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wmj21<\/a><\/p>\n

No. 1, February 2009
\nEditor in Chief
\nDr. P\u0113teris Apinis
\nLatvian Medical Association
\nSkolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@nma.lv
\neditorin-chief@wma.net
\nCo-Editor
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSu\ufb00olk IP143QT, UK
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor Velta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by J\u0101nis Pavlovskis
\nLayout and Artwork
\nThe Latvian Medical Publisher \u201cMedic\u012bnas
\napg\u0101ds\u201d, President Dr. Maija \u0160etlere,
\nHospit\u0101\u013cu iela 55, Riga, Latvia
\nCover painting : A Skin-Slice with Love
\nPainter: Mr. LI Shih-Chiao, 1956
\nOil on canvas 116.5*91cm
\nAuthorized by: A Skin-Slice with Love
\nFoundation
\nThe painting represents a scene of skin-slice
\nsurgery caried out by Dr. David Landsborough
\nin 1928. A child patient su\ufb00ered from skin
\nnecrosis due to an incident. In order to avoid
\namputation operation, Mrs. Landsborough
\ndonated her skin voluntarily to save the child.
\nBackground: Sea Erosion Trenches
\nAuthor: Lin Yu-Wei
\nAuthorized by: Government Information
\nO\ufb03ce, Republic of China (Taiwan).
\nPublisher
\nThe World Medical Association, Inc. BP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
\nDeutscher-\u00c4rzte Verlag GmbH,
\nDieselstr. 2, P.O.Box 40 02 65
\n50832 K\u00f6ln\/Germany
\nPhone (0 22 34) 70 11-0
\nFax (0 22 34) 70 11-2 55
\nBusiness Managers J. F\u00fchrer, D. Weber
\n50859 K\u00f6ln, Dieselstr. 2, Germany
\nIBAN: DE83370100500019250506
\nBIC: PBNKDEFF
\nBank: Deutsche Apotheker- und \u00c4rztebank,
\nIBAN: DE28300606010101107410
\nBIC: DAAEDEDD
\n50670 K\u00f6ln, No. 01 011 07410
\nAt present rate-card No. 3 a is valid
\nThe magazine is published quarterly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or
\nthe World Medical Association
\nSubscription fee \u20ac 22,80 per annum (inkl. 7%
\nMwSt.). For members of the World Medical
\nAssociation and for Associate members the
\nsubscription fee is settled by the membership
\nor associate payment. Details of Associate
\nMembership may be found at the World
\nMedical Association website www.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nK\u00f6ln, Germany
\nISSN: 0049-8122
\nDr. Yoram BLACHAR
\nWMA President
\nIsrael Medical Assn
\n2 Twin Towers
\n35 Jabotinsky Street
\nP.O. Box 3566
\nRamat-Gan 52136
\nIsrael
\nDr. Kazuo IWASA
\nWMA Vice-Chairman of Council
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Mukesh HAIKERWAL
\nWMA Chairperson of the Finance
\nand Planning Committee
\n58 Victoria Street
\nWilliamstown, VIC 3016
\nAustralia
\nDr. Dana HANSON
\nWMA President-Elect
\nFredericton Medical Clinic
\n1015 Regent Street Suite # 302,
\nFredericton, NB, E3B 6H5
\nCanada
\nDr. J\u00f6rg-Dietrich HOPPE
\nWMA Treasurer
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1
\n10623 Berlin
\nGermany
\nDr. Guy DUMONT
\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
\n1380 Lasne
\nBelgium
\nDr. J\u00f3n SN\u00c6DAL
\nWMA Immediate Past-President
\nIcelandic Medicial Assn
\nHlidasmari 8
\n200 Kopavogur
\nIceland
\nDr. Eva NILSSON-
\nB\u00c5GENHOLM
\nWMA Chairperson of the Medical
\nEthics Committee
\nSwedish Medical Assn.
\nP.O. Box 5610
\n11486 Stockholm
\nSweden
\nDr. Karsten VILMAR
\nWMA Treasurer Emeritus
\nSchubertstr. 58
\n28209 Bremen
\nGermany
\nDr. Edward HILL
\nWMA Chairperson of Council
\nAmerican Medical Assn
\n515 North State Street
\nChicago, ILL 60610
\nUSA
\nDr. Jos\u00e9 Luiz GOMES DO
\nAMARAL
\nWMA Chairperson of the Socio-
\nMedical-A\ufb00airs Committee
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nRua Sao Carlos do Pinhal 324
\nBela Vista, CEP 01333-903
\nSao Paulo, SP
\nBrazil
\nDr. Otmar KLOIBER
\nWMA Secretary General
\n13 chemin du Levant
\nFrance 01212 Ferney-Voltaire
\nFrance
\nWorld Medical Association O\ufb03cers, Chairpersons and O\ufb03cials
\nO\ufb03cial Journal of The World Medical Association
\nOpinions expressed in this journal \u2013 especially those in authored contributions \u2013 do not necessarily re\ufb02ect WMA policy or positions
\nwww.wma.net
\n1
\nIt is well recognised that the continuing growth of both knowledge
\nand scienti\ufb01c advances and their applications in medicine, (not to
\nmention the new question they pose) inevitably continue to raise
\nboth medico-social and ethical problems, These tend to be dealt
\nwith on a \u201ccase by case\u201d basis as many of the statements and dec-
\nlarations of the adopted by the World Medical Association illus-
\ntrate. While new specialties and particularly sub-specialities re\ufb02ect
\nadvances in knowledge and techniques, there are circumstances in
\nwhich a topic emerges which a\ufb00ects a wide number of medical spe-
\ncialties and other disciplines.
\nSuch a topic is Gender Medicine which, notably in the past two de-
\ncades and more particularly since 2001, has brought together a wide
\nnumber of disciplines.The 21st
\ncentury has been marked not only by
\nthe development of Departments of Gender Medicine and interna-
\ntional collaboration re\ufb02ected in the Three World Conferences, but
\nalso Journals of Gender Medicine and increasing trends to incorpo-
\nrate this in both undergraduate and postgraduate training.
\nWhile the World Medical Journal does not normally publish re-
\nsearch articles, we felt that this development merited the inclusion
\nin this issue of a paper which illustrates both the breadth of the
\ndisciplines involved in Gender Medicine,and indicates some ethical
\nproblems which may arise.
\nEditorial
\nFollowing nominations for Regional places on the Worid Medical
\nAssociation Council 2009-2010, in accordance with the regulations,
\nthe following were elected automatically or unopposed:
\nThe American Medical Association, the British Medical Asso-
\nciation, Canadian Medical Association, Ethiopean Medical As-
\nsociation, German Medical Association, Indian Medical Asso-
\nciation,Japan Medical Association,the Russian Medical Society,
\nthe Uraguay Medical Association and in the Asian Region, fol-
\nlowing the withdrawal by the Indian Medical Association in favour
\nof the IMA, the Israel Medical Association.
\nElections were necessary in the Euopean and Paci\ufb01c Regions with
\nthe following results :
\nEUROPE The Danish, Norwegian and Royal Dutch Medi-
\ncal Associations were elected, having received
\n28,854, 36,376 and 34,112 votes, respectively.
\nThe Association Beige des Syndicates Medicales, the
\nCzech Medical Association, the Association Medi-
\ncale Francaise and the Consuelo General de Colegios
\nMedicos de Espana, received 599, 2,290, 21,668 and
\n5,454 respectively.
\nPACIFIC The Australian and Korean Medical Associations
\nwere elected having received 18,576 and 35,200 votes,
\nrespectively. In this Region the Indonesian and Thai-
\nland Medical Associations received 2.599 and 2,694
\nvotes respectively.
\nFinal Composition of the Council For 2009-2010
\nTherefore, as a result of the regional election process, conducted in
\naccordance with Chapter IV of the WMA Bylaws, the composition
\nof the Council for the 2009-2010 is:
\nConstituent Member Number of seat(s)
\nAmerican Medical Association 3
\nAustralian Medical Association 1
\nBrazilian Medical Association 2
\nBritish Medical Association 1
\nCanadian Medical Association 1
\nDanish Medical Association 1
\nEthiopian Medical Association 1
\nGerman Medical Association 2
\nIndian Medical Association 2
\nIsrael Medical Association 1
\nJapan Medical Association 3
\nKorean Medical Association 1
\nNorwegian Medical Association 1
\nRoyal Dutch Medical Association 1
\nRussian Medical Society 1
\nSindicato M\u00e9dico del Uruguay 1
\nTOTAL 23
\nThe President, President-Elect and Immediate Past-President of
\nthe WMA are ex-o\ufb03cio members of Council, with no voting privi-
\nleges.
\nElections for the following posts will be held as soon as the Council
\nconvenes for its 182nd
\nSession in Tel Aviv, Israel on 13 May 2009:
\nChairperson of Council; Vice-Chairperson of Council; Treasurer,
\nand Committee Chairpersons for the Finance and Planning Com-
\nmittee, Medical Ethics Committee, Socio-Medical A\ufb00airs Com-
\nmittee.
\nResult of Regional Elections, the Members of WMA Council 2009 \u2013 2010
\nP\u0113teris Apinis, Alan J. Rowe, Elmar Doppelfeld
\n2
\nWMA news
\nAdopted by the 18th
\nWMA General Assembly, Helsinki, Finland, June
\n1964, and amended by the:
\n29th
\nWMA General Assembly, Tokyo, Japan, October 1975
\n35th
\nWMA General Assembly, Venice, Italy, October 1983
\n41st
\nWMA General Assembly, Hong Kong, September 1989
\n48th
\nWMA General Assembly, Somerset West, Republic of South Africa,
\nOctober 1996
\n52nd
\nWMA General Assembly, Edinburgh, Scotland, October 2000
\n53th
\nWMA General Assembly, Washington, United States, October 2002
\n(Note of Clari\ufb01cation on paragraph 29 added)
\n55th
\nWMA General Assembly, Tokyo, Japan, October 2004 (Note of
\nClari\ufb01cation on Paragraph 30 added)
\nWMA General Assembly, Seoul, Korea, October 2008
\nA. Introduction
\n1. The World Medical Association (WMA) has developed the
\nDeclaration of Helsinki as a statement of ethical principles for
\nmedical research involving human subjects, including research
\non identi\ufb01able human material and data.
\nThe Declaration is intended to be read as a whole and each of its
\nconstituent paragraphs should not be applied without consider-
\nation of all other relevant paragraphs.
\n2. Although the Declaration is addressed primarily to physicians,
\nthe WMA encourages other participants in medical research in-
\nvolving human subjects to adopt these principles.
\n3. It is the duty of the physician to promote and safeguard the
\nhealth of patients, including those who are involved in medical
\nresearch. The physician\u2019s knowledge and conscience are dedi-
\ncated to the ful\ufb01lment of this duty.
\n4. The Declaration of Geneva of the WMA binds the physician
\nwith the words, \u201cThe health of my patient will be my \ufb01rst con-
\nsideration,\u201d and the International Code of Medical Ethics de-
\nclares that, \u201cA physician shall act in the patient\u2019s best interest
\nwhen providing medical care.\u201d
\n5. Medical progress is based on research that ultimately must in-
\nclude studies involving human subjects. Populations that are
\nunderrepresented in medical research should be provided ap-
\npropriate access to participation in research.
\n6. In medical research involving human subjects, the well-being
\nof the individual research subject must take precedence over all
\nother interests.
\n7. The primary purpose of medical research involving human sub-
\njects is to understand the causes,development and e\ufb00ects of dis-
\neases and improve preventive, diagnostic and therapeutic inter-
\nventions (methods, procedures and treatments). Even the best
\ncurrent interventions must be evaluated continually through re-
\nsearch for their safety, e\ufb00ectiveness, e\ufb03ciency, accessibility and
\nquality.
\n8. In medical practice and in medical research, most interventions
\ninvolve risks and burdens.
\n9. Medical research is subject to ethical standards that promote re-
\nspect for all human subjects and protect their health and rights.
\nSome research populations are particularly vulnerable and need
\nspecial protection.These include those who cannot give or refuse
\nconsent for themselves and those who may be vulnerable to co-
\nercion or undue in\ufb02uence.
\n10. Physicians should consider the ethical, legal and regulatory
\nnorms and standards for research involving human subjects in
\ntheir own countries as well as applicable international norms
\nand standards. No national or international ethical, legal or
\nregulatory requirement should reduce or eliminate any of the
\nprotections for research subjects set forth in this Declaration.
\nB. Principles for all Medical Research
\n11. It is the duty of physicians who participate in medical research
\nto protect the life, health, dignity, integrity, right to self-deter-
\nmination, privacy, and con\ufb01dentiality of personal information of
\nresearch subjects.
\n12. Medical research involving human subjects must conform to
\ngenerally accepted scienti\ufb01c principles, be based on a thorough
\nknowledge of the scienti\ufb01c literature, other relevant sources of
\ninformation, and adequate laboratory and, as appropriate, ani-
\nmal experimentation. The welfare of animals used for research
\nmust be respected.
\n13. Appropriate caution must be exercised in the conduct of medi-
\ncal research that may harm the environment.
\n14. The design and performance of each research study involving
\nhuman subjects must be clearly described in a research protocol.
\nThe protocol should contain a statement of the ethical consid-
\nerations involved and should indicate how the principles in this
\nDeclaration have been addressed. The protocol should include
\ninformation regarding funding, sponsors, institutional a\ufb03lia-
\ntions, other potential con\ufb02icts of interest, incentives for subjects
\nand provisions for treating and\/or compensating subjects who
\nare harmed as a consequence of participation in the research
\nstudy.The protocol should describe arrangements for post-study
\nDeclaration of Helsinki
\nEthical Principles for Medical Research
\nInvolving Human Subjects
\n3
\nWMA news
\naccess by study subjects to interventions identi\ufb01ed as bene\ufb01cial
\nin the study or access to other appropriate care or bene\ufb01ts.
\n15. The research protocol must be submitted for consideration,
\ncomment, guidance and approval to a research ethics committee
\nbefore the study begins. This committee must be independent
\nof the researcher, the sponsor and any other undue in\ufb02uence.
\nIt must take into consideration the laws and regulations of the
\ncountry or countries in which the research is to be performed as
\nwell as applicable international norms and standards but these
\nmust not be allowed to reduce or eliminate any of the protec-
\ntions for research subjects set forth in this Declaration. The
\ncommittee must have the right to monitor ongoing studies.The
\nresearcher must provide monitoring information to the com-
\nmittee, especially information about any serious adverse events.
\nNo change to the protocol may be made without consideration
\nand approval by the committee.
\n16. Medical research involving human subjects must be conduct-
\ned only by individuals with the appropriate scienti\ufb01c training
\nand quali\ufb01cations. Research on patients or healthy volunteers
\nrequires the supervision of a competent and appropriately quali-
\n\ufb01ed physician or other health care professional.The responsibil-
\nity for the protection of research subjects must always rest with
\nthe physician or other health care professional and never the
\nresearch subjects, even though they have given consent.
\n17. Medical research involving a disadvantaged or vulnerable popu-
\nlation or community is only justi\ufb01ed if the research is responsive
\nto the health needs and priorities of this population or commu-
\nnity and if there is a reasonable likelihood that this population or
\ncommunity stands to bene\ufb01t from the results of the research.
\n18. Every medical research study involving human subjects must be
\npreceded by careful assessment of predictable risks and burdens to
\nthe individuals and communities involved in the research in com-
\nparison with foreseeable bene\ufb01ts to them and to other individuals
\nor communities a\ufb00ected by the condition under investigation.
\n19. Every clinical trial must be registered in a publicly accessible
\ndatabase before recruitment of the \ufb01rst subject.
\n20. Physicians may not participate in a research study involving hu-
\nman subjects unless they are con\ufb01dent that the risks involved
\nhave been adequately assessed and can be satisfactorily man-
\naged. Physicians must immediately stop a study when the risks
\nare found to outweigh the potential bene\ufb01ts or when there is
\nconclusive proof of positive and bene\ufb01cial results.
\n21. Medical research involving human subjects may only be con-
\nducted if the importance of the objective outweighs the inherent
\nrisks and burdens to the research subjects.
\n22. Participation by competent individuals as subjects in medical
\nresearch must be voluntary. Although it may be appropriate to
\nconsult family members or community leaders, no competent
\nindividual may be enrolled in a research study unless he or she
\nfreely agrees.
\n23. Every precaution must be taken to protect the privacy of re-
\nsearch subjects and the con\ufb01dentiality of their personal infor-
\nmation and to minimize the impact of the study on their physi-
\ncal, mental and social integrity.
\n24. In medical research involving competent human subjects, each
\npotential subject must be adequately informed of the aims,
\nmethods, sources of funding, any possible con\ufb02icts of interest,
\ninstitutional a\ufb03liations of the researcher, the anticipated ben-
\ne\ufb01ts and potential risks of the study and the discomfort it may
\nentail, and any other relevant aspects of the study.The potential
\nsubject must be informed of the right to refuse to participate
\nin the study or to withdraw consent to participate at any time
\nwithout reprisal. Special attention should be given to the spe-
\nci\ufb01c information needs of individual potential subjects as well
\nas to the methods used to deliver the information. After ensur-
\ning that the potential subject has understood the information,
\nthe physician or another appropriately quali\ufb01ed individual must
\nthen seek the potential subject\u2019s freely-given informed consent,
\npreferably in writing.If the consent cannot be expressed in writ-
\ning, the non-written consent must be formally documented and
\nwitnessed.
\n25. For medical research using identi\ufb01able human material or data,
\nphysicians must normally seek consent for the collection, analy-
\nsis, storage and\/or reuse.There may be situations where consent
\nwould be impossible or impractical to obtain for such research
\nor would pose a threat to the validity of the research. In such
\nsituations the research may be done only after consideration and
\napproval of a research ethics committee.
\n26. When seeking informed consent for participation in a research
\nstudy the physician should be particularly cautious if the poten-
\ntial subject is in a dependent relationship with the physician or
\nmay consent under duress. In such situations the informed con-
\nsent should be sought by an appropriately quali\ufb01ed individual
\nwho is completely independent of this relationship.
\n27. For a potential research subject who is incompetent, the physi-
\ncian must seek informed consent from the legally authorized
\nrepresentative. These individuals must not be included in a re-
\nsearch study that has no likelihood of bene\ufb01t for them unless it is
\nintended to promote the health of the population represented by
\nthe potential subject, the research cannot instead be performed
\nwith competent persons, and the research entails only minimal
\nrisk and minimal burden.
\n4
\nWMA news
\n28. When a potential research subject who is deemed incompetent
\nis able to give assent to decisions about participation in research,
\nthe physician must seek that assent in addition to the consent
\nof the legally authorized representative. The potential subject\u2019s
\ndissent should be respected.
\n29. Research involving subjects who are physically or mentally inca-
\npable of giving consent, for example, unconscious patients, may
\nbe done only if the physical or mental condition that prevents
\ngiving informed consent is a necessary characteristic of the re-
\nsearch population. In such circumstances the physician should
\nseek informed consent from the legally authorized representa-
\ntive.If no such representative is available and if the research can-
\nnot be delayed,the study may proceed without informed consent
\nprovided that the speci\ufb01c reasons for involving subjects with a
\ncondition that renders them unable to give informed consent
\nhave been stated in the research protocol and the study has been
\napproved by a research ethics committee. Consent to remain in
\nthe research should be obtained as soon as possible from the
\nsubject or a legally authorized representative.
\n30. Authors, editors and publishers all have ethical obligations with
\nregard to the publication of the results of research. Authors have
\na duty to make publicly available the results of their research on
\nhuman subjects and are accountable for the completeness and
\naccuracy of their reports.They should adhere to accepted guide-
\nlines for ethical reporting. Negative and inconclusive as well as
\npositive results should be published or otherwise made publicly
\navailable. Sources of funding, institutional a\ufb03liations and con-
\n\ufb02icts of interest should be declared in the publication. Reports
\nof research not in accordance with the principles of this Decla-
\nration should not be accepted for publication.
\nC. Additional Principles for Medical Research
\nCombined With Medical Care
\n31. The physician may combine medical research with medical care
\nonly to the extent that the research is justi\ufb01ed by its potential
\npreventive, diagnostic or therapeutic value and if the physician
\nhas good reason to believe that participation in the research
\nstudy will not adversely a\ufb00ect the health of the patients who
\nserve as research subjects.
\n32. The bene\ufb01ts, risks, burdens and e\ufb00ectiveness of a new interven-
\ntion must be tested against those of the best current proven in-
\ntervention, except in the following circumstances:
\nThe use of placebo, or no treatment, is acceptable in studies
\nwhere no current proven intervention exists; or
\nWhere for compelling and scienti\ufb01cally sound methodological
\nreasons the use of placebo is necessary to determine the e\ufb03cacy
\nor safety of an intervention and the patients who receive placebo
\nor no treatment will not be subject to any risk of serious or ir-
\nreversible harm. Extreme care must be taken to avoid abuse of
\nthis option.
\n33. At the conclusion of the study, patients entered into the study
\nare entitled to be informed about the outcome of the study and
\nto share any bene\ufb01ts that result from it, for example, access to
\ninterventions identi\ufb01ed as bene\ufb01cial in the study or to other ap-
\npropriate care or bene\ufb01ts.
\n34. The physician must fully inform the patient which aspects of
\nthe care are related to the research. The refusal of a patient to
\nparticipate in a study or the patient\u2019s decision to withdraw from
\nthe study must never interfere with the patient-physician rela-
\ntionship.
\n35. In the treatment of a patient, where proven interventions do not
\nexist or have been ine\ufb00ective, the physician, after seeking ex-
\npert advice, with informed consent from the patient or a legally
\nauthorized representative, may use an unproven intervention
\nif in the physician\u2019s judgement it o\ufb00ers hope of saving life, re-
\nestablishing health or alleviating su\ufb00ering. Where possible, this
\nintervention should be made the object of research, designed
\nto evaluate its safety and e\ufb03cacy. In all cases, new information
\nshould be recorded and, where appropriate, made publicly avail-
\nable.
\n30 years ago the World Health Organiza-
\ntion crafted the Alma Ata Declaration,
\nwhich has served as the core policy of the
\nWHO since that time. According to the
\nAlma Ata Declaration \u201cPrimary health care
\nforms an integral part both of the country’s
\nhealth system, of which it is the central function
\nand main focus, and of the overall social and
\neconomic development of the community. Pri-
\nmary care brings health care as close as possible
\nto where people live and work, and constitutes
\nthe \ufb01rst element of a continuing health care pro-
\ncess. [\u2026] Primary care should be sustained by
\nintegrated, functional and mutually supportive
\nreferral systems, leading to the progressive im-
\nprovement of comprehensive health care for all,
\nand giving priority to those most in need.\u201d
\nAlthough this approach enjoyed nearly uni-
\nversal supported in principle, in practice it
\nhas failed the poor countries of the world.
\nRather than serving as the driver of overall
\nThe Return of Primary Care
\n5
\nWMA news
\nhealth care approaches and the core of com-
\nprehensive systems, all too often primary
\ncare appears to have been assigned the sta-
\ntus of a general ideology and one in which
\nprimary care was, in fact, an end in itself.
\nThe WHO has recognized that the narrow
\ninterpretation of the Alma Ata Declaration
\nhas resulted in its failure. Not only has it led
\nto primary care becoming the substitute for
\nsystematic development of health systems
\nin some countries, in other cases, it has been
\nused as a defense by funders to curtail im-
\nprovements already underway.
\nThe results are evident in many poor coun-
\ntries around the world, where health care
\nsystems at best only marginally serve the
\npopulation, often providing unfocused pub-
\nlic health approaches and no real care for
\nseriously ill patients. Certainly, it can and
\nmust be argued that the \ufb01nancial resourc-
\nes for health care are scarce and the lack
\nof \ufb01nancial resources is and remains the
\nnumber one problem. But there is also an
\ninterdependency between the reductionist
\napproach to primary care and the resources
\nfor it. Primary care in the Alma Ata Decla-
\nration is not only the main building block
\nfor any health care system, it is also intend-
\ned to represent the minimum level of care
\nthat must be delivered. Instead, it has been
\nmischaracterized as the maximum level con-
\nsidered necessary to be \ufb01nanced and thus
\nprimary care in this context has become a
\ndead-end road, a scenario without a future.
\nIn countries where this is the case, patients
\nand health professionals with the \ufb01nancial
\nmeans have simply left. The emigration of
\nthousands of professionals left the scars of
\na painful brain drain epidemic on already
\noverburdened societies and health systems.
\nInternational programme, often construct-
\ned around vertical programme to address
\nsingle diseases like HIV\/AIDS, malaria,
\nriver blindness or tuberculosis, rarely sup-
\nport comprehensive care approaches. Un-
\nfortunately patients in these poor countries
\ntend to have the same, or an even a broader,
\nspectrum of diseases than in a\ufb04uent coun-
\ntries, yet there is no care available to them if
\ntheir health needs do not match one of the
\nvertical programs that may be available.
\nWHO has taken a big step forward to revive
\nprimary care and to ask for the full and ac-
\ncurate interpretation of the Alma Ata Dec-
\nlaration. Primary care as the core building
\nblock of a health system, as opposed to the
\nend goal, can then be extended step-by-step
\nby secondary and tertiary care, which is the
\nprocess required if the full development of
\nhealth systems is to have any chance to suc-
\nceed. Health cares systems require academic
\ncentres for basic and specialist medical edu-
\ncation. They need treatment facilities for
\nmore di\ufb03cult cases and severely ill patients.
\nThe requirements will di\ufb00er from country to
\ncountry and will take time to meet. But in
\nany system of care, there must be a perspec-
\ntive and an objective for treatment that goes
\nbeyond primary care in order to provide trust,
\nhope and the impetus for development.
\nWHO is formally rea\ufb03rming its core
\npolicy though the Alma Ata declaration \u2013
\nand reading it in its full and proper context
\ncreates a new and di\ufb00erent story in which
\nprimary care is returned as the starting posi-
\ntion and the cornerstone for strengthening
\nand maintaining real health care systems.
\nHowever, when listening to the politicians
\nat the Executive Board session of WHO,
\nwhere this policy had to be rea\ufb03rmed,
\nthe crux of our future challenge became
\nevident. While WHO was attempting to
\nframe primary care as the core element of
\ncomprehensive health care systems, some
\nof the politicians were promising to provide
\ncomprehensive primary care.
\nSources
\nAlma Ata declaration:
\nwww.who.int\/hpr\/NPH\/docs\/declaration_
\nalmaata.pdf
\nWHO report EB124\/8 \u201cPrimary health care,
\nincluding health system strengthening\u201d:
\nhttp:\/\/www.who.int\/gb\/ebwha\/pdf_\ufb01les\/
\nEB124\/B124_8-en.pdf
\nResolution EB124\/8 on Primary Care:
\nhttp:\/\/www.who.int\/gb\/ebwha\/pdf_\ufb01les\/
\nEB124\/B124_R8-en.pdf
\nResolution EB124\/9 on Traditional
\nMedicine:
\nhttp:\/\/www.who.int\/gb\/ebwha\/pdf_\ufb01les\/
\nEB124\/B124_R9-en.pdf
\nOtmar Kloiber, WMA Secretary General
\nPrimary Care at the 124th
\nSession of
\nthe WHO Executive Board
\nBetween annual Word Health Assemblies the Executive Board
\nserves as the most in\ufb02uential organ of the WHO. According to
\nthe WHO website, \u201cThe main functions of the Executive Board
\nare to give e\ufb00ect to the decisions and policies of the Health As-
\nsembly, to advise it and generally to facilitate its work.\u201d
\nThe body,composed of 34 country representatives,read among oth-
\ner documents the WHO report EB124\/8 \u201cPrimary health care, in-
\ncluding health system strengthening\u201d. In resolution (EB124\/8) the
\nExecutive Board accepted the report rea\ufb03rming WHO\u2019s commit-
\nment to primary care and connected it to health system strengthen-
\ning e\ufb00orts, emphasising the will for development.
\nIn a side debate some delegates tried to introduce traditional med-
\nicine into the resolution.This e\ufb00ort failed,but a separate resolution
\n(EB124\/9) on traditional medicine opens the door for countries to
\ninclude traditional medicine in primary care. Among other points
\nthe resolution urges member states, \u201cto consider, where appropriate,
\nincluding traditional medicine into their national health systems based
\non national capacities, priorities, relevant legislation and circumstanc-
\nes, and on evidence of safety, e\ufb03cacy and quality\u201d.
\nWhile the resolution o\ufb00ers a chance for the proper evaluation of
\ntraditional medicine, it may, on the other hand, open the door for
\nsubstituting traditional medicine for quality, proven medical care.
\nAfter all, the \u201cevidence\u201d of what constitutes e\ufb03cient, e\ufb00ective and
\nsafe will most likely be determined by those in power.
\n6
\nWMA news
\nCounterfeit medicines are drugs manufac-
\ntured below established standards of safety,
\nquality and e\ufb03cacy and therefore risk causing
\nill health and killing thousands of people ev-
\nery year. Experts estimate that 10 per cent of
\nmedicines around the world could be coun-
\nterfeit.The phenomenon has grown in recent
\nyears due to counterfeiting methods becom-
\ning more sophisticated and to the increasing
\namount of merchandise crossing borders.
\nHealth impact of counterfeit
\nmedication
\nAccording to the WHO, a counterfeit medi-
\ncine is \u201ca medicine, which is deliberately and
\nfraudulently mislabelled with respect to iden-
\ntity and\/or source\u201c. Counterfeiting can apply
\nto both brand name and generic products and
\ncounterfeit medicines may include products
\nwith the correct ingredients but fake pack-
\naging, with the wrong ingredients, without
\nactive ingredients or with insu\ufb03cient active
\ningredients or even poisoning ingredients.
