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wmj41<\/a><\/p>\n

COUNTRY
\n\u2022 WMA General Assembly, Bangkok
\n\u2022 World-leading Plain Packaging Laws
\n\u2022 Physicians on Strike
\nvol. 58
\nMedicalWorld
\nJournalJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 5\/6, November 2012
\nCover picture from Germany
\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
\nVelta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by
\nP\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher
\n\u201cMedic\u012bnas apg\u0101ds\u201d,
\nPresident Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nCover painting:
\nOld illustration celebrating Naturalist and
\nMedical Congress in Bonn, September
\n1857. Created by Fichensker, published on
\nL\u2019Illustration, Journal Universel, Paris, 1857
\nPublisher
\nThe World Medical Association, Inc. BP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
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\nDeutscher-\u00c4rzte Verlag GmbH,
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\nMedical Association website
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\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nCologne, Germany
\nISSN: 0049-8122
\nDr. Cecil B. WILSON
\nWMA President
\nAmerican Medical Association
\n515 North State Street
\n60654 Chicago, Illinois
\nUnited States
\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. Jos\u00e9 Luiz
\nGOMES DO AMARAL
\nWMA Immediate Past-President
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nRua Sao Carlos do Pinhal 324
\nBela Vista, CEP 01333-903
\nSao Paulo, SP Brazil
\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. Margaret MUNGHERERA
\nWMA President-Elect
\nUganda Medical Association
\nPlot 8, 41-43 circular rd., P.O. Box
\n29874
\nKampala
\nUganda
\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
\n01212 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
\n161
\nWMA news
\nMembers of the General Assembly, col-
\nleagues, guests and our hosts the Medical
\nAssociation of Thailand.
\nI am honored to serve as President of the
\nWorld Medical Association.
\nI am committed to being a voice for the
\nWMA and our profession worldwide.
\nAnd as I think about working with the
\nincredibly dedicated members of this pro-
\nfession, this noble profession of medicine,
\nI am enthusiastic and optimistic about the
\nfuture. I am proud that the World Medi-
\ncal Association provides an important voice
\nand speaks for the medical profession on
\nhealth-related issues of worldwide signifi-
\ncance.
\nMy pledge to you is that in speaking to
\nnational medical associations and other or-
\nganizations around the world I will use my
\nbest efforts to enhance the reputation of the
\nWorld Medical Association.
\nAs I work with colleagues around the globe,
\nI am reminded of the commitment we all
\nhave to the profession of medicine.I am re-
\nminded of the similarity of the challenges
\nwe face regardless of our country of origin.
\nReminded, that there are different ways to
\nrespond to those challenges\u00a0\u2013 each of which
\nhas its own value.
\nMost of us went to medical school because
\nof the desire to serve the allure of science
\nand, yes,the thrill of achievement, of doing
\nthe difficult\u00a0\u2013 the hard stuff, of running the
\nfastest mile, sinking the hole in one, pole-
\nvaulting higher than any other.
\nIn my country its major league baseball\u2019s
\nJosh Hamilton of the Texas Rangers hit-
\nting four home runs in one game earlier
\nthis summer. For you fans of real football,
\nit\u2019s Great Britain and Manchester city scor-
\ning twice in two minutes to win the English
\nsoccer championship\u00a0\u2013 a first for Manches-
\nter City in 44 years.
\nFor the future of the WMA and world
\nhealth my three nominees for the most sig-
\nnificant, the difficult, the hard stuff are:
\n1. The moral imperative of ethics in medi-
\ncine;
\n2. The challenge of non-communicable
\ndiseases and
\n3. The threat of climate change.
\nFor this audience of world medical leaders
\nwhat I am going to talk about may seem
\na little like stating the obvious. However,
\nI\u00a0support the rationale that it is important
\nto from time to time state the obvious be-
\ncause what should be obvious, if never stat-
\ned, risks becoming not so obvious.
\nFirst ethics:
\nAs physicians we must have moral author-
\nity and speak and act with moral authority.
\nThat means we must speak out on broad
\npublic health issues. Doing that makes
\nour message more credible\u00a0\u2013 and more ef-
\nfective\u00a0\u2013 when we advocate on matters of
\npublic policy. We are most credible when
\nwe speak from a platform based on principle
\nand ethics.
\nThose physicians from around the world
\nwho came together to form the World
\nMedical Association in 1947 recognized
\nthis. They understood that an organization
\nwas needed to become the authoritative
\nvoice on global standards for medical ethics
\nand professional conduct,rather than focus-
\ning solely on protecting the interests of the
\nprofession.They recognized the importance
\nto the profession of providing guidance,
\nmoral support and practical advice. They
\nrecognized the importance of endeavoring
\nto achieve the highest possible standards of
\nmedical care, ethics and health-related hu-
\nman rights for all people.
\nFrom the beginning this intent was codified
\nin our International Code of Medical Eth-
\nics and the Declaration of Geneva\u00a0 \u2013 also
\nknown as the modern \u201cHippocratic oath\u201d.
\nOther declarations have addressed issues
\nsuch as the patient safety, medical ethics
\nand advanced technology, end of life care,
\naccess to care,protection of medical person-
\nnel in armed conflicts\u00a0\u2013 and more recently
\nthe use of social media.
\nThe Future for Global Health Care
\nCecil B. Wilson, MD, MACP
\nInaugural Speech
\nPresident, World Medical Association
\nOctober 12, 2012
\nCecil B. Wilson
\n162
\nWMA news
\nToday the WMA is bigger, stronger and
\nmore active than ever before and it serves
\nas a voice recognized the world over. There
\nis perhaps no clearer example of that rec-
\nognition than the Declaration of Helsinki
\nthat advises physicians on doing medical re-
\nsearch on human subjects. The Declaration
\nof Helsinki is the loadstone; the North Star
\nif you will that guides physicians, govern-
\nments and industry in this area.Next month
\nin Cape Town, South Africa the WMA is
\nconvening distinguished ethicists, educa-
\ntors and government officials from around
\nthe world to look at potential revisions of
\nthe Declaration\u00a0\u2013 not to change core princi-
\nples\u00a0\u2013 but to determine whether more guid-
\nance is needed to deal with the complexities
\nof today\u2019s world.
\nBut ethical guidance by itself is not enough\u00a0\u2013
\nhence our additional goals of moral support
\nand practical advice.To that end the WMA
\nis active in making its voice heard:
\nmost recently speaking out urging the gov-
\nernment of Bahrain to overturn the crimi-
\nnal court verdict of doctors sentenced to
\njail for providing care to the injured, and
\ncalling on the government of Syria and
\nPresident Assad to protect health care fa-
\ncilities and their workers from interference,
\nintimidation or attack;speaking out in sup-
\nport of professional orders in West Africa,
\nand earlier this year, sending our presi-
\ndent Dr.\u00a0 Do\u00a0 Amaral and chair of coun-
\ncil Dr.\u00a0 Haikerwal to Turkey where they
\nmarched in solidarity with fellow physicians
\nin opposition to threats to professional au-
\ntonomy and self-regulation.
\nNow more than ever, this WMA, this bea-
\ncon of principle and ethics is needed. The
\nWMA is not involved in health care per se,
\nbut does have an important role in seeking
\nto influence the environment, the milieu in
\nwhich health care is delivered\u00a0\u2013 the struc-
\nture of health care systems.
\nWhich leads to my second point\u00a0 \u2013 the
\nchallenge of non-communicable diseases.
\nNon-communicable Diseases (or NCDS)
\nare now the leading cause of death and dis-
\nability worldwide. And that is true in the
\ndeveloped and the developing world. These
\ndiseases including cardiovascular and circu-
\nlatory diseases, diabetes, cancer and chronic
\nlung disease are expected to increase in fre-
\nquency and are largely preventable.They are
\nnot replacing the existing causes of illness
\nsuch as infectious disease and trauma, but
\nare adding to the disease burden. So that
\ndeveloping countries face the triple burden
\nof infectious disease, trauma and chronic
\ndisease. The causes of non-communicable
\ndiseases are smoking, obesity, physical in-
\nactivity and alcohol abuse\u00a0 \u2013 all lifestyle
\nbehaviours. The primary solution is disease
\nprevention. In a statement adopted at this
\nGeneral Assembly in Uruguay last year
\nthe World Medical Association called for
\nnational policies that help people achieve
\nhealthy lifestyles and behaviors; for pro-
\ngrams to increase access to primary care; for
\nmedical education systems to be socially ac-
\ncountable; to direct their education,research
\nand service activities towards addressing the
\npriority health concerns of the community,
\nregion or nation they serve; for strengthen-
\ning the health care infrastructure to care
\nfor the increasing numbers of people with
\nchronic disease. This includes: training the
\nprimary health care team; improved health
\ncare facilities such as hospitals and clinics;
\nchronic disease surveillance; public health
\npromotion campaigns; quality assurance;
\nassuring adequate numbers of well-trained
\nand motivated health care professionals.
\nThis is a challenge that cannot be met solely
\nby the individual physician seeing a patient
\nin the office, important and essential as that
\nis. It is a job for all of society\u00a0\u2013 world gov-
\nernments, national medical associations,
\nmedical schools, patients and yes\u00a0 \u2013 indi-
\nvidual physicians working in their commu-
\nnities seeking to affect health policy. But,
\nlifestyle behaviours, smoking, obesity and
\nalcohol abuse are only part of the story of
\nNCDs.
\nTo get there let me digress.
\nThere is an old fable from this part of the
\nworld about three princes who lived long
\nago in the country of Serendippo\u00a0\u2013 what
\nwe now know as Sri Lanka. Their father,
\nthe king, wanted them to have the best
\npossible education. But even though he
\nhired the very best teachers, he was not
\nconvinced that his sons were getting the
\ntraining they needed to rule as king. So he
\nsent them abroad, away from the privileges
\nof the palace, to sharpen their wits and
\nbroaden their horizons. And in the course
\nof their travels, by keeping their minds
\nopen, more by accident than design, they
\ngained an education that afforded them
\nthe wisdom and knowledge to rule. And
\nyears later, the English writer Harold Wal-
\npole coined the word \u201cserendipity\u201d based
\non these stories. He noted that when the
\nprinces travelled, they were always mak-
\ning discoveries and developing the ability
\nto link together seemingly unrelated facts
\nto come to a valuable conclusion. Louis
\nPasteur, the French chemist and microbi-
\nologist, said it this way:\u201dChance favors the
\nprepared mind.\u201d
\nOur consideration of the proximate causes
\nof non-communicable diseases\u00a0\u2013 tobacco,
\nobesity, alcohol\u00a0 \u2013 has led to the in some
\nways serendipitous understanding that
\nthere are equally important causes of the
\ncauses\u00a0 \u2013 root causes. These causes of the
\ncauses are social determinants of health\u00a0\u2013
\nthe conditions in which people are born,
\ngrow, live, work and age, and the soci-
\netal influences on these conditions. They
\nare major influences on both quality of
\nlife, including good health, and length of
\ndisability-free life. For example: in many
\nsocieties, unhealthy behaviors are higher
\nin people on the lower end of the social
\ngradient. The lower they are in the socio-
\neconomic hierarchy, the more they smoke,
\nthe worse their diet is and the less physi-
\ncal activity they engage in\u00a0\u2013 thus, putting
\nthem at increased risk of non-communica-
\nble disease. Lower levels of education have
\nthe same effect\u00a0 \u2013 increased risk of non-
\ncommunicable disease. Another example
\n163
\nWMA news
\nis that price and availability are key driv-
\ners of alcohol consumption and smoking.
\nThe excellent scientific session we enjoyed
\nyesterday asked the question Megacity \u2013
\nMegahealth?,illustrating another aspect of
\nsocial determinants of health. We are in-
\ndebted to the work of the Council member
\nSir Michael Marmot and his colleagues
\nfor giving understanding and international
\nvisibility to this important subject. For
\ngovernments, understanding this concept
\nmeans that all policies need to be evalu-
\nated as to their effects on the health of its
\ncitizens. Therefore, not just one designated
\nminister of health, all ministers are health
\nministers. And the medical profession has
\na valuable role to play in seeking action on
\nthese social conditions, the causes of the
\ncauses that have such important effects on
\nhealth.
\nMy third point: global warming with its
\naccompanying climate change, and its ac-
\ncompanying extremes of weather is already
\nhaving and will continue to have signifi-
\ncant health effects. Although governments
\nand international organizations have the
\nmain responsibility for creating regulations
\nand legislation to mitigate the effects of
\nclimate change the WMA feels an obliga-
\ntion to highlight the health consequences
\nand suggest solutions. Over the past two
\ndecades extreme heat events have killed
\ntens of thousands around the globe. Heat
\nwaves are becoming more frequent, of lon-
\nger duration and more intense. Heat waves
\ncan cause illness and death from heart dis-
\nease, diabetes, stroke, respiratory disease
\nand even accidents, homicide and suicide.
\nAt the same time increased evaporation
\narising from warming seas is generating
\nheavier downpours increasing flooding and
\nwater-borne disease outbreaks when flood-
\ning overwhelms sewer systems and con-
\ntaminates drinking water. Warmer winters
\nfavor insect migration. In the past decade
\nin the state of Maine in the US reports
\nof tick-borne Lyme disease not only rose
\nten-fold but parts of the state experienced
\nLyme for the first time. Worldwide the ef-
\nfect may be mixed for Malaria. In some re-
\ngions the geographical range will contract
\nand in others expand, and the transmis-
\nsion season may be changed. Worldwide
\ndisruption of the food supply is predicted
\nto increase malnutrition and subsequent
\ndisorders. Social and health inequalities
\ndue to possible desertification, natural di-
\nsasters, changes in agriculture, feeding and
\nwater policy will have consequences on
\nboth human health and human resources
\nin health and disproportionately affect de-
\nveloping countries.
\nPhysicians have a role to play to: encourage
\nadvocacy for environmental protection, re-
\nduction of greenhouse gas production and
\nsustainable development of green adapta-
\ntion practices; work to improve the abil-
\nity of patients to adapt to climate change
\nand catastrophic weather events;work
\nwith others to educate the general pub-
\nlic about the important effects of climate
\nchange on health and the need to mitigate
\nclimate change and adapt to its effects;
\nwork with others, including governments,
\nto address the gaps in research regarding
\nclimate change and health. As individu-
\nals act to minimize their impact on the
\nenvironment and to call all upon govern-
\nments to strengthen public health systems
\nin order to improve the capacity of com-
\nmunities to adapt to climate change.All of
\nwhich brings to mind an ancient Chinese
\nproverb: \u201cWhen is the best time to plant a
\ntree,\u201d asks a young student, sitting in the
\nhot sun with his teacher. \u201cTwenty years
\nago,\u201d replies the teacher. The young boy,
\nfeeling a drop of sweat run down his cheek
\nasks,\u201dWell, then when is the second best
\ntime?\u201d \u201cNow!!\u201d intoned the teacher. Now.
\nNow is the time.
\nFifty years ago\u00a0\u2013 doesn\u2019t seem that long\u00a0\u2013
\nthe US President John F. Kennedy gave
\na speech at Rice University in Houston.
\nKennedy spoke of the conquest not only
\nof physical and technological barriers, but
\npsychological ones. He said: \u201cWe choose to
\ngo to the moon in this decade and do the
\nother things, not because they are easy, but
\nbecause they are hard.Because that goal will
\nserve to organize and measure the best of
\nour energies and skills. Because that chal-
\nlenge is one we are willing to accept, a chal-
\nlenge we are unwilling to postpone. And
\none we intend to win.\u201d
\nEthics, non-communicable disease, climate
\nchange. So, is the job difficult? Yes.
\nIs the path long and winding? Absolutely. Is
\nsuccess assured? Absolutely not.
\nAll the more reason to embrace it. And our
\nsuccess or lack of success depends in the end
\non our attitude.
\nThe American industrialist Henry Ford
\nsaid: \u201cIf you think you can,if you think you
\ncannot,you are right.\u201d From India, Ma-
\nhatma Gandhi said it this way: \u201cMan often
\nbecomes what he believes himself to be. If
\nI keep on saying to myself that I cannot do
\na certain thing, it is possible that I may end
\nby really becoming incapable of doing it.
\nOn the contrary, if I have the belief that I
\ncan do it, I shall surely acquire the capac-
\nity to do it even if I may not have it at the
\nbeginning.\u201dAs physicians, we are joined by
\nour common contract with humanity. We
\nreach out to the sick, the disabled and the
\nchronically ill.
\nSuffering knows no language, and eas-
\ning pain, finding treatments, developing
\ncures\u00a0\u2013 know no borders. Working togeth-
\ner we can create the future of medicineTo-
\ngether, we can open new doors, share new
\ninsights, find new cures, prevent disease
\nand help our patients the world over to live
\nhealthier, happier, longer, more productive
\nlives.
\nI look forward to that.
\nThank you.
\n164
\nWMA news
\nI will start by greeting and thanking you,
\nall delegates from the medical associa-
\ntions, who gave me the privilege and the
\nhonor to represent the WMA. I thank the
\nWMA Officers: the immediate Past Presi-
\ndent, Wonchat Subhachaturas, and all our
\nformer Presidents; the Chairman of the
\nCouncil, my dear friend Mukesh Haik-
\nerwal; the Vice-Chairman, Masami Ishi;
\nour treasurer, Frank-Ullrich Montgomery;
\nthe Chairmen of our Standing Commit-
\ntees,Thorunn Jambu, Michael Marmot and
\nLeonid Eidelman. All the members of the
\nCouncil\u2026 Our always present Secretary
\nGeneral, the bright counselor and friend,
\nOtmar Kloiber.\u00a0
\nThe friends we have in the extraordinary
\nand competent WMA staff: Yoonsun \u201cSun-
\nny\u201d Park, Roderik Dennett, Lamine Smaali,
\nClarice Delorme, Anne-Marie \u201cAnna\u201d
\nDelage, Julia Seyer, Adolph Hallmayr and
\nAnnabel Seebohm; P\u0113teris Apinis and Ni-
\ngel Duncan.Also a very special warm greet-
\ning to Joelle Balfe. Our dear interpreters:
\nthank you so much!
\nMy dear Friends and Colleagues,
\nI will talk about a long journey from Mon-
\ntevideo on the Atlantic Ocean to Bangko,
\non the Pacific Ocean.
\nSince Montevideo (Uruguay), October
\n2011, I have faced an extensive agenda,
\nwhich gave me the opportunity to experi-
\nence the reality of medical practice, prob-
\nlems and accomplishments of many of the
\npresent day more than one hundred Na-
\ntional Medical Associations that form our
\nWorld Medical Association. Just after tak-
\ning over the Office, our first commitment
\nwas to take part in the Social Determinants
\nof Health at the International Conference
\nin Rio de Janeiro (Brazil).
\nAt that time, we talked about the impor-
\ntance of finding a solution for the social
\ninequalities seen in both wealthy and de-
\nveloping countries. Those inequalities are
\nthe main factor responsible for the level
\nof health of our populations. They refer to
\nthe conditions in which people are born
\nand grow up, the differences in education,
\nopportunities and working conditions, and
\nto the conditions how people are ageing.
\nThere,we emphasized the importance of the
\nrole of Physicians in this field. In addition
\nto assisting people in need, the profession
\nincludes interventions in the factors that
\ncause poor health. In Chihuahua (Mexico),
\nlast November, we offered solidarity to our
\nMexican colleagues at the Assembly of the
\nMexican Medical College, where the issue
\nwas the response to violence against health
\nprofessionals related to the drug trafficking
\nwar, particularly in the city of Juarez. There,
\nI could see the many aspects of insecurity
\ndoctors face in many areas around the world.
\nSeveral National Medical Associations from
\nLatin-American Nations met on November
\n19 in Panama City (Panama). Among the
\nproblems that threaten the quality of medi-
\ncal attention and, especially, Medicine, I ob-
\nserved the repeated political interferences
\nin medical organizations, mainly in Bolivia
\nand Venezuela. In Bolivia, the government
\ntried to dismantle the medical profession
\nand\u00a0to regulate it themselves. They also de-
\ncided on ethical issues and technical com-
\npetences that qualify different specialties.
\nThe main goal of the Bolivian government
\nis to fully control the profession.
\nStill in November, in Porto (Portugal), we
\nmet Portuguese medical students in order
\nto discuss the European economic crisis
\nviewed from the stand point of young doc-
\ntors in a continent that is going through
\nmajor challenges. This January and Febru-
\nary, in S\u00e3o Paulo (Brazil), at the headquar-
\nters of the Medical Association of the State
\nof S\u00e3o Paulo and in Rio de Janeiro (Brazil),
\nwe subscribed and announced\u00a0 the world-
\nwide campaign for 2012\u00a0\u2013 \u201cGlobal Appeal\u201d
\nagainst the discrimination faced by persons
\naffected by leprosy, a neglected disease that
\nstill affects hundreds of thousands of people
\nin different regions of the world.
\nOne year after the earthquake followed by
\na tsunami and a nuclear accident in Japan,
\non March 11, 2012, we were in Tokyo (Ja-
\npan) to discuss with our colleagues from
\nthe Japanese Medical Association about the
\nWMA \u201cMontevideo Declaration\u201d, which
\ndeals with the role of the medical asso-
\nciations and the physicians in response to
\ndisaster situations. The successful mobili-
\nzation of Japanese physicians around that
\nkey issue gives us a picture of the enormous
\nbenefits of readiness in decreasing the im-
\npacts of catastrophic events less and less in-
\nfrequent in people\u2019s lives.
\nIn April this year, in Taipei (Taiwan), at
\nthe opening of the 20th
\nInternational Con-
\nference on Health Promoting Hospitals,
\nI\u00a0addressed the role of hospitals and health
\nservices in the promotion of health and in
\ntackling the social determinants of health.
\nDuring that same event, we actively partici-
\nValedictory address
\nJos\u00e9 Luiz Gomes do Amaral,
\nPresident of the World Medical Association
\nJos\u00e9 Luiz Gomes do Amaral
\n165
\nWMA news
\npated in the meeting \u201cHealth without Dan-
\nger\u201d,which was oriented to the management
\nprocesses in health institutions and to envi-
\nronment preservation. More and more, the
\nenvironmental impact of modern hospitals
\nhas been capturing the attention of society.
\nIn Ankara and Istanbul (Turkey), also last
\nApril, WMA was represented by the Presi-
\ndent and by the Chairman of the Council
\nfor the mediation between physicians and
\na parliamentary group in that country in
\nregard to a crisis caused by a decree which
\nbrutally restricted the independency and the
\nauthority of doctors for professional ethics
\nand technical self-regulation.\u00a0 The increas-
\ning animosity of the Turkish government
\ntowards the medical profession created a
\nhostile environment for health profession-
\nals, generating serious situations: Physicians
\nwere blamed for the consequences of the
\nerroneous public system, and the dissemi-
\nnation of false information on the lack of
\ndoctors had been used as a justification to
\n\u201cimport\u201d physicians from neighbouring
\ncountries. The climax of the crisis was the
\nmurder of a 30-year-old doctor, followed
\nby demonstrations all over the country. In
\nIstanbul, as the president of WMA, I par-
\nticipated in a manifestation with more than
\n20 thousand doctors, bringing the city of
\nIstanbul into a halt and raising a popular
\noutcry as an extension of that tragedy.
