WMJ 01 2008

Hon. Editor in Chief
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suffolk IP143QT
UK
Editor in Chief
Dr.Pēteris Apinis
Latvian Medical Association
Skolas iela 3,
Riga, Latvia
Phone +371 67 220 661
peteris@nma.lv
Co-Editor
Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte- Verlag
Dieselstr.2
D-50859 Köln
Germany
Assistant Editor
Dr. Ilze Hāznere,
Pilsoņu iela 13, Riga, Latvia
ilzehaz@inbox.lv
Journal design by Jānis Pavlovskis
Cover design by Ilze Ozola
Cover painting „Physician and
Apothecary” by Miervaldis Polis
(Pauls Stradin Museum
of the History of Medicine)
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ISSN: 0049-8122
Dr. Jon SNAEDAL
President
(Iceland)
Dr. Edward HILL
Chairperson of Council
(USA)
Dr. Otmar KLOIBER
Secretary-General
(Germany)
Dr. Yoram BLACHAR
President-Elect
(Israel)
Dr. Nachiappan ARUMUGAM
Immediate Past-President
(Malaysia)
Dr. Kazuo IWASA
Vice-Chairperson of Council
(Japan)
Dr. Eva N. BAGENHOLM
Chairperson of the Medical Ethics
Committee
(Sweden)
Dr. Mukesh HIKERWAL
Chairperson of the Finance and Planning
Committee
(Australia)
Dr. J.L. GOMES DO AMARAL
Chairperson of the Socio-Medical Affairs
Committee
(Brazil)
Dr. Jörg-Dietrich HOPPE
Treasurer
(Germany)
Dr. André WYNEN
Secretary-General Emeritus
(Belgium)
Dr. Karsten VILMAR
Treasurer Emeritus
(Germany)
Dr. Guy DUMONT
Chairperson of the Associate Members
(Belgium)
Official Journal Of The World Medical Association
World Medical Associations Officers
www.wma.net
1
It is a great honor to address you as the new editor of the World
Medical Journal. The World Medical Journal reflects the thoughts
and ideas of physicians from all parts of the world. I invite you to
not only read the Journal, but to be a part of the Journal by filling
it with your manuscripts, illustrations, reviews and opinions. Your
contributions are the heart and soul of the Journal.
First, I would like to take this opportunity to thank Dr. Alan Rowe
and pay special tribute to his longstanding Editorship of the World
Medical Journal. Dr. Rowe’s global perspective of medicine, strong
sense of ethics, wisdom and brilliant literary skills have shaped this
Journal into a truly outstanding publication. His tireless efforts have
left a unique impact on the global medical community and I will do
my best to continue the work he has begun. We are truly grateful to
Dr. Rowe for his long-standing and altruistic work.
As the new editor, I will have the opportunity to communicate with
leaders of medical associations from all parts of the world.However,
I will do more than speak to the leaders of our member organiza-
tions. I will encourage these organizations to use our Journal as a
means of expressing their views and the concerns of their mem-
bers. The national medical organizations in small and developing
countries may not have the resources to pay dues and attend WMA
meetings and conferences. However, they are in our brotherhood –
gens una sumus. I will work with medical organizations in all coun-
tries to engage their active participation in our Journal.
I will also work directly with physicians throughout the world to try
to make the WMJ more personal.I would like to see the Journal be-
come a voice for our colleagues in all countries. Of course, in order
to converse with someone,it is best to be able to see the person’s face
and to look him or her in the eyes. Global organizations can rarely
do this, so I will try to do the next best thing. I will ask you to write
about who you are, what you feel and what you think. What urgent
issues do you face? What are the pressing medical needs in your
country? We will continue our discussions of social, medical, and
ethical issues on national and international levels, but also expand
the discussions to the personal physician level.
Every country has unique medical problems,but often similar issues
exist elsewhere. For example, in Latvia we currently face the predic-
ament that the government is reluctant to increase the excise-tax for
tobacco. Cigarettes can be bought cheaply in Latvia and many tour-
ists come from other countries in order to buy large quantities of
cigarettes.The low price of cigarettes also affects the Latvian people
because there is little financial incentive to stop smoking. The Lat-
vian Medical Association has taken a stand against smoking and has
urged the government to ban smoking while driving. I would like
to know more about your experiences in the struggle to eliminate
smoking.
I will also ask you to write about your national medical association,
organizations and your personal experiences. Each story may be an
etude, opus, or masterpiece. I would like you to send me pictures so
that along with your publication we can show who you are. This is
a good way to get to know one another. Physicians from Somalia
and Vietnam have already answered my first call.Thank you! In our
very next edition we would like to have stories from many other
countries and their medical organizations. Please don’t hesitate to
communicate with me.
As Editor of the WMJ, I will communicate with editors of medical
journals in countries throughout the world. Large countries with
thousands of physicians have multiple weekly and monthly medical
journals which are readily available. Many journals are supported by
advertising and are provided free of charge to every physician. On
the other hand, in small countries where the health-care budget is
constrained, scanty journals are published infrequently and often
are not accessible to every physician. Most of these medical journals
are edited by physicians who are well aware of the problems facing
physicians and patients in their own country. I will pay particular
attention to physician editors and communications from smaller
countries to help highlight local issues. This may help find common
solutions. I will work to provide a forum for a global perspective on
issues that are important to all.
The World Medical Journal is a global publication and as such I
plan to dedicate each issue to one of our member countries. The
cover will depict a symbol or work of art from that country. As you
can see, I have taken the Editor’s prerogative and begun with my
country, Latvia. Our cover shows a panoramic view of Riga, the
capital of Latvia and a painting „Physician and Apothecary”painted
by Latvian artist, Miervaldis Polis.The painting depicts the medical
environment of Riga in the 15th
century.Our next cover will be from
Norway and the following from Somalia.
Dear colleagues! Thank you for allowing me to serve as your editor.
Please join me in working to improve our common bond: the World
Medical Journal.
Dear colleagues throughout the world!
Sincerely yours –
Pēteris Apinis, M.D.
President of the Latvian Medical Association,
Editor-in-Chief of the World Medical Journal
2
Most countries of the world experience a
shortage of health professionals.This has led
to migration – more or less – along a wealth
or payment gradient from East to West,
from North to South. Countries like the
United States Canada or the Scandinavian
countries are now long time net importers
of physicians and other health professionals
(graph 1),while countries in Asia,like India,
China and the Philippines as well as Sub-
Sahara African countries are net providers
of physicians (graph 2). A third group lies
in the middle: immigration and emigration
are strong and in a few cases even balanced
like Germany, the United Kingdom or the
Czech Republic.
While the rich countries report shortages
especially in rural practice, countries in
Sub-Sahara Africa are factually depleted
from physicians. Comparing the density of
physicians in counties of Sub-Sahara Africa
to the density in Europe or North America
makes it clear that the rich countries suf-
fer from a relative, if not a luxury problem,
when compared to the poorest countries in
the world. But does that mean they don’t
have to worry?
Indeed the shortage of physicians espe-
cially in the European Countries and North
America is harmless only on the first look.
Internally the undersupply of health ser-
vices can produce severe tension within the
countries and regions. But more important,
although the relative numbers of physicians
in demand is comparatively low,it translates
into a high absolute number on a global
scale. This produces a pull to the physicians
in poorer countries. What we find is a sig-
nificant percentage of physicians trained in
Africa or Asia showing up to work in the
United States, Canada, West and Central
Europe. The relative shortage of physicians
in the rich countries leads to an absolute
deficit in the poor countries.
However special migration is by far not the
only problem as money is not the only driv-
ing force. When we look to the reasons for
migration (see graph 3) we find remunera-
tion as the first argument, but closely fol-
lowed by a group of other reasons, which
can be summarized under working and
living conditions. And indeed some migra-
tions streams e.g. from Germany to Scan-
dinavia are not being driven by money, but
by chances for a better and more satisfying
work environment, more time for patient
care, more time for the family.
The quantitatively biggest loss to the
work force in Central Europe occurs be-
cause of its demographic shift combined
with a set of recent health reforms that
are driving the traditionally long work-
ing physicians into early retirement. Loss
of professional autonomy, clinical inde-
pendence, a ridiculous and still growing
amount of bureaucracy and financial dis-
incentives make many physicians to give
up early, if they are not young enough to
go away.
Counteracting this by just producing more
physicians doesn’t work either. Germany
produces more physicians than it need. Yet
during the last decade not only the dropout
rate of medical students increased dramati-
cally, even worse, successful graduates don’t
show up in clinical practice. More than a
fifth of those completing medicine either
seek directly positions abroad or go to other
professions.
What can be an answer: The rich health
care systems developed three strategies that
can be summarized under the terms
• Hotlines: don’t provide care – just talk
about it! Certainly people in western
countries want to be served immediate-
ly, hotlines are a demand of our times.
But they are also used to keep patients
away from their physicians.
• Rationing: pretending that higher qual-
ity requires concentration. Disinvest-
ment strategies usually come with ar-
guments of quality. Services have to be
concentrated to get higher numbers and
more proficiency, drugs have to be in-
tensively tested and evaluated over and
over again. Sometimes these arguments
are true, sometimes this is nothing but a
hidden rationing.
• Substitution: “You don’t need a physi-
cian!” More and more medical tasks
are shifted to nurses, midwives, phar-
macists and other health professionals.
Indeed many automated and standard-
ized procedures can be done by others
than physicians and delegation may be
a reasonable way to discharge physician.
In a number of cases even complex pro-
cedures can be done by specially trained
nurses or other professionals. However,
what we currently see in charging nurse
practitioners, pharmacists and others is
nothing else but to downgrade primary
care to a non-professional, because of
non – educated level.
From the Secretary General’s desk
The global Shortage of Health Professionals must concern all of us
Dr. Otmar Kloiber
Secretary-General
(Germany)
3
To a certain extend it works. People feel sa-
tisfied, because they are immediately taken
care of. What they don’t realize is that do-
ing just something often is not enough and
sometimes even dangerous.
When we turn our look to the poorest coun-
tries of the world, it becomes clear that the
substitution of physician and often nurse
capacity is unavoidable. With physician/
population ratios as low a 1/50000 there
is no way that physicians will be available
for all medical services.Task shifting, as the
WHO calls the provision of medical and
nursing services by laypersons, is necessary.
However, as clear as a necessary and un-
avoidable emergency measure WHO wants
to call it first class care.
Laypersons can be trained and guided to
valuable and often high quality care. The
best example of that is the Red Cross/Red
Crescent workforce,which for most of it is a
voluntary lay structure.They do undoubted-
ly a terrific job.However,they are embedded
in a well-structured organization providing
continuous training, guidance, support and
supervision and most of all they work with
clear and strict limits.
For some specific tasks this may be pos-
sible and actually is already being deployed
in several countries. Often with specific
programs and limited to certain tasks. Un-
fortunately people in those countries don’t
only get the diseases for which there are
programs i.e. for HIV/AIDS, tuberculosis,
malaria and river blindness, they get all the
other problems people get: heart infarcts,
mental disorders, rheumatism, injuries and
so on. How lay community workers should
provide a first class care for all those illness-
es and injuries probably will remain a secret.
But worse: If not combined with measures
to invest and strengthen the remaining pro-
fessional workforce Task Shifting will even
drive out the last health professionals.
Of course all those programs are supposed
to be evaluated. But in the past those evalu-
ations have served as justifications tools
looking to exactly what they wanted to
see. No doubt, as long as there is external
money for a task-shifting project on HIV/
AIDS care you will see a decline of mor-
tality from AIDS. But what happens to all
the other medical needs that can’t no longer
be served. What happens to the surround-
ing communities, which may have nothing
left? How sustainable will be a non-paid lay
force when outside support will be gone?
Now, we already see a huge problem in
rise of Multi-Drug-Resistant Tuberculosis
(MDR-TB) and even worse Extended-
Drug-Resistant TB (XDR-TB). And as a
WHO officer correctly analysed: XDR-TB
is nothing else than badly managed MDR-
TB, and MDR-TB is nothing else than
badly managed TB. This gives us a glimpse
preview on what may happen with resis-
tance development to anti-retroviral drugs
in non-professionally structured treatment
programs.
Health care is highly depending on hope
and trust. For patients and those who work
in the system. If hope and trust is missing,
development will not happen. The health
care systems of many countries of this
world are living proof of this. Task shifting
without strengthening the existing health
professional workforce will down-spiral the
health care systems of the poorest countries
even more leading to the exodus of even the
last health professionals.
Graph1:The health care systems of the richnations are strongly depending on immigrant physicians.
(World Health Report 2006)
Graph 2: Many African countries have lost significant parts of their workforce to the rich countries
of the world. (World Health Report 2006)
4
Unfortunately, the rich countries installing
the programs for task shifting in the poor
countries are at the same time the magnets
for migrant physicians. Bringing the work-
force situation of the rich countries in order,
which means in the first place improving
the work and life conditions for the health
professionals is a necessary prerequisite to
help the health care systems of the poor
countries of this world.
Training sufficient numbers of health pro-
fessionals, but also providing well enough
work and living conditions for them is an
urgent demand in rich and poor countries.
And just because of the strong attraction
the rich countries produce, fixing their
workforce problem is no luxury item but a
question of survival for many nations.
Between the yearly sessions of the World
Health Assembly, the “Executive Board”
is the highest steering body of the World
Health Organisation (WHO). From Janu-
ary 21st
to 26th
, 2008 it met in Geneva for
its 122nd
session. The Executive Board
dealt with many technical and health mat-
ters ranging from the pandemic influenza
preparedness, or the Poliomyelitis to the
strategies to reduce the harmful use of al-
cohol and the monitoring of health-related
Millennium Development Goals1
. Some of
which the Health Professions, admitted as
observers to the Session, took a common
stand on.The board recognized the interna-
tional discussion about climate change and
iterated on its effects on human health.
Developing effective health responses to
climate changes
Of particular interest is the resolution on cli-
mate change and health that was adopted by
1 The working documents and adopted resolution of
WHO Executive Board can be downloaded from:
http://www.who.int/gb/
the Board for submission to the World Health
Assembly. The resolution namely recognizes
that “the scientific evidence of the effect of
the increase in atmospheric greenhouse gases,
and of the potential consequences for human
health, has considerably strengthened”2
and
that “reinforcing health systems to enable
them to deal with both gradual changes and
sudden shocks is a fundamental priority in
terms of addressing the direct and indirect ef-
fects of climate change for health”3
.
The Board therefore recommends the World
Health Assembly to take several actions,
such as for WHO Director General to draw
to the attention of the public and policy-
makers of the serious risk of climate change
to global health security and to the achieve-
ment of the health-related Millennium De-
velopment Goals, and, to work with appro-
priate UN organisations and other agencies
in order to develop capacity to assess the
risks from climate change for human health
and to implement effective responses. Dr
2 Preamble, indent 6
3 Preamble, last indent
Margaret Chan, the Director General of
WHO, is also encouraged to consult Mem-
ber States on the preparation of a work plan
for scaling up WHO’s technical support to
Member States in that area.
Voicing health professions’ concerns to
the Executive Board
The World Medical Association’s secretariat
followed closely the Board session and took
an active role together with the other part-
ners in the World Heath Professional Al-
liance4
The WHPA is a unique alliance of
dentists, nurses, pharmacists and physicians
addressing global health issues and striving to
help deliver cost effective quality health care
worldwide. The World Medical Association
represents the physicians in this Alliance.
The WHPA identified three key themes out
of the WHO Board agenda, on which it
4 FDI World Dental Federation, International Council
of Nurses, International Pharmaceutical Federation,
and the World Medical Association – http://www.
whpa.org/
Graph 3: Payment is an important reason for health professionals to migrate, but working and
living conditions are likewise important. (World Health Report 2006)
WHO Executive Board, 122nd
session, 21– 26 January 2008
5
addressed the Executive Board with joint
statements.
• Female genital mutilation, a severe vio-
lation of women’s human rights
In its statement, the Alliance welcomes the
report by WHO secretariat on female geni-
tal mutilation (FGM), noting the slow rate of
decline of these practices,and praises the draft
resolution submitted to the Board for adop-
tion.Because of its serious detrimental impact
on the physical and mental health of women
and girls,female genital mutilation is a matter
of deep concern to health professionals. The
WHPA therefore urges Medical and Nursing
Associations, and invites the support of other
health professions associations, to develop
educational programs that would:
• Include adequate information on the
acute dangers of female genital mutila-
tion for women and girls;
• Raise awareness on such practices as
a severe violation of women’s human
rights that physicians or other health
professionals should never practice un-
der any circumstances,
• Encourage physicians and nurses to in-
form women, men and children about
FGM and discourage them from per-
forming or promoting such practices.
