal University of S\u00e3o Paulo.
\nOral Report
\nDr.\u00a0Kloiber noted the increasing number of items on the SMAC
\nagenda, reflecting the increased involvement of the WMA in socio-
\nmedical issues.He again highlighted the key importance of address-
\ning violence against health care personnel and facilities that occurred
\nnot only in situations of armed conflict, but also in civil situations.
\nThere were some instances, such as in Mexico, where violence was
\nreaching armed conflict in a war on drug gangs between the state
\nand the people, and doctors were being taken hostage and killed.
\nHe mentioned the WMA\u2019s commitments in this area, in particular
\nwithin the Health Care in Danger Project, initiated by the ICRC.
\nHe called on national medical associations to cooperate with the
\nSecretariat in sharing information on situations in their countries
\nand to become further engaged in addressing this issue.
\nHealth and the Environment
\nDr.\u00a0Shin, Chair of the Environmental Caucus, reported on the ac-
\ntivities of the Caucus that had met the previous day. The meeting
\nhad focused on the forthcoming United Nations Climate Change
\nConference in Paris in early December 2015.The expected outcome
\nof the event was to reach a new universal agreement on climate
\naiming at keeping global warming under 2\u00b0C. So far the draft ne-
\ngotiating text included a plan to completely phase out fossil fuel
\nemissions. The text also for the first time included language on the
\nhealth benefits of climate action.
\nParticipants in the Caucus had discussed ways of influencing the
\nprocess and have doctors\u2019 voices heard at the national and interna-
\ntional level. Dr.\u00a0Deau had presented a plan for the WMA in col-
\nlaboration with the Soci\u00e9t\u00e9 Fran\u00e7aise de Sant\u00e9 Publique (French
\nSociety of Public Health) and the European Public Health Asso-
\nciation to target the French negotiating team, which would have a
\nmajor role in the negotiations as it was the host country of the event.
\nHealth Care in Danger
\nProf. Vivienne Nathanson, Chair of the Work Group on Health
\nCare in Danger, reported on the activities of the Group, which had
\nmet the previous day. She said Dr.\u00a0B. Eshaya-Chauvin (ICRC) had
\nupdated the Group on the latest developments on the ICRC proj-
\nect. He said the project had been extended by two years.The Group
\ndiscussed ways of translating into action the recommendations
\nemerging from the project.Two actions were identified: that NMAs
\nmake contact with Red Crescent societies at the national level and
\nthat the WMA website include a defined area featuring activities
\ndeveloped by NMAs in this area.
\nThe Group had examined a proposed revision of current WMA policy
\non Ethical Issues Concerning Patients with Mental Illness adopted in
\n2006.This revision would reflect doctors\u2019concerns about recent policy
\ndevelopments in this area and reaffirm medical ethics principles in
\nrelation to patients in psychiatric centres. It was proposed that the
\nrevised version be submitted to the Committee for consideration.
\nFinally Prof. Nathanson referred to the draft toolkit the British
\nMedical Association had developed for doctors going into situa-
\ntions of armed conflict for the first time. It was proposed that the
\ndocument, which would be an online publication only, be submitted
\nto the Committee for consideration
\nViolence Against Women and Girls
\nSir Michael Marmot reminded the Committee of the very success-
\nful WMA luncheon held in Geneva in May 2014 alongside the
\nWorld Health Assembly that was dedicated to violence against
\nwomen. He said that one in three women globally would experience
\nphysical or sexual violence. This was a huge public health issue. It
\nwas now proposed that the British Medical Association would host
\na discussion meeting of interested NMAs in London about how the
\nWMA could continue working on this subject.
\nSocial Determinants of Health
\nA report on the successful BMA symposium that was held in March
\norganised jointly by the British Medical Association, the Canadian
\nMedical Association and the Institute of Health Equity was given
\nby Sir Michael Marmot. He updated the Committee on his plans
\nfor following up the conference. The first aim would be to continue
\nstrengthening global networks and building a social movement. The
\nnext would be to increase the visibility of the WMA Statement on
\nSocial Determinants of Health and build on the best evidence to pro-
\nduce a report.The third aim would be to develop educational tools for
\nphysicians to learn what they could do to tackle the Social Determi-
\nnants of Health through online courses and training workshops.
\nRole of Physicians in Preventing theTrafficking with Minors and Illegal
\nAdoptions
\nIt was reported that experts on the topic had been consulted over
\nrecent months. However, having not received enough material or
\nresponses, it had so far not been possible to submit a paper to the
\nWork Group. It was hoped that the Work Group would be in a
\nposition to submit a draft policy in October 2015.
\nIt was decided to postpone further discussion until the next com-
\nmittee meeting in Moscow.
\nProposed Statement on Physicians\u2019 Well-Being
\nA new draft Statement on Physicians\u2019 Well-Being was presented
\nto the Committee by the Work Group. There was a brief debate
\nabout the need for doctors with disabilities to be enabled to return
\nto work by making the necessary adaptions to the workplace. It was
\nalso argued that the paper should contain a more expanded section
\non physicians at risk from alcohol abuse. It was agreed to recom-
\nmend to Council that the paper should be recirculated to NMAs
\nfor comments.
\nRevision of the WFME Standards for Post-Graduate Education and
\nContinuing Professional Development
\nA report was received on the activities of the Work Group on
\nMedical Education. The Group had made comments on revising
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\nthe World Federation of Medical Education Standards for Post-
\nGraduate Education. The revision was considered thorough and
\ncomprehensive.
\nDr.\u00a0Kloiber reported that he has been consulted by the WFME in a
\npersonal capacity on the revision of standards for Continuing Pro-
\nfessional Development. He thanked those members that had sent
\ncomments on the proposed revision and he expected there would
\nalso be an open consultation with the opportunity for NMAs to
\nsubmit further comments.
\nStatement on Providing Health Support to Street Children
\nNew guidelines for National Medical Associations on providing
\nhealth support to street children were set out in a revised Statement
\non Providing Health Support to Street Children.
\nThe reworded Statement was introduced by the Conseil de l\u2019Ordre
\nNational des Medecins. Delegates were told that the issue effect-
\ned a large number of countries in all continents. It was difficult to
\nquantify this phenomenon but it was a reality in large cities w\u00adhich
\n\u00adchildren sought out after leaving their villages and towns. Many
\nchildren were dumped in ships and sent across the sea to find a bet-
\nter future.They often travelled in groups and many died on the way.
\nSo how could doctors help them? A specific response was required.
\nIt was argued that the WMA had a duty to support local organisa-
\ntions working with these children and a duty to sensitise govern-
\nments. It was urgent to work together with people working in the
\nfield and on the streets.
\nThe Committee agreed that the proposed Statement should go to
\nCouncil to be approved and forwarded to the General Assembly for
\napproval and adoption.
\nProposed revision of WMA Statement on Child Abuse and Neglect
\nIt was decided that this proposed document should be withdrawn.
\nStatement on Chemical Weapons
\nThe Committee considered the proposed revision of the WMA
\nStatement on Chemical Weapons which deals with the appropriate
\nuse of riot control agents. It was proposed that the title of the paper
\nbe changed to Statement on Riot Control Agents.
\nThis was approved and it was decided to send the document to
\nCouncil for forwarding to the General Assembly for approval and
\nadoption.
\nProposed Declaration on Alcohol
\nThe Australian Medical Association introduced a draft Declaration
\non Alcohol which recommends priority legal and regulatory mea-
\nsures as well as social policy interventions to address alcohol-related
\nharm.The document was welcomed by a succession of speakers and
\nafter a brief debate it was agreed that with two minor amendments
\nit should be sent to Council for forwarding to the General Assem-
\nbly for approval and adoption.
\nMobile Health
\nA proposed new Statement on Mobile Health was presented to the
\nCommittee by the German Medical Association. Delegates were
\ntold that National Medical Associations had commented on the pa-
\nper and many of their suggestions had been included.
\nSpeakers welcomed the document on what they said was a very
\nimportant issue. There was one suggestion that the Statement
\nshould include more about secrecy and confidentiality. This led to
\na debate during which many speakers argued that the guidelines
\nshould remain as broad and as general as possible. The meeting
\ndecided to reorder the wording of the document and the Commit-
\ntee agreed that the proposed Statement, as amended, be approved
\nby the Council and be forwarded to the General Assembly for
\napproval and adoption.
\nWorld Day for Eliminating Violence Against Health Professionals
\nThe Turkish Medical Association introduced a revised Statement
\non a World Day for Eliminating Violence against Health Profes-
\nsionals. This would be in memory of all those health professionals
\nwho had died in the course of duty, including the young Turkish
\nsurgeon Dr.\u00a0Ersin Arslan who was stabbed by a relative of his pa-
\ntient while on duty in his hospital three years ago.
\nSeveral speakers questioned whether there was a need to adopt new
\npolicy and it was suggested that this proposal should be referred to
\nthe WMA Advocacy Group. Other speakers supported the idea for
\na special day. It was reported that the Conseil de l\u2019Ordre National
\ndes Medecins had set up an observatory to monitor physician safety
\nand a form had been devised for physicians to report physical and
\nverbal attacks. In 2014 they had noted a major increase in incidents
\nof violence. In France it was not as usual for physicians to report
\nsuch attacks and therefore the known figures should be multiplied
\nto get a correct picture of what was going on.
\nSpeakers also said that one of the reasons for violence was the lack
\nof resources for hospitals and doctors when it came to working
\nconditions, and the public sometimes reacted violently as a con-
\nsequence. Doctors felt helpless when confronted with this type of
\nproblem and often resorted to defensive medicine. It was said that
\nin Mexico over four years more than 60 physicians had died at the
\nhands of the drug trafficking industry. The Committee agreed that
\nthe proposed Statement be forwarded to the Advocacy Group for
\nconsidering possible action.
\nNuclear Weapons
\nThe Committee considered the proposed Statement on Nuclear
\nWeapons requesting all National Medical Associations to join the
\nWMA in urging their respective governments to work to ban and
\neliminate nuclear weapons.
\nMembers of the Committee welcomed the Statement and recom-
\nmended that it be sent to Council for forwarding to the General
\nAssembly for approval and adoption.
\nStatement on Destruction of Smallpox Virus Stockpiles
\nThe Junior Doctors Network re-presented a revised proposed State-
\nment on Destruction of Smallpox Virus Stockpiles. The JDN sug-
\ngested setting up a Work Group to work on bringing forward a fur-
\nther paper at the next Committee meeting. This prompted a debate
\non the complexity of the issue. Several speakers said that although
\nthey supported the Statement they would prefer to wait for a pending
\nreport on the issue from the World Health Organisation scientists.
\nAt the end of the debate the Committee decided that the Statement
\nshould be postponed to the next Council meeting, so that members
\ncould review the WHO report when it was published.
\nCorporal Punishment of Children
\nA proposal was made to endorse a statement by international health
\norganizations in support of Prohibition and Elimination of all
\nCorporal Punishment of Children. The Committee considered the
\nStatement and recommended Council that the Statement should be
\nendorsed by the General Assembly.
\nGuidelines on Mass Media Appearances by Physicians
\nThe Korean Medical Association introduced a draft Statement con-
\ntaining guidelines for physicians appearing in the media. Delegates
\nwere told that some physicians misused appearances on the mass media
\nfor marketing purposes misleading patients\u2019trust in physicians. Speak-
\ners generally supported the document but said there needed to be some
\nclarification about whether it related to all media appearances or only
\nappearances related to marketing products. The Committee recom-
\nmended that the guidelines be circulated among NMAs for comment.
\nStatement on Transgender People
\nThe German Medical Association brought forward a proposed
\nStatement on Transgender People as a new item of business. This
\nreferred to the crucial role played by physicians in advising and con-
\nsulting with transgender people and their families about desired
\ntreatments. It was meant to serve as a guideline for patient-phy-
\nsician relations and to foster better training to enable physicians to
\nincrease their knowledge and sensitivity toward transgender people
\nand the unique health issues they faced.
\nSpeakers welcomed the paper,although one delegate expressed some
\nconcern that WMA policy might enter into conflict with national
\nlegislation. However another speaker referred to the saying \u2018Ethics
\ntrumps national law\u2019. The issue of medical ethics and intersexual-
\nity was also raised and it was agreed that this was a separate topic
\nand that a specific paper should be drafted on this. The Committee
\nrecommended that the Statement be circulated among constituent
\nmembers for comments.
\nStatement on Vitamin D Insufficiency
\nA proposed Statement on Vitamin D Insufficiency was introduced
\nby the Czech Medical Association. Delegates were told this was an
\nimportant global health issue with an estimated one third of the
\npopulation having insufficient vitamin D concentrations. It was ar-
\ngued that Vitamin D should now be considered essential for overall
\nhealth and well-being and that attention should be focused on ad-
\nequate action in populations at risk, such as young children, older
\npeople and pregnant women. The Committee recommended that
\nthe Statement be circulated among NMAs for comments.
\nAgeing
\nThe Brazilian Medical Association proposed that a new policy on
\nageing should be drafted. In the last hundred years life expectancy
\nhad increased by more than 30 years worldwide. By 2050 the pro-
\nportion of those over 60years old was likely to increase from 11.9
\nper cent to more than 21 per cent, a total of over two billion people
\nof whom 83 per cent were living in developing countries. There
\nwould be a consequential increase in diseases such as NCDs, car-
\ndiovascular disease,cancer,diabetes and chronic respiratory diseases.
\nThese diseases could be controlled but doctors were not sufficiently
\nprepared for these challenges. It was time to begin considering
\nguidelines on this issue.Committee members heard about the expe-
\nrience of several countries and supported the proposal for a policy.
\nThe Committee recommended that a Work Group be set up with
\nthe mandate to produce a draft policy on ageing.
\nClassification of 2005 Policies
\nThe Committee considered the potential revision of SMAC policies
\nfor which it had been 10 years since adoption or revision.
\nIt recommended that the following policies be rescinded and ar-
\nchived:
\n\u2022\t the Council Resolution on Chronic Non-Communicable Disease
\n\u2022\t the Council Resolution on the Healthcare Skills
\n\u2022\t the Council Resolution on the Genocide in Darfur
\nIt recommended that the following policies undergo a major revi-
\nsion:
\n\u2022\t the Council Resolution on Implementation of the WHO Frame-
\nwork Convention for Tobacco Control
\n\u2022\t the Statement on Boxing
\n\u2022\t the Statement on Body Searches of Prisoners
\n\u2022\t the Statement on Female Genital Mutilation
\nIt recommended that following policies be reaffirmed:
\n\u2022\t the Declaration of Hong Kong on the Abuse of the Elderly
\n\u2022\t the Statement on Drug Substitution
\n\u2022\t the Statement on Medical Liability Reform
\nAdvocacy
\nDr.\u00a0Andr\u00e9 Bernard, Chair of the Advocacy Advisory Committee,
\nreported on the activities of the Committee, including the use of
\nsocial media and the need to develop guidelines on how social
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\n\u00admedia and particularly twitter might fit into WMA\u2019s proceedings.
\nHe said a task group would be set up to draft some guidelines
\nand bring them back to the next meeting of the Advocacy Com-
\nmittee. He also referred to the need to follow up the advocacy
\ntraining session held at the Assembly in Durban and said that the
\nCommittee would explore how to advance the various initiatives
\ndiscussed.
\nFinally he said the Committee was considering how advocacy fit-
\nted with the Association\u2019s policy making process. There was a need
\nto have clear messaging and to consider what levers for advocacy
\ncommunication were available for each piece of work produced by
\nthe WMA.
\nResolution on Trade Agreements and Public Health
\nThe British Medical Association submitted a proposed urgent
\nResolution on Trade Agreements and Public Health. It was re-
\nported that there were a large number of trade agreements moving
\ntowards finality. It was very difficult for individual NMAs to have
\na significant impact on these agreements because of the secrecy
\nsurrounding the negotiations. But it was possible to get concerns
\nheard if it was handled collectively. The key issue was that the
\nWMA wanted to protect the ability of governments to make deci-
\nsions about promoting health and well-being and health equity in
\neach country. It did not want to have those policies damaged or
\nstopped because it was felt by some companies that their trading
\nrights had been infringed and to use the new trade agreements to
\neither stop the policy changes or even worse to make governments
\npay for damage to their trade. This could be policies as simple as
\nplain packaging of cigarettes or something more complicated such
\nas bringing in a new form of competition within the provision of
\nhealth care.
\nWhat was needed was a process within the negotiations which said
\nthat these services introduced by governments for the public would
\nbe protected.
\nSpeakers agreed that this was a particularly hot topic in Europe
\nand in Asia. Health care was being endangered by these nego-
\ntiations. It was also said that the Trans-Atlantic Trade and In-
\nvestment Partnership might lead to the commercialization of
\neducation, particularly medical education. It was argued that
\nGovernment medical services should not be hindered by a trade
\nagreement. Following agreement on an amendment to the Reso-
\nlution on securing services in the public interest, the Committee
\nagreed to recommend that the proposed Resolution, as amended,
\nbe \u00adadopted by the Council.
\nMedical Ethics Committee
\nDr.\u00a0 Heikki P\u00e4lve (Finnish Medical Association) was re-elected
\nChair of the Committee.
\nThe Secretary General highlighted four current international topics
\nof discussion within the committee\u2019s remit:
\n\u2022\t The potential of health databases and biobanks for improving
\ntreatment, while at the same time facing the risk of undue com-
\nmercial exploitation
\n\u2022\t Reproductive health (surrogacy, and social freezing)
\n\u2022\t End of life (physician assisted suicide and euthanasia)
\n\u2022\t Medical confidentiality and reporting of medical findings follow-
\ning the recent German air crash
\n\u2022\t Conscientious objection
\nOn the issue of medical confidentiality, Dr.\u00a0Kloiber said this had
\nbecome an issue following the recent German air crash when the
\nquestion arose about the pilot\u2019s medical fitness.This raised the issue
\nof the obligation on physicians for mandatory reporting of medical
\nfitness. So far the medical associations had reacted very appropri-
\nately, pointing out the value of medical confidentiality and the po-
\ntential damage that could be done by lifting medical confidentiality
\nand secrecy. Delegates were told that in South Africa and Holland
\nphysicians were either legally obliged to or allowed to release infor-
\nmation about a patient if it was in the public interest. However in
\nAustralia, on the issue of the mandatory reporting for physicians
\nwho were unwell, it was unclear whether this was for all physicians
\nwhen they were unwell or only when they were a danger. Although
\nthis was supposed to be a national law, certain states had not ad-
\nopted that policy and doctors were going to these states to get their
\ntreatment.
\nPerson Centred Medicine
\nThe Committee received an oral report about the activities of the
\nWork Group on Person Centred Medicine which had begun its
\nwork in 2012. It was reported that a white paper would be de-
\nveloped for the next meeting in October explaining the different
\nexisting concepts and their challenges. The language had evolved
\nover the different definitions of person centred medicine.The white
\npaper would address the difficulty in balancing the patient focus
\nof medicine and public health and the physicians\u2019 perspective. A
\nWMA policy would be developed out of this white paper.
\nThis led to a brief debate in which speakers elaborated on the defi-
\nnition of person centred medicine and the reason why the name
\npatient centred medicine was an incomplete term.
\nHealth Databases and Biobanks
\nThe activities of the Work Group on Health Databases and Bio-
\nbanks were outlined to the Committee in an oral report. It had pro-
\nduced a draft policy paper and an open public consultation had been
\nstarted, which would run until 5 June 2015. The Work Group in-
\nvited all constituent members to contact experts in their country to
\ncomment on the draft paper or to send the WMA Secretariat sug-
\ngestions of who to contact for this process. A small drafting group
\nwould incorporate the comments received at a drafting meeting in
\nBerlin later this year. The Work Group then proposed to hold an
\nopen meeting with additional experts at the beginning of Septem-
\nber 2015. The Danish Medical Association had offered to host this
\nmeeting in Copenhagen and the Work Group would report back at
\nthe next Council meeting in October.
\nSpeakers emphasised that this was an ever changing topic and
\neven when a paper was produced it would only be a work in prog-
\nress. The topic was a core issue for the profession of patient con-
\nfidentiality.
\nInclusion of Medical Ethics and Human Rights in the Curriculum of
\nMedical Schools
\nA report was given to the Committee on a major revision of the
\nWMA Resolution on the Inclusion of Medical Ethics and Hu-
\nman Rights in the Curriculum of Medical Schools World-Wide.
\nThe aim was that the teaching of medical ethics and human rights
\nat every medical school should be obligatory. It was also recom-
\nmended that medical schools should ensure they had sufficient fac-
\nulty skilled at teaching ethical enquiry and human rights to make
\ncourses sustainable. The revised draft argued that there was a clear
\nneed for physicians in training to understand the social and envi-
\nronmental context within which they would practice. Failures of
\nindividual physicians to recognize the ethical obligations they owed
\ntheir patients and communities damaged the reputation of doctors
\nthroughout a country, and could have a global impact. The Com-
\nmittee recommended that the proposed revision be circulated to
\nNMAs for comment.
\nDeclaration of Geneva
\nThe German Medical Association put forward a proposal that it
\nshould form an informal workgroup to explore the potential revi-
\nsion of the Declaration of Geneva. The Declaration was due to be
\nrevised in 2016 and the German Medical Association said it would
\nlike to express its support for re-exploring this crucial document
\nfrom a 21st
\ncentury perspective.This would be to ensure an appropri-
\nate level of careful preparedness for when the official revision pro-
\ncess began.The informal work group would create an initial draft to
\nserve as a basis for the final revision next year.
\nSome speakers agreed with this approach and said the Declara-
\ntion needed a thorough revision. This led to a lengthy debate dur-
\ning which many other speakers questioned whether such a working
\ngroup would be set up to revise the Declaration or simply to review
\nwhether the Declaration should be revised. Several speakers were
\ndoubtful whether the Declaration needed revising at all, although
\nthere was general agreement that any work group set up should be a
\nformal and not an informal group.
\nThe Committee concluded by recommending to the Council that a
\nformal WMA Work Group be set up to review the Declaration of
\nGeneva and come back to the Committee with recommendations.
\nClassification of 2005 Policies
\nThe Committee considered the status of several policies which were
\nadopted or last revised 10 years ago. It was proposed that the State-
\nment on Physician-Assisted Suicide, rather than being automati-
\ncally reaffirmed, should undergo a major revision. The Canadian
\nMedical Association volunteered to do this. This prompted a brief
\ndebate when it was pointed out that in responses from NMAs, the
\nmajority opinion was that this policy should not be revised. On a
\nvote, the Committee recommended that the Statement on Physi-
\ncian-Assisted Suicide and three other policies be reaffirmed:
\n\u2022\t \tThe Declaration of Lisbon on the Rights of the Patient
\n\u2022\t \tThe Declaration on Euthanasia
\n\u2022\t The Resolution on Academic Sanctions or Boycotts
\nIt recommended that the Statement on Non-discrimination in Pro-
\nfessional Membership and Activities of Physicians be reaffirmed
\nwith a minor revision by the Secretariat and be submitted to the
\nCommittee and Council at the next meeting.
\nHuman Rights
\nClarisse Delorme, the WMA\u2019s Advocacy Advisor, reported on the
\nWMA\u2019s work on human rights in Turkey, Saudi Arabia and else-
\nwhere. She highlighted that the WHO and PAHO were developing
\na training curriculum for health professionals about care for women
\nsubjected to intimate partner violence and sexual violence. As a first
\nstep,a survey had been prepared with the aim of identifying the needs
\nof health professionals in providing adequate care for women sub-
\njected to violence and she asked members to respond to the survey.
\nCouncil
\nOn the final day of the conference, the Council meeting reconvened
\nto hear reports back from the three Committee meetings.
\nMedical Ethics
\nHealth Databases and Biobanks
\nThe Council approved the Committee\u2019s recommendation to hold an
\nopen meeting as part of the public consultation on the Health Data-
\nbases and Biobanks draft document. The meeting, at the beginning
\nof September 2015, would include outside experts.
\nPhysician-Assisted Suicide
\nA lengthy debate took place on the recommendation from the Com-
\nmittee to reaffirm the Statement on Physician-Assisted Suicide.
\nSome speakers spoke strongly in favour of reviewing this policy in
\nview of changing public opinion. It was argued that very few of the
\n111 national medical associations consulted on the issue had argued
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\nfor reaffirmation and that the WMA should not attempt to hush up
\ndebate. Delegates were reminded that there was already legislation
\non physician-assisted suicide in several countries. Other speakers,
\nhowever, said it was not the WMA\u2019s role to follow public opinion
\nand argued that discussion on this policy should not be re-opened.
\nAfter further debate the Council voted to accept the recommenda-
\ntion of the Committee that the Statement on Physician-Assisted
\nSuicide be reaffirmed and invited any NMA who wished a review
\nto produce a paper.
\nClassification of 2005 Policies
\nThe Council also approved the reaffirmation of the Declaration of
\nLisbon on the Rights of the Patient, the Declaration on Eutha-
\nnasia and the Resolution on Academic Sanctions or Boycotts. It
\nagreed that the Statement on Non-discrimination in Professional
\nMembership and Activities of Physicians should undergo a minor
\nrevision by the Secretariat and be submitted to the Committee and
\nCouncil at the next meeting.
