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wmj13<\/a><\/p>\n

WorldMMeeddiiccaall JJoouurrnnaall
\nVol. No.1,March200753
\nOFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
\nG 20438
\nContents
\nEEddiittoorriiaall 1
\nMMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
\nHarmonization of Research Ethics
\nCommittees \u2013 are there limits? 2
\nMMeeddiiccaall SScciieennccee
\nBetter heart transplants
\nwill quadruple lives saved 3
\nPeople in Pain Confused About Pain Relievers
\nand Missing Out On Effective Treatment 4
\nMMeeddiiccaall EEdduuccaattiioonn
\nPatients with Alzheimer\u2019s disease may lack
\nthe mental capacity to give informed consent 8
\nWHO\/WFME strategic partnership
\nto improve medical education 8
\nNew on-line TB training course to be launched
\nby WMA on World TB Day 9
\nThe World Medical Association Statement
\non Medical Education 9
\nFFrroomm tthhee SSeeccrreettaarryy GGeenneerraall
\nHealth Professional Council of South Africa
\nannounces amnesty on restoration fees 11
\nWWoorrlldd MMeeddiiccaall AAssssoocciiaattiioonn
\nScientific Session \u201cHealth as an Investment:
\nLeadership and Advocacy\u201d 12 October 2006 12
\nThe Health Care System in Japan 15
\nThe World Medical Association Statement on
\nHIV\/AIDS and the Medical Profession 17
\nThe World Medical Association Statement on
\nAssisted Reproductive Technologies 20
\nWWHHOO
\nKey Issues for future WHO work 23
\nInternational action needed
\nto increase health workforce 23
\nAfrica Reports 24
\nNew report shows improvements
\nin child survival in Africa for the first time
\nsince the 1980s 25
\nWHO reports some promising results on avian
\ninfluenza vaccines 26
\nUN Global goal to reduce measles deaths in
\nchildren surpassed 27
\nWorld Leprosy Day 2007 28
\nAppeal to migrant physicians to return 28
\n00_US_01_2007.qxd 30.04.2007 09:39 Seite 1
\nWebsite: https:\/\/www.wma.net
\nWMA Directory of National Member Medical Associations Officers and Council
\nAssociation and address\/Officers
\nWMA OFFICERS
\nOF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
\ni see page ii
\nPresident-Elect President Immediate Past-President
\nDr. J. Snaedal Dr. N. Arumagam Dr. Kgosi Letlape
\nIcelandic Medical Assn. Malaysian Medical Association The South African Medical Association
\nHlidasmari 8 4th Floor MMA House P.O Box 74789
\n200 Kopavogur 124 Jalan Pahang Lynnwood Ridge 0040
\nIceland 53000 Kuala Lumpur Pretoria 0153
\nMalaysia South Africa
\nTreasurer Chairman of Council Vice-Chairman of Council
\nProf. Dr. Dr. h.c. J. D. Hoppe Dr. Y. Blachar Dr. K. Iwasa
\nBundes\u00e4rztekammer Israel Medical Association Japan Medical Association
\nHerbert-Lewin-Platz 1 2 Twin Towers 2-28-16 Honkomagome
\n10623 Berlin 35 Jabotinsky 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
\n01212 Ferney-Voltaire Cedex
\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: (54-11) 4381-1548\/4384-5036
\nE-mail:
\ncomra@confederacionmedica.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\/Fax: -933
\nE-mail: international@aek.or.at
\nREPUBLIC OF ARMENIA E
\nArmenian Medical Association
\nP.O. Box 143, Yerevan 375 010
\nTel: (3741) 53 58-68
\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 1857\/Fax: 323 2980
\nE-mail: mabnassau@yahoo.com
\nBANGLADESH E
\nBangladesh Medical Association
\nBMA Bhaban 5\/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
\nCalle Ayacucho 630
\nTarija
\nFax: (591) 4663569
\nE-mail: colmed_tjo@hotmail.com
\nWebsite: colegiomedicodebolivia.org.bo
\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\/Fax: -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 8610\/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: rdelcastillo@colegiomedico.cl
\nWebsite: www.colegiomedico.cl
\nTitle page: The National Hospital of Neurology, London (often referred to as \u201cthe National\u201d or Queen\u2019s Square\u201d). Founded in 1859, the many distinguished physicians who have wor-
\nked there include both J. Hughlings Jackson and C-E. Brown-Sequard, the hospital is internationally famed for its teaching and research. Now part of the UCL Hospital NHS Trust, it
\nis called The National Hospital for Neurology and Neurosurgery. This picture shows the early 20th century building now dwarfed by the much larger complex of buildings, one of
\nwhich is the Institute of Neurology next door (founded in 1950 and merged with University College, London 1997), with which it has retained links.
\nBelow: New building of the German Medical Association (Bundesaerztekammer) in Berlin. After very many years situated in Cologne, following the movement of the givernment and many
\nof the ministries from Bonn to Berlin, following the decision by its General Assembly to relocate in Berlin, in 2004 the Bundesaerztekammer moved into this fine new building in Berlin.
\nU2–4_WMJ_01_07.qxd 30.04.2007 09:38 Seite U2
\n1
\nOFFICIAL JOURNAL OF
\nTHE WORLD MEDICAL
\nASSOCIATION
\nHon. Editor in Chief
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSuffolk IP14 3QT
\nUK
\nCo-Editors
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2
\nD\u201350859 K\u00f6ln
\nGermany
\nDr. Ivan M. Gillibrand
\n19 Wimblehurst Court
\nAshleigh Road
\nHorsham
\nWest Sussex RH12 2AQ
\nUK
\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,
\nDieselstr. 2, P. O. Box 40 02 65,
\n50832 K\u00f6ln\/Germany,
\nPhone (0 22 34) 70 11-0,
\nFax (0 22 34) 70 11-2 55,
\nPostal Cheque Account: K\u00f6ln 192 50-506,
\nBank: Commerzbank K\u00f6ln No. 1 500 057,
\nDeutsche Apotheker- 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. 7 %
\nMwSt.). For members of the World Medical
\nAssociation and for Associate members the
\nsubscription fee is settled by the membership
\nor associate payment. Details of Associate
\nMembership may be found at the World
\nMedical Association website www.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nK\u00f6ln \u2013 Germany
\nISSN: 0049-8122
\nWherever one looks the medical profession it seems to be facing more and more problems
\ndespite, or sometimes due to, advances in medical science and their introduction into med-
\nical practice. They range from the global problems of human resources and health profes-
\nsionals including physicians, inequities in their distribution across the world, continuing
\nefforts to maintain standards for professional practice and ensuring maximum patient safe-
\nty, the changing face of medical practice with increasing emphasis on prevention, huge
\nincreases in the intrusion of management and administrative bureaucracy associated with
\nmedical practice both in hospitals and the communities.
\nAs these problems are addressed, it is vital that the profession in each country is seen to
\nhave considered them and prepared its own position, rather than reacting to short term poli-
\ncies proposed by others which may be neither in the best interests of the community, of
\nindividuals, or of the profession.
\nThe contents of this issue of WMJ reflects the diversity of both the positive developments
\nin medicine, science and in disease control, strategic plans and health policy developments,
\nas well as some of the problems which still need to be solved.
\nIt includes some further WMA policy statements, one of which, that on medical education, is
\nalso the subject of a report on a new strategic partnership between the World Health
\nOrganisation and the World Federation of Medical Education. There is also a report on the
\nfirst meeting of the Taskforce of the Global Health Workforce Alliance (GHWA) to seek prac-
\ntical solutions to the health workforce problems, including investment in education and train-
\ning of all healthcare workers. The WMA Secretary General comments on one particular effort
\nseeking to persuade physicians who have emigrated to return to practice in their own country
\nwhere there is a grave shortage of physicians. Another article addresses the problems of med-
\nical research ethics posing a question as to whether or not there are limits to the possible har-
\nmonisation of activities of ethical research committees. Two papers given at the WMA scien-
\ntific meeting in South Africa address the important topic of \u201cHealth as an investment\u201d
\nIn the context of the problems of shortage of physicians it is interesting to note the results
\nof a ten year cohort study of 545 of doctors who graduated in one country in 1995*. Of
\napproximately 1400 of the final year students who expressed willingness to participate in
\nthe survey, a sample of 600 were drawn and of these 545 participated in the questionnaire
\nwhich was sent to all participants each year for ten years. This was combined with focus
\ngroups which were random sub-samples each year, where questions could be more deeply
\nexamined. Apart from information on type of work, career choice and training, questions
\nwere asked about working conditions and about participants\u2019 attitudes to medicine as a
\ncareer, in the light of their experience year by year.
\nWhile all the results of this study are interesting, as will be those of the next ten year cohort
\nstudy, in the context of the debate on human health resources (particularly recruitment and
\nretention of physicians), it is interesting to note that in this study
\n\u2022 2 in every 5 doctors in the cohort study (40%) found that the reality of a career in medi-
\ncine was very different from that envisaged on graduation in 1995;
\n\u2022 While three quarters (75%) of the cohort doctors ten years after graduating were satisfied
\nwith practising medicine, a fifth (20%) reported a lukewarm desire to practice medicine.
\n\u2022 The rest (5%) had little or no desire to practise medicine. (3% of the cohort had left med-
\nicine during the 10 years of the study, the most common reason being dissatisfaction with
\nmedicine as a career.
\n\u2022 15% had changed their career choice during the study period, a key factor in this being
\n\u201chours of work and working conditions\u201d followed by working\/pay conditions.
\nWhile these findings are disturbing (20% having a weak desire to practice medicine after
\n10 years), when planning to educate more physicians to meet needs it is unfortunate that no
\nother countries have carried out comparable extensive cohort studies. If the profession is to
\naddress its future in the light of the problems it faces, then such studies could contribute
\nvaluable information in the formulation of such plans.
\nAlan Rowe
\n*BMA Cohort Study 10th
\nreport 2005
\nEditorial
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 1
\ning these this view it has served since the
\nage of Aristotle as a method of analysing
\nwhether handling of human beings by
\nresearchers is acceptable or not, as being
\n\u201cgood\u201d or \u201cbad\u201d. The methods of this analy-
\nsis can be harmonized, such as the examina-
\ntion of the scientific merit of research pro-
\njects or of their accordance with national or
\ninternational law. If there are positive
\nanswers to these questions, then the deci-
\nsion on the ethical acceptability is based on
\nthe question of \u201cgood\u201d or \u201cbad\u201d. For the
\nterms \u201cgood\u201d and \u201cbad\u201d there are no defin-
\nitions accepted worldwide. They are more-
\nover influenced by religion, tradition or
\neven different philosophical schools, which
\nmay differ even within a country and of
\ncourse, within the different regions of the
\nworld.
\nA recent example is the worldwide discus-
\nsion on the use of human embryonic stem
\ncells for research. Even in those countries
\nwhere the need for such type of research is
\naccepted, the ethical analysis, as mentioned
\nabove, may lead to the view that it should not
\nbe performed, as it is considered to be \u201cbad\u201d.
\nIn the discussion on the ethical acceptabili-
\nty of medical research, the expression
\n\u201cmedical ethics\u201d is widespread, assuming
\nthat in this way the diversity of ethics, as
\nmarked e.g. by utilitarism or transcendental
\nethics in the sense of Immanuel Kant, could
\nbe overcome. This attempt needs considera-
\ntion as to whether the term \u201cmedical ethics\u201d
\nis appropriate or not. The known general
\nethical principles such as respect for the
\nhuman being, beneficence, non-malefi-
\ncence (\u201cdo no harm\u201d) or justice, are basic
\nand leading guidelines for the whole life of
\nhuman beings in society. They may be, in an
\nappropriate way, applied to special fields
\ne.g. banking, or even medical research.
\nEverybody understands, that in financial
\ntransactions the principles \u201cdo no harm\u201d or
\n\u201cjustice\u201d are obligatory to prevent any kind
\nof betrayal or deception of the person con-
\nMedical Ethics and Human Rights
\n2
\nBiomedical research involving human sub-
\njects has to respect their autonomy, dignity,
\nidentity, integrity and other rights and fun-
\ndamental freedoms. Research ethics com-
\nmittees, initially established at the request
\nof national authorities such as the National
\nInstitute of Health (NIH) in the late sixties
\nin the USA, the \u201cDeutsche Forschungs-
\ngemeinschaft\u201d (DFG) 1973 in Germany and
\nsince 1975, part of the Declaration of
\nHelsinki, are universally charged with safe-
\nguarding these rights.
\nBiomedical research while initially per-
\nformed more on a national level is increas-
\ningly spreading out on an international or
\neven intercontinental field.. For this reason
\nresearchers and research institutions,
\nincluding the pharmaceutical industry (in
\nresearch a very important global player)
\nhave for a long time stressed the need for
\nthe harmonization of the decisions and the
\nprocedures of research ethics committees.
\nThe main argument concerns the suggestion
\nthat there should be only one \u201cmedical
\nethic\u201d in a country, in a continent or around
\nthe globe. On the basis of this assumption
\nall legal obstacles causing diversity of
\nethics committees such as different compo-
\nsition, different kinds of financing, different
\nways of decision making etc. should be
\nabandoned in favour of a \u201cunique, harmo-
\nnized research ethics committees\u2019 proce-
\ndure\u201d. Are these arguments applicable; is
\nthe diversity of ethics committees in differ-
\nent countries or in unions of states justified,
\nor only superficial?
\nFirst of all it must be recalled that the main
\ntask of an ethics committee is the multidis-
\nciplinary assessment of the ethical accept-
\nability of an envisaged research project.
\nThis raises the question of the character of
\nethics and its so often requested worldwide
\nuniformity.
\nEthics is, at least in the circles of experts,
\nunderstood as a part of philosophy. Follow-
\ncerned! The adaptation to special sectors
\nmay not deviate from the basic concept of
\nthe relevant ethical principles.
\nThe use of the term \u201cethics in medicine\u201d,
\nused by preference in some circles rather
\nthan \u201cmedical ethics\u201d is more than a seman-
\ntic suggestion. It underlines this general
\napproach to ethics and is therefore much
\nmore appropriate than \u201cmedical ethics\u201d,
\nwhich can be misunderstood and should be
\navoided, at least in multidisciplinary discus-
\nsions. It should be avoided, at least in a
\nmultidisciplinary discussions. It follows
\nfrom these considerations that ethics in
\nmedicine, so far as analytical methods are
\nconsidered, may be harmonized. The basis
\nof the decision to be taken by research
\nethics committees \u2013 \u201cgood\u201d or \u201cbad\u201d \u2013, can-
\nnot be standardized or harmonized. Any
\nother outcome would be surprising, imply-
\ning the same definition for \u201cgood\u201d and
\n\u201cbad\u201d around a world with differing reli-
\ngions, ethics, differing cultures\/social pat-
\nterns etc.?
\nIn contrast: by long tradition, discussions
\non \u201cgood\u201d and \u201cbad\u201d and conclusions on a
\nregional level are the basis for moral guide-
\nlines in any specific society. Professions
\nsuch as lawyers or physicians, are entitled
\nto contribute to these discussions and deci-
\nsion making for such an ethnic entity. But
\nno professional group has any right to pre-
\nscribe in isolation regulations for that enti-
\nty. This is another argument against profes-
\nsional based ethics or morals as binding
\nprovisions on all. Since in the work of pro-
\nfessions the rights of others have to be
\nrespected, profession linked ethics are not
\nnecessarily appropriate outside the profes-
\nsion.
\nUnavoidable diversity is the principal
\nobstacle to any kind of harmonization of
\nresearch ethics committees other than the
\nprocess leading to a decision, the decision
\nitself is not open to standardisation!
\nHarmonization of Research Ethics Committees \u2013 are there limits?
\nProf. Elmar Doppelfeld MD Chair of the Permanent Working Party of
\nGerman Research Ethics Committees
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 2
\nMedical Science
\n3
\nResearch ethics committees are, at least by
\ntradition, embedded into a national frame-
\nwork, which itself is influenced by religion,
\nhistory, tradition and the system of legisla-
\ntion of that country. In practice the protec-
\ntion of human rights and fundamental free-
\ndoms (even when, as in most cases, it is
\nguaranteed by the constitution of the state)
\nmay be influenced by juridical decisions of
\ncourts competent for constitutional law in
\ndifferent ways. There may exist on that
\nbasis a diversity of interpretations of e.g.
\n\u201cfree informed consent\u201d or conditions of its
\nexpression such as \u201csubstitution\u201d in place of
\nconsent of persons not able to do so, of data
\nprotection etc. Relevant decisions of the
\ncourts and national legislation have to be
\nfollowed in the regulation of ethics commit-
\ntees and their work. These differences
\nappear even in regions of the world with
\nmore or less common traditions.
\nIn preparing the Directive 2001\/20\/EU, the
\nEuropean Union tried to harmonize at least
\nthe administrative part of ethics commit-
\ntees. These attempts failed, and everybody
\nknows the results: Member states are
\nobliged to establish a system of research
\nethics committees which have to consider
\nthe usual international principles of ethical
\nassessment and to make a decision within a
\ngiven time. Nothing is said, for example,
\nabout conditions or interpretation of \u201cfree
\ninformed consent\u201d in the normal situation,
\nor in research in an emergency situation.
\nThe diversity in ethics has been identified
\nas the main obstacle to any kind of harmon-
\nisation or standardisation of the work and
\ndecision making of research ethics commit-
\ntees. The diversity in legal and administra-
\ntive provisions for these committees, them-
\nselves caused, at least in part by the ethical
\ndiversity, constitute a second obstacle.
\nIt is understandable, that researchers and
\nresearch institutions or sponsors (such as the
\npharmaceutical industry) are faced with that
\nsituation and have a special interest in over-
\ncoming it or at least living with it. In an
\nattempt to help in this situation, the
\nEuropean Forum for Good Clinical Practice
\n(EFGCP) recently published an overview on
\nthe \u201cProcedure for the ethical review of pro-
\ntocols for clinical research projects in the
\nEuropean Union\u201d (International Journal of
\nPharmaceutical Medicine, Vol. 21, No 1,
\n2007). This publication gives an excellent
\noverview of the ethics revue systems in 26
\nEuropean countries plus Switzerland and
\nNorway. The report provides an excellent
\noverview showing the different interpreta-
\ntions of the directive 2001\/20\/EG by the
\nmember states of the European Union. In
\nthis way it assists researchers to prepare
\nmultinational research projects within the
\nUnion, while respecting national provisions.
\nProf. Elmar Doppelfeld MD
\nChair of the Permanent Working Party of
\nGerman Research Ethics Committees
\nOttostra\u00dfe 12
\nD-50859 K\u00f6ln
\nTel. 00492234993237
\nFax 00492234993239
\ne-mail: med.ethik.komm@netcologne.de
\nDeath of a valiant defender of human
\nrights of prisoners.
\nThe death of Dr. Fusen Sayek, former
\nPresident of the Turkish Medical
\nAssociation, marks the loss of an out-
\nspoken opponent of torture and inhu-
\nmane conditions in prison.
\nIn particular during the 90’s she put
\nup a fierce battle against the inhu-
\nmane treatment of people in custody
\nin Turkey. Dr. Sayek died after a long
\nstruggle with cancer on 12th
\nFebruary
\n2007.
\nProfessor Bruce Rosengard, Papworth
\nHospital, Cambridge, has perfected a
\nmachine to pump sterile, oxygenated
\nblood, saline and nutrients through
\norgans for transplantation \u2013 especially
\nthe heart. For the last 25 years, hearts for
\ntransplant have been kept on ice, with
\ngradual deterioration, requiring an opera-
\ntion within 3-4 hours. Now using this
\nnew technique, organs in sub-optional
\ncondition can be resuscitated into action;
\nthey can be transported much greater dis-
\ntances, such as for example across
\nMedical Technology
\nBetter heart transplants will quadruple lives saved
\nAmerican or Australia; and the time for
\nsurgery extends to around 12 hours with-
\nout any significant deterioration. A heart
\n(or other organ) can be removed, for
\ninstant at the scene as an accident, where
\nthe patient has died, is brain-dead, but the
\nheart still beating. The heart for trans-
\nplant is connected to the machine via the
\naorta and pulmonary artery with around 1
\nlitre of blood which is recycled. The
\norgan for transplant arrives at the operat-
\ning theatre in a better condition than
\nwhen it left in the donor.