In the end –the members of the Executive
Board could not find a compromise on sev-
eral controversial amendments put forward
by the US delegation.The text will therefore
be submitted – in its current version – to the
World Health Assembly in May.
On the 6th
of February, in a statement to
mark the international day of zero tolerance
to FGM,the WMA repeated its strong con-
demnation of this practice and expressed se-
rious concern about the increasing tendency
for female genital mutilation to be carried
out by medical personnel.
• Addressing the health of migrants from
a human rights’ perspective
While welcoming the initiative from
WHO secretariat in this area, the WHPA
emphasizes in its statement some key issues
that should be addressed by the Board in its
resolution:
• The legal status of migrants, whether
documented or undocumented, consti-
tutes an important health determinant.
Although all migrants are exposed to the
particular trauma of the migration process,
the situation is even more acute for un-
documented migrants in particular when
accessing health care. In addition, the Al-
liance deplores the practice in some des-
tination countries whereby health profes-
sionals are encouraged or even constrained
to denounce or give personal details to the
authorities on undocumented migrants.
This blatantly violates the fundamental
principle of patient confidentiality, threat-
ens the patient/health care professional re-
lationship and, inappropriately, introduces
law enforcement responsibilities within
health professionals’scope of practice.
• Children of undocumented migrants
start their lives disadvantaged because
they may not be registered at birth. The
WHPA is deeply concerned that unreg-
istered and undocumented children face
exclusion from access to health services,
such as immunization, and to schooling
• The Alliance deplores as well the dis-
crimination often faced by migrant
health professionals in accessing social
and health services in receiving coun-
tries. Other forms of discriminations
include lower pay, job insecurity, less
favourable assignments and heavier
workload. Health professions organiza-
tions therefore support a code of ethical
recruitment, including a focus on equal
opportunity, and its full implementation
by employers and other authorities.
• The WHPA emphasizes that the resolu-
tion should address the particular needs
of migrant women. Many are particu-
larly exposed to gender-based violence
and other forms of abuse, due to their
precarious economic, social and legal
status. They encounter difficulties in ac-
cessing health care, including sexual and
reproductive health services, leading –
amongst other things – to inadequate
antenatal care, high rate of stillborn
children and a higher incidence of un-
planned pregnancies amongst the mi-
grant communities.
In conclusion of the statement, the Alliance
recommends that the countries facing migra-
tionchallengesdevelopcomprehensivehuman
rights impact assessments and monitoring
mechanisms that take into consideration the
right of all migrants, women and men, to the
highest attainable standard of health, regard-
less of their legal or social status.
• The strengthening of efficient health
systems as a key determinant of inter-
national migration of health personnel
The health professions readdressed the chal-
lenges resulting from international migration
of health personnel and is pleased to note that
since its foundation,the Global Health Work-
force Alliance5
has developed into a facilitating
body that drives and shapes the global agenda
in this context. However, despite major effort,
the realities of health personnel migration
have not yet changed significantly.Reminding
that migration is a symptom of a disfunctional
health system, the World Health Professions
Alliance stresses the urgent need to translate
international policies, guidelines and codes
into tangible national action, as much as shar-
ing of best practices and successes.It calls upon
all governments, WHO and other stakehold-
ers to seriously address the strengthening of
functional health systems, as well as the rein-
forcement of infrastructures and training ca-
pacity of countries worldwide in order to reach
the goal of self-sufficiency in health human
resources.
5 The Global Health Workforce Alliance is a partner-
ship dedicated to identifying and implementing solu-
tions to the health workforce crisis. It brings together
a variety of actors, including national governments,
civil society, finance institutions, workers, international
agencies, academic institutions and professional as-
sociations.The Alliance is hosted and administered by
WHO – http://www.who.int/workforcealliance/en/
6
Non-communicable diseases are not the
beloved children of public health. Although
WHO deals with them now for a long
time they never have gotten the clear and
programmatic approach infectious diseases
have received.This,of course,has something
to do with the clear aetiology of infectious
diseases. Second traditional public health
was heavily focused to infectious diseases
as the leverage for public or political action
was impediment, while it seemed that non-
communicable diseases where a matter of
fate or personal behaviour.
However, huge progress has been made
when looking on non-communicable diseas-
es from the risk side. Analyzing factors that
lead to non-communicable diseases is an
established and successful strategy. Starting
with the work of Bernardino Ramazzini in-
augurating occupational and environmental
medicine more than 200 years ago coming
to the multinational Frame Work Conven-
tion on Tobacco Control as the most recent
major achievement effective and often very
cheap methods have been found to combat
a large number of non-communicable dis-
eases and injuries.
Risk factors are a key to combating non-
communicable diseases: The draft action
plan especially stresses tobacco use, un-
healthy diet, physical inactivity, and the
harmful use of alcohol. But looking to the
poorest countries of the world childhood
and maternal underweight, high blood
pressure, unsafe water, indoor smoke from
solid fuels, illicit drug use, traffic related
injuries, environmental and occupational
risks, unsafe health care practices, abuse,
violence, poverty and poor housing are cer-
tainly likewise important and preventable
risk factors for non-communicable diseases
and injuries.
The overall purpose of the draft action plan
is to
• “map the emerging epidemics of non-
communicable diseases and analysing
their technical, social, economic, behav-
ioural and political determinants […]
• reduce the level of exposure of individu-
als and populations to the common risk
factors for non-communicable diseases
[…] and
• strengthen health care for people with
non-communicable diseases […]”
The new draft action plan develops 5 ob-
jectives (see box) each with action items for
member states, the WHO secretariat and
international partners. For each of those
action items deliverable as indicators for
successful implementation are defined. The
plan defines its purpose on one hand as to
“provide an overall direction” for all non-
communicable diseases many of which are
chronic and high burden diseases.
On the other hand, it lists four of them
namely: cardiovascular disease, cancer,
chronic respiratory disease, and diabetes
making the largest contribution to mortality
in the majority of low- and middle-income
countries and it delineates the program
against conditions like blindness, deafness,
oral diseases, certain genetic diseases, and
other diseases of a chronic nature, includ-
ing some communicable diseases. The rela-
tion of the action plan to other important
chronic and non-communicable disease
groups like muscular-skeletal diseases or
mental diseases is not mentioned.
This may by just a matter of language and in-
clusion.This may be vague by purpose – not
to exclude any options or for other reasons
e.g. not to produce any conflict with other
programs. However, clarity would help and
that starts with the title: What does “con-
trol” of non-communicable diseases mean?
Does it mean to “influence”, “restrain” or
“manage” them, or does it only mean to
“monitor” them? The ambiguity is resolved
only to some extent by the objectives and
measures described. This gives some indi-
cation of what can be meant by “control”.
The document would win considerably if
the ambiguous term would be replaced with
a more clear and precise one, or at least it
would have to be defined.
But scepticism may remain, because – and
that is most worrying – none of the “perfor-
mance indicators” measures the quality and
accessibility of care for patients with non-
communicable diseases.Instead,numbers of
meeting,administrational units and budgets
are measured. All very important, but what
do they mean, if nothing changes in real
health care? WHO may be reminded from
Non-communicable diseases are in the focus
of a new WHO action plan
Objectives of the “WHO draft action plan for the prevention and control of non-com-
municable diseases”
• To raise awareness of non-communicable diseases and advocate for their prevention
and control
• To establish or strengthen, as appropriate, national policies and plans for the preven-
tion and control of non-communicable diseases
• To promote specific measures and interventions to reduce the main shared risk fac-
tors for non-communicable diseases: tobacco use, unhealthy diets, physical inactivity
and harmful use of alcohol
• To promote research for the prevention and control of non-communicable diseases
• To promote partnerships for the prevention and control of non-communicable dis-
eases
• To establish systems for tracking global progress in the prevention and control of
non-communicable diseases
7
Adopted by the 44th World Medical Assembly,Marbella,
Spain,September 1992 and amended by theWMA Gen-
eral Assembly in Copenhagen, Denmark, October 2007
Preamble
Given growing environmental awareness
and knowledge of the impact of noise on
health, the psyche, performance and well-
being, the fight against environmental noise
is becoming increasingly important. The
World Health Organization (WHO) de-
scribes noise as the principal environmental
nuisance in industrial nations.
Noise affects people in various ways. Its ef-
fects relate to hearing, the vegetative nervous
system, the psyche, spoken communication,
sleep and performance. Since noise acts as
a stressor, an increased burden on the body
leads to higher energy consumption and
greater wear. It is thus suspected that noise
can primarily favour diseases in which stress
plays a contributory role, such as cardiovas-
cular diseases, which can then be manifested
in the form of hypertension, myocardial in-
farction, angina pectoris, or even apoplexy.
The effects in the psychosocial field are
likewise dramatic. The stress caused by en-
vironmental noise – particularly road traffic
noise – is a central concern, not only in the
industrial nations, but increasingly also in
the developing countries.
Owing to the continuous and massive
growth of traffic volumes, both on the roads
and in the air, the stress caused by environ-
mental noise has increased steadily in terms
of both its duration and the area affected.
Damage to hearing caused by leisure-time
noise is also of growing concern. The most
common source of noise in this context is
music, to which the ear is exposed by diffe-
rent audio media at different places (portable
music players, stereo systems, discotheques,
concerts). The risk of suffering hearing
damage is underestimated by most people,
or even consciously denied. The greatest is-
sue (or aspect) lies in creating awareness of
the problem in the high-risk group – which
generally means young people. In this res-
pect, the legislature is called upon to inter-
vene and reduce the potential for damage
by introducing sound level limiters in audio
playback units and maximum permissible
sound levels at music events, or by banning
children’s toys that are excessively loud or
produce excessive noise levels.
In keeping with its socio-medical commit-
ment, the World Medical Association is is-
suing a statement on the problem of noise
pollution with the aim of making a contri-
bution to the fight against environmental
noise through more extensive information
and more acute awareness.
time to time that it is the World’s Health
Organization and not only the World’s
Public Health Organization. This is more
than just a play with words; people suffer-
ing from non-communicable diseases will
be able to tell the difference.
The “Draft WHO action plan for the pre-
vention and control of non-communicable
diseases“ is an important document for
the further development of regional and
national health policies aimed to control
and prevent non-communicable diseases
as leading causes of deaths and burden of
diseases. Just working on the reduction of
the mentioned risk factors should lead to a
measurable reduction of non-communicab-
le diseases. And hopefully it will not only
prevent a large number of cases but also en-
hance availability, quality and accessibility
of care for patients with non-communicable
diseases.
The “WHO draft action plan for the pre-
vention and control of non-communicable
diseases”
(WHO Document EB 122/9) can be
downloaded from:
http://www.who.int/gb/ebwha/pdf_files/
EB122/B122_9-en.pdf
WMA Statement on Noise Pollution
Recommendations
The World Medical Association calls upon the National Medical Associations to:
1. Inform the public,especially persons affected by environmental noise,as well as policy and deci-
sion makers, of the dangers of noise pollution.
2. Call upon ministers of transport and urban planners to develop alternative concepts that are
capable of countering the growing level of environmental noise pollution.
3. Advocate appropriate statutory regulations for combating environmental noise pollution.
4. Support enforcement of noise pollution legislation and monitor the effectiveness of control
measures.
5. Inform young people of the risks associated with listening to excessively loud music,such as that
which emanates,for example,from portable music players,use of stereo systems with earphones,
audio systems in cars, and attendance at rock concerts and discotheques.
6. Prompt the educational authorities to inform pupils at an early stage regarding the effects of
noise on people, how stress due to environmental noise can be counteracted, the role of the in-
dividual in contributing to noise pollution, and the risks associated with listening to excessively
loud music.
7. Provide information about risks of damage to hearing that arise in the private sector as a result
of working with power tools or operating excessively loud motor vehicles.
8. Emphasize to those individuals who are exposed to excessive levels of noise in the workplace the
importance of protecting themselves against irreducible noise.
9. Call upon the persons responsible for occupational safety and health in businesses to take fur-
ther action to reduce noise emission, in order to ensure protection of the health of employees at
the workplace.
8
Serious concern about the increasing ten-
dency for female genital mutilation
(FGM) to be carried out by medical person-
nel has been expressed by the World Medi-
cal Association. In a statement to mark the
international day of zero tolerance to FGM
tomorrow (Feb 6), the WMA repeats its
strong condemnation of this practice that
it says constitutes a severe form of violence
against women.
Dr. Jon Snaedal, President of the WMA,
said a recent World Health Organisation
report indicated that ‘the rate of progress
towards a significant decline in the practice
is slow’, although the practice was interna-
tionally recognised as a violation of human
rights and many countries had put in place
policies and legislations to ban it.
He added: ‘Because of its serious detri-
mental impact on the physical and mental
health of women and girls, female genital
mutilation is a matter of deep concern to
physicians. We are particularly worried to
note the increasing practice of female geni-
tal mutilation by medical personnel. This is
in contradiction with our code of ethics, as
these practices violate the human rights of
women and girls. The WMA is totally op-
posed to this “medicalization” of FGM ‘.
Dr. Snaedal called for all physicians and
other health professionals to mobilise ac-
tively to stop these flagrant forms of vio-
lence against women.
In 1993, the WMA adopted a statement on
female genital mutilation condemning such
practices as a form of oppression of women.
In 2005 it strengthened its opposition, urg-
ing national medical association to develop
educational programmes for physicians,
which would:
• Include adequate information on the
acute dangers of Female Genital Muti-
lations for women and girls;
• Raise awareness on such practices as a
violation of women’s human rights that
physicians or other health professionals
should never practice under any circum-
stances,
• Encourage physicians to inform wom-
en, men and children about FGM and
discourage them from performing or
promoting such practices.
For further information please contact:
Dr. Otmar Kloiber
WMA Secretary General
Nigel Duncan
WMA Public Relations Consultant
nduncan@ndcommunications.co.uk
website: www.wma.net
Physicians Call For Zero Tolerance to Female
Genital Mutilation Across The World
The World Medical Association Statement on Female Genital Mutilation
Adopted by the 45th World Medical Assembly, Budapest, Hungary, October 1993 and edi-
torially revised at the 170th Council Session, Divonne-les-Bains, France, May 2005
Preamble
Female genital mutilation (FGM) is a common practice in over thirty countries. In many
other countries the problem has arisen more recently due to the presence of ethnic groups
from countries in which FGM is common practice, including immigrants and refugees who
fled from hunger and war.
Because of its impact on the physical and mental health of women and children, FGM is a
matter of concern to physicians.Physicians worldwide are confronted with the effects of this
traditional practice. Sometimes they are asked to perform this mutilating procedure.
There are various forms of FGM. It can be a primary circumcision for young girls, usually
between 5 and 12 years of age,or a secondary circumcision,e.g.,after childbirth.The extent of
a primary circumcision may vary: from an incision in the foreskin of the clitoris up to a phara-
onic circumcision or infibulation removing the clitoris and labia minora and stitching up the
labia majora so that only a minimal opening remains to allow for urine and menstrual blood.
Regardless of the extent of the circumcision, FGM affects the health of women and girls.
Research evidence shows the grave permanent damage to health. Acute complications
of FGM are: hemorrhage, infections, bleeding of adjacent organs, and excruciating pain.
Long-term complications include severe scarring, chronic infections, urologic and obstetric
complications, and psychological and social problems. FGM has serious consequences for
sexuality and how it is experienced.There is a multiplicity of complications during childbirth
including expulsion disturbances, formation of fistulae, ruptures and incontinence.
Even with the least drastic version of circumcision, complications and functional conse-
quences can occur, including the loss of all capacity for orgasm.
There are various reasons to explain the existence and continuation of the practice of FGM:
custom, tradition (preserving virginity of young girls and limiting the sexual expression of
women) and social reasons.These reasons do not justify the considerable damages to health.
None of the major religions supports this practice.The current medical opinion is that FGM
is detrimental to the physical and mental health of girls and women. FGM is seen by many
as a form of oppression of women.
By and large there is a strong tendency to condemn FGM more overtly:
– There are active campaigns against the practice in Africa. Many African women leaders
as well as African heads of state have issued strong statements against the practice.
