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wmj39<\/a><\/p>\n

COUNTRY
\n\u2022 White Paper On Ethical Issues Concerning Capital
\nPunishment
\n\u2022 Violence in the Health Care Sector
\n\u2022 The First Global Climate and Health Summit
\n\u2022 Junior Doctors Network
\nvol. 58
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 3, July 2012
\nwmj 3 2012.indd I 7\/18\/12 9:47 AM
\nCover picture from China
\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
\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:
\nDa Yi Jing Cheng, literally translated as great doctor
\nis both exquisite skilled and sincere.This is the title
\nof an article from the classic medical work One
\nthousand golden prescriptions for emergency
\nmedicine,volume I. The book is written by the
\nfamous doctor SUN Simiao in the Tang Dynasty
\n(618AD-907AD), it is a must-read medical book for
\nthe doctors in the ancient China.This article states
\ntwo issues on medical ethics: one is Jing (exquisite)
\nwhich requires the doctor be excellent in their medi-
\ncal skills as medicine is considered from fine to ex-
\nquisite; while doctor should also be Cheng (sincere),
\nwith empathy and noble moral.This demonstrates
\nthe early ethics in ancient China that calls on doc-
\ntors to be outstanding in both hand and mind.
\nPublisher
\nThe World Medical Association, Inc. BP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
\nPublishing House
\nDeutscher-\u00c4rzte Verlag GmbH,
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\nDeutscher \u00c4rzte-Verlag or
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\nSubscription fee \u20ac 22,80 per annum (incl. 7%
\nMwSt.). For members of the World Medical
\nAssociation and for Associate members the
\nsubscription fee is settled by the membership
\nor associate payment. Details of Associate
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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\u00a0\u2013 especially those in authored contributions\u00a0\u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\nwmj 3 2012.indd Sec1:ii 7\/18\/12 9:47 AM
\n81
\nIn 1964 the World Medical Association adopted,in Helsinki,a Decla-
\nration regarding the Ethical Principles for Medical Research Involving
\nHuman Subjects. As we approach the fiftieth anniversary of the Dec-
\nlaration of Helsinki we should pause to reflect on how the world and
\nmedicine have changed,and examine our current needs and challenges.
\nAs civilizations evolve and mature the epidemiology of disease
\nchanges. New morbidity patterns have evolved, especially in Eu-
\nrope, North America and Australia in the last 50 years.Whereas in-
\nfectious diseases and traumatic disorders predominated in the past,
\nchronic and degenerative processes are more common today.Cancer
\nis taking its prominent place in the spectrum of chronic diseases.
\nThe numbers of doctors and medical staffs have grown significant-
\nly, but significant specialization has also taken place. We still take
\nmedical histories and examine patients, but rely more and more on
\nmodern medical technology to arrive at diagnoses.
\nTo an increasing degree in modern times, medical philosophy fo-
\ncuses on topics of life and death, such as the management of pa-
\ntients who have cardiac arrests. In these instances, cardiopulmonary
\nresuscitation is provided not only by medical personnel, but also by
\nnon-professionals who have obtained training in vocational schools.
\nIn solving the dilemma of whether or not to begin resuscitation in a
\nlife-threatening emergency, the doctor should focus on the expected
\noutcome \u2013 what will be the quality of life for the patient upon dis-
\ncharge from the hospital? Using modern medical expertise it is usu-
\nally possible to return patients to fully functional lives and normal
\nlife expectancy following cardiac insult.
\nCardiopulmonary resuscitation of cardiac arrest is successful in 70\u2013
\n98 per cent of attempts. After successful resuscitation, quality of life
\nis ensured for most survivors, and it is very common for people to
\nhave long life expectancy in spite of serious cardiac disease.
\nAn ethical dilemma arises when one has to allocate limited finan-
\ncial resources for health care in the 21st
\ncentury: how much should
\nbe expended to prolong the life of one person versus spending the
\nscarce health care dollar on a larger portion of the population? Since
\n1990 the average lifespan has been extended by one year every four
\nyears. During this same time period health care expenditure has in-
\ncreased three to five per cent a year, a figure much higher than the
\ngrowth of the gross national product.
\nToday, given enough resources, people\u2019s lives can be significantly
\nprolonged with the aid of modern medicine. Doctors, patients and
\ntheir families understand this. These resources are expended espe-
\ncially on prevention, early diagnosis and rehabilitation.
\nThere is competition for the health care dollar. A certain portion
\nusually comes from social security funds that have been paid for
\nby individuals during their lifetimes to which they are entitled. The
\nremainder is typically paid for by the state, to which people also
\nbelieve they are entitled.
\nRegardless of the economic wealth of any country, resources are not
\nunlimited. As a result, dissatisfaction with the health care system
\ndevelops among medical professionals and the general public. In
\nreality, the delivery of medical care in the 21st
\ncentury has become a
\nparadox: the more money that is expended on health care,the longer
\npeople live (although suffering from their chronic illnesses), but the
\nmore financial resources are needed.
\nLeaders of medical associations and other influential health officials
\naround the world are paying increasing attention to health issues,
\nsuch as disease prevention, smoking, alcohol, vaccination, nutritious
\nfood, physical exercise, ecology and a healthy lifestyle. And, a cor-
\nnucopia of ethical problems has opened \u2013 public health issues exist
\nin Europe and Africa, North and South America, Christian and
\nMuslim countries. Implementation of public health improvements
\nhas often been met with a hypocritical attitude toward issues such as
\nthe calamity of smoking and the widespread use of narcotics. More
\nthan three million newborns die each year, mostly in developing
\ncountries.Lack of food in poor countries leaves 170 million children
\nunderweight, while at the same time, nearly a billion people in the
\nworld are overweight due to excess food consumption and lack of
\nexercise.
\nIn studying the social determinants of health, the World Health
\nOrganization has focused on nine broad areas: early child develop-
\nment, globalization, health systems, measurement and evidence, ur-
\nbanization, employment conditions, social exclusion, priority public
\nhealth conditions and women and gender equity. A dominant figure
\nin the study of inequalities of health care and their causes is Eng-
\nland\u2019s Sir Michael Marmot. He maintains that social standing is an
\nimportant determinant of health and life expectancy.
\nRecognizing the far-reaching changes that have occurred in medi-
\ncine in the 21st
\ncentury, it is obvious that a new document that ad-
\ndresses the ethics and philosophy of our modern time is in order.
\nThere is no organization better suited to produce this Declaration
\nthan the World Medical Association.
\nEditorial
\nDr. Peteris Apinis, Editor in Chief
\nwmj 3 2012.indd 81 7\/18\/12 9:47 AM
\n82
\nWMA news
\n1. Why has the WMA engaged in discuss-
\ning the use of capital punishment?
\n2. Is capital punishment torture?
\n3. Is the use of capital punishment unethical?
\n4. Is capital punishment just?
\nLiberty \/ Libertarianism
\nFree market libertarians
\nUtilitarianism
\nVirtue
\nEquality \/ Egalitarianism
\nAn eye for an eye
\nRacial disparities
\nThe dilemma of revenge
\n5. Criminal law and the argument of de-
\nterrence and retribution
\nGregg vs. Georgia 1976
\nBase vs. Rees 2008
\n6. Why the use of medication in capital
\npunishment?
\n7. Some statistics
\nReported executions in 2010
\nReported death sentences in 2010
\n8. References
\nThis paper was drafted by the Danish Medical
\nAssociation with the support of WMA Working
\nGroup on capital punishment.
\n1. Why has the WMA engaged
\nin discussing the use of
\ncapital punishment?
\nThe WMA has a strong tradition oppos-
\ning the involvement of physicians in capital
\npunishment. Recently, it has been debated
\nwhether it is morally and ethically wrong
\nthat drugs produced to cure people are also
\nused in prisons with the aim of ending a
\nperson\u00b4s life.
\nA Danish Pharmaceutical company, H.S.
\nLundbeck A\/S had to take a stance and act
\nto try to prevent the use of one of its prod-
\nucts, Nembutal, for executions after massive
\npressure from media and human rights\u00b4
\ngroups as well as the medical community.
\nThis makes it relevant to discuss the ethics
\nof capital punishment and how it is executed
\ntoday. Since many executions are performed
\nby the use of drugs requiring some kind of
\nguidance from health care personnel, the
\nquestion reappears: Does the medical com-
\nmunity have to take a stance against the use
\nof capital punishment?
\nIn China prisoners are executed by the use
\nof fire arms. But still a doctor may be in-
\nvolved giving a drug before the execution
\nand after when pronouncing the death of
\nthe prisoner. Iran and Saudi Arabia have
\nother methods. Mostly death by hanging
\nis used here. In the United States capital
\npunishment is mainly performed by the
\nuse of lethal injection. In a few states other
\nmethods can be used including firing squad.
\n94 % of all executions happen in these four
\ncountries according to Amnesty Interna-
\ntional (2005).
\n2. Is capital punishment
\ntorture?
\nThe definition of torture according to the
\nUnited Nations (UN) Convention against
\nTorture is: \u201cTorture means any act by which
\nsevere pain or suffering, whether physical or
\nmental, is intentionally inflicted on a person
\nfor such purposes as obtaining from him or
\na third person information or a confession,
\npunishing him for an act he or a third per-
\nson has committed or is suspected of having
\ncommitted, or intimidating or coercing him
\nor a third person, or for any reason based on
\ndiscrimination of any kind, when such pain
\nor suffering is inflicted by or at the instiga-
\ntion of or with the consent or acquiescence
\nof a public official or other person acting in
\nan official capacity. It does not include pain
\nor suffering arising only from,inherent in or
\nincidental to lawful sanctions\u201d.
\nThe crucial point being that capital punish-
\nment is not regarded as torture since the
\ndefinition in the UN Convention against
\nTorture does not include pain and suffering
\narising only from inherent in or incidental
\nto lawful actions, which capital punishment
\nis.
\n3. Is the use of capital
\npunishment unethical?
\nThis question is related to the question of
\nwhether capital punishment is just. There-
\nfore inthe following paragraphs different
\nschools of ethics will be summarized and for
\neach paragraph a conclusion will be drawn
\nas to whether, from the point of view of the
\nindividual way of thinking, capital punish-
\nment can be regarded as ethical.
\n4. Is Capital Punishment just?1
\na. Liberty\/ Libertarianism
\nWhat matters most for justice is liberty. Ar-
\nticle 3 in the Universal Declaration of Hu-
\n1 In an abstract by Matthew Robinson \u201cGovern-
\nment and Justice Studies, Journal of Theoretical
\nand Philosophical Criminology 2011\u201d, different
\ntheories of justice are applied to study whether
\ncapital punishment achieves its purpose of bring-
\ning justice to society. The author investigates
\nwhether libertarian, egalitarian or the utilitarian
\nschool of thought will come to the conclusion
\nthat death penalty is just. The abstract is based
\non a number of references and statistical material
\n(see reference). The author states (p. 50) that the
\nindividual opinion on the death penalty is affect-
\ned by many factors such as race, gender, age, level
\nof income, political party and ideology, geography
\nof residence and religious beliefs.
\nWhite Paper On Ethical Issues Concerning
\nCapital Punishment
\nwmj 3 2012.indd 82 7\/18\/12 9:47 AM
\n83
\nWMA news
\nman Rights posits: \u201cEveryone has the right
\nto life, liberty and security of person.\u201d
\nThe issue over which capital punishment
\nsupporters disagree is whether the right to
\nlife espoused in the US and International
\nLaw should be maintained after a person
\ncommits murder. Death penalty supporters
\nmaintain that, by taking a life, murderers
\nshould sacrifice their own life as a form of
\nretribution; opponents disagree and argue
\nthat these rights cannot be sacrificed1
\n.
\nRobinson continues that such philosophical
\narguments can be resolved with empirical
\nevidence:
\n\u201cThus we must simply examine whether
\ncapital punishment as actually practiced in
\nthe US helps achieve liberty or diminishes
\nit. Empirically it is easy to see that capital
\npunishment is so rarely used that capital
\npunishment does not help achieve or assure
\nliberty in society. Stated simply, if an execu-
\ntion was necessary to help achieve and as-
\nsure liberty for potential victims, states fail
\ncitizens 98\u201399% of the time because only
\n1\u20132 % of convicted murderers are executed
\nor sentenced to death respectively2
\n.
\nIt is also worth noting that innocent people
\nare wrongly accused of murder, sentenced
\nto death and occasionally executed which is
\nan affront to liberty. Sometimes people who
\nwould be regarded as not mentally compe-
\ntent may be executed in other jurisdictions.
\nThe libertarian argument of capital punish-
\nment is thus that the death penalty is un-
\njust.\u201d
\nb. Free market libertarians
\nMost of the arguments put forward by
\nthese libertarians are economic in nature.
\nFree market libertarians have not written
\n1 Robinson, p. 43.
\n2 Robinson p. 44.
\nabout the death penalty but it is interesting
\nto know that capital punishment is gener-
\nally more expensive than other sanctions
\nincluding life imprisonment.
\nAs an example a study in North Carolina
\nshowed that the cost of a death penalty
\nsentence was 216,000 $ and the total cost
\nper execution was $ 2.16 million more than
\nlifeimprisonment3
\n.
\nc. Equality\/Egalitarianism
\nWhat matters most for justice is equality
\nof opportunity in society and taking care of
\nthe least advantaged citizens.
\nThere are significant racial disparities, class
\ndisparities and gender disparities in capital
\npunishment practice4
\n.
\nThe underlying causes are both the race and
\ngender of the prosecutors, the jurors and
\ncharacteristics pertaining to both the defen-
\ndants and the victims.Thus an undeniable
\nconclusion of capital punishment practice is
\nthat the death penalty is applied in an un-
\nequal fashion.
\nd. Utilitarianism
\nThe view of utilitarianism is that whether
\nsomething is just depends on whether it
\nmaximizes the utility or greatest happiness
\nfor the greatest number of people.
\nAs a specific deterrent capital punishment
\nis efficient: the perpetrator cannot kill again
\nand more innocent lives might be saved.
\nThe relevant question might however be:
\nto what degree are murderers likely to kill
\nagain?
\nIs capital punishment likely to prevent fu-
\nture killings? A study quoted by Robinson
\n3 Robinson, p. 44.
\n4 Robinson p. 45 and 36\u201342.
\nsays that, out of 238 paroled offenders, less
\nthan 1 % were returned to prison for com-
\nmitting a subsequent homicide.
\nSunstein and Vermeule suggest that studies
\nshow that 18 lives are saved per execution5
\n.
\nThe very high figure seems to run contrary
\nto other views cited in this paper.
\nYou can however argue that executions may
\nbe excessive because effective incapacitation
\ncan be achieved through life imprisonment,
\nalthough leaving a risk that the offender
\nmight kill again while in prison.
\nCapital punishment can also bring closure
\nfor the victim\u2019s family but the delay in con-
\nviction often makes this point of little com-
\nfort or use to the family.
\nTo determine the relative utility of capital
\npunishment one must assess the benefits
\nagainst the costs of capital punishment.
\nAssessing the contribution of capital pun-
\nishment to the overall welfare of society is
\ndifficult however. How can you measure
\nthe worth of closure to the families? And
\nhow should we evaluate the racial and so-
\ncial bias that has been proven statistically
\nto be true for capital punishment? Robin-
\nson concludes that \u201cIn spite of all this, it is
\na safe conclusion that capital punishment
\nas practiced in the United States has only
\nmodest benefits but enormous costs. Thus
\nthe utilitarian argument of capital punish-
\nment is that the death penalty is unjust.\u201d
\nSunstein and Vermeule argue to the con-
\ntrary6
\n.
\ne. Virtue
\nAristotle\u00b4s theory suggests that justice de-
\nmands giving people what they deserve or
\nwhat they are due.
\n5 Cass R. Sunstein and Adrian Vermeule: \u201cIs Capi-
\ntal punishment morally required? Acts, omissions
\nand life-life trade offs\u201d 58 STAN.L. Rev. 703.
\n6 See above reference.
\nwmj 3 2012.indd 83 7\/18\/12 9:47 AM
\n84
\nWMA news
\nWith regard to virtue based theorists we
\nmust recall that the most important ques-
\ntion is whether capital punishment respects
\nand promotes our values, our moral good-
\nness and whether it is the right thing to do.
\nThe questions are difficult to answer given
\nthe wide variety of values, morals, and sense
\nof right1
\n.
\nf. An eye for an eye
\nIf a state kills only 1 % of murderers, do we
\nachieve an eye for an eye? Should the state
\nexecute more?
\nThe biblical argument to uphold capital
\npunishment is an eye for an eye, a tooth for
\na tooth i.e. the argument of retribution. In
\nopposition to this broad definition which
\naddresses capital punishment is the text
\n\u201cVengeance is mine said the Lord\u201d.
\nDifferent philosophers have related to the
\nsubject of the death penalty but have in-
\nterpreted the great thinkers and schools of
\nphilosophy differently. Some philosophers
\nmight find the utilitarian school in favor of
\ncapital punishment and others might argue
\nagainst.
\nThe Norwegian philosopher Lars Fr.\u00a0H.\u00a0Sven-
\ndsen (\u201cThe philosophy of cruelty\u201d) says about
\nEmmanuel Kant:
\n\u201cThe death penalty is a problem with regard
\nto the fundamental idea of humanity be-
\ncause humanity is based on the idea of the
\nabsolute value of a person\u00b4s life no matter
\nwhat and the death penalty represents the
\nabsolute denial of a person\u00b4s right to life.
\nBut this idea can collide with the idea of a
\njust society:
\nTo Kant justice is absolute and he thinks
\nthat the death penalty is the only right way
\nto punish murder because the punishment
\nhas to be a goal in itself. He believes in
\nthe \u201cius talionis\u201d where the wrong doing
\n1 Robinson p, 51.
\nis punished by a similar punishment. But
\nin fact you can also find arguments in the
\ncategorical imperative by Kant against the
\ndeath penalty which says that a person has
\nto be considered a goal in itself and never
\nas a means to achieving a goal. If you use
\nthe perpetrator as a means to achieving
\njustice you then violate the categorical im-
\nperative.\u201d
\nSunstein and Vermeule say about Kant that
\nhe is a retributivist: For a retributivist the
\npenalty of death is morally justified or per-
\nhaps even required. Other defenders of cap-
\nital punishment are consequentialists and
\noften also welfarists who believe that ethics
\ninvolve the greatest amount of welfare for
\nthe biggest amount of people2
\n.
\nAs opposed to these schools of philosophy
\nmany deontologists believe that capital
\npunishment counts as a moral wrong3
\n.
\ng. Racial disparities
\nAmnesty International (AI)4
\nfinds signifi-
\ncant racial disparities in prosecutors deci-
\nsion on charging,noting that the death pen-
\nalty is sought far more frequently in cases
\nwhere the victims were white than when
\nthey were black.
\nA quoted study by William J. Bowers from
\n1975\u20131976 shows that the racial combina-
\ntion of a black killing a white was virtually
\n\u201cas strong a predictor of a first degree murder
\nindictment as any of the legal relevant factors
\nexcept a felony circumstance.\u201d
\nWilliam J. Bowers and Glenn L. Pierce
\nfound that in Florida, as in other states,
\nthe large majority of homicides were intra-
\nracial, i.e. committed within the same racial
\n2 Sunstein and Vermeule 58 STAN. L. Rev 703 p.
\n704.
\n3 Sunstein and Vermeule.
\n4 Amnesty International, United States of Ameri-
\nca,The Death Penalty, p.30\u201331.
\ngroup. Although there was a high homicide
\nrate among both whites and blacks in all
\nstates examined (Florida, Georgia, Texas,
\nOhio), far more killers of whites than killers
\nof blacks were sentenced to death.They also
\nfound that although most killers of whites
\nwere white, blacks killing whites were pro-
\nportionately more likely to receive a death
\nsentence. In Florida and Texas for example
\nblacks who killed whites were respectively
\nfive to six times more likely to be sentenced
\nto death than those who had killed blacks.
\nNo white offender in Florida had ever been
\nsentenced to death for killing a black per-
\nson during the period studied (late 1970\u00b4s).
\nThe first case presented was in 1980 where a
\nwhite man was sentenced to death for kill-
\ning a black woman.
\nh. The dilemma of revenge
\nKant points out that the necessity of achiev-
\ning justice is a deeply rooted in us: Crimes
\nneed to be punished. However, it is unclear
\nwhat can be regarded as a suitable punish-
\nment from a retribution point of view:
\n\u201cWhen it comes to people like Saddam or
\nEichmann the question is whether any pun-
\nishment can ever counterbalance\/make up
\nfor their actions\u201d.
\nAlso the humane person may reach the
\nconclusion that a death penalty is suitable,
\nexplains Inga Floto:
\n\u201cYou can say that the human life is so valu-
\nable that we do not have any right to take it
\naway. But you can also say the opposite: that
\nit is so valuable that he who wastes his life
\nhas lost his right to live.
\nThis is a dilemma, which I think we cannot
\nsolve. I do not believe that we have the right
\nto take another person\u00b4s life \u2013 not even the
\nlife of murderers, but I cannot judge others
\nwho think that murder is such a cruel act
\nthat it should be punished with death. We
\ndo not have any higher authority to decide
\nthis.We only have our own conscience\u201d, she
\nsays.
\nwmj 3 2012.indd 84 7\/18\/12 9:47 AM
\n85
\nWMA news
\nHuman rights organizations state that
\nthe use of capital punishment is denial of
\nthe ultimate human right, the right to life
\ni.e. the willful state induced denial of the
\nperson\u00b4s right to life. Some may say that a
\nperson can forfeit his right to life by com-
\nmitting a terrible crime.
\nCapital punishment is also a dilemma for
\nthe UN. In the dilemma lies the idea of a
\njust society and at the same time the idea
\nof humanity.
\n5. Criminal law and the
\nargument of deterrence
\nand retribution
\nThe reason to uphold capital punishment
\nin modern times is the argument of deter-
\nrence and to some degree retribution since
\ncertain crimes are so grievous and affront
\nto humanity \u201cthat the only adequate response
\nmay be the penalty of death\u201d1
\n. Still it is debat-
\ned whether capital punishment violates the
\n8th
\namendment\u2019s ban on cruel and unusual
\npunishment.
\na. Gregg vs. Georgia 1976
\nIn a legal challenge to the death penalty as
\ncruel and unusual punishment under the
\nEighth Amendment, the Supreme Court
\nof the United States upheld a state\u2019s right
\nto use capital punishment as a tool in the
\ncriminal court. Though the court admitted
\nthat retribution is no longer a dominant ob-
\njective in criminal law,it emphasized its role
\nin capital punishment where it is \u201cthe com-
\nmunity\u2019s belief that certain crimes are them-
\nselves so grievous an affront to humanity that
\nthe only adequate response may be the penalty
\nof death.\u201d
\nThe Court cited to the British Royal Com-
\nmission on Capital Punishment which
\n1 Gregg v. Georgia, 184.
\nstated that capital punishment in extreme
\ncases is supportable because \u201cthe wrong-doer
\ndeserves it, irrespective of whether it is a deter-
\nrent or not.\u201d
\nThe issue of deterrence was also explored
\nby the Court. At the time of the case, the
\nCourt thought statistical studies of capital
\npunishment\u2019s deterrent effect were incon-
\nclusive, citing a variety of studies from the
\n1950\u2019s\u20131970\u2019s. They assumed that the death
\npenalty may be a significant deterrent for
\nsome criminals, but not for others. In the
\nend, the Court emphasized that it is the
\nstate\u2019s role to adjudicate criminal violations,
\nand permitted capital punishment in accor-
\ndance with the state\u2019s moral consensus and
\nthe social utility of such a sanction, citing
\ndeterrence and retribution as justifiable ra-
\ntionales.
\nStates vary in whether they cite retribution
\n(the more controversial justification) and\/
\nor deterrence as justifications for employ-
\ning capital punishment. Some states have
\ndeemed retribution an invalid rationale for
\ncriminal punishment, but there is evidence
\nthat, in practice, this retribution is still used
\nto justify criminal punishment in these
\nstates.
\nIn the period between 1972 and 1976 the
\nSupreme Court of the United States pro-
\nduced an effective moratorium on capital
\npunishment.
\nIn a discourse on capital punishment, Sun-
\nstein and Vermeule2
\n\u2013 using state data from
\n1977\u20131999 \u2013 focused on the murder rate in
\neach state before and after the death penalty
\nwas suspended and reinstated. The authors
\nfind a substantial deterrent effect.
\nHowever, a recent study offers more refined
\nfindings. By disaggregating state data, Jo-
\nanna Shepherd finds that the nationwide
\n2 Sunstein and Vermeule: \u201cIs capital punishment
\nmorally required? Acts, omissions, and life trade
\noffs\u201d 58 STAN. L. Rev. 703.
