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No. 3, September 2008
Editor in Chief
Dr. Pēteris Apinis
Latvian Medical Association
Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@nma.lv
editorin-chief@wma.net
Co-Editor
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suﬀolk IP143QT, UK
Co-Editor
Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte-Verlag
Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor Velta Pozņaka
wmj-editor@wma.net
Journal design and
cover design by Jānis Pavlovskis
Cover painting : impressions on a wall
in northern Somalia, dated back to over
3000 years. A cover picture is selected as a
moral support of WMA for Somalian people
and physicians
Layout and Artwork
The Latvian Medical Publisher “Medicīnas
apgāds”, President Dr. Maija Šetlere,
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ISSN: 0049-8122
Dr. Jón SNÆDAL
WMA President
Icelandic Medicial Assn
Hlidasmari 8
200 Kopavogur
Iceland
Dr. Kazuo IWASA
WMA Vice-Chairman of Council
Japan Medical Assn
2-28-16 Honkomagome
Bunkyo-ku
Tokyo 113-8621
Japan
Dr. Otmar KLOIBER
WMA Secretary General
13 chemin du Levant
France 01212 Ferney-Voltaire
France
Dr. Yoram BLACHAR
WMA President-Elect
Israel Medical Assn
2 Twin Towers
35 Jabotinsky Street
P.O. Box 3566
Ramat-Gan 52136
Israel
Dr. Eva NILSSON-
BÅGENHOLM
WMA Chairperson of the Medical
Ethics Committee
Swedish Medical Assn.
P.O. Box 5610
11486 Stockholm
Sweden
Dr. Guy DUMONT
WMA Chairperson of the Associate
Members
14 rue des Tiennes
1380 Lasne
Belgium
Dr. Nachiappan ARUMUGAM
WMA Immediate Past President
Malaysian Medical Assn.
4th Floor, MMA House
53000 Kuala Lumpur
Malaysia
Dr. Jörg-Dietrich HOPPE
WMA Treasurer
Bundesärztekammer
Herbert-Lewin-Platz 1
10623 Berlin
Germany
Dr. Mukesh HAIKERWAL
WMA Chairperson of the Finance
and Planning Committee
58 Victoria Street
Williamstown, VIC 3016
Australia
Dr. Edward HILL
WMA Chairperson of Council
American Medical Assn
515 North State Street
Chicago, ILL 60610
USA
Dr. José Luiz GOMES DO
AMARAL
WMA Chairperson of the Socio-
Medical-Aﬀairs Committee
Associaçao Médica Brasileira
Rua Sao Carlos do Pinhal 324
Bela Vista, CEP 01333-903
Sao Paulo, SP
Brazil
Dr. Karsten VILMAR
WMA Treasurer Emeritus
Schubertstr. 58
28209 Bremen
Germany
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
75
We are occasionally faced with the question: What is the role of the
physician? Is it to care for the individual patient, or does the physi-
cian’s responsibility extend to include the health of the whole nation
or even the entire planet?
Some of my colleagues have expressed the view that a national
medical association’s task does not extend to the medical care for
the whole nation. In their opinion, that responsibility belongs to
the government or an agency of the government, or to society as a
whole; the doctor’s job is to care for his or her patients. Although
this latter statement is true, our professional medical education puts
us in the position to be the best guarantors of public health. I hold
physicians in very high regard as specialists who invest and synthe-
size their energy, knowledge and experience in the total care of their
patient.
However, each physician’s mission is broader than the care of in-
dividual patients, just as the mission of every national professional
society extends beyond the inhabitants of the country. The mission
of the physician, the national medical organization, and the World
Medical Association should also be the health of society as a whole.
Because no one else has a grasp of the issues, only the doctors and
their professional associations can eﬀectively deal with the health of
the general population.
The health of the population worldwide could be dramatically im-
proved by paying attention to a few basic concepts: adequate nutri-
tion, suﬃcient exercise, clean water and air, primary and secondary
prophylaxis against disease, access to medication, access to qualiﬁed
medical personnel, improvement in physical and mental well-being
and eradication of harmful behaviors such as smoking, alcoholism
and the use of drugs.
Today, inspired by the Olympic Games in Beijing and the Declara-
tion of Helsinki Conference in São Paolo, I would like to discuss
the importance of exercise in the improvement and maintenance of
good health.
We were enthralled by the incredible new Olympic stadiums in
China, the spectacular opening and closing ceremonies and the
world-class competition of athletes in Beijing.While winning a gold
medal is a signiﬁcant achievement, participation in the competition
is even more important. We should encourage all to participate in
physical activity even if they have no chance of winning a medal.
China provides a good example by the large number of people of
all ages who practice Tai Chi every day as a means to physical and
spiritual well-being. Athletics can inspire as a spectator sport, but it
should be a reality in the everyday life of all people.
The Declaration of Helsinki Conference took place in São Paolo,
Brazil in August 2008. Each conference participant took something
away from this meeting. For me, the most striking insight was the
one I gained during several very early mornings in a park. I was not
the only person running. Many thousand people, primarily 40- to
60-year-olds, were also running, alone or in lively groups. I now
understand why Brazilian athletes are the trend-setters in soccer,
volleyball and athletics worldwide: they simply love to exercise, and
they continue to exercise all their lives.
My proposal is simple. The World Medical Association and each
national medical association should undertake to promote at least
some daily exercise and physical training in every individual, young
and old.
Senior sports should also be included in a nation’s public health
program. In the world literature there are reports of research stud-
ies showing that regular, daily exercise at a suﬃciently high level
of intensity (including activity in an anaerobic regimen) can bring
about a noticeable improvement in health status, increase in muscle
mass,amelioration of coordination disturbances,and stabilization of
the heart and circulatory system. Exercise programs in 80 to 90 year
old patients can save on resources that would otherwise be spent in
the health or social services Furthermore, exercise is the best way
to combat the worldwide epidemic of obesity and the sharply in-
creased incidence of type 2 diabetes.
At the moment there is no clear strategy internationally to pro-
mote exercise in older people. Senior sports enjoy prestige in only a
few countries. In Scandinavian countries, for example, the sport of
orientation attracts many people at retirement age, who then start
training in earnest, attend training camps in mountainous regions,
and go to training camps in the winters in southern Europe. It is
time for us to ﬁnd recognition for senior sports championships equal
to those enjoyed by youths and 20- to 30-year-olds. Most resources
are invested in youth sports, on the assumption that these young
people will then mature into adults who love to exercise. However,
elderly people should also be encouraged to participate in sporting
activities, consistent with their abilities.
Our goal in promoting good health is suﬃcient exercise and optimal
nutrition for every person, regardless of age.
Editorial
Pēteris Apinis, M.D.
Editor-in-Chief of the World Medical Journal
76
The 179th
Council met in Divonne-les-
Bains, France 15-17th
May 2008 under the
chairmanship of Dr. Edward Hill.
Opening the meeting the Chair called on
Dr. Ishii, member of Council and Secretary
General of the Confederation of Medi-
cal Associations in Asia and Oceania, who
spoke of the mortality, injury and devasta-
tion caused by the earthquake in China
and the cyclone in Myanmar. This raised
huge challenges in the Region. The Chair,
echoing these remarks, also referred to the
eﬀects of armed conﬂict and violence on
human health. In particular he referred
to the tragedy aﬀecting the family of Prof
Bartov, member of council. He then read a
letter written on behalf of Council to Pro-
fessor Bartov and Council stood in silent
tribute to those who had lost their lives in
the earthquakes and the victims of natural
disasters, war and violence.
The President, Dr. Snædal reported that he
had he had visited a number of NMAs, re-
ferring in particular to a successful meeting
on Communicable diseases in Taiwan and
to the enormous problems facing NMAs
in Sub-Saharan Africa. He continued by
speaking of meetings which he, with others,
had attended in Ethiopia and Uganda on
Human Health Resources and the concept
of Task Shifting ( also being considered by
the WMA working group). Task shifting
was very important as it removes tasks from
medicine to others. The other health pro-
fessions had also recognised that this had
implications for them. Others important
issues would be referred to in the Report of
the Secretary General.
Dr. Otmar Kloiber, Secretary General, re-
ported that the staﬀ increases would fa-
cilitate increased WMA representation and
advocacy at political level. He was grateful
to the AMA for facilitating the appoint-
ment of Clarisse Delorme, a Human Rights
lawyer, as the Advocacy Adviser. There had
been a lot of activity on Task Shifting (TS).
Task Shifting While this seemed shocking at
ﬁrst,it was nevertheless necessary to address
the problem of areas where the Physician/
Population ration was down to 1 : 50000-
meaning that the sick had no chance of
seeing a physician. In these extraordinary
circumstances there was a compelling need
to act. On the other hand WHO and do-
nor organisations gave the impression of
considering Task Shifting as a general con-
cept widely applicable to dealing with all
179th
WMA Council Meets
Presidium of 179th
WMA Council
Delegates of the Council by the Divonne-les-Bains Palace
77
healthcare human resource problems. They
don’t view this concept as only applicable to
poor countries with human health resource
deprived areas, but rather it could be used
as a tool to solve the problems of Health
care systems in developed and rich coun-
tries. They are looking at countries, nota-
bly in the west such as the USA and UK,
who have already started Task Shifting, etc.
These countries don’t have to face the sort of
shortages experienced by African countries.
Last year and this we have had a chance to
inﬂuence a Task Shifting policy document,
and point out that this is primarily for ad-
dressing the problems of shortages of hu-
man resources. In Addis Ababa we learnt
that the African Ministers of Health were
not aware of the western proposal of Task
Shifting. Dr.Kloiber referring to the Kam-
pala meeting said that the Health Profes-
sions requested but, were given no opportu-
nity for, direct inﬂuence on policy as there
was no open discussion of the prepared
document, but simply information on what
was planned. The Declaration of Kampala*
outlined the importance of Task Shifting,
but pressure by the WHPA resulted in the
inclusion of the President of WMA in a
closed ministerial round and some modi-
ﬁcation of the ﬁnal document to recognise
the needs for health professionals.
Tuberculosis Staﬀ member Dr. Julia Seyer
in charge of MDR-TB project, reported
to council that for some years WMA had
been working with the Stop TB Alliance
and commented that the provision of theo-
retical knowledge as to how to teach about
Tuberculosis on-line should help this cam-
paign. Together with the ICN, WMA was
engaged in workshops on the training and
on healthcare workers’ safety guidelines
in managing tuberculosis. She referred on
agreement signed on the previous day and
the plan for the second phase of the project
and its enlargement (including China, Rus-
sia and India). She would like to extend the
on-line course to a CD-ROM and a Hand-
book. Concerning the training of trainers’
courses on education in learning styles,
there was cooperation with the World Eco-
nomic Forum who had a toolkit for working
in countries such as China (where Tuber-
culosis is stigmatised), addressing the prob-
lems of how to diagnose, treat and manage
tuberculosis. Referring to ethics in relation
to tuberculosis, she highlighted the right of
society to enforce Tuberculosis control.
Tobacco /Alcohol Dr. Kloiber then referred to
the new approach to Tobacco developed in
Copenhagen where WMA were invited to
work on Legal controls.NMAs had selected
the issues of education and communication
in Tobacco Control and also on limiting
exposure to tobacco smoke.The WMA had
co-sponsored a seminar on Tobacco control
at the EFMA/WHO annual meeting in Tel
Aviv and WMA would host a side event at
the World Health Assembly on “Focuss-
ing Opportunities for Tobacco Cessation”.
Responding to a question from India on
collaboration he stressed that there would
be more opportunities for NMA involve-
ment in the projects new phase. Turning to
Alcohol which was now before the World
Health Assembly, the recommendation
before the Assembly included a direction
that the Secretary General should cooper-
ate with the Alcohol industry.In view of the
lobbying by the industry this was a matter
of concern.
Leadership The WMA course Leadership
was held in the autumn together with IN-
SEAD, with 32 participants from all over
the world. Dr. Kloiber thanked Pﬁzer for
making this course possible.The course was
such a success that it would be repeated.
WHPA** The WMA had taken over the
secretariat of the World Health Professions
Alliance (WHPA) from the International
Council of Nurses (ICN) for the next pe-
riod after which it would rotate though the
other professions. WHPA is a very strong
* see page 82
** see more page 95
Meeting „Focussing Oportunities for Tobacco
Cessation” in Geneva
From the left: Burton Conrod, President FDI; Hiroko Minami, ICN President; John Snaedal,
President WMA; Marilyn Moﬀat, President WCPT; Kamal Midha, President FIP
78
alliance of the health professions who found,
to their surprise, that they had a common
experience in their diﬃculties in getting
their views to be taken seriously by WHO,
who considered that their views would be
sectional and partial in the global health
ﬁeld. The professions who joined together
in this alliance found that this changed the
situation and the WHPA had been success-
ful in presenting a broader collective voice
from the health professions. The need for
this alliance had been enhanced by the pro-
fessions recognising the threats implicit in
Task Shifting.
Dr. Kloiber then introduced Ms Clarisse
Delonne, a French Human Rights lawyer
advising on Advocacy for and by the profes-
sion She reminded council that an approach
had been made to Paul Hunt the previous
UN Special Rapporteur on Health in Hu-
man Rights.She set out the role of the Rap-
porteur on the Right to Health and the need
to inﬂuence the Commission to extend the
mandate of the Commissioner to include
integrity of health professionals in the man-
date. WMA has worked extensively with
the ICN lobbying on extending this role.
A joint statement was being prepared which
would be sent to the Human Rights Com-
mission requesting that Independence and
Integrity of health professionals be included
in the Special Rapporteur’s mandate.
In discussion Dr. Nathanson (BMA) point-
ed out that the Special Rapporteur on Tor-
ture had an interest in the problems of phy-
sicians in reporting torture and this aspect
should also be addressed to Mr Nowak with
whom we could also work.
Dr. Wilks (President of the CPME) said
that the BMA had worked with Paul Hunt
and discussed with him the NMAs’ role
in increasing indices of health. With ref-
erence to Alcohol, Europe had experience
to oﬀer. In the European Union they had
been able to harness industry in actions on
Alcohol control. The Chair, Dr. Hill, com-
mented that in the USA where the industry
decided to advise the young on the hazards
of drinking, however, drinking in the young
had increased in those areas where the in-
dustry was involved.
Dr. Letlape considered that WMA needed a
position on this topic. Dr. Nathanson agree-
ing added that alcohol was not as socially ac-
ceptable for control action as was Tobacco.
Dr. Haikerwall returning to Task Shifting
said the trend was towards removing medi-
cal care from Health care.
Human Rights in Zimbabwe. The Chair
of Council introduced Dr. Paul Chimedza,
President of the Zimbabwe Medical As-
sociation (ZiMA) who had been invited to
speak about the report of health related hu-
man rights and violence in Zimbabwe.
Thanking council for the opportunity,
Dr. Chimedza said that political tensions
and violence began to rise after the recent
elections in Zimbabwe and that this was be-
ing perpetrated by both political parties. He
denied that any patients had been refused
medical care on the basis of political aﬃli-
ation and stated that ZiMA had stressed to
its members that they should report any in-
stances in which they were prevented from
treating patients. The ZiMA had received
no such reports from its members.
Referring to Harare he said there was no
problem with the elections but that these
arose after the election, when the political
temperature rose. There had been a lot of
allegations about the profession. He had
received e-mails alleging that the Minister
of Health and Dr. Chimedza himself had
been involved in political violence and that
the ZiMA as an organisation was support-
ing violence. The allegations came from
the Zimbabwe Doctors for Human Rights
(ZIDHR). He had met with the Chair-
man of ZiDHR before travelling to the
WMA council meeting in Divonne. Dur-
ing this meeting the Chairman of ZiDHR
said that they had no evidence to support
the allegation but had heard rumours.
Dr. Chimedza commented that it was sad
“that a professional organisation could
make such serious allegations without evi-
dence to support them.” He accepted that
there was a strained relationship between
ZADHR and ZiMA from the time that
ZADHR had been denied associate mem-
bership of the ZiMA. This was however
because the ZiMA constitution required
aﬃliates to be speciﬁc medical profes-
sional groupings, such as paediatricians
etc. ZADHR as a human rights associa-
tion was therefore not eligible for aﬃlia-
tion. In fact there had been eﬀorts at three
successive ZiMA Congresses to amend the
constitution to admit ZADHR and they
had all failed. Despite this ZiMA had been
accommodating to ZADHR whose Chair-
man was a member of the Executive of Zi-
MA’s Mashonaland branch. Dr. Chimedza
stated that ZiMA was against violence of
any kind, perpetrated by anyone. ZiMA
had resisted being pressurised. In an over-
view of ZiMA’s action he referred to its
Social Responsibility Programme in which
there were many actions such as outreach
to rural health centres, including equip-
ment provision also funding for furniture
in HIV clinics, provision of drugs and as-
sistance in refurbishing hospitals, such as
operating theatres, as well as engaging in
many other actions to assist the Zimba-
bwean people.
Dr. Nathanson commented that ZiMA was
vulnerable to the sort of allegation referred to
and this was because people were not aware
of its work.It was a good example of how the
WMJ could be used to publicise these activi-
ties. Dr. Chimedza felt this would be helpful
and stated that he would request ZiMA Ex-
From the left Dr. J. E. Hill,
Dr. Paul Chimedza
79
ecutive to allow a WMA delegation to con-
duct a fact ﬁnding mission to investigate the
allegations which had been made.This would
also allow WMA to see the work that ZiMA
is doing, the challenges it faces , and identify
ways in which WMA could assist them. Dr.
Plested asked whether in an environment so
politically violent physicians were at personal
risk. Dr. Chimedza said this was a major
worry.There was no violence before but after
the lection.“None of our member physicians
had been targeted”. Problems were related to
the economy.
The immediate Past President proposed
a motion to support such a delegation, to
which the Secretary General observed that
this was unnecessary as it was covered by
the Resolutions adopted by Council and the
General Assembly in 2007.
Dr.Nielsonaskedwhetheritwouldbeappro-
priate for the WMA to call on all physicians
throughout the world to behave according
to the highest standards of the medical pro-
fession, a suggestion subsequently adopted
by the Council. While indicating that the
AMA would support sending a delegation
to Zimbabwe AMA felt that in would not
be appropriate to describe such a delegation
as “a fact ﬁnding mission”.
The Dr. Nakia informed Council that a
Canadian University had for many years
an infective diseases health group going to
Zimbabwe, but had diﬃculty recently in
getting supplies into the country, as well
as concerns about the safety of physicians
and she enquired whether ZiMA would be
able to look into the question of safety for
these physicians. Dr. Chimedza responded
that ZiMA did not have the capacity to
guarantee the safety of anyone who was not
directly involved in ZiMA programmes and
that ZiMA had temporarily suspended its
own programmes until violence subsides.
The Chair of Council reiterated WMA’s wish
to assist ZiMA on issues aﬀecting physicians
and patients and Council adopted a resolu-
tion calling on all physicians to observe the
highest standards of medical ethics.
Medical Ethics Committee
The Chair, Dr. Bagenholm welcomed new
members of the committee and the minutes
of the last meeting in Copenhagen were ap-
proved.
Helsinki Declaration
Moving to the Declaration of Helsinki revi-
sion, Dr. Bagenholm said that the working
group had corresponded, producing a num-
ber of drafts and had had a productive meet-
ing. She asked Dr. Williams, who had done
most of the writing, to set out the situation
and outline the most controversial issues.
Dr. Williams said that the group were con-
scious of their mandate which was to iden-
tify gaps and to promote the Declaration of
Helsinki (DoH).The group meeting in Hel-
sinki looked at the most controversial sec-
tions, considered suggestions for additions,
but had sought not to expand but try to
capitalise the ideas into one or two sentences
and this constituted the agenda.In the report
before the committee most of the changes
were editorial.In considering the vocabulary
it was decided that the best term to be used
for those submitting to research was “re-
search subject”. He then referred to speciﬁc
items setting out the reasons for the group’s
decisions,mentioning the need to avoid long
sentences and points which needed clariﬁca-
tion. The Chair, Dr. Bagenholm speaking of
the process, said that there would be a fur-
ther revision after the Ethics committee and
a workshop in Brazil in September, with a
view to getting a ﬁnal document to Coun-
cil and submission to the General Assembly
this year.She reported that an invitation had
been received to a WHO meeting in Cairo
of the Eastern and North African Medi-
terranean countries to be coordinated by
the WHO Cairo Oﬃce and UNESCO to
discuss “Challenges to Ethics and Medical
Research”It was hoped that there could be a
parallel meeting on DoH for WMA mem-
bers and stakeholders.
Opening the discussion Dr. Nathanson
(UK) referred to the use of the word “hu-
man”. This was a key issue. It should not be
interpreted in DoH as including “embryos”.
In DoH we are talking about humans from
birth to death. President Snædal thanking
Dr. Williams for his work commented that
the paragraphs appeared to be lengthened,
they need dividing. Turning to” Research in
Children” he commented that this subject
had not been worked on. The alternatives
were to include it in DoH, or in the Dec-
larations of Lisbon or Ottawa. Dr. Lemye
requested that Belgium be included in the
working group. An amendment which Bel-
gium had submitted appeared not to have
been considered. Dr. Bagenholm responded
saying that all representation were consid-
ered in Helsinki and were incorporated as
far as possible, if appropriate. Dr. Havaux
(Switzerland) considered the document
generally to be very satisfactory except the
problems arising from the DoH in many
languages. He expressed great concerns
about the French translation. It was not
only a problem of translation but also of
guidance for the French speaking countries.