\nOn April 23rd
\n, in London (England), Presi-
\ndents of WMA and its Council took part
\nin the meeting \u201cHealth Care in Danger\u201d, an
\ninitiative that gathers organizations such as
\nWorld and British Medical Associations,
\nInternational Red Cross\/Crescent and
\nDoctors without Borders on the growing
\nwave of violence against health profession-
\nals in civil and military conflicts in several
\nregions of the world such as Somalia, Libya,
\nEgypt, Bahrain, Syria, Iraq, Afghanistan,
\nIsrael, Mexico, Colombia.\u00a0 At that time, we
\npresented the WMA\u2019s position in the field
\nof ethics and medical neutrality in situations
\nof conflict. Physicians and other medical
\nprofessionals have been arrested,kidnapped,
\ntortured and murdered in retaliation for as-
\nsisting people that eventually belonged to
\nan opposing group. Hospitals have been
\nbombed and invaded. Such incidents have
\ninterrupted humanitarian actions, causing
\nthe withdrawal of voluntary teams to whom
\nsecurity cannot be provided, and leaving a
\ngreat amount of unassisted people behind.
\nAt the end of April,more precisely from the
\n24th
\nto the 29th
\n, many of us were together
\nwhen the Council Meeting of the World
\nMedical Association took place in Prague,
\nthe Czech Republic.\u00a0 In addition to the
\nissues already mentioned before, other im-
\nportant ones such as the review of the Dec-
\nlaration of Helsinki were addressed.
\nIn Geneva (Switzerland), this last May, at
\nthe WHO Assembly, we confirmed our
\npartnership with WHPA and we discussed
\nthe economic crisis and health care. We
\nhosted the traditional \u201cWMA Luncheon\u201d,
\nwhich had the United States Secretary of
\nHealth and Human Services,the Honorable
\nKathleen Sybelius as a lecturer,and counting
\non the presence of Health Ministers from
\nmany countries. Last July, I took part in the
\nSymposium \u201cHealthcare systems in times of
\ncrisis _ Protect the Present\u00a0\u2013 Build the Fu-
\nture\u201d: a debate in Lisbon (Portugal) with the
\nPortuguese health authorities and Michael
\nPorter from Harvard Business School about
\nthe quality of care and the opportunities in
\ntimes of economic difficulties.
\nThe value of a profession can be measured
\nnot only through the reputation of its mem-
\nbers, the quality of the services they provide
\nto their people,and their many contributions
\nto Science, but also through\u00a0their capacity to
\norganize and support other organizations. I
\nalso had the privilege of attending the As-
\nsemblies of the German Medical Associa-
\ntion, last May, in Nurnberg (Germany), the
\nAmerican Medical Association, last June
\nin Chicago (United States), and, in Bour-
\nnemouth (England), the British Medical
\nAssociation Assembly.In each of those occa-
\nsions,I could express to them our deep grati-
\ntude on behalf of the millions of doctors in
\nthe other 100 National Medical Associations
\nwhich integrate the World Medical Associa-
\ntion. In August, CONFEMEL gathered in
\nLima (Peru). This meeting gave me another
\nopportunity to talk about the many reasons
\nwhy they should strengthen the participa-
\ntion of Latin-American countries in WMA.
\nIn Madrid (Spain), last September, the main
\nsubject under discussion was medical atten-
\ntion to immigrants and the different regula-
\ntions in several European countries. Finally,
\nlast September in Tiberias (Israel) on the Sea
\nof Galilee, with Yoran Blachar and Leonid
\nEidelman, we discussed the possibilities of
\nnew partnerships with\u00a0UNESCO in an edu-
\ncational program on medical ethics.
\nDear Friends and Colleagues,
\nBefore leaving, I would like to share with
\nyou a Guarani (South American Indian
\nethnic group) story: Nhanderuvu\u00e7u, the
\nGreat Father, announced that the world
\nwould perish because of men\u2019s iniquity, and
\nordered the sorcerer Guiraypoty\u00a0to pray.The
\nEarth was then got out of the ties that hung
\nit in the sky and fire spread out, forcing
\nGuiraypoty and his tribe to flee toward\u00a0the
\nEast.They started a very long and hard jour-
\nney, nowadays known as the Peabiru way, an
\nancient Indian route that linked the Pacific
\nand the Atlantic Oceans, from Peru to S\u00e3o
\nPaulo.They finally reached, at heaven\u2019s door,
\nthe \u201cyvy mar\u00e3 ei\u201d,which means \u201ca land with-
\nout evilness\u201d, a land with no suffering where
\npeople never get sick, old or die.
\nIn 1947, just after the miseries of World
\nWar II, the millions of doctors represented
\nherein started a long journey, crossing land
\nand ocean. We have completed our path, our
\n\u201cPeabiru\u201d, always praying for\u00a0good standards
\nin medical care,\u00a0standing for human rights
\nin health, and looking for a healthy land of
\nequal opportunities, solidarity and\u00a0 justice.
\nDear Cecil Wilson, now it is your turn to
\nlead us and light our way.
\nI am ready to follow you.
\nThank you very much.
\n166
\nWMA news
\nWednesday October 10
\nDelegates from more than 50 national med-
\nical associations met at the Centara Grand
\nHotel Convention Centre, Bangkok, Thai-
\nland for the 63rd
\nannual General Assembly
\nof the World Medical Association from
\nOctober 10 to 13.
\nCouncil Session
\nThe proceedings of the 192nd
\nCouncil ses-
\nsion were opened by Dr. Mukesh Haikerwal,
\nChair of the WMA, and delegates were wel-
\ncomed by Dr.Wonchat Subhachaturas,Pres-
\nident of the Medical Association ofThailand.
\nDr. Haikerwal reported on recent events he
\nhad attended,including a meeting in Algiers
\nof the Maghreb group of medical associa-
\ntions, including Tunisia, Morocco and Al-
\ngeria. He said it was an important meeting
\nto go to as the WMA had little presence
\nin North Africa or the Gulf. It was a good
\nmeeting to start extending the spread of the
\nWMA to organisations that were not part of
\nthe Association. The meeting also received
\nan oral report from the Vice Chair of Coun-
\ncil, Dr. Masami Ishii, who spoke about the
\ncholera alert in the Middle East and the ef-
\nfect of pilgrims going to Saudi Arabia.
\nThe President, Dr. Jos\u00e9 Luiz Gomes do
\nAmaral, spoke about the many events he
\nhad attended around the world during the
\nyear, including the annual meetings of the
\nGerman, American and British Medical
\nAssociations. At a meeting in Israel he had
\ndiscussed the possibilities of a new partner-
\nship with UNESCO on an educational pro-
\ngramme on medical ethics.
\nDr. Otmar Kloiber, Secretary General, sub-
\nmitted a detailed written report from the
\nsecretariat to the Assembly about the general
\nactivities of the Association. In his oral com-
\nments to Council he said that the WMA
\nhad been very successful in the last eight
\nyears in increasing the amount of financ-
\ning for projects through sponsorship, but in
\nthe current financial crisis this was getting
\ntougher. Funds were being restricted and
\nmore targeted. He thanked those organisa-
\ntions still sponsoring the Association, as well
\nas national medical associations (NMAs)
\nthat had offered help to the WMA, either
\nthrough advice, staff support or other activi-
\nties.He said that for the first time the WMA
\nhad received sponsorship from the World
\nHealth Organisation for transforming one of
\nthe WMA\u2019s educational programmes on TB
\ncontrol into a more mobile device.
\nHe also reported that grants were available
\nthrough the World Health Professions Al-
\nliance for the counterfeit medicines cam-
\npaign. Member organisations that com-
\nbined together from different countries and
\ndifferent professions would be eligible to
\napply for a grant.
\nTwo emergency motions were then present-
\ned to Council.
\nMinimum Unit Price for Alcohol
\nDr. Vivienne Nathanson (British Medical
\nAssociation) said that several legislatures,
\nincluding Scotland, had either passed or
\nwere considering passing a law to enable
\nthem to set a minimum unit price for al-
\ncohol. It was believed this would make a
\nsignificant difference to drinking levels.
\nUnfortunately a number of governments,
\nparticularly within Europe, were trying to
\noppose the right of these governments to
\nset a unit minimum price,saying it was a re-
\nstraint on trade. In many countries, includ-
\ning the United Kingdom, there was a seri-
\nous misuse of alcohol and the government
\nwas trying to take an evidence based public
\nhealth approach and was being stopped by
\nother governments.
\nCouncil agreed that this was an urgent mat-
\nter and should be considered by the Social
\nMedical Affairs Committee.
\nCigarette Packaging
\nDr. Nathanson also presented an emer-
\ngency motion on plain cigarette packaging
\nand said this was about to come into force
\nin Australia. But there were legal challenges
\nfrom the tobacco industry. Many govern-
\nments around the world were watching
\nAustralia and it was important that the pro-
\nfession showed that it supported all moves
\nto reduce the consumption of tobacco.
\nCouncil again agreed that this was an ur-
\ngent matter and should be considered by the
\nSocial Medical Affairs Committee.
\nThe Council meeting was then suspended
\nfor the committee meetings to take place.
\nMedical Ethics Committee
\nThe Medical Ethics Committee met with
\nDr.Torunn Janbu in the Chair.
\nDeclaration of Helsinki
\nDr. Ramin Parsa-Parsi, chair of the Work-
\ngroup on revising the Declaration, reported
\non progress. He spoke about preparations
\nfor two expert conferences in Cape Town,
\nSouth Africa in December and in Tokyo,
\nJapan in February. After these, the Work-
\ngroup would meet to consider a first draft of
\nthe revised Declaration to put to the Coun-
\ncil meeting in April 2013. This would be
\nfollowed by a public consultation until June.
\nDr. Jeff Blackmer (Canada) summarised the
\ncomments received from 21 organisations,
\nincluding eight NMAs,about what the main
\nthemes of the revision should be. These co-
\nalesced around insurance compensation and
\nprotection of research subjects,the use of un-
\nproven interventions, the issue of broad con-
\nsent and medical research involving children.
\nWMA General Assembly
\n63rd
\nWorld Medical Association General Assembly, Bangkok,Thailand, October 2012
\n167
\nWMA news
\nDongchun ShinA. Hallmayr Torunn JanbuLeonid Eidelman Ramin Parsa-Parsi Vivienne Nathanson
\nWonchat Subhachaturas
\nFrank Ulrich
\nMontgomeryMukesh Haikerwal Masami Ishii Sir Michael MarmotMargaret Mungherera
\nAnne-Marie DelageAnnabel SeebhomSunny Park Clarisse DelormeJeff Blackmer Nigel Duncan
\nThe committee then received an oral report
\nfrom the WMA\u2019s medical ethics adviser on
\nthe Declaration, Professor Urban Wiesing
\nfrom the University of Tuebingen in Ger-
\nmany, about a first possible draft of para-
\ngraph 32 of the Declaration concerning the
\nuse of placebo control. He gave a history of
\nprevious changes to paragraph 32 and the
\ncriticisms that each change had provoked.
\nHe explained why the Workgroup was now
\nproposing a more systematic approach.
\nIn a brief debate that followed Dr. Peter
\nCarmel (American Medical Association)
\ncongratulated Prof. Wiesing on his presen-
\ntation. He said that the longer the Decla-
\nration was the more involved the explana-
\ntions, the higher the number of exceptions
\nthat were included and the loss of precision
\nthat was the basis of a universal statement.
\nDr. Jon Snaedal (Iceland) agreed that sat-
\nisfactory progress was being made and the
\nright balance was being struck.
\nMedical Ethics and Advanced Technology
\nRevisions to the Declaration on Medi-
\ncal Ethics and Advanced Technology were
\ndebated and a discussion took place about
\nwhether the document should refer to \u2018pa-
\ntients\u2019 or \u2018persons\u2019. It was decided to use the
\nword\u2019persons\u2019and to recommend forwarding
\nthe document to the Assembly for adoption.
\nSafe Injections in Health Care
\nThe committee considered a proposed revi-
\nsion of the 2002 WMA Statement on Safe
\nInjections in Health Care and after sev-
\neral members proposed amendments it was
\nagreed that the document should be referred
\nback to undergo further minor revision.
\nWomen\u2019s Right to Care
\nDr.Mark Sonderup (South Africa) reported
\nthat the proposed Statement on Women\u2018s
\nRight to Health Care and How that Re-
\nlates to the Prevention of Mother-to-Child
\nHIV Infection was in the process of being
\ncirculated to regional NMAs and a further
\nreport would be made to the next Council
\nmeeting in Bali in April 2013.
\nPerson Centred Medicine
\nDr. Snaedal introduced a proposed State-
\nment on Person Centred Medicine. He said
\nNMAs had commented on the Statement,
\none suggesting that it should be divided in
\ntwo, and another that the document was
\n168
\nWMA news
\ntoo general in nature and needed to be more
\nspecific. Dr. Kloiber said that progress on
\nthis issue had been very interesting because
\nthe WMA had achieved bridging together
\ntwo concepts, the patient centred approach
\nthat most NMAs had fostered for curative
\nmedicine and the more people centred ap-
\nproach of the WHO. The WHO had now
\njoined with the WMA and others in trying
\nto develop the debate and it was important
\nthat the WMA continued to be involved.
\nThe committee agreed that the Statement
\nneeded further consideration before being
\nrecirculated among NMAs.
\nEuthanasia
\nDr. Janbu said that the WMA Resolution
\non Euthanasia was now 10 years old and
\nshould be reviewed. But there was also a
\nDeclaration on Euthanasia which was not
\nsubject to review at this time. The commit-
\ntee decided that the Resolution should un-
\ndergo a minor revision by the secretariat.
\nDeath Penalty
\nDr. Parsa-Parsi (Germany) presented a pro-
\nposed Statement, jointly submitted by the
\nGerman Medical Association, the Norwe-
\ngian Medical Association and the French
\nConseil National de L\u2019Ordre des M\u00e9decins,
\nthat the WMA should support a United
\nNations General Assembly Resolution call-
\ning for a moratorium on the use of the death
\npenalty. He thanked the WMA Workgroup
\nwhich had been set up to consider the ethi-
\ncal issues of capital punishment and had
\nproduced a paper. But it was not enough
\nto simply ask physicians not to participate
\nin capital punishment. The practice of the
\ndeath penalty itself needed to be addressed.
\nHe acknowledged the different views and
\nbeliefs prevalent in the countries of NMA
\nmembers, therefore the proposed Statement
\ndid not ask for a complete abolition of the
\ndeath penalty, but rather a universal mora-
\ntorium or a temporary suspension of the use
\nof the death penalty by all states.There were
\nmany compelling reasons for supporting
\na moratorium. There was, for instance, no
\nconclusive evidence that the death penalty
\nhad any additional value as a deterrent. Also
\na miscarriage of justice could never be com-
\npletely ruled out.
\nBut several delegates from the USA spoke
\nout against the proposal. Dr. Cecil Wilson,
\nChair of the Workgroup on capital punish-
\nment, said the group had already decided to
\nrecommend to the Assembly that as citizens
\nphysicians had the right to form their own
\nviews on capital punishment. He said there
\nwas a separation between what they did as
\nphysicians and what they might decide as
\nnon-physicians. Dr. Peter Carmel (Ameri-
\ncan Medical Association) said it would be
\npremature to circulate the new proposed
\nStatement before the Assembly had con-
\nsidered the Statement from the Workgroup.
\nBut Dr. Snaedal said that the moratorium
\nproposal should be circulated because it was
\nimportant that physicians addressed this is-
\nsue. Dr. Nathanson also thought the issue
\nshould be circulated.
\nThe committee agreed by 10 votes to four
\nwith two abstentions to recommend to
\nCouncil that the proposal for a moratorium
\nbe circulated to NMAs.
\nHuman Rights
\nClarisse Delorme, the WMA\u2019s Advocacy
\nAdvisor, reported on two current issues that
\nhad arisen since the written report on human
\nrights had been submitted. The first related
\nto Professor Cyril Karabus, a South African
\npaediatrician, who was in jail in Abu Dhabi
\nfollowing his arrest on a charge of man-
\nslaughter relating to the death of a child un-
\nder his care in the United Arab Emirates 10
\nyears ago. The second concerned the health
\nprofessionals who had been convicted and
\nimprisoned in Bahrain on charges following a
\npublic demonstration. She told the commit-
\ntee that on both cases the WMA had taken
\naction by writing to the respective authorities.
\nDr. Mark Sonderup (South Africa) thanked
\nthe WMA for its assistance on Professor
\nKarabus, and said the South African Medi-
\ncal Association would like to submit an
\nemergency motion later in the meeting.
\nClinical trials
\nProfessor Andr\u00e9 Herchuelz (Belgium)
\nraised the issue of a European Commission
\ndraft regulation that had been published in
\nJuly regulating clinical trials in Europe.This
\nhad omitted all reference to prior approval
\nby ethical committees which would have
\nthe effect of reducing the protection of pa-
\ntients. Dr. Kloiber said that the WMA was
\naware of the document, which he said was a
\nlegal document, and it was planning to sub-
\nmit a response shortly.
\nFinance and Planning Committee
\nThe Finance and Planning Committee met
\nwith Dr. Leonid Eidelman in the chair.
\nHe opened the proceedings by saying that
\nthe WMA had had a sound financial year
\nand had been able to fulfil its goals and still
\nstay in a good financial position.
\nFinancial Statement
\nThe committee considered and approved
\nthe audited financial statement for 2011
\nand agreed that it should be sent to Council
\nand the Assembly for adoption.
\nBudget for 2013
\nMr Adi H\u00e4llmayr, the Financial Adviser,
\npresented the proposed budget for 2013 and
\nsaid the WMA had not had any exposure
\nto financially risky investments. The policy
\nwas to protect the Association\u2019s assets. He
\nexplained the details of the Association\u2019s in-
\ncome and expenses.The Budget was adopted.
\nMembership Dues
\nThe committee received the report on
\nmembership dues payments for 2012 and
\nMr H\u00e4llmayr reported on dues arrears.
\nDr. Kloiber spoke about the task of stabilis-
\ning the dues, the baselines for payments and
\nallowing some countries to pay by instal-
\n169
\nWMA news
\n170
\nWMA news
\nments. The committee received the report,
\nwhich was forwarded to the Assembly for
\ninformation.
\nDeclaration of Helsinki 50th
\nAnniversary
\nDr. Eidelman, in his capacity as Chair of
\nthe Workgroup on the 50th
\nanniversary of
\nthe Declaration of Helsinki, reported on
\nplans for celebrating the anniversary in
\n2014. He said the goal should be to in-
\ncrease the visibility of the Declaration and
\nstrengthen the ownership of the WMA of
\nthe ethical principles on the experimenta-
\ntion on humans. Among the ideas being
\nconsidered were the holding of a major
\nevent in Helsinki in 2014, simultaneous
\nnational and regional events around the
\nworld on World Medical Ethics Day in
\nSeptember 2014, articles by NMAs for the
\nmedia, a survey of NMAs about the influ-
\nence of the Declaration and a book on the
\nhistory of the document.
\nStrategic Plan 2013\u20132015
\nDr.Robert Ouellet,Chair of the Workgroup
\non the Strategic Plan, gave a progress report
\non the strategic plan. He said the process
\nwhich had been going on for some years
\nhad now reached its conclusion. NMAs had
\ncommented on the draft plan. A list of 38
\nstrategic initiatives had been agreed and
\nmany were now being implemented.
\nDr. Kloiber said that four themes of the
\nplan had been identified as of particular im-
\nportance\u00a0\u2013 ethics, advocacy and representa-
\ntion; partnerships and collaboration; com-
\nmunication and outreach; and operational
\nexcellence. He detailed the plans for tack-
\nling 20 initiatives that had been highlighted
\nfor immediate action.
\nThe committee agreed to forward the Plan
\nto Council to be adopted by the Assembly.
\nBusiness Development
\nMr Tony Bourne,Chair of the Business De-
\nvelopment Group, reported on progress in
\ndeveloping a WMA roundtable of commer-
\ncial and non-commercial organisations who
\nwanted to develop a closer relationship with
\nthe Association. He said this would not be
\nrevenue producing,but it would be cost cov-
\nering.The Group had developed draft terms
\nof reference to govern the roundtable and
\nhad drawn up a short list of possible partici-
\npants. These would be finalised and he said
\na report would be given to the next Council
\nmeeting in Bali in April 2013.
\nDisaster Preparedness and Medical
\nResponse
\nDr. Miguel Roberto Jorge, Chair of the
\nWorkgroup, gave an oral report on disaster
\npreparedness, saying that a questionnaire
\nbased on the Declaration of Montevideo
\nhad been prepared for NMAs. This related
\nto what initiatives should be undertaken.
\nThe summarised responses would be pre-
\nsented to the next Council meeting in Bali
\nfor further discussion.
\nFuture WMA Meetings
\nThe committee considered arrangements
\nfor future WMA meetings. Invitations
\nhad been received from Argentina, Co-
\nlumbia, Taiwan and Russia to meet in
\ntheir countries in 2015 and the com-
\nmittee heard presentations from Argen-
\ntina, Taiwan and Russia. It recommended
\npostponing any decision until the Council
\nmeeting in Bali.
\nGreening of Meetings
\nThe committee received an oral report
\nfrom Dr. Mads Koch Hensen, Chair of the
\nWorkgroup on Greening of WMA meet-
\nings. He highlighted what had been done
\nsince the Council meeting in Sydney by way
\nof reducing the use of paper at meetings,
\nopening a new green page on the WMA
\nwebsite and assisting people to share airport
\ntransportation.
\nMembership
\nA request was received from Romania for a
\nchange in membership. The committee rec-
\nommended to Council that the Romanian
\nMedical Association should be replaced by
\nthe Romanian College of Physicians.
\nRelations with World Veterinary
\nAssociation
\nThe committee received a report on a pro-
\nposed Memorandum of Understanding
\nwith the World Veterinary Association. Dr.
\nCecil Wilson said that one of the realities
\nof the world was that whether their pa-
\ntients walked on two legs or four legs phy-
\nsicians and veterinarians shared two-thirds
\nof all the world\u2019s diseases. It was therefore
\ncritical for the two professions to work to-
\ngether. The Memorandum of Understand
\nset out the principles under which the two
\norganisations would co-operate.
\nSocio-Medical Affairs Committee
\nThe Socio-Medical Affairs Committee met
\nwith Sir Michael Marmot in the chair.
\nHealth and the Environment
\nDr. Dongchun Shin (Korea) reported on a
\nmeeting of the Environment caucus earlier
\nin the day. He said the meeting had discussed
\nthe outcome of the UN Conference on Sus-
\ntainable Development and the outcome of the
\nthird session of the International Conference
\nonChemicalsManagement.Inadditionithad
\nconsidered the promotion of green hospitals
\nand sustainable transport.He said the NMAs
\nwere invited to share their experiences on
\nthe environment page of the WMA website.
