WMJ 02 2006
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WorldMMeeddiiccaall JJoouurrnnaall
Vol. No.2,June200652
OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
G 20438
173rd
WMA
Council Meeting
Contents
Declaration of Geneva 29
EEddiittoorriiaall
Human health resources 30
Trust in Physicians 31
Dr. LEE Jong-wook 33
MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
The World Medical Association Declaration
of Tokyo 34
The World Medical Association regulations
in times of armed conflict 35
WMA Declaration of Malta – A background paper
on the ethical management of hunger strikes 36
FFrroomm tthhee SSeeccrreettaarryy GGeenneerraall’’ss DDeesskk
“What do we expect from the next
WHO Director General?” 43
WWMMAA
173rd
WMA Council Meeting held in Divonne 44
Secretary General’s Report to the
173rd
WMA Council Session 49
WWHHOO
Health workforce crisis is having a deadly impact
on many countries’ ability to fight disease and
improve health 53
Global access to HIV therapy tripled in past two
years, but significant challenges remain 54
Developing country access needed to existing
and new medicines and vaccines 56
00_US_02_2006.qxd 17.07.2006 13:45 Seite 1
Website: https://www.wma.net
WMA Directory of National Member Medical Associations Officers and Council
Association and address/Officers
WMA OFFICERS
OF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
i see page ii
President-Elect President Immediate Past-President
Dr N. Arumagam Dr. Kgosi Letlape Dr. Y. D. Coble
Malaysian Medical Association The South African Medical Association 102 Magnolia Street
4th Floor MMA House P.O Box 74789 Lynnwood Ridge Neptune Beach, FL 32266
124 Jalan Pahang 0040 Pretoria USA
53000 Kuala Lumpur South Africa
Malaysia
Treasurer Chairman of Council Vice-Chairman of Council
Prof. Dr. Dr. h.c. J. D. Hoppe Dr. Y. Blachar Dr. K. Iwasa
Bundesärztekammer Israel Medical Association Japan Medical Association
Herbert-Lewin-Platz 1 2 Twin Towers 2-28-16 Honkomagome
10623 Berlin 35 Jabotisky Street Bunkyo-ku
Germany P.O. Box 3566 Tokyo 113-8621
Ramat-Gan 52136 Japan
Israel
Secretary General
Dr. O. Kloiber
World Medical Association
BP 63
01212 Ferney-Voltaire Cedex
France
ANDORRA S
Col’legi Oficial de Metges
Edifici Plaza esc. B
Verge del Pilar 5,
4art. Despatx 11, Andorra La Vella
Tel: (376) 823 525/Fax: (376) 860 793
E-mail: coma@andorra.ad
Website: www.col-legidemetges.ad
ARGENTINA S
Confederación Médica Argentina
Av. Belgrano 1235
Buenos Aires 1093
Tel/Fax: (54-114) 383-8414/5511
E-mail: comra@sinectis.com.ar
Website: www.comra.health.org.ar
AUSTRALIA E
Australian Medical Association
P.O. Box 6090
Kingston, ACT 2604
Tel: (61-2) 6270-5460/Fax: -5499
Website: www.ama.com.au
E-mail: ama@ama.com.au
AUSTRIA E
Österreichische Ärztekammer
(Austrian Medical Chamber)
Weihburggasse 10-12 – P.O. Box 213
1010 Wien
Tel: (43-1) 51406-931
Fax: (43-1) 51406-933
E-mail: international@aek.or.at
REPUBLIC OF ARMENIA E
Armenian Medical Association
P.O. Box 143, Yerevan 375 010
Tel: (3741) 53 58-63
Fax: (3741) 53 48 79
E-mail:info@armeda.am
Website: www.armeda.am
AZERBAIJAN E
Azerbaijan Medical Association
5 Sona Velikham Str.
AZE 370001, Baku
Tel: (994 50) 328 1888
Fax: (994 12) 315 136
E-mail: Mahirs@lycos.com /
azerma@hotmail.com
BAHAMAS E
Medical Association of the Bahamas
Javon Medical Center
P.O. Box N999
Nassau
Tel: (1-242) 328 6802
Fax: (1-242) 323 2980
E-mail: mabnassau@yahoo.com
BANGLADESH E
Bangladesh Medical Association
B.M.A House
15/2 Topkhana Road,
Dhaka 1000
Tel: (880) 2-9568714/9562527
Fax: (880) 2-9566060/9568714
E-mail: bma@aitlbd.net
BELGIUM F
Association Belge des Syndicats
Médicaux
Chaussée de Boondael 6, bte 4
1050 Bruxelles
Tel: (32-2) 644-12 88/Fax: -1527
E-mail: absym.bras@euronet.be
Website: www.absym-bras.be
BOLIVIA S
Colegio Médico de Bolivia
Casilla 1088
Cochabamba
Tel/Fax: (591-04) 523658
E-mail: colmedbo_oru@hotmail.com
Website: www.colmedbo.org
BRAZIL E
Associaçao Médica Brasileira
R. Sao Carlos do Pinhal 324 – Bela Vista
Sao Paulo SP – CEP 01333-903
Tel: (55-11) 317868 00
Fax: (55-11) 317868 31
E-mail: presidente@amb.org.br
Website: www.amb.org.br
BULGARIA E
Bulgarian Medical Association
15, Acad. Ivan Geshov Blvd.
1431 Sofia
Tel: (359-2) 954 -11 26/Fax:-1186
E-mail: usbls@inagency.com
Website: www.blsbg.com
CANADA E
Canadian Medical Association
P.O. Box 8650
1867 Alta Vista Drive
Ottawa, Ontario K1G 3Y6
Tel: (1-613) 731 9331/Fax: -1779
E-mail: monique.laframboise@cma.ca
Website: www.cma.ca
CHILE S
Colegio Médico de Chile
Esmeralda 678 – Casilla 639
Santiago
Tel: (56-2) 4277800
Fax: (56-2) 6330940 / 6336732
E-mail: sectecni@colegiomedico.c
Website: www.colegiomedico.cl
Titlepage: Title page: Robert Koch Institute, Berlin, Germany. Photo courtesy of Robert Koch Institute. On top: RKI aerial view
(Source: RKI / Ossenbrink). At the bottom: Foyer of the Robert Koch Institute (Source: RKI / Schnartendorff)
This was founded as the “Prussian Institute for Infections Diseases” of which Koch was the Director. His name was added
to the title in 1912 and the Institute finally re-titled the “Robert Koch Institute” in 1942.
U2–4_WMJ_02_06.qxd 17.07.2006 13:46 Seite U2
29
OFFICIAL JOURNAL OF
THE WORLD MEDICAL
ASSOCIATION
Hon. Editor in Chief
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suffolk IP14 3QT
UK
Co-Editors
Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte-Verlag
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Germany
Dr. Ivan M. Gillibrand
19 Wimblehurst Court
Ashleigh Road
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UK
Business Managers
J. Führer, D. Weber
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Publisher
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ASSOCIATION, INC.
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Bank: Commerzbank Köln No. 1 500 057,
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At present rate-card No. 3 a is valid.
The magazine is published quarterly.
Subscriptions will be accepted by
Deutscher Ärzte-Verlag or the World
Medical Association.
Subscription fee € 22,80 per annum (incl. 7 %
MwSt.). For members of the World Medical
Association and for Associate members the
subscription fee is settled by the membership
or associate payment. Details of Associate
Membership may be found at the World
Medical Association website www.wma.net
Printed by
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ISSN: 0049-8122
DECLARATION OF GENEVA
Adopted by the 2nd
General Assembly of the World Medical Association, Geneva,
Switzerland, September 1948 and amended by the 22nd
World Medical Assembly,
Sydney, Australia, August 1968 and the 35th
World Medical Assembly, Venice,
Italy, October 1983 and the 46th
WMA General Assembly, Stockholm, Sweden,
September 1994 and editorially revised at the 170th Council Session, Divonne-les-
Bains, France, May 2005 and the 173rd
Council Session, Divonne-les-Bains,
France, May 2006
AT THE TIME OF BEING ADMITTED AS A MEMBER
OF THE MEDICAL PROFESSION:
I SOLEMNLY PLEDGE to consecrate my life to the service of humanity;
I WILL GIVE to my teachers the respect and gratitude that is their due;
I WILL PRACTISE my profession with conscience and dignity;
THE HEALTH OF MY PATIENT will be my first consideration;
I WILL RESPECT the secrets that are confided in me,
even after the patient has died;
I WILL MAINTAIN by all the means in my power, the honour and
the noble traditions of the medical profession;
MY COLLEAGUES will be my sisters and brothers;
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic
origin, gender, nationality, political affiliation, race, sexual orientation, social
standing or any other factor to intervene between my duty and my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT USE my medical knowledge to violate human rights and
civil liberties, even under threat;
I MAKE THESE PROMISES solemnly, freely and upon my honour.
WMJ_2_29-58.qxd 17.07.2006 13:35 Seite 29
Editorial
30
Editorial
Human health resources
Over the past two years we have drawn attention to the increasing problems facing not only
the medical profession but also all the health professions. These have related both to the
changes and expectations of society globally and the remarkable increases in scientific
knowledge and technological developments which have increased the potential and actual
ability to control and treat many diseases. At the same time the journal has reported the
other side of the picture, the continuing existence of poverty and the inequity in access to
even the most basic, let alone the more sophisticated medical advances which result from
it. Over the past few years these issues have been placed on the international agenda and
we have witnessed increasing public acknowledgement of the need to reduce the gap
between economically successful developed countries and developed or under developing
countries. This has been acknowledged by summits such as those of the G7 and individual
governmental aid programmes, by generous non-governmental donors, and by worldwide
fund raising movements directed towards specific major diseases or natural disasters such
as we have witnessed in the past few months. Nevertheless these international aid contri-
butions still fall far short of the estimated need.
However attention is now being drawn to another major threat to healthcare, the relief of
suffering and the reduction of morbidity and mortality from major diseases and this at a
time when there is increasing concern and awareness of the risk of a new global pandem-
ic. The WHO World Health Report 2006 launched in April 2006 is entitled “Working
together for Health”(1) and marks the beginning of the WHO year of “Human Health
Resources“, to be followed by a decade of action to deal with the global shortage of health
workers. This shortage applies to most groups of personnel working in the health sector and
calls for a radical reappraisal of the activities of the recognised main stream health profes-
sions, doctors, nurses and midwives, pharmacists and dentists etc and for assessment of the
potential for limited training for carrying out specific tasks for some professionals and oth-
ers, as opposed to the wider basic and specialist knowledge and skills training considered
essential for certain professionals to practice in health care professions.
While the report highlights the compelling and urgent need in some of the world’s poorest
countries, where the WHO estimates that some 57 countries (36 in Africa alone) have a
deficit of 2.4 million doctors, nurses and midwives, reflecting the problems of AIDS, skills
drain, rural/urban drain etc. in addition to the factors mentioned above, developed countries
are also experiencing or anticipating a shortage in these professions. The latter is exempli-
fied by a suggestion made in a recent meeting that the anticipated needs of the USA for
physicians in 2020, will be for 200,000 new doctors (half the current estimated global num-
ber of physicians available in the year 2020).
In another part of the WHO report, emphasis is also placed on the need for strong leader-
ship – an issue which is being addressed by the World Health Professions Alliance of which
the World Medical Association is a member. The late Director General Dr. LEE Jong
wook’s opening overview of the Report referred to “Acquiring critical capacities by
strengthening core institutions for sound workforce development. Leadership and manage-
ment development in health and other related sectors such as education and finance is
essential for strategic planning and implementation of workforce policies. Standard setting,
accreditation and licensing must be effectively established to improve the work of worker
unions, educational institutions, professional associations and civil society”.
Later the report calls, amongst other things, for increased licensing and accreditation and
examination of cost and labour efficiency of health professionals, pointing out the evidence
of the better rates of immunisation in the
population when using nurses rather than
doctors in countries where most of the
immunisations are normally given by nurs-
es. In this context the report cites three
“Cochrane” reviews (2) of the results of
substituting nurses for doctors in primary
care. These showed no difference in quality
of care and outcomes between appropriate-
ly trained nurses and doctors and showed
the nurses giving more health care advice.
While on the other hand nurses ordered
more tests and used more other services
than doctors, thus reducing cost saving. In
another review of 85 randomised controlled
trials, 10 of which were considered to be of
high methodological quality), while it was
concluded that audit and feedback can
improve professional practice. the effects
were variable, “small to moderate”. It con-
cludes “results of the trials do not provide
support for mandatory use of audit and or
unevaluated feedback”.
Commenting on self-regulation, while
acknowledging that this can be effective
and that medical associations etc. can regu-
late the behaviour of the profession and
maintain technical competence, the report
states “Self-regulation by professional asso-
ciations is not always effective“ and com-
ments on the difference between the east
and west. In the latter, notably Europe and
America, “the majority of organisations are
at least more than 110 years old, whereas in
low income countries 4 out of 10 are less
than 25 years old.” Even more importantly,
it comments on the strain on self regulation
resulting substantially from employers
increasingly overriding it, Whilst acknowl-
edging this to be the case where the state is
the traditional employer of health workers,
it points out that increasingly the previous-
ly self-employed autonomous health work-
ers are now working in an employer-
employee situation. “The employer,
whether the state, a non-governmental non-
profit making organisation, financial corpo-
ration or international organisation tends to
have the most influence on professional
behaviour, concluding that associations by
themselves can no longer claim to provide
coherent governance, in the public interest,
of the health workforce as a whole.” This
acknowledges important concerns which
WMJ_2_29-58.qxd 17.07.2006 13:35 Seite 30
have already been increasingly occupying
the profession for some time past.
However, while the report does not specif-
ically recommend the abolition of self- reg-
ulation, it urges the creation (where neces-
sary) of the technical bodies for licensing,
accreditation etc. and also suggests the
inclusion of all stake holders in forums
which would permit interaction between all
organisations affecting the behaviour of
health workers and the health institutions,
well illustrated in a diagram showing inter-
action between professional organisations,
institutional regulators and civil society
organisations. (3)
Nevertheless, the report quotations above
reinforce the urgent need for reflection, and
if need be action by the medical profession
and its medical associations, in particular
those with regulating powers. The reflec-
tion must take into account not only the
need to adapt the functions for which the
special training of physicians is required
but also the needs of the globalised society
in which we live.
The World Health Assembly this year, in its
decision addressing the problems of short-
age of human health resources and also the
challenges of international migration of
health personnel in six recommendations in
its resolution (4), urged Member States to
affirm their commitment by:
„Giving consideration to establishing
mechanisms to mitigate the adverse impact
on developing countries of loss of health
personnel through migration including
means of receiving developed countries
supporting health systems, especially in
human resources development, in the coun-
tries of origin;
promoting training in accredited institu-
tions of a full spectrum of quality profes-
sionals and also community health work-
ers, public health workers and profession-
als;
promoting training partnerships between
schools in industrialised developing coun-
tries involving faculty and student
exchange:
Guest Editorial
31
encouraging financial support by global
health partners donors etc. of health training
institutions in developing countries;
promoting planning teams in each country
facing health-worker shortages drawing on
stake holders including professional bodies,
public and private sectors and non-govern-
mental organisations to formulate compre-
hensive strategy for the health workforce,
including consideration of effective mecha-
nisms for utilisation of trained volunteers
using innovative approaches to teaching in
developed and developing countries with
state-of-the-art teaching materials and con-
tinuing education through the innovative
use for information and communications
technology.“
It is clear from this that the crisis in Human
Health Resources is one which National
Medical Associations will neglect at their
peril and need to address, not only in their
own national context but also in the interna-
tional global context. The WMA has
addressed the issue of physician migration
and also referred to countries’ bilateral
agreement to effect meaningful co-opera-
tion in health care delivery in its statement
of Helsinki 2003 “Ethical Guidelines for the
International Recruitment of Physicians.”
However, the issues raised in the WHO
Report, the decade of action and the global
alliance set up to address these issues (6),
call for serious consideration and leadership
if the profession is to influence policy ini-
tiatives proposed by governments to deal
with this serious threat to future health care.
Alan Rowe
(1) The World Health Report 2006 “Working
together for Health”, WHO Geneva
(2) ibid p. 138
(3) Ibid p. 214
(4) WHO,WHA59.23
(5) WMA statement accessible on
www.wma.net
(6) Global Health Workforce Alliance
Trust in Physicians
Abundance of Medical Information –
Shortage of Medical Orientation
by Peter Atteslander, Professor emeritus, University of Augsburg,
Director, INAST Research Univ., Inst. Sociology, University of Neuchatel
Would you trust a machine? Probably you do not. You might rely on its functioning. Trust
however has a quite clear intrinsic meaning: trust is a psychic and social process based on
firm beliefs. You definitely will not trust a medical system as such but specific persons
playing an important role in its institutions. It is above all the medical doctor on the daily
front interacting with the patient before him that you trust, sometimes you have to trust. In
many existential situations the patient lays his life in doctors’ hands. He is confident about
the physician’s professional abilities, judgements and increasingly about medical orienta-
tion which only the physician is a master of. Many of us are lost before the growing amount
of all kinds of public health advice, leaving us over-informed but under-oriented.
Can one measure trust in physicians? Indeed: since many decades, numerous surveys show
that medical doctors are constantly granted one of the highest prestige statuses amongst all
professions. There is no marked decline of trust in physicians, their general acceptance in
spite of the fact that medicine is increasingly experiencing all kinds of pressure, economic,
bureaucratic and stressful through the increasing velocity of medical technology develop-
ment, inevitably leading to more specialisation. General anxieties are felt and unspecified
critique finds its public. Mass media seem to be more interested in either sensationally
reporting cases of malfunctions in our health systems, creating wrong hopes or propagating
WMJ_2_29-58.qxd 17.07.2006 13:35 Seite 31
Guest Editorial
32
new therapies not yet applicable. They fail
to adequate orientate the citizen.
Nevertheless, a traditional image of doctor’s
role still seems to persist today. This in spite
of magnificent medical technologies, new
organization and miracles of medical prac-
tice. It is human empathy with the patient
that the lone horse- and buggy doctor lived
with centuries ago. Compared to our days,
he had rather little to offer but himself and
a handful of medicaments and instruments
to use.What has changed since then? Do we
not still talk of the physician himself as ‘the
most efficient medicament’, and of his prac-
tice as being an art? Until today, the interac-
tion between patient and doctor remains the
most important source of trust.The more
complex health structures become, the more
important it is to safeguard the physician’s
role to offer medical and mental orientation
to patients. Even those expert in using the
internet are essentially in danger of getting
lost in a labyrinth of information they are
unable to interpret. Since trust is a social
and mental process, it can neither be
ordered, regulated or even administrated.