\nDeclaration of Geneva
\nThe Council approved the Committee\u2019s recommendation to set up a
\nWork Group to review the Declaration of Geneva.
\nPerson Centered Medicine
\nThe proposal for a white paper on person-centred medicine to be de-
\nveloped for the next meeting in October was agreed by the Council.
\nInclusion of Medical Ethics and Human Rights in the Curriculum of
\nMedical Schools
\nThe Council approved the Committee\u2019s recommendation that the
\nWMA Resolution on the Inclusion of Medical Ethics and Human
\nRights in the Curriculum of Medical Schools World-Wide be cir-
\nculated to NMAs for comment.
\nFinance and planning committee
\nDues Structure
\nThe Council agreed that a recommendation should be sent to the
\nGeneral Assembly for setting a budget based on a new dues struc-
\nture.
\nFuture Meetings
\nIt was agreed to recommend to the Assembly that Zambia be the
\nvenue for the April 2017 Council meeting. Following the success-
\nful H20 meeting in Melbourne last year, the Council agreed that a
\nfurther meeting, H20+ Health Summit, be held in Istanbul,Turkey.
\nFinancial Statement
\nThe Financial Statement for 2014 was approved.
\nBusiness Development Group
\nThe report of the Group was approved.
\nIFMSA Memorandum of Understanding
\nThe Council approved a new Memorandum of Understanding be-
\ntween the WMA and the International Federation of Medical Stu-
\ndents Associations.
\nSocio medical affairs committee
\nSocial Determinants of Health
\nSir Michael Marmot welcomed the offer from the Zambian Medi-
\ncal for Zambia to become part of the global movement in support
\nof the Social Determinants of Health. He said that to become an
\nactive partner needed the support of the NMA, a university and the
\ngovernment.
\nProposed Declaration on Alcohol
\nThe Council considered the proposed Declaration on Alcohol which
\nhad been brought forward by the Australian Medical Association. It
\nwas proposed that there should be an amendment to the document\u2019s
\nwording on reducing the impact of harmful alcohol consumption in
\nat risk populations,such as children and young people,alcohol depen-
\ndents, pregnant and breast-feeding women, \u2018and minority groups\u2019. It
\nwas proposed that the words \u2018and minority groups\u2019be deleted because
\nin some countries minority groups did not see themselves at risk.This
\nled to a lengthy debate and opposition from the Australian Medi-
\ncal Association on the grounds that it was imperative to highlight
\nAustralia\u2019s indigenous population. Two further amendments were
\nproposed, one to reword the statement to read \u2018and some minority
\ngroups\u2019 and the other to \u2018vulnerable groups\u2019. Other speakers argued
\nthat the document should not list particular groups, which led to a
\nlively debate.The meeting eventually decided to amend the document
\nto read \u2018Reduce the impact of harmful alcohol consumption in at risk
\npopulations\u2019 and the Council approved the Declaration as amended
\nfor forwarding to the General Assembly for approval and adoption.
\nProposed Statement on Physicians\u2019 Well-Being
\nThe Council agreed that the proposed Statement on Physicians\u2019
\nWell-Being be recirculated to NMAs for comments.
\nStatement on Providing Health Support to Street Children
\nThe Council agreed that the proposed Statement on Providing
\nHealth Support to Street Children should be forwarded to the
\nGeneral Assembly for approval and adoption.
\nStatement on Riot Control Agents.
\nThe Council agreed to send the renamed Statement on Riot Con-
\ntrol Agents to the General Assembly for approval and adoption.
\nMobile Health
\nThe Council approved the proposed Statement on Mobile Health
\nand agreed that it be forwarded to the General Assembly for
\n\u00adapproval and adoption.
\nWorld Day for Eliminating Violence Against Health Professionals
\nThe Council agreed that the proposed Statement on a World Day
\nfor Eliminating Violence Against Health Professionals be forward-
\ned to the Advocacy Group for considering possible action.
\nNuclear Weapons
\nThe proposed Statement on Nuclear Weapons was accepted and the
\nCouncil agreed that it should be sent to the General Assembly for
\napproval and adoption.
\nAgeing
\nThe Council agreed that a Work Group be set up with the mandate
\nto produce a draft policy on ageing.
\nReclassification of Policies
\nThe Council agreed that several 10-year-old SMAC policies should
\nbe reclassified as recommended by the Committee.
\nResolution on Trade Agreements and Public Health
\nThe Council approved the emergency Resolution on Trade Agree-
\nments and Public Health without debate.
\nWorld Health Assembly
\nDelegates heard a report on likely items to be discussed at the World
\nHealth Assembly agenda in May. This included the Millennium
\nDevelopment Goals, air pollution, anti-microbial resistance and the
\n\u00adSocial Determinants of Health.Side events included a WHPA Lead-
\nership Forum,the WHPA luncheon celebrating collaborative practice
\nand the WMA luncheon on the topic of investments and their effects
\nin health and healthcare.The Junior Doctors Network would also be
\nhaving a side event with the International Committee of the Red
\nCross on the roles of education and training for preparing students
\nand junior doctors for their possible roles for health care in danger.
\nSocial Determinants of Health
\nThe Council decided to upgrade the WMA Statement on the Social
\nDeterminants of Health. It was decided that the Statement should
\nbe named the Declaration of Oslo. The Council agreed to recom-
\nmend this change to the General Assembly for adoption.
\nWorld Veterinary Association
\nThe meeting concluded with an address from Dr.\u00a0Ren\u00e9 Carlson,
\nPresident of the World Veterinary Association. Dr.\u00a0Carlson, a gen-
\neral private practitioner, said she wanted to share two very impor-
\ntant messages with the WMA. The first was the common ground
\non which the two organisations could collaborate. These included
\nzoonotic diseases, such as rabies. Rabies still killed around 60,000
\nhumans every year primarily through exposure to unvaccinated and
\ninfected dogs.It killed more people every year than Ebola had killed
\nover several decades. Yet rabies was almost one hundred per cent
\npreventable. If the WMA and WVA worked together to strengthen
\nhealth care systems, and advocate to the appropriate government
\nagencies to establish policies that would protect their own citizens\u2019
\nlives, they could have a large impact on improving human and ani-
\nmal health just by eliminating dog-mediated human rabies.
\nA second area of collaboration was animal welfare, which directly
\naffected human well-being in many cases. Healthy and well-cared
\nfor animals produced a safer, more nutritious, more abundant, and
\nmore economically profitable and affordable food supply.
\nA third area was good quality education which improved the
\n\u00adknowledge and core competencies of veterinarians around the world
\nas it did for physicians, and which benefited the global public good.
\nFinally was pharmaceutical stewardship. According to the World
\nHealth Organization, antimicrobial resistance was the next major
\nglobal public health threat. Physicians and veterinarians must be
\npart of the solution and must work together to move toward keeping
\npeople and animals healthy in the first place, rather than depending
\non medicines to treat the consequences of poor management and
\nillness, especially with excessive use of antimicrobials.
\nHer second message was that the WMA and the WVA were hosting
\nthe Global Conference on One Health in Madrid shortly, along with
\nthe Spanish Medical and Veterinary Associations.This meeting could
\nbe a real turning point and was receiving a lot of attention world-
\nwide.This was their opportunity to move past the usual rhetoric and
\ncontinuing justification that One Health issues were important from
\nboth their perspectives. But they must define how they could truly
\nbridge the gap between the two professions to strengthen collabora-
\ntion as these diseases became more prominent in the future.
\nDr.\u00a0Carlson concluded: \u2018The continuing good collaboration between
\nour two organizations is both important and beneficial in many ways.
\nPeople are intricately interconnected to animals as fellow members of
\nthe animal kingdom.We know why we should work together,so now
\nhow do we work together to more effectively protect and improve
\nthe health of humans, animals, and our planet? That is the question
\nwe want to answer next month in Madrid. For that to happen, it is
\nimportant that both physicians and veterinarians attend that meeting.
\n\u2019If we continue to work jointly on many of these common issues, we
\nwill become a working model for national and regional collabora-
\ntion between our two professions leading to a much greater impact
\non improving human, animal, and environmental health\u2019.
\nMr. Nigel Duncan,
\nPublic Relations Consultant, WMA
\nBACK TO CONTENTS
\n52 53
\nWMA News WMA News
\nPreamble
\nTrade agreements are sequelae of globaliza-
\ntion and seek to promote trade liberaliza-
\ntion. They can have a significant impact on
\nthe social determinants of health and thus
\non public health and the delivery of health
\ncare.
\nTrade agreements are designed to produce
\neconomic benefits. Negotiations should
\ntake account of their potential broad impact
\nespecially on health and ensure that health
\nis not damaged by the pursuit of potential
\neconomic gain.
\nTrade agreements may have the ability to
\npromote the health and wellbeing of all
\npeople, including by improving economic
\nstructures, if they are well constructed and
\nprotect the ability of governments to legis-
\nlate,regulate and plan for health promotion,
\nhealth care delivery and health equity, with-
\nout interference.
\nBackground
\nThere have been many trade agreements
\nnegotiated in the past. New agreements
\nunder negotiation include the Trans Pa-
\ncific Partnership (TPP), [1] Trans At-
\nlantic Trade and Investment Partner-
\nship (TTIP)[2], the Trade in Services
\nAgreement (TiSA) and the Compre-
\nhensive Economic and Trade Agreement
\n(CETA\u00a0[3].
\nThese negotiations seek to establish a global
\ngovernance framework for trade and are un-
\nprecedented in their size, scope and secrecy.
\nA lack of transparency and the selective
\nsharing of information with a limited set of
\nstakeholders are anti-democratic.
\nInvestor-state dispute settlement (ISDS)
\nprovides a mechanism for investors to bring
\nclaims against governments and seek com-
\npensation, operating outside existing sys-
\ntems of accountability and transparency.
\nISDS in smaller scale trade agreements has
\nbeen used to challenge evidence-based pub-
\nlic health laws including tobacco plain pack-
\naging. Inclusion of a broad ISDS mecha-
\nnism could threaten public health actions
\ndesigned to effect tobacco control, alcohol
\ncontrol, regulation of obesogenic foods and
\nbeverages, access to medicines, health care
\nservices, environmental protection\/climate
\nchange and occupational\/environmental
\nhealth improvements. This especially in na-
\ntions with limited access to resources.
\nAccess to affordable medicines is critical to
\ncontrolling the global burdens of communi-
\ncable and non-communicable diseases. The
\nWorld Trade Organization\u2019s Agreement
\non Trade-Related Aspects of Intellectual
\nProperty Rights (TRIPS) established a set
\nof common international rules governing
\nthe protection of intellectual property in-
\ncluding the patenting of pharmaceuticals.
\nTRIPS safeguards and flexibilities includ-
\ning compulsory licensing seek to ensure that
\npatent protection does not supersede public
\nhealth.\u00a0[4].
\nTiSA may impact on eHealth provision by
\nchanging rules in licensing and telecoms.Its
\nimpact on the delivery of eHealth could be
\nsubstantial and damage the delivery of com-
\nprehensive, effective, cost-effective efficient
\nhealth care.
\nThe WMA Statement on Patenting Medi-
\ncal Procedures states that patenting of diag-
\nnostic, therapeutic and surgical techniques
\nis unethical and \u201cposes serious risks to the
\neffective practice of medicine by potentially
\nlimiting the availability of new procedures
\nto patients.\u201d
\nThe WMA Statement on Medical Work-
\nforce states that the WMA has recognized
\nthe need for investment in medical educa-
\ntion and has called on governments to \u201c\u2026
\nallocate sufficient financial resources for the
\neducation, training, development, recruit-
\nment and retention of physicians to meet
\nthe medical needs of the entire popula-
\ntion\u2026\u201d
\nThe WMA Declaration of Delhi on Health
\nand Climate Change states that global cli-
\nmate change has had and will continue to
\nhave serious consequences for health and
\ndemands comprehensive action.
\nRecommendations
\nTherefore the WMA calls on national gov-
\nernments and national member associations
\nto: Advocate for trade agreements that pro-
\ntect, promote and prioritize public health
\nover commercial interests and ensure wide
\nexclusions to secure services in the pub-
\nlic interest, especially those impacting on
\nindividual and public health. This should
\ninclude new modalities of health care pro-
\nvision including eHealth, Tele-Health,
\nmHealth and uHealth.
\nEnsure trade agreements do not interfere
\nwith governments\u2019 ability to regulate health
\nand health care, or to guarantee a right to
\nhealth for all. Government action to protect
\nand promote health should not be subject to
\nchallenge through an investor-state dispute
\nsettlement (ISDS) or similar mechanism.
\nOppose any trade agreement provisions
\nwhich would compromise access to health
\nWMA Council Resolution on Trade Agreements and Public Health
\nAdopted by the 200th
\nWMA Council Session, Oslo, April 2015
\ncare services or medicines including but not
\nlimited to:
\n\u2022\t Patenting (or patent enforcement) of diag-
\nnostic,therapeutic and surgical techniques;
\n\u2022\t \u201cEvergreening\u201d, or patent protection for
\nminor modifications of existing drugs;
\n\u2022\t Patent linkage or other patent term ad-
\njustments that serve as a barrier to generic
\nentry into the market;
\n\u2022\t Data exclusivity for biologics;
\n\u2022\t Any effort to undermine TRIPS safe-
\nguards or restrict TRIPS flexibilities in-
\ncluding compulsory licensing;
\n\u2022\t Limits on clinical trial data transparency.
\nOppose any trade agreement provision
\nwhich would reduce public support for or
\nfacilitate commercialization of medical ed-
\nucation.
\nEnsure trade agreements promote environ-
\nmental protection and support efforts to
\nreduce activities that cause climate change.
\nCall for transparency and openness in
\nall trade agreement negotiations includ-
\ning public access to negotiating texts and
\nmeaningful opportunities for stakeholder
\nengagement.
\nReferences
\n1.\t TPP negotiations currently include twelve par-
\nties: the United States, Canada, Mexico, Peru,
\nChile, Australia, New Zealand, Brunei, Singa-
\npore, Malaysia, Japan and Vietnam.
\n2.\t TTIP negotiations currently include the Euro-
\npean Union and the United States.
\n3.\t CETA negotiations currently include the Euro-
\npean Union and Canada.
\n4.\t See World Trade Organization, Declaration on
\nTRIPS and Public Health (\u201cDoha Declaration\u201d)
\n(2001).
\nThe Sixty-eighth session of the World
\nHealth Assembly, the supreme decision-
\nmaking body of the World Health Organ-
\nisation, was held in Geneva May 18\u201326.
\nAs usual it attracted to the city an array
\nof world leaders, health ministers, chief
\nmedical officers, global leaders from the
\nhealth professions and countless lobby-
\nists. More than 3000 delegates from the
\nWHO\u2019s 194 Member States, including
\na large proportion of the world\u2019s health
\nminis\u00adters, \u00adattended the Assembly. This
\nyear, the WMA leaders who were present
\nwere ably assisted by a particularly active
\ngroup from the Junior Doctors Network
\n(JDN), as well as by representatives from
\nthe International Federation of Medi-
\ncal Students Associations (IFMSA), with
\nwhom the WMA has recently signed a
\nMemorandum of Understanding.
\nDuring the Assembly delegates discussed
\na host of topics, including antimicrobial
\nresistance, Ebola, epilepsy, the Interna-
\ntional Health Regulations, malaria, nu-
\ntrition, polio, public health, innovation,
\nintellectual property, counterfeit medical
\nproducts, surgical care and anaesthesia.
\nThey also reviewed progress reports on a
\nwide range of issues such as adolescent
\nhealth, immunization, noncommunica-
\nble diseases, women and health, and the
\nWHO\u2019s response to severe, large-scale
\nemergencies. This year, for the first time,
\nthe WHO provided a live feed from the
\nAssembly to allow people to follow its
\nproceedings remotely. Although the offi-
\ncial Assembly dominated the week, it was
\nthe many side events and unofficial meet-
\nings held simultaneously that proved just
\nas beneficial.
\nDuring the weekend before the Assembly
\nopened, the World Health Professions
\nAlliance held a successful Leadership
\nForum, bringing together representatives
\nfrom the nursing, pharmaceutical, physi-
\ncal therapy, dental and medical associa-
\ntions. The Forum held two sessions, one
\ndevoted to discussing human resources as
\na health component in all WHO policies
\nand the other concerning issues around
\nageing populations and the ageing health
\nworkforce.
\nParticipants discussed the fact that health
\nworkforce implications were often largely
\nignored when public health goals were set,
\nas was the case when targets were set for
\nboth the Millennium Development Goals
\nand the Sustainable Development Goals.
\nOn the issue of ageing populations, the Fo-
\nrum considered the challenges that would
\nbe faced as the number of citizens over 65
\nincreased to almost 30 per cent by 2060,
\nwhile those over 80 would nearly triple.
\nDuring this time, health and health care
\nservices would need to adapt to a growing
\ndemand.
\nAt the same time as the WHPA Forum
\nwas meeting, the WMA\u2019s Junior Doc-
\ntors Network was gathering to prepare
\nits activities for the week. It organized a
\ntwo-day workshop at the WMA office in
\nFerney-Voltaire which was attended by
\nmore than twenty JDN members from
\nfour continents. The focus of the work-
\nshop was on preparing JDN delegates for
\nthe Assembly.
\nJDN members met with Dr.\u00a0Xavier Deau,
\nWMA President, and Dr.\u00a0Otmar Kloiber,
\nWMA Secretary General. Highlights in-
\ncluded discussions on the International
\nRecruitment of Healthcare Personnel, in-
\nfluenza preparedness with Dr.\u00a0 Julia Seyer
\nfrom the WMA, Emergency and Disaster
\nRisk Reduction, Air Pollution and Climate
\nChange, advocacy at the WMA and trade
\nand health.
\nWorld Health Assembly Week
\nGeneva, May 18\u201326, 2015
\nBACK TO CONTENTS
\n54 55
\nWMA News WMA News
\nDr.\u00a0 Caline Mattar, Chair of the JDN\u2019s
\nPre-WHA Organizing Committee, pro-
\nvided attendees with an introduction to
\nthe WHA and what to expect for the
\nweek to come. In addition, JDN mem-
\nbers joined the International Federation
\nof Medical Students\u2019 Associations\u2019 Pre-
\nWHA workshop at the Graduate Institute
\nin Geneva for a successful panel discussion
\nand collaborative issue-based small group
\nsessions on human resources for health,
\nclimate change and antimicrobial resis-
\ntance.These sessions prepared participants
\nfor the Assembly and provided the oppor-
\ntunity to learn more about WHA agenda
\nitems.
\nRepresentatives from both the JDN and
\nIFMSA helped to prepare the various in-
\nterventions to be made by the WMA and
\nthe WHPA to the Assembly during the
\nweek.
\nOn the Monday morning, while thousands
\nof delegations gathered for the opening
\nof the Assembly, leaders of the World
\nHealth Professions Alliance were meet-
\ning a group of African journalists to brief
\nthem on the events of the coming week.
\nOrganised by the World Health Editors
\nNetwork and its founder Franklin Apfel,
\nthe gathering allowed the Presidents and
\nCEOs of the five WHPA professions to
\ntalk to the African media about their pri-
\norities at the \u00adAssembly and their respective
\nroles. Among the priorities mentioned by
\nthe WHPA leaders were childhood obe-
\nsity, antimicrobial resistance, the social
\ndeterminants of health and the problem of
\ncounterfeit medicines.
\nThis was followed by a meeting between
\nthe WHPA leaders and representatives
\nfrom the World Health Students Alli-
\nance and the International Federation of
\nMedical Students Associations. This was
\na useful opportunity for student bodies to
\nexplain to the leaders of the global health
\nprofessions the role and workings of their
\norganizations.
\nMeanwhile, at the UN Palais des Nations
\nthe World Health Assembly was getting
\nunder way with an opening address from
\nAngela Merkel, Chancellor of the Federal
\nRepublic of Germany. She said that the
\nWHO was the only international organiza-
\ntion that had universal political legitimacy
\non global health issues, but said she would
\nlike to see a new plan to deal with \u201ccatas-
\ntrophes\u201dlike the recent Ebola outbreak.The
\noutbreak had highlighted the critical need
\nfor urgent, collaborative action in emergen-
\ncies, and the importance of having efficient
\nstructures in place.
\nShe said that under Germany\u2019s presidency,
\nthe G7 would focus on fighting antimi-
\ncrobial resistance and neglected tropical
\ndiseases. She emphasized the need for all
\ncountries to have strong health systems and
\nhighlighted the key role of health in sus-
\ntainable development.
\nIn the afternoon, WHO Director-\u00ad
\nGeneral Dr.\u00a0Margaret Chan spoke about
\nthe WHO\u2019s response to the Ebola out-
\nbreak and criticism that it should have re-
\nacted earlier. She admitted that the world
\nwas ill prepared to respond to the out-
\nbreak, but promised that the WHO would
\nlearn from what happened and would not
\nbe overwhelmed again. She outlined new
\nplans to create a single new WHO pro-
\ngramme for health emergencies, uniting
\noutbreak and emergency resources across
\nthe three levels of the Organization. She
\nsaid she had heard what the world expect-
\ned from the WHO and she promised it
\nwould deliver.
\nThe new programme would set up a new
\nglobal health emergency workforce, as well
\nas strengthening its own core and surge ca-
\npacity of trained emergency response staff.
\nDr.\u00a0 Chan reiterated Chancellor Merkel\u2019s
\npoints about the importance of building
\nresilient health systems and defeating an-
\ntimicrobial resistance, citing the \u201cspectre
\nof a post-antibiotic era in which common
\ninfections will once again kill,\u201d and urging
\n\u00addelegates to adopt the draft global action
\nplan on antimicrobial resistance on this
\nyear\u2019s Assembly agenda.
\nShe also noted the need to ensure that
\nthe International Health Regulations, the
\nworld\u2019s legal instruments for outbreak pre-
\nparedness and response, were effective. She
\nurged the delegates to ready themselves for
\nthe post-2015 development agenda and to
\nensure that health received the attention,
\nand the resources it needed
\nAt lunchtime on the Monday the WHPA
\nheld its annual reception at the InterCon-
\ntinental Hotel when it presented the first
\nof what will become an annual award for
\ncollaborative practice. This is a new award
\nwhich aims to recognise an outstanding in-
\nterprofessional team which has improved
\npatients\u2019 health and promoted a collabora-
\ntive approach to healthcare.
\nThe winner of the award was the Thai
\nHealth Professional Alliance Against To-
\nbacco (THPAAT). The award was present-
\ned by Dr.\u00a0 Carmen Pe\u00f1a, President of the
\nWorld Dental Federation. She reminded
\nthe audience that the WHPA spoke for
\nmore than 26 million healthcare profession-
\nals through more than 600 national associa-
\ntions of healthcare professionals.
\nShe went on: \u201cWHPA works to improve
\nglobal health and the quality of patient
\ncare and facilitates collaboration among the
\nhealth professions and major stakehold-
\ners. For several years, our motto has been
\n\u201cTeaming up for better health\u201d and clearly,
\nthis is the vision that guided our activities:
\nwe believe that healthcare professionals\u2019im-
\npact is bigger when we are working in syn-
\nergy.\u201d
\nIn 2013 the WHPA adopted its joint state-
\nment on Interprofessional Collaborative
\nPractice, defining collaborative practice as
\nwhen multiple health workers from dif-
\nferent professional backgrounds worked
\ntogether with patients, families, carers and
\ncommunities to deliver the highest quality
\nof care across settings.
\nDr.\u00a0Pe\u00f1a said that the Thai Health Profes-
\nsional Alliance Against Tobacco brought
\ntogether more than 21 different associa-
\ntions, most being healthcare professionals
\nbodies. It had initiated many projects cov-
\nering different areas such as public promo-
\ntion of smoking-free environment, educa-
\ntion, and national health policy. It was also
\nthe pioneer in starting educational centres
\non tobacco hazard in 12 provinces of Thai-
\nland.
\nThe WHPA award was received by Prof.
\nDr.\u00a0 Somsri Pausawasdi, President of the
\nTHPAAT and CEO of the Medical Asso-
\nciation of Thailand. She said that THPAAT
\nwas established in 2005 under the vision of
\nthe Medical Association of Thailand and a
\ntime when the King of Thailand, Bhumibol
\nAdulyadej, had expressed his wish to reduce
\nthe growing problems of cigarettes addic-
\ntion in Thailand. The Medical Association
\nof Thailand had responded to the King\u2019s
\nwish and to the WHO campaign by initiat-
\ning the THPAAT with the goal of recruit-
\ning a mixture of health professionals for an
\nantismoking campaign.
