{"id":3536,"date":"2017-01-19T16:59:45","date_gmt":"2017-01-19T16:59:45","guid":{"rendered":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/wmj7.pdf"},"modified":"2017-01-19T16:59:45","modified_gmt":"2017-01-19T16:59:45","slug":"wmj7-2","status":"inherit","type":"attachment","link":"https:\/\/www.wma.net\/fr\/publications\/world-medical-journal\/wmj7-2\/","title":{"rendered":"wmj7"},"author":2,"comment_status":"open","ping_status":"closed","template":"","meta":[],"acf":[],"description":{"rendered":"

wmj7<\/a><\/p>\n

WorldMedical Journal
\nVol. No.3,Septemer200551
\nOFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
\nG 20438
\nContents
\nEditorial
\nBackward to the future? 57
\nCardiovascular Research Advances 58
\nComprehensive cover for modern medics 61
\nMedical Ethics and Human Rights
\nConference of experts on biological weapons 63
\nAMA position on Physician participation
\nin Guantanamo Interrogations 67
\nWMA
\nThe Significance of the Scientific Session
\nof WMA General Assembly, Tokyo 2004 69
\nWMA Secretary General
\nThe Bologna Process \u2013 not well done,
\nbut well intented? 68
\nMedical Science, Professional Practice
\nand Education
\nCurrent Problems in Medical Education 71
\nDevelopment of new vaccines 73
\nRobots on the Hospital Wards 75
\nDetection Of Faulty Genes In Breast Cancer 76
\nBuilding Capacity for Radiation Therapy
\nin Developing Countries 76
\nWHO
\nWHO declares TB an emergency in Africa 79
\nModels of Disease 79
\nIndonesia launches country\u2019s largest-ever
\nimmunization campaign to tackle expanding
\npolio epidemic 80
\nPartnerships Working for Health Forum 80
\nConcerted Action to Achieve The Millennium
\nDevelopment Goals 81
\nNew Bangkok charter for health promotion
\nadopted to address rapidly changing
\nglobal health issues 81
\nRegional and NMA News
\nEU Project Targets Killer Viruses 82
\nDevelopments in Kazakhstan 83
\nFamily Medicine recruitment in Canada 83
\nTCRC receives WHO Certificate of Appreciation 84
\nBomb explodes outside NMA building 84
\nReview
\nInformation Products Catalogue 2003, 2004 84
\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
\nProf. Dr. Dr. h.c. J. D. Hoppe Dr Y. Blachar Dr N. Hashimoto
\nBundes\u00e4rztekammer Israel Medical Association Japan Medical Association
\nHerbert-Lewin-Platz 1 2 Twin Towers 2-28-16 Honkomagome
\n10623 Berlin 35 Jabotisky Street Bunkyo-ku
\nGermany P.O. Box 3566 Tokyo 113-8621
\nRamat-Gan 52136 Japan
\nIsrael
\nSecretary General
\nDr O. Kloiber
\nWorld Medical Association
\nBP 63
\nFrance
\nANDORRA S
\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 S
\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 E
\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 E
\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 E
\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 E
\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 E
\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 E
\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 F
\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 S
\nColegio M\u00e9dico de Bolivia
\nCasilla 1088
\nCochabamba
\nTel\/Fax: (591-04) 523658
\nE-mail: colmedbo_oru@hotmail.com
\nWebsite: www.colmedbo.org
\nBRAZIL E
\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 E
\nBulgarian Medical Association
\n15, Acad. Ivan Geshov Blvd.
\n1431 Sofia
\nTel: (359-2) 954 -11 26\/Fax:-1186
\nE-mail: usbls@inagency.com
\nWebsite: www.blsbg.com
\nCANADA E
\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 S
\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
\nTitlepage: Great Ormond Street Hospital for Sick Children, London. This hospital was founded in 1852,
\nthe first Children\u2019s Hospital in Britain. From very modest beginnings it has developed into a world famous centre both for the
\ntreatment of childrens\u2019diseases and for teaching and research into paediatric diseases. The photograph shows the entrance to
\nthe present main building. Photo by courtesy of GOS.
\nEditorial
\nBackward to the future?
\nWHO has not only warned about the potential danger of a global pandemic ofAvian Influen-
\nza but recently, in this connection, has also welcomed articles in Nature and in Science
\nreporting possible means of containment of pandemics following work based on two model
\nprojections (1)(2)(3). These suggest both the use of the drug \u2013 Oseltamivir, and strict early
\nindividual and area quarantine as a possible means of avoiding a major pandemic.(see p. 79).
\nTurning to another area of concern namely, Multi-Resistant Stqphylococcus Aureus
\n(MRSA), amongst the world wide activities to contain infections with MRSA, there has
\nbeen a renewed emphasis on the basic principles of strict cleanliness-, hand-washing and
\nscrubbing and non- touch techniques, as well as the use of detergents and bactericides. For
\nyears now there have been repeated warnings to physicians about the dangers of the devel-
\nopment of antibiotic-resistance and the need to avoid over-prescribing of antibiotics, and
\ntheir overuse and misuse. While there is still unfortunately a need to remind some physi-
\ncians to discipline their use of antibiotics, the contributory factors of deregulation of antibi-
\notics and their sale over the counter still exists in some jurisdictions, as well as the use of
\ndrugs in cosmetics and to increase food production.
\nPerhaps the time has come when we should return to basics \u2013 to the principles upon which
\nour predecessors worked before the advent of antibiotics, a re-examination of the applica-
\ntion of fundamental precautions and techniques which were common in the late 1940-
\n1950s, became unfashionable in the present industrialised systems of healthcare, and have
\nbeen forgotten or neglected in a new age of wonder drugs, technology and commercial
\npressures for rapid \u201cthrough put\u201d of patients in healthcare systems and public demands for
\nimmediate cure. We also hear calls for the revision of medical training, from a system
\ngeared to dealing with acute medicine to one capable of dealing with the huge increase of
\nchronic disease morbidity, exacerbated by the increased longevity of mankind.
\nNone of this is suggesting that we should not welcome and utilise the remarkable develop-
\nments in medical science technology, the ability to discover new treatments.
\nIt is, rather, an emphasis on the need to respect the basic principles of medical care and
\ntreatment, which include assessment of the need for sophisticated drugs when others will
\nalso achieve a cure, and to use medications and new technology with respect.
\nCoupled with all of this, there are calls for the re-humanisation of medical care. Is there a
\nneed to stress to those responsible for the administration and organisation of healthcare ser-
\nvices, that these services are for human beings, each having a unique persona and physical
\nneeds? The healthcare services provided are provided to individual human beings \u2013 not
\nsimply to machines requiring servicing or repair.
\nHave we really reached the stage when the qualities which each individual personally pos-
\nsesses can be repaired by standard \u201cspare part\u201d technology taken as a package off the shelf?
\nThe opening paragraphs above address fundamental principles of medical care. Do we need
\nto add to these the basic principles of humanity and care for others? We hear of many exam-
\nples of selfless activity amongst physicians, but are we also hearing cries of despair at
\nchanging attitudes in physicians? Humanity and care for individuals are certainly qualities
\nwhich have for generations been basic to the practice of medicine. Is there nevertheless a
\nneed today to re-emphasise this in basic medical training? Is there is a need to reject an en-
\nthusiastic unquestioning welcoming of the wonders of modern scientific and technological
\ndevelopment in medicine without pause for thought? While an evidence-based approach to
\ntreatment deals with the tools available for treatment, is such a questioning approach ap-
\nplied to individual self analysis of each physicians\u2019 activity?
\nEditorial
\n57
\nOFFICIAL JOURNAL OF
\nTHE WORLD MEDICAL
\nASSOCIATION
\nHon. Editor in Chief
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSuffolk IP14 3QT
\nUK
\nCo-Editors
\nDr. Ivan M. Gillibrand
\n19 Wimblehurst Court
\nAshleigh Road
\nHorsham
\nWest Sussex RH12 2AQ
\nUK
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2
\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
\nWe face a dilemma \u2013 how to deal with new
\nmedical discoveries and technological ad-
\nvances at a rate which has led to a belief that
\nnothing is beyond the reach of a science to-
\nday, and that it should be available to every-
\none immediately. Of course this is unrealis-
\ntic but should we be reconsidering the need
\nto go \u201cback to basics\u201d, both in our daily
\npractice and our approach to the wonders of
\nmedical advances and how we apply them
\nin the 21st century?
\nThere is a need for physicians to renew their
\nallegiance to Hippocratean principles, and
\nto the Geneva Declaration.
\n(1) WHO Statement 3rd August 2005
\n(2 Nature on-line: accessed 31.09.05.
\n(3) Science 2005, 309, 870.
\nAlan Rowe
\nEditorial
\n58
\nDuring embryonic development, the great
\nveins, atrial and ventricular chambers and
\narterial trunks are formed, and the process
\noccurs by which the heart divides into its
\ntwo distinct halves. Following this, further
\ncomplexities kick in when the heart\u2019s out-
\nflow vessels form. An understanding of the
\nway in which the heart normally develops
\nis essential both to fully comprehend the
\nnature and mechanisms which underlie
\ncongenital malformations, such as holes in
\nthe heart and transposition of the great
\narteries (Fallot\u2019s Tetralogy), and for subse-
\nquent corrective surgery to be successful.
\nWe now know that much of the early
\nknowledge of embryonic heart develop-
\nment was incorrect, and that patients were
\ndying following heart repair operations,
\nbecause surgeons put their stitches into
\nessential parts of the heart\u2019s conduction
\nsystem of Purkinje fibres. In turn, in some
\nmalformations, the electrical physiological
\n\u201cwiring\u201d is itself abnormal \u2013 so the ethical
\ndilemma of where it is safe to cut and stitch,
\nand avoid losing a life, becomes even more
\ncomplex. The importance of such work is
\nbacked up by the falling death rates associ-
\nated with heart repair. As many as one in
\nfour patients used to die during or after
\nsurgery 30 years ago, compared with about
\none in 50 today. While this is in part due to
\nadvances in cardiac diagnostics, surgery
\nand intensive care, increased anatomical
\nknowledge has undoubtedly contributed to
\nsafer and more successful surgery.
\nCongenital malformations, which present
\nin a range of degrees of severity, affect as
\nmany as 1% of live births. They are also the
\nprime cause of miscarriage in 2\u20133 times
\nthis number of embryos. Clarifying the
\nstructure of the congenitally malformed
\nheart now underpins much research and
\nseveral treatment approaches in this area
\nworldwide, as well as laying the founda-
\ntions for current research into sub-types of
\nmalformations and how these arise. In
\nterms of refined diagnosis, three-dimen-
\nsional ultrasound, echocardiography and
\ncomputerised imaging methods are being
\nutilised to find out more about the efficien-
\ncy of heart valve function before and after
\nsurgery. Cardiovascular physiology can be
\ninvestigated before, during and following
\nbirth. There is a strong focus now on exer-
\ncise physiology in children with congenital
\nheart disease. Strategies are being devel-
\noped to improve the outcome of surgical
\nrepair of transposition of the great arteries.
\nIndeed, the long-term outcome of congeni-
\ntal heart disease in adults is being studied in
\norder to improve current management in
\nchildhood, and to further anticipate prob-
\nlems in adulthood.
\nThere is a greater emphasis now on inter-
\nventional cardiology, such as introducing
\nstents, closing defects, and even inserting
\nvalves through a catheter \u2013 in some
\ninstances avoiding the need for open heart
\nsurgery. Atrioventricular septal defects
\n(AVSDs) are a type of cardiac malforma-
\ntion, where the septum fails to develop
\nproperly \u2013 leading to septal defects
\nbetween the chambers, with serious abnor-
\nmalities of the atrioventricular valves.
\nDigital imaging technology is being
\nemployed to improve the quality of surgi-
\ncal repair in this malformation. All of the
\noperations carried out by the surgeon are
\nfilmed using a head camera. In a unbal-
\nanced AVSD in the child one ventricle is
\nsmaller than the other. What would be the
\nbest way to increase the size of the smaller
\nventricle? It was discovered that in these
\nunbalanced ventricles there are often thick
\nmuscular bundles that are amenable to sur-
\ngical division, which frees up the small
\nchamber. Three-dimensional functional
\nMRI reconstruction of these imbalanced
\ndefects are performed in order to determine
\nthe position of these muscular bundles
\nbefore the operation is carried out.
\nDividing these muscle fibres means that the
\nsize of the right ventricular cavity, and
\nhence efficient pumping action, can be sig-
\nnificantly increased.
\nComputational fluid dynamics is used to
\nimprove the design of heart operations \u2013
\nand studying cerebral blood flow together
\nwith metabolic pathways during the course
\nof open heart surgery aims to reduce subse-
\nquent brain damage. Pulmonary hyperten-
\nsion is also coming under the spotlight:
\nsevere pulmonary vascular disease pre-
\nvents the surgical repair of congenital heart
\ndefects. Consequently more basic research
\nis needed on the pathogenesis of this condi-
\ntion combined with clinical research on
\ntreatment strategies.
\nIn adults with normally formed hearts, ath-
\nerosclerosis is a major cause of morbidity
\nand mortality, and reducing the burden of
\ncoronary arterial disease is a priority. The
\ndisease has its origins in childhood, and so
\nrisk factors which lead to atherosclerosis
\nare being assessed with the intention of
\nevolving strategies to prevent its onset.
\nHeart attacks
\nVascular smooth muscle cells and inflam-
\nmatory cells comprise the atherosclerotic
\nplaque, where a rupture causes arterial
\nocclusion and heart attacks. Excessive
\naccumulation of vascular smooth muscle
\nCardiovascular Research Advances
\nThe developing human heart and its congenital malformations
\ncells also promotes re-narrowing of arteries
\nafter re-vascularisation, such as intracoro-
\nnary stenting and bypass grafts. The prolif-
\neration of such cells is therefore critical to
\nunderstanding myocardial infarction dis-
\nease processes. A major focus of research
\nhas been to identify the key regulatory path-
\nways that control cell proliferation in ather-
\nosclerosis and re-stenosis. Why should cells
\nin advanced human atherosclerotic plaques
\nproliferate poorly, and therefore be unable
\nto repair minor damage? It has now been
\ndetermined how cells from in-stent narrow-
\nings bypass conventional cell cycle control.
\nSimilarly, how novel therapies such as
\nbrachytherapy (radiation therapy) achieve
\ntheir effect is becoming increasingly clear.
\nThese studies have led to the design of anti-
\nproliferative agents that are disease-specif-
\nic, which are currently being tested. Genetic
\nprofiling has identified new markers of dis-
\nease, a prelude to rational drug design to
\ntarget diseased tissues.
\nNew studies have recently been funded to
\nstudy the various processes of cell ageing, as
\nexemplified by atherosclerosis, and to iden-
\ntify mechanisms that either halt or reverse
\nthe intrinsic biological cellular clock.
\nVascular smooth muscle cell death promotes
\ninstability of atherosclerotic plaques.
\nAdvanced disease plaques have lost the abil-
\nity to protect themselves from cell death,
\nbeing also particularly vulnerable to local
\nscavenging inflammatory cells. Cholesterol-
\nlowering drugs such as the statins have ben-
\neficial effect on these disease states.
\nMechanisms of immune
\nresponse triggered by
\nendothelium
\nAlthough the latest immunosuppressant
\ndrugs have virtually eliminated the risk of
\nacute rejection of heart transplants, the risk
\nof chronic rejection in the form of a gradual
\nhardening of the arteries remains. It was
\npreviously considered that graft rejection is
\ntriggered by \u201cpassenger leukocytes\u201d, donor
\nwhite blood cells present in the graft, which
\nmigrate to the patient\u2019s lymph nodes and
\nactivate host T-cells that attack the graft and
\nlead to rejection. Graft endothelial cells
\nmay be capable of activating host T-cells,
\nwhich would explain why chronic rejection
\noccurs long after the clearance of passenger
\nleucocytes. Differences between subsets of
\nCD4+
\nand CD8+
\nT-cells have been demon-
\nstrated in their ability to be activated by
\nendothelial tissue. It may thus be possible
\nto develop target agents for therapeutic
\nintervention.
\nMyocardial stem cell biology
\nUntil recently, the heart was believed to lack
\nregenerative capacity. However, there is
\nmounting evidence that a population of
\nprogenitor cells within the heart is capable
\nof producing mature cardiac myocytes in
\nresponse to injury. The challenge is to
\nunderstand why this healing process is so
\nlimited in the heart, which results in inade-
\nquate tissue response after large myocardial
\ninfarcts or global insults to the heart such as
\nviral infection. What is the molecular basis
\nfor differentiation of adult cardiac myocytes
\nderived from embryonic stem cells? The
\nprocesses which inhibit complete myocar-
\ndial regeneration need to be identified.
\nIndeed, several approaches are possible for
\nmyocardial tissue engineering towards
\npotential therapeutic strategies in both con-
\ngenital and acquired cardiac disease.
\nTissue engineered vascular
\nconduits
\nIn surgery, both coronary artery and periph-
\neral artery bypass procedures depend on the
\nready availability of adequate arteries or
\nveins. Many patients lack suitable blood
\nvessels for grafting, which limits their abil-
\nity to benefit from surgical re-vascularisa-
\ntion. In collaboration with a biotechnology
\ncompany research will begin with clinical
\ntrials utilising wholly autologous, engi-
\nneered vascular conduits. Engineered ves-
\nsels in the way will have no foreign proteins
\nand will be \u201cgrown\u201d in the laboratory from
\na small skin and vein biopsy donated by the
\npatient. If successful, this will revolutionise
\nvascular surgery and will provide proof in
\nprinciple that similar engineering approach-
\nes for other tissues will be possible.
\nHeart transplantation
\nThe success of heart transplantation is pri-
\nmarily limited by the availability of suitable
\ndonors. Papworth Hospital, University of
\nCambridge, has pioneered approaches to in
\nvivo donor organ resuscitation and evalua-
\ntion, which have become the recognised
\n\u201cstandard of care\u201d both in the UK and
\nNorth America. A surgical device will be
\ntested which can perfuse explanted hearts
\nwith substrate-enhanced, warm, oxygenat-
\ned blood and thereby resuscitate the organ
\noutside the inflammatory milieu of the
\nbrain-dead donor. Moreover, in developing
\nthe resuscitation device, each heart will be
\nfully evaluated in terms of its physiological,
\nanatomical and biochemical performance,
\nso as to provide an evidence-based assess-
\nment of transplant suitability.
\nVascular smooth muscle cell
\ngene expression
\nAt Addenbrooke\u2019s Hospital, Cambridge, an
\nentirely novel gene has been identified and
\nsequenced which is expressed in both
\nsmooth muscle and cardiac muscle. In
\nterms of its chromosomal location it may
\nturn out to be an important agent in excita-
\ntions-contraction coupling and the regula-
\ntion of myocardial contractility.
\nAlso identified is a family of genes, con-
\ntaining some novel members, that regulate
\nthe transcription of smooth muscle specific
\ngenes.
\nVascular calcification
\nIt has been established that vascular calcifi-
\ncation is a regulated process involving both
\ninhibitory and facilitative gene products.
\nApoptotic cell death, under certain circum-
\nstances, may lead to the precipitation of cal-
\ncium salts and the initiation soft tissue cal-
\ncification. With respect to the gene coding
\nfor matrix Gla protein, an important
\ninhibitory protein in calcification, there is
\nsignificant variability in the gene coding
\nwhich may predispose some individuals to
\nEditorial
\n59
\ndevelop either earlier or more pronounced
\ncalcification.