He proposed that the documents should
be circulated in French. Dr. Kloiber agreed
that we need to change the translations and
asked if some of the four language groups
could join the editorial group to agree ﬁnal
versions. Dr. Mot added that France had
also some similar concerns and had added
the African French speaking group to their
editorial group.Dr.Collins -Nakai (Canada)
thought there were three areas of concern:
access of post trial patients,•
use of placebos,•
Dr. John R.Williams, Ph.D.
Dr. Eva Nilsson Bägenholm
80
the current language was too restrictive.•
Informed consent there had been remark-
able developments in the CMA.
Dr. Bagenholm, reverting to the topic of
Research on Children, reported that there
were comments on this from many NMAs.
Dr. Bagenholm opened a discussion on the
proposal on Research in Children reported
that there had been many comments from
NMAs.When the committee had discussed
DoH it could then decide on how to deal
with children. It could either be dealt with
in the context of this revision or dealt with
separately. After recalling that the revision
of DoH was not to include new material,
she called for expressions of interest in in-
cluding it in DoH. The CMA wanted it
included in DoH, using the inclusive term
“vulnerable populations”. Dr. Palve (Fin-
land) felt that the DoH should have a broad
approach “If we take up any one group why
should other groups not be taken up? It
would be better if these were dealt with in
separate statements”. Dr. Nathanson UK
said a lot depended on the timescale. She
recognised that children were particularly
vulnerable. “We could use a small addition
to DoH.It was possibly quicker to deal with
it in DoH”.Dr.Nakai (Canada) felt that re-
search on children was very important- we
could use minor amendments to DoH. But
perhaps the WMA should consider amend-
ment of the Declaration of Ottawa or in-
clude this topic in a Charter on Children’s
Health, which could include the proposed
statement as well as assessment and promo-
tion of children’s health.
Dr.Plested (USA) favoured inclusion in the
DoH. The Declaration would be weakened
if we did not include the issue in this semi-
nal document. Prof Spumont (Switzerland)
said it was a question of principle. This was
the sixth revision of Helsinki. It dealt with
the constitution of research ethics. The
world and science were changing.If we wish
to preserve the value of the DoH it should
be limited to principles. It would be bet-
ter to link speciﬁc declarations/statements
to the DoH. Having analysed the diﬀerent
ways in which the DoH has been incor-
porated in legislation, this would be a way
to proceed. Dr. Ishi (Japan) thought it had
been agreed that the statement proposed on
Research in Children should be dealt with
as a separate document and Dr. Letlape
(South Africa)) considered that while there
might be some amendment, we still needed
a speciﬁc document. Avv. Wapner (Israel)
favoured one document – that of the DoH.
The proposed statement would dilute the
DoH. The problem was with “vulnerable
populations” – children, the elderly, prison-
ers etc. President Snædal felt that the issue
of research in children must be addressed.
We have a proposal, also one on “Making
medicines child size” by WHO. WMA had
approved this initiative on research in chil-
dren it would be very expensive to extend
the DoH. Dr. Letlape felt the DoH should
be generic; we can’t stop initiatives from
outside. The Paediatric Society would pro-
duce a child friendly version of the DoH.
Dr. Parsa Parsi (Germany) supported in-
serting small changes into DoH. Dr. Kumar
(India) called for the inclusion of embryos
in the DoH.
Dr. Williams indicated that Dr. Appleyard
had not proposed alterations in DoH. He
wanted a separate document.This document
applied the principles of DoH to children.
He also reminded the committee that the
word “assent”not “consent”was in the DoH.
In Council later, Dr. Bagenholm reported
that comments on this from NMAs had
been received, but the working group had
not produced any new draft proposals for
action or wording. The options were that
this should be included in DoH, or that the
DoH be considered to be adequate in this
matter, that there should be a new state-
ment, or that the proposal be combined
with the Ottawa Declaration.
Dr. Plested agreed that the proposal should
go back to NMAs for their comments on the
options.Dr.Nathanson said there were many
good reasons to do this. Do NMAs want a
holistic document or a series of statements?
We needed to ask the opinion of NMAs.
The Chair of Council asked what do we do
if we go through a new statement and lose
ownership of the document? Dr.Kloiber re-
sponded that we must try to ensure that we
justify our position. We could ask NMAs if
there was anything in the proposed state-
ment which should go in DoH.Dr.Williams
was worried that this would hold up the re-
vision. He wondered whether the working
group could review the proposed statement
and put it in the next version of DoH i.e. he
suggested that the work group look at this
before the next revision of DoH.
The Council ﬁnally adopted the following
decision,
that the proposed statement on Ethical•
PrinciplesforMedicalResearchonchil-
dren be not accepted as a WMA docu-
ment but that the subject of research on
children be addressed by WMA in the
context of the DoH.
that the DoH workgroup take into con-•
sideration appropriate issues from the
proposed statement in ﬁnalising the
next revision of DoH for broad consul-
tation.
Ethics committee further discussion on Hel-
sinki
The Chair of Ethics committee then com-
mented that the paragraph on disease was very
long,andneededsomeattentionandalsoasked
Dr. Williams what was included in the use of
the word “humans”. Dr. Williams replied that
some thought there were important diﬀerenc-
es.As long as the word was used as an adjective
it meant “being”or “tissue”.When using it as a
noun it meant “born subjects”. He noted that
some had called for a glossary of DoH terms
but the project had been abandoned. Dr. An-
drade(Brazil)consideredtheDoH tobeacore
document. It should therefore remain a basic
document of principles. It deals with the vul-
nerable.The question was who were the most
vulnerable – for him these were children. He
thought DoH should set standards – a docu-
ment which cannot be ignored. It should be
readable and consist of primordial principles.
The deﬁnition of “humans” is biological and
that of “being”,philosophical.
81
The committee then considered the sug-
gested revision document paragraph by
paragraph. In the course of the debate there
was considerable discussion of the issue of
dealing with principles and the danger of
making exceptions was pointed out. When
dealing with the issue of consent and the
emphasis placed on the individual in the
DoH, it was pointed out that this raised
more than matters of consent. It also raised
the issue of the balance between issues of in-
dividual concern and issues which were the
concern of population groups – the speaker
as a further example posed the question as
to whether individuals have the right in ex-
ceptional circumstances to object to the use
of blood taken for one purpose being used
for another. This question and a number of
others were referred to the working group.
After detailed and lengthy discussion of
the proposed amendments and other is-
sues the committee agreed to recommend
that the new draft amended by the working
group would be presented to council before
it concluded its meeting and that this be
sent to NMAs and circulated widely for
public comment. Following the conference
in Brazil, which would include other stake-
holders, a new draft would be prepared for
council and if approved, sent to the General
Assembly in Seoul These recommendation
were adopted by Council.
Stem Cell Research
The committee engaged in further consider-
ation of this draft proposal.There was some
discussion concerning conﬂict with national
law in some countries.It was agreed that the
document, as amended, would be sent out
to NMAs for their views. Council adopted
this recommendation.
Professionally led Regulation
The committee considered a paper on this
topic which, it was pointed out, arose out of
the consideration of the Madrid Statement
and new thinking.Dr.Blackmer pointed out
that the paper had been circulated and the
comments had mostly been editorial. In the
eﬀort to support professionally led regula-
tion there was, however, a need to recognise
that there must be some public involvement.
Dr. Haikerwall (Australia) stressed that this
was an important issue. The question was
how to translate the importance of profes-
sionally led regulation to the public. The
Past President Dr. Letlape, (SouthAfrica)
said that the concern for his country, which
might not apply elsewhere, was that advo-
cacy by physicians for the patient is falling
oﬀ.There was a need to be honest that pro-
fessionalism and advocacy for the patient is
diminishing. We havn’t kept our duty to so-
ciety.The profession needed to be seen to be
the body appropriate to regulate itself and
take this responsibility. The Swedish Medi-
cal Association opposed the statement. Self
regulation was important for some NMAs.
For the SMA this is too much. However,
involvement of outside bodies may be good
or not so good, and in this connection refer-
ence was made to the varying functioning
of patient associations.The Danish Medical
Association agreed with SAMA.It observed
that Dr.Blackmer had had a diﬃcult task In
Denmark and Sweden “we don’t place much
emphasis on self regulation” and the DMA
was happy with the authority in Denmark.
We should try to get a common position.
Sir Charles George (BMA) supported self-
regulation, a concept which is being chal-
lenged in the UK.
After further discussion it was agreed to
recommend to Council that a work group
be established. This recommendation was
approved by Council.
Professional Autonomy
During discussion of a Declaration on Pro-
fessional Autonomy and Clinical Indepen-
dence, a number of speakers pointed out
related issues which need addressing and
agreed that these would not be appropriate
for this document. Dr.Blackmer observed
that the discussion paper would inevitably
lead to a series of papers. It was agreed that
“conﬂict of interest”was not appropriate for
this document but needed addressing and
the committee recommended that the pro-
posed statement should go to the General
Assembly in 2008, a recommendation later
agreed by Council, together with a request
that Dr. Blackmer develop a statement on
“conﬂict of interest”.
Common guidelines for physicians and the
pharmaceutical industry
Following further discussion in committee,
the Council adopted a recommendation
that this issue be not pursued but deter-
mined that the working group should de-
velop a proposal indicating how the WMA
and the Pharmaceutical Industry should
interact.
1998 policy reviews
Continuing its review of 1998 policies
Council accepted that Resolutions on
SIrUS and on Health related Violations
of Human Rights in Kosovo, should be re-
scinded and archived.
It was recommended and agreed by Council
that the Ottawa Declaration should un-
dergo a major revision.
Concerning further revision of the statement
on Capital punishment, it was reported that
further work would be done by the French
and American Medical associations to deal
with the need for legal wording to satisfy
translation and other problems.
Denunciation of Acts of Torture and Cruel
and Degrading Treatment
The committee considered suggested edito-
rial changes to the statement on Denuncia-
tion of Acts of Torture and Cruel or De-
grading Treatment, following the request
of the Copenhagen General Assembly that
duplication be removed. After more exami-
nation and an assurance that the suggested
changes reﬂected the request of the Assem-
bly, Council approved the changes.
Dr. Alan J. Rowe
82
We, the participants at the ﬁrst Global•
Forum on Human Resources for Health
in Kampala, 2-7 March 2008, and repre-
senting a diverse group of governments,
multilateral, bilateral and academic in-
stitutions, civil society, the private sector,
and health workers’ professional associa-
tions and unions;
Recognizing the devastating impact that•
HIV/AIDS has on health systems and
the health workforce, which has com-
pounded the eﬀects of the already heavy
global burden of communicable and non-
communicable diseases, accidents and
injuries and other health problems, and
delayed progress in achieving the health-
related Millennium Development Goals;
Recognizing that in addition to the eﬀec-•
tive health system, there are other deter-
minants to health;
Acknowledging that the enjoyment of•
the highest attainable standard of health
is one of the fundamental human rights;
Further recognizing the need for immedi-•
ate action to resolve the accelerating crisis
in the global health workforce, includ-
ing the global shortage of over 4 million
health workers needed to deliver essential
health care;
Aware that we are building on existing•
commitments made by global and na-
tional leaders to address this crisis, and
desirous and committed to see immediate
and urgent actions taken;
Now call upon:
1. Government leaders to provide the
stewardship to resolve the health worker
crisis, involving all relevant stakeholders
and providing political momentum to
the process.
2. Leaders of bilateral and multilat-
eral development partners to provide
coordinated and coherent support to
formulate and implement comprehen-
sive country health workforce strategies
and plans.
3. Governments to determine the appro-
priate health workforce skill mix and to
institute coordinated policies, including
through public private partnerships, for
an immediate, massive scale-up of com-
munity and mid-level health workers,
while also addressing the need for more
highly trained and specialized staﬀ.
4. Governments to devise rigorous ac-
creditation systems for health worker
education and training, complemented
by stringent regulatory frameworks de-
veloped in close cooperation with health
workers and their professional organiza-
tions.
5. Governments, civil society, private sec-
tor, and professional organizations to
strengthen leadership and management
capacity at all levels.
6. Governments to assure adequate incentives
and an enabling and safe working environ-
ment for eﬀective retention and equitable
distribution of the health workforce.
7. While acknowledging that migration of
health workers is a reality and has both
positive and negative impact, countries
to put appropriate mechanisms in place
to shape the health workforce market in
favour of retention. The World Health
Organization will accelerate negotia-
tions for a code of practice on the inter-
national recruitment of health person-
nel.
8. All countries will work collectively to ad-
dress current and anticipated global health
workforce shortages.Richer countries will
give high priority and adequate funding to
train and recruit suﬃcient health person-
nel from within their own country.
9. Governments to increase their own ﬁ-
nancing of the health workforce, with
international institutions relaxing the
macro-economic constraints on their do-
ing so.
10. Multilateral and bilateral development
partners to provide dependable,sustained
and adequate ﬁnancial support and im-
mediately to fulﬁll existing pledges con-
cerning health and development.
11. Countries to create health workforce
information systems, to improve re-
search and to develop capacity for data
management in order to institutionalize
evidence-based decision-making and
enhance shared learning.
12. The Global Health Workforce Alliance
to monitor the implementation of this
Kampala Declaration and Agenda for
Global Action and to re-convene this
Forum in two years’ time to report-and
evaluate progress.
Human Resources for Health, Kampala
Declaration and Agenda for Global Action
WHO Director General addresses the
61st
World Health Assembly
Dr. Margaret Chan opening her address said
“We are meeting at a time of tragedy”, ex-
pressing her condolences to the millions who
had lost loved ones,homes and livelihoods in
the cyclone in Myanmar and the earthquake
in China.Commenting on the great generos-
ity shown by the international community in
responding to crises of this nature,she stressed
the importance of early warning systems and
preparations to reduce risks in advance.
Dr. Chan referred to three global crises
looming on the horizon, all of which have
health eﬀects. The ﬁrst was Food Security,
in which WHO is part of the “high level”
task force. In order to guide priority actions,
WHO identiﬁed 21 “hot spots” around the
world where there are high levels of acute
and chronic under-nourishment? The sec-
ond was Climate Change, on which she
elaborated and indicated the draft resolu-
tion before the Assembly which deﬁned
clear WHO responsibilities The third global
crisis looming is that of Pandemic Inﬂuenza,
where the threat had by no means receded.
“As with climate change all countries will
be aﬀected, though in a far more rapid and
sweeping way”.While these events “could set
back progress in reducing poverty and hun-
ger”, the Millennium Health related Goals
Health – a global overview
83
reaching the world would vastly increase the
world’s capacity to cope with these interna-
tional threats.
With better data and statistical methods
WHO and UNAIDS had been able to
chart the evolution of HIV/AIDS with
greater precision. Prevalence had been level
since 2001 and deaths from AIDS have sig-
niﬁcantly declined in the past two years.
Referring to Tuberculosis, Dr. Chan said
that poor medical practice, which contrib-
utes to the development of drug resistance,
has continued to be and is a major concern.
MDRTB has now reached the highest level
ever recorded. “To allow this form of TB to
become widespread would be a set back,a set-
back of epic proportions.”. There had contin-
ued to be solid progress in Malaria control.
Turning to immunisation she referred to the
successful Global Immunisation Strategy and
also spoke of the broad based impact of In-
tegrated Management of Childhood Illness
which was now adopted as the principal child
survival strategy in 100 countries. Research
coordinated by WHO had also demonstrated
that home based treatment of pneumonia in
children was as eﬀective as hospital care.
Improving women’s health had proved dis-
appointingly slow, notably in reducing ma-
ternal mortality.
In her comments on non-communicable dis-
eases Dr. Chan referred to the ﬁrst ever Glo-
bal Tobacco Epidemic report launched with
the Bloomberg Foundation in February and
she emphasized that tobacco taxes were the
most powerful tobacco control measures.
It was the aim to control Neglected Tropi-
cal Diseases by 2015, and she noted that
we were on the brink of eradicating guin-
ea-worm disease. While eﬀorts to control
polio in the four remaining countries con-
tinue, she was concerned about a new strain
emerging in Africa.
Dr. Chan stressed the need to return to Pri-
mary Health Care in strengthening health
care systems. Primary Health Care would
be the subject of the World Health Report
and would be published on the 30th
anniver-
sary of Alma Ata in mid-October.
Finally, speaking about the 60th
year of the
foundation of WHO, whose task then was
to restore Health Services in a world devas-
tated by war, she said that the landscape of
Public Health was now very diﬀerent. It is
now a time of unprecedented global interest
and investment in health,as well as an unprec-
edented challenge. WHO had a clear role in
which,amongst the reforms being introduced,
the Global Management System would con-
tribute to improving WHO eﬃciency and
transparency in carrying out its role.
Vital Report of Global Health Group
For more than a decade, the concept of
“global health” has been widely promoted
around the world. Generally speaking, the
term refers to health problems that transcend
national borders and that are best addressed
by cooperative and collective actions.
The recent pandemics of HIV/AIDS,SARS,
and avian ﬂu, as well as the growing health
inequities within and between nations, have
increased the visibility and popularity of
global health. Further, globalization has ac-
celerated and deepened health interdepen-
dence among societies.In 2000,world leaders
committed to the Millennium Development
Goals, (MDGs) – ambitious development
goals to be achieved by 2015 – which speciﬁ-
cally focused on health and seemed to pro-
mote global health even further.
However, many argue that global health ac-
tion is still conﬁned inside the ivory tower
of high-ranking health administrators, or
within the major international organiza-
tions. In other words, many recent global
health initiatives have actually followed a
top-down process. Increasing numbers of
health actors, while trying to prove their
eﬀectiveness in the local context, have
asked the following questions concerning
global health: How do citizens around the
world perceive the value of global health?
Can global health be integrated into public
lives and values, like the stock markets or
oil prices? How can global health be recog-
nized as essential for local health needs?
Local eﬀorts must be taken into consider-
ation in the overall broader scope of global
health. Donors have been advised to con-
sider how local communities beneﬁt from
global health activities and how local com-
munities can possibly recognize the contri-
butions of these eﬀorts. It seems urgent to
re-design the approach to address existing
global health challenges. Focusing on lo-
cal communities and players seem to be the
better alternative.
These considerations lead to the rationale of
the Initiative for a Vital Report on Global
Health (VRGH 2008) launched on April
8th, 2008, in the European Parliament in
Brussels. The VRGH is unique in the sense
that its goal is to provide an analysis on how
people around the world and notably those
living in the developing countries perceive
An alternative to better global health
Focusing on local communities and players seem to be the better alternative
From the left WHO Director General
Dr. Margaret Chan
84
The international Classiﬁcation of Diseases
(ICD) provides a global standard to organ-
ise and classify information about diseases
and related health problems. It was devel-
oped by the WHO, based on the Interna-
tional List of Causes of Death from 1893
and was printed and published for the ﬁrst
time in 1948.
The actual ICD system provides informa-
tion for the morbidity and mortality sta-
tistics worldwide and is the database for
reimbursement systems, hospital records,
the general health situation of population
groups and shows incidences and prevalence
of diseases. The classiﬁcation is designed to
promote international comparability in the
collection, processing, classiﬁcation, and
presentation of these statistics.
The 10th
edition of the ICD has been in use
since 1994 and will now be updated and
adapted to additional necessities and an in-
creased IT usage.
WHO reported that the revision process for
ICD 10 is not only an update but will also
include new information, combines diﬀer-
ent national and international classiﬁca-
tions, oﬀers diﬀerent formats for users and
is will be globally accessible for comments
through the internet. The following sum-
marizes the WHO planning for ICD 11.
The structure of ICD 11
ICD 11 will have a three level approach to
oﬀer the right information for various users.
The ﬁrst level is for the primary care setting,
where the focus is on most frequent con-
ditions in primary care with broader cat-
egories. The second level is for clinical care,
which includes more details.The last level is
for research with standardized detailed cri-
teria and tentative disease labels that are not
yet in oﬃcial classiﬁcations.
The information on disease in ICD 11
will be extended and in comparison to the
ICD 10 version where only the disease, the
epidemiology, physiology and pathology is
included, now interventions and treatment
guidelines will be incorporated as well.
The new ICD 11 version will contain all
diﬀerent international and national clas-
siﬁcations (for example WONCA, ICD,
ICFD, ICHI) and therefore be the mainly
used classiﬁcation.
To capture all this information and make
the use easier, the ICD 11 version will be
placed in a Health Information System and
beneﬁt from new IT technology. Through
the online storage of the data, linkages to
health information bases such as population
registry, insurance systems, and health ser-
vices, can be developed and the direct use
of information for i.e. clinicians, adminis-
tration and health reporting departments
including the electronic health record will
be possible.
The process of the revision
The tentative timeline is that in 2010 an
Alpha version of ICD 11 will be prepared.
That means a draft version will be written.
By 2011 the Beta version including ﬁeld tri-
als will be ready and in 2013 the ﬁnal ver-
sion for public viewing will be available. At
the WHA in 2014 the ICD 11 will get ap-
proval and will be implemented by 2015.