\nShe went on: \u201cIt was clear that the best
\nway to accomplish our goals was to create
\na collaborative interprofessionals team and
\nthus the Medical Association collaborated
\nwith the Thai Health Foundation and re-
\ncruited four more organizations including
\nthe Pharmacy Council,the Nurses\u2019Associa-
\ntion, the Dental Association, and the Public
\nHealth association to join the team. Over
\nthe years, our network has expanded and
\nwe currently comprise 21 different health
\nprofessional bodies under the support of the
\nThai government.The goals of our team are
\nto promote a reduction in tobacco use and
\nenforce the smoking free society as national
\nhealth policy.\u201d
\nShe said the Alliance\u2019s activities included
\nthe aim of improving the awareness of
\ntobacco hazards to all levels of education,
\ncreating a national network of 321 smok-
\ning cessation clinics in the network hos-
\npitals in over 77 provinces throughout the
\nnation and conducting research in 85 proj-
\nects.
\nDr.\u00a0Somsri Pausawasdi continued stating:
\n\u201cThe ultimate goal of our campaign is to
\ncreate a tobacco-free environment for the
\nnation. We now have smoking-free envi-
\nronment in 47 universities, all hospitals
\nand most of the pharmacy in the nation.
\nWe have implemented a larger graphic
\nhealth warning on cigarette packages from
\n55% to 85% of the cover and actively in-
\nvolved in the national policy on tobacco
\ncontrol.
\nFinally, we have joined together with other
\norganizations and many foundations to
\ninitiate \u201cthe National Alliance for To-
\nbacco Free Thailand-NATFT\u201d in 2013 to
\npush forward the act of legislation on to-
\nbacco control for our nation. Currently, the
\nNATFT has more than 1,400 members
\nand 729 organizations. We are working to-
\nwards the United Nations policy on non-
\ncommunicable diseases (NCD) to decrease
\nthe tobacco consumption rate to 15% by
\nthe year 2025.
\nWe do hope that our experience can inspire
\nsome tobacco control initiatives in many
\ncountries,and together we create a healthier
\nworld for us and for our next generations
\nto come.\u201d
\nThe following day it was the turn of the
\nWMA to host its annual luncheon semi-
\nnar at the Pavillon Gallatin, Chateau de
\n\u00adPenthes. This year the theme was \u201cHealth
\nSupport to Street Children\u201d and the speak-
\ner was WMA President Dr.\u00a0Xavier Deau.
\nHe began by saying that the United Na-
\ntions had estimated there could be around
\n150 million street children throughout the
\nworld. This was \u201ca worldwide and grow-
\ning phenomenon\u201d. He said physicians were
\noften the first point of contact for these
\nchildren and should use their trusted posi-
\ntions and skills to reintegrate these children
\nback into society. He also said that national
\nmedical associations had an important role
\nto play in educating their members about
\nwhat they could do to help.
\nDr.\u00a0 Deau quoted WMA policy deriving
\nfrom the Declaration of Ottawa on Child
\nHealth adopted in 1998. This stated that
\nchildren needed to grow up in a place where
\nthey could thrive, spiritually, emotionally,
\nphysically and intellectually. This required
\na safe and secure environment, the oppor-
\ntunity for growth and development, health
\nservices when needed and monitoring and
\nresearch for evidence-based continual im-
\nprovement.
\nHe said that assisting street children re-
\nquired a method, such as a multi profes-
\nsional team including health professionals,
\nsocial workers, drivers, teachers and police.
\nThere had to be a medical and psycho-social
\napproach and co-operation with local and
\ngovernmental authorities.
\nHe said that although there was no official
\ndefinition of street children, all such child\u00ad
\nren faced common issues\u00a0 \u2013 they suffered
\nfrom a lack of cultural identity, they lived
\nin the streets, they were no longer part of
\nany social or family environment, they were
\norganised in small societies and they hardly
\nsurvived.
\nFinally, Dr.\u00a0Deau said that at the WMA\u2019s
\nGeneral Assembly in Moscow delegates
\nwould consider a new Statement for adop-
\ntion, calling for all street children to be
\nprovided with care and where necessary
\nreturned to a living environment. He said
\nthat remaining indifferent towards street
\nchildren was not an option.
\nDuring the Assembly,the JDN and \u00adIFMSA
\ndelivered a number of interventions they
\nhad drafted on behalf of the WMA and\/
\nor World Health Professions Alliance.
\nThese were based on the WMA policy and
\nBACK TO CONTENTS
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\nWMA News GERMANY Epidemiology
\nin collaboration with the WMA staff and
\nleadership and included interventions on
\nantimicrobial drug resistance, polio, non-
\ncommunicable diseases, climate change and
\nEbola.
\nOn the Global Action Plan on Antimicro-
\nbial Drug Resistance the WMA said that
\nantimicrobial resistance was a threat to all
\ncountries without regard for geographical
\nboundaries. A commitment was needed
\nfrom both member states and the WHO
\nto ensure financial sustainability to imple-
\nment interventions in LMICs. The WMA\u2019s
\nintervention emphasized that the Global
\nAction Plan could not be separated from
\nstrengthening healthcare systems, building
\non lessons learned from the Ebola epidemic.
\nA focus on access to primary care, availabil-
\nity of diagnostic labs including rapid diag-
\nnostic methods and surveillance systems
\nwas needed to fight the spread of resistant
\npathogens. The Assembly went on to agree
\non resolutions to improve access to afford-
\nable vaccines.
\nOn polio eradication, the WMA said, it
\nhad condemned in the strongest terms the
\nrecent killing of five health care workers in
\nPakistan while providing polio immuniza-
\ntion to the citizens of Pakistan. This trag-
\nedy had underscored the urgent need to
\nensure the protection of health care work-
\ners in conflict areas. It urged the WHO
\nand member states to ensure adequate se-
\ncurity for the healthcare workers to enable
\neffective implementation of immunization
\nprotocols, to develop systems sensitive sur-
\nveillance and immediate notification to the
\nWHO of any detected poliovirus transmis-
\nsion and to implement adequate immuni-
\nzation training for health professionals.The
\nWMA also wanted to see an increase in
\neffective public awareness and education to
\nprevent and dispel myths.
\nThe IFMSA spoke about the need to
\ntackle, prevent and control the global
\nburden of noncommunicable diseases
\n(NCDs), and reduce the worldwide mor-
\nbidity and mortality related to cardiovas-
\ncular diseases, cancers, chronic respiratory
\ndiseases and diabetes, as well as reduce the
\nfour shared risk factors. It strongly recom-
\nmended that interventions aimed at re-
\nducing the burden of NCDs must include
\naddressing risk factors during childhood
\nand adolescence.
\nThe IFMSA also spoke on the issue of
\nhealth in the post-2015 development agen-
\nda asking the WHO to focus its attention
\non supporting the development of realistic
\ntargets and clear indicators, which would
\nremain a main topic of discussions in the
\nfollowing months. However, it referred to
\nthe absence of several important health
\n\u00adareas, such as recognizing primary health
\ncoverage and the importance of health lite\u00ad
\nracy, patient centered care and patient em-
\npowerment.
\nOn the issue of the International Recruit-
\nment of Health Personnel, the IFMSA
\nraised a concern that the current Code was
\nmainly focused on regulating the migra-
\ntion of health personnel. It was important
\nthat member states tackled fundamental
\nfactors that caused the migration, such as
\npoor or unsafe practice environments, poor
\neducation and excessive workload. Medical
\nstudents were facing mental and physical
\nstrain, harming their practice, decreasing
\npatient safety and exponentially increas-
\ning the costs of healthcare systems, and
\nsometimes even leading to suicide. Health
\nworkers and students must be protected
\nfrom violence, discrimination and exploi-
\ntation in the workplace, and be allowed to
\noperate within a positive practice environ-
\nment that guaranteed occupational safety
\nand health.
\nThe Assembly passed several landmark
\nresolutions on air pollution, on epilepsy and
\nthe next steps in finalizing the framework of
\nengagement with non state actors.
\nAmong the many side events attended by
\nWMA representatives and JDN delegates
\nwas one which the JDN co-hosted with the
\nInternational Committee of the Red Cross
\non the Healthcare in Danger. This focused
\non the role of education and training in ad-
\ndressing healthcare in danger and featured
\na panel discussion including Dr.\u00a0 Ahmed
\nBerzig (Head of Health Unit, ICRC),
\nProf. David Gordon (President, WFME),
\nDr.\u00a0 Bruce Eshaya-Chauvin (Medical Ad-
\nviser,Healthcare in Danger) and Dr.\u00a0\u00adAhmet
\nMurt (Chair, JDN).
\nAt the end of the Assembly, IFMSA Presi-
\ndent Agostinho Sousa said: \u201cThe voices of
\nmedical students, and of youth more gener-
\nally,have been recognized several times dur-
\ning this World Health Assembly. Addresses
\nby Dr.\u00a0 Margaret Chan, Director General
\nof the World Health Organisation, and
\nreferences made by numerous Ministers of
\nHealth or their representatives, have shown
\nthe crucial role that future health profes-
\nsionals play in shaping the global health
\nagenda.\u201d
\nThe Assembly ended with thousands of
\ndelegates returning to their countries, feel-
\ning they had spent a worthwhile 10 days in
\nGeneva.
\nAmong the JDN representatives who spoke
\nat the Assembly were:
\nDr.\u00a0Ahmet Murt (JDN Chair) speaking at
\nthe Assembly
\nDr.\u00a0Thorsten Hornung (JDN)
\nDr.\u00a0Kostas Roditis (JDN)
\nDr.\u00a0Mike Kalmusz-Elias (JDN)
\nMr. Nigel Duncan,
\nPublic Relations Consultant,
\nWMA
\nIn March 2014, the Ebola virus was iden-
\ntified as the force behind a wave of illness
\nin Guinea. According to the latest figures
\nfrom the WHO, there have been nearly
\n27,000 cases of Ebola reported in West
\nAfrica and 11,120 deaths. The approach
\ntaken in response to previous outbreaks of
\nthe Ebola virus (i.e. quarantining patients
\nand monitoring their immediate social cir-
\ncles) proved to be inadequate in this case
\ndue to the mobility of the population and
\nthe prolonged duration of the disease. As
\na result, major cities in West Africa had to
\ncontend with large numbers of victims for
\nthe first time.
\nOne particular problem facing the affect-
\ned countries was the lack of appropriately
\ntrained professionals needed to contain the
\nvirus. In Germany, the German Medical
\nAssociation teamed up with the Federal
\nMinistry of Health and the German Red
\nCross, as well as the national professional
\nassociations of physicians, to promote vol-
\nunteer efforts in the affected regions. On an
\ninternational level, the World Medical As-
\nsociation and the Standing Committee of
\nEuropean Physicians (CPME) called for
\nconcrete measures to contain the virus. The
\nnecessary structures must be developed on
\na national and international level in order
\nto combat epidemics more efficiently in the
\nfuture. Providing protection for physicians
\nbefore,during and after they engage in relief
\nefforts is a key component of this.This pro-
\ntection must include, for example, guaran-
\nteed repatriation for physicians in the case
\nof infection, access to comprehensive medi-
\ncal and psychological care upon their return,
\nas well as sufficient life insurance.
\nIn hindsight, we must concede that govern-
\nments, the scientific community and relief
\norganisations underestimated the severity
\nof the Ebola crisis in West Africa for far
\ntoo long. Although the situation appears
\nto be largely under control and the Ebola
\nepidemic is now only a passing reference in
\nthe media, we cannot fall back into the old
\nhabit of ignoring and avoiding the problem.
\nThe Ebola outbreak continues to demand
\nthe full attention of the international com-
\nmunity.
\nAt the same time, it demonstrates by exam-
\nple that in a globalised world,epidemics not
\nonly have the potential to wipe out entire
\npopulations, but also that they do not stop
\nat national borders, nor are they confined
\nto certain continents. We must work to de-
\nvelop effective global strategies to ensure
\nthat viruses can be contained early going
\nforward. These strategies must incorporate
\nelements of prevention, as well as rapid re-
\nsponse facilities.
\nThe Ebola outbreak made it clear that vac-
\ncines, a sensible tool for combating epidem-
\nics,were initially not developed by the phar-
\nmaceutical industry because the market was
\nnot deemed profitable enough. Although
\nthere are promising trials in progress, there
\nis still no approved vaccine available. The
\nWorld Medical Association and the CPME
\nhave demanded that adequate funding fi-
\nnally be made available for immunization
\nprogrammes and for vaccine research and
\ndevelopment. The Declaration of Helsinki
\ncan and must serve as the basis for these de-
\nvelopments. But this call from the Europe-
\nan and global medical communities should
\nnot be limited to research focused on Ebola
\nvaccines. As a matter of principle, if there is
\na lack of incentives for conducting research
\nand if the development of diagnostic tests,
\ntherapies and vaccines is not being pursued
\nrigorously, governments are called upon to
\ntake effective measures in this regard, start-
\ning with providing access to adequate finan-
\ncial resources.
\nAbove and beyond research into vaccines,
\nthe international community and, in partic-
\nular,the industrialised world are called upon
\nto provide the resources needed to develop
\nthe appropriate infrastructure to ensure
\nthe early containment of epidemics. The
\n\u00adGerman government recently announced
\nthat it will earmark 200 million euros in
\nfunding to support the development of
\nhealthcare systems in the countries affected
\nby this crisis. The administration also plans
\nto organise a team of physicians and other
\nmedical personnel that could be deployed
\nanywhere in the world within three to
\nfive days, and to provide additional medi-
\ncal supplies, like field hospitals and mobile
\nlaboratories. However, a breakthrough will
\nonly be possible if the G7 countries agree to
\ncoordinate their activities effectively on an
\ninternational level and to commit sufficient
\nfinancial resources. It is therefore a welcome
\nsign that neglected diseases and diseases
\nassociated with poverty, as well as Ebola,
\nwere addressed at this year\u2019s G7 summit in
\n\u00adGermany.
\nFrank Ulrich Montgomery
\nGlobal Epidemics. Industrialised Nations Must Develop Global
\nStrategies to Counter Epidemics
\nBACK TO CONTENTS
\n58 59
\nClimate changesClimate changes
\nThe 21st
\nConference of the Parties
\n(COP21) to the UN Framework Conven-
\ntion on Climate Change (UNFCC) will
\nbe held in Paris for two weeks from No-
\nvember 30 to December 11, 2015. COP21
\nis practically the last opportunity to reach
\nan agreement on a plan where all nations
\nwould participate to achieve substantive
\nreduction in greenhouse gas emissions to
\nlimit global warming within 2 \u00b0C. That is
\nwhy some are even calling it the \u201chistoric
\ntwo weeks.\u201d
\nDue to the earth\u2019s feed-back mechanism,
\nany change, once gaining enough mo-
\nmentum in a certain direction, becomes
\nextremely difficult to reverse. Even if all
\nemission of greenhouse gas is stopped now,
\nit would still be difficult to completely pre-
\nvent global warming. The goal of limiting
\nglobal warming to 2 \u00b0C is the minimum
\nmeasure necessary to prevent the worst
\ncase scenario.
\nHealth needs to be given the greatest pri-
\nority in efforts to minimize climate change.
\nClimate change causes change in tempera-
\nWest Africa\u2019s Ebola epidemic demon-
\nstrated the consequences of uncontrolled
\noutbreaks of infectious disease. For this
\nreason, this year\u2019s 118th
\nGerman Medi-
\ncal Assembly in Frankfurt deliberated
\nthe most pressing issues relating to civil
\nprotection under the heading \u201cMedicine
\nin times of global epidemics\u201d. The discus-
\nsion was initiated by presentations meant
\nto shed light on the domestic and inter-
\nnational aspects of battling global epidem-
\nics. Dr.\u00a0 Tankred St\u00f6be, chairman of the
\nboard of the German chapter of M\u00e9decins
\nSans Fronti\u00e8res (Doctors Without Bor-
\nders), drew attention to the preconditions
\nand challenges of establishing a preventive
\nmedical infrastructure in regions affected
\nby epidemics. He reported on practical
\nmeasures taken to stem the disease, which
\nincluded educating the population and in-
\ncreasing public awareness about infectious
\ndisease and safe burials, as well as efforts to
\nstrengthen countries affected by epidem-
\nics. From the perspective of an interna-
\ntional non-governmental organisation, it
\nis also essential to address what is needed
\nto protect and safeguard medical and non-
\nmedical personnel and their employment
\nrights during their deployment abroad.
\nFollowing this talk, Prof. Dr.\u00a0 Ren\u00e9
\n\u00adGottschalk, Director of the Public Health
\nOffice of the city of Frankfurt\/Main, dis-
\ncussed the domestic and European aspects
\nof the fight against global epidemics. Prof.
\nDr.\u00a0 Gottschalk addressed options for re-
\ngional, national and European crisis inter-
\nvention, as well as the limits of each. He
\nalso presented early warning and response
\nsystems for monitoring and controlling
\nthe spread of communicable diseases and
\noptions for improving risk and crisis com-
\nmunication.
\nThe level of engagement with which the
\nparliament of the German medical profes-
\nsion dealt with this issue and formulated
\npolitical demands through a very lively
\ndiscussion is noteworthy. In the battle
\nagainst global epidemics like Ebola, the
\n118th
\nGerman Medical Assembly called
\nfor Germany, Europe and the international
\ncommunity to promote the research of in-
\nfectious disease and the development and
\nimplementation of diagnostic tests, thera-
\npies and vaccines. One resolution of the
\nMedical Assembly expressed that \u201cgovern-
\nment funding must be made available for
\nthe development and provision of pharma-
\nceuticals and vaccines to curb epidemics
\nand to finance comprehensive vaccination
\nprogrammes\u201d. The parliament of physi-
\ncians also called upon drug manufacturers
\nto conduct targeted research, even at low
\nprofit margins, in order to develop the per-
\ntinent drugs and vaccines.
\nFinancial resources to combat epidemics
\nand to rebuild healthcare systems and pub-
\nlic life in the wake of an epidemic should
\nbe allocated to the affected countries in
\nthe form of a fund, according to the Medi-
\ncal Assembly. This fund should be financed
\nby the United Nations, the World Bank,
\nthe International Monetary Fund and the
\n\u00adEuropean Union, among others.The Medi-
\ncal Assembly also demanded essential pro-
\ntection for medical and non-medical per-
\nsonnel during their deployment abroad, as
\nwell as approved leaves of absence and job
\nsecurity for physicians who volunteer to
\nparticipate in aid missions.
\nThe Medical Assembly also called upon the
\nGerman federal government to establish a
\nstate-funded and organised medical relief
\norganisation to provide emergency medical
\nrelief with specially trained health profes-
\nsionals in crisis areas. This would make it
\npossible for doctors and other health profes-
\nsionals to be deployed faster by simplifying
\nthe process of obtaining approved leaves of
\nabsence from their employers and provid-
\ning social protection.The Ebola epidemic in
\nWest Africa demonstrated that the systems
\nin place for gathering the appropriate medi-
\ncal personnel to engage in crisis situations
\nwere inadequate. According to the Medical
\nAssembly, a state-organised medical relief
\norganisation must be created to work with
\nnon-governmental organisations to facilitate
\nprompt delivery of healthcare in crisis areas.
\nProf. Dr.\u00a0Frank Ulrich Montgomery,
\nPresident of the German
\nMedical Association,
\nVice-Chairperson of the WMA Council
\nE-mail: international@baek.de
\nture, wind, and precipitation with profound
\neffects on all natural systems.These, in turn,
\nhave effects on the health, safety, and liveli-
\nhoods of people-especially the poor.
\nWe have already seen previews of the
\nhealth impact that lies ahead if extreme
\nweather events continue to increase. Heat
\nwaves like the one that hit Chicago in
\n1995, killing some 750 people and hospi-
\ntalized thousands, and the 2003 European
\nheat wave, killing 21,000 to 35,000 people
\nin five countries, are becoming more com-
\nmon.
\nBut even more subtle, gradual climatic
\nchange can still harm human health. El-
\nevated carbon dioxide levels promote the
\ngrowth and sporulation of some soil fungi,
\nand diesel particles help deliver these aero-
\nallergens deeper into our alveoli and present
\nthem to immune cells along the way.
\nMosquitoes, which can carry many diseases,
\nare very sensitive to temperature changes.
\nWarming of their environment\u00a0 \u2013 even
\nwithin its viable range\u00a0\u2013 boosts their rates
\nof reproduction and prolongs their breeding
\nseason, and shortens the maturation period
\nfor the microbes they disperse. Extremely
\nwet weather may bring its own share of
\nills. Floods are frequently followed by dis-
\nease clusters. Major coastal storms can also
\ntrigger harmful algal blooms (\u201cred tides\u201d),
\nwhich can be toxic, help to create hypoxic
\n\u201cdead zones\u201d in gulfs and bays, and harbor
\npathogens.
\nThese are only a few examples of what is in
\nstore. The impact of climate change comes
\nin many shapes and sizes from not only
\ndamage from increase in harmful substances
\nor chemicals in the air but also the increase
\nin prevalence of various contagious diseases,
\nwhich are all major public health challenges.
\nIn particular, the detrimental effects of cli-
\nmate change on health are far more serious
\namong the more vulnerable population such
\nas children, the elderly and people in less
\ndeveloped countries.
\nWMA has continuously expressed its con-
\ncern over the health impact by climate
\nchange, and has worked to raise awareness
\nregarding the benefits of putting health in
\nthe center of the climate change agenda.
\nAs a way to tackle the issue in the WMA,
\nthe Environment Caucus was organized.
\nIt\u00a0aims to exchange opinions among WMA
\nmembers and related bodies regarding
\nWMA future activities related with health
\nand environment.
\nThe main activity of the Environmental
\nCaucus is sharing global trends and con-
\nference information regarding environ-
\nment and identifying common topics of
\ninterest and to discuss follow-up measures.
\nIt encourages free exchange of opinions
\nby adopting an informal setting. Major
\nthemes discussed at the Environmental
\nCaucus with regards to the direction of
\nfuture WMA activities include the role of
\nphysicians and of constituent members in
\ngreenhouse gas reduction, promoting re-
\nsearch on the health co-benefits of coun-
\ntering climate change and expansion of
\ngreen hospitals and clinics.
\nAt the last meeting of the Environmental
\nCaucus held in Oslo, Norway, during the
\n200th
\nCouncil Session of WMA, partici-
\npants all agreed on the importance of form-
\ning a coordinated voice representing the
\nentire medical community in anticipation
\nof COP 21 and shared ideas about what we
\ncan do.
\nThe discussion can be summarized into the
\nfollowing approaches:
\n1.\t Recognition of co-benefits of dealing
\nwith health issues in climate action
\n2.\t Getting involved in liaising with each
\ngovernment\u2019s negotiation representa-
\ntives
\n3.\t Active media coverages and journal ex-
\nposes
\n4.\t Collaboration with other professional
\norganizations and NGOs on joint ini-
\ntiatives on the issue
\n5.\t Promoting awareness of members on
\ngreen policies for daily operation of
\nhealth facilities.
\nAs described by LANCET, climate change
\nis \u201cthe greatest global health challenge of
\nthe 21st
\ncentury.\u201d This is a battle cry for all
\nphysicians to take on a more active role in
\ntacking climate change, and for us to feel a
\ngreater sense of responsibility starting from
\nour everyday lives and also at a national level
\nthrough each NMA, and at an international
\nlevel through the WMA.
\nMuch is at stake as COP21 approaches,and
\nhopes are high that we will be able to de-
\nliver our voices effectively so that COP21
\nwill find a meaningful framework to pre-
\nvent and resolve health problems caused by
\nclimate change.
\nDong Chun Shin, MD, PhD,
\nChair, Environment Caucus, WMA
\nChair, Finance and Planning
\nCommittee, WMA
\nProf., Dept. of Preventive Medicine
\nYonsei Univ. College of Medicine
\nE-mail: dshin5@yuhs.ac; intl@kma.org
\nDong Chun Shin
\nWMA Roles for Climate Action
\nBACK TO CONTENTS
\n60 61
\nUNITED KINGDOMUNITED KINGDOM Medical EthicsMedical Ethics
\nThe Art of the conversation between a
\nphysician and their\u2018patien; is at the heart
\nof medical practice [1]. It is a dialogue be-
\ntween a person seeking help and a physi-
\ncian who possesses the relevant medical
\nknowledge\u00adand skills This patient\/physician
\nrelationship is founded both on service and
\non trust within which two way communi-
\ncation is key. The physician\u2019s professional
\nservice to their patient must be conducted
\nwithin a professional code of ethics which
\nhas become enshrined within the World
\nMedical Associations International Code
\nof Medical Ethics 1949 et seq.
\nThis statement includes the requirement
\nthat \u201ca physician shall be dedicated to pro-
\nviding competent medical service in full
\nprofessional and moral independence with
\ncompassion and respect for human dignity\u2019.
\nTrust
\nTrust can only be assured if the patient be-
\nlieves that the physician respects them as in-
\ndividuals,will act only in their best interests,
\navoid \u2018harms\u2019where possible,be truthful and
\nbe treated equally with others according to
\ntheir needs.
\nThe physician also has a duty of care to their
\npatients and should keep their medical re-
\ncords secret within applicable national laws.