– International agencies such as the World Health Organization, the United Nations
Commission on Human Rights and UNICEF have recommended that specific measures
be aimed at the eradication of FGM.
– Governments in several countries have developed legislation, such as prohibiting FGM
in their criminal codes.
Recommendations
1. Taking into account the psychological needs and ‘cultural identity’of the people involved,
physicians should inform women, men and children about FGM and discourage them
from performing or promoting FGM. Physicians should integrate health promotion and
counselling against FGM into their work.
2. As a consequence,physicians should have adequate information and support for doing so.
Educational programmes concerning FGM should be expanded and/or developed.
3. National Medical Associations should stimulate public and professional awareness of the
damaging effects of FGM.
4. National Medical Associations should stimulate governmental action in preventing the
practice of FGM.
5. National Medical Associations should cooperate in organising an appropriate preventive
and legal strategy when a child is at risk of undergoing FGM.
Conclusion
The World Medical Association condemns the practice of genital mutilation including the
circumcision of women and girls and condemns the participation of physicians in such prac-
tices.
9
Informed Consent – Recent Developments
Professor Andreas Spickhoff, LLD
Faculty of Law, Department of Medical and
Health Law
University of Regensburg
Introduction
The principle that any medical intervention,
even if it serves the patient’s health, needs
his informed consent is in accordance with
the international standard of medical ethics
and medical jurisprudence: salus et voluntas
aegroti suprema lex.Generally the therapeu-
tic intervention is seen as a physical injury,
justified only by the patient’s consent which
means with regard to the practitioner’s li-
ability that the physician in charge of the
treatment has the burden of proof for the
patient’s informed consent.1
In the past decades this principle has been
constantly put into practice by the jurisdic-
tion. This has happened particularly with
regard to the application of new and more
unusual methods,above all in the domain of
medical research. Seen thus, it is question-
able whether minors, unconscious persons
or such persons whose self-determination
is restricted are capable of consent. Increas-
1 Gerfried Fischer; Hans Lilie, Ärztliche Verantwortung
im europäischen Rechtsvergleich, 1999; Christian von
Bar, Gemeineuropäisches Deliktsrecht, Bd. II, 1999,
Rn. 299.
ingly it is considered doubtful if and to what
extent an “open consent” is at all possible.
New or unusual methods
In the more recent past the German Federal
High Court of Justice (Bundesgerichtshof)
has on several occasions given its opinion
on the problem of employing new and unu-
sual methods of medical treatment. It must,
however, be emphasized that the particular
decisions in question did in no case concern
clinical tests. So the rules for clinical re-
search were not to be applied unreservedly.
The first decision dealt with the insertion of
a new hip-joint in a computer-aided opera-
tion (the so-called “Robodoc”). In the pro-
cess of the operation certain nerves of the
female patient were damaged which led to
an impaired function of the legs and feet.
The Federal High Court of Justice pointed
out that the employment of a new method
of treatment is only permitted if after care-
ful consideration of the expected advantages
of this method and its possible disadvan-
tages compared with the standard treat-
ment, the application of the new method is
justified. Should that be the case, a mistake
of treatment is excluded because the physi-
cian’s freedom of choice as to the method
of treatment has priority. But in respect of
the patient’s right of self-determination,
the patient has to be informed of alterna-
tive methods of treatment if, with regard to
a specific medical therapy several equally
effective, and in a given case pertinent
methods are available, though this might
cause other physical strains or other risks,
but also other chances of success to the pa-
tient. With respect to standard treatments,
the patient need not be informed in general
about the occurrence of unknown compli-
cations.They might in a particular case even
worry him unnecessarily. This is different
in the case of new methods of operations
which (as for instance Robodocs) have been
only clinically tested abroad for a few years
(in the USA). But in the above mentioned
case the claim against the doctor was dis-
missed, as with the nerve damage a risk had
materialised about which the plaintiff had
been thoroughly instructed, even if only in
connection with the established method of
operation.2
A further decision of the Federal High
Court of Justice dealt with an attempt at
healing by a treatment with a drug deve-
loped in the USA and licensed only when
the treatment had been already applied.The
medicine was meant for the treatment of
epilepsy and caused irreparable eye damage
to the patient. At the time of the treatment
it was licensed neither in the USA nor in
Germany but in some European Countries.
A clinical test in progress conducted by the
defendant physicians, in which the plaintiff
was not included, was undergoing phase III
trials. The physicians knew that the medi-
cal product had not yet been examined for
disturbances of eye functions in humans.
Therefore periodic,say for instance monthly
controls, of the strength of vision were indi-
cated.The plaintiff did notice that his power
of vision was impaired. But the medication
was continued all the same and was stopped
only several weeks later. In this case the
Federal High Court recognised the liability
of the physicians. It held that an individual
attempt at healing with a medicine which
had still to be licensed was not forbidden,
but that the physicians were under the obli-
gation to control the treatment continually,
and particularly with regard to possible eye
damages.Thus the omission of the necessary
observation constituted a fault. The causa-
tion of the fault for the damages was even
presumed since the Federal High Court
assumed a serious fault in treatment, for in
an attempt at healing a special standard of
care has to be adopted, which reduces the
requirements necessary for the affirmation
of a serious fault of treatment. Furthermore,
the Federal High Court assumed insuffi-
2 Bundesgerichtshof, 13.6.2006, VI ZR 323/04, Sam-
mlung des Bundesgerichtshofs in Zivilsachen Band
168, S. 103; aus der Literatur dazu Christian Katzen-
meier, Neue Juristische Wochenschrift 2006 Seite
2738; Benedikt Buchner, Versicherungsrecht 2006, Seite
1460.
10
cient information, because the patient had
not been told that the medical product had
not yet been licensed and that therefore un-
known risks might arise. In such a case it
could not possibly be presumed that the pa-
tient, when informed of the circumstances,
would have given his consent to the treat-
ment with a non-licensed medication.3
ThethirddecisionoftheFederalHighCourt
dealt likewise with a first time-administra-
tion of a medication with a view to testing
its effects. The female patient was treated
in a university hospital for arrhythmia with
the medical drug Cordarex (Amiodaron).
During the treatment her circulation ceased
to function, which caused a permanent da-
mage to the brain. The Federal High Court
ruled that the information given to the pa-
tient had been insufficient. Though, in the
opinion of the lower court the danger of a
cardiac arrest was greater with the standard
medication than with the new medication,
the patient had to be informed that the new
medication might likewise lead to a cardiac
arrest. The Federal High Court has expli-
citly underlined that having regard to the
right of self-determination,.the patient has
to be informed already before the first ad-
ministration of a medication. Therefore, the
Federal High Court rejected the opinion of
the lower court which declared that the ap-
plication of a new medication was tempo-
rarily admissible for an initial test in order
to show if the medical drug is effective at
all.The argument of the patient’s hypotheti-
cal consent was also rejected by the Federal
High Court of Justice since the new medi-
cation was not meant as a treatment with
a view to prolongation of life, but only for
reducing the pain of the patient. In such
cases a hypothetical consent can only be
presumed with great reserve.4
The subject of the most recent decision of
the Federal High Court was again the ap-
3 Bundesgerichtshof, 27.3.2007, VI ZR 55/05, Sam-
mlung des Bundesgerichtshofs in Zivilsachen, Band
172, Seite 1; dazu Dieter Hart, Medizinrecht 2007,
Seite 631; Christian Katzenmeier, Juristenzeitung 2007,
Seite 1108.
4 Bundesgerichtshof, 17.4.2007, VI ZR 108/06, Versich-
erungsrecht 2007, Seite 999.
plication of an outside method which was
new at the time the treatment took place
and which was scientifically disputed – sci-
entific evaluations with statistical relevance
as to the efficaciousness of the therapy were
lacking. In the present case a slipped disc
was treated with a so-called Racz-catheter.
This method consists in injecting several
medical drugs (a “cocktail”) into the spinal
channel with the aid of an epidural catheter.
At the end of this procedure, the patient
was in great pain. The physician prescribed
by telephone an additional dose of pain-
killers. When the pain still recurred he pre-
scribed, again by telephone, a withdrawal of
the catheter of one centimetre. This caused
the pain to diminish, but with an aftermath
of bladder and intestine trouble. Firstly, the
Federal High Court underlined again the
physician’s freedom of treatment: The phy-
sician was not bound to apply in any case
the surest therapeutic method. But a greater
risk had to be justified objectively by a spe-
cial situation in a concrete case, or else by
a more favourable healing prognosis.There-
fore the Federal High Court of Justice took
the view that the present case constituted
an error of treatment. At all events, as se-
vere pain connected with the new method
of treatment occurred, an augmented care
and a detailed medical examination were
indicated. Under the given circumstances,
and even in taking also into consideration
that the patient was medically treated in the
hospital, the physician could by no means
be allowed to give his instructions solely by
telephone, but was bound to examine the
patient personally. In addition, the physi-
cian was liable in the matter of insufficient
consent, for the patient had not been in-
formed that the projected intervention was
not yet a standard medical procedure and
that its effectiveness was not yet statistically
confirmed. Again the Federal High Court
of Justice rejected the appeal of the physi-
cian based on a hypothetical consent. It is
enough if the patient affirms that he would
not have consented to a new medical treat-
ment outside the medical standards.5
5 Bundesgerichtshof, 22.5.2007, VI ZR 35/06, Neue
Juristische Wochenschrift 2007, Seite 2774.
Informed Consent and
Medical Research
Naturally, the above extends also to con-
trolled clinical studies. The existing regula-
tions at the level of international standard
law (Declaration of Helsinki), at the level
of the European Community Directives
(Good Clinical Practice [GCP] Direc-
tive) and at the European level at large (the
Biomedicine Convention together with the
additional protocols) are in harmony with
these principles,or at least do not contradict
them.
It is important in this context to broach
another subject which has likewise turned
up in a more recent decision of the German
Federal High Court.The Court looked into
the matter of a unit of blood from a donor.
In connection with this donation of blood
of the patient, a policeman, the injection
caused trauma to the nerve of the epidermis
on his forearm. This brought on permanent
pain. A complete recovery is more or less
improbable. That the patient had been in-
formed in writing of the slight possibility
of a damage to the nerve was not enough.
The Federal High Court of Justice did not
go into the question of whether a mere in-
formation in writing in connection with a
donation of blood was sufficient. The fact
seems to be that the patient has also to be
informed of the risks verbally. Considering
the serious consequences, the information
which the patient received was at all events
not enough. Especially in a case where a
patient consents to an intervention from
altruistic motives, a particularly straightfor-
ward and clear information is distinctly in-
dicated, because the patient does not profit
personally from the intervention.6
These
principles are important in connection with
medical research, for the decision of the
Federal High Court makes it clear that the
information given to patients in cases of ex-
periments profiting others have to be more
6 Bundesgerichtshof, 15.3.2006, VI ZR 279/04; Sam-
mlung des Bundesgerichtshofs in Zivilsachen, Band
166, Seite 336; dazu Andreas Spickhoff, Neue Juristische
Wochenschrift 2006, 2075; Horst Hasskarl, Pharma
Recht 2006, Seite 311.
11
thorough than in cases of scientific experi-
ments which are undertaken for the benefit
of the patient himself.
Open Consent
There is another question which presents it-
self in connection with medically controlled
research namely, if a possibility exists for
consent to be given in view of future sci-
entific use of the relevant biological human
material to establish a collection of cells,tis-
sues etc. for future scientific use. This ques-
tion is causing controversy in discussion. It
should, however, with the agreement of the
previous National Ethic Council in Germa-
ny (Nationaler Ethikrat) and a recommen-
dation of the Council of Ministers of the
European Council concerning the research
with biological human material, be an-
swered in the affirmative. Nevertheless, the
special provisions as to data protection of a
given country in which the research is car-
ried out have to be respected. The next step
is to inform the patient about the advantag-
es and disadvantages of the “anonymising”
or “pseudonymising” of the relevant tissue.
Finally, examples of typical fields of appli-
cation for a possible research in connection
with a given material should be made plain
to the patient. In addition to the appropri-
ate printed form the information should be
given verbally, since the printed forms of
information are subject to the severe regu-
lations controlling the general terms and
conditions of trade. If all of these condi-
tions are complied with, a general consent
in the form of an “open consent” should be
considered admissible. It has to be seen that
it is even thought feasible for the patient to
waive his right of information.7
This follows
from the patient’s autonomy. Therefore, the
opinion which states that an “open consent”
was not effective cannot be agreed to.8
The
patient’s health in particular is not endan-
gered by such an open consent.
7 Erwin Deutsch; Andreas Spickhoff, Medizinrecht, 8.
Auflage 2008, Rn. 247; Andreas Spickhoff, in: Theodor
Soergel, Bürgerliches Gesetzbuch, Schuldrecht, Band
10, 13. Auflage 2005, § 823, Anhang I: Arzthaftung-
srecht, Rn. 184.
8 Anders aber Adolf Laufs, Arztrecht, 5. Auflage 1993,
Rn. 207.
Minors, Unconscious persons,
persons incapable of consent
Research in connection with minors or
adults incapable of consent presents a spe-
cial problem. The GCP-Directive distin-
guishes in this instance between minors and
adults. In an urgency it is permissible to at-
tend to a patient by presuming his consent
if, according to the state of investigation of
the medical science or other methods of re-
search, no sufficient results from the clinical
examination of persons capable of consent
are to be expected, and if, according to the
knowledge of medical science, the applica-
tion of the medical product still to be tested
is indicated to save the life of the person in
question, to restore his health or to alleviate
his pains. Finally, such researches must be
directly related to a life-endangering con-
dition or a condition of extreme feebleness
of the patient and the clinical examination
must be as far as possible free from stress
or other foreseeable risks. A group benefit
alone – as in the case of minors – is not
sufficient. In the case of minors, however,
a group benefit is enough if the research
includes only a minimal risk or a minimal
stress for the minor.It is hardly understand-
able why under these additional require-
ments, a comparable research cannot be
carried out where adults who are incapable
of consent are concerned.
Another problem has to do with art. 5 of
the GCP-Directive, (in the form of its in-
corporation into national law). According
to the wording of the directive, a treatment
which cannot be delayed in order to save a
given person’s life, to restore his health or
to alleviate his pains is possible even within
the bounds of the clinical research, when in
an emergency a consent cannot be obtained.
This, it is true, applies only to the treat-
ment of adults capable of consent and not
to minors or adults incapable of consent.
The said principle should be nevertheless
applied analogously to persons permanently
incapable of consent or to minors, insofar as
the patient’s presumed opinion is in favour
of his participation in the research project,
and insofar as a legal representative can in
a matter of urgency not be reached, and in-
sofar as the experiment can benefit the pa-
tient directly. Otherwise a whole group of
patients might be excluded from possible
therapeutic experiments in cases where the
appointment of a legal representative before
the beginning of the experiment is not pos-
sible.9
The already mentioned unequal treatment
of minors and adults incapable of consent
can be found also in the German jurisdic-
tion.The Federal High Court of Justice is,at
least where the medical practitioner’s liabili-
ty is concerned,of the opinion that even mi-
nors who have entered into their 16th
year
have only a right of veto against the consent
of their legal representatives, their parents.
The other way round, this means that mi-
nors cannot alone give an effective consent,
even when they are quite capable of under-
standing. The Federal High Court decided
in this sense in the case of a female (minor)
patient who had undergone an operation on
the spinal column that caused a paraplegia.
Fortunately, she finally was awarded dam-
ages for having been insufficiently informed
since she had neither given her consent, nor
been informed at all.10
It would be the right
course of action, if the minor’s decision
alone would count.The jurisdiction does not
rule otherwise in cases of adults incapable
of consent. Even if an adult is incapable of
consent his wishes with regard to the deci-
sion about the treatment are respected up to
the limit of a serious risk to his health, and
this applies equally to his refusal of consent
and to his demand for treatment.11
9 Erwin Deutsch, Neue Juristische Wochenschrift 2001,
Seite 3361 (3363); Andreas Spickhoff, Medizinrecht
2006, Seite 707 (710).
10 Bundesgerichtshof, 10.10.2006, VI ZR 74/05, Neue
Juristische Wochenschrift 2007, Seite 217.
11 Andreas Spickhoff, in: Theodor Soergel, Bürgerliches
Gesetzbuch, Schuldrecht 10, 13. Auflage 2005, § 823
Anhang I: Arzthaftungsrecht, Rn. 108.
