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wmj16<\/a><\/p>\n

WorldMMeeddiiccaall JJoouurrnnaall
\nVol. No. 4, December 200753
\nOFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
\nG 20438
\nContents
\nEEddiittoorriiaall
\nThe challenge to medical care 85
\nMake medicines child size 86
\nMMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
\nMedical Research on Child Subjects 87
\nChina affirms its commitment to
\nWMA Transplantation policy 87
\nWorld Health Professions Alliance Conference
\non Regulation of Health Professions display 90
\nWMA Statement On The Ethics Of Telemedicine 91
\nWMA resolution on the responsibility
\nof physicians 92
\nWMA Resolution On Health And Human Rights
\nAbuses In Zimbabwe 94
\nMMeeddiiccaall SScciieennccee,, MMeeddiiccaall PPrraaccttiiccee
\naanndd MMeeddiiccaall EEdduuccaattiioonn
\nWMA Statement on Health Hazards
\nof Tobacco Products 95
\nAvicenna Directories to replace World Directory
\nof Medical Schools 97
\nGlobal Standards for Quality Improvement
\nin Medical Education 97
\nPPooiinntt ooff vviieeww
\nA Worldwide Tour of Medical Degrees
\nand Qualifications 97
\nFFrroomm tthhee WWMMAA SSeeccrreettaarryy GGeenneerraall
\nTrust me, I\u2019m a Doctor! 99
\nWWMMAA
\nWMA General Assembly 100
\nPlenary Session of the Assembly
\n6th October 2007 103
\nResolution in Support of the Medical Associations
\nin Latin America and the Caribbean 104
\n178th WMA Council meeting 107
\nInter-professional training seminar on infection
\ncontrol in South Africa 108
\nWWHHOO 108\u2013110
\nRReevviieeww aanndd LLeetttteerr 111\u2013112
\nReport on WMA General
\nAssembly, Copenhagen 2007
\nDr. Jon Snaedel
\nWMA-President 2007-2008
\n00_US_04_2007.qxd 10.01.2008 11:33 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 MEDICAL ASSOCIATIONS AND OFFICERS
\ni see page ii
\nPresident-Elect President Immediate Past-President
\nDr. Yoram Blachar Dr. J. Snaedal Dr. N. Arumagam
\nIsrael Medical Association Icelandic Medical Assn. Malaysian Medical Association
\n2 Twin Towers, 35 Jabotinsky St. Hlidasmari 8 4th Floor MMA House
\nP.O. Box 3566, Ramat-Gan 52136 200 Kopavogur 124 Jalan Pahang
\nIsrael Iceland 53000 Kuala Lumpur
\nMalaysia
\nTreasurer Chairman of Council Vice-Chairman of Council
\nProf. Dr. Dr. h.c. J. D. Hoppe Dr. J. E. Hill Dr. K. Iwasa
\nBundes\u00e4rztekammer American Medical Association Japan Medical Association
\nHerbert-Lewin-Platz 1 515 North State Street 2-28-16 Honkomagome
\n10623 Berlin Chicago, ILL 60610 Bunkyo-ku
\nGermany USA Tokyo 113-8621
\nJapan
\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
\nCabo Verde S
\nOrdem Dos Medicos du Cabo Verde
\nAvenue OUA N\u00b06 \u2013 B.P. 421
\nAchada Santo Ant\u00f3nio, Ciadade de
\nPraia, Cabo Verde
\nTel : (238) 262 2503
\nFax : (238) 262 3099
\nE-mail: omecab@cvtelecom.cv
\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
\nU2–4_WMJ_04_07.qxd 10.01.2008 11:34 Seite U2
\n85WMJ 53, December 2007
\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
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\nTHE WORLD MEDICAL
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\nAt present rate-card No. 3 a is valid.
\nThe magazine is published quarterly.
\nSubscriptions will be accepted by
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\nor associate payment. Details of Associate
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\nISSN: 0049-8122
\nEditorial
\nThe challenge to medical care
\nThe Tobacco Control Resource Centre, a resource supported by the British Medical
\nAssociation, the European Commission and the European Regional Office of the World
\nHealth Organisation, published in 2000 a report in the context of Tobacco Control
\nProgramme under the title \u201cTobacco \u2013 Medicine\u2019s Big Challenge.\u201d Now at the end of 2007,
\nwhile Tobacco remains a problem and the great scourges of disease still challenge medi-
\ncine, a huge challenge (possibly \u201cThe Challenge\u201d for the medical profession) faces the
\nhealth professionals providing medical care, namely the problem of the supply and distrib-
\nution of health care workers. The 2006 World Health Report of WHO* highlighted the
\nproblem, notably the huge discrepancies in the distribution of Physicians, Dentists, Nurses,
\nMidwives and other Health care workers, not only within countries but more significantly
\nbetween countries. Scientific advances have made great contributions in our knowledge of
\nthe nature and causes of many diseases, accompanied by discovery and development of
\nmany new drugs to cure or ameliorate the effects of disease. All of these call for increasing
\nskills and increased demands on all sectors of the medical workforce in developed coun-
\ntries It places increased demands on the sparse, sometimes almost non-existent supply of
\nhealth care workers in underdeveloped countries, where healthcare was already minimal,
\nobstructing any implementation of advances in healthcare available elsewhere.
\nHitherto the limited attempts to address manpower problems in the healthcare workforce
\nhad, unsurprisingly, concentrated on workforce problems within national health care sys-
\ntems, substantially disregarding the huge disparities between countries, regions and even
\ncontinents. At the same time concern has been expressed by both the profession and by
\nsome other authorities about the recruiting of physicians in developed countries from devel-
\noping countries who are already under-doctored, Codes of practice and statements of poli-
\ncy to change this have been issued by the World Medical Association** and by some gov-
\nernments and authorities.
\nWhile a great tribute should be paid to those organisations and governments who, in one
\nway or another have, over many years, encouraged the provision of doctors, nurses and
\nother medical assistance to those countries in need, and to those health professionals who
\nundertook to meet the needs, it was effectively only with the arrival of HIV\/AIDS and,
\nmore recently the risk of pandemic disease, coupled with increasing political awareness of
\nthe need to deal with poverty, inequity and human rights, that the need to address the prob-
\nlems associated with the global health workforce have been forced to the forefront of dis-
\ncussion.
\nIn previous editorials in the World Medical Journal, WMJ 52 (1) and (2) we have drawn
\nattention to emerging trends not only in the changing or expanding role of individual health
\nprofessions, but also to problems of training, mobility and availability of health profession-
\nals. Further problems complicating the whole issue relate to the changes in role and func-
\ntions of health professionals, reflecting not only the increasing aspirations of the individual
\nhealth professional, but also the increasing specialisation within individual health profes-
\nsions.
\nIn the first part of 2008 at least two conferences will address some of the issues involved.
\nThe first is a World Health Organisation Global Conference to be held in Addis Ababa
\nEthiopia in January 2008, when the conference will address the topic of Task Shifting (see
\np. 90). \u201cTask Shifting\u201d is defined in a number of WHO documents as \u201cthe name given to a
\n* \u201cWorking together for health\u201d The World Health Report 2006 WHO, Geneva, ISBN 92 4 156317 6
\n** WMA Statement on Ethical Guidelines for the Recruitment of Physicians, Helsinki 2003
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 85
\n86 WMJ 53, December 2007
\nprocess of delegation whereby tasks are
\nmoved, where appropriate, to less spe-
\ncialised health workers\u201d.
\nThe second conference, organised by the
\nWorld Health Professions Alliance in the
\nweek preceding the WHO Assembly, is the
\nFirst World Conference the Role and
\nRegulation of Health Professions which
\nwill be held in Geneva (see p. 90). Both
\nConferences are of huge importance in rela-
\ntion to the provision of health care across
\nthe globe in both developed and developing
\ncountries.
\nThe conferences have great relevance to the
\nfuture role and functions of the Medical
\nProfession. Whereas previously, physicians,
\nwhen recognised for full registration as a
\nmedical practitioner, held the sole licence to
\ncarry out certain specific acts such as the
\nright to prescribe and to engage in the prac-
\ntice of medicine, in an increasingly sophisti-
\ncated and technical world it is clear that
\nsome of these reserved functions can be car-
\nried out by other health professionals under
\nregulation, after appropriate technical spe-
\ncialist training. This has substantial implica-
\ntions for changes in the protected role that
\nphysicians have previously held in certain
\nareas, while possibly calling for new roles in
\nother areas, essentially calling for a reassess-
\nment of the role and functions of physicians
\nin society. In some countries such changes
\nhave already occurred in areas such as the
\nextension of limited prescribing rights to
\nother health professionals such as nurses,
\nand extending the acts carried out by other
\nhealth professionals By enhancing the role
\nof some health professionals, such changes
\nincrease the provision of certain health ser-
\nvices to a much wider population in both
\ndeveloped and developing countries.
\nNevertheless, as indicated earlier, if there is
\na basic shortage of health care workers in
\nall the health professions, the world is faced
\nwith a major problem. This shortage does
\nnot only apply to underdeveloped countries.
\nIn more developed countries as scientific
\nand technical knowledge and development
\nhave increased there is also increased
\ndemand for the implementation of these dis-
\ncoveries and a consequent demand for more
\nhealth workers. Thus the USA estimates
\nthat by 2020 they will require at least
\n200,000 physicians to meet their needs,
\nmore than the current need of the rest of the
\nworld!
\nThe WMA Secretary General in his column
\nrefers to another problem associated with
\nthe changes in role and functions of physi-
\ncians, namely the need for clarity in identi-
\nfying the roles of health professionals and
\nthe titles used to identify them to the public.
\nThe differences in titles used for physicians
\nacross the world are illustrated in an article
\nby Dr. Doren, to which Dr. Kloiber refers.
\n(see p. 97).
\nThe Health Workforce problem which the
\n2006 World Health Report highlighted is
\nnow being actively pursued and it is essen-
\ntial that, as indicated in the editorials
\nreferred to above, both individual physi-
\ncians and their representative organisations
\nactively address these issues. The distribu-
\ntion of certain diseases has been radically
\nchanged as a result of greatly increased
\ninternational travel, with the potential for
\nwider dissemination of communicable dis-
\neases including newly emerging diseases,
\nand the risk of major pandemics need to be
\nbalanced with attention to the global prob-
\nlems of inequitable distribution of physi-
\ncians, with such huge disproportions in
\ntheir distribution. With the calls for \u201ctask
\nshifting\u201d as part of the solution, this may
\nalso call for radical changes in the career
\ncycle of physicians, nurses, pharmacists,
\nincluding professional practice in foreign
\ncountries as a normal part of the profession-
\nal career structure. All of these considera-
\ntions require urgent attention at a time when
\nthe very nature of the regulation of the
\nhealth professions in also under review,
\nincluding the question of the degree to
\nwhich the professions themselves should
\nplay a role in regulation, a matter of major
\nconcern to those professions whose proud
\nrole has for millennia been that of \u201cCaring
\nProfessions\u201d. It is to this end that the med-
\nical profession defends its position in self-
\nregulation of standards of care and its ethi-
\ncal code of conduct in the interests of both
\npatients and profession. All of this must be
\nurgently considered both in discussions at
\nindividual, at national level and in the glob-
\nal conferences referred to above. There is
\nno time to be lost. Just as the profession has
\ntaken a stand on Tobacco so it must face up
\nto this Big Challenge to the profession
\nitself. Both individual physicians and their
\nleaders must act. Time waits for no man!
\nAlan Rowe
\nMake medicines child size
\nOn 6. December 2007, the WHO launched
\na five years initiative to raise awareness and
\naccelerate action on medicines for children.
\nThis project is based on a document which
\nwas accepted at the 60th World Health
\nAssembly in May 2007. At the same time
\nthe WHO released the first international
\nList of Essential Medicines for Children
\n(WMJ 53(2), 50). The list contains 206
\nmedicines that are deemed safe for children
\nand address priority conditions. On this list
\na number of existing medicines are howev-
\ner lacking because they have not been
\nadapted for childrens use.
\nIt has been known for a long time that there
\nis a substantial gap between the availability
\nof childrens medicines and the actual need
\nand that this gap is global even if it is most
\nevident in poor income countries. In indus-
\ntrialized societies more than half of the chil-
\ndren are prescribed medicines authorised
\nand dosed for adults but not authorized or
\ndosed for children. In developing countries,
\nthe problem is compounded by lower
\naccess.
\nIn this project there are three main priori-
\nties.
\n1. To improve access where proper medi-
\ncines for children exist but they are not
\nreaching those in need due to cost and
\ninefficient distribution systems.
\nEditorial
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 86
\n87WMJ 53, December 2007
\n2. To increase development of medicines
\nwhich exist for adults but are either in
\nunsuitible forms for children or have not
\nbeen developed for children taken into
\naccount the different pharmacokinetics
\nin children of various ages.
\n3. To facilitate research into areas where
\nthere are very few or even no medicines
\nand where the efficacy of existing medi-
\ncines is unknown. This applies specially
\nto medicines for various infectious, trop-
\nical disease.
\nThis project has received a wide acceptance
\nand backup from many stakeholders such as
\nUNICEF, the pharmaceutical industry, regu-
\nlatory agencies and various NGO\u00b4s such as
\nSave the children. WMA most certainly will
\ndo its utmost to facilitate this project. The
\nproject starts at a time when WMA is
\nadressing the special situation of children in
\ntwo areas. One is the upcoming revision of
\nthe existing document on Health of
\nChildren since 1998, by many considered
\none of the best documents of the WMA.
\nThis issue should also be kept in mind dur-
\ning the process of revision of the
\nDeclaration of Helsinki and in conjunction
\nto that a new document on research of chil-
\ndren which has been circulated to NMA\u00b4s
\nfor comments. Lastly we should take this
\nopportunity to work closely with the WHO
\nas this is one of many topics where it is of
\nobvious value that these International
\norganisations join forces.
\nJon Snaedal
\nPresident of the WMA
\nEditorial note:
\nThe text of many of the statements etc.
\nadopted by the WMA General Assembly,
\nwhile referred to in the Report (see p. 103)
\nhave been printed in the appropiate sec-
\ntions e.g. Ethics. Due to constraints on
\navailable space, those on Noise and
\nFamily Planning will appear in the next
\nissue. They can also be accessed at
\nwww.wma.net.
\nMedical Ethics and Human Rights
\nMedical Research on Child Subjects
\nDr. James Appleyard, MD, FRCPCH,
\nPast President WMA
\n(see also pp. 86 and 109)
\nChildren worldwide bear the greatest bur-
\nden of disease. Medical research on child
\nsubjects is essential to identify effective and
\nsustainable action that will lead to
\nimprovements in child health (1,2). There
\nis a natural reluctance to involve children in
\nany risk associated with such research.
\nTesting in adults has rightly to precede any
\ntrial of new approaches to treatment
\namongst children.
\nChildren, however, have been subject to
\nresearch studies in residential institutions
\nprior to any independent ethical review
\nbeing introduced . The most public and con-
\ntroversial research study on children during
\nthe second half of the 20th
\ncentury was the
\n\u2018Willowbrook Hepatitis Study\u2019 started in
\n1956 at a New York State Institution for
\nmentally defective persons. (3,4) Such
\nexamples led to the persistence of a pre-
\ndominantly protective approach towards
\nresearch in children.. So much so that ,with
\nthe increasing number of medications avail-
\nable to adults in the last half century, chil-
\ndren were increasingly being \u2018left behind\u2019.
\nThe market for new drugs amongst children
\nwas much smaller and that a combination
\nof the inherent protective environment with
\nthe increased cost of clinical trials meant
\nthat pharmaceutical companies did not
\nundertake the relevant trials in children.
\nPracticing pediatricians faced the dilemma
\nof knowing how effective a new chemical
\nsubstance has been found in adult studies
\nand feeling duty bound to try them on their
\nchild patients \u2018off label\u2019
\nIn the 90\u2019s this had reached such a propor-
\ntion that pediatricians were pressing for
\nchanges in the system. (5,6) The \u2018Children\u2019s
\nrule, evolved in the USA, has had a positive
\neffect on promoting children\u2019s research. (7,
\n12) and Europe has followed with the E.U.
\nDirective 2001\/20\/ECBoth the Food and
\nDrug Administration and the E.U.
\nCommission have been consulting further
\non their existing regulations
\nChina affirms its
\ncommitment to
\nWMA Transplan-
\ntation policy
\nFollowing the visit of a WMA delegation
\nearlier this year (see report in WMJ 53,2),
\nthe Chinese Medical Association, in a let-
\nter from the Secretary General, Dr. Wang
\naffirmed its commitment to WMA poli-
\ncy and wrote as follows:
\n\u201c\u2026 after discussions in the Chinese
\nMedical Association, a consensus has
\nbeen reached, that is, the Chinese
\nMedical Association agrees to the
\nWorld Medical Association Statement
\non Human Organ Transplantation,
\nwhich states that organs of prisoners
\nand other individuals in custody must
\nnot be used for transplantation except
\nfor members of their immediate family.
\nThe Chinese Medical Association will,
\nthrough its influence, further promote
\nthe strengthening of the management of
\nhuman organ transplantation and pre-
\nvent possible violations of the regula-
\ntions made by the Chinese
\nGovernment. We also hope to work
\nmore closely with the WMA and
\nexchange information and views on the
\nmanagement of human organ trans-
\nplantation\u201d.