\nProspects for the heart
\ntransplant surgery
\nAccording to Professor Sir Magdi Yacoub,
\nthis technique will revolutionise the way
\nheart transplants are done in the future.
\nCloning of hearts is not the answer although
\nstem cell regenerative therapy does have
\nthis place alongside transplantation. These
\nmethodologies do interact with one another
\nat the tissue and organ levels very well. It is
\nvery significant that this innovative method
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 3
\nMedical Science
\n4
\nwill improve heart function for thousands of
\npatients when disease begins to set in. In
\nprinciple it could be used for every organ in
\nthe body, and for the liver and lungs with
\nimmediate effect.
\nThe stages are:
\n(1) Assess heart function. Estimate the
\nchances of a heart attack in terms of
\nnarrowing and blockages in the coro-
\nnary arteries.
\n(2) If the heart is impaired, how can be
\nimprove it?
\n(3) More hearts will consequently become
\navailable for transplant, estimates being
\nan increase by a factor of 3-4 times. Only
\n139 heart transplants were carried out in
\nthe UK during the last year, because of an
\nacute shortage of donor organs.
\n(4) This enables more intricate surgical
\nwork to be done on the heart which is
\noutside the patient. Currently 10% of
\ncardiac patients are dying at the waiting
\nlist.
\n(5) The failure rates of tissue grafts in
\nsurgery can be very high, and some
\ndon’t start to function at all. Four inter-
\nnational centres are now running clini-
\ncal trials to confirm the efficacy of the
\ntechnique.
\nAt the present there is a huge shortage of
\norgans for transplantation, and the UK is
\none of the lowest in Europe. Such a method-
\nology would offer hope for the many
\npatients currently condemned to a \u2018living
\ndead\u2019 because of a lack of transplant
\nresources.
\nIvan M. Gillibrand
\nAmsterdam, The Netherlands, 23 June
\n2006 \u2013 Up to 64% of people in pain,
\nincluding those with musculoskeletal pain,
\nare confused about which pain medication
\nthey should and shouldn’t take, and many
\ndo not know how to manage their pain
\nappropriately, according to the results of a
\nglobal patient and physician survey
\nannounced by the Arthritis Action Group
\n(AAG).(1) The survey builds on previous
\nAAG research, the Arthritis Research
\nSurvey, showing major inadequacies in the
\nmanagement of pain,(2) and has compelled
\nthe group to call for improved communica-
\ntion with patients so they don’t endure pain
\nunnecessarily.
\n\u201cThese are disturbing findings \u2013 large num-
\nbers of people in pain are confused about
\ntreatment options and risks, and as a result
\ndo not know how to manage their pain
\nproperly,\u201d said Professor Anthony Woolf,
\nChairman of AAG. \u201cAction is needed now
\nto clear this confusion for support patients
\nPain relief
\nPeople in Pain Confused About Pain Relievers and Missing Out On
\nEffective Treatment
\nExperts Urge Clarity to Reduce the Debilitating Impact of Daily Pain
\nand physicians to manage pain effectively
\nto reduce its pervasive impact on daily life.\u201d
\nThe survey of 1204 people with pain, and
\n604 primary care physicians, was conduct-
\ned by Harris Interactive, on behalf of AAG,
\nin six countries worldwide \u2013 United
\nKingdom, Germany, Italy, France, Mexico
\nand Australia.
\nPain severely impacts on the
\nquality of life
\nOne in five people worldwide has moderate
\nto severe chronic pain, including 100 mil-
\nlion Europeans with musculoskeletal pain
\nand arthritis.(3,4) People in pain report that
\nit strongly impacts on their life, affecting
\ntheir ability to sleep and complete daily
\ntasks.(1) Not only does pain affect quality-
\nof-life, but previous studies show that it can
\nalso predict increased mortality.(5)
\nPeople in pain are confused
\nand under-informed (1)
\n\u2022 Up to 64% of people feel that conflict-
\ning information about pain medications
\nmakes it confusing to know what to
\ntake.
\n\u2022 Up to 78% of people feel they don’t
\nknow enough about the benefits and
\nrisks of pain medications (either pre-
\nscription medications, over-the-counter
\nmedications, or both).
\nPain is not being managed
\nappropriately (1)
\nMany people are putting themselves at risk
\nby using treatments inappropriately:
\n\u2022 If their pain medication doesn\u2019t work
\nafter 10 days of use, less than half of
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 4
\nMedical Science
\n5
\npeople taking prescription medication
\nand less than half taking non-prescrip-
\ntion medication will go to their doctor
\nfor advice or treatment. To get better
\npain relief, people are using strategies
\nsuch as taking more of the same type of
\nmedication, taking a different type of
\nmedication, or exercising.
\n\u2022 Up to 47% of people in pain don’t use
\nmedication at all. Reasons include expe-
\nrience with or concern about side-
\neffects, a perception that they can man-
\nage without medication, their doctor
\nadvised them to stop taking medication,
\nor because they\u2019re worried following
\nstories in the news.
\nInformation gap exposed
\nDespite patient confusion, detailed discus-
\nsions about different treatment options and
\ntheir specific benefits and risks are not tak-
\ning place in consultation with their physi-
\ncian. Patients report that during their last
\nconsultation: (1)
\n\u2022 Less than half discussed how effective
\ntheir current medication was (\u226443%), or
\ntreatment benefits (\u226440%)
\n\u2022 Less than a third discussed potential
\nproblems or medication side-effects
\n(\u226430%)
\nInsufficient information sharing between
\npatients and physicians was attributed to the
\nfollowing:
\n\u2022 Many physicians underestimate the
\nlevel of patient concern about treatment
\nrisks. For example, up to 48% of
\npatients are very concerned about the
\npotential side-effects of non-prescrip-
\ntion NSAIDs (of those who are aware of
\nthem), whereas only a small number of
\nphysicians felt their patients were very,
\nor extremely concerned about this
\n(=14%). Most discussions are about the
\nbenefits and risks of prescription med-
\nications. (1,6)
\n\u2022 Up to 92% of physicians think patients
\ndon’t have the expertise to evaluate the
\nrelative benefits and risks of treatment.
\n(6)
\n\u2022 Up to 25% of physicians find it difficult
\nto communicate the benefits and risks
\nof prescription medications, and up to
\n24% for non-prescription pain medica-
\ntions. (6)
\n\u2022 Less than half of physicians are very
\nfamiliar with the recently updated
\nguidelines for pain medications
\n(=49%). (6)
\n\u2022 Up to 92% of physicians think their
\nelderly patients don\u2019t want responsibility
\nfor treatment decisions. (6)
\n\u2022 Up to 89% of physicians see consulta-
\ntion time constraints as a problem. (6)
\n\u201cThese survey results highlight the large
\ngap in understanding between patients and
\nphysicians,\u201d said Sandra Canadelo, Vice
\nChair of the PARE Manifesto Steering
\nGroup, and Chair of the EULAR Social
\nLeagues. \u201cChronic pain is hugely debilitat-
\ning for patients, and severely impacts qual-
\nity of life. Informed discussions are needed
\nto ensure pain is managed effectively, and
\nthe best decisions are made to improve the
\nlives of patients.\u201d
\nBackground
\nAbout the survey
\nAbout a total of 1204 people with pain, and
\n604 primary care physicians were inter-
\nviewed. This included approximately 200
\npeople with chronic pain and 100 general
\npractice patient-care physicians from each
\nof the following countries: United
\nKingdom, Germany; Italy, France, Mexico
\nand Australia.
\nThe research was conducted by Harris
\nInteractive on behalf of the Arthritis
\nAction Group between 22 December 2005
\nand 22 February 2006. The data were not
\nweighted to the patient and physician pop-
\nulation proportions in each country and
\ntherefore are not representative of those
\npopulations.
\nAbout the Arthritis Action
\nGroup (AAG)
\nArthritis Action is an international, physi-
\ncian-led initiative dedicated to advance
\nawareness of rheumatic conditions and
\nmanagement choices so that healthcare
\nproviders, patients and carers can work in
\nthe true partnership towards maximum
\nquality of life. It aims to help healthcare
\nproviders, people with musculoskeletal
\nproblems and they cares by:
\n\u2022 Raising awareness of unmet needs in the
\nmanagement of musculoskeletal pain
\n\u2022 Improving timely access to the most
\neffective management options
\n\u2022 Promoting the \u201coptimal practice\u201d man-
\nagement of musculoskeletal pain
\nAbout the PARE Manifesto
\nPARE (people with Arthritis\/ Rheumatism
\nin Europe) Manifesto is the campaigning
\narm of the EULAR Social Leagues. It rep-
\nresents the parents\u2019 voice in Europe and
\nseeks to ensure that the \u201cEuropean
\nManifesto\u201d ten calls to action in a single,
\nagreed document, developed by the
\nEULAR Social Leagues, Arthritis and
\nRheumatism International and the
\nOrganisation of Youth with Rheumatism
\nin 1999, is implemented in Europe where
\nmore than 100 Million Europeans are
\naffected by arthritis\/ rheumatism. For
\nmore information visit www.paremani-
\nfesto.org
\nAbout Harris Interactive\u00ae\u00ae
\nHarris Interactive is the 13th largest and
\nfastest-growing market research firm in the
\nworld. The company provides research-dri-
\nven insights and strategic advice to help its
\nclients make more confident decisions
\nwhich lead to measurable and enduring
\nimprovements in performance. Harris
\nInteractive is widely known for The Harris
\nPoll\u00ae
\n, one of the longest running, indepen-
\ndent opinion polls and for pioneering
\nonline market research methods. The com-
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 5
\nMedical Science
\n6
\npany has built what could conceivably be
\nthe world’s largest panel of survey respon-
\ndents, the Harris Poll Online. Harris
\nInteractive serves clients worldwide
\nthrough its United States, Europe and Asia
\noffices, its wholly-owned subsidiary
\nNovatris in France and through a global
\nnetwork of independent market research
\nfirms.
\nReferences
\n1. Insights into Pain Relief Patient Survey.
\nArthritis Action Group.23 June 2006.
\n2. A Woolf, et. al. Musculoskeletal pain in
\nEurope: Its impact and a comparison of popu-
\nlation and medical perception of treatment in
\neight European countries. Annals of the
\nRheumatic Diseases. April 2004.
\n3. WHO press release accessed online 11 May
\n2006: www.painreliefhumanright.com\/pdf\/
\npress-reease.pdf .Statistics released by
\nInternational Association for the Study of Pain
\nand European Federation of IASP Chapters.
\n4. World Health Organisation. World Health
\nReport. Life in the 21th Century. A Vision for
\nall. 1998. pp47-48.
\n5. Sokka T, Pincus T, Pain as a Significant
\nPredictor of Premature Mortality over 5 Years
\nin the General Population, Independent of
\nAge, Sex and Acutely Life- Threatening
\nDiseases. Poster presented at the Annual
\nScientific Meeting of the American College of
\nRheumatology, November 12-17, 2005, San
\nDiego.
\n6. Insights into Pain Relief, Pain Relief
\nPhysician Survey .Arthritis Action Group. 23
\nJune 2006.
\nPain Relief Survey
\n\u2022 The \u201cInsights Into Pain Relief\u201d global
\nsurvey was commissioned by the
\nArthritis Action Group, an international
\ngroup of leading physicians and acade-
\nmics, to gauge the opinions and experi-
\nences of people with pain, including
\narthritis and musculoskeletal pain, and
\nthe physicians who treat people with
\npain.
\n\u2022 The survey was conducted among 1204
\npatients and 604 primary care physicians
\nacross six individual countries \u2013 United
\nKingdom, Germany, Italy, France,
\nMexico and Australia.
\n\u2022 The research was conducted by Harris
\nInteractive, on behalf of AAG, between
\n22 December 2005 and 22 February
\n2006.
\n\u2022 This survey builds on AAG research
\nconducted in 2004, via the Arthritis
\nResearch Survey, which revealed major
\ninadequacies in the management of pain
\nresulting from arthritis and other muscu-
\nloskeletal problems. It showed that one
\nin three people affected by muscu-
\nloskeletal pain never consults a physi-
\ncian about their pain.
\nKey Findings from the
\n\u201cInsights into pain relief\u201d
\nsurvey
\nPain severely impacts quality of life
\n\u2022 Many people in pain report it impacts
\ntheir life, affecting their ability to sleep
\n(up to 42% pf patient) and conduct day-
\nto-day activities (up to 61% of patients).
\n\u2022 Physicians warn that a number of health-
\nrelated issues are likely to result if
\nchronic pain is not managed effectively,
\nincluding loss of normal day-to-day
\nactivity (up to 92% of physicians),
\nimpaired social function (up to 86% pf
\nphysicians), depression (up to 85% of
\nphysicians), weight gain (up to 81% pf
\nphysicians).
\n\u2022 Back pain is the most common muscu-
\nloskeletal ailment suffered \/up to 70% of
\npatients), followed by neck\/shoulder
\npain (up to 61% of patients) and
\nknee\/ankle pain (up to 53% op patients).
\nMany people in pain are confused and
\nunder-informed about pain relievers
\n\u2022 Up to 64% of people feel that conflicting
\ninformation about pain relievers makes it
\nconfusing to know what to take.
\n\u2022 Up to 64% of people feel they don’t
\nknow enough about the benefits and
\nrisks of prescribed pain medications, and
\nup to 63% feel they don’t know enough
\nabout the benefits and risks of non-pre-
\nscription pain medications.
\nPain medications aren\u2019t being used
\nappropriately
\n\u2022 If their pain medication didn’t work
\nafter 10 days of use, less than 47% of
\npeople taking prescription medication
\nwent to their doctor for advice or treat-
\nment, or to ask for a different medica-
\ntion. To get better pain relief, people are
\nusing strategies such as taking more of
\nthe same type of medication, taking a
\ndifferent medication, exercise, massage
\ntherapy, and pain relieving creams and
\nrubs.
\n\u2022 Up to 47% of people in pain don’t use
\nmedication at all. Of those, up to 73%
\nsay they feel they can manage without
\nmedication, up to 25% say it’s because
\nthey are worried about side effects, and
\nup to 22% say that their doctor advised
\nthem to stop taking their medication.
\nMany people in pain find it difficult to
\nget information from their doctor
\n\u2022 Most people in pain (up to 89%) obtain
\ninformation about their condition and
\ntreatment from their doctor, with up 78%
\nseeing their doctor as the most important
\nsource of information.
\n\u2022 Over half of people in pain (up to 52%)
\nuse their pharmacist to find out about
\npain conditions and pain medications,
\nwhilst only a small number of people in
\npain see their pharmacist as the most
\nimportant source in information (\u226410%)
\n\u2022 At their last consultation with their doc-
\ntor or nurse practitioner:
\n– Less than half a patients discussed how
\neffective their current medication was
\n(\u226443%), or treatment benefits (\u226440%)
\n– Less than a third of patients discussed
\npotential problems or medication side-
\neffects (\u226430%)
\nSurvey Methodology
\nPatients
\n\u2022 For inclusion in the study , patients had
\nto be age 18 or older and suffering from
\nat least one qualifying chronic pain con-
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 6
\nMedical Science
\n7
\ndition (pain conditions included back
\npain, neck shoulder pain, knee\/ankle
\npain, joint pain, arthritis, hip pain, morn-
\ning stiffness, migraine pain, dental pain,
\nserve menstrual pain, sprains\/strains,
\nbursitis\/tendonitis, post-operative pain,
\nother body pain).
\n\u2022 Approximately 200 pain sufferers were
\ninterviewed from each of the following
\ncountries: United Kingdom, Germany,
\nItaly, France, Mexico and Australia.
\n\u2022 All respondents were sampled from list
\ngenerated by Random Digit Dialling
\n(RDD) in each country, screened by tele-
\nphone, and if qualified, invited to contin-
\nue with a survey 15 minutes in length.
\n\u2022 The data were not weighted to the
\npatient population proportions in each
\ncountry and therefore are not representa-
\ntive of those populations.
\nPhysicians
\n\u2022 For inclusion in this study, physicians
\nhad to be Primary Care Physicians
\n(PCPs) involved in treatment decisions
\nof patients with pain conditions who
\nwrite 30 or more scripts for pain,
\ninflammation or arthritis per month.
\n\u2022 Approximately 100 general practice
\npatient-care physicians were interviewed
\nfrom each of the following countries:
\nUnited Kingdom, Germany, Italy,
\nFrance, Mexico and Australia.
\n\u2022 All respondents were sampled from
\nphysician lists in each country, contacted
\nby phone, screened, and if qualified,
\ninvited to continue with a survey 10 min-
\nutes in length.
\n\u2022 The data were not weighted to the
\npatient population proportions in each
\ncountry and therefore are not representa-
\ntive of those populations.
\nArthritis Action Group
\nArthritis Action is a physician-led initia-
\ntive, dedicated to advance awareness of
\nrheumatic conditions and management
\nchoices so that healthcare providers,
\npatients and carers can work in the true
\npartnership towards maximum quality of
\nlife. It aims to help healthcare providers,
\npeople with musculoskeletal problems and
\nthey cares by:
\n\u2022 Raising awareness of unmet needs in the
\nmanagement of musculoskeletal pain
\n\u2022 Improving timely access to the most
\neffective management options
\n\u2022 Promoting the \u201coptimal practice\u201d man-
\nagement of musculoskeletal pain
\nArthritis Action currently brings together
\nexperts from eleven countries across the
\nworld, eight of which are in Europe: France,
\nGermany, Ireland, Italy, Spain, Sweden,
\nSwitzerland and the UK. Arthritis Action
\nhas collaborative partnerships with a num-
\nber of other organisations which have an
\ninterest in musculoskeletal conditions, to
\nhelp raise musculoskeletal problems as a
\npriority on the European healthcare agenda,
\nfor example Bone and Joint Decade and the
\nWorld Health Organisation.
\nIn addition to participating in international
\nand European-wide activity, individual
\ncountries involved in Arthritis Action have
\ntheir own National Action Groups, dedicat-
\ned to adressing key national issues to mus-
\ncoloskeletal conditions.
\nThe Arthritis Action initiative is driven by
\nthe AAG, a steering committee of 17 lead-
\ning physicians and academics. The group
\nmembers specialise in the management of
\nmusculoskeletal conditions and work with-
\nin a range of disciplines including: rheuma-
\ntology, epidemiology, gastroenterology,
\ngeriatrics, clinical pharmacology,
\northopaedics and primary care.
\nAAG Research
\nIn 2002 the group conducted The Arthritis
\nResearch Survey, the largest survey of its
\nkind to be carried out in Europe. Published
\nin Annals of Rheumatic Diseases in 2004,
\nthe survey remains the most up to date data
\ncollected which quantifies the impact of
\nmusculoskeletal pain on quality of life,
\nassesses the management of condition
\nacross Europe and identifies the beliefs and
\nperceptions of treatment held by physicians
\nand people with musculoskeletal condi-
\ntions.
