wmj201603

COUNTRY
vol. 62
MedicalWorld
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 3, October 2016
Contents
Currently the Earth is a Planet of Plastics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Interview with Sir Michael Marmot, President of the World Medical Association. . . . . . . . . 82
Migration of Doctors and Working Time Arrangements from an International
Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Women in Migration: Beyond Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
The Growing Threat of Nuclear War and the Role of the Health Community . . . . . . . . . . . . . 86
WMA Calls on Governments to Ban and Eliminate Nuclear Weapons . . . . . . . . . . . . . . . . . . 95
The Value of Resiliency Training in Postgraduate Medical Education . . . . . . . . . . . . . . . . . . . 95
The Role of Physicians Fighting Children Trafficking and Illegal Adoptions:
the Use of Genetic Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Why Should the World Medical Association not Change its Policy towards
Euthanasia? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Voluntary Euthanasia and Physician-assisted Suicide: Should the WMA Drop its
Opposition? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
One Health and Antimicrobial Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Global Development of Medical Science and Publication Opportunities and
Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Southeast European Medical Forum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Paul Cibrie: Defending the Medical Profession in the Age of Internationalization . . . . . . . . 117
Introduction to work at COP22 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Editor in Chief
Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@arstubiedriba.lv, editorin-chief@wma.net
Co-Editor
Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor
Maira Sudraba, Velta Pozņaka; lma@arstubiedriba.lv
Journal design and
cover design by
Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher
The Latvian Medical Association, “Latvijas Ārstu biedrība”,
Skolas street 3, Riga, Latvia.
ISSN: 2256-0580
Sir Michael MARMOT
WMA President
British Medical Association
BMA House,Tavistock Square
London WC1H 9JP
United Kingdom
Dr. Donchun SHIN
WMA Chairperson of the Finance
and Planning Committee
Korean Medical Association
46-gil Ichon-ro
Yongsan-gu, Seoul 140-721
Korea
Prof. Dr. Frank Ulrich
MONTGOMERY
WMA Vice-Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Dr. Xavier DEAU
WMA Immediate Past-President
Conseil National de l’Ordre des
Médecins (CNOM)
180, Blvd. Haussmann
75389 Paris Cedex 08
France
Dr. Joseph HEYMAN
WMA Chairperson
of the Associate Members
163 Middle Street
West Newbury, Massachusetts 01985
United States
Dr. Masami ISHII
WMA Treasurer
Japan Medical Assn
2-28-16 Honkomagome
Bunkyo-ku
Tokyo 113-8621
Japan
Dr. Heikki PÄLVE
WMA Chairperson of the Medical
Ethics Committee
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Finland
Dr. Miguel Roberto JORGE
WMA Chairperson of the Socio-
Medical Affairs Committee
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Ardis D. HOVEN
WMA Chairperson of Council
American Medical Association
AMA Plaza, 330 N. Wabash,
Suite 39300
60611-5885 Chicago, Illinois
United States
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
World Medical Association Officers, Chairpersons and Officials
Official Journal of The World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
81
BACK TO CONTENTS
Plastic is known to mankind for more than 100 years, and it has be-
come part of our lives. It is hard to picture how many times per day
each of us has something to do with plastics. Plastics are produced in
the form of resin from oil, natural gas and coal, while there are also
plastics of biological origin. Elements can be arranged around carbon
in a number of ways to obtain the necessary properties for the plastic.
Globally, right now the four main health concerns for mankind are:
1. global heating and pollution of the planet;
2. agents impeding the development of hormonal system, the
planet as a “chemical warfare”;
3. shortage of potable water;
4. social determinacy problems and inaccessibility to health care
services
As to plastics,global doctors focus on two aspects – the world is being
polluted with plastics to such an extent that the global ocean will soon
be kind of plastic soup, as well as bisphenols, phthalates, brominated
flame retardants that are serious disruptors of hormonal system.
Plastics contain BPA or bisphenol,and most of plastics release it when
heated. Bisphenols make plastics harder and more endurable. Bisphe-
nol A is an agent impeding the functioning of glands of internal secre-
tion; technically it is artificial oestrogen (the female hormone) which
can get from a plastic bottle (including baby bottles) or a vessel into
food or water.As artificial oestrogen,it affects the development of foe-
tus of both sexes, hampers the development of hormonal system and
contributes to the development of breast and prostate tumours.
It is the production of testosterone and sperm quality for males,
increases the insulin resistance and promotes obesity.
Phthalates are chemical substances that are added to plastics to
make it flexible, as well as for other organoleptic reasons. Phthal-
ates cause damage to reproduction organs of foetus, damages DNS
in sperm, damages liver, kidneys and lungs, causes inborn defects,
anaemia, infertility and cancer. They have a serious impact on male
potency and inhibit spermatogenesis in boys.
Apart from bisphenols and phthalates, also brominated flame re-
tardants and other constituents of plastics and heavy metals cause
disturbances to internal secretion system.
Plastics break down very slowly: the decomposition process takes
about a thousand years. This means that all plastics that have ever
been manufactured are still here on the Earth (even recycled) unless
burnt down and polluted the atmosphere with poisonous smoke,
thereby destroying the ozone layer, which is our sole shield against
the solar and cosmic radiation.
Plastics can be recycled 10-15 times. Umbrellas, backpacks, carpets,
blazers, artificial cobble stones, covers for mobile phones and new
PET bottles are made of recycled PET bottles. However, currently
it is about 12% of plastics that get recycled, while the rest is buried in
landfills,and the major part,especially plastic bags,end up in environ-
ment, because part of people still are not aware that a forest, a mead-
ow or a desert, mountains or roadside is not a dumpsite. Large part
of plastics gets into waters and further on to seas and oceans. Most of
this polluting plastic is various types of film, packets and boxes.
The main pollutants of environment are 15–50 micron thick plastic
bags,usually available free of charge in shops.They constitute higher
environmental risk than thicker bags, because are no used repeat-
edly – in 89% of occasions they are discarded after one-time use.
These bags quickly disintegrate in small pieces and are blown by the
wind till end up in water bodies.The 15–50 micron plastic bags have
been found in the stomachs of all water birds.
According to different estimates, 500–700 billion of plastic bags are
used annually worldwide. No less than one third ends up in environ-
ment or ocean.The sources of ocean waste are rivers,contributing 80%,
and vessels, contributing the remaining 20%.The UN Environmental
Programme has estimated each square mile of ocean water to contain
46,000 floating items of waste, mainly of plastic origin. At this mo-
ment, the ocean is kind of plastic soup consisting of plastic objects of
various sizes and their remains, and forming a layer of waste with dif-
ferent density from the surface of the ocean down to the very bottom.
Plastic piles up mainly in ocean gyres, which is water vortex limited
by currents, formed under no wind and high atmospheric pressure.
Vortex keeps the plastic soup in continuous motion. The largest
gyre, North Pacific Gyre, between 1350–1550 west longitude and
250–450 north latitude, is a 1760.000 square kilometres large field
of plastic waste,which is equal to the aggregate area of three Iberian
peninsulas (Spain and Portugal).
Plastics also pollute beaches and discourage tourists. Sea wildlife,
like animals, birds and crustaceans, is trapped in plastic waste and
gets constricted, drowned, immobilised, and dies.
In the sea, plastic is not biodegradable; however, being exposed to the
sun and mechanical forces, it gets decomposed to minute ­particles.
Currently the Earth is a Planet of Plastics
82
WMA News
1. First of all,I would like to ask you aboutTur-
key.We know that televisions are being closed,
judges and teachers are being removed from
their positions,is this affecting physicians,too?
Is Turkey becoming an authoritarian regime
where doctors are also the aim of politicians?
M. M. Turkey. I will answer this question
about Turkey’s current situation the way
I try to answer all questions concerned with
the public’s health: an appeal to evidence
and to notions of social justice. Overall,
evidence suggests that well-functioning
democracies are good for health.There may
be one or two exceptions. But, certainly, the
history of Europe, post war, shows remark-
able divergence between the good health
of Western democracies, and the relatively
poor health of communist countries of
Central and Eastern Europe.There are am-
ple reasons for the health-promoting effects
of democracies: greater attention to human
rights; greater possibility for enlightened
debate; a free press,which includes the free-
dom to be critical of the powers that be. My
own view is that satire, and other brands of
humour, are vital to the functioning of de-
mocracy (perhaps that is a British point of
view). The trend in Turkey has been toward
erosion of democracy, with a dramatic turn
downwards after the aborted coup. A mili-
tary coup is always to be condemned. But
one might have hoped that Turkey’s presi-
dent would have emerged as an even more
vigorous champion for democracy. Regret-
tably, the opposite has occurred. Turkey’s
doctors have stood up and defended the
ethical principle of providing health care to
all members of the population, regardless of
ethnic or political persuasion. This ethical
principle, too, is under threat.
2. Unfortunately this is not new in our
world. Can you remember any other coun-
try going through a situation like this and
how that affects the public health (e.g. Ven-
ezuela) ?
M. M. Is this unique to Turkey? As de-
scribed above,the later stage of communism
in Europe appeared to be bad for health.
This can be illustrated simply by comparing
Austria, and Czechoslovakia – both impor-
tant parts of the previous Austro-Hungari-
an Empire. Post war, health (as measured by
life expectancy) was approximately equal in
the two countries, and improved in parallel
up until the 1970s. It is consistent with the
view that, on both sides of the Iron Curtain,
material conditions for health improved.
There were reductions in poverty, and im-
provements in school, jobs and transport.
But, from the 1970s on, life expectancy
continued to improve in Austria, as it did
in all countries in Western Europe. Life ex-
pectancy stagnated in Czechoslovakia, as it
did in all countries of Central and Eastern
Europe. People do need the basic material
conditions in order to enjoy good health.
But they also need the freedom to lead
Interview with Sir Michael Marmot,
President of the World Medical Association
By Dr. Peteris Apinis. August, 2016
In 2010,the proportion of the minute plastic particles to zooplankton
was as high as 60:1.This means that 5% of a blue whale’s body weight
is plastic which he has consumed instead of plankton.
There is nothing more dangerous for the Earth than burning plas-
tics in low temperature.The end products of burning plastics are in-
credibly poisonous to human beings, plants and animals. The gases
released in burning destroy the ozone layer (plastics can be burnt
only in furnaces in extremely high temperatures, notably over 1000
degrees, where the plastic combustion products are carbon dioxide,
sulphur dioxide and some other relatively simple compounds).
Relatively more girls die in childhood compared to boys.The reason
is that in not so well-to-do countries boys play football, while girls
are supposed to be indoors and help their mothers with cooking.
In many countries trees have already been cut down and cooking is
done by burning trash, namely, plastics. Such smoke in the room is
the cause of unbelievably high mortality of children (girls).
The World Medical Association should become the initiator of in-
troducing a global environmental tax on plastic, imposing a tax on
all plastic bags.We trust that the World Medical Association is able
to lead this initiative and promote it to the UN and other global
organisations for discussion. It is critical that it is the manufacturer
which is to be taxed, because traders will be compelled to pay this
tax in the price as value added tax.
Pēteris Apinis, President,
Latvian Medical Association
Sir Michael Marmot
83
BACK TO CONTENTS
Migration
flourishing lives. Such freedoms were more
likely to be delivered by healthy,functioning
democracies.
3. Turkey is hosting a huge number of
refugees from Syria, Iraq and Afghanistan.
What do you think how this new situation
may affect them?
M.M. What will happen to refugees in Tur-
key? Central to the functioning of a healthy
society is high quality data,and free and open
discussion of the implications of what the
data show.There are two million official Syr-
ian migrants in Turkey, and probably many
more unofficial,in addition to migrants from
Iraq and Afghanistan.With an authoritarian
regime restricting the free flow of informa-
tion, and taking arbitrary action against any
individual it sees as threats, this is a pre-
carious situation: it is quite conceivable that
refugees could be seen as threats. The result
could be calamitous.
4. How do these social determinants and
migration correlate with public health in
Europe? How can we help to improve the
situation?
M.  M. Migrants in general, and refugees
in particular, illustrate the importance of
taking action on the social determinants of
health. Conditions from which people fled,
the circumstances of migration, and condi-
tions in the new country can all influence
health. One obvious way this works is that
refugees are poorer than the host popula-
tion, and suffer ill health as a result. More
generally, the conditions in which people
are born,grow,live,work,and age,and ineq-
uities in power, money and resources – the
social determinants of health – will all im-
pact on the health of refugees.
5. Terrorist attacks are affecting many
countries in the world. Fear is installing in
people›s minds and can lead to psychological
problems. Do you think this might become
a social determinant of «mental» health? Ex-
plain your considerations about this.
M.  M. There is a huge disparity between
rates of crime, and fear of crime. In many,
if not most, advanced countries, crime rates
have been falling, but the public’s fear of
crime isn’t. Each terrorist attack is appalling,
and,rightly,fuels public anxiety about terror-
ism. But, overall, the number of deaths from
terrorist attacks is small. Take the U.S. as an
example. There are approximately 34,000
deaths a year caused by firearms. A tiny mi-
nority of these can be linked to terrorism.
You would not guess that from some of the
public rhetoric of politicians, which fuels
public anxiety.That being said,we should not
be complacent about terrorism. We need to
add the medical voice to the argument for
improving the social determinants of health,
for all members of our populations, and re-
ducing racism and intolerance.
The main aim of the first international
conference of doctors’ unions was to build
a network between doctors’ unions around
the world and to discuss common problems
and challenges. In his opening speech the
Chairman of the Marburger Bund, Rudolf
Henke, pointed out that such an exchange
of experience and information will not only
help to improve working conditions for
doctors but contribute, in the end, towards
better care for patients.Lutz Stroppe,a high
ranking civil servant who reports to the
German Minister of Health, emphasised
the important role that foreign doctors play
in maintaining high quality medical care in
Germany. At the same time he considered
the possible negative effects the emigra-
tion of doctors might have on the source
countries. With his welcoming speech he
reached representatives of 24 different na-
tions from five continents.
Participants from 11 countries made use of
the opportunity to give on the first day a
snapshot presentation on the topic of emi-
gration from and/or immigration of doctors
to their countries. As the situation in the
different countries is diverse the speakers
were free to focus on those issues that are
of special interest to their union. The repre-
sentative from the Sindicato Médico do Rio
Grande do Sul, for example, reported on the
exploitation of Cuban doctors who take part
in a government programme and work in
underserved rural areas in Brazil. Presenta-
tions given by the Austrian Medical Cham-
ber, Swedish Medical Association and Hong
Kong Doctors’ Union explained the system
of recognition of foreign diploma and the in-
tegration process of foreign doctors. In order
to facilitate the free movement of doctors the
representative of Sindicato Médico del Uru-
guay drew upon practical experiences to ad-
vocate better co-operation between countries
Ruth Wichmann
Migration of Doctors and Working
Time Arrangements from an International
Perspective
84
TURKEYMigration
Migration is a move somewhat reliant on
will. But the majority of the migrants are
forced to leave their loved ones, their coun-
try, and their past. Suddenly their lives
change completely and they are forced to
migrate and seek refuge in a foreign country.
Data on the magnitude of the problem
varies according to the source. Migration
is intertwined with human tragedy. This
short article will try to explain the human
dimension of migration, with an emphasis
on women.
Women in Migration: Beyond Statistics
and a facilitation of the recognition process
of foreign diplomas.
Major push factors which make doctors leave
their country such as poor working condi-
tions, bad training opportunities, unemploy-
ment or political circumstances where point-
ed out by the Tanzania Medical, Dental and
Pharmaceutical Workers’ Union, Portuguese
National Federation of Doctors, Bahamas
Doctors’Union, Myanmar Medical Associa-
tion Young Doctor Society and Slovak Doc-
tors’ Trade Union. Workforce shortages in
New Zealand as well as low retention rates
of foreign trained doctors were elaborated on
by the New Zealand Association of Salaried
Medical Specialists.
After the presentations, Armin Ehl, Chief
Executive Officer of the Marburger Bund,
opened the floor for a fruitful discussion
which resulted in the adoption of a resolu-
tion. The participants supported the imple-
mentation of the 2010 WHO Code of
Practice on the International Recruitment of
Health Personnel.It was particularly stressed
in the statement that all countries should
strive to train enough doctors to meet their
own internal needs. Furthermore, the par-
ticipants agreed that doctors’ unions should
ensure that migrant doctors enjoy the same
working conditions as domestically trained
doctors and do not suffer any discrimination.
All doctors’unions present agreed to dissem-
inate relevant information to foreign doctors
and to co-operate with one another in order
to support migrant doctors.
The main topic of the second day of the
conference was the working time of doctors.
As all EU member states have to adhere
to the European Working Time Directive
(EWTD) the key elements of this Direc-
tive were explained by Richard Pond, Pol-
icy Officer of the European Federation of
Public Service Unions (EPSU). Pond also
described the continuous fight of EPSU to
safeguard the health and safety provisions
of this directive.
Examples of the transposition of the
EWTD into national law were given by the
German Marburger Bund, Slovak Doctors’
Trade Union, Portuguese National Fed-
eration of Doctors and Austrian Medical
Chamber. All four presentations focused
on the average maximum weekly working
time and the assessment of on-call periods
as working time in theory and in practice.
Whereas the Austrian Medical Chamber
explained that the use of the opt-out clause
will be gradually phased out so that from July
2021 onwards,the average maximum weekly
working time in Austria will be 48  hours,
appalling working time arrangements of up
to 120 hours per week were reported by the
Jamaica Medical Doctors’Association.Doc-
tors in Jamaica severely compromised not
only their own physical and mental health
but, as a result, are not being able to give ap-
propriate care to their patients.
Long working hours are also a problem
in Hong Kong. The presentation from the
Hong Kong Doctors’ Union showed that
while the average weekly working time of
people in Hong Kong is 50 hours many
doctors work more than 65 hours a week. A
recent survey conducted by the Hong Kong
Doctors’ Union revealed that over 92% of
the participants longed for a significant re-
duction in their working time.The Union of
Employees in the Health and Social Protec-
tion of Serbia also complained that due to a
shortage of doctors, long working hours of
doctors are a reality.However,so far Serbian
doctors are not willing to take action. Other
interesting snapshot presentations were
given by the Sindicato Médico del Uru-
guay, Bahamas Doctors’ Union, Myanmar
Medical Association Young Doctor Society
and New Zealand Association of Salaried
Medical Specialists before the audiences
engaged in a lively discussion.
Again a resolution was adopted in which the
participants demanded that patient safety
and the health and safety of doctors should
be the guiding principles of any working
time regulations that cover doctors. The
participating doctors’ unions called upon
the responsible authorities to enforce exist-
ing working time laws and expressed their
will to fight against any attempts to reduce
the health and safety provisions in existing
working time regulations. Moreover, the
union leaders wanted to reduce long work-
ing hours in accordance with their members’
needs and preferences.
The Marburger Bund who organised the
meeting in mid-June in Berlin was delight-
ed that the Sindicato Médico del Uruguay
expressed an interest in holding a follow-up
conference in Uruguay next year. Also the
Bahamas Doctors’ Union is considering
hosting a future meeting of doctors’ unions.
It is likely that the international co-opera-
tion between doctors’ unions will thrive.
Ruth Wichmann, Head of International
Office of the Marburger Bund
E-mail: wichmann@marburger-bund.de
85
BACK TO CONTENTS
TURKEY Migration
Hundreds of determinants such as coun-
try of origin, the international status of
the country, the prestige of the country,
whether they have legal documents, how
they arrived in the country, whether they
are exiled, the reasons of migration, re-
ligion, gender, age, profession, etc. con-
tribute to determining not only the legal
status but also the social prestige of the
refugees [1]. The conditions in which mi-
grants travel, live and work can carry ex-
ceptional risks for their physical and men-
tal well-being. These include inequality in
access to healthcare and services; vulner-
abilities associated with migrant status,
marginalization and abuse, and are often
linked to restrictive immigration and em-
ployment policies, economic and social
factors, and dominant anti-migrant senti-
ments in societies.These are often referred
to as the social determinants for migrants’
health [2].
Shelter, hygiene and nutrition are the
most problematic areas. There are serious
problems in access to food, both in terms
of quantity and quality, the number of the
meals provided are very few and irregular,
and food hygiene is poor. Basic personal hy-
giene is also very poor due to poor living
conditions.
Women are among the most vulnerable.
As was highlighted by the United Nations
Committee on the Elimination of Dis-
crimination against Women (CEDAW),
migrant women face specific challenges in
the field of health throughout the migration
cycle. Migrant women, for example, may be
subject to sex and gender based discrimi-
nation such as mandatory HIV/AIDS, or
other testing, without their consent as well
as sexual and physical abuse by agents and
escorts during transit [3]. Refugee women
have lower status than men [4] and need
more protection; especially victims of sex-
ual violence, isolated, single parent women,
lesbians and women in custody (The UN
Refugee Agency (UNHCR)).
There are many variables affecting refugees’
health that are not easily controlled. They
include: stress caused by migration, dam-
age of refugees’ social networks, religious
and cultural factors, culturally insensitive
reproductive health services, discrimina-
tion in health services provision and also
a lack of information about the services
available. There are striking differences
between the health status of refugees and
the settled population, and their access to
health care. Refugees are one of the most
neglected groups of the world. They are
usually excluded from health and social
services.
Reproductive health is particularly impor-
tant. There is an increase in fertility during
migration. There are factors that make the
situation more complicated such as: early
marriages, multiple marriages etc. In gen-
eral family planning needs are unmet.