\nMedical Ethics and Human Rights
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 87
\n88 WMJ 53, December 2007
\nRegulations are important within the legal
\nframework of each country. Medical
\nresearch is increasingly a global imperative
\nand the relevant common ethical standards
\nneed to be international. (6)
\nThe WMA\u2019s Declaration of Helsinki (9)
\nhas underpinned the guidelines from the
\nCouncil for International Organisations of
\nMedical Sciences (CIOMS) (7) and ICH
\nGCP (8) It has also been the reference doc-
\nument for many national pediatric guide-
\nlines. (5) The paragraphs specifically relat-
\ned to children are paras. 24 and 25, regard-
\ning consent and\/or assent of \u2018minors\u2019
\n\u201c24 For a research subject who is legally
\nincompetent, physically or mentally inca-
\npable of giving consent or is a legally
\nincompetent minor, the investigator must
\nobtain informed consent from the legally
\nauthorized representative in accordance
\nwith applicable law. These groups should
\nnot be included in research unless the
\nresearch is necessary to promote the health
\nof the population represented and this
\nresearch cannot instead be performed on
\nlegally competent persons\u201d.
\n\u201c25 When a subject deemed legally incom-
\npetent, such as a minor child, is able to
\ngive assent to decisions about participation
\nin research, the investigator must obtain
\nthat assent in addition to the consent of the
\nlegally authorized representative.\u201d
\nIn the WMA\u2019s Declaration of Ottawa on the
\nRight of a Child to Healthcare, a precau-
\ntionary protective approach to research is
\nadopted as one of the General Principles:
\nPara 4 V1 states \u201cIn particular every effort
\n\u2018should be made to protect every child from
\nunnecessary diagnostic procedures, treat-
\nment and research\u201d;
\nWe need to change the emphasis about the
\nneed for research on children for their own
\nbenefit while maintaining full protection
\nThe WMA should provide leadership for
\nthe benefit of children worldwide. Most of
\nthe burden of disease affecting children is
\noutside the rich countries of the USA,
\nEurope and Japan, where regulations and
\nguidelines have moved to a more positive
\napproach to research in children.
\nPrinciples recognizing the importance of
\nresearch and the growing maturity of chil-
\ndren to assent and consent to the process,
\ntheir need for special protection with the
\navoidance of harm, are essential.These are
\nof particular importance in relation to mat-
\nters referred to ethical review committees,
\nwhich must include in their membership
\nspecialist paediatric expertise in study
\ndesign when considering paediatric
\nresearch.
\nIt is difficult to incorporate all these essen-
\ntial points within the Declaration of
\nHelsinki even though there is an opportuni-
\nty to do so now that revisions are being con-
\nsidered. The WMA has already accepted
\nthe special needs of Children in their previ-
\nous agreement to a separate Declaration on
\nthe Right of a Child to Health Care, in addi-
\ntion to the general rights of all patients. The
\nAssociate Members Meeting at the General
\nAssembly of the WMA, with the particular
\nsupport of representatives from the USA,
\nGermany and Nigeria, recommended that a
\nseparate Statement on Medical Research on
\nChild Subjects be considered by the WMA
\nAssembly in Copenhagen with a view to its
\nbeing circulated for comment by national
\nmedical associations (NMAs). The
\nAssembly agreed and the Statement has
\nbeen sent out to nmas by the WMA
\nSecretariat.
\nThe Statement has been drafted from the
\nprinciples underlying the key guidelines on
\npediatric research in Europe (10, 12)
\nUnited States (11) and Japan (13) and
\nrelates directly to the Declaration of
\nHelsinki. The Statement should form a tem-
\nplate for the development of local national
\nguidelines in each country to provide both a
\npositive and protective environment for the
\npromotion of child health and welfare
\nThe Preamble summaries the importance of
\nmedical research for children and the need
\nto protect them from harm. The five main
\nparagraphs highlight issues which are
\neither specific to children or must be con-
\nsidered in the context of childhood. Each
\nstatement underlines a principle and each
\nsentence is both self standing and to be
\ntaken in context. Further clarification of
\nthese principles need to be expanded in
\nlocal national guidelines. Thus the docu-
\nment has been constructed to be a succinct
\nas possible
\nDraft Proposed Statement
\nPreamble
\nAdvances in medical care are based on the
\nscientific evaluation of preventative, diag-
\nnostic and therapeutic measures.
\nChildren should share in the benefits from
\nscientific research relevant to their individ-
\nual age related health needs.
\nResearch on children is essential for the
\ndevelopment of scientifically based med-
\nical knowledge that will ensure the effective
\npromotion of child health and the well
\nbeing of children worldwide.
\nChildren involved in research need special
\nprotection. They differ from adults biologi-
\ncally. \u2013with their increased vulnerability,
\nage specific needs and growth and develop-
\nment potential.
\nChildren must be subject to the safeguards
\napplicable to all research subjects in the
\nDeclaration of Helsinki, together with para-
\ngraphs 24 and 25 concerning legally incom-
\npetent minors.
\nThe Declaration of Ottawa defines the right
\nof a child to health care, which includes the
\nprinciples of consent and self determination
\namongst children in paragraphs 9-13.
\nPhysicians should respect international
\nand national professional guidelines on
\nresearch in children which conform to
\nthese principles.
\nNeed for Protection
\nBiomedical studies involving children as
\nresearch subjects should be focused on the
\nknowledge of epidemiology, pathogenesis,
\ndiagnosis and treatment of diseases or con-
\nditions of childhood.
\nA child should not be involved in research
\nthat can be carried out on laboratory mod-
\nels, animal subjects or adult persons, or that
\nserves only a scientific interest The knowl-
\nedge to be gained from the research must
\nform a necessary contribution to the health-
\ncare of children.
\nDifferent physiological, psychological and
\npathogenic features occur at the different
\nMedical Ethics and Human Rights
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 88
\n89WMJ 53, December 2007
\nages and stages of the growth ,development,
\nsex and ethnicity in childhood. from the
\npremature newborn infant through adoles-
\ncence.
\nThere is a need to balance the potential ben-
\nefits to children against any risk involved
\nin the research.
\nPhysicians must respect the integrity and
\nrelative autonomy of a child and strive to
\nattain the maximal achievable benefit, with
\nthe avoidance of unnecessary risks, discom-
\nfort and stress.
\nAvoidance of harm
\nRisks should be minimised and potential
\nharm leading to physical, psychological,
\nsocial, spiritual impairment should be
\navoided
\nMinimal risk involves procedures, ques-
\ntionnaires, observation and measurements
\neven being carried out in a child sensitive
\nway.
\nGreater than minimal risk is can be associ-
\nated with invasive procedures or therapies.
\nThese should be carried out only when the
\nresearch is concerned with diagnosis and
\ntreatment and the expected benefits to the
\nchild participant outweigh the known or
\nanticipated risks involved where the
\nresearch is likely to yield justifiable gener-
\nalisable knowledge of vital importance
\nabout the child\u2019s disorder or condition and
\nresearch that provides the only opportunity
\nto identify, prevent or alleviate a rare dis-
\nease confined to childhood
\nStudy Designs
\nStudy protocols and study designs must be
\nchild specific. In addition to including the
\nsafeguards for adult subjects , they should
\njustify the necessity of the research on chil-
\ndren
\nPreclinical safety and efficacy data are pre-
\nconditions for the start of paediatric clinical
\ntrials.
\nThe selection of children to participate in a
\nbiomedical research project should not
\ndepend upon the child\u2019s race, nationality,
\ngender or religion, except in cases where
\none or more of these attributes relate to the
\nobjective of the research
\nThe performance of a study must be guaran-
\nteed to be conducted by experts competent
\nin childhood diseases and disorders, empa-
\nthetic and truly conversant with children,
\nparents, and all legal requirements where
\nthe interests of the child are paramount
\nChild specific protocols should be drawn up
\nby experienced experts and the study should
\nbe carried out under the supervision of pae-
\ndiatricians
\nAge specific informed consent\/assent forms
\nneed to be available for child subjects, their
\nparents and legal representatives.
\nThe study protocols should be evaluated by
\nindependent research ethics committees on
\nwhich there are paediatric health profes-
\nsionals.
\nConsent\/Assent
\nChildren are minors who have not reached
\nthe age for self responsible consent.
\nInformed consent means the approval of the
\nchild\u2019s parents or legal representative for
\nthe participation of the child in a research
\nstudy, following sufficient information to
\nenable them to make an informed judgment.
\nInformed Assent means the acquiescence of
\nthe child to participate in the research fol-
\nlowing information being provided in a
\nform understandable to their age group.
\nThe consent of both parents should be
\nsought prior to enrolling a child in a bio-
\nmedical research project.
\nThere must be no forced or undue influ-
\nence, financial or otherwise, on the child\u2019s
\ndecision to participate in the research or on
\nthe parents\/legal representative\u2019s consent.
\nThe refusal to participate in the research by
\nan informed child must be respected .
\nPrivacy
\nThe privacy if the child must be fully
\nassured throughout the research project.
\nAll personal and health related information
\nabout the child and the family, collected and
\nstored, must remain confidential.
\nResearch Ethics Committees
\nThe interests of children should always be
\nrepresented on independent research ethics
\ncommittees when research on children is
\nbeing considered. The membership must
\ninclude children\u2019s physicians experienced
\nin paediatric research and trained in the spe-
\ncial needs of children. Other members
\nshould be well acquainted with the needs of
\nchildren .
\nFurther work on this Statement
\nA detailed scrutiny by national medical
\nassociations and other interested \u2018stake-
\nholders\u2019 is welcomed. The W.M.A has set
\nup an electronic working group to receive
\ncomments and suggestions both on the need
\nfor a document such as this which is specif-
\nic for children and on the core principles in
\nthe statement which can be used to develop
\nboth international and local national guide-
\nlines.
\nPlease send your comments to your
\nNational Medical Association or as individ-
\nuals to the WMA office secretariat@
\nwma.net
\nJames Appleyard MD FRCPCH
\nChildren\u2019s Physician
\nPast President
\nWorld Medical Association
\nNovember 2007
\nReferences
\n1.Child Health Research \u2013 A foundation for
\nimproving Child Health. World Health
\nOrganisation 2001
\n2.Global Forum for Health Research 2005
\nWorld Health Organisation
\n3. Krugman S Experiments at the
\nWillowbrook State School . Lancet 1971
\n1 966-967
\n4. Burns J.P. \u2018Research in Children\u2019 Crit
\nCare Med 2003 31 No 3 (Suppl)
\nMedical Ethics and Human Rights
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 89
\n90 WMJ 53, December 2007
\n5. Guidelines for the Ethical Conduct of
\nMedical Research involving children.
\nRoyal College of Paediatrics and Child
\nHealth: Ethics Advisory Committee
\nArch. Dis. Child. 2000 82 177-182
\n6. Appleyard W.J The Challenge of building
\nan International Framework for Research
\non Medicines for Children. The Joseph J
\nHoet Lecture 2005 The European Forum
\nfor Good Clinical Practice Bruxelles
\n7. International Ethical Guidelines for
\nBiomedical Research involving Human
\nSubjects, Council for International
\nOrganisations of Medical Sciences with
\nthe WHO Geneva 2002
\n8. Department of Health and Human
\nServices, Food and Drug Administration.
\nRegulations requiring manufacturers to
\nassess the safety and effectiveness of new
\ndrugs and biological products in pediatric
\npatients; final rule Ref Reg 1998
\n63(231):666 32-72
\n9. Additional Safeguards for Children in
\nClinical investigations of FDA-regulated
\nProducts \u2013 Interim Rule Food and Drug
\nAdministration, Health and Human
\nServices 2007 www.fda.gov.
\n10. \u2018Ethical Principles for Medical
\nResearch Involving Human Subjects\u2019
\nWMA Declaration of Helsinki 2002
\n11. Ethical Principles and Operational
\nGuidelines for Good Clinical Practice in
\nPaediatric Research in Ethics Working
\nGroup Confederation of European
\nSpecialists in Paediatrics 2002
\n12. Committee on Drugs, American
\nAcademy of Pediatrics Guidelines for
\nthe ethical conduct of studies to evalu-
\nate drugs in pediatric populations
\nPediatrics 1995 286-294
\n13. Ethical Considerations for Clinical tri-
\nals performed in Children – Guidelines
\nby an Ad Hoc Group for E U Directive
\n2001\/20\/EC 2006
\n14. International Ethical Guidelines for
\nBiomedical Research Involving Human
\nSubjects Prepared by the Council for
\nInternational Organizations of Medical
\nSciences (CIOMS) in collaboration
\nwith the World Health Organization
\n(WHO) CIOMS Geneva 2002
\n15. \u2018Clinical Investigation of medicinal
\nproducts in the paediatric population\u2019.
\nInternational Committee on
\nHarmonisation E 11
\n16. Guideline on Ethical considerations for
\nClinical Trials performed in children
\nwithin the scope of the E.U Clinical
\nTrials Directive 2001\/20\/EC . The
\nEuropean Agency for the Evaluation of
\nMedicinal Products (EMEA) 2006
\n17. Improving Child Health : The role of
\nResearch Working Group on Women
\nand Child Health BMJ 2002 324 1444-
\n7
\n18. Forest CB, Shipman SA , Dougherty D,
\nMiller MR \u2018Outcomes Research in
\nPediatric Settings\u2019 Pediatrics 2003 111
\n171-8
\n19. Homan R \u2018Problems with Codes\u2019
\nResearch Ethics Review 2006 2 No3
\n98-103
\n20. Appleyard W.J.\u2019 The Rights of Children
\nto Healthcare\u2019 Medical Ethics 1998 24
\n293-4
\n21. Ross L.F \u2018Do healthy children deserve
\ngreater protection in Medical Research
\n?\u2019 J.Pediatr 2003 142 108-12
\n22. Ondrusek N., Abramovitch R.,
\nPencharz P and Koren G \u2018Empirical
\nexamination of the ability of children to
\nconsent to clinical research\u2019 Journal of
\nMedical Ethics 1998 24 158-165
\n23. Steinbrook R Testing Medications in
\nChildren N Eng J Med 2002 347 1642-
\n1470
\nWorld Health Professions Alliance
\nConference on Regulation of Health
\nProfessions display
\nThe World Medical Association will join with its partners in the World Health
\nProfessions Alliance (WHPA)* and the World Confederation for Physical Therapy in
\nhosting a conference in the Regulation of Health Professions.
\nThe Conference will be held in Geneva, Switzerland on May 17-18 2008 and discuss
\nthe role and future of health professions\u2019 regulation. It will focus on models of health
\nprofessions\u2019 regulation, examples of best practice in regulatory body governance and
\na discussion of trade in services and its implications for regulation.
\nThe Conference, intended to bring together regulators, leaders of health
\nprofessions.policy makers, health system managers and administrators; researchers
\nand scientists and other interested parties, will take place prior to the World Health
\nAssembly (19\u201323 May 2008).
\nFor full details of speakers, programme, registration and submission of abstracts visit:
\nwww.whpa.org\/reg\/index.htm
\n*The World Health Professions Alliance is a unique alliance of dentistry, medicine, nursing and
\npharmacy aiming to address global health issues and striving to help deliver cost effective qual-
\nity health care worldwide. The WHPA member organisations are: the International Council of
\nNurses (ICN), the International Pharmaceutical Federation (FIP), the World Dental federation
\n(FDI) and the World Medical Association (WMA). WHPA will be joined by the World
\nConfederation for Physical Therapy (WPTC).
\nMedical Ethics and Human Rights
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 90
\n91WMJ 53, December 2007
\nDEFINITION
\nTelemedicine is the practice of medicine
\nover a distance, in which interventions,
\ndiagnostic and treatment decisions and
\nrecommendations are based on data, doc-
\numents and other information transmitted
\nthrough telecommunication systems.
\nPREAMBLE
\nThe development and implementation of
\ninformation and communication technol-
\nogy are creating new modalities for pro-
\nviding care for patients. These enabling
\ntools offer different ways of practising
\nmedicine. The adoption of telemedicine is
\njustified because of its speed and its
\ncapacity to reach patients with limited
\naccess to medical assistance, in addition
\nto its power to improve health care.
\nPhysicians must respect the following eth-
\nical guidelines when practising telemedi-
\ncine.
\nPRINCIPLES
\nPatient-physician relationship and confi-
\ndentiality
\nThe patient-physician relationship should
\nbe based on a personal encounter and suf-
\nficient knowledge of the patient’s person-
\nal history. Telemedicine should be
\nemployed primarily in situations in which
\na physician cannot be physically present
\nwithin a safe and acceptable time period.
\nThe patient-physician relationship must
\nbe based on mutual trust and respect. It is
\ntherefore essential that the physician and
\npatient be able to identify each other reli-
\nably when telemedicine is employed.
\nIdeally, telemedicine should be employed
\nonly in cases in which a prior in-person
\nrelationship exists between the patient and
\nthe physician involved in arranging or
\nproviding the telemedicine service.
\nThe physician must aim to ensure that
\npatient confidentiality and data integrity
\nare not compromised. Data obtained dur-
\ning a telemedical consultation must be
\nsecured through encryption and other
\nsecurity precautions must be taken to pre-
\nvent access by unauthorized persons.
\nResponsibilities of the physician
\nA physician whose advice is sought
\nthrough the use of telemedicine should
\nkeep a detailed record of the advice he\/she
\ndelivers as well as the information he\/she
\nreceived and on which the advice was
\nbased.
\nIt is the obligation of the physician to
\nensure that the patient and the health pro-
\nfessionals or family members caring for
\nthe patient are able to use the necessary
\ntelecommunication system and necessary
\ninstruments. The physician must seek to
\nensure that the patient has understood the
\nadvice and treatment suggestions given
\nand that the continuity of care is guaran-
\nteed.
\nThe physician asking for another physi-
\ncian’s advice or second opinion remains
\nresponsible for treatment and other deci-
\nsions and recommendations given to the
\npatient.