\nCounterfeit medicines are a threat to the
\nhealth of individuals and the public health.
\nThe serious harm for individuals can be gen-
\nerated either by excessive activity of the prin-
\ncipal active ingredient,by an insu\ufb03cient dos-
\nage of active ingredient or by the toxicity of
\ningredients that should not be present in the
\nmedicine. Patients may also think they are
\nprotected against a disease or an undesired
\nhealth event when in fact they are not.
\nDiluted or insu\ufb03ciently-dosed medicines are
\na threat to public health as they contribute
\nto drug resistance in populations, leading to
\nincreased infection rates, increased need for
\nresearch and development of new drugs, and
\nincreased health care spending. On the other
\nhand counterfeits interfere with the analysis of
\nadverse events as they give the impression that
\nthe regular drug produced the adverse event.
\nThey deprive the inventors and original
\nproducers of medicines or materials from
\ntheir reward, thus inhibiting further devel-
\nopment. Even worse, they reduce the trust
\nin medication and therefore in physicians
\nand in consequence diminish adherence to
\ntreatment schemes.
\nWMA activities on counterfeit
\nThe World Medical Association, together
\nwith the partner organisations of WHPA,
\njoined the International Medical Products
\nAnti-Counterfeiting Taskforce (IMPACT)
\nled by WHO in 2006 to combat the global
\nproblem of counterfeit pharmaceuticals.
\nIMPACT brings together nearly two hun-
\ndred countries, as well as organizations with
\nexpertise in enforcement, manufacturing,
\nand patient advocacy, and has called atten-
\ntion to the public health and commercial
\nimpact of counterfeit medicines.
\nWHPA have developed a counterfeit medi-
\ncines toolkit \u2018BE AWARE\u2019to assist dentists,
\nnurses, pharmacists and physicians to tackle
\ncounterfeit medicines in their daily prac-
\ntice. The toolkit shows some key steps that
\nhealth professionals can take to identify and
\nreport counterfeit medicines, to help \ufb01ght
\nsuch criminal practices and make treat-
\nments safer (see box).
\nExecutive board meeting of WHO
\nAt the last Executive board meeting of the
\nWHO in January 2009 the report and draft
\nresolution on counterfeit medical products
\nwere discussed and all member states stressed
\nthe importance of protecting public health
\nagainst risks caused by counterfeit medica-
\ntions. However an intense debate started on
\nthe de\ufb01nition of counterfeits versus substan-
\ndards of medicine. So far WHO has focused
\non counterfeits while largely ignoring the
\nbroader and more politically sensitive -cat-
\negory of substandard drugs. WHO\u2019s rec-
\nommendations are subject to the whims of
\nmember states. They \ufb01nd it easier to tackle
\ncounterfeits rather than substandard drugs
\nbecause the latter are often manufactured by
\ntaxpaying \ufb01rms within their borders.
\nOn the other hand substandard drugs are
\ndi\ufb03cult to combat.Identifying poor-quality
\nbatches requires widespread testing, which
\npoor governments may be reluctant or un-
\nable to \ufb01nance. Demanding manufacturer
\ncompliance requires both strict legal codes,
\nwhich countries may lack, and rigorous en-
\nforcement, which many governments are
\nunable or unwilling to perform. Ultimately,
\nsustainable quality control requires each
\ncompany to introduce good techniques and
\nproduction ethics, which can take decades.
\nNevertheless exporting countries are involved
\nin the production and distribution of sub-
\nstandard medication as well. Their exported
\nmedicines do not necessarily meet the same
\nstandards as those for domestic products, ex-
\ncept when the importing countries have less
\nstringent requirements. No consensus was
\nfound during the meeting and therefore the
\nWHO secretariat will do further reporting
\nin order to address the public health dimen-
\nsions of counterfeit and substandard medi-
\ncines and an additional text will be submitted
\nfor further discussion at the World Health
\nAssembly in May 2009.
\nFurther links:
\nhttp:\/\/www.whpa.org\/pubs.htm
\nhttp:\/\/www.who.int\/impact\/FinalBrochureWHA2008a.pdf
\nhttp:\/\/www.who.int\/impact\/en\/
\nJulia Seyer, WMA Medical Advisor
\nCounterfeit Medicines
\nBE AWARE toolkit:
\nB\u2022 e observant and use WHPA visual
\ninspection tool to identify counterfeit
\nmedicines.
\nE\u2022 valuate your patient\u2019s response to the
\nmedicine use.
\nA\u2022 cquire as much information
\nW\u2022 here was the product procured
\nA\u2022 ctively inform your health profes-
\nsional colleagues if medicines have
\nbeen con\ufb01rmed as counterfeit
\nR\u2022 emove any suspect medicines from
\nthe pharmacy, clinic, hospital or con-
\nsulting room
\nE\u2022 ducate your colleagues, patients and
\nthe public
\n7
\nWMA news
\nIntroduction: December 2008 marked the
\nlaunch of Health Sciences Online (www.hso.
\ninfo) the only site with more than 50,000
\ncourses, references, guidelines, and other
\nexpert-reviewed, high-quality, current, cost-
\nfree, and ad-free health sciences resources.
\nFree and accessible to anyone, the up-to-
\ndate, authoritative information is aimed
\nprimarily at physicians, other health care
\npractitioners, and public health providers,
\nenabling their training, continuing educa-
\ntion, and delivery of e\ufb00ective treatments
\nto patients. The information is delivered
\nby search technology from Vivisimo, Inc.,
\nwhich allows users to easily see comprehen-
\nsive search results and quickly \ufb01nd the an-
\nswers they need with an intuitively navigat-
\ned graphic interface. Through integration
\nwith Google Translator, users can search
\nand read materials in 22 languages.
\nFormer CDC Director Dr. Je\ufb00 Koplan calls
\nHealth Sciences Online (HSO) \u201ca visionary
\nundertaking\u201d and the World Bank heralds
\nit as \u201cglobally democratizing health science
\nknowledge.\u201d HSO is expected by the World
\nHealth Organization (WHO) \u201cto make a
\nconsiderable contribution to the advance-
\nment of e-learning worldwide.\u201d
\nHSO is a portal that includes more than
\n50,000 world-class health-sciences re-
\nsources, selected by our knowledgeable
\nsta\ufb00 from already-existing, reliable, pro-
\nfessional sources and resource collections.
\nThese include medical specialty societies,
\naccredited continuing education organiza-
\ntions, governments, and universities such
\nas Cambridge, Columbia, Harvard, Hop-
\nkins, McGill, MIT, Penn, Stanford, and
\nYale. Founding collaborators for this site
\ninclude the World Medical Association,
\nCDC, World Bank, the American College
\nof Preventive Medicine, and the University
\nof British Columbia, and \ufb01nancial support
\nhas come from WHO, the NATO Science
\nfor Peace Program, the Canadian govern-
\nment, the Annenberg Physician Training
\nProgram, and many volunteers.
\nBackground: Health sciences information
\nand training are vital for health and socio-
\neconomic development, but excellent, free
\nlearning resources are di\ufb03cult to \ufb01nd. In
\nrecent years, information and communica-
\ntion technologies, particularly the Internet,
\nhave been central to remedying this situa-
\ntion. But there are still signi\ufb01cant hurdles
\nto accessing online content. WHO notes
\nthat there is an enormous need to identify
\nselective, current, accessible online educa-
\ntional and training resources to promote
\nappropriate care and policies.
\nInitiative details: A portal to a virtual learning
\ncenter with browse and search functions,pro-
\nviding free, online linkages to a comprehen-
\nsive collection of top-quality courses and ref-
\nerences in medicine, public health, pharmacy,
\ndentistry, nursing, basic sciences, and other
\nhealth sciences disciplines. These materials
\nare donated, and typically hosted and main-
\ntained by our distinguished content partners,
\nso materials are constantly updated.
\nOur Advisory Committee includes both
\ndistinguished visionaries in health scienc-
\nes, and experienced practitioners in online
\nhealth sciences education:
\nChris Candler, MD; Associate Dean for\u2022
\nMedical Education, University of Okla-
\nhoma College of Medicine
\nStephen Carson, MFA; Senior Strategist,\u2022
\nOpen Courseware; MIT
\nJim Curran, MD, MPH; Dean, Rollins\u2022
\nSchool of Public Health, Emory Univer-
\nsity
\nJoan Dzenowagis,PhD; Project Manager,\u2022
\nHealth InterNetwork, WHO
\nErica Frank, MD, MPH; HSO Founder\/\u2022
\nExecutive Director, Advisory Committee
\nChair
\nSukon Kanchanaraksa, PhD; Director,\u2022
\nTeaching and Learning with Technol-
\nogy, Johns Hopkins Bloomberg School of
\nPublic Health
\nSteven Kanter, MD; Vice Dean, School\u2022
\nof Medicine, University of Pittsburgh
\nJerome P. Kassirer, MD; Distinguished\u2022
\nProfessor, Tufts Univ. SoM, Former Ed-
\nitor-in-Chief, New England Journal of
\nMedicine
\nJe\ufb00 Koplan, MD, MPH; Former Direc-\u2022
\ntor, CDC, EVP for Health A\ufb00airs, Em-
\nory University
\nEdward Maibach, MPH, PhD; Professor,\u2022
\nSocial Marketing, George Mason Uni-
\nversity
\nAnne Margulies, BS; Executive Director,\u2022
\nOpen Course Ware, MIT
\nJ.B. McGee, MD; Assistant Dean for\u2022
\nMedical Education Technology, Univer-
\nsity of Pittsburgh School of Medicine
\nPat Moholt, EdD; Executive Director,\u2022
\nGlobal Health Care Learning, Interna-
\ntional and Corporate Health, NewYork-
\nPresbyterian
\nHugh Tilson, MD, DrPH Clinical Pro-\u2022
\nfessor of Epidemiology\/Health Policy,
\nSenior Advisor to the Dean, UNC SPH
\n\u201cHSO is an incredible resource for health
\nprofessionals all over the world. Open ac-
\ncess to health information should literally
\nsave millions of lives and lead to important
\nnew discoveries,\u201dsaid Anne Margulies, Ad-
\nvisory Committee member and Executive
\nDirector of Open Course Ware at MIT.
\nAnd our reviews* have been strong, calling
\nHSO \u201cthe internet at its \ufb01nest\u2026 a bonan-
\nza\u2026 a boon\u2026 an incredibly worthwhile en-
\nterprise\u2026 a model of what Health 2.0 and
\nScience 2.0 can be\u2026 one of the most altru-
\nistic and honorable health service resources
\non the planet\u201d. We believe that HSO has
\nsucceeded because our vision of a democ-
\nratization of health sciences knowledge has
\ntremendous appeal to a wide variety of sup-
\nporters. This ranges from an endocrinologist
\nwho donated $50,000 because \u201cHSO will
\nHealth Sciences Online: the First
\nAuthoritative, Comprehensive, Free and
\nAd-Free Resource for the World\u2019s Physicians
\n8
\nWMA news
\nIn August 2008, the Commission on Social
\nDeterminants of Health, chaired by Profes-
\nsor Sir Michael Marmot of the University
\nCollege of London, published its \ufb01nal report
\n\u201cClosing the gap in a generation \u2013 Health eq-
\nuity through action on the social determinants
\nof health\u201d. The report is the result of global
\ncollaboration of policy-makers, researchers
\nand civil society, led by Commissioners with
\nextensive political, academic and advocacy
\nexperience. The purpose of the Commission,
\nlaunched by the late WHO Director general
\nDr. Lee Jong-Wook, was to provide guidance
\nto Member States and WHO\u2019s programmes
\nby gathering evidence on social determinants
\nand ways to overcome inequities. In this com-
\nprehensive 200-page report, the Commission
\naddresses global health through social deter-
\nminants, i.e. the structural determinants and
\nconditions of daily life responsible for a major
\npart of health inequities between and within
\ncountries, and proposes a new global agenda
\nfor health equity. The global agenda includes
\nthree overarching recommendations:
\n1. Improve daily conditions
\nThis recommendation puts major emphasis
\non early child development and education
\nfor girls and boys, improvement of living
\nand working conditions and creating social
\nprotection policy supportive of all.
\n2.Tackle the inequitable distribution
\nof power, money, and resources
\nThis proposal places responsibility for action
\non health equity \u2013 including equity between
\nwomen and men \u2013 at the highest level of gov-
\nernment policy, with the support of a strong
\npublic sector and e\ufb00ective governance.
\n3. Measure and understand the problem
\nand assess the impact of action
\nUnder this recommendation, national and
\nglobal health equity surveillance systems
\nshould be established to conduct routine mon-
\nitoring of health inequity and the social deter-
\nminants of health.This requires investment in
\nresearch,training of policy-makers and health
\npractitioners, and public understanding of the
\nsocial determinants of health.
\nDeveloping a health
\nmainstreaming strategy
\nThe holistic approach taken in the report
\nplaces health equity at the core of the matter,
\ncalling for global and coherent principles of
\naction in order to achieve the health-related
\nMillennium Development Goals (MDGs).
\nThe Commission supports the implementa-
\ntion of \u201chealth mainstreaming\u201d, a strategy
\noriginally designed by the United Nations in
\n19851
\nto advance equality between women
\nand men worldwide. Since then, the concept
\nhas been developed and used in other areas
\nof discriminations and in the environmental
\n\ufb01eld. Applied to health, such a strategy aims
\nto make health matters an integral dimension
\nof the design, implementation and evaluation
\nof policies and programmes in all political,
\neconomic and societal spheres, with the ulti-
\nmate goal of achieving health equality. At the
\nnational level, favouring this horizontal ap-
\nproach, rather than a sectoral one, leverages
\nthe full decision-making spectrum \u2013 from de-
\nsign through monitoring \u2013 to assess the health
\nimpact for the population of any decision
\nplanned.This strategy helps raise awareness of
\nthe intrinsic value of health, from social, eco-
\nnomic and human rights perspectives, and its
\npotential to promote social cohesion and well-
\nbeing. It can also stimulate re\ufb02ections on the
\noverall health system and its relation to the
\nother national policies and structures in place.
\nSimilar to gender-mainstreaming, the suc-
\ncess of a health mainstreaming strategy relies
\non the political will of decision-makers, on
\n1 Third World Conference on Women,Nairobi,1985
\nSocial Determinants of Health as a Driving
\nForce Towards Health Equity
\nchange the world\u201d, to an Armenian special-
\nist in preventive medicine who volunteered
\n>1,000 hours because \u201cHSO will \ufb01nally
\nmake top-quality information available to
\nall the world\u2019s doctors\u201d, to Senator Sam
\nNunn\u2019s Global Health and Security Initia-
\ntive stating that \u201cHSO has abundant high
\nquality resources, so it\u2019s not like putting in
\nkeywords in a normal search engine \u2013 this
\nwill create revolutions in health education,
\ndisease surveillance, and telemedicine.\u201d
\nNext steps \u2013 and how your institution can ben-
\ne\ufb01t: Anyone can use materials from www.
\nhso.info, and we encourage WMAJ\u2019s readers
\nand your colleagues to do so. Additionally,
\nHSO\u2019s next phase is developing programs
\nusing the gathered materials to help train
\nand educate medical and other clinical and
\npublic health providers around the world.
\nWe have already begun collaborating with
\nmedical educators to create certi\ufb01cates,
\ncontinuing education, residency programs,
\nand even degrees, and encourage interested
\ncollaborators to contact us.
\nContact information for corresponding author:
\nErica.Frank@ubc.ca
\n*http:\/\/www.altsearchengines.com\/2008\/12\/26\/
\nhope-for-the-future-health-sciences-online\/
\n*http:\/\/sandnsurf.medbrains.net\/2008\/12\/health-
\nsciences-online\/
\nErica Frank,
\nProfessor of the University of British Columbia
\nLack of emphasis on health professionals
\nas key players to achieve health equity
\nOn the occasion of the 124th
\nsession of
\nWHO Executive Board (January 2009),
\nthe World Medical Association \u2013 on be-
\nhalf of the World Health Professions Al-
\nliance (WHPA) – presented a statement
\non this report, with a focus on the health
\nworkforce. In this statement, the WHPA
\nwelcomed the recommendation directed at
\nnational governments and donors to \u201cin-
\ncrease investment in medical and health
\npersonnel\u201d, but regrets that the report in
\ngeneral does not give more attention to
\nhealth professionals as key players in ad-
\ndressing the social determinants of health
\nand the inequalities health professionals
\nface in their daily work. Concerning more
\nspeci\ufb01cally the recommendation to ad-
\ndress the health human resources brain-
\ndrain, the WHPA recalls the key message
\nof its Joint Health Professions Statement
\non Task Shifting1
\nand insists on the im-
\nportance of developing positive practice
\nenvironments in the health sector as a re-
\ntention strategy.
\n9
\nthe involvement of the actors concerned,and,
\nof course, on \ufb01nancial means. Although the
\nreport of the Commission on Social Deter-
\nminants of Health has been applauded for
\nits comprehensive analysis and data, as well
\nas for its ambitious recommendations, it re-
\nmains to be seen whether the Member States
\nwill have the political will and the means to
\n\u201clead global action on the social determi-
\nnants of health with the aim of achieving
\nhealth equity\u201d2
\n. For now, during its last ses-
\nsion (January 2009) the countries members
\n2 Closing the gap in a generation\u2019, intro, p.1
\nof the Executive Board of the World Health
\nOrganisation were humbly invited \u201cto note\u201d
\nthe report \u2026
\nThe report can be downloaded from WHO web-
\nsite: http:\/\/www.who.int\/social_determinants\/en\/
\nClarisse Delorme, WMA Advocacy Advisor
\nEducation
\nThe Avicenna Directories \u2013 a new tool in quality assurance
\nof medical education
\nThe creation of the Avicenna Directories \u2013
\nthe global directories of education institu-
\ntions for health professions \u2013 is a project in
\nprogress.
\nIntroduction
\nEarly in its history, the World Health Or-
\nganisation (WHO) developed a Directory
\nof Medical Schools, the \ufb01rst edition being
\npublished in 1953 [1]. It was intended, at
\nthat time, that the Directory of Medical
\nSchools would be followed by comparable
\ndirectories of schools of dentistry and of
\nveterinary medicine. The data were gath-
\nered through questionnaires to the institu-
\ntions themselves. The medicine-centred ap-
\nproach, which would not be appropriate in
\nthe 21st century, was clear: the introduction
\nstated \u201cThe physician is the key \ufb01gure in any
\nhealth or medical programme\u201d.
\nThe WHO World Directory of Medical
\nSchools appeared in successive editions
\nuntil the last, seventh, edition published in
\n2000 [2]. Successive editions have varied in
\nstyle and content. Most have included, for
\neach country,a summary of salient informa-
\ntion about the system of medical education
\nand regulation of medical practice in the
\ncountry. The sixth edition (1988) included
\ninformation on admissions and on the cur-
\nriculum for each school,where available,but
\nthis feature is not found in earlier or later
\neditions. Notably, each edition soon fell out
\nof date, because of the rapid evolution of
\nmedical education, because of the inevitable
\ntime-lag between collection of data and
\npublication in book form, and because of
\nthe lack of e\ufb00ective mechanisms for updat-
\ning information.
\nNew Directories
\nIn designing such an important resource,
\nmodern electronic data collection and data
\nmanagement give an opportunity for col-
\nlection of wide-ranging information, in
\nparticular statistical data about institutions
\nand their programmes and about quality as-
\nsurance. Web-based methods allow timely
\nupdating and veri\ufb01cation of such informa-
\ntion. Thus, directories can be created that
\nare more accurate, more up-to-date and
\nmore comprehensive – both in the range of
\ndisciplines covered, and in the amount of
\ninformation on each institution. It is also
\nimportant to extend the range of the direc-
\ntories beyond medicine, because the provi-
\nsion of health care, and the prevention of
\nill-health, is the remit of the entire team of
\nhealth workers: medicine, pharmacy, public
\nhealth, dentistry and so on.
\nIn 2007, WHO and the University of Co-
\npenhagen agreed that the University would
\ndevelop new global directories of higher ed-
\nucation institutions for health professionals,
\non the principles of:
\nComprehensive coverage\u2022
\nImproved high-quality detailed informa-\u2022
\ntion \u2013 and
\nImproved usability\u2022
\nComprehensive coverage includes both the
\nrange of health professions, as above, and
\ncoverage of all schools that meet the fol-
\nlowing criteria:
\nRecognition by the national government\u2022
\nRegular admissions of students for face to\u2022
\nface education
\nSchools with national admission in the\u2022
\ncountry concerned
\nDavid Gordon, Leif Christensen, Hans Karle and Theanne Walters Avicenna Directories, University of Copenhagen
\n10
\nEducation
\nSchools with at least one campus in the\u2022
\ncountry concerned and
\nSchools with administrative and legal\u2022
\nstructures in the country concerned.
\nImproved information includes information
\non management, ownership, accreditation,
\neducational programme and admissions
\nfor each school, and improved usability in-
\ncludes information that can be readily ac-
\ncessed, searched and downloaded.
\nThese principles were set out in a Memo-
\nrandum of Understanding (MoU) between
\nWHO and the University of Copenhagen
\nsigned in August 2007. The MoU established
\na Steering Board jointly between the Univer-
\nsity and WHO,to be assisted by an Advisory
\nCommittee of interested stakeholders, and
\nprovides that the University will be assisted
\nby the World Federation for Medical Edu-
\ncation (WFME [3]) in development of the
\nnew directories: the Avicenna directories.
\nWhy Avicenna?
\nAvicenna \u2013 Abu Ali al-Hussain Ibn Ab-
\ndallah Ibn Sina \u2013 was a polymath, and the
\nleading physician and philosopher of his age
\n[4]. His life (ca. 980 \u2013 1037 CE) and career
\nwas in and around modern-day Iran and Uz-
\nbekistan, but his outlook was international.
\nHis most important medical writing was The
\nCanon of Medicine[5], in which he integrat-
\ned his own learning with sources as disparate
\nas classical Greece, Galen and early Indian
\nmedicine: the Canon was widely translated,
\nfor example into Chinese and Latin, and re-
\nmained an important textbook for centuries.
\nThree principles in Avicenna\u2019s career and
\nwriting are particularly inspiring for the
\nAvicenna Directories: his willingness to
\ngather and synthesise worthwhile knowl-
\nedge from the entire known world; the em-
\nphasis on the practical application of medi-
\ncal principles (it was not enough to know
\nmedicine, the need was to apply knowledge
\nto heal the sick); and the preservation and
\ndissemination of learning to take medicine
\nforward. These principles are as true now as
\na thousand years ago \u2013 therefore the choice.
\nWithin the detailed aims of the MoU estab-
\nlishing the Avicenna directories, these three
\nprinciples associated with Avicenna remain:
\nthe collection of information from world-
\nwide sources; the synthesis of that data into
\na useful and applicable form; and dissemi-
\nnation to all who need the information.
\nProgress since July 2007
\nThe o\ufb03ces of WFME are situated within
\nthe University of Copenhagen,and the Avi-
\ncenna secretariat is based with WFME. The
\nteam that has been created is international
\nand includes experts in medical and social
\nscience and in the work of standard-setting
\nauthorities, as well as IT and database ex-
\npertise. There is regular discussion with col-
\nleagues within the University of Copenha-
\ngen, with WHO, and with an international
\nnetwork of interested advisors. In addition,
\nthe Advisory Committee for the project had
\nits \ufb01rst meeting in 2008.
\nOne early task was to place data from the
\nseventh edition of the WHO World Direc-
\ntory of Medical Schools, with updates re-
\nceived by WHO to the end of 2007, on the
\nAvicenna website[6].These data are still be-
\ning updated on request.Regulatory agencies
\nand other interested parties are increasingly
\nusing the Avicenna website for this infor-
\nmation. One outcome is a steady stream of
\nenquires (between 5 \u2013 20 each week) about
\ninclusion of medical schools in the data-
\nbase, and an increasing number of hits on
\nthe Avicenna website, currently about 2.500
\neach month.
\nCurrent and future issues
\nFor the time being, the only academic dis-
\ncipline represented in the database on the
\nAvicenna website is medicine. In order to
\nexpand the Directories, so that the other
\nprofessions are presented as soon as is prac-
\nticable, discussions have begun with other
\npartners in the Avicenna project. Thus far,
\nthis has included the International Phar-
\nmaceutical Federation (FIP) and the World
\nFederation of Public Health Associations
\n(WFPHA), to plan the development of
\nDirectories of schools of pharmacy, and of
\npublic health, in the Avicenna project.
\nThe MoU between WHO and the Uni-
\nversity sets out the need for information
\nto be gathered from reliable sources, using
\na variety of tools, and explicitly mentions a
\nquestionnaire based approach, as was also
\nthe case for entries for individual medical
\nschools in all editions of the WHO World
\nDirectory. The Avicenna team have no
\ndoubt that this remains the most important
\napproach. It ensures that all schools in a
\ngiven academic discipline are asked iden-
\ntical questions and can provide their own
\nresponse: it is comprehensive and allows a
\nuniform and standardised approach to the
\nchecking and validation of data. The use,
\nas a primary source, of information from
\nplaces other than the institution itself would
\nbe unequal and would require inappropriate
\ninterpretation by the Avicenna team itself.
\nThedevelopmentofaquestionnairetoproduce
\nreliable and valid data is a considerable tech-
\nnical task [7, 8] and has taken many months,
\nwith extensive consultation. A draft version
\nwas piloted the last three months of 2008 by
\n20 medical schools,representing a world-wide
\nrange of many di\ufb00erent types of school. In the
\nlight of these pilot responses, and comments
\nreceived, a \ufb01nal version of the questionnaire
\nfor general use has been developed. The ques-
\ntionnaire is web-based, and will \u2013 where pos-
\nsible \u2013 be completed on line,and is in a format
\nthat, once the information is validated, can be
\ndownloaded into the Avicenna database.
\nThe validation process will extract relevant
\nanswers from the questionnaire response
\nfrom each school, and verify these with the
\nproper national validating authority.
\nIt would logistically not be possible to sur-
\nvey all the medical schools in the world, or
\nall the schools in any discipline, at a single
\ntime. Studies will therefore begin with
\ndata collection from a group of countries
\nthat represent about one quarter of all the
\nworld\u2019s medical schools. The remaining
\nmedical schools will be surveyed in suc-
\ncessive waves. Allowing time for valida-
\n11
\ntion of information, and for transfer to the
\nwebsite, a complete Avicenna Directory for
\nmedicine is expected to be available by early
\n2010. The completion of Avicenna Direc-
\ntories for the next two subjects, pharmacy
\nand public health, depends on the continu-
\ning development of plans with the relevant
\npartners, FIP and WFPHA.
\nUpdating of information according to re-
\nquests will be on a continuing basis. In ad-
\ndition, it is planned to survey all institutions
\nevery three years, on a rolling programme, so
\nthat information is never long out-of-date.
\nIt is clearly desirable for the Avicenna Direc-
\ntories to include relevant information at a na-
\ntional and regional level about the system of
\neducation for health professionals, processes
\nfor evaluation of educational institutions and
\ntheir programmes, the licensing framework
\nfor these professions and so on.
\nConcluding remarks
\nThe Avicenna project will create an up-to-
\ndate, easily accessible, and comprehensive
\nelectronic world list of education institu-
\ntions for the health professions.
\nThere will be detailed information by coun-
\ntry on each educational institution, about
\nthe programmes of study and the resources
\nin each school, about quality assurance, and
\ncontact details \u2013 useful for everyone world-
\nwideconcernedwitheducationforthehealth
\nprofessions,whether as a student,a teacher,a
\nregulator or other health authority.
\nhttp:\/\/avicenna.ku.dk
\nReferences
\n1 World Health Organization. World directory of
\nmedical schools, 1st edn. Geneva: WHO, 1953.
\n2 World Health Organization. World directory of
\nmedical schools, 7th edn. Geneva: WHO, 2000
\n3 http:\/\/www.wfme.org (accessed 4 February
\n2009)
\n4 http:\/\/en.wikipedia.org\/wiki\/Avicenna(accessed
\n4 February 2009)
\n5 http:\/\/en.wikipedia.org\/wiki\/The Canon of
\nMedicine (accessed 4 February 2009)
\n6 http:\/\/avicenna.ku.dk\/ (accessed 4 February
\n2009)
\n7 A N Oppenheim, Questionnaire Design, Inter-
\nviewing and Attitude Measurement. London:
\nPinter, 1992
\n8 R Sapsford & V Jupp, Data Collection and
\nAnalysis. 2nd edn. London: Sage Publications,
\n2006.
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nTom F , Deputy Head, Health Policy
\n& Economic Research, British Medical
\nAssociation
\nBlair\u2019s Plan
\nOn the eve of the 1997 election,Tony Blair,
\nthe soon-to-be Prime Minister, famously
\ntold voters they had \u201824 hours to save the
\nNHS\u2019 (National Health Service). With La-
\nbour\u2019s subsequent victory much was expect-
\ned from a government that had purposefully
\npositioned itself as \u2018the party of the NHS\u2019.
\nA series of pledges and initiatives followed.
\nbut it was with the publication of the \u2018NHS
\nPlan\u20191
\nin 2000 that a watershed moment in
\nmodern NHS reform came to pass which
\nwas to set the direction of health policy for
\nthe coming decade. At its core the NHS
\nPlan articulated a desire to increase capac-
\nity, improve access and forge a new, more
\nresponsive NHS. By promoting the value of
\na more mixed supply side and encouraging
\nan increased challenge to the medical pro-
\nfession\u2019s power, the NHS Plan ushered in
\na period of \u2018constructive discomfort\u20192
\nbased
\non a belief that improvements in the NHS
\nwould require a certain amount of creative
\ntension in order to overcome what was re-
\ngarded as a degree of both complacency and
\ninertia in the system.
