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wmj28<\/a><\/p>\n

vol. 56
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, Inc
\nG20438
\nNr. 4, August 2010
\nHuman Resources for Rural Health\u2022
\nDeveloping Healthcare Technologies for Emerging\u2022
\nMarkets \u2013 Improving Quality, Access and Cost
\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
\nSuffolk IP143QT, UK
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nBachmer Str. 29-33
\nD-50931, K\u00f6ln, Germany
\nAssistant Editor
\nVelta 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:
\nCarl Gustav Carus (1798-1869) was a physi-
\ncian, painter and philosopher of nature. Carus,
\na friend of Johann Wolfgang von Goethe and
\nCaspar David Friedrich, was the first teacher
\nof comparative anatomy in Germany. He is also
\nconsidered to have laid the philosophical founda-
\ntions of depth psychology. The University hospi-
\ntal of Dresden is named after him.
\n\u201cView on Dresden from Augustus bridge\u201d was
\npainted by Carus around 1830. Dresden, his
\nplace of living and working, was the scene of the
\n113th
\nGerman Medical Assembly 2010.
\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
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\nThe magazine is published bi-mounthly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or
\nthe World Medical Association
\nSubscription fee \u20ac 22,80 per annum (incl.
\n7% MwSt.). 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. Dana HANSON
\nWMA President
\nFredericton Medical Clinic
\n1015 Regent Street Suite # 302,
\nFredericton, NB, E3B 6H5
\nCanada
\nDr. Masami ISHII
\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
\nProf. Ketan D. DESAI
\nWMA President-Elect
\nIndian Medical Association
\nIndraprastha Marg
\nNew Delhi 110 002
\nI.M.A. House
\nIndia
\nProf. Dr. 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. Yoram BLACHAR
\nWMA Immediate Past-President
\nIsrael Medical Assn
\n2 Twin Towers
\n35 Jabotinsky Street
\nP.O. Box 3566
\nRamat-Gan 52136
\nIsrael
\nDr.Torunn JANBU
\nWMA Chairperson of the Medical
\nEthics Committee
\nNorwegian Medical Association
\nP.O.Box 1152 sentrum
\n0107 Oslo
\nNorway
\nProf. Dr. 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
\nGOMES DO AMARAL
\nWMA Chairperson of the Socio-
\nMedical-Affairs 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 Officers, Chairpersons and Officials
\nOfficial Journal of the World Medical Association
\nOpinions expressed in this journal \u2013 especially those in authored contributions \u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\n127
\nThe economic crisis has criss-crossed the globe. Just as it appears
\nto be under control in one place, it flares up in another. Emissaries
\nof the World Bank and International Monetary Fund travel from
\ncountry to country with billions in credit and strict controls de-
\nsigned to stabilize the economy. The international assistance is not
\nalways met with open arms, such as in Greece, where public dem-
\nonstrations have protested against the reforms.
\nMedicine reflects the economy.Almost every economic downturn is
\nfollowed by a reduction in health care expenditure, one more severe
\nthan the other. Politicians are much more likely to cut health care
\ncosts than reduce the salaries of civil servants.
\nBut is an economic crisis such a damned phenomenon,that it should
\nlead to the collapse of a health care system? Is it possible to change
\na defect into an effect? What attitude should the World Medical
\nAssociation adopt in the face of economic downturn?
\nThe first slogan we should adopt is: \u201cPoliticians,hands off the health
\ncare budget during economic hard times.\u201d
\nSecondly, we should remind our leaders that in sunny times, they
\nwere the first to spend resources on technological advancements
\nthat offered marginal returns. For example, the latest computerized
\ntomography or magnetic resonance imaging may have cost twice as
\nmuch as the previous one,but may have improved resolution by only
\nten per cent: or, the entry into electronic medical records led to the
\ncollection of massive digital files of which perhaps five percent has
\nany value to the physician. The remainder of the data that has been
\ncollected rests in digital cemeteries. Technology changes so rapidly
\nthat the radiograms that were scanned in the 1990\u2019s are no longer
\nrecognized by newer hospital computers today.The CD we are now
\nusing will someday be as obsolete as are the floppy discs of only a
\nfew years ago.
\nIn the midst of a crisis, politicians will perhaps listen to the fact that
\ndoctors care for patients, not computer monitors. Can our scarce
\nresources be spent more wisely?
\nThirdly, we should take advantage of difficult economic conditions
\nto push for reform. During these times governments are looking
\nearnestly for additional sources of income. Recessions are oppor-
\ntune times to push for tax increases on unhealthy substances, such
\nas tobacco, alcohol and soft drinks. Higher gasoline taxes encourage
\nless automobile driving and more bicycling.
\nBy the way, dear colleagues and medical leaders, how often have you
\ngone to work by bicycle this year?
\nDr. Peteris Apinis,
\nEditor in Chief, WMJ
\nEditorial
\n128
\nWMA news
\nThe 185th
\nmeeting of the World Medical
\nAssociation Council and its committees
\ntook place in Evian-les-Bains, France from
\n20th
\nto 22nd
\nMay 2010, under the Chair-
\nmanship of Dr. Edward Hill.
\nFollowing the adoption of the Minutes of
\nthe 184th
\nCouncil in Delhi, the President
\nDr. Dana Hanson gave a brief report out-
\nlining his extensive travel since Delhi, high-
\nlighting in particular, widespread concerns
\nhe had encountered concerning professional
\nautonomy and regulation. He referred to
\nWHO\u2019s year of Road Safety mentioning in
\nparticular the mortality figures in Russia and
\nfelt that WMA should reconfirm its work
\non Road Safety. The S\u00e3o Paulo Conference
\non the use of placebo in research held in
\nS\u00e3o Paulo, was a great success. He expressed
\nhis thanks to those NMA\u2019s whom he had
\nhad the privilege of visiting and stressed the
\nenormous value of such visits.
\nSecretary General\u2019s Report (see also fuller re-
\nport WMJ,56,87-96)
\nThe Secretary General commenced his re-
\nport by expressing his thanks to the Bra-
\nzilian Medical Association for their help
\nwith the S\u00e3o Paulo conference and to the
\nBundes\u00e4rztekammer, in particular to Dr.
\nRamin Parsa-Parsi,mentioning also the sci-
\nentific work done by the WMA Cooperat-
\ning Centre, Institute of Ethics and History
\nof Medicine at the University of T\u00fcbingen.
\nAcknowledging the continuing work of Dr.
\nCoble, he reported that Books of Hope in
\n2010, supported by the Chinese Centre of
\nDisease Control, the Chinese Medical As-
\nsociation, the Chinese Association on To-
\nbacco Control and the WMA, presented a
\nspeaking book on the dangers of smoking.
\nThis targeted low literacy communities,
\nwhere smoking rates have significantly risen
\nover recent decades. The first 500 speaking
\nbooks have the potential to impact on 50-
\n100,100 people and will be accompanied
\nby research analysing its impact on health
\nliteracy.
\nThe Caring Physicians of the World (CPW)
\nproject extension into Leadership Courses
\norganised by INSEAD Business School in
\nFontainebleau, France, was realised in a sec-
\nond course held in Singapore \u2013 13th
\nFebru-
\nary 2010 – with 29 participants, made pos-
\nsible by unrestricted educational grant from
\nPfizer Inc. The work was supported by the
\nWMA Cooperating Centre at the Centre
\nfor Global Health and Medical Diplomacy
\nin the University of North Florida.
\nDr. Kloiber spoke of studies carried out
\non the need for educational support in the
\nfield of policy creation by the Centre for
\nStudy of International Medical Policies
\nand Practices at George-Mason University
\n(a WMA Cooperating Centre). He also
\ndrew attention to the first issue of a new
\nJournal \u201cWorld Medical and Health Policy
\nDevelopment\u201d in the autumn of 2009. Fi-
\nnally he paid particular tribute to two staff
\nmembers who had extended the coopera-
\ntion with institutions in Geneva, notably
\nWHO with whom the work had intensi-
\nfied. A side event at the UN conference on
\nHuman Rights had been organised by the
\nDanish Medical Association\u2019s initiative on
\nHuman Rights, where there was discussion
\non the role of physicians on combating\/re-
\nporting torture.
\nDr. Kloiber then referred to the revision
\nof the rules of procedure which had been
\ntaking place following council\u2019s decision
\nthat this should be done. All the relevant
\ndocuments had been considered with a
\nview to reducing the documentation, iden-
\ntifying common elements and conflicts of
\nlaws\/rules, etc. and coordinating provisions
\ninto two documents. Documents would
\nbe circulated to council members for their
\ncomments. It identified those areas of du-
\nplication\/conflicts, etc., with suggestions
\nfor consideration and response, prior to a
\nfurther meeting to produce the final revi-
\nsion.
\nNominations
\nDr. Torum Janbu was nominated for the
\nChair of the Medical Ethics Commit-
\ntee and Sir Michael Marmot to serve as a
\nmember of that Committee.
\nCouncil adjourned for the Standing Com-
\nmittees.
\nMedical Ethics Committee
\nThe committee met on 20th
\nMay 2010 and
\nDr. Torum Janbu was elected by acclama-
\ntion.
\nThe Chair welcomed new members of the
\nCommittee, Dr. Poul Jaszcazk, Sir Michael
\nMarmot and Dr. Ramin Parsa-Parsi, and
\nthe Minutes of the October 2009 Meeting
\nin New Delhi were approved.
\nHelsinki and Placebo
\nDr. Ramin Parsa-Parsi, chair of the Work-
\ngroup on Placebo in Medical Research,
\nspoke to the report on the results of the con-
\nference in Sao Paulo and the recommenda-
\ntions which, after referring to there being
\nno urgent need for change in the wording,
\nsuggested that possible future revision of
\nthe Declaration of Helsinki be considered
\nin the light of new findings (methodologi-
\ncal issues, informed consent, research ethics
\ncommittees, etc.), and that a WMA work-
\ngroup should be mandated to:
\ndevelop a strategy in order to continue\u2022
\nthe discussion;
\ndevelop new wording for paragraph 32\u2022
\nwhich should facilitate future revision of
\nthe Declaration;
\nconsider an expert conference in 2011.\u2022
\n185th
\nWMA Council meeting in Evian,
\nFrance 20th
\n\u201322nd
\nMay 2010
\n129
\nWMA news
\nThe Chair stressed the broadening of the
\napproach and Dr. Collins-Nakai respond-
\ning, commented that the wording should
\nrefer to the linking of the use of placebo to
\nwhen agreed treatment was being used in
\nthe research, i.e. the words \u201cthere should be
\nagreement to the use of placebo when agreed
\ntreatment was being used\u201d, be included in
\nany wording, which reflected the view that
\nthe use of placebo in a trial should depend
\non the circumstances,informed consent and
\nthe agreement of Local Ethical Research
\nCommittees ( LERCs).
\nDr.Kloiber supported the concept of further
\nwork and the Committee adopted the Rec-
\nommendations in bold above, and Council
\nlater approved the Working Group report.
\nPrinciples of Health Care for Sports Medicine
\nIn considering comments on the Declara-
\ntion on Principles of Health Care for Sports
\nMedicine, the Chair observed that while it
\nwas a good text,things have changed since it
\nwas adopted and he queried the need for up-
\ndate. Dr. Haikerwal, however, asked wheth-
\ner there was indeed a need for update as the
\ndocument was out of date. He mentioned
\nsuch things as \u201cthe need for exercise in re-
\nlation to non-communicable diseases\u201d and
\n\u201csport\u201d, referring also to \u201cKeeping Healthy\u201d
\nand suggested revision of the statement on
\nChronic Diseases. Dr. Collins-Nakai, rais-
\ning the possibilities of injecting genes to en-
\nhance performance,recommended updating
\nto take account of genetic modification. Ms
\nWapner indicated that the Israel MA would
\nbe willing to do this updating, but Dr. Nel-
\nson felt that the document was not about
\nexercise for the general population, it was
\nfor physicians looking after sportsmen.
\nThe Secretary General reminded the com-
\nmittee that WMA had different policies on
\nsport, e.g. the physician\u2019s role in obesity care
\nis outlined in another document.
\nWhile Dr. Nathanson agreed to looking at
\nObesity and Activity, she would oppose the
\nCMA viewpoint,and leave the document as
\ngeneric cover.The statement should be kept
\nas generic as possible. Dr. Collins-Nakai
\nagreeing with Dr. Nathanson felt, however,
\nthat the document was not generic enough.
\nAfter further discussion a motion to reaf-
\nfirm the document \u201cDeclaration on Prin-
\nciples of Health Care for Sports Medi-
\ncine\u201d was adopted by the Committee and
\nthis recommendation was later adopted by
\nCouncil.
\nHuman Rights
\nMs Clarisse gave a report on organising
\nthe side event at the Human Rights con-
\nference on 9th
\nMarch 2010, chaired by the
\nUN Human Rights Rapporteur. The panel
\nincluded the Slovenian UN Human Rights
\nrepresentative also the Representative on
\nHuman Rights and Torture. She also spoke
\nabout the problems raised by anti-abortion
\nlegislation which could inhibit action in
\npatients with cervical cancer. She reported
\nthat FIGO (Forum of International Gy-
\nnaecology and Obstetrics) had issued a
\nPress Release concerning Female Genital
\nMutilation on International Women\u2019s day
\nin February.
\nDr. Hill and Dr. Hanson reported on their
\nvisit to China where they had discussed
\norgan transplantation with the Chinese
\nMedical Association and the Minister.They
\nwere encouraged by the Chinese Associa-
\ntion and the Minister having established
\nspecific criteria for Transplantation. Three
\nquarters of the hospitals were doing trans-
\nplants and now were better controlled. Al-
\nthough the topic was on the WMA agenda,
\nfor the Chinese this topic was a priority.
\nDeclaration of Tokyo
\nThe committee considered the problems
\nof the implementation of the Declaration
\nof Tokyo and a suggestion that the WMA
\nestablish a mechanism to enable cases of
\ntorture to be notified directly to WMA, to
\navoid the problems associated with notifi-
\ncation in some countries and facilitate the
\nWMA taking action. Dr. Hill also referred
\nto a conference in Sweden on Torture and
\non the reporting of torture. In this context
\nDr. Reis (ICRC) commented that it was
\neasy for doctors working in Geneva to re-
\nport torture, but not so for those working in
\na country where they were afraid that their
\nhouse might be destroyed or their wives
\nraped. He suggested that WMA should do
\nsomething about this.
\nSir Michael Marmot spoke of the real lim-
\nits to what NMA\u2019s can do. They should act
\nand be seen to do what they can.The BMA
\nview is that WMA is doing what it can
\nand the idea of sending this proposal was
\nto give transparency to these actions. The
\nNorwegian MA, appreciating the BMA
\ncomments, felt it crucial that we recognise
\nthe risks for some physicians in notifying
\ntorture, recommending that work continue
\non mechanisms in which they are not seen
\nto be doing this, but also mechanisms by
\nwhich information can get to the UN Spe-
\ncial Rapporteur. Responding to a question
\nas to whether WMA could organise such
\na mechanism, Dr. Kloiber commented that
\nWMA had a small office in which every-
\none had specific tasks. They had neither the
\nmeans nor resources to do this.What is dif-
\nficult is that they are besieged by calls from
\norganisations. They could be faced with
\nprogrammes and campaigns which were not
\nhuman rights issues.
\nDr. Snaedel drew attention to what we in
\nfact have, i.e. the ICRC and WMA work-
\ning with the Istanbul Protocol with outside
\nsupport. This showed what can be done
\nwith specific activities. Dr. Nathanson felt
\nthat we should recommend that the Nor-
\nwegian Medical Association and Dr. Reis
\nidentify simple things which can be done.
\nThe Secretary General commented that
\nWMA as an NGO had been successful in
\ngetting support from governments and the
\nInternational Court in the Hague. What
\nwould happen if we were known to act as
\na monitoring body, what would be the re-
\n130
\nWMA news
\naction? Currently we are aware of doctors
\nin distress and have taken action. Dr. Reis
\nagreed with Dr. Kloiber and was willing to
\nwork on this.
\nA proposal that the BMA, the Norwegian
\nMA and Dr. Reis continue work on this
\nwas recommended and later adopted by
\nCouncil.
\nEnd of Life
\nA WMA Statement on the End of Life
\nand a background paper on End of Life
\nand Medical Care were considered. It was
\nreported that the Spanish Medical As-
\nsociation had been working on a paper on
\nEuthanasia and had prepared a glossary of
\nterms.
\nA Statement on terminal illness had also
\nbeen prepared in the light of the change
\nof attitudes which had taken place. The
\nSpanish Medical Association (SpMA)
\ntherefore recommended changes to the
\nVenice Declaration. Reference was made
\nalso to issues of Informed Consent, Pal-
\nliative Care and to many countries still
\nhaving problems with prescribing opiates
\nwhere national legislation limits interfered
\nwith their adequate prescription \u2013 leading
\nto more suffering by patients. It should
\nbe made clear that terminal sedation was
\nnot Euthanasia, a matter on which the
\nSpMA had issued a Statement. There was
\na need for team work with doctors and
\nparamedical professionals, also for fami-
\nlies to be involved in palliative treatment
\nand for palliative care to be included in
\nmedical school curricula. Dr. Snaedel as a
\ngeriatrician suggested that the documents
\nbe circulated, but Dr. Nathanson observed
\nthat the BMA had many problems with
\nthe document. There was much good in
\nthe paper, but she was concerned about
\nthe translation and the BMA had many
\nproblems with some of the definitions.
\nShe proposed that a working group be
\nformed and address also the problem of
\ncontinuing unbearable conditions.
\nAfter lengthy discussion the Chair thanked
\nthe Spanish for the proposal. A recommen-
\ndation that a working group be set up was
\napproved and later adopted by Council.
\nThe committee also received:
\na report from Dr. Blackmer on WMA\u2019s\u2022
\nwork with WHO on Ethics in TB envi-
\nronment (see Secretary General\u2019s report);
\ncomment from Sir Michael Marmot on\u2022
\nthe work of WHO on Social Determi-
\nnants in the context of Tuberculosis;
\nan offer from Dr. Nathanson to distribute\u2022
\nthrough the WMA secretariat an updat-
\ned UK statement and concept paper on
\nteaching ethical issues, from the Institute
\nof Medical Ethics.
\nSocio-Medical Committee
\nThe committee was called to order by the
\nchair, Dr. Jos\u00e9 Luiz Gomes do Amaral.
\nThe committee approved the minutes of its
\nNew Delhi meeting last autumn.
\nHealth and Environment
\nIn the context of Health and Environment
\n(see also Secretary General\u2019s report) the com-
\nmittee considered comments on the state-
\nments on Environmental Degradation
\nand Sound Management of Chemicals
\nand also a document on Advocacy Strategy
\non Climate Change Process.
\nDr.Nakai,chair of the workgroup on Health
\nand Environment, informed the committee
\nthat the group planned to submit a draft
\npolicy on the \u201cbuilt environment\u201d next
\nspring.
\nDr. Dongehun Shin reported on a con-
\nference convened by the secretariat of
\nthe United Nations Environmental Pro-
\ngramme (UNEP) Strategic Approach to
\nManagement of Chemicals in Ljubljana in
\nFebruary, on the approach to the involve-
\nment of the health sector in chemicals\u2019
\ndisposal. Speaking of the need for further
\nmanagement principles in Chemicals\u2019 dis-
\nposal, he said one of the aims was to re-
\nduce health risk in the life cycle of chemi-
\ncals, i.e. the control of harmful chemicals
\nand the reduction of production. He com-
\nmented that developing countries have a
\nlack of capacity for sound chemical devel-
\nopment.
\nThe committee also received an oral report
\nfrom Dr. Peter Oris concerning the first ne-
\ngotiating meeting of the UN Environment
\nProgramme on legally binding provisions,
\nscheduled for June in Stockholm, at which
\nhe would represent WMA. He intended to
\nhighlight the Seoul WMA Resolution on
\nMercury.
\nMs Clarisse Delorme speaking to a paper
\non advocacy strategy prepared by the sec-
\nretariat for the Health and Environment
\nWMA workgroup, reiterated the Advocacy
\nCommittee\u2019s discussion on the frustration
\nfelt at the failure to include reference to
\nhealth in the final Copenhagen COP 15
\nconference agreement and their failure to
\noptimise the increasingly well-evidenced
\npublic health benefits of climate change
\nmitigation activities.
\nSir Michael Marmot reported that he had
\npersonally been lobbied by physicians in the
\nUK about this. In the UK climate is an is-
\nsue for the people. He therefore supported
\nhighlighting this issue with regard to hu-
\nman health.
\nDr. Dana Hanson, chair of the Advocacy
\nAdvisory Group, supported the proposal by
\nthe group to hold a media briefing session
\non the day before the opening of the UN
\nClimate change Conference to be held in
\nCancun in December 2010.
\nThe Committee recommended and Coun-
\ncil later accepted that the Statement on
\nEnvironmental Degradation and Sound
\nManagement of Chemicals be sent to the
\nGeneral Assembly with a recommenda-
\ntion that it be adopted.
\n131
\nWMA news
\nPrescribing\/Relations between Physicians and
\nPharmacists in Medical Therapy
\nThere was a long and forceful debate in
\nthe committee concerning where ultimate
\nresponsibility for prescribing lies. During
\nthe debate firm views were expressed by all
\nspeakers. Emphasis on the importance of
\nissues of patient safety and access to medi-
\ncines were stressed as were educational re-
\nquirements and skills needed to ensure both
\nquality and safety, in the interest of patients.
\nThe final decision will be taken at the Van-
\ncouver General Assembly in the autumn
\nwhen the texts of recommendations are
\nsubmitted to the General Assembly.
\nViolence against Families, Women and
\nChildren
\nDr. Nakai introduced the Working Group\u2019s
\nrevision of the Proposed Statement on
\nFamily Violence revision, following com-
\nments from NMA\u2019s. After some discussion
\namendments were agreed. A recommen-
\ndation, that the Proposed Statement on
\nFamily Violence be approved and sent to
\nCouncil later approved by Council.
\nDr. Nakai then indicated the efforts of the
\ngroup to amend the document Violence
\nagainst Women and Girls to reflect con-
\ncerns of NMA\u2019s. Dr. Nathanson urged that
\nthe aim of the document be clear. \u201cVio-
\nlence is damaging both to the victim and
\nto society\u201d. The recommendation that it
\nbe approved as amended and sent to the
\nGeneral Assembly was later accepted by
\nCouncil.
\nFemale Genital Mutilation (FGM)
\nIn a discussion on FGM,Dr.Nathanson in-
\ndicated that although we have a Statement
\non this issue, governments can still be por-
\ntrayed as racist in condemning this, since
\nwhile education was improving, there is still
\nthe problem of parents taking children to
\ncountries where FGM was accepted. After
\ntalking to girls who have such forced FGM
\nit is clear that they would prefer action to
\nbe taken.
\nDr. Hill reminded the committee of the
\nWHO\/UNICEF\/UNFPA Global Strategy
\nto stop healthcare providers from perform-
\ning FGM. WMA had been involved in the
\ndrafting process and it fitted in with WMA
\npolicy.
\nDr. Kloiber commented that what we
\nwanted was to achieve FGM abolition and
\nto help victims. We will achieve a preventa-
\ntive effect for those emigrating.The Norwe-
\ngian Medical Association commented that
\nscreening has not been shown to prevent
\nFGM and there remained the question \u201cat
\nwhat age screening should be done?\u201d Also
\nFGM can be difficult to identify. Dr. Na-
\nkai said that screening of immigrants can
\nidentify risk and referred to a European
\nParliamentary document on this issue. Dr.
\nNathanson felt that clearly screening could
\nnot be forced, but often at screening this
\ncan be used as an opportunity to prevent
\nand educate.
\nClassification of WMA 2000 Policies
\nPrisons and Tuberculosis
\nThe committee recommended that the Dec-
\nlaration of Edinburgh on Prison Condi-
\ntions and the Spread of Tuberculosis and
\nother Communicable Diseases undergo a
\nmajor revision on which the BMA and the
\nICRC volunteered to work. Council later
\napproved this recommendation.
\nAdvocacy
\nDr. Hanson, chair of the Advocacy Ad-
\nvisory Group, in his oral report raised
\nAdvocacy issues relating to WMA\u2019s role
\nin climate change. He mentioned also
\nthe increasing role of the World Health
\nProfessional Alliance\u2019s (WHPA) speak-
\ning for more than 26 million health pro-
\nfessionals in global health debates. There
\nwas increasing concern amongst WHO
\nmember states on Primary Health Care,
\nand he proposed that WMA should or-
\nganise a Primary Health Care conference
\nin 2011. Council later agreed to a small
\nworking group examining the feasibility
\nand possibility of cooperation with other
\ninternational PHC bodies of Organis-
\ning a Primary Healthcare conference in
\nMarch 2011.
\nDr. Haikerwal, speaking about the work
\nof WMA with WHO, raised the Issue
\nof Social Determinants of Health which
\nshould be addressed at such a conference.
