WMJ 04 2007

WorldMMeeddiiccaall JJoouurrnnaall
Vol. No. 4, December 200753
OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
G 20438
Contents
EEddiittoorriiaall
The challenge to medical care 85
Make medicines child size 86
MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
Medical Research on Child Subjects 87
China affirms its commitment to
WMA Transplantation policy 87
World Health Professions Alliance Conference
on Regulation of Health Professions display 90
WMA Statement On The Ethics Of Telemedicine 91
WMA resolution on the responsibility
of physicians 92
WMA Resolution On Health And Human Rights
Abuses In Zimbabwe 94
MMeeddiiccaall SScciieennccee,, MMeeddiiccaall PPrraaccttiiccee
aanndd MMeeddiiccaall EEdduuccaattiioonn
WMA Statement on Health Hazards
of Tobacco Products 95
Avicenna Directories to replace World Directory
of Medical Schools 97
Global Standards for Quality Improvement
in Medical Education 97
PPooiinntt ooff vviieeww
A Worldwide Tour of Medical Degrees
and Qualifications 97
FFrroomm tthhee WWMMAA SSeeccrreettaarryy GGeenneerraall
Trust me, I’m a Doctor! 99
WWMMAA
WMA General Assembly 100
Plenary Session of the Assembly
6th October 2007 103
Resolution in Support of the Medical Associations
in Latin America and the Caribbean 104
178th WMA Council meeting 107
Inter-professional training seminar on infection
control in South Africa 108
WWHHOO 108–110
RReevviieeww aanndd LLeetttteerr 111–112
Report on WMA General
Assembly, Copenhagen 2007
Dr. Jon Snaedel
WMA-President 2007-2008
00_US_04_2007.qxd 10.01.2008 11:33 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 MEDICAL ASSOCIATIONS AND OFFICERS
i see page ii
President-Elect President Immediate Past-President
Dr. Yoram Blachar Dr. J. Snaedal Dr. N. Arumagam
Israel Medical Association Icelandic Medical Assn. Malaysian Medical Association
2 Twin Towers, 35 Jabotinsky St. Hlidasmari 8 4th Floor MMA House
P.O. Box 3566, Ramat-Gan 52136 200 Kopavogur 124 Jalan Pahang
Israel Iceland 53000 Kuala Lumpur
Malaysia
Treasurer Chairman of Council Vice-Chairman of Council
Prof. Dr. Dr. h.c. J. D. Hoppe Dr. J. E. Hill Dr. K. Iwasa
Bundesärztekammer American Medical Association Japan Medical Association
Herbert-Lewin-Platz 1 515 North State Street 2-28-16 Honkomagome
10623 Berlin Chicago, ILL 60610 Bunkyo-ku
Germany USA Tokyo 113-8621
Japan
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: (54-11) 4381-1548/4384-5036
E-mail:
comra@confederacionmedica.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: -933
E-mail: international@aek.or.at
REPUBLIC OF ARMENIA E
Armenian Medical Association
P.O. Box 143, Yerevan 375 010
Tel: (3741) 53 58-68
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 1857/Fax: 323 2980
E-mail: mabnassau@yahoo.com
BANGLADESH E
Bangladesh Medical Association
BMA Bhaban 5/2 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
Calle Ayacucho 630
Tarija
Fax: (591) 4663569
E-mail: colmed_tjo@hotmail.com
Website: colegiomedicodebolivia.org.bo
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: -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 8610/Fax: -1779
E-mail: monique.laframboise@cma.ca
Website: www.cma.ca
Cabo Verde S
Ordem Dos Medicos du Cabo Verde
Avenue OUA N°6 – B.P. 421
Achada Santo António, Ciadade de
Praia, Cabo Verde
Tel : (238) 262 2503
Fax : (238) 262 3099
E-mail: omecab@cvtelecom.cv
CHILE S
Colegio Médico de Chile
Esmeralda 678 – Casilla 639
Santiago
Tel: (56-2) 4277800
Fax: (56-2) 6330940 / 6336732
E-mail: rdelcastillo@colegiomedico.cl
Website: www.colegiomedico.cl
U2–4_WMJ_04_07.qxd 10.01.2008 11:34 Seite U2
85WMJ 53, December 2007
OFFICIAL JOURNAL OF
THE WORLD MEDICAL
ASSOCIATION
Hon. Editor in Chief
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suffolk IP14 3QT
UK
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Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte-Verlag
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ISSN: 0049-8122
Editorial
The challenge to medical care
The Tobacco Control Resource Centre, a resource supported by the British Medical
Association, the European Commission and the European Regional Office of the World
Health Organisation, published in 2000 a report in the context of Tobacco Control
Programme under the title “Tobacco – Medicine’s Big Challenge.” Now at the end of 2007,
while Tobacco remains a problem and the great scourges of disease still challenge medi-
cine, a huge challenge (possibly “The Challenge” for the medical profession) faces the
health professionals providing medical care, namely the problem of the supply and distrib-
ution of health care workers. The 2006 World Health Report of WHO* highlighted the
problem, notably the huge discrepancies in the distribution of Physicians, Dentists, Nurses,
Midwives and other Health care workers, not only within countries but more significantly
between countries. Scientific advances have made great contributions in our knowledge of
the nature and causes of many diseases, accompanied by discovery and development of
many new drugs to cure or ameliorate the effects of disease. All of these call for increasing
skills and increased demands on all sectors of the medical workforce in developed coun-
tries It places increased demands on the sparse, sometimes almost non-existent supply of
health care workers in underdeveloped countries, where healthcare was already minimal,
obstructing any implementation of advances in healthcare available elsewhere.
Hitherto the limited attempts to address manpower problems in the healthcare workforce
had, unsurprisingly, concentrated on workforce problems within national health care sys-
tems, substantially disregarding the huge disparities between countries, regions and even
continents. At the same time concern has been expressed by both the profession and by
some other authorities about the recruiting of physicians in developed countries from devel-
oping countries who are already under-doctored, Codes of practice and statements of poli-
cy to change this have been issued by the World Medical Association** and by some gov-
ernments and authorities.
While a great tribute should be paid to those organisations and governments who, in one
way or another have, over many years, encouraged the provision of doctors, nurses and
other medical assistance to those countries in need, and to those health professionals who
undertook to meet the needs, it was effectively only with the arrival of HIV/AIDS and,
more recently the risk of pandemic disease, coupled with increasing political awareness of
the need to deal with poverty, inequity and human rights, that the need to address the prob-
lems associated with the global health workforce have been forced to the forefront of dis-
cussion.
In previous editorials in the World Medical Journal, WMJ 52 (1) and (2) we have drawn
attention to emerging trends not only in the changing or expanding role of individual health
professions, but also to problems of training, mobility and availability of health profession-
als. Further problems complicating the whole issue relate to the changes in role and func-
tions of health professionals, reflecting not only the increasing aspirations of the individual
health professional, but also the increasing specialisation within individual health profes-
sions.
In the first part of 2008 at least two conferences will address some of the issues involved.
The first is a World Health Organisation Global Conference to be held in Addis Ababa
Ethiopia in January 2008, when the conference will address the topic of Task Shifting (see
p. 90). “Task Shifting” is defined in a number of WHO documents as “the name given to a
* “Working together for health” The World Health Report 2006 WHO, Geneva, ISBN 92 4 156317 6
** WMA Statement on Ethical Guidelines for the Recruitment of Physicians, Helsinki 2003
WMJ_4_85-112.qxd 10.01.2008 11:52 Seite 85
86 WMJ 53, December 2007
process of delegation whereby tasks are
moved, where appropriate, to less spe-
cialised health workers”.
The second conference, organised by the
World Health Professions Alliance in the
week preceding the WHO Assembly, is the
First World Conference the Role and
Regulation of Health Professions which
will be held in Geneva (see p. 90). Both
Conferences are of huge importance in rela-
tion to the provision of health care across
the globe in both developed and developing
countries.
The conferences have great relevance to the
future role and functions of the Medical
Profession. Whereas previously, physicians,
when recognised for full registration as a
medical practitioner, held the sole licence to
carry out certain specific acts such as the
right to prescribe and to engage in the prac-
tice of medicine, in an increasingly sophisti-
cated and technical world it is clear that
some of these reserved functions can be car-
ried out by other health professionals under
regulation, after appropriate technical spe-
cialist training. This has substantial implica-
tions for changes in the protected role that
physicians have previously held in certain
areas, while possibly calling for new roles in
other areas, essentially calling for a reassess-
ment of the role and functions of physicians
in society. In some countries such changes
have already occurred in areas such as the
extension of limited prescribing rights to
other health professionals such as nurses,
and extending the acts carried out by other
health professionals By enhancing the role
of some health professionals, such changes
increase the provision of certain health ser-
vices to a much wider population in both
developed and developing countries.
Nevertheless, as indicated earlier, if there is
a basic shortage of health care workers in
all the health professions, the world is faced
with a major problem. This shortage does
not only apply to underdeveloped countries.
In more developed countries as scientific
and technical knowledge and development
have increased there is also increased
demand for the implementation of these dis-
coveries and a consequent demand for more
health workers. Thus the USA estimates
that by 2020 they will require at least
200,000 physicians to meet their needs,
more than the current need of the rest of the
world!
The WMA Secretary General in his column
refers to another problem associated with
the changes in role and functions of physi-
cians, namely the need for clarity in identi-
fying the roles of health professionals and
the titles used to identify them to the public.
The differences in titles used for physicians
across the world are illustrated in an article
by Dr. Doren, to which Dr. Kloiber refers.
(see p. 97).
The Health Workforce problem which the
2006 World Health Report highlighted is
now being actively pursued and it is essen-
tial that, as indicated in the editorials
referred to above, both individual physi-
cians and their representative organisations
actively address these issues. The distribu-
tion of certain diseases has been radically
changed as a result of greatly increased
international travel, with the potential for
wider dissemination of communicable dis-
eases including newly emerging diseases,
and the risk of major pandemics need to be
balanced with attention to the global prob-
lems of inequitable distribution of physi-
cians, with such huge disproportions in
their distribution. With the calls for “task
shifting” as part of the solution, this may
also call for radical changes in the career
cycle of physicians, nurses, pharmacists,
including professional practice in foreign
countries as a normal part of the profession-
al career structure. All of these considera-
tions require urgent attention at a time when
the very nature of the regulation of the
health professions in also under review,
including the question of the degree to
which the professions themselves should
play a role in regulation, a matter of major
concern to those professions whose proud
role has for millennia been that of “Caring
Professions”. It is to this end that the med-
ical profession defends its position in self-
regulation of standards of care and its ethi-
cal code of conduct in the interests of both
patients and profession. All of this must be
urgently considered both in discussions at
individual, at national level and in the glob-
al conferences referred to above. There is
no time to be lost. Just as the profession has
taken a stand on Tobacco so it must face up
to this Big Challenge to the profession
itself. Both individual physicians and their
leaders must act. Time waits for no man!
Alan Rowe
Make medicines child size
On 6. December 2007, the WHO launched
a five years initiative to raise awareness and
accelerate action on medicines for children.
This project is based on a document which
was accepted at the 60th World Health
Assembly in May 2007. At the same time
the WHO released the first international
List of Essential Medicines for Children
(WMJ 53(2), 50). The list contains 206
medicines that are deemed safe for children
and address priority conditions. On this list
a number of existing medicines are howev-
er lacking because they have not been
adapted for childrens use.
It has been known for a long time that there
is a substantial gap between the availability
of childrens medicines and the actual need
and that this gap is global even if it is most
evident in poor income countries. In indus-
trialized societies more than half of the chil-
dren are prescribed medicines authorised
and dosed for adults but not authorized or
dosed for children. In developing countries,
the problem is compounded by lower
access.
In this project there are three main priori-
ties.
1. To improve access where proper medi-
cines for children exist but they are not
reaching those in need due to cost and
inefficient distribution systems.
Editorial
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87WMJ 53, December 2007
2. To increase development of medicines
which exist for adults but are either in
unsuitible forms for children or have not
been developed for children taken into
account the different pharmacokinetics
in children of various ages.
3. To facilitate research into areas where
there are very few or even no medicines
and where the efficacy of existing medi-
cines is unknown. This applies specially
to medicines for various infectious, trop-
ical disease.
This project has received a wide acceptance
and backup from many stakeholders such as
UNICEF, the pharmaceutical industry, regu-
latory agencies and various NGO´s such as
Save the children. WMA most certainly will
do its utmost to facilitate this project. The
project starts at a time when WMA is
adressing the special situation of children in
two areas. One is the upcoming revision of
the existing document on Health of
Children since 1998, by many considered
one of the best documents of the WMA.
This issue should also be kept in mind dur-
ing the process of revision of the
Declaration of Helsinki and in conjunction
to that a new document on research of chil-
dren which has been circulated to NMA´s
for comments. Lastly we should take this
opportunity to work closely with the WHO
as this is one of many topics where it is of
obvious value that these International
organisations join forces.
Jon Snaedal
President of the WMA
Editorial note:
The text of many of the statements etc.
adopted by the WMA General Assembly,
while referred to in the Report (see p. 103)
have been printed in the appropiate sec-
tions e.g. Ethics. Due to constraints on
available space, those on Noise and
Family Planning will appear in the next
issue. They can also be accessed at
www.wma.net.
Medical Ethics and Human Rights
Medical Research on Child Subjects
Dr. James Appleyard, MD, FRCPCH,
Past President WMA
(see also pp. 86 and 109)
Children worldwide bear the greatest bur-
den of disease. Medical research on child
subjects is essential to identify effective and
sustainable action that will lead to
improvements in child health (1,2). There
is a natural reluctance to involve children in
any risk associated with such research.
Testing in adults has rightly to precede any
trial of new approaches to treatment
amongst children.
Children, however, have been subject to
research studies in residential institutions
prior to any independent ethical review
being introduced . The most public and con-
troversial research study on children during
the second half of the 20th
century was the
‘Willowbrook Hepatitis Study’ started in
1956 at a New York State Institution for
mentally defective persons. (3,4) Such
examples led to the persistence of a pre-
dominantly protective approach towards
research in children.. So much so that ,with
the increasing number of medications avail-
able to adults in the last half century, chil-
dren were increasingly being ‘left behind’.
The market for new drugs amongst children
was much smaller and that a combination
of the inherent protective environment with
the increased cost of clinical trials meant
that pharmaceutical companies did not
undertake the relevant trials in children.
Practicing pediatricians faced the dilemma
of knowing how effective a new chemical
substance has been found in adult studies
and feeling duty bound to try them on their
child patients ‘off label’
In the 90’s this had reached such a propor-
tion that pediatricians were pressing for
changes in the system. (5,6) The ‘Children’s
rule, evolved in the USA, has had a positive
effect on promoting children’s research. (7,
12) and Europe has followed with the E.U.
Directive 2001/20/ECBoth the Food and
Drug Administration and the E.U.
Commission have been consulting further
on their existing regulations
China affirms its
commitment to
WMA Transplan-
tation policy
Following the visit of a WMA delegation
earlier this year (see report in WMJ 53,2),
the Chinese Medical Association, in a let-
ter from the Secretary General, Dr. Wang
affirmed its commitment to WMA poli-
cy and wrote as follows:
“… after discussions in the Chinese
Medical Association, a consensus has
been reached, that is, the Chinese
Medical Association agrees to the
World Medical Association Statement
on Human Organ Transplantation,
which states that organs of prisoners
and other individuals in custody must
not be used for transplantation except
for members of their immediate family.
