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wmj23<\/a><\/p>\n

No. 3, October 2009
\nwma 7-2.indd Iwma 7-2.indd I 9\/29\/09 5:24:52 PM9\/29\/09 5:24:52 PM
\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
\n\u201cMedic\u012bnas apg\u0101ds\u201d, President Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nCover painting : Academic painter Juraj
\nOravec. Cosmic gravity (combined technique,
\na visual metaphor for fertilization of a germ
\ncell of an ovulum with cosmologic dimension)
\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
\nwma 7-2.indd IIwma 7-2.indd II 9\/29\/09 5:25:01 PM9\/29\/09 5:25:01 PM
\n85
\nThe Israel Medical Association was delighted to host this year’s
\nCouncil meeting at the HiltonTel Aviv.The meeting went smoothly.
\nThe discussions were fruitful and agreement was reached on many
\nof the statements. The scope of topics discussed was broad, includ-
\ning child health, medical neutrality, inequalities in health, stem cells
\nand the use of placebos. However, my greatest delight was being
\nable to host my long-time friends and colleagues from the WMA
\nin my home country.
\nBefore beginning the actual Council session, an optional informa-
\ntive session was o\ufb00ered by the Israel Medical Association. As an Is-
\nraeli,I am constantly bombarded with questions from my colleagues
\nabroad that re\ufb02ect the complexity of the region in which I live.The
\nrecent con\ufb02ict in Gaza and continued worry in the Middle East
\nover the threat of a nuclear Iran have only increased the amount of
\ninquiries that I receive. This session provided essential background
\ninformation on many of the issues frequently covered by foreign
\nnews agencies, to those WMA participants who wished to attend.
\nMr.Neil Lazarus is an expert on the Middle East and speaks to over
\n25 000 people a year through his seminars. Having him speak with
\nWMA Council visitors was a great opportunity to discuss the real-
\nity of the Middle East and I appreciate those who spent their free
\ntime in order to hear him.
\nParticipants arrived in Israel from countries near and far. For many,
\nthis was their \ufb01rst trip to the country that is holy to three major
\nreligions. Participants experienced the meaning of that on Thursday,
\n14 May when we travelled to Jerusalem. In Jerusalem, we saw the
\nChurch of the Holy Sepulchre where Jesus was cruci\ufb01ed and buried.
\nWe saw the Al-Aqsa Mosque which is the second oldest mosque
\nin Islam and the third in holiness and importance after those in
\nMecca. We also had a chance to visit the Western Wall which has
\nremained intact since the destruction of the Second Jerusalem Tem-
\nple. It was my pleasure to participate in this tour and give WMA
\nguests a taste of Israel. We were led through the Jewish quarter of
\nthe Old City of Jerusalem, the Arab market (or, as we call it, shuk)
\nand we tasted traditional Middle-Eastern cookies and drank freshly
\nsqueezed lemonade with mint leaves. In the shuk our senses were
\noverpowered with the strong smells of co\ufb00ee, tobacco and spices,
\nthe vibrant colours of the di\ufb00erent fabrics and intricate tapestries, as
\nwell as the history of the place.Our tour ended at the historical City
\nof David where actors and musicians painted us a picture of what it
\nmeant to live in Jerusalem at the time of the Temple.This was a truly
\nunique experience. We continued at the City of David with dinner
\nand musical entertainment in the olive garden.
\nAdditional social events included a visit to the Eretz Israel Museum.
\nThere we saw an ancient olive press, \ufb02our mill and other working
\ntools traditionally used in the Middle East in ancient times. We
\nwere lucky to have a cool breeze while we enjoyed dinner on a grassy
\nlawn at the museum.
\nIsrael, as a melting pot and home to people of all nationalities and
\nreligions was a \ufb01tting place to host the WMA, which itself is an
\namalgam of people from various countries, languages and cultures.
\nOur common language, medicine, unites us and allows us to work
\ntogether to reach common goals, making the WMA what it is \u2013 an
\noutstanding organization.
\nWMA meetings in general and this year’s Council Meeting in Tel
\nAviv in particular,provided another great opportunity for physicians
\nfrom around the globe to become acquainted with one another, so-
\ncialize and discuss common issues and challenges in an informal
\nmanner. It was my pleasure and my privilege to host this year’s
\nCouncil Meeting and I invite all the delegates to return to Israel in
\nthe near future.
\nEditorial
\nThe 182nd
\nWMA Council Meeting
\nDr. Yoram Blachar, WMA President
\nwma 7-2.indd 85wma 7-2.indd 85 9\/29\/09 5:25:02 PM9\/29\/09 5:25:02 PM
\n86
\nWMA news
\nCouncil was opened by the Secretary Gen-
\neral who welcomed the following new mem-
\nbers, Dr. Ruth Collins Nakai, Dr. Toram
\nJanbu. Dr. Gebrehiwot, Prof Niewenhui-
\njzen Kruseman, Dr. Leonid Mikhaylov,and
\nDr. Antonio Tunes.
\nFollowing the announcement by the Secre-
\ntary General of the death of Angel Orozeo,
\nlong-time Executive Director and friend of
\nthe WMA, the Council observed a period
\nof silent tribute. (a memorial tribute will ap-
\npear in the next issue of WMJ )
\nDr.Edward Hill was re-elected Chair of
\nCouncil,the following o\ufb03cers were elected,
\nVice- chair of Council Dr. Ishii , Treas-
\nurer Professor Hoppe and members of
\nStanding Committees and Advisers were
\nthen elected.
\nCouncil then received the reports of the
\nPresident and Secretary General
\nInterim Report of the President
\n\u201cIt is my pleasure to host you in Tel Aviv for
\nthis year’s Council. It is an honour to serve
\nas President of this auspicious organization
\nthat impacts physicians in practically every
\ncountry in the world.This organization dic-
\ntates the standards of ethics and care and
\nexcels in progressing our profession for-
\nward. This has been a very busy year for me
\nas President of the WMA and I am excited
\nto share with you some of my experiences. I
\nam pushing many issues and I would like to
\nnow highlight some of them.
\nThroughout the year I have pushed, and I
\ncontinue to push now, the agenda of \ufb01ght-
\ning inequalities in health. On this note I am
\nhappy to report that at this Council session
\na draft resolution on Inequalities in Health
\nwill be discussed. I expect this discussion to
\nlead to the creation of a Work Group on the
\ntopic and I am sure the WMA will reap the
\nbene\ufb01ts of their work and e\ufb00orts for many
\nyears to come. The Israel Medical Associa-
\ntion has also prepared a summary on a sur-
\nvey regarding inequalities in health that was
\ndistributed to national medical associations
\nthrough the WMA. We received responses
\nfrom 17 associations and plan to use the re-
\nsults as a springboard for the work group.
\nIn parallel, I have been working with some
\nof my contacts around the world to create a
\nproject on inequalities in health.This project
\nincludes a few di\ufb00erent aspects but revolves
\naround obesity and diabetes in children. As
\na pediatrician I chose to focus on youth and
\nsince low socio-economic status contributes
\nto obesity and other health complications
\nsuch as diabetes, I focused on this as part
\nof the inequalities in health platform. The
\n\ufb01rst dimension of this project is being de-
\nveloped with the help of Professor Itamar
\nRaz. Together we are developing a special
\ninternet course for physicians on the subject
\nof diabetes.This course will include lectures
\nby internationally renowned diabetes ex-
\nperts and allow online participation from
\nphysicians. This course will provide a global
\nperspective on the issue and will provide
\ntips for physicians in treating diabetes, es-
\npecially to those from low socio-economic
\nbackgrounds. Prof. Raz has been enlisting
\nhis peers in the global medical community
\nto be involved in building the course and
\ngiving lectures. Prof. Raz has also contacted
\nNovo about funding and a decision is pend-
\ning. I hope that I will be able to be able to
\nupdate you on Novo’s positive answer in the
\nnear future.
\nThe second dimension of this project is being
\ndeveloped in conjunction with the American
\nItems from the 182nd
\nWMA Council meeting
\nin Tel Aviv, May 2009
\nwma 7-2.indd 86wma 7-2.indd 86 9\/29\/09 5:25:03 PM9\/29\/09 5:25:03 PM
\n87
\nWMA news
\nCollege of Endocrinology and American As-
\nsociation of Clinical Endocrinologists. The
\nACE\/AACE Power of Prevention program
\nwas initiated by Dr. Don Bergman. Through
\nintroductions provided by Dr. Yank Coble, I
\nhave discussed with members of the AACE
\nthe possibility of expanding Power of Preven-
\ntion to a global level.With the WMA behind
\nthis initiative, healthy lifestyle habits will be
\ntaught to people all over the world. The \ufb01rst
\nstep in this project is translating material that
\nis already available on the Power of Preven-
\ntion website and in their magazines. Interna-
\ntional content will then be added to the web-
\nsite, with some of this content being geared
\ntowards speci\ufb01c countries and some content
\napplicable to all countries. The AACE and I
\nare also discussing the possibility of creating
\na partnership through an entirely new project
\nthat will focus solely on obesity and diabetes.
\nDr. Yank Coble has been an active player in
\nthis collaboration and is currently investigat-
\ning avenues for funding of this project as well.
\nMy agenda as president of the WMA also
\nincludes the encouragement of Arab coun-
\ntries who are not yet involved, or members,
\nof the WMA to become involved.In this ca-
\npacity, I was privileged to attend the March
\nMeeting of the International Federation of
\nMedical Student’s Associations in Tunisia
\nthis year. I was thoroughly impressed by the
\nyoung doctors who organized and attended
\nthe conference. At the conference, I had
\nthe honor of presenting the WMA Medi-
\ncal Ethics Manual to a young and eager
\naudience. Unfortunately, while I was there
\nmembers of the Tunisian Medical Asso-
\nciation were unable to meet with me, but I
\nbelieve the young generation of leaders that
\nI met will eventually propel their national
\nmedical associations to greater collabora-
\ntion. The young generation is interested in
\npursuing more global medical collaboration
\nthrough organizations such as the WMA.
\nI look forward to greater cooperation from
\nthese countries in the near future.
\nMore speci\ufb01cally, through some of my con-
\ntacts in Israel I have made overtures to con-
\ntacts in Tunisia and Morocco in attempt to
\ngreater integrate their medical associations
\nin the WMA. There are many WMA proj-
\nects that they could bene\ufb01t from partici-
\npation in and many other WMA projects
\nthat could bene\ufb01t from their participation.I
\nhope that in the near future I will receive re-
\nsponses and meet with representatives from
\nthe medical associations in Tunisia and Mo-
\nrocco and be able to report positively back
\nto the Council.
\nMy presidency has also faced many unique
\nchallenges, primarily because of my Israeli
\ncitizenship. E\ufb00orts against me have intensi-
\n\ufb01ed in light of the con\ufb02ict in Gaza this year.
\nI must assure you all, as President of the
\nWMA and as President of the Israel Medical
\nAssociation since 1995; I have continuously
\nworked towards bettering the health of Pal-
\nestinians with this last con\ufb02ict in Gaza being
\nno exception. I have continuously and tire-
\nlessly intervened in cases where a Palestinian
\npatient was to be evicted from an Israeli hos-
\npital due to lack of funds; intervened,includ-
\ning by way of petitions to the High Court
\nof Justice, in situations where Palestinian
\npatients, physicians or medical students en-
\ncountered di\ufb03culties at Israeli checkpoints;
\nand called for funds to be transferred to the
\nPA in the form of food and medicineso that
\nhelp could be given where it is truly needed.
\nDuring the recent con\ufb02ict in Gaza I was in
\nconstant contact with various government
\no\ufb03cials in positions to help the Palestinians.
\nI wrote regarding the restriction of medical
\npersonnel in passing from the West Bank
\nto their place of work, regarding the hu-
\nmanitarian situation in the Gaza strip and
\nregarding the safety of medical personnel in
\nthe Gaza strip. I have done my utmost and
\nI continue to work for the health of the Pal-
\nestinians. That being said, there is nothing
\nI can do for combatants who target inno-
\ncents and use innocents as human shields.
\nHamas, a terrorist organization, abhorrently
\nuses hospitals and schools and even a zoo as
\nshields. I sincerely hope that all con\ufb02icts in
\nthis region and around the world will not
\nturn to violence. When this happens, we
\nphysicians will be allowed to focus on pro-
\nviding the highest level of care and not have
\nto spend so much of our e\ufb00orts on patch-
\ning up wounds in\ufb02icted by other people. As
\nit says in Isaiah 2:4, \u00ab\u00a0Nation shall not lift
\nup sword against nation, neither shall they
\nlearn war any more.\u00a0\u00bb
\nI look forward to a fruitful Council meet-
\ning. I am proud of the work that the WMA
\ndoes and the many ways it a\ufb00ects the medi-
\ncal community \u2013 both globally and the im-
\npact of the WMA on individual physicians
\nin di\ufb00erent countries. Throughout my years
\nbeing active in the WMA I have been ex-
\nposed to the great impact the WMA makes
\nand I am proud to be part of it. It is an hon-
\nour and a privilege for me to serve as this
\nyear’s President and I hope that my work
\nwill contribute to the WMA\u201d.
\nFrom the Secretary General\u2019s Reports
\n1. Policy
\nMulti Drug ResistantTuberculosis Project
\n\u201cThe second phase of the Lilly MDR-TB
\npartnership began in May 2008. The con-
\ntinuation of this project includes the devel-
\nopment of a TB refresher course for physi-
\ncians, which will serve as an introductory
\ncourse for the existing MDR-TB course.
\nThe New Jersey Medical School Global
\nTB Institute has \ufb01nalised the draft version
\nof the word document of the TB refresher
\ncourse and has send it out to international
\nTB experts for review. After the review pro-
\ncess the MDR-TB and TB refresher course
\nwill be adjusted in their design and will be
\nmade more interactive with case studies,
\nvideos and more.
\nWHO recently updated their MDR-TB
\nguidelines and emphasise now more on
\ninfection control and laboratory diagno-
\nsis. Based on this and on the International
\nStandards of TB Care we updated our
\nMDR-TB course as well. The MDR-TB
\ncourse has been already translated into
\nwma 7-2.indd 87wma 7-2.indd 87 9\/29\/09 5:25:04 PM9\/29\/09 5:25:04 PM
\n88
\nWMA news
\nSpanish, Russian, Chinese and Azeri and
\nFrench will follow soon. Within the next
\nfew months all courses will be available on
\nthe new server of the Norwegian Medical
\nAssociation.
\nA \u201ctrain-the-trainer course in MDR-TB\u201d
\nwill create champions in the \ufb01eld of TB on a
\nlocal level. Physicians who are experts in TB
\nreceive training in adult learning and accel-
\nerated learning principles in order to better
\nteach their colleagues. The \ufb01rst of a series of
\nworkshops took place in Pretoria, South Af-
\nrica in November 2008 and the next one will
\nfollow in India this year. In cooperation with
\nthe Foundation of Professional Develop-
\nment, 15 physicians from South Africa and
\n\ufb01ve WHO consultants from Namibia,Leso-
\ntho,South Africa and Kenya,were trained in
\na three-day workshop consisting of interac-
\ntive facilitation skills, group assessment and
\neducational strategies. In case studies, role-
\nplays and interactive methodology they im-
\nmediately applied the adult learning theory
\nwithin their group and received feedback
\nfrom the facilitators and the other partici-
\npants. The Indian Medical Association is
\norganising a similar workshop just prior to
\nthe General Assembly. The Chinese Medi-
\ncal Association announced that it would like
\nto organise within the MDR-TB project a
\ntrain-the-trainer workshop or a GP training
\nin MDR-TB as well.
\nThe WHO is in the process of developing a
\n\u201ePolicy on ethics in the TB setting\u201c, with a
\ngoal for its adoption at the World Health As-
\nsembly in 2010.The WMA has been invited
\nto address the issues related to health profes-
\nsionals in the policy. Dr. Je\ufb00 Blackmer from
\nthe Canadian Medical Association kindly
\no\ufb00ered to draft this part of the policy. The
\n\ufb01rst WHO work group meeting to discuss
\nthe policy took place in December 2008 in
\nToronto.Over the next few months the draft
\npolicy will be discussed and revised at several
\ninternational meetings on Ethics and TB.
\nGiven the already critical shortage of health
\nproviders and generally weak health sys-
\ntems in the regions most a\ufb00ected by XDR-
\nTB and MDR-TB, anxiety about safety in
\nthe health care environment runs high and
\ncan dissuade health providers from accept-
\ning assignments in these settings. A set of
\n\u201cInter-professional workshops on health
\ncare worker safety in the context of drug
\nresistant TB\u201d in low and middle-income
\ncountries addressed TB infection protec-
\ntion, with the objective of identifying good
\npractices, implementing joint recommenda-
\ntions for facilities and health workers and
\nestablishing a working group with a plan
\nof action to communicate the identi\ufb01ed
\npractices and recommendations. WMA, to-
\ngether with our South African member and
\nthe ICN, IHF and ICRC, organised the
\n\ufb01rst workshop in Cape Town South Africa
\nin November 2007. a second one took place
\ntogether with the Brazilian Medical Asso-
\nciation in Rio De Janeiro, Brazil in March
\n2009 and the next one will be in South Af-
\nrica again, in Durban in June 2009.
\nTogether with the other NGO partners in-
\nvolved in the \ufb01ght against MDR-TB, the
\nWMA participated in a Brie\ufb01ng on the is-
\nsue for the diplomatic missions in Geneva on
\nMarch19th
\nwhichwasWorldTBDay. MDR-
\nTB still does not receive enough attention and
\nglobal advocacy is urgently needed.
\nOn the invitation of the German Asso-
\nciation of Research-Based Pharmaceutical
\nCompanies, the Secretary General pre-
\nsented the work in the \ufb01eld of MDR-TB to
\nGerman Members of Parliament in Berlin
\non March 19th
\n, 2009. The discussion served
\nto stimulate interest in the re-occurrence of
\ntuberculosis and its relevance for countries
\nthat still have decline in TB incidence.
\nTobacco project
\nThe WMA joined the implementation pro-
\ncess of the WHO Framework Conven-
\ntion on Tobacco Control (FCTC) http:\/\/
\nwww.who.int\/tobacco\/framework\/en\/. The
\nFCTC is an international treaty that con-
\ndemns tobacco as an addictive substance, im-
\nwma 7-2.indd 88wma 7-2.indd 88 9\/29\/09 5:25:04 PM9\/29\/09 5:25:04 PM
\n89
\nWMA news
\nposes bans on advertising and promotion of
\ntobacco and rea\ufb03rms the right of all people to
\nthe highest standard of health.The \ufb01rst inter-
\nnational treaty negotiated under the auspices
\nof the WHO,the FCTC entered into force in
\n2005 and is the most widely embraced treaty
\nin UN history, with 168 signatories and 154
\nrati\ufb01cations to date.
\nWHO FCTC held its Third Conference of
\nthe Parties (COP3) in Durban from 17-22.
\nNovember 2008 to discuss and amend single
\narticles of the treaty and receive the report of
\nthe working groups which are implemented
\nfor some of the articles. WMA is a member
\nof the working groups on article 12 – edu-
\ncation, communication, training and public
\nawareness- and article 14 – measures con-
\ncerning tobacco dependence and cessation.
\nWMA was represented at the COP3 confer-
\nence by Dr.Julia Seyer.WHO recognised the
\nengagement of WMA in this process and is
\neager to increase the cooperation with physi-
\ncians on the international and especially on
\nthe national level.
\nHealth Workforce
\nWMA continues its close involvement in the
\nPositive Practice Environment Campaign
\n(PPE).This global 5-year campaign \u2013 spear-
\nheaded by WHPA members together with
\nthe World Confederation for Physical Ther-
\napy and the International Hospital Federa-
\ntion – aims to ensure high-quality healthcare
\nworkplaces worldwide.During this reporting
\nperiod, the PPE partners have been in dis-
\ncussion with the Global Health Workforce
\nAlliance (GHWA) about the continuation
\nof the project and also explored funding op-
\nportunities. The appointment last March of
\na full-time coordinator in charge of running
\nthe campaign on behalf of the organization
\nmembers, will allow the PPE to kick o\ufb00 in
\nthree selected countries: Uganda, Morocco
\nand Zambia. Taiwan will also be involved in
\nthe PPE as a self-funded country.
\nAt the invitation of the Iceland Medical As-
\nsociation and WMA past president, Dr. Jon
\nSnaedal, the World Medical Association
\nconvened a Seminar on Human Resources
\nfor Health and the Future of Health Care
\non 8-9 March, 2009. This seminar was an
\ne\ufb00ort to bring together stakeholders from a
\nrange of health professions to focus on these
\nissues and help WMA de\ufb01ne some policy
\npriorities in its approach to the subject. The
\n\ufb01nal report of the event includes ideas to
\nfacilitate WMA policy development in this
\narea. WMA Advocacy Working Group will
\nconsider these proposals and explore follow-
\nup opportunities.
\nIn early March, WMA was invited to take
\npart in the planning process of the next
\nConference on Workplace Violence in the
\nHealth Sector, which is scheduled to take
\nplace on 27 – 29 October 2010 in Amster-
\ndam. The event is supported by the Global
\nHealth Workforce Alliance (GHWA),
\nWHO, International Labour Organisation
\n(ILO), the International Council of Nurses
\n(ICN), Public Services International (PSI)
\nand other relevant health organizations. We
\nare still in the very early preparation stage of
\nthis event. The WMA Secretariat intends
\nto take an active role and to involve con-
\nstituent members as appropriate.
\nWHO is developing \u201cGuidelines on reten-
\ntion strategies for health professionals in
\nrural areas\u201d, which should be adopted at the
\nWorld Health Assembly 2010. The aim is to
\nensure access to health care for people living
\nin rural areas and thus improve the health
\noutcomes, including the Millennium Devel-
\nopment Goals (MDGs). The guidelines will
\nbe based on three pillars: educational and
\nregulatory incentives,monetary incentives and
\nmanagement,environment and social support.
\nDecision makers on the national and local lev-
\nel and health facilities should receive evidence
\non the impact and e\ufb00ectiveness of various
\nretention strategies that have been tried and
\ntested. WMA, as the secretariat of the World
\nHealth Professions Alliance,is member of the
\ncore expert group developing the guidelines.
\nTwo meetings in Geneva have already taken
\nplace and the next one will be in June 2009.
\nWMA sta\ufb00 member Dr. Julia Seyer, as
\nsecretariat of the WHPA has been invited
\nto join an independent merit review panel
\norganized by the Global Health Research
\nInitiative. The panel will review research
\nproposals submitted in response to a com-
\npetition launch in January 2009 by the
\n\u201cAfrica Health Systems Initiative Sup-
\nport to African Research Partnerships\u201d
\nprogramme (AHSI-RES). AHSI-RES is
\na 5-year research programme (2008-2013)
\nthat forms one component of the Africa
\nHealth System Initiative (AHSI) supported
\nby the Canadian International Development
\nAgency (CIDA). AHSI is a 10-year initia-
\ntive focused on strengthening national-level
\nhealth strategies and architecture, ensuring
\nappropriate human resources for health,
\nstrengthening front-line service delivery
\nand building stronger health information
\nsystems, all with special attention to equity
\nconsiderations. The \ufb01rst AHSI-RES round
\nof the review process will be in June 2009.
\nWMA participates as a member of the steer-
\ning group in the Mobility of Health Profes-
\nsionalsresearchproject.Thegeneralobjective
\nof the research project is to assess the current
\ntrends of mobility of health professionals to,
\nfrom and within the European Union and
\ntheir reasons for moving.Research will also be
\nconducted in non- European sending and re-
\nceiving countries,but the focus lies on the EU.
\nThis research project is a medium-scale col-
\nlaborative project, with the goal of facilitating
\ninformed policy decisions on health systems
\nby developing a scienti\ufb01c evidence base relat-
\ned to the impact of mobility of health profes-
\nsionals. The \ufb01rst meeting with all partners was
\nheld in November 2008 in Brussels.
\nCounterfeit Medical Products
\nCounterfeit medicines are drugs manufac-
\ntured below established standards of safety,
\nquality and e\ufb03cacy and therefore risk caus-
\ning ill health and killing thousands of people
\nevery year. Experts estimate that 10 per cent
\nof medicines around the world could be
\ncounterfeit. The phenomenon has grown in
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\nrecent years due to increasing sophistication
\nof counterfeiting methods and the increasing
\namount of merchandise crossing borders.
\nAt the last Executive Board Meeting of the
\nWHO in January 2009,a 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 began on
\nthe de\ufb01nition of counterfeits versus sub-
\nstandard medicines. So far WHO has fo-
\ncused on counterfeits while largely ignoring
\nthe broader ( and more politically sensitive)
\ncategory 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.
\nWMA, together with the members of the
\nWHPA, organised a very well attended
\nMission and NGO brie\ufb01ng on this im-
\nportant topic in April 2009 just prior to the
\nWHA.The objective was to raise awareness
\nof this public health threat and communi-
\ncate the opinion of the health professions.
\nPrimary health Care
\nThe World Health Report of 2008, \u2018Pri-
\nmary Health Care \u2013 Now More Than
\nEver\u2019, critically assesses the way that health
\ncare is organized, \ufb01nanced, and delivered in
\nrich and poor countries around the world.
\nThe WHO report documents the failures
\nand shortcomings over the last decades that
\nhave left the health status of di\ufb00erent popu-
\nlations, both within and amongst countries,
\ndangerously out of balance.The report urges
\nthe importance of a holistic health care ap-
\nproach where primary health care plays an
\nimportant role as a facilitator between pre-
\nvention, secondary and tertiary care.The re-
\nport focuses health care systems on 4 pillars:
\nuniversal coverage, people-centred health
\ncare, leadership reform to make health au-
\nthorities more accountable and to promote
\nand protect public health in general. With
\nthe World Health Report 2008, and the
\nreport on Social Determinants of Health,
\nWHO placed inequity in health care and
\nsocial disparities at their centre of activities.
\nThe Executive Board of the WHO in Janu-
\nary 2009 discussed a draft resolution on pri-
\nmary health care, including health care sys-
\ntem strengthening. On behalf of the World
\nHealth Professions Alliance,the WMA made
\na public statement during the Executive Board
\nsession. Further debate will take place during
\nthe World Health Assembly in May 2009.
\nWHO invited WMA to take part in a global
\nconsultation on the contribution of health
\nprofessions to primary health care and the
\nglobal health agenda in June 2009.