In war and migration situations, exploita-
tion of women and sexual abuse increases.
Gender based violence is very common for
refugees. During conflict, before escape
the ruling parties abuse women. There are
reports of sexual violence and torture in-
flicted by soldiers, gang rape and abduc-
tion by the conflicting parties. During the
escape, bandits, border guards and human
traffickers assault women. In the country
of asylum, during the return journey and
even in the reintegration phase, many
similar incidents have been reported [5].
Women point out that human traffickers
abuse women, there is systematic abuse
and violence against women both in cus-
tody and at control points [6]. In other
words, women’s bodies are used as battle-
fields by conflicting parties and captured
by the dominant powers. Women continue
to carry all the burden of the conflicts, war
and migration.
Physicians and health care workers should
be aware of and sensitive to needs of refugee
women and advocate their right to health
and the right to access to health care. Refu-
gees with and emphasis on refugee women
should have the right to live in dignity and
respect. The ultimate solution is the con-
struction and protection of peace. Health
care workers can have a crucial impact in
building a less violent world and ensuring
the protection of peace.
References
1. Özgen, Neşe. Refugee and Woman: Nationalist
Body politics. 10th
International Cultural Stud-
ies Symposium. Ege University – British Coun-
cil, 4–6 May, 2005, İzmir.
2. UNGA High Level Dialogue (HLD) on Mi-
gration and Development, 2013
3. WHO. Health of migrants: the way forward.
Report of a global consultation. Madrid, Spain,
3-5 March, 2010
4. Özgen, Neşe, ibid
5. UNHCR, http://www.unhcr.org/turkey/home.
php?page=15, (accessed 30.06.2016)
6. FIDH Violence Against Women In Syria:
Breaking The Silence Briefing Paper, 2013.
Based on an FIDH assessment mission in Jor-
dan in December 2012
Prof. Dr. Feride Aksu Tanık
Faculty of Medicine,
Department of Public Health
Ege University
E-mail: ferideaksu59@gmail.com
Feride Aksu Tanık
86
Nuclear War
The Growing Risk
of Nuclear War
After the end of the Cold War the in-
tense military rivalry between the Soviet
Union and the United States/NATO was
replaced by a much more cooperative re-
lationship, and fears of war between the
nuclear superpowers faded. As recently
as the 2014 US Quadrennial Defence
Review, conflict between the two former
adversaries was not considered a realistic
possibility [1].
Unfortunately, relations between Rus-
sia and the US/NATO have deteriorated
dramatically since then. In the Syrian and
Ukrainian wars, the two have supported op-
posing sides, raising the possibility of open
military conflict and fears that such conflict
could escalate to nuclear war.
Over the past two years, both sides have
engaged in nuclear sabre rattling that is
reminiscent of the worst periods of the
Cold War. Speaking about the conflict in
Ukraine in August 2014, Russian Presi-
dent Vladimir Putin warned “it is better
not to come against Russia as regards a
possible armed conflict … I want to re-
mind you that Russia is one of the most
powerful nuclear nations” [2]. In the
months following the Russian annexation
of Crimea, the European Leadership Net-
work (ELN) documented a large increase
in incidents involving close encounters
between nuclear capable NATO and Rus-
sian military forces. A report issued by the
ELN concluded, “These events add up to
a highly disturbing picture of violations
of national airspace, emergency scrambles,
narrowly avoided mid-air collisions, close
encounters at sea, simulated attack runs
and other dangerous actions happening on
a regular basis over a very wide geographi-
cal area” [3]. Further, both sides have con-
ducted large scale military exercises in Eu-
rope, leading the ELN to conclude,“Russia
is preparing for a conflict with NATO, and
NATO is preparing for a possible con-
frontation with Russia” [4]. The danger
inherent in this situation is magnified by
the current Russian military doctrine of
“nuclear de-escalation”. Rather than seeing
nuclear weapons purely as a deterrent to
nuclear attack, this doctrine embraces “the
idea that, if Russia were faced with a large-
scale conventional attack that exceeded its
capacity for defence, it might respond with
a limited nuclear strike” in order to force
the other side to quickly end the conflict
and return to the status quo ante” [5]. US/
NATO military planning has always envi-
sioned possible first use of nuclear weapons
in the face of a Soviet/Russian convention-
al attack in Europe.
In this setting prominent leaders on both
sides have expressed alarm about the grow-
ing danger of nuclear war.
Speaking in January, when the Bulletin of
the Atomic Scientists announced that its
Doomsday Clock would remain at three
minutes to midnight, former US Secre-
tary of Defence William Perry stated, “The
danger of a nuclear catastrophe today, in
my judgment is greater that it was during
the Cold War … and yet our policies sim-
ply do not reflect those dangers” [6]. His
assessment was echoed two months later
by Igor Ivanov, Russian Foreign Minister
from 1998 to 2004. Speaking in Brussels
on March 18, Ivanov warned that,“The risk
of confrontation with the use of nuclear
weapons in Europe is higher than in the
1980’s” [7]. The increased tensions between
the US and Russia have been matched by a
similar escalation in the danger of nuclear
war in South Asia.
Since the nuclear weapon tests of May 1998
by India and then Pakistan, the two states
have expanded many-fold their respective
nuclear weapon and fissile material stock-
piles, and undertaken extensive develop-
ment and testing of a diverse array of ballis-
tic and cruise missiles (with ranges from 60
to 5000 km) to acquire the ability to deploy
and launch nuclear weapons from the air,
The Growing Threat of Nuclear War and the Role of the
Health Community
Ira Helfand Andy Haines Tilman Ruff Hans Kristensen Patricia Lewis Zia Mian
87
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Nuclear War
from land, and from submarines at sea.They
have put in place command and control sys-
tems and doctrines that involve, in the case
of Pakistan, first use of nuclear weapons in
a conflict and, in the case of India, massive
retaliatory strikes against population centres
[8–10].
In May-July 1999,the two countries fought
a war which apparently included mobiliza-
tion of nuclear weapons by Pakistan, mak-
ing it the most significant military conflict
between two nuclear armed states [11].
They also went through a major military
crisis (December 2001 to June 2002) trig-
gered by an attack on India’s parliament by
Islamist militants believed in India to be
backed by Pakistan,which included the two
countries moving a combined total of over
half a million troops to their border [12].
The slow pace of Indian deployment and
inconclusive outcome of the stand-off led
India’s army to begin planning and train-
ing for a more decisive and rapid conven-
tional attack on Pakistan [13]. Pakistan
began testing a short-range truck-mounted
mobile missile to deliver low-yield nuclear
weapons on the battlefield [14]. This latter
development has increased long-standing
international concerns about the security
of nuclear weapons and fissile materials in
Pakistan given the large-scale and frequent
Islamist militant attacks on military targets
in the country and the ideological polariza-
tion within the armed forces and broader
society associated with the rise of hard-line
Islamist political groups over the past three
decades [15].
Potential triggers for armed conflict be-
tween Pakistan and India include another
major attack on India by Islamist militant
groups like the one in Mumbai in Novem-
ber 2008 that was linked to intelligence
agencies in Pakistan [16]. A second possible
trigger is the recurring artillery exchanges
along the line of control in Kashmir,and oc-
casionally the international border between
Pakistan and India, which often claim sig-
nificant military and civilian casualties [17].
In April 2016, at the conclusion of the Nu-
clear Security Summit, the White House
Press secretary expressed concern about,
“the risk that a conventional conflict be-
tween India and Pakistan could escalate to
include the use of nuclear weapons”  [18].
Should Pakistan use nuclear weapons
against Indian conventional forces in such
a situation, Indian nuclear doctrine calls for
massive retaliation directed at Pakistani cit-
ies and Pakistan has threatened to respond
in kind.
With Pakistan building ever closer mili-
tary and economic ties to China, and India
becoming a strategic partner of the United
States, such a future South Asian conflict
may quickly take on a global dimension
given the increasingly tense nature of the
great power rivalry between China and the
US [20].
North Korea has a track record of repeatedly
threatening the use of nuclear weapons; for
example, in March 2016 it warned it would
make a “pre-emptive and offensive nuclear
strike” in response to joint US-South Ko-
rean military exercises [21]. It is capable of
enriching uranium and producing weapons-
grade plutonium and has deployed short-
and medium-range ballistic missiles as well
as testing long–range missiles [22].
Unintended Use of
Nuclear Weapons
While these growing tensions amongst nu-
clear armed states could lead to the deliber-
ate use of nuclear weapons, there is also the
continuing danger that they could trigger
the unintended or accidental use of these
weapons.
There have been at least five occasions
since 1979 when either Washington or
Moscow prepared to launch nuclear weap-
ons in the mistaken belief that the other
side had already launched a nuclear attack
or was preparing to do so [23]. In 1979
and again in 1980 computer errors in the
US caused American radar systems to dis-
play, incorrectly, incoming Soviet missiles
on their monitors. In September 1983,
Soviet military radar incorrectly reported
a NATO attack in progress. In November
of that year the Soviet leadership incor-
rectly concluded that a NATO military
exercise was the cover for an actual attack
that was about to be launched. On Janu-
ary 25, 1995, a full 5 years after the end
of the Cold War, Russian military radar
incorrectly identified a Norwegian Black
Brant XII rocket launched to study the
aurora borealis as a Trident missile aimed
at Moscow.
In each of these situations preparations for
a counterstrike were initiated and nuclear
war was averted by minutes.
The danger of this kind of mistake oc-
curring again is amplified by current de-
ficiencies in Russian radar warning sys-
tems. Russia has no space-based satellite
early warning systems to alert them to the
launch of nuclear-armed ballistic missiles
from the ocean, so their warning time
could be as short as 10 to 15 minutes. The
only way for Russia to guarantee the abil-
ity to launch its forces before they are de-
stroyed by a pre-emptive attack would be
to pre-delegate launch authority to field
commanders. Under these conditions, the
time pressure to make a launch decision
could greatly increase the chance of an ac-
cidental launch, especially if a computer
error caused a false warning of attack dur-
ing a crisis [24]. Recently, military lead-
ers have begun to warn of a new threat
that might cause the unintended launch
of nuclear weapons: cyberterrorism. In a
June 2015 speech, retired Marine Gen.
James Cartwright, former head of the
US Strategic Command, warned that it
might be possible for terrorists to hack
into Russian or American command and
control systems and launch one or more
nuclear missiles, a launch which would
have a high probability of triggering a
88
wider nuclear conflict. This danger is in-
tensified by the continued US and Rus-
sian policy of ­maintaining their missiles
on hair trigger alert, fully prepared for use
and simply awaiting an order to launch
[25]. There is also extensive evidence that
individuals with responsibility for nuclear
weapons have breached safety ­regulations.
In 2003, for example, half of the US Air
Force units responsible for nuclear weap-
ons safety failed their safety inspections.
In 2007 six cruise missiles armed with
nuclear warheads were mistakenly loaded
onto a B-52 bomber which sat on the
tarmac overnight without armed guards
before taking off and flying 1500 miles
in violation of regulations which prohibit
transportation of nuclear weapons by air
over the USA [26].
Nuclear Weapons
Modernization
The nuclear danger is amplified further by
the extensive plans of all nine nuclear armed
states to enhance their nuclear arsenals.
Although the world’s inventory of nuclear
weapons has declined significantly over the
past two-and-a-half decades, from around
58,300 warheads in 1991, there remain
roughly 15,375 warheads today of which
4,200 are deployed with operational forces.
Nearly 1,800 warheads are on alert and
ready for use on short notice [27]. (Figure)
While Russia, the US, and Britain con-
tinue to reduce their inventories, the pace
of reduction has slowed compared with the
past two decades. In fact, four of the world’s
nuclear-armed states (China, Pakistan, In-
dia and North Korea) are increasing their
nuclear arsenals.
There are currently no negotiations between
nuclear-armed states about reducing war-
head inventories or curtailing operations
and modernizations. Instead, there are signs
that the deepening crises in Europe and the
South China Sea are causing nuclear-armed
states to increase the role of their nuclear
forces.
Instead of moving decisively toward deep
cuts of their nuclear arsenals and mak-
ing plans for the eventual elimination of
nuclear weapons, the nuclear-armed states
are reaffirming the importance of nuclear
weapons and are carrying out extensive and
costly modernizations of their nuclear arse-
nals [28]. (see table)
The scope of these modernization plans has
led observers to characterize them as the
beginning of a new arms race and a new
Cold War [29].
The Health Consequences
of Nuclear War
Given the growing danger of nuclear war, it
is important to consider the health conse-
quences of such a conflict.
The acute effects of nuclear weapons are
well described in previous major reports by
WHO and the US Institute of Medicine
[30,31]. While there have been important
developments regarding ionising radiation
health effects in recent decades, it is in rela-
tion to the impacts of nuclear war on cli-
mate, agriculture and nutrition that scien-
tific advances of the greatest moment have
been made in the past decade, and these are
therefore our focus here.As a result of these,
we have come to understand that it is not
just large scale nuclear war between the US
and Russia that poses a global threat. A se-
ries of studies have shown that localized,
regional nuclear war will also have cata-
strophic effects worldwide.
We undertook a literature search using
the Web of Science database Topic Search
function, on 14 March 2016, covering doc-
uments in English published from 2005 to
2016, using the search strategy: ((“Nuclear
Weapon*” OR “nuclear war*” OR “atomic
weapon*” OR “atomic war*” OR “nuclear
conflict*”) and (Climate OR “Climate
Change” OR environment* OR “Ozone
Depletion” OR ozone OR Starvation OR
famine OR Agriculture* OR crop* OR
Food)).
The scenario that has been studied most fre-
quently is a limited nuclear war between In-
dia and Pakistan involving 100 Hiroshima
sized warheads, small by modern standards,
targeted on urban centers. (This is a delib-
erate underestimate of the full potential of
war in South Asia: the combined arsenals
Russia IndiaPakistanUKChinaFranceUSA Israel
7000
6000
5000
4000
3000
2000
1000
8000
0
7300
6970
120130215260300
80
Note: North Korea has produced fissile
material for 10–12 warheads and detonated
4 test assemblies, but we’re not aware of public
information that shows it has yet
stockpiled weaponized warheads.
Retired
Stockpiled
Deployed
Figure. Estimated Global Nuclear Warhead Inventories, 2016
Nuclear War
89
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Russia
  • replacing all Soviet-era SS-18, SS-19 and SS-25 intercon-
tinental ballistic missiles (ICBMs) by the early-2020s with
different versions of the SS-27 and a new “heavy”silo-based
ICBM.
  • building eight new ballistic missile submarines (SSBNs)
with the new SS-N-32 (Bulava) missile to replace eight op-
erational Soviet-era Delta-class SSBNs and their missiles.
  • upgrading its old Tu-160 (Blackjack) and Tu-95MS (Bear)
bombers so they can continue to operate until a new bomber
can replace them sometime in the 2020s.
  • gradually replacing the old AS-15 air-launched cruise mis-
sile (ALCM) with a new ALCM known as the Kh-102.
  • modernizing some of its non-strategic nuclear forces, re-
placing the old SS-21 short-range ballistic missile (SRBM)
with the SS-26 (Iskander), replacing the old SS-N-21
sea-launched land-attack cruise missile (SLCM) with the
SS-N-30A (Kalibr), and replacing the old Su-24 (Fencer)
fighter-bomber with the Su-34 (Fullback).
United States
  • building a new fleet of 12 SSBNs to replace the current 14
SSBNs.The new submarines will carry an improved version
of the Trident II D5 sea-launched ballistic missile (SLBM)
with new guidance system and enhanced warheads.
  • modernizing its B-2 and B-52 bombers and developing the
new B-21 stealth-bomber to replace the B-52s (and B-1s)
from the late-2020s.
  • developing a new guided nuclear bomb (B61-12) with in-
creased accuracy, and a new ALCM with longer range and
enhanced warhead.
  • designing a new ICBM with enhanced warheads to replace
the current Minuteman III ICBM by 2030.
  • modernizing its non-strategic nuclear forces by replacing
F-16s (and eventually F-15E) fighter-bombers with the F-
35A stealthy fighter-bomber that will be carrying the new
B61-12 guided nuclear bomb.
China
  • replacing old liquid-fuel land-based missiles with DF-26
and DF-31A solid-fuel missiles on road-mobile launchers.
  • equipping some of its missiles with multiple warheads.
  • deploying a small fleet of Jin-class SSBNs with the new Jl-2
SLCBM.
France
  • modernizing its SSBN fleet with the new M51 SLBM that
will soon receive a new warhead.
  • arming its bomber force with ALCMs.
  • replacing Mirage 2000N aircraft with the Rafale which will
be armed with a new ALCM.
United Kingdom
  • developing a new SSBN class to replace the current Van-
guard-class SSBNs which will carry the life-extended Tri-
dent II D5 with a new guidance system.
  • equipping current SLBMs with enhanced warheads.
Pakistan
  • deploying new and longer-range Shaheen-III ballistic mis-
siles, Ra’ad ALCMs, Babur ground-launched cruise mis-
siles, and developing a nuclear SLCM.
  • deploying a tactical nuclear weapon, the 60-kilometer
NASR missile.
  • increasing production of fissile material for additional war-
heads.
India
  • deploying and developing longer-range ballistic missiles
that can target all of Pakistan and China, including several
new versions of the Agni missile family.
  • conducting sea-trials of its first SSBN, which will carry new
types of SLBMs.
  • building new reactors that can produce plutonium for ad-
ditional warheads and expanding uranium enrichment ca-
pacity.
Israel
  • modernizing its Jericho ballistic missiles and probably also
its fighter-bombers.
  • Possibly equipping its new German-built Dolphin-class
submarines with a nuclear cruise missile.
North Korea
  • deploying two new ballistic missiles (Musudan and Hwa-
song-13) that could potentially in the future be equipped
with weaponized versions of the nuclear devices it has tested.
  • developing a new longer-range missile.
Table. Modernization Activities of the Nine Nuclear-armed States
Nuclear War
90
of India and Pakistan actually contain more
than 220 nuclear warheads.) The direct ef-
fects in South Asia are catastrophic. Some
20 million people would die in the first
week from the direct effects of the explo-
sions, fire and local radiation [32].
The global consequences-global climate
disruption and resultant famine-would be
far more devastating. The fires caused by
these nuclear weapons would loft 6.5 mil-
lion tons of soot into the upper atmosphere.
The impact of this soot has been examined
by three teams of climate scientists using
three different climate models and mak-
ing the conservative assumption that only
5 million tons of soot are injected into the
atmosphere [33-35]. Each model shows
significant drops in average surface temper-
ature and average precipitation across the
globe with the effects lasting for more than
a decade.The most sophisticated and recent
model shows the most persistent declines in
temperature and precipitation, which have
not yet returned to baseline after 26 years,
as long as the model was run. While the
fuel density of modern cities varies, there
is nothing specific to India/Pakistan about
such a scenario. Nuclear weapons are ex-
tremely efficient at igniting, over large areas,
simultaneous fires which rapidly coalesce
and inject large volumes of soot and smoke
into the stratosphere.
This climate disruption would in turn have
profoundly negative impact on food pro-
duction. The maize crop in the US, the
world’s largest producer, would decline
an average of 12% over a full decade [36].
In China, the world’s largest producer of
grain, middle season rice would decline
by 17% over a full decade, maize by 16%,
and winter wheat, by a truly catastrophic
31% [37].
Under current conditions, adequate human
nutrition cannot be sustained in the face of
declines of food production of this magni-
tude. Total world grain reserves in January
2016 amounted to only 84 days of global
consumption, and would not begin to offset
the shortfall over a full decade [38]. Fur-
thermore, there are currently 795 million
people who are already undernourished at
baseline [39]. There are also some 300 mil-
lion people who enjoy adequate nutrition
today, but live in countries highly depen-
dent on food imports which would probably
not be available as grain exporting countries
suspended exports to feed their own people.
In addition, there are nearly a billion people
in China with incomes of $5 a day or less
who are adequately fed today, but who have
shared little in China’s growing prosperity
over the last several decades. All of these
people, around two billion, would be at risk
under the potential famine conditions that
would result from this limited, regional nu-
clear war [40]. Large scale war between the
US and Russia would be far worse. In early
2016, Russia and the US were estimated to
possess 7300 and 6970 nuclear warheads re-
spectively, 93% of the global total of 15,375.
Under the provisions of the New START
treaty, each of these countries will retain
some 1550 strategic (long range) nuclear
warheads when the Treaty is fully imple-
mented in 2018. Most of these weapons
are 10 to 50 times more powerful than the
bombs which destroyed Hiroshima [41]. A
2002 study showed that if just 300 of the
weapons in the Russian arsenal hit urban
targets in the US, 75 to 100 million people
would die in the first half hour from the
firestorms and explosions [42]. This attack
would also destroy most of the infrastruc-
ture  – the electric grid, internet, banking
and public health systems, food distribution
network – needed to support the rest of the
population, most of whom would succumb
to exposure,starvation and epidemic disease
in the months following. A US counterat-
tack would be expected to cause the same
level of destruction in Russia, and if NATO
were involved in the conflict, Canada and
much of Europe would face similar destruc-
tion.
These direct effects are only part of the
story, however. As is true for a limited war
in South Asia, the global climate effects
would be far worse. A war involving only
the strategic weapons that will still be de-
ployed when New START is fully imple-
mented would put some 150 million tons
of soot in the upper atmosphere, and drop
temperatures around the world by 8°C. In
the interior regions of North America and
Eurasia, temperatures would fall by 25 to
30°C. These conditions would persist for
more than a decade.Temperatures on Earth
have not been that cold since the last ice
age. In the temperate regions of the North-
ern Hemisphere, the temperature would fall
below freezing for some portion of every
day for at least two years [43]. Under these
conditions food production would stop and
the vast majority of the human race would
starve.
