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Contents
\nEEddiittoorriiaall
\nHealth professionals and society 29
\n\u201cWHO and WHPA need each other\u201d 30
\nWorld Health Professions
\nAlliance holds its first global meeting 32
\nMMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
\nThe Relationship between
\nPhysicians and Commercial Entities 33
\nPoverty and Health 39
\nWWMMAA
\nActivities of the President 40
\nThe 167th WMA Council
\nmeeting in Divonne, 13-15 May 2004 41
\nMMeeddiiccaall SScciieennccee,, PPrrooffeessssiioonnaall PPrraaccttiiccee
\naanndd EEdduuccaattiioonn
\nPreventing preventable chronic disease \u2013
\ninternational developments 44
\nGenomics \u2013 Strategies in the Battle
\nagainst Malaria 46
\nImmunodiagnostics \u2013 High-Technology
\nMedicine at the Bedside 47
\nWWHHOO
\nCommission on Intellectual Property Rights,
\nInnovation and Public Health 50
\nWorld Health Report 2004
\nand the World Health Assembly 50
\nQuality control \u2013 Action against
\nSubstandard and Counterfeit Medicines 51
\nWWMMAA SSeeccrreettaarryy GGeenneerraall
\nFrom the Secretary General’s Desk, May 2004 51
\nRReeggiioonnaall && NNMMAA NNeewwss 52
\nBBooookk RReevviieewwss 54
\nWorldMMeeddiiccaall JJoouurrnnaall
\nVol. No. 2, june 200450
\nOFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
\n00_US_02_2004.qxd 01.07.2004 13:36 Seite 1
\nANDORRA
\nCol\u2019legi Oficial de Metges
\nEdifici Plaza esc. B
\nVerge del Pilar 5,
\n4art. Despatx 11, Andorra La Vella
\nTel: (376) 823 525 Fax: (376) 860 793
\nE-mail: coma@andorra.ad
\nWebsite: www.col-legidemetges.ad
\nARGENTINA
\nConfederaci\u00f3n M\u00e9dica Argentina
\nAv. Belgrano 1235
\nBuenos Aires 1093
\nTel\/Fax: (54-114) 383-8414\/5511
\nE-mail: comra@sinectis.com.ar
\nWebsite: www.comra.health.org.ar
\nAUSTRALIA
\nAustralian Medical Association
\nP.O. Box 6090
\nKingston, ACT 2604
\nTel: (61-2) 6270-5460\/Fax: -5499
\nWebsite: www.ama.com.au
\nE-mail: ama@ama.com.au
\nAUSTRIA
\n\u00d6sterreichische \u00c4rztekammer
\n(Austrian Medical Chamber)
\nWeihburggasse 10-12 – P.O. Box 213
\n1010 Wien
\nTel: (43-1) 51406-931
\nFax: (43-1) 51406-933
\nE-mail: international@aek.or.at
\nREPUBLIC OF ARMENIA
\nArmenian Medical Association
\nYerevan 375 010
\nTel: (3741) 53 48-63
\nE-mail: armainter@hotmail.com
\nAZERBAIJAN
\nAzerbaijan Medical Association
\nAZE 370001, Baku
\nTel: (994 50) 328 1888
\nFax: (994 12) 315 136
\nE-mail: Mahirs@lycos.com \/
\nazerma@hotmail.com
\nBAHAMAS
\nMedical Association of the Bahamas
\nJavon Medical Center
\nP.O. Box N999
\nNassau
\nTel: (1-242) 328 6802
\nFax: (1-242) 323 2980
\nE-mail: mabnassau@yahoo.com
\nBANGLADESH
\nBangladesh Medical Association
\nB.M.A House (Bangladesh Medical
\nAssociation House)
\n15\/2 Topkhana Road, Dhaka
\nBangladesh
\nTel: (880) 2-9566060
\nFax: (880) 2-9568714
\nE-mail: bma@aitlbd.net.com
\nBELGIUM
\nAssociation Belge des Syndicats
\nM\u00e9dicaux
\nChauss\u00e9e de Boondael 6, bte 4
\n1050 Bruxelles
\nTel: (32-2) 644-12 88\/Fax: -1527
\nBOLIVIA
\nColegio M\u00e9dico de Bolivia
\nCasilla 1088
\nCochabamba
\nTel\/Fax: (591-04) 523658
\nE-mail: colmedbo@supernet.com.bo
\nWebsite: www.colmedbo.org
\nBRAZIL
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nR. Sao Carlos do Pinhal 324 \u2013 Bela Vista
\nSao Paulo SP \u2013 CEP 01333-903
\nTel: (55-11) 3266 9391
\nFax: (55-11) 3266 6631
\nE-mail: presidente@amb.org.br
\nWebsite: www.amb.org.br
\nBULGARIA
\nBulgarian Medical Association
\n15, Acad. Ivan Geshov
\n1431 Sofia
\nTel: (359-2) 954 -11 69\/Fax:-1186
\nE-mail: usbls@inagency.com
\nWebsite: www.blsbg.com
\nCANADA
\nCanadian Medical Association
\nP.O. Box 8650
\n1867 Alta Vista Drive
\nOttawa, Ontario K1G 3Y6
\nTel: (1-613) 731 9331\/Fax: -1779
\nE-mail: monique.laframboise@cma.ca
\nWebsite: www.cma.ca
\nWebsite: https:\/\/www.wma.net
\nWMA Directory of National Member Medical Associations Officers, Council
\nAssociation and address\/Officers
\nWMA OFFICERS
\nOF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
\nPresident-elect President Immediate Past-President
\nDr. J. D. Coble Dr. J. Appleyard Dr. K. Myllymaki
\nAmerican Medical Association British Medical Association Finnish Medical Association
\n515 North State St. BMA House,Tavistock Square P.O. Box 49
\nChicago, Illinois 60610, USA London WC1H 9JP, UK 00501 Helsinki, Finland
\nTreasurer Chairman of Council Vice-Chairman of Council
\nDr. K. Vilmar Dr. Y Blachar Dr. T.J. Moon
\nGerman Medical Association Israel Medical Association Korean Medical Association
\nHerbert-Lewin Strasse 1 2 Twin Towers, 35 Jabotisky St. 302-75 Ichon1-dong,Yongsan-gu,
\n50931 K\u00f6ln P.O. Box 3566, Ramat-Gan 52136 Seoul 140-721
\nSecretary General
\nDr. D. Human
\nWorld Medical Association
\nBP63, 01212 Ferney-Voltaire Cedex
\nFrance
\nTel (33) 4 50 40 75 75
\nE-mail: delon@wma.net
\nFax (33) 4 50 40 59 37
\ni see page ii
\nU2_4_02.2004.QXD 01.07.2004 13:31 Seite U2
\nHealth professionals and society
\nThe month of May has seen the 167th meeting of the WMA Council, the first global meet-
\ning of the World Health ProfessionsAlliance, the launch of the World Health Organisation\u2019s
\n2004 Report and the meeting of the World Health Assembly (WHA). In this issue there are
\nreports of the outcomes of some of these meetings and the key decisions taken by these bo-
\ndies. From these it is clear that major health issues confront all parts of the world. They vary
\nfrom the crises facing countries in Sub-Saharan Africa and appeals to support the urgent ac-
\ntion needed to reduce the potential 6 million deaths from AIDS in the next few years \u2013 not
\nto mention the global actions on tuberculosis and malaria prevention and control, to calls to
\ntake action to contain the increase of AIDS in Eastern Europe and to the links between po-
\nverty and health. These were addressed by all these groups.
\nAmongst the topics addressed by the WHAwas also that of migration of health professional
\nworkers from developing countries to developed countries. This has a special significance.
\nSeen against the huge need for physicians, nurses, pharmacists and all health professionals
\nto deliver the care needed by those affected within the disease groups mentioned above, and
\nthe other problems of ensuring equitable provision of health care in all countries, this calls
\nfor particular reflection and action. In so doing, two other problems need to be addressed.
\nThe fundamental changes in society in general, linked to the major advances in medical
\nscience, increased access to knowledge associated with the huge developments in IT and
\nthe consequent increased expectations of those in need of healthcare, have had a substantial
\nimpact on the health professions and professional practice. These are reflected in challen-
\nges to the perceptions of the role of professionals in society, and the need to critically analy-
\nse and often modify the role of individual professionals from their traditional roles. For
\nsome health professionals this may mean increasingly restricting their activities from broad
\nareas traditionally considered to be within their field of activity, to a narrower, more specia-
\nlised area of activity. In other cases, it may call for the development of new skills with an
\nenhanced role and new responsibilities, For most, it requires coordination through team-
\nwork with relevant health professonals. None of these changes is limited to any one profes-
\nsion. For all, there is some degree to which they have to reassess their relationship with so-
\nciety.
\nAt the same time, society needs to consider what it seeks from the health professions.
\nOne consequence of the many scientific advances and developments in health care has been
\nthe increasing recognition of the value of and necessity for teamwork with other professio-
\nnals. This calls for a real mutual recognition of each other\u2019s skills and competencies, not al-
\nways an easy process, but one which is clearly essential if the fundamental values of profes-
\nsionalism and professional practice, notably in ensuring quality of care, are to be recogni-
\nsed and accepted by society as the basis for the relationship with the professions.
\nFor physicians, the societal changes are particularly important. While often the relationship
\nbetween an individual physician and the patient is highly regarded, in today\u2019s changing
\nworld a more critical assessment of the professional is developing, not infrequently reflec-
\nted in a critical attitude, challenging the role and functioning of the profession. At a time
\nwhen there is a shortage of physicians in many parts of the world (with the associated pro-
\nblem of recruitment from developing to developed countries), physicians are under greater
\npressure than ever before. These pressures not only reflect increased workload, but the de-
\nmands of a globalised world, in which market pressures and competition are promoting
\ncontinuing administrative and managerial change, and demanding higher and higher quali-
\nty of care at a lower cost.
\nOne element of professionalism is the delivery of high-quality services. In medicine this re-
\nquires not only the traditional devotion to the best interests of patients and a high standard
\nEditorial
\n29
\nOFFICIAL JOURNAL OF
\nTHE WORLD MEDICAL
\nASSOCIATION
\nHon. Editor in Chief
\nDr. Alan J Rowe
\nHaughley Grange, Stowmarket
\nSuffolk IP14 3QT
\nUK
\nExecutive Editor
\nDr. Ivan M. Gillibrand
\n19 Wimblehurst Court
\nAshleigh Road
\nHorsham
\nWest Sussex RH12 2AQ
\nUK
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nOttostr. 12
\nD-50859 K\u00f6ln
\nGermany
\nBusiness Managers
\nJ. F\u00fchrer, D. Weber
\n50859 K\u00f6ln
\nDieselstra\u00dfe 2
\nGermany
\nPublisher
\nTHE WORLD MEDICAL
\nASSOCIATION, INC.
\nBP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
\nDeutscher \u00c4rzte-Verlag GmbH, Die-
\nselstr. 2, P. O. Box 40 02 65, 50832 K\u00f6ln\/
\nGermany, Phone (0 22 34) 70 11-0,
\nFax (0 22 34) 70 11-2 55, Postal Cheque
\nAccount: K\u00f6ln 192 50-506, Bank: Com-
\nmerzbank K\u00f6ln No. 1 500 057, Deutsche
\nApotheker- und \u00c4rztebank,
\n50670 K\u00f6ln, No. 015 13330.
\nAt present rate-card No. 3 a is valid.
\nThe magazine is published quarterly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or the World
\nMedical Association.
\nSubscription fee \u20ac 22,80 per annum (incl.
\n7 % MwSt.). For members of the World
\nMedical Association and for Associate
\nmembers the subscription fee is settled
\nby the membership or associate payment.
\nDetails of Associate Membership may be
\nfound at the World Medical Association
\nwebsite www.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nK\u00f6ln \u2014 Germany
\nISSN: 0049-8122
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 29
\nof professional services, but also the main-
\ntenance and enhancing of the knowledge,
\nskills and attitudes necessary to achieve
\nthis. In a climate of increased pressures and
\ndemands on work and work practices from
\nboth patients and health care administra-
\ntions, the allocation of dedicated time for
\ncontinuing professional development beco-
\nmes more and more difficult.
\nThis pressure is increased by continuing
\nproblems of limited resources, and demands
\nfor more working time to be devoted to
\n\u201chands on\u201d delivery of services. With
\nincreasing sophistication of medical tech-
\nnology resulting from important scientific
\nadvances, and the resultant raising of public
\nexpectations, the demands for healthcare re-
\nsources are constantly rising. But in the
\nmarket economies of today, in both public
\nand private sectors this leads to constant
\npressures for cost containment. It is there-
\nfore imperative that time as well as resour-
\nces be made available to individual practi-
\ntioners so that their knowledge, skills and
\nattitudes can be maintained and enhanced
\nthrough Continuing Professional Develop-
\nment (CPD), and that they can provide the
\nhighest standards of medical care within the
\nresources available to them. The WMA
\nCouncil has endorsed a proposed resolution
\non Global Standards for Quality Improve-
\nment of Medical Education which will go to
\nthe General Assembly for adoption. The
\nthird document to which this resolution
\nrefers concerns Quality Improvement
\nand Continuing Professional Development
\n(CPD), emphasising the importance of this
\nin meeting the challenges of health needs.
\nWhat has been said in this paragraph is, as
\nset out above, relevant to all health profes-
\nsionals.
\nContinuing education and maintenance of
\nskills is not limited to any one profession.
\nFor example, the initiatives for the control
\nof AIDS and provision of AVRs and the me-
\nasures to \u201cRoll Back Malaria\u201d all require
\nappropriate education of many health pro-
\nfessionals in new approaches, teamwork
\nand organisation, communication techni-
\nques, etc. This is, of course, but one part of
\nthe resources needed to carry out these pro-
\ngrammes.
\nOne question has to be addressed. How far
\ndoes \u201csociety\u201d recognise even the few
\nexamples of health professionals\u2019 problems
\nreferred to above, major disease threats and
\nchanging disease patterns, manpower, rede-
\nployment of skills, continuing professional
\ndevelopmental needs and overall health re-
\nsources?
\nWhen governments support global policies,
\nas for example the Diet, Physical Activity
\nand Health Initiative adopted at the WHA,
\ndo they intend to simply add these to the
\nburdens of health care demands of health
\nprofessionals, or will they state honestly to
\ntheir citizens that this not only requires
\nmore personal responsibility by individuals
\nfor their own health, but also redeployment
\nof current healthcare resources, the recrui-
\nting and training of new professionals and
\nthe retraining of some existing professio-
\nnals? Of course the policy recognises the
\nsubstantial burden of public education need-
\ned, but this of itself requires specialised
\ntraining.
\nThis is, of course, relevant to the fundamen-
\ntal problem of the relationship of health
\nprofessionals to society.
\nFor most of the past century and a half, the
\nrelationship between physicians, individu-
\nals and society as a whole has, on the part of
\nphysicians, been substantially based on a
\npaternalistic humanistic approach. Increa-
\nsingly, in the later years of the 20th century,
\nboth the profession and society began to re-
\ncognise the need for some change. Some of
\nthe developments triggering this need are
\nset out above. Change however can no long-
\ner be treated as a gradual process. Real dia-
\nlogue between the profession and society,
\nat individual, local and national levels, is
\nimperative, at as clear understanding of this
\nrelationship is fundamental to the practice
\nof medicine. Whilst technology may to an
\nincreasing extent intrude on the more holi-
\nstic approach to medical care, the human
\nrace is not a uniform automated group in
\nwhich the functioning of each individual
\nmember is identical, and repair when nee-
\nded can be provided through a simple ad-
\njustment or replacement. To meet the needs
\nof society and achieve the goals set out in
\nthe WHO definition of health, requires
\nmore than technology. It requires the devo-
\ntion and professional knowledge, skills and
\nattitudes of physicians, the necessary tech-
\nnical resources and the cooperation of indi-
\nviduals, both in responsibility for their own
\nhealth and in an equal partnership with the
\nprofessional(s) to meet the health require-
\nments at any one time.
\nThis all constitutes a challenge which calls
\nfor analysis, leadership and dialogue both at
\nnational level and between individual phy-
\nsicians and members of the public, to identi-
\nfy both those traditional qualities of profes-
\nsional practice which need to be preserved
\nand any new ones necessary to ensure a po-
\nsitive partnership between professionals
\nand society contributing to ensuring suc-
\ncessful health care services and contented
\nhealth professionals and patients.
\nAlan Rowe
\nEditorial
\n30
\nWith these words Dr. Lee Jong-wook
\nDirector-General of the World Health
\nOrganization, ended his address at the con-
\ncluding session of the first global confer-
\nence of the World Health Professions
\nAlliance on \u201cTraining for Better Health\u201d.
\nDr. Lee\u2019s speech to this assembly of leaders
\nof the medical, nursing and pharmaceutical
\nprofessions set out below, highlights the
\nimportance of their role in turning health
\nideas into realities and confronting the huge
\nhealth problems facing the world today.
\n\u201cI am very happy to be with you here today.
\n\u201cMaking it happen\u201d is one of our current
\ncommitments, and you are the people who
\ndo just that. It is the work of doctors, nurses,
\npharmacists and other health professionals
\nthat turns health ideas into realities, and
\nstrategies into achievements.
\n\u201cWHO and WHPA need each other\u201d
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 30
\nOur current efforts include providing treat-
\nment, care and prevention services to con-
\ntrol AIDS, TB and malaria; large-scale im-
\nmunization campaigns to eradicate polio;
\nand promoting healthy lifestyles. These and
\nour other programme areas give some idea
\nof objectives we are working for and they
\nprovide the necessary framework for our
\nefforts. Their attainment, however, depends
\nto a very large extent on the work you do
\nwith the users of the health system.
\nIn addition, we have to respond to emergen-
\ncies. SARS and Avian Influenza continue
\nto be a major concern particularly in our
\nWestern Pacific Region. Their control has
\ndepended to a very significant extent on
\nthe efforts of people in your three profes-
\nsions.
\nArmed conflict and natural disasters also
\ncontinue to impose extreme and unforesee-
\nable demands, particularly on doctors and
\nnurses. They can occur in any part of the
\nworld but are particularly severe at present
\nin parts of our Eastern Mediterranean and
\nAfrican regions. Courage and tenacity will
\ncontinue to be key requirements for health
\nleadership in the future, not only in disaster
\nareas but in the many places where health
\nwork is under-funded, under-equipped and
\nunder-staffed.
\nJust as health authorities depend on your
\nprofessions to put policy into practice, he-
\nalth workers need good policies to work
\nwith. The current shortages of human re-
\nsources, especially in developing countries,
\nreflect the need for an enormous effort at re-
\nthinking and rebuilding health services.
\nThis is a unifying theme in all our acitivities
\nat present.
\nOne of our most important current initiati-
\nves is to scale up access to antiretroviral
\ntherapy for people living with HIV\/AIDS.
\nIn December last year, on World AIDS Day,
\nWHO launched the strategy to accelerate
\naccess to antiretroviral treatment. The initi-
\nal objective is to get three million people in
\ndeveloping countries on to treatment by the
\nend of 2005. We are working with the health
\nservices in countries to achieve this, follow-
\ning a double imperative: universal access to
\ntreatment by the earliest possible date, and
\never more effective approaches to preven-
\ntion.
\nThe Millennium Development target for
\nHIV\/AIDS is to halt the spread of HIV and
\nbegin its reverse by 2015. The ratio of trea-
\nted cases to infections prevented is not yet
\nknown but, if for each person receiving
\ntreatment there were just one new HIV in-
\nfection averted, the \u201c3 by 5\u201d initiative will
\nsignificantly speed up the achievement of
\nthis target.
\nProcurement and distribution of the drugs
\nneeded is involving excellent and innovati-
\nve co-operation with the pharmaceutical
\nprofessions.Ahundred thousand health pro-
\nviders and community treatment supporters
\nwill be needed to staff the necessary delive-
\nry systems. They will need to be trained in
\nantiretroviral therapy in accordance with
\nnational standards. It is the medical, nursing
\nand pharmaceutical professions above all
\nthat will meet this training need.
\nWith your leadership, these efforts can
\nmark the beginning of new strength and
\ncoherence in national health systems, and
\nstart the trend towards solving staff
\nshortage problems. The work of the Interna-
\ntional Council of Nurses in mobilizing skil-
\nled health workers in primary health care is
\nalready making a very valuable contribu-
\ntion.
\nOur long-term disease control programmes
\ninclude polio eradication. Here the key to
\nsuccess will be tenacity, both in our collea-
\ngues running the immunisation campaigns
\nand maintaining surveillance, and in our do-
\nnors. We are on the verge of eradication,
\nwith just twenty-two cases to date this year
\nin all of Afghanistan, Egypt, India and Paki-
\nstan.
\nOn the other hand, we have had setbacks in
\nWest and Central Africa, with an explosive
\noutbreak that has paralysed over 500 chil-
\ndren. The leaders in these areas have now
\nrestarted with massive immunisation cam-
\npaigns and strengthening routine services as
\nan emergency measure. In these last stages
\nof the campaign, where so much can be
\neither lost or gained, high levels of commit-
\nment are needed, and the ability to cope
\nwith practical difficulties as they arise. Here
\nleadership, especially at the local level, is
\nthe key to success, as we have seen in every
\ncountry and region where eradication has
\nbeen achieved.
\nEqually important is the work of health pro-
\nmotion. This is particularly needed for the
\nearly prevention of cancer, cardiovascular
\ndiseases, diabetes and other chronic condi-
\ntions. Sixty per cent of the deaths that occur
\nannually in the world are from non-commu-
\nnicable diseases.
\nThe Framework Convention on Tobacco
\nControl, adopted a year ago, was a great
\nachievement. The efforts of the pharmacists
\nand other associations played a very impor-
\ntant part in the success of the negotiations.
\nThe Convention has now been signed by
\n108 countries plus the European Union, and
\nratified by 12. Your efforts are still needed
\nin the countries that have not yet ratified it,
\nto help speed the process on its way. Once
\nratified by 40 countries, the Convention
\nwill come into force and provide valuable
\nsupport for tobacco legislation and policy. It
\nwill help to protect the public \u2013 especially
\nchildren and adolescents \u2013 from one of to-
\nday\u2019s most serious and most unnecessary
\nhealth hazards.
\nAs requested by the World HealthAssembly
\nin 2002, we have prepared the Global Stra-
\ntegy on Diet, Physical Activity and Health,
\nfor consideration and adoption next week.
\nWhen the Strategy is adopted, we will work
\nwith Member States to implement it accor-
\nding to their particular needs.
\nI attended the World Conference on Health
\nPromotion and Health Education in Mel-
\nbourne last month, and was encouraged to
\nsee the high level of support from health
\nprofessionals for healthy lifestyles. Com-
\nmunity involvement is a central principle in
\nthe health-for-all approach and now, more
\nthan ever, it can make a great contribution
\nto reducing some of the current major cau-
\nses of death and disability. It is the health
\nprofessions that provide the guidance for
\nthis broader effort.
\nThe theme of World Health Day in April
\nthis year was Road Safety. It drew attention
\nto the 1.2 million deaths and up to 50 mil-
\nlion injuries that occur on the roads each
\nyear. The Government of France hosted the
\nglobal World Health Day event in Paris,
\nwith eloquent support from President Chir-
\nac. The highlight of the event was the
\nlaunch of the WHO and World Bank World
\nreport on road traffic injury prevention.
\n31
\nEditorial
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 31
\nAt a historic meeting in Geneva on 15-16
\nMay, the World Health Professions Alliance
\nheld its first global conference under the title
\n\u201cTeaming up for health\u201d The meeting
\nbrought together for the first time at global
\nlevel leaders representing member organisa-
\ntions of the International Council of Nurses
\n(ICN), the International Pharmaceutical
\nFederation (FIP) and the World Medical
\nAssociation (WMA). Sixty-five countries
\nwere represented by more than 250 people,
\nincluding observers from a number of other
\nhealth professions and non-governmental
\nagencies.
