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wmj4<\/a><\/p>\n

WMA General Assembly, Tokyo 2004
\nWorldMMeeddiiccaall JJoouurrnnaall
\nVol. No.4,December200450
\nOFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
\nG 20438
\nContents
\nEEddiittoorriiaall 85
\nNew WMA Secretary-General 85
\nPresidential address by Dr. Yank D. Coble,
\nJr, MD to the world medical assembly, Tokyo 86
\nWMA has a new President 86
\nMMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
\nMedical ethics and bereavement 89
\nThe World Medical Association
\nstatement concerning the relationship
\nbetween physicians and commercial enterprises 91
\nThe World Medical Association
\nRegulations in times of armed conflict 92
\nThe World Medical Association
\nStatement on health emergencies
\ncommunication and coordination 93
\nNote of clarification on paragraph 30
\nof the WMA Declaration of Helsinki 95
\nMMeeddiiccaall SScciieennccee,, PPrrooffeessssiioonnaall PPrraaccttiiccee
\naanndd EEdduuccaattiioonn
\nAccount by Dr. James Appleyard of
\nhis Presidential year of office 2003\u20132004 95
\nThe future of medical technology \u2013
\nImplications for medical education and practice 97
\nBlame your genes for a restless
\nnight\u2019s sleep \u2013 new research revealed 99
\nWWHHOO
\nNew tools and increased funds
\nwill beat malaria, say global leaders 100
\nSkilled attendants vital to
\nsaving lives of mothers and newborns 101
\nA globally effective HIV vaccine
\nrequires greater participation of
\nwomen and adolescents in clinical trials 101
\nLandmark report could influence the
\nfuture of medicines in europe and the world 102
\nWho awards million dollar contract
\nfor global treatment preparedness activities 105
\nWWMMAA SSeeccrreettaarryy GGeenneerraall
\nFrom the Secretary General\u2019s Desk 106
\nWWMMAA
\nThe Ceremonial session of the World Medical
\nAssociation General Assembly, Tokyo 2004 107
\nMeeting of the WMA General
\nAssembly, Tokyo, 9th October 2004 108
\nRReeggiioonnaall aanndd NNMMAA NNeewwss
\nPatients\u2019 Access To Care At Risk With
\nAmerica\u2019s Broken Medical Liability System 110
\nTobacco Control Capacity Building 112
\nThe President addresses the Emperor and Empress
\nat the JMA reception
\nThe new President addresses the WMA Ceremonial session
\n00_US_04_2004.qxd 17.02.2005 10:16 Seite 1
\nWebsite: https:\/\/www.wma.net
\nWMA Directory of National Member Medical Associations Officers and Council
\nAssociation and address\/Officers
\nWMA OFFICERS
\nOF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
\ni see page ii
\nPresident-elect President Immediate Past-President
\nDr K. Letlape Dr Y.D. Coble Dr J. Appleyard
\nSouth African Med. Assn. 102 Magnolia Street Thimble Hall
\nP.O. Box 74789 Neptune Beach, FL 32266 108 Blean Common
\nLynnwood Ridge 0040 USA Blean, Nr Canterbury
\nPretoria 0153 Kent, CT2 9JJ
\nSouth Africa Great Britain
\nTreasurer Chairman of Council Vice-Chairman of Council
\nDr. K. Vilmar Dr. Y Blachar Dr. T.J. Moon
\nSchuberstr.58 Israel Medical Association Korean Medical Association
\n28209 Bremen 2 Twin Towers, 35 Jabotisky St. 302-75 Ichon1-dong,Yongsan-gu,
\nGermany 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
\nFax (33) 4 50 40 59 37
\nE-mail: delon@wma.net
\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
\nP.O. Box 143, Yerevan 375 010
\nTel: (3741) 53 58-63
\nFax: (3741) 53 48 79
\nE-mail:info@armeda.am
\nWebsite: www.armeda.am
\nAZERBAIJAN
\nAzerbaijan Medical Association
\n5 Sona Velikham Str.
\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
\n15\/2 Topkhana Road,
\nDhaka 1000
\nTel: (880) 2-9568714\/9562527
\nFax: (880) 2-9566060\/9568714
\nE-mail: bma@aitlbd.net
\nBELGIUM
\nAssociation Belge des Syndicats
\nM\u00e9dicaux
\nChauss\u00e9e de Boondael 6, bte 4
\n1050 Bruxelles
\nTel: (32-2) 644-12 88\/Fax: -1527
\nE-mail: absym.bras@euronet.be
\nWebsite: www.absym-bras.be
\nBOLIVIA
\nColegio M\u00e9dico de Bolivia
\nCasilla 1088
\nCochabamba
\nTel\/Fax: (591-04) 523658
\nE-mail: colmedbo_oru@hotmail.com
\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) 317868 00
\nFax: (55-11) 317868 31
\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
\nCHILE
\nColegio M\u00e9dico de Chile
\nEsmeralda 678 – Casilla 639
\nSantiago
\nTel: (56-2) 4277800
\nFax: (56-2) 6330940 \/ 6336732
\nE-mail: sectecni@colegiomedico.c
\nWebsite: www.colegiomedico.cl
\nU2_4_WMJ_04_04.qxd 17.02.2005 10:17 Seite U2
\nEditorial
\nThose arriving in Tokyo for the Council, the Scientific meeting and the General Assembly
\nof the World Medical Association, might be forgiven if they felt a sense of forboding when
\nthey were greeted with persistent and rather gloomy rain and mist. Indeed, this may well
\nhave been enhanced by the not insignificant earthquake one night and the typhoon two
\ndays later. However, the excellent scientific meeting, impeccable efficiency of the organi-
\nsation and the warm hospitality of the Japanese Medical Association, more than compen-
\nsated for the vagaries of the weather.
\nThe meeting was further greatly honoured by the presence of the Emperor and Empress of
\nJapan at the Opening Reception, and the Chief Secretary of the Cabinet (the Prime Minister
\nbeing out of the country), the Minister of Health and the Governor of Tokyo at the
\nCeremonial session (see report p. 107).
\nThe scientific session was also a success, addressing the advantages and the problems of
\nadvanced medical technology and also the subject of Continuing Medical Education and
\nPhysicians\u2019Autonomy (various papers appear in this issue).
\nThe GeneralAssembly is reported on page 108.Among the decisions of theAssembly appears
\na note of clarification on article 30 of the Declaration of Helsinki. While this will undoubted-
\nly not be the last we shall hear on this subject, interested parties will no doubt take their time
\nto quietly consider and debate what appears to be the controversial issue of the rights of par-
\nticipants in clinical trials, before returning to the subject at some point in the future.
\nMeanwhile, the world moves on and the unavoidable delay in publishing this issue (due to
\nillness), has meant that we have all experienced the terrible consequences of the \u201cnatural
\ndisaster\u201d in South-East Asia. The global response in terms of aid, both financial and other
\nresources, to this terrible event has been unprecedented. In all of this the medical profes-
\nsion, both through its national medical associations and other organisations geared to deal-
\ning with major disasters, reacted quickly and responsibly both in terms of provision of
\nhuman resources and other forms of assistance. At the same time the profession and the
\npopulation in general must not neglect the continuing needs of populations threatened by
\nmajor scourges such as famine and other forms of deprivation, AIDS\/HIV and Malaria. The
\nneeds of the world are huge \u2013 part of which depends on medical care. This is not only the
\nresponsibility of governments and administrations, but also a professional responsibility
\nfor the medical profession thoughout the world.
\nAlan Rowe
\nEditorial
\n85
\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
\nNew WMA Secretary-General
\nDr. Otmar Kloiber has been appointed to be the next Secretary-Gene-
\nral of the World Medical Association following Dr. Delon Human.
\nDr. Kloiber is currently Deputy Secretary General of the Bundes\u00e4rt-
\nzekammer (German Medical Association) where for many years he
\nwas the Foreign Relations Advisor, and has extensive knowledge
\nboth of WMA, and the affairs of many national medical associations
\n(particularly the problems in Central and Eastern Europe) and of
\ninternational organisations and NGO\u2019s. Dr. Kloiber has also been a
\nmember of the German Parliamentary Commission on Law and Ethics in Modern Medi-
\ncine.He had previously worked at the Max-Plank Institute in Cologne and was a Postdoc-
\ntoral Fellow in the University of Minnesota USA from 1985-86. Dr. Kloiber will take up
\nhis post on the 1st February 2005.
\nWMJ_04_2004.qxd 17.02.2005 09:50 Seite 85
\nFollowing his investiture as President of the
\nWorld Medical Association, Dr. Coble
\nopened his address expressing his gratitude
\nto those who elected him, to the retiring
\nPresident and his fellow officers, to the
\nSecretary-General, Dr. Delon Human, to
\nthe American Medical Association and its
\ndelegation at WMA, also to his WMA pre-
\ndecessors from the USA.
\nDr. Coble continued
\n\u201cAll of you have given me opportunities to
\nwork hard for a worthy cause. To seek and
\nto strive for the best health care for the peo-
\nple of the world, through the pursuit of the
\nhighest standards of medical care, medical
\neducation, medical ethics and medical sci-
\nence.
\nThese things form the intellectual founda-
\ntion and the creative spark of the art of
\nmedicine. They are ingrained in the Charter
\nof the World Medical Association. They are
\nour mission and our charge \u2013\u201cCaring,
\nEthics and Science\u201d \u2013 the three fundamen-
\ntal, enduring traditions. Fulfilling this mis-
\nsion- living out these ideals- is what gives
\nus the power to be strong, effective advo-
\ncates for patients and for our profession the
\nworld over. Through changes in govern-
\nments, changes in policies, changes in eco-
\nnomic and in medical science and methods,
\nwe will flourish.
\nAt this moment of history, the wealth of
\nnations is not the most pressing issue; it is
\nrather, the health of nations.
\nIndeed, one of the most pressing issues fac-
\ning nations, be they first world or third-
\npost-industrial or developing \u2013 is access to
\ncare, how to deliver medical and health care
\nof high quality (including public health and
\npreventive medicine) to the greatest num-
\nber of their citizens, with the maximum
\npossible efficiency. This at a time when the
\nquality of medical care and the good health
\nof our patients, face unprecedented chal-
\nlenges both locally and globally, natural
\nand man-made.
\nThese challenges include AIDS, SARS,
\nresistant tuberculosis, Malaria, the threat of
\nbio-terrorism, bureaucratic meddling,
\nchanging health policies, an unprecedented
\nnumber of ageing citizens, unprecedented
\nmigration of physicians, and the need \u2013 in
\nmany lands if not most \u2013 for health care
\nsystem reform. All of these things make
\nglobal co-operation essential if we as physi-
\ncians are to protect the public health. Our
\nincreasingly open borders and our increas-
\ningly mobile populations are creating a rich
\nenvironment for infectious agents, posing a
\nserious threat to human health and interna-
\ntional security. New infectious diseases
\nsuch as SARS can emerge and travel swift-
\nly around the globe, mutating and infecting
\nless resilient hosts. These microbes respect
\nno international borders or the landscape\u2019s
\nphysical barriers.
\nEditorial
\n86
\nPresidential address by Dr. Yank D. Coble, Jr,
\nMD to the world medical assembly, Tokyo
\nWMA has a new President
\nYank D. Coble, Jr., MD, MACP, MACE, became President
\nof the World Medical Association in Tokyo, Japan, in
\nOctober of 2004. Dr. Coble served as Chair of the WMA\u2019s
\n2003-2004 Committee on Finance and Planning, has been a
\nDelegate to the WMA since 2002, and is Past President of
\nthe American Medical Association.
\nA graduate of Duke Medical School, Dr. Coble also received
\na degree in clinical medicine of the tropics from the London
\nSchool of Hygiene and Tropical Medicine. He is a clinical
\nprofessor of medicine at the University of Florida School of
\nMedicine and was formerly Professor of Medicine and
\nFamily Medicine and Chair of the Department of Community Health and Family
\nMedicine. Dr. Coble is listed in \u201cThe Best Doctors in America\u201d and in 2002 was select-
\ned by Modern Healthcare as one of the \u201c100 Most Powerful People in Healthcare.\u201d
\nUnder the auspices of the Office of International Research at the National Institutes of
\nHealth (NIH), he cared for patients and conducted medical research in Egypt, Nigeria
\nand England from 1964 through 1969. During this time, he made site visits to more than
\n50 countries. Most recently, he served on the U.S. delegation to the WHO\u2019s 2003 and
\n2004 World Health Assembly.
\nAmong his many leadership roles, Dr. Coble has been a member of the Advisory
\nCommittee to the Director of the NIH. He co-chaired both the 35th anniversary celebra-
\ntion of the NIH\u2019s Office of International Medicine and the 50th anniversary celebration
\nof the Human Genome Project.
\nA distinguished leader in medicine, Dr. Coble is a Past President of the American Society
\nof Internal Medicine, American Association of Clinical Endocrinologists, and American
\nCollege of Endocrinology. He currently holds appointments on the boards of Research.
\nAmerica, National Osteoporosis Foundation, Institute of Medicine Roundtable on
\nEnvironmental Health Sciences, Research and Medicine, Campaign for Public Health,
\nand Hospice of Northeast Florida. He has also served on the Board of Directors of the
\nNational Quality Forum, the Joint Commission on the Accreditation of Healthcare
\nOrganizations and the National Guideline Clearinghouse of the Agency for Healthcare
\nResearch and Quality.
\nDr. Coble and his wife Shereth reside in Neptune Beach, Florida and have five children
\nand ten grandchildren.
\nWMJ_04_2004.qxd 17.02.2005 09:50 Seite 86
\nOur weapons against these microbes are
\nbecoming less effective as they develop
\nresistance to the drugs, which once kept
\nthem at bay.
\nFor medicine to survive these threats, it
\nmust continue to push the boundaries of sci-
\nence and technology. By so doing we make
\nlonger, better lives available to all
\nhumankind. From these challenges, from
\nadversity of all kinds we can learn as we
\novercome. Learn because we overcome.
\nRecently, I was in a country where physi-
\ncians offered a candid admission \u2013 that their
\ngovernment delayed the medical communi-
\nty from releasing what they knew about
\nSARS when they knew it.
\nBecause of this, valuable time was lost
\naddressing the epidemic and identifying the
\ndisease. This country\u2019s scientists knew the
\nstructure of SARS, knew what it was and
\nhow dangerous it was for two months
\nbefore it could be reported. Ultimately this
\nsilence cost lives and cost the country $80
\nmillion.
\nBut because of physician inspired public
\npressure there has been a change.
\nPhysicians and other scientists in the coun-
\ntry can now freely report their findings.
\nThis provided clear evidence of the value of
\ndisclosure, of co-operation and the trans-
\nparency of science, not only for the health
\nof a country, but for its economy and its
\nwealth.
\nFrom adversity has come knowledge and
\nprogress in the fight against contagion.
\nIn an African nation, a physician was dis-
\ncharged from his duties as a hospital super-
\nintendent in early 2002 for \u201cinsubordina-
\ntion\u201d, because he allowed a public health
\norganisation to use space in his facility to
\nadminister HIV prophylaxis to rape vic-
\ntims. At the time when he was fired, that
\nnation\u2019s Health Ministry prohibited the use
\nof HIV drugs as a method of prevention and
\ntreatment after HIV exposure. Because of
\nthe international pressure brought to bear,
\nin part because of this physician\u2019s case, this
\ngovernment changed its policy on HIV
\ntreatment.
\nThrough the adversity suffered by these
\nbrave physicians, medicine was advanced.
\nThese are the types of obstacles we face as
\na community, and which we must overcome
\ntogether.
\nThe traditions of medicine are what enable
\nphysicians to work together under difficult
\nconditions.
\nConsider the Addis Ababa Fistula Hospital
\nin Ethiopia, where in one of the world\u2019s
\nmost impoverished regions physicians treat
\nwomen suffering form obstetric fistula, a
\ndebilitating childbirth injury still common
\nin the developing world. Or Dr. Paul
\nFarmer, who for 20 years has worked to
\ndevelop a community-based health network
\nin Haiti. He helped implement one of the
\nfirst AIDS treatment programmes in the
\ndeveloping world and an innovative treat-
\nment for patients with multi-drug-resistant
\ntuberculosis.
\nI have seen adversity and a common goal
\nunite physicians with my own eyes. In
\nNigeria before the Biafran War, I helped
\nwork on a nutrition survey of the entire
\ncountry \u2013 a co-operative effort with physi-
\ncians from America and Nigeria (Ibo,
\nYoruba, Hausa and Faluni) all working
\ntogether.
\nAt the London School of Tropical Medicine
\nat the time of the Six-day War in 1967, I
\nwatched Christian, Jewish, Muslim and
\nHindu physicians work side by side for the
\nbetterment of all nations, all faiths and all
\npeoples.
\nThrough adversity we find co-operation
\nand innovation. We learn from each other
\nand take inspiration from each other,
\nbecause we are all in this together. We must
\ndelight in our diversity, but always remem-
\nber the danger of discord. There is power
\nonly in unity. With enthusiasm, hard work
\nand hope, we can take the challenges we
\nface in medicine and turn them into oppor-
\ntunities for better health. But only if we
\nremain responsible for out traditions of
\nethics, caring and science. Only if we work
\nwith our patients and others to topple the
\nbarriers to quality medical care. Only if we
\nare active, united members of our profes-
\nsion.
\nWithout science and its application, ethics
\nand caring alone are merely good inten-
\ntions, only well intentioned kindness.
\nIt is our commitment to science and the life-
\nlong process of learning that science, that
\ndirects, expands and makes unique what we
\ndo, as physicians. We must not permit oth-
\ners to diminish our scientific standards.
\nEthics is what compels us to put the inter-
\nests of the patient first, or in some
\ninstances, that of the public.
\nThis is the heart of my message today \u2013 that
\neverything we do, we do for our patients \u2013
\nThe sick, the infirm, the elderly \u2013 those
\nmost vulnerable among us throughout the
\nworld, those who most need physicians, our
\ntraditions, our advocacy and our autonomy.
\nSir William Osler said, \u201cCaring is the most
\nimportant thing \u2013 so do it first. For it is the
\ncaring physician who most inspires hope
\nand trust\u201d.
\nIn that spirit, I would like the members of
\nthe World Medical Association to be known
\nas \u201cThe Caring Physicians of the World\u201d.
\nToward that end, we are asking that each of
\nour national medical associations too nom-
\ninate one to three of their physician mem-
\nbers who best reflect the principles of car-
\ning, ethics and science. We will select some
\n50 or 80 of these physicians and feature
\nthem in a publication to be distributed at
\nour annual meeting in Santiago, Chile in
\nOctober 2005. We are grateful for the sup-
\nport of the Pfizer Medical Humanities
\nInitiative in this publication effort. The pub-
\nlication will be disseminated around the
\nworld to national medical associations,
\ngovernments, foundations and other inter-
\nested groups. This activity will also include
\na dedicated website, a series of regional
\nmeetings and bridges to other opportunities.
\nWe seek the most caring physicians in the
\nworld, and we want the world to know who
\nthey are. We also want the world to know
\nwho we are at the World Medical
\nAssociation- what we do, what we stand
\nfor, and the values we embrace in the ser-
\nvice of our patients and the public health
\nCaring \u2013 Ethics \u2013 Science
\nOur Caring is evident in our everyday work
\nand the millions of hours of charity care we
\nprovide in the four corners of the globe.
\nEditorial
\n87
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 87
\nOur Ethics guide not only our practice of
\nmedicine, but also the practice of interna-
\ntional physician organisations
\nOur medical science is evident in our grow-
\ning success at treating and curing diseases
\nonce thought to be fatal, in the miracles of
\norgan transplants, vaccines, chemotherapy,
\nmedical genetics and advanced technology.
\nCaring, Ethics and Science, are the watch-
\nwords of our profession. But everywhere I
\ngo around the world, physicians are being
\nsubjected to ever greater pressures.
\nSubjected to forces that make it more and
\nmore difficult to live out the credo of our
\ncalling. The elimination of patient choice
\nand the erosion of appropriate physician
\nautonomy, put the sacred patient \u2013 physi-
\ncian relationship in jeopardy.
\nSo it falls to us, we who represent interna-
\ntional medicine to help restore pride, pas-
\nsion, enthusiasm and optimism among our
\ncolleagues wherever they practice, wherev-
\ner they are challenged. The irony is that we
\nare small, but our power to do good and to
\nwield influence, is great.
