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wmj36<\/a><\/p>\n

COUNTRY
\n\u2022 WMA General Assembly, Montevideo
\n\u2022 The World Conference on the Social Determinants
\nof\u00a0Health
\nvol. 57
\nMedicalWorld
\nJournalJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 6, December 2011
\nCover picture from Thailand
\nEditor in Chief
\nDr. P\u0113teris Apinis
\nLatvian Medical Association
\nSkolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.lv
\neditorin-chief@wma.net
\nCo-Editor
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSuffolk IP143QT, UK
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor Velta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by P\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher \u201cMedic\u012bnas
\napg\u0101ds\u201d, President Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nCover painting:
\nThe third Lofting, 2002, Watercolour,
\n46\u00a0x\u00a062\u00a0cm
\nPublisher
\nThe World Medical Association, Inc. BP 63
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\nPublishing House
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\nDeutscher-\u00c4rzte Verlag GmbH,
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\nor associate payment. Details of Associate
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\nMedical Association website
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\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nCologne, Germany
\nISSN: 0049-8122
\nDr. Jos\u00e9 Luiz
\nGOMES DO AMARAL
\nWMA President
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nRua Sao Carlos do Pinhal 324
\nBela Vista, CEP 01333-903
\nSao Paulo, SP Brazil
\nDr. Leonid EIDELMAN
\nWMA Chairperson of the Finance
\nand Planning Committee
\nIsrael Medical Asociation
\n2 Twin Towers, 35 Jabotinsky St.
\nP.O.Box 3566, Ramat-Gan 52136
\nIsrael
\nDr. Masami ISHII
\nWMA Vice-Chairman of Council
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Wonchat SUBHACHATURAS
\nWMA Immediate Past-President
\nThai Health Professional Alliance
\nAgainst Tobacco (THPAAT)
\nRoyal Golden Jubilee, 2 Soi
\nSoonvijai, New Petchburi Rd.
\nBangkok,Thailand
\nSir Michael MARMOT
\nWMA Chairperson of the Socio-
\nMedical-Affairs Committee
\nBritish Medical Association
\nBMA House,Tavistock Square
\nLondon WC1H 9JP
\nUnited Kingdom
\nDr. Guy DUMONT
\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
\n1380 Lasne
\nBelgium
\nDr. Cecil B. WILSON
\nWMA President-Elect
\nAmerican Medical Association
\n515 North State Street
\n60654 Chicago, Illinois
\nUnited States
\nDr.Torunn JANBU
\nWMA Chairperson of the Medical
\nEthics Committee
\nNorwegian Medical Association
\nP.O. Box 1152 sentrum
\n0107 Oslo
\nNorway
\nDr.Frank Ulrich MONTGOMERY
\nWMA Treasurer
\nHerbert-Lewin-Platz 1
\n(Wegelystrasse)
\n10623 Berlin
\nGermany
\nDr. Mukesh HAIKERWAL
\nWMA Chairperson of Council
\n58 Victoria Street
\nWilliamstown, VIC 3016
\nAustralia
\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
\n201
\nWMA newsUNITED STATES
\nAs the year is coming to a close, it is time to look back at the
\nachievements and outline new tasks and new directions.The World
\nMedical Journal wishes to thank all the authors and readers for the
\nsuccessful co-operation.
\nFirst of all, I want to thank the President of the WMA, Dr. Won-
\nchat Subhachaturas, for the support and interest in the journal.The
\nPresident made trips to all the continents, visited the medical as-
\nsociations and congresses of many countries and participated in im-
\nportant meetings, as well as found time to write articles and show
\ninterest in the journal. Many thanks to the WMA Council which
\nprovided themes for the articles; this year, Council worked harder
\nthan ever, it could be best seen in Sydney when the Australian gov-
\nernment aligned its anti-smoking activities with the work of the
\nWMA Council and Dr. Mukesh Haikerwal became the Chair of
\nCouncil.
\nThanks to Dr.Otmar Kloiber for his tireless support for creating the
\njournal and forming its trend of development. In 2011, the World
\nMedical Journal was and, in 2012, it will be the main mouthpiece
\nof the World Medical Association\u2019s ideas that publishes the docu-
\nments, declarations and statements of our organisation. Today, the
\nGeneral Assemblies of the World Medical Association and the Ex-
\necutive Committee meetings are so versatile and highly topical that
\nat least two of the six annual issues of the journal are filled with
\nWMA information. Thanks for this to Nigel Duncan, who docu-
\nments everything precisely. Of course, the entire WMJ effectiveness
\ncomes from the successful work of the staff, from which this time I
\nwish to mark out Joelle Balfe; parallel with her own work,she edited
\nmany articles for the journal.
\nI wish to touch upon one, in my opinion, very significant turn of
\nevents. With Professor Sir Michael Marmot joining the WMA
\nCouncil, the WMA has turned its face to the WHO activities, even
\nmore so \u2013 the WMA stands at the head of the WHO ideas, espe-
\ncially regarding issues relating to socially determined medicine.
\nAnd many thanks to my teachers and friends \u2013 co-editors Alan
\nJ.\u00a0Rowe and Elmar Doppelfeld, who perused the journal by cor-
\nrespondence this year, gave good advice and moral support. Let me
\nwish you good health, ALAN, so that we could meet face to face at
\nmeetings next year!
\nDr. P\u0113teris Apinis,
\nEditor-in-Chief of the World Medical Journal
\nEditorial
\n202
\nWMA news
\nDelegates from almost 50 national medical
\nassociations met in Montevideo, Uruguay
\nfor the 62nd
\nannual General Assembly of
\nthe World Medical Association from 12 to
\n15 October. The meeting, which coincided
\nwith celebrations for the 200th
\nanniversary
\nof Uruguay\u2019s independence, was held in
\nthe Grand Ballroom of the Radisson Plaza
\nHotel, the venue of the last WMA meeting
\nheld in Montevideo in 1998.
\nDr.Mukesh Haikerwal,Chair of the WMA,
\nopened the proceedings on Wednesday with
\nthe 189th
\nCouncil session.
\nThe President, Dr.Wonchat Subhachaturas,
\nreported on his visits during the year to 19
\nmedical associations and forums in every
\ncontinent except Africa.
\nThe Secretary General, Dr. Otmar Kloiber,
\nin his report, said the issue of non com-
\nmunicable diseases had been an important
\nrecent issue for the WMA. But it had been
\nan uphill task, both in ensuring the WMA\u2019s
\nattendance at the recent United Nations
\nmeeting in New York and in arguing for a
\nmore horizontal approach to the diseases
\nincluded, beyond the four favoured by the
\nWorld Health Organisation \u2013 cardiovascu-
\nlar and lung diseases, cancer and diabetes.
\nIn the end the WMA achieved its aims and
\nwas quite happy with the final results of the
\nmeeting, although it would still have liked a
\nstronger policy.
\nOn another subject, Dr. Kloiber spoke
\nabout the threat of attack which physicians
\nwere facing in various parts of the world,es-
\npecially in Bahrain, where a number of phy-
\nsicians and other health professionals had
\nbeen tried in a para military court and were
\nfacing lengthy prison sentences. This was a
\nconcern which the meeting would want to
\ndiscuss.
\nSOCIO-MEDICAL
\nAFFAIRS COMMITTEE
\nThe Socio-Medical Affairs Committee
\nconvened under the chairmanship of Sir
\nMichael Marmot (UK).
\nArmed Conflicts
\nTwo papers relating to armed conflicts
\nwere considered. The committee agreed
\nthat against the background of alarming at-
\ntacks on health professionals worldwide the
\nfirst paper, a Statement on Protection and
\nIntegrity of Medical Personnel in Armed
\nConflicts, should be sent to the Assembly
\nfor adoption. The second paper, the WMA
\nRegulations in Times of Armed Conflict,
\nwas mainly about physicians\u2019 duties and
\nconduct during an armed conflict. It was
\nagreed to circulate this to NMAs for com-
\nment.
\nViolence in the Health Sector
\nThe committee considered a proposed
\nStatement on Violence in the Health Sec-
\ntor, put forward by the Israel Medical As-
\nsociation. This suggested a zero-tolerance
\nattitude to threats and acts of violence in the
\nhealth sector, including the right to refuse
\nto treat violent offenders, except in emer-
\ngency situations.
\nDr. Yoram Blachar (Israel) said there was a
\ngrowing problem of violence against health
\npersonnel and it was important NMAs
\nwere aware of this problem and worked to
\nreduce such occurrences. But Dr. Vivienne
\nNathanson (UK) said the paper did not re-
\nally deal with the patient who was violent
\nbecause of an illness, such as somebody
\nwith a serious mental health problem where
\nWMA General Assembly
\n12\u201315 October,Montevideo
\nWonchat Subhachaturas
\nDana Hanson
\nMukesh Haikerwal
\nOtmar Kloiber
\nJose Luiz
\nGomes do Amaral
\nFrank Ulrich
\nMontgomery Sir Michael Marmot
\nYoram Blachar
\nCecil B. Wilson
\nMasami Ishii
\n203
\nWMA news
\nviolence was a part of that and where phy-
\nsicians in psychiatry had to manage that.
\nDr. Heikki P\u00e4lve (Finland) said the same
\ntrend of violence was being experienced in
\nFinland. He said all attacks should be pub-
\nlicised and made known to the police and
\npossibly to the courts. The proposed State-
\nment should mention such a procedure.
\nAfter further suggested amendments, it was
\nagreed to refer the document to an ad hoc
\nworking group to report back to Council
\nlater in the meeting.
\nPain Relief
\nA proposed Resolution from the British
\nMedical Association on Access to Adequate
\nPain Treatment was discussed, setting out a
\nseries of proposals to improve patients\u2019 ac-
\ncess to pain treatment.
\nIt was agreed that the Resolution should be
\nforwarded to Council and the Assembly for
\nadoption.
\nTobacco-Derived Products
\n(Protect Children)
\nThe committee considered a proposed revi-
\nsion to the Statement on Health Hazards
\nof Tobacco and Tobacco-Derived Products
\nsuggested by the American Medical Asso-
\nciation, outlining measures to protect chil-
\ndren from tobacco. After discussion, it was
\namended to include advice to NMAs to re-
\nfuse to invest in companies or firms produc-
\ning or promoting the use or sale of tobacco.
\nIt was agreed to forward the document as
\namended to the Assembly for adoption.
\nEthical Implications of
\nPhysician Strikes
\nA proposed Statement on new guidelines
\nfor physicians about taking strike action
\nwas put forward by the Israel Medical As-
\nsociation.
\nDr. Blachar introduced the document, say-
\ning his Association had been involved in
\nseveral months of negotiations and indus-
\ntrial action. Strikes were becoming more
\ncommon and it was important that clear
\nethical guidelines were available. Dr. Peter
\nCarmel (USA) said the document would be
\nmet with huge controversy, as in each coun-
\ntry there were separate laws about physician
\nstrikes. It was agreed that the document
\nshould be circulated to NMAs for com-
\nment.
\nElectronic Cigarettes
\nThe American Medical Association intro-
\nduced a proposed Statement on Electronic
\nCigarettes calling for a ban on the manufac-
\nture and sale of e-cigarettes until they had
\nbeen fully researched, tested and regulated
\nas either a new form of a tobacco product or
\nas a drug delivery device.
\nIt was agreed that the document should be
\ncirculated to NMAs for comment.
\nLeprosy
\nThe committee received a proposal from
\nthe charity, the Nippon Foundation, for
\nthe WMA to support its Global Appeal
\non leprosy. The committee first consid-
\nered a proposed WMA Declaration on
\nLeprosy Control Around the World and
\nElimination of Discrimination Against
\nPersons Affected by Leprosy. The Dec-
\nlaration from the Brazilian Medical As-
\nsociation called on physicians to lead the
\nway in combating all forms of prejudice
\nand discrimination against people af-
\nfected by leprosy and members of their
\nfamilies.
\nIt was agreed that both the new WMA
\npolicy and the Global Appeal should beJ\u00f3n Sn\u00e6dal
\nRobert Ouellet
\nTorunn Janbu
\nXavier Deau
\nAjay Kumar
\nRoberto Luiz d\u2019Avila
\nA.C. Nieuwenhuijzen
\nKruseman
\nAlarico Rodriguez
\nde Leon
\nA. Hallmayr
\nJeremy A. Lazarus
\n204
\nWMA news
\nsent to Council and to the Assembly for
\nadoption.
\nAdvocacy
\nAn oral report on the Advocacy Workgroup
\nwas given by its chair, Dr. Dana Hanson
\n(Canada). The group had reviewed the ef-
\nfectiveness of the WMA\u2019s relationship with
\noutside organisations. It said that advocacy
\nshould be a key element of the Association\u2019s
\nstrategic plan in reaching out to NMAs.
\nCOUNCIL
\nCouncil then reconvened to consider two
\nemergency resolutions relating to the recent
\ntrial of physicians and other health profes-
\nsionals in Bahrain.
\nBahrain trial of health
\nprofessionals
\nThe first resolution declared that Bahrain
\nmust prove to the watching world that the
\nretrial of 20 physicians, nurses and other
\nhealth professionals sentenced to prison in
\nSeptember followed fair process.
\nDr. Vivienne Nathanson, introducing the
\nresolution, said that those tried included 13
\nphysicians, all of them senior doctors. They
\nhad been found guilty and sentenced to five,
\n10 or 15 years imprisonment and the more
\nsenior the person the longer the sentence.
\nThe accusations against them included
\nhelping enemies of the state who were seek-
\ning regime change, stockpiling guns in the
\nhospital and making political statements.
\nTheir lawyers said the physicians had been
\nabused during the time of arrest and tor-
\ntured while in detention. During the trial,
\nthey were not allowed to give evidence in
\ntheir own defence, nor were their lawyers
\nallowed to question the state\u2019s witnesses,
\nall contrary to international rules. The fi-
\nnal hearing had lasted just seven minutes.
\nThe court was held under special powers
\nwith a military judge. The doctors said the
\nonly thing they did was to treat people who
\ncame to their hospital,fulfilling their ethical
\nobligations to treat all those who presented
\nto them regardless of whether they were
\nfriends or enemies of the government.
\nIndependence of National
\nMedical Associations
\nThe second resolution related to the inde-
\npendence of medical associations and de-
\nnounced attempts by some governments to
\nsilence medical associations. Council ap-
\nproved both emergency resolutions.
\nFINANCE AND PLANNING
\nCOMMITTEE
\nIn the absence of the committee Chair Dr.
\nLeonid Eidelman (Israel), the Finance and
\nPlanning Committee convened under the
\nchairmanship of\u00a0 Dr. Mukesh Haikerwal,
\nChair of Council.
\nThe Financial Advisor, Mr Adi H\u00e4llmayr,
\npresented the Audited Financial Statement
\nfor 2010 and the Budget for 2012, both of
\nwhich were approved by the committee for
\nadoption by the Assembly.
\nThe committee also received a report on
\nMembership Dues Payments for 2011 and
\nDues Categories for 2012.
\nThe Secretary General thanked those mem-
\nbers who had paid their dues promptly de-
\nspite the difficult situations in some coun-
\ntries.He explained the necessity of adopting
\na new dues baseline for members.
\nStrategic Planning
\nDr. Robert Ouellet (Canada), Chair of the
\nWorkgroup on the WMA Strategic Plan,
\nreported on the group\u2019s progress and in-
\nVinay Aggarwal
\nMartin Rebella
\nJoshitake Yokokura
\nDaniel Johnson
\nFlorentino Cardoso
\nPeter W. Carmel
\nDongchun Shin
\nRamin Parsa-ParsiJeff Blackmer
\nVivienne Nathanson
\n205
\nWMA news
\ntroduced Ms Emmanuel Morin from the Canadian Medical As-
\nsociation, who presented the results of a survey carried out among
\nNMAs and key stakeholders.
\nFollowing a discussion on the findings, there was general agreement
\nthat:
\n\u2022 resource capacity and implications must be carefully considered in
\ndeveloping the strategic objectives and the strategic plan;
\n\u2022 the needs of junior physicians should be represented in the new
\nplan as a priority area specific to networking and advocacy, and
\nthe WMA should collaborate with existing stakeholders such as
\nthe Junior Doctors Network;
\n\u2022 the WMA must take a proactive position in developing its new
\nobjectives in order to solidify its role as the foremost international
\nleader in physician ethics and guidance, and in advocacy and rep-
\nresentation;
\n\u2022 given the regulatory role of many NMAs, the WMA needed to
\ncontinue its support and work in the area of quality and regula-
\ntion. However, this should not be a new core area, but rather be
\nintegrated into the three existing core areas as a priority in the
\nnew strategic plan;
\n\u2022 the focus on members, individual physicians and their patients
\nneeded to be highlighted as this was critical to the unique value
\nthe WMA provided globally;
\n\u2022 the strategic plan must continue to include goals that worked to
\nengage existing and new NMA members in order to build aware-
\nness and capacity, and to strengthen the international voice of
\nphysicians.
\nThe committee recommended to Council that the workgroup
\nshould draft a strategic plan for presentation to the Council meet-
\ning in Prague in 2012.
\nMEDICAL ETHICS COMMITTEE
\nThe Medical Ethics Committee convened under the chairmanship
\nof Dr.Torunn Janbu (Norway).
\nOrgan Procurement
\nDr. Nathanson, chair of the WMA\u2019s workgroup on ethical organ
\nprocurement, reported to the committee about its work on a new
\ndraft document. She said it still needed major revision. Dr. Car-
\nmel said this issue represented a Pandora\u2019s Box of troubles with the
\nmoral, ethical and legal complexities surrounding this issue.
\nThe committee recommended to Council that the workgroup be
\nauthorised to continue work on a draft document.
\n206
\nWMA news
\nEthics in Palliative Sedation
\nA proposed Statement was considered on the Ethics in Palliative
\nSedation submitted by the Spanish Medical Association.
\nDr. Janbu said as a result of the many comments received from
\nNMAs on the document, it was clear that they would not be
\nable to approve a new policy at the meeting. Some NMAs said
\nthere should be no separate document on this topic because it
\nwas already covered by existing policy statements. But only a few
\nNMAs had actually suggested changes to the proposed State-
\nment.
\nFollowing a debate, the committee recommended the setting up of
\na workgroup to review the proposed Statement alongside the three
\nexisting WMA policies on euthanasia, terminal illness and end of
\nlife medical care.
\nUse of Placebo in Medical Research
\nDr. Ramin Parsa Parsi (Germany), chair of the workgroup on
\nplacebo in medical research, reported on the activities of the past
\nyear. The WMA\u2019s Ethics Adviser, Prof. Urban Wiesing, then pre-
\nsented a summary of the discussion and the results of a confer-
\nence held in S\u00e3o Paulo, Brazil in July. He said the conference
\ndiscussed new wording for the placebo paragraph (par. 32) of the
\nDeclaration of Helsinki and suggested that the wording should
\nbe broadened. It had also discussed the issue of international
\nclinical research and the use of interventions less effective than
\nthe best proven one in resource poor settings. Although there
\nwere disagreements about how to address this issue in the Decla-
\nration, the discussion helped to identify common ground among
\nparticipants.
\nThe committee recommended to Council that there should be a
\ncomplete revision of the Declaration of Helsinki and that the work-
\ngroup\u2019s mandate should be extended to begin the process of revision.
\nCouncil was also asked to consider organising a satellite conference
\non the Declaration of Helsinki in conjunction with the biannual
\nconference of the International Association on Bioethics in Rot-
\nterdam in June 2012.
\nProfessional and Ethical Usage of Social Media
\nDr. Jon Snaedal (Iceland), chair of the workgroup on social media,
\nreported to the committee on the development of a white paper by
\nthe Junior Doctors Network examining the professional and ethi-
\ncal challenges of the increasing usage of social media by physicians,
\n207
\nWMA news
\nmedical students and patients. Dr. Xaviour Walker, representing the
\nJunior Doctors Network, said the juniors had done a literature re-
\nview on the topic to produce the white paper.
\nThe committee then considered a proposed Statement urging
\nNMAs to establish guidelines for their physicians on the use of so-
\ncial media.There was a debate about whether physicians should ever
\npost identifiable patient information in any social media and the
\nmeeting concluded that they should not.
\nFollowing a discussion, the committee agreed that the document
\nshould be forwarded to Council and the Assembly for adoption. It
\nwas also decided that the workgroup should review the white paper
\nand that the Executive Committee should decide if it should be
\npublished on the WMA website.
\nCapital Punishment
\nDr. Poul Jaszczak (Denmark), Chair of the
\nworkgroup on capital punishment, reported
\nthat the group had decided to develop a
\nwhite paper on the ethical and societal im-
\nplications of capital punishment. Whether
\na policy based on the white paper could be
\ndrafted would be subject to a separate deci-
\nsion in the future.
\nThe committee authorised the workgroup
\nto continue its deliberations and recom-
\nmended to Council that the Executive
\nCommittee should decide if the white paper
\nwould be published on the WMA website.