\nIn setting out a series of strategies designed
\nto reform the NHS \u2013 modernising its in-
\nfrastructure, setting national standards, en-
\nabling \u2018patient choice\u2019, employing market
\nincentives and a growing role for the private
\nsector in delivering NHS care \u2013 the Gov-
\n1
\nDepartmentofHealth(2000)TheNHSPlan:aplan
\nfor investment, a plan for reform, London:DH.
\n2
\nStevens, S (2004) \u2018Reform strategies for the Eng-
\nlish NHS\u2019, Health A\ufb00airs, vol 23, no 3:37-44.
\nernment matched these ambitions with a
\n\ufb01ve-year spending plan to bring the NHS
\nbudget up to European levels by 2008 com-
\nprising year-on-year rises in UK spending
\nfrom \u00a365.4bn in 2002 to \u00a3100.6bn in 2007,
\nmore than 7% in real terms annually.Along-
\nside this health reform agenda, the United
\nKingdom was also witnessing a process of
\ndevolution, with each of its four home na-
\ntions slowly evidencing divergent policy
\nacross a range of areas. The NHS was (and
\nremains) at the vanguard of this process.
\nBrown\u2019s Vision
\nWith a change of Prime Minster in the
\nsummer of 2007 it was not clear whether
\nthe direction of travel would alter, particu-
\nlarly the recent emphasis on market-based
\nreform. Some commentators anticipated a
\nstep-change given the new Prime Minister
\nGordon Brown\u2019s documented reservations
\nconcerning the extent to which the market
\ncould play a role in healthcare and medicine3
\n.
\nThe launch of the NHS Next Stage Review
\nin the months after Brown took charge was
\nregarded as an early signal that change was
\nperhaps on the horizon. The 12-month re-
\nview, led by the eminent surgeon Professor
\n(now Lord) Darzi, was to take stock of the
\n3
\nBrown, G. (2004) A modern agenda for prosperity
\nand social reform, London: Social Market Foun-
\ndation.
\nNational Health Service (England).
\nNext Stage Review \u2013\u201chigh quality care for all? \u201d
\nrusher
\n12
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nreform agenda in the English NHS and pro-
\npose a vision for the next 10 years.
\nThe review\u2019s \ufb01ndings were published in June
\n2008 in \u2018High Quality Care for All\u20194
\nand the
\nvision it comprises is structured around four
\nbroad themes:
\n\u2018high-quality care for patients and the\u2022
\npublic\u2019 \u2013 an NHS that works in partner-
\nship to prevent ill health, providing care
\nthat is personal, e\ufb00ective and safe
\n\u2018quality at the heart of everything\u2019 \u2013 high-\u2022
\nquality care throughout the NHS
\n\u2018freedom to focus on quality\u2019 \u2013 fostering\u2022
\nclinical leadership and putting frontline
\nsta\ufb00 in control
\n\u2018high-quality work in the NHS\u2019 \u2013 sup-\u2022
\nporting sta\ufb00 through education and
\ntraining to deliver high-quality care.
\nA further substantive element of the report
\nestablished proposals for an NHS constitution
\nfor England, with the aim of formally setting
\nout for the \ufb01rst time the purpose, principles
\nand values of the NHS as well as the rights
\nand responsibilities of patients,the public and
\nNHS sta\ufb005
\n.The concept of a constitution has
\nreceived cautious support from a range of
\nstakeholders,including the BMA6
\n.
\nAmongst other headline proposals was the
\nundertaking to o\ufb00er extended choice in pri-
\nmary and community care with improved
\naccess and a wider range of providers, pri-
\nmarily by way of a pledge to create 150 new
\nGP-led health centres (or \u2018polyclinics\u2019).This
\nhas so far proved to be perhaps the most
\ncontroversial proposal with much concern
\namongst the medical profession, in partic-
\nular general practitioners, that these plans
\nwere not only ill-thought through with no
\nthorough assessment of any real local need
\nfor the new centres, but that they would act
\nto divert resources away from existing gen-
\n4
\nDepartment of Health (2008) High Quality Care
\nfor All, London:DH.
\n5
\nThe \u2018NHS Constitution for England\u2019 was formally
\npublished on 21st January 2009. see http:\/\/www.
\ndh.gov.uk\/en\/Healthcare\/NHSConstitution\/in-
\ndex.htm
\n6
\nBritish Medical Association (2008) An NHS
\nConstitution for England, London:BMA. (www.
\nbma.org.uk)
\neral practice and primary care services, de-
\nstabilising local health economies and well-
\nestablished care pathways. Moreover, the
\nview that these plans might o\ufb00er the private
\nsector another opportunity to increase its
\nrole in delivering NHS care further fuelled
\nfears about the ongoing commercialisation
\nof the NHS.
\nThe same, but di\ufb00erent
\nUltimately in looking beyond the detail con-
\ntained in \u201cHigh Quality Care for All\u201d, it is
\nclear that the mainstays of previous English
\nreform \u2013 improving access, patient choice, a
\ndiversity of provision linked to market incen-
\ntives – will continue to feature heavily. Nev-
\nertheless, the report does provide a shift in
\nfocus and with it a change in language and
\napproach. Key to this new focus is the cen-
\ntral desire to target improvements in quality
\n(rather than the previous targeting of capac-
\nity). Furthermore, the \u2018quality agenda\u2019 is ar-
\nticulated by way of a commitment to have
\nfuture reform \u2018locally-led, patient-centred
\nand clinically-driven\u2019. Importantly for the
\nmedical profession in developing this theme,
\nthe review built on an earlier recognition
\nthat NHS sta\ufb00 \u2018had been ignored, that their
\nvalues had not been fully recognised, and
\nthat they had not been given credit for im-
\nprovements that had been made\u20197
\n.The vision
\nfor the future is therefore one that aims to
\nnurture a \u2018new professionalism\u2019 with a much
\ngreater emphasis on clinical leadership in
\ndelivering improvements in the NHS. The
\nvast scope of the report does not lend itself
\nto a brief analysis and so what follows is an
\noverview of two of the fundamental elements
\nof the vision it espouses, the \u2018quest for qual-
\nity\u2019 and \u2018clinical leadership\u2019, and some of the
\nquestions they raise.
\nDarzi\u2019s Quest
\nQuality
\nIn wishing to steer the NHS away from a
\ncentrally driven performance management
\nregime,Lord Darzi\u2019s report seeks to enable a
\nfuture where all change is based on the best
\n7
\nDepartment of Health (2007) Our NHS, Our
\nFuture, NHS Next Stage Review: interim report,
\nLondon:DH.
\navailable evidence, with the aim of improv-
\ning the quality of care that patients receive
\nalways paramount. The \u2018quest for quality\u2019
\nhe sets out is supported by a host of initia-
\ntives including a new set of national quality
\nindicators for acute services, a new quality
\nframework for community services and the
\ndevelopment of a wider range of local qual-
\nity metrics. All providers working for or on
\nbehalf of the NHS will,by 2010,be required
\nto publish \u2018Quality Accounts\u2019 detailing the
\nquality of their services based on measures
\nof patient safety, patient experience and the
\ne\ufb00ectiveness of care (mortality, complica-
\ntion or survival rates and patient-reported
\noutcome measures).
\nTo further incentivise change in this area
\nthe review also proposes payments to hos-
\npitals conditional on the quality of care they
\ndeliver. As a result, by 2010-11 a proportion
\nof annual hospital trust income will be de-
\npendant on meeting service quality require-
\nments. This will be driven by two particular
\ninitiatives. The \ufb01rst will link hospital tari\ufb00
\npayments to patient-reported outcome
\nmeasures and indicators, such as hospital
\nacquired infection rates.The second will see
\nthe introduction of a \u2018best practice tari\ufb00\u2019
\nthrough which payments for a range of pro-
\ncedures that are currently evidencing signif-
\nicant unexplained variation in practice will
\nbe based not on average cost, but rather on
\nbest practice (which notably in most cases
\nwill be at a lower cost than the average).
\nClearly, these initiatives require the NHS
\nto expand the scope and volume of data it
\ncollects. However, the NHS\u2019s ability to pro-
\nduce reliable, comparable data has histori-
\ncally been the subject of much criticism and
\nthe initiatives\u2019 success will therefore depend
\nheavily on a signi\ufb01cant improvement in the
\nquality of data production itself, rather than
\nsimply using existing datasets di\ufb00erently. In
\naddressing this shortcoming one cannot ig-
\nnore the related cost implications. A report
\nto the Department of Health in 2007 sug-
\ngested that the cost of collecting data on pa-
\ntient-reported outcome measures for elective
\nsurgery ranged from \u00a33 to \u00a311 per patient
\n(Browne et al 2007). If such \ufb01gures were ap-
\n13
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nplied to high-volume procedures, the total
\ncost would approximate to many hundreds
\nof thousands of pounds per procedure type.
\nIt is noteworthy that \u201cHigh Quality Care for
\nAll\u201dcontains few details of costings for these
\nand the other proposals it contains.
\nInterestingly, as these examples demon-
\nstrate, despite the report\u2019s focus on localism
\nand its determination to avoid a culture of
\nimposed targets,there remains a critical role
\nfor the centre with large elements of the
\nquality agenda set at the national level. Fur-
\nther to this,the report also proposes that the
\nNational Institute for Clinical Excellence
\n(NICE) has its remit expanded to set and
\napprove more national quality standards,
\nwhilst a new \u2018National Quality Board\u2019 will
\nprovide strategic oversight and leadership
\non quality issues. It remains to be seen how
\nsuccessfully these national and local level
\ninitiatives will interface and where tensions
\nmay arise, how the old charge of a \u2018top-
\ndown\u2019 approach will be avoided.
\nNevertheless, the focus on quality is to be
\nwelcomed. Robust and reliable quality mea-
\nsures should provide a solid, evidence-based
\nplatform for service improvement and will
\nhopefully provide a currency that clinicians
\ncan both identify with and engage in when
\nreviewing clinical practice and looking at ser-
\nvice redesign. For patients, the routine pro-
\nduction of outcome data promises to increase
\ntheir ability to make informed choices about
\ntheir care and with the inclusion of patient
\nexperience indicators, the NHS should be-
\ncome ever more responsive to patients\u2019needs.
\nHowever, whether patients can truly become
\nthe empowered users of this information
\nremains open to question. Past experience
\nsuggests that those patients who might most
\nbene\ufb01t from a more detailed picture of the
\ncare available to them often do not have
\nthe necessary understanding or expertise to
\nmake use of data to this end. Consequently,
\nsuch patients will require support in relating
\nto the quality markers and making informed
\nchoices on this basis thus raising again the
\nissue of where the necessary resource can be
\nfound to enable this.
\nClinical Leadership
\nAs noted above what is striking about the
\noutcome of the NHS Next Stage Review
\nis the unprecedented emphasis it places on
\nthe role that clinicians have to play in lead-
\ning change in the NHS. Where previous
\nreform, imposed from above, often acted
\nto disenfranchise NHS sta\ufb00, the vision for
\nthe future places the medical profession
\n(and other health professions) at the heart
\nof the process, seeking to engage them in
\nits planning, implementation and delivery.
\nThe review contends that where change is
\nled by clinicians and based on evidence of
\nimproved quality of care, sta\ufb00 who work in
\nthe NHS respond better to it and patients
\nand the public are more likely to support it.
\nTo enable this new approach the review
\nproposes a series of initiatives aimed at de-
\nveloping clinical leadership skills across the
\nmedical profession. These range from re-
\nviewing undergraduate curricula for medi-
\ncal students to ensure that they re\ufb02ect the
\nskills required for leadership; establishing
\nClinical Leadership Fellowships to provide
\nprotected time for clinicians to develop
\ntheir leadership skills; and establishing a
\n\u2018Clinical Management for Quality\u2019 pro-
\ngramme for clinicians managing services,
\nespecially clinical directors and primary care
\nprofessionals running practice-based com-
\nmissioning groups. Much of this centres on
\ndeveloping leadership at a local level but in
\nwishing to promote the concept of leader-
\nship further an NHS Leadership Council,
\nchaired by the NHS Chief Executive, has
\nalso been created that will act to nurture the
\nnext generation of NHS leaders.
\nThis investment in new programmes of
\nclinical leadership is welcome but it will be
\nsome time before a proper assessment can
\nbe made as to whether clinicians on the
\nground identify and engage with the process
\nin a meaningful way.There will no doubt be
\nsome initial scepticism amongst those who
\nquestion how meaningful the new oppor-
\ntunities are. The true test of success will be
\nhow these undertakings are taken forward
\nat the local level where doctors and their
\ncolleagues should undoubtedly be central to
\nthe leadership of the organisations in which
\nthey work.
\nWhat next?
\nMany concerns remain about the general
\ndirection of travel that reform over the last
\ndecade has taken, in particular the grow-
\ning commercialisation of the NHS and
\nthe potential for market reforms to foster
\ncompetition rather than collaboration and
\nengender fragmentation not integration.
\nThere is also doubt as to whether the am-
\nbitious programme of reform has begun
\nto deliver substantial bene\ufb01t to patients.8
\nAs with recent past policy, the Next Stage
\nReview su\ufb00ers from its own grand scale.
\nWhilst promising no new reorganisations
\nand o\ufb00ering the hope of stability within the
\nservice,the vision encompasses a wide range
\nof signi\ufb01cant changes \u2013 in primary care, in
\ncommunity care,in acute care,in funding,in
\nmeasurement, in reporting, in training and
\neducation. Does the \u2018quality agenda\u2019 pro-
\nvide enough of a cohesive focus to ensure
\nthat such expected widespread change will
\nbe successful? More worryingly, it is not at
\nall clear that many of the proposals have an
\nadequate evidence-base or have been suf-
\n\ufb01ciently tested in terms of cost or possible
\nunintended consequences.
\nNow, in early 2009, some 6 months or so
\non from the launch of High Quality Care
\nfor All, there are early signs that the NHS
\nin England is pursuing many of the policy
\nchallenges it sets out. But perhaps now even
\nbigger challenges lie ahead. Given the cur-
\nrent economic climate the Treasury has al-
\nready warned that overall public spending
\ngrowth will be cut from the 1.9 per cent real
\nterms growth rate enjoyed for 2008-09 so
\nthat it will be reduced to just 1.2 % a year
\nfrom 2011 onwards. We might predict that
\nthe NHS will see growth close to zero when
\nallocated its share of public funds.The ques-
\ntion is, following on from the exceptional
\nlevels of funding the NHS has experienced
\nin recent years can Lord Darzi\u2019s vision be
\ndelivered on a shoe-string?
\n8
\nAudit Commission (2008). Is the treatment work-
\ning? Progress with the NHS system reform pro-
\ngramme, London: Audit Commission.
\n14
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nIntroduction
\nIn recent times sex di\ufb00erences in cardio-
\nvascular disease have gained increased at-
\ntention. We are learning that the mortal-
\nity of acute myocardial infarction in young
\nwomen is higher than in age-matched
\nmen and stroke is increasingly frequent in
\nyoung women. Systolic heart failure has a
\nmore severe clinical course and outcome in
\nmen. Diastolic heart failure predominates
\nin women. Additional important sex di\ufb00er-
\nences are found in diabetes,hypertension,in
\nthe anti-coagulation system,in cardiovascu-
\nlar metabolism and arrythmia. Women and
\nmen di\ufb00er in many aspects and particularly
\nin metabolic ones.This includes handling of
\ndrugs and drug e\ufb00ects. A large number of
\nmajor studies in cardiovascular therapy in-
\ncluded mainly men. Therefore we have less
\ndata on the mechanisms and side e\ufb00ects in
\nwomen compared with men.
\nDrug metabolism
\nFDA data shows that sex di\ufb00erences in
\nbioavailability are found in about 30 % of
\nall submitted drugs. Lower body mass and
\nhigher lipid levels in total body composition
\nin women account for di\ufb00erences in drug
\nexposure. Dosing adapted to weight would
\nat least partially correct for these di\ufb00erences.
\nWeight adapted dosing recommendations
\nexist for digoxin, for some anti-arrhythmic
\ndrugs, for heparin and some thrombolytic
\ndrugs. These recommendations are, however,
\nnot always respected [1]. Increased bleeding
\nin women with \ufb01xed dosage of thrombolytic
\nor GPIIb\/3a inhibitors underscores the rele-
\nvance of dose-adaptation.In addition to pure
\nweight,the higher lipid content of the female
\nbody is of relevance. Consequently, lipid sol-
\nuble substances have a greater distribution
\nvolume in women. Gastrointestinal function
\nis also a\ufb00ected by sex hormones leading to
\nshorter mean transit times in women [2].
\nSome drug metabolising enzymes are di\ufb00er-
\nently expressed in women and men.The activ-
\nity of gastric alcohol dehydrogenase is much
\nlower in women than in men. Sex di\ufb00er-
\nences in the expression of cytochrome P450
\nisoenzymes also a\ufb00ect metabolism of numer-
\nous substances. Sex di\ufb00erences with clinical
\nrelevance are mainly shown for CYP1A2,
\nCYP2B6, CYP2E1 und CYP3A4 (Tab. 1)
\n[3]. CYP2E1 metabolises anaesthetic drugs
\nsuch as halothane,iso\ufb02uorane,as well as etha-
\nnol. Activity is about 30% lower in women
\ncompared to men. CYP3A4 makes up for
\n30% of total hepatic CYP activity and con-
\ntributes to the metabolism of more than 50%
\nof drugs. It is involved in the metabolism of
\nendogenous and exogenous steroids, and of
\ndrugs like erythromycin, methylprednisolone,
\nmethadone, tacrolimus, diltiazem, nifedipin,
\ntriacelam,cyclosprorine and verapamil.Wom-
\nen have a 20-50% higher activity of this en-
\nzyme than men. Accordingly CYP3A4 sub-
\nstrates are metabolised faster in women [3].
\nRenal function in general is higher in men
\nthan in women. This is only partially ex-
\nplained by di\ufb00erences in body weight. Ac-
\ncordingly, renal drug clearance in general is
\nlower in women than in men. In fact, digox-
\nin displays a 12-14% lower clearance rate in
\nwomen than in men. This di\ufb00erence addi-
\ntionally increases with age [4].
\nPharmacodynamics
\nDigitalis
\nIn 1997 the digitalis study group reported
\nthe positive e\ufb00ects of digitalis on heart
\nGender Aspects in
\nCardiovascular Drug Therapy
\nVera Regitz-Zagrosek, MD PhD, Sabine Oertelt-Prigione, MD; Berlin Institute of Gender
\nin Medicine (GiM), Charite\u00b4- Universit\u00e4tsmedizin Berlin, Germany Deutsches Herzzentrum
\nBerlin (DHZB), Charite\u00b4- Universit\u00e4tsmedizin Berlin, Germany
\nTable 1.
\nSex di\ufb00erences in Cytochrome P450 Isoenzymes
\nIsoenzyme Sex di\ufb00erences Drugs with cardiovascular interaction
\nCYP1A2
\nLower activity in females, in\ufb02u-
\nenced by hormons
\nCa\ufb00eine, paracetamol
\nCYP2C9 No sex di\ufb00erences Warfarin
\nCYP2C19 Controversial data Omeprazole, diazepam
\nCYP2D6 Higher activity in males Propanolol, metoprolol
\nCYP2E1 Higher activity in males Halothane, iso\ufb02uourane
\nCYP3A4 Higher activity in females
\nTacrolimus, diltiazem, nifedipine, tria-
\nzolam, cyclosporine, verapamil
\n15
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nfailure. Thereafter, these study results were
\nadopted as recommendations by numerous
\nguidelines. There was no sex speci\ufb01c analy-
\nsis. However, in 2002 a retrospective gender
\nspeci\ufb01c analysis was undertaken and dem-
\nonstrated that digitalis is associated with
\na signi\ufb01cantly higher mortality in women
\ncompared with men. In the original study, a
\nmodest survival bene\ufb01t could be detected in
\nmen, while the opposite was true for wom-
\nen; nonetheless, as the study population
\nconsisted of a combined study group with
\na 3:1 male:female ratio the opposing e\ufb00ects
\non survival counterbalanced each other al-
\nlowing for no survival di\ufb00erence detection
\nin the mixed population [5]. In the follow-
\ning year it was shown that higher digitalis
\nserum levels were associated with increased
\nmortality in men [4], whereas serum levels
\nin the lower normal range were associated
\nwith better survival. Similar trends were
\nreported in women. Lower drug elimina-
\ntion, higher blood levels and an increased
\nmortality associated with drug levels in the
\nupper normal range explain the unfavour-
\nable survival di\ufb00erence reported in women
\n(Fig. 1).
\nBeta blockers
\nBeta blockers are frequently associated with
\nhigher drug exposure in women. The beta1
\nselective blocker metoprolol is primarily
\nmetabolised by CYP2D6 which has a lower
\nactivity in women. In addition women have
\na lower distribution volume for metoprolol.
\nThus, plasma concentrations are higher in
\nwomen than in men. Moreover, oral contra-
\nceptives can interact with metoprolol [6]and
\nfurther increase its plasma levels.Other beta
\nblockers, like propanolol for example, reach
\nplasma levels that are up to 80% higher in
\nwomen compared to men [7]. Accordingly
\nwomen show stronger beta blocker side ef-
\nfects, a stronger decrease in heart rate and
\nsystolic blood pressure. Positive e\ufb00ects are
\nsimilar in women and men [8, 9] (Fig. 2).
\nACE inhibitors
\nIn the early multicenter randomised trials
\nwith Ace inhibitors (ACEI),bene\ufb01t was more
\nfrequently found in men in comparison to
\nwomen. In Consensus 1 and solvd, mortal-
\nity reduction in women was below 5 % while
\nreaching 30-40 % in men [10]. Since mainly
\nmen were included in these studies, the com-
\nbined analysis of both cohorts showed a ben-
\ne\ufb01cial e\ufb00ect. Side e\ufb00ects in all these studies
\nwere more frequent in women. Later, ACEI
\nstudy such as AIRE and HOPE documented
\na signi\ufb01cant bene\ufb01t for women[11].This was
\nparticularly the case for the secondary preven-
\ntion of cardiovascular events in high risk pa-
\ntients. In contrast, the recently published 2nd
\nAustralian National Blood Pressure Study
\nFemale, Bisoprolol
\nMale, Bisoprol =
\nFemale, Placebo
\nMale, Placebo
\n0 3 6 9 12 15 18 21 24
\nTime (months)
\nSurvival(%)
\n100
\n90
\n80
\n70
\n60
\n50
\n0
\nFigure 1 Digitalis therapy for heart insu\ufb03ciency: survival rates in female and male study popu-
\nlations with digitalis and placebo [5]. Female patients on digitalis display a signi\ufb01cantly worse
\nsurvival rate compared to the placebo group.
\nFigure 2 Survival rates with beta-blocker therapy for systolic insu\ufb03ciency. Sex-speci\ufb01c survival
\ncurves from the bisoprolol study [9]: female patients have better outcomes then male patients, ir-
\nrespective of therapeutic regimen. E\ufb00ects of the beta-blocker therapy are similar in both groups.
\n16
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\n(ACEIs compared with diuretics) showed a
\nsigni\ufb01cant reduction of cardiovascular events
\nwith in men on ACEIs, but not in women
\n[12].
\nAngiotensin receptor blockers,
\nAldosterone antagonists and diuretics
\nThese drugs are e\ufb00ective in women and
\nmen. The large studies LIFE, ELITE,
\nVALHEFT, VALUE, VALIANT and OP-
\nTIMAAL did not show any sex di\ufb00erences.
\n20-30 % of women were generally included
\nin these studies [10]. Aldosterone antago-
\nnists are nowadays used in add-on strategies
\nin the treatment of heart failure showing
\nequal e\ufb00ectiveness in women and men. The
\nmost prominent side e\ufb00ect of these drugs is
\na painful gynecomasty that a\ufb00ects only men
\n[13]. Diuretics are more frequently used in
\nwomen even though they have more un-
\nwanted side e\ufb00ects, such as hyponatremia
\nand hypokalemia [11].
\nAcetyl salicylic acid, thrombolytics
\nand anticoagulation
\nRecently, surprising results were observed.
\nIn a long term study with approx. 40,000
\nwomen the reduction of primary cardiovas-
\ncular events, i.e. myocardial infarction (MI)
\nor cardiovascular death, by Aspirin was not
\nstatistically signi\ufb01cant [14]. However, pri-
\nmary prevention of stroke was achieved.
\nThis is opposite to the e\ufb00ects in men show-
\ning inhibition of a primary MI, but not a
\nprimary stroke by Aspirin. Reasons for
\nthese di\ufb00erences are yet unclear.
\nA recent study (Crusade) documented that
\npercutaneous coronary interventions and
\nsubsequent antithrombotic therapy lead to
\nbleeding more frequently in women com-
\npared with men [15]. Detailed analysis
\nshowed that the substances are more fre-
\nquently overdosed in women compared with
\nmen and that particularly older women are
\na\ufb00ected. However, even after adaptation of
\ndosage to body mass and serum creatinine
\nlevels, women su\ufb00ered from bleeding more
\nfrequently than men. Thus, pharmacody-
\nnamic as well as pharmacokinetic e\ufb00ects
\nmay play a role in these substances [16].
\nAntiarrhythmic drugs
\nWomen exhibit severe arrhythmia more
\nfrequently on QT-prolonging therapy than
\nmen [17, 18]. Women have a longer cor-
\nrected QT-time than men and a greater QT
\nprolongationondrugsthatinhibitpotassium
\ninward channels. This enables the genera-
\ntion of arrhythmia. A number of drugs have
\nbeen identi\ufb01ed that prolong repolarisation
\nby blocking potassium channels. These are
\nmore frequently associated with arrhythmia
\nin women than in men. The group does not
\nonly include anti-arrhythmid drugs, but
\nalso gastrointestinal drugs, antipsychotics,
\nantihistamines and antibiotics [19].
\nReasons for sex di\ufb00erences
\nin drug e\ufb00ects
\nMost drug development in the cardiovascular
\n\ufb01eld is undertaken in young male mice. Rea-
\nsons for this include the greater lethality of
\nmyocardial infarction or heart failure in male
\nmice allowing for easier detection of pharma-
\nceutical e\ufb00ects. Young male mice often have
\nmore severe outcome than female mice with
\nmyocardial infarction (MI) or heart failure for
\nyet unknown reasons. In addition, the greater
\nbiological variability in females due to their
\ncycling makes it more di\ufb03cult to detect ef-
\nfects and more female animals are needed for
\nbreeding than males. Lethality of male mice
\nafter MI in general is about 60%, whereas
\nit\u2019s only 20% in female mice. Consequently,
\na drug that improves mortality by 30% has
\na major e\ufb00ect in male mice. This same drug
\nmay have no e\ufb00ect or a very small, non sig-
\nni\ufb01cant e\ufb00ect on female mice. Unfortunately,
\nthis substance, which is only e\ufb00ective in male
\nmice,is then frequently developed into a drug
\nthat is used to treat women as well as men.
\nSimilar relations are found in heart failure.
\nOf about 20 transgenic animal models that
\nexhibit heart failure, 18 exhibit a more severe
\nphenotype in males and only 2 a more severe
\nphenotype in females. Frequently male mice
\nare dying whereas female mice don\u2019t exhibit a
\nphenotype. Again, drugs are then developed
\nto treat the disease of male mice and are even-
\ntually sold for female and male patients [11].
\nMeasures
\nAre there any measures that can be under-
\ntaken to improve this situation? The Institute
\nfor Gender in Medicine aims at establishing
\na database collecting all relevant data on sex
\ndi\ufb00erences in drug therapy that will be pub-
\nlicly accessible. This database will be based
\non very systematic literature searches using
\nstandardised text mining procedures. Fur-
\nther,medical quality circles are rising that are
\nconsidering gender aspects.The Internation-
\nal Society of Gender Medicine is involved in
\nanalysing sex di\ufb00erences in drug e\ufb00ects and
\nside e\ufb00ects. Most importantly a number of
\nUniversities in Europe have started to devel-
\nop curricula for Gender Medicine including
\nTable 2.
\nSex di\ufb00erences in cardiovascular drug therapy
\nDrug Sex di\ufb00erences Reference
\nBeta-blocker Higher plasma levels, in some cases higher e\ufb00ect
\non female patients
\n10
\nACE inhibitor
\nAngiotensin Receptor
\nBlocker
\nMore side-e\ufb00ects in women 10
\nDigitalis Higher lethality in female patients, most likely
\ndue to dosage
\n4,5
\nDiuretics No reliable data on sex di\ufb00erences 11
\nAcetylsalicylic Acid Sex di\ufb00erences in primary prevention of Myocar-
\ndial infarction and stroke
\n14
\nGlycoprotein IIb\/IIIa
\nAntagonists
\nMore bleeding in women, most likely due to
\ndosage
\n15
\nAntiarrhythmic Agents More severe arrhythmia with QT-prolonging
\ndrugs
\n17,18,19
\n17
\nGender di\ufb00erences in pharmacotherapy.This
\nwill hopefully increase awareness of patients
\nand doctors and lead to better treatment of
\nwomen and men.
\nAcknowledgement:
\nWe greatly appreciate the secretarial help of
\nStefanie Roehner.
\nGrant support:
\nThe Institute of Gender in Medicine is
\nsupported by grants from the EU, BMBF,
\nDFG and Magarethe-Ammon-Stiftung.
\nCon\ufb02ict of interest: The authors have no
\ncon\ufb02ict of interest to declare.
\nReferences
\n1. Gandhi M, Aweeka F, Greenblatt RM, Blaschke
\nTF. Sex di\ufb00erences in pharmacokinetics and phar-
\nmacodynamics. Annu Rev Pharmacol Toxicol
\n2004;44:499-523.