\nBy adopting novel approaches to imaging
\nthe atherosclerotic process, pilot data sug-
\ngest that in patients with symptomatic vas-
\ncular disease, using functional MRI and
\nCAT scans, visualisation of localised
\ninflammatory activity may become feasi-
\nble. The thin layer of cells which lines
\nblood vessels, particularly vulnerable to
\nbuild up of deposits at vessel junctions, is
\ncrucially important in normalising raised
\nblood pressure. Dysfunction here is
\nbelieved to be a key factor in atherosclero-
\nsis, and so mechanisms are being investi-
\ngated and therapies evaluated aimed at
\nrestoring endothelial function.
\nArterial vessel wall injury
\nEarly atheroma development in the arterial
\nwall covers the impact of key genetic,
\ninflammatory and dietary factors. The latter
\ninclude the role of partially oxidised lipids
\nand essential fatty acids. Such early mech-
\nanisms are linked with abnormalities in the
\nfunction of vascular endothelial cells and
\nwith activation of fibrin and platelets trig-
\ngering thrombotic complications, as for
\nexample in stroke and heart attacks. It is
\npossible to identify patients with threatened
\nmyocardial infarction, to inhibit the throm-
\nbin and platelet aggregation mechanisms
\nwith the \u201cclot-buster\u201d group of drugs, and
\nto diminish the risks of major cardiovascu-
\nlar complications, provided that the patient
\nis seen early enough by the doctor. This
\nnow means that, in delivery of healthcare to
\nheart patients, myocardial infarction and
\nunstable anginal pain can be more accu-
\nrately assessed for their frequency and clin-
\nical significance.
\nCardiac specific gene
\ntargeting
\nA research group at the Edinburgh New
\nRoyal Infirmary under Dr. KAA Fox has
\nexamined the molecular genetics of key
\nfactors involved in hypertension. Important
\nsteps have been identified in the control of
\nthe renin-angiotensin cascade, regulating
\nEditorial
\n60
\nIt is with great sadness that we report the death of Sir Richard Doll whose
\nseminal work on Smoking and Lung Cancer was reflected on its fiftieth
\nanniversary last year in his guest editorial in this journal (WMJ50 (3)).
\nWilliam Richard Shaboe DOLL
\nd. 24 July 2005 aged 92
\nIt is over fifty years since the young researcher who had served in a hospital
\nship during the second world war and had lost a kidney to tuberculosis, first
\ndemonstrated in collaboration with Austin Bradford Hill, the close link
\nbetween smoking and lung cancer (and so many other diseases, notably coro-
\nnary heart disease). Inevitably he was frustrated by the subsequent failure both
\nof governments and so many victims of their smoking habit to follow his
\nexample and act on these findings, but, supported by a \u201cpowerful marriage\u201c to
\nJoan Faulkner, he devoted his painstaking epidemiological skills to an infinite
\nrange of diseases related to environmental, occupational and lifestyle factors.
\nHis exact and exacting scientific work, underpinned by a strong humanitari-
\nan drive, made him an example and an inspiration to those who followed him.
\nShowers of honours worldwide failed to spoil a truly modest man. Despite
\nincreasing frailty and the loss of his wife in 2001, he continued to the end to
\nrespond to requests for advice and support to those who shared his commit-
\nment to the prevention of preventable disease and suffering.
\nblood pressure and arterial vascular tone,
\nand in gluccorticoid metabolism, covering
\nsusceptibility to atheroma and accelerated
\nphase hypertension. It has been possible to
\nmark renal juxtaglomerular cells genetical-
\nly, which are critically involvend in the dis-
\nease process.
\nThis group of doctors has the largest single-
\ncentre experience in Europe of survivors
\nfrom out-of-hospital cardiac arrests. Specific
\nbrain enzyme markers can predict the risk of
\ndeath and cognitive impairment amongst
\nthose surviving initial resuscitation Using
\nMRI, the anatomical location and metabolic
\nsubstrate for defects in mental function and
\nmemory loss have been defined. Related
\nwork examines the risk of the patient devel-
\noping further arrhythmias. Thus, specific
\nrehabilitation measures can now be targeted
\nas survivors of cardiac arrest.
\nArrhythmias
\nAccording to Dr. AJ Cann, St. George\u2019s
\nHospital, fatal atrial fibrillation is a com-
\nmon rhythm disorder which requires inves-
\ntigation in a long series of studies. Examples
\ninclude design and testing of pacemaker
\nalgorithms for control of atrial fibrillation
\nand the development of implantable defib-
\nrillators. New medications and medical reg-
\nimens are being discovered to treat paroxys-
\nmal, persistent and permanent atrial fibrilla-
\ntion. Mapping of atrial fibrillation at surgery
\nis being carried out in order to identify areas
\nwhich can be destroyed that will eliminate
\nrhythm disturbance, together with the use of
\ndigital recordings to evaluate oscillatory
\nmechanisms initiating atrial fibrillation.
\nHeart muscle disorders, such as hypertrophic
\nobstructive cardiomyopathy (HOCM) and
\ndilated cardiomyopathy, generally occur in
\nfamilies. These disorders and other genetic
\ncardiac conditions, which may cause sudden
\nunexpected cardiac death, are being studied:
\nthe genetic basis and the phenotype-genotype
\ncorrelations in HOCM; dilated cardiomyopa-
\nthy genetics, arrhythmogenic dysplasia,
\nMarfan syndrome, long QT syndrome,
\nBrugada syndrome, sudden infant death syn-
\ndrome (SIDS) and the conditions responsible
\nfor sudden death in professional athletes.
\nThe latest techniques which can assess the
\ncardiac electrical arrhythmogenic risk of
\npatients suffering from heart disease incor-
\nporate several risk of patients suffering
\nfrom heart disease incorporate several large
\ndatabases taken from multi-centre clinical
\ntrials. Risk factors cover heart rate variabil-
\nity \u2013 frequency, time and non-linear meth-
\nods; a new approach known as heart rate
\nturbulence; and spatial and temporal vari-
\nability of the QT interval (QT dispersion).
\nOutlook
\nAnalysis of hospital records in Western
\nEurope and America by computer has
\nshown that many fatal diseases of Western
\nculture, particularly heart attacks and
\nstrokes, can be brought on by a previous
\ninfection. Clinical technology should there-
\nfore be harnessed to identify patients at risk
\nof cardiac disease progression, whether
\nfrom the genetic point of view of inherited
\ndiseases associated with heart muscle and t
\nhe conduction system, sudden death in the
\nyoung, HOCM, the ion channelopathies
\nand arrhythmogenic right ventricular car-
\ndiomyopathy \u2013 or on the other hand the
\nenvironmental approach via the strength of
\nthe immune reaction in fending off disease.
\nThe recognition of such patients at risk is
\nimportant from an ethical point of view as
\neffective treatments are available.
\nIvan M. Gillibrand
\nFurther reading
\nInstitute of Child Health &
\nGreat Ormond Street Hospital for Children
\nNHS Trust:
\n\u201cLeading The Way\u201d Research Review
\n2003
\nBritish Heart Foundation 2003\/04
\nAnnual Report of the Medical Division
\nMedical Director: Professor Sir Charles
\nGeorge
\nwww.bhf.org.uk
\nGuest Editorial
\n61
\nThis article explores the trends in indemni-
\nty insurance worldwide, set against the UK
\nscene and draws conclusions about the
\nfuture arrangements for liability cover for
\nphysicians and other healthcare workers.
\nThe number of multi-million pound medical
\nnegligence claims has been rising above the
\nrate of inflation for some years and stories
\nabout such cases are a regular feature in the
\nnewspapers. Despite this, some UK doctors
\nand dentists do not always know for certain
\nwhether compensation for harm suffered
\nfrom proven clinical negligence will be avai-
\nlable. Contractual indemnity insurance is in
\nplace throughout the United States, Austra-
\nlia and most of continental Europe but this
\nhas not yet happened in the United Kingdom.
\nThis article investigates whether there is
\nnow irresistible momentum behind insur-
\nance being made compulsory for healthcare
\nprofessionals
\nMedical negligence trends
\nSet against the staggering number of
\nNational Health Service (NHS) consulta-
\ntions which take place in the UK \u2013 around
\n270 million every year1
\n\u2013 the number of
\nmedical negligence claims is very small.
\nThe NHS Litigation Authority (NHSLA),
\nwhich indemnifies NHS bodies, such as
\nhospitals, paid out \u00a3502.9million in claims
\nand legal costs in 2004-5, compared to
\n\u00a3422.5million in 2003-4. In contrast, the
\nnumber of clinical negligence claims
\nagainst the NHS in 2004-5 fell to 5,609,
\ncompared with 6,251 in 2003-42
\n.
\nThe Medical Defence Union (MDU) has
\nrevealed that the costs of medical negligence
\nclaims are rising well above the rate of infla-
\ntion, although the trend seems to be for fewer
\nclaims to be made against members. Those
\nwe do see are generally well thought out and
\nhave a more realistic chance of succeeding.
\nLast year the MDU, which has over 165,000
\nmembers, including over 50 per cent of UK
\ndoctors, paid seven patients more than \u00a31mil-
\nlion each for claims and legal costs against
\nhospital doctor and GP members3
\n. Ten years
\nago just one patient received more than \u00a31mil-
\nlion. The high cost of these cases reflects the
\nseverity of the injury and the amount of care
\nthe patient needs for the rest of his or her life.
\nIt is difficult to draw conclusions in com-
\nparing the claims statistics in different
\ncountries because legal systems differ so
\ngreatly that this would be misleading.
\nSuffice it to say that there is some evidence
\nthat there has been an increase in medical
\nnegligence claims in other countries. In the
\nUnited States, for example, a study by the
\nJoint Economic Committee of US Congress
\nreported in May 2003 that, between 1994
\nand 2001, the average medical malpractice
\naward increased 176 per cent to $1million4
\n.
\nGovernment action
\nSome governments, such as that in Australia,
\nhave sought to tackle the high cost of clini-
\ncal negligence cases by imposing a cap on
\nthe amount of damages that can be awarded.
\nIn the United States too, President Bush has
\nstated his determination to reform the system
\nand reduce the number of lawsuits, including
\na cap on non-economic damages.
\nMeanwhile, the UK Government is investi-
\ngating ways to regulate the claims system.
\nThis may include an attempt to rein in so-
\ncalled \u201cclaims farmers\u201d which offer to assist
\nin pursuing personally injury claims, usual-
\nly in exchange for a share of any compensa-
\ntion recovered. In a speech to the Institute of
\nComprehensive cover for modern medics
\nDr Michael Saunders, Chief Executive of the Medical Defence Union
\nPublic Policy and Research (IPPR) on 26
\nMay 2005 Lord Falconer, the Secretary of
\nState for Constitutional Affairs and Lord
\nChancellor said: \u201cThe growth of claims
\nfarmers has fostered and encouraged the
\nattitude that if you are injured, you should
\nsee if you can turn it into money. Our
\nCompensation Bill will help with that by
\nintroducing regulation of claims farmers.\u201d
\nIn addition, in the 2005 Queen\u2019s Speech at
\nthe opening of parliament a NHS Redress
\nBill was proposed with the aim of reducing
\nlong delays in bringing cases and the high
\nlegal costs in settling some claims.
\nAlthough the details of the scheme have yet
\nto be made available, it is likely to follow
\nthe outline of the scheme outlined in the
\nChief Medical Officer\u2019s consultation paper
\non reforming clinical negligence: \u2018Making
\nAmends\u2019 in 20035
\n. This also included a pro-
\nposal for a scheme of no fault compensa-
\ntion. In 2002, such cases accounted for 5
\nper cent of the cases on the NHS\u2019s books
\nbut 60 per cent of the money paid out by the
\nNHS to compensate patients.
\nMedical indemnity
\nWith the costs of claims rising so rapidly, it
\nis vital that doctors are properly indemni-
\nfied against the cost of a claim which could
\neasily bankrupt them, while leaving a
\npatient uncompensated.
\nIn the past, some doctors have relied on dis-
\ncretionary indemnity \u2013 that is, they have
\npaid a subscription to an organisation that
\ngives them the right to seek assistance from
\nthat company and have that request fairly
\nconsidered, but not the contractual right to
\nreceive help which comes with an insurance
\npolicy. No Company providing discre-
\ntionary indemnity can give a guarantee that
\nthey will assist with clinical negligence
\nclaims. The decision to assist or not can
\nonly be made at the time the practitioner
\npresents the indemnifier with the facts of
\nthe case for which he is seeking help.
\nThe alternative \u2013 contractual indemnity
\ninsurance \u2013 is already a requirement for
\npractising doctors and dentists in most
\ndeveloped countries in order to protect
\npatients, amongst them, the US, France,
\nGermany, Belgium, Holland and Spain.
\nAustralia was the most recent country to con-
\nvert in 2003 following a crisis in the medical
\nindemnity market precipitated by the threat-
\nened failure of one of the biggest organisa-
\ntions that had offered discretionary indemni-
\nty, United Medical Protection (UMP). UMP
\nwas forced into provisional liquidation in
\n2001 by a combination of factors identified
\nby the provisional liquidator (Deloitte)
\nincluding multi-million dollar court payouts,
\nand the collapse of its reinsurer HIH.
\nIn the midst of the crisis, the Australian
\nFederal Government stepped in to rescue
\nUMP (which was allowed to resume trading
\nin 2003) and put in place a new medical
\nindemnity insurance framework, which
\nincluded direct financial support to ensure
\nthat doctors in high-risk specialisms such as
\nobstetrics and gynaecology, could afford pre-
\nmiums. The Government made it a require-
\nment for all Australian doctors and dentists to
\nhave professional indemnity insurance on a
\nclaims-made basis, through an approved
\nprovider. Doctors and dentists are also
\nrequired to buy a \u2018run-off\u2019 policy so that after
\nthe claims made policy has expired (for exam-
\nple because the insured has retired, is disabled
\nor has died), incidents that have occurred dur-
\ning the term of the policy remain insured.
\nLaunching the scheme the Australian gov-
\nernment said the reason for the change was
\nto ensure that doctors and dentists \u201cwill have
\naccess to contracts of insurance that are
\nlegally enforceable rather than discretionary
\narrangements that exist now which provide
\nno certainty that claims will be met.\u201d
\nIndemnity in the UK
\nIn the UK, concerns about discretionary
\nindemnity were expressed as far back as
\n1979 in a judgment of the then Vice-
\nChancellor, Sir Robert Megarry:
\n\u2018\u2026 When a person insures, I think that
\nhe is contracting for the certainty of pay-
\nment in specified events, and not merely
\nfor the certainty of proper consideration
\nbeing given to his claim that the discre-
\ntion to make a payment in those events
\nshould be exercised in his favour. The
\ncertainty must be direct, and not at one
\nremove.\u2019 6
\nToday, lawyers, architects and accountants
\nworking in private practice in the UK have
\nto have professional indemnity insurance,
\nas do health professionals such as chiro-
\npractors and the majority of osteopaths, but
\nthe same is not true of doctors and dentists.
\nHowever, recent events have renewed focus
\non the insurance question.
\nIn 2004, the Department of Health (DoH)
\nissued a consultation, which proposed to
\nmake indemnity insurance compulsory for
\ndentists. However after the consultation had
\nclosed, the DoH said there was a mistake in
\nthe wording and that discretionary indemni-
\nty would be equally acceptable. The Dentists
\nAct 1984 (Amendment) Order 2005 makes
\n\u201cadequate and appropriate insurance\u201d a
\nrequirement for all registered dentists and
\ndental care professionals. However, in defin-
\ning \u201cadequate and appropriate insurance\u201d the
\norder states that as well as a contract of
\ninsurance, \u201can arrangement made for the
\npurpose of indemnifying a person\u2026\u201d is
\nacceptable. It is now up to the General
\nDental Council (GDC) to draw up rules
\nspecifying what type of insurance it consid-
\ners will provide adequate and appropriate
\nsafeguards for dentists and their patients.
\nIn the debate surrounding the DoH consulta-
\ntion and the insurance versus discretion ques-
\ntion, discretionary-only providers suggest
\nthat discretion is more flexible and that the
\nproblem with insurance is the \u2018small print\u2019.
\nHowever, one of the major problems with
\ndiscretion is that there isn\u2019t any print at all, no
\ncontract, any enforceable right to assistance.
\nIn contrast, an insurance policy should set
\nout, in plain English, what is covered and
\nwhat is excluded. If a healthcare professional
\nis refused assistance under their insurance
\npolicy they may seek and be given a reason
\nfor that decision. He or she also has recourse
\nto the Financial Ombudsman Service and the
\ncivil courts for assistance in challenging the
\ndecision. Doctors refused indemnity by a
\ndiscretionary provider have none of these
\nsafeguards and only know if they will be
\nassisted when they make the claim.
\nThe Consumers\u2019 Association has said:
\n\u201c\u2026the provision of clinical indemnity
\nshould be regulated to ensure that one only
\nGuest Editorial
\n62
\npractitioners are assured that they have
\ncover if something goes wrong, but also that
\nconsumers will be able to achieve redress
\nand receive recompense in this event\u2026\u201d
\nDiscretion only indemnifiers are unregulat-
\ned. Only doctors who are insured have the
\nkind of consumer guarantees that one
\nwould expect from a highly regulated
\nindustry. Insurers are authorised and regu-
\nlated by the Financial Services Authority
\n(FSA) which oversees the financial man-
\nagement of insurance companies in order to
\nprotect solvency margins, insure capital
\nadequacy and reduce the risk of capital
\nflight. It also sets standards for systems,
\nsales and policyholder communications,
\nclaims handling and complaints procedures.
\nBoth the UK General Dental Council and the
\nGeneral Optical Council, which has also
\nbeen given the power to make rules specify-
\ning their indemnity requirements, have
\nsought or will seek legal advice and no doubt
\nwill wish to consider whether an indemnity
\narrangement that gives healthcare profes-
\nsionals no contractual rights, and that is not
\nlegally enforceable, provides adequate and
\nappropriate safeguards for healthcare profes-
\nsionals, and patients who sue for negligence.
\nThe need for insurance
\nAs professional accountability increases,
\nthe likelihood also increases that non-med-
\nical healthcare professionals will be sued
\npersonally if a patient they are treating is
\nharmed. Given that discretionary indemnity
\nis no longer acceptable in Australia, in most
\nother EU countries and most states in the
\nUSA, it is the MDU\u2019s view that discre-
\ntionary indemnity does not provide the nec-
\nessary safeguards for UK healthcare profes-
\nsionals and their patients and that all health-
\ncare professionals should be required to
\nhold professional indemnity insurance.
\n\u00a9
\nMDU Services 2005
\nAddress for correspondence:
\nDr. Michael Saunders,
\nThe MDU,
\n302 Blackfriars Rd,
\nLondon SE1 8PT
\nThe Medical Defence Union was founded in
\n1885 and was the first medical mutual pro-
\nfessional assurance organisation in the
\nworld. It continued worldwide coverage for
\nits members who, at various stages, have
\nincluded members from other countries
\npractising in many parts of the world until
\nthe year 2000, when only doctors and den-
\ntists practising in the UK and Ireland
\nbecame eligible for membership. ED
\n1 Office of Health Economics Compendium of
\nHealth Statistics, London 2000, p36
\n2 NHSLA Report and Accounts 2005, London
\n2005
\n3 Medical Defence Union, London 2005
\n4 Liability For Medical Malpractice Issues And
\nEvidence, Joint Economic Committee United
\nStates Congress, Washington 2003 (introduc-
\ntion)
\n5 Making amends: a consultation paper setting
\nout proposals for reforming the approach to
\nclinical negligence in the NHS \u2013 A report by
\nthe Chief Medical Officer, London, July 2003
\n6 MDU Ltd v Department of Trade [1979] 2
\nWLR 686
\nMedical Ethics and Human Rights
\n63
\nThe following presentation was given on
\nbehalf of the WMA at the Conference of
\nExperts on Biological Weapons in Geneva
\n11th
\nJune 2005.