\nThese ethical principles need to become
\n\u2018internalized\u2019 as the individual physician\u2019s
\n\u2018professional\u2019 conscience and act as a com-
\npass through the complex scientific, medical,
\npsychological, social, cultural and spiritual
\nscene. These principles relate both to the in-
\ndividual health care professional as a basis for
\nthe \u2018trust\u2019 given by the patient as a person to
\nthem and to society in general where they
\nform part of the essential \u2018contract\u2019 between
\nthe health care professions and society allow-
\ning the physician to work as an independent
\nclinician whose primary duty is to their pa-
\ntient. Only in this \u2018trusting\u2019culture will a \u2018pa-
\ntient\u2019s inner worries and secrets be gradually
\nshared with their physician\u201d.
\nA person\u2019s narrative
\nA patient\u2019s own story is the key to the phy-
\nsician finding out what may be right and
\nwhat may be wrong during a professional
\nconsultation. A narrative approach encom-
\npasses an open awareness of health and dis-
\nease within a storied structure from which
\nthe meaning and purpose in both an illness
\nand the experience of recovery emerge. Di-
\nagnostic \u2018labels\u2019 become secondary to the
\nlife of the individual person. A story is re-
\ncounted in a complicated narrative of illness
\ntold in words,silences,gestures,physical ob-
\nservations,overlain not only by the objective
\nfindings but also with the fears, hopes and
\nimplications associated with it [2].
\nThe narration is a therapeutic central act be-
\ncause to find the words to contain the disorder
\nand its attendant worries gives shape to and
\ncontrol over the uncertainties of the illness.
\nAs the physician listens to the patient, he or
\nshe follows the narrative thread of the story in
\nall its existential, cultural, familial, biological,
\nsocial, psychological and spiritual dimensions.
\nThe act of listening, so essential to the
\nprocess, enlists the physician\u2019s interior re-
\nsources\u00a0\u2013 memories, association, curiosities,
\ncreativity, interpretive powers and allusions
\nto other stories by the person and others to
\nidentify meaning. Only then the physician
\ncan hear and confront the person\u2019s narrative
\nquestions wWhat is wrong with me? Why
\nis this happening to me? And what will be
\nthe result?\u201d [3]
\nListening to stories of illness and recognizing
\nthat there are often no clear answers to pa-
\ntients\u2019 narrative questions demand the cour-
\nage and generosity to tolerate and to bear
\nwitness to unfair losses and random tragedies
\n[4]. Accomplishing such acts of witnessing
\nallows the physician to proceed to his or her
\nmore recognizably clinical narrative tasks: to
\nestablish a therapeutic alliance, to generate
\nand proceed through a differential diagnosis,
\nto interpret physical findings and laboratory
\nreports correctly, to experience and convey
\nempathy for the patient\u2019s experience [5],and,
\nas a result of all these, to engage the patient
\nfor effective care.
\nIf the physician cannot perform these narra-
\ntive tasks,the patient might not tell the whole
\nstory, might not ask the most frightening
\nquestions, and might not feel heard [6].
\nThe resultant diagnostic workup might be
\nunfocused and therefore more expensive
\nthan need be,the correct diagnosis might be
\nmissed,the clinical care might be marked by
\nnoncompliance and the search for another
\nopinion, and the therapeutic relationship
\nmight be shallow and ineffective. The nar-
\nrative is absorbing. It engages the listening
\nphysician and invites an interpretation. It
\ngives him or her the experience of \u201cliving
\nthrough\u201d, not simply \u201cknowledge abou\u201d the
\ncharacters and events in the story.
\nJames Appleyard
\nThe Art and Heart of Medicine
\nThe erosion of
\nhumanistic medicine
\nWhere this professional space is taken over
\nby an authoritarian organization not only is
\nthis patient\/physician relationship seriously
\ndamaged but also the independent spirit of
\nenquiry that drives advances in medicine is
\ndistorted [7]. As the cost of health care has
\nescalated, additional pressures on this \u2018pro-
\nfessional\u2019space by Healthcare providers, In-
\nsurance Companies and Governments are
\noccurring which are distorting the patient\/
\nphysician discourse [8].
\nDuring the professional consultation, elicit-
\ning a \u2018history\u2019 from a patient is one of the
\nleast perfected and most neglected clinical
\nskills despite a wealth of research and time
\nspent in undergraduate training [9]. Yet for
\nthe great majority of\u2019patient\u2019 the narrative
\nhistory is the most important and most
\nrevealing part of any personal health data
\nbase. Too often a computer generated form
\nis completed with the minimum of narra-
\ntive followed by a cursory clinical examina-
\ntion and a huge array of expensive investiga-
\ntions from which a diagnosis is expected to
\nemerge. It is important to realize that not
\nonly is the patient presenting with symp-
\ntoms of a possible illness but experiencing
\nthe effect of all of their life\u2019s events in their
\nbiological,social,mental,psychological,cul-
\ntural and spiritual dimensions.
\nA person centered approach
\nThose starting out on a medical career may
\nneed a format to act as guidance. The per-
\nson centered Integrated Diagnostic model
\nis being developed and refined to meet this
\nneed. It proposes the whole person in con-
\ntext as the Centre and goal of clinical care
\nand public health [10]. This encourages a
\nmore flexible and conversational style.
\nIt is only through this open style interactive
\nconversation and questioning the physician
\nsorts, extracts, subtracts and adds informa-
\ntion into a meaningful format. As rapport
\nis established elements of the patient\u2019s tem-
\nperament and personality become more
\napparent and the patient\u2019s reaction to each
\nquestion can be noted.
\nVery often the physician will have a very
\ngood idea of the likely diagnosis of the pa-
\ntient\u2019s problem within the first two minutes
\nthrough his or her experienced pattern rec-
\nognition of the common disease processes.
\nThe physician will search for additional
\nclues\u00a0\u2013 information that will aid in the solu-
\ntion of the person\u2019s problem. There is then
\na tendency to move to gather more specific
\ninformation to exclude other possibilities
\nand confirm the presumptive diagnosis.The
\ndanger is that at this stage other pertinent
\ninformation may not be given by the patient
\nor sought by the physician. Some physicians
\nmay avoid eliciting multiple concerns due to
\nthe fear of extending the encounter when
\ntime is limited.
\nHowever, unexpressed patient concerns
\nmay lead to a prolonged investigation of a
\nconcern hypothesized to be the \u201cchief com-
\nplaint\u201d but which in reality was the second
\nmost important problem. Repeated invita-
\ntions to express additional concerns early in
\nthe consultation may enhance the efficiency
\nof the interview by decreasing late-arising
\nconcerns,allowing the physician and patient
\nto prioritize problems at the outset, to make
\nthe best use of their time and minimize im-
\nplicit assumptions of what the patient wants
\nto discuss. Patients may defer emotionally
\nladen topics until the trustworthiness of the
\nphysician is better known or until the physi-
\ncian brings up the topic [11].
\nThe tendency of even experienced family
\nphysicians not to seek the patient\u2019s com-
\nplete agenda is similar to the finding of
\nBeckman and Frankel 15 years ago. Despite
\nconcern that a patient-centered approach
\nwill take more time, the study further re-
\ninforces that exploring all of the patient\u2019s
\nconcerns does not decrease efficiency. Using
\na simple opening empathic enquiry, such as
\n\u201cWhat concerns do you have?,\u201d then asking
\n\u201cAnything else?\u201drepeatedly until a complete
\nagenda has been identified appears to take
\n6 seconds longer than interviews in which
\nthe patient\u2019s agenda is interrupted. Agenda
\nsetting is a teachable and learnable skill that
\ndeserves emphasis and reinforcement.
\nA few verbal affective remarks can be ef-
\nfective and this is not necessarily time con-
\nsuming [12]: In one study it took only 38
\nseconds to make a difference! The affective
\nstatements that caused this reduction were
\nrelated to emphasizing being there for the
\nperson\u00a0\u2013 the sense of a physician\u2019s duty of
\ncare\u00a0 \u2013 providing reassurance of continuing
\nmedical support. These points have been
\ndefined as fundamental for effective patient-
\nphysician communication.Whilst one of the
\nmost difficult tasks for physicians is to convey
\nbad news, physicians who are emotionally
\nsupportive can influence patients\u2019 emotional
\nfunctioning with little effort and time [13].
\nAffective communication may have the
\npower to elicit beneficial effects in clinical
\nencounters as it enables patients to adjust
\nbetter to the emotional and cognitive im-
\npact of medical information [14]. Indirect
\neffects might also be present. When pa-
\ntients remember more about treatment
\nprocedures and their consequences, this
\nmay affect adherence to treatment or medi-
\ncation regimen. A few affective statements
\ncan have a large impact on patients\u2019 anxiety,
\nuncertainty and recall. Affective communi-
\ncation allows physicians to temper patients\u2019
\nemotional responses and improve their abil-
\nity to remember medical information.
\nConclusion
\nA person-centered approach involves a re-
\nnewal of our ethical commitment both to
\neach person as a patient and to society as
\na whole within a wide biomedical, psycho-
\nlogical, social, cultural and spiritual frame-
\nwork. It attends to both ill health and posi-
\ntive health and focusds on the diagnostic
\nBACK TO CONTENTS
\n62 63
\nUNITED STATES OF AMERICAUNITED STATES OF AMERICA One Health conceptOne Health concept
\nOne Health is a new term, but an ancient
\nconcept that recognizes the inherent links
\nbetween human, animal, and environmen-
\ntal health. Humans and animals cannot be
\nhealthy if the environment in which they
\nlive is sick.The One Health concept seeks to
\nincrease communication and collaboration
\nbetween human, animal, and environmental
\nhealth professionals.
\nThe One Health concept is important for
\nmany reasons. Zoonotic disease risks from
\nwildlife, livestock, and pets cannot be ad-
\nequately addressed without meaningful
\ncollaboration and cooperation between vet-
\nerinarians and physicians. Microbes do not
\nnecessarily recognize the differences between
\nspecies and could infect across them if given
\nthe right conditions. Indeed, approximately
\n75 percent of emerging infectious diseases
\nand approximately 60 percent of all human
\npathogens are zoonotic in origin [1].
\nSome of the greatest discoveries in the histo-
\nry of medicine and public health were made
\nat the intersection between human and ani-
\nmal health. For example, Dr.\u00a0Edward Jenner,
\nan apprentice surgeon, learned from dairy-
\nmaids that they were immune from smallpox
\nbecause they had had cowpox. He applied
\nthis concept to the practice of variolation
\nand developed the word \u201cvaccination\u201d from
\nthe Latin word \u201cvacca\u201dmeaning cow [2].Ap-
\nproximately two centuries later, Dr.\u00a0Jenner\u2019s
\nvaccine was used to eradicate smallpox from
\nglobal human populations [3].
\nDrs. Louis Pasteur and Robert Koch, a
\nFrench chemist who studied chicken cholera
\nand a German physician who studied anthrax,
\nrespectively, independently developed the
\ngerm theory of disease. Dr.\u00a0Pasteur discov-
\nered the theory of immunity and developed
\nthe world\u2019s first rabies vaccine, and Dr.\u00a0Koch
\ndeveloped \u201cKoch\u2019s Postulates\u201d for establish-
\ning the infectious causations of disease [4, 5].
\nDrs. Theobald Smith and Frederick
\nL.\u00a0 \u00adKilbourne, a physician and veterinarian
\nteam, respectively, discovered that an arthro-
\npod, in this case a tick, could transmit cattle
\nfever from animal to animal [6].This monu-
\nmental discovery stage for the widespread
\nrecognition that other arthropods could
\nserve as vectors for zoonotic diseases, such as
\nmosquitoes transmitting yellow fever.
\nAs the twentieth century progressed, sci-
\nentific knowledge exploded, and medicine
\nbecame increasingly specialized. Collabo-
\nration between medicine and veterinary
\nmedicine waned, but the challenges of the
\n\u00adcommunication between the patient and
\nphysician. There is shared understanding
\nand decision making with prevention and
\nhealth promotion as shared commitments
\nand the promotion of partnerships at all
\nlevels.
\nReferences
\n1.\t Mezzich J.E. (2011) Building Peron Centered
\nmedicine through dialogue and partnerships.
\nInternational Journal of Person Centered medi-
\ncine,(), 10\u201313
\n2.\t Genette G. (1980) Narrative Discourse: An Essay
\nin Method. Lewin J., trans. Ithaca, NY: Cornell
\nUniversity Pres
\n3.\t Greenhalgh T. Hurwitz. B. (1999)\u201dNarrative
\nbased medicine: Why study narrative\u201d BMJ
\n318,:48\u201350)DeSalvo L. (1999) Writing as a Way
\nof Healing: How Telling Our Stories Transforms
\nOur Lives. San Francisco, Calif: Harpe
\n4.\t Laine C., Davidoff F. (1996) Patient-centered
\nmedicine: a professional evolution. JAMA;
\n27:,152-156
\n5.\t Charon R. (2001) Narrative medicine: form,
\nfunction,and ethics.Ann Intern Med;134,:83-87.
\n6.\t Acare G., Pulmarski B., Acare (2015). Lost in
\ntranslation WMJ 61, 28-30
\n7.\t Lown B. (1996) The Lost Art of Healing.
\nHoughton
\n8.\t Cutler P. (1998) From data to diagnosis. 3rd
\nEn.
\nLippincott Williams and Wilkins
\n9.\t Salloum I,M, Mezzich J.E. (2011) Conceptual
\nappraisal of the person centered Integrative Di-
\nagnostic Model. International Journal of Person
\nCentered medicine 11, 39-42
\n10.\tEpstein R.M., Morse D.S., Frankel R.M., Fra-
\nrey L., Anderson K., Beckman H.B. (1998)
\nAwkward moments in patient-physician
\ncommunication about HIV risk. Ann Intern
\nMed.12:,435-442
\n11.\tMarvel M.K, Epstein R. M., Flowers K.. Beck-
\nman H. B, (1999) Soliciting the Patient\u2019s Agen-
\nda Have We Improved? JAMA 281:283-287
\n12.\tvan Osc, M., Sep M., van Vliet,L. M., van
\nDulme, S., Bensin, J. M. (2014)
\n13.\tReducing patients\u2019 anxiety and uncertainty, and
\nimproving recall in bad news consultations.The im-
\npact of affective communication. In press
\n14.\tStreet R. L. J., Makoul G., Neeraj K. A., Epstein
\nR.M. (2009). How does communication heal?
\nPathways linking clinician-patient communica-
\ntion to health outcomes. Patient education and
\ncounseling, 74, 295-301
\nJames Appleyard MD FRCP,
\nPresident, International College of Person
\ncentered medicine Thimble Hall, Blean
\nCommon Kent CT2 9JJ UK
\nE-mail: jimappleyard2510@aol.com
\ntwenty-first century demand that these two
\ndisciplines re-establish ties and begin work-
\ning collaboratively again. Increasing global
\npopulations, widespread deforestation and
\nenvironmental destruction, intensive agri-
\nculture, global trade and travel, and likely
\nclimate change will adversely impact life
\non the planet [7]. Zoonotic diseases such as
\nHIV\/AIDS,West Nile virus,SARS,MERS,
\nand Ebola that cross species barriers require
\nincreased communication and collaboration
\nbetween the health professions.Occasional-
\nly, animals become infected before humans
\nand should serve as important sentinels for
\nlooming epidemics in human populations.
\nFor people who live with chronic immuno-
\nsuppression such as organ transplant recipi-
\nents or people taking immunosuppressive
\nmedications, the risk of zoonotic disease
\ntransmission becomes much greater than
\nfor the general population. Grant and Olsen
\nfound that assessing zoonotic disease risks in
\nthis vulnerable population often gets ignored
\nbecause physicians are not familiar with the
\ndiseases while veterinarians defer to physi-
\ncians for human health care [8]. Physicians
\nrarely ask their patients about pet ownership
\nor animal exposures,yet pet-associated infec-
\ntions are common and can be deadly [9].
\nBeyond zoonoses, comparative medicine is
\nthe study of disease processes such as asth-
\nma, diabetes, and cancer across species. Dis-
\ncoveries in veterinary medicine can benefit
\nhuman medicine and vice versa.As with hu-
\nmans, an increase in canine and feline obe-
\nsity has led to an increase in diabetes [10].
\nStudying disease similarities and differences
\nbetween species could shed important new
\ninformation on disease progression, treat-
\nment,and control.In another example,a ca-
\nnine vaccine for oral melanoma was the first
\ntherapeutic vaccine approved for the use in
\neither animals or humans [11]. An impor-
\ntant benefit to studying diseases in animals
\nis that they do not experience the placebo
\neffect, so improvements resulting from nov-
\nel treatments demonstrate actual benefits
\nthat warrant further study in humans.
\nAnimals have served as sentinels for toxic
\nenvironmental contamination. In the mid-
\n1950\u2019s, dancing cats of Minamata Bay,
\n\u00adJapan were exhibiting mercury poisoning
\nfrom industrial pollution [12]. Humans
\nbegan suffering from mercury poisoning
\nas well [13]. Pets and other small animals
\ncan develop symptoms of lead poisoning
\nfrom very small doses and should serve as
\nsentinels for potential human cases if they
\nbecome sick [14, 15].
\nPhysicians and veterinarians have much to
\nlearn and benefit from each other. Recently,
\nthe World Medical Association and the
\nWorld Veterinary Association held a joint
\nglobal conference on One Health. Informa-
\ntion was shared, and collegial relationships
\nformed. These two professions are comple-
\nmentary and synergistic, and ideally, if they
\nre-forge old ties, they will make great new
\ndiscoveries that will benefit the health of all
\nspecies as the twenty-first century progresses.
\nReferences
\n1.\t Taylor LH, Latham SM, Woolhouse ME. \u201cRisk
\nFactors for Human Disease Emergence.\u201d Philos
\nTrans R Soc Lond B Biol Sci July 29, 2001.
\nhttp:\/\/rstb.royalsocietypublishing.org\/con-
\ntent\/356\/1411\/983
\n2.\t Riedel S.\u201cEdward Jenner and the history of small-
\npox and vaccination.\u201d BUMC Proceedings. 2005;
\n18: 21\u201325. http:\/\/www.ncbi.nlm.nih.gov\/pmc\/
\narticles\/PMC1200696\/
\n3.\t Deria A, Jezek Z, Markvart K, et al. \u201cThe world\u2019s
\nlast endemic case of smallpox: surveillance and con-
\ntainment measures.\u201d Bull World Health Organi-
\nzation.1980; 58: 279-283.http:\/\/www.ncbi.nlm.
\nnih.gov\/pmc\/articles\/PMC2395794\/
\n4.\t Smith K.A. \u201cLouis Pasteur, the Father of Immu-
\nnology?\u201d Frontiers in Immunology. 2012; 3: 68.
\nhttp:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/
\nPMC3342039\/
\n5.\t Committee to Update Science, Medicine, and
\nAnimals, National Research Council. \u201cScience,
\nMedicine, and Animals.\u201d 2004. National Acad-
\nemies Press. Washington DC. Page 7. http:\/\/
\nwww.ncbi.nlm.nih.gov\/books\/NBK24656\/pdf\/
\nBookshelf_NBK24656.pdf
\n6.\t Assadian O, Stanek G. \u201cTheobald Smith\u2014
\nthe discoverer of ticks as vectors of disease.\u201d
\nWien Klin Wochenschr. 2002 114 (13-14):
\n479-81. http:\/\/www.ncbi.nlm.nih.gov\/pub-
\nmed\/12422586
\n7.\t Morse SS. \u201cFactors in the Emergence of Infec-
\ntious Diseases.\u201d Emerging Infectious Diseases.
\n1995; 1: 7-15. http:\/\/wwwnc.cdc.gov\/eid\/arti-
\ncle\/1\/1\/95-0102_article
\n8.\t Grant S, Olsen CW. \u201cPreventing Zoonotic Dis-
\neases in Immunocompromised Persons: The Role of
\nPhysicians and Veterinarians.\u201d Emerging Infec-
\ntious Diseases. 1999; 5: 159-163. http:\/\/wwwnc.
\ncdc.gov\/eid\/article\/5\/1\/99-0121_article
\n9.\t Rabinowitz PM, Gordon Z, Odofin L. \u201cPet-
\nRelated Infections.\u201d 2007; 76: 1314-1322. http:\/\/
\nwww.aafp.org\/afp\/2007\/1101\/p1314.html
\n10.\tHoenig M. \u201cComparative Aspects of Human,
\nCanine, and Feline Obesity and Factors Pre-
\ndicting Progression to Diabetes.\u201d Vet Sci. 2014;
\n1: 121-135. http:\/\/www.mdpi.com\/2306-
\n7381\/1\/2\/121
\n11.\tHeflin M. \u201cCanine Melanoma Vaccine Gets Con-
\nditional OK.\u201d Veterinary Practice News. May
\n2007. http:\/\/www.veterinarypracticenews.com\/
\nApril-2009\/Canine-Melanoma-Vaccine-Gets-
\nConditional-OK\/
\n12.\tAronson S. \u201cThe Dancing Cats of Minamata
\nBay.\u201d Medicine and Health Rhode Island.
\n2005; 88.7: 209. http:\/\/search.proquest.com\/
\ndocview\/195779436\/fulltext\/2FCF9AF281834
\n074PQ\/1?accountid=13314
\n13.\tEto K, Marumoto M, Takeya M. \u201cThe pathol-
\nogy of methylmercury poisoning (Minamata dis-
\nease).\u201d Neuropathology 2010; 30: 471-479.
\nhttp:\/\/onlinelibrary.wiley.com\/store\/10.1111\/
\nj.1440-1789.2010.01119.x\/asset\/j.1440-
\n1789.2010.01119.x.pdf?v=1&t=iao5jp4n&s=b
\nf561531ab8e6609a20ea4d31ebeb4a45513790a
\n14.\tNewman AA. \u201cFor Small Animals, a Fleck
\nis a Lot.\u201d New York Times. December 22,
\n2007. http:\/\/www.nytimes.com\/2007\/12\/22\/
\nbusiness\/22petside.html
\n15.\tMorgan RV. \u201cLead poisoning in small companion
\nanimals: an update (1987\u20131992).\u201dVet Hum Toxi-
\ncology 1994; 36: 18-22.
\nLaura H. Kahn, MD, MPH, MPP,
\nResearch Scholar,
\nProgram on Science and Global Security,
\nWoodrow Wilson School of Public
\nand International Affairs,
\nPrinceton University
\nE-mail: lkahn@princeton.edu
\nThe author would like to acknowledge
\nher One Health Initiative colleagues:
\nBruce Kaplan, DVM
\nTom Monath, MD
\nJack Woodall, PhD
\nLisa Conti, DVM, MPH
\nLaura H. Kahn
\nOne Health: A Concept for the 21st
\nCentury
\nBACK TO CONTENTS
\n64 65
\nSPAINSPAIN Antimicrobials useAntimicrobials use
\nMost antimicrobial use is probably
\n\u00adinappropriate. It has been estimated that
\nup to 50% of human antibiotic use and up
\nto 80% of veterinary antibiotic use could be
\neliminated without serious consequences
\n[1]. The inappropriate use of these drugs in-
\ncreases the risk of selection of resistant bacte-
\nria and may contribute to antibiotic resistance
\n[2]. Antibiotic resistance has become a global
\nhealth problem and is responsible for signifi-
\ncant morbidity and mortality and, therefore,
\nrestriction of antibiotic use and marketing
\nregulations are among many important strate-
\ngies to control this problem [3,4].
\nThe sale of antibiotics and other antimicro-
\nbial medicines without prescription remains
\nwidespread, with many countries lacking
\nstandard treatment guidelines; thereby in-
\ncreasing the potential for overuse of antimi-
\ncrobial medicines by the public and medical
\nprofessionals [5]. In general, governments
\nsupport policies on the prudent use of
\n\u00adantimicrobials in order to control resistance
\nand recommend control measures to sup-
\nport careful use by encouraging doctors and
\npharmacists to promote the appropriate use
\nof antimicrobials.However,implementation
\nhas generally been weak in many countries,
\nand the prevalence of bacterial resistance
\ncontinues to increase since antimicrobial
\nresistant bacteria are common in commu-
\nnities where over-the-counter policy is still
\navailable.
\nPrevalence
\nThe prevalence of over-the-counter sale
\nof antibiotics varies across countries, be-
\ning common outside Northern Europe
\nand North America [5]. The percentage of
\nnon-prescription access to antimicrobials
\nis often underestimated, and also depends
\non the methodology used to estimate it. In
\n2013, the European Commission published
\na questionnaire-based study (Eurobarom-
\neter), carried out in 28 European countries,
\nincluding 27,680 respondents,in which 35%
\nadmitted having taken at least one dose of
\nantibiotic in the previous 12 months [6].The
\nlarge majority of those who had used antibi-
\notics during the time covered by the survey
\nhad got them from a healthcare provider,but
\n3% of users reported to have obtained them
\nwithout prescription and 2% more stated
\nthat they used the leftovers from a previous
\ncourse. However, when more reliable meth-
\nods are used the results are much higher.
\nOne of the most reliable ways to estimate
\nhow frequent the sale of antibiotics is in-
\ncludes simulated-client-method pharmacy
\nstudies in which actors simulating certain
\ninfectious diseases manage to obtain anti-
\nbiotics at community pharmacies. Table 1
\ndescribes the 30 studies published so far and
\napplying this methodology.