The Chinese Medical Association will,
through its influence, further promote
the strengthening of the management of
human organ transplantation and pre-
vent possible violations of the regula-
tions made by the Chinese
Government. We also hope to work
more closely with the WMA and
exchange information and views on the
management of human organ trans-
plantation”.
Medical Ethics and Human Rights
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88 WMJ 53, December 2007
Regulations are important within the legal
framework of each country. Medical
research is increasingly a global imperative
and the relevant common ethical standards
need to be international. (6)
The WMA’s Declaration of Helsinki (9)
has underpinned the guidelines from the
Council for International Organisations of
Medical Sciences (CIOMS) (7) and ICH
GCP (8) It has also been the reference doc-
ument for many national pediatric guide-
lines. (5) The paragraphs specifically relat-
ed to children are paras. 24 and 25, regard-
ing consent and/or assent of ‘minors’
“24 For a research subject who is legally
incompetent, physically or mentally inca-
pable of giving consent or is a legally
incompetent minor, the investigator must
obtain informed consent from the legally
authorized representative in accordance
with applicable law. These groups should
not be included in research unless the
research is necessary to promote the health
of the population represented and this
research cannot instead be performed on
legally competent persons”.
“25 When a subject deemed legally incom-
petent, such as a minor child, is able to
give assent to decisions about participation
in research, the investigator must obtain
that assent in addition to the consent of the
legally authorized representative.”
In the WMA’s Declaration of Ottawa on the
Right of a Child to Healthcare, a precau-
tionary protective approach to research is
adopted as one of the General Principles:
Para 4 V1 states “In particular every effort
‘should be made to protect every child from
unnecessary diagnostic procedures, treat-
ment and research”;
We need to change the emphasis about the
need for research on children for their own
benefit while maintaining full protection
The WMA should provide leadership for
the benefit of children worldwide. Most of
the burden of disease affecting children is
outside the rich countries of the USA,
Europe and Japan, where regulations and
guidelines have moved to a more positive
approach to research in children.
Principles recognizing the importance of
research and the growing maturity of chil-
dren to assent and consent to the process,
their need for special protection with the
avoidance of harm, are essential.These are
of particular importance in relation to mat-
ters referred to ethical review committees,
which must include in their membership
specialist paediatric expertise in study
design when considering paediatric
research.
It is difficult to incorporate all these essen-
tial points within the Declaration of
Helsinki even though there is an opportuni-
ty to do so now that revisions are being con-
sidered. The WMA has already accepted
the special needs of Children in their previ-
ous agreement to a separate Declaration on
the Right of a Child to Health Care, in addi-
tion to the general rights of all patients. The
Associate Members Meeting at the General
Assembly of the WMA, with the particular
support of representatives from the USA,
Germany and Nigeria, recommended that a
separate Statement on Medical Research on
Child Subjects be considered by the WMA
Assembly in Copenhagen with a view to its
being circulated for comment by national
medical associations (NMAs). The
Assembly agreed and the Statement has
been sent out to nmas by the WMA
Secretariat.
The Statement has been drafted from the
principles underlying the key guidelines on
pediatric research in Europe (10, 12)
United States (11) and Japan (13) and
relates directly to the Declaration of
Helsinki. The Statement should form a tem-
plate for the development of local national
guidelines in each country to provide both a
positive and protective environment for the
promotion of child health and welfare
The Preamble summaries the importance of
medical research for children and the need
to protect them from harm. The five main
paragraphs highlight issues which are
either specific to children or must be con-
sidered in the context of childhood. Each
statement underlines a principle and each
sentence is both self standing and to be
taken in context. Further clarification of
these principles need to be expanded in
local national guidelines. Thus the docu-
ment has been constructed to be a succinct
as possible
Draft Proposed Statement
Preamble
Advances in medical care are based on the
scientific evaluation of preventative, diag-
nostic and therapeutic measures.
Children should share in the benefits from
scientific research relevant to their individ-
ual age related health needs.
Research on children is essential for the
development of scientifically based med-
ical knowledge that will ensure the effective
promotion of child health and the well
being of children worldwide.
Children involved in research need special
protection. They differ from adults biologi-
cally. –with their increased vulnerability,
age specific needs and growth and develop-
ment potential.
Children must be subject to the safeguards
applicable to all research subjects in the
Declaration of Helsinki, together with para-
graphs 24 and 25 concerning legally incom-
petent minors.
The Declaration of Ottawa defines the right
of a child to health care, which includes the
principles of consent and self determination
amongst children in paragraphs 9-13.
Physicians should respect international
and national professional guidelines on
research in children which conform to
these principles.
Need for Protection
Biomedical studies involving children as
research subjects should be focused on the
knowledge of epidemiology, pathogenesis,
diagnosis and treatment of diseases or con-
ditions of childhood.
A child should not be involved in research
that can be carried out on laboratory mod-
els, animal subjects or adult persons, or that
serves only a scientific interest The knowl-
edge to be gained from the research must
form a necessary contribution to the health-
care of children.
Different physiological, psychological and
pathogenic features occur at the different
Medical Ethics and Human Rights
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89WMJ 53, December 2007
ages and stages of the growth ,development,
sex and ethnicity in childhood. from the
premature newborn infant through adoles-
cence.
There is a need to balance the potential ben-
efits to children against any risk involved
in the research.
Physicians must respect the integrity and
relative autonomy of a child and strive to
attain the maximal achievable benefit, with
the avoidance of unnecessary risks, discom-
fort and stress.
Avoidance of harm
Risks should be minimised and potential
harm leading to physical, psychological,
social, spiritual impairment should be
avoided
Minimal risk involves procedures, ques-
tionnaires, observation and measurements
even being carried out in a child sensitive
way.
Greater than minimal risk is can be associ-
ated with invasive procedures or therapies.
These should be carried out only when the
research is concerned with diagnosis and
treatment and the expected benefits to the
child participant outweigh the known or
anticipated risks involved where the
research is likely to yield justifiable gener-
alisable knowledge of vital importance
about the child’s disorder or condition and
research that provides the only opportunity
to identify, prevent or alleviate a rare dis-
ease confined to childhood
Study Designs
Study protocols and study designs must be
child specific. In addition to including the
safeguards for adult subjects , they should
justify the necessity of the research on chil-
dren
Preclinical safety and efficacy data are pre-
conditions for the start of paediatric clinical
trials.
The selection of children to participate in a
biomedical research project should not
depend upon the child’s race, nationality,
gender or religion, except in cases where
one or more of these attributes relate to the
objective of the research
The performance of a study must be guaran-
teed to be conducted by experts competent
in childhood diseases and disorders, empa-
thetic and truly conversant with children,
parents, and all legal requirements where
the interests of the child are paramount
Child specific protocols should be drawn up
by experienced experts and the study should
be carried out under the supervision of pae-
diatricians
Age specific informed consent/assent forms
need to be available for child subjects, their
parents and legal representatives.
The study protocols should be evaluated by
independent research ethics committees on
which there are paediatric health profes-
sionals.
Consent/Assent
Children are minors who have not reached
the age for self responsible consent.
Informed consent means the approval of the
child’s parents or legal representative for
the participation of the child in a research
study, following sufficient information to
enable them to make an informed judgment.
Informed Assent means the acquiescence of
the child to participate in the research fol-
lowing information being provided in a
form understandable to their age group.
The consent of both parents should be
sought prior to enrolling a child in a bio-
medical research project.
There must be no forced or undue influ-
ence, financial or otherwise, on the child’s
decision to participate in the research or on
the parents/legal representative’s consent.
The refusal to participate in the research by
an informed child must be respected .
Privacy
The privacy if the child must be fully
assured throughout the research project.
All personal and health related information
about the child and the family, collected and
stored, must remain confidential.
Research Ethics Committees
The interests of children should always be
represented on independent research ethics
committees when research on children is
being considered. The membership must
include children’s physicians experienced
in paediatric research and trained in the spe-
cial needs of children. Other members
should be well acquainted with the needs of
children .
Further work on this Statement
A detailed scrutiny by national medical
associations and other interested ‘stake-
holders’ is welcomed. The W.M.A has set
up an electronic working group to receive
comments and suggestions both on the need
for a document such as this which is specif-
ic for children and on the core principles in
the statement which can be used to develop
both international and local national guide-
lines.
Please send your comments to your
National Medical Association or as individ-
uals to the WMA office secretariat@
wma.net
James Appleyard MD FRCPCH
Children’s Physician
Past President
World Medical Association
November 2007
References
1.Child Health Research – A foundation for
improving Child Health. World Health
Organisation 2001
2.Global Forum for Health Research 2005
World Health Organisation
3. Krugman S Experiments at the
Willowbrook State School . Lancet 1971
1 966-967
4. Burns J.P. ‘Research in Children’ Crit
Care Med 2003 31 No 3 (Suppl)
Medical Ethics and Human Rights
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90 WMJ 53, December 2007
5. Guidelines for the Ethical Conduct of
Medical Research involving children.
Royal College of Paediatrics and Child
Health: Ethics Advisory Committee
Arch. Dis. Child. 2000 82 177-182
6. Appleyard W.J The Challenge of building
an International Framework for Research
on Medicines for Children. The Joseph J
Hoet Lecture 2005 The European Forum
for Good Clinical Practice Bruxelles
7. International Ethical Guidelines for
Biomedical Research involving Human
Subjects, Council for International
Organisations of Medical Sciences with
the WHO Geneva 2002
8. Department of Health and Human
Services, Food and Drug Administration.
Regulations requiring manufacturers to
assess the safety and effectiveness of new
drugs and biological products in pediatric
patients; final rule Ref Reg 1998
63(231):666 32-72
9. Additional Safeguards for Children in
Clinical investigations of FDA-regulated
Products – Interim Rule Food and Drug
Administration, Health and Human
Services 2007 www.fda.gov.
10. ‘Ethical Principles for Medical
Research Involving Human Subjects’
WMA Declaration of Helsinki 2002
11. Ethical Principles and Operational
Guidelines for Good Clinical Practice in
Paediatric Research in Ethics Working
Group Confederation of European
Specialists in Paediatrics 2002
12. Committee on Drugs, American
Academy of Pediatrics Guidelines for
the ethical conduct of studies to evalu-
ate drugs in pediatric populations
Pediatrics 1995 286-294
13. Ethical Considerations for Clinical tri-
als performed in Children – Guidelines
by an Ad Hoc Group for E U Directive
2001/20/EC 2006
14. International Ethical Guidelines for
Biomedical Research Involving Human
Subjects Prepared by the Council for
International Organizations of Medical
Sciences (CIOMS) in collaboration
with the World Health Organization
(WHO) CIOMS Geneva 2002
15. ‘Clinical Investigation of medicinal
products in the paediatric population’.
International Committee on
Harmonisation E 11
16. Guideline on Ethical considerations for
Clinical Trials performed in children
within the scope of the E.U Clinical
Trials Directive 2001/20/EC . The
European Agency for the Evaluation of
Medicinal Products (EMEA) 2006
17. Improving Child Health : The role of
Research Working Group on Women
and Child Health BMJ 2002 324 1444-
7
18. Forest CB, Shipman SA , Dougherty D,
Miller MR ‘Outcomes Research in
Pediatric Settings’ Pediatrics 2003 111
171-8
19. Homan R ‘Problems with Codes’
Research Ethics Review 2006 2 No3
98-103
20. Appleyard W.J.’ The Rights of Children
to Healthcare’ Medical Ethics 1998 24
293-4
21. Ross L.F ‘Do healthy children deserve
greater protection in Medical Research
?’ J.Pediatr 2003 142 108-12
22. Ondrusek N., Abramovitch R.,
Pencharz P and Koren G ‘Empirical
examination of the ability of children to
consent to clinical research’ Journal of
Medical Ethics 1998 24 158-165
23. Steinbrook R Testing Medications in
Children N Eng J Med 2002 347 1642-
1470
World Health Professions Alliance
Conference on Regulation of Health
Professions display
The World Medical Association will join with its partners in the World Health
Professions Alliance (WHPA)* and the World Confederation for Physical Therapy in
hosting a conference in the Regulation of Health Professions.
The Conference will be held in Geneva, Switzerland on May 17-18 2008 and discuss
the role and future of health professions’ regulation. It will focus on models of health
professions’ regulation, examples of best practice in regulatory body governance and
a discussion of trade in services and its implications for regulation.
The Conference, intended to bring together regulators, leaders of health
professions.policy makers, health system managers and administrators; researchers
and scientists and other interested parties, will take place prior to the World Health
Assembly (19–23 May 2008).
For full details of speakers, programme, registration and submission of abstracts visit:
www.whpa.org/reg/index.htm
*The World Health Professions Alliance is a unique alliance of dentistry, medicine, nursing and
pharmacy aiming to address global health issues and striving to help deliver cost effective qual-
ity health care worldwide. The WHPA member organisations are: the International Council of
Nurses (ICN), the International Pharmaceutical Federation (FIP), the World Dental federation
(FDI) and the World Medical Association (WMA). WHPA will be joined by the World
Confederation for Physical Therapy (WPTC).
Medical Ethics and Human Rights
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91WMJ 53, December 2007
DEFINITION
Telemedicine is the practice of medicine
over a distance, in which interventions,
diagnostic and treatment decisions and
recommendations are based on data, doc-
uments and other information transmitted
through telecommunication systems.
PREAMBLE
The development and implementation of
information and communication technol-
ogy are creating new modalities for pro-
viding care for patients. These enabling
tools offer different ways of practising
medicine. The adoption of telemedicine is
justified because of its speed and its
capacity to reach patients with limited
access to medical assistance, in addition
to its power to improve health care.
Physicians must respect the following eth-
ical guidelines when practising telemedi-
cine.
PRINCIPLES
Patient-physician relationship and confi-
dentiality
The patient-physician relationship should
be based on a personal encounter and suf-
ficient knowledge of the patient’s person-
al history. Telemedicine should be
employed primarily in situations in which
a physician cannot be physically present
within a safe and acceptable time period.
The patient-physician relationship must
be based on mutual trust and respect. It is
therefore essential that the physician and
patient be able to identify each other reli-
ably when telemedicine is employed.
Ideally, telemedicine should be employed
only in cases in which a prior in-person
relationship exists between the patient and
the physician involved in arranging or
providing the telemedicine service.
The physician must aim to ensure that
patient confidentiality and data integrity
are not compromised. Data obtained dur-
ing a telemedical consultation must be
secured through encryption and other
security precautions must be taken to pre-
vent access by unauthorized persons.
Responsibilities of the physician
A physician whose advice is sought
through the use of telemedicine should
keep a detailed record of the advice he/she
delivers as well as the information he/she
received and on which the advice was
based.
It is the obligation of the physician to
ensure that the patient and the health pro-
fessionals or family members caring for
the patient are able to use the necessary
telecommunication system and necessary
instruments. The physician must seek to
ensure that the patient has understood the
advice and treatment suggestions given
and that the continuity of care is guaran-
teed.
The physician asking for another physi-
cian’s advice or second opinion remains
responsible for treatment and other deci-
sions and recommendations given to the
patient.