For the previous revision process for ICD
10 comments could be handed in only in
the annual meetings, which gave an advan-
tage to the richer countries. In order to have
an equal balance in receiving comments an
ICD revision platform (Hi-Ki) via the In-
ternet is implemented to collect comments.
Now everyone is allowed to send comments
and the more comments someone hands in
the more relevance their comments will get
in future.However the governing body con-
sisting of the Top Advisory Group, the Re-
vision Steering Group and the WHO-FIC
committee will ﬁnally revise all comments.
The governing body at WHO
A Revision Steering Group will serve as
the planning and steering authority in the
update and revision process and focus on
reviewing the scope of health care diseases
and ensuring that they are consistent with
the overall structure. They identify users of
the classiﬁcation and address their needs
and deﬁne basic taxonomic and ontological
principals.
global health. The initiative in collecting
and reﬂecting these perceptions represents
a pertinent aim to bring the value of global
health to and from the public, and to advise
the world health decision-makers in forth-
coming actions.
The VRGH has been operated by an inter-
active process,and an online survey has been
launched to lead the opinions of global con-
cerns. This multilingual questionnaire has
been oﬀered through the internet (http://
vrgh2008.blogspot.com).
VRGH has been supported by dozens of
global health advisers and actors through-
out the world, and a report is expected to be
available in December, 2008, to commemo-
rate the 60th anniversary of the Universal
Declaration of Human Rights.
The VRGH represents an essential and
an important ﬁrst advanced and more so-
phisticated step toward harmonizing and
strengthening the global health practices
that will ultimately beneﬁt the health of all
people globally.
Coordinator:
Pr. Peter Chang, MD, MPH, ScD
Co-coordinator:
Vincent Rollet , MIR
The new revision process of the International
Classiﬁcation of Diseases
85
The Topic Advisory Groups (TAG) will
serve as the planning and coordinating ad-
visory body for speciﬁc issues, which are key
topics in the update and revision process,
namely Oncology, Mental Health, External
Causes of Injury, Communicable Diseases,
Non-communicable Diseases, Rare Diseas-
es and others to be established. Each TAG
will determine the number and content ar-
eas of the workgroups, identify the mem-
bers and chairs of the workgroups, present
an initial mandate to each workgroup and
establish procedures for the activities of the
workgroups. They will also give advice in
developing protocols for and in implement-
ing ﬁeld trials.
Further information can be found on the
internet page: http://www.who.int/classiﬁ-
cations/icd/en
Dr. Julia Seyer
The Brazilian Medical Association (AMB)
was honored to host the Work Group
from World Medical Association (WMA),
which discussed the Review of Declaration
of Helsinki, on August 20th
and 21st
. The
meeting was held in São Paulo, one of the
largest cities of Brazil.
On August 19th
and on the morning of
20th
, before the WMA’s Work Group meet-
ing, AMB organized a debating forum and
invited renowned Brazilian researchers to
debate the placebo and post-trial access to
treatment. The event raised diﬀerent points
of view.
Comments given on the ﬁrst day of the event
served the basis for suggestions made to Eva
Bagenholm, President of WMA’s Ethics
Committee, and Otmar Kloiber, General
Secretary, who kindly accepted AMB’s invi-
tation to discuss with the forum participants.
It was a very productive moment, because
Brazilian participants could express their
thoughts about the Declaration.
On 20th
during the afternoon, the Work
Group,composed of Brazilian,South African,
German,Japanese and Swedish representants,
got together to debate changes that eventu-
ally will be presented in Seoul. There were
also representants of Medical Associations
from Uruguay,Canada and Portugal,as well a
member of International Federation of Phar-
maceutical Manufacturers & Associations.
John Williams, Ethics director explained
to participants when previous Declaration
reviews, occurred each review’s purpose and
the need of adding notes of clariﬁcation.
Next, he described how the process of re-
view would be conducted: there will be no
changes in the structure, just on the scope
and terminology; review of controversial is-
sues of paragraphs 29 and 30,besides enclo-
suring notes of clariﬁcation. At that point
came, up a question whether the document
shoud be only destined to physicians or to
all people that do research. After justiﬁed
arguments, it was decided that the Decla-
ration should be destined initially to phy-
sicians, but other participants in medical
research involving human beings should be
encouraged to follow the same principles.
Another aspect discussed was the use of
“should” or “must”. It was explained that
translations are complicated because not all
languages have this diﬀerentiation.To some
people, must has a legal value and the Dec-
laration of Helsinki is just a guide and not a
document with legal validity.
The discussion gained more rhythm and
participation when was announced that
changes would be discussed in the previous
paragraph 29 (version of 2004 of Declara-
tion) and current paragraph 32 (last version
of draft), which embodied one note of clari-
ﬁcation. On that moment, all participants
gave their opinion and the placebo issue
took all afternoon.
Some people defended that the, use of pla-
cebo should not happen when there is eﬀec-
tive treatment,because in face of an innocu-
ous substance, any new medicine would be
valid. All participants agreed that the use of
placebo must be extremely controlled and
limited to circumstances in which there are
no other eﬀective method.
The importance of placebo in certain kinds
of therapeutics and this decision must be
solely based on ethical principles was also
pointed out.
The ﬁrst part of the morning of 21st
was
opened with discussions about paragraph
30, which in the latest review will be the 14th
and will include the second note of clariﬁ-
cation. Among the arguments brought up
about the writing of this paragraph are: un-
til when should treatment be guaranteed? Is
the right endless? How to deal if the drug is
not approved in the country? The remaining
question was how to include the guarantee of
post-trial access to treatment in the current
version of the Declaration of Helsinki. In
this case, they all agreed that arrangements
must be detailed in the protocol.
After a small break, discussion was resumed
with announcement of other proposal
changes. One of them was the possibility of
including in the Declaration a note of clari-
ﬁcation about children research. Changes
done on the paragraph 5 met part of this
need. Besides that, information might be
included in the Declaration of Ottawa,
which regulates rights of children to health
care, that refers to ethical principles of Dec-
laration of Helsinki.
After conclusion, representatives of the
Work Group, Eva Bagenholm, John Wil-
liams and Otmar Kloiber came together
during a private lunch to consolidate the last
issues about the Declaration of Helsinki.
Paula Mobaid,
AMB, International Relations
DoH Revision meeting in São Paulo
86
Dr. Julia Seyer
To achieve the Millennium Development
Goals and established targets for 2015, the
Stop TB Strategy was expanded in 2006 to
address the pressing challenges posed by
HIV/AIDS co-infection, TB drug resist-
ance and limited access to adequate care.
One of the strategy’s chief components is to
engage health care providers from all public
and private sectors, as well as to strengthen
health systems, recognizing that in many
high-burdened countries, ill patients of-
ten seek care outside the National TB
Programs (NTP). The DOTS Expansion
Working Group (DEWG), established un-
der the STOP TB Partnership, has moved
to promote the expansion of quality DOTS
among all relevant public and private health
care providers in TB control through the
Public-Private Mix (PPM) initiative.
The PPM approach starts with a National
Situation Assessment where all relevant
public and private health care providers are
identiﬁed and their roles analyzed in order
to deﬁne where PPM should be imple-
mented and what the requirements are for
this. The National TB programs will have
the responsibility of funding, regulation and
monitoring TB care and control. The actual
TB care and treatment is provided by local
NTP facilities or private and public hospi-
tals, clinics, specialists, GPs. They are called
non-NTP providers.
The 5th
Private-Public-Mix (PPM) sub-
group meeting in Cairo
The ﬁfth meeting was hosted by the WHO
regional oﬃce of the Eastern Mediterrane-
an (EMRO) and concentrated on mecha-
nisms and tools to build capacities of insti-
tutions supporting and/or undertaking TB
care provision such as national professional
organizations, large hospitals, and corporate
sector health establishments.
The conference started with an overview of
the global and regional progress on PPM
from the implementation in 2002 until now.
To date,over 40 PPM projects have been im-
plemented in 14 countries, of which 25 have
been evaluated with regards to progress and
outcomes. The detection rate of TB under
PPM increased from 10 % to 60 % and the
treatment success rate is between 75 % and
90 %. However these ﬁgures are misleading
in this context.Much data is still missing and
only a small proportion of all TB patients are
receiving the PPM DOTS services.
Project managers from NTP national level
reported that they are overwhelmed with
their workload. They have too many dif-
ferent kinds of responsibilities and need a
stricter role deﬁnition. They should focus
mainly on organisation and less on tech-
nical assistance. Other stakeholders like
professional associations or care providers
should be included and could oﬀer the lat-
ter as well.
The PPM subgroup meeting identiﬁed
mechanisms and tools to engage institu-
tions, especially national professional orga-
nizations, large hospitals and the corporate
sector, and patients and communities in TB
care and control.
The group “Mobilizing professional as-
sociations and promoting ISTC (Interna-
tional Standard of TB Care)” developed
key recommendations for PPM subgroup
and NTPs on how to engage professional
associations on a global and national level.
Professional associations are seen as a very
important partner in developing and imple-
menting the PPM strategy and communica-
tion and cooperation needs to be increased.
They should take part in the national situ-
ation assessment, development of regular
outcome reports, delivery of TB treatment
and their facilities should be certiﬁed by
the government. Ways to foster the com-
munication with professional associations
are through TB training, CME, articles in
medical journals, TB campaigns and more.
The main focus is at the moment on the
medical professional associations because
physicians are the main persons oﬀering TB
treatment. It is the expectation that PPM
through professional associations can reach
out to public and private working physi-
cians. However in future other profession-
als like nurses or hospital managers will be
included as well.
During the UNION conference from 15-
18th
October the next PPM subgroup meet-
ing will take place and the PPM strategy
will be announced to the DOTS expansion
working group. All participants and espe-
cially the WHO welcomed the WMA at-
tending the meeting in Cairo. Without the
participation of the physicians the PPM
strategy won’t be possible.
Information material available:
Guidance on implementing PPM- en-•
gaging all health care providers in TB
control
Toolkit for National situation assessment•
General guidelines and practical tools fro•
implementing hospital DOTS linkage
Handbook for using the ISTC•
Report from the inter-regional planning•
workshop on PPM
Co-operation of WMA and the Stop TB
partnership – Private-Public-Mix in the ﬁght
against TB
87
Geneva, 14 May 2008 – Eli Lilly and Com-
pany announced the scaling-up of an exist-
ing partnership with the World Medical
Association (WMA) by providing a grant
of $998,773 to expand training courses for
physicians on multi-drug resistant tuber-
culosis (MDR-TB). Tuberculosis (TB) is
a preventable disease that kills close to two
million people every year and infects an es-
timated nine million more. Of these, nearly
500,000 have multidrug-resistant TB.
The purpose of this online training is to help
physicians, both in the public and private
sector, to use the latest international guide-
lines and treatment protocols for MDR-TB
care in their daily work.This will allow more
physicians around the world to acquire the
basic knowledge on standard TB manage-
ment at a time when there is a resurgence
of the epidemic. A new toolkit will also be
developed for physicians on how to manage
TB in the workplace. This will be produced
with the World Economic Forum for use in
China and South Africa.
The announcement of the new four-year
joint partnership agreement was marked in
Geneva today by a signing ceremony be-
tween Jacques Tapiero, president of Lilly’s
intercontinental operations and WMA
president Dr. Jon Snaedal. Lilly’s key part-
ners including the World Health Organiza-
tion (WHO), the Stop TB Partnership, the
International Council of Nurses, the World
Economic Forum and alongside Geneva-
based diplomats and foreign dignitaries,
were invited to the ceremony.
Dr. Snaedal said: “We shall now be making
the course more interactive with more case
studies and a progressive learning pattern.
A TB refresher course was important to get
physicians back on track regarding the basic
knowledge of standard TB.”
Jacques Tapiero added: “We applaud
WMA’s commitment to developing inno-
vative approaches to stemming the MDR-
TB global burden. Given adequate health-
care infrastructure and adherence to proper
medication regimens, MDR-TB is not only
treatable, but indeed curable. This online
training course was an important addition
to the already existing tools and activities of
a larger partnership of 16 public and private
organizations worldwide dedicated to ﬁght-
ing MDR-TB.”
With underwriting from Lilly, the WMA
over the past year has already developed
an online training course for physicians to
more eﬀectively diagnose, prevent and treat
multi-drug resistant tuberculosis. Clini-
cal guidelines were developed and harmo-
nized with evidence-based material sourced
from the WHO, the International Council
of Nurses and the International Hospital
Federation. The course was tested among
physicians in South Africa. The Norwegian
Medical Association has adapted the mate-
rial to a web-based format and will be pro-
viding CME credits to those following the
course. The German Medical Association
assisted in providing managerial support in
the conception of the project.
The online course will be expanded to de-
velop a TB refresher course and a training
course on MDR-TB training. Training
champions in MDR-TB treatment will be
created in South Africa, India and China.
The course, already available in English, is
being translated into Spanish, French, Chi-
nese and Russian and will be published in
handbook and CD form in addition to the
online format. MDR-TB is a serious pub-
lic health threat in many parts of the world,
notably in Sub-Saharan Africa,Central and
Eastern Europe,mainland China,Southeast
Asia and in Central and South America.
The recent identiﬁcation of extremely
virulent TB and the increasing number of
MDR-TB cases show that the knowledge
and handling of TB treatment is still insuf-
ﬁcient. With concrete evidence that incom-
plete TB treatment is responsible for the
occurrence of extremely drug resistant TB,
an ethics policy is being planned to look at
whether and how patients can be encour-
aged to complete their treatment regimen
and where the autonomy of a patient ends
in order to safeguard public health.
The World Medical Association is the
independent confederation of national
medical associations from more than 80
countries and represents more than eight
million physicians. Acting on behalf of
patients and physicians, the WMA endea-
vours to achieve the highest possible stan-
dards of medical care, ethics, education and
health-related human rights for all people.
www.wma.net
The Lilly MDR-TB Partnership was cre-
ated to confront multidrug-resistant tuber-
culosis, a disease so daunting that no single
organization can ﬁght it alone. Since 2003,
the public-private initiative, mobilizing 16
partners on ﬁve continents, has worked
together to share expertise in the quest to
contain and conquer one of the world’s
oldest diseases. The Partnership’s multi-
pronged approach includes: community
support and patient advocacy; treatment,
training and surveillance; transferring tech-
nology; research; and awareness and pre-
vention. Additional information about The
Lilly MDR-TB. Partnership is available at
www.lillymdr-tb.com
Contact:
Nigel Duncan. WMA Public Relations
Consultant. nduncan@ndcommunications.co.uk
JJ Divino. Communications Manager,
International Aid Unit, Eli Lilly and
Company. divinojj@lilly.com
Lilly Commits $1MM to World Medical
Association to support Innovative
Tuberculosis training course
88
Bob Miglani
Senior Director, External Medical Aﬀairs In-
ternational, Department of the Chief Medical
Oﬃcer, Pﬁzer Inc.
It doesn’t take a doctor to diagnose that
the healthcare systems of the world are in
very bad shape. Factors such as the age-
ing population and increasing prevalence of
lifestyle-related conditions like obesity are
placing untenable pressure on traditional
models of healthcare provision. But while
many healthcare “experts” seek solutions
and propose reforms, those at the delivery
end of healthcare, namely physicians, are
often overlooked and excluded from health
policy decision-making.
The result is that physicians around the
world are working within health systems
imposed upon them, usually without any
consultation let alone involvement. De-
signed with time and money rather than
patient care in mind, these systems restrict
and conﬁne doctors making it increasingly
diﬃcult for them to practice medicine as
they wish. Growing frustration is lead-
ing many healthcare professionals to take
direct action as they seek to inﬂuence
healthcare reform and policy direction for
the future.
Throughout 2006 and 2007 German physi-
cians from across the country held various
protests to demonstrate against new restric-
tive contracts being imposed on them by
the government and which they felt would
greatly reduce their eﬀectiveness. In March
last year UK junior doctors marched in pro-
test against a new training system which
made it impossible for them to apply for the
posts they wanted. In September of 2007
Spanish doctors undertook strikes to ask for
more time with each patient (to a total of
just 10 minutes) and this summer,in the US
physicians and nurses have also made their
voices heard in major cities to advocate for
universal healthcare.
While the exact catalyst for these protests
may vary, they all share a common theme: a
desire to be allowed to exercise their voca-
tion as they wish. To be allowed to do what
they do best: be doctors.
Whether they practice in Barcelona or Bei-
jing, Montreal or Munich, physicians want
to spend their time treating patients to the
best of their ability, not ﬁlling out forms,
wrestling with ﬁnancial targets or poring
over guidelines to determine which treat-
ment approaches they are permitted to take
for their patient.
As part of its Medical Partnerships Initia-
tive, Pﬁzer has been tracking the attitudes
and opinions of health professionals over
the past few years. A series of surveys inves-
tigating how physicians feel about their role
in healthcare, developments in the quality
of care and the future of their profession,
has been conducted in Asia, Europe and
the Americas. The ﬁndings making salutary
reading not only for physicians but for all
those involved in healthcare delivery, and
highlight just how widely shared the con-
cerns and issues discussed above, are across
the globe.
The most recent of these surveys was car-
ried out earlier this year among primary
care physicians and specialists in 13 coun-
tries around the world. Research company
APCO Insight interviewed 1,741 doctors
in Asia, Europe and North America and
found some interesting trends and varia-
tions from region-to-region.
Medicine Moving in a Negative Direc-
tion
While across most of the globe, doctors re-
main moderately satisﬁed with their own
personal experience of practicing medicine
(out of 10 Asia 7.25,Europe 6.32 and North
America 6.94), when it comes to the bigger
picture and the practice of medicine overall,
European and North American doctors are
generally negative. Over half of European
doctors (51 percent) consider that the prac-
tice of medicine is going in a negative direc-
tion and in North America this ﬁgure was
39 percent.
The data from Asia was less homogenous
with a clear split between Chinese and In-
dian doctors and those from Japan and Ko-
rea, with Australian physicians somewhat in
the middle. Japanese and Korean doctors
(79 percent and 87 percent respectively)
agreed with European and North Ameri-
can physicians that medicine is going in a
negative direction. However, Chinese and
Indian doctors (78 percent and 77 percent
respectively) felt medicine was going in a
positive direction. Australian physicians
were less deﬁnitive with 50 percent positive
and 30 percent negative.
The most frequently cited reasons for the
belief that the practice of medicine is going
in a negative direction were “government
mismanagement of healthcare systems” in
Asia (32 percent), “non-medical entities
interfering in medical decisions” in Europe
(36 percent) and “business aspects of medi-
cine” in North America (42 percent).
What Physicians are REALLY Thinking
89
Is the Doctor-Patient Relationship on the
Critical List?
As can be seen above, at the top of the list
was the deterioration of the relationship
between doctor and patient. When asked
about the factors which have changed the
doctor-patient relationship, the majority of
doctors believe this has been aﬀected by pa-
tients:
expecting to spend more time with their•
doctors (Asia 96 percent, Europe 72 per-
cent and North America 64 percent)
being increasingly concerned about being•
able to pay for their care (Asia 93 percent,
Europe 62 percent and North America
81 percent) and,
speciﬁc treatment expectations (Asia 84•
percent, Europe 85 percent and North
America 92 percent), presumably which
the physician cannot always meet.
Other factors which physicians believe ad-
versely impact their relationships with their
patients include patients being concerned
that they are not oﬀered the best choices
for quality care and increasing skepticism
around physicians’ authority. In fact, the
survey found that between 47 percent (Asia
and North America) and 63 percent of phy-
sicians said that government-led clinical
assessments had limited the treatment they
could choose on behalf of patients.
From this analysis of the doctor-patient re-
lationship, it is clear that patients are suf-
fering from the adverse eﬀects of many of
the unwelcome changes in healthcare that
have negatively aﬀected physicians. Pri-
marily, this might best be summarized as a
loss of autonomy or outside interference in
medical practice. As highlighted above,this
is borne out by the fact that “government
mismanagement of healthcare systems” and
“non-medical entities interfering in medical
decisions” were among the most frequently
cited reasons for the perception that medi-
cine is moving in a negative direction. This
is further reinforced by other results of the
survey below.
Time is of the Essence
So reducing the amount of interference in
clinical practice might be one way of im-
proving the ailing doctor-patient relation-
ship. The survey results also highlighted
possible prescription for success: doctors
spending more time with their patients.
In Europe and North America, half of
the doctors surveyed (53 percent and 51
percent, respectively) say the average time
spent with patients has decreased since they
began practicing medicine. While in Asia
the majority (41 percent) believe time spent
with patients has remained the same.
This ﬁnding was reinforced by another
question posed in the survey: “what would
you change to improve the quality of patient
visits”. The most frequently quoted response
was “increase time with patients” with 51
percent of North American and 49 percent
of European respondents giving this answer.
In Asia, 30 percent suggested this, second
only to increased medical facilities.
Time also came to the fore when European
physicians were asked to rank the signiﬁ-
cance of various factors in relation to their
job satisfaction. “Having enough time with
each patient to provide care in the way I
would choose” was the most signiﬁcant is-
sue in Europe with the top score of 8.05 out
of ten.
But when it comes to spending time with
patients,it is not just doctors’desires that are
an issue here: the vast majority of doctors
worldwide (93 percent) agree that spending
more time with each patient would con-
tribute to better health outcomes for those
patients, a view shared equally among Gen-
eralists and Specialists.