\nAlcohol
\nIn May 2008, the World Health Assembly
\nadopted a resolution requiring WHO to
\nintensify its work to curb harmful use of al-
\ncohol. Members States call upon WHO to
\ndevelop a global strategy for this purpose.
\nThe resolution also requests the WHO Di-
\nrector- General to consult with intergovern-
\nmental organizations, health professionals,
\nnongovernmental organizations and eco-
\nnomic operators regarding ways in which
\nthey can contribute to reducing the harmful
\nuse of alcohol.In line with the WMA State-
\nment on Reducing the impact of alcohol on
\nhealth and society (WMA General Assem-
\nbly, Santiago 2005), the WMA secretariat
\nmonitors the drafting process of the WHO
\nstrategy and has developed contacts with
\nrelevant WHO o\ufb03cials and civil society or-
\nganisations to collaborate in the process.
\nOn the 23 October 2008, the WMA Advo-
\ncacy Advisor, Ms. Clarisse Delorme, mod-
\nerated an NGO brie\ufb01ng on reducing the
\nglobal alcohol harm, organised by GAPA
\n(Global Alcohol Policy Alliance). The ob-
\njectives of the brie\ufb01ng were to understand
\nthe WHO process related to the strategy,
\nto begin discussions on substantive and po-
\nlitical proposals to promote an e\ufb00ective, ev-
\nidence-based global strategy, and, \ufb01nally, to
\ndevelop further working relations between
\ncivil society actors involved in this area.
\nOn the 24 November 2008, Dr. Otmar
\nKloiber, and Ms. Clarisse Delorme, par-
\nticipated in the WHO roundtable meeting
\nwith representatives of NGOs and health
\nprofessionals on ways they could contrib-
\nute to reducing harmful use of alcohol.
\nThis was an opportunity to raise, amongst
\nothers issues, WMA\u2019s concerns that medi-
\ncal associations and individual physicians be
\nfully involved in WHO strategy on alcohol.
\nAs a follow-up to this, Ms. Clarisse De-
\nlorme, together with George Hacker from
\nGAPA, met with several Permanent Rep-
\nresentatives (Denmark, Sweden, Norway,
\nChile, South Africa, US, New Zealand) in
\nGeneva to discuss countries\u2019 positions and
\ninvolvement within the WHO regional
\nconsultative process on the draft strategy.
\nObesity and Diabetes
\nThe World Medical Association has devel-
\noped, together with the Geneva Social Ob-
\nservatory, a Workplace Strategy on Diabe-
\ntes and Wellness. The Workplace Strategy
\non Diabetes and Wellbeing is a guideline
\nfor employers and employees to educate and
\nraise awareness about diabetes, and provide
\nexamples of healthier lifestyles during work.
\nThe aim is to mitigate the ill e\ufb00ects of diabe-
\ntes on personal health, workplace productive
\nand health care costs. In a research study,ex-
\namples of activities to improve the well-be-
\ning of employees are collected and o\ufb00ered as
\na menu of choices for companies.Depending
\non their capacity and needs, companies can
\nimplement all or only individual parts of the
\nmenu. The guideline are now \ufb01nalised and
\nthe implementation phase will begin soon.
\nHealth and the environment
\nWMA Workgroup on Health and the
\nEnvironment, chaired by the Canadian
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\n91
\nWMA news
\nMedical Association, was established in the
\nsummer of 2008. For 2009, the workgroup
\nagreed to focus its attention on health and
\nclimate change,in view of the global United
\nNations conference on this topic in Co-
\npenhagen in December 2009. In 2010, the
\nworkgroup will focus on environmental
\ndegradation and the built environment.
\nIn January 2009, the workgroup produced
\na set of recommendations, which it circu-
\nlated to WMA constituent members for
\ninput prior to presentation of a resolution at
\nthe 182nd
\nCouncil Session in May 2009. A
\nWMA conference on health and climate
\nchange will take place on 1 September,
\n2009 in Copenhagen, with a view to \u201ctest-
\ning\u201d and developing further WMA recom-
\nmendations. Following further revision
\nafter this conference, the WMA resolution
\nwill be considered again by the Council at
\nits pre-Assembly meeting. If approved, it
\nwill be submitted to the 2009 General As-
\nsembly for adoption. If adopted, the WMA
\nwill be in a position to advocate strongly for
\ninput and changes at the UN Conference in
\nCopenhagen in December 2009.
\nFollowing the adoption by the 2008 Gen-
\neral Assembly of the WMA Statement on
\nReducing the Global Burden of Mercury,
\nWMA joined the UNEP Global Mercury
\nPartnership in December 2008 in order to
\ncontribute to the partnership goal to pro-
\ntect human health and the global environ-
\nment from the release of mercury and its
\ncompounds (http:\/\/www.chem.unep.ch\/
\nMERCURY\/Sector-Speci\ufb01c-Information\/
\nMercury-in-products.htm)
\nHuman Rights
\nDuring the reporting period, the WMA
\nsecretariat launched several lobbying ac-
\ntions, based on information from Amnesty
\ninternational, to support physicians in dis-
\ntress worldwide:
\n2 Egyptian doctors Raouf Amin al-Arabi
\nand Shawqi Abd Rabbuh sentenced to 15
\nand 20 years of prison and 1500 and 1700
\nlashes respectively in Saudi Arabia for hav-
\ning facilitated the addiction of a patient to
\nmorphine after prescribing the medicine for
\nher pain relief following an accident – De-
\ncember 2008
\nDr. Arash Alaei and Kamiar Alaei (Republic
\nof Iran) sentenced to 6 and 3 years of impris-
\nonment respectively for \u2018cooperating with
\nan enemy government\u2019, speci\ufb01cally with US
\ninstitutions in the \ufb01eld of HIV & AIDS pre-
\nvention and treatment – January 2009;
\nThe WMA also intervened on behalf of
\nMajid Movahedi who was sentenced last
\nMarch in Iran to be blinded in both eyes
\nwith acid \u2013 a process that would involve
\nmedical professionals. Recalling its \ufb01rm
\nopposition to punishments that constitute
\ncruel, inhuman and degrading treatment
\namounting to torture,WMA emphasizes in
\nthe letters to Iran authorities that, accord-
\ning to international medical standards, it is
\nunacceptable to involve physicians in this
\ninhuman and degrading treatment
\nWMA is actively involved in developing the
\n\u201cRight to Health as a Bridge to Peace in
\nthe Middle East\u201d joint seminar, which will
\nto take place 27-30 October 2009 in Tur-
\nkey. The seminar is being organised by the
\nInternational Federation of Health and Hu-
\nman Rights Organisations (IFHHRO), the
\nNorwegian Medical Association (NMA),
\nthe Human Rights Foundation of Turkey
\n(HRFT), the Turkish Medical Association
\n(TMA) and the WMA. The objectives of the
\nmeeting are to discuss what role the medical
\nprofession can play in securing equal access
\nto health care for the population and to fa-
\ncilitate the communication among health
\nprofessionals in the participating nations.
\nWMA maintained regular contact with
\nAnand Grover, the UN Special Rappor-
\nteur on Health in order to increase the role
\nof health professionals in the promotion of
\nthe human right to the highest attainable
\nstandard of health.
\nSocial determinants of health
\nIn August 2008, the Commission on Social
\nDeterminants of Health published its \ufb01nal
\nreport \u201cClosing the Gap in a Generation \u2013
\nHealth Equity through Action on the
\nSocial Determinants of Health\u201d. In this
\n200-page report, the Commission addresses
\nglobal health through social determinants,
\ni.e., the structural determinants and condi-
\ntions of daily life responsible for a major
\npart of health inequities among and within
\ncountries,and proposes a new global agenda
\nfor health equity.
\nWMA \u2013 on behalf of the World Health
\nProfessions Alliance (WHPA) – presented
\na statement on this report, with a focus on
\nthe health workforce. In this statement, the
\nWHPA welcomed the recommendation
\ndirected at national governments and do-
\nnors to \u201cincrease investment in medical and
\nhealth personnel\u201d, but regretted that the
\nreport in general does not give more atten-
\ntion to health professionals as key players in
\naddressing the social determinants of health
\nand the inequalities health professionals
\nface in their daily work.
\nEthics
\nClinical research involving human subjects
\nhas proliferated in developing countries in
\nthe recent past, increasing concerns about
\nethical and legal implications of miscon-
\nduct and violations of subjects\u2019 human
\nrights and welfare because scienti\ufb01c and
\nethical review of protocols are inadequate
\nor as a result of poor or absent drug regu-
\nlatory systems. WMA was invited to the
\ninternational Round Table – Biomedical
\nResearch in Developing Countries: the
\nPromotion of Ethics, Human Rights and
\nJustice – to compare and exchange exper-
\ntise and experiences between national and
\ninternational institutions, on the issue of
\nprotection of human participants in bio-
\nmedical research. Participants stressed the
\nimportance of building capacity in bio-
\nmedical ethics review in developing coun-
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\n92
\nWMA news
\ntries by supporting education and training
\ncurricula of health professionals and com-
\nmunity health workers, in order to facili-
\ntate the creation of institutional Research
\nEthics Committees.
\nSpeaking book
\nWMA launched the Speaking book on
\nClinical Trials on the occasion of its Gen-
\neral Assembly in Seoul 2008. This project
\nwas done together with the South African
\nMedical Association, the SADAG (South
\nAfrican Depression & Anxiety Group) and
\nthe Steve Biko Centre for Bioethics in Jo-
\nhannesburg. The purpose of the project is to
\nprovide proper information on clinical re-
\nsearch to illiterate populations so that they
\ncan make informed decisions about partici-
\npation. The project was made possible by
\nan unrestricted educational grant provided
\nby P\ufb01zer, Inc.
\nCaring Physicians of the World (CPW)
\nInitiative \u201cLeadership Course\u201d
\nThe CPW Project began with the Caring
\nPhysicians of the World book, published
\nin October 2005 in English and then pub-
\nlished in Spanish in March 2007. Regional
\nconferences were held in Latin America,
\nAsia-Paci\ufb01c and Africa regions. The CPW
\nProject was extended to include a leadership
\ncourse organized by the INSEAD Business
\nSchool in Fontainebleau, France, in De-
\ncember 2007, in which thirty-two medical
\nleaders from a wide range of countries par-
\nticipated and the second Leadership Course
\nwas held at the same place in December
\n2008 for one-week with thirty participants
\nand it turned out with successful results
\nand feedbacks. Planning has begun for the
\nthird Leadership Course at the INSEAD
\nBusiness School in Singapore in February
\n2010. The curriculum includes training in
\ndecision-making, policy work, negotiating
\nand coalition building, intercultural rela-
\ntions and media relations. The courses were
\nmade possible by an unrestricted education-
\nal grant provided by P\ufb01zer, Inc.
\n2. External Relations
\nWorld Health Professions Alliance
\nThe WPHA is now a decade old.The context
\nwithin which it is working has changed, and
\nso have the organisations which make up the
\nalliance.Three of the four organisations have
\ntaken on new leadership since the alliance
\nwas created. As a result, the CEO\u2019s feel that
\nit is time to refresh its strategy, and identify
\nhow it can best use the resources available to
\nachieve its objectives. This will be done in a
\ntwo-day strategy seminar in June 2009.
\nWorld Federation for Medical Education
\nThe WFME brings together medical facul-
\nties and the profession. During recent years
\nit has focused on describing global standards
\nfor basic and post-graduate education of
\nphysicians as well as for the Continuing Pro-
\nfessional Development. The WMA General
\nAssembly endorsed these standards.
\nCurrently, the WFME works on encourag-
\ning and supporting countries and medical
\nschools to engage in, or to improve, their ac-
\ncreditation. Although not itself an accredit-
\ning body,the WFME – together with WHO
\n– strongly support the use of accreditation as
\na method of documenting and improving the
\nquality of education and achieving compara-
\nbility in the international arena.
\nBased on a mutual agreement with the
\nWHO, the WFME together with the Uni-
\nversity of Copenhagen (which hosts the
\nWFME o\ufb03ce) has taken over from WHO
\nHeadquarter the register of institutions
\nfor higher education in health care. The
\nWFME now develops this register in an
\nonline database called Avicenna Directo-
\nries, which will not only list the institutions
\nas named by their governments, but also
\nprovide information about their accredita-
\ntion status and the accrediting body.
\nAdministration
\nAfter renegotiating the contract with the
\ncompany DGN-Service, the WMA has
\n\ufb01nally signed a contract with DGN to de-
\nvelop and install a new web portal for the
\nWMA.The new web portal will provide the
\nplatform for cooperation with the members
\nof WMA, allow online payments for meet-
\nings, books and associate membership dues,
\nand, most of all, it will facilitate more timely
\npresentation of content on the public web-
\nsite. Work on the new design and infor-
\nmation structure, as well as for the payment
\nsystem, is underway.
\nThe Secretariat wishes to record its appre-
\nciation to member associations and interna-
\ntional organizations for their interest in, and
\ncooperation with, the World Medical Asso-
\nciation and its Council during the past year.
\nIt thanks all those who have represented the
\nWMA at various meetings and gratefully ac-
\nknowledges the collaboration and guidance
\nreceived from the o\ufb03cers, as well as the As-
\nsociation’s editors, its legal, public relations
\nand \ufb01nancial advisors, and its o\ufb03cials.\u201d
\nCouncil then received the Reports of
\nStanding Committees, noting the appoint-
\nment of Dr. Jen Winther Jensen as Chair
\nof Ethics Committee, of Dr. Haikerwal as
\nChair of Finance and Planning and of Dr.
\nJ.C.Gomez Amiral as Chair of Medical
\nSocial A\ufb00airs Committee.
\nEthics Committee Report
\nIn the course of consideration of the re-
\nport of the Ethics Committee, Council ap-
\nproved the following new or revised state-
\nments for referral to the General Assembly
\nand recommended their adoption:
\nDeclaration of Madrid on Professionally\u2022
\nled Regulation ( revised May 2009);
\nStatement on Con\ufb02ict of Interest\u2022
\nRevision of WMA Declaration of Ot-\u2022
\ntawa on Child Health (Section 1)
\nRevision of Statement of Medical Pro-\u2022
\ncess Patents
\nWMA (revised) Statement on Genetics\u2022
\nand Medicine.
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\nWMA news
\nThe Global Health Workforce Alliance
\n(GHWA) is organising regularly online
\ndiscussions on topics dealing with health
\nworkforce issues.The \ufb01rst one was on Task-
\nShifting in May 2009. Over a duration of
\nnine days round about 250 experts, health
\nprofessionals and politicians from 56 coun-
\ntries highlighted di\ufb00erent important themes
\nof Task Shifting.
\nThe discussion started with an acknowl-
\nedgement of a global shortage of health
\nworkforce, which results in unmet health
\ncare needs in many areas of the world.
\nHowever the problem lies not only in the
\nquantity of delivered health care, it\u2019s also
\nvery important to deliver high quality of
\ncare worldwide, even in areas with a high
\nburden of health care workers shortage.One
\nway to achieve the high quality of care is to
\nshift from an public health care approach
\nonly toward a patient focussed care within a
\nCouncil also approved section 2 of this revi-
\nsion to be used as a guideline for Advocacy..
\nCouncil also approved the Third section of
\nthe revision of the Declaration of Ottawa
\n(revised) for publication on the WMA web-
\nsite, on the understanding that it was not
\nWMA policy. Council approved the ap-
\npointment of Ms Delorme as the WMA\u2019s
\nnominated representative to the Interna-
\ntional Rehabilitation Council on Torture
\nVictims, replacing Professor Nathansen
\nwhose six year term had expired.
\nMedico-Social A\ufb00airs Committee.
\nCouncil approved the following new or
\nrevised Statements and Resolutions to be
\nforwarded with a Recommendation for ap-
\nproval by the General Assembly:
\nDeclaration with Guidelines for Con-\u2022
\ntinuous Quality Improvement in Health
\nCare
\nRevised WMA Resolution on the Medi-\u2022
\ncal Workforce ( as amended)
\nRevised Resolution on Improved Invest-\u2022
\nment in Health now entitled
\n\u201cImproved Investing in Public Health\u201d\u2022
\nProposed Statement on Health and Cli-\u2022
\nmate Change\u201d
\nFinance and Planning Committee
\nCouncil noted that the Committee had re-
\nceived reports on Dues, the Interim unau-
\ndited Financial Statement,and an oral report
\non the Strategic Plan. It was also informed
\nthat the arrangements for the General As-
\nsembly in New Delhi in October 2009 and
\nin Vancouver 2010 had been approved and
\nthat in connection with Future Meeting
\nPlanning, invitations for the 188th
\nGeneral
\nAssembly had been received from the Czech
\nand Australian Medical Associations. It was
\nalso reported that the WMA website was
\nbeing redeveloped and it was hoped that
\nthis would be launched at the meeting in
\nNew Delhi later this year..
\nCouncil also approved a proposal \u201cCoop-
\nerative Relations with Academic Centres
\nand Institutes\u201d.
\nWorld Health Assembly(WHA)
\nCouncil received a report on the agenda for
\nthe World Health Assembly of WHO and
\nthe Advocacy Advisor spoke on the logistics
\nand the WMA activities during the WHA.
\nthe following week,
\nOther business
\nCouncilResolutiononMedicalNeutrality
\nThe Israel Medical Association introduced
\na new proposed resolution (Council 182\/
\nResolution Medical Neutrality\/May2009)
\nrea\ufb03rming existing WMA policy. The
\nCouncil made one amendment to the docu-
\nment and approved the revised resolution.
\n(Council 182\/Resolution Medical Neutral-
\nity\/May2009)..
\nNuclear Weapons
\nA report that the Japanese Medical Asso-
\nciation (JMA) had adopted a Resolution
\non the Abolition of Nuclear Weapons was
\nsupported by Council rea\ufb03rming WMA
\nexisting policy on Nuclear Weapons (.) The
\nJMA also reported that it was trying to in-
\nvolve physicians in environmental issues
\nProhibition of Physician
\nParticipation in Torture
\nCouncil also amended and adopted a
\nResolution from the Norwegian Medical
\nAssociation(NMA) revising the WMA reso-
\nlution on Prohibition of Physician Partici-
\npation in Torture. (Council 182?Resolution
\nNon-participation on Torture\/May2009\/
\nRev) )
\nThe American Medical Association( AMA)
\nrequested that copies of a letter to President
\nObama from the AMA be circulated to
\nCouncil. This expressed its grave concern
\nabout the allegations of involvement of
\nhealth personnel in torture of detainees and
\no\ufb00ered the President its assistance in ensur-
\ning that all physicians were aware of their
\nethical obligations and that such actions
\nnever occur under US jurisdiction.
\nViolence against Physicians
\nThe Spanish Medical Association (EsMA)
\nreported that violence against health profes-
\nsionals was now a major problem in Spain.
\nDr. Alan J. Rowe, Co\u2013Editor of
\nthe World Medical Journal
\nTask Shifting On-Line Moderated Discussion
\nSummary of the discussion, held in May 2009
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\nQuality Control – standards of profes-6.
\nsionalism must be created, monitored
\nand maintained.
\nSystems Development – task shifting7.
\nshould take place within a proper func-
\ntioning system to ensure smooth func-
\ntionality.
\nRegulations – to ensure that equity, re-8.
\nspect, and uniformity of personhood
\nis brought to the persons who are part
\nof the new cadres of workers. Legal
\nframeworks that would support task
\nshifting must be put into place. Task
\nshifting should not be considered cheap
\nlabour.
\nRetention – solutions must be found9.
\nthat will ensure that individuals remain
\ni) not only within the health care sys-
\ntem, but ii) within their own countries’
\nhealth care system and in iii) the areas
\n(regional and district) where demand
\nfor services is greatest.Thus career paths
\nmust be set, incentives created and ac-
\nknowledgements introduced.
\nMore information about this topic and the
\nreport of the discussions can be found under
\nthe link http:\/\/www.who.int\/workforcealli-
\nance\/en\/
\nEach WMA member is welcomed to partic-
\nipate in future GHWA online discussions.
\nIn order to get registered at the GHWA
\nonline platform please contact either Julia
\nSeyer Julia.seyer@wma.net or directly to
\nYann Siegenthaler at GHWA siegenthale-
\nry@who.int .
\nJulia Seyer, WMA Medical Advisor
\nShaping the Future of Health Professionals\u2019 Regulation
\n2nd
\nWorld Health Professions Conference on Regulation
\nThe regulation of health professionals is
\nemerging as one of the most topical issues
\namong health care disciplines in the 21st
\ncentury. Next February 18th
\n,19th
\n2010, the
\n2nd
\nWorld Health Professions Conference
\non Regulation WHPCR 2010 will be held
\nin Geneva, hosted by the World Health
\nProfessions Alliance and World Council of
\nPhysio Therapy.
\nProfessions,governments and policy makers
\nalike are devoting time, money and energy
\ninto investigating how regulation can im-
\nprove comprehensive patient care and out-
\ncomes, and decrease the costs of healthcare.
\nThat is why the World Health Professions
\nAlliance, with World Council of Physio
\nTherapy, has taken up the task of bringing
\ntogether experts in all \ufb01elds of healthcare
\nand regulatory policy at the World Health
\nProfessions Conference on Regulation
\nWHPCR 2010.
\nThis will be the second such conference \u2013
\nthe \ufb01rst was held in May 2008 and was met
\nwith an overwhelmingly positive attend-
\nance and response. Over 500 participants,
\nrepresenting a diverse selection of health
\npractitioners and policy makers, were en-
\ngaged in the theme \u201cThe role and future of
\nhealth professions regulation\u201d.
\nThis time the theme will be \u201cShaping the
\nfuture of health professionals\u2019regulation\u201d. It
\nwill be an opportunity for learning, knowl-
\nedge exchange and multidisciplinary profes-
\nsional growth on an international platform,
\nand is aimed at professional organisations,
\nrepresentatives of regulatory bodies, gov-
\nernments, along with leaders in healthcare,
\nacademia and patient groups. All confer-
\nence delegates will be invited to participate
\nin the \ufb01rst ever global survey designed to
\ncapture information about the regulation of
\nhealth professionals. Data obtained from
\nthis survey will be presented early in the
\nconference and be available for discussion
\nduring the professional group sessions.
\nRegulation is a consequence of the social
\ncontract established between professions
\nand society representatives (i.e. govern-
\npublic health care system approach as well.
\nEmphasis lies also on preventive care,health
\npromotion and \u201chealth literacy\u201d(which is to
\nteaching individuals how to better take care
\nof themselves).
\nFurthermore it is important to focus on ca-
\npacity building and training to attract,retain
\nand educate health professionals. The re-
\ngional imbalance of capacity building leads
\nto migration of health professionals and a
\nlack of health professionals and specialists
\nfor certain diseases.
\nWhile implementing task shifting in the
\nhealthcaresystemmuchresistanceisencoun-
\ntered.The fear in general is that task shifting
\nleads to a downgrading of quality care and
\nends in two class health care. Therefore it\u2019s
\nimportant to understand which type of care
\ncould be shifted?, are the health workers or
\nnew cadres quali\ufb01ed for this?, who is taking
\nthe responsibility and is there supervision?.
\nSometimes governments use task shifting
\nand the implementation of these new cadres
\nas short-term solutions to address the human
\nresources in health crises in countries.
\nKey Summary Recommendations
\nGiven the fact that task shifting could1.
\nbe considered when looking at solutions
\nto human resources in health shortages,
\nbroad recommendations \ufb02owed from
\nthe discussion:
\nPlanning – task shifting must be consid-2.
\nered as only one aspect of the national
\nhealth workforce and health care plan.
\nInvolvement of the local level – a bot-3.
\ntom-up approach in local level planning
\nto ensure what is demanded is necessary
\nand will be supported by the community.
\nAdaptability – there is no one size \ufb01ts all4.
\nfor task shifting thus the implementa-
\ntion of task shifting must be determined
\nin context – situation, resources and
\ntypes of tasks to be shifted.
\nEducation & Training – a minimum5.
\nlevel of education and well-structured
\ntraining programmes are necessary for a
\nsuccessful implementation of tasks.
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\nWMA news
\nAn integrated and e\ufb03cient health system
\nthat provides primary, secondary and tertia-
\nry care is an essential element of a healthy
\nand equitable society. In many parts of the
\nworld, where access to health care is limited
\nto certain groups of the population, there
\nis a persistence of profound inequalities in
\nhealth status.
\nUndocumented migrants are among the
\nmost vulnerable groups in society and they
\noccupy a position from which accessing
\nhealth care is very di\ufb03cult. While health
\ncare provisions are often in place for refu-
\ngees and asylum seekers, undocumented
\nmigrants are repeatedly excluded from so-
\ncial protection plans.
\nDe\ufb01nition
\nUndocumented migrants are people with-
\nout any residence permit authorising them
\nto stay in their desired country of residence.
\nThey may have been unsuccessful in the
\nasylum procedure, entered irregularly by
\nevading boarder control, entered using false
\ndocumentation, or overstayed their visa. In
\nreferring to this group we do not include
\nthose who have been granted refugee sta-
\ntus nor asylum seekers who have applied for
\nrefugee status and whose requests are being
\nprocessed. Asylum seekers whose applica-
\ntion for refugee status has been denied and
\nwhose residency is not o\ufb03cially tolerated
\nare considered undocumented migrants. Ir-
\nregular residency status,ineligibility to work
\nlegally, insu\ufb03cient and ambiguous health
\ncare entitlements, all in combination with
\nthe constant fear of being denounced, pre-
\nvent undocumented migrants from seeking
\nhealth care along normal paths.
\nIn referring to this group, the term \u201cun-
\ndocumented migrant\u201d as opposed to \u201cille-
\ngal migrant\u201d or \u201cillegal alien\u201d is preferred.
\nIn employing this alternative terminology
\nwe avoid the negative and discriminatory
\nstigma of \u2018criminal\u201d that is implied by \u2018ille-
\ngal migrant\u201d.
\nPregnant women, child birth and children
\nare particularly sensitive areas within the
\nlarger discussion of health care for undocu-
\nmented migrants. While this article does
\nnot provide speci\ufb01c details of these issues,
\nit recognizes that they may deserve the par-
\nticular attention of the WMA and national
\nmedical associations.