\nFrom the enthusiasm in the hall it was clear
\nthat the organisers had gone a long way
\ntowards the objective of motivating health
\nprofessionals and their organisations to work
\ntogether at local, national and international
\nlevels to respond to the huge health chal-
\nlenges facing the world today.
\nSpeakers were drawn from the health profes-
\nsions, policy makers, patients\u2019 disease group
\norganisations and supranational bodies, both
\nintergovernmental and non-governmental.
\nFrom the opening remarks of the three pro-
\nfessions, it was clear that few doubted that a
\nunited voice from the professionals deliver-
\ning health care could be more effective when
\ndealing with the huge health problems facing
\nthe world today, which require governments
\nto engage in positive actions for humanity at
\nlarge, not only for their own communities.
\nThose present demonstrated this in a positive
\nway, responding to the clear statement of
\nreality in which Stephen Lewis, UN Special
\nEnvoy for HIV\/AIDS in Africa, underlined
\nthe immediacy of the crisis in Africa, and the
\ngrave risk of this extending in a short time to
\nthe Indian sub-continent and to China. The
\ncertain death of six million people in Africa
\nfrom HIV\/AIDS in the next few years, and
\nthe increasing number of orphans, were
\nillustrations which could not be ignored. The
\nConference adopted unanimously the fol-
\nlowing resolution:
\n\u201cRecognising that
\n– the current HIV\/AIDS pandemic presents
\nan extraordinary human, human rights
\nand humanitarian crisis;
\n– especially women and children are
\naffected;
\n– focused prevention programmes can sig-
\nnificantly reduce new infections;
\n– treatment options allow HIV positive
\npersons to lead a quality life;
\n– without the appropriate prevention and
\ntreatment this crisis will worsen to a
\nlevel where some countries\u2019 populations
\nmay be decimated and their futures
\ndestroyed; and
\nthat countries at the heart of the HIV\/AIDS
\npandemic, provided that they are supported
\nwith the necessary financial and human
\nresources, can rise to the challenge.
\nTherefore we, as leaders of the medical,
\nnursing and pharmacy professions, call on
\nall governments, intergovernmental agen-
\ncies and health professionals to recognise
\nthe scale of the tragedy, to stop procrastinat-
\ning and to commit immediately, the neces-
\nsary funds and resources against HIV\/AIDS.
\nAs health professional leaders we give our
\nfull commitment to this cause and call on all
\nphysicians, nurses and pharmacists to act as
\nstrong advocates and social leaders in the
\nwar against HIV\/AIDS.\u201d
\nIn a final address to the meeting, the Direc-
\ntor-General of the World Health Organiza-
\ntion (WHO), Dr. Lee Jong-wook, acknow-
\nledged and appreciated the resolution set
\nout above, which responded to the concerns
\nexpressed clearly in the World Health Re-
\nport 2004 and to which he had referred in
\nhis presentation.
\nNote:
\nThe World Health Professions Alliance
\nbrings together medicine, nursing and phar-
\nmacy through their representative interna-
\ntional organisations, the International
\nCouncil of Nurses (ICN), the International
\nPharmaceutical Federation (FIP) and the
\nWorld Medical Association (WMA), and
\nrepresents more than 20 million health pro-
\nfessionals worldwide.
\nThe WHPA website is: www.whpa.org
\ne-mail: info@whpa.org
\n32
\nEditorial
\nAs an immediate follow-up to this success-
\nful World Health Day, the UN General
\nAssembly met in plenary session on the glo-
\nbal road safety crisis. They adopted a reso-
\nlution inviting WHO to co-ordinate the
\nUN road safety effort. Your support in
\npromoting the many practices that can redu-
\nce road traffic accidents will be much
\nneeded.
\nI could go on at length, but I\u2019d prefer to lea-
\nve as much time as possible for discussion.
\nSo let me conclude by saying: our organiza-
\ntions need each other. Your work is much
\nmore highly appreciated than you are pro-
\nbably aware of most of the time. I\u2019m very
\nglad we have the opportunity of this Sym-
\nposium to co-ordinate our efforts.\u201d
\nDuring the WHPA meeting an informal poll of participants\u2019 opinion revealed that over
\nthe next five years they expected heart disease, obesity and cancer to be top priorities in
\nboth developing and developed countries. They also identified dietary change, unequal
\naccess to information, and trade policies as top trends affecting these health challenges.
\nOn the other hand, out of a list of 16 health challenges, HIV\/AIDS was rated lower at 10
\n& 11, suggesting that fighting the pandemic is still not regarded as an urgent problem by
\nsome health professionals despite unanimous support by participants in the resolution on
\nthis subject. Dr. Delon Human commented that this choice suggested that \u201chealth pro-
\nfessionals were underlining the importance of the lifestyle changes that the world is wit-
\nnessing \u2013 an increasingly sedentary life and unhealthy eating\u201d.
\nWorld Health Professions Alliance
\nholds its first global meeting
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 32
\nThere is general acceptance that the rela-
\ntionship between physicians and industry is
\ncomplex, and one that has been subject to
\nincreasing scrutiny, in particular in the past
\ndecade.
\nSuch scrutiny has been substantially focu-
\nsed upon the relationship between the phar-
\nmaceutical industry and practising physici-
\nans. Potential problems can arise when phy-
\nsicians are visited by representatives of the
\npharmaceutical industry who, by offering
\ngifts such as equipment, travel expenses or
\nhospitality at medical or scientific mee-
\ntings, offer the possibility of influencing the
\nprescribing of individual physicians.
\nWhile there are substantial differences in
\npractices from one country to another, the
\ndirect relationship between the pharmaceu-
\ntical or other sectors of the technical health
\ncare industry and individual physicians who
\nprescribe or use their products is a real phe-
\nnomenon that can raise serious ethical is-
\nsues.
\nUS papers suggest that an estimated 11 bil-
\nlion dollars is spent by pharmaceutical com-
\npanies each year in promotion and marke-
\nting, of which 5 billion goes to sales repre-
\nsentatives. One recent US report put the fi-
\ngure as high as 9 billion, with some top
\nfirms spending more than 1 billion on their
\nsales representatives each year [1]), inclu-
\nding an outlay of approximately $8000-
\n13,000 per physician. [2]
\nAnother USA study states that physicians
\nmeet with industry representatives about 4
\ntimes a month, a phenomenon that begins
\nas early as residency, and although the fre-
\nquency with which physicians receive gifts
\nand samples decreases as they enter prac-
\ntice, the frequency of receiving honoraria,
\nconference travel and research funding
\nincreases. Both residents and established
\nphysicians frequently use promotional
\nmaterial. [2]
\nHowever, it can be argued that contact
\nbetween physicians and the pharmaceutical
\nindustry is necessary. Industry representa-
\ntives are a convenient and efficient, if not
\nalways the most reliable, way for physi-
\ncians to learn about new medications. In
\naddition, there is little doubt that without
\nthe support of industry, many scientific and
\nmedical developments would not be possi-
\nble For example, 60% of biomedical
\nresearch and development in the USA is
\nprivately funded. [3] Governments and aca-
\ndemic institutions often lack the resources
\nto provide similar support for research.
\nThe increasingly aggressive advertising tac-
\ntics of the pharmaceutical industry, and the
\nnecessity that physicians remove them-
\nselves from any real or suggested conflict of
\ninterest that could potentially affect the
\nhealth of patients, requires that limitations
\nand guidelines be established and adhered to.
\nBecause conferences, even more than other
\nissues, are so often international, and
\ninvolve physicians from various countries,
\nand because sponsorship for conferences
\noften comes from pharmaceutical compa-
\nnies located outside the hosting country,
\nthere is a need for formal guidance at the
\nglobal level, analogous to similar instru-
\nments issued by the WMA for the benefit of
\nboth practising physicians and society as a
\nwhole. There are already a number of
\nsources of advice in this area such as guide-
\nlines from WHO, national medical associa-
\ntions and the pharmaceutical industry itself,
\nbut there is clearly a case for one set of
\nprinciples to be established for the medical
\nprofession globally.
\nWhy such global guidelines
\nfrom the medical profession
\nare needed
\nAs in all matters ethical, reasonable men
\n(and women) can differ. In such cases,
\nwhere there are legitimate interests on both
\nsides and the boundaries of what is appro-
\npriate are not always obvious, there is a
\nneed for clear guidelines.
\nWhile it can be argued that the resources
\nprovided by commercial entities for
\nresearch, continuing medical education, etc.
\nare indispensable, the funding of such
\nactivities, not to mention the offering of
\ngifts to doctors by companies whose inter-
\nests are not purely altruistic in nature, pose
\nethical problems.
\nThe linking of gifts, hospitality or other
\nperks directly to prescribing practices is
\nclearly indefensible and unethical.
\nHowever, there is evidence that, even
\nwhere there is no direct link, gifts do create
\na feeling of social obligation that may sub-
\ntly influence prescribing behavior. [4] On
\nthe most basic level, gifts make one feel
\ngood, and these feelings may be subtly
\ntransferred to the sales representative or
\ncompany\u2019s product. [5] Even \u201cgifts\u201d such
\nas funding for conferences may influence a
\ndoctor\u2019s choice of medical conferences, and
\nthus, the information to which he or she is
\nexposed. [5]
\nUltimately, the cost of any such activity by
\na commercial enterprise in the health field
\nis borne either directly or indirectly by the
\npatients as consumers of the enterprises\u2019
\nproducts. These patients\/consumers may
\nnot be aware that their physicians are
\nreceiving these benefits.
\nThe funding of such benefits to physicians
\nalso damages the image of the profession.
\n[4] The position paper of the American
\nCollege of Physicians-American Society of
\nInternal Medicine (ACP-ASIM) on physi-
\ncian-industry relations states: \u201cA perception
\nthat a physician is dispensing medical
\nadvice on the basis of commercial influence
\n33
\nMedical Ethics and Human Rights
\nMedical Ethics and Human Rights
\nThe Relationship Between Physicians and
\nCommercial Entities
\nMALKE BOROW, Adv.
\nIsrael Medical Association
\nAn overview based on a paper presented to the WMA Council
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 33
\n34
\nis likely to undermine a patient\u2019s trust, not
\nonly in the physician\u2019s competence but also
\nin the physician\u2019s pledge to put patients\u2019
\nwelfare ahead of self-interest.\u201d [6] Even if
\nthere is no direct effect on a physician\u2019s
\nbehavior, the fact that this trust is damaged
\nis reason enough to be wary. In fact, limits
\non the acceptance of gifts to avoid the
\nappearance of impropriety are prevalent in
\nother parts of society, such as holders of
\npublic office in the federal government and
\nmany private companies. [5]
\nStudies have shown that the existence of
\nguidelines has a tangible effect on physici-
\nans\u2019 attitudes and behaviour towards phar-
\nmaceutical representatives. The difference
\nis noticeable, beginning in the training peri-
\nod. In a random sample of 378 residents
\nfrom 14 US family medicine training pro-
\ngrams, half of which had written policies in
\nplace that restricted residents\u2019 behaviour re-
\ngarding pharmaceutical representatives,
\nand half that had no such policies, there was
\na marked difference in attitudes. Twice as
\nmany residents of \u201cnon-restricted\u201d pro-
\ngrams felt that the information received
\nfrom pharmaceutical representatives was of
\ngood quality, that social activities sponso-
\nred by them were beneficial or that contact
\nwith pharmaceutical representatives was
\ngenerally beneficial to the residency expe-
\nrience. In addition, more than twice as
\nmany residents in non-restricted programs
\nfelt that meals, gifts or social outings fun-
\nded by industry were appropriate. [7]
\nThis difference in attitude continues even
\nafter the training period. In a survey of
\nCanadian physicians, some of whom had
\nbeen exposed to such policies, and some of
\nwhom had not, it was found that residents
\nwho had more contact with pharmaceutical
\nrepresentatives during training were more
\nlikely to perceive the information provided
\nby such representatives as beneficial, and to
\nhave greater contact with them in later
\nyears. [8]
\nExisting guidelines
\nCodes of conduct regarding the relationship
\nbetween physicians and the pharmaceutical
\nindustry tend to be written by doctors, i.e.
\nmedical associations, institutions or regula-
\ntory authorities, or by the pharmaceutical
\nindustry itself.
\nCodes developed by industry are generally
\nvoluntary, although they are often rein-
\nforced by complaints procedures with pos-
\nsible sanctions [9]. Such codes, although
\ndiscouraging egregious conduct such as
\ndirect cash payments to doctors, often do
\nlittle more than endorse existing modes of
\nbehavior. [10] For example, under the new
\nvoluntary code of PhRMA (a group of phar-
\nmaceutical industry representatives), if a
\ncompany flies 300 doctors to a golf resort,
\nall expenses paid, and educates them about
\nthe company\u2019s latest drug so the doctors
\nmay then be \u201cpaid spokesmen\u201d for the drug,
\nthis would be entirely legitimate. [10, 11]
\nMany countries with major pharmaceutical
\nindustries such as Britain, Australia and the
\nUnited States have national codes that usu-
\nally prohibit companies from giving doc-
\ntors incentives to prescribe their products
\n(9). In addition, the relevant European
\nUnion Directives on Advertising
\n(92\/28\/EEC & 84\/450\/EEC) also restrict
\nthe nature and value of such \u201cpromotional
\nactivity\u201d. For those countries that lack
\nnational codes, there are two major sets of
\ninternational guidelines: the WHO\u2019s
\nCriteria for Medicinal Drug Promotion and
\nthe Code of Pharmaceutical Marketing
\nPractice, put out by the International
\nFederation of Pharmaceutical Manu-
\nfacturers Associations. [9]
\nWhile the focus of guidelines put out by the
\npharmaceutical industry is generally on
\nmarketing, codes put out by medical profes-
\nsional organizations tend to focus more on
\ncommercially funded research. There are
\nalso guidelines written by organizations
\nsuch as the American Academy of
\nPharmaceutical Physicians and the Royal
\nCollege of Physicians Faculty of
\nPharmaceutical Medicine. [9]
\nIt must be noted that even where guidelines
\nexist, in some countries physicians are
\noften unaware of them [2]. For instance, in
\na US study only 23-50% of medical resi-
\ndents knew of the existence of guidelines
\nand only 62% of practising physicians were
\naware of at least one guideline [12]. In
\naddition, while awareness of guidelines did
\nnot necessarily elicit compliance, enrol-
\nment in a residency program that mandated
\ncompliance with the guidelines, did. [2]
\nNational regulating patterns
\nfor physicians
\nThe range of options for regulating the
\nphysician-industry relationship varies from
\ncountry to country:
\nDenmark \u2013 The Danish Medical
\nAssociation and the Pharmaceutical
\nIndustry (LIP) have signed an agreement on
\nCooperation between the Profession and
\nthe Industry, which is substantially con-
\ncerned with scientific and medical meet-
\nings. Commenting that close cooperation
\nbetween the two bodies \u201cis necessary to
\ndevelop new and better pharmaceutical
\ntherapy and ensure that existing therapies
\nare used in the best possible way in patient
\ntreatment\u201d, both parties find that this coop-
\neration should \u201cbe conducted in such a
\nmanner that it does not include any aspect
\nof pressure between the parties and that the
\nparties are independent of each other\u201d. It
\nincorporates conditions concerning trans-
\nparency and strict accountability, including
\nrequiring the company organising or co-
\norganizing medical or scientific meetings to
\nnotify the National Board of Drug
\nAdvertising (NMI) \u2013 a statutory body \u2013 with
\nthe details of the arrangement. The NMI and
\nthe DMA (Medical Ethics Board) are
\nrespectively responsible for dealing with
\nviolations by the profession or the industry.
\nFrance \u2013 The French Medical Association
\nhas tightened its rulings on issues relating to
\ngifts and conferences. For instance, a doctor
\nshould not accept gifts in cash or otherwise,
\nunless they are small gifts of nominal value
\n(not exceeding 30 Euro). Contributions to a
\ndoctor\u2019s attendance at a scientific conferen-
\nce are authorised if they are reasonable,
\nand\/or if the selection of a remote (i.e., cost-
\nly) location is justified. [13]
\nSpain \u2013 A body representing the Spanish
\npharmaceutical industry issued a code of
\npractice in 2002 stating that drug compa-
\nnies may offer medically related gifts worth
\nup to 19 Euro. Expenses for meetings may
\nnot include social or cultural events or
\nexpenses of spouses. [13]
\nIndia \u2013 The practice of offering gifts to
\ndoctors, including foreign trips and outright
\ncash gifts, is widespread in India, especial-
\nly in \u201cbig money\u201d areas such as cardiology.
\nMedical Ethics and Human Rights
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 34
\nThe Medical Council of India, in its Code
\nof Ethics released March 2002, does not
\nrelate to doctors accepting gifts or cash
\nfrom drug companies. [13]
\nIsrael \u2013 Israel has historically had selected
\nguidelines written by the pharmaceutical
\nindustry, the government, the health funds
\nand the medical profession. Over the past
\nyear, several events occurred that portend
\nchanges in the current status. The Israeli
\nParliament has begun deliberations on a
\nproposed law that seeks to codify the rela-
\ntionship between physicians and the phar-
\nmaceutical industry. The Israel Medical
\nAssociation (IMA) opposes this law, feel-
\ning that legislation is not the proper place
\nfor such guidelines, that the guidelines are
\ntoo far-reaching and that the profession is
\nthe appropriate body to draft such guide-
\nlines. Concurrently, the IMA has released a
\nset of updated, encompassing guidelines. It
\nis also in the process of finalizing an agree-
\nment between the IMA, the pharmaceutical
\nindustry and the providers and insurers of
\nhealth care, that would set guidelines
\nacceptable to all parties and define to whom
\neach party would be accountable. It is felt
\nthat such a formal agreement would have a
\ngreater effect than guidelines put out by
\nindividual parties.
\nSingapore \u2013 The Singapore Medical
\nAssociation, in conjunction with the
\nSingapore Association of Pharmaceutical
\nIndustries, released in August 2000 a
\ndetailed statement regarding the relation-
\nship between the medical profession and
\nthe pharmaceutical industry. The statement
\nbegins by recognising both groups as part-
\nners in health care delivery, but adds that
\nstrict rules for professional conduct
\nbetween the two parties is necessary in
\norder to prevent abuses. The physician must
\nalways be known by his or her patients to
\nbe impartial and not influenced by commer-
\ncial gain when determining the appropriate
\ntreatment for individual patients. Therefore,
\nphysicians must ensure that their profes-
\nsional judgement is in no way clouded by
\ngifts, hospitality or the like. Educational
\nconferences must be first and foremost sci-
\nentific and educational in nature; the level
\nof hospitality must be secondary, and
\nshould not exceed that which physicians
\nmight normally pay for themselves. In addi-
\ntion, making hospitality or other benefits
\nconditional on prescribing performance is
\nprohibited. Any form of sponsorship of
\nsuch events should be clearly disclosed to
\nparticipants.
\nIn accordance with the principles of good
\npractice, scientific research carried out in
\nconjunction with the pharmaceutical indus-
\ntry must be properly planned and executed,
\nincluding approval by an ethics committee,
\nand subject to specific conditions detailed
\nin the statement.
\nGifts and other promotional items given to
\nphysicians by drug companies should pri-
\nmarily benefit patients, be modest in value
\nand be related to the physician\u2019s work. Cash
\npayments as incentives for prescribing are
\nunacceptable. Medical books may be given
\nto physicians if they serve a genuine educa-
\ntional function.
\nTravel expenses to overseas medical con-
\nferences may be offered if the subject of the
\nconference is directly related to the doctor\u2019s
\nwork. They should not be offered if they are
\nconditional on the doctor\u2019s past or present
\nprescribing habits or upon any obligation to
\npromote a specific product, nor should they
\ninclude expenses for additional days or for
\naccompanying persons such as spouses.
\nReasonable honoraria and reimbursement
\nof travel and out-of-pocket expenses for
\nspeakers are acceptable.
\nPhysicians invited to lecture at industry-
\nsponsored events are also subject to strict
\nguidelines regarding the content and pre-
\nsentation of their talks. Every effort must be
\nmade to ensure that the talk is professional-
\nly sound, objective and not influenced by
\nthe sponsoring company. For instance, the
\ncontent of the lecture should be reviewed
\nby others, and any conflict of interest must
\nbe declared. [14]
\nAustralia \u2013 Australia has ethical guidelines
\nprepared by the AMA, by the Royal
\nAustralasian College of Physicians and by
\nthe pharmaceutical industry, represented by
\nAPMA, now known as Medicines Australia
\n\u2013 a body representing over 50 companies
\n(about 95% of the prescription drug mar-
\nket). The latter\u2019s code, although monitored
\npredominantly by industry, involves the
\nTherapeutic Goods Administration, the
\nAustralian Medical Association and the
\nRoyal College, in its complaints body and
\nmonitoring and review process. [15]
\nThe code of the pharmaceutical industry, in
\nparticular, is quite detailed and comes with
\nguidelines regarding each section. Under
\nreforms to the pharmaceutical industry\u2019s
\ncode enacted in 2002, all non-essential hos-
\npitality is prohibited. Thus when sending
\ndoctors to conferences, the code provides
\nthat travel may be subsidised provided the
\nmeeting is directly related to the doctor\u2019s
\narea of expertise. In addition, travel within
\nAustralia should be economy class, abroad
\nit may be economy or business, a reason-
\nable level of accommodation may be
\noffered plus travel costs, but the payment of
\nexpenses for family members is prohibited.
\nThe Code states that hospitality must be
\nsecondary to the educational purpose of the
\nmeeting. The guidelines expand upon this
\nin great detail, even going so far as to list
\ntypes of acceptable foods. \u201cAn appropriate
\nlevel of hospitality would be what is
\nexpected in a normal business meeting. For
\nexample, open sandwiches, rolls and quich-
\nes would be appropriate for lunch. Lavish
\nhospitality such as lobster and caviar would
\nnot be appropriate.\u201d[16]
\nThe Australian Medical Association guide-
\nlines state that any professional interaction
\nbetween doctors and industry should be pri-
\nmarily for the advancement of the health of
\npatients, rather than for any personal self-
\ninterest. Specifically, the guidelines state,
\ninter alia, that before becoming involved in
\nany research project sponsored by industry,
\na physician must satisfy himself that the
\nproject has genuine merit, is ethically
\ndefensible, socially responsible and scien-
\ntifically valid. The project must also be
\nreviewed by an appropriate review body.
\nAll moneys should be held in trust and sub-
\nject to audit and review by the ethics com-
\nmittee. CME activities must address the
\neducational needs of the targeted medical
\naudience, not just the promotional needs of
\nthe contributing pharmaceutical company.
\nThe programme for such activities may
\nacknowledge, but not excessively promote,
\nthe company\u2019s product.
\nDoctors may not accept personal gifts from
\nthe pharmaceutical industry but may accept
\n35
\nMedical Ethics and Human Rights
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 35
\n36
\neducational materials appropriate to their
\narea of practice.
\nThe Code of the Royal Australasian
\nCollege of Physicians is quite similar, but
\ngoes into greater detail; e.g., regarding gifts
\nit adds that payment for dinners, entertain-
\nment or expenses associated with daily liv-
\ning may not be accepted and gives great
\ndetail regarding industry-sponsored travel
\nand attendance at meetings.