Top 5 Unprompted Reasons Practice of Medicine Going a Negative Direction
Reason Global
Total
Asia
Total
Asia
High
Europe
Total
Europe High N
America
Total
NA
High
Doctor patient
relationship dete-
riorating
28% 31% 50%
China
25% 36% France 26% 27%
Canada
General aspects of
profession
25% 28% 55%
China
24% 27% Germany 20% 26%
Canada
Business aspects of
medicine
25% 19% 69%
Korea
28% 40% Germany 42% 45%
US
Government
mismanagement of
healthcare systems
22% 32% 70%
Korea
8% 16% Belgium 13& 15% US
Non-medical enti-
ties interfering in
medical decisions
21% 8% 23%
Austra-
lia
36% 46% Germany 39% 44% US
Percentage who “strongly agree” or “somewhat agree” with statement
Statement Global
Total
Asia
Total
Asia
High
Europe
Total
Europe
High
N America
Total
NA
High
Physicians have lost
control of medical
care decisions to
other people
46% 38% 81%
Korea
67% 87%
Portugal
82% 85% US
Reducing govern-
ment involvement
in healthcare
would be better for
everyone
68% 66% 89%
Korea
72% 85%
Ger-
many
70% 73% US
90
While it could be argued that there is lit-
tle that can be done about the increasing
number of patients who seek their doctors’
time, there is surely a better way to allocate
doctors existing and increasingly precious
time. The survey found that 51 percent of
European doctors who said that they were
spending less time with patients said that
this was because of “administrative bureau-
cratic requirements”.
There is perhaps a correlation here with
another question, when European phy-
sicians were asked “which experience in
the practice of medicine today is the most
unsatisfying to you?”, the most frequently
cited response by some margin was “ad-
ministrative tasks” (30 percent). Perhaps
European doctors would be happier if they
could switch their focus back to treating
their patients rather than ﬁlling in forms.
It is therefore not surprising that, another
business-related aspect of medicine was a
cause of dissatisfaction:
Few physicians take up the profession to
become more familiar with accounting pro-
cedures and indeed, money matters leave
most physicians distinctly deﬂated. When
asked to state the most unsatisfying experi-
ences in their practice, globally, 17 percent
cited “rationing care/cost containment”,
14 percent “compensation” and 13 percent
“payer issues”.
Seeking Solutions and Support
Over the past ﬁve years as our research has
tracked the belief among physicians around
the world that they are no longer masters
of their own destiny, we have seen a cor-
responding rise in what is termed, physi-
cian-activism. A variety of movements and
organizations have emerged in countries
around the world, created by and for physi-
cians as they aim to take their place at the
health policy table. This wave of activism is
reﬂected in the survey, with 90 percent of
physicians worldwide agreeing that improv-
ing healthcare will require public leader-
ship from physicians. This view was shared
across all three regions: strongest in North
America (96 percent), then Europe (90 per-
cent) and Asia (89 percent).
Physicians in all regions, generalists and
specialists, strongly agree that they should
speak out about the problems facing the
practice of medicine. Again, agreement was
strongest in North America at a staggering
98 percent, but Europe at 90 percent and
Asia with 86 percent were not far behind.
An obvious place for physicians to turn
when seeking to have their voices heard
would seem to be the professional organi-
zations and medical societies which exist
to support the profession. Yet member-
ship and enthusiasm levels in our survey
appeared low when questions were asked
about these groups. Globally only 43 per-
cent said they were members of any profes-
sional organization or advocacy group that
advances the interests of physicians. When
questioned about how eﬀective such bodies
are, 82 percent responded either “somewhat
eﬀective” or “somewhat ineﬀective”.
When asked about a group which would
speciﬁcally advocate on behalf of physi-
cians, enthusiasm was more evident. Three
quarters of physicians around the world
professed that they would join an advocacy
organization which aimed to educate the
public about the importance of the role of
physicians to public health and to also inﬂu-
ence government policies aﬀecting the prac-
tice of medicine. This hunger for support
continued when given some suggested ways
in which they might advance their case:
Percentage who “ strongly support” and “somewhat support” the following ideas that
have been suggested to support physicians
Statement Global
Total
Asia
Total
Asia
High
Europe
Total
Europe
High
N
America
Total
NA
High
Participate in train-
ing programs to help
physicians become better
advocates for reform of
healthcare policies
89% 92% 98%
India
79% 99% UK 93% 94%
US
Cooperate with third-
parties to publicize the
important role of physi-
cians in society
84% 84% 86%
China,
India and
Australia
83% 87%
Belgium
90% 91%
US
Form a coalition
between healthcare
professionals and private
companies to defend
physicians’ right to make
independent medical
decisions
79% 81% 94%
India
71% 73%
France
and
Ger-
many
86% 90%
US
For each of the following problems please tell me how signiﬁcant the problem is to your job
satisfaction. Please use a 10 point scale, where a 1 means completely insigniﬁcant and a 10
means extremely signiﬁcant problem aﬀecting job satisfaction
Statement Global
Total
Asia
Total
Asia
High
Europe
Total
Europe
High
N America
Total
NA
High
Protecting my
medical practice
from threat of
lawsuits or civil
actions
8.3 8.58 8.93
China
7.27 7.84 Por-
tugal
7.78 7.89 US
91
A Glimmer of Hope
In summary, then, this latest round in Pﬁz-
er’s continuing investigations into the issues
aﬀecting the medical profession, has paint-
ed a gloomy picture for some countries. On
a macro level, physicians in Europe and
North America are generally negative about
the direction of medicine, as are those in
Japan and Korea. This negativity is largely
attributed to interference in medical prac-
tice by non-medical entities such as govern-
ments and insurance companies. Physicians
in China and India are very satisﬁed with
the direction of medicine and believe their
respective medical societies are serving their
needs eﬀectively and that they are still in
control of medical care.
Taking a closer look at Asia, Indian doctors
tend to be more positive about the practice
of medicine, perhaps partly because they
report little interference in their medical
decisions from third-parties. At the other
extreme, Korean doctors are negative about
the direction of medicine generally: third-
party payer issues dominate their dissatis-
faction and prevent them from providing
care according to their medical judgment.
Japanese doctors express similarly high lev-
els of dissatisfaction with the practice of
medicine; however attribute less blame to
third-party payers than the Koreans. Aus-
tralian and Chinese doctors are more mod-
erate, even variable in their attitudes.
Across the EU, doctors suﬀer from similar
challenges regarding too little time with pa-
tients (which leads to negative health out-
comes) and too much time with administra-
tive burdens (which also leads to negative
health outcomes), causing a decline in the
quality of the doctor-patient relationship.
Consensus also emerges in Europe that
healthcare system changes will require the
public leadership of physicians and they are
supportive of various potential programs to
help them advocate.
US doctors are subject to high levels of
third-party interference, suﬀer burdens of
managing private practice and, therefore,
spend more time than they want with ad-
ministrative burdens. Canadian doctors
suﬀer less from these particular ills though
both countries suﬀer from similar chal-
lenges regarding time management. They
are similarly experiencing changes to the
doctor-patient relationships and agree that
healthcare system changes will require their
public leadership.
Taking a worldwide view, perhaps one of
the most disturbing ﬁndings for the pro-
fession is that the long-cherished doctor-
patient relationship is under severe threat
as patients become frustrated by the time
they get to spend with their physician and
failure to meet their expectations around
treatment.
Another point of agreement and indeed,
hope among doctors across the globe is
that in order to change today’s healthcare
systems and move them away from their
focus on cost rather than patient care, they
are going to have to take a lead themselves.
Physicians need to speak up and make the
broader public aware of the threat facing
medicine. Only by taking a strong leader-
ship position does the profession see any
hope of change.
So, though it may not take a doctor to diag-
nose the problem with healthcare today, it is
certainly going to need doctors to develop,
administer and manage the necessary treat-
ment. Today the profession is faced not so
much with a case of “physician heal thyself ”
as “physician, heal healthcare”.
About the Survey Methodology
Pﬁzer Inc. External Medical Aﬀairs, Inter-
national, commissioned APCO Insight, a
global opinion research ﬁrm, to conduct a
scientiﬁc probability survey with physicians
in North America, Europe and Asia con-
cerning their attitudes toward the practice of
medicine. Interviewswereconductedamong
1,741 general practice and specialist physi-
cians in the United States (n=248), Canada
(n=95), Germany (n=138), France (n=127),
the UK (n=125),Belgium (n=126),Portugal
(n=127), the Netherlands (n=125), China
(n=125), India (n=130), Korea (n=125) Ja-
pan (n=125) and Australia (n=125). Inter-
views were conducted between December
15, 2007 and March 1, 2008 utilizing a va-
riety of data collection methodologies tai-
lored for each country, including mail (US
and Canada), telephone (Germany, France,
UK, Belgium, Portugal, Netherlands, Japan
and Australia) and in-person (China, India
and Korea). Sample frames were selected
in each country to provide maximum cov-
erage of practicing physicians and included
professional association member and non-
member lists, licensing registries, public di-
rectories and health organization databases.
The margin of sampling error for the global
sample is ±2.3%; sampling margin of error
at regional and country levels are higher
depending on sample size. The sample
was stratiﬁed among the 13 countries, and
within each country, stratiﬁed by medical
specialty (general practice and specialists).
The ﬁnal dataset was post-weighted to be
representative of the actual distribution of
practicing physicians across the countries
and specialties.
Bob Miglani,
Senior Director, External Medical Aﬀairs
International, Department of the Chief
Medical Oﬃcer, Pﬁzer Inc.
92
Dr. Analice Gigliotti
President of Brazilian Asoociation on Studies
of Alcohol and Drugs (ABEAD)
Smoking is currently the leading prevent-
able cause of death in the world. If nothing
is done, by the end of the century this ad-
diction will have killed one billion people,
anticipating the death of half the smokers,
who lose from 8 to 22 years of life. Accord-
ing to the World Health Organization, four
million people die every year due to diseases
caused directly by tobacco derivatives. It is
estimated that 100 million individuals died
in the 20th
century due to nicotine depen-
dence and, if the present trend prevails, this
number will be 10 times higher, reaching
one billion deaths in the 21st century. Many
of these deaths are potentially preventable if
tobacco users quit smoking.
Despite all the mortality and morbidity
caused by tobacco, its global consumption
keeps growing. The propagated decrease of
consumption of this product takes place
only in some industrialized countries.
Among the less favoured ethnic minori-
ties, tobacco consumption continues to be
an extremely common problem. China, for
instance, is responsible for great part of the
increase of per capita cigarette consumption
in the world. Following the decrease of to-
bacco consumption in developed countries,
the tobacco industry increased their sales in
developing countries. In the next decades,
70% of the deaths caused by tobacco will
occur in the Third World, where the prob-
lems associated to tobacco consumption
will share the scenario with basic health
problems such as malnutrition and lack of
sanitation.
Most people are unaware of the damage
caused by smoking. About 30% of all cancer
cases and at least 85% of lung cancers are
caused by tobacco. Oral cavity, faring, lar-
ynx,stomach and esophagus cancers are also
closely associated to tobacco consumption.
Even the organs not directed associated to
the habit of cigarette smoking – such as
bladder, kidney and pancreas – are more
aﬀected by cancer among smokers than in
non-smokers.
Other fatal diseases such as Chronic Ob-
structive Pulmonary Disease (COPD), pe-
ripheral arteriopaties, aortal aneurism and
myocardial infarct are also associated to
smoking. Even less lethal diseases such as
respiratory infections, stomach and duode-
nal ulcers, osteoporosis and dental problems
are associated to tobacco. Smoking is the
leading cause of coronary disease among
women.
Tobacco also aﬀects the development of
pregnancy in smoking pregnant women.
Consequently, the loss of the fetus is more
frequent in all phases of pregnancy, with a
probability 70% higher of miscarriage. The
risk of prematurity increases 40% and the
children of smoking mothers are born with
approximately 200 grams less than children
of non-smokers. They are also particularly
more likely to present sudden infant death
and other peri and neonatal diseases. Even
more alarming data shows that non-smok-
ing pregnant women, exposed to environ-
mental tobacco pollution can also give birth
to babies with low weight. The concentra-
tion of seric cotinine (a metabolite of nico-
tine) is higher in non-smoking pregnant
women who live with smokers.
Environmental exposition to the smoke of
cigarettes is also harmful, being the third
leading cause of preventable death in the
world, second to active tobaccoism and ex-
cessive alcohol intake. The main symptoms
non-smokers exposed to environmental to-
bacco pollution (EPS) complain are cough,
headaches and sore eyes. They also have an
exacerbation of rhinitis, sinusitis and asth-
matic bronchitis, besides showing a higher
probability of developing lung cancer. The
U.S Environmental Protection Agency des-
ignated classiﬁed EPS as carcinogen Class
A, that is, showing enough evidence of
cause between exposition and cancer in hu-
man beings.The risk of lung cancer in non-
smokers exposed to cigarette smoke is 30%
higher than in non-smokers who are not
exposed to ETS. Cardiovascular diseases
are also higher in passive smokers. The risk
of coronary disease in non-smokers exposed
to ETS is 24% higher than in non-smokers
who are not exposed to it.
Children of smokers are more easily subject
to develop respiratory infections and pres-
ent worse allergic features than children
who live with non-smokers.
In the last decades, due to the development
of public awareness of the damages of to-
bacco and to anti-smoking governmental
campaigns, a progressive decreasing preva-
lence of smokers can be noticed, especially
in some developed countries, such as the
United States, where the number of smok-
ers stabilized in 25% of the population in
1993, decreasing to only 20.5% in 2007, due
to public health policies in the country.
However, further reducing these rates is
becoming a hard task. Although in the last
years a decrease in the number of adult
smoking women in the United States can
be noticed, more young girls are starting to
Smoking: A disease that starts in the brain
and goes to the whole body
93
smoke, a phenomenon that is also happen-
ing in a great number of countries around
the world,as in Brazil,for instance.Nicotine
dependence prevalence in the United States
fell from 42% in 1965 to 25% in 1982, nev-
ertheless since then these numbers change
with great diﬃculty. This occurs because
of the addictive properties of nicotine that
result in only 2.5% of smokers abstaining
from the drug each year.
The scientiﬁc community made widely
known the addictive characteristics of nico-
tine publishing, in 1988, an important re-
port with the following conclusions:
Cigarette and other tobacco forms cause•
dependence.
The cause of dependence in tobacco is•
nicotine.
The pharmacological and behavioural•
processes that determine the tobacco ad-
diction are similar to those which deter-
mine the addiction to other drugs such as
heroin and cocaine.
Each cigarette contains approximately 8 mg
of nicotine, from which 1 mg is rapidly
absorbed by the lungs. In 10 seconds the
smoker feels the “good” eﬀects of the drug,
such as better attention and concentration,
the diminishing of appetite, the increase of
the alert state, the reduction of anxiety and
depressive mood improvement.
With the suspension of smoking, the symp-
toms of the abstention syndrome reach their
peak in two or three days. At the end of the
ﬁrst week they decrease, normally disap-
pearing in 2 to 4 weeks. Residual symptoms
can persist for even 6 months in some cases,
mainly the symptom of augmented appe-
tite.
The proof that nicotine is a drug that can
lead to addiction is the fact that cigarettes
from which nicotine is taken artiﬁcially is
often abandoned by smokers, who change
to the normal ones.In fact,smokers are used
to regulate the concentration of nicotine in
their body, with the objective of keeping it
in the limits that satisfy their needs. Even
when they change their habitual brand to
another one with lower nicotine content,
tobacco users usually try to compensate it –
increasing the number, depth and length of
drags, for instance – trying to compensate
the changes made and keep the concentra-
tion of nicotine constant.
The direct action of nicotine on nicotinic-
colinergic receptors is distributed all over
the brain. Although its direct action is ex-
clusively in these receptors,the ﬁnal result is
frequently a complex pattern of the indirect
eﬀects in other transmission systems, such
as dopaminergic, adrenergic, serotoningeric
and glutamatergic.
The neurons of the ventral tegmental area,
where the nicotine bonds, are projected to
the nucleus acumbens, where they release
dopamine in large amounts, substance that
is associated to the gratifying sensation ad-
dicts feel. The bigger and faster the libera-
tion of dopamine in this nucleus, the higher
the pleasure users get.
Nicotine has a double eﬀect in the central
nervous system: initially it stimulates the
nicotinic receptor – agonist eﬀect – and
then it blocks it – antagonist eﬀect.To adapt
to the disorganisational eﬀects of the drug,
the brain tries to surmount the blocking ef-
fects of nicotine, through an increase in the
number of nicotinic receptors. On the other
hand, part of the abstinence symptoms is
mediated by desensitization in the nora-
drenergic neurons of the coeruleus locus.
Many smokers use tobacco according to a
classic cyclic model of drug addiction, in
which they search for the beneﬁcial eﬀects
of nicotine, but what keeps the individual
smoking is the relief of the abstinence
symptoms. However, it is not only the nico-
tine which determines the persistence in its
use. As with any other drug, the desire of
consumption can be triggered by environ-
mental stimuli independent from organic
need. That is the reason why the individual
can have a “craving”for smoking, even years
after the abstinence syndrome is over, when
they have any contact with “triggering situ-
ations”, such as drinking and seeing some-
one smoking, for example.
There is a projection for the ﬁrst half of
the XXI century of 500 million premature
deaths, ⅓ being preventable should the
adult individuals stop smoking. This means
that a public health approach aiming to
stop the use of cigarettes is a fundamental
element in governmental policies in the
control of smoking. Other actions recom-
mended by the World Health Organization
include preventing children from becoming
tobacco addicts, protecting non-smokers
from the involuntary exposition to cigarette
smoke; eliminating all publicity, direct or
indirect, of tobacco products, and control-
ling tobacco products, including warnings
in tobacco products and in any publicity
eventually residual, among others.
Although the measures of primary preven-
tion are fundamental,it is a mistake to think
that the treatment of addicts is a minor is-
sue. On the contrary, approaching smokers
is among the best cost/beneﬁt relations in
medical interventions.
Thus, to deal with such lethal pandemic,
one most use a combination of preventive
measures to prevent children from smoking
and treatment measures in order to moti-
vate and support smokers to quit. Cessation
support has also an eﬀect on prevention,
since it turns smoking a less frequent and
less socially accepted behaviour.
Nicotine dependence is a chronically relaps-
ing disorder of the brain. In fact, although
smokers know smoking is harmful for their
health and most of them would like to quit,
only a few really try,and even fewer succeed.
Without treatment,only 3 % of the smokers
are able to achieve six months of abstinence.
With pharmacological and psychotherapic
treatment, abstinence rates raise up to 25-
30% up to 6 months of abstinence. To stop
smoking is much more complicated than
deciding to stop eating avocado. Smokers
need to be motivated to quit, and treatment
should be widely provided.
94
In order to increase the availability of cessa-
tion support, educational measures must be
taken, such as:
the elaboration of guidelines,•
inclusion of diagnosis and treatment of•
tobacco dependence in health profession-
als curricula,
provision of counselling services on ces-•
sation of tobacco use in national pro-
grammes,
oﬀering training programs to all kinds of•
health professionals.
Evidence based treatments should be of-
fered and tailored to individual preferences
and needs. They can be divided in wide
reaching treatments (with low eﬃcacy and
low cost) and face to face treatments (high
eﬃcacy and high cost).
1) Wide reaching treatments:
Telephone help-lines (the proactive•
ones and a bigger probability of eﬃ-
cacy),
SMS messages,•
Web based treatments.•
2) Face to face treatments:
Brief advice (up to 3 min),•
Basic advice (up to 10 min),•
Intensive support (once a week or•
more).
In general, there is a dose-response rate, in
which the higher the dose (the frequency
and time during consultations) the higher
the abstinence rates reached.
In conclusion, those evidence based treat-
ment and preventive measures must be used
to decrease the prevalence of smoking. If
this alert is not heard and the policies here
suggested are not implemented around the
world, we will face the unnecessary death
of hundreds of million people in the near
future.
References
1. American Thoracic Society. Cigarette smok-
ing and health. Am J Respir Crit Care Med
1996;153:861-5.
2. Jha P, Chaloupka FJ. Tobaco control in develop-
ing countries. Oxford University Press on Behalf
of World Bank and World Health Organization;
2000.
3. Mackay J, Eriksen M. Tobacco Atlas. WHO;
2002.
4. Peto R, Lopez AD, Boreham J, Thun M, Heath
C. Mortality from smoking in developed countries
(1950-2000). Indirect estimates from national vital
statistics. New York: Oxford University Press; 1994.
5. Proctor N. Tobacco and the global lung cancer
epidemic. Nat Rev Cancer 2001;1(1):82-6.
6. Raw M, Anderson P, Dubois G, Hasler J, et al.
WHO evidence based recommendations on the
treatment of tobacco dependence. Tobacco Control
2002; 11: 44-46.
7. WHO Report on the Global Tobacco Epidem-
ic, 2008 The MPOWER package. Geneva, World
Health Organization, 2008.
8. United States. Morbidity and Mortality Weekly
Report (MMWR). Cigarette smoking-attributable
mortality and years of potential life lost. Centers for
Disease Control and Prevention. MMWR Morb
Mortal Wkly Rep 1990;42:645-9.
