wmj28

vol. 56
MedicalWorld
Journal
Official Journal of the World Medical Association, Inc
G20438
Nr. 4, August 2010
Human Resources for Rural Health•
Developing Healthcare Technologies for Emerging•
Markets – Improving Quality, Access and Cost
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
Bachmer Str. 29-33
D-50931, Köln, Germany
Assistant Editor
Velta Pozņaka
wmj-editor@wma.net
Journal design and
cover design by Jānis Pavlovskis
Layout and Artwork
The Latvian Medical Publisher
“Medicīnas apgāds”, President Dr. Maija Šetlere,
Katrīnas iela 2, Riga, Latvia
Cover painting:
Carl Gustav Carus (1798-1869) was a physi-
cian, painter and philosopher of nature. Carus,
a friend of Johann Wolfgang von Goethe and
Caspar David Friedrich, was the first teacher
of comparative anatomy in Germany. He is also
considered to have laid the philosophical founda-
tions of depth psychology. The University hospi-
tal of Dresden is named after him.
“View on Dresden from Augustus bridge” was
painted by Carus around 1830. Dresden, his
place of living and working, was the scene of the
113th
German Medical Assembly 2010.
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Dr. Dana HANSON
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Fredericton, NB, E3B 6H5
Canada
Dr. Masami ISHII
WMA Vice-Chairman of Council
Japan Medical Assn
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Dr. Mukesh HAIKERWAL
WMA Chairperson of the Finance
and Planning Committee
58 Victoria Street
Williamstown, VIC 3016
Australia
Prof. Ketan D. DESAI
WMA President-Elect
Indian Medical Association
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I.M.A. House
India
Prof. Dr. Jörg-Dietrich HOPPE
WMA Treasurer
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Dr. Guy DUMONT
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Members
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Dr. Yoram BLACHAR
WMA Immediate Past-President
Israel Medical Assn
2 Twin Towers
35 Jabotinsky Street
P.O. Box 3566
Ramat-Gan 52136
Israel
Dr.Torunn JANBU
WMA Chairperson of the Medical
Ethics Committee
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
Norway
Prof. Dr. Karsten VILMAR
WMA Treasurer Emeritus
Schubertstr. 58
28209 Bremen
Germany
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. Otmar KLOIBER
WMA Secretary General
13 chemin du Levant
France 01212 Ferney-Voltaire
France
World Medical Association Officers, Chairpersons and Officials
Official Journal of the World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
127
The economic crisis has criss-crossed the globe. Just as it appears
to be under control in one place, it flares up in another. Emissaries
of the World Bank and International Monetary Fund travel from
country to country with billions in credit and strict controls de-
signed to stabilize the economy. The international assistance is not
always met with open arms, such as in Greece, where public dem-
onstrations have protested against the reforms.
Medicine reflects the economy.Almost every economic downturn is
followed by a reduction in health care expenditure, one more severe
than the other. Politicians are much more likely to cut health care
costs than reduce the salaries of civil servants.
But is an economic crisis such a damned phenomenon,that it should
lead to the collapse of a health care system? Is it possible to change
a defect into an effect? What attitude should the World Medical
Association adopt in the face of economic downturn?
The first slogan we should adopt is: “Politicians,hands off the health
care budget during economic hard times.”
Secondly, we should remind our leaders that in sunny times, they
were the first to spend resources on technological advancements
that offered marginal returns. For example, the latest computerized
tomography or magnetic resonance imaging may have cost twice as
much as the previous one,but may have improved resolution by only
ten per cent: or, the entry into electronic medical records led to the
collection of massive digital files of which perhaps five percent has
any value to the physician. The remainder of the data that has been
collected rests in digital cemeteries. Technology changes so rapidly
that the radiograms that were scanned in the 1990’s are no longer
recognized by newer hospital computers today.The CD we are now
using will someday be as obsolete as are the floppy discs of only a
few years ago.
In the midst of a crisis, politicians will perhaps listen to the fact that
doctors care for patients, not computer monitors. Can our scarce
resources be spent more wisely?
Thirdly, we should take advantage of difficult economic conditions
to push for reform. During these times governments are looking
earnestly for additional sources of income. Recessions are oppor-
tune times to push for tax increases on unhealthy substances, such
as tobacco, alcohol and soft drinks. Higher gasoline taxes encourage
less automobile driving and more bicycling.
By the way, dear colleagues and medical leaders, how often have you
gone to work by bicycle this year?
Dr. Peteris Apinis,
Editor in Chief, WMJ
Editorial
128
WMA news
The 185th
meeting of the World Medical
Association Council and its committees
took place in Evian-les-Bains, France from
20th
to 22nd
May 2010, under the Chair-
manship of Dr. Edward Hill.
Following the adoption of the Minutes of
the 184th
Council in Delhi, the President
Dr. Dana Hanson gave a brief report out-
lining his extensive travel since Delhi, high-
lighting in particular, widespread concerns
he had encountered concerning professional
autonomy and regulation. He referred to
WHO’s year of Road Safety mentioning in
particular the mortality figures in Russia and
felt that WMA should reconfirm its work
on Road Safety. The São Paulo Conference
on the use of placebo in research held in
São Paulo, was a great success. He expressed
his thanks to those NMA’s whom he had
had the privilege of visiting and stressed the
enormous value of such visits.
Secretary General’s Report (see also fuller re-
port WMJ,56,87-96)
The Secretary General commenced his re-
port by expressing his thanks to the Bra-
zilian Medical Association for their help
with the São Paulo conference and to the
Bundesärztekammer, in particular to Dr.
Ramin Parsa-Parsi,mentioning also the sci-
entific work done by the WMA Cooperat-
ing Centre, Institute of Ethics and History
of Medicine at the University of Tübingen.
Acknowledging the continuing work of Dr.
Coble, he reported that Books of Hope in
2010, supported by the Chinese Centre of
Disease Control, the Chinese Medical As-
sociation, the Chinese Association on To-
bacco Control and the WMA, presented a
speaking book on the dangers of smoking.
This targeted low literacy communities,
where smoking rates have significantly risen
over recent decades. The first 500 speaking
books have the potential to impact on 50-
100,100 people and will be accompanied
by research analysing its impact on health
literacy.
The Caring Physicians of the World (CPW)
project extension into Leadership Courses
organised by INSEAD Business School in
Fontainebleau, France, was realised in a sec-
ond course held in Singapore – 13th
Febru-
ary 2010 – with 29 participants, made pos-
sible by unrestricted educational grant from
Pfizer Inc. The work was supported by the
WMA Cooperating Centre at the Centre
for Global Health and Medical Diplomacy
in the University of North Florida.
Dr. Kloiber spoke of studies carried out
on the need for educational support in the
field of policy creation by the Centre for
Study of International Medical Policies
and Practices at George-Mason University
(a WMA Cooperating Centre). He also
drew attention to the first issue of a new
Journal “World Medical and Health Policy
Development” in the autumn of 2009. Fi-
nally he paid particular tribute to two staff
members who had extended the coopera-
tion with institutions in Geneva, notably
WHO with whom the work had intensi-
fied. A side event at the UN conference on
Human Rights had been organised by the
Danish Medical Association’s initiative on
Human Rights, where there was discussion
on the role of physicians on combating/re-
porting torture.
Dr. Kloiber then referred to the revision
of the rules of procedure which had been
taking place following council’s decision
that this should be done. All the relevant
documents had been considered with a
view to reducing the documentation, iden-
tifying common elements and conflicts of
laws/rules, etc. and coordinating provisions
into two documents. Documents would
be circulated to council members for their
comments. It identified those areas of du-
plication/conflicts, etc., with suggestions
for consideration and response, prior to a
further meeting to produce the final revi-
sion.
Nominations
Dr. Torum Janbu was nominated for the
Chair of the Medical Ethics Commit-
tee and Sir Michael Marmot to serve as a
member of that Committee.
Council adjourned for the Standing Com-
mittees.
Medical Ethics Committee
The committee met on 20th
May 2010 and
Dr. Torum Janbu was elected by acclama-
tion.
The Chair welcomed new members of the
Committee, Dr. Poul Jaszcazk, Sir Michael
Marmot and Dr. Ramin Parsa-Parsi, and
the Minutes of the October 2009 Meeting
in New Delhi were approved.
Helsinki and Placebo
Dr. Ramin Parsa-Parsi, chair of the Work-
group on Placebo in Medical Research,
spoke to the report on the results of the con-
ference in Sao Paulo and the recommenda-
tions which, after referring to there being
no urgent need for change in the wording,
suggested that possible future revision of
the Declaration of Helsinki be considered
in the light of new findings (methodologi-
cal issues, informed consent, research ethics
committees, etc.), and that a WMA work-
group should be mandated to:
develop a strategy in order to continue•
the discussion;
develop new wording for paragraph 32•
which should facilitate future revision of
the Declaration;
consider an expert conference in 2011.•
185th
WMA Council meeting in Evian,
France 20th
–22nd
May 2010
129
WMA news
The Chair stressed the broadening of the
approach and Dr. Collins-Nakai respond-
ing, commented that the wording should
refer to the linking of the use of placebo to
when agreed treatment was being used in
the research, i.e. the words “there should be
agreement to the use of placebo when agreed
treatment was being used”, be included in
any wording, which reflected the view that
the use of placebo in a trial should depend
on the circumstances,informed consent and
the agreement of Local Ethical Research
Committees ( LERCs).
Dr.Kloiber supported the concept of further
work and the Committee adopted the Rec-
ommendations in bold above, and Council
later approved the Working Group report.
Principles of Health Care for Sports Medicine
In considering comments on the Declara-
tion on Principles of Health Care for Sports
Medicine, the Chair observed that while it
was a good text,things have changed since it
was adopted and he queried the need for up-
date. Dr. Haikerwal, however, asked wheth-
er there was indeed a need for update as the
document was out of date. He mentioned
such things as “the need for exercise in re-
lation to non-communicable diseases” and
“sport”, referring also to “Keeping Healthy”
and suggested revision of the statement on
Chronic Diseases. Dr. Collins-Nakai, rais-
ing the possibilities of injecting genes to en-
hance performance,recommended updating
to take account of genetic modification. Ms
Wapner indicated that the Israel MA would
be willing to do this updating, but Dr. Nel-
son felt that the document was not about
exercise for the general population, it was
for physicians looking after sportsmen.
The Secretary General reminded the com-
mittee that WMA had different policies on
sport, e.g. the physician’s role in obesity care
is outlined in another document.
While Dr. Nathanson agreed to looking at
Obesity and Activity, she would oppose the
CMA viewpoint,and leave the document as
generic cover.The statement should be kept
as generic as possible. Dr. Collins-Nakai
agreeing with Dr. Nathanson felt, however,
that the document was not generic enough.
After further discussion a motion to reaf-
firm the document “Declaration on Prin-
ciples of Health Care for Sports Medi-
cine” was adopted by the Committee and
this recommendation was later adopted by
Council.
Human Rights
Ms Clarisse gave a report on organising
the side event at the Human Rights con-
ference on 9th
March 2010, chaired by the
UN Human Rights Rapporteur. The panel
included the Slovenian UN Human Rights
representative also the Representative on
Human Rights and Torture. She also spoke
about the problems raised by anti-abortion
legislation which could inhibit action in
patients with cervical cancer. She reported
that FIGO (Forum of International Gy-
naecology and Obstetrics) had issued a
Press Release concerning Female Genital
Mutilation on International Women’s day
in February.
Dr. Hill and Dr. Hanson reported on their
visit to China where they had discussed
organ transplantation with the Chinese
Medical Association and the Minister.They
were encouraged by the Chinese Associa-
tion and the Minister having established
specific criteria for Transplantation. Three
quarters of the hospitals were doing trans-
plants and now were better controlled. Al-
though the topic was on the WMA agenda,
for the Chinese this topic was a priority.
Declaration of Tokyo
The committee considered the problems
of the implementation of the Declaration
of Tokyo and a suggestion that the WMA
establish a mechanism to enable cases of
torture to be notified directly to WMA, to
avoid the problems associated with notifi-
cation in some countries and facilitate the
WMA taking action. Dr. Hill also referred
to a conference in Sweden on Torture and
on the reporting of torture. In this context
Dr. Reis (ICRC) commented that it was
easy for doctors working in Geneva to re-
port torture, but not so for those working in
a country where they were afraid that their
house might be destroyed or their wives
raped. He suggested that WMA should do
something about this.
Sir Michael Marmot spoke of the real lim-
its to what NMA’s can do. They should act
and be seen to do what they can.The BMA
view is that WMA is doing what it can
and the idea of sending this proposal was
to give transparency to these actions. The
Norwegian MA, appreciating the BMA
comments, felt it crucial that we recognise
the risks for some physicians in notifying
torture, recommending that work continue
on mechanisms in which they are not seen
to be doing this, but also mechanisms by
which information can get to the UN Spe-
cial Rapporteur. Responding to a question
as to whether WMA could organise such
a mechanism, Dr. Kloiber commented that
WMA had a small office in which every-
one had specific tasks. They had neither the
means nor resources to do this.What is dif-
ficult is that they are besieged by calls from
organisations. They could be faced with
programmes and campaigns which were not
human rights issues.
Dr. Snaedel drew attention to what we in
fact have, i.e. the ICRC and WMA work-
ing with the Istanbul Protocol with outside
support. This showed what can be done
with specific activities. Dr. Nathanson felt
that we should recommend that the Nor-
wegian Medical Association and Dr. Reis
identify simple things which can be done.
The Secretary General commented that
WMA as an NGO had been successful in
getting support from governments and the
International Court in the Hague. What
would happen if we were known to act as
a monitoring body, what would be the re-
130
WMA news
action? Currently we are aware of doctors
in distress and have taken action. Dr. Reis
agreed with Dr. Kloiber and was willing to
work on this.
A proposal that the BMA, the Norwegian
MA and Dr. Reis continue work on this
was recommended and later adopted by
Council.
End of Life
A WMA Statement on the End of Life
and a background paper on End of Life
and Medical Care were considered. It was
reported that the Spanish Medical As-
sociation had been working on a paper on
Euthanasia and had prepared a glossary of
terms.
A Statement on terminal illness had also
been prepared in the light of the change
of attitudes which had taken place. The
Spanish Medical Association (SpMA)
therefore recommended changes to the
Venice Declaration. Reference was made
also to issues of Informed Consent, Pal-
liative Care and to many countries still
having problems with prescribing opiates
where national legislation limits interfered
with their adequate prescription – leading
to more suffering by patients. It should
be made clear that terminal sedation was
not Euthanasia, a matter on which the
SpMA had issued a Statement. There was
a need for team work with doctors and
paramedical professionals, also for fami-
lies to be involved in palliative treatment
and for palliative care to be included in
medical school curricula. Dr. Snaedel as a
geriatrician suggested that the documents
be circulated, but Dr. Nathanson observed
that the BMA had many problems with
the document. There was much good in
the paper, but she was concerned about
the translation and the BMA had many
problems with some of the definitions.
She proposed that a working group be
formed and address also the problem of
continuing unbearable conditions.
After lengthy discussion the Chair thanked
the Spanish for the proposal. A recommen-
dation that a working group be set up was
approved and later adopted by Council.
The committee also received:
a report from Dr. Blackmer on WMA’s•
work with WHO on Ethics in TB envi-
ronment (see Secretary General’s report);
comment from Sir Michael Marmot on•
the work of WHO on Social Determi-
nants in the context of Tuberculosis;
an offer from Dr. Nathanson to distribute•
through the WMA secretariat an updat-
ed UK statement and concept paper on
teaching ethical issues, from the Institute
of Medical Ethics.
Socio-Medical Committee
The committee was called to order by the
chair, Dr. José Luiz Gomes do Amaral.
The committee approved the minutes of its
New Delhi meeting last autumn.
Health and Environment
In the context of Health and Environment
(see also Secretary General’s report) the com-
mittee considered comments on the state-
ments on Environmental Degradation
and Sound Management of Chemicals
and also a document on Advocacy Strategy
on Climate Change Process.
Dr.Nakai,chair of the workgroup on Health
and Environment, informed the committee
that the group planned to submit a draft
policy on the “built environment” next
spring.
Dr. Dongehun Shin reported on a con-
ference convened by the secretariat of
the United Nations Environmental Pro-
gramme (UNEP) Strategic Approach to
Management of Chemicals in Ljubljana in
February, on the approach to the involve-
ment of the health sector in chemicals’
disposal. Speaking of the need for further
management principles in Chemicals’ dis-
posal, he said one of the aims was to re-
duce health risk in the life cycle of chemi-
cals, i.e. the control of harmful chemicals
and the reduction of production. He com-
mented that developing countries have a
lack of capacity for sound chemical devel-
opment.
The committee also received an oral report
from Dr. Peter Oris concerning the first ne-
gotiating meeting of the UN Environment
Programme on legally binding provisions,
scheduled for June in Stockholm, at which
he would represent WMA. He intended to
highlight the Seoul WMA Resolution on
Mercury.
Ms Clarisse Delorme speaking to a paper
on advocacy strategy prepared by the sec-
retariat for the Health and Environment
WMA workgroup, reiterated the Advocacy
Committee’s discussion on the frustration
felt at the failure to include reference to
health in the final Copenhagen COP 15
conference agreement and their failure to
optimise the increasingly well-evidenced
public health benefits of climate change
mitigation activities.
Sir Michael Marmot reported that he had
personally been lobbied by physicians in the
UK about this. In the UK climate is an is-
sue for the people. He therefore supported
highlighting this issue with regard to hu-
man health.
Dr. Dana Hanson, chair of the Advocacy
Advisory Group, supported the proposal by
the group to hold a media briefing session
on the day before the opening of the UN
Climate change Conference to be held in
Cancun in December 2010.
The Committee recommended and Coun-
cil later accepted that the Statement on
Environmental Degradation and Sound
Management of Chemicals be sent to the
General Assembly with a recommenda-
tion that it be adopted.
131
WMA news
Prescribing/Relations between Physicians and
Pharmacists in Medical Therapy
There was a long and forceful debate in
the committee concerning where ultimate
responsibility for prescribing lies. During
the debate firm views were expressed by all
speakers. Emphasis on the importance of
issues of patient safety and access to medi-
cines were stressed as were educational re-
quirements and skills needed to ensure both
quality and safety, in the interest of patients.
The final decision will be taken at the Van-
couver General Assembly in the autumn
when the texts of recommendations are
submitted to the General Assembly.
Violence against Families, Women and
Children
Dr. Nakai introduced the Working Group’s
revision of the Proposed Statement on
Family Violence revision, following com-
ments from NMA’s. After some discussion
amendments were agreed. A recommen-
dation, that the Proposed Statement on
Family Violence be approved and sent to
Council later approved by Council.
Dr. Nakai then indicated the efforts of the
group to amend the document Violence
against Women and Girls to reflect con-
cerns of NMA’s. Dr. Nathanson urged that
the aim of the document be clear. “Vio-
lence is damaging both to the victim and
to society”. The recommendation that it
be approved as amended and sent to the
General Assembly was later accepted by
Council.
Female Genital Mutilation (FGM)
In a discussion on FGM,Dr.Nathanson in-
dicated that although we have a Statement
on this issue, governments can still be por-
trayed as racist in condemning this, since
while education was improving, there is still
the problem of parents taking children to
countries where FGM was accepted. After
talking to girls who have such forced FGM
it is clear that they would prefer action to
be taken.
Dr. Hill reminded the committee of the
WHO/UNICEF/UNFPA Global Strategy
to stop healthcare providers from perform-
ing FGM. WMA had been involved in the
drafting process and it fitted in with WMA
policy.
Dr. Kloiber commented that what we
wanted was to achieve FGM abolition and
to help victims. We will achieve a preventa-
tive effect for those emigrating.The Norwe-
gian Medical Association commented that
screening has not been shown to prevent
FGM and there remained the question “at
what age screening should be done?” Also
FGM can be difficult to identify. Dr. Na-
kai said that screening of immigrants can
identify risk and referred to a European
Parliamentary document on this issue. Dr.
Nathanson felt that clearly screening could
not be forced, but often at screening this
can be used as an opportunity to prevent
and educate.
Classification of WMA 2000 Policies
Prisons and Tuberculosis
The committee recommended that the Dec-
laration of Edinburgh on Prison Condi-
tions and the Spread of Tuberculosis and
other Communicable Diseases undergo a
major revision on which the BMA and the
ICRC volunteered to work. Council later
approved this recommendation.
Advocacy
Dr. Hanson, chair of the Advocacy Ad-
visory Group, in his oral report raised
Advocacy issues relating to WMA’s role
in climate change. He mentioned also
the increasing role of the World Health
Professional Alliance’s (WHPA) speak-
ing for more than 26 million health pro-
fessionals in global health debates. There
was increasing concern amongst WHO
member states on Primary Health Care,
and he proposed that WMA should or-
ganise a Primary Health Care conference
in 2011. Council later agreed to a small
working group examining the feasibility
and possibility of cooperation with other
international PHC bodies of Organis-
ing a Primary Healthcare conference in
March 2011.
