WMJ 02 2004

Contents
EEddiittoorriiaall
Health professionals and society 29
“WHO and WHPA need each other” 30
World Health Professions
Alliance holds its first global meeting 32
MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
The Relationship between
Physicians and Commercial Entities 33
Poverty and Health 39
WWMMAA
Activities of the President 40
The 167th WMA Council
meeting in Divonne, 13-15 May 2004 41
MMeeddiiccaall SScciieennccee,, PPrrooffeessssiioonnaall PPrraaccttiiccee
aanndd EEdduuccaattiioonn
Preventing preventable chronic disease –
international developments 44
Genomics – Strategies in the Battle
against Malaria 46
Immunodiagnostics – High-Technology
Medicine at the Bedside 47
WWHHOO
Commission on Intellectual Property Rights,
Innovation and Public Health 50
World Health Report 2004
and the World Health Assembly 50
Quality control – Action against
Substandard and Counterfeit Medicines 51
WWMMAA SSeeccrreettaarryy GGeenneerraall
From the Secretary General’s Desk, May 2004 51
RReeggiioonnaall && NNMMAA NNeewwss 52
BBooookk RReevviieewwss 54
WorldMMeeddiiccaall JJoouurrnnaall
Vol. No. 2, june 200450
OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
00_US_02_2004.qxd 01.07.2004 13:36 Seite 1
ANDORRA
Col’legi Oficial de Metges
Edifici Plaza esc. B
Verge del Pilar 5,
4art. Despatx 11, Andorra La Vella
Tel: (376) 823 525 Fax: (376) 860 793
E-mail: coma@andorra.ad
Website: www.col-legidemetges.ad
ARGENTINA
Confederación Médica Argentina
Av. Belgrano 1235
Buenos Aires 1093
Tel/Fax: (54-114) 383-8414/5511
E-mail: comra@sinectis.com.ar
Website: www.comra.health.org.ar
AUSTRALIA
Australian Medical Association
P.O. Box 6090
Kingston, ACT 2604
Tel: (61-2) 6270-5460/Fax: -5499
Website: www.ama.com.au
E-mail: ama@ama.com.au
AUSTRIA
Österreichische Ärztekammer
(Austrian Medical Chamber)
Weihburggasse 10-12 – P.O. Box 213
1010 Wien
Tel: (43-1) 51406-931
Fax: (43-1) 51406-933
E-mail: international@aek.or.at
REPUBLIC OF ARMENIA
Armenian Medical Association
Yerevan 375 010
Tel: (3741) 53 48-63
E-mail: armainter@hotmail.com
AZERBAIJAN
Azerbaijan Medical Association
AZE 370001, Baku
Tel: (994 50) 328 1888
Fax: (994 12) 315 136
E-mail: Mahirs@lycos.com /
azerma@hotmail.com
BAHAMAS
Medical Association of the Bahamas
Javon Medical Center
P.O. Box N999
Nassau
Tel: (1-242) 328 6802
Fax: (1-242) 323 2980
E-mail: mabnassau@yahoo.com
BANGLADESH
Bangladesh Medical Association
B.M.A House (Bangladesh Medical
Association House)
15/2 Topkhana Road, Dhaka
Bangladesh
Tel: (880) 2-9566060
Fax: (880) 2-9568714
E-mail: bma@aitlbd.net.com
BELGIUM
Association Belge des Syndicats
Médicaux
Chaussée de Boondael 6, bte 4
1050 Bruxelles
Tel: (32-2) 644-12 88/Fax: -1527
BOLIVIA
Colegio Médico de Bolivia
Casilla 1088
Cochabamba
Tel/Fax: (591-04) 523658
E-mail: colmedbo@supernet.com.bo
Website: www.colmedbo.org
BRAZIL
Associaçao Médica Brasileira
R. Sao Carlos do Pinhal 324 – Bela Vista
Sao Paulo SP – CEP 01333-903
Tel: (55-11) 3266 9391
Fax: (55-11) 3266 6631
E-mail: presidente@amb.org.br
Website: www.amb.org.br
BULGARIA
Bulgarian Medical Association
15, Acad. Ivan Geshov
1431 Sofia
Tel: (359-2) 954 -11 69/Fax:-1186
E-mail: usbls@inagency.com
Website: www.blsbg.com
CANADA
Canadian Medical Association
P.O. Box 8650
1867 Alta Vista Drive
Ottawa, Ontario K1G 3Y6
Tel: (1-613) 731 9331/Fax: -1779
E-mail: monique.laframboise@cma.ca
Website: www.cma.ca
Website: https://www.wma.net
WMA Directory of National Member Medical Associations Officers, Council
Association and address/Officers
WMA OFFICERS
OF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
President-elect President Immediate Past-President
Dr. J. D. Coble Dr. J. Appleyard Dr. K. Myllymaki
American Medical Association British Medical Association Finnish Medical Association
515 North State St. BMA House,Tavistock Square P.O. Box 49
Chicago, Illinois 60610, USA London WC1H 9JP, UK 00501 Helsinki, Finland
Treasurer Chairman of Council Vice-Chairman of Council
Dr. K. Vilmar Dr. Y Blachar Dr. T.J. Moon
German Medical Association Israel Medical Association Korean Medical Association
Herbert-Lewin Strasse 1 2 Twin Towers, 35 Jabotisky St. 302-75 Ichon1-dong,Yongsan-gu,
50931 Köln P.O. Box 3566, Ramat-Gan 52136 Seoul 140-721
Secretary General
Dr. D. Human
World Medical Association
BP63, 01212 Ferney-Voltaire Cedex
France
Tel (33) 4 50 40 75 75
E-mail: delon@wma.net
Fax (33) 4 50 40 59 37
i see page ii
U2_4_02.2004.QXD 01.07.2004 13:31 Seite U2
Health professionals and society
The month of May has seen the 167th meeting of the WMA Council, the first global meet-
ing of the World Health ProfessionsAlliance, the launch of the World Health Organisation’s
2004 Report and the meeting of the World Health Assembly (WHA). In this issue there are
reports of the outcomes of some of these meetings and the key decisions taken by these bo-
dies. From these it is clear that major health issues confront all parts of the world. They vary
from the crises facing countries in Sub-Saharan Africa and appeals to support the urgent ac-
tion needed to reduce the potential 6 million deaths from AIDS in the next few years – not
to mention the global actions on tuberculosis and malaria prevention and control, to calls to
take action to contain the increase of AIDS in Eastern Europe and to the links between po-
verty and health. These were addressed by all these groups.
Amongst the topics addressed by the WHAwas also that of migration of health professional
workers from developing countries to developed countries. This has a special significance.
Seen against the huge need for physicians, nurses, pharmacists and all health professionals
to deliver the care needed by those affected within the disease groups mentioned above, and
the other problems of ensuring equitable provision of health care in all countries, this calls
for particular reflection and action. In so doing, two other problems need to be addressed.
The fundamental changes in society in general, linked to the major advances in medical
science, increased access to knowledge associated with the huge developments in IT and
the consequent increased expectations of those in need of healthcare, have had a substantial
impact on the health professions and professional practice. These are reflected in challen-
ges to the perceptions of the role of professionals in society, and the need to critically analy-
se and often modify the role of individual professionals from their traditional roles. For
some health professionals this may mean increasingly restricting their activities from broad
areas traditionally considered to be within their field of activity, to a narrower, more specia-
lised area of activity. In other cases, it may call for the development of new skills with an
enhanced role and new responsibilities, For most, it requires coordination through team-
work with relevant health professonals. None of these changes is limited to any one profes-
sion. For all, there is some degree to which they have to reassess their relationship with so-
ciety.
At the same time, society needs to consider what it seeks from the health professions.
One consequence of the many scientific advances and developments in health care has been
the increasing recognition of the value of and necessity for teamwork with other professio-
nals. This calls for a real mutual recognition of each other’s skills and competencies, not al-
ways an easy process, but one which is clearly essential if the fundamental values of profes-
sionalism and professional practice, notably in ensuring quality of care, are to be recogni-
sed and accepted by society as the basis for the relationship with the professions.
For physicians, the societal changes are particularly important. While often the relationship
between an individual physician and the patient is highly regarded, in today’s changing
world a more critical assessment of the professional is developing, not infrequently reflec-
ted in a critical attitude, challenging the role and functioning of the profession. At a time
when there is a shortage of physicians in many parts of the world (with the associated pro-
blem of recruitment from developing to developed countries), physicians are under greater
pressure than ever before. These pressures not only reflect increased workload, but the de-
mands of a globalised world, in which market pressures and competition are promoting
continuing administrative and managerial change, and demanding higher and higher quali-
ty of care at a lower cost.
One element of professionalism is the delivery of high-quality services. In medicine this re-
quires not only the traditional devotion to the best interests of patients and a high standard
Editorial
29
OFFICIAL JOURNAL OF
THE WORLD MEDICAL
ASSOCIATION
Hon. Editor in Chief
Dr. Alan J Rowe
Haughley Grange, Stowmarket
Suffolk IP14 3QT
UK
Executive Editor
Dr. Ivan M. Gillibrand
19 Wimblehurst Court
Ashleigh Road
Horsham
West Sussex RH12 2AQ
UK
Co-Editor
Prof. Dr. med. Elmar Doppelfeld
Ottostr. 12
D-50859 Köln
Germany
Business Managers
J. Führer, D. Weber
50859 Köln
Dieselstraße 2
Germany
Publisher
THE WORLD MEDICAL
ASSOCIATION, INC.
BP 63
01212 Ferney-Voltaire Cedex, France
Publishing House
Deutscher Ärzte-Verlag GmbH, Die-
selstr. 2, P. O. Box 40 02 65, 50832 Köln/
Germany, Phone (0 22 34) 70 11-0,
Fax (0 22 34) 70 11-2 55, Postal Cheque
Account: Köln 192 50-506, Bank: Com-
merzbank Köln No. 1 500 057, Deutsche
Apotheker- und Ärztebank,
50670 Köln, No. 015 13330.
At present rate-card No. 3 a is valid.
The magazine is published quarterly.
Subscriptions will be accepted by
Deutscher Ärzte-Verlag or the World
Medical Association.
Subscription fee € 22,80 per annum (incl.
7 % MwSt.). For members of the World
Medical Association and for Associate
members the subscription fee is settled
by the membership or associate payment.
Details of Associate Membership may be
found at the World Medical Association
website www.wma.net
Printed by
Deutscher Ärzte-Verlag
Köln — Germany
ISSN: 0049-8122
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 29
of professional services, but also the main-
tenance and enhancing of the knowledge,
skills and attitudes necessary to achieve
this. In a climate of increased pressures and
demands on work and work practices from
both patients and health care administra-
tions, the allocation of dedicated time for
continuing professional development beco-
mes more and more difficult.
This pressure is increased by continuing
problems of limited resources, and demands
for more working time to be devoted to
“hands on” delivery of services. With
increasing sophistication of medical tech-
nology resulting from important scientific
advances, and the resultant raising of public
expectations, the demands for healthcare re-
sources are constantly rising. But in the
market economies of today, in both public
and private sectors this leads to constant
pressures for cost containment. It is there-
fore imperative that time as well as resour-
ces be made available to individual practi-
tioners so that their knowledge, skills and
attitudes can be maintained and enhanced
through Continuing Professional Develop-
ment (CPD), and that they can provide the
highest standards of medical care within the
resources available to them. The WMA
Council has endorsed a proposed resolution
on Global Standards for Quality Improve-
ment of Medical Education which will go to
the General Assembly for adoption. The
third document to which this resolution
refers concerns Quality Improvement
and Continuing Professional Development
(CPD), emphasising the importance of this
in meeting the challenges of health needs.
What has been said in this paragraph is, as
set out above, relevant to all health profes-
sionals.
Continuing education and maintenance of
skills is not limited to any one profession.
For example, the initiatives for the control
of AIDS and provision of AVRs and the me-
asures to “Roll Back Malaria” all require
appropriate education of many health pro-
fessionals in new approaches, teamwork
and organisation, communication techni-
ques, etc. This is, of course, but one part of
the resources needed to carry out these pro-
grammes.
One question has to be addressed. How far
does “society” recognise even the few
examples of health professionals’ problems
referred to above, major disease threats and
changing disease patterns, manpower, rede-
ployment of skills, continuing professional
developmental needs and overall health re-
sources?
When governments support global policies,
as for example the Diet, Physical Activity
and Health Initiative adopted at the WHA,
do they intend to simply add these to the
burdens of health care demands of health
professionals, or will they state honestly to
their citizens that this not only requires
more personal responsibility by individuals
for their own health, but also redeployment
of current healthcare resources, the recrui-
ting and training of new professionals and
the retraining of some existing professio-
nals? Of course the policy recognises the
substantial burden of public education need-
ed, but this of itself requires specialised
training.