\nThe World Medical Association was set up
\nfollowing the Nuremburg trials to deal with
\nthe issue, amongst others, of abuse of med-
\nical expertise. (Box 1) In the concept of the
\ncurrent conference it could even be shown
\nthat some of the abuses were dual use of
\nmedicine. The WMA was also set up
\nbecause doctors\u2019 recognised a need for
\ninternational standards which were codified
\nand formalised. Such standards offer bene-
\nfits to individuals, and help them to resist
\nimprecations to become involved in ethical-
\nly unacceptable practices.
\nWhen we consider common medical stan-
\ndards, it is important to look at issues such
\nas the core values that bind doctors together.
\nThese values are what being a doctor is all
\nabout and include concepts such as compas-
\nsion, caring and commitment (box 2).
\nMedicine has also had the advantage of
\nhaving ethical codes for over two and a half
\nthousand years which most doctors regard
\nas being binding.
\nAs a profession we are also regulated. For
\nmany doctors, this regulation which
\nincludes consideration of the concept of
\nself-development, learning and working to
\nMedical Ethics and Human Rights
\nConference of experts on biological weapons
\nProfessor Vivienne Nathansen
\nDirector of Professional Activities, British Medical Association
\nBox 1 What is the WMA?
\n\u2022 Established in 1948
\n\u2022 An association of associations
\n\u2022 National Medical Associations
\n\u2022 Independent and representative
\n\u2022 Members from all parts of the world (but not all countries)
\n\u2022 Bound by common standards
\nexternally agreed standards, will be wholly
\nby other members of their profession, that
\nis a peer group. Increasingly such regula-
\ntion is only partly self-regulation and
\nincludes input from lawyers, parliamentari-
\nans, patients and many others.
\nBeing a professional includes a commitment
\nto common standards, but also includes the
\nconcept of regulation or licensing.
\nFor most doctors throughout the modern
\nworld, being employed depends upon hav-
\ning a licence, and that licence itself is likely
\nto be in part dependent upon understanding
\neducational achievement and in part upon
\nadherence to ethical and other norms and
\nobservation of ethical standards is therefore
\na routine part of medical practice. (Box 3)
\nEthical codes have been established to raise
\nthe standards of medical practice to a high
\ncommon norm. Whilst they do not guaran-
\ntee the end of abuse by individuals, or
\nindeed of observance of ethical principles
\nby individuals, we believe they have con-
\ntributed significantly to a decrease in the
\nincidence of such abuse.
\nThere are, of course, many ethical codes sur-
\nrounding medicine. While the Hippocratic
\nOath has been around for more than two and
\na half thousand years, there are many other
\ncodes established by the World Medical
\nAssociation. These include the Declaration
\nof Geneva and the International Code of
\nMedical Ethics, established in 1948 effec-
\ntively as a modern re-statement of the princi-
\nples in the Hippocratic Oath. Other codes
\ninclude the Declaration of Tokyo on the
\ntreatment of prisoners, the Declaration of
\nHelsinki on Research Ethics, and the
\nDeclaration of Washington on Biological
\nWeapons. The key to all of these codes and
\nmany others is that the World Medical
\nAssociation has significant experience in
\ncrafting codes and promoting those to doctor
\nmembers of its member associations around
\nthe world.
\nWhere do these codes fit in the network of
\nguidance available doctors? As set out in
\nbox 4. there are many different areas of
\ncontrol of medical practice and these laws
\nvary from country to country. However,
\nethical codes and professional guidance can
\neffectively become customary law within a
\ncountry because the majority of practition-
\ners will practice according to those codes
\nand guidance. Courts do not accept igno-
\nrance of the Geneva code as an excuse for
\nbreaching well accepted principles.
\nHow does the World Medical Association
\ngo about writing a code? The first thing to
\nsay is that although historically these were
\nwritten by doctors for doctors with little
\nexternal advice, based upon Judaeo-
\nChristian ethics and setting doctors apart
\nfrom other professionals, this is gradually
\nbeing changed. Increasingly they are writ-
\nten with a medical view but as codes by
\nhealth professionals for all health profes-
\nsionals and with input from many stake-
\nholders, including patients. This has partic-
\nularly been the case in relation to the revi-
\nsion of the Declaration of Helsinki on
\nresearch ethics, where patients and research
\nsubjects had a major role to play in inform-
\ning the debate.
\nBecause ethical codes are about the frame-
\nwork of limits set by society with the pro-
\nfessions that serve it, it is important to
\nrecognise that there has to be multi-cultur-
\nal, multi-professional input, but the key to
\nthe code being useful remains getting \u201cbuy-
\nin\u201d from those will have to follow it.
\nWhy then did the World MedicalAssociation
\nwrite a Declaration on Biological Weapons
\n(box 5). The simple answer was that a num-
\nber of different associations had been doing
\nwork on biological weapons and related
\nissues for some time. The British Medical
\nWMA
\n64
\nBox 2 Common medical standards
\n\u2022 Core values
\n\u2022 Binding ethical codes
\n\u2022 Professional regualtion \u2013 partly or wholly self regulation
\n\u2022 Continuing education\/professional development
\nBox 3 Ethical codes
\n\u2022 Post Nuremberg
\n\u2022 Code by doctors for doctors
\n\u2022 General adherence even if not formally sworn
\n\u2022 Set of principles
\n\u2022 Interpretation required
\nBox 4 Control of Medical Practice
\n\u2022 Statute Law
\n\u2022 Judicial Decisions
\n\u2022 Customary Law
\n\u2022 Ethical Codes
\n\u2022 Professional guidance
\nWMA
\n65
\nA. Introduction
\n1. The World Medical Association recogni-
\nzes the growing threat that biological wea-
\npons might be used to cause devastating
\nepidemics that could spread international-
\nly.All countries are potentially at risk. The
\nrelease of organisms causing smallpox,
\nplague, anthrax or other diseases could
\nprove catastrophic in terms of the resul-
\nting illnesses and deaths compounded by
\nthe panic such outbreaks would generate.
\nAt the same time, there is a growing po-
\ntential for production of new microbial
\nagents, as expertise in biotechnology
\ngrows and methods for genetic manipula-
\ntion of organisms become simpler. These
\ndevelopments are of special concern to
\nmedical and public health professionals
\nbecause it is they who best know the po-
\ntential human suffering caused by epide-
\nmic disease and it is they who will bear
\nprimary responsibility for dealing with the
\nvictims of biological weapons. Thus, the
\nWorld Medical Association believes that
\nmedical associations and all who are con-
\ncerned with health care bear a special re-
\nsponsibility to lead in educating the public
\nand policy makers about the implications
\nof biological weapons and to mobilize
\nuniversal support for condemning rese-
\narch, development, or use of such wea-
\npons as morally and ethically unaccepta-
\nble.
\n2. Unlike the use of nuclear, chemical, and
\nconventional weapons, the consequences
\nof a biological attack are likely to be insi-
\ndious. Their impact might continue with
\nsecondary and tertiary transmission of the
\nagent, weeks or months after the initial
\nepidemic. The consequences of a success-
\nful biological attack, especially if the in-
\nfection were readily communicable, could
\nfar exceed those of a chemical or even a
\nnuclear event. Given the ease of travel and
\nincreasing globalization, an outbreak an-
\nywhere in the world could be a threat to all
\nnations.
\n3. A great many severe, acute illnesses oc-
\ncurring over a short span of time would al-
\nmost certainly overwhelm the capacities
\nof most health systems in both the develo-
\nping and industrialized world. Health ser-
\nvices throughout the world are struggling
\nto meet the demands created by
\nHIV\/AIDS and antimicrobial-resistant or-
\nganisms, the problems created by civil
\nstrife, refugees and crowded, unsanitary
\nurban environments as well as the increa-
\nsed health needs of aging populations. Co-
\nping over a short period of time with large
\nnumbers of desperately ill persons could
\noverwhelm entire health systems.
\n4. Actions can be taken to diminish the risk
\nof biological weapons as well as the po-
\ntentially harmful consequences of serious
\nepidemics whatever their origin. Interna-
\ntional collaboration is needed to build a
\nuniversal consensus that condemns the de-
\nvelopment, production, or use of biologi-
\ncal weapons. Programs of surveillance are
\nneeded in all countries for the early detec-
\ntion, identification, and response to se-
\nrious epidemic disease; health education
\nand training is needed for professionals,
\ncivic leaders, and the public alike; and
\ncollaborative programs of research are
\nneeded to improve disease diagnosis, pre-
\nvention, and treatment.
\n5. The proliferation of technology and scien-
\ntific progress in biochemistry, biotechno-
\nlogy, and the life sciences provides the op-
\nportunity to create novel pathogens and
\ndiseases and simplified production me-
\nthods for bioweapons. The technology is
\nrelatively inexpensive and, because pro-
\nduction is similar to that used in biological
\nfacilities such as vaccine manufacturing, it
\nis easy to obtain. Capacity to produce and
\neffectively disperse biological weapons
\nexists globally, allowing extremists (ac-
\nting collectively or individually) to threa-
\nten governments and endanger peoples
\naround the world. Nonproliferation and
\narms control measures can diminish but
\ncannot completely eliminate the threat of
\nbiological weapons. Thus, there is a need
\nfor the creation of and adherence to a glo-
\nbally accepted ethos that rejects the deve-
\nlopment and use of biological weapons.
\nB. Strengthening public
\nhealth and disease surveillan-
\nceCE systems
\n6. A critical component in dealing with epi-
\ndemic disease is a strong public health in-
\nfrastructure. Investment in public health
\nsystems will enhance capacity to detect
\nand to contain expeditiously, rare or un-
\nusual disease outbreaks, whether delibera-
\ntely induced or naturally occurring. Core
\npublic health functions (disease surveil-
\nlance and supporting laboratory services)
\nare needed as a foundation for detection,
\ninvestigation, and response to all epidemic
\nthreats. A more effective global surveil-
\nlance program will improve response to
\nnaturally occurring infectious diseases
\nand will permit earlier detection and cha-
\nracterization of new or emerging diseases.
\n7. It is especially important that physicians
\nbe alert to the occurrence of cases or clu-
\nsters of unusual infectious diseases, to
\nseek help from infectious disease specia-
\nlists in diagnosis, and to report cases
\npromptly to public health authorities. Be-
\ncause any physician may see only one or a
\nfew cases and may not recognize that an
\noutbreak is occurring, cooperation bet-
\nween primary care physicians and public
\nhealth authorities is especially important.
\n8. Public health officials, dealing with an
\nepidemic, will require the cooperation of
\nemergency management agencies, law en-
\nforcement officials, healthcare facilities,
\nand a variety of community service orga-
\nnizations. For these different groups to
\nwork together effectively, advance plan-
\nning will be important. In addition to de-
\nveloping surveillance activities for early
\ndetection and reporting, public health eff-
\norts should be directed toward educating
\nprimary caregivers and public health staff
\nabout potential agents that might be used,
\nbuilding laboratory capacity for rapid
\nidentification of biological agents, provi-
\nBox 5: The WMA Declaration of Washington
\non biological weapons
\nWMA
\n66
\nding medical and hospital services as well
\nas vaccines and drugs to control the epide-
\nmic.
\nC. Enhancement of medical
\npreparedness and response
\ncapacity
\n9. The first indication that a biological wea-
\npon may have been disseminated is likely
\nto be the appearance of patients in the of-
\nfices of practicing physicians, especially
\nthose in acute care settings. Physicians
\nthus play a critical role in early detection
\nof an outbreak and must be prepared to
\nrecognize and deal with diseases resul-
\nting from the use of biological weapons
\nas well as other infectious disease agents
\nand to promptly report suspicious illnes-
\nses and diseases to public health officials.
\n10. In the course of an epidemic, physicians
\nwill be directly involved with mass pa-
\ntient care, with mass immunization and
\nantibiotic prophylaxis, with providing in-
\nformation to the public, and in a variety
\nof hospital and community efforts to con-
\ntrol the epidemic. Thus, physicians
\nshould participate with local and national
\nhealth authorities to develop and imple-
\nment disaster preparedness and response
\nplans for intentional and natural infec-
\ntious disease outbreaks.
\nD. Bioweapons research and
\nmedical ethics
\n11. Rapid advances in microbiology, mole-
\ncular biology, and genetic engineering
\nhave created extraordinary opportunities
\nfor biomedical research and hold great
\npromise for improving human health and
\nthe quality of life. Better and more rapid
\ndiagnostic tools, novel vaccines, and the-
\nrapeutic drugs can be foreseen. At the
\nsame time, there is concern about the
\npossible misuse of research for the deve-
\nlopment of more potent biological wea-
\npons and the spread of new infectious di-
\nseases. It may be difficult to distinguish
\nlegitimate biomedical research from re-
\nsearch by unscrupulous scientists with
\nthe malign purpose of producing more
\neffective biological weapons.
\n12. All who participate in biomedical rese-
\narch have a moral and ethical obligation
\nto consider the implications of possible
\nmalicious use of their findings. Through
\ndeliberate or inadvertent means, genetic
\nmodification of microorganisms could
\ncreate organisms that are more virulent,
\nare antibiotic-resistant, or have greater
\nstability in the environment. Genetic
\nmodification of microorganisms could
\nalter their immunogenicity, allowing
\nthem to evade natural- and vaccine-indu-
\nced immunity. Advances in genetic engi-
\nneering and gene therapy may allow mo-
\ndification of the immune response sy-
\nstem of the target population to increase
\nor decrease susceptibility to a pathogen
\nor disrupt the functioning of normal host
\ngenes.
\n13. Research specifically for the purposes of
\ncreating biological weapons is to be con-
\ndemned. As scientists and humanitari-
\nans, physicians have a societal responsi-
\nbility to decry scientific research for the
\ndevelopment and use of biological wea-
\npons and to express abhorrence for the
\nuse of biotechnology and information
\ntechnologies for potentially harmful pur-
\nposes.
\n14. Physicians and medical organizations
\nhave important societal roles in deman-
\nding a global prohibition on biological
\nweapons and stigmatizing their use,
\nguarding against unethical and illicit re-
\nsearch, and mitigating civilian harm
\nfrom use of biological weapons.
\nE. Recommendations
\n15. That the World Medical Association and
\nNational Medical Associations worldwi-
\nde take an active role in promoting an
\ninternational ethos condemning the deve-
\nlopment, production, or use of toxins and
\nbiological agents that have no justifica-
\ntion for prophylactic, protective, or other
\npeaceful purposes.
\n16. That the World Medical Association, Na-
\ntional Medical Associations and health-
\ncare workers worldwide promote, with
\nthe World Health Organization, the Uni-
\nted Nations, and other appropriate ent-
\nities, the establishment of an internatio-
\nnal consortium of medical and public he-
\nalth leaders to monitor the threat of biolo-
\ngical weapons, to identify actions likely
\nto prevent bioweapons proliferation, and
\nto develop a coordinated plan for monito-
\nring the worldwide emergence of infec-
\ntious diseases. This plan should address:
\n(a) international monitoring and repor-
\nting systems so as to enhance the surveil-
\nlance and control of infectious disease
\noutbreaks throughout the world; (b) the
\ndevelopment of an effective verification
\nprotocol under the UN Biological and
\nToxin Weapons Convention; (c) educa-
\ntion of physicians and public health wor-
\nkers about emerging infectious diseases
\nand potential biological weapons; (d) la-
\nboratory capacity to identify biological
\npathogens; (e) availability of appropriate
\nvaccines and pharmaceuticals; and (f) fi-
\nnancial, technical, and research needs to
\nreduce the risk of use of biological wea-
\npons and other major infectious disease
\nthreats.
\n17. That the World Medical Association urge
\nphysicians to be alert to the occurrence of
\nunexplained illnesses and deaths in the
\ncommunity and knowledgeable of disea-
\nse surveillance and control capabilities
\nfor responding to unusual clusters of di-
\nseases, symptoms, or presentations.
\n18. That the World Medical Association en-
\ncourage physicians, National Medical
\nAssociations and other medical societies
\nto participate with local, national, and
\ninternational health authorities in develo-
\nping and implementing disaster prepa-
\nredness and response protocols for acts
\nof bioterrorism and natural infectious di-
\nsease outbreaks. These protocols should
\nbe used as the basis for physician and pu-
\nblic education.
\n19. That the World Medical Association urge
\nall who participate in biomedical rese-
\narch to consider the implications and
\npossible applications of their work and to
\nweigh carefully in the balance the pursuit
\nof scientific knowledge with their ethical
\nresponsibilities to society.
\nAssociation for example wrote book length
\nreports in 1999 and 2004, but first published
\non weapons control issues in the 1890s. The
\nAmerican Medical Association had started
\nthe drafting work on the Washington
\nDeclaration before the Anthrax attacks, and
\nfollowed it up by organising the scientific
\nsession at the 2002 General Assembly on
\nNatural and Deliberately Inflicted
\nBiological Events.
\nThe key is that doctors see disease and are
\nengaged in trying to control, manage and
\nreduce the impact of epidemics. In terms of
\nbiological weapons doctors would like to
\nsee principles of public health applied,
\nincluding both primary and secondary pre-
\nvention, to decrease the likely incidence or
\nprevalence of such biological attacks and
\nalso to manage the seriousness of such
\nattacks including reducing the spread of
\ndisease.
\nIf codes have something to offer, then the
\nquestion is what makes them effective? The
\nWorld Medical Association believes that
\nmaking codes work needs to follow a sim-
\nple set of rules. These include making them
\nrelevant, simple and clear. Similarly ensur-
\ning that the code is taught and understood
\nby those who will have to follow it and
\nensuring that you engage those who must
\nuse it or follow its principle so that they
\nunderstand, are aware of and are compliant
\nwith that code on a voluntary basis
\nThe key to effectiveness is getting those
\nwho should be bound to it, to understand,
\nvalue and internalise it as well as getting
\nsociety itself to recognise the important
\nplace that the code plays.
\nIn terms of this Conference of Experts on
\nBiological Weapons and the concept of
\ncodes, there are a number of questions to
\nask which raise problems in writing these
\ncodes. The first of these is \u201cwhat is a scien-
\ntist?\u201c. The answer is that there are many
\ntypes of scientist, including life scientists,
\nnatural scientists, pure scientists, biolo-
\ngists, physics, chemists and so on who are
\nkey players in reducing the risk of bio-war-
\nfare and bio-terrorism. This makes the sci-
\nences more difficult to regulate than medi-
\ncine which has the advantage of being a
\nrelatively cohesive profession wherever
\nyou are in the world.
\nWMA
\n67
\nThe second problem is that regulation and
\nlicensing of scientists is at a much earlier
\nstage than it is in medicine, where regula-
\ntion has existed for one and a half centuries
\nin many countries. The question that has to
\nbe addressed is whether licensing and regu-
\nlation will be of different groups of scien-
\ntists separately and apart, or whether there
\nwill be a cohesive all-scientist programme.
\nThe third point is whether employment
\nstandards are adequate as an alternative to a
\ncode. The World Medical Association
\nbelieves that employment standards are
\nuseful, but those employment standards
\nwork best when they embody concepts such
\nas adherence to a code of ethics as a pre-
\nrequisite for continuing employment.
\nThere are already a plethora of codes of
\nconduct and practice around the world
\nwhich can in their own way undermine the
\ndevelopment of a new code unless it is seen
\nas being over arching and having real pro-
\nfessional value and support.