Dr. Haikerwal, speaking about the work
of WMA with WHO, raised the Issue
of Social Determinants of Health which
should be addressed at such a conference.
Sir Michael Marmot had hoped to raise
the issue of Ethics in the Committee of the
Commission on Social Care. He referred
to health inequalities and the interest not
only in the causes of health inequalities
but also in the causes of causes in health.
Where do physicians fit in to this? He
listed three points:
the responsibility to put one’s house in or-•
der concerning universal access to health
promotion;
the role of physicians as advocates;•
the importance of knowledge of the de-•
terminants of health.
Council later agreed that this be pursued
(see resumed council below).
Medical Care for Refugees
The committee considered a “Proposed Re-
vision of the WMA Resolution on Medi-
cal care for Refugees and Internally Dis-
placed Persons”.
The Swedish Medical Association moved
that the revised proposal be approved and
also commented that the current legisla-
tion in their country was very restricted
and the Association had highlighted this.
Dr. Nathanson supported this excellent
document being sent to NMA’s for com-
ments and indicated particular difficulties
with medical care of such persons awaiting
the approval of permission to stay in the
country.
132
WMA news
The recommendation that the revised docu-
ment be referred to NMA’s for comments was
later approved by Council.
World Economic Forum (WEF)
Dr. Julia Seyer reported a recent meeting
in London on a WEF initiative to improve
access to health data on the grounds that
such data play an important role in Health
care and health services. To this end WEF
is working with parties with relevant in-
terests such as health professionals, patient
groups, private industry and universities, to
draft a global charter to strengthen access
to health data which can produce more ef-
fective management of health providers
and of individual health interests. Such a
document needs to balance these interests
with ensuring the protection of individual’s
privacy, as well as ensuring the quality and
standardisation of data collected and the
underlying principle of equity. Dr. Haiker-
wal observed that probably most countries
have this information but governance was
needed. Sir Michael Marmot was not clear
about whether principles were concerned
with privacy and data, or about collecting
data. The Secretary General thought it im-
portant to be involved in this. WMA was
in line with the other health professions on
these issues and WEF was providing a plat-
form for discussion.
Medical Aid in Disaster Areas
The Chairman, Dr. Amaral, gave a detailed
account of the Brazilian Medical Asso-
ciation’s organisation of medical aid “SOS
Haiti“ following the earthquake in January
2010. Within 21/22 days following a call
for volunteers 907 physicians from various
specialties had offered to go to Haiti. He
made particular reference to the work which
was enabled to be carried out in a Canadian
Hospital based in Haiti, which made space
available to enable these physicians to en-
gage in surgery, notably the orthopaedic
surgery required. He referred to the many
NMA’s who had provided assistance and
the collaborative assistance in neighbouring
Dominica.
Concluding his remarks he commented,
“A world safety zone does not exist on this
planet” – and appealed for WMA to assist
in coordinating the spread of the experi-
ences of NMA’s in responding to Disasters
and the potential for WMA to participate
in coordinating NMA’s responses to disas-
ter assistance.
A number of NMA’s spoke of their experi-
ence in responding to Haiti and other disas-
ters over recent years, stressing the impor-
tance of disaster preparedness and expressed
the feeling that WMA should act as a focal
point in coordinating the experiences of
NMA’s, etc. Reference was also made to a
forthcoming WHO report on Disasters.
Counterfeit Drugs
Dr.Seyer then gave an account of the launch
of World Health Professions Alliance
(WHPA) campaign on Counterfeit Medi-
cal Products, “Be Aware”. She stressed the
impact of counterfeit drugs,both patent and
generic, on patient safety such as the major
risk of increasing drug resistance in tuber-
culosis. This affected also the confidence
of the public in available drugs. In parts of
Asia and South America 30% of the drugs
were counterfeit and the profits from these
amounted to between 5 and 10 million dol-
lars. It should be noted that counterfeit was
not limited to the developing world. It also
is a problem in the developed world via for
example on-line purchases of which some
50% were counterfeit. The WHPA had
defined principles and had also identified
patients as victims of this activity. WHPA
had set up a tool-kit on “counterfeit drugs”
for both professionals and public. This was
accessible on both WMA and WHPA
websites. Workshops are being organised
at which action points will be emphasised.
These will take place in Africa and America,
to which government representatives will be
among those invited. She asked WMA and
NMA’s to distribute the toolkit which was
available for downloading from the web.
This work was also being coordinated with
WHO.
Non-Communicable Disease Management
In updating the committee on UN policy
work on Non-Communicable Diseases
the AMA reported that together with
the American Academy of Family Physi-
cians it organised a group to influence the
Statement. WHO has also an agenda on
this topic. At the World Health Assembly,
member states’ representatives had spoken
on this issue and the AMA had been in
contact with them. It was anticipated that
a paper would be produced for the General
Assembly in 2011.
Dr. Seyer thanked Dr. Ishii for a draft on
Non-Communicable Diseases and indicat-
ed that there would be a UN conference on
this topic later in the year. There was pres-
sure to add this topic to the MDGs. It was
important that the role of health profes-
sionals be included in these discussions.
Dr. Ishii also reported that there was a col-
lective voice from Asia appealing to phy-
sicians to work with patients on “Patient
Safety”.
Dr. Nathanson said that Sir Michael had
referred to his work on Social Determinants
in Health.The BMA was preparing a paper
on the role of Physicians, which would be
published.
The Chairman, Dr. Gomes do Amaral,
gave an extensive report on the medical aid
“SOS Haiti” rapidly organised by the Bra-
zilian Medical Association responding to
the earthquake disaster in January 2010. In
response to an appeal 907 physicians vol-
unteered to go to Haiti. He detailed the
tremendous problems encountered and
paid tribute in particular to the Canadian
help which arrived and provided much
133
WMA news
needed Ophthalmic and ENT services, to
the supplies sent from Ethiopia, the help
in neighbouring Dominica and to NMA’s
and others who responded to the need for
specialist services, notably orthopaedics. He
warned that “A safety zone does not exist on
this planet” and appealed for volunteers in
WMA to spread the experience of NMA’s
in responding to disasters.
Dr. Ishii in thanking Dr. Amaral said the
Japanese Medical Association had sent
volunteers and stressed that Japan had sub-
stantial experience of earthquakes. Dr. Na-
thanson said that the BMA had links with
the Red Cross, UNICEF, Médecins sans
Frontières, etc., and directed people as ap-
propriate. Resources were provided from
the NHS as donations from their stockpiles
as appropriate, and the government had
doubled its aid.The public in responding to
an appeal gave 10 times more than this.
The Israel Medical Association, whose vice-
president had organised rehabilitation ser-
vices which were also needed, felt that this
type of emergency needs support from the
WMA. The AMA had organised an emer-
gency response team with PAHO and the
Department of Defence organised a con-
sultation on the management of disasters.
An AMA/American College of Surgeons
delegation was sent to organise an evalua-
tion of needs. The SpMA has established a
register of volunteering specialists – more
than 1000 – and expanded the training of
volunteers.
The Chair commented that we had needs
for disaster assistance in 2005, 2006 and
also Haiti. Climate change was also to be
expected. He felt that WMA should play a
role as a central control for Medical Aid in
these circumstances. It would not be easy.
Dr. Haikerwal said they had the same prob-
lems with the Tsunami in 2004. The AMA
had lots of experience: lots of equipment
and manpower arrived but was blocked
from being quickly deployed.WMA should
coordinate learning from these experienc-
es. Dr. Nelson commented we don’t know
when the next disaster will hit us.What was
important was disaster preparedness.WMA
should be a focal point for this.. She had
students from medical school but no means
of coordinating their help. Brazil had given
an example of how to coordinate assistance.
WHO Global Strategy on the Prevention of
Alcohol Abuse
Mr. Dag Rekve,Technical Officer, Manage-
ment of Substance Abuse Department at
WHO, reported that the 63rd meeting of
the World Health Assembly had just ad-
opted the WHO Global Strategy on the
Prevention of Alcohol Abuse.
Addressing the question “Why this Global
Strategy” he explained that a collaborative
study on disease cause and outcome had
identified alcohol as the 3rd leading risk
factor for global causes of diseases It was
therefore a global issue. He illustrated the
huge problems of morbidity and the huge
variation in mortality in sub-groups such
as male/female/age and also referred to
some protective effects of alcohol. Young
people were the most damaged, e.g. 30%
in the European region. There were great
variations in determinants. Addressing
the question of why should this become a
global issue now, he outlined the history
of research and resolutions starting in the
early 80’s with French research into the
social consequences of alcohol abuse and
then further research, expert committees
and WHA resolution over the succeeding
years. In 2002, “Alcohol” – a WHA report
– listed alcohol as the fifth leading fac-
tor in disease causation. In the following
years things moved towards the concept
of a global strategy which was the subject
of wide consultation, and a draft mandate
for a global strategy began to emerge, cul-
minating in the Global Strategy just ad-
opted. While member states have agreed
the Strategy, it is not legally binding, it was
meant to complement governments’ ac-
tions. The evidence basis for damage from
alcohol was good but there were huge dif-
ferences in member states. This called for a
comprehensive approach.There was a need
for leadership as reflected in the WMA
Santiago approach. National Health Ser-
vice commitment was essential. While
there was little evidence basis for actions,
availability and pricing of alcohol were im-
portant.
Harm reduction processes should try to
reduce the negative consequences of alco-
hol abuse. Illicit production needed to be
addressed. Because of ethanol which is an
added risk. Globally WHA has four axes:
public health advocacy;•
resource mobilisation;•
problems of implementation;•
need for a going concern – swings be-•
tween no action and aggressive action.
In the Executive Board, Cuba and Sweden
were working in cooperation. Referring to
the effects in the older generation he spoke
of Diabetes and Alzheimer’s disease. There
was a need to balance between the positive
and the negative aspects of alcohol. Further
information was accessible on the web at
www.who.int/substanceabuse.
Dr. Nathanson was delighted that WHO
had acted. In the UK 25% of the popu-
lation is abusing alcohol and we are see-
ing cirrhosis in the early 20’s. This was a
problem throughout the European Re-
gion of WHO. Referring to the major
problem of how to deal with the Industry,
she referred to the problems the UK had
experienced with the tobacco industry
and said that the UK was now experienc-
ing the same with alcohol. Dr. Snaedel
said the industry had its own strategy.
It had learnt from the tobacco industry
to urge support for programmes to deal
with alcoholism but to oppose limits on
price levels. Dr. Haikerwal observed that
while the WHO Strategy was not legally
binding, there was a need to understand
what governments were signing up to. He
134
WMA news
referred to the problems of binge drink-
ing, Alco-pops, and especially mentioned
cheap wine in Australia, which was dif-
ficult to deal with.
Dr. Hill emphasised that action such as
banning advertising at university sports
and local zoning had been successful. There
was a need to get primary prevention from
childhood to the mid 20’s.
Mr. Rekve said that actions have to be lo-
cal and politically supported and there was a
need to monitor effects as to the efficacy of
actions. Referring to young people’s prob-
lems and patterns of drinking; in the north
this had been picked up because of violence.
For others it was the social consequences
and he quoted the French students and
binge drinking.
The alcohol industry was difficult. Mem-
ber States’ concerns reflect the fact that
the industry is a commercial producer and
governments have an interest because of
alcohol and tax. Member States agree that
distribution should be examined, e.g. Alco
pops.The Industry is focused on its strategy
and Mr. Rekve called for an NMA strategy.
He felt that an index of Member State in-
volvement was the fact that 32 States spoke
in the WHA debate.
Mr. Rekve was warmly thanked for his pre-
sentation.
Finance and Planning Committee
The meeting was opened by Dr. Haik-
erwal, in the Chair, and the minutes of
the previous Tel Aviv meeting were ap-
proved.
Mr. Hallmeyer gave a presentation on the
pre-audited financial statement, detailing
the various aspects of the report and stating
that the finances were in a good position.
The audited Financial Statement was rec-
ommended for approval by Council which
later also adopted it.
The Secretary General, speaking to the Re-
port on Financial Dues, thanked NMA’s for
paying their dues, recognising that in view
of the financial problems they had done
their best. He commented that dues only
reflect part of the contribution of NMA’s,
which also contributed their work,expertise,
and time to WMA, for which he thanked
them.
Turning to the changes to the different
groups’ dues, he said this had had a positive
effect attracting a number of countries that
would not otherwise have joined. Account
had also been taken of countries’with prob-
lems due to disasters, etc.
Strategic Plan
The Secretary General referred to the work
done during the period of the Strategic Plan
suggested in 2004 and which has run from
2006 to 2010. There had been governance
changes, a review of dues which will have a
final review in 2 years. The result of imple-
menting the Strategic plan could be seen
under three heads:
There is a stronger focus on ethical fora.•
Advocacy had been developed.•
Other services developments.•
Speaking of Advocacy and the Business De-
velopment Group, these had been successful
in policy development and its recognition,
especially in Helsinki development and pro-
tocol. We have been successful in Alcohol
and Tobacco actions and recently we have re-
ceived an invitation to participate in a World
Economic Forum initiative. Our actions
should continue to be more proactive.
We had been successful in getting participa-
tion with WHO and with others. Our num-
ber had increased to 95 members of which 15
were new,and we continue receiving new ap-
plications for membership, e.g. Serbia, Mo-
zambique. Turning to the provision of ser-
vices, many educational materials had been
produced and the courses provided on Eth-
ics, Prisons and Tuberculosis and MDRTb
were very successful. We had also worked
with other Health Professions, e.g. on the
problems of Counterfeit Drugs and on the
problems of member states’needs due to lack
of resources. We are now at the end of this
WMA strategic plan and need to produce a
plan for 2011–2015, considering a new focus
possibly on humanitarian aid.
Business Development Group
Dr. Nathanson gave this report on behalf of
the Chairman of the Group.She spoke of the
increasing use of the web portal. Referring to
ways of raising money she congratulated the
Secretary General on the success of the con-
ferences, e.g. Helsinki, São Paulo. The portal
had other uses such a CPME/CPD. Con-
cerning CPME,thebusinessgrouphadheld
two meetings and recognised the need to
speak to major producers. She had had dis-
cussions with the BMA Publishing Group,
or producers of on-line material. She invited
other NMA’s to discuss this. E-learning is
very expensive, £ 20–30 a module. A Round
table had been suggested at which WMA
would invite a number of different industries
to meet together and learn how WMA needs
could be met.At its meeting in April the WG
had set out the principles for such a meeting
to avoid misunderstanding of the purpose of
the meeting and avoid industry influencing
WMA policy. There are concerns about this
and it is hoped that the document of princi-
ples would ensure that these concerns be met.
The portal could have a subset.
Concerns were expressed by a number of
speakers, but Dr. Nakai indicated that she
had worked with the AMA and the Ameri-
can College of Cardiology which have such
a Round Table and found it to be success-
ful without ethical problems. Dr. Hill con-
sidered that the discussion was premature.
However, the Secretary General, bearing
in mind that comments had already been
considered, said the document had been fi-
nalised two days previously. It was decided
that this document be circulated to constit-
uent members for comment.
135
WMA news
WMA Meetings
A working group chaired by Dr. Ramin
Parsa-Parsi had met twice and considered
whether the time connection for Spring
Council meetings with the WHA was nec-
essary. The Business Group considered that
a “disconnect” would provide WMA with
more flexibility. It could permit a better bal-
ance between meetings of Council and the
General Assembly.
It was proposed that the Spring council
meeting in Australia be held on 7–9th
April.
This would have the advantage that hotel
prices would be lower as the date was re-
mote from Easter. Two other issues were
still under discussion.
The Secretary General reminded the com-
mittee that a “disconnect”with WHA was a
general suggestion and Dr. Haikerwal felt it
was time to discuss the pros and cons of the
link with WHA. Dr. Bagenholm observed
that there were a number of people who
were included in national WHA delega-
tions. It was therefore useful to have Coun-
cil meet before WHA. She posed the ques-
tion “Do we lose by a disconnect? ”.
Dr. Parsa-Parsi commented that only two
WHA delegations included NMA individ-
uals.The working group felt that there could
be travel economies. The Secretary General
felt that there could be advantages if the
meeting went elsewhere and that there were
advantages in holding meetings in an NMA
venue. May in Geneva was not economic.
Dr. Nathanson considered that geographi-
cal decoupling could be to the advantage
of non-European countries. Furthermore
the period after May was difficult for the
Secretariat. The committee adopted the
Recommendations, all of which were later
adopted by Council:
The annual spring meeting of the WMA
council not be linked temporarily to the
World Health Assembly meeting and this
proposal was later adopted by Council.
That the 188th
Council session be held in
Sidney on 7–9th
April 2011.
That the Report on the Arrangements
for future WMA General Assembly and
Council meeting be approved.
Dr. Apinis also informed the Committee
and later Council that the Latvian Medical
Association in cooperation with the World
Medical Association is holding a conference
on “ The Financial Crisis – Implications for
Health Care – Lessons for the Future” to
take place in Riga, Latvia 10–11th
Septem-
ber 2010.
Dr. Nakai spoke about the arrangements for
the General Assembly this year in Vancou-
ver mentioning in particular, arrangements
for CPME recognition and also the Spon-
sorship Fund.
United Arab Emirates
Dr. Parsa-Parsi informed the committee
that it was felt that United Arab Emir-
ates were underrepresented. The Secre-
tary General, the Danish and Norwegian
Medical Associations had discussed this.
It was suggested that an expert conference
be held to demonstrate to the UAR the
type of work the WMA did.The Gulf Re-
gion countries have been the most open in
the Region. He had spoken to the Presi-
dent of the Emirates Medical Society
and he seemed keen. He suggested that
an Expert conference be held in Dubai,
jointly organised with the UAE. Possibly
the Arabic Medical Union could join in
the organisation. A topic suggested could
be Patient Safety and Medicine. He sug-
gested that this be a Recommendation to
Council. D. Nathanson thought the topic
“Patient Safety” was very broad, would
this be narrowed? What about policy
and getting experts together? Dr. Parsa-
Parsi said this would have to be discussed
with partners. The Secretary General
commented on the difficulty of commu-
nicating with the UAE. After further
discussion in which a positive mood was
expressed, it was agreed to recommend
that the concept of an expert conference
in December 2011 be explored and this
Recommendation was later adopted by
Council (see below).
Uruguay reported that it was thinking of
having a meeting of the National Medical
Associations of Latin America Forum, to
which the President and Secretary General
would be invited.
The Council approved the following rec-
ommendations of the committee:
“Theannualspringmeetingofthecoun-•
cil be not linked to the World Health
Assembly meeting”.
“• The 188th
Council session be held in
Sydney on 7–9th
April 2011”.
“The Future General Assembly and•
Council session paper be approved:
(General Assembly, Vancouver 13–16th
October 2010, 188th
Council Sydney
28–30th
April 2011, General Assembly,
Montevideo, Uruguay 12–15th
October
2011)
“that holding an expert committee meet-•
ing in Dubai at the beginning of 2011 be
explored and that the topic be determined
in collaboration with the Emirates Medi-
cal Society”.
Membership
The committee recommended and Coun-
cil approved, forwarding the application
for Constituent Membership from the
Associação Médica de Moçambique to
the General Assembly, recommending it
be admitted to membership of the WMA.
Associates
The committee received a report of the
WMA Association Membership for 2009
and considered a Revised Proposal from
the Workgroup on Reform of the Associate
Membership and Comments. Both docu-
ments were later approved by Council.
136
WMA news
Consolidation of WMA Governance Docu-
ments
The committee considered documents
on the Consolidation of the Association’s
Governance, By-Laws, etc., together with
the explanatory memorandum. The com-
mittee thanked those who did this work. It
proposed that the document be circulated
to constituent members for comments and
that the workgroup continue its work on
consolidating these four documents into
two. This was later approved by Council
Outreach
The committee received an oral report from the
WMJ Editor in Chief and the paper written
Public Relations Report 0ctober 2009–April
2010.
Resumed Council meeting
The Council considered the Socio-Medical
Affairs committee report, using the process
of the consent calendar by which only items
in documents before the committee on which
members wished discussion would be debated.
The other items considered to be e-approved
and are formally adopted in the approval of the
committee report.They are shown in bold above
in the text of the committee discussion reports.
Strategic Plan
The American Medical Association sought
clarification on the process for developing
the Strategic 5-year planning, mentioning
in particular, input into the process, e.g. on
disaster planning. The Secretary General re-
plied, explaining that the present document
was a draft and reminded members that last
Strategic Plan draft went to the Executive
and was referred to Finance and Planning.