\nIn 2007 in Spain, making use of a mystery
\nshopper who presented at community phar-
\nmacies requesting an antibiotic for one of
\nthree different clinical scenarios, our group
\nobserved that these drugs were sold in
\n45.6% of the pharmacies without a medi-
\ncal prescription [7]. This percentage was
\nslightly higher at 54.1% when the study was
\nrepeated in 2014 using the same methodol-
\nogy [8]. However, according to the Euroba-
\nrometer, the percentage of Spanish people
\nwho admitted having bought an antimicro-
\nbial at the pharmacy was only 4% [6].
\nBy contrast with Northern Europe and
\nNorth America, non-prescription access
\nto antimicrobials is common in the rest of
\nthe world [5], as shown in Table 1. In a nice
\nstudy carried out in a Finnish community
\nliving in Spain, V\u00e4\u00e4n\u00e4nen et al. found that
\nantibiotics, which are considered as pre-
\nscription-only medicines in Finland, were
\npurchased by 41% of the immigrants who
\nadmitted having taken an antibiotic in the
\nprevious 6 months [9].
\nDrawbacks of the over-the-
\ncounter sale of antimicrobials
\nThe link between the over-the-counter sale
\nof antibiotics and antibiotic overconsump-
\ntion is clearly established. Southern Euro-
\npean countries usually rank at the top in
\nCarl Llor
\nPros and Cons of the Over-the-counter
\nSales\u00a0of Antimicrobials
\nAna Moragas
\nTable 1.\u2002 \u0007Frequency of the sale of antimicrobials based on simulated client method surveys
\nAuthor, year Country Type URTI OM Sin.
\nSore
\nthroat
\nLRTI
\nor flu
\nDia. UTI STI
\nSpecific anti-
\nmicrobials
\nVari-
\nousa
\nEUROPE
\nContopoulos-Ioannidis DG,
\n2000
\nGreece D 78%
\nPlachouras D, 2008 Greece D 53\u2013100%b
\nMarkovi\u0107-Pekovi\u0107 V, 2010 Bosnia&Herzegovina D 58%
\nSim\u00f3 S, 2006c
\nSpain I 12%
\nLlor C, 2007 Spain D 35% 16% 80%
\nGastelorrutia, 2009 Spain D 17%
\nSim\u00f3 S, 2012c
\nSpain I 6%
\nGuinovart M, 2014 Spain D 48% 33% 81%
\nAMERICA
\nGellert GA, 1994 Mexico I 100%
\nBartoloni A, 1992 Bolivia D, Id
\n24% 91% 24% 40\u201392%e
\n58% 67%f
\nVolpato DE, 2002 Brazil I 74%
\nVacca CP, 2007 Colombia D 80%
\nAFRICA
\nNyazema N, 2004 Zimbabwe D 9% 8\u201365%g
\nMIDDLE EAST
\nAmidi S, 1975 Iran D 60% 40%
\nTomson G, 1985 Yemen I 9%
\nAl-Faham Z, 2009 Syria I 97%
\nDameh H, 2005 United Arab Emirates D 69%
\nAl-Ghamdi MS, 1999 Saudi Arabia D 82%
\nBin Abdulhak AA, 2010 Saudi Arabia I 51% 40% 90% 73% 90% 75%
\nASIA
\nWolffers I, 1983 Sri Lanka D 100%
\nTomson G, 1985 Sri Lanka I 41%
\nTomson G, 1985 Bangladesh I 68%
\nHadi U, 2006 Indonesia D 74%
\nPuspitasari HP, 2010 Indonesia D 91%
\nQuagliarello AB, 1999 Vietnam D 99% 75%
\nChalker J, 1999 Vietnam D 98%
\nWachter DA, 1996 Nepal D, Ih
\n97% 38%
\nThajlikitkul V, 1986 Thailand D
\n50\u2013
\n100%
\nChalker J, 1999 Thailand I 76%
\nApisarnthanarak A, 2006 Thailand I 80% 74% 65% 76% 100%
\nType=type of simulated patient (D, direct: the patient him-\/herself; I, indirect: simulating having a relative or friend with an infectious disease); URTI=upper respira-
\ntory tract infection (including rinorrhoea, sneezing, with or without fever); OM=otitis media; Sin.=sinusitis; LRTI=lower respiratory tract infection; Dia.=diarrhoea;
\nUTI=urinary tract infection; STI=sexually transmitted infection
\na
\nVarious infectious diseases considered; b
\nMistery shoppers requested ciprofloxacin (53% of success) and amoxicillin\/clavulanate (100% of success); c
\nRelated to a
\n9-month old baby with an upper respiratory tract infection and fever; d
\nThe indirect simulated patients corresponded to children; e
\n40% in case of a 6-month old child
\nand 92% when an adult with this infection was simulated; f
\nCase of male urethral discharge; g
\n8% in the case of a male urethritis and 65% when a vaginal discharge was
\nsimulated; h
\nThe direct simulated patient corresponded to the case of UTI; the indirect case corresponded to his 5-year son with diarrhoea
\nBACK TO CONTENTS
\n66 67
\nSPAINSPAINAntimicrobials use Antimicrobials use
\nterms of the consumption of antibiotics,
\nas described in the last report issued by the
\nEuropean Surveillance of Antimicrobial
\nConsumption Network (ESAC-Net) [10].
\nIndeed, over-the-counter sale of antibiot-
\nics is reportedly common in countries such
\nas Italy, Greece, and Spain [5]. In a study
\non pharmaceutical surveillance in Spain,
\nCampos et al. observed that about 30% of
\nthe outpatient antimicrobials purchased
\nwas not identified by reimbursement data,
\nlargely because over-the-counter sales were
\nnot tracked [11].
\nSelf-medication with antimicrobials is also
\nwidespread, occurring among the population
\nin the same countries where over-the-coun-
\nter sale is available [12]. Antibiotics available
\nat home have been found to be an important
\nrisk factor for this practice [13], and leftover
\nmedication may later be considered for self-
\nmedication,leading to inappropriate usage of
\nthese drugs. In a study carried out in 2006,
\nthe prevalence of anti\u00adbiotic storage in Span-
\nish households was 37% [14]. This in-home
\nantibiotic storage might also increase the risk
\nof self-prescription of antibiotics to families
\nand friends. In a population survey con-
\nducted in 19 \u00adEuropean countries, covering
\n15,548 respondents, Grigoryan et al. found
\nthat the main reason for self-medication
\nwas a previous medical prescription of the
\nsame medication [15]. Thus, the over-the-
\ncounter sale of antibiotics both encourages
\nself-medication and the storage of leftover
\nantimicrobials, creating a vicious circle that
\nincreases the consumption of antimicrobials
\n(Figure 1).
\nPublic awareness of the issue is low, with
\nmany people still believing that antibiot-
\nics are effective against viral infections. Ac-
\ncording to the last Eurobarometer available,
\ncarried out in November 2013, 84% of re-
\nspondents were aware that the overuse of
\nantibiotics makes them ineffective. When
\nasked questions about antibiotics and how
\nthey work, 49% of Europeans replied that
\nantibiotics kill viruses and 52% correctly re-
\nplied that antibiotics are not effective against
\ncolds and influenza. A north-south gradient
\nwas also observed, with better knowledge of
\nhow antibiotics work in northern countries
\nand, conversely, citizens living in southern
\ncountries were less knowledgeable about this
\nsubject [6].Since 2008,the European Union,
\nthrough the European Centre for Disease
\nPrevention and Control, has encouraged
\npublic information campaigns on prudent
\nantibiotic use in its member countries, by
\npromoting the European \u00adAntibiotic Aware-
\nness Day on the 18 November [16]. Never-
\ntheless, concerns have been raised that such
\ncampaigns are not having their anticipated
\neffect [17]. In addition, the recent Euroba-
\nrometer stated that 60% of respondents had
\ntaken at least one course of antibiotics in the
\nprevious year for flu, acute bronchitis, colds,
\nor sore throat [6].
\nAnother factor is patients\u2019 non-adherence
\nto antibiotic therapy. Our group observed
\nan intentional non-adherence to antibiotic
\nregimens of 35% for respiratory tract in-
\nfections with the use of Medication Event
\nMonitoring System or MEMS contain-
\ners [18], resulting in the presence of some
\nleftover drugs that might be used on future
\noccasions by the members of the house-
\nhold. Although a relationship between in-
\ntentional non-compliance and the storage
\nof antibiotics has not been proven, the fact
\nthat approximately one third of individuals
\nstore antibiotics in their households and a
\nsimilar percentage intentionally do not take
\nthem as requested makes this association
\nvery likely.
\nOver-the-counter sale of antimicrobials of-
\nten leads to a wrong choice of these drugs.
\nFor instance, in our study carried out in
\n2007, fluoroquinolones, which are consid-
\nered as critically important antimicrobials
\nby the World Health Organization as also
\nare third- and fourth-generation cephalo-
\nsporins and macrolides) [19], accounted for
\n40% of the antibiotics sold for urinary tract
\ninfections [7]. Similarly, essential antitu-
\nberculosis drugs are available without pre-
\nscription in many areas, with streptomycin,
\nrifampicin and isoniazid being sold for indi-
\ncations other than tuberculosis as over-the-
\ncounter antimicrobials [20,21]. This easy
\naccess and inappropriate use of these drugs
\nclearly constitute risk factors for further de-
\nvelopment of multidrug resistant tuberculo-
\nsis, which is nowadays challenging due to
\nthe associated high morbidity and mortality
\n[22]. Over-the-counter sale without a pre-
\nscription may also lead to the use of insuf-
\nficient dosages, with lower doses dispensed
\nbeing more common when the antibiotic is
\nsold at the pharmacies compared to other
\nhealthcare facilities [23].
\nSafety issues associated with non-prescrip-
\ntion use also include adverse drug reactions
\nand masking of underlying infectious pro-
\ncesses (Table 2). Antimicrobials frequently
\ncause side effects, despite most being mild;
\nhowever, side effects accounted for nearly
\none fifth of all visits to the emergency room
\nfor adverse drug events in a US study [24].
\nLinked to this, low-quality and counterfeit
\nantimicrobials have been more frequently
\nreported among antimicrobials sold without
\na medical prescription, mainly in develop-
\ning countries, resulting in a possible direct
\nharm and treatment failure [25]. Another
\nconcern of the non-prescription status is
\nthe possibility of drug interactions, particu-
\nlarly in children, elderly patients and preg-
\nnant women.In another study carried out in
\nTaiwan, patients with detectable \u00adantibiotic
\nconcentrations in urine were nearly twice as
\nlikely to have a missed diagnosis of a true
\nbacterial infection compared to the patients
\nwithout any antimicrobial detected [26].
\nProper diagnosis of an infectious disease
\ncan also be challenging in a pharmacy. Di-
\nagnosis is even often difficult in the primary
\ncare clinic and to distinguish between bac-
\nterial and viral aetiology is even more so,
\nmainly in respiratory tract infections.
\nAnother inconvenience is the pressure of
\nthe population on both the pharmacist and
\nthe physician. In the first case this pressure
\nis related to the selling of the antimicrobial
\nand in the second, to obtaining the pre-
\nscription of the drug sold by the pharmacist
\nto thereby be partially or totally reimbursed
\nfor the cost of the antimicrobial.
\nAdvantages of over-the-
\ncounter sale of antimicrobials
\nAccessibility to over-the-counter antimi-
\ncrobials has also some advantages. Some of
\nthese are for the patient,others for the physi-
\ncian, the pharmacist, the pharmaceutical in-
\ndustry itself and others for the government.
\nThe individuals would have a greater choice
\nof access to healthcare both in the way it is
\ndelivered and at a time and place convenient
\nto them. For instance, patients with recur-
\nrent urinary tract infections, who clearly
\nknow their symptoms, can be benefitted
\nfrom an over-the-counter policy. Physicians
\nmay gain from having fewer consultations
\nfor minor ailments; pharmacists would have
\na further opportunity to use their profes-
\nsional knowledge and develop their rangeof
\nservices tothe public. In our study, however,
\nthe pharmacists who refused to sell antibi-
\notics without a prescription gave responses
\nrelated to health or resistance issues in only
\n30% of the cases and pharmacists only asked
\nabout possible allergies, or potential preg-
\nnancy and side effects in less than half of the
\nsubjects to whom antibiotics were sold\u00a0[7].
\nEducation is therefore particularly impor-
\ntant in the over-the-counter sale of anti-
\nmicrobials; when patients choose self-care,
\nthere is often no possibility to obtain advice
\nfrom a physician, and thus the responsibil-
\nity of providing appropriate information
\nfalls on pharmacists. It should not be for-
\ngotten that one of the greatest beneficiaries
\nof the non-prescription use of antimicrobi-
\nals is the pharmaceutical industry, which
\nsees a new marketing opportunity with this
\npolicy. Furthermore, the government could
\nbe relieved of some costs of antimicrobials
\nobtained on National Health Service pre-
\nscriptions. In addition, non-prescription
\nstatus of antimicrobials might be an impor-
\ntant mechanism of access to antimicrobials
\nin countries with low resources. Further-
\nmore, in these low-income settings, a high
\ndemand for antibiotics without a prescrip-
\ntion might be expected from customers who
\ncannot afford to consult a doctor.
\nConclusions
\nAntimicrobial resistance is a global issue
\n[27]. According to the current UK Health
\nChief Officer, we are losing the battle
\nagainst infectious diseases since bacteria are
\nfighting back and are becoming resistant to
\nmodern medicine so that, in short, antibiot-
\nics will no longer work [28]. This reinforces
\nthe need to prescribe antimicrobial agents
\nonly when there is good evidence that the
\nbenefits outweigh the risks. Barring the dis-
\npensing of antibiotics without a prescrip-
\ntion constitutes one of the most valuable
\nstrategies to accomplish this objective. The
\nover-the-counter sale of antimicrobials has
\npros and cons but, in any case, this policy
\nrequires that pharmacists have a key role as
\nhealthcare agents and it must be forbidden
\nto pharmacists who are not familiar with
\nthe management of some mild infectious
\ndiseases, mainly in non-low-income coun-
\ntries. Notwithstanding, critically important
\nantimicrobials should never be purchased
\nwithout a medical prescription anywhere.
\nReferences
\n1.\t Wise R., Hart T., Cars O., Streulens M.; Hel-
\nmuth R., Huovinen P., et al. (1998) Antimicro-
\nbial resistance. Is a major threat to public health?
\nBMJ, 317,609\u201310.
\n2.\t Goossens H.,Ferech M.,Vander Stichele R,.El-
\nseviers M.; ESAC Project Group. (2005) Out-
\npatient antibiotic use in Europe and association
\nTable 2.\u2002 Drawbacks of the over-the-counter sale of antimicrobials
\n\u2022\u2002\u0007Self-medication with antimicrobials
\n\u2022\u2002\u0007Storage of antimicrobials in households
\n\u2022\u2002\u0007Inappropriate use of antimicrobials
\n\u2022\u2002\u0007Potential side effects
\n\u2022\u2002\u0007Masking of underlying clinical syndrome
\n\u2022\u2002\u0007No questioning by pharmacists regarding allergies, pregnancy and side effects
\n\u2022\u2002\u0007Contraindicated antimicrobials
\n\u2022\u2002\u0007Inadequate dose regimens
\n\u2022\u2002\u0007Low-quality medication
\n\u2022\u2002\u0007Pressure of having an antimicrobial prescribed
\nFigure 1.\u2002\u0007Relationship between over-the-counter sale of antimicrobials, storage and self-
\nmedication
\nBACK TO CONTENTS
\n68 69
\nMedicines shortagesSPAINAntimicrobials use
\nwith resistance: a cross-national database study.
\nLancet,;365, 579\u201387.
\n3.\t Butler C.C., Rollnick S., Pill R., Maggs-Rap-
\nport F., Stott N. (1998) Understanding the cul-
\nture of prescribing: qualitative study of general
\npractitioners\u2019 and patients\u2019 perceptions of antibi-
\notics for sore throats. BMJ, 317, 637\u201342.
\n4.\t Carbon C., Bax R.P. (1998) Regulating the
\nuse of antibiotics in the community. BMJ, 317,
\n663\u201365.
\n5.\t Morgan D.J., Okeke I.N., Laxminarayan R.,
\nPerencevich E.N., Weisenberg S. (2011) Non-
\nprescription antimicrobial use worldwide: a sys-
\ntematic review. The Lancet Infectious Diseases.,11,
\n692\u2013701.
\n6.\t European Commission. Special Eurobarometer
\n407 \u2018Antimicrobial resistance\u2019. (2013) Available
\nfrom: http:\/\/ec.europa.eu\/public_opinion\/ar-
\nchives\/ebs\/ebs_407_en.pdf
\n7.\t Llor C., Cots J.M. (2009) The sale of antibiotics
\nwithout prescription in pharmacies in Catalonia,
\nSpain. Clinical Infectious Diseases.,48, 1345\u201349.
\n8.\t Guinovart M.C., FIgueras A., Llop J.C., Llor
\nC. Obtaining antibiotics without prescription in
\nSpain in 2014: even easier now than 6 years ago.
\n(2015) Journal of Antimicrobial Chemotherapy,70,
\n1270\u201371.
\n9.\t V\u00e4\u00e4n\u00e4nen M.H., Pietil\u00e4 K., Airaksinen M. Self-
\nmedication with antibiotics–does it really hap-
\npen in Europe? (2006) Health Policy, 77,166\u201371.
\n10.\tEuropean Centre for Disease and Prevention
\nControl. Summary of the latest data on antibi-
\notic consumption in the European Union, No-
\nvember 2014. Available at: http:\/\/ecdc.europa.
\neu\/en\/eaad\/Documents\/antibiotic-consumptio-
\nESAC-Net-2014-EAAD.pdf
\n11.\tCampos J., Ferech M., L\u00e1zaro E., de Abajo F.,
\nOteo J., Stephens P., Goossens H. Surveillance
\nof outpatient antibiotic consumption in Spain
\naccording to sales data and reimbursement data.
\n(2007) Journal of Antimicrobial Chemotherapy, 60,
\n698\u2013701.
\n12.\tGrigoryan L., Haaijer-Ruskamp F.M., Burger-
\nhof J.G.M., et al. Self-medication with antimi-
\ncrobial drugs in Europe. (2006) Emerging Infec-
\ntious Diseases,12, 452\u201359.
\n13.\tMcNulty C.A., Boyle P., Nichols T., Clappison
\nD.P., Davey P. Antimicrobial drugs in the home,
\nUnited Kingdom. (2006) Emerging Infectious
\nDiseases12, 1523\u201326.
\n14.\tGonz\u00e1lez J.,Orero A.,Prieto J.Almacenamiento
\nde antibi\u00f3ticos en los hogares espa\u00f1oles. (2006)
\nRevista Espanola de Quimioter, 19, 275\u201385.
\n15.\tGrigoryan L.,Burgerhof J.G.,Haaijer-Ruskamp
\nF.M., Degener J.E., Deschepper R., Monnet
\nD.L., et al., on behalf of the SAR group. Is self-
\nmedication with antibiotics in Europe driven by
\nprescribed use? (2007) Journal of Antimicrobial
\nChemotherapy 59,152\u201356.
\n16.\tEarnshaw S., Mancarella G., Mendez A., To-
\ndorova B., Magiorakos A.P., Possenti E., et al.,
\non behalf of the European Antibiotic Awareness
\nDay Technical Advisory Committee; on behalf
\nof the European Antibiotic Awareness Day Col-
\nlaborative Group. European Antibiotic Aware-
\nness Day: a five-year perspective of Europe-wide
\nactions to promote prudent use of antibiotics.
\n(2014) Eurosurveillance,19, 20928.
\n17.\tStockley J.M. European Antibiotic Awareness
\nDay 2010: why doesn\u2019t promoting antibiotic
\nawareness always work? (2010) Journal of Infec-
\ntion,61, 361\u201363.
\n18.\tLlor C., Hern\u00e1ndez S., Bayona C., Moragas A.,
\nSierra N., Hern\u00e1ndez M., et al. A study of ad-
\nherence to antibiotic treatment in ambulatory
\nrespiratory infections. (2013) International Jour-
\nnal of Infectious Diseases,17, e168\u201372.
\n19.\tWorld Health Organization Advisory Group
\non Integrated Surveillance of Antimicro-
\nbial Resistance (AGISAR). Critical impor-
\ntant antimicrobials for human medicine.
\n(2012) World Health Organization. Avail-
\nable at: http:\/\/apps.who.int\/iris\/20.bitstre
\nam\/10665\/77376\/1\/9789241504485_eng.pdf
\n20.\tKobaidze K., Salakaia A., Blumberg H.M.
\nOver-the-counter availability of antituberculosis
\ndrugs in Tbilisi, Georgia in the setting of a high
\nprevalence of MDR-TB. (2009) Interdisciplinary
\nPerspective of Infectious Diseases, 513609.
\n21.\tLambert M.L., Delgado R., Michaux G., Volz
\nA., Van der Stuyft P. Tuberculosis control and
\nthe private health sector in Bolivia: a survey of
\npharmacies. (2004) The International Journal of
\nTuberculosis and Lung Diseases,8, 1325\u201329.
\n22.\tGandhi N.R., Nunn P., Dheda K., Schaaf H.S.,
\nZignol M., van Soolingen D., et al. Multidrug-
\nresistant and extensively drug-resistant tubercu-
\nlosis: a threat to global control of tuberculosis.
\n(2010) The Lancet, 375, 1830\u201343.
\n23.\tMukonzo J.K., Namuwenge P.M., Okure G.,
\nMwesige B.,Namusisi O.K.,Mukanga D. Over-
\nthe-counter suboptimal dispensing of antibiot-
\nics in Uganda.(2013) Journal of Multidisciplinary
\nHealthcare;6, 303\u201310.
\n24.\tShehab N., Patel P.R., Srinivasan A., Budnitz
\nD.S. Emergency department visits for antibi-
\notic-associated adverse events. (2008) Clinical
\nInfectious Diseases, 47, 735\u201343.
\n25.\tTaylor R.B., Shakoor O., Behrens R.H. Drug
\nquality, a contributor to drug resistance? (1995)
\nThe Lancet, 346, 122.
\n26.\tLiu Y.C.,Huang W.K.,Huang T.S.,Kunin C.M.
\nInappropriate use of antibiotics and the risk for
\ndelayed admission and masked diagnosis of in-
\nfectious diseases: a lesson from Taiwan. (2001)
\nArchives of Internal Medicine, 161, 2366\u201370.
\n27.\tOkeke I.N., Edelman R. Dissemination of
\nantibiotic-resistant bacteria across geographic
\nborders. (2001) Clinical Infectious Diseases, 33,
\n364\u201369.
\n28.\tDavies S.C., Grant J., Catchpole M. (2013) The
\nDrugs Don\u2019t Work. A Global Threat. London: Pen-
\nguin Specials
\nCarl Llor, Primary care physician,
\nPrimary Healthcare Centre,
\nVia Roma, Barcelona
\nAna Moragas, Primary care physicians,
\nPrimary Healthcare Centre,
\nJaume I, Tarragona, Spain
\nE-mail: carles.llor@gmail.com
\nIs there a health system in the world at this
\nmoment not suffering from the impacts of
\nmedicines shortages? With strong docu-
\nmentation of the problem in such coun-
\ntries as the USA [1], Australia [2], South
\nAfrica\u00a0 [3], Canada [4] and elsewhere, to
\nthe understanding of the pan-European
\ndimensions of the problem was recently
\nadded the publication of the report by the
\nEuropean Association of Hospital Phar-
\nmacists \u201cMedicines Shortages in European
\nHospitals\u201d (November 2014) [5].
\nDistributed across Europe by the net-
\nwork of 34 EAHP national country asso-
\nciations\u00a0[6], over 600 hospital pharmacists
\nfrom 36 countries responded to a call for
\ninformation about the problems being
\nfaced in practice as a result of medicines
\nshortages. A definitive answer was re-
\nturned: 86% responded in the affirmative
\nthat, yes, medicines shortages are a current
\nproblem in the hospital the responding
\npharmacist works in, in terms of delivering
\nthe best care to patients and\/or operating
\nthe hospital pharmacy. Indeed, no country
\nsurveyed responded with less than 60%
\nagreement that medicines shortages are a
\ncurrent problem. 88% of the respondents
\nexperience medicines shortages at least
\nmonthly, with 66% expressing it as a daily
\nor weekly problem.
\nBut what kinds of problem are being cre-
\nated? The report sheds some further light on
\nthe nature of the negative impacts entailed
\nfor pharmacists, but above all, patients,
\nwhen a medicine prescribed for the patient
\nsimply becomes unavailable.