\n2. Anderson GD. Sex and racial di\ufb00erences in phar-
\nmacological response: where is the evidence? Pharma-
\ncogenetics, pharmacokinetics, and pharmacodynam-
\nics. J Womens Health (Larchmt) 2005;14(1):19-29.
\n3. Franconi F, Brunelleschi S, Steardo L, Cuomo V.
\nGender di\ufb00erences in drug responses. Pharmacol Res
\n2007;55(2):81-95.
\n4. Rathore SS, Curtis JP, Wang Y, Bristow MR,
\nKrumholz HM. Association of serum digoxin
\nconcentration and outcomes in patients with heart
\nfailure. Jama 2003;289(7):871-8.
\n5. Rathore SS, Wang Y, Krumholz HM. Sex-based
\ndi\ufb00erences in the e\ufb00ect of digoxin for the treatment
\nof heart failure. N Engl J Med 2002;347(18):1403-
\n11.
\n6. Kendall MJ, Quarterman CP, Jack DB, Beeley L.
\nMetoprolol pharmacokinetics and the oral contracep-
\ntive pill. Br J Clin Pharmacol 1982;14(1):120-2.
\n7.Walle T,Walle K,Mathur RS,Palesch YY,Conradi
\nEC. Propranolol metabolism in normal subjects: as-
\nsociation with sex steroid hormones. Clin Pharmacol
\nTher 1994;56(2):127-32.
\n8. Ghali JK, Pina IL, Gottlieb SS, Deedwania PC,
\nWikstrand JC.Metoprolol CR\/XL in female patients
\nwith heart failure: analysis of the experience in Meto-
\nprolol Extended-Release Randomized Intervention
\nTrial in Heart Failure (MERIT-HF). Circulation
\n2002;105(13):1585-91.
\n9. Simon T, Mary-Krause M, Funck-Brentano C,
\nJaillon P. Sex di\ufb00erences in the prognosis of conges-
\ntive heart failure: results from the Cardiac Insuf-
\n\ufb01ciency Bisoprolol Study (CIBIS II). Circulation
\n2001;103(3):375-80.
\n10. Regitz-Zagrosek V, Lehmkuhl E, Lehmkuhl HB,
\nHetzer R.Gender aspects in heart failure.Pathophys-
\niology and medical therapy. Arch Mal Coeur Vaiss
\n2004;97(9):899-908.
\n11. Regitz-Zagrosek V. Therapeutic implications of
\nthe gender-speci\ufb01c aspects of cardiovascular disease.
\nNat Rev Drug Discov 2006;5(5):425-38.
\n12.Wing LM, Reid CM, Ryan P, et al. A comparison
\nof outcomes with angiotensin-converting–enzyme
\ninhibitors and diuretics for hypertension in the el-
\nderly. N Engl J Med 2003;348(7):583-92.
\n13. Pitt B, Zannad F, Remme WJ, et al. The e\ufb00ect
\nof spironolactone on morbidity and mortality in pa-
\ntients with severe heart failure. Randomized Aldac-
\ntone Evaluation Study Investigators. N Engl J Med
\n1999;341(10):709-17.
\n14. Ridker PM, Cook NR, Lee IM, et al. A random-
\nized trial of low-dose aspirin in the primary preven-
\ntion of cardiovascular disease in women. N Engl J
\nMed 2005;352(13):1293-304.
\n15. Alexander KP, Chen AY, Newby LK, et al. Sex
\ndi\ufb00erences in major bleeding with glycoprotein IIb\/
\nIIIa inhibitors: results from the CRUSADE (Can
\nRapid risk strati\ufb01cation of Unstable angina patients
\nSuppress ADverse outcomes with Early implementa-
\ntion of the ACC\/AHA guidelines) initiative.Circula-
\ntion 2006;114(13):1380-7.
\n16. Humphries KH, Kerr CR, Connolly SJ, et al.
\nNew-onset atrial \ufb01brillation: sex di\ufb00erences in pre-
\nsentation, treatment, and outcome. Circulation
\n2001;103(19):2365-70.
\n17. Drici MD, Knollmann BC, Wang WX, Woosley
\nRL. Cardiac actions of erythromycin: in\ufb02uence of fe-
\nmale sex. Jama 1998;280(20):1774-6.
\n18. Makkar RR, Fromm BS, Steinman RT, Meissner
\nMD, Lehmann MH. Female gender as a risk factor
\nfor torsades de pointes associated with cardiovascular
\ndrugs. Jama 1993;270(21):2590-7.
\n19. Anthony M. Male\/female di\ufb00erences in phar-
\nmacology: safety issues with QT-prolonging drugs.
\nJ Womens Health (Larchmt) 2005;14(1):47-52.
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nLouis M. Guenin is Lecturer on Ethics in Sci-
\nence, Department of Microbiology and Mo-
\nlecular Genetics, Harvard Medical School. His
\nrecent book The Morality of Embryo Use
\n(Cambridge University Press, 2008) explores
\nethical and metaphysical issues pertaining to
\nembryonic stem cell research and the forma-
\ntion of consensus across diverse views. He has
\nserved as co-chair of the Ethics Committee, In-
\nternational Society for Stem Cell Research.
\nOn occasion, discretionary actions preclude
\ntransfer of extracorporeal embryos into the
\nwomb. Such actions constitute an overlooked
\nand crucial ground for the moral justi\ufb01cation
\nof embryo use in regenerative medicine.
\nIn the \ufb01rst instance, we encounter the
\nsituation, which often arises with fertility
\npatients, in which the one person in the
\nworld who, together with the coprogenitor,
\nis empowered to decide about intrauterine
\ntransfer of an embryo formed from her oo-
\ncyte decides that neither does she wish to
\nbear the embryo, nor does she wish to give
\nit to anyone else. Whereupon she and the
\ncoprogenitor may decide to donate the em-
\nbryo to medical research and therapy. In
\nthe second case, embryos may originate in
\nresearch from cells donated to medicine for
\nthat purpose.
\nIf progenitors,while fully-informed and act-
\ning of their own volition, donate an embryo,
\neither before or after the embryo\u2019s creation,
\non the condition that the embryo shall be
\nused in medical research and therapy, and
\nmay never be transferred into a uterus, such
\nembryo constitutes what I have called an
\n\u201cepidosembryo.\u201d1
\nI have taken this name
\nfrom the Greek epidosis for a citizen\u2019s be-
\nne\ufb01cence to the common weal.
\nAs a moral justi\ufb01cation for the use of epi-
\ndosembryos in accordance with donor in-
\nstructions, I have o\ufb00ered the \u201cargument
\n1 \u201cMorals and Primordials,\u201dScience 292: 1659-1660
\n(2001).
\nThe following article is reprinted below in its complete form as unfortunately part of it was omitted in WMJ(54)4. ED
\nBuilding a Consensus in Regenerative
\nMedicine
\n18
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nfrom nonenablement.\u201d 2
\nThis proceeds as
\nfollows. A woman does not have a duty to
\nundergo a transfer into her of an embryo
\nlying outside her. There does not obtain a
\nduty of intrauterine embryo transfer into
\noneself. We, most of us, regard the decision
\nto undergo such a medical procedure as re-
\nserved to a woman\u2019s autonomous discretion.
\nA separate question is whether a woman
\nand the coprogenitor lie under a duty to
\nsurrender for adoption any embryo that she
\ndeclines to bear. Imposition of such a duty
\nwould likely present such adverse incentives
\nand consequences for fertility patients, in-
\ncluding compelled remote parenthood, that
\nwe are hard pressed to \ufb01nd any moral view
\nthat would support such imposition. For
\nreasons developed in the full account of this
\nargument, the decision whether to surren-
\nder an embryo for adoption also lies within
\nprogenitor discretion.
\nSuppose, then, that a woman forbids intra-
\nuterine transfer of an embryo. She, with the
\ncoprogenitor, donates to medicine either
\nan epidosembryo created during her fertil-
\nity treatment, or an epidosembryo that will
\nbe created by a scientist from their donated
\ncells. This decision is \ufb01nal. The epidosem-
\nbryo has left progenitor control. A distinc-
\ntion now obtains between the developmen-
\ntal potential of this epidosembryo, lying in
\na petri dish where it will remain, and an
\nembryo that lies in a uterus, however it got
\nthere. In consequence of the prohibition
\non intrauterine transfer, the epidosembryo
\nwill not complete gastrulation. If not ear-
\nlier sacri\ufb01ced, the epidosembryo will begin
\nto disintegrate by about day 10. During its
\nremaining life,it cannot acquire any morally
\nsigni\ufb01cant property that it does not already
\npossess. To put the matter in language that
\nI owe to Richard Hare,3
\nno possible person
\ncorresponds to an epidosembryo. We also
\nknow that no embryo is sentient. It can
\nneither form preferences nor adopt ends.
\nNothing that we might do concerning it
\ncan cause it discomfort or frustrate it. We
\n2 The Morality of Embryo Use (Cambridge Univer-
\nsity Press, 2008).
\n3 Richard M. Hare, Essays on Bioethics (Oxford:
\nClarendon Press, 1993).
\ncannot gain anything\u2014neither for it nor for
\nany other being\u2014by classifying it as a per-
\nson for purposes of the duty not to harm.
\nBy forgoing its use in research, we could
\nonly assure that the epidosembryo dies in
\nvain. Scientists maintain the reasonable,
\nthough not certain, belief that embryo ex-
\nperimentation could contribute to the relief
\nof human su\ufb00ering. Use of donated embry-
\nos remains crucial in research even as tech-
\nniques develop for reprogramming somatic
\ncells into pluripotent or specialized cells.
\nEmbryonic stem cell research has been the
\nfountainhead of emerging knowledge of re-
\nprogramming, and the embryonic stem cell
\nremains the gold standard of pluripotency.
\nIn this situation, the duty of mutual aid\u2014
\nthe duty, recognized across moral views, to
\naid those in need when one may do so with-
\nout imposing an unreasonable burden\u2014
\nbids us undertake such research. Hence not
\nonly is it permissible to use epidosembryos
\nin medicine, but to do so will help to ful\ufb01ll
\na collective duty.
\nAccording to this argument, the permissi-
\nbility and virtuousness of epidosembryo use
\nrests on the autonomous decisions of people
\nfrom whose cells such embryos originate.
\nThe moral analysis \ufb02ows entirely from what
\nit is that they decide. Developmental po-
\ntential matters, but it is human decisions
\nthat determine its situation-dependent ex-
\ntent. If it is permissible for progenitors to
\ndonate epidosembryos,then it is permissible
\nfor recipient scientists to use the donations
\nas instructed.
\nSome discussants seem to suppose that the
\njusti\ufb01cation of embryonic stem cell research
\nlies in the circumstance that the embryos
\ndonated were created with procreative in-
\ntent. The argument from nonenablement
\ndoes not invoke procreative intent. The
\nargument applies to any donated embryo,
\nwhether left over from an attempt at preg-
\nnancy, or created in experiment. The use
\nof surplus embryos and the nonprocreative
\nformation of embryos by fertilization, non-
\nreprocloning, and parthenogenesis rest on
\none and the same moral ground.
\nThe argument from nonenablement is a
\nconsensus argument insofar as it does not
\ninvoke any premise peculiar to one or an-
\nother moral or religious view. The bounded
\ndevelopmental potential of an embryo in the
\ndish is a biological circumstance. The duty
\nof bene\ufb01cence and respect for the discre-
\ntion of persons to elect whether they shall
\nundergo medical procedures are common to
\nall leading moral and religious views. Some
\nform of the Golden Rule is found in virtu-
\nally every major moral and religious view
\nsince Confucius.
\nIn this analysis, I accord a wide berth to re-
\nligious views across diverse cultures, provid-
\ned only that when moral verdicts are urged
\non religious grounds, support for them can
\nbe given on the basis of reasonable non-
\nreligious premises. As we all know, many
\nreligious believers condemn the sacri\ufb01ce of
\nembryonic lives in aid of other lives. Hence
\na further task presents itself. It remains to
\nbe shown, if it can be, that if the argument
\nfrom nonenablement is introduced in the
\ncourse of sympathetically reinterpreting
\none or more views presumptively opposed
\nto all embryo use, such views will issue in
\napproval for epidosembryo use. I illustrate
\nhow that task may be accomplished as to
\nthe most in\ufb02uential presumptively contrary
\nview, the magisterium of the Roman Cath-
\nolic Church.
\nIn condemning all manner of embryo de-
\nstruction, the Catholic magisterium speaks
\nconsistently. Just as it condemns destruc-
\ntion of embryos as research subjects, it con-
\ndemns the practice of assisted reproduction
\nbecause that practice brings about destruc-
\ntion of surplus embryos. (Other discussants
\nwho approve in vitro fertilization as prac-
\nticed, but oppose embryo use in research
\nfall into inconsistency: they condone de-
\nstruction of surplus embryos as waste, but
\ncondemn sacri\ufb01ce of surplus embryos for
\nbene\ufb01cent ends.) On what ground does
\nthe magisterium\u2019s condemnation of embryo
\nsacri\ufb01ce rest?
\nOne will often hear it asserted that an em-
\nbryo is a person and that killing a person
\n19
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nis murder. To say that a being is a person
\nis to recite the conclusion that the being
\nfalls within the category of beings protected
\nby the duty not to harm. It remains to ask
\nwhat reasoning supports that conclusion.
\nConceding that the Bible does not assert
\npersonhood of an extracorporeal embryo\u2014
\nin antiquity, people did not even know that
\nthere existed oocytes, hence never thought
\nabout embryos outside the body\u2014the
\nmagisterium allows that personhood of an
\nembryo is a philosophical question.4
\nCon-
\ncerning this, the magisterium\u2019s argument in
\nchief is the following: fertilization creates a
\nnew genome, therefore fertilization creates
\na person. This argument\u2019s premise is true\u2014
\nfertilization produces a new genome\u2014but
\nthe conclusion doesn\u2019t follow. To identify a
\nperson with a genome is to practice genetic
\nreductionism with a vengeance. That view
\ncontradicts the bedrock belief that a person
\nis a corpore et anima unus, a union of body
\nand soul. On pain of internal contradiction,
\nthe argument cannot stand.
\nA defender of zygotic personhood might
\nplead that precisely because embryos cannot
\nform preferences, it is our obligation to act
\naccording to their advantage, hence to clas-
\nsify them as persons. But we cannot foster
\nany advantage of epidosembryos. Entry
\ninto the only kind of environment by which
\nthey could attain the ability to experience
\nbene\ufb01t has been forbidden by the only per-
\nsons in the world empowered to decide such
\nmatters. It is from this recognition that the
\nargument from nonenablement builds a
\nprima facie justi\ufb01cation within Catholicism,
\nas within other views,for epidosembryo use.
\nIs there a countervailing argument?
\nOne argument is that if we do not know
\nwhether an embryo is a person in God\u2019s
\neyes, we should exercise caution and act as
\nif it were. But from within a view hold-
\ning that divine will is the arbiter of morality,
\nsuppose that we could have a conversation
\nwith God. We report that in 1998, we dis-
\n4 Sacred Congregation for the Doctrine of the
\nFaith, Declaration on Procured Abortion (Vatican
\nCity: The Holy See, 1974), and Donum Vitae (Vati-
\ncan City: The Holy See, 1987).
\ncovered how to culture human embryonic
\nstem cells. We describe hopes of relieving
\nhuman su\ufb00ering by using embryos that will
\nnever enter a womb. Is it plausible that He
\nwould tell us that He regards such embryos
\nas persons in the sense that He includes
\nthem in a universe of beings that He never
\nwishes us to use as means? I do not know
\nof a tenable argument according to which
\nan all-merciful and omniscient God would
\nassert that preference. He would know that
\nunenabled embryos would never become
\nsentient if not used in research.
\nAn objection peculiar to nonreprocloning
\nmight be this. An oocyte is created for a
\npurpose, namely to issue in o\ufb00spring, and
\nit is wrong to divert an oocyte to any other
\npurpose. This objection presupposes with
\nAristotle that everything has a \ufb01xed pur-
\npose and that we know what it is. After
\nDarwin, that notion has lost its grip on our
\nthought. We have learned from the history
\nof medicine how mistaken we humans have
\noften been in inferring purposes of various
\ncells and structures of the body. Our for-
\nbears would have said that bones are what
\nhold us up; today we think of the marrow
\nas a blood factory. We think it appropri-
\nate to transfer marrow from one patient to
\nanother. We know that many cells perform
\nmultiple functions, and we are learning to
\nredirect proteins and cellular processes to
\nserve chosen ends. It seems arbitrary to say
\nthat an oocyte can or should serve only one
\npurpose. Such a rule would seem puzzling
\ninsofar as every human female possesses
\nfrom birth a quarter million or more oo-
\ncytes.
\nTurning to public policy, we observe that
\nthere obtains no practical scheme by which
\na government may fund use of embryonic
\nderivatives without complicity in their
\nderivation. Downstream demand induces
\nsupply, and complicity transmits through
\nthe channel of inducement. Our collective
\ndeliberations would bene\ufb01t from moral rea-
\nsoning generally overlooked in the policy
\narena. That is the reasoning adduced in the
\nargument from nonenablement beginning
\nwith the premises that intrauterine embryo
\ntransfer is discretionary and that when pro-
\ngenitors forbid such transfer, developmental
\npotential is permissibly bounded. The key
\nto assuring that legislation endorses morally
\npermissible activity is what it says about pro-
\ngenitors. Progenitors possess unique power:
\neach is the only person in the world (with
\nthe coprogenitor) privileged to decide what
\nwill happen to an embryo. It is because a
\nprogenitor-donor decides that an embryo
\nwill never enter a uterus that a donee may
\nexperiment on it.
\nHence the most compelling justi\ufb01cation
\nfor a donee in performing experiments, and
\nfor a legislature in endorsing experiments,
\nconsists in the donee\u2019s \ufb01delity to permis-
\nsible donative instructions bounding poten-
\ntial. This bring us to the following public
\npolicy:
\nThe government shall support biomedical
\nresearch using human embryos that, before
\nor after formation, have been donated to
\nmedicine under donor instructions forbid-
\nding intrauterine transfer.
\nThis policy wears its moral justi\ufb01cation on
\nits sleeve. That attribute avails for public
\ndiscussion. There the policy may be de-
\nscribed as one that assures that the scope
\nof the publicly-supported is congruent with
\nthe scope of the morally permissible.
\nThere arise various other ethical questions
\nabout embryo use, including fair compen-
\nsation to oocyte contributors, and the for-
\nmation of hybrids and chimeras. In the
\nforegoing, we have canvassed a ground for
\nconsensus on the most fundamental ques-
\ntion.
\n20
\nIntroduction
\nOne of the most widespread beliefs in the
\nmedical community is that smoking is a
\nhabit of personal choice, and quitting does
\nnot require professional help [1]. To quit
\nor not is solely determined by the smoker\u2019s
\nwill power [1,2]. These beliefs by majority
\nof physicians are also shared by smokers
\n[3],and have evolved to form the stumbling
\nblock in our e\ufb00orts to mitigate one of the
\nmost harmful and most preventable health
\nissues worldwide: cigarette smoking.
\nIn forming these beliefs, or mis-beliefs, phy-
\nsicians failed to recognise two important as-
\npects of evidence: (A) \u201cSmoking is a chronic
\naddictive disease\u201d [4,5], and as a highly ad-
\ndictive disease, medical assistance is not just
\nhighly desirable,but absolutely necessary [2].
\n(B) Smokers take their physician\u2019s advice
\nto heart [2,6,7]. Physicians, by wearing the
\nwhite gown with the aura of authority, have
\nthe magic to break the inertia or the disin-
\nterest of smokers [8]. Doctors did not realise
\nthat not only it is their job as care givers, but
\nalso they had the unique magic touch in mo-
\ntivating smokers to quit. Asian patients visit
\ntheir doctors 14 times a year [9], providing
\nnumerous opportunities and perfect mo-
\nments for repeated interventions.
\nIndividual physicians\u2019 view and WMA or-
\nganisational policy position
\nIn a survey conducted by Harris International
\npolling agency of both physicians and smok-
\ners in 16 countries [3],the majority of physi-
\ncians ranked smoking as the most harmful
\nbehaviour globally, outranking obesity, inac-
\ntivity,or poor diet.[The 16 countries surveyed
\nincluded 11 countries from Europe (France,
\nGermany,Greece,Italy,Netherlands,Poland,
\nSpain, Sweden, Switzerland [physician sur-
\nvey only],Turkey,and UK),one from Central
\nAmerica (Mexico),two from North America
\n(Canada and USA), and two from East Asia
\n(Japan and South Korea). Globally, a total of
\n3760 smokers and 2836 physicians were sur-
\nveyed [3]]. However, when physicians were
\nasked as to whether they wanted to help the
\nsmokers to quit, the majority indicated they
\nhad more important things to do and had no
\ntime for smoking cessation. This contradic-
\ntory phenomenon was observed worldwide,
\nin North America, in Europe and in Asia. In
\naddition,this dilemma faced by the individu-
\nals was quite di\ufb00erent in respect of their or-
\nganisational position. As far back as in 1988,
\nthe World Medical Association (WMA) ad-
\nopted a policy statement [10] urging all na-
\ntional medical associations to establish a pol-
\nicy position opposing smoking and the use
\nof tobacco products, and publicise the anti-
\nsmoking policy so adopted. In other words,
\nphysicians worldwide and their national or-
\nganisations are fully aware of the harm from
\nconsuming tobacco, but individual physi-
\ncians do not behave accordingly,despite their
\nstrong belief to the contrary.Obviously,there
\nis a large the perceptional gap and the gap is
\nuniversally observed, and physicians are not
\nbehaving as they should. Why? It is because
\nthere are barriers that seem insurmountable.
\nWhat are the barriers, and can existing bar-
\nriers be overcome? That is the current chal-
\nlenge faced by physicians. The following is
\na summary of the ten most prevalent barri-
\ners to cessation and, by proposing solutions
\nto overcome them, these perceived barriers
\ncould be solved and these seeming \u201cbarriers\u201d
\nwould just become myths.
\nBarriers to cessation
\nThe followings are the ten barriers to cessa-
\ntion perceived by physicians. The proposed
\nsolutions, when internalised by physicians,
\nwould eliminate them:
\n(1) No time: The most common reason for
\nphysicians not to engage in smoking cessa-
\ntion is lack of time [11,12]. Surveys found
\ncontradictory statements by physicians: On
\nthe one hand three quarters of physicians
\nindicate the most harmful behaviour was
\nsmoking, among the four most commonly
\ncited behaviours: smoking, inactivity, obe-
\nsity and poor dietary habits. On the other
\nhand, 75% of physicians worldwide indicate
\nsuch feelings as \u201cI have more important
\nthings to do\u201d as I do not have time for ces-
\nsation based on survey [3]. Smoking cessa-
\ntion takes time.
\nSolution: Not every doctor has to become
\na cessation specialist. There should be ces-
\nsation specialists available. If the individual
\ndoctor believes cessation is important,we all
\nagree that it takes very little time to refer to
\nthe cessation team available in most hospi-
\ntals.This may take from 30 seconds to 5-10
\nminutes, and most doctors should have the
\ntime to do this. In fact,\u201cask, advise and refer
\n(2A\u2019s + R)\u201dis all we need.It takes 30 seconds
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nBarriers to Smoking Cessation:
\nAre they really insurmountable?
\nChi Pang Wen, MD, Dr. PH; Min Kuang Tsai, MPH (National Health Research Institutes,
\nZhunan, Taiwan); Yung Tung Wu, MD, PhD (Past-President of Taiwan Medical Association)
\n21
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nto intervene. Let us tell all physicians to re-
\nmember 2A\u2019s + R in smoking cessation.
\n(2) No skills: Whether the doctors realise
\nor not, the reality is that smoking cessa-
\ntion was rarely taught in the medical school
\nyears and the majority of physicians did not
\nreceive much training after medical schools
\n[3]. Doctors are not interested in smoking
\ncessation and therefore not motivated to
\nlearn as a new skill.
\nSolution\u2022 : As much as not every doctor
\nneeds to become a cessation specialist,the
\nattitude toward smoking cessation will be
\nmore important than the technical skill
\nof cessation per se. The skill to refer can
\nbe learned relatively easy, as long as the
\ndoctor\u2019s attitude is positively favourable.
\nWhether the doctor is committed to the
\nimportance of smoking hazards, his body
\nlanguage will be fully revealed in making
\nthe referral.
\n(3) No money: Smoking cessation is very
\ntime consuming for the doctors, and yet few
\nhealth insurances would reimburse such
\nservices, including many Asian countries.
\nTo view smoking cessation as free services
\nis not placing its value in the right spot or
\nmaking it a sustaining e\ufb00ort
\nSolution\u2022 : The reward for successful cessa-
\ntion could be far more precious and long
\nlasting than \ufb01nancial terms. Cessation
\ngives the smoker a new and healthy life
\nfor him and his family that money cannot
\nbuy. Of the tens of thousands of patients
\na doctor has treated in his long career,
\nfew patients would remember the contri-
\nbution by the doctor after ten or \ufb01fteen
\nyears. One exception is the smoker who
\nwas talked into quitting and succeeded
\nin quitting. Most smokers are so grate-
\nful that they will remember the turning
\npoint when decisive action was taken by
\nthe doctor.
\n(4) No interest from smokers [12,14]:
\nSmoking patients visit the doctors for medi-
\ncal complaints such as diabetes or hyperten-
\nsion and not for smoking. It is just natural
\nfor patients to be more concerned with their
\nchief complaints than other issues.
\nSolution 1\u2022 : The most important reason
\nfor smokers to quit worldwide has been
\nhealth concerns, and most smokers are
\nnot interested in quitting because they feel
\n\ufb01ne health-wise. The self reported health
\nof smokers showed that majority felt they
\nwere in excellent health [15]. However,
\nthis is deceptive feeling,as within the next
\nten years, those who feel good or average
\nhad doubled their mortality risks of their
\nnon-smoking counterparts. The evidence
\nis against the smokers.
\nSolution 2\u2022 : On the website of Philip
\nMorris [16], the international tobac-
\nco giant advised smokers that tobacco
\ncompany agrees with the overwhelming
\nmedical and scienti\ufb01c consensus that
\ncigarette smoking is \u201caddictive\u201d, mak-
\ning it very di\ufb03cult to quit and \u201ccigarette
\nsmoking causes lung cancer, heart disease,
\nemphysema and other serious diseases in
\nsmokers. Smokers are far more likely to
\ndevelop serious diseases, like lung cancer,
\nthan non-smokers [2]. There is no safe
\ncigarette.\u201d Let smokers \ufb01nd out these
\nstatements from the manufactures of
\ncigarettes.
\nSolution 3\u2022 : The advice from tobacco
\nmanufacturer: \u201cThe best thing to do for
\nsmokers is to quit.\u201d (Philip Morris web-
\nsite) Even the manufactures asked the
\nuser not to use their products. What an
\nirony!
\n(5) No more: Doctors feel as long as they
\nhad advised smoking patients once, that
\nwould be su\ufb03cient and do not need more
\nthan that. They are concerned that \u201cnag-
\nging\u201d or repeated reminding, would scare
\naway patients.
\nSolution\u2022 : The global survey [3] revealed
\nthat when physicians were interviewed,
\n75% of them indicated they discussed
\nsmoking with their smoking patients,
\nbut when smokers were interviewed only
\n20% recalled such encounters. This dis-
\ncrepancy re\ufb02ects a major communication
\ngap between the doctors and the smokers.
\nPart of the solution to bridge the gap is
\nfor the doctors to repeat the message in
\nevery visit, and not limited to one visit.
\n(6) No connection: Smoking cessation is
\nnot connected with the chief complaints
\nclinics by the patients,and to bring up smok-
\ning seems to be an entirely di\ufb00erent subject.
\nWhen pressed for time, it is di\ufb03cult to initi-
\nate a new conversation on a di\ufb00erent issue.
\nSolution\u2022 : As patients are interested in the
\nprogress of diabetes or hypertension, they
\nare interested in following their blood
\nglucose and blood pressure. For this, the
\nglucose equivalent of smoking and blood
\npressure equivalent of smoking will help
\ndoctor to talk to their patients. Smoking
\ncessation is equivalent to a reduction of 40
\nmg\/dl of fasting blood glucose [17] or to
\na reduction of 40 mmHg of systolic blood
\npressure[18] (shown in the accompanying
\n\ufb01gures). While some medications might
\nbe able to achieve such a signi\ufb01cant drop
\nin blood sugar or blood pressure, but they
\nare e\ufb00ective only during the time when
\nmedications are taken, and most medica-
\ntions have short term and long term side
\ne\ufb00ects. Smoking cessation provides a life
\nlong reduction of these parameters.
\nResults showed that the addition of smok-
\ning was equivalent to an increase of mortal-
\nity risk approximating a 41 mg\/dL increase
\nin blood pressure [17].
\nResults showed that the addition of smok-
\ning was equivalent to an increase of mortal-
\nity risk approximating a 40 mmHg increase
\nin blood pressure [18].
\n(7) No alternative: Cigarettes acted as the
\nbest friend,with intimate contact 20 times a
\nday (one pack) 365 days a year. Such an in-
\ntimate contact was more than any member
\nFigure1.Comparison of relative risks between
\nsmokers and non-smokers by fasting blood glu-
\ncose for all cause mortality.
\nFasting Blood Glucose (mg\/dL)
\nRealtiveRisk
\n22
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nof his family. How could someone separate
\nrelationship with such a best friend with-
\nout any alternative? For a young man to say
\ngoodbye to his girl friend of more than ten
\nyears will be extremely di\ufb03cult. Even if he
\ndecided to do so, he would miss her day and
\nnight, struggling emotionally. He wished, at
\nany moment, to see her and make up again.