Without orientation, patients will comply
less with medical prescriptions. Comp-
liance is amongst many other aspects pre-
dominantly the result of trust in the pre-
scriptions and advice of the physician.
There are however many factors that endan-
ger this (fortunately still persisting) com-
mon trust. The World Health Organisation
(WHO) stated long ago that governments
are responsible for the health of their citi-
zens and can only discharge that responsi-
bility by taking adequate measures in the
health care and social spheres. To ensure
fair distribution of medical services most so
called OECD-states, representing modern
rather wealthy societies, have introduced
so-called cost-moderating laws. This results
in wide spread fears that increased state
intervention will further undermine the nec-
essary state-free area of doctor- patient rela-
tions. Experience shows that more adminis-
tration does not in itself lead to greater con-
trol over rising costs. States cannot be made
responsible for individual health conditions.
On the other hand it can be expected that
they safeguard general policies which per-
mit the best possible individual medical
actions by all concerned. Adequate health
care and social measures, however, always
imply greater control and planning. It is not
advisable to implement too strict bureau-
cratic norms at the cost of impeding doctor-
patient relations. Individual behaviour is all
too often influenced by state action, but it
cannot be planned in detail, certainly not
where health is involved.
The health care systems are highly com-
plex. Today we do not know exactly how
they function. At best we still find areas
where it does not function. In future it will
be impossible to satisfy every conceivable
need. The total sum of individual needs as
expressed, does not necessarily represent
the need of a society at large on which state
interventions (based on data from social
epidemiological surveys, that rarely meet
methodological expertise), are decided.
General expectations of the kind aroused by
too comprehensive WHO-postulates which
interpret health as a state of “complete
physical, mental and social well-being and
not merely the absence of illness”, cannot
be transposed into legally effective entitle-
ments for the individual. The inadequacy of
a health care system which is widely per-
ceived today, does not in itself point to the
goals which should be set.
There is an increasing pressure not only to
economise in healthcare systems, and also
to harmonize procedures independent of
cultural differences, leading to different
social behaviour. This provokes ever more
new regulation of health reporting.
Warnings by many scientists have evidently
not reached politicians and bureaucrats.
Large sums have been wrongly invested
trying to measure qualitative health matters
with quantitative instruments. Of course
health care has material and economic
aspects, but all other predominantly qualita-
tive processes cannot be measured by pure-
ly quantitative methods. Healing.requires
more than a functioning human body,and
the physician more than a technician. It was
an illusion that the highly dynamic struc-
tures of the health care systems could be
regulated, finally controlled by simple
material indices. It is an essential error to
believe that the role of physicians can be
standardized. There is no such thing as a
standard patient, just as there is no statisti-
cally determined average health situation.
Beware of statistical artefacts when dealing
with sick human beings.
Complex systems tend to be self relevant
and hard to grasp. They are even harder to
govern. In health systems responsibilities
are often nebulous and poorly defined.
Combined with economic restrictions and
bureaucratic standardisation, more and more
non medically trained agents tend to restrict
physicians’traditional as well as prospective
role. Their indispensable moral and ethical
identity is thereby severely menaced.
The progress of modern medicine high-
lights in addition another problem, which
may be described as the concept of pressure
for ‘positivisation’:, especially in medical
technology, surgery and pharmacology,
where the quick and obvious successes and
immediate effects are so apparent, experi-
enced as “relief” and verifiable. Such pres-
sure for their broad and instant application
arises that it, in turn, increases demand
leading to new problems of distribution,
both of human resources and costs. This
happens irrespective of the dangers of inter-
actions with other medicaments, often only
recognised only later.
There is growing hedonisme regarding
health: Eat the pills today, pay tomorrow,
often with illness !
The progress in modern medicine is in
many senses of the word, fantastic. One is
tempted to say that as in other fields of tech-
nology we are offered more answers than
we have questions for. In medicine this
means that there are more investigation
alleys and more therapies at hand than we
can pay for. Ethical problems are not antic-
ipated ; adequate and fair distribution of
medical services remains largely unsolved,
rationing wide spread. Even rationalization,
as the step before restricted distribution of
medical services is declared, should rely on
systematic, optimized action. In practice,
rationing often fails to meet these criteria.
The discussion, as to when it is necessary to
omit certain therapy which has questionable
perspectives, has only just begun. We are
only starting to comprehend that the effects
of modern medicine may also have impor-
tant societal implications.
WMJ_2_29-58.qxd 17.07.2006 13:35 Seite 32
Editorial
33
Illness must no longer be understood solely
as the dysfunction of a biological organism.
We have to learn and to understand it as a
typical social attitude. This changes also the
interaction between physician and patient.
This aspect has been largely disregarded by
medicine up to now since the manifest suc-
cesses of modern medicine conceals this
weak point.
Illnesses which can be precisely defined in
scientific terms and the disorders, for which
clear forms of therapy exist, are increasing.
Nobody would deny this success. Their rel-
ative importance measured against the gen-
eral requirements placed on the medical
system, is however rapidly declining. New
and hard to define syndromes of illness are
spreading. We see modern medicine as
being caught in a dangerous trap between
the growing availability of technical and
medical expertise and the increasingly man-
ifest and perceived lack of social health ori-
entation.
Trust in physicians is in principal a qualita-
tive property of highest importance. This
holds true especially when we speak of
healing processes. The question is pertinent,
as to whether in future the precious asset of
a free and humane doctor-patient interac-
tion can be safeguarded against the strong
influence of growing economization,
bureaucratization (above all) , in view of a
growing non steered quantitative regulation
in the health system.
One of the leading medical social scientists
wrote decades ago “Medicine as a social
institution has extremely broad functions.
Not only does medicine deal with the pre-
vention and treatment of pain, disease, dis-
ability, and impairment, but it also provides
an acceptable excuse for relief from ordinary
obligations and responsibilities, and may be
used to justify behaviours and interventions
not ordinarily tolerated by the social system
without significant sanctions. The definition
of illness may also be used as a mechanism
of social control to contain deviance, to
remove misfits from particular social roles,
or to encourage continued social functioning
and productive activity. Thus, the locus of
control for medical decision making is a key
variable in examining the implications of
medical care for social life more generally”.
Physicians have rapidly to overcome the
manifold effects of the further growing spe-
cialization. More time will be demanded for
interdisciplinary actions. Managing rele-
vant information from different sources
applicable in specific cases has yet to be
learned. Most important, the uniqueness
and intimacy in which human trust in the
patient-doctor relationship can only grow,
has to be defended with all appropriate
means. We follow Mechanic(I)
in as far as
we now witness the increasing velocity of
bureaucratisation of medicine as having the
effect of diluting the personal responsibility
of physicians, making it more likely that
interests other than those of the patient will
prevail in the future.” By segmenting
responsibility for patient care, medical
bureaucracy relieves the physician of direct
continuing responsibility. If the patient can-
not reach a physician at night or on week-
ends, obtain responsive care, have inquiries
answered or whatever, the problem is no
longer focused on the failure of an individ-
ual physician, but on the failures of the
organization. It is far easier for patients to
locate and deal with individual failures
where responsibility is clear, than to con-
front a diffuse organizational structure
where responsibility is often hazy and the
buck is easily passed. To the extent that the
physician knows that a patient is his or her
charge, the physician feels a certain respon-
sibility to protect the patient’s interests
against organizational roadblocks and
requests that may not be fully appropriate.
But when responsibility is less clear it is
easier to make decisions in the name of
other interests such as research, teaching,
demonstration, or the “public welfare,”
whatever that might be” (p. 415).
Trust, as we said before, is based on firm
belief. Belief in the the doctor-patient rela-
tionship is often nurtured by hope, even if it
is unrealistic and not to be granted. The
more pressures of all kinds exist in this
hybris of health systems,. the more pressing
is the question of what to do. My proposi-
tion is that the physician has always to be in
the centre of information. We forsee that
doctors will depend to a greater extent on
other specialised experts and technical sys-
tems, will have to be the centre of informa-
tion , and will not be able to carry the per-
sonal full responsibility for their patients.
The physician may need assistance for the
interpretation of relevant data, but he alone
is in charge of the ultimate decisions. This
entitles him to ask for all means and mea-
sures to live up to his responsibility for the
good of his patient who trusts him. It is high
time that the physician’s role has to be
widely understood, honoured and enforced.
Address for correspondence
Professor Peter Atteslander
Bellevueweg 29
CH 2562 Port
Switzerland
E-Mail: peter.atteslander@bluewin.ch
(I)
David Mechanic, The Growth of Medical
Technology and Bureaucracy: Implications for
Medical Care, in: Patients, Physicians, and Illness,
E.Gartly Jaco, London, New York, 1979, p. 415)
Dr. LEE Jong-wook
We very much regret the sudden death of the Dr. LEE Jong-
wook, Director General of the World Health Organisation, on
the eve of the World Health Assembly. His ambitious project
3 by 5 to tackle HIV/AIDS thought by many to be unrealis-
tic, nevertheless was a real attempt to unite agencies in a
common goal. His promotion of partnerships in dealing with
AIDS, Tuberculosis and Malaria, the agreement on stockpil-
ing Tamiflu and his efforts to stimulate countries to recognise
the real threat of pandemic influenza, were indications of his
determination to engage governments in the fight against the
threats posed by these diseases. Dr. LEE died on 22 May 2006. He was 61.
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Medical Ethics and Human Rights
34
Preamble
It is the privilege of the physician to prac-
tise medicine in the service of humanity, to
preserve and restore bodily and mental
health without distinction as to persons, to
comfort and to ease the suffering of his or
her patients. The utmost respect for human
life is to be maintained even under threat,
and no use made of any medical knowl-
edge contrary to the laws of humanity.
For the purpose of this Declaration, torture
is defined as the deliberate, systematic or
wanton infliction of physical or mental suf-
fering by one or more persons acting alone
or on the orders of any authority, to force
another person to yield information, to
make a confession, or for any other reason.
Declaration
1. The physician shall not countenance,
condone or participate in the practice of
torture or other forms of cruel, inhuman
or degrading procedures, whatever the
offence of which the victim of such
procedures is suspected, accused or
guilty, and whatever the victim’s beliefs
or motives, and in all situations, includ-
ing armed conflict and civil strife.
2. The physician shall not provide any
premises, instruments, substances or
knowledge to facilitate the practice of
torture or other forms of cruel, inhuman
or degrading treatment or to diminish
the ability of the victim to resist such
treatment.
3. When providing medical assistance to
detainees or prisoners who are, or who
could later be, under interrogation,
physicians should be particularly careful
to ensure the confidentiality of all per-
sonal medical information. A breach of
the Geneva Conventions shall in any
case be reported by the physician to rel-
evant authorities.
The physician shall not use nor allow to
be used, as far as he or she can, medical
knowledge or skills, or health informa-
tion specific to individuals, to facilitate
or otherwise aid any interrogation, legal
or illegal, of those individuals.
4. The physician shall not be present during
any procedure during which torture or
any other forms of cruel, inhuman or de-
grading treatment is used or threatened.
5. A physician must have complete clini-
cal independence in deciding upon the
care of a person for whom he or she is
medically responsible. The physician’s
fundamental role is to alleviate the dis-
tress of his or her fellow human beings,
and no motive, whether personal, col-
lective or political, shall prevail against
this higher purpose.
6. Where a prisoner refuses nourishment
and is considered by the physician as
capable of forming an unimpaired and
rational judgment concerning the con-
sequences of such a voluntary refusal of
nourishment, he or she shall not be fed
artificially. The decision as to the ca-
pacity of the prisoner to form such a
judgment should be confirmed by at
least one other independent physician.
The consequences of the refusal of
nourishment shall be explained by the
physician to the prisoner.
7. The World Medical Association will
support, and should encourage the in-
ternational community, the National
Medical Associations and fellow physi-
cians to support, the physician and his
or her family in the face of threats or
reprisals resulting from a refusal to con-
done the use of torture or other forms of
cruel, inhuman or degrading treatment.
The World Medical Association Declaration of Tokyo.
Guidelines for Physicians Concerning Torture and other Cruel,
Inhuman or Degrading Treatment or Punishment in Relation
to Detention and Imprisonment
Adopted by the 29th World Medical Assembly, Tokyo, Japan, October 1975,
editorially revised at the 170th Council Session, Divonne-les-Bains, France, May 2005
and the 173rd Council Session, Divonne-les-Bains, France, May 2006
* the latest revisions are shown underline. See also WMA Council report page 46
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Medical Ethics and Human Rights
35
1. Medical ethics in times of armed con-
flict is identical to medical ethics in
times of peace, as stated in the Interna-
tional Code of Medical Ethics of the
WMA. If, in performing their profes-
sional duty, physicians have conflicting
loyalties, their primary obligation is to
their patients; in all their professional
activities, physicians should adhere to
international conventions on human
rights, international humanitarian law
and WMA declarations on medical
ethics.
2. The primary task of the medical profes-
sion is to preserve health and save life.
Hence it is deemed unethical for physi-
cians to:
a. Give advice or perform prophylac-
tic, diagnostic or therapeutic proce-
dures that are not justifiable for the
patient’s health care.
b. Weaken the physical or mental
strength of a human being without
therapeutic justification.
c. Employ scientific knowledge to im-
peril health or destroy life.
d. Employ personal health information
to facilitate interrogation.
e. Condone, facilitate or participate in
the practice of torture or any form of
cruel, inhuman or degrading treat-
ment.
3. During times of armed conflict, stan-
dard ethical norms apply, not only in re-
gard to treatment but also to all other in-
terventions, such as research. Research
involving experimentation on human
subjects is strictly forbidden on all per-
sons deprived of their liberty, especially
civilian and military prisoners and the
population of occupied countries.
4. The medical duty to treat people with
humanity and respect applies to all pa-
tients. The physician must always give
the required care impartially and with-
out discrimination on the basis of age,
disease or disability, creed, ethnic ori-
gin, gender, nationality, political affilia-
tion, race, sexual orientation, or social
standing or any other similar criterion.
5. Governments, armed forces and others
in positions of power should comply
with the Geneva Conventions to ensure
that physicians and other health care
professionals can provide care to every-
one in need in situations of armed con-
flict. This obligation includes a require-
ment to protect health care personnel.
6. As in peacetime, medical confidentiali-
ty must be preserved by the physician.
Also as in peacetime, however, there
may be circumstances in which a pa-
tient poses a significant risk to other
people and physicians will need to
weigh their obligation to the patient
against their obligation to other individ-
uals threatened.
7. Privileges and facilities afforded to
physicians and other health care profes-
sionals in times of armed conflict must
never be used for other than health care
purposes.
8. Physicians have a clear duty to care for
the sick and injured. Provision of such
care should not be impeded or regarded
as any kind of offence. Physicians must
never be prosecuted or punished for
complying with any of their ethical
obligations.
9. Physicians have a duty to press govern-
ments and other authorities for the pro-
vision of the infrastructure that is a pre-
requisite to health, including potable
water, adequate food and shelter.
10.Where conflict appears to be imminent
and inevitable, physicians should, as far
as they are able, ensure that authorities
are planning for the repair of the public
health infrastructure in the immediate
post-conflict period.
11.In emergencies, physicians are required
to render immediate attention to the
best of their ability. Whether civilian or
combatant, the sick and wounded must
receive promptly the care they need. No
distinction shall be made between pa-
tients except those based upon clinical
need.
12.Physicians must be granted access to
patients, medical facilities and equip-
ment and the protection needed to carry
out their professional activities freely.
Necessary assistance, including unim-
peded passage and complete profes-
sional independence, must be granted.
13.In fulfilling their duties, physicians and
other health care professionals shall
usually be identified by internationally
recognized symbols such as the Red
Cross and Red Crescent.
14.Hospitals and health care facilities situ-
ated in war regions must be respected
by combatants and media personnel.
Health care given to the sick and
wounded, civilians or combatants, can-
not be used for morbid publicity or pro-
paganda. The privacy of the sick,
wounded and dead must always be re-
spected.
The World Medical Association regulations
in times of armed conflict
Adopted by the 10th
World Medical Assembly, Havana, Cuba, October 1956, edited by the 11th
World
Medical Assembly, Istanbul, Turkey, October 1957, amended by the 35th
World Medical Assembly,
Venice, Italy, October 1983 and the WMA General Assembly, Tokyo 2004, and
editorially revised at the 173rd
Council Session, Divonne-les-Bains, France, May 2006
* The latest changes in text are shown underline. See also WMA Council report page 46
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Medical Ethics and Human Rights
36
WMA Declaration of Malta
A background paper on the ethical management of hunger strikes
The following background paper and glos-
sary of terms were prepared by the British
Medical Association in association with the
revision of the Malta Declaration currently
being considered by WMA Council and
National Medical Associations.
See also „glossary of themes“, p. 41-42.
Introduction
Physicians need to understand the back-
ground to the guidance given in the World
Medical Association’s Declaration of
Malta. This paper aims to set out that back-
ground and some authentic case examples
are included to illustrate how complex this
area of practice can be. These cases are
taken from field experience in widely dif-
fering contexts and countries. They have
been simplified and anonymised to protect
individuals’ confidentiality and they reflect
how very different strategies may have to
be adopted by physicians according to the
circumstances of the case.
Although the Malta Declaration sets broad
international standards for managing hunger
strikes in custodial settings, physicians still
need to use their own moral judgement in
particularly complex situations. To do this,
they should be aware of the various different
forms of fasting which stem from differing
intentions on the protesters’ part and which
require different handling. Hunger strikers’
motivations and their perseverance in a par-
ticular kind of hunger strike can differ great-
ly. Gaining their trust can be difficult but is
crucial for doctors, who must be able to act
independently from the detaining authori-
ties. Physicians also need to be alert to the
pressures which can be exerted on hunger
strikers in custodial settings – not only by the
authorities but also by peer group hierar-
chies and sometimes even by physicians
themselves. For example, if doctors ask
hunger strikers to give advance instructions
at the start of a fast saying whether or not
they would refuse resuscitation at a later
stage, it may be difficult for the hunger strik-
ers to do anything other than refuse artificial
feeding, without losing face with their peer
group. This may not be a truly valid and
informed choice unless physicians can dis-
cuss it in private with the hunger striker.
Physicians need to understand the clinical
and moral criteria concerning when to resus-
citate a protester and when to abide by such
a refusal of treatment. The crucial differ-
ences between “artificial” and “force” feed-
ing need to be understood. Physicians also
need to be aware of the symptoms and the
clinical physiology of the different stages of
fasting in order to give accurate medical
counselling to patients about what to expect.