12
The Danish Medical Association dates back
a hundred and fifty years and celebrated its
Birthday in 2007 amongst other initiatives
by inviting the World Medical Association
to Copenhagen to have its General Assem-
bly in the autumn winds and sunshine of
Copenhagen City Centre.
The following is a portrait of an association
which has survived a 150 years of different
regimes and of influence on health policy
making in Denmark but without direct ac-
cess to write the health laws that govern a
public health care system.
The DMA is an umbrella organisation
which seeks to influence the development
of health and social policy and render visible
the interest of the medical profession. Fur-
thermore the DMA coordinates and unites
the opinions of the four associations that
constitute the Danish Medical Association.
95 % of all doctors working in Denmark are
members of the organisation.
The Danish Medical Association
(policy making body)
The Danish Association of Junior Doctors
The Danish Association of
Medical Specialists
The Danish Organisation of
Medical Practitioners
The highest authority of the DMA is the
assembly of representatives which meets an-
nually. The representatives are appointed by
the above mentioned organisations accord-
ing to the number of members.The Assem-
bly of Representatives decides the general
policy of the DMA, the budget, approve
the accounts and elect the president and the
council. The Assembly of representatives
also elects the DMA arbitration committee,
the medical ethics board and the Commit-
tee of Preventive Medicine.
The DMA council is responsible for the day
to day leadership of the DMA. It consists of
a chairman and six members, two each rep-
resenting the three negotiating organsations.
The Council points out a number of stand-
ing and temporary committees and working
groups in order to attend to the various sub-
jects that the organisation has to deal with.
Services
As most professional organisations the
DMA provides services to its members. In
the legal department, the lawyers give ad-
vice on patient complaints, the handling of
criminal cases, duty on confidentiality, ac-
cess to health information, medical ethics
disputes and the overall regulation in the
field of health care.
Training
The DMA offers a great variety of train-
ing. Mostly one day short courses in various
fields and courses for trade union represen-
tatives. Through the DMA Committee on
training and research the DMA influences
the medical and specialist training.
Medical bulletin
The DMA arranges public meetings on
various subjects and offers a medical bul-
letin with important news on research and
debate on a weekly basis.
Working environment
The DMA seeks to improve the working
conditions for Doctors and through influ-
encing the legislation and cooperation with
other health professionals.The DMA Com-
mittee for Doctor´s Occupational environ-
ment especially focuses on inter-collegial
relations and collegial spirit.
Cooperation with
pharmaceutical companies
The DMA has established a cooperation with
the umbrella body of the pharmaceutical com-
panies and other stake holders in order to de-
velop common independent information on
pharmaceuticals. Furthermore the DMA has
made an agreement with the pharmaceutical
companies and the association of pharmacists
in order to regulate the question of sponsor-
ships from the industry towards doctors to
ensure independence of all parties.
Ethics
The DMA has a strong engagement in
ethical matters. The DMA Medical Ethics
Committee has a consultation part and it is
also independently creating policies on the
contemporary ethical dilemmas, both with
regard to the special problems relating to
immigration and the use of new technol-
ogy.
Portrait of a key player
The Danish Medical Association through 150 years
Dr.Jens Winther Jensen, the President of
Danish Medical Association, Dr.Otmar
Kloiber and Dr. Nachiappan Arumugam
13
Organisation and membership
The Norwegian Medical Association
(NMA), was founded in 1886 as the profes-
sional association and trade union for Nor-
wegian physicians. Membership is volun-
tary, and approximately 96 % of Norwegian
physicians are members. The main aims of
the Association are to protect the profes-
sional, social and financial interests of its
members, to promote their interests in mat-
ters concerning medical education, profes-
sional development and scientific activities,
and to advance the quality of the Norwe-
gian health care system.
Some main bodies of the Norwegian
Medical Association:
Annual Representative Meeting (ARM) is
the chief decision-making body and elects
the Central Board of 9 members, including
the president and vice-president. The elec-
tion period for the board is two years. ARM
also elect the The Medical Ethics Commit-
tee (chairperson: Trond Markestad)
The secretariat
The secretariat has five departments: Dep.
of medical education, Dep.of information
and health policy, Dep.of finance and ad-
ministration, Medical journal and Dep.of
negotiation and legal section. The number
of full-time staff members is 130.
The role of The Norwegian
Medical Association
The Norwegian Medical Association
(NMA) is the only nationwide association
for doctors in Norway. NMA has two main
responsibilities:
1 Negotiating salaries and working condi-
tions for the members
2 Taking care of the members professional
and scientific interests
The medical association consists of 19 local
branches, 7 occupational branches and 44
specialty branches.
The local branches represent the 19 coun-
ties.
The seven occupational branches organise
members that share occupational interests:
junior doctors, consultants, GPs, research-
ers, occupational health doctors, private
practicing specialists and public health
doctors. The occupational branches are ne-
gotiating salaries and working conditions,
while the specialty branches take care of the
professional activities like education,quality
improvement etc.
NMA has its own,independent research in-
stitute that among other things do research
on doctors’ health and well being.
Some data about Norway
Norway has a population of 4 525 000 and
is situated in the northern part of Europe
and has borders to Sweden, Finland and
Russia.
Public health services are financed by taxa-
tion and are designed to be equally acces-
sible to all residents, independent of social
status. With its 220 000 employees, the
public health sector is one of the largest sec-
tors in Norwegian society.
The public health system is under the juris-
diction of the Ministry of Health and Care
services, which is responsible for devising
and monitoring national health policy. Res-
ponsibility for provision of services is de-
centralized to the municipal and regional
level. The municipalities are in charge of
providing primary health services such as
general practitioner, while the five Health
regions provide the more specialized medi-
cal services, such as hospital care. Just a few
number of authorized private hospitals and
health services have been established in ad-
dition to the public facilities.
The numbers of doctors, inclusive students
and retired doctors, are about 25 000. In
relation to inhabitants we have among the
highest number of doctors in Europe, in
2007 the ratio was one doctor per 244 in-
habitants.
The Norwegian Medical Association
The president of The Norwegian Medical
Association, dr.med., Torunn Janbu and
secretary general Terje Vigen.
14
The Committee on Human Rights; since
the early 1990s, the NMA has run human
rights programmes in Turkey, the former
Yugoslavia and now in China. These activi-
ties are funded mainly by The Norwegian
Ministry of Foreign Affaires.In cooperation
with WMA, The International Red Cross
and Amnesty International the association
has published, on the web, free of charge, a
course for prison doctors.
The Journal of The Norwegian Medical
Association is issued every second week
and are in charge of the web-site www.lege-
foreningen.no.
Post-graduate medical education
There are 44 recognised medical specialties
in Norway of which eight are subspecialties
under internal medicine and five are sub-
specialties under general surgery. The ma-
jority of the specialties relate to health ser-
vices in institutions (hospitals). Specialties
in primary health care are family medicine,
community medicine, and occupational
medicine.
Health politics
The NMA is involved in many of the activi-
ties run by the health authorities through
appointing members to participate in dif-
ferent task groups, and also by meetings
with the political parties inthe Parliament.
Officers President Torunn Janbu, vice-
president Bård Lilleeng, and secretary ge-
neral Terje Vigen.
Contact information;
The Norwegian Medical Association
Pb 1152 Sentrum,
NO 0107 Oslo
+ 47 23 10 90 00 fax + 47 23 10 90 10
www.legeforeningen.no
The ethics committees of the Nordic medi-
cal associations have a long tradition of
meeting every two years to discuss current
issues in medical ethics. The venue of these
informal gatherings rotates between the five
countries (Denmark, Finland, Iceland, Nor-
way or Sweden).
In September 2007 the meeting was host-
ed by the Finnish Medical Association in
Nauvo, a peaceful seaside resort in south-
western Finland. There were altogether 37
participants, mostly practicing physicians
who are also members of the ethics com-
mittees.
Three themes of discussion at the meeting
were chosen beforehand. They were
– Medical ethics of physicians working in
leadership or administrative tasks
– Ethics of stem cell research
– Liability issues in telemedicine.
Each of the themes was first introduced in a
plenary setting, then discussed in depth by a
working group of about ten participants and
finally reported back to the plenary. This
method proved to be useful as everyone got
a chance to concentrate on the issue closest
to their heart and at the same time com-
ment and reflect on the two other subjects.
Medical ethics of physicians
working in leadership or
administrative tasks
This theme was introduced by Dr. Thomas
Lindén from Sweden. Ethical rules as such
are of course applicable to all doctors, but
the question is whether they differ (and
how) when a doctor is also working as a
leader. Lindén presented the general ethi-
cal guidelines of the Swedish Medical As-
sociation and highlighted the points where
problems might arise.
In the discussion that followed it was con-
cluded that all the ethical rules also apply
to doctors in leadership positions. Special
challenges exist however.These include pri-
oritisation when resources are limited, the
benefits of one patient versus those of many
Joint Medical Ethics Reflections
of the Nordic Countries
15
patients, loyalty conflicts and also potential
conflicts related to economic profit.
Organisations should facilitate physicians
in leadership or managerial positions to be
able to follow high ethical standards. This
could be done by facilitating the knowledge
of ethics as well as ethical discussions and
reflections at the workplaces. Also non-
physician-leaders and managers should be
included in these processes.
Ethics of stem cell research
The meeting was honoured to have the cur-
rent president of the WMA,Dr Jon Snaedal,
as a member of the Icelandic delegation. He
introduced the subject of stem cell research.
The working group focused on the specific
questions of using human embryonic stem
cells. It presented three statements and ar-
gued for and against them.
The first statement was that production of
embryonic stem cells solely for research
purposes should be prohibited. Arguments
speaking for this are the invasiveness of the
procedure and potential harm caused by it
as well as possible uncontrolled commer-
cialisation. Using extra embryonic cells cre-
ated in fertility treatments is therefore a less
risky alternative.On the other hand reliance
on these extra cells only may lead to double
moral in their collection if and when re-
search on embryonic stem cells is accepted.
The second statement argued that produc-
tion and selection of embryos for therapeu-
tic purposes is acceptable if it is performed
under close supervision by an independent
authority and based on individual risk-
benefit estimation. This statement can be
defended by the utility for the sick child,
which may be major (while the harm to
the selected sibling must be small). Help-
ing one sibling does not prohibit the parents
from loving the other also as an individual.
Many western societies already have em-
pirical evidence of tolerance from case ex-
amples. Points against this are the difficulty
of preventing social strains on and between
the children. The therapies using selected
siblings are still experimental and medical
risks therefore unknown. It can also create
as slippery slope towards mass production
of embryos.
Thethirdstatementwasthatcloningofgenes
or genomes into stem cells for reproductive
purposes is ethically unacceptable.Points for
the statement are that the procedures are
biologically uncertain and may have unfore-
seen consequences, they may create a ”slip-
pery slope” to genetic engineering for cos-
metic or sport purposes and genetic copying
of human beings involves unknown social
and human risks. Arguments against the
statement include the possibility of cloning
to provide an alternative to using embryonic
cells genetically identical cell lines without
reproductive purposes. Cloning healthy so-
matic genes to reproductive cells also mir-
rors the selective abortion of severe disease
genes (which is already performed today).
Liability issues in telemedicine
The introduction to the theme on behalf
of the Danish delegation was given by Dr
Mogens Skadborg. He emphasized that as
far as ethics is concerned, telemedicine does
not differ from any other kind of medical
practice. It is simply a new way of treating
patients and requires technical expertise in
fields other than medicine.
Their group discussion centred around three
issues: who is responsible for the quality and
results of the treatment, who has (or should
get) access to patient records and why and
what are the effects to the patient-doctor
relationship.
The discussion produced some further con-
clusions. Ethics does not differ between
different formats of consultation, but face-
to-face contact is still the preferred way.
Accurate documentation of advice is impor-
tant. Communication may be less effective
and relevant information not received when
there is no physical presence. Reliable iden-
tification may also cause problems. There-
fore risks and benefits of using telemedicine
must always be balanced.
The new tools offer new ways of informing
patients of their health status and treatment.
Patients however may have different capa-
bilities of understanding that information.
Misuse of information must be prevented
and the trust of patients maintained.
In addition to the lively discussions on eth-
ics the participants enjoyed each other’s
company on a cruise in the surrounding ar-
chipelago and a traditional Finnish smoke
sauna. An excursion into the history of
medical ethics was also made at the island
of Seili, which was a hospital for lepers
1619-1785 and a then mental institution up
to 1962.
The next meeting on medical ethics in the
Nordic countries will be hosted by the Dan-
ish Medical Association in 2009.
Jukka Siukosaari
International Affairs Officer and secretary of
the Medical Ethics Committee
Finnish Medical Association
16
As far back as before the World War II, the
medical men in Independent Lithuania had
to solve the important health care problems.
Even then, the society was formed which act-
ed for the good of Lithuanian doctors.During
the years of soviet occupation, the society was
closed and only after more than 50 years its
activities have been restored. The Lithuanian
Medical Association (subsequently,the LMA)
is an independently acting trade union, a vol-
unteer organization bringing together 80% of
Lithuanian medical doctors and defending
their professional, labour, economic and social
rights and interests.Founded in October 1924,
the LMA operated until 1940.After regaining
independence in 1989, the sixth congress re-
established the LMA.
In 2004, the 12th congress of the LMA
elected prof. Liutauras Labanauskas presi-
dent of the association for a third term, Lo-
reta Leščinskienė and Virginija Lukšienė
as vice presidents, and Asta Grigaliūnienė
as secretary. Standing commissions of the
LMA are those of professional ethics, fi-
nance, law and the primary level of health
care. Other commissions are non-standing
and are normally established to solve some
specific issues. The LMA represents the
professional interests of its members in their
relationship with employers and other legal
and natural entities. It concludes collective
employment contracts and other agree-
ments with employers and controls their
implementation.The association also analy-
ses salaries of medical doctors and submits
remuneration proposals. The LMA strives
to obtain higher salaries for medical doc-
tors. As a result of implementation of this
objective, on 3 May 2005 the LMA signed
an agreement with the Government “On
the increase of salaries for medical doctors”.
In accordance with the 2001 agreement
with the Ministry of Health and Vilnius and
Kaunas Medical Universities, the LMA ac-
tively participates in the professional training
of medical doctors. The training is financed
by the Ministry of Health and performed by
Vilnius and Kaunas Medical Universities with
the LMA as a coordinator of the process.
In 2006-2007, the LMA successfully im-
plemented a project to strengthen social
partnership. For example, the project “The
development of social partnership in the
Lithuanian health care system”. The key
aim of the project is to develop social part-
nership among the equal partners of health
care system. As a result of cooperation
among the Ministry of Health, the Asso-
ciation of Representative Offices of Ethical
Pharmaceutical Manufacturers, the Asso-
ciation of Pharmaceutical Manufacturers,
and the LMA, the project “Fairer treatment
with pharmaceuticals”has been implement-
ed. Company Transparency International
Lithuania is performing social research
aiming at a more transparent relationship
between the pharmaceutical industry and
medical doctors. The LMA is a partner of
the “Good mood programme”implemented
by the private company AstraZeneca and
aimed at reducing the stress experienced by
both medical personnel and patients. To-
gether with the TV program Sveikatos ABC
(Health ABC) hosted by the TV channel
LNK, the LMA has been implementing a
social project called “Thank you, doctor”.
The LMA actively cooperates with other
professional unions and associations, inter-
national organizations of medical doctors
abroad, as well as participates in the prepa-
ration and implementation of international
programs. The LMA is a member of the
WMA (the World Medical Association)
and the CPME (the Standing Commit-
tee of European Doctors). In May 2006, a
joint conference with other specialist soci-
eties discussed membership in the UEMS
(European Union of Medical Specialists).
This would allow the LMA together with
other specialist unions to confer on pro-
fessional problems of medical specialists
on the highest level. The problems include
internship, post-graduate studies, qualifica-
tion training, and life-long learning.
Six years ago, based on the experience of
foreign countries, the LMA initiated civil li-
ability insurance for medical doctors (natu-
ral entities) that was successfully adopted in
Lithuania. Currently, the LMA is initiating
adoption of voluntary (additional) health
insurance in Lithuania. Head of the LMA
Secretariat Aistė Sivakovaitė is involved in
analyzing information from state and local
government bodies, coordinating the activity
of the association on representation in labor
groups, and preparation of the laws and legal
acts.She also coordinates international coope-
ration and publishing activities of the LMA.