9. United States. Morbidity And Mortality Weekly
Report (MMWR). Trends in Cigarette Smoking
Among High School Students.United States,1991-
2001. Centers For Disease Control And Prevention.
MMWR Morb Mortal Wkly Rep 2002;51(19).
10. United States. Morbidity and Mortal-
ity Weekly Report (MMWR). Cigarette smoking
among adults. MMWR Morb Mortal Wkly Rep
2002;51(29):642-5.
11. United States Department of Health and Hu-
man Services (USDHHS).The health consequences
of involuntary smoking. A report of the Surgeon
General. Washington DC: US Government Print-
ing Oﬃce; 1986.
12. United States Department of Health and Hu-
man Services (USDHHS).The health consequences
of smoking: nicotine addiction. A report of the Sur-
geon General. Rockville: Public Health Service, Of-
ﬁce on Smoking and Health; 1988.
13. United States Department of Health and Hu-
man Services (USDHHS). The health beneﬁts
of Smoking Cessation. A report of the Surgeon
General. Atlanta (GA): Centers for Disease Con-
trol and Prevention; 1990; DHHS Publication No:
(CDC)90-8416L.
14. United States Department of Health and Hu-
man Services (USDHHS). Best practices for com-
prehensive tobacco control programs. Centers for
Disease Control and Prevention, National Center
for Disease Prevention and Health Promotion, Of-
ﬁce on Smoking and Health; 1999.
15. United States Department of Health and Hu-
man Services (USDHHS). Clinical practice guide-
line: treating tobacco use and dependence. Public
Health Service; 2000.
16. United States Department of Health and Hu-
man Services (USDHHS). Reducing tobacco use: a
report of the Surgeon General. Atlanta (GA): Cen-
ters for Disease Control and Prevention, National
Center for Chronic Disease Prevention and Health
Promotion, Oﬃce on Smoking and Health; 2000.
17. United States Department of Health and Hu-
man Services (USDHHS). PHS Clinical Practice
Guideline, Treating Tobacco Use and Dependence;
2007.
Dr. Analice Gigliotti
President of Brazilian Asoociation on Studies
of Alcohol and Drugs (ABEAD)
95
About WHPA
The global organisations representing the
world’s nurses, pharmacists and physicians
joined forces in 1999, creating a unique al-
liance to address global health issues – the
World Health Professions Alliance. In
2005, they were joined by the global rep-
resentative organisation of the dental pro-
fession. Dentists, nurses, pharmacists and
physicians deliver health care to individu-
als, families and communities regardless of
their colour, creed, gender, religion or po-
litical aﬃliation. The World Health Profes-
sions Alliance, speaking for more than 23
million health care professionals worldwide,
assembles essential knowledge and experi-
ence from the key health care professions.
The WHPA aims to facilitate collaboration
between key health professionals and major
international stakeholders such as govern-
ments, policy makers and the World Health
Organization. By working in collaboration,
instead of along parallel tracks, the patient
and health care system beneﬁt.
Member Organisations
TheInternationalCouncilofNurses(ICN)
is a federation of national nurses’associations
in 129 countries, representing the 13 mil-
lion nurses working worldwide. Founded in
1899, ICN works to ensure quality nursing
care for all, sound health policies globally,
the advancement of nursing knowledge, and
the presence worldwide of a respected nurs-
ing profession and a competent and satisﬁed
nursing workforce. www.icn.ch
The International Pharmaceutical Feder-
ation (FIP) is the global federation of 114
national organisations of pharmacists and
pharmaceutical scientists. Pharmacists are
health professionals dedicated to improving
the access to and value of appropriate medi-
cine use. www.ﬁp.org
The FDI World Dental Federation (FDI)
is the authoritative, worldwide voice of
dentistry with more than 130 member asso-
ciations in more than 125 countries around
the world, representing almost one million
dentists internationally. Its main roles are
to bring together the world of dentistry; to
represent the dental profession of the world
and to stimulate and facilitate the exchange
of information across all borders with the
aim of optimal oral health for all people.
www.fdiworldental.org
The World Medical Association (WMA)
is the global federation of national medi-
cal associations, representing millions of
physicians worldwide. Its membership is
made up of national medical associations
from around the world, directly and indi-
rectly representing the views of more than
seven million physicians. The WMA was
founded in 1946 and endeavours to achieve
the highest possible standards of medical
science, education, ethics and health care
for all people. In order to achieve this ideal,
the WMA is active in the ﬁelds of policy
development and the setting of professional
standards. www.wma.net
Priorities and Actions
WHPA is focused on the following key pri-
orities for improved global health care.
Health as a human right
As health professionals, all WHPA mem-
bers support and promote the principle of
health as a basic human right.This includes
the right to access safe and appropriate
health care for all people of the world.
Patient safety
Health care interventions are intended to
beneﬁt the public, but due to the complex
combination of processes, technologies and
human interactions there is an inevitable
risk that adverse events will happen. The
WHPA is working actively to improve sys-
tems and therefore reduce such incidents.
Alliance partners are also acting together
on other issues of patient safety, including
the presence of counterfeit medicines, anti-
microbial resistance and the ﬁght against
HIV/AIDS.
Global tobacco control
The WHPA encourages governments to
ratify and implement the WHO Frame-
work Convention on Tobacco Control.This
includes the developing of policies that ban
tobacco advertising and promotion; require
prominent and signiﬁcant tobacco warnings
on all tobacco products; ban smoking in
public places and commercial airline ﬂights;
provide public education campaigns against
tobacco use; and encourage tobacco farm-
ers to shift to crop substitution.WHPA also
promotes an active role for health profes-
sionals in tobacco control, both on the clin-
ical care level and on the association level
where advocacy is key.
The WHPA Leaders’ Forum
Better health worldwide can only be
achieved through collaboration, commu-
nication and dialogue to explore and ex-
change new approaches and methodologies.
One of WHPA’s important contributions to
this is to bring together leaders represent-
ing the member organisations and other
stakeholders in international health in a bi-
ennial WHPA Leaders’Forum, strengthen-
ing the bond and encouraging collaboration
between the four health professions in all
countries and settings.
The Future
WHPA is dedicated to continuing its role in
addressing global health issues.The Alliance’s
strategic orientation for the future will involve
both proactive work on speciﬁc initiatives
and responsive action to issues as they unfold.
These issues include: ethics, equity and access
to health care, patient safety, tobacco control,
strengthening health professionals’ involve-
ment on policy and health human resources
planning. With a forward looking vision and
collaborative spirit, the Alliance partners have
committed to taking an unprecedented pro-
active role to deliver improved health care to
populations worldwide.
Working together for safe health care,
the World Health Professions Alliance (WHPA)
96
(IFPMA) The International Federation
of Pharmaceutical Manufacturers & As-
sociations (IFPMA) has appointed Alicia
Greenidge as its new Director General. She
took oﬃce on 2 June 2008 and succeeds
Dr. Harvey Bale, who retired after almost
eleven years in the position.
Mr. Fred Hassan, President of the IFPMA
and Chairman and CEO of Schering-
Plough,said:“Ms.Greenidge has extensive
experience working with the Geneva-
based intergovernmental organizations, as
well as substantive knowledge of many is-
sues of concern to the IFPMA.This experi-
ence, combined with a practical approach
and keen mind, will equip her well for this
challenging role. I am very pleased with her
appointment to lead IFPMA.”
Ms. Greenidge comes to the IFPMA with
more than ﬁfteen years experience in bi-
lateral and multilateral negotiations with
governments in the Americas, Africa, Asia,
Paciﬁc, Middle East, and Europe, working
largely for the Oﬃce of the United States
Trade Representative (USTR), both in
Washington and in Geneva. In Geneva for
nearly ten years, Ms. Greenidge served for
a period as Acting Deputy Chief of Mis-
sion and, for the last eight years, as Assis-
tant Deputy Chief of Mission and Senior
Counsel.
Ms. Greenidge has gained a reputation as a
strong and eﬀective negotiator, but also as
a bridge and coalition builder. She has kept
channels of communication open and con-
tributed to many settlements and decisions
before the World Trade Organization, no-
tably the Public Health Declaration lead-
ing up to and at Doha, Qatar in 2001 and
subsequent agreements with regard to local
pharmaceutical manufacturing capacity in
developing countries, especially Africa. She
has participated in deliberations concern-
ing questions on the relationship of the
Trade Related Intellectual Property Rights
agreement (TRIPS), traditional knowledge
and the Convention on Biodiversity and led
in negotiated agreements on Least Devel-
oped Country matters under TRIPS.
Since 1998, she also has interacted with,
and advised on issues before other inter-
governmental organizations, such as WHO
(including IGWG issues and the IGM on
virus sharing and access to vaccines), UN-
AIDS, WIPO, UNCTAD and others. In
addition, she has engaged constructively
with several non-governmental organiza-
tions in Geneva.
During her government service, she has
interacted with industries and associations
representing various sectors, including
Pharmaceuticals and her activities spanned
across other subjects as well, such as trade
remedies, dispute settlement, textiles, elec-
tronic commerce, investment measures,de-
velopment assistance, aspects of the cotton
issue, bananas and services trade.
Ms. Greenidge has a Ju-
ris Doctorate from Boston
College, a Master’s degree
in Public International Law
& International Develop-
ment Economics from the
American University, and
a Bachelor’s degree in In-
ternational Relations and
Sociology from C.W. Post
College/LIU in the United
States.
About the IFPMA
The International Federation
of Pharmaceutical Manu-
facturers & Associations is
the global non-proﬁt NGO
representing the research-
based pharmaceutical, bio-
tech and vaccine sectors. Its members com-
prise 25 leading international companies
and 43 national and regional industry as-
sociations covering developed and develop-
ing countries. The industry’s R&D pipeline
contains hundreds of new medicines and
vaccines being developed to address global
disease threats, including cancer, heart dis-
ease, HIV/AIDS and malaria. The IFPMA
Clinical Trials Portal (www.ifpma.org/
clinicaltrials), the IFPMA’s Ethical Promo-
tion online resource.(www.ifpma.org/Ethi-
calPromotion) and its Health Partnerships
information www.ifpma.org/HealthPart-
netships – Developing World) help make
the industry’s activities more transparent.
The IFPMA strengthens patient safety by
improving risk assessment of medicines
and combating their counterfeiting. It
also provides the secretariat for the Inter-
national Conference on Harmonisation of
Technical Requirements for Registration of
Pharmaceuticals for Human Use (ICH).
IFPMA Appoints Alicia Greenidge as New
Director General
Alica Greenidge, new Director General of IFPMA and
Otmar Kloiber, WMA Secretary General at the WMA oﬃce in
Ferney–Voltaire
97
Myriah Lesko, BSc. Pharm., BSc.
Projects Coordinator FIP
Founded in 1912,the International Pharma-
ceutical Federation (FIP) is the global feder-
ation of national associations of pharmacists
and pharmaceutical scientists. FIP has been
in oﬃcial relations with the World Health
Organization (WHO) since the WHO con-
ception in 1949 and through its 120 Mem-
ber Organisations in 90 countries represents
and serves almost two million practitioners
and scientists around the world.
Throughout its almost 100 year history, FIP
has expanded both literally and ﬁguratively.
The emergence of pharmaceutical care as a
cornerstone of the profession and the grow-
ing recognition of the pharmacist as an
invaluable contributor to health outcomes
have lead FIP to become a visible advocate
of the role of the pharmacist in the provi-
sion of healthcare,while still maintaining its
grounding in pharmaceutical sciences.
Over the past several years, FIP has worked
towards advancing pharmaceutical sciences,
pharmacy practice and more recently phar-
macy education to the ultimate beneﬁt of
the patient.This has resulted from the work
FIP has done internally and through mutu-
ally beneﬁcial partnerships with key global
players, such as WHO. This collaboration
has served to promote the role of pharma-
cists in the WHO healthcare agenda and
has further led to some of the most signiﬁ-
cant partnerships between the key players
on the global healthcare stage.
FIP is focused on improving the health and
well being of communities through speciﬁc
and targeted projects. FIP works within the
WHO International Medical Products Anti
Counterfeiting Taskforce (IMPACT) to ad-
vocate for the input of health professionals
in assuring the integrity of the supply chain
of medicines, inherently including the iden-
tiﬁcation and reporting of counterfeit medi-
cines. The implementation of the WHO-
FIP Good Pharmacy Practice Guidelines
through the Good Pharmacy Practice Pilot
Projects is a prime example of enabling phar-
macists with the opportunity to use their
specialised knowledge and skills, to interact
with their patients and communities in order
to positively inﬂuence health outcomes.
The past several years have seen FIP bring
on an additional focus: pharmacy education.
Firmly believing that inﬂuential scientists and
practitioners are the result of comprehensive
and quality education, FIP has created the
Pharmacy Education Taskforce. The Task-
force is dedicated to coordinating and catalyz-
ing action to develop pharmacy education, to
be accomplished through the Pharmacy Edu-
cation Action Plan. In March of 2008 FIP,
WHO and UNESCO oﬃcially launched the
ﬁrst phase of the Action Plan, which will be
implemented between 2008-2010.
Neverforgettingitsroots,FIPcontinuestobe
fully engaged in the Pharmaceutical Sciences
and has successfully implemented a series of
Pharmaceutical Sciences World Congresses,
which serve as global platforms for the ex-
change of information related to the pharma-
ceutical sciences.The parallel development of
numerous FIP initiatives within pharmacy
practice, education and the pharmaceutical
sciences has demonstrated that the Federa-
tion is able to grow with concurrent streams
of interest without losing ground.
In 1999, FIP, the World Medical Associa-
tion (WMA) and the International Council
of Nurses (ICN) founded the World Health
Professions Alliance (WHPA)(the World
Dental Federation (FDI) came on board
in 2005). This unique and ﬁrst-of-its-kind
alliance brings together pharmacists, phy-
sicians, nurses, and dentists in initiatives
that focus on eﬀective interaction between
health professionals, while recognizing the
unique values and distinctive contributions
that each brings to patient care.
The potential of what may come of the com-
munication and interaction brought about
by the partnerships built within the WHPA
is of pinnacle value to all professions and the
communities we serve. FIP is very pleased
to have clear and open opportunities for
collaboration with our dedicated partners in
health. The Federation believes – and advo-
cates to our Members – that comprehensive
patient care can best be achieved through
partnership, team work and mutual respect
and understanding of what each profession
can contribute.
It is with this philosophy of growth that
FIP is headed into the future: the changing
tides of healthcare, its delivery and the role
of pharmacists and pharmaceutical scien-
tists demand that the Federation not only
keep pace but also provide solid leadership
to its Members and quality information and
solid input to its peers in healthcare,thereby
empowering all to positively inﬂuence glob-
al health.
Representing pharmacists and pharmaceutical
scientists – your partners in healthcare
The International Pharmaceutical Federation
Kamal Midha, President FIP
98
Aquina Thulare, Secretary-General of the
South African Medical Association
The South African Medical Association
(SAMA) is an independent professional asso-
ciationformedicaldoctorswithoutanystatuto-
ry or disciplinary powers. SAMA is a member
of the World Medical Association (WMA), a
global federation of national medical associa-
tions representing doctors worldwide.
The South African Medical Association
was established on 20 September 1997, fol-
lowing the uniﬁcation of the Medical Asso-
ciation of South Africa (MASA), founded
in 1927,and the Progressive Doctors Group
(formerly NAMDA).The name change was
eﬀected on the 21 May 1998.
On 30 April 1999 total uniﬁcation of the
major groupings for medical practitioners
was achieved when the National Medical
Alliance, representing the SA Medical and
Dental Practitioners, Society of Dispensing
Family Practitioners, Family Practitioners
Association, Dispensing Family Practi-
tioners Association and the Eastern Cape
Medical Guild, aﬃliated to SAMA.
Membership to the Association is volun-
tary. It is also a registered trade union for
its members employed in the public sector.
At present some 70% of doctors in both the
public and private sectors are members of
the association, which is registered as an in-
dependent, non-proﬁt section 21 company.
The Association’s activities focus on both
the professional and business aspects of
medical practice.
Our Mission
To represent doctors with authority and•
credibility in all matters concerning their
interests in the health care environment.
To promote the integrity and image of•
the medical profession.
To develop medical leadership and skills.•
To provide doctors with knowledge rele-•
vant to the demands of medical practice.
To promote medical education, research•
and academic excellence.
To encourage involvement in health pro-•
motion and education.
To inﬂuence the health care environment•
to meet the needs and expectations of the
community by promoting improvements
to health reform, policy and legislation.
Objectives
SAMA represents doctors in all matters
concerning their interests with authority
and credibility in the healthcare environ-
ment.
These objectives include:
promoting the integrity and image of the•
medical profession,
providing doctors with knowledge rele-•
vant to the demands of medical practice,
promoting medical education, research•
and academic excellence,
inﬂuencing the health care environment•
to meet the needs and expectations of the
community by promoting improvements
to health reform, policy and legislation,
encouraging involvement in healthcare•
promotion and education,
promoting trust, integrity, professional•
conduct, eﬃciency and goodwill within
the profession,
to support, improve and protect the sta-•
tus, rights, privileges and interests of all
members,
to lobby Government and any relevant•
body on behalf of the profession,
to facilitate in the maintenance of stan-•
dards of practice by members to the pub-
lic via continuing medical education,
to judiciously use all subscriptions, en-•
trance fees, levies and donations for the
pursuance of the aims and objectives of
the Association, while also using funds
entrusted for the furtherance of medicine
by way of bursaries, research grants and
subsidies,
to be the guardian of the codes structure•
for members; setting out the practice
guidelines in all ﬁelds of practice,
to disseminate information to members•
in order to keep them up to date with the
latest developments in our industry by
means of relevant publications; and
to act in an advisory capacity regarding•
member concerns and enquiries where
possible.
SAMA has 20 branches countrywide that
serve members on a more personal level,and
represent their interests and needs in that
particular geographical area. Branch council
TheSouthAfricanMedicalAssociation(SAMA)
Uniting doctors for the health of the nation
Prof. Ralph Kirsch, President of the South
African Medical Association
99
The Nigerian Medical Association founded
in 1960, began as a branch of the British
Medical Association in 1951. It is the larg-
est medical association in the West African
sub-region with over 35 000 members from
36 state branches and a branch from the
Federal Capital Territory. 70% of doctors
practice in urban areas where only 30% of
the population resides. The population of
Nigeria is about 130 million. Policy deci-
sions are made by the Association’s Nation-
al Executive Council (NEC), which is the
governing body. The constitution of NMA
is supreme and its provisions have binding
force on all authorities, organs, branches
and members of the Association and, where
applicable, on any other persons.
While our Vision is to build a formidable
professional body committed to fostering
eﬀective and eﬃcient health care delivery,
high ethical standards and the interest of its
members, our mission is to build a sustain-
able professional association of medical and
dental practitioners that will advance the
delivery of qualitative health care services
through continuing professional develop-
ment, advocacy, and policy development,
knowledge management, public education
members are elected through a democratic
process every three years to represent mem-
bers at the annual National Council meeting
of SAMA. Branch oﬃces arrange their own
activities such as Continuing Professional
Development (CPD) events and regular
branch meetings, and oﬀers a branch peer
review function when needed. Branch sup-
port staﬀ also deals with day-to-day queries
from members, with the assistance from
head oﬃce. New members are encouraged
to contact their local SAMA branch and
become involved in SAMA activities.
Aﬃliated groups
Members also enjoy representation through
the various aﬃliated groups. SAMA has
more than 56 aﬃliated specialist and special
interest groups with proportional represen-
tation on National Council.
Decision making at SAMA
National Council
As a representative body for doctors,SAMA
encourages and facilitates member partici-
pation in decision-making through a dem-
ocratic and transparent governance process.
Ordinary members can participate at local
level in the activities of the 20 branches
and the 56 specialists and specialist inter-
est groups. Branches and groups have pro-
portionate representation on the SAMA
National Council, which meets once a year
when all elected representatives meet to dis-
cuss and debate issues aﬀecting doctors on
a national basis.
Board of Directors
National Council appoints a Board of Di-
rectors, which meet quarterly to discuss
matters regarding the business aﬀairs of the
Association including policy, budget, ﬁnan-
cial, economic and management issues.
Standing Committees
National Council also appoints the members
of ten standing committees,which each have
a speciﬁc mandate. These include human
rights, law and ethics, private practice mat-
ters,public sector doctor issues,health policy,
and education,science and technology.These
committees meet regularly and report back at
the quarterly meetings of the SAMA Board
of Directors, and to their peers at the annual
National Council meeting.
Secretariat
A secretariat is situated in Pretoria, Gau-
teng with a full-time support staﬀ of 55.The
Secretary-General is the head of the Secre-
tariat from where she directs and adminis-
ters the aﬀairs of the Association within the
framework of operating policies established
by National Council and the Board of Di-
rectors. She also exercises control over all
matters concerning the administration and
management of the head oﬃce and staﬀ.
In an environment that is constantly chang-
ing, membership of The South African
Medical Association (SAMA) provides doc-
tors with the kind of support that they need
in order to be able to practise medicine suc-
cessfully. On behalf of its members, the As-
sociation strives for a healthcare dispensation
that addresses the challenges of healthcare
delivery in South Africa.