This is, of course, relevant to the fundamen-
tal problem of the relationship of health
professionals to society.
For most of the past century and a half, the
relationship between physicians, individu-
als and society as a whole has, on the part of
physicians, been substantially based on a
paternalistic humanistic approach. Increa-
singly, in the later years of the 20th century,
both the profession and society began to re-
cognise the need for some change. Some of
the developments triggering this need are
set out above. Change however can no long-
er be treated as a gradual process. Real dia-
logue between the profession and society,
at individual, local and national levels, is
imperative, at as clear understanding of this
relationship is fundamental to the practice
of medicine. Whilst technology may to an
increasing extent intrude on the more holi-
stic approach to medical care, the human
race is not a uniform automated group in
which the functioning of each individual
member is identical, and repair when nee-
ded can be provided through a simple ad-
justment or replacement. To meet the needs
of society and achieve the goals set out in
the WHO definition of health, requires
more than technology. It requires the devo-
tion and professional knowledge, skills and
attitudes of physicians, the necessary tech-
nical resources and the cooperation of indi-
viduals, both in responsibility for their own
health and in an equal partnership with the
professional(s) to meet the health require-
ments at any one time.
This all constitutes a challenge which calls
for analysis, leadership and dialogue both at
national level and between individual phy-
sicians and members of the public, to identi-
fy both those traditional qualities of profes-
sional practice which need to be preserved
and any new ones necessary to ensure a po-
sitive partnership between professionals
and society contributing to ensuring suc-
cessful health care services and contented
health professionals and patients.
Alan Rowe
Editorial
30
With these words Dr. Lee Jong-wook
Director-General of the World Health
Organization, ended his address at the con-
cluding session of the first global confer-
ence of the World Health Professions
Alliance on “Training for Better Health”.
Dr. Lee’s speech to this assembly of leaders
of the medical, nursing and pharmaceutical
professions set out below, highlights the
importance of their role in turning health
ideas into realities and confronting the huge
health problems facing the world today.
“I am very happy to be with you here today.
“Making it happen” is one of our current
commitments, and you are the people who
do just that. It is the work of doctors, nurses,
pharmacists and other health professionals
that turns health ideas into realities, and
strategies into achievements.
“WHO and WHPA need each other”
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 30
Our current efforts include providing treat-
ment, care and prevention services to con-
trol AIDS, TB and malaria; large-scale im-
munization campaigns to eradicate polio;
and promoting healthy lifestyles. These and
our other programme areas give some idea
of objectives we are working for and they
provide the necessary framework for our
efforts. Their attainment, however, depends
to a very large extent on the work you do
with the users of the health system.
In addition, we have to respond to emergen-
cies. SARS and Avian Influenza continue
to be a major concern particularly in our
Western Pacific Region. Their control has
depended to a very significant extent on
the efforts of people in your three profes-
sions.
Armed conflict and natural disasters also
continue to impose extreme and unforesee-
able demands, particularly on doctors and
nurses. They can occur in any part of the
world but are particularly severe at present
in parts of our Eastern Mediterranean and
African regions. Courage and tenacity will
continue to be key requirements for health
leadership in the future, not only in disaster
areas but in the many places where health
work is under-funded, under-equipped and
under-staffed.
Just as health authorities depend on your
professions to put policy into practice, he-
alth workers need good policies to work
with. The current shortages of human re-
sources, especially in developing countries,
reflect the need for an enormous effort at re-
thinking and rebuilding health services.
This is a unifying theme in all our acitivities
at present.
One of our most important current initiati-
ves is to scale up access to antiretroviral
therapy for people living with HIV/AIDS.
In December last year, on World AIDS Day,
WHO launched the strategy to accelerate
access to antiretroviral treatment. The initi-
al objective is to get three million people in
developing countries on to treatment by the
end of 2005. We are working with the health
services in countries to achieve this, follow-
ing a double imperative: universal access to
treatment by the earliest possible date, and
ever more effective approaches to preven-
tion.
The Millennium Development target for
HIV/AIDS is to halt the spread of HIV and
begin its reverse by 2015. The ratio of trea-
ted cases to infections prevented is not yet
known but, if for each person receiving
treatment there were just one new HIV in-
fection averted, the “3 by 5” initiative will
significantly speed up the achievement of
this target.
Procurement and distribution of the drugs
needed is involving excellent and innovati-
ve co-operation with the pharmaceutical
professions.Ahundred thousand health pro-
viders and community treatment supporters
will be needed to staff the necessary delive-
ry systems. They will need to be trained in
antiretroviral therapy in accordance with
national standards. It is the medical, nursing
and pharmaceutical professions above all
that will meet this training need.
With your leadership, these efforts can
mark the beginning of new strength and
coherence in national health systems, and
start the trend towards solving staff
shortage problems. The work of the Interna-
tional Council of Nurses in mobilizing skil-
led health workers in primary health care is
already making a very valuable contribu-
tion.
Our long-term disease control programmes
include polio eradication. Here the key to
success will be tenacity, both in our collea-
gues running the immunisation campaigns
and maintaining surveillance, and in our do-
nors. We are on the verge of eradication,
with just twenty-two cases to date this year
in all of Afghanistan, Egypt, India and Paki-
stan.
On the other hand, we have had setbacks in
West and Central Africa, with an explosive
outbreak that has paralysed over 500 chil-
dren. The leaders in these areas have now
restarted with massive immunisation cam-
paigns and strengthening routine services as
an emergency measure. In these last stages
of the campaign, where so much can be
either lost or gained, high levels of commit-
ment are needed, and the ability to cope
with practical difficulties as they arise. Here
leadership, especially at the local level, is
the key to success, as we have seen in every
country and region where eradication has
been achieved.
Equally important is the work of health pro-
motion. This is particularly needed for the
early prevention of cancer, cardiovascular
diseases, diabetes and other chronic condi-
tions. Sixty per cent of the deaths that occur
annually in the world are from non-commu-
nicable diseases.
The Framework Convention on Tobacco
Control, adopted a year ago, was a great
achievement. The efforts of the pharmacists
and other associations played a very impor-
tant part in the success of the negotiations.
The Convention has now been signed by
108 countries plus the European Union, and
ratified by 12. Your efforts are still needed
in the countries that have not yet ratified it,
to help speed the process on its way. Once
ratified by 40 countries, the Convention
will come into force and provide valuable
support for tobacco legislation and policy. It
will help to protect the public – especially
children and adolescents – from one of to-
day’s most serious and most unnecessary
health hazards.
As requested by the World HealthAssembly
in 2002, we have prepared the Global Stra-
tegy on Diet, Physical Activity and Health,
for consideration and adoption next week.
When the Strategy is adopted, we will work
with Member States to implement it accor-
ding to their particular needs.
I attended the World Conference on Health
Promotion and Health Education in Mel-
bourne last month, and was encouraged to
see the high level of support from health
professionals for healthy lifestyles. Com-
munity involvement is a central principle in
the health-for-all approach and now, more
than ever, it can make a great contribution
to reducing some of the current major cau-
ses of death and disability. It is the health
professions that provide the guidance for
this broader effort.
The theme of World Health Day in April
this year was Road Safety. It drew attention
to the 1.2 million deaths and up to 50 mil-
lion injuries that occur on the roads each
year. The Government of France hosted the
global World Health Day event in Paris,
with eloquent support from President Chir-
ac. The highlight of the event was the
launch of the WHO and World Bank World
report on road traffic injury prevention.
31
Editorial
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 31
At a historic meeting in Geneva on 15-16
May, the World Health Professions Alliance
held its first global conference under the title
“Teaming up for health” The meeting
brought together for the first time at global
level leaders representing member organisa-
tions of the International Council of Nurses
(ICN), the International Pharmaceutical
Federation (FIP) and the World Medical
Association (WMA). Sixty-five countries
were represented by more than 250 people,
including observers from a number of other
health professions and non-governmental
agencies.
From the enthusiasm in the hall it was clear
that the organisers had gone a long way
towards the objective of motivating health
professionals and their organisations to work
together at local, national and international
levels to respond to the huge health chal-
lenges facing the world today.
Speakers were drawn from the health profes-
sions, policy makers, patients’ disease group
organisations and supranational bodies, both
intergovernmental and non-governmental.
From the opening remarks of the three pro-
fessions, it was clear that few doubted that a
united voice from the professionals deliver-
ing health care could be more effective when
dealing with the huge health problems facing
the world today, which require governments
to engage in positive actions for humanity at
large, not only for their own communities.
Those present demonstrated this in a positive
way, responding to the clear statement of
reality in which Stephen Lewis, UN Special
Envoy for HIV/AIDS in Africa, underlined
the immediacy of the crisis in Africa, and the
grave risk of this extending in a short time to
the Indian sub-continent and to China. The
certain death of six million people in Africa
from HIV/AIDS in the next few years, and
the increasing number of orphans, were
illustrations which could not be ignored. The
Conference adopted unanimously the fol-
lowing resolution:
“Recognising that
– the current HIV/AIDS pandemic presents
an extraordinary human, human rights
and humanitarian crisis;
– especially women and children are
affected;
– focused prevention programmes can sig-
nificantly reduce new infections;
– treatment options allow HIV positive
persons to lead a quality life;
– without the appropriate prevention and
treatment this crisis will worsen to a
level where some countries’ populations
may be decimated and their futures
destroyed; and
that countries at the heart of the HIV/AIDS
pandemic, provided that they are supported
with the necessary financial and human
resources, can rise to the challenge.
Therefore we, as leaders of the medical,
nursing and pharmacy professions, call on
all governments, intergovernmental agen-
cies and health professionals to recognise
the scale of the tragedy, to stop procrastinat-
ing and to commit immediately, the neces-
sary funds and resources against HIV/AIDS.
As health professional leaders we give our
full commitment to this cause and call on all
physicians, nurses and pharmacists to act as
strong advocates and social leaders in the
war against HIV/AIDS.”
In a final address to the meeting, the Direc-
tor-General of the World Health Organiza-
tion (WHO), Dr. Lee Jong-wook, acknow-
ledged and appreciated the resolution set
out above, which responded to the concerns
expressed clearly in the World Health Re-
port 2004 and to which he had referred in
his presentation.
Note:
The World Health Professions Alliance
brings together medicine, nursing and phar-
macy through their representative interna-
tional organisations, the International
Council of Nurses (ICN), the International
Pharmaceutical Federation (FIP) and the
World Medical Association (WMA), and
represents more than 20 million health pro-
fessionals worldwide.
The WHPA website is: www.whpa.org
e-mail: info@whpa.org
32
Editorial
As an immediate follow-up to this success-
ful World Health Day, the UN General
Assembly met in plenary session on the glo-
bal road safety crisis. They adopted a reso-
lution inviting WHO to co-ordinate the
UN road safety effort. Your support in
promoting the many practices that can redu-
ce road traffic accidents will be much
needed.
I could go on at length, but I’d prefer to lea-
ve as much time as possible for discussion.
So let me conclude by saying: our organiza-
tions need each other. Your work is much
more highly appreciated than you are pro-
bably aware of most of the time. I’m very
glad we have the opportunity of this Sym-
posium to co-ordinate our efforts.”
During the WHPA meeting an informal poll of participants’ opinion revealed that over
the next five years they expected heart disease, obesity and cancer to be top priorities in
both developing and developed countries. They also identified dietary change, unequal
access to information, and trade policies as top trends affecting these health challenges.
On the other hand, out of a list of 16 health challenges, HIV/AIDS was rated lower at 10
& 11, suggesting that fighting the pandemic is still not regarded as an urgent problem by
some health professionals despite unanimous support by participants in the resolution on
this subject. Dr. Delon Human commented that this choice suggested that “health pro-
fessionals were underlining the importance of the lifestyle changes that the world is wit-
nessing – an increasingly sedentary life and unhealthy eating”.
World Health Professions Alliance
holds its first global meeting
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 32
There is general acceptance that the rela-
tionship between physicians and industry is
complex, and one that has been subject to
increasing scrutiny, in particular in the past
decade.
Such scrutiny has been substantially focu-
sed upon the relationship between the phar-
maceutical industry and practising physici-
ans. Potential problems can arise when phy-
sicians are visited by representatives of the
pharmaceutical industry who, by offering
gifts such as equipment, travel expenses or
hospitality at medical or scientific mee-
tings, offer the possibility of influencing the
prescribing of individual physicians.
While there are substantial differences in
practices from one country to another, the
direct relationship between the pharmaceu-
tical or other sectors of the technical health
care industry and individual physicians who
prescribe or use their products is a real phe-
nomenon that can raise serious ethical is-
sues.