(Such advice can be found in the ‘Course for
prison doctors’, chapter 5, by the World
Medical Association, Norwegian Medical
Association and International Committee of
the Red Cross at http://lupin-nma.net).
Health professionals often act as mediators
between patients, authorities and other peo-
ple such as patients’families. They can be in
a position to facilitate face-saving opportu-
nities which could bring the hunger strike to
an end for the benefit of all involved. This
paper seeks to help them do that.
Definition of “hunger strike”
As explained in the glossary, a “hunger
strike” involves food refusal as a form of
protest or demand. Such fasting is particu-
larly undertaken by people in custodial set-
tings who lack alternative means to gain
attention and bring pressure to bear to
obtain some goal. Short-term rejection of
food rarely gives rise to ethical dilemmas as
health is generally not permanently dam-
aged as long as fluids are accepted. It is
important, however, for physicians to have
a clear frame of reference on how to define
a serious “hunger strike”.
Excluded here are short-lived fasts which
peter out within 72 hours. If hunger strikers
continue to refuse both nutrition and hydra-
tion for more than 48 hours, however, they
risk significant harm. Dry fasting without
any fluid intake which persists for more
than a few days would fall within the defin-
ition of “hunger strike” used here but, fortu-
nately, this is rare. As the body cannot sur-
vive more than a few days without fluid,
death would occur within the first week
which, from the protesters’ perspective, is
too short a period for negotiation to be
effective. In short, the term “hunger strike”
as discussed here refers to protest fasting
without any intake of food but with inges-
tion of adequate quantities of water.
In the first days of fasting, the body uses its
stores of glycogen in the liver and muscles.
Ketosis occurs and is discernible clinically
on the breath or by laboratory test in the
urine. It subdues the voracious sensation of
hunger experienced during the first days of
fasting. It can be argued that total fasting
(taking water only) for longer than 48 – 72
hours is the clearest definition on metabolic
grounds for the term “hunger strike”.
Glycogen stores are exhausted by about day
10-14 and certain amino acids take over as
the substrate for gluconeogenesis. Muscle,
including heart muscle is gradually lost.
Close medical monitoring is recommended
after a weight loss of 10% in lean healthy
individuals and major problems arise at a
weight loss of about 18%. Hunger strikers
need to be aware that dehydration is a risk
as they lose their sensations of hunger and
thirst.
1. The medical duty to establish
competence and motivation
Assessing patient competence and gaining
an understanding of the purpose of the fast
is crucial for physicians. Good communica-
tion and trust are essential here. Fasting as a
symptom or manifestation of a psychiatric
disorder such as anorexia or depression
requires a totally different approach, so
assessing patients’ mental health must be a
first step for physicians. People suffering
from any serious psychiatric or mental dis-
order likely to undermine their judgement
need medical attention for their disorder
and cannot be permitted to fast in a way that
damages their health. Fasting for religious
reasons should also not be confused with
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Medical Ethics and Human Rights
37
protest fasting but should be respected. It is
generally not health threatening and does
not raise dilemmas when undertaken by an
otherwise healthy person.
Two main categories of individuals embark
on hunger strikes with quite different inten-
tions and motivation. In potentially coercive
contexts, (which include any situation of
detention) it is important for physicians
always to determine for themselves what are
the exact motives for refusing nourishment.
Some food refusers fast to gain publicity to
achieve their goal, but have no intention of
permanently damaging their health. Their
goal may seem relatively petty or it may
involve reasons of principle. As they do not
wish to die, these protesters often agree to
artificial feeding being provided at some
stage and may actually request medical
assistance in monitoring their fast. Those
who repeatedly make this type of protest
can come to be seen as exercising a form of
blackmail by the authorities, who then let
strikes continue to test protesters’ resolve.
Physicians need to clarify privately with
protesters, at regular intervals, how far they
are willing to go and when they expect and
desire medical interventions to be made to
prevent lasting harm to their health.
The other very different category consists
of what might be seen as very determined
hunger strikers who are not prepared to
back down unless their goal is actually
attained. Individually or in groups, they
may differ in their mode of fasting but they
share a determination to risk their health or
their lives for a cause. Political hunger
strikers often fall into this category. Unlike
the food refusers who rely on medical help
to prevent serious harm, this category of
protesters often mistrust physicians, whom
they see as belonging to the detaining sys-
tem. Such protesters pose a serious chal-
lenge to medical ethics, as their willingness
to take fasting to the extreme inevitably
raises difficult questions about whether and
when to intervene and the thorny ethical
question of whether feeding contrary to
patients’ expressed wish can ever be justi-
fied. In this paper, we have rejected the term
“death fast” which is sometimes used to
describe a determined hunger strike. The
term is unfortunate in that it appears to
assume death is the inevitable outcome. By
perceiving death as the objective of the fast,
opportunities for constructive dialogue may
be lost from the outset. It is seen by the
authorities as establishing an unacceptable
ultimatum with no leeway for discussion.
This can deter doctors from even attempting
to mediate.
2. The medical duty to attempt to
establish “voluntariness”
“Voluntary total fasting” is a term often
used, but fasts in detention are seldom total.
Most protesters accept fluids and some-
times the rejection of food too is less than
total. Participation can also be more
coerced than voluntary, particularly in long
collective hunger strikes. The authorities
may want to stop protests by finding accept-
able compromises but pressures may come
inadvertently from staff, such as guards,
whose taunts and derision of protesters can
lead to a hardening of positions. Detainees
may also suffer coercion from peer groups
in subtle as well as obvious ways. These
often complex situations can lead to the
point where it becomes virtually impossible
for a protester to cease fasting voluntarily.
The informed and voluntary nature of indi-
viduals’ food refusal are key aspects that
physicians need to ascertain once mental
competence has been established.
Physicians must do their utmost to speak to
each patient privately, out of earshot of all
other people but with an interpreter if nec-
essary. It is important that interpreters are
not connected with the detaining authorities
or the patient’s peer group and that they are
aware of the confidentiality expected of
them. Those orchestrating collective hunger
strikes are often reluctant to allow such
talks, as this undermines their authority.
This is possibly the most complex situation
to deal with in determining whether hunger
strikers are indeed genuine volunteers. The
subsequent extent to which medical confi-
dentiality can be guaranteed in custodial
settings needs to be discussed with the
patient. Physicians should do everything in
their power to engage in frank discussion
with patients and gain their trust. Where
protesters appear to be fasting under duress,
a solution may be to separate those individ-
uals in hospital on a medical pretext, there-
by extracting them from the influence of
others and allowing them, if they agree, to
resume nourishment on medical grounds.
Pressure may still come from relatives or
the media. Families often alert the media,
hoping this will heighten the pressure on the
authorities to make concessions but it can
also increase pressure on the protester not to
give way.
Physicians sometimes cannot gain the trust
of patients. In such situations, it may be
possible to bring in an external physician
unconnected with the detaining authority or
one nominated by the patient to ascertain
whether the fast is truly voluntary. If the
“voluntariness” of the decision appears to
be established, protestors’ decisions should
be respected. It is likely that some cases of
coercion go undetected, even if all reason-
able precautions are taken, but in the
absence of evidence to that effect, physi-
cians must listen to and abide by what
patients say.
Physicians can discuss with patients the
flaws or lack of logic in their expressed
wishes without exercising undue pressure.
Experience shows that particularly in high-
ly political hunger strikes, decision-making
is far from simple. There may be situations
where physicians need to challenge the
patient rather than accept that person’s
views at face value. It is here that the impor-
tance of trust and the confidentiality of the
individual interview become of paramount
importance. There are cases in which physi-
cians, confronted with an apparently fanati-
cal hunger striker, can use their position of
trust and medical authority to try to bring
the protestor to reason.
Case example 1 – Difficulties of establish-
ing a hunger striker’s real wishes
A physician, visiting a collective hunger
strike involving many politically motivated
prisoners, listened carefully to the story of a
female protestor. She had suffered many
hardships, including rape and the loss of
family members. She was barely 20 years
old and appeared politically motivated
almost to the point of fanaticism. Her inten-
tion, she said, was to fast unto death to
protest against oppression. The physician
decided to test her determination as he was
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Medical Ethics and Human Rights
38
not convinced her words reflected her real
wishes. He took a firm stance, arguing that
her apparent choice to die seemed wrong
after all she had already endured and sur-
vived. In his view, her decision was ill
thought out and he said that, as a doctor, he
was unwilling to let her waste her life but
wanted her to reconsider. The young woman
was shocked as nobody – not even she her-
self – had questioned her intention previous-
ly. She burst into tears but, on reflection,
agreed that she did not want to die. As they
talked, the doctor’s careful reasoning and
analysis of her situation helped her to iden-
tify her real wishes. The conversation
between them was kept confidential but the
woman agreed to accept nourishment which
was given on a medical pretext to avoid
pressure being brought to bear upon her by
her peer group. The doctor’s willingness to
probe deeper than the woman’s superficial
statements allowed him to test whether her
statements really were an autonomous
expression of her views. Her readiness to
hear his arguments made the hunger striker
re-evaluate her intentions and realize that
she had suppressed her true feelings. The
example shows how complex such issues
can be and the risks of accepting an individ-
ual’s views without any question.
3. The duty to provide accurate
information to patients
Physicians need to explain to each protester
the implications of fasting for that person.
This entails first taking a detailed medical
history and conducting an examination so
that existing medical conditions are identi-
fied and discussed. They should objectively
warn patients who suffer from ailments that
are incompatible with prolonged fasting,
not to embark on a hunger strike or to
restrict themselves to a limited form of fast-
ing. Conditions such as diabetes, gastritis,
gastric or duodenal ulcer and many meta-
bolic diseases are contra-indications to total
fasting. Only if fully informed, can protest-
ers make a truly voluntary and informed
decision on whether to embark on a hunger
strike. They only have a chance of obtaining
their goals if there is enough time for the
authorities under pressure to react. The like-
ly duration of their fast is therefore of para-
mount importance to hunger strikers, espe-
cially if they have difficulties in making
their plight known to those outside who can
try to exercise influence. It will be essential
for hunger strikers to know as accurately as
possible how long they personally could
fast. The fatal outcomes of total fasting
were first documented during the 1980 and
1981 hunger strikes in Northern Ireland
where death generally occurred between 55
and 75 days. Similar experiences have con-
firmed this wide time bracket. The three-
week interval is due to differences in initial
physical constitution and individual adapta-
tion. It is not possible to predict any time
span more precisely. Protesters need to be
advised that death occurs some time after
six full weeks of fasting and survival after
ten weeks of total fasting is practically
impossible. They also need to know that in
the final clinical stages of fasting, they will
no longer be capable of discernment and
need to make clear in advance what they
expect physicians to do for them then.
4. The duty to give counselling
Medical counselling may often be a key ele-
ment in determining the duration of a
hunger strike. Physicians often find that
some patients do not believe them, even
when they try to give objective counselling.
Some people who are detained understand-
ably mistrust physicians, whom they see as
working for the authorities. Doctors can
have a difficult task convincing hunger-
strikers that they are acting on their behalf,
partly because in many cases doctors are
unable to show that they are neutral. In such
situations, there is a role for outside physi-
cians, not only to give medical advice, but
also to act as neutral intermediaries in nego-
tiations with the authorities. Doctors are
often able to play a crucial role, but only if
they obtain the trust of the patient. In some
cases, transferring a hunger striker to hospi-
tal on the pretext of performing further tests
may serve a humanitarian purpose, allow-
ing the protester to resume nourishment on
the doctor’s orders. Detainees, however,
confide in the physician only if they are
convinced that medical confidentiality will
be respected. The element of trust is here
all-important.
To give accurate advice and counselling,
physicians need to clarify the type of
hunger strike that will occur. Most so-called
“total fasts” involve protesters accepting
water but abstaining from all foodstuffs.
Different cultures, however, have different
notions of how fasting should be defined.
Salt (either NaCl alone or a combination of
minerals) is often added to the water and
possibly sugar or other sweet substances
such as honey. Some cultures define fasting
in terms of abstaining from solid food (sub-
stances that need to be chewed) or from
food that is cooked or heated. They may
discount the ingestion of milk, honey or
even nutrients such as eggs but the duration
of the fast remains the crucial element.
Physicians need to make clear to hunger
strikers that non-total or partial strikes, if
prolonged, lead to death but at a much later
stage than a total fast.
Some forms of partial fasting are consid-
ered as “cheating” by the authorities. This
can lead to controversy about the serious-
ness of the protest. Prolongation of the peri-
od for potential negotiation, however, is
often beneficial to the final outcome and
helps avoid deaths. Therefore physicians
can find themselves in an apparently
counter-intuitive situation. They may see
more advantages in terms of life-saving
opportunities in a longer hunger strike
which allows more time for negotiation
rather than a short fast which is more
restrictive in terms of what can be ingested
and therefore more lethal. Physicians need
to avoid implying to protesters or the
authorities that non-total fasting is not seri-
ous or lacks credibility. They should not
challenge partial hunger strikers on the non-
total quality of their protest fast. Physicians
need to understand that partial fasting for a
lengthy period of time can be a legitimate
form of protest which could provide more
time to find a face-saving solution for all
involved and thus be instrumental in avoid-
ing fatal outcomes. They must not, howev-
er, let themselves be manipulated by either
the authorities or the hunger strikers.
Physicians must not give erroneous clinical
testimony or advice. Prison doctors, for
example, have been known to threaten
hunger strikers with grave medical sequelae
that are fictitious. In one example, doctors
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Medical Ethics and Human Rights
39
told hunger strikers that fasting caused
impotence, with the sole purpose of fright-
ening them into giving up their fasting. This
sort of action is completely unethical and
undermines any trust that hunger strikers
may have in the medical profession.
5. The duty to maintain confidentiality
The duty of confidentiality is as strong in
custodial situations as in the community. It
is never an absolute requirement in either
context if serious harm would result from
non-disclosure and physicians need to make
an evaluation about where the best balance
lies. In situations where physicians are
unable to maintain some aspects of a
patient’s confidentiality, this should ideally
be made clear at the start of the consulta-
tion. Wherever possible, however, physi-
cians should respect patient confidentiality
as the maintenance of trust depends upon it.
This applies to non-medical information
given to physicians by patients. For exam-
ple, physicians interviewing hunger strikers
might learn the names of the ringleaders of
the protest, but they would lose patients’
trust and may put them at risk of reprisals if
they disclosed that information to the
authorities.
Case example 2 – Challenges in maintain-
ing confidentiality
In a collective hunger strike, the physician
realised that the hunger strikers needed to
prolong their protest to allow time for the
negotiation of their goals but none wished
actually to risk their lives. As the protest
was the focus of media attention, however,
they could not be seen to be lacking in com-
mitment and so while ostensibly refusing
normal food, they privately agreed with the
doctor to accept some nutrition and hydra-
tion intravenously. The physician main-
tained the trust and confidentiality of the
prisoners by not disclosing the full situation
to the prison authorities who, recognising
that normal food was still being rejected,
eventually threatened to end the strike by
force feeding. The physician intervened and
explained that he had the situation under
control without force. Both sides in the
protest were engaged in a drama where nei-
ther was willing to be seen to concede. The
doctor’s ability to agree privately with the
prisoners to provide artificial feeding
allowed time for both sides to reach an
acceptable compromise without publicly
losing face.
Hunger strikers also need to be aware that
requiring a doctor to maintain their confi-
dentiality can in some cases have potential
disadvantages for them. Such aspects need
to be discussed at an early stage.
Case example 3 – Challenges in maintaining
confidentiality
A political prisoner on hunger strike com-
plained to a visiting physician that he had
been forcibly fed while semi-conscious con-
trary to his verbal advance instructions. The
prisoner wished to register a formal com-
plaint. Having listened carefully to the pris-
oner’s story, however, the doctor had doubts
as to whether the prisoner had indeed been
fed against his will since although semi-
comatose, he was a strong man who could
have exhibited some signs of resistance. In
fact the prisoner had made no effort to resist
and later, in private, he confided in the
physician that he was relieved to have been
resuscitated but that these facts had to be
kept confidential both from other prisoners
and from the prison authorities. The doctor,
therefore, was obliged to continue the pre-
tence of taking the complaint seriously but
in cases such as this, physicians also need to
explain to hunger strikers the risks of such a
deception since in future situations, it would
be assumed that the hunger strikers did not
want to be resuscitated unless they had
made their real views plain. A hunger strik-
er in this situation would have a particular-
ly difficult dilemma if asked to sign a formal
advance directive refusing future resuscita-
tion since this would either force him to
expose his real views or it would mean that
he risked being allowed to die in future if
evidence were lacking of his real feelings. In
this case, as a last resort, the confidentiality
of the prisoner’s discussion with the visiting
physician could arguably be breached to
avoid that harm but this would really need to
be discussed in advance with him.
6. The advantages and disadvantages of
communicating with families
Families may support detainees’ fasting or
try to get the authorities to intervene to save
the prisoner’s life regardless of that individ-
ual’s views. Given, however, that people in
custodial settings often have only limited
ways of making their own genuine views
known, physicians attending them can find
it useful to communicate with their rela-
tives. Direct contact with them may provide
crucial background information allowing
them to make the best decision. Cases also
arise where physicians find themselves at
odds with a family demanding intervention
which the patient refuses. In many coun-
tries, the family of a prisoner on hunger
strike has the legal right to require medical
intervention. While keeping this in mind,
physicians should never forget that their
primary professional commitment is to the
patient. Where families support the hunger
striker or openly lobby for media attention,
the authorities may be reluctant to allow
family visits and physicians may have an
important role as intermediary. Although
pressures on hunger strikers should obvi-
ously be kept to a minimum, this should not
be an excuse to suppress family visits.
7. Is there a duty to act as mediator?
The role of mediator is outside physicians’
obligations in most circumstances but in the
context of hunger strikes, they can be par-
ticularly influential in saving life if they are
willing to do so and have the trust of both
sides. They also need an objective view of
the true situation. They may then be in a
position to negotiate and possibly obtain
concessions from both sides. They have to
decide from the start, however, whether
they can act as a medical intermediary
between hunger strikers and the authorities
and if they cannot, they need to make that
clear to patients and not pretend to play the
role. Prison doctors are likely to be in a
privileged position if they have the trust of
the prisoners and the confidence of the
prison authorities. If hunger strikers trust
and confide in them, physicians are able to
evaluate how urgent is the need for media-
tion. Most hunger strikers desperately want
to find a way out of the confrontation and
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Medical Ethics and Human Rights
40
often stop fasting if they obtain some minor
form of concession from the authorities. In
such cases physicians may be in the best posi-
tion to negotiate some compromise between
the two parties. When the demands of hunger
strikers are very obviously out of reach,
prison doctors must not fall into the trap of
pretending otherwise or insinuating that a
solution is achievable through mediation.