\nWe will reach out
\n– and encourage national medical associ-
\nations to form where none exist today;
\n– to assist in the development of quality
\ncare and to enhance safety;
\n– and focus attention on developing world
\nissues, HIV\/AIDS, hunger and infec-
\ntious diseases; violence, terrorism and
\ntorture; obesity, diabetes and cardiovas-
\ncular disease; with Regional meetings
\nof our WMA;
\n– in the houses of parliaments, the legisla-
\ntures, the board rooms, in partnership
\nwith our brother and sister organisa-
\ntions.
\nAnd we will reach out with a strong,
\nauthoritative voice, as a fierce guardian of
\nethics and human rights on the internation-
\nal stage \u2013 because we remain the global
\nvoice of medicine.
\nIt is a voice I have constantly heard in the
\nyears since I embarked on my course of
\nstudy in international research \u2013 a journey
\nthat took me to Egypt, Nigeria and London.
\nSince then, I have visited health care, edu-
\ncation and research facilities in more than
\n60 countries. These travels have given me
\nunconditional respect for our global profes-
\nsion of medicine, and a deep sense of awe
\nat the remarkable trust and hope which our
\ncalling commands and inspires.
\nI\u2019ve witnessed the world of physicians like
\nyou more extensively that I could have
\nimagined. I\u2019ve seen your skill and caring
\nand compassion in settings from the most
\nadvanced hospital to the most remote clin-
\nic, and seen how you manage the expecta-
\ntions created by innovations in medicine.
\nIn these forty years I have seen much suf-
\nfering \u2013 but I have also seen much relief of
\nsuffering. I have seen how good health
\nleads to more literacy, more equality of
\nopportunity in political and economic mat-
\nters and in environmental improvements.
\nWhen health improves, all other aspects of
\nlife improve. While health experts and
\neconomists may differ on how to go about
\nit, the goal is the same, and the rewards are
\ntremendous.
\nPoliticians and governments like to to think
\nof medical care and research as a cost- an
\nexpense. But we know that medical care
\nand research is an investment, a value \u2013 one
\nwith tremendous return.
\nIn some countries there is a need for basics
\nsuch as clean water, edible food and reliable
\nelectricity. But in these places they still
\nknow and respect their doctor. Our patients
\nvalue medial research and innovation. They
\nvalue medical care and they do not want
\ntheir care undermined or withheld.
\nWe must make sure that our patients under-
\nstand how the problems we face as physi-
\ncians undermine our ability to deliver that
\ncare. We need to communicate the value of
\nour work and its importance to our patients,
\nto the media and to our governments.
\nWe need to continue to communicate the
\nvalue of our work to each other. Few things
\nare as central to the development of science
\nand medicine as the exchange of informa-
\ntion. By sharing information, either in jour-
\nnals or textbooks, or in international confer-
\nences such as these, we reaffirm what we
\nunderstand about the art and science of
\nmedicine and broaden our knowledge base.
\nThese are gifts we bring back to our
\npatients and our communities \u2013 gifts we can
\nuse to make medical practice in our respec-
\ntive nations better, stronger than ever
\nbefore.
\nExperiences such as this gathering are also
\ngifts to us as physicians. They present
\nopportunities for friendship, for greater
\nunderstanding, not only of science and
\nhealth policy, but also of culture and histo-
\nry. They challenge us to see our profession
\nand ourselves from a new perspective, and
\nchange us for the better.
\nNo one better understands the obstacles to
\nquality health care than physicians and their
\npatients. That is why, as WMA President I
\nwill take my cue from the people in the
\nfrontlines and make your agenda \u2013 your
\nindividual country\u2019s health care agenda,
\nand your patients\u2019 agenda \u2013 my agenda \u2013
\nour agenda.
\nTo fulfil this mission we have to be deter-
\nmined and stay that way \u2013 we can\u2019t give up
\nor give in. This is a time of excitement and
\nanticipation \u2013 for me a time of wonder and
\nexpectation. I look forward to working
\ntogether as we shepherd the spirit of inter-
\nnational medicine into this 21st century. I
\ncan only hope that my time as President
\nwill strengthen the bonds that unite us all.
\nBonds such as our shared commitment to
\nthe best science \u2013 to caring and compassion
\n\u2013 and to excellence in every aspect of med-
\nicine \u2013 bonds such as our commitment to
\nprofessional integrity, and to the ethic that
\nrequires us to put our patients first.
\nAs physicians we can do much on our own,
\nbut we can do even more together. The
\nWMA and its members are, and will contin-
\nue to be an ethical beacon and a force of
\nendless possibilities.
\nSo let us continue to build bridges among
\nour national associations and among the
\nindividual physicians in this room, and con-
\ntinue to share our dreams of better health
\nfor all. As I look ahead to the next year, it
\noccurs to me that there is no greater gift
\nthan this \u201cTo see medicine\u2019s traditions lived
\nto the fullest, and to work to protect those
\ntraditions from harm\u201d.
\nHow can we not be enthusiastic and opti-
\nmistic about our profession with such
\nenduring traditions- about our opportunity
\nEditorial
\n88
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 88
\nto be useful and of value every day- and
\nabout the marvels of modern medicine?
\nThere is an old Japanese proverb \u201cThe go-
\nbetween wears out a thousand sandals\u201d.
\nWe must be willing to wear out a thousand
\nsandals \u2013 or more \u2013 in our advocacy for our
\npatients and our profession.
\nTogether, the family of medicine will bring
\nits agenda to the global stage. We will
\nencourage and lead patients and other part-
\nners to stand beside us. We will tear down
\nthe barriers that stand between our patients
\nand us, and between us and quality medical
\ncare. We will be \u201cThe Caring Physicians of
\nthe World\u201d.
\nMedical Ethics and Human Rights
\n89
\nMedical Ethics and Human Rights
\nMedical ethics and bereavement
\nAlthough there have been a great many
\npublications and conference presentations
\non ethical issues related to death and dying,
\nthe ethical literature on the physician\u2019s
\nresponsibilities to bereaved persons is rela-
\ntively scant. In their interactions with the
\nbereaved, physicians can either provide
\nbenefit or inflict harm, and so such interac-
\ntions require ethical analysis and guidance.
\nThe bereaved are not the physician\u2019s
\npatients, so the well-established principles
\nof the physician-patient relationship are
\nnot necessarily applicable.
\nIn this article I propose a set of ethical prin-
\nciples for the interactions of physicians
\nwith the bereaved, namely, respect, com-
\npassion and truthfulness. The application of
\nthe principles will be illustrated by case
\nvignettes. Particular attention will be given
\nto the resolution of possible conflicts
\nbetween principles, for example, compas-
\nsion vs. truthfulness.
\nEthical Responsibilities
\nThe WMA Declaration of Geneva requires
\nof the physician that \u201cThe health of my
\npatient will be my first consideration\u201d, and
\nthe International Code of Medical Ethics
\nstates, \u201cA physician shall owe his patients
\ncomplete loyalty and all the resources of his
\nscience\u201d. However, the care of patients
\noften involves interactions with family
\nmembers, particularly when the patients are
\nunable to make decisions about their own
\nmedical care. A considerable degree of con-
\nsensus has developed on the ethical and
\nlegal principles for dealing with family
\nmembers in such situations, although the
\napplication of these principles is often prob-
\nlematic.2 However, there has been very lit-
\ntle consideration to date of the responsibili-
\nties of physicians to family members after
\nthe patient\u2019s death.
\nSome might argue that physicians have no
\nsuch responsibilities. Just as the physician-
\npatient relationship ends with the death of
\nthe patient, so also do any professional rela-
\ntionships with the bereaved family mem-
\nbers. If they are in need of consolation or
\nsome other type of care, they should seek it
\nfrom bereavement counsellors, clergy or
\nother specialists in the field.
\nA strong case can be made for an opposing
\nview, namely, that physicians should
\naddress the needs of the bereaved.
\nSometimes physicians are the only ones
\nwho can fulfil these needs and their refusal
\nto do so can result in harm to the bereaved.
\nExamples of such situations are presented
\nbelow.
\nEthical Principles
\nSome of the ethical principles that govern
\nthe physician-patient relationship are equally
\nappropriate to the relationship of physicians
\nwith the bereaved. Others, such as informed
\nconsent and confidentiality, are not as appro-
\npriate. The shared principles are these:
\n\u2022 Compassion \u2013 have understanding and
\nempathy for those who are suffering.
\n\u2022 Respect for persons \u2013 acknowledge and
\npromote their dignity and their autono-
\nmy.
\n\u2022 Truthfulness \u2013 do not lie, and be discreet
\nwhen disclosing unwelcome or unwant-
\ned information.
\nSometimes the application of these princi-
\nples can be challenging, not least because
\nthey can conflict with one another.
\nMoreover, the needs and wishes of the
\nbereaved may conflict with those of the
\npatient prior to death. It is, of course,
\npreferable to anticipate and prevent con-
\nflicts before they arise. But if this has not
\nbeen done, then a conflict-resolution
\nprocess is required.
\nCase 1 \u2013 Compassion vs.
\ntruthfulness
\nMr. A, a 30 year old single male, is
\nadmitted to an emergency ward with
\nsevere injuries resulting from an auto-
\nmobile accident and dies soon after-
\nwards. Medical tests administered upon
\nadmission revealed the presence of
\nheroin, which may well have con-
\ntributed to the accident. When Mr. A\u2019s
\nparents arrive at the hospital, they ask
\nthe attending physician what caused the
\ndeath. The physician wonders whether
\nshe should mention only the accident or
\nshould reveal the possible contributing
\nfactor as well. She fears that the family
\nmight be devastated by this knowledge.
\nThis case demonstrates a conflict between
\nthe physician\u2019s compassionate desire not to
\nharm the family members and her duty to
\ntell the truth. It is also about the limits of
\nconfidentiality. Traditional medical ethics
\nwas clear on this point, as is stated in the
\nWMA International Code of Medical
\nEthics: \u201cA physician shall preserve
\nabsolute confidentiality on all he knows
\nabout his patient even after the patient has
\ndied.\u201d However, current medical ethics rec-
\nognizes some exceptions to this principle.
\nThe British Medical Association advises
\nthat the obligation of confidentiality after
\nthe patient\u2019s death \u201cneeds to be balanced
\nwith other considerations, such as the inter-
\nests of justice and of people close to the
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 89
\ndeceased person\u201d.3 And the American
\nMedical Association allows that, \u201cWhen a
\nfamily or other decision maker has given
\nconsent to an autopsy, physicians may dis-
\nclose the results of the autopsy to the indi-
\nvidual(s) that granted consent to the proce-
\ndure\u201d.4
\nIn the case of Mr. A, it would be advisable
\nfor the physician to enter into discussion
\nwith the family to determine whether her
\nfear of harming them is justified. Perhaps
\nthey already knew that their son was addict-
\ned to heroin, and therefore they would not
\nbe disturbed to know that this might have
\nbeen a factor in his death. But if, after dis-
\ncussion, her fear is confirmed, she could be
\njustified in withholding some information
\nboth to respect patient confidentiality and
\nto avoid harming the family. Lying, howev-
\ner, is never permissible.5
\nCase 2 \u2013 Compassion and
\nrespect in the face of blame
\nMrs. B is an elderly patient in a critical
\ncare unit for management of multiple
\norgan failure. The medical team are
\nagreed that there is no possibility of
\narresting her decline and that henceforth
\nher care should be palliative only. The
\npatient is non-communicative so the
\nteam turns to her family to seek agree-
\nment with this plan. The family mem-
\nbers, perhaps hoping for a miracle, are
\nadamant that the team continue their
\nefforts to prolong the patient\u2019s life. The
\nteam agrees reluctantly to do so. After
\nfive days of aggressive and apparently
\nuncomfortable treatment, Mrs. B dies.
\nThe family members are angry and
\naccuse the team of not doing enough to
\nsave their mother. Some of the team,
\namong themselves, blame the family for
\nMrs. B\u2019s unnecessary suffering and want
\nto confront them openly about this.
\nOthers feel that compassion for the fam-
\nily requires that they accept these unjus-
\ntified criticisms as part of the bereave-
\nment process.
\nIn retrospect, the medical team may have
\nwished that they had not acceded to the
\nfamily\u2019s wishes to continue aggressive
\ntreatment for Mrs. B.6 However, they now
\nhave to make the best of a bad situation. It
\nseems clear to them that the family\u2019s grief
\nat the death of the patient is compounded by
\ntheir anger that the treatment was not suc-
\ncessful and perhaps also by remorse for
\ncontributing to Mrs. B.\u2019s prolonged suffer-
\ning and dying. Team members may share
\nthis remorse, which is made worse by the
\nfamily\u2019s unjust accusation.
\nIn such a situation, the medical team may
\nwell consider that they have no further
\nresponsibility to the family. However, as in
\nthe first case, the family members have
\nneeds that only the medical team can meet,
\nand despite the obstacles, the team should
\ntry to provide compassionate help to the
\nfamily in coping with their grief. This may
\ninvolve inviting the family members to dis-
\ncuss the case while reassuring them that
\neverybody had the best interests of Mrs. B.
\nin mind, even though the decision to contin-
\nue treatment was, in retrospect, probably
\nnot appropriate. Prior to encountering the
\nfamily, the team members should meet by
\nthemselves and try to come to terms with
\ntheir own remorse and anger.
\nCase 3 \u2013 Patient\u2019s Directive
\nvs. Survivors\u2019 Needs
\nMr. C. a 64-year-old man, has just died
\nof a cardiac arrest. In his last will, made
\nwhen he was 55, he stipulated that he did
\nnot want any funeral or memorial ser-
\nvice. His surviving wife, four children
\nand eight grandchildren were very close
\nto him and are devastated by his death.
\nUpon learning of his directive regarding
\nno funeral or memorial service, they are
\ntorn between their need to bring closure
\nto their grief at losing him and their
\ndesire to respect his wishes. To help
\nresolve this conflict, they turn to his per-
\nsonal physician for advice.
\nAlthough the physician is not the decision
\nmaker in this case, he has been asked for
\nadvice because of his professional relation-
\nship with the patient while alive. The physi-
\ncian is faced with a conflict between his
\nloyalty to his former patient and his com-
\npassion for the bereaved survivors. Here
\nagain, the survivors\u2019 grief at losing their
\nloved one is compounded by another factor,
\nin this case, his directive to have no funeral
\nor memorial service. Even if the physician
\nfavours the survivors, he has to decide
\nwhether they have the right to counteract
\nthe express wishes of the deceased for their
\nown benefit.
\nOn this latter point, the physician must con-
\nsider two opposing views. The first is that
\nindividuals have the right to dispose of their
\npossessions after death, as expressed in
\ntheir last will and testament, and nobody
\ncan change their decisions. Arguably this
\ncan apply to how their corpse should be
\ntreated, even though it is not considered
\nproperty. The second view is that overrid-
\ning previously expressed wishes regarding
\nfuneral arrangements cannot harm the
\ndeceased person and therefore is permissi-
\nble if it will benefit others. At present there
\nis no ethical consensus as to which of these
\nviews should prevail, and hence physicians
\nhave to decide for themselves which to
\nfavour in specific situations.
\nConclusion
\nEach of these cases illustrates a conflict
\nbetween important ethical principles.
\nAlthough it is preferable that all principles
\nbe upheld, sometimes one must take priori-
\nty over another. When such conflict arises,
\ndiscussion among all those involved is
\nimportant for reaching a decision that, if not
\nunanimous, at least reflects a compromise
\nthat is tolerable to all. As medical authori-
\nties, physicians have a special responsibili-
\nty to initiate such discussions and to con-
\ntribute to their successful outcome.
\nJohn R. Williams
\nReaders\u2019 comments on these cases are wel-
\ncome and a selection will be published in
\nthe next issue of the Journal. Please send
\nthem to the Hon. Editor in Chief, Haughley
\nGrange, Stowmarket, Suffolk 1P14 3QT,
\nUnited Kingdom, email:
\nefmara@rowe110.fsnet.co.uk
\n1 An earlier version of this article was present-
\ned at the 21st International Conference on
\nDeath and Bereavement, Eilat, Israel, 23-25
\nMedical Ethics and Human Rights
\n90
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 90
\nMarch 2004. The views expressed here are
\nthose of the author, not of the World Medical
\nAssociation.
\n2 WMA (2005) Medical Ethics Manual 47-50,
\navailable at www.wma.net
\n3 BMA (2004) Medical Ethics Today: The
\nBMA\u2019s handbook of ethics and law (2nd ed.),
\nLondon, BMJ Books, 439
\n4 AMA (2002) Confidentiality of Medical
\nInformation Postmortem, available at www.
\nama-assn.org\/ama\/pub\/category\/print\/8354.html
\n5 Jackson, J (2001) Truth, Trust and Medicine,
\nLondon and New York, Routledge
\n6 WMA (2005) Medical Ethics Manual 46 and
\n92, available at www.wma.net
\nMedical Ethics and Human Rights
\n91
\nApproved by the WMA General
\nAssembly, Tokyo 2004
\nA. Preamble
\n1. In the treatment of their patients, physi-
\ncians use drugs, instruments, diagnostic
\ntools, equipment and materials developed
\nand produced by commercial enterprises.
\nIndustry possesses resources to finance
\nexpensive research and development pro-
\ngrammes, for which the knowledge and
\nexperience of physicians are essential.
\nMoreover, industry support enables the
\nfurtherance of medical research, scientif-
\nic conferences and continuing medical
\neducation that can be of benefit to
\npatients and the entire health care system.
\nThe combination of financial resources
\nand product knowledge contributed by
\nindustry and the medical knowledge pos-
\nsessed by physicians enables the develop-
\nment of new diagnostic procedures,
\ndrugs, therapies, and treatments and can
\nlead to great advances in medicine.
\n2. However, conflicts of interest between
\ncommercial enterprises and physicians
\noccur that can affect the care of patients
\nand the reputation of the medical pro-
\nfession. The duty of the physician is to
\nobjectively evaluate what is best for the
\npatient, while commercial enterprises
\nare expected to bring profit to owners
\nby selling their own products and com-
\npeting for customers. Commercial con-
\nsiderations can affect the physician\u2019s
\nobjectivity, especially if the physician is
\nin any way dependent on the enterprise.
\n3. Rather than forbidding any relationships
\nbetween physicians and industry, it is
\npreferable to establish guidelines for
\nsuch relationships. These guidelines
\nmust incorporate the key principles of
\ndisclosure, avoidance of obvious con-
\nflicts of interest and the physician\u2019s
\nclinical autonomy to act in the best
\ninterest of patients.
\n4. These guidelines should serve as the basis
\nfor the review of existing guidelines and
\nthe development of any future guidelines.
\nB. Medical Conferences
\n5. Physicians may attend medical confer-
\nences sponsored in whole or in part by a
\ncommercial entity if these conform to
\nthe following principles:
\n5.1 The main purpose of the conference
\nis the exchange of professional or
\nscientific information.
\n5.2 Hospitality during the conference is
\nsecondary to the professional
\nexchange of information and does
\nnot exceed what is locally customary
\nand generally acceptable.
\n5.3 Physicians do not receive payment
\ndircetly from a commercial entity
\nto cover travelling expenses, room
\nand board at the conference or com-
\npensation for their time unless
\nprovided for by law and\/or the pol-
\nicy of their National Medical
\nAssociation.
\n5.4 The name of a commercial entity
\nproviding financial support is pub-
\nThe World Medical Association statement
\nconcerning the relationship between
\nphysicians and commercial enterprises
\nlicly disclosed in order to allow
\nthe medical community and the
\npublic to assess the information
\npresented in light of the source of
\nfunding. In addition, conference
\norganizers and lecturers disclose
\nto conference participants any
\nfinancial affiliations they may
\nhave with manufacturers of prod-
\nucts mentioned at the event or
\nwith manufacturers of competing
\nproducts.
\n5.5 Presentation of material by a
\nphysician is scientifically accu-
\nrate, gives a balanced review of
\npossible treatment options, and is
\nnot influenced by the sponsoring
\norganization.
\n5.6 A conference can be recognised
\nfor purposes of continuing med-
\nical education\/continuing profes-
\nsional development (CME\/CPD)
\nonly if it conforms to the follow-
\ning principles:
\n5.6.1 The commercial entities acting
\nas sponsors, such as pharmaceu-
\ntical companies, have no influ-
\nence on the content, presenta-
\ntion, choice of lecturers, or pub-
\nlication of results.