US papers suggest that an estimated 11 bil-
lion dollars is spent by pharmaceutical com-
panies each year in promotion and marke-
ting, of which 5 billion goes to sales repre-
sentatives. One recent US report put the fi-
gure as high as 9 billion, with some top
firms spending more than 1 billion on their
sales representatives each year [1]), inclu-
ding an outlay of approximately $8000-
13,000 per physician. [2]
Another USA study states that physicians
meet with industry representatives about 4
times a month, a phenomenon that begins
as early as residency, and although the fre-
quency with which physicians receive gifts
and samples decreases as they enter prac-
tice, the frequency of receiving honoraria,
conference travel and research funding
increases. Both residents and established
physicians frequently use promotional
material. [2]
However, it can be argued that contact
between physicians and the pharmaceutical
industry is necessary. Industry representa-
tives are a convenient and efficient, if not
always the most reliable, way for physi-
cians to learn about new medications. In
addition, there is little doubt that without
the support of industry, many scientific and
medical developments would not be possi-
ble For example, 60% of biomedical
research and development in the USA is
privately funded. [3] Governments and aca-
demic institutions often lack the resources
to provide similar support for research.
The increasingly aggressive advertising tac-
tics of the pharmaceutical industry, and the
necessity that physicians remove them-
selves from any real or suggested conflict of
interest that could potentially affect the
health of patients, requires that limitations
and guidelines be established and adhered to.
Because conferences, even more than other
issues, are so often international, and
involve physicians from various countries,
and because sponsorship for conferences
often comes from pharmaceutical compa-
nies located outside the hosting country,
there is a need for formal guidance at the
global level, analogous to similar instru-
ments issued by the WMA for the benefit of
both practising physicians and society as a
whole. There are already a number of
sources of advice in this area such as guide-
lines from WHO, national medical associa-
tions and the pharmaceutical industry itself,
but there is clearly a case for one set of
principles to be established for the medical
profession globally.
Why such global guidelines
from the medical profession
are needed
As in all matters ethical, reasonable men
(and women) can differ. In such cases,
where there are legitimate interests on both
sides and the boundaries of what is appro-
priate are not always obvious, there is a
need for clear guidelines.
While it can be argued that the resources
provided by commercial entities for
research, continuing medical education, etc.
are indispensable, the funding of such
activities, not to mention the offering of
gifts to doctors by companies whose inter-
ests are not purely altruistic in nature, pose
ethical problems.
The linking of gifts, hospitality or other
perks directly to prescribing practices is
clearly indefensible and unethical.
However, there is evidence that, even
where there is no direct link, gifts do create
a feeling of social obligation that may sub-
tly influence prescribing behavior. [4] On
the most basic level, gifts make one feel
good, and these feelings may be subtly
transferred to the sales representative or
company’s product. [5] Even “gifts” such
as funding for conferences may influence a
doctor’s choice of medical conferences, and
thus, the information to which he or she is
exposed. [5]
Ultimately, the cost of any such activity by
a commercial enterprise in the health field
is borne either directly or indirectly by the
patients as consumers of the enterprises’
products. These patients/consumers may
not be aware that their physicians are
receiving these benefits.
The funding of such benefits to physicians
also damages the image of the profession.
[4] The position paper of the American
College of Physicians-American Society of
Internal Medicine (ACP-ASIM) on physi-
cian-industry relations states: “A perception
that a physician is dispensing medical
advice on the basis of commercial influence
33
Medical Ethics and Human Rights
Medical Ethics and Human Rights
The Relationship Between Physicians and
Commercial Entities
MALKE BOROW, Adv.
Israel Medical Association
An overview based on a paper presented to the WMA Council
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 33
34
is likely to undermine a patient’s trust, not
only in the physician’s competence but also
in the physician’s pledge to put patients’
welfare ahead of self-interest.” [6] Even if
there is no direct effect on a physician’s
behavior, the fact that this trust is damaged
is reason enough to be wary. In fact, limits
on the acceptance of gifts to avoid the
appearance of impropriety are prevalent in
other parts of society, such as holders of
public office in the federal government and
many private companies. [5]
Studies have shown that the existence of
guidelines has a tangible effect on physici-
ans’ attitudes and behaviour towards phar-
maceutical representatives. The difference
is noticeable, beginning in the training peri-
od. In a random sample of 378 residents
from 14 US family medicine training pro-
grams, half of which had written policies in
place that restricted residents’ behaviour re-
garding pharmaceutical representatives,
and half that had no such policies, there was
a marked difference in attitudes. Twice as
many residents of “non-restricted” pro-
grams felt that the information received
from pharmaceutical representatives was of
good quality, that social activities sponso-
red by them were beneficial or that contact
with pharmaceutical representatives was
generally beneficial to the residency expe-
rience. In addition, more than twice as
many residents in non-restricted programs
felt that meals, gifts or social outings fun-
ded by industry were appropriate. [7]
This difference in attitude continues even
after the training period. In a survey of
Canadian physicians, some of whom had
been exposed to such policies, and some of
whom had not, it was found that residents
who had more contact with pharmaceutical
representatives during training were more
likely to perceive the information provided
by such representatives as beneficial, and to
have greater contact with them in later
years. [8]
Existing guidelines
Codes of conduct regarding the relationship
between physicians and the pharmaceutical
industry tend to be written by doctors, i.e.
medical associations, institutions or regula-
tory authorities, or by the pharmaceutical
industry itself.
Codes developed by industry are generally
voluntary, although they are often rein-
forced by complaints procedures with pos-
sible sanctions [9]. Such codes, although
discouraging egregious conduct such as
direct cash payments to doctors, often do
little more than endorse existing modes of
behavior. [10] For example, under the new
voluntary code of PhRMA (a group of phar-
maceutical industry representatives), if a
company flies 300 doctors to a golf resort,
all expenses paid, and educates them about
the company’s latest drug so the doctors
may then be “paid spokesmen” for the drug,
this would be entirely legitimate. [10, 11]
Many countries with major pharmaceutical
industries such as Britain, Australia and the
United States have national codes that usu-
ally prohibit companies from giving doc-
tors incentives to prescribe their products
(9). In addition, the relevant European
Union Directives on Advertising
(92/28/EEC & 84/450/EEC) also restrict
the nature and value of such “promotional
activity”. For those countries that lack
national codes, there are two major sets of
international guidelines: the WHO’s
Criteria for Medicinal Drug Promotion and
the Code of Pharmaceutical Marketing
Practice, put out by the International
Federation of Pharmaceutical Manu-
facturers Associations. [9]
While the focus of guidelines put out by the
pharmaceutical industry is generally on
marketing, codes put out by medical profes-
sional organizations tend to focus more on
commercially funded research. There are
also guidelines written by organizations
such as the American Academy of
Pharmaceutical Physicians and the Royal
College of Physicians Faculty of
Pharmaceutical Medicine. [9]
It must be noted that even where guidelines
exist, in some countries physicians are
often unaware of them [2]. For instance, in
a US study only 23-50% of medical resi-
dents knew of the existence of guidelines
and only 62% of practising physicians were
aware of at least one guideline [12]. In
addition, while awareness of guidelines did
not necessarily elicit compliance, enrol-
ment in a residency program that mandated
compliance with the guidelines, did. [2]
National regulating patterns
for physicians
The range of options for regulating the
physician-industry relationship varies from
country to country:
Denmark – The Danish Medical
Association and the Pharmaceutical
Industry (LIP) have signed an agreement on
Cooperation between the Profession and
the Industry, which is substantially con-
cerned with scientific and medical meet-
ings. Commenting that close cooperation
between the two bodies “is necessary to
develop new and better pharmaceutical
therapy and ensure that existing therapies
are used in the best possible way in patient
treatment”, both parties find that this coop-
eration should “be conducted in such a
manner that it does not include any aspect
of pressure between the parties and that the
parties are independent of each other”. It
incorporates conditions concerning trans-
parency and strict accountability, including
requiring the company organising or co-
organizing medical or scientific meetings to
notify the National Board of Drug
Advertising (NMI) – a statutory body – with
the details of the arrangement. The NMI and
the DMA (Medical Ethics Board) are
respectively responsible for dealing with
violations by the profession or the industry.
France – The French Medical Association
has tightened its rulings on issues relating to
gifts and conferences. For instance, a doctor
should not accept gifts in cash or otherwise,
unless they are small gifts of nominal value
(not exceeding 30 Euro). Contributions to a
doctor’s attendance at a scientific conferen-
ce are authorised if they are reasonable,
and/or if the selection of a remote (i.e., cost-
ly) location is justified. [13]
Spain – A body representing the Spanish
pharmaceutical industry issued a code of
practice in 2002 stating that drug compa-
nies may offer medically related gifts worth
up to 19 Euro. Expenses for meetings may
not include social or cultural events or
expenses of spouses. [13]
India – The practice of offering gifts to
doctors, including foreign trips and outright
cash gifts, is widespread in India, especial-
ly in “big money” areas such as cardiology.
Medical Ethics and Human Rights
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 34
The Medical Council of India, in its Code
of Ethics released March 2002, does not
relate to doctors accepting gifts or cash
from drug companies. [13]
Israel – Israel has historically had selected
guidelines written by the pharmaceutical
industry, the government, the health funds
and the medical profession. Over the past
year, several events occurred that portend
changes in the current status. The Israeli
Parliament has begun deliberations on a
proposed law that seeks to codify the rela-
tionship between physicians and the phar-
maceutical industry. The Israel Medical
Association (IMA) opposes this law, feel-
ing that legislation is not the proper place
for such guidelines, that the guidelines are
too far-reaching and that the profession is
the appropriate body to draft such guide-
lines. Concurrently, the IMA has released a
set of updated, encompassing guidelines. It
is also in the process of finalizing an agree-
ment between the IMA, the pharmaceutical
industry and the providers and insurers of
health care, that would set guidelines
acceptable to all parties and define to whom
each party would be accountable. It is felt
that such a formal agreement would have a
greater effect than guidelines put out by
individual parties.
Singapore – The Singapore Medical
Association, in conjunction with the
Singapore Association of Pharmaceutical
Industries, released in August 2000 a
detailed statement regarding the relation-
ship between the medical profession and
the pharmaceutical industry. The statement
begins by recognising both groups as part-
ners in health care delivery, but adds that
strict rules for professional conduct
between the two parties is necessary in
order to prevent abuses. The physician must
always be known by his or her patients to
be impartial and not influenced by commer-
cial gain when determining the appropriate
treatment for individual patients. Therefore,
physicians must ensure that their profes-
sional judgement is in no way clouded by
gifts, hospitality or the like. Educational
conferences must be first and foremost sci-
entific and educational in nature; the level
of hospitality must be secondary, and
should not exceed that which physicians
might normally pay for themselves. In addi-
tion, making hospitality or other benefits
conditional on prescribing performance is
prohibited. Any form of sponsorship of
such events should be clearly disclosed to
participants.
In accordance with the principles of good
practice, scientific research carried out in
conjunction with the pharmaceutical indus-
try must be properly planned and executed,
including approval by an ethics committee,
and subject to specific conditions detailed
in the statement.
Gifts and other promotional items given to
physicians by drug companies should pri-
marily benefit patients, be modest in value
and be related to the physician’s work. Cash
payments as incentives for prescribing are
unacceptable. Medical books may be given
to physicians if they serve a genuine educa-
tional function.
Travel expenses to overseas medical con-
ferences may be offered if the subject of the
conference is directly related to the doctor’s
work. They should not be offered if they are
conditional on the doctor’s past or present
prescribing habits or upon any obligation to
promote a specific product, nor should they
include expenses for additional days or for
accompanying persons such as spouses.
Reasonable honoraria and reimbursement
of travel and out-of-pocket expenses for
speakers are acceptable.
Physicians invited to lecture at industry-
sponsored events are also subject to strict
guidelines regarding the content and pre-
sentation of their talks. Every effort must be
made to ensure that the talk is professional-
ly sound, objective and not influenced by
the sponsoring company. For instance, the
content of the lecture should be reviewed
by others, and any conflict of interest must
be declared. [14]
Australia – Australia has ethical guidelines
prepared by the AMA, by the Royal
Australasian College of Physicians and by
the pharmaceutical industry, represented by
APMA, now known as Medicines Australia
– a body representing over 50 companies
(about 95% of the prescription drug mar-
ket). The latter’s code, although monitored
predominantly by industry, involves the
Therapeutic Goods Administration, the
Australian Medical Association and the
Royal College, in its complaints body and
monitoring and review process. [15]
The code of the pharmaceutical industry, in
particular, is quite detailed and comes with
guidelines regarding each section. Under
reforms to the pharmaceutical industry’s
code enacted in 2002, all non-essential hos-
pitality is prohibited. Thus when sending
doctors to conferences, the code provides
that travel may be subsidised provided the
meeting is directly related to the doctor’s
area of expertise. In addition, travel within
Australia should be economy class, abroad
it may be economy or business, a reason-
able level of accommodation may be
offered plus travel costs, but the payment of
expenses for family members is prohibited.