\nFor pharmacists,enormous amounts of time
\ncan suddenly be absorbed into the pressing
\ntask of finding a new source of supply for
\nthe medicine. In the European context, this
\nmight often be from other countries, with
\nall the delay, and potential knock-on im-
\npacts for supply in the source country that
\ncan be involved [5]. EAHP\u2019s 2014 report
\nfinds that 55% of hospital pharmacists in
\nEurope say that up to 5 hours of staff time
\na week is being diverted from other tasks in
\norder to deal with shortage problems, with
\na further 32% indicating that more than 5
\nhours a week is consumed with managing
\nthe situations caused by shortages. Indeed,
\nsome respondents reported the need to em-
\nploy full time equivalents dedicated solely
\nto locating new sources for out-of-stock
\nmedicines.
\nHowever, if the medicines shortages prob-
\nlem was simply a question of inefficiency it
\nwould not excite the attention and momen-
\ntum that the matter has been gaining at the
\ninternational level [8]. The most telling and
\npressing impact is for patients. Here again,
\nEAHP\u2019s 2014 report provides some addi-
\ntional insight.
\nOver 75% of the respondents to the survey
\neither agreed or strongly agreed with the
\nstatement \u201cmedicines shortages in my hos-
\npital are having a negative impact on patient
\ncare\u201d. Many respondents then went on to
\nprovide examples including:
\n\u2022\t The aggravation caused to patients, main-
\nly elderly, when explaining the required
\nchanges or delays to their treatment;
\n\u2022\t The distress caused by delays or interrup-
\ntions to chemotherapy treatments;
\n\u2022\t The confusion experienced by prescrib-
\ners and nurses when out-of-stock but
\nfamiliar medicines must be replaced by
\navailable alternatives, and the potential
\nincrease in medication error risk;
\n\u2022\t Heightened risk of hospital acquired in-
\nfection as a result of antibiotic shortage;
\n\u2022\t Deterioration in patients\u2019 condition due
\nto shortage of the most efficacious medi-
\ncines;
\n\u2022\t Raised risk levels from the required use
\nof unlicensed alternatives to a medicine in
\nshortage; and,
\n\u2022\t Additional hospital admissions as a result
\nof some shortages (e.g. cardiology medi-
\ncines).
\nAs suggested by the title, however, simply
\ndrawing attention to the problems caused
\nby medicines shortages is not enough. Ef-
\nfort, energy and awareness must be drawn
\nto potential solutions. With the causes of
\nshortages acknowledged to be so multi-fac-
\neted, as well as situation and region-specific,
\nit need barely to be mentioned that it is a
\nlist of mitigating policy actions that are re-
\nquired, rather than any single answer.
\nThe reflections of the International Phar-
\nmaceutical Federation (FIP) and, indeed,
\nthe regulatory action advocated for by
\nour colleagues at the American Society
\nof Health System Pharmacists (ASHP)
\nhave certainly informed the outlook of the
\n\u00adEuropean Association of Hospital Pharma-
\ncists on the matter of potential solutions to
\nthe medicines shortages problem.
\nIn 2013 FIP brought together pharmacy
\nprofessionals from across the globe in an in-
\nternational summit on medicines shortages
\nRichard Price
\nMedicines Shortages: Global Problems
\nNeed Global Solutions
\nBACK TO CONTENTS
\n70 71
\nMedicines shortages Medicines shortages
\nheld in Toronto, Canada [8]. At the end of
\ntwo days of deliberations they made a series
\nof principal recommendations for tackling
\nthe problem, including:
\n\u2022\t Improved publicly available information
\non shortages;
\n\u2022\t A globally agreed list of critical\/vulner-
\nable products;
\n\u2022\t Improved procurement processes to as-
\nsure continuity of supply; and,
\n\u2022\t Improved regulatory cooperation be-
\ntween countries on the matter.
\nMeanwhile, in the United States, some
\ncase study examples of what can be
\nachieved, at least as interim steps, have
\nbeen provided via the FDA Innovation
\nAct (FDASIA) of 2012 [9]. This legisla-
\ntion not only clarified the statutory remit
\nof the USA\u2019s medicines agency to be in-
\nvolved in resolving medicine shortages
\nproblem, but also addressed problems in
\nrelation to the legal responsibilities of
\nmanufacturers to report likely disrup-
\ntions to supply at an early stage in order
\nto enable better contingency planning.
\nSome early monitoring results from the
\nUniversity of Utah has suggested such ac-
\ntion, whilst by no means eliminating the
\nproblem, it has proven effective in so far
\nas reducing the difficulties [10].
\nDrawing inspiration, EAHP\u2019s 2014 report
\non medicines shortages in European hospi-
\ntals ends with a set of policy calls to political
\ndecision makers:
\n\u2022\t Improved collection and sharing of in-
\nformation about medicines shortages
\nin Europe, by both national medicines
\nagencies and the European Medicines
\nAgency;
\n\u2022\t Clarification and enforcement of legal re-
\nsponsibilities on manufacturers of medi-
\ncines to report disruptions to supply;
\n\u2022\t An inquiry at the European level into the
\nprimary factors causing medicines short-
\nages;
\n\u2022\t Criteria for a fair distribution of supply in
\ncases of shortage, based on primary con-
\nsideration of patient need.
\nEAHP is now working with counterpart
\nhealthcare professional and patient organ-
\nisations at the European level to promote
\nthis much needed policy agenda [11] and
\nhope that in time a positive European ex-
\nample of response to the shortages prob-
\nlem may yet be provided to our colleagues
\nelsewhere in the world. That work, how-
\never, remains ongoing. A new European
\nCommission settling into its 5 year term
\nof office could provide the opportunity re-
\nquired [12].
\nReferences
\n1.\t McLaughlin M., et al. Empty Shelves, Full of
\nFrustration: Consequences of Drug Shortages
\nand the Need for Action. (2013) Hospital Phar-
\nmacy, 48(8). 617-618
\n2.\t Quilty S. Medicines shortages in Australia\u00a0\u2013 the
\nreality. (2014). The Australasian Medical Journal,
\n7(6), 240-242
\n3.\t Bateman C. Drug stock-outs: Inept supply-
\nchain management and corruption. (2013)
\nSAMJ: South African Medical Journal, 103, 600-
\n602.
\n4.\t Barthelemy I., Lebel D., Bussieres J-F. Drug
\nshortages in health care institutions: perspec-
\ntives in early 2013. (2013) Canadian Journal of
\nHospital Pharmacy, 66(1), 39\u201340
\n5.\t European Association of Hospital Pharmacists.
\nMedicines shortages in European hospitals. (2014)
\nAvailable: http:\/\/www.eahp.eu\/press-room\/
\npatients-suffering-medicines-shortages-all-eu-
\nropean-countries. Accessed 17 June 2015.
\n6.\t European Association of Hospital Pharmacists.
\nEAHP Members. (2015) Available at: http:\/\/
\nwww.eahp.eu\/about-us\/members. Accessed 17
\nJune 2015.
\n7.\t Gray A., & Manasse H. R. (2012). Shortages
\nof medicines: a complex global challenge. Bul-
\nletin of the World Health Organization, 90(3),
\n158\u2013158A.
\n8.\t Besancon L., Chaar B. Report of the interna-
\ntional summit on medicines shortage. (2013)
\nInternational Pharmaceutical Federation (FIP),
\nToronto. Available at: http:\/\/www.fip.org\/files\/
\nfip\/publications\/FIP_Summit_On_Medicines_
\nShortage.pdf. Accessed 17 June 2015.
\n9.\t Fact Sheet: Drug Products in Shortage in the Unit-
\ned States.(2015) [ONLINE] Available at: http:\/\/
\nwww.fda.gov\/RegulatoryInformation\/Legisla-
\ntion\/FederalFoodDrugandCosmeticActFD-
\nCAct\/SignificantAmendmentstotheFDCAct\/
\nFDASIA\/ucm313121.htm. Accessed 17 June
\n2015.
\n10.\tAre Shortages Going Down Or Not? Interpreting
\nData From The FDA And The University Of Utah
\nDrug Information Service. [ONLINE] Available
\nat: http:\/\/healthaffairs.org\/blog\/2015\/04\/08\/
\nare-shortages-going-down-or-not-interpreting-
\ndata-from-the-fda-and-the-university-of-utah-
\ndrug-information-service\/Accessed 17 June
\n2015.
\n11.\tHou\u00ffez F., et al. Common position between
\npatients\u2019, consumers, and healthcare profession-
\nals\u2019 organisations involved in the activities of the
\nEuropean Medicines Agency on Supply Short-
\nages of Medicines. (2013) [cited 21.03.2014.];
\nAvailable from: http:\/\/download.eurordis.org.
\ns3.amazonaws.com\/documents\/pdf\/common-
\nposition-supply-shortages-final-10-2013.pdf.
\n12.\tEuropean Commission (2014, Sep 10) The
\nJuncker Commission: A strong and experienced
\nteam standing for change, http:\/\/europa.eu\/rapid\/
\npress-release_IP-14-984_en.htm Accessed 17
\nJune 2015.
\nRichard Price,
\nPolicy and Advocacy
\nOfficer at the European Association of
\nHospital Pharmacists (EAHP)
\nE-mail: richard.price@eahp.eu
\nWhich type of medicine do you most commonly experience to be in short supply?
\nAccording to the respondents they most commonly experience originator (patented) products to be in
\nshort supply. 51.8% (n=221) reported them as the most common category of shortage.
\nGeneric products (including branded generics) were a\ufb00ected to a lesser degree, with 36.5% (n=156) of
\nhospital pharmacists starting that they are the most a\ufb00ected category in theri experience.
\n11.7% (n=50) of respondents considered that unlicensed medicines are the most common type of
\nmedicines in short supply.
\nGeneric
\n36.5%
\nUnlicensed
\nmedicines
\n11.7%
\nOriginator
\n51.8%
\nThe countries with highest recordes prevalence of originator (patented) shortages are Belgium
\n(78.3%, n=69), Spain (64.5%, n=62), Austria (73.3%, n=15) and Slovakia (78.6%, n=14). The pharmaceu-
\ntical markets of Bulgaria, Ireland, Switzerland, Italy, Norway, France, and Poland also expressed that
\npatented products were the most common category of shortages.
\nFigure 2.\u2002 Nature of the shortages reported from all of the respnseces. N=427
\nIn which area of medicine does your hospital experience shortage most commonly?
\nThe areas in which shortages of medicines are most commonly reported are:
\n\u2022 antimicrobial agents
\n\u2022 oncology medicines
\n\u2022 emergency medicines
\n\u2022 cardiovascular medicines
\n\u2022 anaesthetic agents
\nIt is interesting to note that at least 19 (4.5%) reports were received for the lowest a\ufb00ected category:
\ntransplant medicines. This indicates the many categories of medicine are a\ufb00ected by shortage.
\n57%
\n55%
\n30% 30%
\n26%
\n0.0%
\n10.0%
\n20.0%
\n30.0%
\n40.0%
\n50.0%
\n60.0%
\nAntimicrobilalagents(Antibiotics\/
\nAntivirals\/Antifungals)
\nOncology
\nEmergency
\nCardiovascularmedicines
\nAnaestheticagents
\nEndocrinemedicines
\nPreventivemedicines
\n(e.g.vaccines)
\nHaematologymedicines
\nOther
\nPaediatricmedicines
\nRespiratory
\nTopicaltreatments
\nGastrointestinal
\nOrphan
\nRenal
\nUrology
\nTransplant
\nFigure 3.\u2002\u0007Category of shorages reported overall.The categories with the highest responds
\ninclude antimirobials (56.7%), oncology (54.5%), emergency medicines (30.4%)
\nand cardiovascular medicines (30.4%). n=418
\nApproximately how often does your hospital pharmacy experience shortages?
\nMost hospital pharmacists responded that they are a\ufb00ected by shortages on a weekly basis.
\nHospital pharmacists are a\ufb00ected by shortages on a daily basis, with 21.1% (n=111) replying that they
\nexperience a shortage of a medicine every day.
\nThe situation for the majority of those who replied was that they experience shortages at least weekly,
\n45.2% (n=238) selecting this response.
\n21.2% (n=112) replied that they are a\ufb00ected by shortages on a monthly basis with 12.4% (n=65) stating
\nthat they are a\ufb00ected occasionally.
\nThis resulted in a combined 87.6% (n=112) of the respondents replying by saying that they are a\ufb00ected
\nby medicines shortages at least monthly.y
\nMonthly
\n21.2%
\nOccasionally
\n12.4%
\nDaily
\n21.2%
\nWeekly
\n45.2%
\nFigure 1.
\nBACK TO CONTENTS
\n72 73
\nGERMANYGERMANY Mobile HealthMobile Health
\nThe rapid advancement of technology does
\nnot stop at mobile devices: For most people,
\nthese sophisticated gadgets have become
\nan integral part of their daily life. Smart
\nphones and tablets as well as various wear-
\nable devices, e.g. smart watches, perform
\ntheir duties in an unobtrusive way but still
\nprovide users with impressive functional-
\nities that would have been unthinkable of
\nonly a few years ago: the sensor technology
\nincluded in most of these devices can record
\ndata relating to many different aspects of
\nthe user\u2019s life and these data can easily be
\nstored and evaluated either on the devices
\nthemselves or be sent to some remote loca-
\ntion for further processing and storage.
\nAt first gaining great popularity with busi-
\nnesspeople as well as private users who feel
\nthey can rarely do without their constant
\nmobile companions, the devices have also
\nbecome accepted in other sectors, including
\nthe medical field. Part of this stems from
\nthe fact that economists as well as politi-
\ncians have come to realize that mobile de-
\nvices along with the (public) health related
\napps running on them offer great potential
\nfor the medical field, not only by improv-
\ning the quality of care for patients, but also
\nfrom an economic point of view. Their uses
\nin the medical context are manifold. For
\nexample, they are regarded as invaluable
\nfor prevention, e.g. for monitoring chronic
\nconditions such as high blood pressure or
\ndiabetes [1,\u00a02] and improving adherence to
\ntherapies. For patients, the main aspect is
\nthe added comfort of such mobile solutions
\ncompared to conventional methods, while
\nfrom a professional point of view, better ad-
\nherence to a prescribed regimen as well as
\nmeticulous monitoring may serve to prevent
\nlong-term damages that might be caused as
\na result of a more careless approach. Never-
\ntheless, despite the perceived benefits mo-
\nbile technologies can offer in healthcare, the
\nhighly sensitive nature of this field of appli-
\ncation raises a number of ethical questions
\nthat need to be answered [3].
\nPeople who use health related apps for re\u00ad
\ncreational purposes, training or other health
\nrelated tasks are usually confident that those
\nwho provide the apps (vendors as well as
\ndevelopers) follow the unwritten rules with
\nrespect to how personal data should be han-
\ndled or not.They are not necessarily ignorant
\nor careless, but often, they like to think that
\ndatasets recorded by the mHealth applica-
\ntions they use are deleted as soon as they are
\nno longer needed or that only they them-
\nselves can gain access to their data because
\nthey do not suspect anything else. However,
\nthere are divergent interests involved that
\nmay lead some providers of mHealth apps to
\ncollect data and use them for purposes that
\nthe users are not aware of (and would never
\nor only hesitatingly acquiesce to if they were
\ntold), e.g. marketing. The consequences of
\nthis \u201cmisinterpretation\u201d of the other party\u2019s
\ngoals are not trivial.This is not about wheth-
\ner people should clap hand in the British
\nHouse of Parliament or not\u00a0\u2013 it is about seri-
\nous issues regarding autonomy, participation,
\npersonal health, economy and public inter-
\nests. Different interests and different notions
\nabout \u201cwhat should be done\u201d cause tensions
\nand conflicts of goals and norms. Conflicts
\nlike these are well known to medicine at
\nlarge, but mHealth in its ubiquity, availabil-
\nity and accessibility may provoke a new and
\nenhanced debate about some ethical aspects
\nthat are already being discussed in medicine
\nin general.
\nThe power of mHealth apps to medicalise
\n[4] the behaviour of individuals causes us
\nto start a debate about ethics in mHealth.
\n\u00adUsers often make excessive use of mobile
\ntechnologies when it comes to monitoring
\ntheir health because they have been told this
\nmay help to reduce their risk for disease.
\nAlso, they believe that being well informed
\nmay also serve to mitigate potential risks.
\nAt the same time apps have already proven
\nto be effective tools for boosting adherence
\nto therapies (for example, via text messag-
\ning reminders) or for disease management
\n[5]. However, these developments go hand
\nin hand with technical challenges and ethi-
\ncal concerns: Above all, the medicalisation
\nof apps results in limited consumer choices.
\nThis refers as much to using the apps them-
\nselves as to targeted advertising users may
\nreceive which is specifically adapted to their
\n\u201chealth\u201d-related data or their health pro-
\nfile. Consumers may be led to think that
\nthey need certain apps or commercialized
\nproducts for their well-being. Having these
\nradical examples in mind, we believe that it
\nis essential to transparently describe what
\npeople using mobile devices for mHealth
\ncan expect from mHealth providers. Thus,
\nmHealth ethics is not so much about find-
\ning out which rules people want mHealth
\nproviders to follow, but about which rules
\nmHealth providers promise to follow in the
\nfuture.
\nOur objective in this article is to provide
\nsome starting points for the clearly need-
\ned discussion about ethics in mHealth.
\nTherefore, after an introductory definition
\nof what constitutes \u201cmHealth\u201d, we outline
\nhow the fundamental principles of medical
\nethics as they are described in several stan-
\ndard codices can be transformed in order to
\nmake them applicable to mHealth.In a nut-
\nshell, we propose mHealth specific ethical
\nprinciples to be developed that\u00a0\u2013 while they
\nare still based on established principles and
\nguidelines\u00a0\u2013 also take the specific require-
\nments of mHealth under consideration.
\nDo Ethics Need to Be Adapted to mHealth?
\nA Plea for Developing a Consistent Framework
\nWhat Constitutes mHealth?
\nAs specified by the WHO\u2019s Global Obser-
\nvatory for eHealth (GOe), mHealth, also
\nknown as mobile health, can be seen as the
\n\u201cmedical and public health practice support-
\ned by mobile devices, such as mobile phones,
\npatient monitoring devices, personal digital
\nassistants (PDAs), and other wireless devic-
\nes.\u201d[6].However,considering the rapid tech-
\nnological evolution that of course does not
\nstop at mobile devices,this definition (dating
\nback to 2011) falls short of what is possible
\nnowadays. Even sensors commonly found in
\nmobile devices but developed with entirely
\ndifferent fields of application in mind are of-
\nten used for medical and health related pur-
\nposes.Apart from applications making use of
\nsensor based data, there are also those that
\naim at providing users with health related
\ninformation, while even others target bio-
\nmedical research or can be used for (preven-
\ntive) healthcare. Often, it is impossible (and
\nnot even desirable) to clearly distinguish
\nbetween these areas, since they all make use
\nof monitoring, recording as well as surveil-
\nlance functionalities and there are many
\noverlaps. A \u201cdefinition\u201d guideline has been
\nprovided, for example, by the FDA in their
\n\u201cGuidance for Industry and Food and Drug
\nAdministration Staff\u00a0 \u2013 Priority Review of
\nPremarket Submissions for Devices\u201d [7] re-
\nvised on February 9, 2015. Also, the manner
\nin which mHealth is being used means that
\nthe \u00adaccess to health related services is no lon-
\nger restricted to time or location, i.e. getting
\nto a doctor\u2019s office or a hospital at a specific
\ntime. Instead, by using mHealth technolo-
\ngies, \u00adusers can gain access to an impressive
\nnumber of health related services whenever
\nthey need them [5].
\nEvaluating Existing Biomedical
\nPrinciples and Codes
\nDue to the vast number of imaginable areas
\nof application for mHealth solutions, start-
\ning with their use in private settings in the
\npatient\u2019s home and further extending to re-
\nmote monitoring of various data as well as
\nlarge scale collection of health related data
\nfor biomedical research (the so called \u201cbig
\ndata\u201d approaches [8, 9]), many different lev-
\nels of medical ethics are affected and must be
\nconsidered.
\nFor example, as soon as data originally re-
\ncorded in a care context is (additionally)
\nevaluated in a research project, research eth-
\nics need to be included in the equation. On
\nthe other hand, if mobile devices are em-
\nployed to record physiological parameters
\n(independent of whether this patient care or
\nresearch in mind), patient autonomy as well
\nas the patient\u2019s right \u201cnot to know\u201d must be
\nrespected. Also, sometimes, the target ori-
\nented approach commonly used in medicine,
\nnamely, research vs. treating patients, stands
\nin the way of applying the value-rational
\nprinciples of medical ethics as would be
\n\u00adappropriate. And lastly, the use of mHealth
\nmay also influence the relationship between
\npatients and their physicians. A striking ex-
\nample is the reference to the traditional issue
\nof confidentiality: mHealth app users might
\nuse them to communicate their disease spe-
\ncific parameters with their physician, either
\nactively, for example, via text messaging or
\npassively by having their data monitored.This
\ncommunication can only be frank, trustful,
\ntrue and free of manipulation if confidential-
\nity, as a crucial element of patient-physician
\nrelationships, is guaranteed. For both sides,
\nconfidentiality is of utmost importance and
\nthis also holds true for third parties because
\nthis is essential for guaranteeing mutual re-
\nspect,full disclosure of symptoms to the phy-
\nsician and privacy, including protection from
\nstigmatization.
\nConsidering the different spheres of pa-
\ntient\u2019s life which apps can monitor and
\nrecord, it becomes clear that at least in the
\nmedical field, the health related use of apps
\nneeds some ethical guidance. Referring to
\nclassical elements of medical ethics this
\nmeans that, for example, the four principles
\nof \u201cautonomy\u201d, \u201cnonmaleficence\u201d, \u201cbenefi-
\ncence\u201d, and \u201cjustice\u201d mentioned in the so-
\ncalled \u201cGeorgetown mantra\u201d [10] as well as
\nsimilar aspects mentioned in other docu-
\nments and normative analyses have to be an
\nessential part of all further work.
\nCodes of ethics that are already available
\nand deal with issues related to the conse-
\nquences of using technologies, public health
\n[11], research [10, 12], or telemedicine [13]
\nas well as the general use of internet based
\nservices [14] or other subject areas such as
\nmedical informatics [15] also need to be
\nscrutinized with respect to their applicabil-
\nity to the mHealth sector.
\nHowever, such an analysis reveals that there
\nare certain dimensions that might be in con-
\nflict with each other. For example, while a
\nuser may simply want to have his or her data
\nmonitored to stay healthy and continue to be
\nable to participate in public, mHealth pro-
\nviders may rather have the collection of data
\nfor research or marketing purposes in mind
\nand may also want to influence the behavior
\nof consumer in one or the other direction.
\nHere, specifically the above mentioned tra-
\nditional concepts like autonomy, confiden-
\ntiality, beneficence and maleficience are at
\nstake.At the same time and on another level,
\na consumer using mHealth may have the im-
\npression that the promise of confidentiality
\ncommonly applied in medical contexts also
\nextends toward mHealth settings in gen-
\neral and, thus, his or her health related data
\nare also protected similarly. However, many
\nmHealth providers have a more or less legiti-
\nmate interest to simply make use of the data
\nthey obtain. Additionally, the interest in data
\ndoes not stop with researchers. Public health
\nofficials, a \u201cmedical police\u201d, insurances or
\nemployers might also have interest in these
\ndata to increase their chances on the market
\nby choosing the clients or employers with the
\nbest risk profile. Transparency usually has a
\ngood reputation, but from a patient perspec-
\ntive, mHealth transparency interpreted in
\nthis manner may go too far.
\nAs a first approach,we would therefore sug-
\ngest to follow the classical codes of medical
\nBACK TO CONTENTS
\n74 75
\nHealth AppsGERMANYGERMANYMobile Health
\nethics and codes for e-health and telemedi-
\ncine in order to examine the dimensions of
\nnormative conflicts involved. From this ba-
\nsis, we propose to develop a specific WHO
\nmHealth code of ethics along the following
\nlines:
\n1.\t \tAbove all, patient interests need to be
\naddressed and questions of autonomy
\nhave to be integrated in such a mHealth
\ncode as well.This would involve
\n— respecting the right to self-determina-
\ntion with respect to active or passive
\nparticipation where use or application
\nof mHealth are concerned,
\n— voluntary participation and the right to
\nwithdraw at any time,
\n— providing comprehensive and target-
\ngroup as well as situation specific in-
\nformation to allow for an informed
\ndecision,
\n— promotion of health awareness for
\n(self-) confident decision making in
\nhealth contexts.
\n2.\t Furthermore, the mHealth code of eth-
\nics needs to address possible settings
\nwhere mHealth apps can be beneficial,
\ntheir inclusive or exclusive character and
\ntheir accessibility for people potentially
\nbenefitting from their use. This would
\nfor example mean that
\n— the primary benefits for the affected
\npersons must be obvious or deducible,
\n— objectives of the mHealth app must be
\nachieved based on valid data,
\n— decision processes must be transparent
\nand need to include all stakeholders
\nconcerned (affected persons) in order
\nto justify an intervention in a compre-
\nhensible manner.
\n3.\t Additionally,
\n— mHealth interventions must be avail-
\nable to everyone, regardless of social
\nstatus, income, education, political ori-
\nentation, religious faith, inclinations
\nand ideals,gender,age,ethnic group but
\nalso when it comes to technical affinity,
\nhealth competence, mental or physical
\nimpairments. Neither discrimination
\nnor stigmatization may be caused by
\nthe intervention.