\nUnited States \u2013 In 1990, following a
\ndecade of lavish gifts, cash and trips to lux-
\nury resorts offered to physicians by the
\npharmaceutical industry, both the AMA and
\nthe American College of Physicians
\nreleased guidelines to prevent inappropriate
\ngift giving, later included in the AMA\u2019s
\ncode of medical ethics. These guidelines
\nwere adopted by the industry, represented
\nby PhRMA. The AMA supplemented their
\nguidelines with a series of questions and
\nanswers designed to clarify the issues. Gifts
\nof minimal value (less than $100) and relat-
\ned to the physician\u2019s work (such as pens
\nand notepads) or intended for the patient\u2019s
\nbenefit (such as medical textbooks) are per-
\nmitted under the guidelines. Cash may not
\nbe accepted, and no gifts may be accepted if
\nthere are strings attached. Pharmaceutical
\ncompanies may underwrite CME confer-
\nences that serve a genuine educational func-
\ntion and are not lavish in their attending
\nhospitality; disclosure of financial support
\nshould be made. Despite the detailed guide-
\nlines of the code, an AMA-sponsored sur-
\nvey in 2000 indicated that up to half of
\nAmerican physicians were unfamiliar with
\nit, and many routinely ignore it. [17]
\nAs mentioned above, the pharmaceutical in-
\ndustry, represented by PhRMA, has also is-
\nsued guidelines regarding interactions be-
\ntween healthcare professionals and the phar-
\nmaceutical industry, the most recent of
\nwhich took effect in July 2002. Their new
\ncode makes it clear that interactions between
\nthe two groups must be intended to benefit
\npatients and enhance the practice of medici-
\nne. The code permits professional presenta-
\ntions by industry that provide valuable
\nscientific and educational benefits (a term
\nthat can, of course, be loosely applied) and
\nassumes that such presentations occur at ve-
\nnues conducive to providing scientific or
\neducational information. Modest meals, but
\nno other entertainment, may accompany the-
\nse presentations. The code also specifies that
\ngifts worth less than $100 may be offered to
\ndoctors if they are primarily for the benefit
\nof patients. Consulting arrangements with
\nphysicians are allowed if they serve a legiti-
\nmate need. The PhRMA code, like the AMA
\ncode, also contains FAQs. [11]
\nIn addition to the voluntary codes estab-
\nlished by the AMA and PhRMA, the
\nDepartment of Health and Human Services\u2019
\nOffice of Inspector General issued in 2002
\na 44-page document dealing with the mak-
\ning and marketing of pharmaceutical prod-
\nucts. Unlike the AMA and PhRMA codes
\nwhich are totally voluntary and which the
\nOIG refers to as a \u201cgood starting point\u201d, the
\nOIG guidelines, although apparently volun-
\ntary, can prompt government investigations
\nif not adhered to. [18]
\nUnited Kingdom \u2013 In the UK, the prevail-
\ning Code of Practice is that of the
\nAssociation of the British Pharmaceutical
\nIndustry (ABPI), the most recent version of
\nwhich was released in 2001 in consultation
\nwith the British Medical Association. The
\nABPI code states that gifts from companies
\nmust cost less than 6 pounds (about 9 US
\ndollars), and be relevant to the doctor\u2019s
\nwork. The accompanying text explains that
\n\u201cpens, diaries and surgical gloves are
\nacceptable, while table mats, plant seeds
\nand music CD\u2019s are not.\u201d[19] The ABPI
\ncode also contains guidelines on research.
\nSelf-policing of the ABPI code seems to
\nwork. Complaints are reviewed by the
\nPrescription Medicines Code of Practice
\nAuthority, which is independent of the
\nABPI and comprises 12 members from
\npharmaceutical companies, six independent
\nmembers and a chairman. [9]
\nWorld Health Organization \u2013 WHO re-
\nleased in 1999 a preliminary version of
\nguidelines on interaction with commercial
\nenterprises. Although the guidelines deal
\nwith interactions between WHO as an
\norganisation, and commercial enterprises of
\nvarious sorts (as such they cover a broader
\nbase than do guidelines relating to the typi-
\ncal individual doctor and the pharmaceuti-
\ncal industry), there is still much to be
\ngleaned from these guidelines. It should be
\nnoted, however, that the WHO guidelines
\nare stricter than the typical doctor-pharma-
\nceutical industry guidelines. For instance,
\nWHO receptions and similar functions may
\nnot be paid for at all by commercial enter-
\nprises.
\nIn companies where codes or other guideli-
\nnes exist, physicians may be subject to sanc-
\ntions for failing to adhere to such guidelines.
\nFor example, in Germany, thousands of doc-
\ntors in 100 public hospitals were accused of
\naccepting money and gifts from SmithKline
\nBeecham, an international drug firm, and
\nwere subsequently investigated. [20] In the
\nNetherlands, also, the marketing code has
\nresulted in legal cases against pharmaceuti-
\ncal companies and individual doctors in
\nmatters of giving and receiving excess ho-
\nspitality and other drug promotion \u201cbonu-
\nses.\u201d[13, 21] Italy and France have also seen
\ninvestigations of cases where doctors were
\ngiven computers, trips and cellular phones
\nfor prescribing certain drugs.
\nSpecific Issues
\nGifts
\nGifts from industry are problematic
\nbecause they are so widespread and because
\nof their potential to influence a physician\u2019s
\nobjectivity and\/or prescribing practices.
\nMedical decisions, by their nature, must be
\npredicated on objective, scientific informa-
\ntion (coupled, of course, with the patient\u2019s
\nlifestyle and preferences) and not influ-
\nenced by external factors and biases, such
\nas insurer economics, personal financial
\ninterests (kickbacks) or the largesse of drug
\ncompanies. Not only does \u201cnon-rational\u201d
\nprescribing, as it is referred to in the litera-
\nture, result in higher and often unwarranted
\ndrug costs, it can even have serious delete-
\nrious effects such as the over-prescribing of
\nbroad-spectrum antibiotics. [1, 22].
\nSeveral studies have examined the effect of
\ngifts from pharmaceutical companies on
\nphysician behaviour. Research shows a
\nstrong correlation between receiving indus-
\ntry benefits and favouring specific products
\n[6, 2]. However, interestingly, physicians
\nclaim that they are not affected by such
\ngifts [6, 23, 2, 24]. Even more interestingly,
\nMedical Ethics and Human Rights
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 36
\nalthough most physicians do not view
\nthemselves as subject to bias, they do admit
\nthat conflicts of interest might influence
\nother physicians\u2019 decisions [24, 25].
\nIn particular, gifts of nominal value such as
\npens, notepads or mugs are viewed as not
\naffecting a physician\u2019s behaviour. In addi-
\ntion, certain \u201cgifts\u201d such as drug samples
\nare not really viewed as gifts at all, since
\nthey are medically related and intended in
\nessence for the patient rather than the physi-
\ncian. One might even suggest that drug
\nsamples serve to promote equitable access
\nin health care, since they allow patients to
\ntry out products before committing them-
\nselves to an expensive product. [6]
\nHowever, such products are really intended
\nto induce the physician to prescribe the new
\nproduct, and research shows that when
\npatients run out of a free sample, physicians
\nare more likely to prescribe that same prod-
\nuct rather than a less expensive one such as
\na generic product. [26] In essence, all
\nindustry-supplied medical information or
\nproducts are promotional. In addition, as
\npreviously stated, all personal gifts estab-
\nlish an implied social contract of obligation
\nand expected reciprocation. [4]
\nOne position paper, put out by the
\nAmerican College of Physicians in con-
\njunction with the American Society of
\nInternal Medicine, lists the following ques-
\ntions as helpful in gauging whether a gift
\nrelationship is ethically appropriate: \u201cWhat
\nwould my patients think about it, what is
\nthe purpose of the industry offer, and what
\nwould my colleagues think about the
\narrangement?\u201d
\nStudies have shown, in fact, that patients\u2019
\nattitudes and physicians\u2019 attitudes towards
\naccepting gifts are not always the same.
\nOverall, patients tended to find gifts less
\nappropriate than did physicians \u2013 this was
\ntrue even for gifts that existing guidelines
\ndeem acceptable, such as pens, medical
\nbooks, and conference meals. [12] About
\nhalf the patients in one study were aware
\nthat physicians receive gifts from the phar-
\nmaceutical industry. Among those who
\nwere not aware, 24% felt that this knowl-
\nedge changed their perception of the profes-
\nsion. However, more than 90% of physi-
\ncians accepting a gift were willing to have
\nit generally known, indicating that perhaps
\nphysicians overestimate patients\u2019 feelings
\nregarding the appropriateness of gifts. [12]
\nIf one accepts that modest gifts that
\nenhance medical practice or knowledge are
\nacceptable, can one set a limit or specific
\nparameters as to what is acceptable? It is
\ndifficult to set an exact amount or descrip-
\ntion, although several countries do so, as
\nmentioned above. However, it is generally
\naccepted that inexpensive gifts for office
\nuse such as pens, notepads or calendars
\nmeant for educational purposes or patient
\ncare such as medical books are more
\nacceptable.
\nIn one USA study, researchers questioned
\nover 100 residents in internal medicine con-
\ncerning their attitudes towards nine promo-
\ntions or gifts offered by pharmaceutical
\ncompanies. Most residents considered 7 of
\nthe 9 items as appropriate (the exceptions
\nbeing luggage and funding for travel to
\nCME conferences). Where differences in
\nthe appropriateness of a gift were per-
\nceived, they were based more on cost and
\nless on its educational or professional
\nvalue. As a result, 83% felt that an inexpen-
\nsive but not educational item such as a pen
\nwas appropriate, whereas an expensive yet
\neducational sponsorship for travel to a con-
\nference was inappropriate. The authors sug-
\ngest as an explanation for this phenomenon
\nthat some physicians may think that expen-
\nsive gifts create an appearance of impropri-
\nety. Others may object to the cost of gifts
\nbeing passed on to patients, and yet others
\nmay perceive a strong correlation between
\nthe value of a gift and its potential to influ-
\nence prescribing behaviour. [25]
\nIn contrast, another US study refutes the
\nnotion that gifts of lesser value or gifts
\nrelated to a physician\u2019s practice are less
\nproblematic than others. It states, as its
\nbasic premise, that the biasing effect of
\naccepting gifts is accepted as a matter of
\ndeliberate choice, that physicians are delib-
\nerately choosing to do something unethical.
\nIt is therefore not surprising that physicians
\nobject so vociferously to the suggestion that
\ngifts create bias. Therefore, guidelines that
\nlimit gifts to those of nominal value and
\nrelated to the practice of medicine stem
\nfrom the assumption that such gifts are not
\ntempting enough to influence a physician\u2019s
\nprescription choices. However, the authors
\nmaintain that this deliberate choice view is
\ninconsistent with the social science
\nresearch which shows that even when indi-
\nviduals attempt to be objective, they are
\nsubject to unintentional bias. Therefore,
\nsmall gifts may be influential. In fact, why
\ndo pharmaceutical firms offer these gifts if
\nnot to influence a physician\u2019s behavior in
\nsome respect? The figures cited above for
\nthe amount of money spent each year by the
\npharmaceutical industry are clear evidence
\nthat the industry expects and intends that
\nthese costs produce some marketing bene-
\nfit. Because physicians are unaware of this
\ninfluence, they do not take steps to correct
\nit. As such, policies that make sense if bias
\nis seen as a matter of deliberate choice are
\nunlikely to be effective if bias is uninten-
\ntional and unconscious. [24]
\nThe authors of this study, members of the
\nDepartment of Social and Decision
\nSciences at Carnegie Mellon University in
\nPittsburgh, cite several earlier studies that
\nshow that individuals are unable to remain
\nobjective even when they are motivated to
\nbe impartial, and even when they are
\nexplicitly instructed about it. This shows
\nthat such bias is unintentional and uncon-
\nscious. Furthermore, the studies suggest
\nthat self-interest affects people\u2019s choices,
\nchanging the way the assess information that
\nthey will use as the basis for choices. [24]
\nIn addition, disclosure of a doctor\u2019s finan-
\ncial interest in a particular product as an
\nantidote to bias can only be effective if
\npatients know how to relate to such disclo-
\nsure, and how much to discount the doc-
\ntor\u2019s advice in light of the disclosure. In
\nfact, recent social science research suggests
\nthat disclosure may even generate the oppo-
\nsite effect. [24]
\nOf physicians who felt that gift-taking did
\nnot influence their prescribing behaviour,
\nexplanations offered ranged from the fact
\nthat the doctor\u2019s clinical knowledge was
\nstrong enough, the formulary restrictions
\nsevere enough to prevent bias in prescri-
\nbing, to the fact that the resident\u2019s financial
\nhardship and exhausting schedule entitled
\nhim to enjoy these rewards. The acceptabili-
\nty of taking gifts was also influenced by so-
\n37
\nMedical Ethics and Human Rights
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 37
\n38
\ncial norms, i.e., did others (particularly su-
\nperiors) engage in such behaviour? (This
\nmay also help explain why residency pro-
\ngrams with guidelines yield more residents
\nthat comply with restrictions on gift-ta-
\nking). The bottom line was that most physi-
\ncians felt that they enjoyed the benefits wi-
\nthout being subject to insidious influence on
\nthe part of the pharmaceutical industry. [25]
\nThis despite the fact that one representative
\nstudy proved that physicians got more of
\ntheir information about the drugs they were
\nprescribing from drug advertisements than
\nfrom the scientific literature. [23]
\nResearch and Conferences
\nThe ACP-ASIM position paper states that
\n\u201cphysicians who have financial relations-
\nhips with industry, whether as researchers,
\nspeakers, consultants\u2026 or others, must not
\nin any way compromise their objective clini-
\ncal judgment or the best interests of patients
\nor research subjects\u2026\u201d.[6] The rationale for
\nthis prohibition is similar to the rationale
\npresented in the case of gifts: financial rela-
\ntionships can impair objectivity and create
\nconflicts of interest.As a rule of thumb, phy-
\nsicians may accept honoraria for teaching,
\nlecturing or research that advances profes-
\nsional knowledge and is commensurate with
\nthe work done. In addition, any financial re-
\nlationship must be disclosed.
\nAccording to one US report, in 1996, there
\nwere 151,434 industry-sponsored events;
\nby 2001 this number tripled, to 370,348 or
\nan average of more than 1000 such events
\nevery day of the year. [1]
\nParticular care must be exercised when a
\nphysician is invited to speak at a conference
\ndeveloped by a pharmaceutical company
\n(as opposed to one merely sponsored by
\nsuch company). In such cases, the physician
\nmust be very careful that the company does
\nnot script his or her presentation, but that
\nhe\/she has full and free professional discre-
\ntion and independence. Similarly, physici-
\nans who participate in industry-sponsored
\nresearch must guard against bias in publish-
\ning results. Physicians with financial ties to
\nindustry should refrain from participating in
\nsuch research, as studies have shown that
\nphysicians with such ties are significantly
\nmore likely to report findings that support
\nthe sponsor\u2019s drugs, and not report unfavou-
\nrable findings. [6]
\nConclusions:
\nThe relationship between physicians and
\npharmaceutical companies is indeed com-
\nplex, but that is no reason to shy away from
\nan attempt to regulate it. Like so many other
\ncomplex issues, ignoring it is an option but
\nultimately not a very successful one, as do-
\ning so would damage physicians and pa-
\ntients alike. There is a clear case for the
\nWMA to address these issues in the context
\nof its aims to protect the honour and inter-
\nests of the medical profession, to assist all
\npeoples of the world to attain the highest
\npossible level of health, and to set some
\nstandards, be they general or specific, for
\nthis relationship. These standards can then
\nserve as guidance for doctors and industry
\naround the world, and advance the cause of
\nmedicine, which, in the final analysis, is the
\ngoal of us all.
\nReferences:
\n1. Getting doctors to say yes to drugs: the cost and
\nquality impact of drug company marketing to
\nphysicians. Report of the Blue Cross Blue
\nShield Association, 2003.
\n2. Wazana A. Physicians and the pharmaceutical
\nindustry: Is a gift ever just a gift? JAMA 2000;
\n283: 373-380.
\n3. Bekelman J, Li Y, Gross C. Scope and impact of
\nfinancial conflicts of interest in biomedical re-
\nsearch. JAMA 2003; 289: 454-65.
\n4. Chren MM, Landefeld S, Murray TH. Doctors,
\ndrug companies and gifts. JAMA 1989; 262:
\n3448-3451.
\n5. The Council on Ethical and Judicial Affairs of
\nthe American Medical Association. Guidelines
\non gifts to physicians from industry: an update.
\n56 Food Drug L.J. 27 (2001).
\n6. Coyle SD. ACP-ASIM Position Paper: Physi-
\ncian-Industry Relations. Ann Intern Med 2002;
\n136: 396-402.
\n7. Brotzman GL, Mark DH. The effect on resident
\nattitudes of regulatory policies regarding phar-
\nmaceutical representative activities. J Gen In-
\ntern Med 1993; 8: 130-134.
\n8. McCormick BB, Tomlinson G, Brill-Edwards P,
\nDetsky AS. Effect of restricting contact be-
\ntween pharmaceutical representatives and inter-
\nnal medicine residents on post training attitudes
\nand behavior. JAMA 2001; 286: 1994.
\n9. Wager E. How to dance with porcupines: rules
\nand guidelines on doctors’ relations with drug
\ncompanies. BMJ 2003; 326:1196-1198.
\n10. Moynihan R. Who pays for the pizza? Redefin-
\ning the relationships between doctors and drug
\ncompanies. 1: Entanglement. BMJ 2003; 326:
\n1189-1192.
\n11. Pharmaceutical Research and Manufacturers of
\nAmerica. PhRMA code on interactions with
\nhealthcare professionals. 2002. www.phrma.
\norg\/publications\/policy\/\/2002-04-19.391.pdf.
\n12. Gibbons RV, Landry FJ, Blouch DL, et al. A
\ncomparison of physicians’ and patients’ atti-
\ntudes toward pharmaceutical industry gifts. J
\nGen Intern Med 1998; 13: 151-154.
\n13. McGuaran A. Royal College issues new guide-
\nlines on gifts from drug companies. BMJ 2002;
\n325:511.
\n14. The medical profession and the pharmaceutical
\nindustry \u2013 a joint SMA and SAPI paper. Aug 1,
\n2000. http:\/\/www.sma.org.sg\/cmep\/
\n15. Tasman Asia Pacific Report on behalf of the
\nTask Force on Industry Self-Regulation. Aus-
\ntralian Pharmaceutical Manufacturers Associa-
\ntion Code of Conduct. www.selfregulation.
\ngov.au\/publications\/TaskForceOnIndustrySelf-
\nRegulation\/ ConsultantReport\/ch6.pdf
\n16. Medicines Australia Code of Conduct.
\nwww.medicinesaustralia.com.au
\n17. Romano M. Prescription for conflict. Modern
\nHealthcare, June 18, 2001, p. 14.
\n18. Robeznieks A. OIG issues drug marketing
\nguidelines. Amednews.com, Oct 21, 2002.
\nhttp:\/\/www.ama-assn.org\/sci-
\npubs\/amnews\/pick_02\/prsa1021.htm
\n19. Association of the British Pharmaceutical In-
\ndustry. ABPI code of practice for the pharma-
\nceutical industry 2001. www.abpi.org.uk\/publi-
\ncations\/pdfs\/CodeOfPractice2001.pdf
\n20. Orellana C. German doctors’ links with drug
\nfirm investigated. Lancet 2002;359, 1039.
\n21. Sheldon T. GPs warned on accepting hospitality
\nfrom drug companies. BMJ 2001; 322: 194.
\n22. Watkins C, Moore L, Harvey I, Carthy P et al.
\nCharacteristics of general practitioners who fre-
\nquently see drug industry representatives: na-
\ntional cross sectional study. BMJ 2003;326:
\n1178-1179.
\n23. Avorn J, Chen M, Hartley R. Scientific versus
\ncommercial sources of influence on the pre-
\nscribing behavior of physicians. Am J Med
\n1982; 73:4-8.
\n24. Dana J, Loewenstein G. A social science per-
\nspective on gifts to physicians from industry.
\nJAMA 2003; 290: 252-255.
\n25. Steinman MA, Shlipak MG, McPhee SJ. Of prin-
\nciples and pens: Attitudes and practices of medi-
\ncine housestaff toward pharmaceutical industry
\npromotions.Am J Med 2001; 110: 551-557.
\n26. Chew LD, O’Young TS, Hazlet TK, Bradley
\nKA, Maynard C, Lessler DS. A physician sur-
\nvey of the effect of drug sample availability on
\nphysicians’ behavior. J Gen Intern Med 2000;
\n15: 478-83.
\nMedical Ethics and Human Rights
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 38
\n39
\nPoverty and Health
\nChanging the common ground: national
\nmedical associations, health, poverty,
\nand the Millennium Development Goals
\n\u2013 a new initiative.
\n\u201cA world not advancing towards the
\nMillennium Development Goals will not be
\na world at peace. And a world awash in vio-
\nlence and conflict will have little chance of
\nachieving the goals. But if the common
\nground we used to stand on no longer seems
\nsolid, we must seek new common ground
\nfor our collective efforts.\u201d
\n(Kofi Annan, Secretary-General of the
\nUnited Nations, at the International
\nChamber of Commerce Conference on
\n\u201cGlobal Economic Governance and
\nChallenges of Multilateralism\u201d, Dhaka, 17
\nJanuary 2004)
\nOn the eve of what should be a milestone
\nfor global health, Kofi Annan\u2019s words have
\ngreat significance for national medical
\nassociations (NMAs) and their members.
\nNext year marks the fifth anniversary of the
\nMillennium Declaration, an historic agree-
\nment between nations to overcome the
\nobstacles to human development in the 21st
\ncentury. In it, poverty, hunger and disease
\nwere given a renewed emphasis, and the
\nMillennium Development Goals (MDGs-
\nsee box) were established as the drivers for
\nchange, aiming to halve poverty by 2015
\nand to combat HIV\/AIDS, TB and Malaria.
\nThe agenda was ambitious, but the
\nDeclaration had consolidated a great deal of
\nthe work done by international develop-
\nMedical Ethics and Human Rights
\nThe Millenium Development GoalsThe Millenium Development Goals
\nGoal Targets and further information
\n1. Eradicate extreme pover-
\nty and hunger
\nTarget for 2015: Halve the proportion of people living on less than $1 a day and those who suffer from hunger.
\nMore than a billion people still live on less than US$1 a day: sub-Saharan Africa, Latin America and the Caribbean, and
\nparts of Europe and Central Asia are falling short of the poverty target.
\n2. Achieve universal prima-
\nry education
\nTarget for 2015: Ensure that all boys and girls complete primary school.
\nAs many as 113 million children do not attend school, but the target is within reach. India, for example, should have 95
\npercent of its children in school by 2005.
\n3. Promote gender equality
\nand empower women
\nTargets for 2005 and 2015: Eliminate gender disparities in primary and secondary education preferably by 2005, and at
\nall levels by 2015.
\nTwo-thirds of illiterates are women, and the rate of employment among women is two-thirds that of men. The proportion of
\nseats in parliaments held by women is increasing, reaching about one third in Argentina, Mozambique and South Africa.
\n4. Reduce child mortality Target for 2015: Reduce by two-thirds the mortality rate among children under five.
\nEvery year nearly 11 million young children die before their fifth birthday, mainly from preventable illnesses, but that num-
\nber is down from 15 million in 1980.
\n5. Improve maternal health Target for 2015: Reduce by three-quarters the ratio of women dying in childbirth.
\nIn the developing world, the risk of dying in childbirth is one in 48, but virtually all countries now have safe motherhood
\nprogrammes.
\n6. Combat HIV\/AIDS, ma-
\nlaria and other diseases
\nTarget for 2015: Halt and begin to reverse the spread of HIV\/AIDS and the incidence of malaria and other major diseases.
\nForty million people are living with HIV, including five million newly infected in 2001. Countries like Brazil, Senegal,
\nThailand and Uganda have shown that the spread of HIV can be stemmed.