A physician should be aware of and
respect the special difficulties and uncer-
tainties that may arise when he/she is in
contact with the patient through means of
tele-communication. A physician must be
prepared to recommend direct patient-
doctor contact when he/she feels that the
situation calls for it.
Quality of care
Quality assessment measures must be
used regularly to ensure the best possible
diagnostic and treatment practices in
telemedicine.
The possibilities and weaknesses of
telemedicine in emergencies must be
acknowledged. If it is necessary to use
telemedicine in an emergency situation,
the advice and treatment suggestions are
influenced by the level of threat to the
patient and the know-how and capacity of
the persons who are with the patient.
RECOMMENDATION
The WMA and National Medical
Associations should encourage the devel-
opment of national legislation and inter-
national agreements on subjects related to
the practise of telemedicine, such as e-
prescribing, physician registration, liabili-
ty and the legal status of electronic med-
ical records.
WMA Statement On The Ethics Of Telemedicine
Adopted by the WMA General Assembly, Copenhagen, Denmark, October 2007
Medical Ethics and Human Rights
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92 WMJ 53, December 2007
The World Medical Association,
1. Considering the Preamble to the United
Nations Charter of 26 June 1945 solemn-
ly proclaiming the faith of the people of
the United Nations in the fundamental
human rights, the dignity and value of
the human person,
2. Considering the Preamble to the Universal
Declaration of Human Rights of 10
December 1948 which states that disre-
gard and contempt for human rights have
resulted in barbarous acts which have out-
raged the conscience of mankind,
3. Considering Article 5 of that Declaration
which proclaims that no one shall be sub-
jected to torture or cruel, inhuman or
degrading treatment,
4. Considering the American Convention
on Human Rights, which was adopted by
the Organization of American States on
22 November 1969 and entered into
force on 18 July 1978, and the Inter-
American Convention to Prevent and
Punish Torture, which entered into force
on 28 February 1987,
5. Considering the Declaration of Tokyo,
adopted by the World MedicalAssociation
in 1975, which reaffirms the prohibition of
any form of medical involvement or pres-
ence of a physician during torture or inhu-
man or degrading treatment,
6. Considering the Declaration of Hawaii,
adopted by the World Psychiatric
Association in 1977,
7. Considering the Declaration of Kuwait,
adopted by the International Conference
of Islamic Medical Associations in 1981,
8. Considering the Principles of Medical
Ethics Relevant to the Role of Health
Personnel, Particularly Physicians, in the
Protection of Prisoners and Detainees
Against Torture and Other Cruel,
Inhuman or Degrading Treatment or
Punishment, adopted by the United
Nations General Assembly on 18
December 1982, and particularly
Principle 2, which states: “It is a gross
contravention of medical ethics… for
health personnel, particularly physicians,
to engage, actively or passively, in acts
which constitute participation in, com-
plicity in, incitement to or attempts to
commit torture or other cruel, inhuman
or degrading treatment…”,
9. Considering the Convention Against
Torture and Other Cruel, Inhuman or
Degrading Treatment or Punishment,
which was adopted by the United
Nations General Assembly on December
1984 and entered into force on 26 June,
1987,
10. Considering the European Convention
for the Prevention of Torture and
Inhuman or Degrading Treatment or
Punishment, which was adopted by the
Council of Europe on 26 June 1987 and
entered into force on 1 February 1989,
11. Considering the Resolution on Human
Rights adopted by the World Medical
Association in Rancho Mirage, in
October 1990 during the 42nd General
Assembly and amended by the 45th,
46th and 47th General Assemblies,
12. Considering the Declaration of
Hamburg, adopted by the World
MedicalAssociation in November 1997
during the 49th General Assembly, call-
ing on physicians to protest individual-
ly against ill-treatment and on national
and international medical organizations
to support physicians in such actions,
13. Considering the Istanbul Protocol
(Manual on the Effective Investigation
and Documentation of Torture and
Other Cruel, Inhuman or Degrading
Treatment or Punishment), adopted by
the United Nations General Assembly
on 4 December 2000,
14. Considering the Convention on the
Rights of the Child, which was adopted
by the United Nations on 20 November
1989 and entered into force on 2
September 1990, and
15. Considering the World Medical
Association Declaration of Malta on
Hunger Strikers, adopted by the 43rd
World Medical Assembly Malta,
November 1991and amended by the
WMA General Assembly, Pilanesberg,
South Africa, October, 2006,
Recognizing
16. That careful and consistent documenta-
tion and denunciation by physicians of
cases of torture and of those responsi-
ble contributes to the protection of the
physical and mental integrity of vic-
tims and in a general way to the strug-
gle against a major affront to human
dignity,
WMA resolution on the responsibility of physicians in the documen-
tation and denunciation of acts of torture or cruel or inhuman or
degrading treatment
Initiated: September 2002, Adopted by the WMA General Assembly, Helsinki 2003 and amended
by the WMA General Assembly, Copenhagen, Denmark, October 2007
Medical Ethics and Human Rights
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93WMJ 53, December 2007
17. That physicians, by ascertaining the
sequelae and treating the victims of tor-
ture, either early or late after the event,
are privileged witnesses of this viola-
tion of human rights,
18. That the victims, because of the psycho-
logical sequelae from which they suffer
or the pressures brought on them, are
often unable to formulate by themselves
complaints against those responsible for
the ill-treatment they have undergone,
19. That the absence of documenting and
denouncing acts of torture may be con-
sidered as a form of tolerance thereof
and of non-assistance to the victims,
20. That nevertheless there is no consistent
and explicit reference in the profession-
al codes of medical ethics and legisla-
tive texts of the obligation upon physi-
cians to document, report or denounce
acts of torture or inhuman or degrading
treatment of which they are aware,
Recommends that National
Medical Associations
1. Attempt to ensure that detainees or vic-
tims of torture or cruelty or mistreatment
have access to immediate and indepen-
dent health care. Attempt to ensure that
physicians include assessment and docu-
mentation of symptoms of torture or ill-
treatment in the medical records using
the necessary procedural safeguards to
prevent endangering detainees.
2. Promote awareness of the Istanbul
Protocol and its Principles on the Effective
Investigation and Documentation of
Torture and Other Cruel, Inhuman or
Degrading Treatment. This should be done
at country level using different methods of
information dissemination; including
trainings, publications and web docu-
ments.
3. Disseminate to physicians the Istanbul
Protocol.
4. Promote training of physicians on the
identification of different modes of tor-
ture, in recognizing physical and psycho-
logical symptoms following specific
forms of torture and in using the docu-
mentation techniques foreseen in the
Istanbul Protocol to create documenta-
tion that can be used as evidence in legal
or administrative proceedings.
5. Promote awareness of the correlation
between the examination findings,
understanding torture methods and the
patients’ allegations of abuse;
6. Facilitate the production of high-quality
medical reports on torture victims for
submission to judicial and administrative
bodies;
7. Attempt to ensure that physicians
observe informed consent and avoid
putting individuals in danger while
assessing or documenting signs of torture
and ill-treatment;
8. Attempt to ensure that physicians include
assessment and documentation of symp-
toms of torture or ill-treatment in the
medical records using the necessary pro-
cedural safeguards to prevent endanger-
ing detainees.
9. Support the adoption in their country of
ethical rules and legislative provisions:
9.1 aimed at affirming the ethical obligation
on physicians to report or denounce acts
of torture or cruel, inhuman or degrad-
ing treatment of which they are aware;
depending on the circumstances, the
report or denunciation would be
addressed to medical, legal, national or
international authorities, to non-govern-
mental organizations or to the
International Criminal Court. Doctors
should use their discretion in this mat-
ter, bearing in mind paragraph 68 of the
Istanbul Protocol.
9.2 establishing, to that effect, an ethical
and legislative exception to profession-
al confidentiality that allows the physi-
cian to report abuses, where possible
with the subject’s consent, but in certain
circumstances where the victim is
unable to express him/herself freely,
without explicit consent.
9.3 cautioning physicians to avoid putting
individuals in danger by reporting on a
named basis a victim who is deprived of
freedom, subjected to constraint or
threat or in a compromised psychologi-
cal situation
10. Place at their disposal all useful infor-
mation on reporting procedures, partic-
ularly to the national authorities, non-
governmental organizations and the
International Criminal Court.
Istanbul Protocol, paragraph 68: “In some
cases, two ethical obligations are in con-
flict. International codes and ethical princi-
ples require the reporting of information
concerning torture or maltreatment to a
responsible body. In some jurisdictions, this
is also a legal requirement. In some cases,
however, patients may refuse to give con-
sent to being examined for such purposes or
to having the information gained from
examination disclosed to others. They may
be fearful of the risks of reprisals for them-
selves or their families. In such situations,
health professionals have dual responsibili-
ties: to the patient and to society at large,
which has an interest in ensuring that jus-
tice is done and perpetrators of abuse are
brought to justice. The fundamental princi-
ple of avoiding harm must feature promi-
nently in consideration of such dilemmas.
Health professionals should seek solutions
that promote justice without breaking the
individual’s right to confidentiality. Advice
should be sought from reliable agencies; in
some cases this may be the national medical
association or non-governmental agencies.
Alternatively, with supportive encourage-
ment, some reluctant patients may agree to
disclosure within agreed parameters.”
Medical Ethics and Human Rights
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94 WMJ 53, December 2007
PREAMBLE
Noting information and reports of system-
atic and repeated violations of human
rights, interference with the right to health
in Zimbabwe, failure to provide resources
essential for provision of basic health care,
declining health status of Zimbabweans,
dual loyalties and threats to health care
workers striving to maintain clinical inde-
pendence, denial of access to health care
for persons deemed to be associated with
opposition political parties and escalating
state torture, the WMA wishes to confirm
its support of, and commitment to:
• Attaining the World Health Organization
principle that the “enjoyment of the
highest attainable standard of health is
one of the fundamental rights of every
human being”
• Defending the fundamental purpose of
physicians to alleviate distress of
patients and not to let personal, collec-
tive or political will prevail against such
purpose
• Supporting the role of physicians in
upholding the human rights of their
patients as central to their professional
obligations
• Supporting physicians who are persecut-
ed because of their adherence to medical
ethics
RECOMMENDATION
Therefore, the World Medical Association,
recognizing the collapsing health care sys-
tem and public health crisis in Zimbabwe,
calls on its affiliated national medical asso-
ciations to:
1. Publicly denounce all human rights
abuses and violations of the right to
health in Zimbabwe
2. Actively protect physicians who are
threatened or intimidated for actions
which are part of their ethical and pro-
fessional obligations
3. Engage with the Zimbabwean Medical
Association (ZiMA) to ensure the
autonomy of the medical profession in
Zimbabwe
4. Urge and support ZiMA to invite an
international fact finding mission to
Zimbabwe as a means for urgent action
to address the health and health needs
of Zimbabweans
In addition, the WMA encourages ZiMA,
as a member organization of the WMA,
to:
5. Uphold its commitment to the WMA
Declarations of Tokyo, Hamburg and
Madrid as well as the WMA Statement
on Access to Health Care
6. Facilitate an environment where all
Zimbabweans have equal access to qual-
ity health care and medical treatment,
irrespective of their political affiliations
7. Commit to eradicating torture and inhu-
mane, degrading treatment of citizens
in Zimbabwe
8. Reaffirm their support for the clinical
independence of physicians treating
any citizen of Zimbabwe
9. Obtain and publicize accurate and nec-
essary information on the state of
health services in Zimbabwe
10. Advocate for inclusion in medical cur-
ricula, teachings on human rights and
the ethical obligations of physicians to
maintain full and clinical indepen-
dence when dealing with patients in
vulnerable situations
The WMA encourages ZiMA to seek assis-
tance in achieving the above by engaging
with the WMA, the Commonwealth
Medical Association and the NMAs of
neighboring countries and to report on its
progress from time to time.
WMA Resolution On Health And Human Rights Abuses In Zimbabwe
Adopted by the WMA General Assembly, Copenhagen, Denmark, October 2007
Medical Ethics and Human Rights
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95WMJ 53, December 2007
PREAMBLE
More than one in three adults worldwide
(more than 1.1 billion people) smokes, 80
percent of whom live in low- and middle-
income countries. Smoking and other
forms of tobacco use affect every organ
system in the body, and are major causes
of cancer, heart disease, stroke, chronic
obstructive pulmonary disease, fetal dam-
age, and many other conditions. Five mil-
lion deaths occur worldwide each year
due to tobacco use. If current smoking
patterns continue, it will cause some 10
million deaths each year by 2020 and 70
percent of these will occur in developing
countries. Tobacco use was responsible
for 100 million deaths in the 20th century
and will kill one billion people in the 21st
century unless effective interventions are
implemented. Furthermore, secondhand
smoke – which contains more than 4000
chemicals, including more than 50 car-
cinogens and many other toxins – causes
lung cancer, heart disease, and other ill-
nesses in nonsmokers.
The global public health community,
through the World Health Organization
(WHO), has expressed increasing concern
about the alarming trends in tobacco use
and tobacco-attributable disease. As of 20
September 2007, 150 countries had rati-
fied the Framework Convention on
Tobacco Control (FCTC), whose provi-
sions call for ratifying countries to take
strong action against tobacco use by
increasing tobacco taxation, banning
tobacco advertising and promotion, pro-
hibiting smoking in public places and
worksites, implementing effective health
warnings on tobacco packaging, improv-
ing access to tobacco cessation treatment
services and medications, regulating the
contents and emissions of tobacco prod-
ucts, and eliminating illegal trade in
tobacco products.
Exposure to secondhand smoke occurs
anywhere smoking is permitted: homes,
workplaces, and other public places.
According to the WHO, some 200,000
workers die each year due to exposure to
smoke at work, while about 700 million
children, around half the world’s total,
breathe air polluted by tobacco smoke,
particularly in the home. Based on the evi-
dence of three recent comprehensive
reports (the International Agency for
Research on Cancer’s Monograph 83,
Tobacco Smoke and Involuntary
Smoking; the United States Surgeon
General’s Report on The Health
Consequences of Involuntary Exposure to
Tobacco Smoke; and the California
Environmental Protection Agency’s
Proposed Identification of Environmental
Tobacco Smoke as a Toxic Air
Contaminant), on May 29, 2007, the
WHO called for a global ban on smoking
at work and in enclosed public places.
The tobacco industry claims that it is
committed to determining the scientific
truth about the health effects of tobacco,
both by conducting internal research and
by funding external research through
jointly funded industry programs.
However, the industry has consistently
denied, withheld, and suppressed infor-
mation concerning the deleterious effects
of tobacco smoking. For many years the
industry claimed that there was no conclu-
sive proof that smoking tobacco causes
diseases such as cancer and heart disease.
It has also claimed that nicotine is not
addictive. These claims have been repeat-
edly refuted by the global medical profes-
sion, which because of this is also res-
olutely opposed to the massive advertis-
ing campaigns mounted by the industry
and believes strongly that the medical
associations themselves must provide a
firm leadership role in the campaign
against tobacco.
The tobacco industry and its subsidiaries
have for many years supported research
and the preparation of reports on various
aspects of tobacco and health. By being
involved in such activities, individual
researchers and/or their organizations
give the tobacco industry an appearance
of credibility even in cases where the
industry is not able to use the results
directly in its marketing. Such involve-
ment also raises major conflicts of interest
with the goals of health promotion.