\nA physician should be aware of and
\nrespect the special difficulties and uncer-
\ntainties that may arise when he\/she is in
\ncontact with the patient through means of
\ntele-communication. A physician must be
\nprepared to recommend direct patient-
\ndoctor contact when he\/she feels that the
\nsituation calls for it.
\nQuality of care
\nQuality assessment measures must be
\nused regularly to ensure the best possible
\ndiagnostic and treatment practices in
\ntelemedicine.
\nThe possibilities and weaknesses of
\ntelemedicine in emergencies must be
\nacknowledged. If it is necessary to use
\ntelemedicine in an emergency situation,
\nthe advice and treatment suggestions are
\ninfluenced by the level of threat to the
\npatient and the know-how and capacity of
\nthe persons who are with the patient.
\nRECOMMENDATION
\nThe WMA and National Medical
\nAssociations should encourage the devel-
\nopment of national legislation and inter-
\nnational agreements on subjects related to
\nthe practise of telemedicine, such as e-
\nprescribing, physician registration, liabili-
\nty and the legal status of electronic med-
\nical records.
\nWMA Statement On The Ethics Of Telemedicine
\nAdopted by the WMA General Assembly, Copenhagen, Denmark, October 2007
\nMedical Ethics and Human Rights
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 91
\n92 WMJ 53, December 2007
\nThe World Medical Association,
\n1. Considering the Preamble to the United
\nNations Charter of 26 June 1945 solemn-
\nly proclaiming the faith of the people of
\nthe United Nations in the fundamental
\nhuman rights, the dignity and value of
\nthe human person,
\n2. Considering the Preamble to the Universal
\nDeclaration of Human Rights of 10
\nDecember 1948 which states that disre-
\ngard and contempt for human rights have
\nresulted in barbarous acts which have out-
\nraged the conscience of mankind,
\n3. Considering Article 5 of that Declaration
\nwhich proclaims that no one shall be sub-
\njected to torture or cruel, inhuman or
\ndegrading treatment,
\n4. Considering the American Convention
\non Human Rights, which was adopted by
\nthe Organization of American States on
\n22 November 1969 and entered into
\nforce on 18 July 1978, and the Inter-
\nAmerican Convention to Prevent and
\nPunish Torture, which entered into force
\non 28 February 1987,
\n5. Considering the Declaration of Tokyo,
\nadopted by the World MedicalAssociation
\nin 1975, which reaffirms the prohibition of
\nany form of medical involvement or pres-
\nence of a physician during torture or inhu-
\nman or degrading treatment,
\n6. Considering the Declaration of Hawaii,
\nadopted by the World Psychiatric
\nAssociation in 1977,
\n7. Considering the Declaration of Kuwait,
\nadopted by the International Conference
\nof Islamic Medical Associations in 1981,
\n8. Considering the Principles of Medical
\nEthics Relevant to the Role of Health
\nPersonnel, Particularly Physicians, in the
\nProtection of Prisoners and Detainees
\nAgainst Torture and Other Cruel,
\nInhuman or Degrading Treatment or
\nPunishment, adopted by the United
\nNations General Assembly on 18
\nDecember 1982, and particularly
\nPrinciple 2, which states: \u00ab\u00a0It is a gross
\ncontravention of medical ethics\u2026 for
\nhealth personnel, particularly physicians,
\nto engage, actively or passively, in acts
\nwhich constitute participation in, com-
\nplicity in, incitement to or attempts to
\ncommit torture or other cruel, inhuman
\nor degrading treatment\u2026\u00a0\u00bb,
\n9. Considering the Convention Against
\nTorture and Other Cruel, Inhuman or
\nDegrading Treatment or Punishment,
\nwhich was adopted by the United
\nNations General Assembly on December
\n1984 and entered into force on 26 June,
\n1987,
\n10. Considering the European Convention
\nfor the Prevention of Torture and
\nInhuman or Degrading Treatment or
\nPunishment, which was adopted by the
\nCouncil of Europe on 26 June 1987 and
\nentered into force on 1 February 1989,
\n11. Considering the Resolution on Human
\nRights adopted by the World Medical
\nAssociation in Rancho Mirage, in
\nOctober 1990 during the 42nd General
\nAssembly and amended by the 45th,
\n46th and 47th General Assemblies,
\n12. Considering the Declaration of
\nHamburg, adopted by the World
\nMedicalAssociation in November 1997
\nduring the 49th General Assembly, call-
\ning on physicians to protest individual-
\nly against ill-treatment and on national
\nand international medical organizations
\nto support physicians in such actions,
\n13. Considering the Istanbul Protocol
\n(Manual on the Effective Investigation
\nand Documentation of Torture and
\nOther Cruel, Inhuman or Degrading
\nTreatment or Punishment), adopted by
\nthe United Nations General Assembly
\non 4 December 2000,
\n14. Considering the Convention on the
\nRights of the Child, which was adopted
\nby the United Nations on 20 November
\n1989 and entered into force on 2
\nSeptember 1990, and
\n15. Considering the World Medical
\nAssociation Declaration of Malta on
\nHunger Strikers, adopted by the 43rd
\nWorld Medical Assembly Malta,
\nNovember 1991and amended by the
\nWMA General Assembly, Pilanesberg,
\nSouth Africa, October, 2006,
\nRecognizing
\n16. That careful and consistent documenta-
\ntion and denunciation by physicians of
\ncases of torture and of those responsi-
\nble contributes to the protection of the
\nphysical and mental integrity of vic-
\ntims and in a general way to the strug-
\ngle against a major affront to human
\ndignity,
\nWMA resolution on the responsibility of physicians in the documen-
\ntation and denunciation of acts of torture or cruel or inhuman or
\ndegrading treatment
\nInitiated: September 2002, Adopted by the WMA General Assembly, Helsinki 2003 and amended
\nby the WMA General Assembly, Copenhagen, Denmark, October 2007
\nMedical Ethics and Human Rights
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 92
\n93WMJ 53, December 2007
\n17. That physicians, by ascertaining the
\nsequelae and treating the victims of tor-
\nture, either early or late after the event,
\nare privileged witnesses of this viola-
\ntion of human rights,
\n18. That the victims, because of the psycho-
\nlogical sequelae from which they suffer
\nor the pressures brought on them, are
\noften unable to formulate by themselves
\ncomplaints against those responsible for
\nthe ill-treatment they have undergone,
\n19. That the absence of documenting and
\ndenouncing acts of torture may be con-
\nsidered as a form of tolerance thereof
\nand of non-assistance to the victims,
\n20. That nevertheless there is no consistent
\nand explicit reference in the profession-
\nal codes of medical ethics and legisla-
\ntive texts of the obligation upon physi-
\ncians to document, report or denounce
\nacts of torture or inhuman or degrading
\ntreatment of which they are aware,
\nRecommends that National
\nMedical Associations
\n1. Attempt to ensure that detainees or vic-
\ntims of torture or cruelty or mistreatment
\nhave access to immediate and indepen-
\ndent health care. Attempt to ensure that
\nphysicians include assessment and docu-
\nmentation of symptoms of torture or ill-
\ntreatment in the medical records using
\nthe necessary procedural safeguards to
\nprevent endangering detainees.
\n2. Promote awareness of the Istanbul
\nProtocol and its Principles on the Effective
\nInvestigation and Documentation of
\nTorture and Other Cruel, Inhuman or
\nDegrading Treatment. This should be done
\nat country level using different methods of
\ninformation dissemination; including
\ntrainings, publications and web docu-
\nments.
\n3. Disseminate to physicians the Istanbul
\nProtocol.
\n4. Promote training of physicians on the
\nidentification of different modes of tor-
\nture, in recognizing physical and psycho-
\nlogical symptoms following specific
\nforms of torture and in using the docu-
\nmentation techniques foreseen in the
\nIstanbul Protocol to create documenta-
\ntion that can be used as evidence in legal
\nor administrative proceedings.
\n5. Promote awareness of the correlation
\nbetween the examination findings,
\nunderstanding torture methods and the
\npatients’ allegations of abuse;
\n6. Facilitate the production of high-quality
\nmedical reports on torture victims for
\nsubmission to judicial and administrative
\nbodies;
\n7. Attempt to ensure that physicians
\nobserve informed consent and avoid
\nputting individuals in danger while
\nassessing or documenting signs of torture
\nand ill-treatment;
\n8. Attempt to ensure that physicians include
\nassessment and documentation of symp-
\ntoms of torture or ill-treatment in the
\nmedical records using the necessary pro-
\ncedural safeguards to prevent endanger-
\ning detainees.
\n9. Support the adoption in their country of
\nethical rules and legislative provisions:
\n9.1 aimed at affirming the ethical obligation
\non physicians to report or denounce acts
\nof torture or cruel, inhuman or degrad-
\ning treatment of which they are aware;
\ndepending on the circumstances, the
\nreport or denunciation would be
\naddressed to medical, legal, national or
\ninternational authorities, to non-govern-
\nmental organizations or to the
\nInternational Criminal Court. Doctors
\nshould use their discretion in this mat-
\nter, bearing in mind paragraph 68 of the
\nIstanbul Protocol.
\n9.2 establishing, to that effect, an ethical
\nand legislative exception to profession-
\nal confidentiality that allows the physi-
\ncian to report abuses, where possible
\nwith the subject’s consent, but in certain
\ncircumstances where the victim is
\nunable to express him\/herself freely,
\nwithout explicit consent.
\n9.3 cautioning physicians to avoid putting
\nindividuals in danger by reporting on a
\nnamed basis a victim who is deprived of
\nfreedom, subjected to constraint or
\nthreat or in a compromised psychologi-
\ncal situation
\n10. Place at their disposal all useful infor-
\nmation on reporting procedures, partic-
\nularly to the national authorities, non-
\ngovernmental organizations and the
\nInternational Criminal Court.
\nIstanbul Protocol, paragraph 68: \u00ab\u00a0In some
\ncases, two ethical obligations are in con-
\nflict. International codes and ethical princi-
\nples require the reporting of information
\nconcerning torture or maltreatment to a
\nresponsible body. In some jurisdictions, this
\nis also a legal requirement. In some cases,
\nhowever, patients may refuse to give con-
\nsent to being examined for such purposes or
\nto having the information gained from
\nexamination disclosed to others. They may
\nbe fearful of the risks of reprisals for them-
\nselves or their families. In such situations,
\nhealth professionals have dual responsibili-
\nties: to the patient and to society at large,
\nwhich has an interest in ensuring that jus-
\ntice is done and perpetrators of abuse are
\nbrought to justice. The fundamental princi-
\nple of avoiding harm must feature promi-
\nnently in consideration of such dilemmas.
\nHealth professionals should seek solutions
\nthat promote justice without breaking the
\nindividual’s right to confidentiality. Advice
\nshould be sought from reliable agencies; in
\nsome cases this may be the national medical
\nassociation or non-governmental agencies.
\nAlternatively, with supportive encourage-
\nment, some reluctant patients may agree to
\ndisclosure within agreed parameters.\u00a0\u00bb
\nMedical Ethics and Human Rights
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 93
\n94 WMJ 53, December 2007
\nPREAMBLE
\nNoting information and reports of system-
\natic and repeated violations of human
\nrights, interference with the right to health
\nin Zimbabwe, failure to provide resources
\nessential for provision of basic health care,
\ndeclining health status of Zimbabweans,
\ndual loyalties and threats to health care
\nworkers striving to maintain clinical inde-
\npendence, denial of access to health care
\nfor persons deemed to be associated with
\nopposition political parties and escalating
\nstate torture, the WMA wishes to confirm
\nits support of, and commitment to:
\n\u2022 Attaining the World Health Organization
\nprinciple that the \u00ab\u00a0enjoyment of the
\nhighest attainable standard of health is
\none of the fundamental rights of every
\nhuman being\u00a0\u00bb
\n\u2022 Defending the fundamental purpose of
\nphysicians to alleviate distress of
\npatients and not to let personal, collec-
\ntive or political will prevail against such
\npurpose
\n\u2022 Supporting the role of physicians in
\nupholding the human rights of their
\npatients as central to their professional
\nobligations
\n\u2022 Supporting physicians who are persecut-
\ned because of their adherence to medical
\nethics
\nRECOMMENDATION
\nTherefore, the World Medical Association,
\nrecognizing the collapsing health care sys-
\ntem and public health crisis in Zimbabwe,
\ncalls on its affiliated national medical asso-
\nciations to:
\n1. Publicly denounce all human rights
\nabuses and violations of the right to
\nhealth in Zimbabwe
\n2. Actively protect physicians who are
\nthreatened or intimidated for actions
\nwhich are part of their ethical and pro-
\nfessional obligations
\n3. Engage with the Zimbabwean Medical
\nAssociation (ZiMA) to ensure the
\nautonomy of the medical profession in
\nZimbabwe
\n4. Urge and support ZiMA to invite an
\ninternational fact finding mission to
\nZimbabwe as a means for urgent action
\nto address the health and health needs
\nof Zimbabweans
\nIn addition, the WMA encourages ZiMA,
\nas a member organization of the WMA,
\nto:
\n5. Uphold its commitment to the WMA
\nDeclarations of Tokyo, Hamburg and
\nMadrid as well as the WMA Statement
\non Access to Health Care
\n6. Facilitate an environment where all
\nZimbabweans have equal access to qual-
\nity health care and medical treatment,
\nirrespective of their political affiliations
\n7. Commit to eradicating torture and inhu-
\nmane, degrading treatment of citizens
\nin Zimbabwe
\n8. Reaffirm their support for the clinical
\nindependence of physicians treating
\nany citizen of Zimbabwe
\n9. Obtain and publicize accurate and nec-
\nessary information on the state of
\nhealth services in Zimbabwe
\n10. Advocate for inclusion in medical cur-
\nricula, teachings on human rights and
\nthe ethical obligations of physicians to
\nmaintain full and clinical indepen-
\ndence when dealing with patients in
\nvulnerable situations
\nThe WMA encourages ZiMA to seek assis-
\ntance in achieving the above by engaging
\nwith the WMA, the Commonwealth
\nMedical Association and the NMAs of
\nneighboring countries and to report on its
\nprogress from time to time.
\nWMA Resolution On Health And Human Rights Abuses In Zimbabwe
\nAdopted by the WMA General Assembly, Copenhagen, Denmark, October 2007
\nMedical Ethics and Human Rights
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 94
\n95WMJ 53, December 2007
\nPREAMBLE
\nMore than one in three adults worldwide
\n(more than 1.1 billion people) smokes, 80
\npercent of whom live in low- and middle-
\nincome countries. Smoking and other
\nforms of tobacco use affect every organ
\nsystem in the body, and are major causes
\nof cancer, heart disease, stroke, chronic
\nobstructive pulmonary disease, fetal dam-
\nage, and many other conditions. Five mil-
\nlion deaths occur worldwide each year
\ndue to tobacco use. If current smoking
\npatterns continue, it will cause some 10
\nmillion deaths each year by 2020 and 70
\npercent of these will occur in developing
\ncountries. Tobacco use was responsible
\nfor 100 million deaths in the 20th century
\nand will kill one billion people in the 21st
\ncentury unless effective interventions are
\nimplemented. Furthermore, secondhand
\nsmoke – which contains more than 4000
\nchemicals, including more than 50 car-
\ncinogens and many other toxins – causes
\nlung cancer, heart disease, and other ill-
\nnesses in nonsmokers.
\nThe global public health community,
\nthrough the World Health Organization
\n(WHO), has expressed increasing concern
\nabout the alarming trends in tobacco use
\nand tobacco-attributable disease. As of 20
\nSeptember 2007, 150 countries had rati-
\nfied the Framework Convention on
\nTobacco Control (FCTC), whose provi-
\nsions call for ratifying countries to take
\nstrong action against tobacco use by
\nincreasing tobacco taxation, banning
\ntobacco advertising and promotion, pro-
\nhibiting smoking in public places and
\nworksites, implementing effective health
\nwarnings on tobacco packaging, improv-
\ning access to tobacco cessation treatment
\nservices and medications, regulating the
\ncontents and emissions of tobacco prod-
\nucts, and eliminating illegal trade in
\ntobacco products.
\nExposure to secondhand smoke occurs
\nanywhere smoking is permitted: homes,
\nworkplaces, and other public places.
\nAccording to the WHO, some 200,000
\nworkers die each year due to exposure to
\nsmoke at work, while about 700 million
\nchildren, around half the world’s total,
\nbreathe air polluted by tobacco smoke,
\nparticularly in the home. Based on the evi-
\ndence of three recent comprehensive
\nreports (the International Agency for
\nResearch on Cancer’s Monograph 83,
\nTobacco Smoke and Involuntary
\nSmoking; the United States Surgeon
\nGeneral’s Report on The Health
\nConsequences of Involuntary Exposure to
\nTobacco Smoke; and the California
\nEnvironmental Protection Agency’s
\nProposed Identification of Environmental
\nTobacco Smoke as a Toxic Air
\nContaminant), on May 29, 2007, the
\nWHO called for a global ban on smoking
\nat work and in enclosed public places.
\nThe tobacco industry claims that it is
\ncommitted to determining the scientific
\ntruth about the health effects of tobacco,
\nboth by conducting internal research and
\nby funding external research through
\njointly funded industry programs.
\nHowever, the industry has consistently
\ndenied, withheld, and suppressed infor-
\nmation concerning the deleterious effects
\nof tobacco smoking. For many years the
\nindustry claimed that there was no conclu-
\nsive proof that smoking tobacco causes
\ndiseases such as cancer and heart disease.