\nThe final problem that we see is the absence
\nof a single international body representing
\nscientists. There is a plethora of representa-
\ntive bodies, both national and international,
\nwithin the sciences. The key factor here is to
\ncreate a new international body which can
\nover arch in all these areas and get input and
\n\u201cbuy-in\u201d to an emerging code from all spe-
\ncialities and subspecialties.
\nFinally \u2013 what can the World Medical
\nAssociation do to help in this process? The
\nfirst simple answer is that we can help write
\na code based upon our significant expertise
\nin doing just that. The second way in which
\nthe World Medical Association can and will
\nhelp, is to publicise and engage with med-
\nical researchers and their colleagues to
\nspread the message and achieve engage-
\nment from the scientific community.
\nThe third thing that the World Medical
\nAssociation can do is use its links with
\nother professional groups such as the World
\nHealth Professionals Alliance to get further
\npublicity for, and \u201cbuy in\u201d to, an emerging
\ncode.
\nThe final thing that the World Medical
\nAssociation can do is to offer reassurance
\nto scientists. Codes are far from being the
\nend of freedom. They are a part of the
\nresponsibility that scientists have to the
\nsociety which they serve. They are a frame-
\nwork which helps to ensure that scientists
\nkeep within the limits that society would
\nwish and expect to have in place and they
\nwill contribute to all of our overall safety.
\nThe WMA looks forward to continuing the
\ndebate.
\nAMA position on Physician participation in
\nGuantanamo Interrogations
\nDr J. Edward Hill, President of the American
\nMedical Association, speaking at the BMA
\nAnnual Representative Meeting made the fol-
\nlowing points concerning the position of the
\nAMA on allegations of physician participa-
\ntion in Guantanamo Interrogations e.g arti-
\ncles in the New England Journal of Medicine
\n(7 July) New York Times (June 24) and earli-
\ner report in the Press etc.
\nThe American Medical Association Code of
\nMedical Ethics clearly prohibits any form
\nof physician participation in torture. Any
\nphysician involvement in torture compro-
\nmises te integrity of the medical profession.
\nThe AMA defines torture as the use of
\n\u201ccruel, inhumane and degrading treatments
\nor punishments during imprisonment or
\ndetainment\u201d. The AMA CODE specifies that
\n\u201cparticipation in torture includes, but is not
\nlimited to, providing, or with-holding any
\nservices, substances or knowledge, to facili-
\ntate the practice of torture\u201d. \u201cPhysicians
\nshould provide support for victims of torture
\nand whenever possible, strive to change sit-
\nuations in which torture is practised or the
\npotential for torture is great.\u201d
\nThe confidentiality of medical records and
\npatient-physician communications should
\nbe protected, when that confidentiality is
\nviolated, trust in undermined and patients
\nmay not provide full and accurate informa-
\ntion to their physicians (AMA Policy E-5
\n05). This applies even to patients who are
\nprisoners or detainees.
\nAs the leading voice of the American
\nMedical Profession, the AMA calls on all
\nphysicians to stand together in opposing
\ntorture, physician participation in torture,
\nand breaches of patient confidentiality.
\nDr. Hill also referred to AMA meetings with
\nthe US Department of Defence to express
\nconcern over published reports alleging
\nphysician participation in coercive interro-
\ngations in Guantanamo Prison Camp. DOD
\nofficials assured the AMA that aggressive
\ninvestigation of these complaints was taking
\nplace but disputed whether military physi-
\ncians were involved in any unethical mis-
\nconduct. Further conversations with DOD
\nOfficials had subsequently taken place,
\ndetailing AMA concerns about the allega-
\ntions. In June 2005 a document outlining the
\nethical principles for all health personnel of
\nthe Armed Forces was sent to the AMA.
\nAt the June meeting of the House of
\nDelegates of the AMA, the house reaf-
\nfirmed its support of the ethical medical
\ntreatment of prisoners of war and said it
\nwould \u201cencourage medical schools to
\ninclude ethics training on the issue of med-
\nical treatment of prisoners of war and
\ndetainees\u201d.
\nThe AMA is working with colleagues from
\nthe British, Icelandic, French and Danish
\nMedical associations to study the
\nDeclarations of Geneva and Tokyo to deter-
\nmine whether additional provisions are nec-
\nessary to provide guidance to physicians
\nand address violations by physicians in
\nconflict settings.
\nThe AMA policy that \u201cphysician participa-
\ntion in torture and\/or abuse of prisoners is
\nunethical and unacceptable has been com-
\nmunicated to the media, public and the
\nPentagon itself, and the AMA will continue
\nboth to monitor the situation and to advo-
\ncate that all physicians honour these ethical
\nprinciples.
\nWMA
\n68
\nIn the Middle Ages studying was a fairly
\ninternational activity. Many of the universi-
\nties were in southern Europe and persons
\nseeking education had to travel a long way
\nto find their teachers. However, the power
\nof the titles academicians earned at that
\ntime was not questioned. Once bestowed
\nthe title remained with the person.
\nNowadays students may travel much faster,
\nbut to take their degrees and credits from
\none country to another takes not only longer
\nthan any journey across Europe in the
\nMiddle Ages, it is also very cumbersome
\nand sometimes even very expensive.
\nUniversities, claiming their independence,
\noften do not care about the interests of their
\nmigrating students, and governments find it
\ndifficult to compare degrees and to proper-
\nly recognize them.
\nMoreover, many students feel unprepared
\nfor university studies and many drop out
\nearly without acquiring a degree.
\nOne of the most unknown international
\nmega-projects is the so-called Bologna
\nProcess. In 1999, twentynine European
\nMinisters of Education meeting in Bologna,
\nagreed to install a uniform system of
\nUniversity degrees and credits with two
\nmajor aims:
\n\u2022 To facilitate migration by awarding easily
\nunderstandable and comparable credits
\nand degrees and
\n\u2022 To provide two study cycles for all disci-
\nplines\/fields, each ending with a degree
\ngiving access to the labour market.
\nThis step was unprecedented: The Ministers
\nof Education met and decided to take com-
\nmon action to provide easier migration
\nacross Europe, not only in the European
\nUnion, which had at that time 15 member
\nstates. And of course, such changes had to
\nbe mandatory for all studies, all disciplines\/
\nfields, all Universities and Colleges. In the
\nfuture there should be two degrees a
\nEuropean Bachelor to be reached after 3 or
\n4 years of undergraduate education, and a
\nEuropean master to be reached after anoth-
\ner 1 to 2 years of graduate studies. (The
\ndoctorate degree was later added to this sys-
\ntem as an additional third degree.)
\nHowever the Ministers of Education took
\nthis decision on their own: Experts from the
\ndifferent disciplines were obviously not
\ninvolved, students and representatives of
\nthe professions were not heard. In conse-
\nquence, the result is a reform which looks
\nnice on first sight, but which raises many
\ndoubts on further examination.
\nInterestingly, in medicine the Bologna
\nprocess was widely ignored and this for a
\ngood reason. For the last thirty years many
\nefforts have been made to unify the tradi-
\ntionally bi-phasic medical undergraduate
\neducation. The formerly separated basic
\nand clinical sciences were combined into
\none study cycle in order to expose the stu-
\ndent to a medical setting from the very
\nbeginning of medical education. Of course,
\nthis cycle has precisely one end product, the
\nphysician. There is no half-way product \u2013
\nthis was never intended nor would it have
\nFrom the Secretary General\u2019s Desk
\nThe Bologna Process \u2013 not well done,
\nbut well intended?
\nbeen meaningful. Splitting this up again
\njust doesn’t make sense!
\nConfusion in the medical field is complete.
\nSome countries decided to split the medical
\nstudies in accordance with the Bologna
\nprocess, so that the Bachelor degree defines
\nmore or less only the theoretically educated
\nphysician, and the Masters degree the com-
\npletion of internship. Other countries want
\nto introduce just a mock Bachelor \u2013 an inter-
\nmediate degree without any meaning and
\nwithout any use. Most countries have not
\ndecided what to do with medicine, while
\nother countries are certain that they will not
\ninclude medicine in the Bologna process.
\nOne thing is clear: better comparability of
\nequal and qualifying degrees remains far
\naway, the new situation actually appears to
\nbe more difficult than before the Bologna
\nprocess.
\nAcademic studies at public universities in
\nmany of the European countries are offered
\nmore or less free of tuition fees. This is a
\nhuge burden for governments, most of
\nwhich are in financial troubles. But the
\npromise always is repeated: \u201cEducation
\nwill remain free\u201c. However, the small print
\nin the political programmes reads rather
\ndifferently. A closer look reveals that in the
\nfuture, studies may be free only up to the
\nfirst professional degree, and thanks to
\nBologna, in all countries this will now be
\nafter three to four years instead of four to
\nsix years as it was previously.
\nWMA
\n69
\nWMA
\nThe Significance of the Scientific Session of
\nWMA General Assembly, Tokyo 2004
\nNobuya Hashimoto, MD Vice-Chairperson, WMA Council
\nExecutive Board Member, JMA
\nThe Scientific Session of the WMA General
\nAssembly Tokyo held from October 6 to 9,
\n2004 gave direction to resolving a variety of
\nissues that directly confront global health
\ncare today. As a person involved in planning
\nthis session from the JMA side and as an
\nexecutive board member from the host
\nNMA responsible for this event, I wish to
\nreview the significance of the Scientific
\nSession (and WMA General Assembly), and
\nmake a few suggestions.
\nThe Scientific Session provided a forum
\nthrough which the overall state of medical
\nand health care in the 21st
\ncentury was
\nreviewed through two themes \u2013 \u201cAdvanced
\nMedical Technology and Medical Ethics\u201d
\n(Theme I) and \u201cProgress in Information
\nTechnology and Health Care\u201d (Theme II).
\nProgress made in science and technology has
\ngreatly changed the environment around us
\ntoday and has also affected medical and
\nhealth care. Subsequently, it has also pro-
\nduced a variety of unforeseen problems that
\ninevitably accompany the progress made by
\nhumanity and which are unavoidable. Thus, I
\nbelieve a consensus was reached on how the
\nissues that were discussed at the Scientific
\nSession should be addressed. In summary,
\nwe, physicians, should secure the patient\u2019s
\nsafety based on a relationship of physician-
\npatient trust and do our utmost best to pro-
\nvide high quality medical care. The themes
\nthat were addressed at the Scientific Session
\ndealt with problems that health care related
\npersonnel have never had to face in the past.
\nTherefore, there are no exemplar models that
\nmay provide the answers. However, the out-
\ncome of the day and a half of active discus-
\nsions, was a shared recognition of the need
\nfor a code of behaviour for our profession by
\nthe participants from 42 countries. Thus, I
\nhope that what was discussed at the Scientific
\nSession will contribute to more effective dis-
\ncussions at the WMA.
\nThe essential points of the Scientific
\nSession were summarised as follows. The
\nachievements of advanced medical tech-
\nnology and information technology (IT)
\nbased on the knowledge of past generations
\nare indeed wonderful, and no one will deny
\nthis fact. But these achievements are not
\nshared at large within the global communi-
\nty. As pointed out by Dr. Takaku, we must
\nnot forget the view that the benefits that are
\nderived from this new technology should
\nbe shared equally and globally. In the
\nadvanced countries, concern regarding
\nadvanced medical technology and progress
\nin IT has been increasing. As emphasized
\nby JMA president, Dr. Uematsu, society as
\na whole must recognise that advanced med-
\nical technology should guarantee the safety
\nand happiness of humanity, and that a sys-
\ntem which enables only a handful of people
\nto benefit from costly advanced medical
\ntechnology should be reformed. As Dr.
\nSakurai has explained, in Japan the JMA
\nhas lobbied the Japanese government to
\nenable medical insurance to cover
\nadvanced medical technology under the
\nguidance of the JMA. This is, of course,
\nrelated to national financial issues, but it is
\nthe duty of medical associations to protect
\nthe public health by lobbying the govern-
\nment to prevent fiscal initiatives from dom-
\ninating medical and health care issues. To
\nachieve this, physicians must have the abil-
\nity to foresee future developments in med-
\nical technology.
\nAs Dr. Haddad has pointed out, we should
\nconstantly bear in mind that future devel-
\nopments in science and technology should
\nsupplement the knowledge and experience
\nthat physicians have accumulated through
\ntraditional methods and they should not
\nreplace them. If we lose sight of this basic
\nconcept, then physicians become merely
\nthe subcontractors of electronic engineers.
\nThe need for common ethical guidelines for
\nadvanced medical technology was pointed
\nout; and at the 2002 WMA General
\nAssembly in Washington the Japanese
\nMedical Association\u2019s draft proposal on
\nMedical Ethics and Advanced Medical
\nTechnology was adopted as a WMA
\nDeclaration. This declaration is a general
\nstatement on advanced medical technology
\nand medical ethics, and there is a continued
\nneed to review this issue from many differ-
\nent perspectives. For example, Japan has
\nachieved the world\u2019s highest life expectancy
\nwith low health costs. But to sustain this
\nfeat, it has become essential to secure finan-
\ncial resources. In advanced countries,
\nimproving the financial foundations needed
\nto secure the health level of its population
\nhas become a major problem, and there is
\nwide scope for discussion.
\nIn the area of medical technology and
\nadvanced IT, Dr. Kim pointed out the
\ninevitable transformation of health care due
\nto IT and genomics. But, as Dr. Uematsu
\nhas advocated, the goals that we physicians
\nshould aim for are to practice holistic med-
\nicine and to provide safe and high quality
\nmedical care. It is to be expected that med-
\nical costs will rise when quality medical
\ncare is provided. But, its quality should not
\nbe lowered as a means of containing health
\ncosts. However, financial resources for
\nmedical and health care are limited.
\nTherefore, how these resources are allocat-
\ned is a major issue which should be
\nreviewed by the WMA.
\nCertainly, as Dr. Groth has pointed out,
\nmore than 90 percent of advanced technol-
\nogy is currently developed by less than 10
\npercent of the countries in the world
\n(advanced countries). Of course, it is a fact
\nthat the social and financial foundations of
\nadvanced and developing countries differ
\ngreatly. However, it is also a fact that physi-
\ncians in developing countries should do
\ntheir ultimate best within the respective
\nenvironment of the country.
\nProgress in IT technology will continue to
\ninfluence developments in medical care. As
\nnoted by Dr. Kaihara, obtaining correct
\ninformation will promote physician-patient
\nrelations and will help realize better med-
\nical care. Thus, balancing IT and medical
\ncare is one of the goals before us to attain.
\nBut, again, as stated by attorney, Dr.
\nHiguchi, medical information must ulti-
\nmately function under the principle that it
\nwill be used to provide the best treatment
\nfor patients and allow society at large to
\nbenefit from it. As pointed out by Dr.
\nTakaku, that is the difficulty of resolving
\nspecific issues such as the need to protect
\nindividual gene related data. By whom, and
\nhow such issues will be resolved should be
\ncarefully addressed with the co-operation
\nof physicians on a global scale through the
\nWMA General Assembly meetings, rather
\nthan under the leadership of individual
\ncountry governments and their financial
\nconcerns. Therefore, the WMA should be
\nwilling to provide a forum to discuss these
\nissues as needed. As Dr. Haddad has indi-
\ncated, WMA is also duty bound to alert
\neach country about the responsibility not to
\nleave our future generations with the bur-
\nden of dealing with the destruction of the
\nnatural environment and environmental
\npollution caused by national greed.
\nThese are my personal views on the impor-
\ntant issues of CME and professional auton-
\nomy that are being debated in Japan today,
\nbased on the discussions that took place at
\nthe Scientific Session. Against a back-
\nground of extensive mass media coverage
\nabout medical errors and publicity about
\ndistrust of medical care, CME for physi-
\ncians is a vital issue that must be addressed
\nto enable physicians to provide high quality
\nmedical care. Moreover, physicians volun-
\ntarily undertake CME, and this is where
\nprofessional autonomy becomes important.
\nTherefore, I would like to emphasise the
\nneed for voluntary discipline by physicians
\nthrough reaffirmation of the WMA
\nDeclaration of Madrid on Professional
\nAutonomy and Self-Regulation.
\nThe following observations and proposals
\nare made in the light of the opportunities
\nwhich were presented at the Tokyo General
\nAssembly.
\nIn the past, many prominent declarations
\nand statements have been drafted and
\nadopted by the WMA Council and General
\nAssembly, which have been used as guide-
\nlines by NMAs in resolving different
\nissues, and I pay sincere homage to the
\nefforts of the WMA to produce these
\ninvaluable statements.
\nIn particular, the Declaration of Geneva,
\nDeclaration of Helsinki, Declaration of
\nMadrid on Professional Autonomy and
\nSelf-Regulation are some of the many very
\ndistinguished statements that have been
\nproduced so far. They have served as the
\ngolden rule for physicians throughout the
\nworld during both under and postgraduate
\neducation. Their principles remain
\nimmutable in both the East and the West.
\nDespite this fact, the WMA has repeatedly
\nrevised these historical declarations begin-
\nning with the Declaration of Helsinki. The
\nPhysician\u2019s Oath in the Declaration of
\nGeneva embodied the Hippocratic Oath, the
\nDeclaration of Helsinki had incidently the
\neffect of applying some of the principles of
\nthe Nuremburg Code to the ethical princi-
\nples for medical research involving human
\nsubjects, and the Declaration of Madrid
\nprovided the principles governing the com-
\nplex physician-patient relationship and
\ndefined the attitude of the physician about
\nprofessional autonomy and self-regulation.
\nWMA
\n70
\nWORLD MEDICAL ASSOCIATION
\nThe General Assembly and Scientific Meeting of the World Medical
\nAssociation will take place in the Hyatt Regency Hotel, Santiago,
\nChile, on the 12\u201315 October 2005.
\nThe Scientific Meeting on \u201cHealth System Reform and Access to
\nMedicine\u201c will be held on Thursday 13th October, preceded an
\nAssociates meeting.
\nThe General Assembly Ceremonial Session will be on the morning
\nof the Friday 14th October and the rest of the General Assembly will
\ntake place on Saturday, the 15th October;
\nThe basic principles that are inherent in
\nthese declarations are important and they
\nrepresent WMA\u2019s recognition of their sig-
\nnificance in adopting them at that time.
\nTherefore, they are also invaluable histori-
\ncal assets. To revise them unnecessarily
\nmay be to ignore the intent of those who
\noriginally drafted them. Moreover, it may
\nalso obliterate their significance as histori-
\ncal assets of the time. There is also concern
\nthat the original text will eventually disap-
\npear with repeated revisions.
\nThe revisions of WMA declarations have
\nhitherto been limited to unavoidable cir-
\ncumstances. But I would like to propose that
\nin future, when there is a need for a declara-
\ntion to reflect present-day medical and
\nhealth care issues, a new and separate decla-
\nration be proposed, discussed, and adopted.
\nI would like to see the WMA Council spend
\nits valuable time discussing current and
\nimportant issues rather than revising past
\ndocuments. There is a backlog of many sig-
\nnificant issues that we must discuss.
\nDisclosure of medical information and pro-
\ntection of personal information, the spread
\nof advanced medicine and soaring medical
\nexpenses, policies to control medical costs
\nand improve quality of medical care, and
\nthe specialist and the general practitioner
\nare just some of the many issues at hand
\nthat the WMA should address.
\nAs a global professional organisation for
\nphysicians, the WMA must contribute to
\nproviding high quality medical care, based
\non professional medical ethics against a
\nbackground of changing social conditions
\nand public awareness. Therefore, it must be
\nvigilant in its efforts to resolve the many
\nissues at hand.