\ndeterrent effect of capital punishment is en-
\ntirely driven by 6 states that are executing
\nmore people than the rest3
\n.
\nb. Base vs. Rees 2008
\nIn a videotaped debate in the New England
\nJournal of Medicine three physicians and a
\nlawyer in 2008 debated the case of Base vs.
\nRees.The case was brought before the court
\nof Kentucky and the object was to establish
\nwhether or not the formula used for capi-
\ntal punishment was in violation of the 8th
\namendment on cruel and inhuman punish-
\nment.
\nThe formula dates back to 1977 and was
\nintroduced by a doctor A.J. Chaplin. It con-
\nsists of thiopental (to sedate), pancuronium
\nbromide (to avoid twitching and spasms)
\nand potassium chloride (to stop the heart).
\nThe court found that the petitioners failed
\nto show that Kentucky\u00b4s execution method
\namounted to \u201ccruel and unusual punishment\u201d.
\nOne of the judges of the court decided that
\nalthough the use of pancuroinium bromide
\nraised legitimate concerns, the petitioners
\nfailed to show that Kentucky\u00b4s execution
\nmethod amounted to \u201ccruel and unusual
\npunishment\u201d. However this judge also re-
\nmarked: \u201cAlthough the death penalty has
\nserious risks \u2013 e.g. that the wrong person
\nmay be executed, that unwarranted animus
\nabout the victim\u00b4s race, for example, may
\nplay a role, and that those convicted will
\nfind themselves on the death row for many
\nyears \u2013 the penalty\u00b4s lawfulness is not before
\nthe court\u201d.
\nAI addressed the question of deterrence in a
\npublication from 19874
\n.
\n3 Shepherd: \u201cDeterrence versus Brutilization\u201d, su-
\npra note 9.
\n4 Amnesty International: United States of Amer-
\nica, The Death Penalty, Amnesty International
\nPublications, p. 162\u2013166.
\nwmj 3 2012.indd 85 7\/18\/12 9:47 AM
\n86
\nWMA news
\nAI states that detailed research in the USA
\nand other countries has provided no evi-
\ndence that the death penalty deters crime
\nmore effectively than other punishments. In
\nsome countries, the number of homicides
\nactually declined after abolition. In Canada
\nfor example the murder rate fell from 3.09
\nper 100,000 in 1975 (the year before aboli-
\ntion) to 2.74 in 1983.
\nA United Nations study published in 1980
\nfound that: \u201cDespite much more advanced
\nresearch efforts mounted to determine the
\ndeterrent value of the death penalty,no con-
\nclusive evidence has been obtained on its
\nefficacy.\u201d
\nAccording to AI, US studies have shown
\nthat, under past and present death penalty
\nstatutes, the murder rate in death penalty
\nstates has differed little from that in other
\nstates with similar populations and social
\nand economic conditions. A study by Thor-
\nsten Sellin who studied murder rates be-
\ntween 1920 and 1974 is referenced.
\nIn the same publication by AI, crime trends
\nare referenced. In Florida and Georgia re-
\nsearch has shown an increase in homicides
\nin the period immediately following the re-
\nsumption of executions. Florida had carried
\nout no executions for nearly 15 years when
\na prisoner was executed in 1979.Three years
\nfollowing the resumption of executions in
\n1980, 1981 and 1982 Florida had the high-
\nest murder rates in the state\u00b4s recent history,
\nwith a 28 percent increase in homicides in
\n1980.
\n6. Why the use of medication
\nin capital punishment?
\nA member of the panel of the New Eng-
\nland Journal of Medicine, Professor Debo-
\nrah Denno (lawyer), states why the combi-
\nnation of drugs was introduced in 1977.
\n\u201cThe law turned to medicine to save the
\ndeath penalty\u201d. The drugs were to replace
\nthe electric chair and the object was to
\nmake the death penalty look more hu-
\nmane.
\nSoon after this, the AMA took a position
\nagainst the involvement of physicians in ex-
\necutions. From Gawande \u2013 \u201cWhen law and
\nethics collide\u201d 1
\n:
\n\u201cBut medicine balked. In 1980, when the first
\nexecution was planned using Dr. Deutsch\u2019s
\ntechnique, the AMA passed a resolution
\nagainst physician participation as a violation
\nof core medical ethics. It affirmed that ban in
\ndetail in its 1992 Code of Medical Ethics.
\nArticle 2.06 states, \u201cA physician, as a mem-
\nber of a profession dedicated to preserving
\nlife when there is hope of doing so, should not
\nbe a participant in a legally authorized ex-
\necution,\u201d although an individual physician\u2019s
\nopinion about capital punishment remains
\n\u201cthe personal moral decision of the individ-
\nual.\u201d It states that unacceptable participation
\nincludes prescribing or administering medi-
\ncations as part of the execution procedure,
\nmonitoring vital signs, rendering technical
\nadvice, selecting injection sites, starting or
\nsupervising placement of intravenous lines,
\nor simply being present as a physician. Pro-
\nnouncing death is also considered unaccept-
\nable, because the physician is not permitted to
\nrevive the prisoner if he or she is found to be
\nalive. Only two actions were acceptable: pro-
\nvision at the prisoner\u2019s request of a sedative to
\ncalm anxiety beforehand and certification of
\ndeath after another person had pronounced it.
\nThe code of ethics of the Society of Correctional
\nPhysicians establishes an even stricter ban:
\n\u201cThe correctional health professional shall . .
\n. not be involved in any aspect of execution
\nof the death penalty.\u201d The American Nurses
\nAssociation (ANA) has adopted a similar
\nprohibition. Only the national pharmacists\u2019
\nsociety, the American Pharmaceutical Asso-
\nciation, permits involvement, accepting the
\nvoluntary provision of execution medications
\nby pharmacists as ethical conduct\u201d.
\n1 Gawande A. (2006) \u201cWhen Law and Ethics
\nCollide \u2014 Why Physicians Participate in Execu-
\ntions\u201d. NEJM 354:1221-1229
\nThe method of lethal injection has given rise
\nto problems and concerns in the medical
\ncommunity worldwide.The WMA adopted
\nits policy on non involvement of physicians
\nin capital punishment in 1981. The Reso-
\nlution on Physician participation in Capi-
\ntal punishment has since been amended in
\n2000 and 2008.
\nRecently in 2010 and 2011 some pharma-
\nceutical companies and some European
\ngovernments have adopted policies against
\nexporting drugs that may be used for execu-
\ntions with or without pressure from human
\nrights activists.
\nTurning back to the New England Journal
\nof Medicine, the panel concludes:
\n\u201cThe involvement of physicians in some part of
\nthe procedure is necessary if it should be per-
\nformed without complications and pain.\u201d
\n7. Some statistics on
\ncapital punishment
\nSource: web.amnesty.org
\n\u2022 In 2005 at least 2,148 people were ex-
\necuted in 22 countries and at least 5,186
\npeople were sentenced to death in 53
\ncountries.
\n\u2022 94 percent of all executions took place in
\nChina, Iran, Saudi-Arabia and the US.
\n\u2022 AI estimates that at least 1,770 were ex-
\necuted in China in this year but the num-
\nber may be higher.
\n\u2022 AI estimates that at least 20,000 people
\nawait their execution.
\nReported death sentences and executions
\nin 2010:
\nWhere \u201c+\u201d is indicated after a country and it
\nis preceded by a number, it means that the fig-
\nure Amnesty International has calculated is a
\nminimum figure. Where \u201c+\u201d is indicated after
\na country and is not preceded by a number, it
\nindicates that there were executions or death
\nsentences (at least more than one) in that coun-
\ntry but it was not possible to obtain any figures.
\nwmj 3 2012.indd 86 7\/18\/12 9:47 AM
\n87
\nHighlights on the WMA\u2019s
\nactivities during the World
\nHealth Assembly
\nThe last World Health Assembly has been a
\nbusy time for the World Medical Associa-
\ntion.This year, the WMA co-organised two
\nside-events with other organisations \u2013 one
\non palliative care and the other on social de-
\nterminants of health. In parallel, the World
\nHealth Professions Alliance (WHPA) \u2013 in
\nwhich the WMA is an active member \u2013
\npresented four public statements respec-
\ntively on non-communicable diseases, the
\nMillennium Development Goals (MDGs),
\nCounterfeit medicines and on the role of
\nWHO in collecting and disseminating data
\non attacks on health in complex humanitar-
\nian emergencies.
\nReducing the Burden of Pain and
\nSuffering: Developing Palliative Care
\nin Low and Middle Income Countries
\nThis side-event took place on May 23rd
\nat
\nthe initiative of Human Rights Watch, in
\ncooperation with the Worldwide Palliative
\nCare Alliance, the WMA and other rel-
\nevant partners1
\n.The event was sponsored by
\n1 Union for International Cancer Control, Inter-
\nnational Association of Hospice and Palliative
\nCare, Trivandrum Insitute of Palliative Sciences,
\nOpen Society Foundations, Kenya Hospice and
\nPalliative Care Association. With the support of
\nthe Open Society Foundations.
\nReferences
\n1. Allen, Ronald J. & Shavell, Amy: \u201cFurther re-
\nflections on the Guillotine\u201d (2005).
\n2. Amnesty International: United States of
\nAmerica, The Death Penalty. Amnesty Interna-
\ntional Publications, 1987.
\n3. Daly R.: \u201cParticipation in the death Penalty\u201d
\n(2006).
\n4. Floto,Inga: \u201cThe Cultural History of the Death
\nPenalty \u2013 rituals and methods 1600\u20132000\u201d
\n(\u201cD\u00f8dsstraffens kulturhistorie \u2013 ritualer og me-
\ntoder 1600\u20132000\u201d).
\n5. Gawande A: \u201cWhen law and ethics collide\u00a0 \u2013
\nWhy Physicians participate in executions\u201d
\nNEJM 354 (2006).
\n6. Gawande A. et al: \u201cPhysicians and Execution \u2013
\nHighlights from a discussion on Lethal Injec-
\ntion\u201d NEJM 358 (2008).
\n7. Robinson M.: \u201cAssessing the Death Penalty us-
\ning Justice Theory\u201d (2011).
\n8. Sunstein and Vermeule: \u201cIs Capital Punish-
\nment Morally required? \u2013 Acts, omissions and
\nlife-life trade offs\u201d.
\n9. Steiker, Carol S.: \u201cNo capital punishment is not
\nmorally required \u2013 deterrence, deontology and
\nthe death penalty\u201d.
\n10. Williams,Daniel R.:\u201cThe futile debate over the
\nmorality of the death penalty\u00a0\u2013 a critical com-
\nmentary on the Steiker and Sunstein-Vermeule
\ndebate\u201d.
\n11. Svendsen,Lars Fr.H.: \u201cThe Philosophy of Cru-
\nelty\u201d (Ondskabens filosofi) 2005.
\nReported executions
\nin\u00a02010
\nChina 1000s
\nIran 252+
\nNorth Korea 60+
\nYemen 53+
\nUnited States of
\nAmerica\u00a046
\nSaudi Arabia 27+
\nLibya 18+
\nSyria 17+
\nBangladesh 9+
\nSomalia 8+
\nSudan 6+
\nPalestinian Authority 5
\nReported death sentences
\nin 2010
\nChina +
\nPakistan 365
\nIraq 279+
\nEgypt 185
\nWMA page 11
\nNigeria 151+
\nAlgeria 130+
\nMalaysia 114+
\nUnited States of
\nAmerica\u00a0110+
\nIndia 105+
\nAfghanistan 100+
\nZambia 35
\nSaudi Arabia 34+
\nViet Nam 34+
\nBangladesh 32+
\nUnited Arab Emirates 28+
\nYemen 27+
\nTunisia 22+
\nGhana 17
\nMauritania 16+
\nMali 14+
\nCentral African
\nRepublic\u00a014
\nJapan 14
\nGambia 13
\nLebanon 12+
\nPalestinian Authority 11+
\nLiberia 11
\nSudan 10+
\nSyria 10+
\nJordan 9
\nTaiwan 9
\nSingapore 8+
\nSomalia 8+
\nZimbabwe 8
\nIndonesia 7+
\nThailand 7+
\nEthiopia 5+
\nKenya 5+
\nTanzania 5+
\nUganda 5+
\nBahamas 5+
\nEquatorial Guinea 4
\nJamaica 4
\nLaos 4
\nMorocco\/Western Sahara 4
\nSouth Korea 4
\nKuwait 3+
\nBelarus 3
\nMadagascar 2+
\nMalawi 2
\nMyanmar 2
\nBenin 1+
\nBurkina Faso 1+
\nGuyana 1+
\nBahrain 1
\nBarbados 1
\nWMA page 12
\nChad 1
\nGuatemala 1
\nMaldives 1
\nSierra Leone 1
\nBrunei Darussalam +
\nCameroon +
\nDemocratic Republic of
\nCongo +
\nIran +
\nLibya +
\nNorth Korea +
\nSri Lanka +
\nTrinidad and Tobago +
\nWorld Health Assembly Report,
\nGeneva, Switzerland, 2012
\nWMA news
\nwmj 3 2012.indd 87 7\/18\/12 9:47 AM
\n88
\nthe Republic of Kenya, the United States
\nof America, the Republic of Panama and
\nAustralia.
\nFollowing the September 2011 UN Gen-
\neral Assembly Political Declaration on
\nNon-Communicable Diseases, which com-
\nmitted countries to ensure the availability
\nof palliative care, the WHA was seen as an
\nimportant forum for sharing experiences in
\nimplementing palliative care and providing
\nguidance to countries as they implement
\nthis commitment.
\nDr. Cecil Wilson, the WMA President-
\nElect, talked about the critical role of the
\nmedical community in ensuring the avail-
\nability of palliative care. Denouncing the
\nnegative economic impact and human suf-
\nfering of inadequate pain treatment, Dr.
\nWilson called for equal access to pain treat-
\nment without discrimination and the in-
\nclusion of end-of-life care issues in under-
\ngraduate and postgraduate medical training.
\nAs well, Dr. Wilson reminded the partici-
\npants that the duty of physicians was to heal
\nwhere possible, to relieve suffering and to
\nprotect the best interests of their patients.
\nOther interventions included Hon.\u00a0Dr.\u00a0Beth
\nMugo, Minister of Public Health and Sani-
\ntation of the Republic of Kenya; Hon. Dr.
\nChristine Ondoa, Minister of Health of the
\nRepublic of Uganda; as well as leading ex-
\nperts on palliative care. Ambassador Jimmy
\nKolker, Principal Deputy Director of the
\nGlobal Health Office, the United States
\nDepartment of Health and Human Ser-
\nvices, moderated the event.
\nIt is hoped that this event will encourage
\nsustained attention from the World Health
\nAssembly to the situation of millions of
\npeople with incurable illnesses who cur-
\nrently do not have access to palliative care.
\nWMA Resolution on the Access to Ad-
\nequate Pain Treatment, Montevideo
\nOctober 2011\u00a0: https:\/\/www.wma.net\/
\nen\/30publications\/10policies\/p2\/index.html
\nGovernments Must Do More to
\nInvest in end-of-life Care
\nGovernments and research institutions must be encouraged by
\nnational medical associations to invest additional resources in
\ndeveloping treatments to improve end-of-life care, according to
\nDr.\u00a0Cecil Wilson, President elect of the World Medical Associa-
\ntion.
\nSpeaking in Geneva today (Wednesday), he said that millions of
\npeople around the world with cancer and other diseases suffered
\nmoderate to severe pain without access to adequate treatment.
\n\u2018A consequence of inadequate pain treatment is a negative eco-
\nnomic impact and human suffering, \u2018 he said. \u2018In most cases pain
\ncan be stopped or relieved with inexpensive and relatively simple
\ntreatment interventions.\u2019
\nDr. Wilson, who was speaking at a side meeting of the World
\nHealth Assembly, added \u2018All people should have the right to ac-
\ncess to pain treatment without discrimination\u2026.Governments
\nmust ensure the adequate availability of controlled medicines,and
\ngovernmental drug control agencies\u2019.
\nHe said that the appropriate use of morphine, new analgesics and
\nother measures could relieve pain and other distressing symptoms
\nin the majority of cases. Health authorities must make necessary
\nmedications accessible and available to physicians and their pa-
\ntients.
\nYet in many parts of the world palliative and life-sustaining mea-
\nsures required technologies and\/or financial resources that were
\nsimply not available. He also said that as far as pain and symptom
\nmanagement were concerned it was essential to identify patients
\napproaching the end-of-life as early as possible
\nThe increasing number of people who required palliative care and
\nthe increased availability of effective treatment options meant
\nthat end-of-life care issues should be an important part of under-
\ngraduate and postgraduate medical training. The duty of physi-
\ncians was to heal where possible,to relieve suffering and to protect
\nthe best interests of their patients.
\nSocial Determinants of
\nHealth: Building capacity to
\nachieve health equity
\nIn October 2011, the World Health Or-
\nganization invited the member states and
\ncivil society partners to the World Con-
\nference on Social Determinants of Health
\n(SDH) in Rio de Janeiro. The purpose was
\nto build support to implement policies and
\nstrategies to reduce health inequities, by
\naddressing these social determinants. The
\nRio Declaration adopted by the Confer-
\nence translated this call into a global polit-
\nical commitment for the implementation
\nof a SDH approach to reducing health in-
\nequities and achieving other global health
\npriorities. Further reorienting the health
\nsector towards reducing health inequities
\nwas one of the identified priority action
\nareas.
\nWMA news
\nwmj 3 2012.indd 88 7\/18\/12 9:47 AM
\n89
\nAs a follow-up, the UK Government, in
\npartnership with the WMA and the Inter-
\nnational Federation of Medical Students
\nAssociations (IFMSA), with the support
\nof WHO, held a side-event on May 24th
\nto explore concrete mechanisms for the
\nhealth sector to engage in achieving health
\nequity.
\nThis side event was moderated by Kathryn
\nTyson, Director of International Health
\nand Public Health Delivery, Department of
\nHealth, United Kingdom. It opened with
\na film produced by WHO, Department of
\nEthics, Equity, Trade and Human Rights,
\nfollowing the World Conference on Social
\nDeterminants of Health.
\nProfessor Sir Michael Marmot, Chair of
\nthe Socio-Medical Affairs Committee of
\nthe WMA and former Chair of the WHO
\nCommission on Social Determinants of
\nHealth, underlined the role of doctors and
\nnational medical associations to advance
\nhealth equity through Social Determinants
\nof Health. Christopher Pleyer, President
\nof IFMSA, talked about education and
\ntraining as a pre-requisite to reduce and
\nprevent health inequities. Finally, Dr. R\u00fcdi-
\nger Krech, Director of the Department of
\nEthics, Equity,Trade and Human Rights at
\nWHO, emphasized the indispensable role
\nof the UN in promoting a global agenda for
\nhealth equity.
\nIn parallel, the Rio Declaration was official-
\nly adopted by the World Health Assembly.
\nThe presentations of the side event are
\navailable on WHO website:
\nhttp:\/\/www.who.int\/social_determinants\/ad-
\nvocacy\/en\/index.html
\nOutcome of the World Conference
\non Social Determinants of Health
\nThe Sixty-fifth World Health Assembly, Having considered
\nthe report on the World Conference on Social Determinants of
\nHealth (Rio de Janeiro, Brazil, 19\u201321 October 2011);1
\nReiterating the determination to take action on social determi-
\nnants of health as collectively agreed by the World Health As-
\nsembly and reflected in resolution WHA62.14 on reducing
\nhealth inequities through action on the social determinants of
\nhealth, which notes the three overarching recommendations of
\nthe Commission on Social Determinants of Health: to improve
\ndaily living conditions; to tackle the inequitable distribution of
\npower, money and resources; and to measure and understand the
\nproblem and assess the impact of action;
\nRecognizing the need to do more to accelerate progress in ad-
\ndressing the unequal distribution of health resources as well as
\nconditions damaging to health at all levels;
\nRecognizing also the need to safeguard the health of the popula-
\ntions regardless of global economic downturns;
\nFurther acknowledging that health equity is a shared goal and
\nresponsibility and requires the engagement of all sectors of gov-
\nernment, all segments of society, and all members of the interna-
\ntional community, in \u201call-for-equity\u201d and \u201chealth-for-all\u201d global
\nactions;
\n1 Document A65\/16.
\nRecognizing the benefits of universal health coverage in enhanc-
\ning health equity and reducing impoverishment;
\nReaffirming the political will to make health equity a national,
\nregional and global goal and to address current challenges \u2013 such
\nas eradicating hunger and poverty; ensuring food and nutritional
\nsecurity, access to affordable, safe, efficacious and quality medi-
\ncines as well as to safe drinking-water and sanitation, employ-
\nment and decent work and social protection; protecting envi-
\nronments and delivering equitable economic growth through
\nresolute action on social determinants of health across all sectors
\nand at all levels;
\nWelcoming the discussions and results of the World Conference
\non Social Determinants of Health (Rio de Janeiro, Brazil, 19\u201321
\nOctober 2011),
\n1. ENDORSES the Rio Political Declaration on Social Deter-
\nminants of Health adopted by the World Conference on Social
\nDeterminants of Health,1 including as a key input to the work of
\nMember States and WHO;
\n2. URGES Member States:
\n(1) to implement the pledges made in the Rio Political
\nDeclaration on Social Determinants of Health with
\nregard to (i) better governance for health and devel-
\nopment, (ii) promoting participation in policy-mak-
\ning and implementation, (iii) further reorienting the
\nhealth sector towards reducing health inequities, (iv)
\nstrengthening global governance and collaboration,
\nand (v) monitoring progress and increasing account-
\nability;
\nWMA news
\nwmj 3 2012.indd 89 7\/18\/12 9:47 AM
\n90
\nWMA news
\nWMA Luncheon on Women\u2019s,
\nMaternal and Girls\u2019 Health
\nEvery year during the World Health As-
\nsembly, the WMA organises a reception for
\nMinisters of Health and Heads of Delega-
\ntions of the Assembly.This year the Honor-
\nable Kathleen Sebelius,\u00a0the U.S. Secretary
\nof Health and Human Services, was the
\nkey note speaker on the topic of Women\u2019s,
\nMaternal and Girls\u2019 Health \u2013 Their Futures in
\nOur Hands (see p. 95).
\nSecretary Sebelius emphasised the need for
\nuniversal access to care in general, and the
\nbenefit in investing in health care. Further-
\nmore, she highlighted that while women
\nplay a key role as health keepers for fami-
\nlies, many health care systems failed to con-
\nsider the unique health needs of women.
\nDr.\u00a0 Mukesh Heikerwal accentuated the
\nvision and engagement of the WMA in
\nemphasizing the special situation of women
\nin health care. The reception was very well
\nattended with more than 200 participants.
\nWHA\u2019s Results related to the
\nWMA Advocacy Priorities
\nNon-communicable diseases
\nThe Political Declaration of the UN High
\nLevel Meeting on NCDs in 2011 urged
\nWHO and the member states to develop a
\nglobal monitoring framework with targets
\nand indicators on NCD before the end of
\n2012. At the 65th
\nWHA a discussion on
\n(2) to develop and support policies, strategies, programmes
\nand action plans that address social determinants of
\nhealth,with clearly defined goals,activities and account-
\nability mechanisms and with resources for their imple-
\nmentation;
\n(3) to support the further development of the \u201chealth-in-
\nall-policies\u201d approach as a way to promote health eq-
\nuity;
\n(4) to build capacities among policy-makers, managers, and
\nprogramme workers in health and other sectors to facili-
\ntate work on social determinants of health;
\n(5) to give due consideration to social determinants of
\nhealth as part of the deliberations on sustainable de-
\nvelopment, in particular in the Rio+20 United Nations
\nConference on Sustainable Development and deliber-
\nations in other United Nations forums with relevance
\nto health;
\n3. CALLS UPON the international community to support the
\nimplementation of the pledges made in the Rio Political Dec-
\nlaration on Social Determinants of Health for action on social
\ndeterminants of health, including through:
\n(1) supporting the leading role of WHO in global health
\ngovernance and promoting alignment of policies, plans
\nand activities on social determinants of health with
\nthose of its partner organizations in the United Nations
\nsystem, development banks and other key international
\norganizations, including in joint advocacy, and in facili-
\ntating access to the provision of financial and technical
\nsupport to countries and regions, in particular develop-
\ning countries;
\n(2) strengthening international cooperation, with a view to
\npromoting health equity in all countries, through facili-
\ntating transfer on mutually agreed terms of expertise,
\ntechnologies and scientific data in the field of social de-
\nterminants of health, as well as exchanging good prac-
\ntices for managing intersectoral policy development;
\n(3) facilitating access to financial resources;
\n4. URGES those developed countries that have pledged to
\nachieve the target of 0.7% of gross national product for official
\ndevelopment assistance by 2015, and those developed countries
\nthat have not yet done so, to make additional concrete efforts to
\nfulfil their commitments in this regard, and also urges developing
\ncountries to build on progress achieved in ensuring that official
\ndevelopment assistance is used effectively to help to achieve de-
\nvelopment goals and targets;
\n5. REQUESTS the Director-General:
\n(1) to duly consider social determinants of health in the
\nassessment of global needs for health, including in the
\nWHO reform process and WHO\u2019s future work;
\n(2) to provide support to Member States in implementing
\nthe Rio Political Declaration on Social Determinants of
\nHealth through approaches such as \u201chealth-in-all poli-
\ncies\u201d in order to address social determinants of health;
\n(3) to work closely with other organizations in the United
\nNations system on advocacy, research, capacity-building
\nand direct technical support to Member States for work
\non social determinants of health;
\n(4) to continue to convey and advocate the importance of
\nintegrating social determinants of health perspectives
\ninto forthcoming United Nations and other high-level
\nmeetings related to health and\/or social development;
\n(5) to report to the Sixty-sixth and Sixty-eighth World
\nHealth Assemblies, through the Executive Board, on
\nprogress in implementing this resolution and the Rio
\nPolitical Declaration on Social Determinants of Health.