\nSocial Determinants of Health
\nSir Michael Marmot reported that the
\nWMA and the International Federation of
\nMedical Students had held a successful side
\nevent at the World Health Assembly where
\nparticipants had discussed how physicians
\nand medical students could get engaged in
\nthe issue of social determinants.Two NMAs,
\nfrom Britain and Canada, had produced
\ninitiatives on this, preparing position state-
\nments on how doctors could get involved.He
\nsaid it was planned to present a paper on this
\nissue to the next meeting of Council.
\nHealth Care in Danger
\nDr. Nathanson, Chair of the Workgroup
\non Health Care in Danger, reported on
\n171
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\n172
\nWMA news
\nhow the group was supporting the cam-
\npaign of the International Committee
\nof the Red Cross on the issue of protect-
\ning health care in areas of armed conflict.
\nThe Workgroup had agreed to work on an
\nethics toolkit to mirror an ICRC publica-
\ntion on ethics law for doctors working in
\nconflict situations. It would assist WMA
\nspeakers with slides for use in presenta-
\ntions and NMAs with advocacy materials.
\nIt had also agreed to work with the World
\nPsychiatric Association on examining ex-
\nisting evidence on reducing violence in the
\nhealth care workplace and it would moni-
\ntor the WHO\u2019s activities.
\nEthical Implications of Physician Strikes
\nLeah Wapner (Israel) reported on the activ-
\nities of the Workgroup on physician strikes.
\nThe Israeli Medical Association had put
\nforward a proposed Statement on this issue
\nat the last Council meeting. She presented
\na revised document, recognising that some
\nNMAs did not have responsibility for trade
\nunion issues. But she said that at least half
\nthe NMA members were involved with ne-
\ngotiations and every NMA was involved in
\ndoctors\u2019 working conditions in some way or
\nanother. The proposed Statement had been
\nrevised to focus on the ethical principles
\nthat should be faced by NMAs and physi-
\ncians once they had decided to engage in
\nindustrial action.
\nDr. Janbu (Norway) thought the paper was
\nstill an unfortunate mix of ethical consider-
\nations and trade union issues.It also dealt with
\nmatters that were regulated by national laws.
\nDr. Jon Snaedal (Iceland) said this was a con-
\ntroversial document which should now been
\nsent out for consideration by NMAs. But Dr.
\nFrank Ulrich Montgomery (Germany) asked
\nhow a document such as this could be written
\nwithout mixing up ethical and trade union is-
\nsues. He thought this was a good document.
\nDr. Konstanty Radzwill, President of the
\nStanding Committee of European Doctors,
\nalso supported the Statement as a balanced
\ndocument, which on the one hand showed
\nthe responsibility of the profession and on
\nthe other hand reminded doctors to re-
\nmember their patients when protesting.
\nDr. Heikki P\u00e4lve (Finland) said doctors
\nshould have the right to strike, but they
\nshould not strike to achieve political goals.
\nPhysicians should carry out protest actions
\nonly to improve their working conditions
\nand should not strike about patient care
\nbecause that was for politicians to decide.
\nThe committee decided to recommend to
\nCouncil that the document should be circu-
\nlated for further consideration.
\nMs Wapner said this was a matter of ur-
\ngency because with so many NMAs taking
\nstrike action it was inconceivable that the
\nWMA had no policy on the issue.
\nForced Sterilisations
\nDr. Nathanson presented a proposed State-
\nment on Forced and Coerced Sterilisation
\nthat had been submitted by the British
\nMedical Association and had been circulat-
\ned for comments. Several friendly amend-
\nments were suggested and agreed.The com-
\nmittee recommended that the Statement
\nshould be forwarded to Council for adop-
\ntion by the Assembly.
\nPrioritisation of Vaccination
\nDr.Claire Camilleri (Irish Medical Associa-
\ntion) presented a proposed Statement jointly
\nwith the Icelandic Medical Association. She
\nsaid it was a reminder of the role of immuni-
\nsation in global health. Smallpox had been
\neradicated and polio was on the verge of
\nbeing eradicated. This Statement presented
\nan opportunity to refocus attention onto the
\npriority of delivering vaccination and im-
\nmunisation programmes around the world.
\nThe committee recommended that the
\nStatement be forwarded to Council for
\nadoption by the Assembly.
\nHealth Databases
\nDr. Snaedal presented a proposed revision
\nof the Declaration on Ethical Consider-
\nations regarding Health Databases. He pro-
\nposed that a Workgroup be established to
\nfurther discuss the document and this was
\nagreed by the committee.
\nPolitical Abuse of Psychiatry
\nDr.Jeremy Lazarus (American Medical As-
\nsociation) presented a proposed revision of
\nthe WMA Resolution on Political Abuse of
\nPsychiatry. The document had been revised
\nto add the use of psychiatric hospitals for
\nreligious persecution. It was agreed that this
\nbe forwarded to Council for adoption by the
\nAssembly.
\nDrugs and Methadone
\nA proposed Statement on drugs and metha-
\ndone had been submitted by the National
\nMedical Association of Kazakstan. No-one
\nfrom the association was present and after
\na brief debate, during which it was argued
\nthat the paper was contrary to scientific evi-
\ndence and WMA policy, it was decided not
\nto approve the paper.
\nWMA Advocacy
\nDr. Jeff Blackmer (Canada) reported on the
\nactivities of the Advocacy Advisory Com-
\nmittee and a survey that had been under-
\ntaken among NMAs.There had been a very
\ngood response rate showing a strong de-
\nmand for training and workshops on advo-
\ncacy.The Group suggested organising train-
\ning sessions during a General Assembly and
\nthis topic could be the focus of a scientific
\nsession.
\nMinimum Unit Price for Alcohol
\nThe committee considered the emergency
\nResolution proposed earlier in the day. Dr.
\nNathanson said there was very clear evi-
\ndence that if a minimum unit price was set
\nas part of a strategy for dealing with alco-
\nhol abuse it influenced young people who
\nwere beginning to drink as well as older
\npeople with higher disposable incomes who
\nwere heavy drinkers. It reduced the average
\namount of alcohol consumed. Minimum
\nunit pricing was part of a strategy that
\nwould include higher taxation and a ban on
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\nWMA news
\nadvertising. The evidence from the UK was
\nthat a minimum unit price might reduce the
\nlevel of drinking by between 10 and 25 per
\ncent.But certain parts of the drinks industry
\nhad persuaded some governments to back
\nthem in opposing minimum unit pricing as
\na restraint of trade.
\nThe committee agreed to forward the Reso-
\nlution to Council for further discussion.
\nPlain Packaging of Cigarettes
\nThe committee also considered the emer-
\ngency Resolution on plain packaging of cig-
\narettes and it was agreed that this should be
\nforwarded to Council for further discussion.
\nThursday October 11
\nAssociates Members Meeting
\nThe meeting opened with Dr. Guy Du-
\nmont in the Chair. Dr. Xaviour Walker
\ngave a report on the Junior Doctors Net-
\nwork, which had met earlier in the week.
\nThe Network had been busy during the
\nyear, producing a white paper on social me-
\ndia and medicine. It was now working on
\nthe issues of physician wellbeing and glob-
\nal health training and its ethical implica-
\ntions. Elections had been held at its meet-
\ning and the new Chair of the Network was
\nThorsten Hornung from Germany. It had
\nrepresented the WMA at many meetings
\nduring the year.
\nScientific Session
\n\u2018MegaCity\u00a0\u2013 MegaHealth\u2019
\nDr. Jos\u00e9 Luiz Gomes do Amaral opened the
\nproceedings by saying that cities generated
\nbetween 30 and 50 per cent of the gross do-
\nmestic product for their respective countries.
\nBut pollution, violence, traffic jams and traf-
\nfic accidents, floods and poor infrastructure
\nwere common to most of them, affecting
\npeople\u2019s health. However big cities also con-
\ntained big ideas and this was what speakers at
\nthe Scientific Session would be talking about.
\nDr. Malinee Sukavejworakit, Deputy Gov-
\nernor of Bangkok, spoke about the goals of
\nthe Bangkok Metropolitan Administration
\nto improve the health of its population. She
\nsaid that with an inner city population of
\n5.7 million and an outer population of 10
\nmillion the city was faced with numerous
\nhealth problems, including traffic conges-
\ntion and accidents, poverty, social inclusion,
\nnoise pollution, crime, violence and mental
\nhealth care. The goals were for Bangkok to
\nbecome a healthy city where its residents
\nhad good health, good quality of life, hap-
\npiness, safety, secure income, a pleasant en-
\nvironment for living with good governance
\nand participation from all concerned. To
\nthat end the city had developed a \u2018Green
\nand Clean\u2019 project that involved four devel-
\nopment strategies\u00a0\u2013 on shelter supply, social
\ndevelopment and eradication of poverty,
\non progressive economic development, on
\ngood environmental management and on
\ngood governance.
\nShe spoke about the city\u2019s response to last
\nyear\u2019s flood and the fact that no communi-
\ncable diseases resulted from the event. The
\ncity was now putting in place measures to
\nstrengthen the city\u2019s flood defences.
\nProfessor Yasuhide Nakamura, Professor of
\nInternational Collaboration at Osaka Uni-
\nversity, said Tokyo Metropolitan City had
\na population of 13 million, 23 per cent of
\nwhom were 65 years old and over. United
\nNations statistics showed that the greater
\nTokyo area, including its neighbouring pre-
\nfectures, was the biggest urban conglomera-
\ntion in the world with a total population of
\n37.2 million.
\nHe referred to the decline in the infant
\nmortality rate in Tokyo and said that when
\nthe rate was high, fighting against starva-
\ntion and infectious diseases were the main
\ncounter measures.Nowadays,improving the
\nprovision of psychosocial support for chil-
\ndrearing was one of the most critical issues
\nbecause of the decrease in the number of
\nchildren being born. In the city there were
\nmany programmes to improve maternal,
\nneonatal, and child health, with the empha-
\nsis on the importance of starting childcare
\nduring pregnancy and continuing maternal
\nhealth care after delivery.
\nHe said the elderly population had also in-
\ncreased rapidly in the city, the majority be-
\ning born in rural areas and moving to Tokyo
\nfor work during Japan\u2019s period of rapid eco-
\nnomic growth. Most had chosen to stay and
\ndie in Tokyo, instead of returning to their
\nhometowns. The characteristics of the \u201cno
\nreturn elderly\u201d were very different from the
\nelderly who had remained in rural areas.The
\n\u201cNo return elderly\u201d had relatively high lev-
\nels of education and had often had business
\ncareers but they tended to lack social capital
\ndue to relatively weak family and commu-
\nnity networks.
\nFinally, Professor Nakamura spoke about
\nthe city\u2019s disaster preparedness plans in the
\nlight of the earthquake and tsunami of 2011
\nand the lessons that had been learned. Sev-
\neral hundreds of the Japan Disaster Medical
\nAssistance Team had provided emergency
\nmedical services just after the earthquake.
\nThen, the Japan Medical Association, the
\nJapanese Red Cross Society, and the Japan
\nPrimary Care Association, as well as mu-
\nnicipalities and private hospitals gave their
\nsupport.
\nHe said that megacities had big advantag-
\nes: a lot of human resources such as health
\nprofessionals, universities and institutes
\nconducting health research and highly ad-
\nvanced infrastructures. However, from the
\nviewpoint of human resources, both strong
\nleadership with regard to public protection
\nand the empowerment of local communi-
\nties were essential. The roles of frontline
\nhealth workers became more important at
\nthe interface of protection and empower-
\nment.The final target of health for everyone
\nin a megacity was to entail a harmonious
\nsociety, where people felt secure growing
\nup, having children, working, growing old,
\nand dying.
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\nWMA news
\nDr. Bechara Choucair, Commissioner of
\nthe Chicago Department of Public Health,
\nspoke about the Healthy Chicago public
\nhealth agenda developed in 2011, which
\nserved as a framework for how the Chicago
\nDepartment of Public Health was improv-
\ning the health and well-being of all residents
\nof the city. Healthy Chicago\u2019s development
\nwas guided by a commitment to implement
\npolicies, systems, and environmental chang-
\nes to improve population health in partner-
\nship with the community. He highlighted a
\npart of Chicago that many people did not
\nsee\u00a0\u2013 with crowded housing, poverty, poorer
\neducation and health. Healthy Chicago
\nwas about making a difference in people\u2019s
\nhealth\u00a0\u2013 by identifying public health priori-
\nties, setting measurable targets for each of
\nthe priorities, identifying specific strategies
\naround policy systems and environmental
\nchange, and finally finding more meaning-
\nful ways to engage community partners.
\nHe gave a snapshot of various measures be-
\ning taken. On tobacco he referred to the de-
\nvelopment of smoke free zones in the city,
\nthe prohibition of vending machines and
\nthe increase in fines for illegal cigarette sales.
\nThe city also faced a problem with obesity.
\nSixty per cent of the population was obese
\nor overweight and 20 per cent of children
\nentering kindergarten were obese. So the
\ncity was working with the public schools on
\na number of measures to tackle the problem.
\nThey were also providing neighbourhood
\nfresh produce carts selling fresh food and
\nvegetable. He spoke about the measures be-
\ning taken on HIV Aids, leading to a signifi-
\ncant decrease in the number of new cases in
\nthe city. He referred to disparities in breast
\ncancer death rates between black and white
\nwomen and about heart disease. Access to
\nhealth care was also one of their priorities
\nwith half a million of the city\u2019s population
\nhaving no access to health insurance.
\nThe final speaker was Dr. Jos\u00e9 Bonamigo,
\nfrom Brazil, an internist and haematologist
\npracticing at the Albert Einstein Hospital
\nin S\u00e3o Paulo.
\nHe spoke about the Brazilian health system,
\nparticularly relating to S\u00e3o Paulo. He said
\nthe population of the city was 11 million
\npeople, with 20 million in the metro region.
\nIt was a very rich city. The national health
\nsystem was mixed public and private created
\nin 1990. There were three levels\u00a0\u2013 the fed-
\neral government, state level and city level.
\nSeventy five per cent of the population de-
\npended on the public system with private
\nhealth for those who had insurance. Sixty
\nper cent of health expenditure was private
\nand only 40 per cent public. In S\u00e3o Paulo
\n55 per cent of the population depended on
\npublic health, while 45 per cent had private
\ninsurance, much higher than the national
\naverage. While the older population was
\nincreasing, the younger population was
\nshrinking.
\nHe said the challenges facing the city in-
\ncluded planning and managing demo-
\ngraphic transition, improving access and
\nimproving primary care, which was the
\nweakest part of the system. He also said
\nthere was a need to implement information
\ntechnology projects so that health budgets
\ncould be better used.
\nHe spoke in support of Brazil\u2019s public
\nprivate partnership on health which had
\nbrought about an improvement in people\u2019s
\nhealth. The old system was 100 per cent
\npublic health with huge underfunding. Un-
\nder the new model, more money was being
\nspent for clinical work with market rates
\nbeing paid and the system was more trans-
\nparent. In S\u00e3o Paulo the demand for doc-
\ntors increased, as did the salaries.
\nFriday October 12
\nCouncil
\nCouncil met to consider the reports from
\nits three committees and agreed to for-
\nward these to the Assembly for adoption.
\nFurther debates were held on the follow-
\ning:
\nDeclaration of Helsinki
\nIt was agreed to hold an event in Helsinki
\nto celebrate the 50th
\nanniversary of the Dec-
\nlaration in 2014 and that a history of the
\ndocument be published.
\nPrimary Health Care
\nDr. Haikerwal reported on the idea of hold-
\ning a global conference on primary health
\ncare.The idea was to hear about best practice
\nmodels around the world and to discuss how
\nthe WMA might promote the best use of
\nprimary care physicians.It was proposed that
\na conference be held in the early part of 2013.
\nEthical Implications of Physician Strikes
\nLeah Wapner (Israel) proposed amend-
\nments to the proposed Statement that had
\nalready been discussed in the Socio-Medical
\nAffairs Committee, adding the words \u2018Phy-
\nsicians carry out protest action and sanc-
\ntions in order to improve direct and indirect
\nworking conditions which also may affect
\npatient care\u2019. She said the document did not
\nstate whether physicians should or should
\nnot take industrial action. It was ethical ad-
\nvice for when physicians decided to strike.
\nDr. Eidelman proposed that the document
\nshould be forwarded to the Assembly for
\nadoption rather than recirculated for further
\ndiscussion.
\nBut several delegates said that the Statement
\nconflicted with the legislation in their coun-
\ntries. Dr. Janbu said that although the inten-
\ntion was good, the paper was not ready to be
\naccepted as policy and she could not support it.
\nDr. Lazarus said that it would be very haz-
\nardous for doctors in the USA to go on
\nstrike, but he thought the changed word-
\ning had improved the document as an ethi-
\ncal statement and he supported the idea of
\nadoption. Dr. Montgomery said the fact
\nwas that physicians did take industrial ac-
\ntion and the WMA had to give them ethi-
\ncal guidance. It was impossible to cover the
\nlegal situation in all 102 different states and
\nhe supported adopting the Statement.
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\nWMA news
\nDr. Xaviour Walker said that junior doctors
\naround the world faced very bad conditions,
\nworking with no employment contracts,
\nvery short maternity leave and unsafe work-
\ning conditions. He therefore supported the
\nStatement. Council agreed to recommend
\nto the Assembly that the Statement should
\nbe adopted.
\nDrugs and Methadone
\nDr. Aizhan Sadykova (Kazakstan) proposed
\na Statement on drugs and methadone. She
\nsaid the doctors of Kasakstan were united in
\nthe belief that drug addiction could not be
\ntreated by narcotics. She urged the WMA
\nto support this position and to consider
\ninstead therapy that included preventive
\ntreatment, psychological and social reha-
\nbilitation of dependents.
\nDr.Lazarus said the proposed Statement was
\ncontrary to existing WMA policy and con-
\ntrary to 30 years research in the use of meth-
\nadone as part of a treatment for addiction.
\nCouncil agreed with the Socio-Medical Af-
\nfairs Committee that the Statement should
\nnot be adopted. Council then considered
\nthe three emergency motions that had been
\nproposed.
\nMinimum Unit Price of Alcohol
\nDr. Nathanson said this Resolution was
\nabout the right of a state to set a public
\nhealth policy in place requiring legislation.
\nA minimum unit price for alcohol was es-
\nsential because countries like the UK,which
\nhad the second highest tax for alcohol any-
\nwhere in the world, had a major problem
\nwith alcohol. Simply increasing tax did not
\nwork. Minimum unit price was a method
\nfor saying that there was an amount below
\nwhich nobody could sell alcohol. The alco-
\nhol industry was pressing a number of gov-
\nernments to support them in trying to stop
\nin this case Scotland from enacting public
\nhealth legislation. It seemed unacceptable
\nthat governments of other countries should
\nbe interfering with a public health measure
\nby a government of a country with a serious
\npublic health crisis.
\nDr. Lazarus proposed new wording that
\n\u2018The WMA supports states seeking to use
\nsuch innovative measures to combat the se-
\nrious public and individual health effects of
\nexcessive and problem drinking.\u2019
\nCouncil agreed to recommend the Resolu-
\ntion as amended to the Assembly for adop-
\ntion.
\nPlain Packaging of Cigarettes
\nDr. Nathanson said the Australian legisla-
\ntion on plain packaging had passed but the
\ntobacco industry was challenging the legal
\naspects of the changes. Several countries
\nhad said they would introduce such legisla-
\ntion if the Australian Government won the
\nlegal case. Doctors and the WMA should
\nbe seen to be supporting them.
\nDr. Steve Hambleton (Australia) said the
\nWMA should support the stand against to-
\nbacco companies.Big tobacco was now sup-
\nporting individuals to take this issue to the
\nWorld Trade Organisation. This emergency
\nResolution would give the Australian Gov-
\nernment encouragement that they could
\nmake a stand.
\nCouncil agreed to recommend the Assem-
\nbly to adopt the Resolution.
\nProfessor Cyril Karabus
\nDr. Mark Sonderup (South Africa) pro-
\nposed an emergency Resolution on the
\ncase of Professor Cyril Karabus. He said
\nProf. Karabus, a 78-year-old retired pae-
\ndiatric haematologist from South Africa,
\nwas working in the United Arab Emirates
\n10 years ago for a six week period. While
\nthere a child under his care died. Prof.
\nKarabus returned to South Africa and
\nunknown to him a charge was brought
\nagainst him and in his absence he was
\nfound guilty of murder. This was never
\ncommunicated to him and in August
\nwhile he was travelling through Dubai
\nhe was arrested and jailed in Abu Dhabi.
\nDespite six court appearances he was re-
\nfused bail. The original murder charge was
\ndropped and this week he was granted bail
\nto await his trial in November. Dr. Sond-
\nerup said they were extremely concerned
\nabout a number of issues and they were
\nnot convinced that Prof. Karabus would
\nget access to a fair trial.
\nDr. Kloiber thanked those NMAs who had
\nraised this issue and urged other associations
\nto take action.Council agreed to recommend
\nthe Assembly to adopt the Resolution.
\nCeremonial Session
\nThe official opening of the 63rd
\nGeneral As-
\nsembly then took place. WMA President
\nDr. Jos\u00e9 Luiz Gomes do Amaral called the
\nAssembly to order, before Dr. Kloiber in-
\ntroduced the delegations from the national
\nmedical associations and the observers of
\ninternational organisations.
\nDelegates were welcomed by the guest of
\nhonour, Royal Privy Council, Prof. Dr.\u00a0Kas-
\nem Wattanakul, and by Dr. Wonchat Sub-
\nhachaturas, President of the Medical Asso-
\nciation of Thailand.
\nDr. Haikerwal, Chair of Council, paid trib-
\nute to the retiring President, Dr. Gomes do
\nAmaral, who delivered a valedictory ad-
\ndress.
\nDr.Cecil Wilson was then installed as Pres-
\nident of the WMA for 2012\/13 and gave
\nhis inaugural address.
\nSaturday October 13
\nAssembly Plenary Session
\nPresident Elect
\nDr. Margaret Mungherera, President of the
\nUganda Medical Association, was elected
\nunopposed as President-elect. Dr. Mung-
\nherera, a psychiatrist, will take up office
\nin October 2013 and will serve for a year,
\nbecoming the first woman President of the
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\nWMA news
\nWMA since 2002 and the first African
\nwoman.
\nDr. Mungherera thanked the Assembly for
\ntheir support and said she had been a doctor
\nfor 30 years and a psychiatrist for 20\u00a0years
\nwith forensic psychiatry as her special area
\nof interest. She had studied medicine at
\nMakerere University Medical School in
\nKampala, Uganda, before taking a diploma
\nin tropical medicine at the London School
\nof Tropical Medicine and Hygiene. For the
\npast 10 years she had been senior consul-
\ntant psychiatrist at Mulago National Refer-
\nral Hospital, Kampala. She was a founder
\nmember of Uganda Women Medical Doc-
\ntors Association and was the first woman
\nin Uganda to be elected President of the
\nUganda Medical Association in 1998 and
\nagain in 2010. She was in the forefront of
\nbringing together the national medical as-
\nsociations in Eastern Africa (Kenya, Ugan-
\nda, Tanzania and Rwanda) long before the
\nrevived East African Community started its
\nwork.