\nHuman Rights
\nMs Clarisse Delorme, the WMA\u2019s Advocacy Adviser, gave an oral
\nreport on the WMA\u2019s human rights activities during the year, in-
\ncluding its many efforts to address the growing number of assaults
\non health personnel and health facilities in areas of armed conflict
\nand civil unrest. She said the WMA had joined other health or-
\nganisations in signing a joint letter requesting the UN Security
\nCouncil to adopt a new resolution to include attacks on schools
\nand hospitals in the existing monitoring and reporting mechanism
\nthat protected children in armed conflicts. This resolution had
\nbeen passed.
\nThe WMA was also in discussion with the International Commit-
\ntee of the Red Cross about a possible partnership with the ICRC\u2019s
\n208
\nWMA news
\ncampaign to improve the security and de-
\nlivery of healthcare in situations of armed
\nconflict.
\nASSOCIATE MEMBERS
\nMEETING
\nDr. Guy Dumont (Belgium) was re-elected
\nChair of the meeting on Thursday.
\nOrgan Procurement in China
\nA Resolution on Human Organ Procure-
\nment in the People\u2019s Republic of China was
\nproposed on behalf of Dr. A. L. Halpern by
\nDr.Alejandro Centurion.He explained that
\nin China organs were removed from prison-
\ners, which was allowed by law. However, in
\nline with WMA policy on transplantation,
\nprisoners were not in a position to give free
\nand informed consent.There was strong ev-
\nidence that organs were still being removed
\nnot only from executed prisoners but also
\nfrom individuals in detention centres, work
\ncamps and hospitals.
\nDr.Guoming Qi,Vice President of the Chi-
\nnese Medical Association,explained that the
\nChinese Medical Association and the Chi-
\nnese Government were trying to change the
\nsituation. The Chinese Vice Health Minis-
\nter agreed with the Chinese Medical Asso-
\nciation that removing organs from executed
\nprisoners was not acceptable. As the law was
\nrevised, the medical association would advo-
\ncate for changes. He said the Chinese Gov-
\nernment was about to establish allocation
\nas well as data collection systems to ensure
\nfair organ transplantation. Together with
\nthe medical association, the government
\nhad started investigating hospitals and other
\nvenues in 18 provinces. Originally 600 hos-
\npitals were enabled to carry out organ trans-
\nplantations. That number had been reduced
\nto 100 hospitals. Hospitals were about to be
\nsubject to sanctions if they violated medical
\nethics. Also, organ tourism was to be pro-
\nhibited by the government. Dr. Qi said the
\nChinese Medical Association and the gov-
\nernment would use their best efforts to meet
\nthe standards of the WMA.
\nDr. Daniel Johnson (USA), a Past President
\nof the WMA, commended the Chinese
\nMedical Association for its work in trying
\nto tackle this issue and suggested that the
\nmeeting should adopt a less confrontational
\nstatement. Dr. Nathanson said that there
\nwere many countries where practices on
\norgan procurement were far from ideal. The
\nWMA had a workgroup revising policy on
\nethical organ procurement and she hoped
\nits work would be finished in time for the
\nnext Assembly.
\nFollowing further discussion, the meeting
\namended the Resolution reiterating its op-
\nposition to any involuntary organ removal,
\nnot only from executed prisoners but also
\nfrom all individuals in detention centres,
\nwork camps, hospitals and other places of
\nconfinement.
\nPast Presidents
\nDr. Dana Hanson (Canada), a Past Presi-
\ndent of the WMA, proposed setting up a
\nPast Presidents and Past Chairs Network
\nalong the lines of the Junior Doctors Net-
\nwork. It was agreed to recommend this to
\nthe Assembly.
\nJunior Doctors Network
\nDr. Xaviour Walker, Chair of the Junior
\nDoctors Network, reported on the inaugu-
\nral meeting of the newly established Net-
\nwork and its work on a white paper on so-
\ncial media.
\nSCIENTIFIC SESSION
\nThe theme of the all-day session was \u2018To-
\nbacco Cessation\u2019, with speakers addressing
\nthe issue of tobacco control policies.
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\nWMA news
\nThe session was introduced by Dr. Mart\u00edn
\nRebella, President of the Uruguyuan Medi-
\ncal Association, who spoke about the health
\nand economic damage caused by tobacco
\nsmoking. This hindered economic develop-
\nment, particularly of poorer countries. But
\nanti tobacco activities in his country had
\nachieved successful health effects and were
\nsupported by public opinion.
\nThe first speaker, Dr. Tom Glynn, Director,
\nCancer Science and Trends and Director,
\nInternational Cancer Control at the Amer-
\nican Cancer Society, gave a brief overview
\nof the tobacco pandemic and spoke about
\nwhat might be done to start to address it.
\nHe said Asia and Australia had more than
\nhalf of the smokers in the world and tobac-
\nco was now moving from being a disease
\nof the industrialised western countries to
\none of the middle and low income coun-
\ntries. But the good news was that the pan-
\ndemic was preventable and reversible and
\nhe referred to the actions proposed by the
\nWHO, including better monitoring and
\nprotection, good treatment, more warnings,
\nthe enforcement of advertising bans and
\nhigher taxes.
\nDr. Tabar\u00e9 V\u00e1zquez, former President of
\nUruguay, spoke about tobacco control in
\nUruguay and the progress that had been
\nmade.But a lot more needed to be done and
\nhe referred to his country\u2019s fight against the
\nmultinational tobacco industry and vowed
\nthat the companies would not triumph.
\nDr. Suthat Rungruanghiranya, Assistant
\nProfessor at the Medical Faculty of Srina-
\nkarinth University in Bangkok, said that in
\nThailand they had successfully implement-
\ned tobacco control measures over 20 years,
\nreducing the prevalence rate from 32 per
\ncent to 21 per cent.Now they were trying to
\ndeal with changes in taxation, more graphic
\nwarnings on cigarette packets, tougher law
\nenforcement and a greater focus on teenage
\nsmokers.
\nDuring the session on tobacco dependence
\nand treatment, Professor Richard Hurt
\nfrom the Mayo Clinic in Minnesota, USA,
\nspoke about the neurobiology of tobacco
\ndependence, while Dr. Glynn, in his second
\nspeech, explained article 14 of the Tobacco
\nFramework Convention which mandated
\nthe development of treatment guidelines
\nfor parties to the treaty.
\nSpeakers from Uruguay and Australia re-
\nported on actions being taken in their coun-
\ntries against Philip Morris International
\nabout cigarette package designs. Dr. An-
\ndrew Pesce from Australia referred to the
\nprogress in his country to legislate for plain
\npackaging and Philip Morris\u2019s response
\nin suing the Australian Government. He
\nurged all governments to continue to act to
\ndecrease smoking and to introduce whatever
\nlegislation was possible. Dr. Eduardo Cazap
\nfrom Argentina, President of the Oncology
\nAssociation of Latin America and the Ca-
\nribbean, said the UN Non Communicable
\nDiseases High Level Meeting in New York
\npresented challenges to all national medical
\nassociations.
\nIn the final session, Uruguay\u2019s anti-tobacco
\nactivities were outlined by several speak-
\ners. Dr. Eduardo Bianco, a member of the
\nTobacco Commission of the Sindicato
\nM\u00e9dico del Uruguay, said that among his
\nassociation\u2019s aims was to reduce the preva-
\nlence of smoking among physicians in the
\ncountry to less than five per cent by 2015, a
\ngoal he thought was achievable.The session
\nended with a speech from Uruguay\u2019s Min-
\nister of Public Health, who spoke optimis-
\ntically about his country\u2019s fight against the
\ntobacco industry, likening it to the struggle
\nbetween David and Goliath. But it was not
\nan isolated struggle. It included all of civil
\nsociety and he said the ethics were with
\nthem.
\nCOUNCIL
\nWhen the Council reconvened on Friday
\nto approve the reports from the commit-
\ntees, it discussed a Statement on Disaster
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\nWMA news
\nPreparedness and Medical Response and
\nagreed to send it to the Assembly for adop-
\ntion.
\nIt debated possible venues for future meet-
\nings and recommended meeting in Brazil
\nfor the 2013 Assembly. For the Council
\nmeetings in the spring of 2013 and 2014,
\nboth Japan and the UK were suggested, al-
\nthough this remained to be decided.
\nThe meeting heard a report from Dr. Mads
\nHansen (Denmark) about the greening of
\nactivities at the Assembly to reduce the
\nWMA\u2019s environmental impact. This in-
\ncluded the move to organising a paperless
\nmeeting and he said there had been a reduc-
\ntion of two thirds in the use of paper at this
\nAssembly.
\nAn oral report was received from Mr Tony
\nBourne (UK), Chair of the Business De-
\nvelopment Group, outlining its work to
\nstrengthen and diversify WMA revenue
\nsources and it was agreed that this work
\nshould continue.
\nFollowing a workgroup report to Council,
\nfurther debate took place on amendments
\nto the proposed Statement on Violence in
\nthe Health Sector and it was decided that
\nfurther work was needed on the document.
\nCEREMONIAL SESSION OF
\nTHE GENERAL ASSEMBLY
\nAt the ceremonial opening of the Assem-
\nbly, participants were welcomed by Dr.
\nLeonel Briozzo, Vice Minister for Health
\nin Uruguay. He spoke about the substan-
\ntial reform of the health system going on
\nin his country and the autonomy of the
\nmedical profession. He also thanked the
\nWMA for its support on anti-tobacco ac-
\ntivities.
\nHis Excellency Jo\u00e3o Carlos de Souza-
\nGomes, Brazil\u2019s ambassador to Uruguay,
\nwelcomed the election as WMA President
\nfor 2011\/12 of Dr. Gomes do Amaral and
\nspoke about his work to improve the quality
\nof health in Brazil. He congratulated Uru-
\nguay on its reforming health policies and
\nspoke about the importance of international
\nco-operation and the exchange of ideas and
\nexperiences.
\nDr. Wonchat Subhachaturas, in his vale-
\ndictory address as WMA President for
\n2010\/11, referred to the various natural and
\nmanmade disasters that had happened dur-
\ning his year of office, as well as the many
\nattacks on physicians around the world who
\nwere simply carrying out their job caring for
\nthe sick and injured.
\nDuring the past year, he had visited 19
\nmedical associations and forums in every
\ncontinent except Africa.The three challeng-
\nes he identified were the political conflicts
\namong countries, which were impacting on
\nhealth provision, the economic crisis which
\nwas proving to be a great barrier to the de-
\nvelopment of medical care in many coun-
\ntries and the manmade disasters especially
\naround the Mediterranean. He listed those
\nfactors which were essential to the provision
\nof healthcare \u2013 among them professional
\nunity, ethical practice, equitable provision
\nof health, global collaboration and indepen-
\ndence from politics.
\nDr. Jos\u00e9 Gomes do Amaral, President of the
\nBrazilian Medical Association, was then
\ninstalled as the 62nd
\nWMA President for
\n2011\/12. He said it was time for physicians
\nto reaffirm their leadership of the healthcare
\nprocess and to stand up for medicine. He
\nsaid physicians had to decide if they wanted
\nto be the key players in the healthcare pro-
\ncess or simply \u2018mere spectators\u2019.
\n\u2018This is no time to be vague. We cannot
\nbe supporting actors in a play where the
\npeople expect us to be protagonists. It is
\ntime for us to reaffirm our leadership of
\nthe healthcare process. This is what we
\nwere educated to do. We were given the
\nprivilege and responsibility to take care of
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\nWMA news
\nthe lives of our patients. This is our duty
\nand society trusts us to behave up to their
\nexpectations.\u2019
\nDr. Gomes do Amaral said this was a pe-
\nriod of uncertainty and indecision for phy-
\nsicians around the world and he was taking
\nover the Presidency as the medical pro-
\nfession was facing formidable challenges.
\nPhysicians found themselves surrounded
\nby a complex healthcare network, the pri-
\nmary purpose of which was to broaden ac-
\ncess to care. But the role of physicians in
\nthis network was often misrepresented and
\nthe medical profession could not accept
\nthat. Under no circumstances could physi-
\ncians contemplate a retreat from their role
\nand responsibilities.
\nHe said that in the field of health, immense
\npossibilities of diagnosis and treatment had
\nbeen brought about by science and techno-
\nlogical development, unimaginable a few
\ndecades ago. Physicians had played their
\npart in this and they would certainly do
\nmore in this field. Specialisation and spe-
\ncialists were more necessary than ever and
\ndoctors, who had helped to build and inte-
\ngrate the health system, should not now be
\ndisregarded. It was time for doctors to stand
\nup for medicine.
\nPLENARY SESSION
\nOF THE ASSEMBLY
\nWhen the Assembly reconvened on Satur-
\nday, an election was held for WMA Presi-
\ndent for 2012\/13. Two nominations were
\nreceived, from Dr. Shamsuddin Ahmed
\n(Bangladesh) and from Dr. Cecil B. Wilson
\n(USA). After each candidate had addressed
\nthe meeting, there was a vote and Dr. Wil-
\nson, past President of the American Medi-
\ncal Association, was elected. He will take
\nup office at the 2012 Assembly in Bangkok,
\nThailand.
\nThe Assembly then received a detailed re-
\nport from Council about its activities since
\nthe last General Assembly in Vancouver in
\n2010.
\nAmong the significant activities not being
\ndiscussed in Montevideo, were the WMA\u2019s
\nwork on the multidrug-resistant tuberculo-
\nsis project and its involvement in the imple-
\nmentation process of the WHO Frame-
\nwork Convention on Tobacco Control. The
\nreport referred to work in monitoring the
\ndrafting process of the WHO strategy on
\nalcohol and collaboration with the World
\nHealth Professions Alliance in stepping up
\nactivities on counterfeit medicines. Other
\nissues included activities on climate change
\nand the forthcoming UN Conference in
\nDurban, South Africa in December and
\nthe WMA\u2019s continuing close involvement
\nin the positive practice environment cam-
\npaign.
\nThe WMA Treasurer, Dr. Frank Ulrich
\nMontgomery, presented his financial report,
\nsaying that the Association\u2019s net income had
\ncontinued the positive trend it had shown
\nsince the turnaround in 2005. In 2010 there
\nwas a financial surplus of \u20ac60,000 which was
\nvery reassuring for the future. Total income
\nfor the year was \u20ac2,120,000 and expenses
\ntotalled \u20ac2,060,000. The membership dues
\nhad reached their highest level during 2010.
\nHe said the Association\u2019s money was safely
\nand solidly invested.
\nThe Assembly approved the Financial
\nStatement for 2010 and the Budget for
\n2012.
\nThe Assembly then adopted a number
\nof policy documents brought to it by the
\nCouncil.
\nFrom the Medical Ethics Committee it ad-
\nopted three documents:
\n\u2022 Recommendation on the Development
\nof a Monitoring and Reporting Mecha-
\nnism to Permit Audit of Adherence of
\nStates to the Declaration of Tokyo (see
\np.\u00a0215), which sets out ways to increase
\nsupport for physicians with dual loyalties
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\nWMA news
\nwho are pressured to violate their profes-
\nsional ethics.
\n\u2022 Statement on End of Life Care (see
\np.\u00a0 215) which emphasises the need for
\nimproved palliative care.
\n\u2022 Statement on Professional and Ethical
\nUsage of Social Media (see\u00a0p.\u00a0217).
\nFrom the Socio-Medical Affairs Commit-
\ntee it adopted the following:
\n\u2022 Statement on the Global Burden of
\nChronic Disease (see\u00a0p.\u00a0218).
\n\u2022 Revision of the Declaration on Prison
\nConditions and the Spread of Tubercu-
\nlosis and other Communicable Diseases
\n(see\u00a0p.\u00a0219).
\n\u2022 Statement on Social Determinants of
\nHealth (see\u00a0p.\u00a0221).
\n\u2022 Statement on Health Hazards of To-
\nbacco and Tobacco-Derived Products
\n(see\u00a0p.\u00a0224).
\n\u2022 Statement on Protection and Integrity
\nof Medical Personnel in Armed Con-
\nflicts (see\u00a0p.\u00a0222).
\n\u2022 Resolution on the Access to Adequate
\nPain Treatment (see\u00a0p.\u00a0223).
\n\u2022 Revision of the WMA Statement on
\nHealth Hazards of Tobacco and To-
\nbacco-Derived Products (Protect Chil-
\ndren).
\n\u2022 Declaration on Leprosy Control
\nAround the World and Elimination of
\nDiscrimination Against Persons Af-
\nfected by Leprosy (see\u00a0p.\u00a0225).
\n\u2022 Endorsement of the Global Leprosy
\nAppeal 2012.
\nSocial Determinants
\nIn a short debate on the importance of so-
\ncial determinants, Dr.\u00a0Vivienne Nathanson
\nspoke about the forthcoming summit on
\nthe issue to be held in Rio de Janeiro. She
\nsaid this presented important opportunities
\nfor the WMA to make sure that social de-
\nterminants was not only firmly on people\u2019s
\nagendas but that the medical community
\ncould offer help and expertise for health
\nministers to understand the importance of
\ncross government working. After the sum-
\nmit meeting in Brazil, it was hoped that the
\nWMA would start to develop a bigger web
\nresource that listed the types of activities
\nthat doctors had been involved in in differ-
\nent countries. So many countries had done
\nremarkable things in changing health and
\nhealth outcomes by looking at social deter-
\nminants.
\nDr.Gomes do Amaral said it was important
\nthat the WMA developed a regional net-
\nwork to implement this initiative.
\nFrom the Finance and Planning Commit-
\ntee the Assembly adopted:
\n\u2022 proposed Baseline of Membership
\nDues.
\n\u2022 applications for membership of the WMA
\nfrom national medical associations from
\nTrinidad and Tobago, Uzbekistan and
\nTanzania.
\n\u2022 This brought the total membership of the
\nWMA to 100 NMAs, the highest ever
\nrecorded number.
\n\u2022 amendments on Bylaws relating to the
\nduties and responsibilities of the Trea-
\nsurer.
\n\u2022 amendments to governance documents
\nrelating to the termination of officers.
\n\u2022 Statement on Disaster Preparedness
\nand Medical Response (see\u00a0p.\u00a0227).
\nMeetings
\nThe Assembly agreed that the 2013 General
\nAssembly should be
\nheld in Fortaleza in
\nBrazil.
\nBahrain
\nThe emergency resolu-
\ntions on Bahrain and
\non the Independence
\nof National Medi-
\ncal Associations were
\nadopted (see\u00a0 p.\u00a0 226).
\nOrgan Procurement
\nThe Resolution from the Associate Mem-
\nbers Group on Human Organ Procure-
\nment in the People\u2019s Republic of China was
\ndiscussed. Dr. Nathanson said the WMA\u2019s
\ncurrent policy was that executed prisoners
\nshould not be organ donors and that prison-
\ners should not,other than in the most excep-
\ntional circumstances, be living donors. She
\nsaid the working party on organ procure-
\nment would be looking at WMA advice and
\nrevising it.The new document would contain
\nmore details about the situation of prisoners
\nin different circumstances \u2013 prisoners who
\nhad died naturally, prisoners who had been
\nexecuted and prisoners as living donors. She
\nhoped the working party\u2019s report would be
\nready for next year\u2019s Assembly.
\nThe Assembly agreed to remove from the
\ntitle of the Resolution the words \u2018the People\u2019s
\nRepublic of China\u2019and to send it to Council
\nfor further consideration by the workgroup.
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\nWMA news
\nPast Presidents Network
\nThe Assembly agreed to ask Council to
\nconsider setting up a network of Past Presi-
\ndents and Chairs.
\nDisaster Preparedness
\nIn a special session on disaster response,
\nDr.\u00a0 Masami Ishii (Japan), Vice Chair of
\nCouncil, spoke about the earthquake and
\ntsunami that struck Japan in March and their
\naftermath. He said his hospital had been se-
\nverely damaged and he referred to the ways
\nin which medical help was organised and the
\nrole played by the Japan Medical Association.
\nDr. Jeremy Lazarus (USA) described the
\nAmerican Medical Association\u2019s work on
\ndisaster medicine involving physicians. He
\nsaid every physician should have a second
\nspeciality, that of disaster medicine and
\npreparedness. He referred to the National
\nDisaster Life Support Foundation,in which
\nthe AMA was involved, and its network of
\ntraining centres.
\nDr. Gomes do Amaral, the President, said
\nthat the Statement on Disaster Prepared-
\nness and Medical Response, which had
\nbeen adopted by the Assembly, would be
\ncalled the Declaration of Montevideo.
\nNon Communicable Diseases
\nDr. Julia Seyer, WMA Medical Adviser, re-
\nported on the toolkit on NCDs, the Health
\nImprovement Card, which had been put to-
\ngether with the World Health Professions
\nAlliance. This was an educational tool for
\nphysicians and the public to empower the
\nindividual to achieve a healthy lifestyle.