\nSir Michael Marmot had hoped to raise
\nthe issue of Ethics in the Committee of the
\nCommission on Social Care. He referred
\nto health inequalities and the interest not
\nonly in the causes of health inequalities
\nbut also in the causes of causes in health.
\nWhere do physicians fit in to this? He
\nlisted three points:
\nthe responsibility to put one\u2019s house in or-\u2022
\nder concerning universal access to health
\npromotion;
\nthe role of physicians as advocates;\u2022
\nthe importance of knowledge of the de-\u2022
\nterminants of health.
\nCouncil later agreed that this be pursued
\n(see resumed council below).
\nMedical Care for Refugees
\nThe committee considered a \u201cProposed Re-
\nvision of the WMA Resolution on Medi-
\ncal care for Refugees and Internally Dis-
\nplaced Persons\u201d.
\nThe Swedish Medical Association moved
\nthat the revised proposal be approved and
\nalso commented that the current legisla-
\ntion in their country was very restricted
\nand the Association had highlighted this.
\nDr. Nathanson supported this excellent
\ndocument being sent to NMA\u2019s for com-
\nments and indicated particular difficulties
\nwith medical care of such persons awaiting
\nthe approval of permission to stay in the
\ncountry.
\n132
\nWMA news
\nThe recommendation that the revised docu-
\nment be referred to NMA\u2019s for comments was
\nlater approved by Council.
\nWorld Economic Forum (WEF)
\nDr. Julia Seyer reported a recent meeting
\nin London on a WEF initiative to improve
\naccess to health data on the grounds that
\nsuch data play an important role in Health
\ncare and health services. To this end WEF
\nis working with parties with relevant in-
\nterests such as health professionals, patient
\ngroups, private industry and universities, to
\ndraft a global charter to strengthen access
\nto health data which can produce more ef-
\nfective management of health providers
\nand of individual health interests. Such a
\ndocument needs to balance these interests
\nwith ensuring the protection of individual\u2019s
\nprivacy, as well as ensuring the quality and
\nstandardisation of data collected and the
\nunderlying principle of equity. Dr. Haiker-
\nwal observed that probably most countries
\nhave this information but governance was
\nneeded. Sir Michael Marmot was not clear
\nabout whether principles were concerned
\nwith privacy and data, or about collecting
\ndata. The Secretary General thought it im-
\nportant to be involved in this. WMA was
\nin line with the other health professions on
\nthese issues and WEF was providing a plat-
\nform for discussion.
\nMedical Aid in Disaster Areas
\nThe Chairman, Dr. Amaral, gave a detailed
\naccount of the Brazilian Medical Asso-
\nciation\u2019s organisation of medical aid \u201cSOS
\nHaiti\u201c following the earthquake in January
\n2010. Within 21\/22 days following a call
\nfor volunteers 907 physicians from various
\nspecialties had offered to go to Haiti. He
\nmade particular reference to the work which
\nwas enabled to be carried out in a Canadian
\nHospital based in Haiti, which made space
\navailable to enable these physicians to en-
\ngage in surgery, notably the orthopaedic
\nsurgery required. He referred to the many
\nNMA\u2019s who had provided assistance and
\nthe collaborative assistance in neighbouring
\nDominica.
\nConcluding his remarks he commented,
\n\u201cA world safety zone does not exist on this
\nplanet\u201d \u2013 and appealed for WMA to assist
\nin coordinating the spread of the experi-
\nences of NMA\u2019s in responding to Disasters
\nand the potential for WMA to participate
\nin coordinating NMA\u2019s responses to disas-
\nter assistance.
\nA number of NMA\u2019s spoke of their experi-
\nence in responding to Haiti and other disas-
\nters over recent years, stressing the impor-
\ntance of disaster preparedness and expressed
\nthe feeling that WMA should act as a focal
\npoint in coordinating the experiences of
\nNMA\u2019s, etc. Reference was also made to a
\nforthcoming WHO report on Disasters.
\nCounterfeit Drugs
\nDr.Seyer then gave an account of the launch
\nof World Health Professions Alliance
\n(WHPA) campaign on Counterfeit Medi-
\ncal Products, \u201cBe Aware\u201d. She stressed the
\nimpact of counterfeit drugs,both patent and
\ngeneric, on patient safety such as the major
\nrisk of increasing drug resistance in tuber-
\nculosis. This affected also the confidence
\nof the public in available drugs. In parts of
\nAsia and South America 30% of the drugs
\nwere counterfeit and the profits from these
\namounted to between 5 and 10 million dol-
\nlars. It should be noted that counterfeit was
\nnot limited to the developing world. It also
\nis a problem in the developed world via for
\nexample on-line purchases of which some
\n50% were counterfeit. The WHPA had
\ndefined principles and had also identified
\npatients as victims of this activity. WHPA
\nhad set up a tool-kit on \u201ccounterfeit drugs\u201d
\nfor both professionals and public. This was
\naccessible on both WMA and WHPA
\nwebsites. Workshops are being organised
\nat which action points will be emphasised.
\nThese will take place in Africa and America,
\nto which government representatives will be
\namong those invited. She asked WMA and
\nNMA\u2019s to distribute the toolkit which was
\navailable for downloading from the web.
\nThis work was also being coordinated with
\nWHO.
\nNon-Communicable Disease Management
\nIn updating the committee on UN policy
\nwork on Non-Communicable Diseases
\nthe AMA reported that together with
\nthe American Academy of Family Physi-
\ncians it organised a group to influence the
\nStatement. WHO has also an agenda on
\nthis topic. At the World Health Assembly,
\nmember states\u2019 representatives had spoken
\non this issue and the AMA had been in
\ncontact with them. It was anticipated that
\na paper would be produced for the General
\nAssembly in 2011.
\nDr. Seyer thanked Dr. Ishii for a draft on
\nNon-Communicable Diseases and indicat-
\ned that there would be a UN conference on
\nthis topic later in the year. There was pres-
\nsure to add this topic to the MDGs. It was
\nimportant that the role of health profes-
\nsionals be included in these discussions.
\nDr. Ishii also reported that there was a col-
\nlective voice from Asia appealing to phy-
\nsicians to work with patients on \u201cPatient
\nSafety\u201d.
\nDr. Nathanson said that Sir Michael had
\nreferred to his work on Social Determinants
\nin Health.The BMA was preparing a paper
\non the role of Physicians, which would be
\npublished.
\nThe Chairman, Dr. Gomes do Amaral,
\ngave an extensive report on the medical aid
\n\u201cSOS Haiti\u201d rapidly organised by the Bra-
\nzilian Medical Association responding to
\nthe earthquake disaster in January 2010. In
\nresponse to an appeal 907 physicians vol-
\nunteered to go to Haiti. He detailed the
\ntremendous problems encountered and
\npaid tribute in particular to the Canadian
\nhelp which arrived and provided much
\n133
\nWMA news
\nneeded Ophthalmic and ENT services, to
\nthe supplies sent from Ethiopia, the help
\nin neighbouring Dominica and to NMA\u2019s
\nand others who responded to the need for
\nspecialist services, notably orthopaedics. He
\nwarned that \u201cA safety zone does not exist on
\nthis planet\u201d and appealed for volunteers in
\nWMA to spread the experience of NMA\u2019s
\nin responding to disasters.
\nDr. Ishii in thanking Dr. Amaral said the
\nJapanese Medical Association had sent
\nvolunteers and stressed that Japan had sub-
\nstantial experience of earthquakes. Dr. Na-
\nthanson said that the BMA had links with
\nthe Red Cross, UNICEF, M\u00e9decins sans
\nFronti\u00e8res, etc., and directed people as ap-
\npropriate. Resources were provided from
\nthe NHS as donations from their stockpiles
\nas appropriate, and the government had
\ndoubled its aid.The public in responding to
\nan appeal gave 10 times more than this.
\nThe Israel Medical Association, whose vice-
\npresident had organised rehabilitation ser-
\nvices which were also needed, felt that this
\ntype of emergency needs support from the
\nWMA. The AMA had organised an emer-
\ngency response team with PAHO and the
\nDepartment of Defence organised a con-
\nsultation on the management of disasters.
\nAn AMA\/American College of Surgeons
\ndelegation was sent to organise an evalua-
\ntion of needs. The SpMA has established a
\nregister of volunteering specialists \u2013 more
\nthan 1000 \u2013 and expanded the training of
\nvolunteers.
\nThe Chair commented that we had needs
\nfor disaster assistance in 2005, 2006 and
\nalso Haiti. Climate change was also to be
\nexpected. He felt that WMA should play a
\nrole as a central control for Medical Aid in
\nthese circumstances. It would not be easy.
\nDr. Haikerwal said they had the same prob-
\nlems with the Tsunami in 2004. The AMA
\nhad lots of experience: lots of equipment
\nand manpower arrived but was blocked
\nfrom being quickly deployed.WMA should
\ncoordinate learning from these experienc-
\nes. Dr. Nelson commented we don\u2019t know
\nwhen the next disaster will hit us.What was
\nimportant was disaster preparedness.WMA
\nshould be a focal point for this.. She had
\nstudents from medical school but no means
\nof coordinating their help. Brazil had given
\nan example of how to coordinate assistance.
\nWHO Global Strategy on the Prevention of
\nAlcohol Abuse
\nMr. Dag Rekve,Technical Officer, Manage-
\nment of Substance Abuse Department at
\nWHO, reported that the 63rd meeting of
\nthe World Health Assembly had just ad-
\nopted the WHO Global Strategy on the
\nPrevention of Alcohol Abuse.
\nAddressing the question \u201cWhy this Global
\nStrategy\u201d he explained that a collaborative
\nstudy on disease cause and outcome had
\nidentified alcohol as the 3rd leading risk
\nfactor for global causes of diseases It was
\ntherefore a global issue. He illustrated the
\nhuge problems of morbidity and the huge
\nvariation in mortality in sub-groups such
\nas male\/female\/age and also referred to
\nsome protective effects of alcohol. Young
\npeople were the most damaged, e.g. 30%
\nin the European region. There were great
\nvariations in determinants. Addressing
\nthe question of why should this become a
\nglobal issue now, he outlined the history
\nof research and resolutions starting in the
\nearly 80\u2019s with French research into the
\nsocial consequences of alcohol abuse and
\nthen further research, expert committees
\nand WHA resolution over the succeeding
\nyears. In 2002, \u201cAlcohol\u201d \u2013 a WHA report
\n\u2013 listed alcohol as the fifth leading fac-
\ntor in disease causation. In the following
\nyears things moved towards the concept
\nof a global strategy which was the subject
\nof wide consultation, and a draft mandate
\nfor a global strategy began to emerge, cul-
\nminating in the Global Strategy just ad-
\nopted. While member states have agreed
\nthe Strategy, it is not legally binding, it was
\nmeant to complement governments\u2019 ac-
\ntions. The evidence basis for damage from
\nalcohol was good but there were huge dif-
\nferences in member states. This called for a
\ncomprehensive approach.There was a need
\nfor leadership as reflected in the WMA
\nSantiago approach. National Health Ser-
\nvice commitment was essential. While
\nthere was little evidence basis for actions,
\navailability and pricing of alcohol were im-
\nportant.
\nHarm reduction processes should try to
\nreduce the negative consequences of alco-
\nhol abuse. Illicit production needed to be
\naddressed. Because of ethanol which is an
\nadded risk. Globally WHA has four axes:
\npublic health advocacy;\u2022
\nresource mobilisation;\u2022
\nproblems of implementation;\u2022
\nneed for a going concern \u2013 swings be-\u2022
\ntween no action and aggressive action.
\nIn the Executive Board, Cuba and Sweden
\nwere working in cooperation. Referring to
\nthe effects in the older generation he spoke
\nof Diabetes and Alzheimer\u2019s disease. There
\nwas a need to balance between the positive
\nand the negative aspects of alcohol. Further
\ninformation was accessible on the web at
\nwww.who.int\/substanceabuse.
\nDr. Nathanson was delighted that WHO
\nhad acted. In the UK 25% of the popu-
\nlation is abusing alcohol and we are see-
\ning cirrhosis in the early 20\u2019s. This was a
\nproblem throughout the European Re-
\ngion of WHO. Referring to the major
\nproblem of how to deal with the Industry,
\nshe referred to the problems the UK had
\nexperienced with the tobacco industry
\nand said that the UK was now experienc-
\ning the same with alcohol. Dr. Snaedel
\nsaid the industry had its own strategy.
\nIt had learnt from the tobacco industry
\nto urge support for programmes to deal
\nwith alcoholism but to oppose limits on
\nprice levels. Dr. Haikerwal observed that
\nwhile the WHO Strategy was not legally
\nbinding, there was a need to understand
\nwhat governments were signing up to. He
\n134
\nWMA news
\nreferred to the problems of binge drink-
\ning, Alco-pops, and especially mentioned
\ncheap wine in Australia, which was dif-
\nficult to deal with.
\nDr. Hill emphasised that action such as
\nbanning advertising at university sports
\nand local zoning had been successful. There
\nwas a need to get primary prevention from
\nchildhood to the mid 20\u2019s.
\nMr. Rekve said that actions have to be lo-
\ncal and politically supported and there was a
\nneed to monitor effects as to the efficacy of
\nactions. Referring to young people\u2019s prob-
\nlems and patterns of drinking; in the north
\nthis had been picked up because of violence.
\nFor others it was the social consequences
\nand he quoted the French students and
\nbinge drinking.
\nThe alcohol industry was difficult. Mem-
\nber States\u2019 concerns reflect the fact that
\nthe industry is a commercial producer and
\ngovernments have an interest because of
\nalcohol and tax. Member States agree that
\ndistribution should be examined, e.g. Alco
\npops.The Industry is focused on its strategy
\nand Mr. Rekve called for an NMA strategy.
\nHe felt that an index of Member State in-
\nvolvement was the fact that 32 States spoke
\nin the WHA debate.
\nMr. Rekve was warmly thanked for his pre-
\nsentation.
\nFinance and Planning Committee
\nThe meeting was opened by Dr. Haik-
\nerwal, in the Chair, and the minutes of
\nthe previous Tel Aviv meeting were ap-
\nproved.
\nMr. Hallmeyer gave a presentation on the
\npre-audited financial statement, detailing
\nthe various aspects of the report and stating
\nthat the finances were in a good position.
\nThe audited Financial Statement was rec-
\nommended for approval by Council which
\nlater also adopted it.
\nThe Secretary General, speaking to the Re-
\nport on Financial Dues, thanked NMA\u2019s for
\npaying their dues, recognising that in view
\nof the financial problems they had done
\ntheir best. He commented that dues only
\nreflect part of the contribution of NMA\u2019s,
\nwhich also contributed their work,expertise,
\nand time to WMA, for which he thanked
\nthem.
\nTurning to the changes to the different
\ngroups\u2019 dues, he said this had had a positive
\neffect attracting a number of countries that
\nwould not otherwise have joined. Account
\nhad also been taken of countries\u2019with prob-
\nlems due to disasters, etc.
\nStrategic Plan
\nThe Secretary General referred to the work
\ndone during the period of the Strategic Plan
\nsuggested in 2004 and which has run from
\n2006 to 2010. There had been governance
\nchanges, a review of dues which will have a
\nfinal review in 2 years. The result of imple-
\nmenting the Strategic plan could be seen
\nunder three heads:
\nThere is a stronger focus on ethical fora.\u2022
\nAdvocacy had been developed.\u2022
\nOther services developments.\u2022
\nSpeaking of Advocacy and the Business De-
\nvelopment Group, these had been successful
\nin policy development and its recognition,
\nespecially in Helsinki development and pro-
\ntocol. We have been successful in Alcohol
\nand Tobacco actions and recently we have re-
\nceived an invitation to participate in a World
\nEconomic Forum initiative. Our actions
\nshould continue to be more proactive.
\nWe had been successful in getting participa-
\ntion with WHO and with others. Our num-
\nber had increased to 95 members of which 15
\nwere new,and we continue receiving new ap-
\nplications for membership, e.g. Serbia, Mo-
\nzambique. Turning to the provision of ser-
\nvices, many educational materials had been
\nproduced and the courses provided on Eth-
\nics, Prisons and Tuberculosis and MDRTb
\nwere very successful. We had also worked
\nwith other Health Professions, e.g. on the
\nproblems of Counterfeit Drugs and on the
\nproblems of member states\u2019needs due to lack
\nof resources. We are now at the end of this
\nWMA strategic plan and need to produce a
\nplan for 2011\u20132015, considering a new focus
\npossibly on humanitarian aid.
\nBusiness Development Group
\nDr. Nathanson gave this report on behalf of
\nthe Chairman of the Group.She spoke of the
\nincreasing use of the web portal. Referring to
\nways of raising money she congratulated the
\nSecretary General on the success of the con-
\nferences, e.g. Helsinki, S\u00e3o Paulo. The portal
\nhad other uses such a CPME\/CPD. Con-
\ncerning CPME,thebusinessgrouphadheld
\ntwo meetings and recognised the need to
\nspeak to major producers. She had had dis-
\ncussions with the BMA Publishing Group,
\nor producers of on-line material. She invited
\nother NMA\u2019s to discuss this. E-learning is
\nvery expensive, \u00a3 20\u201330 a module. A Round
\ntable had been suggested at which WMA
\nwould invite a number of different industries
\nto meet together and learn how WMA needs
\ncould be met.At its meeting in April the WG
\nhad set out the principles for such a meeting
\nto avoid misunderstanding of the purpose of
\nthe meeting and avoid industry influencing
\nWMA policy. There are concerns about this
\nand it is hoped that the document of princi-
\nples would ensure that these concerns be met.
\nThe portal could have a subset.
\nConcerns were expressed by a number of
\nspeakers, but Dr. Nakai indicated that she
\nhad worked with the AMA and the Ameri-
\ncan College of Cardiology which have such
\na Round Table and found it to be success-
\nful without ethical problems. Dr. Hill con-
\nsidered that the discussion was premature.
\nHowever, the Secretary General, bearing
\nin mind that comments had already been
\nconsidered, said the document had been fi-
\nnalised two days previously. It was decided
\nthat this document be circulated to constit-
\nuent members for comment.
\n135
\nWMA news
\nWMA Meetings
\nA working group chaired by Dr. Ramin
\nParsa-Parsi had met twice and considered
\nwhether the time connection for Spring
\nCouncil meetings with the WHA was nec-
\nessary. The Business Group considered that
\na \u201cdisconnect\u201d would provide WMA with
\nmore flexibility. It could permit a better bal-
\nance between meetings of Council and the
\nGeneral Assembly.
\nIt was proposed that the Spring council
\nmeeting in Australia be held on 7\u20139th
\nApril.
\nThis would have the advantage that hotel
\nprices would be lower as the date was re-
\nmote from Easter. Two other issues were
\nstill under discussion.
\nThe Secretary General reminded the com-
\nmittee that a \u201cdisconnect\u201dwith WHA was a
\ngeneral suggestion and Dr. Haikerwal felt it
\nwas time to discuss the pros and cons of the
\nlink with WHA. Dr. Bagenholm observed
\nthat there were a number of people who
\nwere included in national WHA delega-
\ntions. It was therefore useful to have Coun-
\ncil meet before WHA. She posed the ques-
\ntion \u201cDo we lose by a disconnect? \u201d.
\nDr. Parsa-Parsi commented that only two
\nWHA delegations included NMA individ-
\nuals.The working group felt that there could
\nbe travel economies. The Secretary General
\nfelt that there could be advantages if the
\nmeeting went elsewhere and that there were
\nadvantages in holding meetings in an NMA
\nvenue. May in Geneva was not economic.
\nDr. Nathanson considered that geographi-
\ncal decoupling could be to the advantage
\nof non-European countries. Furthermore
\nthe period after May was difficult for the
\nSecretariat. The committee adopted the
\nRecommendations, all of which were later
\nadopted by Council:
\nThe annual spring meeting of the WMA
\ncouncil not be linked temporarily to the
\nWorld Health Assembly meeting and this
\nproposal was later adopted by Council.
\nThat the 188th
\nCouncil session be held in
\nSidney on 7\u20139th
\nApril 2011.
\nThat the Report on the Arrangements
\nfor future WMA General Assembly and
\nCouncil meeting be approved.
\nDr. Apinis also informed the Committee
\nand later Council that the Latvian Medical
\nAssociation in cooperation with the World
\nMedical Association is holding a conference
\non \u201c The Financial Crisis \u2013 Implications for
\nHealth Care \u2013 Lessons for the Future\u201d to
\ntake place in Riga, Latvia 10\u201311th
\nSeptem-
\nber 2010.
\nDr. Nakai spoke about the arrangements for
\nthe General Assembly this year in Vancou-
\nver mentioning in particular, arrangements
\nfor CPME recognition and also the Spon-
\nsorship Fund.
\nUnited Arab Emirates
\nDr. Parsa-Parsi informed the committee
\nthat it was felt that United Arab Emir-
\nates were underrepresented. The Secre-
\ntary General, the Danish and Norwegian
\nMedical Associations had discussed this.
\nIt was suggested that an expert conference
\nbe held to demonstrate to the UAR the
\ntype of work the WMA did.The Gulf Re-
\ngion countries have been the most open in
\nthe Region. He had spoken to the Presi-
\ndent of the Emirates Medical Society
\nand he seemed keen. He suggested that
\nan Expert conference be held in Dubai,
\njointly organised with the UAE. Possibly
\nthe Arabic Medical Union could join in
\nthe organisation. A topic suggested could
\nbe Patient Safety and Medicine. He sug-
\ngested that this be a Recommendation to
\nCouncil. D. Nathanson thought the topic
\n\u201cPatient Safety\u201d was very broad, would
\nthis be narrowed? What about policy
\nand getting experts together? Dr. Parsa-
\nParsi said this would have to be discussed
\nwith partners. The Secretary General
\ncommented on the difficulty of commu-
\nnicating with the UAE. After further
\ndiscussion in which a positive mood was
\nexpressed, it was agreed to recommend
\nthat the concept of an expert conference
\nin December 2011 be explored and this
\nRecommendation was later adopted by
\nCouncil (see below).
\nUruguay reported that it was thinking of
\nhaving a meeting of the National Medical
\nAssociations of Latin America Forum, to
\nwhich the President and Secretary General
\nwould be invited.
\nThe Council approved the following rec-
\nommendations of the committee:
\n\u201cTheannualspringmeetingofthecoun-\u2022
\ncil be not linked to the World Health
\nAssembly meeting\u201d.
\n\u201c\u2022\t The 188th
\nCouncil session be held in
\nSydney on 7\u20139th
\nApril 2011\u201d.
\n\u201cThe Future General Assembly and\u2022
\nCouncil session paper be approved:
\n(General Assembly, Vancouver 13\u201316th
\nOctober 2010, 188th
\nCouncil Sydney
\n28\u201330th
\nApril 2011, General Assembly,
\nMontevideo, Uruguay 12\u201315th
\nOctober
\n2011)
\n\u201cthat holding an expert committee meet-\u2022
\ning in Dubai at the beginning of 2011 be
\nexplored and that the topic be determined
\nin collaboration with the Emirates Medi-
\ncal Society\u201d.
\nMembership
\nThe committee recommended and Coun-
\ncil approved, forwarding the application
\nfor Constituent Membership from the
\nAssocia\u00e7\u00e3o M\u00e9dica de Mo\u00e7ambique to
\nthe General Assembly, recommending it
\nbe admitted to membership of the WMA.
\nAssociates
\nThe committee received a report of the
\nWMA Association Membership for 2009
\nand considered a Revised Proposal from
\nthe Workgroup on Reform of the Associate
\nMembership and Comments. Both docu-
\nments were later approved by Council.
\n136
\nWMA news
\nConsolidation of WMA Governance Docu-
\nments
\nThe committee considered documents
\non the Consolidation of the Association\u2019s
\nGovernance, By-Laws, etc., together with
\nthe explanatory memorandum. The com-
\nmittee thanked those who did this work. It
\nproposed that the document be circulated
\nto constituent members for comments and
\nthat the workgroup continue its work on
\nconsolidating these four documents into
\ntwo. This was later approved by Council
\nOutreach
\nThe committee received an oral report from the
\nWMJ Editor in Chief and the paper written
\nPublic Relations Report 0ctober 2009\u2013April
\n2010.
\nResumed Council meeting
\nThe Council considered the Socio-Medical
\nAffairs committee report, using the process
\nof the consent calendar by which only items
\nin documents before the committee on which
\nmembers wished discussion would be debated.
\nThe other items considered to be e-approved
\nand are formally adopted in the approval of the
\ncommittee report.They are shown in bold above
\nin the text of the committee discussion reports.
\nStrategic Plan
\nThe American Medical Association sought
\nclarification on the process for developing
\nthe Strategic 5-year planning, mentioning
\nin particular, input into the process, e.g. on
\ndisaster planning. The Secretary General re-
\nplied, explaining that the present document
\nwas a draft and reminded members that last
\nStrategic Plan draft went to the Executive
\nand was referred to Finance and Planning.