\n— mHealth interventions should aim at
\neliminating existing inequalities. For
\nthis, the fair distribution of potential
\nbenefits and potential harm within the
\ntarget group is a prerequisite.
\n4.\t It is often forgotten that mHealth apps
\ndiffer from other apps in the very aspect
\nthat they address the fundamental issue
\nof health. Therefore, mHealth providers
\nshould\u00a0\u2013 in line with the medical tra-
\ndition\u00a0\u2013 promise not to cause harm to
\ntheir users. For example,
\n— the mHealth intervention shall not in
\nany way have a negative impact on its
\nuser or on the receiving party. Specifi-
\ncally, this applies to the physical and
\nmental wellbeing of each individual, a
\ngroup of individuals or the individual\u2019s
\nenvironment.
\n— The risks of an intervention must be
\ncommensurate with its expected ben-
\nefits. This requires carefully weighing
\nup the risks and benefits based on valid
\nand reliable information.
\n— The right to privacy, which aside from
\nconfidentiality also includes protecting
\npersonal integrity, must be protected in
\norder to prevent any harm.
\n5.\t Finally, when using mHealth tools for
\nresearch purposes, one should be care-
\nful to respect the existing principles for
\ngood scientific practice, specifically
\n— that research using mHealth appli-
\ncations needs to generate valid and
\nreliable data and that the commonly
\nknown principles of good scientific
\npractice as well as the biomedical prin-
\nciples of research must be observed.
\nConclusion
\nThe presented catalogue of principles is
\nsupposed to offer a first glimpse of a pos-
\nsible code promising certain behaviors (on
\nthe part of mHealth providers) to users of
\nmHealth apps. Users seek health, provid-
\ners may seek data as well as novel revenue
\ngenerating areas of application and, thus,
\nthey may follow public, individual or eco-
\nnomic interests. Maintaining the overview
\nof all aspects that need to be respected by
\nstakeholders involved in mHealth is not an
\neasy task as the aforementioned consider-
\nations reveal. Although several codes re-
\ngarding eHealth exist, we think that, due to
\nits ubiquity, the requirements to be met for
\nmHealth are even more challenging. Hav-
\ning a unified \u201ccode of ethics\u201d specifically
\ntargeting mHealth would simplify the ten-
\nsion caused by the mismatch between users\u2019
\nexpectations and the morals of providers
\nand it might improve compliance with the
\nrequired principles.
\nReferences
\n1.\t Eng D.S.,Lee J.M.The promise and peril of mo-
\nbile health applications for diabetes and endo-
\ncrinology. (2013) Pediatric Diabetes,2013,14(4,)
\n231\u2013238.
\n2.\t Fangerau H., Martin M. (2014) Blutdruck
\nmessen: Die \u201aTechnikalisierung\u2018 der Kreislauf-
\ndiagnostik. Technomuseum (Hrsg): \u201cHerzblut.
\nGeschichte und Zukunft der Medizintechnik\u201d,
\nTheiss\/WBG, Darmstadt, S. 74-93
\n3.\t Albrecht U.V., Pramann O. (2014) Ethical and
\nLegal Implications on Apps in Clinical Trials.
\n(2014) Biomed Tech 59 (s1,) pp. 674-675 DOI
\n10.1515\/bmt-2014-4290
\n4.\t Conrad P. (2007) The Medicalization of Society.
\nOn the Transformation of Human Conditions into
\nTreatable Disorders. Baltimore
\n5.\t Boulos M.N., Brewer A.C., Karimkhani C.,
\nBuller D.B., Dellavalle R.P. Mobile medical and
\nhealth apps: state of the art, concerns, regulatory
\ncontrol and certification.(2014) Online Journal of
\nPublic Health Informatics.5(3),229. doi:10.5210\/
\nojphi.v5i3.4814.
\n6.\t World Health Organization. (2011) mHealth\u00a0\u2013
\nNew horizons for health through mobile technolo-
\ngies. Global Observatory for eHealth series. V.3, 6
\n7.\t FDA. Mobile Medical Applications. Guidance
\nfor Industry and Food and Drug Administration
\nStaff. http:\/\/www.fda.gov\/downloads\/Medi-
\ncalDevices\/…\/UCM263366.pdf. (Last access:
\n18.06.2015)
\n8.\t Sungmee Park, Jayaraman S. A transdiscipli-
\nnary approach to wearables, big data and qual-
\nity of life. (2014) Conference Proceedings of the
\nIEEE Engineering in Medicine and Biology Soci-
\nety.4,155-58.
\n9.\t Hsieh J.C., Li AH, Yang C.C. Mobile, cloud,
\nand big data computing: contributions, chal-
\nlenges, and new directions in telecardiology.
\n(2013) International Journal of Environmental
\nResearch and Public Health, Nov.10(11),6131-53.
\n10.\tBeauchamp T.L., Childress J.F. (2009) Principles
\nof Biomedical Ethics. Oxford University Press.
\n11.\tPublic Health Leadership Society. (2002) Prin-
\nciples of the Ethical Practice of Public Health.
\nhttp:\/\/phls.org\/CMSuploads\/Principles-of-the-
\nEthical-Practice-of-PH-Version-2.2-68496.pdf
\n12.\tWorld Medical Association.(2014) World Med-
\nical Association Declaration of Helsinki. Ethical
\nPrinciples for Medical Research Involving Hu-
\nman Subjects. JAMA. 2013; 310(20):2191-2194.
\ndoi:10.1001\/jama.2013.281053
\n13.\tIserson K.V.Telemedicine: a proposal for an eth-
\nical code. (2000) Cambridge Quarterly of Health-
\ncare Ethics.9, 404\u2013406
\n14.\tRippen H., Risk A. e-Health Code of Eth-
\nics. (2000) Journal of Medical Internet Research.
\n2(2):e9 URL: http:\/\/www.jmir.org\/2000\/2\/e9
\nDOI: 10.2196\/jmir.2.2.e9 PMID: 11720928
\nPMCID: PMC1761853
\n15.\tInternational Medical Informatics Association.
\nIMIA Code of Ethics for Health Information Pro-
\nfessionals. http:\/\/www.imia-medinfo.org\/new2\/
\nnode\/39
\nDr.\u00a0med. Urs-Vito Albrecht, MPH,
\nHannover Medical School,
\nPeter L. Reichertz
\nInstitute for Medical Informatics, Germany
\nE-mail: albrecht.urs-vito@mh-hannover.de
\nProf. Dr.\u00a0med. Heiner Fangerau,
\nInstitute of the History,
\nPhilosophy and Ethics
\nof Medicine at Cologne
\nUniversity of Cologne, Germany
\nE-mail: heiner.fangerau@uni-koeln.de
\nA gold rush mood is prevailing among all
\nstakeholders who are active in healthcare
\nand everybody is clamoring for \u201ctheir\u201d app:
\nHealthy users want to track their fitness and
\nto obtain health related information and pa-
\ntients hope to get a comfortable means to
\nmanage their condition or to get into con-
\ntact with their doctors. For manufacturers,
\napps and mobile technology in general stand
\nfor an additional chance for selling \u201chealth\u201d,
\neither under a new guise, or ideally based on
\nentirely new and exciting ideas. The market
\nis diverse and it is hard to maintain an over-
\nview\u00a0\u2013 for those interested in health related
\nmobile offers, the situation is often confus-
\ning. The most difficult part in determining
\nwhether an offer is acceptable or not is rat-
\ning the quality of health apps. Most users\u00a0\u2013
\npatients and healthcare professionals alike\u00a0\u2013
\nare simply not familiar with the strategies
\nneeded for carrying out such an assessment
\non their own. Although various tools exist
\nthat could help them in this process (e.g. [1,
\n2]), many of these are still under develop-
\nment or users are simply not aware of their
\nexistence. What are the dangers users may
\nbe confronted with in this context? This ar-
\nticle is meant to shed some light on the cur-
\nrent situation and to provide some remedies.
\nThe App Market, Health
\nApps and Medical Apps
\nThe smartphone and app hype really started
\nin 2008 when 500 apps were made available
\non one app store [3].In May 2015,the num-
\nber of offered apps had already grown to the
\nformidable number of 3,730,000 [4] for four
\nmobile platforms in five app stores.The con-
\ntinuing growth of the app market in general
\nalso applies to apps for health and fitness
\nand, in fact, some analysts predict that this
\npart of the app market will have the largest
\npercentage change [5]. Recent estimates are
\nthat there are about 100 000 mHealth apps
\n[6] with an estimated growth of about 1 000
\napps per month [7]. An exact number for
\nmHealth apps cannot be determined since
\nthe app stores only offer very basic rules for
\nassigning apps to one category or another.
\nRather, this is left to the manufacturers, who
\nwill often choose a category that promises
\nbetter sales. To clarify the classification and
\nto give users a better understanding, we rec-
\nommend the following to clearly differenti-
\nate between health apps and medical apps
\n[8]. While, following the WHO\u2019s definition
\nof health as \u201ca state of complete physical,
\nmental and social well-being and not merely
\nthe absence of disease or infirmity\u201d [9]\u00a0 \u2013
\nthe term \u201chealth apps\u201d encompasses a wide
\nrange of health related apps, \u201cmedical apps\u201d
\nare primarily intended for diagnosing, treat-
\ning or preventing illnesses or injuries.
\nRisks and Limitations
\nThe relevance of this categorization becomes
\napparent when one considers the potential
\nrisks and ramifications that may arise in the
\nintended field of application. For medical
\napps, the inherent risks of causing harm are
\nconsiderably greater, since their focus is pri-
\nmarily on diagnosing or treating patients\u00a0\u2013
\nsupported by the app and the mobile devices
\nthey run on\u00a0\u2013 whose health is already com-
\npromised in some way. However, the desired
\nsuccess may either fail to materialize or, in a
\nworst-case scenario, it may come to an exac-
\nerbation or additional health problems. Of
\ncourse, this outcome is highly undesirable,
\nUrs-Vito Albrecht
\nHealth Apps\u00a0\u2013 Sound and Trustworthy?
\nBACK TO CONTENTS
\n76 77
\nHealth Apps Health AppsGERMANYGERMANY
\nnot only for the patients themselves but of-
\nten also for the medical staff, their employ-
\ners, as well as the manufacturers. There exist
\nmany possible sources of risks and the fol-
\nlowing paragraphs will mention the most
\nobvious ones\u00a0\u2013 the list is by no means ex-
\nhaustive. Roughly speaking, two areas where
\nproblems can arise can be discerned:
\n1.\t \u201cThe app does not do what is supposed
\nto do!\u201d This sentence and other simi-
\nlar utterances, often voiced by discon-
\ntented users, for example in user com-
\nments that they leave on the stores, is
\noften caused not only by shortfalls in
\nperformance that may for example be
\ncaused by technical limitations of the
\ndevices used to run the app, but also by
\nprogramming errors, deficiencies of the
\ncontent or simply bad usability.
\n2.\t \u201cThe app does more than it should!\u201d
\nThis is often caused by non-obvious
\n\u201cfeatures\u201d of an app, for example when
\ndata protection and data security or
\nthe user\u2019s right to self-determination
\nare compromised. This may be caused
\neither with or without intent, e.g. by
\nfailing to observe due security measures
\nwhen dealing with this highly sensitive
\ntype of data,lack of providing users with
\nadequate information regarding data
\nhandling or even worse, secret and illicit
\ndata transmission and evaluation.
\nThe App as a Medical Device
\nAlthough many aspects of the app business
\ngive the impression of a \u201cwild west\u201d scenario,
\nat least some apps, namely, those where the
\nmanufacturers have specified that they are a
\n\u201cmedical device\u201d, have to conform to the of-
\nficial regulatory requirements that apply to
\nsuch products. However, whether these re-
\nquirements apply also depends on whether
\nthe manufacturer has assigned a medical pur-
\npose to his product, in this case the app. Go-
\ning through the processes is often time-con-
\nsuming and costly.Thus, although some apps
\ncan be medical products and would therefore
\nhave to comply with regulations for such
\nproducts,manufacturers often avoid or ignore
\nthis due to the considerable hurdles raised by
\nthe necessary regulatory processes. Currently,
\ncompared to the number of available apps,
\nonly a relatively small number of apps have so
\nfar gained approval by a federal authority (e.g.
\nby the Food and Drug Administration in the
\nUSA) or passed an assessment following the
\nfederal laws of other states (e.g. conformity
\nassessment for European countries). The im-
\npossibility of closer scrutiny of all apps by the
\nauthorities, which would be appropriate, can
\nalso easily be explained by the sheer number
\nof apps and additionally contributes to the
\nuncertainties in this area, although the intent
\nof regulation is to protect patients as well as
\nusers of these products. An exhaustive over-
\nview of the subject of \u201capps and regulations\u201d
\ncan be found in [10].
\nPrivate Certification
\nFor many apps, regulations simply do not
\napply, while for others, manufacturers ig-
\nnore the regulatory processes either due to
\na lack of knowledge about the requirements
\nor intentionally. Unfortunately, this means
\nthat in order to obtain some sort of qual-
\nity seal for their product, the manufacturers
\nhave to resort to using the services offered
\nby a number of private contractors. These
\nseals can also be used for advertising pur-
\nposes. Of course, this comes with a price
\nand such services are offered both nationally
\nas well as on an international level. Still, the
\nreliability of these offers is highly variable,
\nas was recently underlined by the deficien-
\ncies found in the recently halted certifica-
\ntion processes offered by Happtique [11].
\nAppraising the
\nTrustworthiness of Apps
\nUltimately,the decision on whether to use an
\napp or to refrain from using it remains with
\nthe users.They carry the prime responsibility
\nand can also be held accountable\u00a0\u2013 at least
\nin a professional context\u00a0\u2013 when using apps
\n[12]. Users of health apps are in a difficult
\nsituation: they have to decide for themselves
\nwhether they place their trust in an app.This
\nis a difficult and error prone decision mak-
\ning process.The probability for errors can be
\nreduced if users can base their decision on
\nreadily available and valid information, but
\nsuch information is often hard to come by.
\nAvailableInformationIsnotAlways
\nReliable and Reliable Information
\nIs Only Rarely Available
\nUsers often rely on comments made by other
\nusers on the distribution platforms.Such com-
\nments can be easily created and publicized.
\nThe more \u201cstars\u201d and positive comments an
\napp has received, the greater its attractiveness
\nfor users as well as for the search algorithms
\nof the stores. However, these comments and
\nratings are not subject to any review and do
\nnot follow any standards. They can be freely
\nassigned and given pseudonymously. Their
\nquality is often questionable, but still they
\nare generally the main source of information
\nfor those interested. Other information can
\nusually only be found via time-consuming
\nsearches: blogs, evaluations done by (private)
\ninitiatives or databases containing specific in-
\nformation provided by the manufacturers that
\nare often not widely known. If available, peer
\nreviews of apps or corresponding scientific
\nstudies provide more reliable information,but
\nfinding this information often requires con-
\nsiderable effort on the users\u2019part.
\nWhich Information Is Important
\nfor Making a Decision?
\nFor users, the situation is quite chaotic due to
\nthe vast number of available apps. Identify-
\ning apps that match the desired use and are
\ntrustworthy is like a mixture between finding
\na needle in the haystack and playing Wheel of
\nFortune. The emphasis of available informa-
\ntion is often on marketing aspects and infor-
\nmation that can support the claimed credibil-
\nity and trustworthiness can rarely be found.
\nAlternative sources of information need to be
\nidentified and are often only available some
\ntime after an app has been published. Certifi-
\ncations are also rare and they often suffer from
\nquestionable credibility. There are even fewer
\napps conforming to regulatory standards.
\nWhat can be done to make things work?
\nSensitizing Users as well as
\nManufacturers Combined with
\nStandardized Information
\nUsers need reliable applications, especially
\nwhere either their own health or that of
\nthe patients they treat is concerned. This
\nis not only an ethical imperative, but also a
\nstrict requirement from a legal point of view
\n(buzzword: \u201cmedical device\u201d). Imprudent
\nuse of apps can cause serious harm. There
\nis no alternative to requiring manufacturers
\nto actively provide reliable and trustworthy
\napps and corresponding information. Ex-
\nerting pressure will work best if sales are af-
\nfected. In order to enable users to use their
\npower in this context, they need tools that
\ncan support them in their decision whether
\nto purchase an app or not.Information to be
\nused towards this end may be gained from
\na number of different sources. For example,
\nit may be based on standardized reporting
\nmechanisms, such as an app synopsis [4,
\n10] which covers all important aspects and
\nprovides the crucial information in a single
\nlocation.Information covered by the synop-
\nsis contains not only the background of the
\nmanufacturer or distributor of an app and
\nhis associates as well as the experts involved
\nin the development, but also the rationale
\nbehind the app, i.e. its intended purpose(s)
\nand target audience. It also makes provi-
\nsions for aspects such as functionality and
\nreliability of the app as well as data acquisi-
\ntion, data transmission and storage and, of
\ncourse, also calls for information on how
\ndata protection and privacy are handled. A
\nmore exhaustive description of the app syn-
\nopsis can be found in [8, 13, 14].
\nTransparency as an Added Value
\nThe situation in the market can be improved
\nas soon as manufacturers acknowledge that
\nproviding transparent information about their
\nproduct can significantly contribute towards
\nan app\u2019s perceived quality. Users will appreci-
\nate the added value they receive via this trans-
\nparent reporting. For manufacturers, it is an
\neasy task to compile the information point by
\npoint and to publish it,for example on the app
\nstores,since they already possess the necessary
\nknowledge. Thus, users have a fair chance to
\ninform themselves about an app even before
\nthey download it. For users, this is only fair
\nsince they are also affected by the potential
\nconsequences of using the app.This can serve
\nboth as an important confidence building
\nmeasure as well as towards improving sales.
\nStill, just providing this information does
\nnot suffice as in addition users must be made
\naware of the inherent risks of apps that are to
\nbe used in a health context and they must also
\nlearn to ask the right questions. Educating
\n\u00adusers towards this goal is imperative.
\nConclusion
\nOne objective of the article was to present
\naspects relevant for assessing the trustwor-
\nthiness of a health related app, while also
\nsensitizing readers to what needs to be in-
\ncluded even during the development phase
\nof a trustworthy app. Only based on trust-
\nworthy apps will it be possible to fully re-
\nalize the potential apps offer for healthcare
\nwithout risking to lose the trust users place
\nin them\u00a0 \u2013 only an app that can be used
\nwithout any problems will be a success.
\nReferences
\n1.\t Bonacina S.,Marceglia S.,Pinciroli F.A pictorial
\nschema for a comprehensive user-oriented iden-
\ntification of medical Apps. (2014) Methods of In-
\nformation in Medicine;53, 208\u201324. doi:10.3414\/
\nME13-01-0093.
\n2.\t Lewis T.L. A systematic self-certification mod-
\nel for mobile medical apps. (2013) Journal of
\nMedical Internet Research;15:e89. doi:10.2196\/
\njmir.2446.
\n3.\t Engadget. Jobs: App Store launching with 500
\niPhone applications, 25% free. (2008) http:\/\/
\nwww.engadget.com\/2008\/07\/10\/jobs-app-
\nstore-launching-with-500-iphone-applications-
\n25-free\/(accessed June 17, 2015).
\n4.\t Statista. Number of apps available in leading app
\nstores as of May 2015. (2015) http:\/\/www.statista.
\ncom\/statistics\/276623\/number-of-apps-available-
\nin-leading-app-stores\/(accessed June 17, 2015).
\n5.\t Research2Guidance. Mobile Health Market Re-
\nport 2013-2017. Available from http:\/\/www.re-
\nsearch2guidance.com\/shop\/index.php\/mhealth-
\nreport-2 (accessed June 17, 2015).
\n6.\t Research2Guidance. mHealth App Devel-
\noper Economics 2014. Available from http:\/\/
\nmhealtheconomics.com\/mhealth-developer-
\neconomics-report\/(accessed June 17, 2015).
\n7.\t Becker S., Miron-Shatz T., Schumacher N.,
\nKrocza J., Diamantidis C., Albrecht UV.
\nmHealth 2.0: Experiences, Possibilities, and
\nPerspectives. (2014) Journal of Medical Internet
\nResearch, 2:e24.
\n8.\t Albrecht U.V., Pramann O., von Jan U. Synopsis
\nfor Health Apps\u00a0\u2013 Transparency for Trust and
\nDecision Making. (2014) In: Househ M, Bory-
\ncki E, Kushniruk A (Hrsg): Social Media and
\nMobile Technologies for Healthcare. (pp. 94-
\n108) Medical Information Science Reference (an
\nimprint of IGI Global), Hershey PA, USA.
\n9.\t WHO. Preamble to the constitution of the
\nWorld Health Organization as adopted by the
\nInternational Health Conference, New York,
\n19-22 June, 1946; signed on 22 July 1946 by the
\nrepresentatives of 61 states (official records of
\nthe World Health Organization, No. 2, p. 100)
\nand entered into force on 7 April 1948
\n10.\tPramann O.,Albrecht UV.: Medical Apps\u00a0\u2013 Alles
\nwas recht ist: Ein rechtlicher \u00dcberblick \u00fcber den
\nEinsatz von Apps und Mobilger\u00e4ten im Kinikbe-
\ntrieb. (2013) E-HEALTH-COM, 1, 22-27.
\n11.\tDolan P.L. Health app certification program
\nhalted. (2013) Irving, TX: MultiView, Inc;.
\nURL: http:\/\/exclusive.multibriefs.com\/content\/
\nhealth-app-certification-program-halted [ac-
\ncessed 2014-02-15]
\n12.\tPramann O., Albrecht UV.: Medical-Apps im
\nKrankenhaus\u00a0\u2013 Sicherheit, Verantwortung, Haf-
\ntung. (2013) Krankenhausjustitiar 04, 16-17.
\n13.\tAlbrecht UV.: Transparency of Health-Apps for
\nTrust and Decision Making (2013) Journal of
\nMedical Internet Research 15(12): e277.
\n14.\tAlbrecht UV., Pramann O., U von J. Medical
\nApps\u00a0 \u2013 The Road To Trust. (2015) European
\nJournal for Biomedical Informatics,11:en7\u201312.
\nDr.\u00a0med. Urs-Vito Albrecht,
\nMPH, Deputy Director,
\nPeter L. Reichertz Institute for Medical
\nInformatics, Hannover Medical School,
\nGermany
\nE-mail: albrecht.urs-vito@mh-hannover.de
\nhttp:\/\/www.plrimedapplab.de
\nBACK TO CONTENTS
\n78 79
\nLATVIALATVIA NMA NewsNMA News
\nQ. The half-year of the Latvian Presidency
\nof the Council of the European Union has
\ncometoanend.\u00a0Astohealthcare,wehaveor-
\nganised a number of European-level confer-
\nences on the topics of healthy lifestyles and
\nnutritionforchildren,tuberculosis,eHealth,
\npopular sports, healthcare financing as well
\nas addressed a number of other important
\nissues. How do you evaluate Latvia\u2019s per-
\nformance in its half a year of presidency?
\nI would like to congratulate Latvia for
\nsucceeding in delivering results on a set
\nof priority issues during its Presidency of
\nthe Council of the EU. Latvia took up the
\nPresidency at a very important moment and
\ncontributed to the discussions on the future
\ndirections for health policy at EU level. In
\naddition, the European conferences organ-
\nised under Latvian leadership helped make
\nprogress in reducing the risks associated
\nwith poor nutrition and lack of exercise.The
\nLatvian Presidency has put the spotlight on
\ntuberculosis \u2013 and led discussions towards
\nthe adoption of the Riga Declaration which
\nwill be guiding action to address this im-
\nportant \u2013 and often neglected \u2013 disease in
\nthe European Union. The Presidency has
\nfurther explored how eHealth could benefit
\nboth citizens and health systems, and con-
\ntributed to the discussions on how to create
\nefficient, equitable health systems.
\nQ. Currently there is a tendency all across
\nEurope that patients obtain information
\nabout diseases and health from the Inter-
\nnet or magazines. Over 80% of Internet
\nportals and social sites which are dedicated
\nto health topics are financed by businesses:
\ndrugs, dietary supplements or a special
\nmethod. More often than not, it is difficult
\nfor patients to discriminate between the
\ntruth about health and surreptitious adver-
\ntising. As to Latvia, there is even a publi-
\ncation, the magazine Ko \u0100rsti Tev Nest\u0101sta
\n(What Doctors Don\u2019t Tell You), advertis-
\ning dietary supplements, Ayurveda, unjus-
\ntified diets, and at the same time discour-
\naging patients from seeing an oncologist
\nor gynaecologist. How to deliver correct
\ninformation to the patient? Is the Euro-
\npean Commission going to set up a health
\ninformation site for Europe containing ev-
\nidence-based information, similar to Med-
\nlinePlus in the USA?\u00a0What is your opinion
\non pan-European level information cam-
\npaigns on healthcare topics?