\n5.6.2 Funding for the conference is
\naccepted only as a contribution to
\nthe general costs of the meeting.
\nC. Gifts
\n6. Physicians may not receive gifts from a
\ncommercial entity unless this is permit-
\nted by law and\/or by the policy of their
\nNational Medical Association and it
\nconforms to the following conditions:
\n6.1 The gift is only of nominal value.
\n6.2 The gift is not in cash.
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 91
\n6.3 The gift, even one of nominal
\nvalue, is not connected to any stip-
\nulation that the physician pre-
\nscribes a certain medication, uses
\ncertain instruments or materials or
\nrefers patients to a certain facility.
\nD. Research
\n7. Aphysician may carry out research fund-
\ned by a commercial entity, whether indi-
\nvidually or in an institutional setting, if it
\nconforms to the following principles:
\n7.1 The physician is subject only to the
\nlaw, the ethical principles and guide-
\nlines of the Declaration of Helsinki,
\nand clinical judgmenet in performing
\nresearch and does not allow himself
\nor herself to be subject to external
\npressure regarding the results of his
\nor her research or their publication.
\n7.2 If possible, a physician or institution
\nwishing to undertake research
\napproaches more than one company
\nto request funding for the research.
\n7.3 Identifiable information about
\nresearch patients or voluntary par-
\nticipants is not passed to the spon-
\nsoring company without the con-
\nsent of the individuals concerned.
\n7.4 A physician\u2019s compensation for
\nresearch is based on his or her time
\nand effort and such compensation
\nis in no way connected to the
\nresults of the research.
\n7.5 The results of research are made
\npublic with the name of the spon-
\nsoring entity disclosed, along with
\na statement disclosing who request-
\ned the research. This applies
\nwhether the sponsorship is direct or
\nindirect, full or patial.
\n7.6 Commercial entities do not suppress
\nthe publication of research results. If
\nresults of research are not made pub-
\nlic, especially if they are negative,
\nthe research may be repeated unne-
\ncessarily and thereby expose future
\nparticipants to potential harm.
\nE. Affiliations with
\nCommercial Entities
\n8. A physician may not enter into an affil-
\niation with a commercial entity such as
\nconsulting or membership on an advi-
\nsory board unless the affiliation con-
\nforms to the following prinicples:
\n8.1 The affiliation does not compro-
\nmise the physician\u2019s integrity.
\n8.2 The affiliation does not conflict
\nwith the physician\u2019s obligations to
\nhis or her patients.
\n8.3 Affiliations and\/or other relationships
\nwith commercial entities are fully
\ndisclosed in all relevant situations
\nsuch as lecturers, articles and reports.
\n9.10.2004
\nMedical Ethics and Human Rights
\n92
\n1. Medical ethics in times of armed con-
\nflict is identical to medical ethics in
\ntimes of peace, as established in the
\nInternational Code of Medical Ethics
\nof the World Medical Association. The
\nprimary obligation of physicians is to
\ntheir patients; in performing their pro-
\nfessional duty, their conscience should
\nbe their guide.
\n2. The primary task of the medical pro-
\nfession is to preserve health and save
\nlife. Hence it is deemed unethical for
\nphysicians to:
\na. Give advice or perform prophylac-
\ntic, diagnostic or therapeutic proce-
\ndures that are not justifiable for the
\npatient\u2019s health care.
\nb. Weaken the physical or mental
\nstrength of a human being without
\ntherapeutic justification.
\nc. Employ scientific knowledge to
\nimperil health or destroy life.
\n3. During times of armed conflict, stan-
\ndard ethical norms apply, not only in
\nregard to treatment but also to all other
\ninterventions, such as research. Research
\ninvolving experimentation on human
\nsubjects is strictly forbidden on all per-
\nsons deprived of their liberty, especially
\ncivilian and military prisoners and the
\npopulation of occupied countries.
\n4. The medical duty to treat people with
\nhumanity and respect applies to all
\npatients. The physician must always
\ngive the required care impartially and
\nwithout discrimination on the basis of
\nage, disease or disability, creed, ethnic
\norigin, gender, nationality, political
\naffiliation, race, sexual orientation, or
\nsocial standing or any other similar
\ncriterion.
\n5. Governments, armed forces and others
\nin positions of power should comply
\nwith the Geneva Conventions to
\nensure that physicians and other health
\ncare professionals can provide care to
\neveryone in need in situations of armed
\nconflict. This obligation includes a
\nrequirement to protect health care per-
\nsonnel.
\n6. As in peacetime, medical confidential-
\nity must be preserved by the physician.
\nAlso as in peacetime, however, there
\nmay be circumstances in which a
\npatient poses a significant risk to other
\npeople and physicians will need to
\nweigh their obligation to the patient
\nagainst their obligation to other indi-
\nviduals threatened.
\nThe World Medical Association
\nRegulations in times of armed conflict
\nAdopted by the 10th World Medical Assembly, Havana, Cuba, October 1956,
\nEdited by the 11th World Medical Assembly, Istanbul, Turkey, October 1957, and
\nAmended by the 35th World Medical Assembly, Venice, Italy, October 1983 and
\nThe WMA General Assembly, Tokyo 2004
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 92
\n7. Privileges and facilities afforded to
\nphysicians and other health care pro-
\nfessionals in times of armed conflict
\nmust never be used for other than
\nhealth care purposes.
\n8. Physicians have a clear duty to care for
\nthe sick and injured. Provision of such
\ncare should not be impeded or regard-
\ned as any kind of offence. Physicians
\nmust never be prosecuted or punished
\nfor complying with any of their ethical
\nobligations.
\n9. Physicians have a duty to press gov-
\nernments and other authorities for the
\nprovision of the infrastructure that is
\na prerequisite to health, including
\npotable water, adequate food and
\nshelter.
\n10. Where conflict appears to be imminent
\nand inevitable, physicians should, as
\nfar as they are able, ensure that author-
\nities are planning for the repair of the
\npublic health infrastructure in the
\nimmediate post-conflict period.
\n11. In emergencies, physicians are
\nrequired to render immediate attention
\nto the best of their ability. Whether
\ncivilian or combatant, the sick and
\nwounded must receive promptly the
\ncare they need. No distinction shall be
\nmade between patients except those
\nbased upon clinical need.
\n12. Physicians must be granted access to
\npatients, medical facilities and equip-
\nment and the protection needed to
\ncarry out their professional activities
\nfreely. Necessary assistance, includ-
\ning unimpeded passage and complete
\nprofessional independence, must be
\ngranted.
\n13. In fulfilling their duties, physicians
\nand other health care professionals
\nshall usually be identified by interna-
\ntionally recognized symbols such as
\nthe Red Cross and Red Crescent.
\n14. Hospitals and health care facilities sit-
\nuated in war regions must be respected
\nby combatants and media personnel.
\nHealth care given to the sick and
\nwounded, civilians or combatants,
\ncannot be used for morbid publicity or
\npropaganda. The privacy of the sick,
\nwounded and dead must always be
\nrespected.
\nInitiated February 2004
\nApproved by the WMA General
\nAssembly, Tokyo 2004
\nA. INTRODUCTION
\n1. In late 2002, an outbreak of a new
\nsevere acute respiratory syndrome
\n(SARS) began in southern China. The
\ndisease, which was caused by the
\nSARS coronavirus, spread internation-
\nally in late February 2003. The most
\nseverely affected countries were
\nChina, Canada, Singapore and
\nVietnam, all of which experienced out-
\nbreaks before the issue of global alerts
\nby the World Health Organization
\n(WHO). According to WHO data, alto-
\ngether 8422 cases occurred in 29 coun-
\ntries; in the four afore-mentioned
\ncountries, 908 cases were fatal.
\n2. SARS was an especially difficult new
\ndisease to diagnose and treat – it passed
\nreadily from person to person, required
\nno vector, had no particular geograph-
\nic affinity, mimicked the symptoms of
\nmany other diseases, took its heaviest
\ntoll on hospital staff, and spread inter-
\nnationally with alarming ease. The
\nspread of SARS along the routes of
\ninternational air travel emphasizes the
\nfact that pathogens know no bound-
\naries and reinforces the critical need
\nfor global public health strategies.
\n3. The main outbreaks of SARS occurred
\nin areas with well-developed health
\nsystems. If SARS had become estab-
\nlished in areas with weak health infra-
\nstructure, it is unlikely that contain-
\nment would have been achieved so
\nquickly. But even in well-developed
\nhealth care systems, certain very sig-
\nnificant flaws were demonstrated dur-
\ning this epidemic:
\n\u2022 Lack of effective real-time, two-way
\ncommunication channels to front-
\nline physicians;
\n\u2022 Lack of adequate resources, stock-
\npiles of medication and supplies to
\ndeal with this type of catastrophe;
\n\u2022 Lack of surge capacity within acute
\ncare and public health systems.
\n4. A gap between public health authori-
\nties (national and international) and
\nclinical medicine was demonstrated
\nduring this episode. At its September
\n2003 General Assembly, the WMA
\nadopted a Resolution on SARS that:
\n\u201estrongly encouraged the World
\nHealth Organization to enhance its
\nemergency response protocol to pro-
\nvide for the early, ongoing and mean-
\ningful engagement and involvement of
\nthe medical community globally.\u2026\u201c
\nB. BASIC PRINCIPLES
\n5. The international community must be
\nconstantly alert to the threat of emerg-
\ning disease outbreaks and ready to
\nrespond with a global strategy. The
\nGlobal Outbreak Alert and Response
\nNetwork (GOARN) of WHO has a sig-
\nnificant role to play in global health
\nsecurity by:
\n\u2022 combating the international spread of
\noutbreaks;
\n\u2022 ensuring that appropriate technical
\nassistance reaches affected states
\nrapidly; and
\nThe World Medical Association Statement on
\nhealth emergencies communication and
\ncoordination
\nMedical Ethics and Human Rights
\n93
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 93
\n\u2022 contributing to long-term epidemic
\npreparedness and capacity-building.
\nThe WMA has been actively
\ninvolved in GOARN, where appro-
\npriate. The role of GOARN must,
\nhowever, be acknowledged and
\nactively promoted within the med-
\nical profession.
\n6. Sovereign states have a responsibility
\nto address the health needs within their
\nborders. Today, however, many urgent
\nhealth security risks are not confined
\nby national boundaries. Early detec-
\ntion, through effective national sur-
\nveillance systems, of unusual disease
\nevents that threaten public health, and
\ninternational cooperation between
\nWHO, its member states, and non-
\ngovernmental partners like the WMA,
\nare required to effectively respond to
\npublic health emergencies of interna-
\ntional concern. A strengthening of the
\nInternational Health Regulations to
\nbroaden their scope to include new
\nand future health emergencies and
\nenable WHO to actively assist States
\nin responding to international health
\nsecurity threats will provide additional
\ntools for global epidemic control.
\n7. Effective communication between
\nWHO and the WMA, the WMA and its
\nmember National Medical Associations
\n(NMAs), and NMAs and physicians
\ncan strengthen the information
\nexchange between WHO and its
\nMember States during public health
\nemergencies.
\n8. Physicians are often the first point of
\ncontact with the emergence of new
\ndiseases; therefore they are in a posi-
\ntion to aid in all elements of diagnosis,
\ntreatment and reporting of affected
\npatients and prevention of disease.
\nPhysicians with key expertise must be
\nincorporated into the health emer-
\ngency decision-making process so that
\nthe impact of national and internation-
\nal directives on clinical settings and
\npatient care is understood.
\n9. WHO and its Member States must work
\nwith the WMA and NMAs to proactive-
\nly address the safety of patients and of
\nhealth professionals involved in caring
\nfor the sick during outbreaks of new dis-
\neases. Delays in identifying and distrib-
\nuting supplies of protective equipment to
\nhealth professionals and their patients
\nexacerbate anxiety and risk of spread of
\ninfectious disease. National and interna-
\ntional systems that stockpile relevant
\nand adequate supplies and rapidly move
\nthem to affected areas should be created
\nor enhanced. All the principles employed
\nin the safeguarding of patient safety
\nshould be respected and followed in
\nemergencies such as SARS.
\nC. RECOMMENDATIONS
\n10. That the WMA and member NMAs
\nshould work closely with WHO,
\nnational governments, and other pro-
\nfessional groups to jointly promote the
\nelements of this Statement.
\n11. That the WMA urge physicians to a) be
\nalert to the occurrence of unexplained
\nillnesses and deaths in the community,
\nb) be knowledgeable of disease sur-
\nveillance and control capabilities for
\nresponding to unusual clusters of dis-
\neases, symptoms and presentations,
\nand assiduous in the timely reporting
\nof suspicious cases of illness to appro-
\npriate authorities; c) utilize appropriate
\nprocedures to prevent exposure of
\ninfectious pathogens to themselves and
\nothers; d) understand the principles of
\nrisk communication so that they can
\ncommunicate clearly and non-threaten-
\ningly with patients, their families, and
\nthe media about issues such as expo-
\nsure risks and potential preventive
\nmeasures (e.g., vaccinations); and e)
\nunderstand the roles of the public
\nhealth, emergency medical services,
\nemergency management, and incident
\nmanagement systems in response to a
\nhealth crisis and the individual health
\nprofessional\u2019s role in these systems.
\n12. That the WMA encourage physicians,
\nNMAs, and other medical societies to
\nparticipate with local, national, and
\ninternational health authorities in devel-
\noping and implementing disaster pre-
\nparedness and response protocols for
\nnatural infectious disease outbreaks.
\nThese protocols should be used as the
\nbasis for physician and public education.
\n13.That the WMA call on NMAs to pro-
\nmote and support WHO\u2019s GOARN as
\na control coordinating entity in com-
\nbating global health security threats.
\n14.That the WMA call for the establish-
\nment of a strategic partnership agree-
\nment with WHO, so that in case of
\nepidemics, health communication can
\nbe stepped up considerably and two-
\nway flow of information ensured.
\n15.That WHO should coordinate the
\ndevelopment of an inventory based
\non existing stockpiles of supplies, so
\nthat such supplies can be rapidly
\ndeployed and accessed by physicians
\ninvolved in the care of victims.
\n16.That WHO should strengthen the
\nInternational Health Regulations to
\nbroaden their scope to include report-
\ning of new and future health emer-
\ngencies, and to enable WHO to
\nactively assist States in responding to
\ninternational health security threats.
\n17. That international agreements should
\nbe proactively explored to facilitate
\nthe movement of health professionals
\nwho are involved in the management
\nof epidemics.
\n18. That research in the field of emergency
\npreparedness should be enhanced by
\nnational governments and NMAs
\nwhere appropriate, to better understand
\ncurrent flaws in the system and how to
\nimprove preparedness in the future.
\n19. That education and training of physi-
\ncians should be modified to take into
\naccount the realities and specific needs
\nrequired in the event of emergencies,
\nand to ensure that due diligence is paid
\nto patient and health care worker safe-
\nty when managing patients with acute
\ninfectious diseases.
\n20. That physicians everywhere in the world,
\nincluding those in Taiwan, have unlimit-
\ned access to WHO programs and infor-
\nmation concerning health emergencies.
\nMedical Ethics and Human Rights
\n94
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 94
\nNote of clarification on paragraph 30 of the
\nWMA Declaration of Helsinki
\n\u201cThe WMA hereby reaffirms its position that it is necessary during the study planning
\nprocess to identify post-trial access by study participants to prophylactic, diagnostic and
\ntherapeutic procedures identified as beneficial in the study or access to other appropri-
\nate care. Post-trial access arrangements or other care must be described in the study pro-
\ntocol so the ethical review committee may consider such arrangements during its review.\u201d
\nMedical Science, Professional Practice and Education
\nAccount by Dr. James Appleyard of his
\nPresidential year of office 2003\u20132004
\nIt has been a great honour and privilege to
\nhave represented the World Medical
\nAssociation over the last twelve months as
\nyour President. My enduring memory has
\nbeen the warm, friendly and respectful wel-
\ncome from physicians worldwide. This was
\na the reaffirmation of our Declaration of
\nGeneva that \u201emy colleagues will be my
\nbrothers and my sisters\u201c. We all share a
\ncommon professionalism underpinned by
\nour core values.
\nMy main theme has been the Right of a
\nChild to Health Care advocating our
\nDeclaration of Ottawa, highlighting the
\ngap between the rich and poor both between
\nand within the nations of the World, seeking
\nto raise awareness and encouraging profes-
\nsional links particularly in education and
\nresearch. I was able to spread the message
\nfrom Africa (at the Ugandan Medical
\nAssociation and in South Africa), to
\nAmerica (in Miami at the Academy of
\nPharmaceutical Physicians, New York, at
\nthe Hispanic Development Foundation,
\nPortland Oregon to the medical students
\nduring their Global Health Week) and in
\nMalta, where the theme was taken up in a
\nfour minute television feature augmented
\nby their own archives.
\nEmphasizing that Violence is a leading pub-
\nlic health problem particularly impacting on
\nthe lives and wellbeing of children, it was
\npossible to stress the message of the
\nHelsinki WMA statement on Violence at
\nmeetings in the UK, Dominica, and notably
\nat the annual meeting of the International
\nFederation of Medical Student Associations
\n(IFMSA) in Ohrid, Macedonia where the
\nmajor theme was \u201cViolence and Health\u201d.
\nFinally I addressed the Symposium on
\n\u201cThe application of Children\u2019s Rights\u201d at
\nthe 24th International Congress of
\nPediatrics in Mexico. At the Congress, Ms.
\nCarol Bellamy from UNICEF emphasized
\nthat six out of the eight Millennium Goals
\nwere Child focused and that these were the
\ngoals of each government of the nations of
\nthe World. (UNICEF is publishing a Report
\non \u201cProgress for Children\u201d this autumn),
\nJoy Phumaphi from WHO stressed the
\n\u201cunfinished agenda\u201d of the \u201cAlive at Five\u201d
\ninitiative also pointing out that 11 million
\nchildren are dying each year from pre-
\nventable and treatable conditions. Thus
\nchildren are bearing 1\/3 rd of the world\u2019s
\nburden of disease, 9\/10ths of which was
\naffecting the poorer countries who had the
\nleast resources to cope with it. She said that
\nthe conference knew who was at risk, where
\nthey were, what must be done and how to
\ndo it. There are several concomitant initia-
\ntives such as the \u201cChild Survival
\nPartnership\u201d with UNICEF, WHO and the
\nWorld Bank that WMA, as the Association
\nof the Worlds\u2019 Physicians needs to join and
\nthere are also two effective pilot projects
\n\u201cChild Watch Africa\u201d and the Save the
\nChildren\u2019s \u201cSaving New Born Lives\u201d,
\nwhich are physician driven.
\nI have contacted all our national medical
\nassociation members about the need to
\ndevelop the WMA Declaration of Ottawa
\nfurther, and am currently collating the
\nreplies.
\nThere were two other areas for which, as
\nPresident, I sought your support. Firstly,
\naction to stop the increasing health prob-
\nlems of sub-Saharan Africa and to try and
\ninclude more African National Medical
\nAssociations in our work; and secondly, the
\nimportance of medical education in this
\nmission. My first engagement was to attend
\nthe \u201cStrategies for Survival\u201d Conference of
\nthe South African Medical Association
\nunder the inspired leadership of Dr. Kgosi
\nLetlape. In the very challenging times
\nahead, all the members of the profession in
\nSouth Africa are united both in the ethical
\nvalues that underpin medical practice and
\nin their quest for improved health services
\nfor the underserved. At the Annual Meeting
\nof the Ugandan Medical Association, there
\nwas an opportunity to meet the Presidents
\nof the Kenyan and Tanzanian Medical
\nAssociations in conjunction with the World
\nHealth Organization who were discussing
\nthe setting up of an East African Medical
\nand Dental Association.