\nThe question of Humanitarian Aid was not
\nin the draft and would have to be considered
\nthis time. It was open to Council members
\nto make suggestions and comments. Dr. Na-
\nthanson (BMA) commented that many or-
\nganisations had a 3 or 5-year plan and also
\nannual priorities for particular years,e.g.gov-
\nernment actions, economic crises, etc. Could
\nWMA have both a 5-year plan and consider
\nshort term plans also such as – for the next
\nyear – the Economic Crisis? The Secretary
\nGeneral indicated that WMA had had this
\nin 2005 and 2006 largely because WMA was
\nproactive but it faded away in 2007. BMA
\nsaid that in its annual plan it was proactive \u2013
\ndealing with things one wants to deal with.
\nRolling plans were somewhat generic. The
\nSecretary General said WMA had done this
\nin the Advocacy Group. Dr. Haikerwal felt
\nwe were in a better position in our work as
\na result of the Secretary General\u2019s action. It
\nwould be useful to define times for discussion
\nof this in the run up to Vancouver to support
\nthe Secretary General. Such support should
\nbe available to the Secretary at the right time.
\nDr. Kloiber responded that the Social Work
\nGroup would start on the website in June.
\nThe process could be made transparent in
\nthis way for committee members to contrib-
\nute. Dr. Bagenholm agreed that it was im-
\nportant to have a role in contributing to the
\nStrategic Plan. She supported also an annual
\nplan and also felt that there should be input
\nbefore October. Dr. Nakai agreed that the
\nprocess should include more than the Execu-
\ntive Committee and supported an extra half
\nday for this in Vancouver. Mr. Wapner said
\nthe WMA had moved forward. The Strat-
\negy Group had discussed how much this fits
\nin with NMA aims and strategic plans. The
\nSecretary General was open to new ideas.
\nDr. Kloiber responding to this said it would
\nhave to be done with the Executive well be-
\nfore Vancouver.Dr.Haikerwal indicated that
\nthe Finance and Planning committee would
\ntake this planning on board in relation to the
\nWMJ through the Finance and Planning
\nCommittee in Vancouver.
\nPrescribing\/Relations between Physicians and
\nPharmacists in Medical Therapy
\nThere was a resumption of the lively discus-
\nsions on Recommendations on the docu-
\nments on Drug Prescription and that on the
\nRelationship between Physicians and Phar-
\nmacists in Medical Therapy. The Council, fol-
\nlowing a reconsideration of the recommenda-
\ntion on Drug Prescription, decided that \u201cThe
\nProposed Revision to the Proposed WMA
\nresolution on Drug Prescription\u201d be circu-
\nlated to WMA constituent members for their
\ncomments.
\nFollowing discussion and a number of divisions
\non motions to amend the document on Physi-
\ncians and Pharmacists in Medical Therapy,
\nCouncil decided that: \u201cThe Proposed revi-
\nsion of WMA Statement on the Relation-
\nship between Physicians and Pharmacists
\nin Medical Therapy, as amended, be for-
\nwarded to the General Assembly with the
\nrecommendation that it be adopted\u201d.
\nUnited Arab Emirates
\nThere was also further discussion on the
\nrecommendation concerning the holding of
\nan Expert Conference in the United Arab
\nEmirates (see above).
\nDisasters
\nDr. Amaral, referring to the discussion in
\nSMAC on Disasters asked if it was possible
\nto set up a work group to consider the role
\nof WMA in Disasters. The Secretary Gen-
\neral responded that before doing this a pa-
\nper on the topic was needed and asked the
\nBrazilian Medical Association to prepare a
\npreparatory paper.
\nA motion to approve the rest of the Fi-
\nnance and Planning Committee report
\nwas approved.
\nMedical Ethics Committee Report
\nCouncil then turned to report of the Medi-
\ncal Ethics Committee and, following the
\ncalendar extraction process (see above), there
\nwas a short discussion on the proposal for
\ndiscussions with the Emirates. Concern was
\nexpressed about the absence of any refer-
\nence to possible partners in the suggested
\nexpert conference,nor to content,e.g.Qual-
\n137
\nWMA news
\nity or Patient Safety. It was suggested that
\nthe conference would be jointly organised
\nand topics would be chosen after joint dis-
\ncussion with EMA.The Chair said that the
\nExecutive would make decisions on how
\nthis matter be processed.
\nFollowing a motion,the report of the Medi-
\ncal Ethics committee was approved.
\nWHO and World Health Assembly
\nCouncil heard a report from Ms Julia Seyer
\non the WHO and the World Health As-
\nsembly. She emphasised two issues. Con-
\ncerning Counterfeit Medicine she said the
\nWHA had had some conflict with WHO
\nover this issue. Some emerging countries
\nconsidered that this was more an issue for
\nThe World Trade Organisation rather than
\nWHO as it primarily concerned Intellectual
\nProperty. Dr. Margaret Chan, the WHO
\nDirector General, said it was about Public
\nHealth. There had been an emotional de-
\nbate and a lot of redrafting was going on but
\nthere was no news of the outcome.The sec-
\nond issue was Codes of Practice concern-
\ning the migration of Professionals. After 2
\nyears Member States had tried to get eth-
\nics and migration out of the debate and the
\ndocument had been weakened. The Global
\nHealth Force Alliance is to hold the Second
\nGlobal Forum on Human Resources for
\nHealth in Bangkok in January 2011.
\nDr. Bagenholm spoke of the importance of
\ngetting medical representatives into nation-
\nal WHA delegations as there were very few
\ndoctors on the delegations. She had been a
\ndelegate for six years. The Chair comment-
\ned that delegations were very political and
\nlargely administrative. Dr. Wilson (USA)
\ncommented that the USA usually included
\na physician in their delegation and added
\nthat the removal of links between the date
\nof WMA meetings and WHA would be of
\nassistance.
\nOther business
\nDr. Nathanson reminded council that Sir
\nMichael Marmot had mentioned trying to
\nensure that physicians were represented at
\nthe Global Conference on Social Deter-
\nminants in Health Conference. The BMA
\nwill bring a paper on this topic to the Gen-
\neral Assembly in Vancouver.. Following a
\nsuggestion to have a work group to consider
\nhow WMA could be involved in this con-
\nference, Dr. Nathanson indicated that she
\ncould work with Sir Michael to prepare a
\npaper on our involvement rather than hav-
\ning a work group, a view with which the
\nChair agreed.
\nDr. Seyer reported that the WHPA works
\nclosely with WHEN, the World Health
\nEditors Network which had published a
\nHealth Literacy guide and an Advocacy
\nguide. Both of which were accessible on the
\nWMA website.
\nThe Council meeting was terminated with
\nthe extending of thanks to the staff and to
\nthe interpreters and to members for their
\nwork.
\nDr. Alan J. Rowe
\nThe WMA has appealed to the President
\nof Sudan, Omar Al Bashir, for the release
\nof six Sudanese doctors, arrested and de-
\ntained without charge for their activities
\nas members of the Doctors\u2019 Strike Com-
\nmittee calling for better pay and working
\nconditions for doctors in Sudan.
\nDr. Dana Hanson, President of the
\nWMA, has written to the President urg-
\ning the Sudanese authorities to release the
\nsix doctors immediately and uncondition-
\nally and to provide them with any medi-
\ncal attention they might require. The six
\ndoctors \u2013 Dr. Alhadi Bahkit, Dr. Ahmed
\nAlabwabi, Dr. Ashraf Hammad, Dr. Mah-
\nmoud Khairallah, Dr. Abdelaziz Ali Jamee
\nand Dr. Ahmed Abdallah Khalafallah \u2013
\nhad, according to reports, been detained
\nwithout charges and some had been se-
\nverely beaten.
\nDr. Hanson added:
\n\u2018The World Medical Association is deeply
\nconcerned by the situation of these six doc-
\ntors who have been denied the fundamen-
\ntal right to a fair trial and are exposed to ill
\ntreatments and torture.
\nWe consider them prisoners of conscience,
\nas they appear to have been imprisoned
\nsolely in relation to their activities of the
\ncommittee calling for better working con-
\nditions for doctors in Sudan.\u2019
\nHe also called on the President to re-
\nform the 2010 National Security Act to
\nremove the excessive powers of the Na-
\ntional Intelligence and Security Services
\n(NISS), in particular powers of arrest
\nand detention without judicial oversight
\nfor four-and-a-half months. Dr. Hanson
\nhas also written to Mohamed Atta Al-
\nMoula Abbas, Director of the NISS, in
\nKhartoum.
\nA committee of Sudanese doctors has been
\ncampaigning since 2003, to improve the
\nworking conditions of doctors in Sudan. It
\nhas organised several strikes, the latest of
\nwhich led to their arrests.
\nWorld Medical Association Appeals for
\nRelease of Sudanese Doctors
\n28th
\nJune 2010
\n138
\nWMA news
\nThe Third Geneva Conference on Person-
\ncentred Medicine in May 2010 followed the
\ninaugural Geneva Conference of May 2008
\n[1] and the Second Geneva Conference of
\nMay 2009 [2] as landmarks in a process of
\nbuilding an initiative on Medicine for the
\nPerson through the collaboration of major
\nglobal medical and health organisations and
\na growing group of committed international
\nexperts [3].
\nThe Conference took place on 3\u20135 May
\n2010 at the Marcel Jenny Auditorium of the
\nGeneva University Hospital and the Ex-
\necutive Board Room of the World Health
\nOrganisation. It was organised by the In-
\nternational Network for Person-centred
\nMedicine (INPCM), the World Medical
\nAssociation (WMA), the World Organisa-
\ntion of Family Doctors (Wonca), and the
\nWorld Health Organisation (WHO), in
\ncollaboration with the International Alli-
\nance of Patients\u2019Organizations (IAPO), the
\nInternational Council of Nurses (ICN), the
\nInternational Federation of Social Workers
\n(IFSW), the International Pharmaceutical
\nFederation (FIP), the Council for Interna-
\ntional Organisations of Medical Sciences
\n(CIOMS), the World Federation for Men-
\ntal Health (WFMH),the World Federation
\nof Neurology (WFN), the International
\nFederation of Gynaecology and Obstetrics
\n(FIGO), the World Association for Sexual
\nHealth (WAS), the World Association for
\nDynamic Psychiatry (WADP), the Interna-
\ntional Federation of Medical Students\u2019 As-
\nsociations (IFMSA), the World Federation
\nfor Medical Education (WFME), the In-
\nternational Association of Medical Colleges
\n(IAOMC), the European Association for
\nCommunication in Health Care (EACH),
\nthe European Federation of Associations
\nof Families of People with Mental Illness
\n(EUFAMI), Ambrosiana University, Ge-
\nneva University, and the Paul Tournier As-
\nsociation.
\nThe Third Geneva Conference on Person-
\ncentred Medicine, under the overall theme
\nof Collaboration across Disciplines, Specialties
\nand Programs, examined through a set of
\nsessions the guiding value of person- and
\npeople-centredness, ethical aspirations, ba-
\nsic communication skills, fundamental clin-
\nical care activities, the challenge of surgical
\nand intensive care procedures, the vicissi-
\ntudes of the life cycle, and the implications
\nof cultural diversity.
\nThe Conference Core Organising Com-
\nmittee was composed of J. E. Mezzich
\n(INPCM President and World Psychiatric
\nAssociation President 2005- 2008), J. Snae-
\ndal (World Medical Association President
\n2007–2008), C. van Weel (World Organi-
\nsation of Family Doctors President 2007\u2013
\n2010), I. Heath (Royal College of General
\nPractitioners President), M. Botbol (WPA
\nFrench Member Societies Association
\nPresident), I. Salloum (WPA Classifica-
\ntion Section Chair), and W. Van Lerberghe
\n(Director of WHO Department for Health
\nSystem Governance and Service Delivery).
\nAlso collaborating organisationally were
\nO. Kloiber (WMA Secretary General),
\nA. M. Delage (WMA Secretariat), R. Ka-
\nwar (WHO), and J. Dyrhauge (WHO).
\nFinancial or in-kind support for the Confer-
\nence was provided by 1) the International
\nNetwork for Person-centred Medicine (core
\nfunding), 2) the World Health Organisa-
\ntion (covering invited participants\u2019 travel
\nand accommodation expenses, a conference
\nreception, and some secretarial and logistic
\nservices), 3) University of Geneva Medi-
\ncal School (auditorium services and coffee
\nbreaks), 4) Paul Tournier Association (a con-
\nference reception and the conference dinner
\nfor a group of invited participants), 5) The
\nWorld Medical Association (local secretariat
\nand printing services and support to extend
\nthe conference dinner to all participants) and
\n6) Participants\u2019registration fees.
\nThe Conference was opened by authori-
\nties of the University of Geneva Medical
\nSchool, the Director of the WHO Depart-
\nment for Health System Governance and
\nService Delivery representing the WHO
\nAssistant Director-General for Health
\nSystems and Services, the President of the
\nWorld Medical Association (WMA), and
\nthe core members of the Organising Com-
\nmittee. The opening address was delivered
\nby the INPCM President, who presented
\na progress report on the INPCM\u2019s first
\nmonths of existence emerging from the
\nSecond Geneva Conference.He touched on
\nthe establishment of a governing Board and
\ninitial organisational bases, development of
\nan active publications programme including
\na journal supplement with the edited papers
\nfrom the First Geneva Conference, a well-
\nvisited website, an institutional logo, and
\nthe organisation of the Third Geneva Con-
\nHighlights of the Third Geneva Conference
\non Person-centred Medicine
\nLogos of the institutions collaborating on the organisation of the Third Geneva Conference on
\nPerson-centred Medicine
\n139
\nWMA news
\nference including presentations from stellar
\nacademic leaders and a record number (22)
\nof collaborating organisations, most promi-
\nnently the World Medical Association and
\nthe World Health Organisation.
\nThe first session of the scientific program in-
\nvolved a symposium on person-centred med-
\nicine and primary health care organised by
\nWHO. The key speaker was the Director of
\nthe WHO Department for Health System
\nGovernance and Service Delivery who pre-
\nsented arguments on why measuring person-
\ncentred medicine and people-centred care is
\nvital. His presentation was commented by
\ngeneral practitioner, academic and patient
\nrepresentatives. The need to develop pro-
\ncedures for appraising the extent to which
\nperson- and people-centred care take place
\nemerged as a clear recommendation.
\nA symposium on ethics and the person-cen-
\ntred approach constituted the second scientific
\nsession. It started with an examination of the
\nproblems derived from reifying disease and
\nrestrictively considering numerical data which
\nundermine full attention to subjective experi-
\nence and the suffering person.The second pre-
\nsentation argued that attention to the social
\ndeterminants of health is crucial for advancing
\nhuman rights and ethics in health care. The
\nfinal paper presented an African perspective
\nincluding references to local concepts (Ubuntu
\nand Batho Pele) suggesting the value of placing
\npeople first,respect for diversity,and that what
\nis good for the person is more important than
\nwhat is good for his health.
\nThe third session was a symposium on basic
\ncommunication skills, a topic of increasing
\ninterest for person-centred care. Discussed
\nfirst was an overview of research on com-
\nmunication behaviours which critically in-
\nfluence health care process and outcome.
\nSuch behaviours include providing room for
\na patient\u2019s story, exploring emotional cues,
\nshowing empathy, and framing information
\nand advice in a positive way, as well as op-
\ntimising outcomes through patient enable-
\nment, control, reassurance and adherence to
\njointly decided care plans. The second pres-
\nentation pointed out that adequate person-
\ncentred communication is a cornerstone of
\ngood clinical practice and requires dedicated
\ntraining, and that the content of person-cen-
\ntredness can vary depending on context and
\nculture. It included interactive discussions
\nattending to literature-based guidelines and
\nparticipants\u2019 views. The third presentation
\non clinical teaching reviewed interviewing
\neducational technologies while consistently
\nfocusing upon person-centred principles.
\nThe fourth symposium examined central
\nclinical care activities from a person-cen-
\ntred perspective. The first presentation on
\npersonalised diagnosis suggested a para-
\ndigmatic shift by focusing on both ill and
\npositive health and the whole person, and
\nreported on international surveys and focus
\ngroups yielding salient recommendations
\nfor improving diagnostic systems. The sec-
\nond reviewed treatment plans as the written
\nrecord of shared decisional and interactive
\nprocesses between patients and clinicians,
\naimed at achieving desired life goals be-
\nyond the illnesses that threaten hopes and
\ndreams. A third presentation charged that
\nmost contemporary medical treatment is
\nfocused on relief of acute symptoms of ill-
\nness rather than the promotion of health
\nand well-being, and that specific procedures
\nare emerging to facilitate the latter.The final
\npresentation commented on current clinical
\nservices with constrained incentives based
\non volume rather than persons\u2019 values, and
\nreviewed evolving person-centred medical
\nhome models that demonstrate the challenges
\nand rewards of transforming practices and
\nare gaining acceptance from health profes-
\nsionals, business leaders and policy makers.
\nThe fifth session involved a panel discussion
\non special initiatives for person-centred care
\npresented by representatives of international
\norganisations of patients (\u201cfocus on the whole
\nperson, not just the disease\u201d) and medi-
\ncal students (\u201cholistically seeing the person
\nas a whole and not a sum of parts\u201d), Ital-
\nian (\u201cforming PCM clinical teachers\u201d) and
\nBritish (\u201cneed for a medicine of the whole
\nperson\u201d) universities, the World Federation
\nfor Mental Health (\u201ctreating the whole per-
\nson concerning both physical and mental
\nhealth\u201d),psychodynamic (\u201cself-reflection and
\nself-monitoring of transference and counter-
\ntransference feelings in daily clinical work\u201d)
\nand public health (\u201cglobal strategy for intro-
\nduction of the PCM model\u201d) programmes,
\nand INPCM projects on person-centred di-
\nagnosis (\u201ca new model with related regional
\nand national developments\u201d) and informa-
\ntional platforms (\u201cto facilitate INPCM in-
\nternal and external communication and full
\nrange of activities\u201d).
\nThe sixth session, a symposium on the team
\napproach in person-centred health care em-
\nLeft to right: I. Salloum, M. Botbol, J. Snaedal, D. Hanson, C. van Weel, I. Heath, G. Gold, and
\nW. van Lerberghe, at the Opening of the Third Geneva Conference while the president of the
\nInternational Network JE Mezzich speaks from the podium.
\n140
\nWMA news
\nblematic of the Conference\u2019s overall theme,
\nwas presented by officers from the top glo-
\nbal organisations of family doctors, nurses,
\nsocial workers, and pharmacists. For the
\nWonca\u2019s president, responsiveness to the
\nperson\u2019s needs and values, continuity of care,
\nand team work based on common values and
\nobjectives are at the core of person-centred
\nmedicine. The International Council of
\nNurses representative proposed that health
\nsystems be redesigned to optimise nursing
\ncontributions to health teams in general and
\nto person-centred care in particular. Accord-
\ning to the representative of the International
\nFederation of Social Workers, these profes-
\nsionals bring emphases on contextualisation
\nand patient\u2019s empowerment to person-cen-
\ntred team work. Finally, the representative of
\nthe International Pharmaceutical Federation
\nhighlighted the specific expertise that phar-
\nmacists can bring to collaborative practices in
\na variety of hospital and ambulatory settings
\nand to adherence to care programmes.
\nSeventh in the core programme was a sym-
\nposium on person-centred care in the context
\nof surgical and intensive procedures. First
\ndiscussed was person-centred surgery which
\nreviewed the importance of dialogue under
\ntime pressures, the need for understanding
\nthe person\u2019s condition and avoiding harmful
\nprocedures.Next a presentation from the In-
\nternational Federation of Gynaecology and
\nObstetrics reviewed the enormous develop-
\nment of multiple marker screening in early
\npregnancy which has led to more individual-
\nised informed consent decision making and
\ncounselling as well as to health care system
\nefficiencies. Finally considered were experi-
\nences at a Mongolia hospital intensive care
\nunit where simple procedures such as pro-
\nviding a protective gown and conducting
\nauscultation with body positions that afford
\ngreater patient privacy seemed to enhance
\nperson-centred and more effective care.
\nNext was a symposium on life cycle and
\nperson-centred care. It started with a pres-
\nentation on person-centred paediatric care,
\nwhich emphasised the uniqueness of every
\nchild, the need to attend to his physical,
\nemotional,social and spiritual needs through
\nprimary, secondary and tertiary prevention.
\nNext was a discussion of old-age person-
\ncentred care,which pointed out that personal
\nlife-style and historical patterns of diseases
\ninfluence the presentation of symptoms and
\nneeds. It also noted that clinical care should
\npay special attention to abilities and disabili-
\nties to decide on a care plan, which should
\nbe designed considering the patient\u2019s wishes
\nand aspirations. Completing this symposium
\nwas an examination of human development
\nas fundamental to defining a person and
\nperson-centred care. Such definition lies at
\ncross-roads between changes and continuity,
\nmaturation and personal history.
\nThe last symposium of the core conference
\ndealt with cultural and social diversity in
\nperson-centred care. The role of culture in
\nthe conceptualisation and experience of ill-
\nness and positive health, as well as for effec-
\ntive health communication was considered
\nfirst. A second presentation reviewed the so-
\ncioeconomic implications of comprehensive
\ndiagnosis, treatment and research, particu-
\nlarly in lesser-developed countries. Health
\npolicies based on the assessment of positive
\nhealth- and person-centred care were noted
\nas promising to deal with the less resourced
\nand more vulnerable sectors of the popula-
\ntion. The last paper referred to the abundant
\ndocumentation on gender having a profound
\nimpact on clinician-patient interactions
\nacross many countries and medical condi-
\ntions, and in terms of diagnosis, treatment
\nas well as patient adherence and patient sat-
\nisfaction, and noted that this information
\nseems to have been largely ignored in general
\nhealth care planning.
\nAfter the core conference and as the last
\nsession of the whole event, a special meet-
\ning was held at the WHO Executive Board
\nRoom focused on people-centred care in
\nlow and middle income countries. After
\nopening words from the WHO Assistant
\nDirector General for Health Systems and
\nServices and the INPCM President, a set
\npresentations highlighted experiences in
\nimplementing people-centred services in
\nseveral low and middle income countries: El
\nSalvador, Malaysia, Rwanda, Thailand, and
\nthe United Republic of Tanzania.
\nLeft to right: E. Velasquez, J. Wallcraft, S. Steffen, M. Dayrit, R. Montenegro, W. Van Lerberghe, T. Sensky, C. Etienne, A. Miles, CW. van Staden,
\nJE. Mezzich, I. Salloum, R. Cloninger, J. Trivedi, and S. Rawaf, at the WHO Satellite Meeting on People-centererd Care in Low and Middle In-
\ncome Countries at the WHO Executive Board Meeting Room
\n141
\nWMA news
\nThe presentation from El Salvador focused on
\nempowering women,men,families,and com-
\nmunities to improve maternal and neonatal
\nhealth.Communities participated in identify-
\ning and implementing new ways of ensuring
\ncare around pregnancy and childbirth. Since
\nthe initiation of the programme in 2006, ma-
\nternal deaths have dropped to zero in 90%
\nof the municipalities involved. Furthermore,
\nthe process of consensus building has devel-
\noped community capacity and ownership by
\nits various participants. Intersectoral links
\nand coordination mechanisms also have been
\nstrengthened. In Malaysia, the Government
\nhas incorporated the principles of people-
\ncentred care into numerous national policies
\nand strategies. These \u201cperson-centric\u201d policies
\nincluded a focus on wellness, empowerment
\nof individuals, families and communities, as
\nwell as integrated services throughout the life
\ncourse. Malaysia also introduced several in-
\nnovations to improve health care quality and
\npeople-centredness such as the home-based
\nhealth cards. The presentation from Rwanda
\nhighlighted the integration of mental health
\nservices in the national health system and at
\nthe community level. Mental disorders are
\nmanaged with a holistic perspective whereby
\naffected individuals are not only seen in terms
\nof their disorders, but also in terms of their
\nhistory, community, and current life circum-
\nstances. Families are key partners in care and
\ncommunities are involved in fighting stigma
\nand supporting people with mental disorders
\nto join the health centres and also to reinte-
\ngrate into society.The presentation fromThai-
\nland reviewed the multiple settings engaged
\nin people-centred care, its prime movers and
\nactivities aimed at dissemination and transfor-
\nmation into policy, and found people-centred
\nprimary care as a key element of universal cov-
\nerage policies. The person-centred experience
\nreported from Tanzania dealt with efforts to
\nimprove care of people receiving antiretroviral
\ntherapy through organising focus groups to
\nunderstand patients\u2019 concerns and barriers to
\ncare and addressing them.Since the initiation
\nof the project, one year ago, demand for serv-
\nices has increased three-fold in participating
\nhealth centres.