Efforts to Eliminate
Nuclear Weapons
Understanding of the unprecedented ex-
istential threat posed by nuclear weapons
was widely recognized in the very first
resolution of the United Nations General
Assembly in January 1946, calling for the
elimination of atomic weapons [44]. The
preamble of the 1970 nuclear Non-Prolif-
eration Treaty (NPT) opens: “Consider-
ing the devastation that would be visited
upon all mankind by a nuclear war and the
consequent need to make every effort to
avert the danger of such a war …” [45]. Yet
for most of the past 71 years, the shared
interests of humanity, based on the real
consequences of any use of nuclear weap-
ons, have been sidelined by the perceived
interests of the 9 governments that pos-
sess and threaten use of nuclear weapons,
which have dictated the pace and extent
of nuclear arms control and disarmament.
However, the obligation to pursue effective
measures towards nuclear disarmament is
a shared responsibility of all 190 NPT sig-
natory states, and the International Court
of Justice in its 1996 Advisory Opinion on
nuclear weapons unanimously ruled that
Nuclear War
91
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there exists an obligation not only to pur-
sue in good faith, but to bring to a conclu-
sion, negotiations leading to nuclear disar-
mament [46].
The contemporary ‘Humanitarian Initiative’
on nuclear weapons began with Interna-
tional Committee of the Red Cross (ICRC)
president Jacob Kellenberger informing the
Geneva Diplomatic Corps in 2010 that the
world’s largest humanitarian organization
would make elimination of nuclear weap-
ons – something it first called for on 5 Sep-
tember 1945 – a renewed priority [47]. A
few weeks later, the five yearly 2010 NPT
Review Conference outcome document
referred for the first time to “deep concern
about the catastrophic consequences of any
use of nuclear weapons” [48]. In 2011, the
Council of Delegates, the highest govern-
ing body of the Red Cross/Red Crescent
Movement, called on all states “to ensure
that nuclear weapons are never again used”,
and “to pursue in good faith and conclude
with urgency and determination negotia-
tions to prohibit the use of and completely
eliminate nuclear weapons through a legally
binding international agreement, based on
existing commitments and international
obligations” [49]. A special issue of the
Movement’s flagship journal, the Interna-
tional Review of the Red Cross, “The human
costs of nuclear weapons”,was recently pub-
lished.
Beginning in 2012, at every NPT meet-
ing and UN General Assembly (UNGA), a
growing number of states, from 16 in 2012
to 144 in 2015, have supported resolutions
affirming the centrality of humanitarian
considerations in advancing nuclear dis-
armament, and the need to prevent use of
nuclear weapons under any circumstances
[50]. In 2013 and 2014 three successive
fact-based international conferences on the
Humanitarian Impact of Nuclear Weapons
were held in Norway [51], Mexico [52] and
Austria [53], the last with participation of
146 states. Remarkably, 68 years into the
nuclear age, these were the first ever inter-
governmental meetings dedicated to the
humanitarian impacts of nuclear weapons.
There was no significant disagreement at
these conferences regarding the exten-
sive expert evidence presented, leading to
the conclusions 1) that any use of nuclear
weapons would be catastrophic; 2) that no
effective humanitarian response was pos-
sible to even a single nuclear detonation in
an urban centre; 3) that the risk of nuclear
weapons use had previously been underesti-
mated, is growing, and exists as long as the
weapons do; and 4) that there is a legal gap
for nuclear weapons, in that the most de-
structive and indiscriminate of all weapons
are the only weapon of mass destruction
not yet explicitly prohibited under interna-
tional law [54]. At the end of the Vienna
conference, the Austrian government is-
sued a pledge “to cooperate with all relevant
stakeholders … to stigmatize, prohibit and
eliminate nuclear weapons in light of their
unacceptable humanitarian consequences
and associated risks”; to “fill the legal gap
for the prohibition and elimination of nu-
clear weapons” [55]. As of 20 March 2016,
127 states have endorsed this Humanitarian
Pledge, with an additional 22 states voting
in favour of a resolution bringing the Pledge
to the UNGA [56].
The 2015 General Assembly also voted
overwhelmingly to establish an Open End-
ed Working Group (OEWG) to address
this legal gap, which though open to all
states, was opposed and boycotted by all the
nuclear-armed states. The Working Group
was charged with reporting back to the
2016 UNGA on effective legal measures
required to attain and maintain a world
free of nuclear weapons. It “recommended
with widespread support for the General
Assembly to convene a conference in 2017,
open to all States, with the participation
and contribution of civil society, to negoti-
ate a legally-binding instrument to prohibit
nuclear weapons, leading towards their total
elimination …”[57]. The Working Group’s
report provided detailed suggestions on spe-
cific elements that could be included in such
a treaty. This recommendation was taken
forward in a resolution co-sponsored by 57
states [58] and adopted by the UNGA First
Committee on 27 October 2016, with 123
States voting yes, 38 (predominantly nucle-
ar-armed and nuclear-allied) voting no, and
16 abstentions.The full UNGA will under-
take a final vote in early December 2016,
and the first negotiating conference will
convene in New York on 27 March 2017.
A new international treaty comprehensively
prohibiting nuclear weapons is thus within
sight.This is increasingly seen by a substan-
tial majority of states as the most promising
and realistic step which can now be taken to
progress the eradication of nuclear weapons,
and the conclusion of such a treaty would
constitute the most significant development
in nuclear disarmament since the end of the
Cold War. Treaties unequivocally prohibit-
ing unacceptable weapons and providing for
their subsequent elimination has been the
approach successfully used in relation to ev-
ery other kind of indiscriminate, inhumane
weapon – biological, toxin [59] and chemi-
cal weapons [60], followed by antipersonnel
landmines [61] and cluster munitions [62].
The Role of the Health
Community
Involvement of the medical community in
these efforts to eliminate nuclear weapons
flows from a long history of medical and
scientific concern about nuclear weapons.
After the hydrogen bomb code named
Castle Bravo was detonated at Bikini Atoll
with a yield of around 15 megatons (mil-
lions of tons of TNT equivalent), double
that predicted, there was widespread pro-
test from many world leaders together
with Albert Einstein and the Federation
of American Scientists [63]. In 1957, as
atmospheric testing of nuclear weapons
continued unabated, an appeal from Albert
Schweitzer for a ban on nuclear tests was
broadcast to audiences in 50 nations and a
petition initiated by Linus Pauling, 1954
Nobel laureate in Chemistry, also demand-
Nuclear War
92
ing a test ban was signed by 9000 scientists
in 43 countries. Pauling was awarded the
Nobel Peace Prize in 1963 for his opposi-
tion to nuclear testing. Also in 1957 the
British Atomic Scientists’ Association set
up a committee to assess the risks of cancer
arising from the fallout from atmospheric
nuclear tests, chaired by Professor Joseph
Rotblat, a medical physicist (and during
the 2nd
World War an atomic scientist,
working on the atomic bomb at Los Ala-
mos). It concluded that for every 1 mega-
ton exploded in the atmosphere, around
1000 people were likely to develop bone
cancers, and made other estimates of the
likely health consequences of atmospheric
nuclear testing [64].
A series of four [65-68] influential articles
appeared in the New England Journal of
Medicine in 1962 describing the medical
effects of a thermonuclear attack on Mas-
sachusetts, the (limited) role of the medical
profession in dealing with the consequences,
and the psychiatric and social aspects of civ-
il defence. The authors, who were members
of a new organization Physicians for Social
Responsibility, concluded that as no effective
clinical response was possible,doctors “must
begin to explore a new area of preventive
medicine, the prevention of thermonuclear,
chemical and biological warfare”.
Negotiations on a ban on nuclear testing
continued inconclusively until 1963 because
of concerns about the potential to conceal
clandestine tests. With evidence of wide-
spread radioactive fallout and accumulation
of strontium-90 in the deciduous teeth of
children around the world, public opinion
swung strongly in favour of banning atmo-
spheric nuclear testing and the Limited Test
Ban treaty was agreed in 1963, but progress
towards a comprehensive treaty proved
frustratingly slow.
In the early 1980s a number of reports on
the health effects of nuclear weapons ap-
peared including a BMA report of 1983
which concluded that the casualties from
the detonation of a single megaton weapon
would overwhelm the resources of the en-
tire UK National Health Service [69]. The
World Health Assembly adopted a resolu-
tion in 1983 including reference to nuclear
weapons as “the greatest immediate threat
to the health and welfare of mankind”
[70]. Scientific and medical evidence that
civil defence programs against nuclear
war provided at best an illusion of protec-
tion led to their widespread abandonment
[71]. Evidence on the catastrophic health
effects of nuclear war brought by physi-
cians to Presidents Ronald Reagan and
Mikhail Gorbachev had profound effect,
bringing them to declare in 1985 that “A
nuclear war cannot be won and must never
be fought”; to end their nuclear arms race;
agree on the elimination of intermediate
range nuclear missiles; and come close to
an agreement to eliminate their nuclear
arsenals entirely. Gorbachev wrote that
without the efforts of IPPNW – awarded
the Nobel Peace Prize in 1985 – these dis-
armament initiatives “would probably have
been impossible” [72]. Given the potential
for nuclear war to occur as a result of er-
ror and the lack of evidence that a planned
medical response can have any perceptible
impact on the outcome, it has been sug-
gested that “support for deterrence with
these weapons as a policy for national or
global security appears to be incompatible
with basic principles of medical ethics and
international law. The primary medical re-
sponsibility under such circumstances is to
participate in attempts to prevent nuclear
war”  [73]. New evidence about the per-
vasive threats to health of the detonation
of even a small percentage of the world’s
nuclear arsenals, together with the failure
of the Non-Proliferation Treaty to prevent
the retention and modernization of nu-
clear weapons has given impetus to a new
global movement to ban nuclear weapons.
The health professions therefore have a
central role in advocating for the abolition
of nuclear weapons, reflecting their ethical
responsibility to protect health and prevent
illness.
In 2007, IPPNW founded the Internation-
al Campaign to Abolish Nuclear Weapons
(ICAN) – a broad global campaign coalition
working for a treaty banning nuclear weap-
ons. ICAN now has 440 partner organisa-
tions in 98 countries, is the lead civil society
partner for the governments hosting the
Humanitarian conferences, and continues
to grow as a major civil society coordinating
initiative and partner for governments seri-
ous about the humanitarian imperative for
nuclear disarmament.
In Moscow in October 2015, the World
Medical Association General Assembly
unanimously updated its Statement on
Nuclear Weapons, adopted in 1998 and
amended in 2008, requesting all National
Medical Associations to educate their pub-
lics and governments about the health im-
pacts of nuclear war and “to join the WMA
in supporting this Declaration and to urge
their respective governments to work to ban
and eliminate nuclear weapons” [74].
In April 2016, the WMA joined with
IPPNW, the World Federation of Public
Health Associations and the International
Council of Nurses, in submitting to the
UN Working Group the first such united
statement detailing the health and humani-
tarian imperative to ban and eliminate nu-
clear weapons [75]. All other global health
progress and efforts could come to nought
if we do not succeed in eradicating nuclear
weapons before they are again used in war.
There has never been a better opportunity
nor greater need for united and effective
health professional engagement to remove
the most acute existential threat to global
health and survival.
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93
BACK TO CONTENTS
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Ira Helfand, MD
Co-President, International Physicians
for the Prevention of Nuclear War,
Malden, Massachusetts, 413 320 7829,
E-mail: ihelfand@igc.org
Andy Haines, MD
Professor, Departments of Social and
Environmental Health Research and of
Epidemiology and Population Health,
London School of Hygiene and Tropical
Medicine, London, WC1H 9SH,
E-mail: aphaines@doctors.org.uk
Tilman Ruff,
FRACP, Nossal Institute for Global Health,
School of Population and Global Health,
University of Melbourne, Melbourne,
Co-President, International Physicians
for the Prevention of Nuclear War,
E-mail: tar@unimelb.edu.au
Hans Kristensen
Federation of American Scientists,
Washington DC,
E-mail: hkristensen@fas.org
Patricia Lewis, PhD
Chatham House, London,
E-mail: PLewis@chathamhouse.org
Zia Mian, PhD
Program on Science and Global Security,
Princeton University, Princeton, NJ,
E-mail: zia@princeton.edu
Nuclear War
95
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Medical Education
World Medical Association (WMA)
Statement on Nuclear Weapons
Adopted 17 October 2015
The WMA Declarations of Geneva, of Helsinki and of Tokyo
make clear the duties and responsibilities of the medical profession
to preserve and safeguard the health of the patient and to conse-
crate itself to the service of humanity.The WMA considers that it
has a duty to work for the elimination of nuclear weapons.
Therefore the WMA:
2.1 Condemns the development, testing, production, stockpiling,
transfer, deployment, threat and use of nuclear weapons;
2.2 Requests all governments to refrain from the development,
testing, production, stockpiling, transfer, deployment, threat and
use of nuclear weapons and to work in good faith towards the
elimination of nuclear weapons;
2.3 Advises all governments that even a limited nuclear war
would bring about immense human suffering and substantial
death toll together with catastrophic effects on the earth’s ecosys-
tem, which could subsequently decrease the worlds food supply
and would put a significant portion of the world’s population at
risk of famine; and
2.4 Requests that all National Medical Associations join the
WMA in supporting this Declaration, use available educational
resources to educate the general public and to urge their respec-
tive governments to work towards the elimination of nuclear
weapons.
2.5 Requests all National Medical Associations to join the WMA
in supporting this Declaration and to urge their respective govern-
ments to work to ban and eliminate nuclear weapons.
WMA Calls on Governments to Ban
and Eliminate Nuclear Weapons
Residency is a dynamic and stressful
time. Trainees must continually balance
their roles as both learners and clini-
cians within a high-stakes environment.
Whether it’s hearing that first code pager,
witnessing a patient death, feeling the cu-
mulative impact of long hours and on-call
responsibilities, or missing an important
life event at home – every resident deals
with stress.
Stress impacts physician well-being. The
majority of Canadian medical residents
report that work-related fatigue affects
their mental health, physical health, and
relationships with family and friends
(Resident Doctors of Canada National
Resident Survey, 2015). The overall de-
pression rate in U.S. medical students and
residents is as high as 1 in 5 [1]. Burnout,
a work-related syndrome due to chronic
exposure to occupational stress, is preva-
lent in 27–75% of residents, depending on
specialty [2].
RDoC’s Resiliency Curriculum
Resiliency is the ability to recover from or
adjust easily to adverse situations, and it is
a critical trait for resident doctors. Training
residents in resiliency skills equips them to
effectively identify, cope with, and recover
from challenging experiences in their per-
sonal and professional lives, while setting
them up for rewarding and sustainable ca-
reers.
With content support from the Mental
Health Commission of Canada and the
Department of National Defence’s Road
to Mental Readiness Program, Resident
Doctors of Canada (RDoC) has developed
a practical, skills-based resiliency curricu-
lum to help mitigate the negative conse-
quences of stress during residency and
beyond.
The curriculum is based on the importance
of promoting mental resiliency in physi-
cians by fostering supportive and positive
The Value of Resiliency Training in
Postgraduate Medical Education
96
SPAIN
1. Human trafficking
According to UNODC, Article 3, para-
graph (a) of the Protocol to Prevent, Sup-
press and Punish Trafficking in Persons,
“trafficking in Persons is the recruitment,
transportation, transfer, harboring or receipt of
persons, by means of the threat or use of force or
other forms of coercion,of abduction,of fraud,of
deception, of the abuse of power or of a position
of vulnerability or of the giving or receiving of
payments or benefits to achieve the consent of a
person having control over another person, for
the purpose of exploitation. Exploitation shall
include, at a minimum, the exploitation of the
prostitution of others or other forms of sexual
exploitation, forced labour or services, slavery
or practices similar to slavery, servitude or the
removal of organs.” [1]
Human trafficking involves the forced trans-
fer of a person and the use of their services
in order to recruit them for commercial traf-
ficking. Frequently, the consent is obtained
but through deceitful acts and false promises.
Many times, due to the social conditions of
the victim, they are not aware of being ex-
ploited. To make it easier, a person is traf-
ficked if she or he is forced or tricked into
a situation in which he or she is exploited.
Child trafficking differs from human traf-
ficking in that no force or deception needs to
take place in order to prove that a child has
been trafficked. This difference is based on
Medical Affairs
The Role of Physicians Fighting Children Trafficking
and Illegal Adoptions: the Use of Genetic Identification
Jose A. Lorente
learning environments. It advocates for a
systematic approach to understanding and
addressing anticipated stresses, and assists
residents in overcoming personal adversity
by providing them with tools to better sup-
port their peers and patients.
RDoC’s resiliency curriculum encourages
residents to learn how to become more
aware of their own mental health, and to
take action early when they start to notice
shifts in their well-being. Students learn
and practice a series of tools based on cog-
nitive behavioural therapy, performance
psychology and mindfulness to build and
strengthen their resiliency. The curriculum
also explores the barriers to seeking help,
such as concerns regarding privacy or a fear
of losing control, as well as some guidelines
for approaching colleagues and peers who
appear to be in distress.
What’s Next?
RDoC has completed a pilot project that
involved delivering and evaluating the re-
siliency curriculum in five clinical special-
ties at two Canadian faculties of medicine.
The overwhelming response from par-
ticipants has been that resiliency train-
ing is highly valuable to residents and is
an essential part of medication education.
RDoC’s next steps include developing a
strategy to continue delivering resiliency
training across the country, in order to
help residents manage stress, support their
peers, and ultimately provide better patient
care.
For more information, please e-mail
resiliency@residentdoctors.ca
References
1. Goebert D, Thompson D, Takeshita J, Beach
C, Bryson P, Ephgrave K, Kent A, Kunkel M,
Schechter J, Tate J. Depressive symptoms in
medical students and residents: a multischool
study. Acad Med. 2009; 84(2): 236-41.
2. Ishak WW, Lederer S, Mandili C, Nikravesh R,
Seligman L, Vasa M, Ogunyemi D, Bernstein
CA. Burnout During Residency Training: A
Literature Review. J Grad Med Educ. 2009 Dec;
1(2): 236–242.
Kimberly Williams, MD
President, Resident
Doctors of Canada
Kimberly Williams
97
BACK TO CONTENTS
Medical AffairsSPAIN
the fact that a child is considered incapable
of taking an informed decision.
2.Trafficking in children
Children, the most fragile members of so-
ciety, can be subjected to many abuses. In-
deed, one of these abuses is human traffick-
ing, an apparently lucrative criminal activity.
According to UNICEF, “an estimated 300
million children worldwide are subjected to
violence, exploitation and abuse including the
worst forms of child labour in communities,
schools and institutions; during armed conflict;
and to harmful practices such as female genital
mutilation/cutting and child marriage”. Only
in the United States are there figures to begin
to appreciate the magnitude of the missing
children problem within the country. Ap-
proximately 800,000 children are reported
missing each year. Of these, approximately
360,000 are runaways and 340,000 are clas-
sified as “missing with benign explanation”,
and about 100,000 are abducted either by
family members or other known individuals
or are lost and/or injured (UNICEF 2004;
Crimes 2009). While these figures are dis-
turbing,they relate to mostly domestic situa-
tions and do not represent the greater inter-
national problem where children are illegally
sold for malevolent purposes.These numbers
also mainly show domestic situations and do
not represent the huge international prob-
lem of the harmful illegal trade of children.
Recent reports give information about the
nature of trafficking of children but its real
significance is still not clear. In 2002, the
International Labour Organization (ILO)
estimated that 1.2 million children are kid-
napped and trafficked in a year [2].
3.The role of Physicians
fighting children trafficking
and illegal adoptions
The UNICEF’s Convention on the Rights of
the Child (resolution 44/25 of 20 ­November
1989, entered into force on 2 September
1990), states in art. 24.1 that States Parties
recognize the right of the child to receive
the highest attainable standard of health
care and to have access to appropriate fa-
cilities for the treatment of illness and reha-
bilitation of health [3]. States Parties shall
strive to ensure that no child is deprived of
his or her right of access to such health care
services.
Besides that, and according to art. 21,
States Parties that recognize and/or permit
the system of adoption shall ensure that
the best interests of the child shall be the
paramount consideration and they shall:
(a) Ensure that the adoption of a child is
authorized only by accredited authorities
who determine, in accordance with appli-
cable law and procedures and on the basis
of all pertinent and reliable information,
that the adoption is permissible in view
of the child’s status concerning parents,
relatives and legal guardians and that, if
required, the persons concerned have given
their informed consent to the adoption on
the basis of such counselling as may be
deemed necessary.
There is no doubt that physicians have a role
to play, since their professional activities are
crucial in seeking to ensure the adherence
to children’s rights, and in particular to ar-
ticles 21 & 24. Physicians play a relevant
role in two different positions during the
whole adoption process before the adoption
is completed. First, in countries and areas
where children are going to be given for
adoption, because they will deal with chil-
dren who are going to be adopted, and they
must be sure that the child is healthy, with
no injuries that could show battering or
abuses; they must report to the proper au-
thorities any suspicious adoption activities
related to minors whose identities are not
clear or where legal safeguards are not in
place. Second, in countries and areas where
children are going to be adopted, physicians
should advise those families who are con-
sidering adoption of minors to verify that
the adoption procedures meet all legal re-
quirements in their jurisdiction. Since they
are trusted, the fact of providing informa-
tion about networks related to illegal adop-
tions is important.