\nShe said that one of her dreams was to get
\nthe poorer nations participating more in the
\nWMA. She said she would like to see regu-
\nlar regional meetings so that the poorer and
\nsmaller member associations could gather
\ntogether to discuss the many policies ad-
\nopted by the WMA.
\nCouncil Report
\nThe Assembly received the report of the
\nCouncil. Dr. Kloiber spoke about the year\u2019s
\nactivities and emphasised that the WMA
\nwas there to support NMAs if needed. He
\nencouraged NMAs to consider applying for
\na grant related to the counterfeit medicine
\nproject and to consider nominating candi-
\ndates to attend the next leadership course in
\nJanuary 2013.
\nAdvanced Technology
\nDr. Haikerwal said that when there was a
\ndiscussion on this topic earlier in the meet-
\ning it became clear there was little consid-
\neration of the positive role of health profes-
\nsionals in relation to the use of technology
\nin the health care sector. As a result a paper
\nwould be drafted by Dr. Hambleton (Aus-
\ntralia) for presentation at the next meeting.
\nEthical Implications of Collective Action
\nby Physicians
\nA further lengthy debate took place about
\nthe wording of the document after Dr. Son-
\nderup proposed an amendment to make it
\nclear that \u2018Physicians may take part in in-
\ndividual acts or collective actions provided
\na minimum level of health care service is
\nmaintained.\u2019 This led to a discussion about
\nthe meaning of the word \u2018minimum\u2019, with
\ndelegates arguing that this could not be pre-
\ncisely defined. After several interventions,
\nDr. Hambleton said the document should
\nsimply read \u2018Physicians may carry out pro-
\ntest action.\u2019This was eventually supported.
\nSeveral speakers then opposed the idea of
\nopening the document with a negative sen-
\ntence about physicians\u2019 dissatisfaction with
\ntheir working conditions. This prompted a
\nwider debate about whether the document
\nshould be recirculated among NMAs or ad-
\nopted by the Assembly. On a vote, it was
\noverwhelmingly decided against recirculat-
\ning the document.
\nThe meeting then voted to retain the open-
\ning sentence about physicians\u2019working con-
\nditions, but agreed to amend it to read \u2018In
\nrecent years, in countries where physicians\u2019
\nsatisfaction with their working conditions
\nhas decreased, collective action by physi-
\ncians has become increasingly common.\u2019
\nDr.\u00a0 Hambleton said it was important for
\nthe WMA to be seen to be providing lead-
\nership on this issue.
\nThe amended Statement was finally adopt-
\ned as WMA policy.
\nAdopted Statements and Resolutions
\nThe Assembly also adopted the following
\ndocuments:
\n\u2022 Resolution on a Minimum Price for Al-
\ncohol
\n\u2022 Resolution on Plain Packaging of Ciga-
\nrettes
\n\u2022 Resolution in Support of Professor Cyril
\nKarabus
\n\u2022 Revised Declaration on Medical Ethics
\nand Advanced Technology
\n\u2022 Statement on Organ Tissue and Dona-
\ntion
\n\u2022 Resolution on Physician Participation in
\nCapital Punishment
\n\u2022 Revised Regulations in Times of Armed
\nConflict and Other Situations of Vio-
\nlence
\n\u2022 Statement on Electronic Cigarettes and
\nOther Nicotine Delivery Systems
\n\u2022 Statement on Violence in the Health
\nSector by Patients and Those Close to
\nThem
\n\u2022 Statement on Forced and Coerced Ster-
\nilisation
\n\u2022 Statement on the Prioritisation of Vac-
\ncination
\n\u2022 Resolution on the Abuse of Psychiatry
\nReport of the Treasurer
\nDr. Frank Ulrich Montgomery, the Trea-
\nsurer, reported that net income had
\nstrengthened over recent years, although
\nthere had been a decrease in membership
\ndues. He hoped that associations would pay
\ntheir dues each year. He assured the As-
\nsembly that the money of the Association
\nwas safely invested and that the positive
\nfinancial trend started in 2005 had been
\nmaintained.
\nThe Assembly adopted the Financial State-
\nment for the year ended 2011 and the Bud-
\nget for 2013.
\nMembership
\nThe Assembly agreed that the Myanmar
\nMedical Association and the Sri Lanka
\nMedical Association be admitted into
\nWMA membership, bringing the total
\nnumber of NMA members to 102.
\nIt was also agreed that the French Medical
\nAssociation be replaced by the Conseil Na-
\ntional de l\u2019Ordre des Medecins and that the
\n179
\nWMA news
\nRomanian Medical Association be replaced
\nby the Romanian College of Physicians.
\nStrategic Plan
\nThe Strategic Plan 2013\u201315 was adopted.
\nWMA Meetings
\nIt was agreed that the 2014 Assembly take
\nplace in Durban, South Africa and that
\nthe decision about a venue for the 2015
\nmeetings should be taken by the Executive
\nCommittee.
\nWorld Dental Federation
\nIn a presentation to the Assembly, Dr. Tin
\nChun Wong, President elect of the World
\nDental Federation, said that the FDI and
\nthe WMA had been working closely to-
\ngether through joint membership of World
\nHealth Professions Alliance. They had
\nworked together on producing the toolkit
\nfor prevention of NCDs, first in paper form
\nand now online. Both organisations should
\ntake immense pride in developing one of
\nthe few practical tools available on the mar-
\nket.
\nShe then spoke about the FDI\u2019s new stra-
\ntegic plan, Vision 2020, which she de-
\nscribed as a road map for the future of the
\ndental profession. Its aim was to focus on
\nemerging issues likely to impact the den-
\ntal profession, such as areas of regulation,
\nlegislation and advocacy, and she added
\nthat if they did not do this other bod-
\nies would, notably politicians. The docu-
\nment provided a sketch of how oral health
\nmight look in 2020 and paved the way for
\na new model of oral health care. Vision
\n2020 was of extreme importance to den-
\ntal profession and also to the partners of
\nthe WHPA. Dr. Wong said she trusted it
\nwould generate collaboration with other
\nprofessions.
\nThe document laid bare a number of is-
\nsues, such as unequal access to oral health
\ncare around the world. In some parts of
\nEurope there was one dentist for every
\n560 people and in some parts of the un-
\nder developed world that figure was 1 per
\n1.2 million. Even in a wealthy area such as
\nCalifornia some two million people, eight
\nper cent of the population, were missing
\nhours of work and school because of den-
\ntal diseases.
\nDr. Wong said the document focused on a
\nnew model for oral health care which called
\nfor a move to a preventive approach.
\nWorld Veterinary Association
\nA short ceremony was held for the WMA
\nand the World Veterinary Association to
\nsign a Memorandum of Understanding.
\nDr. Cecil Wilson, President of the WMA,
\nsaid the two professions shared much in
\ncommon, whether on drug research, ag-
\nriculture or nutrition. The interaction be-
\ntween the two professions was critical in
\ntreating and diagnosing.The Memorandum
\ncommitted both organisations to the inter-
\nnational movement, One Health Initiative,
\nwith the opportunity for continuing col-
\nlaboration.
\nDr. Faouzi Kechrid, President of the WVA,
\nwelcomed this new mutually beneficial re-
\nlationship, which would allow both organ-
\nisations to collaborate on improving global
\nhealth and working on surveillance to pre-
\nvent zoonotic disease.
\nAssociate Members
\nDr. Xaviour Walker, outgoing Chair of the
\nJunior Doctors Network, reported on the
\nprogress that the network had made over
\nthe past year. The Network was a platform
\nfor experience sharing and resource devel-
\nopment and worked closely with the NMAs
\nand with the International Federation of
\nMedical Students Associations. The Net-
\nwork had held three meetings and he said
\nit was important to keep contributing to
\nWMA policies.The Network had produced
\nthe Social Media white paper, and were
\ncurrently working on a review of physician
\nwellbeing and global health training.
\nOpen Forum
\nAn Open Meeting was then held, when
\nNMAs and observers were invited to talk
\nabout any issue.
\nOrgan Transplants
\nHernan Reyes, from the International
\nCommittee of the Red Cross, who said he
\nhad spent 22 years working with the WMA,
\ncongratulated the Assembly on adopting its
\ndocument on organs transplants. But he
\nsaid that there was no mention about living
\ndonors and the hidden issue of economic
\npressure where people felt under pressure
\nto sell their kidneys for an iPad or a car.
\nAlthough this was not allowed, there was a
\n\u2018don\u2019t ask don\u2019t tell\u2019tendency and some doc-
\ntors were discreetly making a lot of money
\nselling organs from so called relatives. He
\nurged NMAs to be alert to these pressures
\nand to ensure their physicians knew they
\nshould not accept organs unless they knew
\nwhere they came from.
\nBahrain
\nDr. Rudolph Henke (Germany), a delegate
\nin the German Parliament, reported on his
\nvisit to Bahrain with a delegation from the
\nGerman Parliament. They had met official
\nrepresentatives of the Royal Family, hu-
\nman rights activists and with four people
\nwho had received prison sentences. Those
\nwho had been jailed said that a number of
\ndoctors and nurses had been detained and
\nabused, stripped of their clothes made to
\ndance naked in front of their guards, beaten
\nand subjected to other ill treatment. Other
\ncolleagues from academia and scientific cir-
\ncles had also been detained and some had
\nbeen stripped of their licence and could no
\nlonger work. He said that after the dem-
\nonstrations in the country the Royal Fam-
\nily had appointed a committee to examine
\nthese accusations. A 500-page report had
\nnow been published, answering the accusa-
\ntions levelled at government. Health pro-
\nfessionals who had been jailed were more
\nor less pardoned or reprieved. But recently
\nthere had been more arrests, trials and con-
\nvictions. Some of these sentences, ranging
\n180
\nWMA news
\nDr. Otmar Kloiber, Secretary General,
\npresented the annual report of Council to
\nthe General Assembly, combined with his
\nreport from the secretariat. Among the sig-
\nnificant activities during the year were:
\nNon-Communicable Diseases
\nThis was one of the most important top-
\nics on the public health agenda.The WMA
\nhad concerns from the beginning about
\nthe WHO\u2019s identification of four specific
\nNCDs-namely, cardiovascular disease,
\ncancer, lung and respiratory disease, and
\ndiabetes-as a focus of the NCD initiative.
\nThe risk of selecting particular diseases as
\na focus was a return to a silo-based ap-
\nproach to public health, similar to that of
\nprevious years when the focus was largely
\nconcentrated on HIV\/AIDS, tuberculosis,
\nmalaria, and river blindness. The WMA
\nadvocated a comprehensive approach that
\nlinked individual risk factors with social
\nand economic determinants of health, con-
\nditions in which people were born, grew up,
\nlived, worked and aged, and the influences
\nof society. The WMA emphasised the need
\nto take a holistic approach, and suggested
\ntargets should address the elimination of
\ninequalities in health care. The WHO was
\ncurrently developing a 2013\u20132020 Global
\nAction Plan for the Prevention and Con-
\ntrol of NCDs.
\nTogether with the partners at the World
\nHealth Professions Alliance (WHPA), the
\nWMA participated in the development of
\nthe NCD toolkit to assess the risk level in
\nlife style behaviours and bio measures in the
\nform of NCD indicators. It was also setting
\nup an independent project together with Sir
\nMichael Marmot (British Medical Asso-
\nciation) and his team to develop a common
\nset of Social Determinants of Health and
\nNCD indicators.
\nMulti Drug Resistant
\nTuberculosis Project
\nIn March, the WMA launched the revised
\nMDR-TB online course. There was now a
\ncomplete set of TB and MDR-TB cours-
\nes as online versions, printed formats and
\nCDs.The printed courses had been translat-
\ned into Azeri, Chinese, French, Georgian,
\nfrom imprisonment for a few months to
\nseveral years, were still on appeal.
\nDr. Henke said that those health profes-
\nsionals he had met were very grateful for
\nthe WMA support. He said he and his col-
\nleagues were planning to return next year to
\nassess the situation and review progress.
\nSouth East European Medical Forum
\nDr. Andrey Kehayov, from the South East
\nEuropean Medical Forum, reported on the
\norganisation\u2019s progress. It now had more
\nthan 15 members and was anxious to work
\nclosely with the WMA.
\nIndependence of Medical Associations
\nDr. Konstanty Radzwill, from the Standing
\nCommittee of European Doctors, warned
\nthat they were facing in Europe attempts
\nto standardise medicine and healthcare
\nfrom outside the profession. This was a real
\ndanger for physicians\u2019 autonomy and their
\npatients. He said that with some support
\nfrom parts of the medical profession there
\nwere bodies in Europe that were trying to
\nstandardise what doctors did. The Standing
\nCommittee was of the opinion that these is-
\nsues should be done only by the profession
\nand not by anyone outside.
\nDr. Haikerwal referred to the independence
\nof medical associations and problems that
\nhad occurred in Bolivia, Mexico, Slova-
\nkia, Poland and other countries, where the
\nWMA had offered its support. He said he
\nwas particularly impressed at how the Turk-
\nish Medical Association had confronted
\ntheir problems and had involved the WMA
\nin helping them. He said this was an ex-
\nample that should be used as a template by
\nother NMAs.
\nDr. Ozdemir Aktar (Turkey) thanked the
\nWMA for its help with the problems fac-
\ning the Turkish Medical Association. The
\nissues were still unresolved and were await-
\ning a decision of the Supreme Court. Last
\nweek a new report on Turkey was pub-
\nlished, strongly criticising the country\u2019s
\nrecord on freedom of speech, the number
\nof people in jail and the pressure on cer-
\ntain organisations and unions, including
\nthe Turkish Medical Association. He said
\nthey were now faced with another prob-
\nlem, with 13 medical students who were in
\njail.These students had been in jail for four
\nmonths, but did not know what they were
\naccused of.
\nDr. Kloiber said that the secretariat was in
\ndiscussions with the Turkish Medical Asso-
\nciation about future action.
\nSecretary General\u2019s Report
\nOtmar Kloiber
\n181
\nWMA news
\nRussian Spanish and other languages may
\nfollow. All courses could be accessed free of
\ncharge via the WMA webpage.The printed
\nTB refresher course and the new MDR-
\nTB course were nominated by the United
\nStates Centre for Disease Control (CDC)
\nas an educational highlight and received an
\naward.
\nThe WMA was collaborating with the
\nWHO to develop the MDR-TB course as
\nan application for tablet computers, espe-
\ncially for low-cost 10-inch devices running
\non Android which were increasingly used
\nin low-income countries. The app would be
\naccessible from the WMA and WHO web-
\nsites and, once downloaded, would be self-
\ncontained and able to run offline without an
\ninternet connection.
\nTobacco Project
\nThe WMA was involved in the implemen-
\ntation process of the WHO Framework
\nConvention on Tobacco Control and was
\nco-operating with the public private part-
\nnership \u201cQuitNowTXT program\u201d to de-
\nvelop an evidence-based diffusion of health
\ninformation for tobacco cessation via mo-
\nbile phones to reach people at risk from pre-
\nventable NCDs.
\nAlcohol
\nThe WMA was monitoring progress on the
\nGlobal Strategy to Reduce the Harmful
\nUse of Alcohol and was involved in confer-
\nences on the issues.
\nCounterfeit Medical Products
\nThe WMA and the members of the
\nWHPA had stepped up their activities on
\ncounterfeit medical issues and developed
\nan Anti-Counterfeit campaign with an
\neducational grant from Pfizer Inc. and Eli
\nLilly.The basis of the campaign was the \u2018Be
\nAware\u2019 toolkit for health professionals and
\npatients to increase awareness of this topic
\nand provide practical advice for action to
\ntake in case of a suspected counterfeit med-
\nical product. A\u00a0 grant application process
\nfor all national members was due to start
\nfrom mid-October. All national members
\nand national student organisations could
\napply for a grant of 2,500\u20135,000 US$ for a
\nhalf year project where at least two different
\nhealth professional groups were involved.
\nThe deadline for applications was 30 No-
\nvember 2012.
\nHealth and the environment
\nClimate change
\nThe WMA had been involved in the UN
\nClimate Change Conference in Durban in
\nDecember 2011, and in an informal con-
\nsultation group set up by the WHO which
\nbrought together civil society actors work-
\ning on health and environmental issues.
\nThe WMA agreed to be a partner for the
\nGlobal Climate and Health Summit and
\nProf. Dong Chun Shin (Korean Medi-
\ncal Association), represented the WMA
\nat the Summit and presented the WMA
\nDelhi Declaration on Health and Climate
\nChange.
\nMercury
\nThe WMA had been a member of the
\nUNEP Global Mercury Partnership since
\nDecember 2008 in order to contribute to
\nthe goal of protecting human health and
\nthe global environment from the release
\nof mercury and its compounds. This en-
\ngagement was based on the WMA State-
\nment on Reducing the Global Burden of
\nMercury (Seoul, 2008). Together with the
\nrepresentatives of the Mercury Partner-
\nship, the WHO and other relevant health
\nprofessionals, the WMA Secretariat was
\nexploring the possibility of developing joint
\nactions in this area.
\nChemicals
\nSince December 2009, the WMA had been
\nengaged in the Strategic Approach to In-
\nternational Chemicals Management of the
\nChemicals Branch of the United Nations
\nEnvironment Programme, which aimed to
\ndevelop a strategy for strengthening the en-
\ngagement of the health sector in the imple-
\nmentation of the Strategic Approach. In
\nconsultation with the WHO,Prof.Shin had
\nrepresented the WMA at several meetings.
\nIn September 2012, the WMA,\u00a0 togeth-
\ner with the World Federation of Public
\nHealth Associations, the Government of
\nSlovenia and the WHO, organised a side
\nevent focussing on strengthening of the
\nrole of the health sector in international
\nchemicals management. This event took
\nplace in the context of the third session of
\nthe International Conference on Chemi-
\ncals Management, held in Nairobi in Sept.
\n2012. Participants looked at strategies while
\npresenting examples of some recent innova-
\ntions in multi-stakeholder engagement that
\npromise a healthy outcome for all.
\nSocial Determinants of Health
\nThe WMA attended as observer at the
\nWHO World Conference on Social Deter-
\nminants of Health in Rio de Janeiro in Oc-
\ntober 2011, which adopted a Declaration,
\nemphasizing the role of the health sector
\nin reducing health inequities. The WMA
\nand the International Federation of Medi-
\ncal Students Associations held a side-event
\nduring the World Health Assembly in Ge-
\nneva to discuss ways for health care provid-
\ners to implement the Rio Declaration and
\nengage in reducing health inequities.
\nHealth Care Systems
\nThe World Economic Forum had organized
\na working group to develop and define the
\nprinciples of a Global Charter on Health
\nData and the WMA represented the phy-
\nsicians\u2019 perspective in this group and had
\ndemanded the anonymity and aggregation
\nof data, as well as patient ownership rights
\nto the data. As the position of the WMA
\nrelating to patient advocacy had not been
\nproperly incorporated into this Charter, the
\nWMA Executive Committee had not yet
\nrecommended signing it.
\n182
\nWMA news
\nIn June, the first ever Asia Pacific Influenza
\nSummit took place in Bangkok, Thailand.
\nDr. Wonchat Subhachaturas was invited as
\npast president of WMA to present a paper
\non the effect of influenza on health care
\nworkers. The aim of the conference was to
\nincrease awareness of the burden of influ-
\nenza on public health in the Asia-Pacific
\nregion.
\nPerson Centred Medicine
\nTogether with the World Psychiatric Asso-
\nciation, the World Organization of Family
\nDoctors, the World Health Organization,
\nthe International Association of Patient
\nOrganizations and many other partners,
\nthe WMA held the 4th
\nConference on Per-
\nson Centered Medicine in Geneva in May
\n2012.The partners were currently preparing
\nfor the 5th
\nConference to be held from April
\n28-May 1 2013. Dr. Jon Snaedal represent-
\ned the WMA.
\nPositive Practice Environment
\nCampaign
\nThe WMA continued its close involvement
\nwith this campaign,spearheaded by WHPA
\nmembers together with the International
\nHospital Federation, which aimed to ensure
\nhigh-quality health workplaces for qual-
\nity care. Activities on a country level con-
\ntinued in Uganda, Morocco and Zambia,
\nwhich were among the fifty-seven countries
\nworldwide suffering from a critical shortage
\nof health care workers. The PPE Partners
\nwere working with national health profes-
\nsional and hospital organisations in these
\nthree countries to develop country projects
\nand improve their practice environments.
\nMigration & Retention
\nThe WHO had developed the Guidelines
\non Retention Strategies for Health Profes-
\nsionals in Rural Areas, with the WMA tak-
\ning part in the drafting process. The guide-
\nlines were based on three pillars: educational
\nand regulatory incentives, monetary incen-
\ntives and management, and environment
\nand social support.
\nWorkplace Violence in
\nthe Health Sector
\nThe 3rd
\nConference on Workplace Violence
\nin the Health Sector was due take place
\nfrom 24\u201326 October 2012 in Vancouver.
\nThis was supported by the International La-
\nbour Organisation,the International Coun-
\ncil of Nurses, Public Services International,
\nthe WHO and other health organizations.
\nThe WMA was a member of the planning
\ncommittee.
\nEducation & Research
\nThe World Federation for Medical Educa-
\ntion had started a discussion process on the
\nfuture role of the physician, involving the
\nWMA, and international and regional or-
\nganizations for medical education
\nThe WMA had also participated as a mem-
\nber of steering groups in two projects com-
\nmissioned by the European Union on the
\nMobility and Migration of Health Profes-
\nsionals.
\nPatient Safety
\nThe WHO had stepped up its commitment
\nto patient safety and had revised the exist-
\ning Patient Safety Curriculum Guide for
\nmedical schools and transformed it into a
\nMulti-professional Patient Safety Cur-
\nriculum Guide. The WMA was a member
\nof the reviewing committee for the multi-
\nprofessional guidelines
\nCaring Physicians of the
\nWorld Initiative
\nThe fourth leadership course, organized by
\nthe INSEAD, was held at the INSEAD
\ncampus in Singapore from November 20\u201325
\n2011.The courses were made possible by an
\nunrestricted educational grant provided by
\nPfizer, Inc. This work, including the prepa-
\nration and evaluation of the course, was
\nsupported by the WMA cooperating centre,
\nthe Center for Global Health and Medi-
\ncal Diplomacy at the University of North
\nFlorida.The fifth course was planned, again
\nat the INSEAD campus in Singapore, for
\nearly 2013.
\nHealth Politics
\nAt the beginning of the year the, WMA
\nintervened three times on health politics
\nmatters at the request of member associa-
\ntions:
\nIn Slovakia,the government declared a state
\nof emergency in hospitals in order to stop
\nprotests and industrial action by physicians
\nfighting for better working conditions and
\nagainst the privatisation of public hospitals.
\nIn consultation with the Slovak Medical
\nAssociation, the WMA wrote to the Prime
\nMinister and the President of the Republic
\nto call for proper working conditions and
\nfair payment.