The question of Humanitarian Aid was not
in the draft and would have to be considered
this time. It was open to Council members
to make suggestions and comments. Dr. Na-
thanson (BMA) commented that many or-
ganisations had a 3 or 5-year plan and also
annual priorities for particular years,e.g.gov-
ernment actions, economic crises, etc. Could
WMA have both a 5-year plan and consider
short term plans also such as – for the next
year – the Economic Crisis? The Secretary
General indicated that WMA had had this
in 2005 and 2006 largely because WMA was
proactive but it faded away in 2007. BMA
said that in its annual plan it was proactive –
dealing with things one wants to deal with.
Rolling plans were somewhat generic. The
Secretary General said WMA had done this
in the Advocacy Group. Dr. Haikerwal felt
we were in a better position in our work as
a result of the Secretary General’s action. It
would be useful to define times for discussion
of this in the run up to Vancouver to support
the Secretary General. Such support should
be available to the Secretary at the right time.
Dr. Kloiber responded that the Social Work
Group would start on the website in June.
The process could be made transparent in
this way for committee members to contrib-
ute. Dr. Bagenholm agreed that it was im-
portant to have a role in contributing to the
Strategic Plan. She supported also an annual
plan and also felt that there should be input
before October. Dr. Nakai agreed that the
process should include more than the Execu-
tive Committee and supported an extra half
day for this in Vancouver. Mr. Wapner said
the WMA had moved forward. The Strat-
egy Group had discussed how much this fits
in with NMA aims and strategic plans. The
Secretary General was open to new ideas.
Dr. Kloiber responding to this said it would
have to be done with the Executive well be-
fore Vancouver.Dr.Haikerwal indicated that
the Finance and Planning committee would
take this planning on board in relation to the
WMJ through the Finance and Planning
Committee in Vancouver.
Prescribing/Relations between Physicians and
Pharmacists in Medical Therapy
There was a resumption of the lively discus-
sions on Recommendations on the docu-
ments on Drug Prescription and that on the
Relationship between Physicians and Phar-
macists in Medical Therapy. The Council, fol-
lowing a reconsideration of the recommenda-
tion on Drug Prescription, decided that “The
Proposed Revision to the Proposed WMA
resolution on Drug Prescription” be circu-
lated to WMA constituent members for their
comments.
Following discussion and a number of divisions
on motions to amend the document on Physi-
cians and Pharmacists in Medical Therapy,
Council decided that: “The Proposed revi-
sion of WMA Statement on the Relation-
ship between Physicians and Pharmacists
in Medical Therapy, as amended, be for-
warded to the General Assembly with the
recommendation that it be adopted”.
United Arab Emirates
There was also further discussion on the
recommendation concerning the holding of
an Expert Conference in the United Arab
Emirates (see above).
Disasters
Dr. Amaral, referring to the discussion in
SMAC on Disasters asked if it was possible
to set up a work group to consider the role
of WMA in Disasters. The Secretary Gen-
eral responded that before doing this a pa-
per on the topic was needed and asked the
Brazilian Medical Association to prepare a
preparatory paper.
A motion to approve the rest of the Fi-
nance and Planning Committee report
was approved.
Medical Ethics Committee Report
Council then turned to report of the Medi-
cal Ethics Committee and, following the
calendar extraction process (see above), there
was a short discussion on the proposal for
discussions with the Emirates. Concern was
expressed about the absence of any refer-
ence to possible partners in the suggested
expert conference,nor to content,e.g.Qual-
137
WMA news
ity or Patient Safety. It was suggested that
the conference would be jointly organised
and topics would be chosen after joint dis-
cussion with EMA.The Chair said that the
Executive would make decisions on how
this matter be processed.
Following a motion,the report of the Medi-
cal Ethics committee was approved.
WHO and World Health Assembly
Council heard a report from Ms Julia Seyer
on the WHO and the World Health As-
sembly. She emphasised two issues. Con-
cerning Counterfeit Medicine she said the
WHA had had some conflict with WHO
over this issue. Some emerging countries
considered that this was more an issue for
The World Trade Organisation rather than
WHO as it primarily concerned Intellectual
Property. Dr. Margaret Chan, the WHO
Director General, said it was about Public
Health. There had been an emotional de-
bate and a lot of redrafting was going on but
there was no news of the outcome.The sec-
ond issue was Codes of Practice concern-
ing the migration of Professionals. After 2
years Member States had tried to get eth-
ics and migration out of the debate and the
document had been weakened. The Global
Health Force Alliance is to hold the Second
Global Forum on Human Resources for
Health in Bangkok in January 2011.
Dr. Bagenholm spoke of the importance of
getting medical representatives into nation-
al WHA delegations as there were very few
doctors on the delegations. She had been a
delegate for six years. The Chair comment-
ed that delegations were very political and
largely administrative. Dr. Wilson (USA)
commented that the USA usually included
a physician in their delegation and added
that the removal of links between the date
of WMA meetings and WHA would be of
assistance.
Other business
Dr. Nathanson reminded council that Sir
Michael Marmot had mentioned trying to
ensure that physicians were represented at
the Global Conference on Social Deter-
minants in Health Conference. The BMA
will bring a paper on this topic to the Gen-
eral Assembly in Vancouver.. Following a
suggestion to have a work group to consider
how WMA could be involved in this con-
ference, Dr. Nathanson indicated that she
could work with Sir Michael to prepare a
paper on our involvement rather than hav-
ing a work group, a view with which the
Chair agreed.
Dr. Seyer reported that the WHPA works
closely with WHEN, the World Health
Editors Network which had published a
Health Literacy guide and an Advocacy
guide. Both of which were accessible on the
WMA website.
The Council meeting was terminated with
the extending of thanks to the staff and to
the interpreters and to members for their
work.
Dr. Alan J. Rowe
The WMA has appealed to the President
of Sudan, Omar Al Bashir, for the release
of six Sudanese doctors, arrested and de-
tained without charge for their activities
as members of the Doctors’ Strike Com-
mittee calling for better pay and working
conditions for doctors in Sudan.
Dr. Dana Hanson, President of the
WMA, has written to the President urg-
ing the Sudanese authorities to release the
six doctors immediately and uncondition-
ally and to provide them with any medi-
cal attention they might require. The six
doctors – Dr. Alhadi Bahkit, Dr. Ahmed
Alabwabi, Dr. Ashraf Hammad, Dr. Mah-
moud Khairallah, Dr. Abdelaziz Ali Jamee
and Dr. Ahmed Abdallah Khalafallah –
had, according to reports, been detained
without charges and some had been se-
verely beaten.
Dr. Hanson added:
‘The World Medical Association is deeply
concerned by the situation of these six doc-
tors who have been denied the fundamen-
tal right to a fair trial and are exposed to ill
treatments and torture.
We consider them prisoners of conscience,
as they appear to have been imprisoned
solely in relation to their activities of the
committee calling for better working con-
ditions for doctors in Sudan.’
He also called on the President to re-
form the 2010 National Security Act to
remove the excessive powers of the Na-
tional Intelligence and Security Services
(NISS), in particular powers of arrest
and detention without judicial oversight
for four-and-a-half months. Dr. Hanson
has also written to Mohamed Atta Al-
Moula Abbas, Director of the NISS, in
Khartoum.
A committee of Sudanese doctors has been
campaigning since 2003, to improve the
working conditions of doctors in Sudan. It
has organised several strikes, the latest of
which led to their arrests.
World Medical Association Appeals for
Release of Sudanese Doctors
28th
June 2010
138
WMA news
The Third Geneva Conference on Person-
centred Medicine in May 2010 followed the
inaugural Geneva Conference of May 2008
[1] and the Second Geneva Conference of
May 2009 [2] as landmarks in a process of
building an initiative on Medicine for the
Person through the collaboration of major
global medical and health organisations and
a growing group of committed international
experts [3].
The Conference took place on 3–5 May
2010 at the Marcel Jenny Auditorium of the
Geneva University Hospital and the Ex-
ecutive Board Room of the World Health
Organisation. It was organised by the In-
ternational Network for Person-centred
Medicine (INPCM), the World Medical
Association (WMA), the World Organisa-
tion of Family Doctors (Wonca), and the
World Health Organisation (WHO), in
collaboration with the International Alli-
ance of Patients’Organizations (IAPO), the
International Council of Nurses (ICN), the
International Federation of Social Workers
(IFSW), the International Pharmaceutical
Federation (FIP), the Council for Interna-
tional Organisations of Medical Sciences
(CIOMS), the World Federation for Men-
tal Health (WFMH),the World Federation
of Neurology (WFN), the International
Federation of Gynaecology and Obstetrics
(FIGO), the World Association for Sexual
Health (WAS), the World Association for
Dynamic Psychiatry (WADP), the Interna-
tional Federation of Medical Students’ As-
sociations (IFMSA), the World Federation
for Medical Education (WFME), the In-
ternational Association of Medical Colleges
(IAOMC), the European Association for
Communication in Health Care (EACH),
the European Federation of Associations
of Families of People with Mental Illness
(EUFAMI), Ambrosiana University, Ge-
neva University, and the Paul Tournier As-
sociation.
The Third Geneva Conference on Person-
centred Medicine, under the overall theme
of Collaboration across Disciplines, Specialties
and Programs, examined through a set of
sessions the guiding value of person- and
people-centredness, ethical aspirations, ba-
sic communication skills, fundamental clin-
ical care activities, the challenge of surgical
and intensive care procedures, the vicissi-
tudes of the life cycle, and the implications
of cultural diversity.
The Conference Core Organising Com-
mittee was composed of J. E. Mezzich
(INPCM President and World Psychiatric
Association President 2005- 2008), J. Snae-
dal (World Medical Association President
2007–2008), C. van Weel (World Organi-
sation of Family Doctors President 2007–
2010), I. Heath (Royal College of General
Practitioners President), M. Botbol (WPA
French Member Societies Association
President), I. Salloum (WPA Classifica-
tion Section Chair), and W. Van Lerberghe
(Director of WHO Department for Health
System Governance and Service Delivery).
Also collaborating organisationally were
O. Kloiber (WMA Secretary General),
A. M. Delage (WMA Secretariat), R. Ka-
war (WHO), and J. Dyrhauge (WHO).
Financial or in-kind support for the Confer-
ence was provided by 1) the International
Network for Person-centred Medicine (core
funding), 2) the World Health Organisa-
tion (covering invited participants’ travel
and accommodation expenses, a conference
reception, and some secretarial and logistic
services), 3) University of Geneva Medi-
cal School (auditorium services and coffee
breaks), 4) Paul Tournier Association (a con-
ference reception and the conference dinner
for a group of invited participants), 5) The
World Medical Association (local secretariat
and printing services and support to extend
the conference dinner to all participants) and
6) Participants’registration fees.
The Conference was opened by authori-
ties of the University of Geneva Medical
School, the Director of the WHO Depart-
ment for Health System Governance and
Service Delivery representing the WHO
Assistant Director-General for Health
Systems and Services, the President of the
World Medical Association (WMA), and
the core members of the Organising Com-
mittee. The opening address was delivered
by the INPCM President, who presented
a progress report on the INPCM’s first
months of existence emerging from the
Second Geneva Conference.He touched on
the establishment of a governing Board and
initial organisational bases, development of
an active publications programme including
a journal supplement with the edited papers
from the First Geneva Conference, a well-
visited website, an institutional logo, and
the organisation of the Third Geneva Con-
Highlights of the Third Geneva Conference
on Person-centred Medicine
Logos of the institutions collaborating on the organisation of the Third Geneva Conference on
Person-centred Medicine
139
WMA news
ference including presentations from stellar
academic leaders and a record number (22)
of collaborating organisations, most promi-
nently the World Medical Association and
the World Health Organisation.
The first session of the scientific program in-
volved a symposium on person-centred med-
icine and primary health care organised by
WHO. The key speaker was the Director of
the WHO Department for Health System
Governance and Service Delivery who pre-
sented arguments on why measuring person-
centred medicine and people-centred care is
vital. His presentation was commented by
general practitioner, academic and patient
representatives. The need to develop pro-
cedures for appraising the extent to which
person- and people-centred care take place
emerged as a clear recommendation.
A symposium on ethics and the person-cen-
tred approach constituted the second scientific
session. It started with an examination of the
problems derived from reifying disease and
restrictively considering numerical data which
undermine full attention to subjective experi-
ence and the suffering person.The second pre-
sentation argued that attention to the social
determinants of health is crucial for advancing
human rights and ethics in health care. The
final paper presented an African perspective
including references to local concepts (Ubuntu
and Batho Pele) suggesting the value of placing
people first,respect for diversity,and that what
is good for the person is more important than
what is good for his health.
The third session was a symposium on basic
communication skills, a topic of increasing
interest for person-centred care. Discussed
first was an overview of research on com-
munication behaviours which critically in-
fluence health care process and outcome.
Such behaviours include providing room for
a patient’s story, exploring emotional cues,
showing empathy, and framing information
and advice in a positive way, as well as op-
timising outcomes through patient enable-
ment, control, reassurance and adherence to
jointly decided care plans. The second pres-
entation pointed out that adequate person-
centred communication is a cornerstone of
good clinical practice and requires dedicated
training, and that the content of person-cen-
tredness can vary depending on context and
culture. It included interactive discussions
attending to literature-based guidelines and
participants’ views. The third presentation
on clinical teaching reviewed interviewing
educational technologies while consistently
focusing upon person-centred principles.
The fourth symposium examined central
clinical care activities from a person-cen-
tred perspective. The first presentation on
personalised diagnosis suggested a para-
digmatic shift by focusing on both ill and
positive health and the whole person, and
reported on international surveys and focus
groups yielding salient recommendations
for improving diagnostic systems. The sec-
ond reviewed treatment plans as the written
record of shared decisional and interactive
processes between patients and clinicians,
aimed at achieving desired life goals be-
yond the illnesses that threaten hopes and
dreams. A third presentation charged that
most contemporary medical treatment is
focused on relief of acute symptoms of ill-
ness rather than the promotion of health
and well-being, and that specific procedures
are emerging to facilitate the latter.The final
presentation commented on current clinical
services with constrained incentives based
on volume rather than persons’ values, and
reviewed evolving person-centred medical
home models that demonstrate the challenges
and rewards of transforming practices and
are gaining acceptance from health profes-
sionals, business leaders and policy makers.
The fifth session involved a panel discussion
on special initiatives for person-centred care
presented by representatives of international
organisations of patients (“focus on the whole
person, not just the disease”) and medi-
cal students (“holistically seeing the person
as a whole and not a sum of parts”), Ital-
ian (“forming PCM clinical teachers”) and
British (“need for a medicine of the whole
person”) universities, the World Federation
for Mental Health (“treating the whole per-
son concerning both physical and mental
health”),psychodynamic (“self-reflection and
self-monitoring of transference and counter-
transference feelings in daily clinical work”)
and public health (“global strategy for intro-
duction of the PCM model”) programmes,
and INPCM projects on person-centred di-
agnosis (“a new model with related regional
and national developments”) and informa-
tional platforms (“to facilitate INPCM in-
ternal and external communication and full
range of activities”).
The sixth session, a symposium on the team
approach in person-centred health care em-
Left to right: I. Salloum, M. Botbol, J. Snaedal, D. Hanson, C. van Weel, I. Heath, G. Gold, and
W. van Lerberghe, at the Opening of the Third Geneva Conference while the president of the
International Network JE Mezzich speaks from the podium.
140
WMA news
blematic of the Conference’s overall theme,
was presented by officers from the top glo-
bal organisations of family doctors, nurses,
social workers, and pharmacists. For the
Wonca’s president, responsiveness to the
person’s needs and values, continuity of care,
and team work based on common values and
objectives are at the core of person-centred
medicine. The International Council of
Nurses representative proposed that health
systems be redesigned to optimise nursing
contributions to health teams in general and
to person-centred care in particular. Accord-
ing to the representative of the International
Federation of Social Workers, these profes-
sionals bring emphases on contextualisation
and patient’s empowerment to person-cen-
tred team work. Finally, the representative of
the International Pharmaceutical Federation
highlighted the specific expertise that phar-
macists can bring to collaborative practices in
a variety of hospital and ambulatory settings
and to adherence to care programmes.
Seventh in the core programme was a sym-
posium on person-centred care in the context
of surgical and intensive procedures. First
discussed was person-centred surgery which
reviewed the importance of dialogue under
time pressures, the need for understanding
the person’s condition and avoiding harmful
procedures.Next a presentation from the In-
ternational Federation of Gynaecology and
Obstetrics reviewed the enormous develop-
ment of multiple marker screening in early
pregnancy which has led to more individual-
ised informed consent decision making and
counselling as well as to health care system
efficiencies. Finally considered were experi-
ences at a Mongolia hospital intensive care
unit where simple procedures such as pro-
viding a protective gown and conducting
auscultation with body positions that afford
greater patient privacy seemed to enhance
person-centred and more effective care.
Next was a symposium on life cycle and
person-centred care. It started with a pres-
entation on person-centred paediatric care,
which emphasised the uniqueness of every
child, the need to attend to his physical,
emotional,social and spiritual needs through
primary, secondary and tertiary prevention.
Next was a discussion of old-age person-
centred care,which pointed out that personal
life-style and historical patterns of diseases
influence the presentation of symptoms and
needs. It also noted that clinical care should
pay special attention to abilities and disabili-
ties to decide on a care plan, which should
be designed considering the patient’s wishes
and aspirations. Completing this symposium
was an examination of human development
as fundamental to defining a person and
person-centred care. Such definition lies at
cross-roads between changes and continuity,
maturation and personal history.
The last symposium of the core conference
dealt with cultural and social diversity in
person-centred care. The role of culture in
the conceptualisation and experience of ill-
ness and positive health, as well as for effec-
tive health communication was considered
first. A second presentation reviewed the so-
cioeconomic implications of comprehensive
diagnosis, treatment and research, particu-
larly in lesser-developed countries. Health
policies based on the assessment of positive
health- and person-centred care were noted
as promising to deal with the less resourced
and more vulnerable sectors of the popula-
tion. The last paper referred to the abundant
documentation on gender having a profound
impact on clinician-patient interactions
across many countries and medical condi-
tions, and in terms of diagnosis, treatment
as well as patient adherence and patient sat-
isfaction, and noted that this information
seems to have been largely ignored in general
health care planning.
After the core conference and as the last
session of the whole event, a special meet-
ing was held at the WHO Executive Board
Room focused on people-centred care in
low and middle income countries. After
opening words from the WHO Assistant
Director General for Health Systems and
Services and the INPCM President, a set
presentations highlighted experiences in
implementing people-centred services in
several low and middle income countries: El
Salvador, Malaysia, Rwanda, Thailand, and
the United Republic of Tanzania.
Left to right: E. Velasquez, J. Wallcraft, S. Steffen, M. Dayrit, R. Montenegro, W. Van Lerberghe, T. Sensky, C. Etienne, A. Miles, CW. van Staden,
JE. Mezzich, I. Salloum, R. Cloninger, J. Trivedi, and S. Rawaf, at the WHO Satellite Meeting on People-centererd Care in Low and Middle In-
come Countries at the WHO Executive Board Meeting Room
141
WMA news
The presentation from El Salvador focused on
empowering women,men,families,and com-
munities to improve maternal and neonatal
health.Communities participated in identify-
ing and implementing new ways of ensuring
care around pregnancy and childbirth. Since
the initiation of the programme in 2006, ma-
ternal deaths have dropped to zero in 90%
of the municipalities involved. Furthermore,
the process of consensus building has devel-
oped community capacity and ownership by
its various participants. Intersectoral links
and coordination mechanisms also have been
strengthened. In Malaysia, the Government
has incorporated the principles of people-
centred care into numerous national policies
and strategies. These “person-centric” policies
included a focus on wellness, empowerment
of individuals, families and communities, as
well as integrated services throughout the life
course. Malaysia also introduced several in-
novations to improve health care quality and
people-centredness such as the home-based
health cards. The presentation from Rwanda
highlighted the integration of mental health
services in the national health system and at
the community level. Mental disorders are
managed with a holistic perspective whereby
affected individuals are not only seen in terms
of their disorders, but also in terms of their
history, community, and current life circum-
stances. Families are key partners in care and
communities are involved in fighting stigma
and supporting people with mental disorders
to join the health centres and also to reinte-
grate into society.The presentation fromThai-
land reviewed the multiple settings engaged
in people-centred care, its prime movers and
activities aimed at dissemination and transfor-
mation into policy, and found people-centred
primary care as a key element of universal cov-
erage policies. The person-centred experience
reported from Tanzania dealt with efforts to
improve care of people receiving antiretroviral
therapy through organising focus groups to
understand patients’ concerns and barriers to
care and addressing them.Since the initiation
of the project, one year ago, demand for serv-
ices has increased three-fold in participating
health centres.