\nLack of Data
\nThere is little quantitative data about this
\npopulation\u2019s general health status and access
\nto health care.There is a need for publication
\nof data where it exists and further research
\nwhere it does not. Even the number of un-
\ndocumented migrants in Europe remains at
\nbest a rough estimate. Increased publication
\nof data,and research would prevent instanc-
\nes in which legislation is developed based
\non qualitative or anecdotal evidence.
\nThe 2007 the Hamburg Institute of Eco-
\nnomics was involved in a study funded by
\nthe European Commission, DG Research,
\nunder the Sixth Framework Programme,
\ncalled \u201cClandestino: Counting the Un-
\ncountable\u201d. This project estimates that in
\n2005, 2.8 – 6 million undocumented im-
\nmigrants resided in Europe. This number
\nincludes foreign nationals without any valid
\nresidence permit and working tourists, but
\nexcludes asylum seekers and o\ufb03cially toler-
\nated persons [1].
\nA report by M\u00e9decins du Monde in 2007
\npublished the \ufb01ndings of a survey given to
\n835 undocumented migrants from seven
\ncountries within Europe (Belgium, Spain,
\nFrance,Greece,Italy,Portugal,and the Unit-
\ned Kingdom). Among other \ufb01ndings, the
\nmost common reported health concerns were
\ndigestive, musculoskeletal, physiological and,
\nfor women, gynaecological [2]. This survey,
\nsimilar to others like it, is not representative
\nof the health status of the entire population
\nof undocumented migrants, as participants
\nhad already made contact with a treatment
\ncenter when they completed the survey.
\nBarriers to accessing health care for undoc-
\numented migrants vary signi\ufb01cantly among
\nmigrant-receiving countries, as national
\nlegislation varies. Though not providing
\nAccessing Health Care for Undocumented
\nMigrants – European observations
\nment). While the scope and practice of
\nmany healthcare professions change and
\nwill change throughout the world, so is and
\nwill be the regulation model. Regulation
\nencompasses many aspects of the health-
\ncare professionals\u2019 life, from their educa-
\ntion to their activities and their entry in the
\nprofession. Each of the chosen themes will
\nexplore these aspects of regulation and how
\neach profession may best contribute to the
\nconstructive evolution of health professions
\nregulation worldwide.
\nThe objectives for the themes of WHPCR
\n2010 are to:
\nDebate the future control and direction of\u2022
\nhealth professional regulation within the
\ncontext of changing scopes of practice;
\nExamine the regulatory and professional\u2022
\nissues related to the international migra-
\ntion of health professionals;
\nCritically evaluate the relationship be-\u2022
\ntween health professional education, reg-
\nulation and standards of practice.
\nThe 2nd
\nWorld Health Professions Confer-
\nence on Regulation (WHPCR 2010) 18-19
\nFebruary, 2010 Geneva. For more informa-
\ntion on the programme and how to register,
\nplease visit www.whpa.org\/whpcr2010
\nJulia Seyer, WMA Medical Advisor
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\n96
\nWMA news
\nspeci\ufb01c details into each of these situations,
\nthis article should serve as a general intro-
\nduction to the issue.
\nThere are a number of factors that prevent
\nundocumented migrants from seeking
\nhealth care along normal paths.
\nInsu\ufb03cient Entitlement
\nIn the majority of migrant-receiving coun-
\nties, health care entitlements for undocu-
\nmented migrants are insu\ufb03cient; entitle-
\nments are limited to \u201cemergency\u201d, \u201curgent\u201d,
\nor \u201cimmediately necessary\u201d care [3, 4].These
\nconcepts are poorly de\ufb01ned and, as a result,
\nthe provision or withholding of health care is
\noften at the discretion of health care sta\ufb00. In
\nsome instances these de\ufb01nitions are largely
\nmeaningless. In the case of chronically ill
\npatients, long-term regular treatment, which
\nmight not be considered emergency care, is
\nnonetheless vital to the patient\u2019s health. In
\nmany instances, national law does not re\ufb02ect
\ninternational obligations to recognize access
\nto health care as a basic human right.
\nArticle 25 of the 1947 United Nations Uni-
\nversal Declaration of Human Rights states
\n\u201cEveryone has the right to a standard of liv-
\ning adequate for the health and well-being
\nof himself and of his family, including food,
\nclothing,housing and medical care and neces-
\nsary social services,and the right to security in
\nthe event of unemployment, sickness, disabil-
\nity,widowhood,old age or other lack of liveli-
\nhood in circumstances beyond his control.\u201d
\nSimilarly, article 12 of the International
\nCovenant on Economic, Social and Cul-
\ntural Rights, which entered into force 1976
\nand which 160 parties have rati\ufb01ed to date,
\nstates that member states are obligated to
\nrecognize the \u201cright of everyone to the en-
\njoyment of the highest attainable standard
\nof physical and mental health.\u201d
\nAccording to the WHO fact sheet No.31 ti-
\ntled The Right to Health,\u201cthe right to health
\nis a fundamental part of our human rights and
\nof our understanding of a life in dignity.\u201d
\nThe WHO understands the Right to Health
\nto include the following entitlements: The
\nright to a system of health protection pro-
\nviding equality of opportunity for every-
\none to enjoy the highest attainable level
\nof health, the right to prevention, treat-
\nment and control of diseases, access to
\nessential medicines, maternal, child and
\nreproductive health, equal and timely ac-
\ncess to basic health services, the provision
\nof health-related education and informa-
\ntion, participation of the population in
\nhealth-related decision making at the na-
\ntional and community levels.
\nFurthermore, the WHO maintains that
\n\u201cNon-discrimination is a key principle in
\nhuman rights and is crucial to the enjoy-
\nment of the right to the highest attainable
\nstandard of health\u201d [5].
\nThe International Convention on the Pro-
\ntection of the Rights of all Migrant Work-
\ners and Members of Their Families, which
\nentered into force in 2003, seeks to outline
\nthe rights of migrant workers, including
\nthose residing irregularly whose irregular
\nstatus renders them natural targets of ex-
\nploitation. Articles 25 and 28 speak directly
\nto the right of health care of migrants resid-
\ning irregularly. Unfortunately, while several
\ncountries of origin of migrants have rati\ufb01ed
\nthe convention, critical western migrant-re-
\nceiving states have not. (neither the United
\nStates, Canada nor any nation of the Euro-
\npean Union has rati\ufb01ed the Convention).
\nSweden has been long hailed as a leader in
\nhuman rights and social welfare programs.
\nHealth care access of vulnerable groups in
\nSweden was examined by Paul Hunt, former
\nUN Special Rapporteur on Health, in his
\n2007 report \u201cMission to Sweden\u201d.This report
\nreveals some signi\ufb01cant gaps in the Swedish
\nhealth care system. In it he communicates
\nclearly the right to health as a fundamental
\nhuman right. He makes an interesting point
\nby distinguishing human rights from citizen
\nrights. In section 72 of his report he writes
\n\u201cThe Special Rapporteur notes that under
\ninternational human rights law, some rights,
\nnotably the right to participate in elections,
\nto vote and to stand for election,may be con-
\n\ufb01ned to citizens. However, human rights are,
\nin principle, to be enjoyed by all persons\u201d[6].
\nHealth care, as it follows, is not a citizen\u2019s
\nright but a human right. In many countries
\nthe right to health is not enjoyed universally
\nas it is linked to citizenship.
\nOften national law does not fully integrate
\nthe right to health into domestic policy. Ex-
\nclusionary legislation and in other cases lack
\nof legal entitlements limit access to second-
\nary care for undocumented migrants.
\nIn the UK, subsidized care to undocu-
\nmented migrants is limited to emergency
\ncare. Here, when undocumented migrants
\nare unsuccessful in registering with a GP to
\nacquire coverage under the National Health
\nSystem, they are liable for all charges for
\ncare beyond that deemed \u201curgent\u201d and \u201cim-
\nmediately necessary\u201d. In the UK a pregnant
\nundocumented woman with HIV is not
\nentitled to subsidized medication to reduce
\nthe risks of HIV transmission to her baby
\n[3]. In the UK all undocumented migrants
\nare liable for the full charge of ARV treat-
\nment. Undocumented migrants, as a popu-
\nlation, when left unable to access subsidized
\nhealth care, pose a risk to public health.
\nLack of Health Literacy
\nThere is signi\ufb01cant lack of awareness and
\nunderstanding of health care entitlements
\nof undocumented migrants on the part of
\nboth health care professionals and undocu-
\nmented migrants themselves. This concept
\ncan be referred to as Health Literacy. Even
\nin situations where legal entitlements to
\nsubsidized care do exits, a lack of aware-
\nness and understanding of entitlements and
\nother administrative barriers inhibit the re-
\nalization of those entitlements.
\nIn France undocumented migrants are
\ntheoretically entitled to State Medical As-
\nsistance (Aide M\u00e9dicale de l\u2019Etat \u2013 AME)
\nwhich entitles them to all kinds of free
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\n97
\nWMA news
\nhealth care. However, according to a report
\nreleased by M\u00e9decins du Monde in 2005,
\nthis right is rarely realized [7]. Undocu-
\nmented migrants often do not know they
\nhave the right to health care and when they
\ndo, sometimes have di\ufb03culty meeting ad-
\nministrative requirements. Among other
\ndocuments, applicants for AME coverage
\nare required to provide a valid identity card
\n(passport,birth certi\ufb01cate,national ID card)
\nand proof of residency in France (even if ir-
\nregular) for more than three months. Both
\nrequirements can prevent undocumented
\nmigrants from accessing healthcare.
\nIn Germany providing assistance to un-
\ndocumented migrants for \ufb01nancial gain can
\nbe criminalised under the \u201cpenalization of
\nassistance\u201d regulation and some public in-
\nstitutions have the \u201cduty to denounce\u201dwhen
\nthey interact with undocumented migrants.
\nWhile medical professionals are exempt
\nfrom both these regulations, a report by
\nNGO PICUM suggests that the mere ex-
\nistence of these laws creates an atmosphere
\nof distrust that further discourages undoc-
\numented migrants from seeking out the
\nhealthcare they may be entitled to [3].
\nEthical perspective versus
\npolitical perspective?
\nThe WMA Declaration of Geneva – In-
\nternational Code of Medical Ethics,adopted
\nin 1949 by the World Medical Association
\nduring its 3rd
\nGeneral Assembly, outlines a
\nphysician\u2019s ethical obligation to the patient.
\nThe Lisbon Declaration, adopted by the 34th
\nWorld Medical Assembly in 1981, outlines
\nthe rights of the patient. Within the Lisbon
\nDeclaration, Principle 1 – Right to Medical
\nCare of Good Quality speci\ufb01es that \u201cevery
\nperson is entitled without discrimination
\nto appropriate medical care.\u201d The Lisbon
\nDeclaration further speci\ufb01es that \u201cwhenever
\nlegislation, government action or any other
\nadministration or institution denies patients
\nthese rights,physicians should pursue appro-
\npriate means to assure or to restore them.\u201d
\nFrom some perspectives this clause could be
\napplied to the professional ethical dilemma
\nphysicians face as they treat undocumented
\nmigrants. National regulations may indicate
\nthat as a result of his or her status a patient
\nis not entitled to a particular form of care.
\nPhysicians, however, have the responsibility
\nto provide unbiased evaluation of patient
\nhealth and treatment. Once a patient\u2019s sta-
\ntus becomes known, physicians may have to
\ninterpret ambiguous health policy to deter-
\nmine whether care will be covered. In cases
\nwhere patients are liable for all charges,
\nphysicians may need to decide whether he
\nor she will give care to someone who may be
\nnot legally entitled to it. In situations where
\nundocumented migrants have no entitle-
\nments to healthcare beyond that which is
\n\u201cemergency\u201din nature,physicians who agree
\nto give care to undocumented migrants may
\nreceive no remuneration. Such regulations
\nattempt to force physicians to compromise
\ntheir ethical obligation to give treatment on
\na non discriminatory basis.
\nThe protection of the physician, therefore,
\ndeserves the particular attention of the
\nWMA. Individual physicians and hospitals
\nwho treat undocumented migrants should
\nnot be perceived as taking a political stance,
\nnor seen as acting in discordance with na-
\ntional regulations as they carry out their
\nethical obligations to provide care.
\nIn many countries access to state subsidized
\nhealth care is linked to legal residency status.
\nIn some nations there is a trend to strength-
\nen this link as a method of immigration
\ncontrol. Denying undocumented migrants
\naccess to health care becomes a punitive
\nmeasure; a method of deterring future ir-
\nregular immigration and encouraging those
\nwho are residing irregularly to leave. There
\nis debate surrounding not only the ethics
\nof this trend, but also the notion of health
\ncare as a \u201cpull factor\u201c.What role does access
\nto healthcare have in the decision-making
\nprocess of migrants? There is fear that equal
\naccess to health care for undocumented
\nmigrants would trigger a wave of irregular
\nimmigration that would overwhelm west-
\nern health care systems. Non governmental
\norganization PICUM argues that the belief
\nin health care as a \u201cpull factor\u201dis poorly sub-
\nstantiated [8, 9].
\nIt is the opinion of some that immigration
\npolicy should be kept entirely separate from
\nhealth care. According to Dr. Henry As-
\ncher of the Nordic School of Public Health
\nbased in Sweden, it is inappropriate for
\ndoctors to function as part of the immigra-
\ntion control system. He illustrated his point
\nwith the example of a physician working in
\nan emergency ward giving treatment to a
\ngroup of young people who have been in-
\njured following a street gang \ufb01ght. It is not
\nthe physician\u2019s role to make judgments in
\nregard to which of his or her patients acted
\nas aggressors and which were victims in the
\n\ufb01ght, and then proceed to give care based
\non these judgements. These judgments are
\nthe responsibility of the justice system. The
\nphysician should proceed by administering
\ntreatment based on severity of the condi-
\ntion. Similarly, requiring physicians to con-
\nsider the residency status of patients forces
\nphysicians to assume a role that is not theirs
\nand asks them to compromise their ethical
\nobligations to the patient.
\nDr. Ascher stresses the importance of pre-
\nserving public trust in health care providers.
\nJust as the public should have trust in the
\njustice system to defend the right to rep-
\nresentation and a fair trial, patients should
\nhave security in knowing that doctors will
\nevaluate their condition and administer ap-
\npropriate treatment based on no consider-
\nation beyond that of their health status.
\nA role for the WMA
\nThe World Medical Association could play
\na key role in identifying the role of national
\nmedical associations in addressing access
\nto health care of undocumented migrants.
\nThe WMA could encourage medical asso-
\nciations to support physicians as they hon-
\nour their ethical obligations to patients. In
\nconformity with WMA policy, this would
\nwma 7-2.indd 97wma 7-2.indd 97 9\/29\/09 5:25:08 PM9\/29\/09 5:25:08 PM
\n98
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\ndemonstrate WMA\u2019s dedication to reduce
\nhealth inequality through the development
\nof integrated and non-exclusionary health
\ncare systems around the world.
\nWMA survey
\nThe WMA recently created and sent a sur-
\nvey to member medical associations that
\nlooked into undocumented migrant access
\nto health care. Among the 18 participat-
\ning medical associations, 12 are within the
\nEuropean Union. 70% reported they were
\naware that undocumented migrants were
\nexperiencing di\ufb03culty in accessing health-
\ncare and 50% reported that they had taken
\nsome form of action to address the issue.
\nThese initiatives vary in nature and scale.
\n82% reported that they considered insu\ufb03-
\ncient entitlements and lack of health liter-
\nacy as barriers that prevent undocumented
\nmigrants from accessing care.
\nReferences
\n1. Hamborg Institute of international Economics,
\nDatabase on Irregular Migration, http:\/\/irregular-
\nmigration.hwwi.net\/Europe.5248.0.html
\n2. M\u00e9decins du Monde European Observatory on
\nAccess to Health Care, European survey on undoc-
\numented migrants access to health care, 2007, avail-
\nable at http:\/\/www.mdm-international.org\/IMG\/
\npdf\/rapportobservatoireenglish.pdf
\n3. PICUM (Platform for International Cooperation
\nfor Undocumented Migrants), Access to Health
\nCare for Undocumented Migrants in Europe, 2007,
\navailable at http:\/\/www.picum.org\/data\/Undocu-
\nmented%20Children%20in%20Euorpe%20EN.pdf
\n4. Averroes Project, Health for Undocumented Mi-
\ngrants and Alyssum Seekers Network, http:\/\/www.
\nhuma-network.org
\n5. UN O\ufb03ce of the High Commissioner for Hu-
\nman Rights, Fact Sheet No. 31, The Right to Health,
\nJune 2008, No. 31, available at: http:\/\/www.unhcr.
\norg\/refworld\/docid\/48625a742.html
\n6. Paul Hunt, Report of the Special Rapporteur
\non the right of everyone to the enjoyment of the
\nhighest attainable standard of physical and men-
\ntal health \u201cMission to Sweden\u201d, 2008, available at
\nhttp:\/\/www2.essex.ac.uk\/human_rights_centre\/rth\/
\ndocs\/sweden.pdf
\n7. M\u00e9decins du Monde, Rapport 2005 de l\u2019obser-
\nvatoire de l\u2019Acc\u00e8s aux Soins de la Mission France
\nde M\u00e9decins du Monde, 2005, avalable at http:\/\/
\nwww.medecinsdumonde.org\/thematiques\/l_obser-
\nvatoire_de_l_acces_aux_soins
\n8. Robinson. V and Segrott.J, Understanding the
\ndecision making of asylum seekers,Home o\ufb03ce Re-
\nsearch Study, Home o\ufb03ce Research, Development,
\nand Statistics Directorate, 2002, available at http:\/\/
\nwww.homeo\ufb03ce.gov.uk\/rds\/pdfs2\/r172.pdf
\n9.Albrecht,H.J Fortress Europe? Controlling illegal
\nimmigration, European Journal of Crime, Criminal
\nLaw and Criminal Justice, Volume 10, Number 1,
\n2002 , pp. 1-22(22); 2002.
\nLauren Storwick, WMA Secretariat
\nMost people would not knowingly buy
\ngoods produced by children in dangerous
\nconditions, earning less than US $2 a day.
\nYet unfair and unethical working condi-
\ntions are behind the supply of some medi-
\ncal products and services to health systems
\nthroughout the world.
\nAn article in the British Medical Journal
\nin August 2006 reported concerns in the
\nmanufacture and supply of surgical instru-
\nments from Sialkot, northern Pakistan, to
\nhealthcare markets in the developed world.
\nThe 50,000 skilled manual labourers who
\nmanufacture instruments in Sialkot typically
\nearn less than US $2 per day, have no secure
\nincome, and are exposed to a wide variety of
\noccupational hazards. Furthermore,there are
\nan estimated 5,800 children employed in the
\nindustry,mostly working full-time,and some
\nas young as seven years old. Research by
\nSwedish NGO,Swedwatch,con\ufb01rmed these
\nproblems in supply chains to health systems
\nin Europe and the United States.
\nSurgical instrument manufacture is not the
\nonly industry where labour abuses are a con-
\ncern. Research has also identi\ufb01ed problems
\nin the production of textiles for healthcare
\nfrom India and Pakistan. A risk assessment
\nby the Ethical Trading Initiative suggests
\nthat a signi\ufb01cant number of goods and ser-
\nvices for healthcare are at risk of abuse of
\nlabour standards,and one report identi\ufb01ed a
\nnumber of medical products manufactured
\nin South and South-East Asia that may be
\nsubject to unethical trade practices.
\nTalking to suppliers to the UK and Swe-
\nden, we know that their products end up in
\nhospitals and clinics around the world. As
\nthese are global supply chains, with manu-
\nfacturers supplying multiple markets, it is
\nreasonable to assume that the same prod-
\nucts supply markets in the rest of Europe,
\nthe United States, Canada, Australasia and
\nother regions and countries.
\nSo what does this mean for medical asso-
\nciations? The British Medical Association
\n(BMA) has been working closely with part-
\nners to investigate and address these issues.
\nThe BMA formed the Medical Fair and
\nBringing Fair Trade to Health Systems:
\nWhat You Can Do
\nOlivia Roberts Mahmood Bhutta Eva Nilsson B\u00e5genholm
\nwma 7-2.indd 98wma 7-2.indd 98 9\/29\/09 5:25:08 PM9\/29\/09 5:25:08 PM
\n99
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nEthical Trade Group (MFETG), which is
\nan independent group with membership
\nfrom fair trade groups, industry associations
\nand government bodies.The MFET Group
\nis coordinated by the BMA International
\nDepartment and the promotion of fair trade
\nin healthcare goods is a key objective for the
\nBMA\u2019s work on improving global health.
\nThe Group aims to promote fair and ethi-
\ncal trade in the manufacture and supply of
\nmedical commodities. Recent successes in-
\nclude a code of conduct for all major suppli-
\ners of healthcare goods to the UK, and the
\ndevelopment of guidance by the NHS Pur-
\nchasing and Supply Agency – the group re-
\nsponsible for national purchasing decisions.
\nThese tools enable the UK health system to
\nquestion suppliers about whether they have
\nadhered to basic labour rights in the produc-
\ntion and supply of their goods. The British
\nMedical Association will be engaging with
\nits members and other health professionals
\nto help them learn to ask the right questions
\nand bring change to these industries. An-
\nother exciting e\ufb00ort is supporting the devel-
\nopment of product lines that may represent
\nespecially good practice in fair and ethical
\ntrade, including fair trade and environmen-
\ntally friendly rubber for surgical gloves, and
\nfair trade cotton for healthcare textiles.
\nIn Sweden, the three largest authorities for
\nhealth care have jointly produced a Code of
\nConduct for fundamental social responsi-
\nbility in procurement contracts with suppli-
\ners, and there are plans to make the Code
\napply nationally in the near future. Recently
\nsigned contracts will be monitored annually,
\nand suppliers asked how they comply with
\nthe contract. If problems are discovered,
\nfurther steps include requesting the supplier
\nto contact the producing factory or to un-
\ndertake independent audits to assess labour
\nconditions.
\nBoth the guidance in England and the
\nSwedish Code of Conduct contain the fol-
\nlowing points as key principles of develop-
\ning fair and ethical trade:
\nSuppliers shall respect principles of fun-\u2022
\ndamental social responsibility in business
\ndeals.
\nAll products shall be produced accord-\u2022
\ning to ILO and UN fundamental labour
\nconventions and shall be related to health
\nand safety legislation in the manufactur-
\ning country.
\nDiscrimination, forced labour or child la-\u2022
\nbour must not occur.
\nWages shall be paid as agreed directly to\u2022
\nworkers.
\nRemuneration must not be below nation-\u2022
\nal statutory minimum wage.
\nWeekly working hours must not exceed\u2022
\nlegal limit and overtime is to be paid for.
\nWorking environment shall correspond\u2022
\nto international guidelines.
\nWhen combined, the policies in the UK
\nand Sweden have the potential to a\ufb00ect bil-
\nlions of dollars of health service contracts
\nper year. However, this is still only a small
\npercentage of healthcare expenditure: the
\nUK and Sweden together account for only
\n7% of hundreds of billions of dollars global
\npurchasing of medical devices. If guidance
\nand policies were developed in other coun-
\ntries throughout the world,the impact could
\nbe much more signi\ufb01cant. But this will only
\nhappen if key partners work together, and
\nwith suppliers, to identify problems and \ufb01x
\nthem.
\nWe are now working with other medical
\nassociations in Europe and recommend the
\nfollowing actions for all medical associa-
\ntions:
\nContact the British Medical Association\u2022
\nfor advice (email fairtrade@bma.org.uk).
\nContact your members about this issue to\u2022
\nget their support.
\nContact your national health service pur-\u2022
\nchasing agency or regional body to ask
\nthem to engage on this issue.
\nContact your local industry association\u2022
\nand ask them about their supply chains.
\nWe need you to join us to mobilise health
\nprofessionals throughout the world to insist
\nthat their health system treats the world
\nfairly.
\nReferences
\nBritish Medical Association [homepage on the1.
\nInternet] [cited 2009 September 11]. Available
\nfrom: www.bma.org.uk\/fairtrade
\nBhutta MF. Fair trade for surgical instru-2.
\nments. British Medical Journal [serial on the
\nInternet] [cited 2009 September 11]. Avail-
\nable from: http:\/\/www.bmj.com\/cgi\/pdf_
\nextract\/333\/7562\/297?rss=
\nImpactt \u2013 supply chain strategy organisa-3.
\ntion [homepage on the Internet] [cited 2009
\nSeptember 11]. Available from: http:\/\/www.
\nimpacttlimited.com\/2008\/12\/09\/nhs-pasa-
\npublish-%E2%80%98ethical-procurement-
\nfor-health%E2%80%99-to-develop-ethical-
\ntrade-for-health-supplies\/
\nEthical procurement for health guidance. NHS4.
\n[homepage on the Internet] [cited 2009 Sep-
\ntember 11]. Available from: http:\/\/www.pasa.
\nnhs.uk\/PASAWeb\/NHSprocurement\/Sustain-
\nabledevelopment\/Ethicalprocurement\/
\nPurchasing and Supply Agency Sustainabil-5.
\nity reports. NHS [homepage on the Internet]
\n[cited 2009 September 11]. Available from:
\nhttp:\/\/www.pasa.nhs.uk\/PASAWeb\/NHSpro-
\ncurement\/Sustainabledevelopment\/
\nBjurling K. The dark side of healthcare. 2007.6.
\nSwedwatch [homepage on the Internet] [cited
\n2009 September 11]. Available from: http:\/\/
\nwww.swedwatch.org\/swedwatch\/in_english\/
\nreports
\nThe Stockholm County Council, V\u00e4stra G\u00f6ta-7.
\nland Region and Region Sk\u00e5ne. Sustainable
\nprocurement [homepage on the Internet] [cited
\n2009 September 11]. Available from: http:\/\/
\nwww.skane.se\/upload\/Webbplatser\/MASkane\/
\nDokument\/Socialt_ansvar_Hallbar_upph_
\nen.pdf
\nDepartment of Health.K Global Health Strat-8.