\n7. Ensure environmental
\nsustainability
\nTargets:
\n\u2022 Integrate the principles of sustainable development into country policies and programmes and reverse the loss of envi-
\nronmental resources.
\n\u2022 By 2015, reduce by half the proportion of people without access to safe drinking water.
\n\u2022 By 2020 achieve significant improvement in the lives of at least 100 million slum dwellers.
\nMore than one billion people lack access to safe drinking water and more than two billion lack sanitation. During the 1990s,
\nhowever, nearly one billion people gained access to safe water and the same number to sanitation.
\n8. Develop a global part-
\nnership for development
\nTargets:
\n\u2022 Develop further an open trading and financial system that includes a commitment to good governance, development and
\npoverty reduction \u2013 nationally and internationally
\n\u2022 Address the least developed countries\u2019special needs, and the special needs of landlocked and small island developing States
\n\u2022 Deal comprehensively with developing countries\u2019 debt problems
\n\u2022 Develop decent and productive work for youth
\n\u2022 In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries
\n\u2022 In cooperation with the private sector, make available the benefits of new technologies \u2013 especially information and com-
\nmunications technologies.
\nMany developing countries spend more on debt service than on social services. New aid commitments made in the first
\nhalf of 2002 could mean an additional $12 billion per year by 2006.
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 39
\n40
\nment conferences during the 1990s and pre-
\nsented a clear, well-timed vision, which
\nwas both inspirational and feasible.
\nWith the year 2005 approaching, however,
\nthe ideals of 2000 lie in disarray. There are
\nnow strong indications that none of the
\nMDGs will be achieved by the target date,
\nand many developing countries are increas-
\ningly falling behind. Recalling the
\nDeclaration of Alma-Ata (1978), Annan
\ncites the breakdown of the mutual bond
\nbetween peace and good health \u2013 also
\nimplicit in Alma-Ata\u2019s Millennium succes-
\nsor \u2013 as the underlying reason for the
\nMDGs slipping off track. Whilst it is cer-
\ntainly true that the post-Millennial world of
\narmed conflict and terrorism has severely
\ntested that bond, there is a risk that an
\nemphasis upon global problems such as
\nthese may obscure other factors which are
\nundermining efforts to achieve the MDGs
\nat local, regional and national level. As far
\nas the health-related goals are concerned,
\nthese issues are highly relevant, e.g. lack of
\nprogress on the goal to reduce the under-
\nfive child mortality rate by two-thirds
\nbetween 1990 and 2015 is frequently attrib-
\nuted, at least in part, to the problems facing
\nhealth systems in rural areas. If a change to
\nthe common ground of 2000 occurs \u2013 and
\nKofi Annan has indicated elsewhere that a
\nhigh-level review of the MDGs is being
\nplanned for 2005 \u2013 then it is imperative that
\n\u201cdevolved\u201d issues such as these are taken
\nfully into account in the outcome.
\nCollaboration between national medical
\nassociations (NMAs) across the world
\ncould play a crucial role in pushing these
\nissues up the agenda. For example, devel-
\noping nations\u2019 NMAs and their members
\nare in a key position to assess the chal-
\nlenges to health and healthcare provision in
\ntheir own countries. They are also able to
\nprovide from the experience of their mem-
\nbers a definitive account of the needs of
\nhealth systems at national, regional and
\nlocal levels, and the problems faced by
\nthose who work to meet those needs. This
\nlevel of insight could also help to redress
\none of the perceived imbalances of the
\nMDGs: the undue emphasis on what
\nshould be achieved rather than how.
\nDeveloped nations\u2019 NMAs, on the other
\nhand, are able to relate their experience of
\nproviding assistance to developing nations.
\nDo they feel that such support is being
\ndirected in the most effective way? How
\ncan their governments\u2019 policies on the pro-
\nvision of assistance be developed to meet
\nthe needs of recipient countries? There is
\nclearly tremendous scope for constructive
\ndialogue on all of these points.
\nIn an effort to stimulate positive action to
\nimprove the situation, during the past year
\nthe British Medical Association has been
\nworking in partnership with the Department
\nfor International Development (DfID), the
\nUK government department responsible for
\npromoting development and the reduction
\nof poverty internationally. Our primary aim
\nhas been to build our members\u2019 awareness
\nof the international development agenda
\nand to encourage them to consider how they
\ncan contribute to the campaign to eradicate
\npoverty in the developing world. An over-
\nwhelmingly positive response to our initia-
\ntives has been received from our members
\nwho are keen to become involved in our
\nfuture work in this area. The aims of this
\nwork, however, go beyond raising aware-
\nness of individual physicians.
\nIt was recognised from the outset that it is
\nessential to engage with organisations
\nwhich have substantial experience of devel-
\noping initiatives to address the health chal-
\nlenges in developing countries. Therefore
\nin January 2005, a Poverty and Health
\nPolicy Group was formed, comprising a
\nmix of such UK-based organisations. In
\nearly discussions within this group, topics
\nincluded the impact of migration and health
\nskills drainage from developing countries,
\nand the continuing inhibition of research
\ninto \u201corphan drugs\u201d. These are, however,
\nmere indications of the many problems
\nwhich need to be addressed. As indicated
\nabove, it is clear that a vital element in this
\nprocess is to obtain first-hand evidence
\nwhich identifies the obstacles to achieve-
\nment of the MDGs. In this respect, the con-
\ntribution of NMAs and their members is
\nessential. It is hoped therefore that NMAs
\nwill provide this vital input into the process
\nof containing the health threats associated
\nwith poverty and realising the aims of the
\nMDGs.
\nMMC
\nFurther information: mcarroll@bma.org.uk
\nWMA
\nDuring the first six months of his WMA
\nPresidency, Dr. James Appleyard has been
\nextremely busy as the following highlights
\nof his activities demonstrate.
\nIn South Africa he attended and addressed
\nthe South African Medical Association
\nmeeting on Strategies for the Survival of
\nDoctors, where the profession is united in
\npursuing the ethical standards underlying
\nmedical practice and in seeking improved
\nhealthcare services for those under-served
\nin the population.
\nIn Uganda he participated in a series of
\nmeetings to arrange training seminars for
\n250 health professionals and 125 lawyers
\non the principles underlying the Istanbul
\nProtocol.
\nOn another occasion he joined in a WHO-
\nsponsored meeting, at which a draft consti-
\ntution for the Federation of East African
\nMedical and Dental Associations was con-
\nsidered. WHO is looking to this body for as-
\nsistance with medical education, disease
\nsurveillance and prevention, including a
\nprogramme of measles vaccination.
\nThe President gave a guest lecture at the
\nOral Health Planning Conference in the
\nAfrican Region, organised by WHO and the
\nFDI (International Dental Federation). This
\nimportant regional conference produced a
\nConsensus Statement on Oral Health (the
\nDeclaration of Nairobi). This was a good
\ndemonstration of the effectiveness of colla-
\nborative working at national and local level
\non clearly defined and agreed objectives.
\nHe also addressed the Annual Assembly of
\nthe Ugandan Medical Association on \u201cThe
\nright of a child to health care\u201d.
\nWMA
\nActivities of the President
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 40
\n41
\nIn Taiwan, attending the International
\nConference on Influenza and the
\nResurgence of SARS, the President spoke
\nof the WMA interest and role in such out-
\nbreaks and of the work group led by the
\nCanadian Medical Association. He also vis-
\nited the Chinese Medical Association, the
\nTaiwanese Medical Association, the Bureau
\nof Health Promotion, the Joint Commission
\non Hospital Accreditation and the National
\nHealth Research Institute, noting particular-
\nly the role of the Bureau of National Health
\nInsurance whose emphasis was on purchas-
\ning Health – not Health Care!
\nIn the USA Dr. Appleyard addressed the
\nAmerican Academy of Pharmaceutical
\nPhysicians in Miami on \u201cHow we should
\ntreat our children\u201c, and had some discus-
\nsions on the Declaration of Helsinki. At the
\nHispanic Development Foundation at
\nOregon Health and Sciences University, Dr.
\nAppleyard gave the guest\/keynote lectures
\non \u201cHow does the world treat our children\u201d.
\nVisiting the International Department of
\nCornell University and New York Medical
\nCollege, he sought support for and recogni-
\ntion of the need for all students to extend
\ntheir experience through an elective in a
\ndeveloping country.
\nAt the UK International Water Summit in
\nLondon, video-linked with Brussels, the
\nPresident spoke on the relevant health issues
\nrelating to the developing world and the need
\nfor collective support. In Brussels also,
\naddressing the European Forum for Good
\nClinical Practice, he emphasised the pivotal
\nrole of the Declaration of Helsinki in the eth-
\nical framework for research on children and
\nof the WMA Declaration of Ottawa on the
\nRight of a Child to Health Care. He also
\nstressed the importance of the role for the EU
\nin supporting poor countries where the burden
\nof infectious disease impaired their economy.
\nOther concerns involved the many other
\nvital issues relating to human rights. These
\ninclude the case of Dr. Biscet imprisoned
\nwith three colleagues in Cuba, the deterio-
\nrating situation in Zimbabwe where there is
\nincreasing under-five child mortality, and
\nthe need for support of doctors on both
\nsides of the Israeli\/Palestine conflict.
\nThe WMA Council held its 167th
\nmeeting in
\nDivonne (France) in the presence of mem-
\nbers of the standing committees and a num-
\nber of observers. Many also attended the
\nfirst Conference of the World Health
\nProfessions Alliance, held in Geneva on the
\nfollowing two days (see WHPA p. 32).
\nFollowing the opening by the Chairman,
\nDr. Yoram Blachar, and adoption of the
\n166th
\nCouncil minutes, the Council received
\nthe reports of the President (see above) and
\nof the Secretary General.
\nDr. Delon Human in his presentation high-
\nlighted the following important develop-
\nments since the Helsinki meeting:
\n– the work of the Medical Ethics Unit
\nunder the direction of Dr. John
\nWilliams. The first draft of the Manual
\non Medical Ethics should be available
\nby the Tokyo meeting;
\n– collaboration with the World Health
\nOrganisation (WHO) has significantly
\nstrengthened, and WHO has confirmed
\nits wish to remain in official relations
\nwith WMA. Positive projects or activi-
\nties include participation in the negotia-
\ntions and debates leading up to the
\nadoption of the Framework Convention
\non Tobacco Control;
\ninclusion of WMA in the WHO Global
\nAlert and Response Network to combat
\ncommunicable diseases. This has been
\nupdated to deal more effectively with
\nepidemics such as SARS. In this con-
\nnection the Secretary General paid a
\nspecial tribute to the outstanding work
\nof the Canadian Medical Association;
\nthe development of policy on \u201cViolence
\n& Health\u201d, and participation in the
\nWHO launch of this project;
\ndevelopment of policy on safe injec-
\ntions with the WHO section \u201cSafe
\nInjection Global Network\u201d (SIGN);
\nSurvey of Human Resources for Health
\nCare;
\n– Adoption in Helsinki of the resolution
\ndesignating an annual \u201cMedical Ethics
\nDay\u201d to be marked by WMA members
\non 18th
\nSeptember, the anniversary of
\nWMA\u2019s foundation.
\n– Restructuring the content and format of
\nthe World Medical Journal now in its
\n50th
\nyear, under its new Hon. Editor in
\nChief, Dr Alan Rowe, with future
\ngreater orientation towards medical
\nethics, physician-related human rights
\nand to other issues. Particular tribute
\nwas paid to the work of Dr. Ivan
\nGillibrand as Executive Editor since
\n1986 and to that of Professor Elmar
\nDoppelfeld, the Co-Editor.
\n– Continuing growth and effectiveness of
\nthe World Health Professions Alliance
\n(see WHPA p. 32)
\n– the development of a new website
\ndevoted to health care technology, and
\nthe webcasting of the Helsinki
\nScientific Session.
\n– progress with the Human Rights pro-
\ngrams: also, the WMA anti-torture pro-
\nject jointly with the International
\nRehabilitation Council for Torture
\nVictims (ICRT) has gained increasing
\nmomentum, and some WMA leaders
\nhave visited the five pilot countries to
\nhelp develop training material and cen-
\ntres for physicians in them.
\nTurning to membership he reported that the
\nMedical Associations of Armenia, Bang-
\nladesh, the Bahamas and Kazakhstan had
\njoined the WMA.
\nDr. Human concluded his report by indica-
\nting his intention to resign after the seventh
\nanniversary of his appointment later in the
\nWMA
\nWMA
\nThe 167th WMA Council meeting in Divonne
\n13-15 May 2004
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 41
\n42
\nyear. He would, of course, continue for the
\nnecessary transitional period after the
\nTokyo General Assembly.
\nStrategic plan
\nIn preparation for discussions on the future
\nstrategy of WMA which was a major topic
\nthroughout the Divonne meetings, Council
\nmembers were asked to respond to three
\nquestions. These were to identify what were
\nthe most pressing problems for their
\nNMAs, which single issue their members
\nconsidered to be the most important priori-
\nty, and what their NMA considered to be
\nthe most important priority for the
\nWMA.What was most impressive in a vari-
\nety of responses was the undercurrent of
\nrecognition of the pressures on profession-
\nalism at all levels of society, and the need
\nfor the medical profession to consider both
\nits relationship with society and its own
\nidentity (see boxes A and B).
\nThe Chairman commenting that the discus-
\nsion of these replies reflected a number of
\ncommon problems, the most notable relat-
\ning to health care systems said that WMA
\nhas a vital role to play in identifying
\nanswers to these problems.
\nWorld Health Assembly
\nCouncil discussed the World Health
\nAssembly which would take place the fol-
\nlowing week. In this connection Council
\nwelcomed the inclusion of members of
\nNMAs in an increasing number of delega-
\ntions to the Assembly.
\nMedical Ethics
\nCouncil considered the report of the
\nMedical Ethics Committee.
\nDeclaration of Helsinki
\nAfter receiving the report and its recom-
\nmendations, \u2013 \u201c1. That para. 30 be not
\namended; and 2. That the Medical Ethics
\nCommittee at its May meeting decide
\nwhether either an accompanying statement
\nor preamble for the DoH, or a note of clari-
\nfication for para. 30, be developed,\u201c
\nCouncil adopted the recommendations, and
\nafter a short debate a motion that the recom-
\nmendation be referred to NMAs for com-
\nment was defeated.
\nThe recommendations (in boxes C and
\nD) were adopted for referral to the
\nGeneral Assembly in Tokyo.
\nThe following note outlines the discussion
\nin the Medical Ethics Committee on the
\nreport and recommendations of the working
\ngroup, and the comments already received
\non them.
\nSeveral members in supporting the recom-
\nmendation that there be no amendment,
\nobserved that the debate had continued for
\na considerable period of time, and that the
\nlonger it went on the more it could weaken
\nthe status of both the DoH and the WMA.
\nAttention was drawn to the problems relat-
\ning to the European Union Clinical
\nResearch Directive and the position of the
\nFDA, which didn\u2019t accept the current DoH
\nbecause of paragraph 30. A plea was made
\nfor a separate statement on access to care
\nnot being related to ability to pay. The
\nSecretary General observed that the FDA
\nwould not feel able to accept paragraph 30
\neven if amended. This also applied to
\nEMEA. An opposer to any amendment
\ncommented that the problems related to
\nhealth care systems should be considered
\nseparately and that one could then return to
\nthe DoH. The AMA proposed that the
\nwords \u201cit is important to consider post-trial
\naccess (to treatment)\u201c be considered. There
\nwas a real need to talk about access to treat-
\nment.
\nAgreeing that there should be no change,
\nthree members were opposed to a preamble
\nbut would accept an explanatory document.
\nIt was also suggested that paragraph 30
\nshould be considered as aspirational, and
\nthat the real issues were those of justice and
\nequity. The speaker could accept a note or
\npreamble which didn\u2019t weaken the DoH
\nand suggested that a draft declaration on the
\nright to health be available in Tokyo.
\nMeanwhile a moratorium (later withdrawn)
\non further discussion for two years after
\nTokyo should be considered. This would
\nnot inhibit discussion but there should be no
\nformal proposal for change during this peri-
\nod. Later, in clarification it was made clear
\nthat this would not inhibit any action were
\nthere to be some remarkable breakthrough
\nor change of circumstance.
\nA strong plea was made however that, bear-
\ning in mind that the FDA and EMEA would
\nnot change, paragraph 30 should be
\nchanged.
\nThe first recommendation was then put to
\nthe vote and was approved with one vote
\ncontra and no abstentions.
\nWMA
\n(A) Most Pressing Problem to NMAs (n=17) (B) Most Important Task for WMA (n=17)
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 42
\nReference was then made to a suggested
\nnote of clarification from Dr. William
\nSteiger (US Dept. of Health and Human
\nServices). Bearing in mind the problems
\nassociated with an insertion into the pre-
\namble, it was then proposed that this be a
\nnote of clarification of paragraph 30, anal-
\nogous with the note concerning paragraph
\n29.
\nAfter an extensive debate and some modi-
\nfication of the wording, the following
\nform of wording for the note of clarifica-
\ntion to paragraph 30 was adopted as a rec-
\nommendation.
\nClinical trials in Populations with In-
\nsufficient access to Health Care
\nThe Committee considered a Proposed
\nWMA Statement on \u201cClinical Trials in
\nPopulations with Insufficient Access to
\nHealth Care\u201d and agreed that the Finnish
\nMedical Association would review this in
\nthe light of the recommendations on para-
\ngraph 30 of the Declaration of Helsinki.
\nRelationship between Physicians and
\nCommercial Enterprises (also see article
\np. 33)
\nThis subject will be further discussed at
\nthe October WMA meeting.
\nSocio-Medical Affairs
\nDr. Henry Haddad was elected Chair of
\nthe Socio-Medical Affairs Committee.
\nWater and Health Care
\nCouncil approved a proposed Statement
\non Water and Health Care, to be for-
\nwarded to the General Assembly.
\nArmed Conflict
\nCouncil approved amendments to the
\nRegulations in Time of Armed Conflict,
\nto be forwarded to the General Assembly.
\nQuality Improvement in Medical
\nEducation
\nCouncil approved a proposed WMA
\nResolution on Global Standards for
\nQuality Improvement of Medical Edu-
\ncation, to be forwarded to the General
\nAssembly
\nHealth Emergencies Communication and
\nCoordination
\nThe Recommendations of a proposed
\nWMA Statement were approved as a
\nCouncil Resolution (box, p. 44)
\nCouncil also approved circulation of the
\nproposed Statement and set up a Work
\nGroup to develop a plan for the establish-
\nment of a global physician network to
\nimprove preparedness for health emergen-
\ncies.
\nFinance and Planning
\nDr. J. C. Nelson was elected Chair of the
\nPlanning and Finance Committee.
\nFinance
\nSubject to an unqualified audit opinion,
\nthe Financial Statements for 2003 were
\napproved.
\nSantiago 2005
\nCouncil approved the themes for the
\nScientific Session and the arrangements for
\nthe 2005 General Assembly in Santiago.
\nThe themes will be \u201cHealth Care Systems
\nReform\u201d and \u201cAccess in Medicines\u201d.
\nPolicy review
\nCouncil endorsed the recommendation
\nthat the Secretariat should develop a simpli-
\nfied process for review of existing WMA
\npolicies.
\nMembership
\nRecommendations that the applications
\nfor constituent membership of the
\nMedical Associations of Estonia and
\nVietnam be forwarded to the General
\nAssembly, were approved.
\nAn application for cooperative relations
\nwith WMA from Project HOPE, was
\napproved.
\nOfficial Languages
\nCouncil approved the establishment of a
\nwork group of officers to review the prob-
\nlems of official languages of the WMA.
\nObligatory notification of AIDS as an
\ninfectious disease
\nCouncil also referred an emergency pro-
\nposed Council resolution that AIDS be clas-
\nsified as a notifiable disease, to the Socio-
\nMedical Affair Committee.
\nZimbabwe
\nThe Council discussed its serious concerns
\nabout reports of the collapse of the health
\ncare system in Zimbabwe and mandated
\nthe WMA leadership to investigate the sit-
\nuation in Zimbabwe and take appropriate
\nactions.
\nStrategic Plan
\nThe Council concluded with a further
\ndebate on a Strategic Plan in which many
\nissues were aired and discussed. It was
\ndecided that a survey should be commis-
\nsioned, to be overseen by a working group;
\na full report of discussions would be sent to
\nNMAs and that the business group looking
\nat non-dues issues report to the supervisory
\ngroup, to whom it would where appropriate
\nact as a tool.
\nSuccession of Secretary General
\nThe Council approved actions necessary to
\nidentify a new Secretary General.
\n43
\nWMA
\n(C) Recommendation to General
\nAssembly
\n1. That there be no change to paragraph
\n30 of the Declaration of Helsinki.
\n(D) Recommendation to GeneralAssembly
\n2. Addition of a Note of clarification to
\nparagraph 30
\n\u201cThe WMA hereby reaffirms its posi-
\ntion that it is necessary during the
\nstudy planning process, to identify
\npost-trial access by study applicants to
\nprophylactic, diagnostic and thera-
\npeutic interventions identified as ben-
\neficial in the study, or access to other
\nappropriate care. Post- trial access
\narrangements or other care must be
\ndescribed in the study protocol, so that
\nthe ethical review committee may con-
\nsider such arrangements.\u201d
\nThe meeting heard a plea from the
\nBulgarian delegate to WMA on behalf of
\nthe doctor and five nurses imprisoned
\nand condemned to death in Libya for
\nallegedly infecting more than 400 chil-
\ndren with AIDS, in spite of expert evi-
\ndence of their innocence.
\nThe Chairman of Council has appealed to
\ntheLibyanauthoritiestoquashthissentence.
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 43
\n44
\nSir Alexander Macara, FRCP, President,
\nNational Heart Forum, UK
\nTwo important actions in the past year mark
\nsignificant potential for the future control of
\nthe major causes of morbidity and mortality
\nfrom non-communicable diseases. They are
\nthe publication of the results of the global
\nheart disease study MONICA, and the
\nendorsement by the World Health Assembly
\nof the Global Strategy for Diet, Physical
\nActivity and Health. The following overview
\nof these and other developments comments
\non the underlying factors influencing
\nprogress in this area and the importance of
\ncollaborative action.
\nAs the frequency of many non-communica-
\nble diseases (NCDs) \u2013 notably heart and
\ncirculatory disease, cancers and diabetes \u2013
\nincreases in developed countries and are
\nalarmingly superimposed on the continuing
\nburden of communicable disease in devel-
\noping countries, the need for effective and
\nconcerted international action to attack
\ntheir root causes is urgent.
\nSince the Alma-Ata initiative of the WHO
\nand UNICEF in 1978 it is accepted wisdom
\nthat there are three main thrusts in all health
\npolicy \u2013 control of adverse environmental
\nfactors, the promotion of healthy life-styles,
\nand the reorientation of health care services
\ntowards prevention and early diagnosis and
\ntreatment. The intervening quarter-century
\nhas shown the crucial significance of two
\nfactors \u2013 one internal to the health sector of
\nsociety and its governance, the other exter-
\nnal to it. The internal factor is the lack of
\nbasic knowledge and consequently the
\ninadequacy of the evidence, which is
\nrequired to stimulate policy-makers and to
\ngoad decision-makers; the lethal nature of
\ntobacco is a notable exception to this defi-
\nciency. The external factor is the globaliza-
\ntion of markets for consumer products which
\nshould be a force for economic and social
\nprogress but which poses a growing threat to
\nhealth, especially in developing countries,
\nwhen the profit motive mocks any ethical
\nconsiderations.