After the individual country presentations,
the Director of the WHO Department for
Health System Governance and Service De-
livery formulated comments recognising the
importance of the reports for person- and
people-centred care and pointing out the
need for advances in systematic conceptuali-
sation and measurement. An ensuing round-
table discussion on future avenues for mak-
ing health care more people-centred across
the world was chaired by the Director of the
WHO Department for Human Resources
for Health,and had as panelists the Secretary
General of the World Medical Association,
a psychiatry professor from India, a primary
care and public health professor from the
United Kingdom, and a patient/user consul-
tant. Comments were also offered by a num-
ber of conference participants including the
President of the World Medical Association.
After an agile and interactive general discus-
sion, conclusions by the Assistant Director
General for Health Systems and Services
highlighted the importance of the event for
advancing people-centredness and the recent
World Health Assembly resolution on the
renewal of primary health care [4].
Preceding the core conference, a work meet-
ing on person-centred medicine was held.
It dealt with the ongoing building of the
International Network for Person-centred
Medicine [5] and its projects on person-cen-
tred diagnosis and clinical care guidelines, a
South Asian effort, public health guidelines,
and collaboration with the World Federation
for Mental Health as well as on institutional
developments on publications, internet plat-
form, and informational base.
A conference closing session offered sum-
mary comments and a consideration of next
steps.These included broadening the engage-
ment of health organisations,academic insti-
tutions, and experts across the world; further
construction of the International Network
for Person-centred Medicine, its institu-
tional identity, governance, and operational
structure; upgrading of the INPCM Web-
site, informational base and clearinghouse
functions; continuing publications in major
journals and development of an international
journal of person-centred medicine; research
projects on diagnosis, clinical care and public
health; increasing collaboration with WHO,
based on 2009 World Health Assembly reso-
lutions promoting people-centred care; and
planning for a Fourth Geneva Conference on
Person-centred Medicine in early May 2011.
Members of the Third Geneva Conference
Organising Committee: Juan E. Mezzich
(International Network for Person-centred
Medicine, President; World Psychiatric As-
sociation, President 2005–2008), Jon Snae-
dal (World Medical Association, President
2007–2008), Chris van Weel (Wonca, Presi-
dent 2007–2010),Iona Heath (Royal College
of General Practitioners, President), Michel
Botbol (WPA French Member Societies As-
sociation, President), Ihsan Salloum (WPA
Classification Section, Chair), Wim Van
Lerberghe (Director of the WHO Depart-
ment for Health System Governance and
Service Delivery)
References
Mezzich JE, Snaedal J, Van Weel C, Heath1.
I. Person-centered medicine: a conceptual ex-
ploration. Int J Integr Care. 2010; Suppl.
Mezzich JE. The Second Geneva conference2.
on person-centered medicine. World Medical
Journal. 2009; 55 : 100-1.
Mezzich J,Snaedal J,van Weel C,Heath I.To-3.
ward person-centered medicine: from disease
to patient to person. Mount Sinai Journal of
Medicine 2010; 77: 304-6.
World Health Organization: Resolution4.
WHA62.12. Primary health care, includ-
ing health system strengthening. In: Sixty-
Second World Health As¬sembly, Geneva,
18–22 May 2009. Resolutions and decisions.
(WHA62/2009/REC/1). Geneva; 2009. p. 16.
Mezzich JE, Snaedal J, van Weel C, Heath5.
I. The international network for person-cen-
tered medicine: background and first steps.
World Medical Journal. 2009; 55: 104-7.
Juan E. Mezzich, International Network
for Person-centred Medicine, President
142
Medical Ethics, Human Rights and Socio-medical affairs
Edward Hill
The year 2009 has now come and gone and
clearly we are a very long way to having at-
tained “Health for All.”
Despite the differences between devel-
oping and developed countries, access is
the major health care issue in rural areas
around the world. Even in countries where
the majority of the population lives in rural
areas, the resources are concentrated in the
cities.
All countries have difficulty with transport
and communication, and they all face the
challenge of shortages of doctors and other
health professionals in rural and remote ar-
eas.
The World Health Report 2006 concluded
that there is a sharp demand for human re-
sources in health care in many countries of
this world.For 57 countries in Latin-Amer-
ica, Africa and Asia, the World Health Or-
ganization classified the shortage of health
professionals as “critical.”
Looking at the ratio of physicians to popula-
tion,we find a ratio of 1:500 in the wealthier
countries of the world. In some places, such
as European countries, that ratio is as low
as 1:250, compared to a ratio of 1 physician
for every 50,000 people in some parts of
the world.This unfair distribution is further
aggravated by the fact that the populations
with the fewest health professionals carry
the highest burden of disease.
But this is not the only mal-distribution we
have. We have seen a strong tendency to-
wards urbanization during the last decades.
This has been accompanied by a concentra-
tion, often an overconcentration, of health
professionals in urban areas and a corre-
sponding shortage of physicians in rural
areas.
Urban centers, which offer better pay and
better opportunities, are especially attrac-
tive to highly skilled people like physicians
and other health professionals. We as pro-
fessionals cannot stop this trend; rather, it
is up to the politicians to decide whether
they wish to mitigate it. Perhaps a paradigm
shift will be necessary, as mass urbanization
appears to generate more problems than
solutions. While politicians, governments
and international bodies like the Europe-
an Union have focused to bring people to
work, it may be time to do the opposite and
to bring work to people.
Fortunately, not many governments in the
world force their professionals to work at
a certain location or another. On the other
hand, the freedom to migrate leaves us with
the question of how to provide services to
rural populations, especially for those in the
poorer countries of this world. So what is
our role as health professionals?
Let me return to the World Health Report
2006: the report demonstrates why health
professionals and especially physicians from
Sub-Saharan Africa leave their home coun-
tries.
Yes, money is the most important factor,
but close behind are other reasons, which
taken together may be even more impor-
tant.These include bad working conditions,
a lack of treatment options for patients,
missed opportunities for professional de-
velopment, violence in the workplace, and
others.
Living conditions are also important fac-
tors: substandard housing, no schools, no
infrastructure, a lack of mobility and, again,
no chances for development would provide
reasons for anyone to move their family to
a better place.
So what can be done to alleviate the situa-
tion in the most affected areas? The World
Health Organization has developed the
strategy of task shifting. Put simply, this
means leaving the work of health profes-
sionals to minimally trained lay people. I
can only agree with Lincoln Chen, who
wrote in the last issue of the WHO Bul-
letin:
“The recent rush of “crash programmes” to train
large numbers of community health workers
has rightly attempted to address long-standing
deficiencies but these emergency actions cannot
be seen as a sustainable solution.”
This is a key statement reminding us that a
sustainable approach is still missing at the
global level.
We have to attract as well as effect a high-
er retention rate of health professionals in
their areas. Fair payment is a good start,
but it will not be enough. Better work-
ing and living conditions are essential as
well; there must be prospects for health
professionals’ work, their lives, and their
families.
Human Resources for Rural Health
143
Medical Ethics, Human Rights and Socio-medical affairs
Here are a few examples of what can bring
about improvement:
As a part of the World Health Profes-•
sions Alliance and together with many
partners and the support of the Global
Health Workforce Alliance, we are
driving the Positive Practice Environ-
ments Campaign. We are collecting
and disseminating knowledge about
best practices for improving workplac-
es in health care.We see this as a major
strategy not only to improve retention,
but also to make the health care work-
place more attractive for young people.
On the policy level, we have supported•
the development of strategies by the
WHO addressing the high demand
for human resources in health care in
rural areas.
The most recent WHO recommenda-•
tions for education,regulation,financial
incentives, and management and social
systems support should help to identify
and attract more health professionals
for rural areas and to encourage them
to stay in those environments.
Dana Hanson, the president of our or-•
ganization, has just started a program
looking into questions such as: what
makes physicians resilient? What
gives them staying power? What are
the success factors that make physi-
cians stay and continue to work in
their home places and countries?
What is it that causes them to stay
when they could find a better income
in other places?
In India, the ministry of health is look-•
ing into a new curriculum that reaches
out to students, especially from rural
areas, who normally would not have
the opportunity to enter a medical
school. In a stepwise process, these
students will be educated to become fi-
nally fully qualified physicians, receiv-
ing much of their practical training in
rural settings.
It is hoped that the World Health•
Assembly will pass a charter on ethi-
cal recruiting and encourage wealthy
countries to do more to become self-
sufficient and avoid contributing to
brain-drain from poor countries.
Finally, there are e-health, telemedi-•
cine, and yet-to-be-implemented tech-
nological advances to help foster pro-
fessional development in rural regions.
These examples are not exhaustive. I recom-
mend the last issue of the WHO Bulletin
for your attention; it deals specifically with
the problems of rural health and gives a
good overview of the current problems and
potential solutions.
As a family physician myself, I would like
to mention the 2008 World Health Report
entitled “Primary Health Care – Now more
than ever.” It provides more than a fresh
look on primary health care; it is truly a new
and more serious approach towards putting
high quality primary care at the center of
comprehensive health care systems.
Understanding primary care as the core of
the health care system, instead of seeing it
as a cheap substitute for comprehensive care,
will make a huge difference to the people
served. And at the least the relative absence
of secondary and tertiary care in many rural
areas will underline the necessity of excel-
lent primary care.
In conclusion, we must work on both ends:
self sufficiency and ethical recruiting prac-
tices on the side of the wealthier nations,
and improving working and living condi-
tions in poorer countries for physicians or
health professionals in general.
Physicians want to be sure that what they
do is meaningful and beneficial to their
patients. They want to have at least a fair
chance to help their patients and to serve
their communities. The strategies I men-
tioned should be stepping stones to improve
rural health care, including the poorer and
under-resourced areas of the world.
What we are calling for is nothing more
than a basic human right. Regardless of
where one lives – in a rich country or a poor,
in a city or in the countryside – everybody
should have access to good health care.
We will only see reduced costs and im-
proved quality in health care in the world
when every world citizen has access to a
well-educated and well-trained primary
care team to manage their medical needs
and health care.
Dr. Edward Hill
WMA Chairman of Council
144
Medical Ethics, Human Rights and Socio-medical affairs
Sir Michael Marmot
In his acceptance speech as BMA president,
Michael Marmot told the BMA annual rep-
resentative meeting on Brighton on 29 June
2010 that doctors should be active in tackling
health inequalitiesand social injustice.
It is midsummer. It is appropriate to have
a midsummer night’s dream. In my mid-
summer night’s dream, what visions did
appear!
Me thought I was translated: president of
the BMA.
To quote Puck: Lord, what fools these mor-
tals be!
President of the BMA? Surely not. Not
me.
I confess to a rich fantasy life but, had I but
thought about it, presidency of the BMA
would have seemed marginally less prob-
able than playing the viola with the English
Chamber Orchestra or winning the senior
tournament at Wimbledon.
That I should be surprised to be approached
to be presidentof the BMA is not false mod-
esty – remember: don’tbe modest,you’re not
that great – no, my surprisewas entirely rea-
sonable. My research has been focused on
inequalities in health. Latterly the focus has
been on what can be done toaddress the is-
sue. Both in research and policy I have em-
phasised the circumstances in which people
are born, grow, live, work,and age. These all
loom larger as causes of health inequalities
than defects in our healthcare system.Heart
disease is not caused by statin deficiency;
stroke is not caused by deficiency of hy-
potensive agents.I have emphasised not just
the causes of health inequalities – behav-
iours, biological risk factors – butthe causes
of the causes.The causes of the causes reside
in the social and economic arrangements of
society: the socialdeterminants of health.
My first reaction, then, was that I was an
odd choice for BMA president. My inner
monologue quickly changed that to: an
imaginative choice. No one is more con-
cerned about health inequalities than the
medical profession, whether the causes lie
within or without the medical care system.
Either way we have to deal with the con-
sequences of inequalities in health. I would
argue, and will argue now, that a concern
with social injustice as a cause of health in-
equalities engages the best instincts of the
medical profession. For all these reasons, I
am really pleased to be taking on the presi-
dency of the BMA.
(Not just pleased, but reassured, when it
was explained that the president does not
get engaged with the trade union sideof the
house.)
Agreeing to become president of the BMA
presents me with a major challenge: learn-
ing to speak without a PowerPoint presen-
tation. I’m an academic. We like our data
to support us. The last time I performed in
public without slides was in the school play.
I played MacDuff in Shakespeare’s Macbeth.
Macbethwas of course brought down by the
dread virus of ambition.
Shakespeare had ambivalence about ambi-
tion. Julius Caesar was assassinated because
Brutus and the rest were worried about his
ambition.
I want to say a word about ambition.
When I was a student in the 1960s it was
uncool to admit toambition.That, of course,
was ridiculous, as everyone in this room,
each with ambition, can testify. But the key
questionis ambitious for what?
My predecessor, Averil Mansfield, said to
me: you may be the first BMA president
with an agenda – perhaps a politer wordfor
ambition.I do have an agenda,an ambition,
an obsession,even, and that is to contribute
to reduction of health inequalities.My year
as president will have real meaning if I can
help encourageother doctors to be active in
the challenge to reduce avoidable inequali-
ties in health, not just here within Britain,
but globally between countries.
At such a moment as this, perhaps I may
be allowed a personal reflection on the link
between research and action. I have spent
much of my working life on curiosity driven
research. A central hypothesis was that the
gateway between society and health was
through the mind.
I retain that ambition. But something
changed along the way.
If, after publishing a paper, someone asked:
so what? the answerwas: to publish another
paper.
At the end of every paper, there was a
distinctive bird call: more research is
needed, more research is needed. But I
now have a new bird call: more action is
BMA Presidency Acceptance Speech:
Fighting the Alligators of Health Inequalities
145
Medical Ethics, Human Rights and Socio-medical affairs
needed, more action is needed. The two
calls harmonise well. To caricature only
slightly,I went from wanting to work to-
wards good research to wanting to work
towards a good society AND have good
research done.
I can sum up the change: I was invited
by the British government to conduct a
review of health inequalities, and what
could be done to address them. I pub-
lished my review in February this year
and entitled it: Fair Society: Healthy
Lives. It was a statement that in my judg-
ment, and that of the people who worked
with me on the review, if we took seri-
ously the move to a fairer society, health
would improve, and health inequalities
would diminish.
So close is the link between social and eco-
nomic arrangementsand health that we can
see health as social accountant. Health and
the fair distribution of health – health in-
equalities – tellus how we are doing as a so-
ciety. The simple answer is: we’re doing well
but can do better.
Let me illustrate. In my review of health
inequalities, Fair Society Healthy Lives, we
emphasised not just the poor health of the
poor, but that health follows a social gradi-
ent; forexample,the more years of education
the longer the life expectancyand the better
the health. Those with university education
have the best health. We calculated that if
everyone over 30 had the mortality rate as
low as those with university education we
could prevent 202 000 premature deaths,
EACH YEAR. Does anyone in this room
think other than that should be largely
avoidable?
In the US, a similar calculation suggested
that if African-Americans had the same
mortality rates as whites there would have
been 800 000 fewer deaths over a decade.
When I spoke of this to the American
Public Health Association one commen-
tator asked movingly, how many times do
we need to learn the same lesson? 800 000
times is too many.
Let me go further: life expectancy for
women in Zimbabwe is 42, in Afghanistan
44. By contrast, in Japan it is 86.Thereis no
good biological reason why there should
be a 44 year difference in life expectancy
across the world. This 44 year difference
arises because of our social and economic
arrangements.
To address these inequalities in health
within and between countries, the World
Health Organization set up the Commis-
sion on Social Determinants of Health.The
director-general of WHO, JW Lee,invited
me to chair the CSDH.
Our report was published in 2008 as “Clos-
ing the gap in a generation.” Closing the
gap? Are we bonkers? A 44 year gap in life
expectancy between countries, an 18 year
gap within countries, and we want to close
the gap in a generation?
It was a statement that we have in our heads
the knowledge, we have in our hands the
means, to close the gap in a generation.The
question is: what do we have in our hearts?
Do we have thepolitical will?
An illustration: we said in the CSDH re-
port that one billion people live in slums.
We estimated that it would cost $100 bil-
lionto upgrade the world’s slums.I thought:
no one will take us seriously. Who would
find $100 billion for anything?
When I last looked we had found $9 trillion
to bail out the banks. For one ninetieth of
the money we found to bail out the banks
every urban dweller could have clean run-
ning water. Dowe have the knowledge? We
have the knowledge.Do we have themeans?
We have the means. Do we have the will?
When I formulated this view, I was not
aware that I knew the motto on the BMA
crest – with head, and heart, and hand.
Clearly, it was destiny. BMA and I were
made for each other.
To come to the heart of the matter. With
both the CSDH and the English review of
health inequalities, we said that the reason
for taking action to reduce social inequali-
ties in health between and within countries
was one of social justice. We said that “so-
cial injustice was killing on a grand scale”; a
toxic combination of poor policies and pro-
grammes,unfair economics,and bad politics
was responsible for most of the problems of
health inequity in the world. The reason for
action was an ethical one not an economic
one.
In the English review, in my introductory
note from the chair,I pointed out that the
CSDH report had been criticised as ideol-
ogy with evidence. The same could be said
of the English review.We do have an ideol-
ogy: health inequalities that are avoidableby
reasonable means are quite wrong. Putting
them right is a matter of social justice. But
the evidence matters.
The evidence suggests that action has to be
on the conditions in which people are born,
grow, live, work, and age.
Commonly, when we think about action
to reduce health inequalities, we debate
whether we should focus on smoking, or
obesity, or immunisation. Let us remember
Halfdan Mahler, the legendary director-
general of WHO. In a speech to the World
Health Assembly in the mid-1980s Mahler
said: “Imagine you are up to your neck in a
swamp, fighting alligators; just remember
we came to drain the swamp in the first in-
stance.”
Colleagues, if we really want to fight the
alligators of health inequalities, we have to
drain the swamp. We have to deal with the
consequences of an unfair set of econom-
ic and social arrangements, and with the
causes and the causes of the causes of health
inequalities.
146
WMA news
We published the commission’s report.
What happened? I travelled the world, get-
ting jet lag and interference with my gas-
trointestinal function; did something more
happen?
Parenthetically, I have developed a wonder-
ful cure for jet lag.I lie in bed rehearsing one
of my speeches and I’m asleep in seconds. I
recommend it. Faster than reading Henry
Jamesin bed.
On the gastrointestinal front, I did ask at
one hotel: Is the water safe to drink? I was
told: all the drinking water in this hotel has
been passed personally by the manager. I
was impressed by the manager’s prodigious
talents if not greatly reassured.
Since indulging in this work on social justice
and health, Ihave, however, developed three
other medical conditions that perhaps, as a
medical audience, you can help me with.
First, a state of near continuous excitement.
There must be some pills for this condition.
We said we wanted to create a social move-
ment. I scarcely understood what that was.
But I would say that the signs are promis-
ing.
A Peruvian colleague wrote to me with a
quote from Don Quixote.“Ladran, Sancho,
segnal que cabalgamos.”The dogs are bark-
ing,Sancho, it a sign that we are moving.
Among the signs of movement are:
A WHO resolution.•
A discussion at ECOSOC, and an en-•
dorsement of the CSDH from Ban Ki-
Moon
Spain made social determinants• of health
a priority for theirpresidency of the EU.
A number of countries have taken it on:
Chile, Brazil, Costa Rica, Sri Lanka, Nor-
way, Denmark. I am excited.
Now we have the UK with my inequalities
review. With the help of the BMA and the
royal colleges I want to keep this on thena-
tional agenda.
Is this ambitious? Good heavens yes! Ambi-
tious to create a better society, and a better
world.
The second condition I have developed is
selective hearing loss. It is somewhat re-
lated to my state of evidence based opti-
mism. I cannot hear cynicism. With both
the CSDH and the English review the
process was inclusive. It involved hundreds
of people. The English review of health in-
equalities is being implemented locally and
regionally.Thirty local areas and regions are
developingplans to implement the Marmot
review. As one US colleague putit: when he
argued for social determinants of health, his
director told him he had become Marmo-
tised.
The third medical condition is that some-
thing has happened to my eyes: they water
at embarrassing moments.
Pascaol Macoumbi, former PM of Mozam-
bique and a member of the Commission on
Social Determinants of Health, said at the
end of our meeting in Vancouver: I haven’t
felt so energised since my country got in-
dependence. I had this watery condition of
my eyes.
When I saw how the Self Employed
Women’s Association works to improve
life for the poorest most marginal women
in India – the right to work, micro-credit
schemes, child care, health care, insurance,
upgrading slums – again this watery condi-
tionof the eyes developed.
In Thailand, they talk of the triangle that
moves the mountain: knowledge, politics,
and people. That softened me up but I was
dry eyed until Thai children sang:
“We are all stars of the same sky.