\nKey points from the survey findings
\ninclude:
\n\u2022 From the physician perspective it
\nappears that musculoskeletal pain is well
\nmanaged, from the population perspec-
\ntive the pasture is less optimistic
\n\u2022 There is lack of communication between
\nphysicians and patients concerning mus-
\nculoskeletal pain and the benefits and
\nrisk of medications
\n\u2022 Some people with musculoskeletal pain
\nmay be receiving inadequate treatment
\nand therefore may be at risk for avoid-
\nable pain or side effects
\n\u2022 Barriers to diagnosis and optimum man-
\nagement of musculoskeletal pain may be
\nattitudinal and could be improved by
\nbetter communication between patients
\nand their physicians
\nPan- European findings from the survey
\nwere published in the Annals of the
\nRheumatic Diseases (ARD), April 2004.
\nCurrently underway is the Environmental
\nFactors Programme, which is aims to
\nidentify the barriers and facilitators to the
\nbest practice management of musculoskele-
\ntal conditions, using the WHO classified
\ncontextual factors.
\nArthritis Action Mission
\nAdvancing awareness of rheumatic con-
\nditions and management choices so that
\nhealthcare providers, patients and carers
\ncan work in true partnership towards
\nmaximum quality of life
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 7
\nMedical Education
\n8
\nnumbers of mentally incapacitated patients
\nmay be being significantly underestimated.
\nProfessor Matthew Hotopf and colleagues
\nat the Institute of Psychiatry, Preston and
\nYale tested the degree of cognitive impair-
\nment of patients admitted to a London hos-
\npital. Some 31 per cent of inpatients were
\nconsidered to lack mental capacity.
\nHowever, when clinical teams interviewed
\ninpatients, they rated just 8 per cent as lack-
\ning mental capacity.1
\nMost patients probably rely on doctors to
\nmake the most appropriate decision for
\nthem. A need to assess mental capacity in a
\nmedically pressing situation could present
\nPatients should consent to medical treat-
\nment. But an inability to give reasoned
\nconsent may be more common than doctors
\nappreciate.
\nThe consent to medical treatment, patients
\nshould be making voluntary and informed
\nchoices, and have the mental capacity to
\nmake a decision. Patients lack mental
\ncapacity when they cannot understand the
\ninformation being given to them, or use it to
\ndecide on a course of action, or are unable
\nto communicate their decision. Usually,
\nmental capacity is taken as read unless the
\npatient\u2019s difficulties are very obvious.
\nHowever, recent research suggests that the
\nInformed Consent
\nPatients with Alzheimer\u2019s disease may lack the mental capacity
\nto give informed consent
\nsignificant difficulties to the medical pro-
\nfession. On the other hand, there is clearly
\nalso a need to protect vulnerable patients,
\nparticularly when major \u2013 and irreversible \u2013
\nmedical decisions are being made.
\nThese kinds of issues are being considered
\nin the UK\u2019s draft Mental Capacity Bill. The
\nresearchers suggest that, even if legislation
\nis seen as too heavy handed, the issue of
\npatients\u2019 mental capacity should be given
\nmore attention by doctors.
\n1 Raymont V et al. Prevalence of mental inca-
\npacity in medical inpatients and associated risk
\nfactors: cross-sectional study. Lancet 2004; 364
\n(9443): 1421-7.
\nWHO and the World Federation for Medical
\nEducation (WFME) propose a strategic
\npartnership to pursue a long-term work plan
\n\u2013 open to participation by all medical
\nschools and other educational providers \u2013
\nintended to have a decisive impact on med-
\nical education in particular and ultimately
\non health professions education in general.
\nThe WHO\/WFME work plan will benefit
\nfrom the accumulated experience and assets
\nof each partner and will result in:
\n\u2013 A shared database that will include up-to-
\ndate experience in implementing quality-
\nimprovement processes in medical
\nschools
\n\u2013 Access, via the database, to information
\non specific schools and in particular to a
\nWHO\/WFME strategic partnership
\nto improve medical education
\ndescription of their approach to quality
\nimprovement
\n\u2013 Promoting twinning between schools and
\nother institutions in processes to foster
\ninnovative education
\n\u2013 Means to update the management of med-
\nical schools
\n\u2013 Identification and analysis, by WHO
\nregions, of innovations in medical educa-
\ntion in order to help define appropriate
\nlines of work for each region
\n\u2013 Assistance to institutions or national\/
\nregional organizations and agencies in
\ndeveloping and implementing reform pro-
\ngrammes or establishing recognition\/
\naccreditation systems
\n\u2013 A review of good practices in medical
\neducation that can serve as examples and
\nas a source for further innovation.
\nThe strategic partnership will also address
\nother crucial questions that medical schools
\nnow face, such as improving their leader-
\nship function. Through a systematic dia-
\nlogue, the partners will pursue the work
\nplan and provide useful information to med-
\nical schools worldwide.
\nThe strategic partnership is another out-
\ngrowth of WHO\u2019s strong commitment to
\nsupporting Member States’ efforts to attain
\nthe Millennium Development Goals
\n(MDGs) (http:\/\/www.who.int\/mdg\/en\/),
\nadopted at the Millennium Summit of the
\nUnited Nations in September 2000. A major
\nthrust of the MDGs is improved health sta-
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 8
\nMedical Education
\n9
\ntus, towards which human resources for
\nhealth will make a crucial contribution. But
\nin order to contribute optimally, the health
\nworkforce must receive the best possible
\neducational preparation.
\nPlanning and providing high-quality human
\nresources education demands the active par-
\nticipation of medical schools and other
\nproviders of medical education and training,
\nsince physicians are important to any model
\nof a health team for developing and developed
\ncountries alike. WHO and the WFME have
\nbeen working together since 1972 towards
\nimproving medical education worldwide.
\nThere is no single path towards improving
\nthe quality of medical education. Each
\nregion and country features different
\napproaches that must be acknowledged,
\nexplored and brought to wider use. But to
\nachieve significant and lasting results, insti-
\ntutions must be committed to an ongoing
\nprocess of quality development. The
\nWHO\/WFME strategic partnership aims to
\nfoster this commitment.
\nOn World TB Day (March 24th
\n), WMA will
\nlaunch a new on-line course to improve
\nearlier diagnosis, prevention and treatment
\nof multi-drug resistant tuberculosis
\n(MDRTb).
\nThis course has been in development with
\nthe Foundation for Professional Develop-
\nment of the South African Medical
\nAssociation and the Norwegian Medical
\nAssociation is coordinated by the German
\nMedical Association.
\nBased on the WHO guidelines on the man-
\nagement of MDRTb, it will allow physician
\nto train on-line at their own pace. The web-
\nbased course will be available in several
\nNew on-line TB training course to be launched
\nby WMA on World TB Day
\nlanguages and participating physicians may
\nable to receive credits as part of their con-
\ntinuing medical education. It will be avail-
\nable in several languages.
\nThe course will be piloted first amongst
\nphysicians in South Africa, extended to
\nphysicians in Estonia and the Philippines in
\nthe summer and then be available globally.
\nIt has been made possible by an education-
\nal grant from Eli Lilly.
\nThis new course follows the successful
\nweb-based course already developed and
\nrun by WMA and the Norwegian Medical
\nAssociation for Prison Doctors on Human
\nRights and Ethics.
\nAdopted by the WMA General Assembly,
\nPilanesberg, South Africa, October 2006
\nPreamble
\n1. The practice of medicine is dynamic
\nand continues to evolve. Medical edu-
\ncation represents a continuum of learn-
\ning that commences with undergraduate
\nmedical school and endures until a
\nphysician retires from active practice.
\nIts goal is to prepare practitioners of
\nmedicine to apply the latest scientific
\nknowledge for the promotion of health
\nand the prevention and cure of human
\ndiseases and the mitigation of symp-
\ntoms of presently incurable diseases.
\nMedical education also comprises the
\nThe World Medical Association Statement on Medical Education
\nethical standards governing the thought
\nand behaviour of physicians. All physi-
\ncians have a responsibility to them-
\nselves, the profession and their patients
\nto maintain a high standard for their
\nmedical education.
\nBasic Principles of Medical
\nEducation
\n2. Medical education consists of basic
\nmedical education, postgraduate med-
\nical education, and continuing profes-
\nsional development. The profession, the
\nfaculties and educational institutions,
\nand the government share the responsi-
\nbility for guaranteeing that medical
\neducation meets a high quality standard
\nthroughout this continuum. The aim of
\nmedical education is to develop compe-
\ntent and ethical physicians that deliver
\nhigh quality healthcare to the public.
\nBasic Medical Education
\n3. The goal of basic medical education is
\nto instruct students in the practice of the
\nprofession, and to supply the public
\nwith well-qualified physicians. The first
\nprofessional degree should represent
\nthe completion of a curriculum that
\nqualifies the student for a spectrum of
\ncareer choices, including, but not limit-
\ned to, patient care, public health, clini-
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 9
\nMedical Education
\n10
\ncal or basic research, or medical educa-
\ntion. Each of these choices will require
\nadditional education beyond the first
\nprofessional degree.
\nSelection of Students
\n4. A general liberal education is beneficial
\nfor anyone embarking on the study of
\nmedicine. A broad cultural education in
\nthe arts, humanities, and social sci-
\nences, as well as biological and physical
\nsciences, is advantageous. Students
\nshould be chosen for the study of medi-
\ncine on the basis of their intellectual
\nability, motivation, previous experi-
\nences, and character and integrity. The
\nnumbers admitted for training must
\nmeet the needs of the population and be
\nmatched by appropriate resources.
\nSelection of students should not be
\ninfluenced by age, sex, race, creed,
\npolitical persuasion or national origin,
\nalthough the mix of students should
\nreflect the population.
\nFaculty
\n5. Basic medical education must be taught
\nby a structured faculty. The faculty must
\npossess the appropriate qualifications
\nthat can only be achieved through for-
\nmal training and experience. The selec-
\ntion should not be based on age, race,
\ncreed, political affiliation, or national
\norigin.
\n6. The faculty must foster an academic
\nenvironment in which learning and
\ninquiry are encouraged and can thrive.
\nAs such, active research to advance the
\nbody of medical knowledge and the
\nquality of care must take place in acad-
\nemic settings that promote the highest
\nmedical standards. The goals, content,
\nformat and evaluation of the education
\nprovided are the responsibility of the
\nfaculty. Medical schools should ensure
\ncontinued growth of the teaching skills
\nof the faculty.
\n7. The faculty is accountable for providing
\nits own basic curriculum in an academ-
\nic environment that allows learning to
\nflourish. The faculty should review the
\ncurriculum frequently, allowing for the
\nneeds of the community and for input
\nfrom practising physicians.
\nFurthermore, the faculty is responsible
\nfor regularly evaluating the quality of
\neach educational experience and for
\nreviewing each other.
\n8. In addition to competent faculty, the
\ninstitution must require that library
\nresources, research laboratories, clinical
\nfacilities, and study areas be available
\nin sufficient quantity to meet the needs
\nof all learners. Moreover, a proper
\nadministrative structure, including but
\nnot limited to academic records, must
\nbe maintained in order to provide the
\nmost comprehensive education.
\nContent of Basic Medical
\nEducation
\n9. The educational content should equip
\nthe student with a broad base of general
\nknowledge in the whole field of medi-
\ncine. This includes a study of the bio-
\nlogical and behavioural sciences as well
\nas the socio-economics of health care.
\nThese sciences are basic to an under-
\nstanding of clinical medicine. Critical
\nthinking and self-directed learning
\nshould also be required, as should firm
\ngrounding in the ethical principles upon
\nwhich the physicians will function and
\nin the principles of human rights. The
\nstudent should also be introduced to
\nmedical research and its methodology
\nat this stage.
\nClinical Education
\n10. The clinical component of medical edu-
\ncation must be centered on the super-
\nvised study of patients and must involve
\ndirect experiences in the diagnosis and
\ntreatment of disease. The clinical com-
\nponent should include personal diag-
\nnostic and therapeutic experiences with
\na gradual increase in responsibilities.
\nAn appropriate balance among the
\npatient base, trainees and teachers must
\nbe observed.
\n11. Before beginning independent practice,
\nevery physician should complete a for-
\nmal program of supervised clinical edu-
\ncation. This clinical experience should
\nrange from primary to tertiary care in a
\nvariety of inpatient and outpatient set-
\ntings, such as university hospitals, com-
\nmunity hospitals and other health care
\nfacilities.
\n12. The faculty and medical schools have
\nthe responsibility to ensure that students
\nwho have graduated and received the
\nfirst professional degree have acquired
\na basic understanding of clinical medi-
\ncine and the basic skills needed to eval-
\nuate clinical problems and take appro-
\npriate action independently, and exhibit
\nthe attitude and character to be an ethi-
\ncal physician.
\nPostgraduate Medical
\nEducation
\n13. It is highly desirable, and in many juris-
\ndictions it is already a requirement, that
\na graduate from a basic medical educa-
\ntion institution participate in a postgrad-
\nuate training program prior to obtaining
\na license. Postgraduate medical educa-
\ntion, the second phase of medical edu-
\ncation, prepares physicians for practice
\nin a medical specialty. Postgraduate
\nmedical education focuses on the devel-
\nopment of clinical skills and general
\nand professional competencies and on
\nthe acquisition of detailed factual
\nknowledge in a medical specialty. This
\nlearning process prepares the physician
\nfor the independent practice of medi-
\ncine in that specialty.
\n14. The programs are based in communi-
\nties, clinics, hospitals or other health
\ncare institutions and should, in most
\nspecialties, utilize both inpatient and
\nambulatory settings, reflecting the
\nimportance of care for adequate num-
\nbers of patients in the postgraduate
\nmedical education experience.
\nPostgraduate medical education pro-
\ngrams, including Transitional Year pro-
\ngrams, are usually called residency pro-
\ngrams, and the physicians being educat-
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 10
\nFrom the Secretary General
\n11
\ned in them, residents. A resident takes
\non progressively greater responsibility
\nthroughout the course of a residency,
\nconsistent with individual growth in
\nclinical experience, knowledge, and
\nskill.
\n15. The education of resident physicians
\nrelies on an integration of didactic activ-
\nity in a structured curriculum with diag-
\nnosis and management of patients under
\nappropriate levels of supervision and
\nscholarly activity aimed at developing
\nand maintaining life-long learning
\nskills. The quality of this experience is
\ndirectly related to the quality of patient
\ncare, which is always the highest priori-
\nty. Educational quality and patient care
\nquality are interdependent and must be
\npursued in such a manner that they
\nenhance one another. A proper balance
\nmust be maintained so that a program of
\npostgraduate medical education does
\nnot rely on residents to meet service
\nneeds at the expense of educational
\nobjectives. A resident is prepared to
\nundertake independent medical practice
\nwithin a chosen specialty on the satis-
\nfactory completion of a residency.
\nProfessional Development of
\nPhysicians
\n16. Continuing professional development*
\nis defined as the educational activities
\nthat serve to maintain, develop, or
\nincrease the knowledge, skills, and pro-
\nfessional performance and relationships
\na physician uses to provide services for
\npatients, the public, or the profession.
\nPhysicians should strive to further their
\nmedical education throughout their
\ncareers. These educational experiences
\nare essential to the physician\u2019s continu-
\ning professional development: to keep
\nabreast of developments in clinical
\nmedicine and the health care delivery
\nenvironment, and to maintain the
\nknowledge and skills necessary to pro-
\nvide high quality care. The goal of con-
\ntinuing professional development is to
\nsustain and enhance the competent physi-
\ncian. Medical schools, hospitals and pro-
\nfessional societies all share a responsibil-
\nity for developing and making available
\nto all physicians effective opportunities
\nfor continuing professional development.
\n17. The demand for physicians to provide
\nmedical care, prevent disease, and give
\nadvice in health matters calls for the
\nhighest standards of basic, postgradu-
\nate, and continuing professional devel-
\nopment.
\n* Note on terminology: There are different uses
\nof the term \u2018Continuing Professional
\nDevelopment\u2019 (CPD). One way to describe it is
\nall those activities that contribute to the profes-
\nsional development of a physician including
\ninvolvement in organized medicine, committee
\nwork in hospitals or group practices, teaching,
\nmentoring and reading, to name just a few. One
\nof the components of CPD should be Continuing
\nMedical Education, which in many jurisdictions
\nis specially defined and possibly required for
\nlicensure.
\nSouth Africa has lost a significant part of its
\nphysician work force to other countries dur-
\ning recent years. WHO\u2019s World Health
\nReport 2006 estimates that more than
\n12.000 doctors who have originally been
\ntrained in South Africa now work in 8
\nOECD countries (Australia, Canada,
\nFinland, France, Germany, Portugal, United
\nKingdom and the United States of America).
\nThis amounts to nearly 37% of the South
\nAfrican physician work force and is only the
\nnumber for these selected 8 countries.
\nOf course these countries may be the most
\nattractive and certainly physicians did not
\nturn their back to South Africa because it
\noffered them good working conditions, a
\nhealthy motivated population and excellent
\nFrom the Secretary General
\nHealth Professional Council of South Africa announces amnesty
\non restoration fees
\nAn Amnesty difficult to understand
\nsalaries. South Africa has some of the most
\ndifficult problems in the world. It has a high
\nburden of HIV\/AIDS cases and during last
\nfall the occurrence of the so-called
\n\u201cExtended Drug Resistant Tuberculosis\u201d
\n(XDR-TB) became a nightmare for TB
\npatients and their care givers.
\nAlthough South Africa is a country rich in
\nresources, the majority of its population is
\nstill very poor and what Europeans would
\ndescribe as a regular access to health care,
\nfor many of the South Africans is far out of
\nreach. This country badly needs physicians.
\nThere are a lot of South African physicians
\nin this world who have left their country.
\nWouldn\u2019t it be good, if some of them
\nreturned?
\nEarlier this year the South African Medical
\nAssociation (SAMA) reached out to their
\nlost colleagues to bring them news from the
\nSouth African Medical Council: In a \u201cCall
\non South African doctors to return home\u201c
\nthey told the South African Physicians that
\n\u201cthe Health Professions Council of South
\nAfrica has agreed to a once-off waiver of
\npenalties for those practitioners, both local
\nand abroad, who failed to pay their annual
\nregistration fees on time, or who had
\nallowed their registration to lapse without
\ninforming Council.\u201d And while the SAMA
\nsees this as a win, the foreign observer still
\nmay find this strange.
\nIt is even more difficult to understand when
\non a further look the amnesty is not really an
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 11
\nWMA
\n12
\namnesty, as the Council expects \u201call health
\ncare practitioners who take advantage of this
\namnesty period to render professional ser-
\nvices to any public sector institution of their
\nchoice. We expect them to work for 100
\nhours in service to public health within six
\nmonths of their restoration.\u201d
\nIt is certainly without question that physi-
\ncian have to be subject to supervision. The
\nsupervision is a public service. If it is done
\nby self-governance there is good reason to
\npay it by contributions from the physicians.
\nOtherwise it should be paid by the state. To
\navoid supervision is not acceptable.
\nHowever, if physicians who have left the
\ncountry they are simply out of this supervi-
\nsion, and there is absolutely no reason to
\nexpect money from them.
\nTo make this clear once more: South Africa is
\none of the countries with the sharpest loss of
\nhealth professionals in this world, South
\nAfrica is one of the countries with the highest
\ndemand for physicians and yet \u2013 as this publi-
\ncized amnesty reveals \u2013 it is threatening pun-
\nishment to physicians who have not paid fees
\nto the SA Council while they were abroad.
\nYes, some may have forgotten to de-regis-
\nter. I did so, when I left my country for the
\nfirst time. My chamber sent me a letter
\n(after locating me abroad) and told me that,
\nsince I had left the country they would
\nstrike me off the register. They also told me
\nthat I had to reregister as soon as I wanted
\nto come back. I did so. No penalty, no
\namnesty, no fuss. Even professional matters
\ncan be dealt with professionally.
\nSouth Africa should embrace every physi-
\ncian who wants to come back wholeheart-
\nedly. Instead it threatens them with punish-
\nments or an amnesty, which in fact is noth-
\ning else than a punishment-in-kind.