They should make clear that they are outside
the negotiations but the crucial role of provid-
ing accurate information to patients about
their medical condition should continue.
8. The duty to remain objective and inde-
pendent
Medicalisation of hunger strikes often
occurs and can threaten physicians’ ability
to act independently. Local law may require
medical monitoring of the hunger strike and
the status of a particular hunger striker can
also influence the attention given to that
person. Physicians may have to balance
objective medical observations with prag-
matic face-saving situations, in order to buy
time for essential negotiations to produce
results. They must avoid pandering to any
particular interest group by giving medical
information or advice that is scientifically
questionable or inaccurate.
Physicians working for prison administra-
tions or other detaining authorities some-
times cannot be really independent. Even if
they are fully aware of the ethical implica-
tions of a terminal hunger strike, without
external support they are often powerless to
oppose administrative decisions imposed
on them by the authorities. Medical associ-
ations have a duty to inform physicians of
international ethical guidelines that should
be respected at all times and to provide sup-
port for them. Independent physicians ide-
ally should be permitted to counsel hunger
strikers in the interest of all involved and in
order to try to avoid any fatal outcome.
Some countries do allow this, and these
physicians’ independent status ensures their
credibility as acceptable intermediaries for
all parties concerned.
9. Management of medical conditions
during a hunger strike
The WMA’s training module on prison
health care contains a detailed account of
the clinical stages undergone by hunger
strikers between the first days of fasting and
the final stage between 45 to 75 days later
when death occurs from cardiovascular col-
lapse or severe arrhythmias. As well as the
physical aspects, physicians need to be
aware of patients’ mental and psychological
disruptions. Refusal to take sustenance
leads to a clinical syndrome that resembles,
but is not equivalent to starvation. In the lat-
ter case, body depletion is a dragged-out
process, with little caloric intake, but still
minimum absorption of vital elements such
as vitamins or proteins. It is this intake that
differentiates total fasting in a hunger strike
situation (taking just water) with starvation
in concentration camps. Among the symp-
toms experienced by long term hunger
strikers are significant gaps in memory and
inability to concentrate. They live for the
moment. Total fasting forces the body to
find substitute sources of glucose, essential
for providing energy, to the brain in partic-
ular. Lack of calorie intake disrupts the
usual pathways, and complex mechanisms
kick in to replace the external energy
source. The body begins to digest itself,
breaking down the various tissues so as to
have a constant supply of glucose. If the
fasting leads to medical complications, it is
the duty of physicians to do more than
merely take notes and monitor vital signs.
There is need for them to enter into a seri-
ous discussion with each hunger striker. It
cannot be stressed enough that the privacy
of the medical consultation is of paramount
importance, so as to avoid any meddling or
coercion, from any side, and for physicians
to be able to play their role.
10. Artificial feeding, force-feeding and
resuscitation
It is important that physicians understand
the moral and practical distinctions between
forcible feeding, artificial feeding and
resuscitation. The WMA Malta Declaration
gives some leeway to the treating physician,
who should have the final word in deciding
what is best for the patient, all factors being
taken into consideration. Force-feeding,
however, is out of the question. If the pro-
tester’s intent is to extend the fasting as
long as possible, there should be advance
discussion between the physician and
hunger striker to clarify the expectations on
either side. In particular, physicians need to
be clear what actions they have patient con-
sent for once the fasting has clouded the
patient’s mind and coherent communication
becomes impossible. Physicians must dis-
cuss the crucial issue of artificial feeding
and resuscitation before that stage. In some
countries, patients’ known wishes dictate
what the physician does after consciousness
is lost. In others, this is not an option and
physicians may be prosecuted if they fail to
intervene to save the hunger striker’s life.
Physicians need to know clearly what atti-
tude to adopt and also make this clear to the
hunger striker, so that they can reach a deci-
sion in common. If, for personal reasons,
physicians cannot accept the patient’s deci-
sion, they should say so and step aside so
that another physician can act according to
the informed decision of the hunger striker.
Artificial feeding should not involve coer-
cion. It may be prescribed by a physician or
be imposed by a judicial authority. This
occurs usually at a stage when the hunger
striker is no longer fully conscious and too
weak to express a view. Artificial feeding
involves administering nutriments and liq-
uids parenterally or through a naso-gastric
tube. Even when physicians agree to respect
patients’ advance refusals, some circum-
stances may justify a decision to resuscitate
or artificially feed a hunger striker who has
lost competence. A justification would be
for example, that the situation has changed
after the patient lost awareness so that the
advance refusal may be considered inap-
plicable to the new scenario. If, however,
when competence is regained, the hunger
striker persists in the refusal of feeding or
treatment, the physician should allow the
person to die in dignity, without repeated
resuscitations.
Physicians should never condone or partic-
ipate in forcible feeding or any other
enforced measures which may amount to
cruel, inhuman and degrading treatment.
When hunger strikes have a political com-
ponent, the authority in charge may decide
to end them by force and order the forcible
artificial feeding of protesters. This may be
decided very early on in the fasting, when
there is no actual medical need to adminis-
ter nutrition. It should be realized in this
continue on p. 42
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Medical Ethics and Human Rights
41
Declaration of Malta
Glossary
To be read in conjunction with the background discussion paper on management of hunger strikes.
Advance instructions/advance directive
Mentally competent patients can give consent or refusal in advance for future medical
interventions, in order for their wishes to be known if later mental impairment leaves them
unable to express a view. Advance instructions are a useful indicator of an individual’s
views but only if the person making them is aware of the implications and not pressured
to make a certain choice. These criteria can be hard to meet in custodial settings but are
not invariably absent. Physicians need to be aware that at the start of hunger strikes, there
can be pressure for hunger strikers to prove that their intentions are serious which may
push them into making an ill-considered advance refusal of resuscitation. Where possible,
physicians need to discuss this privately with hunger strikers and ascertain their real inten-
tion. Some advance instructions truly reflect the individual’s wishes but others do not.
Physicians need to assess the evidence. Advance instructions can be written or verbal but
have no value if made under duress. They may also be invalid if the situation has under-
gone significant change since the individual lost competence and it is no longer what he
or she expected it to be. (See WMA statement on advance directives, Helsinki 2003).
Artificial feeding
Although often seen as synonymous, artificial feeding is not the same as forcible feeding.
All force-feeding is artificial but not all artificial feeding is forced. Artificial feeding in
hunger strikes can be a solution for hunger strikers who do not want to endanger their
health but who refuse to take nourishment normally for reasons of their own. Artificial
feeding is acceptable if hunger strikers make known their agreement to it by any means or,
if incompetent, they have not refused it in advance.
Force feeding
Force feeding not acceptable. It involves use of force and physical restraints to immobilise
the hunger striker. Although described as life saving, it is sometimes implemented as a
coercive measure to break a hunger strike
Autonomy
Physicians should respect patients’ autonomy by not overriding their voluntary, informed
and competent decisions. In the case of hunger strikes, this means physicians should
respect patients’ refusal of feeding. It is important for physicians to explain accurately to
hunger strikers the potential health impact of prolonged fasting and to advise them on how
to minimise the harmful consequences by for example, increasing fluid and vitamin
intake. Consent and refusal are invalid if the result of coercion. Autonomy is one of four
key principles that are frequently portrayed as core to modern medical ethics.
Beneficence & Non-maleficence
The duty to benefit (beneficence) and not harm (non-maleficence) are also part of the four
key principles but need to be interpreted holistically. Imposing treatment in the face of
valid patient refusal is seen as a harm not a benefit. In custodial settings, this raises ques-
tions about whether prisoners or detainees can make such free choices.
Best interests
Physicians are morally obliged to act in patients’ best interests but this does not mean pro-
longing life at all costs. An assessment of best interests must be a balance between seek-
ing the best medical outcome and a consideration of the patient’s own views, values and
preferences. Physicians do not act in patients’ best interests by overriding patients’ strong-
ly held wishes.
Confidentiality
All patients, including detainees, have rights of confidentiality but these are not absolute
rights. Consent to disclosure should generally be sought from competent individuals.
Information about incapacitated individuals can be disclosed if it is in their best interests.
For all patients, disclosure is also permitted if it prevents serious harm to others. In hunger
strikes, information about the patients’ views and medical condition should be shared
among health professionals providing care. Information can be given to other people such
as relatives and lawyers with hunger strikers’ consent.
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Medical Ethics and Human Rights
42
respect that the authorities often have spe-
cific agendas when ordering doctors to arti-
ficially feed (or force-feed) hunger strikers.
While claiming to want to save lives, some
coercive authorities clearly intend to repress
the principle of protest. For example, the
authority may decide to force-feed hunger
strikers after two weeks of fasting, when
there is no immediate medical need to inter-
vene. It may also be decided to feed prison-
ers who resist by brute force, tying down
their limbs and forcibly inserting a naso-
gastric tube. This coercion is what defines
force-feeding. It is not necessarily carried
out by medical staff but may involve med-
ical orderlies if doctors refuse.
Case example 4
In a collective hunger strike, the degree of
commitment to the fast varied considerably
among the hunger strikers. It was clear to
the visiting physician that some prisoners
were absolutely determined to fast until
they died. These prisoners not only refused
all nourishment and drank only water but
they resisted all attempts to provide nutri-
tion by naso-gastric tube. If tubes were
inserted against their will, they used them
to suck out any nourishment that had gone
into their stomach. Other prisoners in the
same strike however, told the doctor pri-
vately that they were willing to accept an
intravenous line or naso-gastric tube as
long as they could maintain the pretence
publicly that these interventions were done
against their will. Since all the prisoners
were saying publicly that they were unwill-
ing to be artificially fed (even though pri-
vately some were saying the opposite), the
first task for the doctor was to separate the
Confidentiality
All patients, including detainees, have rights of confidentiality but these are not absolute
rights. Consent to disclosure should generally be sought from competent individuals.
Information about incapacitated individuals can be disclosed if it is in their best interests.
For all patients, disclosure is also permitted if it prevents serious harm to others. In hunger
strikes, information about the patients’views and medical condition should be shared among
health professionals providing care. Information can be given to other people such as rela-
tives and lawyers with hunger strikers’ consent.
Dual loyalties
Physicians supervising the management of hunger strikers often have contractual duties and
obligations to other agencies, such as prison authorities. The WMA strongly emphasises that
medicine is a privilege that invariably carries certain responsibilities. All medically quali-
fied individuals must demonstrate the professional duties of beneficence and non-malefi-
cence even when they have dual loyalties and even if their work does not involve the actu-
al provision of care. This means that all people who have been trained as care givers have
the same ethical duties of care givers even when not employed to provide care.
Eating/fasting
Good communication depends on all parties understanding common terms in the same way.
Different cultures have very differing views on what constitutes fasting or accepting nutri-
tion. This is addressed in the WMA background paper and also in chapter 5 of the WMA’s
Internet course for prison doctors on www.lupin.nma.net.
Hunger strike and „Voluntary Total
Fasting“
Refusing nutrition takes different forms. The terms “hunger strike” and “voluntary total fast-
ing“ are sometimes used inter-changeably even though fasting may be neither voluntary nor
total. The” voluntariness” of the individual’s decision is a key issue for physicians in assess-
ing whether to abide by it.
Partial or short-term food refusal rarely raises ethical dilemmas. The most accepted defini-
tion of a hunger strike is total fasting (taking only water) for over 48-72 hours. Salt, miner-
als or sugar may be added to water. Dry fasting where all nutrition and hydration are refused
is uncommon and leads to death within a week. A hunger strike is not equivalent to suicide.
Individuals who embark on hunger strikes aim to achieve goals important to them but gen-
erally hope and intend to survive.
Justice
Justice is another of the commonly cited four key principles of medical ethics. In this con-
text, it is the requirement for physicians to treat hunger strikers fairly, by listening to their
views and trying to minimise undue coercion from any source.
Physician/physician assistant
The WMA primarily addresses its guidance to physicians but in the context of hunger strike
management, other health professionals are likely to be involved and should be encouraged
to abide by the Malta Declaration. Professional guidance for other groups such as nurses and
paramedics, for example, generally reflects the same principles.
Undue pressure/coersion
Informing hunger strikers of the implications of their decisions and encouraging them to
reflect are essential and do not constitute undue pressure. Attempting to dissuade them from
fasting by threats, including the threat of forcible feeding, is not acceptable.
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From the Secretary Gerneral’s desk
43
prisoners from each other without in any
way indicating that some were willingly
accepting nutrition. Eventually, however, it
was bound to become clear which prisoners
were determined to fast to death since the
physician recognised that it would be
unethical to force feed those who were gen-
uinely resistant. He hoped that by separat-
ing them, each of the prisoners would have
some opportunity to reconsider their deci-
sion away from the influence of the peer
group in a situation of privacy. For those
who maintained their fast, their decisions
were respected.
11. Gaining support from professional
associations
Physicians can themselves in difficult situa-
tions if they want to comply with the inter-
national guidelines which are in conflict
with local legislation. They may face the
dilemma of whether to do everything to
save a person’s life or respect the right of
individuals to dispose of their bodies as
they please. This question is often further
complicated by religious or legal issues.
Local law may require physicians to inter-
vene, even against their will, if a hunger
striker’s life is at stake. On the other hand,
international ethics guidelines focus on the
rights of individuals to determine what is
done to them. Where individual rights are
respected, hunger strikers have a chance to
have their decisions respected. Physicians
encountering difficult dilemmas should
appeal to their national associations or
directly to the World Medical Association
for guidance and support. It may also some-
times be necessary to have help from a per-
ceived neutral organization, such as doctors
from the ICRC (International Committee of
the Red Cross), Council of Europe CPT
(Committee for Prevention of Torture and
Inhuman Degrading Treatment and
Punishment) or similar organizations.
From the Secretary General’s Desk
“What do we expect from the next WHO Director General?”
On the day he was supposed to open the 59th
World Health Assembly on May 22nd
this
year, the Director General of the World
Health Organization (WHO) tragically died
following a sudden illness. The World
Health Assembly decided to hold an extra-
ordinary session later this year to determine
the next Director General (DG).
Dr. Lee was committed to give more power
to the regional organizations of WHO.
Certainly all health care is local and coming
closer to place of need was logical and nec-
essary. He headed a difficult institution,
because a political organisation is struggling
between opposing political interests, increas-
ing challenges for health and an always inad-
equa te budget. This task is like squaring a
the circle – there is no final solution.
Geneva is the home of the Red Cross, the
United Nations Commission on Human
Rights, the first assembly place of a supra-
national organization preceding the United
Nations. The Conventions regulating mini-
mal human behavior in wars have the name
of this city and what ever is connected with
it has the bonus of being of high moral
standing. But that is an illusion. The WHO
is a good example of an institution which
many people believe it to be a moral author-
ity for health care. Something it never was,
and most likely never will be.
The organization was build right in the mid-
dle of a political minefield between the east
and the west. In times of cold war it was one
of the green tables where leaders of the
political blocks could meet and discuss,
without pretending to like each other. The
old demarcation lines have gone. In time of
globalisation, trade determines the rules.
But the borders and frontiers are not gone.
They are now more complex, sometimes
invisible and often blurry. Players in the
globalisation game often don’t know
whether they are friends or foes. And all
may be different tomorrow. The problem is:
“the old mines are still hot”.
The WHO is a governmental organization
and it is only as good as the governments it
represents. No government of this world is
made of Saints, no government is without
mistakes, yet many deserve our respect. But
many others have no democratic back-
ground – they are not elected leaders of
their people. Many governments of this
world deny their people basic rights, the
freedom of speech, the right to work, the
right to move, the right to build coalitions.
Many governments deny their people even
the right to live, they torture and abuse their
own people. Yet they sit in the World Health
Assembly, the highest deliberative body of
the WHO.
WHO has driven many health campaigns:
The fight against small pox and polio are
wonderful success stories, much of it Dr.
Lee’s achievement. The WHO works suc-
cessfully on tobacco control and fights
tuberculosis world wide, it has programmes
on injury prevention and disaster relief, it
supports medical reference centres and pro-
vides administrative guidance for the recog-
nition of education and training. In other
words there are many, many things the
WHO has to be praised for. If it wasn’t
there, we would have to build it.
But then it is a political organisation with
the parameters described above, excluding
many people from cooperation just for
political reasons: Taiwan is a good example
of this. Its basis of work are the decisions of
the World Health Assembly and reports,
facts and figures provided by the countries
– or better their governments. How much
do we trust reports from countries without
WMJ_2_29-58.qxd 17.07.2006 13:35 Seite 43
WMA
44
free press, without the freedom of expres-
sion? Large parts of the WHO work are ide-
ologically biased, they are neither the
reflection of high morals nor of good sci-
ence but just of political powers.
Whoever goes there to be the new DG has
an uphill battle before him. Organisational
reform like with the rest of the UN-
Institutions is urgently needed. So what can
we realistically expect? The political prob-
lems will remain. However, a re-focusing
on true health issues and a closer coopera-
tion with the health care community would
be a good start. There is a strong alliance
out there for health care, but WHO is going
in another direction. The revitalization of
bare-foot-doctor concepts in the recent dis-
cussion on “human resources for health” is
just one example of the misled attempts to
tackle one of the worst current problems in
global health care: the global shortage of
health professionals.
To take out politics will be the biggest politi-
cal challenge for the new DG. To orient WHO
towards health and not political problems will
help to shift resources in the right direction.
More transparency to and cooperation with
the health community is high on our wish list.
At WHO many people work as staff and as
volunteers who care for health. They
deserve our cooperation and support. They
also deserve a powerful DG who is able to
free their way. WHO doesn’t need a com-
promise candidate, it needs a strong and
courageous leader. WHO needs a leader
who knows that the Organization is there to
serve the people of the world – and govern-
ments only if they do exactly the same.
WMA
173rd
WMA Council Meeting held in Divonne
The 173rd
Council met in Divonne les Bain,
France 18-20th
May 2006 under the chair-
manship of Dr. Yoram Blachar.
After welcoming new members the first
item of business was to elect a new Vice
Chairman to replace Dr. Hashimoto, who
had resigned. Following nomination
Dr. K. Iwasa (Japan) was elected as Vice-
Chairman of Council.
Following the approval of the
minutes of the 171st
and 172nd
meetings, the President, Dr.
Kgnosi Letlape reported on his
activities since the last meeting.
He had just visited Finland
where he participated in a very
productive WHO meeting on
“Health as a bridge for Peace”.