\nIn conclusion, I look forward to WMA\u2019s
\nfurther growth and development.
\nMedical Science, Professional Practice and Education
\n71
\nA prerequisite for progress towards the
\nUnited Nations (UN) Millennium
\nDevelopment Goals (MDG), relevant for
\nthe health care sector, will be adjustments
\nin the capacity of the professional health
\nworkforce worldwide1
\n. This requirement
\nwill have considerable implications for
\nmedical education and education and train-
\ning of other health professions in many
\nparts of the world. The World Health
\nOrganisation (WHO) decision to launch a
\ndecade dedicated to human resources for
\nhealth (HRH), starting with the World
\nHealth Day and the World Health Report in
\n2006, is a clear indication of the fact that
\nwe are challenged by tremendous problems
\nof ensuring the necessary HRH basis for
\nsustainability and efficiency of health care
\nsystems. HRH is the central asset of health
\nsystems\u2019 development.
\nA new Strategic Partnership to Improve
\nMedical Education and ultimately health
\nprofessions education in general, formed
\njointly in 2004 by the World Health
\nOrganization and the World Federation for
\nMedical Education2
\n, is based on the rather
\nsimple concept (unfortunately not always
\nrecognised by all stakeholders) that quality
\nmedical education is of fundamental signi-
\nficance for quality health care.
\nThe actual situation is that medical educa-
\ntion is facing huge quantitative and qualita-
\ntive problems worldwide. They are to a cer-
\ntain extent interrelated. The former are
\nforemost determined by insufficient plan-
\nning of production and distribution of med-
\nical doctors and their uncontrolled migra-
\ntion; the latter by insufficient leadership,
\nconservatism and lack of incentives at the
\ninstitutional level. For both, lack of or not
\nusing proper priorities of resources is a crit-
\nical factor.
\nFocus is presently put on negative effects
\nof migration of doctors. What from ancient
\ntimes has traditionally been considered an
\nadvantage for the medical profession has
\nnow become a threat to health care systems
\nin the developing world. In earlier periods,
\nmobility was mostly a temporary phenom-
\nenon resulting in the achievement or deliv-
\nery of expertise, whereas the present trend
\nis a (unfortunately unclosed) circular
\nmovement in a chain reaction with the end
\nresult of the developing world being
\ndeprived of medical doctors. The mecha-
\nnisms behind this traffic are, on one side,
\ninsufficient capacity of the educational sys-
\ntem in some rich countries, the major sin-
\nners (USA, Canada and UK) benefiting
\nfrom brain-gain without providing the nec-
\nessary investments in health professionals
\neducation. On the other side, insufficient
\npostgraduate training possibilities and the
\nunattractive working and remunerative
\nconditions for medical doctors in the poor
\ncountries, lead to external brain-drain and
\nsubsequently to increased in-country
\nmigration from rural areas to the big cities.
\nEvidently, this pattern has catastrophic
\nconsequences for the health care systems,
\nespecially in Sub-Saharan Africa. The den-
\nsity of doctors in some parts of Africa is
\nbelow 1 per 100,000 compared to 160\u2013350
\n(in a few countries up to 550) per 100,000
\nin the Western world.
\nThe existence of a vicious circle is under-
\npinned by the fact that the underdeveloped
\ncountries are loosing some of the best qual-
\nified doctors and thereby part of the foun-
\ndation for their training institutions.
\nThe problem of migration, which is in fact
\neven more complicated by the existence of
\nactive recruitment by some countries, and
\nalso by deliberate brain-export by other
\ncountries, have already been discussed
\nextensively. In 2004, a World Health
\nAssembly resolution3
\nemphasised the criti-
\ncal situation and follow-up is planned, e.g.
\nat the upcoming UN General Assembly
\nSpecial Session (UNGASS) on migration.
\nSome initiatives to remedy the critical situ-
\nation have been taken, but the fundamental
\nMedical Science, Professional Practice and Education
\nCurrent Problems in Medical Education
\nHans Karle
\nPresident World Federation of Medical Education (WFME)
\ncauses have so far not been tackled. A recent
\nproposal to obtain solutions points to the
\nneed for internationally adopted standards
\nor norms for numbers of doctors in the
\ndeveloped part of the world and also for
\neffective compensation to the developing
\ncountries4
\n. Discussion at high political lev-
\nels like the G8 Forum has included the HRH
\narea in their considerations for support. It is
\ngenerally agreed that capacity building
\nregarding HRH is needed in many countries
\nin Sub-Saharan Africa. This will require bet-
\nter data on the situation country-wise, eval-
\nuation of the existing training capacity and
\nthe needed conditions for expansion, and
\nprobably the establishment of new institu-
\ntions in some countries as well as direct sup-
\nport from institutions in other Regions. The
\nlatter could include twinning arrangements
\nbetween universities and hospitals and tele-
\neducation programmes.
\nFacing the present HRH capacity problems,
\nmany authorities seem to be looking for a
\nreduction of the training programmes in
\nmedical schools below the present norm of
\n5\u20137 years for graduate and 3.5\u20134 years for
\npostgraduate medical curricula, which
\nwould enable higher production rates. The
\nmedical profession should resist such a
\ndevelopment without thorough analysis of
\nconsequences. A curriculum programme
\nbelow 5 years is generally not compatible
\nwith production of a medical doctor. Health
\nworkers coming out of such programmes
\nmust have other designations than \u201cmedical
\ndoctor\u201d, and instead of shortening the cur-
\nriculum, a more realistic approach would be
\nto consider the role of medical doctors and
\ntheir relationship to the function and educa-
\ntion of other health professions, including
\nperhaps new cadres.
\nOn the qualitative side, the problems are
\nclosely related to the mushrooming of new
\nmedical schools. Over the last decade, there
\nhas been an increase in number of about 100
\nper year. At the moment, there are no clear
\ndata regarding the overall number of medical
\nschools. It is also becoming an issue of con-
\ncern that this question depends on how we
\ndefine a medical school. In this respect,
\nsome of the new schools have been estab-
\nlished without adequate resources and often
\nwithout sufficient clinical training facilities.
\nA transition from a situation with largely
\npublic financed medical schools to an
\nincreasing private enterprise (in some cases
\neven with for-profit purposes), adds to the
\nproblem of ensuring quality. Medical educa-
\ntion like other types of higher education has
\nnow become a trade commodity which not
\nonly invites the establishment of diploma
\nmills without proper training activities, but
\nwhich also has led to off-shore satellites
\nfrom some highly estimated medical
\nschools, looking for opportunities to stabilise
\ntheir economy by attracting affluent students
\nmore than thinking about quality education.
\nHowever, on the qualitative side of the coin
\nthere are also positive trends. Medical edu-
\ncation is gradually being directed into an
\nevidence-based educational activity with
\nmany valuable innovations as far as curric-
\nular design, teaching- and learning methods
\nand assessment are concerned. More focus
\non social accountability, introduction of
\nintegrated curricula and community orien-
\ntation as well as more reliable examination
\nsystems are examples of this development.
\nWith respect to mutual integration of basic
\nsciences and integration between basic and
\nclinical sciences in education and assess-
\nments, medical education is now threatened
\nby the European Bologna Declaration and
\nProcess, which tends to influence higher
\neducation principles also beyond Europe.
\nThis process, which otherwise includes
\nimportant and valuable qualitative elements,
\nrequires a two-cycle model of independent
\nbachelor- and master-degrees. Although
\nseveral stakeholders5
\nhave criticised such a
\ndevelopment in medicine, arguing that cur-
\nrent attempts to create integrated curricula
\nwill be invalidated, there is still major con-
\ncern in many countries and institutions.
\nOn the positive side could be added broad
\ninternational consensus about the use of
\nstandards in medical education and the
\nattention to quality assurance and accredita-
\ntion of medical education institutions and
\nprogrammes. The WFME Global Standards
\nProgramme for Quality Improvement,
\nwhich received broad international
\nendorsement at the World Conference on
\nMedical Education in 20036
\nis now being
\nimplemented in all Regions of the world.
\nThe Trilogy of WFME Standards7
\nare being
\nused in institutional self-evaluation and
\npeer reviews as basis for reforms (in the
\nnear future to be supported by a new
\nWFME Advisor function) and are also
\nbeing incorporated in National and
\nRegional standards and accreditation proce-
\ndures of both well-established and new
\naccreditation systems. In most parts of the
\nworld there is a growing awareness of the
\nneed for effective, but transparent accredi-
\ntation systems. Recently, the WHO\/WFME
\nPartnership has developed Guidelines for
\naccreditation8
\n. This development will most
\nlikely result in a Register of accredited
\nmedical schools based on quality indica-
\ntors. The plans for developments of the
\nWHO Directory of Medical Schools9
\nare in
\naccordance with this.
\nThe ongoing focus on outcome-based cur-
\nricular design might be seen as a germ to
\nthe creation of new problems. While every-
\nbody would agree that attempts to use out-
\ncome definition is a valuable lighthouse in
\ncurricular planning, too narrow and short-
\ntermed specification of the outcome of the
\neducational process (which already seems
\nto be the case in some medical schools),
\nwill have the risk of spoiling the fundamen-
\ntals of academic medicine. Medical educa-
\ntion should not only be determined by the
\nendeavour to achieve a number of concrete
\npractical competencies, but should fore-
\nmost foster understanding and methodolog-
\nical capabilities.
\nReferences
\n1. Mercer, H., Dal Poz, M., Adams, O., Stilwell,
\nB., Buchan, J., Dreesch, N., Zurn, P. and
\nBeaglehole, R. Human Resources for Health:
\nDeveloping Policy Options for Change. In:
\nTowards a Global Health Workforce Strategy.
\nEds.: Paulo Ferrinho and Mario Dal Poz.
\nStudies in Health Services Organisation &
\nPolicy, 21, 2003.
\n2. WHO\/WFME Strategic Partnership to
\nImprove Medical Education. Geneva\/Copen-
\nhagen 2004. www.who.int & www.wfme.org
\n3. World Health Assembly Resolution:
\nInternational Migration of Health Personnel:
\nA Challenge for Health Systems in
\nDeveloping Countries. WHA 57.19, 2004.
\n4. Eastwood, J.B., Conroy, R.E., Naicker, S.,
\nWest, P.A., Tutt, R.C. and Plange-Rhule, J.
\nLoss of Health Professionals from Sub-
\nSaharan Africa: The Pivotal Role of the UK.
\nMedical Science, Professional Practice and Education
\n72
\n5. World Federation for Medical Education and
\nthe Association for Medical Education in
\nEurope: Statement on the Bologna Process
\nand Medical Education. 2005. www.wfme.org.
\n6. van Niekerk JP de V. WFME Global
\nStandards Receive Ringing Endorsement.
\nCommentary. Medical Education 2003, 37,
\n585-86
\n7. WFME Global Standards for Quality
\nImprovement: (a) Basic Medical Education;
\n(b) Postgraduate Medical Education; (c)
\nContinuing Professional Development (CPD).
\nCopenhagen 2003. www.wfme.org
\n8. WHO\/WFME Guidelines for Accreditation of
\nBasic Medical Education. Geneva\/Copen-
\nhagen 2005. www.wfme.org
\n9. World Directory of Medical Schools. Seventh
\nEdition. World Health Organization, Geneva,
\n2000 and www.who.int.
\nCorrespondence to:
\nDr. Hans Karle
\nWFME Office
\nUniversity of Copenhagen
\nFaculty of Health Sciences
\nThe Panum Institute
\nBlegdamsvej 3
\nDK-2200 Copenhagen N
\nDenmark
\nMedical Science, Professional Practice and Education
\n73
\nA number of new vaccines with major
\npotential for controlling infectious diseases
\nare at advanced stages of development.
\nAmong the illnesses targeted are rotavirus
\ndiarrhoea, pneumococcal disease, and cer-
\nvical cancer (as caused by human papillo-
\nmavirus), which together kill more than a
\nmillion people each year, most of them in
\ndeveloping countries. In addition to these
\nefforts against diseases of global impor-
\ntance, progress is being made on a vaccine
\nfor the regional menace posed by meningo-
\ncoccal meningitis serogroup A, which caus-
\nes frequent epidemics and high rates of
\ndeath and disability in African countries
\nsouth of the Sahara.
\nThese advanced candidate vaccines are the
\nfocus of the information provided below.
\nHowever, it should be noted that continu-
\ning, intensive efforts are under way to
\ndevelop effective vaccines for AIDS,
\nmalaria, dengue, leishmaniasis, and shigel-
\nla dysentery, among others.
\nVaccine development proceeds through dis-
\ncovery, process engineering, toxicology
\nand animal studies to human Phase I, II,
\nand III trials. The process can take more
\nthan 10 years, depending on the disease.
\nThe human trials focus initially on safety,
\ninvolving small groups of people (I); then
\nprogress to moderate-sized \u201ctarget\u201d popula-
\ntions (persons close to the age and other
\ncharacteristics for whom the vaccine is
\nintended) to determine both safety and the
\nstimulation of immune response (II); and
\nfinally to large target populations to estab-
\nlish whether a vaccine actually prevents a
\ndisease as intended (efficacy) (III).
\nThe current situation of a number of new
\nvaccines in development:
\nRotavirus
\nAcute diarrhoea is responsible for nearly 1.9
\nmillion deaths per year in children under age
\nfive. Rotavirus is responsible for as much as
\none quarter of these casualties, almost all of
\nwhich occur in developing countries.
\nStatus of vaccine development:
\nRotaRix, a vaccine developed by
\nGlaxoSmithKline (GSK), showed an effica-
\ncy rate against severe rotavirus diarrhoea of
\n87% in a clinical study of 1986 infants in
\nVenezuela, Brazil, and Mexico, and is now
\nlicensed in Mexico, the Dominican Republic,
\nand Kuwait, although currently used only in
\nthe private market.APhase III trial of over 60
\n000 infants was carried out in Latin America
\nin 2003\u20132004, and efficacy results are
\nexpected soon. Phase III trials also are under
\nway in South Africa and Bangladesh.
\nRotaTeq, a vaccine developed by Merck,
\nprotected more than 95% of recipients from
\nsevere rotavirus diarrhoea in a clinical trial
\nof 1,946 infants in Finland. A Phase III trial
\nof more than 70,000 infants in the United
\nStates and European countries has been
\ncarried out to investigate safety, and a sub-
\nset of that group was followed to determine
\nefficacy. The results of these studies are
\nexpected by mid 2005. Trials in Asia and
\nAfrica \u2013 where different strains of the virus
\nmay predominate \u2013 are likely to start this
\nyear but may not be completed for several
\nyears.
\nRotavirus vaccines in earlier stages of
\ndevelopment include two vaccines spon-
\nsored by the United States National
\nInstitutes of Health; a neonatal vaccine
\ndeveloped by an Indian-US consortium;
\nand an Australian neonatal vaccine.
\nChallenges: A vaccine must be effective
\nagainst numerous rotavirus strains
\n(serotypes), including those prominent in
\ndeveloping countries. Large, stringent safe-
\nty trials are necessary because an earlier,
\nunrelated rotavirus vaccine appeared to
\ncause, in rare cases, a serious complication.
\nCandidate vaccines, since they are live,
\noral vaccines, must be shown not to inter-
\nfere with oral polio vaccine; and must be
\nshown to be safe in HIV-infected children.
\nPrice is also likely to be an issue.
\nProspects: Rotavirus vaccines will be
\nready for use in some additional countries
\nby 2006, but information on their effective-
\nness in Africa and Asia will not be avail-
\nable until 2008. They are expected to be
\nready for widespread use in immunization
\nprogrammes in Africa and Asia by 2009.
\nPneumococcal disease
\nAcute lower respiratory infections are
\nresponsible for two million deaths per year
\nand a large proportion of these are pneumo-
\ncoccal disease. A recent study (Cutts F. et
\nal., The Lancet 2005) in The Gambia indi-
\ncates that more than one third of these
\ndeaths might be caused by the bacterium
\nStreptococcus pneumoniae. Most victims
\nare children in developing countries.
\nDevelopment of new vaccines
\nPneumonia deaths far outnumber deaths
\nfrom meningitis. Nonetheless, in non-epi-
\ndemic situations, Streptococcus pneumoniae
\nis the main cause of meningitis fatalities in
\nsub-Saharan Africa; of those who develop
\npneumococcal meningitis, 40\u201375% either
\ndie or are permanently disabled. Children
\ninfected with HIV\/AIDS are 20\u201340 times
\nmore likely to contract pneumococcal dis-
\nease than children without HIV\/AIDS.
\nStatus of vaccine development: A seven-
\nvalent conjugate vaccine called Prevnar is
\ndesigned to act against seven strains of
\npneumococcal disease. It has been devel-
\noped by Wyeth and is licensed in the United
\nStates and several other countries, but does
\nnot include two serotypes (types 1 and 5)
\nthat cause a high percentage of pneumococ-
\ncal illness in developing countries.
\n(Conjugate vaccines, which have proved to
\nbe highly effective, are made by linking
\npurified polysaccharides \u2013 complex sugars
\n\u2013 from the coat of a disease-causing bacteri-
\num to a protein \u201ccarrier.\u201d) In the United
\nStates, use of this vaccine has led to a dra-
\nmatic decline in rates of pneumococcal dis-
\nease, not only in immunized children, but
\nalso in the un-immunized population
\nthrough reduced transmission. Wyeth has
\nnow completed evaluation of a nine-valent
\nconjugate vaccine, including serotypes 1
\nand 5. A Phase III trial of the vaccine
\ninvolving 40,000 people was completed in
\nSouth Africa in 2002, and a Phase III trial
\nwith 17,437 subjects was concluded in the
\nGambia in 2004. In the South African trial,
\nthe vaccine offered a rate of protection
\nagainst invasive disease caused by the rele-
\nvant serotypes of 83% in HIV-uninfected
\nchildren and 65% in HIV-infected children.
\nResults just released from The Gambia trial
\nshow the vaccine was 77% effective in pre-
\nventing infections caused by the relevant
\nserotypes; that it resulted in 37% fewer
\ncases of pneumonia (as confirmed by chest
\nX-ray) as compared with a control group;
\nand that recipients experienced a 16%
\nreduction in overall mortality. A vaccine
\ncontaining these nine serotypes with or
\nwithout additional serotypes is expected to
\nbe submitted for licensure within the next
\nthree to four years.
\nIn addition, two 11-valent vaccines for
\npneumococcal disease \u2013 developed by two
\ndifferent pharmaceutical firms \u2013 are under-
\ngoing evaluation.
\nChallenges: It can be difficult to establish
\nthe extent of pneumococcal disease as
\ndeveloping countries often lack the clinical
\nand laboratory facilities, the expertise, and
\nthe resources to do so. As a result, public
\nhealth decision-makers are often unaware
\nof the prevalence of the disease and of the
\ntoll it exacts in death and disability.
\nBecause of the scarcity of data from devel-
\noping countries, there is concern over
\nwhether the seven- and nine-valent vac-
\ncines contain the serotypes appropriate for
\nall countries. Concerns remain \u2013 although
\nresults to date are encouraging \u2013 that pre-
\nvention of some serotypes of pneumococcal
\ndisease may lead to increased incidence of
\nother serotypes. The price of the vaccine,
\nalthough still to be set for developing coun-
\ntries, may be too high for them to afford
\nwithout special financing arrangements.
\nProspects: A vaccine providing effective
\nprotection against pneumococcal disease
\nfor young children in developing countries
\nmay be ready for use in 2008\u20132009, and
\ncould be introduced in such countries pro-
\nvided adequate supply and financial help
\nare arranged.