\nIt has also claimed that nicotine is not
\naddictive. These claims have been repeat-
\nedly refuted by the global medical profes-
\nsion, which because of this is also res-
\nolutely opposed to the massive advertis-
\ning campaigns mounted by the industry
\nand believes strongly that the medical
\nassociations themselves must provide a
\nfirm leadership role in the campaign
\nagainst tobacco.
\nThe tobacco industry and its subsidiaries
\nhave for many years supported research
\nand the preparation of reports on various
\naspects of tobacco and health. By being
\ninvolved in such activities, individual
\nresearchers and\/or their organizations
\ngive the tobacco industry an appearance
\nof credibility even in cases where the
\nindustry is not able to use the results
\ndirectly in its marketing. Such involve-
\nment also raises major conflicts of interest
\nwith the goals of health promotion.
\nRECOMMENDATIONS
\nThe WMA urges the national medical
\nassociations and all physicians to take the
\nfollowing actions to help reduce the
\nhealth hazards related to tobacco use:
\n1. Adopt a policy position opposing
\nsmoking and the use of tobacco prod-
\nucts, and publicize the policy so adopt-
\ned.
\n2. Prohibit smoking at all business, social,
\nscientific, and ceremonial meetings of
\nthe National Medical Association, in
\nline with the decision of the World
\nMedical Association to impose a simi-
\nlar ban at all its own such meetings.
\n3. Develop, support, and participate in
\nprograms to educate the profession and
\nthe public about the health hazards of
\ntobacco use (including addiction) and
\nexposure to secondhand smoke.
\nPrograms aimed at convincing and
\nhelping smokers and smokeless tobac-
\nco users to cease the use of tobacco
\nWMA Statement on Health Hazards of Tobacco Products
\nAdopted by the 40th World Medical Assembly, Vienna, Austria, September 1988 amended by the
\n49th WMA General Assembly, Hamburg, Germany, November 1997 and the WMA General
\nAssembly, Copenhagen, Denmark, October 2007
\nMedical Science, Medical Practice and Medical Education
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 95
\n96 WMJ 53, December 2007
\nproducts and programs for non-smok-
\ners and non-users of smokeless tobacco
\nproducts aimed at avoidance are both
\nimportant.
\n4. Encourage individual physicians to be
\nrole models (by not using tobacco prod-
\nucts) and spokespersons for the cam-
\npaign to educate the public about the
\ndeleterious health effects of tobacco
\nuse and the benefits of tobacco-use ces-
\nsation. Ask all medical schools, bio-
\nmedical research institutions, hospitals,
\nand other health care facilities to pro-
\nhibit smoking on their premises.
\n5. Introduce or strengthen educational
\nprograms for medical students and
\nphysicians to prepare them to identify
\nand treat tobacco dependence in their
\npatients.
\n6. Support widespread access to evi-
\ndence-based treatment for tobacco
\ndependence – including counseling and
\npharmacotherapy – through individual
\npatient encounters, cessation classes,
\ntelephone quit-lines, web-based cessa-
\ntion services, and other appropriate
\nmeans.
\n7. Develop or endorse a clinical practice
\nguideline on the treatment of tobacco
\nuse and dependence.
\n8. Join the WMA in urging the World
\nHealth Organization to add tobacco
\ncessation medications with established
\nefficacy to the WHO’s Model List of
\nEssential Medicines.
\n9. Refrain from accepting any funding or
\neducational materials from the tobacco
\nindustry, and to urge medical schools,
\nresearch institutions, and individual
\nresearchers to do the same, in order to
\navoid giving any credibility to that
\nindustry.
\n10. Urge national governments to ratify
\nand fully implement the Framework
\nConvention on Tobacco Control in
\norder to protect public health.
\n11. Speak out against the shift in focus of
\ntobacco marketing from developed to
\nless developed nations and urge
\nnational governments to do the same.
\n12. Advocate the enactment and enforce-
\nment of laws that:
\na. provide for comprehensive regula-
\ntion of the manufacture, sale, distrib-
\nution, and promotion of tobacco
\nproducts, including the specific pro-
\nvisions listed below.
\nb. require written and pictorial warn-
\nings about health hazards to be print-
\ned on all packages in which tobacco
\nproducts are sold and in all advertis-
\ning and promotional materials for
\ntobacco products. Such warnings
\nshould be prominent and should refer
\nthose interested in quitting to avail-
\nable telephone quit-lines, websites,
\nor other sources of assistance.
\nc. prohibit smoking in all enclosed pub-
\nlic places (including health care
\nfacilities, schools, and education
\nfacilities), workplaces (including
\nrestaurants, bars and nightclubs) and
\npublic transport. Mental health and
\nchemical dependence treatment cen-
\nters should also be smoke-free.
\nSmoking in prisons should not be
\npermitted.
\nd. ban all advertising and promotion of
\ntobacco products.
\ne. prohibit the sale, distribution, and
\naccessibility of cigarettes and other
\ntobacco products to children and
\nadolescents.
\nf. prohibit smoking on all commercial
\nairline flights within national borders
\nand on all international commercial
\nairline flights, and prohibit the sale of
\ntax-free tobacco products at airports
\nand all other locations.
\ng. prohibit all government subsidies for
\ntobacco and tobacco products.
\nh. provide for research into the preva-
\nlence of tobacco use and the effects
\nof tobacco products on the health sta-
\ntus of the population.
\ni. prohibit the promotion, distribution,
\nand sale of any new forms of tobacco
\nproducts that are not currently avail-
\nable.
\nj. increase taxation of tobacco products,
\nusing the increased revenues for pre-
\nvention programs, evidence-based
\ncessation programs and services, and
\nother health care measures.
\nk. curtail or eliminate illegal trade in
\ntobacco products and the sale of
\nsmuggled tobacco products.
\nl. help tobacco farmers switch to alter-
\nnative crops.
\nm. urge governments to exclude tobac-
\nco products from international trade
\nagreements.
\nMedical Science, Medical Practice and Medical Education
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 96
\n97WMJ 53, December 2007
\nEducation
\nAvicenna Directories to replace World Directory of Medical Schools
\nDiscussions have been taking place
\nbetween WHO and the University of
\nCopenhagen with a view to replacing the
\nWorld Directory of Medical Schools with
\nthe establishment of a Global database of
\nhealth professions. It is planned is to
\ninclude other academic health institutions
\nrelating to the other health professions such
\nas dentistry, midwifery, nursing, pharmacy,
\npublic health and will include information
\non schools’ accreditation, number of admis-
\nsions, students, graduates , Faculty, educa-
\ntional resources, address, and national offi-
\ncial recognition. The database will be run
\nby the University of Copenhagen in collab-
\noration with WHO, the World Federation
\nfor Medical Education (WFME), the
\nFoundation for the4 Advancement of
\nInternational Medical Education and
\nResearch (FAIMER), the International
\nPharmaceutical Federation and other part-
\nners.
\nThe database will be based in the Faculty
\nof Health Sciences in the University of
\nCopenhagen with the close collaboration
\nof WFME. These electronic resources will
\nbe called the Avicenna Directories. It
\nis understood that the work has already
\nstarted.
\nGlobal Standards for Quality Improvement in Medical Education
\nThe World Federation of Medical Education
\nhas published European Specifications for
\nBasic and Postgraduate Medical Education
\nand Continuing Professional Development.
\nThese have been developed by a WFMA\/
\nAMSE international task force set up by
\nMEDINE, chaired by WFME and ASME,
\nsponsored by the European Commission,
\nand provides a valuable tool adapting the
\nglobal standards in medical education to the
\nEuropean Region of WHO. It is directed
\ntowards national and international authori-
\nties, institutions and organisations with
\nresponsibility for medical education and
\nrepresents a valuable tool in planning qual-
\nity improvement in medical education, set-
\nting out the essential elements which need
\nto be considered in planning necessary
\nreforms in medical education. While this is
\nan essential tool for authorities and institu-
\ntions concerned with medical education it is
\nof value to all physicans who have respon-
\nsibilities in medical education,
\nWFME Global Standards for Quality
\nImprovement in Medical Education
\nEuropean Specifications.
\nISBN 978-87-989108-6-2
\nPublication facilitated by WHO EURO
\nInformation from:
\nWorld Federation of Medical Educuation
\nwww.wfme.org
\nPoint of view
\nA Worldwide Tour of Medical Degrees and Qualifications
\nDr. Denis Doran MD
\nIn recent years, attempting to recognise a
\nmedical degree or qualification can be chal-
\nlenging With the reunification of East and
\nWest Germany, the opening of the European
\nCommunity to several new member states,
\nthe break-up of the Soviet Union and the
\nfragmentation of Yugoslavia into several
\nindividual nations, medical degrees and
\nqualifications which were not familiar
\nbefore are now more commonly seen.
\nAnother problem that Boards, Medical
\nCouncils and Colleges have had to deal with
\nfor many years, is to differentiate and recog-
\nnise which degrees relate to clinical prac-
\ntice, which ones are linked to academic
\ncareers and which ones are honorary. The
\nincrease in international migration has made
\nthis problem even more pressing.
\nThis article will review the broad range of
\nmedical degrees and evidence of qualifica-
\ntion presented nowadays to licensing bod-
\nies, dental committees and residency pro-
\ngramme applications. It is not intended to
\nprovide an official or exhaustive list of
\nmedical qualifications but merely to reflect
\non the great variety of titles for medical
\ndiplomas and qualifications.
\nEUROPE
\nIn Europe, the medical degrees awarded
\nvary from country to country (and also
\nMedical Science, Medical Practice and Medical Education \/ Point of view
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 97
\n98 WMJ 53, December 2007
\nwithin countries), of which the following
\nare examples.
\nIn Belgium, the French university diploma
\nis Docteur en Medicine,Chirugie et
\nAccouchement. The Flemish university
\ndegree is Aerts, Arts (Physician).
\nIn the countries of the former Soviet Union
\nRussia, Ukraine, Moldova, Armenia and
\nEstonia all issue a Doctor in Medicine
\nDiploma; Uzbekistan awards a General
\nPractitioner diploma and the rest of the 15
\nrepublics award a Vrach (Physician) diploma.
\nIn the nations of the former Yugoslavia,
\nCroatia and Macedonia award a Doctor of
\nMedicine diploma, while Bosnia-
\nHerzegovina, Serbia and Slovenia formerly
\nissued a Lekar (or Zdravnik) diploma – now
\na Doctor of Medicine diploma.
\nThe graduates from medical schools in
\nAustria, The Czech Republic and Slovakia
\nreceive a Medicinae Universae Doctor
\nDiploma.
\nIn Scandinavia, Norwegian and Danish
\nmedical schools award a Candidatus
\nMedicinae diploma; Iceland – a Candidatus
\nMedicinae et Chirurgiae diploma; Sweden –
\na Lakaexamen diploma and in Finland – a
\n\u201cLisensiatti (Licence in Medicine). The
\ndegree Laaketieteen Tohtori (Doctor of
\nMedicine) is a traditional university doctor-
\nate, the highest degree and is a requirement
\nfor the position of Professor..
\nIn the Netherlands an Arts (or Artsexamen)
\ndiploma is awarded, in Luxembourg a
\nBachelor Academique en Sciences de la
\nVie-Medicine, and in Bulgaria, a
\nMaster\u2019s\/Physician or State Examination
\ncertificate is awarded
\nA few degrees have unusual sounding
\nnames: in Albania Mjek I Prerjithshem; in
\nGreece, Psycho Iatrikes; Belarus currently
\nKvaliifi Kaciya (Physician diploma ) for-
\nmerly a Vrach.)
\nRomania awards a Doctor-Medic diploma;
\nPoland, a Lekarz diploma; Hungary \u2013 an
\nOrvos doctor or MD diploma, and Turkey \u2013
\na Doctor of Medicine diploma.
\nIn the United Kingdom, the basic British
\nmedical degree is the MB, BCh, (Medicinae
\nBaccalaureus, Baccalaureus Chirugiae).
\nVarieties of the same degree exist through-
\nout Britain and the rest of the
\nCommonwealth. These are BM BCh , MB
\nChB, MB BChir, MB, BS. In the UK, an
\nMD could be awarded to one who does
\nresearch and submits a thesis in the field of
\nmedicine, or as an honorary degree, to a
\nsenior or academic physician. Throughout
\nthe world, many countries with former edu-
\ncational associations with Britain award
\ndegrees reflecting the British type of med-
\nical degree.
\nThe Conjoint Diploma LRCP, MRCS , and
\nthe LMSSA (Licentiate of the Royal College
\nof Physicians of London, Member of the
\nRoyal College of Surgeons of England, and
\nthe Licentiate in Medicine, Surgery of the
\nSociety of Apothecaries) were registrable
\nqualifications with the General Medical
\nCouncil (where all practising physicians
\nhave to be registered if they wish to prac-
\ntice) until 1999. The Scottish Triple
\nConjoint Diplomas, LRCPE, LRCSE,
\nLRCPSG are similar qualifications which
\nwere registrable with the GMC until 1999.
\nIn Ireland, the basic medical degree is MB,
\nChB, BAO (Baccalaureus in Arte
\nObstetrician). The LRCPI, LRCSI diplo-
\nmas, unlike England and Scotland are still
\nregistrable with the Irish Medical Council.
\nAlso recognised is the LM (Licence in
\nMidwifery)
\nFor Germany there is a State Examination
\nCertificate , either on passing a three part
\nState exam (Dritter Abschnitt Certificate ) or
\na two part State exam, (Zweiter Abschnitt
\nCertificate).which are recognised for basic
\nlicensing purposes. Italy awards a Laurea in
\nMedecina e Chirurgia diploma) (Bachelor of
\nMedicine and Surgery), Portugal awards a
\nLicenciatura em Medecina diploma and
\nSpain, a Licenciado en Medecina y Cirurgia.
\nSwitzerland awards a Diploma Federal.
\nLATIN AMERICA
\nBrazil awards a Medico (or MD) diploma;
\nBolivia a Titulo en Provision Nacional de
\nMedico Cirujano; Costa Rica,Venezuela
\nand Chile, a Medico Chirujano diploma:
\nEcuador, Honduras and Nicaragua, a
\nDoctor en Medicina y Chirugia; Mexico
\nand Peru, a Titulo de Medico Cirujano.
\nSurinam awards an Arts or Geneesheren
\ndiploma.
\nNORTH AMERICA
\nIn Canada, francophone universities award
\na Docteur\/ Doctorat en M\u00e9decine diploma:
\nAnglophone universities offer the MD diplo-
\nma. In the USA, most graduates of medical
\nschools receive an MD. Another medical
\ndegree awarded by 19 medical schools is the
\nDoctor of Osteopathy or DO diploma.
\nASIA
\nChina and Taiwan offer a Bachelor of
\nMedicine degree. China also offers a
\nBachelor of Traditional Medicine and Japan
\noffers an Igaku (Bachelor of Medicine). In
\nMalaysia following the British system the
\nMB,BS or MB,ChB are awarded as well as
\nthe Doctor \u201cPerubatan\u201d. North Korea offers
\na Doctor diploma and South Korea, earlier a
\nHak Sa diploma and now a Bachelor of
\nMedicine; Indonesia awards a Doktor diplo-
\nma and Mongolia a Physician diploma.
\nAFRICA
\nAngola and Mozambique ex-Portuguese
\ncolonies offer the same diplomas as
\nPortugal; the Democratic Republic of
\nCongo, an ex-Belgian colony, awards a
\nDocteur en Med., Chir et Accouchement
\ndiploma, as well as a number of others,
\nwhich are accepted for basic medical licens-
\ning purposes. Gabon, Benin and Ivory
\nCoast have a Doctorat d\u2019Etat en Medicine.
\nMost other countries of the world issue
\neither an MD, Doctorat en Medecine or
\nMBBS\/MB ChB degree.
\nNON-MEDICAL QUALIFI-
\nCATIONS
\nThe PhD is a university awarded research
\nDoctorate, not necessarily associated with
\nclinical practice, awarded after supervised
\nacademic research and the submission of a
\nPoint of view
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\n99WMJ 53, December 2007
\nthesis. (Often Clinical Psychologists, who
\nunlike Psychiatrists cannot prescribe med-
\nications have a PhD.).
\nMEMBERSHIP\/FELLOW-
\nSHIP OF COLLEGES AND
\nOTHER SPECIALIST
\nINSTITUTIONS
\nMedical Colleges and Academic Institutions,
\nmany of which have existed many or for
\nhundreds of years, award fellowships. The
\nColleges are normally concerned with spe-
\ncialities, although, as, mentioned above,
\nsome conduct examinations related to their
\nown specialty which are recognised for basic
\nlicensing purposes to practice medicine e.g.
\nLRCPI, LRCPI. Fellowships, on the other
\nhand normally require the passing of a high-
\ner examination or assessment and election
\nby the College as Fellows. Honorary
\nFellowships are mostly awarded for excep-
\ntional and distinguished practice in medicine
\nSuch Colleges have as their aim the develop-
\nment of the specialty and the maintenance of
\nhigh standards and excellence, a condition
\nwhich their members are bound to fulfil as a
\ncondition of Membership or Fellowship. The
\nuse of titles varies greatly between countries
\nand institutions.
\nMEMBERSHIP
\ne.g MCCFP Membership of Canadian
\nCollege of Family Physicians;
\nMACP Membership of American College
\nof Physicians;
\nMRCGP Membership of the Royal College
\nof General Practitioners.
\nMembership of these bodies, while not
\nobligatory in some countries, often marks
\nthe end point of specialist training and is
\nawarded after an examination This type of
\nMembership is, in certain countries, recog-
\nnised as achieving formal specialist qualifi-
\ncation, notably in the UK where for exam-
\nple, the MRCP is the recognised basic spe-
\ncialist qualification in medicine, whereas
\nthe FRCS is the basic specialist qualifica-
\ntion for surgery.