Turning to Africa he reported
that the establishment of an
African Regional meeting was
progressing very well. This
should be formalised at a meeting in July
and it was anticipated that it would meet
later in the year. HIV/AIDS remained a
major problem and he felt that actions of
WMA needed to become more open in this
area. Priorities were preventing the exten-
sion of HIV/AIDS and increasing access to
treatment. In this connection he stressed
that the unavailability of medicines was
aggravated by problems with patent sys-
tems.
He was also concerned about those infec-
tious diseases which were not adequately
covered and welcomed the role of the
Health Protection Agency He was very dis-
turbed by the lack of disaster plans and
preparations still in many countries. NMAs
could assist with these, but there was a lack
of appropriate mechanisms for mobilisation
of the profession.
On a different note he stressed
the need for coordination of
those health professionals who
rapidly respond to the need for
assistance in major disasters.
He paid a special tribute to Dr.
Yank Coble for his work in
inspiring the “Caring Physicians
of the World” project, especially
in promoting and supporting
regional meetings. These had
permitted real dialogues on major issues
relating to medicine.
He felt that WMA needed to become more
engaged in policy decisions in the health-
field, particularly with WHO. It also needed
to promote leadership within the profession.
Concluding by referring again to the prob-
lems of Africa he said that while the “3 in
5” initiative was a most welcome one,
unfortuntely the target was not being
achieved. Only 1.3 of the three million tar-
get had been achieved by the programme.
At the same time he paid tribute to the work
of the catholic missions who quietly got on
with work providing care, particularly in
the most remote areas.They were one of the
biggest providers of help globally and in
Africa provided 10% of the aid for
HIV/AIDS care.
The Secretary General invited to speak to
his written report, (see 49 for the full
report), said that the first part concerned
the Caring Physicians of the World
Initiatative and it was appropriate there-
fore that Dr. Yank Coble should present
this.
Dr. Coble, referring to the World Medical
Journal (WMJ 2006, 52, (1), 11) said that
the start of this project was in Helsinki. The
book had been launched in Santiago, had
been sent to NMAs and will go to all
Ministries of Health. It had been distrib-
uted to Ministers in Bangkok, Taiwan,
India, to the President of the United States
of America and also to many international
bodies. The programme had been expanded
through regional meetings in Johannisburg,
Bangkok, Prague, North and South
America. He was delighted that these meet-
ing provided firm evidence that people
would agree on the enduring traditions of
Caring, Ethics and Science in medicine.
Dr. K. Iwasa
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The Secretary General, Dr. Otmar Kloiber,
expressed his pleasure at being part of these
activities which also increased the visibility
of the WMA, especially for those members
who cannot get to global meetings such as
those of the Council and the General
Assembly. Returning to his report he said that
much of the work had concentrated on gover-
nance, statutory reform, finance and balanc-
ing the budget. Referring to problems of get-
ting NMA subscriptions, he reminded NMAs
of the need to pay both in time, and in full.
There had been continuing discussion on
finance and partnerships and he pointed out
that engagement in new activites could not
be done without forming partnerships.
Turning to the World Health Professions’
Alliance (WHPA), he reported that cooper-
ation had been very positive, although pos-
sible points of critical discussion had still to
be faced by the Alliance, such as shared
competences and the limits of each profes-
sion. The Alliance was in agreement that the
World Health Report (WHR) on the work
force was distorted. There was an emphasis
in this WHO report on training lay people,
but while some of this emphasis had been
modified during the preparation of the
report, there were still statements about self
regulation and a preference for a “command
and control” style. The so called “Global
Alliance for the Workforce for Health” had
prepared its work without the Health
Professions. The WHPA had asked for a dis-
cussion on the World Health Report with
the Director General. As it was not possible
to see him about their concerns before
World Health Day, the Health Professions
Organizations did not participate in this.
There was a need to cope with the problem
of representation at WHO. This would be a
core part of the strategic development of the
WMA.
Both Dr. Blachar and Dr. Letlape concurred
in their concern that the WHR possibly
downgrades the profession.
Dr. Blachar thanked Dr. Kloiber, in particu-
lar for his work in taking over WMA at a
difficult time and in fulfilling the Council’s
expectations.
In response to a question about the obliga-
tion of the Chinese Medical Association to
include a member of the government
amongst the senior officers of the
Association, Dr Coble observed that at the
time of the SARS epidemic, the Vice
President of the Chinese Medical
Association was a Minister, the executive
Vice President and executive staff were
politically determined.
Council then adjourned for the Meeting of
the
Finance and Planning
Committee
This meeting was opened by the Chairman,
Dr. John Nelson and the minutes of the last
meeting in Santiago were approved.
Dues
The committee considered various reports
concerning NMAs’ dues and actual dues
payment; also the status of council mem-
bers and officers during their term of office
in the event of irregularities in payment of
dues by their NMA. Legal counsel con-
firmed that NMAs who are represented on
Council are required to pay their dues on
schedule, or have a written agreement with
the Secretary General that they will be reg-
ularised before the General Assembly. The
Secretary General outlined the process of
dealing with non dues payment, a process
which now leads to the termination of sin-
gle membership.
Financial statement 2005
After further discussion on the issue of non
dues payment, the committee considered
the financial statement for 2005, presented
by Mr. Adi Häallmayr who gave a particu-
larly clear transparent presentation of the
situation. The Council noted the remarkable
achievement of “turn round” in the financial
position which had taken place, achieving a
balanced budget for the first time in years.
This was thought to be impossible in the
space of a year and the Secretary General
was congratulated on this achievement.
This, Dr. Kloiber reported had been largely
due to strict budgetary constraints on activ-
ities and a number of other factors which
were included in Mr Häallmayr’s report.
In response to a question as to whether this
improvement was sustainable, the Secretary
General responded positively, but only if
the WMA confined itself to its Core busi-
ness. Any extra activity would call for extra
financing. Concerning any advantage to be
gained by moving from Ferney Voltaire to
Geneva, he referred to a relevant study cur-
rently being undertaken by the World
Dental Federation.
The committee recommended that the pre-
liminary financial statement for 2005 be
approved, also by council later.
Governance changes
The Finance and Planning Committee dealt
with the Governance changes that had been
developed over the last year. These recom-
mended changes in the Bye laws including
a limitation of the terms of officers to a
maximum time of six years, during which a
council member could hold a specific func-
tion. Furthermore the Executive Committee
consisting of the chairpersons of Council,
the Committees and the Treasurer, was
enlarged to include the President as a non-
voting member. The executive committee
will serve at the request of the Council
Chair and will advise the Chair of Council,
Council and the Secretary General. The
amendments to the Bye-Laws were recom-
mended for approval and submission to the
General Assembly. This was subsequently
approved by Council.
Business development Group
An oral report from the Business develop-
ment Group was considered. Eight options
were identified and the group sought to
identify two for initial consideration. A sur-
vey of the views of participants present at
the council meeting on the options was dis-
tributed.
Strategic Plan
The Secretary General presented the
Strategic Plan for 2006-2010. He comment-
ed that during the Caring Physicians of the
World Initiative and the Strategic survey
they had learnt that there was a need for
clear advocacy work called for by most
NMAs, an issue which was also discussed
in parallel by the Business Group. Referring
to the document he indicated that before the
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committee there were three areas reflecting
NMAs needs, namely, Ethics Guidance
including Social- Medical Questions,
Advocacy Representation and Service and
Outreach.
Dr. Kloiber said that outreach services
needed to be developed, as did Advocacy.
The Ethics Unit needed to be strengthened
and this was the way forward to maintain
the high reputation of WMA, as exempli-
fied by Helsinki, Geneva and Tokyo. He
paid tribute to the outstanding work of Dr.
John Williams both in the unit and his other
contributions in the representational work.
Speaking generally about ethics, he felt that
more attention needed to be given to begin-
ning and end of life issues, many of which
may not lead easily to consensus agree-
ments. Issues of cloning, of stem cells and
of the use of modern technology and its
problems need equal attention. We also
have our own problems. NMAs should be
challenged to report back if WMA guidance
was not acceptable. Prison Medicine and
multi-drug resistant tuberculosis need to be
tackled. Awareness of the problems of
young physicians and young students must
be strengthened and WMA needs to advo-
cate for them. Referring to the importance
of the location of the Office near to Geneva,
he outlined the opportunities this provided
for discussions with the UN, WHO, ILO,
the Commission on Human Rights etc..
There was however some limit on how
much the Secretary General and Dr.
Williams could do. Asking NMAs to sit in
on some meetings was difficult as meetings
were often at short notice and air fares cost-
ly. Nevertheless in order to avoid lost
opportunities, there is a need for more
involvement of NMAs.
Services and support to NMAs also need to
be strengthened. In this connection he was
glad to respond to NMAs who ask for help,
but this had to be within the limits imposed
by shortage of staff.
The services to individual associate mem-
bers need to be broadened. The web portal
and other projects should to be part of the
outreach to associates. The benefits of asso-
ciate membership need to be strengthened
beyond receipt of the WMJ and insurance.
The Journal now has a new image, is now
more orientated to WMA work and offers a
platform for discussion.
Dr. Haddad welcomed the Secretary
General’s plan. The three areas highlighted
were absolutely right and should be used to
build upon. He agreed with the emphasis on
Advocacy, but more resources were needed.
The committee recommended that the Chair
of the committee and the Secretary General
convene a working party to develop an
implementation plan proposing specific
objectives, deliverables and time tables,
with cost estimates for the actions proposed
in the Strategic Plan.
In further discussion the committee consid-
ered the financial implications of expanding
the advocacy role, the manpower needs to
develop the Ethics Unit, to deal with
Documentation and the development of the
www portal etc.
Future General Assemblies
The arrangements for the 2006 WMA
General Assembly in South Africa were
reported. The Danish Medical Association
proposed “Health Care Information
Technology” as the theme of the Scientific
Session in Copenhagen in 2007, but the
final decision on the theme would be for the
2006 General Assembly to decide.
Associate members
The report on Associate membership was
received.
Public relations
The Committee received the report of the
Public Relations consultant and thanked
Mr. Nigel Duncan for his work.
World Medical Journal
The committee received the report of the
Editor of the World Medical Journal and the
Hon Editor stressed that a successor had not
yet been identified. The Chair recognised
the need to identify a successor to Dr. Alan
Rowe soon and thanked him for his consid-
erable efforts.
The Ethics Committee
Dr. Eva Bagenholm, opening the meeting
welcomed new members, following which
the minutes of the last meeting in Santiago
2006 were approved.
Ethics Unit
Dr. Williams, who will be leaving the
WMA Ethics Unit at the end of the year,
presenting the report of the Ethics Unit,
informed the committee that the Ethics
Manual had now been translated into
Macedonian, Albanian, Taiwanese, Indo-
nesian and Chinese, French and Spanish. It
was hoped to produce the manual as a CD
ROM in three languages. The Bulgarians
had also offered to translate it, bringing the
total translations to 19 languages. An on-
line version in Norwegian will soon be
available as well as Arabic, if funds are
available.
Policy review
The committee then considered proposed
changes to policy and NMAs comments on
them.
The Declarations of Geneva, of Tokyo and
the Regulations in Times of Armed Conflict
which had undergone minor revision (see
pages 29, 34, 35 for the revised texts), were
recommended for approval and were later
approved by council.
The committee then considered policies
classified as requiring major amendment.
In the list of amended documents recom-
mended for approval (see list below),
notable points raised included the removal
of Human Tissue from the proposed revised
Statement on Human Organ Donation and
Transplantation. This was requested in
order to distinguish between organs and tis-
sues, which were subject to different legal
treatment in European Community legisla-
tion. The German Medical association
agreed to develop a new proposal for a
statement on Human Tissue Donation.
Other amendments to the original text were
adopted.
The proposed revision of the International
Code of Medical Ethics led to considerable
discussion which substantially focused as
much on the concepts underlying proposed
phrasing, as on individual words. After
agreement on some word changes, it was
agreed that a new working group would fur-
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47
ther consider the revision, the group to be
led by the Icelandic Medical Association
and includes members from the Medical
Associations of Canada, Israel, Slovakia
and the United Kingdom.
After some discussion of the 1996 Policy
Statement on Weapons and their relation to
Life and Health Issues which had been rec-
ommended for minor revision, following
NMAs’ expression of views, it was agreed
that the BMA would do a revision for con-
sideration at the next meeting.
Concerning those WMA policies undergo-
ing major revision the committee recom-
mended and, with some changes in the
Declaration of Oslo, the Council later
approved the following:
• That the Proposed Revision of the
International Code of Medical Ethics be
assigned to a new working group led by
the Icelandic Medical Association and
including the NMAs from Canada,
Israel, Slovakia and the United
Kingdom;
the Proposed WMA Statement on
HIV/AIDS and the Medical Profession
be approved and forwarded to the 2006
General Assembly for adoption and that
the
Interim Statement on AIDS, Statement on
the Professional Responsibility of
Physicians in Treating AIDS Patients,
and the Statement on Issues Raised by
the HIV Epidemic be rescinded and
archived.
• That the Proposed Revision of the
Declaration of Venice on Terminal
Illness be approved and forwarded to the
2006 General Assembly for adoption and
that the Statement on the Care of
Patients with Severe Chronic Pain in
Terminal Illness be rescinded and
archived;
the Proposed Revision of the Statement
on Human Organ Donation and
Transplantation, as revised, be approved
and forwarded to the 2006 General
Assembly for adoption;
the Proposed Revision of the Statement
on Ethical Issues Concerning Patients
with Mental Illness, as revised be
approved and forwarded to the 2006
General Assembly for adoption;
the Proposed Revision of the
Declaration of Sydney on the
Determination of Death and the
Recovery of Organs as re-titled, be
approved and forwarded to the 2006
General Assembly for adoption;
the Proposed Revision of the Declaration
of Oslo on Therapeutic Abortion, as
revised and amended by Council, be
approved and forwarded to the 2006
General Assembly for adoption;
the Proposed Statement on Assisted
Reproductive Technologies be approved
and forwarded to the 2006 General
Assembly for adoption; and that the
Statement on In-vitro Fertilisation and
Embryo Transplantation and the
Statement on Ethical Aspects of
Embryonic Reduction be rescinded and
archived.
• That the Proposed Revision of the
Statement on Animal Use in Biomedical
Research be approved and forwarded to
the 2006 General Assembly for adop-
tion;
the Proposed Revision of the Statement
on Medical Ethics in the Event of
Disasters, as revised be approved and
forwarded to the 2006 General Assembly
for adoption;
the Proposed Revision of the Statement
on Child Abuse and Neglect, as revised,
be approved and forwarded to the 2006
General Assembly for adoption;
the Proposed Revision of the Statement
on Patient Advocacy and Confiden-
tiality, be approved and forwarded to the
2006 General Assembly for adoption;
and
the Statement on Foetal Tissue Trans-
plantation be rescinded and archived.
• That the Proposed Revision of the
Declaration of Malta on Hunger Strikers
be referred to NMAs for comment, along
with a background paper and glossary of
terms prepared by the BMA.(see pxxx)
The recommendations were later app-
roved by council.
Human Rights
The Secretary General reporting on Human
Rights matters, said that the CD ROM
Course for Prison Doctors was completed in
English and Spanish, Mr. Hernan Reyes
(ICRC) added that the French version was
virtually complete and the CD ROM would
then be in English, French and Spanish. Dr.
Terje Vigen (Norway) stated that a Chinese
version was under discussion. Dr. Kloiber
resuming his report reminded the commit-
tee of WMA’s participation in the teaching
project in relation to the Istanbul Protocol.
The number of countries who would permit
this to take place was unfortunately limited.
Speaking of problems which had come to
the WMA, he spoke first about Guantanamo
Bay. The American Medical Associations in
their discussions with the USA government
had made WMA policy on this issue very
clear and the AMA continued to be very
helpful.
Referring to Cuba he reminded the commit-
tee that two years ago doctors were impris-
oned for speaking among other issues about
problems of health care and of preferential
treatment for some parts of the population.
The WMA had appealed for better condi-
tions and for the release of those doctors
imprisoned. Dr. Parsa-Parsi had attended a
meeting on Medical Apartheid in Cuba
which was held in Germany. Dr. Parsa-Parsi
said that medical care was available for
Tourists and High Officials in reasonable
conditions but there were few facilities for
the rest of the population. There was a high
abortion rate in the absence of birth control,
especially amongst the younger population.
He also spoke of the suffering of doctors
imprisoned in inhuman conditions whose
families had evidence of their bad physical
state. Dr. Kloiber urged NMAs to pick up
this issue and support these doctors.
China
The Secretary General then addressed the
subject of China. He reminded the commit-
tee that they had asked him to write to the
Chinese Medical Association about the har-
vesting of organs from executed Chinese
prisoners. This matter had already been dis-
cussed at a time when China applied to be a
member of WMA in 1997. Last year the
Times newspaper had reported that the
Deputy Minister of Health admitted that
this activity had taken place but stated that
regulations would deal with this.
Nevertheless advertisements still appeared
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from hospitals offering kidney transplants
obtained from this source. Since then there
have been reports that Chinese doctors have
participated in removing organs from exe-
cuted prisoners, and allegations have even
been made that vivisection is taking place.
The Secretary General wrote to the Chinese
Medical Association as instructed and had
had no reply. Likewise there had been no
reply to a second letter in December 2005,
requesting that the association confirm its
support of WMA policy on this matter as
for all other policies, in accordance with the
WMA conditions of membership.
In view of the consistent failure to reply not
only to letters but also to e-mails and faxes
etc, the Council now had to consider further
action.
In the ensuing discussion, speakers sought
clarification that the policy referred to was
that prisoners were in no position to give
informed consent and that physicians
should not participate when organs were
removed from prisoners after execution.
This was confirmed and it was further indi-
cated that China was a fully paid up mem-
ber of WMA in 2004.
Following extensive discussions during
which very deep concern was widely
expressed, it was proposed and agreed that
the secretariat prepare a document with all
the evidence of these practices, for informa-
tion and use by NMAs. The following
Resolution was later adopted unanimous-
ly by the Council after further discussion.
The committee also recommended and
council later approved:
“That the Secretary General forward the
Resolution on Organ donation in China to the
Chinese Medical Association with a letter
expressing the council’s grave concerns. The
letter will indicate that the Council had dis-
cussed future possible actions with respect to
the Chinese Medical Association in the event
that it did not respond to WMA with an
express condemnation of this practice and its
support of WMA policy on this issue.”