\nHuman Papillomavirus (HPV)
\nSexually transmitted HPV is the major
\ncause of cervical cancer, the most common
\ncause of cancer deaths among women in
\ndeveloping countries. About 500,000 cases
\noccur each year, 80% of them in developing
\ncountries. Cervical cancer kills some
\n240,000 women annually.
\nStatus of vaccine development: Phase III tri-
\nals are under way of two commercial vac-
\ncines, each given in three doses. One, devel-
\noped by Merck, covers four types of HPV,
\nincluding the cancer-causing types 16 and
\n18 and types 6 and 11 for non-cancerous
\ngenital warts. The multi-year Merck trial,
\nwith an enrolment of over 25 000 women, is
\nexpected to conclude this year. The second
\nvaccine, developed by GSK, covers HPV
\ntypes 16 and 18 alone. The GSK trial began
\nin 2004, has an enrolment of about 30000
\nwomen, and is still under way.
\nResults of a Phase II trial on a monovalent
\ntype 16 vaccine were published by Merck
\nin 2002. GSK published Phase II results of
\nits bivalent type 16 and 18 vaccine in 2004.
\nBoth studies indicate that the candidate
\nvaccines are well-tolerated; that they are
\nhighly immunogenic (produce antibodies);
\nthat they are greater than 90% effective in
\nprotecting against the relevant viral infec-
\ntions; and that they offer virtually complete
\nprotection against persistent infections by
\nthe target viruses.
\nChallenges: HPV types 16 and 18 cause
\n70% of HPV cervical cancers, but the vac-
\ncines in development will not cover the
\n30% of cancers attributed to other HPV
\ntypes. Because these other types are numer-
\nous, significantly expanding vaccine cover-
\nage against them may present technical
\nchallenges for manufacturers. The duration
\nof the immunity conferred by the vaccines
\nis not yet known, but studies are planned
\nthat will look at this question. Because
\nHPV is spread by sexual contact, and the
\nhigh-risk years for infection are roughly
\nfrom ages 18 to 25, the best subjects for
\nvaccination will likely be pre-adolescents
\nor adolescents, unlike for traditional vacci-
\nnation programmes, which are aimed most-
\nly at infants and pregnant women. Access to
\nthe vaccines is likely to be an issue in
\ndeveloping countries due to limited
\nresources for the implementation of vacci-
\nnation programmes.
\nProspects: Both vaccines may be licensed
\nwithin one or two years in the United
\nStates and Europe. Discussions are ongo-
\ning about collecting the necessary data for
\nintroducing the vaccines into developing
\ncountries. Their systematic use in develop-
\ning countries may well depend on local
\nepidemiology, acceptability, financial
\nresources, and the feasibility of vaccinating
\nadolescents.
\nMeningococcal meningitis A (Men A)
\nThe African \u201cmeningitis belt\u201d \u2013 which
\nincludes all or part of 21 countries stretch-
\ning south of the Sahara desert from Senegal
\nto Ethiopia \u2013 is the site of frequent epi-
\ndemics, usually caused by serogroup A
\nmeningitis. Over the past decade more than
\n700,000 cases have been reported. Roughly
\n10\u201320% of persons infected die, and one
\nout of five survivors is likely to suffer from
\na permanent disability such as hearing loss,
\nMedical Science, Professional Practice and Education
\n74
\nmental retardation, or paralysis. The rate of
\nmeningitis epidemics in the region has
\nincreased in recent years.
\nStatus of vaccine development: Polysaccha-
\nride vaccines (vaccines made from complex
\nsugars taken from the outer coats of the
\nMen bacterium) are currently in use, but are
\nnot very effective at protecting young chil-
\ndren, do not create long-lasting immunity,
\nand do not confer a \u201cherd effect\u201d \u2013 that is,
\ndo not prevent spread of the disease in non-
\nvaccinated people through reduction of the
\ncarriage of the infectious agent by vaccinat-
\ned people during epidemics. Because of
\nthese shortcomings, immunization with
\npolysaccharide vaccines is usually under-
\ntaken only after the onset of an epidemic.
\nTo provide greater and more efficient pro-
\ntection, a public-private effort called the
\nMeningitis Vaccine Project (MVP) is
\ndeveloping a Men A conjugate vaccine.
\nThis vaccine is intended to have long-last-
\ning effect, to create immunity in infants,
\nand to allow protection to be conferred in
\nadvance through mass immunization pro-
\ngrammes. Toxicology studies and animal
\nstudies have been successfully completed,
\nand the animal studies suggest the conju-
\ngate vaccine is highly immunogenic \u2013 that
\nis, stimulates high levels of antibodies
\nagainst Men A infection. Phase I trials will
\nbegin in May 2005 in India.
\nOther conjugate vaccines, including a
\ntetravalent vaccine covering serogroups A,
\nC, Y, and W135, are being developed by
\nthe private sector; and a tetravalent vaccine
\nhas recently been licensed by Sanofi-
\nPasteur in the United States.
\nChallenges: Clinical development of the
\nMen A conjugate vaccine must still be car-
\nried out \u2013 it must be shown to be safe and
\neffective in humans in Phase I, II, and III
\ntrials. In addition, other meningococcal
\nmeningitis strains are circulating in Africa
\nwhich will not be controlled by a vaccine
\nfor serogroup A. One strain, referred to as
\nW135, has recently caused epidemics in
\nBurkina Faso and has become more preva-
\nlent, although its long-term potential as an
\nepidemic agent is not known.
\nProspects: A low-priced conjugate vac-
\ncine for Men A may be ready for wide-
\nMedical Science, Professional Practice and Education
\n75
\nspread use in the African meningitis belt
\nby 2008 or 2009, thanks to an innovative
\narrangement for development and produc-
\ntion. The vaccine was designed by the
\nCenter for Biological Evaluation and
\nResearch of the United States Food and
\nDrug Administration. The technology was
\nthen transferred without intellectual prop-
\nerty charges to the Serum Institute of
\nIndia, which carries out production at the
\nlower costs prevailing in a developing
\ncountry. The Serum Institute uses raw
\nmaterials (group A polysaccharides) sup-
\nplied by SynCo Bio Partners of the
\nNetherlands. The arrangement is expected
\nto keep costs as low as US$ 0.40 per dose,
\nmaking the vaccine affordable for low-
\nincome countries. Much of this vaccine-
\ndevelopment project was underwritten by
\na US$ 70 million grant from the Bill &
\nMelinda Gates Foundation.
\nWHO Initiative for Vaccine Research
\n(IVR)
\nThe WHO Initiative for Vaccine Research
\nwas established in 2001 to streamline the
\nvarious vaccine research and development
\nprojects being carried out by different
\ndepartments of WHO (including the
\nSpecial Programme for Research and
\nTraining in Tropical Diseases: TDR) and
\nUNAIDS. IVR also provides leadership,
\npriority setting, and coordination among
\nefforts worldwide to develop vaccines
\nagainst neglected diseases, particularly dis-
\neases endemic in developing countries. In
\naddition to collaboration within WHO, IVR
\nworks in close association with internation-
\nal organizations, philanthropic organiza-
\ntions, academic medical institutions, and
\nprivate- and public-sector partners active in
\nthe research and development of vaccines.
\nRobots on the Hospital Wards
\nIn a pilot scheme Remote Presence (RP6)
\nRobots are being tried out in a trial con-
\nducted in a General Surgery Ward and
\nAccident and Emergency Department in St.
\nMary\u2019s Hospital, London and for training
\npurposes, in the Academic and Clinical
\nSkills Unit at Imperial College, London.
\nThe robots are controlled with a joystick
\nfrom a remote site and, via the machine and
\nusing wireless technology, permit the doc-
\ntor to see the patient, ask questions and read
\npatient notes, view x-rays and test results
\nfrom the console. The patient can see the
\ndoctor\u2019s image on the robot\u2019s face.
\nParv Sains, Surgical Specialist registrar and
\nResearch Fellow, who leads the project,
\nsaid benefits include allowing patients
\ndirect access (for consultation) to experts
\nworldwide and to the doctor who per-
\nformed their surgery even if they cannot be
\nphysically at the patient\u2019s bedside.
\nDr. Sains said:
\n\u201cOur robots certainly would never replace
\nall doctors on ward rounds, but they are a
\ncommunication tool with allows doctors to
\nhave direct contact with their patient if they
\nare unable to get to them.\u201d
\nThe RP6 was developed by In Touch
\nHealth, a US robotics company. Trials of
\nthe robots are taking also place in the UAA
\n(3) and in Strassbourg (1).
\nThe robot runs on a wireless system with
\nthe doctor at another location. It is con-
\ntrolled by a secure internet connection, the
\ndoctor (controller) and patient are able to
\nhave a real time two way audiovisual inter-
\naction, with the controller in full command
\nof the robot\u2019s movements.
\nThis first trial in the United Kingdom is the
\nlatest strand in pioneering integration of
\nrobots into healthcare Professor Sir Ara sur-
\ngeon at St. Mary\u2019s Hospital, who is the
\nhead of Imperial\u2019s Division of Surgery,
\nAnaesthetics and Intensive care.
\nProfessor Darzi added \u201cThis revolutionary
\nconcept which opens new avenues for
\ntelemedicine research an integrates technol-
\nogy with healthcare at the grass roots level,
\nincreasing the interface between patients,
\nclinicians and teaching staff.\u201d
\nFour genes on chromosome 8 have been
\ndiscovered by Professor Caldas and his
\nresearchers at Cambridge University which
\nappear in breast cancer tumours but not in
\nnormal tissue. During the 1990s defects in
\nthe breast cancer tumour suppressor genes
\nwere established as the major cause of
\nhereditary or familial breast cancer. Now
\nmutations of genes within tumours have
\nbeen discovered linking cancer to the envi-
\nronmental and non-hereditary forms of
\nbreast cancer. Nevertheless scientists are
\nstill puzzling over why these genes are so
\nrarely mutated in sporadic forms of the dis-
\nease, which represent the vast majority of
\ncases.
\nAggressive tumours
\nWhy should breast cancer, in terms of its
\nmetastasis, be so aggressive in its attack on
\nother organs when its cells are transported
\nround the body? The disease is known to be
\ntriggered by faulty genes, and now we have
\nthe technology to isolate rogue gene muta-
\ntions in tumours from hundreds of other
\ngenes which are also present. Making mul-
\ntiple copies of gene sequences could lead
\nultimately to sensitive diagnostic tests for
\ncancer and treatments that work far more
\neffectively.
\nAccording to Professor Tony Kouzarides of
\nCancer Research UK, a protein binding on
\nthe BRCA2 breast cancer gene, in a region
\ndeleted in cancer, might itself be involved
\nin the cancer process. Such a gene, known
\nas EMSY, has been mapped to a large
\nregion on chromosome 11, at q13.5, which
\nis amplified in many breast cancers. An
\nantibody has been raised against EMSY
\nwhich could mean further diagnostic
\nprogress, but to date the gene hasn\u2019t been
\npersuaded to over-express itself or been
\nknocked out by a new technique known as
\nRNA interference. However it has been
\nshown to be involved in DNA repair and in
\ntranscriptional control. A search of
\nBRCA2\u2019s lengthy DNA sequence could
\nreveal similarities to other known genes,
\nMedical Science, Professional Practice and Education
\n76
\nDetection Of Faulty Genes In Breast Cancer
\nwhich would provide clues as to its func-
\ntion. It turned out that there was a similari-
\nty between a small region of BRCA2 and a
\ntranscription factor. Such a finding is clini-
\ncally important, because it is known that
\nthis sequence in BRCA2 is deleted in
\npatients with familial breast cancer.
\nMapping studies confirmed that the func-
\ntion of the EMSY gene lay in the binding of
\nmethylated chromatin in the chromosome,
\nwhich links EMSY to specific signals
\nrecognised by the nuclear transcription
\nmachinery.
\nEMSY as a cancer gene
\nProfessor David Huntsman\u2019s group in
\nVancouver have analysed very large num-
\nbers of tumour samples. EMSY was ampli-
\nfied in 13% of breast cancers and 17% of
\novarian cancers \u2013 another particularly
\naggressive tumour \u2013 with a clinical profile
\nthat perfectly mirrored deletions of BRCA2
\nin hereditary cancers. It was found that
\nbreasts cancer patients, in whose tumours
\nEMSY was amplified, lived on average for
\na further 6.4 years, compared with 14 years
\notherwise, which suggests that EMSY has
\nthe potential when cloned up to be a very
\nuseful prognostic marker.
\nIvan M. Gillibrand
\nIAEA Programme of Action for Cancer Therapy (PACT)
\nBuilding Capacity for Radiation Therapy in
\nDeveloping Countries
\nWerner Burkart, G. Gellert, M.D. Rosenthal, Massoud Samiei, Susan Snyder
\nand Bhadrasain Vikram
\nAbstract
\nWorld Health Organization (WHO) data
\npredict a growing cancer epidemic, espe-
\ncially in the developing world. In 2003,
\nWHO issued a global call to action to
\naddress increasing cancer needs. The
\nInternational Atomic Energy Agency
\n(IAEA) answered this call in June, 2004,
\nand established the Programme of Action
\nfor Cancer Therapy (PACT). The IAEA has
\nlong standing experience in developing
\ncountries with the delivery of technical
\nassistance related to cancer detection and
\ntreatment through nuclear technologies.
\nPACT is designed to respond to the needs of
\ndeveloping countries by addressing the
\ntechnical, human resource, legal, and regu-
\nlatory needs to establish, improve, or
\nexpand radiotherapy programs in the con-
\ntext of sound national cancer control
\nstrategies. PACT invites organisations
\nsharing this interest in advancing cancer
\ncontrol in developing nations to partner
\nwith the IAEA and others in a global effort
\nto respond immediately and effectively to
\nthe WHO call to action.
\nCancer in the Developing
\nWorld
\nCancer is a global problem today, and its
\nprevalence will increase dramatically over
\nthe next decade, especially in the developing
\nworld. According to the World Health
\nOrganization (WHO), 12.5% of all deaths
\nworld-wide are currently caused by cancer, a
\ngreater percentage than caused by
\nHIV\/AIDS, tuberculosis, and malaria com-
\nbined. (1) And while cancer is often viewed
\nas primarily a disease affecting the advanced
\nindustrialized states, where it is already the
\nsecond leading cause of death, it is among
\nthe three leading causes of death for adults in
\nthe developing world. (1)
\nBased on recent incidence and mortality
\ndata, in 2000, there were 10.1 million new
\ncancer cases, 6.2 million deaths and 22.4
\nmillion persons living with cancer. (2) This
\nrepresents an increase of 19% in incidence
\nand 18% in mortality since 1990. The
\nInternational Agency for Research on
\nCancer (IARC) data predict that cancer rates
\ncould further increase by 50% from 10 mil-
\nlion new cases in 2000 to 15 million new
\ncases by 2020. (1) The largest rates of
\nincrease of new cases are foreseen to occur
\nin developing countries, where governments
\nare least prepared to address the growing
\ncancer burden. (1) This dramatic increase
\nwill result, in part, from changing demo-
\ngraphics with steadily aging populations in
\ndeveloping countries, as well as current
\ntrends in smoking prevalence and the grow-
\ning adoption of unhealthy lifestyles and
\nbehaviours. (2)
\nCancer varies between developing and
\ndeveloped nations in both incidence and site.
\nCancers associated with infectious agents,
\nincluding cancers of the stomach, uterine
\ncervix, and liver, impact more heavily on
\npopulations in developing countries. (2) The
\ndeveloped world has a higher incidence of
\ncolorectal and prostate cancers. The differ-
\nences are attributable to many factors,
\nincluding tobacco use and diet. (2) Up to 25
\npercent of malignancies in the developing
\nworld are caused by infectious agents, while
\nin developed countries these malignancies
\naccount for only about 8 percent. (2) This
\ndifference is especially large for cervical
\ncancer. In developed countries, early detec-
\ntion has led to impressive cure rates, to such
\nthat among cancer deaths, the death rate
\nfrom cervical cancer is more than 4 times
\nhigher in the developing world than it is in
\ndeveloped countries.
\nTobacco use, a leading cause of cancer,
\nstroke, chronic lung, and cardiovascular
\ndisease, is also on the increase in the devel-
\noping world. In the 20th
\ncentury, approxi-
\nmately 100 million people died from tobac-
\nco-related diseases, including cancer. (3)
\nAlmost half of all men in developing coun-
\ntries now smoke, and the tendency of youth
\naround the world to start smoking at
\nyounger and younger ages is alarming. (4)
\nThe data are unequivocal: a cancer epidem-
\nic is emerging in the developing world.
\nAction to stem the increase, manage the
\ngrowing burden of morbidity, and reduce
\nthe suffering caused by cancer in the devel-
\noping world should begin immediately.
\nIndeed, the World Health Organization has
\ncalled for action from all sectors, public and
\nprivate, in a global effort against cancer.
\nThe International Atomic Energy
\nAgency and Promotion of Human Health
\nand Development
\nThe International Atomic Energy Agency
\n(IAEA) is highly regarded for its successful
\nlong-term effort in safeguarding nuclear
\nmaterial and preventing nuclear prolifera-
\ntion. The IAEA is less well known for
\nadvancing development in the areas of agri-
\nculture, nutrition, water, and health. Since its
\ninception, the IAEA has had a dual mandate:
\ncontaining the spread of nuclear weapons
\nwhile advancing the peaceful application of
\nnuclear sciences and technology. Over the
\npast five decades, nuclear applications have
\nexpanded to become an almost ubiquitous
\nfactor in daily life, especially in the devel-
\noped world. Around the globe, nuclear tech-
\nnologies are used widely to support industri-
\nal applications and to combat disease, pover-
\nty, hunger and a shortage of drinking water.
\nRadiation medicine, including the diagnosis
\nand treatment of cancer, is an area where
\nthe IAEA has excelled in the past 50 years.
\nThe IAEA is the only international organi-
\nsation with the specific mandate to \u201caccel-
\nerate and enlarge\u201d (5) the use of nuclear and
\nradiation techniques for the prevention,
\ndiagnosis, and treatment of health prob-
\nlems. Nuclear techniques play a major role
\nin modern medicine. They are important
\ntools for the diagnosis and treatment of
\nmany diseases and are indispensable in
\nfighting cancer, where radiation therapy
\nplays a fundamental role. Alone or in com-
\nbination with surgery and\/or chemotherapy,
\nradiation therapy is recommended for the
\nmajority of cancer patients, although this
\ncan vary by country or region.
\nThe IAEA has solid technical and manage-
\nrial experience in working in developing
\ncountries over the past 30 years to develop
\nand deploy essential elements of sound can-
\ncer management programmes. Since 1980,
\nthe IAEA has delivered to developing coun-
\ntries some $150 million worth of cancer-
\nrelated assistance under its Technical
\nCooperation programme. This assistance
\nhas involved over a 100 countries and has
\nenabled many of them to establish for the
\nfirst time safe and effective radiotherapy
\ncapabilities. (Figure 1 \u2013 World Map show-
\ning IAEA assistance in RT transfer)
\nHowever, in order to meet the ever growing
\nneeds placed on developing countries by
\nthe burgeoning cancer epidemic, much
\nmore needs to be done. More staff needs to
\nbe trained, diagnostic and treatment tech-
\nnology needs to be in place, and at least
\nhundreds of millions of additional dollars
\nneed to be raised over the next 10 years.
\nAlthough it is anticipated that the IAEA\u2019s
\nsupport for cancer programmes will remain
\nsignificant, at about $15 million per year,
\nthe resources available to the IAEA fall
\nwell short of what is needed to meet the
\ngrowing needs of developing countries.