\nWe will have to learn how many have
\naccepted the amnesty that ended April
\n30th. If the number of physicians is small,
\nthe Council may have to consider that an
\namnesty which includes a punishment
\nmay not really be perceived as an amnesty.
\nIf the number of physicians is significant,
\nthe South Africans must consider to waive
\nthe penalties and fees for physicians
\nabroad all together, because in that case
\nthey would have given proof that their
\nregulation is part of the cause for the
\nhealth professional shortage. But maybe
\nthat is what the Council fears finding out
\nand why there is no real amnesty in the
\nfirst place.
\nI wonder what else South Africa does to
\nmake the everyday-life of a physician a lit-
\ntle bit harder than necessary.
\nOtmar Kloiber
\nFurther informations:
\nhttp:\/\/www.hpcsa.co.za\/
\n(See also page 28)
\nSpeech by Dr. Thami D. Mseleku,
\nDirector National Department of Health,
\nSouth Africa to the WMA Scientific
\nSession, Pilanesberg.
\nLet me start by thanking you for extending
\nan invitation to the Minister of Health, Dr.
\nManto Tshabalala-Msimang, to this gather-
\ning of eminent medical professionals.
\nUnfortunately she is unable to be here due
\nto ill health. As we gather here this morn-
\ning, the South African medical fraternity is
\nalso gathering elsewhere to pay tribute to
\none of the sons of our country, Professor
\nSam Mhlongo who was known by many,
\nand dared to push the boundaries of medical
\nscience. May his soul rest in piece.
\nIt is of great significance that the World
\nMedical Association consciously took a
\ndecision more than five years ago to hold its
\nGeneral Assembly in our country, barely
\nGeneral Assembly, Pilanesberg South Africa \u201eContinued\u201c
\nScientific Session \u201cHealth as an Investment:
\nLeadership and Advocacy\u201d 12 October 2006
\nfive years after an earlier one in Somerset
\nWest in 1996. That assembly was attended
\nat a very high level by our government in
\nthe form of the then Minister of Health and
\ncurrent Minister of Foreign Affairs Dr.
\nNkosazana Dlamini-Zuma and the then
\nDeputy President and now President of the
\ncountry Mr. Thabo Mbeki. When you visit-
\ned our country in 1996, this country\u2019s med-
\nical associations were many. There was a lot
\nof resistance to unifying into a single
\nnational association. It is without doubt that
\nholding the 48th WMA General Assembly
\non our shores in 1996 gave some impetus to
\nthe unity talks of the medical profession
\nbecause almost two years later on 21 June
\n1998, a new medical association was
\nlaunched.
\nYou have come again to South Africa just
\ntwo years before the South African Medical
\nAssociation celebrates its first ten years of
\nexistence. An evaluation of SAMA activi-
\nties will certainly take into consideration
\ninternal, national and international perfor-
\nmance in line with the goals the association
\nset itself and the promise the association
\nmade to the country at its inception. This
\ncongress will have some influence in shap-
\ning such an evaluation.
\nInternationalism in the world of medical
\npolitics is an important element in the
\ndevelopment of health systems. Like all
\ninternational instruments it must be based
\non sound principles and have clear focused
\ngoals and objectives. Your theme: \u2018Health
\nas an Investment: Leadership and
\nAdvocacy\u2019 is in my view an appropriate
\none to adopt as the world is facing serious
\nchallenges on the health front. Over the past
\ntwo decades the world has seen and experi-
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 12
\nWMA
\n13
\nenced increasing burden of diseases (both
\ncommunicable and non-communicable)
\nrequiring global, national and local collabo-
\nration on a scale never envisaged before.
\nOne can immediately bring to mind a num-
\nber of public health incidents that have
\nrequired intensive investments in scientific
\nresearch to avoid them becoming emergen-
\ncies. The emergence of HIV and its progres-
\nsion over the years should be taken as a les-
\nson by all of us that innovative research
\nmust be prioritized in our countries, and
\ntrans-nationally. It is of course a fact that
\nthe size of investment, who really does the
\ninvestment and the purposes of the invest-
\nment, are critical factors in determining
\nsocial and economic outcomes of the health
\ninvestment. As a country, we have been
\ncommitted to investing in this area and pro-
\nvided funding to bodies like the Medical
\nResearch Council and the South African
\nAIDS Vaccine Initiative to ensure that we
\nconfront HIV challenges from all health
\nissue fronts. Severe Acute Respiratory
\nSyndrome is another, which recently served
\nto remind the scientific community that our
\nefforts should always be to prioritise public
\nhealth. It took the eminent scientists to
\nrapidly come up with measures to curb what
\nseemed a very serious threat to humankind.
\nThese reminders emphasise the absolute
\nneed to invest in scientific research in antic-
\nipation of new diseases that will certainly
\nchallenge and push the boundaries of what
\nhealth systems should provide. Medical
\nresearch brings together many stakeholders
\nincluding communities and individuals.
\nWith many facets of research spanning
\ndiverse areas, it is critical that the guide-
\nlines are clear and mechanisms are put in
\nplace to monitor how it is conducted.
\nIncreasingly the nature of the public health
\npressures faced by countries, particularly
\ndeveloping countries, will necessarily
\ninvolve research by allied professionals in
\nmultidisciplinary research teams which
\nfocus on health issues, as well as health
\nresearchers and academics. Costing of
\ninterventions and public health strategies
\nincreasingly features in research work on
\nmanaging public health crises for example.
\nSimilarly we cannot say we are investing in
\nhealth if we continue to marginalize indige-
\nnous knowledge systems, in particular the
\nknowledge that lies in African traditional
\nmedical practices. Those African practices
\ncontinue to be denigrated and called unsci-
\nentific when they have sustained our people
\nfor many years.
\nAs far back as the 1980\u2019s the progressive
\nhealth forces in our country led by the
\nNational Medical and Dental Associations,
\nwaged endless protests against apartheid
\nhealth, calling for not only an end to
\napartheid health but also increased invest-
\nment in the national health system. This was
\ninformed by the tireless work of the health
\nprofessionals who had gained a lot of expe-
\nrience serving the poor and marginalized of
\nthis country. International experiences and
\nlessons shared, played a major role. It was
\ntherefore no coincidence that our health
\nsystem was initially modeled on UK\u2019s
\nNational Health Service. The foundation of
\nthe role of the medical organizations in pol-
\nicy advocacy was therefore laid and it is our
\nexpectation that SAMA should be in a posi-
\ntion to continue on that trajectory, ensuring
\nthat it becomes a partner in developing a
\nsustainable health system to serve the poor,
\nso that the distribution of quality health pro-
\nvision becomes more equitable in our sys-
\ntem.
\nSouth Africa inherited serious challenges on
\nattainment of its freedom in 1994. The
\nextent of social, educational, health and
\nother challenges we inherited is often
\nunderestimated. There was therefore a con-
\nscious decision to waste no time in trans-
\nforming the services, choosing the primary
\nhealth care route as the preferred mecha-
\nnism to bring and provide health services
\nnearer to our people. We built on the work
\nalready done by various non-governmental
\nbodies like NAMDA and the National
\nProgressive Primary Health Care Network
\nwhich had paved the way for developing a
\nhealth system that should be responsive to
\nthe needs of ordinary South Africans.
\nSAMA, as a successor to previous doctor
\nformations, was expected to ensure that
\nthose values are not lost. It is however not
\nan issue of prescription of one to another
\nbut one of ensuring that our health services,
\nwhilst trying to compete with the best in the
\nworld in some respects as driven by profes-
\nsionals, remain rooted in prioritizing provi-
\nsion for the poor. Focusing and contextual-
\nizing this is critical for ensuring appropri-
\nateness of health care.
\nIt is no mistake that South Africa invests
\njust under 4% of GDP in the health services
\nif one considers the serious socio-econom-
\nic challenges it faces. In our opinion,
\ninvesting in health care is fundamental and
\nthere should be no disagreement on that.
\nThe debate should be on what it is that
\nmust be prioritized in doing such invest-
\nment. The preamble to a resolution adopted
\nby the 50th World Medical Assembly in
\nOttawa in October 1998 notes WMA\u2019s con-
\ncern \u2018about health care systems in all coun-
\ntries not having adequate resources to meet
\nthe basic needs of their populations\u2019. In
\nadopting that resolution WMA reconfirmed
\nthe guidelines on access to health care,
\nwhich were adopted at the 1988 Assembly
\nin Vienna. That resolution had emphasized
\nequity in access irrespective of economic
\nfactors, cost financing and transportation.
\nThis is just but two of your own resolutions
\nthat indicate the need to invest better in
\nhealth care. Almost all health systems,
\nalmost ten years on from 1998, are battling
\neven more trying to improve health care
\ninvestment.
\nHowever, health care investment must be
\nviewed from a variety of perspectives. Let
\nus start with the most critical aspect \u2013 the
\nhealth workforce. Many health system plan-
\nners fail to adequately deal with this aspect
\neven in the well-resourced health systems
\nof the West. It is without doubt that certain
\nprofessional categories were however prior-
\nitized, probably by default, such that even
\nlimited resources would be poured to their
\neducation and training. The medical profes-
\nsion has certainly benefited immensely
\nfrom that approach. The nursing profession,
\neven though forming the majority of health
\nprofessionals in all countries and on whose
\nshoulders health care services rest, has not
\nnecessarily enjoyed the kind of resource
\nallocation invested in the medical profes-
\nsion. The breakthrough was only achieved
\nto some extent with the adoption of the
\nAlma Ata Declaration in 1984, which
\nemphasized a primary health care approach
\nto providing health services as being the
\nmost preferred vehicle. This still did not
\nmean that countries started investing better
\nin health.
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 13
\nWMA
\n14
\nOur government has prioritized the health
\nhuman resource element by developing a
\ncomprehensive human resource plan for
\nhealth to address the serious challenges we
\nare facing specifically with the health work-
\nforce. These range from planning, develop-
\nment, to management. Our efforts now are
\nfocused on how each of the sub-sectors
\nengages and implements aspects of the plan
\nthat affect their core business. We are inter-
\nacting and collaborating with the Health
\nProfessions Council of South Africa, South
\nAfrican Nursing Council and the South
\nAfrican Pharmacy Council in developing
\nsub-sector specific human resource plans to
\ninform the country\u2019s investment in produc-
\ning the skills that our health system needs
\nnow and in the future. This work is very
\ncritical to directing investment appropriate-
\nly so that we can derive better value.
\nDirected investment in education and train-
\ning of health professionals is just a single
\nelement. Economic development and its
\nimpact on health care is a recognized factor.
\nThe better the economic prospects of a
\ncountry the more tension arises within its
\nhealth system. The presence of a strong pri-
\nvate health sector always retards the
\nstrengthening of the public health sector. A
\nstrong private health sector serves as a
\nmajor attraction for health professionals
\nbecause of the economic prosperity that it
\noffers. Several formations within health
\ncare have been discussing and debating
\nthese issues for some time now, culminating
\nin the World Health Organisation setting up
\na Commission on Macro-Economics in
\nHealth. This was driven by a realization that
\nthe country\u2019s economic development status
\nand the economic opportunities that ordi-
\nnary citizens have or do not have, have a
\ndirect impact on the health status of a
\nnation. A similar scenario exists in the
\nmigration phenomenon, with highly skilled
\nhealth professionals being attracted more to
\nthe better-resourced health systems of west-
\nern countries. This only perpetuates
\ninequity in the world health care systems.
\nAlthough the private health sector is largely
\na recipient of public goods it has not con-
\ntributed to developing, there is little evi-
\ndence of a willingness to invest massively
\nin strengthening the public health sector.
\nMany individual practitioners are doing a
\nsterling job in providing health care ser-
\nvices at State institutions, some at no cost at
\nall. This is highly appreciated; however, it is
\nalways the collective efforts that bring real-
\nizable benefits on a national scale. This is
\nthe case in all countries of the world.
\nOn the infrastructure investment side, our
\ngovernment took a strategic decision
\nthrough its 1994 policy declaration that
\nhealth services would be transformed. This
\nmeant amalgamating 14 separate depart-
\nments into a single national health system
\nwith nine provincial departments responsi-
\nble for health service provision and one
\nnational department responsible for policy
\nformulation. There had to be a massive
\ninfrastructure development \u2013 building many
\nnew primary care clinics and revamping
\nand\/or constructing new hospitals. Our hos-
\npital revitalization project has been a phe-
\nnomenal success in improving infrastruc-
\nture. Where possible we have partnered
\nwith the private health sector in erecting
\nnew facilities e.g. Inkosi Albert Luthuli
\nAcademic Hospital in Durban.
\nAll the issues that I have raised above need
\ngood quality leadership. As you may know,
\nleadership also has to be taken into context
\nwith the political landscape integral to that.
\nA leadership confronted by serious fiscal
\nconstraints in a developing world situation
\nwill respond differently to the same stimu-
\nlus when compared to leadership that has
\nlittle constraints in financial and human
\ncapital terms. That is why for many years it
\nhas been easier for western countries to
\nfreely recruit doctors and nurses from poor
\ncountries and difficult for poor countries to
\nput in place monetary incentives to retain
\ntheir expensively trained human assets. The
\nlack of proper planning by rich countries
\nhas a lot to do with this. Health is a complex
\nand very diverse sector. It is comprised of
\ndisparate sections of health professionals
\nthat are not necessarily driven by the same
\nvalues. One may not refer to the centuries
\nold fight between doctors and pharmacists
\nover dispensing of medicines!
\nThe essence of this is that as policy planners
\nand decisions makers, we have to always
\nbalance the aspirations of the health profes-
\nsions with the needs of citizens who depend
\nentirely on public health facilities to receive
\nhealth care. So whilst your Vienna resolu-
\ntion called for improved investment in
\nhealth care, resource availability has
\nremained a serious constraint globally.
\nCertainly the policies of some international
\nfinance institutions have not necessarily
\nassisted despite the efforts. In our situation
\nwe are confronted with challenges that
\nrequire government to drastically improve
\nthe quality of life of ordinary South
\nAfricans. This means providing households
\nwith running tap water, providing sanitation
\nDeath of Erwin Odenbach, long time
\nphysician leader.
\nDr. Paul Erwin Odenbach, former
\nSecretary General of the German
\nMedical Association has been a long
\nterm adviser to the WMA Council and
\nAssociate Members. As a physician,
\nteacher, leader, and friend Erwin has
\nbeen tirelessly engaged for his
\npatients, society and our work. Being
\nengaged in medical education, regula-
\ntion, humanitarian action and med-
\nical ethics his attitude was always dri-
\nven by values. It made him an out-
\nstanding example for our profession.
\nHis leadership career started with his
\ninvolvement in the medical students’
\norganization in Germany soon after
\nWorld War II. He surfaced interna-
\ntionally as the second president of the
\nInternational Federation of Medical
\nStudents Association (IFMSA) and
\nsince then has been a leader in orga-
\nnized medicine on the national and
\ninternational level.
\nHe first encountered the World
\nMedical Association in 1954, address-
\ning the General Assembly in Rome as
\nthe IFMSA representative. He contin-
\nued to be actively engaged with WMA
\nuntil recently. His last policy piece, a
\nResolution on Medical Assistance in
\nAir Travel, was adopted by the WMA
\nat its General Assembly in
\nPilanesberg in October 2006.
\nOn Saturday, February 10th
\n, 2007 Dr.
\nPaul Erwin Odenbach, passed away in
\npeace surrounded by his loved family.
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 14
\nWMA
\n15
\nservices and habitable housing, while con-
\ncentrating on growing the economy. We
\nhave a government that has a mandate to
\nimprove social welfare, provide access to
\neducation, promote access to individual eco-
\nnomic development through providing the
\nyoung people of the country with opportuni-
\nties to be productive citizens and ensure that
\nSouth Africa continues to play its role with
\nothers in developing the African continent.
\nLeadership and advocacy in our context
\ntherefore have to be seen through that prism.
\nThe leadership of the professions has a duty
\nto advocate for improved patient care, not
\nover-emphasise its own self-interest in
\nrationing of health care resources. Advocacy
\nmust not be concentrated and limited to pub-
\nlic platforms that serve to highlight only the
\nperceived failings of interventions without
\nengaging robustly with government agen-
\ncies responsible for health. Advocacy in our
\ncontext must also be a broad health profes-
\nsional focus, guided by the desire to propa-
\ngate the good professional values that are
\ninherent in each. It must go beyond the pub-
\nlic health sector and must influence the cul-
\nture of the private health sector. Without
\nsuch intensified focus, your resolutions on
\nimproving investment in health care will fall
\nshort. In many instances the private health
\nindustry has massive resources that should
\nbe used for public good without compromis-
\ning the drivers of that sector \u2013 profit making.
\nYour leadership as a profession must be able
\nto go beyond advocating for political rea-
\nsons. It must be guided and be rooted in
\nensuring delivery of good quality health care
\nto the most poor of society. It must engage
\nprofessionally and robustly to advance the
\npro-poor agenda. South Africa invests a lot
\nof resources to educating and training health
\nprofessionals who form part of our intellec-
\ntual base as a country. It is only through
\nworking hard at establishing and nurturing
\ngood relations that we can influence each
\nother.
\nI therefore hope that SAMA will, after this
\nassembly, engage with my department on
\nthe resolutions that you will have adopted.
\nMr. Thami D. Mseleku
\nDirector General
\nNational Department of Health \u2013
\nSouth Africa
\nhygienic conditions was the supply of run-
\nning water and maintenance of water quali-
\nty. The improvement of these secured the
\nsupply of pure water for drinking and other
\ndomestic uses, enabling the supply and con-
\nsumption of hygienic food and clean cloth-
\ning. By 1956, Japan was no longer regarded
\nas being \u201cpostwar\u201d, and the average life
\nexpectancy had grown to 63.6 for men and
\n67.75 for women. The country entered a
\nperiod of economic expansion that saw busi-
\nness boom. Housing improved, and at the
\nsame time as the use of electrical appliances
\nsuch as refrigerators, washing machines,
\nand television sets became widespread, so
\ntoo did the use of medical equipment such as
\nX-ray, electrocardiographic, and endoscopic
\nequipment spread rapidly amongst medical
\ninstitutions, with medical technology also
\nadvancing rapidly. Throughout the country
\neveryday living became hygienic and con-
\nsideration to the environment improved with
\nthe installation of sewage systems and treat-
\nment of waste water, and these develop-
\nments in particular contributed significantly
\nto the enterprise of the people.
\nHowever, as industry expanded, atmospher-
\nic pollution was caused by smoke and other
\npollution was caused by industrial waste
\nwater; environmental pollution became a
\nserious concern in some situations and
\nefforts were made to rectify these. Against
\nthis background, health management mea-
\nsures to prevent over-consumption of salt
\nand ensure the adequate consumption of
\nprotein were spreading. At the same time
\nthat medical examinations became com-
\nmonly carried out as a means of preventing
\ndiseases. Group examinations were held for
\nstomach cancer and businesses implement-
\ned health check-ups for their employees.
\nConsequently, the early diagnosis of fre-
\nquently occurring diseases and preventative
\nexaminations expanded on a national scale,
\nproducing highly significant results. Thus
\nsince about 30 years ago, people\u2019s nutrition
\nhas improved and the incidence of infec-
\nDr. Yoichi Hozumi,Vice President, Japan
\nMedical Association
\n(presentation given during the Scientific
\nSession \u201cInvestment in Health\u201d, Palens-
\nberg)
\nA general overview of health care in Japan,
\nwith particular mention of health care as an
\ninvestment.
\nOverview
\nApproximately 60 years ago, Japan had just
\nbegun postwar reconstruction. Food was
\ninadequate and nutritional and hygienic
\nconditions for the general public were
\nextremely bad. The incidence of infectious
\nand other diseases was high in both urban
\nand rural areas, and life expectancy in 1947
\nwas 50 for Japanese men and 54 for women.