RECOMMENDATIONS
The WMA urges the national medical
associations and all physicians to take the
following actions to help reduce the
health hazards related to tobacco use:
1. Adopt a policy position opposing
smoking and the use of tobacco prod-
ucts, and publicize the policy so adopt-
ed.
2. Prohibit smoking at all business, social,
scientific, and ceremonial meetings of
the National Medical Association, in
line with the decision of the World
Medical Association to impose a simi-
lar ban at all its own such meetings.
3. Develop, support, and participate in
programs to educate the profession and
the public about the health hazards of
tobacco use (including addiction) and
exposure to secondhand smoke.
Programs aimed at convincing and
helping smokers and smokeless tobac-
co users to cease the use of tobacco
WMA Statement on Health Hazards of Tobacco Products
Adopted by the 40th World Medical Assembly, Vienna, Austria, September 1988 amended by the
49th WMA General Assembly, Hamburg, Germany, November 1997 and the WMA General
Assembly, Copenhagen, Denmark, October 2007
Medical Science, Medical Practice and Medical Education
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96 WMJ 53, December 2007
products and programs for non-smok-
ers and non-users of smokeless tobacco
products aimed at avoidance are both
important.
4. Encourage individual physicians to be
role models (by not using tobacco prod-
ucts) and spokespersons for the cam-
paign to educate the public about the
deleterious health effects of tobacco
use and the benefits of tobacco-use ces-
sation. Ask all medical schools, bio-
medical research institutions, hospitals,
and other health care facilities to pro-
hibit smoking on their premises.
5. Introduce or strengthen educational
programs for medical students and
physicians to prepare them to identify
and treat tobacco dependence in their
patients.
6. Support widespread access to evi-
dence-based treatment for tobacco
dependence – including counseling and
pharmacotherapy – through individual
patient encounters, cessation classes,
telephone quit-lines, web-based cessa-
tion services, and other appropriate
means.
7. Develop or endorse a clinical practice
guideline on the treatment of tobacco
use and dependence.
8. Join the WMA in urging the World
Health Organization to add tobacco
cessation medications with established
efficacy to the WHO’s Model List of
Essential Medicines.
9. Refrain from accepting any funding or
educational materials from the tobacco
industry, and to urge medical schools,
research institutions, and individual
researchers to do the same, in order to
avoid giving any credibility to that
industry.
10. Urge national governments to ratify
and fully implement the Framework
Convention on Tobacco Control in
order to protect public health.
11. Speak out against the shift in focus of
tobacco marketing from developed to
less developed nations and urge
national governments to do the same.
12. Advocate the enactment and enforce-
ment of laws that:
a. provide for comprehensive regula-
tion of the manufacture, sale, distrib-
ution, and promotion of tobacco
products, including the specific pro-
visions listed below.
b. require written and pictorial warn-
ings about health hazards to be print-
ed on all packages in which tobacco
products are sold and in all advertis-
ing and promotional materials for
tobacco products. Such warnings
should be prominent and should refer
those interested in quitting to avail-
able telephone quit-lines, websites,
or other sources of assistance.
c. prohibit smoking in all enclosed pub-
lic places (including health care
facilities, schools, and education
facilities), workplaces (including
restaurants, bars and nightclubs) and
public transport. Mental health and
chemical dependence treatment cen-
ters should also be smoke-free.
Smoking in prisons should not be
permitted.
d. ban all advertising and promotion of
tobacco products.
e. prohibit the sale, distribution, and
accessibility of cigarettes and other
tobacco products to children and
adolescents.
f. prohibit smoking on all commercial
airline flights within national borders
and on all international commercial
airline flights, and prohibit the sale of
tax-free tobacco products at airports
and all other locations.
g. prohibit all government subsidies for
tobacco and tobacco products.
h. provide for research into the preva-
lence of tobacco use and the effects
of tobacco products on the health sta-
tus of the population.
i. prohibit the promotion, distribution,
and sale of any new forms of tobacco
products that are not currently avail-
able.
j. increase taxation of tobacco products,
using the increased revenues for pre-
vention programs, evidence-based
cessation programs and services, and
other health care measures.
k. curtail or eliminate illegal trade in
tobacco products and the sale of
smuggled tobacco products.
l. help tobacco farmers switch to alter-
native crops.
m. urge governments to exclude tobac-
co products from international trade
agreements.
Medical Science, Medical Practice and Medical Education
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97WMJ 53, December 2007
Education
Avicenna Directories to replace World Directory of Medical Schools
Discussions have been taking place
between WHO and the University of
Copenhagen with a view to replacing the
World Directory of Medical Schools with
the establishment of a Global database of
health professions. It is planned is to
include other academic health institutions
relating to the other health professions such
as dentistry, midwifery, nursing, pharmacy,
public health and will include information
on schools’ accreditation, number of admis-
sions, students, graduates , Faculty, educa-
tional resources, address, and national offi-
cial recognition. The database will be run
by the University of Copenhagen in collab-
oration with WHO, the World Federation
for Medical Education (WFME), the
Foundation for the4 Advancement of
International Medical Education and
Research (FAIMER), the International
Pharmaceutical Federation and other part-
ners.
The database will be based in the Faculty
of Health Sciences in the University of
Copenhagen with the close collaboration
of WFME. These electronic resources will
be called the Avicenna Directories. It
is understood that the work has already
started.
Global Standards for Quality Improvement in Medical Education
The World Federation of Medical Education
has published European Specifications for
Basic and Postgraduate Medical Education
and Continuing Professional Development.
These have been developed by a WFMA/
AMSE international task force set up by
MEDINE, chaired by WFME and ASME,
sponsored by the European Commission,
and provides a valuable tool adapting the
global standards in medical education to the
European Region of WHO. It is directed
towards national and international authori-
ties, institutions and organisations with
responsibility for medical education and
represents a valuable tool in planning qual-
ity improvement in medical education, set-
ting out the essential elements which need
to be considered in planning necessary
reforms in medical education. While this is
an essential tool for authorities and institu-
tions concerned with medical education it is
of value to all physicans who have respon-
sibilities in medical education,
WFME Global Standards for Quality
Improvement in Medical Education
European Specifications.
ISBN 978-87-989108-6-2
Publication facilitated by WHO EURO
Information from:
World Federation of Medical Educuation
www.wfme.org
Point of view
A Worldwide Tour of Medical Degrees and Qualifications
Dr. Denis Doran MD
In recent years, attempting to recognise a
medical degree or qualification can be chal-
lenging With the reunification of East and
West Germany, the opening of the European
Community to several new member states,
the break-up of the Soviet Union and the
fragmentation of Yugoslavia into several
individual nations, medical degrees and
qualifications which were not familiar
before are now more commonly seen.
Another problem that Boards, Medical
Councils and Colleges have had to deal with
for many years, is to differentiate and recog-
nise which degrees relate to clinical prac-
tice, which ones are linked to academic
careers and which ones are honorary. The
increase in international migration has made
this problem even more pressing.
This article will review the broad range of
medical degrees and evidence of qualifica-
tion presented nowadays to licensing bod-
ies, dental committees and residency pro-
gramme applications. It is not intended to
provide an official or exhaustive list of
medical qualifications but merely to reflect
on the great variety of titles for medical
diplomas and qualifications.
EUROPE
In Europe, the medical degrees awarded
vary from country to country (and also
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98 WMJ 53, December 2007
within countries), of which the following
are examples.
In Belgium, the French university diploma
is Docteur en Medicine,Chirugie et
Accouchement. The Flemish university
degree is Aerts, Arts (Physician).
In the countries of the former Soviet Union
Russia, Ukraine, Moldova, Armenia and
Estonia all issue a Doctor in Medicine
Diploma; Uzbekistan awards a General
Practitioner diploma and the rest of the 15
republics award a Vrach (Physician) diploma.
In the nations of the former Yugoslavia,
Croatia and Macedonia award a Doctor of
Medicine diploma, while Bosnia-
Herzegovina, Serbia and Slovenia formerly
issued a Lekar (or Zdravnik) diploma – now
a Doctor of Medicine diploma.
The graduates from medical schools in
Austria, The Czech Republic and Slovakia
receive a Medicinae Universae Doctor
Diploma.
In Scandinavia, Norwegian and Danish
medical schools award a Candidatus
Medicinae diploma; Iceland – a Candidatus
Medicinae et Chirurgiae diploma; Sweden –
a Lakaexamen diploma and in Finland – a
“Lisensiatti (Licence in Medicine). The
degree Laaketieteen Tohtori (Doctor of
Medicine) is a traditional university doctor-
ate, the highest degree and is a requirement
for the position of Professor..
In the Netherlands an Arts (or Artsexamen)
diploma is awarded, in Luxembourg a
Bachelor Academique en Sciences de la
Vie-Medicine, and in Bulgaria, a
Master’s/Physician or State Examination
certificate is awarded
A few degrees have unusual sounding
names: in Albania Mjek I Prerjithshem; in
Greece, Psycho Iatrikes; Belarus currently
Kvaliifi Kaciya (Physician diploma ) for-
merly a Vrach.)
Romania awards a Doctor-Medic diploma;
Poland, a Lekarz diploma; Hungary – an
Orvos doctor or MD diploma, and Turkey –
a Doctor of Medicine diploma.
In the United Kingdom, the basic British
medical degree is the MB, BCh, (Medicinae
Baccalaureus, Baccalaureus Chirugiae).
Varieties of the same degree exist through-
out Britain and the rest of the
Commonwealth. These are BM BCh , MB
ChB, MB BChir, MB, BS. In the UK, an
MD could be awarded to one who does
research and submits a thesis in the field of
medicine, or as an honorary degree, to a
senior or academic physician. Throughout
the world, many countries with former edu-
cational associations with Britain award
degrees reflecting the British type of med-
ical degree.
The Conjoint Diploma LRCP, MRCS , and
the LMSSA (Licentiate of the Royal College
of Physicians of London, Member of the
Royal College of Surgeons of England, and
the Licentiate in Medicine, Surgery of the
Society of Apothecaries) were registrable
qualifications with the General Medical
Council (where all practising physicians
have to be registered if they wish to prac-
tice) until 1999. The Scottish Triple
Conjoint Diplomas, LRCPE, LRCSE,
LRCPSG are similar qualifications which
were registrable with the GMC until 1999.
In Ireland, the basic medical degree is MB,
ChB, BAO (Baccalaureus in Arte
Obstetrician). The LRCPI, LRCSI diplo-
mas, unlike England and Scotland are still
registrable with the Irish Medical Council.
Also recognised is the LM (Licence in
Midwifery)
For Germany there is a State Examination
Certificate , either on passing a three part
State exam (Dritter Abschnitt Certificate ) or
a two part State exam, (Zweiter Abschnitt
Certificate).which are recognised for basic
licensing purposes. Italy awards a Laurea in
Medecina e Chirurgia diploma) (Bachelor of
Medicine and Surgery), Portugal awards a
Licenciatura em Medecina diploma and
Spain, a Licenciado en Medecina y Cirurgia.
Switzerland awards a Diploma Federal.
LATIN AMERICA
Brazil awards a Medico (or MD) diploma;
Bolivia a Titulo en Provision Nacional de
Medico Cirujano; Costa Rica,Venezuela
and Chile, a Medico Chirujano diploma:
Ecuador, Honduras and Nicaragua, a
Doctor en Medicina y Chirugia; Mexico
and Peru, a Titulo de Medico Cirujano.
Surinam awards an Arts or Geneesheren
diploma.
NORTH AMERICA
In Canada, francophone universities award
a Docteur/ Doctorat en Médecine diploma:
Anglophone universities offer the MD diplo-
ma. In the USA, most graduates of medical
schools receive an MD. Another medical
degree awarded by 19 medical schools is the
Doctor of Osteopathy or DO diploma.
ASIA
China and Taiwan offer a Bachelor of
Medicine degree. China also offers a
Bachelor of Traditional Medicine and Japan
offers an Igaku (Bachelor of Medicine). In
Malaysia following the British system the
MB,BS or MB,ChB are awarded as well as
the Doctor “Perubatan”. North Korea offers
a Doctor diploma and South Korea, earlier a
Hak Sa diploma and now a Bachelor of
Medicine; Indonesia awards a Doktor diplo-
ma and Mongolia a Physician diploma.
AFRICA
Angola and Mozambique ex-Portuguese
colonies offer the same diplomas as
Portugal; the Democratic Republic of
Congo, an ex-Belgian colony, awards a
Docteur en Med., Chir et Accouchement
diploma, as well as a number of others,
which are accepted for basic medical licens-
ing purposes. Gabon, Benin and Ivory
Coast have a Doctorat d’Etat en Medicine.
Most other countries of the world issue
either an MD, Doctorat en Medecine or
MBBS/MB ChB degree.
NON-MEDICAL QUALIFI-
CATIONS
The PhD is a university awarded research
Doctorate, not necessarily associated with
clinical practice, awarded after supervised
academic research and the submission of a
Point of view
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99WMJ 53, December 2007
thesis. (Often Clinical Psychologists, who
unlike Psychiatrists cannot prescribe med-
ications have a PhD.).
MEMBERSHIP/FELLOW-
SHIP OF COLLEGES AND
OTHER SPECIALIST
INSTITUTIONS
Medical Colleges and Academic Institutions,
many of which have existed many or for
hundreds of years, award fellowships. The
Colleges are normally concerned with spe-
cialities, although, as, mentioned above,
some conduct examinations related to their
own specialty which are recognised for basic
licensing purposes to practice medicine e.g.
LRCPI, LRCPI. Fellowships, on the other
hand normally require the passing of a high-
er examination or assessment and election
by the College as Fellows. Honorary
Fellowships are mostly awarded for excep-
tional and distinguished practice in medicine
Such Colleges have as their aim the develop-
ment of the specialty and the maintenance of
high standards and excellence, a condition
which their members are bound to fulfil as a
condition of Membership or Fellowship. The
use of titles varies greatly between countries
and institutions.
MEMBERSHIP
e.g MCCFP Membership of Canadian
College of Family Physicians;
MACP Membership of American College
of Physicians;
MRCGP Membership of the Royal College
of General Practitioners.
Membership of these bodies, while not
obligatory in some countries, often marks
the end point of specialist training and is
awarded after an examination This type of
Membership is, in certain countries, recog-
nised as achieving formal specialist qualifi-
cation, notably in the UK where for exam-
ple, the MRCP is the recognised basic spe-
cialist qualification in medicine, whereas
the FRCS is the basic specialist qualifica-
tion for surgery.
FELLOWSHIP
e.g FAAP Fellow of the American Academy
of Paediatrics.
FRCP Fellow of the Royal College of
Physicians.
Fellowships require a much higher distinc-
tion and status. They are usually awarded
after passing a very difficult examination or
are elected for distinction in the relevant
branch of medicine.
In many countries of Europe and to a cer-
tain extent throughout the world, physicians
appointed as Professors prefer to be called
Professor rather than Doctor and in
England, Fellows of the Royal College of
Surgeons are referred to as Mister In fact all
surgeons are called Mister but “Obstetric
and Gynaecologist” specialists if they hold
an MD, may use the title Doctor.
CONCLUSION
It is not the purpose of this article to discuss
the details of qualifications associated with
the great variety of medical degrees listed
above.