Taiwan
The committee also reviewed its concerns
about WHO denial of participation of
Taiwan in the World Health Assembly and
other technical meetings and adopted the
following recommendation which Council
later endorsed:
“That the WMA issue a press release reaf-
firming its position on the status of Taiwan
as an observer at the World Health
Assembly, the importance of the meaning-
ful participation of Taiwan in technical
meetings of the World Health Organisation
and urging that Taiwan’s status and partici-
pation not be hindered by excessive bureau-
cratic or administrative requirements.“
Socio-Medical Committee
The Socio-Medical Affairs committee met
under the Chairmanship of Dr. Henry
Haddad and approved the minutes of the
meeting in Santiago 2006.
Policy Revision
The committee proceeded to consider com-
ments from NMAs on policies requiring
major revision, using the consent agenda
procedure (the final recommendations of
the committee are set out below). Under this
procedure, which agrees all items other than
those identified by committee members as
indicating a need for discussion, following
short discussion, the Statement on Medical
Education was approved, as was that on
Adolescent Suicide and Traffic Injury.
There was some discussion on the Role of
Physicians in Environmental Issues in
which the importance of the environment in
disease was stressed It was pointed out that
the European Union had addressed this
topic, but that this was ,of course, a world-
wide issue. The document was drawn up in
1997 and it was suggested that the docu-
ment needed to be expanded. It was recom-
mended that a working group be established
(see below)
The committee’s recommendations, later
agreed by Council, were
• That the Proposed Statement on Medical
Education be approved and forwarded to
the 2006 General Assembly for adop-
tion;
the Fifth World Conference on Medical
Education and the Declaration of
Rancho Mirage on Medical Education
be rescinded and archived;
the Proposed Revision of the Statement
on Adolescent Suicide, (as revised), be
approved and forwarded to the 2006
General Assembly for adoption;
the Proposed Revision of the Statement
on Traffic Injury, as revised be approved
and forwarded to the 2006 General
Assembly for adoption.
• That a Working Group be established to
address the topic of the Role of
Physicians in Environmental Issues.
• The Working Group, composed of the
NMAs from France, Brazil, South Africa
and the United States, will review all of
the proposed documents developed to
date on this subject.
• That the Proposed Revision of the
Statement on Health Promotion be
referred to NMAs for comment;
the Proposed Revision of the Statement
on Injury Control be referred to NMAs
for comment;
Council Resolution on Organ
Donation in China
Whereas, the WMA Statement on Human
Organ and Tissue Donation and Transplanta-
tion stresses the importance of free and
informed choice in organ donation, and
Whereas, the statement explicitly states that
prisoners and other individuals in custody are
not in a position to give consent freely, and
therefore their organs must not be used for
transplantation, and
Whereas, there have been reports of Chinese
prisoners being executed and their organs har-
vested for donation,
Therefore, the WMAreiterates its position that
organ donation be achieved through the free
and informed consent of the potential donor.
The WMA demands that the Chinese Medical
Association condemn any practice in violation
of these ethical principles and basic human
rights and ensure that Chinese doctors are not
involved in the removal or transplantation of
organs from executed Chinese prisoners.
The WMA demands that China immediately
cease the practice of using prisoners as organ
donors. 20.05.06
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49
the Proposed Revision of the Statement
on Access to Health Care be referred to
NMAs for comment;
the Proposed Revision of the Statement
on the Twelve Principles of Provision of
Health Care in Any National Health
Care System be referred to NMAs for
comment;
the Proposed Statement on the
Responsibilities of Physicians in
Preventing and Treating Opiate and
Psychotropic Drug Abuse be referred to
NMAs for comment and
the Proposed Revision of the Statement
on Alcohol and Road Safety be referred
to NMAs for comment.
After considering NMAs’ suggestions for
classifying the five Socio-Medical Affairs
policies adopted in 1996 the committee rec-
ommended and Council later agreed
• that the Statement on Family Planning
and the Right of a Woman to
Contraception undergo major revision
by the British Medical Association and
the Statement on Resistance to
Antimicrobial Drugs undergo major
revision by the American Medical
Association;
• That the Declaration on Family Violence
and the Statement on Professional
Responsibility for Standards of Medical
Care undergo minor revision.
• That the Resolution concerning Dr.
Radovan Karadzic be rescinded and
archived.
Tuberculosis
During the consideration of NMAs’ com-
ments on a proposed Statement on
Tuberculosis, the committee proposed that
the Resolution on Tuberculosis as revised,
be approved and forwarded to the 2006
General Assembly for adoption and that the
1997 Statement on Drug treatment of
Tuberculosis be rescinded and archived.
This was subsequently agreed by Council
In an oral report by the Secretariat on
progress in the development of the on-line
course on the treatment of drug-resistant
TB, reference was made to the success of
the Geneva Press conference, that a chapter
on Tuberculosis in prisons had been added
by ICRC, that the text material would be
tested in South Africa and then be translat-
ed into other languages.
Medical Assistance in Air Travel
There was considerable discussion on a
Resolution, originally proposed in the
Associates’ meeting, on Medical Assistance
in Air Travel. The Secretary General point-
ed out that this dealt with the problems and
the risk of physicians’ liability when
responding to calls for medical assistance in
the air. He considered that this needed to be
regulated internationally. While in some
legislation there was a limit on the financial
liability in these circumstances, a speaker
called for the enactment of legislation to
provide immunity from liability action to
those physicians who provide emergency
assistance in in-flight incidents. A further
speaker pointed out that the request for
assistance came from the airline and it
could be that the Aviation Authority should
accept the liability. It was also suggested
that the Airlines should regard the doctor as
an employee in these circumstances.
Several speakers observed that there could
be no immunity from criminal liability and
a suggestion was made that in the absence
of immunity from legal liability, airlines
must “accept all legal and financial conse-
quences of asking for assistance”.
Dr Kloiber said that there were differences
in legal responsibilities in different coun-
tries. After amendment, the committee rec-
ommended “that the Resolution on Medical
assistance in Air Travel, as revised, be rec-
ommended for approval and forwarding to
the 2006 General Assembly for adoption.
This was subsequently approved by
Council.
Discussion of a proposed Resolution on
Child Safety in Airline Travel was deferred,
pending a review of this topic by the
German Medical Association
Avian and Pandemic Influenza
Finally, the committee recommended that in
view of the importance and urgency of this
issue:
“The Proposed WMA Resolution on Avian
and Pandemic Influenza, be sent without
delay to NMAs, and that NMAs be urged to
use the recommendations in the document
in their policy and advocacy activities, in
advance of further consideration of this
topic at the 2006 General Assembly”.
Further Council discussion
In addition to the decisions of Council in
the second part of its meeting set out above,
the Russian Medical Society made a state-
ment about the situation of physicians in
Russia clarifying that the Pirogov
Conferences were called by the Health
Minister. They were not meetings of
National Medical Associations. The
Chairman of Council took note of this.
Secretary General’s Report
to the 173rd
WMA Council Session
(October 2005 – April 2006)
Consolidation
The year 2005 was determined by the seri-
ous financial situation of the WMA. The
years before the operation of the WMA
ended with deficits, thus consuming signif-
icant parts of its assets. It therefore was the
first priority to maintain strict control over
the WMA finances. This has been success-
fully achieved by
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50
• Consulting with the executive treasurer,
who immediately reorganized our
investments and cash management and
thereby stopped financial losses.
• Quarterly financial reports, allowing bet-
ter control over the financial and eco-
nomic situation.
• Priority setting: The World Medical
Association has been involved in a vari-
ety of fields which certainly are related
to medicine and the work of physicians,
however we were not able to provide a
useful and sustainable service. Those
activities were terminated or reduced
and will only be revived, if an idealistic
or material net value can be obtained for
the association or its members.
• Reviewing contracts and business rela-
tions. We examined all contracts for
necessity and price-worthiness. In many
cases we achieved better prices for the
same service or better service for the
same price. We reduced spending for
travel and representational expenses to
an absolute minimum.
• Outsourcing. After the resignation of our
French translator the position has not
been refilled. French translations are
now being done by an outside translator
at lower cost to the association with no
loss in quality and speed.
• Application of rules. Consulting with the
executive committee, the financial offi-
cers or the Sponsorship advisory com-
mittee leed to clear governance and
financially sustainable partnerships and
sponsorship arrangements, thus reducing
the risk of financially non-sustainable
engagements or ethically questionable
liaisons.
The strict application of these methods
helped to achieve a balanced budget for
2005 much earlier than anticipated.
However, this does not mean that the WMA
is in a financially comfortable situation:
• The income from dues is still unstable.
Again in 2006 some major dues did not
come in time or as agreed, some did not
come in full.
• Some member associations pay only
nominal dues, some because clearly their
financial situation does not allow other,
some which have obviously other rea-
sons.
• Even with a complete income from dues
this would not allow extra activities,
which increase our visibility, presence at
international organization or own activi-
ties providing service to our members or
the general public.
• Revenue from sponsorship is problemat-
ic as it may produce dependency we do
not wish and as it is of course in the
hands of a partner whether to engage or
not.
• With the opening of the borders between
Switzerland and the European Union
consumer prices and labour costs adapt-
ed to the level of the dominating Swiss
neighborhood,.the once very cheap
French area “Pays de Gex” west of
Geneva has become one of the most
expensive areas in Europe.
Caring Physicians of the
World Initiative
Prior to our General Assembly in Santiago
de Chile, October 2006 we organized a
regional conference with the Latin
American Confederation of Medical
Associations CONFEMEL in Santiago on
10/11 October 2006 and we publicly
launched the Caring Physicians of the
World-Book on October 12th
. Since then the
distribution of the Caring Physicians of the
World-Book has continued and its reception
is overwhelmingly positive. We have not
received a single negative comment on the
book, but a great deal of support and inter-
est in it.
The campaign is about values, dedication
and pride and upholding our traditions of
caring, ethics and science. At the same time
in our conferences we are addressing the
current needs of the member associations
on a very practical level. With own confer-
ences in Europe and North America and the
participation of WMA leaders in regional or
national meetings in various places, we are
continuing the CPW campaign.
Regional Leadership
Conferences
Latin America
Together with the Confederation of Medical
Associations in Latin-America CON-
FEMEL the World Medical Association
held a regional conference prior to our
General Assembly in Santiago de Chile,
October 9th
and 10th
. The Cooperation with
CONFEMEL allowed us to meet not only
with our regional member associations, but
also other medical associations which exist
either in parallel with our members in some
of the countries or which are from countries
having no association with WMA member
status. The conference dealt with issues of
health system reform and continuing pro-
fessional development.
Europe
The heads of the European Medical
Associations in the WMA met in Prague,
December 9th
and 10th
. The leadership sem-
inar focused on:
• Health and Human Resources, analysing
the global trends of migration from south
to north and in the European region from
east to west. In general the migration fol-
lows an economic gradient from poorer
to richer countries, from less favorable to
better working conditions. Concerning
the situation in Africa it was noted that
for many countries there, the loss of
health professionals is catastrophic. In
some of the European countries it
already leads to a significant shortage of
professionals endangering continuation
of care especially in rural areas.
Among the factors that make profession-
als migrate are not only payment issues
but also too high workloads, inadequate
working circumstances and overburden-
ing democracies. In European countries
the loss by migration into other countries
is even exceeded by loss to other occu-
pations of young physicians and the
choosing of early retirement by estab-
lished physicians.
• In Germany, Belgium and France, strikes
and demonstrations of doctors were the
apparent signs of a deep dissatisfaction
with the conditions doctors have to work
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51
under in many European Countries. A
presentation on the perception of the cur-
rent protest actions taken by doctors
especially in Belgium and Germany
showed an overwhelming support by the
public for the strikes and demonstrations
of the doctors.
• A second session dealt with pandemic
preparedness and the threat of the avian
flu outbreak turning into a human pan-
demic. Although in all of the countries
represented pandemic plans were
already prepared or under preparation,
the overall preparedness was not seen to
be sufficient. Questions of management,
resource allocation but also preventive
strategies remained still open. The repre-
sented leadership felt it necessary that
the National Medical Associations
should be more strongly involved in the
discussion of and preparation for a pos-
sible pandemic. Finding a fine line and
appropriate risk communication that on
the one hand explains the threats and
necessity for preparation, but on the
other hand does not trigger panic, seems
to be the challenge in which the organi-
sations of physicians can help most.
It was mentioned by some of those present
that regional conferences like the one in
Prague would offer possibilities for partici-
pation
North Americas
Leaders of the Canadian, American and
Mexican Medical Associations met on
Amelia Island, Florida, March 24th
and 25th
to discuss – for the first time in this group –
emerging health topics for the region with
leading experts from academic institutions
and the industry.
• The development of the profession, its
new challenges through rapid changes in
technology, demography and patient
demands meet in North America with a
sharp deficit of health professionals.
Currently the health care markets in
Canada and the United States are the
strongest magnets for health profession-
als. This stimulates a global migration as
it has been described in our preceeding
European conference (see above). New
technologies but also better planning for
the health work force may counteract the
problems of human resources.
• For many years now counterfeit drugs
have been observed and registered as a
serious threat to the developing nations.
However the notion that this is a prob-
lem of developing countries is a mistake.
Counterfeit drugs probably occur in all
countries, certainly in the rich countries
of the northern hemisphere. This poses
multiple dangers:
• Counterfeits are theft of intellectual
property. They reduce the return on
investments others have made and
reduce the resources for new develop-
ments.
• Counterfeits are of uncontrolled qual-
ity. They may or may not contain the
active substance, they may or may not
be dosed correctly, they may or may
not carry other poisonous substances,
and they may deteriorate faster than
described on the package
• Counterfeits destroy trust. The occur-
rence of counterfeits severely endan-
gers patients’ compliance.
It will be challenge for us to help to
detect counterfeits (by just considering
them), but at the same time not to dimin-
ish the compliance of our patients.
• Although North America has been
spared from infection with the avian
influenza virus H5N1, the threat of a
global health pandemic exists for the
Americas as for any other region in the
world. Although our knowledge about
the pandemic development and the med-
ication options, both those for prevention
(vaccines), therapy (anti-virals) and the
treatment of opportunistic infections
(antibiotics) have strongly improved, the
risk has grown as well. A century ago
pandemic spread was somewhat limited
by the slowness and low density of trans-
portation. At that time traveling around
the world took weeks, but now it takes
only hours and before a serious virus
may be diagnosed, it most likely to have
already landed on another continent. Our
awareness of this threat has to be
increased and our resources, communi-
cations structures and our regulations,
have to be tested in the preparedness for
a global pandemic.
The three North American Medical
Associations agreed to work on a common
action plan.
World Health Professions
Alliance (WHPA)
(www.whpa.org)
In 1999 the International Council of Nurses
(www.icn.ch), the International Pharma-
ceutical Federation (FIP) (www.fip.org) and
the WMA founded the World Health
Professions Alliance. The alliance aims are
to foster the cooperation of the professional
organizations and to augment our advocacy
work with the international organizations,
especially the WHO and the public. Last
year the World Dental Federation (FDI)
(www.fdiworldental.org) joined the alli-
ance.
Since its inauguration the WHPA has taken
an active role in the anti-tobacco initiative,
in the fight to protect human rights, the
recognition of the HIV/AIDS pandemic and
against discrimination of the mentally ill. It
promoted awareness on issues such as
antimicrobial resistance, nutrition and
health care for the elderly. The WHPA has
engaged in leadership issues and has often
overcome objections of officials who prefer
to speak with a “single” health profession.
During the last year WHPA has cooperated
with the International Alliance of Patient
Organisations, IAPO (www.iapo.org). On
the occasion of its second annual meeting in
February 2006 the WMA President, Dr.
Kgosi Letlape, represented the World
Health Professions Alliance and spoke on
their behalf on patient safety.
The WHPA serves as a platform for various
discussions and initiatives in health care.
• it cooperates closely with the WHO and
the Industry to combat counterfeit drugs
and materials,
• it develops guidelines for the compe-
tence of international health care consul-
tants,
• it discusses overlapping educational
issues and
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52
• it serves as a common platform on health
professional issues with WHO.
The latter point has led to a personal discus-
sion with the Director General of WHO, Dr.
Lee Jong-wook. Dr. Lee met with the
Secretaries of the four WHPA Associations
on April 3rd
, 2006. In the meeting the
Associations documented their interest and
need for a closer relationship with WHO
and their preparedness for a stronger coop-
eration especially on human resource relat-
ed issues. The secretaries’ expressed their
opinion that there is a need to further dis-
cuss some aspects of the World Health
Report 2006 in common. It was agreed that
the relative status of the health professions
associations be revised and that common
work on human resources issues with a
focus on regulation should start as soon as
possible. We were not able to achieve a sig-
nificant role in the “Alliance for the work-
force for health” under preparation by
WHO.
The WHPA Leadership
Symposium
In May 2004 the WHPA staged its first
WHPA leadership symposium. The sympo-
sium aimed to strengthen the bond and
encourage collaboration between the three
health professions at the country level.
The second biennial WHPA Leaders’Forum
will be held on May 20-21, 2006 in Geneva,
Switzerland. The main focus of this forum
is patient safety, highlighting the critical
role of health professionals. Daniel Ford of
the National Patient Safety Foundation
Patient and Family Advisory Council will
lead a discussion on building blame-free,
responsible health care environments. The
ways in which health professionals can
combat counterfeit medicines will also be
discussed, along with the importance of
health professionals working together.
The European Forum of
Medical Associations and
WHO (EFMA)
Budapest 21-22 April 2006
The EFMA is a common forum of Medical
Associations of the WHO-Region “Europe”
and the WHO EURO in Copenhagen.
Although existing now for nearly a quarter
of a century WHO has lost interest in the
Forum during the last years under the lead-
ership of the current director, Dr. Marc
Danzon in the year 2000. This year the
deputy director of WHO EURO, Dr. Nata
Menabde, joined the Forum in lieu of the
Regional Director who was unable to attend
because of illness. This was the first partic-
ipation of WHO leadership since the year
2000.
The current leadership made it clear that the
support formerly given to this Forum could
not be reestablished. However, the WHO
offered partnerships for the establishment
of common projects.
The Forum discussed among others topics
• National patients’ records databases, and
stressing the importance of having the
users of these systems, patients and
health professional included in the plan-
ning of the systems.
• Collaboration between the medical pro-
fession and the pharmaceutical industry,
including the guidance given by the
Standing Committee of European
Doctors (CPME).
• Threats to health and pandemic pre-
paredness
• Patient safety and “no blame” approach-
es were discussed using the example of
the legally regulated blame free report-
ing system in Denmark, and
• Health policy reforms in Europe. The
Forum received reports on the current sit-
uation in Albania, Germany, Kazakhstan,
Croatia, United Kingdom, Byelorussia
and Azerbaijan. It was apparent that in
most of the countries the governments,
while on one hand talking about more
competition, on the other they are more
and more regulating the health care sys-
tems directly and by that doing just the
opposite of what they are preaching.