\nConcerning medical education, my aim
\nwas to raise awareness of international
\nissues in a sustainable way by encouraging
\nall medical students to do a month\u2019s elec-
\ntive in a developing country and to suggest
\n\u201cexchanges\u201d during residency training pro-
\ngrammes, with the support and encourage-
\nment of joint research initiatives. I visited
\nthe International Department of Cornell
\nMedical School where 40% of the students
\nalready have international assignments,
\nmet the Dean of New York College of
\nMedicine and joined an inspired core of
\ndedicated medical students who had
\narranged a Global Health Week at Oregon
\nHealth and Sciences University in
\nPortland, Oregon. The energy and enthusi-
\nasm apparent at the International
\nFederation of Medical Students
\nAssociations (IFMSA) in Ohrid,
\nMacedonia, where I participated in the
\nimpressive opening ceremony held in the
\nMedical Science, Professional Practice and Education
\n95
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 95
\nRoman Amphitheatre, bodes well for the
\nfuture. Members of the IFMSA are given
\nfree associate membership of the WMA
\nafter they graduate and have to move on
\nfrom their own association. I hope as many
\nof these young and dedicated physicians
\nwill attend our meetings and continue to
\nhelp shape the future.
\nOur continuing work with other interna-
\ntional professional associations is essential
\nif we are to get our important messages
\nacross to the wider world community. I
\nattended the excellent International
\nFederation of Dentist\u2019s (FDI) first Regional
\nConference on Oral Health of the African
\nRegion, where the importance of including
\nthe major oral health problems within the
\ncollaborative general health programs was
\nstressed in the presence of the Ministers of
\nHealth, WHO, representatives from
\nAcademia and dental practitioners. This
\nwas an inclusive conference dealing with
\nthe particular problems of the Region and
\none which we should be emulated in other
\nRegions. The European Forum for Good
\nClinical Practice held a Conference on
\nClinical Research involving Academia,
\nIndustry, Medical Organizations, NGOs.,
\nseeking to influence current European leg-
\nislation The European Platform for Patient
\nOrganizations also expressed a concern to
\nrescue reliable, ethical research
\ninitiatives on children.
\nThe World Health Professions Alliance
\nConference held in Geneva after our
\nCouncil Meeting in Divonne was a major
\ninnovation for the WMA. It is essential that
\nwe use such forums to join with other
\nhealth professional colleagues to help tack-
\nle the global problems such as AIDS in a
\ncoordinated way. We must rise above the
\nunnecessary turf battles that have belittled
\nus all. The combined energy should be used
\nto advocate our own shared policies so that
\ntogether we can have much greater impact.
\nWe are also a Founder Member of Oxford
\nVision 2020 dedicated to the prevention of
\nthe forecast pandemic growth of largely
\npreventable chronic diseases in the low and
\nmiddle income countries and the poorer
\nsegments of society in the developed world.
\nThe forum includes academia, industry,
\nprofessional and other non governmental
\norganization, patient groups and young
\npeople. It focuses on three risk factors
\ntobacco, diet and lack of exercise, and four
\nchronic diseases, diabetes, cardiovascular
\ndisease, chronic lung disease and some can-
\ncers, which lead to 50% of deaths globally.
\nOur profession should set an example and
\nfollow the lead of our American colleagues
\nwith regard to diet, smoking, and exercise
\nand reduce our own BMI\u2019s!
\nDuring a meeting of the Maltese Medical
\nAssociation, I had the opportunity to
\nencourage policy development to imple-
\nment the Framework convention on
\nTobacco Control in a meeting with the
\nMinister of Health. Some progress has been
\nmade with regard to the hazards of passive
\nsmoking on the island. Increasingly other
\ncountries are following the example of the
\nRepublic of Ireland. I wrote to the Prime
\nMinister in the UK but he has so far failed
\nto respond to the lead of his own Chief
\nMedical Officer.
\nAs the global representative body of some 7
\nmillion physicians we have a duty to sup-
\nport our \u201cbrothers and sisters\u201d in times of
\ngreat difficulty. In conjunction with our
\nHuman Rights Unit I tried through contacts
\nto help free Dr. Biscet who is still languish-
\ning in a Cuban Jail as a result of his endeav-
\nors to promote human rights.
\nSome 10.000 doctors were on strike when
\nI visited the Dominican Republic. Their
\nconcerns were the deteriorating situation in
\nGovernment Hospitals, and the catastrophic
\neffects of the fall in the value on the peso on
\nbasic maintenance of hospitals and on their
\nown salaries. With the President of the
\nColegio Medico Dominicano I visited the
\nHospital General Materno Infantil and met
\nthe faculty, residents and the administra-
\ntion. The acute services budget was running
\nat 15% of the hospitals needs. Hospital
\nblackouts could last up to 13 hours, and
\nsometimes the only available light during
\nemergency operations had been from the
\nLCD display of a mobile phone.
\nThe collapse of the health system in
\nZimbabwe, whose government has ratified
\nwith the other African Countries the
\nWHO\u2019s \u201cRight to Health\u201d, is a humanitari-
\nan disaster with an additional 20.000 chil-
\ndren dying each year in the year 2002 than
\nwould have died ten years previously.
\nCuban doctors have been imported to try
\nand reverse the effects of the loss of physi-
\ncians from the country but they are unable
\nto provide a proper primary care service
\nbecause of language difficulties, and have
\nsettled in the cities. I met a dynamic group
\nof non governmental organizations includ-
\ning the Amani Trust, Amnesty
\nInternational, Zimbabwe Association and
\nZADHR to be informed about the current
\nculture of repressive violence and torture in
\nZimbabwe which is being reinforced by the
\n\u201cWar Veterans\u201d and Youth Militia.
\nAt the BMA Annual Representative Body
\nin Llandudno, I met Dr Raj Doolabh, who
\nthen was Treasurer of the Zimbabwe
\nMedical Association, one of our member
\nassociations. He did not expect significant
\nchange in Zimbabwe until Mr. Mugabe
\nretired. Members of the opposition were
\nbeing denied treatment for HIV\/Aids. By-
\nelections caused by their deaths allowed
\ntheir replacement by ZANU members. Raj
\nDoolabh suggested that the main help
\nphysicians from outside Zimbabwe could
\ngive their colleagues in Zimbabwe was
\nthrough Continuing Medical Education,
\nwhich is now mandatory in the Country. It
\nwas hoped that it would be possible to
\narrange a meeting with the ZIMA executive
\nduring a conference on AIDS which Dr.
\nLetlape was organising in September but
\nunfortunately this has not been possible.
\nPhysicians in Iraq have started to develop
\nlinks with the WMA following the atten-
\ndance of Dr. Brennan on their behalf at the
\nCouncil Meeting in May. At a recent Iraqi
\nMedical Specialty Forum in Washington I
\nmet some Iraqi physicians from Baghdad
\nand several others who had emigrated to the
\nUS. The security situation for physicians
\nwas very serious. Dr Khalili, a
\nNeurosurgeon, who had been kidnapped
\nhimself, said the main problems were secu-
\nrity, a regular supply of electricity and
\nwater and the maintenance of medical sup-
\nplies and provisions for Government
\nHospitals. On the other hand the budget for
\nHealth had been increased from $16 million
\nin Saddam Hussein\u2019s time to $905 million.
\n600 extra medical facilities for essential
\ncare had been developed with 110 primary
\nhealth care centers. Certain areas of the
\nMedical Science, Professional Practice and Education
\n96
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 96
\nMedical Science, Professional Practice and Education
\n97
\ncountry such as Kurdistan were peaceful
\nand safe. It was suggested that a conference
\nincluding all interested national medical
\nassociations in the region might be held to
\nlook how the health problems in the Region
\nand in particular how those in Iraq could be
\naddressed. This is a contribution that the
\nWMA might make with the WHO subject
\nto funding which I gather could be raised.
\nMy last visit before handing over the badge
\nof office to the President-elect, Dr. Yank
\nCoble, was to talk about \u201cProfessionalism\u201d
\nat the annual meeting of the Icelandic
\nMedical Association, a subject already
\ntaken up by the Editor of the WMJ. Here it
\nwas emphasized that we need to guard our
\nprofessional autonomy by ensuring the
\nhighest standards of education, care and
\nethics.
\nThis last visit had a timely topic for reflec-
\ntion and illustrates the importance of the
\nWMA continuing to support the work of
\nphysicians worldwide.
\n\u201cWherever the Art of Medicine is loved,
\nthere is also the love of humanity\u201d
\nHippocrates 400 BC
\nJames Appleyard MA (Oxon), MD (Kent),
\nFRCP (Lon), FRCPCH (UK)
\nPresident of the World Medical Association
\n2003\u20132004
\nThe future of medical technology \u2013
\nImplications for medical education and practice
\nAddress to the World Medical Associa-
\ntion (Tokyo, Japan)
\nHenry Haddad, MD, FRCPC
\nPast President
\nCanadian Medical Association
\nThank you very much for asking me to
\nspeak to you today. It is indeed a great hon-
\nour, and I would like to express my gratitude
\nto our Japanese hosts for having invited me
\nto address this distinguished gathering.
\nAs many of you know, medical technology
\nhas revolutionized both medical education
\nand the clinical practice of medicine in most
\nparts of the world. Some people may still
\nview advances in the field as a relatively
\nrecent development, and medical technolo-
\ngy as a modern phenomenon.
\nHowever, medical technology as we under-
\nstand it has been developing over many
\nyears, from the discovery of medical appli-
\ncations of radioactivity by Roentgen to the
\nisolation of insulin by our own Canadian
\nresearchers Banting and Best. More recent
\ndevelopments have included implantable
\nmedical devices such as pacemakers and
\nartificial valves, and the refinement of
\norgan transplantation techniques and antire-
\njection drug regimens.
\nAlthough medical technology is not new, its
\ndevelopment has certainly accelerated sig-
\nnificantly, and keeping up with these
\nchanges has become a difficult challenge
\nfor many medical practitioners.
\nBefore expanding on the concept of medical
\ntechnology, it may be useful to take a step
\nback and consider human achievements
\nwhich are in today\u2019s terms decidedly \u201clow-
\ntech\u201d. Some of our most prominent medical
\npractitioners, such as Pasteur, Burkett,
\nOsler and Freud worked without the benefit
\nof high technology.
\nIt was in 1950 that Dicke suggested, in a
\nlandmark study, that certain dietary cereal
\ngrains were harmful to children with a
\ncoeliac sprue \u2013 a malabsorbtion disorder
\nthat is potentially fatal. He acutely observed
\nthat the incidence of coeliac sprue in chil-
\ndren in Holland during World War II was
\nmarkedly reduced and that previously diag-
\nnosed coeliac patients improved during the
\nwar years. During this period, grain produc-
\ntion such as wheat and rye flour, were in
\nshort supply in Holland. When cereal grains
\nagain became plentiful after the war, the
\nincidence of coeliac sprue rapidly returned
\nto previous levels. It was subsequentely
\ndemonstrated that the gluten moiety of wheat
\nwas the offending agent. This simple obser-
\nvation has improved the quality of life of
\nmany thousands of people, including some of
\nmy relations.
\nThere are also other factors of determants
\nof health that have had a tremendous
\nimpact on global health, these include
\npatient education, improved diet and recog-
\nnition of environmental factors. Inventions
\nnot directly related to medicine have also
\nplayed an important role. For example, the
\ninvention of refrigeration may have saved
\nmore human lives than any other. Having
\nsaid this, most people would still probably
\nagree that, on balance, medical technology
\nhas had a positive impact on patient health
\nand well-being. Life expectancy in most
\ncountries around the world has increased
\nsignificantly and other markers of health,
\nsuch as neonatal and maternal mortality,
\nhave also improved.
\nIn general, medical technology has enhanced
\ndiagnostic accuracy and efficiency.
\nThis has allowed physicians to see, diag-
\nnose and treat more patients in a shorter
\nperiod of time, an important development
\nin those many places with insufficient med-
\nical human resources. Patients live longer
\nand have higher quality of life because of
\ndevelopments such as insulin pumps, pros-
\nthetic heart valves and artificial joints.
\nHowever, in many parts of the world
\nincluding my own country, great advances
\nin medical technology have not generally
\ntranslated into the large leaps in productiv-
\nity as witnessed in other industries.
\nIt would now appear that what we once
\nreferred to as the \u201cfuture\u201d of medical tech-
\nnology is nearly upon us.
\nAdvances previously thought to be in the
\nrealm of science fiction are fast approach-
\ning reality. Among the numerous examples
\nof medical technology, the most widely dis-
\ncussed is the genetic\/genomic revolution.
\nFollowing the unravelling of the human
\ngenome, we have been witness to wide-
\nspread and diverse predictions regarding
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 97
\nfuture applications of this new knowledge.
\nThe genomic revolution has raised many
\nquestions:
\n\u2022 Is the development of designer drugs
\nbased on a person\u2019s genetic makeup far
\noff?
\n\u2022 Is gene therapy for currently untreatable
\nconditions on the horizon or will the
\npotential roadblocks prove insurmount-
\nable?
\nAnd what of stem cell transplantation?
\n\u2022 Is it truly the answer we have been seek-
\ning to help cure diabetes, Parkinson\u2019s
\nDisease and spinal cord injury?
\nAlong with these questions, which tend to
\nprovoke much excitement and optimism
\namongst medical practitioners and their
\npatients, are other, potentially more trou-
\nbling ones, which also deserve some atten-
\ntion and discussion.
\nWho will have access to these new tech-
\nnologies?
\nAccess to care remains a major concern in
\nmany parts of the globe.
\nAccess to care based on need rather than
\nability to pay, is still a pipe dream for most.
\nIt is certainly possible that as medical tech-
\nnology advances further, inequities in
\naccess to care will become more rather than
\nless apparent and profound.
\nWealthier nations who are able to fund the
\ndevelopment of technologies will move fur-
\nther ahead, while those without the
\nresources to compete will fall further
\nbehind.
\nThis also has to do with the broader issues
\nof resource allocation and priority setting.
\nHi-tech interventions tend to be relatively
\nmore expensive, both in terms of initial
\ncapital outlay and recurrent expenditures.
\nWe need to ask ourselves how far we
\nshould go in allocating scarce resources to
\nmeeting increasing patient demands for
\nthese more costly interventions, when the
\nend result may be decreased availability of
\nsimpler, but often equally effective, treat-
\nments. For example, many countries,
\nincluding Canada, devote inadequate
\nresources to caring for the terminally ill. It
\nis difficult to compare results seen from the
\nuse of medical technology to the benefits of
\ncompassionate care at the end of life. But
\ndecisions about where to allocate our pre-
\ncious resources must be made, and we must
\ngrapple with the issue of what kind of
\nrationing in health care is morally acceptable.
\nWill predictive genetic testing disadvantage
\nthose with a genetic susceptibility to dis-
\neases for which there is no cure? For exam-
\nple, the development of a test could deter-
\nmine with certainty that a person would
\ndevelop incapacitating and untreatable can-
\ncer or a neurological disorder at a young age
\nwould be likely to affect their insurability
\nand employability if insurers and employers
\nwere able to gain access to this information.
\nCurrently the insurance industry is lobbying
\nfor exactly this type of access.
\nThis threatens to have a detrimental impact
\non the doctor-patient relationship.
\nPresently in Canada it is known that in
\napproximately 11% of medical encounters,
\nthe patient withholds relevant medical
\ninformation because of concerns about who
\nwill have access to this data (including
\nemployers, banks and insurance compa-
\nnies). In the United States this percentage
\nappears to be about 15% of patients. This
\nproblem is likely to become worse over
\ntime, with the advent of predictive genetic
\ntesting and the use of electronic health
\nrecords, which could be accessed by other
\nparties. If more medical information is
\nwithheld, and many experts estimate that
\nthe figure will rise to 20% of patients, the
\ndoctor-patient relationship will be further
\ncompromised, and there can be little doubt
\nthat patient care will suffer.
\nAnd what about the psychological impact of
\nthis type of information on these patients?
\nJust because we have the ability to uncover
\ncertain medical information, does that mean
\nwe should, especially when treatment or
\ncures do not exist?
\nDoes the benefit of planning for the future
\noutweigh the potential burden of knowing
\nwhen this future will end? Experts in this
\nimportant field are currently considering
\nthese questions and others.
\nWill those who bear the burden of medical
\nresearch ultimately reap the rewards of dis-
\ncovery? There are many examples of stud-
\nies done in populations which ultimately do
\nnot derive the primary benefits from their
\nresults. There is no reason to believe that
\ntechnological research might be any differ-
\nent, and as physicians we must do whatev-
\ner we can to guard against this, and to
\nensure that the burdens and benefits of
\nmedical research are equitably distributed,
\n\u2013 a major concern of the WMA:
\nWhere is the line drawn between innovative
\nmedical practice and medical research? If a
\nsurgeon is perfecting a new procedure such
\nas implantation of a new mechanical pump,
\ndoes this qualify as standard medical prac-
\ntice or as research? The distinction can be a
\ncritical one. If it is research, it would
\nrequire review by a duly constituted resarch
\nethics board and would be subject to a dif-
\nferent standard of informed consent.
\nOversight and monitoring of the procedure
\nwould also be more stringent in many parts
\nof the world if it were considered to be
\nresearch rather than standard treatment.
\nDoes the advance of medical technology
\nfurther skew the balance between art and
\nscience in the practice of bedside medicine
\ntowards science, and what impact will this
\nhave on the education and development of
\nfuture physicians?
\nOver many centuries, medical practitioniers
\nrelied on the art of medicine to help relieve
\nsuffering. This was true for both diagnosis
\nand treatment. As a very famous Canadian
\nphysician, Sir William Osler, once said:
\n\u201cAlways listen to the patient, they will tell
\nyou the diagnosis.\u201d The point is that test-
\ning should never be used as a substitute
\nfor a good history. The emphasis is today
\n\u2013 and I see this every day at my University
\nHospital \u2013 on scan and blood test. Keep
\nrepeating to your students that there is noth-
\ning more satisfying or more informative
\nthan sitting down with the patient and real-
\nly considering what they are saying. Sir
\nWilliam Osler was right \u2013 \u201cTechnology is
\nthere to complete the art of medicine \u2013 it is
\nnot a substitute\u201d!
\nHowever, in modern times, the thorough
\nbedside medical examination has often
\ngiven way to the full-body or MRI scan.The
\nMedical Science, Professional Practice and Education
\n98
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\nMedical Science, Professional Practice and Education
\n99
\nlong and emotional discussion about the
\nimpact of a person\u2019s physical illness on
\ntheir psychological well-being has been
\nreplaced by the prescription for the newest
\nanti-depressant, often one the patient has
\nseen advertised on TV. These changes have
\naltered the physician-patient relationship,
\nand usually not for the better.
\nMedical students today train in an environ-
\nment with a bias towards specialization of
\ncare, often driven by rapid advances in
\ntechnology.
\nPhysicians cannot be expected to keep up
\nwith every new development when the
\nbody of medical knowledge is, by some
\nestimates, doubling every year. These fac-
\ntors have led to increasing subspecializa-
\ntion and the gradual erosion of the role of
\nthe primary care practitioner, which is so
\ncrucial to the maintenance of overall
\npatient health and well being.
\nStudents are also often attracted to the more
\nglamorous and higher paying specialities,
\nwhich not coincidentally, are often those
\nwhich make the most use of technology.
\nUnless we are able to swing the pendulum
\nback towards the art of medicine, and
\ndemonstrate to a greater number of stu-
\ndents the merits and rewards of primary
\npractice, we will see a further decline of the
\ndoctor-patient relationship and a further
\ndehumanization of the practice of medi-
\ncine. This is not in the best interest of either
\nthe physicians or their patients.
\nAs we have focused more attention on
\nacute care and life-saving technologies,
\nhave we neglected areas such as public
\nhealth and health promotion? Certainly
\nmuch of the attention and publicity tends to
\nbe focused on those medical interventions
\nthat save individual lives \u2013 the coronary
\nbypass, the new cancer treatment, the kid-
\nney transplant. And while this attention
\n(and, not coincidentally, much of the fund-
\ning) has been focused on acute care and the
\nimpact of new advances, the public health
\nand promotion infrastructure has been
\nslowly deteriorating.
\nWe need look no further than SARS for an
\nexample. Billions of dollars world-wide are
\ncurrently being poured into the develop-
\nment of medical databases so that, for
\nexample, emergency physicians can access
\npatient information and test results at the
\ntouch of a button. This we would all agree
\nis a positive development-improving health
\ncare and eventually hopefully reducing
\ncost. In the meantime, public health care
\nworkers in Toronto were faced with a com-
\npletely outdated and inadequate computer
\nsystem to try and track new cases of SARS
\nand their contacts during the height of the
\nepidemic. In many offices, sticky notes were
\nused instead of computer databases to keep
\ntrack of new developments. While we may
\nhave learned a lesson from this example,
\nwhether or not we can apply it in a meaning-
\nful and ongoing way remains to be seen.