Nevertheless, licensing bodies have the role
of recognising (or not) these medical
degrees and qualifications and to suggest,
when necessary, updates to qualify for a
licence to practice.
Accordingly, the public at large need to
accept the fact that physicians qualified to
practice in their region may not necessarily
have the usual MD after their name.
Address for communication
Dr Denis Doren
Box70 1 Hastings St N,
Bancroft. KOL 1CO
Canada
From the WMA Secretary General
Trust me, I’m a Doctor!
Although you never should say this to your
patients – you often will enjoy exactly the
desired high degree of confidence in what
you do and what you are – a physician.
However, we are about to lose this!
No, I am not referring to the sermon-like
repeated “doctor bashing” of politicians and
media, I am referring to what may be
thought to be advertising, but may be large-
ly a lack of precision and carelessness in
communication, with which we are endan-
gering our image.
More and more people are reaching out
their hands to patients saying „Hallo! I am
your doctor.“ But what kind of doctors are
they? At best they may be scientifically
trained persons but they may well be doc-
tors of podology. This not a joke! There is
an economic war and we are about to lose it,
because as it looks as if we have not even
understood that it is going on.
The battles our associations are fighting
about scope of practice and task shifting,
are not an academic entertainment.
Politicians and economists are trying to de-
professionalize medicine and make it a
cheap commodity for the masses.
Why? Is it – at least partially – our fault
because we have produced the confusion, or
at least we let it happen? . Not only does a
normal person already have a hard time to
understand what an Endocrinologist is and
From the WMA Secretary General
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100 WMJ 53, December 2007
does, we even top-up this non-communica-
tion with academic degrees, titles and
abbreviations that are cryptic, confusing
and worst of all – misleading.
Appendices of titles, consisting of dozens
of apparently randomly combined letters
make us look like amateurs rather than seri-
ous professionals. Yes, we may be proud to
be a fellow of a college or society and why
not talk about it. Yes, it is more than correct
to display specialist qualifications. But
titles that even our colleagues can only
decipher when they hold exactly the same
title could be considered vain advertising.
Whom are medical titles good for? Should
they not serve our patients to find the right
physician, to find the right treatment from a
qualified physician?
In this issue, Denis Doren, MD, from
Ontario (Canada) has taken a look at the
medical degrees, qualifications and titles
that are being awarded and used around the
world. One might attribute the wide variety
he found as a sign of pluralism, cultural
diversity and tradition. But let’s face it, for
our patients it is simply a mess. To make
this more transparent, at least to the con-
sumer (the patient), is there not some justi-
fication for simplifying the whole thing to “
Licensed Medical Practitioner”, with the
addition “and Licensed xxxxx Specialist”,
where appropriate. If then, the letters indi-
cating qualifications degrees e.g. MD, and
Fellowships of Colleges etc are added, they
will be less confusing.
In this day and age, access to the computer
surely permits patients to find the meaning
and significance of the letters.
And of course there are others who wel-
come our own confusion. While we don’t
delivery clarity – they do it by simply clas-
sifying us as “service providers” or “health
workers”. Separating us from our patients is
made easy by our use of terms and abbrevi-
ations and making physicians accede to the
generic group of “service providers” in
health care, neglecting the additional quali-
ties implicit in a practicing profession.
Do we want to maintain a special role in
health care? Do we want to remains advo-
cates for our patients? Do we want to keep
our leadership role in healthcare teams? If
the answer is “yes” we should avoid the
ridiculous variety of titles and acronyms we
are currently using and should make sure
that patients can identify us as what we are:
physicians. This still permits the nomina-
tion of a speciality, provided the qualifica-
tion has been earned and awarded, but we
should do it with the degree of transparency
and clarity we owe our patients and the pub-
lic.
Only then we will be able to protect our
titles. This will not be enough as a sufficient
strategy to protect our scope of practice, but
we have to realize that it is a necessary
requirement.
Trust me, I’m a doctor!
Ceremonial Session 5th
October2007
The President, Dr. N. Arumugam formally
opened the Session.
The Secretary General Dr. Otmar Kloiber
reported the death on 10th
of June of Dr.
André Wynen, former Chair of Council and
Secretary General Paying a tribute, he said
”André Wynen was our friend, teacher and
leader, serving the World Medical
Association and the whole medical profes-
sion with dedication and passion.
The meeting stood in silent tribute.
The Secretary General, then took the Roll
Call, introducing the Delegates and the
Observers of other organisations present
which included the International
Committee of the Red Cross, CIOMS,
Confemel, the Danish Nursing Association,
the Federal Council of Brazilian Doctors,
the International Dental Federation, the
International Federation of Medical
Students, the International Federation of
Pharmaceutical Manufacturers and
Associations, the Medical Women’s
International Association, the Standing
Committee of European Doctors, the World
Federation of Medical Education, the
World Psychiatric Association, the
International Rehabilitation Council for
Torture Victims and the World Self-
Medication Industry.
Dr. Jensen, President of the Danish Medical
Association welcomed World Medical
Association and all the participants to
Copenhagen. He congratulated Dr. Snædel,
the incoming President on his election and
paid tribute to his work, notably for his con-
tribution in the revision of the International
Code of Ethics. He thanked the outgoing
President Dr. Arumugam for all is work
over the past year.
The Chair of Council Dr. Hill warmly
thanked Dr. Jensen and the Danish Medical
Association for the invitation to return to
Copenhagen for this year’s Assembly and
for the hospitality, which was greatly appre-
ciated. Proposing a vote of thanks to the
President, he reminded the meeting that Dr.
Arumugam, a cardiologist in Malaysia, was
a champion of Public Health, had played a
major role in the introduction of Tobacco
Legislation in that country.
WMA General Assembly
The General Assembly of the World Medical Association was held in the Marriott Hotel,
Copenhagen on 5th
and 6th
October 2007
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101WMJ 53, December 2007
Retiring President’s Address
Dr. Arumugam said that it had been a ter-
rific year in which it had been an honour
and a privilege to represent the World
Medical Association. He had tried to
advance the views of WMA, had witnessed
the challenges facing Health Care Services
and Medicine in different countries and
met fellow doctors across the world. He
expressed his thanks both to Council and
to his fellow Officers for their work and
support during the past year. His main task
had been to emphasise the work of the
WMA and improve its visibility. He had
visited and attended the Annual meetings
of many National Medical Associations
and referred to the problems of the profes-
sion such as increasing regulation reducing
the time for professional work. Focusing
on Continuing Professional Development,
he noted that this had been a special prob-
lem over the past 10 years where there
were many hurdles in developing coun-
tries. Addressing the problems in South
East Asia in particular, he referred to the
development of a points system for CPD in
that region.
Patient Safety was also an important prob-
lem especially in hospitals. This had been
addressed by the Hospitals Association in
Malta which had recognised the WMA
Statement on this issue. A Conference of
Medical Associations in SEA had included
CME on Ethics in Medicine and Clinical
Practice. Dr. Arugunam also referred to
the increasing problem of medical litiga-
tion.
Turning to China he reported that the seven
persons in the delegation had discussed the
problems of Organ Transplants and harvest-
ing organs from prisoners, the shortage of
organs and other problems with the Chinese
Medical Association and the Minister of
Health. At the end of the meeting it was
concluded that Trade in Organs must stop.
He was encouraged by the recent accep-
tance of the WMA Code on Transplantation
of Organs by the Chinese Medical
Association. He commented that the prob-
lems of transplantation, including ethical
and legislative aspects had been discussed
by the German Medical Association whose
meeting he had addressed.
Obesity was a major problem and the loom-
ing epidemic needed addressing with a pre-
ventive healthy diet and food labelling.
The problems of tobacco continue. While
the Framework Convention on Tobacco
Control was welcomed, he felt that it so far
had had a limited effect and the World
Medical Association must continue its
efforts to encourage Tobacco Control activ-
ities.
Turning to the World Health Professions
Alliance he commented that the Presidents
of these professions met to discuss the prob-
lem of Health Personnel Migration and
Task shifting, where areas of difference still
need to be addressed.
The President referred to his presence in
India, the Philippines and most recently at a
meeting of CONFEMEL, finally comment-
ing that at the recent AMA meeting there
was concern over the development of clin-
ics in supermarkets and that in Australia
there was a need for vigilance over the issue
of what is being called “Task Shifting“. He
closed by stating that the most unforgettable
event for him had been the reading and
affirmation of the WMA Oath of the
Medical Profession.
The Assembly rose in a Standing Ovation.
Installation of the new President
Dr. Hill in thanking Dr. Arumugam for all
his work for the profession referred to the
wisdom, care and understanding he had
shown as President. He then presented Dr.
Arumugam with the Past President’s medal.
Introducing Dr. Snædel as the new
President, Dr. Hill said he had been elected
in recognition of his many services to the
profession and the WMA. Dr. Snædel took
the oath on assuming the office of President
and was invested with the Presidents Badge
of Office.
Presidential Address by Dr. Jon Snædel
“Dear colleagues, distinguished guests.
During the last decades new discoveries in
clinical research as well as in basic research
have been stretching the ethical boundaries
of medicine. The World Medical
Association has managed to be at the fore-
front of this evolution and during the past
few years the WMA has revised many of its
old documents in ethics as well as in other
fields. It has been a privilege to participate
in the solution of many of these dilemmas,
not least when the International Code of
Medical Ethics was revised after a process
of 2 years and finally finished in South-
Africa last year. To take an example of how
new thoughts are integrated in such a docu-
ment I will mention one paragraph of the
Code.
One of the paragraphs has been unchanged
since its earliest version in 1949:“A PHYSI-
CIAN SHALL always bear in mind the
obligation to preserve human life.” In the
last revision one word was changed and the
word preserve was replaced by the word
respect and now it reads: “A PHYSICIAN
SHALL always bear in mind the obligation
to respect human life.” The change of just
one word reflects a fundamental change in
our way of thinking of our duties. Our abil-
ities to treat our fellow human beings have
vastly increased as we are now able to pre-
serve live for a long time even if this life is
without any obvious quality. There is a say-
ing that life is a disease with 100% mortali-
ty, a saying that medicalises life itself. We
have to acknowledge the fact that death is
inevitable and that in its last phases it is of
more value to the person to treat the symp-
toms rather than the disease. In this phase of
life our obligation is thus to respect the
patient rather than to preserve his life.
There are many other ethical questions we
have to address and the WMA is working
constantly on these. Just to mention two
issues we are dealing with in the coming
months – a revision of the Helsinki declara-
tion on research involving human subjects
and a new document on stem cell research.
Every now and then we are faced with ethi-
cal dilemmas we did not foresee. I will give
you an example of such an issue which
unfolded in my country just 3 weeks ago. A
private company in genetic research has
now offered those who wish for and are
willing to pay, an analysis of their genetic
makeup. The whole genome is analyzed by
half a million markers and the person will
get a report on his chances of getting a num-
ber of diseases. But is it not just wonderful
that we have a technique that can provide us
with such information of your health and
WMA
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WMA
102 WMJ 53, December 2007
health risks? In our view there are, howev-
er, obvious problems with this type of infor-
mation. One is clearly that you are not able
to change your genes, which means that if
you know that your chances of getting say a
certain type of cancer; you will not be able
to affect that chance. Another is that this
technique will obviously be very interesting
to insurance companies who could then
insist that you will go through such a test
whether you like or not. There are even
more obstacles to this idea than I have
accounted for and this is just one example
of many of what medical ethics is about.
During my year of presidency of the World
Medical Association my main concerns will
therefore be medical ethics and its manifold
tasks. I will build on the traditions of our
Association and work in harmony with the
Council and the Secretariat, as it is of great
importance that we work together for our
mutual cause even if I have chosen this spe-
cific part of work of our Association for my
mission. There are many means to achieve
our goals. At this Assembly we will discuss
the future of the World Medical Journal. I
would like to see this Journal, and thereby
the WMA itself, have a much greater role in
medical ethics and public health than it has
had up to now. When I asked the librarian in
my University hospital to take a look into
the accessible Journals of Medical Ethics it
became clear to me that there is a place for
one more. The Journals are far less in num-
ber than in many specific fields of medi-
cine, even subspecialties, and the distribu-
tion of most of them seems to be confined
to the society they are published for. This
can be seen by their limited impact factor. A
new international journal on medical ethics
and public health published by the WMA
will in my mind not only be an asset to the
association but more importantly, of clear
benefit to the clinical doctor which this new
journal should be aimed at.
Closely linked to ethics are human rights. I
feel that the WMA is on the right track in its
collaboration with very important organisa-
tions in this field such as the Red Cross,
Amnesty International and not least the
International Council for Torture Victims
which actually have their main office here
in Copenhagen. The important task of pre-
venting torture by using a tool called the
Istanbul Protocol in ten countries has now
been underway during the last 4 years. It is
my hope that the WMA will continue to
work for this important human rights issue
in all possible ways during the coming
years.
The WMA has during the last years dis-
cussed advocacy because that is the means
by which the association will have effect.
The WMA aims its work mainly towards
three types of receivers, the individual
doctor, the association of doctors, mainly
the NMA’s of the WMA, and towards
international organisations. The main
receivers of the work of the WMA
throughout the years have been the
NMA’s. That is of course good, but to have
a real effect on health issues, ethics and
international politics of medicine our
Association needs more visibility. By
revamping the WMJ we will increase our
visibility towards the individual doctor.
Doctors will hopefully go to our new
Journal for advice and inspiration and we
will reach out with a printed version as
well as an electronic one to all parts of the
world in spite of language barriers.
Another important and imminent task is to
increase our presence and influence in
international organisations. One specific
task will be to work to preserve our educa-
tion and training because it has been on the
agenda of the WHO to solve the problem
of shortage of doctors by proposing a
shorter training, some kind of technical
doctor trained for limited purposes. Even
if we can understand that some countries
need to address this difficult problem
urgently, we feel that in the long run this
method will undermine the health service
in these countries. I would therefore like to
echo the words of our past president,
Kgosi Letlape, when he said in his address
in South-Africa that the solution to this
problem is to “keep the pastures green in
our countries.”
Doctors are not working alone. Team work
is an increasing issue in our daily routine
and we are accustomed to work alongside
other health professionals, most often nurs-
es and pharmacists. The WMA participates
in an international collaboration with the
respective organisations of these two pro-
fessions as well as the dentists. However,
we need to address the collaboration of
these professionals on the ground better.
Another task of mine will be to work on that
in a task looking specifically at collabora-
tion for better pharmacological treatment.
More tasks of this kind are obvious and will
most likely be looked at in the near future.
Lastly I will mention the specific group of
patients I care for and treat in my daily
work as a geriatrician, persons with demen-
tia, more specifically Alzheimer’s disease.
Even if I feel some urge to place their prob-
lems on the agenda I realize that the prob-
lems of specific group of patients are not an
issue for the WMA. We work for all of
them. However I will use this opportunity
to correct a prevalent misunderstanding,
that this is a specific problem for the devel-
oped world. In fact most demented persons
are found today in the developing world and
the greatest increase of this patient group is
without question in Asia and Africa.
During the coming year I hope to bring
some benefit to the WMA but I acknowl-
edge that one person will not be able to
achieve much. It is therefore my sincere
hope that I will be able to collaborate with
as many of you as possible during my pres-
idency. May the WMA continue to thrive
and prosper for many years.”