Beside that, physicians should explain to
families about genetic testing (DNA anal-
ysis) that can be used to confirm the bio-
logical relationship between the children
that are going to be given for adoptions
and the relatives (usually parents) who are
presenting the children for adoption. It is
crucial to make sure that children are be-
ing given for adoption on a voluntary basis
and by their biological parents or relatives.
Genetic analysis can also help to identify
missing children that were not previously
identified and facilitate family reunifica-
tion.
4. One example: the DNA-
PROKIDS Program:
DNA to identify missing
and vulnerable children
After a number of successful missing per-
sons identification initiatives, as e.g. the
Spanish Phoenix Program [4], DNA-
PROKIDS was created in 2004 by Dr. Jose
Antonio Lorente, Director of the Genetic
Identification Laboratory of University of
Granada. After a pilot study from 2006 to
2008 in countries from Central America
and Asia, it became a worldwide action.
The goal of DNA-PROKIDS is the use
of human genetic identification technolo-
gies (i.e. DNA analysis) to identify missing
children. DNA-PROKIDS is supporting a
number of countries in Latin America and
Asia analysis to generate two independent
databases, always according to the laws and
regulations in each country:
QUESTIONED DATABASE: DNA pro-
files of unidentified children under protec-
tion of the authorities living in orphanages,
98
Medical Affairs SPAIN
NGO’s facilities, or other institutions. In all
cases these are children whose family is not
known.The legal tutor of the child must au-
thorize the collection of the sample.
REFERENCE DATABASE: DNA pro-
files of relatives of missing children: par-
ents, grandparents, etc. who have reported
that his/her biologically-related child is lost.
These samples are voluntarily provided by
the relatives and collected after an informed
consent form has been signed.
Globally, DNA-PROKIDS is composed
of three tiers.The first tier is at the national
level with two genetic databases or indices
per country, as previously described. The
DNA profiles in these two indices will be
compared routinely to assist in identifying
missing children. The second tier implies
coordination amongst different countries;
it is highly recommended for neighbor-
ing countries in affected regions. The lack
of coordination plays in detriment of an
effective strategy to fight child traffick-
ing globally. The third tier would be the
adoption of international conventions that
should require the correct identification of
every child by using all available method-
ologies, including DNA analysis. No child
should be given for adoption without be-
ing sure that his or her family is not look-
ing for him or her.
The application and usefulness of DNA
identity testing are already well-document-
ed. To date DNA-PROKIDS participating
countries have analyzed over 10.500 sam-
ples (from Mexico, Guatemala, El Salvador,
Paraguay, Peru, Bolivia in Latin America,
and the Philippines, Thailand, Indonesia,
and India in Asia). DNA analyses first, and
subsequent application of accompanying
meta-data, have already helped to identify
more than 860 missing children who have
been returned to their families; and more
than 250  illegal adoptions that have been
avoided.
Guatemala is the first and so far the only
country in the world that has passed a law
(Ley de Alerta Alba-Keneth) in 2010 to
request DNA analysis on all unidentified
children and to offer the analysis for free to
the relatives of missing children [5].
More operational data and updated informa-
tion can be found at www.dna-prokids.org
References
1. UNODC. https://www.unodc.org/unodc/trea-
ties/CTOC, 2016.
2. Hagemann, F. Every Child Counts. New Global
Estimates on Child Labour, International Or-
ganization for Migration, 2011. Counter traf-
ficking and assistance to vulnerable migrants.
Annual report of activities 2011.
3. UNICEF Office of Research. https://www.
unicef-irc.org/portfolios/crc.html, 2016.
4. Lorente JA, Entrala C, Alvarez JC, Lorente M,
Villanueva E, Carrasco F, et al. Missing persons
identification: Genetics at work for society. Sci-
ence, 2000, 290(5500), 2257–2258.
5. Ley de Alerta Alb-Keneth-Guatemala. http://
www.pgn.gob.gt/ley-alba-keneth, 2016.
Jose A. Lorente1,2
, MD, PhD, Maria Saiz1
,
Maria Jesus Alvarez‑Cubero2
,
Juan Carlos Alvarez1
,
Juan Jose Rodriguez‑Sendin3
, MD,
Fernando Rivas3
, MD, PhD
1. DNA-PROKIDS Program- Department
of Legal Medicine, Toxicology and Physical
Anthropology. Faculty of Medicine.
PTS Granada. Av. Investigación
11. 18016. Granada. Spain
2. GENYO. Centre for Genomics and
Oncological Research. PTS Granada. Avenida
de la Ilustración 114. 18016 Granada. Spain
3. Consejo General de Colegios Oficiales
de Médicos de España, Madrid
E-mail: jose.lorente@genyo.es
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EuthanasiaVATICAN
In Maxence Van Der Meersch’s popular
novel Bodies and Souls Michele Doutreval,
a young country doctor, the son of a well-
known university professor in Angers, due
to several turns of events, finds himself
working in a small town in the North of
France. One of the episodes in particular
describes doctor Doutreval’s great human-
ity and good approach to Medicine. On his
way back home after a long day at work,
he meets a man on his doorstep. The man,
who looks clearly sorry to trouble the doctor
at such a late hour, tells him that his little
daughter, Franchina Ray is dying of tuber-
culosis and wishes to say goodbye.Michele’s
answer is concise but very illustrative: “Yes,
sure. I’ll be right back”. He enters his house
to greet his wife and to tell her that once
again they will not be able to spend the
night together. Then he sets out on his way
to the sick girl’s house where he stands by
her side until she dies. The episode ends
with the remark that it was late when the
doctor finally got back home [1]. Medical
science has certainly changed in the century
that separates us from doctor Doutreval’s
time, and it has changed irreversibly… Nev-
ertheless, every doctor would wish to have
the same availability and friendliness that
Michele had in his medical practice.
It seems to me that Van Der Meersch’s sto-
ry can be a useful backdrop for the compli-
cated topic of this article. Medical science
changes with society,not only because today
we have more diagnostic and therapeutic
means than we used to have a few decades
ago. The introduction of technology into
medical care has caused a great transforma-
tion in the way of conceiving the doctor-
patient relationship. Patients are each time
seen by more and more professionals and
this represents a temptation for the doctor,
who can easily become another stranger at
the bedside [2]. Moreover, autonomy, one
of the basic principles of Bioethics, has in-
duced many doctors to shirk their duty of
providing advice and orientation, and bar-
ricade themselves behind technical means.
It is within this complicated medical con-
text and the prolongation of pathological
processes, that the demand for euthanasia
can insinuate itself. So far and with few ex-
ceptions, medical science, through its con-
stituent bodies,has refused to take this path.
However, social pressure is strong in some
countries and consequently it is essential to
engage in a calm and well-considered de-
bate on the topic.
The World Medical Association (WMA),
which defines euthanasia as “the act of de-
liberately ending the life of a patient,even at
the patient’s own request or at the request of
close relatives”, has condemned euthanasia
since 1987 in a clear and explicit way, stat-
ing that “it is unethical”. It then goes on to
clarify what is and what is not euthanasia,
by adding that “This does not prevent the
physician from respecting the desire of a
patient to allow the natural process of death
to follow its course in the terminal phase
of sickness”[3]. Moreover, according to the
2002 resolution on euthanasia: “The World
Medical Association reaffirms its strong
belief that euthanasia is in conflict with
basic ethical principles of medical practice
and the WMA strongly encourages all Na-
tional Medical Associations and physicians
to refrain from participating in euthanasia,
even if national law allows it or decriminal-
izes it under certain conditions”[4]. In this
paper I would like to highlight some of the
arguments that justify this policy bearing
in mind that negative moral prescriptions
are not an end in themselves, but are the
starting point for a profound and creative
reflection on medical assistance at the end
of life; an end of life which has benefited
immensely over the last decades from ad-
vances in palliative care. Unfortunately, the
teaching of this area of medical science has
been insufficient in many instances. For
this reason, this reflection is also a call for
a more substantial engagement in order to
stimulate an increase in undergraduate and
graduate training in this important field of
modern medicine.
Since its inception, Medical Ethics has re-
jected euthanasia following a basic deon-
tological principle: “doctors must not kill”.
Deontology, which is currently represented
by Kantian ethics, highlights what can be
done and what cannot be done. The ratio-
nale for these norms may vary according to
the various moral formulations, but what is
more important here is the assumption of a
series of obligations and prohibitions; pro-
hibitions of acts which contravene the good
of the person or of society. Apart from the
deontological argument, utilitarian argu-
ments have also been added to recent de-
bates on euthanasia. Their argument claims
that a particular action is to be considered
wrong not because there is a norm prohib-
iting it, but rather because the action goes
against the greatest good for the great-
est number of the people. For the case in
point, the utilitarian or consequentialist
argument rejects the practice of euthanasia.
Pablo Requena
Why Should the World Medical Association
not Change its Policy towards Euthanasia?
100
Euthanasia VATICAN
Even though utilitarianism does not con-
sider the practice immoral in itself, and in
fact considers it justified in some cases, it
accepts that allowing it would result in seri-
ous abuses. This form of argumentation has
entered the bioethical bibliography using
the term “slippery slope”.
“Doctors must not kill”
The deontological principle condemning eu-
thanasia finds its paradigmatic expression in
the Hippocratic Oath,which has constituted
the basis of Medical Ethics from the origins
of medical science to this day. This text, dat-
ing back to the 4th century BC,states: “I will
neither give a deadly drug to anybody if
asked for it, nor will I make a suggestion to
this effect”[5]. This is a brief statement, like
the rest of the statements that are mentioned
in the Oath, which instructs doctors not to
provide patients with any means to end their
lives. Actually, what the Oath condemns is
what we know today as “assisted suicide”.
However, medical tradition has always seen
it as a prohibition of any lethal act on the part
of the doctor. The anthropologist Margaret
Mead explains that Greek medicine distin-
guished the doctor from the magician, when
the definitive separation between to kill and
to cure was achieved [6].
As concerns the current debate on euthana-
sia, this ethical rule is extremely important,
for it was written in a social and philosophi-
cal context that widely favoured suicide.
Platonists as well as cynics and stoics were
in favour of euthanasia in the event of ill-
ness, and in some cases it was actually seen
as an act of courage. Aristotle and Epicu-
rus held a less positive outlook on suicide,
though left certain space for its justification
[7].This is a significant fact,for even though
it was a relatively common and socially jus-
tified practice, Medical Ethics considered
it important for doctors to avoid in order
not to contradict their profession which is
precisely to cure and not to kill the patient.
It was also important in order to avoid any
suspicion that doctors would anticipate
their patients’ death.
Throughout the centuries, the moral prin-
ciple “doctors must not kill”has been passed
on from generation to generation as a ba-
sic pillar of the doctor’s vocation. For some,
the idea of converting this rule into a mere
prima facie principle, or a simple piece of
advice that can be ignored in certain cir-
cumstances, constitutes an alteration, not of
some peripheral element of Medicine but
of its very essence: “The very soul of medi-
cine is on trial” [8]. Lonnie Bristow, former
president of the AMA, in a statement read
before the Congressional Committee of
the United States voiced the same opinion:
“Laws sanctioning physician assisted sui-
cide serve to undermine the foundation of
the physician-patient relationship, which
is grounded in the patient’s trust that the
physician is working wholeheartedly for the
patient’s health and welfare” [9].
Daniel Callahan, in his thought provoking
book The Trouble Dream of Life, holds that
the request for euthanasia is a manifestation
of patients’ and society’s lack of trust in the
healthcare system. Euthanasia would repre-
sent the illusion of being in control of ill-
ness at all times and of being able to put an
end to life, when considered the best choice,
without having to succumb to the domi-
nance of technology that can keep people
alive as long as possible. Fundamentally,
there is a feeling of mistrust towards the
doctor and his medicine. What the author
finds paradoxical is that in order to protect
itself from this technological assault, society
would so easily choose this path and happily
entrust the doctor with the power of delib-
erately ending a life [10]. This view appears
as the bottom line in Herbert Hendin’s in-
teresting book Seduced by Death, in which
the history of euthanasia in the Netherlands
is described directly by the people who have
been involved in it and which concludes
with the message that it is not worth fol-
lowing this path. The author is of the per-
sonal view that there is no moral issue in ap-
plying euthanasia to specific cases; but the
European experience shows the great influ-
ence the legalisation of this practice has on
the doctor-patient relationship. Ultimately
this means increasing the power of medi-
cine to decide end-of-life situations which
are extremely complex and which could find
in euthanasia a far too easy “solution” [11].
Another important aspect when consider-
ing euthanasia that goes beyond the doctor-
patient relationship is the weighty matter
of critically ill patients having to make a
decision, and in a certain sense justify, their
desire to carry on living. Although its pro-
ponents insist that the choice of euthanasia
must be free from coercion, in practice this
hardly ever happens. If the sick person is
aware that her/his condition constitutes a
burden to their family and the community,
it is logical that she/he would wish to spare
them the burden and decide for euthanasia
for this reason. In 2002, Tonti-Filippini, an
Australian bioethicist (who recently passed
away), wrote an open letter in plain and di-
rect language to the then Prime Minister
of his Country, Mike Rann, concerning a
legislative proposal in favour of euthanasia.
He pointed out that for people like himself,
who found themselves in a situation eligible
for euthanasia, the last thing they needed
was precisely such a possibility. What they
needed was human contact, support and
good medical care, since their critical state
of health was already dulling their will to
fight…and to live [12]. It seems to me that
this aspect of the matter is rarely taken into
serious consideration,whereas it should give
healthcare professionals food for thought.
Slippery slope
The debate on euthanasia has increasingly
given greater weight to moral arguments
based on consequences caused by actions
and on healthcare policies. The “slippery
slope”argument holds that if a law is passed
allowing euthanasia for a number of very
concrete cases and with strict conditions,
101
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EuthanasiaVATICAN
this would not prevent abuse. Experience
proves, moreover, that in time the restric-
tions are weakened and euthanasia ends up
being applied to patients who in principle
should have been excluded.
Before we move on to study this issue, let us
look at some data. Even though these num-
bers do not represent “a fall down the slope”,
they certainly deserve special attention, as
they are illustrative of this situation bear-
ing in mind that when the law in favour of
euthanasia was approved in the Netherlands
and Belgium in 2002 the thought was that
it would apply to a very limited number of
cases. As a matter of fact in the Netherlands
it was legalised in 1984 as a result of a deci-
sion of the Dutch Suprme Court.In the de-
bates previous to the ratification of the law,
they talked of limit cases in which medical
care, it was held, was incapable of provid-
ing a satisfactory answer. Instead what has
been witnessed over the years has been an
annual increase in the practice of euthanasia
as more and more justifications have been
given for it. It is true that, in the years fol-
lowing the approval of the law in favour of
euthanasia in the Netherlands, there was a
slight decrease in the number of cases com-
pared to the previous years. In 2001, deaths
from euthanasia and assisted suicide repre-
sented 2.6% of all deaths, whereas in 2005
they represented 1.7% [13]. Nevertheless,
after the numbers settled, there has been a
considerable increase over the last few years.
In the 2003 report of the Regional euthana-
sia review committees which gives data from
the first year of the promulgation of the law,
1815 cases of euthanasia and assisted sui-
cide were recorded; in 2004, they increased
to 1886 and in 2005, they reached 1933
cases. In the 2015 report, the total number
of deaths by euthanasia and assisted suicides
was 5516 [14]. It is also worth noting as
Van Der Heide does in her 2007 article that
apart from the recorded increase in cases of
euthanasia over the years, there has been a
parallel increase in cases of continuous deep
sedation intended as a means to hasten pa-
tients’ death. In 2001, the deaths from con-
tinuous deep sedation amounted to 5.6% of
all deaths, whereas in 2005 the number had
risen to 7.1%. Increased numbers have also
been recorded in cases referred to as “volun-
tary stopping of eating and drinking”which,
according to the Royal Dutch Medical Associ-
ation (2011), account for up to 2500 deaths
a year. Although the Dutch Medical Associa-
tion considers this practice distinct from as-
sisted suicide, in our opinion there is hardly
any difference between the two [15]. These
statistics help give an idea of the situation
regarding euthanasia and similar practices
at the end-of-life in the country with the
most experience of such issues.
Going back to the “slippery slope” argu-
ment, special mention should be made of
the works of Professor John Keown, who
has produced one of the most in-depth
studies of the debate over voluntary eutha-
nasia from a legal perspective, and who of-
fers a good overview of this tool of moral
reasoning [16]. He distinguishes two main
aspects of the argument: an empirical and a
logical one.The first is a simple observation:
in those places in which euthanasia was ap-
proved for persons with incurable illness as-
sociated with intolerable suffering and who
would repeatedly request for an end to their
lives, it is has been seen that, over the years,
euthanasia has been performed on patients
with curable illnesses, who did not have in-
tolerable suffering or who had not requested
to die. The logical aspect of the argument,
holds that the specific precautions, which
are taken with the specific purpose of reduc-
ing the practice of euthanasia to only limit
cases, disappears not only because of the
practical question at the moment of imple-
mentation, but also because of a theoretical
reason. What justifies euthanasia in certain
limit cases, making reference to patient au-
tonomy or to the fact that some patients
would be better off dead, can also be used to
justify its practice when patients voluntarily
ask for it even if they do not have intoler-
able suffering such as in the case for elderly
people. Similarly, non-voluntary euthanasia
would be also considered justifiable in those
cases in which chronically unconscious pa-
tients are considered to be better off dead.
Some authors claim that “the Dutch experi-
ence” demonstrates a sufficiently transpar-
ent system in which the incidence of eu-
thanasia abuses would not occur frequently
[17]. However, a considerable number of
authors have found flaws in the system, and
the inability of avoiding a slip down the
“slippery slope”. Raphael Cohen-Almagor,
another author who has made an in-depth
study of euthanasia in the countries that
have legalised it, is of the same opinion. In
one of his articles, he writes that, although
some deny slipping on the “slippery slope”,
the two major studies carried out in Hol-
land in 1990 and 1995 show that frequently,
it is the doctors who first propose eutha-
nasia or the patient’s family members who
initiate the discussion process; these initia-
tives in turn have a marked influence on the
decision-making process.In other cases, pa-
tients’requests are not adequately evaluated;
and more seriously,and in quite a number of
cases, people who did not ask for euthanasia
end up dead [18].
The entire system controlling euthanasia in
the Netherlands and Belgium relies on the
information gleaned from questionnaires
completed by doctors for each case and sent
to the relevant Commission for evaluation.
This control system fails in the assessment
of less clear cases or when not all the legal
provisions have been followed. In a study
published in the British Medical Journal in
2010, Smets et al. analysed questionnaires
sent to doctors in Flanders covering a pe-
riod in which there had been 137 certified
cases of euthanasia out of a total of 6202
deaths.The conclusion of the study was that
only half of the cases of euthanasia were re-
ported to the Commission. In some cases,
the error was due to the fact that doctors did
not consider the death as due to euthanasia;
in others it was due to the feeling that com-
pleting the documentation was an admin-
istrative burden, or that not all the legal re-
quirements had been applied. Some doctors
102
Euthanasia VATICAN
even claimed that euthanasia was a private
matter between the doctor and patient [19].
A number of monographs have been writ-
ten on the subject of the “slippery slope”[20].
Due to limited space, we will only mention
three major points: euthanasia for the el-
derly people who are not suffering from any
incurable illness; euthanasia for newborns
or minors and euthanasia for patients with
depression. The first point is a clear example
of the “slippery slope”argument in action.At
the beginning, the law required an incurable
illness, which would cause intolerable suffer-
ing. However, according to the 2015 “Code
of Practice”of the Regional euthanasia review
committees in the Netherlands,the practice of
euthanasia is granted to those elderly peo-
ple who think that their lives are no longer
worth living and would rather die than con-
tinue living. The text goes as far as pointing
out that this question was the issue of previ-
ous debate but which has been resolved as it
has been noted that intolerable suffering is
not only caused by terminal illnesses but also
by many geriatric conditions [21]. It is easy
to understand how difficult it is for doctors
to evaluate such a request.There are very few
objective elements foreseen by law on which
a request could be based to justify a more or
less autonomous decision to end one’s life,
independent of one’s health.
Euthanasia is also problematic when con-
sidered at the opposite extreme of age.In the
first years of the debate on euthanasia and
during the drafting of the first legislation,
the practice of euthanasia was intended for
adults,who could provide a valid consent.In
the Dutch situation, it only took a few years
to extend euthanasia to those over 16 with-
out their parents consent, and to those be-
tween 12 and 16 with parental consent [22].
Neither did it take long to justify euthanasia
for newborns born with serious conditions
[23]. Although it may be true that these are
very complex cases, in which the best inter-
ests of the child are being sought, it is also
true that in their justification the basic mor-
al element of autonomous decision is lost.
In 2014, Belgium abolished the age limit on
euthanasia. A similar problem arises when
euthanasia is granted to people with psychi-
atric illnesses, and in particular those who
suffer from depression. In these cases, it is
very hard to ascertain that the request to
die is the result of a well informed decision
made with the minimum amount of interior
freedom required for such a decision.
A final thought
Although many points and much of the de-
bate on euthanasia could still be analysed
and addressed, based on what has been said
so far,it appears quite clear that euthanasia is
presented as a “help”and even as a “solution”
for a few hopeless cases. We can conclude
that, from both a medical and ethical point
of view, it represents an inadequate solution
to a real problem; a solution that, as we have
seen, leads doctors and patients to get used
to it and to consider it as one more therapeu-
tic option.This in turn explains the growing
number of euthanasia cases every year.