\negy 2008-13 [homepage on the Internet] [cited
\n2009 September 11]. Available from: : http:\/\/
\nwww.dh.gov.uk\/en\/Publicationsandstatistics\/
\nPublications\/PublicationsPolicyAndGuidance\/
\nDH_088702
\nOlivia Roberts,
\nBritish Medical Association
\nDr. Mahmood Bhutta,
\nMedical Fair and Ethical Trade Group
\nDr. Eva Nilsson B\u00e5genholm,
\nSwedish Medical Association
\nwma 7-2.indd 99wma 7-2.indd 99 9\/29\/09 5:25:09 PM9\/29\/09 5:25:09 PM
\n100
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nThe 2nd
\nGeneva Conference on Person-cen-
\ntred Medicine in May 2009 followed the
\ninaugural Geneva Conference of May 2008,
\nboth as landmarks in a process of building
\nan initiative on medicine for the person
\nthrough collaboration of major global med-
\nical and health organizations and a growing
\ngroup of committed individuals.
\nThe Conference took place on 28 and 29
\nMay 2009 under the auspices of the Uni-
\nversity of Geneva Medical School and the
\nUniversity Hospitals of Geneva organized
\nby the World Medical Association (WMA),
\nthe World Organization of Family Doctors
\n(Wonca), and the International Network
\nfor Person-centred Medicine, in collabora-
\ntion with the Council for International Or-
\nganizations of Medical Sciences (CIOMS),
\nthe World Federation for Mental Health
\n(WFMH), the World Federation of Neu-
\nrology (WFN), the World Association for
\nSexual Health (WAS), the International As-
\nsociation of Medical Colleges (IAOMC),
\nthe World Federation for Medical Educa-
\ntion (WFME), the International Federation
\nof Social Workers (IFSW),the International
\nCouncil of Nurses (ICN),the European Fed-
\neration of Associations of Families of People
\nwith Mental Illness (EUFAMI), the Inter-
\nnational Alliance of Patients\u2019 Organizations
\n(IAPO), and the Paul Tournier Association.
\nThe editor-in-chief of the World Medical
\nJournal was in attendance and invited the
\npreparation of this report.
\nThe Conference had as its aims: to examine
\nand discuss key concepts of person-centred
\nmedicine and practical approaches for its
\nimplementation, to elicit useful initiatives
\non person-centred medicine, and to engage
\ninternational medical and health organiza-
\ntions on the Conference’s theme.
\nThe Conference Core Organizing Commit-
\ntee was composed of J.E. Mezzich (World
\nPsychiatric Association President 2005-
\n2008), J. Snaedal (World Medical Asso-
\nciation President 2007-2008), C. Van Weel
\n(World Organization of Family Doctors
\nPresident 2007-2010), and I. Heath (World
\nOrganization of Family Doctors Executive
\nCommittee Member at Large). The Con-
\nference Secretariat was based at the Inter-
\nnational Centre for Mental Health, Mount
\nSinai School of Medicine, Fifth Ave &
\n100th Street, Box 1093, New York, New
\nYork 10029-6574, USA.
\nFinancial or in-kind support for the Con-
\nference was provided by the University of
\nGeneva, the Paul Tournier Association of
\nGeneva, Person-centred Medicine & Psy-
\nchiatry Programs, Conference registration
\nfees, and the International Network for
\nPerson-centred Medicine.
\nThe Conference was opened by the Rector
\nof the University of Geneva and the Vice-
\nDean of its Medical School, as well as by
\nthe members of the Conference Core Orga-
\nnizing Committee.All remarked on the tra-
\ndition that was emerging engaging Geneva
\nas encounter point for the development of
\nperson-centred medicine.
\nThe 1st
\nscienti\ufb01c session involved presenta-
\ntions of leaders and representatives of the
\nInternational Alliance of Patients’ Organi-
\nzations, the International Network for Per-
\nson-centred Medicine, the World Health
\nOrganization, the World Medical Asso-
\nciation, the World Organization of Family
\nDoctors, the Council of International Or-
\nganizations of Medical Sciences, and the
\nInternational Council of Nurses. The pre-
\nsentation of policy statements and relevant
\ninstitutional programs re\ufb02ected the value
\nascribed by these organizations to person-
\ncentred medicine. Details on the presenta-
\ntions made in this session and the following
\nsessions can be found in the abstracts pre-
\nsented at the SGCPCM Report at www.
\npersoncenteredmedicine.org.
\nEight special initiatives relevant to person-
\ncentred care were presented in the 2nd
\nses-
\nsion. The presentations were made by rep-
\nresentatives of several major organizations
\ncollaborating in the Second Geneva Con-
\nference and other prominent work groups.
\nThe diverse experiences presented from a
\nrange of \ufb01elds revealed a number of sub-
\nstantive achievements and promising op-
\nportunities for a medicine of the person.
\nConcepts and meanings of person-centred
\nmedicine were the subject of the 3rd
\nsession.
\nThey focused on the role and worth of the
\nperson in medicine,the cruciality of a sense of
\nidentity,empathy and engagement for optimal
\nclinical care, and the value and impact of life
\nexperiences for the development in each indi-
\nvidual of personalized medicine and health.
\nThe 4th
\nsession presented and discussed
\nprocedures for person-centred diagnosis.
\nThe Second Geneva Conference on
\nPerson-centred Medicine
\nwma 7-2.indd 100wma 7-2.indd 100 9\/29\/09 5:25:09 PM9\/29\/09 5:25:09 PM
\n101
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nParticularly covered were the signi\ufb01cance
\nof multilevel explanations and diagnosis in
\nmedicine, the key features of a person-cen-
\ntred integrative diagnosis addressed to ap-
\npraise whole health using standardized and
\nnarrative descriptions re\ufb02ecting interactions
\namong clinicians, patient and family, as well
\nas the prospects for person-centred diagno-
\nsis in general medicine.
\nA panel on programmatic contributions for
\nperson-centred medicine in a 5th
\nsession
\no\ufb00ered an opportunity for the presenta-
\ntion of brief statements by representatives
\nof the twelve collaborating organizations
\nand groups from across the world. They at-
\ntested to the relevance of person-centred
\napproaches to medicine for an ample range
\nof medical, health and social institutions.
\nThe 6th
\nsession, at the beginning of the sec-
\nond day of the Conference, discussed pro-
\ncedures for person-centred treatment and
\nhealth promotion. These included general
\nfeatures of person-centred integrative care,
\nthe prospects for a person-centred medi-
\ncal home in the United States, and WHO
\nperspectives on person-centred healthiness,
\nsocial determinants, and health promotion.
\nPerson-centred medicine for children and
\nolder people was discussed in the 7th
\nsession
\nof the Conference. Such vulnerable popula-
\ntions represent particular challenges and op-
\nportunities from scienti\ufb01c and ethical view-
\npoints. The uniqueness and developmental
\nsensitivity of the child were highlighted.
\nAlso pointed out were the complexity of
\nhealth conditions in older people and the
\nimperative need to attend to their values
\nand perspectives.
\nTraining and research on person-centred
\nmedicine was the subject of the 8th
\nses-
\nsion. Speci\ufb01c topics included the develop-
\nment of pertinent guidelines and curricula
\nfor person-centred clinical care, the assess-
\nment of a epistemologically based person
\ncentred medicine at Ambrosiana University
\nin Milan, training and research on commu-
\nnication for person-centred outcomes, and
\nbroad programmatic features and objectives
\nof research on person-centred clinical care.
\nThe 9th
\nsession of the Conference reviewed
\nperson-centred health systems and policies.
\nWHO\u2019s new focus on persons for the de-
\nvelopment of more promising global health
\npolicies and systems, as a\ufb03rmed by the
\nlatest World Health Assembly, was given
\npointed attention. Also discussed was the
\nrole of health informatics for the construc-
\ntion of personalized medicine and complex
\nhealth care systems. Last but not least was a
\nreview of the role and documented value of
\nthe person for the conduction of health care,
\ntraining and research
\nThe \ufb01nal 10th
\nsession presented a confer-
\nence summary and outlined next steps.
\nAmong the general conclusions were:
\na commitment to the importance of per-\u2022
\nson-centred medicine for the health of
\npeople, noting the participation of a vast
\narray of important medical and health or-
\nganizations, a wish to share and collabo-
\nrate, and an understanding of the impor-
\ntance of grasping opportunities;
\nthe growing availability of resources,includ-\u2022
\ning general concepts and procedures as well
\nas teaching materials and research tools;
\nthe importance of \ufb01tting the above re-\u2022
\nsources into health care systems and into
\nparticular health care encounters, with
\nparticular attention to person-centred-
\nness as an intrinsic quality rather than as
\nan additional commodity,and the value of
\ncomprehensiveness,continuity,and atten-
\ntion to context as crucial features of good
\nclinical care.
\nProposals for future conferences included
\nthe need to build bridges to the various
\nspecialties in medicine, the participation of
\ndi\ufb00erent patient groups, and the inclusion
\nof representatives of additional health dis-
\nciplines.Emphasis was made on consolidat-
\ning the ideas from the \ufb01rst two conferences,
\nand to use that for further work to enhance
\nperson-centred medicine.
\nAnticipated next steps include the following:
\nCompletion of a joint editorial to be pub-\u2022
\nlished in a wide circulation international
\njournal.
\nPreparation of a 2\u2022 nd
\nGeneva Conference
\nSummary Report.
\nPublication of a monograph containing\u2022
\nthe papers presented at the 2nd
\nGeneva
\nConference.
\nCollaboration with WHO on Person-\u2022
\ncentred Medicine topics related to the
\n2009 World Health Assembly Resolu-
\ntions.
\nOrganization of scienti\ufb01c events rel-\u2022
\nevant to person-centred medicine, such
\nas a prospective New York Conference on
\nWell-Being and Person in Medicine and
\nHealth.
\nOrganization of a 3\u2022 rd
\nGeneva Conference
\non Person Centred-Medicine in early
\nMay 2010, prospectively focused on a
\nteam approach across specialties and dis-
\nciplines.
\nEstablishment of a clearinghouse of Per-\u2022
\nson-centred Medicine documents.
\nUpgrading an internet platform to sup-\u2022
\nport our archival, informational, commu-
\nnicational, and programmatic needs.
\nDevelopment of an International Network\u2022
\nfor Person-centred Medicine to stimulate
\nthe above activities and to organize ini-
\ntiatives on conceptual and ethical bases,
\ndiagnosis, clinical care, training, research,
\nhealth systems, and public policies.
\nThe 2nd
\nGeneva Conference was distinctly
\nperceived by its participants as a stimulat-
\ning success in terms of food for thought and
\nshared commitment to build a paradigmatic
\nshift in medicine and health care. A 3rd
\nGe-
\nneva Conference is widely anticipated as
\nthe next landmark in this unfolding process
\nwith the emerging International Network
\nfor Person-centred Medicine as the collab-
\norative and \ufb02exible structure to co-ordinate
\nand move forward our vision and program-
\nmatic e\ufb00orts.
\nJuan E. Mezzich
\nWPA President 2005-2008
\nwma 7-2.indd 101wma 7-2.indd 101 9\/29\/09 5:25:09 PM9\/29\/09 5:25:09 PM
\n102
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nJames Appleyard
\nEach child is a unique individual. Each
\nchild is conceived within and delivered
\nfrom their mother. Each child is in\ufb02uenced
\nuniquely by their father, the wider family,
\nthe culture of the local community and the
\nnation state. The infant grows and develops
\nthrough childhood and adolescence into an
\nadult within \ufb01ve areas – mentally, physically,
\nintellectually emotionally and spiritually.
\nIn those children nurtured in an environ-
\nment of love, joy and peace, their spiritual
\ndimension will widen. They are more likely
\nto survive the journey to adulthood and the
\nsigni\ufb01cantly di\ufb00erent physiological,psycho-
\nlogical and pathogenic features which occur
\nat the di\ufb00erent ages.
\nThe paper looks at how this person centred
\nparadigm e\ufb00ects the individual child and the
\ncommunity in which he or she lives and the
\nharmful consequences of \u201cdepersonalization\u201d.
\nAt \ufb01rst thought such a paradigm seems vague
\nand without much scienti\ufb01c credibility.
\nBut in a comparative study by Cigdem
\nKagitcibasi and colleagues, the motivations
\nfor child rearing by 20,000 parents from
\n9 countries were assessed as \u201cvaluable\u201d in
\nthree domains \u2013 economic, social and psy-
\nchological [1]:
\nthe\u2022 \u201ceconomic\u201d reason which involved the
\nmaterial bene\ufb01ts that children may bring
\nboth when they are children and when
\nthey grow up, to be a security in old age;
\nthe\u2022 \u201cSocial\u201d reasons which are related to
\nthe general social acceptance that normal
\nadults are given when they have children,
\nand the desire for continuation of the
\nfamily;
\nthe\u2022 \u201cPsychological\u201d intention for the ful-
\n\ufb01lment of children \u2013 with love, joy, pride
\nand companionship.
\nIn those countries whose mothers viewed
\ntheir children to ful\ufb01l their own individual
\npotential with love, joy pride and compan-
\nionship had the best child survival rates
\nPoverty breeds disease and disease causes
\npoverty. Disease in just one family member
\nmay have disastrous e\ufb00ects on the children
\nthrough loss of care and reduced family in-
\ncome, causing older children to leave school
\nto support the family. The tragedy of the
\nAIDS orphans is all too apparent in Africa.
\nPoor families compensate for children\u2019s
\ndeaths by having a large number of children,
\nwith the expectation that su\ufb03cient will sur-
\nvive to care for the parents in their old age.
\nLarge families simply cannot a\ufb00ord educa-
\ntion and health care for each child. Con-
\nversely reduction in mortality can be a spur
\nto reducing fertility rates.The evidence link-
\ning fertility levels to infants under the age of
\n1 yr and child mortality under 5 is powerful.
\nCountries who have infant mortality rates
\nof less than 20 have an average total fertility
\nrate of 1.7 children.In countries which have
\ninfant mortality rates of over 100 have an
\naverage total fertility rate of 6.2. children.
\nWhen children are valued in their own right
\nrather than for utilitarian purposes, family
\nsize is smaller. This demonstrates the im-
\nportance given to each individual child on
\nthe survival of the community
\nThe mother\u2019s education is clearly another
\nimportant factor but one which is also as-
\nsociated with the family\u2019s increased earning
\ncapacity. The clear message is that looking
\nafter children means less and not more
\nmouths to feed, better education, healthier
\nadults and improved economic progress
\nYet UNICEF\u2019s statistics reveal that some
\n10 million children worldwide are not ad-
\nequately cared for [2]. They die under the
\nage of 5years, mainly unnecessarily, from
\ntreatable illnesses and from lack of local,
\nnational and international will to recognise
\nthe importance of each child as an indi-
\nvidual person
\nAt international level the overwhelming ma-
\njority of countries have signed up to Article
\n24 of the 1989 United Nations Convention
\non the Rights of the Child. This recognises
\nthe right of the child to the enjoyment of
\nthe highest attainable standard of health
\nand to facilities for the treatment of illness
\nand rehabilitation of health, and states that
\nPerson Centred Pediatric Care
\nwma 7-2.indd 102wma 7-2.indd 102 9\/29\/09 5:25:10 PM9\/29\/09 5:25:10 PM
\n103
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nnations shall strive to ensure that no child is
\ndeprived of his or her right of access to such
\nhealth care services.
\nHealth care systems tend to respond by
\nidentifying and measuring some measur-
\nable constituent parts of a child\u2019s problem at
\nthe expense of the child as a whole person
\nwhose complex needs interact \u2013 the whole
\nchild being more than the sum of the in-
\ndividual components. What counts for
\neach child may not be counted and what is
\ncounted may not count.
\nThis reductionist approach has fostered the
\nmove towards greater specialisation and the
\nrelative deskilling in primary care at which
\nlevel it is practical to look at a child in the
\nfamily and community setting.
\nA target culture has grown up in the un-
\nderstandably cost conscious management
\nenvironment of most health care providers,
\nwhere individual episodes of care are mea-
\nsured in isolation of a child\u2019s overall needs
\n.The overall costs to the child, the family
\nand the local community are not measured.
\nWhat appears to be a \u201csaving\u201d may shift the
\ncost to another sector and create an even
\ngreater burden for the family
\nThis culture of isolated short episodes of
\ncare has had an e\ufb00ect, that of the physicians
\nworking \u201cshifts\u201d within the health provider
\nsystem. The concept of any continuing duty
\nof care by the physicians towards their child
\npatient is vanishing.
\nAt individual level such professional care for
\na child is crucial \u2013 the child must be treated
\nas a person. This is only possible when the
\nattending physician is an independent pro-
\nfessional and inspires trust.
\nA profession is de\ufb01ned as \u201ca vocation in
\nwhich knowledge of some department of
\nscience or learning\u201d, or \u201cthe practice of an
\nart founded upon it is used in the service of
\nothers\u201d [3].
\nA profession is characterized as having a
\ncode of ethics re\ufb02ecting the integrity and
\nmorality of its members, a complex body of
\nknowledge which should be used altruisti-
\ncally in the service of others as an autono-
\nmous professional person yet accountable to
\na professional association and through the
\ncode of ethics to society in general.
\nThe code of ethics from the time of Hippo-
\ncrates that should govern the behaviour of
\nmembers of the medical profession is based,
\nin my opinion [4], on seven principles:
\n1. The prime importance of the person
\nseeking help from a physician \u2013 patients
\nand their individual autonomy;
\n2. Bene\ufb01cence \u2013 to do good and act in
\ntheir best interests;
\n3. Non malfeasance \u2013 to limit any harm;
\n4. Fidelity \u2013 the duty of care;
\n5. Truthfulness \u2013 the need for transpar-
\nency;
\n6. Con\ufb01dentiality \u2013 it is essential to keep
\nthe patients \u201csecrets\u201d;
\n7. Justice \u2013 to be fair to all.
\nThese principles need to be inscribed into
\nthe conscience of the physician as part of
\nthe medical ethical culture [5].They provide
\nthe ethical \u201ccompass\u201d to navigate through
\nthe complex issues that confront physicians
\nthroughout their professional lives.
\nA physician\u2019s personal ethics and his integ-
\nrity \u2013 his conscience – form the most impor-
\ntant and safest resource in medical practice
\nworldwide. It is the basis of the trust be-
\ntween the physician and his or her patient.
\nThat is what makes the art of medicine so
\nchallenging and at the same time rewarding.
\nThere is no one right answer. Just the right
\nanswer, based on the best judgment for the
\nindividual.
\nWithin the medical care of children, it is
\nthe child who is the person central to the
\nphysician\u2019s attention.
\nThe World Medical Association\u2019s current
\nDeclaration of Ottawa (1998) provides an
\nimportant ethical framework [6].
\nIt states:
\n\u201cThe health care of a child,whether at home
\nor in hospital, includes medical, emotional,
\nsocial and \ufb01nancial aspects which interact
\nin the healing process and which require
\nspecial attention to the rights of the child
\nas a patient\u201d.
\n\u201cThe wishes of each child need be taken
\ninto account in any clinical decision. These
\nwishes should be given increasing weight
\ndependant on her\/his capacity of under-
\nstanding.The mature child, in the judgment
\nof the physician, is entitled to make her\/his
\nown decisions about health care.\u201d
\nFrom this person centred paradigm, as Staf-
\nford Beer\u2019s work in the \ufb01eld of cybernetics
\nhas illustrated, a viable system model can be
\nconstructed so that knowledge sharing and
\ndecision making can evolve without hierar-
\nchical control [7] to further the best inter-
\nests of each child in every community.
\nReferences
\n1. Kagitcibasi C.The value of children: a key to gen-
\nder issues. Int Child Health. 1998; 9: 15-24.
\n2.The United Nations Children\u2019s Fund.The state of
\nthe world\u2019s children 2007. UNICEF, 2006.
\n3. The shorter Oxford English dictionary. 3rd
\ned.
\nOxford: Oxford University Press, 1944.
\n4. Appleyard W.J. \u2018Professionalism\u2019 Icelandic Medi-
\ncal Association. Laeknaping, 2004.
\n5.Vikstrom J.\u2018Service of humanity\u2019 Pro humanitate.
\nFinnish Medical Association , 2000.
\n6. World Medical Association Declaration of Ot-
\ntawa on the rights of the child to health care. Ot-
\ntawa, 1998.
\n7. Kawalek P. Athenaeum Forum Exchange, 2009.
\nJames Appleyard MD FRCP FRCPCH
\nChildren\u2019s Physician
\nPast President , WMA.
\nwma 7-2.indd 103wma 7-2.indd 103 9\/29\/09 5:25:11 PM9\/29\/09 5:25:11 PM
\n104
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nThe earliest roots of person-centred medi-
\ncine can be found in ancient civiliza-
\ntions, both Eastern (such as Chinese and
\nAyurvedic) and Western (particularly an-
\ncient Greek),which tended to conceptualize
\nhealth broadly and holistically. This notion
\nis re\ufb02ected in the encompassing de\ufb01nition
\nof health inscribed in the constitution of the
\nWorld Health Organization (WHO,1946).
\nAlso noticeable in medical traditions from
\nthose early civilizations is a personalized
\napproach to health care.
\nThe modern development of medicine has,
\nhowever,neglected the above considerations
\nand privileged conceptual reductionism,
\npaid absorbed attention to disease, super
\nspecialization and fragmentation of services
\nas well as commoditization and commer-
\ncialism in the \ufb01eld. This has interfered with
\nattentiveness to the whole person and his\/
\nher ill- and positive-health as the natural
\nfocus of medical science and practice and
\nto the ethical imperatives connected to pro-
\nmoting the autonomy, responsibility, and
\ndignity of every person involved.
\nEndeavors to refocus medicine on the per-
\nson of the patient, the clinician and the
\nmembers of the community at large have
\nbeen distinctly noted in the past century.
\nIllustratively, Paul Tournier, a Swiss general
\npractitioner discovered the transformational
\nvalue of critical interpersonal experiences
\nand of attending to the whole person and the
\nbiological,psychological,social and spiritual
\naspects of health.He presented his vision on
\nMedicine de la Personne (Tournier,1940) and
\n19 other books translated to over 20 lan-
\nguages. Around the same time, American
\npsychologist Carl Rogers demonstrated the
\nsigni\ufb01cance of open communication and of
\nempowering for individuals to achieve their
\nfull potential (Rogers, 1961) and proceeded
\nto develop a person-centred approach to ther-
\napy, counseling and education.
\nDuring the second half of the 20th
\nCen-
\ntury, Frans Huygen in the Netherlands,
\nIan Mc Whinney in the UK and Canada,
\nand Jack Medalie in the United States and
\nIsrael struggled with the ongoing limita-
\ntions of modern medicine noted above and
\ncommitted themselves to promote a broad
\nand contextualized understanding of health
\nwith high concern for their patients\u2019 well-
\nbeing. They went on to develop a generalist
\nmedical specialty under the terms of gen-
\neral practice and family medicine (Huygens,
\n1978; McWhinney, 1989), which has char-
\nacteristically focused on patient-centred care.
\nSustained e\ufb00orts to establish a person-cen-
\ntred medicine program on epistemological
\ngrounds and to build a corresponding medi-
\ncal school and clinical teaching method have
\nbeen undertaken by Giuseppe Brera (1992),
\nrector of Ambrosiana University in Milan.
\nAnother inspirational medical \ufb01gure has
\nbeen Finn psychiatrist Yrjo Alanen, who
\nengaged patients by paying careful attention
\nto the meaning of their experiences and the
\nnature and signi\ufb01cance of their needs, and
\nartfully combined pharmacological and psy-
\nchosocial therapeutic techniques. His need-
\nadaptive assessment and treatment approach
\n(Alanen, 1997) has impressed not only pro-
\nfessional colleagues but even critical patient
\ngroups.
\nNoteworthy too are the emerging responses
\nfrom a number of global medical and health
\norganizations. The World Health Organiza-
\ntion, which incorporated in its constitution
\nthe above mentioned comprehensive de\ufb01ni-
\ntion of health, has recently introduced the
\nterm dynamic, meaning interactive, to char-
\nacterize the relationship among dimensions
\nof well-being and has started discussions on
\nthe possibility of adding a spirituality dimen-
\nsion. Furthermore, for the \ufb01rst time WHO
\nis placing people\/person at the center of
\nhealthcare and public health, as re\ufb02ected on
\nthe resolutions of the World Health Organi-
\nzation\u2019s 2009 World Health Assembly.
\nLinked to person-centred care perspec-
\ntives is an ethical frame of reference that
\nThe International Network for
\nPerson-centred Medicine:
\nBackground and First Steps
\nIona HeathJuan Mezzich Jon Snaedal Chris van Weel
\nwma 7-2.indd 104wma 7-2.indd 104 9\/29\/09 5:25:11 PM9\/29\/09 5:25:11 PM
\n105
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nseeks to assure equal opportunities for all,
\nparticularly in terms of access to care, with
\nan emphasis on the rights of individuals in
\nneed of health care (www.wma.net\/policy).
\nThe triad of caring, ethics, and science are
\nrea\ufb03rmed as the enduring traditions of
\nthe medical profession (Coble, 2005). The
\nphysicians’ obligation to respect human life
\nrather than to extend it blindly has been
\ncogently argued (Snaedal, 2007). This has
\nbeen incorporated by the World Medical
\nAssociation (WMA) into the Declara-
\ntion of Helsinki for Medical Research and
\nthe International Code of Medical Ethics
\n(www.wma.net\/press releases).
\nThe renaissance of family medicine after the
\nSecond World War was informed by holistic
\nperspectives which grounded the role of the
\ngeneral practitioner\/family physician in an
\nintegrated approach to the care of patients
\nand their families in the context of a spe-
\nci\ufb01c local community (Mc Whinney, 1989).
\nThe World Organization of Family Doctors
\n(Wonca) has recorded its commitment to
\npersons and community in its basic con-
\ncepts and values \u2013 continuity of care, care
\nfor all health problems in all patients within
\na societal context (www.woncaeurope.org).
\nThe tension between the disease and the per-
\nson experiencing the disease is particularly
\ntangible in mental health care. In fact, as
\ndocumented by Garrabe (2008), the begin-
\nnings of the World Psychiatric Association
\n(WPA) in 1950 already revealed interest on
\nthe concept of the person as central to the
\n\ufb01eld. That interest evolved to the point that
\nin 2005 the WPA General Assembly estab-
\nlished an Institutional Program on Psychia-
\ntry for the Person. This program sought to
\narticulate science and humanism to promote
\na psychiatry of the person, for the person, by
\nthe person, and with the person (Mezzich,
\n2007). Among its signal conferences were
\nthose organized in London (October 2007)
\nin collaboration with the UK Department
\nof Health and in Paris (February, 2008) in
\ncooperation with the WPA French Mem-
\nber Societies. In addition to a number of
\njournal papers, monographs have been pre-
\npared on the Conceptual Bases of Psychia-
\ntry for the Person (Mezzich, Christodoulou
\n& Fulford, in press) and on Psychiatric Di-
\nagnosis: Challenges and Prospects (Salloum
\n& Mezzich, 2009).