We are all waves of the same sea.
It is time to learn to live as one.”
Then, I lost it.
Let me come back to my theme of ambi-
tion for what? The dominantview of the last
30 years has been that we are all greedy and
motivated by self interest. Further, by pursu-
ing our self interest society benefits. Wow!
The intellectual fount for such viewis Adam
Smith: “It is not from the benevolence of the
butcher,the brewer, or the baker that we ex-
pect our dinner,but fromtheir regard to their
own interest.” In other words, by pursuing
our own self interest society flourishes. That
idea seems tohave driven out all others.
Adam Smith did say that.That’s the part we
remember.It is a travesty of Adam Smith to
think that is all he said.We’ve forgotten his
important other insights: “No society can
surely be flourishing and happy, of which
the far greaterpart of the members are poor
and miserable.”
“To feel much for others and little for our-
selves; to restrain our selfishness and exer-
cise our benevolent affections,constitutethe
perfection of human nature.”
In the name of self interest we have allowed
inequality to flourish.
Tony Judt: “Under conditions of endemic
inequality, all other desirable goals become
hard to achieve.
“Inequality is not just a technical problem.It
illustrates and exacerbates the loss of social
cohesion and the tendency to confine our
advantages to ourselves and our families…
“If we remain grotesquely unequal, we shall
lose all sense of fraternity…The inculcation
of a sense of common purpose and mutual
dependence has long been regarded as the
linchpin ofany community.”
At the invitation of the French Ministry of
Health I went to Paris to do a day on the
Commission on Social Determinants of
Health and the English review. For that
or other reasons, France is taking up the
health inequalities agenda. I asked a French
147
Medical Ethics, Human Rights,Socio-medical affairs and Environmental Policy
colleague why President Sarkozy, a right
of centre president, would embrace this? I
was told that all French children grow up
with the motto of the French Revolution:
Liberté, Egalité, Fraternité. In France they
may not dotoo much about the first and the
third, but égalitéis central.
In the UK, and the US, the degree of in-
equality that we have created is harming
the next generation. Which among the rich
countries has the least social mobility? The
US, followed bythe UK.
Ambition: If the medical profession were
out only for its own interests, we would
not have become doctors. Of course, we are
exercised by pay and conditions, but at the
core our ambitionsare not selfish and we are
concerned with social justice.
Let us use those twin concerns – for the
wellbeing of othersand for social justice – to
make a difference to healthinequalities.
I referred to Don Quixote a few moments
ago. At times Don Quixote seemed an ap-
propriate caricature of what I have been
doing: a supposed knight running around
trying to be chivalrous and everyone laugh-
ing at him. When I said this to the Span-
ish ministerof health he said: “We need the
idealism of a Don Quixote,thedreamer,and
the pragmatism of a Sancho Panza.”
So, dream with me of a fairer world, but
let us take the pragmatic steps necessary
to achieve it. In the words of Pablo Neru-
da,which I used both at the launch of the
global commission and the English review:
“Rise up with me against the organisation
of misery.”
Sir Michael Marmot, BMA President,
professor of epidemiology and public
health, University College London
e-mail m.marmot@ucl.ac.uk
Speech is reproduced by kind permission
of the British Medical Journal.
Dong-Chun Shin
“Urbanization and Health” was selected
by WHO as the theme for World Health
Day 2010 to highlight the serious health
impact of urbanization. The theme is
most timely and highly relevant because
the majority of the world population al-
ready lives in urban areas and this pro-
portion is expected to further increase.
Accordingly, urban health should be rec-
ognized as the key focus of global public
health policy.
Even though each city faces its own unique
set of health challenges, a range of common
health risks can be associated with today’s
typical urban environment. Most of such
threats are operated and controlled outside
the health sector domain including unsafe
drinking-water, sustained solid waste, un-
healthy diets, road traffic, and urban air pol-
lution.
Urban air pollution by excessive particu-
late matter or ozone levels is one of the
most widespread and dangerous. Accord-
ing to numerous studies, air pollution
reduces life expectancy and aggravates
many respiratory and cardiovascular
diseases. Premature deaths associated
with air pollutants were more likely to
be from cardiac causes than respiratory
ones1
. Although the general public may
not yet fully grasp the severity of air pol-
lution s hazards, concern about air pollu-
tion and other environmental health im-
pacts has increased significantly in many
countries.
Most air pollution and health studies report-
ing an adverse health effect have focused on
physical illness. More recently, researchers
have started to study the possibility of brain
pollution or air pollution-related mental
conditions such as suicide and IQ deficits.In
Korea, the association between particulate
matter and suicide was identified. A pos-
sible association between particulate matter
and suicide was observed among individuals
with cardiovascular disease2
. Also, prenatal
exposure to air pollutants may adversely af-
fect a child s intelligence. In New York City,
children exposed to high levels of air pollut-
ants (especially, polycyclic aromatic hydro-
carbons) in the womb demonstrated lower
IQ scores than less exposed children3
.
Air pollution has long been a problem in
the industrial nations of the West. It has
now become an increasing source of envi-
ronmental degradation in the developing
nations of Asia. Air pollution has become
part of the daily existence of many people
who work, live and use the streets in Asian
cities. Each day, millions of city dwellers
breathe air polluted with chemicals, smoke
Recent Progress in Air Pollution
and Health Studies
148
Medical Ethics, Human Rights,Socio-medical affairs and Environmental Policy
and particles that dramatically exceed
World Health Organization guidelines.
Deteriorating air quality has resulted in a
significant impact on human health and en-
vironment in Asia.
While some improvements in air quality
have been achieved, levels of PM and ozone
continue to exceed WHO air quality guide-
lines in large Asian cities. Tokyo and Seoul
have succeeded in turning around their air
quality and establishing management plans
including source control, stricter air quality
standards and health protection programs.
But air quality in New Delhi, Kolkata, Ha-
noi, Beijing and other developing country
cities are still unhealthy. These cities need
immediate technical and medical assis-
tance.
National Medical Associations in each
country should be prepared to cooperate
with the World Health Organization to re-
duce air pollution and protect public health.
Preventive action is critical in good public
health management. Governments in each
country should set up national level institu-
tional mechanisms for air pollution related
medical research and monitoring to support
more effective policy-making. Medical as-
sociations have to address the health issues
related to air pollution and encourage their
governments to take corrective action.
References
Pope CA 3rd, Burnett RT, Thurston GD,1.
Thun MJ, Calle EE, Krewski D, Godleski JJ.
Cardiovascular mortality and long-term ex-
posure to particulate air pollution: epidemio-
logical evidence of general pathophysiological
pathways of disease. Circulation. 2004 Jan
6;109(1):71-7.
Kim C, Jung SH, Kang DR, Kim HC, Moon2.
KT, Hur NW, Shin DC, Suh I. Ambient par-
ticulate matter as a risk factor for suicide. Am
J Psychiatry. 2010 Jul 15.
Perera FP, Li Z, Whyatt R, Hoepner L, Wang3.
S, Camann D, Rauh V. Prenatal airborne
polycyclic aromatic hydrocarbon exposure
and child IQ at age 5 years. Pediatrics. 2009
Aug;124(2):e195-202.
Dong-Chun Shin, MD, PhD
Chair, Executive Committee of International
Affairs,
Korean Medical Association
Professor, Dept. of Preventive Medicine,
Yonsei University College of Medicine
Jon Snaedal
Iceland has been the focus of international
attention because of catastrophes on two
occasions in the last two years. Even though
these events have seemingly nothing in
common, there are some similarities. The
first catastrophe was late in 2008, a man
made economic crisis. The second one was
a recent natural catastrophe, a volcanic
eruption in a glacier. The similarities are
that both were uncontrollable. The differ-
ence was however in the preparation for the
catastrophes. In the case of the economic
crisis there was hardly any preparations and
because of that there was a great unrest in
the society leading to change in government
and a replacement of all individuals respon-
sible for any preparatory measures. In the
latter case there was however a feeling by
the people of responsible actions by all in-
volved.The scientists had warned of a possi-
ble eruption for over a year but in a low pro-
file. All preparatory actions were therefore
in place and could be mobilised in a couple
of hours, the most dramatic one a total and
immediate evacuation of a defined area on
two separate occasions. The population has
therefore great confidence in the scientists
and the civil service responsible for all ac-
tions for such an event.
The most grave immediate health implica-
tion of a natural catastrophe is the loss of
lives. That did fortunately not happen in
this case. Because of the swift actions, no
individual was ever in a real danger. The
other possible health implications are either
physical or psychological. The attention has
been on the effects of the ash pouring down
on the population. There has been an in-
creasing number of pulmonary cases, rarely
serious, and a greater number of cases with
irritation in the eyes. Interestingly, this has
only been seen in adults, mostly those that
needed to work outdoors for attending the
animals but the children seem not to have
been affected. The reasons for this is that
many of them have been sent away and the
others not allowed to be outdoors while the
ash was pouring down. It has to be stressed
that the depth of ash has only been up to 5
cm in the most affected areas, most often of
some few millimetres but it is made up of
very small particles that can easily been in-
haled deep into the lungs.There was a fear of
toxic effects of the ash as the experience has
shown that some volcano’s produce ash with
high concentration of fluoride. This proved
to be toxic to animals and some speculations
were on toxic effect on humans (an erup-
tion in 1947 in Hekla) but that was never
verified. Measurements during the current
eruption showed rather low concentration
Volcanic Eruptions – Health Implications
149
Medical Ethics, Human Rights,Socio-medical affairs and Environmental Policy
of fluoride or in fact other elements that
could be toxic to humans.
Other possible health effects of the eruption
are psychological. To live nearby an erupt-
ing mountain is a stressful situation and
many are not able to cope with that. They
have to leave their homes and live elsewhere
for an uncertain amount of time. Some of
them have already decided not to turn back
to their homes but as this eruption has not
been prolonged, this number will most
likely not increase. The long term effect of
the displacement is not known in this event
but by experience from the displacement of
a community of 5000 individuals in 1973
after a volcanic eruption in Heimaey (= The
island of our homes) south of Iceland the
effects are minimal in most cases providing
there is social, psychological and economi-
cal help.This experience is helpful now.
To be affected by the effects on air traffic is
another issue. This was the greatest disrup-
tion of air traffic in the world measured by
the number of flights and passengers affect-
ed. The most serious effect is on emergency
air traffic, which was not allowed either.The
patients in these cases had to rely on ground
transportation, which resulted in delays in
attending a medical facility. It has not been
evaluated how many patients were affected
in this way or the consequences of that.
Apart from this there is the huge number
of passengers worldwide that have been af-
fected by delays of air traffic, which resulted
in many kinds of inconveniences, practical,
economic and psychological. The full scale
of that will hardly ever be known but there
are many tales of various difficulties because
of this eruption of the volcano with the un-
pronounceable name, Eyjafjallajökull (= The
glacier on the mountains of the islands).
Dr. Jon Snaedal,
Icelandic Medical Association
Wonchat Subhachaturas
Summary
On February 25-28 2010, the Medical As-
sociation of Thailand hosted the first Inter-
national Summit on Tobacco Control in the
Asia and Oceania Region at the Rose Gar-
den Riverside Hotel in Sampran district,
Nakhonpathom Province, Thailand. The
event was assigned by the Confederation of
the Medical Associations in Asia and Ocea-
nia (CMAAO) Congress and Assembly in
Bali, Indonesia, November 5-7, 2009. A
Tobacco Control Programme was decided
upon and approved as a flagship programme
of the CMAAO starting this year; progress
will be reported annually at the Conference
and General Assembly, wherein member
countries can share experiences of success
and barriers.
The Summit was attended by 12 countries
in the region: Hong Kong, India, Indonesia,
Japan, Korea, Malaysia, Myanmar, Philip-
pines, Singapore, Taiwan, Vietnam and
Thailand. The programme consisted of pre-
sentations from experts, evidence-based re-
ports of the current situation in each country
on the health hazards from tobacco smok-
ing and the effects of second-hand smoke,
group discussion, and the production of a
statement and declaration on tobacco con-
trol in the Asia and Oceania Region, with
recommendations for member countries
to practice and collaborate at three levels:
medical associations, individual physicians,
and the national level. All participating
NMAs signed the proclamation, agreeing
to unite and work together towards devel-
oping a regional network on tobacco control
and to make tobacco control one of their
highest priorities.
Dr. Wonchat Subhachaturas,
Chair of CMAAO, President-elect of
the Medical Association of Thailand
1st
International Summit on Tobacco Control
in Asia and Oceania Region
CMAAO‘s Activities on Tobacco Control in the Region
February 25 to 27, 2010 Sampran,Thailand
Masami Ishii
150
Medical Ethics, Human Rights,Socio-medical affairs and Environmental Policy
The overview of the historical
efforts of CMAAO for
Tobacco Control
Short history
The Confederation of Medical Associa-
tions in Asia and Oceania (CMAAO) has
marked more than 50 years of history.I have
held the position of CMAAO Secretary
General since 2006.
The 44th CMAAO Midterm Council
Meeting, held in Manila, Philippines, cel-
ebrated the CMAAO’s 50th anniversary.
This meeting started the discussion of to-
bacco control as a major agenda item and
successfully built momentum toward re-
gional cooperation for tobacco control.
The WMA has several statements on tobac-
co and smoking, the first of which was ad-
opted in Austria in 1988.The WMA joined
the implementation process of the WHO’s
Framework Convention of Tobacco Con-
trol, or FCTC. The WMA’s statements in-
clude:
Statement on Health Hazards of Tobacco•
Products (adopted in Austria, 1988; re-
vised in Germany, 1997 and in Denmark,
2007)
Statement on Physicians and Public•
Health (adopted in Indonesia, 1995;
amended in South Africa, 2006)
Statement on Health Promotion (adopt-•
ed in Indonesia, 1995)
Statement on Tobacco Manufacture,•
Import, Export, Sale and Advertising
(adopted in the United States, 1990, re-
scinded in Santiago 2005)
If we look back over the history of the
CMAAO, the symposium theme at the
CMAAO Midterm Council Meeting held
in Taipei 1988 was “Tobacco or Health,
for Asia and Oceania.” This theme seems
to have been selected as a response to the
“Tobacco or Health Plan of Action for the
period 1988-1995” proposed by the Di-
rector General of the WHO in 1988. The
CMAAO Midterm Council in Taipei ad-
opted a Declaration on Health Hazards of
Tobacco Products. By citing the WMA’s
Statement on Health Hazards of Tobacco
Products, which was adopted the same year,
it strongly urges CMAAO members to pur-
sue the actions in the statement. Stickers to
promote Smoke Free Asia and Oceania were
also produced.The president of CMAAO at
that time was Dr. Songkram of Thailand.
The momentum against tobacco smoking
has been sustained in Thailand since that
year, and has now emerged again in the
CMAAO with greater energy. We are cur-
rently involved in the second wave of the
CMAAO’s efforts to tackle this crucial is-
sue in our region. Tobacco control is a very
difficult issue, so we should consider vari-
ous, up-to-date efforts, and regularly evalu-
ate their performance.
The theme of the 53rd
Annual Scientific
Meeting of the Medical Association of
Thailand, which was held in Krabi,Thailand
in October 2009, was “Smoking Cessation
Programme in Asia and Oceania.” This
meeting was very successful due to the ef-
forts of Dr. Somsri and Dr. Wonchat.
The meeting was attended by international
representatives from the medical asso-
ciations of Thailand, Malaysia, Myanmar,
Brunei, Japan, and representatives from
governments and the WHO. We had very
informative lectures on each country and
the Asia and Oceania region, followed by
active discussions on smoking cessation
programmes.
At the CMAAO Bali Congress in Novem-
ber 2009, a proposal to take cross-regional
anti-smoking actions was adopted. The ex-
pansion of these activities is currently be-
ing considered under the leadership of the
Medical Association of Thailand.
As a result of the efforts made so far, the
first International Summit of the Asia and
Oceania Region on Tobacco Control was
held in Thailand, hosted by the CMAAO,
the Medical Association of Thailand
(MAT), MASEAN and the Thai office of
the WHO. It adopted a declaration “The
Sampran Declaration of Asia and Oceania
Region on Tobacco Control”.
The Sampran Declaration on Tobacco
Control in the Asia and Oceania Region
has been circulated to all member coun-
tries in the CMAAO and MASEAN, and
the project’s progress will be followed up at
the CMAAO Conference each year. This
will be the first and leading collaboration
in controlling tobacco consumption at the
regional level.
Dr. Masami Ishii,
Secretary General of CMAAO,
Council Member of WMA, Executive
Board Member of JMA
February 2010
The Sampran Declaration on
Tobacco Control in Asia and
Oceania Region
CMAAO, Medical Association
of Thailand,MASEAN
and WHO Thai Office
Preamble
Tobacco use is the leading cause of pre-
ventable death, killing more than 5 million
people each year worldwide. Second-hand
smoke kills about 600,000 people who were
non-smokers each year.Most of these deaths
are in low- and middle-income countries
including countries in Asia and Oceania.
Apart from other well-known health haz-
ards, tobacco use also increases morbidities
such as malnutrition and subfertility, hence
urgent action is needed.
The WMA, representing the medical asso-
ciations of the world, issued a statement on
151
Medical Ethics, Human Rights,Socio-medical affairs and Environmental Policy
the health hazards of tobacco products in
1988 at the 40th
World Medical Assembly.
This was amended at the 49th
and 59th
WMA
general assemblies. The CMAAO adopted
the WMA statement in1988. With the
entry into force of the WHO Framework
Convention on Tobacco Control (WHO
FCTC) in 2005, the global tobacco control
community has made considerable progress
against the global tobacco epidemic.
According to the WHO Report on the
Global Tobacco Epidemic, 2008 and 2009,
the majority of the world’s smokers are in
Asia and Oceania, which makes tobacco
control in the region the main challenge.
Only a few countries have a national policy
on comprehensive tobacco control. Most
users are inadequately warned about the ex-
treme addictiveness of tobacco and the full
range of health risks. In all CMAAO coun-
tries, cessation services are still insufficient
to help the 360 million smokers. Although
second hand smoke is easily prevented, only
few countries have comprehensive smoke-
free environment legislation. The health of
more than one third of population in the re-
gion is at risk from exposure to second-hand
tobacco smoke and remains unprotected.
In this regard, government and policy mak-
ers must play a pivotal role in ratifying and
enforcing the WHO FCTC. The medical
profession must recognize its role and social
responsibility in tobacco control.
At the individual level, doctors should be
agents of change in the battle against to-
bacco use. The medical profession is deeply
committed to tobacco control and a smoke-
free society.The CMAAO,together with all
other organizations such as the WHO, will
partner with the regional and national to-
bacco control organizations to act decisively
against the tobacco epidemic – the leading
global cause of preventable death.
The success of this program is going to be
wholly dependent on the proactive role of
the medical profession in tobacco control
and prevention of its health hazards, the co-
operation of the general public through the
civil societies who will reinforce the medical
profession and the commitment of the na-
tional government to enact and enforce laws
directed towards tobacco control.
Recommendations
The CMAAO urges the CMAAO mem-
bers to take the following actions to help
reduce the health hazards related to tobacco
use, at:
I. National Medical Association Level
1. Adopt a policy position opposing smok-
ing and the use of tobacco products, and
publicize the policy so adopted.
2. Prohibit smoking at all business, social,
scientific and ceremonial meetings of
the National Medical Association.
3. Develop, support, and participate in
programs to educate the profession
about the health hazards of all forms of
tobacco use. Convince and help smok-
ers and smokeless tobacco users to cease
the use of tobacco products,and develop
cessation programmes for tobacco users
and avoidance programmes for non-
smokers and non-users of tobacco.
4. Strongly urge individual physicians to
be role models (by not using tobacco
products), healthcare team leaders and
spokespersons to campaign and to edu-
cate the public about the deleterious
health effects of tobacco use,exposure to
second-hand smoke and the benefits of
tobacco cessation and making a smoke-
free home.
5. Mandate all medical schools, hospitals
and other health-care facilities to pro-
hibit smoking on their premises.
6. Introduce or strengthen educational
programs for physicians to prepare them
to identify and treat tobacco dependence
in their patients.
7. Strengthen and cooperate with the re-
gional network to develop an effective
regional system on tobacco cessation.
Support widespread access to effective
treatment for tobacco dependence – in-
cluding identification of smokers in the
routine services and provision of coun-
seling, necessary pharmacotherapy and
other appropriate means.
8. Develop and endorse a clinical practice
guideline on the treatment of tobacco
use and dependence.
9. Urge the national authorities to add to-
bacco cessation medications to the List
of National Essential Medicines and
Health Security System.
10. Mandate medical schools, research in-
stitutions, and individual researchers
not to accept any funding or any form
of support from the tobacco industry.