\nFELLOWSHIP
\ne.g FAAP Fellow of the American Academy
\nof Paediatrics.
\nFRCP Fellow of the Royal College of
\nPhysicians.
\nFellowships require a much higher distinc-
\ntion and status. They are usually awarded
\nafter passing a very difficult examination or
\nare elected for distinction in the relevant
\nbranch of medicine.
\nIn many countries of Europe and to a cer-
\ntain extent throughout the world, physicians
\nappointed as Professors prefer to be called
\nProfessor rather than Doctor and in
\nEngland, Fellows of the Royal College of
\nSurgeons are referred to as Mister In fact all
\nsurgeons are called Mister but \u201cObstetric
\nand Gynaecologist\u201d specialists if they hold
\nan MD, may use the title Doctor.
\nCONCLUSION
\nIt is not the purpose of this article to discuss
\nthe details of qualifications associated with
\nthe great variety of medical degrees listed
\nabove.
\nNevertheless, licensing bodies have the role
\nof recognising (or not) these medical
\ndegrees and qualifications and to suggest,
\nwhen necessary, updates to qualify for a
\nlicence to practice.
\nAccordingly, the public at large need to
\naccept the fact that physicians qualified to
\npractice in their region may not necessarily
\nhave the usual MD after their name.
\nAddress for communication
\nDr Denis Doren
\nBox70 1 Hastings St N,
\nBancroft. KOL 1CO
\nCanada
\nFrom the WMA Secretary General
\nTrust me, I\u2019m a Doctor!
\nAlthough you never should say this to your
\npatients \u2013 you often will enjoy exactly the
\ndesired high degree of confidence in what
\nyou do and what you are \u2013 a physician.
\nHowever, we are about to lose this!
\nNo, I am not referring to the sermon-like
\nrepeated \u201cdoctor bashing\u201d of politicians and
\nmedia, I am referring to what may be
\nthought to be advertising, but may be large-
\nly a lack of precision and carelessness in
\ncommunication, with which we are endan-
\ngering our image.
\nMore and more people are reaching out
\ntheir hands to patients saying \u201eHallo! I am
\nyour doctor.\u201c But what kind of doctors are
\nthey? At best they may be scientifically
\ntrained persons but they may well be doc-
\ntors of podology. This not a joke! There is
\nan economic war and we are about to lose it,
\nbecause as it looks as if we have not even
\nunderstood that it is going on.
\nThe battles our associations are fighting
\nabout scope of practice and task shifting,
\nare not an academic entertainment.
\nPoliticians and economists are trying to de-
\nprofessionalize medicine and make it a
\ncheap commodity for the masses.
\nWhy? Is it \u2013 at least partially \u2013 our fault
\nbecause we have produced the confusion, or
\nat least we let it happen? . Not only does a
\nnormal person already have a hard time to
\nunderstand what an Endocrinologist is and
\nFrom the WMA Secretary General
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 99
\n100 WMJ 53, December 2007
\ndoes, we even top-up this non-communica-
\ntion with academic degrees, titles and
\nabbreviations that are cryptic, confusing
\nand worst of all \u2013 misleading.
\nAppendices of titles, consisting of dozens
\nof apparently randomly combined letters
\nmake us look like amateurs rather than seri-
\nous professionals. Yes, we may be proud to
\nbe a fellow of a college or society and why
\nnot talk about it. Yes, it is more than correct
\nto display specialist qualifications. But
\ntitles that even our colleagues can only
\ndecipher when they hold exactly the same
\ntitle could be considered vain advertising.
\nWhom are medical titles good for? Should
\nthey not serve our patients to find the right
\nphysician, to find the right treatment from a
\nqualified physician?
\nIn this issue, Denis Doren, MD, from
\nOntario (Canada) has taken a look at the
\nmedical degrees, qualifications and titles
\nthat are being awarded and used around the
\nworld. One might attribute the wide variety
\nhe found as a sign of pluralism, cultural
\ndiversity and tradition. But let\u2019s face it, for
\nour patients it is simply a mess. To make
\nthis more transparent, at least to the con-
\nsumer (the patient), is there not some justi-
\nfication for simplifying the whole thing to \u201c
\nLicensed Medical Practitioner\u201d, with the
\naddition \u201cand Licensed xxxxx Specialist\u201d,
\nwhere appropriate. If then, the letters indi-
\ncating qualifications degrees e.g. MD, and
\nFellowships of Colleges etc are added, they
\nwill be less confusing.
\nIn this day and age, access to the computer
\nsurely permits patients to find the meaning
\nand significance of the letters.
\nAnd of course there are others who wel-
\ncome our own confusion. While we don\u2019t
\ndelivery clarity \u2013 they do it by simply clas-
\nsifying us as \u201cservice providers\u201d or \u201chealth
\nworkers\u201d. Separating us from our patients is
\nmade easy by our use of terms and abbrevi-
\nations and making physicians accede to the
\ngeneric group of \u201cservice providers\u201d in
\nhealth care, neglecting the additional quali-
\nties implicit in a practicing profession.
\nDo we want to maintain a special role in
\nhealth care? Do we want to remains advo-
\ncates for our patients? Do we want to keep
\nour leadership role in healthcare teams? If
\nthe answer is \u201cyes\u201d we should avoid the
\nridiculous variety of titles and acronyms we
\nare currently using and should make sure
\nthat patients can identify us as what we are:
\nphysicians. This still permits the nomina-
\ntion of a speciality, provided the qualifica-
\ntion has been earned and awarded, but we
\nshould do it with the degree of transparency
\nand clarity we owe our patients and the pub-
\nlic.
\nOnly then we will be able to protect our
\ntitles. This will not be enough as a sufficient
\nstrategy to protect our scope of practice, but
\nwe have to realize that it is a necessary
\nrequirement.
\nTrust me, I\u2019m a doctor!
\nCeremonial Session 5th
\nOctober2007
\nThe President, Dr. N. Arumugam formally
\nopened the Session.
\nThe Secretary General Dr. Otmar Kloiber
\nreported the death on 10th
\nof June of Dr.
\nAndr\u00e9 Wynen, former Chair of Council and
\nSecretary General Paying a tribute, he said
\n\u201dAndr\u00e9 Wynen was our friend, teacher and
\nleader, serving the World Medical
\nAssociation and the whole medical profes-
\nsion with dedication and passion.
\nThe meeting stood in silent tribute.
\nThe Secretary General, then took the Roll
\nCall, introducing the Delegates and the
\nObservers of other organisations present
\nwhich included the International
\nCommittee of the Red Cross, CIOMS,
\nConfemel, the Danish Nursing Association,
\nthe Federal Council of Brazilian Doctors,
\nthe International Dental Federation, the
\nInternational Federation of Medical
\nStudents, the International Federation of
\nPharmaceutical Manufacturers and
\nAssociations, the Medical Women\u2019s
\nInternational Association, the Standing
\nCommittee of European Doctors, the World
\nFederation of Medical Education, the
\nWorld Psychiatric Association, the
\nInternational Rehabilitation Council for
\nTorture Victims and the World Self-
\nMedication Industry.
\nDr. Jensen, President of the Danish Medical
\nAssociation welcomed World Medical
\nAssociation and all the participants to
\nCopenhagen. He congratulated Dr. Sn\u00e6del,
\nthe incoming President on his election and
\npaid tribute to his work, notably for his con-
\ntribution in the revision of the International
\nCode of Ethics. He thanked the outgoing
\nPresident Dr. Arumugam for all is work
\nover the past year.
\nThe Chair of Council Dr. Hill warmly
\nthanked Dr. Jensen and the Danish Medical
\nAssociation for the invitation to return to
\nCopenhagen for this year\u2019s Assembly and
\nfor the hospitality, which was greatly appre-
\nciated. Proposing a vote of thanks to the
\nPresident, he reminded the meeting that Dr.
\nArumugam, a cardiologist in Malaysia, was
\na champion of Public Health, had played a
\nmajor role in the introduction of Tobacco
\nLegislation in that country.
\nWMA General Assembly
\nThe General Assembly of the World Medical Association was held in the Marriott Hotel,
\nCopenhagen on 5th
\nand 6th
\nOctober 2007
\nFrom the WMA Secretary General \/ WMA
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 100
\n101WMJ 53, December 2007
\nRetiring President\u2019s Address
\nDr. Arumugam said that it had been a ter-
\nrific year in which it had been an honour
\nand a privilege to represent the World
\nMedical Association. He had tried to
\nadvance the views of WMA, had witnessed
\nthe challenges facing Health Care Services
\nand Medicine in different countries and
\nmet fellow doctors across the world. He
\nexpressed his thanks both to Council and
\nto his fellow Officers for their work and
\nsupport during the past year. His main task
\nhad been to emphasise the work of the
\nWMA and improve its visibility. He had
\nvisited and attended the Annual meetings
\nof many National Medical Associations
\nand referred to the problems of the profes-
\nsion such as increasing regulation reducing
\nthe time for professional work. Focusing
\non Continuing Professional Development,
\nhe noted that this had been a special prob-
\nlem over the past 10 years where there
\nwere many hurdles in developing coun-
\ntries. Addressing the problems in South
\nEast Asia in particular, he referred to the
\ndevelopment of a points system for CPD in
\nthat region.
\nPatient Safety was also an important prob-
\nlem especially in hospitals. This had been
\naddressed by the Hospitals Association in
\nMalta which had recognised the WMA
\nStatement on this issue. A Conference of
\nMedical Associations in SEA had included
\nCME on Ethics in Medicine and Clinical
\nPractice. Dr. Arugunam also referred to
\nthe increasing problem of medical litiga-
\ntion.
\nTurning to China he reported that the seven
\npersons in the delegation had discussed the
\nproblems of Organ Transplants and harvest-
\ning organs from prisoners, the shortage of
\norgans and other problems with the Chinese
\nMedical Association and the Minister of
\nHealth. At the end of the meeting it was
\nconcluded that Trade in Organs must stop.
\nHe was encouraged by the recent accep-
\ntance of the WMA Code on Transplantation
\nof Organs by the Chinese Medical
\nAssociation. He commented that the prob-
\nlems of transplantation, including ethical
\nand legislative aspects had been discussed
\nby the German Medical Association whose
\nmeeting he had addressed.
\nObesity was a major problem and the loom-
\ning epidemic needed addressing with a pre-
\nventive healthy diet and food labelling.
\nThe problems of tobacco continue. While
\nthe Framework Convention on Tobacco
\nControl was welcomed, he felt that it so far
\nhad had a limited effect and the World
\nMedical Association must continue its
\nefforts to encourage Tobacco Control activ-
\nities.
\nTurning to the World Health Professions
\nAlliance he commented that the Presidents
\nof these professions met to discuss the prob-
\nlem of Health Personnel Migration and
\nTask shifting, where areas of difference still
\nneed to be addressed.
\nThe President referred to his presence in
\nIndia, the Philippines and most recently at a
\nmeeting of CONFEMEL, finally comment-
\ning that at the recent AMA meeting there
\nwas concern over the development of clin-
\nics in supermarkets and that in Australia
\nthere was a need for vigilance over the issue
\nof what is being called \u201cTask Shifting\u201c. He
\nclosed by stating that the most unforgettable
\nevent for him had been the reading and
\naffirmation of the WMA Oath of the
\nMedical Profession.
\nThe Assembly rose in a Standing Ovation.
\nInstallation of the new President
\nDr. Hill in thanking Dr. Arumugam for all
\nhis work for the profession referred to the
\nwisdom, care and understanding he had
\nshown as President. He then presented Dr.
\nArumugam with the Past President\u2019s medal.
\nIntroducing Dr. Sn\u00e6del as the new
\nPresident, Dr. Hill said he had been elected
\nin recognition of his many services to the
\nprofession and the WMA. Dr. Sn\u00e6del took
\nthe oath on assuming the office of President
\nand was invested with the Presidents Badge
\nof Office.
\nPresidential Address by Dr. Jon Sn\u00e6del
\n\u201cDear colleagues, distinguished guests.
\nDuring the last decades new discoveries in
\nclinical research as well as in basic research
\nhave been stretching the ethical boundaries
\nof medicine. The World Medical
\nAssociation has managed to be at the fore-
\nfront of this evolution and during the past
\nfew years the WMA has revised many of its
\nold documents in ethics as well as in other
\nfields. It has been a privilege to participate
\nin the solution of many of these dilemmas,
\nnot least when the International Code of
\nMedical Ethics was revised after a process
\nof 2 years and finally finished in South-
\nAfrica last year. To take an example of how
\nnew thoughts are integrated in such a docu-
\nment I will mention one paragraph of the
\nCode.
\nOne of the paragraphs has been unchanged
\nsince its earliest version in 1949:\u201cA PHYSI-
\nCIAN SHALL always bear in mind the
\nobligation to preserve human life.\u201d In the
\nlast revision one word was changed and the
\nword preserve was replaced by the word
\nrespect and now it reads: \u201cA PHYSICIAN
\nSHALL always bear in mind the obligation
\nto respect human life.\u201d The change of just
\none word reflects a fundamental change in
\nour way of thinking of our duties. Our abil-
\nities to treat our fellow human beings have
\nvastly increased as we are now able to pre-
\nserve live for a long time even if this life is
\nwithout any obvious quality. There is a say-
\ning that life is a disease with 100% mortali-
\nty, a saying that medicalises life itself. We
\nhave to acknowledge the fact that death is
\ninevitable and that in its last phases it is of
\nmore value to the person to treat the symp-
\ntoms rather than the disease. In this phase of
\nlife our obligation is thus to respect the
\npatient rather than to preserve his life.
\nThere are many other ethical questions we
\nhave to address and the WMA is working
\nconstantly on these. Just to mention two
\nissues we are dealing with in the coming
\nmonths \u2013 a revision of the Helsinki declara-
\ntion on research involving human subjects
\nand a new document on stem cell research.
\nEvery now and then we are faced with ethi-
\ncal dilemmas we did not foresee. I will give
\nyou an example of such an issue which
\nunfolded in my country just 3 weeks ago. A
\nprivate company in genetic research has
\nnow offered those who wish for and are
\nwilling to pay, an analysis of their genetic
\nmakeup. The whole genome is analyzed by
\nhalf a million markers and the person will
\nget a report on his chances of getting a num-
\nber of diseases. But is it not just wonderful
\nthat we have a technique that can provide us
\nwith such information of your health and
\nWMA
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 101
\nWMA
\n102 WMJ 53, December 2007
\nhealth risks? In our view there are, howev-
\ner, obvious problems with this type of infor-
\nmation. One is clearly that you are not able
\nto change your genes, which means that if
\nyou know that your chances of getting say a
\ncertain type of cancer; you will not be able
\nto affect that chance. Another is that this
\ntechnique will obviously be very interesting
\nto insurance companies who could then
\ninsist that you will go through such a test
\nwhether you like or not. There are even
\nmore obstacles to this idea than I have
\naccounted for and this is just one example
\nof many of what medical ethics is about.
\nDuring my year of presidency of the World
\nMedical Association my main concerns will
\ntherefore be medical ethics and its manifold
\ntasks. I will build on the traditions of our
\nAssociation and work in harmony with the
\nCouncil and the Secretariat, as it is of great
\nimportance that we work together for our
\nmutual cause even if I have chosen this spe-
\ncific part of work of our Association for my
\nmission. There are many means to achieve
\nour goals. At this Assembly we will discuss
\nthe future of the World Medical Journal. I
\nwould like to see this Journal, and thereby
\nthe WMA itself, have a much greater role in
\nmedical ethics and public health than it has
\nhad up to now. When I asked the librarian in
\nmy University hospital to take a look into
\nthe accessible Journals of Medical Ethics it
\nbecame clear to me that there is a place for
\none more. The Journals are far less in num-
\nber than in many specific fields of medi-
\ncine, even subspecialties, and the distribu-
\ntion of most of them seems to be confined
\nto the society they are published for. This
\ncan be seen by their limited impact factor. A
\nnew international journal on medical ethics
\nand public health published by the WMA
\nwill in my mind not only be an asset to the
\nassociation but more importantly, of clear
\nbenefit to the clinical doctor which this new
\njournal should be aimed at.
\nClosely linked to ethics are human rights. I
\nfeel that the WMA is on the right track in its
\ncollaboration with very important organisa-
\ntions in this field such as the Red Cross,
\nAmnesty International and not least the
\nInternational Council for Torture Victims
\nwhich actually have their main office here
\nin Copenhagen. The important task of pre-
\nventing torture by using a tool called the
\nIstanbul Protocol in ten countries has now
\nbeen underway during the last 4 years. It is
\nmy hope that the WMA will continue to
\nwork for this important human rights issue
\nin all possible ways during the coming
\nyears.
\nThe WMA has during the last years dis-
\ncussed advocacy because that is the means
\nby which the association will have effect.
\nThe WMA aims its work mainly towards
\nthree types of receivers, the individual
\ndoctor, the association of doctors, mainly
\nthe NMA\u2019s of the WMA, and towards
\ninternational organisations. The main
\nreceivers of the work of the WMA
\nthroughout the years have been the
\nNMA\u2019s. That is of course good, but to have
\na real effect on health issues, ethics and
\ninternational politics of medicine our
\nAssociation needs more visibility. By
\nrevamping the WMJ we will increase our
\nvisibility towards the individual doctor.
\nDoctors will hopefully go to our new
\nJournal for advice and inspiration and we
\nwill reach out with a printed version as
\nwell as an electronic one to all parts of the
\nworld in spite of language barriers.