\nSolution\u2022 : The only way to separate with
\nhis girl friend successfully is to cultivate
\nanother girl friend before separation is
\nto take e\ufb00ect. The analogy in this case
\nfor separating with cigarettes is to culti-
\nvate the love for physical activity: walk-
\ning, running, sports, climbing or going to
\nthe gym. In comparing and analysing the
\ncaloric expenditure between smokers and
\nnon-smokers, we found, as shown in the
\ntable,that ex-smokers had twice the levels
\nof exercise as smokers. This implied that
\neither through picking up exercise the
\nsmokers quit smoking or smokers start to
\nexercise after quitting.
\nTable 1.
\nExercise levels by smoking status in Tai-
\nwan [19].
\n>750
\nKcal\/
\nWeek
\n>1,000
\nKcal\/
\nWeek
\n>2,000
\nKcal\/
\nWeek
\nNon-smoker 19.6% 14.3% 4.5%
\nSmoker 15.1% 11.1% 4.4%
\nEx-Smoker 31.8% 25.4% 11.6%
\nEx-smokers doubled their activity levels
\n(8) No e\ufb00ect: Cessation treatment is not
\nfail-proof, having only one or two successes
\nin ten attempts, even with the availability of
\nthe most recent medication like Varenicline
\n[20]. In other words, failure is the rule and
\nsuccess from quitting attempts is an excep-
\ntion or a miracle.
\nSolution\u2022 : The success rate noted above is
\nde\ufb01ned as one year from treatment. The
\nrate quitting within 2-3 months of treat-
\nment was nearly 60% [21]. What hap-
\npened after that and why the decline? One
\nreason was the lack of intensive follow up
\nafter the \ufb01rst few weeks when intensive
\ncare was invariably provided. The quit-
\nters were very vulnerable and should be
\ngiven all the TLC (Tender Loving Care)
\nfrom the health care team and from their
\nfriends and families, particularly when
\nthey were struggling to quit.
\n(9) No reminder: During clinical encoun-
\nters with smoking patients, physicians fo-
\ncused on the medical problem and in many
\ninstances failed to note the smoking status
\nof the patients.This is also true for inpatient
\ncare.
\nSolution 1\u2022 : The entire medical group, in-
\ncluding the hospital administrator and
\nmedical director, should all agree with
\nthe importance of this issue and set up a
\nseries of support system. For reminder, a
\nred tag, a computer prompt, or smoking
\nstatus being included as part of the vital
\nsigns can all be instituted. A cessation
\nteam should be available and referral can
\nbe conveniently made and intensive fol-
\nlow up will be carried out. .
\nSolution 2\u2022 : Tobacco company stated in
\ntheir website that \u201csecond-hand smoke
\nfrom cigarettes causes disease, including
\nlung cancer and heart disease, in non-
\nsmoking adults, as well as causes condi-
\ntions in children such as asthma, respi-
\nratory infections, cough, wheeze, otitis
\nmedia (middle ear infection) and Sud-
\nden Infant Death Syndrome\u201d [22]. This
\nshould be posted in the examining room
\nand in the corridor.
\n(10) No environmental support: With
\nlimited legal restrictions on second hand
\nsmoking, low cigarette price, or no reim-
\nbursement for cessation services, the hostile
\nenvironment will be barriers for cessation
\nservices.
\nSolution:
\nPhysicians become advocates of tobacco
\ncontrol in the society and let the public
\nknow their stance. Examples of issues
\ninclude:
\nIncrease in cigarette price [23].
\nThis has been proven to curb youth\u2022
\nsmoking. Smoking rates will de-
\ncrease,\ufb01rst among the poorer smok-
\ners and then followed by the rest, if
\nthe increase is su\ufb03ciently large. For
\n10% increase in price, there will be
\na 8% reduction in youth smoking
\nand 4% reduction in adult smoking
\nrates [24].
\nExperience in France showed a re-\u2022
\nduction of 1.5 million smokers in 2
\nyears after the price increase [25].
\nThe added revenue can be tapped\u2022
\nfor mounting more tobacco control
\nprograms [26].
\nSmoke free home when there are
\nsmall children or pregnant women at
\nhome
\nThis has been proven to reduce\u2022
\nheart attacks and emergency visits
\nFree cessation services for all smokers
\nWith tax increase, it is just natural\u2022
\nto return the money to the smokers,
\nso that next increase will be sup-
\nported by them.
\nFigure 2. Comparison of relative risks between smokers and non-smokers by systolic blood pressure
\nfor all cause mortality.
\n23
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nPhysicians become more involved with
\nnational policy setting on tobacco con-
\ntrol.
\nThis has the policy statement of
\nWorld Medical Association.
\nMedical societies issue position state-
\nment on smoking and smoking cessa-
\ntion
\nHospitals become exemplary institution
\nin tobacco control by setting up \u201cNo
\nsmoking policy for the hospitals\u201d and
\nby voicing out loud on the hazards of
\nsmoking and the availability of cessation
\ninside the hospitals. Inpatients are more
\nopen for cessation, as they su\ufb00er from
\nmore serious medical conditions.
\nPhysicians who share similar concerns on
\ntobacco control form alliances for tobacco
\ncontrol. They can make their views known
\nto the public, such as tax increases or reim-
\nbursement for cessation services.
\nUnless we do things di\ufb00erently, quickly
\nand e\ufb00ectively, this coming 21st
\ncentury
\nwill see 1 billion deaths from tobacco [23].
\nJust imagine every single day, the number
\npeople dying from tobacco is equivalent
\nto 5 times the number of deaths occurred
\nin 9\/11 tragedies in 2001. In other words,
\n9\/11 is happening every 5 hours. Among all
\nthe care and \u201ctreatment\u201d o\ufb00ered by a physi-
\ncian, including counselling, doing a physi-
\ncal, giving out prescriptions, or ordering lab
\ntests, there is nothing more important and
\ncould have more health impact than help-
\ning smokers quit. Most everyday interven-
\ntions are \u201cband-aid relief \u201d for symptoms to
\nmake patients happier, but helping smok-
\ners quit is to make them \u201chealthier\u201d. While
\nmaking them happier is important, physi-
\ncians should focus on more important goal,
\n\u201cHealthier\u201d.
\nConclusion
\nIn summary, the physicians\u2019 attitude toward
\nsmoking is the turning point, rather than
\nthe skill. Making smokers quit will be the
\nmost rewarding activities for physicians.
\nAsk, advise and refer (2A\u2019s + R), and it takes
\nonly 30 seconds to intervene. Overcom-
\ning 10 excuses, by changing ten No\u2019s to ten
\nYeses, will make the seemingly di\ufb03cult task
\none of the most valuable and meaningful
\nwork physicians could o\ufb00er the patients. In
\naddition, physicians need to stand up and
\nbe visible in position against smoking.With
\nthis,public respect toward physicians will be
\ngreatly furthered.
\nReferences
\n1. Schroeder SA. What to Do With a Patient
\nWho Smokes. JAMA 2005;294:482-487.
\n2. Fiore MC, Jaen CR, Baker TB, et al. Treating
\ntobacco use and dependence: 2008 update. Clini-
\ncal Practice Guideline. Rockville MD: US De-
\npartment of Health and Human Services, 2008.
\n3. Wen CP, Tsai MK, Chiang PH, Lee MC, Tsai
\nSP. Comparing attitudes toward smoking between
\nphysicians and smokers in East Asia: Analysis from
\na global survey of 16 countries. Submitted 2009.
\n4. Kessler DA, Witt AM, Barnett PS, et al. The
\nFood and Drug Administration’s regulation of to-
\nbacco products. N Engl J Med 1996;335:988-994.
\n5. Davis RM, Novotny TE, Lynn WR. Center for
\nHealth Promotion and Education: The Health
\nConsequences of Smoking: Nicotine Addiction: A
\nReport of the Surgeon General Center for Health
\nPromotion and Education. O\ufb03ce on Smoking
\nand Health 1988.
\n6. Health Education Authority of U.K.: Cochrane
\nCollaboration’s Tobacco Addiction Review
\nGroup (Available from http:\/\/www.cochrane.org\/
\ncochrane\/revabstr).
\n7. Katz DA, Muehlenbruch DR, Brown RL, Fiore
\nMC, Baker TB. E\ufb00ectiveness of Implimenting
\nthe Agency for Healthcare Research and Quality
\nSmoking Cessation Clinical Practice Guideline:
\nA Randomized, Control Trial. J Natl Cancer Inst
\n2004;96(8):594-603.
\n8. Dixon DM, Sweeney KG, Gray DJP.The physi-
\ncian healer: ancient magic or modern science? . Br
\nJ Gen Pract 1999;49(441):309-312.
\n9. Wen CP, Tsai SP, Chung W-SI. A 10-year ex-
\nperience of universal health insurance in Taiwan:
\nAssessing the health impact and disparity reduc-
\ntion. Ann Intern Med 2008;148:258-267.
\n10.The World Medical Association. Policy,World
\nMedical Association statement on health hazards
\nof tobacco products. (Available from http:\/\/www.
\nwma.net\/e\/policy\/h4.htm), 2009.
\n11. Schroeder SA. What to do wtih a patient who
\nsmokes. JAMA 2005;294:482-487.
\n12. Makni H, OLoughlin JL, Tremblay M, et al.
\nSmoking prevention counseling practices of Mon-
\ntreal general practitioners.Arch Pediatr Adolesc Med
\n2002;156:1263-1267.
\n13. Schnoll RA, Engstrom PF. Tobacco Con-
\ntrol in the Physician’s O\ufb03ce: A Matter of Ad-
\nequate Training and Resources. J Natl Cancer Inst
\n2004;96(8):573-575.
\n14. Blumentbal D. Barriers to the provision of
\nsmoking cessation services reported by clinicians
\nin underserved communities.J Am Board Fam Med
\n2007;20:272-279.
\n15. Wen CP. Facilitating the critical process in
\ntobacco control. Tob Control 2005;14(Suppl 1):i1-
\ni3.
\n16. Philip Morris USA. Addiction. Smoking &
\nHealth Issues.(Available from http:\/\/www.philip-
\nmorrisusa.com\/en\/health_issues\/addiction.asp).
\n17.Wen C,Cheng T,Tsai S,Hsu H,Chan H,Hsu
\nC. Exploring the relationships between diabetes
\nand smoking: with the development of \u00ab\u00a0glucose
\nequivalent\u00a0\u00bb concept for diabetes management.
\nDiabetes Res Clin Pract 2006;73:70-76.
\n18. Wen CP, Tsai MK, Chan HT, Tsai SP, Cheng
\nTYD, Chiang PH. Making hypertensive smokers
\nmotivated in quitting: developing blood pressure
\nequivalence of smoking. J Hypertens 2008;26:672-
\n677.
\n19. Wen CP, Wai JPm, Chan HT, Chan YC,
\nChiang PH, Cheng TYD. Evaluating the physi-
\ncal activity policy in Taiwan: comparison of the
\nprevalence of physical activity between Taiwan
\nand the U.S. (In Chinese). Taiwan J Public Health
\n2007;26(5):386-399.
\n20. Aveyard P, West R. Managing smoking cessa-
\ntion. BMJ 2007;335:37-41.
\n21. Gonzales D, Rennard SI, Nides M, et al.
\nVarenicline, an a4b2 nicotinic acetylcholine re-
\nceptor partial agonist, vs sustained release bur-
\npopion nad placebo for smoking cessation. JAMA
\n2006;296:47-55.
\n22. U.S. Department of Health and Human Ser-
\nvices. The Health Consequences of Involuntary
\nExposure to Tobacco Smoke: A Report of the
\nSurgeon General, U.S. Department of Health and
\nHuman Services. There is No Risk-Free Level of
\nExposure to Secondhand Smoke. (Available from
\nhttp:\/\/www.surgeongeneral.gov\/library\/second-
\nhandsmoke\/factsheets\/factsheet7.html), 2007.
\n23.WHO Report of the Global Tobacco Epidem-
\nic. 2008: The MPOWER package Geneva World
\nHealth Organization,2008 (Available from http:\/\/
\nwww.who.int\/tobacco\/mpower\/en\/).
\n24. Farrelly M, Baray J. Responses to increases in
\ncigatette prices by race\/ethnicity, income, and age
\ngroups- United States, 1976-1993. MMWR Morb
\nMortal Wkly Rep 1998;47:605-609.
\n25. The French Cancer Plan: (Available from
\nhttp:\/\/www.canceropole-toulouse.com\/en\/page.
\nphp?menu=4&ssmenu=1), 2009.
\n26. American Lung Association. State of tobacco
\ncontrol: 2008. Few States Increase Tobacco Taxes,
\nA Missed Opportunity to Save Lives and Raise
\nRevenues. (Available from http:\/\/www.stateof-
\ntobaccocontrol.org\/2008\/2008-tobacco-control-
\ntrends.html), 2008.
\n24
\nEpidemiological investigations in occupa-
\ntional health accept the ideals of free in-
\nquiry and pursuit of knowledge.The goal of
\noccupational health science, after all, is to
\nexplain and to predict natural phenomena
\nof occupational exposure. However, epide-
\nmiologists in occupational health also cher-
\nish values of improving the public\u2019s health
\nof workers through application of scienti\ufb01c
\nknowledge to the di\ufb00erent hazards of the
\nworking environment. These dual profes-
\nsional obligations sometimes give rise to
\nmedical moral problems [1, 2, 3].
\nMany occupations are necessarily associated
\nwith exposure of a worker to ionizing radia-
\ntion in the course of their activities. From
\nUkrainian uranium miners and oil drillers to
\ninterventional radiologists and airline crews,
\nthe population associated with this exposure
\nis diverse and has varied speci\ufb01c job param-
\neters. Occasionally, workers can receive a
\nsigni\ufb01cant radiation dose as a result of ef-
\nforts to mitigate an accidental occurrence,
\nwherein radioactive substances are acciden-
\ntally released into uncontrolled environ-
\nments [2, 4]. These situations often create a
\nhigher exposure than would otherwise be al-
\nlowable. There are also cumulative exposures
\nfrom unique activities, such as space \ufb02ights,
\nwhich are treated as exceptional cases. Thus,
\nthe permissible radiation load is di\ufb00erent for
\nthe general population, radiological work-
\ners and extraordinary occupational activities.
\nThe timeframes associated with allowable
\nexposure also vary with the population in
\nquestion allowable exposure e.g. determin-
\ning permissible doses for the visual system,
\nfor which radiogenic cataract can serve as a
\ndose-limiting expression of the damage.
\nIn the e\ufb00ort to be illustrated in guidelines,
\nseveral determining parameters are given dif-
\nfering weights depending on the particular
\nactivity. In the early hours of April 26, 1986,
\nReactor Number Four of the Chernobyl
\nNuclear Power Plant (ChNPP) underwent
\na power excursion during a turbine rundown
\nexperiment, resulting in a steam explosion
\nthat spewed radioactive materials into the en-
\nvironment. It is estimated that at least 4% of
\nthe fuel inventory was ejected as well as all the
\nnoble gases and most of the volatile isotopes.
\nTo deal with the accident,workers,conscripts,
\nand army reservists were assigned to clean up
\nand perform maintenance duties in the weeks
\nand months following the disaster. The so-
\ncalled \u201cLiquidators\u201d (those who would reme-
\ndiate or eliminate,\u201c\u043b\u0456\u043a\u0432\u0456\u0434\u0443\u0432\u0430\u0442\u0438\u201d,the damage)
\nnumbered more than 250,000 during the pe-
\nriod of activity considered in this publication
\n(April 26,1986 \u2013 December 31,1987).
\nIn 1996, ten years after the event, a cohort
\nepidemiological study of radiation-exposed
\nChernobyl Liquidators was initiated [5].The
\nprogramme is a joint e\ufb00ort by scientists and
\nophthalmologists of Ukraine and the United
\nStates, known as the Ukrainian\/American
\nChernobyl Ocular Study (UACOS) [3].Two
\nmajor objectives are to: 1) address whether or
\nnot ocular disease such as radiation cataracts
\ndata are compatible with a high dose thresh-
\nold,and 2) de\ufb01ne the magnitude of the dose-
\nresponse association for radiogenic cataracts
\namong Liquidators. The \ufb01rst two rounds of
\nophthalmologic exams of 8,607 subjects at
\napproximately 12 and 14 years post-radiation
\nexposure permit us to draw conclusions re-
\ngarding the relative sensitivity of the human
\nlens to radiation injury that are pertinent to
\ncurrent guidelines for ocular protection of ra-
\ndiation exposed individuals [6].
\nWe should indicate that development of
\nthe National System for Ethical Review in
\nUkraine was done as a part of joint e\ufb00orts in
\nEastern Europe and Central Asia [7].In the
\ncase of cataracts, the considerations are not
\nstraightforward. Irrespective of job descrip-
\ntion, cataracts generally appear in the last
\ndecade(s) of individuals\u2019 working life-time
\nand, more often than not, the subject is un-
\naware of their presence.
\nBefore the examination we settled legal and
\nethical considerations of the epidemiologi-
\ncal investigation which included the secured
\nconsent in epidemiological medical research
\nin the USA and in Ukraine. Con\ufb01dentiality
\nand privacy aspects and protection of hu-
\nman rights in epidemiologic research were
\nconsidered.
\nThe ophthalmic examinations were conduc-
\nted in six cities \u2013 Dnipropetrosk, Donetsk,
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nOcular Risk Standards and Medical Ethics.
\nA Development on Occupational Radiation
\nExposure in an Epidemiological Study
\nPetro Vitte, Iurii Kundiiev, The Ukrainian Medical Association; SI \u201cInstitute for Occupational
\nHealth of Academy of Medical Sciences of Ukraine\u201d; Bioethics Committee of National Academy of
\nSciences of Ukraine
\n25
\nKharkiv, Kyiv, Poltava and Slavutych \u2013 lo-
\ncated in \ufb01ve Ukrainian regions (oblasts)
\nproximal to Chernobyl. The database col-
\nlection and analysis were done at the SI
\n\u201cInstitute for Occupational Health of AMS
\nof Ukraine\u201d (responsible organization), and
\nthe ophthalmology data quality control and
\neducation of the ophthalmologists per-
\nformed in the National Medical Academy
\nfor Post-Graduate Education. The SI \u201cSci-
\nenti\ufb01c Center for Radiation Medicine of
\nAMS of Ukraine\u201d was responsible for the
\ndosimetry part of these studies.
\nAnnual human subjects\u2019 reviews and bio-
\nethical approval were provided by the In-
\nstitutional Review Boards of Columbia
\nUniversity, Health Sciences Division (New
\nYork),the Institute for Occupational Health
\n(Kyiv) and New York University School of
\nMedicine (New York) from the 1992.
\nTo complicate matters, lens changes appear
\nwith age in a speci\ufb01c manner and the rate
\nof development (worsening) varies among
\nindividuals. Until recently, the presence of
\na potential background level of cataract was
\nnot considered a problem because it was
\nbelieved that radiation cataracts were a de-
\nterministic response and therefore required
\na dose threshold to be exceeded if the radia-
\ntion was to be considered cataractogenic.
\nThe data indicate that radiation cataracto-
\ngenesis has a dose threshold much lower
\nthan the current radiation protection guide-
\nlines specify. For highly fractionated or
\nprotracted exposures the ICRP assumed
\nthe dose-e\ufb00ect threshold was 5 Gy for
\n\u201cdetectable opacities\u201d and >8 Gy for \u201cvi-
\nsual impairment\u201d [8].The NCRP, following
\nUNSCEAR, indicated a cataract threshold
\ndose of 4 Gy for fractionated low-LET ex-
\nposures,therefore recommended dose limits
\nto the eye were 2 Gy-Equivalent in a year
\nor 4 Gy-Eq over a career for space activities
\n[9].These dose values are incompatible with
\nthe \ufb01ndings of the present study, which in-
\nvolves predominantly protracted exposures;
\nour formal threshold analyses are statisti-
\ncally inconsistent with a cumulative-dose
\nthreshold less 700 mGy.
\nHowever, accumulated data suggest that a
\nreal threshold does not yet exist. In allow-
\ning for such a possibility,standards in special
\nconditions, such as the astronaut corps, were
\nbased on the concept of \u201cclinical relevance,\u201d
\ni.e. induced lens changes might be accept-
\nable if an individual does not su\ufb00er from
\nvisual decrements by their presence. This is
\none more medical moral question.This posi-
\ntion is fraught with a host of problems, not
\nleast of which is the variegated distribution
\nand pleomorphism of early lens changes.
\nHowever, perhaps the most problematic to
\nsuch considerations is a recent follow-up of
\nthe Chernobyl Liquidators, which clearly
\nshows that if a threshold exists it is at least
\nof an order of magnitude lower than pres-
\nently thought and is likely not to exist at all
\n(for Lens \u2013 200 mGy). Under such circum-
\nstances,the potential to develop cataracts oc-
\ncupies the same stochastic realm as cancer.
\nThe problem was discussed on the Na-
\ntional Committee of Radiation Protection
\nof Population of Ukraine under the \u201cVerk-
\nhovna Rada\u201d (Parliament of Ukraine) in
\nAugust 2008 and our proposal to decrease
\nthe threshold for lens was adopted. The last
\npublication of the ICRP indicates that this
\nquestion must be discussed and the target
\ngroup created. The ethical issue then ap-
\npears: \u201cHow many excess cataracts in a
\nparticular age we are willing to accept?\u201d Al-
\nthough there are other cataract-speci\ufb01c as-
\npects which must also be considered, philo-
\nsophically and ethically the acceptance of a
\ncertain damage is the main issue.
\nOnce decisions have been made regarding
\npermissible exposures, the bioethical issue
\nbecomes one of the informed consent. How
\nshould the actual health risk be framed, so
\nthat the individual can make a judgment as
\nto whether or not the added risk to cata-
\nract development is personally acceptable?
\nClearly, occupational activity that leads
\nto compromised visual acuity could eas-
\nily constitute a trigger to change an indi-
\nvidual\u2019s environment in order to minimize
\nthe exposure. However, what of clinically
\ndetectable, but not \u201cclinically relevant\u201d lens
\nchanges characterize a radiogenic damage?
\nWhat provision should be made to deal
\nwith the individual? Is simply informing the
\npatient of the \ufb01nding without further action
\nan appropriate response? Should a worker
\nbe educated on realities of the only proven
\nmethod to deal with visually debilitating
\ncataracts, namely, eye surgery? Or, should a
\nworker quit his\/her job?
\nThese are only some of ethical issues to be
\nexamined and although, in this case, they
\napply to cataract as the medical ethical
\njudgment, they are similarly to a problem of
\nother work-related pathologies.
\nReferences:
\nEthics and Epidemiology. \/ Eds. Steven S.1.
\nCoughlin & Tom L. Beauchamp.\/ Oxford Univ.
\nPress.\/1996. – 311 P.
\nOccupational Medicine: State of the Art Re-2.
\nviews. Vol.17, No.4, October-December 2002.
\nETHICS IN THE WORKPLACE. Eds. By
\nLinda Forst, MD, MPH and Peter Orris, MD,
\nMPH.\/Publisher HANLEY&BELFUS, Inc.,\/
\n2002. -720 P.
\nAnthology of bioethics. Kundiiev Y.I., editor.3.
\nKiev: BaK, 2003\/ – 592 P.
\nOcular Radiation Risk Assessment in Popula-4.
\ntions Exposed to Environmental Radiation Con-
\ntamination \/ Ed. A.K. Junk, Y.Kundiev, P.Vitte,
\nB.V.Worgul\/ Kluwer Academic Publishers, Dor-
\ndrecht, NATO ASI Series, 1999, vol. 50. \u2013 225 P.
\nB.V. Worgul, Y.I. Kundiev, N.M. Sergienko,5.
\nV.V.Chumak, P.M.Vitte, C.Medvedovsky,
\nE.V.Bakhanova, A.K.Junk, O.Y.Kyrychenko,
\nN.V.Musijachenko, S.A.Shylo, O.P.Vitte, S.Xu,
\nX.Xue and R.E.Shore. Cataracts among Cher-
\nnobyl Clean-up Workers: Implications Regard-
\ning Permissible Eye Exposures.\/\/ Radiation Re-
\nsearch. \u2013 2007. \u2013 167. – P. 233-243.
\nV.V.Chumak, B. V. Worgul, Y.I. Kundiev,6.
\nN.M. Sergienko, P.M.Vitte, C. Medvedovsky,
\nE.V.Bakhanova, A.K Junk, O.Y.Kyrychenko,
\nN.V.Musijachenko, S.V.Sholom, S.A.Shylo,
\nO.P.Vitte, S.Xu, X.Xue and R.E. Shore. Dosim-
\netry for a Study of Low-Dose radiation Cataracts
\namong Chernobyl Clean-up Workers \/\/ Radia-
\ntion Research. \u2013 2007. \u2013 167. – P. 606-614.
\nYurii I. Kundiiev, Peter N. Vitte, Mykola Chash-7.
\nchin, Tatyana Mishatkina, Bakhyt Sarymsakova.
\nDeveloping National Systems for Ethical Review
\nin Eastern Europe and Central Asia: Legitimacy
\nand Responsibility. Pharmaceutical Medicine\/
\nVol.22, No,5. 2008. – P. 285-287.
\nICRP, 1990 Recommendations of the Interna-8.
\ntional Commission on Radiological Protection.
\nAnn. ICRP 21 (Publication 60), 1-201 (1991).
\nUNSCEAR, Ionizing Radiation: Sources and Bi-9.
\nological E\ufb00ects. United Nations, New York 1982
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\n26
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nProf. (Dr.) Ketan Desai, Council Member,
\nWorld Medical Association, Past National
\nPresident, Indian Medical Association, Past
\nPresident, Medical Council of India
\nMedical ethics can be de\ufb01ned as principles
\nof proper professional conduct concerning
\nthe rights and duties of patients, doctors
\nand fellow practitioners, as well as physi-
\ncian\u2019s action in the care of patients and in
\nrelation with their families.
\nWith the explosion of scienti\ufb01c knowledge,
\nintroduction of newer medical technologies
\nof investigation and treatment, as well as
\nan increasing level of consciousness of the
\npublic, the importance of Medical Ethics
\nhas evolved tremendously over the years.
\nThe question of medical ethics and its dis-
\ncussion became very relevant and urgent in
\ncontemporary times owing to the practice
\nof medicine increasingly becoming more
\nand more legalistic. Consumer laws also
\nembraced medical practice which became
\nmore defensive with doctors taking recourse
\nto writing many investigations.
\nThe relation between the doctor and the pa-
\ntient,which was essentially based on mutual
\nrespect and trust, came to be based more on
\nevidence and documentation.
\nMedical practice in India is governed by the
\nregulations of the Medical Council of India
\nwhich is the apex medical regulatory body of
\nthe country, legally endowed not only with
\nregulatory powers, but also with the author-
\nity to discipline errant doctors as well.Being
\nthe statutory authority to register doctors,
\nit can punish them also with deregistration
\nfor a certain time or permanently. This is a
\nfunction no court of law does, but only the
\nMedical Council. In the contemporary sce-
\nnario, the ethical role of the Medical Coun-
\ncil has also increased greatly. Basically, eth-
\nics are the moral requirements of medical
\npractice. It has various areas. We will try to
\nhighlight few of them.
\nDoctor – Patient Relationship:
\nThe doctor has to be careful at all times so as
\nto be able to earn the trust and respect of pa-
\ntients.And to be able to do so,he has not only
\nto be professional and competent, but has to
\nbe compassionate and caring and well versed
\nin codes of ethics and the laws governing this
\nsphere as well.Truthfulness is the \ufb01rst ethical
\nprinciple a doctor has to follow and also it is
\nthe \ufb01rst expectation of the patient.
\nA doctor\u2019s attitude towards the patient is of
\nvital importance. When a person chooses
\nthe medical profession the die is cast. He or
\nshe is then expected to behave in a certain
\nway, uphold certain value systems, follow
\nan exemplary and disciplined conduct both
\nin public and private life, be transparent in
\nall dealings including \ufb01nancial ones and be
\naware at all times that once the profession
\nof medicine has been chosen, it will be nec-
\nessary to have a mentality of service towards
\nthe people, towards the patient.
\nPatient Autonomy:
\nThe patient has the right not only to choose
\nthe modality of treatment, but also the doc-
\ntor who would be treating him. Thus, doc-
\ntor must explain the details of treatment,
\ndiagnostic procedures, surgical procedural
\ndetails and others, if any.
\nOnly in emergencies, a doctor should know
\nwhat has to be done and why.In such situation,
\nproper documentation is important which
\ndoctor must bear in mind. Doctors otherwise
\nshould always respect the patient\u2019s right of
\nautonomy and never fail to inform about the
\nvarious treatment modalities available and the
\ndetails of the management plan chosen for the
\npatient in a particular case. Even in ward set-
\ntings these principles must be adhered to.
\nCon\ufb01dentiality:
\nPreserving con\ufb01dentiality is another area
\nof a doctor-patient relationship, a doctor
\nis bound by his code of honour (read eth-
\nics code) not to divulge this information to
\nanyone at anytime except possibly in a court
\nof law and that too in camera. A patient\u2019s
\ntrust of his doctor (and respect too) greatly
\ndepends on this. It also involves not divulg-
\ning medical secrets of wives to husbands and
\nvice versa. The principles of ethics demand
\nthat the patient and the patient alone must
\nbe told fully about the diagnosis.
\nCommunication with the patient:
\nThis is another central aspect of doctor-
\npatient relations.
\nInformed Consent:
\nA patient\u2019s acceptance is required in writing,
\nbut it has to be obtained after informing the
\npatient regarding invasive procedures, dan-
\ngerous drugs (such as in Chemotherapy),
\nanaesthesia and surgery to be undertaken.