\nThese two factors point to two absolute pri-
\norities. The first is the essential criterion for
\ninformed policy and action of accurate and
\nreliable epidemiological information about
\ntime, place and persons. The second imper-
\native is to apply all the evidence obtained
\nfrom epidemiological studies to underpin
\nand improve existing programs, to inform
\ndevelopment in international collaboration,
\nand to combat the inimical effects of irre-
\nsponsible commercial activities.
\nThe good news is that there are grounds for
\nqualified optimism in the outcomes of
\nrecent collaborative activities and in the fer-
\nment of current policy proposals which call
\nMedical Science, Professional Practice and Education
\nCouncil Resolution on Health Emergencies Communication and Coordination
\n1.That the WMA and member NMAs should work closely with WHO, national governments and other professional groups to jointly
\npromote elements of this policy.
\n2.That the WMA urge physicians to be
\n– alert to the occurrence of unexplained diseases and deaths in the community,
\n– knowledgeable of disease surveillance and control capabilities, and
\n– assiduous in the timely reporting of suspicious cases of illness to appropriate authorities.
\n3.That the WMA encourage physicians, NMAs and other medical societies to participate with local, national and international health
\nauthorities, in developing and implementing disaster preparedness and response protocols for natural infectious disease outbreaks.
\nThese protocols should be used as the basis for physician and public education.
\n4.That the WMA call on NMAs to promote and support the GOARN network as a control coordinating entity in combating global
\nhealth security threats.
\n5.That the WMA call for the establishment of a strategic partnership agreement with WHO, so that in the case of epidemics, health
\ncommunication can be stepped up considerably and two-way flow of information ensured.
\n6.That WHO should coordinate the development of an inventory based on existing stockpile supplies, so that such supplies can be
\nrapidly deployed and accessed by physicians involved in the care of victims.
\n7.That international agreements should be proactively explored to facilitate the movement of health professionals who are involved in
\nthe management of epidemics.
\n8.That research in the field of emergency preparedness should be enhanced by national governments and NMAs where appropriate,
\nto better understand current flaws in the system and how to improve preparedness in the future.
\n9.That education and training of physicians should be amended to take into account the realities and specific needs required in the
\nevent of emergencies, and to ensure that due diligence is paid to patient and healthcare worker safety when managing patients with
\nacute infectious diseases.
\n10.That physicians everywhere in the world, including Taiwan, should have access to WHO programmes and information, and infor-
\nmation concerning health emergencies.
\nMedical Science, Professional Practice and Education
\nPreventing preventable chronic disease \u2013
\ninternational developments
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 44
\nfor international collaboration between
\nnon-governmental organizations (NGOs)
\nand intergovernmental organizations
\n(IGOs) such as WHO and the European
\nUnion. The outstanding example of interna-
\ntional collaboration is the MONICA study,
\n\u201cthe world\u2019s largest study of heart disease,
\nstroke, risk factors and population trends\u201d
\nwhich WHO was instrumental in establish-
\ning and supporting. The compilation of the
\nresultant monographs, edited by Professor
\nHugh Tunstall-Pedoe of Dundee, is now
\navailable from WHO in hard copy and in
\nCD-ROM, the MONICA Monograph and
\nMultimedia Sourcebook (WHO 2004)
\n(www.ktl.fi(monica). This presents unique
\ndata on CVD factors, mortality and morbid-
\nity and medical care from 21 countries over
\nfour continents involving 38 research
\ngroups from 1979 to 2002. It offers chal-
\nlenging hypotheses about the relationship
\nbetween risk factors and changes in the pat-
\ntern of CVD, and is a unique and invaluable
\nresource for clinicians, public health practi-
\ntioners, researchers, policy-makers and stu-
\ndents. It is particularly to be praised for
\nacknowledging the difficulties involved in
\nsuch a complex exercise.
\nIn this context, it is timely that WHO has
\ndeveloped its STEPWISE (STEPS)
\napproach to surveillance of risk factors
\n(2003) relating to NCDs. This aims to pro-
\nvide standardized materials and methods to
\nhelp countries, especially those that lack
\nresources, to initiate NCD activities. The
\ngoal is to achieve quality data compatibility
\nand comparability over time. WHO is
\nmaintaining the NCD data at a country level
\non the WHO Global NCD InfoBase.
\nWHO has shown superb leadership in forg-
\ning the Framework Convention on Tobacco
\nControl (FCTC) \u2013 its first-ever global
\nhealth convention. This will proceed to
\nimplementation in September 2004 assum-
\ning ratification by the requisite forty coun-
\ntries. Further, in May 2004, the World
\nHealth Assembly also approved a Global
\nStrategy for Diet, Physical Activity and
\nHealth. Although this does not have the
\nforce of a binding treaty, it marks a signifi-
\ncant advance in setting out standards of
\ngood practice for competent national public
\nhealth strategies. Predictably, those ele-
\nments of this strategy which require collec-
\ntive governance, such as effective controls
\non the marketing of foods high in fat, sugar,
\nand salt, may also become the subject of
\nanother international convention.
\nDr. Derek Yach and Dr. Corrina Hawkes of
\nWHO have just published a compelling
\nframework for action \u2013 \u201cTowards a WHO
\nlong term strategy for the prevention and
\ncontrol of leading chronic diseases\u201d (2004).
\nThis has as yet no formal status, but it rais-
\nes many fundamental and controversial
\nissues, notably the health impact of foreign
\ndirect investments in developing countries.
\nIt calls for global cooperation between the
\nWHO and other IGOs such as the World
\nBank and the World Trade Organization in
\ntackling the global epidemics of linked
\navoidable chronic diseases.
\nInternational NGOs such as the World
\nHealth Federation, the International Diabe-
\ntes Association, the International Obesity
\nTask Force, the International Association for
\nthe Study of Obesity and the Cancer Lea-
\ngues are increasingly making a significant
\ncontribution to the prevention of avoidable
\nchronic diseases. They are key civil society
\nstakeholders and act in particular as a coun-
\ntervailing force to the market-driven vested
\ninterests of the corporate sector. They share
\na common agenda for collective action and
\nare closely involved with WHO in advoca-
\nting and shaping evidence-based strategies
\nfor action. The most recent example was to
\ncounter the influence of the sugar industry at
\nthis year\u2019s World Health Assembly. Similar
\naction by NGOs is taking place within the
\nEuropean Union. The European Heart
\nHealth Network (EHN), whose membership
\ncomprises national heart foundations which
\nare increasingly active in public health ad-
\nvocacy, has worked closely with internatio-
\nnal cancer organizations in pressing the EU
\ninstitutions to introduce tobacco control
\nmeasures such as banning advertising and
\nsponsorship throughout the EU. It is now
\nembarking on a project to investigate the ex-
\ntent of the marketing of foods high in fat, su-
\ngar and salt to children in Europe and the ef-
\nfectiveness of any national controls.
\nThe prevention of linked avoidable chronic
\ndiseases at all levels will be greatly enhan-
\nced by greater strategic collaboration be-
\ntween NGOs, which share a common agen-
\nda. Action on tobacco control, food and nu-
\ntrition and the promotion of physical activi-
\nty are obvious priorities. A national exam-
\nple of collaboration is the UK\u2019s National
\nHeart Forum (www.heartforum.org.uk),
\nwhich brings together the leading national
\nprofessional and social policy NGOs which
\nare concerned about the causes and effects
\nof heart disease, strokes and diabetes, to de-
\nvelop and advocate collective public policy
\npositions.
\nThe bad news is that those transnational
\ncompanies whose activities are inimical to
\nhealth, frequently escape controls due to the
\nabsence of structures and mechanisms for
\ninternational action. The prevailing \u201cnew-li-
\nberal\u201d approach by most governments is mi-
\nnimal intervention, with non-binding part-
\nnership agreements or dependence on self-
\nregulated corporate social responsibility
\n(CSR) in the jargon). International Public
\nInterest NGOs (PINGOs) have a putative
\nrole in the promotion of CSR, but that ap-
\nproach has proved to be sadly futile in the
\nabsence of international standards and any
\nmeaningful involvement of independent
\ncivil society monitoring and audit. As the
\nopen-ended extrinsic economic, social and
\nhealth costs of uncontrolled commercial ac-
\ntivity are borne by society, it must be right
\nthat society is involved in its regulation.
\nThe Director-General of WHO, Dr LEE
\nJong-wook, pledged in July 2003 to devel-
\nop and implement a comprehensive plan for
\ncombating the preventable chronic NGOs,
\nwhich account for a growing share \u2013 esti-
\nmated at 60% \u2013 of the burden of disease
\nworld-wide. Tackling the power and influ-
\nence of irresponsible transnational compa-
\nnies will require continuing strong leader-
\nship by WHO and other international IGOs
\nworking closely with health NGOs. This is
\na particular challenge to the health profes-
\nsionals. In the global war against disease,
\nwe are in the forefront of the battle. We
\nmust not fail.
\nAddress for correspondence:
\nNational Heart Forum
\nTavistock House South,
\nTavistock Square,
\nLondon WC1H 9LG,
\nUK
\n45
\nMedical Science, Professional Practice and Education
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 45
\n46
\nThe fight against malaria over the past
\ntwenty-five years or so has been a story of
\nsuccess and disappointments. The discov-
\nery of various drugs has advanced and
\nimproved the control of the disease but also
\nunfortunately resistance caused problems
\nand currently, this remains a major prob-
\nlem. Now the complete sequence for Homo
\nsapiens and Plasmodium falciparum is
\nknown, new strategies can be worked out in
\nthe world-wide battle against malaria. It is
\nanticipated that new targets for drugs will
\nbe identified \u2013 and that drugs in future will
\nbe computer-designed to attack at metabol-
\nic and genetic weak points. If the present
\narmamentarium of anti-malarial drugs fails
\nto act against resistant parasites, there is
\nhope that new classes of drugs will achieve
\nmore effective cures and ultimately eradica-
\ntion of malaria.This article reviews the
\nscene and the exciting possibilities for
\ndefinitive mechanisms for dealing with the
\nremaining problems which can flow from
\nthe genomics revolution.
\nTackling rising levels of medicine resistance
\nis one of the key challenges to African
\nStates in their efforts to control malaria and
\nmeet the declared target of saving the lives
\nof half the 800,000 children who die of the
\ndisease each year by 2010. Recognising that
\nthe cheapest and most readily available
\nmedicines are increasingly ineffective, the
\nWHO \u201cRoll Back Malaria\u201d programme
\nurges countries to switch to the combination
\ntherapy, Artemisinin-based Combination
\nTherapies (ACT\u2019s) when there is strong evi-
\ndence that existing conventional medicines
\nare no longer working. As ACT\u2019s combine
\ntwo medicines which work in different
\nways, it is unlikely that the malaria parasite
\nwhich has rapidly developed resistance to
\nother single treatments will evolve to resist
\nthese medicine combinations. WHO added
\nthe ACT\u2019s (Artemether\/lumefantrine) to its
\nEssential Drugs List. Furthermore, the
\nGlobal Fund Against AIDS, BTB and
\nMalaria funded proposals to \u201cRoll Back
\nMalaria\u201d in Zanzibar and Zambia which
\nincluded purchasing and phasing-in the use
\nof new ACTs. Expressing the hope that this
\nFund and other funding mechanisms would
\nbe used to purchase ACT\u2019s where they are
\nneeded to treat and control malaria, Dr. Gro
\nHarlem Brundland, stressing the need to
\nreduce their prices in developing countries
\nsaid \u201cIt is important that countries, which
\nneed ACTs are able to access and use them
\nin a sustainable manner\u201d.
\nMany countries in Eastern, Central and
\nSouthern Africa are experiencing resistance
\nto chloroquine, and resistance is also
\nappearing in West Africa. As a result many
\ncountries have moved to sulphadoxine-
\npyrimethamine (\u201cSP\u201d or \u201cFansidar\u201d) as a
\nfirst line treatment, but resistance to SP is
\nalso spreading.
\nThere is new evidence that the number of
\nchild deaths due to malaria is increasing
\ndue to failing medicines and medicines of
\npoor quality. There is also evidence that due
\nto rising levels of medicine resistance,
\nalmost half the money spent on anti-malar-
\nials is being used to pay for inappropriate
\ntreatment. This also highlights the need for
\nmore efforts on preventing malaria using
\nproven cost-effective measures such as
\ninsecticide-treated bednets.
\nThe WHO recommendation is that coun-
\ntries begin the transition of medication as
\nsoon as levels of resistance exceed 15% and
\nthat the change will be implemented before
\nresistance reaches 25%.
\nThe rise of resistance
\nHalofantrine, which like mefloquine was
\nproduced as a direct result of the Vietnam
\nWar, is highly effective against multi-drug
\nresistant Falciparum malaria.
\nUnfortunately, during clinical evaluation in
\nThailand \u2013 after it had been registered in
\nseveral countries \u2013 halofantrine was found
\nto predispose to potentially lethal cardiac
\narrhythmias. Its use is now restricted.
\nThere has been a global initiative to evalu-
\nate artemisinin-based combination treat-
\nments throughout Africa and South
\nAmerica. The artemisinin combinations
\nprovide consistently rapid resolution of
\nsymptoms, they are highly effective and
\nwell tolerated, and in low transmission
\nareas, use of the combinations provides the
\nbonus of reducing malaria transmission and
\ntherefore the incidence of malaria.
\nThe rediscovery of artemisinin and the syn-
\nthesis of piperaquine, lumefantrine and
\npyronaridone in China have provided a new
\ngeneration of effective, well-tolerated, and
\nin some cases affordable, countrywide anti-
\nmalarial drugs rather than time-honoured
\nquinine, and may be effective.
\nDouble Act
\nCombination therapy \u2013 combining two
\ndrugs together to prevent the evolution of
\nresistance \u2013 is a practice already used for
\nthe treatment of tuberculosis, leprosy, HIV,
\nand many cancers. As the probability of the
\ndevelopment of a mutant resistant to one
\ncompound is very low, simultaneous resis-
\ntance to a combination is therefore extreme-
\nly unlikely to emerge.
\nThus, in order to prevent resistance to the
\nartemisinins, these drugs are being com-
\nbined with other synthetic compounds. As
\nartemisinin works quickly and is removed
\nfrom the body rapidly, these additional
\ncompounds should be those that last longer
\nin the body, mopping up any parasites that
\nhave escaped.
\nThe malaria genome project
\nWithin the genome of Plasmodium falci-
\nparum are the genes that make this malaria
\nparasite so deadly to humans. However, to
\ndate deciphering the genome in terms of
\nweak spots in the sequence, and on\/off
\nswitches used during development, has
\nbeen difficult. Despite its relatively small
\nsize \u2013 the human genome is 100 times larg-
\ner \u2013 the nature of the malaria genome has
\nremained elusive. Each of the 14 malaria
\nchromosomes has its own set of genes, but
\nthey all have highly conserved central
\nregions, and highly diverse regions near the
\nMedical Science, Professional Practice and Education
\nGenomics
\nStrategies in the Battle Against Malaria
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 46
\ntelomeres at the ends. There are 22.8 mil-
\nlion bases (Mb) of DNA, of which com-
\nplete sequences are available for chromo-
\nsomes 1-5, 12 and 14. The other chromo-
\nsomes still have some gaps remaining that
\nare being \u201cclosed up\u201d.
\nWithin the genome, 5279 genes have been
\nidentified. Only 40% of the proteins
\nexpressed by the genes resemble others in
\ndatabases, where a similarity often suggests
\nwhat their function might be. So around 60%
\nof the proteins may well be unique to this
\norganism, which is a very high percentage in
\ncomparison with other sequenced eukary-
\notes. This reflects both a massive evolution-
\nary distance and a highly specialised ecolog-
\nical niche occupied by this organism. The
\nsubtelomeric regions are of particular inter-
\nest because they contain highly variable
\ngene families, a variation due largely to the
\ndeletion or insertion of DNA sequences, that
\nhelp the parasite evade the human immune
\nsystem. They are also highly diverged
\nbetween species of Plasmodium and undergo
\nhigh levels of recombination, which gener-
\nates further diversity.
\nInsights into metabolism
\nOnly 733 of the 5277 genes have been iden-
\ntified as enzymes, proteins that make the
\nparasite tick, driving the metabolic path-
\nways that build up or break down the organ-
\nism\u2019s tissues for parasite use. Not only is
\nthis a lower percentage than in all other
\nsequenced organisms, but the parasite also
\nappears to lack some key biosynthetic path-
\nways. For example, it has little capability at
\nall for making purines \u2013 the adenine (A)
\nand guanine (G) in DNA.
\nMost of the biosynthetic pathways in
\nPlasmodium, such as in the synthesis of
\nhaem, isoprenoids and fatty acids, appear to
\nbe localised in the apicoplast, a structure
\nwithin the cell that has its own genome, and
\nis similar to the chloroplast of plants and
\nalgae. Although this genome encodes for
\nonly 57 proteins, it is calculated that around
\n10% of the proteins expressed genetically by
\nthe nucleus may come from this structure.
\nSome of the metabolic pathways identified
\nare not present in humans, and therefore are
\npotential targets for novel drugs and indeed,
\nthe availability of new possibilities for anti-
\nmalarial drugs.
\nInsights into pathogenesis and
\nimmune evasion
\nThe particular danger Plasmodium falci-
\nparum presents to humans is due in part to
\nthe way it can modify the surface of the
\nhost red blood cell in which it grows.
\nApproximately 16 hours after invasion, par-
\nasite-producing proteins can be detected on
\nthe surface of red blood cells. These then
\nmediate adhesion to a variety of host mole-
\ncules on endothelial cells and some other
\ncell types. Infected red blood cells do not
\ncirculate as normal, but instead accumulate
\nin the small blood vessels in a variety of
\norgans, where they may initiate life-threat-
\nening complications. The host immune sys-
\ntem is aware of these changed surface pro-
\nteins and launches a protective antibody
\nresponse. Yet the parasite is able to avoid
\nthis response by regularly switching
\nbetween different versions of the proteins \u2013
\na trick known as antigenic variation.
\nThe main benefits likely to come from the
\ngenomes of host and parasite will be analy-
\nsis of data using high throughput technolo-
\ngies of gene expression. Knowing the gene
\nsequences means DNA microassays can be
\ndesigned to look at the changes in gene
\nexpression, for example, during the cell
\ncycle and during drug treatment. Such novel
\ntechniques will help identify the pyramidal
\nnetworks of genes that are regulated in uni-
\nson \u2013 and shed much light on the way genes
\nare involved in drug resistance.
\nFurthermore, the complete genome will ena-
\nble proteomics to identify all the proteins
\nproduced in the different stages of the cell
\ncycle governing the parasite\u2019s existence, or
\nin different compartments within the cell.
\nConclusion
\nBig international science combined with
\nmedicine, utilising high throughputs of
\nfunctional genomics, will help researchers
\nto understand what the genes of parasite and
\nhost actually do. \u201cDNA chips\u201d or \u201cDNA mi-
\ncroassays\u201d, as a grid of tiny spots of DNA
\nfrom hundreds or thousands of genes, are
\nused to examine the expression of many ge-
\nnes at once. Subject areas include cyto-ad-
\nherence; antigenic variation; merozoite in-
\nvasion of red blood cells; sexual stage bio-
\nlogy, gametocytogenesis and parasite deve-
\nlopment in the mosquito; structural biology
\nof parasite proteins; and bio-informatics.
\nUsing parasites isolated at different stages
\nin their life cycle, DNA microassays will be
\nable to analyse which genes are switched on
\nor off at the various stages. Weak spots will
\nbe targeted for drug attack. High-through-
\nput identification of proteins using mass
\nspectrometry will enable crucial genes to be
\n\u201cknocked out\u201d or modified. The structures
\nof proteins in 3-dimensions, and the time di-
\nmension, will be analysed to learn more ab-
\nout how molecular orbital theory fits into
\ncatalytic function.
\nAs Dr. Tony Holden explains:
\n\u201cIn the last 20 years, only about 20 proteins
\nhave been characterised, whereas in the next
\n10 years, we hope to characterise several
\nhundred key proteins. These findings will
\nfeed into applied research for new drugs,
\ntreatments and vaccine against malaria.\u201d
\nIvan M. Gillibrand
\n47
\nMedical Science, Professional Practice and Education
\nImmunodiagnostics
\nHigh-Technology
\nMedicine At The
\nBedside
\nThe interesting technological inventions
\nfrom the Institute of Bioscience and
\nTechnology, Cranfield University, reported
\nbelow illustrate more potential for the use of
\n\u201chigh-tech\u201d diagnostic aids at the bedside.
\nDiagnosis in Public Health
\nDisorders
\nH. pylori (HP) infection is recognised as the
\nmost common gastrointestinal bacterial di-
\nsease world-wide. It is now accepted as the
\nmajor cause of gastroduodenal ulceration in
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 47
\n48
\nover 80-90% of patients. Tuberculosis (TB)
\nis another major public health problem, with
\napproximately one-third (1.9 billion) of the
\nworld\u2019s population infected. Typically, the
\ndiagnosis of these infections requires both
\nhigh-cost instrumentation and highly skilled
\npersonnel. This invention provides a rapid
\ndevice for measuring these bacterial infec-
\ntions at or near the patient\u2019s bedside.
\nAdvantages
\nThe use of electronic technology via the
\nnose\/nostrils has been successfully develo-
\nped since its introduction in the early 1980s,
\nprimarily aimed at the food industry. This
\ninvention exploits this technology further
\nfor medical applications, resulting in a devi-
\nce offering a number of advantages for dia-
\ngnosing bacterial infections, for example:
\n\u2022 The device can be applied to the analy-
\nsis of gas samples generated in vitro
\nfrom samples obtained from patients e.g.
\nsputum samples
\n\u2022 The device can be used to diagnose
\nand\/or monitor gastric and\/or lung disor-
\nders
\n\u2022 By utilising dedicated software, a fast
\nodour recognition system can be
\nemployed, significantly reducing diag-
\nnosis time
\n\u2022 Fast inexpensive collection of volatile
\nsamples can be achieved
\n\u2022 Storage and rapid analysis (within 10
\nminutes) of patient data, using a bedside
\ndiagnostic system
\nApplicability
\nThe device is ideally suited to the rapid,
\ncost-effective diagnosis of major bacterial
\ninfections of the human lung and stomach.
\nTechnical field
\nThe device operates by a unique enzymatic
\npre-treatment followed by passing the gas
\nsample over a multiplicity of chemical sen-
\nsors that generate electrical outputs. These
\noutputs are passed to a data processing sy-
\nstem, e.g. a hybrid intelligent system em-
\nploying a search optimisation engine of ge-
\nnetic algorithms and many neural networks.
\nThis determines the distinctive patterns cha-
\nracteristic of particular disease states.
\nReplication of Nucleic Acid
\nArrays
\nDNA analysis is now a vital tool used for a
\nwide variety of application from medical
\ndiagnosis and criminal forensics to military
\nand civil defence. Undoubtedly, the use of
\nthis technology will accelerate over the
\ncoming decades, largely as a result of inno-
\nvations and improvements to the existing
\ndevices. This invention relates to methods
\nfor manufacturing nucleic acid arrays and
\ntheir application in sequencing, detecting
\nand identifying specific nucleic acids. The
\ninvention is also directed towards methods
\nfor the replication of probe assays, used for
\nscreening biological samples for target
\nnucleic acids and nucleic acid variations.
\nAdvantages
\nCurrent methods for fabricating arrays suf-
\nfer from a common limitation, i.e. each
\narray and each element of each array
\nrequires a separate synthesis and fabrication
\nprotocol which is normally laborious, time-
\nconsuming and expensive. This invention
\novercomes these problems and provides
\nnew methods for rapidly and accurately
\nreplicating complementary copies of nucle-
\nic acid arrays. The solid supports that can be
\nused for the array base include porous or
\nnon-porous plastic, ceramics, glass, metals,
\nresins, gels, silicon and semiconductors.