\nAnother important and imminent task is to
\nincrease our presence and influence in
\ninternational organisations. One specific
\ntask will be to work to preserve our educa-
\ntion and training because it has been on the
\nagenda of the WHO to solve the problem
\nof shortage of doctors by proposing a
\nshorter training, some kind of technical
\ndoctor trained for limited purposes. Even
\nif we can understand that some countries
\nneed to address this difficult problem
\nurgently, we feel that in the long run this
\nmethod will undermine the health service
\nin these countries. I would therefore like to
\necho the words of our past president,
\nKgosi Letlape, when he said in his address
\nin South-Africa that the solution to this
\nproblem is to \u201ckeep the pastures green in
\nour countries.\u201d
\nDoctors are not working alone. Team work
\nis an increasing issue in our daily routine
\nand we are accustomed to work alongside
\nother health professionals, most often nurs-
\nes and pharmacists. The WMA participates
\nin an international collaboration with the
\nrespective organisations of these two pro-
\nfessions as well as the dentists. However,
\nwe need to address the collaboration of
\nthese professionals on the ground better.
\nAnother task of mine will be to work on that
\nin a task looking specifically at collabora-
\ntion for better pharmacological treatment.
\nMore tasks of this kind are obvious and will
\nmost likely be looked at in the near future.
\nLastly I will mention the specific group of
\npatients I care for and treat in my daily
\nwork as a geriatrician, persons with demen-
\ntia, more specifically Alzheimer\u2019s disease.
\nEven if I feel some urge to place their prob-
\nlems on the agenda I realize that the prob-
\nlems of specific group of patients are not an
\nissue for the WMA. We work for all of
\nthem. However I will use this opportunity
\nto correct a prevalent misunderstanding,
\nthat this is a specific problem for the devel-
\noped world. In fact most demented persons
\nare found today in the developing world and
\nthe greatest increase of this patient group is
\nwithout question in Asia and Africa.
\nDuring the coming year I hope to bring
\nsome benefit to the WMA but I acknowl-
\nedge that one person will not be able to
\nachieve much. It is therefore my sincere
\nhope that I will be able to collaborate with
\nas many of you as possible during my pres-
\nidency. May the WMA continue to thrive
\nand prosper for many years.\u201d
\nThe President then thanked the Assembly
\nmembers and their guests for attending and
\nformally closed the Ceremonial Session.
\nWMJ_4_85-112.qxd 10.01.2008 11:52 Seite 102
\nWMA
\n103WMJ 53, December 2007
\nPlenary Session of the Assembly 6th
\nOctober 2007
\nDr. Hill, Chair of Council, opened the
\nmeeting and the Secretary General, Dr.
\nKloiber referred to the sad death of Dr.
\nAndr\u00e9 Wynen and informed the Assembly
\nthat a Memorial Book was open for signa-
\nture.
\nHe also reminded the Assembly that the
\nWorld Health Professions Association\u2019s
\nLeadership would take place in November.
\nThere were 30 places on the course and 24
\napplications had so far been received and
\napproved. There were still six vacancies and
\nhe invited applications for these places,
\npreferably female candidates.
\nDr. Hill, after listing the apologies for
\nabsence, stated that there were three nomi-
\nnations for the Presidency of the World
\nMedical Association for 1908-9 and opened
\nthe floor for further nominations. In the
\nabsence of any other proposals he declared
\nthe three candidates to be Drs. Blachar
\n(Israel), Desai(India) and Boswell(New
\nZealand).
\nDr. Hill then referred to the presence as an
\nobserver of the President of the
\nInternational Dental Federation (FDI), Dr.
\nMich\u00e9le Aerden, and invited her to address
\nthe meeting.
\nDr. Aerden referring to the FDI as one of the
\npartners in the World Health Professions\u2019
\nAlliance (WHPA), said that it was the third
\noldest health professional organisation in
\nthe world. As a worldwide independent
\norganisation representing 140 Dental
\nAssociations FDI it was the voice of den-
\ntistry and was represented at the UN, WHO
\nand ISO. Recognising that Health was a
\nfundamental human right she pointed out
\nthat this included the need for Oral Health.
\nIn 1981 WHO recognised the goal of glob-
\nal oral health. In 2007 Oral Health was on
\nthe Agenda of the World Health Assembly
\nand the important role of prevention in Oral
\nHealth was recognised, including the role of
\nFluoride.
\nDr. Aerden said that it was important to col-
\nlect data on oral health because of its value,
\nparticularly in developing countries where
\nprojects had been set up.
\nTurning to the importance of ethics she
\nstressed that this was also true of Dentistry.
\nShe spoke of the importance of defending
\nthe position of the profession in recognising
\nthe dignity of individual and the well-being
\nof patients. Speaking of the effects of oral
\ndisease on morbidity and mortality, she
\nreferred the effects of pain on the quality of
\nlife and to the link between oral disease and
\nthe rest of the body
\nA proposal was being made in WHPA for
\naction to make things HAPPEN. There was
\na \u201cHealth in Africa\u201d Vision. In Africa,
\nwhere there were major gaps in health care,
\nconferences were planned in Africa in 2007
\nand in America in 2008, to address the prob-
\nlems of health access policy and also educa-
\ntion in health promotion and disease pre-
\nvention. Action by the WHPA would make
\na difference.
\nDr. Hill thanked Dr. Aerden and reminded
\nthe meeting that Dr. Letlape had been sit-
\nting on the working group in WHPA for the
\npast year.
\nDr. Haikerwald presented the report of the
\nCredentials Committee. 45 Delegations
\nwere present of which 43 had the right to
\nvote.
\nThe Standing Orders and the Minutes of the
\nPilanesberg meeting were both adopted,
\nfollowing which each of the three candi-
\ndates in the presidential election addressed
\nthe meeting. At the conclusion of these pre-
\nsentations delegations proceeded to a for-
\nmal ballot for the electing the President-
\nelect 2008-2009.
\nPresident-elect
\nThe Secretary General declared the result of
\nthe ballot was that Dr. Yoram Blachar had
\nbeen elected to the office of President-elect
\nfor the year 2008-2009.
\nDr Blachar, responding to this said that he
\nwas deeply touched by the trust place in
\nhim and thanked those who had elected
\nhim, expressing in particular his thanks to
\nhis wife and to Ms. Leah Wapner for their
\ngreat continuing support and help.
\nReport of Council
\n(Much of the written report of Council cir-
\nculated before the November meeting
\nappears in the report of the 176th
\nCouncil
\nmeeting in WMJ52(2): matters other than
\nthe statements and resolutions adopted by
\nthe Assembly which are set out below, are
\nset out in the account of the 178th
\nCouncil
\nmeeting (see page 107).
\nFinance and Planning
\nDr. Hill presenting the report, turned first to
\nrecommendations arising from the Finance
\nand Planning Committee business.
\nCabo Verde
\nThe application for constituent membership
\nof the Ordem dos Medical de Capo Verde
\nwas approved.
\nScientific Session, Seoul 2008
\nThe theme of \u201cHealth and Human Rights\u201d
\nwas approved for the 2008 scientific meet-
\ning in Seoul.
\nTreasurer\u2019s Report
\nThe Treasurer, Dr. J.D. Hoppe presenting
\nhis report reviewing the period 2005-2006,
\nreferred to the Financial Statement prepared
\nwith Mr. Hallmayr which had been
\napproved by the auditors KPMG, and then
\nspoke to the document in some detail. He
\nreported that the net balance, reversing the
\ndeficit of the years 2004-5 which had been
\novercome through the efforts and actions of
\nthe Secretary General, had continued to
\nWMJ_4_85-112.qxd 10.01.2008 11:53 Seite 103
\n104 WMJ 53, December 2007
\nimprove, both from Dr Kloiber\u2019s continuing
\nactions, from the improvement in income
\nfrom members dues and other financial
\nearnings.
\nThe Financial Statement for 2006 was unan-
\nimously approved.
\nDr. Hoppe then presented the Budget for
\n2008 which, in the absence of any questions
\nfrom the floor, was approved unanimously.
\nDr. Hill expressed his thanks both to Dr.
\nHoppe and to Mr Hallmayr for their work
\nduring the year.He reminded delegates that
\nthe new dues categories had been approved
\nand sent to delegations.
\nBefore turning to Medical Ethics Dr. Hill
\nput to the Assembly the following Council
\nResolution which was adopted unanimous-
\nly by the Assembly.
\nAdopted by the WMA General Assembly,
\nCopenhagen, Denmark, October 2007
\nThere are credible reports that arrange-
\nments between the Cuban government
\nand certain Latin American and Caribbean
\ngovernments to supply Cuban health
\nworkers as physicians to these countries
\nare bypassing systems, established to pro-
\ntect patients, that have been set up to ver-
\nify physicians\u2019 credentials and compe-
\ntence.
\nThe World Medical Association is signifi-
\ncantly concerned that patients are put at
\nrisk by unregulated medical practices.
\nThere exist already duly constituted and
\nlegally authorized medical associations
\nwithin this region that are charged with
\nthe registration of physicians and which
\nshould be consulted by their respective
\nMinistries of Health.
\nTherefore, the WMA:
\n1) Condemns any actions by governments
\nin policies and practices that subvert or
\nbypass the accepted standards of med-
\nical credentialing and medical care;
\n2) Calls upon the governments in Latin
\nAmerica and the Caribbean to work
\nwith the medical associations on all
\nmatters related to physician certifica-
\ntion and the practice of medicine and to
\nrespect the role and rights of these
\nmedical associations and the autonomy
\nof the medical profession.
\n3) Urges, as a matter of utmost concern,
\nthat the governments in Latin America
\nand the Caribbean respect the WMA
\nInternational Code of Medical Ethics
\nand the Declaration of Madrid that
\nguide the medical practice of physi-
\ncians all over the world.
\nResolution in Support of the Medical Associations
\nin Latin America and the Caribbean
\nWMA
\nMedical Ethics and Human
\nRights
\nDr. Hill then put to the Assembly the fol-
\nlowing statements and resolutions arising
\nfrom Medical Ethics Committee business.
\nTelemedicine
\nA proposed Statement on the Ethics of
\nTelemedicine (see medical ethics page 91 )
\nwas unanimously approved.
\nHuman Tissue for Transplantations.
\nA proposed Statement on Human Tissue for
\nTransplantation was approved unanimous-
\nly
\nDocumentation and Denunciation of Acts
\nof Torture
\nDr. Hill asked Britte Sydhoff, Secretary
\nGeneral of the International Rehabilitation
\nCouncil for Torture Victims (IRCTV) to
\naddress the meeting.
\nBritte Sydhoff, introducing the IRCTV as
\nan international NGO said that it was a plea-
\nsure to stand before the WMA and thank
\nthem for their support. She explained that
\nthe ICRTV had 130 rehabilitation centres in
\n78 countries.
\nShe was very pleased with the WMA stand
\non Torture, as exemplified by the Tokyo and
\nHamburg Statements. The proposed
\nimprovements in the Statement on
\nDocumentation of Torture constituted a
\nstrong supplement to the existing statement.
\nThe need for proof of torture is vital and
\nspecific training in how to note and provide
\nsuch documentation is important, as physi-
\ncians do not know how to do this. She com-
\nmented that often victims are detained until
\nthe evidence is gone.
\nThe Istambul Protocol and Guidelines help
\nin producing good reports to be used in
\ncourt. IRCTV is carrying out advocacy and
\ntraining activities and she stressed that
\nPrevention through documentation can help
\nboth the Health and Legal professions. The
\ncollaboration of National Medical
\nAssociations has been a real part of the suc-
\ncess of the training about the Istambul
\nProtocol.
\nDr. Hill thanked the IRCTV for its work and
\ncooperation, in which Dr. Snaedel had been
\ndeeply involved.
\nThe proposed revision of the WMA
\nResolution on the Responsibility of
\nPhysicians in the Documentation and
\nDenunciation of Acts of Torture or Cruel or
\nInhuman or Degrading Treatment (see
\nMedical Ethics p. 92) was approved unani-
\nmously.
\nWMJ_4_85-112.qxd 10.01.2008 11:53 Seite 104
\n105WMJ 53, December 2007
\nWMA
\nSocio-Medical Affairs
\nDr. Hill put to the Assembly the following
\nrecommendations arising from the Socio-
\nMedical committee business:
\nNoise Pollution
\nThe proposed revision of the WMA
\nStatement on Noise Pollution was adopted
\nunanimously.
\nFamily Planning and Right to
\nContraception
\nThe WMA Statement on Family Planning
\nand the Right of a woman to Contraception
\nwas adopted.
\nHealth Hazards of Tobacco Products
\nThe proposed Statement on Health Hazards
\nof Tobacco Products (see page 95) was
\nadopted unanimously.
\nDr. Hill announced that in the Spring, an
\nexciting new project on Tobacco will be
\nannounced.
\nHealth and Human Rights Abuses in
\nZimbabwe
\nThe proposed Resolution on Health and
\nHuman Rights Abuses in Zimbabwe (see
\nHuman Rights (see page 94).
\nThe rest of the Council report was
\napproved.
\nAssociates Meeting
\nIn the absence of the Chair, Dr. DuMont,
\nDr. D. Johnson gave the report of the
\nAssociate\u2019s meeting. He indicated that there
\nwere very spirited discussions although
\nonly one Resolution was adopted. This was
\na Statement on \u201cEthical Principles for
\nResearch on Child Subjects\u201d which, it
\nrequested, should be referred to Council for
\nprocessing.
\nDr. J. Appleyard who had made the original
\nproposal said he appreciated the support of
\nthe Associates\u2019 meeting in referring it to the
\nAssembly with the suggestion of referral to
\nCouncil. He also urged the Assembly and
\nNMAs to take this matter forward. It was
\nparallel to Helsinki and reflected the con-
\ncern about child subjects and research in
\nAmerica, Europe and Japan.
\nThe Chair drew attention again to the rec-
\nommendation that this be referred to
\nCouncil and Dr. Kloiber commented that it
\ncould be considered by Council at its post-
\nAssembly meeting and then be processed.
\nThe proposal that the Statement be referred
\nto Council for processing was approved.
\nDr. Johnson further reported that the
\nAssociates meeting had appointed two rep-
\nresentatives and deputies to the Assembly
\nexpressed the hope that this would be to the
\nadvantage of the Associates, requesting that
\ntheir role be examined when the analasys
\nAssociates\u2019 Membership is considered The
\nreport was adopted.
\nOpen session
\nDr. Siguero wished to propose a resolution
\nthat the writing of prescriptions must be
\nlimited to physicians. He was concerned
\nthat with pending elections in Spain the
\nnurses asked that they might prescribe.
\nCurrently there was a fear of a nurses strike
\nand Dr. Siguero pointed out that the
\nInternational Council of Nurses supported
\nthe concept of nurse prescribing. He con-
\nsiders that prescribing must be limited to
\nphysicians exclusively, as only physicians,
\nbecause of their education, can diagnose
\nand ensure the quality of the appropriate
\ndrug prescription. Only the qualified physi-
\ncian has the knowledge of both the appro-
\npriate drug and of the risks associated with
\ntheir prescription. He appealed to the
\nWMA to defend the right to prescribe for
\nphysicians. There was a need to appeal to
\nhealth authorities to ensure this through
\nappropriate legislation. Dr. Nathansen
\n(UK) said that a number of physician\u2019s sup-
\nport nurse prescribing from a Limited List
\nand that the UK is about to move to nurse
\nprescribing from the National Formulary.
\nThe BMA is opposed to this. There is a
\nneed for very great care in the drafting of
\nlegislation to ensure that the intended nurse
\nprescribing is restricted to a Limited
\nFormulary. There are many problems
\nwhich are related to \u201cTask Shifting\u201d.
\nPrescribing by non-physicians is a world
\nwide trend. WMA must express its posi-
\ntion, we have generally enough physicians
\nto deal with prescribing needs.
\nDr. Letlape considered the matter to be very
\ncomplex. It would be difficult to produce a
\nresolution to cover the whole area of needs
\nfor prescribing, as we have to consider the
\nchallenges of areas in which there are no
\nqualified physicians and patients need care
\nthere; people are specially trained to diag-
\nnose and prescribe in such areas.
\nThe responsibilities which go with prescrib-
\ning need to be included in the training. The
\nPresident, Dr. Snaedel, thanked the Spanish
\nMedical Association for raising this issue.
\nWhile Dr. Nathansen had indicated that \u201cthe
\nball was lost\u201d, he felt that it was not lost \u2013 we
\ncan dialogue with the professions and rele-
\nvant authorities. The International Federation
\nof Pharmacists was looking at this issue and
\nwe must dialogue with them. The matter
\nwould be on the agenda of Council.
\nDr. Haikerwal (Aust) expressed sympathy
\nfor Spain, stating, however, that\u201d the train
\nhas moved on\u201d. In Australia physicians,
\nnurses and optometrists are moving in this
\ndirection. Dialogue is vital. Task substitu-
\ntion must be avoided and medical supervi-
\nsion was essential in any such job substitu-
\ntion. Dr. Mckie (Canada) reported that in
\nAlberta and some other provinces, allied
\nhealth professionals have the right to pre-
\nscribe. The Alberta Medical Association set
\nout generic guidelines for allied health pro-
\nfessionals including provisions on conflict
\nof interest. There was a need to ensure ade-
\nquate records. Collaborative care was based
\non the skills of the provider. The CMA
\nwould provide further information to the
\nWMA. A speaker from the Japanese delega-
\ntion agreed with others that this was a fun-
\ndamental issue. Dr. Montgomery (Germany)
\nagreed with others that the train had left. He
\nfelt that the Ministry of Health was using
\nthis concept as a means of breaking down
\nphysicans\u2019domination. While he understood
\nthe situation in some countries he felt that a
\nCouncil Working group should be set up.