The Code states that hospitality must be
secondary to the educational purpose of the
meeting. The guidelines expand upon this
in great detail, even going so far as to list
types of acceptable foods. “An appropriate
level of hospitality would be what is
expected in a normal business meeting. For
example, open sandwiches, rolls and quich-
es would be appropriate for lunch. Lavish
hospitality such as lobster and caviar would
not be appropriate.”[16]
The Australian Medical Association guide-
lines state that any professional interaction
between doctors and industry should be pri-
marily for the advancement of the health of
patients, rather than for any personal self-
interest. Specifically, the guidelines state,
inter alia, that before becoming involved in
any research project sponsored by industry,
a physician must satisfy himself that the
project has genuine merit, is ethically
defensible, socially responsible and scien-
tifically valid. The project must also be
reviewed by an appropriate review body.
All moneys should be held in trust and sub-
ject to audit and review by the ethics com-
mittee. CME activities must address the
educational needs of the targeted medical
audience, not just the promotional needs of
the contributing pharmaceutical company.
The programme for such activities may
acknowledge, but not excessively promote,
the company’s product.
Doctors may not accept personal gifts from
the pharmaceutical industry but may accept
35
Medical Ethics and Human Rights
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 35
36
educational materials appropriate to their
area of practice.
The Code of the Royal Australasian
College of Physicians is quite similar, but
goes into greater detail; e.g., regarding gifts
it adds that payment for dinners, entertain-
ment or expenses associated with daily liv-
ing may not be accepted and gives great
detail regarding industry-sponsored travel
and attendance at meetings.
United States – In 1990, following a
decade of lavish gifts, cash and trips to lux-
ury resorts offered to physicians by the
pharmaceutical industry, both the AMA and
the American College of Physicians
released guidelines to prevent inappropriate
gift giving, later included in the AMA’s
code of medical ethics. These guidelines
were adopted by the industry, represented
by PhRMA. The AMA supplemented their
guidelines with a series of questions and
answers designed to clarify the issues. Gifts
of minimal value (less than $100) and relat-
ed to the physician’s work (such as pens
and notepads) or intended for the patient’s
benefit (such as medical textbooks) are per-
mitted under the guidelines. Cash may not
be accepted, and no gifts may be accepted if
there are strings attached. Pharmaceutical
companies may underwrite CME confer-
ences that serve a genuine educational func-
tion and are not lavish in their attending
hospitality; disclosure of financial support
should be made. Despite the detailed guide-
lines of the code, an AMA-sponsored sur-
vey in 2000 indicated that up to half of
American physicians were unfamiliar with
it, and many routinely ignore it. [17]
As mentioned above, the pharmaceutical in-
dustry, represented by PhRMA, has also is-
sued guidelines regarding interactions be-
tween healthcare professionals and the phar-
maceutical industry, the most recent of
which took effect in July 2002. Their new
code makes it clear that interactions between
the two groups must be intended to benefit
patients and enhance the practice of medici-
ne. The code permits professional presenta-
tions by industry that provide valuable
scientific and educational benefits (a term
that can, of course, be loosely applied) and
assumes that such presentations occur at ve-
nues conducive to providing scientific or
educational information. Modest meals, but
no other entertainment, may accompany the-
se presentations. The code also specifies that
gifts worth less than $100 may be offered to
doctors if they are primarily for the benefit
of patients. Consulting arrangements with
physicians are allowed if they serve a legiti-
mate need. The PhRMA code, like the AMA
code, also contains FAQs. [11]
In addition to the voluntary codes estab-
lished by the AMA and PhRMA, the
Department of Health and Human Services’
Office of Inspector General issued in 2002
a 44-page document dealing with the mak-
ing and marketing of pharmaceutical prod-
ucts. Unlike the AMA and PhRMA codes
which are totally voluntary and which the
OIG refers to as a “good starting point”, the
OIG guidelines, although apparently volun-
tary, can prompt government investigations
if not adhered to. [18]
United Kingdom – In the UK, the prevail-
ing Code of Practice is that of the
Association of the British Pharmaceutical
Industry (ABPI), the most recent version of
which was released in 2001 in consultation
with the British Medical Association. The
ABPI code states that gifts from companies
must cost less than 6 pounds (about 9 US
dollars), and be relevant to the doctor’s
work. The accompanying text explains that
“pens, diaries and surgical gloves are
acceptable, while table mats, plant seeds
and music CD’s are not.”[19] The ABPI
code also contains guidelines on research.
Self-policing of the ABPI code seems to
work. Complaints are reviewed by the
Prescription Medicines Code of Practice
Authority, which is independent of the
ABPI and comprises 12 members from
pharmaceutical companies, six independent
members and a chairman. [9]
World Health Organization – WHO re-
leased in 1999 a preliminary version of
guidelines on interaction with commercial
enterprises. Although the guidelines deal
with interactions between WHO as an
organisation, and commercial enterprises of
various sorts (as such they cover a broader
base than do guidelines relating to the typi-
cal individual doctor and the pharmaceuti-
cal industry), there is still much to be
gleaned from these guidelines. It should be
noted, however, that the WHO guidelines
are stricter than the typical doctor-pharma-
ceutical industry guidelines. For instance,
WHO receptions and similar functions may
not be paid for at all by commercial enter-
prises.
In companies where codes or other guideli-
nes exist, physicians may be subject to sanc-
tions for failing to adhere to such guidelines.
For example, in Germany, thousands of doc-
tors in 100 public hospitals were accused of
accepting money and gifts from SmithKline
Beecham, an international drug firm, and
were subsequently investigated. [20] In the
Netherlands, also, the marketing code has
resulted in legal cases against pharmaceuti-
cal companies and individual doctors in
matters of giving and receiving excess ho-
spitality and other drug promotion “bonu-
ses.”[13, 21] Italy and France have also seen
investigations of cases where doctors were
given computers, trips and cellular phones
for prescribing certain drugs.
Specific Issues
Gifts
Gifts from industry are problematic
because they are so widespread and because
of their potential to influence a physician’s
objectivity and/or prescribing practices.
Medical decisions, by their nature, must be
predicated on objective, scientific informa-
tion (coupled, of course, with the patient’s
lifestyle and preferences) and not influ-
enced by external factors and biases, such
as insurer economics, personal financial
interests (kickbacks) or the largesse of drug
companies. Not only does “non-rational”
prescribing, as it is referred to in the litera-
ture, result in higher and often unwarranted
drug costs, it can even have serious delete-
rious effects such as the over-prescribing of
broad-spectrum antibiotics. [1, 22].
Several studies have examined the effect of
gifts from pharmaceutical companies on
physician behaviour. Research shows a
strong correlation between receiving indus-
try benefits and favouring specific products
[6, 2]. However, interestingly, physicians
claim that they are not affected by such
gifts [6, 23, 2, 24]. Even more interestingly,
Medical Ethics and Human Rights
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 36
although most physicians do not view
themselves as subject to bias, they do admit
that conflicts of interest might influence
other physicians’ decisions [24, 25].
In particular, gifts of nominal value such as
pens, notepads or mugs are viewed as not
affecting a physician’s behaviour. In addi-
tion, certain “gifts” such as drug samples
are not really viewed as gifts at all, since
they are medically related and intended in
essence for the patient rather than the physi-
cian. One might even suggest that drug
samples serve to promote equitable access
in health care, since they allow patients to
try out products before committing them-
selves to an expensive product. [6]
However, such products are really intended
to induce the physician to prescribe the new
product, and research shows that when
patients run out of a free sample, physicians
are more likely to prescribe that same prod-
uct rather than a less expensive one such as
a generic product. [26] In essence, all
industry-supplied medical information or
products are promotional. In addition, as
previously stated, all personal gifts estab-
lish an implied social contract of obligation
and expected reciprocation. [4]
One position paper, put out by the
American College of Physicians in con-
junction with the American Society of
Internal Medicine, lists the following ques-
tions as helpful in gauging whether a gift
relationship is ethically appropriate: “What
would my patients think about it, what is
the purpose of the industry offer, and what
would my colleagues think about the
arrangement?”
Studies have shown, in fact, that patients’
attitudes and physicians’ attitudes towards
accepting gifts are not always the same.
Overall, patients tended to find gifts less
appropriate than did physicians – this was
true even for gifts that existing guidelines
deem acceptable, such as pens, medical
books, and conference meals. [12] About
half the patients in one study were aware
that physicians receive gifts from the phar-
maceutical industry. Among those who
were not aware, 24% felt that this knowl-
edge changed their perception of the profes-
sion. However, more than 90% of physi-
cians accepting a gift were willing to have
it generally known, indicating that perhaps
physicians overestimate patients’ feelings
regarding the appropriateness of gifts. [12]
If one accepts that modest gifts that
enhance medical practice or knowledge are
acceptable, can one set a limit or specific
parameters as to what is acceptable? It is
difficult to set an exact amount or descrip-
tion, although several countries do so, as
mentioned above. However, it is generally
accepted that inexpensive gifts for office
use such as pens, notepads or calendars
meant for educational purposes or patient
care such as medical books are more
acceptable.
In one USA study, researchers questioned
over 100 residents in internal medicine con-
cerning their attitudes towards nine promo-
tions or gifts offered by pharmaceutical
companies. Most residents considered 7 of
the 9 items as appropriate (the exceptions
being luggage and funding for travel to
CME conferences). Where differences in
the appropriateness of a gift were per-
ceived, they were based more on cost and
less on its educational or professional
value. As a result, 83% felt that an inexpen-
sive but not educational item such as a pen
was appropriate, whereas an expensive yet
educational sponsorship for travel to a con-
ference was inappropriate. The authors sug-
gest as an explanation for this phenomenon
that some physicians may think that expen-
sive gifts create an appearance of impropri-
ety. Others may object to the cost of gifts
being passed on to patients, and yet others
may perceive a strong correlation between
the value of a gift and its potential to influ-
ence prescribing behaviour. [25]
In contrast, another US study refutes the
notion that gifts of lesser value or gifts
related to a physician’s practice are less
problematic than others. It states, as its
basic premise, that the biasing effect of
accepting gifts is accepted as a matter of
deliberate choice, that physicians are delib-
erately choosing to do something unethical.
It is therefore not surprising that physicians
object so vociferously to the suggestion that
gifts create bias. Therefore, guidelines that
limit gifts to those of nominal value and
related to the practice of medicine stem
from the assumption that such gifts are not
tempting enough to influence a physician’s
prescription choices. However, the authors
maintain that this deliberate choice view is
inconsistent with the social science
research which shows that even when indi-
viduals attempt to be objective, they are
subject to unintentional bias. Therefore,
small gifts may be influential. In fact, why
do pharmaceutical firms offer these gifts if
not to influence a physician’s behavior in
some respect? The figures cited above for
the amount of money spent each year by the
pharmaceutical industry are clear evidence
that the industry expects and intends that
these costs produce some marketing bene-
fit. Because physicians are unaware of this
influence, they do not take steps to correct
it. As such, policies that make sense if bias
is seen as a matter of deliberate choice are
unlikely to be effective if bias is uninten-
tional and unconscious. [24]
The authors of this study, members of the
Department of Social and Decision
Sciences at Carnegie Mellon University in
Pittsburgh, cite several earlier studies that
show that individuals are unable to remain
objective even when they are motivated to
be impartial, and even when they are
explicitly instructed about it. This shows
that such bias is unintentional and uncon-
scious. Furthermore, the studies suggest
that self-interest affects people’s choices,
changing the way the assess information that
they will use as the basis for choices. [24]
In addition, disclosure of a doctor’s finan-
cial interest in a particular product as an
antidote to bias can only be effective if
patients know how to relate to such disclo-
sure, and how much to discount the doc-
tor’s advice in light of the disclosure. In
fact, recent social science research suggests
that disclosure may even generate the oppo-
site effect. [24]
Of physicians who felt that gift-taking did
not influence their prescribing behaviour,
explanations offered ranged from the fact
that the doctor’s clinical knowledge was
strong enough, the formulary restrictions
severe enough to prevent bias in prescri-
bing, to the fact that the resident’s financial
hardship and exhausting schedule entitled
him to enjoy these rewards. The acceptabili-
ty of taking gifts was also influenced by so-
37
Medical Ethics and Human Rights
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 37
38
cial norms, i.e., did others (particularly su-
periors) engage in such behaviour? (This
may also help explain why residency pro-
grams with guidelines yield more residents
that comply with restrictions on gift-ta-
king). The bottom line was that most physi-
cians felt that they enjoyed the benefits wi-
thout being subject to insidious influence on
the part of the pharmaceutical industry. [25]
This despite the fact that one representative
study proved that physicians got more of
their information about the drugs they were
prescribing from drug advertisements than
from the scientific literature. [23]
Research and Conferences
The ACP-ASIM position paper states that
“physicians who have financial relations-
hips with industry, whether as researchers,
speakers, consultants… or others, must not
in any way compromise their objective clini-
cal judgment or the best interests of patients
or research subjects…”.[6] The rationale for
this prohibition is similar to the rationale
presented in the case of gifts: financial rela-
tionships can impair objectivity and create
conflicts of interest.As a rule of thumb, phy-
sicians may accept honoraria for teaching,
lecturing or research that advances profes-
sional knowledge and is commensurate with
the work done. In addition, any financial re-
lationship must be disclosed.