\nGeneva Conferences on
\nPerson-centred Medicine
\nThe Geneva Conferences on Person-centred
\nMedicine took place at the Geneva Uni-
\nversity Hospitals on May 29-30, 2008 and
\nMay 28-29, 2009 as landmarks in a process
\nof building an initiative on medicine for the
\nperson through the collaboration of major
\nglobal medical and health organizations and
\na growing group of committed individuals.
\nThe institutions formally involved in either
\nor both Conferences included the World
\nMedical Association (WMA), the World
\nOrganization of Family Doctors (Wonca),
\nthe WPA Institutional Program on Psychia-
\ntry for the Person (IPPP), the International
\nNetwork for Person-centred Medicine, the
\nCouncil for International Organizations
\nof Medical Sciences (CIOMS), the World
\nFederation for Mental Health (WFMH),
\nthe World Federation of Neurology
\n(WFN), the World Association for Sexual
\nHealth (WAS), the International Asso-
\nciation of Medical Colleges (IAOMC), the
\nWorld Federation for Medical Education
\n(WFME), the International Federation of
\nSocial Workers (IFSW), the International
\nCouncil of Nurses (ICN), the European
\nFederation of Associations of Families of
\nPeople with Mental Illness (EUFAMI), the
\nInternational Alliance of Patients\u2019 Organi-
\nzations (IAPO), the University of Geneva
\nSchool of Medicine, and the Paul Tournier
\nAssociation.
\nThe 1st
\nGeneva Conference on Person-cen-
\ntred Medicine was aimed at presenting and
\ndiscussing the experience on person-centred
\nprinciples and procedures gained through a
\nPerson-centred Psychiatry Program,explor-
\ning the conceptual bases of person-centred
\nmedicine, and engaging interactively major
\ninternational medical and health organiza-
\ntions. It included sessions on international
\norganization perspectives on person-centred
\nmedicine, related special initiatives, con-
\nceptual bases of person-centred medicine,
\npersonal identity, experience and meaning
\nin health, a review of Paul Tournier\u2019s vision
\nand contributions, person-centred health
\ndomains, clinical care organization, person-
\ncentred care in critical areas, and person-
\ncentred public health. The upgraded papers
\npresented at the Conference are being pub-
\nlished as a supplement of the International
\nJournal of Integrated Care (Mezzich, Snae-
\ndal, van Weel & Heath, in press)
\nThe 2nd
\nGeneva Conference was aimed at
\nprobing further key concepts of person-
\ncentred medicine and reviewing a number
\nof practical approaches for the implementa-
\ntion of this approach through a collaborative
\ne\ufb00ort with an enlarged number of interna-
\ntional health organizations. Through nine
\nsessions, it covered institutional perspec-
\ntives and activities on person-centred medi-
\ncine, other relevant initiatives, concepts and
\nmeanings of person-centred medicine, pro-
\ncedures for diagnosis, treatment and health
\npromotion in medicine for the person,
\nperson-centred medicine for children and
\nolder people, as well as training, research,
\nhealth systems and policies on person-
\ncentred medicine. Among the conference
\nconclusions were a wide commitment to the
\nimportance of person-centred medicine for
\nthe health of persons and populations,clari-
\n\ufb01cation of the availability of conceptual, ed-
\nucational and research tools,and the need to
\n\ufb01t these into health encounters and systems,
\na\ufb03rming person-centredness as an intrinsic
\nquality rather than an additional commod-
\nity. There was consensus on organizing a 3rd
\nGeneva Conference where emphasis would
\nbe placed on building further bridges to the
\nspecialized sphere of medicine, other health
\nprofessions, and various patient groups.
\nAmong additional next steps are the orga-
\nnization of relevant scienti\ufb01c events such
\nas a New York Conference on Well-Being
\nand the Person, publication of a joint edito-
\nwma 7-2.indd 105wma 7-2.indd 105 9\/29\/09 5:25:12 PM9\/29\/09 5:25:12 PM
\n106
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nrial in an international journal, preparing
\na monograph with the papers presented at
\nthe Second Geneva Conference, respond-
\ning positively to requests from WHO for
\ncollaboration on people-centred care strat-
\negies adopted by the 2009 World Health
\nAssembly, and further development of the
\nInternational Network for Person-centred
\nMedicine to help move forward collabora-
\ntively an optimized vision for health care.
\nConstructing the International
\nNetwork for Person-centred Medicine
\nThe International Network for Person-cen-
\ntred Medicine (INPCM) is a non-for-pro\ufb01t
\neducational, research, and advocacy organi-
\nzation emerging from the above outlined
\nGeneva Conferences process and aimed at
\ndeveloping opportunities for a fundamental
\nre-examination of medicine and health care
\nto refocus the \ufb01eld on genuinely person-
\ncentred care.
\nPerson-centred medicine is dedicated to
\nthe promotion of health as a state of physi-
\ncal, mental, social and spiritual wellbeing
\nas well as to the reduction of disease, and
\nfounded on mutual respect for the dignity
\nand responsibility of each individual per-
\nson. To this e\ufb00ect, the INPCM seeks to
\narticulate science and humanism in a bal-
\nanced manner, engaging them at the service
\nof the person. The purposes of the INPCM
\nmay be further summarized as promoting a
\nmedicine of the person (of the totality of the
\nperson’s health, including its ill and posi-
\ntive aspects), for the person (promoting the
\nful\ufb01llment of the person\u2019s life project), by
\nthe person (with clinicians extending them-
\nselves as full human beings with high ethi-
\ncal aspirations), and with the person (work-
\ning respectfully, in collaboration, and in an
\nempowering manner).
\nThe expected INPCM activities include the
\nfollowing:
\nOrganization of conferences and other\u2022
\nscienti\ufb01c meetings promoting person-
\ncentred care in medicine at large and in
\nits various specialties and related health
\n\ufb01elds;
\nPreparation of person-centred clinical\u2022
\npractice guidelines relevant to diagnosis,
\ntreatment, prevention, rehabilitation and
\nhealth promotion;
\nPreparation of educational programs, in-\u2022
\ncluding curricula, aimed at the training of
\nhealth professionals on person-centred
\ncare;
\nConduction of studies and research proj-\u2022
\nects to explore and validate person-cen-
\ntred care concepts and procedures;
\nPreparation of publications to dissemi-\u2022
\nnate and advance the principles and prac-
\ntice of person-centred medicine;
\nDevelopment of advocacy forums and ac-\u2022
\ntivities to extend and strengthen person-
\ncentred medicine with the participation
\nof clinicians, patients and families, as well
\nas members of the community at large;
\nEstablishment of an internet platform to\u2022
\nsupport archival, informational, commu-
\nnicational, and programmatic e\ufb00orts on
\nperson-centred medicine.
\nAll organizations and individuals who
\nhave participated actively in relevant pro-
\ngrammatic activities, such as the Geneva
\nConferences, will be invited to participate
\nin the INPCM. It will be organizationally
\ndeveloped and guided initially by a board
\nof \ufb01ve to eight persons with a clear track
\nrecord of work on person-centred medicine
\nand who are committed to the promotion
\nof the fundamental purposes of the orga-
\nnization. Additional structures to be con-
\nsidered are an advisory council (composed
\nof eminent experts and representatives of
\nmajor collaborating organizations) and an
\noperational council (composed of leaders
\nof emerging INPCM Programs, i.e., con-
\nceptual and ethical bases, diagnosis, clinical
\ncare, training, research, health systems, and
\npublic policies).
\nSupport for the INPCM and its activities is
\nexpected to come, as it has been for its ini-
\ntial steps, from academic institutions, pro-
\nfessional societies, governmental organiza-
\ntions,foundations,person-centred medicine
\nand psychiatry non-pro\ufb01t program funds,
\nand conference registration fees. Any sup-
\nport from industry sources will be accepted
\nprovided it is transparent and unrestricted.
\nFurther information on the INPCM can be
\nobtained at www.personcenteredmedicine.
\norg.
\nColophon
\nEarly scienti\ufb01c and ethical e\ufb00orts coalesced
\nthrough the First and Second Geneva Con-
\nferences, and are \ufb01nding fruition in the
\nInternational Network for Person-centred
\nMedicine. Encouragement is a\ufb00orded by
\nthe wide array of collaborating organiza-
\ntions, the scholarly dedication of commit-
\nted individuals, and the conviction that the
\ngreatest asset of any community is its capac-
\nity to organize itself.
\nReferences
\nAlanen YO. Schizophrenia: its origins and1.
\nneed-adaptive treatment. London: Karnak,
\n1997.
\nBrera GR. Epistemological aspects of medical2.
\nscience. Medicine and mind, 7: 5-12, 1992.
\nCoble Y, ed. Caring Physicians of the world.3.
\nWorld Medical Association, Ferney-Voltaire,
\nFrance, 2005.
\nGarrabe J. Historical views on psychiatry4.
\nfor the person. Paris Conference on Person-
\ncentered psychiatry; World Psychiatric Asso-
\nciation, French Member Societies Association,
\n2008 Feb. 6-8.
\nHuygen FJA. Family medicine, the medical life5.
\nhistory of families. New York: Brunner Mazel,
\n1982.
\nMcWhinney IR. A textbook of family medi-6.
\ncine. Oxford: Oxford University Press, 1989.
\nMezzich JE. Psychiatry for the person: articu-7.
\nlating medicine\u2019s science and humanism.World
\nPsychiatry. 2007; 6: 1-3.
\nMezzich JE, Christodoulou G, Fulford KWM,8.
\neditors. Conceptual bases of psychiatry for the
\nperson. Psychopathology. In press.
\nwma 7-2.indd 106wma 7-2.indd 106 9\/29\/09 5:25:12 PM9\/29\/09 5:25:12 PM
\n107
\nPoint of View
\nMezzich JE, Snaedal J, van Weel C, Heath I,9.
\neditors. Conceptual explorations on person-
\ncentered medicine. International Journal of In-
\ntegrated Care. In press.
\nRogers CR. On becoming a person: a thera-10.
\npist\u2019s view of psychotherapy. Boston: Houghton
\nMi\ufb04in, 1961.
\nSalloum IM, Mezzich JE, editors. Psychiatric11.
\ndiagnosis: challenges and prospects. Chichester,
\nUK: Wiley-Blackwell, 2009.
\nSnaedal J. Presidential Address. World Medical12.
\nJournal, 2007; 53: 101-2.
\nTournier P. Medicine de la personne. Neucha-13.
\ntel: Delachaux et Niestle, 1940.
\nWorld Health Organization. WHO Constitu-14.
\ntion. Geneva: WHO, 1946.
\nJuan Mezzich,
\nWPA President 2005-2008.
\nJon Snaedal,
\nWMA President 2007-2008.
\nChris van Weel,
\nWonca President 2007-2010.
\nIona Heath,
\nWonca Executive Committee.
\nNariman Safarli
\nAzerbaijan as Muslim country. Azerbai-
\njan, an oil-rich republic of 8.1 million on
\nthe shores of the Caspian Sea, has seen a
\nrevival of Muslim faith since it became in-
\ndependent with the collapse of the Soviet
\nUnion in 1991. Approximately 93.4 to 96
\npercent of the population of Azerbaijan is
\nnominally Muslim. Azerbaijan at the same
\ntime is a secular country, Article 48 of its
\nConstitution ensures the liberty of worship
\nto everyone. According to paragraphs 1-3
\nof Article 18 of the Constitution religion
\nacts separately from the government, each
\nreligion is equal before the law and the pro-
\npaganda of religions, abating human per-
\nsonality and contradicting the principles of
\nhumanism is prohibited. At the same time
\nthe state system of education is also secu-
\nlar. The law of the Republic of Azerbaijan
\n(1992) \u00ab\u00a0On freedom of faith\u00a0\u00bb ensures the
\nright of any human being to determine and
\nexpress his or her view on religion and to
\nexecute this right.
\nAs a Muslim physician. In my paper I
\nadd information about the responsibilities
\nand duties, basic norms and values, which a
\nMuslim doctor in particular and any doctor
\nin general must adhere to while delivering
\nhis or her services in the society.
\nI know that the most important thing for
\na Muslim doctor is to be interested in the
\nbasic values and principles of Islam.This in-
\nterest will be in the foreground of his or her
\nduties and responsibilities which will bestow
\nloyalty and wisdom upon his or her profes-
\nsion, as well as cast his or her perceptions
\nupon a strong foundation of our religion so
\nthat he or she may perform his or her duties
\nas a real faithful believer.
\nMost of this information was extracted
\nfrom the Islamic Code of Medical Ethics
\nKuwait Document published by the Inter-
\nnational Organization of Islamic Medicine
\nin 1981 and from FIMA Year Books which
\nare published regularly by the Federation of
\nIslamic Medical Association. Some of these
\nrecommendations were taken from the pa-
\nper \u2013 \u201cThe Medical Ethics – An Islamic
\nPerspective\u201d written by Dr. Mohammad
\nIqbal Khan and from the paper -\u201cMedical
\nEthics from Islamic Law\u201d written by the
\nProf. Omar Hassan Kasule, and some of
\nthis information I collected during my par-
\nticipation at various professional workshops
\nand seminars held in Malaysia, Jordan, and
\nthe USA.
\nEthics, morality and law are vitally impor-
\ntant in our world. Ethical, moral, and legal
\nresponsibilities are at the heart of a physi-
\ncian\u2019s competent professional behaviour and
\nscienti\ufb01c undertakings.
\nIslamic and Secularized Ethics. The main
\ntask of Islamic ethics is to understand and
\nexpound the ethos of Islam as conceived in
\nthe Qur\u2019an and elaborated in the Sunnah of
\nthe Prophet.
\nIn Muslim countries, in any discussion of
\nethics, there is a tendency to look towards
\nreligion. Islam is believed to be able to fully
\nrestore the harmony between religion and
\nscience. Ethics in Muslim countries is in-
\nseparable from religious jurisprudence.New
\nregulations and guidelines on ethics were
\ncompiled and put into practice using the
\nIslamic point of view as the basis.
\nIslamic bioethics is intimately linked to
\nthe broad ethical teachings of the Qur’an
\nand the tradition of the Prophet Muham-
\nmad (s.a.w.), and thus to the interpretation
\nof Islamic law. Bioethical deliberation is
\ninseparable from the religion itself, which
\nemphasizes continuities between body and
\nmind, the material and spiritual realms
\nEthical , Moral, and Legal Responsibilities of
\nPhysicians: an Islamic Perspective
\nwma 7-2.indd 107wma 7-2.indd 107 9\/29\/09 5:25:12 PM9\/29\/09 5:25:12 PM
\n108
\nPoint of View
\nand between ethics and jurisprudence. The
\nQur’an and the traditions of the Prophet
\nhave laid down detailed and speci\ufb01c ethical
\nguidelines regarding various medical issues.
\nThe Qur’an itself has a surprising amount
\nof accurate detail regarding human em-
\nbryological development, which informs
\ndiscourse on the ethical and legal status of
\nthe embryo and foetus before birth.
\nThe main principles of \u201cwestern\u201d bioethics
\n(autonomy, bene\ufb01cence, non-malfeasance
\nand justice) are acceptable according to Is-
\nlam, but interpretation of them can di\ufb00er.
\nFor example, there is a limit on autonomy;
\nsometimes the interests of the society is
\npreferred to individual rights.Also the main
\nprinciples of the Hippocratic oath are ac-
\nknowledged in Islamic bioethics, although
\nthe invocation of multiple gods in the origi-
\nnal version, and the exclusion of any god in
\nlater versions, have led Muslims to adopt
\nthe Oath of the Muslim Doctor, which
\ninvokes the name of Allah. It appears in
\nthe 1981 Islamic Code of Medical Ethics,
\nwhich deals with many modern biomedical
\nissues such as organ transplantation and as-
\nsisted reproduction.
\nSome physicians in Westernized Muslim
\ncountries say that to strictly apply Islamic
\nmedical ethics to modern medicine is tanta-
\nmount to a reactionary movement of a return
\nto subduing science under the hegemony of
\nreligion. They say that modern medicine is
\nembarking on new unprecedented frontiers
\nof cloning, genetic engineering and hu-
\nman spare parts generated by stem cells. It
\nshould be given full freedom to develop and
\nexperiment without any religious restric-
\ntions or hindering rigid ethical codes.These
\nphysicians believe that the ‘non-religious’
\nrational ‘versatility’ of medical ethics is a
\nmore suitable moral guide to modern medi-
\ncine. Such physicians share with their west-
\nern colleagues a negative approach towards
\nthe role that religion can play in moulding
\nmedical ethics and practice. In e\ufb00ect they
\nare opposed to the whole \ufb01eld of the Islam-
\nization of western sciences, often discussing
\nthis subject with mockery and ridicule.
\nTo the average Muslim doctor and to those
\nwho show respect to their religion, such
\nstatements can only come from a person
\nwho is ignorant about Islam as a religion
\nand world view and one who lacks depth
\nof knowledge about the religious aspects of
\nmedical ethics. One does need neither to
\ndefend Islam as a way of life nor the \ufb02exibil-
\nity of its usul al \ufb01qh in creating a spiritually
\nguided modern medical ethics. It encour-
\nages every new development, discovery or
\ninnovation in the \ufb01eld of science and medi-
\ncine, but within the framework of the spiri-
\ntual honour Bestowed on man by his Great
\nCreator.The impressive literature published
\nby the Federation of Islamic Medical Asso-
\nciation (FIMA) and other Islamic medical
\norganizations and universities is quite con-
\nvincing to any unbiased scientist.
\nIslamic Ethics are derived from religious
\nconvictions and traditions and are therefore
\nconstant and will remain so for all time. On
\nthe other hand, secular ethics are framed by
\na society which is \ufb01ckle,inconsistently ruled
\nby a majority vote and devoid of religious
\nrestrictions. For example, one has seen the
\nchange from a total prohibition of abortion
\nto the current \u201cabortion on demand\u201d by the
\npatient accepted by society.
\nSimilarly, Euthanasia (Mercy Killing),
\nwhich was illegal and still is in most coun-
\ntries in the west is \u201cquietly\u201dacceptable to so-
\ncieties where elderly people, with children
\nnot prepared to look after them, opt for
\nending their lives with the cooperation of
\ntheir doctors while the Governments look
\nthe other way!
\nIn much the same way, at \ufb01rst arti\ufb01cial in-
\nsemination involved egg and sperm fertiliza-
\ntion of legally wedded couples, then sperm
\n\u201cbanks\u201d resulted in children with unknown
\nfathers and now with surrogate motherhood
\nthe children may not know either their real
\nfather or mother! These are the result of sci-
\nenti\ufb01c advancement; and what cloning may
\nproduce will be an ethical nightmare. The
\nconceptual and moral problems of secular-
\nized medicine has some paradigms that we
\ndo not accept as Muslims. Death is rejected
\nas a natural phenomenon and resources are
\nwasted in terminal illnesses. Aging is also
\nnot accepted as a normal process. There is
\nno consideration of balance and equilibrium
\nin selecting treatment modalities with the
\nresult that an unacceptably high number of
\npatients are being treated for side e\ufb00ects of
\nmodern therapeutic agents. Too much nar-
\nrow specialization leads to lack of a holistic
\napproach to the patient. The physician be-
\nhaves as a technician and turns a blind eye
\nto the moral and social issue of the day that
\na\ufb00ect the health of his or her patients and
\nclaims that his or her responsibility is medi-
\ncal care only. Secularized medicine has no
\nconsistent set of ethics regarding malprac-
\ntice, fraud, and bias in research. Accepting
\nonly empirical knowledge and negating
\nother sources of knowledge had also created
\nnew problems. By denying a religious and
\nmoral dimension, secularized medicine op-
\nerates in a presumed moral vacuum. It is a
\ngross mistake to attempt to solve social and
\nmedical problems of a moral or spiritual na-
\nture by use of technology. At the time when
\nthe \ufb01rst discussions among Islamic scholars
\nwere held about organ transplants, attitudes
\nwere more divided than they are today.There
\nhave always been those against and those for
\ntransplantation. A belief from earlier times
\nhas been passed on, i.e., that it is permit-
\nted to transfer not only tissues, but also a
\nbone from an animal whose meat is edible.
\nBy analogy, the possibility of transplanting
\nan organ from a non-Muslim to a Muslim
\nand vice versa is pointed out. A Muslim
\nphysician is obliged to give the same aid, or
\nmedical care, both to a non-Muslim, as well
\nas to a Muslim.
\nBut when the patient deteriorates and real-
\nizes that he or she is being terminal, it is the
\nIslamic responsibility of the Muslim doctor
\nto council the patient and to convince him
\nor her that all his or her agony will wash
\nwma 7-2.indd 108wma 7-2.indd 108 9\/29\/09 5:25:12 PM9\/29\/09 5:25:12 PM
\n109
\nPoint of View
\naway his or her sins, and his or her patience
\nwill surely secure for him or her the plea-
\nsure of Allah. But if the patient is actually
\ndying, then spiritual words of optimism
\nabout the forgiveness of our Merciful Lord
\nand happiness in life after death can have
\nunequalled positive e\ufb00ects on the patient
\nand much reward to the doctor. Repeating
\nthe creed to those whose soul has already
\nreached their throat is again an act of great
\nIslamic importance particularly for those
\npoor Muslims who die alone in a hospital
\nbed. For the Muslim doctor to ask the nurse
\nabout a dying person, give a quick glance at
\nhis or her medical reports and just go away
\nwithout contemplation or du\u2019a\u2019 or feelings
\nabout the angels around the death bed or
\nthe unseen pleasures and punishments
\nround the corner, is the action of a secular-
\nized physician.
\nIslamic Law (Shariat ) is comprehensive
\nand encompasses moral principles directly
\napplicable to medicine.It is noteworthy that
\nthere is a wide overlap between Islamic eth-
\nics,the Islamic rulings and law,so that some
\nreligious principles such as eternity of life or
\nseeking perfection could be very important
\nin ethical decision-making in an Islamic
\nsetting.
\nSecularized Law denied moral consid-
\nerations associated with \u201creligion\u201d and
\ntherefore failed to solve issues in modern
\nmedicine requiring moral considerations.
\nThe medical profession and society at large
\nwere not ready to face the new challenges.
\nThe existing positive secular laws are lack-
\ning in moral spine. It becomes necessary to
\ndevelop secular ethics as a new discipline to
\ndeal with the challenges.
\nMoral responsibilities of Muslim doctors. A
\nMuslim doctor is a Muslim even before he
\nor she becomes a doctor, but after becoming
\na doctor his or her responsibilities increase
\nmanifold. During his or her professional
\nduties, he or she comes into contact with
\na large number of people. To them all, his
\nor her character is like a model. He or she,
\ntherefore,should exhibit good character and
\nIslamic way of life, keeping his or her life
\nin accordance with the teachings of Islam.
\nThere should be no controversy in the prac-
\ntical life of a Muslim physician and he or
\nshe must be a living example of the Islamic
\nway of life and should never exhibit any ac-
\ntion contrary to his or her beliefs.Only then
\nphysicians can be sources of inspiration for
\nothers and only then they can link their pa-
\ntients with The Lord.
\nBut what is it that makes a Muslim doctor
\ndi\ufb00erent from other non- Muslim doctors?
\nFrom the technological and scienti\ufb01c points
\nof view, all doctors fall in one category.
\nHowever, when it comes to practice, the
\nMuslim doctor \ufb01nds him or herself bound
\nby particular professional ethics plus his or
\nher Islamic directives issuing from his or
\nher belief. In fact, the Muslim doctor\u2014i.e.,
\na doctor who tries to live his or her Islam
\nby following its teachings all through\u2014is
\nexpected to behave di\ufb00erently in some oc-
\ncasions and to meet greater responsibilities
\nthan other non-Muslim doctors.
\nA Muslim physician should be a good role
\nmodel. He or she must present him or her-
\nself as a person of high moral character.
\nHe or she must be polite, humble dutiful,
\nhonest, truthful and trustworthy. He or she
\nshould be performing his or her duties with
\nexcellence as the rewards of excellence are
\nexcellence \u201cCould the reward for excellence
\nbe anything but excellence\u201d(Qur\u2019an- 55:60).
\nOne can only provide the excellent service if
\nhe or she excels in professional knowledge,
\nexpertise and strength of personal character.
\nProphet Mohammad PBUH said, \u201cI was
\nsent down by Almighty Allah for the per-
\nfection and excellence in morality\u201d (Hadith
\nIbne Majah).
\nA Muslim doctor has a two-fold of moti-
\nvation to remain ethical and maintain good
\nmoral characters i.e. he or she is answerable
\nto the society, profession and has to abide
\nthe law of the land, but a Muslim doctor
\nhas the added motivation to remain ethi-
\ncally correct due to his or her beliefs, his
\nor her piety and his or her Islamic obliga-
\ntions. This second motivation which might
\nor might not be observed by others is the
\nmost powerful tool to keep a Muslim doctor
\nethical and God fearing.
\nAn important demand of academic honesty
\nis that a doctor should continue throughout
\nhis or her life to develop his or her scienti\ufb01c
\nknowledge and keep him or herself updat-
\ned about new researches. Allah Almighty
\ntaught this prayer to the Prophet: O My
\nLord! Advance me in knowledge (Qur\u2019an-
\n20:114).
\nA \ufb01eld of knowledge that deals with human
\nlife warrants even more careful attention
\nand continued expansion. Regular weekly
\nor monthly meetings of doctors at the local
\nlevel for discussion on di\ufb03cult and interest-
\ning cases may also be an e\ufb00ective means for
\nincreasing one\u2019s knowledge. Meeting other
\ndoctors from time to time or to seek their
\nadvice about patients is another means of
\nadding to one\u2019s knowledge. Allah has said
\nin the Qur\u2019an: If you do not know, ask those
\nwho are knowledgeable (Qur\u2019an-16:43).