\nFinally, will the emphasis currently placed
\non technological research and its transla-
\ntional application detract both attention and
\nfunding from equally important basic sci-
\nence research?
\nJust as medical students are more likely to
\nbe attracted to the more glamorous spe-
\ncialities, so too will scientists in training
\noften follow their mentors as they pursue
\nthe dollars and glory promised by the next
\ntechnological miracle. Let me conclude by
\nsaying that, overall, we have been well
\nserved by advances in medical technology,
\nand our patients in general are living
\nlonger and healthier lives because of these
\ndevelopments.
\nHowever, we must not push ahead blindly
\nor unquestioningly.
\nI have tried to raise several questions,
\nwhich I think require further thought and
\ndiscussion. Until we can answer these ques-
\ntions, and others, the future of medical tech-
\nnology is likely to remain uncertain at best
\nand troubling at worst.
\nTwin Studies
\nBlame your genes for a restless night\u2019s sleep \u2013
\nnew research revealed
\nNew research carried out by doctors in the
\nTwin Research Unit at St. Thomas\u2019
\nHospital, London, U.K. indicates that
\ngenetic factors make a \u201csubstantial contri-
\nbution\u201d to common sleep disorders.
\nProfessor Tim Spector, Director of the Unit,
\nhas revealed the results of a new study of
\nalmost 2,000 pairs of female twins during a
\npress briefing at the Science Media Centre.
\n1,937 pairs of identical and non-identical
\ntwins from the Twin Research Unit data-
\nbase were asked questions on sleep disor-
\nders such as obstructive sleep apnoea
\n(OSA) and restless legs syndrome (RLS).
\nDr. Adrian Williams, a co-author of the
\nresearch study and Consultant in the Sleep
\nDisorders Centre at St. Thomas\u2019 Hospital,
\nsays: \u201cSleep disorders are surprisingly com-
\nmon and it is increasingly recognised that
\nthey can have a devasting impact on suffer-
\ners\u2019 everyday lives.\u201d
\n\u201cFor example, OSA affects approximately
\n24% of men and 9% of women aged 30 to 60.
\nIt even contributes to road traffic accidents
\nwhen sufferers fall asleep at the wheel.\u201d
\nTwins were asked, in connection with OSA,
\nif they ever snored and, if so, how often
\ntheir snoring disturbed others or caused
\nthem to wake up \u2013 they were also asked if
\nthey experienced daytime sleepiness.
\nIn relation to RLS, twins were asked if they
\never experienced an urge to move their legs
\nduring the night to relieve tingling or numb-
\nness and also if they ever found their legs
\njerked involuntarily during the night.
\nKey findings of the research study include:
\n\u2022 Genes contribute significantly to sleep
\ndisorders \u2013 approximately 50% of the
\nvariance in liability to these symptoms is
\ndue to genetic factors.
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 99
\nWorld Health Organization
\n100
\n\u2022 Heritability was estimated to be 42%
\n(disruptive snoring), 45% (daytime
\nsleepiness), 54% (restless legs) and 60%
\n(legs jerking).
\n\u2022 An important strength of the research
\nstudy is that these heritability estimates
\nhave been corrected to take into account
\nother influences on the symptoms of
\nsnoring and daytime sleepiness such as
\nsufferers being overweight or heavy
\nsmokers.
\nProfessor Spector says: \u201cThese results sug-
\ngest a substantial genetic contribution to the
\nsymptoms of both obstructive sleep apnoea
\nand restless legs syndrome and that could
\nbe good news for people who suffer from
\nthese conditions if the genes responsible
\ncan be identified.
\n\u201cOne reason the genes for disruptive sleep
\nmay have persisted is that poor sleep pat-
\nterns make people gain weight and retain
\nfat. These genes may have helped our
\nancestors through periods of famine and the
\nIce Age.\u201d
\nThe Twin Research Unit was originally set
\nup at St. Thomas\u2019 Hospital (London U.K.)
\nin 1992 to look at the role that genes play
\nin the development of rheumatic diseases
\nin older women and has now expanded to
\nlook at most common diseases, behaviours
\nand traits.
\nWorld Health Organization
\nNew tools and increased funds will
\nbeat malaria, say global leaders
\nArusha, Tanzania \u2013 New technologies for
\nmalaria prevention and treatment, com-
\nbined with an increase in available funding,
\nare fuelling optimism in the fight against
\nmalaria. Global leaders gathered in Arusha
\nfor the launch of the Olyset\u00ae Net at A to Z
\nTextile Mills \u2013 the first factory in Africa to
\nproduce this long-lasting insecticidal mos-
\nquito net \u2013 agreed that conditions were right
\nfor a massive scale-up in the battle against
\nthe disease, which claims more than a mil-
\nlion lives each year and hampers develop-
\nment, especially in Africa.
\nThe President of the United Republic of
\nTanzania, Benjamin W. Mkapa, delivered a
\nmessage of hope to a group of dignitaries
\nincluding US Secretary of Health and
\nHuman Services Tommy Thompson, Roll
\nBack Malaria Partnership Executive
\nSecretary Awa Marie Coll-Seck, and Global
\nFund to Fight AIDS, Tuberculosis and
\nMalaria Executive Director Richard
\nFeachem, as well as representatives of the
\nRoll Back Malaria partners who had made
\nthe A to Z technology transfer possible.
\n\u201cLong-lasting insecticidal nets are Africa\u2019s
\nbest hope for preventing malaria, and we
\nare very proud that Tanzania is the home of
\nAfrica\u2019s first manufacturer of these nets,\u201d
\nsaid President Mkapa. \u201cWe hope that this
\nshining example of technology transfer and
\nstrengthening of local industry will serve as
\na model for similar efforts, making the nets
\nmore affordable and available to the mil-
\nlions of Africans who need them.\u201d
\nThe technology for long-lasting insecticidal
\nnets, which embed insecticide within the
\nnet\u2019s very fibres and therefore retain their
\nefficacy for up to five years without retreat-
\nment, was transferred to Tanzania last year
\nin a groundbreaking collaboration between
\nprivate and public sector players including
\nthe Acumen Fund, Sumitomo Chemical, the
\nWorld Health Organization, UNICEF,
\nExxonMobil, and Population Services
\nInternational. A to Z Textiles now produces
\nnearly half a million of these new nets each
\nyear and hopes to ramp up production to
\npass the one-million mark in 2005.
\nThe latest generation of highly effective
\nmalaria treatments known as artemisinin-
\nbased combination therapy (ACT) offer a
\ncure that so far has met only minimal resis-
\ntance from the malaria parasite. Derived
\nfrom the Artemisia annua (sweet worm-
\nwood) plant traditionally used to treat
\nmalaria in China, these medicines have
\nbecome the drug of choice for more than 40
\ncountries (20 of them in Africa), and
\ndemand for them has increased rapidly.
\nThe factory visit took place in the context
\nof th 9th
\nboard meeting of the Global Fund,
\nwhich was held in Arusha from 17\u201319
\nNovember. \u201cThe Global Fund has commit-
\nted nearly US$ 1 billion over the coming
\ntwo years and expects to scale up malaria
\nfunding substantially,\u201d said Global Fund
\nExecutive Director Feachem. \u201cThese funds
\nwill be used by countries to purchase both
\npreventive and curative tools \u2013 including
\nlong-lasting nets, artemisinin-based combi-
\nnation therapy, and insecticide spraying
\nwhere suitable \u2013 for maximum impact
\nagainst malaria.\u201d The Global Fund is also
\nworking with Roll Back Malaria partners to
\nprovide the financial incentives that will
\nbring a new malaria vaccine to the market.
\n\u201cThis is a new era for malaria control,\u201d
\ndeclared the Roll Back Malaria
\nPartnership\u2019s Executive Secretary Coll-
\nSeck. \u201cDemand for this latest generation of
\neffective malaria-control tools is increasing
\nrapidly, and so is funding. If we can repli-
\ncate the success of A to Z to ensure an ade-
\nquate supply of long-lasting insecticidal
\nnets, and work with pharmaceutical com-
\npanies to ensure ACT supplies, we will
\ndemonstrate the true power of public-pri-
\nvate partnerships by dramatically reducing
\nmalaria deaths.\u201d
\nBackground
\nTo provide a coordinated global approach
\nto fighting malaria, the Roll Back Malaria
\nPartnership was launched in 1998 by the
\nWorld Health Oarganization, the United
\nNations Children\u2019s Fund (UNICEF), the
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 100
\nWorld Health Organization
\n101
\nUnited Nations development Programme
\n(UNDP) and the World Bank. The
\nPartnership\u2019s goal is to halve the global
\nburden of malaria by 2010.
\nThe Partnership now includes malaria-
\nendemic countries, their bilateral and multi-
\nlateral development partners, the private sec-
\ntor, non-governmental and community-based
\norganizations, foundations, and research and
\nacademic institutions and has succeeded in
\nraising global awareness of malaria, generat-
\ning increased resources and achieving con-
\nsensus on the tools and priority interventions
\nrequired to control the disease.
\nMidwives\/Gynaecologists
\nSkilled attendants vital to saving lives
\nof mothers and newborns
\nGeneva \u2013 The number of skilled attendants in
\ndeveloping countries needs to be increased by
\nat least 333,000 if the international communi-
\nty is to meet the Millennium Development
\nGoal (MDG) of reducing maternal deaths by
\ntwo thirds by 2015, according to a joint state-
\nment* issued by the World Health
\nOrganization, the International Federation of
\nGynaecologists (FIGO) and the International
\nConfederation of Midwives (ICM).
\nA skilled attendant is a health professional
\nwith the competencies for care during nor-
\nmal birth and the capacity to recognize,
\nmanage and refer complications in the
\nwoman and newborn. Skilled attendants
\nplay a pivotal role in reducing maternal and
\nnewborn mortality and morbidity, says the
\njoint statement of WHO, ICM and FIGO.
\nThe statement calls for better monitoring
\nand reporting on progress in achieving the
\nMDG target of increasing the proportion of
\nbirths attended by a skilled attendant to
\n90% by 2015.
\nThe shortfall is most acute in the developing
\nworld. In developed countries and countries
\nin transition, the average rate is above 90%.
\nThe lowest levels are in Eastern Africa
\n(33.6%), South-Central Asia (37.5%) and
\nWestern Africa (39.6%), with much higher
\nlevels in South America (84.8%). Globally,
\nonly 61% of all childbirths are attended by a
\nskilled birth attendant.
\n\u201cLife-threatening complications occur in
\n15% of all births,\u201d says Joy Phumaphi,
\nAssistant Director-General of Family and
\nCommunity Health at WHO. \u201cFor a moth-
\ner and her newborn, a skilled birth atten-
\ndant can make the difference between life
\nand death. Not only can they recognize and
\nprevent medical crises on the spot, but they
\ncan refer women for life-saving care when
\ncomplications arise.\u201d
\nThe joint statement defines a skilled atten-
\ndant, sets out what skills they should have,
\nand the training and support they need. In
\ntheir statement, WHO, ICM and FIGO
\njointly urge the international community,
\nprofessional associations and donors to
\nmake skilled care for all pregnant women
\nand their newborns a priority \u2013 focusing on
\nincreasing the number of skilled birth
\nattendants, strengthening their capacity and
\nincreasing the resources available to them.
\nAids
\nA globally effective HIV vaccine requires
\ngreater participation of women and
\nadolescents in clinical trials
\nGeneva \u2013 Greater participation of women
\nand adolescents is needed in HIV vaccine
\nclinical trials, according to a group of inter-
\nnational experts, who attended a consulta-
\ntion on HIV vaccine trials in Lausanne,
\nSwitzerland.
\nThe meeting, organized by the World
\nHealth Organization and the Joint United
\nnations Programme on HIV\/AIDS
\n(UNAIDS), brought together for the first
\ntime 40 experts from around the world to
\naddress the issues of gender and age in par-
\nticular, as well as race in HIV vaccine-
\nrelated research and clinical trials.
\n\u201cWe have identified measures aimed at recti-
\nfying the injustice stemming from the fre-
\nquent exclusion or low participation of
\nwomen and adolescents in HIV vaccine clin-
\nical trials. Clinical trial enrolment needs to be
\nmore inclusive, so the benefits of research
\nare more fairly distributed,\u201d said Dr. Ruth
\nMacklin, co-Chair of the meeting and a
\nbioethics professor at the Albert Einstein
\nCollege of Medicine in New York City.
\nStudies show that women, when exposed to
\nHIV, are at least twice as likely to become
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 101
\nWorld Health Organization
\n102
\nof VaxGen\u2019s AIDSVAX, the only candidate
\nvaccine so far to reach Phase III efficacy
\ntesting in large numbers of people, found
\nthat although the vaccine was not effective
\noverall, non-whites and women possibly
\nhad some degree of protection. This finding
\nmerits further investigation.
\nMore than 30 promising, new candidate
\nHIV vaccines are currently being tested in
\nhuman clinical trials, the majority of which
\nbegan in the past four years. The number of
\nAIDS vaccine candidates in small-scale
\nhuman trials has doubled since 2000. The
\ntrials are taking place in 19 countries. A
\nsafe, effective and affordable vaccine
\nagainst HIV would be a powerful arm
\nagainst the AIDS epidemic which continues
\nto infect five million adults and children
\nand kill three million people every year.
\nThe international HIV vaccine research
\nmission is to develop HIV vaccines that are
\nlicensed, acceptable, available and accessi-
\nble by all populations regardless of their
\ngender, age, socio-economic status, race,
\nethnicity or country, and that are effective
\nacross the board. Special attention must be
\npaid to ensure that vulnerable groups, par-
\nticularly women and girls, benefit from an
\nHIV vaccine.
\nRecommendations \u2013 covering ethics, poli-
\ncy, advocacy, community participation,
\nclinical trial design and research gaps \u2013
\nissued at the consultation will form the
\nbasis of a policy document that will help
\nguide those designing and conducting HIV
\nvaccine clinical trials. An important sug-
\ngestion for future work was to study HIV
\nclinical trial sites with enrolments that
\ninclude appropriate numbers of people
\nfrom different sub-groups, and to try to bet-
\nter understand the barriers that have pre-
\nvented wider participation.
\nThe challenges to the creation of an HIV
\nvaccine are mainly and economic, primari-
\nly due to the lack of incentive by the private
\nsector to engage in product development.
\nHowever, new momentum has been gener-
\nated in the field of HIV vaccine research. In
\nJune 2004, the G8 countries endorsed a
\nGlobal HIV Vaccine Enterprise to acceler-
\nate efforts to develop an HIV vaccine
\nthrough an expanded capacity to test and
\nmanufacture vaccines, the establishment of
\nvaccine development centres around the
\nworld and the development of an integrated
\nglobal clinical trials system allowing labo-
\nratories to easily share data.
\nRepresented at the consultation, co-spon-
\nsored by WHO and UNAIDS, were govern-
\nmental public health research institutions in
\ndeveloping and industrialized countries,
\nmedical schools, industry, foundations and
\nnon-governmental organizations.
\ninfected with HIV as their male counter-
\nparts. In parts of sub-Saharan Africa, girls
\nand young women are up to six times more
\nlikely to be infected than their male peers.
\nGirls and young women aged 15-24 make
\nup 62% of the young people in developing
\ncountries living with HIV or AIDS.
\n\u201cWomen and girls are particularly vulnera-
\nble to HIV infection for biological, social
\nand economic reasons,\u201d said Dr. Catherine
\nHankins, Chief Scientific Advisor at
\nUNAIDS, who spoke at the opening of the
\nmeeting.
\nYouth and young adults are also at high risk
\nfor HIV: about half of new HIV infections
\nin the developing world occur among 15 to
\n24 year olds.
\n\u201cIn spite of the epidemiological reality,
\nwomen and adolescents, especially girls,
\nhave often had minimal involvement in
\nclinical trials of HIV vaccines, as compared
\nto men. This is in spite of the fact that they
\nwould be major beneficiaries of a future
\nHIV vaccine,\u201d said Dr. Saladin Osmanov,
\nActing Coordinator, WHO-UNAIDS HIV
\nVaccine Initiative, WHO. The Initiative
\npromotes the development of an HIV vac-
\ncine, including through the facilitation of
\nclinical trials.
\nReasons for the lack of participation of
\nwomen and young people in HIV vaccine
\ntrials to date are numerous and include:
\nlack of empowerment, independent deci-
\nsion-making and education in some set-
\ntings; social isolation; discrimination; preg-
\nnancy and the potential effects of a candi-
\ndate vaccine on a foetus; stigma associated
\nwith high-risk behaviour; trial enrolment
\ncriteria; and issues concerning confidential-
\nity and informed consent. For instance, the
\nparticipation of a minor in a clinical trial
\nwould require the parents\u2019 or guardian\u2019s
\nconsent, and youth must fully understand
\nwhat receiving a candidate HIV vaccine
\ndoes or does not mean for their health.
\nExperts agreed that these obstacles could
\nand should be overcome because HIV vac-
\ncines need to be tested in a heterogeneous
\npopulation, particularly in those most in
\nneed of vaccine. Vaccines for several infec-
\ntious diseases have shown varying levels of
\nefficacy in different gender, age and radical
\nor ethnic sub-groups. The 1998-2003 trial
\nPriority Medicines
\nLandmark report could influence the future
\nof medicines in europe and the world
\nGaps in pharmaceutical research and innovation can be closed, says WHO report
\nGeneva \u2013 The World Health Organization
\nhas released a groundbreaking report which
\nrecommends ways in which pharmaceutical
\nresearch and innovation can best address
\nhealth needs and emerging threats in
\nEurope and the world.
\nPriority Medicines for Europe and the World,
\ncommissioned by the Dutch Government as
\ncurrent president of the European Union
\n(EU), identifies a priority list of medicines
\nfor Europe and the rest of the world, taking
\ninto account Europe\u2019s ageing population,
\nthe increasing burden of non-communica-
\nbel illness in developing countries and dis-
\neases which persist in spite of the availibil-
\nity of effective treatments. The report looks
\nat the gaps in research and innovation for
\nthese medicines and provides specific poli-
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 102
\ncy recommendations on creating incentives
\nand closing those gaps.
\nAt present, pharmaceutical research and
\ndevelopment are based on a market-driven
\nincentive system relying primarily on
\npatents and protected pricing as a prime
\nfinancing mechanism. As a result, a number
\nof health needs are left unaddressed.
\nThe report identifies gaps for diseases for
\nwhich treatments do not exist, are inade-
\nquate or are not reaching patients. Threats
\nto public health such as antibacterial resis-
\ntance or pandemic influenza, for which pre-
\nsent treatments or preventive measures are
\nunlikely to be effective in the future, also
\nrequire immediate action.
\n\u201cThis report identifies health gaps and
\npotential solutions. It is particularly timely
\nfor a continent where an ageing population
\nfaces increasing health problems, and for a
\nworld where old and new threats no longer
\nrespect national borders,\u201d said Dr. LEE
\nJong-wook, Director-General of WHO
\nfrom the Ministerial Summit on Health
\nResearch, taking place in Mexico.
\nIn addition, the report addresses obstacles
\nwhere effective medicines could be better
\ndelivered to the patient. It emphasizes fixed
\ndose combination medicines (medicines
\nwhich include more than one active ingre-
\ndient in one pill) as worthy of further
\nresearch and development. Finally, it looks
\nat particular groups such as children,
\nwomen and the elderly, who have frequent-
\nly been neglected in the scientific or medi-
\ncine development process.
\nThe 17 priority conditions identified by the
\nreport are:
\nFuture public health threats: infections
\ndue to antibacterial resistance; pandemic
\ninfluenza;
\nDiseases for which better formulations
\nare required: cardiovascular disease (sec-
\nondary prevention); diabetes; postpartum
\nhaemorrhage, paediatric HIV\/AIDS,
\ndepression in the elderly and adolescents;
\nDiseases for which biomarkers are
\nabsent: Alzheimer disease; osteoarthritis;
\nNeglected diseases or areas: tuberculosis;
\nmalaria and other tropical infectious dis-
\neases such as trypanosomiasis, leishmania-
\nsis and Buruli ulcer, HIV vaccine;
\nDiseases for which prevention is particu-
\nlarly effective: chronic obstructive pul-
\nmonary disease including smoking cessa-
\ntion; alcohol use disorders; alcoholic liver
\ndiseases and alcohol dependency.