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\nthis framework took place with limited
\nopportunities for the member states to
\nreach agreement. Thanks to the initiative
\nof several countries, finally the 193 mem-
\nber states adopted the resolution to reduce
\npreventable deaths from NCDs by 25% by
\nthe year 2025, with the remaining targets
\nto be agreed at a formal Member State
\nconsultation before the end of October
\n2012.
\nWHO Reform
\nAt the 65th
\nWHA member states endorsed
\nreforms to the management and priority
\nsetting processes at WHO.
\nIt was agreed that WHO should become
\nmore transparent, result-focused, account-
\nable and effective. As the five priorities for
\nfuture WHO activity, the member states
\ndefined: communicable diseases; non-
\ncommunicable diseases; health through
\nthe life-course; health systems; and pre-
\nparedness, surveillance and response. Fur-
\nthermore, the delegates emphasized that
\nWHO should increase its focus on\u00a0 the
\nsocial, economic and environmental deter-
\nminants of health.
\nOne critical point of the reform process
\nwas not discussed\u2014\u00a0how to make WHO\u2019s
\nfuture governance more inclusive and par-
\nticipatory by involving external stakeholders
\nsuch as philanthropic bodies and industry.
\nThis topic is too controversial for many
\ncountries. It\u00a0 raises many questions, start-
\ning with the question of mandate and not
\nending with the fact that some foundations
\ncontribute more to global health than many
\ncountries do.
\nAnother core reform issue that wasn\u2019t dis-
\ncussed was how WHO finances its opera-
\ntions. The organization is suffering a finan-
\ncial crisis due to several factors, including
\nreduced government funding. Last year, it
\nslashed its annual budget of $US4.5\u00a0billion
\nby nearly a quarter.
\nA New Role for WHO in Complex
\nHumanitarian Emergencies\u00a0
\nOne of the items on the agenda of the last
\nWorld Health Assembly related to the role
\nof WHO as the health cluster lead\u00a0in meet-
\ning\u00a0the growing demands of health in\u00a0hu-
\nmanitarian emergencies. A draft resolution
\nwas submitted to the Assembly for adop-
\ntion.
\nWith the resolution, the Member States
\ncalled on WHO\u00a0 Director-General: \u201c…to
\nprovide leadership at the global level in de-
\nveloping methods for systematic collection and
\ndissemination of data on attacks on health
\nfacilities,\u00a0 health workers, health transports,
\nand patients in complex humanitarian emer-
\ngencies, in coordination with other relevant
\nUnited Nations bodies,\u00a0other relevant actors,
\nand intergovernmental and nongovernmen-
\ntal organizations, avoiding duplication of ef-
\nforts\u201d.
\nFrom the start, the initiative had been
\nactively supported by the Safeguarding
\nHealth Coalition1
\n, in which the WMA is
\nan observer. The proposal had been first
\nsubmitted to the Executive Board in Janu-
\nary. The Coalition and other organisations
\nconcerned had sent an open letter to the
\nattention of Dr. Margaret Chan and made
\nan oral statement in support of the initia-
\ntive.
\nSimilarly, last May at the World Health
\nAssembly, numerous organizations joined
\n1 The Safeguarding Health in Conflict coalition
\npromotes respect for international humanitarian
\nand human rights laws that relate to the safety
\nand security of health facilities, workers, am-
\nbulances and patients during periods of armed
\nconflict or civil violence. The founding members
\ninclude Intra Health International, Center for
\nPublic Health and Human Rights at the Johns
\nHopkins Bloomberg School of Public Health,
\nDoctors for Human Rights, International
\nCouncil of Nurses, International Health Pro-
\ntection Initiative, Karen Human Rights Group,
\nMedact, Merlin \u2013 UK and Physicians for Hu-
\nman Rights.
\nthe coalition in a statement encourag-
\ning the WHO member states to adopt
\nthe resolution so that the work of devel-
\noping methods to collect data and report
\non attacks can commence. The statement
\nwas made on behalf of the World Health
\nProfessional Alliance, and was supported
\nby the American Public Health Associa-
\ntion, CARE, the Center for Public Health
\nand Human Rights at the John Hopkins
\nBloomberg School of Public Health, Doc-
\ntors for Human Rights, International
\nHealth Protection Initiative, Interna-
\ntional Federation of Health and Human
\nRights Organisations, International Medi-
\ncal Corps, International Rehabilitation
\nCouncil for Torture Victims, International
\nRescue Committee, Intra Health Interna-
\ntional, Management Sciences for Health,
\nMedact, Merlin, Physicians for Human
\nRights, Women\u2019s Refugee Commission
\nand World Federation of Public Health
\nAssociations.
\nGoing forward, the coalition will advocate
\nfor effective implementation of the World
\nHealth Assembly resolution.
\nThe resolutions adopted by the World
\nHealth Assembly can be downloaded from
\nWHO\u2019s following website:
\nhttp:\/\/apps.who.int\/gb\/e\/e_wha65.html
\nMs Clarisse Delorme,
\nWMA Advocacy Advisor
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\nOn behalf of the World Health Professional
\nAlliance, which includes:
\nWorld Medical Association
\nInternational Council of Nurses
\nInternational Pharmaceutical Federation
\nWorld Confederation for Physical Therapy
\nWorld Dental Federation.
\nThese organizations speak on behalf of mil-
\nlions of health workers worldwide. This
\nstatement is also supported by the following
\norganizations:
\nAmerican Public Health Association
\nCARE
\nCenter for Public Health and Human
\nRights of the John Hopkins Bloomberg
\nSchool of Public Health
\nDoctors for Human Rights
\nHuman Rights Watch
\nInternational Health Protection Initiative
\nInternational Federation of Health and
\nHuman Rights Organisations
\nInternational Medical Corps
\nInternational Rehabilitation Council for
\nTorture Victims
\nInternational Rescue Committee
\nIntraHealth International
\nManagement Sciences for Health
\nMedact
\nMerlin
\nPhysicians for Human Rights
\nWomen\u2019s Refugee Commission
\nWorld Federation of Public Health Asso-
\nciations
\nHealth care workers are on the frontline
\nduring complex humanitarian emergen-
\ncies. Health providers and those they serve
\ndeserve protection. Indeed, the strength
\nand performance of the health system re-
\nquire it. Yet, in crises where health needs
\nare most urgent, health care workers are at
\ngreatest risk of assault, arrest, obstruction of
\ntheir duties, kidnapping and death. Health
\nfacilities and ambulances are also at risk of
\nattack. The health community must mobi-
\nlize to assure adherence to the principle of
\nimpartiality of health care in humanitarian
\nemergencies.
\nAt the 64th
\nAssembly, and again at the Ex-
\necutive Board, WHO\u2019s Director General,
\nDr. Margaret Chan, spoke eloquently of the
\nneed for WHO to respond.
\nThe foundation of protection and preven-
\ntion is information. WHO has a unique
\nrole to play in collecting and disseminating
\ndata on attacks. For that reason, we support
\nresolution EB130.R14 (see below), in par-
\nticular, paragraph 8, calling on the Director
\nGeneral:
\n\u201c\u2026to provide leadership at the global level in
\ndeveloping methods for systematic collection
\nand dissemination\u00a0of data on attacks on health
\nfacilities, health workers, health transports,
\nand patients in complex humanitarian emer-
\ngencies…\u201d
\nWe call on the WHO Member States to
\nadopt the resolution. This will be a strong
\naffirmation of the Member States commit-
\nment to protect health workers, services and
\npatients.
\nStatement of World Health Professional
\nAlliance adressed to World Health Assembly
\nWHO\u2019s response, and role as the health
\ncluster lead, in meeting the growing demands
\nof health in humanitarian emergencies
\nThe Executive Board,
\nHaving considered the report on WHO\u2019s response, and role as
\nthe health cluster lead,in meeting the growing demands of health
\nin humanitarian emergencies,1
\nRECOMMENDS to the Sixty-fifth World Health Assembly
\nthe adoption of the following resolution:
\nThe Sixty-fifth World Health Assembly,
\n1 Document EB130\/24.
\nHaving considered the report on WHO\u2019s response, and role as
\nthe health cluster lead,in meeting the growing demands of health
\nin humanitarian emergencies;
\nRecognizing that humanitarian emergencies result in avoidable
\nloss of life and human suffering, weaken the ability of health sys-
\ntems to deliver essential life-saving health services, produce set-
\nbacks for health development and hinder the achievement of the
\nMillennium Development Goals;
\nReaffirming the principles of neutrality, humanity, impartiality and
\nindependence in the provision of humanitarian assistance, and reaf-
\nfirming the need for all actors engaged in the provision of humani-
\ntarian assistance in situations of complex humanitarian emergencies
\nand natural disasters to promote and fully respect these principles;
\nRecalling Article 2(d) of the Constitution of the World Health
\nOrganization on the mandate of WHO in emergencies,and reso-
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\nlutions WHA58.1 on health action in relation to crises and disas-
\nters and WHA59.22 on emergency preparedness and response;1
\nRecalling United Nations General Assembly resolution 46\/182
\non the strengthening of the coordination of humanitarian emer-
\ngency assistance of the United Nations and the guiding principles
\nthereof, confirming the central and unique role for the United
\nNations in providing leadership and coordinating the efforts of
\nthe international community to support countries affected by hu-
\nmanitarian emergencies, establishing, inter alia, the Inter-Agency
\nStanding Committee, chaired by the Emergency Relief Coordi-
\nnator, supported by the United Nations Office for the Coordina-
\ntion of Humanitarian Affairs;
\nTakin note of the humanitarian response review in 2005, led by
\nthe Emergency Relief Coordinator and by the Principals of the
\nInter-Agency Standing Committee aiming at improving urgency,
\ntimeliness, accountability, leadership and surge capacity, and rec-
\nommending the strengthening of humanitarian leadership, the
\nimprovement of humanitarian financing mechanisms and the
\nintroduction of the clusters as a means of sectoral coordination;
\nTaking note of the Inter-Agency Standing Committee Princi-
\npals\u2019 Reform Agenda 2011\u20132012 to improve the international
\nhumanitarian response by strengthening leadership, coordination,
\naccountability, building global capacity for preparedness and in-
\ncreasing advocacy and communications;
\nRecognizing United Nations General Assembly Resolution
\n60\/124, and taking note of WHO\u2019s subsequent commitment to
\nsupporting the Inter-Agency Standing Committee transforma-
\ntive humanitarian agenda and contributing to the implementa-
\ntion of the Principals\u2019 priority actions designed to strengthen in-
\nternational humanitarian response to affected populations;
\nReaffirming that it is the national authority that has the primary
\nresponsibility to take care of victims of natural disasters and other
\nemergencies occurring on its territory, and that the affected State
\nhas the primary role in the initiation, organization, coordination,
\nand implementation of humanitarian assistance within its territory;
\nTaking note of the 2011 Inter-Agency Standing Committee
\nguidance note on working with national authorities, that clusters
\nshould support and\/or complement existing nationalcoordina-
\ntion mechanisms for response and preparedness and where ap-
\n1 Resolutions WHA34.26, WHA46.6, WHA48.2, WHA58.1, WHA59.22
\nand WHA64.10 reiterate WHO\u2019s role in emergencies.
\npropriate,government,or other appropriate national counterparts
\nshould be actively encouraged to co-chair cluster meetings with
\nthe Cluster Lead Agency;
\nRecalling resolution WHA64.10 on strengthening national
\nhealth emergency and disaster management capacities and resil-
\nience of health systems, which urges Member States, inter alia, to
\nstrengthen all-hazards health emergency and disaster risk-man-
\nagement programmes;
\nReaffirming also that countries are responsible for ensuring the
\nprotection of the health, safety and welfare of their people and
\nfor ensuring the resilience and self-reliance of the health system,
\nwhich is critical for minimizing health hazards and vulnerabilities
\nand delivering effective response and recovery in emergencies and
\ndisasters;
\nRecognizing the comparative advantage of WHO through its
\npresence in,and its relationship with Member States,and through
\nits capacity to provide independent expertise from a wide range of
\nhealth-related disciplines, its history of providing the evidence-
\nbased advice necessary for prioritizing effective health interven-
\ntions,and that the Organization is in a unique position to support
\nhealth ministries and partners as the global health cluster lead
\nagency in the coordination of preparing for, responding to and
\nrecovering from humanitarian emergencies;
\nRecalling WHO\u2019s reform agenda and taking note of the report in
\n2011 by the Director-General on Reforms for a healthy future,1
\nwhich led to the creation of a new WHO cluster, Polio, Emer-
\ngencies and Country Collaboration, aimed at supporting regional
\nand country offices to improve outcomes and increase WHO\u2019s
\neffectiveness at the country level, by redefining its commitment
\nto emergency work and placing the cluster on a more sustainable
\nbudgetary footing;
\nWelcoming the reform in 2011 transforming the WHO cluster
\nHealth Action in Crisis into the Emergency Risk Management
\nand Humanitarian Response department as a means of imple-
\nmenting these reforms, ensuring that the Organization becomes
\nfaster, more effective and more predictable in delivering higher
\nquality response in health, and that the Organization holds itself
\naccountable for its performance;
\nRecalling resolutions WHA46.39 on health and medical services
\nin times of armed conflict; WHA55.13 on protection of medical
\nmissions during armed conflict; and the United Nations General
\nAssembly resolution 65\/132 on safety and security of humanitar-
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\nWMA news
\nian personnel and protection of United Nations personnel, con-
\nsiders that there is a need of systematic data collection on attacks
\nor lack of respect for patients and\/or health workers, facilities and
\ntransports in complex humanitarian emergencies,
\n1. CALLS ON Member States and donors:
\n(1) to allocate resources for the health sector activities dur-
\ning humanitarian emergencies through United Nations
\nConsolidated Appeal Process and Flash Appeals, and
\nfor strengthening WHO\u2019s institutional capacity to exer-
\ncise its role as the Global Health Cluster Lead Agency
\nand to assume health cluster lead in the field;
\n(2) to ensure that humanitarian activities are carried out in
\nconsultation with the country concerned for an efficient
\nresponse to the humanitarian needs, and to encourage
\nall humanitarian partners, including nongovernmental
\norganizations, to participate actively in the health clus-
\nter coordination;
\n(3) to strengthen the national level risk management,health
\nemergency preparedness and contingency planning pro-
\ncesses and disaster management units in the health min-
\nistry, as outlined in resolution WHA64.10, and, in this
\ncontext, as part of the national preparedness planning,
\nwith the Office for the Coordination of Humanitarian
\nAffairs where appropriate, identify in advance the best
\nway to ensure that the coordination between the inter-
\nnational humanitarian partners and existing national
\ncoordination mechanisms will take place in a comple-
\nmentary manner in order to guarantee an effective and
\nwell-coordinated humanitarian response;
\n(4) to build the capacity of national authorities at all levels
\nin managing the recovery process in synergy with the
\nlonger-term health system strengthening and reform
\nstrategies, as appropriate, in collaboration with WHO
\nand the health cluster;
\n2. CALLS ON the Director-General:
\n(1) to have in place the necessary WHO policies,guidelines,
\nadequate management structures and processes required
\nfor effective and successful humanitarian action at the
\ncountry level, as well as the organizational capacity and
\nresources to enable itself to discharge its function as the
\nGlobal Health Cluster Lead Agency,in accordance with
\nagreements made by the Inter-Agency Standing Com-
\nmittee Principals; and assume a role as Health Cluster
\nLead Agency in the field;
\n(2) to strengthen WHO\u2019s surge capacity, including develop-
\ning standby arrangements with Global Health Cluster
\npartners,to ensure that WHO has qualified humanitarian
\npersonnel to be mobilized at short notice when required;
\n(3) to ensure that in humanitarian crises WHO provides
\nMember States and humanitarian partners with pre-
\ndictable support by coordinating rapid assessment and
\nanalysis of humanitarian needs, including as a part of
\nthe coordinated Inter-Agency Standing Committee
\nresponse, building an evidence-based strategy and ac-
\ntion plan, monitoring the health situation and health
\nsector response, identifying gaps, mobilizing resources
\nand performing the necessary advocacy for humanitar-
\nian health action;
\n(4) to define the core commitments,core functions and per-
\nformance standards of the Organization in humanitar-
\nian emergencies, including its role as the Global Health
\nCluster Lead Agency and as Health Cluster Lead
\nAgency in the field, and to ensure full engagement of
\ncountry, regional and global levels of the Organiza-
\ntion to their implementation according to established
\nbenchmarks, keeping in mind the ongoing work on the
\nInter-Agency Standing Committee transformative hu-
\nmanitarian agenda;
\n(5) to provide a faster, more effective and more predictable
\nhumanitarian response by operationalizing the Emer-
\ngency Response Framework, with the performance
\nbenchmarks in line with the humanitarian reform, and
\nto ensure the accountability of its performance against
\nthose standards;
\n(6) to establish necessary mechanisms to mobilize WHO\u2019s
\ntechnical expertise across all disciplines and levels, for
\nthe provision of necessary guidance and support to
\nMember States, as well as partners of the health cluster
\nin humanitarian crises;
\n(7) to support Member States and partners in the transition
\nto recovery, aligning the recovery planning, including
\nemergency risk management as well as disaster riskre-
\nduction and preparedness, with the national develop-
\nment policies and ongoing health sector reforms, and\/
\nor using the opportunities of post-disaster and\/or post-
\nconflict recovery planning;
\n(8) to provide leadership at the global level in developing
\nmethods for systematic collection and dissemination
\nof data on attacks on health facilities, health workers,
\nhealth transports, and patients in complex humanitarian
\nemergencies, in coordination with other relevant United
\nNations bodies,the International Committee of the Red
\nCross, and intergovernmental and nongovernmental or-
\nganizations, avoiding duplication of efforts;
\n(9) to provide a report to the Sixty-seventh World Health
\nAssembly, through the Executive Board, and thereafter
\nevery two years, on progress made in the implementa-
\ntion of this resolution.
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\nEvery country in the world recognizes the
\nhuge benefits of investing in health. Healthy
\nchildren are better students. Healthy adults
\nare more productive workers. Healthy fami-
\nlies can make greater contributions to their
\ncommunities. And when we live longer,
\nhealthier lives, we have more time to do our
\njobs, play with our children, and watch our
\ngrandchildren grow up.
\nAnd yet, in too many countries, including
\nmy own, we fall short when it comes to the
\nhealth of women.
\nOne reason for this is that women are more
\nlikely to depend on a male partner to access
\nhealth care.And they\u2019re often less likely to have
\nthe resources they need to get care on their own.
\nAnother obstacle is health systems that too
\noften fail to consider the unique health needs
\nof women.
\nIn the United States, it wasn\u2019t until the 1980s
\nthatwomenwereevenincludedinclinicaltrials.
\nAs a result, we had no idea what treatments or
\nmedicines were particularly effective for wom-
\nen. We didn\u2019t know what might happen when
\na drug that had been tested on a 180-pound
\nman, was given to a 110-pound woman.
\nDespite the progress we\u2019ve made since then,
\ndisparities persist to this day. Women in
\nAmerica often pay more for health insur-
\nance,just because they\u2019re women.And to add
\ninsult to injury, these plans often don\u2019t even
\ncover the basic care they need. In my coun-
\ntry, just one out of 8 plans for those who buy
\ntheir own insurance cover maternity care\u00a0\u2013 as
\nif getting pregnant were some very rare con-
\ndition.
\nThe result is that far too many women, who
\noften serve as the health care gatekeepers for
\ntheir families, go without care themselves.
\nOf course, we see the same thing around the
\nworld. Every two minutes, a woman dies
\nfrom complications related to pregnancy or
\nchildbirth. The risks are even greater if you
\nlive in the developing world\u00a0\u2013 where three
\nout of every four women needing care for
\ncomplications from pregnancy do not re-
\nceive it.
\nEven in places where care is available, the
\ndemand is so great that it often stretches re-
\nsources to their limits.
\nLast year I visited the maternity ward of the
\nMnaziMmoja Hospital in Zanzibar, Tanza-
\nnia. There were so few beds and nurses that
\nsome women had to share beds in the post-
\nnatal room. And others were discharged just
\nhours after giving birth.The hospital was do-
\ning heroic work. And the women who were
\nable to deliver there, were among the lucky
\nones. Yet, so much need still went unmet.
\nWe know that when we under-invest in
\nwomen\u2019s health, whole families pay the price.
\nWhen a mother dies the chance of her child
\ndying within 12 months, increases seven fold.
\nSo under President Obama, we\u2019re putting
\na new focus on women\u2019s health\u00a0\u2013 at home
\nand abroad. In the United States, the key to
\nthose efforts is the Affordable Care Act, our
\nmost important women\u2019s health legislation in
\nyears.
\nThe health care law starts by ending dis-
\ncrimination against pre-existing conditions.
\nInsurers are already prohibited from denying
\ncoverage to children because they have asth-
\nma or diabetes. And beginning in 2014, all
\nwomen will be protected from being locked
\nout of the market because they\u2019re a breast
\ncancer survivor,or gave birth by c-section,or
\nwere a victim of domestic violence.
\nIn the past\u00a0 \u2013 because they were worried
\nabout losing their health coverage\u00a0 \u2013 too
\nmany women didn\u2019t have the freedom to
\nmake important decisions like changing jobs,
\nstarting a new company, even leaving a bad
\nmarriage. Now that women know they can\u2019t
\nbe turned away because of their health sta-
\ntus, we\u2019re taking those choices back from the
\ninsurance companies and returning them to
\nthe women where they belong.
\nNext, the law prohibits insurers from charg-
\ning women more just because they\u2019re women.
\nTo put it another way: this means that being a
\nwoman is no longer a pre-existing condition.
\nAnd the law helps women get the preventive
\ncare they need to stay healthy,from mammo-
\ngrams to contraception to an annual check-up
\nwhere you get to sit down and talk with your
\ndoctor, as a basic part of any insurance plan.
\nThese improvements are happening across
\nthe lifespan. Young girls now have access to
\nthe vaccinations they need stay healthy with-
\nout their parents worrying about additional
\ncosts. And seniors are getting better care to
\nhelp manage their chronic conditions.
\nSpeech given by the US Secretary of Health and
\nHuman Services Kathleen Sebelius at the WMA
\nLuncheon in Geneva, Switzerland, May 22, 2012
\nKathleen Sebelius
\nwmj 3 2012.indd 95 7\/18\/12 9:47 AM
\n96
\nWMA news
\nPut all these changes together and they rep-
\nresent the most important and comprehen-
\nsive American law affecting women\u2019s health
\nin decades.
\nNow,we\u2019ve also made women and girls a pri-
\nority for our Global Health Initiative\u00a0\u2013 a new
\napproach to coordinating the US govern-
\nment\u2019s global health work around the world.
\nWith a focus on collaboration, and innova-
\ntion, this initiative\u00a0\u2013 launched by President
\nObama\u00a0\u2013 allows us to maximize America\u2019s
\nown strengths and support other nations as
\nthey work to improve their people\u2019s health.
\nWe are integrating our programs across the
\nU.S. Government so they can work together
\nmore effectively. And we are looking for new
\nand better ways to work with international
\npartners, multilateral organizations, NGOs
\nand foundations to meet our common goals.