\nEven at the stage of investigation, where
\ninvasive procedures, endoscopic procedures,
\nbiopsy etc. are required then it is also neces-
\nsary to obtain informed consent. It is a legal
\nrequirement and not only an ethical require-
\nment alone. Consent from nearest relatives,
\nchildren or legal guardians have to be ob-
\ntained if legal consent from the patient is
\nunobtainable owing to patient\u2019s condition.
\nMedical Ethics in the Present Scenario:
\nRevisiting the Basics and Recognizing
\nEmerging Concerns
\n27
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nThe doctor must never forget that a patient
\nhas the right to withhold consent.
\nA doctor must also know what are the
\npatient\u2019s rights and what are the doc-
\ntor\u2019s rights i.e. the respective rights of the
\npatient and the service provider. There are
\nmany authorities who have charted out
\nthese rights of the patient. Mostly, these are
\nmatters of ethical principles, but in USA
\nand some countries these have the sanctity
\nof law. Whether such rights are within the
\nrealm of law or morality (ethics), the doctor
\nmust be well conversant with them.
\nThere should be no discrimination on the
\nbasis of race, religion, language, colour and
\nculture.The doctors must also ensure that in
\nall treatment decisions there is participation
\nof the patient.
\nNo doctor can refuse to attend to a patient
\nif called in an emergency; however, in non-
\nemergency situations, in routine practice, a
\ndoctor has every right to refuse to see a pa-
\ntient. A Doctors function within rules and
\nat certain times only they may be available
\nfor consultation.
\nA doctor may have to take certain tough
\ndecisions at the end stage of the patient\u2019s
\nlife, specially, death declaration of patients,
\non life support systems which should de-
\npend to a large extent on the relevant laws
\nof the country. These are called end of life
\ndecisions. One aspect of it concerns eutha-
\nnasia. In India, euthanasia is not allowed.
\nBut for every medical action there is a code
\nof ethical conduct which is based on com-
\nmonsense, cultural practices, social codes
\nand even law. For not following these self
\nregulatory codes, a doctor can be accused of
\nmisconduct or infamous conduct which may
\nattract various censures, penalties, \ufb01nes, etc
\nas per the laws set by the regulatory authori-
\nties, government, employers and courts.
\nMedical negligence is one part of the
\nsphere of ethics which every doctor is afraid
\nof and is a very serious matter. Civil and
\ncriminal negligence is the broader indexing
\nof all negligence.
\nIf a doctor, without required and recog-
\nnized competence performs a procedure on
\na patient for which the doctor has no legal
\nsanction and competence, he is bound to be
\ncommitting an act of medical negligence,
\nwhether something untoward occurred to
\nthe patient or not.This could be act of com-
\nmission by a medical doctor.
\nNegligence can be by an act of omission,
\nthe doctor has not done a particular act he
\nwas required to do, or by forgetting it or not
\nhaving the competence. To avoid malprac-
\ntice and negligence suits, it is essential that
\nthe doctors follow a disciplined scienti\ufb01c
\napproach and maintain self regulation.
\nDoctors need to be \ufb01rm to refuse the lure
\nof unethical grati\ufb01cation and withstand the
\ninappropriate promotion practices of the
\npharmaceutical industry. Similarly, work-
\ning in private practice brings many ethical
\ndilemmas before the doctor. Management
\npressure on the doctors to perform in terms
\nof more patients, more investigations, more
\noperations, more revenue can create an un-
\nhealthy atmosphere and pose serious ethi-
\ncal problems. The doctors should be strong
\nenough to withstand these pressures and in-
\nsist of working in a professional atmosphere
\nonly.
\nThe tremendous development of scienti\ufb01c
\nknowledge and treatment techniques in the
\nlast two-three decades have brought many
\nnew ethical problems for the doctors. But,
\nthis \ufb01eld is so vast that it is not possible
\nto cover the entire sphere of these newly
\nemerging ethical concerns in medical prac-
\ntice in the scope of one single article.
\nGenetic screening, gene therapy, sex deter-
\nmination of the foetus and female foeticide,
\norgan transplantation and donation all de-
\nserve special attention owing to newer laws
\nof the land. In India, where female foeticide
\nabuse is not insubstantial, has quite strict
\nlaws regarding these (Prenatal sex determi-
\nnation test act 1994 PNDT act). Similarly,
\nin India,the whole spectrum of organ dona-
\ntion and transplantation is covered by the
\nTransplantation of human organ act, 1994.
\nSuch screenings have to be kept con\ufb01den-
\ntial; as such genetic information can be used
\nto discriminate individuals by employers,
\ninsurers and even by spouses and relatives.
\nDoctors must ensure that such test results
\nare kept strictly con\ufb01dential and disclosure
\nshould be only done in a manner prescribed
\nby law. Doctors should not attempt genetic
\ncounselling unless they are trained and usu-
\nally such counselling should be con\ufb01ned to
\nones own speciality.Breach of laid down law,
\nprofessional protocols, need of maintaining
\ncon\ufb01dentiality can be considered as serious
\nethical infamous conduct.
\nDrug trials, animal experimentation, stem
\ncell research, everywhere newer ethical is-
\nsues are cropping up which are subject
\nand situation speci\ufb01c. In India, the Indian
\nCouncil of Medical Research and also the
\nDrug Controller of India have laid down
\nlegal and ethical guidelines for medical
\nresearch and doctor should strictly follow
\nthese guidelines. Those who are in the \ufb01eld
\nof medical research should scrupulously
\nfollow the principles of the Helsinki Dec-
\nlaration. No doctor should undertake drug
\ntrials or clinical research unless these are
\nspeci\ufb01cally approved.
\nEthical issues are emerging in the treatment
\nof patients su\ufb00ering from HIV\/AIDS. Re-
\nfusal to treat, stigmatization, and unfair re-
\nsource allocation are some of the most un-
\nethical practices that a doctor can indulge
\nin. Ethical issues also crop up in instances
\nwhere noti\ufb01cation or partner tracing are re-
\nquired to be done.
\nWith the development of medical science,
\nwith newer treatment and diagnostic mo-
\ndalities,newer ethical issues are cropping up
\neveryday and they are likely to continue to
\ndo so in the foreseeable future as well. It is
\nthe legal, moral and ethical duty of all doc-
\ntors to keep track of these newly emerging
\nmedical issues. Ethical practice is the bed-
\nrock where the reputation and respect of
\na medical practitioner is based. We must
\nnever lose sight of this.
\n28
\nEducation
\nMasami ISHII, MD, Executive Board
\nMember of JMA, Council Member of WMA
\n1. Introduction
\nIn 1987 the Japan Medical Association
\n(JMA) initiated systematized continuing
\nmedical education (CME) programs to
\nprovide systematic support to the broad-
\nbased, e\ufb00ective engagement of physicians in
\nCME under the philosophy of professional
\nautonomy based on self-regulation.
\n2. School Education
\nSystem in Japan
\nThe compulsory education in Japan con-
\nsists of nine years from elementary school
\nto junior high school. After compul-
\nsory education, students must undergo
\na three-year high school education and
\nthen complete a university medical course
\nto be eligible for quali\ufb01cation as physi-
\ncians. The university medical education
\ncomprises six years, including basic and
\nclinical education. The courses up to this
\npoint are under the supervision of the
\nMinistry of Education, Culture, Sports,
\nScience and Technology. There are pres-
\nently 80 medical colleges and university
\nmedical departments in Japan, admitting
\napproximately 7,500 students every year.
\nIn response to the shortage of physicians,
\nthe annual admission capacity is expected
\nto increase gradually. After the six-year
\nmedical education program, students must
\npass the National Examination for Medi-
\ncal Practitioners, be registered with the
\nMinistry of Health, Labour and Welfare,
\nand complete two years of postgraduate
\ntraining. While this postgraduate train-
\ning was voluntary in the past, it was made
\ncompulsory in 2004. With this education,
\nnew physicians are trained and allowed to
\nperform medical acts in Japan.
\n3. CME Program of JMA
\n(1) Basic Policy
\nThe CME Promotion Committee of the
\nJMA has been established to promote and
\nsupport the CME of members. Local as-
\nsociations also have similar committees for
\nphysicians in respective regions, and the
\nJMA is working in close cooperation with
\nthese committees.The CME Committee of
\neach local association supports the teaching
\nof members with programs incorporating
\nregional policies and characteristics. The
\ncontent of learning covers not only medical
\nscience but also various fundamental issues
\nphysicians must understand in their daily
\npractice, such as medical ethics. Respecting
\nthe self-determination of physicians, the
\nCME activities undertaken by individual
\nphysicians are evaluated on the principle of
\nself-reporting, and no penalty is imposed
\non physicians who fail to report.\u201cThe CME
\nCerti\ufb01cate\u201d is awarded to physicians who
\ndeclare that they have completed 10 credit
\nunits or more in a year. Physicians achieving
\nthis certi\ufb01cate in three successive years are
\ngranted \u201cthe Certi\ufb01cate of Recognition for
\nCompletion of CME.\u201d
\n(2) Curricula
\nThe curricula sets the goals and outlines the
\nlearning directions of the physicians. The
\nstudy topics in the curricula are divided into
\nbasic healthcare topics and medical topics.
\n1) Basic Healthcare Topics
\nThese include about 100 basic healthcare
\ntopics that all physicians should know, ir-
\nrespective of the \ufb01elds in which they spe-
\ncialize. Examples of such topics are medi-
\ncal ethics, laws, welfare, social security, and
\nhealth economics. This part of the curricu-
\nlum is intended for the acquisition of broad
\nknowledge related to healthcare.
\n2) Medical Topics
\nThese are the learning of medical science,
\ncomprising the two parts covering \u201cimpor-
\ntant matters in medical practice\u201d and \u201cim-
\nportant diseases,\u201d respectively. The former
\npart, \u201cimportant matters in medical prac-
\ntice,\u201d assesses the attainment of knowledge,
\nskills, and attitudes related to the important
\nmatters in the process of medical practice.
\nThe latter part, \u201cimportant diseases,\u201d is a
\ncurriculum that assesses the attainment of
\nsu\ufb03cient knowledge and treatment skills
\nfor diseases commonly seen in daily prac-
\ntice and diseases of clinical importance.
\nThe JMA recommends the following ways
\nof utilizing these curricula.
\nThe CME Committee of a local medical as-
\nsociation may plan a CME workshop, fea-
\nturing some of the themes in the curricula.
\nThe curricula may be used in self-directed
\nhome learning and group learning.
\nIt is recommended to select study topics
\nreferring to the curriculum of experience-
\nbased learning in hospital-clinic collabora-
\ntion.
\n(3) Main Learning Media
\nMain learning media tools include the Jour-
\nnal of JMA published in Japanese by the
\nJMA. The Journal, produced by the Edito-
\nrial Committee of the JMA, is published in
\ntwelve regular issues and two special issues
\nThe Continuing Medical Education Program
\nof the Japan Medical Association
\n29
\nEducation
\nevery year. The JMA CME Courses refer
\ncollectively to the CME courses supported
\nby collaborating companies, re\ufb02ecting the
\ndiversi\ufb01cation of learning media. These
\ncourses are also planned by the Editorial
\nCommittee.
\nThe JMA website allows visitors to search
\nand read papers in the Journal of JMA, to
\nsearch titles in the video library, to view
\nvideo-streamed medical TV programs, and
\nto view Internet-based CME courses.
\nIn addition, journals and websites of local
\nmedical associations are also used as learn-
\ning media.
\n(4) Learning Methods
\nLearners may obtain credit units de\ufb01ned as
\nfollows.
\nA learner attending a lecture meeting or a
\nworkshop receives a certi\ufb01cate (card, sticker,
\netc.) from the host organization and sub-
\nmits it with the declaration to acquire 3-5
\ncredit units. In the case of experience-based
\nlearning (learning in hospital-clinic or clin-
\nic-clinic collaboration), the learner submits
\nthe theme, the name of facility, and other
\ndetails with the report form, and receives
\n\ufb01ve credit units. Some professional achieve-
\nments may be recognized as credit units. A
\nlearner making an academic presentation or
\npublishing a paper attaches the records of
\npresentation title, author name, etc. to the
\ndeclaration and receives 3-10 credit units.
\nHome learning, such as sending an answer
\nto a question in the Journal of JMA via mail
\nor the Internet or answering the self-assess-
\nment in the Internet-based CME courses,
\nis worth one credit unit each time.
\n(5) Self-declaration Practice
\nThe acquisition of credit units is based on
\nthe principle of self-reporting. Some local
\nmedical associations collect declarations
\nfrom the members send them to the JMA.
\nThe report form is distributed as a supple-
\nment to the March issue of the Journal of
\nJMA every year. A person making a decla-
\nration \ufb01lls in the report form, attaches the
\ncerti\ufb01cates of attendance to seminars and
\nother events and records of achievements,
\nand submits the completed form to the
\ncounty, city, or ward medical association or
\nthe university medical association to which
\nhe or she belongs by the end of April ev-
\nery year. The submitted declaration forms
\nare sent to the JMA via prefectural medical
\nassociations and processed and managed by
\ncomputer.
\n(6) Interchangeability of Credit Units
\nThe certi\ufb01cates of attendance obtained from
\nthe participation in the JMA CME Courses
\nare interchangeable with the credit units
\nneeded for the renewal of specialist certi-
\n\ufb01cation in several specialty societies. In the
\nCME system of JMA, attendance of a lec-
\nture meeting or other events of a specialty
\nsociety is counted as three credit units.As of
\n2008, arrangement for credit interchange-
\nability has been made with the specialist
\nphysician\/certi\ufb01cate physician systems of
\n27 specialty societies
\n(7) Awarding of \u201cthe CME Certi\ufb01cate\u201d
\nand \u201cthe Certi\ufb01cate of Recognition
\nfor Completion of CME\u201d
\n\u201cThe CME Certi\ufb01cate\u201dis awarded to physi-
\ncians submitting the CME declaration and
\ndocumented (by certi\ufb01cates of attendance,
\nrecords, etc.) to have achieved ten credit
\nunits or more in a year. Physicians achieving
\nthis certi\ufb01cate in three successive years are
\ngranted \u201cthe Certi\ufb01cate of Recognition for
\nCompletion of CME\u201d.
\nAlthough these certi\ufb01cates of completion
\nand certi\ufb01cates of recognition do not signify
\nany quali\ufb01cation, the proof of participation
\nin CME as indicated by the declaration rate
\nprovides a yardstick for measuring the atti-
\ntude of a physician towards CME.The phy-
\nsician may display these certi\ufb01cates in the
\nclinic, for example, as a means of building a
\ntrust relationship with patients.
\n4. Conclusion
\nThe medical care system of Japan faces a
\ncrisis as a result of the government\u2019s policy
\nof cutting expenditure and curtailing social
\nsecurity measures. In this di\ufb03cult situation,
\nthe JMA is doing everything in its power
\nto enrich community health, ensure patient
\nsafety and build a reliable foundation for
\nsocial security. The CME program is one
\nof the most reliable means of improving
\nthe quality and skills of individual physi-
\ncians, and the importance of CME is will
\nundoubtedly increase in the future.
\nIn addition, the JMA has been engaged
\nin international a\ufb00airs through participa-
\ntion in WMA and continuing interactions
\nwith the medical associations of various
\ncountries to exchange opinions regarding
\nworld healthcare problems.The enrichment
\nof community health in Japan is directly
\nlinked to Japan\u2019s contribution to the health
\nof people in the world. From this perspec-
\ntive, the JMA is committed to continue its
\ne\ufb00orts to improve the health standard of the
\nworld from the standpoint of patients. The
\nJMA intends to compile records of success-
\nful solutions of various problems of com-
\nmunity health and share these experiences
\nwith the physicians of the world, so that
\nit may be of help to physicians working in
\nvarious environments.
\n30
\nInternational, Regional and NMA news
\nDr. Tin Chun Wong, FDI Treasurer
\nDespite oral diseases being some of the most
\ncommonandmostwidespread in populations
\naround the world there has been,and remains
\nin many countries, surprisingly little atten-
\ntion paid to them. This may be a re\ufb02ection
\nof their often chronic and low grade nature,
\nexcept for episodes of acute pain manifested
\nas toothache, or that other diseases and con-
\nditions steal the limelight due to their more
\ndramatic or life threatening potential.
\nAs part of its role,and enshrined in its Mission
\nStatement, the FDI World Dental Federa-
\ntion has the vision of optimal oral health for
\nall and strives through its activities to achieve
\nthis goal.This article,by Dr.Tin Chun Wong,
\nTreasurer of the FDI and based on her pre-
\nsentation to the World Assembly in Seoul \u2013
\nOral Health and Human Rights \u2013 describes
\nthe work of the FDI and its importance in
\nrelation to oral health and human rights, and
\nin turn the importance of oral health within
\nthe context of general health.
\nThe FDI
\nFounded in 1900 in Paris, France the F\u00e9-
\nd\u00e9ration Dentaire Internationale (FDI)
\nwas the brainchild of Dr. Charles Godon,
\nDean of the Ecole Dentaire de Paris who
\nhas planned three International Dental
\nCongresses in that city in the years 1889,
\n1893 and 1900. With a founding group of
\n\ufb01ve other colleagues, on the morning of 15
\nAugust 1900 the Federation was born. Lit-
\ntle could those dentists have imagined that
\nover a century later the organisation would
\nrepresent 135 countries, 190 national dental
\nassociations and special interest groups and
\nthrough them e\ufb00ectively speak for over one
\nmillion dentists and dental care profession-
\nals worldwide.
\nThe FDI\u2019s mission
\nAs a federation of National Dental Asso-
\nciations the FDI\u2019s main roles are to bring
\ntogether the world of dentistry, to repre-
\nsent the dental profession of the world and
\nto stimulate and facilitate the exchange of
\ninformation across all borders with the aim
\nof optimal oral health for all peoples. It has
\nfour main areas of activity:
\nThe voice of dentistry
\nTo be the worldwide, authoritative and in-
\ndependent voice of the dental profession.
\nThis it achieves by producing position state-
\nments on various aspects of dentistry and oral
\nhealth, providing authoritative information
\nfor governments,the media and other organi-
\nsations, and holding the Annual World Den-
\ntal Parliament as part of its Congresses. The
\nFDI develops and disseminates policies, stan-
\ndards and information related to all aspects of
\noral health care around the world.FDI Policy
\nStatements lay out the profession\u2019s views on
\nvarious issues related to oral health,oral health
\npolicies and the dental profession.
\nOptimal oral health
\nTo promote optimal oral and general health for
\nall peoples
\nBeing an advocate for oral health at the
\nWHO, UN and in a variety of other fora,
\nthe Federation also runs projects through its
\nDental Development Fund (see below).
\nMember support
\nTo promote the interests of the Member Asso-
\nciations and their members
\nWith its headquarters in the Geneva area,
\nthe FDI gives support and promotion to
\nits constituent associations across a variety
\nof project areas including sponsorship, oral
\nhealth campaigns and expert advice net-
\nworks.
\nInformation transfer
\nTo advance and promote the ethics, art, science
\nand practice of dentistry
\nThis aim is achieved through a range of
\nactivities including the Federation\u2019s three
\nmain publications and website (www.fdi-
\nworldental.org) as well as its Annual World
\nDental Congress (AWDC). This encom-
\npasses an extensive scienti\ufb01c programme
\nwith international speakers, as well as those
\nfrom the host country or region, focusing
\non the latest scienti\ufb01c topics a\ufb00ecting the
\ndental profession globally. Recent venues
\nhave included China, Dubai and Sweden,
\nwith Singapore and Brazil in 2009 and
\n2010 respectively. Congresses also provide
\nthe opportunity for meetings of the Practice
\nCommittee, Science Committee and other
\nspecialist groupings whose ongoing projects
\nproduce position papers, papers for publi-
\ncation and fora for discussion and develop-
\nment.
\nAdvocacy Activities
\nAs well as its Policy Statements the Federa-
\ntion\u2019s involvement in global health extends
\nto the promotion of general health, with
\noral health as an integral component as one
\nof the elements of a healthy lifestyle and a
\nproductive society. Oral health inequalities
\nare addressed through the implementation
\nof e\ufb00ective oral health policies. The FDI is
\na member of the World Health Professions
\nAlliance, together with the International
\nThe FDI World Dental Federation and the
\ngrowing realisation of oral health worldwide
\n31
\nInternational, Regional and NMA news
\nCouncil of Nurses, International Pharma-
\nceutical Federation and World Medical As-
\nsociation. It is also active in tobacco control
\nsince use of tobacco has both direct impact
\non oral health, such as oral cancer, as well
\nas on general health issues. Tobacco cessa-
\ntion advice is e\ufb00ectively given by members
\nof the oral health care team, which the FDI
\npromotes as an active role.
\nDevelopment Projects
\nThe FDI promotes and supports global oral
\nhealth development for deprived communi-
\nties and populations in various ways.
\nProjects at grassroots level
\nThese are carried out in co-operation with
\nFDI member associations and non-govern-
\nmental organisations and supported through
\ngrants from the FDI\u2019s World Dental Devel-
\nopment Fund.Projects have been established
\nin Latin America, Asia and Africa.
\nSupport in developing appropriate policies
\nThe FDI supports governments and other
\norganisations in the formulation of com-
\nprehensive oral health policies and helps in
\ntheir implementation.
\nGlobal partnerships to improve oral health
\nWorkinginclosepartnershipwiththeWHO,
\nother UN agencies, health professions and
\norganisations the Federation collaborates
\nto improve oral health worldwide. Active
\ninvolvement with FDI\u2019s corporate partners
\nis another way of engaging broadly in pro-
\nmoting better oral health. The Live. Learn.
\nLaugh programme, created as a unique part-
\nnership with a corporate partner, aims to in-
\ncrease oral health education and promotion
\nin countries throughout the world.
\nEducation Programmes
\nContinuing Dental Education
\nTogether with its member associations, the
\nFDI participates in and supports continu-
\ning dental education programmes in many
\nregions. The organisation is currently in-
\nvolved with more than 20 continuing dental
\neducation programmes each year.
\nAs mentioned above, the AWDC plays an
\nimportant role in the advancement of den-
\ntistry. In addition to the scienti\ufb01c element,
\ntheprogrammealsofeaturesspecialitywork-
\nshops and forums on oral health promotion,
\nthe World Dental Exhibition \u2013 a showcase
\nof state-of-the-art advanced dental technol-
\nogy,equipment and products and the World
\nDental Parliament,a gathering of about 350
\nrepresentatives from FDI member associa-
\ntions to establish the organisation\u2019s strategic
\ndirection and adopt policy statements that
\nin\ufb02uence the world of dentistry.
\nCommunications
\nThe Federation produces a series of repu-
\ntable publications on topics related to oral
\nhealth through its publishing division, FDI
\nWorld Dental Press, based in the United
\nKingdom.
\nThe International Dental Journal (IDJ)
\nThe renowned IDJ has been FDI\u2019s \ufb02agship
\npublication for nearly 60 years. It features
\npeer-reviewed, scienti\ufb01c papers relevant to
\ninternational oral health issues in addition
\nto practical and informative articles aimed
\nat clinicians. Published six times a year, IDJ
\nis the FDI\u2019s main scienti\ufb01c publication. It is
\navailable in print and online (www.idj.org).
\nDeveloping Dentistry
\nThis biannual journal is the worldwide voice
\nof oral health development. It o\ufb00ers a posi-
\ntive, forward-looking approach to dental
\ndevelopment and tries to provoke discus-
\nsions and debates around these topics by
\nfeaturing papers from around the world.
\nDeveloping Dentistry is distributed free of
\ncharge.
\nWorldental Communiqu\u00e9
\nThis newsletter provides FDI member asso-
\nciations and other dental and health related
\ngroups with updates of our organisation. It
\nis published six times a year.
\nAnnual Report
\nProvides members,partners and other inter-
\nested parties with an overview of the FDI\u2019s
\nrecent achievements and an outlook of the
\norganisation\u2019s future. It includes messages
\nfrom the organisation\u2019s President, Execu-
\ntive Director and Chairman of the Finance
\nCommittee, in addition to \ufb01nancial state-
\nments and reports on the FDI\u2019s activities.
\nWebsite
\nThe website features information about the
\nFDI as a federation of member associa-
\ntions a world renowned section on scienti\ufb01c
\nguidelines for the dental profession, details
\nabout FDI development and public health
\nactivities and information about Annual
\nWorld Dental Congresses and continuing
\neducation programmes.
\nOral health worldwide
\nIt is now widely held that good oral health
\nis a basic human right and should not be
\nregarded as a privilege of a minority. The
\nFDI believes strongly in this and indeed
\nthis emerged as the declaration of the April
\n2004 Nairobi Conference for Oral Health
\nin the African Region, organised by the
\nFederation. This was the \ufb01rst conference on
\noral health on the African continent and
\nwas supported by WHO.
\nThere is a strong association between oral
\nhealth and socio-economic status so that
\npoor oral health is often a feature of low
\nsocietal position also leading to a similarly
\nstrong association between oral health and
\ninequalities.
\nThere are two main oral diseases; dental
\ndecay and gum disease. Both are mediated
\nby dental plaque which is formed of micro-
\n32
\nInternational, Regional and NMA news
\norganisms that colonise tooth surfaces. De-
\ncay, or caries, is essentially a gradual process
\nof demineralisation with calcium being re-
\nmoved from the outer enamel surface of the
\nteeth by acid attack from the plaque bacte-
\nria.The process is driven primarily by sugars
\nand carbohydrates in the diet which are then
\nmetabolised by the micro-organisms which
\ncreate acidic by-products and toxins.
\nGum disease is similarly promoted by the
\ntoxins from bacterial plaque that grows
\naround the gum margins. In its early stages
\nit causes in\ufb02ammation of the gingivae (gin-
\ngivitis) but can progress to destroy the sup-
\nporting tissues of the teeth, the periodon-
\ntium (periodontitis).
\nIn an ideal world, removal of dental plaque
\nin an e\ufb03cient way and on a regular basis
\nwould prevent or limit the extent of both of
\nthese conditions. In the real world however
\nthis is either not possible at all, or only in
\npart depending on a wide range of factors.
\nPrevention rather than cure
\nBecause the conditions are preventable,
\nthe FDI is a strong supporter of the two
\nmain methods of prevention and this runs
\nthroughout its activities and programmes.
\nPeriodontal disease prevention, reliant on
\ne\ufb00ective and thorough removal of plaque,
\nrelies on good oral hygiene through tooth-
\nbrushing, \ufb02ossing and other mechanical
\nmeans such as the miswak, as well as chemi-
\ncal adjuncts such as appropriate mouth
\nrinses and on occasion other anti-microbial
\nagents.
\nAs far as caries is concerned there are two
\napproaches to prevention. One is dietary
\nmodi\ufb01cation to reduce the frequency and
\nquantity of re\ufb01ned carbohydrates consumed
\ncombined with good oral hygiene.However,
\nthis necessarily involves not only motivation
\nfrom the patient but also the resources of
\ntime, \ufb01nance and equipment to achieve it.
\nIt is in these situations in which inequali-
\nties impact so heavily on oral health. An-
\nother approach is the use of \ufb02uoride as an
\nagent to help strengthen the tooth enamel
\nagainst the acid attack from the plaque.
\nThe incorporation of \ufb02uoride into the outer
\nsurface of the enamel makes it chemically
\nmore resistant to acid meaning that it can
\nsustain an attack for longer, enabling it to
\nsurvive intact for longer and until the saliva
\ncan restore the pH balance in the mouth al-
\nlow remineralisation to take place from the
\ncalcium in the saliva.
\nFluoride advocacy
\nCurrently only 20 % of the global popula-
\ntion bene\ufb01ts from \ufb02uoride as a form of car-
\nies prevention.The FDI,working with other
\nstakeholders, recommends to governments
\nand other international organisations ways
\nof increasing this availability on a popula-
\ntion and individual basis.
\nCommunity \ufb02uoridation schemes are par-
\nticularly e\ufb00ective as public health measures
\nand none more so than water \ufb02uoridation.
\nThis is one of the great achievements in
\npublic health in the last century and is an
\ninexpensive and cost e\ufb00ective way of reduc-
\ning caries rates that bene\ufb01ts all members
\nof society, preventing or reducing the pain,
\ndisruption to life su\ufb00ering and hardship
\ncaused by caries; especially for children.This
\nuniversal access to \ufb02uoride is a central part
\nof the basic human right to oral health as
\nnoted above.
\nFluoride in toothpaste is also a valuable
\npreventive tool.Moves to provide a\ufb00ordable
\n\ufb02uoride toothpaste in less advantaged coun-
\ntries are increasing in pressure as are discus-
\nsions to convince governments that taxes
\nand duties on \ufb02uoride toothpaste should be
\nreduced or abolished so as to increase its af-
\nfordability and spread its health gain.
\nOral health and general health
\nThere is increasing evidence of the connec-
\ntion between poor oral health and other
\nsystemic health problems. In particular
\nthere are links between periodontal dis-
\nease and both premature births and low-
\nweight births.Diabetes is another condition
\nstrongly associated with periodontal disease
\nand there is a growing body of research sug-
\ngesting links with heart disease and stroke.
\nAlthough not fully explained, the mediation
\nof bacterial plaque is never far away from the
\ncentre of suspicion and it may be that the mi-
\ncro-organisms cause problems either through
\nthe production of their toxins escaping into
\nthe blood stream or that they somehow alter
\nthe host immunological response.The net ef-
\nfect however has been to create a framework
\nin which it makes perfect sense for oral dis-
\nease prevention to operate in tandem with
\ngeneral disease prevention. The days of per-
\nceiving the mouth as being separate from the
\nrest of the body are numbered.