According to one US report, in 1996, there
were 151,434 industry-sponsored events;
by 2001 this number tripled, to 370,348 or
an average of more than 1000 such events
every day of the year. [1]
Particular care must be exercised when a
physician is invited to speak at a conference
developed by a pharmaceutical company
(as opposed to one merely sponsored by
such company). In such cases, the physician
must be very careful that the company does
not script his or her presentation, but that
he/she has full and free professional discre-
tion and independence. Similarly, physici-
ans who participate in industry-sponsored
research must guard against bias in publish-
ing results. Physicians with financial ties to
industry should refrain from participating in
such research, as studies have shown that
physicians with such ties are significantly
more likely to report findings that support
the sponsor’s drugs, and not report unfavou-
rable findings. [6]
Conclusions:
The relationship between physicians and
pharmaceutical companies is indeed com-
plex, but that is no reason to shy away from
an attempt to regulate it. Like so many other
complex issues, ignoring it is an option but
ultimately not a very successful one, as do-
ing so would damage physicians and pa-
tients alike. There is a clear case for the
WMA to address these issues in the context
of its aims to protect the honour and inter-
ests of the medical profession, to assist all
peoples of the world to attain the highest
possible level of health, and to set some
standards, be they general or specific, for
this relationship. These standards can then
serve as guidance for doctors and industry
around the world, and advance the cause of
medicine, which, in the final analysis, is the
goal of us all.
References:
1. Getting doctors to say yes to drugs: the cost and
quality impact of drug company marketing to
physicians. Report of the Blue Cross Blue
Shield Association, 2003.
2. Wazana A. Physicians and the pharmaceutical
industry: Is a gift ever just a gift? JAMA 2000;
283: 373-380.
3. Bekelman J, Li Y, Gross C. Scope and impact of
financial conflicts of interest in biomedical re-
search. JAMA 2003; 289: 454-65.
4. Chren MM, Landefeld S, Murray TH. Doctors,
drug companies and gifts. JAMA 1989; 262:
3448-3451.
5. The Council on Ethical and Judicial Affairs of
the American Medical Association. Guidelines
on gifts to physicians from industry: an update.
56 Food Drug L.J. 27 (2001).
6. Coyle SD. ACP-ASIM Position Paper: Physi-
cian-Industry Relations. Ann Intern Med 2002;
136: 396-402.
7. Brotzman GL, Mark DH. The effect on resident
attitudes of regulatory policies regarding phar-
maceutical representative activities. J Gen In-
tern Med 1993; 8: 130-134.
8. McCormick BB, Tomlinson G, Brill-Edwards P,
Detsky AS. Effect of restricting contact be-
tween pharmaceutical representatives and inter-
nal medicine residents on post training attitudes
and behavior. JAMA 2001; 286: 1994.
9. Wager E. How to dance with porcupines: rules
and guidelines on doctors’ relations with drug
companies. BMJ 2003; 326:1196-1198.
10. Moynihan R. Who pays for the pizza? Redefin-
ing the relationships between doctors and drug
companies. 1: Entanglement. BMJ 2003; 326:
1189-1192.
11. Pharmaceutical Research and Manufacturers of
America. PhRMA code on interactions with
healthcare professionals. 2002. www.phrma.
org/publications/policy//2002-04-19.391.pdf.
12. Gibbons RV, Landry FJ, Blouch DL, et al. A
comparison of physicians’ and patients’ atti-
tudes toward pharmaceutical industry gifts. J
Gen Intern Med 1998; 13: 151-154.
13. McGuaran A. Royal College issues new guide-
lines on gifts from drug companies. BMJ 2002;
325:511.
14. The medical profession and the pharmaceutical
industry – a joint SMA and SAPI paper. Aug 1,
2000. http://www.sma.org.sg/cmep/
15. Tasman Asia Pacific Report on behalf of the
Task Force on Industry Self-Regulation. Aus-
tralian Pharmaceutical Manufacturers Associa-
tion Code of Conduct. www.selfregulation.
gov.au/publications/TaskForceOnIndustrySelf-
Regulation/ ConsultantReport/ch6.pdf
16. Medicines Australia Code of Conduct.
www.medicinesaustralia.com.au
17. Romano M. Prescription for conflict. Modern
Healthcare, June 18, 2001, p. 14.
18. Robeznieks A. OIG issues drug marketing
guidelines. Amednews.com, Oct 21, 2002.
http://www.ama-assn.org/sci-
pubs/amnews/pick_02/prsa1021.htm
19. Association of the British Pharmaceutical In-
dustry. ABPI code of practice for the pharma-
ceutical industry 2001. www.abpi.org.uk/publi-
cations/pdfs/CodeOfPractice2001.pdf
20. Orellana C. German doctors’ links with drug
firm investigated. Lancet 2002;359, 1039.
21. Sheldon T. GPs warned on accepting hospitality
from drug companies. BMJ 2001; 322: 194.
22. Watkins C, Moore L, Harvey I, Carthy P et al.
Characteristics of general practitioners who fre-
quently see drug industry representatives: na-
tional cross sectional study. BMJ 2003;326:
1178-1179.
23. Avorn J, Chen M, Hartley R. Scientific versus
commercial sources of influence on the pre-
scribing behavior of physicians. Am J Med
1982; 73:4-8.
24. Dana J, Loewenstein G. A social science per-
spective on gifts to physicians from industry.
JAMA 2003; 290: 252-255.
25. Steinman MA, Shlipak MG, McPhee SJ. Of prin-
ciples and pens: Attitudes and practices of medi-
cine housestaff toward pharmaceutical industry
promotions.Am J Med 2001; 110: 551-557.
26. Chew LD, O’Young TS, Hazlet TK, Bradley
KA, Maynard C, Lessler DS. A physician sur-
vey of the effect of drug sample availability on
physicians’ behavior. J Gen Intern Med 2000;
15: 478-83.
Medical Ethics and Human Rights
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 38
39
Poverty and Health
Changing the common ground: national
medical associations, health, poverty,
and the Millennium Development Goals
– a new initiative.
“A world not advancing towards the
Millennium Development Goals will not be
a world at peace. And a world awash in vio-
lence and conflict will have little chance of
achieving the goals. But if the common
ground we used to stand on no longer seems
solid, we must seek new common ground
for our collective efforts.”
(Kofi Annan, Secretary-General of the
United Nations, at the International
Chamber of Commerce Conference on
“Global Economic Governance and
Challenges of Multilateralism”, Dhaka, 17
January 2004)
On the eve of what should be a milestone
for global health, Kofi Annan’s words have
great significance for national medical
associations (NMAs) and their members.
Next year marks the fifth anniversary of the
Millennium Declaration, an historic agree-
ment between nations to overcome the
obstacles to human development in the 21st
century. In it, poverty, hunger and disease
were given a renewed emphasis, and the
Millennium Development Goals (MDGs-
see box) were established as the drivers for
change, aiming to halve poverty by 2015
and to combat HIV/AIDS, TB and Malaria.
The agenda was ambitious, but the
Declaration had consolidated a great deal of
the work done by international develop-
Medical Ethics and Human Rights
The Millenium Development GoalsThe Millenium Development Goals
Goal Targets and further information
1. Eradicate extreme pover-
ty and hunger
Target for 2015: Halve the proportion of people living on less than $1 a day and those who suffer from hunger.
More than a billion people still live on less than US$1 a day: sub-Saharan Africa, Latin America and the Caribbean, and
parts of Europe and Central Asia are falling short of the poverty target.
2. Achieve universal prima-
ry education
Target for 2015: Ensure that all boys and girls complete primary school.
As many as 113 million children do not attend school, but the target is within reach. India, for example, should have 95
percent of its children in school by 2005.
3. Promote gender equality
and empower women
Targets for 2005 and 2015: Eliminate gender disparities in primary and secondary education preferably by 2005, and at
all levels by 2015.
Two-thirds of illiterates are women, and the rate of employment among women is two-thirds that of men. The proportion of
seats in parliaments held by women is increasing, reaching about one third in Argentina, Mozambique and South Africa.
4. Reduce child mortality Target for 2015: Reduce by two-thirds the mortality rate among children under five.
Every year nearly 11 million young children die before their fifth birthday, mainly from preventable illnesses, but that num-
ber is down from 15 million in 1980.
5. Improve maternal health Target for 2015: Reduce by three-quarters the ratio of women dying in childbirth.
In the developing world, the risk of dying in childbirth is one in 48, but virtually all countries now have safe motherhood
programmes.
6. Combat HIV/AIDS, ma-
laria and other diseases
Target for 2015: Halt and begin to reverse the spread of HIV/AIDS and the incidence of malaria and other major diseases.
Forty million people are living with HIV, including five million newly infected in 2001. Countries like Brazil, Senegal,
Thailand and Uganda have shown that the spread of HIV can be stemmed.
7. Ensure environmental
sustainability
Targets:
• Integrate the principles of sustainable development into country policies and programmes and reverse the loss of envi-
ronmental resources.
• By 2015, reduce by half the proportion of people without access to safe drinking water.
• By 2020 achieve significant improvement in the lives of at least 100 million slum dwellers.
More than one billion people lack access to safe drinking water and more than two billion lack sanitation. During the 1990s,
however, nearly one billion people gained access to safe water and the same number to sanitation.
8. Develop a global part-
nership for development
Targets:
• Develop further an open trading and financial system that includes a commitment to good governance, development and
poverty reduction – nationally and internationally
• Address the least developed countries’special needs, and the special needs of landlocked and small island developing States
• Deal comprehensively with developing countries’ debt problems
• Develop decent and productive work for youth
• In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries
• In cooperation with the private sector, make available the benefits of new technologies – especially information and com-
munications technologies.
Many developing countries spend more on debt service than on social services. New aid commitments made in the first
half of 2002 could mean an additional $12 billion per year by 2006.
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 39
40
ment conferences during the 1990s and pre-
sented a clear, well-timed vision, which
was both inspirational and feasible.
With the year 2005 approaching, however,
the ideals of 2000 lie in disarray. There are
now strong indications that none of the
MDGs will be achieved by the target date,
and many developing countries are increas-
ingly falling behind. Recalling the
Declaration of Alma-Ata (1978), Annan
cites the breakdown of the mutual bond
between peace and good health – also
implicit in Alma-Ata’s Millennium succes-
sor – as the underlying reason for the
MDGs slipping off track. Whilst it is cer-
tainly true that the post-Millennial world of
armed conflict and terrorism has severely
tested that bond, there is a risk that an
emphasis upon global problems such as
these may obscure other factors which are
undermining efforts to achieve the MDGs
at local, regional and national level. As far
as the health-related goals are concerned,
these issues are highly relevant, e.g. lack of
progress on the goal to reduce the under-
five child mortality rate by two-thirds
between 1990 and 2015 is frequently attrib-
uted, at least in part, to the problems facing
health systems in rural areas. If a change to
the common ground of 2000 occurs – and
Kofi Annan has indicated elsewhere that a
high-level review of the MDGs is being
planned for 2005 – then it is imperative that
“devolved” issues such as these are taken
fully into account in the outcome.
Collaboration between national medical
associations (NMAs) across the world
could play a crucial role in pushing these
issues up the agenda. For example, devel-
oping nations’ NMAs and their members
are in a key position to assess the chal-
lenges to health and healthcare provision in
their own countries. They are also able to
provide from the experience of their mem-
bers a definitive account of the needs of
health systems at national, regional and
local levels, and the problems faced by
those who work to meet those needs. This
level of insight could also help to redress
one of the perceived imbalances of the
MDGs: the undue emphasis on what
should be achieved rather than how.
Developed nations’ NMAs, on the other
hand, are able to relate their experience of
providing assistance to developing nations.
Do they feel that such support is being
directed in the most effective way? How
can their governments’ policies on the pro-
vision of assistance be developed to meet
the needs of recipient countries? There is
clearly tremendous scope for constructive
dialogue on all of these points.