\nApplicability
\nThe broad scope of this invention means
\nthat it can be applied to a wide range of
\napplications, where nucleic acid determina-
\ntion plays a key role including:
\n\u2022 Pharmacology
\n\u2022 Environmental diagnostics
\n\u2022 Medical diagnostics
\n\u2022 Forensic analysis
\n\u2022 Clinical analysis
\nTechnical field
\nThis invention covers a number of methods
\nfor producing arrays. Broadly, the methods
\nare based on the use of a pre-formed nucle-
\nic acid array (master copy) replicated by
\nbringing it into contact with a blank copy
\nwhich contains immobilised primers and by
\ninitiating specific replication of the nucleic
\nacid sequences either chemically or enzy-
\nmatically.
\nCholesterol in Heart Disease
\nOne of the main causes of death in the
\ndeveloped world is cardiovascular disease
\nand the contribution of elevated blood cho-
\nlesterol levels to this is well established.
\nThere is, consequently, a need to measure
\nlevels of cholesterol in order to diagnose the
\ncondition and prescribe appropriate dietary
\nor pharmaceutical treatment. This invention
\nprovides a rapid, accurate and low-cost
\napproach to measuring cholesterol, based on
\nscreen-printed biosensors that can be mass-
\nproduced.
\nAdvantages
\nThis is a very easy to use, rapid, low-cost
\nbiosensor system that can readily be used by
\nmost members of the general public. Indeed,
\nits method of use is very similar to that used
\nby diabetics (throughout the world), who
\nrely on an electrochemical-based biosensor
\nto measure their blood glucose levels. In
\ncontrast to most conventional home test kits,
\nused for measuring cholesterol levels, which
\ntend to be colour-based (hence relies on a
\nsubjective interpretation of a chart), this sen-
\nsor provides an accurate quantitative read-
\nout of cholesterol concentrations. In addi-
\ntion, this invention circumvents the lack of
\nwell-known direct electrochemical media-
\ntors for cholesterol oxidase.
\nApplicability
\nThe sensor provides an accurate measure-
\nment of blood cholesterol levels. However,
\nthe format of the device is not limited to
\ncholesterol. In effect, the invention pro-
\nvides a method for detecting almost any
\nanalyte that is oxidisable by means of an
\noxidase with the generation of hydrogen
\nperoxide. The list of potential target ana-
\nlytes includes:
\n\u2022 Glucose
\n\u2022 Amino acids
\n\u2022 Alcohols
\n\u2022 Xanthine (levels of which can be indica-
\ntive of liver pathology)
\nMedical Science, Professional Practice and Education
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 48
\nThis is not an exhaustive list and serves
\nsimply to illustrate the potential offered by
\nthis invention.
\nTechnical field
\nThe invention is based on a novel use of a
\nhorseradish peroxidase substrate, ABTS, as
\na mediator in an electrochemical enzyme
\nelectrode.
\nPreparation of Biologically-
\nActive Molecules by Template
\nPolymerization
\nThis invention provides an innovative
\nmethod for the synthesis of biologically-
\nactive molecules (e.g. drugs, effectors,
\nmodulators, inhibitors), providing a power-
\nful tool for many applications in analytical
\nchemistry. The synthetic molecules have a
\nstructure that is complementary to that of
\nthe original template, i.e. it is a replica that
\nresembles the drug molecule. However,
\ncompared to the conventional methods for
\nproducing biologically-active molecules
\nthis approach is quicker, easier and hence
\nlow-cost.
\nAdvantages
\nPrevious efforts in drug design have typi-
\ncally been based on the cumbersome inves-
\ntigation into the structure-activity relation-
\nships of a large number of chemical struc-
\ntures. This invention provides a much more
\nsimple and direct method to design biolog-
\nically-active substances.
\nApplicability
\nThis invention can be adapted to provide
\nbiologically-active molecules, derived from
\na wide range of receptors including:
\n\u2022 Enzymes and nucleic acids
\n\u2022 Cells, prions and viruses
\n\u2022 Tissue samples and drugs
\nHence, once prepared these molecules have
\na wide range of applications, e.g. used as
\ndrugs for pharmacology and medicine, as
\nreceptor-specific ligands in analytical
\nchemistry (sensors, assays) and for separa-
\ntions in the biotechnology and pharmaceu-
\ntical industries.
\nTechnical field
\nThe biologically-active molecules are syn-
\nthesised using the following sequence of
\nevents: 1) polymerisation of functional
\nmonomers in the presence of a biological
\nreceptor, 2) separation of the complex
\nformed, 3) removal of the template mole-
\ncule, and 4) solubilisation of the synthesised
\nreplica. Synthesised using this method, the
\ntarget molecules (dimers, oligomers, poly-
\nmers, or a mixture of these compounds) can
\nrebind either in vitro and\/or in vivo.
\nA Novel Building Block
\nApproach for Designing
\nAffinity Ligands for
\nGlycosylated Haemoglobin
\nThe exponential increase in the number of
\nstructures available in the Brookhaven
\nProtein Databank has led to a growing inter-
\nest in the direct approach to drug design.
\nBased on the development, this invention
\nexploits the tools developed and used by
\npharmaceutical companies to aid the devel-
\nopment of synthetic receptors.This inven-
\ntion provides the novel concept of using a
\n\u201cbuilding blocks\u201d approach for designing
\naffinity ligands; significantly enhancing the
\npotential for constructing specific sensor
\nsystems that, hitherto, would have proved to
\nbe extremely difficult.
\nAdvantages
\nUsing this technology it is possible to char-
\nacterise the target protein molecule efficient-
\nly, estimate the interactions between individ-
\nual combinatorial \u201cbuilding blocks\u201d and any
\nproposed binding site, rationally designing
\nnew peptide sequences and also to investi-
\ngate the interaction between lead ligands and
\nthe binding site. Hence, the invention pro-
\nvides a highly efficient and effective method
\nfor the design of \u201cbespoke\u201d synthetic recep-
\ntors. This is a distinct advantage when it is
\ndesirable to either replace a less robust, bio-
\nlogically derived, receptor or to designing a
\nligand for a particular sensor system when
\nno such (biological) element exists.
\nApplicability
\nThis invention can be used for a number of
\napplications including:
\n\u2022 The rational design of new peptide
\nsequences
\n\u2022 The rational design of synthetic recep-
\ntors that could be used in conjunction
\nwith a wide range of sensor systems,
\ne.g. amperometric, potentiometric, opti-
\ncal, magnetic and gravimetric based
\ntransducers
\nTechnical field
\nThis invention relates to the generation of
\nsynthetic affinity ligands. It is based on a
\nthree-domain approach that can be general-
\nly applied to the design of artificial ligands,
\nintended for analytical purposes. These
\ndomains are comprised of recognition,
\naffinity, and flexible components, each
\ndomain fulfilling a specific function. The
\ndesign of each is obtained through a virtual
\nscreening of chemical databases.
\nAn Intelligent Volatile Pattern
\nAnalyser for Diagnosis of Uri-
\nnary Tract Infections in vivo
\nUrinary tract infections (UTI) are a signifi-
\ncant cause of morbidity with around 3 mil-
\nlion UTI cases each in the USA alone.
\nThirty-one percent of nosocomial infec-
\ntions in medical intensive care units are
\nattributable to UTI. Current diagnostic
\ntechniques require 24-48 hours to identify
\npathogenic species in urine midstream
\nspecimens. Despite the introduction of mol-
\necular tests, culture remains the gold stan-
\ndard in everyday clinical practice. This
\ninvention greatly reduces the time required
\nto carry out a diagnostic test. Based on the
\nuse of an intelligent diagnostic model,
\ndetection and recognition of UTIs can be
\naccomplished within 5 hours of the receipt
\nof specimens in the laboratory.
\nAdvantages
\nThe application of this novel technique,
\ncombining sensor technology with artifical
\nintelligence, offers the opportunity for rapid
\nand accurate discriminating between differ-
\nent infective organisms in fresh samples of
\nurine. Based on this invention, future devel-
\nopments could lead to a new generation of
\ndiagnostic instruments capable of providing
\nrapid detection of infectious agents in vitro
\n49
\nMedical Science, Professional Practice and Education
\n00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 49
\n50
\nThe Commission on Intellectual Property
\nRights, Innovation and Public Health held
\nits first meeting on 5-6 April at the World
\nHealth Organization (WHO) in Geneva.
\nThe Commission was established as a result
\nof a World Health Assembly Resolution in
\n2003 which called for WHO to establish a
\ntime-limited body to \u201cproduce an analysis
\nof intellectual property rights, innovation,
\nand public health, including the question of
\nappropriate funding and incentive mecha-
\nnisms for the creation of new medicines and
\nother products against diseases that dispro-
\nportionately affect developing countries.\u201d
\nWelcoming the members of the
\nCommission, Dr. LEE Jong-wook,
\nDirector-General of WHO, said: \u201cMaking
\ntreatments available for diseases associated
\nwith poverty has been a major priority for
\nWHO ever since the organization came into
\nexistence. These diseases confront us with
\nhighly urgent needs that are usually
\nextremely difficult to meet. Bold and inno-
\nvative thinking is required \u2013 not only to find
\ntechnical solutions but to find economic,
\nsocial and political ones as well.\u201d
\nThe Commission held discussions with
\nsenior officials from WHO, representatives
\nfrom international organizations (UNC-
\nTAD, UNAIDS, WIPO, WTO), from the
\nresearch-based pharmaceutical industry and
\nfrom civil society.
\nIn her opening remarks, the chairperson of
\nthe Commission, Ms Ruth Dreifuss, said:
\n\u201cThe advance of medical science is of the
\nutmost importance in attacking these prob-
\nlems. The issue we are asked to address is
\nthat medical science tends to focus dispro-
\nportionately on diseases and ailments of the
\ndeveloped world.\u201d
\nThe Commission agreed on a policy of
\nopenness in consulting the many different
\nstakeholders with an interest in its work,
\nand in drawing on the expertise they have to
\noffer in supporting the work of the
\nCommission. It requested the Secretariat to
\ncompile a register of stakeholders and indi-
\nviduals with expertise to offer. Its publica-
\ntions, and submissions received by the
\nCommission, will be placed on the
\nCommission website.
\nWorld Health Report
\n2004 and the World
\nHealth Assembly
\nThe World Health Report 2004 has as its
\nmain theme the problem of the pandemic of
\nHIV\/AIDS and concentrates on the call for
\na comprehensive strategy linking preven-
\ntion, treatment, care and long-term support.
\nIt stresses the need for international organi-
\nsations, national governments, the private
\nsector and communities to combine their
\nstrengths to tackle HIV\/AIDS and in parall-
\nel, strengthen their health systems, which
\nwill also benefit whole communities. The
\nWorld Health Assembly itself reflected both
\nthe immediacy of the HIV\/AIDS crisis and
\nthe importance of improving public health
\nin the resolutions it adopted. This was
\nsummed up by the comment of Dr. LEE
\nJong-wook, WHO Director-General, that
\n\u201cThis World Health Assembly clearly
\nraised the bar for improving public health
\nof all people\u201d.
\n(A full comment will appear in the next
\nissue of WMJ-Ed.)
\nWHO
\nand in vivo, with enormous implications for
\nfuture clinical practice.
\nApplicabilitiy
\nThis apparatus will be ideally suited for use
\nin a hospital laboratory environment, where
\nthe rapid (and hence more economical)
\ndetermination of UTIs can be achieved.
\nTechnical field
\nThe apparatus comprises a vapour or gas
\ngenerating system which, by interaction
\nwith a urine sample, produces volatile
\nchemicals that are characteristic of infec-
\ntion. The product of this interaction is then
\ndelivered to a detection system in a precise
\nand reproducible way. This detection sys-
\ntem comprises an array of sensors, each
\nhaving a different sensitivity to potential
\ncomponents of the gas stream. An electrical
\noutput signal is generated in response to
\nthese components. A data processing sys-
\ntem then analyses this output signal, pro-
\nviding a profile of the urine sample \u2013 high-
\nlighting any UTIs.
\nCranfield University
\nSilsoe
\nInstitute of Bioscience and Technology
\nBedfordshire MK45 4DT
\nEngland
\nTel.: +44 (0) 1525 863000
\nFax: +44 (0) 1525 863001
\nWebsite: www.silsoe.cranfield.ac.uk
\nWHO
\nCommission on Intellectual Property Rights,
\nInnovation and Public Health
\nWORLD HEALTH
\nASSEMBLY
\nRESOLUTIONS 2004
\nWHO Global strategy on Diet, Physical
\nactivity and Health
\nHealth Promotion and healthy lifestyles
\nReproductive health
\nResolution on the family and reproductive
\nhealth
\nResponse to HIV\/AIDS
\nGlobal effort to eradicate Polio
\nGuinea-worm disease
\nBuruli ulcer
\nHuman African Trypanosomiasis
\nReducing Measles deaths
\nHuman organ and tissue transplantation
\nInternational migration of Health Per-
\nsonnel
\nFramework Convention on Tobacco control
\n00_WMJ_02_2004.qxd 23.07.2004 12:12 Seite 50
\nAsian and African Countries Move to
\nImprove the Quality of their Medicines
\nGeneva \u2013 The World Health Organization
\nhas launched an action plan against sub-
\nstandard and counterfeit medicines with six
\ncountries from the Greater Mekong sub-
\nregion. The plan follows similar initiatives
\nin Africa and will continue to expand in
\nresponse to countries\u2019 increasing call for
\nassistance to improve the quality of their
\nmedicines.
\nCounterfeit and substandard medicines are
\nfrequently detected in Cambodia, China,
\nthe Lao People\u2019s Democratic Republic, My-
\nanmar, Thailand and Viet Nam and the pro-
\nblem seems to be increasing. Products most
\ncommonly counterfeited in this region in-
\nclude antibiotics and those used in the treat-
\nment of tuberculosis, malaria and
\nHIV\/AIDS. The use of poor-quality or
\ncounterfeit medicines has little or no thera-
\npeutic effect and in poor settings often leads
\nto death.
\n\u201cCombating low quality or illegal medici-
\nnes is now more important than ever. Ex-
\npanding access to safe, effective treatment
\nfor AIDS and other illnesses is no longer an
\noption, it is an imperative,\u201d says Dr LEE
\nJong-wook, WHO Director-General.
\nAt a meeting from 11-13 November 2003 in
\nHanoi, Viet Nam, WHO and the six coun-
\ntries kick-started joint activities directed at
\nkey decision-makers, health professionals
\nand the general public to strengthen inspec-
\ntion and post-marketing surveillance.
\nSubstandard medicines are thought to
\naccount for 8.5% of medicines on the mar-
\nket in Thailand. Eight per cent of randomly
\ncollected samples in Viet Nam and 16% in
\nMyanmar failed laboratory testing for qual-
\nity assessment. From these batches,
\nRifampicin (used to treat tuberculosis)
\nshowed the highest failure rate at 26% fol-
\nlowed by Cotrimoxazole (an antibiotic used
\nmostly for children) at 24%.
\nIn 2001 it was estimated there were 2,800
\nillegal medicine sellers in Cambodia and
\n1000 unregistered medicines on the market.
\nIn the Lao People\u2019s Democratic Republic
\n2,100 illegal drug sellers are said to exist.
\nWith more complex combination medicines
\nnow being recommended for drug-resistant
\nmalaria, there is a strong possibility that
\nmore substandard and counterfeit medi-
\ncines will enter the market in malaria-
\nendemic countries. Even in terms of older,
\nmore traditional antimalarials, the quality
\nof the medicines is often poor.
\nA recent WHO survey of the quality of anti-
\nmalarials in seven African countries (sam-
\nples from Gabon, Ghana, Kenya, Mali,
\nMozambique, Sudan, and Zimbabwe)
\nrevealed that between 20% and 90% of the
\nproducts failed quality testing. The anti-
\nmalarials in question were chloroquine-
\nbased syrup and tablets, whose failure rate
\nranged from 23% to 38%; and sulphadox-
\nine\/pyrimethamine tablets, up to 90 % of
\nwhich were found to be below standard.
\nThe medicines were a mixture of locally
\nproduced and imported products.
\nThe reason why many of the antimaterials
\ntested were substandard seems to stem from
\npervasive poverty. Poorly equipped labora-
\ntories, under-funded regulatory authorities,
\nand poor handling and manufacturing prac-
\ntices mostly contributed to the results of the
\ntests.
\n\u201cMany tools exist to improve medicines\u2019
\nquality control and supply systems,\u201d
\nexplains Dr Vladimir Lepakhin, Head of
\nHealth Technology and Pharmaceuticals at
\nWHO. \u201cThe problem is one of resources.
\nMost of the countries with the lowest qual-
\nity pharmaceuticals are also the ones with
\nthe highest disease burden and the poorest
\neconomies.\u201d
\nThe findings of the report have provided a
\nbasis from which to address potential prob-
\nlems in the transition to the combination
\nartesimin-based medicines for drug-resis-
\ntant malaria and have given impetus to the
\nfight against poor quality and counterfeit
\nmedicines in Africa.WHO is now running a
\nseries of training workshops in several
\nAfrican countries assisting manufacturers
\nto upgrade their standards, and regulatory
\nauthorities (the national bodies meant to
\nassure the quality and safety of medicines)
\nto improve their practices in the screening
\nand testing of local and imported products.
\n51
\nWHO
\nQuality control
\nAction Against Substandard and Counterfeit
\nMedicines
\nIn political circles, the term VISIBILITY
\nmeans a great deal. If a politician or organi-
\nzation has visibility, it has a better chance of
\nconvincing the electorate or general public of
\nnew directions or policies which should be
\nfollowed, or the importance of maintaining a
\ncurrent position. Translated into our world of
\nhealth care, the World Medical Association
\n(WMA) can only act effectively as a strong
\nadvocate for the profession and the patients it
\nserves, if it is VISIBLE on the global stage
\nof leadership in health care. The question is
\ntherefore how visible the WMA is today, par-
\nticularly in relation to its collaboration with
\nthe World Health Organization (WHO) and
\nits impact on the members of WHO (the gov-
\nernments of the world).
\nCurrently, the global leadership in health
\ncare is represented by a curious mix of
\nplayers, including governmental, intergov-
\nernmental, non-governmental, and private
\ngroups, as well as some public-private part-
\nnerships. Because these groups have to get
\ntheir message communicated and heard in a
\nglobalizing and highly information-driven
\nworld, there is tremendous competition to
\nbe the one to actually set or influence the
\nWMA Secretary General
\nFrom the Secretary General\u2019s Desk, May 2004
\n00_WMJ_02_2004.qxd 23.07.2004 12:12 Seite 51
\n52
\nglobal health agenda. This battle often takes
\nplace during the WHO\u2019s annual meeting,
\nthe World Health Assembly (WHA), which
\nhappened to follow the WMA Council
\nmeeting in May 2004. During the WHA,
\ngovernmental delegations from all countries
\nof the world gather to discuss and set policy.
\nAs with all political meetings, the most
\nimportant actions and political deal-making
\noften take place in the corridors. It is there-
\nfore understandable that one would find in
\nthese corridors representatives of health
\nprofessions\u2019 associations, non-governmen-
\ntal organisations and private industry, all
\ntrying to influence the decision-makers in a
\nway which would be of benefit to the groups
\nthey represent. One of the most effective
\nhealth professional groups in terms of lob-
\nbying has been the International Council of
\nNurses (ICN). During the WHA, they have
\na team advocating on behalf of nursing and
\nmake several interventions on matters
\nwhich might have an impact on nursing and
\nits future. Reflecting on how the WMA has
\nperformed in this regard, one must unfortu-
\nnately concede that until the year 1999, the
\nWMAvoice had been largely absent. In fact,
\nfor several years, the WMA was not even in
\nofficial relations with WHO.
\nFortunately, this was rectified in 1996 when
\nofficial relations were re-established.
\nHowever, even after the \u201cre-unification\u201d, it
\nwas distressing to find at that time a quite
\npalpable \u201canti-physician\u201d sentiment in
\nWHO. In response to this undesirable situa-
\ntion, and in an effort to make the WMA
\nmore visible, the WMA leadership estab-
\nlished a clear strategy in 1998 to improve
\nrelations with WHO and other international
\nstakeholders. Almost immediately, the strat-
\negy bore fruit. In 1999, the WMA was
\nrequested by WHO to chair a planning com-
\nmittee of all the health professional associa-
\ntions for the development of a global pro-
\ngram supporting World No Tobacco Day
\n1999. Subsequently, relations have been
\ngreatly strengthened, with many tangible
\nresults to confirm this increased visibility
\nand political effectiveness, as for example:
\n– the WMA participated in all the negoti-
\nations and debates leading up to the
\nadoption of the Framework Convention
\non Tobacco Control;
\n– the inclusion of the WMA in the WHO
\nGlobal Alert and Response Network to
\ncombat communicable diseases. This
\nhas been updated to deal more effective-
\nly with new epidemics such as SARS;
\n– the development of policy on safe injec-
\ntions, with the Safe Injection Global
\nNetwork (SIGN);
\n– the development of policy on \u201cViolence
\nand Health\u201d, and participation in the
\nWHO launch of this project;
\n– the management of human resources for
\nhealth.
\nAnother important part of the WMA\u2019s \u201cvis-
\nibility\u201d strategy was to encourage its mem-
\nbers to work to become regular advisers to
\nthe governmental delegations participating
\nin the World Health Assembly. In this
\nregard, the May 2004 event had unprece-
\ndented levels of visibility for the WMA:
\n– 9 Governmental delegations to the
\nWHA included representatives from the
\nWMA leadership;
\n– 10 members of Council stayed on to
\nattend part of the WHA;
\n– during the WHA, several interventions
\nwere made on behalf of the WMA;
\n– the WMA arranged a leadership sympo-
\nsium, in partnership with the
\nInternational Council of Nurses and the
\nInternational Pharmaceutical Federation,
\nwhich was attended by the Councils of
\nthe three groups and WHO. This historic
\nevent was sponsored, in part, by WHO
\n(another first) and the WHO Director-
\nGeneral was the keynote speaker;
\n– the WMA had two further receptions for
\nMinisters of Health during the
\nAssembly, each time drawing more than
\n40 Ministers of Health with their dele-
\ngations. At one of the receptions, the
\nWMA chose the theme of HIV\/ AIDS,
\nand it was remarkable that the three
\nmost prominent groups involved in this
\narea all accepted invitations to speak \u2013
\nthe Executive Director of UNAIDS, Dr.
\nPeter Piot, the WHO Assistant Director-
\nGeneral, Dr. Jack Chow, and the Chair
\nof the Global Fund to Fight AIDS,
\nTuberculosis and Malaria, Secretary
\nTommy Thompson of the USA.
\nQuite a remarkable turnaround in relations
\nand visibility! In fact, it can be argued that
\nthe WMA has never been more VISIBLE
\non both the WHO and international stage of
\nhealth leadership than it has been over the
\nlast month. This has required tremendous
\ntime and effort from all the leadership and
\nstaff of the WMA, but for a cause well
\nworth it \u2013 our profession and our patients.
\nNeedless to say, this was only the introduc-
\ntion to greater visibility and effectiveness in
\na never-ending quest for relevance and
\ninfluence. In fact, Churchill\u2019s words ring
\ntrue when we reflect on our \u201cvisibility\u201d
\nstrategy and its first fruits:
\n\u201cThis was neither the beginning nor the
\nend, rather, it was the end of the beginning.\u201d
\nRegional & NMA News
\nRegional & NMA News
\nBANGLADESH
\nThe Bangladesh Medical Association, with
\nthe collaboration of the Ministry of health
\nand Family Welfare, the Ministry of LGRD
\nand Co-operation has launched a Health
\nSector Strengthening Programme for capa-
\ncity building of doctors and other staff
\nfighting Arsenicosis and published a Trai-
\nning Manual for Trainers on the Early
\nDiagnosis and Management of Arsenicosis,
\na major public health problem in this coun-
\ntry. Whilst referring to the first case of large
\nscale health problems caused by naturally
\noccurring arsenic being in Taiwan in 1968,
\nto its existence in many other countries and
\nheavy dependence on groundwater for pu-
\nblic drinking water supply, it is stated that
\nproblems in groundwater from the alluvial
\nand deltaic aquifers of Bangladesh repre-
\nsent the most serious occurrences identified
\nglobally. In one survey across the country,
\n46% of wells less than 150m deep excee-
\nded the WHO guideline of 10 \u00b5g\/l. Dr.