\nIn Poland, physicians were made liable for
\nmanaging the reimbursement entitlements
\nof the insured. Everyone in Poland was in-
\nsured under a state insurance scheme which
\ngave various entitlements for reimburse-
\nment. These different entitlements were at
\nleast in part non-transparent to the physi-
\ncians, who should not be held liable for
\nwrongly assigning reimbursement statuses
\nfor drugs on prescription.Together with the
\nPolish Chamber of Physicians and Dentist,
\nthe WMA protested against this measure,
\nwhich later was revoked.
\nAt the end of last year, the Turkish Gov-
\nernment removed key functions such as the
\nsupervision of physicians and the regulation
\nof post-graduate education from the Turk-
\nish Medical Association and other self-
\ngoverning institutions. Together with the
\nTurkish Medical Association, the WMA
\nstaged public events in Ankara and Istanbul
\nin April to fight for retaining these critical
\nrights of physician self-governance.
\n183
\nWMA news
\nSocial Media
\nThe WMA Junior Doctors Network had
\ndeveloped a White Paper on Social Media
\nand Medicine, helping to facilitate under-
\nstanding of the mechanisms of social media,
\nand giving guidance on the potential uses
\nand risks of social media in medicine.
\nPhysicians and Patients in
\nDistress Worldwide
\nBahrain
\nSince February 2011, the WMA had been
\nmonitoring the situation in Bahrain where
\nassaults on health professionals by security
\nforces had been reported by Amnesty In-
\nternational. Several appeals were sent to the
\nBahrain authorities expressing deep concern
\nabout access to appropriate healthcare for
\nvictims, as well as regarding the indepen-
\ndence of health professionals. The WMA
\nhighlighted more specifically the case of
\n20 Bahraini health professionals who were
\nsentenced by a military court last Septem-
\nber to between five and 15 years in prison in
\nconnection with popular anti-government
\nprotests in February and March.
\nLast June, following the verdict of the High
\nCriminal Court of Appeal regarding the 20
\nhealth professionals, the Secretariat sent
\nanother letter expressing concern for the
\n4\u00a0doctors Ali \u2018Esa\u00a0Mansoor al-\u2018Ekri, Ebra-
\nhim \u2018Abdullah Ebrahim, Ghassan Ahmed
\n\u2018Ali Dhaif and Sa\u2019eed Mothaher Habib Al
\nSamahij for whom the court issued arrest
\norders.
\nEgypt
\nIn June,the WMA sent letters to the Egyp-
\ntian authorities regarding the case of Mah-
\nmoud Mohamed Amin arrested by military
\nforces near Al-Nour Mosque, Cairo in May
\n2012 because he had participated in a dem-
\nonstration alongside hundreds of others to
\nprotest against military rule. He was then
\nreferred to the military prosecutor. Accord-
\ning to Amnesty International, he already
\nhad a medical condition caused by military
\nforces and during his arrest was assaulted
\nand injured and did not receive adequate
\nmedical care.
\nThe WMA called upon the Egyptian au-
\nthorities to allow Mahmoud Mohamed
\nAmin to receive adequate medical care for
\nhis medical condition, and for his immedi-
\nate and unconditional release.
\nIran
\nThe Secretariat had acted in support of the
\nIranian blogger Hossein Ronaghi Maleki
\nwho was sentenced to 15 years in prison
\nafter a trial in 2010 for being a member of
\nan illegal internet group, for spreading pro-
\npaganda against the system and for insult-
\ning the leader and the President.The WMA
\ncalled on the Iranian authorities to ensure
\nthat Mr Meleki received all necessary medi-
\ncal attention, including post-operative care
\nas called for by his doctors and the Medical
\nExaminer.
\nSyria
\nThe Association had issued press releases
\nurging the Syrian authorities to call an im-
\nmediate ceasefire to allow the sick and the
\nwounded to be properly treated. The prin-
\nciple of neutrality was reiterated along with
\nthe Declaration of Tokyo, which clearly set
\nout guidelines prohibiting physicians from
\nparticipating in, or even being present dur-
\ning the practice of torture or other forms of
\ncruel, inhuman or degrading procedures.
\nRomania
\nIn July 2012, the WMA responded at the
\nrequest of the Romanian College of Phy-
\nsicians to interference by Romanian law
\nenforcement agencies apparently violating
\nthe confidentiality of medical communica-
\ntion between physicians and their patients
\nand relatives respectively. Following the
\nattempted arrest of the previous president
\nof Romania, who tried to commit suicide
\nduring the arrest and injured himself in
\nthe process, doctors where accused of being
\ncomplicit in preventing the arrest by hos-
\npitalizing the injured person. The WMA
\nPresident wrote to the Romanian authori-
\nties demanding that they respect the con-
\nfidentiality of medical communication and
\nrespect the rights of every patient, regard-
\nless of his or her civil status. The Romanian
\ngovernment responded with assurances of
\ncorrect treatment.
\nWHO Role in Humanitarian
\nEmergencies
\nThe growing threats to health personnel in
\narmed conflicts areas and other situations of
\nviolence had been the subject of increasing
\nglobal debate and action over the last year.
\nIn January 2012, the WHO Executive
\nBoard discussed the role of the WHO
\nas the health cluster lead\u00a0 in meeting\u00a0 the
\ngrowing demands of health in\u00a0humanitar-
\nian emergencies with a draft resolution for
\nthe Board\u2019s consideration.The Safeguarding
\nHealth in Conflict Coalition (composed of
\nNGOs active in the field of health and\/or
\nhumanitarian issues, including the WMA
\nas an observer) sent an open letter for the
\nattention of Member States in support of
\nthe draft resolution. The resolution was en-
\ndorsed by the WHO Board, which recom-
\nmended its adoption by the World Health
\nAssembly in May.
\nFurther to this resolution,the WHO organ-
\nised a technical meeting in March, attended
\nby the WMA, to discuss the methods for
\nsystematic collection and dissemination of
\ndata on attacks on health facilities, health
\nworkers, health transports, and patients in
\ncomplex humanitarian emergencies.
\nThe resolution was finally adopted by the
\nWorld Health Assembly in May.\u00a0 With
\nthe resolution, Member States called on
\nWHO\u00a0 Director General: \u201cto provide lead-
\nership at the global level in developing meth-
\nods for systematic collection and dissemination
\nof data on attacks on health facilities,\u00a0 health
\nworkers, health transports, and patients in
\ncomplex humanitarian emergencies, in coor-
\ndination with other relevant United Nations
\n184
\nWMA news
\nbodies,\u00a0other relevant actors, and intergovern-
\nmental and nongovernmental organizations,
\navoiding duplication of efforts;\u201d
\nICRC Campaign \u201cHealth
\nCare in Danger\u201d
\nThe WMA jointly organised a symposium
\nentitled \u201cThe security and delivery\u00a0of effec-
\ntive and impartial health care in\u00a0armed con-
\nflict and other\u00a0situations of violence\u201d which
\ntook place in London in April 2012.Partici-
\npants examined how to improve security\u00a0and
\ndelivery of effective and impartial health
\ncare in armed conflict\u00a0and other situations
\nof violence, and provided\u00a0 the health\u00a0 com-
\nmunity and other important stakeholders
\nwith an opportunity for greater\u00a0engagement
\nwith this global humanitarian issue. Dr. Jos\u00e9
\nLuiz Gomes Do Amaral presented WMA
\npolicies related to this area.
\nCooperation with the
\nInternational Rehabilitation
\nCouncil for Torture Victims
\nAs an elected member of the Executive
\nCommittee of the IRCT, Clarisse Delorme
\nattended the meetings which took place in
\nLondon last November,and in Copenhagen
\nin September. Issues discussed included the
\npreparations for the upcoming General As-
\nsembly (November 2012, Budapest), as well
\nas the activities of the UN Subcommittee
\non Prevention of Torture and more gener-
\nally the Human Rights Council.
\nDetention
\nThe WMA had been involved in the possi-
\nble revision of the UN Standard Minimum
\nRules for the Treatment of Prisoners by the
\nUN Office on Drugs and Crime, drawing
\nthe UN Office\u2019s attention to several relevant
\nWMA policies on the conditions of prison-
\ners from a medical ethics and human rights
\nperspective.
\nIn June, the WMA was invited by the UN
\nSubcommittee on Prevention of Torture to
\nparticipate in a roundtable discussion with
\nNGOs on mental health issues in places of
\ndeprivation of liberty. The aim of the event
\nwas to enhance the Committee\u2019s skills and
\nefficiency in preventing torture and ill-
\ntreatment in mental health institutions and
\nto improve the situation of the mentally ill
\nand the disabled by raising human rights
\nstandards and legal safeguards for this pop-
\nulation.
\nWomen and Children,
\nand Health
\nDuring the World Health Assembly, the
\nWMA organised a reception for Ministers
\nof Health and Heads of Delegations of the
\nAssembly. The Honorable Kathleen Sebel-
\nius, the U.S. Secretary of Health and Hu-
\nman Services, was the key note speaker on
\nthe topic of Women\u2019s, Maternal and Girls\u2019
\nHealth\u00a0\u2013 Their Futures in Our Hands.
\nThe WMA was an observer of the advocacy
\ngroup of the mission of the Every Woman
\nEvery Child initiative, spearheaded by\u00a0UN
\nSecretary-General Ban Ki-moon, set up
\nto mobilize and intensify global action to
\nimprove the health of women and children
\naround the world.
\nThe WMA had been involved in aiming
\nto increase the health status of children, by
\ndeveloping with the German Development
\nAid Agency GIZ and the South East Asian
\nMinisters of Education Organisation the
\n\u2018Fit for School course\u2019. This was designed
\nto promote and facilitate effective school
\nhealth programmes worldwide through
\nbuilding conceptual, implementation, and
\nmanagement capacity along with govern-
\nments, international organisations and
\nNGOs in low and middle-income coun-
\ntries. The course would be developed in a
\ncomprehensive yet modular way, enabling it
\nto be adapted to different target audiences
\nand national settings.
\nThe Declaration of Helsinki
\nIn October 2011, the WMA Council de-
\ncided to embark on a new process of re-
\nvising the Declaration. A workgroup was
\nformed with the mandate to present a re-
\nvised wording of the Declaration to the
\nEthics Committee.The revision process was
\naccompanied by a series of expert confer-
\nences to provide a platform for the inter-
\nnational biomedical ethics community to
\nair diverse viewpoints on the Declaration.
\nThe first conference was to be hosted by
\nthe South African Medical Association in
\nCape Town from 5\u20137 December 2012.This
\nwould be followed by a second conference
\nhosted by the Japan Medical Association in
\nTokyo from February 28\u2013March 1 2013.
\nThe Workgroup aimed to gather as much
\ninput as possible from WMA members,
\nthe international expert community and
\nrelevant international organisations. A call
\nfor comments had been sent to all WMA
\nmembers, and selected international organ-
\nisations had been invited to submit their
\nsuggestions for topics requiring revision. A
\npublic consultation on the revision process
\nwas envisioned for spring 2013.
\nWorld Health Professions Alliance
\nIn May 2012, the fifth WHPA leader-
\nship forum discussed collaborative practice
\namong health professionals and the impli-
\ncations of the financial crisis for national
\nand international associations. As an out-
\ncome of the forum, the WHPA was devel-
\noping a policy statement on collaborative
\npractice focusing on the principle of collab-
\norative practice with a global and universal
\napproach.
\nWMA Newsletter
\nThe Secretariat has started a bi-monthly
\nnewsletter for its members.The first two is-
\nsues were in July and September.
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\nWMA news
\nWMA Declaration on Medical
\nEthics and Advanced Medical
\nTechnology
\nAdopted by the 53rd
\nWMA General Assembly, Washington, DC, USA,
\nOctober 2002 and revised by the 63rd
\nWMA General Assembly, Bangkok,
\nThailand, October 2012
\nIt is essential to balance the benefits and risks for persons inherent
\nin the development and application of advanced medical technology.
\nMaintaining this balance is entrusted to the judgment of the physician.
\nTherefore:
\nMedical technology should be used to promote health. Patient safe-
\nty should be fully considered by the physician in the development
\nand application of medical technology.
\nIn order to foster physicians\u203a ability to provide appropriate medical
\ncare and having sufficient knowledge of medical technology efforts
\nmust be made to ensure the provision of comprehensive medical
\neducation focusing on the safe and effective use and development
\nof medical technology.
\nWMA Statement on Electronic
\nCigarettes and Other Electronic
\nNicotine Delivery Systems
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok, Thailand,
\nOctober 2012
\nINTRODUCTION
\nelectronic cigarettes (e-cigarettes) are products designed to deliver
\nnicotine to a user in the form of a vapor.They are usually composed
\nof a rechargeable battery-operated heating element, a replaceable
\ncartridge that contains nicotine and\/or other chemicals, and an at-
\nomizer that, when heated, turns the contents of the cartridge into
\na vapor (not smoke). This vapor is then inhaled by the user. These
\nproducts are often made to look like other tobacco-derived products
\nlike cigarettes, cigars, and pipes. They can also be made to look like
\neveryday items such as pens and USB memory sticks.
\nNo standard definition of e-cigarettes exists and different manufac-
\nturers use different designs and different ingredients. Quality control
\nprocesses used to manufacture these products are substandard or non-
\nexistent. Few studies have been done to analyze the level of nicotine
\ndelivered to the user and the composition of the vapor produced.
\nManufacturers and marketers of e-cigarettes often claim that use
\nof their products is a safe alternative to smoking, particularly since
\nthey do not produce carcinogenic smoke. However, no studies have
\nbeen conducted to determine that the vapor is not carcinogenic, and
\nthere are other potential risks associated with these devices: Appeal
\nto children, especially when flavors like strawberry or chocolate are
\nadded to the cartridges. E-cigarettes can increase nicotine addiction
\namong young people and their use may lead to experimenting with
\nother tobacco products.
\nManufacturers and distributors mislead people into believing these
\ndevices are acceptable alternatives to scientifically proven cessation
\ntechniques, thus delaying actual smoking cessation. E-cigarettes are
\nnot comparable to scientifically-proven methods of smoking cessa-
\ntion. Their dosage, manufacture, and ingredients are not consistent
\nor clearly labelled. Brand stretching by using known cigarette logos
\nis to be deplored.
\nUnknown amounts of nicotine are delivered to the user, and the
\nlevel of absorption is unclear, leading to potentially toxic levels of
\nnicotine in the system.These products may also contain other ingre-
\ndients toxic to humans.
\nHigh potential of toxic exposure to nicotine by children, either by
\ningestion or dermal absorption, because the nicotine cartridges and
\nrefill liquid are readily available over the Internet and are not sold in
\nchild resistant packaging.
\nDue to the lack of rigorous chemical and animal studies, as well as
\nclinical trials on commercially available e-cigarettes, neither their
\nvalue as therapeutic aids for smoking cessation nor their safety as
\ncigarette replacements is established. Lack of product testing does
\nnot permit the conclusion that e-cigarettes do not produce any
\nharmful products even if they produce fewer dangerous substances
\nthan conventional cigarettes.
\nClinical testing, large population studies and full analyses of e-ciga-
\nrette ingredients and manufacturing processes need to be conducted
\nbefore their safety, viability and impacts can be determined as either
\nclinical tools or as widely available effective alternatives to tobacco
\nuse.
\nRECOMMENDATIONS
\nThat the manufacture and sale of e-cigarettes and other electronic
\nnicotine delivery systems be subject to national regulatory bodies
\n186
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\nprior approval based on testing and research as either a new form of
\ntobacco product or as a drug delivery device.
\nThat the marketing of e-cigarettes and other electronic nicotine
\ndelivery systems as a valid method for smoking cessation must be
\nbased on evidence and must be approved by appropriate regulatory
\nbodies based on safety and efficacy data.
\nThat e-cigarettes and other electronic nicotine delivery systems be
\nincluded in smoke free laws.
\nPhysicians should inform their patients of the risks of using e-ciga-
\nrettes even if regulatory authorities have not taken a position on the
\nefficacy and safety of these products.
\nWMA Statement on the Ethical
\nImplications of Collective Action
\nby Physicians
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok, Thailand,
\nOctober 2012
\nPREAMBLE
\nIn recent years, in countries where physicians\u2019satisfaction with their
\nworking conditions has decreased, collective action by physicians
\nhas become increasingly common.
\nPhysicians may carry out protest action and sanctions in order to
\nimprove direct and indirect working conditions that also may affect
\npatient care. Physicians must consider not only their duty to indi-
\nvidual patients, but also their responsibility to improve the system
\nsuch that it meets the requirements of accessibility and quality.
\nIn addition to their professional obligations, physicians are often also
\nemployees.There may be tension between physicians\u2019duty not to cause
\nharm, and their rights as employees. Therefore, physicians\u2019 strikes or
\nother forms of collective action often give rise to public debate on ethi-
\ncal and moral issues. This statement attempts to address these issues.
\nRECOMMENDATIONS
\nThe World Medical Association recommends that National Medi-
\ncal Associations (NMAs) adopt the following guidelines for physi-
\ncians with regard to collective action:
\nPhysicians who take part in collective action are not exempt from
\ntheir ethical or professional obligations to patients.
\nEven when the action taken is not organized by or associated with
\nthe National Medical Association,the NMA should ensure that the
\nindividual physician is aware of and abides by his or her ethical ob-
\nligations.
\nWhenever possible, physicians should press for reforms through
\nnon-violent public demonstrations, lobbying and publicity or infor-
\nmational campaigns or negotiation or mediation.
\nIf involved in collective action, NMAs should act to minimize the
\nharm to the public and ensure that essential and emergency health
\nservices,and the continuity of care,are provided throughout a strike.
\nFurther, NMAs should advocate for measures to review exceptional
\ncases.If involved in collective action, NMAs should provide contin-
\nuous and up-to-date information to their patients and the general
\npublic with regard to the demands of the conflict and the actions
\nbeing undertaken. The general public must be kept informed in a
\ntimely manner about any strike actions and the restrictions they
\nmay have on health care.
\nWMA Statement on Forced and
\nCoerced Sterilisation
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok , Thailand,
\nOctober 2012
\nThe WMA recognises that no person, regardless of gender, ethnic-
\nity, socio-economic status, medical condition or disability, should be
\nsubjected to forced or coerced permanent sterilisation.
\nA full range of contraceptive services, including sterilisation, should
\nbe accessible and affordable to every individual. The state may have
\na role to play in ensuring that such services are available, along with
\nprivate, charitable and third sector organisations. The decision to
\nundergo contraception, including sterilisation, must be the sole de-
\ncision of the individual concerned.
\nAs with all other medical treatments,sterilisation should only be per-
\nformed on a competent patient after an informed choice has been
\nmade and the free and valid consent of the individual has been ob-
\ntained. Where a patient is incompetent, a valid decision about treat-
\nment must be made in accordance with relevant legal requirements
\nand the ethical standards of the WMA before the procedure is carried
\nout. Sterilization of those unable to give consent would be extremely
\nrare and done only with the consent of the surrogate decision maker.
\nSuch consent should be obtained when the patient is not facing a
\nmedical emergency, or other major stressor.
\n187
\nWMA news
\nThe WMA condemns practices where a state or any other actor at-
\ntempts to bypass ethical requirements necessary for obtaining free
\nand valid consent.
\nConsent to sterilisation should be free from material or social in-
\ncentives which might distort freedom of choice and should not be
\na condition of other medical care (including safe abortion), social,
\ninsurance, institutional or other benefits.
\nThe WMA calls on national medical associations to advocate against
\nforced and coerced sterilisation in their own countries and globally.
\nWMA Regulations in Times
\nof Armed Conflict and Other
\nSituations of Violence
\nAdopted by the 10th
\nWorld Medical Assembly, Havana, Cuba, October
\n1956, and edited by the 11th
\nWorld Medical Assembly, Istanbul, Turkey,
\nOctober 1957, revised by the 35th
\nWorld Medical Assembly, Venice, Italy,
\nOctober 1983, the 55th
\nWMA General Assembly, Tokyo, Japan, October
\n2004, editorially revised by the 173rd
\nWMA Council Session, Divonne-
\nles-Bains, France, May 2006, and revised by the 63rd
\nWMA General
\nAssembly, Bangkok, Thailand, October 2012
\nGeneral guidelines
\nMedical ethics in times of armed conflict is identical to medical eth-
\nics in times of peace, as stated in the International Code of Medi-
\ncal Ethics of the WMA. If, in performing their professional duty,
\nphysicians have conflicting loyalties, their primary obligation is to
\ntheir patients; in all their professional activities, physicians should
\nadhere to international conventions on human rights, international
\nhumanitarian law and WMA declarations on medical ethics.
\nThe primary task of the medical profession is to preserve health and
\nsave life. Hence it is deemed unethical for physicians to:
\n\u2022 Give advice or perform prophylactic, diagnostic or therapeutic
\nprocedures that are not justifiable for the patient\u2019s health care;
\n\u2022 Weaken the physical or mental strength of a human being with-
\nout therapeutic justification;
\n\u2022 Employ scientific knowledge to imperil health or destroy life;
\n\u2022 Employ personal health information to facilitate interrogation;
\n\u2022 Condone, facilitate or participate in the practice of torture or any
\nform of cruel, inhuman or degrading treatment.
\nDuring times of armed conflict and other situations of violence,
\nstandard ethical norms apply, not only in regard to treatment but
\nalso to all other interventions, such as research. Research involving
\nexperimentation on human subjects is strictly forbidden on all per-
\nsons deprived of their liberty, especially civilian and military prison-
\ners and the population of occupied countries.
\nThe medical duty to treat people with humanity and respect applies
\nto all patients. The physician must always give the necessary care
\nimpartially and without discrimination on the basis of age, disease
\nor disability, creed, ethnic origin, gender, nationality, political affilia-
\ntion, race, sexual orientation, or social standing or any other similar
\ncriterion.
\nGovernments, armed forces and others in positions of power should
\ncomply with the Geneva Conventions to ensure that physicians and
\nother health care professionals can provide care to everyone in need
\nin situations of armed conflict and other situations of violence.This
\nobligation includes a requirement to protect health care personnel
\nand facilities.
\nWhatever the context, medical confidentiality must be preserved
\nby the physician. However, in armed conflict or other situations of
\nviolence, and in peacetime, there may be circumstances in which a
\npatient poses a significant risk to other people and physicians will
\nneed to weigh their obligation to the patient against their obligation
\nto other individuals threatened.
\nPrivileges and facilities afforded to physicians and other health care
\nprofessionals in times of armed conflict and other situations of vio-
\nlence must never be used other than for health care purposes.
\nPhysicians have a clear duty to care for the sick and injured.Physicians
\nshould recognise the special vulnerability of some groups, including
\nwomen and children. Provision of such care should not be impeded
\nor regarded as any kind of offence. Physicians must never be prose-
\ncuted or punished for complying with any of their ethical obligations.
\nPhysicians have a duty to press governments and other authorities
\nfor the provision of the infrastructure that is a prerequisite to health,
\nincluding potable water, adequate food and shelter.