We believe that Medicine has much more
to offer and that, today, its ability to deal
with many symptoms is incomparably bet-
ter than it was a few years ago. In many
articles that describe the experience of eu-
thanasia in the Netherlands and Belgium,
pain, and generally pain caused by cancer, is
one of the major reasons why people ask for
euthanasia [24].In some cases,it is true that
treating this kind of pain might be very dif-
ficult, but modern palliative care is capable
of alleviating the majority of this type of
pain. The problem is that, often, physicians
do not possess the appropriate competence
to do so.The fifth report of the Federal Com-
mission for Control and Assessment of Eutha-
nasia in Belgium (2010-2011) indicates
that, of all the doctors who had received
requests for euthanasia, only 10% had been
trained in palliative care.This figure appears
to us to suggest that the solution to requests
for euthanasia, which in reality are always
a request for help, lies in this direction. A
request for help can be answered in many
different ways, but not all the answers are
equally beneficial. As we said at the begin-
ning, closing the door on euthanasia should
represent a starting point for substantially
improving professional training in the ter-
minal care of patients.
Therefore, we believe that WMA should
not change its policy on euthanasia. A pol-
icy based on a Medical Ethic thousands of
years old, which does not involve any exter-
nal control of medical care but rather is a
constant stimulus to better the care of pa-
tients in the final moments of their lives, al-
ways guaranteeing their personal autonomy.
I am very grateful to Dr. Paul Kioko and
Prof. John Keown for their invaluable help
with the final draft of this article.
References
1. Maxence van der Meersch. Bodies and Souls.
New York: Pellegrini & Cudahy, 1948.
2. David J. Rothman. Strangers at the Bedside:
A History of How Law and Bioethics Trans-
formed Medical Decision Making. New Brun-
swick: AldineTransaction, 2008.
3. WMA. Adopted by the 39th WMA in Madrid,
Spain,October 1987 and reaffirmed by the 170th
Council meeting in Divonne-les-Bains, France,
May 2005 and by the 200th WMA Council ses-
sion in Oslo, Norway, April 2015: http://www.
wma.net/es/30publications/10policies/e13/
(consulted on 15.09.2016).
4. WMA.Adopted by the 53rd WMA General As-
sembly in Washington,May 2002 and reaffirmed
in view of the revision by the 194th Council
meeting in Bali, Indonesia, April 2013: http://
www.wma.net/es/30publications/10policies/
e13b/ (consulted on 15.09.2016).
5. Hippocrates. The Hippocratic Oath. In Ludwig
Edelstein Supplements to the Bulletin of the
History of Medicine. Baltimore: Johns Hopkins
Press, 1943; 3.
6. Cfr. Nigel M. de S. Cameron. The New Medi-
cine: Life and Death after Hippocrates. New ed
Chicago; London: Bioethics Press, 2001; 162.
7. William Frankena. The ethics of respect for life.
In O. Temkin, W.K. Frankena, S.H. Kadish
(eds.) Respect for life in medicine, philosophy,
and the law. Baltimore: The Johns Hopkins Uni-
versity Press, 1977; 37-38.
103
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UNITED STATES OF AMERICA Euthanasia
Introduction
The WMA has long opposed the decrimi-
nalisation of voluntary euthanasia (VE)
and/or physician-assisted suicide (PAS) [1].
Its opposition to lethal injections and/or
prescriptions for lethal drugs, reinforced by
that of national medical associations, has
proved a political bulwark against decrimi-
nalisation. Precisely because of this, cam-
paigners for VE/PAS will increasingly be
pressuring the WMA, and national medical
associations, to drop their opposition, and
adopt at least a ‘neutral’ position.
This paper will outline seven arguments
that will likely be pressed on the WMA;
and why they all fail [2]. As the first two
arguments are typically at the forefront of
the case for decriminalisation, more space
will be devoted to them.
Seven Arguments for
Decriminalisation
1. Respect for
Autonomy
“The law should respect a patient’s right to
decide the time and manner of their death, at
least if they are ‘terminally ill’ and/or experi-
encing ‘unbearable suffering’.”
(a) limits to respect for autonomy
The short answer to this argument is there
is no such right. While autonomy is an im-
portant capacity, respect for autonomy has its
8. W. Gaylin et al.‘Doctors Must Not Kill’. JAMA
259, No.14 (April 8, 1988): 2139–40.
9. Massachusetts Medical Society on the Ballot on
Prescribing Medication to End Life (November
6, 2012), p. 6.
10. Daniel Callahan. The Troubled Dream of Life:
In Search of a Peaceful Death. Washington DC:
Georgetown University Press, 2000.
11. Herbert Hendin. Seduced by Death: Doctors,
Patients, and Assisted Suicide. New York: W.W.
Norton, 1998.
12. Published in the Herald Sun (21.11.20110):
http://www.heraldsun.com.au/blogs/andrew-
bolt/a-dying-man-explains-why-euthana-
sia-is-so-dangerous/news-story/ec8b23ae-
24376e980085f88ef0837b3e (consulted on
15.09.2016)
13. Agnes van der Heide et al. End-of-Life Prac-
tices in the Netherlands under the Euthanasia
Act.The New England Journal of Medicine 356,
No. 19 (May 10, 2007): 1957–65.
14. This data can be consulted on the website del
Regionale toetsingscommissies euthanasie:
https://www.euthanasiecommissie.nl/ consulted
15.09.2016).
15. Royal Dutch Medical Association. The Role of
the Physician in the Voluntary Termination of
Life.Amsterdam: KNMG,2011; 34–36.https://
www.knmg.nl/over-knmg/contact/about-knmg.
htm (consulted on 15.09.2016).
16. John Keown.Euthanasia,Ethics and Public Pol-
icy: An Argument against Legalisation. Cam-
bridge: Cambridge University Press; 2002.
17. Bregje D. Onwuteaka-Philipsen et al.Trends in
End-of-Life Practices before and after the Enact-
ment of the Euthanasia Law in the Netherlands
from 1990 to 2010: A Repeated Cross-Sectional
Survey. Lancet, 380, No.9845 (September 8,
2012): 908–15; Bernard Lo. Euthanasia in the
Netherlands: What Lessons for Elsewhere? Lan-
cet 380, No.9845 (September 8, 2012): 869–70.
18. This study shows 1000 cases of speeding death
without request in 1990 and 900 cases in 1995:
Raphael Cohen-Almagor. Non-Voluntary and
Involuntary Euthanasia in the Netherlands:
Dutch Perspectives. Issues in Law & Medicine
18, No. 3 (2003): 239–57.
19. Tinne Smets et al. Reporting of Euthanasia in
Medical Practice in Flanders, Belgium.
20. David Lamb. Down the Slippery Slope: Argu-
ing in Applied Ethics. New York: Croom Helm,
1988; Iñigo Ortega Larrea. Eutanasia: ética y ley
frente a frente.Rome: Pontifical University of the
Holy Cross, 1996; Roberto Aguado Aguarón. El
cuidado del enfermo en la fase terminal: un es-
tudio moral a partir de la práctica de la eutanasia
en Oregón – USA. Rome: Pontifical University
of the Holy Cross, 2003; Javier Vega Gutiérrez,
La pendiente resbaladiza en la eutanasia: una
valoración moral. Rome: Pontifical University of
the Holy Cross, 2006.
21. Regional euthanasia review committees.Code of
Practice. The Hague, April 2015: https://www.
euthanasiecommissie.nl/actueel/nieuws/2016/
mei/27/code-of-pratice-translated-in-english
(consulted on 15.09.2016).
22. More information on the practice in the Nether-
lands can be found on https://www.government.
nl/topics/euthanasia (consulted on 15.09.2016).
23. Eduard Verhagen and Pieter J.J. Sauer.The Gro-
ningen Protocol — Euthanasia in Severely Ill
Newborns. New England Journal of Medicine,
352, No.10 (March 10, 2005): 959–62.
24. See for example the Code of Practice (2015),p.13.
Pablo Requena
Associate Professor of Moral
Theology and Bioethics
Pontifical University of the
Holy Cross in Rome
Vatican Medical Association
E-mail: requena@pusc.it
John Keown
Voluntary Euthanasia and Physician-
assisted Suicide: Should the WMA
Drop its Opposition?
104
Euthanasia UNITED STATES OF AMERICA
limits and the law places all sorts of reason-
able restrictions on our autonomy.Patients no
more have the right to a lethal injection from
their physician than they have to the amputa-
tion of a healthy limb.Patients have a right to
refuse treatment, but that is a negative right,
not a positive right; a shield, not a sword.
One key limit on respect for autonomy is the
principle of the inviolability of life (or the
‘sanctity of life’) [3]. Laws in most countries
of the world continue to prohibit a choice
to be killed.This prohibition is grounded in
a recognition of our fundamental equality-
in-dignity, however sick or disabled we may
be. As the preamble to the UN Declaration
of Human Rights puts it: “Recognition of
the inherent dignity and of the equal and
inalienable rights of all members of the hu-
man family is the foundation of freedom,
justice and peace in the world” [4]. We all
enjoy the ‘right to life’, the inalienable right
not to be intentionally killed. In its 1994 re-
port unanimously rejecting the case for VE/
PAS,the UK’s House of Lords Select Com-
mittee on Medical Ethics defended the pro-
hibition on intentional killing, observing:
That prohibition is the cornerstone of law
and of social relationships. It protects each
one of us impartially, embodying the belief
that all are equal [5].
And, in any event, how many requests for
VE/PAS would be truly autonomous, espe-
cially when suicidal ideation is often asso-
ciated with clinical depression? The Select
Committee concluded: [W]e do not think
it possible to set secure limits on voluntary
euthanasia…It would be next to impossible
to ensure that all acts of euthanasia were
truly voluntary, and that any liberalisation
of the law was not abused [6].
(b) protecting the vulnerable
Concern for the vulnerable is another pow-
erful reason for limiting individual auton-
omy. The Select Committee stated: We are
also concerned that vulnerable people – the
elderly, lonely, sick or distressed – would feel
pressure, whether real or imagined, to re-
quest early death… The message which so-
ciety sends to vulnerable and disadvantaged
people should not, however obliquely, en-
courage them to seek death, but should as-
sure them of our care and support in life [7].
Similarly, philosopher Onora O’Neill has
argued: Legalising ‘assisted dying’ amounts
to adopting a principle of indifference to-
wards a special and acute form of vulner-
ability: in order to allow a few independent
folk to get others to kill them on demand,
we are to be indifferent to the fact that many
less independent people would come under
pressure to request the same [8].
It is no surprise, then, that disability groups
(like ‘Not Dead Yet’) [9] are at the forefront
of opposition to decriminalisation.They see
more clearly than many that, despite the
emphasis placed by euthanasia campaigners
on choice, the case for VE/PAS rests funda-
mentally on the judgement that certain pa-
tients have lives that are not ‘worth living’,
that they would be ‘better off dead’.
(c) judging patients ‘better off dead’
Typical legal proposals for decriminalisation
would not allow patients obtain VE/PAS on
request: patients would also have to satisfy
some other criterion, such as ‘unbearable
suffering’. In other words, doctors would
have to judge which autonomous requests to
grant, and which to refuse. And how would
the doctor decide, other than on the basis of
a judgment that the patient would,or would
not,be ‘better off dead’? (“I think patient A’s
suffering is so severe that death would ben-
efit her, but that patient B’s suffering is in-
sufficient to render his life no longer worth
living.”) Moreover,once a doctor is prepared
to make that judgment,that certain patients
would be ‘better off dead’, why shouldn’t the
doctor make the same judgment in relation
to incompetent patients and end their suf-
fering, by performing ‘non-voluntary’ eu-
thanasia (NVE)? If death can be a benefit
for a patient with ‘unbearable suffering’who
requests it, why can’t it equally benefit a pa-
tient with ‘unbearable suffering’ incapable
of requesting it? The absence of a request in
the latter case is no reason for denying the
‘benefit’. In short, anyone who supports VE
is, logically, committed to supporting NVE.
2. Compassion
“Physicians have a duty of compassion, a duty
to relieve their patients’ suffering, even if that
means administering a lethal injection.”
(a) limits to compassion
There is a duty to relieve suffering but, like
the duty to respect autonomy,it is not unlim-
ited. It is trumped by the duty not intention-
ally to kill patients. This duty not to kill has
formed the bedrock of professional medical
ethics since the Hippocratic Oath [10]. The
core vocation of the physician is to heal, to
make whole, not to make dead [11].
This vocation includes a duty to alleviate
suffering even if, as an unintended side-ef-
fect, life is shortened. But it rules out inten-
tional killing.Once physicians embrace kill-
ing as a ‘therapeutic’intervention,this surely
endangers the trust that patients now have,
that their physician will never judge them to
be ‘better off dead’. As Alexander Capron,
the leading US health lawyer, once starkly
put it, he never wanted to have to wonder
whether the physician entering his room
was wearing the white coat of the healer or
the black hood of the executioner [12].
(b) palliative care
Not only is killing unethical; it is unneces-
sary. The enormous progress that has been
made in palliative care, not least since the
establishment of the hospice movement by
Dame Cicely Saunders 50 years ago, means
that no patient need suffer unbearably.Even
in rare cases of refractory pain, there is the
option of palliative sedation. In 2014, a poll
of the Royal College of Physicians showed
that over 60% of its members agreed that
patients could die with dignity under the
existing law, and that relaxation of the law
is not needed [13].
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EuthanasiaUNITED STATES OF AMERICA
(c) ‘unbearable suffering’?
Although euthanasia advocates typically use
emotionally-charged cases of dying patients
with painful symptoms to front their cam-
paign, the reality is that after decriminalisa-
tion VE and PAS come to be condoned a
much wider range of cases.
The Dutch Supreme Court decriminalised
VE/PAS in 1984 (the guidelines gaining
statutory force in 2002) [14]. In 1994 the
Court held that purely mental suffering
could qualify [15]. The Dutch government
proposes to permit assisted suicide for el-
derly people with a ‘completed life’; and
even under the present law elderly people
who are ‘tired of life’ may obtain VE/PAS,
provided they can also point to some medi-
cal condition in support of their request
(and what elderly person does not have
some medical condition?) [16] In Belgium,
the ‘bracket creep’has been even faster, from
VE to PAS (the euthanasia review commis-
sion endorses PAS even though the statute
mentions only VE); from adults to compe-
tent minors; and from physical to mental
suffering [17]. Cases such as the purblind
twins [18], the distressed transsexual [19],
and the grieving mother [20], have all illus-
trated the disturbing elasticity of the legal
criteria.
Moreover, the official reports from the US
State of Oregon, where PAS has been prac-
tised for almost 20 years, show that the two
main reasons for requesting PAS have not
been suffering but ‘losing autonomy’ and
a decreasing ability ‘to engage in activities
making life enjoyable’ [21].
(d) compassion for the incompetent
If compassion justifies killing suffering pa-
tients who request it, why does it not justify
killing suffering patients who cannot re-
quest it? Why should compassion be con-
fined to the competent? Yet again, we see
the logical link between VE and NVE. The
Dutch courts endorsed VE/PAS in 1984.
Twelve years later, logically, they endorsed
NVE, in the form of infanticide [22].
3. Legal Hypocrisy
“The law allows doctors to end lives by withhold-
ing/withdrawing life-prolonging treatment or
by administering drugs which, as a side-effect,
shorten life, so it is hypocritical of the law to pro-
hibit them from performing VE/PAS.”
Leaving aside the fact that, properly ti-
trated, palliative drugs do not in fact hasten
death [23], the short answer to this argument
is that there is a cardinal ethical and legal dis-
tinction between intending and merely fore-
seeing the shortening of life.The US Supreme
Court rejected the argument that respecting a
patient’s refusal of life-prolonging treatment is
the same as PAS,noting that in PAS the phy-
sician intends to assist the patient’s death, but
thisisnotnecessarilysowithrespectingarefus-
al of treatment [24]. Chief Justice Rehnquist
noted that the fact that General Eisenhower
foresaw on D-Day that he was sending many
American soldiers to certain death did not
mean he intended their death: his purpose
was to liberate Europe from the Nazis [25].
Even the Dutch and the Belgians euthana-
sia laws, which reject the Hippocractic ethic
against medical killing, agree that eutha-
nasia involves intentional, and not merely
foreseen, life-shortening [26].
This distinction drawn by the law and by
professional medical ethics is not, then,
hypo­critical: it is Hippocratic.
4. A Right to Suicide
“In many countries suicide has been decrimi-
nalised.This means that the law now recognises
a right to commit suicide. If there is a right to
commit suicide, it should be legal to assist some-
one to exercise that right.”
The argument is misconceived. It does not
follow that decriminalisation represents a
condonation of suicide, let alone recogni-
tion of a ‘right to suicide’. In the UK, for ex-
ample, legislators made it crystal clear that
decriminalisation did not imply condona-
tion [27]. The explanation for decriminali-
sation lay elsewhere.
Legislators increasingly appreciated, thanks
to the development of the specialty of psy-
chiatry, that suicidal ideation is associated
with psychiatric disturbance, and that the
suicidal would be better diverted from sui-
cide by the mental health system than by
the criminal justice system. Moreover, the
crime stigmatised family members and led
to the unfortunate consequence of pros-
ecuting attempted suicides [28].
Moreover, assisting or encouraging suicide
remained a serious crime, which confirms
that there is no ‘right to suicide’ and that
suicide remains contrary to public policy.
5. Public Opinion Polls
“Opinion polls show that a clear majority of the
public want the law to allow VE/PAS.The law
should reflect the will of the people.”
It does seem that polls tend to show a clear
majority in favour of decriminalisation. But,
first, polls can be misleading. Much can de-
pend on the phrasing of questions and on the
amount of background information, if any,
given to those polled. One expert commit-
tee concluded that the polls tended to reflect
‘kneejerk’reactions to VE/PAS,not informed
opinion [29]. Second, it may well be that the
majority of the public support the restoration
of capital and corporal punishment. Is that a
sound argument for their restoration?
6. Legal Failure
“The law is ineffective. VE/PAS are practised
illegally. Decriminalisation would bring them
out into the open and subject them to effective
legal control.”
All criminal laws are broken to some extent,
sometimes (like speeding laws) to a con-
106
Euthanasia UNITED STATES OF AMERICA
siderable extent, but that is hardly by itself
a reason to repeal them. And there is little
evidence that laws against VE/PAS are any
less effective than many other criminal laws.
For example, research by Professor Clive
Seale found that the incidence of VE/PAS
in the UK was ‘extremely low’ (and signifi-
cantly lower than in the Netherlands, which
permits them) [30]. There will be breaches
of the law, to a greater or lesser extent, in
different jurisdictions,depending on a range
of cultural factors.This is not by itself an ar-
gument for repeal (especially when repeal is
very likely to provoke a substantial increase
in the incidence of VE/PAS).
Moreover, the claim that decriminalisa-
tion brings VE/PAS ‘out into the open’
and subjects them to ‘effective legal con-
trol’ is belied by the experience of the two
main jurisdictions to have decriminalised
VE/PAS: the Netherlands and Belgium.
The Dutch in particular have carried out
valuable surveys into end-of-life decision-
making. Those surveys have shown that
doctors have failed to report thousands of
cases to the Dutch monitoring authorities.
In 1990 only 20% were reported, and al-
though more recently the proportion has
grown to 80% [31], this means that around
1 in 5 cases of VE/PAS is still being il-
legally certified by Dutch physicians as
death by ‘natural causes’. Belgian surveys
have disclosed that only 50% of cases are
reported to the authorities [32].
It is not surprising that the Dutch law has
now been criticised, twice, by the UN Hu-
man Rights Committee. In 2001 the Com-
mittee expressed concern not only about
the adequacy of the regulatory system, but
about the extension of the law to minors,
and the practice of infanticide [33]. In 2009
it remained concerned about the extent of
VE/PAS and the fact that a physician could
terminate a patient’s life without any in-
dependent review by a judge or magistrate
to guarantee that the decision was not the
subject of undue influence or misapprehen-
sion [34].
As for Oregon, there have been no compre-
hensive surveys, so any claims that its law
is achieving effective control lack substan-
tiation. Its so-called ‘safeguards’, which are
even laxer than those in the Low Countries,
have been aptly described by Professor Cap-
ron as “largely illusory” [35].
The regulatory mechanism in all three ju-
risdictions depends on self-reporting by
physicians. It is, therefore, intrinsically inef-
fective. How many physicians are going to
report that they have broken the law?
In 2015 the Supreme Court of Canada
controversially created a legal right to VE/
PAS [36]. In arriving at this decision, which
was out of line with decisions of the Su-
preme Courts of the US and the UK, the
court agreed with the trial judge’s factual
finding that the risks of decriminalisation
‘can very largely be avoided through carefully
designed, well-monitored safeguards’  [37].
However, three judges of the Irish High
Court,who later carefully reviewed the same
evidence as the trial judge, rejected her find-
ing [38]. And rightly so. Given that no ju-
risdiction has ‘carefully designed, well moni-
tored safeguards’, and given the disturbing
experience of the Low Countries, one can
only guess what led the Canadian judges to
their strange conclusion [39].
7. Religion
“Opposition to decriminalisation is essentially
religious, and religious views should not be im-
posed in secular societies.”