\nAfter the individual country presentations,
\nthe Director of the WHO Department for
\nHealth System Governance and Service De-
\nlivery formulated comments recognising the
\nimportance of the reports for person- and
\npeople-centred care and pointing out the
\nneed for advances in systematic conceptuali-
\nsation and measurement. An ensuing round-
\ntable discussion on future avenues for mak-
\ning health care more people-centred across
\nthe world was chaired by the Director of the
\nWHO Department for Human Resources
\nfor Health,and had as panelists the Secretary
\nGeneral of the World Medical Association,
\na psychiatry professor from India, a primary
\ncare and public health professor from the
\nUnited Kingdom, and a patient\/user consul-
\ntant. Comments were also offered by a num-
\nber of conference participants including the
\nPresident of the World Medical Association.
\nAfter an agile and interactive general discus-
\nsion, conclusions by the Assistant Director
\nGeneral for Health Systems and Services
\nhighlighted the importance of the event for
\nadvancing people-centredness and the recent
\nWorld Health Assembly resolution on the
\nrenewal of primary health care [4].
\nPreceding the core conference, a work meet-
\ning on person-centred medicine was held.
\nIt dealt with the ongoing building of the
\nInternational Network for Person-centred
\nMedicine [5] and its projects on person-cen-
\ntred diagnosis and clinical care guidelines, a
\nSouth Asian effort, public health guidelines,
\nand collaboration with the World Federation
\nfor Mental Health as well as on institutional
\ndevelopments on publications, internet plat-
\nform, and informational base.
\nA conference closing session offered sum-
\nmary comments and a consideration of next
\nsteps.These included broadening the engage-
\nment of health organisations,academic insti-
\ntutions, and experts across the world; further
\nconstruction of the International Network
\nfor Person-centred Medicine, its institu-
\ntional identity, governance, and operational
\nstructure; upgrading of the INPCM Web-
\nsite, informational base and clearinghouse
\nfunctions; continuing publications in major
\njournals and development of an international
\njournal of person-centred medicine; research
\nprojects on diagnosis, clinical care and public
\nhealth; increasing collaboration with WHO,
\nbased on 2009 World Health Assembly reso-
\nlutions promoting people-centred care; and
\nplanning for a Fourth Geneva Conference on
\nPerson-centred Medicine in early May 2011.
\nMembers of the Third Geneva Conference
\nOrganising Committee: Juan E. Mezzich
\n(International Network for Person-centred
\nMedicine, President; World Psychiatric As-
\nsociation, President 2005\u20132008), Jon Snae-
\ndal (World Medical Association, President
\n2007\u20132008), Chris van Weel (Wonca, Presi-
\ndent 2007\u20132010),Iona Heath (Royal College
\nof General Practitioners, President), Michel
\nBotbol (WPA French Member Societies As-
\nsociation, President), Ihsan Salloum (WPA
\nClassification Section, Chair), Wim Van
\nLerberghe (Director of the WHO Depart-
\nment for Health System Governance and
\nService Delivery)
\nReferences
\nMezzich JE, Snaedal J, Van Weel C, Heath1.
\nI. Person-centered medicine: a conceptual ex-
\nploration. Int J Integr Care. 2010; Suppl.
\nMezzich JE. The Second Geneva conference2.
\non person-centered medicine. World Medical
\nJournal. 2009; 55 : 100-1.
\nMezzich J,Snaedal J,van Weel C,Heath I.To-3.
\nward person-centered medicine: from disease
\nto patient to person. Mount Sinai Journal of
\nMedicine 2010; 77: 304-6.
\nWorld Health Organization: Resolution4.
\nWHA62.12. Primary health care, includ-
\ning health system strengthening. In: Sixty-
\nSecond World Health As\u00acsembly, Geneva,
\n18\u201322 May 2009. Resolutions and decisions.
\n(WHA62\/2009\/REC\/1). Geneva; 2009. p. 16.
\nMezzich JE, Snaedal J, van Weel C, Heath5.
\nI. The international network for person-cen-
\ntered medicine: background and first steps.
\nWorld Medical Journal. 2009; 55: 104-7.
\nJuan E. Mezzich, International Network
\nfor Person-centred Medicine, President
\n142
\nMedical Ethics, Human Rights and Socio-medical affairs
\nEdward Hill
\nThe year 2009 has now come and gone and
\nclearly we are a very long way to having at-
\ntained \u201cHealth for All.\u201d
\nDespite the differences between devel-
\noping and developed countries, access is
\nthe major health care issue in rural areas
\naround the world. Even in countries where
\nthe majority of the population lives in rural
\nareas, the resources are concentrated in the
\ncities.
\nAll countries have difficulty with transport
\nand communication, and they all face the
\nchallenge of shortages of doctors and other
\nhealth professionals in rural and remote ar-
\neas.
\nThe World Health Report 2006 concluded
\nthat there is a sharp demand for human re-
\nsources in health care in many countries of
\nthis world.For 57 countries in Latin-Amer-
\nica, Africa and Asia, the World Health Or-
\nganization classified the shortage of health
\nprofessionals as \u201ccritical.\u201d
\nLooking at the ratio of physicians to popula-
\ntion,we find a ratio of 1:500 in the wealthier
\ncountries of the world. In some places, such
\nas European countries, that ratio is as low
\nas 1:250, compared to a ratio of 1 physician
\nfor every 50,000 people in some parts of
\nthe world.This unfair distribution is further
\naggravated by the fact that the populations
\nwith the fewest health professionals carry
\nthe highest burden of disease.
\nBut this is not the only mal-distribution we
\nhave. We have seen a strong tendency to-
\nwards urbanization during the last decades.
\nThis has been accompanied by a concentra-
\ntion, often an overconcentration, of health
\nprofessionals in urban areas and a corre-
\nsponding shortage of physicians in rural
\nareas.
\nUrban centers, which offer better pay and
\nbetter opportunities, are especially attrac-
\ntive to highly skilled people like physicians
\nand other health professionals. We as pro-
\nfessionals cannot stop this trend; rather, it
\nis up to the politicians to decide whether
\nthey wish to mitigate it. Perhaps a paradigm
\nshift will be necessary, as mass urbanization
\nappears to generate more problems than
\nsolutions. While politicians, governments
\nand international bodies like the Europe-
\nan Union have focused to bring people to
\nwork, it may be time to do the opposite and
\nto bring work to people.
\nFortunately, not many governments in the
\nworld force their professionals to work at
\na certain location or another. On the other
\nhand, the freedom to migrate leaves us with
\nthe question of how to provide services to
\nrural populations, especially for those in the
\npoorer countries of this world. So what is
\nour role as health professionals?
\nLet me return to the World Health Report
\n2006: the report demonstrates why health
\nprofessionals and especially physicians from
\nSub-Saharan Africa leave their home coun-
\ntries.
\nYes, money is the most important factor,
\nbut close behind are other reasons, which
\ntaken together may be even more impor-
\ntant.These include bad working conditions,
\na lack of treatment options for patients,
\nmissed opportunities for professional de-
\nvelopment, violence in the workplace, and
\nothers.
\nLiving conditions are also important fac-
\ntors: substandard housing, no schools, no
\ninfrastructure, a lack of mobility and, again,
\nno chances for development would provide
\nreasons for anyone to move their family to
\na better place.
\nSo what can be done to alleviate the situa-
\ntion in the most affected areas? The World
\nHealth Organization has developed the
\nstrategy of task shifting. Put simply, this
\nmeans leaving the work of health profes-
\nsionals to minimally trained lay people. I
\ncan only agree with Lincoln Chen, who
\nwrote in the last issue of the WHO Bul-
\nletin:
\n\u201cThe recent rush of \u201ccrash programmes\u201d to train
\nlarge numbers of community health workers
\nhas rightly attempted to address long-standing
\ndeficiencies but these emergency actions cannot
\nbe seen as a sustainable solution.\u201d
\nThis is a key statement reminding us that a
\nsustainable approach is still missing at the
\nglobal level.
\nWe have to attract as well as effect a high-
\ner retention rate of health professionals in
\ntheir areas. Fair payment is a good start,
\nbut it will not be enough. Better work-
\ning and living conditions are essential as
\nwell; there must be prospects for health
\nprofessionals\u2019 work, their lives, and their
\nfamilies.
\nHuman Resources for Rural Health
\n143
\nMedical Ethics, Human Rights and Socio-medical affairs
\nHere are a few examples of what can bring
\nabout improvement:
\nAs a part of the World Health Profes-\u2022
\nsions Alliance and together with many
\npartners and the support of the Global
\nHealth Workforce Alliance, we are
\ndriving the Positive Practice Environ-
\nments Campaign. We are collecting
\nand disseminating knowledge about
\nbest practices for improving workplac-
\nes in health care.We see this as a major
\nstrategy not only to improve retention,
\nbut also to make the health care work-
\nplace more attractive for young people.
\nOn the policy level, we have supported\u2022
\nthe development of strategies by the
\nWHO addressing the high demand
\nfor human resources in health care in
\nrural areas.
\nThe most recent WHO recommenda-\u2022
\ntions for education,regulation,financial
\nincentives, and management and social
\nsystems support should help to identify
\nand attract more health professionals
\nfor rural areas and to encourage them
\nto stay in those environments.
\nDana Hanson, the president of our or-\u2022
\nganization, has just started a program
\nlooking into questions such as: what
\nmakes physicians resilient? What
\ngives them staying power? What are
\nthe success factors that make physi-
\ncians stay and continue to work in
\ntheir home places and countries?
\nWhat is it that causes them to stay
\nwhen they could find a better income
\nin other places?
\nIn India, the ministry of health is look-\u2022
\ning into a new curriculum that reaches
\nout to students, especially from rural
\nareas, who normally would not have
\nthe opportunity to enter a medical
\nschool. In a stepwise process, these
\nstudents will be educated to become fi-
\nnally fully qualified physicians, receiv-
\ning much of their practical training in
\nrural settings.
\nIt is hoped that the World Health\u2022
\nAssembly will pass a charter on ethi-
\ncal recruiting and encourage wealthy
\ncountries to do more to become self-
\nsufficient and avoid contributing to
\nbrain-drain from poor countries.
\nFinally, there are e-health, telemedi-\u2022
\ncine, and yet-to-be-implemented tech-
\nnological advances to help foster pro-
\nfessional development in rural regions.
\nThese examples are not exhaustive. I recom-
\nmend the last issue of the WHO Bulletin
\nfor your attention; it deals specifically with
\nthe problems of rural health and gives a
\ngood overview of the current problems and
\npotential solutions.
\nAs a family physician myself, I would like
\nto mention the 2008 World Health Report
\nentitled \u201cPrimary Health Care \u2013 Now more
\nthan ever.\u201d It provides more than a fresh
\nlook on primary health care; it is truly a new
\nand more serious approach towards putting
\nhigh quality primary care at the center of
\ncomprehensive health care systems.
\nUnderstanding primary care as the core of
\nthe health care system, instead of seeing it
\nas a cheap substitute for comprehensive care,
\nwill make a huge difference to the people
\nserved. And at the least the relative absence
\nof secondary and tertiary care in many rural
\nareas will underline the necessity of excel-
\nlent primary care.
\nIn conclusion, we must work on both ends:
\nself sufficiency and ethical recruiting prac-
\ntices on the side of the wealthier nations,
\nand improving working and living condi-
\ntions in poorer countries for physicians or
\nhealth professionals in general.
\nPhysicians want to be sure that what they
\ndo is meaningful and beneficial to their
\npatients. They want to have at least a fair
\nchance to help their patients and to serve
\ntheir communities. The strategies I men-
\ntioned should be stepping stones to improve
\nrural health care, including the poorer and
\nunder-resourced areas of the world.
\nWhat we are calling for is nothing more
\nthan a basic human right. Regardless of
\nwhere one lives \u2013 in a rich country or a poor,
\nin a city or in the countryside \u2013 everybody
\nshould have access to good health care.
\nWe will only see reduced costs and im-
\nproved quality in health care in the world
\nwhen every world citizen has access to a
\nwell-educated and well-trained primary
\ncare team to manage their medical needs
\nand health care.
\nDr. Edward Hill
\nWMA Chairman of Council
\n144
\nMedical Ethics, Human Rights and Socio-medical affairs
\nSir Michael Marmot
\nIn his acceptance speech as BMA president,
\nMichael Marmot told the BMA annual rep-
\nresentative meeting on Brighton on 29 June
\n2010 that doctors should be active in tackling
\nhealth inequalitiesand social injustice.
\nIt is midsummer. It is appropriate to have
\na midsummer night\u2019s dream. In my mid-
\nsummer night\u2019s dream, what visions did
\nappear!
\nMe thought I was translated: president of
\nthe BMA.
\nTo quote Puck: Lord, what fools these mor-
\ntals be!
\nPresident of the BMA? Surely not. Not
\nme.
\nI confess to a rich fantasy life but, had I but
\nthought about it, presidency of the BMA
\nwould have seemed marginally less prob-
\nable than playing the viola with the English
\nChamber Orchestra or winning the senior
\ntournament at Wimbledon.
\nThat I should be surprised to be approached
\nto be presidentof the BMA is not false mod-
\nesty \u2013 remember: don\u2019tbe modest,you\u2019re not
\nthat great \u2013 no, my surprisewas entirely rea-
\nsonable. My research has been focused on
\ninequalities in health. Latterly the focus has
\nbeen on what can be done toaddress the is-
\nsue. Both in research and policy I have em-
\nphasised the circumstances in which people
\nare born, grow, live, work,and age. These all
\nloom larger as causes of health inequalities
\nthan defects in our healthcare system.Heart
\ndisease is not caused by statin deficiency;
\nstroke is not caused by deficiency of hy-
\npotensive agents.I have emphasised not just
\nthe causes of health inequalities \u2013 behav-
\niours, biological risk factors \u2013 butthe causes
\nof the causes.The causes of the causes reside
\nin the social and economic arrangements of
\nsociety: the socialdeterminants of health.
\nMy first reaction, then, was that I was an
\nodd choice for BMA president. My inner
\nmonologue quickly changed that to: an
\nimaginative choice. No one is more con-
\ncerned about health inequalities than the
\nmedical profession, whether the causes lie
\nwithin or without the medical care system.
\nEither way we have to deal with the con-
\nsequences of inequalities in health. I would
\nargue, and will argue now, that a concern
\nwith social injustice as a cause of health in-
\nequalities engages the best instincts of the
\nmedical profession. For all these reasons, I
\nam really pleased to be taking on the presi-
\ndency of the BMA.
\n(Not just pleased, but reassured, when it
\nwas explained that the president does not
\nget engaged with the trade union sideof the
\nhouse.)
\nAgreeing to become president of the BMA
\npresents me with a major challenge: learn-
\ning to speak without a PowerPoint presen-
\ntation. I\u2019m an academic. We like our data
\nto support us. The last time I performed in
\npublic without slides was in the school play.
\nI played MacDuff in Shakespeare\u2019s Macbeth.
\nMacbethwas of course brought down by the
\ndread virus of ambition.
\nShakespeare had ambivalence about ambi-
\ntion. Julius Caesar was assassinated because
\nBrutus and the rest were worried about his
\nambition.
\nI want to say a word about ambition.
\nWhen I was a student in the 1960s it was
\nuncool to admit toambition.That, of course,
\nwas ridiculous, as everyone in this room,
\neach with ambition, can testify. But the key
\nquestionis ambitious for what?
\nMy predecessor, Averil Mansfield, said to
\nme: you may be the first BMA president
\nwith an agenda \u2013 perhaps a politer wordfor
\nambition.I do have an agenda,an ambition,
\nan obsession,even, and that is to contribute
\nto reduction of health inequalities.My year
\nas president will have real meaning if I can
\nhelp encourageother doctors to be active in
\nthe challenge to reduce avoidable inequali-
\nties in health, not just here within Britain,
\nbut globally between countries.
\nAt such a moment as this, perhaps I may
\nbe allowed a personal reflection on the link
\nbetween research and action. I have spent
\nmuch of my working life on curiosity driven
\nresearch. A central hypothesis was that the
\ngateway between society and health was
\nthrough the mind.
\nI retain that ambition. But something
\nchanged along the way.
\nIf, after publishing a paper, someone asked:
\nso what? the answerwas: to publish another
\npaper.
\nAt the end of every paper, there was a
\ndistinctive bird call: more research is
\nneeded, more research is needed. But I
\nnow have a new bird call: more action is
\nBMA Presidency Acceptance Speech:
\nFighting the Alligators of Health Inequalities
\n145
\nMedical Ethics, Human Rights and Socio-medical affairs
\nneeded, more action is needed. The two
\ncalls harmonise well. To caricature only
\nslightly,I went from wanting to work to-
\nwards good research to wanting to work
\ntowards a good society AND have good
\nresearch done.
\nI can sum up the change: I was invited
\nby the British government to conduct a
\nreview of health inequalities, and what
\ncould be done to address them. I pub-
\nlished my review in February this year
\nand entitled it: Fair Society: Healthy
\nLives. It was a statement that in my judg-
\nment, and that of the people who worked
\nwith me on the review, if we took seri-
\nously the move to a fairer society, health
\nwould improve, and health inequalities
\nwould diminish.
\nSo close is the link between social and eco-
\nnomic arrangementsand health that we can
\nsee health as social accountant. Health and
\nthe fair distribution of health \u2013 health in-
\nequalities \u2013 tellus how we are doing as a so-
\nciety. The simple answer is: we\u2019re doing well
\nbut can do better.
\nLet me illustrate. In my review of health
\ninequalities, Fair Society Healthy Lives, we
\nemphasised not just the poor health of the
\npoor, but that health follows a social gradi-
\nent; forexample,the more years of education
\nthe longer the life expectancyand the better
\nthe health. Those with university education
\nhave the best health. We calculated that if
\neveryone over 30 had the mortality rate as
\nlow as those with university education we
\ncould prevent 202 000 premature deaths,
\nEACH YEAR. Does anyone in this room
\nthink other than that should be largely
\navoidable?
\nIn the US, a similar calculation suggested
\nthat if African-Americans had the same
\nmortality rates as whites there would have
\nbeen 800 000 fewer deaths over a decade.
\nWhen I spoke of this to the American
\nPublic Health Association one commen-
\ntator asked movingly, how many times do
\nwe need to learn the same lesson? 800 000
\ntimes is too many.
\nLet me go further: life expectancy for
\nwomen in Zimbabwe is 42, in Afghanistan
\n44. By contrast, in Japan it is 86.Thereis no
\ngood biological reason why there should
\nbe a 44 year difference in life expectancy
\nacross the world. This 44 year difference
\narises because of our social and economic
\narrangements.
\nTo address these inequalities in health
\nwithin and between countries, the World
\nHealth Organization set up the Commis-
\nsion on Social Determinants of Health.The
\ndirector-general of WHO, JW Lee,invited
\nme to chair the CSDH.
\nOur report was published in 2008 as \u201cClos-
\ning the gap in a generation.\u201d Closing the
\ngap? Are we bonkers? A 44 year gap in life
\nexpectancy between countries, an 18 year
\ngap within countries, and we want to close
\nthe gap in a generation?
\nIt was a statement that we have in our heads
\nthe knowledge, we have in our hands the
\nmeans, to close the gap in a generation.The
\nquestion is: what do we have in our hearts?
\nDo we have thepolitical will?
\nAn illustration: we said in the CSDH re-
\nport that one billion people live in slums.
\nWe estimated that it would cost $100 bil-
\nlionto upgrade the world\u2019s slums.I thought:
\nno one will take us seriously. Who would
\nfind $100 billion for anything?
\nWhen I last looked we had found $9 trillion
\nto bail out the banks. For one ninetieth of
\nthe money we found to bail out the banks
\nevery urban dweller could have clean run-
\nning water. Dowe have the knowledge? We
\nhave the knowledge.Do we have themeans?
\nWe have the means. Do we have the will?
\nWhen I formulated this view, I was not
\naware that I knew the motto on the BMA
\ncrest \u2013 with head, and heart, and hand.
\nClearly, it was destiny. BMA and I were
\nmade for each other.
\nTo come to the heart of the matter. With
\nboth the CSDH and the English review of
\nhealth inequalities, we said that the reason
\nfor taking action to reduce social inequali-
\nties in health between and within countries
\nwas one of social justice. We said that \u201cso-
\ncial injustice was killing on a grand scale\u201d; a
\ntoxic combination of poor policies and pro-
\ngrammes,unfair economics,and bad politics
\nwas responsible for most of the problems of
\nhealth inequity in the world. The reason for
\naction was an ethical one not an economic
\none.
\nIn the English review, in my introductory
\nnote from the chair,I pointed out that the
\nCSDH report had been criticised as ideol-
\nogy with evidence. The same could be said
\nof the English review.We do have an ideol-
\nogy: health inequalities that are avoidableby
\nreasonable means are quite wrong. Putting
\nthem right is a matter of social justice. But
\nthe evidence matters.
\nThe evidence suggests that action has to be
\non the conditions in which people are born,
\ngrow, live, work, and age.
\nCommonly, when we think about action
\nto reduce health inequalities, we debate
\nwhether we should focus on smoking, or
\nobesity, or immunisation. Let us remember
\nHalfdan Mahler, the legendary director-
\ngeneral of WHO. In a speech to the World
\nHealth Assembly in the mid-1980s Mahler
\nsaid: \u201cImagine you are up to your neck in a
\nswamp, fighting alligators; just remember
\nwe came to drain the swamp in the first in-
\nstance.\u201d
\nColleagues, if we really want to fight the
\nalligators of health inequalities, we have to
\ndrain the swamp. We have to deal with the
\nconsequences of an unfair set of econom-
\nic and social arrangements, and with the
\ncauses and the causes of the causes of health
\ninequalities.
\n146
\nWMA news
\nWe published the commission\u2019s report.
\nWhat happened? I travelled the world, get-
\nting jet lag and interference with my gas-
\ntrointestinal function; did something more
\nhappen?
\nParenthetically, I have developed a wonder-
\nful cure for jet lag.I lie in bed rehearsing one
\nof my speeches and I\u2019m asleep in seconds. I
\nrecommend it. Faster than reading Henry
\nJamesin bed.
\nOn the gastrointestinal front, I did ask at
\none hotel: Is the water safe to drink? I was
\ntold: all the drinking water in this hotel has
\nbeen passed personally by the manager. I
\nwas impressed by the manager\u2019s prodigious
\ntalents if not greatly reassured.
\nSince indulging in this work on social justice
\nand health, Ihave, however, developed three
\nother medical conditions that perhaps, as a
\nmedical audience, you can help me with.
\nFirst, a state of near continuous excitement.
\nThere must be some pills for this condition.
\nWe said we wanted to create a social move-
\nment. I scarcely understood what that was.
\nBut I would say that the signs are promis-
\ning.
\nA Peruvian colleague wrote to me with a
\nquote from Don Quixote.\u201cLadran, Sancho,
\nsegnal que cabalgamos.\u201dThe dogs are bark-
\ning,Sancho, it a sign that we are moving.
\nAmong the signs of movement are:
\nA WHO resolution.\u2022
\nA discussion at ECOSOC, and an en-\u2022
\ndorsement of the CSDH from Ban Ki-
\nMoon
\nSpain made social determinants\u2022\t of health
\na priority for theirpresidency of the EU.
\nA number of countries have taken it on:
\nChile, Brazil, Costa Rica, Sri Lanka, Nor-
\nway, Denmark. I am excited.
\nNow we have the UK with my inequalities
\nreview. With the help of the BMA and the
\nroyal colleges I want to keep this on thena-
\ntional agenda.
\nIs this ambitious? Good heavens yes! Ambi-
\ntious to create a better society, and a better
\nworld.
\nThe second condition I have developed is
\nselective hearing loss. It is somewhat re-
\nlated to my state of evidence based opti-
\nmism. I cannot hear cynicism. With both
\nthe CSDH and the English review the
\nprocess was inclusive. It involved hundreds
\nof people. The English review of health in-
\nequalities is being implemented locally and
\nregionally.Thirty local areas and regions are
\ndevelopingplans to implement the Marmot
\nreview. As one US colleague putit: when he
\nargued for social determinants of health, his
\ndirector told him he had become Marmo-
\ntised.
\nThe third medical condition is that some-
\nthing has happened to my eyes: they water
\nat embarrassing moments.
\nPascaol Macoumbi, former PM of Mozam-
\nbique and a member of the Commission on
\nSocial Determinants of Health, said at the
\nend of our meeting in Vancouver: I haven\u2019t
\nfelt so energised since my country got in-
\ndependence. I had this watery condition of
\nmy eyes.
\nWhen I saw how the Self Employed
\nWomen\u2019s Association works to improve
\nlife for the poorest most marginal women
\nin India \u2013 the right to work, micro-credit
\nschemes, child care, health care, insurance,
\nupgrading slums \u2013 again this watery condi-
\ntionof the eyes developed.
\nIn Thailand, they talk of the triangle that
\nmoves the mountain: knowledge, politics,
\nand people. That softened me up but I was
\ndry eyed until Thai children sang:
\n\u201cWe are all stars of the same sky.
\nWe are all waves of the same sea.
\nIt is time to learn to live as one.\u201d
\nThen, I lost it.
\nLet me come back to my theme of ambi-
\ntion for what? The dominantview of the last
\n30 years has been that we are all greedy and
\nmotivated by self interest. Further, by pursu-
\ning our self interest society benefits. Wow!