\nOpen Session
\nDuring the final open session of the As-
\nsembly, delegates heard from several NMAs
\nAnnabel SeebhomNigel Duncan
\nSunny ParkLamine Smaali
\nAnne-Marie Delage
\nClarisse Delorme
\nJulia Seyer
\nRoderic Dennett
\n214
\nWMA news
\nabout issues they were facing. Delegates
\nfrom Venezuela and Uruguay raised their
\nconcerns about proposed legislation in
\nBolivia penalising poor medical activi-
\nties and said they proposed to discuss
\nthis further at the next WMA Council
\nmeeting.
\nDr. Peter Carmel, President of the Amer-
\nican Medical Association, reported on
\ntwo new AMA projects to tackle obesity,
\nphysical inactivity, tobacco and alcohol
\nuse.
\nDr. Paul Ockelford (New Zealand) spoke
\nabout the earthquake that struck New
\nZealand in February. This led to 181
\ndeaths and more than 6000 injuries. He
\ndescribed the immediate emergency re-
\nsponse that took place.
\nCOUNCIL
\nThe week\u2019s deliberations ended with
\na brief Council meeting at which it
\nwas agreed that the Resolution on Or-
\ngan Procurement should be sent to the
\nworkgroup for consideration and that a
\nnetwork of Past Presidents and Chairs
\nshould be set up.
\nNigel Duncan,
\nWMA Public Relations Consultant
\n215
\nWMA news
\nWMA Recommendation
\non the Development\u00a0of
\na Monitoring and Reporting
\nMechanism to Permit Audit
\nof\u00a0Adherence of States
\nto\u00a0the Declaration of Tokyo
\nAdopted by the 62nd
\nGeneral Assembly, Montevideo,
\nUruguay, October\u00a02011
\nThe wma recommends that
\n1. Where physicians are working in situations of dual loyalties,
\nsupport must be offered to ensure they are not put in positions
\nthat might lead to violations of fundamental professional eth-
\nics, whether by active breaches of medical ethics or omission
\nof ethical conduct, and\/or of human rights, as laid out in the
\nDeclaration of Tokyo.
\n2. National Medical Associations (NMA\u2019s) should offer support
\nfor physicians in difficult situations, including, as feasible and
\nwithout endangering either patients or doctors, helping individ-
\nuals to report violations of patients\u2019health rights and physicians\u2019
\nprofessional ethics in custodial settings.
\n3. The WMA should review the evidence available, in cases
\nbrought to it by its members, of the violation of human rights
\ncodes by states and\/or the forcing of physicians to violate the
\nDeclaration of Tokyo, and refer as appropriate such cases to the
\nrelevant national and international authorities.
\n4. The WMA should contact member associations and encour-
\nage them to investigate accusations of physician involvement in
\ntorture and similar abuses of human rights reported to it from
\nreputable sources, and to report back in particular on whether
\nphysicians are at risk and in need of support.The WMA should
\nprovide support to the NMAs and their members to resist such
\nviolations, and as far as realistically possible, stand firm in their
\nethical convictions.
\n5. The WMA shall encourage and support NMAs in their calls for
\ninvestigations by the relevant special rapporteur (or other indi-
\nvidual or organization) when NMAs and their members raise
\nvalid concerns.
\nDeclaration on End-of-Life
\nMedical Care
\nINTRODUCTION
\nAll people have the right to high-quality, scientifically-based, and
\nhumane healthcare. Therefore, receiving appropriate end-of-life
\nmedical care must not be considered a privilege but a true right,
\nindependent of age or any other associated factors.The WMA reaf-
\nfirms the principles articulated in the WMA Declaration on Termi-
\nnal illness and the WMA Declaration on Euthanasia. These Dec-
\nlarations support and complement the Declaration on End of Life
\nMedical Care.
\nPalliative care at the end of life is part of good medical care. The
\nneed for access to improved quality palliative care is great, espe-
\ncially in resource-poor countries.The objective of palliative care is to
\nachieve the best possible quality of life through appropriate pallia-
\ntion of pain and other distressing physical symptoms, and attention
\nto the social, psychological and spiritual needs of the patient.
\nPalliative care may be provided at home as well as in various levels
\nof health care institutions.
\nThe physician must adopt an attitude to suffering that is compas-
\nsionate and humane, and act with empathy, respect and tact. Aban-
\ndonment of the patient when he or she needs such care is unaccept-
\nable medical practice.
\nRECOMMENDATIONS
\n1. Pain and symptom management
\n1.1. It is essential to identify patients approaching the end of
\nlife as early as possible so that the physician can perform
\na detailed assessment of their needs. A care plan for the
\npatient must always be developed; whenever possible, this
\ncare plan will be developed in direct consultation with the
\npatient.
\nFor some this process may begin months or a year before
\ndeath is anticipated.It includes recognising and addressing
\nthe likelihood of pain and other distressing symptoms and
\nproviding for patients\u2019 social, psychological and spiritual
\nneeds in the time remaining to them.The primary aim is to
\nmaintain patients\u2019dignity and their freedom from distress-
\ning symptoms. Care plans pay attention to keeping them
\nas comfortable and in control as possible and recognise the
\nimportance of supporting the family and treating the body
\nwith respect after death.
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\nWMA news
\n1.2. Important advances in the relief of pain and other distress-
\ning symptoms have been made.The appropriate use of mor-
\nphine, new analgesics, and other measures can suppress or
\nrelieve pain and other distressing symptoms in the major-
\nity of cases. The appropriate health authorities must make
\nnecessary medications accessible and available to physicians
\nand their patients. Physician groups should develop guide-
\nlines on their appropriate use,including dose escalation and
\nthe possibility of unintended secondary effects.
\n1.3. In a very limited number of cases, generally in the very
\nadvanced stages of a physical illness, some symptoms may
\narise that are refractory to standard therapy. In such cas-
\nes, palliative sedation to unconsciousness may be offered
\nwhen life expectancy is a few days, as an extraordinary
\nmeasure in response to suffering which the patient and cli-
\nnician agree is intolerable. Palliative sedation must never
\nbe used to intentionally cause a patient\u2019s death or without
\nthe agreement of a patient who remains mentally compe-
\ntent. The degree and timing of palliative sedation must be
\nproportionate to the situation. The dosage must be care-
\nfully calculated to relieve symptoms but should still be the
\nlowest possible to achieve a benefit.
\n2. Communication and consent; ethics and values
\n2.1. Information and communication among the patient, their
\nfamily and members of the health care team is one of the
\nfundamental pillars of quality care at the end of life. The
\npatient should be encouraged to express his or her prefer-
\nences regarding care, and his or her emotions and existen-
\ntial angst must be taken into consideration.
\n2.2. Ethically-appropriate care at the end of life should rou-
\ntinely promote patient autonomy and shared decision-
\nmaking, and be respectful of the values of the patient and
\nhis or her family.
\n2.3. Physicians should directly discuss a patient\u2019s preferences
\nwith the patient and\/or the patient\u2019s substitute health care
\ndecision maker, as appropriate. These discussions should
\nbe initiated early and routinely offered to all patients and
\nshould be revisited regularly to explore any changes pa-
\ntients may have in their wishes, especially as their clini-
\ncal conditions change. Physicians should encourage their
\npatients to formally document their goals, values and
\ntreatment preferences and to appoint a substitute health
\ncare decision maker with whom the patient can discuss in
\nadvance his or her values regarding health care and treat-
\nment. Patients who are in denial about the implications of
\ntheir condition may not want to engage in such discussion
\nat some stages of their illness, but should know that they
\ncan change their minds. Because documented advance
\ndirectives are often not available in emergency situations,
\nphysicians should emphasize to patients the importance of
\ndiscussing treatment preferences with individuals who are
\nlikely to act as substitute health care decision makers.
\n2.4. If a patient is capable of giving consent, care should be
\nbased on the patient\u2019s wishes as long as preferences can be
\njustified medically, ethically and legally. Consent needs to
\nbe based on sufficient information and dialogue, and it is
\nthe physician\u2019s obligation to make sure that the patient is
\nadequately treated for pain and discomfort before consent
\nis obtained in order to assure that unnecessary physical
\nand mental suffering do not interfere with the decision-
\nmaking process.
\n2.5. The patient\u2019s next-of-kin or family should be informed
\nand involved in the decision-making process, provided the
\npatient is not opposed to this. If the patient is unable to
\nexpress consent and an advance directive is not available,
\nthe views of the health care substitute decision maker, ap-
\npointed by the patient on care and treatment,must be con-
\nsidered.
\n3. Medical records and medico-legal aspects
\n3.1. Physicians caring for a patient in the final stages of life
\nmust carefully document treatment decisions and the
\nreasons for choosing particular procedures, including the
\npatient\u2019s and family\u2019s wishes and consent, in the progress
\nnotes of the medical records. An adequate medical record
\nis of the utmost importance for continuity and quality of
\nmedical care in general and palliative care in particular.
\n3.2. The physician must also take into account that these notes
\nmay serve a medico-legal purpose, e.g., in determining the
\npatient\u2019s decision-making capacity.
\n4. Family members
\nIt is necessary to acknowledge the importance of the family and
\nthe emotional environment of the patient.The needs of the fam-
\nily and other close caregivers throughout the course of the illness
\nmust be recognized and attended to.The heath care team should
\npromote collaboration in the care of the patient and provide
\nbereavement support, when required, after the patient\u2019s death.
\nChildren\u2019s and families\u2019 needs may require special attention and
\ncompetence, both when children are patients and dependents.
\n5. Teamwork
\nPalliative care is usually provided by multiprofessional and inter-
\ndisciplinary teams of healthcare and non-healthcare professions.
\nThe physician must be the leader of the team, being responsible,
\namongst other obligations, for diagnosis and medical treatment.
\nContinuity of care is very important. The team should do all it
\ncan to facilitate a patient\u2019s wish to die at home, if applicable and
\npossible.
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\n6. Physician training
\nThe increasing number of people who require palliative
\ncare and the increased availability of effective treatment
\noptions mean that end-of-life care issues should be an im-
\nportant part of undergraduate and postgraduate medical
\ntraining.
\n7. Research and education
\nMore research is needed to improve palliative care.This in-
\ncludes, but is not limited to, general medical care, specific
\ntreatments, psychological implications and organization.
\nThe WMA will support efforts to better educate physi-
\ncians in the skills necessary to increase the prevalence and
\nquality of meaningful advance care planning.
\nConclusion
\nThe care that a people give to dying patients, within available re-
\nsources, is an indication of their degree of civilisation. As physicians
\nrepresenting the best humanitarian tradition, we should always
\ncommit ourselves to delivering the best possible end-of-life care.
\nThe WMA recommends that all National Medical Associations
\ndevelop a national policy on palliative care and palliative sedation
\nbased on the recommendations in this declaration.
\nStatement on the Professional and
\nEthical Usage of Social Media
\nDEFINITION
\nSocial Media is generally understood to be a collective term for the
\ndifferent platforms and applications that allow user-generated con-
\ntent to be created and shared electronically.
\nPREAMBLE
\nThe objectives of the proposed policy are to:
\n\u2022 Examine the professional and ethical challenges related to the
\nincreasing usage of social media by physicians, medical students
\nand patients.
\n\u2022 Establish a framework that protects their respective interests.
\n\u2022 Ensure trust and reputation by maintaining high professional and
\nethical standards.
\nThe use of social media has become a fact of life for many millions
\nof people world wide including physicians, medical students and
\npatients.
\nInteractive, collaborative tools such as wikis, social networks, chat
\nrooms and blogs have transformed passive Internet users into active
\nparticipants.They are means for gathering, sharing and disseminat-
\ning personal information, including health information, socializing
\nand connecting with friends, relatives, professionals etc.They can be
\nused to seek medical advice, and patients with chronic diseases can
\nshare their experiences with each other. They can also been used in
\nresearch, public health, education and direct or indirect professional
\npromotion.
\nThe positive aspects of social media should be recognized such as in
\npromoting healthy life style, in empowering patients and in reduc-
\ning patients\u2019 isolation.
\nAreas, which may require special attention:
\n\u2022 Sensitive content, photographs, other personal materials posted
\non online social forums often exists in the public domain and
\nhave the capacity to remain on the internet permanently. Indi-
\nviduals may not have control over the ultimate distribution of
\nmaterial they post on-line.
\n\u2022 Patient portal, blogs and tweets are not a substitute for one on
\none consultation with physicians but may widen engagement
\nwith health services amongst certain groups. Online \u201cfriendships\u201d
\nwith patients may also alter the patient-physician relationship,
\nand may result in unnecessary,possibly problematic physician and
\npatient self-disclosure.
\n\u2022 Each party\u2019s privacy may be compromised in the absence of ad-
\nequate and conservative privacy settings or by their inappropri-
\nate use. Privacy settings are not absolute; social media sites may
\nchange default privacy settings unilaterally, without the user\u2019s
\nknowledge. Social media sites may also make communications
\navailable to third parties.
\nInterested stakeholders such as current\/prospective employers, in-
\nsurance companies and commercial entities may monitor these In-
\nternet web sites for various purposes such as to better understand
\ntheir customer\u2019s needs and expectations, to profile job candidates or
\nto improve a product or a service.
\nRECOMMENDATIONS
\nThe WMA urges their NMA\u00b4s to establish guidelines for their phy-
\nsicians addressing the following issues:
\n1. To maintain appropriate boundaries of the patient-physician re-
\nlationship in accordance with professional ethical guidelines just
\nas they would in any other context.
\n2. To study carefully and understand the privacy provisions of so-
\ncial networking sites, bearing in mind their limitations.
\n3. For physicians to routinely monitor their own Internet presence
\nto ensure that the personal and professional information on
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\ntheir own sites and, to the extent possible, content posted about
\nthem by others is accurate and appropriate.
\n4. To consider the intended audience and assess whether it is tech-
\nnically feasible to restrict access to the content to pre-defined
\nindividuals or groups.
\n5. To adopt a conservative approach when disclosing personal
\ninformation as patients can access the profile. The professional
\nboundaries that should exist between the physician and the pa-
\ntient can thereby be blurred. Physicians should acknowledge the
\npotential associated risks of social media and accept them, and
\ncarefully select the recipients and privacy settings.
\n6. To provide factual and concise information,declare any conflicts
\nof interest and adopt a sober tone when discussing professional
\nmatters.
\n7. To ensure that no identifiable patient information be posted in
\nany social media by their physician. Breaching confidentiality
\nundermines the public\u2019s trust in the medical profession, impair-
\ning the ability to treat patients effectively.
\n8. To draw the attention of medical students and physicians to the
\nfact that online posting may contribute also to the public per-
\nception of the profession.
\n9. To consider the inclusion of educational programs with relevant
\ncase studies and appropriate guidelines in medical curricula and
\ncontinuing medical education.
\n10. To bring their concerns to a colleague when observing his or her
\nclearly inappropriate behaviour. If the behaviour significantly
\nviolates professional norms and the individual does not take ap-
\npropriate action to resolve the situation, physicians should re-
\nport the conduct to appropriate authorities.
\nWMA Statement on the Global
\nBurden of Chronic Disease
\nAdopted by the 62nd
\nGeneral Assembly, Montevideo, Uruguay,
\nOctober 2011
\nINTRODUCTION
\nChronic diseases, including cardiovascular and circulatory diseases,
\ndiabetes, cancer, and chronic lung disease are the leading cause of
\ndeath and disability in both the developed and developing world.
\nChronic diseases are not replacing existing causes of disease and
\ndisability (infectious disease and trauma), but are adding to the dis-
\nease burden. Developing countries now face the triple burden of
\ninfectious disease, trauma and chronic disease. This increased bur-
\nden is straining the capacity of many countries to provide adequate
\nhealth care services. This burden is also undermining these nations\u2019
\nefforts to increase life expectancy and spur economic growth.
\nOngoing and anticipated global trends that will lead to more
\nchronic disease problems in the future include an aging population,
\nurbanization and community planning, increasingly sedentary life-
\nstyles, climate change and the rapidly increasing cost of medical
\ntechnology to treat chronic disease. Chronic disease prevalence is
\nclosely linked to global social and economic development, global-
\nization and mass marketing of unhealthy foods and other products.
\nThe prevalence and cost of addressing the chronic disease burden is
\nexpected to rise in coming years.
\nPossible Solutions
\nThe primary solution is disease prevention. National policies that
\nhelp people achieve healthy lifestyles and behaviours are the foun-
\ndation for all possible solutions.
\nIncreased access to primary care combined with well designed and
\naffordable disease-control programs can greatly improve health care.
\nPartnerships of national ministries of health with institutions in de-
\nveloped countries may overcome many barriers in the poorest set-
\ntings.Effective partnerships currently exist in rural Malawi,Rwanda
\nand Haiti. In these settings where no oncologists are available, care
\nis provided by local physicians and nurse teams.These teams deliver
\nchemotherapy to patients with a variety of treatable malignancies
\nMedical education systems should become more socially account-
\nable. The World Health Organization (WHO) defines social ac-
\ncountability of medical schools as the obligation to direct their
\neducation, research and service activities towards addressing the
\npriority health concerns of the community, region, or nation they
\nhave a mandate to serve. The priority health concerns are to be
\nidentified jointly by governments, health care organizations, health
\nprofessionals and the public. There is an urgent need to adopt ac-
\ncreditation standards and norms that support social accountability.
\nEducating physicians and other health care professionals to deliver
\nhealth care that is concordant with the resources of the country
\nmust be a primary consideration. Led by primary care physicians,
\nteams of physicians, nurses and community health workers will pro-
\nvide care that is driven by the principles of quality, equity, relevance
\nand effectiveness. [see WMA Resolution on Medical Workforce]
\nStrengthening the health care infrastructure is important in caring
\nfor the increasing numbers of people with chronic disease. Com-
\nponents of this infrastructure include training the primary health
\ncare team, improved facilities, chronic disease surveillance, public
\nhealth promotion campaigns, quality assurance and establishment
\nof national and local standards of care. One of the most important
\ncomponents of health care infrastructure is human resources; well-
\ntrained and motivated health care professionals led by primary care
\nphysicians are crucial to success. International aid and development
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\nprograms need to move from \u201cvertical focus\u201d on single diseases or
\nobjectives to a more sustainable and effective primary care health
\ninfrastructure development.
\nNote: Depending on the country, different stakeholders will assume
\ngreater or lesser responsibility for change.
\nFor World Governments:
\n1. Support global immunization strategies;
\n2. Support global tobacco and alcohol control strategies;
\n3. Promote healthy living and implement policies that support
\nprevention and healthy lifestyle behaviours;
\n4. Set aside a fixed percentage of national budget for health infra-
\nstructure development and promotion of healthy lifestyles.
\n5. Promote trade policy that protects public health;
\n6. Promote research for prevention and treatment of chronic disease;
\n7. Develop global strategies for the prevention of obesity.
\nFor National Medical Associations:
\n1. work to create communities that promote healthy lifestyles and
\nprevention behaviours and to increase physician awareness of
\noptimal disease prevention behaviours;
\n2. offer patients smoking cessation, weight control strategies, sub-
\nstance abuse counselling, self-management education and sup-
\nport, and nutritional counselling;
\n3. promote a team-based approach to chronic disease management;
\n4. advocate for integration of chronic disease prevention and con-
\ntrol strategies in government-wide policies;
\n5. invest in high quality training for more primary care physicians
\nand an equitable distribution of them among populations;
\n6. provide high quality accessible resources for continuing medical
\neducation;
\n7. support establishing evidence-based standards of care for chro-
\nnic disease;
\n8. establish, support and strengthen professional associations for
\nprimary care physicians
\n9. promote medical education that is responsive to societal needs;
\n10. promote an environment of support for continuity of care for
\nchronic disease, including patient education and self-manage-
\nment;
\n11. advocate for policies and regulations to reduce factors that pro-
\nmote chronic disease such as smoking cessation and blood pres-
\nsure control;
\n12. support strong public health infrastructure; and
\n13. support the concept that social determinants are part of preven-
\ntion and health care.
\nFor Medical Schools:
\n1. develop curriculum objectives that meet societal needs; e.g., so-
\ncial accountability;
\n2. focus on providing primary care training opportunities that
\nhighlight the integrative and continuity elements of the primary
\ncare specialties including family medicine;
\n3. provide community-oriented and community-based primary
\ncare educational venues so that students become acquainted
\nwith the basic elements of chronic care infrastructure and con-
\ntinuity care provision;
\n4. create departments of family medicine that are of equal aca-
\ndemic standing in the university; and
\n5. promote the use of interdisciplinary and other collaborative
\ntraining methodologies within primary and continuing educa-
\ntion programs.
\n6. Include instruction in prevention of chronic diseases in the gen-
\neral curriculum.
\nFor Individual Physicians:
\n1. work to create communities that promote healthy lifestyles and
\nprevention behaviours;
\n2. offer patients smoking cessation, weight control strategies, sub-
\nstance abuse counselling, self-management education and sup-
\nport, and nutritional counselling;
\n3. promote a team-based approach to chronic disease manage-
\nment;
\n4. ensure continuity of care for patients with chronic disease;
\n5. model prevention behaviours to patients by maintaining per-
\nsonal health;
\n6. become community advocates for positive social determinants
\nof health and for best prevention methods;
\n7. work with parents and the community to ensure that the par-
\nents have the best advice on maintaining the health of their
\nchildren.