The Association provides doctors with in-
dividual and collective representation aimed
at inﬂuencing medical and health legisla-
tion, regulation and policies.
Dr. Kgosi (TKS) Letlape,
Chairperson SAMA, former President WMA
Overview of the Nigerian Medical
Association (NMA)
Dr. Ishaq Abdul (R) handing over to the Current
Secretary General,Dr.Kenneth Okoro (L)
100
in collaboration with other collaborating
partners in health.
Any medical or dental practitioner regis-
tered under the Medical and Dental Prac-
titioners’Act CAP 221 Laws of the Federa-
tion of Nigeria (1990) and as subsequently
amended shall have a right of membership
of the Association on payment of the an-
nual practicing fee in the said Act as may be
reviewed from time to time, unless other-
wise prescribed in the constitution.The As-
sociation has both governance and manage-
ment structures with the Annual Delegates’
Meeting (ADM) as the highest decision
making body. The management is by the
National Oﬃcers’ Committee (NOC) led
by the President and this occupies the third
level. The NOC has seven elected members
who are democratically elected every two
years and has responsibilities for manag-
ing the aﬀairs of the Association. The cur-
rent National Oﬃcers’ (2008/2010) are: Dr.
Prosper Ikechukwu Igboeli, President; Dr.
Bala Mohammed Audu, 1st
Vice President;
Dr. O.O. Alan Taiwo, 2nd
Vice President;
Dr. Kenneth Johnson Okoro, Secretary-
General; Dr. Chris Enoch, Deputy Secre-
tary-General; Dr. Ibrahim Abubakar Kana,
Treasurer; Dr. S.N.C. Anyanwu, Editor, Ni-
gerian Medical Journal
The administrative head of the secretariat is
the Secretary-General and is assisted by a
core of support staﬀ for the smooth running
of the secretariat.
The Association’s Journal, Nigerian Medi-
cal Journal (NMJ) was founded in 1964
with the following aims:
• to provide a medium
for the dissemina-
tion and permanent
record of the result
of clinical experience
and scientiﬁc medical
research, particularly
in Nigeria.
• to serve as a forum
for the dissemination
of general information
and report on conference of the Nigerian
Medical Association among members.
Although the Association is involved in
many of the government’s activities,it is con-
sulted formally by the government only on an
‘ad-hoc’ basis. It is not consulted as ‘of right’
on health issues and has to press for its par-
ticipation.The Association nominates eleven
members of the Medical and Dental Coun-
cil of Nigeria (MDCN), which regulates the
practice of medicine & dentistry in Nigeria
and the curricula of its medical schools.
The NMA is at present involved in inﬂuenc-
ing health policy formulation in an ad hoc
manner. This is done by making unsolicited
recommendations to government on vari-
ous health issues and also by making inputs,
whenever invited, to some of the national
committee meetings on policy formulations.
The Association holds training courses
for doctors, and participates in radio pro-
grammes and TV talk shows. It has several
on-going projects including those on AIDS,
on family planning and on Primary Health
Care (PHC). Project development is depen-
dent upon outside funding. Funding agen-
cies supporting the Association’s activities
include UNFPA,UNICEF,WHO,USAID,
the Ford Foundation, and the John D and
Catherine T MacArthur Foundation.
The Association collaborates in speciﬁc
projects on health issues with individual
NGOs and with the National Association
of Non-governmental Organizations on
Health (NANGOH). The NMA plans to
make more in-roads into the Federal Min-
istry of Health to ensure that it is involved
in all aspects of policy formulation, espe-
cially in the planning stages.
It is also planned that the NMA continues
to cooperate with government in project
development so that the association may be
represented on the delegations to regional
and international health conferences.
The Nigerian Medical Association (NMA)
is the host of the permanent secretariat of
the Confederation of African Medical As-
sociation and Societies (CAMAS). The
Association is developing a proposal to in-
volve all African Medical Associations and
Societies in eﬀorts to improve reproductive
health and safe motherhood in Africa.
The Nigerian Health System performance has
been poor, having been ranked 187th
amongst
191 member states in 2000. Infant Mortality
rate was 97 per 1000 live births and has wors-
ened to 110 per 1000 live births in 2005.This
is against the MDG – 4 targeted improve-
ment to 30 per 1000 live births by 2015. Ma-
ternal Mortality rate was 704/100,000 births
and has also worsened to 800/100,000 births
in 2004 as against the MDG – 5 targeted im-
provement to 75/100,000 births by 2015.Life
expectancy at birth is 45 years for males and
46 years for females.
While budgetary provisions for health re-
main grossly inadequate,other major factors
contributing to the above poor health indi-
ces include unfavourable working environ-
ment, inadequate lack of essential medical
equipment, poor health seeking behaviour
of many Nigerians, lopsided distribution of
health facilities and very poor remuneration
of Medical Personnel. Lack of desired mo-
tivation has led to the massive brain drain of
Medical Professionals whose exodus from
Nigeria became very noticeable in 1985.
In deed, over 10,000 Nigerian Doctors are
practising outside the country.
It is hoped that the above scenario will
change for the better in the coming years.
Dr. Kenneth Johnson Okoro,
Secretary-General
Group picture of both the Immediate Past and Current Executives
after the Handing Over Ceremony
101
Dr. Florent Aka Kroo,
President of the NOPCI
Located in the Guinea Gulf, the Republic
of Côte d’Ivoire is a West African country,
independent since August 1960 and with
currently about 18 million inhabitants.
The National Order of Physicians of Côte
d’Ivoire (NOPCI) was established in Sep-
tember 1960, one month after the birth of
the Ivorian State by Parliament # 60-284
law of 10 September 1960.
The NOPCI has two major missions, which
are as follows:
to empower all physicians who are will-•
ing to practice Medicine in the Country;
they must go through a yearly registration
with the National Board of Physicians;
to see that all physicians are respectful•
of the principles of morality, probity, and
devotion which are indispensable for the
practice of Medicine; the NOPCI ensures
as well the respect by all its members of
the professional duties and the rules of
the code of ethics; its defends the honour
and independence of the medical profes-
sion; it can also provide support and as-
sistance to its members.
The NOPCI went through a long 40-year
period of lethargy. However, since 30 Oc-
tober 2004, it is becoming more dynamic
thanks to a new management team.
Therefore the participation index which
was 15% (about 350 registered physicians
in good standing), is currently up to 85%
(about 3800 physicians out of 4500). The
national ratio is 1 physician for 5000 inhab-
itants.
The new team’s eﬀort is also extended out-
side the national area, to:
the sub-regional area in relation to the•
Orders Conference of the West African
Economic and Monetary Union States
(WAEMUS),
the French speaking area with the re-•
cently established French-speaking Or-
ders Conference (over 30 countries with
French as a full or partial language),
the international and global arena with•
the NOPCI membership application to
the World Medical Association (WMA).
This application shall go through a vote at
the General Assembly of the WMA to be
held in Seoul (Korea) on 15-18 October
2008 and we hope it will succeed.
The NOPCI is aware of its position of
“Guardian of the Temple” in Ivorian Medi-
cal practice. However it considers it impor-
tant to be informed of its members’acts and
thoughts should they be willing to do so.
Therefore it is planning to establish the Ivo-
rian Medical Association prior to the WMA
General Assembly of October 2008. Such
an initiative will bring Ivorian physicians to
more representation at a global level.
The Côte d’Ivoire went through an eco-
logical disaster in September 2006 as toxic
waste was poured out in Abidjan, the eco-
nomic capital and its suburbs.
Over 100 000 inhabitants of the City were
considered victims of gas emissions, 12 of
them died, 79 were admitted to care set-
tings, and more than 100 000 consultations
were recorded.
In January 2007, the NOPCI organised a
scientiﬁc workshop in order to check the
medical aspects of this disaster,and its mean
and long term eﬀects, as well in exposed
subjects. It is now planning to establish a
non-governmental Observatory, and needs
technical and ﬁnancial support.
The NOPCI along with the upcoming Ivo-
rian Medical Association is willing to be on
the same wavelength as the WMA, regard-
ing its objectives: improvement of patients’
care, respect of medical ethics, patients’
rights, and sustained eﬀort to ensure a post-
academic training of quality.
The National Order of Physicians of Côte
d’Ivoire: presentation and perspectives
National Order of Physicians of CI with CI President Gbagbo
102
Background
The Medical Association of Thailand is a
non-governmental non-proﬁt making so-
cial promotion organisation of the Medical
Professions in Thailand. It was founded in
1921 in Bangkok. It is, at present, located
at the Royal Golden Jubilee Building #
2 Soi Soonvijai, New Petchburi Road,
Huaykwang district, Bangkok 10310, Thai-
land. CABLE Address “MEDITHAI”
Tel. (66) 2 3144344, (66) 2 3188170 Fax.
(66) 2 3146305 Email address: math@lox-
info.co.th and http://www.mat.or.th.
The present governing body of the Associa-
tion is composed of a President (Dr.Aurchart
Kanjanapitak), President Elect (Pol. Major
General Dr. Jongjate Aojanepong), Vice
President (Dr. Chatri Banchuin), Secretary
General (Associated Professor Dr. Prasert
Sarnvivad) with other 16 council members
and also Presidents of all specialty colleges
and faculties and invited past presidents and
recognised members. The term of the com-
mittee will be 2 years from general election
amongst members. The membership of the
Association at present is 23,000 out of a total
33,000 graduates or about 70 %
Functions:
The Medical Association of Thailand•
works towards;
Promoting and coordinating Medical•
Professions under ethical integrity;
Promoting relationship amongst mem-•
bers;
Promoting education, research and medi-•
cal services;
Providing welfare to members;•
Coordinating and collaborating with other•
medical organisations both in governmen-
tal and in private sectors to improve better
standard of medical provision and public
health to meet international standard;
Advocating health promotion (exercise•
and antismoking campaigns), prevention,
and medical services to public;
Collaborating with international health•
and medical organizations to keep the
global standard.
The Medical Association of Thailand has a
role in bringing all health and medical pro-
viders from both governmental and private
sectors to work together through the elective
executive committee which is composed of
members from various sectors. The Medi-
cal Association of Thailand is also one of the
three components forming a collaborative
body from the Ministry of Public Health, the
Medical Council and the Medical Associa-
tion as a platform to oversee and overcome the
arising problems in the Medical profession
and allied professions at monthly meetings.
The Medical Association is also taking a role
in providing compromises in the conﬂicts
amongst medical providers and consumers.
Journal of the Medical Association of Thai-
land is an accepted world class medical pub-
lication for medical education, research and
medicalknow-how.Itispublishedbi-monthly
and distributed amongst members and medi-
cal institutes including medical faculties and
medical libraries in the whole country.
The Medical Association of Thailand is also
currently providing not only mobile teach-
ing teams to the remote areas, but also sup-
ports them with the professional insurance.
International Relationship
At present the Medical Association of Thai-
land is taking more part in the international
aﬀairs. One of its past Presidents (Prof. Dr.
Somsri Pausawasdi) has currently been elect-
ed to the President of CMAAO (Confed-
eration of the Medical Association in Asia
and Oceania with 17 member countries).
Also its international relations chief oﬃcer
(Dr. Wonchat Subhachaturas) is the elected
Chairman of the Council in CMAAO, as
well the President of the Association is au-
tomatically a councillor in the CMAAO and
the MASEAN ( The Medical Associations
in South East Asian Nations).
The Medical Association of Thailand pro-
vides full support to the WMA (World
Medical Association) as an active member
and send its representatives to participate in
every General Assembly Meeting and al-
ways works closely with member countries
through e-mails and the website (http://
mat.or.th). Exchange visiting programmes
are also well ongoing within the region and
outside upon the invitations.
Wonchat Subhachaturas M.D.,FRTCS
International Relations for the MAT
The Medical Association of Thailand under
the Royal Patronage of his Majesty the King
Dr. Aurchart Kanjanapitak, President of The
Medical Association of Thailand
Prof. Dr. Somsri Pausawasdi, Presi-
dent of CMAAO
103
The Hong Kong Medical Association
(HKMA) was established in 1920. It is
the professional body representing doctors
in Hong Kong, and is an independent non-
government organization. It has a mem-
bership of 7,943, out of the 10,979 doctors
within a population of 7 million in the Spe-
cial Administrative Region of China. Hong
Kong enjoys freedom due to the “One
Country Two System”policy and practice of
the People’s Republic of China.
The motto of HKMA is “Safe-guarding the
Health of People”.
We have roughly half of our members work-
ing in the public sector, and another half in
the private. The issues that HKMA is con-
cerned with are usually important to both
the private and public doctors.
The professional autonomy of the medical
profession is manifest by the peer-groups-
review practice and self-regulatory power of
the Medical Council of Hong Kong which
is the quasi-statutory body responsible for
the setting of standards, implementation of
regulation and disciplining doctors.
We are aiming at a better democratic rep-
resentation on the Medical Council as our
medical regulatory body and independence
from the government.
The Food and Health Bureau has been
considering health reform with Healthcare
Financing Consultation. The HKMA has
conducted survey within the profession to
collect the opinions of physicians towards
the proposed health reform and healthcare
ﬁnancing, especially the pros and cons of
mandatory medical insurance and medi-
cal saving. HKMA also met regularly with
medical insurers to work on core elements
of good medical insurance scheme.
In Hong Kong, we are concerned that the
family doctor concept should be better im-
plemented and more training opportunities
for family physicians. There is a specialist
register here but not a primary care regis-
ter. We also strive to improve public-private
collaboration. The HKMA proposed a pri-
mary care register but the medical council is
apparently not yet ready.
The HKMA has been ﬁghting for main-
taining the right of dispensing by physi-
cians. Public opinion poll was done in
2007, conducted by the public opinion
program of the University of Hong Kong.
The results showed that 3/4 respondents
objected to the separation of dispensing and
consultation. However, the pharmacists are
still campaigning to change the practice in
Hong Kong to strip doctors of the rights
to dispense and to deprive patients of the
choice of getting medicine from the doctors
they consult.
We had published the Good Dispensing
Manual, encouraging members and their
staﬀ to continually update themselves with
good dispensing methods and risk manage-
ment. Dispensing errors occurred not only
in the private sector, but also in the public,
i.e.the Hospital Authority; not only by doc-
tors but also by dispensers or pharmacists.
The HKMA cooperates with the Medical
Protection Society (MPS) to assist doctors
in medico-legal litigation. These disputes
often cause immense stress and serious
consequences to doctors. The secretariat
of HKMA will help members to contact
the MPS. The soaring annual premiums
for doctors become unbearable. HKMA is
negotiating with MPS and the government
to think of ways to limit these burdens of
doctors. We have established a mediation
committee to promote this “win-win” me-
diation approach to solve patient-physician
conﬂicts.
In the private sector,doctors suﬀer from un-
scrupulous rental increase in public housing
estates which cause tremendous diﬃculties
in running clinics. HKMA led our mem-
bers to protest against Link Real Estate In-
vestment Trust (Link REIT) and organized
rally and march by our members together
with workers of other trades. Private Doc-
tors are also troubled by medical groups and
HMOs which have too much emphasis on
customers’ service, marketing and commer-
cial elements of medical practice, but might
erode professional autonomy. HKMA
strived to persuade the government and the
legislature to regulate HMO, group practic-
es as well as insurance-run clinics to ensure
level playing ﬁeld for solo practitioners.
In the public sector doctors suﬀer from long
inhuman working hours, poor working en-
vironment, inadequate training and low re-
spect for professionalism from the govern-
ment and the public. The morale has been
worsening and there has been staﬀ exodus
from Hospital Authority, resulting in de-
terioration in quality service. This problem
will eventually jeopardize the whole medi-
cal work force in the territory. The HKMA
is ﬁghting the battle together with our pub-
lic colleagues especially our junior members
who were so demoralized. We had sent a
letter to WMA to see the working condi-
tions of junior colleagues in other NMAs.
Our members demonstrated together and
The Hong Kong Medical Association
(HKMA)
104
marched to the government house to ﬁght,
hoping to bring a brighter future for our
profession and our next generation. Now,
there has been some improvement in work-
ing hours and training prospects after
lengthy battles, but more need to be done.
The government (the Education Bureau,
Food and Health Bureau and University
Medical School) proposed to increase the
intake of medical students,aiming to double
the number of graduates. HKMA opposed
and the Secretary for Education promised
to look into the matter from the perspective
of overall supply and demand of physicians
and also the training prospect of the medi-
cal graduates.
We have regular exchange programmes and
cooperation with the Chinese Medical As-
sociation, while we are totally independent
of each other. The HKMA has 12 monthly
HKMA newsletters, 12 monthly CME
Bulletins, and bi-monthly Hong Kong
Medical Journals. We are providers, orga-
nizing CME activities, as well as accredi-
tor of CME activities. We have an on-line
CME website as well as lots of cultural and
sports activities organized for our members.
There are HKMA orchestra, HKMA choir
and singing group, HKMA no. one band,
and a HKMA charitable foundation. We
have a theme song of the HKMA: “We are
concerned”. This year, the HKMA has or-
ganized several concerts in theatres, as well
as mini-concerts in malls and streets to raise
donations for needy people, patient groups
and the earthquake victims in Sichuan.
Dr. Alvin Yee Shing CHAN,
Vice President of the Hong Kong Medical
Association, Chairman of International
Aﬀairs Committee, Chairman of
Rehabilitation Committee, Central
Coordinator of the HKMA Community
Network, Chairman of HKMA Orchestra
Committee and Choir Committee, Elected
members of the Medical Council of
Hong Kong
Dr.Safarli Nariman, AzMA president
The Azerbaijan Medical Association
(AzMA) is the country’s leading voluntary,
independent, non-governmental, profes-
sional, membership medical organization
for physicians, residents and medical stu-
dents who represent all medical specialties
in Azerbaijan.
In 1999, Dr. Nariman Safarli and his col-
leagues founded the Azerbaijan Medical
Association (AzMA) and association was
oﬃcially registered by Ministry of Justice
of Azerbaijan Republic in December 22,
1999.
Since its inception, the AzMA continues
serving for a singular purpose: to advance
healthcare in Azerbaijan.
The mission of the AzMA – is to unite all
members of the medical profession, to serve
as the premier advocate for its members and
their patients, to promote the science of
medicine and to advance healthcare in Azer-
baijan.
The main aims of AzMA are:
to protect the integrity, independence,•
professional interests and rights of the
members,
to promote high standards in medical•
education and ethics,
to promote laws and regulation that pro-•
tect and enhance the physician-patient
relationship,
to improve access and delivery of quality•
medical care,
to promote and advance ethical behavior•
by the medical profession,
to support members in their scientiﬁc and•
public activities,
to promote and coordinate the activity of•
member- specialty societies and sections,
to represent members’ professional inter-•
ests at national and international level,
to create relationship with other interna-•
tional Medical Associations.
The AzMA’s vision for the future, and all
its goals and objectives are intended to sup-
port the principles and ideals of the AzMA’s
mission.
In 2000, the AzMA established its Per-
manent Committees and the mission of
the association is accomplished through its
committees as it realizes the decisions of the
AzMA General Assembly, studies health
care delivery in Azerbaijan, and works out
and performs health policy and activities
through the Executive Board. The AzMA
The Azerbaijan Medical Association (AzMA)
105
Permanent Committees are: Science and
Education Committee, International Re-
lations Committee, Ethics Committee,
Administration & Finance Committee,
Membership & Bylaws Committee, Pub-
lic Health Committee, Information &
Publications Committee, Private Medical
Practice Committee, Legislative Services
Committee, Public Relations Committee,
Physicians Health Committee. Member
physicians volunteer countless hours to par-
ticipate in one or more of the 11 Permanent
Committees which meet on a regular basis
throughout the year.
In 2000, the AzMA has developed special
membership sections to address the unique
interests and concerns of association mem-
bers. These sections are following- Medical
Student Section, Organized Medical Staﬀ
Section, Resident Physician Section, Young
Physician Section, International Medical
Graduate Section.Now AzMA is in the pro-
cess of establishing its local AzMA branches
in 13 regions and also assists in creation of
member-scientiﬁc societies on specialty
level.
International Relationship
Today AzMA continue to work closely with
other medical organizations both within the
country and at an international level. The
following are the AzMA’s national and in-
ternational aﬃliations.
National aﬃliations: In 2000, AzMA be-
came a full member of the National NGO
Forum of Azerbaijan Republic.
International aﬃliations: The year 2002
yielded memorable and historical events
for Azerbaijan Medical Association such as
membership to the World Medical Associa-
tion (WMA). AzMA became a part of the
WMA family. AzMA president participated
in several General Assemblies of WMA,and
these were unique chance for our association
to develop its relations with other member
National Medical Associations and also gain
new experience in diﬀerent ﬁelds of part-
nership within the WMA family. In 2002,
AzMA became an associate member of the
European Union of Medical Specialists
(UEMS). In 2000, AzMA was admitted as
member in the European Forum of Medical
Associations(EFMA) with the right for con-
sultation. In 2000 Azerbaijan Medical Asso-
ciation became a full member in the Forum
for Ethics Committees in the Confederation
of Independent States (FECCIS).
AzMA Membership Services
As a professional organization the AzMA
provides services to its members.In the Leg-
islative Services Committee, lawyers provide
eﬀective advocacy and legislative represen-
tation for member physicians. They give
consultation on related legislative matters.