\nThe intellectual fount for such viewis Adam
\nSmith: \u201cIt is not from the benevolence of the
\nbutcher,the brewer, or the baker that we ex-
\npect our dinner,but fromtheir regard to their
\nown interest.\u201d In other words, by pursuing
\nour own self interest society flourishes. That
\nidea seems tohave driven out all others.
\nAdam Smith did say that.That\u2019s the part we
\nremember.It is a travesty of Adam Smith to
\nthink that is all he said.We\u2019ve forgotten his
\nimportant other insights: \u201cNo society can
\nsurely be flourishing and happy, of which
\nthe far greaterpart of the members are poor
\nand miserable.\u201d
\n\u201cTo feel much for others and little for our-
\nselves; to restrain our selfishness and exer-
\ncise our benevolent affections,constitutethe
\nperfection of human nature.\u201d
\nIn the name of self interest we have allowed
\ninequality to flourish.
\nTony Judt: \u201cUnder conditions of endemic
\ninequality, all other desirable goals become
\nhard to achieve.
\n\u201cInequality is not just a technical problem.It
\nillustrates and exacerbates the loss of social
\ncohesion and the tendency to confine our
\nadvantages to ourselves and our families…
\n\u201cIf we remain grotesquely unequal, we shall
\nlose all sense of fraternity…The inculcation
\nof a sense of common purpose and mutual
\ndependence has long been regarded as the
\nlinchpin ofany community.\u201d
\nAt the invitation of the French Ministry of
\nHealth I went to Paris to do a day on the
\nCommission on Social Determinants of
\nHealth and the English review. For that
\nor other reasons, France is taking up the
\nhealth inequalities agenda. I asked a French
\n147
\nMedical Ethics, Human Rights,Socio-medical affairs and Environmental Policy
\ncolleague why President Sarkozy, a right
\nof centre president, would embrace this? I
\nwas told that all French children grow up
\nwith the motto of the French Revolution:
\nLibert\u00e9, Egalit\u00e9, Fraternit\u00e9. In France they
\nmay not dotoo much about the first and the
\nthird, but \u00e9galit\u00e9is central.
\nIn the UK, and the US, the degree of in-
\nequality that we have created is harming
\nthe next generation. Which among the rich
\ncountries has the least social mobility? The
\nUS, followed bythe UK.
\nAmbition: If the medical profession were
\nout only for its own interests, we would
\nnot have become doctors. Of course, we are
\nexercised by pay and conditions, but at the
\ncore our ambitionsare not selfish and we are
\nconcerned with social justice.
\nLet us use those twin concerns \u2013 for the
\nwellbeing of othersand for social justice \u2013 to
\nmake a difference to healthinequalities.
\nI referred to Don Quixote a few moments
\nago. At times Don Quixote seemed an ap-
\npropriate caricature of what I have been
\ndoing: a supposed knight running around
\ntrying to be chivalrous and everyone laugh-
\ning at him. When I said this to the Span-
\nish ministerof health he said: \u201cWe need the
\nidealism of a Don Quixote,thedreamer,and
\nthe pragmatism of a Sancho Panza.\u201d
\nSo, dream with me of a fairer world, but
\nlet us take the pragmatic steps necessary
\nto achieve it. In the words of Pablo Neru-
\nda,which I used both at the launch of the
\nglobal commission and the English review:
\n\u201cRise up with me against the organisation
\nof misery.\u201d
\nSir Michael Marmot, BMA President,
\nprofessor of epidemiology and public
\nhealth, University College London
\ne-mail m.marmot@ucl.ac.uk
\nSpeech is reproduced by kind permission
\nof the British Medical Journal.
\nDong-Chun Shin
\n\u201cUrbanization and Health\u201d was selected
\nby WHO as the theme for World Health
\nDay 2010 to highlight the serious health
\nimpact of urbanization. The theme is
\nmost timely and highly relevant because
\nthe majority of the world population al-
\nready lives in urban areas and this pro-
\nportion is expected to further increase.
\nAccordingly, urban health should be rec-
\nognized as the key focus of global public
\nhealth policy.
\nEven though each city faces its own unique
\nset of health challenges, a range of common
\nhealth risks can be associated with today\u2019s
\ntypical urban environment. Most of such
\nthreats are operated and controlled outside
\nthe health sector domain including unsafe
\ndrinking-water, sustained solid waste, un-
\nhealthy diets, road traffic, and urban air pol-
\nlution.
\nUrban air pollution by excessive particu-
\nlate matter or ozone levels is one of the
\nmost widespread and dangerous. Accord-
\ning to numerous studies, air pollution
\nreduces life expectancy and aggravates
\nmany respiratory and cardiovascular
\ndiseases. Premature deaths associated
\nwith air pollutants were more likely to
\nbe from cardiac causes than respiratory
\nones1
\n. Although the general public may
\nnot yet fully grasp the severity of air pol-
\nlution s hazards, concern about air pollu-
\ntion and other environmental health im-
\npacts has increased significantly in many
\ncountries.
\nMost air pollution and health studies report-
\ning an adverse health effect have focused on
\nphysical illness. More recently, researchers
\nhave started to study the possibility of brain
\npollution or air pollution-related mental
\nconditions such as suicide and IQ deficits.In
\nKorea, the association between particulate
\nmatter and suicide was identified. A pos-
\nsible association between particulate matter
\nand suicide was observed among individuals
\nwith cardiovascular disease2
\n. Also, prenatal
\nexposure to air pollutants may adversely af-
\nfect a child s intelligence. In New York City,
\nchildren exposed to high levels of air pollut-
\nants (especially, polycyclic aromatic hydro-
\ncarbons) in the womb demonstrated lower
\nIQ scores than less exposed children3
\n.
\nAir pollution has long been a problem in
\nthe industrial nations of the West. It has
\nnow become an increasing source of envi-
\nronmental degradation in the developing
\nnations of Asia. Air pollution has become
\npart of the daily existence of many people
\nwho work, live and use the streets in Asian
\ncities. Each day, millions of city dwellers
\nbreathe air polluted with chemicals, smoke
\nRecent Progress in Air Pollution
\nand Health Studies
\n148
\nMedical Ethics, Human Rights,Socio-medical affairs and Environmental Policy
\nand particles that dramatically exceed
\nWorld Health Organization guidelines.
\nDeteriorating air quality has resulted in a
\nsignificant impact on human health and en-
\nvironment in Asia.
\nWhile some improvements in air quality
\nhave been achieved, levels of PM and ozone
\ncontinue to exceed WHO air quality guide-
\nlines in large Asian cities. Tokyo and Seoul
\nhave succeeded in turning around their air
\nquality and establishing management plans
\nincluding source control, stricter air quality
\nstandards and health protection programs.
\nBut air quality in New Delhi, Kolkata, Ha-
\nnoi, Beijing and other developing country
\ncities are still unhealthy. These cities need
\nimmediate technical and medical assis-
\ntance.
\nNational Medical Associations in each
\ncountry should be prepared to cooperate
\nwith the World Health Organization to re-
\nduce air pollution and protect public health.
\nPreventive action is critical in good public
\nhealth management. Governments in each
\ncountry should set up national level institu-
\ntional mechanisms for air pollution related
\nmedical research and monitoring to support
\nmore effective policy-making. Medical as-
\nsociations have to address the health issues
\nrelated to air pollution and encourage their
\ngovernments to take corrective action.
\nReferences
\nPope CA 3rd, Burnett RT, Thurston GD,1.
\nThun MJ, Calle EE, Krewski D, Godleski JJ.
\nCardiovascular mortality and long-term ex-
\nposure to particulate air pollution: epidemio-
\nlogical evidence of general pathophysiological
\npathways of disease. Circulation. 2004 Jan
\n6;109(1):71-7.
\nKim C, Jung SH, Kang DR, Kim HC, Moon2.
\nKT, Hur NW, Shin DC, Suh I. Ambient par-
\nticulate matter as a risk factor for suicide. Am
\nJ Psychiatry. 2010 Jul 15.
\nPerera FP, Li Z, Whyatt R, Hoepner L, Wang3.
\nS, Camann D, Rauh V. Prenatal airborne
\npolycyclic aromatic hydrocarbon exposure
\nand child IQ at age 5 years. Pediatrics. 2009
\nAug;124(2):e195-202.
\nDong-Chun Shin, MD, PhD
\nChair, Executive Committee of International
\nAffairs,
\nKorean Medical Association
\nProfessor, Dept. of Preventive Medicine,
\nYonsei University College of Medicine
\nJon Snaedal
\nIceland has been the focus of international
\nattention because of catastrophes on two
\noccasions in the last two years. Even though
\nthese events have seemingly nothing in
\ncommon, there are some similarities. The
\nfirst catastrophe was late in 2008, a man
\nmade economic crisis. The second one was
\na recent natural catastrophe, a volcanic
\neruption in a glacier. The similarities are
\nthat both were uncontrollable. The differ-
\nence was however in the preparation for the
\ncatastrophes. In the case of the economic
\ncrisis there was hardly any preparations and
\nbecause of that there was a great unrest in
\nthe society leading to change in government
\nand a replacement of all individuals respon-
\nsible for any preparatory measures. In the
\nlatter case there was however a feeling by
\nthe people of responsible actions by all in-
\nvolved.The scientists had warned of a possi-
\nble eruption for over a year but in a low pro-
\nfile. All preparatory actions were therefore
\nin place and could be mobilised in a couple
\nof hours, the most dramatic one a total and
\nimmediate evacuation of a defined area on
\ntwo separate occasions. The population has
\ntherefore great confidence in the scientists
\nand the civil service responsible for all ac-
\ntions for such an event.
\nThe most grave immediate health implica-
\ntion of a natural catastrophe is the loss of
\nlives. That did fortunately not happen in
\nthis case. Because of the swift actions, no
\nindividual was ever in a real danger. The
\nother possible health implications are either
\nphysical or psychological. The attention has
\nbeen on the effects of the ash pouring down
\non the population. There has been an in-
\ncreasing number of pulmonary cases, rarely
\nserious, and a greater number of cases with
\nirritation in the eyes. Interestingly, this has
\nonly been seen in adults, mostly those that
\nneeded to work outdoors for attending the
\nanimals but the children seem not to have
\nbeen affected. The reasons for this is that
\nmany of them have been sent away and the
\nothers not allowed to be outdoors while the
\nash was pouring down. It has to be stressed
\nthat the depth of ash has only been up to 5
\ncm in the most affected areas, most often of
\nsome few millimetres but it is made up of
\nvery small particles that can easily been in-
\nhaled deep into the lungs.There was a fear of
\ntoxic effects of the ash as the experience has
\nshown that some volcano\u2019s produce ash with
\nhigh concentration of fluoride. This proved
\nto be toxic to animals and some speculations
\nwere on toxic effect on humans (an erup-
\ntion in 1947 in Hekla) but that was never
\nverified. Measurements during the current
\neruption showed rather low concentration
\nVolcanic Eruptions \u2013 Health Implications
\n149
\nMedical Ethics, Human Rights,Socio-medical affairs and Environmental Policy
\nof fluoride or in fact other elements that
\ncould be toxic to humans.
\nOther possible health effects of the eruption
\nare psychological. To live nearby an erupt-
\ning mountain is a stressful situation and
\nmany are not able to cope with that. They
\nhave to leave their homes and live elsewhere
\nfor an uncertain amount of time. Some of
\nthem have already decided not to turn back
\nto their homes but as this eruption has not
\nbeen prolonged, this number will most
\nlikely not increase. The long term effect of
\nthe displacement is not known in this event
\nbut by experience from the displacement of
\na community of 5000 individuals in 1973
\nafter a volcanic eruption in Heimaey (= The
\nisland of our homes) south of Iceland the
\neffects are minimal in most cases providing
\nthere is social, psychological and economi-
\ncal help.This experience is helpful now.
\nTo be affected by the effects on air traffic is
\nanother issue. This was the greatest disrup-
\ntion of air traffic in the world measured by
\nthe number of flights and passengers affect-
\ned. The most serious effect is on emergency
\nair traffic, which was not allowed either.The
\npatients in these cases had to rely on ground
\ntransportation, which resulted in delays in
\nattending a medical facility. It has not been
\nevaluated how many patients were affected
\nin this way or the consequences of that.
\nApart from this there is the huge number
\nof passengers worldwide that have been af-
\nfected by delays of air traffic, which resulted
\nin many kinds of inconveniences, practical,
\neconomic and psychological. The full scale
\nof that will hardly ever be known but there
\nare many tales of various difficulties because
\nof this eruption of the volcano with the un-
\npronounceable name, Eyjafjallaj\u00f6kull (= The
\nglacier on the mountains of the islands).
\nDr. Jon Snaedal,
\nIcelandic Medical Association
\nWonchat Subhachaturas
\nSummary
\nOn February 25-28 2010, the Medical As-
\nsociation of Thailand hosted the first Inter-
\nnational Summit on Tobacco Control in the
\nAsia and Oceania Region at the Rose Gar-
\nden Riverside Hotel in Sampran district,
\nNakhonpathom Province, Thailand. The
\nevent was assigned by the Confederation of
\nthe Medical Associations in Asia and Ocea-
\nnia (CMAAO) Congress and Assembly in
\nBali, Indonesia, November 5-7, 2009. A
\nTobacco Control Programme was decided
\nupon and approved as a flagship programme
\nof the CMAAO starting this year; progress
\nwill be reported annually at the Conference
\nand General Assembly, wherein member
\ncountries can share experiences of success
\nand barriers.
\nThe Summit was attended by 12 countries
\nin the region: Hong Kong, India, Indonesia,
\nJapan, Korea, Malaysia, Myanmar, Philip-
\npines, Singapore, Taiwan, Vietnam and
\nThailand. The programme consisted of pre-
\nsentations from experts, evidence-based re-
\nports of the current situation in each country
\non the health hazards from tobacco smok-
\ning and the effects of second-hand smoke,
\ngroup discussion, and the production of a
\nstatement and declaration on tobacco con-
\ntrol in the Asia and Oceania Region, with
\nrecommendations for member countries
\nto practice and collaborate at three levels:
\nmedical associations, individual physicians,
\nand the national level. All participating
\nNMAs signed the proclamation, agreeing
\nto unite and work together towards devel-
\noping a regional network on tobacco control
\nand to make tobacco control one of their
\nhighest priorities.
\nDr. Wonchat Subhachaturas,
\nChair of CMAAO, President-elect of
\nthe Medical Association of Thailand
\n1st
\nInternational Summit on Tobacco Control
\nin Asia and Oceania Region
\nCMAAO\u2018s Activities on Tobacco Control in the Region
\nFebruary 25 to 27, 2010 Sampran,Thailand
\nMasami Ishii
\n150
\nMedical Ethics, Human Rights,Socio-medical affairs and Environmental Policy
\nThe overview of the historical
\nefforts of CMAAO for
\nTobacco Control
\nShort history
\nThe Confederation of Medical Associa-
\ntions in Asia and Oceania (CMAAO) has
\nmarked more than 50 years of history.I have
\nheld the position of CMAAO Secretary
\nGeneral since 2006.
\nThe 44th CMAAO Midterm Council
\nMeeting, held in Manila, Philippines, cel-
\nebrated the CMAAO\u2019s 50th anniversary.
\nThis meeting started the discussion of to-
\nbacco control as a major agenda item and
\nsuccessfully built momentum toward re-
\ngional cooperation for tobacco control.
\nThe WMA has several statements on tobac-
\nco and smoking, the first of which was ad-
\nopted in Austria in 1988.The WMA joined
\nthe implementation process of the WHO\u2019s
\nFramework Convention of Tobacco Con-
\ntrol, or FCTC. The WMA\u2019s statements in-
\nclude:
\nStatement on Health Hazards of Tobacco\u2022
\nProducts (adopted in Austria, 1988; re-
\nvised in Germany, 1997 and in Denmark,
\n2007)
\nStatement on Physicians and Public\u2022
\nHealth (adopted in Indonesia, 1995;
\namended in South Africa, 2006)
\nStatement on Health Promotion (adopt-\u2022
\ned in Indonesia, 1995)
\nStatement on Tobacco Manufacture,\u2022
\nImport, Export, Sale and Advertising
\n(adopted in the United States, 1990, re-
\nscinded in Santiago 2005)
\nIf we look back over the history of the
\nCMAAO, the symposium theme at the
\nCMAAO Midterm Council Meeting held
\nin Taipei 1988 was \u201cTobacco or Health,
\nfor Asia and Oceania.\u201d This theme seems
\nto have been selected as a response to the
\n\u201cTobacco or Health Plan of Action for the
\nperiod 1988-1995\u201d proposed by the Di-
\nrector General of the WHO in 1988. The
\nCMAAO Midterm Council in Taipei ad-
\nopted a Declaration on Health Hazards of
\nTobacco Products. By citing the WMA\u2019s
\nStatement on Health Hazards of Tobacco
\nProducts, which was adopted the same year,
\nit strongly urges CMAAO members to pur-
\nsue the actions in the statement. Stickers to
\npromote Smoke Free Asia and Oceania were
\nalso produced.The president of CMAAO at
\nthat time was Dr. Songkram of Thailand.
\nThe momentum against tobacco smoking
\nhas been sustained in Thailand since that
\nyear, and has now emerged again in the
\nCMAAO with greater energy. We are cur-
\nrently involved in the second wave of the
\nCMAAO\u2019s efforts to tackle this crucial is-
\nsue in our region. Tobacco control is a very
\ndifficult issue, so we should consider vari-
\nous, up-to-date efforts, and regularly evalu-
\nate their performance.
\nThe theme of the 53rd
\nAnnual Scientific
\nMeeting of the Medical Association of
\nThailand, which was held in Krabi,Thailand
\nin October 2009, was \u201cSmoking Cessation
\nProgramme in Asia and Oceania.\u201d This
\nmeeting was very successful due to the ef-
\nforts of Dr. Somsri and Dr. Wonchat.
\nThe meeting was attended by international
\nrepresentatives from the medical asso-
\nciations of Thailand, Malaysia, Myanmar,
\nBrunei, Japan, and representatives from
\ngovernments and the WHO. We had very
\ninformative lectures on each country and
\nthe Asia and Oceania region, followed by
\nactive discussions on smoking cessation
\nprogrammes.
\nAt the CMAAO Bali Congress in Novem-
\nber 2009, a proposal to take cross-regional
\nanti-smoking actions was adopted. The ex-
\npansion of these activities is currently be-
\ning considered under the leadership of the
\nMedical Association of Thailand.
\nAs a result of the efforts made so far, the
\nfirst International Summit of the Asia and
\nOceania Region on Tobacco Control was
\nheld in Thailand, hosted by the CMAAO,
\nthe Medical Association of Thailand
\n(MAT), MASEAN and the Thai office of
\nthe WHO. It adopted a declaration \u201cThe
\nSampran Declaration of Asia and Oceania
\nRegion on Tobacco Control\u201d.
\nThe Sampran Declaration on Tobacco
\nControl in the Asia and Oceania Region
\nhas been circulated to all member coun-
\ntries in the CMAAO and MASEAN, and
\nthe project\u2019s progress will be followed up at
\nthe CMAAO Conference each year. This
\nwill be the first and leading collaboration
\nin controlling tobacco consumption at the
\nregional level.
\nDr. Masami Ishii,
\nSecretary General of CMAAO,
\nCouncil Member of WMA, Executive
\nBoard Member of JMA
\nFebruary 2010
\nThe Sampran Declaration on
\nTobacco Control in Asia and
\nOceania Region
\nCMAAO, Medical Association
\nof Thailand,MASEAN
\nand WHO Thai Office
\nPreamble
\nTobacco use is the leading cause of pre-
\nventable death, killing more than 5 million
\npeople each year worldwide. Second-hand
\nsmoke kills about 600,000 people who were
\nnon-smokers each year.Most of these deaths
\nare in low- and middle-income countries
\nincluding countries in Asia and Oceania.
\nApart from other well-known health haz-
\nards, tobacco use also increases morbidities
\nsuch as malnutrition and subfertility, hence
\nurgent action is needed.
\nThe WMA, representing the medical asso-
\nciations of the world, issued a statement on
\n151
\nMedical Ethics, Human Rights,Socio-medical affairs and Environmental Policy
\nthe health hazards of tobacco products in
\n1988 at the 40th
\nWorld Medical Assembly.
\nThis was amended at the 49th
\nand 59th
\nWMA
\ngeneral assemblies. The CMAAO adopted
\nthe WMA statement in1988. With the
\nentry into force of the WHO Framework
\nConvention on Tobacco Control (WHO
\nFCTC) in 2005, the global tobacco control
\ncommunity has made considerable progress
\nagainst the global tobacco epidemic.
\nAccording to the WHO Report on the
\nGlobal Tobacco Epidemic, 2008 and 2009,
\nthe majority of the world\u2019s smokers are in
\nAsia and Oceania, which makes tobacco
\ncontrol in the region the main challenge.
\nOnly a few countries have a national policy
\non comprehensive tobacco control. Most
\nusers are inadequately warned about the ex-
\ntreme addictiveness of tobacco and the full
\nrange of health risks. In all CMAAO coun-
\ntries, cessation services are still insufficient
\nto help the 360 million smokers. Although
\nsecond hand smoke is easily prevented, only
\nfew countries have comprehensive smoke-
\nfree environment legislation. The health of
\nmore than one third of population in the re-
\ngion is at risk from exposure to second-hand
\ntobacco smoke and remains unprotected.
\nIn this regard, government and policy mak-
\ners must play a pivotal role in ratifying and
\nenforcing the WHO FCTC. The medical
\nprofession must recognize its role and social
\nresponsibility in tobacco control.
\nAt the individual level, doctors should be
\nagents of change in the battle against to-
\nbacco use. The medical profession is deeply
\ncommitted to tobacco control and a smoke-
\nfree society.The CMAAO,together with all
\nother organizations such as the WHO, will
\npartner with the regional and national to-
\nbacco control organizations to act decisively
\nagainst the tobacco epidemic \u2013 the leading
\nglobal cause of preventable death.
\nThe success of this program is going to be
\nwholly dependent on the proactive role of
\nthe medical profession in tobacco control
\nand prevention of its health hazards, the co-
\noperation of the general public through the
\ncivil societies who will reinforce the medical
\nprofession and the commitment of the na-
\ntional government to enact and enforce laws
\ndirected towards tobacco control.
\nRecommendations
\nThe CMAAO urges the CMAAO mem-
\nbers to take the following actions to help
\nreduce the health hazards related to tobacco
\nuse, at:
\nI. National Medical Association Level
\n1. Adopt a policy position opposing smok-
\ning and the use of tobacco products, and
\npublicize the policy so adopted.
\n2. Prohibit smoking at all business, social,
\nscientific and ceremonial meetings of
\nthe National Medical Association.
\n3. Develop, support, and participate in
\nprograms to educate the profession
\nabout the health hazards of all forms of
\ntobacco use. Convince and help smok-
\ners and smokeless tobacco users to cease
\nthe use of tobacco products,and develop
\ncessation programmes for tobacco users
\nand avoidance programmes for non-
\nsmokers and non-users of tobacco.
\n4. Strongly urge individual physicians to
\nbe role models (by not using tobacco
\nproducts), healthcare team leaders and
\nspokespersons to campaign and to edu-
\ncate the public about the deleterious
\nhealth effects of tobacco use,exposure to
\nsecond-hand smoke and the benefits of
\ntobacco cessation and making a smoke-
\nfree home.
\n5. Mandate all medical schools, hospitals
\nand other health-care facilities to pro-
\nhibit smoking on their premises.
\n6. Introduce or strengthen educational
\nprograms for physicians to prepare them
\nto identify and treat tobacco dependence
\nin their patients.
\n7. Strengthen and cooperate with the re-
\ngional network to develop an effective
\nregional system on tobacco cessation.
\nSupport widespread access to effective
\ntreatment for tobacco dependence – in-
\ncluding identification of smokers in the
\nroutine services and provision of coun-
\nseling, necessary pharmacotherapy and
\nother appropriate means.
\n8. Develop and endorse a clinical practice
\nguideline on the treatment of tobacco
\nuse and dependence.
\n9. Urge the national authorities to add to-
\nbacco cessation medications to the List
\nof National Essential Medicines and
\nHealth Security System.
\n10. Mandate medical schools, research in-
\nstitutions, and individual researchers
\nnot to accept any funding or any form
\nof support from the tobacco industry.
\nII. Individual Physician Level
\n1. Ask every patient for smoking history
\nand provide brief advice to every patient
\nalong with referral to specialized cessa-
\ntion treatment.
\n2. Do not accept any funding or any form
\nof support from the tobacco industry.
\nIII. Government Level:
\n1. Support MPOWER1
\nas the main tobac-
\nco control strategy released by WHO.
\n2. Advocate the enactment and enforce-
\nment of laws that:
\na. provide for comprehensive regula-
\ntion of the manufacture, sale, dis-
\ntribution and prohibit any form of
\npromotion and advertisement of to-
\nbacco products.All forms of promo-
\ntion of tobacco products including
\nsponsoring sports events and enter-
\ntainment should be banned.