\nThrough it all, we\u2019ve made women\u2019s health a
\nkey priority\u00a0\u2013 and that includes family plan-
\nning. We know that access to contraception
\nallows women to space their pregnancies and
\nhave children during their healthiest years.
\nAnd delaying pregnancy beyond adolescence
\ncan reduce infant mortality and dramatically
\nimprove a child\u2019s long-term health. Provid-
\ning a woman the tools to plan how many
\nchildren she has, and when she has them, is
\nessential to her health and her family\u2019s health.
\nNow, just as important is making sure that,
\nwhen women are pregnant, they get the care
\nand support they need to have a safe and
\nhealthy pregnancy and delivery.
\nThe Global Health Initiative\u2019s \u2018Saving Moth-
\ners Giving Life\u2019 campaign is a great example
\nof these efforts. We know that for mothers
\nand children at risk, the first 24 hours post-
\npartum are the most dangerous.That\u2019s when
\ntwo out of every three maternal deaths, and
\nalmost half of newborn deaths occur.
\nSo we\u2019re working together with groups like
\nMerck for Mothers, the American College of
\nObstetricians and Gynecologists,Every Moth-
\ner Counts,and the Government of Norway,to
\nmake sure mothers get the essential care they
\nneed during labor, delivery, and those crucial
\nfirst 24 hours, so they can survive and thrive.
\nWe\u2019re focusing on countries with the po-
\nlitical will to bring about change. And with
\nmore than $90 million in generous support
\nfrom our non-governmental partners, we
\nhave begun selecting pilot sites in the regions
\nof Uganda and Zambia where women are
\nfacing some of the highest maternal mortal-
\nity ratios in the world.
\n\u2018Saving Mothers Giving Life\u2019 is just one ex-
\nample.But it illustrates an approach that runs
\nthroughout the Global Health Initiative. It
\nstarts by identifying the most urgent health
\nchallenges affecting some of the world\u2019s
\npoorest nations. Next, we identify the best
\npeople in the world with the specific exper-
\ntise to solve these problems. Then we bring
\nthem together, and make sure they have the
\ntools, resources and flexibility to take action.
\nFor too long,too many women and girls have
\nhad their lives marred by illness or disability,
\njust because they didn\u2019t have access to health
\nservices. When we deprive women of the
\ncare and support they need to stay healthy
\nor get well, we\u2019re also robbing them of hope
\nfor the future.
\nThat\u2019s the moral argument for making wom-
\nen\u2019s health a priority. But there\u2019s a strategic
\nargument too.
\nWomen are gateways to their communities.
\nAround the world, women are primarily re-
\nsponsible for managing water, nutrition, and
\nhousehold resources. They\u2019re responsible for
\naccessing health services for their families.
\nMany of them are closely involved in actually
\nproviding health care for those around them.
\nSo by improving the health of women, we
\ncan improve the health of communities too.
\nConsider the story of Jemima, a woman liv-
\ning with HIV in rural western Kenya. At
\none point, the effects of her HIV got so bad
\nshe had wasted to 77 pounds. That\u2019s when a
\nvolunteer brought Jemima, her husband, and
\nher sick grandchild to a U.S. government-
\nsupported health clinic.
\nThey went home with what is called a \u201cBasic
\nCare Package\u201d\u00a0\u2013 a bundle of low-cost health
\ninterventions, developed by public health
\nresearchers from our CDC Global AIDS
\nProgram to prevent the most debilitating,
\nopportunistic infections among people living
\nwith HIV.
\nJemima bounced back.She regained a healthy
\nweight. And today she is a health leader in
\nher community. She founded a group that
\noffers emotional support and small loans to
\nfamilies touched by HIV. She sells health
\nproducts to help support the eight sick and
\norphaned children she has adopted. And she
\nhas referred more than 100 HIV-infected
\nmen, women, and children to receive care at
\nthe same facility where she got help.
\nIn Jemima, our investment saved not only a
\nlife,but a mother,a community leader,an en-
\ntrepreneur and a health advocate.
\nWhat we know from our work with part-
\nners around the world is that improving the
\nhealth of women and girls, unleashes pow-
\nerful new opportunities\u00a0\u2013 not just for them
\nor their families\u00a0\u2013 but for their communities
\nand countries.
\nIf we want to improve education, we should
\nbe giving our young women the healthy start
\nthey need to succeed in school. If we want to
\nboost productivity, we can make sure women
\nhave access to health care, including family
\nplanning and other reproductive health ser-
\nvices.If we want to build stronger communi-
\nties, let\u2019s enable women to teach their neigh-
\nbors how to prevent disease and stay healthy.
\nAround the globe, our nations face many
\nchallenges. And investing in women\u2019s health
\nis one of the best ways we can address them
\ntogether.
\nwmj 3 2012.indd 96 7\/18\/12 9:47 AM
\n97
\nThank you for this profound honour.As you
\nknow, the summer Olympics start soon in
\nLondon.
\nI mention this because my journey to this
\nstage has been\u00a0\u2013 for me\u00a0\u2013 something of an
\nOlympic race itself.
\nI love watching athletes compete. And at
\nthe Olympic level, they inspire a pride of
\naccomplishment in each of us, and each of
\nus feels part of their success.
\nWhen an American athlete wins, we cheer.
\nWhen they stand on the podium with a
\nmedal on their chest,as the national anthem
\nplays, we share their tears of joy.
\nNow some of you may know that I\u2019ve run
\na race or two in my time, but I can tell you,
\nrunning 13 marathons or completing 13
\ntriathlons is something completely differ-
\nent than becoming the 167th
\npresident of
\nthe AMA.
\nThis was much harder.
\nThe truth is, I\u2019ve learned we all need each
\nother\u2019s support to make great things hap-
\npen.
\nTonight, there are many people to thank\u00a0\u2013
\nthose who supported me and encouraged
\nme to keep on going. You are the ones who
\ndidn\u2019t think I was completely crazy to keep
\non going race after race\u2026well, most of you.
\nI\u2019m reminded of what Olympic marathoner
\nDon Kardong said: \u201cNo doubt a brain and
\nsome shoes are essential for success, al-
\nthough if it comes down to a choice, pick
\nthe shoes. More people finish marathons
\nwith no brains than with no shoes.\u201d
\nRest assured I\u2019ve laced up my sneakers for
\nthe start of my run as AMA president.
\nAnd I look forward to making great strides
\ntogether with you, who represent the best of
\nour profession.
\nJust like the Olympic athletes, when one of
\nus wins, we all win. It\u2019s all of us on that po-
\ndium, wearing the medal.
\nNow, my path into this profession may have
\nbeen different than that chosen by many of
\nyou.
\nIt turns out that my high school, here in
\nChicago, was named for Nicholas Senn,
\nwho happened to be the AMA\u2019s 49th
\npresi-
\ndent.
\nSay what you will about foreshadowing or
\nfate, but given my skill set at the time, it was
\nprobably for the best that I didn\u2019t go some-
\nplace named for another prominent Chica-
\ngoan\u00a0\u2013 say, Michael Jordan Prep, or Mike
\nDitka Magnet School.
\nCould\u2019ve been a disaster.
\nFor me, medicine and then psychiatry be-
\ncame a calling. When I was in college, my
\nbrother died in an accident.
\nThat tragedy fueled my desire to do some-
\nthing that made a difference to help people.
\nTo become a physician.
\nI wanted to help repair shattered minds\u00a0\u2013
\nto guide people through the minefields of
\ndepression, or personality disorders\u00a0 \u2013 or
\ncrushing changes in circumstance.
\nI wanted to help someone who was trou-
\nbled\u00a0\u2013 lead a fulfilling, normal and healthy
\nlife.
\nI wanted to pull a profoundly depressed
\nperson back from the ledge of a potential
\nsuicide, and watch him grow from a trou-
\nbled adolescent \u2013 to a productive adult.
\nIn 40 years as a psychiatrist, I\u2019ve been for-
\ntunate to help many people. For me, that\u2019s
\nwhat it\u2019s all about.
\nFor our specialty, taking a person whose
\nmental health is in jeopardy\u00a0\u2013 and helping
\nthem toward recovery\u00a0 \u2013 is like watching
\nsomeone walk again, or curing cancer.
\nWhen something is wrong in the brain or
\nthe mind, it affects the whole person. The
\nchallenge is in how we determine what\u2019s re-
\nally going on\u00a0\u2013 whether it\u2019s psychological or
\nneurochemical or both.
\nIt\u2019s no coincidence the words, psychiatrist,
\nand psychic, are in some way connected.We
\nare trained to listen both to what is said out
\nloud\u00a0\u2013 and what isn\u2019t said at all.
\n\u201cTo Run and Not Grow Weary\u201d
\nJeremy A. Lazarus, MD, President,
\nAmerican Medical Association
\nInaugural Address, American Medical Association,
\n2012 Annual Meeting,
\nJune 19, 2012, Chicago, Illinois
\nJeremy A. Lazarus
\nUNITED STATES OF AMERICA Regional and NMA news
\nwmj 3 2012.indd 97 7\/18\/12 9:47 AM
\n98
\nListen to all sides\u00a0\u2013 and then help people
\nfind their own path.
\nBy listening\u00a0\u2013 and working to find common
\nground, I want to bring greater unity to our
\nAMA.
\nAnd while we can be thoughtful and delib-
\nerative and not act in haste, we recognize
\nalso that we stand at a healthcare crossroad.
\nOur patients cannot afford the luxury of
\nindefinite time for us to simply talk about
\nthe issues.
\nIn the 21st
\ncentury,we can advance and grow
\nonly by incorporating the insights of physi-
\ncians from all specialties, cultures, practice
\nsettings, states and regions, and ideologies.
\nThere\u2019s a real opportunity, regardless of the
\npolitical paralysis in Washington, for us to
\nunify to promote the practice of medicine\u00a0\u2013
\nto AMA members and non-member physi-
\ncians alike\u00a0\u2013 around the country.
\nBut any success will materialize only if we
\nare unified on the issues that matter most to
\nus, and our patients.
\nAsk a random physician about what the
\nAMA does and how it represent physicians
\n. . . chances are you would get a variety of
\nresponses.
\nSo we\u2019re working to harness the legacy of
\nthe AMA\u00a0\u2013 what was\u00a0\u2013 in a way that helps
\nus all define what the future of the AMA
\ncan be.
\nYou\u2019ve heard a lot about the \u201cAMA equa-
\ntion\u201d this week.
\nBut it bears repeating: The AMA is the sum
\nof many parts: Our House of Delegates,
\nwith more than 185 physician groups rep-
\nresented.
\nMembership\u00a0\u2013 in which physicians engage
\neach other\u00a0\u2013 and learn from each other.
\nThe tools and expertise we provide to help
\nphysicians manage practices.
\nOur pacesetting work in ethics\u00a0\u2013 our efforts
\nto end disparities\u00a0 \u2013 and our crown jewel
\npublication JAMA and others\u00a0\u2013 that make
\nus a leader in research and education.
\nAnd advocacy\u00a0\u2013 giving voice to physicians
\nin courthouses, statehouses, the media and
\nin Washington, DC.
\nWe are proof that those with opposing views
\ncan see the bigger picture and do what\u2019s best
\nfor physicians and patients. That\u2019s how we
\nall win.
\nOne recent example is the 200 million dol-
\nlars returned to physicians because of AMA
\nleadership in the United Health settlement.
\nOr the needed delays the AMA won in
\nimplementing costly and confusing ICD-
\n10 measures.
\nIn these ways, the AMA touches the vast
\nmajority of physicians in this country\u00a0 \u2013
\nmembers and non-members\u00a0 \u2013 in tangible
\nways.
\nAnd the AMA is well-positioned to influ-
\nence an uncertain future.
\nNonetheless, to improve health outcomes,
\naccelerate change in medical education and
\nshape health care delivery and payment sys-
\ntems so they work better for physicians\u00a0\u2013 are
\nnot modest ambitions.
\nTo meet these challenges we sometimes go
\nover them. Or go under them, or around
\nthem. Sometimes we ask for help\u00a0\u2013 ask for
\na hand up to clear the obstacle. That\u2019s what
\nachievers do.
\nI\u2019ve been with the AMA and in the medical
\nprofession long enough to understand and
\nrespect the differences we have.
\nBut I\u2019ve been witness to our mutual inter-
\nests. And how powerful we are when we
\nwork together to fulfil them. I ask you to
\nhelp me explore that aspect\u00a0\u2013 and expand
\nit.
\nThis year, the AMA celebrates its 165th
\nbirthday. Since our founding, we\u2019ve been a
\nplayer on the national stage.
\nBut great organizations with a long history
\ndo not need to live in the past. Respecting
\ntradition does not mean we can\u2019t create\u00a0 \u2013
\nand pursue\u00a0\u2013 our future.
\nThe years ahead are a new race to be run\u00a0\u2013
\nand to finish we\u2019ll need more than just tal-
\nented physicians.
\nThe AMA has shown both courage and a
\nwillingness to face what\u2019s ahead\u00a0\u2013 to shape
\nit\u00a0\u2013 confront it\u00a0\u2013 and when sensible, to con-
\nform to it.
\nTo succeed is to evolve. It reminds me of
\nwhen Woody Allen compared a relationship
\nto a shark\u00a0\u2013 that it has to move forward or
\nit dies.
\nIt\u2019s not enough for the AMA merely to act,
\nbut to keep at it. To refuse to quit. To face
\nchallenges and rise above them.
\nOne of the most important lessons I have
\nlearned in medicine, in my pursuits\u00a0\u2013 in my
\nlife\u00a0\u2013 is the value of persistence.
\nAs I mentioned, competing in marathons
\nand triathlons has been a passion for me.
\nI enjoy the challenge and pushing myself
\nbeyond what some may find reasonable.
\nAnd running 26.2 miles or finishing a
\n140.6-mile triathlon is no cakewalk.
\nMary Wittenberg of the New York Road
\nRunners Club described it this way. She
\nsaid: \u201cVirtually everyone who tries the mar-
\nathon has trained for months. That com-
\nmitment, physical and mental, gives it its
\nmeaning, be the day\u2019s effort fast or slow. It\u2019s
\nall in conquering the challenge.\u201d
\nUNITED STATES OF AMERICARegional and NMA news
\nwmj 3 2012.indd 98 7\/18\/12 9:47 AM
\n99
\nThis persistence\u00a0 \u2013 this effort\u00a0 \u2013 helps give
\nmeaning to what the AMA accomplishes
\non behalf of physicians and patients, every
\nday.
\nThis is what we have in common.Each of us
\nhas already run a marathon.
\nYou completed medical school. Or you
\nrun a medical practice\u00a0 \u2013 a small business.
\nOr make split-second treatment decisions
\nwhere life and death are in the balance.
\nSometimes all of these.
\nYou, like me, want a positive outcome even
\nwhen the unexpected happens.
\nAn example. In one triathlon, I was on the
\nbicycle leg of the race going over Vail Pass
\nin Colorado.
\nI rounded a curve and came upon a wom-
\nan who had wrecked her bike. She was
\nsprawled on the ground, injured, exhausted,
\ndazed from a concussion.
\nWith her was a fellow competitor\u00a0\u2013 also a
\nphysician (and fortunately an ER doc)\u00a0\u2013 ad-
\nministering first aid. I stopped as well\u00a0\u2013 and
\nwhen I could not be of further help, went
\non my way.
\nBut the doctor who stopped first ulti-
\nmately suspended his race. He stayed
\nwith his new patient for two hours\u00a0\u2013 and
\nsacrificed his chance to complete an event
\nfor which he\u2019d trained for months. Why?
\nBecause he\u2019d trained for years to be a phy-
\nsician.
\nThe well-being of the patient always comes
\nfirst\u00a0\u2013 even when it isn\u2019t our own patient.
\nThis selfless service has been a hallmark of
\nwho we are, as physicians, since the dawn
\nof time.
\nAnd it\u2019s one of the valuable lessons I\u2019ve
\nlearned from my own encounters with the
\nhard ground. Not to give up.
\nIn this most contentious time in our coun-
\ntry, the AMA will do more than step up to
\na podium.
\nWe will run\u00a0\u2013 we will win the race to pro-
\nvide medical and mental health care services
\nto all, and we will hear the cheers of those
\ntoo often silent.
\nThe AMA rejects the idea of media \u2018spin
\ndoctors\u2019\u00a0\u2013 who hold no medical degree\u00a0\u2013
\nattempting to dictate our future. We\u2019ll
\nstand with physicians and take back our
\nmessage.
\nThe AMA rejects the idea that bowing to
\nthe policies of government and insurance
\nindustry bureaucracies are simply inevitable
\ncosts of doing business.
\nThe AMA rejects the notion that legislators
\ncan impose themselves into the patient-
\nphysician relationship and legislate how we
\npractice\u00a0\u2013
\nWhether it concerns what we can ask or say
\nto our patients\u00a0\u2013 or what tests and proce-
\ndures are appropriate.
\nWe fight for the interests of physicians.
\nSometimes we have prevailed, sometimes
\nwe haven\u2019t, but we\u2019ve been on the course,
\npushing our limits, testing our endurance.
\nNot always winning\u00a0 \u2013 but always being
\nheard and always finishing.
\nThe documentary filmmaker Bud Greens-
\npan, who chronicled the Olympic Games
\nfor almost 60 years, once described a mo-
\nment he believed best captured the Olym-
\npic ideal of perseverance and commitment.
\nIn Mexico City in 1968,the Tanzanian run-
\nner John Ahkwari finished last in the mara-
\nthon.
\nMidway through the race, he had fallen
\nand torn a deep gash in his leg. In agony,
\nhe limped into the stadium 90 minutes af-
\nter the winner, his leg bruised, bandaged
\nand bleeding. For everyone else, the race
\nwas over.The stadium was nearly empty, the
\nlights dimmed.
\nBud Greenspan was still there, his cameras
\nstill rolling. He asked John Ahkwari why on
\nearth he kept going with such a serious in-
\njury, with no hope of winning.
\nHe replied, \u201cMy country did not send me
\n5,000 miles to start a race\u00a0\u2013 they sent me
\nto finish it.\u201d
\nThat thought will guide me as AMA presi-
\ndent.
\nTraining for medicine was much like train-
\ning for a marathon or triathlon. You learn
\nyour strengths, focus on what you do best,
\ndo it\u00a0\u2013 and don\u2019t quit.
\nIf you get off course on the swim, adjust
\nyour stroke.(Unless you\u2019re fortunate enough
\nto see Dr. Cecil Wilson\u2019s sailboat in the dis-
\ntance)
\nIf you get tired on the bike, shift to a lower
\ngear.
\nIf you can\u2019t run, walk. If you can\u2019t walk, take
\na break and try again.
\nThat is an approach we can take to address
\nthe newest challenge we face\u00a0\u2013 health sys-
\ntem reform.
\nIt means changes for those previously with-
\nout coverage, changes in payment methods,
\nchanges in how care is delivered.
\nThe Affordable Care Act will soon cover
\n32 million people without health insurance,
\nprovided neither the Supreme Court nor a
\nnew president overturns the law.
\nIt requires insurance market reforms.
\nIt invests in quality, prevention and well-
\nness.
\nUNITED STATES OF AMERICA Regional and NMA news
\nwmj 3 2012.indd 99 7\/18\/12 9:47 AM
\n100
\nAnd it does something else\u00a0 \u2013 it starts us
\ndown the road to a very different system of
\npayment and delivery.
\nWe\u2019re hearing jargon like \u201cAccountable
\nCare Organization,\u201d and \u201cmedical home,\u201d
\nand \u201cintegration.\u201d
\nWe\u2019ve come far since the days of a family
\ndoctor with a black bag holding the tools
\nof his trade.
\nToday, a physician may text a patient on an
\niPad while viewing their medical history
\nand coordinate care among a team of phy-
\nsicians and other health care professionals.
\nSuch physician-led teams are crucial com-
\nponents of medicine\u2019s future.
\nAs more patients live longer and accumu-
\nlate more complex medical conditions, their
\ncare will require more coordination, more
\nuse of clinical data, and professionals work-
\ning together.
\nTo be part of a team\u00a0\u2013 and following guide-
\nlines and best practices\u00a0 \u2013 doesn\u2019t mean
\nyou\u2019ve lost your ability to think, to create, to
\nact on behalf of your patients.
\nIn the mental health field, a good example
\nis the DIAMOND Initiative in Minnesota.
\nPsychiatrists are paid to consult with pri-
\nmary care practices on the best way to man-
\nage patients with depression. It\u2019s resulted
\nin dramatic improvements in patient out-
\ncomes.
\nThe current system discourages this, since
\nspecialists are paid for face-to-face visits
\nwith patients, but not when they advise the
\nprimary care physician.
\nIn 2008, this House of Delegates adopted
\nprinciples that support this approach.
\nThe AMA has also backed the medical
\nhome model for mental illness and the prin-
\nciple of parity for mental health coverage\u00a0\u2013
\nand is part of the Coalition for Fairness in
\nMental Illness. We\u2019ve made tremendous
\nprogress, but we can do more.
\nAs AMA president, I will note the need
\nto better integrate mental health care into
\nother aspects of medical care\u00a0\u2013 to provide
\nmore resources to treat more people.
\nBecause you can no more separate the heart
\nfrom the mind of a person any more than
\nyou can separate the heart from the lungs
\nand expect them still to function.
\nI\u2019ll also want to highlight the impact of
\nviolence on both the mental and physical
\nhealth of those abused\u2026
\nJust like we\u2019ll need you to make a concerted
\neffort through our Joining Forces Initiative
\nto help our returning troops, veterans and
\ntheir families who suffer with traumatic
\nbrain injury, post-traumatic stress disorder
\nor post-combat depression.
\nThe wounds of those who have borne the
\nbattle are not always visible.
\nWe\u2019re not just playing defence. Just like in
\nfootball, you need a good offense, too.We\u2019re
\nbeing proactive, not just reactive.
\nEducation on exercise, preventive health
\nand nutrition starting in early childhood
\nthat continues through a lifetime will help
\ncreate a healthier society.
\nOne with less obesity, cancer and the other
\nillnesses that debilitate the very people we
\ncare about\u00a0\u2013 and which exact a staggering
\nsocietal and financial cost.
\nFor them, physicians must be the role mod-
\nels for our patient\u2019s health\u00a0\u2013 and for each
\nother\u2019s.
\nWe have a duty to care not only for our pa-
\ntient\u2019s health,but for our own,both physical
\nand psychological.
\nThat\u2019s hard for many physicians to admit\u00a0\u2013
\nthat they, too, may sometimes need help or
\nguidance.
\nWhen we treat our patients\u00a0\u2013 especially our
\nyoungest ones\u00a0\u2013 remember that you might
\nbe treating or inspiring a future physician.
\nOur family internist, Dr. Lerner, who suf-
\nfered from poor circulation in his legs,
\nnonetheless would climb four flights of
\nstairs to make a house call.
\nThe doctor I saw was the doctor I knew, and
\nto me, he represented the profession and as
\nDr. Carmel would say, he was my hero.
\nTo me, his actions said: Treat people the
\nway you want to be cared for, because too
\noften, this is an uncaring world.
\nAs physicians, as AMA members, we are
\nthe face of this profession,this organization.
\nWe are also its voice.
\nLet\u2019s be willing to sing from the same page.
\nThose of you who have sung in choirs know
\nhow a collection of varied but trained voic-
\nes can lift a crowd to their feet. When the
\nAMA combines our many voices in harmo-
\nny\u00a0\u2013 we can do just that.
\nFor me, it\u2019s not just a metaphor. I paid my
\nway through college and medical school by
\ndirecting synagogue choirs.
\nThere, you have to combine many disparate
\nvoices\u00a0\u2013 and help them sing in harmony.
\nAs director, you work with sopranos and
\ntenors, altos and baritones, contraltos and
\nbasses. And in some choirs you have to des-
\nignate a section called the \u201clip synchers\u201d.
\nBut even if a voice is out of tune, or the
\npipes rusty\u00a0\u2013 I learned that even a mono-
\ntone can learn a second note.
\nSo we need to rise up\u00a0\u2013 raise our voices\u00a0\u2013 and
\nsing out for medical liability reform, to end
\nUNITED STATES OF AMERICARegional and NMA news
\nwmj 3 2012.indd 100 7\/18\/12 9:47 AM
\n101
\nHealth Care
\nSqueezing Out the Doctor
\nThe role of physicians at the centre of health care is under pressure
\nIn a windowless room on a quiet street in
\nFramingham, outside Boston, Rob Goud-
\nswaard and his colleagues are trying to un-
\npick the knottiest problem in health care:
\nhow to look after an ageing and thus sicken-
\ning population efficiently.The walls are plas-
\ntered with photographs of typical patient-
\nshere a man who exercises occasionally,there
\na woman with many chronic ailments. Big
\nsheets of paper chart each patients course
\nfrom the hospital back to a comfortable
\nlife at home, with divergent lines showing
\nall the problems that might arise and ways
\nto handle them. To map the many paths to
\nhealth in this way Mr Goudswaards team
\ninterviewed a lot of patients and nurses.