\n8. Physicians should collaborate with patients\u2019 associations in de-
\nsigning and delivering prevention education.
\nRevision of WMA Declaration
\nof Edinburgh on Prison
\nConditions and the Spread
\nof Tuberculosis and other
\nCommunicable Diseases
\nPrisoners enjoy the same health care rights as all other people. This
\nincludes the right to humane treatment and appropriate medical
\ncare. The standards for the treatment of prisoners have been set
\ndown in a number of Declarations and Guidelines adopted by vari-
\nous bodies of the United Nations.
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\nThe relationship between physician and prisoner is governed by the
\nsame ethical principles as that between the physician and any other
\npatient. There are specific tensions within the patient\/physician re-
\nlationship, which do not exist in other settings, in particular the re-
\nlationship of the physician with his\/her employer,the prison service,
\nand the general attitude of society to prisoners.
\nThere are also strong public health reasons for reinforcing the im-
\nportance of these rules.The high incidence of tuberculosis amongst
\nprisoners in a number of countries reinforces the need for consid-
\nering public health as an important element when designing new
\nprison regimens, and for reforming existing penal and prison sys-
\ntems.
\nIndividuals facing imprisonment are often from the most margin-
\nalised sections of society, may have had limited access to health care
\nbefore imprisonment, may suffer worse health that many other citi-
\nzens and may enter prison with undiagnosed, undetected and un-
\ntreated health problems.
\nPrisons can be breeding grounds for infection. Overcrowding,
\nlengthy confinement within tightly enclosed, poorly lit, badly
\nheated and consequently poorly ventilated and often humid spaces
\nare all conditions frequently associated with imprisonment and all
\nof which contribute to the spread of disease and ill-health. Where
\nthese factors are combined with poor hygiene, inadequate nutrition
\nand limited access to adequate health care, prisons can represent a
\nmajor public health challenge.
\nKeeping prisoners in conditions, which expose them to substantial
\nmedical risk,poses a humanitarian challenge.An infectious prisoner
\nis a risk to other prisoners,prison personnel,relatives and other pris-
\non visitors and the wider community \u2013 not only when the prisoner
\nis released, but also because prison bars do not keep Tuberculosis
\nbacilli from spreading into the outside world. The most effective
\nand efficient way of reducing disease transmission is to improve the
\nprison environment, by putting together an efficient medical service
\nthat is capable of detecting and treating the disease,and by targeting
\nprison overcrowding as the most urgent action.
\nThe increase in active Tuberculosis in prison populations and the
\ndevelopment within some of these populations of resistant and es-
\npecially \u201cmulti-drug\u201dand \u201cextremely-drug\u201dresistant forms of TB, as
\nrecognised by the World Medical Association in its Statement on
\nDrug Treatment of Tuberculosis, is reaching very high prevalence
\nand incidence rates in prisons in some parts of the world.
\nOther conditions, such as Hepatitis C and HIV Disease, do not
\nhave as high a risk of person-to- person communicability as TB but
\npose transmission risks from blood to blood borne spread, or shar-
\ning and exchange of body fluids. Overcrowded prison conditions
\nalso promote the spread of sexually transmitted diseases. Intrave-
\nnous drug use will also contribute to the spread of HIV as well as
\nthe more contagious Hepatitis B and C. These need specific solu-
\ntions that are not dealt with in this statement. However the prin-
\nciples set out below will also be helpful in reducing the risk from
\nsuch infective agents.
\nActions Required
\nThe World Medical Association considers it essential both for pub-
\nlic health and humanitarian reasons that careful attention is paid to:
\n1. Protecting the rights of prisoners according to the various UN
\ninstruments relating to conditions of imprisonment. Prisoners
\nshould enjoy the same rights as other patients, as outlined in the
\nWMA Declaration of Lisbon;
\n2. Not allowing the rights of prisoners to be ignored or invalidated
\nbecause they have an infectious illness;
\n3. Ensuring that the conditions in which detainees and prisoners
\nare kept, whether they are held during the investigation of a
\ncrime, whilst waiting for trial, or as punishment once sentenced,
\ndo not contribute to the development, worsening or transmis-
\nsion of disease.
\n4. Ensuring that persons being held while going through immi-
\ngration procedures, are kept in conditions which do not encour-
\nage the spread of disease, although prisons should not normally
\nbe used to house such persons;
\n5. Ensuring the coordination of health services within and out-
\nside prisons to facilitate continuity of care and epidemiological
\nmonitoring of inmate patients when they are released;
\n6. Ensuring that prisoners are not isolated, or placed in solitary
\nconfinement, as a response to their infected status without ad-
\nequate access to health care and the appropriate medical treat-
\nment of their infected status;
\n7. Ensuring that, upon admission to or transfer to a different pris-
\non, inmates\u2019 health status is reviewed within 24 hours of arrival
\nto assure continuity of care;
\n8. Ensuring the provision of follow-up treatment for prisoners
\nwho, on their release, are still ill, particularly with TB or any
\nother infectious disease. Because erratic treatments or inter-
\nruptions of treatment may be particularly hazardous epide-
\nmiologically and to the individual, planning for and providing
\ncontinuing care are essential elements of prison health care
\nprovision;
\n9. Recognising that the public health mechanisms, which may in
\nthe rarest and most exceptional cases involve the compulsory
\ndetention of individuals who pose a serious risk of infection to
\nthe wider community must be efficacious, necessary and justi-
\nfied, and proportional to the risks posed. Such steps should be
\nexceptional and must follow careful and critical questioning of
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\nWMA newsUNITED STATES
\nthe need for such constraints and the absence of any effective al-
\nternative.In such circumstances detention should be for as short
\na time as possible and be as limited in restrictions as feasible.
\nThere must also be a system of independent appraisal and pe-
\nriodic review of any such measures, including a mechanism for
\nappeal by the patients themselves. Wherever possible alterna-
\ntives to such detention should be used;
\n10. This model should be used in considering all steps to prevent
\ncross infection and to treat existing infected persons within the
\nprison environment.
\n11. Physicians working in prisons have a duty to report to the health
\nauthorities and professional organisations of their country any
\ndeficiency in health care provided to the inmates and any situ-
\nation involving high epidemiological risk. NMAs are obliged
\nto attempt to protect those physicians against any possible re-
\nprisals.
\n12. Physicians working in prisons have a duty to follow national
\npublic health guidelines, where these are ethically appropriate,
\nparticularly concerning the mandatory reporting of infectious
\nand communicable diseases.
\n13. The WMA calls upon member associations to work with na-
\ntional and local governments and prison authorities to address
\nhealth promotion and health care in their institutions, and to
\nadopt programmes that ensure a safe and healthy prison envi-
\nronment.
\nWMA Statement on Social
\nDeterminants of Health
\nAdopted by the 62nd
\nWMA General Assembly, Montevideo, Uruguay,
\nOctober 2011
\nThe social determinants of health are: the conditions in which peo-
\nple are born, grow, live, work and age; and the societal influences
\non these conditions. The social determinants of health are major
\ninfluences on both quality of life, including good health, and length
\nof disability-free life expectancy. While health care will attempt to
\npick up the pieces and repair the damage caused by premature ill
\nhealth,it is these social,cultural,environmental,economic and other
\nfactors that are the major causes of rates of illness and, in particular,
\nthe magnitude of health inequalities.
\nHistorically, the primary role of doctors and other health care pro-
\nfessionals has been to treat the sick \u2013 a vital and much cherished
\nrole in all societies.To a lesser extent, health care professionals have
\ndealt with individual exposures to the causes of disease \u2013 smoking,
\nobesity, and alcohol in chronic disease, for example. These familiar
\naspects of life style can be thought of as \u2018proximate\u2019causes of disease.
\nThe work on social determinants goes far beyond this focus on prox-
\nimate causes and considers the \u201ccauses of the causes\u201d. For example,
\nsmoking, obesity, alcohol, sedentary life style are all causes of ill-
\nness. A social determinants approach addresses the causes of these
\ncauses; and in particular how they contribute to social inequalities
\nin health. It focuses not only on individual behaviours but seeks
\nto address the social and economic circumstances that give rise to
\npremature ill health, throughout the life course: early child devel-
\nopment, education, work and living conditions, and the structural
\ncauses that give rise to these living and working conditions.In many
\nsocieties, unhealthy behaviours follow the social gradient: the lower
\npeople are in the socioeconomic hierarchy, the more they smoke,
\nthe worse their diet, and the less physical activity they engage in.
\nA major, but not the only, cause of the social distribution of these
\ncauses is level of education. Other specific examples of addressing
\nthe causes of the causes: price and availability, which are key drivers
\nof alcohol consumption; taxation, package labelling, bans on adver-
\ntising, and smoking in public places, which have had demonstrable
\neffects on tobacco consumption.The voice of the medical profession
\nhas been most important in these examples of tackling the causes
\nof the causes.
\nThere is a growing movement, globally, that seeks to address gross
\ninequalities in health and length of life through action on the so-
\ncial determinants of health.This movement has involved the World
\nHealth Organisation, several national governments, civil society or-
\nganization, and academics. Solutions are being sought and learning
\nshared. Doctors should be well informed participants in this debate.
\nThere is much that can happen within the practice of medicine that
\ncan contribute directly and through working with other sectors.The
\nmedical profession can be advocates for action on those social con-
\nditions that have important effects on health.
\nThe WMA could add significant value to the global efforts to ad-
\ndress these social determinants by helping doctors, other health
\nprofessionals and National Medical Associations understand what
\nthe emerging evidence shows and what works, in different circum-
\nstances. It could help doctors to lobby more effectively within their
\ncountries and across international borders, and ensure that medical
\nknowledge and skills are shared.
\nThe WMA should help to gather data of examples that are working,
\nand help to engage doctors and other health professionals in trying
\nnew and innovative solutions. It should work with national associa-
\ntions to educate and inform their members and put pressure on na-
\ntional governments to take the appropriate steps to try to minimise
\nthese root causes of premature ill health. In Britain, for example, the
\nnational government has issued a public health white paper that has
\nat its heart reduction of health inequalities through action on the so-
\ncial determinants of health; several local areas have drawn up plans of
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\naction; there are good examples of general practice that work across
\nsectors improve the quality of people\u2019s lives and hence reduce health
\ninequalities. The WMA should gather examples of good practice
\nfrom its members and promote further work in this area.
\nWMA Resolution reaffirming the
\nWMA Resolution on Economic
\nEmbargoes and Health
\nAdopted by the 62nd
\nGeneral Assembly, Montevideo, Uruguay
\nThe World Medical Association is deeply concerned about reports
\nof potential serious health impacts resulting from economic sanc-
\ntions imposed by the European Union against Ivory Coast leader,
\nLaurent Gbagbo, and numerous individuals and entities associated
\nwith his regime, including two major ports linked to Gbagbo\u2019s gov-
\nernment. The sanctions aim to severely restrict EU-registered ves-
\nsels from transacting business with these ports, which could inhibit
\nthe delivery of necessary and life-saving medicines.
\nThe WMA General Assembly reiterates the following position
\nfrom the WMA Resolution on Economic Embargoes and Health:
\n\u2022 All people have the right to the preservation of health; and,
\n\u2022 the Geneva Convention (Article 23, Number IV, 1949) requires the
\nfree passage of medical supplies intended for civilians;
\nThe WMA therefore urges the European Union to take steps im-
\nmediately to ensure the delivery of medical supplies to the Ivory
\nCoast, in order to protect the life and health of the population.
\nWMA Statement on the
\nProtection and Integrity of
\nMedical Personnel in Armed
\nConflicts and Other Situations
\nof Violence
\nAdopted by the 62nd
\nGeneral Assembly, Montevideo, Uruguay,
\nOctober 2011
\nPREAMBLE
\n1. During wars and armed conflicts hospitals and other medical
\nfacilities have often been attacked and misused and patients and
\nmedical personnel have been killed or wounded. Such attacks
\nare a violation of the Geneva Conventions (1949), Additional
\nProtocols to the Geneva Conventions (1977) and WMA regu-
\nlations in times of war (2006).
\n2. The World Medical Association (WMA) has been active in
\ncondemning documented attacks on medical personnel and fa-
\ncilities in armed conflicts. The International Committee of the
\nRed Cross (ICRC) Geneva Conventions and their Additional
\nProtocols shall protect medical personnel in international and
\nnon-international armed conflicts. The warring parties have
\nduty not to interfere with medical care for wounded or sick
\ncombatants and civilians, and not attack, threaten or impede
\nmedical functions. Physicians and other health care personnel
\nmust be considered as neutral and must not be prevented from
\nfulfilling their duties.
\n3. The lack of systematic reporting and documentation of vio-
\nlence against medical personnel and facilities creates threats
\nto both civilians and military personnel. The development of
\nstrategies for protection and efforts to improve compliance
\nwith the laws of war are impeded as long as such information
\nis not available.
\nSTATEMENT
\n4. The World Medical Association condemns all attacks on and
\nmisuse of medical personnel, facilities and vehicles in armed
\nconflicts. These attacks put people in need of help in great dan-
\nger and can lead to the flight of physicians and other health
\npersonnel from the conflict areas with a lack of available medical
\npersonnel as a result.
\n5. Currently no party is responsible for collecting data regarding
\nassaults on medical personnel and facilities. Data collection af-
\nter attacks is vital to identify the reasons why medical person-
\nnel and facilities are attacked. Such data are important in order
\nto understand the nature of the attacks and to take necessary
\nsteps to prevent attacks in the future. All attacks must also be
\nproperly investigated and those responsible for the violations
\nof the Geneva Conventions and Protocols must be brought to
\njustice.
\n6. The WMA requests that appropriate international bodies
\nestablish mechanisms with the necessary resources to collect
\nand disseminate data regarding assaults on physicians, other
\nhealth care personnel and medical facilities in armed conflicts.
\nSuch mechanisms could include the establishment of a new
\nUnited Nations post of Rapporteur on the independence and
\nintegrity of health professionals. As stated in the WMA pro-
\nposal for a United Nations Rapporteur on the Independence
\nand Integrity of Health Professionals (1997), \u201cThe new rap-
\nporteur would be charged with the task of monitoring that
\ndoctors are allowed to move freely and that patients have ac-
\ncess to medical treatment, without discrimination as to na-
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\nWMA newsUNITED STATES
\ntionality or ethnic origin, in war zones or in situations of po-
\nlitical tension\u201d.
\n7. When a reporting system is established the WMA will recom-
\nmend to their member organisations reporting armed conflicts
\nwhich they become aware of.
\nWMA Resolution on the
\nAccess to Adequate Pain
\nTreatment
\nAdopted by the 62nd
\nWMA General Assembly, Montevideo, Uruguay,
\nOctober 2011
\nPREAMBLE
\n1. Around the world, tens of millions of people with cancer and
\nother diseases and conditions experience moderate to severe
\npain without access to adequate treatment. These people face
\nsevere suffering, often for months on end, and many eventually
\ndie in pain, which is unnecessary and almost always preventable
\nand treatable. People who may not be able to adequately express
\ntheir pain \u2013 such as children and people with intellectual dis-
\nabilities or with consciousness impairments \u2013 are especially at
\nrisk of receiving inadequate pain treatment.
\n2. It is important to acknowledge the indirect consequences of in-
\nadequate pain treatment, such as a negative economic impact, as
\nwell as the individual human suffering directly resulting from
\nuntreated pain.
\n3. In most cases, pain can be stopped or relieved with inexpensive
\nand relatively simple treatment interventions, which can dra-
\nmatically improve the quality of life for patients.
\n4. It is accepted that some pain is particularly difficult to treat and
\nrequires the application of complex techniques by, for example,
\nmultidisciplinary teams. Sometimes, especially in cases of severe
\nchronic pain,psycho-emotional factors are even more important
\nthan biological factors.
\n5. Lack of education for health professionals in the assessment
\nand treatment of pain and other symptoms, and unnecessarily
\nrestrictive government regulations (including limiting access to
\nopioid pain medications) are two major reasons for this treat-
\nment gap.
\nPRINCIPLES
\n6. The right to access to pain treatment for all people without dis-
\ncrimination, as laid down in professional standards and guide-
\nlines and in international law, should be respected and effec-
\ntively implemented.
\n7. Physicians and other health care professionals have an ethical
\nduty to offer proper clinical assessments to patients with pain
\nand to offer appropriate treatment, which may require prescrib-
\ning medications \u2013 including opioid analgesics \u2013 as medically
\nindicated. This also applies to children and other patients who
\ncannot always adequately express their pain.
\n8. Instruction on pain management, including clinical training
\nlectures and practical cases, should be included in mandatory
\ncurricula and continuing education for physicians and other
\nhealth professionals. Such education should include evidence-
\nbased therapies effective for pain, both pharmacological and
\nnon-pharmacological. Education about opioid therapy for pain
\nshould include the benefits and risks of the therapy. Safety con-
\ncerns regarding opioid therapy should be emphasized to allow
\nthe use of adequate doses of analgesia while mitigating detri-
\nmental effects of the therapy. Training should also include rec-
\nognition of pain in those who may not be able to adequately
\nexpress their pain, including children, and cognitively impaired
\nand mentally challenged individuals.
\n9. Governments must ensure the adequate availability of controlled
\nmedicines, including opioids, for the relief of pain and suffering.
\nGovernmental drug control agencies should recognize severe
\nand\/or chronic pain as a serious and common health care issue
\nand appropriately balance the need to relieve suffering with the
\npotential for the illegal use of analgesic drugs. Under the right
\nto health, people facing pain have a right to appropriate pain
\nmanagement, including effective medications such as morphine.
\nDenial of pain treatment violates the right to health and may be
\nmedically unethical.
\n10. Many countries lack necessary economic, human and logistic
\nresources to provide optimal pain treatment to their population.
\nThe reasons for not providing adequate pain relief must there-
\nfore be fully clarified and made public before accusations of vio-
\nlating the right to health are made.
\n11. International and national drug control policies should balance
\nthe need for adequate availability and accessibility of controlled
\nmedicines like morphine and other opioids for the relief of pain
\nand suffering with efforts to prevent the misuse of these con-
\ntrolled substances. Countries should review their drug control
\npolicies and regulations to ensure that they do not contain pro-
\nvisions that unnecessarily restrict the availability and accessibil-
\nity of controlled medicines for the treatment of pain. Where
\nunnecessarily or disproportionately restrictive policies exist,they
\nshould be revised to ensure the adequate availability of con-
\ntrolled medicines.
\n12. Each government should provide the necessary resources for the
\ndevelopment and implementation of a national pain treatment
\nplan, including a responsive monitoring mechanism and process
\nfor receiving complaints when pain is inadequately treated.
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\nWMA Statement on Health
\nHazards of Tobacco Products and
\nTobacco-Derived Products
\nAdopted by the 40th
\nWorld Medical Assembly, Vienna, Austria, Septem-
\nber 1988 and amended by the 49th
\nWMA General Assembly, Hamburg,
\nGermany, November 1997 the 58th
\nWMA General Assembly, Copenha-
\ngen, Denmark, October 2007 and the 62nd
\nGeneral Assembly, Montevi-
\ndeo, Uruguay, October 2011
\nPREAMBLE
\nMore than one in three adults worldwide (more than 1.1 billion
\npeople) smokes, 80 percent of whom live in low- and middle-in-
\ncome countries. Smoking and other forms of tobacco use affect ev-
\nery organ system in the body, and are major causes of cancer, heart
\ndisease, stroke, chronic obstructive pulmonary disease, fetal damage,
\nand many other conditions. Five million deaths occur worldwide
\neach year due to tobacco use. If current smoking patterns continue,
\nit will cause some 10 million deaths each year by 2020 and 70 per-
\ncent of these will occur in developing countries.Tobacco use was re-
\nsponsible for 100 million deaths in the 20th
\ncentury and will kill one
\nbillion people in the 21st
\ncentury unless effective interventions are
\nimplemented. Furthermore, secondhand smoke \u2013 which contains
\nmore than 4000 chemicals, including more than 50 carcinogens and
\nmany other toxins \u2013 causes lung cancer, heart disease, and other ill-
\nnesses in nonsmokers.
\nThe global public health community, through the World Health
\nOrganization (WHO), has expressed increasing concern about the
\nalarming trends in tobacco use and tobacco-attributable disease. As
\nof 20 September 2007, 150 countries had ratified the Framework
\nConvention on Tobacco Control (FCTC), whose provisions call
\nfor ratifying countries to take strong action against tobacco use by
\nincreasing tobacco taxation, banning tobacco advertising and pro-
\nmotion, prohibiting smoking in public places and worksites, imple-
\nmenting effective health warnings on tobacco packaging, improv-
\ning access to tobacco cessation treatment services and medications,
\nregulating the contents and emissions of tobacco products, and
\neliminating illegal trade in tobacco products.