II. Individual Physician Level
1. Ask every patient for smoking history
and provide brief advice to every patient
along with referral to specialized cessa-
tion treatment.
2. Do not accept any funding or any form
of support from the tobacco industry.
III. Government Level:
1. Support MPOWER1
as the main tobac-
co control strategy released by WHO.
2. Advocate the enactment and enforce-
ment of laws that:
a. provide for comprehensive regula-
tion of the manufacture, sale, dis-
tribution and prohibit any form of
promotion and advertisement of to-
bacco products.All forms of promo-
tion of tobacco products including
sponsoring sports events and enter-
tainment should be banned.
b. require written and pictorial warn-
ings about health hazards to be
printed on all packages of tobacco
products.
c. prohibit smoking in all enclosed
public places (including health care
(M= Monitor tobacco use and prevention pol-1.
icies, P=Protect people from tobacco smoke,
O=Offer help to quit tobacco use, W=Warn
about the dangers to tobacco, E=Enforce
bans on tobacco advertising and promotion,
R=Raise taxes on tobacco products)
152
Medical Ethics, Human Rights,Socio-medical affairs and Environmental Policy
facilities, schools, and education fa-
cilities), workplaces (including res-
taurants, bars and nightclubs) and
public transport.
d. prohibit the sale, distribution, and
accessibility of cigarettes and other
tobacco products to children and
adolescents.
e. prohibit the sale of tax-free tobacco
products.
f. prohibit all government subsidies
for tobacco and tobacco products.
g. prohibit the promotion,distribution,
and sale of any new forms of tobacco
products that are not currently avail-
able.
h. increase taxation of tobacco prod-
ucts, using the increased revenues
for prevention programs, effective
cessation programs and services and
other health care measures.
i. curtail or eliminate illegal trade in
tobacco products and the sale of
smuggled tobacco products.
Florian Stigler
IFMSA and its Standing
Committee on Public Health
The International Federation of Medical
Students’ Associations (IFMSA) represents
1.2 million medical students through its 97
national member organisations. Founded
in 1951, it was officially recognised by the
WHO in 1969. IFMSA works as an inde-
pendent, non-governmental organisation
towards improving global health.
Running one of the biggest student-led ex-
changeprogrammes worldwide and working
at community levels to tackle health-related
problems sum up our main focus.Every year
more than 10,000 students go on exchange
through the IFMSA and get to appreciate
the culture and medical practice, or par-
ticiparte in research in a different country.
Our local level activities and projects focus
on medical education, human rights, repro-
ductive health and public health.This article
will focus on one of our public health-relat-
ed activities: Our fight against the harmful
use of alcohol on a global scale.
But first, an introduction to some of our
main public health activities. Medical stu-
dents from all over the world are part of
the IFMSA Standing Committee on Pub-
lic Health. These students execute projects
and activities that aim to promote health in
the local communities, by laying emphasis
on preventive measures. Students work on
topics ranging from child health, tobacco,
alcohol abuse, diabetes and obesity, to ma-
laria and TB in high-risk countries. Other
initiatives try to advocate for change by ap-
proaching key stakeholders and using the
media to make our voice heard.Last but not
least, we try to focus on ourselves. As pub-
lic health topics and advocacy are not core
topics in most universities worldwide, we
try to develop our skills and knowledge and
those of other medical students. We want
to become health professionals with a more
holistic concept of health and who are able
to promote change within our profession.
The harmful use of alcohol –
a youth perspective
Alcohol consumption is responsible for 2.5
million unnecessary deaths worldwide[1].
It is also accountable for additional damage
towards the immediate environment and
the society as a whole. The damage attrib-
utable to alcohol consumption is described
by the Royal College of Physicians as “cata-
strophic”. Altogether, “passive drinking” af-
fects more people than “passive smoking”
[2].
When we look at the European Union
(EU), alcohol is a huge burden. It is the
“third most significant risk factor”, being
responsible for 6.5% of all deaths and an-
nual cost of €400 billion (social and intan-
gible costs),which equals almost 4% of EU’s
GDP [3, 4].
What can society do?
Most measures employed to fight the bur-
den of the harmful use of alcohol are meas-
ures at a population level. Increasing taxes
on alcohol products seems to be the most
effective intervention. Although govern-
ments are often concerned about losing
revenue, the opposite is the case. Revenue
increases as the reduction of consumption is
smaller than the increase in taxes [5]. Other
IFMSA and 1.2 million Worldwide Medical
Students Fighting Against the HARMFUL
USE OF ALCOHOL
153
Medical Ethics, Human Rights,Socio-medical affairs and Environmental Policy
common measures are the introduction of
a minimum age for drinking or anti-drink-
driving measures like the reduction of blood
alcohol concentration limits.
What can physicians do?
We as (future) physicians are in regular
contact with high-risk individuals.Brief ad-
vice in a primary care setting is proven to
be effective and cost-effective [4, 6]. A Co-
chrane Review even showed that the mean
consumption was reduced by 12% [7]. We,
as the next generation of health profession-
als, will need more training on approaches
to delivering brief advice than we currently
receive. Physicians can play a much bigger
role against the burden of harmful alcohol
consumption than just curing the damage
it causes.
As physicians, we are respected members of
our societies and our health advice is tak-
en seriously. Still, there is misinformation
even within physicians as well as medical
students worldwide. “Small amounts of al-
cohol can have beneficial effects”. There is
evidence supporting this statement – but
is there evidence that this is also a helpful
advice…? Every harmful drinker started
with small amounts. The following figure
might put the beneficial effects of alcohol
consumption into a broader picture. Indeed,
there are deaths prevented by low-dose al-
cohol consumption. But in every age group,
there are more deaths caused than prevent-
ed by alcohol consumption!
Why are we as a youth
organisation concerned?
We are concerned because young people
are strongly affected. Of all years lived with
disability attributed to alcohol, 34% were
experienced by persons aged 15–29 years
[9]. We, as representatives of young people,
think that we have the right to be protected.
We are dissatisfied if manipulative market-
ing by the alcohol industry is used to influ-
ence our decisions and behaviour.
IFMSA, GAPA & the WHO Global
Strategy to Reduce the Harmful Use of
Alcohol
In May 2010, during the WHO World
Health Assembly, all 193 member states
adopted the “Global Strategy to Reduce the
Harmful Use of Alcohol” (1)
. This milestone
for global public health describes harm-
ful consumption as a major threat for glo-
bal health and offers solutions which can
and should be implemented by all member
states.
We, as IFMSA, do welcome the adoption
of the strategy although we know that it is a
long way towards achieving its aims. We, as
worldwide medical students, are an affected
high-risk group on our own. Therefore we
advocated towards the World Health As-
semblies in 2008 and 2010 to support a
stronger protection of medical students and
youth in general.
We are proud of our persistence in our ac-
tions and our fight against the harmful use
of alcohol.
We are proud of being members of a strong
youth movement, the Alcohol Policy Youth
Network (APYN), which successfully
hosted the European Conference “Alco-
hol Policy and Young People” in Budapest,
Hungary.
We are proud of our great collaboration with
the Global Alcohol Policy Alliance (GAPA).
Our fruitful partnership was especially high-
lighted by the attendance of GAPA Chairper-
son Mr.Derek Rutherford at our last IFMSA
General Assembly in Thailand.We have been
inspired by his speech towards our 850 par-
ticipants and it was fantastic to see the enthu-
siasm of worldwide medical students towards
such an important but often neglected topic.
We are looking forward towards further col-
laborations of IFMSA and GAPA.
Percentage of male deaths attributable to alcohol consumption in 2005 (England) [8].
Derek Rutherford (GAPA) and
Florian Stigler (IFMSA)
154
Healthcare technologies
We as IFMSA are proud to represent the
voice of 1.2 million medical students and to
fight the global burden of the harmful use
of alcohol!
References
World Health Organization. Global Strategy1.
to Reduce the Harmful Use of Alcohol. Ge-
neva, 2010.
House of Commons Health Committee. Al-2.
cohol. First Report of Sessions 2009–10. Lon-
don, 2010.
World Health Organization Europe. Hand-3.
book for action to reduce alcohol-related
harm. WHO, 2009.
World Health Organization Europe.Evidence4.
for the effectiveness and cost-effectiveness of
interventions to reduce alcohol-related harm.
WHO, 2009.
The University of Sheffield. Modelling to as-5.
sess the effectiveness and cost-effectiveness of
public health related strategies and interven-
tions to reduce alcohol attributable harm in
England using the Sheffield Alcohol Policy
Model version 2.0. Sheffield, 2009.
Anderson P., Chisholm D., Fuhr D. C. Effec-6.
tiveness and cost-effectiveness of policies and
programmes to reduce the harm caused by al-
cohol. Lancet. 2009; 373; 2234–46.
Kaner E. F., Dickinson H. O., Beyer F. R.,7.
Campbell F., Schlesinger C., Heather N.,
Saunders J. B., Burnand B., Pienaar E. D. Ef-
fectiveness of brief alcohol interventions in
primary care populations. Cochrane Database
of Systematic Reviews 2007, Issue 2.
Jones L. et al. Alcohol attributable fractions8.
for England; alcohol attributable mortality
and hospital admissions. North-West Pub-
lic Health Observatory and Dept of Health;
2008; p 26.
Rehm J. et al. Global burden of disease and in-9.
jury and economic cost attributable to alcohol
use and alcohol-use disorders. Lancet. 2009;
373: 2223–33.
Dr. Florian Stigler,
IFMSA Liaison Officer on Public Health
e-mail: lph@ifmsa.org
Introduction
Healthcare technologies have seldom been
under more scrutiny. In mature and devel-
oped markets, governments and providers
are using methodologies such as compara-
tive effectiveness and health technology
assessments to evaluate the benefits of di-
agnostics and other medical devices. Some
observers view this as simply a way to limit
ever growing expenditure in healthcare, but
most accept that new technology should
show that it has clinical utility and be more
cost effective than current practice.
Similar logic is being applied to health
technologies for emerging markets. Con-
sideration of cost and clinical effectiveness
is being conducted in tandem with the
additional challenges that these markets
pose – such as isolated geographies, short-
ages of professional medical workers, poor
infrastructure, often overwhelming demand
and, of course, very limited funding. With
such challenging circumstances, emerging
nations’ needs for better access to appro-
priate technologies is paramount. It is in-
cumbent upon companies like GE1
to do all
they can to help.
As a global, technology based, diagnos-
tics and healthcare solutions business, GE
sees its critical contribution as making
cost-effective life-saving technology more
accessible in the semi-urban, rural and de-
veloping areas which often bear the brunt
of the disease burden. This is epitomised by
GE’s healthymagination programme which
aims to deliver technologies and solutions
that improve the quality, access and cost of
health in all of our markets.
Healthymagination
Healthymagination is GE’s commitment
to work in our businesses and in partner-
ships to develop the appropriate new tech-
nologies and solutions that will help deliver
improved access to better quality and cost
effective healthcare [1]. That commitment
applies to the poorest and richest coun-
tries alike: to those places with underserved
1 GE is a trademark of General Electric Company
healthcare systems where technology can
improve access and patient outcomes; and
to places where technology is regarded as
a driver of healthcare costs and where, in-
stead, it needs be used to drive efficiencies
and improvements in delivery.
So, how does healthymagination apply to,
say, rural India, China or Africa? When
healthymagination was launched in May
2009, GE CEO Jeff Immelt highlighted
two products that looked to the future. The
MAC 400 Electrocardiogram device and the
Developing Healthcare Technologies for
Emerging Markets – Improving Quality,
Access and Cost
Mike Barber
155
Venue2
40 tablet sized portable ultrasound
scanner. These devices are battery powered,
portable, self contained and simple to use.
They are examples of using the consumer
electronics boom to miniaturise and adapt
technology that was once the sole preserve
of the hospital, and take it into clinics and
rural locations remote from mainstream
medical facilities. Both take healthcare to
the patient rather than the patient to the
healthcare provider and both were devel-
oped and manufactured in the markets for
which they are designed.
In an article published in the Harvard Busi-
ness Review [2] Jeff Immelt, Vijay Govin-
darajan and Chris Trimble describe how
GE has changed its traditional “glocalisa-
tion” business model, where products were
developed in home markets like the USA
and Europe for these markets, then adapt-
ed for sale elsewhere – often by reducing
specifications and manufacturing locally.
This model worked to some extent, but fre-
quently the products were not suitable for
local circumstances – too big, too compli-
cated, susceptible to power fluctuations and
difficult to use and maintain in physical
2 MAC, Venue and VSCAN are trademarks of GE
Healthcare companies
environments quite differ-
ent from those they were
originally designed for. And,
despite lowering the capital
cost of equipment, financial
models for its use and up-
keep based upon home mar-
ket experience did not work
and were not sustainable.
There needed to be a major
change in mindset.
The company now increas-
ingly researches, develops
and manufactures the right
technology for local needs
in the country or region of
use as part of GE’s “in coun-
try for country” approach to
new technology development. This is easier
said than done, and the Harvard Business
Review paper describes in detail how the
management structures and systems of GE
had to change to allow local autonomy and
responsibility to take decisions,research local
needs and critically, in a company renowned
for financial rigor, secure and allocate fi-
nancing for the new products. In short, GE
teams with deep local knowledge and un-
precedented autonomy in China, India and
a dozen other countries now manage the de-
velopment and production of new products
to meet local needs. In an interesting twist,
because these new products do not compro-
mise on quality, some are finding a use “back
home”in the developed markets.This has be-
come known as “reverse innovation.”
Reverse innovation
Technologies designed to meet the specific
medical needs and circumstances of devel-
oping nations are proving popular in more
developed markets, particularly where there
are large rural,underserved populations.The
MAC series of electrocardiograms (ECG)
is a good example of this. Originally devel-
oped in India,their ease of use and portabil-
ity make them equally attractive for primary
care physicians and nurses in clinics and on
home visits in other countries including the
USA.These machines are even used by “fly-
ing doctors”serving the Inuit populations in
Northern Canada and data from examina-
tions can be examined on the spot or trans-
mitted to specialists in urban centres for
analysis or second opinion.
In today’s financially restrained times, tech-
nology that enables more diagnostic tests to
be conducted outside of the hospital envi-
ronment or at the patient’s bedside, rather
than referral and physical transport, are
likely to be attractive in helping to improve
healthcare system efficiencies. Marketing
these technologies in developed as well as
emerging markets allows the development
costs to be spread wider and hence the price
point to the developing market can be set
at a level that enables the country to pur-
chase and maintain the technology – meet-
ing GE’s healthymagination commitments
relating to quality, access and cost.
New healthcare technologies for global
challenges
Innovative medical technology is now be-
ing developed for almost all the diseases and
conditions found across developing nations.
Until relatively recently the predominant fo-
cus was on medicines, vaccines and preven-
tion and awareness campaigns. Now there
is a welcome shift towards new and better
technologies for screening, earlier diagnosis,
treatment assessment and monitoring.
The World Health Organisation is a case
in point. It recently published the result of
its call for innovative devices that address
global health concerns [3]. Six out of fifteen
applications that it has selected to high-
light are in diagnostics and screening.These
range from a portable on site cell sorter and
counter for HIV and malaria diagnosis, to
a transcutaneous bilirubin measurement
system to provide an alternative to blood
sample analysis for the diagnosis of hyper-
bilirubinaemia in newborn infants. Other
devices selected have applications in mater-
Healthcare technologies
Mike Barber with the Vscan ultrasound scanner at the WMA
lunch The portable MAC ECG device and Venue 40 ultrasound
scanner being demonstrated
156
Healthcare technologies
nal and newborn care, such as neonatal suc-
tion devices and baby warmers.These reflect
the rising global focus on the challenges of
Maternal and Newborn Health which are
prominent in the United Nations Millen-
nium Development Goals (MDGs).
Maternal and Newborn Health
MDG 5 aims to reduce by two-thirds the
mortality rate among children under five –
and deliver this by 2015. Of the 139 million
babies born worldwide every year, nearly 4
million die in the neonatal period, the main
direct causes being preterm birth, severe in-
fections and asphyxia.The real tragedy is that
most of these deaths are preventable. With
just five years to go, reaching the MDG will
requirenew levelsofcooperationamongstev-
eryone concerned,from doctors to midwives,
Governments to NGOs and researchers to
businesses. It will also require a reappraisal
of the ways in which healthcare technologies
are developed and deployed, especially in
areas where neonatal mortality rates are the
highest. GE is playing its part.
As part of GE’s global healthymagination
commitment, we expect to expand our Ma-
ternal-Infant Care portfolio by 35% – offer-
ing targeted technologies to over 80 coun-
tries in order to increase local access to care.
Included already are safety tested, affordable
and easy-to-use infant care products that
provide warmth for newborns, phototherapy
to treat jaundiced infants and incubators for
premature babies. Some of these products
are designed and manufactured in India and
Turkey. GE is now working on developing
very simple warmers and phototherapy de-
vices for developing nations at dramatically
reduced cost. A novel method for providing
oxygen to mothers in childbirth and to new-
born babies is also under consideration.
Another new product already available is
the Vscan handheld portable ultrasound
scanner, developed in emerging markets.
Its clinical applications are currently being
assessed in both emerging and developed
markets for a wide range of diseases and
conditions. Though not yet approved, these
include assessing its capabilities and proto-
cols for its use in maternal and neonatal care
applications in emerging markets.
Ultimately, our vision is for Vscan to be as
ubiquitous as a stethoscope and to achieve
that it must have a truly global reach. As
in consumer electronics, unit costs will be
reduced as more clinical applications are
approved, production increased and other
design innovations are deployed. The goal is
to reach a point where the purchase, train-
ing and upkeep costs can be recovered by a
sustainable pricing model in even the lowest
income countries of the world.This is a goal
that was simply unimaginable only a few
years ago and now promises to bring to any-
where powerful diagnostic capabilities previ-
ously the exclusive domain of the hospital.
Working in partnership
Having designed new technologies the next
challenge is to test,refine and deploy them in
the field.Lessons have been learned from the
GE Foundation’s keystone philanthropy pro-
gramme “Developing Health Globally” [4].
This programme is improving the healthcare
capacity in Africa, South East Asia and Lat-
in America by equipping hospitals and clin-
ics with the technology they need and ensur-
ing staff are properly trained in its use. Using
volunteers from GE and GE Healthcare the
programme has shown that what is actually
required on the ground is often not what is
perceived from afar and that what works in
Geneva, may not in Ghana. In short, the
learning is that there is no substitute for hav-
ing people in situ on the ground.
It is here that GE is actively seeking part-
nership with Governments, professional or-
ganisations and increasingly NGOs with a
presence in developing markets. While we
may have design team and sales and mar-
keting and business expertise in many coun-
tries, we sometimes lack the infrastructure
on the ground to take the new technologies
out to the patients. Fortunately, there are
many global and local NGOs experienced
in this type of work and we are keen to
join with them to provide the training pro-
grammes and capacity building in country
for testing new technologies. Through this
type of partnership we can better reach the
end users to determine if a new technology
really will be of use on the ground. If yes,
working in a partnership could also allow
us to develop clinical protocols and appro-
priate uses for the technologies, speed up
delivery, provide the right training and sup-
port needs and minimise costs.
Much remains to be done. GE is not claim-
ing to have all the answers to ensure that
all parts of the world have access to innova-
tive technologies that improve health. We
do however understand the problems and
can see many of the obstacles in the way.
Through healthymagination and the de-
velopment of new technologies ‘in country
for country’ we are committed to working
to help overcome the challenges. It will re-
quire more collaboration,partnerships,clear
thinking and the courage to do things dif-
ferently. Please join us in our journey.
References
Healthymagination [Internet] [cited 20101.
May 8]. Available from http:// www.healthy-
magination.com
Immelt JR,Govindarajan V,Trimble Ch.How2.
GE is disrupting itself. Harvard Business Re-
view. 2009 Oct : 3 –11.
Call for innovative technologies that address3.
global health concerns [Internet]. World
Health Organisation: Department of Essen-
tial Health Technologies [cited 2010 May 8]
Available from http:// www.who.int/medi-
cal_devices/call/en/index.html
Renewing responsibilities: Citizenship Report4.
2009 [Internet] [cited 2010 May 8]. Available
from http:// http://www.ge.com/citizenship/
Note: This article is based on an address by Mike
Barber to the World Medical Association’s Annual
Lunch at the World Health Assembly, Geneva, 18
May 2010
Mike Barber, Vice President
healthymagination, General Electric
157
Regional and NMA news
Birgit Beger
Introduction
At its Board meeting on 22nd June, chaired
by CPME President Dr Konstanty Radzi-
will, the CPME said good-bye to Lisette
Tiddens-Engwirda, who left the CPME
upon her retirement after 8.5 years as sec-
retary general. The board welcomed Birgit
Beger, the new secretary general as of 1st
July 2010.