The President then thanked the Assembly
members and their guests for attending and
formally closed the Ceremonial Session.
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WMA
103WMJ 53, December 2007
Plenary Session of the Assembly 6th
October 2007
Dr. Hill, Chair of Council, opened the
meeting and the Secretary General, Dr.
Kloiber referred to the sad death of Dr.
André Wynen and informed the Assembly
that a Memorial Book was open for signa-
ture.
He also reminded the Assembly that the
World Health Professions Association’s
Leadership would take place in November.
There were 30 places on the course and 24
applications had so far been received and
approved. There were still six vacancies and
he invited applications for these places,
preferably female candidates.
Dr. Hill, after listing the apologies for
absence, stated that there were three nomi-
nations for the Presidency of the World
Medical Association for 1908-9 and opened
the floor for further nominations. In the
absence of any other proposals he declared
the three candidates to be Drs. Blachar
(Israel), Desai(India) and Boswell(New
Zealand).
Dr. Hill then referred to the presence as an
observer of the President of the
International Dental Federation (FDI), Dr.
Michéle Aerden, and invited her to address
the meeting.
Dr. Aerden referring to the FDI as one of the
partners in the World Health Professions’
Alliance (WHPA), said that it was the third
oldest health professional organisation in
the world. As a worldwide independent
organisation representing 140 Dental
Associations FDI it was the voice of den-
tistry and was represented at the UN, WHO
and ISO. Recognising that Health was a
fundamental human right she pointed out
that this included the need for Oral Health.
In 1981 WHO recognised the goal of glob-
al oral health. In 2007 Oral Health was on
the Agenda of the World Health Assembly
and the important role of prevention in Oral
Health was recognised, including the role of
Fluoride.
Dr. Aerden said that it was important to col-
lect data on oral health because of its value,
particularly in developing countries where
projects had been set up.
Turning to the importance of ethics she
stressed that this was also true of Dentistry.
She spoke of the importance of defending
the position of the profession in recognising
the dignity of individual and the well-being
of patients. Speaking of the effects of oral
disease on morbidity and mortality, she
referred the effects of pain on the quality of
life and to the link between oral disease and
the rest of the body
A proposal was being made in WHPA for
action to make things HAPPEN. There was
a “Health in Africa” Vision. In Africa,
where there were major gaps in health care,
conferences were planned in Africa in 2007
and in America in 2008, to address the prob-
lems of health access policy and also educa-
tion in health promotion and disease pre-
vention. Action by the WHPA would make
a difference.
Dr. Hill thanked Dr. Aerden and reminded
the meeting that Dr. Letlape had been sit-
ting on the working group in WHPA for the
past year.
Dr. Haikerwald presented the report of the
Credentials Committee. 45 Delegations
were present of which 43 had the right to
vote.
The Standing Orders and the Minutes of the
Pilanesberg meeting were both adopted,
following which each of the three candi-
dates in the presidential election addressed
the meeting. At the conclusion of these pre-
sentations delegations proceeded to a for-
mal ballot for the electing the President-
elect 2008-2009.
President-elect
The Secretary General declared the result of
the ballot was that Dr. Yoram Blachar had
been elected to the office of President-elect
for the year 2008-2009.
Dr Blachar, responding to this said that he
was deeply touched by the trust place in
him and thanked those who had elected
him, expressing in particular his thanks to
his wife and to Ms. Leah Wapner for their
great continuing support and help.
Report of Council
(Much of the written report of Council cir-
culated before the November meeting
appears in the report of the 176th
Council
meeting in WMJ52(2): matters other than
the statements and resolutions adopted by
the Assembly which are set out below, are
set out in the account of the 178th
Council
meeting (see page 107).
Finance and Planning
Dr. Hill presenting the report, turned first to
recommendations arising from the Finance
and Planning Committee business.
Cabo Verde
The application for constituent membership
of the Ordem dos Medical de Capo Verde
was approved.
Scientific Session, Seoul 2008
The theme of “Health and Human Rights”
was approved for the 2008 scientific meet-
ing in Seoul.
Treasurer’s Report
The Treasurer, Dr. J.D. Hoppe presenting
his report reviewing the period 2005-2006,
referred to the Financial Statement prepared
with Mr. Hallmayr which had been
approved by the auditors KPMG, and then
spoke to the document in some detail. He
reported that the net balance, reversing the
deficit of the years 2004-5 which had been
overcome through the efforts and actions of
the Secretary General, had continued to
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104 WMJ 53, December 2007
improve, both from Dr Kloiber’s continuing
actions, from the improvement in income
from members dues and other financial
earnings.
The Financial Statement for 2006 was unan-
imously approved.
Dr. Hoppe then presented the Budget for
2008 which, in the absence of any questions
from the floor, was approved unanimously.
Dr. Hill expressed his thanks both to Dr.
Hoppe and to Mr Hallmayr for their work
during the year.He reminded delegates that
the new dues categories had been approved
and sent to delegations.
Before turning to Medical Ethics Dr. Hill
put to the Assembly the following Council
Resolution which was adopted unanimous-
ly by the Assembly.
Adopted by the WMA General Assembly,
Copenhagen, Denmark, October 2007
There are credible reports that arrange-
ments between the Cuban government
and certain Latin American and Caribbean
governments to supply Cuban health
workers as physicians to these countries
are bypassing systems, established to pro-
tect patients, that have been set up to ver-
ify physicians’ credentials and compe-
tence.
The World Medical Association is signifi-
cantly concerned that patients are put at
risk by unregulated medical practices.
There exist already duly constituted and
legally authorized medical associations
within this region that are charged with
the registration of physicians and which
should be consulted by their respective
Ministries of Health.
Therefore, the WMA:
1) Condemns any actions by governments
in policies and practices that subvert or
bypass the accepted standards of med-
ical credentialing and medical care;
2) Calls upon the governments in Latin
America and the Caribbean to work
with the medical associations on all
matters related to physician certifica-
tion and the practice of medicine and to
respect the role and rights of these
medical associations and the autonomy
of the medical profession.
3) Urges, as a matter of utmost concern,
that the governments in Latin America
and the Caribbean respect the WMA
International Code of Medical Ethics
and the Declaration of Madrid that
guide the medical practice of physi-
cians all over the world.
Resolution in Support of the Medical Associations
in Latin America and the Caribbean
WMA
Medical Ethics and Human
Rights
Dr. Hill then put to the Assembly the fol-
lowing statements and resolutions arising
from Medical Ethics Committee business.
Telemedicine
A proposed Statement on the Ethics of
Telemedicine (see medical ethics page 91 )
was unanimously approved.
Human Tissue for Transplantations.
A proposed Statement on Human Tissue for
Transplantation was approved unanimous-
ly
Documentation and Denunciation of Acts
of Torture
Dr. Hill asked Britte Sydhoff, Secretary
General of the International Rehabilitation
Council for Torture Victims (IRCTV) to
address the meeting.
Britte Sydhoff, introducing the IRCTV as
an international NGO said that it was a plea-
sure to stand before the WMA and thank
them for their support. She explained that
the ICRTV had 130 rehabilitation centres in
78 countries.
She was very pleased with the WMA stand
on Torture, as exemplified by the Tokyo and
Hamburg Statements. The proposed
improvements in the Statement on
Documentation of Torture constituted a
strong supplement to the existing statement.
The need for proof of torture is vital and
specific training in how to note and provide
such documentation is important, as physi-
cians do not know how to do this. She com-
mented that often victims are detained until
the evidence is gone.
The Istambul Protocol and Guidelines help
in producing good reports to be used in
court. IRCTV is carrying out advocacy and
training activities and she stressed that
Prevention through documentation can help
both the Health and Legal professions. The
collaboration of National Medical
Associations has been a real part of the suc-
cess of the training about the Istambul
Protocol.
Dr. Hill thanked the IRCTV for its work and
cooperation, in which Dr. Snaedel had been
deeply involved.
The proposed revision of the WMA
Resolution on the Responsibility of
Physicians in the Documentation and
Denunciation of Acts of Torture or Cruel or
Inhuman or Degrading Treatment (see
Medical Ethics p. 92) was approved unani-
mously.
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105WMJ 53, December 2007
WMA
Socio-Medical Affairs
Dr. Hill put to the Assembly the following
recommendations arising from the Socio-
Medical committee business:
Noise Pollution
The proposed revision of the WMA
Statement on Noise Pollution was adopted
unanimously.
Family Planning and Right to
Contraception
The WMA Statement on Family Planning
and the Right of a woman to Contraception
was adopted.
Health Hazards of Tobacco Products
The proposed Statement on Health Hazards
of Tobacco Products (see page 95) was
adopted unanimously.
Dr. Hill announced that in the Spring, an
exciting new project on Tobacco will be
announced.
Health and Human Rights Abuses in
Zimbabwe
The proposed Resolution on Health and
Human Rights Abuses in Zimbabwe (see
Human Rights (see page 94).
The rest of the Council report was
approved.
Associates Meeting
In the absence of the Chair, Dr. DuMont,
Dr. D. Johnson gave the report of the
Associate’s meeting. He indicated that there
were very spirited discussions although
only one Resolution was adopted. This was
a Statement on “Ethical Principles for
Research on Child Subjects” which, it
requested, should be referred to Council for
processing.
Dr. J. Appleyard who had made the original
proposal said he appreciated the support of
the Associates’ meeting in referring it to the
Assembly with the suggestion of referral to
Council. He also urged the Assembly and
NMAs to take this matter forward. It was
parallel to Helsinki and reflected the con-
cern about child subjects and research in
America, Europe and Japan.
The Chair drew attention again to the rec-
ommendation that this be referred to
Council and Dr. Kloiber commented that it
could be considered by Council at its post-
Assembly meeting and then be processed.
The proposal that the Statement be referred
to Council for processing was approved.
Dr. Johnson further reported that the
Associates meeting had appointed two rep-
resentatives and deputies to the Assembly
expressed the hope that this would be to the
advantage of the Associates, requesting that
their role be examined when the analasys
Associates’ Membership is considered The
report was adopted.
Open session
Dr. Siguero wished to propose a resolution
that the writing of prescriptions must be
limited to physicians. He was concerned
that with pending elections in Spain the
nurses asked that they might prescribe.
Currently there was a fear of a nurses strike
and Dr. Siguero pointed out that the
International Council of Nurses supported
the concept of nurse prescribing. He con-
siders that prescribing must be limited to
physicians exclusively, as only physicians,
because of their education, can diagnose
and ensure the quality of the appropriate
drug prescription. Only the qualified physi-
cian has the knowledge of both the appro-
priate drug and of the risks associated with
their prescription. He appealed to the
WMA to defend the right to prescribe for
physicians. There was a need to appeal to
health authorities to ensure this through
appropriate legislation. Dr. Nathansen
(UK) said that a number of physician’s sup-
port nurse prescribing from a Limited List
and that the UK is about to move to nurse
prescribing from the National Formulary.
The BMA is opposed to this. There is a
need for very great care in the drafting of
legislation to ensure that the intended nurse
prescribing is restricted to a Limited
Formulary. There are many problems
which are related to “Task Shifting”.
Prescribing by non-physicians is a world
wide trend. WMA must express its posi-
tion, we have generally enough physicians
to deal with prescribing needs.
Dr. Letlape considered the matter to be very
complex. It would be difficult to produce a
resolution to cover the whole area of needs
for prescribing, as we have to consider the
challenges of areas in which there are no
qualified physicians and patients need care
there; people are specially trained to diag-
nose and prescribe in such areas.
The responsibilities which go with prescrib-
ing need to be included in the training. The
President, Dr. Snaedel, thanked the Spanish
Medical Association for raising this issue.
While Dr. Nathansen had indicated that “the
ball was lost”, he felt that it was not lost – we
can dialogue with the professions and rele-
vant authorities. The International Federation
of Pharmacists was looking at this issue and
we must dialogue with them. The matter
would be on the agenda of Council.
Dr. Haikerwal (Aust) expressed sympathy
for Spain, stating, however, that” the train
has moved on”. In Australia physicians,
nurses and optometrists are moving in this
direction. Dialogue is vital. Task substitu-
tion must be avoided and medical supervi-
sion was essential in any such job substitu-
tion. Dr. Mckie (Canada) reported that in
Alberta and some other provinces, allied
health professionals have the right to pre-
scribe. The Alberta Medical Association set
out generic guidelines for allied health pro-
fessionals including provisions on conflict
of interest. There was a need to ensure ade-
quate records. Collaborative care was based
on the skills of the provider. The CMA
would provide further information to the
WMA. A speaker from the Japanese delega-
tion agreed with others that this was a fun-
damental issue. Dr. Montgomery (Germany)
agreed with others that the train had left. He
felt that the Ministry of Health was using
this concept as a means of breaking down
physicans’domination. While he understood
the situation in some countries he felt that a
Council Working group should be set up.
The Adminstrators think that by using this
mechanism they will save money. Dr.
Lemye (Belg.) also agreed that “the train
had left”. Such extension of the right to pre-
scribe could be useful in, for example,
Disaster Medicine, but these powers should
be provided by the use of exemption mech-
anisms. Governments, however, do not only
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WMA
106 WMJ 53, December 2007
consider the lack of qualified physicians as
the problem. but also look at curtailing the
prerogatives of physicians. Dr. Figueredo
(Uraguay) supported this. There was no lack
of qualified physicians in South America but
nevertheless the other health professionals
were being used to treat some sections of the
population even where patently there were
enough physicians, and he proceeded to
quote a case illustrating this situation.
Dr. Blachar (IMA and President-elect) felt
the situation to be both fundamental and
threatening. He strongly supported setting
up a Working Group to produce a paper for
the May meeting of Council.
Dr. Siguero (Spain) thanked contributors
for their support and said that he supported
Dr. Montgomery’s proposal. He had a feel-
ing that some physicians were helping the
train to leave! There was no lack of quali-
fied physicians in Spain, politics and some
professionals were behind this move. WHO
should not be promoting it.
Dr. Hill said this had been a good debate
and the issue would be placed on the
Council agenda.
Dr. Sabilli (Philippines) referred to a recent
television broadcast in which comments
were made about Philippine doctors in
derogatory chauvinistic terms. He pointed
out that his country was spending its own
money training physicians who then went
abroad to assist in providing healthcare. At
the same time, he thanked those countries
who had assisted his country with sec-
ondary care. However he appealed to other
NMAs to assist in stopping the derogatory
remarks being made suggesting that diplo-
mas of Philippine physicians could not be
checked etc. Such remarks were deplorable.
Philippine physicians are asking for an
apology from those who do this.
Dr. Hill assured the speaker that the AMA
had found the TV statement distasteful.
Yesterday the AMA had approached the TV
programme supporting the Philippine
Doctors in their desire for an apology.
Dr. Chan (Hong Kong) thanked Dr. Kloiber
for supporting a small survey on the regula-
tion of the Profession in South East Asia and
welcomed the article on Medical
Professional in the WMJ. He would like it to
be translated into other languages, notably
Chinese, and would also like it to be fol-
lowed up by a survey, perhaps by other
NMAs, concerning the right to prescribe. He
also felt that it would be most helpful if we
could see the results of follow-up of
Resolutions and Statements issued by WMA.
Finally he suggested that the effects of air
pollution should be studied in the profession,
both in developed and developing countries
considering that this would also need both
mid and long term surveys.