\nWhere conflict appears to be imminent and inevitable, physicians
\nshould, as far as they are able, ensure that authorities are planning
\nfor the protection of the public health infrastructure and for any
\nnecessary repair in the immediate post-conflict period.
\nIn emergencies, physicians are required to render immediate atten-
\ntion to the best of their ability. Whether civilian or combatant, the
\nsick and wounded must receive promptly the care they need. No
\ndistinction shall be made between patients except those based upon
\nclinical need.
\n188
\nWMA news
\nPhysicians must be granted access to patients, medical facilities and
\nequipment and the protection needed to carry out their professional
\nactivities freely. Such access must include patients in detention cen-
\ntres and prisons.Necessary assistance,including unimpeded passage
\nand complete professional independence, must be granted.
\nIn fulfilling their duties and where they have the legal right, physi-
\ncians and other health care professionals shall be identified and pro-
\ntected by internationally recognized symbols such as the Red Cross,
\nRed Crescent or Red Crystal.
\nHospitals and health care facilities situated in areas where there
\nis either armed conflict or other situations of violence must be re-
\nspected by all combatants and media personnel. Health care given
\nto the sick and wounded, civilians or combatants, cannot be used
\nfor publicity or propaganda. The privacy of the sick, wounded and
\ndead must always be respected. This includes visits from important
\npolitical figures for media purposes and also when important politi-
\ncal figures are among the wounded and the sick.
\nPhysicians must be aware that, during armed conflict or other situ-
\nations of violence, health care becomes increasingly susceptible to
\nunscrupulous practice and the distribution of poor quality\/counter-
\nfeit materials and medicines, and attempt to take action on such
\npractices.
\nThe WMA supports the collection and dissemination of data relat-
\ned to assaults on physicians, other health care personnel and medi-
\ncal facilities, by an international body. Such data are important to
\nunderstand the nature of such attacks and to set up mechanisms to
\nprevent them. Assaults against medical personnel must be investi-
\ngated and those responsible must be brought to justice.
\nCode of conduct: duties of physicians working in armed conflict
\nand other situations of violence
\nPhysicians must in all circumstances:
\n\u2022 Neither commit nor assist violations of international law (inter-
\nnational humanitarian law or human rights law);
\n\u2022 Not abandon the wounded and sick;
\n\u2022 Not take part in any act of hostility;
\n\u2022 Remind authorities of their obligation to search for the wounded
\nand sick and to ensure access to health care without unfair dis-
\ncrimination;
\n\u2022 Advocate and provide effective and impartial care to the wounded
\nand sick (without reference to any ground of unfair discrimina-
\ntion, including whether they are the \u201cenemy\u201d;);
\n\u2022 Recognise that security of individuals, patients and institutions
\nare a major constraint to ethical behaviour and not take undue
\nrisk in the discharge of their duties;
\n\u2022 Respect the individual wounded or sick person, his\/her will, con-
\nfidence and his\/her dignity;
\n\u2022 Not take advantage of the situation and the vulnerability of the
\nwounded and sick for personal financial gain;
\n\u2022 Not undertake any kind of experimentation on the wounded and
\nsick without their real and valid consent and never where they are
\ndeprived of liberty;
\n\u2022 Give special consideration to the greater vulnerability of women
\nand children in armed conflict and other situations of violence
\nand to their specific health-care needs;
\n\u2022 Respect the right of a family to know the fate and whereabouts
\nof a missing family member whether or not that person is dead or
\nreceiving health care;
\n\u2022 Provide health care for anyone taken prisoner;
\n\u2022 Advocate for regular visits to prisons and prisoners by physicians,
\nif such a mechanism is not already in place;
\n\u2022 Denounce and act,where possible,to put an end to any unscrupu-
\nlous practices or distribution of poor quality\/counterfeit materials
\nand medicines;
\n\u2022 Encourage authorities to recognise their obligations under in-
\nternational humanitarian law and other pertinent bodies of in-
\nternational law with respect to protection of health care person-
\nnel and infrastructure in armed conflict and other situations of
\nviolence;
\n\u2022 Be aware of the legal obligations to report to authorities the out-
\nbreak of any notifiable disease or trauma;
\n\u2022 Do anything within their power to prevent reprisals against the
\nwounded and sick or health care;
\n\u2022 Recognise that there are other situations where health care might
\nbe compromised but in which there are dilemmas.
\nPhysicians should to the degree possible:
\n\u2022 Refuse to obey an illegal or unethical order;
\n\u2022 Give careful consideration to any dual loyalties that the physician
\nmay be bound by and discuss these dual loyalties with colleagues
\nand anyone in authority;
\n\u2022 As an exception to professional confidentiality, and in line with
\nWMA Resolution on the Responsibility of Physicians in the
\nDocumentation and Denunciation of Acts of Torture or Cruel or
\nInhuman or Degrading Treatment and the Istanbul Protocol1
\n,de-
\nnounce acts of torture or cruel, inhuman or degrading treatment
\nof which physicians are aware, where possible with the subject\u2019s
\nconsent, but in certain circumstances where the victim is unable
\nto express him\/herself freely, without explicit consent;
\n\u2022 Listen to and respect the opinions of colleagues;
\n\u2022 Reflect on and try to improve the standards of care appropriate
\nto the situation;
\n1 Manual on Effective Investigation and Documentation of Torture and Other
\nCruel, Inhuman or Degrading Treatment or Punishment, OHCHR, 1999
\n189
\nWMA news
\n\u2022 Report unethical behaviour of a colleague to the appropriate su-
\nperior;
\n\u2022 Keep adequate health care records;
\n\u2022 Support sustainability of civilian health care disrupted by the
\ncontext;
\n\u2022 Report to a commander or to other appropriate authorities if
\nhealth care needs are not met;
\n\u2022 Give consideration to how health care personnel might shorten
\nor mitigate the effects of the violence in question, for example by
\nreacting to violations of international humanitarian law or human
\nrights law.
\nWMA Statement on Organ and
\nTissue Donation
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok, Thailand,
\nOctober 2012
\nPREAMBLE
\nAdvances in medical sciences, especially surgical techniques, tis-
\nsue typing and immuno-suppressive drugs, have made possible
\na significant increase in the rates of successful transplantation of
\nhuman organs and tissue. Yet, in all countries, a shortage of organ
\ndonors results in potentially avoidable loss of life. National medi-
\ncal associations should support attempts to maximise the num-
\nber of donor organs available in their countries and to ensure that
\nthe highest ethical standards are maintained. The World Medical
\nAssociation has developed this policy to assist medical associa-
\ntions, physicians, other health care providers and policy makers to
\nachieve this.
\n\u2022 This policy is based on a number of core principles: altruism, au-
\ntonomy, beneficence, equity and justice. These principles should
\nguide those developing local policies and those operating within
\nit, both in relation to organ procurement and to the distribution
\nand transplantation of donor organs. All systems and processes
\nshould be transparent and open to scrutiny.
\n\u2022 This statement applies to organ and tissue donation from both
\ndeceased and living donors. It does not apply to blood donation.
\nRaising public awareness
\nIt is important that individuals are aware of the option of dona-
\ntion and have the opportunity to choose whether or not to do-
\nnate organs and\/or tissue after their death. Awareness and choice
\nshould be facilitated in a coordinated multi-faceted approach
\nby a variety of stakeholders and means, including media aware-
\nness and public campaigns. In designing such campaigns account
\nneeds to be taken of any religious or cultural sensitivities of the
\ntarget audience.
\nThrough awareness raising campaigns, individuals should be in-
\nformed of the benefits of transplantation, the impact on the lives
\nof those who are waiting for a transplant and the shortage of do-
\nnors available.They should be encouraged to think about their own
\nwishes about donation, to discuss their wishes with their family and
\nfriends and to use established mechanisms to formally record them
\nby opting into, or out of, donation.
\nThe WMA advocates informed donor choice. National medical as-
\nsociations in countries that have adopted or are considering a policy
\nof \u201cpresumed consent\u201d (or opt-out), in which there is an assump-
\ntion that the individual wishes to donate unless there is evidence to
\nthe contrary, or \u201cmandated choice\u201d, in which all persons would be
\nrequired to declare whether they wish to donate, should make every
\neffort to ensure that these policies have been adequately publicised
\nand do not diminish informed donor choice, including the patient\u2019s
\nright not to donate.
\nConsideration should be given to the establishment of national do-
\nnor registries to collect and maintain a list of citizens who have cho-
\nsen either to donate or not to donate their organs and\/or tissue. Any
\nsuch registry must protect individual privacy and the individual\u2019s
\nability to control the collection, use, disclosure of, and access to, his
\nor her health information for other purposes. Provisions must be in
\nplace to ensure that the decision to sign up to a register is adequately
\ninformed and that registrants can withdraw from the registry easily
\nand quickly and without prejudice.
\nLiving organ donation is becoming an increasingly important
\ncomponent of transplantation programmes in many countries.
\nMost living donation is between related or emotionally close in-
\ndividuals but small but increasing numbers are donating to people
\nthey do not know. Given that there are health risks associated
\nwith living organ donation, proper controls and safeguards are
\nessential. Information aimed at informing people about the pos-
\nsibility of donating organs as a living donor should be carefully
\ndesigned so as not to put pressure on them to donate. Potential
\ndonors should know where to obtain detailed information about
\nwhat is involved, should be informed of the inherent risks and
\nshould know that there are safeguard in place to protect those
\noffering to donate.
\nProtocols for organ and tissue donation from deceased donors
\nThe WMA encourages its members to support the development of
\ncomprehensive, coordinated national protocols for deceased (also
\nreferred to as cadaveric) organ and tissue procurement in consulta-
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\ntion and cooperation with all relevant stakeholders. Ethical, cultural
\nand societal issues arising in connection with donation and trans-
\nplantation should be resolved, wherever possible, in an open process
\ninvolving public debate informed by sound evidence.
\nNational and local protocols should provide detailed information
\nabout the identification, referral and management of potential do-
\nnors as well as communication with those close to people who have
\ndied. They should encourage the procurement of organs and tissues
\nconsistent with this statement. Protocols should uphold the follow-
\ning key principles:
\n\u2022 Decisions to withhold or withdraw life-prolonging treatment
\nshould be based on an assessment of whether the treatment is
\nable to benefit the patient. Such decisions must be, and must be
\nseen to be,completely separate from any decisions about donation
\n\u2022 The diagnosis of death should be made according to national
\nguidelines and as outlined in the WMA\u2019s Declaration of Sydney
\non the Determination of Death and Recovery of Organs.
\n\u2022 There should be a clear separation between the treating team and
\nthe transplant team. In particular, the physician who declares or
\ncertifies the death of a potential donor should not be involved in
\nthe transplantation procedure. Nor should he\/she be responsible
\nfor the care of the organ recipient.
\n\u2022 Countries that carry out donation following circulatory death
\nshould have specific and detailed protocols for this practice.
\n\u2022 Where an individual has expressed a clear and voluntary wish to
\ndonate organs and\/or tissue after death, steps should be taken to
\nfacilitate that wish wherever possible. This is part of the treating
\nteam\u2019s responsibility to the dying patient.
\n\u2022 The WMA considers that the potential donor\u2019s wishes are para-
\nmount.Relatives and those close to the patient should be strongly
\nencouraged to support a deceased person\u2019s previously expressed
\nwish to donate organs and\/or tissues.
\n\u2022 Those charged with approaching the patient, family members or
\nother designated decision maker about organ and tissue donation
\nshould possess the appropriate combination of knowledge, skill
\nand sensitivity for engaging in such discussions. Medical students
\nand practising physicians should seek the necessary training for
\nthis task, and the appropriate authorities should provide the re-
\nsources necessary to secure that training.
\n\u2022 Donation should be unconditional. In exceptional cases, requests
\nby potential donors, or their substitute decision makers, for the
\norgan or tissue to be given to a particular recipient may be consid-
\nered if permitted by national law. Donors seeking to apply condi-
\ntions that could be seen as discriminatory against certain groups,
\nhowever, should be declined.
\nHospitals and other institutions where donation occurs should en-
\nsure that donation protocols are publicised amongst those likely to
\nuse them and that adequate resources are available for their imple-
\nmentation. They should also foster a pro-donation culture within
\nthe institution in which consideration of donation is the norm,
\nrather than the exception, when a patient dies.
\nThe role of transplant coordination is critical to organ donation.
\nThose performing coordination act as the key point of contact be-
\ntween the bereaved family and the donation team and usually also
\nundertake the complex logistical arrangements to make donation
\nhappen.Their role should be recognised and supported.
\nDeceased organ donation must be based on the notion of a gift,
\nfreely and voluntarily given. It should involve the voluntary and un-
\npressured consent of the individual provided before death (by opt-
\ning in or opting out of donation depending upon the jurisdiction) or
\nthe voluntary authorisation of those close to the deceased patient if
\nthat person\u2019s wishes are unknown.The WMA is strongly opposed to
\nthe commercialisation of donation and transplantation.
\nProspective donors or their substitute health care decision makers1
\nshould have access to accurate and relevant information, including
\nthrough their general practitioners. Normally, this will include in-
\nformation about:
\n\u2022 the procedures and definitions involved in the determination of
\ndeath,
\n\u2022 the testing that is undertaken to determine the suitability of the
\norgans and\/or tissue for transplantation and that this may reveal
\npreviously unsuspected health risks in prospective donors and
\ntheir families,
\n\u2022 measures that may be required to preserve organ function until
\ndeath is determined and transplantation can occur,
\n\u2022 what will happen to the body once death has been declared,
\n\u2022 what organs and tissues can be donated,
\n\u2022 the protocol that will be followed in the event that the family
\nobjects to donation, and
\n\u2022 the possibility of withdrawing consent.
\nProspective donors or their substitute health care decision makers
\nshould be given the opportunity to ask questions about donation
\nand should have their questions answered sensitively and intelligibly.
\nWhere both organs and tissues are to be donated, information
\nshould be provided,and consent obtained,for both together in order
\nto minimise distress and disruption to those close to the deceased.
\nIn some parts of the world a contribution towards funeral costs is
\ngiven to the family of those who donate.This can be viewed either
\n1 The term \u201csubstitute health care decision maker\u201d is intended to refer to any
\nperson properly designated to make health care related decisions on behalf
\nof the patient.
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\nas appropriate recognition of their altruistic act or as a payment
\nthat compromises the voluntariness of the choice and the altruistic
\nbasis for donation. The interpretation may depend, in part, on the
\nway it is set up and managed. When considering the introduction
\nof such a system, care needs to be taken to ensure that the core
\nprinciples of altruism, autonomy, beneficence, equity and justice
\nare met.
\nFree and informed decision making requires not only the provision
\nof information but also the absence of coercion.Any concerns about
\npressure or coercion should be resolved before the decision to do-
\nnate organs or tissue is made.
\nPrisoners and other people who are effectively detained in institu-
\ntions should be eligible to donate after death only in exceptional
\ncircumstances where:
\n\u2022 there is evidence that this represents their long-standing and con-
\nsidered wish and safeguards are in place to confirm this; and
\n\u2022 their death is from natural causes; and
\n\u2022 the organs are donated to a first or second degree relative either
\ndirectly or through a properly regulated pool.
\nIn jurisdictions where the death penalty is practised, executed pris-
\noners must not be considered as organ and\/or tissue donors. While
\nthere may be individual cases where prisoners are acting voluntar-
\nily and free from pressure, it is impossible to put in place adequate
\nsafeguards to protect against coercion in all cases.
\nAllocation of organs from deceased donors
\nThe WMA considers there should be explicit policies, open to pub-
\nlic scrutiny, governing all aspects of organ and tissue donation and
\ntransplantation, including the management of waiting lists for or-
\ngans to ensure fair and appropriate access.
\nPolicies governing the management of waiting lists should ensure
\nefficiency and fairness.Criteria that should be considered in allocat-
\ning organs or tissue include:
\n\u2022 severity and urgency of medical need
\n\u2022 length of time on the waiting list
\n\u2022 medical probability of success measured by such factors as age,
\ntype of disease, likely improvements in quality of life, other com-
\nplications, and histocompatibility.
\nThere should be no discrimination based on social status, lifestyle or
\nbehaviour. Non-medical criteria should not be considered.
\nLiving donation is becoming increasingly common as a way to over-
\ncome the shortage of organs from deceased donors. In most cases
\ndonors provide organs to relatives or people to whom they are emo-
\ntionally close. A small number of individuals choose to donate an
\norgan altruistically to a stranger. Another scenario is where one or
\nmore donor and recipient pairs are incompatible with each other but
\ndonate in the form of a cross-over or pooled donation system (for
\nexample, donor A donates to recipient B, donor B donates to recipi-
\nent C and donor C donates to recipient A).
\nAll potential donors should be given accurate and up to date in-
\nformation about the procedure and the risks of donation and have
\nthe opportunity to discuss the issue privately with a member of the
\nhealthcare team or a counsellor. Normally this information will in-
\nclude:
\n\u2022 the risks of becoming a living donor,
\n\u2022 the tests that are undertaken to assess suitability for donation and
\nthat this may reveal previously unsuspected health problems,
\n\u2022 what will happen before, during and after donation takes place,
\nand
\n\u2022 in the case of solid organs, the long-term implications of living
\nwithout the donated organ.
\nProspective donors should be given the opportunity to ask ques-
\ntions about donation and should have their questions answered sen-
\nsitively and intelligibly.
\nProcedures should be in place to ensure that living donors are act-
\ning voluntarily and free from pressure or coercion. In order to avoid
\ndonors being paid and then posing as a known donor, independent
\nchecks should also be undertaken to verify the claimed relationship
\nand, where this cannot be proven, the donation should not proceed.
\nSuch checks should be independent of the transplant team and
\nthose who are caring for the potential recipient.
\nAdditional safeguards should be in place for vulnerable donors, in-
\ncluding but not only, people who are dependent in some way (such
\nas competent minors donating to a parent or sibling).
\nPrisoners should be eligible to be living donors only in exceptional
\ncircumstances, to first or second degree family members; evidence
\nshould be provided of any claimed relationship before the donation
\nmay proceed.Where prisoners are to be considered as living donors,
\nextra safeguards are required to ensure they are acting voluntarily
\nand are not subject to coercion.
\nThose who lack the capacity to consent should not be considered
\nas living organ donors because of their inability to understand and
\ndecide voluntarily. Exceptions may be made in very limited circum-
\nstances, following legal and ethical review.
\nDonors should not lose out financially as a result of their donation
\nand so should be reimbursed for general and medical expenses and
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\nany loss of earnings incurred. In some parts of the world individuals
\nare paid for donating a kidney, although in virtually all countries
\nthe sale of organs is unlawful. The WMA is opposed to a market
\nin organs.
\nProtocols for free and informed decision making should be followed
\nin the case of recipients of organs or tissue. Normally, this will in-
\nclude providing information about:
\n\u2022 the risks of the procedure,
\n\u2022 the likely short, medium and long-term survival, morbidity, and
\nquality-of-life prospects,
\n\u2022 alternatives to transplantation, and
\n\u2022 how organs and tissues are obtained.
\nOrgans or tissue suspected to have been obtained through unlawful
\nmeans must not be accepted for transplantation
\nOrgans and tissues must not be sold for profit. In calculating the
\ncost of transplantation, charges related to the organ or tissue itself
\nshould be restricted to those costs directly associated with its re-
\ntrieval, storage, allocation and transplantation.
\nTransplant surgeons should seek to ensure that the organs and tis-
\nsues they transplant have been obtained in accordance with the pro-
\nvisions of this policy and should refrain from transplanting organs
\nand tissues that they know, or suspect, have not been procured in a
\nlegal and ethical manner.
\nIn the case of a delayed diagnosis for infection, disease or malig-
\nnancy in the donor, there should be a strong presumption that the
\nrecipient will be informed of any risk to which they may have been
\nexposed. Individual decisions about disclosure need to take account
\nof the particular circumstances, including the level and severity of
\nrisk. In most cases disclosure will be appropriate and should be
\nmanaged carefully and sensitively.
\nFUTURE OPTIONS
\nPublic health measures to reduce the demand for donated organs
\nshould be seen as a priority, alongside moves to increase the effec-
\ntiveness and success of organ donation systems.
\nNew developments and possibilities, such as xenotransplan-
\ntation and the use of stem cell technology to repair damaged
\norgans, should be monitored. Before their introduction into
\nclinical practice such technologies should be subject to scien-
\ntific review and robust safety checks as well as ethical review.
\nWhere, as with xenotransplantation, there are potential risks
\nthat go beyond individual recipients, this process should also
\ninvolve public debate.
\nWMA Statement on
\nthe Prioritisation of
\nImmunisation
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok, Thailand,
\nOctober 2012
\nPREAMBLE
\nVaccination use to prevent against disease was first done successfully
\nby Jenner in 1796 when he used cowpox material for vaccination
\nagainst smallpox. Since then, vaccination and immunisation have
\nbeen acknowledged as an effective preventive strategy for several
\ncommunicable diseases and are now being developed for the control
\nof some non-communicable diseases.
\nVaccine development and administration are some of the most sig-
\nnificant interventions to influence global health in modern times.
\nIt is estimated that immunisation currently prevents approximately
\n2.5 million deaths every year, saving lives from diseases such as
\ndiphtheria, tetanus, whooping cough (pertussis) and measles. Ap-
\nproximately 109 million children under the age of one are fully
\nvaccinated with the diphtheria-tetanus-pertussis (DTP3) vaccine
\nalone.
\nMostly the ultimate goal of immunisation is the total eradication
\nof a communicable disease. This was achieved for smallpox in 1980
\nand there is a realistic goal for the eradication of polio within the
\nnext few years.
\nThe Global Immunisation Vision Strategy (GIVS) 2006\u20132015 was
\ndeveloped by the WHO and UNICEF in the hope of reaching tar-
\nget populations who currently do not have immunisation services or
\nwho do not have an adequate level of coverage.
\nThe four strategies promoted in this vision are:
\n\u2022 Protecting more people in a changing world
\n\u2022 Introducing new vaccines and technologies
\n\u2022 Integrating immunisation, other linked health interventions and
\n\u2022 Surveillance in the health systems context
\n\u2022 Immunizing in the context of global interdependence1
\n1 World Health Organization and United Nations Children\u2019s Fund. Global
\nImmunisation Vision and Strategy, 2006\u20132015. Geneva, Switzerland:
\nWorld Health Organization and United Nations Children\u2019s Fund; 2005.
\nAvailable at: http:\/\/www.who.int\/immunisation\/givs\/related_docs\/en\/in-
\ndex.html
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\nVaccine research is constantly revealing new possibilities to protect
\npopulations from serious health threats. Additionally, new strains
\nof diseases emerge requiring the adaptation of vaccines in order to
\noffer protection.
\nThe process of immunisation requires an environment that is re-
\nsourced with appropriate materials and health workers to ensure the
\nsafe and effective administration of vaccines. Administration of vac-
\ncines often requires injections, and safety procedures for injections
\nmust always be followed.