\nExposure to secondhand smoke occurs anywhere smoking is per-
\nmitted: homes, workplaces, and other public places. According to
\nthe WHO, some 200,000 workers die each year due to exposure
\nto smoke at work, while about 700 million children, around half
\nthe world\u2019s total, breathe air polluted by tobacco smoke, particularly
\nin the home. Based on the evidence of three recent comprehensive
\nreports (the International Agency for Research on Cancer\u2019s Mono-
\ngraph 83, Tobacco Smoke and Involuntary Smoking; the United
\nStates Surgeon General\u2019s Report on The Health Consequences of
\nInvoluntary Exposure to Tobacco Smoke; and the California Envi-
\nronmental Protection Agency\u2019s Proposed Identification of Environ-
\nmental Tobacco Smoke as a Toxic Air Contaminant), on May 29,
\n2007, the WHO called for a global ban on smoking at work and in
\nenclosed public places.
\nThe tobacco industry claims that it is committed to determining the
\nscientific truth about the health effects of tobacco, both by conduct-
\ning internal research and by funding external research through jointly
\nfunded industry programs.However,the industry has consistently de-
\nnied, withheld, and suppressed information concerning the deleteri-
\nous effects of tobacco smoking. For many years the industry claimed
\nthat there was no conclusive proof that smoking tobacco causes dis-
\neases such as cancer and heart disease. It has also claimed that nico-
\ntine is not addictive.These claims have been repeatedly refuted by the
\nglobal medical profession, which because of this is also resolutely op-
\nposed to the massive advertising campaigns mounted by the industry
\nand believes strongly that the medical associations themselves must
\nprovide a firm leadership role in the campaign against tobacco.
\nThe tobacco industry and its subsidiaries have for many years sup-
\nported research and the preparation of reports on various aspects of
\ntobacco and health. By being involved in such activities, individual
\nresearchers and\/or their organizations give the tobacco industry an
\nappearance of credibility even in cases where the industry is not able
\nto use the results directly in its marketing. Such involvement also
\nraises major conflicts of interest with the goals of health promotion.
\nRECOMMENDATIONS
\nThe WMA urges the national medical associations and all physi-
\ncians to take the following actions to help reduce the health hazards
\nrelated to tobacco use:
\n1. Adopt a policy position opposing smoking and the use of to-
\nbacco products, and publicize the policy so adopted.
\n2. Prohibit smoking, including use of smokeless tobacco, at all
\nbusiness, social, scientific, and ceremonial meetings of the Na-
\ntional Medical Association, in line with the decision of the
\nWorld Medical Association to impose a similar ban at all its
\nown such meetings.
\n3. Develop, support, and participate in programs to educate the
\nprofession and the public about the health hazards of tobacco
\nuse (including addiction) and exposure to secondhand smoke.
\nPrograms aimed at convincing and helping smokers and smoke-
\nless tobacco users to cease the use of tobacco products and pro-
\ngrams for non-smokers and non-users of smokeless tobacco
\nproducts aimed at avoidance are both important.
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\n4. Encourage individual physicians to be role models (by not using to-
\nbacco products) and spokespersons for the campaign to educate the
\npublic about the deleterious health effects of tobacco use and the
\nbenefits of tobacco-use cessation.Ask all medical schools,biomedi-
\ncal research institutions, hospitals, and other health care facilities
\nto prohibit smoking, use of smokeless tobacco on their premises.
\n5. Introduce or strengthen educational programs for medical stu-
\ndents and physicians to prepare them to identify and treat to-
\nbacco dependence in their patients.
\n6. Support widespread access to evidence-based treatment for to-
\nbacco dependence \u2013 including counselling and pharmacother-
\napy \u2013 through individual patient encounters, cessation classes,
\ntelephone quit-lines, web-based cessation services, and other
\nappropriate means.
\n7. Develop or endorse a clinical practice guideline on the treat-
\nment of tobacco use and dependence.
\n8. Join the WMA in urging the World Health Organization to
\nadd tobacco cessation medications with established efficacy to
\nthe WHO\u2019s Model List of Essential Medicines.
\n9. Refrain from accepting any funding or educational materials
\nfrom the tobacco industry, and to urge medical schools, research
\ninstitutions, and individual researchers to do the same, in order
\nto avoid giving any credibility to that industry.
\n10. Urge national governments to ratify and fully implement the
\nFramework Convention on Tobacco Control in order to protect
\npublic health.
\n11. Speak out against the shift in focus of tobacco marketing from
\ndeveloped to less developed nations and urge national govern-
\nments to do the same.
\n12. Advocate the enactment and enforcement of laws that:
\n\u2022 provide for comprehensive regulation of the manufacture,sale,
\ndistribution, and promotion of tobacco and tobacco-derived
\nproducts, including the specific provisions listed below.
\n\u2022 require written and pictorial warnings about health hazards to
\nbe printed on all packages in which tobacco products are sold
\nand in all advertising and promotional materials for tobacco
\nproducts. Such warnings should be prominent and should
\nrefer those interested in quitting to available telephone quit-
\nlines, websites, or other sources of assistance.
\n\u2022 prohibit smoking in all enclosed public places (including
\nhealth care facilities, schools, and education facilities), work-
\nplaces (including restaurants, bars and nightclubs) and public
\ntransport. Mental health and chemical dependence treatment
\ncenters should also be smoke-free. Smoking in prisons should
\nnot be permitted.
\n\u2022 ban all advertising and promotion of tobacco and tobacco-
\nderived products.
\n\u2022 encourage the development of plain packaging legislation
\n\u2022 prohibit the sale, distribution, and accessibility of cigarettes,
\nand other tobacco products to children and adolescents. Ban
\nthe production, distribution and sale of candy products that
\ndepict or resemble tobacco products.
\n\u2022 prohibit smoking on all commercial airline flights within
\nnational borders and on all international commercial airline
\nflights, and prohibit the sale of tax-free tobacco products at
\nairports and all other locations.
\n\u2022 prohibit all government subsidies for tobacco and tobacco-
\nderived products.
\n\u2022 provide for research into the prevalence of tobacco use and the
\neffects of tobacco products on the health status of the popula-
\ntion.
\n\u2022 prohibit the promotion, distribution, and sale of any new
\nforms of tobacco products that are not currently available.
\n\u2022 increase taxation of tobacco products, using the increased rev-
\nenues for prevention programs, evidence-based cessation pro-
\ngrams and services, and other health care measures.
\n\u2022 curtail or eliminate illegal trade in tobacco products and the
\nsale of smuggled tobacco products.
\n\u2022 help tobacco farmers switch to alternative crops.
\n\u2022 urge governments to exclude tobacco products from interna-
\ntional trade agreements.
\n13. Recognize that tobacco use may lead to pediatric disease be-
\ncause of the harm done to children caused by tobacco use and
\nsecond-hand smoke exposure, the relationship of tobacco use by
\nchildren and exposure to adult tobacco use, and the existence
\nof effective interventions to reduce tobacco use. Special efforts
\nshould be made by physicians to:
\n\u2022 provide tobacco-free environments for children
\n\u2022 target parents who smoke for tobacco cessation interventions
\n\u2022 promote programs that contribute to the prevention and de-
\ncrease of tobacco use by youth
\n\u2022 control access to and marketing of tobacco products, and
\n\u2022 make pediatric tobacco-control research a high priority
\n14. Refuse to invest in companies or firms producing or promoting
\nthe use or sale of tobacco.
\nWMA Declaration on Leprosy
\nControl around the World and
\nElimination of Discrimination
\nagainst Persons affected by Leprosy
\nAdopted by the 62nd
\nWMA General Assembly, Montevideo, Uruguay,
\nOctober 2011
\nLeprosy is a widespread public health problem, with approximately
\n250,000 new cases diagnosed annually worldwide. It is a curable
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\nWMA news UNITED STATES
\ndisease and after starting treatment, the chain of transmission is
\ninterrupted. Leprosy is a disease that have been inadequately ad-
\ndressed from the point of view of investments in research and medi-
\ncal treatment.
\nThe World Medical Association recommends to all National Medi-
\ncal Associations to defend the right of the people affected with
\nleprosy and members of their families, that they should be treated
\nwith dignity and free from any kind of prejudice or discrimination.
\nPhysicians, health professionals and civil society should be engaged
\nin combating all forms of prejudice and discrimination. Research
\ncentres should acknowledge leprosy as a major public health prob-
\nlem, and continue to research this disease since there are still gaps
\nin understanding its patho-physiological mechanisms.These gaps in
\nknowledge may be overcome through the allocation of resources to
\nnew research, which will contribute to more efficient control world-
\nwide. Medical schools, especially in countries with high prevalence
\nof leprosy, should enhance its importance in the curriculum. The
\npublic, private, and civil sectors should unify their best efforts in
\norder to disseminate information that would counteract prejudice
\ntowards leprosy and that acknowledges its curability.
\nWMA Resolution on Bahrain
\nAdopted by the 62nd
\nGeneral Assembly, Montevideo, Uruguay,
\nOctober 2011
\nThe WMA General Assembly notes that
\nA number of doctors, nurses and other health care professionals in
\nthe Kingdom of Bahrain were arrested in March 2011 after the civil
\nunrest in that country and tried under emergency powers before
\na special court, led by a military judge. Twenty of this group were
\nfound guilty of a number of charges, on 29 September 2011 and
\nsentenced to fifteen, ten or five years\u2019 imprisonment.
\nThese trials failed to meet international standards for fair trials, in-
\ncluding the accused not being allowed to make statements in their
\nown defence, and their lawyers not being allowed to question all the
\nwitnesses. Allegations from the accused and their lawyers of mis-
\ntreatment, abuse and other human right violations during arrest and
\nwhile in detention have not been investigated.
\nWhile various criminal charges were brought it appears that the
\nmajor offence was treating all the patients who presented for care,
\nincluding leaders and members of the rebellion. Other charges ap-
\npear to be closely related to providing such treatment and were, in
\nany case, not proven to the standard expected in court proceedings.
\nIn treating patients without considering the circumstances of their
\ninjury these health care professionals were honouring their ethical
\nduty as set out in the Declaration of Geneva.
\nThe WMA welcomes the announcement by the government of
\nBahrain of 6 October 2011 that all twenty will be re-tried before
\na full civil court.
\nTherefore, the WMA requires that no doctor or other health care
\nprofessional be arrested, accused or tried for treating patients, re-
\ngardless of the origins of the patient\u2019s injury or illness.
\nThe WMA demands that all states understand, respect and honour
\nthe concept of medical neutrality. This includes providing working
\nconditions which are as safe as possible, even under difficult circum-
\nstances, including armed conflict or civil unrest.
\nThe WMA expects that if any individual, including health care pro-
\nfessionals, are subject to trial that there is due process of law in-
\ncluding during arrest, questioning and trial in accordance with the
\nhighest standards of international law.
\nThe WMA demands that states investigate any allegations of torture
\nor cruel and inhumane treatment by prisoners against its agents,and
\nact quickly to stop such abuses.
\nThe WMA recommends that independent international assessors
\nare allowed to observe the trials and meet privately with the accused,
\nso that the state of Bahrain can prove to the watching world that the
\nfuture legal proceedings follow fair process.
\nThe WMA recognises that health care workers and health care fa-
\ncilities are increasingly under attack during wars, conflicts and civil
\nunrest. We demand that states throughout the world recognise, re-
\nspect and honour principles of medical neutrality and their duty
\nto protect health care institutions and facilities for humanitarian
\nreasons.
\nWMA Resolution on the
\nIndependence of National
\nMedical Associations
\nAdopted by the 62nd
\nWMA General Assembly, Montevideo, Uruguay,
\nOctober 2011
\nNational medical associations are established to act as representa-
\ntives of their physicians, and to negotiate on their behalf, sometimes
\nas a trade union or regulatory body but also as a professional asso-
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\nWMA newsUNITED STATES
\nciation, representing the expertise of medical doctors in relation to
\nmatters of public health and wellbeing.
\nThey represent the views of the medical profession, including at-
\ntempting to ensure the practice of ethical medicine, the provision of
\ngood quality medical care, and the adherence to high standards by
\nall practitioners.
\nThese associations may also campaign or advocate on behalf of their
\nmembers, often in the field of public health. Such advocacy is not
\nalways welcomed by governments who may consider the advocacy
\nto have oppositional politics attached, when in reality it is based
\nupon an understanding of the medical evidence and the needs of
\npatients and populations.
\nThe WMA is aware that because of those advocacy efforts some
\ngovernments attempt to silence the medical association by placing
\nits own nominated representatives into positions of authority, to
\nsubvert the message into one they are better able to tolerate.
\nThe WMA denounces such action and demands that no govern-
\nment interferes with the independent functioning of national medi-
\ncal associations.It encourages governments to understand better the
\nreasons behind the work of their national medical association, to
\nconsider the medical evidence and to work with physicians to im-
\nprove the health and well being of their populations.
\nWMA Declaration of Montevideo
\non Disaster Preparedness and
\nMedical Response
\nAdopted by the 62nd
\nWMA General Assembly, Montevideo, Uruguay,
\nOctober 2011
\nIn the last decade, the attention of the world has been drawn to a
\nnumber of severe events which seriously tested and overwhelmed
\nthe capacity of local healthcare and emergency medical response
\nsystems. Armed conflicts, terrorist attacks and natural distasters
\nsuch as earthquakes, floods and tsunamies in various parts of the
\nworld have not only affected the health of people living in these
\nareas but have also drawn the support and response of the interna-
\ntional community. Many National Medical Associations have sent
\ngroups to assist in such disaster situations.
\nAccording to the World Health Organization (WHO) Center for
\nResearch on the Epidemiology of Disasters (CRED),the frequency,
\nmagnitude,and toll of natural disasters and terrorism have increased
\nthroughout the world. In the previous century, about 3.5 million
\npeople were killed worldwide as a result of natural disasters; about
\n200 million were killed as a result of human-caused disasters (e.g.,
\nwars, terrorism, genocides). Each year, disasters cause hundreds of
\ndeaths and cost billions of dollars due to disruption of commerce
\nand destruction of homes and critical infrastructure.
\nPopulation vulnerability (e.g., due to increased population density,
\nurbanization, aging) has increased the risk of disasters and pub-
\nlic health emergencies. Globalization, which connects countries
\nthrough economic interdependencies, has led to increased interna-
\ntional travel and commerce. Such activity has also led to increased
\npopulation density in cities around the world and increased move-
\nment of people to coastal areas and other disaster-prone regions.
\nIncreases in international travel may speed the rate at which an
\nemerging infectious disease or bioterrorism agent spreads across the
\nglobe. Climate change and terrorism have emerged as important
\nglobal factors that can influence disaster trends and thus require
\ncontinued monitoring and attention.
\nThe emergence of infectious diseases, such as H1N1 influenza A
\nand severe acute respiratory syndrome (SARS), and the recent ar-
\nrival of West Nile virus and monkey pox in the Western hemisphere,
\nreinforces the need for constant vigilance and planning to prepare
\nfor and respond to new and unexpected public health emergencies.
\nThe growing likelihood of terrorist-related disasters affecting large
\ncivilian populations affects all nations. Concern continues about the
\nsecurity of the worldwide arsenal of nuclear, chemical, and biologi-
\ncal agents as well as the recruitment of people capable of manufac-
\nturing or deploying them. The potentially catastrophic nature of a
\n\u201csuccessful\u201d terrorist attack configures an event that may demand
\na disproportionate amount of resources and healthcare profession-
\nals preparedness.. Natural disasters such as tornadoes, hurricanes,
\nfloods, and earthquakes, as well as industrial and transportation-re-
\nlated catastrophes, are far more common and can also severely stress
\nexisting medical, public health, and emergency response systems.
\nIn light of recent world events, it is increasingly clear that all physi-
\ncians need to become more proficient in the recognition, diagnosis,
\nand treatment of mass casualties under an all-hazards approach to
\ndisaster management and response. They must be able to recognize
\nthe general features of disasters and public health emergencies, and
\nbe knowledgeable about how to report them and where to get more
\ninformation should the need arise. Physicians are on the front lines
\nwhen dealing with injury and disease-whether caused by microbes,
\nenvironmental hazards, natural disasters, highway collisions, terror-
\nism, or other calamities. Early detection and reporting are critical
\nto minimize casualties through astute teamwork by public- and
\nprivate-sector health and emergency response personnel.
\n228
\nSocial Determinants of Health WHO
\nWhen the Global Commission on the
\nSocial Determinants of Health (Closing
\nthe Gap in a Generation) reported to the
\nWHO in 2009, one of its recommendations
\nwas that a global conference should be held
\nto take forward its recommendations, to de-
\nliver commitments from governments and
\nto ensure that learning from the commis-
\nsion report and subsequent actions in differ-
\nent countries became embedded in govern-
\nmental strategies.
\nIn October, the conference was held in Rio
\nde Janeiro. Hosted by the government of
\nBrazil working with the WHO, the confer-
\nence was an opportunity for activists, health
\ncare professionals and governments to come
\ntogether and share this important agenda.
\nThe conference was the largest WHO
\nhas pulled together since Alma Ata. Over
\n120 countries were present with ministers
\nfrom the majority attending the ministe-
\nrial \u201cstream\u201d. The question is whether Rio
\nwill become as seminal an event and the
\nRio Declaration as much of a \u201cmust read\u201d
\nfor generations of health workers and policy
\nadvisers.
\nThere could be no doubt from the opening
\nof the conference that the government of
\nBrazil \u201cgot it\u201d. The various ministers, gov-
\nernors and the acting President (or their
\nrespective speech writers) understood that
\nthis is not about simple inequities in health
\ncare access, but in the fundamental bases of
\nhealth, wellbeing and prosperity. Poverty,
\neducation, access to education, housing, and
\nwork all matter; equitable access to health
\ncare complements these elements.
\nAs Sir Michael Marmot states in his report,
\nit is the conditions into which we are born
\nand in which we grow, learn, live, work and
\nage, that shape our expectation of health.
\nIt is by action within areas including the
\nenvironment, housing and transport poli-
\ncies, access to employment, education, to
\nfood, clean water and sanitation that we
\ncan have an impact on children not yet
\nborn, and from their birth throughout their
\nlives. Medicine and the delivery of health
\ncare can pick up some of the pieces, make
\ngood some elements of loss or damage but it
\ncannot remove the differences these factors
\nmake to the lifelong expectations of health
\nin people born into different circumstances.
\nIn Brazil, we heard of work to raise tens of
\nmillions of people out of poverty; an essen-
\ntial step in securing the environmental and
\nother factors that will promote health rather
\nthan cause illness. Reducing poverty means
\nan improvement in living conditions every
\nday for individuals, families and communi-
\nThe WMA, representing the doctors of the world, calls upon its
\nmembers to advocate for the following:
\n\u2022 To promote a standard competency set to ensure consistency
\namong disaster training programs for physicians across all special-
\nties. Many NMAs have disaster courses and previous experiences
\nin disaster response. These NMAs can share this knowledge and
\nadvocate for the integration of some standardized level of training
\nfor all physicians, regardless of specialty or nationality.
\n\u2022 To work with national and local governments to establish or up-
\ndate regional databases and geographic mapping of information
\non health system assets, capacities, capabilities, and logistics to
\nassist medical response efforts,domestically and worldwide,when
\nneeded.This could include information on local response organi-
\nzations, the condition of local hospitals and health system infra-
\nstructures, endemic and emerging diseases, and other important
\npublic health and clinical information to assist medical response
\nin the event of a disaster. In addition, systems for communicating
\ndirectly with physicians and other front line health care providers
\nshould be identified and strengthened.
\n\u2022 To work with national and local governments to ensure the devel-
\noping and testing of disaster management plans for clinical care
\nand public health including the ethical basis for delivering such
\nplans.
\n\u2022 To encourage governments at national and local levels to work
\nacross normal departmental and other boundaries in developing
\nthe necessary planning.
\nThe WMA could serve as a channel of communication for NMAs
\nduring such times of crisis, enabling them to coordinate activities
\nand work together.
\nReport on the World Conference on the
\nSocial Determinants of Health
\nRio de Janeiro, Brazil, 19\u201321 October 2011
\nVivienne Nathanson
\n229
\nWHO Social Determinants of Health
\nties. But financial, power and resource dif-
\nferences remain in every society.
\nThe gradients seen in every health and well-
\nbeing measurement between the richest and
\npoorest, the best and least well educated,
\nthose employed and those under or unem-
\nployed, the powerful and the powerless all
\nremain. In countries where such social dif-
\nference are relatively small, such as Finland,
\nthe differences between those with power,
\nresources, money, education and so on and
\nthose without are relatively small. In most
\ncountries, where such differences can be
\nvery large, the differences can be enormous.