\nHealth care in these circumstances was
\ncompletely inadequate.
\nJapan lost approximately 1.85 million people
\nin the Second World War; most cities were
\nrazed and the national wealth lost. The post-
\nwar reconstruction of Japan\u2019s social security
\nsystem proceeded with the establishment of
\na new National Constitution under the pow-
\nerful supervision of the occupational forces
\nGHQ. The new Japanese Constitution guar-
\nanteed fundamental human rights for citizens
\nin Article 11 and based on this, guaranteed
\ncitizens\u2019 right to live in Article 25, establish-
\ning the State\u2019s social responsibility in
\nParagraph 2, which states that \u201cIn all spheres
\nof life, the State shall use its endeavors for
\nthe promotion and extension of social wel-
\nfare and security, and of public health.\u201d
\nAmidst the harsh conditions imposed by the
\ndevastation left by the war, Japan began to
\nrebuild, and through the many efforts of its
\ncitizens the society\u2019s productive, economic,
\nand educational conditions began to gradual-
\nly and steadily improve.
\nLittle by little, everyday living conditions
\nalso improved. The greatest issue for
\nThe Health Care System in Japan:
\nCurrent Situation and Future Perspectives
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 15
\nWMA
\n16
\ntious diseases has decreased; in 2002 the
\naverage life expectancy for men was 78,
\nand for women was 85, making Japan the
\nworld\u2019s top country for longevity.
\nJapan is an island nation with little flat land;
\n90% of the country is forest-covered moun-
\ntains. Not only is Japan a volcanic country
\nthat faces the constant threat of massive and
\nepicentral earthquakes, but it also faces
\nwind and water damage every typhoon sea-
\nson. Since plentiful rainfall is beneficial for
\ntree growth, Japan has many fast-flowing
\nrivers. Compared with continents, rivers
\nflow only short distances from their well-
\nsprings to the ocean. These plentiful, clear
\nrivers play an important role in rice cultiva-
\ntion, in hydroelectric power generation, and
\nin many other functions in which water has
\nbeen innovatively utilized. Japan cannot
\nproduce oil or natural gas as energy sources
\nand its mineral resources are also small.
\nConsequently, national production in Japan
\ntends towards importing raw materials from
\noverseas, then manufacturing products using
\nvarious original processing technologies;
\npromotion of high intelligent added value in
\nindustrial production and high computeriza-
\ntion, Industrial structuring in areas such as
\nfinance, distribution, and services increasing
\nmore and more, invigorating the economy.
\nMany innovations have been made to pro-
\nduction methods for traditional rice, fruit,
\nand vegetable crops; developments in pro-
\nduction technology are not only used in
\ndomestic production but are also spread
\noverseas, with the export of production tech-
\nnology now becoming an important industry
\nthat also contributes internationally. Deep-
\nsea and coastal fishing are two other impor-
\ntant industries; the development and promo-
\ntion of innovative fish farming technology is
\nbecoming increasingly important as a means
\nof securing resources. The international
\nexport of seafood is a small industry in
\nJapan, but it also contributes greatly to the
\ndevelopment and diffusion of technology.
\nSince the industrial revolution, Japan\u2019s basic
\npolicy has been to enhance the education
\nsystem; citizens make efforts to promote
\nintelligent industry, understanding that we
\nreceive praise and great benefits from other
\ncountries through the development of sci-
\nence and technology and our contributions
\nto the international community.
\nThe development of transportation facilities
\nin Japan has enabled many people and goods
\nto be transported anywhere within the coun-
\ntry within half a day, and information can be
\ntransmitted instantly throughout the country.
\nThis was a huge leap forward for emer-
\ngency and disaster medicine in Japan. With
\nthese developments, from the 1950s on-
\nwards the basic components necessary for
\nproviding health care \u2013 hospitals, clinics,
\ndoctors, and nurses \u2013 all of which had been
\ninadequate, gradually increased and health
\ncare in regional areas expanded. A health
\ninsurance system which operated indepen-
\ndently for each health field continued to
\nexist, but there continued to be a large num-
\nber of people who had not paid their insur-
\nance. The Japan Medical Association re-
\ncommended that the individual insurance
\nsystems be integrated and the entire system
\nexpanded. Eventually, in 1961, the total
\nhealth insurance was expanded and a uni-
\nversal health care system available to all cit-
\nizens was introduced. Through the process
\nof establishing this system, medical fields
\nwere classified broadly into four groups.
\nAll citizens were required to join one of four
\ninsurance plans depending on their occupa-
\ntion and position: government-managed
\nhealth insurance administered by medium
\nand small businesses; association-managed
\nhealth insurance administered by the majori-
\nty of large businesses; National Health
\nInsurance administered by local government
\nauthorities; and National Health Cooperative
\nInsurance, also administered by the same
\nkind of businesses on a local level. The estab-
\nlishment of this system enabled citizens to
\nreceive health care equally and fairly any-
\nwhere in Japan, at any time and for whatever
\nreason, for a minimal self-payment and with-
\nout having to undergo screening simply by
\nshowing their insurance card to prove they
\nwere insured. Under this system, the medical
\ninstitution providing treatment receives the
\nportion of payment covered by public funds
\nunder a reimbursement system known as a
\nfee-for-service system. The system operates
\nsmoothly due to the efficient functioning of a
\nmedical fee payment fund that carefully
\nchecks the details of medical treatment.
\nImprovement of medical institution facilities
\nand the implementation of this medical insur-
\nance system have enabled huge advances in
\nregional health care systems and provided the
\ntremendous benefit of care being available
\nequally and fairly to all citizens.
\nBecause of differences in the history of their
\nestablishment and composition of member
\nbusinesses and organizations, each of the
\nheath insurance plans has difference insurance
\nrates. The government-managed health insur-
\nance plan is the largest in scale and imposes
\npublic benefits in addition to the insurance
\nburden on employers and members.
\nAgainst this background the Japan Medical
\nAssociation, as a pillar supporting the
\nhealth care of citizens, proactively promot-
\ned the establishment and maintenance of
\nthis system, and with the cooperation of
\nmedical institutions nationwide, the
\nNational Health System has made a huge
\ncontribution to the health system in Japan.
\nWith the development of the economy and
\nindustry in Japan, already outlined, the
\nemergency medicine infrastructure and
\ntreatment of chronic illness improved
\nthrough the continued improvement of
\nhygienic conditions, better nutrition, and
\nthe creation of infrastructure for the univer-
\nsal and fair provision of health care.
\nIn 2000 and 2004, the World Health
\nOrganization named Japan as a country with
\none of the highest longevity rates in the
\nworld, recognizing the excellence of Japan\u2019s
\nhealth system. Japan ranks Number 1 in the
\nworld in a comparison of health achievement;
\nin 2002 longevity was again the highest in the
\nworld, with the average life expectancy for
\nmen being 78.4 and for women 85.3; and
\nJapan also has one of the lowest infant mor-
\ntality rates in the world. Japan\u2019s excellent
\nNational Health Insurance system is the most
\neffective health insurance system of all the
\ndeveloped countries. Since the 1970s, Japan\u2019s
\nGNP has skyrocketed. With citizens\u2019growing
\nhealth consciousness and medical care
\nawareness as well as improvements in medi-
\ncine and medical technology, the total cost of
\nmedical treatment in Japan is gradually grow-
\ning and management of the health insurance
\nsystem has been revised repeatedly.
\nSince 1980, the total fertility rate has
\ndropped below 2.0 for a variety of reasons,
\nand in 2005 dropped to a marked low of
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 16
\nWMA
\n17
\n1.25. In a world rapidly ageing, Japan has
\nhurtled fastest into an aging society with
\nfewer children.
\nAs I have explained, medical expenses in
\nJapan are not high compared with other
\ndeveloped countries. Total health expenses
\nare 7.9% of GDP, a low rank of 17 amongst
\nthe developing countries. However, in 2000
\nJapan established a national Long-term Care
\nInsurance system, administered on a munic-
\nipal basis, aimed at elderly citizens requiring
\nnursing care as a means of lightening the
\ncontinuously increasing cost of health care
\nfor the elderly. The degree of nursing care
\nrequired is determined through screening
\nand nursing care services appropriate for the
\nelderly person\u2019s needs are provided.
\n\u201cHealth as an Investment\u201d
\nConsidering the population dynamics of
\nJapan, despite the difficulty of boosting the
\nproductive-age population, it could be possi-
\nble to secure a potential working population
\nby improving the health of senior citizens.
\nIncreased numbers of elderly people capable
\nof working would be an enormous opportu-
\nnity, creating fresh consumer activity and
\ninvigorating the economy. In other words,
\nproactive health care to restore, maintain, or
\nincrease health \u2013 such as avoiding the risk of
\ndisease occurring through preventative med-
\nicine and the promotion of social rehabilita-
\ntion and independence through early diag-
\nnosis and treatment \u2013 has ample potential to
\nincrease the health investment of each indi-
\nvidual, thereby increasing the population of
\npotential workers, bringing about an
\nincrease in productivity, GDP, and revenue
\nfrom tax, and thus more stable employment
\nand fresh economic activity. Furthermore,
\nhealth care is a labor-intensive industry, so a
\nstable supply of workers for medical institu-
\ntions will facilitate more stable health care.
\nMoreover, the construction of the necessary
\nmedical facilities could also create a wave
\neffect in the economy. In this way, there are
\ncertainly investment aspects in health care,
\nand it is vital that this is recognized widely
\nby members of the general public. The JMA
\nis currently seeking the understanding of the
\ngovernment headed by Prime Minister Abe,
\nnewly formed in September this year, of the
\nnecessity of promoting basic policies such
\nas this.
\nThe JMA is proactively pursuing the fol-
\nlowing items as comprehensive and central
\npolicies for health reform, including the
\nviews just mentioned.
\n1. Creation of a society able to truly rejoice
\nat longevity through enhanced health
\ncare and welfare for the elderly.
\n2. Creation of a society where one can give
\nbirth with peace of mind through the
\nexpansion of obstetrical care and mater-
\nnal and child health.
\n3. Creation of a society where children can
\nthrive and grow healthily through
\nenhanced pediatric care and school
\nhealth.
\n4. Creation of a society where people can
\nwork healthily and enthusiastically
\nthrough enhanced industrial health and
\nworkers\u2019 compensation insurance.
\n5. Creation of a society with as little occur-
\nrence of disease as possible through the
\npromotion of healthy lifestyle and
\nlifestyle disease countermeasures and
\nanti-smoking campaigns.
\n6. Creation of a society able to provide
\nhigh quality medical care for those who
\nare sick, through the guarantee and
\nenhancement of community health care
\nand health insurance.
\n7. Creation of a society that provides an
\nexcellent health care system through the
\nenhancement of community heath care
\ncentred on primary care doctors and the
\npromotion of cooperation between
\nhealth services.
\n8. Creation of a society able to put medical
\nadvances into practice in health care
\nthrough the establishment of lifetime edu-
\ncation and a medical specialist system.
\nFinally, with regard to approaches to gov-
\nernment agencies concerning issues such as
\nthese, the JMA is campaigning to prevent
\ncorruption of the medical care system,
\nincluding financially motivated proposals
\nfor medical system reform, mainly through
\npetitions and the endorsement of Diet mem-
\nbers who represent the position of the JMA
\nin the government.
\nThe JMA intends to continue to promote the
\nconstruction of a foundation for communi-
\nty health care, working with the general
\npublic to formulate and propose strategies
\nfor realizing the establishment of a health
\ncare framework that people trust, in order to
\ncreate a durable social insurance system
\nthat safeguards the heath and welfare of
\nJapan\u2019s citizens.
\nAdopted by the WMA General Assembly,
\nPilanesberg, South Africa, October 2006
\nIntroduction
\n1. HIV\/AIDS is a global pandemic that
\nhas created unprecedented challenges
\nfor physicians and health infrastruc-
\ntures. In addition to representing a stag-
\ngering public health crisis, HIV\/AIDS
\nis also fundamentally a human rights
\nissue. Many factors drive the spread of
\nThe World Medical Association Statement on
\nHIV\/AIDS and the Medical Profession
\nthe disease, such as poverty, homeless-
\nness, illiteracy, prostitution, human traf-
\nficking, stigma, discrimination and gen-
\nder-based inequality. Efforts to tackle
\nthe disease are constrained by the lack
\nof human and financial resources avail-
\nable in health care systems. These
\nsocial, economic, legal and human
\nrights factors affect not only the public
\nhealth dimension of HIV\/AIDS but also
\nindividual physicians\/health workers
\nand patients, their decisions and rela-
\ntionships.
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 17
\nWMA
\n18
\nDiscrimination
\n2. Unfair discrimination against
\nHIV\/AIDS patients by physicians must
\nbe eliminated completely from the prac-
\ntice of medicine.
\na. All persons infected or affected by
\nHIV\/AIDS are entitled to adequate
\nprevention, support, treatment and
\ncare with compassion and respect for
\nhuman dignity.
\nb. A physician may not ethically refuse
\nto treat a patient whose condition is
\nwithin his or her current realm of
\ncompetence, solely because the
\npatient is seropositive.
\nc. National Medical Associations
\nshould work with governments,
\npatient groups and relevant national
\nand international organizations to
\nensure that national health policies
\nclearly and explicitly prohibit dis-
\ncrimination against people infected
\nwith or affected by HIV\/AIDS.
\nAppropriate \/ Competent
\nMedical Care
\n3. Patients with HIV\/AIDS must be pro-
\nvided with competent and appropriate
\nmedical care at all stages of the disease.
\n4. A physician who is not able to provide
\nthe care and services required by
\npatients with HIV\/AIDS should make
\nan appropriate referral to those physi-
\ncians or facilities that are equipped to
\nprovide such services. Unless or until
\nthe referral can be accomplished, the
\nphysician must care for the patient to
\nthe best of his or her ability.
\n5. Physicians and other appropriate bodies
\nshould ensure that patients have accu-
\nrate information regarding means of
\ntransmission of HIV\/AIDS and strate-
\ngies to protect themselves against infec-
\ntion. Proactive measures should be
\ntaken to ensure that all members of the
\npopulation, and at-risk groups in partic-
\nular, are educated to this effect.
\n6. With reference to those patients who are
\nfound to be seropositive, physicians
\nmust be able to effectively counsel them
\nregarding: (a) responsible behaviour to
\nprevent the spread of the disease; (b)
\nstrategies for their own health protec-
\ntion; and (c) the necessity of alerting
\nsexual and needle-sharing contacts, past
\nand present, as well as other relevant
\ncontacts (such as medical and dental
\npersonnel) regarding their possible
\ninfection.
\n7. Physicians must recognize that many
\npeople still believe HIV\/AIDS to be an
\nautomatic and immediate death sentence
\nand therefore will not seek testing.
\nPhysicians must ensure that patients
\nhave accurate information regarding the
\ntreatment options available to them.
\nPatients should understand the potential
\nof antiretroviral treatment (ART) to
\nimprove not only their medical condi-
\ntion but also the quality of their lives.
\nEffective ART can greatly extend the
\nperiod of time that patients are able to
\nlead healthy productive lives, function-
\ning socially and in the workplace and
\nmaintaining their independence.
\nHIV\/AIDS is increasingly looked upon
\nas a manageable chronic condition.
\n8. While strongly advocating ART as the
\nbest course of action for HIV\/AIDS
\npatients, physicians must also ensure
\nthat their patients are fully and accurate-
\nly informed about all aspects of ART,
\nincluding potential toxicity and side
\neffects. Physicians must also counsel
\npatients honestly about the possibility
\nof failure of first line ART, and the sub-
\nsequent options should failure occur.
\nThe importance of adhering to the regi-
\nmens and thereby reducing the risk of
\nfailure should be emphasized.
\n9. Physicians should be aware that misin-
\nformation regarding the negative
\naspects of ART has created resistance
\ntoward treatment by patients in some
\nareas. Where misinformation is being
\nspread about ART, physicians and med-
\nical associations must make it an imme-
\ndiate priority to publicly challenge the
\nsource of the misinformation and to
\nwork with the HIV\/AIDS community to
\ncounteract the negative effects of the
\nmisinformation.
\n10. Physicians should encourage the
\ninvolvement of support networks to
\nassist patients in adhering to ART regi-
\nmens. With the patient\u2019s consent, coun-
\nselling and training should be available
\nto family members to assist them in pro-
\nviding family based care. Physicians
\nmust recognize families and other sup-
\nport networks as crucial partners in
\nadherence strategies and, in many
\nplaces, the only means to adequately
\nexpand the care system so that patients
\nreceive the required attention.
\n11. Physicians must be aware of the discrim-
\ninatory attitudes toward HIV\/AIDS that
\nare prevalent in society and local culture.
\nBecause physicians are the first, and
\nsometimes the only, people who are
\ninformed of their patients\u2019 HIV status,
\nphysicians should be able to counsel
\nthem about their basic social and legal
\nrights and responsibilities or should refer
\nthem to counsellors who specialize in the
\nrights of persons living with HIV\/AIDS.
\nTesting
\n12. Mandatory testing for HIV must be
\nrequired of: donated blood and blood
\nfractions collected for donation or to be
\nused in the manufacture of blood prod-
\nucts; organs and other tissues intended
\nfor transplantation; and semen or ova
\ncollected for assisted reproduction pro-
\ncedures.
\n13. Mandatory HIV testing of an individual
\nagainst his or her will is a violation of
\nmedical ethics and human rights.
\nExceptions to this rule may be made
\nonly in the most extreme cases and
\nshould be subject to review by an ethics
\npanel or to judicial review.
\n14. Physicians must clearly explain the pur-
\npose of an HIV test, the reasons it is rec-
\nommended and the implications of a pos-
\nitive test result. Before a test is adminis-
\ntered, the physician should have an
\naction plan in place in case of a positive
\ntest result. Informed consent must be
\nobtained from the patient prior to testing.
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 18
\nWMA
\n19
\n15. While certain groups are labelled \u201ehigh
\nrisk\u201c, anyone who has had unprotected
\nsex should be considered at some risk.
\nPhysicians must become increasingly
\nproactive about recommending testing to
\npatients, based on a mutual understand-
\ning of the level of risk and the potential
\nto benefit from testing. Pregnant women
\nshould routinely be offered testing.
\n16. Counselling and voluntary anonymous
\ntesting for HIV should be available to all
\npersons who request it, along with ade-
\nquate post-testing support mechanisms.
\nProtection from HIV in the
\nHealth Care Environment
\n17. Physicians and all health care workers
\nhave the right to a safe work environ-
\nment. Especially in developing coun-
\ntries, the problem of occupational expo-
\nsure to HIV has contributed to high
\nattrition rates of the health labour force.
\nIn some cases, employees become
\ninfected with HIV, and in other cases
\nfear of infection causes health care
\nworkers to leave their jobs voluntarily.
\nFear of infection among health workers
\ncan also lead to refusal to treat
\nHIV\/AIDS patients. Likewise, patients
\nhave the right to be protected to the
\ngreatest degree possible from transmis-
\nsion of HIV from health professionals
\nand in health care institutions.
\na. Proper infection control procedures
\nand universal precautions consistent
\nwith the most current national or
\ninternational standards, as appropri-
\nate, should be implemented in all
\nhealth care facilities. This includes
\nprocedures for the use of preventive
\nART for health professionals who
\nhave been exposed to HIV.
\nb. If the appropriate safeguards for pro-
\ntecting physicians or patients against
\ninfection are not in place, physicians
\nand National Medical Associations
\nshould take action to correct the situ-
\nation.
\nc. Physicians who are infected with HIV
\nshould not engage in any activity that
\ncreates a risk of transmission of the dis-
\nease to others. In the context of possi-
\nble exposure to HIV, the activity in
\nwhich the physician wishes to engage
\nwill be the determining factor. Whether
\nor not an activity is acceptable should
\nbe determined by a panel or committee
\nof health care workers with specific
\nexpertise in infectious diseases.