\nM.A. Hadi, President of the Bangladesh
\nMedical Association, writes:
\n\u201cOne of the most serious public health pro-
\nblems that we are facing in Bangladesh isAr-
\nsenicosis. The majority of our people are ex-
\nposed to this health hazard and a large num-
\nber are also suffering from complications.\u201d
\n00_WMJ_02_2004.qxd 23.07.2004 12:12 Seite 52
\nUN, World Bank and Global Fund call on
\nEuropean Ministers to scale up HIV pre-
\nvention and treatment programmes
\nDublin \u2013 AIDS is rapidly spreading in
\nEastern Europe and is on the rise again in
\nWestern Europe because integrated preven-
\ntion and treatment programmes have not
\nbeen sustained or do not exist. Countries in
\nEastern Europe, home to the fastest-grow-
\ning epidemic in the world, will be in
\nEurope\u2019s borders following the European
\nUnion\u2019s enlargement on 1 May 2004. The
\nBaltic States, which will be part ot the EU,
\nare also experiencing a rapid rise in HIV
\ninfections.
\nLeading UN agencies, the Global Fund to
\nFight AIDS, Tuberculosis and Malaria and
\nthe World Bank are calling on European
\nMinisters to urgently take decisive action to
\nprevent the further spread of AIDS across
\nEurope and to treat those in need. They warn
\nthat young people and other groups, such as
\nsex workers, men who have sex with men
\nand injecting drug users, are particularly at
\nrisk of HIV infection. The agencies partici-
\npated in a Ministerial Conference hosted by
\nthe Irish EU Presidency, \u201cBreaking the bar-
\nriers \u2013 Partnership to fight HIV\/AIDS in
\nEurope and Central Asia\u201d, in Dublin.
\n\u201cEurope and Central Asia are the centre of
\nthe fastest-growing HIV epidemic in the
\nworld. There is no time to waste \u2013 European
\nMinisters must urgently scale up and roll
\nout effective HIV prevention and treatment
\nprogrammes,\u201d said Dr Peter Piot, UNAIDS
\nExecutive Director. \u201cGiven that the EU will
\nform the biggest trading bloc in the world,
\ncovering more than 500 million people, it is
\nin the EU\u2019s best interest to prevent the
\nAIDS epidemic from crippling Europe\u2019s
\nsocial and economic development.\u201d
\nAlthough most people in Western Europe
\nnow have access to free treatment through
\nnational health systems, many governments
\nhave not focused as much on prevention as
\nthey did in the 1990s. Infection rates are
\nonce again on the increase. Integrated pre-
\nvention and treatment programmes are also
\nurgently needed to ensure that life-prolong-
\ning treatment is not seen as a cure and to
\nensure that people living with HIV\/AIDS
\ncontinue to protect themselves and their
\npartners.
\nOver 1.5 million people are living with HIV
\nin Eastern Europe and Central Asia, com-
\npared to only 30,000 in 1995. Young peo-
\nple, who make up 40% of the population in
\nthe region, account for the majority of HIV
\ninfections among injecting drug users. A
\nlarge number of them also engage in unsafe
\nsex, increasing the risk of HIV. There is
\nalso evidence that people are having sex at
\na much younger age without protection.
\nThe percentage of people reporting premar-
\nital sexual relations more than doubled
\nbetween 1993 and 1999, from 9% to 22%.
\nOnly 10% of girls in Tajikistan have ever
\nheard of HIV\/AIDS.
\n\u201cSchools are the best defence against HIV
\ninfection,\u201d said Carol Bellamy, Executive
\nDirector of UNICEF. \u201cThey offer the best
\nmechanism to deliver HIV prevention
\ninformation, as well as the long-term edu-
\ncational and social skills that protect
\nagainst infection. With knowledge so criti-
\ncal in the fight against HIV\/AIDS, the best
\ndefence against the epidemic is keeping
\nvulnerable young people, especially girls,
\nin school.\u201d
\nIn Eastern Europe and Central Asia, only
\n7000 people receive antiretroviral therapy
\nfor HIV, which is 9% of those in need in the
\nregion. For many, the treatment is too
\nexpensive or simply not available. To
\naddress this imbalance, the World Health
\nOrganization and UNAIDS have launched
\nan ambitious challenge to get three million
\npeople on antiretrovirals by 2005 in devel-
\noping countries and emerging economies.
\nDr LEE Jong-wook, WHO Director-
\nGeneral, said: \u201cTreatment saves lives.
\nWithout treatment, the millions of people
\nliving with HIV will die prematurely.
\nPrevention must go hand in hand with treat-
\nment. Europe cannot divide over the issue
\nof AIDS treatment, and only provide treat-
\nment in the richer countries. Treatment
\nshould be a right for all, including for sex
\nworkers and injecting drug users.\u201d
\nIn many countries of Western Europe, there
\nare increasing rates of sexually transmitted
\ninfections, indicating resurgence in unsafe
\nsex, primarily among young heterosexuals.
\nIn 2003 alone, between 30,000 and 40,000
\npeople became infected with HIV, raising
\nthe number of people living with HIV to
\nbetween 520,000 and 680,000. \u201cThe
\nenlarged EU and its neighbours could
\nrapidly be faced with a more vigorous
\nphase of the epidemic unless political lead-
\ners transform their verbal commitments
\ninto concrete action on the ground,\u201d said
\nLars Kallings, the UN Secretary-General\u2019s
\nSpecial Envoy for HIV\/AIDS in Eastern
\nEurope, speaking at the conference.
\n53
\nReviews
\nGERMANY
\nAt the 107th
\nmeeting of the Deutscher
\n\u00c4rztetag (Annual Meeting of the German
\nMedical Association) in Bremen, adherence
\nto the provisions of the Helsinki Declaration
\nwas reinserted into the professional Ethical
\nRegulations. At this meeting Dame Cicely
\nSaunders, the pioneer of palliative medicine,
\nwas honoured by the award of the
\nParacelsus Medal, the highest award which
\nthe German Medical profession can bestow.
\nDue to Dame Cicely\u2019s indisposition, the pre-
\nsentation was made in the U.K. by the
\nPresident of the Bundes\u00e4rztekammer,
\nProfessor J\u00f6rg-Dietrich Hoppe.
\nEU Enlargement
\nThe enlargement of the European Union to 25 Member States means that the EU will
\nconstitute almost half of the WHO European Region (51 Member States).
\nTB Resistance and Aids Threat Growing
\nThroughout Europe
\n00_WMJ_02_2004.qxd 23.07.2004 12:12 Seite 53
\n54
\nHumans in the service of medical science
\nin the twentieth century
\nJordan Goodman, Anthony McEllgott, and
\nLara Marks, Des.
\nJohns Hopkins University Press, 2003,
\n\u00a331, pp. 217
\nISBN 0 8018 7342 8
\nThis multi-disciplinary volume is based on
\ncontributions to a workshop on Human
\nExperimentation at the Wellcome Institute
\nfor the History of Medicine in London in
\n1998.
\nIn a comprehensive introductory chapter
\n\u201cMaking Human Bodies Useful\u201d, the edi-
\ntors set out their aim of presenting an his-
\ntorical review of medical experimentation
\nin the 20th century based \u201cnot around the
\nfamiliar doctor-patient or scientist-subject
\naxis, \u2026 but on the role of the state as actor,
\nlegitimator and provider.\u201d They aver that
\n\u201cthe concept of usefulness is the point of
\ncontact between human experimentation,
\nknowledge, and the state. \u201cWith reference
\nto the \u201chorrible uniqueness\u201d of medical
\nexperimentation in Nazi Germany and the
\nconsequential Nuremberg Code, they claim
\n\u2013 with melancholy justification \u2013 that abu-
\nsive practices flourished in medical practice
\nin situations where the state was not so
\ncoercive as in Germany. They argue that
\n\u2018medical science has become a constitutive
\nforce in the creation of a knowledge soci-
\nety\u2019, and they show that the hallowed con-
\ncept of \u2018informed consent\u2019 which has dom-
\ninated ethical discussion since Nuremberg
\nis seriously flawed; even when it has been
\nobtained, human experiments \u201cmay still
\nviolate the patient\u2019s autonomity\u201d. Examples
\nabound of the experimental dilemma in
\nwhich they are torn between the conflicting
\nimperatives of obtaining information and
\npreserving their ethical integrity. Subjects
\nare too often unwitting if not unwilling.
\nThe following seven chapters range widely
\nthroughout the world and the century, with
\nreference to earlier ethical codes from Hip-
\npocrates, through Thomas Percival, to Clau-
\nde Bernard, reviewing and discussing expe-
\nriments on healthy individuals, groups of
\npatients, military service personnel, and
\nwhole populations. Readers may be familiar
\nwith some of the examples, such as the in-
\nvestigations during and after the Second
\nWorld War aimed at elaborating the com-
\nplexities of viral hepatitis, and the exposure
\nof 35,000 service personnel and 2,000 civi-
\nlians to atomic blasts in Australia and on
\nChristmas Island. Other examples may
\ncome as a shock, notably the germ warfare
\ntests in the UK after World War II in which
\ngreat swathes of the country were sprayed
\n(without the knowledge or consent of the
\npopulation, needless to say) with \u2018simu-
\nlants\u2019which post-hoc evaluation fortunately
\nadjudged to be innocuous, and \u2013 at the other
\nextreme of the spectrum of harm \u2013 the injec-
\ntion of comatose patients with uranium. The
\noutstanding feature of every chapter is a
\ncornucopia of notes (extended references
\nand explanatory comments) which are a tre-
\nasure for researchers. Conversely, an index
\nwas evidently considered redundant.
\nAlthough the authors address particularly
\nthe role of the state in influencing medical
\nexperimentation either directly as in the
\n\u201ceuthanasia\u201d of \u201clives unworthy of life\u201d
\n(lebensunwertes Leben) in pursuit of the de-
\nmented \u201ceugenic\u201d policy of the Herrenvolk,
\nor indirectly sponsoring selective experi-
\nments in its own interests as in the exposure
\nof thousands of people to nuclear radiation,
\nthe compelling challenge of this book is to
\nthe medical experimenter. That challenge is
\nto resist the temptation to rationalise, e.g.
\nthat the subjects are in a situation where it is
\nassumed that they will become infected
\nsooner or later, as in the case of the mentally
\nretarded children in the Willowbrook State
\nSchool on Staten Island who were admini-
\nstered infected material from patients with
\nhepatitis. Arguably, it may be thought even
\nless defensible to inflict potentially dange-
\nrous and traumatic experiments on \u201cuse-
\nless\u201d patients suffering from, eg. an uncura-
\nble brain tumour or neurosyphilis, on the
\npretext that they can be rendered useful to
\nmedical science and its future beneficiaries.
\nUltimately the challenge is to the integrity
\nand the conscience of researchers and their
\nability to resist the blandishments of
\nfinance, fame and fortune.
\nA. W. Macara
\nReviews
\n\u201cData from the region unambigously points
\nto the socio-economic and governance
\ndimensions of the epidemic. Members of at-
\nrisk groups are often subject to social exclu-
\nsion, poverty, stigmatisation, or incarcera-
\ntion \u2013 factors which actually heighten the
\nspread of the disease,\u201d said Kalman Mizsei,
\nAssistant UNDP Administrator and
\nRegional Director for Europe and the CIS.
\nIn addition to increased AIDS funding from
\nnational governments, the World Bank and
\nthe European Union, the Global Fund to
\nFight AIDS, Tuberculosis and Malaria has
\napproved over US$ 400 million in funding
\nover five years for 22 programmes in 16
\ncountries in Eastern Europe and Central
\nAsia. Most of these funds are earmarked for
\nHIV prevention and treatment programmes,
\nalong with programmes to control tubercu-
\nlosis, the biggest killer of people living with
\nHIV. Dr Richard Feachem, Executive
\nDirector of the Global Fund, said: \u201cSwift
\nimplementation of programmes is possible,
\nas our experience in Estonia has shown,
\nmoving from grant signing to first disburse-
\nment to implementation of targeted preven-
\ntion and treatment programmes in just 12
\nweeks. Urgent action is needed throughout
\nthe region to turn the tide of the disease.\u201d
\n\u201cEffective HIV\/AIDS prevention and care
\nprogrammes will require that funding from
\nall sources increase to about US$ 1.5 billion
\nby 2007. But money alone is not the issue.
\nIt is crucial to improve the information base
\nfor programmes, to support what works
\nagainst HIV\/AIDS, and to break down the
\npolicy and social barriers to effective
\nactions across the region,\u201d said Shigeo
\nKatsu, World Bank Regional Vice President
\nfor Europe and Central Asia.
\nReviews
\nUSEFUL BODIES
\n00_WMJ_02_2004.qxd 23.07.2004 12:12 Seite 54
\nRoy Porter and David Wright,Eds.,
\nCambridge University Press 2003,
\n\u00a359, pp 371, ISBN 0521802067, Hardback
\nSamuel Johnson defined \u2018to enlighten\u2019 as
\n\u2018to illuminate, to supply with light, to in-
\nstruct, to furnish with increase of knowled-
\nge, to cheer, to exhilarate, to gladden, to
\nsupply with sight, to quicken the faculty of
\nvision\u2019. So we are informed in Roy Porter\u2019s
\nbrilliant book \u2018Enlightenment\u2019 (2000). In
\nall senses of the word, Roy Porter himself
\nenlightened the history of medicine, inclu-
\nding psychiatry, in his own writings and in
\nhis exhilarating teaching of a host of glad-
\ndened and quickened students at the Well-
\ncome Institute for the History of Medicine.
\nMany of these have contributed to this vo-
\nlume, which is dedicated to him. He died \u2013
\nmuch too early \u2013 in March 2002, but not
\nbefore contributing a characteristically li-
\nvely and generous Introduction, summari-
\nsing all the contributions and reviewing
\nsome of the conflicting interpretations of
\nthe chequered history of psychiatry. He re-
\nlished the clash of views, and the opportu-
\nnies to challenge all of them in turn,
\nthrough careful research.
\nThe sub-title \u2018International Perspectives\u2019 is
\nfully justified, as every continent gets atten-
\ntion \u2013 Switzerland, Germany, France,
\nEngland and Ireland in Europe; Nigeria and
\nthe Cape (Robben Island) in Africa;
\nVictoria in Australia; Canada, USA,
\nMexico and Argentina in America; India
\nand Japan in Asia. All the contributions
\nmake interesting reading.
\nThe dates are not so precise as suggested, a
\nfew accounts beginning before 1800 and
\nseveral going up to the end of the last cen-
\ntury. The print is clear, but some of the fig-
\nures, a murky patchwork of grey stippling,
\nare rather difficult to make out.
\nA simplistic narrative of British psychiatry
\nbegins in the late 18th century, when some
\nleading local benefactors decided to build
\nhandsome hospitals, each with a classical
\nportico, which would care for unfortunate
\nlunatics in a humane and up-to-date fashion
\nand return them to their homes or other
\naccommodation in due course. But these
\npatients did not all recover, nor did they die,
\nbut survived as an increasing burden \u2013 a
\nspace-occupying lesion which required the
\ngradual enlargement of the hospital. The
\nresult was a degraded and deteriorating
\nenvironment, with the portico dwarfed by
\nthe ramparts of later building, and the disil-
\nlusionment of staff patients and their fami-
\nlies; and a fall in income. One of the found-
\ning notions had been that the better-off
\npatients would pay for better accommoda-
\ntion. But these now stayed away, and their
\ncontributions, always smaller than expect-
\ned, became insignificant. The occasional
\nscandal led to management changes and
\nsome transient improvement. Meanwhile,
\nall this did not deter a considerable invest-
\nment of public money in the construction
\nand staffing of local mental hospitals
\nthroughout the 19th century.
\nIn his lifetime, Roy Porter encouraged a
\ndifferent approach of \u2018history from below\u2019,
\nbased on, the people and processes
\ninvolved in the system and their networks.
\nThere are several examples of this approach
\nin the book, as well as others on more tradi-
\ntional lines.
\nFor instance, in Argentina, a country with a
\nstormy political history, the first asylum to
\nbe opened, in an old convent in Buenos
\nAires in 1854, admitted only women. The
\nmen\u2019s asylum opened 9 years later. There
\nwere only 200 beds in each, to serve not
\njust the capital but the whole country,
\nwhose welfare system was focussed on the
\nneeds of working people in various indus-
\ntries rather than on the indigent poor. The
\nMinistry in charge was that of \u2018Foreign
\nRelations and Religion\u2019 (the Health
\nMinistry only took responsibilty reluctant-
\nly, and under intense pressure, in 1947).
\nBoth hospitals were soon in trouble with,
\namong other things, a serious shortage of
\nnurses. The women\u2019s hospital had a tradi-
\ntion of recruiting its staff from female
\nimmigrants as they arrived at the dockside.
\n(In Ontario, by contrast, recently arrived
\nand homeless female immigrants, mostly
\nfrom Ireland, made a considerable contribu-
\ntion to the hospital \u2013 as patients.) Argentina
\npassed its first mental health act in 1983.
\nIn Mexico (1910 – 1930), the opening of the
\nGeneral Insane Asylum in 1910, in a village
\njust outside the city boundary, had been
\npreceded by nearly 20 years of planning
\nand consultation, including advice from
\nBaron Haussmann, the transformer of Paris.
\n(The administrative building had an impos-
\ning classical facade.) The paying patients
\nhad bedrooms and the others were housed
\nin wards. This hospital could accommodate
\n1,330 patients \u2013 some 500 more than the
\ntwo which had preceded it. But the social
\nupheavals of the long Mexican revolution
\nled to greatly increased demands and short-
\nage of funds. The hospital was destitute by
\n1920, starved of food, shelter and staff. Yet
\nit remained open, serving particularly the
\nhomeless and indigent, and providing 24
\nhours\u2019shelter for drying out a drunken man,
\nor 24 years for someone with a chronic
\nmental illness. Cristina Rivera-Garza
\nemphasises the important role which the
\nfamilies played in initiating admissions \u2013
\nthose on a State Order as well as \u2018volun-
\ntary\u2019 \u2013 and in remaining in touch with the
\npatients and liaising with staff concerning
\ntheir progress.
\nContinuing the view from below, Patricia
\nPrestwich reports on a development in Paris,
\nwhere in 1876 the psychiatrists at St Anne,
\nthe city asylum, negotiated a system of \u2018vol-
\nuntary admisssion\u2019, in which the patient was
\nadmitted at the request of the family, who
\nretained control of the decision for dis-
\ncharge. The current police proceedings had
\nbeen fiercely criticised as heavy-handed and
\nintimidating. The psychiatrists wanted more
\nacute and curable patients and a better image
\n\u2013 and also a financial contribution from the
\nfamilies, some of whom paid for separate
\nrooms and better food. The new system was
\na success, and was extended to some other
\nasylums. Dangerousness was not a neces-
\n55
\nReviews
\nThe Confinement
\nof the Insane:
\nInternational Perspectives 1800-1965
\n00_WMJ_02_2004.qxd 23.07.2004 12:12 Seite 55
\nsary criterion for admisssion, as it was for
\nthe \u2018official\u2019 patients, so people could be
\nadmitted before they had frightened their
\nfamilies irrevocably. Nearly 40% were
\nadmitted by their spouses, husbands and
\nwives in equal proportions. Compared with
\nthe \u2018official\u2019 patients, they were more likely
\nto be released \u2013 too early, the psychiatrists
\ncomplained \u2013 but they were transferred to
\nother asylums less frequently, and after
\nmuch longer stays, often more than two
\nyears, at St Anne. In general, the relatives
\nwere not waiting for a complete recovery but
\nfor a tolerable level of behaviour, with a
\ncapacity to provide support either at work or
\nat household tasks. The prolonged absence
\nof a wife could result in children being sent
\naway to relatives and the husband left to
\nfend for himself. Although in hospital, the
\npatient retained the important support of
\nremaining involved in his or her r\u00f4le in the
\nfamily.
\nThe scenario in Paris in the late 19th centu-
\nry may seem fairly familiar to most readers
\nof the World Medical Journal. But Akihito
\nSuzuki\u2019s contribution on \u2019The state, the
\nfamily and the insane in Japan 1900 – 1945\u2019
\ntakes them to a different society, where
\nhome care meant confinement in a cage, in
\nor near the family house, and where
\nlunatics, beggars (and also Koreans, social-
\nists and those suffering from infectious dis-
\neases) were \u2018swept\u2019off the streets into some
\nsort of confinement on the days preceding
\nand during a Royal visit or ceremony \u2013 a
\npractice which also occurred in the Soviet
\nUnion on certain public holidays.
\nThe responsibility for confining lunatics,
\ngenerally regarded as dangerous, rested
\nwith the family. In one village during the
\nlate 19th century, when a lunatic son
\nescaped from his father\u2019s house, killing two
\nvillagers and then himself, half of the
\nfather\u2019s property was confiscated and he
\nwas expelled from his village. Such family
\nconfinement could be and was abused. The
\nfirst Mental Patients\u2019 Custody Act was
\npassed by the Westernising regime in 1900.
\nThis codified home confinement and crimi-
\nnalised its unjust use. A \u2018competent custodi-
\nan\u2019 would be appointed. and the imposition
\nof custody and release from it required the
\napproval of a \u2018local senior administrator. In
\nfact all real responsibility rested locally,
\nwith the family and the village chief. No
\ncentral authority was involved. Hospital
\nconfinement was also legal, but at that time
\nthere was only one hospital, in Tokyo.
\nThe pressure for expansion was increased
\nby the Mental Hospitals Act of 1919. At this
\ndate, while England and Wales with a pop-
\nulation of 35 million had 100,000 hospital
\nbeds, Japan with a population of 55 million
\nhad 4,000, of which only 450 were in the
\nsingle public hospital in Tokyo. The rest
\nwere in 57 private hospitals. By 1940 there
\nwere 7 public and 160 private hospitals
\nwith a median length of stay of 717 days
\nand 44 days respectively. The number of
\nhome custody cases continued to grow
\nslowly until the late 1930s and remained a
\ncrucial part of psychiatric provision; but the
\nhospitalisation rate grew much faster \u2013
\nmainly in the private sector which looked
\nafter a considerable number of long-stay
\npatients who brought in a stable income
\nfrom the public purse. At the same time
\nthey were competing (successfully) for the
\nacute patients and touting for trade at the
\nentrance to the Tokyo Metropolitan
\nAsylum, where the private Tokyo Brain
\nAsylum advertised an \u2018inpatients\u2019 informa-
\ntion office\u2019 on a large billboard. Suzuki
\ncomments that \u2018the mutual stimulation
\nbetween the public and private sector seems
\nto have been the main engine behind the
\nincreased institutionalisation of the insane\u2019.