\nBut this war room does not belong to a hos-
\npital. It belongs to Philips, a Dutch elec-
\ntronics company. Mr Goudswaard, the head
\nof innovation for Philipss home-monitor-
\ning business, has no medical training. His
\nspeciality is the consumer.
\nIn this section
\nThe past 150 years have been a golden age
\nfor doctors. In some ways, their job is much
\nas it has been for millennia: they examine
\npatients, diagnose their ailments and try
\nto make them better. Since the mid-19th
\ncentury, however, they have enjoyed new
\neminence. The rise of doctors associations
\nand medical schools helped separate doc-
\ntors from quacks. Licensing and prescrib-
\ning laws enshrined their status. And as
\nunderstanding, technology and technique
\nevolved, doctors became more effective,
\nable to diagnose consistently, treat effec-
\ntively and advise on public-health interven-
\ntionssuch as hygiene and vaccinationthat
\nactually worked.
\nThis has brought rewards. In developed
\ncountries, excluding America, doctors with
\nno speciality earn about twice the income of
\nfrivolous lawsuits, to end the fear of being
\ndragged into court for no good reason, and
\nto slow spending on defensive medicine.
\nSing out, and demand the Sustainable
\nGrowth Rate be scrapped\u00a0\u2013 and be replaced
\nwith a system that recognizes reality\u00a0\u2013 and
\nreflects the actual costs of medical care\u00a0\u2013 in
\nall its effective forms.
\nSing out for private contracting legislation,
\nand physician-led delivery and payment re-
\nforms.
\nSing out our commitment that Americans
\nneed health insurance coverage and that we
\nfinally end health care disparities.
\nSing out\u00a0\u2013 for an equitable health care sys-
\ntem. Where all its elements exist in har-
\nmony.
\nWe trained all of our adult lives to be the
\nbest physicians we can be. Now is the time
\nto combine our voices and make a joyful
\nnoise. Rise to this occasion. Be persistent.
\nAnd keep going no matter how rough the
\nterrain, or how tiring the course.
\nI\u2019ll be alongside AMA staff,every physician,
\nand this House of Delegates. Together, we
\ncan finish this\u00a0\u2013 and we can win.
\nAmong the most inspirational words I\u2019ve
\never seen were at the 130-mile marker of
\na triathlon course, in the 100-degree lava
\nfield in Kona, Hawaii. They were from
\nIsaiah, and it read: \u201cThey that hope in the
\nLord will renew their strength. They will
\nsoar like wings on eagles. They will run
\nand not grow weary\u00a0\u2013 walk and not grow
\nfaint.\u201d
\nAnd to that I will add: we will rise up and
\nbe heard.We will run this race,together.We
\nwill persist. And together, we will cross the
\nfinish line.
\nThank you.
\nwmj 3 2012.indd 101 7\/18\/12 9:47 AM
\n102
\nHealth Care
\nthe average worker, according to McKinsey,
\na consultancy. Americas specialist doctors
\nearn ten times Americas average wage. A
\nmedical degree is a universal badge of re-
\nspectability. Others make a living. Doctors
\nsave lives, too.
\nWith the 21st
\ncentury certain to see soar-
\ning demand for health care, the doctors
\nstar might seem in the ascendant still. By
\n2030, 22% of people in the OECD club
\nof rich countries will be 65 or older, nearly
\ndouble the share in 1990. China will catch
\nup just six years later. About half of Ameri-
\ncan adults already have a chronic condi-
\ntion, such as diabetes or hypertension, and
\nas the world becomes richer the diseases of
\nthe rich spread farther. In the slums of Cal-
\ncutta, infectious diseases claim the young;
\nfor middle-aged adults, heart disease and
\ncancer are the most common killers. Last
\nyear the United Nations held a summit on
\nhealth (only the second in its history) that
\ngave warning about the rising toll of chronic
\ndisease worldwide.
\nBut this demand for health care looks un-
\nlikely to be met by doctors in the way the
\npast centurys was.For one thing,to treat the
\n21st
\ncenturys problems with a 20th
\n-century
\napproach to health care would require an
\nimpossible number of doctors. For another,
\ncaring for chronic conditions is not what
\ndoctors are best at. For both these reasons
\ndoctors look set to become much less cen-
\ntral to health carea process which, in some
\nplaces, has already started.
\nMake do and mend
\nMost countries suffer from a simple mis-
\nmatch: the demand for health care is rising
\nfaster than the supply of doctors. The prob-
\nlem is most acute in the developing world,
\nthough rich countries are not immune (see
\narticle). It does not help that health care is
\nnotoriously inefficient. Whereas Americas
\noverall labour productivity has increased by
\n1.8% annually for the past two decades, the
\nfigure for health care has declined by 0.6%
\neach year, according to Robert Kocher of
\nthe Brookings Institution and Nikhil Sahni,
\nuntil recently of Harvard University. But it
\nis in poor countries that interest in alterna-
\ntive ways of training doctors and in alter-
\nnatives to doctors themselves has produced
\nthe most innovation.
\nOne approach to making doctors more effi-
\ncient is to focus what they do. India is home
\nto some of the worlds most exciting models
\nalong this line, argues Nicolaus Henke of
\nMcKinsey, who leads the consultancys work
\nwith health systems. Britain has 27.4 doc-
\ntors for every 10,000 patients. India has just
\nsix. With so few doctors, it is changing the
\nway it uses them.
\nYour correspondent recently watched Devi
\nShetty, chief executive of Narayana Hru-
\ndayalaya hospital in Bangalore, making
\ncareful incisions in a yellowed heart, pulling
\nout clots that resembled tiny octopuses. It
\nlooked difficult. Some of the other tasks at
\nNarayana Hrudayalaya hospital do not, and
\nare not. Dr. Shettys goal is to offer as many
\nsurgeries as possible,without compromising
\non quality. To do that, he ensures that his
\nsurgeons do only the most complex proce-
\ndures; an army of other workers do every-
\nthing else. The result is surgeries that cost
\nless than $2,000 each, about one-fifteenth
\nas much as a similar procedure in America.
\nThe trick is repeated in other areas of health
\ncare. Indias LifeSpring hospitals slash the
\nprice of childbirth by augmenting doctors
\nwith less expensive midwives. The costs are
\nabout one-sixth of those in a private clinic.
\nThe Aravind Eye Care System offers surgery
\nto about 350,000 patients a year. Operating
\nrooms have at least two beds, so surgeons
\ncan swivel from one patient to the next.
\nMost important, for every surgeon there are
\nsix eye-care techniciansyoung women re-
\ncruited and trained by Aravindwho perform
\nthe myriad tasks in the operating room that
\ndo not require a surgeons training.
\nOther problems have inspired other solu-
\ntions, with technology filling gaps in the
\nlabour force. The Bill and Melinda Gates
\nFoundation supports a programme that
\nuses mobile phones to deliver advice and re-
\nminders to pregnant women in Ghana. In
\nDecember the foundation and Grand Chal-
\nlenges Canada, a non-profit organisation,
\nannounced $32m in grants for new mobile
\ntools that will help health-care workers di-
\nwmj 3 2012.indd 102 7\/18\/12 9:47 AM
\n103
\nHealth Care
\nagnose various ailments. In Mexico, wor-
\nried patients can phone Medicall Home, a
\ntelehealth service. If a patient needs care,
\nMedicall Home can help to arrange a doc-
\ntors visit. But about two-thirds of patients
\nconcerns can be addressed over the phone by
\na doctor (often one only recently qualified).
\nThese programmes are expanding. Medicall
\nHome is rolling out its service in Colombia
\nand plans to be operating in Peru by the end
\nof the year. Aravind has exported its train-
\ning model to about 30 developing countries.
\nDr. Shetty already has 14 hospitals in India.
\nHe plans to add 30,000 hospital beds in big
\nhealth complexes and small hospitals there
\nover the next seven years, as well as build a
\nhospital in the Cayman Islands.
\nTechnology does not just allow diagnosis
\nat a distanceit allows surgery at a distance,
\ntoo. In 2001 doctors in New York used ro-
\nbotic instruments under remote control to
\nremove the gall bladder of a brave woman
\nin Strasbourg. Robots allow doctors to be
\nmore precise, as well as more omnipresent,
\nmaking incisions more neatly than human
\nhands can. As yet they are enhancements
\nfor surgeons more than they are replace-
\nments, but that may change in time. Mili-
\ntary drones started off being flown by of-
\nficers who had gone through the expensive
\nrigours of flight school; these days other
\nranks with far less exhaustive training can
\ntake the controls.
\nTeam effort
\nLess flashy technology, though, could make
\nthe biggest difference by reducing the
\nnumber of crises which require a doctors
\nintervention. Marta Pettit works on a pro-
\ngramme to manage chronic conditions that
\nis run from Montefiore Medical Centre,
\nthe largest hospital system in the Bronx, a
\nNew York borough. Ms Pettit and a squad-
\nron of other care co-ordinators examine a
\nstream of data gathered from health records
\nand devices in patients homes, such as the
\nHealth Buddy. Made by Bosch, a German
\nengineering company, the Health Buddy
\nasks patients questions about their symp-
\ntoms each day. If a diabetics blood sugar
\njumps, or a patient with congestive heart
\nfailure shows a sudden weight gain,Ms Pet-
\ntit calls the patient and, if necessary, alerts
\nher superior, a nurse.
\nOther tasks are simpler, but no less im-
\nportant. Montefiore noticed that one old
\nwoman was not seeing her doctor because
\nshe was scared of crossing the Grand Con-
\ncourse, a busy road in the Bronx. So Mon-
\ntefiore found a new doctor on her side of
\nthe Concourse. Together, such measures
\nmake a difference. Diabetics trips to hospi-
\ntal plunged by 30% between 2006 and 2010;
\ntheir costs dropped by 12%.
\nSimilar programmes will become even more
\nsophisticated as monitors evolve. Patients
\nare much happier to monitor themselves
\nat home with gadgets bought online than
\nthey used to be, and gadget-makers think
\nthere is a huge potential for growth in tak-
\ning the trend further. Philips, General Elec-
\ntric (GE) and others are all upping their
\ninvestments in home health, and widening
\nthe markets in which they sell their existing
\nproducts (Philips is trying to crack Japan
\nwith emergency-alert devices for the elder-
\nly). GEs design gurus predict that a patients
\noverall condition will soon be measured as
\neasily as a thermometer measures his tem-
\nperature.
\nSuch technologies have long seemed prom-
\nising; recently the promise has begun to be
\nborne out.Britain has completed the worlds
\nbiggest randomised trial of telehealth tech-
\nnology, including gizmos from Philips. The
\nstudy examined 6,000 patients with chronic
\ndiseases. According to preliminary results
\nof a study by Britains health department in
\nDecember 2011, admissions to the emer-
\ngency room dropped by 20% and mortality
\nplummeted by 45%.
\nNursed back to health
\nChanging health systems is tortuous. Re-
\nformers are stymied by medical lobbies,ner-
\nvous patients and heaps of regulations about
\nwho may do what and where. But there is
\nmovement, particularly in the lower ranks
\nof the labour market. Indias health ministry
\nhas proposed a new three-and-a-half-year
\ndegree that would let graduates deliver ba-
\nsic primary care in rural areas. Dr. Shetty
\nthinks his hospitals could benefit from a
\nbroader range of training programmes, to
\ncreate workers with a wider array of skills.
\nWorkers with a lot less training than doc-
\ntors can still be highly effective. Physician
\nassistants in America can do about 85% of
\nthe work of a general practitioner, accord-
\ning to James Cawley of George Washing-
\nton University. A pilot programme of rural
\nhealth-care workers in Indiathe type that
\nthe health ministry wants to expandfound
\nthat the workers were perfectly able to di-
\nagnose basic ailments and prescribe ap-
\npropriate drugs. In some areas non-doctors
\nactually look preferable. A review of stud-
\nies of nurse practitioners in Britain, South
\nAfrica, America, Japan, Israel and Austra-
\nlia, published in the British Medical Journal,
\ndetermined that patients treated by nurses
\nwere more satisfied and no less healthy than
\nthose treated by doctors.
\nwmj 3 2012.indd 103 7\/18\/12 9:47 AM
\n104
\nHistory
\nAs early as the 4th
\nand 5th
\ncentury BCE,
\nthe heart, lungs, veins, and arteries were
\nknown to be critically important organs in
\nthe human body\u00a0\u2013 although it would be a
\nfew more centuries before dissection al-
\nlowed scientists of the time to better un-
\nderstand how these parts worked to pump
\nblood and give life.When modern medicine
\nemerged in the 19th
\ncentury, a new under-
\nstanding of microbiology and bacteriology
\ngreatly reduced infection rates and the use
\nof anesthetics such as ether and chloroform
\nalso became more common. These two ad-
\nvancements set the stage for the astound-
\ning medical innovations of the next century.
\nAnd yet, surgery of the heart and lungs pre-
\nsented special problems because the heart
\nperformed the important task of carrying
\nblood to the brain. A beating heart would
\nlead to excessive blood loss, and a heart that
\nwasn\u2019t beating resulted in a brain-dead pa-
\ntient after only four minutes.
\nThe devastation of World War II led to
\nmore progress in the field of surgical medi-
\ncine. Doctors on the battlefield, desperate
\nto help save the lives of injured soldiers,
\npioneered new advancements in antibi-
\notics, anesthesia, and blood transfusions.
\nArmy surgeon Dr. Dwight Harken suc-
\ncessfully removed shrapnel from the hearts
\nof wounded soldiers during the war, prov-
\ning that the heart could in fact be operated
\nupon. Soon after the end of the war, Har-
\nken and Dr. Charles Bailey of Philadelphia
\nused the same technique to repair defective
\nheart valves, a condition known as mitral
\nstenosis. However, this type of closed-heart
\nsurgery had its limitations, and patients
\nwith more serious heart conditions had few
\noptions.
\nSolving this problem became a defining is-
\nsue in the mid 20th
\ncentury. Doctors from
\nall over the world worked furiously to re-
\nsolve the conundrum. One solution came
\nwhen Dr. Wilfred Bigelow discovered that
\ncooling the body\u2019s core temperature slows
\n50 Years of Cardiothoracic Surgery
\nBut expanding the supply of non-doctors is
\nnot, in itself, enough. America has led the
\nworld in developing the roles of nurse prac-
\ntitioners and physician assistants. Other,
\nless trained workers are proliferating there
\ntoo. The number of diagnostic medical so-
\nnographers, who have two years of training,
\nis expected to jump by 44% between 2010
\nand 2020, according to the Bureau of La-
\nbour Statistics. Yet productivity still falls.
\nThis seems to be because new ways of doing
\nthings, and of managing health teams, have
\nnot kept paceand are still under the control
\nof doctors.
\nThe doctors power rests on their profes-
\nsional prestige rather than managerial acu-
\nmen, for which they are neither selected nor
\ntrained. But it is a power that they wish to
\nkeep. The Confederation of Medical As-
\nsociations in Asia and Oceania, a regional
\ngroup of doctors lobbies, wants task-shift-
\ning limited to emergencies. Japans medical
\nlobby has vehemently opposed the creation
\nof nurse practitioners. Indias proposal for
\na rural cadre outraged the countrys medi-
\ncal establishment, and legislation to create
\nthe three-and-a-half-year degree has gone
\nnowhere.
\nIn 2010 Americas respected Institute of
\nMedicine (IOM) called for nurses to play
\na greater role in primary care. Among other
\nbarriers, nurses face wildly different con-
\nstraints from one state to another. But any
\nchange will first require swaying the doc-
\ntors. The American Medical Association,
\nthe main doctors lobby, greeted the IOMs
\nreport with a veiled snarl. Nurses are critical
\nto the health-care team, but there is no sub-
\nstitute for education and training, the group
\nsaid in a statement.
\nAs doctors become scarcer and health costs
\ncontinue to rise, more and more systems
\nwill seek to innovate, and the successes they
\nhave will become ever more widely known.
\nAlready, programmes such as Montefiores
\nare becoming the paradigm for keeping
\npatients healthy. In December Americas
\nhealth department chose Montefiore for a
\npilot to improve care and lower costs for the
\nold.
\nAll this should be cause for excitement. Re-
\nsources are slowly being reallocated. Nurses
\nand other health workers will put their
\ntraining to better use. Devices will bolster
\ncare in ways previously unthinkable. Doc-
\ntors,meanwhile,will devote their skill to the
\ncomplex tasks worthy of their highly trained
\nabilities. Doctors may thus lose some of
\ntheir old standing. But patients will clearly
\nwin.
\nPrinted from The Economist, June 2, 2012
\nwmj 3 2012.indd 104 7\/18\/12 9:47 AM
\n105
\nHistory
\nthe heart rate and allows a longer time in
\nwhich to operate-ten minutes as opposed
\nto four. Drs. John Lewis and Walton Lille-
\nhei of the University of Minnesota used
\nthe hypothermia method to close an atrial
\nseptal defect in 1952, and Dr. Henry Swan
\nperfected the procedure, eventually per-
\nforming hundreds of open-heart surgeries
\nwith relatively low mortality. This rather
\ncumbersome method was ultimately short-
\nlived, however, when it became clear that
\nmore complex heart conditions would re-
\nquire more time than the cooling of the
\nbody allowed. It was evident that a better
\napproach was needed.
\nHeart surgeons of the time understood that
\na successful heart-lung machine\u00a0\u2013 that is, a
\nmachine that would bypass the heart and
\nlungs and take over circulation of the blood
\nduring the surgery\u2013had to not only pump
\nblood, but also resupply oxygen to the red
\nblood cells and pump blood at sufficient
\npressure to supply all the organs in the body,
\nall without damaging blood platelets in the
\nprocess. Anticoagulation was also necessary
\nto prevent bleeding out during surgery. The
\nlatter problem had been earlier solved by the
\ndiscovery of heparin in the early 1900s.The
\nheart-lung machine had several prototypes,
\nbut it wasn\u2019t until the 1950s that surgeons
\nwere able to use such a device to repair the
\nhearts of patients.
\nFrom 1950\u20132000, the following timeline
\ndescribes some of the important milestones
\nin cardiothoracic surgery that followed the
\ndevelopment of cardiopulmonary bypass, a
\nrevolutionary advancement that has since
\nsaved thousands of lives.
\n1951 \u2013 Dr. Clarence Dennis of the Univer-
\nsity of Minnesota performed the first open-
\nheart surgery using a heart-lung machine.
\nThe patient is a six-year-old girl suffering
\nfrom an atrial septal defect. She does not
\nsurvive.
\n1952 \u2013 Dr. Forest Dodrill and colleagues
\nuse a mechanical pump (developed with
\nGeneral Motors) to perform the first suc-
\ncessful total left-sided heart bypass on a
\n41-year-old man in Detroit. The patient\u2019s
\nown lungs were used for oxygenation.
\n1952 \u2013 Dr. Paul Zoll applies electrical
\ncharges to the outside of a patient\u2019s chest to
\nsuccessfully restart his heart.
\n1953 \u2013 Dr. John Gibbon performs the first
\nsuccessful intercardiac surgery of its kind
\nusing a heart-lung machine he developed
\nwith IBM. The patient is an 18-year-old
\ngirl with congestive heart failure due to an
\natrial septal defect. Unfortunately, the next
\ntwo patients to receive surgery with the ma-
\nchine do not survive. Gibbon declares a one
\nyear moratorium on further surgeries using
\nhis machine.
\n1955\u20131956 \u2013 A team led by Dr. John Kirk-
\nlin of the Mayo Clinic uses a heart-lung
\nmachine based on Gibbon\u2019s model to per-
\nform intercardiac surgery on eight patients,
\nfour of whom survive.
\n1958 \u2013 Swedish surgeon Dr. Ake Senning
\nplaces the first implantable pacemaker in a
\npatient with Stokes-Adams syndrome.
\n1960 \u2013 The first aortic valve replacements
\nare placed by Dr. Dwight Harken and
\nDr.\u00a0 Lowell Edwards, both of whom use
\na caged ball valve. In the next seven years,
\n2000 of these valves are implanted.
\n1960 \u2013 Dr. Robert Goetz performs what
\nappears to be the first coronary artery by-
\npass operation on a human. He receives
\ncriticism for attempting the experimental
\nsurgery, and never performs another.
\n1963 \u2013 An artificial left ventricle assist
\ndevice is successfully used to help wean a
\npatient from cardiopulmonary bypass after
\nheart valve surgery.
\n1964 \u2013 Dr. Charles Dotter performs the
\nworld\u2019s first percutaneous transluminal an-
\ngioplasty in Oregon.
\n1967 \u2013 A South African surgeon,Dr.\u00a0Chris-
\ntiaan Barnard, transplants the heart of a
\n23-year-old woman into a middle-aged
\nman. He survives for 18-days before dying
\nof pneumonia brought on by powerful anti-
\nrejection drugs.
\n1968 \u2013 Dr. Norman Shumway of Stanford
\nUniversity performs the first heart trans-
\nplant in the United States.The patient sur-
\nvives for 14 days. Following the sensation
\nof this first operation, several more trans-
\nplant surgeries take place, but with high
\nmortality.
\n1974 \u2013 Dr.Andreas Gruentzig performs the
\nfirst peripheral human balloon angioplasty
\n1981 \u2013 Shumway performs the first suc-
\ncessful heart-lung transplant with colleague
\nDr.\u00a0Bruce Reitz.
\n1982 \u2013 American surgeon Dr. William
\nDeVries implants a permanent artificial
\nheart into a patient at the University of
\nUtah
\n1998 \u2013 Dr. Friedrich Wilhelm Mohr and
\nDr. Alain Carpentier perform the first
\nrobot-assisted mitral valve repair and coro-
\nnary bypass surgery in France.
\nSources:
\n1. http:\/\/cirugiadetorax.org\/2011\/04\/29\/history-of-
\nthoracic-surgery\/
\n2. http:\/\/cardiacsurgery.ctsnetbooks.org\/cgi\/content\/
\nfull\/2\/2003\/3?ck=nck
\n3. http:\/\/profiles.nlm.nih.gov\/BX\/
\n4. http:\/\/www.pbs.org\/wgbh\/nova\/body\/pioneers-
\nheart-surgery.html
\n5. http:\/\/www.med.yale.edu\/library\/heartbk\/
\n25.pdf
\n6. http:\/\/www.nytimes.com\/1999\/01\/08\/us\/paul-m-
\nzoll-is-dead-at-87-pioneered-use-of-pacemakers.
\nhtml
\n7. http:\/\/www.ohsu.edu\/dotter\/40th_anniv.htm
\n8. http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/
\nPMC101071\/
\nProvided by
\nAdie Harrington
\nhttp:\/\/www.surgicaltechnologist.net
\nwmj 3 2012.indd 105 7\/18\/12 9:47 AM
\n106
\nViolence in the Health Care Sector
\nSummary
\nIn the recent report \u2018Doctoring the Evi-
\ndence, Abandoning the Victim\u2019 the Israeli
\nPublic Committee against Torture accuses
\nseveral Israeli medical doctors of medical
\ncomplicity in torture. When analyzing the
\nreport\u2019s outcomes, the author pleas for a
\nstrong condemnation by the Israeli medical
\nassociation of these illicit practices. What\u2019s
\nmore, in line with the report, urging Israel
\nto restructure its medical system of checks
\nand balances and recommending the rati-
\nfication the Optional Protocol of the Con-
\nvention against Torture aimed at preventing
\ntorture and thus strengthening the rights of
\nthe detained.
\nIntroduction
\nThe alarming report \u2018Doctoring the Evi-
\ndence,Abandoning the Victim\u2019of the Israeli
\nPublic Committee against Torture accuses
\nIsraeli medical doctors of medical complic-
\nity in torture.1
\nThese allegations are not new
\nand have been mentioned before.2
\nWhat\u2019s
\nnew is the figures and systematic approach
\nof these human rights violations. Based on
\na series of testimonies and other evidence,
\nsuch as medical files of over 100 victims of
\ntorture since 2007, the report demonstrates
\nthat several doctors are (in)directly involved
\nin torture or cruel and degrading treatment
\n1 Public Committee against Torture in Israel en
\nPhysicians for Human Rights, \u2018Doctoring the
\nEvidence, Abandoning the Victim. The Involve-
\nment of medical professionals in torture and ill-
\ntreatment in Israel\u2019, in collaboration with Physi-
\ncians for Human Rights, October 2011, .