\nb. require written and pictorial warn-
\nings about health hazards to be
\nprinted on all packages of tobacco
\nproducts.
\nc. prohibit smoking in all enclosed
\npublic places (including health care
\n(M= Monitor tobacco use and prevention pol-1.
\nicies, P=Protect people from tobacco smoke,
\nO=Offer help to quit tobacco use, W=Warn
\nabout the dangers to tobacco, E=Enforce
\nbans on tobacco advertising and promotion,
\nR=Raise taxes on tobacco products)
\n152
\nMedical Ethics, Human Rights,Socio-medical affairs and Environmental Policy
\nfacilities, schools, and education fa-
\ncilities), workplaces (including res-
\ntaurants, bars and nightclubs) and
\npublic transport.
\nd. prohibit the sale, distribution, and
\naccessibility of cigarettes and other
\ntobacco products to children and
\nadolescents.
\ne. prohibit the sale of tax-free tobacco
\nproducts.
\nf. prohibit all government subsidies
\nfor tobacco and tobacco products.
\ng. prohibit the promotion,distribution,
\nand sale of any new forms of tobacco
\nproducts that are not currently avail-
\nable.
\nh. increase taxation of tobacco prod-
\nucts, using the increased revenues
\nfor prevention programs, effective
\ncessation programs and services and
\nother health care measures.
\ni. curtail or eliminate illegal trade in
\ntobacco products and the sale of
\nsmuggled tobacco products.
\nFlorian Stigler
\nIFMSA and its Standing
\nCommittee on Public Health
\nThe International Federation of Medical
\nStudents\u2019 Associations (IFMSA) represents
\n1.2 million medical students through its 97
\nnational member organisations. Founded
\nin 1951, it was officially recognised by the
\nWHO in 1969. IFMSA works as an inde-
\npendent, non-governmental organisation
\ntowards improving global health.
\nRunning one of the biggest student-led ex-
\nchangeprogrammes worldwide and working
\nat community levels to tackle health-related
\nproblems sum up our main focus.Every year
\nmore than 10,000 students go on exchange
\nthrough the IFMSA and get to appreciate
\nthe culture and medical practice, or par-
\nticiparte in research in a different country.
\nOur local level activities and projects focus
\non medical education, human rights, repro-
\nductive health and public health.This article
\nwill focus on one of our public health-relat-
\ned activities: Our fight against the harmful
\nuse of alcohol on a global scale.
\nBut first, an introduction to some of our
\nmain public health activities. Medical stu-
\ndents from all over the world are part of
\nthe IFMSA Standing Committee on Pub-
\nlic Health. These students execute projects
\nand activities that aim to promote health in
\nthe local communities, by laying emphasis
\non preventive measures. Students work on
\ntopics ranging from child health, tobacco,
\nalcohol abuse, diabetes and obesity, to ma-
\nlaria and TB in high-risk countries. Other
\ninitiatives try to advocate for change by ap-
\nproaching key stakeholders and using the
\nmedia to make our voice heard.Last but not
\nleast, we try to focus on ourselves. As pub-
\nlic health topics and advocacy are not core
\ntopics in most universities worldwide, we
\ntry to develop our skills and knowledge and
\nthose of other medical students. We want
\nto become health professionals with a more
\nholistic concept of health and who are able
\nto promote change within our profession.
\nThe harmful use of alcohol \u2013
\na youth perspective
\nAlcohol consumption is responsible for 2.5
\nmillion unnecessary deaths worldwide[1].
\nIt is also accountable for additional damage
\ntowards the immediate environment and
\nthe society as a whole. The damage attrib-
\nutable to alcohol consumption is described
\nby the Royal College of Physicians as \u201ccata-
\nstrophic\u201d. Altogether, \u201cpassive drinking\u201d af-
\nfects more people than \u201cpassive smoking\u201d
\n[2].
\nWhen we look at the European Union
\n(EU), alcohol is a huge burden. It is the
\n\u201cthird most significant risk factor\u201d, being
\nresponsible for 6.5% of all deaths and an-
\nnual cost of \u20ac400 billion (social and intan-
\ngible costs),which equals almost 4% of EU\u2019s
\nGDP [3, 4].
\nWhat can society do?
\nMost measures employed to fight the bur-
\nden of the harmful use of alcohol are meas-
\nures at a population level. Increasing taxes
\non alcohol products seems to be the most
\neffective intervention. Although govern-
\nments are often concerned about losing
\nrevenue, the opposite is the case. Revenue
\nincreases as the reduction of consumption is
\nsmaller than the increase in taxes [5]. Other
\nIFMSA and 1.2 million Worldwide Medical
\nStudents Fighting Against the HARMFUL
\nUSE OF ALCOHOL
\n153
\nMedical Ethics, Human Rights,Socio-medical affairs and Environmental Policy
\ncommon measures are the introduction of
\na minimum age for drinking or anti-drink-
\ndriving measures like the reduction of blood
\nalcohol concentration limits.
\nWhat can physicians do?
\nWe as (future) physicians are in regular
\ncontact with high-risk individuals.Brief ad-
\nvice in a primary care setting is proven to
\nbe effective and cost-effective [4, 6]. A Co-
\nchrane Review even showed that the mean
\nconsumption was reduced by 12% [7]. We,
\nas the next generation of health profession-
\nals, will need more training on approaches
\nto delivering brief advice than we currently
\nreceive. Physicians can play a much bigger
\nrole against the burden of harmful alcohol
\nconsumption than just curing the damage
\nit causes.
\nAs physicians, we are respected members of
\nour societies and our health advice is tak-
\nen seriously. Still, there is misinformation
\neven within physicians as well as medical
\nstudents worldwide. \u201cSmall amounts of al-
\ncohol can have beneficial effects\u201d. There is
\nevidence supporting this statement \u2013 but
\nis there evidence that this is also a helpful
\nadvice\u2026? Every harmful drinker started
\nwith small amounts. The following figure
\nmight put the beneficial effects of alcohol
\nconsumption into a broader picture. Indeed,
\nthere are deaths prevented by low-dose al-
\ncohol consumption. But in every age group,
\nthere are more deaths caused than prevent-
\ned by alcohol consumption!
\nWhy are we as a youth
\norganisation concerned?
\nWe are concerned because young people
\nare strongly affected. Of all years lived with
\ndisability attributed to alcohol, 34% were
\nexperienced by persons aged 15\u201329 years
\n[9]. We, as representatives of young people,
\nthink that we have the right to be protected.
\nWe are dissatisfied if manipulative market-
\ning by the alcohol industry is used to influ-
\nence our decisions and behaviour.
\nIFMSA, GAPA & the WHO Global
\nStrategy to Reduce the Harmful Use of
\nAlcohol
\nIn May 2010, during the WHO World
\nHealth Assembly, all 193 member states
\nadopted the \u201cGlobal Strategy to Reduce the
\nHarmful Use of Alcohol\u201d (1)
\n. This milestone
\nfor global public health describes harm-
\nful consumption as a major threat for glo-
\nbal health and offers solutions which can
\nand should be implemented by all member
\nstates.
\nWe, as IFMSA, do welcome the adoption
\nof the strategy although we know that it is a
\nlong way towards achieving its aims. We, as
\nworldwide medical students, are an affected
\nhigh-risk group on our own. Therefore we
\nadvocated towards the World Health As-
\nsemblies in 2008 and 2010 to support a
\nstronger protection of medical students and
\nyouth in general.
\nWe are proud of our persistence in our ac-
\ntions and our fight against the harmful use
\nof alcohol.
\nWe are proud of being members of a strong
\nyouth movement, the Alcohol Policy Youth
\nNetwork (APYN), which successfully
\nhosted the European Conference \u201cAlco-
\nhol Policy and Young People\u201d in Budapest,
\nHungary.
\nWe are proud of our great collaboration with
\nthe Global Alcohol Policy Alliance (GAPA).
\nOur fruitful partnership was especially high-
\nlighted by the attendance of GAPA Chairper-
\nson Mr.Derek Rutherford at our last IFMSA
\nGeneral Assembly in Thailand.We have been
\ninspired by his speech towards our 850 par-
\nticipants and it was fantastic to see the enthu-
\nsiasm of worldwide medical students towards
\nsuch an important but often neglected topic.
\nWe are looking forward towards further col-
\nlaborations of IFMSA and GAPA.
\nPercentage of male deaths attributable to alcohol consumption in 2005 (England) [8].
\nDerek Rutherford (GAPA) and
\nFlorian Stigler (IFMSA)
\n154
\nHealthcare technologies
\nWe as IFMSA are proud to represent the
\nvoice of 1.2 million medical students and to
\nfight the global burden of the harmful use
\nof alcohol!
\nReferences
\nWorld Health Organization. Global Strategy1.
\nto Reduce the Harmful Use of Alcohol. Ge-
\nneva, 2010.
\nHouse of Commons Health Committee. Al-2.
\ncohol. First Report of Sessions 2009\u201310. Lon-
\ndon, 2010.
\nWorld Health Organization Europe. Hand-3.
\nbook for action to reduce alcohol-related
\nharm. WHO, 2009.
\nWorld Health Organization Europe.Evidence4.
\nfor the effectiveness and cost-effectiveness of
\ninterventions to reduce alcohol-related harm.
\nWHO, 2009.
\nThe University of Sheffield. Modelling to as-5.
\nsess the effectiveness and cost-effectiveness of
\npublic health related strategies and interven-
\ntions to reduce alcohol attributable harm in
\nEngland using the Sheffield Alcohol Policy
\nModel version 2.0. Sheffield, 2009.
\nAnderson P., Chisholm D., Fuhr D. C. Effec-6.
\ntiveness and cost-effectiveness of policies and
\nprogrammes to reduce the harm caused by al-
\ncohol. Lancet. 2009; 373; 2234\u201346.
\nKaner E. F., Dickinson H. O., Beyer F. R.,7.
\nCampbell F., Schlesinger C., Heather N.,
\nSaunders J. B., Burnand B., Pienaar E. D. Ef-
\nfectiveness of brief alcohol interventions in
\nprimary care populations. Cochrane Database
\nof Systematic Reviews 2007, Issue 2.
\nJones L. et al. Alcohol attributable fractions8.
\nfor England; alcohol attributable mortality
\nand hospital admissions. North-West Pub-
\nlic Health Observatory and Dept of Health;
\n2008; p 26.
\nRehm J. et al. Global burden of disease and in-9.
\njury and economic cost attributable to alcohol
\nuse and alcohol-use disorders. Lancet. 2009;
\n373: 2223\u201333.
\nDr. Florian Stigler,
\nIFMSA Liaison Officer on Public Health
\ne-mail: lph@ifmsa.org
\nIntroduction
\nHealthcare technologies have seldom been
\nunder more scrutiny. In mature and devel-
\noped markets, governments and providers
\nare using methodologies such as compara-
\ntive effectiveness and health technology
\nassessments to evaluate the benefits of di-
\nagnostics and other medical devices. Some
\nobservers view this as simply a way to limit
\never growing expenditure in healthcare, but
\nmost accept that new technology should
\nshow that it has clinical utility and be more
\ncost effective than current practice.
\nSimilar logic is being applied to health
\ntechnologies for emerging markets. Con-
\nsideration of cost and clinical effectiveness
\nis being conducted in tandem with the
\nadditional challenges that these markets
\npose \u2013 such as isolated geographies, short-
\nages of professional medical workers, poor
\ninfrastructure, often overwhelming demand
\nand, of course, very limited funding. With
\nsuch challenging circumstances, emerging
\nnations\u2019 needs for better access to appro-
\npriate technologies is paramount. It is in-
\ncumbent upon companies like GE1
\nto do all
\nthey can to help.
\nAs a global, technology based, diagnos-
\ntics and healthcare solutions business, GE
\nsees its critical contribution as making
\ncost-effective life-saving technology more
\naccessible in the semi-urban, rural and de-
\nveloping areas which often bear the brunt
\nof the disease burden. This is epitomised by
\nGE\u2019s healthymagination programme which
\naims to deliver technologies and solutions
\nthat improve the quality, access and cost of
\nhealth in all of our markets.
\nHealthymagination
\nHealthymagination is GE\u2019s commitment
\nto work in our businesses and in partner-
\nships to develop the appropriate new tech-
\nnologies and solutions that will help deliver
\nimproved access to better quality and cost
\neffective healthcare [1]. That commitment
\napplies to the poorest and richest coun-
\ntries alike: to those places with underserved
\n1 GE is a trademark of General Electric Company
\nhealthcare systems where technology can
\nimprove access and patient outcomes; and
\nto places where technology is regarded as
\na driver of healthcare costs and where, in-
\nstead, it needs be used to drive efficiencies
\nand improvements in delivery.
\nSo, how does healthymagination apply to,
\nsay, rural India, China or Africa? When
\nhealthymagination was launched in May
\n2009, GE CEO Jeff Immelt highlighted
\ntwo products that looked to the future. The
\nMAC 400 Electrocardiogram device and the
\nDeveloping Healthcare Technologies for
\nEmerging Markets \u2013 Improving Quality,
\nAccess and Cost
\nMike Barber
\n155
\nVenue2
\n40 tablet sized portable ultrasound
\nscanner. These devices are battery powered,
\nportable, self contained and simple to use.
\nThey are examples of using the consumer
\nelectronics boom to miniaturise and adapt
\ntechnology that was once the sole preserve
\nof the hospital, and take it into clinics and
\nrural locations remote from mainstream
\nmedical facilities. Both take healthcare to
\nthe patient rather than the patient to the
\nhealthcare provider and both were devel-
\noped and manufactured in the markets for
\nwhich they are designed.
\nIn an article published in the Harvard Busi-
\nness Review [2] Jeff Immelt, Vijay Govin-
\ndarajan and Chris Trimble describe how
\nGE has changed its traditional \u201cglocalisa-
\ntion\u201d business model, where products were
\ndeveloped in home markets like the USA
\nand Europe for these markets, then adapt-
\ned for sale elsewhere \u2013 often by reducing
\nspecifications and manufacturing locally.
\nThis model worked to some extent, but fre-
\nquently the products were not suitable for
\nlocal circumstances – too big, too compli-
\ncated, susceptible to power fluctuations and
\ndifficult to use and maintain in physical
\n2 MAC, Venue and VSCAN are trademarks of GE
\nHealthcare companies
\nenvironments quite differ-
\nent from those they were
\noriginally designed for. And,
\ndespite lowering the capital
\ncost of equipment, financial
\nmodels for its use and up-
\nkeep based upon home mar-
\nket experience did not work
\nand were not sustainable.
\nThere needed to be a major
\nchange in mindset.
\nThe company now increas-
\ningly researches, develops
\nand manufactures the right
\ntechnology for local needs
\nin the country or region of
\nuse as part of GE\u2019s \u201cin coun-
\ntry for country\u201d approach to
\nnew technology development. This is easier
\nsaid than done, and the Harvard Business
\nReview paper describes in detail how the
\nmanagement structures and systems of GE
\nhad to change to allow local autonomy and
\nresponsibility to take decisions,research local
\nneeds and critically, in a company renowned
\nfor financial rigor, secure and allocate fi-
\nnancing for the new products. In short, GE
\nteams with deep local knowledge and un-
\nprecedented autonomy in China, India and
\na dozen other countries now manage the de-
\nvelopment and production of new products
\nto meet local needs. In an interesting twist,
\nbecause these new products do not compro-
\nmise on quality, some are finding a use \u201cback
\nhome\u201din the developed markets.This has be-
\ncome known as \u201creverse innovation.\u201d
\nReverse innovation
\nTechnologies designed to meet the specific
\nmedical needs and circumstances of devel-
\noping nations are proving popular in more
\ndeveloped markets, particularly where there
\nare large rural,underserved populations.The
\nMAC series of electrocardiograms (ECG)
\nis a good example of this. Originally devel-
\noped in India,their ease of use and portabil-
\nity make them equally attractive for primary
\ncare physicians and nurses in clinics and on
\nhome visits in other countries including the
\nUSA.These machines are even used by \u201cfly-
\ning doctors\u201dserving the Inuit populations in
\nNorthern Canada and data from examina-
\ntions can be examined on the spot or trans-
\nmitted to specialists in urban centres for
\nanalysis or second opinion.
\nIn today\u2019s financially restrained times, tech-
\nnology that enables more diagnostic tests to
\nbe conducted outside of the hospital envi-
\nronment or at the patient\u2019s bedside, rather
\nthan referral and physical transport, are
\nlikely to be attractive in helping to improve
\nhealthcare system efficiencies. Marketing
\nthese technologies in developed as well as
\nemerging markets allows the development
\ncosts to be spread wider and hence the price
\npoint to the developing market can be set
\nat a level that enables the country to pur-
\nchase and maintain the technology \u2013 meet-
\ning GE\u2019s healthymagination commitments
\nrelating to quality, access and cost.
\nNew healthcare technologies for global
\nchallenges
\nInnovative medical technology is now be-
\ning developed for almost all the diseases and
\nconditions found across developing nations.
\nUntil relatively recently the predominant fo-
\ncus was on medicines, vaccines and preven-
\ntion and awareness campaigns. Now there
\nis a welcome shift towards new and better
\ntechnologies for screening, earlier diagnosis,
\ntreatment assessment and monitoring.
\nThe World Health Organisation is a case
\nin point. It recently published the result of
\nits call for innovative devices that address
\nglobal health concerns [3]. Six out of fifteen
\napplications that it has selected to high-
\nlight are in diagnostics and screening.These
\nrange from a portable on site cell sorter and
\ncounter for HIV and malaria diagnosis, to
\na transcutaneous bilirubin measurement
\nsystem to provide an alternative to blood
\nsample analysis for the diagnosis of hyper-
\nbilirubinaemia in newborn infants. Other
\ndevices selected have applications in mater-
\nHealthcare technologies
\nMike Barber with the Vscan ultrasound scanner at the WMA
\nlunch The portable MAC ECG device and Venue 40 ultrasound
\nscanner being demonstrated
\n156
\nHealthcare technologies
\nnal and newborn care, such as neonatal suc-
\ntion devices and baby warmers.These reflect
\nthe rising global focus on the challenges of
\nMaternal and Newborn Health which are
\nprominent in the United Nations Millen-
\nnium Development Goals (MDGs).
\nMaternal and Newborn Health
\nMDG 5 aims to reduce by two-thirds the
\nmortality rate among children under five \u2013
\nand deliver this by 2015. Of the 139 million
\nbabies born worldwide every year, nearly 4
\nmillion die in the neonatal period, the main
\ndirect causes being preterm birth, severe in-
\nfections and asphyxia.The real tragedy is that
\nmost of these deaths are preventable. With
\njust five years to go, reaching the MDG will
\nrequirenew levelsofcooperationamongstev-
\neryone concerned,from doctors to midwives,
\nGovernments to NGOs and researchers to
\nbusinesses. It will also require a reappraisal
\nof the ways in which healthcare technologies
\nare developed and deployed, especially in
\nareas where neonatal mortality rates are the
\nhighest. GE is playing its part.
\nAs part of GE\u2019s global healthymagination
\ncommitment, we expect to expand our Ma-
\nternal-Infant Care portfolio by 35% – offer-
\ning targeted technologies to over 80 coun-
\ntries in order to increase local access to care.
\nIncluded already are safety tested, affordable
\nand easy-to-use infant care products that
\nprovide warmth for newborns, phototherapy
\nto treat jaundiced infants and incubators for
\npremature babies. Some of these products
\nare designed and manufactured in India and
\nTurkey. GE is now working on developing
\nvery simple warmers and phototherapy de-
\nvices for developing nations at dramatically
\nreduced cost. A novel method for providing
\noxygen to mothers in childbirth and to new-
\nborn babies is also under consideration.
\nAnother new product already available is
\nthe Vscan handheld portable ultrasound
\nscanner, developed in emerging markets.
\nIts clinical applications are currently being
\nassessed in both emerging and developed
\nmarkets for a wide range of diseases and
\nconditions. Though not yet approved, these
\ninclude assessing its capabilities and proto-
\ncols for its use in maternal and neonatal care
\napplications in emerging markets.
\nUltimately, our vision is for Vscan to be as
\nubiquitous as a stethoscope and to achieve
\nthat it must have a truly global reach. As
\nin consumer electronics, unit costs will be
\nreduced as more clinical applications are
\napproved, production increased and other
\ndesign innovations are deployed. The goal is
\nto reach a point where the purchase, train-
\ning and upkeep costs can be recovered by a
\nsustainable pricing model in even the lowest
\nincome countries of the world.This is a goal
\nthat was simply unimaginable only a few
\nyears ago and now promises to bring to any-
\nwhere powerful diagnostic capabilities previ-
\nously the exclusive domain of the hospital.
\nWorking in partnership
\nHaving designed new technologies the next
\nchallenge is to test,refine and deploy them in
\nthe field.Lessons have been learned from the
\nGE Foundation\u2019s keystone philanthropy pro-
\ngramme \u201cDeveloping Health Globally\u201d [4].
\nThis programme is improving the healthcare
\ncapacity in Africa, South East Asia and Lat-
\nin America by equipping hospitals and clin-
\nics with the technology they need and ensur-
\ning staff are properly trained in its use. Using
\nvolunteers from GE and GE Healthcare the
\nprogramme has shown that what is actually
\nrequired on the ground is often not what is
\nperceived from afar and that what works in
\nGeneva, may not in Ghana. In short, the
\nlearning is that there is no substitute for hav-
\ning people in situ on the ground.
\nIt is here that GE is actively seeking part-
\nnership with Governments, professional or-
\nganisations and increasingly NGOs with a
\npresence in developing markets. While we
\nmay have design team and sales and mar-
\nketing and business expertise in many coun-
\ntries, we sometimes lack the infrastructure
\non the ground to take the new technologies
\nout to the patients. Fortunately, there are
\nmany global and local NGOs experienced
\nin this type of work and we are keen to
\njoin with them to provide the training pro-
\ngrammes and capacity building in country
\nfor testing new technologies. Through this
\ntype of partnership we can better reach the
\nend users to determine if a new technology
\nreally will be of use on the ground. If yes,
\nworking in a partnership could also allow
\nus to develop clinical protocols and appro-
\npriate uses for the technologies, speed up
\ndelivery, provide the right training and sup-
\nport needs and minimise costs.
\nMuch remains to be done. GE is not claim-
\ning to have all the answers to ensure that
\nall parts of the world have access to innova-
\ntive technologies that improve health. We
\ndo however understand the problems and
\ncan see many of the obstacles in the way.
\nThrough healthymagination and the de-
\nvelopment of new technologies \u2018in country
\nfor country\u2019 we are committed to working
\nto help overcome the challenges. It will re-
\nquire more collaboration,partnerships,clear
\nthinking and the courage to do things dif-
\nferently. Please join us in our journey.
\nReferences
\nHealthymagination [Internet] [cited 20101.
\nMay 8]. Available from http:\/\/ www.healthy-
\nmagination.com
\nImmelt JR,Govindarajan V,Trimble Ch.How2.
\nGE is disrupting itself. Harvard Business Re-
\nview. 2009 Oct : 3 \u201311.
\nCall for innovative technologies that address3.
\nglobal health concerns [Internet]. World
\nHealth Organisation: Department of Essen-
\ntial Health Technologies [cited 2010 May 8]
\nAvailable from http:\/\/ www.who.int\/medi-
\ncal_devices\/call\/en\/index.html
\nRenewing responsibilities: Citizenship Report4.
\n2009 [Internet] [cited 2010 May 8]. Available
\nfrom http:\/\/ http:\/\/www.ge.com\/citizenship\/
\nNote: This article is based on an address by Mike
\nBarber to the World Medical Association\u2019s Annual
\nLunch at the World Health Assembly, Geneva, 18
\nMay 2010
\nMike Barber, Vice President
\nhealthymagination, General Electric
\n157
\nRegional and NMA news
\nBirgit Beger
\nIntroduction
\nAt its Board meeting on 22nd June, chaired
\nby CPME President Dr Konstanty Radzi-
\nwill, the CPME said good-bye to Lisette
\nTiddens-Engwirda, who left the CPME
\nupon her retirement after 8.5 years as sec-
\nretary general. The board welcomed Birgit
\nBeger, the new secretary general as of 1st
\nJuly 2010.
\nContent discussions were in-depth and the
\nagenda full, since the meeting in April had
\nfallen victim to the travel restriction based
\non the Icelandic volcano. From the many
\nsubjects dealt with in June, there are a num-
\nber of significant items of interest to the
\nmedical profession.
\ne-Health
\nIn the world of electronic communication
\nthere are no national borders, and e-health
\npresents a rapidly changing healthcare
\npolicy area. The CPME has made involve-
\nment in this policy area a focus for years,
\nwith the aim of ensuring that technology
\nis used to support the cornerstones of the
\npatient\/doctor relationship with a view to
\nbetter and easier access to healthcare. With
\nthis engagement we try to countervene ten-
\ndencies of focussing e-health on economical
\nand technology developments, circumvent-
\ning the importance of departing from pa-
\ntients\u2019 needs.