\nThe report suggests that Europe can and
\nshould play a global leadership role in pub-
\nlic health, as reflected by its history of
\nsocial services provision and social safety
\nnets for all citiziens. In many developing
\ncountries, the poor are increasingly affected
\nby the chronic diseases that are widespread
\nin Europe, including cardiovascular dis-
\nease, diabetes, tobacco-related diseases and
\nmental illnesses such as depression.
\nMoreover, the ten countries that joint the
\nEU in 2004 have additional public health
\nchallenges.
\nFor all number of diseases that effect peo-
\nple in all members of the EU, no effective
\nand safe medicinal treatment is yet avail-
\nable (e.g. Alzheimer diseases and several
\ncancers). For some diseases, potentially
\nlarge markets exist for medicines (e.g.
\nbreast cancer) and associated pharmaceuti-
\ncal research is likely to be intensive for cer-
\ntain therapeutic classes. For other cate-
\ngories of medicines, the number of patients
\nis low (e.g. cystic fibrosis) or the market-
\ndriven pharmaceutical industry has failed to
\npursue research and development (e.g. new
\nmedicines for tuberculosis).
\nInnovative solutions
\nThe report suggests that efforts to shorten
\nthe medicine development process without
\ncompromising patient safety would greatly
\nassist in promoting pharmaceutical innova-
\ntion. For instance, the EU could create and
\nsupport a broad research agenda through
\nwhich the European Agency for Evaluating
\nMedicines (EMEA), national regulatory
\nauthorities, scientists, industry and the pub-
\nlic would critically review the regulatory
\nrequirements within the medicine develop-
\nment process for their relevance, costing,
\nand predictive value.
\nHealth authorities are responsible for medi-
\ncines reimbursement decisions that aim to
\nensure safe and effective treatment for all
\npatients, while reconciling this with bud-
\ngetary constraints. Health and reimburse-
\nment authorities and manufacturers should
\nagree on general principles for the evalua-
\ntion of future medicines. For example, the
\nEU Commission and national authorities
\nshould support a research agenda on the
\nvarious methods of rewarding clinical per-
\nformance and linking prices to national
\nincome levels. The report authors believe
\nthat these measure will help encourage
\nindustry to invest in the discovery of inno-
\nvative medicines that address priority
\nhealth care needs.
\nThe report maintains that where the market
\nis strong and the problem is poor under-
\nstanding of the basic biology of the disease,
\ninvestment in basic research and in faciliat-
\ning innovation by the pharmaceutical
\nindustry will be needed. Where the biology
\nis well understood but the market is weak,
\npublic support for breaching the gap
\nbetween basic and clinical research \u2013 possi-
\nbly through public-private partnerships and
\nother not-for-profit development initiatives
\n\u2013 will be the preferred solution. Where the
\nbiology is not well understood and there is
\nalso a weak market, then biological
\nresearch can be supported while market
\nincentives are created for the pharmaceuti-
\ncal industry, through reducing barriers to
\ninnovation and through improving reim-
\nbursement rewards.
\nThe report points out that major pharma-
\nceutical gaps have been closed in the past.
\nFor example, until 1975 the main treatment
\nfor severe peptic ulcer \u2013 a common ailment
\n\u2013 was surgery. Following a long period of
\nfocused research in biological mechanisms
\nunderlying ulcer disease, effective medical
\ntreatments werde discovered. These break-
\nthrough discoveries, combined with the dis-
\ncovery that most ulceration was caused by a
\nbacteria treatable with antibiotics, made
\nsurgery unnecessary.
\nThe recommendations contained in the
\nreport could have a significant impact on
\nresearch innovation and policy, with sup-
\nport from Europan leaders. The report was
\ndiscussed further at a High Level Meeting
\nin the Hague on November 18th 2004.
\nWorld Health Organization
\n103
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 103
\nWorld Health Organization
\n104
\nGeneva \u2013 The first international standard
\nfor a human genetic test has been approved
\nby the World Health Organization. Use of
\nthe standard will help to improve the accu-
\nracy and quality of laboratory results world-
\nwide from a frequently used genetic test.
\nThis test identifies a genetic predisposition
\nto thrombosis \u2013 a potentially life-threaten-
\ning blood condition \u2013 and could therefore
\nenable people to take preventive measures.
\n\u201cEstablishment of the first international
\nstandard for a genetic test is an important
\nmilestone. Genetic testing procedures are
\nplaying a vital and growing part in clinical
\nmedicine. This new standard will help to
\nensure that the tests are giving accurate
\nresults worldwide,\u201d said Dr. Davie Wood,
\nCoordinator of Quality Assurance and
\nSafety of Biologicals at WHO.
\nThe newly established standard, formally
\ncalled an international Reference Panel,
\nrelates to the testing of patients for a partic-
\nular genetic mutation known as Factor V
\nLeiden. Discovered in 1994, this mutation
\nis one of the most common genetic risk fac-
\ntors for venous thrombosis (blood clot), and
\nis involved in 20\u201340% of all cases. Factor V
\nLeiden induces a defect in the natural anti-
\ncoagulation system.
\nThe test for Factor V Leiden is one of the
\nmost frequent genetic tests carried out in
\nclinical laboratories. It determines the pres-
\nence or absence of the mutation, which has
\nbeen shown to result in a seven-fold to 80-
\nfold higher risk of thrombosis depending on
\nwhether the individual carries one or two
\ncopies of the gene respectively.
\nThe new standard was agreed at the 55th
\nsession of one of WHO\u2019s longest-standing
\ncommittees, the WHO Expert Committee on
\nBiological Standardization (WHO ECBS)
\nwhich met from 15 to 18 November in
\nGeneva. It is composed of ten global experts
\nfrom academia, industry and national regu-
\nlatory authorities, as well as 25 advisors.
\nOne of WHO\u2019s key functions, specified in
\nits Constitution, is to develop, establish and
\npromote international standards with
\nrespect to biological and other products.
\nWHO is the world authority on biological
\nstandards, and has established more than
\n300 standards covering vaccines; blood
\nproducts; therapeutic biological products,
\nsuch as insulin; and diagnostic tests, such as
\nthose that detect HIV in a blood product.
\nResearchers are currently investigating
\nwhether or not there is a link between air
\ntravel and deep vein thrombosis. This is one
\nexample of a condition which may be more
\nlikely as a result of the Factor V Leiden
\nmutation. Having information about their
\ngenetic make-up could allow travellers at
\nrisk to take additional precautions.
\nThe standard for Factor V Leiden was devel-
\noped by WHO partner and the leading inter-
\nnational laboratory for biological standards,
\nthe National Institute for Biological Standards
\nand Control (NIBSC) in the United Kingdom,
\nin collaboration with colleagues from the clin-
\nical National Quality Assessment schemes
\nfor Blood Coagulation and the Royal
\nHallamshire Hospital in Sheffield, UK.
\n\u201cThis is an important step in genetic medi-
\ncine. I am delighted that the NIBSC has
\ntaken the international lead in developing the
\nfirst WHO standard for a genetic test. This
\nwill provide information on susceptibility to
\nvenous thrombosis, and ultimately will
\ndeliver clinical benefits for people at
\nincreased risk of developing thrombosis,\u201d
\nsaid Professor Gordon Duff, Chairman of the
\nNIBSC Board. NIBSC is currently develop-
\ning several other new reference standards to
\nsupport testing for a range of other clinically
\nimportant genetic characteristics.
\nDNA-based genetic testing offers enor-
\nmous promise for improved disease man-
\nagement by giving doctors better informa-
\ntion about patients on which to base diagno-
\nsis and decisions about treatment or coun-
\nselling. It also offers the potential for better
\ntargeting of therapies and drugs to those
\npatients most likely to benefit. Hundreds of
\ndifferent genetic tests are currently available.
\nA recent study estimated that in the European
\nUnion alone more than 700,000 genetic tests
\nwere performed in 2002; and found that at
\nleast 700 laboratories and 900 clinical centres
\nin Europe were carrying out genetic tests.1
\nThough the exact number is unknown, it is
\nlikely that millions of genetic tests are being
\ncarried out worldwide each year.
\nSetting standards is particularly critical as
\ngenetic testing has expanded to more and
\nmore laboratories throughout the world.
\nGenetic testing must be done consistently
\nin all laboratories around the world and to
\nhigh standards in order to give confidence
\nin the results.
\nA standard for a biological product is essen-
\ntially a yardstick (either on paper or in an
\nampoule, in which there is a specially pre-
\npared reference material) which enables
\nlaboratories around the world to compare
\nresults. The work of the WHO Expert
\nCommittee on Biological Standardization
\ncontributes to global public health in a fun-
\ndamental way since the written guidance
\nand reference preparations established on
\nits recommendations define international
\ntechnical specifications for the quality and
\nsafety of biological medicines and in vitro
\ndiagnostic procedures.
\nOnce a WHO collaborating laboratory
\nphysically creates a standard, it is typically
\nevaluated by 15 other top laboratories. The
\nWHO ECBS reviews all the laboratory data
\nand decides to approve or not the proposed
\nstandard for international use. The rigorous
\nassessment of the standard for the Factor V
\nLeiden genetic test was carried out by an
\ninternational panel of investigators in con-
\njunction with the International Society on
\nThrombosis and Hemostasis (ISTH).
\nThe announcement of the first international
\nstandard for the genetic diagnosis of the
\nFactor V Leiden mutation is a significant
\nstep forward in the assurance of high quali-
\nty genetic testing. In the future, the WHO
\nECBS will likely approve standards for
\nother genetic tests, the increasing use of
\nwhich will enable prevention and early
\ntreatment of genetic disorders, improving
\nquality of life.
\n1 Ibarreta, D., Elles, R., Cassisman, J-J.,
\nRodriguez-Cerezo, E., and Dequeker, E.
\nTowards quality assurance and harmoniza-
\ntion of genetic testing services in the
\nEuropean Union. Nature Biotechnology, 22,
\n1230\u20131235 (October 2004).
\nCommon Genetic Test
\nFirst standard adopted by WHO
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 104
\nWorld Health Organization
\n105
\nGeneva \u2013 The World Health Organization
\nis awarding a US$ 1 million contract to a
\nglobal consortium of people living with
\nHIV\/AIDS and treatment activists to help
\nprepare people living with HIV\/AIDS
\n(PLWHA) for antiretroviral (ART).
\nFollowing a competitive process, the
\nCollaborative Fund for HIV Treatment
\nPreparedness consortium \u2013 a programme
\ncreated in 2003 to channel funds for com-
\nmunity-based education, managed by the
\nUS-based organization Tides Foundation \u2013
\nwas awarded the contract through WHO\u2019s
\n\u2018Preparing for Treatment\u2019 programme.
\nThe WHO initiative supports community-
\nbased treatment preparedness activities as
\npart of the drive to increase access to treat-
\nment and prevention in line the \u201c3 by 5\u201d
\ntarget to get three million people living
\nwith AIDS on antiretroviral treatment by
\nthe end of 2005.
\n\u201cPeople living with HIV\/AIDS need to
\nknow about antiretroviral medicines. Those
\nwho currently have access to treatment need
\nthis knowledge to be informed about their
\ntreatment and to ensure they know how and
\nwhen to take their medicines. Those without
\naccess need this knowledge in order to
\nbecome active in advocating for scale up in
\ntheir countries,\u201d said Dr. LEE Jong-wook,
\nWHO Director-General.
\nIn implementing the million dollar grant,
\nTides Foundation-Collaborative Fund is
\nsupporting more than 30 networks of
\nPLWHA around the world in treatment pre-
\nparedness activities, including treatment lit-
\neracy projects and civil society advocacy
\ninitiatives.
\nThe Collaborative Fund distributes funding
\nto regional networks of people living with
\nHIV\/AIDS who then establish grants initia-
\ntives and tendering processes at the commu-
\nnity level. In each of these regions, work-
\nshops are already under way to help devel-
\nop the treatment preparedness agenda.
\nSupporting the \u2018Preparing for Treatment
\nProgramme\u2019, UNAIDS has contributed
\nover US$ 100,000 over the past year to
\nthese regional meetings and will be provid-
\ning a \u2018best practices\u2019 document based on
\nexperiences of programmes in late 2005.
\n\u201cUNAIDS is pleased to support WHO in
\nthis innovative movement to expand treat-
\nment access. Providing people living with
\nHIV with the necessary tools to access
\ntreatment is vital to improving their quality
\nof life and engaging them in expanding
\naccess to treatment and care,\u201d said Dr. Peter
\nPiot, UNAIDS Executive Dirctor.
\n\u201cThis proposal ensures the participation of
\npeople living with HIV\/AIDS in all aspects of
\nthe programme and at all levels of decision-
\nmaking and activity,\u201d said Dr. Jim Yong Kim,
\nDirector of the HIV Department at WHO.
\nTreatment preparedness activities aim to give
\npeople on or in need of antiretroviral treat-
\nment easy-to-understand information about
\nissues such as how HIV works in the body,
\nHIV testing, opportunistic infections, the dif-
\nferent treatment types available and how they
\nwork, how to take treatment correctly and the
\nsupport services that are available.
\nThis information can be conveyed in many
\nways, including through workshops, publica-
\ntions and other activities designed to educate
\ncommunities about obstacles to accessing
\ntreatment and enable them to contribute to
\nlocal treatment policy development and
\nadvocacy efforts. All treatment preparedness
\nactivities aim to ensure the meaningful
\ninvolvement of people living with AIDS and
\ntheir communities in decisions regarding
\ntheir care, including the distribution of
\nresources.
\n\u201cThis is perhaps one of the greatest UN-led
\nexamples of implementation of the GIPA
\n(Greater Involvement of People with AIDS)
\nprinciple [established in 1994]. The con-
\ntract award shows a commitment to a com-
\nmunity-driven model, relying on the exper-
\ntise of people living with AIDS and com-
\nmunity-based groups to developing projects
\nthey need to do. It also acknowledges that
\ntreatment preparedness is as important a
\ncomponent of the \u201c3 by 5\u201d success as is
\nreceiving the drugs\u201d, said David Barr,
\nSenior Philanthropic Advisor for Tides
\nFoundation.
\nIn addition to WHO, the Collaborative Fund
\nis supported by a growing number of donors
\nfrom around the world including Rockefeller
\nFoundation, Ford Foundation, Open Society
\nInstitute, the Stephen Lewis Foundation, and
\nAIDS Fonds Netherlands. To date, US$ 3.4
\nmillion has been raised to support activities
\nthrough the end of 2005 and fundraising for
\ncontinued activities is on-going.
\nThe concept of treatment preparedness was
\ndefined at the international treatment pre-
\nparedness summit, held in Cape Town,
\nSouth Africa in March 2003 and was based
\noriginally on examples of activists prepar-
\ning for their own treatment. The summit led
\nto the creation of the Collaborative Fund to
\ngenerate funding for such activities.
\nWHO\u2019s \u2018Preparing for Treatment
\nProgramme\u2019 was initiated in July 2004 when
\nWHO called for applicants with global reach
\nand local capacity in the world\u2019s most affect-
\ned countries to submit tenders to design and
\noperate programmes. With over 140
\nenquiries, some 30 tenders were reviewed by
\na WHO panel before the award of the contract
\nto Tides Foundation-Collaborative Fund.
\n\u201cMaking this happen has been a dream for
\nWHO and underlines the recognition that
\nthe future of health belongs as much in the
\nhands of those affected as those who care
\nfor them. Treatment preparedness is key to
\n\u201c3 by 5\u201d and a first instalment towards
\nreaching universal access for all who need
\nit,\u201d said Dr. Kim.
\nThe million dollar contract is the first of
\nwhat WHO hopes will be an ongoing
\nprocess within the Preparing for Treatment
\nProgramme with the aim of supporting addi-
\ntional community-based treatment prepared-
\nness activities as funding becomes available.
\nThe Tides Foundation has a long history of
\nadministering community-based grant pro-
\nAids
\nWho awards million dollar contract
\nfor global treatment preparedness activities
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 105
\nWMA Secretary General
\n106
\ngrammes in countries worldwide including
\nBrazil, Afghanistan, Sierra Leone, Peru,
\nRussia, Ukraine and Croatia, as well as
\nacross the United States.The Foundation
\nmanages over 300 donor advised funds and
\nover the past decade has administered more
\nthan $235 million in grants to not-for-profit
\norganizations. To help countries achieve this
\ngoal, WHO provides normative guidance
\nand direct technical support in country.
\nThe World Health Organization aims to
\nhelp people attain the highest possible level
\nof health by providing leadership on nor-
\nmative issues and technical assistance to its
\n192 Member States. In 2003, WHO joined
\nUNAIDS in declaring the lack of
\nHIV\/AIDS treatment to be a global public
\nhealth emergency and jointly launched the
\n\u201c3 by 5\u201d target to get 3 million people on
\ntreatment by 2005. To help countries
\nachieve this goal, WHO provides norma-
\ntive guidance and direct technical support
\nin country.
\nDuring February 2005 I will leave the office
\nof WMA Secretary General. After eights
\nyears of service to the WMA and the med-
\nical profession, I can only say that it was a
\ntremendous privilege and an outstanding
\nexperience. May I use this opportunity to
\nthank you all from the bottom of my heart
\nfor your support and care during my tenure.
\nAt the same time I would like to express
\nmy sincere congratulations to my succes-
\nsor, Dr. Otmar Kloiber from Germany.
\nOtmar has a wealth of experience and the
\nWMA is fortunate to have such a champion
\nof medical ethics and sound health care
\npolicy join our team.
\nThe last four months have been a particular-
\nly impressive period in the existence of the
\nWMA, and I would like to mention three
\nreasons why:
\nWMA General Assembly
\nin Tokyo, Japan
\nMedical leaders from around fifty countries
\nof the world gathered, during October 2004,
\nin the Imperial Hotel, Tokyo for our annual
\nAssembly. Most fittingly, it was the
\nEmperor and Empress of Japan themselves
\nwho wished to welcome the leaders to this
\nhistoric occasion. Having started the meet-
\ning in such an auspicious way, the rest of
\nthe meeting followed suit with high quality
\ndiscussions and content. The Japan Medical
\nAssociation excelled in developing a world-
\nclass scientific session on the relationship
\nbetween advanced medical technology and
\nmedicine. Dr. Yank Coble was inaugurated
\nas the new WMA President and had the
\nopportunity to officially launch the \u201cCaring
\nPhysicians of the World\u201d project (www.car-
\ningphysicians.info). This is the most ambi-
\ntious Presidential project to date, with the
\ndevelopment of a book on examples of
\nphysicians from around the world who
\nvividly display the traditional values of
\nmedicine \u2013 science, ethics and care. In addi-
\ntion, he will be visiting most of the WMA
\nMember Associatons during regional meet-
\nings planned for 2005.
\nWorld Ocean Forum
\nin New York, USA
\nThe WMA identified the important link
\nbetween water and health as one of the pri-
\nority areas for the organization some 3
\nyears ago. It was decided to develop a more
\ncomprehensive policy on this subject,
\nwhich was completed when the WMA
\nGeneral Assembly in Tokyo adopted the
\nWMA Statement on Water and Health
\n(www.wma.net \u2013 see \u201cPolicy\u201d). In addi-
\ntion, a two-day symposium was planned
\nwith the World Ocean Observatory to fur-
\nFrom the Secretary General\u2019s Desk
\nther investigate and debate some of the
\nmore pressing water and ocean issues such
\nas sanitation, ocean preservation, the bio-
\nmedical potential of the oceans and access
\nto water. Several high- level leaders attend-
\ned the event, including the Executive
\nDirector of the World Health Organization
\ntasked with Environmental Health, Dr.
\nKerstin Leitner. It is tragic and prophetic
\nthat this event preceded the tsunami disas-
\nter. In the aftermath of the tragedy, all the
\nwater- and ocean-related issues discussed
\nduring the meeting came into play in the
\nmost dramatic fashion. Please read the full
\nreport on the symposium, including slides
\nand speeches, at www.worldoceanfo-
\nrum.org.
\nLaunch of the WMA Ethics
\nManual
\nIt is incredible to think that despite the fact
\nthat medical ethics is more than 2000 years
\nold, there is no one universally used train-
\ning manual for the teaching of medical
\nethics. The WMA had adopted a Statement
\non the Inclusion of Medical Ethics and
\nHuman Rights in the Curriculum of
\nMedical Schools Worldwide (www.