\n2 Eg,J.S.Yudkin,\u201cThe responsibilities of the World
\nMedical Association President\u201d, Comment, the
\nLancet, 373 (2009) 1115-6.
\nof Palestinian detained persons in Israeli
\ndetention centres.
\nReport Outcomes
\nAccording to the report, physicians will-
\ningly take part in, facilitate or allow torture
\nby failing to report clinical evidence of it to
\nthe relevant authorities. Evidence of active
\ninvolvement includes falsification of medi-
\ncal records and disclosure of medical infor-
\nmation to the interrogators of the security
\nservices. Information that is relevant to the
\ninterrogation techniques to be used by the
\nintelligence services.3
\nAs such Israeli medi-
\ncal doctors failed to protect detainee\u2019s hu-
\nman rights, violated the basic principles of
\nmedical ethics and ignored the basic tenets
\nof medical professionalism.
\nMore common is passive engagement in-
\ncluding: the failure to oppose, accurately
\ndocument,report (suspicion of) torture,and
\nreturn the detainees they examined or treat
\nto their interrogators.4
\nAs such, these doc-
\ntors remain silent of what they see and hear,
\noffering moral license for torturers.
\nInternational Law and Ethics
\nInternational law and international medi-
\ncal ethics are very clear about the prohibi-
\ntion of torture.5
\nTorture violates the essen-
\n3 See note 1, pp. 28\u201340.
\n4 Ibid, pp. 43\u201345.
\n5 According to the United Nations Convention
\nagainst Torture (UNCAT 1984, Art. 1 section
\n1),\u00a0torture is defined as \u2018any act by which severe
\npain or suffering, whether physical or mental, is
\nintentionally inflicted on a person for such pur-
\nposes as obtaining from him or a third person
\ntial ethical obligation on all physicians to
\n\u201cfirst do no harm\u201d and human dignity.6
\nThe
\nsame international standards condemn all
\nforms of torture and inhuman or degrad-
\ning treatment at any time and in any place
\nwhatsoever and can thus never be justified.7
\nAll States are obliged to ensure fully the
\nimplementation of the absolute prohibition
\nof torture, for instance by means of crimi-
\nnalizing all acts of torture, never request-
\ning medical personnel to commit any act
\nof torture and respecting the professional
\nindependence and duties of health person-
\nnel, as well as respecting the doctor\u2019s duty
\nto report or denounce acts of torture with-
\nout fear of retribution or harassment, and
\nnot punishing or intimidating medical per-
\nsonnel not obeying orders or instructions to
\ninformation for a confession, punishing him for
\nan act he or a third person has committed or is
\nsuspected of having committed, or intimidating
\nor coercing him or a third person or for any rea-
\nson based on discrimination of any kind, when
\nsuch pain or suffering is inflicted by or at the in-
\nstigation of or with consent or acquiescence of a
\npublic official or other person acting in an official
\ncapacity\u2019.
\nApart from UNCAT, the international com-
\nmunity has developed various instruments con-
\ndemning torture and other forms of ill-treatment,
\nsuch as the Art. 7 of the International Covenant
\non Civil and Political Rights of December 19,
\n1966 and Art. 3 of the European Convention for
\nthe Protection of Human Rights and Fundamen-
\ntal Freedoms of November 4, 1950; UN Human
\nRights Council. Resolution on torture and other
\ncruel,inhuman or degrading treatment or punish-
\nment: The role and responsibility of medical and
\nother health personnel, 2009, A\/HRC\/10\/L.32.
\n6 WMA International Code of Medical Ethics.
\nAdopted by the 3rd
\nGeneral Assembly of the
\nWorld Medical Association, London, England,
\nOctober 1949, latest revision: the 57th
\nWMA
\nGeneral Assembly, Pilanesberg, South Africa,
\nOctober 2006.
\n7 The UN Istanbul Protocol (1999): A manual for
\nthe efficient investigation and documentation of
\ntorture and other cruel, inhuman or degrading
\ntreatment; WMA Declaration of Tokyo (1975)\u00a0\u2013
\nGuidelines for Physicians Concerning Torture
\nand other Cruel, Inhuman or Degrading Treat-
\nment or Punishment in Relation to Detention
\nand Imprisonment
\nIsraeli Torture Doctors:
\nMedical Ethics Betrayed
\nwmj 3 2012.indd 106 7\/18\/12 9:47 AM
\n107
\nViolence in the Health Care Sector
\ncommit, facilitate or conceal acts amount-
\ning to torture.1
\nVague National Standards
\nDespite these clear international standards,
\nthe gap between the national norms and
\npractice remains too wide.Israeli law and eth-
\nical guidelines on this matter are overly vague
\nin asserting the duty of the doctor to the pa-
\ntient\u2019s well-being. What is worse, misinter-
\npret international standards by including a
\n\u2018national security\u2019exception allowing the doc-
\ntor to compromise the patient\u2019s health in the
\nface of the security services.2
\nAs such, prison
\ndoctors are being trapped by the so-called
\n\u201cdual loyalty\u201d conflict: confronted with a pa-
\ntient who happened to be an Arab detained
\nin medical need, and their duty towards
\ntheir employer security services fighting a
\nwar on terrorism. Balancing these interests
\nhas led to blatant breaches of human rights.
\nUnfortunately, this \u2018dual loyalty\u2019 situation is
\nnot unique for Israeli doctors. In the past
\nseveral colleagues have been struggling with
\nthat dilemma.
\n\u201cHealers\u201das Torturers:
\nInternational Experiences
\nExtreme cases of torture doctors occurred
\nin Nazi death camps during World War
\nII.3
\nThe report considers incidents of medi-
\ncal complicity in torture in several coun-
\ntries (the former USSR, South and Central
\nAmerica, Sri Lanka, etc.).4
\nMore recently
\n1 Examples based on the United Nations Conven-
\ntion against Torture (CAT, 1984) and the United
\nNations\u2019Human Rights Council recommendation
\nagainst torture, A\/HRC\/10\/L32, 20 March 2009.
\n2 Ibid note 1, pp. 19-26.
\n3 Eg, M. Lippman, \u201cThe Nazi Doctors Trial and
\nthe International Prohibition on Medical In-
\nvolvement in Torture\u201d Loy. L.A. Int\u2019l & Comp.
\nLaw J. (1992-3) 395-441.
\n4 Ibid note 1, pp. 47\u201351.
\nthere is participation in the so-called \u2018water
\nboarding\u2019 interrogation techniques in the
\nUS \u2018war on terror\u2019 performed in Guantana-
\nmo Bay and the Abu Ghraib prison in Iraq.5
\nThese cases show a clear ignorance of physi-
\ncians towards internationals ethics and law.
\nEducating doctors on human rights,humani-
\ntarianlawandmedicalethicsappearstherefore
\nan essential element in the medical curricu-
\nlum. Inadequate training in human rights is
\npart of the problem,but alone it cannot justify
\nthe actions or inactions of the prison medical
\npersonnel. Similar as in the Abu Ghraib pris-
\non,the Israeli medical system failed to protect
\nthe detainee\u2019s health and failed to accurately
\nreport witnessed or suspected abuse.6
\nThese
\nfailures of the Israeli (prison) medical system
\nillustrate a more fundamental problem: the
\nabsence of functioning checks and balances
\nand being subject to professional discipline.7
\nRole of the International
\nCommunity
\nWhat can the international community
\ndo to raise its voice against this? Efforts to
\neradicate torture should first and foremost
\nbe concentrated on prevention. Therefore,
\nIsrael should be invited to adopt the Op-
\ntional Protocol to the Convention against
\nTorture.8
\nThis Protocol introduces a system
\nof regular visits to places of detention,aimed
\nat preventing torture and thus strengthen-
\ning the rights of the detained. By ratifica-
\n5 S.H. Miles, Oath Betrayed: America\u2019s Torture
\nDoctors (2nd
\ned. Univ. of California Press, 2009).
\n6 Compare: P.A. Clark, \u201cMedical Ethics at Guan-
\ntanamo Bay and Abu Ghraib: The Problem of
\nDual Loyalty\u201d, Journal of Law, Medicine & Eth-
\nics Fall (2006) 570-580: 573.
\n7 Ibid note 1, pp. 54\u201355.
\n8 Officially, Optional Protocol to the Convention
\nagainst Torture and other Cruel, Inhuman or De-
\ngrading Treatment or Punishment, Adopted on
\n18 December 2002 at the fifty-seventh session of
\nthe General Assembly of the United Nations by
\nresolution A\/RES\/57\/199. Entered into force on
\n22 June 2006, see www.ohchr.org.
\ntion, each State shall allow these visits by
\nan independent committee, granted with
\nextended powers, including access to all rel-
\nevant information, the opportunity having
\nprivate interviews with detained persons,
\nand submitting proposals for legislation.
\nApart from prevention, the World Medical
\nAssociation (WMA) as the world\u2019s largest as-
\nsociation representing the international medi-
\ncal community, should urge the Israeli mem-
\nber association to speak out in support of the
\nfundamental principle of medical ethics and
\nto investigate any breach of these principles
\nby their members.9
\nMore important,the voice
\nof the international medical profession should
\nurge the Israeli medical association to bring
\nits ethical guidelines in line with international
\nstandards, which means rejecting the security
\nexception as a justification for torture. The
\nmessage should be univocal: respecting this
\ncore principle is nothing less than is a condi-
\ntio sine qua non for the WMA-membership.
\nConclusion
\nThe report made painfully clear that there
\nis a fundamental need for improvement and
\nenforcement of the checks and balances in
\nthe Israeli medical system. In a way, this is
\none of the recommendations made by the
\nIsraeli Public Committee against Torture
\nsuggesting the introduction of independent
\nboard of inquiry to examine the full nature
\noftheseabuses.10
\nInternationalpressurefrom
\nboth UNCAT and the WMA could be ef-
\nfective to realize these changes.
\nAndr\u00e9 den Exter, Lecturer in Health
\nLaw, Institute of Health Policy and
\nManagement, Erasmus University
\nRotterdam, The Netherlands
\nE-mail: Denexter@bmg.eur.nl.
\n9 As they did in the case of Iran, calling to respect
\nthe International Code of Medical Ethics, 18
\nOctober 2009 .
\n10 Ibid, note 1, p. 55.
\nwmj 3 2012.indd 107 7\/18\/12 9:47 AM
\n108
\nViolence in the Health Care Sector
\nIn October 2010, the Israeli Medical As-
\nsociation (IMA) first proposed a state-
\nment for adoption by the WMA on the
\nsubject of violence in the health sector.The
\nstatement was the result of the worrying
\ntrend of increasing violence against health
\nprofessionals by patients and their family
\nmembers. Since the initial proposal, this
\ntrend has not abated, and if anything, has
\nworsened.
\nSome statistics: According to the US Bu-
\nreau of Labor Statistics, in 2007 there were
\n670,600 injuries and illnesses in the health
\ncare and social assistance industry, with an
\ninjury and illness rate of 5.6 per 100 full-
\ntime workers compared with 4.2 for all of
\nprivate industry. Nearly half (45.3%) of
\nthese injuries and illnesses required days
\naway from work, job transfer, or restriction
\n[1].
\nIn an updated study conducted by the Brit-
\nish Medical Association (BMA) and pub-
\nlished in 2008,almost half of those surveyed,
\nboth GPs and hospital doctors, reported
\nviolence to be a problem in the workplace,
\nwith a third reporting experiencing violence
\nor abuse in the workplace in the preceding
\nyear. The majority reported cases of verbal
\nabuse, but almost a third reported (instead
\nor in addition) physical violence or abuse
\n[2].
\nFinally, the 2011 summary of violent in-
\ncidents in Israeli healthcare workplaces
\nshowed a total of 752 reported cases of
\nphysical violence and another 2406 cases
\nof verbal abuse, a rise from 2010, although
\nlower than in 2008\u20132009. More cases were
\nreported in hospitals than in ambulatory
\nclinics, and the department with the most
\nreported cases was the emergency depart-
\nment [3].
\nThe effects of violence,as we reported previ-
\nously [4],are devastating and include physi-
\ncal and emotional stress, anger, helplessness
\nand anxiety [5], lost work days, low worker
\nmorale, increased turnover and direct and
\nindirect effects on work ability [6].
\nIn a personal plaint by a Chinese medi-
\ncal student following the fatal stabbing of
\nan intern, she reports her own regret in
\nchoosing medicine as a career and asserts
\nthat many of her fellow students do not
\nknow whether to continue to study medi-
\ncine or not [7]. Besides the direct effects
\nof violence, in an era of workplace short-
\nages, this is a byproduct we cannot afford
\nto accept.
\nIsrael has introduced a series of reforms
\nover the last several years in an effort to
\ncombat this worrisome phenomenon, in-
\ncluding financial, legal and social initia-
\ntives. The IMA, in particular, initiated
\nseveral important actions, including an
\nemergency hotline for physicians, a profes-
\nsional security company that accompanies
\nphysicians perceived to be in danger, and
\nan ad campaign, including posters and
\na video clip that was broadcast on cable
\ntelevision. In addition, we partnered with
\ncertain hospitals on a pilot \u201cemergency call
\nbutton\u201d program.
\nOn the legal front, the IMA proposed two
\nbills that were subsequently passed into law.
\nThese bills were developed, in part, on the
\nbasis of a successful action plan implement-
\ned in England in 2000 in order to reduce
\nviolence against medical staff.
\nIn 2011, the law preventing violence in
\nhealthcare institutions in Israel was passed
\n[8]. This law allows a hospital or clinic to
\nwarn family members or accompanying
\npersons of patients, who previously en-
\ngaged in verbal or physical violence against
\nhospital\/clinic personnel or destroyed in-
\nstitutional property, that if they repeat such
\nan act they will not be permitted on the
\nhospital\/clinic grounds for a period of 3\u20136
\nmonths unless they themselves need medi-
\ncal care.
\nThe second law was an amendment to the
\nPenal Code that lengthens the punishment
\nfor one who attacks medical personnel in
\nthe ER or while they are trying to treat
\nsomeone in serious danger from three years
\nto five years [9].
\nThe legal system also, indirectly, helped re-
\nduce some of the pressures that lead to vio-
\nlence when, in June 2008, the district court
\nin Tel Aviv ruled that doctors are not al-
\nlowed to include budgetary considerations
\nin their medical decisions [10]. It is hoped
\nthat this decision will restore the doctor\u2019s
\nprofessional autonomy and minimize the
\ntension between doctor and patient.
\nAs we noted in our previous article, verbal
\naggression is more insidious and no less
\nproblematic than physical aggression. Al-
\nthough the results may be less dramatic \u2013
\nclearly a fatal or disfiguring attack has more
\nimmediate and dramatic consequences
\nViolence in the Health Care Sector \u2014
\nan Updated Look
\nMalke Borow
\nwmj 3 2012.indd 108 7\/18\/12 9:47 AM
\n109
\nViolence in the Health Care Sector
\nthan verbal attack \u2013 because verbal aggres-
\nsion is more prevalent, over time it erodes
\nworker confidence, morale and feelings of
\nsafety in the workplace. In these types of
\ncases, training to deal with aggressive pa-
\ntients can be especially effective [11], per-
\nhaps because it is easier to equip people
\nwith tools to handle verbal aggression than
\nphysical aggression.
\nOne issue that was hotly debated among the
\nNational Medical Associations (NMAs)
\nwas the issue of violence among psychiat-
\nric patients. It was recognized that this is
\na unique problem that cannot be addressed
\nin the same way as other violent events. In
\na study conducted in Egypt, 80% of workers
\nin psychiatric departments reported expo-
\nsure to one or more violent incidents in the
\nprevious year as compared to 23% of work-
\ners in internal medicine departments. In
\nboth departments, verbal violence was the
\nmost common type reported, followed by
\nthreat and then physical violence. Also, in
\nboth departments doctors and nurses were
\nexposed to more violence than social work-
\ners or psychiatrists [12].
\nIt does appear that mental illness raises the
\nlikelihood of violent behavior. This is nec-
\nessary knowledge not to further stigmatize
\nthe community of mentally ill patients but
\nin order to give health workers a realistic
\nunderstanding of the risk and the precau-
\ntions they should take. One survey showed
\na 5% lifetime risk of schizophrenia among
\npeople convicted of homicide, a prevalence
\nthat exceeds the rate of schizophrenia in the
\ngeneral population. Nonetheless, it is im-
\nportant to note the difficulty of establishing
\nan accurate profile of people committing
\nacts of workplace violence, and to acknowl-
\nedge the risks associated with generaliza-
\ntion and stereotyping in this area.
\nConclusion
\nA key motive in preparing the statement for
\nadoption by the WMA was to raise aware-
\nness of the issue among the NMAs and to
\nbuild greater understanding among health
\ncare professionals of the causes and associ-
\nated risks of workplace violence.
\nThere was general consensus among the
\nNMAs as to the importance of such a state-
\nment and the need for action on the part
\nof NMAs, medical institutions and govern-
\nments, including the allocation of appropri-
\nate funds to combat the problem.
\nPrevention is as important as the provision
\nof tools and strategies to deal with violence
\nwhen it occurs. Effective reporting mecha-
\nnisms are also crucial in order to keep tabs
\non the scope and characteristics of the prob-
\nlem.
\nIt is hoped that the adoption of this state-
\nment by the General Assembly in October
\nwill lead to renewed commitment among
\ngovernments and health care workers to ad-
\ndress the problem on all levels and slowly
\nreverse the worrisome trend that leads to
\nphysical and emotional debilitation and
\neventual attrition of the healthcare work-
\nforce.
\nReferences
\n1. Janocha J, Smith RT. Workplace Safety and
\nHealth in the Health Care and Social Assis-
\ntance Industry, 2003-07. http:\/\/www.bls.gov\/
\nopub\/cwc\/sh20100825ar01p1.htm (accessed June
\n13, 2002).
\n2. Violence in the workplace-The experience of
\ndoctors in Great Britain. Health Policy and Re-
\nsearch Unit, BMA, January 2008.
\n3. Summary of violent incidents in the healthcare
\nsystem-2011. Israeli Ministry of Health (2011).
\n4. Blachar Y. Violence in the health care sector-a
\nglobal issue. WMJ (2011); 57(3): 87-89.
\n5. Shalom-Azar S, Liben A. The writing was on
\nthe wall-coping with violence against the staff.
\nPaper presented at the Second International
\nConference on Violence in the Health Sector,
\nOctober 2010.
\n6. Privitera M, Arnetz J. Workplace violence
\n(WPV): Effect on staff, institution and quality
\nof care. Paper presented at the Second Interna-
\ntional Conference on Violence in the Health
\nSector, October 2010.
\n7. Jie L. New generation of Chinese doctors face
\ncrisis. www.thelancet.com vol. 379 May 19,
\n2012.
\n8. Prevention of Violence in Medical Institutions
\nAct-2011.
\n9. Israeli Penal Code section 382A (c), amended
\n2010.
\n10. Appeal No. 001199\/07 Dr. Zvi Raviv v. Ministry
\nof Health.
\n11. Herath P, Forrest L, McRae I, Parker R. Patient
\ninitiated aggression. Australian Family Physi-
\ncian (2011); 40 (6): 418.
\n12. Hady A, El-Hawary A, Shoada M. Workplace
\nviolence against psychiatrist health care staff in
\nMansoura, Egypt. Paper presented at the Sec-
\nond International Conference on Violence in
\nthe Health Sector, October 2010.
\nMalke Borow, Director,
\nDivision of Law and Policy,
\nIsraeli Medical Association
\nwmj 3 2012.indd 109 7\/18\/12 9:47 AM
\n110
\nMedical Research
\nThe main themes at the MedicReS World
\nCongress June 6\u20139, 2012, at Hofburg Palace
\nin Vienna,were Good Medical Research and
\nGood Biostatistical Practice which had been
\nintroduced to the medical literature by Med-
\nicReS for the first time at the MedicReS In-
\nternational Conference 2011 in Istanbul [1].
\nAt the MedicReS World Congress 2012,
\nthese themes were made open for contrib-
\nuted discussions for all medical scientists
\nworking at different stages of medical re-
\nsearch. This is the first time that authors,
\neditors, reviewers, ethical board members,
\nresearch education professionals, publishers,
\nclinical research organizations and manage-
\nment teams of medical sector were brought
\ntogether to discuss the concept of \u201cGood
\nMedical Research\u201d.
\n20 invited and 30 contributed speakers and
\nmore than 50 presentations from 37 dif-
\nferent countries took part in the Scientific
\nProgram of the MedicReS World Congress.
\nDiscussions about ethical issues and global
\nethics training, handling with bias, creating
\ngood evidence, turning evidence to good
\npolicy, publication policies for medical jour-
\nnals, good publication practice measure-
\nments, the future of electronic publishing,
\nstatistical consulting, and differences be-
\ntween peer review systems of journals have
\nbeen discussed.
\nReport on
\nMedicReS World Congress 2012 on Good Medical Research
\nMedicReS International Conference on Good Biostatistical Practice
\nE. Arzu Kanik
\nTable 1. MedicReS Good Biostatistical Practice (GBP) Guide (GBRS release 1.2)
\nMain Parts Subtitles\u00a0
\nPart I
\n\u201cDesign \u2013 Good Planning\u201d, consisting
\nof 20 subtitles in the form of Expanded
\nPICOS (E-PICOS); E-PICOS
\n\u2022 7P: Purpose & Population & Patients
\n& Participants & Power & P value &
\nProtocol (7 subtitles)
\n\u2022 2I: Intervention & Interpretation (2\u00a0sub-
\ntitles)
\n\u2022 4C: Comparators & Controls & Covari-
\nate & Confounding (4 subtitles)
\n\u2022 2O: Outcomes & Outputs (2 subtitles)
\n\u2022 5S: Study Design, Sample Size, Sum-
\nmary Statistics, Statistical Software and
\nSubmitting (5 subtitles)
\nPart II
\n\u201cAnalysis \u2013 Good Executing\u201d, this part of
\nGBP consists of 12 subtitles of 4D (Data
\nCollecting, Data Control, Data Analysis,
\nand Data Interpretation)
\n\u2022 Data Collection (2 subtitles): \u00a0Valid-
\nity, \u00a0Reliability
\n\u2022 Data Control (2 subtitles): \u00a0Missing
\nvalues,\u00a0Outliers
\n\u2022 Data Analysis (4 subtitles): \u00a0Preparing
\ndata for analysis,\u00a0Calculating summary
\nstatistics,\u00a0controlling assumptions,\u00a0de-
\nciding statistical methods for testing
\nhypothesis
\n\u2022 Data Interpretation (4 subtitles): \u00a0Pa-
\nrameter estimating, Interpretation of p
\nvalues, Clinical significance vs. statistical
\nsignificance, Small sample size vs. large
\nsample size
\nPart III
\n\u201cPublication \u2013 Good Reporting and Re-
\nviewing \u201c,consisting of 8 main parts from
\nthe MedicReS Good Biostatistical Review-
\ning Standards, GBRS. GBRS also endorse
\nGood Reporting Guidelines from Equator
\nNetwork
\nGOOD BIOSTATISTICAL REVIEW-
\nING STANDARDS (GBRS release 1.2)
\nwmj 3 2012.indd 110 7\/18\/12 9:47 AM
\n111
\nMedical Research
\nTable 2. MedicReS Good Biostatistical Reviewing Standards (GBRS release 1.2)
\nGBRS Subtitles GBRS Questions ?\u00a0
\n1. Study Design Was a suitable design used to achieve the objective?
\nWas\/Were reporting guideline(s) suitable for the study design used? (GBRS also endorse Good Report-
\ning Guidelines from Equator Network )
\nWas an appropriate control group used?
\nWere any efforts made to avoid potential sources of bias?
\n2. Sample Size Was the minimum sample size needed calculated?
\nIf calculated, was the pre-study calculation of the sample size reported?
\n3. Participants Were the socio-demographic characteristics of participants and those who didn\u2019t wish to participate
\nreported in the study?
\nWere withdrawals from the study independent of the study groups and\/or doses?
\nWas a flow diagram of participants given for all stages of the study?
\n4. Summary Statistics Were the validity and reliability of the measurement methods used reported in the study? (Gold stan-
\ndard, inter-rater agreement)
\nWas the analysis of randomness of missing values and outliers made?
\nWere appropriate summary statistics used?
\nWere there any misuses of standard error?
\nWere confidence intervals calculated for all of the summary statistics used in the study?
\nWere the terms \u2018relation\u2019, \u2018correlation\u2019, \u2018difference\u2019 and risk terms used correctly?
\n5. Statistical Analysis Were statistical methods compatible with the study design and variables, used in this study?