\nThe conference heard examples of differ-
\nences within countries; in Glasgow, Scot-
\nland a 28 year difference in male life expec-
\ntancy for those born a mere five kilometres
\napart. Similar pictures exist everywhere, but
\nnot always this extreme, and disparities also
\nexist between countries. The North\/South
\ndivide is seen in social determinants terms,
\nwith the poorest countries showing the low-
\nest life and health expectancies. As well as
\nthe gradients between countries, even the
\npoorest country has gradients within it.
\nConcentrating efforts to improve health and
\nwellbeing on the poorest means missing out
\non the opportunity to help those just a little
\nhigher up the income, social class and other
\nladders, who are also falling far short of the
\nbest. This means either we tailor many dif-
\nferent plans to deal with people in different
\ngroups or we work in a different manner to
\ndeal first with the underpinning causes of
\nthe causes of ill health.
\nIf, in all our countries, we could not only re-
\nduce absolute poverty but ensure that the in-
\nequitable distribution of wealth, power and
\nresources was lessened, producing a flatter
\ncurve on all these variables, we would be go-
\ning a long way towards producing better dai-
\nly living conditions for all our populations.
\nIf that work looked not only at our own
\ncountries but considered global resources,
\nwe would be able to affect the inequities be-
\ntween countries as well as within them.
\nBut these interventions are not things that
\ncan be undertaken by one group alone.
\nTime after time throughout the conference,
\nspeakers referred to working across disci-
\nplines, across government departments and
\nacross natural boundaries. The silo mental-
\nity of thinking will not and cannot work.
\nFor doctors this is an interesting challenge.
\nWe are amongst the best educated members
\nof our societies. Our education is focused
\non health and illness; thinking about well-
\nbeing requires changing our mind-frames
\nand normal spheres of reference. But our
\nstrength is that we are trained to examine
\nthe evidence, to consider trends, statistics,
\nevidence bases and information and to criti-
\ncally appraise it. We are also well versed in
\nthe importance of evidence and of testing,
\nmonitoring and reviewing actions and ac-
\ntivities.This will be essential as policy shifts
\nstrategically. If we fail to measure and to
\ncritically appraise and evaluate actions, we
\nwill fail to make effective policies.
\nSo what was said at
\nthe conference?
\nFirstly, and of course, every speaker recog-
\nnised the importance of SDH, and of a so-
\ncial determinants based approach to health.
\nEqually, however, it was clear that many of
\nthe speakers, especially those representing
\nhealth ministries, were struggling with the
\nconcept, and were too willing to revert to
\ndiscussing methods of dealing with inequi-
\nties in access to health care.
\nOne interesting technique used at the con-
\nference was to have a journalist interview
\nspeakers, rather than having too many
\n\u201ctalking heads\u201d.Zeinab Badawi of the BBC,
\nwho hosts their daily World News and the
\nseries Hard Talk, filled several linked roles.
\nOn the opening day, immediately after the
\nformal opening session, she chaired a panel
\nin which she asked questions of a number of
\nspeakers. Her questions were incisive, dem-
\nonstrated a real knowledge of the subject,
\nand as with good journalism attempted to
\nget real answers from the politicians on the
\npanel.
\nAt the opening of the second day, she
\nshowed a film she had made in Rio and else-
\nwhere talking to the public and highlight-
\ning the huge differences in life and health
\nexpectancy within and between countries.
\nBased as she is in the UK, she picked up
\nthe Glasgow example where life expectan-
\ncy in men can vary by 28 years depending
\nupon where they are born, live, work and
\nage. There are many factors that adversely
\naffect boys born into this part of Glasgow.
\nThey include the greatly increased risks of
\npremature death due to violence, suicide
\nand drug use, including alcohol and tobac-
\nco. There are also other factors common in
\nthe poorest populations in developed world
\ncountries, such as low educational attain-
\nment, poor employment prospects leading
\nto insecure employment, and poorly paid
\nemployment. Housing is also worse for this
\ncohort. So there are many factors which can
\nin and of themselves lead to, for example,
\nlittle hope for a better future, and therefore
\nan increased risk of involvement in high risk
\nactivities such as drug and alcohol abuse.
\nThese factors seen in poverty are the causes
\nof the causes of ill health,and even the most
\nequitable health care system in the world
\ncannot deal with these factors and their
\nconsequences.
\nThe interesting experiment in Brazil, to
\nbring millions out of poverty, giving fami-
\nlies money and tokens to use to buy food,
\nhousehold cleaners,and education,may well
\nmake a difference that passes through gen-
\nerations.
\nThe Brazilian minister emphasised that this
\nprogramme did not ignore the economic
\ncontext. Policies are holistic and consider
\npoverty and family allowances and seek to
\nensure no back slipping in social policies.
\nThey try to link human development with
\n230
\nSocial Determinants of Health WHO
\nnew jobs. Redistribution of resources has,
\nin Brazil, brought 28 million out of poverty
\nand into the middle classes. They have used
\nfinancial interventions to build up and un-
\nderpin minimum wages and family finances.
\nThere is universal access to social and health
\ncare services. Specific schemes include a
\nfamily tax credits schemes (conditional tax
\nallowances) for 50 million Brazilians, and
\na programme which helps three million el-
\nderly. These schemes help to keep children
\nin school, and better nourished. They are
\nalso still working to increase the minimum
\nwage and other social benefits. Brazil ac-
\ncepts that it cannot eradicate poverty, but it
\nis trying to improve incomes, opportunities,
\neducation, social welfare and security and to
\nprovide universal access, not least by target-
\ning areas where poverty is rampant. Gains
\nare emblematic and practical.
\nThere are still problems. As Ms Badawi
\nasked the minister, \u201cIs there not a danger
\nthat a male family member might take the
\ntokens by force to use to support, for exam-
\nple, his alcohol habit?\u201d, the reply was wor-
\nryingly complacent, \u201cThis never happens.\u201d
\nAs doctors we know that even in the best
\nregulated system such abuses are inevitable;
\nthe question for those running the system is
\nwhat you can do to minimise that risk,espe-
\ncially as it carries an increased level of risk to
\nthe woman given the tokens, with the state
\nessentially increasing her likelihood of be-
\ning a victim of abuse.
\nSoundbites from the opening
\nsession included the following
\nfrom Margaret Chan
\nMargaret Chan of WHO stressed that
\nthere are elements in what needs to be
\ndone that stretch through all areas of life.
\nWe must embed social equity into mindsets
\nand actions; if we succeed, we may have an
\neffect. Millions of lives are cut short as the
\nright policies are not in place. Governments
\nworldwide could lift more than a billion
\npeople out of poverty. All governments have
\na responsibility for the health of popula-
\ntions, which includes dealing with social
\nissues. How many do not have a safety net
\nto stop people from falling into poverty be-
\ncause of catastrophic medical bills?
\nGlobalisation has benefits but has no rules
\nto ensure fair dispersal of those benefits.The
\ngoal of advocates of globalisation is to pro-
\nduce benefits; consideration of the fair dis-
\ntribution is rarely an aim. The world is out
\nof balance in health terms. This also means
\nit is neither stable nor secure.
\nShe went on to stress that there had been
\ntwo momentous events in 2011: the Arab
\nSpring and the UN conference on Non
\nCommunicable Diseases. Left unchecked,
\nNCDs cancel out the benefits of moderni-
\nsation and break the bank.It is essential that
\nwe tackle NCDs in all parts of the world. In
\nthe less developed world, such diseases are
\noften diagnosed late. This can lead to cata-
\nstrophic medical expenses for individuals
\nand their families, and cause billions of lost
\nincomes in terms of tax, as well as pushing
\nmillions below the poverty line.
\nBig tobacco\u2019s attempts to derail tobacco
\npolicies continue and, in Dr. Chan\u2019s view,
\nthe tobacco industry has reached a new low.
\nThe challenges are enormous. Will govern-
\nments put the health of all people ahead of
\nthe health of corporations? There are com-
\npelling personal and economic reasons for
\nacting and, in many cases, we know what
\nworks. The benefits of real success in re-
\nducing the Social Determinants are a prize
\nworth fighting for.
\nSoundbites from Andreas
\nLaverdos, Health and Social
\nSolidarity Minister in Greece
\nHe spoke about trying to maintain better so-
\ncial equity at a time of huge social and eco-
\nnomic pressures.It is widely known how bad
\nthe economic problems in Greece are.There
\nis no time to hesitate; it is essential that the
\ngovernment get it right, and lower the cost
\nof health care services while improving qual-
\nity and equity. The health care system deals
\nwith 30% more cases than before 2009, with
\n20% less resources.It is essential that Greece
\ndecreases salaries and presses for better use
\nof human and physical resources. They are
\nseeking to assure the best buying of mate-
\nrials. They are also undertaking structural
\nreforms, merging hospitals and departments
\nwithin them, and upgrading the role of pri-
\nmary health care services.
\nThey are also looking at who gets access to
\nthe health care system and seeking to im-
\nprove public health. One practical example
\nis that the waiting list for drug detoxifica-
\ntion treatment used to be seven years and is
\nnow one month.
\nAn excellent question from Ms Badawi on
\nmental health in times of economic cri-
\nsis led to a brief discussion of the lack of
\ndiscussion of mental health at the NCD
\nsummit. While all accept that time and
\ntherefore the agenda was limited, there was
\ncertainly concern in the hall that this essen-
\ntial area was omitted.
\nSoundbites from Kathleen
\nSebbelius, Secretary for
\nHealth in the USA
\nShe explained that they are active in the
\nUS at trying to improve health coverage for
\nmarginalised peoples, including the elderly.
\nThey are working to promote inter-sectoral
\ncollaboration.
\nUSA believes that working together we
\ncan produce a better world. Social causes
\nof disease cost people and economies dear.
\nDiabetes and Cardiovascular Disease cost
\nbillions but very few health care dollars are
\nspent on prevention. The current trend is
\n231
\nSocial Determinants of HealthWHO
\nthat one in three children born in the USA
\nwill suffer from diabetes; higher rates are
\nseen in Hispanic and African communities.
\nThis is imposing an economic burden on us
\nall. The cost of poor health is continuing to
\ngrow.
\nIt is essential to have a broad agenda to
\nmake sure every citizen has a chance to live
\nwell. She went on to say that we must rec-
\nognize that health is not a health care issue.
\nWe must design neighbourhoods to make it
\neasier to walk and cycle. Every government
\ndepartment is involved; every government
\ndecision should be considered to establish
\nwhat the health consequences will be; an es-
\nsential tool for Health in All Policies.
\nSoundbites from Rebecca
\nGreenspan of UN
\ndevelopment agency
\nShe identified some important areas for
\nunderstanding and action including that
\npoor people pay more for water, power
\nsupplies, etc. She also stressed that women
\nare poor in terms of income and of time,
\nwhich is itself an important driver of poor
\nhealth.
\nDuring the discussion a number of other
\nimportant points were raised. Societal and
\ncultural influences are very important. Is-
\nsues such as access by women to reproduc-
\ntive and health rights are very important,
\nbut no one seems to want to deal with this
\ntopic.
\nThe second session opened with
\nMs Badawi\u2019s film
\nand then interviews with
\nSir Michael Marmot and
\nKathleen Sebbelius
\nThe discussion with Michael Marmot ad-
\ndressed the issue of prioritisation. With so
\nmuch needing to be done what do you do
\nfirst? How do you set priorities? What is the
\nmost important action?
\nSir Michael said we must first look at the
\nproblem, and consider doing things such as
\nempowering and educating women, chang-
\ning their life expectancy. We should recog-
\nnise that all differences in life expectancy
\nare preventable.
\nAs a priority we must first determine to take
\na life course approach, and then there are
\npriorities for all areas of that life course.
\nMs Badawi asked how you do this in the
\ncurrent global economic crisis. Sir Michael
\ncommented that currently income inequali-
\nties are increasing almost everywhere. But
\ngovernments can save money if they im-
\nprove early child development and educa-
\ntion. Giving all children better education
\nincreases happiness, and, for example, leads
\nto less civil disruption including riots. Ev-
\nery dollar spent on early child development
\nsaves seven; this is good news economically.
\nWe cannot afford not to do this.
\nWe are at a time of dramatic change. We
\nnow recognise this is not only about pov-
\nerty and absolute deprivation. We are also
\nseeing the gradient in health. The nature
\nand content of our discussions has changed
\ndramatically, hence the agenda for the
\nglobal commission. Individuals must be at
\nthe centre of our considerations. We must
\nseek to empower people and create the con-
\nditions for individual to have control over
\ntheir lives, which requires changes to social
\nconditions.
\nIn a second interview setting the scene for
\nthe day of workshops, Kathleen Sebbelius
\nwas interviewed.
\nThe main determinants in US are poverty
\nand education. While poverty crosses all
\nracial and ethnic groups, leading are native
\nAmericans, African Americans and His-
\npanic people. They have more poverty with
\nworse health outcomes. 1\/3 of white chil-
\ndren are obese, 40% of African Americans
\nand Hispanic people are obese. In response
\nto a question as to what health problems
\nhave arisen from neglect of NCDs, Secre-
\ntary Sebbelius stated that as well as health
\ncosts there are workplace costs associated
\nwith absenteeism. These costs amount to
\ntwo and a half trillion dollars a year. Presi-
\ndent Obama cannot fix the US economy
\nwithout first fixing health and health care.
\nThe major cause of personal bankruptcy in
\nthe USA is health care costs. 2 1\/2 trillion
\ndollars on health are each year. Obama can-
\nnot fix the economy without fixing health
\nand health care. Major reason for bankrupt-
\ncy is health care costs.
\nHer department is now working in this
\narea. One major focus is on prevention,
\nwellness, etc recruiting more providers
\nwith cultural competency in barrio culture
\nto access those traditionally hard to reach
\nwith health promotion interventions.There
\nis a new focus on health and wellness in
\nschools, reintroducing exercise classes and
\nchanging school diets. Identification of this
\nstrategy to improving health is now better
\nresourced.
\nThe conference then broke into different
\nstreams, with workshop presentations and
\ndiscussions.
\nAlthough the conference was meant to be
\ninclusive, it was noticeable that at each of
\nDr. Margaret Chan,
\nWHO Director\u00a0\u2013
\nGeneral
\nProf. Sir Michael
\nMarmot
\n232
\nWHOSocial Determinants of Health
\nthe workshops a wide panel of presenters
\neach spoke, followed by questions clearly
\nflagged up in advance; many respondents
\nreading out pre-prepared answers. Few if
\nany questions were taken from the floor,
\nleaving the large numbers from civil society
\norganisations and non-governmental or-
\nganisations frustrated at the lack of interest
\nin their views.
\nIt was also noticeable that in answering
\nquestions, even those partially or wholly
\nscripted, some speakers slipped into the old
\nconcept and reverted to discussing equitable
\naccess to health care, not equitable access
\nto health. One minister was asked about
\nwhether educating women was important
\nand responded, that it was at that made
\nthem better able to understand hygiene in
\nthe home! While we have come a long way
\nin getting governments to speak about and
\nespouse the cause of SDH, it is clear that
\nmany still fail to understand the core con-
\ncepts. On the final morning, Ms Badawi
\nopened with a short film of interviews with
\npeople attending the conference and then
\ninterviews with a panel.
\nDuring this and a subsequent high level
\npanel session chaired by Riz Khan of Al
\nJazeera, groups representing public and
\ncalling for a stronger voice for people made
\ntheir voices heard.
\nA few short soundbites are set out below.
\n\u2022 Good governance brings transparency for
\npublic participation and leadership.
\n\u2022 Why is there a ten year gap in life expec-
\ntancy between indigenous people and the
\nrest of the population of Canada?
\n\u2022 We must deal with inequities. Health eq-
\nuity is a justice issue. And it is one that is
\ncost effective to deal with.
\n\u2022 If countries addressed global commis-
\nsion\u2019s recommendations, they would
\nimprove the equity issue. A life cycle
\napproach is at the centre of UNFPA ap-
\nproach.
\n\u2022 50% of maternal deaths happen in Africa
\nwhich has just 14% of world population.
\nWhy?
\n\u2022 Why are trade and food insecurity not in
\nthe Rio declaration? Agricultural subsi-
\ndies are rampant and hugely increase food
\ninsecurity.
\n\u2022 We must consider unfair trade in health
\npersonnel. Africa and Asia are being
\nstripped of their skilled personnel. We
\nshould look at compensation for brain
\nrobbery.
\n\u2022 Migration is an underconsidered issue.
\nThere are 214 million international mi-
\ngrants and 740 million internal migrants,
\neg in China. Migrants almost always ig-
\nnored including in global commission on
\nSDH. Since 1980s has been a feminisa-
\ntion of migrants.
\nAt this point, there were some few ques-
\ntions from the floor, including a sideswipe
\nat politicians, accused of being corrupt and
\nbought off by commercial organisations
\nsuch as tobacco and alcohol industries.
\nDuring the final session, another element
\nthat arose was the needs of indigenous
\npeoples. These groups are, in every country,
\nlikely to be those at the bottom of the gra-
\ndient in health and wellbeing. The reasons
\nare often very similar; they are often in the
\nworst housing, with the highest rates of
\npoor educational achievement and therefore
\npoor employment opportunities. In addi-
\ntion, in many countries they may have a far
\nhigher than average rate of alcohol or other
\ndrug dependence, which in addition to dire
\nhealth consequences further reduces their
\nopportunity to get and keep well paid em-
\nployment. As a group, they are often seri-
\nously distanced from the wishes and aspira-
\ntions of the rest of society,leading to further
\nsocial distancing and isolation. Their social
\nand cultural values may be dismissed by the
\nlarger society. To our shame, many societies
\ndo not care about this distancing,and rather
\nthan seeing it as something that the whole
\nsociety should address, seeking a solution
\nthat works for all social and cultural groups,
\nPresident of WMA Dr. Jos\u00e9 Luiz Gomes Do Amaral (first from the right) during the discussion
\n233
\nPsychological TherapiesGREAT BRITAIN
\nIt is well known that both new diagnoses
\nof psychiatric disorders and the suicide rate
\nhave gone up alarmingly since the recent
\nworld financial crisis began, but the back-
\nground psychiatric morbidity in most of
\nEurope was already of concern. This paper
\nlooks at a previously relatively poorly served
\npart of South London, which developed
\ncomprehensive psychological therapies ser-
\nvices over the last decade. Comparisons are
\ndrawn with potential service development
\nin Latvia and other similar states.
\nCurrently about 18% of the adult popula-
\ntion of England has at least one common
\nmental disorder. A similar proportion expe-
\nriences \u201csubthreshold symptoms\u201d [1]. An-
\nother survey found that 27% of the adult
\nEU population had a mental disorder in the
\nlast year [2].
\nThe King\u2019s Fund,an organisation in England
\nwhich researches important questions of
\nfunding, did a large survey of costs to soci-
\nety of mental health problems in 2006.They
\nlooked at what might be described as \u201cservice
\ncosts\u201dwhich included direct health and social
\ncare expenses.They added in, where possible,
\nthe expenses related to other \u201cinformal care\u201d,
\nand the criminal justice system. They also
\nestimated costs to the state, especially the
\ncosts of lost employment.The current service
\ncosts for treating mental health disorders is
\naround \u00a322.5 billion pounds per year, whilst
\nthe cost of lost employment currently is \u00a326
\nbillion per year. There are estimates which
\nadd in other costs (e.g. time lost to work by
\nfamily members looking after their unwell
\nrelatives). These estimates put the true total
\ncosts many times higher.In the EU,other re-
\nsearchers have found that the vast majority of
\nthe cost of mental ill health is not treatment.
\nThese studies looked at indirect costs marked
\nby the loss of productivity due to early death,
\npremature death or early retirement all of
\nwhich mount up. The low direct costs of
\ntreatment contrast to the typical picture for
\nsomatic disorders.
\nThe King\u2019s Fund estimated various costs as-
\nsociated with depression, anxiety and per-
\nsonality disorders [8]. Something like 1.24
\nmillion people have a diagnosis of depres-
\nWhat can be Gained by
\nDeveloping Psychological Therapies
\nfor the General Public?
\nAnita Timans
\nsocieties may further reject their indigenous
\npeople.
\nAnd then, in the final session, the Rio Dec-
\nlaration was adopted. It is remarkably quiet
\nin its references to the Global Commission
\nreport which led to the conference; perhaps
\nthe leadership is not ready to take on vested
\ninterests, including those of the 1% who
\ncontrol so much of global resources. Those
\nof us who were not part of national delega-
\ntions came away revitalised and reinvigorat-
\ned, with new contacts, new role models and
\nrenewed hope that we can make a difference.
\nAs Peter Carmel of the American Medical
\nAssociation says of Michael Marmot, he
\nis a quiet revolutionary. The need for that
\nrevolution is real and profound. Unless we
\nchange the way in which all our societies
\nconsider the rights of all, and then act on
\nthose values to produce systems in which
\nevery person has an opportunity to thrive
\nthroughout their life, then we will continue
\nto see gradients in health and wellbeing.