In an effort to stimulate positive action to
improve the situation, during the past year
the British Medical Association has been
working in partnership with the Department
for International Development (DfID), the
UK government department responsible for
promoting development and the reduction
of poverty internationally. Our primary aim
has been to build our members’ awareness
of the international development agenda
and to encourage them to consider how they
can contribute to the campaign to eradicate
poverty in the developing world. An over-
whelmingly positive response to our initia-
tives has been received from our members
who are keen to become involved in our
future work in this area. The aims of this
work, however, go beyond raising aware-
ness of individual physicians.
It was recognised from the outset that it is
essential to engage with organisations
which have substantial experience of devel-
oping initiatives to address the health chal-
lenges in developing countries. Therefore
in January 2005, a Poverty and Health
Policy Group was formed, comprising a
mix of such UK-based organisations. In
early discussions within this group, topics
included the impact of migration and health
skills drainage from developing countries,
and the continuing inhibition of research
into “orphan drugs”. These are, however,
mere indications of the many problems
which need to be addressed. As indicated
above, it is clear that a vital element in this
process is to obtain first-hand evidence
which identifies the obstacles to achieve-
ment of the MDGs. In this respect, the con-
tribution of NMAs and their members is
essential. It is hoped therefore that NMAs
will provide this vital input into the process
of containing the health threats associated
with poverty and realising the aims of the
MDGs.
MMC
Further information: mcarroll@bma.org.uk
WMA
During the first six months of his WMA
Presidency, Dr. James Appleyard has been
extremely busy as the following highlights
of his activities demonstrate.
In South Africa he attended and addressed
the South African Medical Association
meeting on Strategies for the Survival of
Doctors, where the profession is united in
pursuing the ethical standards underlying
medical practice and in seeking improved
healthcare services for those under-served
in the population.
In Uganda he participated in a series of
meetings to arrange training seminars for
250 health professionals and 125 lawyers
on the principles underlying the Istanbul
Protocol.
On another occasion he joined in a WHO-
sponsored meeting, at which a draft consti-
tution for the Federation of East African
Medical and Dental Associations was con-
sidered. WHO is looking to this body for as-
sistance with medical education, disease
surveillance and prevention, including a
programme of measles vaccination.
The President gave a guest lecture at the
Oral Health Planning Conference in the
African Region, organised by WHO and the
FDI (International Dental Federation). This
important regional conference produced a
Consensus Statement on Oral Health (the
Declaration of Nairobi). This was a good
demonstration of the effectiveness of colla-
borative working at national and local level
on clearly defined and agreed objectives.
He also addressed the Annual Assembly of
the Ugandan Medical Association on “The
right of a child to health care”.
WMA
Activities of the President
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 40
41
In Taiwan, attending the International
Conference on Influenza and the
Resurgence of SARS, the President spoke
of the WMA interest and role in such out-
breaks and of the work group led by the
Canadian Medical Association. He also vis-
ited the Chinese Medical Association, the
Taiwanese Medical Association, the Bureau
of Health Promotion, the Joint Commission
on Hospital Accreditation and the National
Health Research Institute, noting particular-
ly the role of the Bureau of National Health
Insurance whose emphasis was on purchas-
ing Health – not Health Care!
In the USA Dr. Appleyard addressed the
American Academy of Pharmaceutical
Physicians in Miami on “How we should
treat our children“, and had some discus-
sions on the Declaration of Helsinki. At the
Hispanic Development Foundation at
Oregon Health and Sciences University, Dr.
Appleyard gave the guest/keynote lectures
on “How does the world treat our children”.
Visiting the International Department of
Cornell University and New York Medical
College, he sought support for and recogni-
tion of the need for all students to extend
their experience through an elective in a
developing country.
At the UK International Water Summit in
London, video-linked with Brussels, the
President spoke on the relevant health issues
relating to the developing world and the need
for collective support. In Brussels also,
addressing the European Forum for Good
Clinical Practice, he emphasised the pivotal
role of the Declaration of Helsinki in the eth-
ical framework for research on children and
of the WMA Declaration of Ottawa on the
Right of a Child to Health Care. He also
stressed the importance of the role for the EU
in supporting poor countries where the burden
of infectious disease impaired their economy.
Other concerns involved the many other
vital issues relating to human rights. These
include the case of Dr. Biscet imprisoned
with three colleagues in Cuba, the deterio-
rating situation in Zimbabwe where there is
increasing under-five child mortality, and
the need for support of doctors on both
sides of the Israeli/Palestine conflict.
The WMA Council held its 167th
meeting in
Divonne (France) in the presence of mem-
bers of the standing committees and a num-
ber of observers. Many also attended the
first Conference of the World Health
Professions Alliance, held in Geneva on the
following two days (see WHPA p. 32).
Following the opening by the Chairman,
Dr. Yoram Blachar, and adoption of the
166th
Council minutes, the Council received
the reports of the President (see above) and
of the Secretary General.
Dr. Delon Human in his presentation high-
lighted the following important develop-
ments since the Helsinki meeting:
– the work of the Medical Ethics Unit
under the direction of Dr. John
Williams. The first draft of the Manual
on Medical Ethics should be available
by the Tokyo meeting;
– collaboration with the World Health
Organisation (WHO) has significantly
strengthened, and WHO has confirmed
its wish to remain in official relations
with WMA. Positive projects or activi-
ties include participation in the negotia-
tions and debates leading up to the
adoption of the Framework Convention
on Tobacco Control;
inclusion of WMA in the WHO Global
Alert and Response Network to combat
communicable diseases. This has been
updated to deal more effectively with
epidemics such as SARS. In this con-
nection the Secretary General paid a
special tribute to the outstanding work
of the Canadian Medical Association;
the development of policy on “Violence
& Health”, and participation in the
WHO launch of this project;
development of policy on safe injec-
tions with the WHO section “Safe
Injection Global Network” (SIGN);
Survey of Human Resources for Health
Care;
– Adoption in Helsinki of the resolution
designating an annual “Medical Ethics
Day” to be marked by WMA members
on 18th
September, the anniversary of
WMA’s foundation.
– Restructuring the content and format of
the World Medical Journal now in its
50th
year, under its new Hon. Editor in
Chief, Dr Alan Rowe, with future
greater orientation towards medical
ethics, physician-related human rights
and to other issues. Particular tribute
was paid to the work of Dr. Ivan
Gillibrand as Executive Editor since
1986 and to that of Professor Elmar
Doppelfeld, the Co-Editor.
– Continuing growth and effectiveness of
the World Health Professions Alliance
(see WHPA p. 32)
– the development of a new website
devoted to health care technology, and
the webcasting of the Helsinki
Scientific Session.
– progress with the Human Rights pro-
grams: also, the WMA anti-torture pro-
ject jointly with the International
Rehabilitation Council for Torture
Victims (ICRT) has gained increasing
momentum, and some WMA leaders
have visited the five pilot countries to
help develop training material and cen-
tres for physicians in them.
Turning to membership he reported that the
Medical Associations of Armenia, Bang-
ladesh, the Bahamas and Kazakhstan had
joined the WMA.
Dr. Human concluded his report by indica-
ting his intention to resign after the seventh
anniversary of his appointment later in the
WMA
WMA
The 167th WMA Council meeting in Divonne
13-15 May 2004
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 41
42
year. He would, of course, continue for the
necessary transitional period after the
Tokyo General Assembly.
Strategic plan
In preparation for discussions on the future
strategy of WMA which was a major topic
throughout the Divonne meetings, Council
members were asked to respond to three
questions. These were to identify what were
the most pressing problems for their
NMAs, which single issue their members
considered to be the most important priori-
ty, and what their NMA considered to be
the most important priority for the
WMA.What was most impressive in a vari-
ety of responses was the undercurrent of
recognition of the pressures on profession-
alism at all levels of society, and the need
for the medical profession to consider both
its relationship with society and its own
identity (see boxes A and B).
The Chairman commenting that the discus-
sion of these replies reflected a number of
common problems, the most notable relat-
ing to health care systems said that WMA
has a vital role to play in identifying
answers to these problems.
World Health Assembly
Council discussed the World Health
Assembly which would take place the fol-
lowing week. In this connection Council
welcomed the inclusion of members of
NMAs in an increasing number of delega-
tions to the Assembly.
Medical Ethics
Council considered the report of the
Medical Ethics Committee.
Declaration of Helsinki
After receiving the report and its recom-
mendations, – “1. That para. 30 be not
amended; and 2. That the Medical Ethics
Committee at its May meeting decide
whether either an accompanying statement
or preamble for the DoH, or a note of clari-
fication for para. 30, be developed,“
Council adopted the recommendations, and
after a short debate a motion that the recom-
mendation be referred to NMAs for com-
ment was defeated.
The recommendations (in boxes C and
D) were adopted for referral to the
General Assembly in Tokyo.
The following note outlines the discussion
in the Medical Ethics Committee on the
report and recommendations of the working
group, and the comments already received
on them.
Several members in supporting the recom-
mendation that there be no amendment,
observed that the debate had continued for
a considerable period of time, and that the
longer it went on the more it could weaken
the status of both the DoH and the WMA.
Attention was drawn to the problems relat-
ing to the European Union Clinical
Research Directive and the position of the
FDA, which didn’t accept the current DoH
because of paragraph 30. A plea was made
for a separate statement on access to care
not being related to ability to pay. The
Secretary General observed that the FDA
would not feel able to accept paragraph 30
even if amended. This also applied to
EMEA. An opposer to any amendment
commented that the problems related to
health care systems should be considered
separately and that one could then return to
the DoH. The AMA proposed that the
words “it is important to consider post-trial
access (to treatment)“ be considered. There
was a real need to talk about access to treat-
ment.
Agreeing that there should be no change,
three members were opposed to a preamble
but would accept an explanatory document.
It was also suggested that paragraph 30
should be considered as aspirational, and
that the real issues were those of justice and
equity. The speaker could accept a note or
preamble which didn’t weaken the DoH
and suggested that a draft declaration on the
right to health be available in Tokyo.
Meanwhile a moratorium (later withdrawn)
on further discussion for two years after
Tokyo should be considered. This would
not inhibit discussion but there should be no
formal proposal for change during this peri-
od. Later, in clarification it was made clear
that this would not inhibit any action were
there to be some remarkable breakthrough
or change of circumstance.
A strong plea was made however that, bear-
ing in mind that the FDA and EMEA would
not change, paragraph 30 should be
changed.
The first recommendation was then put to
the vote and was approved with one vote
contra and no abstentions.
WMA
(A) Most Pressing Problem to NMAs (n=17) (B) Most Important Task for WMA (n=17)
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 42
Reference was then made to a suggested
note of clarification from Dr. William
Steiger (US Dept. of Health and Human
Services). Bearing in mind the problems
associated with an insertion into the pre-
amble, it was then proposed that this be a
note of clarification of paragraph 30, anal-
ogous with the note concerning paragraph
29.
After an extensive debate and some modi-
fication of the wording, the following
form of wording for the note of clarifica-
tion to paragraph 30 was adopted as a rec-
ommendation.
Clinical trials in Populations with In-
sufficient access to Health Care
The Committee considered a Proposed
WMA Statement on “Clinical Trials in
Populations with Insufficient Access to
Health Care” and agreed that the Finnish
Medical Association would review this in
the light of the recommendations on para-
graph 30 of the Declaration of Helsinki.
Relationship between Physicians and
Commercial Enterprises (also see article
p. 33)
This subject will be further discussed at
the October WMA meeting.
Socio-Medical Affairs
Dr. Henry Haddad was elected Chair of
the Socio-Medical Affairs Committee.
Water and Health Care
Council approved a proposed Statement
on Water and Health Care, to be for-
warded to the General Assembly.
Armed Conflict
Council approved amendments to the
Regulations in Time of Armed Conflict,
to be forwarded to the General Assembly.
Quality Improvement in Medical
Education
Council approved a proposed WMA
Resolution on Global Standards for
Quality Improvement of Medical Edu-
cation, to be forwarded to the General
Assembly
Health Emergencies Communication and
Coordination
The Recommendations of a proposed
WMA Statement were approved as a
Council Resolution (box, p. 44)
Council also approved circulation of the
proposed Statement and set up a Work
Group to develop a plan for the establish-
ment of a global physician network to
improve preparedness for health emergen-
cies.
Finance and Planning
Dr. J. C. Nelson was elected Chair of the
Planning and Finance Committee.
Finance
Subject to an unqualified audit opinion,
the Financial Statements for 2003 were
approved.
Santiago 2005
Council approved the themes for the
Scientific Session and the arrangements for
the 2005 General Assembly in Santiago.
The themes will be “Health Care Systems
Reform” and “Access in Medicines”.
Policy review
Council endorsed the recommendation
that the Secretariat should develop a simpli-
fied process for review of existing WMA
policies.
Membership
Recommendations that the applications
for constituent membership of the
Medical Associations of Estonia and
Vietnam be forwarded to the General
Assembly, were approved.
An application for cooperative relations
with WMA from Project HOPE, was
approved.