The Secretary General commented that
there were strict limitations on what WMA,
with a limited staff of seven could do.
Speaking of Resolutions and Statements
etc, he said that implementation was in the
hands of NMAs. Developing this he said
would like feedback, giving as examples:
a) Work on Task-shifting. (He had been
asked by WHPA to seek this.)
b) Discussion of the White Paper on
Regulation (WMJ 53(3) p. 58).
Dr. Kloiber then referred to the forthcoming
WHPA conference next year on
International Regulation of Health
Professions. It was essential that we achieve
a common understanding on Self
Regulation. Some of the problems he had
reported to the WHO. NMAs must also take
up this issue. At the Chief Executive
Officer’s conference concerns over issues
of regulation and licensing were expressed
and he was looking to NMAs to act on this.
Dr. Hill, closing the session, thanked all
those who had contributed to what had been
a very valuable session.
General Assembly – 2008
Dr. Shin then presented a film on Korea and
the forthcoming General Assembly, 15-18
October 2008, thanking WMA for agreeing
to come to Seoul and extending a warm
invitation to delegates to go to Korea.
Closure
There being no other business the
Secretary General, Dr. Otmar Kloiber,
expressed his appreciation of the support
received from NMAs, notably in paying
their Dues on time. He said that the change
in the Dues structure had gone smoothly.
We have never had such strong representa-
tion from some parts of the world. We need
to continue to strengthen this. In thanking
NMAs, he particularly mentioned the out-
standing commitments of Japan and of
India in responding to the increases in
dues. He expressed warm thanks to all
NMAs who had supported projects on
Advocacy including the AMA and the
BAK, also the DMA for acting as hosts to
the Assembly – observing that this impos-
es costs on the host NMAs. He reminded
the Assembly that the WMA office was a
small one and had to depend on members
for support.
Turning to direct support, he particularly
mentioned the CMA’s engagement in
Advocacy, Information Technology, and
Ethics. He continued that, while it was
not possible to identify all contributions,
he had to mention the Officers, Chairs of
committees etc and the Chair of Council –
all of whom contribute a great deal. The
BMA, Norwegian MA, SAMA and BAK
had all supported projects or given techni-
cal support, such as the legal advice pro-
vided by the Israel MA. Finally, he
thanked most warmly Dr. Jensen and his
Vice Chair Dr. Buhl, the DMA and its
staff for the splendid organisation,
arrangements and hospitality we had
experienced during the meeting in
Copenhagen.
Dr. Hill finally gave a warm thanks to the
interpreters and to delegates for all their
enthusiasm and hard work and formally
closed the Assembly.
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WMA
107WMJ 53, December 2007
The Chairman, Dr. Hill opened the meeting
with business arising from the General
Assembly and sought the views of Council
on the subject of “task shifting” which was
a matter of major concern to NMAs. He
said that there were considerable differ-
ences in the degree to which this was occur-
ring in different parts of the world and
called for expressions of interest in mem-
bership of a working group on this topic.
Prof. Nathanson was interested, in particu-
lar because this was a matter of special
importance in the UK and members from
Canada, Israel, Belgium, Germany,
Norway, Brazil, Korea, Spain, Iceland indi-
cated an interest. After the Chair pointed
out that working groups were limited to six
members and it was agreed that the Chair
would select the group of six.
Dr. Davis (AMA) wondered whether it was
too late to set up a working group. Had the
train not already left the station?
Council considered a proposed Statement
on “Research and Children” from the
Associates’ group, referred to the Council
by the Assembly. Dr. Kloiber pointed out
that the Assembly’s wish was that this be
referred to NMAs, was there a need for a
working group? Dr. Nathanson said that this
was an important area, it overlapped
Helsinki. She wondered whether there
should be a self – standing group or that this
be included in the Helsinki group remit. Dr.
Appleyard, a Past President, who had made
the original proposition agreed that this was
important -a feeling which was reflected at
the Associates’ meeting. Helsinki was an
“umbrella” declaration. The concerns about
children were difficult to incorporate in
Helsinki. The proposal was specifically
geared to the needs of children it would not
interfere with Helsinki. He would welcome
this going to NMAs for their comments and
178th
WMA Council Meeting
178th
Council took place in the Marriott Hotel, Copenhagen on 6th
October 2007
also for them to take this forward”. Dr.
Bagenholm, Chair of Ethics, thought that
this should be a separate statement,
although it might eventually be part of
Helsinki. She supported its referral to
NMAs for their comments.
The Council agreed that the proposed state-
ment should be circulated to NMAs for
their views and that the Helsinki working
group should co-ordinate the comments of
NMAs for the next Council meeting.
Amongst the views expressed there
appeared to be a consensus that the state-
ment should be a separate one but should be
linked to the Helsinki Declaration.
Dr. Williams (Ethics consultant) said that
the issue had not been dealt with adequate-
ly in Helsinki up to the present. Now there
was a new interest in research ethics.
Helsinki set out the principles but WMA
did not want to go any further than that. It
was a question of why stop here with chil-
dren? Suggestions had been received
which included vulnerable populations,
concerns about women etc – would we not
be asked to include the aged and deprived
populations? Dr. Hill expressed his per-
sonal view that the issues relating to chil-
dren were really different. Dr. Kloiber
pointed out that the request before Council
was whether to include something, exclude
it or include other areas. The Working
Group could come back with a considered
view, taking into account the views of
NMAs.
Mr Tholl pointed out that the Canadian
Medical Association already had a state-
ment. The issue could go into Helsinki or,
as in Canada, be a separate document. It
should be left to the working group to come
forward with a suggestion.
Dr. Bagenholm felt that it might be better to
have separate working groups rather than
making Helsinki larger while Dr. Vilmar
considered that we should concentrate on
children first. We “lack knowledge about
research in children. It might in the end
have to be taken up in the general review”.
In response to a call by Dr. Hill, expressions
of interest in working on this were made by
Israel,Brazil, Canada, South Africa and the
UK.
Under Any Other Business, Dr. Hakerwal
(Aust) raised the issue of corporate gover-
nance. He asked who were directors –
which countries? Dr. Hill said that WMA
was a USA state registered organisation and
that Council members are directors.
Dr. Plested (AMA) referred to the new
advocacy adviser’s contract needed for the
new Advocacy position, which would have
to be in France. He pointed out that if the
person was hired in another country this
might be illegal in France. He wondered
whether it would be possible for a third
member association to do the hiring or if he
could be made a 90 day adviser, as we have
to use French rules. Dr. Davies queried
whether he could be hired in Geneva, or an
NMA could second someone.
Dr. Kloiber indicated that similar problems
would arise in Geneva as in France and that
he had sought legal advice on how to deal
with the employment in the most efficient
and legal manor
Finally the Council considered how the
WMA in its activities could be more inclu-
sive and how the Associate members could
participate in a more productive way..The
Chair said that he would look into all issues
concerning the Associates, and refered to
the valuable Open Session of the Assembly
which we had experienced earlier. In the
absence of any other business the meeting
was closed.
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WMA / WHO
108 WMJ 53, December 2007
Inter-professional training seminar on infection control in South Africa
Health care workers safety in the context of drug resistant TB in low and middle-income countries
The World Medical Association (WMA)
initiated together with the International
Council of Nurses (ICN), the International
Hospital Federation (IHF) and the
International Federation of Red Cross and
Red Crescent Societies (IFRC)/South
African Red Cross Society, members of the
Lilly MDR-TB Partnership, a workshop in
Cape Town, South Africa, on health care
worker safety and infection control, in the
context of drug-resistant TB in low and
middle income countries. The 2-day work-
shop,12-13.November 2007, brought
together South African community support
workers, hospital managers, nurses and
physicians working in the context of drug-
resistant TB to jointly examine and address
these issues. This common seminar for all
four health care professions was the first
one held in South Africa.
Given the already critical shortage of health
providers and the generally weak health sys-
tems in the regions most affected by XDR-
TB and MDR-TB, particularly in southern
Africa, anxiety about safety in the health
care environment runs high and can dis-
suade health providers from accepting
assignments in these settings. The workshop
programme, therefore addressed administra-
tive, environmental and personal respiratory
protection with the objective of identifying
good practices and challenges to the imple-
mentation of joint recommendations for
facilities and health workers It drew up rec-
ommendations for implementing guidelines
in their hospitals and suggested establishing
a common working group with a plan of
action to communicate the identified prac-
tices and recommendations.
WHO publishes new standard for documenting
the health of children and youth
GENEVA/VENICE – WHO published the
first internationally agreed upon classifica-
tion code for assessing the health of chil-
dren and youth in the context of their stages
of development and the environments in
which they live.
The International Classification of
Functioning, Disability and Health for
Children and Youth (ICF–CY) confirms
the importance of precise descriptions of
children’s health status through a methodol-
ogy that has long been standard for adults.
Viewing children and youth within the con-
text of their environment and development
continuum, the ICF–CY applies classifica-
tion codes to hundreds of bodily functions
and structures, activities and participation,
and various environmental factors that
restrict or allow young people to function in
an array of every day activities.
The rapid growth and changes that occur in
first two decades of life were not sufficient-
ly captured in the International
Classification of Functioning, Disability
and Health (ICF), the precursor to the
ICF–CY. The launch of the ICF–CY
addresses this important developmental
period with greater detail. Its new standard-
ized coding system will assist clinicians,
educators, researchers, administrators, poli-
cy makers and parents to document and
measure the important growth, health and
development characteristics of children and
youth.
Children who are chronically hungry,
thirsty or insecure, for example, are often
not healthy and have trouble learning and
developing normally. This classification
provides a way to capture the impacts of the
physical and social environment so that
these can be addressed through social poli-
cy, health care and education systems to
improve children’s well-being.
“The ICF-CY will help us get past simple
diagnostic labels. It will ground the picture
of children and youth functioning and dis-
ability on a continuum within the context of
their everyday life and activities. In this
way it enables the accurate and constructive
description of children’s health and identi-
fies the areas where care, assistance and
policy change are most needed,“ said Ros
Madden, Australian Commission on Safety
and Quality in Health Care, and, Chair of
the Functioning and Disability Reference
Group of the WHO Family of International
Classifications (WHO-FIC) Network.
The ICF–CY has important implications
globally for research, standard setting and
mobilizing resources. “For the first time, we
now have a tool that enables us to track and
compare the health of children and youth
between countries and over time,“ said
Nenad Kostanjsek of WHO’s Measurement
and Health Information team. “The
ICF–CY will allow countries and the inter-
national community to take informed action
to improve children’s health, education and
rights, by treating their health as a function
of the environment that adults provide.“
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WHO
109WMJ 53, December 2007
The classification also covers developmen-
tal delay. Children who achieve certain
milestones later than their peers may be at
increased risk of disability. Using this clas-
sification, health practitioners, parents and
teachers can describe these delays precisely
in order to plan for health and educational
needs and frame policy debates. The chil-
dren and youth version of the International
Classification of Functioning, Disability
and Health (ICF-CY) was launched in
Venice, with international praise:
“The publication of the ICF-CY by the
WHO provides, for the first time, a standard
language to unify health, education and
social services for children,“ said Dr.
Margaret Giannini, Director of the Office of
Disability, U.S. Department of Health and
Human Services.
For further information,
please contact:
Lina Reinders
Communications Officer
WHO,
Geneva
Tel.: +41 22 791 1828
Fax: +41 22 791 1967
E-mail: reindersl@who.int
First List of Essential Medicines for Children released –
WHO increases efforts to ensure appropriate medicines for children
WHO launched a new research and devel-
opment campaign entitled “Make
Medicinces Child Size”, launched in
London intensifies efforts to ensure that
children have better access to medicines
which are appropriate for them.
The campaign also coincided with the
release by WHO of the first International
List of Essential Medicines for Children.
The List contains 206 medicines deemed
safe for children and addresses priority con-
ditions. More than half of the medicines
prescribed for children in industrialised
countries are medicines prescribed and
dosed for adults and are not authorised for
children. Lower access to medicines in
developing countries adds to the problems
there.
Dr. Hans Hogerzeil, Director of Medicines
Policy and Standards at WHO emphasized
this saying “A lot more needs to be done.
There are priority medicines that have not
been adapted for childrens’ use or are not
available when needed”.
WHO will also work with governments to
promote changes in their legal and regula-
tion requirements for childrens’ medi-
cines.
Information contact:
WHO Geneva:
Daniela Bagozzi
e-mail: bagozzid@who.int
Projected supply of pandemic influenza vaccine sharply increases
23 OCTOBER 2007 | GENEVA – Recent
scientific advances and increased vaccine
manufacturing capacity have prompted
experts to increase their projections of how
many pandemic influenza vaccine courses
can be made available in the coming years.
Last spring, the World Health Organization
(WHO) and vaccine manufacturers said that
about 100 million courses of pandemic
influenza vaccine based on the H5N1 avian
influenza strain could be produced immedi-
ately with standard technology. Experts
now anticipate that global production
capacity will rise to 4.5 billion pandemic
immunization courses per year in 2010.
“With influenza vaccine production capaci-
ty on the rise, we are beginning to be in a
much better position vis-à-vis the threat of
an influenza pandemic,“ Dr Marie-Paule
Kieny, Director of the Initiative for Vaccine
Research at WHO, said today. „However,
although this is significant progress, it is
still far from the 6.7 billion immunization
courses that would be needed in a six month
period to protect the whole world.“
“Accelerated preparedness activities must
continue, backed by political impetus and
financial support, to further bridge the still
substantial gap between supply and
demand,“ she said.
This year, manufacturers have been able to
step up production capacity of trivalent
(three viral strains) seasonal influenza vac-
cines to an estimated 565 million doses,
from 350 million doses produced in 2006,
according to the International Federation of
Pharmaceutical Manufacturers &
Associations. According to experts working
in this field, the yearly production capacity
for seasonal influenza vaccine is expected
to rise to 1 billion doses in 2010, provided
corresponding demand exists.
This would help manufacturers to be able to
deliver around 4.5 billion pandemic
influenza vaccine courses because a pan-
WMJ_4_85-112.qxd 10.01.2008 11:53 Seite 109
WHO
110 WMJ 53, December 2007
demic vaccine would need about eight times
less antigen, the substance that stimulates
an immune response. Vaccine production
capacity is linked to the amount of antigen
that has to be used to make each dose of the
vaccine. Scientists have recently discovered
they can reduce the amount of antigen used
to produce pandemic influenza vaccines by
using water-in-oil substances that enhance
the immune response.
The progress was reported at the first meeting
of a WHO Advisory Group on pandemic
influenza vaccine production and supply. The
Global Action Plan Advisory Group, an inde-
pendent, international committee of 10 mem-
bers, met at WHO headquarters one year after
eight new strategies to increase pandemic
influenza vaccine were identified and pub-
lished in the WHO Global pandemic influen-
za action plan to increase vaccine supply.
At the Advisory Group meeting, other
progress on the Global Action Plan was dis-
cussed. WHO reported it is setting up a
training hub that would serve as a source of
technology transfer to developing countries.
The Advisory Group also discussed a new
business plan which assessed options for
further increasing vaccine production
capacity and reviewed priority next steps.
The three most valuable options include
continuing to promote seasonal influenza
vaccine programmes, supporting the indus-
try to sustain production capacity beyond
seasonal demand and enabling some vac-
cine production facilities to change, at the
onset of a pandemic, from producing inacti-
vated vaccines to live attenuated vaccines.