The LMA publishes the bi-weekly maga-
zine Gydytojų žinios (Medical News) and,
together with Vilnius and Kaunas Medical
Universities,the magazine Medicina (Medi-
cine). One-off publications such as Lietuvos
gydytojų sąjunga (The Lithuanian Medical
Association), Lietuvos gydytojai (Doctors
of Lithuania), and a collection of laws for
doctors and administrators. In 2007, the as-
sessment of the situation in the world and
Lithuania and the desire to help doctors
who face challenges in their professional
activities prompted publication of the book
Medical Ethics Manual by the LMA in co-
operation with the ethics committee of the
World Medical Association (WMA) and
the Lithuanian Bioethics Committee.
The Lithuanian Medical Association
and its Priorities
LMA vice president Loreta Leščinskiene,
LMA president prof. Liutauras Labanauskas,
LMA vicepresident Virginija Lukšienė, LMA
Secretary General Asta Grigaliūnienė
17
General Information about the State
The Republic of Belarus is situated in the
centre of Europe. The shortest transport
communications connecting the CIS coun-
tries and Western Europe countries run
through its territory. Belarus has common
border lines with Poland, the Baltic states,
Russia and the Ukraine.
The territory of the republic comprises
207 000 square kilometers, its population is
about 10 million people, with 70% living in
the cities. Nearly one-fifth of the population
resides in Minsk, the capital of Belarus. Ac-
cording to its administrative division there are
six regions in the republic. The official lan-
guages are Belarusian and Russian.The most
common languages for business communica-
tion are Russian, English and German.
The Republic of Belarus is a unitary demo-
cratic social legal state and recognizes the
priority of conventional principles of the
international law.
The state power is conducted on the basis
of its division into legislative, executive and
legal. Belarus is a presidential republic. The
President of the Republic of Belarus is the
head of the state, the guarantor of the Con-
stitution, the rights and liberties of an indi-
vidual and a citizen. The legislative body of
power is the Parliament consisting of two
chambers. The executive power is run by
the Government – the Soviet of Ministers,
which is the central organ of power. Local
power and self-government are carried out
through local executive and administrative
organs, self-government organs, referen-
dums, etc.
Belarus is one of the economically deve-
loped CIS states. Industry comprises about
one-third of the national output volume.
The most developed branches of industry
are motor-car industry, tractor construction
and agricultural engineering, machine-tool
and bearing construction, electrotechni-
cal industry, oil extraction and processing,
synthetic fibres production, mineral ferti-
lizers production, pharmaceutical industry,
production of building materials, light and
food industry.
Governmental Support
of the Health Care
The state system makes the basis of the
health care and is financed from state bud-
get (4,5% of gross national output).The sys-
tem of social standards has been developed
for health care, which includes the norms
for covering health care expenses from the
budget for 1 citizen per year. This flattens
the disproportion while distributing the re-
sources over the regions of the republic.
The policy for developing paid medical ser-
vices is aimed both at allocating additional
means for health care development, and
controlling the substitution of free medical
services by paid ones, since the latter are not
vitally important.
Development of the
Health Care System
The programme of social and economic
development for 2006-2010 provides in-
creased access and quality of health care for
all population based on:
• introducing up-to-date medical tech-
nologies and creating scientific and
practical centres;
• reconstructing the system for providing
health care including the redistribution
of the resources from in-patient to out-
patient medical care, developing medi-
cal and social care and general medical
practice;
• improving the system of social stan-
dards, as well as territorial programmes
of guaranteed state health care;
• enlarging access to effective, safe and
high quality medicines, creating the
complex programme for providing some
categories of citizens with medicines;
• improving the management and qual-
ity control, standardizing medical tech-
nologies, working out prevention and
rehabilitation technologies.
The development and the implementation
of standards for medical information sys-
tems, advanced medical technologies, tele-
medicine including, large computerization
of medical institutions, creating local elec-
tronic computing systems,introducing elec-
tronic patients’ medical charts are planned.
There are more than 40 000 doctors and
about 109 000 nurses, more than 150 sana-
torium and prophylactic establishments and
1700 treatment and prophylactic institutions.
Medical staff is trained at 4 medical univer-
sities, 17 colleges, at the Belarusian Medical
Academy of Post-Graduate Education and
some centers for advanced training and im-
proving the qualification of the nursing staff.
The reform of health care system is in prog-
ress, with the state budget financing being
followed.The positive dynamics of the basic
indices is seen. These are increase of birth
rate, decrease of infant and mother mortal-
ity rate, postoperative lethality, morbidity
The Republic of Belarus and its
Health Care System in Brief
In the photo V.I. Zharko, Minister of Health,
Republic of Belarus; V.N. Lektorov, Deputy
Chairman of the Commission for Social
Protection, Chamber of Representatives of
the National Assembly, Republic of Belarus,
Chairman of the Belarusian Association of
Physicians.
18
History of the Ukrainian Medical Associa-
tion (UMA) – in Ukrainian language: Vse-
Ukrainske Likarske Tovarystvo (VULT)
was founded in 1910, but its activities were
interrupted by the Soviet Communist re-
gime.
In 1990 on June 30, in Kyiv the First Con-
gress of Ukrainian Medical Association
was held, which renewed the organization
interrupted during the Soviet period. On
August 17, 1990 in the 3-rd Congress of
the WFUMA the UMA was accepted to
the World Federation of Ukrainian’s Medi-
cal Associations (WFUMA). Later on the
UMA was involved in:
– In 1991,May 24-30,in Ivano-Frankivsk
the 1-st Congress of Medical Associa-
tions for Ukrainians from Europe was
held;
– In 1992, February 24, the UMA was
registered by the Ministry of Justice of
Ukraine (No.209).
– In 1992,November 7,in Uzhghorod the
2-nd Congress of UMA and scientific
conference “Natural factors in sanatori-
um-resort treatment” took place;
– In 1995,April 28,in Kyiv the 3-rd Con-
gress of UMA and scientific conference
«History of Ukrainian medicine» were
held;
– In 1997, May 17, in Kyiv the scientific
conference on the problems of organiza-
tion of public health and 4-th Congress
of UMA were organized.
– In 1999, May 28-29, in Kyiv the 5-th
Congress of the UMA and scientific
conference “Primary medical healthcare
and family medicine” were arranged.
– In 2001, May 18-19, in Chernivci in the
Bukovina Medical Academy the 6-th
Congress of the UMA was held;
– In 2002, January 25-26, in Kyiv the
scientific conference of the UMA “The
system of public health of Ukraine and
the ways of reforms” took place;
– In 2003, May 16-17, in Ternopil the
7-th Congress of the UMA gathered.
– In 2005 on April 21-22, in Ivano-
Frankivsk the 8-th Congress of the
UMA dedicated to the 15th Anniver-
sary of re-establishment of the UMA
(1990-2005) in modern independent
Ukraine was held;
– In 2008 on May 10-12, in Vinnycja the
9-th Congress of the UMA took place.
During the Congress the President of
the UMA – Dr.Oleg Musii,the Honou-
rary President (Previous President of the
UMA) Dr.Ljubomyr Pyrih, the Chair-
man of Board of UMA Dr.Stanislav Ne-
chaiv and the Board of UMA (includes
33 people) were elected.
The total number of the members of the
Ukrainian Medical Association – around to
20 000 physicians from 25 regions (oblast)
of Ukraine. The number of physicians in
Ukraine is about 200 000 persons. At this
time the UMA is a non-governmental and
non-profit public organization. There is in-
dividual and collective membership in the
UMA. The individual members are physi-
cians by education. The collective members
are medical organizations of narrow special-
ists, scientists etc.
The UMA publishes a periodical of the
UMA “The Ukrainian Medical News”
journal. It was founded in 1918 and re-
newed again in 1997. Besides apart from
this UMA publishes articles and interviews
in different journals and newspapers in
Ukraine and abroad.
from common infectious diseases. Great
attention is payed to the modernization and
re-equipment of all treatment institutions.
Medical modalities are planned to corre-
spond to European standards by 2010.
Public Organizations in the
Health Care System
There are 32 medical public organizations
including the multiprofile Belarusian As-
sociation of Physicians, founded in Febru-
ary 1992. During its history, it contributed
to developing the draft of new legislation for
medicine, as well as concepts and plans for
evolving medical system, working out Medi-
cal Ethics Code.In 2007,the new agreement
on cooperation with the Ministry of Health
was signed. Currently, the re-registration of
fellows and structural units is under way, the
plans for further evolution are being made.
Some Basic Indices in 2007
Birth rate, mortality rate, infant mortal-
ity rate 10,7‰; 13,7‰; 5,2‰. Number
of medical visits per 1 inhabitant per year
12,7 (including 1,5 in dentistry). Number
of hospital beds per 10 000 of the popula-
tion 105,5. Number of admissions to the
hospital per 1000 274 individuals. Average
hospital stay 11,7 days per 1000 live births.
The following information sources have
been used:
http://www.president.gov.by/
http://medicine.belmapo.by/
http://minzdrav.by/
The Ukrainian Medical Association
is going to Europe
Part of the Board of UMA with our
international partners.
19
Financing of the UMA consists of:
– membership dues 5%
– income from publications in the journal
of the UMA – 20%
– income from participating in various
grant projects – 10%
– income from the participants of congress-
es,conferences,seminars etc.- 10%
– income from firms-sponsors, exhibitors
in the UMA congresses, conferences,
seminars etc. – 45%
In Ukraine the UMA takes part in the ac-
tivities of Public Council of the Ministry of
Health of Ukraine and in Advisory Council
of the Committee of Health of the Parlia-
ment of Ukraine.The UMA also cooperates
with the Ukrainian Medical Law Asso-
ciation and the Ukrainian organization of
protection of the patients rights «Health of
People».
In Ukraine, the system of public health
is under the control and regulation of the
government. During the two last years the
UMA has been writting and submiting to
the Parliament of Ukraine the Draft Law
“About medical self-government” (The Eu-
ropean model of public health) for intro-
duction in Ukraine.Today the promotion of
this law is one of the basic activities of the
UMA.In the international arena since 1990
the UMA is a member of the World Fed-
eration of Ukrainian’s Medical Associations
(WFUMA). The WFUMA includes the
medical associations of Ukrainians from 14
countries around the world. In addition, the
UMA has close contacts with many medi-
cal associations in other countries, first of
all with the German Medical Association
(Bundesärztekammer), the Finnish Medical
Association (Suomen Lääkäriliitto), and the
Polish Medical Association (Naczelna Izba
Lekarska).
Among strategic objectives at an interna-
tional level for the UMA is entering the
leading international medical organiza-
tions like the World Medical Association
(WMA), European Forum of Medical As-
sociations (EFMA/WHO), the Standing
Committee of European Doctors (SCED/
CPME), etc. It is decided that introduction
of the World achievments of Medicare in
Ukraine is utmost important to the citizens
of our country. The importance of health
management in Ukraine through introduc-
tion of medical self-government and medi-
cal ethics is also on UMA agenda for to-
day Entry into the WMA,SCED/CPME,
EFMA/WHO will enable us to learn the
principles represented in declarations and
decisions accepted on the World Medical
Assemblies and Forums of these organiza-
tions and introduction of these principles
in Ukraine.
Mission of the UMA is:
– to promote the prestige of doctors in
society through the observance by them
the highest standards of professional-
ism, medical ethics and education in
serving for health benefits to all Ukrai-
nian people;
– to provide a high-quality medicare;
– to help medical doctors in their influ-
ence, participation and adaptation to
changes in the system of public health;
Aims and objectives of the association:
– Assistance to protect and strengthen the
health of people in Ukraine, development
of national medical sciences, participation
in discussing medical questions,assistance
for professional growth of medical em-
ployees, their legal and social protection,
satisfaction of legitimate social, economic,
creative or other general interests.
The main tasks of UMA are:
– to assist in moral, cultural and national
renaissance of Ukrainian physicians and
all people of Ukraine;
– to increase the state and public signifi-
canceofphysician’sprofession;assistance
with the renaissance of its authority and
prestige; assistance in the improvement
of level and qualities of medical service
to all levels of population;
– to assist in growth of the professional
level of Ukrainian physicians to interna-
tional standards, by increase of qualifi-
cation and practical skills; improvement
of medical education; development of
creative potential and realization of the
right of everyone for intellectual work
and its results;
– to assist the formation of priority direc-
tions of a medical science; organize and
participate in implementation of scien-
tific researches of medicine and public
health; introduction of such achieve-
ments in practice;
– to protect the interests of members of
UMA in institutions of the government
and state control, public organizations,
court and office of the public prosecu-
tor; assistance to ensure the legal pro-
tection of their civil rights, professional,
social and economic interests.
Besides in the Ukrainian Medical Asso-
ciation (UMA) there are many societies of
narrow specialties and subspecialties for ex-
ample: cardiology, surgery, neurology, cardio
surgery, plastically surgery, pediatric, oph-
thalmology, neurosurgery, pediatric oph-
thalmology, nephrology, sexology, internal
medicine, radiology, gastroenterology, oto-
laryngology, hematology, dermatology, ger-
ontology, urology, family medicine, oncol-
ogy and etc. A physician at the same time
can be a member of various such societies.
Their basic activities are scientific researche,
improvement of qualification and training
medical doctors in their specialties. A part
of such narrow professional societies are also
collective members of our Ukrainian Medi-
cal Association. Besides in Odessa (the one
of the 25 regions of Ukraine) the Society of
Ukrainian Doctors was established with the
aim to embrace the whole Ukraine. Unfor-
tunately, it incorporated only the Odessa
region. For all the time of its existence, not
being able to expand, to our regret the Soci-
ety practically has halted its activity. There
is also a trade union of medical workers in
Ukraine. It has remained since the times
of Soviet Union. Its members are doctors,
nurses, junior nurses; hospital attendants,
paramedics and all other people who works
in medical institutions. Competence of this
trade union mainly is the treatment of so-
cial issues..
20
TheBulgarianMedicalAssociation(BuMA)
was established one hundred and six years
ago, and is therefore among the oldest pro-
fessional organizations of physicians in Eu-
rope. During the period of socialist regime,
however, it ceased to exist and was restored
in 1991 by a group of enthusiasts. At that
time membership was voluntary and the
functions of the Association were rather
limited. But the situation changed quickly
and in 1998, thanks to a strong lobby, an
act was adopted for the professional asso-
ciations of medical doctors and dentists in
Bulgaria, which regulated its functions and
was practically a legal recognition of the ex-
istence of the BuMA. Membership became
mandatory which enabled better control
to be exercised on health service quality as
well as the rights of the physicians to be de-
fended.
As a lawful representative of the physicians,
the BuMA won am important victory – the
right to be a party to the negotiation process
of determining the budget of the National
Health Insurance Fund (NHIF) and fund
allocation. From the very beginning the As-
sociation aimed at procuring the necessary
resources for improvement of healthcare
quality. Regretfully recently the NHIF did
not seem to be willing to cooperate in that
respect as a consequence of which in 2006
and in 2007 no framework contracts were
signed. This resulted in disregard of the
rights of patients and physicians and deteri-
oration of the healthcare system as a whole.
Despite the difficult situation in which it is
functioning, the Bulgarian Medical Associ-
ation makes efforts to ensure very good level
of health services through providing incen-
tives for the continuous medical education
and professional development of physicians.
It developed a credit system and undertook
crediting of different forms of CME.
The BuMA pays much attention to the
ethical issues of the profession. That is why,
besides adopting its own Code of Medical
Ethics, it acquaints the Bulgarian physi-
cians with documents of international sig-
nificance in this field, such as the Medical
Ethics Manual of the WMA, which is not
only a convenient tool for solving practical
problems, but also brings about unification
of standards and criteria in different coun-
tries. It was a privilege for the Bulgarian
physicians to have this Manual presented
personally by its author, Prof. John Wil-
liams, at a meeting held in Bulgaria in Sep-
tember, 2006.
From its restoration the organization real-
ized the significance of international rela-
tions and the need to share ideas. That is
why two years after it resumed its activi-
ties the BuMA joined the big family of the
WMA, and during the last few years be-
came full member of a number of European
organizations of physicians. This was done
for the purpose of exchange of experience
which enables finding better solutions to
problems.