\nThese gradients are worsening in many
\ncountries where new techniques, knowledge
\nand actions that improve the likelihood of
\nachieving a good health outcome are the
\nadvantage most often taken by the educated
\n\u00e9lites. They therefore enjoy the best health
\nimprovements. To reduce the gradients, we
\nmust get the least well educated,the least af-
\nfluent to aspire to better health, to demand
\neducational and employment opportunities
\nand to follow that with improved access to
\nhealth promotion and ill health prevention
\nas well as treatment for existing illness.
\nThere are elements of good news. As Mar-
\nmot told Zeinab Badawi, every dollar spent
\non child health improvement reaps a seven
\ndollar reward so even the most reluctant
\npolitician may see the financial sense, if not
\nthe moral imperative. But the best news is
\nthat social movements to change the world,
\nto give everyone a vice and an opportuni-
\nty are spreading like wildfire. Change will
\nhappen, with or without governments. The
\npeople will make sure that we do \u201cClose the
\nGap\u201d in a generation. Michael Marmot\u2019s
\nquiet revolution is underway.
\nProf. Vivienne Nathanson
\nDirector of Professional
\nactivities in Health,
\nBritish Medical Association
\n234
\nPsychological Therapies GREAT BRITAIN
\nsion. The costs for treatment for depression
\nin England in 2007 were approximately \u00a31.7
\nbillion. Lost employment brings the total
\ncost to \u00a37.5 billion. This doesn\u2019t include all
\nthe other associated costs. The number of
\npeople with anxiety disorders is estimated
\nto be 2.3 million.The costs of treatment and
\nfor lost employment are about \u00a38.9 billion.
\nThe prevalence of personality disorders in
\nthe community is estimated to be at least
\n5.8%. Thus at least 2.5 million people have
\na significant personality disorder. With lost
\nemployment,the costs come up to \u00a38 billion
\nfor 2007.
\nIn 2000,it was estimated that mental health
\ncould cost as much as 3 to 4% of the GNP
\nof the EU states [3]. In 2006, the cost of
\ndepression corresponded to 1% of the total
\neconomy of Europe (GDP) [4]. Typically
\nthe early onset, high prevalence, persistence,
\nand low treatment rates lead to high levels
\nof disability in most EU countries.
\nDisability-adjusted life years (DALYs) are
\na measure of overall disease burden, and
\nthe number of years lost due to ill health,
\ndisability or early death. DALYs combine
\nmortality and morbidity into a single com-
\nmon measure.The WHO (2008) figures for
\nthe UK in percentages are for cancer 16%,
\ncardiovascular disease 16.2% and mental
\ndisorder 23%.
\nIt has been found that mental health prob-
\nlems occupy at least one third of family
\ndoctor\u2019s time. In the UK no other health
\ncondition matches mental ill health in the
\ncombined extent of prevalence, persistence
\nand breadth of impact. The reach of poor
\nmental health is very wide [6]. It is not only
\non the patient, but the patients\u2019families and
\ncommunity in general. For instance, chil-
\ndren of parents with mental health prob-
\nlems can become young carers, and damage
\ntheir own future mental health prospects.
\nThe effects also include poor educational
\noutcomes for adults, and school dropouts
\namong the children of those with mental
\nhealth disorders.
\nOf course, there can be serious problems
\nwith employment. Sickness absence and
\nchronic underperformance build up to a
\nvery significant matter for both patients
\nand their employer. There is an association
\nbetween poor mental health and poor diet,
\nless exercise,more smoking,and alcohol and
\ndrug misuse which all have further conse-
\nquences. Then there are the impacts on
\nphysical health. Patients with mental health
\ndifficulties in general suffer from reduced
\nlife expectancy. Depression is, for instance,
\nassociated with 50% increased mortal-
\nity from all deaths. Anti-social behaviour
\nof various types can be a consequence. Of
\ncourse, there is the stigma and discrimina-
\ntion suffered by many with psychiatric dis-
\norders, which can become prolonging fac-
\ntors themselves.
\nIn June 2006, the London School of Eco-
\nnomics (LSE) produced a major report on
\ndepression and anxiety in the general popu-
\nlation. This stated, \u201cCrippling depression
\nand chronic anxiety are the biggest causes of
\nmisery in Britain today… They are the great
\nsubmerged problem which shame keeps out
\nof sight.In Britain,only one in four of those
\nwho suffer from depression or chronic anxi-
\nety receives any kind of help.This is a waste
\nof people\u2019s lives, and it is also costing a lot
\nof money. The depression and anxiety make
\nit difficult or impossible to work and drive
\npeople onto benefits\u201d [7].
\nIn Britain, it is noted we now have a mil-
\nlion people on Incapacity Benefits because
\nof mental illness. Whilst there are patients
\nwho have a diagnosis of schizophrenia,
\nthe great majority of the claimants have
\ndepression, anxiety disorders, and mixed
\ndepression and anxiety. There is another
\ngroup of people not covered directly by the
\nLSE report. These are the patients with a
\ndiagnosis of personality disorder or diffi-
\nculties. It seems likely that many patients
\nwith chronic depression and anxiety may
\nhave elements of personality difficulties
\n\u201chidden behind\u201d the primary diagnosis.
\nIt is this which sometimes makes them
\nharder to treat. Of course, the costs of
\npsychosomatic disorders should not be
\nforgotten.
\nWhilst depression and anxiety account for
\na third of all disability in mental health dis-
\norders, they attract only a small percentage
\nof health expenditure. Most finance usually
\ngoes to patients who suffer from schizo-
\nphrenia or bipolar affective disorder and, of
\ncourse, dementia.
\nThere is also a great deal of evidence on how
\ndepression\/anxiety in particular effect the
\nquality of life in the Primary Care popula-
\ntion [9]. Anxiety and depressive symptoms
\nhave been found to be significantly associ-
\nated with difficulties in all domains of qual-
\nity of life. As anxiety or depressive symp-
\ntoms increase, the quality of life decreases.
\nFurthermore, patients with moderate to se-
\nvere anxiety or depressive symptoms suffer
\ngreater impairments in most quality of life
\ndomains than those with congestive heart
\nfailure or diabetes.
\nMental well-being has increasingly been
\nused as another way to look at mental
\nhealth.There are numerous ways of describ-
\ning mental well-being. The simplest defini-
\ntion of wellness is as an absence of mental
\nill health and thus the absence of the conse-
\nquences noted earlier.
\nA well-known model is that of Myers,
\nSweeney and Witmer [10]. After review-
\ning literature from multiple disciplines, they
\nconcluded that wellness is:
\na way of life oriented toward optimal health
\nand well-being, in which body, mind, and
\nspirit are integrated by the individual to live
\nlife more fully within the human and natu-
\nral community. Ideally, it is the optimum
\nstate of health and well-being that each in-
\ndividual is capable of achieving.
\nThey divided the characteristics, which have
\nbeen noted in good mental health, into
\ntwelve domains. These are having a sense
\n235
\nPsychological TherapiesGREAT BRITAIN
\nof worth, sense of control, realistic beliefs,
\nemotional awareness and coping, problem
\nsolving and creativity abilities, a sense of
\nhumour, balanced nutrition, adequate exer-
\ncise, appropriate self-care, ability to manage
\nstress, a sense of gender identity, and a sense
\nof cultural identity.
\nStudies on well-being in Europe give fas-
\ncinating insights into the different cultural
\nenvironments, the wealth and the history
\nof individual countries. Improving mental
\nwell-being has been shown to improve re-
\nsilience to a broad range of adversity, reduce
\nphysical and mental illness plus health care
\nuse and mortality [11,12].
\nAs one might expect, the benefits outside
\nhealth include improved educational out-
\ncomes, reduced anti-social behaviour and
\nsubstance misuse, healthier lifestyle\/re-
\nduced risk factors plus increased produc-
\ntivity in work and elsewhere and stronger
\nsocial relationships.
\nThere is an increasing understanding that
\nwe need to have wider mental health strate-
\ngies, which emphasises good mental health
\nis essential for everyone [13]. It is hoped
\nthat more people will have good mental
\nand physical health and recover if they have
\nbeen ill, plus experience less stigma and dis-
\ncrimination.
\nMany governments have been looking at
\na variety of ways to improve services for
\nmental health patients. This has generated
\nconsiderable work on evidence bases for the
\npsychological therapies, their cost-effective-
\nness and outcomes of therapy at local and
\nwider levels.
\nThe United Kingdom government are in-
\ntending to improve mental health services,
\nand in particular psychological therapy ser-
\nvices by trying to put patients at the centre
\nin shared decision making, giving choice
\nand information to patients and by making
\nsure there is quality at the centre of the psy-
\nchological therapies service. Patient choice
\nis taken seriously in the United Kingdom.
\nEmphasis is given to aspects of care such
\nas easy access to services, and special re-
\nquirements of minority groups of various
\ndescriptions. It has, for instance, proven
\nharder for men to take their mental health
\nseriously, and indeed for service provid-
\ners to take men\u2019s mental health seriously
\nenough.
\nThis is not to dismiss other important as-
\npects of care especially for patients with
\ndepression. These are notably medication
\nand for more complex patients in particu-
\nlar \u2013 social care. This important work is al-
\nready done in the UK, by psychiatrists and
\ntheir teams at the more complex level, and
\nby family doctors and nurses plus others at
\nprimary care level.
\nOf course, depression can be well treated
\nby medication. For many patients, that is
\nan essential or an important part of the
\ntreatment, and, of course, it is cost-effective.
\nCertainly there is excellent evidence of
\nmedication being extremely useful for many
\npatients with psychiatric disorders. Some
\npatients want this and nothing else.
\nHowever, for many patients, the addition
\nof a psychological therapy to medication is
\nvital. There is also increasing evidence that
\nthis is the case. For other patients, medica-
\ntion is not helpful, or makes a minimal im-
\npact. Some find the side effects intolerable
\nor for some other reason find it impossible
\nto take it.
\nA substantial group of patients with de-
\npressive, anxiety-related or psychosomatic
\ndisorders have symptoms that are clearly
\nlinked to previous history or current life
\nproblems. The taking of medication is just
\nnot a long-term solution to their difficul-
\nties. There is increasing evidence that a va-
\nriety of psychotherapies are useful in treat-
\ning such symptoms and disorders. Patients
\nwith personality disorders rarely respond to
\nmedication, except for some symptomatic
\nrelief.Medication is actively discouraged for
\npatients with a diagnosis of personality dis-
\norder, according to recent United Kingdom
\ngovernment guidance [14].
\nSetting up comprehensive psychological
\ntherapies service for all who might want or
\nneed them has got to be balanced against a
\nreality of what a country can afford at any
\none time. Of course, not everything can
\nbe done at the same time. However, cur-
\nrently the British Government is rolling
\nout a programme of services called \u201cIm-
\nproving Access to Psychological Therapies\u201d
\n(IAPTS) for the patients with primary care
\nlevel depression and anxiety disorders [15].
\nThis is a service which works with general
\npractitioners. IAPTS treats all those who
\nneed relatively brief psychological therapy
\nat Primary Care level. In our circumstanc-
\nes, Cognitive Behavioural Therapy and
\nInterpersonal Therapy initially formed the
\ngreat majority of this service. This comple-
\nmented the psychodynamic psychotherapy
\navailable in the voluntary sector in the
\nUnited Kingdom. Interpersonal Therapy
\ncan most conveniently be described as a
\n\u201crelative\u201d of Psychodynamic Psychothera-
\npy, though in a rather specialised focused
\nformat. The remit of IAPTS has now ex-
\npanded to health-related and somewhat
\nmore complex conditions. IAPTS has
\nadded counselling of a short-term nature,
\nshort-term Psychodynamic Psychotherapy,
\ncouple work and a variety of problem solv-
\ning type interventions to its portfolio. It is
\nset up to be closely linked to employment
\nservices and involves the voluntary sector
\nto help people begin to think about a re-
\nturn to work or vocational training. De-
\nspite the current economic problems in
\nthe United Kingdom, this continues to be
\nfunded.
\nTraumatic events and losses are closely
\nlinked to all the above mentioned condi-
\ntions, particularly personality and psycho-
\nsomatic disorders. Attachment theorists
\nknow that broken and disturbed early life
\nattachments can lead to lifelong difficul-
\nties, but not only for those who suffer the
\n236
\nPsychological Therapies GREAT BRITAIN
\ntraumas and losses.The effects can be trans-
\ngenerational, and thus can be passed to the
\nchildren of those who experienced them
\noriginally. There is therefore a special need
\nin many highly traumatised states, given
\ntheir history, for the possibility to access
\nsomewhat longer- term Psychodynamic
\nPsychotherapy, which particularly effective-
\nly tackles such difficulties.There is,of course
\nnow, a developing evidence base with excit-
\ning prospects. A newer form of brief psy-
\nchodynamic psychotherapy, currently being
\nresearched in the USA and Canada, looks
\nas if it will be particularly useful in treating
\npatients with medically unexplained symp-
\ntoms [16]. The cost savings of such inter-
\nventions could be massive if a significant
\npercentage of patients could improve their
\nfunctioning and, for instance, be less depen-
\ndent on relatives or even in the longer-term
\nreturn to work.
\nPsychodynamic Psychotherapy can also
\nmake considerable changes to patients with
\na wide variety of complex presentations at
\nsecondary care level especially with trau-
\nmatic, abusive or emotionally neglectful
\nbackgrounds [17].
\nA good example of the changes brought
\nabout by the government policies in the last
\ndecade is that of Croydon, a large borough
\nin South London. Croydon has a popula-
\ntion of about 330,000 which is ethnically
\nand economically very diverse. It would be
\nunrealistic to say that everything is perfect
\nnow or that anything has been achieved
\nwithout considerable work. Ten years ago,
\nthere were relatively few psychological
\ntherapy services for patients who had what
\nmight be broadly called by the old-fash-
\nioned term \u201cneurotic disorders\u201d, psychoso-
\nmatic disorders and personality disorders
\nwithin the National Health Service. Some
\npsychologists covered parts of general
\npsychiatry, which in the main were rather
\ndated. There were some Primary Care level
\ntherapists and opportunities for a number
\nof patients to find therapy in the voluntary
\nand private sectors.
\nThe last decade has brought numerous de-
\nvelopments at various levels of care. The
\nCroydon services now cover all levels of
\npsychological therapies from mild depres-
\nsion, anxiety and associated disorders, to
\nthose suitable for extremely complex multi-
\ndiagnostic patients with personality disor-
\nders.There is a developing IAPTS.
\nA Croydon-wide department covers the
\npsychological therapy needs of secondary
\ncare level patients who come mostly but not
\nsolely from the general psychiatric services.
\nThere is also an all-encompassing service
\nfor patients with a diagnosis of personality
\ndisorder or difficulty, with \u201cbuilt-in easy ac-
\ncess\u201d. The work carried out by psychiatrists
\nand managers re-structuring the general
\npsychiatric services should not be mini-
\nmised, nor should the increasing volume of
\nwork, mainly of psychodynamic nature
\ndone in the voluntary sector. The voluntary
\nsector is, paradoxically, extensively support-
\ned by the government. In Croydon, there is,
\nfor instance, a particularly effective volun-
\ntary sector service for teenagers and young
\nadults up to the age of 25.
\nTo achieve major change,however,adequate
\nfunding was needed. This is essential if the
\nwider population is to be reached. Strong
\nleadership and excellent management skills
\nwere also vital to ensure that services were
\nset up efficiently and remained highly com-
\npetent, but also cost-effective.
\nOutcome measuring is carried after treat-
\nment, and for instance, within the psycho-
\nlogical therapies service in Croydon signifi-
\ncant improvements in levels of depression,
\nanxiety and personality disorder have been
\nrecorded. These are fed individually to pa-
\ntients and in collated form to patient rep-
\nresentative groups and those who fund the
\nservices.
\nAn area, which was often neglected in the
\npast, is that of the patients\u2019 own wishes
\nabout what would be particularly useful for
\ntheir problems in their particular locality.
\nThe involvement of patients and their car-
\ners or families has been invaluable. A wide
\nrange of ways has been used to try and help
\nto obtain their views. There are, of course,
\nmany complications with getting genuine
\nfeedback from an appropriately wide range
\nof people. However, matters such as the
\nphysical location of services and having ap-
\npropriate access for ethnic minorities have
\nbeen influenced for the benefit of the local
\npeople.
\nHowever, some of the best expressions of
\nthe change can be obtained from patients
\nthemselves. The Croydon mental health
\nservices run forums for patients to give
\nfeedback, both good and bad, to those run-
\nning the services. A patient recently talked
\nabout how things had changed for her. She
\nbegan by saying that she had woken up next
\nto her husband, peeped in at her sleeping
\nchild before going downstairs, having an
\norange juice and some toast. As she ate, she
\nthought about her day\u2019s work schedule. The
\nformer patient noted that this was ordinary
\nfor most people in the room, but for her
\na few years before it would have been un-
\nimaginable. She had been a chaotic young
\nwoman whose life was risky, and who se-
\nriously self- harmed on a regular basis, for
\nwhich she frequently attended the emer-
\ngency service at our local general hospi-
\ntal. She had significant mood swings, and
\nvicious arguments with anyone she knew
\nincluding boyfriends. She binge drank al-
\ncohol and her physical health was already
\ndeteriorating. She had a significant Border-
\nline Personality Disorder. The chances of
\nher having a husband, let alone a child that
\nwould not be taken into care by social ser-
\nvices,had seemed remote.The author of this
\narticle was also involved in her psychologi-
\ncal treatment. She had come to the conclu-
\nsion that things just could not go on the way
\nthey were. Most of the people at the patient
\nforum were deeply moved by what she said.
\nOf course, job insecurity, indebtedness and
\nunemployment have a major part to play
\nin the mental health of a nation\u2019s people.
\n237
\nTobacco HazardsTAIWAN
\nThe amended Tobacco Hazards Prevention
\nAct in Taiwan was promulgated by the pres-
\nident on July 11, 2007 and after 18 months
\nof grace period, it was put into effect on
\nJanuary 11, 2009. It represents a revolution-
\nary advance for Taiwan\u2019s Tobacco Hazards
\nPrevention Act, and put Taiwan at the fore-
\nfront of global tobacco control.
\nThe amended Act focuses on enlarging the
\nscope of smoke free environments to include
\nindoor public places,indoor workplaces with
\nthree or more people, public transportation
\nand even some outdoor place. Venues are
\nresponsible for posting no smoking signs at
\nall entrances and other places as appropri-
\nate, and ensuring that smoking parapher-
\nnalia is not installed. Violators can be fined
\nfrom NT$10,000 to 50,000 (approximately
\nUS$\u00a0350 to US$ 1,750). In addition to test
\nwarnings, tobacco products are required to
\ncarry one of six graphic warnings and smok-
\ning cessation related information, and shall
\nnot use words like \u201clow tar\u201d,\u201clight\u201d,or \u201cmild\u201d
\nA New Milestone for the Tobacco Hazards
\nPrevention Act
\nBureau of Health Promotion, Department of Health, R.O.C. (Taiwan)
\nThere is a well-known long-term associa-
\ntion between the wealth of a country and
\nbroad mental health. As one would expect,
\na higher level of wealth is associated with
\na higher level of good mental health [18].
\nBut, of course, this is not the entire picture.
\nMore than the right economic changes are
\nneeded to improve mental health.
\nThe current economic pressures, signifi-
\ncant as they are, also reveal major un-
\nderlying problems. As Robert Kennedy
\nsomewhat cheekily said in 1968, \u201cGross
\nNational Product measures everything,
\nexcept that which makes life worthwhile\u201d.
\nThe main resource of any nation, of course,
\nis its people. The quality of their mental
\nhealth plays a vital part in the functioning
\nof the state.
\nOf course, there will be some people who
\nare either unwilling or unable to take on
\nany form of psychotherapy or indeed any
\nkind of treatment. There will be people on
\nwhom it will have minimal effect. This is
\ntrue of all treatments in medicine.However,
\nif it is not possible to help ordinary citizens
\nwho wish to change, and are brave enough
\nto want to attempt it, if it proves impossible
\nto help these people become more compas-
\nsionate adults who are satisfied with their
\nlives, then other changes seem really rather
\npointless. Too many have been lost already.
\nAs the patient said, \u201cIt really is time things
\nchanged\u201d.
\nReferences
\n1. McManus, S., Meltzer, H., Brugha, T., Beb-
\nbington, P., Jenkins, R. (2009) Adult Psychi-
\natric Morbidity in England, 2007: results of a
\nhousehold survey, National Centre for Social
\nResearch.
\n2. Wittchen H U. Size and Burden of mental dis-
\norders in Europe Official press Conference- 20th
\nECNP Congress for Neuropsychopharmacol-
\nogy in Vienna (Oct 13\u201317 2007).
\n3. Gabrielk P, Liimatainen, Mental Health in the
\nWorkplace- International Labour Organization
\nStudy (2000).
\n4. Sobocki P,Jonsson B,Angst J,Rehnberg C.Cost
\nof depression in Europe.J Mental Health Policy
\nEcon, 2006 Jun; 9(2):87\u201398.