\nd. In the provision of medical care, if a
\nrisk of transmission of an infectious
\ndisease from a physician to a patient
\nexists, disclosure of that risk to patients
\nis not enough; patients are entitled to
\nexpect that their physicians will not
\nincrease their exposure to the risk of
\ncontracting an infectious disease.
\ne. If no risk exists, disclosure of the
\nphysician\u2019s medical condition to his
\nor her patients will serve no rational
\npurpose.
\nProtecting Patient Privacy
\nand Issues Related to
\nNotification
\n18. Fear of stigma and discrimination is a
\ndriving force behind the spread of
\nHIV\/AIDS. The social and economic
\nrepercussions of being identified as
\ninfected can be devastating and can
\ninclude violence, rejection by family and
\ncommunity members, loss of housing
\nand loss of employment, to name only a
\nfew. Normalizing the presence of
\nHIV\/AIDS in society through public
\neducation is the only way to reduce dis-
\ncriminatory attitudes and practices. Until
\nthat can be universally achieved, or a
\ncure is developed, potentially infected
\nindividuals will refuse testing to avoid
\nthese consequences. The result of indi-
\nviduals not knowing their HIV status is
\nnot only disastrous on a personal level in
\nterms of not receiving treatment, but
\nmay also lead to high rates of avoidable
\ntransmission of the disease. Fear of
\nunauthorized disclosure of information
\nalso provides a disincentive to partici-
\npate in HIV\/AIDS research and general-
\nly thwarts the efficacy of prevention pro-
\ngrams. Lack of confidence in protection
\nof personal medical information regard-
\ning HIV status is a threat to public health
\nglobally and a core factor in the contin-
\nued spread of HIV\/AIDS. At the same
\ntime, in certain circumstances, the right
\nto privacy must be balanced with the
\nright of partners (sexual and injection
\ndrug) of persons with HIV\/AIDS to be
\ninformed of their potential infection.
\nFailure to inform partners not only vio-
\nlates their rights but also leads to the
\nsame health problems of avoidable
\ntransmission and delay in treatment.
\n19. All standard ethical principles and
\nduties related to confidentiality and pro-
\ntection of patients\u2019 health information,
\nas articulated in the WMA Declaration
\nof Lisbon on the Rights of the Patient,
\napply equally in the context of
\nHIV\/AIDS. In addition, National
\nMedical Associations and physicians
\nshould take note of the special circum-
\nstances and obligations (outlined
\nbelow) associated with the treatment of
\nHIV\/AIDS patients.
\na. National Medical Associations and
\nphysicians must, as a matter of prior-
\nity, ensure that HIV\/AIDS public
\neducation, prevention and coun-
\nselling programs contain explicit
\ninformation related to protection of
\npatient information as a matter not
\nonly of medical ethics but of their
\nhuman right to privacy.
\nb. Special safeguards are required when
\nHIV\/AIDS care involves a physically
\ndispersed care team that includes
\nhome-based service providers, family
\nmembers, counsellors, case workers
\nor others who require medical infor-
\nmation to provide comprehensive
\ncare and assist in adherence to treat-
\nment regimens. In addition to imple-
\nmenting protection mechanisms
\nregarding transfer of information,
\nethics training regarding patient pri-
\nvacy should be given to all team
\nmembers.
\nc. Physicians must make all efforts to
\nconvince HIV\/AIDS patients to take
\naction to notify all partners (sexual
\nand\/or injection drug) about their
\nexposure and potential infection.
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 19
\nWMA
\n20
\nPhysicians must be competent to
\ncounsel patients about the options for
\nnotifying partners. These options
\nshould include:
\n1. notification of the partner(s) by the
\npatient. In this case, the patient
\nshould receive counselling regard-
\ning the information that must be
\nprovided to the partner and strate-
\ngies for delivering it with sensitivi-
\nty and in a manner that is easily
\nunderstood. A timetable for notifi-
\ncation should be established and
\nthe physician should follow-up
\nwith the patient to ensure that noti-
\nfication has occurred.
\n2. notification of the partner(s) by a
\nthird party. In this case, the third
\nparty must make every effort to
\nprotect the identity of the patient.
\nd. When all strategies to convince the
\npatient to take such action have been
\nexhausted, and if the physician knows
\nthe identity of the patient\u2019s partner(s),
\nthe physician is compelled, either by
\nlaw or by moral obligation, to take
\naction to notify the partner(s) of their
\npotential infection. Depending on the
\nsystem in place, the physician will
\neither notify directly the person at risk
\nor report the information to a desig-
\nnated authority responsible for notifi-
\ncation. In cases where a physician
\nmust disclose the information regard-
\ning exposure, the physician must:
\n1. inform the patient of his or her
\nintentions,
\n2. to the extent possible, ensure that
\nthe identity of the patient is pro-
\ntected,
\n3. take the appropriate measures to pro-
\ntect the safety of the patient, espe-
\ncially in the case of a female patient
\nvulnerable to domestic violence.
\ne. Regardless of whether it is the
\npatient, the physician or a third party
\nwho undertakes notification, the per-
\nson learning of his or her potential
\ninfection should be offered support
\nand assistance in order to access test-
\ning and treatment.
\nf. National Medical Associations should
\ndevelop guidelines to assist physi-
\ncians in decision-making related to
\nnotification. These guidelines should
\nhelp physicians understand the legal
\nrequirements and consequences of
\nnotification decisions as well as the
\nmedical, psychological, social and
\nethical considerations.
\ng. National Medical Associations
\nshould work with governments to
\nensure that physicians who carry out
\ntheir ethical obligation to notify indi-
\nviduals at risk, and who take precau-
\ntions to protect the identity of their
\npatient, are afforded adequate legal
\nprotection.
\nMedical Education
\n20. National Medical Associations should
\nassist in ensuring that there is training
\nand education of physicians in the most
\ncurrent prevention strategies and med-
\nical treatments available for all stages of
\nHIV\/AIDS, including prevention and
\nsupport.
\n21. National Medical Associations should
\ninsist upon and assist with, when possi-
\nble, the education of physicians in the
\nrelevant psychological, legal, cultural
\nand social dimensions of HIV\/AIDS.
\n22. National Medical Associations should
\nfully support the efforts of physicians
\nwishing to concentrate their expertise in
\nHIV\/AIDS care, even where HIV\/AIDS
\nis not recognized as an official specialty
\nor sub-specialty within the medical edu-
\ncation system.
\n23. The WMA encourages its National
\nMedical Associations to promote the
\ninclusion of designated, comprehensive
\ncourses on HIV\/AIDS in undergraduate
\nand postgraduate medical education
\nprograms, as well as continuing medical
\neducation.
\nAdopted by the WMA General Assembly,
\nPilanesberg, South Africa, October 2006
\nPreamble
\n1. Assisted reproductive technology
\nencompasses a wide range of tech-
\nniques designed primarily to aid cou-
\nples unable to conceive without medical
\nassistance. Since the birth of the first
\nso-called \u2018test-tube baby\u2019 in 1978, more
\nthan 1.5 million children worldwide
\nhave been born following IVF treat-
\nment.
\nThe World Medical Association Statement on
\nAssisted Reproductive Technologies
\n2. The term \u2018assisted reproductive tech-
\nnology\u2019 includes techniques such as
\nin-vitro fertilisation (IVF) and intra-
\ncytoplasmic sperm injection (ICSI). It
\ncan be defined as including all treat-
\nments that include medical and scien-
\ntific manipulation of human gametes
\nand embryos in order to produce a
\nterm pregnancy. Although some legis-
\nlatures have considered artificial
\ninsemination, whether using donor
\nsemen or semen from the patient\u2019s
\npartner, as different, many of the
\nissues about regulation in relation to
\nobtaining, storing, using and dispos-
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 20
\nWMA
\n21
\ning of gametes and embryos are close-
\nly interlinked. In this statement treat-
\nments such as artificial insemination
\nare excluded.
\n3. Assisted reproductive technologies
\nraise profound moral issues. Views
\nand beliefs about the moral status of
\nthe embryo, which are central to much
\nof the debate in this area, vary both
\nwithin and among countries. Assisted
\nconception is also regulated different-
\nly in various countries. Whilst consen-
\nsus can be reached on some issues,
\nthere remain fundamental differences
\nof opinion that cannot be resolved.
\nThis statement identifies areas of
\nagreement and also highlights those
\nmatters on which agreement cannot be
\nreached. Physicians faced with such
\nsituations should comply with applic-
\nable laws and regulations as well as
\nthe ethical requirements and profes-
\nsional standards established by their
\nNational Medical Association and
\nother appropriate organisations in the
\ncommunity.
\n4. Physicians involved in providing assist-
\ned reproductive technologies should
\nalways consider their ethical responsi-
\nbilities towards any child who may be
\nborn as a result of the treatment. If there
\nis evidence that a future child would be
\nexposed to serious harm, treatment
\nshould not be provided.
\n5. As with all other medical procedures,
\nphysicians also have an ethical obliga-
\ntion to limit their practice to areas in
\nwhich they have relevant expertise and
\nexperience and to respect the rights of
\npatients. These rights include that of
\npersonal bodily integrity and freedom
\nfrom coercion. In practice this means
\nthat valid or real consent is required as
\nwith other medical procedures; the
\nvalidity of such consent is dependent
\nupon the adequacy of the information
\noffered to the patient and their freedom
\nto make a decision, including freedom
\nfrom coercion or other pressures to
\ndecide in a particular way.
\n6. Assisted conception differs from the
\ntreatment of illness in that the inability
\nto become a parent without medical
\nintervention is not always regarded as
\nan illness. While it may have profound
\npsychosocial, and thus medical, conse-
\nquences, it is not in itself life limiting. It
\nis, however, a significant cause of major
\npsychological illness and its treatment
\nis clearly medical.
\n7. Obtaining informed consent from those
\nconsidering undertaking treatment must
\ninclude consideration of the alterna-
\ntives, including accepting childlessness
\nor pursuing adoption, the risks associat-
\ned with the various techniques, and the
\npossibility of failure. In many jurisdic-
\ntions the process of obtaining consent
\nmust follow a process of information
\ngiving and the offer of counselling and
\nmight also include a formal assessment
\nof the patient in terms of the welfare of
\nthe potential child.
\n8. Patients seeking assisted reproductive
\ntechnologies are entitled to the same
\nlevel of confidentiality and privacy as
\nfor any other medical treatment.
\n9. Assisted reproductive technology
\nalways involves handling and manipu-
\nlation of human gametes and embryos.
\nDifferent individuals regard this with
\ndifferent levels of concern but there is
\ngeneral agreement that these special
\nconcerns should be met by specific
\nsafeguards to protect from abuse. In
\nsome jurisdictions all centres handling
\nsuch materials require a licence and
\nmust demonstrate compliance with high
\nnormative standards.
\nSuccess of the
\ntechniques
\n10. The success of different techniques
\nmay differ widely from centre to cen-
\ntre. Physicians have an obligation to
\ngive realistic information about success
\nrates to potential patients. If their suc-
\ncess rates are widely different from the
\ncurrent norm they should disclose this
\nfact to patients. They also have an
\nobligation to consider the reasons for
\nthis as they might relate to poor prac-
\ntice, and if so, to correct their deficien-
\ncies.
\nMultiple pregnancies
\n11. Replacement of more than one embryo
\nmay raise the likelihood of at least one
\nembryo implanting. This is offset by
\nthe increased risk, especially of prema-
\nture labour, in multiple pregnancies.
\nThe risk of twin pregnancies, while
\nhigher than that of singleton pregnan-
\ncies, is considered acceptable by most
\npeople. Practitioners should follow pro-
\nfessional guidance on the maximum
\nnumber of embryos to be transferred
\nper treatment cycle. If multiple preg-
\nnancies occur, selective termination
\nmight be considered on medical
\ngrounds to increase the chances of the
\npregnancy proceeding to term where
\nthis is compatible with the national law
\nand code of ethics.
\nDonation
\n12. Some patients are unable to produce
\nusable gametes. They require ova or
\nsperm from donors. Donation should
\nfollow counselling and be carefully
\ncontrolled to avoid abuses, including
\ncoercion of potential donors. It is inap-
\npropriate to offer money or benefits in
\nkind (for example free or lower cost
\ntreatment cycles) to encourage donation
\nbut donors may be reimbursed for rea-
\nsonable expenses.
\n13. Where a child is born following dona-
\ntion, families should be encouraged to
\nbe open with him\/her about this, irre-
\nspective of whether domestic law enti-
\ntles the child to information about the
\ndonor. Keeping secrets within families
\nis difficult and can be harmful to chil-
\ndren if information about donor concep-
\ntion is disclosed inadvertently and with-
\nout appropriate support.
\nPre-implantation Genetic
\nDiagnosis (PGD)
\n14. Pre-implantation genetic diagnosis
\n(PGD) may be performed on early
\nembryos to search for the presence of
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 21
\nWMA
\n22
\ngenetic or chromosomal abnormalities,
\nespecially those associated with severe
\nillness and very premature death and
\nfor other reasons, including identifying
\nthose embryos most likely to implant
\nsuccessfully in women who have had
\nmultiple spontaneous abortions.
\nEmbryos carrying the abnormality are
\ndiscarded; only embryos with apparent-
\nly normal genetic and chromosomal
\ncomplements are implanted.
\n15. Neither this powerful technique nor
\nsimpler means should be used for triv-
\nial reasons such as sex selection for rea-
\nsons of gender preference. The WMA
\nholds that physicians should only be
\ninvolved with sex selection where it is
\nused to avoid a serious sex-chromo-
\nsome related condition such as
\nDuchenne\u2019s Muscular Dystrophy.
\n16. PGD can also be combined with HLA
\nmatching to select embryos on the basis
\nthat stem cells from the resulting
\nchild\u2019s umbilical cord blood could be
\nused to treat a seriously ill sibling.
\nViews on the acceptability of this prac-
\ntice vary and physicians should follow
\nnational laws and local ethical and pro-
\nfessional standards if confronted with
\nsuch requests.
\nUse of spare gametes
\nand embryos and disposal
\nof unused gametes and
\nembryos
\n17. In most cases, assisted conception
\nresults in the production of gametes and
\nembryos that will not be used to treat
\nthose from whom they are procured.
\nSuch so-called spare gametes and
\nembryos may be stored, cryo-preserved
\nfor future use, donated to other patients
\nor disposed of. One alternative to dis-
\nposal, in countries that permit embryo
\nresearch, is donation to a research facil-
\nity. The available options must be
\nexplained clearly and precisely to indi-
\nviduals before donations are made or
\nretrievals performed.
\nSurrogacy
\n18. Where a woman is unable, for medical
\nreasons, to carry a child to term, surro-
\ngacy may be used to overcome child-
\nlessness, unless prohibited by national
\nlaw or the ethical rules of the National
\nMedical Association or other relevant
\norganisation. Where surrogacy is prac-
\ntised, great care must be taken to protect
\nthe interests of all parties involved.
\nResearch
\n19. Physicians should promote the impor-
\ntance of research using tissues
\nobtained during assisted conception
\nprocedures. Because of the special sta-
\ntus of the material being used, research
\non human gametes and especially on
\nhuman embryos is, in many jurisdic-
\ntions, specifically regulated.
\nPhysicians have an ethical duty to
\ncomply with such regulation and to
\nhelp inform public debate and under-
\nstanding of the issues.
\n20. Due to the special nature of human
\nembryos, research should be carefully
\ncontrolled and should be limited to
\nareas in which the use of alternative
\nmaterials will not provide an adequate
\nalternative.
\n21. Views, and legislation, differ on
\nwhether embryos may be created
\nspecifically for, or in the course of,
\nresearch. Physicians should act in
\naccordance with national legislation and
\nlocal ethical advice.
\nCell Nuclear Replacement
\n22. The WMA opposes the use of cell
\nnuclear replacement with the aim of
\ncloning human beings.
\n23. Cell nuclear replacement may also be
\nused to develop embryonic stem cells
\nfor research and ultimately, it is hoped,
\nfor therapy for many serious diseases.
\nViews on the acceptability of such
\nresearch differ and physicians wishing
\nto participate in such research should
\nensure that they are acting in accor-
\ndance with national laws and local ethi-
\ncal guidance.
\nRecommendations
\n24. Assisted reproductive technology is a
\ndynamic, rapidly developing field of
\nmedical practice. Developments should
\nbe subject to careful ethical considera-
\ntion alongside the scientific monitoring.
\n25. Human gametes and embryos are
\naccorded a special status. Their use,
\nincluding for research, donation to oth-
\ners and disposal, should be carefully
\nexplained to potential donors and sub-
\nject to local regulation.
\n26. Embryo research should only be carried
\nout if local law and ethical standards
\npermit it and should be limited to areas
\nwhere the use of alternative materials or
\ncomputer modelling does not provide
\nan adequate alternative.
\n27. Physicians should follow professional
\nguidance on the maximum number of
\nembryos to transfer in any treatment
\ncycle.
\n28. It is inappropriate to offer money or
\nbenefits in kind (for example free or
\nlower cost treatment cycles) to encour-
\nage donation but donors may be reim-
\nbursed for reasonable expenses
\n29. Families using donated embryos or
\ngametes should be encouraged and sup-
\nported to be open with the child about
\nthis.
\n30. Sex selection should only be carried out
\nto avoid serious, including life threaten-
\ning, medical conditions.
\n31. Physicians have an important role in
\nensuring that public debate about the
\npossibilities of assisted conception, and
\nthe limits to be applied to its practice, is
\ninformed.
\n32. Physicians should comply with national
\nlegislation and should demonstrate
\ncompliance with high normative stan-
\ndards.
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 22
\nWHO
\n23
\nnations and their populations interact inter-
\nnationally. Referring to SARS as an exam-
\nple of how vulnerability to health threats
\nhad changed in a mobile and interconnected
\nworld, she referred to the impact on health
\nof emerging infective diseases, natural dis-
\nasters or environmental change.
\nIn 2008, the 60th
\nanniversary of WHO and the
\n30th
\nof Alma- Ata, the focus of the World
\nHealth report would be on primary health care
\nand its role in strengthening health systems.
\nDr. Chan spoke of the unprecedented
\ngrowth in numbers of partnerships, initia-
\ntives and funding agencies devoted to pub-
\nlic health in terms of avoiding duplication
\nand fragmentation of efforts. One way for-
\nward to integrated service delivery such as
\nmalaria and neglected tropical diseases was
\nto use an integrated primary health care
\napproach. Stress was also laid on health sys-
\ntems, evidence for measuring impact, and
\naccess to essential care.
\nDr. Chan concluded by commenting on
\navian influenza and the \u201cneed not to let
\ndown our guard\u201d, Commenting on this she
\nobserved that the new International Health
\nRegulations come into effect in June, which
\nshould help to reinforce the preparations of
\nthe past three years.
\nIn her first address to the Executive
\nCommittee of WHO as Director General,
\nDr. Margaret Chan identified six issues to
\nguide the approach to future work. Two
\naddressed fundamental needs \u2013 health
\ndevelopment and health security. Two
\nreferred to strengthening health systems and
\nacquiring better evidence to measure and
\nshape results, and the last two concern oper-
\nation reliance on partners and good perfor-
\nmance of WHO as an organisation.
\nAddressing health development, Dr. Chan
\nreferred to her earlier indication that the mea-
\nsure of WHO\u2019s work should be its impact on
\ntwo groups, women in particular, and the peo-
\nple ofAfrica, which would require more to be
\ndone in some areas of work. In developing
\nthese issues particularly in relation to Africa
\nand Women stress was laid on the high atten-
\ntion already taking place to achieve the mille-
\nnium goals and the importance of the links
\nbetween poverty and health. The measles
\nreduction success in Africa was an indication
\nof the real potential for health improvement.