The BuMA has welcomed different initia-
tives of the WMA which we believe are im-
portant for preservation of the good tradi-
tions of the profession.Bulgarian physicians
were nominated for the WMA publication
Caring Physicians of the World.We all owe
well deserved respect and recognition for
physicians who are fully devoted to their
mission and serve as an example of high
ethical standards and humanity in practi-
cing the profession.
Looking back to the years after the resto-
ration of the BuMA – almost two decades
now, and taking into account its achieve-
ments, one may say that the organization
is going in the right direction, because the
Association is heading to a future where no
boundaries would exist both for the patients
and for the physicians and everyone would
have access to high quality healthcare, re-
gardless of where they live. But this might
only happen if the professionals could make
the governments understand that health-
care is and should be regarded as a priority
issue. Otherwise total collapse of the system
might occur due to lack of medical person-
nel as we are living in a very dynamic and
mobile world and this problem is already
very familiar in some parts of the globe.
Dr. Andrey Kehayov
President
Dr. Plamen Demirov
Secretary General
The Bulgarian Medical Association
21
Dear Colleagues,
One of my proposals as president
in 2000 of the WMA was to estab-
lish the regional offices of WMA
in different parts of the world.
The rationale of this proposal was
to take into consideration differ-
ences which exist among regions
of the world in health care, medical
education, medical ethics, medical
policy, management, human right
issues etc. The WMA as a non-
governmental body may directly
contact individual NMAs and
get valid information about their
health care systems in different regions. Another output of the ac-
tivities of the regional offices is the increased visibility of the WMA
in individual regions giving them an occasion to more detailed dis-
cussions on the WMA documents, which could be tailored to their
specific conditions.
The role of the regional offices seems to me even more advantages
at present when the World Health Professional Alliance unites the
WMA, World Dental Federation (FDI), International Pharmaceu-
tical Federation (FIP) and International Council of Nurses (ICN)
bringing together more than 23 million health care professionals
worldwide. (The WHPI should consider accepting also the World
Federation of Medical Education) with the secretariat recently tak-
en over by the secretariat of WMA.
The Regional office for Central and East European countries was
founded in 2000 and hosted already 4 meetings. At the last one in
Prague in December 2006 also other European NMAs were present
including the general secretary and the president of the WMA.The
program of the meeting included actual health care issues as avian
influence, smoking and nutrition in respective regions.
The CzMA proposes to revitalize the activities of the regional offic-
es and establish the regional offices of WHPA, perhaps in Prague.
With kind regards,
Professor Jaroslav C MD.,DSc.
President, Czech Medical Association
Former president, WMA
Our Association is a voluntary and in-
dependent organization of medical doc-
tors, pharmacists and other workers in the
healthcare service and related fields in the
Czech Republic.
The number of our members has been grad-
ually rising since 1989 when the CzMA be-
came a democratic institution with demo-
cratically elected president and council. The
members of the CzMA are affiliated on the
basis of their specialities in individual scien-
tific societies. In larger cities the doctors or-
ganize the local medical clubs.104 scientific
societes and 40 local medical organizations
are currently working within CzMA. Both
Czech citizens and foreigners may become
members of the CzMA. Medical doctors
and associated health workers represent 90
p. cent of all health personnel in the repub-
lic.
The history of the CzMA dates from the
middle of the 19th century and is closely
linked with propagators of national Czech
medical science. Their main representative
was Jan Evangelista Purkyně (1787-1869),
a world renowned scientist in physiology.
His name thus gives prestige to the title of
our Association. By associating ourselves
with this great personality we wish to ex-
press that we are continuing the traditions
of the humane and scientific legacy.The aim
of J. E. Purkyně and his colleagues was,
above all, the development and propagation
of knowledge of medical sciences and relat-
ed fields and their application in healthcare
for people. These fundamental aims remain
unchanged to the present time.
The CZMA is involved in postgraduate and
continuing medical education in almost all
fields of medicine, in organizing national
and international congresses, symposia,
course etc.
The CzMA has also close relations with Eu-
ropean and medical associations worldwide.
Of these the most important is the World
Medical Association (WMA), the Forum
of European Medical Associations within
WHO, the Council for the International
Organization of Medical Sciences within
WHO (CIOMS).
Thanks to the reputation of our Associa-
tion, the CzMA also awards honours and
prizes which are received with the respect
they deserve.
The Czech Medical Association
J. E. Purkyně (CzMA).
22
The Austrian Medical Chamber is the statu-
tory professional organization of all doctors
practising in Austria. We represent approxi-
mately 38 000 doctors – working either in
a self-employed, or in an employed capac-
ity. On the one hand, the Austrian Medi-
cal Chamber represents their professional,
social and economic interests, on the other
it constitutes the competent national author-
ity for Austrian doctors. The responsibilities
of the Chamber comprise, besides others,
the following areas: involvement in medical
training, continuing medical education and
professional development, quality assurance
in continuing medical education and medi-
cal practice, the conclusion of contracts with
social insurance institutions and of collective
agreements,admission to and administration
of the medical register,recognition of foreign
medical diplomas, execution of disciplinary
legislation and arbitration.
The Austrian Medical Chamber deals with
a variety of issues at national and interna-
tional level.The reform of the medical train-
ing system and a recent governmental plan
to restructure the Austrian health system are
some of the current issues at the national
level. At the international level, the Medi-
cal Chamber is mainly concerned by Euro-
pean Union issues such as the migration of
doctors, the Working Time Directive, the
Health Services Directive, eHealth, etc.
In Austria, the medical training system is
structured as follows: after having completed
6-year medical studies, doctors must engage
in a 3-year medical training as a general
practitioner or a 6-year medical training as
a specialist in order to obtain their licence to
practice. Due to a lack of training positions
in Austria, many doctors migrate to other
EU-countries for training purposes. At pres-
ent, there are concrete plans for a reform of
the training system and the introduction of
a one year post-gradual training programme,
after which doctors will be awarded their
licence to practice. Besides, general practice
will become a specialty with 5 years of practi-
cal training after the first, basic year. In 2007,
Austria also underwent some changes in the
training regulations introducing 3 new spe-
cialties: cardiac surgery, thoracic surgery and
child and adolescent psychiatry.
The Austrian Medical Chamber is very con-
cerned about the above-mentioned govern-
mental plans to restructure the health system.
Despite Austria was awarded the top position
intherankingofconsumer-friendlyhealthsys-
tems in Europe (European Health Consumer
Index 2007), the Health Ministry tried to in-
troduce what the Austrian Medical Chamber
qualifies as a nationalisation and centralisation
of healthcare,i.e.transfer of the Austrian Med-
ical Chamber’s competence of decision on the
number of contracts with social security bod-
ies to the ministry, introduction of guidelines
on the treatment of patients by the ministry,
control of the ministry over quality assurance,
etc. For that reason the president of the Aus-
trian Medical Chamber, Dr. Walter Dorner,
met with the Health Minister, and a declara-
tion of intention was signed, confirming that
there will be no reform of the health system
before a discussion with the Medical Chamber
has taken place. In addition, the Austrian and
the regional medical chambers called upon all
Austrian doctors to inform their patients on
the dangers of the initial plans of the govern-
ment.For this purpose,a so-called information
day was organised on November 8th, 2007 in
medical practices all over Austria. Unfortu-
nately,some of the concerns raised by the med-
ical body proved later not to have been taken
into account.Therefore, the Austrian Medical
Chamber is still monitoring very carefully the
next steps of the government.
From the international point of view, the
Austrian Medical Chamber is very active and
thus a member of different European and in-
ternational organisations such as the WMA,
CPME, EFMA/WHO, FEMS, UEMS,
etc. Migration of doctors within the EU is
also an important issue. As described earlier,
Austria is soon to adapt its system so as to en-
able an even smoother migration of Austrian
doctors. The Austrian Medical Chamber is
also in close contact with Germany and has
recently concluded a friendship treaty with
the German federal state of Saxony aiming to
promote bilateral mobility of doctors. Friend-
ship treaties with other German states are to
follow. This initiative is also supported by the
European Union in the framework of the life
long learning initiative.
The Austrian Medical Chamber
Vice-President Harald Mayer, President Walter Dorner, Vice-President Artur Wechselberger,
Vice-President Günther Wawrowsky. Photo: Alfred Habitzl.
23
Liberal practice,which for physicians means
clinical independence in selecting the best
therapy for patients, seems to be a disrup-
tive factor in a system of increasingly state-
controlled health management in Germany.
But physicians are demonstrating a new
degree of solidarity, and the German Medi-
cal Association is fighting fiercely for the
freedom and independence of the medi-
cal profession and the provision of the best
medical services available for patients.
The Federation of the German Chambers of
Physicians(“GermanMedicalAssociation”-
GMA) was founded in 1947 as the working
group of the West German Chambers of
Physicians. Today, all 17 State Chambers
of Physicians are represented by the GMA.
Membership in a Chamber of Physicians is
obligatory; the GMA represents all 413,696
physicians, of whom 314,912 are practising
(2007) – about 48% in the inpatient sector
and 44% in the outpatient sector1
. As part
of the statutorily regulated system of self-
government of the medical profession, the
Chambers of Physicians are responsible for
safeguarding the professional interests of
1 National Association of Statutory Health Insurance
Physicians, Department 4.1 (Need Related Planning,
Federal Registry of Physicians and Data Exchange)
the physician community and exercise the
sovereign task of registering and supervising
physicians.They regulate and promote post-
graduate medical education and continuing
medical education and ensure the high ethi-
cal and scientific standards of doctors.
The elected presidents of all 17 State
Chambers become members of the GMA
Council, which convenes every month for
an all-day meeting at the GMA’s headquar-
ters in Berlin. The GMA mediates the ex-
change of opinions and activities between
the State Chambers, mutually coordinating
their goals and working towards the most
uniform possible regulation of all activities
in the different regions.The 17 State Cham-
bers send a total of 250 delegates to the an-
nual Medical Assembly, which serves as the
“parliament” of the physicians in Germany.
The Assembly elaborates and adopts regu-
lations regarding the professional code of
conduct and postgraduate medical educa-
tion curricula, passes changes in the statutes
of the GMA and agrees on official positions
on health policy issues. It establishes per-
manent or temporary committees to deal
with individual subject areas and ongoing
questions. The Assembly also elects the
President and two Vice-Presidents of the
German Medical Association. Prof. Jörg-
Dietrich Hoppe was re-elected as President
for another four-year term at last year’s
Medical Assembly. Dr. Cornelia Goesmann
and Dr.Frank-Ulrich Montgomery are cur-
rently serving as Vice-Presidents.
With a population of 82.3 million, Ger-
many has about 3.8 practicing physicians
per 1,000 residents (2007)*. Although the
number of medical school graduates has re-
mained relatively constant in recent years, it
seems that a serious shortage of physicians
will become a major issue in the near future.
In 2006, more than 2,500 mostly young
physicians left the country for better salary
and improved working conditions abroad*.
In addition, many medical school graduates
chose to work in other, better-paid indus-
tries. Although Germany records a relative-
ly high number of physicians immigrating
from abroad, many more physicians will be
retiring in the next few years. As a result,
the provision of medical care may be jeop-
ardised, especially in rural areas.
One of the tasks of the GMA is to respond
to the needs of the high number of migrat-
ing physicians. Another task is maintaining
contacts with other national medical asso-
ciations and international healthcare organi-
sations worldwide. On behalf of Germany’s
physicians, the GMA collaborates with the
Standing Committee of European Doctors
(CPME) and has been an active member
of the World Medical Association (WMA)
since 1951,where two GMA representatives
are currently serving on the Council of the
WMA. The GMA continuously supports
the WMA’s various activities, and GMA
staff is actively involved in several WMA
working groups, task forces and a number of
projects, most recently the MDR-TB online
course for physicians. The publishing house
of the GMA’s weekly “Deutsches Ärzteblatt”
journal has been serving as the publisher of
the World Medical Journal for many years.
Dr. Ramin Parsa-Parsi, MD, MPH
Head of the Department for
International Affairs
The German Medical Association
Fighting fiercely for the freedom and independence of the medical profession
Prof.Dr.Dr.h.c. Jörg-Dietrich Hoppe
Prof.Dr.Dr.h.c.Dr.Karsten Vilmar,Treasurer
Emeritus of WMA
24
The Georgian Medical Association (GMA)
isthedoctors’independent,professionalorga-
nization established to look after the profes-
sional needs of Georgian Physicians. GMA
was established in 1989 and is considered
as the first professional non-governmental
organization in the country.The GMA rep-
resents doctors in all fields of medicine all
over the country. The GMA is the voice for
doctors, residents and medical students – in
constant contact with relevant national au-
thorities.The Georgian Medical Association
plays an active role in the opinion-forming
process in relation to health policy in society,
and in legislative procedures.
The mission of Georgian Medical Associa-
tion is to serve and unite the physicians in
the country, for the highest achievable stan-
dards of health care; to promote the art and
science of medicine and the improvement
of the public health.GMA works for and by
the medical doctors. In addition, the one of
the important directions of activities are the
patients’ rights, quality of care and patients’
safety.
GMA Membership is voluntary based. The
types of membership include: individual,
collective, junior and honorary members.
More than 50 professional field associations,
working in different branches of medicine
are the collective members of the GMA.
Thus, the Georgian Medical Association
represents the umbrella organization for the
medical profession and organized medicine
in the country.
The GMA is governed by the General As-
sembly (GA), which is the highest legisla-
tive and decision making representative
body. General Assembly elects the GMA
Board of Directors and giving the creden-
tial to this structure for governing the asso-
ciation between the periods of the GA.The
Board of Directors includes the leaders of
GMA: President, Vice-President, Secretary
General and heads of committees. Geor-
gian Medical Association represents the
Georgian Medical Profession on European
(European Forum of Medical Associations
and the WHO) and International (World
Medical Association) levels.
The relations with the Parliamentary Com-
mittee on Health care are developing ra-
pidly and fruitfully. We are often invited
by the parliamentary committee for Health
Care to participate in discussions on health
care legislation and initiatives. During the
years we have submitted several proposals to
the Parliament to strength the protection of
physicians’ legal, social and professional in-
terests. Georgian Medical Association ini-
tiated the preparation of amendments and
additions to the Georgian Law of Medical
Activities. The GMA requested to add to
the Law the additional chapter (94-1) on
Legal Safeguards of Physicians. The GMA
presidium discussed the amendments and
submitted the document to the Health Care
Committee of the Parliament. Another im-
portant direction of our activities is the rela-
tionship with the Office of Georgian Public
Defender. We are participating in joint task
force for elaboration of the amendments
and changes in the Georgian Law of Pa-
tients’ Rights.
The Georgian Medical Association is ac-
quiring more and more important functions
in health care sector of the country. The as-
sociation closely cooperates with the Minis-
try of Health, Labor and Social Affairs and
State Medical Regulation Agency.Based on
this cooperation, GMA is carrying out the
following activities:
Medical Education: The members of the
GMA in association with the Tbilisi State
Medical University elaborated the Post-
graduate Curricula in several medical spe-
cialties.
Professional Liability: The physicians’
rights were widely violated several months
ago. The complaints of the patients (one
year ago) in most of the cases were the back-
ground for professional or even criminal li-
The Georgian Medical Association
25
ability of practitioners.The GMA expressed
its concern and strong position against this
trend. GMA raised this issue in Health
Care Committee of the Parliament. The
negotiations with the ministry of Health,
Labor and Social affairs finished success-
fully.The GMA was delegated the privilege
to appoint professional medical experts for
investigation and review of medical records.
Nowadays, any professional complaints
against the physicians are forwarded to the
GMA and the decision of the Licensing
Board now is based on alove conclusions.
As a result, the physicians now are more
protected and professional issues are solved
only by professionals.
Professional Standards: The GMA started
elaboration of the document about the Pro-
fessional Framework of medical special-
ties. A part of the documents are already
submitted to the Ministry of Health. As
a result, the ministry reviewed existing
standards and started amendments. The
GMA is continuing the work on National
Guidelines on Good Medical Practice. We
strongly believe that mentioned document
will improve the relations between the state
and medical professionals. The members
of the GMA, together with the different
professional associations are very active in
elaboration of the National Medical Guide-
lines and Protocols. Recently,The Georgian
Medical Association, in association with
the Georgian Association of Surgeons
elaborated the guidelines for management
of surgical emergencies in clinical practice
for 4 diseases.