\n(He might have added \u2018and remains so
\ntoday, in Japan.\u2019)
\nOne question which many contributors
\naddress is \u2018Did the Great Confinement as
\nproclaimed by Michel Foucault in his
\n\u201cMadness and Civilisation\u201d really exist?\u2019
\nThe answer seems to be No, in so far as the
\npopulation of those being admitted was
\nquite representative of the population as a
\nwhole, with rather more \u2018unsupported\u2019
\ngroups \u2013 single men and the poor \u2013 but not
\nspecifically deviant. And the numbers \u2018con-
\nfined\u2019, at least at first, were quite small, not
\ngreat in epidemiological terms; and at least
\n50% would be discharged. But there was a
\n\u2018great accumulation\u2019 which required expan-
\nsion, and made the hospitals look and feel
\nlike factories or warehouses. Elaine
\nMurphy in her chapter on \u2018Insanity in
\nEngland 1800-1870\u2019 makes the important
\npoint that in London large asylums replaced
\nthe large network of private asylums, pau-
\nper houses and farms which provided the
\nrefuge for \u2018dull-witted, incompetent and
\ndependent paupers\u2019 which was adminis-
\ntered by the Poor Law Commissioners. The
\nattraction of the new asylums was their
\nlower charges: eight shillings and
\nninepence a week at Hanwell compared to
\neleven shillings for the private asylums.
\nHowever, Hanwell\u2019s low cost depended on
\nits high occupancy. Foucault\u2019s insistence on
\nthe Great Confinement may be wide of the
\nmark, but Andrew Scull\u2019s economic inter-
\npretation remains closer to the truth. Lord
\nShaftesbury, the reforming Chairman of the
\nLunacy Commisssion, would have support-
\ned it. In 1859 he commented that:
\nWhen I look into the whole matter I see that
\nthe principle of profit vitiates the whole
\nthing. It is at the bottom of all these move-
\nments that we are obliged to counteract by
\ncomplicated legislation, and if we could but
\nremove that principle of making a profit we
\nshould confer an inestimable blessing upon
\nthe middle classes, getting rid of half the le-
\ngislation and securing an admirable, sound
\nand efficient system of treatment of lunacy.
\nDoctors are taught that \u2018taking a careful his-
\ntory\u2019 is an essential skill for clinical compe-
\ntence. In psychiatry this is of particular
\nimportance. Over the past ten years there has
\nbeen a huge expansion of studies of its his-
\ntory. This volume is one of them; and its
\nworld perspective makes it particularly help-
\nful in diagnosing and treating our current
\nlocal problems. lt is indeed enlightening.
\nPorter R. (2000) Enlightenment. Britain
\nand the Creation of the Modem World.
\nLondon.
\nFoucault M. (1965) Madness and
\nCivilisation. A History of Insanity in the
\nAge of Reason. New York.
\nScull A. (1979) Museums of Madness. The
\nSocial Organisation of Insanity in
\nNineteenth Century England. London
\nJim Birley
\n56
\nWeb-based course on Human Rights for Prison Doctors
\nThe web-based accredited course for Prison Doctors on
\nHuman Rights and Ethical Dilemmas announced in the
\nWorld Medical Journal (WMJ 50 (1), 27) has been
\nfinalised and is now accessible via the WMA website at
\nwww.wma.net. No course fee is charged.
\n00_WMJ_02_2004.qxd 23.07.2004 12:12 Seite 56
\nCHILE
\nColegio M\u00e9dico de Chile
\nEsmeralda 678 – Casilla 639
\nSantiago
\nTel: (56-2) 4277800
\nFax: (56-2) 6330940 \/ 6336732
\nE-mail: sectecni@colegiomedico.cl
\nWebsite: www.colegiomedico.cl
\nVicepresidente
\nCHINA
\nChinese Medical Association
\n42 Dongsi Xidajie
\nBeijing 100710
\nTel: (86-10) 6513 4885
\nFax: (86-10) 6512 3754
\nE-mail: cmafrd@public3.bta.net.cn
\nCOLOMBIA
\nFederaci\u00f3n M\u00e9dica Colombiana
\nCalle 72 – N\u00b0 6-44, Piso 11
\nSantaf\u00e9 de Bogot\u00e1, D.E.
\nTel: (57-1) 211 0208
\nTel\/Fax: (57-1) 212 6082
\nE-mail: federacionmedicacol@
\nhotmail.com
\nDEMOCRATIC REP. OF CONGO
\nOrdre des M\u00e9decins du Zaire
\nB.P. 4922
\nKinshasa \u2013 Gombe
\nTel: (242-12) 24589\/
\nFax (secr.Gen): (242) 8846574
\nCOSTA RICA
\nUni\u00f3n M\u00e9dica Nacional
\nApartado 5920-1000
\nSan Jos\u00e9
\nTel: (506) 290-5490
\nFax: (506) 231 7373
\nE-mail: unmedica@sol.racsa.co.cr
\nCROATIA
\nCroatian Medical Association
\nSubiceva 9
\n10000 Zagreb
\nTel: (385-1) 46 93 300
\nFax: (385-1) 46 55 066
\nE-mail: orlic@mamef.mef.hr
\nCZECH REPUBLIC
\nCzech Medical Association .
\nJ.E. Purkyne
\nSokolsk\u00e1 31 – P.O. Box 88
\n120 26 Prague 2
\nTel: (420-2) 242 66 201\/202\/203\/204
\nFax: (420-2) 242 66 212 \/ 96 18 18 69
\nE-mail: czma@cls.cz
\nWebsite: www.cls.cz
\nUNITED STATES
\nColegio M\u00e9dico Cubano Libre
\nP.O. Box 141016
\nCoral Gables, FL 33114-1016
\nTel: (1-305) 446 9902\/445 1429
\nFax: (1-305) 4459310
\nDENMARK
\nDanish Medical Association
\n9 Trondhjemsgade
\n2100 Copenhagen 0
\nTel: (45) 35 44 -82 29\/Fax:-8505
\nE-mail: dadl@dadl.dk
\nWebsite: www.laegeforeningen.dk
\nDOMINICAN REPUBLIC
\nAsociaci\u00f3n M\u00e9dica Dominicana
\nCalle Paseo de los Medicos
\nEsquina Modesto Diaz Zona
\nUniversitaria
\nSanto Domingo
\nTel: (1809) 533-4602\/533-4686
\n\/533-8700
\nFax: (1809) 535 7337
\nE-mail: asoc.medica@codetel.net.do
\nECUADOR
\nFederaci\u00f3n M\u00e9dica Ecuatoriana
\nV.M. Rend\u00f3n 923 \u2013 2 do.Piso Of. 201
\nP.O. Box 09-01-9848
\nGuayaquil
\nTel\/Fax: (593) 4 562569
\nE-mail: fedmedec@andinanet.net
\nEGYPT
\nEgyptian Medical Association
\n\u201eDar El Hekmah\u201c
\n42, Kasr El-Eini Street
\nCairo
\nTel: (20-2) 3543406
\nEL SALVADOR, C.A
\nColegio M\u00e9dico de El Salvador
\nFinal Pasaje N\u00b0 10
\nColonia Miramonte
\nSan Salvador
\nTel: (503) 260-1111, 260-1112\/
\nFax: -0324
\nE-mail: comcolmed@telesal.net
\nETHIOPIA
\nEthiopian Medical Association
\nP.O. Box 2179
\nAddis Ababa
\nTel: (251-1) 158174
\nFax: (251-1) 533742
\nE-mail: ema.emj@telecom.net.et \/
\nema@eth.healthnet.org
\nFIJI ISLANDS
\nFiji Medical Association
\n2nd Fl. Narsey\u2019s Bldg, Renwick Road
\nG.P.O. Box 1116
\nSuva
\nTel: (679) \u2013315388
\nFax: (679) 387671
\nE-mail: fijimedassoc@connect.com.fi
\nFINLAND
\nFinnish Medical Association
\nP.O. Box 49
\n00501 Helsinki
\nTel: (358-9) 3930 826\/Fax-794
\nTelex: 125336 sll sf
\nE-mail: fma@fimnet.fi
\nWebsite: www.medassoc.fi
\nFRANCE
\nAssociation M\u00e9dicale Fran\u00e7aise
\n180, Blvd. Haussmann
\n75389 Paris Cedex 08
\nTel: (33) 1 53 89 32 41
\nFax: (33) 1 53 89 33 44
\nE-mail: cnom-international@
\ncn.medecin.fr
\nGEORGIA
\nGeorgian Medical Association
\n7 Asatiani Street
\n380077 Tbilisi
\nTel: (995 32) 39868 \/ Fax: -398083
\nE-mail: Gma@posta.ge
\nGERMANY
\nBundes\u00e4rztekammer
\n(German Medical Association)
\nHerbert-Lewin-Strasse 1
\n50931 K\u00f6ln
\nTel: (49-221) 400-4360\/Fax: -4384
\nTeletex: 2211315 – BAK
\nE-mail:auslandsdienst@baek.de
\nWebsite: www.bundesaerztekammer.de
\nGHANA
\nGhana Medical Association
\nP.O. Box 1596
\nAccra
\nTel: (233-21) 670-510\/Fax: -511
\nE-mail: gma@ghana.com
\nHAITI, W.I.
\nAssociation M\u00e9dicale Haitienne
\n1\u00e8re
\nAv. du Travail #33 \u2013 Bois Verna
\nPort-au-Prince
\nTel: (509) 245-2060\/511-0253
\nFax: (509) 223-9885
\nE-mail: amh@acn2..net
\nWebsite: www.amhhaiti.org
\nHONG KONG
\nHong Kong Medical Association, China
\nDuke of Windsor Building, 5th Floor
\n15 Hennessy Road
\nTel: (852) 2527-8285
\nFax: (852) 2865-0943
\nE-mail: hkma@hkma.org
\nWebsite: www.hkma.org
\nHUNGARY
\nAssociation of Hungarian Medical
\nSocieties (MOTESZ)
\nN\u00e1dor u. 36
\n1443 Budapest, PO.Box 145
\nGeneral Director
\nTel: (36-1) 312 3807 \u2013 311 6687
\nFax: (36-1) 383-7918
\nE-mail: motesz@motesz.hu
\nWebsite: www.motesz.hu
\nICELAND
\nIcelandic Medical Association
\nHlidasmari 8
\n200 K\u00f3pavogur
\nTel: (354) 5 864 0478
\nFax: (354) 5 644106
\nE-mail: icemed@icemed.is
\nINDIA
\nIndian Medical Association
\nIndraprastha Marg
\nNew Delhi 110 002
\nTel: (91-11) 337009\/3378819\/3378680
\nFax: (91-11) 3379178\/3379470
\nE-mail: inmedici@vsnl.com \/
\ninmedici@ndb.vsnl.com
\nINDONESIA
\nIndonesian Medical Association
\nJalan Dr Sam Ratulangie N\u00b0 29
\nJakarta 10350
\nTel: (62-21) 3150679
\nFax: (62-21) 390 0473\/3154 091
\nE-mail: pbidi@idola.net.id
\nIRELAND
\nIrish Medical Organisation
\n10 Fitzwilliam Place
\nDublin 2
\nTel: (353-1) 676-7273
\nFax: (353-1) 6612758\/6682168
\nWebsite: www.imo.ie
\nISRAEL
\nIsrael Medical Association
\n2 Twin Towers, 35 Jabotinsky St.
\nP.O. Box 3566, Ramat-Gan 52136
\nTel: (972-3) 6100444 \/ 424
\nFax: (972-3) 5751616 \/ 5753303
\nE-mail: estish@ima.org.il
\nWebsite: www.ima.org.il
\nJAPAN
\nJapan Medical Association
\n2-28-16 Honkomagome, Bunkyo-ku
\nTokyo 113-8621
\nTel: (81-3) 3946 2121\/3942 6489
\nFax: (81-3) 3946 6295
\nE-mail: jmaintl@po.med.or.jp
\nKAZAKHSTAN
\nAssociation of Medical Doctors
\nof Kazakhstan
\n117\/1 Kazybek bi St.,
\nAlmaty
\nTel: (3272) 62 -43 01 \/ -92 92
\nFax: -3606
\nE-mail: sadykova-aizhan@yahoo.com
\nREP. OF KOREA
\nKorean Medical Association
\n302-75 Ichon 1-dong, Yongsan-gu
\nSeoul 140-721
\nTel: (82-2) 794 2474
\nFax: (82-2) 793 9190
\nE-mail: intl@kma.org
\nWebsite: www.kma.org
\nKUWAIT
\nKuwait Medical Association
\nP.O. Box 1202
\nSafat 13013
\nTel: (965) 5333278, 5317971
\nFax: (965) 5333276
\nE-mail: aks.shatti@kma.org.kw
\nLATVIA
\nLatvian Physicians Association
\nSkolas Str. 3
\nRiga
\n1010 Latvia
\nTel: (371-7) 22 06 61; 22 06 57
\nFax: (371-7) 22 06 57
\nE-mail: lab@parks.lv
\nLIECHTENSTEIN
\nLiechtensteinischer \u00c4rzteverein
\nPostfach 52
\n9490 Vaduz
\nTel: (423) 232 -3440
\nFax: (423) 232 3455
\nWebsite: www.aerzte-net.li
\nLITHUANIA
\nLithuanian Medical Association
\nLiubarto 2
\n2004 Vilnius
\nTel\/Fax: (370-5) 2731400
\nE-mail: lgs@takas.lt
\nLUXEMBOURG
\nAssociation des M\u00e9decins et
\nM\u00e9decins Dentistes du Grand-
\nAssociation and address\/Officers
\nii
\nU2_4_02.2004.QXD 01.07.2004 13:31 Seite U3
\nAssociation and address\/Officers
\nDuch\u00e9 de Luxembourg
\n29, rue de Vianden
\n2680 Luxembourg
\nTel: (352) 44 40 331
\nFax: (352) 45 83 49
\nE-mail: secretariat@ammd.lu
\nWebsite: www.ammd.lu
\nMACEDONIA
\nMacedonian Medical Association
\nDame Gruev St. 3
\nP.O. Box 174
\n91000 Skopje
\nTel\/Fax: (389-91) 232577
\nMALAYSIA
\nMalaysian Medical Association
\n4th Floor, MMA House
\n124 Jalan Pahang
\n53000 Kuala Lumpur
\nTel: (60-3) 40418972\/40411375
\nFax: (60-3) 40418187\/40434444
\nE-mail: mma@tm.net.my
\nWebsite: http:\/\/www.mma.org.my
\nMALTA
\nMedical Association of Malta
\nThe Professional Centre
\nSliema Road, Gzira GZR 06
\nTel: (356) 21312888
\nFax: (356) 21331713
\nE-mail: mfpb@maltanet.net
\nWebsite: www.mam.org.mt
\nMEXICO
\nColegio Medico de Mexico
\nFenacome
\nHidalgo 1828 Pte. Cons. 410
\nColonia Obispado C.P. 64060
\nMonterrey, Nuevo L\u00e9on
\nTel\/Fax: (52-8) 348-41-55
\nE-mail: fenacomemexico@usa.net
\nWebsite: www.fenacome.org
\nNEPAL
\nNepal Medical Association
\nSiddhi Sadan, Post Box 189
\nExhibition Road
\nKatmandu
\nTel: (977 1) 225860, 231825
\nFax: (977 1) 225300
\nE-mail: nma@healthnet.org.np
\nNETHERLANDS
\nRoyal Dutch Medical Association
\nP.O. Box 20051
\n3502 LB Utrecht
\nTel: (31-30) 28 23-267\/Fax-318
\nE-mail: j.bouwman@fed.knmg.nl
\nWebsite: http:\/\/www.knmg.nl
\nNEW ZEALAND
\nNew Zealand Medical Association
\nP.O. Box 156
\nWellington 1
\nTel: (64-4) 472 \u20134741\/ Fax-0838
\nFax: (64-4) 471 0838
\nE-mail: nzma@nzma.org.nz
\nWebsite: www.nzma.org.nz
\nNIGERIA
\nNigerian Medical Association
\n74, Adeniyi Jones Avenue Ikeja
\nP.O. Box 1108, Marina
\nLagos
\nTel: (234-1) 497 7262,
\nFax: (234-1) 585 1432 (ext 2197)
\nE-mail: nigeriannma@hotmail.com
\nNORWAY
\nNorwegian Medical Association
\nP.O.Box 1152 sentrum
\n0107 Oslo
\nTel: (47) 23 10 -90 00\/Fax: -9010
\nE-mail: ellen.pettersen@
\nlegeforeningen.no
\nWebsite: www.legeforeningen.no
\nPANAMA
\nAsociaci\u00f3n M\u00e9dica Nacional
\nde la Rep\u00fablica de Panam\u00e1
\nApartado Postal 2020
\nPanam\u00e1 1
\nTel: (507) 263 7622 \/263-7758
\nFax: (507) 223 1462
\nFax modem: (507) 223-5555
\nE-mail: amenalpa@sinfo.net
\nPERU
\nColegio M\u00e9dico del Per\u00fa
\nMalec\u00f3n Armend\u00e1riz N\u00b0 791
\nMiraflores
\nLima
\nTel: (51-1) 241 75 72
\nFax: (51-1) 242 3917
\nE-mail: decano@colmedi.org.pe
\nWebsite: www.colmed.org.pe
\nPHILIPPINES
\nPhilippine Medical Association
\nPMA Bldg, North Avenue
\nQuezon City
\nTel: (63-2) 929-63 66\/Fax: -6951
\nE-mail: pmasec1@edsamail.com.ph
\nPOLAND
\nPolish Medical Association
\nAl. Ujazdowskie 24
\n00-478 Warszawa
\nTel: (48-22) 628 86 99
\nFax: (48-22) 628 86 99
\nPORTUGAL
\nOrdem dos M\u00e9dicos
\nAv. Almirante Gago Coutinho, 151
\n1749-084 Lisbon
\nTel: (351-21) 842 71 00\/842 71 11
\nFax: (351-21) 842 71 99
\nE-mail: ordemmedicos@mail.telepac.pt
\n\/ intl.omcne@netcabo.pt
\nWebsite: www.ordemdosmedicos.pt
\nROMANIA
\nRomanian Medical Association
\nStr. Progresului 10
\nSect. 1, Bucarest, cod 70754
\nTel: (40-1) 6141071
\nFax: (40-1) 3121357
\nE-mail: amr@amr.sfos.ro
\nWebsite: www.cdi.pub.ro\/CDI\/
\nParteneri\/AMR_main.htm
\nRUSSIA
\nRussian Medical Society
\n34, Build. 1, Novy Arbat
\n121099 Moscow
\nTel: (7-095)205-7371
\nFax: (7-095) 205-3293
\nE-mail: rusmed@rusmed.rmt.ru
\nSLOVAK REPUBLIC
\nSlovak Medical Association
\nLegionarska 4
\n81322 Bratislavia
\nTel: (421-2) 554 24 015
\nFax: (421-2) 554 223 63
\nE-mail: secretarysma@ba.telecom.sk
\nSLOVENIA
\nSlovenian Medical Association
\nKomenskega 4
\n61001 Ljubljana
\nTel: (386-61) 323 469
\nFax: (386-61) 301 955
\nSOUTH AFRICA
\nThe South African Medical Association
\nP.O. Box 74789, Lynnwood Rydge
\n0040 Pretoria
\nTel: (27-12) 481 2036\/7
\nFax: (27-12) 481 2058
\nE-mail: liliang@samedical.org
\nWebsite: www.samedical.org
\nSPAIN
\nConsejo General de Colegios
\nOficiales de M\u00e9dicos
\nVillanueva 11
\nMadrid 28001
\nTel: (34-91) 4317780
\nFax: (34-91) 5764388
\nE-mail: internacional1@cgcom.org
\nSWEDEN
\nSwedish Medical Association
\n(Villagatan 5)
\nP.O. Box 5610
\nSE – 114 86 Stockholm
\nTel: (46-8) 790 33 00
\nFax: (46-8) 20 57 18
\nE-mail: info@slf.se
\nWebsite: www.lakarforbundet.se
\nSWITZERLAND
\nF\u00e9d\u00e9ration des M\u00e9decins Suisses
\nElfenstrasse 18 \u2013 POB 293
\n3000 Berne 16
\nTel: (41-31) 359 \u20131111\/Fax: -1112
\nE-mail: fmh@hin.ch
\nWebsite: www.fmh.ch\/ww\/fr\/pub\/fmh\/
\nhistoire_fmh.htm
\nTAIWAN
\nChinese Medical Association – Taipei
\n201, Shih-pai Rd., Sec. 2
\nP.O. Box 3043
\nTaipei 11217
\nTel: (886-2) 2871-2121, ext 7358
\nFax: (886-2) 28741097
\nE-mail: cma@vghtpe.gov.tw
\nTHAILAND
\nMedical Association of Thailand
\n2 Soi Soonvijai
\nNew Petchburi Road
\nBangkok 10320
\nTel: (66-2) 314 4333\/318-8170
\nFax: (66-2) 314 6305
\nE-mail: math@loxinfo.co.th
\nWebsite: http:\/\/www.medassocthai.org\/
\nindex.htm.
\nTUNISIA
\nConseil National de l\u2019Ordre
\ndes M\u00e9decins de Tunisie
\n16, rue de Touraine
\n1082 Tunis Cit\u00e9 Jardins
\nTel: (216-1) 792 736\/799 041
\nFax: (216-1) 788 729
\nE-mail: ordremed.na@planet.tn
\nTURKEY
\nTurkish Medical Association
\nGMK Bulvary,.
\nPehit Danip Tunalygil Sok. N\u00b0 2 Kat 4
\nMaltepe
\nAnkara
\nTel: (90-312) 231 \u20133179\/Fax: -1952
\nE-mail: Ttb@ttb.org.tr
\nUGANDA
\nUganda Medical Association
\nPlot 8, 41-43 circular rd.
\nP.O. Box 29874
\nKampala
\nTel: (256) 41 32 1795
\nFax: (256) 41 34 5597
\nE-mail: myers28@hotmail.com
\nUNITED KINGDOM
\nBritish Medical Association
\nBMA House, Tavistock Square
\nLondon WC1H 9JP
\nTel: (44-207) 387-4499
\nFax: (44- 207) 383-6711
\nE-mail: vivn@bma.org.uk
\nWebsite: www.bma.org.uk
\nUNITED STATES OF AMERICA
\nAmerican Medical Association
\n515 North State Street
\nChicago, Illinois 60610
\nTel: (1-312) 464 5040
\nFax: (1-312) 464 5973
\nWebsite: http:\/\/www.ama-assn.org
\nURUGUAY
\nSindicato M\u00e9dico del Uruguay
\nBulevar Artigas 1515
\nCP 11200 Montevideo
\nTel: (598-2) 401 47 01
\nFax: (598-2) 409 16 03
\nE-mail: secretaria@smu.org.uy
\nVATICAN STATE
\nAssociazione Medica del Vaticano
\nStato della Citta del Vaticano 00120
\nTel: (39-06) 6983552
\nFax: (39-06) 69885364
\nVENEZUELA
\nFederacion M\u00e9dica Venezolana
\nAvenida Orinoco
\nTorre Federacion M\u00e9dica Venezolana
\nUrbanizacion Las Mercedes
\nCaracas
\nTel: (58-2) 9934547
\nFax: (58-2) 9932890
\nWebsite: www.saludfmv.org and
\ninfo@saludgmv.org
\nZIMBABWE
\nZimbabwe Medical Association
\nP.O. Box 3671
\nHarare
\nTel: (263-4) 791\/553
\nFax: (263-4) 791561
\nE-mail: zima@healthnet.zw
\niii
\nU2_4_02.2004.QXD 01.07.2004 13:31 Seite U4<\/p>\n"},"caption":{"rendered":"

wmj2 Contents EEddiittoorriiaall Health professionals and society 29 \u201cWHO and WHPA need each other\u201d 30 World Health Professions Alliance holds its first global meeting 32 MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss The Relationship between Physicians and Commercial Entities 33 Poverty and Health 39 WWMMAA Activities of the President 40 The 167th WMA Council meeting in Divonne, […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":727,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/wmj2.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3521"}],"collection":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media"}],"about":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/types\/attachment"}],"author":[{"embeddable":true,"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/comments?post=3521"}]}}