This last argument is as lame as it is fre-
quent. The key arguments against legalisa-
tion, not least that it would undermine ‘the
cornerstone of law and of social relation-
ships’ by endorsing intentional killing, and
that it would threaten vulnerable patients,
are philosophical, not theological [40].
Moreover, many secular bodies have op-
posed decriminalisation. One example is
the UK Parliament, which has repeatedly
rejected the case for decriminalisation, most
recently in 2015, when the House of Com-
mons voted by a margin of 3-1 against a Bill
to decriminalise PAS [41]. Another exam-
ple is the World Medical Association itself.
Conclusion
Campaigners for VE/PAS will, on the basis
of some or all of the above seven arguments,
increasingly urge that the WMA should
drop its opposition to VE/PAS. Those ar-
guments are, however, unpersuasive. The
WMA’s opposition is as well-grounded as it
is well-established.
Moreover, if the WMA were to shift to a
‘neutral’position, the move would be widely
perceived as at least a tacit endorsement of
VE/PAS. It would be used by campaign-
ers as a powerful lever to prise open the
door to decriminalisation worldwide, de-
criminalisation which would not only sub-
vert the traditional healing vocation of the
medical profession, but would lead to VE/
PAS becoming increasingly perceived as a
part of normal medical practice, and even a
patient’s right, as appears to be happening
in the Low Countries. And with VE/PAS
transformed from a crime to a ‘treatment’,
doctors would be expected to deliver it, or
at least to refer patients to colleagues pre-
pared to do so. The recent call by two lead-
ing advocates of decriminalisation that doc-
tors in Canada be legally required to refer
patients, and for students with objections to
referral to be denied admission to medical
school [42], is but a foretaste of what medi-
cal professionals worldwide can expect if
the law in their countries is relaxed.
References
1. World Medical Association. WMA Resolu-
tion on Euthanasia [Internet] [cited 2016
Oct 3] Available from: https://www.wma.net/
en/30publications/10policies/e13b/
2. For a fuller treatment of these arguments see
Keown, John. Against Legalising Euthanasia;
For Improving Care. In Jackson, Emily and
107
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EuthanasiaUNITED STATES OF AMERICA
Keown, John. Debating Euthanasia. Oxford:
Hart Publishing, 2011, hereafter ‘DE’, 83-174.
See also Keown, John. Debating Euthanasia: A
Reply to Emily Jackson. In: Heneghan, Mark
and Wall, Jesse. Law, Ethics and Medicine: Es-
says in Honour of Peter Skegg (2016) 65-95.See
also Keown,John.Euthanasia,Ethics and Public
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3. See generally Keown, John. The Law and Eth-
ics of Medicine: Essays on the Inviolability of
Human Life. Oxford: Oxford University Press,
2012; chapter 1.
4. United Nations. The Universal Declaration of
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5. Report of the Select Committee on Medical
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94; para. 237.
6. Ibid. para. 238.
7. Ibid. para. 239.
8. ‘A Note on Autonomy and Assisted Dying’. Un-
published memorandum (quoted in DE at 93)
circulated to members of the House of Lords
during its consideration of Lord Joffe’s Assisted
Dying for the Terminally Ill Bill, which fell in
2006.
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AAA Home Page

10. “I will not give a lethal drug to anyone if I am
asked, nor will I advise such a plan…”. Hip-
pocratic Oath. History of Medicine Division,
National Library of Medicine, National Insti-
tutes of Health. [Internet] [cited 2016 Oct 3]
Available from: https://www.nlm.nih.gov/hmd/
greek/greek_oath.html
11. See Kass, Leon R. I Will Give No Deadly Drug:
Why Doctors Must Not Kill.In: Foley,Kathleen
and Hendin, Herbert (eds) The Case against
Assisted Suicide: For the Right to End of Life
Care. Baltimore: The John Hopkins University
Press, 2002:17-40, and Pellegrino, Edmund D.
Compassion is Not Enough. In ibid. 41-51.
12. Quoted in DE 104.
13. RCP affirms position against assisted dying [In-
ternet] [cited 2016 Oct 3]. Available from: htt-
ps://www.rcplondon.ac.uk/news/rcp-reaffirms-
position-against-assisted-dying
14. See generally Keown, John. Euthanasia, Ethics
and Public Policy. Cambridge: Cambridge Uni-
versity Press, 2002: part III; Cohen-Almagor,
Raphael. Euthanasia in the Netherlands: The
Policy and Practice of Mercy Killing. Dordrecht:
Kluwer, 2004; Griffiths, John et al. Euthanasia
and Law in Europe. Oxford: Hart Publishing,
2008; part I.
15. Keown, John. Euthanasia, Ethics and Public
Policy. Cambridge: Cambridge University Press,
2002: 87.
16. Lemmens, Willem et al, ‘The Dangers of Eu-
thanasia on Demand’. The Chicago Tribune.
17 October 2016. Cf. ‘The Royal Dutch Medi-
cal Association.The Role of the Physician in the
Voluntary Termination of Life (KNMG posi-
tion paper, June 2011). This paper states (at 40):
“Before deciding to grant a request for euthana-
sia or assisted suicide, the physician must gain or
facilitate insight into the suffering and be con-
vinced that the suffering is unbearable and has
at least in part a medical basis.” The paper con-
tinues (at 41) that, even if the patient is refused
euthanasia,the patient may decide to refuse food
and drink,and that “the physician is obligated,in
such cases, to supervise the patient and to allevi-
ate the suffering by arranging effective palliative
care.” All Dutch patients would now appear to
have a right to medical assistance in suicide, at
least by palliated self-starvation.
17. See generally Montero, Étienne. The Belgian
experience of euthanasia: 14 years of legal
implementation. In: Jones, David Albert et al,
Euthanasia and Assisted Suicide: Lessons from
Belgium. Cambridge: Cambridge University
Press, forthcoming. (I am grateful to Professors
Jones and Montero for a view of this essay). See
also Montero, Étienne. Rendez-Vous Avec La
Mort: Dix ans d’euthanasie légale en Bélgique.
Limal: Anthemis, 2013; (available in Spanish
as: Cita Con La Muerte: 10 años de eutanasia
legal en Bélgica. Madrid: Ediciones RIALP,
2013).
18. Waterfield, Bruno. Euthanasia twins ‘had noth-
ing to live for’. The Daily Telegraph. 14 January
2013.
19. Waterfield, Bruno. Belgian killed by euthanasia
after a botched sex change operation. The Daily
Telegraph. 1 October 2013.
20. The subject of a disturbing documentary on
Australian channel SBS. Allow Me to Die. 24
November 2015. [Internet] [cited 2016 Oct 3]
Available from: http://www.sbs.com.au/news/
dateline/story/allow-me-die.
21. Oregon Health Authority. Oregon Death with
Dignity Act: 2015 Data Summary. Table 1. End
of life concerns. [Cited 2016 Oct 3] Available
from: https://public.health.oregon.gov/Provider-
PartnerResources/EvaluationResearch/Death-
withDignityAct/Documents/year18.pdf
22. Keown, John. Euthanasia, Ethics and Public
Policy. Cambridge: Cambridge University Press,
2002: 119-20. And see Verhagen, Eduard and
Sauer, Pieter JJ. The Groningen Protocol – Eu-
thanasia in Severely Ill Newborns. New Engl J
Med 2005; 352: 959-62.
23. Twycross, Robert. Where there is hope there is
life: a view from the hospice. In: Keown, John
(ed) Euthanasia Examined. Cambridge: Cam-
bridge University Press, 1995: 141, 161-62.
24. Vacco v Quill 521 US 793, 800-02 (1997).
25. Ibid. 803.
26. Nys, Herman. A Presentation of the Belgian
Act on Euthanasia Against the Background of
Dutch Euthanasia Law. European Journal of
Health Law 2003; 10: 239, 240.
27. See Keown, John. Euthanasia, Ethics and Public
Policy. Cambridge: Cambridge University Press,
2002: 64-6.
28. See ibid. 286-87.
29. See DE 113-14.
30. Seale, Clive. National survey of end-of-life deci-
sions made by UK medical practitioners. Pallia-
tive Medicine 2006; 20: 3, 6.
31. Griffiths, John et al. Euthanasia and Law in Eu-
rope. Oxford: Hart Publishing, 2008: 199.
32. Chambaere, K et al. Recent Trends in Euthana-
sia and Other End-of-Life Practices in Belgium.
New Engl J Med 2015; 372; 1179-81.
33. UN Press Release. Human Rights Commit-
tee Concludes Seventy-Second Session. (HR/
CT/610; 2001 July 30).
34. UN Human Rights Committee. Consideration
of Reports Submitted by States Parties Under
Article 40 of the Covenant. (CCPR/C/NLD/
CO/4, 25 August 2009) para. 7.
35. Capron, Alexander M. Legalizing Physician-
Aided Death. Camb Q Healthc Ethics 1996;
5(1); 10.
36. Carter v. Canada (Attorney-General) [2015]
SCC 5.
37. Ibid. at [117].
38. Fleming v Ireland [2013] IEHC 2 at [88]  –
[105]. Remarkably, the Canadian Supreme
Court simply ignored the Irish judges’ rejection
of the Canadian trial judge’s finding.
39. See Keown, John. A Right to Voluntary Eutha-
nasia? Confusion in Canada in Carter. Notre
Dame JL, Ethics & Pub Pol’y 2014; 28; 1.
40. An early, and now classic, philosophical case
against decriminalisation, by a ‘self-styled lib-
eral’ law professor, is Kamisar, Yale. Some Non-
Religious Views against Proposed Mercy-Killing
Legislation. Minnesota Law Review 1958; 42(6);
969-1042. [Internet] [cited 2016 Oct 3]. Avail-
able from: http://repository.law.umich.edu/cgi/
viewcontent.cgi?article=2065&context=articles
41. Gallagher, James and Roxby, Philippa. Assisted
Dying Bill: MPs reject ‘right to die’ law. BBC
News 11 September 2015.
42. Savulescu, Julian and Schuklenk, Udo. Doctors
Have no Right to Refuse Medical Assistance in
Dying, Abortion, or Contraception. Bioethics
10.1111/bioe.12288.
Professor John Keown,
MA, DPhil, PhD, DCL
Kennedy Institute of Ethics
Georgetown University
E-mail: ijk2@georgetown.edu
108
Antimicrobial Resistance
Introduction
Antimicrobial Resistance (AMR) is a grow-
ing concern globally and a significant threat
to public health.It has been demonstrated to
be on a steady rise and new mechanisms of
resistance are emerging every day,exhausting
the antibiotic options currently available.
AMR has both health and economic im-
plications. The UK Review on AMR has
estimated that the costs of AMR will be
staggering – by 2050 the annual death toll
of AMR will surpass cancer, and the lost
global production will equal the equivalent
of the United Kingdom’s gross domestic
product (GDP) or 100 trillion USD [1].
Increasing evidence that the overuse and
misuse of antibiotics in food animal produc-
tion is contributing to this rise in resistance
has also emerged. In November 2015, re-
searchers in China discovered mcr-1, a gene
conferring plasmid mediated resistance to
colistin in pigs, which since has been found
in humans as well.
The root cause of rising resistance has many
facets and involves a multitude of stake-
holders from different sectors, however
today, an overwhelming proportion of the
worldwide consumption of antibiotics is
for animal use. This puts the veterinary and
agricultural sector use at the essence of the
fight against AMR. In May of 2015, the
World Health Assembly adopted the Glob-
al Action Plan on Antimicrobial Resistance,
which articulated five main objectives. Ob-
jective four more notably focuses on opti-
mizing the use of antibiotics in both human
and animal health [2]. At this stage of the
action plan implementation, it is critical for
all stakeholders to engage and commit to
combat the rampant AMR threat.
The Intersection of
Antimicrobial Resistance and
the “One Health” Concept
Infectious pathogens, whether by endemic
or epidemic trends, continue to produce sig-
nificant morbidity and mortality across com-
munities. The World Health Organization
(WHO) reported that infectious diseases rep-
resented 12 million deaths (23%) in 2000 and
9.5 million deaths (17%) in 2012,of all causes
of global mortality in humans [3].These esti-
mates may be underreported, however, since
they do not account for pathogens that cause
chronic diseases (e.g., rheumatic heart dis-
ease caused by Streptococcus) or other disease
complications (e.g., hepatocellular carcinoma
caused by chronic hepatitis B or C infec-
tion) [4]. As global mortality trends due to
infectious diseases have declined over the past
decade, public health leaders should quickly
identify economic, environmental, political
and social challenges encountered in disease
control and form multi-sectoral collabora-
tions to continue this downhill disease trend.
Since the 1990s, globalization has facilitated
the spread of infectious diseases, especially
through increased travel for humans,expand-
ed geographic boundaries for commerce and
trade for animal products and other goods,
and anthropogenic changes to the physi-
cal environment such as deforestation or air
and water pollution [5]. These new environ-
ments have facilitated the emergence and re-
emergence of infectious diseases which add
to the global health burden. These “emerg-
ing diseases” are novel pathogens or existing
pathogens that have increased in number or
expanded in geographic distribution within
the environment [6]. Zoonotic infections, or
those pathogens transmitted from animals
to humans, are estimated to represent up to
75% of these emerging diseases [7]. Zoonot-
ic disease transmission may include contact
with domestic or wild animals or exposure
to animal products, vectors or contaminated
environments.
In order to strengthen the global control and
prevention of emerging diseases, the “One
Health” approach should be implemented
into public health practice. Recognized since
the 1800s, yet more recently coined the term,
the“One Health”concept links human health,
animal health and the environment. Six pri-
mary factors have been described to drive the
spread of these emerging diseases: 1) human
population growth and mobility (e.g., chol-
era, influenza A virus); 2) food production
through agriculture and livestock farming
(e.g., Escherichia coli, Salmonella enterica);
One Health and Antimicrobial Resistance
Caline Mattar Ana Sofia Ore Steen K. Fagerberg Wunna TunReshma
Ramachandran
Elizabeth Wiley Helena J. Chapman
109
BACK TO CONTENTS
Antimicrobial Resistance
3)  wildlife trade by legal or illegal means
(e.g., influenza virus); 4) environmental fac-
tors such as land use changes and manmade
influences on loss of biodiversity (e.g., malar-
ia, leishmaniasis); 5) technological advance-
ments such as improved disease detection or
unintentional or intentional release of labo-
ratory agents (e.g., anthrax, brucellosis); and
8) poor leadership and infrastructure across
public and private sectors (cholera, tubercu-
losis) [8; 9]. Among these factors, the com-
mon element lies in the potential of increased
proximity to domestic or wild animals. First,
companion animals, primarily dogs and cats,
may enhance the human-animal emotional
bond, but remain a threat for various zoonot-
ic disease transmission, such as bartonellosis,
giardiasis and toxoplasmosis [10]. Second,
animal husbandry or caring for and manag-
ing livestock represents a significant source
of food security and economic sustainability
for livestock owners and families.Thus,public
health programs can effectively prepare and
educate their local communities about health
hazards if they understand this interplay be-
tween zoonotic disease transmission and un-
derlying cultural, economic and environmen-
tal influences related to animal contact.
AMR has been reported in emerging infec-
tious diseases, emphasizing this intimate
connection to the “One Health” concept
and human, animal and environmental
health [11]. More specifically, three specific
challenges should be addressed. First, food-
borne zoonoses are increasing in incidence
and becoming more resistant to antibiot-
ics [12]. Thus, food safety education and
proper hygiene when handling domestic or
livestock animals can inform communities
about the health risks of food-borne zoo-
noses. Second, specific driving factors that
influence the spread of emerging diseases
in target communities should be identi-
fied [13]. Public health practitioners can
then be prepared to act promptly and ap-
propriately to reduce disease transmission
or propagation to new geographic areas.
Third, low- and middle-income countries
may not have elaborate surveillance systems
to monitor food production or veterinary
health risks due to inadequate leadership,
political or economic conflict, or natural di-
sasters [14; 15]. Since complex epidemiol-
ogy describes pathogen transmission in the
human-animal interface, which challenges
the formal assessment of AMR [16], estab-
lishing the infrastructure of the surveillance
system should be a priority for the health
sector. As such, by using the “One Health”
approach, public health leaders can collabo-
rate across disciplines to reduce zoonotic
transmission and AMR, thereby improving
disease control and prevention strategies.
Antibiotics for non-
Therapeutic Use
When discussing AMR, another essential
point to mention would be Antibiotics for
non-therapeutic use, which is a practice pe-
culiar to the animal sector.
Non therapeutic indications for antibiotic
use in animal agriculture and aquaculture
involve administering antimicrobial drugs
to healthy animals for prophylaxis or growth
production. Hypothesized mechanisms in-
clude a more rapid growth of animals while
preventing disease. Studies have linked an-
tibiotic induced changes to changes in me-
tabolism, adiposity and higher fat mass [17].
In some countries gross weight of antibiot-
ics used in animals is higher than the gross
weight used in humans and the classes of
antibiotics used are mostly the same  [18].
There are several pathways for transmission
of antibiotic resistant bacteria from food
animal production to humans. These might
include transmission of resistant pathogens
from food animals to producers and proces-
sors, through contaminated food or animal
products, environmental releases from pro-
duction facilities,poor control of waste man-
agement and non-domesticated animals [19].
Clinical studies have confirmed that the use of
antibiotics in agricultural settings contributes
to the development and spread of resistant
bacteria. In 1940, antibiotic use to increase
the amount of meat produced in animals was
found to be effective.This constituted the first
step into widely using antibiotics as growth
promoters, despite some early studies like
Levy et al.[20] showing an increase in antibi-
otic resistance.This study tested a long course
of low-dose tetracycline in chickens; this led
to single drug resistance which rapidly devel-
oped into multidrug resistance that spread
beyond individual animals exposed and into
humans. A more recent study performed by
Price et al. [21] found evidence that Methi-
cillin-resistant Staphylococcus aureus (MRSA)
acquired tetracycline and methicillin resis-
tance in livestock. This has been confirmed
by another study [22] which found MRSA in
meat and poultry in the United States.
Many governments have taken actions into
this matter. One of the first countries to ad-
dress this issue was Denmark. By 1995 they
banned avoparcin, one of many antibiotics
used for growth promotion; this was the be-
ginning of a series of regulations which lead
to the European Union (EU) in 1998 banning
feeding of antibiotics to animals that are valu-
able to human health. Less than 10 years later
theEUbannedallantibioticsandrelateddrugs
to livestock for growth promotion purposes.
Denmark also created DANMAP in 1995,
their own system for monitoring antibiotic
resistance in farm animals with the objective
of following the outcomes of banning anti-
biotic drugs for growth promotion which
through VETSTAT, a monitoring system
which task was to gather and process records
of drug use in animal herds.They also creat-
ed the Yellow Card scheme which decreased
the total consumption of antibiotics in pigs
by implementing a monitoring system with
penalties and regular visits to producers.
When measuring its effect, antimicrobial
agent usage dropped and AMR for growth
promotion also decreased.These actions did
not have a negative effect in Danish swine
and poultry production.
110
Antimicrobial Resistance
Despite their efforts, the use of antibiotics
for therapeutic indications in animals and an
increase in meat imports makes resistance a
continuing problem [23].In 2003 a scientific
assessment by the Food and Agriculture Or-
ganization and the WHO determined that
the use of antibiotics in the agricultural set-
ting is the principal contributing factor to the
emergence and dissemination of AMR [24].
Many recommendations have been made
to incorporate surveillance in all countries
using antibiotics for non-therapeutic uses,
but only a limited number of countries have
complied. Monitoring in most of the EU
member states is performed by the Europe-
an Food Safety Authority (EFSA). Starting
in 2011, a combined report with animal and
human data is now being compiled.
All improvements in monitoring and regula-
tion lead up to the concept of integrated sur-
veillance of antimicrobial resistance in food-
borne bacteria.This covers testing of bacteria
from food animals, foods, environmental
sources and clinically ill humans and the
antibiotic resistance found during the proce-
dures that encompass this elements. WHO
has recommended the use of this integrated
surveillance in all countries to monitor and
control the spread of resistant bacteria in
animal products [18]. One of the biggest
challenges to perform and share this infor-
mation globally is the lack of harmonization
between reports in different countries.This is
one of the objectives of the WHO Advisory
Group on Integrated Surveillance of Anti-
microbial Resistance (WHO-AGISAR).
Their main objective being to minimize the
public health impact of AMR associated
with food producing animals.
The Current State of
the Danish Model
Even though the Danish Ministry of Agri-
culture continuously focuses on the preven-
tion of the development of AMR, several
scenarios are challenging the Danish posi-
tion. A major part of Danish export is based
on swine production, and the demand of ani-
mal export is increasing. Increased produc-
tion has led to a rise in the use of antibiotics,
especially tetracyclines, which holds a central
role in the treatment of animal infections in
Denmark. A consequence of rising demands
is an increased number of animals per area
in piggeries, and hence, a higher possibility
of animal-to-animal transmitted infections.
This has led to a general increase in the use of
broad-spectrum antibiotics, which started in
2009.Despite that,the total use of antibiotics
in 2014 was 86 tonnes which is five percent
lower than in 2013 when adjusted for the in-
creased export [25]. In the past five years, the
total use in swine production has been stable,
and there has been a small increase in the use
of antibiotics for pig finishers, but a signifi-
cant decrease in the use of systematic use of
cephalosporins for pigs in general. Based on
these data, it is fair to conclude that Danish
farmers are balancing the use of antibiotics
responsibly, but that the guidance of DAN-
MAP surveillance and regulations are critical
to secure a sustainable development.