Official Languages
Council approved the establishment of a
work group of officers to review the prob-
lems of official languages of the WMA.
Obligatory notification of AIDS as an
infectious disease
Council also referred an emergency pro-
posed Council resolution that AIDS be clas-
sified as a notifiable disease, to the Socio-
Medical Affair Committee.
Zimbabwe
The Council discussed its serious concerns
about reports of the collapse of the health
care system in Zimbabwe and mandated
the WMA leadership to investigate the sit-
uation in Zimbabwe and take appropriate
actions.
Strategic Plan
The Council concluded with a further
debate on a Strategic Plan in which many
issues were aired and discussed. It was
decided that a survey should be commis-
sioned, to be overseen by a working group;
a full report of discussions would be sent to
NMAs and that the business group looking
at non-dues issues report to the supervisory
group, to whom it would where appropriate
act as a tool.
Succession of Secretary General
The Council approved actions necessary to
identify a new Secretary General.
43
WMA
(C) Recommendation to General
Assembly
1. That there be no change to paragraph
30 of the Declaration of Helsinki.
(D) Recommendation to GeneralAssembly
2. Addition of a Note of clarification to
paragraph 30
“The WMA hereby reaffirms its posi-
tion that it is necessary during the
study planning process, to identify
post-trial access by study applicants to
prophylactic, diagnostic and thera-
peutic interventions identified as ben-
eficial in the study, or access to other
appropriate care. Post- trial access
arrangements or other care must be
described in the study protocol, so that
the ethical review committee may con-
sider such arrangements.”
The meeting heard a plea from the
Bulgarian delegate to WMA on behalf of
the doctor and five nurses imprisoned
and condemned to death in Libya for
allegedly infecting more than 400 chil-
dren with AIDS, in spite of expert evi-
dence of their innocence.
The Chairman of Council has appealed to
theLibyanauthoritiestoquashthissentence.
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 43
44
Sir Alexander Macara, FRCP, President,
National Heart Forum, UK
Two important actions in the past year mark
significant potential for the future control of
the major causes of morbidity and mortality
from non-communicable diseases. They are
the publication of the results of the global
heart disease study MONICA, and the
endorsement by the World Health Assembly
of the Global Strategy for Diet, Physical
Activity and Health. The following overview
of these and other developments comments
on the underlying factors influencing
progress in this area and the importance of
collaborative action.
As the frequency of many non-communica-
ble diseases (NCDs) – notably heart and
circulatory disease, cancers and diabetes –
increases in developed countries and are
alarmingly superimposed on the continuing
burden of communicable disease in devel-
oping countries, the need for effective and
concerted international action to attack
their root causes is urgent.
Since the Alma-Ata initiative of the WHO
and UNICEF in 1978 it is accepted wisdom
that there are three main thrusts in all health
policy – control of adverse environmental
factors, the promotion of healthy life-styles,
and the reorientation of health care services
towards prevention and early diagnosis and
treatment. The intervening quarter-century
has shown the crucial significance of two
factors – one internal to the health sector of
society and its governance, the other exter-
nal to it. The internal factor is the lack of
basic knowledge and consequently the
inadequacy of the evidence, which is
required to stimulate policy-makers and to
goad decision-makers; the lethal nature of
tobacco is a notable exception to this defi-
ciency. The external factor is the globaliza-
tion of markets for consumer products which
should be a force for economic and social
progress but which poses a growing threat to
health, especially in developing countries,
when the profit motive mocks any ethical
considerations.
These two factors point to two absolute pri-
orities. The first is the essential criterion for
informed policy and action of accurate and
reliable epidemiological information about
time, place and persons. The second imper-
ative is to apply all the evidence obtained
from epidemiological studies to underpin
and improve existing programs, to inform
development in international collaboration,
and to combat the inimical effects of irre-
sponsible commercial activities.
The good news is that there are grounds for
qualified optimism in the outcomes of
recent collaborative activities and in the fer-
ment of current policy proposals which call
Medical Science, Professional Practice and Education
Council Resolution on Health Emergencies Communication and Coordination
1.That the WMA and member NMAs should work closely with WHO, national governments and other professional groups to jointly
promote elements of this policy.
2.That the WMA urge physicians to be
– alert to the occurrence of unexplained diseases and deaths in the community,
– knowledgeable of disease surveillance and control capabilities, and
– assiduous in the timely reporting of suspicious cases of illness to appropriate authorities.
3.That the WMA encourage physicians, NMAs and other medical societies to participate with local, national and international health
authorities, in developing and implementing disaster preparedness and response protocols for natural infectious disease outbreaks.
These protocols should be used as the basis for physician and public education.
4.That the WMA call on NMAs to promote and support the GOARN network as a control coordinating entity in combating global
health security threats.
5.That the WMA call for the establishment of a strategic partnership agreement with WHO, so that in the case of epidemics, health
communication can be stepped up considerably and two-way flow of information ensured.
6.That WHO should coordinate the development of an inventory based on existing stockpile supplies, so that such supplies can be
rapidly deployed and accessed by physicians involved in the care of victims.
7.That international agreements should be proactively explored to facilitate the movement of health professionals who are involved in
the management of epidemics.
8.That research in the field of emergency preparedness should be enhanced by national governments and NMAs where appropriate,
to better understand current flaws in the system and how to improve preparedness in the future.
9.That education and training of physicians should be amended to take into account the realities and specific needs required in the
event of emergencies, and to ensure that due diligence is paid to patient and healthcare worker safety when managing patients with
acute infectious diseases.
10.That physicians everywhere in the world, including Taiwan, should have access to WHO programmes and information, and infor-
mation concerning health emergencies.
Medical Science, Professional Practice and Education
Preventing preventable chronic disease –
international developments
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 44
for international collaboration between
non-governmental organizations (NGOs)
and intergovernmental organizations
(IGOs) such as WHO and the European
Union. The outstanding example of interna-
tional collaboration is the MONICA study,
“the world’s largest study of heart disease,
stroke, risk factors and population trends”
which WHO was instrumental in establish-
ing and supporting. The compilation of the
resultant monographs, edited by Professor
Hugh Tunstall-Pedoe of Dundee, is now
available from WHO in hard copy and in
CD-ROM, the MONICA Monograph and
Multimedia Sourcebook (WHO 2004)
(www.ktl.fi(monica). This presents unique
data on CVD factors, mortality and morbid-
ity and medical care from 21 countries over
four continents involving 38 research
groups from 1979 to 2002. It offers chal-
lenging hypotheses about the relationship
between risk factors and changes in the pat-
tern of CVD, and is a unique and invaluable
resource for clinicians, public health practi-
tioners, researchers, policy-makers and stu-
dents. It is particularly to be praised for
acknowledging the difficulties involved in
such a complex exercise.
In this context, it is timely that WHO has
developed its STEPWISE (STEPS)
approach to surveillance of risk factors
(2003) relating to NCDs. This aims to pro-
vide standardized materials and methods to
help countries, especially those that lack
resources, to initiate NCD activities. The
goal is to achieve quality data compatibility
and comparability over time. WHO is
maintaining the NCD data at a country level
on the WHO Global NCD InfoBase.
WHO has shown superb leadership in forg-
ing the Framework Convention on Tobacco
Control (FCTC) – its first-ever global
health convention. This will proceed to
implementation in September 2004 assum-
ing ratification by the requisite forty coun-
tries. Further, in May 2004, the World
Health Assembly also approved a Global
Strategy for Diet, Physical Activity and
Health. Although this does not have the
force of a binding treaty, it marks a signifi-
cant advance in setting out standards of
good practice for competent national public
health strategies. Predictably, those ele-
ments of this strategy which require collec-
tive governance, such as effective controls
on the marketing of foods high in fat, sugar,
and salt, may also become the subject of
another international convention.
Dr. Derek Yach and Dr. Corrina Hawkes of
WHO have just published a compelling
framework for action – “Towards a WHO
long term strategy for the prevention and
control of leading chronic diseases” (2004).
This has as yet no formal status, but it rais-
es many fundamental and controversial
issues, notably the health impact of foreign
direct investments in developing countries.
It calls for global cooperation between the
WHO and other IGOs such as the World
Bank and the World Trade Organization in
tackling the global epidemics of linked
avoidable chronic diseases.
International NGOs such as the World
Health Federation, the International Diabe-
tes Association, the International Obesity
Task Force, the International Association for
the Study of Obesity and the Cancer Lea-
gues are increasingly making a significant
contribution to the prevention of avoidable
chronic diseases. They are key civil society
stakeholders and act in particular as a coun-
tervailing force to the market-driven vested
interests of the corporate sector. They share
a common agenda for collective action and
are closely involved with WHO in advoca-
ting and shaping evidence-based strategies
for action. The most recent example was to
counter the influence of the sugar industry at
this year’s World Health Assembly. Similar
action by NGOs is taking place within the
European Union. The European Heart
Health Network (EHN), whose membership
comprises national heart foundations which
are increasingly active in public health ad-
vocacy, has worked closely with internatio-
nal cancer organizations in pressing the EU
institutions to introduce tobacco control
measures such as banning advertising and
sponsorship throughout the EU. It is now
embarking on a project to investigate the ex-
tent of the marketing of foods high in fat, su-
gar and salt to children in Europe and the ef-
fectiveness of any national controls.
The prevention of linked avoidable chronic
diseases at all levels will be greatly enhan-
ced by greater strategic collaboration be-
tween NGOs, which share a common agen-
da. Action on tobacco control, food and nu-
trition and the promotion of physical activi-
ty are obvious priorities. A national exam-
ple of collaboration is the UK’s National
Heart Forum (www.heartforum.org.uk),
which brings together the leading national
professional and social policy NGOs which
are concerned about the causes and effects
of heart disease, strokes and diabetes, to de-
velop and advocate collective public policy
positions.
The bad news is that those transnational
companies whose activities are inimical to
health, frequently escape controls due to the
absence of structures and mechanisms for
international action. The prevailing “new-li-
beral” approach by most governments is mi-
nimal intervention, with non-binding part-
nership agreements or dependence on self-
regulated corporate social responsibility
(CSR) in the jargon). International Public
Interest NGOs (PINGOs) have a putative
role in the promotion of CSR, but that ap-
proach has proved to be sadly futile in the
absence of international standards and any
meaningful involvement of independent
civil society monitoring and audit. As the
open-ended extrinsic economic, social and
health costs of uncontrolled commercial ac-
tivity are borne by society, it must be right
that society is involved in its regulation.
The Director-General of WHO, Dr LEE
Jong-wook, pledged in July 2003 to devel-
op and implement a comprehensive plan for
combating the preventable chronic NGOs,
which account for a growing share – esti-
mated at 60% – of the burden of disease
world-wide. Tackling the power and influ-
ence of irresponsible transnational compa-
nies will require continuing strong leader-
ship by WHO and other international IGOs
working closely with health NGOs. This is
a particular challenge to the health profes-
sionals. In the global war against disease,
we are in the forefront of the battle. We
must not fail.
Address for correspondence:
National Heart Forum
Tavistock House South,
Tavistock Square,
London WC1H 9LG,
UK
45
Medical Science, Professional Practice and Education
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 45
46
The fight against malaria over the past
twenty-five years or so has been a story of
success and disappointments. The discov-
ery of various drugs has advanced and
improved the control of the disease but also
unfortunately resistance caused problems
and currently, this remains a major prob-
lem. Now the complete sequence for Homo
sapiens and Plasmodium falciparum is
known, new strategies can be worked out in
the world-wide battle against malaria. It is
anticipated that new targets for drugs will
be identified – and that drugs in future will
be computer-designed to attack at metabol-
ic and genetic weak points. If the present
armamentarium of anti-malarial drugs fails
to act against resistant parasites, there is
hope that new classes of drugs will achieve
more effective cures and ultimately eradica-
tion of malaria.This article reviews the
scene and the exciting possibilities for
definitive mechanisms for dealing with the
remaining problems which can flow from
the genomics revolution.
Tackling rising levels of medicine resistance
is one of the key challenges to African
States in their efforts to control malaria and
meet the declared target of saving the lives
of half the 800,000 children who die of the
disease each year by 2010. Recognising that
the cheapest and most readily available
medicines are increasingly ineffective, the
WHO “Roll Back Malaria” programme
urges countries to switch to the combination
therapy, Artemisinin-based Combination
Therapies (ACT’s) when there is strong evi-
dence that existing conventional medicines
are no longer working. As ACT’s combine
two medicines which work in different
ways, it is unlikely that the malaria parasite
which has rapidly developed resistance to
other single treatments will evolve to resist
these medicine combinations. WHO added
the ACT’s (Artemether/lumefantrine) to its
Essential Drugs List. Furthermore, the
Global Fund Against AIDS, BTB and
Malaria funded proposals to “Roll Back
Malaria” in Zanzibar and Zambia which
included purchasing and phasing-in the use
of new ACTs. Expressing the hope that this
Fund and other funding mechanisms would
be used to purchase ACT’s where they are
needed to treat and control malaria, Dr. Gro
Harlem Brundland, stressing the need to
reduce their prices in developing countries
said “It is important that countries, which
need ACTs are able to access and use them
in a sustainable manner”.