\nThe European Commission has a dedicated
\nwebsite on health and healthcare topics\u00a0[1]
\nand several specialised EU agencies offer
\nhealth-specific information to the citizens
\n[2]. The Commission has also supported a
\nnumber of recent and ongoing health cam-
\npaigns, carried out by the EU in collabora-
\ntion with Member States and neighbouring
\ncountries, for example, awareness raising
\ncampaigns about tobacco, the initiative
\nEuropean Action Against Cancer, healthy
\nworkplaces campaigns and European Anti-
\nbiotic Awareness Day, to name a few. With
\nMember States facing common challenges
\nsuch as a rise in chronic diseases, and in-
\ncreasing antimicrobial resistance, I find
\nthese types of pan-EU initiatives extremely
\nvaluable.
\nOne of my priorities is to increase the avail-
\nability of scientifically sound, comparable
\nand high quality health information to
\nidentify the key challenges in health. Policy
\nmakers need this type of reliable health in-
\nformation, based on good indicators, sound
\ndata and regular analysis.The overall aim of
\nEU health information policy is to support
\nevidence-based development, implementa-
\ntion and evaluation of actions for health at
\nEU-level and in Member States.
\nQ. Right now, there is quite an opposi-
\ntion to vaccination in Latvia. The situa-
\ntion is pretty similar in other European
\ncountries. There are excellent lecturers,
\nnice-looking books and You Tube files
\ndiscouraging people from vaccination and
\nexplaining about the dangers of vaccina-
\ntion. What could the European Commis-
\nsion do in order to present information on
\nthe need of immunization in an equally
\nattractive manner from the visual and in-
\nformative aspect? Maybe it is the time to
\nhave a common immunization calendar in
\nEurope? This issue is more and more topi-
\ncal due to the increasing labour mobil-
\nity in Europe. Children are moving along
\nwith their parents. Each single country in
\nEurope has its own vaccination calendar,
\nwhich is the reason why many children do
\nnot get adequate vaccination and immu-
\nnization. Shouldn\u2019t such vaccinations as
\nagainst diphtheria, poliomyelitis, tetanus
\nand some more be declared as mandatory,
\nto be administered according to strictly
\ndefined time schedule, whereas the rest
\n(rotavirus, German measles, pneumo-
\ncocci) could be left on the national level?
\nIsn\u2019t it high time that we have a mandatory
\nrequirement to vaccinate all immigrants
\nfrom third countries because their earlier
\nvaccination is unreliable?
\nInterview with Vytenis Andriukaitis, EU
\nCommissioner for Health and Food Safety
\nBy Dr.Peteris Apinis. June, 2015
\nVytenis Andriukaitis
\nVaccination is one of the most effective
\nmeans of preventing diseases. I am keen
\nto support Member States in securing ef-
\nficient vaccination programmes, and to
\nfoster co-operation at European level in
\nthis area, while bearing in mind that in the
\nEU vaccination is a responsibility of the
\nindividual Member States. As such, the
\nway national immunisation programmes
\nare organised differs considerably between
\ncountries. National immunisation strate-
\ngies range from voluntary vaccinations to
\nalmost complete mandatory vaccination
\nprogrammes.
\nThe Commission provides support to
\nMember States on vaccination, e.g. in the
\nfield of seasonal influenza and childhood
\nvaccination. The Commission is working
\nwith Member States within the Health Se-
\ncurity Committee to be better prepared to
\naddress vaccine shortages as well as scepti-
\ncism about vaccines; to prevent cases like
\nthe recent tragic death of an unvaccinated
\nchild in Spain. Last year\u2019s Council conclu-
\nsions on vaccination provide an opportunity
\nto co-operate further in this area, and en-
\ncourage Member States to share best prac-
\ntices on their vaccination policies.
\nWhen it comes to vaccination of immi-
\ngrants from third countries, this is also the
\nresponsibility of individual Member States.
\nThe Commission, together with ECDC, is
\ndeveloping screening guidance that includes
\nthe issue of vaccination of migrants to sup-
\nport EU countries. We have also financed
\nthe project \u201cPromote Vaccinations among
\nMigrant Populations in Europe\u201d under our
\nhealth programme, which has resulted in
\nrecommendations for policy-makers on the
\nimmunisation of migrants and educational
\nmaterial for health professionals and mi-
\ngrants.
\nQ. In Europe, the manufacturing and
\ndistribution of dietary supplements is
\nbecoming increasingly widespread. Con-
\ntrary to drugs, the supervision of manu-
\nfacturing, distribution and advertising
\nof dietary supplements is much more
\nlenient. As a rule, dietary supplements
\ncontain chemically active substances: vi-
\ntamins, ferments and minerals, and their
\nabuse may cause health problems. Is the
\nCommission for Health going to intro-
\nduce somewhat more stringent restric-
\ntions to the distribution and advertising
\nof dietary supplements?
\nEU rules are in place to ensure that food
\nsupplements placed on the EU market are
\nsafe. The list of vitamins and minerals that
\nmay be used in food supplements is har-
\nmonised at EU level; however, maximum
\nlevels of such substances are not harmon-
\nised and may be set by Member States in
\naccordance with the rules of the Treaty. Bo-
\ntanicals are covered by the general frame-
\nwork on food safety together with appli-
\ncable national rules. The Commission does
\nnot envisage at this stage any measures to
\nrestrict the marketing of such foods.
\nQ. Today, health of and polypragmasia
\nin senior citizens is becoming an ever in-
\ncreasing problem all across Europe. On
\naverage, each senior citizen in Europe
\nconsumes 6.4 various drugs daily. Doesn\u2019t
\nthe pharmaceutical business have a too
\nheavy influence on the healthcare system?
\nDemographic and epidemiologic trends,to-
\ngether with a range of other factors as phar-
\nmaceutical markets\u2019 own dynamics, changes
\nin medical practice and pharmaceutical
\npolicies influence pharmaceutical spend-
\ning, which is an important component of
\nhealthcare expenditure in Member States.
\nIn addition, changes in the therapeutic
\nmix of medicines used that occur with new
\ntreatments can also influence the share of
\nthe overall pharmaceutical bill accounted
\nfor by hospitals. The use of multiple medi-
\ncations in elderly increases the possibility of
\nadverse reactions to drugs, increases the risk
\nof hospitalisation, of medical errors caused
\nby these medicines and may question the
\nquality of healthcare in general. This is an
\narea of Member States competence; how-
\never, the Commission supports Member
\nStates to exchange experience and in par-
\nticular on developing of tools and method-
\nologies to assess the quality of care.
\nQ. More often than not, the pharmaceuti-
\ncal business in Europe would not supply
\nall countries with drugs on equal terms,
\nand the prices vary significantly across the
\ncountries. If there were a common phar-
\nmaceutical policy for Europe, what would
\nthe effect be like?
\nAt EU level, prices of medicines are un-
\nder the responsibility of Member States.
\nThe only field of EU regulatory interven-
\ntion is the so-called \u201ctransparency directive\u201d
\n(Directive 89\/105\/EEC) which lays down
\nprocedural rules for regulating prices of
\nmedicines and their inclusion in the scope
\nof health insurance systems. I am keen to
\nfoster discussions and support co-operation
\nbetween Member States in this area so as
\nto make medicines more affordable and
\naccessible to patients. I am encouraged by
\nrecent developments including the Coun-
\ncil conclusions whereby Member States
\nhave agreed to exchange information about
\nthe prices of innovative medicines; about
\non-going discussions on this issue, as well
\nas emerging pilot project amongst some
\nMember States.
\nOther challenges of pharmaceutical policy
\nin Member States that also gained atten-
\ntion lately at EU level relate to the optimal
\nuse of current regulatory framework, the
\nearly dialogue with all relevant stakehold-
\ners and the bilateral agreements between
\nmember states. Such issues also relate to
\nthe efficiency of pharmaceutical spending,
\ni.e. the capacity to get the most value from
\ntoday\u2019s expenditure while keeping appro-
\npriate incentives for future innovation,
\n\u00adassociated with challenges for affordabil-
\nity in some countries. It is agreed in the
\nCouncil that further cooperation between
\nMember States is needed in such areas and
\nthe Commission is ready to further coop-
\nerate based on an integrated approach and
\na long term agenda.
\nQ. Today the biggest issue concerning
\nchildren all over Europe is sedentary
\nlifestyle and obesity. Every fifth child in
\n\u00adEurope is overweight. Unfortunately, in
\nLatvia the national Ministry for Educa-
\nBACK TO CONTENTS
\n80 III
\ntion resists to introduce the third sports
\nclass per week.Could the European Com-
\nmission be more active in making the
\nnational governments to introduce daily
\nsports classes for children?
\nI regret to report that the figures are even
\nworse. One out of three children in Europe
\nin 2010 was overweight or obese. This is
\na major increase compared to 2008 when
\none out of four children was overweight or
\nobese.
\nMember States play the key role in provid-
\ning education for school children in relation
\nto nutrition, physical activity, overweight
\nand obesity \u2013 and this is something most
\nare addressing.
\nI am ready to use all the tools at my dis-
\nposal to support them in their efforts to
\npromote healthy lifestyles.The Commission
\nis working with Member States in this re-
\ngard within the High Level Group on Nu-
\ntrition and Physical Activity. In 2014 this
\ngroup \u00adadopted an Action Plan on Child-
\nhood Obesity with the aim to prevent the
\nincrease in obesity in children by 2020.
\nA\u00a0Joint Action on Nutrition and Physical
\nActivity will start after the summer period
\nto further support Member States in the
\nimplementation of this Action Plan.
\nQ. In Latvia, the attitude of the Minis-
\ntry of Education to children\u2019s health is
\nquite an issue. Since 2002, health educa-
\ntion is no longer in the school curricula.
\nThe situation (i.e., no health education
\nfor children) is similar in many countries
\nin Eastern Europe. Could the Commis-
\nsioner make some pressure on national
\ngovernments with regard to educating
\nchildren in the basics of health?
\nAgain, the competence in the field of edu-
\ncation lies with the 28 EU Member States.
\nHowever, under the EU Strategy on Nu-
\ntrition, Overweight, and Obesity-related
\nHealth Issues for example, the Commis-
\nsion closely cooperates with the national
\ngovernments to promote healthy lifestyles
\nin children. The High Level Group on
\nNutrition and Physical Activity brings to-
\ngether governmental experts that promote
\nand exchange best practices in this area.The
\npromotion of healthier environments, espe-
\ncially at schools and pre-schools, is one of
\nthe key areas of the 2014 Action Plan on
\nChildhood Obesity.
\nQ. In the past two years, the Latvian
\nMedical Association managed to intro-
\nduce two important regulations in legal
\nacts. The first is that smoking in the pres-
\nence of minors should be treated as child
\nabuse. This means that in Latvia an adult
\nmust not smoke in the presence of a child,
\nbe it at home, in the street or at a bus stop.
\nThe other amendment to the law stipu-
\nlates that a person has the statutory right
\nto clean smoke-free air, and this right
\nhas a priority over other persons\u2019 right to
\nsmoke. Thereby, smoking in the presence
\nof another person is impermissible, un-
\nless the latter has given permission. Apart
\nfrom that, in Latvia it is absolutely pro-
\nhibited to smoke at sports and cultural fa-
\ncilities,in the premises of central and local
\ngovernment institutions, in cafes, restau-
\nrants, work places, on loggias, balconies,
\ncommon staircases and elsewhere where
\nit can harm other people\u2019s health. How
\nwould you evaluate our achievement and
\nhow could we attain this in entire Europe?
\nI am very pleased to hear about Latvia\u2019s
\nefforts towards achieving a smoke-free
\nenvironment and, in particular, to protect
\nchildren. Furthermore, strengthening the
\nright of the individual person wishing to
\nbe protected against tobacco smoke is an
\nimportant step in that direction. While the
\nlegislative competence in this area lies pri-
\nmarily with the Member States, the Euro-
\npean Commission is indeed committed to
\ncontinue working with Member States in
\ntheir implementation and enforcement of
\nthe Council recommendation on smoke-
\nfree environments (2009\/C 296\/02). We
\nregularly discuss the state-of-play and
\nprogress in this area with representatives of
\nthe Member States\u2019 competent authorities.
\nWe know from past experience that good
\nexamples from one country often motivate
\nothers to follow.
\nQ. In terms of percentage of GDP, \u00adLatvia
\nhas the lowest healthcare financing in
\nEurope, it is less than 3%. Could the
\nEuropean Union make a pressure on na-
\ntional governments that the accessibility
\nto healthcare services for population is
\na priority and thus healthcare financing
\nthroughout Europe should be at least
\n4.5% of GDP?
\nThe Commission acknowledges that
\nhealthcare systems need to be reformed
\nto provide accessible and quality health-
\ncare through efficient structures. Sustain-
\nability challenges of healthcare systems
\nin the EU are addressed and monitored
\nwithin the process of the European
\n\u00adSemester.
\nUnder the 2014 European Semester Latvia
\nreceived for the first time a country-specific
\nrecommendation (CSR) calling for the
\nreform of its health system with concrete,
\ntargeted areas including the quality and ac-
\ncessibility. Since then, the Latvian govern-
\nment increased the health budget by \u20ac 31.2
\nmillion in 2015 compared with 2014 and
\napproved a \u20ac 30.6 million increase each year
\nuntil 2017. But even with this additional
\nfunding, still below 3% of GDP, the finan-
\ncial burden on patients in Latvia remains
\nvery high and accessibility is still a prob-
\nlem. Therefore, in 2015 the Commission\u00ad
\nonce again proposed the same health CSR
\nto Latvia, and we will closely monitor its
\nimplementation.
\nThe Commission provides help and sup-
\nport, which is what countries that are fac-
\ning difficulties need. For example, Member
\nStates can make use of the European Stra-
\ntegic and Investment Funds (ESIF) for
\nhealth investments. I welcome the com-
\nmitment made by the Latvian authorities
\nto use ESIF for better access to healthcare,
\nespecially for those socially and territori-
\nally excluded. For the years 2014\u20132020 the
\nhealth infrastructure allocation for Latvia
\nexceeds \u20ac152 million and further alloca-
\ntions have been programmed for measures
\nsuch as health promotion and prevention,
\nenhancing qualifications of the medical
\nstaff and health.
\nQ. Shouldn\u2019t public health issues override
\nthe national level? For example, isn\u2019t it the
\ntime for the European Union to declare
\nthatithasacommonpolicyastopesticides
\nand other substances which inhibit the de-
\nvelopment of hormonal system? Isn\u2019t it the
\ntime to have a common European strategy
\nin place for reducing the consumption of
\nalcoholic beverages and tobacco products,
\nand for prohibiting trans fatty acids?
\nThe overriding principle of EU health pol-
\nicy is that human health is well protected
\nand accounted for in the development of all
\nEU policies and activities. All EU policies
\nare required by the EU treaty to follow this
\n\u201cHealth in all Policies\u201d (HIAP) approach.
\nTaking some of your specific examples:
\nEndocrine disruptors are already regulated
\nin some sectors. Currently, the European
\nCommission is carrying out an impact as-
\nsessment to analyse different options for
\ndefining the criteria for the identification
\nof endocrine disruptors in the context of
\nthe plant protection products and biocidal
\nproducts regulations. The decision at EU
\nlevel concerning the criteria will be made
\nonce the impact assessment is concluded.
\nOn alcohol, whereas the main responsibility
\nfor public health interventions lies with Mem-
\nber States, the Commission will continue\u00ad
\nto support them in reducing alcohol related
\nharm. This will be done based on the objec-
\ntives of the 2006 Strategy and by making use
\nof existing structures like the Committee on
\nNational Alcohol Policy and Action. In line
\nwith the Commission\u2019s \u201chealth in all policies\u201d
\napproach, we will further consider how to en-
\nshrine alcohol harm into a holistic approach
\nto reduce the burden of chronic diseases.
\nQ. Would you agree that the vast dif-
\nference as to the availability of medical
\nservices is actually a shame for Europe?
\nMaybe it is the time we start considering
\na common European health strategy, uni-
\nfied health tax,unified standards for emer-
\ngency medical care and first aid?
\nAt present there is no unified health sys-
\ntems policy in the EU: it is for Member
\nStates to decide which services to provide
\nto their citizens and how this should be
\nfunded. However, the EU does have a role
\nin supporting Member States and we are
\nactively working on ways to try to help
\nthem increase availability of services. The
\ncross-border healthcare Directive makes
\nit easier for patients to access services in
\nother Member States. We are in the pro-
\ncess of setting up European Reference
\nNetworks which will bring together cen-
\ntres of expertise for conditions or treat-
\nments where expertise is rare: these will act
\nas a resource for all Member States. We are
\nworking together to deliver the consider-
\nable potential benefits of Health Technol-
\nogy Assessments and eHealth. And we are
\nincreasingly looking at the question of how
\ncollaboration in border areas can improve
\nthe delivery of health services.
\nReferences
\n1.\t See link: http:\/\/ec.europa.eu\/health\/index_
\nen.htm
\n2.\t e.g. the European Centre for Disease Prevention
\nand Control (ECDC) (http:\/\/ecdc.europa.eu\/
\nen\/Pages\/home.aspx), the European Medicines
\nAgency (http:\/\/www.ema.europa.eu\/ema\/), the
\nEuropean Agency for Health and Safety at
\nWork (https:\/\/osha.europa.eu\/), and the Euro-
\npean Monitoring Centre for Drugs and Drug
\nAddiction (http:\/\/www.emcdda.europa.eu\/).
\nHunger strikes have been used as a means of
\nnon-violent resistance by political prisoners
\nthroughout history in an effort to achieve
\nspecific objectives.
\nFamous examples include Mahatma
\n\u00adGandhi, British and American suffragettes,
\nand the Irish Republican hunger strike of
\n1981. In Israel, Palestinian detainees and
\nprisoners have used the hunger strike as a
\ntool for soliciting acquiescence to their de-
\nmands. Over one thousand hunger strikes
\nhave occurred in Israel to this point. In
\ngeneral, these hunger strikes began in the
\nfacilities of the Israeli Prison Services (IPS),
\nand, when the prisoners\u2019 medical condition
\ndeteriorated,this stage was followed by hos-
\npitalization in public hospitals. The hunger
\nstrikes lasted everywhere from several days
\nto weeks and months, during which most,
\nthough not all, prisoners drank and agreed
\nperiodically to undergo tests, and take vita-
\nmins and carbohydrates intravenously. Each
\ntime,the duration and extent of cooperation
\nwith IPS and\/or hospital physicians varied.
\nNo detainee or prisoner in Israel has ever
\ndied during a hunger strike.
\nIn the early months of 2014, the Israeli
\nMedical Association (IMA) became aware
\nof legislation being prepared in Israel that
\nwould allow the forced feeding of prisoners.
\nThe IMA immediately requested a meeting
\nwith the Ministry of Health and the Min-
\nistry of Justice, in which we expressed, in no
\nuncertain terms, our complete opposition to
\nsuch a bill and the fact that we would in-
\nstruct our physicians not to comply with it.
\nWe followed this with a letter to then Jus-
\ntice Minister, Tzippi Livni, explaining our
\nstrong ethical positon.
\nOur objections notwithstanding, the Min-
\nistry of Justice continued work on the bill
\nand brought it before our Parliament (the
\nKnesset). We sent a letter to the Knesset
\nmembers before the bill was considered in
\nthe Ministerial Committee for Legislation,
\nbut unfortunately it passed this commit-
\ntee. Although we urged those Ministers
\nPosition of Israeli Medical Association in
\nForced Feeding Issue
\nISRAELLATVIA NMA NewsNMA News
\nBACK TO CONTENTS
\nwho opposed the bill in the Committee to
\n\u00adappeal the decision, the bill continued to a
\nfirst review in the Knesset plenum, where
\nit passed.
\nSeeing that the bill was progressing, and
\nagainst the backdrop of a mass hunger strike
\nin the Israeli prisons in June 2014, the IMA
\nand its Ethics Bureau convened an emer-
\ngency consensus conference, under the title
\n\u201cTreatment of prisoners\/detainees on hunger
\nstrikes \u2013 the medical challenge.\u201d Participat-
\ning in the conference were representatives of
\nthe IMA scientific associations, members of
\nthe IMA ethics bureau,representatives of the
\nMinistry of Health,the National Council for
\nBioethics, IPS physicians, representatives
\nof the International Committee of the Red
\nCross and others.
\nAt this conference, IMA officials made it
\nclear that the law does not change a doctor\u2019s
\nethical obligations not to coerce feeding on
\na competent individual. At the end of the
\nconference, all parties agreed on a list of
\nprinciples which can be viewed on the IMA
\nwebsite [1].
\nRecently,Gilad Erdan,the new Israeli Min-
\nister for Interior Security, announced plans
\nto renew the proposed legislation regard-
\ning forced feeding of hunger strikers. The
\nproposal will be put for discussion in the
\n\u00adKnesset Committee for Internal Affairs and
\nthen for final voting.
\nThe proposal enables obtaining legal per-
\nmission for the provision of medical care
\nand\/or nutrients (including force-feeding
\nthrough a tube) despite the active opposi-
\ntion of the prisoner.
\nIn our view,the proposed law is both unethi-
\ncal and unrealistic and does not help solve
\nthe problem.It creates an illusion that forced
\nfeeding will prevent medical harm to the
\npatient, whereas the opposite may in fact be
\ntrue.We cannot approve a law that puts phy-
\nsicians at the forefront of a policy \u2013 both as
\na group and as individuals \u2013 which is against
\ntheir professional and ethical obligations.
\nThe fundamental change underlying this
\nproposal is in contradiction with and con-
\ntrary to the accepted medical ethics in Israel
\nand throughout the world, including the
\nIMA\u2019s ethical Code and the WMA\u2019s Dec-
\nlaration of Tokyo and Declaration of Malta,
\nwhich recognize it as a form of inhuman
\nand degrading treatment.
\nThe IMA is strongly opposed to the in-
\ntended force feeding law. Our opposition
\nwas expressed to the government offices
\nand representatives of the attorney general
\nat every possible opportunity. We are pre-
\npared to continue to protect the doctors at
\nall levels, including in the public sphere and
\nparliamentary level, in order to thwart the
\nlegislative process.
\nWe know our hospital doctors will be pre-
\nsented with ethical dilemmas and be placed
\nin an impossible position professionally.
\nTherefore, we have established a hotline for
\nthese physicians to call with any questions
\nthey may have, as well as professional and
\nethical guidelines that we released in a hand-
\nbook following last year\u2019s mass hunger strikes.
\nOur concern is that the proposed law will
\nmove quickly through the legislative process
\nand we are taking measures to ensure that
\nit does not materialize. The IMA took out
\npaid announcements in major Israeli news-
\npapers (in addition to regular press coverage
\non the matter) explaining our opposition to
\nthe proposed law.
\nThe World Medical Association (WMA)
\nhas also been a steadfast partner in our
\nstruggle against this unethical bill. On
\nJune\u00a022, Drs. Deau and Hoven sent a let-
\nter to Prime Minister Benjamin Netanyahu
\nexplaining the WMA\u2019s position and its sup-
\nport of the IMA,and the inevitable interna-
\ntional condemnation that would follow the
\npassage of such a law.
\nIn its letter, the WMA stated the following:
\n\u201cOver the past four decades there have been
\nclear directives developed on what physi-
\ncians can do, and from what they must
\nrefrain. Clearly torture, inhuman and de-
\ngrading treatments are nothing with which
\na doctor should be involved in any way.
\nForce-feeding is violent, very painful and
\nabsolutely in opposition to the principle of
\nindividual autonomy. It is a degrading, in-
\nhumane treatment, amounting to torture.
\nBut worse: It can be dangerous and is the
\nmost unsuitable approach to save lives.
\nThe evidence from many cases around the
\nworld that our colleagues have been work-
\ning on over the past four decades shows that
\nthe best results are obtained when the pa-
\ntient\/physician relationship is maintained,
\neven under the difficult circumstance of a
\nhunger strike. This includes patient confi-
\ndentiality, proper medical care and advice
\nby the physician, but also respecting the free
\nwill of the patient. Force-feeding is com-
\npletely incompatible with this and destroys
\nany patient\/physician trust.\u201d
\nWe are determined to prevent force feeding
\nin Israel and we will continue to support our
\nphysicians and remind them of their ethical
\nobligations.
\nReferences
\n1.\t http:\/\/www.ima.org.il\/ENG\/ViewCategory.
\naspx?CategoryId=4497
\n2.\t http:\/\/www.ima.org.il\/Ima\/FormStorage\/
\nType8\/IMAHungerEN.pdf
\nDr. Leonid Eidelman, President, IMA
\nMalke Borow, Director, Division
\nof Law and Policy, IMA
\nE-mail: malkeb@ima.org.il
\nLeonid Eidelman Malke Borow<\/p>\n"},"caption":{"rendered":"

wmj201502 COUNTRY vol. 61 MedicalWorld Journal Official Journal of The World Medical Association, Inc. ISSN 2256-0580 Nr. 2, July 2015 Contents The General Assembly in Moscow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . […]<\/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\/wmj201502.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3678"}],"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=3678"}]}}