\nHealth care for the ageing population and
\nchronic disease management indeed find a
\nbackup in e-health tools, as does cross-bor-
\nder prescription in Europe where citizens
\nare more and more mobile. E-health is high
\non the agenda of EU governments and the
\nEuropean Commission. In the last years we
\nhave seen projects like epSOS (transfer of
\nelectronic patient summaries,e-prescribing)
\nand CALLIOPE (interoperability project) ,
\nCALLepSO (combination of both projects),
\nas well as the 2009 Council conclusions on
\ne-health which present a political mandate
\nfor a more consolidated approach to co-op-
\neration on e-Health in the EU.The CPME
\nis involved in these concrete projects as well
\nas in the e-Health users\u2019 stakeholder group
\nwhich is chaired by the previous president
\nof the CPME, Dr Michael Wilks.
\nAt the CPME it was agreed that the issue of
\ndata protection and patients\u2019consent should
\nbe further strengthened in the debate, since
\nthis is a particular area in which the inter-
\nest of the patient is under potential risk.The
\nfocus for this topic will be brought into the
\nuser group and a thematic network on limits
\nand barriers of e-health.
\nPharmaceuticals\u2013CPMEresponsetoEu-
\nropean Medicines Agency consultation1
\n1 The European Medicines Agency Road Map
\nto 2015: The Agency\u2019s contribution to Science,
\nMedicines, Health is available here: http:\/\/www.
\nema.europa.eu\/htms\/general\/direct\/roadmap\/
\nroadmapintro.htm
\nThe European Medicines Agency launched
\na consultation on its Road Map to 2015
\nwhich presents the EMA\u2019s new strategic vi-
\nsion and sets out the Agency\u2019s priorities for
\nthe next five years.
\nIn its response to the consultation, the
\nCPME in general agreed with the roadmap
\nproposed, but underlined the importance of
\nengaging the medical profession in order to
\nproperly address public health needs.More-
\nover, the CPME stressed the global nature
\nof medicine development and research in
\nsupport of the Helsinki Declaration2
\n.This is
\none of the most important documents and
\nguideline for doctors when it comes to re-
\nsearch on human beings and it deals with
\nthe ethical issues implied. Furthermore, as
\nregards clinical trials, the CPME stressed
\nthat it is of great importance that all clinical
\ntrials are registered in a publicly accessible
\nglobal database to avoid redundant clinical
\nstudies which is another important topic
\ncovered by the Helsinki Declaration.
\nOrgan donation
\nThe CPME rapporteur on organ donation,
\nDr Frank Ulrich Montgomery,reported that
\nthe CPME\u2019s amendments to the draft pro-
\nposal for a \u201cDirective of the European Par-
\nliament and of the Council of 8th Decem-
\nber 2008 on standards of quality and safety
\nof human organs intended for transplanta-
\ntion [COM (2008) 818]\u201d3
\nwere accepted by
\nthe rapporteur MEP Miroslav Mikol\u00e1\u009aik
\n(SK, PES), so that the final version of the
\ndocument now includes all key demands of
\nthe CPME and safeguards the interests of
\ndoctors and patients.The CPME\u2019s advocacy
\nwork was very successful in this initiative.
\n2. WORLD MEDICAL ASSOCIATION DEC-
\nLARATION OF HELSINKI, Ethical Principles
\nfor Medical Research Involving Human Subjects,
\nadopted by the 18th WMA General Assembly,Hel-
\nsinki, Finland, June 1964, please see: http:\/\/www.
\nwma.net\/en\/30publications\/10policies\/b3\/17c.pdf
\n3 http:\/\/eur-lex.europa.eu\/LexUriServ\/LexUriServ.
\ndo?uri=COM:2008:0818:FIN:EN:PDF
\nNews from the CPME: Board meeting in
\nBrussels on 22nd
\nJune
\n158
\nRegional and NMA news
\nThe draft directive now aims to integrate
\nharmonised regulations for the fields of
\n\u201cblood, blood products, cells, tissue and
\norgans of human origin\u201d. The CPME
\namendments sought to avoid loopholes in
\nthe draft directive as regards parts of or-
\ngans if it is their function to be used for
\nthe same purpose as the entire organ in the
\nhuman body, and for so-called \u201ccomplex
\ntissue\u201d. Furthermore, the amendments aim
\nto diminish bureaucratic hurdles and try
\nto ensure the good practices of the tissue
\ndirective 2004\/23\/EC and its implement-
\ning directives. In light of the communalism
\nof transplantation medicine successfully
\nestablished over many years in some EU
\nmember states, the CPME amendments
\nare of crucial significance; retaining the
\nprevious formulations of the draft directive
\nwould, in some countries, have unnecessar-
\nily resulted in abandoning the proven and
\ntested organisational structures. In coun-
\ntries where there are high standards these
\nstandards will, thus, be maintained. The
\nCouncil approved the directive on 29th
\nJune 2010 and it awaits its publication in
\nthe Official Journal.
\nEuropean Working Time Directive
\nOn 24th March 2010, the Commis-
\nsion published a communication (COM
\n2010(106) final)4
\non reviewing the Working
\nTime Directive 2003\/88\/EC.5
\nIn the years
\n2004\u20132009 the Commission\u2019s proposal to
\namend the Directive could not reach agree-
\nment with the Council and the Parliament
\ndespite intensive discussions and a concili-
\nation process.
\nThe CPME believes that it is vital in the
\ninterest of the healthcare work force and
\ntheir patients to maintain high standards
\nof protection from long working hours and
\ndepraving working conditions as well as
\nguaranteeing safety for the patients. The
\n4 http:\/\/eur-lex.europa.eu\/LexUriServ\/LexUriServ.
\ndo?uri=COM:2010:0106:FIN:EN:PDF
\n5 http:\/\/eur-lex.europa.eu\/LexUriServ\/LexUriServ.
\ndo?uri=OJ:L:2003:299:0009:0019:EN:PDF
\ncurrent Working Time Directive provides
\nsound definitions for \u201cworking time\u201d and
\n\u201crest period\u201d which have proven successful
\nin bringing down overall working times
\nand in reconciling private-life and work-
\nlife. Also, the European Court of Justice
\nin the cases SIMAP, Jaeger and Dellas,
\nruled that the \u201con-call time periods\u201d must
\nbe counted hour-for-hour as working time
\nwhich is strongly supported by the CPME.
\nSince the Working Time Directive is a val-
\nuable tool \u2013 provided Member States have
\nimplemented it \u2013 the CPME is rather hes-
\nitant towards a review. In particular, if one
\nof the motives for the revision is to create
\ncompetitive cost advantages for businesses
\nby making production times more flexible.
\nFor example, individual opt-outs from the
\n48-hour limit to average weekly working
\ntime are considered as a very critical ele-
\nment in the current Working Time Direc-
\ntive and any review should not allow fur-
\nther derogations from the full protective
\nscope of the directive. The overall scope
\nof the European Working Time Directive
\nshould not turn from a protective to an
\neconomic one.
\nThe CPME will closely monitor further de-
\nvelopments in the review process and will
\ntake an active stand for the interests of the
\nhealthcare workforce and their patients.
\nHealth inequalities
\nThe well-being of and care for their pa-
\ntients is the prime concern and respon-
\nsibility of physicians. Physicians apply
\ntheir expertise to the best of their knowl-
\nedge for the benefit of the sick and for
\nthe prevention of ill health. Research for
\nnew approaches and technologies to im-
\nprove health, and contribution to policy
\nmaking in clinical and public health are
\nalso important obligations for the medical
\nprofession.
\nAt the board meeting, the CPME ad-
\nopted a position paper on health in-
\nequalities, please see: http:\/\/cpme.dyndns.
\norg:591\/adopted\/2010\/CPME_AD_
\nBrd_220610_014_final_EN.pdf
\nIn the position paper reference is made to
\na CPME response to a Consultation on
\nEuropean Commission Communication
\n\u201cSolidarity in Health\u201d of 2009, (please see:
\nhttp:\/\/ec.europa.eu\/health\/archive\/ph_de-
\nterminants\/socio_economics\/documents\/
\ncons_paper_en_.pdf), where the CPME
\nsuggested several measures to reduce in-
\nequalities in health. Some of these are not
\ndirectly healthcare-related as for example
\neducation, social cohesion, fiscal and taxa-
\ntion policy, etc. While the CPME supports
\naction in these areas to reduce health in-
\nequalities, as an organisation for medical
\ndoctors, CPME concentrates its lobby ac-
\ntivities on health issues and give priority to
\nthese measures:
\nImproving the data and knowledge base\u2022
\nand mechanism for measuring, monitoring,
\nevaluation and reporting.
\nImprovement in infrastructure, especially\u2022
\nwater and housing.
\nSecure the right to health for disadvantaged\u2022
\npeople including illegal entrants and asylum
\nseekers.
\nThe current position paper addresses also
\nthe decisive national level (National Medi-
\ncal Organisations) as regards ways of im-
\nprovement of health inequalities, like for
\nexample:
\nDrawing the attention of governments to\u2022
\ninternational conventions or charters that
\nsecure the right to health.
\nLobbying national health authorities for\u2022
\nbetter health care particularly for disadvan-
\ntaged groups.
\nEthical trade in medical goods
\nThe CPME has started work on a net-
\nwork which brings together national
\nreports on ethical trade in medical sup-
\nplies. In the UK and Sweden good prac-
\ntices already exist which aim to tackle the
\nethical implication of producing medical
\ngoods in low cost countries, for example
\n159
\nRegional and NMA news
\nchild labour, health and safety, and work-
\ners\u2019 rights.
\nIn 2009, the CPME already undertook first
\nsteps to raise awareness among the Euro-
\npean medical associations and EU decision
\nmakers.
\nThe aim of the current work is to assess
\nwhether European standards on ethical
\ntrade will be helpful to safeguard rights.
\nFurthermore, the CPME is aware that the
\nEuropean Commission is developing social
\nstandards for ethical procurement to which
\nthe CPME could contribute from the Eu-
\nropean doctors\u2019 point of view.
\nThe next CPME board meeting and general
\nassembly will take place in Brussels on 27th
\nNovember 2010. For further information,
\nplease contact Birgit Beger at birgit.beger@
\ncpme.eu
\nBirgit Beger, Secretary General, CPME
\nBernard Maillet
\nIntroduction
\nA hybrid yet comprehensive structure \u2013
\nspecialist, political and scientific
\nThe European Union of Medical Special-
\nists (UEMS) was established in 1958, one
\nyear after the signing of the Rome Treaty,
\nand is the representative organisation of the
\nNational Associations of Medical Special-
\nists in the European Union, its associated
\nand observer countries and beyond. With
\na current membership of 35 countries, the
\nUEMS represents an estimated 1.5 million
\nspecialist doctors, notably through its 38
\nSpecialist Sections and Boards and 8 Mul-
\ntidisciplinary Joint Committees (MJC\u2019s).
\nIt has strong links and relations with the
\nEuropean Institutions (Commission and
\nParliament), the other independent Euro-
\npean Medical Organisations (e.g. PWG,
\nUEMO, CPME) and the European Medi-
\ncal \/ Scientific Societies.
\nIts structure consists of a Council respon-
\nsible for and working through its Special-
\nist Sections and MJC\u2019s, each with its own
\nEuropean Board, addressing training in the
\nSpecialty and incorporating representatives
\nfrom academia (Scientific Societies,Colleges
\nand Universities).An Executive,made up the
\nPresident,the Secretary-General,the Liaison
\nOfficer, and the Treasurer, is responsible for
\nthe daily functioning of the organisation.
\nBy its agreed documents, the UEMS sets
\nstandards for high quality healthcare prac-
\ntice for the benefit of patients and the har-
\nmonisation of high level training across Eu-
\nrope that are transmitted to the Authorities
\nand Institutions of the EU and the National
\nMedical Associations (and through them
\nthe National Health Authorities) stimulat-
\ning and encouraging them to implement its
\nrecommendations.
\nIn 2000, the UEMS established the ex-
\ntremely important European Accredita-
\ntion Council for Continuing Medical
\nEducation (EACCME\u00ae
\n), which facilitates
\nthe exchange of CME credits obtained by
\nattending international medical congress-
\nes. This recognition is achieved by virtue
\nof common memoranda of agreement
\non mutual recognition reached between
\nUEMS, the National Accreditation Au-
\nthorities and the American Medical As-
\nsociation.
\nA further step forward was realised in 2010
\nat the Istanbul Council of the UEMS where
\nthe European Accreditation Council for
\nMedical Specialist Qualification was of-
\nficially created. It was agreed to start with
\na pilot project for a period of two years for
\nthree Specialties and have a harmonisation
\nof the Assessment of the Training.
\nThe oldest of the European
\nmedical organisations
\nOn 20th July 1958, delegates from the
\nprofessional organisations representing
\nmedical specialists of the six founding
\ncountries of the new European Economic
\nCommunity convened in Brussels and set
\nup the UEMS. Thanks to the leadership
\nand perspicacity of its founding members,
\nthe UEMS soon established contacts with
\nthe newly created European Institutions
\nto define the basic principles in the field
\nof training for European medical special-
\nists. During its 50 years of existence, the
\nUEMS continued to deliver a considerable
\namount of work with the constant aim to
\npromote the quality of care across Europe.
\nThe Training, Qualification and Continuous
\nProfessional Development of the Medical
\nSpecialist in the Future, a Challenge for the UEMS
\n160
\nRegional and NMA news
\nWhen addressing the issue of quality, the
\nUEMS obtained from the European Com-
\nmission and the Member States that the
\nhighest levels of training for the future medi-
\ncal specialists of the Six Common Market
\ncountries would be guaranteed by European
\nlegislation. This vision of the future resulted
\nin the elaboration of common general cri-
\nteria, applicable to all specialists wishing to
\nmove from one member country to another.
\nTo realise this ambitious objective, the
\nUEMS created in 1962 Specialist Sections
\nfor each of the main disciplines then prac-
\nticed in the Member States.These groups of
\nexperts, made up of representatives of the
\nnational associations of the specialty con-
\ncerned, carried out a considerable workload
\nwith the idea of coordinating and harmon-
\nising specialist training and criteria for the
\nrecognition of medical specialists. Today
\nthe UEMS has 38 Specialist Sections and
\nBoards as well as 8 Multidisciplinary Joint
\nCommittees (MJC\u2019s) all together having
\nabout 2000 specialists working on those
\nimportant issues.
\nThis active collaboration with the Europe-
\nan Institutions and Member States led to
\nthe adoption in 1975 of the first Directives
\nproviding for the free movement of doctors
\nacross Europe by ensuring the recognition
\nof their qualifications.
\nThe UEMS naturally contributed to further
\nimprovements and updates to the Doctors\u2019
\nDirectives following to the successive en-
\nlargements of the European Community.
\nThese also led to important changes in the
\nbodies and composition of UEMS.Progres-
\nsively, the number of UEMS Sections in-
\ncreased and reaches now 38.
\nIn order to support the implementation to
\nthese Directives, the European Commis-
\nsion established the Advisory Commit-
\ntee on Medical Training (ACMT) with
\nan aim to engage European professional
\nmedical organisations, universities and na-
\ntional governments. The UEMS, through
\nits Specialist Sections, was naturally deeply
\ninvolved in the consultations launched by
\nthis body. Each Section was asked to report
\non its understanding and possible propos-
\nals regarding the developments occurring in
\nthe specialty. Progressively, four reports of
\nthe ACMT, conducted by Members of the
\nUEMS Executive,were implemented by the
\nCommission when updating its legislation.
\nConfronted with the need to a greater
\ninvolvement of the academic world, the
\nUEMS created in 1990 European Boards
\nas working groups of its Specialist Sections
\nto address issues related to medical train-
\ning and ultimately guarantee optimal care
\nby raising quality and training standards.
\nThanks to this closer collaboration, Euro-
\npean Charters were elaborated on various
\nissues such as specialist training, quality
\nassurance in specialist medicine or the au-
\ntonomy of practice for medical specialists.
\nIn 1999,the UEMS set up the European Ac-
\ncreditation Council for Continuing Educa-
\ntion (EACCME\u00ae
\n) with an aim to harmonise
\nand improve the quality of specialist medical
\ncare in Europe through facilitating the mo-
\nbility of health professionals for learning and
\ntraining purposes. In the fields of continuing
\nmedical education (CME) and continuing
\nprofessional development (CPD), the EAC-
\nCME ensures access to recognised high
\nquality CME-CPD activities by securing
\nthe exchange and recognition of CME cred-
\nits for medical specialists in Europe through
\nthe European CME Credits (ECMEC\u2019s).
\nIn the recent years, the UEMS has shown
\nitself to be very active in major issues dealt
\nwith at the EU level. These include among
\nothers the consolidation of the Doctors\u2019Di-
\nrective into the Directive on the recognition
\nof professional qualifications; the organisa-
\ntion of working time; and patient mobility
\nand cross-border care.
\nThe UEMS has celebrated its 50th Anni-
\nversary having celebrations held in Brussels
\nfrom 17th to 19th April 2008.
\nIn 2007 at the initiative of the Section of Pe-
\ndiatric Surgery a meeting was organised in
\nGlasgow where the Sections met that were
\norganising European Board Examinations
\nwith the aim to harmonise those. At that
\ntime 11 UEMS Sections were represented
\nand the so-called Glasgow Declaration was
\nissued at the end of the meeting.
\nThe main points on the Glasgow declara-
\ntion are: the European Board Examinations
\nhave no Legal Value and they can be seen as
\ncomplimentary to National Examinations.
\nWe have to promote the European Exami-
\nnations, as they can be considered as a La-
\nbel of Excellence. Important is to set a clear
\nCurriculum and to have a Reference Book.
\nThere should be clear Eligibility criteria and
\nwe have to harmonise the certificates for
\nsuccessful application.
\nIn the meanwhile, the Council for Europe-
\nan Specialty Medical Assessment (UEMS-
\nCESMA) has been more formally installed
\nand working very well. Today 28 UEMS
\nSections are participating in the activities of
\nthis group and have support of the UEMS
\nCouncil and Executive, the UEMS Presi-
\ndent as well as the UEMS Secretary-Gen-
\neral being ex-officio members of UEMS-
\nCESMA.
\nUEMS\u2013CESMA together with the Work-
\ning Group of the UEMS Council on Post
\nGraduate Training will be part of the
\nECAMSQ together with the National Li-
\ncensing Authorities in the European Union
\nas well as the UEMS Executive.
\nThe introduction of e-learning
\nmaterial in the EACCME\u00ae
\n(European
\nAccreditation Council for Continuous
\nMedical Education) \u00ab package \u00bb
\nfrom 9th April 2009 onwards
\nSince 2000 the UEMS is working on the
\nharmonisation of the Continuous Medi-
\ncal Education and Continuous Profes-
\nsional Education in the European area,
\nby creating the European Accreditation
\n161
\nRegional and NMA news
\nCouncil for Continuous Medical Edu-
\ncation (EACCME\u00ae
\n). From 2004 on the
\nEACCME\u00ae
\nhas signed an agreement
\nwith the American Medical Association
\nfor the mutual recognition of internation-
\nal events happening on both sides of the
\nAtlantic Ocean.
\nFirst the EACCME\u00ae
\ntook into consider-
\nation for the accreditation only live events
\nbut obviously e-learning is becoming an
\nimportant tool for physicians to improve
\ntheir knowledge, skills and attitudes so it
\nwas decided by the UEMS Council to also
\nconsider e-learning material for accredita-
\ntion and this started on 6th April 2009.
\nThe introduction of long distance learning
\nwas also an opportunity for the UEMS to
\nimprove the quality criteria for the evalu-
\nation of the e-learning activities and those
\ncriteria, being very strict and of high stan-
\ndards, will in the future be retrofitted to live
\nevents.
\nThe document UEMS 2008.20 (Revised)
\npresents the criteria that have to be ful-
\nfilled for e-learning material before being
\napproved and granted for credits by the
\nUEMS-EACCME\u00ae
\n.
\nAnother important improvement in the
\nUEMS-EACCME\u00ae
\nprocess was the change
\nin provider who is taking care of the web-
\nbased application form. In January 2008
\nthe UEMS decided to introduce a web-
\nbased application form as the numbers of
\nevents applying for UEMS-EACCME\u00ae
\nac-
\ncreditation were increasing and the manual
\nprocessing became too demanding for the
\nUEMS Brussels Office Staff.
\nFrom the start the intention was to have a
\nfully efficient system including the evalua-
\ntion by the experts of both UEMS Sections
\nas the National Accreditation Authorities
\nand also to increase and improve the com-
\nmunication between the different partners
\nin the process,the applicant,the experts and
\nthe UEMS-EACCME\u00ae
\n.
\nAs with all new systems that are intro-
\nduced, we experienced some problems at
\nthe start but unfortunately, it seemed that
\nthey were not appropriately solved and
\nmany complaints remained so that we had
\nto change the webmaster and since Janu-
\nary 2010 the system works extremely well
\nand there are nearly no complaints any
\nmore concerning the processing of the
\napplications.
\nThe actual webmaster is providing an
\nexcellent service to UEMS-EACCME\u00ae
\nand things are going softly and efficiently
\nnow.
\nThis can be measured as since the introduc-
\ntion of the new webmaster, the number of
\napplications is increasing quite strongly but
\nglobally, the quality of the events remains
\noutstanding in a large proportion.
\nAlso the number of agreements between
\nthe UEMS Sections and Boards and the
\nMJC\u2019s as well as the National Accredi-
\ntation Authorities is increasing steadily
\nand moreover, contacts have been under-
\ntaken with other areas of the world such
\nas Canada, Australia and the Middle
\nEast to reinforce the position of EAC-
\nCME\u00ae
\nand the accreditation issue all
\nover the world.
\nThe agreement between the UEMS-EAC-
\nCME\u00ae
\nand the American Medical Asso-
\nciation on the mutual recognition of credits
\nwas first issued in 2002 as a pilot and since
\n2006 it was a real agreement.
\nNow in July 2010, the agreement has been
\nrenewed as both parties reviewed the pro-
\ncess and decided to include also e-learning
\nmaterial being an important tool nowa-
\ndays.
\nWe do not have to forget that especially
\nwith the introduction of the e-learning ma-
\nterial, borders are vanishing and the whole
\nissue of CME-CPD is getting more and
\nmore global and worldwide.
\nThe launch of a new structure:
\nthe European Accreditation
\nCouncil for Medical Specialist
\nQualficiation (EACMSQ)
\nBoth the \u201cCharter on Specialist Training\u201d
\nand the \u201cCharter on Quality Assurance of
\nSpecialist Practice in the EU\u201d stresses the
\nimportance of assessing the training at one
\nlevel or another.Obviously,the Policy State-
\nment on Assessments during Postgraduate
\nMedical Training crystallises the thinking
\nof the UEMS Council in this respect. Ev-
\nerything starts with the definition of clear
\nand harmonised training programmes and
\ncurricula so that candidates have a strong
\nbase to build their education upon.
\nThis work has been done by our different
\nUEMS Sections and Boards as well as the
\nMJC\u2019s and is continuously updated. Many
\nSections are also participating in the UEMS
\nCouncil for European Specialist Medical
\nAssessment (CESMA) project. CESMA
\nstarted in February 2007 at a meeting or-
\nganised by the Section of Paediatric Sur-
\ngery in Glasgow and has gained momen-
\ntum steadily since with more Sections and
\nBoards becoming involved.
\nIn 2009, at the April Council meeting, a
\nfirst presentation of the ECAMSQ was
\ngiven by the UEMS President, and this can
\nbe seen as the first step in the starting up
\nof this very important initiative. The aim is
\nto combine the UEMS-CESMA project
\nand the Working Group for Post Graduate
\nTraining of the UEMS Council and create a
\nstructure, similar to EACCME\u00ae
\nfor CME-
\nCPD involving all the important stakehold-
\ners in the field of PGT in Europe.
\nSimilarly to the EACCME\u00ae
\n, the partners
\ninvolved here are the UEMS Sections and
\nBoards and the MJC\u2019s as well as the Na-
\ntional Licencing Authorities.
\nThe Council decided in it meeting of Is-
\ntanbul in October 2009 to establish the
\nECAMSQ, with the ECAMSQ becoming
\n162
\nRegional and NMA news
\noperational in 2010 (starting with a pilot
\nproject lasting for two years and involving
\nthree specialties, Anaesthesiology, Cardiol-
\nogy as well as Radiology).
\nOrzone and UEMS share the vision of
\nimproving healthcare quality through the
\nharmonisation of training and education
\nin Europe. For this purpose a collaboration
\nhas been established for developing a com-
\nprehensive electronic platform to support
\nmedical training, assessment and continu-
\nous professional development. The strategic
\ndirection for the establishment and the pri-
\nmary focus of this initiative is to extensively
\nimprove the education and training of Eu-
\nropean medical doctors, improving medical
\noutcome and patient safety.