Due to the higher yields obtained with live
attenuated influenza vaccine technology,
facility conversion could, by 2012, bridge
the expected supply-demand gap and pro-
duce enough vaccine to protect the global
population within six months of the declara-
tion of a pandemic.
For further information, please contact:
Hayatee Hasan
Department of Immunization, Vaccines and
Biologicals
WHO, Geneva
Tel.: +41 22 791 2103
Mobile: +41 79 351 6330
hasanh@who.int
Protecting health from climate change – World Health Day 2008
WHO has announced that the topic for
World Health Day 2008 will be “Protecting
Health from climate change”. Sixty years
ago WHO was founded as part of the inter-
national commitment to build global secu-
rity and peace In the same spirit of univer-
sal solidarity, WHO is seeking to unite the
nations of the world in combating the threat
to public health safety from climate
change.
In parallel with the increasing international
emphasis on the need to place the reduction
of environmental climate change high on
the international agenda to maintain sus-
tainable development, the need to also
address the environmental effects on public
health is essential. Dr. Chan, Director
General of WHO comments “Health profes-
sionals are on the front line in dealing with
the impacts of climate change. The most
vulnerable populations are those who live in
countries where the health sector already
struggles to prevent, detect, control and
treat diseases and health conditions includ-
ing malaria, malnutrition and diarrhoea.
Climate change will highlight and exacer-
bate these weaknesses by bringing new
pressures on public health, wit h greater fre-
quency.”
She added “We need to put public health at
the heart of the climate change agenda. This
includes mobilising governments and stake-
holders to collaborate on strengthening sur-
veillance and control of infectious diseases,
safer use of diminishing water supplies, and
health action in emergencies”.
On World Health Day, 7th
April 2008, mark-
ing the Sixtieth anniversary of the World
Health Organisation, communities and
organisations around the world will host
activities to create greater awareness and
public understanding of the health conse-
quences of climate change and the impact
and interdependency of health with other
measures taken to reduce and control the
effects of climate change in policy deci-
sions and policies taken at national and
international level.
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Review
111WMJ 53, December 2007
New Internet course on multidrug-resistant tuberculosis MDR-TB
Multi Drug Resistant Tuberculosis is difficult to treat and knowledge about it is scattered around the world. Thanks to WHO there
is not only a strategy to treat tuberculosis the “DOT Strategy” but now there are also WHO guidelines on how to prevent and treat
MDR-TB using the existing evidence in the world.
Guidelines however are theoretical knowledge that doesn’t easily transfer into practice in the real world. The WMA therefore volun-
teered, together with its member organizations, the South African Medical Association, the Norwegian Medical Association, to pro-
duce a learning programme for the MDR-TB Guidelines and offer it electronically though the Internet.
This course is a free self-learning tool allowing physicians in all parts of the world to learn and test their knowledge about MDR-TB
using the Internet. The Foundation for Professional Development of South Africa wrote the learning programme, which subsequent-
ly has been reviewed by an international advisory committee and then transformed into an Internet-based course by the Norwegian
Medical Association. A first testing phase with an evaluation was implemented in South Africa. The CME accredited MDR-TB online
training course is now accessible from the WMA web page www.wma.net.
The course is free of charge and is available in English. Soon it will be translated into French, Spanish, Chinese and Russian.
Review
Human Rights and Prisons – a training programme on
human rights for prison officials
Professional Training Series No. 11, UN Publications, UN New York and Geneva 2005, ISBN 92-1-15416-3
Prisons are places where a higher propor-
tion of people with significant physical and
mental health problems are incarcerated,
but also where the health care they receive
is likely to be substandard. Pressures on
medical staff, lack of funding, uncertainty
about the ethical duties of doctors and the
potentially restrictive attitude of prison gov-
ernors can all reduce access to good quality
and impartial healthcare.
Although the rights of prisoners, and the
duties of those who supervise them are well
established, and comprehensively set out in
a variety of declarations, treaties, covenants
and conventions, these are often poorly
understood by prison officials. Either they
are not seen as applicable to a particular
institution, or inflexible procedures that
undermine human rights are not reviewed
or changed.
It is therefore welcome that the European
Regional Office of WHO has published a
modular course on human rights training for
people who have a responsibility for
detainee care. While its focus is prison
detention, it is equally applicable to other
forms of custody, such as police stations
and detention centres. It has direct rele-
vance to doctors, but unfortunately does not
suggest that prison medical staff, who are
often as much in need of human rights and
ethics teaching, should be exposed to the
principles that the document promotes.
Designed in modular form, and backed by a
manual, listing standards, sources and sys-
tems, a compilation of relevant human
rights instruments, and a condensed pocket
guide, the training is designed to be deliv-
ered over a period of five days. While aspir-
ing to a variety of aims, a key purpose is to
equip students with a broad knowledge of
human rights practice in relation to prisons,
and to relate these to their day-to-day expe-
rience. An important and measurable out-
come must be to change attitudes, so that
prejudice is replaced with an understanding
of the need to protect the dignity of the vul-
nerable.
Much of the success of the courses that are
based on these documents will depend on
the quality of those delivering the training.
It is not suggested that these should include
doctors, and this is a gap that should be
filled, since the relationship between doc-
tor, prisoner and institution is fertile ground
for highlighting human rights and ethical
dilemmas that are real and practical.
Through their relevance and familiarity
they can provide a good basis for the group
discussions that form a major part of the
training.
The section on health is adequate, but not
fully complete. There is little reference to
assessment of self-harm risk – a major
cause of death in custody being suicide –
and the monitoring of prisoners with psy-
*
* This is the first of two reviews on Prison
Health. The second will review a recent
publication by the WHO European Office
on Health in Prisons and will appear in
the next issue WMJ 54 (1).
WMJ_4_85-112.qxd 10.01.2008 11:53 Seite 111
Review / Letter
112 WMJ 53, December 2007
chiatric problems. In any prison in the
world, there will be a relatively high pro-
portion of inmates with alcohol and/or drug
dependence, and a range of psychiatric dis-
orders. Prison staff can be very influential
in helping patients to develop a willingness
to address their addiction, and more could
be taught on the often simple and accessible
services that prisons can provide. Alcohol
and drug misuse are common causes of
recurrent, often petty crime, and more
understanding about the nature of the dis-
ease of addiction, and the capacity for the
addict to change, would be welcome. The
sections on drug misuse are written in disci-
plinary, rather than therapeutic terms.
Backed by high-level declarations, and
written in the language of rights, the start-
ing point for the training module on health
is that prisoners, like other members of their
society, deserve access to the highest avail-
able standard of health. Given that a prison
population is disproportionately unhealthy,
and that resources, particularly in secondary
care are limited, the realisation of that right
is often a distant aspiration. Prison staff
who carry an attitude that equates a loss of
liberty with a removal of basic rights, add
fuel to the fires of resentment and stigmati-
sation, thereby increasing a sense of help-
lessness in those for whom they are respon-
sible. An institution run on principles that
acknowledges rights is more likely to be
one in which staff have a higher level of
work satisfaction and esteem. Training in
human rights may not turn them into advo-
cates for change, but may help them to
operate in a way that promotes decency and
dignity.
For doctors who access the training manual,
there is much to challenge attitudes that in
my experience have developed more as a
result of a lack of knowledge than through
outright discrimination. Prison medical
staff frequently assume that the “dual rela-
tionship” that exists in their specialty (and
in others), implies a reduction in their fun-
damental medical ethical duties. While the
need to consider the interests of the prison
is ever-present in the doctor’s mind, it
should only rarely lead to breaches of con-
sent and confidentiality. A relationship of
trust between the detained patient and the
doctor has therapeutic value, allowing the
doctor more opportunities to provide care,
along with reassurance that confidentiality
will usually be kept.
Welcome elements in the training package
are the need for prisoners to undergo a med-
ical examination as soon as possible after
arrival, respect for cultural beliefs, and the
risks that HIV/AIDS sufferers will be iso-
lated through ignorance and fear of infec-
tion. However, more could be said about the
need to be alert to signs of abuse and inap-
propriate restraint measures, and on the
duty of medical staff to report abuse.
Doctors have the benefit of independence
and an ethical duty to report abuse, so are
well-placed to speak out when they
encounter abusive behaviour. They also
have an obligation to record, not just the
nature of the abuse and the injuries sus-
tained, but also the action they take as a
result.
The training manual will not help doctors
looking for more certainty on the issue of
gross abuse. Definitions of torture and
degrading treatment are not sufficiently
robust or clear, leaving the student in some
doubt as to where the involvement of a doc-
tor begins and ends. While there is a clear
condemnation of physician involvement in
torture, current examples such as force-
feeding and the provision of advice on
interrogation should be illustrated. At a time
when the ethical duties of doctors have been
redefined in the interests of national securi-
ty, these contemporary situations deserve
more reflection.
An essential part of training is evaluating its
effect, and the course recognises that this
should be built in over the long-term, using
attitudes and system change as key markers
of progress. As the manual states, there is a
lot more to the teaching of human rights
than a “lecture and a wave”. Participants
need to be challenged, and their attitudes
and behaviour changed, if our prisons are to
become more humane places.
Michael Wilks
Michael Wilks is a forensic physician, and
Chairman of the Rehabilitation of Addicted
Prisoners Trust in the UK. He is President
of the Standing Committee of European
Doctors (CPME) for 2008/9.
Letter
Correspondence
Hon. Editor
World Medical Journal
Sir,
The September 7th
, 2007 issue of the
Medical Journal of the World Medical
Association is carrying a story about “pre-
sumed Consent” for the removal of organs
from dead for transplantation.
The U.K. Chief Medical Officer, Sir Liam
Donaldson is quoted as saying that the prac-
tice of “presumed Consent” would increase
the number of organs available for trans-
plantation to the betterment of the health of
the recipients.
I am troubled by the apparent violation of
the first tenet of the Nuremberg Code of
Medicas Ethics which clearly states that
“Freely Given Informed Consent” is the
sine quo non of all activities by physicians
in dealing with patients.
I would suggest that this practice be stopped
immediately.
I would also suggest that physicians all over
the world should sign the donor card and
carry it in their wallets and stipulate to their
loved ones that they want their organs har-
vested for transplantation.
Unless we, physicians show by example the
importance of the donation of organs there
is little chance that there will ever be
enough organs available to help the living.
Michael J. Franzblau MD, FAAD
Clinical Professor of Dermatology
(emeritus)
University of California
WMJ_4_85-112.qxd 10.01.2008 11:53 Seite 112
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
Carrera 7 N° 82-66, Oficinas 218/219
Santafé de Bogotá, D.E.
Tel/Fax: (57-1) 256 8050/256 8010
E-mail: federacionmedicacol@
sky.net.co
DEMOCRATIC REP. OF CONGO F
Ordre des Médecins du Zaire
B.P. 4922
Kinshasa – Gombe
Tel: (243-12) 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: hlz@email.htnet.hr
Website: www.hlk.hr/default.asp
CZECH REPUBLIC E
Czech Medical Association
J.E. Purkyne
Sokolská 31 – P.O. Box 88
120 26 Prague 2
Tel: (420-2) 242 66 201-4
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 91/Fax-794
E-mail: fma@fimnet.fi
Website: www.medassoc.fi
FRANCE F
Association Médicale Française
180, Blvd. Haussmann
75389 Paris Cedex 08
Tel/Fax: (33) 1 45 25 22 68
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) 400-456 369/Fax: -387
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, Chi-
naDuke 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 – PO.Box 145
1443 Budapest
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) 23370009/23378819/
23378680
Fax: (91-11) 23379178/23379470
E-mail: inmedici@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) 676-7273Fax: (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: doritb@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
Website: www.lgs.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
MACEDONIA E
Macedonian Medical Association
Dame Gruev St. 3
P.O. Box 174
91000 Skopje
Tel/Fax: (389-91) 232577
E-mail: mld@unet.com.mk
MALAYSIA E
Malaysian Medical Association
4th Floor, MMA House
124 Jalan Pahang
53000 Kuala Lumpur
Tel: (60-3) 40413740/40411375
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Association and address/Officers
iii
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. D-107
Colonia Deportivo Obispado
Monterrey, Nuevo Léon
Tel/Fax: (52-8) 348-41-55
E-mail: rcantum@doctor.com
Website: www.cmm-fenacome.org
NAMIBIA E
Medical Association of Namibia
403 Maerua Park – POB 3369
Windhoek
Tel: (264) 61 22 44 55/Fax: -48 26
E-mail: man.office@iway.na
NEPAL E
Nepal Medical Association
Siddhi Sadan, Post Box 189
Exhibition Road
Katmandu
Tel: (977 1) 4225860, 231825
Fax: (977 1) 4225300
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) 492 4179
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@cwpanama.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@cmp.org.pe
Website: www.cmp.org.pe
PHILIPPINES E
Philippine Medical Association
PMA Bldg, North Avenue
Quezon City
Tel: (63-2) 929-63 66/Fax: -6951
E-mail: medical@pma.com.ph
Website: www.pma.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: intl@omcne.pt
Website: www.ordemdosmedicos.pt
ROMANIA F
Romanian Medical Association
Str. Ionel Perlea, nr 10
Sect. 1, Bucarest
Tel: (40-1) 460 08 30
Fax: (40-1) 312 13 57
E-mail: AMR@itcnet.ro
Website: ong.ro/ong/amr
RUSSIA E
Russian Medical Society
Udaltsova Street 85
119607 Moscow
Tel: (7-095)932-83-02
E-mail: info@rusmed.ru
Website: www.russmed.ru
SAMOA E
Samoa Medical Association
Tupua Tamasese Meaole Hospital
Private Bag – National Health Services
Apia
Tel: (685) 778 5858
E-mail: vialil_lameko@yahoo.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
www.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
SOMALIA E
Somali Medical Association
14 Wardigley Road – POB 199
Mogadishu
Tel: (252-1) 595 599
Fax: (252-1) 225 858
E-mail: drdalmar@yahoo.co.uk
SOUTH AFRICA E
The South African Medical Associa-
tionP.O. Box 74789, Lynnwood Rydge
0040 Pretoria
Tel: (27-12) 481 2036/2063
Fax: (27-12) 481 2100/2058
E-mail: sginterim@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 – C.P. 170
3000 Berne 15
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
Tel: (886-2) 2752-7286
Fax: (886-2) 2771-8392
E-mail: intl@med-assn.org.tw
Website: www.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: www.medassocthai.org
TUNISIA F
Conseil National de l’Ordre
des Médecins de Tunisie
16, rue de Touraine
1002 Tunis
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
Sehit Danis Tunaligil Sok. N° 2 Kat 4
Maltepe 06570
Ankara
Tel: (90-312) 231 –3179/Fax: -1952
E-mail: Ttb@ttb.org.tr
Website: www.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 Città del Vaticano
00120 Città del Vaticano
Tel: (39-06) 69879300
Fax: (39-06) 69883328
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 Medical Association
(VGAMP)68A Ba Trieu-Street
Hoau Kiem District
Hanoi
Tel/Fax: (84) 4 943 9323
ZIMBABWE E
Zimbabwe Medical Association
P.O. Box 3671
Harare
Tel: (263-4) 791553
Fax: (263-4) 791561
E-mail: zima@zol.co.zw
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