\nProgramme of Action for Cancer
\nTherapy (PACT)
\nIn the light of rapidly increasing rates of
\ncancer in the developing world, in June,
\n2004, the IAEA launched a Programme of
\nAction for Cancer Therapy (PACT). This
\nnew programme offers a crucial element in
\nthe global response to the growing cancer
\nburden. Radiotherapy is a mature, robust
\nand cost-effective technology that can,
\ndepending on stage of presentation, cure
\nmany cancer patients and relieve many oth-
\ners\u2019 suffering. Currently, radiotherapy is not
\navailable to most cancer patients in the
\ndeveloping world.
\nPACT is designed to respond to the needs of
\ndeveloping countries by addressing the
\ntechnical, human resource, legal, and regu-
\nlatory needs to establish, improve, or
\nexpand radiotherapy programmes in the
\ncontext of sound national cancer control
\nstrategies. PACT will develop a systematic,
\nglobal, sustainable and accountable pro-
\ngramme to prevent and treat cancer and
\nMedical Science, Professional Practice and Education
\n77
\nrelieve the pain and suffering of cancer
\npatients throughout the developing world.
\nSpecifically PACT will: (a) build an inter-
\nnational, public-private coalition of inter-
\nested parties committed to addressing the
\nchallenge of cancer in developing countries
\nin all of its aspects; and (b) mobilize
\nresources from foundations, charitable
\ntrusts, industry and others in the public and
\nprivate sectors for the benefit of cancer
\npatients. PACT will build partnerships
\namong countries, with other UN institutions
\nsuch as WHO and IARC, and other interna-
\ntional stakeholders. In addition to securing
\nresources for radiotherapy centres, PACT
\nwill respond to the most frequent problems
\nencountered by developing countries in
\nbuilding effective cancer control infrastruc-
\nture. In order to assist countries in the
\nanalysis of options and to put in place can-
\ncer therapy programmes appropriate to
\ntheir needs: PACT will:
\n\u2022 Increase capacity within ministries of
\nhealth and other health sector institutions,
\nto formulate policies and set priorities for
\ninvestments in radiotherapy. According to
\nWHO, \u201cmany policy makers do not
\nattach enough importance to the provi-
\nsion of good radiotherapy.Although it has
\na strong clinical background, its role has
\nnot been understood as well as other can-
\ncer treatment modalities such as surgery
\nand chemotherapy.\u201d(6)
\n\u2022 Provide training, management skills and
\nother resources that will help institutions
\nleverage the initial investments in trained
\nstaff and equipment towards safe, effec-
\ntive, and sustainable operations.
\n\u2022 Promote the development and imple-
\nmentation of effective, well balanced
\nnational strategies for cancer control,
\nincluding generation of surveillance data
\nto ascertain local cancer disease bur-
\ndens, care needs, and outcomes.
\n\u2022 Enhance technical, legal and administra-
\ntive capabilities to establish and imple-
\nment regulatory systems, including
\nthose appropriate for radiation protec-
\ntion, safety and security.
\nSpecifically, PACT will meet the needs of
\ndeveloping countries because it will:
\n\u2022 Strengthen national programmes for
\ncancer control.
\n\u2022 Enable health sector institutions to
\ndesign and support the implementation
\nof policies and projects for the sound
\napplication of radiation therapy.
\n\u2022 Establish radiotherapy centres in each
\ndeveloping country appropriate to its
\nneeds and national cancer control strate-
\ngy, taking into account economic and
\ndemographic factors.
\n\u2022 Establish centres of excellence for radia-
\ntion therapy that will serve as training
\nsites for regions served by PACT.
\n\u2022 Review the status of radiation protection,
\nsafety, and security arrangements at
\nnational and local levels, and, as needed,
\nhelp nations put in place the technical,
\nlegal, and regulatory capacities appropriate
\nto take best advantage of radiation therapy.
\n\u2022 Promote strategic partnerships between
\ncountries in cancer therapy and in their
\nnational research, education, and regula-
\ntory systems at the sub-regional and
\nregional levels; between national and
\ninternational organizations; and between
\nthe public and private sectors that are
\nboth South-South as well as North-South.
\nMost importantly, the investment of signif-
\nicant resources to advance cancer preven-
\ntion and therapy in developing countries
\nwill save untold lives and relieve suffering.
\nCall To Collaboration
\nPACT invites organisations sharing this
\ninterest in advancing cancer care in develop-
\ning nations to partner with the IAEAand oth-
\ners in a global effort to respond immediately
\nand effectively to the WHO call to action.
\nPACT seeks organisations with pertinent
\ndeveloping world experience and capability
\nin cancer control, including, but not limited
\nto radiation oncology, cancer screening and
\ndiagnosis, cancer prevention programmes,
\nfundraising, programme impact evaluation
\nand outcomes research. Interested parties
\nshould contact PACT at PACT@iaea.org to
\nlearn more, or volunteer support.
\nReferences
\n1. Global Action Against Cancer, World
\nHealth Organisation, International Union
\nAgainst Cancer (2005)
\n2. World Cancer Report, World Health
\nOrganization, International Agency for
\nResearch on Cancer (2003)
\nMedical Science, Professional Practice and Education
\n78
\n3. World Health Organization, Press
\nRelease, Geneva, 3 April 2003 \u201cGlobal
\nCancer Rates Could Increase by 50% to 15
\nMillion by 2020\u201d
\n4. Sener, Stephen F., \u201cDisease Without
\nBorders,\u201d CA A Cancer Journal for
\nClinicians (2005) Vol. 55
\n5. IAEA Statute, Article 2, \u201cThe Agency
\nshall seek to accelerate and enlarge the con-
\ntribution of atomic energy to peace, health
\nand prosperity throughout the world.\u201d
\nA Global Strategy for Radiotherapy: A
\nWHO Consultation, Clinical Oncology
\nWHO
\n79
\nThe World Health Organization (WHO)
\nRegional Committee for Africa comprising
\nhealth ministers from 46 Member States
\nhas declared tuberculosis an emergency in
\nthe African region – a response to an epi-
\ndemic that has more than quadrupled the
\nannual number of new TB cases in most
\nAfrican countries since 1990 and is contin-
\nuing to rise across the continent, killing
\nmore than half a million people every year.
\nThe declaration was made in a resolution
\nadopted today at the end of the Committee\u2019s
\nfifty-fifth session in Maputo, Mozambique.
\nThe resolution urges Member States in the
\nAfrican Region to commit more human and
\nfinancial resources to strengthen DOTS pro-
\ngrammes and scale up collaborative inter-
\nventions to fight the co-epidemic of TB and
\nHIV. These and other measures recom-
\nmended by the Committee encompass those
\nlaid out in a \u201cblueprint\u201d developed by the
\nglobal Stop TB Partnership, which calls for
\nUS $2.2 billion in new funding for TB con-
\ntrol in Africa during 2006-2007.
\n\u201cDespite commendable efforts by countries
\nand partners to control tuberculosis, impact
\non incidence has not been significant and
\nthe epidemic has now reached unprecedent-
\ned proportions,\u201d said WHO Regional
\nDirector for Africa, Dr. Luis Gomes
\nSambo. \u201cUrgent and extraordinary actions
\nmust be taken, or else the situation will only
\nget worse and the TB targets in the Abuja
\nDeclaration and the Millennium
\nDevelopment Goals will not be achieved.\u201d
\nIn the late 1970s and early 1980s, African
\ncountries like Tanzania, Mozambique and
\nMalawi were among the first to apply what
\nbecame the global TB control strategy now
\nknown as DOTS. But in the past 15 years,
\nTB incidence rates have soared in the
\nregion – to as high as four-fold in Malawi
\nand five-fold in Kenya, to cite some typical
\nexamples -due largely to the link with
\nHIV\/AIDS, poverty and weak health sys-
\ntems. Although countries have made efforts
\nto treat the rising tide of TB cases, they are
\nstill being outpaced by the epidemic.
\n\u201cIt is tragic that this disease has not been
\nbrought under control, because I am living
\nproof that TB can be effectively treated and
\ncured,\u201d said Nobel laureate Archbishop
\nDesmond Tutu, who along with former
\nSouth African President Nelson Mandela is
\na survivor of the disease. \u201cThe problem is
\nhuge and medical authorities cannot over-
\ncome it alone, they need help. A full course
\nof TB drugs that costs 15 dollars will save
\nthe lives of TB patients – and in the case of
\npeople who are co-infected with HIV,
\nextend their lives by precious years until
\nARVs become more widely available in
\nAfrica.\u201d
\nAmong the constraints to fighting the epi-
\ndemic cited in the Maputo meeting is the
\ninadequate financial support currently
\navailable for TB control. A large majority
\nof African countries that provided financial
\ndata to WHO in 2003 reported funding
\ngaps, including eight of the nine countries
\nwith the highest TB burden.
\nBut more financial resources alone will not
\nsolve the TB problem. Dedicated efforts
\nmust also be made to strengthen health sys-
\ntems and respond to the crisis of health
\nworkforce attrition in the region. The specif-
\nic actions called for by the Regional
\nCommittee to address the TB emergency are:
\n\u2022 improve the quantity and quality of staff
\ninvolved in TB control;
\n\u2022 rapidly improve TB case detection and
\ntreatment success rates with expanded
\nDOTS coverage at national and district
\nlevels;
\n\u2022 reduce the combined TB patient default
\nand transfer out rates to 10% or less;
\n\u2022 scale up interventions to manage TB and
\nHIV together, including increased access
\nto anti-retroviral therapy for TB patients
\nwho are co-infected with HIV, and to
\nchemoprophylaxis against TB for people
\nwith HIV;
\n\u2022 expand national TB partnerships, public-
\nprivate collaboration and community
\nparticipation in TB control activities.
\nIn the other four WHO regions of the world,
\nTB trends are either stable or in decline and
\nare on track to reach the MDG targets of
\nhalving TB prevalence and deaths by 2015.
\nWHO
\nWHO declares TB an emergency in Africa and
\nCalls for \u201curgent and extraordinary actions\u201d
\nto halt worsening epidemic
\nModels of Disease
\nGeneva 3 August 2005 \u2013 Statement
\nThe World Health Organization welcomes
\nthe pandemic influenza response modelling
\npapers published in the journals Science
\nand Nature 3rd
\nAugust 2005. This is work
\ndone by expert scientists using two differ-
\nent sets of assumptions. The models pro-
\nvide additonal information which will help
\nWHO and public health officials in our
\nMember States to improve pandemic
\ninfluenza preparedness planning.
\nBoth papers suggest that a combination of
\nearly, targeted use of antiviral medicines and
\nsocial distancing (measures such as can-
\ncelling mass gatherings and closing schools)
\ncan stop a pandemic, or at least slow its
\nspread. There would be significant practical
\nchallenges to implementing such measures,
\nbut the enormous social trauma and human
\nsuffering that an influenza pandemic could
\ninflict creates an obligation to thoroughly
\nexplore all proposals to limit this damage.
\nSeveral countries have already purchased
\nstockpiles of antiviral drugs and WHO has
\ntaken steps to establish an international stock-
\npile. National and international stockpiles of
\nantiviral drugs may be an essential compo-
\nnent of comprehensive international pandem-
\nic preparedness, that also includes vaccine
\ndevelopment and disease surveillance.
\nIf we have a chance to reduce the scale of a
\npandemic with antivirals and other public
\nhealth measures, the success of these inter-
\nventions will depend on effective disease
\nsurveillance and early reporting in risk-
\nprone countries. Before any stockpile can
\nbe used effectively, both must be strength-
\nened.
\nWHO
\n80
\nTo combat Indonesia\u2019s largest recorded
\npolio epidemic, which now threatens a
\nbroad swath of countries across Asia, on 30
\nAugust, 24 million children were to be
\nimmunized during the country\u2019s largest-
\never mass immunization campaign.
\nSince March, 225 children have been paral-
\nysed, due to a poliovirus imported into the
\ncountry earlier this year. Initially restricted
\nto two provinces on Java island (Banten
\nand West Java provinces), the outbreak is
\ngeographically expanding, recently infect-
\ning the country\u2019s capital Jakarta, as well as
\nSumatra and Central Java.
\n\u201cIn addition to paralysing children through-
\nout Java and southern Sumatra, the outbreak
\ncontinues to expand, and there is great risk
\nthat it could spread into neighbouring coun-
\ntries,\u201d confirmed Dr David Heymann,
\nRepresentative for Polio Eradication at the
\nWorld Health Organization (WHO), who
\nrecently returned from Jakarta. \u201cAs with
\nother infectious diseases, the poliovirus does
\nnot respect borders. The Government of
\nIndonesia has assured the polio partners that
\nit is fully engaged and committed to stop-
\nping this outbreak, and to doing everything
\nit can to prevent further international spread
\nof the virus.\u201d
\nThe polio eradication partnership is urgent-
\nly scaling-up both technical and financial
\nassistance to the Indonesia authorities.
\nLeading the civil society sector charge is
\nRotary International, which has raised
\nmore than US$600 million for polio eradi-
\ncation since 1985.
\n\u201cWe are more than ever committed to the
\nattainment of a polio-free world,\u201d com-
\nmented Frank J Devlyn, Chairman, The
\nRotary Foundation. \u201cConcerned Rotarians
\nare mobilising across Asia. Rotarians from
\nMalaysia, Thailand and Singapore are join-
\ning their fellow Rotary members in
\nIndonesia in supporting these important
\nactivities.\u201d
\n\u201cReaching every, single child requires a
\nmassive communication effort, in high-
\nlighting to parents the dangers of the cur-
\nrent polio outbreak and of the need to
\nimmunize every child,\u201d said Alan Court,
\nDirector of UNICEF\u2019s Programme
\nDivision. \u201cThis is our best chance to pro-
\ntect Indonesia\u2019s children, safeguard vulner-
\nable children across the region, and keep a
\npolio-free world within our sight.\u201d
\nThe campaign on 30 August will be fol-
\nlowed by additional immunization rounds
\non 27 September and early November.
\nIndonesia launches country\u2019s largest-ever
\nimmunization campaign to tackle expanding
\npolio epidemic
\nPartnerships Working for Health Forum
\nIn announcing a WHO Forum on
\nPartnership, WHO states that the proposed
\ntheme will be \u201cMaking Partnerships work
\nfor Health\u201d, with subsidiary illustrative
\nthemes of \u201cPreventing Chronic Diseases\u201d,
\n\u201cHuman Resources for Health\u201d and
\n\u201cMaking every mother and child count\u201d \u2013
\nthe theme of this year\u2019s World Health report
\nand World Health Day.
\n\u201cHuman resources for Health\u201d is the sub-
\nject of the World Health report and World
\nHealth Day in 2006, which will also mark
\nthe beginning of a decade of action on this
\ntheme. The WHO, which, for the first time
\nhas offered open consultation encouraging
\nbroad participation on the 2006 World
\nHealth report theme via e-mails and the
\nweb, stresses that the WHO workforce is
\ncrucial to scaling up health interventions to
\nmeet the MDG health goals. Pointing out
\nthat a common problem is overall health
\nworkforce shortage, it says that this is
\naggravated by in-balanced distribution
\nbetween urban and rural areas. This all
\nleads to low productivity and is made worse
\nby inadequate investment and pre-service
\ntraining, work overload, inadequate remu-
\nneration and negative working conditions.
\nAn interim working group has already been
\nformed to explore workforce problems fac-
\ning leaders, which call for long term strate-
\ngies and high level commitment.
\nThe Forum, to be held on 26-28 October,
\nwill involve UN organisations, NGO\u2019s, pro-
\nfessional and research institutions, as well
\nas private sector entities.
\nGeneva \u2013 The World Health Organization
\nhas joined the United Nations in supporting
\nthe mean message of the Millennium
\nDevelopment Goals Report 2005: Despite
\nuneven progress towards achieving the
\nglobal development goals, they are still
\nachievable with determination, renewed
\ncommitment and immediate concerted
\naction from global leaders.
\nProgress on the health-related Millennium
\nDevelopment Goals (MDGs) is mixed and
\nif current trends continue, most poor coun-
\ntries will not meet these goals. However,
\ninvesting in proven solutions can still turn
\nthe tide and help to achieve the goals.
\n\u201cWe have the means to achieve those goals.
\nWe have the technology. What we need are
\nthe resources and the political will\u201d, said Dr
\nLEE Jong-wook, WHO Director-General.
\n\u201cWe cannot wait any longer to do what we
\nhave promised to achieve in the coming
\ndecade.\u201d
\nNo region of the developing world is cur-
\nrently on track to meet the child mortality
\ntarget of reducing by two-thirds the mortal-
\nity rate of children under the age of five.
\nFor maternal mortality, evidence indicates
\nthat declines have been limited to countries
\nwith lower levels of mortality; countries
\nwith high maternal mortality are experienc-
\ning stagnation or even reversals.
\nData on coverage of some health interven-
\ntions are more hopeful. For example, the
\nproportion of women who have a skilled
\nmedical person with them during delivery
\nhas increased rapidly in some regions \u2013
\nespecially in Asia, albeit from a low base-
\nline; use of insecticide-treated bednets has
\nrisen; and coverage of effective tuberculo-
\nsis treatment has expanded.
\nIn June 2005, WHO launched its own MDG
\nreport, Health in the Millennium
\nDevelopment Goals, which looks beyond
\nthe target-by-target information and identi-
\nfies trends, successes and failures which are
\ncurrently affecting the health sector as a
\nwhole.
\nIn September 2000, 189 world leaders
\nsigned the Millennium Declaration, and
\nmade a commitment to achieve the
\nMillennium Development Goals by 2015.
\nThree of the eight goals relate directly to
\nhealth: to reduce maternal mortality by
\nthree-quarters, child mortality by two-thirds
\nand combat HIV\/AIDS, malaria and other
\ndiseases. Health is an essential component
\nof three further targets: to halve the propor-
\ntion of people who suffer from hunger,
\nimprove access to safe drinking water and
\nsanitation and ensure affordable, safe
\naccess to essential drugs.
\nWHO
\n81
\nConcerted Action to Achieve The Millennium
\nDevelopment Goals
\nThe 6th
\nGlobal Conference on Health
\nPromotion. Thailand, 7-11 August, adopted
\na new Bangkok Charter for Health
\nPromotion. It identifies major challenges,
\nactions and the commitments needed to
\naddress the determinants of health in a
\nglobalized world by engaging the many
\nactors and stakeholders critical to achieving
\nhealth for all.
\nThe Charter highlights the changing con-
\ntext of global health and the challenges
\nfaced in achieving its aims, including the
\ngrowing double burden of communicable
\nand chronic diseases which include heart
\ndisease, stroke, cancer and diabetes. There
\nis also the need to address and harness the
\nhealth effects of globalization such as
\nwidening inequities, rapid urbanization and
\nthe degradation of environments.
\nThe Bangkok Charter gives new direction
\nto Health Promotion by calling for policy
\ncoherence, investment and partnering
\nacross governments, international organiza-
\ntions, civil society and the private sector to
\nwork towards four key commitments.
\nThese include ensuring that health promo-
\ntion is central to the global development
\nagenda, that it is a core responsibility of all
\ngovernments and part of good corporate
\npractice, as well as a focus of community
\nand civil society initiatives.
\n\u201cThe Bangkok Charter for Health
\nPromotion will be the product of many
\norganizations, networks, groups and indi-
\nviduals in many countries. It will urge all
\nstakeholders to work together in a world-
\nwide partnership to fulfill its commitments
\nand carry out its strategies,\u201d said Dr. LEE
\nJong-wook, Director-General of the World
\nHealth Organization in his opening address
\nto the conference. \u201cThe action you take in
\nthe light of this Charter can radically
\nNew Bangkok charter for health promotion adopted to address rapidly
\nchanging global health issues
\nA new project targeting the increasing
\nresistance of some viruses to drugs is being
\nfunded with the help of nine million euros
\nunder the Life Sciences, Genomics and
\nBiotechnology for Health area of the EU\u2019s
\nFramework Programme.