\nThis concept found particularly strong back-
\ning in 2007 at the World Health Assembly
\n(WHA) where, thanks to the work of the
\nFDI and others over a long period of time,
\nthe WHA passed a resolution which calls
\nfor oral health to be integrated into chronic
\ndisease prevention programmes. Whilst
\nperhaps not seeming to be earth shattering
\nin its extent, the recognition of this is a ma-
\njor breakthrough and means that the FDI\u2019s
\nmember associations can use the resolution
\nin advocacy for oral health programmes
\nthroughout the world, citing to govern-
\nments the WHA\u2019s acknowledgment of the
\nimportance of this health measure.
\nWorking at many levels
\nThe Federation\u2019s long history and its ability
\nto attract the best of the profession means
\nthat it can work at many levels. Recent in-
\nnovations have included the development
\nof a Dental Ethics Manual which has found
\nconsiderable popularity and is currently be-
\ning translated into the FDI\u2019s main languag-
\nes French, German, Spanish and Japanese.
\nThe manual includes FDI Guidelines for
\ndentists against torture, again strengthen-
\ning the Federation\u2019s stand on human rights.
\nThrough this means the organisation is
\naiming towards better integration of eth-
\nics into dental curricula around the world
\nto help guide an in\ufb02uence the dental care
\nprofessionals of tomorrow.
\n33
\nInternational, Regional and NMA news
\nDr. Jos\u00e9 Luiz Gomes do Amaral, President of
\nBrazilian Medical Association
\nThe Brazilian Medical Association (AMB)
\n(www.amb.org.br) was founded in 1951
\nwith a mission to ensure the dignity of the
\nmedical profession and quality health care
\nfor the Brazilian people. It consists of 27
\nState medical associations and 396 regional
\nassociations. In addition, 53 Medical Soci-
\neties compose its Scienti\ufb01c Council, repre-
\nsenting all specialties accredited in Brazil.
\nThe AMB is a member of the Council of
\nthe World Medical Association and is the
\nfounder of the Portuguese Language Medi-
\ncal Community.
\nIn 2000, the AMB launched a team to elab-
\norate medical guidelines based on scienti\ufb01c
\nevidence in order to standardize procedures
\nand assist physicians in making clinical di-
\nagnostic and treatment decisions. Each of
\nthe specialty societies a\ufb03liated with AMB
\nis responsible for the substantive content
\nand written elaboration of their guidelines.
\nSo far, more than 300 guidelines have been
\ndeveloped. They are available on the web-
\nsite: www.projetodiretrizes.org.br.
\nThe AMB collaborates with the Ministry of
\nEducation and House of Representatives to
\n\ufb01ght for the quality of medical education.
\nIn pursuit of scienti\ufb01c improvement and
\nprofessional validation since 1958, the
\nAMB grants specialization certi\ufb01cates to
\nphysicians who pass strict oral and practi-
\ncal evaluations.Through its National Com-
\nmission of Credit, the AMB records credits
\nearned and updates physicians\u2019 certi\ufb01cates.
\nThe Continuing Medical Education Pro-
\ngram (EMC) is freely accessible to all
\nBrazilian physicians and includes distance
\nlearning.
\nThrough the Parliamentary A\ufb00airs Com-
\nmission, the AMB actively participates in
\nthe development of legislation that a\ufb00ects
\nthe health profession and health system.
\nThe AMB has three key channels of com-
\nmunication: the Jornal da Associa\u00e7\u00e3o M\u00e9di-
\nca Brasileira (the AMB\u2019s journal), which is
\npublished every two months tracking devel-
\nopments in medical politics ; the Revista da
\nAssocia\u00e7\u00e3o M\u00e9dica Brasileira (the AMB\u2019s
\nmagazine), which gathers scienti\ufb01c articles
\nfrom renowned physicians throughout the
\ncountry; and its website \u2013 www.amb.org.br.
\nThe Brazilian Hierarchical Classi\ufb01cation of
\nMedical Procedures (CBHPM), developed
\nand continually reviewed by the AMB, the
\nFederal Council of Medicine and Specialty
\nSocieties, includes all scienti\ufb01cally accepted
\nmedical procedures and serves as a critical
\nreference in the provision of quality health
\ncare. The present CBHPM was designed
\nbased on technical criteria. The AMB also
\nparticipates on a Commission created to
\nelaborate a proposed Plan of Position, Ca-
\nreer and Salaries within the Public Health
\nSystem, enabling medical entities to nego-
\ntiate their implementation with States and
\nmunicipal districts.
\nInformation about Brazil
\nBrazil has 190 million inhabitants and oc-
\ncupies an area of 8,514,876.599 km\u00b2, equal
\n47% of South American continent. There
\nare 331,000 active physicians (1 doctor per
\n600 inhabitants).
\nBrazil has a public health system available
\nto everyone, as well as a supplementary
\nhealth insurance system that bene\ufb01ts ap-
\nproximately 40 million citizens. The public
\nhealth system is structured with three levels:
\nfederal, state and municipal. It is \ufb01nanced
\nby taxes and social contributions paid by the
\npopulation.
\nIn 2006, the federal government spent R$
\n40.78 billions (US$ 22.45 billions). State
\nand municipal sectors spent,respectively,R$
\n18.69 (US$ 10.2) and R$ 19.44 (US$ 10.7)
\nbillions, in total R$ 78.91 (US$ 43.4) bil-
\nlions were invested in public health. The
\nprivate sector invested R$ 87.54 (US$ 48.2)
\nbillions, including health insurance, direct
\ndisbursement and medicines. Summarizing
\nboth private and public investments, the
\nBrazilian health system received R$ 166.45
\n(US$ 91.6) billions (around R$ 892 per in-
\nhabitant \u2013 US$ 491).
\nAccording to the Brazilian Institute of Sta-
\ntistics, the main diseases in the country are:
\ncirculatory system, cancer, diabetes, respira-
\ntory diseases and AIDS.
\nThe fertility rate among Brazilian women is
\n1.95 child per woman.In 1960,this rate was
\n6.3 children per woman; in 1980, it was 4.4;
\nand in 2000, it was 2.3.The ratio of males to
\nfemales in Brazil is 48.8 (93 million) males
\nto 51.2% (97 million) females.
\n* Currency values converted on September
\n15th
\n, 2008
\nComunication Deptartment of AMB
\nThe Brazilian Medical Association (AMB):
\npurpose and actions
\n34
\nInternational, Regional and NMA news
\nDr. Wong Chiang Yin, President of the 49th
\nSMA Council, Hospital Administrator,
\na Public Health Physician
\nDr. Lee Hsien Chieh, a Public Health Trainee
\nat Changi General Hospital under the Singa-
\npore Health Services Group
\nSingapore Healthcare System
\nSingapore, a city-state with a land area
\nof 707.1 square kilometres [1], is located
\n137 kilometres north of the equator at the
\nsouthern tip of the Malay Peninsula. The
\nRepublic has a total population size of 4.59
\nmillion [1] and a population density of
\n6489 persons per square kilometre [1]. As
\nof 31 December 2007, there were a total of
\n7348 registered medical practitioners,out of
\nwhich 2781 (37.6%) were trained specialists
\nin 35 recognised specialties [2].The doctor-
\nto-population ratio is 1:620 [2], and there
\nare about 2.6 hospital beds per 1000 total
\npopulation [3].
\nPrimary healthcare is easily accessible
\nthrough an extensive network of 2000 pri-
\nvate medical practitioners\u2019 clinics, which
\nprovide 80% of primary healthcare services,
\nas well as 18 government polyclinics, which
\nprovide the remaining 20% [3]. In contrast,
\nthe public sector accounts for 80% of tertiary
\nhospital care vis-\u00e0-vis 7 public hospitals and
\n6 national specialty centres, with 16 private
\nhospitals accounting for the remaining 20%
\n[3]. Patients are free to choose their health-
\ncare providers within this dual healthcare
\ndelivery model. The average length of stay
\nin acute care hospitals is 4.7 days [3], and
\nthe average waiting time for elective surgery
\nis one week [4].
\nIn 2007, the Life Expectancy at Birth was
\n80.6 years (78.2 years for males; 82.9 years
\nfor females) [1]. Total Fertility Rate was
\n1.29 per female, while Infant Mortality
\nRate was 2.1 per 1,000 live-births [1]. The
\nCrude Birth Rate was 10.3 per 1,000 popu-
\nlation and Crude Death Rate was 4.5 per
\n1,000 population [1].
\nHealthcare Financing
\nSingapore\u2019s healthcare \ufb01nancing framework
\nis formed by the \u201c3M\u201d system \u2013 Medisave,
\nMedishield and Medifund. Medisave is
\na state-run compulsory medical savings
\nscheme introduced in 1984, under which
\nevery working employee contributes 6.5
\n% to 9.0 % [3] of his monthly income to a
\npersonal Medisave account.The savings can
\nbe withdrawn either to pay his own hospi-
\ntal bills, or those of his immediate family
\nmembers.
\nMedishield is a medical insurance scheme
\nintroduced in 1990 to help members cover
\nmedical expenses and protect against \ufb01nan-
\ncial ruin from major illnesses. Premiums for
\nMedishield can be paid for by savings under
\nthe Medisave account. Medishield covers
\nalmost 80 % of the Singaporean population
\ntoday [3].
\nMedifund is an endowment fund set up in
\n1993 for needy patients who have exhaust-
\ned all other means and cannot a\ufb00ord their
\nmedical expenses. Starting with an initial
\ncapital of S$200 million in 1993 [3], ad-
\nditional capital injections are made during
\nbudget surpluses. Only the interest income
\nfrom the capital sum,which currently stands
\nat S$1.66 billion [3] is utilised. Medifund
\nensures that no Singaporean is denied ac-
\ncess to the healthcare system due to an in-
\nability to pay.
\nIn 2005, Singapore spent a total of S$7.6
\nbillion, the equivalent of 3.8% Gross Do-
\nmestic Product (GDP) on healthcare. The
\namount of government healthcare expendi-
\nture made up S$1.8 billion (0.9% of GDP)
\n[3].
\nSingapore Medical Association
\nThe Singapore Medical Association (SMA)
\nis the national body for the medical profes-
\nsion.It is a voluntary NGO with 4917 mem-
\nbers, or about 64% of all registered medical
\npractitioners in Singapore (as at 31st
\nAu-
\ngust 2008). The membership make-up re-
\n\ufb02ects the medical profession in Singapore
\nwith approximately 30 % who are general
\npractitioners, 31 % who are specialists and
\nthe remainder being doctors-in-training.
\nThis makes the SMA the largest voluntary
\norganisation for doctors in both the private
\nand public sectors in Singapore.
\nThe SMA was formed in 1959 when the
\nMalayan Branch of the British Medical As-
\nsociation split to form the Malaysian Medi-
\ncal Association and the SMA. Some of the
\ncore activities of the SMA include promot-
\ning ethics and professionalism, publishing
\nthe monthly Singapore Medical Journal and
\nSMA Newsletter, dealing with professional
\npractice issues and organising medical talks\/
\nworkshops for doctors. The SMA is also
\nthe secretariat for Medical Associations in
\nSouth East Asian Nations (MASEAN), as
\nwell as a member of the World Medical As-
\nsociation and Confederation of Medical As-
\nsociations in Asia and Oceania (CMAAO).
\nReferences
\n1. Singapore Department of Statistics website http:\/\/
\nwww.singstat.gov.sg\/stats\/keyind.html#keyind
\n(Last accessed 22 Sep 08)
\n2. Singapore Medical Council Annual Report 2007
\n3. Singapore Ministry of Health website http:\/\/www.
\nmoh.gov.sg (Last accessed 22 Sep 08)
\n4. World Health Organization (Regional O\ufb03ce for the
\nWestern Paci\ufb01c) website http:\/\/www.wpro.who.int\/
\ncountries\/
\n05sin\/health_situation.htm (Last accessed 24 Sep 08)
\nHealthcare in Singapore and the Singapore
\nMedical Association
\n35
\nInternational, Regional and NMA news
\nJovan Tofoski, Prof. Dr. Sci. Med, President
\nof the MMA
\nThe Macedonian Medical Association –
\nMMA, in Macedonian language Makedon-
\nsko lekarsko drustvo \u2013 MLD, was founded as
\nan Association of doctors,dentists and phar-
\nmacists (then it joined only 123 doctors and
\ndentists and 96 pharmacists).Today it gath-
\ners around 5000 doctors in all the branches
\nof medicine,of whom 3025 are specialists in
\nvarious \ufb01elds while there are 2106 general
\npractitioners of whom 35 % are family doc-
\ntors. The doctors in the MMA are formed
\nin 70 specialists and sub-specialist associa-
\ntions, as well as 20 local associations in the
\nlarge towns of Macedonia.
\nIn the course of its existence and its contin-
\nuous growth and development the Macedo-
\nnian Medical Association has, among other
\nthings,held sixteen congresses for all doctors
\nand more than sixty-\ufb01ve congresses of its
\nspecialized branches,and all the papers sub-
\nmitted and edited, numbering 12 077 in all,
\nhave been published in special Proceedings
\nor supplements of the Macedonian Medical
\nReview (Makedonski Medicinski Pregled). In
\nthe period in question the regular profes-
\nsional meetings of the associations, which
\nare held on average four times a year,with at
\nleast three subjects apiece, have reached an
\noverall total of more than 12 800 meetings
\nwith that a great number of various courses,
\nworkshops, seminars and other forms of
\ncontinuous and higher education of the
\nmembers have also been organized. Within
\nthe framework of the MMA the medical
\njournal Macedonian Medical Review has
\nbeen coming out for sixty-three years now
\nwith a total of 5196 papers reviewed and
\npublished in Macedonian and abstracts in
\nthe English language.
\nThe Macedonian Medical Association was
\nproceeded of the Medical Faculty (1947)
\nand many of its members later became pro-
\nfessors in the Faculty. The MMA also took
\nthe initiative of forming, from among its
\nown ranks, the Macedonian Chamber of
\nMedicine as a separate institution (1992).
\nDuring the period of its activity the MMA
\nhas managed to accomplish an enormous
\namount of work and activities, which has up
\nto the present,been carried out on an entirely
\nvoluntary basis. This shows of the enormous
\nenthusiasm of generations of doctors-mem-
\nbers of the MMA,in their e\ufb00orts to o\ufb00er the
\nMacedonian public health protection which
\nis wide-ranging and of as high quality as
\npossible, by the application of good medical
\npractice and high ethical standards.
\nThroughout its existence the MMA has not
\nonly followed, but also been an active par-
\nticipant, initiator and consultant in the cre-
\nation and improvement of the laws a\ufb00ecting
\nthe sphere of health service provision in the
\ncountry. Its proposals and conclusions have
\nfrequently been in\ufb02uential in the passing of
\nspeci\ufb01c legislation.There have also been oc-
\ncasions where these have been rejected only
\nfor it to be recognised later that such rejec-
\ntions have had a negative e\ufb00ect in practice.
\nThroughout its long continuous activity and
\nfruitful and successful work the Macedo-
\nnian Medical Association has established
\nitself as one of the pillars of health protec-
\ntion in Macedonia, as an exceptionally im-
\nportant factor in the development of medi-
\ncine in the country, and as one of the key
\nelements in the improvement and raising of
\nthe standards of the health protection of the
\npopulation.
\nAt the same time the Macedonian Medi-
\ncal Association established its identity and
\ngained recognition as an extremely signi\ufb01-
\ncant segment in the overall social develop-
\nment of the Republic of Macedonia and as a
\nrelevant factor in the development of medi-
\ncal profession and science in Macedonia.
\nThere has so far been a high level of co-
\noperation on the part of the MMA with
\nthe Faculty of Medicine, the Macedonian
\nChamber of Medicine and the Ministry of
\nHealth.
\nAs a recognition of all its worthy and vis-
\nible services the Macedonian Medical As-
\nsociation, on its 60th
\nJubilee, has received
\nThe Macedonian Medical Association
\nDelegates of General Assembly of MMA.
\n36
\nInternational, Regional and NMA news
\nthe highest state honour, the 11th
\nOctober
\nAward.
\nThe basic task of the MMA is to contribute
\nto more e\ufb03cient, rational and high-quality
\nhealth protection for the population and to
\nreconciling those health needs with the real
\npossibilities of the society.
\nContinuing medical education, continu-
\ning medical development and professional
\nguidelines are key factors in high quality
\nand rational health protection, therefore the
\nEducational Centre has been established for
\nthe regulation,promotion,organizing,mon-
\nitoring and evaluation of CME and CPR.
\nThe MMA with \ufb01nancial support of Minis-
\ntry of Health produced and distributed free
\nof charge to all doctors GUIDLINES FOR
\nPRACTICING EVIDENCE BASED
\nMEDICINE (4500 pages), in printed and
\nelectronic form.
\nThe MMA has a clear stand that more pro-
\nfound education in ethics is an integral part
\nof CME. Besides the textbook on ethics
\nfor our colleagues, the MMA translated in
\n(2005) the Medical Ethics Manual (WMA)
\ninto the Macedonian and Albanian lan-
\nguages and it was distributed to all indi-
\nvidual doctors in Macedonia.The Manual is
\nalso available in pdf form on the web site of
\nthe MMA www.mld.org.mk
\nWork on patients rights, doctors rights and
\npatients safety are very high on the agenda
\nof the MMA, especially fostering and pro-
\nmotion of good medical practice and high
\nethical standards, as well as harmonization
\nof the Macedonian health service provision
\nwith that of the EU and membership of
\nEurope, which presupposes the acceptance
\nof appropriate standards.
\nThe Macedonian Medical Association
\nmakes a continuous e\ufb00ort to a positive
\nchange in the social status of doctors and
\nan equitable and worthy recognition of the
\nmedical profession,protection of the respect
\nand the dignity of medical profession and
\n\ufb01ghting for the freedom and independence
\nof the medical profession and the provi-
\nsion of the best medical services available
\nfor the patients, in a system of increasingly
\nstate controlled health management in the
\ncountry.
\nThe Royal Dutch Medical Association
\n(KNMG) is the professional organisation
\nfor physicians of The Netherlands. It was
\nestablished in 1849. Since 1st
\nJanuary 1999
\nthe KNMG has become a federation of
\nmedical practitioners\u2019 professional associa-
\ntions.The federation consists of the Nation-
\nal Association of Salaried Doctors (LAD),
\nthe National Association of General Prac-
\ntitioners (LHV), the Dutch Association for
\nOccupational Health (NVAB), the Dutch
\nAssociation for Nursing Home Physicians
\n(NVVA), the Dutch Association of Insur-
\nance Medicine (NVVG), the Dutch Order
\nof Medical Specialists (Orde van Medisch
\nSpecialisten) and a group of individual
\nKNMG members and students.
\nThe main objectives of the KNMG are to
\nimprove the quality of medical care and
\nhealthcare in general. This is achieved by
\nproactively responding to technological and
\nsocial developments, by developing policy,
\nlobbying and in\ufb02uencing stakeholders and
\nby providing services to our members. We
\nwork in close collaboration with other stake-
\nholders, e.g. government, politics, health
\ncare insurance companies, patient organisa-
\ntions, and other organisations in healthcare.
\nThe goal is to promote the medical and as-
\nsociated sciences, and achieve high quality
\nhealthcare. Our policies cover the full range
\nfrom public health issues, medical ethics,
\nscience, health law to medical education.
\nAnother important task of the KNMG is
\nthe legal system concerning the postgraduate
\ntraining and registration of specialists.Legis-
\nlative boards issue rules on specialist training,
\nrecognition of trainers, hospitals etc., spe-
\ncialist registration and the recerti\ufb01cation of
\nspecialists.The registration committees carry
\nout legislation regarding the tasks mentioned
\nabove in the interest of the public.
\nKNMG activities in 2009
\n1.A campaign on medical professional-
\nism. In 2009 a national campaign will
\nbe launched, aimed at all physicians. The
\nmain goal is to support doctors in their
\nprofessional conduct: good quality, earn-
\ning trust of their patients and account-
\nability.
\n2.Promoting quality of healthcare, safety
\nand transparency of medical practice and
\nprofessional integrity, through the estab-
\nlishment of guidelines and advice and in-
\n\ufb02uencing government and politics.
\nThe Royal Dutch Medical Association
\n(KNMG)
\nProf. Dr. A.C. Nieuwenhuijzen Kruseman, President. Mr. Paul Rijksen, General Manager
\n37
\nInternational, Regional and NMA news
\nDr. Ifereimi Waqainabete, Hon. President, of
\nthe Fiji Medical Association
\nThe Fiji Medical Association (FMA) is a
\nprofessional association, established under
\nthe Fiji medical and dental practitioner
\nact of 1978 and is \ufb01nanced by its members
\nthrough an annual subscription of $260.00.
\nThe Act itself speci\ufb01es that \u201cmembership of
\nFMA shall be open to every person who is
\nregistered in Part II of the Medical Regis-
\ntrar\u201d,however,membership is voluntary and
\nopen to any medical practitioner registered
\nin Part II of the Register, maintained by the
\nFiji Medical Council.
\nFMA is recognized by Fiji\u2019s civil service ad-
\nministrative body (Fiji Public Service Com-
\nmission) as the collective voice of doctors in
\nthe Civil Service. FMA has a considerable
\nrole in the medical profession, (within the
\nguidelines of the ACT) and appoints 3 of
\nthe 7 members of the Fiji Medical Coun-
\ncil. FMA is also represented on all various
\nadvisory bodies which deal with health is-
\nsues including: National Advisory Council
\non AIDS (NACA), Non Communicable
\nDisease (NCD) Taskforce, Mental Health
\nServices Planning, National Research Eth-
\nics Committee, Fiji School of Medicine
\nCouncil, and the Tobacco Act monitoring
\ntask force. The FMA is also included with
\nother NGOs in such bodies as the summit
\nworking Groups monitoring the National
\nDevelopment Plans implementation.
\nThe operational functions of FMA are guid-
\ned by its constitution which in turn is over-
\nseen by an Executive council whose mem-
\nbers are elected during our annual general
\nmeeting. The FMA annual general meeting
\nis usually held during our annual Medical
\nScienti\ufb01c conference which encompasses
\nall specialties and includes overseas and lo-
\ncal speakers. During the year the FMA also
\nkeeps members informed through:
\nThe Fiji Medical Association Journal\u2022
\n(FMAJ) which is released every four
\nmonths
\nThe Fiji Medical Association Newsletter\u2022
\nnamely Medmail, which is released every
\ntwo months and by Email
\nThe Fiji Medical Association
\nActivities are:
\nDevelopment of a quality framework: the\u2022
\nquality and patient safety requirements
\nany doctor in The Netherlands should
\nmeet;
\nContribute to educational modernisation\u2022
\nof the training of medical specialists and
\nthe curriculum in accordance with the
\nCanMEDs model;
\nContribute to the modernisation of the\u2022
\nIndividual Health Care Professionals
\nAct (Wet BIG). This Act is concerned
\nwith the quality of care and protection
\nprovided to patients, and provides a reg-
\nister of health care professionals (the
\nBIG-register). The BIG-register registers
\npharmacists, physicians, physiotherapists,
\nhealth care psychologists, psychothera-
\npists, dentists, midwives and nurses. Only
\nthose listed in this register may carry the
\nlegally protected titles belonging to these
\nprofessions;
\nMonitoring Health Insurance Act: under\u2022
\nthe new Health Insurance Act, all resi-
\ndents of the Netherlands are obliged to
\ntake out a health insurance. The system
\nis a private health insurance with social
\nconditions.The system is operated by pri-
\nvate health insurance companies; the in-
\nsurers are obliged to accept every resident
\nin their area of activity. A system of risk
\nequalisation enables the acceptance obli-
\ngation and prevents direct or indirect risk
\nselection.
\nContribute to strengthening patients and\u2022
\npatient organisations. Especially in the
\n\ufb01elds of quality, safety and legal com-
\nplaints.
\nActivities related to \u201cend of life\u201d care: im-\u2022
\nplementing the Directive palliative seda-
\ntion, research on decisions of physicians
\nconcerning the \ufb01nal stage of life.
\n3. The KNMG studies trends and in\ufb02u-
\nences legislation in relevant areas where
\nprofessional values and responsibilities
\nare of major signi\ufb01cance.
\nMonitoring, and if possible, in\ufb02uencing\u2022
\ndevelopments on health insurances and
\nthe Exceptional Medical Expenses Act
\n(AWBZ) which is a national insurance
\nscheme for long-term care.This is intend-
\ned to provide for insured with chronic
\nand continuous care. This involves con-
\nsiderable \ufb01nancial consequences, such as
\ncare for disabled people with congenital,
\nphysical or mental disorders;
\nCommenting on reports from govern-\u2022
\nment advisory boards;
\nICT in healthcare, Electronic Medical\u2022
\nRecord (EPD).This is a plan for a nation-
\nwide system which is intended to facili-
\ntate the exchange of patient information.
\nData from di\ufb00erent healthcare informa-
\ntion systems will be brought together
\nin the EPD. KNMG is involved in the
\ndevelopment and implementation of the
\nEPD, lobbying etc.
\n4. International activities:
\nThe KNMG is an active member in the
\nStanding Committee des M\u00e9decins Euro-
\np\u00e9ens (CPME) and the World Medical As-
\nsociation (WMA). The CPME is involved
\nin in\ufb02uencing policy at European level and
\nthis is of great importance, because the
\npractice of doctors is increasingly a Euro-
\npean dimension.
\n38
\nWMA news
\nOrder of Physicians of Albania (OPA)
\nRr. Dibres. Poliklinika Nr.10, Kati 3
\nTirana
\nALBANIA
\nTel\/Fax: (355) 4 2340 458
\nE-mail: albmedorder@albmail.com
\nWebsite: www.umsh.org
\nCol\u2019legi de Metges
\nC\/Verge del Pilar 5,
\nEdi\ufb01ci Plaza 4t. Despatx 11
\n500 Andorra La Vella
\nANDORRA
\nTel: (376) 823 525
\nFax: (376) 860 793
\nE-mail: coma@andorra.ad
\nWebsite: www.col-legidemetges.ad
\nOrdem dos M\u00e9dicos de Angola (OMA)
\nRua Amilcar Cabral 151-153
\nLuanda
\nANGOLA
\nTel. (244) 222 39 23 57
\nFax (221) 222 39 16 31
\nE-mail: secretariatdormed@gmail.com
\nWebsite: www.ordemmedicosangola.com
\nConfederaci\u00f3n M\u00e9dica de la Rep\u00fablica
\nArgentina
\nAv. Belgrano 1235
\nBuenos Aires 1093
\nARGENTINA
\nTel\/Fax: (54-11) 4381-1548 \/ 4384-5036
\nE-mail: comra@confederacionmedica.com.ar
\nWebsite: www.comra.health.org.ar
\nAustralian Medical Association
\nP.O. Box 6090
\nKingston, ACT 2604
\nAUSTRALIA
\nTel: (61-2) 6270 5460
\nFax: (61-2) 6270 5499
\nE-mail: ama@ama.com.au
\nWebsite: www.ama.com.au
\nOsterreichische Arztekammer
\n(Austrian Medical Chamber)
\nWeihburggasse 10-12 – P.O. Box 213
\n1010 Wien
\nAUSTRIA
\nTel: (43-1) 514 06 64
\nFax: (43-1) 514 06 933
\nE-mail: international@aerztekammer.at
\nWebsite: www.aerztekammer.at
\nArmenian Medical Association
\nP.O. Box 143
\nYerevan 375 010
\nREPUBLIC OF ARMENIA
\nTel. (3741) 53 58 68
\nFax. (3741) 53 48 79
\nE-mail: info@armeda.am
\nWebsite: www.armeda.am
\nAzerbaijan Medical Association
\nP.O. Box 16
\nAZE 1000, Baku
\nREP OF AZERBAIJAN
\nTel.(99 450) 328 18 88
\nFax. (99 412) 431 88 66
\nE-mail.info@azmed.az \/ azerma@hotmail.com
\nWebsite: www.azmed.az
\nMedical Association of the Bahamas
\nJavon Medical Center
\nP.O. Box N999
\nNassau
\nBAHAMAS
\nTel. (1-242) 328 1857
\nFax (1-242) 323 2980
\nE-mail: mabnassau@yahoo.com
\nBangladesh Medical Association
\nBMA Bhaban 5\/2 Topkhana Road
\nDhaka 1000
\nBANGLADESH
\nTel. (880) 2-9568714 \/ 9562527
\nFax. (880) 2 9566060 \/ 9562527
\nE-mail: bma@aitlbd.net
\nAssociation Belge des Syndicats
\nM\u00e9dicaux
\nChauss\u00e9e de Boondael 6, bte 4
\n1050 Bruxelles
\nBELGIUM
\nTel: (32-2) 644 12 88
\nFax: (32-2) 644 15 27
\nE-mail: absym.bvas@euronet.be
\nWebsite: www.absym-bvas.be
\nColegio M\u00e9dico de Bolivia
\nCalle Ayacucho 630
\nTarija
\nBOLIVIA
\nFax. (591) 4 666 3569
\nE-mail: colmedbol_tjo@hotmail.com
\nWebsite: www.colegiomedicodebolivia.
\norg.bo
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nR. Sao Carlos do Pinhal 324 \u2013 Bairro Bela
\nVista
\nSao Paulo SP \u2013 CEP 01333-903
\nBRAZIL
\nTel. (55-11) 3178 6810
\nFax. (55-11) 3178 6830
\nE-mail: presidente@amb.org.br
\nWebsite: www.amb.org.br
\nBulgarian Medical Association
\n15, Acad. Ivan Geshov Blvd.