\nBefore commencing medical practice, it is
\nobligatory for a Muslim physician to ob-
\ntain the required knowledge and skill, and
\nto remain at the cutting edge in his or her
\n\ufb01eld of interest in medicine. It is further
\nstressed in another Hadith \u201cThat a Muslim
\nperforms his duties with excellence\u201d. One
\ncannot achieve excellence in his or her pro-
\nfessional skills without constant e\ufb00ort and
\ndesire to excel in his or her profession.
\nThe Muslim doctor is obliged to acquire the
\nbest possible knowledge and expertise and
\nhas to deliver his or her services to ailing
\nhumanity without any discrimination and
\nwithout any worldly gain. If a patient can
\npay for the consultation, it is fair enough to
\ntake the fee. But if he or she is unable to
\npay, the physician cannot refuse his or her
\nservices. If a physician refuses to give his or
\nher services because he or she is not being
\nwma 7-2.indd 109wma 7-2.indd 109 9\/29\/09 5:25:13 PM9\/29\/09 5:25:13 PM
\n110
\nPoint of View
\npaid, he or she is committing sin. One of
\nthe several rights which a Muslim has on
\nanother Muslim is, \u201cWhenever he falls ill
\nhe is being visited by other Muslim; when-
\never he is consulted for some matter he
\nmust impart his consultation with the best
\nof knowledge and taqwa\u201d. A medical pro-
\nfessional is directly responsible to his or her
\nfellow human beings.
\nMuslim physician strongly believes that he
\nor she is not only accountable for all his
\nor her deeds, but he or she is quite hope-
\nful that while he or she is abiding by the
\ndivine guidelines he or she shall never go
\nastray. \u201cSurely it is for us to give guidance\u201d
\n(Qur\u2019an 92-12).
\nHowever, honesty includes academic hon-
\nesty, but it is being mentioned separately
\nbecause of its importance. It is a must for
\na doctor to acquire adequate knowledge
\nabout the profession he or she has studied
\nand adopted as a career. The Holy Prophet
\nhas said,\u201cThe one, who treats patients with-
\nout enough knowledge, will be answerable
\nbefore Allah for the harm he might cause\u201d
\n(Hadith: Abu Dawud).
\nApart from many other rights of a Muslim
\non another Muslim, two important aspects
\nof this act of Ibada are directly related to
\nmedical profession. A doctor has to provide
\nmedical consultation to his or her patient
\nwhether paid or unpaid. If a person is un-
\nable to pay the consultation fee of a doctor,
\na Muslim doctor has to provide consulta-
\ntion free of cost according to the best of
\nhis or her knowledge and expertise.Though
\ncharging consultation fee is permissible
\nwithin limits.
\nWhen Muslim doctor deals with a patient,
\nhe or she seeks Allah\u2019s pleasure through it.
\nImmediate and material gains are not his
\nor her objective, though Allah accepts his
\nor her e\ufb00orts and gives health to his or her
\npatients. Bene\ufb01ts, material gains, name and
\nfame are all a reward, but these are of only
\nsecondary importance to a Muslim doctor
\nwho seeks Allah\u2019s pleasure.
\nA Muslim physician must be honest in all
\nof his or her dealings, especially when pro-
\nviding necessary care and advice to his or
\nher patients and their concerned relatives.
\nHe or she must honestly evaluate his or her
\ncapabilities and practice those sections of
\nmedicine over which he or she has gained
\nmastery. He or she should not hesitate to
\nconsult a specialist in a particular \ufb01eld for the
\nbest handling and management of his or her
\npatients. According to the Qur\u2019anic injunc-
\ntions and the Sunnah \u201cone must not indulge
\nhimself in matters about which he does not
\nhave knowledge and expertise\u201d. You shall
\nnot follow any one blindly in those matters
\nof which you have no knowledge, surely, the
\nuse of your ears and the eyes and interpreta-
\ntion \u2013 all of these,shall be questioned on the
\nday of Judgment (Qur\u2019an- 17:36).
\nProphet PUH said \u201c Those who practice
\nmedicine without having its proper knowl-
\nedge and expertise will be responsible for
\ntheir acts\u201d (Nisai; Ibne Majah). Those who
\nwill cause damage to the body or soul of
\ntheir fellow human beings, due to lack of
\nknowledge or expertise, will fall in this cat-
\negory of ignorance and negligence. One
\nmust also not discriminate between the
\npatients irrespective of their social status or
\neconomic backgrounds. \u201cNo white has any
\nsuperiority over a black or a black over a
\nwhite except on the basis of Taqwa (God
\nconsciousness). A doctor is supposed to de-
\nliver his or her services and expertise by the
\nbest possible means and ways irrespective of
\nwhat is he or she going to get out of it in
\nterms of money. One should not discrimi-
\nnate between his or her private and o\ufb03cial
\npractice.A person who is unable to pay does
\nnot deserve an inferior quality or obsolete
\ntreatment options.
\nThe deeper a doctor feels for humanity
\nand considers him or herself a healer ap-
\npointed by the Creator,the greater he or she
\nwould strive for removing sorrow.The Holy
\nProphet has said that Allah loves a person
\nwho performs whatever he does in the best
\nmanner (Hadith: Abu Dawud).
\nThe Holy Prophet has told us: He who
\ngives wrong advice to his brother commits
\ndishonesty (Hadith: Mishkat). If there are
\nmore than one way for treating a patient,
\nthen bene\ufb01ts and harms of every treatment
\nshould be explained to the patient besides
\ngiving the honest opinion as to which treat-
\nment is best for him or her. The decision,
\nthen, should be left to the patient and see
\nwhat he or she opts for. If another doctor
\nhas a better treatment, you should refer the
\npatient to him or her without hesitation. It
\nwould be dishonest to keep the patient as a
\nsource of income.
\nThe Physician is truthful whenever he or she
\nspeaks, writes or gives testimony. He or she
\nshould be invincible to the dictates of greed,
\nfriendship or authority that might pressur-
\nize him or her to make a statement or tes-
\ntimony that he or she knows is false. Testi-
\nmony is a grave responsibility in Islam.
\nLegal responsibility of Muslim physicians.
\nMore than any other professional, the Mus-
\nlim medical doctor is confronted more fre-
\nquently with questions regarding the Islam-
\nic legitimacy of his or her activities. There
\nare almost daily controversial problematic
\nissues on which he or she is supposed to
\ndecide: e.g. birth control, abortions, oppo-
\nsite sex hormonal injections, trans-sexual
\noperations, brain operations a\ufb00ecting hu-
\nman personality, plastic surgery, extra-uter-
\nine conception, and so forth. The Muslim
\ndoctor should not be guided in such issues
\nmerely by the law of the country in which
\nhe or she is residing (which may be non-
\nMuslim). He or she must also \ufb01nd the Is-
\nlamic answer and rather adopt it as much as
\nhe or she can. To \ufb01nd the answer is not an
\neasy matter, especially if the doctor him or
\nherself has no reasonably solid background
\nin the \ufb01eld of Islamic teachings. Yet, to gain
\nsuch knowledge is very simple and would
\nnot consume as much time as generally
\nwma 7-2.indd 110wma 7-2.indd 110 9\/29\/09 5:25:13 PM9\/29\/09 5:25:13 PM
\n111
\nPoint of View
\npresumed. In general, every Muslim must
\nhave a preliminary knowledge of what is
\nreprehensible and what is prohibited. One
\nhas to admit that our early education as in-
\ndividuals is very de\ufb01cient in this regard. But
\nthis does not justify our ignorance of the es-
\nsentials of our religion and our indi\ufb00erence
\ntowards its injunctions.There is no di\ufb03culty
\nnowadays to obtain a few reference books
\nabout our Shari\u2019ah and to \ufb01nd out the an-
\nswers to most, if not all, our medical que-
\nries. The importance of Islamic knowledge
\nbecomes conspicuous when the subject of
\nthe issue is purely technical and thus lies
\nbeyond the reach of the normal religious
\nscholar. Besides, there are many secondary
\nquestions that arise in the course of deal-
\ning with patients where the personal judg-
\nment of the doctor is the only arbiter.There,
\nas always, the doctor needs a criterion on
\nwhich he or she can build his or her code of
\nbehaviour and the ethics of his or her medi-
\ncal procedure. The Practice of Medicine is
\nlawful only to persons suitably educated,
\ntrained and quali\ufb01ed, ful\ufb01lling the criteria
\nspelt out in the Law. A clear guidance is the
\nProphet’s tradition: \u00ab\u00a0Who-so-ever treats
\npeople without knowledge of medicine, be-
\ncomes liable\u00a0\u00bb.
\nAfter medical graduation, though a doctor
\nhas legal right to treat all patients, but it is
\nneither practically possible nor morally per-
\nmissible for every doctor to start treatment
\nfor every ailment or try to do that. This is
\nwhy a doctor has to limit the area of his
\npractice. In this limited area, it is his or her
\nduty to acquire comprehensive knowledge
\nabout the ailments, and keep updated. It is
\nalso because the knowledge about ailments
\nand their treatment has grown so vast that it
\nis almost impossible for one person to have
\na grasp over the entire \ufb01eld of knowledge.
\nThis is how, long ago, the idea of special-
\nization in di\ufb00erent areas of medical sciences
\nstarted. Now, specialization is required al-
\nmost in every \ufb01eld.
\nMorality, ethics and law are not the same.
\nMorality refers to standards of behaviours
\nby which people are judged and ethics en-
\ncompasses the system(s) of beliefs that sup-
\nport a particular view of morality. Ethical
\nconcepts and principles are used to criticize,
\nevaluate, propose, or interpret laws. Soci-
\neties use laws to enforce widely accepted
\nmoral standards. Societies use laws to regu-
\nlate con\ufb02icts over ethical issues in order to
\nguarantee social stability and democratic
\norder. Legal systems often illustrate nation-
\nal morality. Ethical systems are enforced
\nand codi\ufb01ed for the \u201cpublic good.\u201dLaws are
\nbased on the ethical system of a society. Be-
\ncause laws change slowly, the morality of a
\nsociety can and often does con\ufb02ict with the
\ncodi\ufb01ed ethics of the society. Moral systems
\nbegin with the individual, based on a sense
\nof \u201cgood\u201d and \u201cevil\u201d in some cases. Religious
\nmorality often con\ufb02icts with social ethics,
\nespecially when a religion\u2019s morality con-
\n\ufb02icts with existing laws and greater social
\nethics.
\nAchieving the holistic balance is only pos-
\nsible where action in medical practice has its
\nmoral, ethical and legal basis.
\nTo clearly understand what is the relation-
\nship and interrelatedness between ethics,
\nmorality and the law in an Islamic setting I
\nwould like to illustrate ethics, morality and
\nlaw as a basis of medical practice from view-
\npoint of Muslim doctors with very simply
\nthree overlapping circles in iconic model \u2013 a
\nsimple Venn Diagram as below. Any action
\nin medical practice must be ethical, moral
\nand legal (ethical, moral and legal spheres
\noverlap each other equally and completely).
\nWe suggest that ethical, moral and legal
\nconcepts as a basis of medical practice must
\nbe present in every medical curriculum, if
\nwe want that medicine may play in the fu-
\nture its decisive role in shaping a civilized
\nworld concerned for the respect of the hu-
\nman person. Increasing interrelation of
\nmedicine, religion, ethics and law requires
\ngreater understanding and analysis of medi-
\ncal ethics issues and the provision of cultur-
\nally-adapted solutions.
\nTo conclude, the role of the Muslim doc-
\ntor is brie\ufb02y to put his or her profession in
\nservice of the pure religion Al-Islam.To this
\nend, he or she must know both: medicine
\nand Islam.
\nReferences
\nMohammad Iqbal Khan. Medical Ethics – An1.
\nIslamic Perspective, FIMA Year Book 2004
\nKasule, Sr., Omar Hasan. Medical ethics from2.
\nMaqasid al Shariat : Presented at the Interna-
\ntional Scienti\ufb01c Convention jointly organized
\nby the Jordan Society for Islamic Medical Stud-
\nies,JMA and the Federation of Islamic Medical
\nAssociations at Amman, Jordan 15-17 July .
\nThe Islamic code of medical ethics. World Med3.
\nJ 1982;29(5):78-80
\nAthar,S., Fadel,H.E.,Ahmad,W.D. et al. Islam-4.
\nic Medical Ethics: The IMANA Perspective. J
\nIslam Med Assn 2005;37:33-42
\nAbdallah S. Daar and A. Khitamy \u201cBioethics5.
\nfor clinicians: 21. Islamic bioethics CMAJ –
\nJanuary 9, 2001; 164 (1).
\nIslamic Code of Medical Ethics \u2013 Kuwait Doc-6.
\nument \u2013 published by International Organiza-
\ntion of Islamic Medicine -1981, revised 2004.
\nInternational Ethical Guidelines for Biomedi-7.
\ncal Research involving Human Subjects ( An
\nIslamic Perspective)- prepared by Islamic orga-
\nnization for Medical Sciences-2004
\nNariman Safarli MD, President of the
\nAzerbaijan Medical Association, Chairman
\nof Forum for Medical Ethics in Azerbaijan
\n(FMEA), Fellow of Fogarty International
\nCentre and NIH on Research Ethics
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\n112
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nIntroduction
\nGlobal burden of diseases especially in the
\ndeveloping parts of the world is a threat to
\nhuman existence. Low income, poor infra-
\nstructures, inadequate skilled manpower to
\ncontain the controllable diseases in Africa
\nand other developing nations make the situ-
\nation pitiable[1, 2].
\nThe millennium development goals (MDG)
\nof the United Nations (UN) [3] and World
\nhealth Organization Programs had iden-
\nti\ufb01ed these problems; however, a lot still
\nneeds to be done in the areas of supportive
\ninitiatives to assist the developing nations
\nachieve these goals. The collaborative ef-
\nforts of international organizations, donor
\nagencies, are very much needed to help de-
\nvelop adequate work force and infrastruc-
\ntural know how to tackle this challenge.
\nThe bene\ufb01t from such e\ufb00orts on our health
\ninstitutes on short and long term basis
\ncould be unimaginable as will be illustrated
\nin this presentation. Yet there are so many
\nunexplored areas of human health develop-
\nment. To this end, we focus on illustrating
\nthe positive multiplier e\ufb00ects on manpower
\nand community development a well orga-
\nnized and coordinated collaborative e\ufb00ort
\nin highly skilled surgical specialties (Oph-
\nthalmology, Plastic Surgery and Otorhi-
\nnolaryngology) and the need to expand to
\nother areas like Pediatric Otolaryngology
\nwhere hearing loss is a common problem as
\nobserved in the UCH.
\nSpeech, a social attribute unique to man
\nis invariably a product of good hearing.
\nTherefore early evaluation and subsequent
\nhearing conservation and rehabilitation are
\nnecessary. Unfortunately, the cost of achiev-
\ning this is prohibitive making international
\nCollaboration indispensable especially in
\nthe developing nations of the world.
\nIt is on this concept we highlight the im-
\nportance of international collaboration.
\nReviewed records on
\ncollaborative activities
\nOther major collaborative institutes in Ni-
\ngeria include:
\nEbonyi State University Teaching Hospi-\u2022
\ntal Abakiliki
\nMilitary Hospital Ikoyi lagos\u2022
\nJos University Teaching Hospital Jos\u2022
\nUniversity of Nigeria Teaching Hospital\u2022
\nEnugu
\nFederal Medical Centre Owerri\u2022
\nLagos State university Teaching Hospital\u2022
\nlagos
\nMurtala Muhammad Specialist Hospital\u2022
\nKano
\nSpecialist Hospital Bauchi\u2022
\nFurthermore, applications from many more
\nmedical centers in Nigeria were being con-
\nsidered by the smile train.
\nThe burden of Cataract and blindness
\nThe most recent global data on the preva-
\nlence of blindness estimates that about 37
\nmillion people are blind while another 124
\nmillion are visually impaired [4, 5]. The
\nWHO estimates that about 75% of global
\nblindness is avoidable and over 90% of
\nblind people live in developing countries
\n[6].Cataract is responsible for about 48% of
\nglobal blindness [4] and 33-70% of blind-
\nness in Nigeria [7-13]. Majority of those
\nInternational collaborative initiative surgical
\nManpower development: a plea to do more in
\nlow \u2013income-countries
\nCollaborative Surgical Manpower Development
\nTitus S Ibekwe
\nAdeyinka O Ashaye
\nBolutife A Olusanya
\nOnyekwere GB Nwaorgu
\nPaul A Onakoya
\nOdunayo M Oluwatosin
\nwma 7-2.indd 112wma 7-2.indd 112 9\/29\/09 5:25:14 PM9\/29\/09 5:25:14 PM
\n113
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\na\ufb00ected have little or no access (geographic
\nand \ufb01nancial) to health services [14, 15].As
\na result the quality of lives of these patients
\ndeteriorates and fewer patients present to
\nthe hospitals. The low volume of patients
\nundergoing cataract surgery had a negative
\nimpact on the training capacities of the eye
\ncare training centers available in Nigeria.
\nCollaborative remedial
\ne\ufb00orts and outcome
\nInternational Council of Ophthalmology
\n(ICO) conducted site visits to a number of
\neye care facilities in Nigeria in April 2004.
\nTraining and infrastructural de\ufb01ciencies in
\nthe delivery of eye care services in Nigeria
\nwere found and this resulted in the initiative
\nto establish a model regional ophthalmic
\ntraining center in West Africa. The Oph-
\nthalmology Department of the University
\nCollege Hospital Ibadan, Nigeria was cho-
\nsen for this purpose. The initiative was co-
\nsponsored by the International Agency for
\nPrevention of Blindness (IAPB) and Carl
\nZeiss Company. The main aim was to im-
\nprove ophthalmic training through imple-
\nmenting initiatives to increase patients\u2019
\nvolume, focus on subspecialty training, pro-
\nvision of infrastructure and strengthening
\nof management \/ operational systems.
\nAn initial take-o\ufb00 boost was given by Dr.
\nEl-Margaby, the then president of Middle
\nEast African Council (MEACO)], who
\ndonated consumables for 500 cataract sur-
\ngeries. The surgical programme started in
\nSeptember 2006. The patient load for cata-
\nract surgeries increased by 247.9% within
\nthe year (table 1). A positive impact was
\nalso felt on the residency training as regards
\nthe increased number of cataract surgeries
\n(211.1%) performed by the senior resident
\nDoctors as primary operators.
\nDespite the increase in the volume of sur-
\ngical turnover, the quality of surgeries were
\nnot compromised rather the frequent expo-
\nsure and hands-on experience of the resi-
\ndent doctors made room for good quality
\nassurance in the patients management. This
\nwas demonstrated by a signi\ufb01cant increase
\nin the proportion of patients with good
\nvisual outcome de\ufb01ned at Visual Acuity
\n(VA) 6\/18 or better after cataract surgery.
\nAn increment from 68.4% to 85.5% was re-
\ncorded. This is close to the WHO standard
\nof about 90% record of VA 6\/18 or more.
\nAgain, the insertion of intraocular lens after
\nthe cataract extraction has been perfected
\nby the trainees and is now the standard
\npractice in the hospital. The impact of the
\ninitiative on the social lives of the patients is
\ncurrently being evaluated, however, the goal
\nof VISION 2020: the right to sight is being
\nachieved in no small way.
\nCleft lips and palate disorders
\nand collaborative remedies
\nCleft lip and \/or palate are major problems
\nof the developing nations where millions of
\nchildren carry their clefts un-repaired due
\nto economic and infrastructural impover-
\nishment [16, 17]. Apart from the distorted
\ncosmesis, feeding and speech are usually
\nimpaired and is often associated with social
\nstigmatization [18, 20]. As a result, inte-
\ngration in schools, work places and social
\ngatherings are seriously hampered .The
\nsurgical time for the repairs of cleft could
\nbe as short as 45 minutes and the cost as
\nTable 1.
\nCataract surgeries and ICO initiatives
\nParameters Pre ICO
\nInitiative
\n(2006)
\nPost ICO
\nInitiative
\n(2007)
\nPercentage
\n(%)Increase
\nZ-test @ 95% con\ufb01-
\ndence
\nInterval
\n(Z-values)
\nAverage Cataract sur-
\ngery load per Annum
\n282 699 247.9 12.03
\nAverage cataract
\nextractions per senior
\nResident Dr.
\n45 95 211.1 3.85
\nTable 2.
\nEstablished centers for the smile train cleft repair initiatives in Nigeria and activities in
\n2008\/2009
\nInstitutes Proposed no of
\nfree repairs \/year
\nAchieved no of
\nfree repairs \/ year
\nLagos University Teaching Hospital 100 90
\nNational orthopaedic Hospital Enugu 100 75
\nUniversity College Hospital Ibadan 60 20
\nUniv. of Maiduguri Teach. Hospital 50 61
\nObafemi Awolowo Teach. Hosp. Ile Ife 50 50
\nFed Med Center Gombe 50 48
\nNational hospital Abuja 40 25
\nLadoke Akintola Univ.Teach Hosp. Osogbo 40 23
\nAhmadu Bello University Teaching
\nHospital Zaria
\n40 47
\nUsman Danfodio UTH Sokoto 33 13
\nAminu kano Univ.Teach. Hospital kano 25 40
\nUniv. of Ilorin Teach. Hospital 20 15
\nwma 7-2.indd 113wma 7-2.indd 113 9\/29\/09 5:25:15 PM9\/29\/09 5:25:15 PM
\n114
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nlow as $250.00 [21, 22]. However, bearing
\nin mind that most developing countries of
\nthe world, including Nigeria, live below the
\npoverty line (per capita income less than
\nUSD$ 826) [17] it stands to reason why this
\nis not readily a\ufb00ordable. Since March 2000,
\na non-governmental organization called
\n\u201cSmile Train\u201d has o\ufb00ered free cleft surger-
\nies for 280,738 children worldwide. The
\nmission was to focus on cleft lip and palate
\nrepairs, empower local doctors in develop-
\ning countries with the skills and resources
\nthrough collaborative training to achieve
\nbest safety\/quality rewards among cleft
\ncharities at lowest possible costs [21].
\nThe University College Hospital (UCH)
\nIbadan Nigeria is one of the centres in Ni-
\ngeria where the Smile Train services are
\no\ufb00ered. This is mainly a plastic and recon-
\nstruction teams\u2019 work, however, a multi-
\ndisciplinary management of the patient is
\nnecessary.The ENT surgeons, speech thera-
\npists\/pathologists,maxillofacial surgeons are
\nmembers of the team in the UCH, Ibadan.
\nAs shown on table 2 above, UCH center has
\none of the highest renewable quotas of 60
\ncleft repairs.The contract was signed in De-
\ncember 2006 and \ufb01rst installment of pay-
\nment for sponsorship of the repairs made
\nin January 2007. Within the \ufb01rst quarter of
\nthe year, 33.0% of the target per year has
\nbeen achieved with good outcome (devoid
\nof signi\ufb01cant anesthetic or surgical compli-
\ncations). Apart from the social bene\ufb01ts to
\nthe patients and the relations, it is also an
\navenue for exposure and training of the resi-
\ndent doctors in this \ufb01eld of endeavor.
\nBene\ufb01ts and other area of need
\nLike the ICO surgical initiative, the pro-
\ngram helps to pool the cases of cleft to the
\ndesignated centers. This enhances skill and
\nexposure of the trainee surgeons and as
\nnoted by the co-coordinator of the program
\nin UCH Ibadan, the exposure to the trainee
\ndoctors has been worthwhile. A similar ob-
\nservation was also made by the trainees.
\nRegional workshops and trainings are also
\nheld regularly on the cleft repairs. A bi-
\nmonthly and quarterly academic conference
\nby the members of the multidisciplinary
\nteam is being integrated into the program
\nin UCH Ibadan. This will ensure proper
\nevaluation, auditing and a high standard of
\npractice.
\nA close evaluation of the above two proj-
\nects resulting from international surgical
\ninitiatives and collaborations had revealed
\na tremendous improvement on the train-
\ning of resident doctors in skill acquisition
\nand manpower development. It has also
\nimproved the health and social lives of the
\npopulace especially the less privileged in the
\ndeveloping countries who cannot a\ufb00ord the
\nsurgical fees. It is in this light we identi\ufb01ed
\nSNHL among children (excluding acute or
\nchronic otitis media) as an important area
\nthat has constituted a burden to the Oto-
\nrhinolaryngologists in a developing country
\nlike Nigeria.
\nSensorineural hearing loss in children
\nThe disease burden posed by this ailment in
\nour environment deserves an urgent atten-
\ntion including assistance from donor agen-
\ncies just like the ICO\/IAPB \u2018Cataract\u2019 and
\nthe \u2018Smile train cleft repair\u2019 initiatives. In
\n1995 , the WHO indices showed that about
\n12 million people world wide had disabling
\nhearing loss (>40dB) and that warranted a
\ndeclaration by the World Health Council
\nthat all member countries should prepare
\naction plan for early detection of hearing
\nloss through screening tests for newborn,
\ntoddlers and infants [24]. Ten years later
\n(2005), statistics showed that this \u201chidden
\nhandicap\u201d had a\ufb00ected about 250 million
\npeople, out of which about 75% live in the
\ndeveloping countries and 25% were of early
\nchildhood onset [25].
\nFrom the above review, Sensorineural hear-
\ning loss among children constituted about
\n14.6% of all pediatric cases seen in ORL
\nDepartment out of which about 72.0% fall
\nwithin the under 5 age group. Regrettably,
\nthe actual onset and possible etiologies in
\nmost of these cases are not known. This is
\nin consonance with the \ufb01ndings in earlier
\nstudies in Nigeria, Ghana, Sierra Leone and
\nthe Gambia which revealed that 21-36.5%
\nof cases of Sensorineural hearing losses
\nwere either of unknown cause or suspected
\ncongenital causes [26-30]. In fact, presen-
\ntations are mostly dependent on when the
\nparents feel that there is undue prolonged
\npoor cognitive response. Most times these
\npatients are presented to the hospital be-
\nyond the critical period of the acquisition
\nof speech, language and cognitive functions
\n(within the 1st
\nyear of life) [31,32].
\nIn the past these late presentations were at-
\ntributed to socio-cultural and superstitious
\nbeliefs of the parents [27, 33]. However,
\nemerging facts have shown that this trend
\nis changing and most parents are becoming
\naware but the impending limitation is in the
\na\ufb00ordability of the medical bills [26, 34].