Professional autonomy and self-regula-
tion are under pressure. A presentation on
the perception of the current industrial
actions taken by doctors especially in
Belgium (last year) and Germany (ongo-
ing) showed an overwhelming support by
the public for the strikes and demonstra-
tions of the doctors.
Other national or regional
meetings
WMA officers or the Secretary General
attended national meetings of the following
WMA member associations or their region-
al groups:
• Colegio Médico de México
• Indian Medical Association
• Medical Associations of the South East
Asian Nations (MASEAN)
• Standing Committee of European
Doctors (CPME),
On-line Course on treatment
of multi-drug resistant tuber-
culosis (MDR-TB)
Following the success of the online course
for prison medicine,WMA decided to trans-
late the new WHO guidelines for the treat-
ment of multi-drug-resistant tuberculosis
into a course that would help doctors who
treat patients with MDR-TB. The guide-
lines were finally published with a consid-
erable delay in the fall of last year.
The development of an online course on the
treatment of multi-drug-resistant tuberculo-
sis has been nearly completed. The final
product will be launched in mid-June. The
project is a cooperation with the Foundation
for Professional Development of the South
African Medical Association and the
Norwegian Medical Association. It was
made possible by a grant from Eli Lilly, Inc.
Assignment to regions
The Indonesian Medical Association has
been reassigned to the Pacific Region on
their own request. This assignment is effec-
tive from the beginning of 2006.
The new member, the Singapore Medical
Association, has been assigned to the
Pacific Region.
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WHO
53
national sources, as well as from interna-
tional development partners. The Report
recommends that of all new donor funds for
health, 50% should be dedicated to
strengthening health systems, of which 50%
should be dedicated specifically to training,
retaining and sustaining the health work-
force.
At least 1.3 billion people worldwide lack
access to the most basic healthcare, often
because there is no health worker. The
shortage is global, but the burden is greatest
in countries overwhelmed by poverty and
disease where these health workers are
needed most. Shortages are most severe in
sub-Saharan Africa, which has 11% of the
world’s population and 24% of the global
burden of disease but only 3% of the
world’s health workers.
The Report calls for prompt and innovative
initiatives to improve efficiency. For exam-
ple, HIV/AIDS, TB and other priority dis-
ease programmes have implemented ways
for health workers with limited formal
training to successfully carry out specific
health tasks. These experiences should be
drawn upon to develop national health
workforce strategies.
The World Health Report recommends that
in order to achieve the goal of getting “the
right workers with the right skills in the
right place doing the right things,“ countries
should develop plans that include the fol-
lowing:
• Acting now for workforce productivity:
better working conditions for health work-
ers, improved safety, better access to treat-
ment and care;
• Anticipating what lies ahead: a well-
developed plan to train the health work-
force of the future;
• Acquiring critical capacity: workforce
planning; development of leadership and
management; standard setting, accredita-
tion and licensing as drivers for quality
improvement.
Beyond the national strategies the report
urges global cooperation:
• Joint investment in research and informa-
tion systems;
WHO
Health workforce crisis is having a deadly
impact on many countries’ ability to fight
disease and improve health
World Health Report outlines need for more investment in health workforce to
improve working conditions, revitalize training institutions and anticipate future
challenges
GENEVA/LUSAKA/LONDON – A serious
shortage of health workers in 57 countries is
impairing provision of essential, life-saving
interventions such as childhood immuniza-
tion, safe pregnancy and delivery services
for mothers, and access to treatment for
HIV/AIDS, malaria and tuberculosis. This
shortage, combined with a lack of training
and knowledge, is also a major obstacle for
health systems as they attempt to respond
effectively to chronic diseases, avian
influenza and other health challenges,
according to The World Health Report 2006
– Working together for health, published by
the World Health Organization.
More than four million additional doctors,
nurses, midwives, managers and public
health workers are urgently needed to fill
the gap in these 57 countries, 36 of which
are in sub-Saharan Africa, says the Report,
which is highlighted by events in many
cities around the world to mark World
Health Day. Every country needs to
improve the way it plans for, educates and
employs the doctors, nurses and support
staff who make up the health workforce and
provide them with better working condi-
tions, it concludes.
“The global population is growing, but the
number of health workers is stagnating or
even falling in many of the places where
they are needed most,“ said WHO Director-
General Dr LEE Jong-wook. “Across the
developing world, health workers face eco-
nomic hardship, deteriorating infrastructure
and social unrest. In many countries, the
HIV/AIDS epidemic has also destroyed the
health and lives of health workers.“
The World Health Report sets out a 10-year
plan to address the crisis. It calls for nation-
al leadership to urgently formulate and
implement country strategies for the health
workforce. These need to be backed by
international donor assistance.
Infectious diseases and complications of
pregnancy and delivery cause at least 10
million deaths each year. Better access to
health workers could prevent many of those
deaths. There is clear evidence that as the
ratio of health workers to population
increases, so in turn does infant, child and
maternal survival.
“Not enough health workers are being
trained or recruited where they are most
needed, and increasing numbers are joining
a brain drain of qualified professionals who
are migrating to better-paid jobs in richer
countries, whether those countries are near
neighbours or wealthy industrialized
nations. Such countries are likely to attract
even more foreign staff because of their
ageing populations, who will need more
long-term, chronic care,“ said WHO
Assistant Director-General Dr Timothy
Evans.
To tackle this crisis, more direct investment
in the training and support of health work-
ers is needed now. Initial costs will be for
the training of more health workers. As they
graduate and enter the workforce, funds
will be needed to pay their salaries. Health
budgets will have to increase by at least
US$10 per person per year in the 57 coun-
tries with severe shortages to educate and
pay the salaries of the four million health
workers needed to fill the gap. To meet that
target within 20 years is an ambitious but
reasonable goal, the Report concludes.
Financing this gap will require significant,
dedicated and predictable funding from
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54
• Agreements on ethical recruitment of and
working conditions for migrant health
workers and international planning on the
health workforce for humanitarian emer-
gencies or global health threats such as an
influenza pandemic;
• Commitment from donor countries to
assist crisis countries with their efforts to
improve and support the health workforce.
for example that the number of treatment
sites in Malawi increased from three in
early 2003 to 60, and in Zambia increased
from three to more than 110 facilities in just
over two years.
Globally, 18 developing countries met the “3
by 5” target of providing treatment to at least
half of those in need by the end of 2005, and
are now concentrating their efforts on mov-
ing towards universal access to treatment.
While other countries fell short of this target,
lessons learned in expanding treatment
access and overcoming critical weaknesses
in health systems are informing new initia-
tives to further scale-up HIV prevention,
treatment and care services. Increased avail-
ability of ART averted an estimated 250 000
to 350 000 premature deaths in the develop-
ing world in 2005 alone.
Launched by WHO and UNAIDS on World
AIDS Day, 1 December 2003, “3 by 5“
aimed to provide treatment to 3 million peo-
ple in low- and middle-income countries by
the end of 2005. This ambitious target was
based on a 2001 analysis of what could be
accomplished with an optimal combination
of funding, technical capacity building,
health systems strengthening and political
will and cooperation. The initiative con-
firmed that HIV treatment can be delivered
effectively in a wide variety of health sys-
tems, including those in poor countries and
rural settings, and that large-scale ART
access is both achievable and increasingly
affordable.
Between 2003 and 2005, global expenditure
on AIDS increased from US$ 4.7 billion to
an estimated US$ 8.3 billion. Significant
proportions of this funding were provided
by the US President’s Emergency Plan for
AIDS Relief, the Global Fund to Fight
AIDS, TB and Malaria and the World Bank.
During the same period, the price of first-
line treatment decreased by between 37%
and 53%, depending on the regimen used.
Progress: Treatment Access
by Region
Between end-2003 and 2005, HIV treat-
ment access expanded in every region of the
world. Sub-Saharan Africa and East, South
Global Access to HIV Therapy Tripled in Past
Two Years, But Significant Challenges Remain
1.3 Million People Now Receiving Treatment in Low- and Middle-income
Countries; Sub-Saharan Africa Leads in Treatment Scale-up. Lessons learned
in “3 by 5” should guide efforts to move towards Universal Access to Treatment
by 2010
GENEVA, 28 MARCH 2006 – A new
report by the World Health Organization
and the Joint United Nations Programme on
HIV/AIDS (UNAIDS) shows that the num-
ber of people on HIV antiretroviral treat-
ment (ART) in low- and middle-income
countries more than tripled to 1.3 million in
December 2005 from 400 000 in December
2003. Charting the final progress of the “3
by 5“ strategy to expand access to HIV ther-
apy in the developing world, the report also
says that the lessons learned in the last two
years provide a foundation for global efforts
now underway to provide universal access
to HIV treatment by 2010.
Progress in treatment scale-up, while sub-
stantial, was less than initially hoped. The
report notes, however, that treatment access
expanded in every region of the world dur-
ing the “3 by 5” initiative, with approxi-
mately 50 000 additional people beginning
ART every month in the past year. Sub-
Saharan Africa, the region most severely
impacted, led the scale-up effort, with the
number of people receiving HIV treatment
there increasing more than eight-fold to 810
000 from 100 000 in the two-year period.
By the end of 2005, more than half of all
people receiving HIV treatment in low- and
middle-income countries resided in sub-
Saharan Africa, up from one-quarter two
years earlier.
“Two years ago, political support and
resources for the rapid scale-up of HIV
treatment were very limited,” said WHO
Director-General, Dr LEE Jong-wook.
“Today “3 by 5“ has helped to mobilize
political and financial commitment to
achieving much broader access to treatment.
This fundamental change in expectations is
transforming our hopes of tackling not just
HIV/AIDS, but other diseases as well.”
In July 2005, the G8 nations endorsed a
goal of working with WHO and UNAIDS
to develop an essential package of HIV pre-
vention, treatment and care, with the aim of
moving as close as possible to universal
access to treatment by 2010, a target subse-
quently endorsed by the United Nations
General Assembly in September 2005. The
new WHO/UNAIDS report outlines a num-
ber of steps that must be taken to continue
and expand treatment scale-up toward
achieving this goal.
Substantial increases in HIV
treatment access
Countries in every region of the world made
substantial gains during the “3 by 5” period
in closing the gap between those in need of
treatment and those receiving it. The num-
ber of public sector treatment sites in low-
and middle-income countries increased
from fewer than 500 providing ART to
more than 5100 operational treatment sites
by the end of 2005. A recent survey showed
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WHO
55
and Southeast Asia, the regions most heavi-
ly affected by the epidemic, achieved the
most rapid and sustained progress.
• More than 810 000 people in sub-Saharan
Africa, or 17% of those in need of ART,
had accessed treatment by the end of
2005. Well over half the people on ART in
the developing world live in this region.
This substantial increase in ART availabil-
ity in sub-Saharan Africa occurred despite
considerable regional challenges: the
region is home to over 20 of the world’s
25 poorest countries, and suffers a short-
age of some 1 million professional health
workers, with an additional 20 000 trained
staff lost each year to emigration.
• East, South and Southeast Asia recorded
significant gains in ART access from end-
2003 (70 000 people) to 2005 (180 000
people), with coverage in the region
expanding more than 75% in 2005.
Thailand was a major driver of this
increase, particularly during 2004 and the
first half of 2005.
• Latin America and the Caribbean, with
more than 315 000 people on ART (up
from 210 000 at the end of 2003), is pro-
viding treatment to approximately 68% of
its population in need – the highest cover-
age of any region in the developing world.
Thirteen countries in this region provide
treatment to more than half of the popula-
tion in need.
• Despite gains in overall numbers on treat-
ment, ART access in low- and middle-
income countries in Eastern Europe,
Central Asia, the Middle East and North
Africa was lower than in other regions,
with just 21 000 people in Eastern Europe
and Central Asia and 4000 in the Middle
East and North Africa receiving treatment
as compared to 15 000 and 1000 respec-
tively at the end of 2003. Virtually all
countries in these regions are experienc-
ing low-level epidemics that involve diffi-
cult-to-reach populations such as injecting
drug users (IDUs) and sex workers.
Reaching Women, Children
and Vulnerable Populations
While the new report found no systematic
bias against women in ART access, rates of
coverage for women varied. In some coun-
tries, more women receive treatment; in
others, more men. One notable area of con-
cern is access to therapy to prevent mother-
to-child HIV transmission, which remains
unacceptably low. Between 2003 and 2005,
fewer than 10% of HIV-positive pregnant
women received antiretroviral prophylaxis
before or during childbirth. As a result,
1800 infants were born with HIV every day.
Each year, over 570 000 children under the
age of 15 die of AIDS, most having
acquired HIV from their mothers. In 2005,
660 000 children under the age of 15 were
in need of immediate ART, representing
more than 10% of unmet global need. Nine
out of ten children needing treatment live in
sub-Saharan Africa.
While an estimated 36 000 injecting drug
users (IDUs) were receiving ART by the
end of 2005, more than 80% (30 000) of
these are in Brazil. The remaining 6000
patients were distributed among 45 other
countries. These figures suggest a large
unmet need, particularly in Eastern Europe
and Central Asia, where IDUs represent
70% of HIV cases, but just 24% of patients
currently on treatment.
“Misinformation about the disease and stig-
ma against people living with HIV still
hamper prevention, care and treatment
efforts everywhere,” said Dr Peter Piot,
UNAIDS Executive Director. “If we are to
get ahead of the AIDS epidemic, we must
tackle stigma, ensure that the available
funds are spent effectively to scale-up HIV
prevention, care and treatment pro-
grammes, and mobilize more resources.”
Moving toward universal
access
While important advances in HIV treatment
access have been achieved in the past two
years, the report also acknowledges that,
despite the efforts of many partners and sig-
nificant funding from a number of donors,
the “3 by 5“ strategy fell short of its ambi-
tions. Obstacles to scaling up HIV treatment
and prevention highlighted in the report
include poorly harmonized partnerships;
constraints on the procurement and supply
of drugs, diagnostics and other commodi-
ties; strained human resources capacity and
other critical weaknesses in health systems;
difficulties in ensuring equitable access;
and lack of standardized systems for the
management of programmes and monitor-
ing progress.
“The past two years have provided a wealth
of experience and information on which we
must now continue to build,” said Kevin De
Cock, Director, HIV/AIDS Department at
the World Health Organization. “We intend
to utilize this knowledge to focus future
efforts on overcoming persistent challenges
and obstacles. It is particularly important
that scaling-up HIV prevention, treatment
and care services contributes to strengthen-
ing of health systems overall.”
A number of lessons learned in treatment
scale-up efforts and outlined in the new
report provide a valuable roadmap for
efforts to achieve universal access to treat-
ment. Among these are:
• The positive impact of targets in creating
and sustaining momentum for action and
in increasing accountability among stake-
holders. A key element of the “3 by 5”
strategy was developing bold country-
level targets that encouraged national gov-
ernments to expand capacity beyond what
was previously considered possible.
Moving forward, targets for treatment
must be complemented by achievable tar-
gets for other elements of a comprehen-
sive response to AIDS, including preven-
tion and mitigating impact.
• The need to strengthen health systems.
Building universal access to HIV treat-
ment will require significant ongoing
efforts to re-build, reinforce and expand
under-staffed and under-funded health
care systems that are already severely
challenged in many countries.
• Promoting a ‘public health approach’ to
health care delivery that emphasizes ser-
vice decentralization, community mobili-
sation and education, team-based
approaches and the delegation of routine
tasks to trained nurses and health workers.
The approach also promotes use of mech-
anisms to ensure the consistency and qual-
ity of supplies of drugs and diagnostics as
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WHO
56
well as the routine offer of voluntary test-
ing and counselling to increase knowledge
of HIV status in settings where there is
high HIV prevalence.
• The ongoing need to intensify prevention
efforts and to integrate prevention and
treatment scale-up, using all effective
approaches and paying particular attention
to the needs of vulnerable groups.
Epidemiological modelling consistently
shows that more deaths can be averted
with a comprehensive response including
both prevention and treatment, than by
focusing on treatment or prevention alone.
• The need for substantial increases in
resources and sustainable financing.
UNAIDS estimates that the gap between
available resources and those needed is
US$18 billion for the period 2005-2007,
and that at least US$22 billion per year
will be needed by 2008 to fund compre-
hensive national HIV prevention, treat-
ment and care programmes.
• Long-term donor commitments are essen-
tial to ensuring sustainable treatment
scale-up, as placing large numbers of peo-
ple on ART is impractical for many coun-
tries without firm funding. The report
encourages the use of innovative financ-
ing mechanisms to fund increased
resources for AIDS. These include a pro-
posal by France to introduce an airline sol-
idarity contribution and the UK’s
International Finance Facility, which aims
to “front-load” additional funds leveraged
from international capital markets to make
them immediately available for sustain-
able investments that support the achieve-
ment of the Millennium Development
Goals.
The new report emphasizes that WHO and
UNAIDS will continue to build upon these
lessons learned, as well as on the priorities,
strategies and partnerships of “3 by 5“ in
accelerating the AIDS response. UNAIDS
is currently facilitating the development of
nationally agreed plans and targets to move
towards universal access to HIV preven-
tion, treatment, care and support. WHO’s
contribution to realizing the goal of univer-
sal access will be based on a set of priority
interventions in the following five strategic
directions known to be able to significantly
influence the epidemic in different epidemi-
ological contexts:
– enabling people to know their HIV status
through HIV testing and counselling;
– accelerating the scale-up of treatment and
care;
– maximizing the health sector’s contribu-
tion to HIV prevention;
– investing in strategic information to guide
a more effective response; and
– strengthening and expanding health sys-
tems.
Intellectual property rights,
Innovation and Public Health Commission
Developing country access needed to existing
and new medicines and vaccines
GENEVA. The independent Commission
on Intellectual Property Rights, Innovation
and Public Health has presented its report to
the World Health Organization. The report
recommends key actions needed to ensure
that poor people in developing countries
have access to existing and new products to
diagnose, treat and prevent the diseases
which most affect them.
Over half of the people in the poorest parts
of Africa and Asia lack regular access to
existing essential medicines because they
cannot afford them, or because the health
system in their country is too weak. Apart
from access to existing medicines, some
health products specifically for diseases
which disproportionately affect developing
countries are simply not developed at all
due to the lack of a sustainable market. The
relationship between intellectual property
rights, innovation and public health has
been at the heart of debate on these issues.
The report of the Commission: “Public
Health, Innovation and Intellectual Property
Rights“ is the result of two years’ analysis
of how governments, industry, scientists,
international law and financing mecha-
nisms can work best to overcome the chal-
lenges.