Licensing and Certification of Physicians:
The Georgian Medical Association is ac-
tively involved in the process of the Licens-
ing and Accreditation of the Physicians.
Recent times, GMA was invited by the
ministry of health to carry out the techni-
cal and organizational support of the exams.
The persons recommended by the GMA
are appointed as a Chairs and Members of
the Examination Commissions. The GMA
leaders are chairing the examination com-
mission for the GP Licensing process, as
well as the Appellation Commissions. The
examination tests are to be renewed before
each examination session. The GMA in
collaboration with the professional medi-
cal associations are making the mentioned
updates and amendments.
Medical-SocialExpertise:GeorgianMedi-
cal Association and the experts from GMA,
are providing the training cycles for the staff
responsible for provision of Social-Medical
Expertise to decide about the matter and
degree of disability (mental and physical).
RightofPhysicians: Georgian Medical As-
sociation is supporting its members, as well
as non-member physicians in case of medi-
cal litigation. GMA representatives are at-
tending the judiciary processes and submit-
ting the professional conclusions in favor of
medical doctors if the association believes
that the doctor is deserving support. GMA
tries to make the evident border between
the medical error and medical crime. We
strongly believe that the physicians should
not be sentenced by the criminal courts for
medical errors!
Ethical Standards: One of the most im-
portant directions of the GMA’s activities is
the development of Code of Medical Eth-
ics. The Code is obligatory for the GMA
members.
Human Rights: Georgian Medical As-
sociation, in close partnership with lo-
cal organizations (RCT/EMPATHY and
ARTICLE 42) developed and successfully
completed the Istanbul Protocol Develop-
ment Project (1 and 2 phase 2003-2007).
The international partners of the project
were: WMA, Physicians for the Human
Rights – USA, Human Rights Founda-
tion – Turkey,Redress and the International
Rehabilitation Council of Torture Victims
(Denmark).In the Frames of the Project,15
medical professional was prepared and cer-
tified as an international expert in effective
medical investigation and documentation of
torture victims. The physicians prepared by
the project now are used as trainers in other
countries of the world.
Undergraduate Medical Education Stan-
dards: GMA is working now on the under-
graduate medical education curricula. The
standards should be based on recommen-
dation of the World Federation of Medical
Education / WHO. All the Quality Assur-
ance tools are emphasized. In this respect,
the GMA has the close partnership with
Tbilisi State Medical University. Tbilisi
State Medical University is kindly offering
the office space for GMA during the past
years up today.
Foreign Medical Graduated: According
to the Georgian Law on Medical Activi-
ties, any foreign graduate, applying for the
working License of the physician in Geor-
gia should be recommended by the profes-
sional association. Recent years, more and
more foreign graduates are applying us for
recommendation. GMA is reviewing the
applications and after the final interview is
giving or declining the recommendations.
Georgian Law on Medical Activities stipu-
lates that any incoming foreign practitioner
should have a temporary license for tempo-
rary work permit in the country. Georgian
Medical Association is active also in this
direction. In this respect our obligation is to
find and collect the data about the clinical
competence of the incoming physician and
recommend them to the Licensing Board
for granting the temporary working license.
Regulatory Boards: The leaders of the
Georgian Medical Association, according
to the local legislation are invited to work in
different health care regulatory boards, such
as: State Licensing Board of Medical Per-
sonnel; The Board of Postgraduate Medical
Education and CPD; National Bioethical
Council.
Abovementioned activities carried out by
GMA is positively reflects on physicians
professional environment and conditions.
Dr. Levan Labauri M.D., Ph.D.
Secretary General, Georgian
Medical Association
26
The Israeli Medical Association (IMA) is
an independent professional organization,
advocating for the rights of physicians and
patients throughout Israel. Established in
1912, 36 years before the founding of the
State of Israel,the IMA has been confirmed
by the courts as the representative body of
physicians in Israel. Although membership
is on a voluntary basis, 94% of physicians in
Israel are members of the IMA. The IMA
also includes within its ranks 155 scien-
tific associations, societies and workgroups.
The IMA is responsible for setting profes-
sional norms and ensuring high standards
of medicine along with ethical behavior and
professional integrity.It also strives to secure
the physician’s status, rights and autonomy.
In recent years, the IMA has expanded its
function to take a greater role in shaping
national health policy, influencing the legis-
lative process, and promoting public health
and quality assurance.
The IMA has recently been involved in seve-
ral key processes intended to improve the
situation of both the individual physician as
well as the state of health care in Israel.
In July 2000, the IMA agreed on behalf of
all publicly employed physicians to give up
the right to strike for ten years in exchange
for mandatory arbitration. The arbitration
process only began in 2005 and continues
today. The arbitrators are expected to ar-
rive at a final decision within the coming
months.
The IMA’s list of demands include an ad-
ditional salary of approximately 32% (for
public doctors), accounting for a physician’s
overtime work when calculating his/her ba-
sic salary, a solution to the shortage of pro-
fessionals in certain specialties, allocation of
time and remuneration for those physicians
who participate in CME/CPD and increas-
ing pension pay from 70 to 85% of a physi-
cian’s basic salary.
Another recent development which the
IMA initiated was the establishment of
the Public Forum to Update the Basket
of Health Services. This public forum was
formed when the Ministry of Health’s ad-
visory committee on the yearly basket of
health services reduced the amount of phy-
sician and patient advocates allowed to serve
on the committee. The Forum included
experts in ethics and health economics, pa-
tient advocates, public representatives, and
clergy members. As a result of the estab-
lishment of this alternative committee, the
Israeli Medical Association was successful
at expanding the amount of resources com-
mitted to the basket of health services from
250 million New Israeli Shekels to 400
million New Israeli Shekels. Additionally,
the alternative committee’s establishment
caused a ripple effect on the Ministry of
Health’s advisory committee, resulting in
more transparent procedures, hearings that
included patient testimony,the allowance of
criticism from the media, and the opening
of an advisory committee website.
On the international front, the IMA has
been an active member of the World Medi-
cal Association for many years, drafting and
contributing to statements and declarations
and providing representation to several com-
mittees. Dr. Yoram Blachar, current WMA
President-Elect, has served as chairman of
the Socio-Medical Affairs Committee and
the Finance and Planning Committee, in
addition to two consecutive terms as Chair-
man of Council. Adv. Leah Wapner assists
with legal counsel to the WMA and Adv.
Malke Borow serves as an advisory member
of the Medical Ethics Committee.
Currently, the IMA serves as a member of
the workgroup on stem cells, and a member
of the workgroup on clinical trials involving
children, as well as leading the workgroup
on task shifting, which will result in the
drafting of a statement on the topic. Addi-
tionally, the IMA is at work on a number of
other draft statements on different topics.
One of Dr. Yoram Blachar’s goals for his
upcoming presidency at the WMA is to in-
crease the WMA’s Arab member constitu-
ency. During his term as President-Elect,
Dr. Blachar has already made contacts with
various heads of NMAs of Arab countries
currently not members of the WMA. Dr.
Blachar will continue with these recruitment
efforts during his upcoming presidency.
The Israeli Medical Association
Adv. Leah WapnerDr. Yoram Blachar,
President–Elect of WMA
27
The Estonian Medical Association (EMA)
is a voluntary nongovernmental organisa-
tion representing the interests of Estonian
doctors. The EMA was founded on Febru-
ary 28 1921 as an Association of Estonian
Medical Societies, dismissed in year 1940
by Soviet regime, and refounded on June
11, 1988 as a National Medical Association.
EMA has the functions of trade union since
1992.
The main objectives of The Estonian Medi-
cal Association are to unite the physicians,
develop and elaborate health policy,medical
culture and ethics in Estonia as well as re-
present and protect the professional inter-
ests and rights of the members of the EMA.
The EMA participates in the elaboration of
the legislation concerning health and is rep-
resented in a number of organizations and
commissions coordinating health care.
More than 70 % of Estonian doctors belong
to Estonian Medical Association. Besides
regional medical associations also the Esto-
nian Junior Doctors’ Association belongs to
the EMA.
Dr. Andres Kork- a general surgeon at the
West Tallinn Central Hospital has held the
post of the president of association since
2002. The General Assembly is the highest
decision-making body that is summoned
once a year in November. The Council pre-
sides the EMA in the recesses.The Council
is comprised of the president, Board mem-
bers and the representatives of the regional
associations. The Board is the organ of the
executive-organizational administration of
the EMA.
The EMA publishes its journal,the Estonian
Medical Journal (www.eestiarst.ee), which
also contains original research reports. De-
spite the fact that the number of people
speaking Estonian is fairly low, EMA has
made the best efforts to translate most of
the medical terms int Estonian and keep
the language medically useful.
International relations
The Estonian Medical Association is a full
member of the major medical organizations
in Europe: the Standing Committee of Eu-
ropean Doctors (CPME) and the European
Union of Medical Specialists (UEMS). Es-
tonian Junior Doctors’ Association (EJDA)
is a full member of the Permanent Working
Group of European Doctors (PWG).EMA
has joined World Medical Association in
year 2004.
EMA and WMA
There is no doubt that the World Medical
Association is one of the most influential
medical organizations worldwide. As Esto-
nians have experienced the soviet political
system which did not comply with the ba-
sic human rights and democracy we highly
value the firm standpoint WMA has always
had in these key questions.
Last year the EMA in conjunction with the
Medical School of Tartu University pub-
lished the Estonian version of the WMA
Medical Ethics Manual. Now every medi-
cal student will receive his or her own copy
of the WMA ethics manual when having
ethics classes. Besides being a very clear and
concise handbook of ethics, I believe that
many students will realize with the help of
that book, that the work and ethical stan-
dards of doctors is very similar in various
countries.
Vallo Volke MD, PhD
Board member of Estonian Medical
Association
The Estonian Medical Association and WMA
28
Outline of the JMA
The Japan Medical Association (JMA) was
first established in 1916 and took on its
present form following the Second World
War in 1947. Membership comprises mem-
bers of Japan’s 47 local medical associations.
As an academic organization,the JMA aims
to promote policies that ensure the health
of the general public and the autonomy of
medical professionals through the formula-
tion of national medical policies. Member-
ship is voluntary, and currently numbers
165,000 (as of December 2007), which is
60% of the number of physicians in nation-
wide (approx. 270,000). Of these, approx.
85,000 are clinic physicians and 80,000 are
hospital-based physicians.
Association affairs and important matters
must be decided by the JMA Board; the
highest decision-maiking organ is the Gen-
eral Assembly of House of Delegates. The
Secretariat comprises 226 staff (as of Decem-
ber 2007) and the Secretary General must be
a qualified physician (Tables 1 and 2).
Two WMA Presidents
The JMA has provided by two WMA Presi-
dents,Dr.Taro Takemi and Dr.Eitaka Tsuboi.
Dr. Taro Takemi served as President of the
JMA for 25 consecutive years, from 1957
until 1982. In 1975, he was appointed as
the 29th WMA President and the WMA
General Assembly was held in Tokyo in the
same year.Early in his research efforts on the
theme of “the development and distribution
of medical resources”, Dr. Takemi foresaw
that Japanese healthcare would in the fu-
ture become intertwined with global health
in the future. Dr. Takemi also took part in
the establishment of the Confederation of
Medical Associations in Asia and Oceania
(CMAAO) in 1956, a major aim of which
was to gather together of the voices of Asian
physicians and to deliver them to the WMA
for discussion. CMAAO membership now
comprises the national medical associations
of 17 countries, with the confederation car-
rying out various activities in order to raise
health standards for the people of the region
through the promotion of exchange between
physicians and information exchange.
Dr. Takemi also founded the Takemi Pro-
gram in International Health at the Har-
vard School of Public Health in Boston in
1983 with the aim of providing opportu-
nities for health professionals, particularly
those in developing countries, to futher
improve their skills. Even now, the program
recruits approximately 10 researchers from
all around the world every year. Those who
have completed the program are known as
“Takemi Fellows”and they play central roles
in healthcare all over the world.
Dr. Eitaka Tsuboi served as JMA President
from 1996 to 2004; in 2000,he was appoint-
ed as the 52nd WMA President and the
WMA General Assembly was held again
in Tokyo in 2004 after a break of 25 years.
Dr. Tsuboi was tireless in his international
contributions, such as the implementation
of health programs in developing countries.
In 1997, the Japan Medical Association
Research Institute (JMARI) was estab-
lished as a Think Tank for supporting the
“Development of Health Care Policies for
the Japanese People” promoted by the JMA
through research activities, information
gathering, and survey analysis. The JMA
incorporates the results of JMARI research
into its policy proposals and on occasion
presents these directly to political party re-
views as “Medical Workplace-led Policies”,
The International Activities of
the JMA and the WMA
Table 1. Organization of the JMA
1. Membership is voluntary.
2. There are 165,000 members (out of
270,000 physicians in Japan).
3. The highest organ is the General
Assembly of House of Delegates.
4. The JMA Board serves as actual
decision-maker.
5. Secretariat of 226 people works
to implement the decision of the
board.
Table 2. Secretariat of the JMA
1. Number of staff: 226; 185 are full-
time.
2. Three departments and 20 divisions.
The International Division has
5 staff.
2. JMA Research Institute: est. in 1997
3. Top is Secretary General (MD).
4. Office hours: 9:30 to 17:30; Monday
to Friday.
CMAAO Congress in Pattaya, 2007
29
Long tradition
The Viet Nam Medical Association (VMA)
was established more than half a century
ago, in 1955, and since then has brought
medical doctors and pharmacists together
under the mission of unification for the de-
velopment of Viet Nam and to improve the
quality of heath care for all, with a focus on
independence and medical ethics.
During the development of the VMA,some
specialties,including pharmacists,tradition-
al medical doctors and acupuncture doctors,
lobbied to create independent associations
for each of these professions. Based on the
principles of voluntarism,the Exco of VMA
agreed with this request to split these pro-
fessional groups into specialty associations
as well as incorporate a number of new as-
sociations under the VMA umbrella. Now
the VMA has 43 national specialties and 63
provincial Medical Associations, as well as
the Viet Nam Nurses Association and the
Viet Nam Midwives Association.
Since its establishment, the Presidents of
the VMA have been symbols of Viet Nam
intellects, both in general and especially
within the medical sector. Two of them
have been chosen as the namesakes for two
streets of the capital city HaNoi.
Transparency
The VMA concentrates on publishing
Medical Journals. Four of the journals were
established fifty years ago, a further journal
The Viet Nam Medical Association (VMA)
as opposed to bureaucracy-led or financially
led policy proposals.
Current and Future
International Activities
The current executive of the JMA regards
community healthcare in Japan as a part of
global health and has carried out activities
with an emphasis on international coop-
eration. The JMA Journal, official English
journal of JMA, together with its English
website, introduces major activities of the
JMA including those of local medical as-
sociations, such as health policies, advocacy
policies, analysis of health systems, reports
of Takemi fellows and conferences and lec-
tures. It also publishes international topics
contributed by WMA and CMAAO re-
lated to physicians. This journal is a com-
prehensive one introducing JMA activities
from the global perspective.
Three of the current WMA council mem-
bers are from the JMA, and thus policy do-
cuments adopted by the WMA are always
reported to the JMA Board.Important doc-
uments such as the Declaration of Geneva,
Declaration of Helsinki, and Declaration
of Lisbon are used as necessary as reference
materials in JMA Ethics Committee and
Patient Safety Committee discussions. In
the spring of 2007, 220,000 copies of the
Japanese version of the “WMA Medical
Ethics Manual” were published and not
only distributed to all JMA members, but
also given to 45,000 medical students at 80
medical colleges nationwide as part of the
JMA’s support for medical education.
Information is also actively exchanged with
individual national medical associations
throughout the world. A broad range of
information from both around Japan and
from overseas is necessary for resolving
various health issues faced in Japan and
international community as well, but over-
seas information obtained from the inter-
net does not always meet our requirements.
An international network centered on the
WMA and CMAAO would be an extreme-
ly effective means for medical associations
to efficiently acquire accurate and wide
scope of information from overseas. In ad-
dition to expressing our heartfelt gratitude
to the responsible officers in the NMAs that
cooperate regularly with the JMA, we hope
that this type of cooperation in exchanging
information among NMAs will be main-
tained in the future.