The pressure on lowering use of antibiotics
has created an incentive to use zinc-based
agents, such as zinc oxide or zinc chloride.
These agents have been used increasingly
instead of antibiotics, but most recent stud-
ies indicate that the use of zinc possesses
a risk of developing MRSA strains in the
treated animals [26], and are at this point
being monitored carefully.
Another more direct challenge is the in-
creasing numbers of cases of MRSA and
ESBL bacterial strains in Danish pigger-
ies where DANMAP described increases
in MRSA in their 2011 report [27]. In the
following years, the same agency docu-
mented several new cases of both MRSA
and ESBL, and scientists documented the
rise of the multidrug resistant MRSA strain
ST398 [28] within the meat production fa-
cilities. Alongside this, new cases of animal-
human transmitted infections appeared
country wide, leading to an increasing
number of deaths in the years 2013-2015,
in particular due to MRSA ST398.
A series of screenings and quarantine regu-
lations for people living in close proximity
to animal production facilities was imple-
mented, and a mandatory screening for
farmers at the admission to hospitals was
initiated. From October 1, 2014, it became
mandatory for all Danish farmers to create
and implement an approved strategy for
prevention of transmissions approved by a
veterinarian, and among other initiatives it
became a requirement that only sick ani-
mals are to be treated with antibiotics [29].
The Danish Models has been proven to be
successful in terms of creating awareness
of the problem of AMR development, and
the initiative implemented over the past
20 years such as the Yellow Card, new re-
strictive legislation, and research and sur-
veillance have created a strong platform and
tradition to battle the emerging challenges.
Conclusion
It is evident today that the issue of AMR
cannot be restricted to the silo of human
or animal health. At this point, it is critical
for healthcare professionals, researchers and
policy makers to join efforts with the veteri-
nary and agriculture professionals, to gain a
better understanding of the “One Health”
approach, more specifically in the context of
AMR,which is an urgent threat to global and
public health. Stronger policies and innova-
tive research to address the use of antibiotics
and to explore new solutions to minimize
the development of resistance in the ani-
mal and agricultural sector are needed. The
World Medical Association and the World
Veterinary Medicine Association have initi-
ated this dialogue several years ago, and will
continue this academic exchange during the
second One Health Conference in Novem-
ber 2016. On the United Nations system
level, a much anticipated high-level AMR
meeting will occur in September 2016, with
111
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Antimicrobial Resistance
hope that decision makers will acknowledge
the importance of a multisectoral approach
to the issue at hand.
References
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15. Fisman DN, Laupland KB. The ‘One Health’
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16. Wegener HC. Antibiotic resistance – linking
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um AM (eds). DANMAP 2014 – Use of anti-
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2014/Danmap_2014.ashx (Accessed September
13, 2016).
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ance genes among livestock-associated methicil-
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Microbiol. 2016; 191:88–95.
27. Korsgaard H, Agersø Y, Hammerum AM,
Skjøt-Rasmussen L (eds). DANMAP 2011 –
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danmap_2011.ashx. (Accessed September 13,
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28. Agersø Y, Hasman H, Cavaco LM, Pedersen
K, Aarestrup FM. Study of methicillin resistant
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at slaughter and in imported retail meat reveals a
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29. New requirements for zoonotic infection pro-
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svinebes%C3%A6tninger-(MRSA).aspx. (Ac-
cessed September 10, 2016).
Caline Mattar M.D,
Washington University in
St Louis, St Louis, MO, USA
Ana Sofia Ore M.D,
Beth Israel Deaconess Medical
Center, Boston, MA, USA
Steen K. Fagerberg, M.D,
Aarhus University, Denmark
Wunna Tun MBBS,
University of Medicine 1,
Yangon, Myanmar
Reshma Ramachandran, M.D, M.P.P,
Johns Hopkins University,
Baltimore, MD, USA
Elizabeth Wiley, M.D, J.D, M.P.H,
Johns Hopkins University, 
Baltimore, MD, USA
Helena J. Chapman M.D, M.P.H,
University of Florida,
Gainesville, Florida, USA
E-mail: cmattar@wustl.edu
112
Medical Science AUSTRALIA
Everything changes but we live in a time
of quiet revolution, a time when medical
knowledge is exploding and instant com-
munication and interconnectivity are al-
tering our world. More than 1.8 million
peer review articles are now published ev-
ery year in over 28,000 scholarly journals
[1]. Sweeping changes are impacting the
practice of medicine and medical research,
and in turn impacting the world of Journal
publishing. Scientific journals have a long
and proud history since the first scientific
journal was published; the longest lived
Journal is the Philosophical Transactions
started by the Royal Society of London
in 1665 and there are now thousands of
medical journals with new ones added
every week. As a front line clinician and
active medical researcher, I rely on the
published literature to guide my practice,
update me on the latest developments and
hopefully inspire me. And I rely on the
Journals I publish in to disseminate the
research findings with the hope that the
results will influence and perhaps change
my field. But the world of research and
publishing as we know them is changing,
and here I will discuss some of the emerg-
ing outcomes.
More and more medical research is pro-
duced and published each year. As an expe-
rienced journal editor I know authors want
to publish in the most prestigious journal
possible. The reasons are obvious; publish-
ing in one of the best journals in the field is
more likely to be noticed, the paper may be
more likely to be read, and it adds greater
weight to a promotion application, to name
a few. In many parts of the world authors
base their decision to submit on the jour-
nals impact factor (a metric based on the
number of cited articles in the prior two
years divided by the number of published
citable articles in the journal); the higher
the impact factor, the more prestigious the
journal in the eyes of many, a fact editors
recognise and fret over annually. The New
England Journal of Medicine is top of the list
with currently the world’s highest impact
factor (59.558 in 2015). However, the im-
pact factor is obviously a flawed measure;
even in the New England Journal of Medi-
cine, only a minority of articles are highly
cited which drives up the impact factor
while many papers attract little attention.
Further, journal editors can manipulate
the metric (e.g. by publishing more or only
reviews which are statistically much more
likely to be cited than original research),
and citations do not equal impact in terms
of promoting a paradigm shift in thinking
or practice change.
When I began my first Co-Editor-in-
Chief role in 2003 at the American Jour-
nal of Gastroenterology (AJG), open access
journals were in their infancy, print was
still dominant, and advertising revenue
was still strong. In 2016, the Editor of
the Canadian Medical Association Journal
(CMAJ) was fired reportedly because the
impact factor of the Journal and submis-
sions were both falling [2]. Richard Smith,
the former editor of the British Medical
Journal (BMJ) has recently blogged most
if not all national Journals potentially face
failing too if they do not adapt, as submis-
sions fall because authors will only send
their best work to more prestigious Jour-
nals (blogs.bmj.com/bmj/2016/03/02). The
underlying business model of traditional
Journals is indeed under threat; there is in-
creasing competition from other Journals,
and falling advertising revenue as advertis-
ers flee from print (and Journals) to inter-
net rivals. Print is declining although older
readers still prefer it. Despite all of these
trends I expect the top Journals will sur-
vive (or be the last to disappear). Journal
rankings (like University rankings) matter
and for Journals despite all the acknowl-
edged limitations and flaws, the impact
factor remains the most widely accepted
measure authors consider and Editors live
and die by.
Not everyone can publish their work in one
of the top Journals. The new world of open
access Journals had the noble aim of de-
mocratising research, of trying to ensure all
sound research is published (even if negative
or relatively uninteresting) and made avail-
able for everyone, applying an author pays
model. A noble aim but flawed. By 2015,
over 10,000 journals were listed in the Di-
rectory of Open Access Journals. There are
now high ranking open access megajournals
such as PLoS Medicine which have shaken
the publishing world. But publishing high
volumes negatively affects the rankings
based on impact factor as for example the
journal PLoS One has found out; their
huge submission rates are now falling as
their impact factor, once quite high, steadily
declines. More and more open access Jour-
nals are opening; I now receive every single
Nicholas J. Talley
Global Development of Medical Science
and Publication Opportunities and
Challenges
113
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Medical ScienceAUSTRALIA
week multiple requests sometimes begging
me to submit to a new open access Journal.
Publishing in open access journals with du-
bious business models that may not exist to-
morrow in an era of intense Darwinian style
competition is a risk for emerging research-
ers. Predator journals have also been a seri-
ous contaminating influence; these are jour-
nals that charge a fee for publishing yet fail
to carry out any or adequate peer review or
careful editorial oversight, which is likely to
promote the publication of false or mislead-
ing data. I predict many of the open access
Journals will disappear and I fear it will take
decades to undo the damage of publishing
poor quality research.
The counter argument has been that jour-
nal peer review is inadequate anyway and
just openly publishing all available research
undertaken is a better model. I know the
research into journal peer review has not
provided convincing evidence flaws are all
or even mostly detected although this needs
looking at across a range of journals [3, 4].
Many published articles with positive find-
ings are later shown to be incorrect [5].
However, I am still convinced strong review
and editorial processes minimise obvious
mistakes and improve articles, and I am
committed to research into strengthening
the model.
No one can now read everything published
in their field today even if it is a very highly
specialized one; how generalists can be ex-
pected to maintain very broad expertise is
becoming more and more troublesome even
though the generalist represents a key player
in the delivery of best medical care. In 2015
I was appointed to be the Editor-in-Chief
of a major general medical Journal glob-
ally, Australia’s leading Journal, the Medical
Journal of Australia (MJA), a Journal that
publishes 22 issuers per year in print and
on-line. While already an excellent journal
admired by the community and government,
the challenge I face is how to maximise the
relevance of the Journal, better educate
clinicians, disseminate and showcase clini-
cally impactful research, accelerate change
in practice and positively influence health
policy. I relish the challenge. In my Jour-
nal now, for example, all original research
is published in full and is available for free
to all with no author charges, a challenge
to the open access user pays model. This is
consistent with the European Competitive
Council recommendation that all publicly
funded research be made freely available by
2020. We also conduct blinded peer review
and routine statistical review as part of our
quality processes.
One of my goals is to measure the impact
of the Medical Journal of Australia in terms
of changing practice or policy. It is generally
stated it takes 17 years to translate research
into practice but this is highly variable and
excellent data are unavailable, plus our in-
terest is post publication impact [6]. For ex-
ample, most guidelines are simply ignored
in practice in Australia and everywhere [7].
Rather than focussing on an artificial metric
like the impact factor, instead our interest
should be in knowing is our Journal pro-
moting translation (because funders, gov-
ernments and the public do now want to
know about this today). In my view transla-
tion should be the true Journal value added
metric.
In conclusion, I would suggest that science
is permanently about self-correction and
testing the evidence, and Journal Editors
play a key gatekeeper role in the process.
Any study can be wrong despite the best
possible peer review, but it is the accumula-
tion and synthesis of new knowledge that
we as editors proudly contribute to dissemi-
nating. General medical journals like the
Medical Journal of Australia play a special
role in presenting and explaining research,
making research and data accessible, edu-
cating, translating, engaging the public and
shaping health policy. Finally, I would argue
we are all still failing to help translate new
medical knowledge quickly enough, and it
is here as a profession we can and must aim
to do better.
References
1. Ware M, Mabe M. The STM report. An over-
view of scientific and scholarly journal publish-
ing. 2012; 3rd ed.
2. Kassirer JP. Editorial independence: painful les-
sons. Lancet 2016; 387(10026): 1358-9.
3. Jefferson T, Alderson P, Wager E, Davidoff F.
Effects of editorial peer review: a systematic re-
view. JAMA 2002; 287(21):2784-6.
4. Smith R. Peer review: a flawed process at the
heart of science and journals.J R Soc Med.2006;
99(4):178-82.
5. Ioannidis JP.Why most published research find-
ings are false. PLoS Med. 2005; 2(8):e124.
6. Morris ZS, Wooding S, Grant J. The answer is
17 years, what is the question: understanding
time lags in translational research. J R Soc Med.
2011;104(12): 510-20.
7. NHMRC. NHMRC Annual Report on Aus-
tralian Clinical Practice Guidelines. 2014.
Nicholas J. Talley, MD, PhD
Editor-in-Chief,
Medical Journal of Australia
Pro Vice-Chancellor and Laureate Professor,
University of Newcastle, Australia
E-mail: Nicholas.talley@newcastle.edu.au
114
Regional News
During the last seven years the South-
east European Medical Forum (SEEMF)
holds large scientific medical multidisci-
plinary meetings every year. Georgia hold
the 7th International Medical Congress of
the SEEMF from the 7-10 of September.
The Congress was organized jointly with
the Georgian Medical Association and the
University of Tbilisi and was attended by
numerous medical professionals from over
20 countries: Georgia, Bulgaria, Belarus,
Macedonia, Slovenia, Kazakhstan, Serbia,
Latvia, Spain, Greece, etc.
Distinguished specialists and experts, such
as Acad. Vladimir Ovcharov, Bulgaria, Prof.
Ognyan Hadjiiski,Deputy Chairman of the
Bulgarian Medical Association, Prof. Pavel
Poredos, President of the Slovenian Medi-
cal Association, Prof. Giya Lobzhanidze,
President of the Georgian Medical Associ-
ation, Dr. Goran Dimitrov, President of the
Macedonian Medical Association, Assoc.
Prof. Gligor Tofoski of the Medical Faculty
of the University of Skopje,Macedonia,and
over a hundred of medical specialists pre-
sented reports on the latest achievements
and innovations and shared experience and
views in different medical fields such as
surgery, oncology, neurology, pediatrics and
endocrinology among others. The scientific
program of the VII Congress of SEEMF
was dominated by lectures, reports and
presentations, striving to outline the nov-
elties, to discuss achievements, to track the
prospects of application in practice of the
conclusions of fundamental discoveries and
clinical trials. Impressive was the presenta-
tion of Georgian researchers from medical
schools in Tbilisi, Batumi, medical centers
and research institutes.
During the event a meeting of the SEEMF
Board was held. The Board voted on the
traditional award nominations in the field
of medicine.Prof.Giya Lobzhanidze,Presi-
dent of the Georgian Medical Association,
was honored with the award Outstanding
Physician of Southeast Europe. The Presi-
dent of the Latvian Medical Association
Dr. Peteris Apinis and Assoc. Prof. Tatiana
Tserekhovich, Belarus, were awarded for
their contribution to the development of
public health, Prof. Alexander Tsiskaradze,
Georgia, and Prof. Daniela Miladinova,
Macedonia, were awarded for outstanding
contribution in the field of medical science,
the Medical Faculty of the Ss Cyril and
Methodius University in Skopje, Macedo-
nia, and the State University of Tbilisi were
awarded for contribution to the develop-
ment of medical science and SEEMF. Two
new members were elected to the Board of
the Organization – Acad. Vladimir Ovcha-
rov and Assoc. Prof. Todor Cherkezov. The
Board of SEEMF approved an open letter
to the Albanian Order of Physicians declar-
ing that SEEMF firmly supports the pro-
fessional independence and self-governance
of the medical profession and considers any
kind of administrative interference in the
work of professional organizations of phy-
sicians unacceptable and inappropriate and
that governmental bodies, including Health
Ministries,should respect the independence
of such organizations and develop partner-
ship with them.
The VII Congress of SEEMF in Batumi
proved the strength and meaningfulness
of cooperation between doctors and medi-
cal scientists from different countries with
different specialties for the achievement
of common goals – better health systems,
progress in medical science, faster imple-
mentation of medical achievements in
practice. Once again the SEEMF Congress
reaffirmed its unique role and proved that
such an international organization can sig-
nificantly contribute to the health and wel-
fare of millions of people in the region.
Today in the process of global changes in
state structures and policies, more than ever
SEEMF proves its constructive role and
influence in the medical community – to
bring together physicians and scientists and
commit to the mission of being a peace-
maker of the future. This is an achievement
that demonstrate that the efforts of Dr. An-
drey Kehayov and the SEEMF Board for
11 years now lead to success,to good results.
With the mission of peacekeepers
The VII Congress of SEEMF is further evi-
dence of the progress of our organization,of
proven benefits of the unification of medi-
cal professionals from different countries
united by core values of the profession. Be-
cause only the medical profession uniquely
brings together science, law, ethics. The of-
ficial opening, the respect witnessed by the
authorities in the autonomous Adjara with
the main city of Batumi, the participation
of representatives from over 20 countries –
these are real facts which measure the au-
thority of SEEMF.
Once again the variety and richness of the
scientific program determine the appear-
ance of the event. The massive presence of
Southeast European Medical Forum
Andrey Kehayov
115
BACK TO CONTENTS
Regional News
scientific speakers from Georgia, young
scientists, post-graduates turned the Con-
gress into a bright event for the country.
The presence of outstanding speakers from
other countries and the latest developments
in the field of socially significant diseases
represent impetus to improve practice. It is
not by chance that the Congress has been
accredited by EACCME with 15 credits.
I am very glad that young physicians and
researchers attended this year. Yet we intend
to work hard in this direction. Even at the
meeting of the SEEMF Board we discussed
the idea each year to organize a seminar or
a conference for young doctors in Greece at
Kos – the island of Hippocrates – and there is
hardly a better place to express support for fu-
ture representatives of the medical profession.
During the traditional board meeting im-
portant decisions were taken about the
special SEEMF awards. The new board
members – Acad. Vl. Ovcharov and Assoc.
Prof. T. Cherkezov from Bulgaria  – were
unanimously welcomed.The award voting is
extremely enjoyable because the number of
nominees from different organizations and
countries is growing and scientific reports
are becoming more profound. And partici-
pants in the general discussion on the cur-
rent problems in health systems express very
wise and bold ideas. Part of the mission of
SEEMF is to make these ideas available to
governments and health politicians,to insist
and work for their implementation in the
member-countries of our organization.
In the complex global environment in
terms of the ever-changing governmental
structures and policies in SEEMF member
countries, our organization proves its con-
structive role. SEEMF doctors and scien-
tists confirm daily their mission of peace-
keepers in the region and the world.
I dream of a better world!
Dr. Andrey Kehayov, SEEMF
President, Bulgaria
Factor on the European map
Now we can say with pleasure that our
Southeast European Medical Forum is
among the fastest growing organizations
and is a factor in the scientific medical
community in Europe because it is a multi-
disciplinary structure that deals with vari-
ous fields of medicine, and also discusses
organizational aspects of health systems in
different countries, seeking ever better solu-
tions for millions of patients. The Seventh
Congress of our forum can be described
as highly successful since it confirmed its
specificity by combining science, profes-
sionalism and friendship in a joint effort to
better health. It is important to emphasize
that SEEMF is continuously evolving  –
I did not even expect that so many coun-
tries will join in for achieving our goals and
mission. I think it is time to promote new
activities to organize seminars, workshops,
conferences on specific topics.
The rapid development of our forum is a
prerequisite to establish more intense con-
nections with European scientific and med-
ical societies and organizations to show that
we live actively and physicians of Southeast
Europe are working hard to get evaluation
and support from European centers and
networks.
Prof. Paul Poredos,
Vice President of SEEMF,
Slovenia
Times of Hardship
We are all satisfied because we put a lot of
effort in each subsequent year to watch our
forum grow and develop, including more
countries, not only from Southeast Europe
but also from Asia, Central Europe, the
Nordic countries. So SEEMF provides a
unique opportunity to share new and best
medical knowledge. The congresses of the
organization fulfill the mission to contrib-
ute to the development of medical science
and the organization of health systems, to
influence public health of millions of people
in a vast area of the world. I would like to
remind that SEEMF made important pro-
posals to the World Medical Association –
related to climate change, to reduction of
harmful emissions in the Mediterranean
region, to closing of nuclear reactors.
Today we face a new challenge – the crisis
of migrants and on the one hand its impact
on health activities, health budgets of re-
ceiving countries, and on the other hand –
the existing centers, changes in the struc-
ture and composition of the settlements
represent a danger and challenge to public
health throughout the region. This global
change poses new conditions and requires
unconventional approaches by doctors, by
health politicians, by the governments of all
countries.
I am glad that what we have achieved today
is far beyond the wildest expectations of the
time when we created SEEMF.
Prof. Stylianos Antipas, Secretary
General of SEEMF, Greece
Interviews by Dr. Andrey
Kehayev, September 2016
Prof. Giya LobzhanidzePresident
of the Association of Physicians
in Georgia, professor at Tbilisi
State University, co-chairman of
the Organizing Committee of
the VII Congress of SEEMF
– Dear Professor, please provide some in-
formation about the association of doctors in
Georgia.
– Our association was founded in 1989
and is the first organization of this type.
23  thousand doctors work in Georgia, of
which 8 thousand are our members  – we
are the largest organization in the country.
We have regional structures. Now we are in
116
Regional News
Adjara, where our organization is good and
strong.
The objectives of the Association are: as-
sistance to doctors, post-graduate educa-
tion,work with patients,social protection of
doctors. We help our members to improve
their skills abroad, assist post- and under-
graduate students. We regularly organize
scientific conferences and publish a journal.
– These are scientific and educational activities.
And do you participate in making the health-
care policy of Georgia?
– We work as consultants, as experts. In our
country we have the opportunity to interact
with the government and parliament repre-
sentatives.There are parliamentary commit-
tees on health and social security, we offer
specific amendments, bills.
– What is your assessment of the state of health
care in Georgia today?
– There are some good changes now in
Georgian health care. Indeed, a few years
ago all hospitals were sold – 99% of them
are now in private hands, and only 3-4
hospitals remained state-owned. Therefore
there is a need for the State University to
build a new hospital.Today the Ministry of
Health faces difficulties because little has
remained under their control as everything
has been sold.
Of course, in private hands hospitals thrive.