\n1431 So\ufb01a
\nBULGARIA
\nTel: (359-2) 954 11 81
\nFax: (359-2) 954 11 86
\nE-mail: int@mbox.contact.bg
\nWebsite: www.blsbg.com
\nCanadian Medical Association
\nP.O. Box 8650
\n1867 Alta Vista Drive
\nOttawa, Ontario K1G 3Y6
\nCANADA
\nTel: (1-613) 731 8610 ext. 2236
\nFax: (1-613) 731 1779
\nE-mail: karen.clark@cma.ca
\nWebsite: www.cma.ca
\nOrdem Dos Medicos du Cabo Verde
\n(OMCV)
\nAvenue OUA N\u00b0 6 \u2013 B.P. 421
\nAchada Santo Ant\u00f3nio
\nCiadade de Praia-Cabo Verde
\nCABO VERDE
\nTel. (238) 262 2503
\nFax (238) 262 3099
\nE-mail: omecab@cvtelecom.cv
\nWebsite: www.ordemdosmedicos.cv
\nColegio M\u00e9dico de Chile
\nEsmeralda 678 – Casilla 639
\nSantiago
\nCHILE
\nTel: (56-2) 4277800
\nFax: (56-2) 6330940 \/ 6336732
\nE-mail: rdelcastillo@colegiomedico.cl
\nWebsite: www.colegiomedico.cl
\nChinese Medical Association
\n42 Dongsi Xidajie
\nBeijing 100710
\nCHINA
\nTel: (86-10) 8515 8136
\nFax: (86-10) 8515 8551
\nE-mail: intl@cma.org.cn
\nCyprus Medical Association (CyMA)
\n14 Thasou Street
\n1087 Nicosia
\nCYPRUS
\nTel. (357) 22 33 16 87
\nFax: (357) 22 31 69 37
\nE-mail: cyma@cytanet.com.cy
\nFederaci\u00f3n M\u00e9dica Colombiana
\nCarrera 7 N\u00b0 82-66, O\ufb01cinas 218\/219
\nSantaf\u00e9 de Bogot\u00e1, D.E.
\nCOLOMBIA
\nTel.\/Fax: (57-1) 8050073
\nE-mail: federacionmedicacolombiana@
\nencolombia.com
\nOrdre des M\u00e9decins du Zaire
\nB.P. 4922
\nKinshasa \u2013 Gombe
\nDEMOCRATIC REP. OF CONGO
\nTel: (243-12) 24589
\nUni\u00f3n M\u00e9dica Nacional
\nApartado 5920-1000
\nSan Jos\u00e9
\nCOSTA RICA
\nTel: (506) 290-5490
\nFax: (506) 231 7373
\nE-mail: unmedica@racsa.co.cr
\nCroatian Medical Association
\nSubiceva 9
\n10000 Zagreb
\nCROATIA
\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 Medical Association – J.E. Purkyne
\nSokolsk\u00e1 31 – P.O. Box 88
\n120 26 Prague 2
\nCZECH REPUBLIC
\nTel: (420) 224 266 201-4
\nFax: (420) 224 266 212
\nE-mail: czma@cls.cz
\nWebsite: www.cls.cz
\nColegio M\u00e9dico Cubano Libre
\nP.O. Box 141016
\nCoral Gables, FL 33114-1016
\nUNITED STATES
\n717 Ponce de Leon Boulevard
\nCoral Gables, FL 33134
\nTel: (1-305) 446 9902\/445 1429
\nFax: (1-305) 4459310
\nDanish Medical Association
\n9 Trondhjemsgade
\n2100 Copenhagen 0
\nDENMARK
\nTel: (45) 35 44 82 29
\nFax: (45) 35 44 85 05
\nE-mail: er@dadl.dk \/ clr@dadl.dk
\nWebsite: www.laeger.dk
\nEgyptian Medical Association
\n\u00ab\u00a0Dar El Hekmah\u00a0\u00bb
\n42, Kasr El-Eini Street
\nCairo
\nEGYPT
\nTel: (20-2) 3543406
\nColegio M\u00e9dico de El Salvador
\nFinal Pasaje N\u00b0 10
\nColonia Miramonte
\nSan Salvador
\nEL SALVADOR, C.A.
\nTel: (503) 260-1111, 260-1112
\nFax: (503) 260-0324
\nE-mail: marnuca@hotmail.com
\nEstonian Medical Association (EsMA)
\nPepleri 32
\n51010 Tartu
\nESTONIA
\nTel: (372) 7 420 429
\nFax: (372) 7 420 429
\nE-mail: eal@arstideliit.ee
\nWebsite: www.arstideliit.ee
\nEthiopian Medical Association
\nP.O. Box 2179
\nAddis Ababa
\nETHIOPIA
\nTel: (251-1) 158174
\nFax: (251-1) 533742
\nE-mail: ema.emj@telecom.net.et \/
\nema@eth.healthnet.org
\nFiji Medical Association
\n304 Wainamu Road
\nG.P.O. Box 1116
\nSuva
\nFIJI ISLANDS
\nTel. (679) 3315388
\nFax. (679) 3315388
\nE-mail. fma@unwired.com.fj
\nWMA Directory of Constituent Members
\n39
\nWMA news
\nFinnish Medical Association
\nP.O. Box 49
\n00501 Helsinki
\nFINLAND
\nTel: (358-9) 393 091
\nFax: (358-9) 393 0794
\nE-mail: fma@\ufb01mnet.\ufb01
\nWebsite: .www.medassoc.\ufb01
\nAssociation M\u00e9dicale Fran\u00e7aise
\n180, Blvd. Haussmann
\n75389 Paris Cedex 08
\nFRANCE
\nTel: (33) 1 53 89 32 41
\nE-mail: deletoile.sylvie@cn.medecin.fr
\nGeorgian Medical Association
\n7 Asatiani Street
\n0177 Tbilisi
\nGEORGIA
\nTel. (995 32) 398686
\nFax. (995 32) 396751 \/ 398083
\nE-mail: gma@posta.ge
\nWebsite: www.gma.ge
\nBundes\u00e4rztekammer
\n(German Medical Association)
\nHerbert-Lewin-Platz 1
\n10623 Berlin
\nGERMANY
\nTel: +49-(0) 30-4004 56-361
\nFax: +49-(0) 30-4004 56-384
\nE-mail: auslandsdienst@baek.de
\nWebsite: www.baek.de
\nGhana Medical Association
\nP.O. Box 1596
\nAccra
\nGHANA
\nTel. (233-21) 670510 \/ 665458
\nFax. (233-21) 670511
\nE-mail: gma@dslghana.com
\nWebsite: www.ghanamedassn.org
\nAssociation M\u00e9dicale Haitienne
\n1\u00e8re
\nAv. du Travail #33 \u2013 Bois Verna
\nPort-au-Prince
\nHAITI, W.I.
\nTel: (509) 245-2060
\nFax: (509) 245 6323
\nE-mail: secretariatamh@hainet.net
\nWebsite: www.amhhaiti.net
\nHong Kong Medical Association, China
\nDuke of Windsor Building
\n5th Floor
\n15 Hennessy Road
\nHONG KONG
\nTel: (852) 2527-8285
\nFax: (852) 2865-0943
\nE-mail: hkma@hkma.org
\nWebsite: www.hkma.org
\nAssociation of Hungarian Medical
\nSocieties (MOTESZ)
\nN\u00e1dor u. 36 – PO.Box 145
\n1051 Budapest
\nHUNGARY
\nTel: (36-1) 312 3807 \u2013 312 0066
\nFax: (36-1) 383-7918
\nE-mail: international@motesz.hu
\nWebsite: www.motesz.hu
\nIcelandic Medical Association
\nHlidasmari 8
\n200 K\u00f3pavogur
\nICELAND
\nTel: (354) 864 0478
\nFax: (354) 5 644106
\nE-mail: icemed@icemed.is
\nIndian Medical Association
\nIndraprastha Marg
\nNew Delhi 110 002
\nINDIA
\nTel: (91-11) 23370009\/23378819\/23378680
\nFax: (91-11) 23379178\/23379470
\nE-mail: inmedici@vsnl.com
\nWebsite: www.imanational.com
\nIndonesian Medical Association
\nJl. G.S.S.Y. Ratulangie N\u00b0 29 Menteng
\nJakarta 10350
\nINDONESIA
\nTel: (62-21) 3150679 \/ 3900277
\nFax: (62-21) 390 0473
\nE-mail: pbidi@idola.net.id
\nWebsite:www.idionline.org
\nIrish Medical Organisation
\n10 Fitzwilliam Place
\nDublin 2
\nIRELAND
\nTel: (353-1) 6767273
\nFax: (353-1) 662758
\nE-mail: imo@imo.ie
\nWebsite: www.imo.ie
\nIsrael Medical Association
\n2 Twin Towers, 35 Jabotinsky St.
\nP.O. Box 3566, Ramat-Gan 52136
\nISRAEL
\nTel: (972-3) 610 0444
\nFax: (972-3) 575 0704
\nE-mail: saraf@ima.org.il
\nWebsite: www.ima.org.il
\nOrdre des M\u00e9decins de la C\u00f4te d\u2019Ivoire
\n(ONMCI)
\nCocody Cit\u00e9 des Arts, B\u00e2t. U1, Esc.D,
\nRdC, Porte n\u00b01
\nBP 1584
\nAbidjan 01
\nIVORY COAST
\nTel. (225) 22 48 61 53 \/22 44 30 78\/
\nTel. (225) 02 02 44 01 \/08 14 55 80
\nFax: (225) 22 44 30 78
\nE-mail: onmci@yahoo.fr
\nWebsite: www.onmci.org
\nJapan Medical Association
\n2-28-16 Honkomagome, Bunkyo-ku
\nTokyo 113-8621
\nJAPAN
\nTel: (81-3) 3946 2121\/3942 6489
\nFax: (81-3) 3946 6295
\nE-mail: jmaintl@po.med.or.jp
\nAssociation of Medical Doctors of
\nKazakhstan
\n117\/1 Kazybek bi St.,
\nAlmaty
\nKAZAKHSTAN
\nTel. (7-327 2) 624301 \/ 2629292
\nFax. (7-327 2) 623606
\nE-mail: sadykova-aizhan@yahoo.com
\nKorean Medical Association
\n302-75 Ichon 1-dong, Yongsan-gu
\nSeoul 140-721
\nREP. OF KOREA
\nTel: (82-2) 794 2474
\nFax: (82-2) 793 9190\/795 1345
\nE-mail: intl@kma.org
\nWebsite: www.kma.org
\nKuwait Medical Association
\nP.O. Box 1202
\nSafat 13013
\nKUWAIT
\nTel. (965) 5333278, 5317971
\nFax. (965) 5333276
\nE-mail: kma@kma.org.kw\/alzeabi@hotmail.
\ncom
\nLatvian Physicians Association
\nSkolas Str. 3
\nRiga 1010
\nLATVIA
\nTel: (371) 67287321 \/ 67220661
\nFax: (371) 67220657
\nE-mail: lab@arstubiedriba.lv
\nLiechtensteinische \u00c4rztekammer
\nPostfach 52
\n9490 Vaduz
\nLIECHTENSTEIN
\nTel: (423) 231 1690
\nFax. (423) 231 1691
\nE-mail: o\ufb03ce@aerztekammer.li
\nWebsite: www.aerzte-net.li
\nLithuanian Medical Association
\nLiubarto Str. 2
\n2004 Vilnius
\nLITHUANIA
\nTel.\/Fax. (370-5) 2731400
\nE-mail: lgs@takas.lt
\nWebsite: www.lgs.lt\/
\nAssociation des M\u00e9decins et
\nM\u00e9decins Dentistes du Grand-
\nDuch\u00e9 de Luxembourg (AMMD)
\n29, rue de Vianden
\n2680 Luxembourg
\nLUXEMBOURG
\nTel: (352) 44 40 33 1
\nFax: (352) 45 83 49
\nE-mail: secretariat@ammd.lu
\nWebsite: www.ammd.lu
\nMacedonian Medical Association
\nDame Gruev St. 3
\nP.O. Box 174
\n91000 Skopje
\nMACEDONIA
\nTel: (389-91) 232577
\nFax: (389-91) 232577
\nE-mail: mld@unet.com.mk
\nMalaysian Medical Association
\n4th Floor, MMA House
\n124 Jalan Pahang
\n53000 Kuala Lumpur
\nMALAYSIA
\nTel: (60-3) 4041 1375
\nFax: (60-3) 4041 8187
\nE-mail: info@mma.org.my \/ research@
\nmma.org.my
\nWebsite: http:\/\/www.mma.org.my
\nOrdre National des M\u00e9decins du Mali
\n(ONMM)
\nH\u00f4pital Gabriel Tour\u00e9
\nCour du Service d\u2019Hygi\u00e8ne
\nBP E 674
\nBamako
\nMALI
\nTel. (223) 223 03 20\/ 222 20 58\/
\nE-mail: cnommali@gmai.com
\nWebsite: www.keneya.net\/cnommali.com
\nMedical Association of Malta
\nThe Professional Centre
\nSliema Road, Gzira GZR 06
\nMALTA
\nTel: (356) 21312888
\nFax: (356) 21331713
\nE-mail: martix@maltanet.net
\nWebsite: www.mam.org.mt
\nColegio Medico de Mexico
\n(FENACOME)
\nAdolfo Prieto #812
\nCol.Del Valle
\nD. Benito Ju\u00e1rez
\nMexico 03100
\nMEXICO
\nTel. 52 55 5543 8989
\nFax. 52 55 5543 1422
\nE-mail: fenacome_relint@teyco.com.mx
\nWebsite: www.cmm-fenacome.org
\nMedical Association of Namibia
\n403 Maerua Park \u2013 POB 3369
\nWindhoek
\nNAMIBIA
\nTel. (264) 61 22 4455
\nFax. (264) 61 22 4826
\nE-mail: man.o\ufb03ce@iway.na
\nNepal Medical Association
\nSiddhi Sadan, Post Box 189
\nExhibition Road
\nKatmandu
\nNEPAL
\nTel. (977 1) 4225860, 4231825
\nFax. (977 1) 4225300
\nE-mail: nma@healthnet.org.np
\nRoyal Dutch Medical Association
\nP.O. Box 20051
\n3502 LB Utrecht
\nNETHERLANDS
\nTel: (31-30) 282 38 28
\nFax: (31-30) 282 33 18
\nE-mail: j.bouwman@fed.knmg.nl
\nWebsite: knmg. artsennet. nl
\nNew Zealand Medical Association
\nP.O. Box 156, 26 The Terrace
\nWellington 1
\nNEW ZEALAND
\nTel: (64-4) 472 4741
\nFax: (64-4) 471 0838
\nE-mail: lianne@nzma.org.nz
\nWebsite: www.nzma.org.nz
\nNigerian Medical Association
\n74, Adeniyi Jones Avenue Ikeja
\nP.O. Box 1108, Marina
\nLagos
\nNIGERIA
\nTel: (234-1) 480 1569, 876 4238
\nFax: (234-1) 493 6854
\nE-mail: info@nigeriannma.org
\nWebsite: www.nigeriannma.org
\n40
\nWMA news
\nNorwegian Medical Association
\nP.O.Box 1152 sentrum
\n0107 Oslo
\nNORWAY
\nTel: (47) 23 10 90 00
\nFax: (47) 23 10 90 10
\nE-mail: ellen.pettersen@legeforeningen.no
\nWebsite: www.legeforeningen.no
\nAsociaci\u00f3n M\u00e9dica Nacional
\nde la Rep\u00fablica de Panam\u00e1
\nApartado Postal 2020
\nPanam\u00e1 1
\nPANAMA
\nTel: (507) 263 7622 \/263-7758
\nFax: (507) 223 1462
\nFax modem: (507) 223-5555
\nE-mail: amenalpa@cwpanama.net
\nColegio M\u00e9dico del Per\u00fa
\nMalec\u00f3n Armend\u00e1riz N\u00b0 791
\nMira\ufb02ores
\nLima
\nPERU
\nTel: (51-1) 241 75 72
\nFax: (51-1) 242 3917
\nE-mail: decano@cmp.org.pe
\nWebsite: www.cmp.org.pe
\nPhilippine Medical Association
\n2\/F Administration Bldg.
\nPMA Compound, North Avenue
\nQuezon City 1105
\nPHILIPPINES
\nTel: (63-2) 929-63 66
\nFax: (63-2) 929-69 51
\nE-mail: philmedas@yahoo.com
\nWebsite: www.pma.com.ph
\nPolish Chamber of Physicians and
\nDentists
\n(Naczelna Izba Lekarska)
\n110 Jana Sobieskiego
\n00-764 Warsaw
\nPOLAND
\nTel. (48) 22 55 91 300\/324
\nFax: (48) 22 55 91 323
\nE-mail: secretariat@hipokrates.org
\nWebsite: www.nil.org.pl
\nOrdem dos M\u00e9dicos
\nAv. Almirante Gago Coutinho, 151
\n1749-084 Lisbon
\nPORTUGAL
\nTel: (351-21) 842 71 00\/842 71 11
\nFax: (351-21) 842 71 99
\nE-mail: ordemmedicos@mail.telepac.pt \/
\nWebsite: www.ordemdosmedicos.pt
\nRomanian Medical Association
\nStr. Ionel Perlea, nr 10,
\nSect. 1, Bucarest
\nROMANIA
\nTel: (40-21) 460 08 30
\nFax: (40-21) 312 13 57
\nE-mail: amr@itcnet.ro
\nWebsite: www.ong.ro\/ong\/amr\/
\nRussian Medical Society
\nUdaltsova Street 85
\n119607 Moscow
\nRUSSIA
\nTel.\/Fax (7-495) 734-12-12
\nTel. (7-495) 734-11-00\/(7-495)734 11 00
\nE-mail: info@russmed.ru
\nWebsite: www.russmed.ru\/eng\/who.htm
\nSamoa Medical Association
\nTupua Tamasese Meaole Hospital
\nPrivate Bag \u2013 National Health Services
\nApia
\nSAMOA
\nTel. (685) 778 5858
\nE-mail: vialil_lameko@yahoo.com
\nOrdre National des M\u00e9decins du S\u00e9n\u00e9gal
\n(ONMS)
\nInstitut d\u2019Hygi\u00e8ne Sociale (Polyclinique)
\nBP 27115
\nDakar
\nSENEGAL
\nTel. (221) 33 822 29 89
\nFax: (221) 33 821 11 61
\nE-mail: onms@orange.sn
\nWebsite: www.ordremedecins.sn
\nSingapore Medical Association (SiMA)
\nAlumni Medical Centre, Level 2
\n2 College Road
\nSINGAPORE 169850
\nTel. (65) 6223 1264
\nFax. (65) 6224 7827
\nE-mail. sma@sma.org.sg
\nWebsite: www.sma.org.sg
\nSlovak Medical Association
\nCukrova 3
\n813 22 Bratislava 1
\nSLOVAK REPUBLIC
\nTel. (421) 5292 2020
\nFax. (421) 5263 5611
\nE-mail: secretarysma@ba.telecom.sk
\nWebsite: www.sls.sk
\nSlovenian Medical Association
\nKomenskega 4
\n61001 Ljubljana
\nSLOVENIA
\nTel. (386-61) 323 469
\nFax: (386-61) 301 955
\nSomali Medical Association
\n14 Wardigley Road \u2013 POB 199
\nMogadishu
\nSOMALIA
\nTel. (252-1) 595 599
\nFax. (252-1) 225 858
\nE-mail: drdalmar@yahoo.co.uk
\nThe South African Medical Association
\nP.O. Box 74789, Lynnwood Rydge
\n0040 Pretoria
\nSOUTH AFRICA
\nTel: (27-12) 481 2045
\nFax: (27-12) 481 2100
\nE-mail: sginterim@samedical.org
\nWebsite: www.samedical.org
\nConsejo General de Colegios M\u00e9dicos
\nPlaza de las Cortes 11, 4a
\nMadrid 28014
\nSPAIN
\nTel: (34-91) 431 77 80
\nFax: (34-91) 431 96 20
\nE-mail: ccuesta@cgcom.es
\nWebsite: www.cgcom.es
\nSwedish Medical Association
\n(Villagatan 5)
\nP.O. Box 5610
\nSE – 114 86 Stockholm
\nSWEDEN
\nTel: (46-8) 790 35 01
\nFax: (46-8) 10 31 44
\nE-mail: info@slf.se
\nWebsite: www.lakarforbundet.se
\nF\u00e9d\u00e9ration des M\u00e9decins Suisses (FMH)
\nElfenstrasse 18 \u2013 C.P. 170
\n3000 Berne 15
\nSWITZERLAND
\nTel. (41-31) 359 11 11
\nFax. (41-31) 359 11 12
\nE-mail: info@fmh.ch
\nWebsite: www.fmh.ch
\nTaiwan Medical Association
\n9F, No 29, Sec.1
\nAn-Ho Road
\nTaipei 10688
\nTAIWAN
\nTel: (886-2) 2752-7286
\nFax: (886-2) 2771-8392
\nE-mail: intl@tma.tw
\nWebsite: www.tma.tw
\nMedical Association of Thailand
\n2 Soi Soonvijai
\nNew Petchburi Road, Huaykwang Dist.
\nBangkok 10310
\nTHAILAND
\nTel: (66-2) 314 4333\/318-8170
\nFax: (66-2) 314 6305
\nE-mail: math@loxinfo.co.th
\nConseil National de l\u2019Ordre
\ndes M\u00e9decins de Tunisie
\n16, rue de Touraine
\n1002 Tunis
\nTUNISIA
\nTel: (216-71) 792 736\/799 041
\nFax: (216-71) 788 729
\nE-mail: cnom@planet.tn
\nTurkish Medical Association
\nGMK Bulvari
\n\u015eehit Dani\u015f Tunaligil Sok. N\u00b0 2 Kat 4
\nMaltepe 06570
\nAnkara
\nTURKEY
\nTel: (90-312) 231 31 79
\nFax: (90-312) 231 19 52
\nE-mail: Ttb@ttb.org.tr
\nWebsite: www.ttb.org.tr
\nUganda Medical Association
\nPlot 8, 41-43 circular rd.
\nP.O. Box 29874
\nKampala
\nUGANDA
\nTel. (256) 41 321795
\nFax. (256) 41 345597
\nE-mail: myers28@hotmail.com
\nUkrainian Medical Association (UkMA)
\n7 Eva Totstoho Street
\nPO Box 13
\nKyiv 01601
\nUKRAINE
\nTel. (380) 50 355 24 25
\nFax: (380) 44 501 23 66
\nE-mail: sfult@ukr.net
\nWebsite: www.sfult.org.ua
\nBritish Medical Association
\nBMA House,Tavistock Square
\nLondon WC1H 9JP
\nUNITED KINGDOM
\nTel: (44-207) 387-4499
\nFax: (44- 207) 383-6400
\nWebsite: www.bma.org.uk
\nAmerican Medical Association
\n515 North State Street
\nChicago, Illinois 60654
\nUNITED STATES
\nTel: (1-312) 464 5291 \/ 464 5040
\nFax: (1-312) 464 5973
\nE.mail: ellen.waterman@ama-assn.org
\nWebsite: www.ama-assn.org
\nSindicato M\u00e9dico del Uruguay
\nBulevar Artigas 1515
\nCP 11200 Montevideo
\nURUGUAY
\nTel: (598-2) 401 47 01
\nFax: (598-2) 409 16 03
\nE-mail: secretaria@smu.org.uy
\nAssociazione Medica del Vaticano
\n00120 Citt\u00e0 del Vaticano
\nVATICAN STATE
\nTel: (39-06) 69879300
\nFax: (39-06) 69883328
\nE-mail: servizi.sanitari@scv.va
\nFederacion MedicaVenezolana
\nAv. Orinoco con Avenida Perija
\nUrbanizacion Las Mercedes
\nCaracas 1060 CP
\nVENEZUELA
\nWebsite: www.
\nfederacionmedicavenezolana.org
\nVietnam Medical Association (VGAMP)
\n68A Ba Trieu-Street
\nHoau Kiem District
\nHanoi
\nVIETNAM
\nTel: (84) 4 943 9323
\nFax: (84) 4 943 9323
\nZimbabwe Medical Association
\nP.O. Box 3671
\nHarare
\nZIMBABWE
\nTel. (263-4) 791553
\nFax. (263-4) 791561
\nE-mail: zima@zol.co.zw
\nwww.zima.org.zw
\nContents
\nEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
\nResult of Regional Elections,
\nthe Members of WMA Council 2009 \u2013 2010 . . . . . . . . . . . . . . . . . 1
\nDeclaration of Helsinki. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
\nThe Return of Primary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
\nCounterfeit Medicines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
\nHealth Sciences Online: the First Authoritative,
\nComprehensive, Free andAd-Free Resource
\nfor the World\u2019s Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
\nSocial Determinants of Health
\nas a Driving Force Towards Health Equity . . . . . . . . . . . . . . . . . . . . 8
\nThe Avicenna Directories \u2013
\na new tool in quality assurance of medical education . . . . . . . . . . . . 9
\nNational Health Serwice (England).
\nNext Stage Review \u2013 \u201chigh quality care for all? \u201d . . . . . . . . . . . . . . . . . 11
\nGender aspects in Cardiovascular Drug Therapy. . . . . . . . . . . . . . . 14
\nBuilding a Consensus in Regenerative Medicine . . . . . . . . . . . . . . 17
\nBarriers to Smoking Cessation:
\nAre they really insurmountable? . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
\nOcular Risk Standards and Medical Ethics.
\nA development on Occupational Radiation Exposure
\nin an Epidemiological Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
\nMedical Ethics in the present scenario:
\nRevisiting the Basics and recognizing emerging concerns. . . . . . . . 26
\nThe Continuing Medical Education Program
\nof the Japan Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . 28
\nThe FDI World Dental Federation
\nand the growing realisation of oral health worldwide . . . . . . . . . . . 30
\nThe Brazilian Medical Association (AMB):
\npurpose and actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
\nHealthcare in Singapore and
\nthe Singapore Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . 34
\nThe Macedonian Medical Association . . . . . . . . . . . . . . . . . . . . . . 35
\nThe Royal Dutch Medical Association (KNMG) . . . . . . . . . . . . . . 36
\nThe Fiji Medical Association. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
\nWma Directory of National Constituent Members
\nAssociation And Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
\nThe World Medical and Health Games . . . . . . . . . . . . . . . . . . . . . 41
\nThe World Medical
\nand Health Games
\nIn the beautiful Spanish city, Alicante will tace part the World
\nMedical and Health Games. So, don\u2019t waste time and join Spain
\nfrom July 4th
\nto 11th
\nto celebrate all together the 30th
\nedition of the
\nWorld Medical and Health Games!
\nSince their creation in 1978, the WMHG have claimed to have
\n\u201cThe Olympic Spirit\u201d as it was intended by the Baron Pierre De
\nCoubertin: Beauty of sport and abundance of e\ufb00ort.
\nThese are the values that still guide us today in the organisation of
\nthis event: every sports enthusiast that enrols in the Games agrees
\nto honour the following motto : \u201cIn the World Medical and Health
\nGames, we agree to face each other in our sporting challenges with
\nthe willingness to try our chances, in a spirit of friendship, with re-
\nspect for our counterparts and for sporting and indeed professional
\nethics, hoping to revive a spirit of \u201cfair-play\u201d even beyond our per-
\nformance, a spirit that might act as an example for more important
\ninternational competitions. \u201c
\n54 countries have already participated in the Games since their cre-
\nation: South Africa, Algeria, Germany, Argentina, Australia, Aus-
\ntria, Belgium, Bosnia, Brazil, Cameroon, Canada, Chile, Colom-
\nbia, Korea, Croatia, Denmark, Spain, Estonia, The United States,
\nFinland, France, Georgia, Greece, Hungary, India, Iran, Ireland,
\nIsrael, Italy, Japan, Latvia, Liechtenstein, Lithuania, Luxembourg,
\nMorocco, Mexico, Moldavia, Norway, The Netherlands, Pakistan,
\nPoland, Portugal, The Republic of Slovakia, The Czech Repub-
\nlic, The United Kingdom, Slovenia, Sweden, Tunisia, Turkey, The
\nUkraine, Uruguay, Venezuela, Yugoslavia
\nSports in the Programme
\nAthletics, Badminton, Basket-Ball, Beach-Volley, Cycling, Chess,
\nFencing, 11-a-side Football, 11-a-side Senior Football and 6-a-side
\nFootball, Power Lifting, Golf, Judo, Squash Rackets, Swimming,
\nWindsur\ufb01ng,Tennis,Table Tennis, Pistol Shooting, Ri\ufb02e Shooting,
\nClay Pigeon Shooting, Triathlon, Sailing, Volley-Ball, Mountain
\nBiking.
\nThe Age Categories
\nThe date of reference that is taken into consideration is the date on
\nwhich the Games are scheduled to begin, therefore 4th July 2009.
\nA \u2013 under 35 years; B \u2013 from 35 to 45 years ; C \u2013 from 45 to 55 years;
\nD \u2013 from 55 to 65 years; E \u2013 over 65 years; F \u2013 Students: all those
\nregistered as students,without consideration of age Students will not
\nbe able to be part of the classi\ufb01cations in categories A, B, C, D or
\nE. There are no age categories for collective sports, golf and chess.
\nwww.medigames.com
\nWMA news<\/p>\n"},"caption":{"rendered":"

wmj21 No. 1, February 2009 Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 661 peteris@nma.lv editorin-chief@wma.net Co-Editor Dr. Alan J. Rowe Haughley Grange, Stowmarket Su\ufb00olk IP143QT, UK Co-Editor Prof. Dr. med. Elmar Doppelfeld Deutscher \u00c4rzte-Verlag Dieselstr. 2, D-50859 K\u00f6ln, Germany Assistant Editor Velta Poz\u0146aka wmj-editor@wma.net […]<\/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\/wmj21.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3578"}],"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=3578"}]}}