\nWere any assumptions of statistical methods violated?
\nWas the choice of parametric or nonparametric test correct?
\nWere all statistical methods used in the study reported in the methods section of the paper?
\nWas it stated in the study which statistical method was used for which hypothesis?
\nWere a covariant and the effect of mixing variables considered during the analysis? If necessary, was a
\nmultiple data analysis conducted?
\nWas a multivariate analysis necessary? If necessary, was it used correctly?
\nWere subgroups constituted during the data analysis?
\nWere the method and the aim of subgroup analysis correct?
\nWere cutoffs used for quantitative tests? If used, how were they determined?
\nWere subjective criteria used for qualitative tests? If used, how were they determined?
\nWas the sample size sufficient for subgroup analysis?
\n6. Tables and Graphics Was the number of significant digits in the tables used correctly?
\nWere the graphics selected compatible with the data analysis?
\nWere the indications and interpretations of ratios and percentages in the tables in accordance with the
\ncontent?
\nWere both significant and non significant p-values given in the tables? (to avoid publication bias)?
\n7. Statistical Interpretation Were the indication, interpretation of p-values in the study and generalizations made correctly?
\nWere both statistical and clinical significance values of the results discussed?
\n8. Statistical Ethics Was the statistical or commercial software used? If commercial, was this usage legal?
\nWas there a statistical expert contribution in the material? If so, was this contribution valued?
\nwmj 3 2012.indd 111 7\/18\/12 9:47 AM
\n112
\nMedical Research
\nAt the MedicReS World Congress, the
\nsubject \u201cethics\u201d was handled within the
\nframe of showing respect to humans, ani-
\nmals, women, child, patients, and their rela-
\ntives in the planning stage. Ethics in the
\nanalyzing stage of data collecting, analyz-
\ning and interpreting processes was consid-
\nered within the frame of respect for science
\nand self-respect. Subjects on research eth-
\nics and biostatistical ethics were discussed
\nand new concepts were put forward related
\nto electronic publishing in the publishing
\nstage. In the sessions discussing the struc-
\ntures of global and local ethics boards the
\ntime, place and way of training on ethics
\nin undergraduate and graduate levels were
\nalso debated [3].
\nAnother important issue that was high-
\nlighted at the Congress was the impor-
\ntance of guidance of researchers, ethical
\nboard members, referees, and editors who
\nare in charge of practice and publishing.
\nOne of the most important results of the
\nMedicReS World Congress was certifi-
\ncation of researchers. As to the programs
\nthe following were certified: Good Medi-
\ncal Researcher Certificate program and
\nGood Ethical Practice, Good Biostatisti-
\ncal Practice, and Good Reviewing Practice
\nCertificate. These programs should be of-
\nfered locally in small interactive classes and
\nshould be controlled by the center as well.
\nIt is advised that trainings on good medical
\nresearch should be updated every five years
\nbecause of their dynamic methodological
\ninfrastructure. The aim of these certificate
\nprograms is to maintain the reliability of
\nmedical research in the eyes of the media
\nand the readers.
\nThe Lancet wrote that \u201cMedicReS aims to
\neducate researchers and provoke discussion
\nabout good scientific method,statistics,eth-
\nics, publication, and education. Faced with
\nstifling bureaucracy, competition for funds,
\nand employer pressure to deliver results,
\nfinding the time and space to produce the
\nbest research can seem an arduous process\u201d
\n(9 June 2012 issue [2]).
\nAccording to MedicReS, researchers should
\nhave sufficient knowledge not only in their
\nown disciplines but also on ethical, biosta-
\ntistical and methodological principles while
\nconducting their research. MedicReS also
\naims at putting into practice Good Medical
\nResearch philosophy and its components,
\nnamely,good planning, good analyzing,
\ngood reporting, good reviewing and good
\npublishing, creating good evidence, turning
\nevidence to good policy, developing a cur-
\nriculum for good medical research educa-
\ntion, defined not only as ethical and unbi-
\nased, but also powerful.
\nMedicReS Guide for Creating Evidence
\nwas named as Good Biostatistical Practice
\n(GBP) and introduced into the medical
\nliterature for the first time by MedicReS
\nwhen it opened for discussion all the items
\nat the contributed sessions at the MedicReS
\nWorld Congress.The ratio of the three main
\nparts of GBP are as follows: Design \u2013 Good
\nPlanning (50%), Analysis \u2013 Good Execut-
\ning (30%), Publication \u2013 Good Reporting
\n(20%) (Table 1). This guide contains three
\nmain parts: Part I is \u201cDesign \u2013 Good Plan-
\nning\u201d, consisting of 20 subtitles in the form
\nof Expanded PICOS (E-PICOS); E-PI-
\nCOS includes the follow-up From Purpose
\nto Submitting; Part II is \u201c Analysis \u2013 Good
\nExecuting\u201d which consists of 12 subtitles of
\n4D (Data Collecting, Data Control, Data
\nAnalysis and Data Interpretation); the
\nlast part, Part III is \u201c Publication \u2013 Good
\nReporting and Reviewing\u201d, consisting of
\n8 main parts from the MedicReS Good
\nBiostatistical Reviewing Standards, GBRS
\n(Table 2).
\nOne of the new themes that will be featured
\nin the Third MedicReS World Congress on
\nGood Medical Research which will take
\nplace in Vienna next year is clinically signif-
\nicant range for outcomes. Clinically signifi-
\ncant range for primary outcomes is an input
\nrequired for estimating the sample size of
\nresearch, yet it does not have a standard.
\nAlthough this subject is the most impor-
\ntant tool for a powerful research, there is no
\nguide for determining clinically significant
\neffect sizes based on diseases and popula-
\ntions.
\nWe hope to meet medical researchers from
\nall over the world next year June 13\u201315 in
\nVienna for the Third MedicReS World
\nCongress.
\nReferences
\n1. Kanik EA. Good Biostatistical Practice (GBP),
\nMedicReS International Conference Proceed-
\nings Book, on Good Medical Research, March
\n25-27, 2011, Istanbul, p. 85.
\n2. \u201cThe Truth about Good Medical Research \u201c,The
\nLancet, Volume 379, Issue 9832, p.2118, 9 June
\n2012, doi:10.1016\/S0140-6736(12)60924-6.
\n3. Wolf D. Global Research Ethic Training, Medi-
\ncReS World Congress Proceedings Book, on
\nGood Medical Research, June 06-09, 2012 in
\nVienna.
\nE. Arzu Kanik, PhD, Professor and
\nChair Department of Biostatistics and
\nBioinformatics, University of Mersin, Mersin;
\nScientific Coordinator of MedicReS and Chair
\nof MedicReS World Congress 2012, Vienna
\nwww.medicres.org,
\nE-mail: info@medicres.org
\nwmj 3 2012.indd 112 7\/18\/12 9:47 AM
\n113
\nClimate and Health
\nThe First Global Climate and Health Sum-
\nmit was held on 4th
\nDecember 2011, in
\nDurban parallel to the UNFCCC climate
\nnegotiations. The summit was organized by
\nHealth Care Without Harm (HCWH) in
\npartnership with more than 10 major health
\norganizations from around the world in-
\ncluding the World Medical Association
\n(WMA) to raise awareness of health risks
\nof climate change and urge delegations to
\ntake immediate and bold action to tackle
\nthe climate change issue.
\nThe summit was very successful with a high
\nturnout of over 250 participants mostly
\nfrom the health sector and from more
\nthan 40 countries. Speakers at the summit
\nwarned that climate change will be a disas-
\nter to health crises if governments don\u2019t take
\nimmediate strong action and stressed that
\nambitious commitments have many health
\nbenefits. In a panel discussion following
\nthe keynote speeches, ways to commit to
\nmitigating the climate change were dis-
\ncussed from various viewpoints from green
\nmanagement of health sectors to dietary
\nchanges.As a result of all the discussion, the
\nparticipants issued the Durban Declaration
\nurging substantial progress in governmental
\ntalks, and A Global Call to Action (www.
\nclimateandhealthcare.org) urging the health
\nsector to play increased roles in advocacy
\nand capacity building in addressing the is-
\nsue.The voices collected at the summit were
\ndelivered to the participants of the UN-
\nFCCC meeting at a press conference of the
\nUN meeting with a performance of doctors
\ntaking the temperature of a model earth and
\nfinding that it was overheating.
\nRepresenting the WMA, I had an oppor-
\ntunity to introduce the WMA\u2019s commit-
\nments to tackling health impacts of climate
\nchange including the Delhi Declaration
\nand a lobbying action with the NMAs to
\nmake health an inherent component of
\ngovernmental climate talks. I approached
\nthe issue especially focusing on the role
\nof the organized medicine and leadership:
\nencouraging the NMAs to press their gov-
\nernments to fully consider the issue, get-
\nting physicians and patients involved in the
\ncommitment for a healthy climate, foster-
\ning studies and research on the burden of
\ndisease caused by the climate change and
\nimpact of the climate change on the most
\nvulnerable population, strengthening col-
\nlaboration with other health organizations
\nand NGOs.
\nAs strategies to effective action plans, I
\npointed out strengthening professional edu-
\ncation on environmental health and physi-
\ncians\u2019 obligation and responsibilities for the
\ncommitment, getting physicians engaged
\nin networks and groups that can work to-
\ngether, and raising physicians\u2019 involvement
\nin the development of policies to protect the
\nhealth from the climate change.The partici-
\npants expressed high hopes in the WMA\u2019s
\nfurther commitments and leading roles as
\nthe only body representing physicians over
\nthe world.
\nAlthough governmental delegations to the
\nUNFCCC meeting in Durban reached
\na consensus to extend the Kyoto Protocol
\nand draft a universal legal agreement to be
\nadopted and come into force by 2020, it
\nfailed to take an immediate action to save
\nthe burning planet.This slow progress gives
\norganizations in the health sector around
\nthe world the responsibility to collaborate
\nand strengthen their voices.
\nRealizing the responsibilities, at a post-
\nconference strategy meeting, the partici-
\npants agreed to establish a network among
\nthe organizations that attended the summit
\nand work on follow-ups to promote aware-
\nness in the health sector on the health and
\nclimate change and continue to urge gov-
\nernments to make substantial progress in
\nreducing greenhouse gas emissions, capital-
\nizing on collective influences of the network.
\nAlong with political pressure, the network
\ncan step up research on co-benefits of the
\nclimate change mitigation and adaptation.
\nGathering momentum on the initiative, the
\nhosting organizations plan to continue the
\nglobal climate and health summit annually
\nin parallel to the UNFCCC meeting.
\nExchanging ideas and experiences with oth-
\ner participants representing various medical
\nprofessionals,I felt the WMA needs to draft
\na second phase action plan for the health
\nand climate change, if we call the adoption
\nof the Delhi Declaration as the first phase.
\nOrganized medicine through the WMA
\nand NMAs can effectively raise individual
\nphysician\u2019s interests and involvement in
\nprotecting health from the climate change.
\nCollective knowledge and action can achieve
\nfar better results than separate efforts. Par-
\nticipating in the network is also important
\nfor the WMA to move its initiatives on the
\nhealth and climate change to the next level.
\nIt will widen its horizon in drafting future
\nplans and strengthen collectivity.
\nProf. Dong Chun SHIN, MD, PhD,
\nYonsei University College of Medicine,
\nDepartment of Public Health
\nThe First Global Climate and Health Summit
\nDong Chun Shin
\nwmj 3 2012.indd 113 7\/18\/12 9:47 AM
\n114
\nInfluenza
\nBangkok, 12th
\nJune 2012\u00a0\u2013 A group of more
\nthan 200 leading international influenza ex-
\nperts will meet in Bangkok during 12 & 13
\nJune for an information sharing exercise,the
\nfirst of its kind for the region. Concerned
\nabout the low influenza vaccination levels
\nin the region, the experts will discuss the
\nneed to improve awareness and implement
\ninfluenza control policies to protect those at
\ngreatest risk for serious complications.They
\nwill also underscore the importance of an-
\nnual influenza vaccination to control the
\ndisease and improve influenza pandemic
\npreparedness.
\nEach year, approximately 5 to 10% of adults
\nand up to 30% of children worldwide will
\nsuffer from seasonal influenza, resulting in
\nmedical visits, hospitalization and death,
\nas well as millions of lost work and school
\ndays. It is estimated that seasonal influenza
\ncauses up to 1 million deaths annually but
\nmany of these go undiagnosed or misdiag-
\nnosed leaving the influenza that underlies
\nother conditions unrecognized. Health au-
\nthorities, scientific institutions and profes-
\nsional organizations worldwide undertake
\na variety of seasonal influenza vaccination
\ninitiatives. Despite these efforts, vaccine
\ncoverage rates vary greatly between coun-
\ntries and between different targeted groups.
\nWhat\u2019s more, it has been shown that ro-
\nbust annual influenza vaccination programs
\nare an important foundation for pandemic
\nvaccination capabilities, while also helping
\nto protect against annual epidemics. \u201cPan-
\ndemic influenza poses an ongoing threat to
\nglobal public health and the Asia-Pacific
\nregion is not immune to it.\u201d \u2013 says Prof
\nPrasert Thongcharoen,Chairman of the In-
\nfluenza Foundation Thailand. \u201cVaccination
\nis the best way to fight this risk. However,
\nvaccinating large populations during a pan-
\ndemic is highly challenging and requires
\nrobust vaccine production, distribution and
\nadministration capabilities. Seasonal vac-
\ncination can provide an important founda-
\ntion for this infrastructure, while also help-
\ning to protect against annual epidemics\u201d, he
\nadded.
\nExperts are concerned that not enough is
\nbeing done to protect those most at risk for
\nserious complications. \u201cVaccination levels
\namong the Asian-Pacific population, in-
\ncluding health care professionals, are still
\nmuch too low\u201d, says Prof Jennings, Chair-
\nman of the Asia-Pacific Alliance for the
\nControl of Influenza (APACI). \u201cWe hope
\nthe meeting will stimulate policy and advo-
\ncacy approaches to improve influenza vac-
\ncine uptake in high-risk groups and health-
\ncare workers in the region\u201d, he went on to
\nsay.
\nThe Summit is modeled on the success-
\nful European (ESWI) and United States
\n(CDC\/AMA) Influenza Summits held in
\n2011. Key aims of the Summit are to review
\nthe current state of official seasonal influen-
\nza control policies in Asia-Pacific countries,
\nand to establish collaborative relationships
\nto promote best practices for the control of
\ninfluenza. \u201cEven though awareness of the
\nburden of influenza on public health con-
\ntinues to develop in the Asia-Pacific region,
\nthere is presently no consensus on the best
\nway to prevent and treat the disease\u201d, \u2013add-
\ned Prof Lance Jennings. \u201cA meeting such as
\nthis one will help to ensure that policies for
\nthe use of seasonal influenza vaccines and
\nspecific treatments are in place\u201dhe also said.
\nAPACI is leading a partnership with the
\nInfluenza Foundation of Thailand (IFT)
\nand the Department of Disease Control
\n(Thailand), to present the Inaugural Asia-
\nPacific Influenza Summit.
\nThailand is one of the countries in Asia that
\nhas developed an effective influenza control
\nprogram that communicates the health and
\neconomic impacts of influenza as well as the
\nbenefits of prevention to healthcare work-
\ners and high risk groups, including children,
\nthe elderly and those with chronic diseases.
\nHowever the program had not been with-
\nout its challenges in particular in relation to
\nacceptance of vaccination among healthcare
\nworkers.
\nDr. Porntep Siriwanarangsun, Director
\nGeneral at the Department of Disease
\nControl in the Ministry of Public Health
\nof Thailand added: \u201cIn view of all the chal-
\nlenges there is no doubt that continuous
\nstudies about influenza, including policy
\ndevelopment, are important. No one can do
\nit alone. We need networks\u2019 and partners\u2019
\ncollaboration to brainstorm, share experi-
\nence and support each other. This summit
\nis a perfect occasion for this and its work
\nwill serve not only Thailand, but the whole
\nAsia-Pacific region.\u201d
\nFor more information, please contact:
\nKim Sampson
\nExecutive Director
\nAsia-Pacific Alliance for the
\nControl of Influenza (APACI)
\nE-mail: kim@apaci.asia
\nTamara Music
\nManager, Influenza Vaccines
\n& Code Compliance
\nInternational Federation of Pharmaceutical
\nManufacturers & Associations (IFPMA)
\nE-mail: t.music@ifpma.org
\nAsia-Pacific Influenza Summit
\nExperts at inaugural Asia-Pacific Influenza Summit warn that
\nannual influenza vaccination levels are too low
\nwmj 3 2012.indd 114 7\/18\/12 9:47 AM
\n115
\nInfluenza
\nThere are more than 59 million health
\nworkers worldwide and the nature of our
\nwork leaves us exposed to a complex vari-
\nety of health and safety hazards every day.
\nYet, as our job is to care for the sick we
\nsometimes fall into the trap of not thinking
\nabout ourselves and believing that we are
\n\u201cimmune\u201d to illness. We live and work by
\nthe adage that the patient comes first.How-
\never, influenza does not share this point of
\nview. It is a risk to us as well as our patients.
\nFurthermore, if we do not protect ourselves,
\nthen we increase the risk to our patients. So,
\nin fact, the fight against influenza in health
\ncare settings starts with us.
\nAccording to the World Health each year,
\napproximately 5 to 10% of adults suffer
\nfrom seasonal influenza [1]. At the same
\ntime, rates of 11\u201359% have been reported in
\nhealthcare workers caring for infected pa-
\ntients [2].What it means in clinical practice
\nis that we can get influenza from patients
\nand coworkers, as well as from family and
\nother contacts outside the workplace. Some
\nof us are also at risk of the more severe ef-
\nfects of influenza, such as pregnant health-
\ncare professionals or those with underlying
\nmedical conditions. We get sick and then
\nwe pass it on!
\nHealthcare professionals can act as vectors
\nfor influenza viruses. Some dedicated pro-
\nfessionals actually avoid taking sick leave
\nthinking that they cannot stop providing
\nsupport to their patients. In fact, they are
\nalso likely to pass the disease to their pa-
\ntients. However, influenza may be asymp-
\ntomatic while still posing a transmission
\nrisk. In one study, 23% of healthcare work-
\ners tested positive for infection following a
\nmild season, while 59% of these workers did
\nnot remember having influenza and 28%
\ndid not recall any respiratory illness [3, 4].
\nTherefore, as well as staying home when
\nthey are sick, health care workers need to
\nmake sure they don\u2019t get infected them-
\nselves, if they are to protect their patients.
\nSickness comes first to our mind when we
\nthink about influenza. Yet, the infection
\nhas also a potentially serious impact on the
\nhealth care services and related costs. In
\nextreme cases, it forces medical centers to
\nlimit or stop admissions. This was the case
\ndescribed in a study where an influenza
\noutbreak in a 19-bed internal medicine unit
\nprevented emergency admissions for 11
\ndays and led to the postponement of eight
\nscheduled admissions [5].
\nAlthough influenza presents a major chal-
\nlenge, there is substantial evidence for its
\ncontrol. Vaccination is safe and the most
\neffective way to prevent influenza [6]. The
\nWHO estimates that vaccination can pre-
\nvent 70\u201390% of influenza illness in healthy
\nadults.
\nSeveral studies have also associated health-
\ncare worker immunizations with enhanced
\npatient outcomes. A US study found that
\nincreases in healthcare worker vaccina-
\ntion from 4% to 67% were associated with
\nsignificant reductions in both the relative
\nfrequency of influenza cases among staff
\nand the proportion of hospitalized patients
\nacquiring nosocomial infections. In this
\nparticular study, nosocomial influenza rep-
\nresented 32% of cases amongst the patients
\nat the beginning of the study period and
\nsubsequently fell to 0% [7, 8].
\nRobust annual influenza vaccination pro-
\ngrams are also an important foundation for
\npandemic vaccination capabilities. In the
\ncase of the healthcare workers, they help
\nensure the continuity of the health services
\nduring pandemics.
\nYet, despite all this evidence, many people,
\nincluding us \u2013 those involved in caring for
\nothers, the healthcare workers\u00a0\u2013 do not get
\nvaccinated.
\nStakeholders around the globe are increas-
\ningly aware that in order to succeed in
\nthe fight against this disease, we need to
\nincrease the seasonal influenza vaccina-
\ntion levels among the general public and
\nespecially among the most vulnerable and
\nhealth-care workers. This is consistent with
\nthe recent recommendations of the WHO
\nStrategic Advisory Group of Experts as
\nwell as with the conclusions of high level
\ninfluenza summits held in different regions
\nof the world,the most recent being Asia Pa-
\ncific Influenza Summit in Bangkok, which
\nbuilt on successful European and US sum-
\nmits from 2011.
\nAs far as healthcare workers are concerned
\nthe experts advising healthcare policy
\nmakers suggest different approaches to
\npreventing influenza and increasing vac-
\ncination levels \u2013 from the use of declina-
\ntion forms, to providing free or subsidized
\nvaccines to the priority groups or more
\ndrastic measures such as mandatory vac-
\ncination. Regardless of the preferred policy
\napproach, there seems to be one point that
\nEffective Fight Against Influenza Starts in
\nOur Daily Practice and Hospitals!
\nLance Jennings
\nwmj 3 2012.indd 115 7\/18\/12 9:47 AM
\n116
\nSOUTH AFRICAProfessionalism in Health Care
\nCentral to health care practice and the mor-
\nal contract between the public and the pro-
\nfession lies professionalism and professional
\nintegrity.The purpose of health care practice
\nis to always care for the ailing and the sick,
\npromote health interests and well-being
\nand strive towards healing environments.
\nProfessionalism, which sets the standard
\nof what a patient should expect from his or
\nher health care practitioner, is an ideal that
\nshould be sustained [1]. Health care practi-
\ntioners are important agents through which
\nscientific knowledge is applied to human
\nhealth, thereby bridging the gap between
\nscience and society. But health care practice
\ngoes beyond just clinical or technical excel-
\nlence. It is more than just knowledge about
\ndisease. It is also about experiences, feelings,
\nand interpretations of human beings in of-
\nten extraordinary moments of fear, anxiety
\nand doubt. In this very vulnerable position,
\nprofessionalism underpins the public\u2019s trust
\nin health care practitioners [2] and profes-
\nsional integrity and honesty should be a
\nmeasure of the extent to which the profes-
\nsional\u2019s reputation and credibility remains
\nassured and untainted.
\nPolitical, social and economic factors to-
\ngether with advances in science and tech-
\nnology have reshaped attitudes and ex-
\npectations of the public and health care
\npractitioners, whose roles and professional
\nresponsibilities up till now were clear and
\nunequivocally well understood. In addition,
\nWhat does Professionalism in Health Care
\nMean in the 21st
\nCentury?
\nAmes Dhai David J McQuoid-Mason
\nresonates strongly with all experts \u2013 the
\nneed to raise awareness, communicate and
\neducate healthcare workers on the neces-
\nsity of vaccination not only for themselves
\nbut more importantly for their patients.
\nPart of this process should also include
\nlistening to healthcare workers concerns\u2019
\nand responding to false beliefs that might
\nprevent them from both getting vaccinated
\nand recommending influenza vaccination
\nto their patients.
\nI have been dealing with influenza for many
\nyears now and I strongly believe that vac-
\ncination among healthcare workers is a nec-
\nessary and effective way forward in fight-
\ning this disease as well for preventing and
\ncontrolling future pandemics. As healthcare
\nworkers, responsible both for our own and
\nour patients\u2019health, we must get vaccinated.
\nWe should also be at the forefront of rais-
\ning the awareness among patients as to why
\ninfluenza vaccination is the best option for
\nthem and their families as well as for the
\nsociety at large.
\nReferences
\n1. WHO. Influenza vaccines, WHO position pa-
\nper. Weekly Epidemiol Rec 2005:33:279-287;
\n2. Salgado C, Farr B, Hall K et al. Influenza in the
\nacute hospital setting. Lancet Infect Dis 2002;
\n2:145-155.
\n3. Elder A, O\u2019Donnell B, McCruden E et al. In-
\ncidence and recall of influenza in a cohort of
\nGlasgow healthcare workers during the 1993-4
\nepidemic: results of serum testing and question-
\nnaire. BMJ 1996; 313:1241-1242.
\n4. CDC. Influenza Vaccination of Health-Care
\nPersonnel, Recommendations of the Healthcare
\nInfection Control Practices Advisory Commit-
\ntee (HICPAC) and the Advisory Committee
\non Immunization Practices (ACIP). MMWR
\n2006; 55(RR-2):1-16.
\n5. Sartor C, Zandotti C, Romain F et al. Disrup-
\ntion of services in an internal medicine unit due
\nto a nosocomial influenza outbreak. Infect Con-
\ntrol Hosp Epidemiol 2002; 23:615-619.