Content discussions were in-depth and the
agenda full, since the meeting in April had
fallen victim to the travel restriction based
on the Icelandic volcano. From the many
subjects dealt with in June, there are a num-
ber of significant items of interest to the
medical profession.
e-Health
In the world of electronic communication
there are no national borders, and e-health
presents a rapidly changing healthcare
policy area. The CPME has made involve-
ment in this policy area a focus for years,
with the aim of ensuring that technology
is used to support the cornerstones of the
patient/doctor relationship with a view to
better and easier access to healthcare. With
this engagement we try to countervene ten-
dencies of focussing e-health on economical
and technology developments, circumvent-
ing the importance of departing from pa-
tients’ needs.
Health care for the ageing population and
chronic disease management indeed find a
backup in e-health tools, as does cross-bor-
der prescription in Europe where citizens
are more and more mobile. E-health is high
on the agenda of EU governments and the
European Commission. In the last years we
have seen projects like epSOS (transfer of
electronic patient summaries,e-prescribing)
and CALLIOPE (interoperability project) ,
CALLepSO (combination of both projects),
as well as the 2009 Council conclusions on
e-health which present a political mandate
for a more consolidated approach to co-op-
eration on e-Health in the EU.The CPME
is involved in these concrete projects as well
as in the e-Health users’ stakeholder group
which is chaired by the previous president
of the CPME, Dr Michael Wilks.
At the CPME it was agreed that the issue of
data protection and patients’consent should
be further strengthened in the debate, since
this is a particular area in which the inter-
est of the patient is under potential risk.The
focus for this topic will be brought into the
user group and a thematic network on limits
and barriers of e-health.
Pharmaceuticals–CPMEresponsetoEu-
ropean Medicines Agency consultation1
1 The European Medicines Agency Road Map
to 2015: The Agency’s contribution to Science,
Medicines, Health is available here: http://www.
ema.europa.eu/htms/general/direct/roadmap/
roadmapintro.htm
The European Medicines Agency launched
a consultation on its Road Map to 2015
which presents the EMA’s new strategic vi-
sion and sets out the Agency’s priorities for
the next five years.
In its response to the consultation, the
CPME in general agreed with the roadmap
proposed, but underlined the importance of
engaging the medical profession in order to
properly address public health needs.More-
over, the CPME stressed the global nature
of medicine development and research in
support of the Helsinki Declaration2
.This is
one of the most important documents and
guideline for doctors when it comes to re-
search on human beings and it deals with
the ethical issues implied. Furthermore, as
regards clinical trials, the CPME stressed
that it is of great importance that all clinical
trials are registered in a publicly accessible
global database to avoid redundant clinical
studies which is another important topic
covered by the Helsinki Declaration.
Organ donation
The CPME rapporteur on organ donation,
Dr Frank Ulrich Montgomery,reported that
the CPME’s amendments to the draft pro-
posal for a “Directive of the European Par-
liament and of the Council of 8th Decem-
ber 2008 on standards of quality and safety
of human organs intended for transplanta-
tion [COM (2008) 818]”3
were accepted by
the rapporteur MEP Miroslav Mikolášik
(SK, PES), so that the final version of the
document now includes all key demands of
the CPME and safeguards the interests of
doctors and patients.The CPME’s advocacy
work was very successful in this initiative.
2. WORLD MEDICAL ASSOCIATION DEC-
LARATION OF HELSINKI, Ethical Principles
for Medical Research Involving Human Subjects,
adopted by the 18th WMA General Assembly,Hel-
sinki, Finland, June 1964, please see: http://www.
wma.net/en/30publications/10policies/b3/17c.pdf
3 http://eur-lex.europa.eu/LexUriServ/LexUriServ.
do?uri=COM:2008:0818:FIN:EN:PDF
News from the CPME: Board meeting in
Brussels on 22nd
June
158
Regional and NMA news
The draft directive now aims to integrate
harmonised regulations for the fields of
“blood, blood products, cells, tissue and
organs of human origin”. The CPME
amendments sought to avoid loopholes in
the draft directive as regards parts of or-
gans if it is their function to be used for
the same purpose as the entire organ in the
human body, and for so-called “complex
tissue”. Furthermore, the amendments aim
to diminish bureaucratic hurdles and try
to ensure the good practices of the tissue
directive 2004/23/EC and its implement-
ing directives. In light of the communalism
of transplantation medicine successfully
established over many years in some EU
member states, the CPME amendments
are of crucial significance; retaining the
previous formulations of the draft directive
would, in some countries, have unnecessar-
ily resulted in abandoning the proven and
tested organisational structures. In coun-
tries where there are high standards these
standards will, thus, be maintained. The
Council approved the directive on 29th
June 2010 and it awaits its publication in
the Official Journal.
European Working Time Directive
On 24th March 2010, the Commis-
sion published a communication (COM
2010(106) final)4
on reviewing the Working
Time Directive 2003/88/EC.5
In the years
2004–2009 the Commission’s proposal to
amend the Directive could not reach agree-
ment with the Council and the Parliament
despite intensive discussions and a concili-
ation process.
The CPME believes that it is vital in the
interest of the healthcare work force and
their patients to maintain high standards
of protection from long working hours and
depraving working conditions as well as
guaranteeing safety for the patients. The
4 http://eur-lex.europa.eu/LexUriServ/LexUriServ.
do?uri=COM:2010:0106:FIN:EN:PDF
5 http://eur-lex.europa.eu/LexUriServ/LexUriServ.
do?uri=OJ:L:2003:299:0009:0019:EN:PDF
current Working Time Directive provides
sound definitions for “working time” and
“rest period” which have proven successful
in bringing down overall working times
and in reconciling private-life and work-
life. Also, the European Court of Justice
in the cases SIMAP, Jaeger and Dellas,
ruled that the “on-call time periods” must
be counted hour-for-hour as working time
which is strongly supported by the CPME.
Since the Working Time Directive is a val-
uable tool – provided Member States have
implemented it – the CPME is rather hes-
itant towards a review. In particular, if one
of the motives for the revision is to create
competitive cost advantages for businesses
by making production times more flexible.
For example, individual opt-outs from the
48-hour limit to average weekly working
time are considered as a very critical ele-
ment in the current Working Time Direc-
tive and any review should not allow fur-
ther derogations from the full protective
scope of the directive. The overall scope
of the European Working Time Directive
should not turn from a protective to an
economic one.
The CPME will closely monitor further de-
velopments in the review process and will
take an active stand for the interests of the
healthcare workforce and their patients.
Health inequalities
The well-being of and care for their pa-
tients is the prime concern and respon-
sibility of physicians. Physicians apply
their expertise to the best of their knowl-
edge for the benefit of the sick and for
the prevention of ill health. Research for
new approaches and technologies to im-
prove health, and contribution to policy
making in clinical and public health are
also important obligations for the medical
profession.
At the board meeting, the CPME ad-
opted a position paper on health in-
equalities, please see: http://cpme.dyndns.
org:591/adopted/2010/CPME_AD_
Brd_220610_014_final_EN.pdf
In the position paper reference is made to
a CPME response to a Consultation on
European Commission Communication
“Solidarity in Health” of 2009, (please see:
http://ec.europa.eu/health/archive/ph_de-
terminants/socio_economics/documents/
cons_paper_en_.pdf), where the CPME
suggested several measures to reduce in-
equalities in health. Some of these are not
directly healthcare-related as for example
education, social cohesion, fiscal and taxa-
tion policy, etc. While the CPME supports
action in these areas to reduce health in-
equalities, as an organisation for medical
doctors, CPME concentrates its lobby ac-
tivities on health issues and give priority to
these measures:
Improving the data and knowledge base•
and mechanism for measuring, monitoring,
evaluation and reporting.
Improvement in infrastructure, especially•
water and housing.
Secure the right to health for disadvantaged•
people including illegal entrants and asylum
seekers.
The current position paper addresses also
the decisive national level (National Medi-
cal Organisations) as regards ways of im-
provement of health inequalities, like for
example:
Drawing the attention of governments to•
international conventions or charters that
secure the right to health.
Lobbying national health authorities for•
better health care particularly for disadvan-
taged groups.
Ethical trade in medical goods
The CPME has started work on a net-
work which brings together national
reports on ethical trade in medical sup-
plies. In the UK and Sweden good prac-
tices already exist which aim to tackle the
ethical implication of producing medical
goods in low cost countries, for example
159
Regional and NMA news
child labour, health and safety, and work-
ers’ rights.
In 2009, the CPME already undertook first
steps to raise awareness among the Euro-
pean medical associations and EU decision
makers.
The aim of the current work is to assess
whether European standards on ethical
trade will be helpful to safeguard rights.
Furthermore, the CPME is aware that the
European Commission is developing social
standards for ethical procurement to which
the CPME could contribute from the Eu-
ropean doctors’ point of view.
The next CPME board meeting and general
assembly will take place in Brussels on 27th
November 2010. For further information,
please contact Birgit Beger at birgit.beger@
cpme.eu
Birgit Beger, Secretary General, CPME
Bernard Maillet
Introduction
A hybrid yet comprehensive structure –
specialist, political and scientific
The European Union of Medical Special-
ists (UEMS) was established in 1958, one
year after the signing of the Rome Treaty,
and is the representative organisation of the
National Associations of Medical Special-
ists in the European Union, its associated
and observer countries and beyond. With
a current membership of 35 countries, the
UEMS represents an estimated 1.5 million
specialist doctors, notably through its 38
Specialist Sections and Boards and 8 Mul-
tidisciplinary Joint Committees (MJC’s).
It has strong links and relations with the
European Institutions (Commission and
Parliament), the other independent Euro-
pean Medical Organisations (e.g. PWG,
UEMO, CPME) and the European Medi-
cal / Scientific Societies.
Its structure consists of a Council respon-
sible for and working through its Special-
ist Sections and MJC’s, each with its own
European Board, addressing training in the
Specialty and incorporating representatives
from academia (Scientific Societies,Colleges
and Universities).An Executive,made up the
President,the Secretary-General,the Liaison
Officer, and the Treasurer, is responsible for
the daily functioning of the organisation.
By its agreed documents, the UEMS sets
standards for high quality healthcare prac-
tice for the benefit of patients and the har-
monisation of high level training across Eu-
rope that are transmitted to the Authorities
and Institutions of the EU and the National
Medical Associations (and through them
the National Health Authorities) stimulat-
ing and encouraging them to implement its
recommendations.
In 2000, the UEMS established the ex-
tremely important European Accredita-
tion Council for Continuing Medical
Education (EACCME®
), which facilitates
the exchange of CME credits obtained by
attending international medical congress-
es. This recognition is achieved by virtue
of common memoranda of agreement
on mutual recognition reached between
UEMS, the National Accreditation Au-
thorities and the American Medical As-
sociation.
A further step forward was realised in 2010
at the Istanbul Council of the UEMS where
the European Accreditation Council for
Medical Specialist Qualification was of-
ficially created. It was agreed to start with
a pilot project for a period of two years for
three Specialties and have a harmonisation
of the Assessment of the Training.
The oldest of the European
medical organisations
On 20th July 1958, delegates from the
professional organisations representing
medical specialists of the six founding
countries of the new European Economic
Community convened in Brussels and set
up the UEMS. Thanks to the leadership
and perspicacity of its founding members,
the UEMS soon established contacts with
the newly created European Institutions
to define the basic principles in the field
of training for European medical special-
ists. During its 50 years of existence, the
UEMS continued to deliver a considerable
amount of work with the constant aim to
promote the quality of care across Europe.
The Training, Qualification and Continuous
Professional Development of the Medical
Specialist in the Future, a Challenge for the UEMS
160
Regional and NMA news
When addressing the issue of quality, the
UEMS obtained from the European Com-
mission and the Member States that the
highest levels of training for the future medi-
cal specialists of the Six Common Market
countries would be guaranteed by European
legislation. This vision of the future resulted
in the elaboration of common general cri-
teria, applicable to all specialists wishing to
move from one member country to another.
To realise this ambitious objective, the
UEMS created in 1962 Specialist Sections
for each of the main disciplines then prac-
ticed in the Member States.These groups of
experts, made up of representatives of the
national associations of the specialty con-
cerned, carried out a considerable workload
with the idea of coordinating and harmon-
ising specialist training and criteria for the
recognition of medical specialists. Today
the UEMS has 38 Specialist Sections and
Boards as well as 8 Multidisciplinary Joint
Committees (MJC’s) all together having
about 2000 specialists working on those
important issues.
This active collaboration with the Europe-
an Institutions and Member States led to
the adoption in 1975 of the first Directives
providing for the free movement of doctors
across Europe by ensuring the recognition
of their qualifications.
The UEMS naturally contributed to further
improvements and updates to the Doctors’
Directives following to the successive en-
largements of the European Community.
These also led to important changes in the
bodies and composition of UEMS.Progres-
sively, the number of UEMS Sections in-
creased and reaches now 38.
In order to support the implementation to
these Directives, the European Commis-
sion established the Advisory Commit-
tee on Medical Training (ACMT) with
an aim to engage European professional
medical organisations, universities and na-
tional governments. The UEMS, through
its Specialist Sections, was naturally deeply
involved in the consultations launched by
this body. Each Section was asked to report
on its understanding and possible propos-
als regarding the developments occurring in
the specialty. Progressively, four reports of
the ACMT, conducted by Members of the
UEMS Executive,were implemented by the
Commission when updating its legislation.
Confronted with the need to a greater
involvement of the academic world, the
UEMS created in 1990 European Boards
as working groups of its Specialist Sections
to address issues related to medical train-
ing and ultimately guarantee optimal care
by raising quality and training standards.
Thanks to this closer collaboration, Euro-
pean Charters were elaborated on various
issues such as specialist training, quality
assurance in specialist medicine or the au-
tonomy of practice for medical specialists.
In 1999,the UEMS set up the European Ac-
creditation Council for Continuing Educa-
tion (EACCME®
) with an aim to harmonise
and improve the quality of specialist medical
care in Europe through facilitating the mo-
bility of health professionals for learning and
training purposes. In the fields of continuing
medical education (CME) and continuing
professional development (CPD), the EAC-
CME ensures access to recognised high
quality CME-CPD activities by securing
the exchange and recognition of CME cred-
its for medical specialists in Europe through
the European CME Credits (ECMEC’s).
In the recent years, the UEMS has shown
itself to be very active in major issues dealt
with at the EU level. These include among
others the consolidation of the Doctors’Di-
rective into the Directive on the recognition
of professional qualifications; the organisa-
tion of working time; and patient mobility
and cross-border care.
The UEMS has celebrated its 50th Anni-
versary having celebrations held in Brussels
from 17th to 19th April 2008.
In 2007 at the initiative of the Section of Pe-
diatric Surgery a meeting was organised in
Glasgow where the Sections met that were
organising European Board Examinations
with the aim to harmonise those. At that
time 11 UEMS Sections were represented
and the so-called Glasgow Declaration was
issued at the end of the meeting.
The main points on the Glasgow declara-
tion are: the European Board Examinations
have no Legal Value and they can be seen as
complimentary to National Examinations.
We have to promote the European Exami-
nations, as they can be considered as a La-
bel of Excellence. Important is to set a clear
Curriculum and to have a Reference Book.
There should be clear Eligibility criteria and
we have to harmonise the certificates for
successful application.
In the meanwhile, the Council for Europe-
an Specialty Medical Assessment (UEMS-
CESMA) has been more formally installed
and working very well. Today 28 UEMS
Sections are participating in the activities of
this group and have support of the UEMS
Council and Executive, the UEMS Presi-
dent as well as the UEMS Secretary-Gen-
eral being ex-officio members of UEMS-
CESMA.
UEMS–CESMA together with the Work-
ing Group of the UEMS Council on Post
Graduate Training will be part of the
ECAMSQ together with the National Li-
censing Authorities in the European Union
as well as the UEMS Executive.
The introduction of e-learning
material in the EACCME®
(European
Accreditation Council for Continuous
Medical Education) « package »
from 9th April 2009 onwards
Since 2000 the UEMS is working on the
harmonisation of the Continuous Medi-
cal Education and Continuous Profes-
sional Education in the European area,
by creating the European Accreditation
161
Regional and NMA news
Council for Continuous Medical Edu-
cation (EACCME®
). From 2004 on the
EACCME®
has signed an agreement
with the American Medical Association
for the mutual recognition of internation-
al events happening on both sides of the
Atlantic Ocean.
First the EACCME®
took into consider-
ation for the accreditation only live events
but obviously e-learning is becoming an
important tool for physicians to improve
their knowledge, skills and attitudes so it
was decided by the UEMS Council to also
consider e-learning material for accredita-
tion and this started on 6th April 2009.
The introduction of long distance learning
was also an opportunity for the UEMS to
improve the quality criteria for the evalu-
ation of the e-learning activities and those
criteria, being very strict and of high stan-
dards, will in the future be retrofitted to live
events.
The document UEMS 2008.20 (Revised)
presents the criteria that have to be ful-
filled for e-learning material before being
approved and granted for credits by the
UEMS-EACCME®
.
Another important improvement in the
UEMS-EACCME®
process was the change
in provider who is taking care of the web-
based application form. In January 2008
the UEMS decided to introduce a web-
based application form as the numbers of
events applying for UEMS-EACCME®
ac-
creditation were increasing and the manual
processing became too demanding for the
UEMS Brussels Office Staff.
From the start the intention was to have a
fully efficient system including the evalua-
tion by the experts of both UEMS Sections
as the National Accreditation Authorities
and also to increase and improve the com-
munication between the different partners
in the process,the applicant,the experts and
the UEMS-EACCME®
.
As with all new systems that are intro-
duced, we experienced some problems at
the start but unfortunately, it seemed that
they were not appropriately solved and
many complaints remained so that we had
to change the webmaster and since Janu-
ary 2010 the system works extremely well
and there are nearly no complaints any
more concerning the processing of the
applications.
The actual webmaster is providing an
excellent service to UEMS-EACCME®
and things are going softly and efficiently
now.
This can be measured as since the introduc-
tion of the new webmaster, the number of
applications is increasing quite strongly but
globally, the quality of the events remains
outstanding in a large proportion.
Also the number of agreements between
the UEMS Sections and Boards and the
MJC’s as well as the National Accredi-
tation Authorities is increasing steadily
and moreover, contacts have been under-
taken with other areas of the world such
as Canada, Australia and the Middle
East to reinforce the position of EAC-
CME®
and the accreditation issue all
over the world.
The agreement between the UEMS-EAC-
CME®
and the American Medical Asso-
ciation on the mutual recognition of credits
was first issued in 2002 as a pilot and since
2006 it was a real agreement.
Now in July 2010, the agreement has been
renewed as both parties reviewed the pro-
cess and decided to include also e-learning
material being an important tool nowa-
days.
We do not have to forget that especially
with the introduction of the e-learning ma-
terial, borders are vanishing and the whole
issue of CME-CPD is getting more and
more global and worldwide.
The launch of a new structure:
the European Accreditation
Council for Medical Specialist
Qualficiation (EACMSQ)
Both the “Charter on Specialist Training”
and the “Charter on Quality Assurance of
Specialist Practice in the EU” stresses the
importance of assessing the training at one
level or another.Obviously,the Policy State-
ment on Assessments during Postgraduate
Medical Training crystallises the thinking
of the UEMS Council in this respect. Ev-
erything starts with the definition of clear
and harmonised training programmes and
curricula so that candidates have a strong
base to build their education upon.
This work has been done by our different
UEMS Sections and Boards as well as the
MJC’s and is continuously updated. Many
Sections are also participating in the UEMS
Council for European Specialist Medical
Assessment (CESMA) project. CESMA
started in February 2007 at a meeting or-
ganised by the Section of Paediatric Sur-
gery in Glasgow and has gained momen-
tum steadily since with more Sections and
Boards becoming involved.
In 2009, at the April Council meeting, a
first presentation of the ECAMSQ was
given by the UEMS President, and this can
be seen as the first step in the starting up
of this very important initiative. The aim is
to combine the UEMS-CESMA project
and the Working Group for Post Graduate
Training of the UEMS Council and create a
structure, similar to EACCME®
for CME-
CPD involving all the important stakehold-
ers in the field of PGT in Europe.
Similarly to the EACCME®
, the partners
involved here are the UEMS Sections and
Boards and the MJC’s as well as the Na-
tional Licencing Authorities.
The Council decided in it meeting of Is-
tanbul in October 2009 to establish the
ECAMSQ, with the ECAMSQ becoming
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Regional and NMA news
operational in 2010 (starting with a pilot
project lasting for two years and involving
three specialties, Anaesthesiology, Cardiol-
ogy as well as Radiology).