\nThe Adminstrators think that by using this
\nmechanism they will save money. Dr.
\nLemye (Belg.) also agreed that \u201cthe train
\nhad left\u201d. Such extension of the right to pre-
\nscribe could be useful in, for example,
\nDisaster Medicine, but these powers should
\nbe provided by the use of exemption mech-
\nanisms. Governments, however, do not only
\nWMJ_4_85-112.qxd 10.01.2008 11:53 Seite 105
\nWMA
\n106 WMJ 53, December 2007
\nconsider the lack of qualified physicians as
\nthe problem. but also look at curtailing the
\nprerogatives of physicians. Dr. Figueredo
\n(Uraguay) supported this. There was no lack
\nof qualified physicians in South America but
\nnevertheless the other health professionals
\nwere being used to treat some sections of the
\npopulation even where patently there were
\nenough physicians, and he proceeded to
\nquote a case illustrating this situation.
\nDr. Blachar (IMA and President-elect) felt
\nthe situation to be both fundamental and
\nthreatening. He strongly supported setting
\nup a Working Group to produce a paper for
\nthe May meeting of Council.
\nDr. Siguero (Spain) thanked contributors
\nfor their support and said that he supported
\nDr. Montgomery\u2019s proposal. He had a feel-
\ning that some physicians were helping the
\ntrain to leave! There was no lack of quali-
\nfied physicians in Spain, politics and some
\nprofessionals were behind this move. WHO
\nshould not be promoting it.
\nDr. Hill said this had been a good debate
\nand the issue would be placed on the
\nCouncil agenda.
\nDr. Sabilli (Philippines) referred to a recent
\ntelevision broadcast in which comments
\nwere made about Philippine doctors in
\nderogatory chauvinistic terms. He pointed
\nout that his country was spending its own
\nmoney training physicians who then went
\nabroad to assist in providing healthcare. At
\nthe same time, he thanked those countries
\nwho had assisted his country with sec-
\nondary care. However he appealed to other
\nNMAs to assist in stopping the derogatory
\nremarks being made suggesting that diplo-
\nmas of Philippine physicians could not be
\nchecked etc. Such remarks were deplorable.
\nPhilippine physicians are asking for an
\napology from those who do this.
\nDr. Hill assured the speaker that the AMA
\nhad found the TV statement distasteful.
\nYesterday the AMA had approached the TV
\nprogramme supporting the Philippine
\nDoctors in their desire for an apology.
\nDr. Chan (Hong Kong) thanked Dr. Kloiber
\nfor supporting a small survey on the regula-
\ntion of the Profession in South East Asia and
\nwelcomed the article on Medical
\nProfessional in the WMJ. He would like it to
\nbe translated into other languages, notably
\nChinese, and would also like it to be fol-
\nlowed up by a survey, perhaps by other
\nNMAs, concerning the right to prescribe. He
\nalso felt that it would be most helpful if we
\ncould see the results of follow-up of
\nResolutions and Statements issued by WMA.
\nFinally he suggested that the effects of air
\npollution should be studied in the profession,
\nboth in developed and developing countries
\nconsidering that this would also need both
\nmid and long term surveys.
\nThe Secretary General commented that
\nthere were strict limitations on what WMA,
\nwith a limited staff of seven could do.
\nSpeaking of Resolutions and Statements
\netc, he said that implementation was in the
\nhands of NMAs. Developing this he said
\nwould like feedback, giving as examples:
\na) Work on Task-shifting. (He had been
\nasked by WHPA to seek this.)
\nb) Discussion of the White Paper on
\nRegulation (WMJ 53(3) p. 58).
\nDr. Kloiber then referred to the forthcoming
\nWHPA conference next year on
\nInternational Regulation of Health
\nProfessions. It was essential that we achieve
\na common understanding on Self
\nRegulation. Some of the problems he had
\nreported to the WHO. NMAs must also take
\nup this issue. At the Chief Executive
\nOfficer\u2019s conference concerns over issues
\nof regulation and licensing were expressed
\nand he was looking to NMAs to act on this.
\nDr. Hill, closing the session, thanked all
\nthose who had contributed to what had been
\na very valuable session.
\nGeneral Assembly \u2013 2008
\nDr. Shin then presented a film on Korea and
\nthe forthcoming General Assembly, 15-18
\nOctober 2008, thanking WMA for agreeing
\nto come to Seoul and extending a warm
\ninvitation to delegates to go to Korea.
\nClosure
\nThere being no other business the
\nSecretary General, Dr. Otmar Kloiber,
\nexpressed his appreciation of the support
\nreceived from NMAs, notably in paying
\ntheir Dues on time. He said that the change
\nin the Dues structure had gone smoothly.
\nWe have never had such strong representa-
\ntion from some parts of the world. We need
\nto continue to strengthen this. In thanking
\nNMAs, he particularly mentioned the out-
\nstanding commitments of Japan and of
\nIndia in responding to the increases in
\ndues. He expressed warm thanks to all
\nNMAs who had supported projects on
\nAdvocacy including the AMA and the
\nBAK, also the DMA for acting as hosts to
\nthe Assembly \u2013 observing that this impos-
\nes costs on the host NMAs. He reminded
\nthe Assembly that the WMA office was a
\nsmall one and had to depend on members
\nfor support.
\nTurning to direct support, he particularly
\nmentioned the CMA\u2019s engagement in
\nAdvocacy, Information Technology, and
\nEthics. He continued that, while it was
\nnot possible to identify all contributions,
\nhe had to mention the Officers, Chairs of
\ncommittees etc and the Chair of Council \u2013
\nall of whom contribute a great deal. The
\nBMA, Norwegian MA, SAMA and BAK
\nhad all supported projects or given techni-
\ncal support, such as the legal advice pro-
\nvided by the Israel MA. Finally, he
\nthanked most warmly Dr. Jensen and his
\nVice Chair Dr. Buhl, the DMA and its
\nstaff for the splendid organisation,
\narrangements and hospitality we had
\nexperienced during the meeting in
\nCopenhagen.
\nDr. Hill finally gave a warm thanks to the
\ninterpreters and to delegates for all their
\nenthusiasm and hard work and formally
\nclosed the Assembly.
\nWMJ_4_85-112.qxd 10.01.2008 11:53 Seite 106
\nWMA
\n107WMJ 53, December 2007
\nThe Chairman, Dr. Hill opened the meeting
\nwith business arising from the General
\nAssembly and sought the views of Council
\non the subject of \u201ctask shifting\u201d which was
\na matter of major concern to NMAs. He
\nsaid that there were considerable differ-
\nences in the degree to which this was occur-
\nring in different parts of the world and
\ncalled for expressions of interest in mem-
\nbership of a working group on this topic.
\nProf. Nathanson was interested, in particu-
\nlar because this was a matter of special
\nimportance in the UK and members from
\nCanada, Israel, Belgium, Germany,
\nNorway, Brazil, Korea, Spain, Iceland indi-
\ncated an interest. After the Chair pointed
\nout that working groups were limited to six
\nmembers and it was agreed that the Chair
\nwould select the group of six.
\nDr. Davis (AMA) wondered whether it was
\ntoo late to set up a working group. Had the
\ntrain not already left the station?
\nCouncil considered a proposed Statement
\non \u201cResearch and Children\u201d from the
\nAssociates\u2019 group, referred to the Council
\nby the Assembly. Dr. Kloiber pointed out
\nthat the Assembly\u2019s wish was that this be
\nreferred to NMAs, was there a need for a
\nworking group? Dr. Nathanson said that this
\nwas an important area, it overlapped
\nHelsinki. She wondered whether there
\nshould be a self \u2013 standing group or that this
\nbe included in the Helsinki group remit. Dr.
\nAppleyard, a Past President, who had made
\nthe original proposition agreed that this was
\nimportant -a feeling which was reflected at
\nthe Associates\u2019 meeting. Helsinki was an
\n\u201cumbrella\u201d declaration. The concerns about
\nchildren were difficult to incorporate in
\nHelsinki. The proposal was specifically
\ngeared to the needs of children it would not
\ninterfere with Helsinki. He would welcome
\nthis going to NMAs for their comments and
\n178th
\nWMA Council Meeting
\n178th
\nCouncil took place in the Marriott Hotel, Copenhagen on 6th
\nOctober 2007
\nalso for them to take this forward\u201d. Dr.
\nBagenholm, Chair of Ethics, thought that
\nthis should be a separate statement,
\nalthough it might eventually be part of
\nHelsinki. She supported its referral to
\nNMAs for their comments.
\nThe Council agreed that the proposed state-
\nment should be circulated to NMAs for
\ntheir views and that the Helsinki working
\ngroup should co-ordinate the comments of
\nNMAs for the next Council meeting.
\nAmongst the views expressed there
\nappeared to be a consensus that the state-
\nment should be a separate one but should be
\nlinked to the Helsinki Declaration.
\nDr. Williams (Ethics consultant) said that
\nthe issue had not been dealt with adequate-
\nly in Helsinki up to the present. Now there
\nwas a new interest in research ethics.
\nHelsinki set out the principles but WMA
\ndid not want to go any further than that. It
\nwas a question of why stop here with chil-
\ndren? Suggestions had been received
\nwhich included vulnerable populations,
\nconcerns about women etc \u2013 would we not
\nbe asked to include the aged and deprived
\npopulations? Dr. Hill expressed his per-
\nsonal view that the issues relating to chil-
\ndren were really different. Dr. Kloiber
\npointed out that the request before Council
\nwas whether to include something, exclude
\nit or include other areas. The Working
\nGroup could come back with a considered
\nview, taking into account the views of
\nNMAs.
\nMr Tholl pointed out that the Canadian
\nMedical Association already had a state-
\nment. The issue could go into Helsinki or,
\nas in Canada, be a separate document. It
\nshould be left to the working group to come
\nforward with a suggestion.
\nDr. Bagenholm felt that it might be better to
\nhave separate working groups rather than
\nmaking Helsinki larger while Dr. Vilmar
\nconsidered that we should concentrate on
\nchildren first. We \u201clack knowledge about
\nresearch in children. It might in the end
\nhave to be taken up in the general review\u201d.
\nIn response to a call by Dr. Hill, expressions
\nof interest in working on this were made by
\nIsrael,Brazil, Canada, South Africa and the
\nUK.
\nUnder Any Other Business, Dr. Hakerwal
\n(Aust) raised the issue of corporate gover-
\nnance. He asked who were directors \u2013
\nwhich countries? Dr. Hill said that WMA
\nwas a USA state registered organisation and
\nthat Council members are directors.
\nDr. Plested (AMA) referred to the new
\nadvocacy adviser\u2019s contract needed for the
\nnew Advocacy position, which would have
\nto be in France. He pointed out that if the
\nperson was hired in another country this
\nmight be illegal in France. He wondered
\nwhether it would be possible for a third
\nmember association to do the hiring or if he
\ncould be made a 90 day adviser, as we have
\nto use French rules. Dr. Davies queried
\nwhether he could be hired in Geneva, or an
\nNMA could second someone.
\nDr. Kloiber indicated that similar problems
\nwould arise in Geneva as in France and that
\nhe had sought legal advice on how to deal
\nwith the employment in the most efficient
\nand legal manor
\nFinally the Council considered how the
\nWMA in its activities could be more inclu-
\nsive and how the Associate members could
\nparticipate in a more productive way..The
\nChair said that he would look into all issues
\nconcerning the Associates, and refered to
\nthe valuable Open Session of the Assembly
\nwhich we had experienced earlier. In the
\nabsence of any other business the meeting
\nwas closed.
\nWMJ_4_85-112.qxd 10.01.2008 11:53 Seite 107
\nWMA \/ WHO
\n108 WMJ 53, December 2007
\nInter-professional training seminar on infection control in South Africa
\nHealth care workers safety in the context of drug resistant TB in low and middle-income countries
\nThe World Medical Association (WMA)
\ninitiated together with the International
\nCouncil of Nurses (ICN), the International
\nHospital Federation (IHF) and the
\nInternational Federation of Red Cross and
\nRed Crescent Societies (IFRC)\/South
\nAfrican Red Cross Society, members of the
\nLilly MDR-TB Partnership, a workshop in
\nCape Town, South Africa, on health care
\nworker safety and infection control, in the
\ncontext of drug-resistant TB in low and
\nmiddle income countries. The 2-day work-
\nshop,12-13.November 2007, brought
\ntogether South African community support
\nworkers, hospital managers, nurses and
\nphysicians working in the context of drug-
\nresistant TB to jointly examine and address
\nthese issues. This common seminar for all
\nfour health care professions was the first
\none held in South Africa.
\nGiven the already critical shortage of health
\nproviders and the generally weak health sys-
\ntems in the regions most affected by XDR-
\nTB and MDR-TB, particularly in southern
\nAfrica, anxiety about safety in the health
\ncare environment runs high and can dis-
\nsuade health providers from accepting
\nassignments in these settings. The workshop
\nprogramme, therefore addressed administra-
\ntive, environmental and personal respiratory
\nprotection with the objective of identifying
\ngood practices and challenges to the imple-
\nmentation of joint recommendations for
\nfacilities and health workers It drew up rec-
\nommendations for implementing guidelines
\nin their hospitals and suggested establishing
\na common working group with a plan of
\naction to communicate the identified prac-
\ntices and recommendations.
\nWHO publishes new standard for documenting
\nthe health of children and youth
\nGENEVA\/VENICE \u2013 WHO published the
\nfirst internationally agreed upon classifica-
\ntion code for assessing the health of chil-
\ndren and youth in the context of their stages
\nof development and the environments in
\nwhich they live.
\nThe International Classification of
\nFunctioning, Disability and Health for
\nChildren and Youth (ICF\u2013CY) confirms
\nthe importance of precise descriptions of
\nchildren\u2019s health status through a methodol-
\nogy that has long been standard for adults.
\nViewing children and youth within the con-
\ntext of their environment and development
\ncontinuum, the ICF\u2013CY applies classifica-
\ntion codes to hundreds of bodily functions
\nand structures, activities and participation,
\nand various environmental factors that
\nrestrict or allow young people to function in
\nan array of every day activities.
\nThe rapid growth and changes that occur in
\nfirst two decades of life were not sufficient-
\nly captured in the International
\nClassification of Functioning, Disability
\nand Health (ICF), the precursor to the
\nICF\u2013CY. The launch of the ICF\u2013CY
\naddresses this important developmental
\nperiod with greater detail. Its new standard-
\nized coding system will assist clinicians,
\neducators, researchers, administrators, poli-
\ncy makers and parents to document and
\nmeasure the important growth, health and
\ndevelopment characteristics of children and
\nyouth.
\nChildren who are chronically hungry,
\nthirsty or insecure, for example, are often
\nnot healthy and have trouble learning and
\ndeveloping normally. This classification
\nprovides a way to capture the impacts of the
\nphysical and social environment so that
\nthese can be addressed through social poli-
\ncy, health care and education systems to
\nimprove children\u2019s well-being.
\n\u201cThe ICF-CY will help us get past simple
\ndiagnostic labels. It will ground the picture
\nof children and youth functioning and dis-
\nability on a continuum within the context of
\ntheir everyday life and activities. In this
\nway it enables the accurate and constructive
\ndescription of children\u2019s health and identi-
\nfies the areas where care, assistance and
\npolicy change are most needed,\u201c said Ros
\nMadden, Australian Commission on Safety
\nand Quality in Health Care, and, Chair of
\nthe Functioning and Disability Reference
\nGroup of the WHO Family of International
\nClassifications (WHO-FIC) Network.
\nThe ICF\u2013CY has important implications
\nglobally for research, standard setting and
\nmobilizing resources. \u201cFor the first time, we
\nnow have a tool that enables us to track and
\ncompare the health of children and youth
\nbetween countries and over time,\u201c said
\nNenad Kostanjsek of WHO\u2019s Measurement
\nand Health Information team. \u201cThe
\nICF\u2013CY will allow countries and the inter-
\nnational community to take informed action
\nto improve children\u2019s health, education and
\nrights, by treating their health as a function
\nof the environment that adults provide.\u201c
\nWMJ_4_85-112.qxd 10.01.2008 11:53 Seite 108
\nWHO
\n109WMJ 53, December 2007
\nThe classification also covers developmen-
\ntal delay. Children who achieve certain
\nmilestones later than their peers may be at
\nincreased risk of disability. Using this clas-
\nsification, health practitioners, parents and
\nteachers can describe these delays precisely
\nin order to plan for health and educational
\nneeds and frame policy debates. The chil-
\ndren and youth version of the International
\nClassification of Functioning, Disability
\nand Health (ICF-CY) was launched in
\nVenice, with international praise:
\n\u201cThe publication of the ICF-CY by the
\nWHO provides, for the first time, a standard
\nlanguage to unify health, education and
\nsocial services for children,\u201c said Dr.
\nMargaret Giannini, Director of the Office of
\nDisability, U.S. Department of Health and
\nHuman Services.
\nFor further information,
\nplease contact:
\nLina Reinders
\nCommunications Officer
\nWHO,
\nGeneva
\nTel.: +41 22 791 1828
\nFax: +41 22 791 1967
\nE-mail: reindersl@who.int
\nFirst List of Essential Medicines for Children released \u2013
\nWHO increases efforts to ensure appropriate medicines for children
\nWHO launched a new research and devel-
\nopment campaign entitled \u201cMake
\nMedicinces Child Size\u201d, launched in
\nLondon intensifies efforts to ensure that
\nchildren have better access to medicines
\nwhich are appropriate for them.
\nThe campaign also coincided with the
\nrelease by WHO of the first International
\nList of Essential Medicines for Children.