\n6. Fiore AE, Uyeki TM, Broder K, et al. Preven-
\ntion and control of influenza with vaccines:
\nrecommendations of the Advisory Committee
\non Immunization Practices (ACIIP). MMWR
\nRecomm Rep 2010;59(RR-8):1-62.
\n7. CDC. Influenza Vaccination., op.cit.
\n8. Salgado C, Giannetta E, Hayden F et al. Pre-
\nventing nosocomial influenza by improving the
\nvaccine acceptance rate of clinicians.Infect Con-
\ntrol Hosp Epidemiol 2004; 25:923-928.
\nAssoc. Prof Lance Jennings,
\nChairman of the Asia-Pacific Alliance
\nfor the Control of Influenza
\n(APACI)
\nwmj 3 2012.indd 116 7\/18\/12 9:47 AM
\n117
\nSOUTH AFRICA Professionalism in Health Care
\nseveral notorious failures of professional-
\nism, including avaricious pursuits, with
\nconcomitant adverse media coverage have
\nundermined public trust in health practice
\nand have led to a questioning of traditional
\nvalues and behaviour, challenging charac-
\nteristics that were once seen as the hallmark
\nof health practice [2]. Professional integrity
\ncan easily be tainted when the nature of
\nthe practitioner-patient relationship starts
\nto become transactional and patients are
\nviewed as customers and health care as a
\ncommodity. Moreover, we have progressed
\nto an era where professional autonomy has
\nhad to give way to accountability. Percep-
\ntions of practitioners as healers have also
\nbeen eroded by error and iatrogenic injury
\n[3]. What\u2019s more, an emphasis on litiga-
\ntion as a tool in social justice has led to a
\ngreater level of public awareness of the
\nharms that practitioners can be guilty of [4].
\nWithout doubt, trust is critical to successful
\ncare and where patients cannot trust their
\npractitioners, the quality of their care could
\nbe seriously jeopardised. It is not because
\npractitioners have special knowledge and
\ntechnologies that they should be trusted.
\nThey are trusted only if this knowledge
\nand technology is firmly attached to values
\nthat are explicit, understood and altruistic.
\nThe principal objective of practitioners is to
\ntreat their patients well. Unfortunately, sur-
\nvey data over decades reveal that the level
\nof confidence and trust that was accorded
\nthe profession several decades ago has been
\nsubstantially eroded [5].
\nCompassion, competence and autonomy
\nare judged to be core foundational values
\nin the practice of health care. Understand-
\ning and concern for a person\u2019s distress is es-
\nsential in this context. An extremely high
\ndegree of competence is expected and re-
\nquired of practitioners. This is not limited
\nto scientific knowledge and technical skills,
\nbut also includes ethical knowledge, skills
\nand attitudes, and an understanding of hu-
\nman rights and health law. As new ethical
\nissues arise with changes in practice and its
\nsocial and political environment, it is im-
\nportant that knowledge and skills are regu-
\nlarly updated and maintained in this arena.
\nAutonomy has changed the most over time,
\nwith practitioner autonomy being moder-
\nated by governments and other authorities
\nand patient autonomy gaining widespread
\nacceptance[6].
\nThe ethical and moral duties accorded to
\nhealth practitioners impose an obligation
\nof effacement of self-interest on the prac-
\ntitioner that distinguishes health practice
\nfrom business and most other careers or
\nforms of livelihood [7]. Pellegrino states
\nthat there are at least three things specific to
\nhealth practice that have led to this position.
\nFirstly, it is the nature of illness itself with
\npatients being in a uniquely dependent,
\nanxious, vulnerable and easily exploited
\nstate,being forced into a position of trusting
\nthe practitioner in a relationship of relative
\npowerlessness. Furthermore, when practi-
\ntioners offer to put knowledge at the service
\nof the sick, they invite that trust. Hence,
\na health need in itself constitutes a moral
\nclaim on those equipped to help. Secondly,
\nthe knowledge gained by the practitioner
\nis not proprietary as it is acquired through
\nsociety sanctioning certain invasions of
\nprivacy, e.g. experimenting with humans
\nand allowing for financial subsidisation of
\nhealth education. The practitioner\u2019s knowl-
\nedge is therefore not individually owned
\nand should not be used primarily for per-
\nsonal gain, prestige or power. Finally, the
\noath that is taken at graduation is a public
\npromise that the practitioner understands
\nthe gravity of her\/his calling and promises
\nto be competent and use that competence
\nin the interests of the sick [8].
\nProfessionalism in health practice matters
\njust as much in the 21st
\ncentury as it did at
\nthe time of Hippocrates over 2 500 years
\nago. It has its roots in almost all aspects
\nof modern health care. Practitioners must
\naccept that financial and personal gain
\nare not all-important and need to look at
\nother ways to think about what else mat-
\nters. Moreover, social responsibility, social
\nconscience and a resilience to external pres-
\nsures, political or otherwise, that interfere
\nwith the \u2018best interests\u2019 principle are more
\nimportant now than ever before. Core val-
\nues, principles and competencies must be
\nreflected upon and the question of what
\nit means to be a health care professional
\nand what is required to claim all privileges
\ngranted by society to health professionals
\nshould be re-appraised.
\nThe South African Journal of Bioethics
\nand the Law has been launched to provide
\na forum for experts and health care prac-
\ntitioners to engage with their colleagues in
\ndebate about the pressing ethical and legal
\nissues confronting the medical world during
\nthe 21st
\ncentury.
\nReferences
\n1. Cruess RL, Cruess SR, Johnston SE. Profes-
\nsionalism: an ideal to be sustained. Lancet 2000;
\n356: 156-169.
\n2. Royal College of Physicians. Doctors in Society.
\nMedical Professionalism in a Changing World.
\nReport of a Working Party of the Royal College
\nof Physicians of London. London: RCP, 2005.
\n3. Institute of Medicine. Crossing the Quality
\nChasm: A New Health System for the Twenty
\nFirst Century.Washington,DC: National Acad-
\nemy Press, 2001.
\n4. Association of American Medical Colleges. A
\nFlag in the Wind. Educating for Professional-
\nism in Medicine. 2003. mwhitcombe@aamc.org
\n(accessed 16 March 2008).
\n5. Schlesinger M. A loss of faith: the sources of
\nreduced political legitimacy for the American
\nmedical profession. Milbank Q 2002; 80: 185\u2013
\n236.
\n6. World Medical Association. Medical Ethics
\nManual. 2005.
\n7. Pellegrino ED, Thomasma DC. The Good of
\nthe Patient: The Restitution of Beneficence in
\nMedical Ethics. New York: Oxford University
\nPress, 1987.
\n8. Pellegrino ED. Altruism, self-interest, and med-
\nical ethics. JAMA 1987; 258: 1939\u20131940.
\nAmes Dhai, Editor of SAJBL;
\nDavid J McQuoid-Mason,
\nCo-Editor of SAJBL
\n2 June 2008, Vol. 1, No. 1 SAJBL
\nwmj 3 2012.indd 117 7\/18\/12 9:47 AM
\n118
\nMedical Ethics
\nWith the institutional support of the re-
\ngional communities of the Economic Com-
\nmunity of West African States (ECOWAS)
\nand particularly its department responsible
\nfor health \u2013 the West African Health Or-
\nganization (WAHO) \u2013 the Orders doc-
\ntors in the region that regroup 15 countries
\nincluding Anglophone, Francophone and
\nPortuguese countries, started in 2008 and in
\n2011resulted in the finalization of the har-
\nmonization of the codes of ethics.
\nWhile elaborating two harmonized codes,
\none for the French-Portuguese space and
\nthe other for the English-speaking, it has
\nbeen found that the major ethical principles
\nwere similar in the respective national codes.
\nDifferences, particularly between the Eng-
\nlish-speaking and French-Portuguese con-
\ncern details; indeed, the inspiring ethical
\ncodes of France are enunciative but not limi-
\ntative. The actions, even if they are not spe-
\ncifically detailed in the articles,are amenable
\nto disciplinary actions if they go against the
\ncustoms and practices of physicians.
\nMap of ECOWAS (15 countries \u2013 population
\naround 275 million)
\nManagers of medical Orders, in real-
\nity pioneers, showed consensual spirit
\nundeniable to harmonize and to final-
\nize the 02 codes in the common area.
\nWe should pay homage to Professor Odu-
\nsote Kayode, former director of the De-
\npartment of Health and Professor Diallo
\nAbdoulaye, current director, who have con-
\nsistently demonstrated selflessness and ded-
\nication in their tasks to arrive at the con-
\nclusion of this harmonization The difficulty
\nfor recognizing the harmonized codes could
\nhave come from Franco-Portuguese dental
\nsurgeons most of whom have separate codes
\nof physicians while the English doctors and
\ndental surgeons have the same code.
\nThe political leaders of ECOWAS welcomed
\nthis advance which resulted in this harmoni-
\nzation, and stating that teachers in medical
\nschools have managed to develop a common
\ncurriculum of general medical training, it
\nwas ordered to continue working at integra-
\ntion for attaining the WAHO objective \u2013 the
\nrealization of a unified code of ethics. This
\nis an exciting and a more difficult challenge
\nbecause the final objective is to ensure that
\ndoctors and dental surgeons both Anglo-
\nphone and French-Lusophone recognize
\nand incorporate the provisions of the new
\nunified code.
\nThe ad-hoc committee composed of Dr. Sal-
\nlah, Tapsoba, Abdulmumini, and Ekra and
\nchaired by Dr. Aka Kroo Florent has a chal-
\nlenge. The task will be facilitated by the fact
\nthat it is based on harmonized codes that will
\nbe developed in the Uniform Code by retain-
\ning the similarities while taking into account
\nthe specific differences to be adapted.
\nDr. Aka Kroo Florent
\nPresident of the National
\nCollege of Physicians of C\u00f4te d\u2019Ivoire
\nE-mail: florent.aka@medecins.ci
\nThe Uniform Codes of Ethics in the Focus of Physicians and Dental
\nSurgeons of ECOWAS after Harmonization
\nKroo Florent
\nThe pioneers of harmonized codes with the ends and standing.
\nProf.Abdoulaye Diallo left and Prof. Kayode Odusote right.
\nwmj 3 2012.indd 118 7\/18\/12 9:47 AM
\n119
\nWMA news
\nBackground
\nThe World Medical Association (WMA)
\nJunior Doctors Network (JDN) represents
\nthe world\u2019s first international body of junior
\ndoctors, operating under the auspices of the
\norganization recognized as the voice of phy-
\nsicians worldwide.It provides junior doctors
\nwith a global forum to exchange ideas, col-
\nlaborate, and conduct research relevant to
\nissues they face in their training and career
\ndevelopment, while providing them the op-
\nportunity to participate and contribute to
\nthe wider policy and advocacy work of the
\nWMA.
\nFounded in 2010 after acceptance at the
\nWMA General Assembly in Vancouver,
\nthe JDN\u2019s Draft Terms of Reference were
\nsubsequently accepted at the 188th
\n\u00a0Council
\nMeeting in April 2011 in Sydney, Australia.
\nThis groundwork allowed the growth of a
\nnumber of initiatives and culminated in the
\nsuccessful inaugural JDN meeting, held in
\nconjunction with the 2011 WMA General
\nAssembly in Montevideo, Uruguay.
\nWhat is the Junior
\nDoctors Network?
\nThe JDN is made up of junior doctors who
\nindependently join the World Medical As-
\nsociation as Associate Members. Any ju-
\nnior physician may join and participate. As
\nthe representative voice of young doctors
\nworldwide, the JDN attracts many mem-
\nbers who also hold leadership positions in
\nthe resident or junior doctor sections of
\ntheir respective National Member Associa-
\ntions.
\nThe JDN founding members were largely
\nalumni participants from the International
\nFederation of Medical Students\u2019 Asso-
\nciations (IFMSA) alumni. Other notable
\nfounding members included junior doctors
\nfrom the Korean Interns and Residents As-
\nsociation, Australia Medical Association
\nDoctors-in-Training Council, Doctors-in-
\nTraining New Zealand Medical Associa-
\ntion, American Medical Association, Brit-
\nish Medical Association, Canadian Interns
\nand Residents Association, Brazilian Medi-
\ncal Association Junior Doctors, Singapore
\nMedical Association, and the Permanent
\nWorking Group of European Junior Doc-
\ntors.
\nWhy the Junior
\nDoctors Network?
\nThe JDN acts as a forum for experience
\nsharing, policy discussions, and resource
\ndevelopment putting focus on issues per-
\ntaining to junior doctors. Before the JDN,
\nthere was no global forum directly voicing
\nthe concerns and views of junior doctors,
\ninterns, residents, and fellows at a global
\nlevel.This left a void in representation in the
\nmiddle of young physicians\u2019 continuum of
\ntraining, since the interests of medical stu-
\ndents were represented by the IFMSA, with
\nthe WMA representing physicians globally.
\nThe development of the JDN now provides
\na natural progression, further developing
\nthe existing relationship between the IFM-
\nSA and the WMA. It fulfills the very im-
\nportant role of representing junior doctors
\nat a global level. Recognized in official rela-
\ntions, the JDN also supports the IFMSA
\nby strengthening the recruitment and de-
\nvelopment of the IFMSA alumni network.
\nFinally, the JDN offers participants an op-
\nportunity to make an impact and to con-
\ntribute to the many levels of global health
\nvia policy change at the WMA and with
\nthe WMA\u2019s partner organizations, such as
\nthe WHO.
\nJunior Doctors Network
\nFrom the left :Thorsten\u00a0Hornung, Lawrence\u00a0Loh, Jos\u00e9\u00a0Luiz Gomes\u00a0Do\u00a0Amaral, Xaviour\u00a0Walker
\nwmj 3 2012.indd 119 7\/18\/12 9:47 AM
\n120
\nWMA news
\nDefined functions and
\nobjectives
\nThe Junior Doctor Network has the follow-
\ning functions and objectives:
\n1. Participate, advocate, and consult with
\nConstituent and Associate members of
\nthe WMA on issues of interest to junior
\ndoctors.
\n2. Collaborate with Constituent and As-
\nsociate members of the WMA and oth-
\ner stakeholders to increase the number
\nof junior doctors registered as Associate
\nmembers of the WMA.
\n3. Develop reference materials on issues
\nof interest to junior doctors, including
\n(but not limited to) literature reviews,
\nsurveys, reports, and policy papers.
\n4. Communicate information on emerg-
\ning issues of interest to junior doctors
\ninternationally,in collaboration with the
\nNational Medical Associations of the
\nWMA and other stakeholders.
\n5. Organize professional development ac-
\ntivities and develop resources for junior
\ndoctors
\n6. Coordinate and disseminate informa-
\ntion on global health research and clini-
\ncal elective opportunities and resources
\nfor junior doctors worldwide.
\n7. Develop and implement relevant ju-
\nnior-doctor led projects and programs.
\nCurrent projects and work
\nThe JDN identified social media as an ini-
\ntial area of interest and expertise among
\njunior doctors, and one of the first proj-
\nects undertaken was the development of a
\nwhite paper to provide additional scientific
\ndetail for the WMA Policy on the Profes-
\nsional and Ethical Use of Social Media.
\nSubsequent projects are focused on other
\nissues of concern to junior doctors and
\ntrainees, and include reviews of physi-
\ncian well-being and the ethical consider-
\nations surrounding global health training.
\nThe JDN also works in concert with other
\nWMA workgroups on identified issues of
\ninterest to its members, such as the current
\nWMA workgroup on the ethics of physi-
\ncian strikes.
\nThe JDN members participate as repre-
\nsentatives of the WMA at a number of
\nhigh profile conferences worldwide as well.
\nMembers of the JDN have been actively in-
\nvolved in working with the WMA team at
\nthe World Health Assembly and other con-
\nferences such as a recent patient centered
\nconference in Geneva, Switzerland.
\nWhere to from here?
\nThe JDN continues to grow and adapt to
\nthe increasing interest and commitment
\nfrom members all over the world.The orga-
\nnization is presently undergoing a structural
\nreview to improve its capacity and workflow
\nas the network grows. An important struc-
\ntural change concerns focusing on regional
\ngrowth, particularly related to the WMA
\nmeeting venues in different continents. The
\nJDN hopes to support the development of
\na website, as well as electronic resources and
\nvirtual participation for its members. The
\nJDN also hopes to inspire and support the
\ngrowth of new national junior doctor bod-
\nies as part of national medical associations,
\nto ensure that those residents, interns, and
\ntrainees have a voice during this critical
\nphase in their career. Recently the JDN was
\nidentified as a potential resource for two
\nnew junior doctor bodies in the Asian re-
\ngion.
\nThe JDN is working hard to develop sus-
\ntainable structures prior to the WMA
\nOctober General Assembly in Bangkok,
\nwhere the current committee is targeting to
\nincrease the involvement and contribution
\nlevel of Asian junior doctors to wider activi-
\nties of the WMA.
\nXaviour Walker, MD
\nLawrence Loh, MD MPH
\nThorsten Hornung
\nE-mail: chair.jdn@wma.net
\nwmj 3 2012.indd 120 7\/18\/12 9:47 AM
\nIII
\nOver the past weeks, we have witnessed
\nthe intimidation of two prestigious Roma-
\nnian doctors, who were heard for 7 hours
\nat the National Anticorruption Directorate
\n(DNA), regarding the interception of the
\ndialogue between the doctors and the pa-
\ntient\u2019s family.At the same time,the patient\u2019s
\ndiagnosis was made public and the whole
\ncase had unallowable media coverage.
\nThe context
\nThe background of this national situation
\nrelates to the case of the former Prime Min-
\nister of Romania, Adrian N\u0103stase, and his
\nsuicide attempt. Mr. N\u0103stase was sentenced
\nto two years in prison (after 8 years of trial).
\nOn the night the Police came to his house to
\narrest him, the former Prime Minister tried
\nto commit suicide by firing a bullet into
\nhis head. To prevent it, one of the police-
\nmen grabbed his hand and the bullet passed
\nthrough his neck.He was taken to Floreasca
\nHospital where he was hospitalized.
\nDoctors\u2019 intervention in the case
\nThe next day, both Dr. \u015eerban Br\u0103disteanu
\n(cardiologist at Floreasca Hospital and the
\nperformer of the first human heart trans-
\nplant in Romania), and professor Ioan Las-
\ncar (famous surgeon and Chairman of the
\nBucharest College of Physicians) were part
\nof the multidisciplinary team that operated
\non Mr Nastase after his suicide attempt.
\nThe leader of the surgical team Dr. Bradis-
\nteanu said after the surgery that the patient
\nis under medical treatment and psychologi-
\ncal counseling at Floreasca Hospital, pre-
\nsenting a high heart attack risk.The doctors
\nsaid that the former Prime Minister needed
\n14 days of hospitalization.
\nDr. Bradisteanu was intercepted by the
\nDNA while telling to the patient\u2019s family
\nthat he was in a good condition.The doctor
\nis suspected of covering up the real condi-
\ntion of Adrian Nastase and of emphasizing
\nit for the media and for the public opin-
\nion. Giving the context, the state institu-
\ntions accused the doctors that they kept
\nMr N\u0103stase in Floreasca longer than it was
\nneeded.They wanted to transfer him to the
\npenitentiary immediately after the surgery.
\nMr Nastase remained in Floreasca Hospi-
\ntal only 4 days.
\nIn this case, the doctors who provided him
\nmedical assistance were summoned to the
\nDNA. Thus, the DNA started the prosecu-
\ntion against Dr.Serban Bradisteanu because
\nof the absence of a medical expertise with a
\nconclusion on the real state of health of Mr
\nNastase. Furthermore, Prof. Dr. Ioan Las-
\ncar, Chairman of the Bucharest College of
\nPhysicians, was summoned to be a witness
\nin this case.
\nOn the second day after the admission to
\nthe hospital, MEP Monica Macovei said
\npublicly that she did not trust the diagnosis
\nbecause Dr. Bradisteanu is a former PSD
\nsenator. Also, Prosecutor General Codruta
\nKovesi voiced suspicions concerning the
\ndiagnosis made by the doctors. One day
\nbefore the experts of the Institute of Legal
\nMedicine made their expertise, the doctors
\nfrom Floreasca were forced to sign the re-
\nlease of Adrian Nastase, so that he could be
\nmoved to the penitentiary at 11 p.m.This is
\nthe most clear-cut case in which the doc-
\ntors are intimidated and threatened by the
\nDNA, but it is not the only one.
\nOfficial position of the Romanian
\nCollege of Physicians
\nThe Romanian College of Physicians draws
\nattention to the extremely severe situation
\nof the medical professionals whose inde-
\npendence is affected by the national investi-
\ngating committees.
\nIn doing so, the investigators impose to
\nthe medical professionals an illegal atitude,
\nunconformable with the doctor\u2019s role in so-
\nciety. The violent action, extensively propa-
\ngated through the media, does anything but
\npasses to the physicians the message that
\nwhenever a medical act in the authorities\u2019
\nview might have an impact on public in-
\nterests, the respective doctor is likely to be
\nsummoned and stigmatized.
\nIn this particular case, the patient\u2019s rights
\nwere infringed, the physician\u2013patient-
\nfamily confidentiality relationship (accord-
\ning to the law on patients\u2019 rights) was vio-
\nlated. The diagnostic communication and
\nthe dialogue between the doctor and the
\npatient or his familiy, without the consent
\nof the patient, violate the privacy stipulated
\nby law.
\nAll these happenings constitute serious vio-
\nlations of human rights.
\nIt has become a practice in Romania that
\n\u201cincommodious\u201d doctors are threatened
\nwith criminal cases. The Romanian doctors
\nconsider that such practices are unaccept-
\nable in a European country. Therefore, the
\nRomanian College of Physicians,requested
\nthe Superior Council of Magistracy to be-
\ngin an investigation in the matter.
\nLumini\u0163a V\u00e2lcea
\nRomanian College of Physicians
\nThe Position of the Romanian College of
\nPhysicians Regarding the Attempts to Violate
\nthe Professional Independence of Doctors
\nRegional and NMA newsROMANIA
\nwmj 3 2012.indd III 7\/18\/12 9:47 AM
\nIV
\nContents
\nEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
\nWhite Paper On Ethical Issues Concerning Capital
\nPunishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
\nWorld Health Assembly Report, 2012,
\nGeneva, Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
\nStatement of World Health Professional Alliance
\nadressed to World Health Assembly . . . . . . . . . . . . . . . . . 92
\nSpeech given by the US Secretary of Health and Human
\nServices Kathleen Sebelius at the WMA Luncheon in
\nGeneva, Switzerland, May 22, 2012 . . . . . . . . . . . . . . . . . . 95
\n\u201cTo Run and Not Grow Weary\u201d . . . . . . . . . . . . . . . . . . . . . 97
\nSqueezing Out the Doctor . . . . . . . . . . . . . . . . . . . . . . . . . 101
\n50 Years of Cardiothoracic Surgery . . . . . . . . . . . . . . . . . . 104
\nIsraeli Torture Doctors: Medical Ethics Betrayed . . . . . . . 106
\nViolence in the Health Care Sector \u2013
\nan Updated Look . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
\nReport on MedicReS World Congress 2012 on Good
\nMedical Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
\nMedicReS International Conference on Good
\nBiostatistical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
\nThe First Global Climate and Health Summit . . . . . . . . . . 113
\nAsia-Pacific Influenza Summit . . . . . . . . . . . . . . . . . . . . . . 114
\nEffective Fight Against Influenza Starts in Our Daily
\nPractice and Hospitals! . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
\nWhat does Professionalism in Health Care Mean
\nin the 21st
\nCentury? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
\nThe Uniform Codes of Ethics in the Focus of
\nPhysicians and Dental Surgeons of ECOWAS after
\nHarmonization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
\nJunior Doctors Network . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
\nThe Position of the Romanian College of Physicians
\nRegarding the Attempts to Violate the Professional
\nIndependence of Doctors . . . . . . . . . . . . . . . . . . . . . . . . . . III
\nwmj 3 2012.indd IV 7\/18\/12 9:47 AM<\/p>\n"},"caption":{"rendered":"

wmj39 COUNTRY \u2022 White Paper On Ethical Issues Concerning Capital Punishment \u2022 Violence in the Health Care Sector \u2022 The First Global Climate and Health Summit \u2022 Junior Doctors Network vol. 58 MedicalWorld Journal Official Journal of the World Medical Association, INC G20438 Nr. 3, July 2012 wmj 3 2012.indd I 7\/18\/12 9:47 AM Cover […]<\/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\/wmj39.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3635"}],"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=3635"}]}}