\nImmunisation schedules can vary according to the type of vaccine,
\nwith some requiring multiple administrations to be effective. It is
\nvitally important that the full schedule is followed otherwise the
\neffectiveness of the vaccine may be compromised.
\nThe benefits of immunisation have had a profound effect on popula-
\ntions,not only in terms of preventing ill health but also in permitting
\nresources previously required to treat the diseases to be redirected to
\nother health priorities. Healthier populations are economically ben-
\neficial and can contribute more to society.
\nReducing child mortality is the fourth of the United Nation\u2019s Mil-
\nlennium Development Goals, with immunisation of children hav-
\ning a significant impact on mortality rates on children aged under
\nfive. According to the WHO, there are still more than 19 million
\nchildren who have not received the DTP3 vaccine.In addition,basic
\nhealth care services for maternal health with qualified health care
\npersonnel must be established.
\nImmunisation of adults for diseases such as influenza and pneu-
\nmococcal infections has been shown to be effective, not only in
\ndecreasing the number of cases amongst those that have received
\nimmunisation but also in decreasing the disease burden in soci-
\nety.
\nThe medical profession denounce any claims that are unfounded
\nand inaccurate with respect to the possible dangers of vaccine ad-
\nministration. Claims such as these have resulted in diminished im-
\nmunisation rates in some countries.The result is that the incidences
\nof the diseases to be prevented have increased with serious conse-
\nquences for a number of persons.
\nCountries differ in immunisation priorities, with the prevalence
\nand risk of diseases varying among populations. Not all countries
\nhave the same coverage rates, nor do they have the resources to
\nacquire, coordinate, distribute or effectively administer vaccines to
\ntheir populations, often relying on non-governmental organizations
\nto support immunisation programmes. These organizations in turn
\noften rely on external funding that may not be secure. In times of
\nglobal financial crisis, funding for such programmes is under con-
\nsiderable pressure.
\nThe risk of health complications from vaccine-preventable diseases
\nis greatest in those who experience barriers in accessing immunisa-
\ntion services.These barriers could be cost,location,lack of awareness
\nof immunisation services and their health benefits or other limiting
\nfactors.
\nThose with chronic diseases, underlying health issues or other risk
\nfactors such as age are at particular risk of major complications due
\nto vaccine-preventable diseases and therefore should be targeted to
\nensure adequate immunisation.
\nSupply chains can be difficult to secure,particularly in countries that
\nlack coordination or support of their immunisation programmes.
\nSecuring the appropriate resources, such as qualified health profes-
\nsionals, equipment and administrative support can present signifi-
\ncant challenges.
\nData collection on vaccine administration rates, side effects of
\nvaccines and disease surveillance can often be difficult to achieve,
\nparticularly in isolated and under-resourced areas. Nevertheless, re-
\nporting incidents and monitoring disease spread are vital tools in
\ncombating global health threats.
\nRECOMMENDATIONS
\nThe WMA supports the recommendations of the Global Immuni-
\nsation Vision Strategy (GIVS) 2006\u20132015, and calls on the inter-
\nnational community to:
\n\u2022 Encourage governments to commit resources to immunisation
\nprogrammes targeted to meet country specific needs.
\n\u2022 Recognise the importance of vaccination\/immunisation through
\nthe continued support and adoption of measures to achieve global
\nvaccination targets and to meet the Millennium Development
\nGoals, especially four (reduce child mortality), five (improve ma-
\nternal health) and six (combat HIV\/AIDS, malaria and other
\ndiseases).
\n\u2022 Recognise the global responsibility of immunisation against pre-
\nventable diseases and support work in countries that have difficul-
\nties in meeting the 2012 targets in the Global Polio Eradication
\nInitiative1
\n.
\n\u2022 Support national governments with vulnerable populations at risk
\nof vaccine-preventable diseases, and the local agencies that work
\n1 World Health Organization. Global Polio Eradication Initiative: Strategic
\nPlan 2010\u20132012. Geneva, Switzerland: World Health Organization; 2010.
\nAvailable at:http:\/\/www.polioeradication.org\/Portals\/0\/Document\/Strategic-
\nPlan\/StratPlan2010_2012_ENG.pdf
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\nWMA news
\nto deliver immunisation services and to work with them to allevi-
\nate retrictions in accessing services.
\n\u2022 Support vaccine research and development and ensure commit-
\nment through the adequate funding of vital vaccine research.
\n\u2022 Promote vaccination and the benefits of immunisation, particu-
\nlarly targeting those at-risk and those who are difficult to reach.
\nComply with monitoring activities undertaken by WHO and
\nother health authorities.Promote high standards in the research,
\ndevelopment and administration of vaccines to ensure patient
\nsafety. Vaccines need to be thoroughly tested before implemented
\non a large scale and subsequently monitored in order to identify
\npossible complications and untoward side effects. In order to be
\nsuccessful, immunisation programmes need public trust which
\ndepends on safety.
\nIn delivering vaccination programmes, the WMA recommends
\nthat:
\n\u2022 The full immunisation schedule is delivered to provide optimum
\ncoverage. Where possible, the schedule should be managed and
\nmonitored by suitably trained individuals to ensure consistent de-
\nlivery and prompt appropriate management of adverse reactions
\nto vaccines.
\n\u2022 Strategies are employed to reach populations that may be isolated
\nbecause of location, race, religion, economic status, social margin-
\nalization, gender and\/or age.
\n\u2022 Ensure that qualified health professionals receive comprehensive
\ntraining to safely deliver vaccinations and immunisations, and
\nthat vaccination\/immunisations are targeted to those whose need
\nis greatest.
\n\u2022 Educate people on the benefits of immunisation and how to ac-
\ncess immunisation services.
\n\u2022 Maintain accurate medical records to ensure that valid data on
\nvaccine administration and coverage rates are available, enabling
\nimmunisation policies to be based upon sound and reliable evi-
\ndence.
\n\u2022 Healthcare professionals should be seen as a priority population
\nfor the receipt of immunisation services due to their exposure to
\npatients and to diseases.
\nThe WMA calls upon its members to advocate the following:
\n\u2022 To increase awareness of national immunisation schedules and
\nof their own (and their dependents) personal immunisation his-
\ntory.
\n\u2022 To work with national and local governments to ensure that im-
\nmunisation programmes are resourced and implemented.
\n\u2022 To ensure that health personnel delivering vaccines and immuni-
\nsation services receive proper education and training.
\n\u2022 To promote the evidence base and increase awareness about
\nthe benefits of immunisation amongst physicians and the pub-
\nlic.
\nWMA Statement on Violence in
\nthe Health Sector by Patients and
\nThose Close to Them
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok, Thailand,
\nOctober 2012
\nPREAMBLE
\nAll persons have the right to work in a safe environment without
\nthe threat of violence. Workplace violence includes both physical
\nand non-physical (psychological) violence. Given that non-physical
\nabuse, such as harassment and threats, can have severe psychologi-
\ncal consequences, a broad definition of workplace violence should
\nbe used. For the purposes of this statement we will use the widely
\naccepted definition of workplace violence, as used by the WHO:
\n\u201cThe intentional use of power, threatened or actual, against another
\nperson or against a group, in work-related circumstances, that either
\nresults in or has a high degree of likelihood of resulting in injury,
\ndeath, psychological harm, mal-development, or deprivation\u201d.
\nViolence, apart from the numerous health effects it can have on
\nits victims, also has potentially destructive social effects. Violence
\nagainst health workers, including physicians, not only affects the
\nindividuals directly involved, but also impacts the entire healthcare
\nsystem and its delivery. Such acts of violence affect the quality of
\nthe working environment, which has the potential to detrimentally
\nimpact the quality of patient care. Further, violence can affect the
\navailability of care, particularly in impoverished areas.
\nWhile workplace violence is indisputably a global issue, various cul-
\ntural differences among countries must be taken into consideration in
\norder to accurately understand the concept of violence on a universal
\nlevel. Significant differences exist in terms of what constitutes vio-
\nlence and what specific forms of workplace violence are most likely
\nto occur.Threats and other forms of psychological violence are widely
\nrecognized to be more prevalent than physical violence. Reasons and
\ncauses of violence in the healthcare setting are extremely complex.
\nSeveral studies have identified common triggers for acts of violence
\nin the health sector to be delays in receiving treatment and dissatis-
\nfaction with the treatment provided.1
\nMoreover,patients may act ag-
\n1 Carmi-Iluz T, Peleg R, Freud T, Shvartzman P. Verbal and physical violence
\ntowards hospital- and community- based physicians in the Negev: an observa-
\ntional study BMC Health Service Research 2005, 5:54. Derazon H, Nissimian
\nS, Yosefy C, Peled R, Hay E. Violence in the emergency department (Article
\nin Hebrew) Harefuah. 1999 Aug;137(3-4):95-101, 175. Landua S F. Violence
\n195
\nWMA news
\ngressively as a result of their medical condition, the medication they
\ntake or the use of alcohol and other drugs.Another important exam-
\nple is that individuals may threaten or perpetrate physical violence
\nagainst healthcare workers because they oppose, on the basis of their
\nsocial, political or religious beliefs, a specific area of medical practice.
\nA multi-faceted approach encompassing the areas of legislation, se-
\ncurity, data collection, training, environmental factors, public aware-
\nness and financial incentives is required in order to successfully ad-
\ndress the issue of violence in the health sector.
\nIn addition, collaboration among various stakeholders (including
\ngovernments, National Medical Associations (NMAs), hospitals,
\ngeneral health services, management, insurance companies, trainers,
\npreceptors,researchers,police and legal authorities) is more effective
\nthan the individual efforts of any one party.As the representatives of
\nphysicians, NMAs should take an active role in combating violence
\nin the health sector and also encourage other key stakeholders to act,
\nthus further protecting the quality of the working environment for
\nhealthcare employees and the quality of patient care.
\nThis collaborative approach to addressing violence in the health sec-
\ntor must be promoted throughout the world.
\nRECOMMENDATIONS
\nThe WMA encourages National Medical Associations (NMAs) to
\nact in the following areas:
\nStrategy\u00a0\u2013 NMAs should encourage healthcare institutions to de-
\nvelop and implement a protocol to deal with acts of violence. The
\nprotocol should include the following:
\n\u2022 A zero-tolerance policy towards workplace violence.
\n\u2022 A universal definition of workplace violence.
\n\u2022 A predetermined plan for maintaining security in the workplace.
\n\u2022 A designated plan of action for healthcare professionals to take
\nwhen violence takes place.
\n\u2022 A system for reporting and recording acts of violence, which may
\ninclude reporting to legal and\/or police authorities.
\n\u2022 A means to ensure that employees who report violence do not
\nface reprisals.
\nIn order for this protocol to be effective, it is necessary for the man-
\nagement and administration of healthcare institutions to commu-
\nnicate and take the necessary steps to ensure that all staff are aware
\nof the strategy.
\nagainst medical and non-medical personnel in hospital emergency wards in
\nIsrael Research Report, Submitted to the Israel National Institute for Health
\nPolicyand Health Services Research, December 2004
\nPolicymaking\u00a0\u2013 In order to help increase patient satisfaction, na-
\ntional priorities and limitations on medical care should be clearly
\naddressed by government institutions.
\nThe state has obligations to ensure the safety and security of patients,
\nphysicians, and other healthcare workers. This includes providing
\nan appropriate physical environment. Hence, healthcare systems
\nshould be designed to promote the safety of healthcare staff and
\npatients. An institution which has experienced an act of violence by
\na patient may require the provision of extra security,as all healthcare
\nworkers have the right to be protected in their work place.
\nIn some jurisdictions, physicians might have the right to refuse to
\ntreat a violent patient. In such cases, they must ensure that adequate
\nalternative arrangements are made by the relevant authorities in or-
\nder to safeguard the patient\u203as health and treatment.
\nPatients with acute, chronic or illness-induced mental health dis-
\nturbances may act violently toward caregivers; those offering care to
\nthese patients must be adequately protected.
\nTraining\u00a0\u2013 A well-trained and vigilant staff supported by manage-
\nment can be a key deterrent of violent acts. NMAs should work
\nwith undergraduate and postgraduate education providers to ensure
\nthat healthcare professionals are trained in the following: com-
\nmunication skills and recognising and handling potentially violent
\npersons and high risk situations in order to prevent incidents of
\nviolence.The cultivation of physician-patient relationships based on
\nrespect and mutual trust will not only improve the quality of patient
\ncare, but will also foster feelings of security resulting in a reduced
\nrisk of violence.
\nCommunication\u00a0\u2013 NMAs should work with other key stakehold-
\ners to increase awareness of violence in the health sector. When
\nappropriate, they should inform healthcare workers and the public
\nwhen acts of violence occur and encourage physicians to report acts
\nof violence through the appropriate channels.
\nFurther,once an act of violence has taken place,the victim should be
\ninformed about the procedures undertaken thereafter.
\nSupport to victims\u00a0\u2013 Medical, psychological and legal counselling
\nand support should be provided to staff members who have been the
\nvictims of threats and\/or acts of violence while at work.
\nData Collection\u00a0\u2013 NMAs should lobby their governments and\/or
\nhospital boards to establish appropriate reporting systems enabling
\nall healthcare workers to report anonymously and without reprisal,
\nany threats or incidents of violence. Such a system should assess
\nin terms of number, type and severity, incidents of violence within
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\nWMA news
\nan institution and resulting injuries. The system should be used to
\nanalyse the effectiveness of preventative strategies. Aggregated data
\nand analyses should be made available to NMAs.
\nInvestigation\u00a0\u2013 In all cases of violence there should be some form of
\ninvestigation to better understand the causes and to aid in preven-
\ntion of future violence. In some cases, the investigation may lead to
\nprosecution under civil or criminal codes. The procedure should be,
\nas much as possible, authoritative-led and uncomplicated for the
\nvictim.
\nSecurity\u00a0\u2013 NMAs should work to ensure that appropriate security
\nmeasures are in place in all healthcare institutions and that acts of
\nviolence in the healthcare sector are given a high priority by law-
\nenforcement institutions. A routine violence risk audit should be
\nimplemented in order to identify which jobs and locations are at
\nhighest risk for violence.Examples of high risk areas include general
\npractice premises, mental health treatment facilities and high traffic
\nareas of hospitals including the emergency department.
\nThe risk of violence may be ameliorated by a variety of means which
\ncould include placing security guards in these high risk areas and at
\nthe entrance of buildings, by the installation of security cameras and
\nalarm devices for use by health professionals, and by maintaining
\nsufficient lighting in work areas, contributing to an environment
\nconducive to vigilance and safety.
\nFinancial\u00a0\u2013 NMAs should encourage their governments to allocate
\nappropriate funds in order to effectively tackle violence in the health
\nsector.
\nWMA Resolution on the Abuse
\nof Psychiatry
\nAdopted by the 53rd
\nWMA General Assembly, Washington, DC, USA,
\nOctober 2002 and revised by the WMA General Assembly, Bangkok
\n2012
\nThe World Medical Association (WMA) notes with concern evi-
\ndence from a number of countries that political dissidents, practi-
\ntioners of various religions and social activists have been detained
\nin psychiatric institutions and subjected to unnecessary psychiatric
\ntreatment as a punishment and not to treat a substantiated psychi-
\natric illness.
\nThe WMA:
\n\u2022 Declares that such detention and unwarranted treatment is abu-
\nsive, unethical and unacceptable;
\n\u2022 Calls on physicians and psychiatrists to resist involvement in
\nthese abusive practices;
\n\u2022 Calls on member NMAs to support their physician members
\nwho resist involvement in these abuses, and
\n\u2022 Calls on governments to stop abusing medicine and psychiatry
\nin this manner, and on non-governmental organizations and the
\nWorld Health Organization to work to end these abuses; and
\n\u2022 Calls on governments to uphold the United Nations Interna-
\ntional Covenant on Civil and Political Rights, which states that
\n\u201call persons are equal before the law and are entitled without any
\ndiscrimination to the equal protection of the law.\u201d
\nWMA Resolution to Reaffirm the
\nWMA\u2019s Prohibition of Physician
\nParticipation in Capital
\nPunishment
\nAdopted by the 63rd
\nGeneral Assembly of the World Medical Association,
\nBangkok, Thailand, October 2012
\nThere is universal agreement that physicians must not participate
\nin executions because such participation is incompatible with the
\nphysician\u203as role as healer. The use of a physician\u203as knowledge and
\nclinical skill for purposes other than promoting health, wellbeing
\nand welfare undermines a basic ethical foundation of medicine\u00a0\u2013
\nfirst, do no harm.
\nThe WMA Declaration of Geneva states: \u201cI will maintain the ut-
\nmost respect for human life\u201d; and,\u201cI will not use my medical knowl-
\nedge to violate human rights and civil liberties, even under threat.\u201d
\nAs citizens, physicians have the right to form views about capital
\npunishment based on their individual moral beliefs. As members
\nof the medical profession, they must uphold the prohibition against
\nparticipation in capital punishment.
\nTherefore, be it RESOLVED that:
\n\u2022 Physicians will not facilitate the importation or prescription of
\ndrugs for execution.
\n\u2022 The WMA reaffirms:\u201cthat it is unethical for physicians to partici-
\npate in capital punishment, in any way, or during any step of the
\nexecution process, including its planning and the instruction and\/
\nor training of persons to perform executions\u201d, and
\n\u2022 The WMA reaffirms: that physicians \u201cwill maintain the utmost
\nrespect for human life and will not use [my] medical knowledge
\nto violate human rights and civil liberties, even under threat.\u201d
\n197
\nWMA news
\nWMA Resolution on a Minimum
\nUnit Price for Alcohol
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok, Thailand,
\nOctober 2012
\nEvidence from epidemiological and other research demonstrates a
\nclear link between the price of alcohol and levels of consumption,
\nespecially amongst young drinkers and those who are heavy alcohol
\nusers.
\nSetting a minimum unit price at a level that will reduce alcohol
\nconsumption is a strong public health measure, which will both re-
\nduce average alcohol consumption throughout the population and
\nbe especially effective in heavy drinkers and young drinkers.
\nSome states are intending to set a minimum unit price in order to
\nreduce the medical and social effects of excessive alcohol consump-
\ntion.
\nThe WMA supports states seeking to use such innovative measures
\nto combat the serious public and individual health effects of exces-
\nsive and problem drinking.
\nWMA Resolution on Plain
\nPackaging of Cigarettes
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok, Thailand,
\nOctober 2012
\nThe WMA recognises that:
\n\u2022 Cigarettes offer a serious threat to the life and health of indi-
\nviduals that use them, and a considerable cost to the health care
\nservices of every country;
\n\u2022 Those who smoke predominantly start to do so while adolescents;
\n\u2022 There is a proven link between brand recognition and likelihood
\nof starting to smoke;
\n\u2022 Brand recognition is strongly linked to cigarette packaging;
\n\u2022 Plain packaging reduces the impact of branding, promotion and
\nmarketing of cigarettes.
\nThe WMA encourages national governments to support moves
\nto introduce plain packaging of cigarettes, initially by the Federal
\nGovernment of Australia, to break the brand recognition\/smoking
\ncycle and commends adoption of this policy to other national gov-
\nernments and deplores the legal moves being taken by the tobacco
\nindustry to oppose this policy.
\nWMA Resolution in Support of
\nProfessor Cyril Karabus
\nAdopted by the 63rd
\nWMA General Assembly, Bangkok, Thailand,
\nOctober 2012
\nThe WMA welcomes the bail granted on the 11th
\nof October to the
\nretired South African paediatric haematologist, 78-year-old Profes-
\nsor Cyril Karabus, as a positive step given his state of health; he has
\ncardiac disease. Dr. Karabus had been detained in an Abu Dhabi,
\nUAE prison since August 18th
\n2012. He was arrested in Dubai,
\nwhilst in transit to South Africa, owing to alleged charges emanat-
\ning from a brief period that he worked in the UAE in 2002.
\nProfessor Karabus was neither informed of the charges leveled
\nagainst him nor the subsequent trial that was held in absentia relat-
\ning to the unfortunate death of a child with acute leukemia under
\nhis care during his tenure in the UAE in 2002. His defense lawyer
\nhas also been unable to access any documents or files relating to the
\ncase that may assist in providing a fair defense.
\nTherefore,
\nThe WMA General Assembly urgently calls on the authorities of
\nthe United Arab Emirates to ensure that Professor Karabus:
\n\u2022 Is guaranteed a fair trial according to international standards;
\n\u2022 Has access to the relevant documents or information he may re-
\nquire to prepare his defense.
\n198
\nWMA news
\nPreamble
\nAcknowledging that the World Veteri-
\nnary Association [hereinafter referred to as
\nWVA] is the recogn ized global professional
\nveterinary organisation, founded in 1863, as
\nan Association of 100 national veterinary
\nmedical associations supporting the global
\npublic good, including in animal health
\nand veterinary public health internationally,
\nfood safety and the management of zoo-
\nnotic diseases, animal welfare and disease
\nmonitoring based on veterinary education
\nand evidence based science, representing
\nthe veterinarians by promoting their health
\nand well-being.
\nAcknowledging that the World Medi-
\ncal Association [hereinafter referred to as
\nWMA] is an international professional
\norganisation representing physicians,
\nfounded in 1947, and is an independent
\nconfederation of 100 national medical as-
\nsociations whose purpose is to serve hu-
\nmanity by endeavouring to achieve the
\nhighest international standards in medical
\neducation, medical science, medical art and
\nmedical ethics and health care for all people
\nin the world.
\nBearing in mind that collaboration with
\nthe World Health Organisation [WHO]
\nis a key focus of WMA\u2019s external relations
\nbecause the WMA\u2019s core mission is to pro-
\nmote health and well-being of physicians
\nand patients. Therefore the WMA com-
\nmits itself to actively collaborating with
\nthe WHO in the areas of medicine with
\na strong focus on health systems develop-
\nment and strengthening public health pro-
\ngrams.
\nBearing in mind also that WVA has a
\nlongstanding collaborative agreement with
\nWHO based on mutually agreed objectives
\nthat outlines activities for three-year periods.
\nMain areas of involvement include lowering
\nthe burden of zoonotic diseases, increasing
\nfood safety and improving the global health
\nstatus [healthy animals = healthy people];
\nraising the quality of teaching of veterinar-
\nians in food safety issues and zoonosis; ad-
\ndressing food safety; and responsible use of
\nantimicrobials.
\nRecognizing that the World Animal
\nHealth Organisation [OIE] is the formal-
\nly mandated international animal health
\nstandard setting body recognized by the
\nWorld Trade Organisation [WTO] and
\nthat a long term collaborative agreement
\nbetween WVA and OIE exists. That WVA
\nhas a Memorandum of Understanding with
\nthe Food and Agriculture Organisation of
\nthe United Nations [FAO] to support in-
\nternational [animal] health capacity build-
\ning, that extends to public health and food
\nsafety-food security.
\nBoth parties assist global efforts to redress
\npathogen emergence and re-emergence
\nat the animal-human-ecosystems inter-
\nface. WVA is an observer in the Codex
\nAlimentarius Commission. Therefore it is
\nimportant to have a Memorandum of Un-
\nderstanding between WVA and WMA as
\nwell.