But they have no interest in education and
training; they do not accept undergraduate
or graduate students for training. So the
goal is to create university clinics – district,
municipal,to build hospitals where the poor
can be treated. I think that after the Oc-
tober elections it will be decided to create
such public hospitals in large cities.
– Is there health insurance in Georgia?
– We have private companies. Four years
ago the government adopted a program of
universal health care to provide for all peo-
ple who have no private insurance.There are
changes in store, but the government has
not yet decided what is to be done.
– How would you define the role of SEEMF
Congress in Batumi for the development of
Georgian Medical Association?
– This SEEMF Congress reached in my
opinion two goals. First, we heard a lot of
good lecturers from abroad; it had an ex-
tremely strong scientific program with
renowned lecturers. The Congress is an
incredible platform for exchange of expe-
rience. We showed all participants the sci-
entific potential of Georgia; showed it to
Europe and the world.
Moreover, there was the young doctors
section at the Congress and their meetings
were successful, interesting discussions
were held. We will publish the most inter-
esting presentations in the international
Georgian Medical Journal, which becomes
the official journal of SEEMF. I must un-
derline that almost no international orga-
nization of this type has got its own jour-
nal.
– What impressed you personally apart from
Professor Padilla from Seville?
– A very serious and impressive was the
report of Academician Vl. Ovcharov – im-
munology is the future, which he outlined.
In fact Acad. Ovcharov spoke about tomor-
row’s medicine.
Extremely serious was the report of Prof.
Pavel Poredos from Slovenia  – a practical
dimension to the program for prevention.
I think in each section there were very good
presenters.
– What are your personal dreams?
– I’m a surgeon. As I said, we are build-
ing a university hospital and I expect it to
open in two years time – it is located in the
center of Tbilisi.The hospital will be a uni-
versity hospital and of the Association, it is
a joint project of achieving European stan-
dards, combining treatment, teaching and
research. My dream is that undergraduate
and graduate students work there. My oth-
er dream is to see that my students com-
plete their studies successfully and become
medical doctors. And the greatest dream –
to see that the world becomes a better place
to live.
Moreover, I have three granddaughters  –
I dream that they will grow up healthy and
happy.
Assoc. Prof. Goran Dimitrov
Chairman of the Macedonian
Medical Association:
We safeguard the honor of doctors
– What is your assessment of the past Congress?
– The SEEMF Congress held in Batumi,
Georgia, was an impressive meeting at
which scientific ideas were shared, and
also friendships developed. Representa-
tives of SEEMF member associations from
17 countries were present. The hosts from
the Georgian Medical Association provided
a wonderful and diverse scientific and cul-
tural program.
– In general, how do you assess the scientific
events organized by SEEMF?
– Each subsequent Congress is becoming
better and better. I hope that the next one
will be rich in scientific activities and new
friendships. This year a large number of
participants presented for discussion many
novelties, especially in the field of surgery.
For example, I listened with interest to the
report of Prof. Padilla of the University of
Seville on liver transplants. The number of
Bulgarian participants was also big. The
117
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WMA History
topic on a heart transplant impressed me
particularly.
– What do you think should be the future of
such a specific organization as SEEMF?
– I believe that in the future SEEMF will
expand even more, attracting more mem-
bers from Eastern and Southern Europe to
share their problems and successes in medi-
cine.
– Tell us please about the Macedonian Medical
Association.
– Last year, the Macedonian Medical As-
sociation celebrated its 70th anniversary.
Currently 5,500 doctors are our members.
When the Association was established it
included also dentists and pharmacists, but
today they are already in separate structures,
associations. The Association brings to-
gether 73 associations of different medical
specialties that annually organize between
120 and 170 scientific events – congresses,
symposia, conferences, many of which are
international.
The first and main task of the Association
is to retain the honor and reputation of
doctors in Macedonia. We daily monitor
everything that is related to the health and
status of doctors in the country.We manage
to keep the authority of doctors.We react in
all cases in which the life of our doctors is
endangered, we support them before insti-
tutions. I would add that a Medical Cham-
ber operates in our country, which deals
with legal aspects of the profession and the
trade unions fight for better pay and better
working conditions.
– What should be the role of the Macedonian
Medical Association after 10 years?
– Such a union must continue in the future
to protect the reputation and honor of doc-
tors and take care of their education, con-
tinuing medical education and welfare.
E-mail: bulgmed@gmail.com
The history and memory of the professional
reorganization of medicine after WWII re-
mains understudied today and we still know
little about detailed events and individuals ac-
tors including the early history of the WMA.
This contribution intends to present the life
and work of the French physician Paul Cibrie
(1881–1965) who played an active role in the
foundation of the WMA. This summary ac-
count is based on my MD thesis investigat-
ing the life and work of Paul Cibrie, poorly
studied by historians and the medical com-
munity [1]. Cibrie’s work was of prime im-
portance first for reforming French medicine
during the interwar period and second for the
formulation and promotion of professional
medical ethics by the WMA after WWII.
Paul Cibrie was born in 1881 in Dordogne.
He studied medicine in Toulouse and com-
pleted his medical training in Paris. By the
age of 30 he started to work for the Alliance
of the French Medical Unions (USMF:
Union des Syndicats Médicaux Français)
and continued to do so with its successor,
the French Medical Trade Union Confed-
eration (CSMF: Confédération des Syndi-
cats Médicaux Français). He participated
in essential debates about the creation of a
public healthcare system in France in the
1920s and 1930s. In this context Paul Cib-
rie drafted and promoted a Medical Char-
ter that laid the foundations for medical
practice in France during the rest of the 20th
century based on the following principles:
patient’s freedom to choose their physi-
cian, professional confidentiality, liberty to
set fees and direct payment by the patient
without intervention of a third party for fee
setting and payment, therapeutic liberty for
the physician and finally control over the
profession exclusively done by the profes-
sion itself.
In 1928, Paul Cibrie was designated sec-
retary-general of the CSMF and editor-
in-chief of the physicians association and
labour union journal. His engagement for
a social medicine went along with a stout
defense of the professional and economic
interests of French physicians. In order
to keep control over professional affairs
among members of the profession, he took
part in the creation of the French Medi-
cal Council/College (Ordre des Médecins)
under the French Vichy regime and there-
by became entangled and compromised
himself expressing controversial opinions
supporting xenophobic and anti-Semitic
ideas common within the French medical
community of the time.
Paul Cibrie: Defending the Medical
Profession in the Age of Internationalization
Paul Cibrie
FRANCE
118
WMA History
Fabrice Noyer
Immediately after WWII, the interna-
tional medical community reacted strongly
to the shocking revelations about medical
war crimes and Nazis atrocities, physi-
cians from several allied countries joined
to discuss the need of professional and
international medical relations and pro-
ceeded with the creation of an Organiz-
ing Committee for what would become
the WMA. Paul Cibrie represented France
at these meetings. He pledged for the re-
establishment of the Professional Interna-
tional Association of Physicians (APIM:
Association Professionnelle Internationale
des Médecins) founded in July 1926 under
French leadership. French preeminence in
international medical decisions supported
by the country’s role in APIM was chal-
lenged by the rising English and Ameri-
can influence in international affairs after
WWII. Debates ended with the official
creation of the WMA in September 1947
and Paul Cibrie became one of the two
French delegates a member of the WMA
Council. The initially declared main objec-
tive of the WMA was: to promote closer ties
among the national medical and among the
doctors of the world […] to assist all people of
the world to attain the highest possible level
of health. In concert with the British phy-
sician Charles Hill, Paul Cibrie drafted
the constitution of the WMA, which was
ratified at the First General Assembly in
September 1947. Continuously Paul Cib-
rie sought to promote French interest and
perceptions in the WMA’s positioning and
attempted to resist a medical “Marshall
plan” for the WMA. Nevertheless, WMA
main offices were shared between Paris and
London and finally left these two cities for
New-York in 1947.
Paul Cibrie contributed extensively to many
committees of the WMA. First, he was in
charge of the delicate question of Nazis
medical war crimes. Acknowledging that
the Hippocratic Oath had been abandoned
by medical education and its institutions,the
members of the WMA War Crimes Com-
mittee suggested a rewriting of the Hippo-
cratic Oath and proposed to make pledg-
ing it compulsory before getting a medical
degree. WMA member countries agreed to
adopt the revised version of the oath, which
became known under the name of Geneva
Declaration. Then, the committee obliged
the German Medical Association to pres-
ent an official statement and apology and a
public declaration about crimes committed
by Nazis doctors since 1933.
Second, as president of the Ethics Com-
mittee of WMA, Paul Cibrie was a leading
force in the formulation of the Interna-
tional Code of Medical Ethics stipulating
the duties of physicians in general, their
duties to patients and colleagues. Along
with the Geneva Declaration, this Code
of Ethics was the basis and became the
introduction of the Helsinki Declaration,
a major achievement of the WMA, voted
in 1964, and establishing ethical principles
for medical research involving human sub-
jects.
Third, Paul Cibrie brought his prewar ex-
perience with state-run social and health
insurance to the WMA Committee on
Social Security Systems. After the reorga-
nization of the French, the Vichy regime
initiated, Social Security System in 1945,
his engagement in the WMA committee
gave Paul Cibrie the opportunity to con-
tinue to battle for a defense and promotion
of the medical profession interests in face
of governmental organizations and private
healthcare providers and organisms at an
international level. In a sense he continued
within the WMA his engagement for his
Medical Charter elaborated in the interwar
period in the French context.
Paul Cibrie left the WMA in 1957 and
continued his activities in the CSMF’s
Council as honorary president until one
month before his passing away on 7 March
1965. Throughout his career, he displayed a
complex and at times ambiguous position-
ing that may be characterized possibly as a
“reactionary modernism”: authoritarian and
receptive, loyal and compromising, coura-
geous and opportunistic. The height of his
paradoxical personality probably is that at
the same time he was a driving force and
main author of the International Code of
Medical Ethics and a personal friend of
Pierre Laval, a notorious anti-Semitic and
influential member of the Vichy govern-
ment, whom Paul Cibrie provided with a
cyanide capsule while in prosecution cus-
tody offering Laval the possibility of suicide
in order to avoid his outstanding execution
in October 1945, an attempt that neverthe-
less failed.
Despite his complex and compromising
personality Paul Cibrie has to be considered
as one of the building figures of the WMA.
A tenacious member of the medical pro-
fession, he defended throughout his whole
life the honor and interests of the medical
profession from his engagement in French
medical professional unions and promoted
professional independence at an interna-
tional level in the WMA. Despising party
politics and the public sphere, Paul Cibrie
never campaigned for a party, but he has
oriented and labored professional politics
of the medical profession in a lasting and
highly influential way in the age of post-
WWII reorganization and internationaliza-
FRANCE
119
BACK TO CONTENTS
Climate Change
tion.His work at the WMA was pathbreak-
ing and influential for the way medicine has
been practiced on a daily basis eversince and
on a global scale by rendering the revised
Hippocratic Oath mandatory to obtain a
medical degree, and by preparing the Inter-
national Code of Medical Ethics and the
Helsinki Declaration creating ethical rules
for research with human subjects.
References
1. Noyer, Fabrice. Du syndicalisme médical de
l’entre-deux guerres à l’Association Médicale
Mondiale: vie et œuvre du docteur Paul Cibrie
(1881–1965).Thèse de médecine,Faculté de mé-
decine de Strasbourg, 22 septembre 2016.
Fabrice Noyer, MD
General practitioner, graduate of the
University of Strasbourg, France
E-mail: fa.noyer@laposte.net
In November 2016, the WMA will attend
the 22nd
Conference of the Parties to the
United Nations Framework Convention on
Climate Change (COP22).
At this conference, the delegation will de-
fend the New Delhi Declaration and other
WMA policies which have to deal with cli-
mate change and environmental protection.
Following the very recent adoption of the
Paris Agreement and its swift ratification
by 81 parties which happened much sooner
than previously expected,the agreement will
come into force on 4 November 2016 This
means that the first meeting of the Parties
to the Paris Agreement will take place dur-
ing this upcoming COP22 in Marrakech,
Morocco, something unexpected. There is
lot of work ahead to implement the Paris
Agreement through concrete and effective
climate actions that will eventually decrease
and perhaps prevent the serious health im-
pacts of climate change.
Indeed, many elements of how the world
will address climate change still remain un-
certain:
• despite having pledged 100 billion dollars
to mitigation and adaptation, the coun-
tries of the world have not yet individu-
ally committed enough resources to meet
their common pledge;
• despite having set an ambitious objective
of reaching a maximal increase of 2 de-
grees Celsius, and even striving to limit
temperature rise to 1.5 degrees, the sum
of all contributions only reach 2.7 degrees
even with the most optimistic previsions
which assume that all conditional pledges
are respected;
• while the COP21 surprisingly recognized
loss and damage alongside mitigation
and adaptation within the Paris Agree-
ment, progress on defining how it will be
addressed by the Warsaw International
Mechanism has been slow, and many
crucial pieces including financing and
non-economic loss and damage (which
includes health and loss of life) are still
unclear;
• health remains central to climate change
adaptation discussions while also having
an important place in mitigation action
especially in the pre-2020 agenda defined
with the adoption of the Paris Agree-
ment; how those commitments will be
implemented still remains to be seen.
This year the WMA will be represented
at COP22 by a delegation of 8 individuals
from a wide range of National Member or-
ganisations.
You may find their biographies below.
Week 1
Lujain Aloqdmani
Lujain Alqodmani is the International Of-
ficer and the Chair of Environment Com-
mittee of Kuwait Medical Association. She
is currently also the National Health NGO
representative for climate change at Kuwait
Environment Public Authority. Lujain is
currently an Emergency Physician at Amiri
Yassen Tcholakov
Introduction to work at COP22
Lujain Aloqdmani
120
Climate Change
Hospital in Kuwait. She did an internship
with Climate Change Unit at the Depart-
ment of Public Health and Environment
at the WHO HQ in Geneva and worked
greatly in the past years in climate change
health policy in past UNFCCC meetings
including COP18 and COP21.
Sofia Lindegren
Sofia Lindegren
is a Medical Doc-
tor at Karolinska
University hospital.
She is part of Swe-
den’s Medical As-
sociations working
group for Climate
and Health where
she has been part of
creating their climate policy as well as been
lecturing for the public and healthcare pro-
fessionals about health effects of climate
changes. She is a board member of Swedish
Doctors for the Environment and Swedish
Younger Medical Association and will start
a residency in Environmental and Occupa-
tional Health.
Mardelangel Zapata Ponze de Leon
Mardelangel Zapata
Ponze de Leon has
finished her Medi-
cal Surgeon degree
at the Catolica de
Santa María Univer-
sity in Peru. She now
works at the San
Juan de Dios Home
Clinic as medical
and surgical assistant. She is also an associ-
ate researcher of the Cardiological Institute
Research Center PREVENCION.
She works actively within the Peruvian
Medical Association, at the moment she is
President of the Junior Doctors Committee
in her regional council. She is also an as-
sociate member of the World Medical As-
sociation, and Communications Officer of
the Junior Doctors Network.
Diogo Correia Martins
Diogo Correia
Martins is a Pub-
lic Health medical
resident in Portu-
gal, currently un-
dertaking a Masters
(MSc) degree in
Public Health at the
London School of
Hygiene & Tropi-
cal Medicine (LSHTM). Along with his
undergraduate and postgraduate studies, he
has gathered extensive experience in work-
ing with student organisations in a leader-
ship capacity, on national and international
levels, as well as interacting with the UN
system (WHO, UNESCO, UNFCCC,
among others). Particular areas of interests
include global health and sustainable de-
velopment, with a special focus on health
co-benefits resulting from climate change
mitigation and adaptation.
Week 2
Yassen Tcholakov
Yassen Tcholakov is a Public Health and
Preventative Medicine resident at McGill
University in Canada. He is the Socio-
Medical Affairs Officer of the Junior Doc-
tors’ Network of the World Medical Asso-
ciation. Yassen has extensive experience in
climate change: he has worked at the WHO
Department of Public Health and Environ-
ment, his master’s thesis was on the topic
of climate change policy-making and he has
contributed to NGO representation to the
UN on climate change and sustainable de-
velopment including the proceedings which
led to the drafting of the Paris Agreement.
Nadim Nimeh
Nadim Nimeh is a
medical oncologist
hematologist. He
has been in practice
for many years and
he is involved in pa-
tient care and clini-
cal trials. He has a
special interest in
the effects of climate
change on health, particularly as it relates to
diseases of the blood and cancer. Dr. Nimeh
is a physician who has a keen interest in
global health issues,he is of the opinion that
doctors need to know more on this subject,
not only because it affects us individually,
but because it affects our communities, our
children and our very existence. We need to
know enough details to impact the behavior
of all who we faithfully and diligently serve.
Gbujie Daniel Chidubem
Gbujie Daniel
Chidubem is an
Associate Member
of World Medical
Association from
Africa; he is practic-
ing as a general Oral
surgeon in Nigeria.
He is the Publication
Director of the Junior
Doctors’ Network
of the World Medical Association and also
the Regional Executive Director/ Coordina-
tor of Junior Doctors’ of Africa. He has de-
veloped a youth based program in an NGO
in which he is the chief medical volunteer,
this program communicates and collaborates
with rural residents on climate change giv-
ing an African perspective and supporting
the WMA policy on climate change. Gbujie
believes that mankind has a moral obligation
to protect the earth and help ensure that ev-
ery individual shares the benefits of a better
environment and a healthy climate.
Mardelangel Zapata
Ponze de Leon
Diogo Correia
Martins
Nadim Nimeh
Gbujie Daniel
Chidubem
Sofia Lindegren
Climate Change
Mukti Ram Shrestha
Mukti Ram Shrestha
is a public health and
curative medicine
expert at Tribhuvan
University Institute
of Medicine from
where he received
most of his distin-
guished medical de-
grees in the field of
medical education through his dedication,
devotion and loyalty to the cause of human-
ity. At present, he is the elected president of
Nepal Medical Association. He has worked
15 years as a public health officer in differ-
ent parts of Nepal under the Ministry of
Health. Dr. Shrestha served as the chairman
of Greenery Nepal, a non-governmental or-
ganization.This organization worked mainly
in the field of climate change and biodiver-
sity sector. He has completed the Master’s
Degree in Hospital Management and post
graduate in obstetrics and gynaecology. His
untiring,selfless effort in medical services in-
cluding reproductive health and safe moth-
erhood, public health, and clinical medicine
in remote districts of Nepal is an inspiration
and example for the whole medical fraternity.
Yassen Tcholakov, MD MIH,
McGill University,Canada;
E-mail: yassen.tcholakov@mail.mcgill.ca
Lujain Aloqdmani, International Officer
and the Chair of Environment Committee
of Kuwait Medical Association
E-mail: alqodmanil@kma.org.kw
Mukti Ram Shrestha
A great loss was felt by the public health community when physi-
cian and epidemiologist D.A. Henderson, MD, MPH, who led
the global smallpox eradication program, died on August 19th
at the age of 87 of complications of a hip fracture in Baltimore,
Maryland, USA.
Smallpox a painful and often fatal disease killed over 300 million
people in the 20th century alone. During a 10 year World Health
Organization (WHO) campaign, Dr. Henderson led a historic
global public health effort to officially eradicate smallpox, with
the last naturally acquired case occurring in 1977. The success of
the smallpox eradication program led to the Expanded Program
on Immunization (EPI), which has helped drastically to reduce
many of the world’s preventable childhood diseases through im-
munization.
Donald Ainslie Henderson, known as D.A. was born in 1928 in
Lakewood,Ohio.He graduated from Oberlin College in 1950 and
received his MD from the University of Rochester in 1954.He was
a resident physician at the Mary Imogene Bassett Hospital in Coo-
perstown, New York, and later was a Public Health Service Officer
in the Epidemic Intelligence Services (EIS) of the Communicable
Disease Center (now the Centers for Disease Control and Preven-
tion, CDC). He earned a Masters in Public Health in 1960 from
the Johns Hopkins School of Hygiene and Public Health (now the
Johns Hopkins Bloomberg School of Public Health).
In the 1950s and 1960s, Dr. Henderson was at the CDC, where he
served as the chief of the EIS before being asked to head the WHO
global smallpox eradication campaign in 1966. After the successful
eradication of small-
pox he became the
Dean of the Johns
Hopkins School of
Public Health, then
following the 2001
United States an-
thrax attacks, an ad-
visor and director of
the Office of Public
Health Emergency
Preparedness in
Washington, D.C.
In 1998 he founded
the Johns Hopkins
Center for Civilian
Biodefense Strate-
gies, which is now
the Center of Biosecurity, University of Pittsburg Medical Center
where he was the distinguished scholar.
As an expert on bioterrorism,Dr.Henderson headed the scientific
program at the World Medical Association General Assembly in
Washington, DC, in 2002, speaking about the past and future
realities of bioterrorism, and about the dangers of smallpox as a
bioweapon. During that General Assembly, the WMA adopted
the Declaration of Washington on Biological Weapons.
Dr. Henderson was a firm and vocal advocate that the World
Health Assembly destroy the remaining smallpox virus stockpiles
remaining in the United States and Russian Federation to reduce
the risks associated with bioterrorism.Dr.Henderson served as an
expert advisor to the Junior Doctors Network in a proposed policy
on the ‘destruction of the smallpox virus,’which will be presented
at the WMA General Assembly in Taiwan in October.
Obituary
D. A. Henderson, MD, MPH
September 7, 1928 – August 19, 2016
IV