\nwma.net \u2013 see \u201cPolicy\u201d) during 1999, and
\nit was therefore quite fitting that the WMA
\ndevelop a simple and concise ethics train-
\ning manual for use by medical students and
\nphysicians. The WMA Director of Ethics,
\nDr. John Williams, did a splendid job in
\nputting this manual together along with a
\ncommitted team of advisors. At a launch
\nevent in January 2005, the first edition of
\nthe manual was released to the press and
\nsome partner organizations. The launch
\nwas a huge success, as we are confident the
\ndistribution and use of the manual will be.
\nThe manual can be downloaded from the
\nWMA website at www.wma.net.
\nLooking at the huge strides the WMA has
\nmade over the last quarter, it bodes well for
\nthe future growth and expansion of the
\nWMA and the profession. It gives me great
\njoy to see this happen as I leave the WMA
\nstage. Thank you and au revoir.
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 106
\nWMA Secretary General
\n107
\nThe meeting was opened by the President,
\nDr. James Appleyard, who welcomed the
\nMr. Assodo Chief Secretary of the Cabinet
\n(representing the Prime Minister who was
\nabroad), the Minster of Health and the
\nGovernor of Tokyo.
\nThe Secretary General, Dr. Delon Human
\nintroduced the delegations of the National
\nAssociation Members of the WMA, and the
\nofficial observers from other international
\norganisations.
\nDr. Uematsu, President of the Japanese
\nMedical Association expressed his pleasure
\nat being able to welcome the members of the
\nWMA to Tokyo once again after 29 years.
\nHe was delighted to see 500 people present
\nduring the Assembly and considered that
\nthere had been very valuable exchanges of
\ninformation at the Scientific Sessions during
\nwhich various aspects of Advanced Medical
\nTechnology had been discussed, including
\nMedical Ethics, IT and Healthcare. There
\nwas much valuable information which
\nwould contribute to the advance of World
\nPeace. The JAMA looked forward to suc-
\ncessful conclusions at the end of the
\nAssembly. Referring to the earthquake the
\nprevious day and to the tornado to be
\nexpected later, he expressed the view that,
\nno doubt, these were part of the global
\nweather changes.
\nThe President then thanked Dr. Uematsu
\nand the Japanese Medical Association for
\ntheir excellent organisation and hospital
\nduring the Assembly. He then introduced
\nMr. Assodo who extended the good wishes
\nof the Prime Minister who had planned to
\nbe present but had had to travel to Vietnam.
\nHe informed the assembly that the
\napproaching Typhoon was unusually large
\nand warned delegates not to leave the hotel.
\nHowever, he then cheered them with news
\nof expected good weather the next day.
\nJapan had been challenged by new
\ninfections such as SARS and AIDS.
\nExpectations of the population were rising.
\nOn the other hand, after referring to the
\nincreasing role of the Japanese Medical
\nAssociation, he drew attention to the rise in
\nlife expectancy between 1997 and 2003
\nfrom 76,68 to 85. Infant mortality had fall-
\nen from 1 to 3 per 10.000. All of these were
\ndue to the efforts of the nation and of the
\ndoctors. Health Care reform was a universal
\nchallenge, notably with the increase in the
\nelderly population and the diminishing birth
\nrate, also the economic and environmental
\nenvironments. Safety is a key to health care.
\nThe discussions of the Assembly on
\nMedical Healthcare Technology an Medical
\nEthics was particularly timely. The
\nJapanese were trying to introduce safety of
\nhealth technology into health care. He
\nhoped that the outcome of the meeting
\nwould enlarge the understanding of these
\nissues. He felt that the World Medical
\nAssociation is an organisation which con-
\ntributes to the world\u2019s good future.
\nMr. Ossuchio the Minister of Health, congrat-
\nulated the Assembly. WMA had a fifty year
\nhistory of engagement in major problems
\naffecting health care globally. The WMA
\nworks with the World Health Organisation
\nand other international organisations to
\nenhance the health of the peoples of the
\nworld.
\nIn Japan, Healthcare Services and advanced
\ntechnology have improved the health of the
\npeople. The major challenges were Safety,
\nQuality, and higher efficiency in Health Care,
\nhe looked forward to benefiting from the con-
\nclusions of the discussions on Health Care
\nTechnology. Finally he also expressed his
\nthanks to the Japanese Medical Association
\nfor their work in organising this meeting.
\nThe governor of Tokyo Mr. Ishiharo pointed
\nout that medicine in Japan was referred to as
\nWestern Medicine. However there was also a
\nschool of Oriental Medicine which, contrary
\nto belief, was a schematic system of care.
\nRecently there had been an evaluation of this
\ntype of medicine by members of the
\nJapanese Medical Association and now
\nAcupuncture had been included in the
\nJapanese Healthcare system. He personally
\nvalues the work of experts in acupuncture
\nwhich, he noted, was appreciated also in the
\nUSA. He quoted various examples of natur-
\nopathy applied successfully to various condi-
\ntions ranging from obstetric complications to
\ndiseases of the liver and of the kidney. He
\nspecifically referred to CHI and to
\nChiropractic and stressed that they were not
\nSharmatic. It was important that there should
\nbe co-operation between both systems of
\nmedicine. He urged physicians to be gener-
\nous in their approach to oriental medicine
\nand closed by referring to the fact that the
\nJapanese enjoyed the greatest longevity in
\nthe world.
\nDr. Blachar, Chairman of Council,
\nexpressed the appreciation of the Assembly
\nto the three high representatives of govern-
\nment and authority in Japan for kindly
\nattending and addressing the Assembly. He
\nthen paid tribute to Dr. James Appleyard, the
\nretiring 54th President who had served the
\nAssocation with great distinction. Dr.
\nAppleyard had many accomplishments.
\nPersonally Dr. Blachar had enjoyed the
\nassociation with a fellow paediatrician who
\nalso had three children. Dr. Appleyard had
\nbrought to fruition the Declaration if Ottawa
\non the Rights of the Child and had consis-
\ntently lobbied for childrens\u2019 rights to health
\nand for child health services. In addition he
\nhad promoted Oral health and had supported
\nthe ICRC project on notification of torture
\nand the treatment of torture victims. He had
\nbeen chairman of the Ethics committee
\n1995-99, and oversaw the Declaration of
\nHelsinki changes, speaking in New York,
\nThe Ceremonial session of the World Medical
\nAssociation General Assembly was held in
\nThe Imperial Hotel, Tokyo 9th October 2004
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 107
\nWorld Medical Association
\n108
\nJapan, Malta, Uganda and many other
\nplaces.
\nDr. Appleyard had enhanced the image of
\nWMA. He had been most a helpful person
\nto work with and had greatly assisted the
\nChairman in promoting the changes within
\nthe organisation. Dr. Blachar looked for-
\nward to his playing a further role in the
\nfuture.
\nDr Appleyard in response expressed his
\nenjoyment of the work in his past year as
\nPresident. —-(see text of speech page 95) Dr.
\nBlachar then presented Dr. Appleyard with
\nthe Past President\u2019s medal and conferred on
\nhim lifelong membership of the WMA.
\nThe Secretary General then invited the
\nincoming President Dr. Coble, to take the
\nPresidential Oath, following which he was
\ninvested as President and delivered his
\nPresidential address (see page 86).
\nDr. Moon, retiring Vice Chair of Council
\nthen briefly addressed the Assembly
\nexpressing his pleasure at being invited to
\nmake some closing remarks. The WMA was
\nfounded in 1947 by a group of idealistic
\nphysicians, to build something better out of
\nthe ashes of World War II. WMA has done
\nthis by issuing declarations over the years
\nand helping to define Medical Ethics and
\nstandards in a changing world. It had worked
\nto promote idealistic ideas and continue the
\nethical tradition of the medical profession.
\nWMA now includes 84 National Medical
\nAssociations and millions of doctors. Huge
\nstrides have been made in health care and in
\nhuman rights. For all. Tokyo is very memo-
\nrable because Advanced Medical
\nTechnology and related issues promise
\ntogether with IT to improve global health.
\nHe could think of no better way to address
\nthe agenda of global health care and Health
\nfor All. He expressed his appreciation of Dr.
\nUematsu and the leaders of JAMA for the
\nhospitality enjoyed by all during the
\nAssembly. Thanks to this he had been able to
\nwitness the Tokyo Assembly as a great occa-
\nsion. He gave a special tribute to the work of
\nDr. Tsuboi for his leadership over many
\nyears to millions of doctors. Finally he paid
\na tribute to Dr. Delon Human for his work
\nover the past seven years, for his tolerance
\nand patience and devotion to the WMA. He
\nthanked him and expressed the best wishes
\nof everyone his future. The audience rose
\nand endorsed this appreciation.
\nDr. Coble thanked Dr. Moon for his address
\nand closed the meeting.
\nDr. Begenholm reported that the Credential\u2019s
\nCommittee had verified that there were 35
\nMembers present who were in good stand-
\ning. This amounted to a total of 87 votes, and
\nthat 65 would be necessary to adopt any pro-
\nposal relating to Medical Ethics.
\nAfter the Annual Report of Council and the
\nStanding Orders had been adopted, Dr.
\nLetlape (South Africa) was unanimously
\nelected President-elect.
\nDr. Letlape expressing his appreciation of
\nthe responsibility of this office and thanking
\nthe Assembly, said this was the time of the
\nnew President and his remarks would be
\nbrief. He referred first to the very few
\nJunior doctors present and speculated that if
\nthe age of the President was linked to life
\nexpectancy, for South Africa the age would
\nbe 39. He intended to carry forward the
\nwork of Drs. Millymakki, Appleyard and
\nCoble, not only in advocating \u201cpatients
\nfirst\u201d but also \u201cpatients\u2019 rights\u201d. This would
\nfit the theme of \u201cAccess to Medical Care\u201d
\nin Chile 2005 and would be most appropri-
\nate. There was inequality in South Africa,
\nwhere, with finite resources, privatisation
\nwas a key issue.
\nDr. Otmar Kloiber, Secretary General-
\nelect, then addressed the Assembly, thank-
\ning Council and those who supported him
\nfor the trust they had placed in him. He
\nMeeting of the WMA General Assembly,
\nTokyo, 9th October 2004
\nreferred to earlier remarks about the
\nmeaning of service, namely \u201chelping doc-
\ntors doing a good job and to save our
\npatients\u201d. He thanked Dr. Delon Human
\nfor his work in restructuring the secretari-
\nat, and opening new networks and new
\navenues to explore. He was proud to be
\nhere also as a successor to Dr. Andre
\nWynen who had been designated
\nSecretary General 29 years ago in Tokyo.
\nFor Dr. Kloiber the commitment of the
\nrepresentative members of the Assembly
\nwas most important and gives power to
\nthe WMA. National Medical
\nAssociations\u2019 commitment is what counts.
\nIf the members did not carry this out,
\nWMA would be nothing. His primary job
\nwas to ask for this and to service their
\ncommitment. The first priority was the
\nDues, and the second was to participate
\nand work in the WMA. Continuing the
\nreconstruction was dependant on mem-
\nbers\u2019 support and participation leading to a
\nstrong, visible organisation for the future.
\nThe Assembly then adopted the following:
\n\u2022 A note of clarification on paragraph 30
\nof the Helsinki Declaration (see 95)
\n\u2022 A Statement on Physicians and
\nCommercial Enterprises (see 91)
\n\u2022 A statement on Water and Health
\n\u2022 Amendment to the Regulations in times
\nof Armed Conflict (see 92)
\n\u2022 A statement on the World Federation of
\nMedical Education
\n\u2022 A statement on Health Emergencies
\nCommunication and Co-ordination (see 93)
\nAn Addition to Section M of the WMA
\nSchedule of Functions and Operation
\nPolicies also was adopted.
\nApplications from the Vietnamese Medical
\nAssociation and the Estonian Medical
\nAssociation were unanimously approved
\nwith acclamation.
\nThe Assembly also approved the themes of
\nthe 2005 Santiago General Assembly scien-
\ntific meeting \u201cHealth Care system reform\u201d
\nand \u201cAccess to Medicine\u201d.
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 108
\nApproval was also given for the meeting in
\n2008 to take place in Seoul, in the anniver-
\nsary year of the Seoul Medical Association.
\nFollowing the Treasurer\u2019s report, the
\nFinancial Statement for the year 2003 and
\nthe budget were adopted.
\nThe report of the Associates meeting, which
\nincluded their resolution concerning Enfor-
\nced Sterilisation, was approved.
\nThe Assembly then proceeded
\nto an open session
\nThe first speaker from the Frauenarzte-
\nVerlag (Germany), referring to the lack of
\nrepresentation of women both in the
\nAssembly and on the platform, pleaded for
\nthe enlistment of more women doctors who
\ncare about the medical profession and
\npatients. It should be possible for the organ-
\nisations of women doctors and the WMA to
\nwork together.
\nDr. Arumugam (Malaya) was concerned
\nthat the topic of \u201cOriental medicine\u201d had
\nbeen raised during the formal ceremonial
\nsession of the Assembly and asked whether
\nWMA had any policy on this. Ministers did
\nnot know whether or not medically-quali-
\nfied doctors should be involved in this. He
\nreferred to \u201cover the counter\u201d sales and tra-
\nditional medicine treatments now compris-
\ning 50% more than Western medical activi-
\nty in the East. Dr. Blachar responding
\nasked whether this was controllable. He felt
\nthat WMA should have a policy and hoped
\nthat an NMA would produce a background
\npaper for discussion. Dr. Human, the
\nSecretary General, hoped that the Malay
\nMedical Association would send a consul-
\ntation paper. He commented that WMA had
\na position on this. There were no controls
\non this type of medicine. He would send a
\npaper to the MMA. Then Dr. Haikerwal
\n(Australia) informed the meeting that legis-
\nlation governing this issue in Victoria,
\nAustralia was the first in the world.
\nDr. Adu-Gyanfi (Ghana) spoke about the
\nimportance of student exchanges and also,
\nin relation to human resources, mentioned
\nthat while in 1969 there were 5500 doctors
\nfor a population of 7 million, now there were
\nonly 6500 for a population of 20 million.
\nDr. Millymakki (Past President) drew
\nattention to the absence of delegates from
\nTurkey, although they sent their greetings.
\nRecently there had been three strikes by
\nTurkish doctors, respectively of one, one,
\nand two days duration, during which doc-
\ntors saw all emergencies and any sick chil-
\ndren. The strike related to the need for more
\nfinancing of health care. She also reported
\nthat 85 doctors were in court, including
\nmembers of the doctors\u2019 Chamber. Doctors,
\nwho were classified as civil servants, had
\nthe right to be members of a Union, but not
\nthe right to strike. NMAs should be in touch
\nwith the Turkish Medical Association to
\nassist their colleagues. Dr. Human reported
\nthat he had spoken to the Vice-President of
\nthe Turkish Medical Association to give
\nsupport to their leaders. He had written to
\nthe Ministers of Health, of Justice and of
\nForeign Affairs concerning the unfair trial of
\n85 doctors, including their leaders. There
\nwas a conference of the Turkish doctors dur-
\ning this week. The WMA would try to send
\na WMA leader to be present at the trial.
\nDr. Montgomery (Germany) referring to
\nthe comments from Ghana, said that doc-
\ntors\u2019 workload in much of the world was
\nrising to such an extent that some could
\nwork no more. There was a problem con-
\ncerning the Worktime Directive in the EU,
\nand in the USA doctors were working 90
\nhours a week. WMA could define a safe-
\nguard mechanism when the workload was
\ntoo great. The Secretary General said this
\nsuggestion was useful and asked the BAK to
\nproduce paper on physician \u201cburn-out\u201d etc.
\nIn response to a question from Dr. Masson
\nconcerning the doctor and other health
\nworkers condemned to death in Libya, Dr.
\nHuman reported that the WMA and ICN
\nhad met the Libyan delegation during the
\nWorld Health Assembly. They received a
\npoor reception from the delegates who
\ndespite offering to send them a reply, had not
\nresponded so far despite three reminders. As
\nan NGO, WMA would continue to seek dis-
\ncussions with the government.
\nDr. Chan Yee Shing (Hong Kong)
\nobserved that Chinese Medicine is not
\nalternative medicine, it is mainstream.
\nThere is a need to deal with question of its
\nrecognition and registration. There is a
\nproblem concerning the difficulties with
\nstandardisation. There were major medico-
\nlegal problems. For example in the case of
\ncoronary heart disease treated under both
\nwestern and eastern medicine, when there is
\na lawsuit how can the court rules on the
\nproblem. In the scientific discussion of the
\nprevious day the medical profession
\nseemed to be moving in the direction of
\nMedical Technology. Physicians were
\nworking as members of a team. If the two
\nprofessions were to be treated equally this
\nwas very difficult as there was no scientific
\nbasis for Traditional Medicine. He won-
\ndered whether WMA could help.
\nDr. Appleyard (the President), referring to
\nthe problem raised by Ghana mentioned the
\nimportance of links with Medical
\nInstitutions in the West to help developing
\ncountries. He cited as an example a Surgeon
\nfrom Germany who went for three months
\nto work in a hospital in which there was no
\nsurgeon. Such a three months period could
\nnot only provide much needed assistance
\nbut also a valuable experience. Other alter-
\nnatives were Fellowships linked with
\nMedical Academic Institutions, or for indi-
\nvidual doctors just to go and assist. He urged
\nNational Medical Associations to take this
\nmessage back to their own countries and
\nstressed the importance of such links being
\nestablished as between equal partners.
\nDr. Harma from the International
\nRehabilitation Council for Torture Victims,
\nreferred to the real problem for doctors who
\nhave been treating victims of torture in
\nTurkey. The work of the WMA both in con-
\nnection with the Tokyo declaration and
\nmore recently with the new initiative on
\ntraining doctors in connection with the
\nIstanbul Protocol was very valuable. He
\nalso referred to the recent Lancet article on
\nWorld Medical Association
\n109
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 109
\nRegional & NMA News
\n110
\npossible involvement of physicians in
\nMiddle Eastern prisons and the Norwegian
\nMedical Association\/WMA programme of
\ntraining for prison doctors and others in
\nHuman Rights. IRCT sought a WMA part-
\nnership.
\nDr. Blachar (chairman of Council) spoke
\nof the visits to Morocco, Uganda and
\nGeorgia in connection with the
\nIstanbul\/EU project of training in how to
\nrecognise victims of torture.
\nDr Grewin, (President of CPME), had
\nwritten to the relevant EU Commissioner
\nconcerning the Turkish situation.
\nDr. Letlape (South Africa) informed the
\nAssembly that in South Africa legislation
\nrecognising traditional medicine is produc-
\ning problems, as there is competition for
\nlimited resources, which were already in
\ngreat difficulty. One part of traditional med-
\nicine is spiritual \u2013 there was a family tradi-
\ntion of training its members who were initi-
\nated into healing. If patients don\u2019t recover
\nthe blame lay with their ancestors!
\nA speaker from the Thai delegation report-
\ned that they had 30,000 doctors for a popu-
\nlation of 63 million people. Herbal medi-
\ncine has been known for 200 years and does
\nwork in a limited context. Currently the
\nMinistry of Health and the University were
\nconducting a trial under the Professor of
\nMedicine from Hong Kong. He pointed out
\nthat because of the very few physicians in
\nrural areas the population has to use
\nTraditional Medicine.
\nThe Vietnamese delegation commented that
\nthe discussion was really about oriental
\nmedicine. There was a need for a careful
\nlook at the evidence. If the evidence is pos-
\nitive we should accept it.
\nDr. Blachar, summing up, welcomed the
\ndiscussion. There was clearly a need to look
\ninto the problems and he welcomed the
\nMalayan lead.
\nAfter a presentation by the Chilean delega-
\ntion in preparation for next year\u2019s
\nAssembly, Dr. Blachar thanked the
\nJapanese Medical Association for their
\ngreat organisation and hospitality in the
\norganisation of the Assembly, and extend-
\ned his thanks to the Council, the Secretary
\nGeneral and to the staff of WMA.
\nBy Donald J. Palmisano, MD, JD
\nImmediate Past President,
\nAmerican Medical Association
\nThe United States is not alone in con-
\nfronting the deleterious effects of overzeal-
\nous personal injury lawyers who seek mil-
\nlion-dollar awards and settlements that
\nresult in scores of physicians restricting their
\nservices and patients losing access to care.