\nConscious of the prospects of a mutually
\nbeneficial relationship and the need to es-
\ntablish working arrangements within a
\nframework of their respective rules, regula-
\ntions and bylaws:
\nThe WVA and the WMA [hereinafter re-
\nferred to as \u201cThe Parties\u201d] agree to the fol-
\nlowing:
\nSection 1.Global Development Objective
\nThe Parties will collaborate in The One-
\nHealth concept, which is a unified approach
\nto veterinary and human medicine [veteri-
\nnarians and physicians] in order to improve
\nGlobal Health.
\nSection 2. Scope of Cooperation
\nThe scope of cooperation proposed by this
\nMemorandum of Understanding will in-
\nclude
\n2.1 Support the concept of joint educational
\nefforts between human medical and vet-
\nerinary medical schools;
\n2.2 Support cross species disease surveil-
\nlance and control efforts in order to pre-
\nvent zoonotic diseases
\n2.3 Collaborate in the responsible use of
\nantimicrobials with respect to critical
\nantimicrobial lists for humans and ani-
\nmals.
\n2.4 Enhance collaboration between hu-
\nman and veterinary medical profes-
\nsions in medical education, clinical
\ncare, and public health and biomedical
\nresearch.
\nSection 3. Use of Logos
\nThe use of the WVA-logo is specifically
\nprohibited without prior written approval
\nfrom WVA. The use of the WMA-logo is
\nspecifically prohibited without prior written
\napproval from WMA.
\nSection 4. Final Provisions
\nThis Memorandum of Understanding re-
\nflects the professional collaboration be-
\ntween WVA and WMA on a basis of
\ngood-fellowship and shall represent the un-
\nderstanding of the Parties upon its signing
\nby the WVA and the WMA.
\nMemorandum of Understanding between
\nthe World Veterinary Association and
\nthe World Medical Association
\n199
\nTobacco HazardsAUSTRALIA
\nAustralian smokers will soon be plucking
\ntheir cigarettes, cigars and other tobacco
\nproducts from drab olive brown packets
\nemblazoned with graphic health images and
\nwarnings, as the world\u2019s first tobacco plain
\npackaging laws come into effect.
\nIn a measure that has drawn widespread in-
\nternational interest, the Australian Govern-
\nment has successfully enacted laws virtually
\neliminating the ability of tobacco compa-
\nnies to market their products through their
\npackaging.
\nFrom 1 December all tobacco products sold
\nin Australia must be in plain packaging,car-
\nrying large and explicit health images and
\nwarnings covering at least 75 per cent of the
\npacket. Any product branding will be lim-
\nited to words in small areas at the bottom
\nand sides of packs.
\nThe tough measures, strongly backed by
\npublic health organisations, came into effect
\nafter the High Court of Australia rejected a
\nlegal challenge mounted by the world\u2019s major
\ntobacco companies. The Australian Medical
\nAssociation has been a strong advocate for
\nplain packaging, which it sees as an effec-
\ntive tool for combating the glamorisation of
\nsmoking, particularly to young people.
\nIn their challenge, British American Tobac-
\nco Australia, Japan Tobacco International,
\nPhilip Morris and Imperial Tobacco Aus-
\ntralia, argued the new measures amounted
\nto the acquisition of their brands and logos
\nby the Government without just compensa-
\ntion, and should be ruled unconstitutional.
\nBut the High Court found in favour of the
\ncounter argument from the Government
\nthat although the laws required the removal
\nof trademarks from all cigarette packets,
\nthey did not weaken the companies\u2019 exclu-
\nsive ownership of their trademarks.
\n\u201cAlthough the Act regulated the plaintiffs\u2019
\nintellectual property rights and imposed
\ncontrols on the packaging and presenta-
\ntion of tobacco products, it did not confer a
\nproprietary benefit or interest on the Com-
\nmonwealth,\u201dthe High Court said in a sum-
\nmary of its judgement.
\nThe Government has insisted that the laws
\nwere aimed solely at reducing the incidence
\nof smoking.
\n\u201cResearch shows that industry branding
\nand packaging design on tobacco products
\ncan mislead consumers about the harms of
\nsmoking, make smoking more appealing\u00a0\u2013
\nparticularly among young people\u00a0\u2013 and re-
\nduce the effectiveness of health warnings
\non tobacco products,\u201d the Department of
\nHealth and Ageing said.
\nAttorney-General Nicola Roxon, who in-
\ntroduced the plain packaging legislation as
\nHealth Minister, and her successor Tanya
\nPlibersek, said the High Court decision was
\n\u201ca victory for all those families who have
\nlost someone to a tobacco-related illness
\n[and] a relief for every parent who worries
\nabout their child picking up this deadly and
\naddictive habit\u201d.
\n\u201cPlain packaging is a vital preventative pub-
\nlic health measure, which removes the last
\nway for big tobacco to promote its deadly
\nproducts,\u201d the Ministers said in a joint
\nstatement. \u201cOver the past two decades,
\nmore than 24 different studies have backed
\nplain packaging, and now it will finally be-
\ncome a reality.\u201dBut the tobacco industry has
\nnot given up the fight completely.
\nIn addition to the High Court challenge, it
\nhas also backed action being taken by sev-
\neral countries against the legislation under
\ntrade laws.
\nThe Dominican Republic has joined
\nUkraine and Honduras in complaining that
\nthe laws unfairly restrict trade and should
\nbe scrapped.
\nWhile the Caribbean nation is a tiny trade
\npartner, exporting just $20 million worth
\nof goods to Australia in 2011, it is a major
\nproducer of cigars, and has lodged a formal
\ncomplaint about the plain packaging laws
\nwith the global trade umpire, the World
\nTrade Organisation.
\nThe Dominican Republic Government
\nformally notified of a trade dispute by re-
\nquesting consultations with Australia \u201con
\ncertain measures concerning trademarks,
\ngeographical indications and other plain
\npackaging requirements applicable to to-
\nbacco products and packaging\u201d through the
\nauspices of the WTO.
\nBoth Honduras and Ukraine, both tobacco-
\nexporting nations, are already well advanced
\nin the preliminary steps that need to be tak-
\nen before the matter proceeds to the WTO
\nadjudication, having requested consulta-
\ntions with Australia over the measure.
\nWorld-leading Plain Packaging Laws
\nSqueeze Big Tobacco
\nSteve Hambleton
\n200
\nRegional and NMA news ESTONIA
\nUnder the WTO rules, if the matter cannot
\nbe resolved by negotiation within 60 days,
\nthe complainant can ask the WTO to set up
\na panel to adjudicate the case.
\nThe issue has drawn significant internation-
\nal interest, with a large number of countries
\nacting as third-party observers in the case.
\nThe plain packaging laws are among a range
\nof measures being taken by Australian
\ngovernments at all levels to curb smoking,
\nwhich is estimated to cost the nation $31.5
\nbillion a year in health expenses.
\nIn its May Budget,the Federal Government
\nslashed the duty-free allowance for travel-
\nlers bringing tobacco products into the
\ncountry from 250 cigarettes or 250 grams
\nof tobacco to 50 cigarettes or 50 grams of
\ntobacco, and two years ago it raised the to-
\nbacco excise by 25 per cent.
\nThe range and appearance of health warn-
\nings on tobacco products has been in-
\ncreased, restrictions have been imposed on
\nadvertising tobacco products on the internet
\nin Australia, and access to nicotine replace-
\nment therapies and other aids to quitting
\nsmoking is subsidised.
\nThese more recent measures follow a long-
\nstanding nationwide ban on tobacco ad-
\nvertising and sponsorships, particularly of
\nsporting events, and the progressive in-
\ntroduction of laws prohibiting smoking at
\nworkplaces, sporting and entertainment
\nvenues and enclosed public places.
\nOfficial figures show the incidence of smok-
\ning among adults, particularly men, has
\nbeen steadily decreasing in recent decades.
\nAccording to the Australian Bureau of Sta-
\ntistics, the proportion of men who smoke
\ndropped from more than 27 per cent in
\n2001 to 23 per cent in 2008, while among
\nwomen there was a more modest reduction
\nfrom 21.2 to 19 per cent over the same pe-
\nriod.
\nThe AMA has been a long-standing advo-
\ncate for plain packaging laws.
\nIn mid-2009 it lobbied federal politicians to
\nsupport the Plain Tobacco Packaging Bill
\nintroduced by independent Senator Steve
\nFielding, and eight months later threw its
\npublic support behind a decision by the
\nRudd Government to introduce plain pack-
\naging laws in 2012.
\nA year later, in July 2011, the Association
\nmade a submission to a Parliamentary in-
\nquiry in which it strongly backed the Gov-
\nernment\u2019s Tobacco Plain Packaging Bill,
\nand AMA officials were prominent advo-
\ncates for the measure in the media.
\nDespite the breakthrough plain packaging
\nlaws, the Australian Government is under
\npressure to do more to combat smoking.
\nThe AMA is among health groups critical
\nof recent investments made by a public fund
\nin tobacco companies.
\nThe Government\u2019s $73 billion Future Fund,
\nset up to offset future public servant su-
\nperannuation liabilities, invested almost
\n$38\u00a0million in tobacco company shares be-
\ntween December 2010 and February 2012.
\nThe AMA believes it is simply irrational to
\nhave the good work that the Federal Govern-
\nment has done in tobacco plain packaging
\nand tax measures undermined by Future Fund
\ninvestments that help the tobacco industry to
\nprofit from selling a lethal substance.
\nThe Future Fund has a responsibility to in-
\nvest taxpayer money in a way that was con-
\nsistent with the interests of the country and
\nits people.
\nBut the Government has so far firmly re-
\nsisted pressure to dictate to the Future
\nFund how it should invest the money it
\nmanages.
\nDr. Steve Hambleton,
\nPresident of Australian
\nMedical Association
\nEstonian Medical Association and the
\nTrade Union Association of Health Offi-
\ncers of Estonia organised a strike to fight
\nfor better working conditions (workload!!!
\n1 doctor does 2,5 \u201cplaces\u201d) to medical staff,
\ntheir salary and emigration policy!
\nFirst week of the strike\u00a0\u2013 1\u20137 october\u00a0\u2013 in
\ntwo biggest towns in Estonia (Tartu and
\nTallinn) strike was in action in ambula-
\ntory clinic\u00a0\u2013 only children, oncological and
\npregnant patients were seen during elec-
\ntive hours. All emergency departments and
\nICU\u2019s of course were working.
\nSecond week of the strike\u00a0\u2013 8\u201314 october\u00a0\u2013
\nin Tartu and Tallinn\u00a0 \u2013 strike affects also
\nstationary care (about 50% of the elective
\noperations are postponed and those patients
\ncoming to hospital for evaluation\/investiga-
\ntions are cancelled.) + ambulatory stop in
\nsmaller hospitals in Estonia. Third week\u00a0\u2013
\n15-smaller hospitals also stop\/inhibit their
\nstationary care.
\nStill going on…
\nAfter two weeks of strike no compromise
\nhas been made.
\nDuring strike, government and major poli-
\ntic forces have gone really cheap\u00a0\u2013 the me-
\ndia is publishing extreme numbers of doc-
\ntors\u2019salaries to show people that doctors are
\nEstonian Physician on Strike
\nIII
\nRegional and NMA newsESTONIA
\njust a \u201cbunch of greedy and dumb people
\nwho do not want to work\u201d. Fortunately the
\nnurses and orderlies are not attacked, the
\ndoctors\u2019 take all the blame.
\nThe demands of the strike are:
\n\u2022 changes in health care system in gen-
\neral (more money to health sector out of
\nGDP, currently 6,3% )
\n\u2022 raising salaries for nurses, orderlies and
\ndoctors!
\n\u2022 Workload management!
\n\u2022 To stop people leaving Estonia
\nNegotiations about raising salaries of medi-
\ncal workers which started as much as 3 years
\nago, are still in progress.The salaries are still
\nstaying the same due to the fact that no of-
\nficial meetings have been successful.
\nThe counter-act from the political side
\nseems to be affecting media in producing
\nunbelievable stories about over-paid doc-
\ntors who don\u2019t know how to treat people
\nand only take their money out of pure
\ngreed.
\nThe picture the media is painting of Esto-
\nnian doctors right now is in really dark and
\ngloomy colors and we have a hard time do-
\ning our jobs because there\u2019s a lot of people
\nlacking trust towards us.
\n(Currently minimum gross wages per hour
\nare for doctors and dentists 7,16 \u20ac (resident
\nhave usually 0,8 place),nurses and midwives
\n3,83 \u20ac and caregivers 2,11 \u20ac. Minimum sal-
\nary suggestions are respectively for year
\n2012 8,6\/5,5\/3 \u20ac, 2013 10\/6,6\/3,35 \u20ac and
\n2014 12\/7,7\/4,2 \u20ac per hour, for assistant
\ndoctors 60% of minimum doctors wages.
\nFor the residents a normal 40 hours work-
\nweek (at the moment it is paid for 32 hours
\nper week).
\nEmigrating healthcare professionals
\n(Doctors and nurses migration to the
\nabroad have been increased, partly due to
\nadverse environmental healthcare situa-
\ntion, low salaries and high workload. This
\napplies in particular to young doctors, for
\nexample, 28 (26%) of this year MD gradu-
\nates did not even apply to residency, most
\nof them went to work or study abroad.
\nHealthcare workers leaving: year \u201804 439,
\n\u201905 279, \u201906 196, \u201907 182, \u201908 188, \u201909 254,
\n\u201910 398. From 2010 it costs 200\u20ac to have
\ncertificate to work abroad as a doctor and
\nit is valid for 3 month. Nurses leave have
\nbeen doubled in a year (200 versus 100).
\nIn Estonia are approximately 2 nurses per
\n1\u00a0doctor, for 1000 inhabitant are 7,1 nurs-
\nes, which is low in Europe.
\nFurther, new doctors\u2019 addition is not
\nenough. Annual retirement age exceeds
\nresidency graduates from year 2014 (until
\n2027), for example, in 2023 is estimated to
\nhave at least 100 doctor less. In 2010 there
\nwas 4510 working doctors, 81 new doctors
\ngraduated residency but in same time went
\nto abroad 146 and retired 126.)
\n*Campaign \u201cI believe in the
\nfuture of Estonian Medicine\u201d
\nIn association with Estonian Medical
\nStudents Association we have launched a
\ncampaign saying \u201c I believe in the future of
\nEstonian Medicine\u201d to promote discussion
\namong medical workers of what\u2019s good in
\nour system and what\u2019s bad, and to show
\npatients that there are still some doctors
\nwho want to stay here and treat our own
\npeople. The campaign t-shirts where sent
\nto important people in Estonia and in all
\nthe hospitals, they were sold during the Es-
\ntonian Doctors Days and one can order it
\non our webpage. Also little pins with the
\nsame slogan were handed out and those
\nwho wanted had the possibility to order
\nfleeces with the same slogan. The idea was
\nto promote discussion and that has worked
\nout fine\u00a0\u2013 people are talking to each other
\ntrying to figure out the weak spots in our
\nsystem and finding solutions to make situ-
\nation better. We have had quite many doc-
\ntors and associations telling us that we\u2019re on
\nthe right track.
\nNext step of the campaign is a meeting be-
\ntween all different parties\u00a0 \u2013 the Ministry,
\nthe employers, employees, nurses, students,
\ndoctors etc. For the meeting all those who
\nare joining in are asked to think of 3 goals
\nthat should be fulfilled by the year of 2020
\n(without thinking of any restrictions\u00a0 \u2013
\nmoney ie).The main idea is to make clear if
\nwe\u2019re all aiming the same target or our ideas
\nare totally different.
\n\u2022 the campaign is still in action but a bit
\nless from our part.
\n\u2022 Now the minister of Social affaires has
\novertaken the idea about \u201cchatroom\u201d \u2013
\nwhat should we change by the time 2020.
\nRaili Ermel
\nEstonian Junior Doctors Association
\n16th
\nOctober 2012
\nUpdate on strike of Estoniana
\ndoctors and nurses
\nA preliminary agreement was approved on Oc-
\ntober 25th
\nby Estonian Medical Assoication and
\nEstonian Union of Hospitals and Minister of
\nSocial Affairs. The strike was stopped with the
\nagreement. Agreement encompasses: Work in-
\ntensity of doctors will be decreased by 20% in
\noutpatient clinics and 16% in case of inpatient
\nwork. Trainees will be paid for longer hours
\n(from 32 hours per week currently to 40 hours
\nper week). Minimum salary of specialst doctors
\nwill be increased by 11% and |that of nurses
\nby 17,5%.
\nIV
\nContents
\nMy first English Christmas, on 25 Decem-
\nber 1964, was a white Christmas, in a true
\nsense. I was born in India, medically quali-
\nfied in Pakistan and started work in Whipps
\nCross Hospital, East London. Those were
\nhappy days. I saw for the first time in my
\nlife that:
\n\u2022 The ground, cars, trees, rose bushes and
\nbuildings were covered with snow.
\n\u2022 The patients, other doctors, the matron,
\nnurses, some nuns who were nurses, para-
\nmedics, porters and all other staff includ-
\ning cleaners were white.
\n\u2022 There were some male nurses. This was
\nnew for me. A charge nurse was called
\n\u201cMr Rowbottom.\u201d He was a cockney,
\nborn in east London within sounds of
\nBow bells.
\n\u2022 Pearly kings and queens came to hospi-
\ntal, sang carols and danced. I saw western
\ndancing for the first time. England was
\npeaceful, no war. Everyone looked happy
\nand praised the Lord. I thought it was
\nakin to what,I had been told,is in heaven.
\n\u2022 The ward sisters waited for a male consul-
\ntant to cut the turkey,for Christmas lunch.
\nHe was wearing a Father Christmas cos-
\ntume.The atmosphere was magical.
\n\u2022 On the Christmas day ward round, as a
\nhouseman, I was pushing a trolley, full
\nof bottles of wines and spirits. The con-
\nsultant poured every patient\u2019s choice in
\na glass and the ward sister, with a rare
\nsmile, offered it to each patient, includ-
\ning the one with alcoholic cirrhosis, with
\na greeting \u201cMerry Christmas & a Happy
\nNew Year.\u201d
\n\u2022 I joined the nurses in carol singing, with-
\nout opening my lips. I did not know car-
\nols and the singing tone, but I joined in.
\nSince then, I am skilled in team working.
\n\u2022 Traditionally, some ward nurses, called
\n\u201csisters\u201d were very powerful under the
\nMatron\u2019s rule. They even influenced con-
\nsultants in decision making. Ironically,
\nI observed that one in three ward sisters
\nwere unkind to house doctors,especially to
\nfemale doctors. However, their staff nurses
\nwere extremely nice.They were all nicer at
\nChristmas time. Fortunately, I was alright,
\nas I am cheerful, careful and tactful.
\n\u2022 Charge nurses were merrier at Christmas.
\nI was amused, bemused and confused.
\nWhat a new white world. As a child,
\nI\u00a0learnt that angles were white, made of
\nlight.
\n\u2022 Mr Rowbottom, a Charge nurse, advised
\nme on my first night ward round on the
\nChristmas eve \u201cDoctor, write a laxative
\nfor each patient and the night nurse can
\nchoose to give it without waking you up
\nto write for it.\u201dThen he winked at me and
\nsaid \u201cIf you keep their bowels open they
\nwould keep their mouths shut!\u201d
\n\u2022 I was taken aback as I knew that winking,
\nby a male or a female, is a sexual gesture in
\nthe East! I was startled to see that a Charge
\nnurse was winking at me, a strictly hetero-
\nsexual soul. I learnt later on that \u201cwinking\u201d
\nis a benign friendly gesture in the West.
\nNo Easterner needs to worry.This was the
\nbeginning of my strong interest in pio-
\nneering new disciplines of \u201cTranscultural
\nMedicine\u201dand \u201cTranscultural Litigation\u201d.
\nThat Christmas, I had thick black hair, a
\nmoustache turning upward, slim figure, and
\nno sense of humour. I was a typical East-
\nerner. Some nurses thought that I was very
\nhandsome. As a result of my age and west-
\nernisation over last 48 years, I shall not need
\na comb this Christmas and I am not be a
\nslim guy anymore, but I have acquired the
\nBritish sense of humour, including satire.
\nI\u00a0 enjoy western music and dancing. I do
\nmy best to help people, as a caring doctor
\nand I\u00a0 issue all prescriptions or certificates
\ncarefully. Yesterday was history, tomorrow
\nis mystery, I enjoy today. I hope to remain
\na jolly good fellow for many more Christ-
\nmases. As a jolly good fellow, I wish readers
\nMerry Christmas and Happy New Year.
\nDr. Bashir Qureshi
\nE-mail: drbashirqureshi@hotmail.com
\nHappy Christmas 2012\u00a0\u2013 My First Christmas
\nin 1964 was a truly White Christmas in London
\nThe Future for Global Health Care . . . . . . . . . . . . . . . . . . 161
\nValedictory address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
\nWMA General Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . 166
\nSecretary General\u2019s Report . . . . . . . . . . . . . . . . . . . . . . . . . 180
\nWMA Declaration on Medical Ethics
\nand Advanced Medical Technology . . . . . . . . . . . . . . . . . . 185
\nWMA Statement on Electronic Cigarettes
\nand Other Electronic Nicotine Delivery Systems . . . . . . . . 185
\nWMA Statement on the Ethical Implications
\nof Collective Action by Physicians . . . . . . . . . . . . . . . . . . . 186
\nWMA Statement on Forced and Coerced Sterilisation . . . 186
\nWMA Regulations in Times of Armed Conflict
\nand Other Situations of Violence . . . . . . . . . . . . . . . . . . . . 187
\nWMA Statement on Organ and Tissue Donation . . . . . . . 189
\nWMA Statement on the Prioritisation of Immunisation . . 192
\nWMA Statement on Violence in the Health Sector
\nby Patients and Those Close to Them . . . . . . . . . . . . . . . . . 194
\nWMA Resolution on the Abuse of Psychiatry . . . . . . . . . . 196
\nWMA Resolution to Reaffirm the WMA\u2019s Prohibition
\nof Physician Participation in Capital Punishment . . . . . . . 196
\nWMA Resolution on a Minimum Unit Price
\nfor Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
\nWMA Resolution on Plain Packaging of Cigarettes . . . . . 197
\nWMA Resolution in Support of Professor
\nCyril Karabus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
\nMemorandum of Understanding between
\nthe World Veterinary Association and
\nthe World Medical Association . . . . . . . . . . . . . . . . . . . . . 198
\nWorld-leading Plain Packaging Laws Squeeze
\nBig Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
\nEstonian Physician on Strike . . . . . . . . . . . . . . . . . . . . . . . 200<\/p>\n"},"caption":{"rendered":"

wmj41 COUNTRY \u2022 WMA General Assembly, Bangkok \u2022 World-leading Plain Packaging Laws \u2022 Physicians on Strike vol. 58 MedicalWorld JournalJournal Official Journal of the World Medical Association, INC G20438 Nr. 5\/6, November 2012 Cover picture from Germany Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":727,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/wmj41.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3641"}],"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=3641"}]}}