\nThere was need for the capacities of African
\npeople to be released. Turning to the
\nimmense suffering due to Malaria in many
\nparts of the world, she stressed that in Africa,
\nwhere there was no malaria season as trans-
\nmission occurs throughout the year, in terms
\nof economic impact 25 % of household
\nincomes were consumed by malaria.
\nHowever the progress in scaling up interven-
\ntions on Malaria was good news.
\nShe also referred both to neglected tropical
\ndiseases and also to the impact of chronic
\ndiseases, especially their impact on low and
\nmiddle income countries. The demands and
\ncosts of chronic care challenge health sys-
\ntems across the world and for this preven-
\ntion is the best option .WHO must continue
\nto convince health leaders that chronic dis-
\nease is part of the development agenda.
\nHealth and Security, the topic for World
\nHealth Day, would be the topic for this
\nyear\u2019s World Health Report ( and for World
\nHealth Day) would focus on risks and dan-
\ngers to health from the ways in which
\nWorld Health Organisation
\nKey Issues for future WHO work
\nGENEVA March 2007 \u2013 A new internation-
\nal Task Force was launched and has met to
\ntackle the global shortage of health work-
\ners. With a shortfall of 4.3 million health
\nworkers worldwide, including more than 1
\nmillion in Africa alone, there is an urgent
\nneed to increase the number of doctors,
\nnurses, health managers and other health
\ncare workers needed to face immediate
\nhealth crises.
\nDr. Margaret Chan, Director-General of the
\nWorld Health Organization (WHO), wel-
\ncomed the new Task Force: \u201cThe simple
\nfact is that the world needs many more
\nhealth workers. The world faces global as
\nwell as local threats to health. Infectious
\ndiseases have staged a dramatic comeback,
\nand chronic diseases are on the rise. We
\ncannot improve people\u2019s health without
\nstaff to deliver health care.\u201d
\nThe new global Task Force, chaired by Lord
\nNigel Crisp, former Chief Executive of the
\nNational Health Service in England, and
\nBience Gawanas, the African Union
\nCommissioner for Social Affairs, has been
\nset up under the auspices of the Global
\nInternational action needed
\nto increase health workforce
\nHealth Workforce Alliance (GHWA). It
\nincludes two African Ministers of Health \u2013
\nDr. Stephen Mallinga of Uganda and
\nMarjorie Ngaunje of Malawi \u2013 and senior
\nhealth policy makers from across the globe,
\nfrom public and private sectors, and both
\ndeveloping and developed countries.
\nTogether these leaders in health and educa-
\ntion will champion the need for significant-
\nly increased investment in the education
\nand training of health workers in develop-
\ning countries, and will build international
\ncommitment to practical action.
\nThe Joint Learning Initiative (2004) and the
\nWorld Health Report 2006 have brought this
\nshortage of health workers to the world\u2019s
\nattention, and the World Health Assembly
\nhas called for urgent action. Fifty-seven
\ncountries have critical shortages of health
\nworkers of which 36 are in sub-Saharan
\nAfrica. If the crisis is not tackled, these
\ncountries will not be able to provide their
\npopulations with basic health care.
\n\u201cHIV\/AIDS, malaria and TB, and maternal
\nand child mortality \u2013 which together kill
\nmany millions of people annually across the
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 23
\nWHO
\n24
\nworld, will not be significantly reduced
\nunless the crisis in health workers is tack-
\nled,\u201d said Lord Crisp. \u201cThere is an urgent
\nneed for a massive international effort to
\ntrain more health care workers, including
\ndoctors, nurses, managers and community
\nhealth workers.\u201d
\nThe Task Force will focus on practical
\nsolutions, also considering the need and
\nscope for international financial and tech-
\nnical support, links between training insti-
\ntutions and universities in the developed
\nand developing world, and innovative use
\nof distance-learning technology. Already
\nsome countries are beginning to address
\nthe problem with programmes of education
\nand training. Some countries such as
\nEthiopia, India and Malawi are beginning
\nto address the problem, rapidly increasing
\nthe production of health workers through
\neducation and training in various ways.
\nThe Task Force will look at the impact of
\nsuch programmes and assess the scope to
\nreplicate these and the resources needed to
\ndo so.
\nThe Task Force GHWA Executive Director
\nDr. Francis Omaswa, welcomed the Task
\nForce. \u201cGHWA has identified a need for
\nsome type of \u2018fast-track\u2019 training initiative
\nto address the health worker shortage. This
\nnew GHWA Task Force will make practical
\nrecommendations for action. The Task
\nForce will also work closely with other pro-
\ngrammes which address issues such as
\nhealth worker migration, health financing,
\nand access to HIV\/AIDS treatment, preven-
\ntion and care.\u201c
\nThe Task Force is due to present its initial
\nrecommendations to the GHWA Forum in
\nAutumn 2007.
\nThe Task Force members are
\n\u2022 Lord Nigel Crisp (co-chair)
\n\u2022 Bience Gawanas (co-chair,African Union
\nCommission)
\n\u2022 Hon. Stephen Mallinga (Health Minister
\nUganda)
\n\u2022 Hon. Marjorie Ngaunje (Health Minister
\nMalawi)
\n\u2022 Prof. Srinath Reddy (Director, Public
\nHealth Foundation of India)
\n\u2022 Peter Loescher (President Global Human
\nHealth Merck and Co)\/Jeff Sturchio (Vice
\nPresident External Affairs, Merck and Co).
\n\u2022 Dr. Joy Phumaphi (Vice-President and
\nHead Human Health Development
\nNetwork\/Alexander Prekker (Lead Eco-
\nnomist, Health, Nutrition and Population,
\nWorld Bank)
\n\u2022 Judith Oulton (CEO, International
\nCouncil of Nurses)
\n\u2022 Kathy Cahill (Gates Foundation)
\n\u2022 Sarita Bhatla (CIDA,DG Governance and
\nSocial Directorate)\/Jeea Sarawati (CIDA,
\nHealth Specialist African Branch)
\nFurther information:
\nP. Ben Fouquet, Communications Officer,
\nGHWA, WHO Geneva tel+41 22 791 3554
\ne-mail fouquetp@who.int
\nAfrica is developing solutions for fighting
\ndisease and improving health, a new WHO
\nreport finds
\n20 NOVEMBER 2006 | ADDIS
\nABABA\/GENEVA\/LONDON \u2013 The signs
\nare everywhere, across the continent: Africa
\nis finding African approaches to solving its
\nhealth problems.
\nIn Uganda, 50 percent of all HIV\/AIDS
\npatients have been reached with life-saving
\nantiretroviral medicine through an innova-
\ntive programme that trains nurses to do
\nsome of the work traditionally done by doc-
\ntors and community health workers to take
\non some of the work of nurses.
\nIn Mali, community cost-sharing schemes
\nhave provided 35 of the country\u2019s 57 com-
\nmunity health centres with staff trained to
\ndeliver babies and perform emergency cae-
\nsarian sections, making skilled obstetric
\ncare available to thousands of women who
\ncould not previously afford it.
\nIn Rwanda, a police-led road safety cam-
\npaign, which has included introduction of
\nfines for failure to wear seatbelts or hel-
\nmets, resulted in a drop of nearly one quar-
\nter in the number of deaths from road traffic
\ninjuries in a single year.
\nAnd in South Africa, a health-care train rou-
\ntinely transports young doctors and final-
\nyear medical students to isolated farming
\nareas that would otherwise have no access
\nto basic medical services. To date the train
\nAfrica Reports
\nAfrican Regional Health Report
\nhas provided health care to half a million
\npeople and health screening and education
\nto an additional 800000.
\nThese steps forward and others chronicled
\nin The African Regional Health Report:
\nThe Health of the People \u2013 the first report
\nto focus on the health of the 738 million
\npeople living in the African Region of the
\nWorld Health Organization \u2013 offer hope that
\nover time the Region can address the mas-
\nsive health challenges it faces, given suffi-
\ncient international support.
\n\u201cAfrica confronts the world\u2019s most dramatic
\npublic health crisis, but this report shows
\nthere are public health solutions that work
\nin the African setting. These can be exten-
\nded to all Africans in need, if governments
\nbuild on lessons learnt from successful
\ninterventions while seeking better coordina-
\ntion with the efforts of international part-
\nners\u201d, said Alpha Oumar Konar\u00e9, Chairman
\nof the Commission of the African Union.
\nThe Report provides a comprehensive
\nanalysis of key public health issues and
\nprogress made on them in the Africa
\nRegion.
\n\u2022 HIV\/AIDS continues to devastate the
\nWHO Africa Region, which has 11% of
\nthe world\u2019s population but 60% of the
\npeople living with HIV. Although
\nHIV\/AIDS remains the leading cause of
\ndeath for adults, more and more people
\nare receiving life-saving treatment. The
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 24
\nWHO
\n25
\nnumber of HIV-positive people on anti-
\nretroviral medicines increased eight-fold,
\nto 810 000 in December 2005 from
\n100000 in December 2003.
\n\u2022 More than 90% of the estimated 300\u2013500
\nmillion malaria cases that occur worldwide
\nevery year are in Africans, mainly in chil-
\ndren under five years of age, but most coun-
\ntries are moving towards better treatment
\npolicies. Of the 42 malaria-endemic coun-
\ntries in the African Region, 33 have adopt-
\ned artemisinin-based combination therapy \u2013
\nthe most effective antimalarial medicines
\navailable today \u2013 as first-line treatment.
\n\u2022 River blindness has been eliminated as a
\npublic health problem, and guinea worm
\ncontrol efforts have resulted in a 97 %
\nreduction in cases since 1986. Leprosy is
\nclose to elimination \u2013 defined as less than
\none case per 10 000 people in the Region.
\n\u2022 Most countries are making good progress
\non preventable childhood illness. Polio is
\nclose to eradication, and 37 countries are
\nreaching 60% or more of their children
\nwith measles immunization. Overall
\nmeasles deaths have declined by more than
\n50% since 1999. In 2005 alone 75 million
\nchildren received measles vaccines.
\nWhile drawing the world\u2019s attention to
\nrecent successes, the Report offers a candid
\nappraisal of major hurdles such as the high
\nrate of maternal and newborn mortality
\noverall in the Region. Of the 20 countries
\nwith the highest maternal mortality ratios
\nworldwide, 19 are in Africa; and the Region
\nhas the highest neonatal death rate in the
\nworld. There is the strain on African health
\nsystems imposed by the high burden of life-
\nthreatening communicable diseases coupled
\nwith increasing rates of noncommunicable
\ndiseases. Basic sanitation needs remain
\nunmet for many: only 58% of people living
\nin Sub-Saharan Africa have access to safe
\nwater supplies. Noncommunicable dis-
\neases, such as hypertension, heart disease
\nand diabetes are on the rise; and injuries
\nremain among the top causes of death in the
\nRegion.
\n\u201cWe know what the challenges are, and we
\nknow how to address them \u2013 but we also
\nrecognize that Africa\u2019s fragile health sys-
\ntems represent an enormous barrier to wider
\napplication of the solutions highlighted in
\nthis report. If we are to continue moving
\nforward, African governments and their
\npartners must make a major commitment
\nand invest more funds to strengthen health
\nsystems,\u201c said Dr. Luis Gomes Sambo,
\nRegional Director of the WHO Regional
\nOffice for Africa.
\n22 NOVEMBER 2006 | JOHANNES-
\nBURG\/GENEVA \u2013 Sub-Saharan Africa
\nremains the most dangerous region in the
\nworld for a baby to be born \u2013 with 1.16 mil-
\nlion babies dying each year in the first 28
\ndays of life \u2013 but six low-income African
\ncountries, Burkina Faso, Eritrea, Madagascar,
\nMalawi, Uganda and the United Republic of
\nTanzania, have made significant progress in
\nreducing deaths among newborn babies,
\naccording to a report.
\nThe report, \u201cOpportunities for Africa\u2019s
\nnewborns\u201c, brings together new data and
\nanalysis from a team of 60 authors and nine
\ninternational organizations from the
\nPartnership for Maternal, Newborn and
\nChild Health, (PMNCH). The Partnership
\nrepresents developing and donor countries,
\nnon-governmental agencies, foundations
\nand multi-lateral organizations, including
\nthe World Health Organization.*
\n\u201cGood news does come out of Africa\u201c, said
\nDr. Joy Lawn, co-editor of the report, who
\nNew report shows improvements in child survival in Africa
\nfor the first time since the 1980s
\nworks in Africa for Saving Newborn
\nLives\/Save the Children-US. \u201cWhilst the sur-
\nvival of the African child has shown almost
\nno improvement since the 1980s, the fact that
\nduring 2006 several large African countries
\nhave reported a dramatic reduction in the risk
\nof child deaths gives us new hope of more
\nrapid progress to save Africa\u2019s children.\u201d
\nAlthough no measurable progress has been
\nmade in reducing newborn mortality rates
\nfor babies during the first month of life in
\nAfrica at regional level, a turnaround has
\nbeen seen in the six countries highlighted in
\nthe report, with an average reduction of
\n29% over the last 10 years. Across the six
\ncountries, the reduction ranges from 20% in
\nTanzania and Malawi to 39% in Burkina
\nFaso and 47% in Eritrea.* The authors iden-
\ntified factors that contributed to this
\nprogress. For example:
\n\u2022 In Malawi, there is presidential-level
\ncommitment to maternal newborn and
\nchild health and increased investment by
\npartners to address the lack of human
\nresources.
\n\u2022 United Republic of Tanzania has recorded
\na 30% reduction in child mortality and a
\n20% fall in newborn deaths over the last 5
\nyears. District health managers set local
\nbudget priorities based on deaths in each
\ndistrict and this has meant increased gov-
\nernment spending on essential maternal
\nand child healthcare.
\n\u2022 In Uganda, the performance of district
\nhealth services is ranked each year and
\npublished in the national newspaper.
\n\u2022 Eritrea has made consistent progress over
\n20 years in reducing child and newborn
\ndeaths with an average annual reduction of
\naround 4% over the last decade through a
\nfocus on reaching high coverage of basic
\npublic health services, including to the poor.
\n\u2022 Burkina Faso ensures that poor women do
\nnot pay for the catastrophic cost of an
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 25
\nWHO
\n26
\nemergency caesarean section \u2013 often more
\nthan an average family income for the
\nyear.
\nUp to half a million African babies die on
\nthe day they are born \u2013 most at home and
\nuncounted. According to the report, Liberia
\nhas the world\u2019s highest newborn mortality
\nrate at 66 deaths per 1,000 births compared
\nto less than 2 deaths per 1,000 births in
\nJapan and 6 deaths per 1,000 births in
\nLatvia. Half of Africa\u2019s 1.16 million new-
\nborn deaths occur in just five countries \u2013
\nNigeria, Democratic Republic of the
\nCongo, Ethiopia, United Republic of
\nTanzania and Uganda. Nigeria alone has
\nover 255,000 newborn deaths each year.
\n\u201cThe health of newborn babies has fallen
\nbetween the cracks \u2013 Africa\u2019s un-named, and
\nuncounted, lost children,\u201c said Dr. Francisco
\nSongane, Director of the Partnership. \u201cWe
\nmust count newborn deaths and make them
\ncount, instead of accepting these deaths as
\ninevitable. The progress of these six African
\ncountries demonstrates that even the world\u2019s
\npoorest countries can look after their new-
\nborns, their most vulnerable citizens. They
\nhave shown the way \u2013 we must seize the
\nopportunity.\u201d
\nThe President of the Pan-African
\nParliament, Hon. Amb. Gertrude Mongella,
\nis spearheading action in maternal, newborn
\nand child health through the African Union
\nand the Pan African Parliament in
\nJohannesburg. \u201cReaching every woman,
\nbaby and child in Africa with essential care
\nwill depend on us, the users of this publica-
\ntion. We all have a role to play as govern-
\nments to lead, as policymakers to guarantee
\nessential interventions and equity, as part-
\nners and donors to support programmes,\u201c
\nshe said.
\nThe authors warn that opportunities to save
\nnewborn lives within existing programmes
\nare often missed. For example two-thirds of
\nwomen in Africa attend antenatal care yet
\nonly 10% receive preventive treatment for
\nmalaria and a mere 1 % of mothers with
\nHIV receive the recommended treatment to
\nprevent mother to child transmission of
\nHIV\/AIDS.
\nThe report found that two-thirds of newborn
\ndeaths in sub-Saharan Africa \u2013 up to 800000
\nbabies a year \u2013 could be saved if 90% of
\nwomen and babies received feasible, low-
\ncost health interventions. These include
\nimmunizing women against tetanus, provid-
\ning a skilled attendant at birth, treating new-
\nborn infections promptly and educating
\nmothers about hygiene, warmth and breast-
\nfeeding for infants. Saving these lives would
\ntake only an estimated US $ 1.39 per capita
\n\u2013 or US $1 billion per year. According to the
\nreport, this cost would benefit others, in par-
\nticular the one million stillborns and 250
\n000 mothers who also die each year.
\nQuotations from other
\nPartnership members
\nProfessor E. Oluwole Akande, chair of
\nthe African Regional Maternal Newborn
\nand Child Health Task Force
\n\u201cPolicy frameworks such as the Roadmap
\nfor Maternal and Newborn Survival are
\nnow in place in many African countries to
\nreach every mother and baby with essential
\ncare. The gap remains between policy and
\naction,\u201d said Professor E. Oluwole Akande.
\n\u201cThis publication helps to bridge this gap
\nand will be an invaluable toolkit for action.\u201c
\nKate Kerber, co-editor of the publication
\n\u201cWe identified the ABCD of progress by
\nexamining the six low income countries that
\nare progressing\u201d, said Kate Kerber.
\n\u201cAccountable leadership, Bringing national
\npolicy into district-level action, Community
\nownership, and Demonstrated focus on
\nreaching all mothers, newborn and children
\nwith essential life-saving care.\u201d
\nDr. Doyin Oluwole, Director of Africa
\n2010 (one of the authors of the report)
\n\u201cMaternal, newborn and child health care is
\nthe backbone of a healthy health system.\u201d
\nstates Doyin Oluwole. \u201cAfrican decision
\nmakers are finding that systematically
\naddressing newborn health benefits existing
\nmaternal and child health care and promotes
\nintegration with other programmes.
\nIntegration saves lives and money.\u201d
\n* The Partnership Maternal, Maternal, Newborn
\n& Child Health (PMNCH)
\nGENEVA \u2013 At a two day meeting at the
\nWorld Health Organization (WHO) on
\nadvances in pandemic influenza vaccine
\ndevelopment, experts reported encouraging
\nprogress.
\nSixteen manufacturers from 10 countries
\nare developing prototype pandemic influen-
\nza vaccines against H5N1 avian influenza
\nvirus. Five of them are also involved in the
\ndevelopment of vaccines against other
\navian viruses (H9N2, H5N2, and H5N3).
\nAt present, more then 40 clinical trials have
\nbeen completed or are ongoing. Most of them
\nhave focused on healthy adults. Some compa-
\nnies, after completing safety analyses in
\nadults, have initiated clinical trials in the
\nelderly and in children.All vaccines were safe
\nand well tolerated in all age groups tested.
\nWHO reports some promising results on avian
\ninfluenza vaccines but also concerned by glob-
\nal vaccine production capacity
\nFor the first time, results presented at the
\nmeeting have convincingly demonstrated
\nthat vaccination with newly developed
\navian influenza vaccines can bring about a
\npotentially protective immune response
\nagainst strains of H5N1 virus found in a
\nvariety of geographical locations. Some of
\nthe vaccines work with low doses of anti-
\ngen, which means that significantly more
\nvaccine doses can be available in case of a
\npandemic.