Masami Ishi, MD
Executive Board Member, Japan
Medical Association
Council Member, World Medical Association
MASEAN 12th Midterm Meeting Council Hanoi Vietnam 10. November 2007. Delegates
from: Indonesian Medical Association, Medical Association of Lao PDR, Malaysian Medical
Association, Myanmar Medical Association, Philippines Medical Association, Singapore Medical
Association, Medical Association of Thailand, Vietnam Medical Association, Ministry of Health,
Brunei Bandar Seri Begawan
30
By all the historical accounts, the 4th
of Janu-
ary 1958 was a significant defining moment
for the future of the medical profession in
Ghana. In many ways, the significance of
that achievement was not without drama of
its own, deeply steeped in the rich colonial
and political ethos of the time.
Mind you, 1958 was the year after Ghana,
the first country south of the Sahara had
achieved its independence. Kwame Nkrumah
the Osagyefo was busily stamping the Gha-
naian seal on all National emblems, monu-
ments and organizations. Above all perhaps,
he was also breaking off the shackles of
colonialism from the minds of the recently
colonized. The year was also interesting for
keen observers of the medical scene not
least because it witnessed the co-existence
of two bodies which could neither be said to
be serious rivals and yet not exactly comple-
mentary of each other’s activities. Within
this politically charged context, there had
existed 25 years back in 1933, an organiza-
tion of mainly African medical practitioners
whose main purpose according to celebrated
medical historian, Prof Stephen Addae was
to “act as a vehicle for redressing grievances
of African medical officers in government
employment.” It had Dr. F. V. Nanka-Bruce
as its first President and Spokesman and was
officially known as the Gold Coast Medical
Practitioners Union.
But it was a beginning.
The second more powerful group of doc-
tors was formed in January 1953 and was
known as the Ghana Branch of the Brit-
ish Medical Association. Mind you, in
the Gold Coast, the interests of medical
practitioners were advanced by the parent
British Medical Association whose branch
it was. With an African government taking
up the reigns of leadership in 1951, it must
have felt increasingly anachronistic to look
back to Great Britain for leadership. Be-
ing better connected and grouping a larger
body of doctors, this second group was
more vibrant.
In fact in the words of Prof Addae, “the re-
cords indicate that the Branch Association
was a very active body…It quickly established
a good working relationship with the new Af-
rican government and was soon recognized
as the negotiating body for the medical pro-
fession in the country. It participated in the
new Ministry of Health’s plans for setting up
a Medical and Dental Board and amending
the existing Medical and Dental Practitioners
Ordinance. Political goodwill prevailed.” This
Branch was led first by Dr. F. V. Nanka-Bruce
of the initial Practitioners Union whose brief
tenure was followed by the election of anoth-
er African, Dr. C. E. Reindorf following the
former’s sudden death after only five months
in office.
Theoretically therefore, by 1958 when the
Ghana Medical Association was formed, we
had these two bodies championing the cause
of doctors in modern Ghana. Increasingly
however, according to the late Dr. M. A Bar-
nor, third GMA President in his book A Socio-
Medical Adventure in Ghana, debate had long
been on-going as to how to transform the
Branch organization as the Gold Coast itself
began in 2007 and 30 journals belong to na-
tional specialties.
International relations
The VMA was accepted fully as member of
the South East Medical Association (Mase-
an) and have hosted two Masean meetings
in Ha Noi .
In addition, we have good relationships
with the UK and USA Medical Associa-
tions as well as excellent linkages with the
World Medical Association.
VMA will advocate a comprehensive policy
approach against Hepatitis B, supported
by Bristol Squich Meyer. In addition, Path-
finder International will provide a project of
capacity building for VMA in three years,
starting from 2008.
Consultant for MOH
VMA has been actively involved as a con-
sultant for MOH, especially on policy and
health system structure and organization.
The VMA now conducts monthly meet-
ings with the Minister of Health to ensure a
regular dialogue on key issues.
VMA will continue to promote a prior-
ity focus on improvements in the mental
health of mothers and infants in collabora-
tion with the Research and Training Centre
for Community Development (RTCCD), a
local NGO with remerkable skills and abili-
ties in this area.
Some ideas on further
activities of WMA.
The 21 century is the Century of Knowl-
edge and globalisation is on the way to be-
ing realized. The WMA must be the key
association to provide continuing education
as well as communication on the key health
issues throughout the world. However the
majority of medical associations are not in a
position to make large payments, therefore
free membership is necessary to ensure that
the collaboration between organizations
as well as knowledge dissemination by the
WMA continues.The VMA hopes that the
WMA will have the innovation to realize
this noble task.
Pham Song
President of VMA .
The Ghana Medical Association
50 years of health advocacy, policy dialogue and welfare
31
moved from a colonial status to an indepen-
dent nation.
Now, this is where the plot thickens for within
less than a year of his return to Ghana after
his studies in America and Canada, one Dr.
Schandorf in partnership with a few others
achieved what others had only been debating
for years. In Dr. Barnor’s opinion, Dr. J. A.
Schandorf whom he described as a “medi-
cal entrepreneur” and who was later elected
the second president of the Ghana Medical
Association was not controversial in what he
set out to do.
“It was the way he went about doing it-which
was the right way-but which people thought
was controversial”, observes Dr. Barnor.
And just what did our second president do?
Once again, we defer to the first hand ac-
count of second general secretary and third
president, Dr. Barnor.
“One day in 1958, there was a newsflash in
the ‘Daily Graphic’ newspaper. The newspa-
per announcement indicated that a newly ar-
rived doctor and a medical entrepreneur from
the United States, Dr. J. A Schandorf had an-
nounced he was going to launch a ‘Ghana
Medical Association’ which would be recog-
nized by government and would also be the
mouthpiece of the profession in the country.
The ceremony was to be performed by the
Prime Minister, Dr. Kwame Nkrumah”
From all indications, Schandorf was strate-
gic if not radical. As an American-trained
doctor, he had been denied registration in
England when he tried. He, therefore must
have had his motivation for wanting a Ghana
Medical Association that was not a branch of
the British Medical Association. Secondly, he
had a personal relationship with the Prime
Minister with whom he had attended Lincoln
University in the United States. Thirdly, he
managed to rope in other heavy weights like
Dr. C. E. Reindorf, Chairman of the Gold
Coast Branch of the British Medical Associa-
tion and Dr. W.A.C Nanka-Bruce, one time
Secretary of the original Gold Coast Medical
Practitioners Union.
And so it happened that on the 4th of Janu-
ary 1958 at 5 pm in the Arden Hall of the
Ambassador Hotel, Prime Minister Kwame
Nkrumah duly launched the GMA after
stating “how pleased he was that the Ghana
Medical Association was going to be formed,
and that that would mean a strong body of
doctors would from then on exist to help
both the government and the medical pro-
fession itself.The Prime Minister also added
that ‘from now on, the Ghana Medical As-
sociation is the only organization of doctors
my government is prepared to recognize’.
Growing Pains
In the immediate aftermath of its formation,
the GMA had to deal with issues of estab-
lishing the credibility of this first professional
body including popularizing it among doctors
and the general public, securing funding for its
activities and contributing to the larger health
agenda of the newly independent nation. And
so it was that a new Executive was elected led
by Prof Charles Odamtten Easmon as First
President and Dr. F. T Sai as his Secretary with
the latter being later succeeded by Dr M. A.
Barnor on his departure to the United King-
dom for further studies in Internal Medicine.
As early as July 1959, Divisions of the GMA
began to be set up in various parts of the coun-
try with Ashanti-Brong Ahafo being the first
Division. This Division, an amalgamation of
doctors from two Regions was led by Dr. Evans
Anfom who would later become the 5th GMA
President. This was followed almost immedi-
ately the following month by the inauguration
of the Western Division which incorporated
the Western and Central Divisions. To quote Dr.
M. A Barnor, “this was a momentous occasion,
exhibited by the rapidity with which almost all
doctors in the region-private and government
medical officers without exception – in no
time became active, enthusiastic and pioneering
members. It was a timely development and Dr.
A. A. Akiwumi of Effia-Nkwanta Hospital was
elected the first Chairman of the Western Divi-
sion of the Ghana Medical Association.”
The Eastern Division was to follow, curiously
with its administrative base in the Greater
Accra Region with Dr. R.H.O Bannerman as
Chairman. Then came the Northern Divi-
sion comprising all three Northern Regions
in 1973 and then finally Volta came. Today,
of course, the Association consists of ten
Divisions whose Chairmen together with
representatives each of the Ghana Dental
Association, Society of Private Medical and
Dental Practitioners and Junior Doctors and
the seven elected members of the National
Executive Committee constitute the National
Executive Council, the highest decision ma-
king body, second only to the authority of the
Annual General Meeting.
Even at that early stage, the GMA quickly
started organizing public lectures on health
education, nutrition and hygiene in Accra, a
tradition which it has maintained till date as its
contribution to health education and policy di-
alogue. Today also, beyond the organization of
Annual Public lectures, the GMA has sourced
funding and is very advanced in its attempts to
publish public lectures on Hypertension and
Road Traffic Accidents etc as Supplementary
Readers for Children in Ghana.
As part of its growing efforts, the Ghana
Medical Association sought and gained inter-
national recognition when in 1959, it applied
for and was granted membership of the World
Medical Association followed in May 1960 by
affiliation to the British Medical Association
(BMA). Two years later, following a proposal
from the BMA, the GMA would significantly
co-sponsor the conversion of the ‘British
Commonwealth Medical Conference’ into the
Commonwealth Medical Association.
Today it is indeed a source of great pride to
the Ghana Medical Association to have Prof
Agyeman Badu Akosa, himself a Past Presi-
dent ascend to the high office of President
of the Commonwealth Medical Association
from 2005-2007. Having completed his ten-
ure, he has been succeeded on the Executive
by Past GMA General Secretary Dr. Ohen-
eba Danso who is the current Secretary of
the Commonwealth Medical Association.
Sodzi Sodzi-Tettey
32
Somalia Republic is situated in the horn of
Africa. Its land is estimated to be 638,000 sq.
km.,and its coastline extends 3,330 km.Ethi-
opia borders it in the west,Kenya in the south,
the Indian Ocean in the east, in addition to
the Red Sea and the Republic of Djibouti in
the north (Fig 3.1).The population of Soma-
lia is estimated to be 10.8 million (2003); the
capital city is Mogadishu with 2.5 million in-
habitants. Somalia is divided into 18 regions.
Major climatic factors are a year-round hot
weather,seasonal monsoon winds,and irregu-
lar rainfall with recurring droughts.
Intermittent civil wars have been a fact of
life in Somalia since 1977 with much ca-
sualties and famine. One of the world’s
least developed countries, Somalia has few
resources with much of the economy be-
ing devastated by the civil war. Agriculture
is the most important sector, with livestock
accounting for about 40% of GDP and
about 65% of export earnings.
Somali Medical Association. Aims:
• To represent the Somali medical doc-
tors and advocate for their rights.
• To provide continued medical educa-
tion to its own members.
• To implement medical relief projects
Establishment:
• Was founded in 1961, with the first 4
newly qualified medical doctors Founded
in 1961 with the first 4 Somali doctors.
• Grew in number and quality, and in
1990 the members were 1142.
• Ceased to work in 1991, due to civil war
in the country.
• A lot of its members fled the country
Current SMA:
• Re-established in 2000 by 143 doctors
in Mogadishu.
• The current number is 481 working
throughout the country.
• Member of the World Medical Asso-
ciation and Arab Medical Union
• Applied to become a FIMA member
• In late 2006 the Transitional federal
government relocated to the capital city,
Mogadishu with the support of Ethio-
pian troops.
• In early 2007 a local armed insurgency
against the Ethiopian army presence
started all over south-central Somalia.
• This caused a lot of internal and inter-
national displacement of the local popu-
lation, including the medical doctors.
• There are only two major hospitals
working at the moment, down from 15
hospitals in 2006.
Structure of SMA
• General assembly: Held every two
years, where all members are eligible to
participate and elect the executive com-
mittee.
• Executive committee: Is elected for a
period of two years, and it is composed
of 10 members, including the Chair-
man, Deputy chairman, Treasurer and
heads of different subcommittees
• Subcommittees: We have subcommit-
tee on ethics, medical defense, interna-
tional relations, training and research,
social affairs, public health etc.
Dr. Abdirisak A Dalmar
MD MScOphth PhD
Chairman
Somali Medical Association
The Somali Medical Association
Table 1:
Selected demographic and economic
characteristics in Somalia
Demographic
Indicators
Year Value
Population 2004 10.8 million*
Population
Growth Rate
2000 3.41%
Age Structure: 2000
0-14 years: 44%
15-64 years: 53%
65 years and over: 3%
Life Expectancy
at Birth
2000
Total population:
46.2 years
male: 44.7 years
female: 47.9 years
Total Fertility
Rate
2000
7.18 children born/
woman
Birth Rate 2000
47.7 births/1,000
population
Death Rate 2000
18.69 deaths/1,000
population
Infant Mortality
Rate
2000
125.77 deaths/1,000
live births
Literacy (defini-
tion: age 15 and
over can read and
write)
1990
total population: 24%
male: 36%
female: 14%
Per Capita
Income
$600
* This estimate was derived from an official
census taken in 1975 by the Somali Govern-
ment; population counting in Somalia is
complicated by the large number of nomads
and by refugee movements in response to fam-
ine and clan warfare.
Table 2:
Selected health indicators in Somalia
Health Indicators Year Value
Physician Per 10,000 Population 1997 0.4
Dentists Per 10,000 Population 1997 0.02
Pharmacists Per 10,000 Popula-
tion
1997 0.01
Nursing and Midwifery Person-
nel Per 10,000 Population
1997 2
Hospital Beds Per 10,000
Population
1997 4.2
Households with Access to Lo-
cal Health Facilities (%)
2003 72.2
Population with Access to Safe
Drinking Water (%)
1999 23.1
Population with Adequate
Excreta Disposal Facilities
1999 48.5
Dr. Abdirisak A Dalmar
The WMA Statement on Family Planning
and the Right of a Woman to Contraception
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
From the Secretary General’s desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
WHO Executive Board, 122nd
session, 21– 26 January 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Non-communicable diseases are in the focus of a new WHO action plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
WMA Statement on Noise Pollution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Physicians Call For Zero Tolerance to Female Genital Mutilation Across The World . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Informed Consent – Recent Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Portrait of a key player . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
The Norwegian Medical Association. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Joint Medical Ethics Reflections of the Nordic Countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
The Lithuanian Medical Association and its Priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
The Republic of Belarus and its Health Care System in Brief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
The Ukrainian Medical Association is going to Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
The Bulgarian Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
The Czech Medical Association J. E. Purkyně (CzMA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
The Austrian Medical Chamber . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
The German Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
The Georgian Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
The Israeli Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
The Estonian Medical Association and WMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
The International Activities of the JMA and the WMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
The Viet Nam Medical Association (VMA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
The Ghana Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
The Somali Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
The WMA Statement on Family Planning and the Right of a Woman to Contraception . . . . . . . . . . . . . . . . . . . . . . . .33
Adopted by the 48th
General Assembly, Somerset
West, Republic of South Africa, October
1996 and amended by the General Assembly,
Copenhagen, Denmark, October 2007
The WMA recognizes that unwanted preg-
nancies and pregnancies that are too closely
spaced can have a serious adverse effect on
the health of a woman and of her children.
These adverse effects can include the prema-
ture deaths of women. Existing children in
the family can also suffer starvation, neglect
or abandonment resulting in their death or
impaired health, when families are unable
to provide for all their children. Social func-
tioning and the ability to reach their full
potential can also be impaired.
The WMA recognizes the benefits for
women who are able to control their fer-
tility. They should be helped to make such
choices themselves, as well as in discussion
with their partners. The ability to do so by
choice and not chance is a principal compo-
nent of women’s physical and mental health
and social well being.
Access to adequate fertility control meth-
ods is not universal; many of the poorest
women in the world have the least access.
Knowledge about how their bodies work,
information on how to control their fer-
tility and the materials necessary to make
those choices are universal and basic human
rights for all women.
The role of family planning and secure ac-
cess to appropriate methods is recognized
in the 5th Millennium Development goal
as a major factor promoting maternal and
child health.
The WMA recommends that National
Medical Associations:
Promote family planning education by
working with governments, NGOs and
others to provide secure and high-quality
services and assistance
Attempt to ensure that such information,
materials, products and services are avail-
able without regard to nationality, creed,
race, religion or socioeconomic status.