“There is now global momentum to address
these issues, and we have a unique opportu-
nity to build on this. There is more aware-
ness, more money potentially available,
more utilization of scientific capacity in
developing countries and new institutions
such as public–private partnerships. The
Commission report is clear that we must
build on all of these to ensure that poor peo-
ple in developing countries have sustainable
access to the medicines, vaccines and diag-
nostics they need now, and critically, in the
future. The report maps out the ways this
can be done,“ said Mme Ruth Dreifuss, the
Chair of the Commission.
The report was commissioned by the World
Health Assembly and WHO’s Director-
General, Dr LEE Jong-wook, established
the Commission on Intellectual Property
Rights, Innovation and Public Health in
February 2004 meeting first in April (as
reported in WMJ 50(2), 50).
“We are grateful to the Commissioners for
undertaking this difficult task. With this
report, the Commission has built a solid
foundation from which countries can move
forward. I encourage all countries to give
serious consideration to their role in
addressing these critical issues,“ said Dr
LEE Jong-wook, today as Mme Dreifuss
presented the report, which contains more
than 50 recommendations which serve as a
road map for tackling the issues in different
country settings. The report after considera-
tion by the Executive Board, goes to the
World Health Assembly. (see next issue)
WMJ_2_29-58.qxd 17.07.2006 13:36 Seite 56
CHINA E
Chinese Medical Association
42 Dongsi Xidajie
Beijing 100710
Tel: (86-10) 6524 9989
Fax: (86-10) 6512 3754
E-mail: suyumu@cma.org.cn
Website: www.chinamed.com.cn
COLOMBIA S
Federación Médica Colombiana
Calle 72 – N° 6-44, Piso 11
Santafé de Bogotá, D.E.
Tel: (57-1) 211 0208
Tel/Fax: (57-1) 212 6082
E-mail: federacionmedicacol@
hotmail.com
DEMOCRATIC REP. OF CONGO F
Ordre des Médecins du Zaire
B.P. 4922
Kinshasa – Gombe
Tel: (242-12) 24589/
Fax (Présidente): (242) 8846574
COSTA RICA S
Unión Médica Nacional
Apartado 5920-1000
San José
Tel: (506) 290-5490
Fax: (506) 231 7373
E-mail: unmedica@sol.racsa.co.cr
CROATIA E
Croatian Medical Association
Subiceva 9
10000 Zagreb
Tel: (385-1) 46 93 300
Fax: (385-1) 46 55 066
E-mail: orlic@mamef.mef.hr
CZECH REPUBLIC E
Czech Medical Association .
J.E. Purkyne
Sokolská 31 – P.O. Box 88
120 26 Prague 2
Tel: (420-2) 242 66 201/202/203/204
Fax: (420-2) 242 66 212 / 96 18 18 69
E-mail: czma@cls.cz
Website: www.cls.cz
CUBA S
Colegio Médico Cubano Libre
P.O. Box 141016
717 Ponce de Leon Boulevard
Coral Gables, FL 33114-1016
United States
Tel: (1-305) 446 9902/445 1429
Fax: (1-305) 4459310
DENMARK E
Danish Medical Association
9 Trondhjemsgade
2100 Copenhagen 0
Tel: (45) 35 44 -82 29/Fax:-8505
E-mail: er@dadl.dk
Website: www.laegeforeningen.dk
DOMINICAN REPUBLIC S
Asociación Médica Dominicana
Calle Paseo de los Medicos
Esquina Modesto Diaz Zona
Universitaria
Santo Domingo
Tel: (1809) 533-4602/533-4686/
533-8700
Fax: (1809) 535 7337
E-mail: asoc.medica@codetel.net.do
ECUADOR S
Federación Médica Ecuatoriana
V.M. Rendón 923 – 2 do.Piso Of. 201
P.O. Box 09-01-9848
Guayaquil
Tel/Fax: (593) 4 562569
E-mail: fdmedec@andinanet.net
EGYPT E
Egyptian Medical Association
„Dar El Hekmah“
42, Kasr El-Eini Street
Cairo
Tel: (20-2) 3543406
EL SALVADOR, C.A S
Colegio Médico de El Salvador
Final Pasaje N° 10
Colonia Miramonte
San Salvador
Tel: (503) 260-1111, 260-1112
Fax: -0324
E-mail: comcolmed@telesal.net
marnuca@hotmail.com
ESTONIA E
Estonian Medical Association (EsMA)
Pepleri 32
51010 Tartu
Tel/Fax (372) 7420429
E-mail: eal@arstideliit.ee
Website: www.arstideliit.ee
ETHIOPIA E
Ethiopian Medical Association
P.O. Box 2179
Addis Ababa
Tel: (251-1) 158174
Fax: (251-1) 533742
E-mail: ema.emj@telecom.net.et /
ema@eth.healthnet.org
FIJI ISLANDS E
Fiji Medical Association
2nd Fl. Narsey’s Bldg, Renwick Road
G.P.O. Box 1116
Suva
Tel: (679) 315388
Fax: (679) 387671
E-mail: fijimedassoc@connect.com.fj
FINLAND E
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Tel: (358-9) 3930 826/Fax-794
Telex: 125336 sll sf
E-mail: fma@fimnet.fi
Website: www.medassoc.fi
FRANCE F
Association Médicale Française
180, Blvd. Haussmann
75389 Paris Cedex 08
Tel: (33) 1 53 89 32 41
Fax: (33) 1 53 89 33 44
E-mail: cnom-international@
cn.medecin.fr
GEORGIA E
Georgian Medical Association
7 Asatiani Street
380077 Tbilisi
Tel: (995 32) 398686 / Fax: -398083
E-mail: Gma@posta.ge
GERMANY E
Bundesärztekammer
(German Medical Association)
Herbert-Lewin-Platz 1
10623 Berlin
Tel: (49-30) 400-456 363/Fax: -384
E-mail: renate.vonhoff-winter@baek.de
Website: www.bundesaerztekammer.de
GHANA E
Ghana Medical Association
P.O. Box 1596
Accra
Tel: (233-21) 670-510/Fax: -511
E-mail: gma@ghana.com
HAITI, W.I. F
Association Médicale Haitienne
1ère
Av. du Travail #33 – Bois Verna
Port-au-Prince
Tel: (509) 245-2060
Fax: (509) 245-6323
E-mail: amh@amhhaiti.net
Website: www.amhhaiti.net
HONG KONG E
Hong Kong Medical Association, China
Duke of Windsor Building, 5th Floor
15 Hennessy Road
Tel: (852) 2527-8285
Fax: (852) 2865-0943
E-mail: hkma@hkma.org
Website: www.hkma.org
HUNGARY E
Association of Hungarian Medical
Societies (MOTESZ)
Nádor u. 36
1443 Budapest, PO.Box 145
Tel: (36-1) 312 3807 – 311 6687
Fax: (36-1) 383-7918
E-mail: motesz@motesz.hu
Website: www.motesz.hu
ICELAND E
Icelandic Medical Association
Hlidasmari 8
200 Kópavogur
Tel: (354) 8640478
Fax: (354) 5644106
E-mail: icemed@icemed.is
INDIA E
Indian Medical Association
Indraprastha Marg
New Delhi 110 002
Tel: (91-11) 337009/3378819/3378680
Fax: (91-11) 3379178/3379470
E-mail: inmedici@vsnl.com /
inmedici@ndb.vsnl.com
INDONESIA E
Indonesian Medical Association
Jalan Dr Sam Ratulangie N° 29
Jakarta 10350
Tel: (62-21) 3150679
Fax: (62-21) 390 0473/3154 091
E-mail: pbidi@idola.net.id
IRELAND E
Irish Medical Organisation
10 Fitzwilliam Place
Dublin 2
Tel: (353-1) 676-7273
Fax: (353-1) 6612758/6682168
Website: www.imo.ie
ISRAEL E
Israel Medical Association
2 Twin Towers, 35 Jabotinsky St.
P.O. Box 3566, Ramat-Gan 52136
Tel: (972-3) 6100444 / 424
Fax: (972-3) 5751616 / 5753303
E-mail: estish@ima.org.il
Website: www.ima.org.il
JAPAN E
Japan Medical Association
2-28-16 Honkomagome, Bunkyo-ku
Tokyo 113-8621
Tel: (81-3) 3946 2121/3942 6489
Fax: (81-3) 3946 6295
E-mail: jmaintl@po.med.or.jp
KAZAKHSTAN F
Association of Medical Doctors
of Kazakhstan
117/1 Kazybek bi St.,
Almaty
Tel: (3272) 62 -43 01 / -92 92
Fax: -3606
E-mail: sadykova-aizhan@yahoo.com
REP. OF KOREA E
Korean Medical Association
302-75 Ichon 1-dong, Yongsan-gu
Seoul 140-721
Tel: (82-2) 794 2474
Fax: (82-2) 793 9190
E-mail: intl@kma.org
Website: www.kma.org
KUWAIT E
Kuwait Medical Association
P.O. Box 1202
Safat 13013
Tel: (965) 5333278, 5317971
Fax: (965) 5333276
E-mail: aks.shatti@kma.org.kw
LATVIA E
Latvian Physicians Association
Skolas Str. 3
Riga
1010 Latvia
Tel: (371-7) 22 06 61; 22 06 57
Fax: (371-7) 22 06 57
E-mail: lab@parks.lv
LIECHTENSTEIN E
Liechtensteinischer Ärztekammer
Postfach 52
9490 Vaduz
Tel: (423) 231-1690
Fax: (423) 231-1691
E-mail: office@aerztekammer.li
Website: www.aerzte-net.li
LITHUANIA E
Lithuanian Medical Association
Liubarto Str. 2
2004 Vilnius
Tel/Fax: (370-5) 2731400
E-mail: lgs@takas.lt
LUXEMBOURG F
Association des Médecins et
Médecins Dentistes du Grand-
Duché de Luxembourg
29, rue de Vianden
2680 Luxembourg
Tel: (352) 44 40 331
Fax: (352) 45 83 49
E-mail: secretariat@ammd.lu
Website: www.ammd.lu
Association and address/Officers
ii
U2–4_WMJ_02_06.qxd 17.07.2006 13:46 Seite U3
Association and address/Officers
iii
MACEDONIA E
Macedonian Medical Association
Dame Gruev St. 3
P.O. Box 174
91000 Skopje
Tel/Fax: (389-91) 232577
MALAYSIA E
Malaysian Medical Association
4th Floor, MMA House
124 Jalan Pahang
53000 Kuala Lumpur
Tel: (60-3) 40418972/40411375
Fax: (60-3) 40418187/40434444
E-mail: mma@tm.net.my
Website: http://www.mma.org.my
MALTA E
Medical Association of Malta
The Professional Centre
Sliema Road, Gzira GZR 06
Tel: (356) 21312888
Fax: (356) 21331713
E-mail: mfpb@maltanet.net
Website: www.mam.org.mt
MEXICO S
Colegio Medico de Mexico
Fenacome
Hidalgo 1828 Pte. Cons. 410
Colonia Obispado C.P. 64060
Monterrey, Nuevo Léon
Tel/Fax: (52-8) 348-41-55
E-mail: fenacomemexico@usa.net
Website: www.fenacome.org
NEPAL E
Nepal Medical Association
Siddhi Sadan, Post Box 189
Exhibition Road
Katmandu
Tel: (977 1) 225860, 231825
Fax: (977 1) 225300
E-mail: nma@healthnet.org.np
NETHERLANDS E
Royal Dutch Medical Association
P.O. Box 20051
3502 LB Utrecht
Tel: (31-30) 28 23-267/Fax-318
E-mail: j.bouwman@fed.knmg.nl
Website: www.knmg.nl
NEW ZEALAND E
New Zealand Medical Association
P.O. Box 156
Wellington 1
Tel: (64-4) 472-4741
Fax: (64-4) 471 0838
E-mail: nzma@nzma.org.nz
Website: www.nzma.org.nz
NIGERIA E
Nigerian Medical Association
74, Adeniyi Jones Avenue Ikeja
P.O. Box 1108, Marina
Lagos
Tel: (234-1) 480 1569,
Fax: (234-1) 493 6854
E-mail: info@nigeriannma.org
Website: www.nigeriannma.org
NORWAY E
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
Tel: (47) 23 10 -90 00/Fax: -9010
E-mail: ellen.pettersen@
legeforeningen.no
Website: www.legeforeningen.no
PANAMA S
Asociación Médica Nacional
de la República de Panamá
Apartado Postal 2020
Panamá 1
Tel: (507) 263 7622 /263-7758
Fax: (507) 223 1462
Fax modem: (507) 223-5555
E-mail: amenalpa@sinfo.net
PERU S
Colegio Médico del Perú
Malecón Armendáriz N° 791
Miraflores, Lima
Tel: (51-1) 241 75 72
Fax: (51-1) 242 3917
E-mail: decano@colmedi.org.pe
Website: www.colmed.org.pe
PHILIPPINES E
Philippine Medical Association
PMA Bldg, North Avenue
Quezon City
Tel: (63-2) 929-63 66/Fax: -6951
E-mail: pmasec1@edsamail.com.ph
POLAND E
Polish Medical Association
Al. Ujazdowskie 24, 00-478 Warszawa
Tel/Fax: (48-22) 628 86 99
PORTUGAL E
Ordem dos Médicos
Av. Almirante Gago Coutinho, 151
1749-084 Lisbon
Tel: (351-21) 842 71 00/842 71 11
Fax: (351-21) 842 71 99
E-mail: ordemmedicos@mail.telepac.pt
/ intl.omcne@omsul.com
Website: www.ordemdosmedicos.pt
ROMANIA F
Romanian Medical Association
Str. Ionel Perlea, nr 10
Sect. 1, Bucarest, cod 70754
Tel: (40-1) 6141071
Fax: (40-1) 3121357
E-mail: AMR@itcnet.ro
Website: www.cdi.pub.ro/CDI/
Parteneri/AMR_main.htm
RUSSIA E
Russian Medical Society
Udaltsova Street 85
121099 Moscow
Tel: (7-095)932-83-02
E-mail: rusmed@rusmed.rmt.ru
info@russmed.com
SINGAPORE E
Singapore Medical Association
Alumni Medical Centre, Level 2
2 College Road, 169850 Singapore
Tel: (65) 6223 1264
Fax: (65) 6224 7827
E-Mail: sma@sma.org.sg
SLOVAK REPUBLIC E
Slovak Medical Association
Legionarska 4
81322 Bratislava
Tel: (421-2) 554 24 015
Fax: (421-2) 554 223 63
E-mail: secretarysma@ba.telecom.sk
SLOVENIA E
Slovenian Medical Association
Komenskega 4, 61001 Ljubljana
Tel: (386-61) 323 469
Fax: (386-61) 301 955
SOUTH AFRICA E
The South African Medical Association
P.O. Box 74789, Lynnwood Rydge
0040 Pretoria
Tel: (27-12) 481 2036/7
Fax: (27-12) 481 2058
E-mail: liliang@samedical.org
Website: www.samedical.org
SPAIN S
Consejo General de Colegios Médicos
Plaza de las Cortes 11, Madrid 28014
Tel: (34-91) 431 7780
Fax: (34-91) 431 9620
E-mail: internacional1@cgcom.es
SWEDEN E
Swedish Medical Association
(Villagatan 5)
P.O. Box 5610, SE – 114 86 Stockholm
Tel: (46-8) 790 33 00
Fax: (46-8) 20 57 18
E-mail: info@slf.se
Website: www.lakarforbundet.se
SWITZERLAND F
Fédération des Médecins Suisses
Elfenstrasse 18 – POB 293
3000 Berne 16
Tel: (41-31) 359 –1111/Fax: -1112
E-mail: fmh@hin.ch
Website: www.fmh.ch
TAIWAN E
Taiwan Medical Association
9F No 29 Sec1
An-Ho Road
Taipei
Deputy Secretary General
Tel: (886-2) 2752-7286
Fax: (886-2) 2771-8392
E-mail: intl@med-assn.org.tw
THAILAND E
Medical Association of Thailand
2 Soi Soonvijai
New Petchburi Road
Bangkok 10320
Tel: (66-2) 314 4333/318-8170
Fax: (66-2) 314 6305
E-mail: math@loxinfo.co.th
Website: http://www.medassocthai.org/
index.htm.
TUNISIA F
Conseil National de l’Ordre
des Médecins de Tunisie
16, rue de Touraine
1082 Tunis Cité Jardins
Tel: (216-71) 792 736/799 041
Fax: (216-71) 788 729
E-mail: ordremed.na@planet.tn
TURKEY E
Turkish Medical Association
GMK Bulvary,.
Pehit Danip Tunalygil Sok. N° 2 Kat 4
Maltepe
Ankara
Tel: (90-312) 231 –3179/Fax: -1952
E-mail: Ttb@ttb.org.tr
UGANDA E
Uganda Medical Association
Plot 8, 41-43 circular rd.
P.O. Box 29874
Kampala
Tel: (256) 41 32 1795
Fax: (256) 41 34 5597
E-mail: myers28@hotmail.com
UNITED KINGDOM E
British Medical Association
BMA House, Tavistock Square
London WC1H 9JP
Tel: (44-207) 387-4499
Fax: (44- 207) 383-6710
E-mail: vivn@bma.org.uk
Website: www.bma.org.uk
UNITED STATES OF AMERICA E
American Medical Association
515 North State Street
Chicago, Illinois 60610
Tel: (1-312) 464 5040
Fax: (1-312) 464 5973
Website: http://www.ama-assn.org
URUGUAY S
Sindicato Médico del Uruguay
Bulevar Artigas 1515
CP 11200 Montevideo
Tel: (598-2) 401 47 01
Fax: (598-2) 409 16 03
E-mail: secretaria@smu.org.uy
VATICAN STATE F
Associazione Medica del Vaticano
Stato della Citta del Vaticano 00120
Tel: (39-06) 6983552
Fax: (39-06) 69885364
E-mail: servizi.sanitari@scv.va
VENEZUELA S
Federacion Médica Venezolana
Avenida Orinoco
Torre Federacion Médica Venezolana
Urbanizacion Las Mercedes
Caracas
Tel: (58-2) 9934547
Fax: (58-2) 9932890
Website: www.saludfmv.org
E-mail: info@saludgmv.org
VIETNAM E
Vietnam General Association
of Medicine and Pharmacy (VGAMP)
68A Ba Trieu-Street
Hoau Kiem district
Hanoi
Tel: (84) 4 943 9323
Fax: (84) 4 943 9323
ZIMBABWE E
Zimbabwe Medical Association
P.O. Box 3671
Harare
Tel: (263-4) 791/553
Fax: (263-4) 791561
E-mail: zima@healthnet.zw
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