\n5. WHO (2008) The Global Burden of Disease:
\n2004 update, available at:
\nwww.who.int\/healthinfo\/ global_burden_dis-
\nease
\n6. HM Government United Kingdom. No health
\nwithout Mental Health. A cross-government
\nmental health outcomes strategy for people of
\nall ages. (2011) 5\u201315.
\n7. The Centre for Economic Performance\u2019s Mental
\nHealth Policy Group The Depression Report. A
\nNew Deal for Depression and Anxiety Disor-
\nders. London School of Economics (2006).
\n8. McCrone P, Dhanasasiri S, Patel A, Knapp M,
\nLawton-Smith S.The cost of mental health care
\nin England to 2026. The King\u2019s Fund (2008)
\nxvii\u2013xviii.
\n9. Brenes, G. Anxiety, Depression and Quality of
\nlife in Primary Care Patients Prim Care Com-
\npanion J Clin Psychiatry 2007; 9: 437\u2013443.
\n10. Myers J E, Sweeney T J Wellness in Counsel-
\nling: An Overview. Professional Counselling
\nDigest 2007:1\u20132.
\n11. HM Government, United Kingdom. No health
\nwithout Mental Health. A cross-government
\nmental health outcomes strategy for people of
\nall ages (2011) 18\u201329.
\n12. Campion J. Mental Health Strategy and Public
\nHealth White Paper-presentation (2011).
\n13. Michaelson J, Abdullah S, Steuer N, Thompson
\nS, Marks N. National Accounts of well being.
\n(2009). \u2013 www.nationalaccountsofwellbeing.org
\nand well-being@neweconomics.org
\n14. National Institute for Health and Clinical Ex-
\ncellence. Borderline Personality Disorder. Treat-
\nment and Management (2009).
\n15. Improving access to psychological therapy: Ini-
\ntial evaluation of two UK demonstration sites.
\nBehaviour Research and Therapy. Clark D M,
\nLayard R, Smithies R, Richards D A, Suckling
\nR, Wright B 2009; 1-11.
\n16. Abbass A A, The cost-effectiveness of short-
\nterm dynamic psychotherapy-Special report,
\nThe Centre for Emotions and Health, Dalhou-
\nsie University, Halifax, Nova Scotia. (Originally
\nAbbass, A (2003) Cost Effectiveness of Short-
\nterm Dynamic Psychotherapy: Expert Rev.
\nPharmacoeconomics Outcomes Res. 3(5), 2003,
\n535\u2013539).
\n17. LeichsenringF,RabungS.EffectivenessofLong-
\nterm Psychodynamic Psychotherapy. A Meta-
\nanalysis. JAMA. 2008;300(13): 1551\u20131565.
\n18. http:\/\/www.eurofound.europa.eu\/pubdocs\/2008\/
\n52\/en\/1\/EF0852EN.pdf The Second Euro-
\npean Survey on Quality of Life for the Dublin
\nFoundation for the Improvement of Living and
\nWorking Conditions.
\nAnita Timans,
\nMB BS, MRCPsych,
\nMember of Society
\nof Analytical Psychology
\n238
\nTobacco Hazards TAIWAN
\nthat might implicate less harmful health ef-
\nfects. To protect children and fetuses, preg-
\nnant women will not be allowed to smoke,
\nand people who provide tobacco products
\nto minors will face fines of NT$10,000 to
\n50,000 (approximately US$ 350 to US$
\n1,750). Tobacco hazards education will also
\nbe provided to minors. Regulations govern-
\ning tobacco promotions, advertising and
\nsponsorship have been strengthened as well.
\nVendors are restricted on tobacco displays,
\nand fines have been greatly increased. Pen-
\nalties for illegal tobacco advertising have
\nbeen increased from NT$100,000\u2013300,000
\nto NT$5 million\u201325 million (approxi-
\nmately US$ 3,500\u201310,500 to US$ 175,000\u2013
\n875,000). In addition, tobacco manufac-
\nturers and distributors are now required to
\ndisclose tobacco product contents, additives,
\nemissions, and their toxicity. People caught
\nsmoking in non-smoking areas can be fined
\nNT$2,000\u201310,000 (approximately US$
\n70\u2013350). The regulations governing the col-
\nlection and use of the Tobacco Health and
\nWelfare Surcharge have been amended,with
\nthe surcharge now being used to fund ser-
\nvices for the underprivileged.
\nTo carry out the new Tobacco Hazards
\nPrevention Act that took effect on Janu-
\nary 11, 2009, schools, governmental agen-
\ncies, workplaces, and public places all must
\nbe smoke-free. In order to accomplish this,
\nwe have used education (law enforcement
\nand hotline staff training, FAQs, and in-
\nformation meetings) and promotional ma-
\nterials in a wide variety of media including
\nTV, radio, print, outdoor media (signs, TV
\nwalls, public transport, public displays),
\nLED displays, websites, and banners. The
\nSmoke Free Public Places, 25 County and
\nMunicipal Leaders Go All Out educational
\nfilm was also released on May 30, the eve of
\nWorld No Smoking Day. In order to secure
\ncounty and municipal support for the new
\nregulations,the Director General of the Bu-
\nreau of Health Promotion has visited eight
\ncounty and municipal leaders and held three
\nmeetings with county and municipal health
\nofficials. We have also conducted in-depth
\ninvestigations and training with local com-
\npanies in 25 counties and municipalities.
\nRole play exercise helped train personnel in
\nhow to deal with potential issues that may
\narise. In December 2008, 22 county and
\nmunicipal health bureaus hired 665 tempo-
\nrary workers to post no smoking signs and
\nhand out promotional materials. 485 tobac-
\nco control volunteer training sessions were
\nheld and attended by 13,549 people, and a
\ntotal of 31,517 promotional activities were
\nheld. Community organizations were also
\nenlisted to help hang signs and undertake
\npromotional activities.
\n58.558.858.859.8 61 62.6
\n60.4
\n62.9
\n61
\n54.754.8
\n59.4
\n55.354.855.1
\n47.348.2
\n42.9
\n40 39.6 39 38.6
\n35.4
\n31.331.331.532.232.433.331.8
\n33.933.4
\n28.228.7
\n32.5
\n29.5
\n27
\n24.122.722.122.321.9
\n20
\n4.3 4.2 4.6 4.1 4 4.1 3.4 4.2 3.3 2.3 2.9 3.8 3.2 3.3 3.3
\n5.2 5.3 4.5 4.8 4.1 5.1 4.8 4.2
\n0
\n10
\n20
\n30
\n40
\n50
\n60
\n70
\n1971
\n1972
\n1973
\n1974
\n1976
\n1978
\n1980
\n1982
\n1984
\n1986
\n1988
\n1990
\n1992
\n1994
\n1996
\n1999
\n2002
\n2004
\n2005
\n2006
\n2007
\n2008
\n2009
\nMale Female Overall
\n1997 tobacco
\nhazards
\nprevention
\nact passed
\n2002 health
\nand weifare
\nsurcharge of
\nNT$5\/pack levled
\n2006
\nsurcharge
\nincrease to
\nNT$10\/pack
\n2009 new
\nregulations
\nraise surcharge
\nto NT$20\/pack
\nFigure 1. Smoking rates in Taiwan among adults, from 1971
\nTable 1. Perception of the New Law by Telephone Survey
\nITEM Jun 2008 Dec 2008 Mar 2009
\nImprove-
\nment
\nPublic transportation: Train
\n(Bus) Station
\n58.5 82.1 92.9 \u2191 34.4
\nRestaurant, Mall, Online-game
\nCafe, KTV
\n58.8 87.0 95.4 \u2191 36.6
\nIndoor Workplace 32.9 87.9 93.7 \u2191 60.8
\nBan of children, adolescent and
\npregnancy smoking
\n53.0 66.4 88.5 \u2191 35.5
\nSmoking violation fine $60\u2013300 28.7 73.4 90.8 \u2191 62.1
\nNon-smoking labeling violation
\nfine $300\u20131,500
\n16.4 56.7 83.0 \u2191 66.6
\n239
\nTobacco HazardsTAIWAN
\n0
\n10
\n20
\n30
\n40
\n50
\n60
\n10-20
\n2004 2005 2006 2007 2008 2009
\n21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 65+ AGE
\n%
\nFigure 2. Line graph of smoking rates among males 18 and above.
\nA telephone survey conducted one month
\nafter the implementation of the new To-
\nbacco Hazards Prevention Act found that
\nover 90% of people are aware that public
\nplaces are now smoke-free; awareness of
\nregulations for smoking in workplaces of
\nthree people or more has risen over 60%
\nsince the regulations were announced in
\nJuly 2008; and awareness of regulations
\ngoverning public transportation, restau-
\nrants, hotels, and stores has risen by 35%
\n(see Table 1).
\nSmoking Rate
\nA review at recent smoking levels among
\npeople 18 years of age and above shows
\nthat in 1980, 60.4% of males and 3.4% of
\nfemales smoked. In 2002, the rate among
\nmales dropped to 48.2% while it rose to
\n5.3% among females, and in 2008, it fell
\nfurther to 38.6% among males and 4.8%
\namong females. After January 11, 2009,
\nwhen the amended Tobacco Hazards
\nPrevention Act took effect, changes in-
\nclude expanding the range of places where
\nsmoking is not permitted; prohibiting to-
\nbacco advertising, promotions and spon-
\nsorship deals; modifying health warning
\npictures and test on tobacco packaging,
\nincluding info about quitting smoking;
\nputting greater oversight on tobacco ven-
\ndors; and raising the health and welfare
\nsurcharge on cigarettes. After these new
\nregulations came into effect, the smoking
\nrate among men dropped to 35.4% and
\nfemales experienced a slight drop to 4.2%
\n(see Figure 1).
\nThere were about 3.61 million smokers 18
\nyears of age and above in 2009, 3.23 million
\nof whom were male and 380,000 of whom
\nwere female, representing a drop of 330,000
\nfrom the previous year. Data suggest, how-
\never, that the smoking rate increased dra-
\nmatically among young males when they
\nwere between the ages of 18 and 25. Start-
\ning at age 18, the smoking rate for men in-
\ncreased as the age increased,reaching a peak
\nin the 36 to 40 age category. In fact, of every
\ntwo young-to-middle-aged adult males,one
\nis a smoker (see Figure 2). For women, the
\nsmoking rate likewise rose with each in-
\ncrease in age, starting at 18 and reaching a
\npeak in the 31 to 35 age category. For every
\n14 adult females, there was one who smokes
\n(see Figure 3).The data reveal that planners
\nand policymakers need to place their focus
\non the problem of smoking among young
\nmales and females.
\n1. The Taiwan Tobacco and Wine Monop-
\noly Bureau gathered the data from 1973\u2013
\n1996.
\n2.Professor L. Lan gathered the data from 1999.
\n3. The data from 2002 were found in the
\nBureau of Health Promotion\u2019s 2002 Survey
\nof Knowledge, Attitude, and Behavior to-
\nward Health in Taiwan.
\n4. The Bureau of Health Promotion gath-
\nered the data from 2004\u20132009 in the Adult
\nSmoking Behavior Survey.
\n5. For results from 1999\u20132009, a smoker
\nwas defined as a person who has smoked
\nmore than 100 cigarettes (five packs) and
\nwho smoked within the past 30 days.
\n0
\n10
\n10-20
\n2004 2005 2006 2007 2008 2009
\n21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 65+ AGE
\n%
\nFigure 3 Line graph of smoking rates among females 18 and above.
\n240
\nTobacco Hazards TAIWAN
\nTry to Quit Smoking
\nAn investigation from 2009 showed a de-
\ncrease in the smoking rate among adults
\nand an increase over the past year in efforts
\nto quit smoking (see Figure 4).
\n1. Data gathered from the Bureau of Health
\nPromotion Adult Smoking Behavior Survey.
\n2. We defined a person who tried to quit
\nsmoking as a smoker who gave up cigarettes
\nfor one day or more over the past 12 months
\nbecause he or she wanted to quit.
\nExposure to Secondhand Smoke
\nIn a 2009 survey that asked people about
\ntheir exposure to secondhand smoke
\nover the previous week, 20.8% of respon-
\ndents said they were exposed to second-
\nhand smoke in their households, 14.0%
\nsaid someone smoked in front of them in
\nan enclosed workplace or office and 7.8%
\nsaid they were exposed in indoor public
\nplaces. Ever since the range of places where
\nsmoking is banned was expanded in 2009,
\nthere has been a decrease in secondhand
\nsmoke exposure in the household and at the
\nworkplace (see Figure 5).
\n1. Exposure to secondhand smoke at home
\nwas defined as having someone smoke in
\nfront of you at your home within the pre-
\nvious week. Data source: Bureau of Health
\nPromotion,Adult Smoking Behavior Survey.
\n2. Exposure to secondhand smoke in the
\nworkplace indoors was defined as the rate at
\nwhich the worker smelled cigarette smoke
\nin enclosed spaces at the workplace. Data
\nsource: Bureau of Health Promotion, Na-
\ntional Occupational Health Workplace
\nEnvironment Investigation. Those surveyed
\nwere full-time employees aged 15 and above.
\n3. Exposure to secondhand smoke in pub-
\nlic places was defined as having someone
\nsmoke in front of you during the previous
\nweek in an indoor public place, not includ-
\ning home or workplace. Data source: Bu-
\nreau of Health Promotion, Adult Smoking
\nBehavior Telephone Survey.Those surveyed
\nwere adults aged 18 and above. Since sur-
\nveys on exposure to secondhand smoke
\nfrom 2008 and 2009 subdivided indoor and
\noutdoor locations, it is not easy to make a
\ndirect comparison between the results from
\nthese two years and previous years.
\nAfter nearly one year of promotion, a sur-
\nvey indicated that 94.6% of the population
\nwas aware of regulations related to banning
\nsmoking in certain locations and 92% was
\nsatisfied with the smoke-free environment
\ncreated after the promulgation of the regu-
\nlation. In addition, the proportion of en-
\ntirely smoke-free workplaces increased from
\n55.8% in 2008 to 80.5% in 2009. Refusing
\ntobacco is becoming a social norm.
\nTaiwan Medical Association
\n35.2
\n33
\n30.7
\n27.2
\n20.8
\n29.9
\n28.6
\n29.4
\n25.9 26
\n14
\n34 35
\n27.8
\n7.8
\n0
\n5
\n10
\n15
\n20
\n25
\n30
\n35
\n40
\n2004 2005 2006 2007 2008 2009
\nHouse Indoor Public
\nFigure 5. Exposure to secondhand smoke among adults
\n44.3
\n40.5
\n45.8 44.8
\n35.8
\n42.8
\n54.2
\n45.9
\n41.2
\n40.8
\n43.2
\n47.545.8
\n41
\n40.3
\n44.3
\n36.6
\n43.4
\n0
\n30
\n40
\n50
\n60
\n2004 2005 2006 2007 2008 2009
\nMale Female Overall
\nFigure 4. Percentage of adult smokers who tried quitting smoking, from 2004
\niii
\nHis life began with tragedy and hardship.
\nBorn in 1940 in Torun, his family had to
\nflee from their home and a young boy\u2019s life
\nstarted as that of a refugee and displaced
\nperson. Toward the end of World War II,
\nat the age of four, he lost an eye from an
\nexploding grenade and his memory of that
\ntime was strongly impressed by the starva-
\ntion he suffered.
\nHe wanted to help make this world a bet-
\nter place. So he became a doctor in 1966
\nand engaged in politics early on. Although
\na very non-dogmatic thinker from a strong
\nCatholic background, he was active in the
\nChristian Democrat Party. But they could
\nnot relate to the young man with these in-
\nnovative ideas about social issues, working
\nconditions and the environment.They never
\nreally understood him. He was decades
\nahead of them in his thinking.
\nHis superior, Professor Ulrich Kanzow, a
\nphysician activist himself, became his initial
\nmentor and brought him to organized med-
\nicine. In the physician trade union, Mar-
\nburger Bund, his natural leadership began
\nto reveal itself and in 1970-only four years
\ninto his medical career \u2013 he became one of
\nthe co-organizers of the first (and for a long
\nonly) post-war physician strike in Germany.
\nIn 1975 he qualified as specialist in pathol-
\nogy and family practice. He decided to stay
\nin pathology where he built an extraordi-
\nnary successful career.
\nNeither the success in his clinical work (he
\nlater became a Professor at the University of
\nCologne) nor his early success as a leader in
\norganized medicine (he became chairman
\nof the Marburger Bund in 1979), affected
\nhis ego-as positions of influence and power
\noften do. He never pretended to have all the
\nanswers; instead he was constantly asking
\nquestions. He understood his work as a ser-
\nvice to community and so he behaved. His
\nauthority was based on a sharp mind com-
\nbined with a humble character and a strong
\ncommitment to philanthropy. It may have
\nbeen his personal experience that made him
\nso careful not to look down on anybody. His
\ninterest in medical ethics was always driven
\nfrom a humanistic view, rather than a deon-
\ntological perspective. His aim was to help,
\nnot to judge. To make him your foe was a
\nvery difficult exercise.
\nJ\u00f6rg-Dietrich Hoppe was perceived as quiet
\nbut very efficient advocate for his profession.
\nIndeed his ultimate interest always was that
\npatients would receive the right care. That
\nno group or individuals would be left be-
\nhind was his concern, regardless of whether
\nthey were poor, asylum seekers, or just chil-
\ndren. He was a truly caring physician.
\nIn 1989 he became Vice-President of the
\nFederation of the Bundes\u00e4rztekammer, the
\nGerman Medical Association, and he re-
\ntired from his position as chairman of the
\nMarburger Bund. Ten years later the An-
\nnual Assembly elected him President, suc-
\nceeding his friend and mentor, Karsten Vil-
\nmar. He held the office of President of the
\nGerman Medical Association for 12 years,
\nuntil this past June when he retired. During
\nthe last Annual Assembly, it was visible that
\nsomething was taking his life away. The tall
\nand always very slim man now was cachec-
\ntic and his voice was frail.
\nOn November 7th, 2011, J\u00f6rg-Dietrich
\nHoppe died at the age of 71 after severe ill-
\nness.
\nWith J\u00f6rg-Dietrich we lose a strong sup-
\nporter of the World Medical Association, a
\nCouncil member for decades, and Treasurer
\nfrom 2005 to 2011. To many of us he was
\na friend and teacher and foremost an out-
\nstanding person and inspirational leader.
\nOtmar Kloiber with Joelle Balfe
\nIn memoriam J\u00f6rg-Dietrich Hoppe
\n24 October 1940 \u2014 7 November 2011
\nIn memoriam
\niv
\nContents
\nEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
\nWMA General Assembly 12\u201315 October, Montevideo . . . . . 202
\nWMA Recommendation on the Development\u00a0of a
\nMonitoring and Reporting Mechanism to Permit Audit
\nof\u00a0Adherence of States to\u00a0the Declaration of Tokyo . . . . . . . . 215
\nDeclaration on End-of-Life Medical Care . . . . . . . . . . . . . . 215
\nStatement on the Professional and Ethical Usage
\nof Social Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
\nWMA Statement on the Global Burden of Chronic
\nDisease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
\nRevision of WMA Declaration of Edinburgh on Prison
\nConditions and the Spread of Tuberculosis and other
\nCommunicable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
\nWMA Statement on Social Determinants of Health . . . . . . . 221
\nWMA Resolution reaffirming the WMA Resolution on
\nEconomic Embargoes and Health . . . . . . . . . . . . . . . . . . . . . 222
\nWMA Statement on the Protection and Integrity
\nof Medical Personnel in Armed Conflicts and Other
\nSituations of Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
\nWMA Resolution on the Access to Adequate Pain
\nTreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
\nWMA Statement on Health Hazards of Tobacco Products
\nand Tobacco-Derived Products . . . . . . . . . . . . . . . . . . . . . . . 224
\nWMA Declaration on Leprosy Control around the World
\nand Elimination of Discrimination against Persons affected
\nby Leprosy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
\nWMA Resolution on Bahrain . . . . . . . . . . . . . . . . . . . . . . . . 226
\nWMA Resolution on the Independence of National
\nMedical Associations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
\nWMA Declaration of Montevideo on Disaster Preparedness
\nand Medical Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
\nReport on the World Conference on the Social
\nDeterminants of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
\nWhat can be Gained by Developing Psychological Therapies
\nfor the General Public? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
\nA New Milestone for the Tobacco Hazards Prevention
\nAct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
\nIn memoriam J\u00f6rg-Dietrich Hoppe . . . . . . . . . . . . . . . . . . . . iii<\/p>\n"},"caption":{"rendered":"

wmj36 COUNTRY \u2022 WMA General Assembly, Montevideo \u2022 The World Conference on the Social Determinants of\u00a0Health vol. 57 MedicalWorld JournalJournal Official Journal of the World Medical Association, INC G20438 Nr. 6, December 2011 Cover picture from Thailand Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 […]<\/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\/wmj36.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3626"}],"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=3626"}]}}