\nThe List contains 206 medicines deemed
\nsafe for children and addresses priority con-
\nditions. More than half of the medicines
\nprescribed for children in industrialised
\ncountries are medicines prescribed and
\ndosed for adults and are not authorised for
\nchildren. Lower access to medicines in
\ndeveloping countries adds to the problems
\nthere.
\nDr. Hans Hogerzeil, Director of Medicines
\nPolicy and Standards at WHO emphasized
\nthis saying \u201cA lot more needs to be done.
\nThere are priority medicines that have not
\nbeen adapted for childrens\u2019 use or are not
\navailable when needed\u201d.
\nWHO will also work with governments to
\npromote changes in their legal and regula-
\ntion requirements for childrens\u2019 medi-
\ncines.
\nInformation contact:
\nWHO Geneva:
\nDaniela Bagozzi
\ne-mail: bagozzid@who.int
\nProjected supply of pandemic influenza vaccine sharply increases
\n23 OCTOBER 2007 | GENEVA \u2013 Recent
\nscientific advances and increased vaccine
\nmanufacturing capacity have prompted
\nexperts to increase their projections of how
\nmany pandemic influenza vaccine courses
\ncan be made available in the coming years.
\nLast spring, the World Health Organization
\n(WHO) and vaccine manufacturers said that
\nabout 100 million courses of pandemic
\ninfluenza vaccine based on the H5N1 avian
\ninfluenza strain could be produced immedi-
\nately with standard technology. Experts
\nnow anticipate that global production
\ncapacity will rise to 4.5 billion pandemic
\nimmunization courses per year in 2010.
\n\u201cWith influenza vaccine production capaci-
\nty on the rise, we are beginning to be in a
\nmuch better position vis-\u00e0-vis the threat of
\nan influenza pandemic,\u201c Dr Marie-Paule
\nKieny, Director of the Initiative for Vaccine
\nResearch at WHO, said today. \u201eHowever,
\nalthough this is significant progress, it is
\nstill far from the 6.7 billion immunization
\ncourses that would be needed in a six month
\nperiod to protect the whole world.\u201c
\n\u201cAccelerated preparedness activities must
\ncontinue, backed by political impetus and
\nfinancial support, to further bridge the still
\nsubstantial gap between supply and
\ndemand,\u201c she said.
\nThis year, manufacturers have been able to
\nstep up production capacity of trivalent
\n(three viral strains) seasonal influenza vac-
\ncines to an estimated 565 million doses,
\nfrom 350 million doses produced in 2006,
\naccording to the International Federation of
\nPharmaceutical Manufacturers &
\nAssociations. According to experts working
\nin this field, the yearly production capacity
\nfor seasonal influenza vaccine is expected
\nto rise to 1 billion doses in 2010, provided
\ncorresponding demand exists.
\nThis would help manufacturers to be able to
\ndeliver around 4.5 billion pandemic
\ninfluenza vaccine courses because a pan-
\nWMJ_4_85-112.qxd 10.01.2008 11:53 Seite 109
\nWHO
\n110 WMJ 53, December 2007
\ndemic vaccine would need about eight times
\nless antigen, the substance that stimulates
\nan immune response. Vaccine production
\ncapacity is linked to the amount of antigen
\nthat has to be used to make each dose of the
\nvaccine. Scientists have recently discovered
\nthey can reduce the amount of antigen used
\nto produce pandemic influenza vaccines by
\nusing water-in-oil substances that enhance
\nthe immune response.
\nThe progress was reported at the first meeting
\nof a WHO Advisory Group on pandemic
\ninfluenza vaccine production and supply. The
\nGlobal Action Plan Advisory Group, an inde-
\npendent, international committee of 10 mem-
\nbers, met at WHO headquarters one year after
\neight new strategies to increase pandemic
\ninfluenza vaccine were identified and pub-
\nlished in the WHO Global pandemic influen-
\nza action plan to increase vaccine supply.
\nAt the Advisory Group meeting, other
\nprogress on the Global Action Plan was dis-
\ncussed. WHO reported it is setting up a
\ntraining hub that would serve as a source of
\ntechnology transfer to developing countries.
\nThe Advisory Group also discussed a new
\nbusiness plan which assessed options for
\nfurther increasing vaccine production
\ncapacity and reviewed priority next steps.
\nThe three most valuable options include
\ncontinuing to promote seasonal influenza
\nvaccine programmes, supporting the indus-
\ntry to sustain production capacity beyond
\nseasonal demand and enabling some vac-
\ncine production facilities to change, at the
\nonset of a pandemic, from producing inacti-
\nvated vaccines to live attenuated vaccines.
\nDue to the higher yields obtained with live
\nattenuated influenza vaccine technology,
\nfacility conversion could, by 2012, bridge
\nthe expected supply-demand gap and pro-
\nduce enough vaccine to protect the global
\npopulation within six months of the declara-
\ntion of a pandemic.
\nFor further information, please contact:
\nHayatee Hasan
\nDepartment of Immunization, Vaccines and
\nBiologicals
\nWHO, Geneva
\nTel.: +41 22 791 2103
\nMobile: +41 79 351 6330
\nhasanh@who.int
\nProtecting health from climate change \u2013 World Health Day 2008
\nWHO has announced that the topic for
\nWorld Health Day 2008 will be \u201cProtecting
\nHealth from climate change\u201d. Sixty years
\nago WHO was founded as part of the inter-
\nnational commitment to build global secu-
\nrity and peace In the same spirit of univer-
\nsal solidarity, WHO is seeking to unite the
\nnations of the world in combating the threat
\nto public health safety from climate
\nchange.
\nIn parallel with the increasing international
\nemphasis on the need to place the reduction
\nof environmental climate change high on
\nthe international agenda to maintain sus-
\ntainable development, the need to also
\naddress the environmental effects on public
\nhealth is essential. Dr. Chan, Director
\nGeneral of WHO comments \u201cHealth profes-
\nsionals are on the front line in dealing with
\nthe impacts of climate change. The most
\nvulnerable populations are those who live in
\ncountries where the health sector already
\nstruggles to prevent, detect, control and
\ntreat diseases and health conditions includ-
\ning malaria, malnutrition and diarrhoea.
\nClimate change will highlight and exacer-
\nbate these weaknesses by bringing new
\npressures on public health, wit h greater fre-
\nquency.\u201d
\nShe added \u201cWe need to put public health at
\nthe heart of the climate change agenda. This
\nincludes mobilising governments and stake-
\nholders to collaborate on strengthening sur-
\nveillance and control of infectious diseases,
\nsafer use of diminishing water supplies, and
\nhealth action in emergencies\u201d.
\nOn World Health Day, 7th
\nApril 2008, mark-
\ning the Sixtieth anniversary of the World
\nHealth Organisation, communities and
\norganisations around the world will host
\nactivities to create greater awareness and
\npublic understanding of the health conse-
\nquences of climate change and the impact
\nand interdependency of health with other
\nmeasures taken to reduce and control the
\neffects of climate change in policy deci-
\nsions and policies taken at national and
\ninternational level.
\nWMJ_4_85-112.qxd 10.01.2008 11:53 Seite 110
\nReview
\n111WMJ 53, December 2007
\nNew Internet course on multidrug-resistant tuberculosis MDR-TB
\nMulti Drug Resistant Tuberculosis is difficult to treat and knowledge about it is scattered around the world. Thanks to WHO there
\nis not only a strategy to treat tuberculosis the \u201cDOT Strategy\u201d but now there are also WHO guidelines on how to prevent and treat
\nMDR-TB using the existing evidence in the world.
\nGuidelines however are theoretical knowledge that doesn\u2019t easily transfer into practice in the real world. The WMA therefore volun-
\nteered, together with its member organizations, the South African Medical Association, the Norwegian Medical Association, to pro-
\nduce a learning programme for the MDR-TB Guidelines and offer it electronically though the Internet.
\nThis course is a free self-learning tool allowing physicians in all parts of the world to learn and test their knowledge about MDR-TB
\nusing the Internet. The Foundation for Professional Development of South Africa wrote the learning programme, which subsequent-
\nly has been reviewed by an international advisory committee and then transformed into an Internet-based course by the Norwegian
\nMedical Association. A first testing phase with an evaluation was implemented in South Africa. The CME accredited MDR-TB online
\ntraining course is now accessible from the WMA web page www.wma.net.
\nThe course is free of charge and is available in English. Soon it will be translated into French, Spanish, Chinese and Russian.
\nReview
\nHuman Rights and Prisons \u2013 a training programme on
\nhuman rights for prison officials
\nProfessional Training Series No. 11, UN Publications, UN New York and Geneva 2005, ISBN 92-1-15416-3
\nPrisons are places where a higher propor-
\ntion of people with significant physical and
\nmental health problems are incarcerated,
\nbut also where the health care they receive
\nis likely to be substandard. Pressures on
\nmedical staff, lack of funding, uncertainty
\nabout the ethical duties of doctors and the
\npotentially restrictive attitude of prison gov-
\nernors can all reduce access to good quality
\nand impartial healthcare.
\nAlthough the rights of prisoners, and the
\nduties of those who supervise them are well
\nestablished, and comprehensively set out in
\na variety of declarations, treaties, covenants
\nand conventions, these are often poorly
\nunderstood by prison officials. Either they
\nare not seen as applicable to a particular
\ninstitution, or inflexible procedures that
\nundermine human rights are not reviewed
\nor changed.
\nIt is therefore welcome that the European
\nRegional Office of WHO has published a
\nmodular course on human rights training for
\npeople who have a responsibility for
\ndetainee care. While its focus is prison
\ndetention, it is equally applicable to other
\nforms of custody, such as police stations
\nand detention centres. It has direct rele-
\nvance to doctors, but unfortunately does not
\nsuggest that prison medical staff, who are
\noften as much in need of human rights and
\nethics teaching, should be exposed to the
\nprinciples that the document promotes.
\nDesigned in modular form, and backed by a
\nmanual, listing standards, sources and sys-
\ntems, a compilation of relevant human
\nrights instruments, and a condensed pocket
\nguide, the training is designed to be deliv-
\nered over a period of five days. While aspir-
\ning to a variety of aims, a key purpose is to
\nequip students with a broad knowledge of
\nhuman rights practice in relation to prisons,
\nand to relate these to their day-to-day expe-
\nrience. An important and measurable out-
\ncome must be to change attitudes, so that
\nprejudice is replaced with an understanding
\nof the need to protect the dignity of the vul-
\nnerable.
\nMuch of the success of the courses that are
\nbased on these documents will depend on
\nthe quality of those delivering the training.
\nIt is not suggested that these should include
\ndoctors, and this is a gap that should be
\nfilled, since the relationship between doc-
\ntor, prisoner and institution is fertile ground
\nfor highlighting human rights and ethical
\ndilemmas that are real and practical.
\nThrough their relevance and familiarity
\nthey can provide a good basis for the group
\ndiscussions that form a major part of the
\ntraining.
\nThe section on health is adequate, but not
\nfully complete. There is little reference to
\nassessment of self-harm risk \u2013 a major
\ncause of death in custody being suicide –
\nand the monitoring of prisoners with psy-
\n*
\n* This is the first of two reviews on Prison
\nHealth. The second will review a recent
\npublication by the WHO European Office
\non Health in Prisons and will appear in
\nthe next issue WMJ 54 (1).
\nWMJ_4_85-112.qxd 10.01.2008 11:53 Seite 111
\nReview \/ Letter
\n112 WMJ 53, December 2007
\nchiatric problems. In any prison in the
\nworld, there will be a relatively high pro-
\nportion of inmates with alcohol and\/or drug
\ndependence, and a range of psychiatric dis-
\norders. Prison staff can be very influential
\nin helping patients to develop a willingness
\nto address their addiction, and more could
\nbe taught on the often simple and accessible
\nservices that prisons can provide. Alcohol
\nand drug misuse are common causes of
\nrecurrent, often petty crime, and more
\nunderstanding about the nature of the dis-
\nease of addiction, and the capacity for the
\naddict to change, would be welcome. The
\nsections on drug misuse are written in disci-
\nplinary, rather than therapeutic terms.
\nBacked by high-level declarations, and
\nwritten in the language of rights, the start-
\ning point for the training module on health
\nis that prisoners, like other members of their
\nsociety, deserve access to the highest avail-
\nable standard of health. Given that a prison
\npopulation is disproportionately unhealthy,
\nand that resources, particularly in secondary
\ncare are limited, the realisation of that right
\nis often a distant aspiration. Prison staff
\nwho carry an attitude that equates a loss of
\nliberty with a removal of basic rights, add
\nfuel to the fires of resentment and stigmati-
\nsation, thereby increasing a sense of help-
\nlessness in those for whom they are respon-
\nsible. An institution run on principles that
\nacknowledges rights is more likely to be
\none in which staff have a higher level of
\nwork satisfaction and esteem. Training in
\nhuman rights may not turn them into advo-
\ncates for change, but may help them to
\noperate in a way that promotes decency and
\ndignity.
\nFor doctors who access the training manual,
\nthere is much to challenge attitudes that in
\nmy experience have developed more as a
\nresult of a lack of knowledge than through
\noutright discrimination. Prison medical
\nstaff frequently assume that the \u00ab\u00a0dual rela-
\ntionship\u00a0\u00bb that exists in their specialty (and
\nin others), implies a reduction in their fun-
\ndamental medical ethical duties. While the
\nneed to consider the interests of the prison
\nis ever-present in the doctor’s mind, it
\nshould only rarely lead to breaches of con-
\nsent and confidentiality. A relationship of
\ntrust between the detained patient and the
\ndoctor has therapeutic value, allowing the
\ndoctor more opportunities to provide care,
\nalong with reassurance that confidentiality
\nwill usually be kept.
\nWelcome elements in the training package
\nare the need for prisoners to undergo a med-
\nical examination as soon as possible after
\narrival, respect for cultural beliefs, and the
\nrisks that HIV\/AIDS sufferers will be iso-
\nlated through ignorance and fear of infec-
\ntion. However, more could be said about the
\nneed to be alert to signs of abuse and inap-
\npropriate restraint measures, and on the
\nduty of medical staff to report abuse.
\nDoctors have the benefit of independence
\nand an ethical duty to report abuse, so are
\nwell-placed to speak out when they
\nencounter abusive behaviour. They also
\nhave an obligation to record, not just the
\nnature of the abuse and the injuries sus-
\ntained, but also the action they take as a
\nresult.
\nThe training manual will not help doctors
\nlooking for more certainty on the issue of
\ngross abuse. Definitions of torture and
\ndegrading treatment are not sufficiently
\nrobust or clear, leaving the student in some
\ndoubt as to where the involvement of a doc-
\ntor begins and ends. While there is a clear
\ncondemnation of physician involvement in
\ntorture, current examples such as force-
\nfeeding and the provision of advice on
\ninterrogation should be illustrated. At a time
\nwhen the ethical duties of doctors have been
\nredefined in the interests of national securi-
\nty, these contemporary situations deserve
\nmore reflection.
\nAn essential part of training is evaluating its
\neffect, and the course recognises that this
\nshould be built in over the long-term, using
\nattitudes and system change as key markers
\nof progress. As the manual states, there is a
\nlot more to the teaching of human rights
\nthan a \u201clecture and a wave\u201d. Participants
\nneed to be challenged, and their attitudes
\nand behaviour changed, if our prisons are to
\nbecome more humane places.
\nMichael Wilks
\nMichael Wilks is a forensic physician, and
\nChairman of the Rehabilitation of Addicted
\nPrisoners Trust in the UK. He is President
\nof the Standing Committee of European
\nDoctors (CPME) for 2008\/9.
\nLetter
\nCorrespondence
\nHon. Editor
\nWorld Medical Journal
\nSir,
\nThe September 7th
\n, 2007 issue of the
\nMedical Journal of the World Medical
\nAssociation is carrying a story about \u201cpre-
\nsumed Consent\u201d for the removal of organs
\nfrom dead for transplantation.
\nThe U.K. Chief Medical Officer, Sir Liam
\nDonaldson is quoted as saying that the prac-
\ntice of \u201cpresumed Consent\u201d would increase
\nthe number of organs available for trans-
\nplantation to the betterment of the health of
\nthe recipients.
\nI am troubled by the apparent violation of
\nthe first tenet of the Nuremberg Code of
\nMedicas Ethics which clearly states that
\n\u201cFreely Given Informed Consent\u201d is the
\nsine quo non of all activities by physicians
\nin dealing with patients.
\nI would suggest that this practice be stopped
\nimmediately.
\nI would also suggest that physicians all over
\nthe world should sign the donor card and
\ncarry it in their wallets and stipulate to their
\nloved ones that they want their organs har-
\nvested for transplantation.
\nUnless we, physicians show by example the
\nimportance of the donation of organs there
\nis little chance that there will ever be
\nenough organs available to help the living.
\nMichael J. Franzblau MD, FAAD
\nClinical Professor of Dermatology
\n(emeritus)
\nUniversity of California
\nWMJ_4_85-112.qxd 10.01.2008 11:53 Seite 112
\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_04_07.qxd 10.01.2008 11:35 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_04_07.qxd 10.01.2008 11:35 Seite U4<\/p>\n"},"caption":{"rendered":"

wmj16 WorldMMeeddiiccaall JJoouurrnnaall Vol. No. 4, December 200753 OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC. G 20438 Contents EEddiittoorriiaall The challenge to medical care 85 Make medicines child size 86 MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss Medical Research on Child Subjects 87 China affirms its commitment to WMA Transplantation policy 87 World Health Professions Alliance […]<\/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\/wmj16.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3563"}],"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=3563"}]}}