\nAgain, most of the medical facilities in Ni-
\ngeria and indeed most developing countries
\nlack the needed infrastructures and man-
\npower to tackle the challenges. The intense
\ninvestigative (genetic, audiological and im-
\naging) and rehabilitative tools required for
\nthe e\ufb00ective management of these patients
\nare lacking.
\nGenetic\/familial factors are recognized
\nworld wide as strong links to immediate or
\nlate manifestations of Sensorineural hearing
\nloss [35]. Syndromic and non-Syndromic
\nforms have equally been identi\ufb01ed. Sickle
\ncell anemia, predominant in black race,
\nhas been identi\ufb01ed by several authors as
\na predisposition to Sensorineural hearing
\nloss probably through the vaso-occlusive
\ne\ufb00ect on the microvasculature of the co-
\nchlea of the young infants [36-38]. Apart
\nfrom Sickle cell anemia and probably Con-
\nnexin 26 (detected in Ghana through col-
\nlaborative e\ufb00orts by Brobby et al) [39, 40],
\nother hereditary causes are poorly studied
\nand hardly detected early in our sub region.
\nNecessary manpower for hearing genetic
\nwma 7-2.indd 114wma 7-2.indd 114 9\/29\/09 5:25:15 PM9\/29\/09 5:25:15 PM
\n115
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nstudies in Africa is needed in designated
\ncenters to \ufb01ll in this gap.
\nObstacles to remedy
\nThe basic universal hearing screening for
\nthe newborn, infants and pre-school aged,
\nwhich is the expected standard worldwide
\n[41 \u2013 43], has a great set back in Nige-
\nria. The tools needed for this purpose like
\nOtoacoustic emission (OAE), Automated
\nBrain Response (ABR), Screening and
\ndiagnostic Audiometers and Tympa-
\nnometers are lacking. These are not read-
\nily available in specialists\u2019 centres not to
\ntalk of the other health facilities where
\nbirth deliveries are taken. OAE and ABR,
\nwhich are automated machines designed
\nfor the purpose of hearing screening in
\nchildren costs about USD$3,000.00 and
\n$8,000.00 respectively. At least two each
\nare needed in designated screening centres
\nto enhance maintenance and sustainability
\nof this program. As correctly observed by
\nOlusanya et al , government contributions
\nto health in developing countries (as low
\nas 24%) are far cries compared to devel-
\noped countries (as high as 81%)and this
\ntranslates to nearly 90% out of pocket ex-
\npenses for the populace in the developing
\ncountries within their limited income.
\nThis means that at best the government
\nrole in these countries could only be facil-
\nlitatory \u2013i.e. sensitization and creation of
\nawareness among the populace on the ex-
\nisting programme. Therefore, sponsorship
\nof such programs in developing nations
\nlike Nigeria will largely depend on Inter-
\nnational collaborations with professional
\norganizations, donor agencies through
\nprivate public partnerships [44].
\nRehabilitative technologies through hear-
\ning aids and cochlear implants are either too
\nexpensive or non-existent in Nigeria. Most
\nfamilies cannot a\ufb00ord hearing aids. Up to
\ndate, only two cases of cochlear implanta-
\ntion carried out in Jos, Nigeria, in 2005 at
\nECWA missionary hospital in collabora-
\ntion with House Institute USA has been
\nrecorded. Temporal bone surgeries and
\nOtology training in Nigeria needs urgent
\nattention from international surgical and
\nOtorhinolaryngological initiatives. Basic
\nand functional temporal bone laboratories
\nare few amongst our ORL training centers
\nin Nigeria.
\nConclusion and way forward
\nAs observed on the impact in these special-
\nties, e\ufb00orts need to be improved, sustained
\nand expanded to other \ufb01elds to avoid a
\nskewed e\ufb00ect where other areas are neglect-
\ned with the anticipated consequences as ex-
\nempli\ufb01ed in the Pediatric Otolaryngology
\nspecialty.
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\nDr. Titus S Ibekwe, MBBS (Nig),
\nFWACS, FMCORL, ENT Division,
\nDepartment of Surgery, College of Health
\nSciences, University of Abuja Nigeria.
\nDr. Bolutife A Olusanya, MBBS (Ib),
\nFWACS, Department of Ophthalmology
\nUniversity College hospital Ibadan.
\nDr. Paul A Onakoya MBBS (Ib), FWACS,
\nFMCORL Department of ORL University
\nCollege Hospital Ibadan Nigeria.
\nDr. Adeyinka O Ashaye MBBS, FMCOph,
\nFWACS, Department of Ophthalmology
\nUniversity College hospital Ibadan.
\nDr. Onyekwere GB Nwaorgu, MBBS (Ib),
\nFWACS, FMCORL, Department of ORL
\nUniversity College Hospital Ibadan Nigeria.
\nProf. Odunayo M Oluwatosin MBBS
\n(Ib), FMCS, FWACS, Division of Plastic
\nSurgery, Department of Surgery University
\nCollege Hospital Ibadan Nigeria.
\nAbout a year ago, a crisis related to devel-
\noped countries\u2019 housing markets contrib-
\nuted to a global \ufb01nances collapse and led to
\nthe worst world economic crisis since 1929.
\nYears of equity wealth in world market cap-
\nitalization have been destroyed and millions
\nhave lost their jobs. An additional twelve
\nmillion people more than expected before
\nthe crisis will fall below the $2-a-day pover-
\nty line this year and seven million more than
\nexpected will experience \u201cabsolute poverty\u201d
\n($1.25 a day). The pandemic H1N1 threat-
\nens to make things even worse while major
\nlingering contributing crises to health prob-
\nlems (demographics, environment, energy)
\nhave not been resolved. Billions have been
\ninvested in rescuing banks and funding re-
\ncovery programs, the revenue base of social
\nprotection is shattered and debt may jeop-
\nardize the economic prospects of coming
\ngenerations.
\nThe World Health Organization is coor-
\ndinating the health response. A high-level
\nconsultation on \u201cFinancial Crisis and Glob-
\nal Health\u201d was held in Geneva in January
\n2009. The April 2009 meeting on \u201cHealth
\nin Times of Global Economic Crisis\u201d in
\nOslo and the 62nd
\nWorld Health Assembly
\nin May were also crucial. The 59th
\nEurope-
\nan Regional Committee in September will
\nhold further discussions.
\nWhat are the likely implications for health
\nin Europe? No \u201cscienti\ufb01c\u201d predictions can
\nbe made. I will brie\ufb02y review what is known
\nabout the determinants of health (including
\navailable evidence from previous economic
\ncrises) and issues related to regional health
\nservices access.
\nThere is consensus about the causes for the
\nimprovement in world health in recent dec-
\nRe-thinking Means and Ends: Economic Crises,
\nHealth and Access to Health Services in Europe
\nNata Menabde
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\n117
\nMedical Ethics, Human Rights and Socio-medical a\ufb00airs
\nades. In 2008 both the report of the Com-
\nmission on Social Determinants of Health
\nand the European Ministerial Conference
\non Health Systems, Health and Wealth
\ncon\ufb01rmed that in a context of declining fer-
\ntility, improvements were due to combined
\ninterventions at social level (nutrition,hous-
\ning, education, etc) and at the health system
\nlevel (population and personal services,such
\nas care of the newborn, vaccines, treatment
\nof injuries, etc.).
\nHowever severe equity gaps persist. World-
\nwide, 42 countries account for 90% of total
\nchild deaths. In the European Region there
\nis a di\ufb00erence of 35-40 years in average life
\nexpectancy between rich people in Luxem-
\nbourg and poor people in Tajikistan; a child
\nborn in the Commonwealth of Independent
\nStates is three times as likely to die before
\nthe age of \ufb01ve as a child born in the Eu-
\nropean Union (EU); maternal mortality in
\nCentral Asian Republics double the region-
\nal average. Problem exists even within the
\nEU: men in Latvia and Lithuania live 14
\nyears less than in Sweden and Ireland (65
\nversus 79 years); in Slovakia, infant mortal-
\nity from respiratory diseases in 2001 was
\n8.34 per 1000 live births, while the median
\nin the European Region was 1.6.
\nDo previous recessions o\ufb00er clues about the
\nlikely evolution of health in Europe in the
\nfuture?
\nDi\ufb00erent negative health impacts were re-
\nported: low income countries experienced
\nincreases in infant and child mortality and
\nmicronutrient de\ufb01ciency, plus anemia in
\nwomen; in higher income countries, prob-
\nlems included mental health problems and
\nsuicides, with occasional crisis duration-
\nrelated increases in adult male mortality.
\nSpain in the 1980s and Finland in the 1990s
\nshowed no noticeable negative impact; al-
\nthough perhaps the adverse consequences
\nof recession took longer to manifest, or only
\nappeared within marginalised subgroups.
\nState welfare institutions, including health
\nsystems, seem crucial, i.e., whether or not
\ngovernment spending fell and rapid action
\nwas taken even if revenues decreased. If so,
\ncapital expenditure -infrastructure, equip-
\nment- was usually delayed. Imported medi-
\ncines and technologies became more expen-
\nsive if the local currency was devalued.
\nWhenever household incomes fell,domestic
\nhealth spending (especially private) also fell.
\nUtilisation of health facilities that charged
\nfor services always declined, with people
\nswitching to government and subsidised
\n(e.g. NGO) facilities.
\nThis leads to the issue of comparative health
\nservice utilization in Europe. Clearly, uni-
\nversal access to health services is an e\ufb00ective
\nand e\ufb03cient way to reduce poverty and social
\ninequalities by ensuring the positive e\ufb00ects
\nof preventive, therapeutic and care related
\naction and preventing the catastrophic ex-
\npenses attached to health services utiliza-
\ntion.
\nBeyond that broad objective, squaring
\nhealth service accessibility in Europe raises
\nenormous challenges. First, access indica-
\ntors have little comparability; if outpatient
\ncontacts per person were used as standard,
\nfor example, the baseline in the WHO Eu-
\nropean Region would rank from more than
\n15 (Czech Republic) to 1.5 (Albania). If
\nhospital admissions as a percent of the pop-
\nulation were used instead, the range would
\ngo from 26% (Austria) and 23% (Russia) to
\n5% (Azerbaijan) or 8% (Netherlands).
\nSecond, such \u201ccontacts\u201dreveal little in terms
\nof services to the population because of the
\ndi\ufb00erent input combinations each country
\nuses in producing them.For example,health
\nprofessionals\u2019 density is three times higher
\nin Germany (46.5\/1,000 inhabitants) than
\nin Portugal (13.5\/1,000 inhabitants) and
\nindeed those numbers are split di\ufb00erently
\namong professional categories (doctors,
\nnurses, etc); Ireland for example has 15.5
\nnurses\/1,000 inhabitants,which is \ufb01ve times
\nmore than Turkey\u2019s 3.1\/1,000 inhabitants.
\nThird,there are huge di\ufb00erences in ways that
\nresources are spent, ranging (at purchasing
\npower parity (PPP)) from US$ 5,686 per
\nperson per year in Luxembourg to US$ 93
\nin Tajikistan. The fractions spent by the
\npublic versus the private sectors, collected
\nas pre-paid insurance versus as direct out-
\nof-pocket payments, etc., are enormously
\nvaried as well.
\nFourth and most importantly, comparing
\nquality (\u201c\ufb01tness for use\u201d) would require a
\ndeeper understanding of health needs (bur-
\nden of disease and equity), context (values,
\nexpectations,socioeconomic situation,tech-
\nnological development, political climate)
\nand health systems (\u201cthe ensemble of all
\npublic and private organizations, institu-
\ntions and resources mandated to improve,
\nmaintain or restore health within the po-
\nlitical and institutional framework of each
\ncountry: it encompasses personal and popu-
\nlation services as well as activities to in\ufb02u-
\nence policies and actions of other sectors
\naddressing the social, environmental and
\neconomic determinants of health\u201d). Health
\nintelligence for policy making and better as-
\nsessing health system performance is mostly
\n\u201cwork in progress\u201dat the moment and needs
\nto be further developed.
\nIn summary, overcoming this economic cri-
\nsis requires well targeted,timely investments
\nin health systems as part of economic stimu-
\nlus packages because it is good for health, social
\nstability and the economy. Improved access
\nis a particularly critical objective. The crisis
\nhowever calls for doing things di\ufb00erently,
\navoiding duplication, fostering partnership,
\nstrengthening health governance and im-
\nproving performance assessment, as stated
\nin the \u201cTallinn Charter\u201dfrom the European
\nMinisterial Conference on Health Systems,
\nHealth and Wealth in June 2008.
\nDr. Nata Menabde
\nDeputy Regional Director,
\nWorld Health Organization
\nRegional O\ufb03ce for Europe
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\n118
\nWMA news
\nJens Winther Jensen
\nThe WMA has entered into the debate on
\nclimate and health. Recently, the WMA
\nand the Danish Medical Association held
\na seminar in Copenhagen to discuss the
\nWMA draft Statement on Health and Cli-
\nmate Change and the state of the climate
\nin the world today. Immediately after the
\nseminar the WMA issued a statement de-
\nclaring that health should be given a much
\ngreater priority at the UN Global Climate
\nChange Conference in Copenhagen in De-
\ncember 2009. You can access this statement
\non the Danish Medical Association website
\nwww.laeger.dk.
\nThe purpose of the WMA-DMA spon-
\nsored Copenhagen, seminar which took
\nplace 1 September 2009, was to gather the
\nknowledge on the present global situation
\nand provide input to the WMA Statement
\non Health and Climate Change. The state-
\nment will inspire National Medical As-
\nsociations to take action to prevent health
\nrelated consequences of climate change.
\nThe Statement is being edited and will be
\npresented for adoption at the upcoming
\nWMA General Assembly in New Delhi in
\nOctober, Thereafter, the statement will be
\ndirected at the United Nations Conferences
\nof the Parties \u2013 COP15 in December 2009
\nalso to be held in Copenhagen.
\nHowever, the initiative to get health on the
\nglobal agenda must begin now.
\nAt the seminar we learned that global warm-
\ning will have very serious consequences on
\nhealth. Everybody will feel the consequenc-
\nes in their daily lives and the consequences
\nare irreversible.
\nAll signals of melt-down – waters rising,
\ndroughts, heat waves, \ufb01res, desert spread-
\ning – are well described and were explained
\nagain at the seminar by presenters from
\nAsia, Africa, Australia, Europe and North
\nAmerica.
\nNot so widely understood are the conse-
\nquences for the respective physicians and
\nthe health care systems all over the world.
\nHow will climate changes a\ufb00ect health pro-
\nfessionals and the ability to provide health
\ncare? Do we need to adjust health infra-
\nstructures now \u2013 and if so, how?
\nThe presenter from the WHO expressed
\nbewilderment that we have been discussing
\nclimate change for so long, but only within
\nthe last couple of years have we begun to talk
\nabout the health aspects and consequences
\non health of the global change in climate.
\nAre we reacting too late? Time will tell.
\nThere are many regional di\ufb00erences in the
\ne\ufb00ects of climate change and the reaction
\nof authorities. France is the \ufb01rst western
\ncountry to give the health aspect top pri-
\nority when discussing climate change.
\nMaybe this is related to the fact that France
\nhas experienced heat waves that have cost
\nlives, mainly of elderly people. Besides this
\nfact, former French colonies in Africa will
\nprobably experience some of the worst con-
\nsequences of global warming.
\nThere are also huge di\ufb00erences in the fa-
\ncilities that greatly impact how the country
\ndeals with dramatic changes in the climate.
\nThese facilities relate to infrastructure.
\nIn South Africa 40 percent of all hospitals
\nare without clean water and water shortages
\nare critical. It will be the responsibility of
\ngovernments to ensure that strategies on in-
\nfrastructure are implemented to avoid the
\nmost severe consequences of climate change
\nand do not increase inequality in the access
\nto health care.
\nThe climate changes will further accentuate
\ninequalities in health if we do not react in
\ntime.
\nThe good news is that there is strong correla-
\ntion between what is good for our health and
\nwhat will bene\ufb01t the climate. Get out of the
\ncars and hop on a bike! This will lower the
\nCO2 emission. The consumption of salads
\nand vegetables instead of beef will also ben-
\ne\ufb01t the climate,since a lot of CO2 is used in
\nthe production of meat. In these and many
\nother ways, the preventive meassures of ill
\nhealth and climate change coincide. One of
\nthe positive outcomes of the Copenhagen
\nseminar was the statement: \u201dWhat is good
\nfor the climate is good for health.\u201d Now, we
\nall must begin working to change habits and
\nin\ufb02uence our governments.
\nDr. Jens Winther Jensen
\nClimate Changes and Health \u2013
\nThere is Some Good News\u2026
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\n119
\nWMA news
\nOngoing global warming is caused by hu-
\nmans\u2019 increasing emission of greenhouse
\ngases, this warming is causing global cli-
\nmate changes, and these changes have local,
\nregional and global health implications.The
\nseminar in Copenhagen was an opportunity
\nto review the state of the art concerning
\nhealth implications of climate change, and
\nto comment on the proposed WMA posi-
\ntion statement.
\nThe health consequences of climate change
\ncould, according to Colin D. Butler (The
\nAustralian National University), be under-
\nstood using a classic health model: primary,
\nsecondary and tertiary health impacts. The
\nprimary health impacts include heat waves,
\ninjuries after \ufb02oods or \ufb01res, infrastructure
\ncollapse; secondary consequences are vec-
\ntor-borne diseases, food and water-borne
\ninfections, and allergies; and the tertiary
\nconsequences would be famine,local and re-
\ngional con\ufb02icts, displacement, refugees, and
\ndevelopmental failure. Dr. Butler stressed
\nthat tertiary consequences would cause the
\ngreatest health impacts in this century.
\nEducation is crucial, though not su\ufb03cient
\nto solve these problems. Dr. Butler empha-
\nsized the need for changes in university and
\nprofessional education. In particular, educa-
\ntion at the undergraduate and postgraduate
\nlevels needs to focus on sustainability and
\nlimits to growth.
\nMs. Francesca Racioppi Acting Head of Rome
\nO\ufb03ce, (WHO) noted that when we think
\nabout the trends created by the \ufb01nancial cri-
\nsis, we can quickly understand that a crisis
\ncaused by climate change would similarly
\nweaken our capacity to respond.We need to
\nthink in the medium and long term and not
\njust about the next election.
\nDr. Mike Gill (Professor Public Health, Uni-
\nversity of Surrey, UK) proposed that health
\nprofessionals became more aware of certain
\nand immediate health bene\ufb01ts of climate
\nchange mitigation. Life style changes, such
\nas active transportation will mitigate climate
\nchange and will have a positive in\ufb02uence on
\nobesity, heart diseases, diabetes, cancer, re-
\nspiratory diseases, road tra\ufb03c injuries, and
\nosteoporosis. As those in wealthier coun-
\ntries change their lifestyles, they will also
\nbring about equity.
\nThe WHO estimates that the prevalence
\nof preventable disease in high income and
\nlow-income countries due to environmen-
\ntal degradation is, respectively, 17% vs. 25%.
\nUnderstanding and surveying for the socio-
\neconomic determinants of health are es-
\nsential to developing e\ufb00ective public policy.
\nDr. Maura N. Ricketts (Director, O\ufb03ce for
\nPublic Health, Canadian Medical Association)
\nconcluded that an understanding is not
\nachieved without an emphasis on research.
\nMs. Susan Wilbum (Dep. of Public Health
\nand Environment, WHO) urged physicians,
\nmedical associations and countries to work
\ncollaboratively to develop systems for event
\nalerts to ensure that health care systems
\nand physicians become aware of high risk
\nclimate events as they unfold, and receive
\ntimely accurate information regarding the
\nmanagement of emerging health events.
\nIn Asia, the most populous continent, the
\nmarine and coastal ecosystems are likely to
\nbe a\ufb00ected by sea-level rise and temperature
\nincrease, as is agriculture. The risk of hun-
\nger and water resource scarcity is growing,
\nreported Professor Dongchun Shin. The Hi-
\nmalayas provide water to a billion people.
\nSouth Asian countries must prepare for the
\nimpacts of global warming, melting glaciers
\nand subsequent loss of potable water.
\nEven without climate change Africa is al-
\nready su\ufb00ering severely from public health
\nproblems that are exacerbating morbidity
\nand mortality more than in other continents,
\nDrs. Sandrine Segovia-Kueny and Louis-Jean
\nCalloc\u2019h summarized. WHO estimates that
\nclimate change is already claiming 150,000
\nhuman lives annually and most of this hap-
\npens in Africa. Climate change (and global
\nwarming) is creating climatic instability,
\nwhich interferes with the rainfall patterns
\nand a\ufb00ects domestic agricultural produc-
\ntion. Minister for Development Corporation,
\nMrs. Ulla Toernaes in her closing remarks
\nreminded us that the poorest countries are
\nthe most vulnerable to the negative impacts
\nof climate change and thus that those who
\nhave contributed least to the problem are
\nfacing the most severe consequences. WMA
\nGeneral Secretary, Dr. Otmar Kloiber further
\ncontributed to this perspective by his clos-
\ning remark that \u201cwe owe our possibilities (to
\nact, mitigate and adapt) to those who don\u2019t
\nhave them\u201d.
\n\u00d8jvind Lidegaard, Professor, Rigshospitalet,
\nDept. of Obstetrics & Gynaeocology,
\nUniversity of Copenhagen, Denmark
\nMaura N. Ricketts, Director,
\nO\ufb03ce for Public Health, Canadian
\nMedical Association, Canada
\nClimate Change and Health Care \u2013
\na Summary of the Sessions at the
\nWMA Seminar held in Copenhagen
\non September 1st
\n, 2009
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\n120
\nWMA news
\nMike Gill
\n\u201dI believe that climate change will ride across
\nthis landscape as the \ufb01fth horseman. It will in-
\ncrease the power of the four horsemen that rule
\nover war, famine, pestilence, and death \u2013 those
\nancient adversaries that have a\ufb00ected health
\nand human progress since the beginning of re-
\ncorded history\u201d (Dr. Margaret Chan, Director
\nGeneral World Health Organisation,The 2007
\nDavid E. Barmes Global Health Lecture)
\nThe welter of arguments to justify immedi-
\nate action to mitigate climate change is now
\nwell known. Increasingly the arguments
\nlinking climate change to global health are
\nbeing loudly articulated. Indeed, Dr. Mar-
\ngaret Chan, Director-General of the World
\nHealth Organisation, two years ago de-
\nscribed climate change as the de\ufb01ning issue
\nfor public health during this century. \u201eWith
\nimpoverished populations in the develop-
\ning world the \ufb01rst and hardest hit, climate
\nchange is very likely to increase the number
\nof preventable deaths. The gaps in health
\noutcomes we are trying so hard to address
\nright now may grow even greater.\u201d (David
\nE. Barmes Global Health Lecture 2007) .
\nSince then two major publications have
\nset out the detail of the impact of climate
\nchange on humans and on human health [1,
\n2] (see Figure 1). There is no getting away
\nfrom the facts that climate change is now
\nhaving huge impacts on human health, that
\nthese will become greater if no action is
\ntaken, and that the most vulnerable are the
\nworld\u2019s poorest, already most vulnerable to
\npoor health and premature death, and least
\nresponsible for greenhouse gas emissions.
\nThis growing threat has to be added to the
\nother major threats to the health of poor
\npeople across the world. Chronic diseases,
\nfor example, now impose their heaviest
\nburden in low- and middle-income coun-
\ntries.They place enormous strains on health
\nsystems. In many parts of the world the
\nadditional burden of climate change will
\nbreak them. Some of
\nits e\ufb00ect will be direct
\n\u2013 for example through
\nincreased insect-borne
\ndisease, food poisoning,
\nand injury and infectious
\ndisease from \ufb02ooding.
\nMuch larger though will
\nbe its indirect e\ufb00ects.
\nCrop failures will cause
\nfamine, water shortages
\nwill cause con\ufb02ict, as
\nwill mass migration and
\neconomic collapse. All
\nwill cause death.
\nThese are perhaps the
\nmost obvious reasons
\nwhy health professionals
\nshould be clamouring
\nfor \ufb01rm global action to
\ncontrol greenhouse gas
\nemissions to mitigate
\nclimate change, and to
\nprovide su\ufb03cient re-
\nsources for middle and
\nlow-income countries to
\nincrease their adaptive
\ncapacity, in other words
\nto become more resilient
\nto the threats to which they are already ex-
\nposed or which are now unavoidable.
\nThere is also a very di\ufb00erent set of argu-
\nments which health professionals in general,
\nand doctors in particular, need to state, and
\nwhich politicians and negotiators from the
\nrich countries may \ufb01nd easier to hear and act
\non. These arguments are based on the size
\nof the bene\ufb01ts to population and individual
\nhealth which arise from mitigation actions.
\nActions in the energy sector, for example
\nhow we choose to generate electricity, in the
\ntransport sector, for example through the
\npromotion of active transport, in the built
\nenvironment, for example how energy- ef-
\n\ufb01cient buildings are, and in the food sector,
\nfor example through adjustments in our
\nmeat and diary product consumption, all
\nIs Climate Change the Fifth Horseman?
\nFigure 1
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\n121
\nWMA news
\nthese may have a profound e\ufb00ect on health
\nin both rich and poor countries.
\nMitigation actions will halt the spread of
\nmany of those chronic diseases borne of
\nurbanisation – increasingly unhealthy di-
\nets, sedentary lifestyles, and obesity. These
\nare already putting health and health sys-
\ntems under intolerable strain, often in the
\npoorest countries.In Cambodia for example
\none in ten adults has diabetes and one in
\nfour hypertension. Cardiovascular disease
\naccounts for 27% of deaths in low-income
\ncountries (often at a younger age than in
\nhigher-income countries). The combined
\ndeaths from malaria, tuberculosis and HIV\/
\nAIDS account for only 11% [3, 4].
\nSo on top of the arguments rooted in social
\njustice – that we should end poverty and re-
\nduce global inequalities in health – it is clear
\nthat health is no longer a mere consumer of
\nresources. It is also a producer of economic
\ngains, as a result of those very actions being
\nconsidered to avoid runaway climate change.
\nOne of the most important of these is in
\nthe realm of transport, a major and increas-
\ning source of greenhouse gas emissions. As
\nwell as the important e\ufb00ects on road-tra\ufb03c
\ninjuries, urban air pollution, energy-related
\ncon\ufb02ict, and environmental degradation,
\nthere are signi\ufb01cant
\nhealth gains associ-
\nated with replacing
\nfossil-fuel based
\ntransportation with
\nwalking and cycling.