The committee regularly organize legislative
seminars for physicians, students, hospital
and private medical centers staﬀ members.
Also since 2000,the “AZMED”Resource &
Training Center – organize for its members
regular courses on following issue: Basic
Principles of Bioethics, Medical Law and
Health Legislation, English for Doctors,
Basic and Advanced Computer and Inter-
net courses, Project proposals writing and
fundraising courses for Doctors, Leader-
ship and Management for Doctors.
The total number of members of the Azer-
baijan Medical Association is 1250 (in-
cluding student membership). The admin-
istrative bodies of the Association are the
General Assembly, the Councils, and the
Executive board. AzMA staﬀ consists of 8
persons, who are working on voluntary ba-
sis. Also working group which consists of
30 doctors and students actively involved to
organize the AzMA regular seminars,train-
ings, conferences and work on edition and
publication of AzMA quarterly bulletin
for members- “AzMA VISION”.
Relationship with Government
Since its establishment the AzMA work
closely with MOH,especially on policy and
health system structure and organization.
In 2001-2003 years, AzMA has been ac-
tively involved as Health NGO joining
Public Health Workgroup of the coopera-
tive program of World Bank and Azerbai-
jan Republic about “Eradication of Poverty
in Azerbaijan”,In 2008,AzMA also actively
cooperate with MOH in National Health
Reforms program,which ﬁnancially support
by World Bank. During this year AzMA
conduct meetings several times with Health
Reforms Center of MOH which have au-
thority to make decisions in the ﬁeld of
Health Care Policy.
Future plans
Currently AzMA is preparing to realize in
near future its next project in Public health
ﬁeld named as “Be Healthy” online health
education for population of Azerbaijan.
Project goals:to make available online health
information and consultation to Azerbaijan
citizens who use internet. In 2009, AzMA
planning to publish a scientiﬁc journal“Azer-
baijan Medical Association Journal” for Az-
eri physicians.On 17-18 June 2009, AzMA
will organize the International conference
“Cross-Cultural Aspects in Bioethics”.
Today, AzMA members work hard to pro-
mote the science of medicine and to protect the
health of Azerbaijan citizens.
Contact information:
E-mail: info@azmed.az
azerma@hotmail.com
Website: www.azmed.az
Meeting “Role of Health Organizations in Na-
tional Health System” with the representatives of
Ministry of Health, UN agencies and other In-
ternational organizations functioning in Public
Health ﬁeld in Baku 2003
106
Dr. Rosanna Capolingua, AMA President
About the AuMA
The Australian Medical Association serves
to represent and protect the needs of pa-
tients in Australia. In doing so, it represents
the goals of the Medical Profession. The
Australian Medical Association (AMA),
the country’s peak health advocacy organi-
sation, was incorporated in 1961. Prior to
this, it operated as a branch of the BMA.
We currently represent more than 27,000
doctors from each Australian state and ter-
ritory and across every specialty craft group.
These include salaried doctors in the public
sector and doctors in private practice, doc-
tors-in-training and medical students.
The President, Vice President, Chair of
Council and Treasurer are elected annually
at the National Conference. The Executive
committee is made up of these oﬃce bear-
ers and two Federal councillors elected by
the Federal Council. The policy setting for
the organisation is performed the Federal
Council. This comprises 34 elected repre-
sentatives from the Australian States and
Territories and each craft group (including
the Australian Medical Students’ Associa-
tion President and the Committee of Doc-
tors-in-Training) together with the four
Oﬃce-bearers.
AMA membership is discretionary. AMA
branches are set up in each state and ter-
ritory. These run independently and focus
primarily on State issues, industrial repre-
sentation and services for members. They
enjoy a close, collaborative relationship with
the federal Association – with all State and
territory members being members of the
Federal AMA. The federal AMA drives
the national agenda – primarily in lobbying
Federal Government, policy development
and dissemination,and maintains a national
media proﬁle of the Federal President.
The AMA is a strong voice in the medico-
political arena. Australians deserve a health
system that continues to improve and go
forwards. Government decisions on health
care based on a political foundation and not
quality of care are not acceptable.The AMA
is loud and clear that it will not accept com-
promise to patient care. Our Association be-
lieves the solution is to build on the strengths
of our current system, using clinically-driven
reform to improve access to services.
Current Challenges in Healthcare for
the Australian Medical Association
The Australian health system ranks well in
the world on many of the measures used
by the WHO and amongst OECD coun-
tries. We acknowledge that there are some
problems within the system but, overall, it
provides well for the vast majority of Aus-
tralians. There are many reasons for this
consistently good performance but central
is the system of universal access to medical
services, pharmaceuticals, free public hospi-
tal care and a subsidised private health in-
surance scheme, which equalises premiums
across the community with a ‘community
rating’. This is underpinned by good ac-
cess to highly-trained medical practitioners
providing excellent patient-centred care to
individuals whilst participating in continu-
ous improvement cycles that enhance that
quality of medical care.
However, key challenges for health care
delivery within Australia mirror the rest
of the world – primarily due to increasing
costs of innovation and technology, an age-
ing population, increased needs for patients
with chronic and complex conditions and a
workforce struggling to meet demand as the
average working age increases, participation
time at work reduces and morale and reten-
tion rates of health care professionals fall.
One of the strengths of our health system
is that it is predominantly a primary health
care delivered system with the general med-
ical practitioner role being central as the
physician, philosopher and friend or guide
of the patient through what is the health
care maze. GPs perform roles in acute care,
initiating investigations and diagnosing as
well as making referrals to the other spe-
cialist medical and allied health providers in
the system. This is an eﬀective and eﬃcient
system but the current reform environment
The Australian Medical Association –
a voice for patients and doctors
Dr. Mukesh Haikerwal, Immediate Past Pres-
ident AMA,Representative on WMA Council
107
sees proposals to shift some of the medi-
cal practitioner’s responsibilities and roles
to other health providers including allied
health, paramedics, physicians’ assistants,
pharmacists and nurses.
Achieving a balance within a multi-disci-
plinary team is challenging. The medical
practitioners should provide the medical
care coordination. They do work collabora-
tively with the various providers of health
care, in a cooperative, holistic and continu-
ous way avoiding duplication or, worse still,
fragmentation and neglect. Responsibility
and oversight as well as support for health
providers by medical practitioners are cur-
rently markers of quality and the safety of
the patient, which is paramount.
There are notable exceptions to the overall
good health outcomes in Australia, these
being Aboriginal and Torres Strait Islander
Australians and people in regional, rural
and remote areas that are currently disad-
vantaged in terms of care provision and
outcomes. Aboriginal and Torres Strait Is-
landers have a 17-year less life expectancy
compared to non-Indigenous Australians.
The AMA has entered a coalition of health
and welfare groups to ‘Close the Gap’.There
is a concerted and detailed plan of action
setting out an agenda to improve health out-
comes for Indigenous people and increase
the number of people in the Indigenous
health workforce. A series of indicators and
benchmarks for success have been detailed
and agreed by the coalition. AMA mem-
bers are also concerned about the proposed
National Registration and Accreditation
scheme. At the moment, each state and ter-
ritory has its own medical registration body.
The Australian Medical Council provides
national consistency for new entrants from
medical schools and overseas. Professional
accreditation has always been a professional
responsibility exercised by the learned Col-
leges. The AMA supports a system of Na-
tional Registration of doctors to enhance
workforce mobility. The new scheme for
Australia will however, be centralised, bu-
reaucratised and removed from where
medicine is practised. At the same time the
new scheme holds greater dangers with the
proﬁciencies and standards for clinical cre-
dentialing and accreditation wrestled from
the profession and placed into the political
control of government.
The loss of the independence of standard
setting and accreditation of medical train-
ing will serve to undermine standards and
compromise quality of patient care.
Access to free service in the nation’s pub-
lic hospitals is a core component of our
system. Unfortunately, these have suﬀered
from funding shortages and administra-
tive and bureaucratic failures. Many doctors
stop working in these hospitals, as they feel
under-valued, unable to teach or to partici-
pate in research. Further, they feel they are
compromised in their ability to deliver care
to patients.
Public hospitals run close to or above 100
per cent occupancy throughout the year and
this often results in no availability for care in
the hospital. Cancellation of elective wait-
ing lists, long delays in elective and some-
times more urgent surgery, overcrowding in
emergency departments, ambulance bypass
and ambulance ramping are all symptoms of
bed shortages and excessive occupancy.
The AMA wants two immediate measures
undertaken: establishing 85 per cent occu-
pancy as a national safety benchmark; and
the provision of 3,750 additional acute beds.
Australia is lucky to be looking forward to
signiﬁcantly more medical graduates. The
challenge is to provide adequate high-quality
clinical training for these students and then
specialist training places to allow them to
practice independently as GPs or other spe-
cialists.General practice and the private sector
and other settings will be needed to contribute
to providing this training environment.
Around 36 per cent of doctors practicing
in Australia at the moment have graduated
from an overseas medical school. Interna-
tional medical graduates are an essential
part of looking after patients in Australia.
Recently, there has been a focus on their
role and the need for nationally-consistent
assessment processes. There is an identiﬁed
need to support new entrants from overseas
as they enter the Australian workforce.
The Australian Medical Association has
been going strong and celebrates its 50th
anniversary in 2011. We will continue to
ﬁght for the best outcome for doctors, but
our fundamental concern will always be the
health and welfare that beneﬁt patients.
AMA Federal Council in Canberra in 2007. Front row, from the left, AMA Vice President
Dr. Gary Speck, AMA Chairman of Council Dr. Dana Wainwright, Dr. Capolingua, and AMA
Treasurer Dr. Samuel Lees
108
The New Zealand Medical Association
(NZMA) is the largest pan-professional
medical representative group in New Zea-
land. The NZMA aims to provide leader-
ship of the medical profession; and pro-
mote professional unity and values, and the
health of New Zealanders. The key roles of
the NZMA are to provide advocacy on be-
half of doctors and their patients, to provide
support and services to members and their
practices, to publish and maintain the Code
of Ethics for the profession, and to publish
the New Zealand Medical Journal.
Completely independent, the NZMA is a
strong advocate on medico-political issues,
with a strategic programme of advocacy
with politicians and oﬃcials at the highest
levels, aimed at inﬂuencing the direction of
government policy. NZMA representatives
are in regular contact with the Minister of
Health, Director General of Health, Op-
position party health spokespeople, and
oﬃcials from the Ministry of Health, and
many other agencies.
The NZMA’s main focus in recent years has
been the ongoing workforce issue, which is
the greatest risk to New Zealand’s ability
to provide ongoing quality health care. It is
not just a crisis of the number of doctors or
sub-specialities, but a shortage of all health
workers. The average age of doctors is in-
creasing. While we acknowledge the global
marketplace for health professionals – doc-
tors, nurses, and others – in New Zealand
we have become aware that we need to be
smarter in creating an environment that
keeps those professionals in our country,
rather than has them leaving to work in
countries which pay higher salaries.
New Zealand is extremely reliant on over-
seas trained doctors. More than 42 per-
cent of doctors registered in New Zealand
trained elsewhere in the world. For every
315-320 new doctors registered here each
year (the medical schools’ output of gradu-
ates), between 1200-1600 doctors who
trained overseas are also being registered
(although around half of them do not stay
more than a year). It is imprudent for a ﬁrst
world country to not strive for self sustain-
ability in medical practitioners.
New Zealand is not training enough medi-
cal graduates. Compare us with Australia
which has doubled its medical student in-
take. The NZMA has called on the Gov-
ernment to double the number of medical
graduates trained here.
Another aspect of New Zealand’s health
system which continues to be of great inter-
est to the international medical community
is our no-fault accident compensation leg-
islation.
This dates back to 1966 when the Royal
Commission on Worker’s Compensation
(known as the Woodhouse Commission)
proposed sweeping reforms. The Accident
Compensation Act was passed in 1972 and
came into force in 1974, and remains to this
day, with some changes.
The Woodhouse Commission proposed ﬁve
general principles:
community responsibility,•
comprehensive entitlement,•
complete rehabilitation,•
real compensation,•
administrative eﬃciency.•
The ACC system replaced a system of com-
pensation which, similarly to many other
countries, was expensive in legal costs, slow
in operation, and capricious in that similar
injuries suﬀered under similar circumstanc-
es might produce vastly diﬀerent ﬁnancial
outcomes. The outcome was a scheme that
was considered radical. The right to sue for
damages for the tort of negligence causing
injury was removed, and in return injury
would be compensated regardless of fault,
including fault of the injured.
Four main factors have contributed to the
system’s aﬀordability.First, New Zealanders
beneﬁt from a strong social security system.
Injured patients, like everyone else, receive
free hospital care and subsidized pharma-
ceuticals. (Yet per capita health spending
was only US$ 2448 in 2006, compared with
US$ 6714 in the United States.) Thus, New
Zealand’s public health and welfare systems
cover many of the damages that would be
at issue in a U.S. medical malpractice claim,
leaving the ACCwith a much smaller com-
pensation burden. Second, compensation
awards are generally lower and more con-
sistent than under a malpractice equivalent.
Third,the New Zealand experience suggests
that even under such a system (which in-
cludes a legal duty of open disclosure), most
entitled patients never seek compensation,
and many may be unaware that they have
even suﬀered an adverse event. And ﬁnally,
the New Zealand system does not incur
large legaland administrative costs.The sys-
tem has been very cost-eﬀective, with ad-
ministrative costs absorbing only 10 percent
of the ACC’s expenditures compared with
50–60 percent among malpractice systems
in other countries.
Separate and independent processes are
available for responding to patients’ non-
monetary interests (such as the desire for
an apology, an explanation, or corrective ac-
tion to prevent harm to future patients). In
particular, the Health and Disability Com-
missioner resolves complaints by advocacy,
investigation,or mediation.
One of the anomalies in the ﬁrst 30 years
of the scheme was its handling of compli-
cations and undesirable outcomes of medi-
cal treatment. If the provider of care was
at fault, then this was an injury and was
compensated. If it was a rare occurrence,
for which the provider was not at fault (ex-
pected in fewer than 1% of cases) then it
was a medical mishap, and compensated. If
it did not meet either of these criteria, then
it was not compensated.This always seemed
The New Zealand Medical Association
anomalous in a no-fault scheme. A review
carried out in 2003 found that the require-
ment to establish fault impacted on health
professionals by creating an overly blam-
ing culture (rather than a culture of learn-
ing from mistakes) – by focusing too much
on the actions of individual health profes-
sionals, and by making health professionals
uneasy about participating in the medi-
cal misadventure claims process for fear of
the repercussions, particularly from inter-
agency reporting. The consequences of this
included less focus on the patient’s injury,
less focus on the prevention of similar inju-
ries, confusion over the ACC’s role, and op-
portunities to learn (and therefore improve)
safety being limited.
The NZMA had advocated for,and strongly
supported, the amendment that came into
force in April 2005 redeﬁning all such oc-
currences as “treatment injury”, and com-
pensating regardless of perceived fault. That
provides a much more equitable outcome for
patients, and helps to avoid the adversarial
situation that could previously arise where
a patient was required to assert negligence
on the part of the doctor in order to receive
compensation.
In a population of four million people, in
2005/2006 more than 1.2 million people
had injuries treated by their local GP and
paid for by ACC,with ACC paying for over
2.3 million visits. ACC funded 2.6 million
physiotherapist visits, 2.4 million visits to
other treatment providers and 250,000 re-
habilitation services. Rehabilitation rates
are high: 66 % of people return to work af-
ter three months, 84 % after six months and
93 % after a year. Injury prevention is a pri-
mary focus of ACC’s work, with campaigns
focused on safety at work, at home, on the
road and playing sports.
Another issue which has been high on the
NZMA’s priorities is the membership of
the statutory registration body, the Medi-
cal Council of New Zealand (MCNZ).The
general public needs to have conﬁdence that
the regulation of doctors is fair and open and
transparent. In essence the public needs to
be able to trust the medical profession, and
the NZMA strongly supports this need.
The Health Practitioners Competence
Assurance Act 2003 (which regulates all
health practitioners) took away the right
of the medical profession to have directly
elected members on the MCNZ. This can
be viewed as part of a global trend to move
away from pure self-regulation to regula-
tion in partnership between the profession
and the public.
Self regulation is a cornerstone of profes-
sionalism, and the NZMA has called for at
least 50% of members to be elected from
the profession.
New Zealand has had a Primary Health
Care Strategy since 2001, and the NZMA
is fully supportive of many of its aims, such
as improving access to primary health care.
The Government has substantially increased
funding to primary care, particularly by in-
creasing the level of patient subsidies with
consequent improved access to general prac-
tice services. However, with this has come
attempts by the Government to impose
controls on the setting of general practice
fees. The NZMA has since 1938 supported
the right of private sector medical practitio-
ners, including GPs, to set and charge fees
commensurate with the services they pro-
vide. This right has come under increasing
and unprecedented pressure in recent years.
General practices are, in the main, private
businesses whose continued existence is de-
pendent on them remaining viable.
The NZMA is working with other general
practice organisations to assist the Govern-
ment in achieving its health goals in pri-
mary care.
Towards the end of this year New Zealand
will have a General Election. A Labour-led
Government, headed by Helen Clark, has
been in place for nine years, but political
polls are consistently putting the Opposi-
tion National Party substantially ahead.
This means there may be a new government
in place by the end of the year. But whoever
is in power, the NZMA is willing to work
closely with them to ensure that the health
system and the health of New Zealanders
remains a top priority.
References
1. Bismark M and Paterson R. No-Fault Com-
pensation In New Zealand: Harmonizing Injury
Compensation, Provider Accountability, And Pa-
tient Safety. Health Aﬀairs. 2006. 278-283.
2. Bismark M. Compensation and Complaints in
New Zealand. BMJ. 2006 332:1095.
3. Accident Compensation Corporation. Review of
ACC Medical Misadventure: Consultation Docu-
ment.Wellington: ACC; 2003 (quoted in: Coates J
and Smith K.Reform of ACC Medical Misadven-
ture. NZ Med J. 2004.Vol 117 No 1201)
Dr. Peter Foley, Chairman
From the left Dr. Peter Foley, Chairman, Steve Chadwick, Associate Minister of Health,
Dr. Mark Peterson, GP Council Chair
109
110
Jeﬀ Blackmer, MD MHSc FRCPC
Ethics and professionalism have long been
priority issues at the Canadian Medical As-
sociation. The Association was established
in 1867 and produced its ﬁrst Code of
Ethics in 1868, making it one of the oldest
such documents in existence.
The CMA Code of Ethics is arguably the
most important policy produced by the or-
ganization. Since its original inception, it
has undergone several modiﬁcations. The
last revision, considered to be “minor” in
nature, was completed in 2004. In general,
major revisions of the document occur every
15-20 years, with 1-2 minor revisions in be-
tween.The Code is considered to be “hybrid”
in nature as it is somewhere in length and
content between setting out basic principles
at the one end, and trying to cover all ethi-
cal topics and eventualities at the other. It
is intended to be of suﬃcient detail so as to
provide clinicians with practical guidance in
dealing with complex ethical issues, but not
so detailed as to be behaviour-determining.
The CMA Code of Ethics has been adopted
by all major medical bodies in Canada (with
the exception of the province of Quebec,
which generally produces its own Codes and
regulations separate from the rest of the coun-
try).For example,the provincial medical regu-
latory bodies, the national educational col-
leges and the provincial medical associations
have all adopted the CMA Code. It is to the
beneﬁt of physicians to have only one Code of
Ethics,and not competing codes which would
serve as a point of confusion and potentially
conﬂict. This harmonization has occurred
through extensive and open dialogue and ne-
gotiations over the years to try and ensure that
the Code meets, to the extent possible, the
needs of all the stakeholders involved.
The Canadian Medical Association Oﬃce
of Ethics,Professionalism and International
Aﬀairs is responsible for working on poli-
cies, providing support and education to the
Association and its member divisions and
aﬃliate specialty societies, and providing
support to the CMA Committee on Eth-
ics. The Oﬃce has existed in one form or
another at the CMA for many years.
In 1989,the CMA increased its commitment
to ethics with the establishment of the Divi-
sion (later Department) of Ethics and Legal
Aﬀairs. Work began on abortion, status of
the foetus, transplantation of organs, repro-
ductive technologies, and physicians and the
pharmaceutical industry. In 1991 the CMA
rejoined the World Medical Association and
CMA ethics staﬀ began to play a major role
in the ethics activities of the WMA. In 1996
the CMA staﬀ structure was reorganized and
Ethics and Legal Aﬀairs were separated.The
Director of Ethics became a member of the
Professional Aﬀairs Directorate.In 2001,the
staﬀ structure was reorganized again and the
Director of Ethics became a member of the
Research, Policy and Planning Directorate
(now titled the Research, Policy and Ethics
Directorate).
The Oﬃce is currently staﬀed by a full time
Ethicist (with a background in basic philoso-
phy and ethical theory,as well as formal train-
ing in clinical bioethics),an Executive Direc-
tor (who has an advanced degree in bioethics
and also continues to work part time as a
physician) and administrative support. At
any point in time it is common to have stu-
dents or interns rotating through the Oﬃce,
as well as temporary staﬀ who are employed
to work on speciﬁc projects or policies for a
ﬁnite period of time.The Oﬃce has provided
training and experience for several students
over the past few years in research, policy
development and the practical application of
ethical concepts and principles.