\nThese developments were discussed at the
\nWHO meeting on the evaluation of pan-
\ndemic influenza prototype vaccines in clini-
\ncal trials which took place in Geneva,
\nSwitzerland, on 15-16 February 2007. It
\nwas a third such meeting in two years the
\nobjectives to review progress in the devel-
\nopment of candidate vaccines against pan-
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 26
\nWHO
\n27
\ndemic influenza viruses and to reach con-
\nsensus on future priority activities.
\nMore than 100 influenza vaccine experts \u2013
\nfrom academia, national and regional public
\nhealth institutions, the pharmaceutical
\nindustry and regulatory bodies throughout
\nthe world \u2013 attended the meeting convened
\nby the WHO Initiative for Vaccine Research
\nand the WHO Global Influenza Program-
\nme. Information on more than 20 projects
\nwas presented and discussed. Most manu-
\nfacturers are using reference vaccine strains
\ncorresponding to H5N1 viruses provided
\nfrom by WHO Collaborating Centres.
\nIn spite of the encouraging progress noted
\nat the WHO meeting, WHO stresses that the
\nworld still lacks the manufacturing capacity
\nto meet potential global pandemic influenza
\nvaccine demand as current capacity is esti-
\nmated at less than 400 million doses per
\nyear of trivalent seasonal influenza vaccine.
\nIn response to this challenge, WHO
\nlaunched in 2006 the Global pandemic
\ninfluenza action plan (GAP) to increase
\nvaccine supply, a US$10 billion effort over
\n10 years. One of its aims is to enable devel-
\noping countries to establish their own
\ninfluenza vaccine production facilities
\nthrough transfer of technology, providing
\nthem with the most sustainable and reliable
\nresponse to the threat of pandemic influen-
\nza. WHO is currently working with several
\nvaccine producers, mainly in developing
\ncountries affected by H5N1, to facilitate
\nestablishment of in-country influenza vac-
\ncine production.
\nInformation contact:
\nMelinda Henry
\nCommunications officer
\nWHO Department of Immunization, Vaccines
\nand Biologicals
\nTelephone: +41 22 791 2535
\nMobile phone: +41 79 477 1738
\nE-mail: henrym@who.int
\nroutine dose increased from 71% to 77%
\nand through immunisation campaigns more
\nthan 360 million aged 9 months to 15 years
\nreceived the vaccine.
\nThe measles vaccination campaigns have
\nalso contributed both to the development of
\na global public health laboratory network
\nand provided a channel for the delivery of
\nother life saving interventions, such as bed
\nnets providing protection against malaria,
\nde-worming medicines and vitamin A sup-
\nplements. Such activities, combining
\nmeasles intervention with other health inter-
\nventions is a contribution to the achieve-
\nment of MDG 4, \u2013 a 2\/3 reduction in child
\ndeaths between 1990 and 2015.
\nUNICEF Executive Director Ann M.
\nVeneman said \u201cImmunising children is
\nclearly saving lives and contributing to the
\nachievement of the Millennium Develop-
\nment Goals. We must urgently build on this
\nmomentum with integrated community-
\nbased health programmes to help save the
\nlives of more than 10 million children who
\ndie of preventable causes every year\u201d.
\nOf the estimated 345,000 measles deaths in
\n2005, 90% were among children under the
\nage of five, many deaths resulting from the
\ncomplications related to severe diarrhoea,
\npneumonia and encephalitis.
\nThe challenge now is to reach a new global
\ngoal \u2013 the reduction of global measles
\ndeaths by 90% by 2010, compared with
\n2000 levels. This calls for the sustaining of
\nthe gains made in countries that have imple-
\nmented accelerated measles control strate-
\ngies and for similar strategies to be imple-
\nmented in countries with high numbers of
\nmeasles deaths, such as India and Pakistan.
\nIn a joint news release the partners in the
\nMeasles Initiative, WHO, UNICEF, ARC,
\nCDC and UNF, announced earlier this year
\nthat Measles deaths worldwide have fallen
\nby 60% since 1999, exceeding the United
\nNations goal \u201cto halve measles deaths
\nbetween 1999 and 2005\u201d.
\nAccording to new data from WHO, global
\nmeasles deaths fell from an estimated
\n873,000 deaths in 1999 to 345,000 in 2006.
\nThe progress was even greater in Africa
\nwhere measles deaths fell by 75% from an
\nestimated 506,000 to 126,000. (see Wolfson
\nL.J. et al., Lancet 2007, 369, 191-200).
\nDr. Margaret Chan, WHO Director-General,
\nis reported as saying \u201cThis is an historic vic-
\ntory for global public health, for the power
\nof partnership and for commitment by coun-
\ntries to fight a terrible disease. Our promise
\nto cut measles deaths by half and save hun-
\ndreds of thousands of lives has not only been
\nfulfilled, it has been surpassed in just six
\nyears with Africa leading the way\u201d.
\nThe strategy to reduce measles, comprising
\nfour components, has been the key to ensur-
\ning the massive decrease in measles deaths
\ncalled for:
\n\u2022 the provision of one dose of measles
\nvaccine for all infants via routine
\nhealth services,
\n\u2022 a second opportunity for measles
\nimmunisation for all children, generally
\nthrough mass vaccination campaigns,
\n\u2022 effective surveillance for measles, and
\n\u2022 enhanced care, including the provision
\nof supplemental vitamin A.
\nIn consequence, between 1999 and 2005
\nglobal immunisation coverage with the first
\nUN Global goal to reduce measles deaths
\nin children surpassed
\nWorld Leprosy Day 2007
\nInternationalAppeal to end stigma and ostraci-
\nsation of leprosy sufferers and their families.
\nWhile the availability of multi-drug therapy
\n(MDT) since the 1980s has revolutionised
\nthe treatment of leprosy and resulted in the
\ncure of over 15 million people, the age-old
\nstigma and discrimination attached to lep-
\nrosy continues to add to the suffering of
\nthose now cured of the disease and their
\nfamilies.
\nFollowing World Leprosy Day, a second
\nGlobal Appeal signed by amongst others, Dr.
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 27
\nRegional and NMA News
\n28
\nMr Sasakawi said \u201cConsidering the long
\nhistory of discrimination against people
\nwith leprosy and their families, action to
\nresolve this issue is long overdue. An
\nimportant step toward eradicating this dis-
\nPK Gopal, President of the National Forum,
\nIndia (an organisation of people affected by
\nleprosy) and Hilarion M Guia the first Mayor
\nof Culion an island municipality which was
\nonce the worlds largest leprosy colony, was
\nlaunched by Mr Yohei Sasakawa, WHO
\nGoodwill Ambassador for the elimination of
\nleprosy, on 29th January 2007.
\nThis year the appeal, organised by Ateneo de
\nManila University, the Department of Health
\nof the Philippines, WHO, the Nippon
\nFoundation and Sasakawa Memorial Health
\nFoundation, was led by leaders of people
\naffected by leprosy standing beside Mr.
\nSasakawa at the launch. It builds on the First
\nAppeal in New Delhi 2006 which \u201ccalled on
\npeople all over the word to change their per-
\nception and foster an environment in which
\nleprosy patients ,cured persons and their fami-
\nlies can lead normal lives free from stigma and
\ndiscrimination\u201d This was signed by 11 World
\nLeaders including former Presidents of Brazil,
\nCosta Rica, India, Nigeria, the USA, by the
\nDalai Lama and Archbishop Desmond Tutu.
\nSince 1995 WHO has supplied MDT free to
\nall identified leprosy patients. Initially this
\nwas with funding from the Nippon
\nFoundation and subsequently through MDT
\ndonated by Novartis and the Novartis
\nFoundation for Sustainable Development.
\nDespite the initial appeal and the fact that such
\ntherapy produces a cure the discrimination
\nand stigma. Associated with leprosy, (active
\nand cured) persist largely due to lack of edu-
\ncation. According to John Sasakawa\u201c leprosy
\nand the mystery surrounding its transmission
\nhave always given rise to fear- and fear has
\ngenerated discrimination \u2013 not just to those
\nwith the disease but their families as well\u201d.
\nJohei Sasakawa, who for more than 30
\nyears has supported efforts to tackle leprosy
\n\u201cas a medical problem\u201d approached the UN
\nSub-commission on the Promotion and
\nProtection of Human Rights on this issue in
\n2005 and 2006. They unanimously adopted
\nresolutions recommending that govern-
\nments take action to redress the issue of
\nstigma and discrimination associated with
\nleprosy. A report is currently being prepared
\non this issue by a Special Rapporteur which
\nwill go to the Human Rights Council (suc-
\ncessor to UNCHR) and hopefully lead to
\nfull UN support.
\nNMA news
\nAppeal to migrant physicians to return
\ncrimination is to educate society about the
\ndisease\u201d. He also commented \u201cI have come
\nto appreciate that no one who has had lep-
\nrosy will be truly free of the disease so long
\nas discrimination remains\u201d
\nThe subject of the World Health Report 2006
\nwas Human Resources for Health. Over the
\npast few years there has been increasing con-
\ncern, debate and pronouncements on this topic
\nwhich, following the WHA decision last year,
\nwill be a topic for active consideration and
\naction over the next decade. In consequence
\nthere appears to a move towards openness both
\nin the declarations of countries who are net
\nconsumers of migrant health professionals\u2019
\nservices and also of the realities of the internal
\neffects of emigration on countries who are net
\nlosers of health care professionals.
\nRecently the Health Professions Council of
\nSouth Africa, expressly in the context of the
\nhealth care need in that country, has written
\nto all South African physicians currently
\npractising in other countries, seeking to
\nencourage their return to practice in their
\nown country. As an incentive, a one off
\n\u201eamnesty\u201c until 30th April 2007 is being
\noffered to those professionals willing to
\nreturn to practice in South Africa. For those
\nreturning, the current punitive financial
\nrequirements for those wishing to reregister
\nto practice in their own country, will be
\nwaived. In a letter, the Head of corporate
\ncommunications of the Health Professions
\nCouncil writes \u201eIn the interest of encourag-
\ning our doctors to return to SA, where they
\nare desperately needed ,we will waive the
\npenalty fees for doctors whose names have
\nbeen erased from the register\u201c. The only
\ncondition required is an undertaking to prac-
\ntice in the public health care system for 100
\nhours within six months. Whilst previously
\nsome countries have appealed to nationals to
\nreturn to practice in their own country, such
\nan open appeal with incentives to return
\nmust be considered as an index of the seri-
\nousness of the shortage in South Africa.
\nIn a commentary on the relevance of both the
\nnumbers of African doctors practising in
\nCanada and its dependence on migrant physi-
\ncians, the Canadian Medical Association
\ncomments that South Africa’s medical dias-
\npora involves more than 1500 physicians
\nnow practising in Canada and thousands
\nmore who have moved to the UK ,Australia,
\nNew Zealand and the USA. In CMA news(1)
\nsetting out the background to Canadian and
\nInternational concerns about this problem
\n,attention is also drawn to a report issued by
\nthe Canadian Policy Research Networks in
\n1st February (2) quoting a remark which,
\nwhile it is made with reference to Canada, is
\nhighly relevant to the realities of addressing
\nthis problem both from the point of view of
\ndeveloped and developing countries \u201eThe
\nethics of international recruitment has to be
\ndealt with in the overall context of domestic
\nhealth human resource planning\u201c While this
\nreport considers the options for Canada in
\ndealing with the ethical problems associated
\nwith planning its own domestic health human
\nresources, it also presents a valuable exten-
\nsive overview not only of the ethical prob-
\nlems relating to international recruitment, but
\nalso of national and international statements,
\ncodes of practice of international bodies both
\nintergovernmental and non-governmental,
\nand of national governments who have
\naddressed this issue in the past 3-4 years.
\n(1) \u201cSouth Africa Licensing body issues\u201c
\namnesty\u201c, begs MDs to return home\u201c
\nhttp:\/\/www.cma.ca\/index.cfm?ci_id=100376
\n23&1a_id=1 consulted 19.02.07
\n(2) McIntosh T.,Torgeson R,,Klassen N.\u201cEthical
\nRecruitment of Internationally Educated
\nHealth Professionals from abroad and
\nOptions for Canada\u201c Research Report H\/11,
\nCanadian Policy Research Network, Ottawa.
\nWMJ_1_01-28.qxd 30.04.2007 09:37 Seite 28
\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
\nCarrera 7 N\u00b0 82-66, Oficinas 218\/219
\nSantaf\u00e9 de Bogot\u00e1, D.E.
\nTel\/Fax: (57-1) 256 8050\/256 8010
\nE-mail: federacionmedicacol@
\nsky.net.co
\nDEMOCRATIC REP. OF CONGO F
\nOrdre des M\u00e9decins du Zaire
\nB.P. 4922
\nKinshasa \u2013 Gombe
\nTel: (243-12) 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: hlz@email.htnet.hr
\nWebsite: www.hlk.hr\/default.asp
\nCZECH REPUBLIC E
\nCzech Medical Association
\nJ.E. Purkyne
\nSokolsk\u00e1 31 – P.O. Box 88
\n120 26 Prague 2
\nTel: (420-2) 242 66 201-4
\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
\n(EsMA)Pepleri 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\/Fax: (679) 387671
\nE-mail: fijimedassoc@connect.com.fj
\nFINLAND E
\nFinnish Medical Association
\nP.O. Box 49
\n00501 Helsinki
\nTel: (358-9) 3930 91\/Fax-794
\nE-mail: fma@fimnet.fi
\nWebsite: www.medassoc.fi
\nFRANCE F
\nAssociation M\u00e9dicale Fran\u00e7aise
\n180, Blvd. Haussmann
\n75389 Paris Cedex 08
\nTel\/Fax: (33) 1 45 25 22 68
\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) 400-456 369\/Fax: -387
\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, Chi-
\nnaDuke 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 \u2013 PO.Box 145
\n1443 Budapest
\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) 23370009\/23378819\/
\n23378680
\nFax: (91-11) 23379178\/23379470
\nE-mail: inmedici@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) 676-7273Fax: (353-1)
\n6612758\/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: doritb@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
\nWebsite: www.lgs.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
\nMACEDONIA E
\nMacedonian Medical Association
\nDame Gruev St. 3
\nP.O. Box 174
\n91000 Skopje
\nTel\/Fax: (389-91) 232577
\nE-mail: mld@unet.com.mk
\nMALAYSIA E
\nMalaysian Medical Association
\n4th Floor, MMA House
\n124 Jalan Pahang
\n53000 Kuala Lumpur
\nTel: (60-3) 40413740\/40411375
\nAssociation and address\/Officers
\nii
\nU2–4_WMJ_01_07.qxd 30.04.2007 09:38 Seite U3
\nAssociation and address\/Officers
\niii
\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. D-107
\nColonia Deportivo Obispado
\nMonterrey, Nuevo L\u00e9on
\nTel\/Fax: (52-8) 348-41-55
\nE-mail: rcantum@doctor.com
\nWebsite: www.cmm-fenacome.org
\nNAMIBIA E
\nMedical Association of Namibia
\n403 Maerua Park \u2013 POB 3369
\nWindhoek
\nTel: (264) 61 22 44 55\/Fax: -48 26
\nE-mail: man.office@iway.na
\nNEPAL E
\nNepal Medical Association
\nSiddhi Sadan, Post Box 189
\nExhibition Road
\nKatmandu
\nTel: (977 1) 4225860, 231825
\nFax: (977 1) 4225300
\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) 492 4179
\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@cwpanama.net
\nPERU S
\nColegio M\u00e9dico del Per\u00fa
\nMalec\u00f3n Armend\u00e1riz N\u00b0 791
\nMiraflores, Lima
\nTel: (51-1) 241 75 72
\nFax: (51-1) 242 3917
\nE-mail: decano@cmp.org.pe
\nWebsite: www.cmp.org.pe
\nPHILIPPINES E
\nPhilippine Medical Association
\nPMA Bldg, North Avenue
\nQuezon City
\nTel: (63-2) 929-63 66\/Fax: -6951
\nE-mail: medical@pma.com.ph
\nWebsite: www.pma.com.ph
\nPOLAND E
\nPolish Medical Association
\nAl. Ujazdowskie 24, 00-478 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: intl@omcne.pt
\nWebsite: www.ordemdosmedicos.pt
\nROMANIA F
\nRomanian Medical Association
\nStr. Ionel Perlea, nr 10
\nSect. 1, Bucarest
\nTel: (40-1) 460 08 30
\nFax: (40-1) 312 13 57
\nE-mail: AMR@itcnet.ro
\nWebsite: ong.ro\/ong\/amr
\nRUSSIA E
\nRussian Medical Society
\nUdaltsova Street 85
\n119607 Moscow
\nTel: (7-095)932-83-02
\nE-mail: info@rusmed.ru
\nWebsite: www.russmed.ru
\nSAMOA E
\nSamoa Medical Association
\nTupua Tamasese Meaole Hospital
\nPrivate Bag \u2013 National Health Services
\nApia
\nTel: (685) 778 5858
\nE-mail: vialil_lameko@yahoo.com
\nSINGAPORE E
\nSingapore Medical Association
\nAlumni Medical Centre, Level 2
\n2 College Road, 169850 Singapore
\nTel: (65) 6223 1264
\nFax: (65) 6224 7827
\nE-Mail: sma@sma.org.sg
\nwww.sma.org.sg
\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, 61001 Ljubljana
\nTel: (386-61) 323 469
\nFax: (386-61) 301 955
\nSOMALIA E
\nSomali Medical Association
\n14 Wardigley Road \u2013 POB 199
\nMogadishu
\nTel: (252-1) 595 599
\nFax: (252-1) 225 858
\nE-mail: drdalmar@yahoo.co.uk
\nSOUTH AFRICA E
\nThe South African Medical Associa-
\ntionP.O. Box 74789, Lynnwood Rydge
\n0040 Pretoria
\nTel: (27-12) 481 2036\/2063
\nFax: (27-12) 481 2100\/2058
\nE-mail: sginterim@samedical.org
\nWebsite: www.samedical.org
\nSPAIN S
\nConsejo General de Colegios M\u00e9dicos
\nPlaza de las Cortes 11, Madrid 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, SE – 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 C.P. 170
\n3000 Berne 15
\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
\nTel: (886-2) 2752-7286
\nFax: (886-2) 2771-8392
\nE-mail: intl@med-assn.org.tw
\nWebsite: www.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: www.medassocthai.org
\nTUNISIA F
\nConseil National de l\u2019Ordre
\ndes M\u00e9decins de Tunisie
\n16, rue de Touraine
\n1002 Tunis
\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
\nSehit Danis Tunaligil Sok. N\u00b0 2 Kat 4
\nMaltepe 06570
\nAnkara
\nTel: (90-312) 231 \u20133179\/Fax: -1952
\nE-mail: Ttb@ttb.org.tr
\nWebsite: www.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 Citt\u00e0 del Vaticano
\n00120 Citt\u00e0 del Vaticano
\nTel: (39-06) 69879300
\nFax: (39-06) 69883328
\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 Medical Association
\n(VGAMP)68A Ba Trieu-Street
\nHoau Kiem District
\nHanoi
\nTel\/Fax: (84) 4 943 9323
\nZIMBABWE E
\nZimbabwe Medical Association
\nP.O. Box 3671
\nHarare
\nTel: (263-4) 791553
\nFax: (263-4) 791561
\nE-mail: zima@zol.co.zw
\nU2–4_WMJ_01_07.qxd 30.04.2007 09:38 Seite U4<\/p>\n"},"caption":{"rendered":"

wmj13 WorldMMeeddiiccaall JJoouurrnnaall Vol. No.1,March200753 OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC. G 20438 Contents EEddiittoorriiaall 1 MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss Harmonization of Research Ethics Committees \u2013 are there limits? 2 MMeeddiiccaall SScciieennccee Better heart transplants will quadruple lives saved 3 People in Pain Confused About Pain Relievers and Missing Out On Effective […]<\/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\/wmj13.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3554"}],"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=3554"}]}}