\nFor example the eco-
\nnomic cost of obesity
\nto the UK by 2050
\nhas recently been
\nprojected to reach
\n\u00a350 billion at today\u2019s
\nprices, in addition to
\nthe \u00a310 billion direct
\ncost to the NHS [5]
\n. On the other hand
\nWoodcock and col-
\nleagues have mod-
\nelled the potential
\nhealth gains for an average car-driving
\nwomen, age 35-44 years, changing to rid-
\ning a bicycle in London, where almost three
\nquarters of car trips are less than eight kilo-
\nmetres. They conclude she would lose 15g
\nfat tissue per day, the equivalent of 5.6kg
\nfat tissue per year. She would rapidly reduce
\nher risk of premature mortality by 20\u201340%,
\nbreast cancer risk by 25%, all cancer risk by
\nmore than 20%, and risk of developing dia-
\nbetes mellitus by more than 30% [6].
\nInterventions to curb the current global in-
\ncrease in meat consumption, which is \ufb01ve
\ntimes what it was \ufb01fty years ago (see Fig-
\nure 2), are similarly likely both to reduce
\ngreenhouse gas emissions (agriculture is re-
\nsponsible for 22% of total global emissions,
\nmore even than transport) and to bene\ufb01t
\nhealth, especially in high-income countries
\nmainly through reducing the risk of ischae-
\nmic heart disease (especially related to satu-
\nrated fat in domesticated animal products),
\nobesity,colorectal cancer,and,perhaps,some
\nother cancers[7].
\nCurrently 2.4 billion people depend on tra-
\nditional biomass for cooking. This has major
\nhealth e\ufb00ects: about 1.6 million people die
\nevery year from the e\ufb00ects of exposure to high
\nlevels of indoor air pollution, largely in low-
\nincome countries [8]. It also generates large
\nquantities of black carbon, now known to be
\nthe second strongest contribution to global
\nwarming after carbon dioxide emissions [9].
\nA mitigation action essential to controlling
\nclimate change \u2013 addressing the lack of ac-
\ncess to clean energy for such large numbers
\nof people in low-income countries \u2013 will thus
\nalso confer huge health bene\ufb01ts.
\nRealizing these potential health bene\ufb01ts re-
\nquires public and political support for the
\nmitigation actions that will induce them.
\nTo achieve this, health professionals must
\nmake both politicians and the public aware
\nof the scale of those bene\ufb01ts. In this task so
\nfar we have not done well. A recent article
\nby a doctor in the Times newspaper in the
\nUK likened climate change to cholera in the
\nnineteenth century. Just as fear of cholera
\noutbreaks that killed rich and poor in Vic-
\ntorian times led to vast sums being spent on
\nsewers and ensuring clean water supplies,
\nthe physician asserted, so \u201ethe medical pro-
\nfession should be in the vanguard of this
\nnew revolution in public health\u201d [10] (see
\nFigure 3). The responses to this call to ac-
\ntion were revealing: as well as bringing out
\nthe frank \u201eclimate change deniers\u2019 in force,
\nthere was a strong theme of \u201edoctors should
\nstick to their own area of expertise\u201d. While
\nthose who respond to newspaper articles are
\nnot a scienti\ufb01cally random sample, this re-
\nsponse nontheless supports the impression
\nthat there is much work to be done before
\nthe public in the UK understands the dual
\nFigure 2
\nWorld meat production (1950-2006)
\nFigure 3
\nThe Times
\nMay 25, 2009
\nClimate change is the cholera of our
\nera
\nThe medical profession needs to wake
\nup: we should be in the vanguard of the
\ngreen revolution
\nMuir Gray
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\nWMA news
\nbene\ufb01ts of low carbon living. With this un-
\nderstanding comes a critical reduction of the
\npolitical risk associated with promoting and
\nsupporting an equitable global agreement to
\ncontrol greenhouse gas emissions.The health
\nbene\ufb01ts of low carbon economies and low
\ncarbon lifestyles provide powerful impetus
\nto politicians in terms of being able to carry
\ntheir electorates with them along what is an
\nirreducibly radical path if the global agree-
\nment is to achieve its objectives.
\nThe stakes are high and so the level of our
\ne\ufb00orts must be commensurate with what
\nwe have to gain by achieving our goals.
\nWe must leverage the public\u2019s trust of the
\nmedical profession, which endures despite
\nglobal health crises and occasional bad pub-
\nlicity [11,12]. We need to do a better job
\nof illustrating the clear links between envi-
\nronmental strategies and improved health,
\nclearly articulating the major bene\ufb01ts of ap-
\npropriate action. Where possible we should
\nlead personal life styles which are climate-
\nfriendly, and encourage our patients to do
\nthe same. And we should hone our advo-
\ncacy, ensuring that politicians, as well as the
\npublic, get the message.
\nAt a time when health systems across the
\nworld face signi\ufb01cant \ufb01nancial constraints,
\nthis message is one of the few \u201egood news\u201d
\nstories around. Health systems based on
\nstrategies that facilitate low carbon living
\nand deliver health care using low-carbon
\napproaches and technologies, will indeed
\ndeliver better health outcomes, save money
\nand protect our planet.
\nUntil now the voice of the health professions
\nhas been virtually silent in the UN negotia-
\ntions and conferences on the environment.
\nThis is in contrast to the business sector,
\nwhich in 2007 produced, for example, the
\nBali communiqu\u00e9 [13]. The Climate and
\nHealth Council is working to rectify this.
\nThis Council is an organization led by doc-
\ntors with the aim of mobilising health pro-
\nfessionals across the world to tackle climate
\nchange. They have mounted an ambitious
\nglobal campaign, designed to ensure that
\nthe voice of the health profession is heard
\nbefore and during the forthcoming interna-
\ntional Climate Conference in Copenhagen
\nin December 2009. By the commencement
\nof the conference, the objective is to have
\ngathered hundreds of thousands of health
\nprofessional signatories from across the
\nworld to apply pressure on governments to
\nsign a meaningful agreement in Copenha-
\ngen. For the Council, \u201emeaningful\u201d means
\nthat the deal should be based on the follow-
\ning three principles.
\na) A scienti\ufb01cally-assessed and globally\u2022
\nbinding commitment to cap and reduce
\ncarbon emissions to avoid atmospheric
\nconcentrations greater than 450ppm ,rec-
\nognising that this target may be subject
\nto revision in light of further scienti\ufb01c
\ninformation.
\nb) A mechanism for ensuring that re-\u2022
\nsources are transferred to those countries
\nwhere both living standards and fossil
\nfuel use have been low. These resources
\ninclude those needed to enable popula-
\ntion stabilisation.
\nc) An approach to development which,\u2022
\nby giving people the capability of mak-
\ning low carbon choices, minimises green
\nhouse gas emissions.
\nFor more information, please visit the Cli-
\nmate and Health Council website at (www.
\nclimateandhealth.org). All health profes-
\nsionals are encouraged to sign the pledge,
\nwhich can be found at (www.climateand-
\nhealth.org\/pledge).
\nReferences
\nThe anatomy of a silent crisis: the human impact1.
\nreport. Global humanitarian forum. Geneva,
\n2009 [homepage on the Internet] [cited 2009
\nSeptember 11]. Available from: : http:\/\/www.
\nghf-geneva.org\/OurWork\/RaisingAwareness\/
\nHumanImpactReport\/tabid\/180\/Default.aspx
\nCostello A, Abbas M, Allen B, Ball S, Bell S,2.
\nBellamy R, [et al.]. Managing the Health ef-
\nfects of climate change. Lancet and Univer-
\nsity College London Institute for global health
\nCommission. Lancet 2009; 373: 1693-733.
\nAnderson GF, Chu E. Expanding priorities\u20143.
\nconfronting chronic disease in countries with
\nlow income. N Engl J Med. 2007; 356: 209\u201311.
\nNeglected global epidemics: three growing4.
\nthreats: chapter 6.In: World health report 2003:
\nshaping the future. Geneva: World Health Or-
\nganization, 2003
\nForesight – tackling obesities: future choices.5.
\nForesight [homepage on the Internet] [cited
\n2009 September 11]. Available from: http:\/\/
\nwww.foresight.gov.uk\/OurWork\/ActiveProj-
\nects\/Obesity\/Obesity.asp
\nWoodcock J, Barister D, Edwards P, Prentice6.
\nAM, Roberts J. Energy and transport: series on
\nenergy and health. Lancet. 2007; 370: 1078-88.
\nMcMichael AJ, Powles J, Butler C, Uauy R.7.
\nFood, livestock production, energy, climate
\nchange, and health. Lancet 2007; 370: 1253-
\n63.
\nHaines A,Smith KR,Anderson D,Epstein PR,8.
\nMcMichael AJ, [et al ]. Policies for accelerat-
\ning access to clean energy, improving health,
\nadvancing development, and mitigating climate
\nchange. Lancet 2007; 370: 1264-81.
\nRamanathan V, Carmichael G.9. Global and
\nregional climate changes due to black carbon.
\nNature Geoscience. 2008; 1: 221-27.
\nMuir Gray J. Climate change is the cholera10.
\nof our era. The Times [serial on the Internet].
\n2009 May 25 [cited 2009 September 11].
\nAvailable from: http:\/\/www.timesonline.co.uk\/
\ntol\/comment\/columnists\/guest_contributors\/
\narticle6355257.ece
\nIpsos Mori. Trust in Professions [homepage11.
\non the Internet] [cited 2009 September 11].
\nAvailable from:http:\/\/www.ipsos-mori.com\/
\nresearchpublications\/researcharchive\/poll.
\naspx?oItemId=15&view=wide
\nAmerican Medical Association. Which profes-12.
\nsionals does the public trust the most, and the
\nleast? American Medical News [serial on the
\nInternet]. 2005 Jan. 3-10 [cited 2009 Septem-
\nber 11]. Available from: www.ama-assn.org\/
\namednews\/2005\/01\/03\/prca0103.htm
\nBali communiqu\u00e9 [homepage on the Internet]13.
\n[cited 2009 September 11]. Available from:
\nhttp:\/\/www.cpsl.cam.ac.uk\/our_work\/climate_
\nleaders_groups\/clgcc\/international_work\/the_
\nbali_communiqu%C3%A9.aspx
\nProf. Mike Gill, The Climate and
\nHealth Council Board member,
\nUniversity of Surrey, UK
\nwma 7-2.indd 122wma 7-2.indd 122 9\/29\/09 5:25:18 PM9\/29\/09 5:25:18 PM
\n123
\nIn memoriam
\nIn 1955, at the age of 25, Angel Orozco fol-
\nlowed his father from his then poor home
\ncountry, Chile, to New York City. With the
\nambition of \ufb01nding a job in America and mak-
\ning a living for himself, he left Chile by boat
\nand landed in Norfolk, Virginia. In Norfolk,
\nhe bought a bus ticket northbound to New
\nYork. Oblivious to the laws of segregation
\nin the American south, he was confused by
\nthe stares of the other passengers as he made
\nhis way to the back of the bus and sat down
\namong a group of black women. His neigh-
\nbours welcomed the friendly, buoyant young
\nman and Angel had found a group of friends
\nwith whom he remained in contact for the rest
\nof his life.
\nAt that time, the World Medical Association
\nwas located at New York\u2019s Columbus Circle.
\nThere Angel found his \ufb01rst and last employer
\nin the beginning of 1956. Though he probably
\ndid not know it at the time, this job would take
\nhim across the globe and back many times. He
\nbegan his WMA career as a helping hand and
\n\ufb01nished it as the organization\u2019s Executive Di-
\nrector \u2013 a position he occupied for more than
\ntwo decades.It was he and fellow sta\ufb00-member,
\nThomas Kennedy, who took responsibility in
\n1975 for moving the WMA from New York to
\nthe Geneva area to be closer to the WHO and
\nthe heart of the international community. He
\nand Tom (who later moved to Denmark and
\njoined the sta\ufb00 of the Danish Medical Associa-
\ntion) settled the o\ufb03ce just outside of Geneva in
\nFerney-Voltaire, a tiny French village with only
\n6,000 inhabitants. There were not even proper
\no\ufb03ce buildings in Ferney to house the WMA
\nat that time, so the WMA purchased a villa in
\na residential area and this became home for the
\nWMA and its sta\ufb00 for the next 25 years. Dur-
\ning his many years in France, Angel remained
\na legal resident of New York state and a US
\ncitizen, an identity he cherished along with his
\nChilean citizenship.
\nDuring most of Angel\u2019s tenure as Executive
\nDirector, the WMA did not have a full-time
\nSecretary General present in the o\ufb03ce, but a
\nseries of volunteer Secretaries General who re-
\nmained in their own countries and served pri-
\nmarily as spokesmen for the organization.The
\nrunning of the o\ufb03ce, the management of the
\nsta\ufb00, and the work of the WMA was Angel\u2019s
\nresponsibility \u2013 and one he took very seriously.
\nHe rarely left the o\ufb03ce until 7 or 8pm and of-
\nten stayed late into the night. He helped lead
\nthe WMA through, and beyond, its \ufb01rst half-
\ncentury, a successful era marked by progress as
\nwell as controversy. Through all of that, Angel
\nwas wholly committed to serving the WMA
\nmembers and o\ufb03cers, no matter what level of
\ne\ufb00ort was required. He was universally loved
\nby his sta\ufb00 \u2013 an extreme rarity for the boss
\nof any organization. In a nutshell, working
\nwith Angel was fun. He demanded a lot, but
\nhis informal style, \ufb01erce loyalty and protective
\nnature made him more than a boss to most
\nwho worked for him. He was also a friend, a
\ncon\ufb01dant and even a father \ufb01gure to some of
\nhis younger sta\ufb00.
\nAngel\u2019s work with the WMA was full of ad-
\nventure \u2013 and the occasional misadventure!
\nHe was arrested twice in relation to WMA
\nbusiness: once due to false allegations and once
\nfor transporting the registration fees from the
\nGeneral Assembly in Venice with him on his
\nattempted return to France. Carrying that
\namount cash over the Italian border was illegal
\nat the time. It never occurred to Angel that a
\nperson could be prohibited from carrying his
\nown money with him – a law of which he be-
\ncame aware only after being was arrested on
\nthe train on the border Italian-Swiss border
\nand taken in custody. In both cases, Secretary
\nGeneral Dr. Andr\u00e9 Wynen, bailed Angel out
\nof jail and brought him home.
\nO\ufb03cially, Angel retired from the WMA in
\n1994 at the age of 65. He returned to his home
\ncountry, Chile, re-established himself with his
\nfamily in Vi\u00f1a del Mar, and bought a small
\nfarm in the hills between the coast and Santia-
\ngo. Despite his o\ufb03cial retirement,he remained
\na consultant and a friend to the WMA until
\nlast year, helping with annual meetings and
\nproviding invaluable institutional memory in
\nevery area, from process, to policy, to politics.
\nHis \ufb01nal meeting with WMA was in Divonne
\nin 2008. Although most of us probably did
\nnot realize it beforehand, Angel had been bat-
\ntling cancer for many years already when he
\n\ufb01nally he felt too tired to make the trip to the
\n2008 General Assembly in Korea.
\nFor 54 years, Angel Orozco was a \ufb01xture in the
\nWorld Medical Association. He was a\ufb00ection-
\nately considered by many to be the \u201cgodfather\u201d
\nof the WMA. He was honoured by numerous
\nmember associations for his service to orga-
\nnized medicine, including the German Medi-
\ncal Association\u2019s Medal of Honour. However,
\nthose who knew Angel know that he would
\ncount as far more signi\ufb01cant than his profes-
\nsional accomplishments, the deep and lasting
\nfriendships he developed and maintained un-
\ntil the very end of his days. Those who treated
\nAngel with respect were rewarded with a life-
\nlong friend, full of energy, entertainment and
\nhumour. From the women on the bus in Nor-
\nfolk to new WMA members who may only
\nhave met him last year,Angel was quick to o\ufb00er
\nhis friendship and steadfast in sustaining it.
\nAlthough we learned of the severity of his ill-
\nness nearly a year before his death on April
\n20, 2009, the news of Angel\u2019s passing came
\nas a terrible shock to all of his friends and
\ncolleagues. The WMA will not be the same
\nwithout him. It was an immense pleasure to
\nwork with him and a wonderful and enriching
\nexperience to know him. Angel may be gone,
\nbut his ideas and spirit will forever remain part
\nof our organization and our lives. He is deeply
\nmissed.
\nOtmar Kloiber with Joelle Balfe
\nIn memoriam: Angel Orozco
\nAngel Orozco
\nBorn 4 September 1929 in Iquique, Chile
\nDied 21 April 2009 in Vi\u00f1a del Mar, Chile
\nwma 7-2.indd 123wma 7-2.indd 123 9\/29\/09 5:25:19 PM9\/29\/09 5:25:19 PM
\n124
\nIn memoriam
\nEDWARD R. Annis, M.D., died September
\n14, 2009 at his home in Miami with several
\nof his children and loved ones at his bedside.
\nHe was predeceased by his wife, Betty McCue
\nStarck, to whom he was married for 64 years.
\nThey raised 8 children.
\nIn 2005 Dr. Annis was honored to be includ-
\ned in the book Caring Physicians of the World,
\nwhich pro\ufb01led 65 \u201ccaring physicians\u201d from 58
\ncountries around the world, exemplifying the
\nuniversal and enduring medical traditions of
\ncaring, ethics and science. \u201cThe term \u201cCaring
\nPhysicians\u201d immediately conjures up images
\nof those who spend their lives serving patients
\nin poor and disease-stricken environments.
\nThere are however other types of caring phy-
\nsicians, with roles equally important. These
\nare the physicians whose caring is manifest by
\nworking in the public arena to in\ufb02uence public
\npolicy to meet the healthcare needs of patients
\nand the physicians who serve them.\u201d
\nDr. Annis excelled at caring for patients as a
\npracticing physician for many years. He began
\nhis medical career in Tallahassee, Florida, be-
\nfore moving to Miami, Florida, where he be-
\ncame Chief of Surgery at Mercy Hospital. Dr.
\nAnnis was passionate about healthcare access
\nfor all patients,and used his medical and social
\nleadership skills to advocate for patients and
\nthe medical profession throughout the world.
\nHe served as President of the American Med-
\nical Association from 1963 -1964, and in the
\nsame year as President of the World Medical
\nAssociation.
\nDr. Annis was a gifted orator with an excep-
\ntional understanding of the advocacy pro-
\ncess for developing health policy. Despite
\nthe emotion created by the complex issues,
\nDr. Annis was always clear, constructive and
\nstatesman like. He honed his oratory skills in
\nhigh school, at the University of Detroit and
\nMarquette Medical School in Milwaukee,
\nWisconsin where he received his medical de-
\ngree in 1938. In his role as advocate for physi-
\ncians and patients, he made many appearances
\non national television and radio, and spoke
\nwith politicians and presidents including John
\nF. Kennedy and Senators Humphrey, McNa-
\nmara, Proxmire, Javits and Gore.
\nDr. Annis was a strong critic of ine\ufb03ciencies
\nand unnecessary bureaucracy in healthcare.
\nIn 1962 he gave a famous speech in Madison
\nSquare Garden, to a television audience of 30
\nmillion people, presenting the physicians\u2019 re-
\nsponse to government dominated medicine.
\nRecently, this famous televised speech was
\nentered into the United States Congressional
\nRecord. His book, Code Blue: Health Care in
\nCrisis, was published in 1993.
\nRegarded as one of the giants of American
\nmedicine, Dr. Annis mentored and inspired
\nmany and achieved much, receiving many
\nhonors and \ufb01lling many important leadership
\npositions over his lifetime. When asked what
\nhad been his greatest achievement in life, his
\nanswer speaks volumes for this caring physi-
\ncian: \u201cMy family\u201d. When asked to explain his
\npassionate service to patients and medicine,
\nhe responded, \u201cMy whole approach is that no
\nperson in the nation should be denied medical
\ncare if they need it, whether they can pay for
\nit or not.\u201d
\nDr. Yank D. Coble
\nIn memoriam Pedro
\nSalom\u00e3o Kassab
\nPedro Salom\u00e3o Jos\u00e9 Kassab, a Brazilian physi-
\ncian,grandson of Lebaneses immigrants,grad-
\nuated in medicine at University of S\u00e3o Paulo
\n(USP) in 1953 and specialized in dermatology.
\nHe had highlighted activity on medical asso-
\nciative a\ufb00airs. He served as general secretary
\nof the Brazilian Medical Association (AMB)
\nfrom 1963 to 1968 and between 1968-1981,
\nhe became president of this association. In
\n1976 he was elected president of the World
\nMedical Association. He was the second Bra-
\nzilian doctor to hold this position.
\nDr. Kassab was also a member of the consult-
\ning council at the University of S\u00e3o Paulo,
\nSchool of Medicine. Beyond medicine, educa-
\ntion was another passion for him. In 1957 he
\nbecame director of one of the most important
\nand traditional schools of S\u00e3o Paulo, The Li-
\nceu Pasteur. He was president of the Educa-
\ntion State Council in 2006-07 and he also
\ndirected The Superior Education Chamber of
\nthis organ.
\nPedro Kassab passed away on 15th September
\n2009. He had seven sons and ten grandsons.
\nOne of his son\u00b4s is the current mayor of S\u00e3o
\nPaulo.
\nThe Brazilian Medical Association
\nIn memoriam Edward R. Annis
\nwma 7-2.indd 124wma 7-2.indd 124 9\/29\/09 5:25:19 PM9\/29\/09 5:25:19 PM
\n125
\nThe British Medical Association (BMA)
\nhas issued a report focusing on the damag-
\ning e\ufb00ects of alcohol marketing on young
\npeople. The Association\u2019s Science and Edu-
\ncation department and its Board of Science
\nhas published the report \u201cUnder the in\ufb02u-
\nence\u201d, which is authored by Professor Ge-
\nrard Hastings and Kathryn Angus.
\nThe report points out that alcohol consump-
\ntion in the UK has increased rapidly in re-
\ncent years,not just among young people,but
\nacross society.The population is drinking in
\nincreasingly harmful ways and the result is
\na range of avoidable medical, psychological
\nand social harm, damaged lives and early
\ndeaths. Alcohol marketing communications
\nhave a powerful e\ufb00ect on young people and
\ncome in many forms. These include tradi-
\ntional advertisements on television through
\nubiquitous ambient advertising to new me-
\ndia such as social network sites and viral
\ncampaigns. The cumulative e\ufb00ect of this
\npromotion is to reinforce and exaggerate
\nstrong pro-alcohol social norms.
\nThe report also points out that stakeholder
\nmarketing by the alcohol industry, includ-
\ning partnership working and industry fund-
\ned health education, has served the needs of
\nthe alcohol industry, not public health.
\nIn it\u2019s conclusions, BMA reports that \u201cThe
\nreality is that young people are drink-
\ning more because the whole population is
\ndrinking more and our society is awash with
\npro-alcohol messaging, marketing and be-
\nhaviour.\u201d
\nThe measures recommended by the BMA
\ninclude a comprehensive ban on all alco-
\nhol marketing communications; minimum
\nprice levels; increase the level of excise duty;
\nand several other measures.
\nAlthough the report is based on the British
\nalcohol scene, it would be interesting read-
\ning around the world.
\nThe alcohol industry has protested against
\nthe recommendations of the report.
\nThe report may be downloaded from the
\nBMA web site: http:\/\/www.bma.org.uk\/
\nhealth_promotion_ethics\/alcohol\/underthein-
\n\ufb02uence.jsp?page=1
\nUnder the In\ufb02uence – the Damaging E\ufb00ect of
\nAlcohol Marketing on Young People
\nEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
\nThe 182nd
\nWMA Council Meeting . . . . . . . . . . . . . . . . . . . . . . . . . 85
\nItems from the 182nd
\nWMA Council meeting in Tel Aviv,
\nMay 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
\nTask Shifting On-Line Moderated Discussion. . . . . . . . . . . . . . . . 93
\nShaping the Future of Health Professionals\u2019 Regulation . . . . . . . . . 94
\nAccessing Health Care
\nfor Undocumented Migrants – European observations. . . . . . . . . . 95
\nBringing Fair Trade to Health Systems: What You Can Do. . . . . . 98
\nThe Second Geneva Conference on Person-centred Medicine . . . 100
\nPerson Centred Pediatric Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
\nThe International Network for Person-centred Medicine:. . . . . . . 104
\nEthical , Moral, and Legal Responsibilities of Physicians:
\nan Islamic Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
\nInternational collaborative initiative surgical Manpower
\ndevelopment: a plea to do more in low \u2013income-countries . . . . . . 112
\nRe-thinking Means and Ends: Economic Crises,
\nHealth and Access to Health Services in Europe . . . . . . . . . . . . . 116
\nClimate Changes and Health \u2013 There is Some Good News\u2026 . . . 118
\nClimate Change and Health Care \u2013 a Summary
\nof the Sessions at the WMA Seminar held in Copenhagen
\non September 1st
\n, 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
\nIs Climate Change the Fifth Horseman? . . . . . . . . . . . . . . . . . . . 120
\nIn memoriam Angel Orozco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
\nIn memoriam: Edward R. Annis,
\nMD President, World Medical Association, 1963-64 . . . . . . . . . 124
\nIn memoriam: Pedro Salom\u00e3o Kassab. . . . . . . . . . . . . . . . . . . . . . 124
\nUnder the In\ufb02uence – the Damaging E\ufb00ect
\nof Alcohol Marketing on Young People . . . . . . . . . . . . . . . . . . . . 125
\nContents
\nwma 7-2.indd 125wma 7-2.indd 125 9\/29\/09 5:25:20 PM9\/29\/09 5:25:20 PM
\nWMA news
\nBelgrade, 17th
\nto 19th
\nof September, ZEVA Meeting
\nWMA Conference on Climate Change, Copenhagen, 1st
\nof September
\nwma 7-2.indd 126wma 7-2.indd 126 9\/29\/09 5:25:20 PM9\/29\/09 5:25:20 PM<\/p>\n"},"caption":{"rendered":"

wmj23 No. 3, October 2009 wma 7-2.indd Iwma 7-2.indd I 9\/29\/09 5:24:52 PM9\/29\/09 5:24:52 PM 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 […]<\/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\/wmj23.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3584"}],"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=3584"}]}}