\nReports from the United Kingdom state
\nhow negligence claims against physicians
\nare rising1 as are the expected payouts \u2013
\nE150m by 20102. In Australia, increased
\nconcern has led to \u201cseveral of the country\u2019s
\nstates and territories taking action to limit
\ndamages for non-economic loss and cap
\neconomic loss,\u201d3 among other measures.
\nAnd in New Zealand, health officials are
\nalarmed by the large increases in payouts.
\nIn Wales, for example, claims have
\nremained relatively steady, but payouts
\nhave seen from \u00a363.3 million to \u00a3117.8 mil-
\nlion from 1999-2000 to 2002-20034.
\nIn the United States, the costs are even more
\nsevere. Medical liability tort costs have
\nincreased from $9.5 billion in 1991 to more
\nthan $21 billion by 20015. But rather than
\nthe money going to compensate injured par-
\nties, the U.S. tort system is so grossly inef-
\nRegional & NMA News
\nPatients\u2019Access To Care At Risk With
\nAmerica\u2019s Broken Medical Liability System
\nficient that only 22 cents in the dollar actu-
\nally goes toward compensating those
\ninjured for economic losses, and 24 cents
\ngoes toward non-economic damages6.
\nConsider, too, that in most jurisdictions,
\npersonal injury lawyers can receive as
\nmuch as 50 percent of a jury award, and it
\nbecomes more clear why personal injury
\nlawyers fight tooth-and-nail to defeat rea-
\nsonable measures at limiting non-economic
\ndamages in state legislatures and the U.S.
\nCongress. The U.S. medical liability tort sys-
\ntem is the personal injury lawyers\u2019 cash cow.
\nThe bitterness of the dispute can be traced
\ndirectly to personal injury lawyers\u2019 desire
\nto maintain the status quo of a civil justice
\nsystem where multimillion-dollar jury
\nawards benefit a very few, but have nega-
\ntive ripple effects that affect many.
\nBlockbuster medical liability cases in 2003
\nin the United States have included verdicts
\nand settlements of $112 million, $70 mil-
\nlion, $50 million, $40.4 million and 10 that
\nwere $20 million or more7.
\nThe broken system becomes obvious when
\nyou consider that 70 percent of all cases
\nfiled against physicians are closed without
\nany payment8. As a surgeon, I don\u2019t operate
\non demand. There must be valid indica-
\ntions. And surgeons get instant peer review.
\nEvery appendix I remove for the preopera-
\ntive diagnosis of appendicitis is examined
\nby a pathologist. If it was found that 70
\npercent of my operations were on normal
\nappendices, I would not be allowed to oper-
\nate. Shouldn\u2019t attorneys also be subject to
\npeer review for the cases they file? Why is
\nthat personal injury attorneys are not held
\nto a similar standard? Why is that these
\nattorneys rarely \u2013 if ever \u2013 sanctioned for
\nfiling a suit without merit?
\nThis lack of accountability is very expen-
\nsive. Even though 70 percent of claims are
\ndropped or dismissed, they still incur legal
\ncosts that average $16,743. Expense costs
\nfor settled claims average $39,891 and
\nclaims in which the defendant wins at trial,
\n$85,718.9 Now consider that on any given
\nday, there are 125,000 suits active in the
\nU.S. court system, and the costs grow
\nexponentially.
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 110
\nSnapshot of a Crisis
\nThere are 20 states which the AMA believes
\nare in a full-blown medical liability crisis10.
\nWe define this crisis after careful analysis
\nof several key factors, including:
\n\u2022 The magnitude of patients losing access
\nto health care.
\n\u2022 What type of medical liability reform
\nlegislation currently exists in a state \u2013 and
\nfor how long the reforms have been in
\nplace.
\n\u2022 The actions of a state court system to
\nuphold or overturn medical liability
\nreforms.
\n\u2022 The affordability and availability of pro-
\nfessional liability insurance.
\n\u2022 The actions of a state\u2019s legal community,
\nparticularly the trend of increasing fre-
\nquency and severity of jury awards.
\nMedical liability reform has been the
\nAMA\u2019s top legislative priority for several
\nyears. Our fight has been on two simultane-
\nous fronts: namely the U.S. Congress and
\nthe state legislatures throughout the coun-
\ntry. We also have supported state medical
\nsocieties in their efforts to protect existing
\nreforms before state supreme courts11.
\nUnfortunately, the U.S. Congress and state
\nlegislatures have become the battlegrounds
\nfor deciding whether patients will have
\naccess to care. Because of a runaway legal
\nsystems, patients have suffered as physi-
\ncians have been forced to relocate, retire
\nearly, or restrict their services \u2013 such as
\ndelivering babies or performing trauma
\nsurgery12.
\nIn my travels across the United States, I
\nhave personally spoken with scores of
\nphysicians who have given up part of their
\npractice because of excessive lawsuits and
\nskyrocketing liability insurance premiums.
\nIt is distressing to hear a young paediatric
\nspecialist tell the story of how he moved to
\nthe Mississippi Delta as part of \u201ca calling\u201d
\nto treat rural patients, but he was forced to
\nleave the state after being sued by patients
\nwho did not even realize they were suing
\nhim. One patient who hoped to earn a few
\nthousand dollars said \u201cI\u2019m kind of upset. I
\ndo not want him leaving because of all the
\nsuits. If we run off all the doctors, what are
\nthe people gonna do?\u201d13
\nIt is even more distressing to be speaking to
\na group of America\u2019s top surgeons about
\nthis crisis and learn from a young surgeon
\nthat he \u201cunderstood the crisis all too well
\nbecause he recently lost his son because
\nthere was no neurosurgeon available.\u201d
\nMississippi surgeon John Lucas, III, MD,
\ntold me that his son was in a car accident
\nand needed immediate neurosurgical inter-
\nvention, but the area\u2019s neurosurgeons had
\nalready either quit doing head trauma cases
\nor had moved away. His son had a cor-
\nrectible problem if immediate attention by a
\nneurosurgeon could be given. Dr. Lucas did
\neverything he could to expedite the transfer
\nand find a neurosurgeon. Unfortunately his
\nson John Lucas IV died despite the subse-
\nquent transfer.
\nA Solution Exists
\nExperience tells us that there are a few
\nstates that have had long-term medical lia-
\nbility reforms: California, Colorado,
\nIndiana, Louisiana, New Mexico and
\nWisconsin. They all have in common a rea-
\nsonable limit on damages. California, in
\nparticular, places a $250,000 limit on non-
\neconomic damages, and there is no limit for
\neconomic damages. If a patient is harmed
\nby negligence, the AMA strongly believes
\nthat the patient should be able to receive
\nfair and quick compensation. The model
\nthe AMA has advocated for the United
\nStates Congress to pass into law is the
\nCalifornia model which gives all medical
\nexpenses, lost wages and benefits, future
\nwages and benefits, child care costs and
\nmore, but limits non-economic damages to
\n$250,000. Without a proven performer such
\nas the California $250,000 limit on non-
\neconomic damages, the system breaks
\ndown. The majority of individuals in the
\nUnited States House of Representatives and
\nthe Senate as well as President Bush favor
\nsuch a law but a minority of Senators fili-
\nbuster it and currently there are not the nec-
\nessary 60 votes to overcome the filibuster.
\nCalifornia\u2019s reasonable reforms also
\ninclude limits on attorney contingency fees,
\nallocating responsibility for damages fairly,
\nproviding for periodic payment of damages
\nover time, and more. California\u2019s law \u2013 for-
\nmally known as the Medical Injury
\nCompensation and Reform Act (MICRA) \u2013
\nwas enacted in 1975. Between 1976 and
\n2002, medical liability insurance rates have
\nincreased in the United States by 750 per-
\ncent. In California, they only have
\nincreased 245 percent. MICRA is the rea-
\nson why an obstetrician pays about $69,000
\nper year for professional liability insurance
\nwhile the same physician would pay more
\nthan $277,000 per year in Southern Florida,
\nwhich does not have MICRA-style reforms.
\nMICRA provides the predictability and sta-
\nbility for the liability insurance market that
\nmoderates physicians\u2019 insurance rates and
\nprotects patients\u2019 access to care.14
\nRecent State Actions Cause
\nfor Optimism
\nIn the recent November elections, four
\nstates had constitutional ballot measures
\nregarding different medical liability
\nreforms. In each case, the AMA stood side-
\nby-side with our state medical societies to
\npresent the facts. In each case, our opposi-
\ntion tried to suggest that there was no need
\nfor reform, that the status quo worked just
\nfine to protect patients.
\nIn Florida, where women have been forced
\nto wait as long as six months for a mammo-
\ngram because radiologists are scared to read
\nthem, the physicians won a great victory.
\nDespite personal injury lawyers and their
\nsupporters spending an estimated $24 mil-
\nlion, voters enacted new limits on contin-
\ngency fees. Now, patients will be assured to
\nreceive at least 70 percent of the first
\n$250,000 of a jury award; and 90 percent of
\nany amount more than $250,000.
\nIn Nevada, where Jim Lawson died in cir-
\ncumstances similar to Dr. Lucas\u2019 son, and
\nscores of women searched for months to
\nfind a doctor to deliver their babies, the
\nmedical community also had a great victo-
\nry when voters amended the state constitu-
\ntion to eliminate all exceptions to the state\u2019s
\n$350,000 limit on non-economic damages.
\nPreviously, a crafty personal injury lawyer
\nRegional & NMA News
\n111
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 111
\ncould use rhetorical arguments to circum-
\nvent the cap.
\nIn Oregon \u2013 despite the fact that more than 40
\npercent of the state\u2019s neurosurgeons and near-
\nly one quarter of its obstetricians have
\nalready stopped providing certain services or
\nwill soon do so \u2013 voters narrowly defeated
\n(50.7 percent to 49.3 percent) a measure that
\nwould have restored a $500,000 limit on non-
\neconomic damages. The AMA is deeply con-
\ncerned Oregon\u2019s crisis will become worse.
\nAnd in Wyoming, where rural health care is
\nthe norm, the loss of even one physician can
\nhave negative consequences. But despite
\nwidespread examples of physicians restricting
\ntheir practices and patients being forced to
\ndrive an hour or more to find care, voters nar-
\nrowly defeated a measure designed to allow
\nthe legislature to enact a limit on non-eco-
\nnomic damages. However, voters did approve
\na measure that could lead to legislation enact-
\ning medical review panels to weed out the
\nfrivolous cases currently choking the system.
\nClearly, these results are mixed, but they
\nshow forward momentum, building on the
\noutstanding win in Texas in 2003 where the
\nlegislature passed reforms and the citizens
\nvoted to change the state constitution to be
\ncertain the new law would allow caps on
\nnon-economic damages. Since enactment of
\nthe Texas law, the largest insurer of physi-
\ncians in Texas lowered the medical liability
\npremiums 17%. The AMA plans on carrying
\nthat momentum into 2005. We will continue
\nto work with our champions in Washington,
\nD.C., as well as in the halls of state legisla-
\ntures across the country. We stand ready to
\nsupport our international colleagues in their
\nefforts as well, including the efforts to enact
\npatient safety legislation akin to the success-
\nful Aviation Safety Reporting System of
\nvoluntary confidential reporting of errors or
\n\u201cnear-misses\u201d for review by experts, with
\nfeedback for a system change to enhance
\nsafety and then communicate the lesson
\nlearned to all in a \u201cno shame, no blame\u201d de-
\nidentified manner. Such a proposed law,
\nentitled the Patient Safety and Quality
\nImprovement Act, has passed both the
\nHouse and Senate in the United States
\nCongress but it is questionable whether it
\nwill get out of the conference committee
\nduring the few days left in the 2003-2004
\nCongress. We also continue to support the
\nNational Patient Safety Foundation (NPSF)
\nthat we founded with others. To date we
\nhave contributed $7.3 million to it and are
\nvery proud of its extensive patient safety
\nbibliography and teaching modules.15
\nIn my 40+ years as a physician, I have wit-
\nnessed the miracles of organ transplants, vac-
\ncines, chemotherapy, and more. Today, we
\ncan treat birth defects with the baby still in the
\nmother\u2019s womb. We can perform microsurg-
\neries on the brain. We can re-attach severed
\nlimbs. Tomorrow holds great promise here in
\nthe United States and abroad, but we must
\nsafeguard our future. The rising threat of
\nunchecked lawsuits and out-of-control costs
\nthreatens us all, which is why we must share
\nthe commitment to be relentless in the fight to
\nenact reasonable reforms that protect patients\u2019
\naccess to the courtrooms without sacrificing
\nour patients\u2019 access to medical care.
\n1. \u201cHospital awards bill to cost E400m,\u201d
\nThe Sunday Tribune, Dec. 7, 2003.
\n2. Ibid
\n3. \u201cLiability insurance: a global concern,\u201d
\nInsurance Day, Sept. 9, 2003.
\n4. \u201cClaims now cost NHS trust more,\u201d
\nSouth Wales Evening Post, Sept. 2, 2003.
\n5. U.S. Tort Costs: 2002 Update. Trends and
\nFindings on the Costs of the U.S. Tort
\nSystem. Tillinghast-Towers Perrin.
\nAppendix 5.
\n6. Id at 17.
\n7. VerdictSerach:
\nhttp:\/\/www.verdictsearch.com\/news\/top100\/
\n(note: page last accessed June 8, 2004)
\n8. Physician Insurers Association of America,
\nPIAA Claim Trend Analysis: 2002 edition
\n(2003), exhibit 1-2.
\n9. Physician Insurers Association of America
\n(PIAA) testimony United States House of
\nRepresentatives Committee on Energy and
\nCommerce Subcommittee on Health,
\nFebruary 23, 2003
\n10. For an extensive look at America\u2019s medical
\nliability crisis, please visit
\nwww.ama-assn.org\/go\/crisismap
\n11. The AMA filed amicus briefs in support of
\nexisting medical liability reforms in
\nWisconsin and West Virginia in 2004.
\n12. Several patient-specific examples of the loss
\nof care can be found in the
\nNovember\/December 2004 issue of the
\nSaturday Evening Post. See: Open Forum:
\n\u201cWhy Your Doctor Might Quit,\u201d by Donald
\nJ. Palmisano, M.D.
\n13. Clarion-Ledger, July 29, 2002
\n14. To ensure an accurate and extensive discus-
\nsion of MICRA and other types of reforms,
\nincluding action in the U.S. Congress and
\nstate legislatures, the AMA has prepared a
\nresearch compendium, Medical Liability
\nReform \u2013 Now!, which is regularly updated.
\nSee www.ama-assn.org\/go\/mlrnow for the
\nmost recent version.
\n15. Visit the NPSF at www.npsf.org
\nRegional & NMA News
\n112
\nTobacco Control Capacity Building
\nAt the British Medical Asociation\u2019s TCRC* meeting, held in Edinburgh during the 50th
\nanniversary year of the 1954 paper by Doll, participants heard a keynote address by its
\nauthor. Sir Richard Doll, after outlining the latest evidence of the health effects of tobac-
\nco stressed that the important messages were that in Europe half of all smokers are killed
\nby their smoking, a quarter of whom are killed by middle age, stopping smoking extends
\nlifespan, and that doctors must become involved. He suggested that the choices open to
\ndoctors were to make a commitment to reduce smoking rates, or to do nothing and see
\ntobacco related illnesses increase! Presentations were also made by Sir Richard Peto and
\nDr. Carolyn Dressler, Head of Tobacco Control at WHO\u2019s IARC and many others.
\nParticipants each outlined their individual priorities for action and in a joint resolution
\nagreed to make every effort to persuade member states to ratify the WHO Framework
\nConvention of Tobacco control and also welcomed the WHO Code of Practice for
\nHealth professionals\u2019 organisations
\n*The Tobacco Control Resource Centre (TCRC) the global first such institution \u2013 was founded in
\n1998 by the British Medical Association, WHO Europe ,and supported by the European
\nCommission Commission.
\nWMJ_04_2004.qxd 17.02.2005 09:51 Seite 112
\nCHINA
\nChinese Medical Association
\n42 Dongsi Xidajie
\nBeijing 100710
\nTel: (86-10) 6524 9989
\nFax: (86-10) 6512 3754
\nE-mail: suyumu@cma.org.cn
\nWebsite: www.chinamed.com.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 (Pr\u00e9sidente): (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
\n717 Ponce de Leon Boulevard
\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: er@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\/
\n533-8700
\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: fdmedec@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
\nmarnuca@hotmail.com
\nESTONIA
\nEstonian Medical Association (EsMA)
\nPepleri 32
\n51010 Tartu
\nTel\/Fax (372) 7420429
\nE-mail: eal@arstideliit.ee
\nWebsite: www.arstideliit.ee
\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) 315388
\nFax: (679) 387671
\nE-mail: fijimedassoc@connect.com.fj
\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) 398686 \/ Fax: -398083
\nE-mail: Gma@posta.ge
\nGERMANY
\nBundes\u00e4rztekammer
\n(German Medical Association)
\nHerbert-Lewin-Platz 1
\n10623 Berlin
\nTel: (49-30) 400-456 363\/Fax: -384
\nE-mail: renate.vonhoff-winter@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
\nFax: (509) 245-6323
\nE-mail: amh@amhhaiti.net
\nWebsite: www.amhhaiti.net
\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
\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) 8640478
\nFax: (354) 5644106
\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 \u00c4rztekammer
\nPostfach 52
\n9490 Vaduz
\nTel: (423) 231-1690
\nFax: (423) 231-1691
\nE-mail: office@aerztekammer.li
\nWebsite: www.aerzte-net.li
\nLITHUANIA
\nLithuanian Medical Association
\nLiubarto Str. 2
\n2004 Vilnius
\nTel\/Fax: (370-5) 2731400
\nE-mail: lgs@takas.lt
\nLUXEMBOURG
\nAssociation des M\u00e9decins et
\nM\u00e9decins Dentistes du Grand-
\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
\nAssociation and address\/Officers
\nii
\nU2_4_WMJ_04_04.qxd 17.02.2005 10:17 Seite U3
\nAssociation and address\/Officers
\niii
\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: www.knmg.nl
\nNEW ZEALAND
\nNew Zealand Medical Association
\nP.O. Box 156
\nWellington 1
\nTel: (64-4) 472-4741
\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) 480 1569,
\nFax: (234-1) 493 6854
\nE-mail: info@nigeriannma.org
\nWebsite: www.nigeriannma.org
\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\/Fax: (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@omsul.com
\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
\nUdaltsova Street 85
\n121099 Moscow
\nTel: (7-095)932-83-02
\nE-mail: rusmed@rusmed.rmt.ru
\ninfo@russmed.com
\nSLOVAK REPUBLIC
\nSlovak Medical Association
\nLegionarska 4
\n81322 Bratislava
\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 M\u00e9dicos
\nPlaza de las Cortes 11
\nMadrid 28014
\nTel: (34-91) 431 7780
\nFax: (34-91) 431 9620
\nE-mail: internacional1@cgcom.es
\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
\nTAIWAN
\nMedical Association
\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) 383-6710
\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
\nE-mail: servizi.sanitari@scv.va
\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
\nE-mail: info@saludgmv.org
\nVIETNAM
\nVietnam General Association
\nof Medicine and Pharmacy (VGAMP)
\n68A Ba Trieu-Street
\nHoau Kiem district
\nHanoi
\nTel: (84) 4 943 9323
\nFax: (84) 4 943 9323
\nZIMBABWE
\nZimbabwe Medical Association
\nP.O. Box 3671
\nHarare
\nTel: (263-4) 791\/553
\nFax: (263-4) 791561
\nE-mail: zima@healthnet.zw
\nU2_4_WMJ_04_04.qxd 17.02.2005 10:17 Seite U4<\/p>\n"},"caption":{"rendered":"

wmj4 WMA General Assembly, Tokyo 2004 WorldMMeeddiiccaall JJoouurrnnaall Vol. No.4,December200450 OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC. G 20438 Contents EEddiittoorriiaall 85 New WMA Secretary-General 85 Presidential address by Dr. Yank D. Coble, Jr, MD to the world medical assembly, Tokyo 86 WMA has a new President 86 MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss Medical […]<\/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\/wmj4.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3527"}],"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=3527"}]}}