\nThe VIRGIL (Vigilance against Viral
\nResistance) project brings together experts
\nfrom 55 organisations in 12 European
\ncountries to examine the problems being
\nfaced in treating certain diseases. Many of
\nthese problems have been caused by heavy
\nuse of antivirals in treating viruses and this
\nis resulting in a growing number of muta-
\ntions in viruses that are becoming increas-
\ningly resistant to drugs.
\nVIRGIL draws on the experience of the top
\nacademic researchers within Europe as well
\nas the pharmaceutical industry, clinicians
\nand public health authorities to help save
\nlives by overcoming the problems associat-
\ned with viral drug resistance.
\n\u201cAcute and chronic viral infections repre-
\nsent a major public health problem in
\nEurope and are responsible for a major
\nsocio-economical burden\u201d, says Howard
\nThomas, Professor of Medicine at Imperial
\nCollege. \u201cThe development of new antivi-
\nral drugs and new diagnostic tools in the
\npast decade has played a major role in the
\nimprovement of patient care and treatment
\nof viral diseases to extend the quality and
\nduration of human life. However, their
\nincreased use \u2013 and sometimes misuse \u2013 in
\nmedicine have brought about viral drug
\nresistance. This has led to treatment failure
\nand increased costs for health care and soci-
\nety.\u201d
\nimprove the prospects for health in com-
\nmunities and countries around the world.\u201d
\nThe Charter was developed through an
\nopen consultation process involving partic-
\nipants from a wide range of groups and
\norganizations around the globe. The discus-
\nsion was concluded at the conference this
\nweek, attended by 700 participants from
\nmore than 100 countries including leading
\nHealth Promotion experts, government pol-
\nicy makers, non-governmental organiza-
\ntions, health specialists and representatives
\nfrom the private sector.
\nThe Ottawa Charter of 1986 established the
\ncore principles of Health Promotion which
\nseek to identify and positively affect the
\nroot causes, or determinants, of health.
\nThese are social and economic factors that
\ndetermine health status such as income,
\neducation, profession, working conditions,
\nmental status, which in turn can affect risk
\nfactors such as smoking, alcohol consump-
\ntion, eating habits and physical inactivity.
\nHealth Promotion works to enable people
\nto increase control over their health and its
\ndeterminants by developing personal skills,
\nembracing community action, and foster-
\ning appropriate public policies, health ser-
\nvices and supportive environments. Health
\nPromotion is currently guiding global,
\nnational and community health policies,
\nthereby contributing to reducing health
\nrisks. The WHO Framework Convention
\non Tobacco Control and The WHO Global
\nStrategy on Diet, Physical Activity and
\nHealth represent just two examples of such
\nactivity.
\nNevertheless major inequities persist glob-
\nally, particularly in the developing world.
\nSpeaking at the Bangkok conference,
\nProfessor Sir Michael Marmot, Chair of
\nWHO\u2019s Commission on the Social
\nDeterminants of Health, identified a funda-
\nmental concern: \u201cIt is not inevitable that
\nthere should be a spread of life expectancy
\nof 48 years among countries and 20 years
\nor more within countries. A burgeoning
\nvolume of research identifies social factors
\nat the root of much of these inequalities in
\nhealth.\u201d The challenge of the Bangkok
\nCharter has been to determine how best to
\nrespond to the many global changes and
\ntrends that are critically affecting health
\nRegional and NMA News
\n82
\nand well-being and how to evolve Health
\nPromotion strategies to address these
\ninequalities and to be more relevant to the
\ndemands of the new millennium.
\nThe conference has also examined many
\nissues pertaining to these challenges.
\nDiscussion ranged from trade agreements
\nand public health to the regulation of prod-
\nucts harmful to health, and from the health
\nexperience of marginalized groups to the
\nrole of private sector foundations. The con-
\nference proved a valuable forum for dis-
\nseminating results and lessons learnt of the
\neffectiveness of Health Promotion and how
\nto evolve these to better address ongoing
\ninequalities.
\nSpeaking at the opening ceremony of the
\nconference, the Prime Minister of Thailand,
\nH. E. Pol. Lt. Col. Dr. Thaksin Shinawatra,
\nnoted, \u201cIt is clear that good health is a key
\nto progress. In those societies where people
\nare healthy, such communities are sure to
\nprogress in many ways. Building health has
\nthus become a priority on national and
\nglobal agendas.\u201d
\nInformation contact:
\nMike Shaw
\nConference Communications Coordinator,
\nTelephone: + 66 9 534 5177
\nJane McElligott
\nCommunications Officer,
\nTelephone: +41 22 791 3353
\nEmail: mcelligottj@who.int
\nRegional and NMA News
\nEU Project Targets Killer Viruses
\n83
\nRegional and NMA News
\n\u201cAs there is no global programme to devel-
\nop strategies for the surveillance and con-
\ntainment of viral resistance to antiviral
\nagents, there is a clear need to implement a
\nEuropean programme to optimise patients
\ncare and to minimise emergence and spread
\nof antiviral drug resistance. The overall
\nobjective of the VIRGIL Network of
\nExcellence is to set up the first-ever
\nEuropean Vigilance Network capable of
\naddressing current and emerging antiviral
\ndrug resistance developments that will
\nallow for the management of this critical
\nproblem in Europe.\u201d
\nInitially, VIRGIL will be looking into drug
\nresistance in the treatment of three major
\ndiseases \u2013 hepatitis B and C and influenza.
\nResearch shows that more than 520 million
\npeople around the world are chronically
\ninfected by hepatitis viruses (B or C). In
\naddition, new strains of influenza cause up
\nto 500,000 deaths every year worldwide.
\nHowever, it is intended to broaden the viral
\nscope later in the project, to treat further
\ndiseases VIRGIL is being built around
\nseven \u201cresearch and technological plat-
\nforms\u201d all centred around the patients. Two
\nof them will test and monitor antiviral drug
\nresistance in patients with the aim of
\nimproving and standardising the manage-
\nment of viral resistance on a global level.
\nOther platforms will look to find the rea-
\nsons for the increasing drug resistance with
\nparticular focus on patient-related factors.
\nThe project will also investigate how drugs,
\npharmacology, innovation and technology
\ncan be brought together to anticipate ways
\nwhich will beat drug resistance.
\n\u201cViral resistance is becoming a major
\nhealth problem\u201d, says Claire Horton,
\nFP6UK\u2019s National Contact Point for Life
\nSciences, Genomics and Biotechnology for
\nHealth. \u201cThe VIRGIL project complements
\na 30 million Euro EU research investment
\ninto antimicrobial drug resistance over the
\npast two years to address this growing prob-
\nlem.\u201d
\ninformation on the VIRGIL project visit
\nhttp:\/\/www.virgil-net.org.
\nThe Canadian Medical Association reports
\nthat after a period during which there has
\nbeen a fall \u2013 off in the number of new grad-
\nuates choosing Family Medicine as a career
\nchoice, the latest figures indicate some
\nincrease. In the first quarter of this year the
\nresidency match indicated that 28% of
\ngraduating students from English language
\nmedical schools made family medicine
\ntheir first choice in 2005. Whilst this is far
\nfrom the 35% level achieved in 1997 it is
\nan improvement. It shows an improvement
\non the low of 24% two years ago. Dr.
\nGutkin Chief Executive of the College of
\nFamily Physicians of Canada said \u201cPublic
\nsurvey after public survey reinforces the
\nfact that patients value having a family
\ndoctor very highly and that Canadians see
\nthe shortage of FPs as one of the nation\u2019s
\nmain health system problems\u201d.
\nRecent polls indicate that more than three
\nmillion Canadians do not have a family
\nphysician.
\nFamily Medicine
\nrecruitment in
\nCanada
\nDevelopments in Kazakhstan (Kazakhstan
\nMedical Association)
\nThe Kazakhstan Medical Association
\n(KzMA) established in 1990, continues
\nits development not only by its represen-
\ntation on relevant governmental commis-
\nsions, influencing draft health legislation,
\nstate programmes and projects in health
\nand other professional activities, but also
\nby its strong interest and action in the
\nethics of biomedical research. It partici-
\npated in the Central and Independent
\nStates (CIS) Ethics Commission in 2001,
\nsuggesting the need for a Forum for
\nEthics Committees in the CIS which was
\nsubsequently adopted, and holding an
\ninternational conference on \u201cQualitative
\nEthical Practice in Biomedical Research\u201d
\nin 2002. This led to a further initiative,
\nthe Second International Conference in
\n2005 on \u201cBioethical Problems in Health
\nin the Twenty-first century\u201d. The out-
\ncome of this conference was a Resolution
\nrecommending that the Kazakhstan gov-
\nernment and other relevant institutions
\nshould institute the development of edu-
\ncational programmes on ethics and the
\nestablishment of an Ethics and Bioethics
\ncommittees. It further considered it nec-
\nessary to support cooperation on issues
\nrelating to the ethics of science and
\nbioethics with international organisations
\nsuch as the UNESCO, World Health
\nOrganization, the Council of Europe and
\nother Non-governmental organisations
\nsuch as the World Medical Association
\nand European Forum of Good Clinical
\nPractice etc. The KzMA has developed a
\ndraft Regulation on National Committees
\nfor Bioethics, which has been submitted
\nto the government.
\n84
\nThe Tobacco Control Resource Centre
\n(TCRC) run by the British Medical
\nAssociation and supported by the European
\nCommunity and the World Health
\nOrganisation has been awarded a Certificate
\nof Appreciation by the World Health
\nOrganisation, in recognition of its outstand-
\ning contribution to Tobacco Control.
\nThe TCRC is well known not only to NMAs
\nin the European Region but to NMAs
\nworldwide, both for its assistance to NMAs
\nindividually and its international seminars
\nlectures and research. TCRC has produced a
\nrange of important publications, in particu-
\nlar \u201cDoctors and Tobacco \u2013 medicine\u2019s big
\nchallenge\u201d (now translated into nine lan-
\nguages) and \u201cDoctors and Tobacco: The
\nMasterclass\u201d which includes the reports
\n\u201cSmoking and reproductive life\u201d, \u201cSmoke
\nfree World: doctors\u2019notes on clean air laws\u201d
\nand \u201cTowards smoke-free public places\u201d.
\nThe TCRC is based in the BMA Office in
\nEdinburgh e-mail: tcrc@bma.org.uk
\nRegional and NMA News
\nTCRC receives WHO Certificate of Appreciation
\nIt is unique in these columns to review a
\ncatalogue, but on this occasion the contents
\ncould be so useful to those working in any
\nfield of Healthcare provision, no matter in
\nwhich part of the world, that this review is
\nparticularly justified.
\nThe second publication by the WHO
\nEuropean Regional Office of the second
\nInformation Products Catalogue is a
\nremarkable document which could easily
\nbe overlooked by those who could benefit
\nfrom it. It provides bibliographic data,
\nincluding descriptions of the material avail-
\nable, categorised to reflect the WHO global
\ndatabase for 130 publications issued in
\n2003\/2004. But even more commendably,
\nthe full text of each publication is available
\nin the CD ROM which is attached to the
\ncatalogue.
\nThe scatter of topics is vast. The ready
\navailability of the full material of papers or
\nbooks in fields as variable as Chronic
\nDisease control, Communicable Diseases
\nand their control, Environmental and Public
\nHealth, Epidemiology and Statistics, Health
\nManpower and Planning, Mental Health,
\nParasitic Diseases and their control,
\nSmoking and Health (to mention but a few
\nof the diverse topics covered by the 18
\nbroad categories under which the 130
\nreports and books are classified) is indica-
\ntive of their potential value.
\nAnyone with an interest in any one of these
\nareas would be well advised to look at this
\ncatalogue and, if they so wish, access
\nimmediately any relevant documents
\nwhose full text is available in the CD ROM
\nprovided with the Catalogue.
\nReview
\nInformation Products Catalogue 2003, 2004
\n(WHO Regional Office for Europe, Copenhagen p. 47 + CD ROM)
\nWalter Burkart
\nIt is with great regret that we report the
\ndeath of Walter Burkart who was for many
\nyears the Co-Editor of the World Medical
\nJournal.Amulti-linguist, his comments on
\nthe international scene were clear and pen-
\netrating. In his activities he was particular-
\nly interested in psychiatry and in the pro-
\nvision of further medical education. The
\nearlier part of his career was as Editor and
\nBonn correspondent of The Hamburg Ad-
\nvertiser and later among many other activ-
\nities Publisher of the Social Press Service
\n\u201eBonn Social Politics\u201c Later he joined the
\neditorial staff in the scientific division \u2013 of
\nthe German Medical Journal (Deutsches
\n\u00c4rzteblatt) He was a good friend and
\ncolleague to all who knew and worked
\nwith him.
\nBomb explodes
\noutside NMA
\nbuilding
\nDuring the bomb incidents in London in
\nJuly, a bomb exploded in a bus immediate-
\nly outside the headquarters building of the
\nBritish Medical Association, killing 13
\npeople and injuring many more. Hospital
\ndoctors and GPs who were in the building,
\nled by the Deputy Chairman of Council and
\nthe Deputy Chairman of the General
\nPractice Committee, converted the building
\ninto an effective and efficient casualty unit
\nfor emergency care. Staff and doctors
\njoined together to comfort the injured, cre-
\nate makeshift stretchers and move the dead
\nand injured to the safety of the building.
\nThe Chairman of Council who is also
\nmember of WMA Council, commented
\n\u201cI want to pay a huge tribute to BMA staff
\nand doctors, who pulled together to help
\nthe victims of this atrocious terrorist act. I
\nbelieve that without the skills of our doc-
\ntors on the scene the death rate would have
\nbeen significantly higher.
\nIt is also a tribute to the organisation which
\nI am honoured to lead, that within a day
\nplans were made to keep services to mem-
\nbers functioning even though only a hand-
\nful of BMA staff and members were able to
\nget into our HQ for the next ten days\u201d.
\nCHINA E
\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 S
\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 F
\nOrdre des M\u00e9decins du Zaire
\nB.P. 4922
\nKinshasa \u2013 Gombe
\nTel: (242-12) 24589\/
\nFax (Pr\u00e9sidente): (242) 8846574
\nCOSTA RICA S
\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 E
\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 E
\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
\nCUBA S
\nColegio M\u00e9dico Cubano Libre
\nP.O. Box 141016
\n717 Ponce de Leon Boulevard
\nCoral Gables, FL 33114-1016
\nUnited States
\nTel: (1-305) 446 9902\/445 1429
\nFax: (1-305) 4459310
\nDENMARK E
\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 S
\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 S
\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 E
\nEgyptian Medical Association
\n\u201eDar El Hekmah\u201c
\n42, Kasr El-Eini Street
\nCairo
\nTel: (20-2) 3543406
\nEL SALVADOR, C.A S
\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 E
\nEstonian Medical Association (EsMA)
\nPepleri 32
\n51010 Tartu
\nTel\/Fax (372) 7420429
\nE-mail: eal@arstideliit.ee
\nWebsite: www.arstideliit.ee
\nETHIOPIA E
\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 E
\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 E
\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 F
\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 E
\nGeorgian Medical Association
\n7 Asatiani Street
\n380077 Tbilisi
\nTel: (995 32) 398686 \/ Fax: -398083
\nE-mail: Gma@posta.ge
\nGERMANY E
\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 E
\nGhana Medical Association
\nP.O. Box 1596
\nAccra
\nTel: (233-21) 670-510\/Fax: -511
\nE-mail: gma@ghana.com
\nHAITI, W.I. F
\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 E
\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 E
\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 E
\nIcelandic Medical Association
\nHlidasmari 8
\n200 K\u00f3pavogur
\nTel: (354) 8640478
\nFax: (354) 5644106
\nE-mail: icemed@icemed.is
\nINDIA E
\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 E
\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 E
\nIrish Medical Organisation
\n10 Fitzwilliam Place
\nDublin 2
\nTel: (353-1) 676-7273
\nFax: (353-1) 6612758\/6682168
\nWebsite: www.imo.ie
\nISRAEL E
\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 E
\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 F
\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 E
\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 E
\nKuwait Medical Association
\nP.O. Box 1202
\nSafat 13013
\nTel: (965) 5333278, 5317971
\nFax: (965) 5333276
\nE-mail: aks.shatti@kma.org.kw
\nLATVIA E
\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 E
\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 E
\nLithuanian Medical Association
\nLiubarto Str. 2
\n2004 Vilnius
\nTel\/Fax: (370-5) 2731400
\nE-mail: lgs@takas.lt
\nLUXEMBOURG F
\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
\nAssociation and address\/Officers
\niii
\nMACEDONIA E
\nMacedonian Medical Association
\nDame Gruev St. 3
\nP.O. Box 174
\n91000 Skopje
\nTel\/Fax: (389-91) 232577
\nMALAYSIA E
\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 E
\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 S
\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 E
\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 E
\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 E
\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 E
\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 E
\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 S
\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 S
\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 E
\nPhilippine Medical Association
\nPMA Bldg, North Avenue
\nQuezon City
\nTel: (63-2) 929-63 66\/Fax: -6951
\nE-mail: pmasec1@edsamail.com.ph
\nPOLAND E
\nPolish Medical Association
\nAl. Ujazdowskie 24
\n00-478 Warszawa
\nTel\/Fax: (48-22) 628 86 99
\nPORTUGAL E
\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 F
\nRomanian Medical Association
\nStr. Ionel Perlea, nr 10
\nSect. 1, Bucarest, cod 70754
\nTel: (40-1) 6141071
\nFax: (40-1) 3121357
\nE-mail: AMR@itcnet.ro
\nWebsite: www.cdi.pub.ro\/CDI\/
\nParteneri\/AMR_main.htm
\nRUSSIA E
\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 E
\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 E
\nSlovenian Medical Association
\nKomenskega 4
\n61001 Ljubljana
\nTel: (386-61) 323 469
\nFax: (386-61) 301 955
\nSOUTH AFRICA E
\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 S
\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 E
\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 F
\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 E
\nTaiwan Medical Association
\n9F No 29 Sec1
\nAn-Ho Road
\nTaipei
\nDeputy Secretary General
\nTel: (886-2) 2752-7286
\nFax: (886-2) 2771-8392
\nE-mail: intl@med-assn.org.tw
\nTHAILAND E
\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 F
\nConseil National de l\u2019Ordre
\ndes M\u00e9decins de Tunisie
\n16, rue de Touraine
\n1082 Tunis Cit\u00e9 Jardins
\nTel: (216-71) 792 736\/799 041
\nFax: (216-71) 788 729
\nE-mail: ordremed.na@planet.tn
\nTURKEY E
\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 E
\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 E
\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 E
\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 S
\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 F
\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 S
\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 E
\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 E
\nZimbabwe Medical Association
\nP.O. Box 3671
\nHarare
\nTel: (263-4) 791\/553
\nFax: (263-4) 791561
\nE-mail: zima@healthnet.zw<\/p>\n"},"caption":{"rendered":"

wmj7 WorldMedical Journal Vol. No.3,Septemer200551 OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC. G 20438 Contents Editorial Backward to the future? 57 Cardiovascular Research Advances 58 Comprehensive cover for modern medics 61 Medical Ethics and Human Rights Conference of experts on biological weapons 63 AMA position on Physician participation in Guantanamo Interrogations 67 WMA The […]<\/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\/wmj7.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3536"}],"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=3536"}]}}