Orzone and UEMS share the vision of
improving healthcare quality through the
harmonisation of training and education
in Europe. For this purpose a collaboration
has been established for developing a com-
prehensive electronic platform to support
medical training, assessment and continu-
ous professional development. The strategic
direction for the establishment and the pri-
mary focus of this initiative is to extensively
improve the education and training of Eu-
ropean medical doctors, improving medical
outcome and patient safety.
As an organisation, the UEMS promotes
the best possible standards of harmonised
specialist training, continuing medical edu-
cation (CME) and professional develop-
ment (CPD), as well as quality assurance of
specialist medical practice.
By doing so, the UEMS is committed and
serves to encourage decision-makers as well
as healthcare professionals to ensure appro-
priate mechanisms for safe specialist medi-
cal care across Europe and this for each Eu-
ropean citizen.
As this topic clearly involves Trainees in
the different specialties, the Permanent
Working Group for Trainees (PWG) will
have a delegate in the EACMSQ. It is ob-
vious, that in order to have free movement
of Specialists in the European Union and
the Specialties to be recognized throughout
the Member States, the training curriculum
and content should be very similar every-
where in Europe and an Assessment would
confirm the ability of a Specialist to work
in similar conditions within the European
region.
ECAMSQ will be a structure that will help
in this harmonisation process easing access
to all EU specialists to all kinds of equiva-
lent positions all over Europe. Obviously, as
in EACCME®
it is fundamental to involve
strongly the National Training & Licensing
Authorities of the different Member States
in the process in order to guarantee the val-
ue of the end product.
It is clear that the ECAMSQ has to receive
its mandate from the national licencing au-
thorities.
Thougths on the revision of the
Directive on the Recognition
of Qualifications (Dir 2005/36
EC and 2006/100 EC)
The Directive on the Recognition of Quali-
fications was updated in 2006 with the ad-
mission of Bulgaria and Romania as Mem-
ber States of the European Union but there
were no major amendments introduced at
that time.
As the Directive will be revised in 2012,
we have to think on issues that are im-
portant and that could be introduced or
modified. First of all, the denomination
of the Specialties have to be looked at and
for instance the name of one Specialty,
“Physical and Rehabilitation Medicine”
has to be corrected as it is now cited as
“Physiotherapy”. Secondly, the minimal
length of training of the different special-
ties has to be updated as for instance for
Anaesthesiology, the Directive only con-
siders a minimal Training Time of 3 years
although the profession globally advocates
a training of at least 5 years. In this respect
it should be also good to consider includ-
ing not only length of training but also
the required competences as identified by
the Core Curriculum as proposed by the
different UEMS Sections and Boards as
well as the MJC’s (the so-called Chapter
6 of the UEMS Charter on Post Graduate
Training).
A crucial concept that could be introduced
and would help a lot in the recognition of
special fields of activities in medicine is the
concept of so-called “Particular Qualifica-
tion”.
Nowadays, the actual Directive only recog-
nises Basic Specialties but activities such as
Intensive Care Medicine and Oncology are
left aside and ignored.
It will be a major task of the UEMS to
convince the European Parliament, the
European Commission and the National
Authorities of the different EU Member
States,that the introduction of these Partic-
ular Qualifications are an important issue to
help many of our Colleagues active in some
fields of Medicine to be recognised all over
Europe and by having this, help to enhance
the healthcare of the European Citizen.
Likewise the actual version of the Directive,
there will be a list in the Addendum listing
the different Particular Competences that
would be recognized also presenting the
countries where they are already existing.
Conclusion
As reflected in this article, the UEMS is
very active in many different fields concern-
ing Specialised Medicine and there are still
a lot of important challenges that remain to
be realised. One of those being the whole
issue of e-Health that will increasingly in-
fluence our practice through telemedicine,
e-prescription or electronic patient record
for instance.
The mobilisation of all the actively involved
members of the UEMS in the different
bodies, the delegates from the National
Medical Associations, the delegates of the
UEMS Sections and Boards as well as the
MJC’s as well as the participants in both
the EACCME®
and the ECAMSQ will
be needed to achieve those important goals
that have been set up in the Strategy Docu-
ment of the UEMS that lies at the basis of
all those initiatives.
Dr. Bernard Maillet,
Secretary General UEMS
163
Regional and NMA news
TSE Hung Hing
Our Purpose
Founded in 1920, the Hong Kong Medi-
cal Association brings together all medical
practitioners practising in, and serving the
people of, Hong Kong. Its objective is to
promote the welfare of the medical profes-
sion and the health of the public. With the
current membership of over 8000 from all
sectors of medical practice, it speaks col-
lectively for its members and aims to keep
its members abreast of medical ethics and
issues around the world.
Our Role
The Association is the official representative
body of the local medical profession. It
represents the medical profession in local
governmental and professional bodies, as
well as regional and international medical
organisations. Post-1997, the relationship
betweentheAssociationanditscounterparts
in Mainland China has become closer. Into
the new Millennium, its representative role
has been further enhanced with the staunch
support of its membership and strong
affiliation to organisations with laudable
missions and objectives.
Our Structure
The Association is now directed by a Coun-
cil of 25 members elected from the mem-
bership at the Annual General Meeting.
The Council is advised and assisted by a
number of standing and ad hoc committees
in its deliberation and formulation of poli-
cies. As a non-governmental and non-profit
organisation, the Hong Kong Medical As-
sociation runs numerous programs, profes-
sional or community alike, with volunteers
and resources mainly from its own mem-
bership.
Our Home
The Association’s headquarter is in
Wanchai since 1975. In view of increasing
membership and activities, the Association
established an education centre in the city
centre in 2002.
Our Programmes
Consensus Building
The Association holds discussion forums on
public health policies, on health care fund-
ing policies, on professional code and con-
duct, on all issues concerning public health
and safety as well as the professional prac-
tice. Discussion forums facilitate person-
to-person exchange of views. Such discus-
sions are also held on the Internet, via the
HKMA News and direct communication
with council members and representatives
in various government and non-govern-
mental boards and councils. The collective
views are reflected to the authorities via the
Association.
Continuous Medical Education
The Association runs regular CME activi-
ties in form of lectures, seminars, sympo-
sia, workshops, discussion group, clinical
attachments in hospital, etc. to provide
opportunities for continuous medical edu-
cation. The Association also set up a struc-
tured and systematic programme for the
recording and accreditation of members’
efforts in CME.
Since 2002, an online CME program has
been set up on www.hkmacme.org and
members can login to do CME online.
Membership Development
The Duty Council Member Scheme helps
solve problems encountered by members in
their daily practice.The Young Doctors Pro-
gramme serves the new graduates by hold-
ing career talks, tracking the career paths,
monitoring the employment opportunities
in the public sector and facilitating place-
ments in the private sector.The District Or-
ganisation links and brings closer doctors
practicing in outlying districts. We have
now developed 8 community networks,
which are vested with the role of developing
district programmes of continuing medical
education, private-public cooperation and
public medical education.
Special Interests Groups
Members with similar interests are grouped
together to promote a good cause while
sharing their common interests. The
HKMA Choir and the HKMA Orchestra
present concerts to raise funds for charity.
The Hikers challenge the MacLehose Trail
of 100 km within 48 hours to raise funds
for Oxfam.The Sportsmen compete at vari-
ous sports tournaments organised by the
Association to promote sportsmanship and
fraternity. The Dragon Boat Teams culture
team spirit while testing their physique and
mind to the extreme at the races.
Social Functions
The Association organises regular hiking,
outings, visits and annual dinner to foster
The Hong Kong Medical Association
164
Regional and NMA news
friendly relationship amongst members and
their families and friends.
Community Projects
For the past fifteen years, the Association
maintains the only territory-wide Organ
Donation Register, which not only records
the wishes of willing donors but also serves
as an indicator of the awareness and accep-
tance of organ donation after death. Aware-
ness promotion programmes are conducted
from time to time in conjunction with
the Department of Health, the Hospital
Authority. In December 2008, with our
cooperation, the HKSAR Government
set up a Centralised Organ Donation
Register. Data stored in the HKMA Organ
Donation Register migrated gradually to
the centralised system.
In conjunction with various government
and non-governmental health-conscious
organisations, the Association is also pro-
moting healthy life styles such as quit
smoking, healthy eating and “Say No to
Drugs” to the younger generation via the
one-school one-doctor scheme.
The Association is working in collaboration
with public-spirited organisations in
promoting the use of serving chopsticks &
spoons, and regular daily physical activities
such as walking 8000 steps a day to the
general public.
Hotlines & Directory
Sponsored by Pacific Century CyberWorks
Ltd., the Association runs the MediLink
Hotline 90000-222-322 for the public to
search for medical clinics, which are open
during long holidays. A directory of doctors
is put on the Internet for public information
at www.hkdoctors.org to facilitate referral
of patients between the public and private
sectors. A hotline for report of illegal sales
of drugs is run at Tel No. 2528 6644.
The HKMA Charitable Foundation
Since 1990,the Association has been raising
funds for various charitable organisations
through public performance of its Orchestra
and Choir. The unreserved support of its
membership and friends of the medical
profession has endeavored to alleviate
the sufferings of the sick, the poor and
the underprivileged. For the Association
to work more closely with its supporters
in community and charity projects,
the Hong Kong Medical Association
Charitable Foundation was formed in
2006 to consolidate and manage all efforts
with a view to better recognition of the
contribution of the supporters. Public-
spirited individuals and corporations are
welcome to join the Foundation. Together
we make the world, in particular the Hong
Kong Special Administrative Region, a
healthier and happier place to live.
Our Pledge
The patient’s well-being is in the heart of
our members whose welfare is in the heart
of the Hong Kong Medical Association.We
pledge to serve both the community and the
doctors. Together, we speak with one heart
and in one voice to safeguard the health of
the people of Hong Kong.
Dr. TSE Hung Hing, Immediate
Past President of the Hong
Kong Medical Association
The HKMA Council 2009–2010
165
Regional and NMA news
Domen Podnar
“The health policy framework must be designed
to ensure that each patient receives quality care.
It must be about the individual and not about
power. Likewise, it must be about the patient
and not about politics,” said Professor Dr.
Jörg-Dietrich Hoppe, President of the Ger-
man Medical Association at the opening of
the German Medical Assembly.
A total of 250 delegates from the 17 Ger-
man State Chambers of Physicians met to
discuss health, social and medical profes-
sional policy issues at the 113th
German
Medical Assembly in Dresden on 11th
to
14th
May, 2010.
The German Medical Assembly is the
“Parliament of the Medical Profession”
in Germany. This annual general assem-
bly of the German Medical Association
(Bundesärztekammer) is held at different
venues each year. The location is selected
from proposals by the individual state
chambers of physicians. Each state cham-
ber of physicians (SCP) receives two seats
as their Basic Representation at the assem-
bly. The remaining 216 seats are distributed
among the individual state medical associa-
tions in proportion to the number of mem-
bers in the SCP according to the d’Hondt
system. The German Medical Assembly,
initially founded as the Annual Meeting
of the Deutscher Ärztevereinsbund, has been
held annually since 1873 except in years
when it was forced to break during World
Wars I and II and the Nazi regime. It con-
vened for the 113th time in the historic city
of Dresden. Prof. Dr. Jörg-Dietrich Hoppe,
President of the German Medical Associa-
tion (GMA), has served as President and
Chairman of the German Medical Assem-
bly since 1999.
“The future challenges are enormous, and the
physicians want to help tackle them,” said
Hoppe in his opening address. That is why
the German Medical Assembly focuses on
different core themes each year. This year’s
core themes were
Health Care Provision Research,•
Regulation on Post-graduate Medical•
Education and
Rights of Patients – Duties of the State•
and Society.
Health care provision research is a top pri-
ority of the German Medical Association
(GMA). Therefore, the GMA launched a
funding initiative to promote research into
routine health care provision to individual
patients and the patient populations in hos-
pitals, medical practices and other health
care facilities in 2005. The goal of the ini-
tiative is to develop concepts for better pa-
tient care, to produce reliable statistics on
the shortage of physicians, and to provide
information on the work situation of physi-
cians, among other things. The GMA has
provided a total of €750,000 in funding for
various projects relating to health care sup-
ply research each year since 2005.The fund-
ing initiative covers a period of six years.The
delegates voted to extend support for the
German Medical Association’s initiative.
A conceptual draft of the follow-up initia-
tive is to be elaborated by the next German
Medical Assembly meeting.
The new (Model) Regulation on Post-grad-
uate Medical Education was also on the
agenda. In Germany, post-graduate medical
education falls under the jurisdiction of the
17 state chambers of physicians (SCP). The
Model Regulation on Post-graduate Medi-
cal Education is a proposal submitted to the
state chambers of physicians to ensure a cer-
tain degree of harmonisation, and the SCPs
are not bound to accept it. The state cham-
bers of physicians and professional groups
were involved in the drafting of the proposed
Regulation on Post-graduate Medical Edu-
cation to ensure that it was up-to-date.Eval-
uation of post-graduate medical education
was another topic of discussion in Dresden.
Post-graduate education teachers and stu-
dents were asked about their experiences in a
survey conducted according to a Swiss mod-
el. The German Medical Association hopes
that these efforts will help to achieve higher
quality continuing medical education.
“Health care provision structures should focus
primarily on the medical needs of the patient.
They should not be dominated by cost reduc-
tion targets,” demanded Dr. Frank-Ulrich
Montgomery, Vice-President of the Ger-
man Medical Association in his speech on
the core theme “Patient Rights”. The Ger-
man Medical Assembly is in favor of codi-
fying the rights of patients in Germany, but
does not consider a new law to be necessary.
Standards on patient rights in Germany
have already been developed in a number
of laws, professional codes for physicians,
and many years of case law. Furthermore,
the German Medical Assembly ascer-
tained that a growing “Europeanisation”
of patient’s rights issues was unmistakable.
The proposed new regulations on patients’
rights in cross-border health care provision,
patient information in the pharmaceutical
sector, and organ transplantation are a case
in point.
Helping to Meet the Challenges of the Future
113th
German Medical Assembly in Dresden
166
Regional and NMA news
In further resolutions, the German Medi-
cal Assembly called for the government to
introduce anonymous health insurance for
foreigners without residence permit status
and to systematically implement the UN
Convention on the Rights of Persons with
Disabilities, among other things.
The German Medical Assembly engaged
in an intensive discussion of the challenges
that doctors face in their professional lives
due to politics.
The 250 delegates as well as 80 international
guests from 27 countries followed the dis-
cussions. In addition to the World Medi-
cal Association leadership, the presidents
or representatives of many national medical
associations were present in Dresden.
Several resolutions were adopted to guide
the direction of policy-making in the next
years, particularly that of the German Med-
ical Association.
The Board of the GMA will take this man-
date and will present the results at the 114th
German Medical Assembly in the north
German city of Kiel.The next president and
the two vice-presidents of the GMA will
be elected for a period of four years at that
time.
Domen Podnar, German Medical
Association, International Department
Vallo Volke
The Estonians are really keen on new tech-
nologies. In Estonia it is a common prac-
tice to cast your vote in parliament elections
via the internet, make your tax declaration
in the internet or park your car by using
a mobile phone. Thus, it is not surprising
that many e-health projects have also been
established in Estonia. Small population
(1.34 million) makes the country a perfect
place to test new innovative ideas.
However,not all of the projects have been that
successful.Atthebeginningof2010auniversal
electronic prescription system was launched.
The goal was to collect all prescriptions in a
central database, so that to make all currently
or previously active prescriptions of the patient
easily accessible to doctors and pharmacists.
Despite the fact that the new system has suf-
fered from frequent technical problems and
has not yet gained the planned dominance, it
is time to share the experience of doctors after
using the system for half a year.
Strong points of the new system
The central database gives a clear and quick
overview of the drugs used by the patient.
Thus, unnecessary or potentially dangerous
drugs or drug combinations can be easily
identified and stopped. As currently only
about 50% of prescriptions are made elec-
tronically, the full advantage for the patients
is yet to be seen.
The majority of drugs are used chronically
by patients.The electronic system makes the
renewal of the prescription a one click pro-
cedure for the doctor.
Occasionally, it may be very useful to have
a possibility to make prescription while the
patient is not present in your office.Howev-
er, there is also a risk that some doctors may
abuse the possibility and prescribe without
seeing the patient.
Problems and limitations
When relying on a universal electronic sys-
tem, the technical functioning of the system
must be guaranteed. Unfortunately, the Es-
tonian system has had major blackouts dur-
ing the so-called rush-hours;
From the patient point of view, not having a
paper prescription makes it harder to recall
when the renewal of prescription is needed;
Protecting patient confidentiality is always
an issue with electronic systems;
With older patients it is common that
someone else buys the drugs prescribed. In
such a situation the traditional prescription
is actually more reliable. To make a pur-
chase for someone else by using electronic
prescription in Estonia you have to present
your ID card and you need to know the so-
cial security code of the patient. I am not
completely convinced that it is a safe and
reliable practice.
What went wrong with the project?
The electronic prescription system project
was led by the Estonian Health Insurance
Fund and it is part of a bigger e-health ini-
tiative in the Estonian healthcare. The vast
Lessons Learned from the Estonian
Electronic Prescription System
167
Regional and NMA news
majority of the problems seem to derive
from inadequate involvement of key part-
ners, namely doctors and pharmacists. The
importance of the involvement of doctors in
every step of the project development could
not be overestimated.
All in all — how satisfied are Estonian doc-
tors with the electronic prescription sys-
tem?
Well, the current 50% prescription rate via
e-system is pretty much the answer. Hope-
fully, the technical problems will be solved
and the full potential of the system will be
seen soon.
Useful links: Estonian Health Insurance
Fund (www.haigekassa.ee)
Vallo Volke, MD, PhD, Estonian
Medical Association
In most low- and middle-income countries, there is a critical
shortage of skilled eye care personnel – including ophthalmolo-
gists, optometrists, ophthalmic nurses and others – and a desper-
ate need to build human resource capacity. The Community Eye
Health Journal is a free publication which helps to address this
need by providing up-to-date and practical eye care information
to eye care personnel underserved cities, towns, villages and rural
areas across the developing world and have little or no access to
refresher training, libraries or the internet.
The journal is published by the International Centre for Eye
Health, London School of Hygiene and Tropical Medicine, UK,
and paper copies are sent free to readers in low- and middle-
income countries; it is also available on CD-Rom and online
at www.cehjournal.org. As of June 2010, each issue contains a
continued professional development (CPD component), consist-
ing of multiple-choice questions readers can use to test their un-
derstanding of the articles. These questions are written for us by
the International Council of Ophthalmology in the style of their
Advanced Examination and are relevant to the widest possible
range of readers.
At present, we have editions in five languages (English, French,
Portuguese, Spanish and Chinese) and reach a total of 26,000
readers in 184 countries across Africa, Asia and Latin America.
From our readership survey, we know that 94% of readers find
the journal ‘useful’ or ‘very useful’ and that it has influenced the
practice of 71% of readers.
How you can help: We know that many eye care workers do not
yet know about this free resource. If you have ideas on how to
reach them, would like to subscribe, or even wish to donate to
support the journal, please visit www.cehjournal.org or write to
Anita Shah, admin@cehjournal.org, International Centre for Eye
Health, London School of Hygiene and Tropical Medicine, Kep-
pel Street, London WC1E 7HT, United Kingdom.
We are on Facebook (search for ‘Community Eye Health Jour-
nal’) and on Twitter (www.twitter.com/cehjournal) and welcome
your input and feedback.
Bringing eye care information to those who need it most
168
WMA news
Editorial ………………………………………………………………………..127
185th
WMA Council meeting in Evian,
France 20th
–22nd
May 2010……………………………………………….128
World Medical Association Appeals for
Release of Sudanese Doctors…………………………………………….137
Highlights of the Third Geneva Conference on
Person-centred Medicine………………………………………………….138
Human Resources for Rural Health…………………………………..142
BMA Presidency Acceptance Speech:
Fighting the Alligators of Health Inequalities……………………..144
Recent Progress in Air Pollution and Health Studies ………….147
Volcanic Eruptions – Health Implications ………………………….148
1st
International Summit on Tobacco Control
in Asia and Oceania Region……………………………………………..149
IFMSA and 1.2 million Worldwide Medical Students
Fighting Against the HARMFUL USE OF ALCOHOL ….152
Developing Healthcare Technologies for Emerging Markets –
Improving Quality, Access and Cost ………………………………….154
News from the CPME:
Board meeting in Brussels on 22nd
June ……………………………..157
The Training, Qualification and Continuous Professional
Development of the Medical Specialist in the Future,
a Challenge for the UEMS ………………………………………………159
The Hong Kong Medical Association ………………………………..163
Helping to Meet the Challenges of the Future ……………………165
Lessons Learned from the
Estonian Electronic Prescription System ……………………………166
Bringing eye care information to those who need it most ……..167
Contents
113th
German Medical Assembly in Dresden