The CMA Committee on Ethics meets in
Ottawa twice a year for two-day sessions.
During this time, Committee members
debate ethical issues and help direct policy
development in this area. With the support
of Oﬃce staﬀ, they assist in identifying cur-
rent ethical and professional issues that are
of importance to Association members, and
decide how best to address these issues.
The Committee on Ethics is the longest
standing Committee at the CMA and is
considered unique in many respects.It is the
only Committee that is elected by, and re-
ports to, the General Council of the CMA,
which is considered to be the “Parliament”
of Canadian organized medicine. Commit-
tee members are selected on a regional rath-
er than provincial basis, and the smaller size
of the Committee allows it to respond more
quickly to issues as they arise. In addition,
Committee members are expected to have
some background or expertise in the area of
ethics as part of their membership on the
Committee. Between General Council ses-
sions, which happen only once a year, the
Committee reports through its Chair to the
CMA Board of Directors,and most policies
are discussed and approved at this level.
Untilthe1970stheCommitteeonEthicscon-
cerned itself mainly with professional issues.
During the 1970s it began addressing bioethi-
cal issues. During the 1980s the Committee
presented reports to General Council on is-
sues such as AIDS, as well as some amend-
ments to the CMA Code of Ethics. Between
1991 and 1996 the Committee completed
policies on advance directives, conﬁdential-
ity, and physician-assisted dying; revised the
Ethics and professionalism at the
Canadian Medical Association
111
Dr. Isacio SIGUERO, President
The “Consejo General de Colegios Oﬁciales
de Médicos”(general medical council) is the
body that brings together, co-ordinates and
represents the 52 local medical associations
(colegios oﬁciales de médicos) at national
and international level, and for all purposes
it has the status of Public Law Corporation,
with own legal personality and full capacity
to comply with its objectives.
Since 1898 it has been compulsory for doc-
tors to register as members in Spain and
there is a local medical association for each
of the 52 Spanish provinces. The overall
representation of this “Consejo General”
dates back to the year 1930. The Spanish
Constitution recognises the existence and
representation of professional associations,
with the requisite of having a democratic
functioning, like the undertaking of the
“Consejo General”, the ﬁnal purpose of
these institutions being to oversee a good
professional practice, namely the defence of
the professional and patient.
The “Consejo General” is made up of a
Board and a General Assembly. The Board
is formed by the president, vice president,
general secretary, vice secretary and trea-
surer, all these being positions democrati-
cally elected every four years.The rights and
interests of the corporation and profession
are defended through this Board vis à vis all
classes of jurisdictional, administrative and
institutional bodies.
The General Assembly is integrated by the
Board, by the Presidents of the 52 local
medical associations, and by the national
Code of Ethics and the policy statement on
physicians and the pharmaceutical industry;
and advised on CMA’s brief on the revision of
the Criminal Code and the “Joint Statement
on resuscitative interventions.”
Between 1996 and 2001 the Committee
revised policies on organ and tissue dona-
tion and transplantation, physicians and the
pharmaceutical industry, and, together with
the Council on Health Care and Promotion,
viral serological status testing; and guided
CMA participation in the development of
a “Joint Statement on preventing and re-
solving ethical conﬂicts involving health
care providers and persons receiving care.”
It contributed to CMA policy development
on assisted reproduction, health informa-
tion privacy, direct-to-consumer advertis-
ing, the Charter for Physicians, the future
of medicine and scopes of practice.
Recent work by the Committee has in-
cluded an extensive revision of the policy
on physician-industry interactions, the de-
velopment of a new policy on ethical ob-
ligations of physicians during a pandemic
and a new policy on blood borne pathogens
in the health care setting. Current work is
underway on a major revision to the CMA
Health Information Privacy Code, the issue
of conscientious objection by health care
providers, a research ethics template for
practicing physicians and a project, together
with the national organization of medical
regulators, to produce a series of clinical vi-
gnettes based on the CMA Code of Ethics.
Theissueofmedicalprofessionalismisextreme-
ly topical in organized medicine.To reﬂect the
importance of professionalism, the Canadian
Medical Association has added the term to the
title of the Oﬃce (a recent development) and
has also included work in medical professional-
ism (and ethics) in one of the Key Result Areas
in its current strategic plan.This has helped to
demonstrate in a tangible way the importance
of these issues within the overall structure and
strategy of the organization.
The CMA is the founder and Chair of the
Canadian Stakeholders Coalition on Medi-
cal Professionalism, a collection of several
medical organizations from around the
country with an interest in medical profes-
sionalism, including educators, regulators,
professional liability insurers and others.
The Coalition has been active in trying to
ensure a consistent nation-wide approach
to deﬁning, teaching, measuring, assessing,
promoting and role modelling the key as-
pects of medical professionalism to physi-
cians and physicians-in-training through-
out the continuum of the medical life cycle.
Current eﬀorts are aimed at ensuring con-
sistency in how professional behaviours and
traits are evaluated.
Staﬀ at the CMA Oﬃce of Ethics, Profes-
sionalism and International Aﬀairs works
closely with the World Medical Association
both during and between WMA meetings.
Currently,CMA staﬀ is assisting the WMA
with the drafting of new policies in medical
professionalism (including professionally-
led regulation, professional autonomy and
conﬂict of interest) and revision of current
WMA policies (including telemedicine and
health human resources). The relationship
between the CMA and WMA has always
been a close one, as evidenced by the fact
that John Williams has served as the direc-
tor of ethics for both organizations, and the
author of this paper recently completed a
secondment at the WMA oﬃce where he
assisted with policy development and coor-
dination in ethics and professionalism.
The “Consejo General
de Colegios Oﬁciales de Médicos”
112
The Slovak Medical Association (SkMA)
is an aﬃliation of professional medical and
pharmaceutical societies and also regional so-
cieties of physicians, nurses and pharmacists.
SkMA is a non-proﬁt, non-governmental
association representing more than 22 000
members. The tradition
of SkMA goes back to
the 19th century. On 3
January 1833 a group of
young medical students
established the Slavonic
Medical Association as
a self-learning medical
society. Following the
founding of Czechoslo-
vak republic there was
in place local medical
societies in Ko ice and
Bratislava (1919-1920)
and various professional
associations, which from
1949 comprised the or-
ganisational units of
the Czechoslovak Medical Association, and
from 1969 separate Czech and Slovak Medi-
cal Association. After the establishment of
independent Czech and Slovak republics in
1993, the Slovak Medical Association con-
tinued to work on an autonomous basis.
Main activities:
Education (Continuing Medical Educa-•
tion, Non-institutional life-long Educa-
tion)
Publications of Medical Journals (co-op-•
eration with professional medical societ-
ies, editors and publishers)
International Activities and Contacts,•
Medical ethics
Health care legislation, Quality of health-•
care development
Membership service, awards approval,•
public relations
1. Education
One of the main missions of the Slovak Medi-
cal Association is the organisation of scientiﬁc
events and scientiﬁc congresses, conferences,
symposiums and other professional meet-
ings with domestic and foreign participation,
to support the involvement of own experts
in similar events abroad and to publish and
support the issue of professional magazines
and publications. On basis of a mutual agree-
ment among the statutory representatives of
the Slovak Chamber of Physicians, the Slo-
The Slovak Medical Association
Prof. MUDr. Peter Krištúfek,
CSc. President
MUDr. Irina Šebová, CSc.
MPH, Scientiﬁc Secretary
representatives from the diﬀerent profes-
sional sections through which doctors are
represented according to the modality and
form of professional practice they under-
take: hospitals, urban and rural primary
care, pensioners, in training, public admin-
istrations, with unstable employment, and
own private medical practice or as employ-
ee. The task of these sections is to provide
guidance in matters of their speciality and
to undertake studies and proposals.Togeth-
er, the Board, local Presidents and sections’
representatives form the General Assembly,
which is the top governing authority of the
“Consejo General”.
The “Consejo General” and the 52 local
medical associations form what is known as
“Organización Médica Colegial (OMC)”.
This body represents all registered doctors
in Spain, acting as safeguard for the core
values of the medical profession: deontol-
ogy and code of ethics.
The “Consejo General” is oﬃcially respon-
sible for representing the OMC before the
General Administration of State and the
public agencies related with or dependent
on it, as well as for coordinating the profes-
sion at the diﬀerent organisational levels.
To quote a few examples, the work of the
“Consejo General” is today centred on vari-
ous questions of professional and social in-
terest that include the study of medical de-
mography to try and correct the deﬁcit in
doctors and carry out a suitable planning of
human resources, even controlling the oﬃ-
cial recognition of foreign medical qualiﬁ-
cations,fostering training and accreditation,
using its own Council oﬃcially recognised
by the Government.
Other facets of its work include professional
and social promotion of doctors and their
adaptation to scientiﬁc and professional
changes, as well as permanent and accred-
ited professional development. It also has a
social Foundation to assist the needs of doc-
tors and their families, this being one of the
most important works of the health sector.
Through its “Consejo General”, the OMC
is present at almost all international medical
organisations, at which it provides its expe-
rience. These actions imply beneﬁts for the
professional practice, for the patient – end
receiver of such actions and true central hub
of the National Health System – and ﬁnally
for society as a whole.
Defending the values of the medical profes-
sion and rights of doctors and the patients,
the “Consejo General” is now undertaking
actions in favour of prescriptions being an
act that is the exclusive competence of the
doctor being the only professional who,con-
sidering his training and qualiﬁcations, can
assure a safe and eﬃcient quality treatment
for the patient; without waiving collabora-
tion with other health professionals, to as-
sure the quality of the health care process.
113
vak Medical Association, the Slovak Medical
University, the Association of Private Physi-
cians and the Association of Medical Facul-
ties in Slovakia, the Slovak Accreditation
Council for Continual Medical Education
(SACCME) was established in May 2004.
The SACCME provides credits for CME ac-
tivities, as well as with the implementation of
a quality control mechanism (standard partic-
ipants satisfaction questionnaire). 250 credits
over a 5-year period were proposed, 150 from
them are obtained from external educational
activities (passive or active participation,auto-
didactic tests in medical journals,publications,
presentations, teaching) and 100 credits are
received for professional performance and for
self-teaching.
2. Publications
17 medical journals (mainly in the Slovak
language with English summaries):
Medical Monitor (6/year),•
Revue of Nursing and Laboratory Methods•
(4/year)
Acta Chemotherapeutica (6/year)•
Head and Neck Diseases (4/year)•
Clinical Immunology and Allergology•
(4/year)
Slovak Physician (12/yars)•
Urology (2/year)•
Practical Gynaecology (4/year)•
Haematology and Transfuziology (4/year)•
Atherosclerosis, Clinic,Treatment (3/year)
Laboratory Diagnosis (4/year),•
Surgical News (4/year)•
Slovak Radiology (4/year)•
Cardiology (4/year)•
Pediatricon (4/year)•
Respiro (4/year)•
Geriatria (4/year)•
Accupunctura Bohemo-Slovaca (2/year)•
Slovak Sexulogy (2/year)•
Microbiology and Epidemiology News•
(4/year)
Farmacoeconomics and Drug´s Policy•
(4/year).
3. International activities and contacts
The Slovak Medical Association is a mem-
ber of World Medical Association (WMA),
European Forum of Medical Associations
and WHO (EFMA/WHO), Union of
European Medical Specialists (UEMS),
Council for International Organizations
of Medical Sciences (CIOMS). Interna-
tional cooperation is supplied also directly
by means of various SkMA professional
societies and their colleagues in European
Union or abroad.
In co-operation with WMA representatives
the Slovak version of the Medical Ethics
Manual was ﬁnalised and will be distrib-
uted among our members. The SkMA sup-
port all ethical, social and environmental
activities of the WMA. On 19 September
2006, the SkMA and Slovak Association of
Pharmaceutical Companies (SAFS) signed
an agreement concerning ethical principles
co-operation between the medical profes-
sion and the pharmaceutical industry.
From 2007, the SkMA has representation
on the EFMA/WHO committee (Irina
Sebova-liaison oﬃcer). On 1-3 April 2009,
we will be organising the Annual Confer-
ence of EFMA/WHO in Bratislava. Pro-
posed topics: CME/CPD, Palliative Care,
Creation of quality standards, Seniors Care.
The good co-operation between the SkMa
and the UEMS was conﬁrmed on 19 March
2006 in Brussels by the signing of an agree-
ment between the European and Slovak ac-
creditation councils for CME (EACCME
and SACCME). The institutions declared
that they are interested in co-operation in
ﬁeld of CME accreditation through a formal
agreement aimed to foster the interchang-
ing of experiences and the implementation
of a formal system mutual recognition of
CME credits.The SkMA was the organiser
of UEMS Meeting (Board and Council) on
11-13 October 2007 in Bratislava. One of
the most important documents adopted at
this Meeting was the Bratislava Declaration
on E-Medicine.
Of growing importance are activities
with regard to international contacts with
CIOMS, as well as membership of profes-
sional SkMA societies in partnership with
European or non-European organisations.
The SkMA co-operates very closely and in-
tensively with the Czech Medical Associa-
tion.
4. Health Care Legislation, Quality
of Healthcare Development
The public Health System in Slovak repub-
lic is under the jurisdiction of the Ministry
of Health, which is responsible for manag-
ing national health policy. The SkMA acts
as an opponent in discussions on health
care legislation proposals from Minis-
try of Health, proposes the nomination of
the Main Experts, the Consultants for the
Drug Categorization Commissions and
the Members of the Medical Performance
Catalogue Committees.
In co-operation with other medical institu-
tions and professional associations submits
SkMA suggestions or projects for improve-
ment of healthcare quality.
5. Membership service, awards
approval, public relations
The SkMA has 87 professional societies ac-
cording to specialization or ﬁeld of particular
interests and a total of 48 regional societies
or alliances according to geographic loca-
tion independent from profession. Mem-
bership in the SkMA is voluntary. Main ex-
ecutive bodies of the SkMA in place of the
Representative Plenary Meetings are the
Presidium, Supervisory Board and Execu-
tive Secretariat. The Presidium of SkMA,
elected for 4 years period, encompasses 13
members including the President, Scientiﬁc
Secretary and two Vice-Presidents.The Su-
pervisory Board has 3 members including
the chief of Administration and is staﬀed
with 19 full time employed persons headed
by the Director of Secretariat.
The oﬃcial residence of SkMA is the House
of Medical Oﬃcers (Domus Medica, Dom
zdravotníkov) with a Congress oﬃce, De-
partment of membership service, Economic
department and Auditorium.
114
Korean Medical Association
The WMA General Assembly Seoul 2008
The year of 2008 is very signiﬁcant in the
history of Korean Medical Association
(KMA), as it celebrates its 100-year anni-
versary. Modern medicine was introduced
in Korea in the year of 1884 by an American
missionary physician. During a relatively
short period,Korea has made rapid progress
in medical science and the practice.
In 1908, KMA was established in Seoul and
soon became the national organization repre-
senting all medical doctors in Korea.In spite of
many diﬃcult situations occurred in the Ko-
rean peninsula,KMA has made uniﬁed eﬀorts
to promote health of the people.Through the
period of Japanese occupation, Korean War,
rapid economic development, and advance to
the democratic society, KMA has always been
for the people to secure health and happiness,
enhancing the standard of medical science and
education, and participating actively to the
decision-making process. With the devotion
and support of physicians in care for people,
the government could achieve the universal
health insurance policy in 1989 only 12 years
after the launch of the national health insur-
ance program.
KMA’s eﬀorts to enhance international
cooperation contributed to the drastic im-
provement of the standard of health care
and now it reached the highest standard
akin to the advanced countries in OECD.
The number of members has increased into
90,000 physicians today and the roles and
responsibilities of KMA become more and
more important in observance of medical
ethics and provision of continuous medical
education: training and certiﬁcation of spe-
cialists, introduction of malpractice insur-
ance program.
In this October, KMA is privileged to host
the WMA General Assembly Seoul 2008.
The Organizing Committee was launched
in September 2006 as the oﬃcial decision-
making body for KMA and is spearheaded
by Dr. Tai Joon MOON, the President
Emeritus and Dr. Soo Ho CHOO, the
President of KMA. Dr. Dong Chun SHIN
serves as secretary general of the commit-
tee. To make the Assembly successful and
meaningful, KMA has been working very
hard. We have organized the scientiﬁc ses-
sion under the theme of “Health and Hu-
man Rights” to cover health equity, health
for under-privileged people, health prob-
lems from environmental perspectives and
medical ethics and human rights, and so on.
As keynote speeches, UN’s activities and
strategies for protecting human rights and
an overview on WMA’s policies and history
of health and human rights will be present-
ed and discussed.
To commemorate the meaningful centen-
nial anniversary, KMA is planning a photo
exhibition on the sidelines of the Assembly
showing historic highlights of development
of medical sciences from the late 19th
till
present days in front of the main meeting
hall of Shilla hotel during the Assembly.
Tour programs will include beautiful sites of
Seoul city. We expect excellent weather in
October and you will enjoy the unique at-
tractiveness of Seoul where tradition meets
modern vitality.
KMA would like to welcome you all to Seoul
and we are honored to share important dis-
cussions with you and exchange friendship
among leaders of organized medicine of the
world during the Assembly.
Bo-kyung Kang,
International Relations
32nd
KMA Scientiﬁc Congress Korea launch of universal health care
insurance
The hosting of the 12nd
CMAAO Meeting
115
The roundtable “High Quality Healthcare
in Europe,” organized jointly by the Coun-
cil of European Dentists (CED) and the
Standing Committee of European Doctors
(CPME) on the 11th
of September,in Brus-
sels, provided one of the ﬁrst opportunities
for stakeholders to discuss the Commis-
sion’s recent proposal for a Directive on Pa-
tients’ Rights in Cross-Border Healthcare.
The event under the patronage of Othmar
Karas, MEP, brought together Commission
oﬃcials and MEPs to exchange views with
the main organisations of European health
professionals and patients on the proposed
Directive, as well as on the wider institu-
tional and political framework for cross-
border healthcare in Europe.
EU Commissioner for Health and Con-
sumers,Androulla Vassiliou,opened the de-
bate with a keynote presentation. She con-
ﬁrmed the continued commitment of the
Commission to dialogue and cooperation
in the process leading to the adoption of the
proposed Directive on Patients’ Rights in
Cross-Border Healthcare with those most
directly aﬀected by it: the health profession-
als and the patients.
During the debate, all representatives, those
of the health professionals as well as the
patients, welcomed the directive and reiter-
ated the need to enshrine patients’ rights of
access to safe and high quality healthcare
throughout the EU in a legal document.
CPME President Dr.Michael Wilks point-
ed out, among other issues, the necessity of
good information systems for both patients
and physicians that support cross-border
care.
CED President Dr. Orlando Monteiro da
Silva noted that quality is deﬁnable but very
diﬃcult to measure. “We must focus on
the three main principles of strategy, high
quality and eﬃciency, doing the right thing
right.”
The moderator,Dr.Matthias Wismar of the
European Observatory on Health Systems
and Policies, concluded that there is a con-
sensus among the panellists on the need for
this directive.
Othmar Karas, MEP (EPP), played a lead
role in negotiating an agreement between
the European Parliament and the Council
under the Austrian EU Presidency in 2005,
leading to the exclusion of health services
from the Services Directive. Other speakers
included DG SANCO Head of Unit Ber-
nard Merkel, MEPs Bernadette Vergnaud
(PES) and Holger Krahmer (ALDE), and
Dr. Anders Olauson, President of the Euro-
pean Patients’ Forum.
Claudia Ritter, Director / Brussels
Oﬃce,CED, Council of European Dentists.
www.eudental.eu
Lisette Tiddens-Engwirda, Secretary
General,CPME, Standing Committee of
European Doctors. www.cpme.eu
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
179th
WMA Council Meets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Human Resources for Health, Kampala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Health – a global overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
An alternative to better global health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
The new revision process of the International Classiﬁcation of Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
DoH Revision meeting in São Paulo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Co-operation of WMA and the Stop TB partnership – Private-Public-Mix in the ﬁght against TB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Lilly Commits $1MM to World Medical Association to support Innovative Tuberculosis training course . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
What Physicians are REALLY Thinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Smoking: A disease that starts in the brain and goes to the whole body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Working together for safe health care,the World Health Professions Alliance (WHPA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
IFPMA Appoints Alicia Greenidge as New Director General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Representing pharmacists and pharmaceutical scientists — your partners in healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
The South African Medical Association (SAMA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Overview of the Nigerian Medical Association (NMA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
The National Order of Physicians of Côte d’Ivoire: presentation and perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
The Medical Association of Thailand under the Royal Patronage of his Majesty the King . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102
The Hong Kong Medical Association (HKMA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
The Azerbaijan Medical Association (AzMA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104
The Australian Medical Association – a voice for patients and doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106
The New Zealand Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108
Ethics and professionalism at the Canadian Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110
The “Consejo General de Colegios Oﬁciales de Médicos” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111
The Slovak Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112
Korean Medical Association.The WMA General Assembly Seoul 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114
Cross-border healthcare:
Debate between the EU institutions, health professionals
and patients on the draft directive launched

Voir dossier