\nAs an organisation, the UEMS promotes
\nthe best possible standards of harmonised
\nspecialist training, continuing medical edu-
\ncation (CME) and professional develop-
\nment (CPD), as well as quality assurance of
\nspecialist medical practice.
\nBy doing so, the UEMS is committed and
\nserves to encourage decision-makers as well
\nas healthcare professionals to ensure appro-
\npriate mechanisms for safe specialist medi-
\ncal care across Europe and this for each Eu-
\nropean citizen.
\nAs this topic clearly involves Trainees in
\nthe different specialties, the Permanent
\nWorking Group for Trainees (PWG) will
\nhave a delegate in the EACMSQ. It is ob-
\nvious, that in order to have free movement
\nof Specialists in the European Union and
\nthe Specialties to be recognized throughout
\nthe Member States, the training curriculum
\nand content should be very similar every-
\nwhere in Europe and an Assessment would
\nconfirm the ability of a Specialist to work
\nin similar conditions within the European
\nregion.
\nECAMSQ will be a structure that will help
\nin this harmonisation process easing access
\nto all EU specialists to all kinds of equiva-
\nlent positions all over Europe. Obviously, as
\nin EACCME\u00ae
\nit is fundamental to involve
\nstrongly the National Training & Licensing
\nAuthorities of the different Member States
\nin the process in order to guarantee the val-
\nue of the end product.
\nIt is clear that the ECAMSQ has to receive
\nits mandate from the national licencing au-
\nthorities.
\nThougths on the revision of the
\nDirective on the Recognition
\nof Qualifications (Dir 2005\/36
\nEC and 2006\/100 EC)
\nThe Directive on the Recognition of Quali-
\nfications was updated in 2006 with the ad-
\nmission of Bulgaria and Romania as Mem-
\nber States of the European Union but there
\nwere no major amendments introduced at
\nthat time.
\nAs the Directive will be revised in 2012,
\nwe have to think on issues that are im-
\nportant and that could be introduced or
\nmodified. First of all, the denomination
\nof the Specialties have to be looked at and
\nfor instance the name of one Specialty,
\n\u201cPhysical and Rehabilitation Medicine\u201d
\nhas to be corrected as it is now cited as
\n\u201cPhysiotherapy\u201d. Secondly, the minimal
\nlength of training of the different special-
\nties has to be updated as for instance for
\nAnaesthesiology, the Directive only con-
\nsiders a minimal Training Time of 3 years
\nalthough the profession globally advocates
\na training of at least 5 years. In this respect
\nit should be also good to consider includ-
\ning not only length of training but also
\nthe required competences as identified by
\nthe Core Curriculum as proposed by the
\ndifferent UEMS Sections and Boards as
\nwell as the MJC\u2019s (the so-called Chapter
\n6 of the UEMS Charter on Post Graduate
\nTraining).
\nA crucial concept that could be introduced
\nand would help a lot in the recognition of
\nspecial fields of activities in medicine is the
\nconcept of so-called \u201cParticular Qualifica-
\ntion\u201d.
\nNowadays, the actual Directive only recog-
\nnises Basic Specialties but activities such as
\nIntensive Care Medicine and Oncology are
\nleft aside and ignored.
\nIt will be a major task of the UEMS to
\nconvince the European Parliament, the
\nEuropean Commission and the National
\nAuthorities of the different EU Member
\nStates,that the introduction of these Partic-
\nular Qualifications are an important issue to
\nhelp many of our Colleagues active in some
\nfields of Medicine to be recognised all over
\nEurope and by having this, help to enhance
\nthe healthcare of the European Citizen.
\nLikewise the actual version of the Directive,
\nthere will be a list in the Addendum listing
\nthe different Particular Competences that
\nwould be recognized also presenting the
\ncountries where they are already existing.
\nConclusion
\nAs reflected in this article, the UEMS is
\nvery active in many different fields concern-
\ning Specialised Medicine and there are still
\na lot of important challenges that remain to
\nbe realised. One of those being the whole
\nissue of e-Health that will increasingly in-
\nfluence our practice through telemedicine,
\ne-prescription or electronic patient record
\nfor instance.
\nThe mobilisation of all the actively involved
\nmembers of the UEMS in the different
\nbodies, the delegates from the National
\nMedical Associations, the delegates of the
\nUEMS Sections and Boards as well as the
\nMJC\u2019s as well as the participants in both
\nthe EACCME\u00ae
\nand the ECAMSQ will
\nbe needed to achieve those important goals
\nthat have been set up in the Strategy Docu-
\nment of the UEMS that lies at the basis of
\nall those initiatives.
\nDr. Bernard Maillet,
\nSecretary General UEMS
\n163
\nRegional and NMA news
\nTSE Hung Hing
\nOur Purpose
\nFounded in 1920, the Hong Kong Medi-
\ncal Association brings together all medical
\npractitioners practising in, and serving the
\npeople of, Hong Kong. Its objective is to
\npromote the welfare of the medical profes-
\nsion and the health of the public. With the
\ncurrent membership of over 8000 from all
\nsectors of medical practice, it speaks col-
\nlectively for its members and aims to keep
\nits members abreast of medical ethics and
\nissues around the world.
\nOur Role
\nThe Association is the official representative
\nbody of the local medical profession. It
\nrepresents the medical profession in local
\ngovernmental and professional bodies, as
\nwell as regional and international medical
\norganisations. Post-1997, the relationship
\nbetweentheAssociationanditscounterparts
\nin Mainland China has become closer. Into
\nthe new Millennium, its representative role
\nhas been further enhanced with the staunch
\nsupport of its membership and strong
\naffiliation to organisations with laudable
\nmissions and objectives.
\nOur Structure
\nThe Association is now directed by a Coun-
\ncil of 25 members elected from the mem-
\nbership at the Annual General Meeting.
\nThe Council is advised and assisted by a
\nnumber of standing and ad hoc committees
\nin its deliberation and formulation of poli-
\ncies. As a non-governmental and non-profit
\norganisation, the Hong Kong Medical As-
\nsociation runs numerous programs, profes-
\nsional or community alike, with volunteers
\nand resources mainly from its own mem-
\nbership.
\nOur Home
\nThe Association\u2019s headquarter is in
\nWanchai since 1975. In view of increasing
\nmembership and activities, the Association
\nestablished an education centre in the city
\ncentre in 2002.
\nOur Programmes
\nConsensus Building
\nThe Association holds discussion forums on
\npublic health policies, on health care fund-
\ning policies, on professional code and con-
\nduct, on all issues concerning public health
\nand safety as well as the professional prac-
\ntice. Discussion forums facilitate person-
\nto-person exchange of views. Such discus-
\nsions are also held on the Internet, via the
\nHKMA News and direct communication
\nwith council members and representatives
\nin various government and non-govern-
\nmental boards and councils. The collective
\nviews are reflected to the authorities via the
\nAssociation.
\nContinuous Medical Education
\nThe Association runs regular CME activi-
\nties in form of lectures, seminars, sympo-
\nsia, workshops, discussion group, clinical
\nattachments in hospital, etc. to provide
\nopportunities for continuous medical edu-
\ncation. The Association also set up a struc-
\ntured and systematic programme for the
\nrecording and accreditation of members\u2019
\nefforts in CME.
\nSince 2002, an online CME program has
\nbeen set up on www.hkmacme.org and
\nmembers can login to do CME online.
\nMembership Development
\nThe Duty Council Member Scheme helps
\nsolve problems encountered by members in
\ntheir daily practice.The Young Doctors Pro-
\ngramme serves the new graduates by hold-
\ning career talks, tracking the career paths,
\nmonitoring the employment opportunities
\nin the public sector and facilitating place-
\nments in the private sector.The District Or-
\nganisation links and brings closer doctors
\npracticing in outlying districts. We have
\nnow developed 8 community networks,
\nwhich are vested with the role of developing
\ndistrict programmes of continuing medical
\neducation, private-public cooperation and
\npublic medical education.
\nSpecial Interests Groups
\nMembers with similar interests are grouped
\ntogether to promote a good cause while
\nsharing their common interests. The
\nHKMA Choir and the HKMA Orchestra
\npresent concerts to raise funds for charity.
\nThe Hikers challenge the MacLehose Trail
\nof 100 km within 48 hours to raise funds
\nfor Oxfam.The Sportsmen compete at vari-
\nous sports tournaments organised by the
\nAssociation to promote sportsmanship and
\nfraternity. The Dragon Boat Teams culture
\nteam spirit while testing their physique and
\nmind to the extreme at the races.
\nSocial Functions
\nThe Association organises regular hiking,
\noutings, visits and annual dinner to foster
\nThe Hong Kong Medical Association
\n164
\nRegional and NMA news
\nfriendly relationship amongst members and
\ntheir families and friends.
\nCommunity Projects
\nFor the past fifteen years, the Association
\nmaintains the only territory-wide Organ
\nDonation Register, which not only records
\nthe wishes of willing donors but also serves
\nas an indicator of the awareness and accep-
\ntance of organ donation after death. Aware-
\nness promotion programmes are conducted
\nfrom time to time in conjunction with
\nthe Department of Health, the Hospital
\nAuthority. In December 2008, with our
\ncooperation, the HKSAR Government
\nset up a Centralised Organ Donation
\nRegister. Data stored in the HKMA Organ
\nDonation Register migrated gradually to
\nthe centralised system.
\nIn conjunction with various government
\nand non-governmental health-conscious
\norganisations, the Association is also pro-
\nmoting healthy life styles such as quit
\nsmoking, healthy eating and \u201cSay No to
\nDrugs\u201d to the younger generation via the
\none-school one-doctor scheme.
\nThe Association is working in collaboration
\nwith public-spirited organisations in
\npromoting the use of serving chopsticks &
\nspoons, and regular daily physical activities
\nsuch as walking 8000 steps a day to the
\ngeneral public.
\nHotlines & Directory
\nSponsored by Pacific Century CyberWorks
\nLtd., the Association runs the MediLink
\nHotline 90000-222-322 for the public to
\nsearch for medical clinics, which are open
\nduring long holidays. A directory of doctors
\nis put on the Internet for public information
\nat www.hkdoctors.org to facilitate referral
\nof patients between the public and private
\nsectors. A hotline for report of illegal sales
\nof drugs is run at Tel No. 2528 6644.
\nThe HKMA Charitable Foundation
\nSince 1990,the Association has been raising
\nfunds for various charitable organisations
\nthrough public performance of its Orchestra
\nand Choir. The unreserved support of its
\nmembership and friends of the medical
\nprofession has endeavored to alleviate
\nthe sufferings of the sick, the poor and
\nthe underprivileged. For the Association
\nto work more closely with its supporters
\nin community and charity projects,
\nthe Hong Kong Medical Association
\nCharitable Foundation was formed in
\n2006 to consolidate and manage all efforts
\nwith a view to better recognition of the
\ncontribution of the supporters. Public-
\nspirited individuals and corporations are
\nwelcome to join the Foundation. Together
\nwe make the world, in particular the Hong
\nKong Special Administrative Region, a
\nhealthier and happier place to live.
\nOur Pledge
\nThe patient\u2019s well-being is in the heart of
\nour members whose welfare is in the heart
\nof the Hong Kong Medical Association.We
\npledge to serve both the community and the
\ndoctors. Together, we speak with one heart
\nand in one voice to safeguard the health of
\nthe people of Hong Kong.
\nDr. TSE Hung Hing, Immediate
\nPast President of the Hong
\nKong Medical Association
\nThe HKMA Council 2009\u20132010
\n165
\nRegional and NMA news
\nDomen Podnar
\n\u201cThe health policy framework must be designed
\nto ensure that each patient receives quality care.
\nIt must be about the individual and not about
\npower. Likewise, it must be about the patient
\nand not about politics,\u201d said Professor Dr.
\nJ\u00f6rg-Dietrich Hoppe, President of the Ger-
\nman Medical Association at the opening of
\nthe German Medical Assembly.
\nA total of 250 delegates from the 17 Ger-
\nman State Chambers of Physicians met to
\ndiscuss health, social and medical profes-
\nsional policy issues at the 113th
\nGerman
\nMedical Assembly in Dresden on 11th
\nto
\n14th
\nMay, 2010.
\nThe German Medical Assembly is the
\n\u201cParliament of the Medical Profession\u201d
\nin Germany. This annual general assem-
\nbly of the German Medical Association
\n(Bundes\u00e4rztekammer) is held at different
\nvenues each year. The location is selected
\nfrom proposals by the individual state
\nchambers of physicians. Each state cham-
\nber of physicians (SCP) receives two seats
\nas their Basic Representation at the assem-
\nbly. The remaining 216 seats are distributed
\namong the individual state medical associa-
\ntions in proportion to the number of mem-
\nbers in the SCP according to the d\u2019Hondt
\nsystem. The German Medical Assembly,
\ninitially founded as the Annual Meeting
\nof the Deutscher \u00c4rztevereinsbund, has been
\nheld annually since 1873 except in years
\nwhen it was forced to break during World
\nWars I and II and the Nazi regime. It con-
\nvened for the 113th time in the historic city
\nof Dresden. Prof. Dr. J\u00f6rg-Dietrich Hoppe,
\nPresident of the German Medical Associa-
\ntion (GMA), has served as President and
\nChairman of the German Medical Assem-
\nbly since 1999.
\n\u201cThe future challenges are enormous, and the
\nphysicians want to help tackle them,\u201d said
\nHoppe in his opening address. That is why
\nthe German Medical Assembly focuses on
\ndifferent core themes each year. This year\u2019s
\ncore themes were
\nHealth Care Provision Research,\u2022
\nRegulation on Post-graduate Medical\u2022
\nEducation and
\nRights of Patients \u2013 Duties of the State\u2022
\nand Society.
\nHealth care provision research is a top pri-
\nority of the German Medical Association
\n(GMA). Therefore, the GMA launched a
\nfunding initiative to promote research into
\nroutine health care provision to individual
\npatients and the patient populations in hos-
\npitals, medical practices and other health
\ncare facilities in 2005. The goal of the ini-
\ntiative is to develop concepts for better pa-
\ntient care, to produce reliable statistics on
\nthe shortage of physicians, and to provide
\ninformation on the work situation of physi-
\ncians, among other things. The GMA has
\nprovided a total of \u20ac750,000 in funding for
\nvarious projects relating to health care sup-
\nply research each year since 2005.The fund-
\ning initiative covers a period of six years.The
\ndelegates voted to extend support for the
\nGerman Medical Association\u2019s initiative.
\nA conceptual draft of the follow-up initia-
\ntive is to be elaborated by the next German
\nMedical Assembly meeting.
\nThe new (Model) Regulation on Post-grad-
\nuate Medical Education was also on the
\nagenda. In Germany, post-graduate medical
\neducation falls under the jurisdiction of the
\n17 state chambers of physicians (SCP). The
\nModel Regulation on Post-graduate Medi-
\ncal Education is a proposal submitted to the
\nstate chambers of physicians to ensure a cer-
\ntain degree of harmonisation, and the SCPs
\nare not bound to accept it. The state cham-
\nbers of physicians and professional groups
\nwere involved in the drafting of the proposed
\nRegulation on Post-graduate Medical Edu-
\ncation to ensure that it was up-to-date.Eval-
\nuation of post-graduate medical education
\nwas another topic of discussion in Dresden.
\nPost-graduate education teachers and stu-
\ndents were asked about their experiences in a
\nsurvey conducted according to a Swiss mod-
\nel. The German Medical Association hopes
\nthat these efforts will help to achieve higher
\nquality continuing medical education.
\n\u201cHealth care provision structures should focus
\nprimarily on the medical needs of the patient.
\nThey should not be dominated by cost reduc-
\ntion targets,\u201d demanded Dr. Frank-Ulrich
\nMontgomery, Vice-President of the Ger-
\nman Medical Association in his speech on
\nthe core theme \u201cPatient Rights\u201d. The Ger-
\nman Medical Assembly is in favor of codi-
\nfying the rights of patients in Germany, but
\ndoes not consider a new law to be necessary.
\nStandards on patient rights in Germany
\nhave already been developed in a number
\nof laws, professional codes for physicians,
\nand many years of case law. Furthermore,
\nthe German Medical Assembly ascer-
\ntained that a growing \u201cEuropeanisation\u201d
\nof patient\u2019s rights issues was unmistakable.
\nThe proposed new regulations on patients\u2019
\nrights in cross-border health care provision,
\npatient information in the pharmaceutical
\nsector, and organ transplantation are a case
\nin point.
\nHelping to Meet the Challenges of the Future
\n113th
\nGerman Medical Assembly in Dresden
\n166
\nRegional and NMA news
\nIn further resolutions, the German Medi-
\ncal Assembly called for the government to
\nintroduce anonymous health insurance for
\nforeigners without residence permit status
\nand to systematically implement the UN
\nConvention on the Rights of Persons with
\nDisabilities, among other things.
\nThe German Medical Assembly engaged
\nin an intensive discussion of the challenges
\nthat doctors face in their professional lives
\ndue to politics.
\nThe 250 delegates as well as 80 international
\nguests from 27 countries followed the dis-
\ncussions. In addition to the World Medi-
\ncal Association leadership, the presidents
\nor representatives of many national medical
\nassociations were present in Dresden.
\nSeveral resolutions were adopted to guide
\nthe direction of policy-making in the next
\nyears, particularly that of the German Med-
\nical Association.
\nThe Board of the GMA will take this man-
\ndate and will present the results at the 114th
\nGerman Medical Assembly in the north
\nGerman city of Kiel.The next president and
\nthe two vice-presidents of the GMA will
\nbe elected for a period of four years at that
\ntime.
\nDomen Podnar, German Medical
\nAssociation, International Department
\nVallo Volke
\nThe Estonians are really keen on new tech-
\nnologies. In Estonia it is a common prac-
\ntice to cast your vote in parliament elections
\nvia the internet, make your tax declaration
\nin the internet or park your car by using
\na mobile phone. Thus, it is not surprising
\nthat many e-health projects have also been
\nestablished in Estonia. Small population
\n(1.34 million) makes the country a perfect
\nplace to test new innovative ideas.
\nHowever,not all of the projects have been that
\nsuccessful.Atthebeginningof2010auniversal
\nelectronic prescription system was launched.
\nThe goal was to collect all prescriptions in a
\ncentral database, so that to make all currently
\nor previously active prescriptions of the patient
\neasily accessible to doctors and pharmacists.
\nDespite the fact that the new system has suf-
\nfered from frequent technical problems and
\nhas not yet gained the planned dominance, it
\nis time to share the experience of doctors after
\nusing the system for half a year.
\nStrong points of the new system
\nThe central database gives a clear and quick
\noverview of the drugs used by the patient.
\nThus, unnecessary or potentially dangerous
\ndrugs or drug combinations can be easily
\nidentified and stopped. As currently only
\nabout 50% of prescriptions are made elec-
\ntronically, the full advantage for the patients
\nis yet to be seen.
\nThe majority of drugs are used chronically
\nby patients.The electronic system makes the
\nrenewal of the prescription a one click pro-
\ncedure for the doctor.
\nOccasionally, it may be very useful to have
\na possibility to make prescription while the
\npatient is not present in your office.Howev-
\ner, there is also a risk that some doctors may
\nabuse the possibility and prescribe without
\nseeing the patient.
\nProblems and limitations
\nWhen relying on a universal electronic sys-
\ntem, the technical functioning of the system
\nmust be guaranteed. Unfortunately, the Es-
\ntonian system has had major blackouts dur-
\ning the so-called rush-hours;
\nFrom the patient point of view, not having a
\npaper prescription makes it harder to recall
\nwhen the renewal of prescription is needed;
\nProtecting patient confidentiality is always
\nan issue with electronic systems;
\nWith older patients it is common that
\nsomeone else buys the drugs prescribed. In
\nsuch a situation the traditional prescription
\nis actually more reliable. To make a pur-
\nchase for someone else by using electronic
\nprescription in Estonia you have to present
\nyour ID card and you need to know the so-
\ncial security code of the patient. I am not
\ncompletely convinced that it is a safe and
\nreliable practice.
\nWhat went wrong with the project?
\nThe electronic prescription system project
\nwas led by the Estonian Health Insurance
\nFund and it is part of a bigger e-health ini-
\ntiative in the Estonian healthcare. The vast
\nLessons Learned from the Estonian
\nElectronic Prescription System
\n167
\nRegional and NMA news
\nmajority of the problems seem to derive
\nfrom inadequate involvement of key part-
\nners, namely doctors and pharmacists. The
\nimportance of the involvement of doctors in
\nevery step of the project development could
\nnot be overestimated.
\nAll in all — how satisfied are Estonian doc-
\ntors with the electronic prescription sys-
\ntem?
\nWell, the current 50% prescription rate via
\ne-system is pretty much the answer. Hope-
\nfully, the technical problems will be solved
\nand the full potential of the system will be
\nseen soon.
\nUseful links: Estonian Health Insurance
\nFund (www.haigekassa.ee)
\nVallo Volke, MD, PhD, Estonian
\nMedical Association
\nIn most low- and middle-income countries, there is a critical
\nshortage of skilled eye care personnel – including ophthalmolo-
\ngists, optometrists, ophthalmic nurses and others – and a desper-
\nate need to build human resource capacity. The Community Eye
\nHealth Journal is a free publication which helps to address this
\nneed by providing up-to-date and practical eye care information
\nto eye care personnel underserved cities, towns, villages and rural
\nareas across the developing world and have little or no access to
\nrefresher training, libraries or the internet.
\nThe journal is published by the International Centre for Eye
\nHealth, London School of Hygiene and Tropical Medicine, UK,
\nand paper copies are sent free to readers in low- and middle-
\nincome countries; it is also available on CD-Rom and online
\nat www.cehjournal.org. As of June 2010, each issue contains a
\ncontinued professional development (CPD component), consist-
\ning of multiple-choice questions readers can use to test their un-
\nderstanding of the articles. These questions are written for us by
\nthe International Council of Ophthalmology in the style of their
\nAdvanced Examination and are relevant to the widest possible
\nrange of readers.
\nAt present, we have editions in five languages (English, French,
\nPortuguese, Spanish and Chinese) and reach a total of 26,000
\nreaders in 184 countries across Africa, Asia and Latin America.
\nFrom our readership survey, we know that 94% of readers find
\nthe journal \u2018useful\u2019 or \u2018very useful\u2019 and that it has influenced the
\npractice of 71% of readers.
\nHow you can help: We know that many eye care workers do not
\nyet know about this free resource. If you have ideas on how to
\nreach them, would like to subscribe, or even wish to donate to
\nsupport the journal, please visit www.cehjournal.org or write to
\nAnita Shah, admin@cehjournal.org, International Centre for Eye
\nHealth, London School of Hygiene and Tropical Medicine, Kep-
\npel Street, London WC1E 7HT, United Kingdom.
\nWe are on Facebook (search for \u2018Community Eye Health Jour-
\nnal\u2019) and on Twitter (www.twitter.com\/cehjournal) and welcome
\nyour input and feedback.
\nBringing eye care information to those who need it most
\n168
\nWMA news
\nEditorial ………………………………………………………………………..127
\n185th
\nWMA Council meeting in Evian,
\nFrance 20th
\n\u201322nd
\nMay 2010……………………………………………….128
\nWorld Medical Association Appeals for
\nRelease of Sudanese Doctors…………………………………………….137
\nHighlights of the Third Geneva Conference on
\nPerson-centred Medicine………………………………………………….138
\nHuman Resources for Rural Health…………………………………..142
\nBMA Presidency Acceptance Speech:
\nFighting the Alligators of Health Inequalities……………………..144
\nRecent Progress in Air Pollution and Health Studies ………….147
\nVolcanic Eruptions \u2013 Health Implications ………………………….148
\n1st
\nInternational Summit on Tobacco Control
\nin Asia and Oceania Region……………………………………………..149
\nIFMSA and 1.2 million Worldwide Medical Students
\nFighting Against the HARMFUL USE OF ALCOHOL ….152
\nDeveloping Healthcare Technologies for Emerging Markets \u2013
\nImproving Quality, Access and Cost ………………………………….154
\nNews from the CPME:
\nBoard meeting in Brussels on 22nd
\nJune ……………………………..157
\nThe Training, Qualification and Continuous Professional
\nDevelopment of the Medical Specialist in the Future,
\na Challenge for the UEMS ………………………………………………159
\nThe Hong Kong Medical Association ………………………………..163
\nHelping to Meet the Challenges of the Future ……………………165
\nLessons Learned from the
\nEstonian Electronic Prescription System ……………………………166
\nBringing eye care information to those who need it most ……..167
\nContents
\n113th
\nGerman Medical Assembly in Dresden<\/p>\n"},"caption":{"rendered":"

wmj28 vol. 56 MedicalWorld Journal Official Journal of the World Medical Association, Inc G20438 Nr. 4, August 2010 Human Resources for Rural Health\u2022 Developing Healthcare Technologies for Emerging\u2022 Markets \u2013 Improving Quality, Access and Cost Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 661 peteris@nma.lv […]<\/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\/wmj28.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3602"}],"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=3602"}]}}