Many countries in Eastern, Central and
Southern Africa are experiencing resistance
to chloroquine, and resistance is also
appearing in West Africa. As a result many
countries have moved to sulphadoxine-
pyrimethamine (“SP” or “Fansidar”) as a
first line treatment, but resistance to SP is
also spreading.
There is new evidence that the number of
child deaths due to malaria is increasing
due to failing medicines and medicines of
poor quality. There is also evidence that due
to rising levels of medicine resistance,
almost half the money spent on anti-malar-
ials is being used to pay for inappropriate
treatment. This also highlights the need for
more efforts on preventing malaria using
proven cost-effective measures such as
insecticide-treated bednets.
The WHO recommendation is that coun-
tries begin the transition of medication as
soon as levels of resistance exceed 15% and
that the change will be implemented before
resistance reaches 25%.
The rise of resistance
Halofantrine, which like mefloquine was
produced as a direct result of the Vietnam
War, is highly effective against multi-drug
resistant Falciparum malaria.
Unfortunately, during clinical evaluation in
Thailand – after it had been registered in
several countries – halofantrine was found
to predispose to potentially lethal cardiac
arrhythmias. Its use is now restricted.
There has been a global initiative to evalu-
ate artemisinin-based combination treat-
ments throughout Africa and South
America. The artemisinin combinations
provide consistently rapid resolution of
symptoms, they are highly effective and
well tolerated, and in low transmission
areas, use of the combinations provides the
bonus of reducing malaria transmission and
therefore the incidence of malaria.
The rediscovery of artemisinin and the syn-
thesis of piperaquine, lumefantrine and
pyronaridone in China have provided a new
generation of effective, well-tolerated, and
in some cases affordable, countrywide anti-
malarial drugs rather than time-honoured
quinine, and may be effective.
Double Act
Combination therapy – combining two
drugs together to prevent the evolution of
resistance – is a practice already used for
the treatment of tuberculosis, leprosy, HIV,
and many cancers. As the probability of the
development of a mutant resistant to one
compound is very low, simultaneous resis-
tance to a combination is therefore extreme-
ly unlikely to emerge.
Thus, in order to prevent resistance to the
artemisinins, these drugs are being com-
bined with other synthetic compounds. As
artemisinin works quickly and is removed
from the body rapidly, these additional
compounds should be those that last longer
in the body, mopping up any parasites that
have escaped.
The malaria genome project
Within the genome of Plasmodium falci-
parum are the genes that make this malaria
parasite so deadly to humans. However, to
date deciphering the genome in terms of
weak spots in the sequence, and on/off
switches used during development, has
been difficult. Despite its relatively small
size – the human genome is 100 times larg-
er – the nature of the malaria genome has
remained elusive. Each of the 14 malaria
chromosomes has its own set of genes, but
they all have highly conserved central
regions, and highly diverse regions near the
Medical Science, Professional Practice and Education
Genomics
Strategies in the Battle Against Malaria
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 46
telomeres at the ends. There are 22.8 mil-
lion bases (Mb) of DNA, of which com-
plete sequences are available for chromo-
somes 1-5, 12 and 14. The other chromo-
somes still have some gaps remaining that
are being “closed up”.
Within the genome, 5279 genes have been
identified. Only 40% of the proteins
expressed by the genes resemble others in
databases, where a similarity often suggests
what their function might be. So around 60%
of the proteins may well be unique to this
organism, which is a very high percentage in
comparison with other sequenced eukary-
otes. This reflects both a massive evolution-
ary distance and a highly specialised ecolog-
ical niche occupied by this organism. The
subtelomeric regions are of particular inter-
est because they contain highly variable
gene families, a variation due largely to the
deletion or insertion of DNA sequences, that
help the parasite evade the human immune
system. They are also highly diverged
between species of Plasmodium and undergo
high levels of recombination, which gener-
ates further diversity.
Insights into metabolism
Only 733 of the 5277 genes have been iden-
tified as enzymes, proteins that make the
parasite tick, driving the metabolic path-
ways that build up or break down the organ-
ism’s tissues for parasite use. Not only is
this a lower percentage than in all other
sequenced organisms, but the parasite also
appears to lack some key biosynthetic path-
ways. For example, it has little capability at
all for making purines – the adenine (A)
and guanine (G) in DNA.
Most of the biosynthetic pathways in
Plasmodium, such as in the synthesis of
haem, isoprenoids and fatty acids, appear to
be localised in the apicoplast, a structure
within the cell that has its own genome, and
is similar to the chloroplast of plants and
algae. Although this genome encodes for
only 57 proteins, it is calculated that around
10% of the proteins expressed genetically by
the nucleus may come from this structure.
Some of the metabolic pathways identified
are not present in humans, and therefore are
potential targets for novel drugs and indeed,
the availability of new possibilities for anti-
malarial drugs.
Insights into pathogenesis and
immune evasion
The particular danger Plasmodium falci-
parum presents to humans is due in part to
the way it can modify the surface of the
host red blood cell in which it grows.
Approximately 16 hours after invasion, par-
asite-producing proteins can be detected on
the surface of red blood cells. These then
mediate adhesion to a variety of host mole-
cules on endothelial cells and some other
cell types. Infected red blood cells do not
circulate as normal, but instead accumulate
in the small blood vessels in a variety of
organs, where they may initiate life-threat-
ening complications. The host immune sys-
tem is aware of these changed surface pro-
teins and launches a protective antibody
response. Yet the parasite is able to avoid
this response by regularly switching
between different versions of the proteins –
a trick known as antigenic variation.
The main benefits likely to come from the
genomes of host and parasite will be analy-
sis of data using high throughput technolo-
gies of gene expression. Knowing the gene
sequences means DNA microassays can be
designed to look at the changes in gene
expression, for example, during the cell
cycle and during drug treatment. Such novel
techniques will help identify the pyramidal
networks of genes that are regulated in uni-
son – and shed much light on the way genes
are involved in drug resistance.
Furthermore, the complete genome will ena-
ble proteomics to identify all the proteins
produced in the different stages of the cell
cycle governing the parasite’s existence, or
in different compartments within the cell.
Conclusion
Big international science combined with
medicine, utilising high throughputs of
functional genomics, will help researchers
to understand what the genes of parasite and
host actually do. “DNA chips” or “DNA mi-
croassays”, as a grid of tiny spots of DNA
from hundreds or thousands of genes, are
used to examine the expression of many ge-
nes at once. Subject areas include cyto-ad-
herence; antigenic variation; merozoite in-
vasion of red blood cells; sexual stage bio-
logy, gametocytogenesis and parasite deve-
lopment in the mosquito; structural biology
of parasite proteins; and bio-informatics.
Using parasites isolated at different stages
in their life cycle, DNA microassays will be
able to analyse which genes are switched on
or off at the various stages. Weak spots will
be targeted for drug attack. High-through-
put identification of proteins using mass
spectrometry will enable crucial genes to be
“knocked out” or modified. The structures
of proteins in 3-dimensions, and the time di-
mension, will be analysed to learn more ab-
out how molecular orbital theory fits into
catalytic function.
As Dr. Tony Holden explains:
“In the last 20 years, only about 20 proteins
have been characterised, whereas in the next
10 years, we hope to characterise several
hundred key proteins. These findings will
feed into applied research for new drugs,
treatments and vaccine against malaria.”
Ivan M. Gillibrand
47
Medical Science, Professional Practice and Education
Immunodiagnostics
High-Technology
Medicine At The
Bedside
The interesting technological inventions
from the Institute of Bioscience and
Technology, Cranfield University, reported
below illustrate more potential for the use of
“high-tech” diagnostic aids at the bedside.
Diagnosis in Public Health
Disorders
H. pylori (HP) infection is recognised as the
most common gastrointestinal bacterial di-
sease world-wide. It is now accepted as the
major cause of gastroduodenal ulceration in
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 47
48
over 80-90% of patients. Tuberculosis (TB)
is another major public health problem, with
approximately one-third (1.9 billion) of the
world’s population infected. Typically, the
diagnosis of these infections requires both
high-cost instrumentation and highly skilled
personnel. This invention provides a rapid
device for measuring these bacterial infec-
tions at or near the patient’s bedside.
Advantages
The use of electronic technology via the
nose/nostrils has been successfully develo-
ped since its introduction in the early 1980s,
primarily aimed at the food industry. This
invention exploits this technology further
for medical applications, resulting in a devi-
ce offering a number of advantages for dia-
gnosing bacterial infections, for example:
• The device can be applied to the analy-
sis of gas samples generated in vitro
from samples obtained from patients e.g.
sputum samples
• The device can be used to diagnose
and/or monitor gastric and/or lung disor-
ders
• By utilising dedicated software, a fast
odour recognition system can be
employed, significantly reducing diag-
nosis time
• Fast inexpensive collection of volatile
samples can be achieved
• Storage and rapid analysis (within 10
minutes) of patient data, using a bedside
diagnostic system
Applicability
The device is ideally suited to the rapid,
cost-effective diagnosis of major bacterial
infections of the human lung and stomach.
Technical field
The device operates by a unique enzymatic
pre-treatment followed by passing the gas
sample over a multiplicity of chemical sen-
sors that generate electrical outputs. These
outputs are passed to a data processing sy-
stem, e.g. a hybrid intelligent system em-
ploying a search optimisation engine of ge-
netic algorithms and many neural networks.
This determines the distinctive patterns cha-
racteristic of particular disease states.
Replication of Nucleic Acid
Arrays
DNA analysis is now a vital tool used for a
wide variety of application from medical
diagnosis and criminal forensics to military
and civil defence. Undoubtedly, the use of
this technology will accelerate over the
coming decades, largely as a result of inno-
vations and improvements to the existing
devices. This invention relates to methods
for manufacturing nucleic acid arrays and
their application in sequencing, detecting
and identifying specific nucleic acids. The
invention is also directed towards methods
for the replication of probe assays, used for
screening biological samples for target
nucleic acids and nucleic acid variations.
Advantages
Current methods for fabricating arrays suf-
fer from a common limitation, i.e. each
array and each element of each array
requires a separate synthesis and fabrication
protocol which is normally laborious, time-
consuming and expensive. This invention
overcomes these problems and provides
new methods for rapidly and accurately
replicating complementary copies of nucle-
ic acid arrays. The solid supports that can be
used for the array base include porous or
non-porous plastic, ceramics, glass, metals,
resins, gels, silicon and semiconductors.
Applicability
The broad scope of this invention means
that it can be applied to a wide range of
applications, where nucleic acid determina-
tion plays a key role including:
• Pharmacology
• Environmental diagnostics
• Medical diagnostics
• Forensic analysis
• Clinical analysis
Technical field
This invention covers a number of methods
for producing arrays. Broadly, the methods
are based on the use of a pre-formed nucle-
ic acid array (master copy) replicated by
bringing it into contact with a blank copy
which contains immobilised primers and by
initiating specific replication of the nucleic
acid sequences either chemically or enzy-
matically.
Cholesterol in Heart Disease
One of the main causes of death in the
developed world is cardiovascular disease
and the contribution of elevated blood cho-
lesterol levels to this is well established.
There is, consequently, a need to measure
levels of cholesterol in order to diagnose the
condition and prescribe appropriate dietary
or pharmaceutical treatment. This invention
provides a rapid, accurate and low-cost
approach to measuring cholesterol, based on
screen-printed biosensors that can be mass-
produced.
Advantages
This is a very easy to use, rapid, low-cost
biosensor system that can readily be used by
most members of the general public. Indeed,
its method of use is very similar to that used
by diabetics (throughout the world), who
rely on an electrochemical-based biosensor
to measure their blood glucose levels. In
contrast to most conventional home test kits,
used for measuring cholesterol levels, which
tend to be colour-based (hence relies on a
subjective interpretation of a chart), this sen-
sor provides an accurate quantitative read-
out of cholesterol concentrations. In addi-
tion, this invention circumvents the lack of
well-known direct electrochemical media-
tors for cholesterol oxidase.
Applicability
The sensor provides an accurate measure-
ment of blood cholesterol levels. However,
the format of the device is not limited to
cholesterol. In effect, the invention pro-
vides a method for detecting almost any
analyte that is oxidisable by means of an
oxidase with the generation of hydrogen
peroxide. The list of potential target ana-
lytes includes:
• Glucose
• Amino acids
• Alcohols
• Xanthine (levels of which can be indica-
tive of liver pathology)
Medical Science, Professional Practice and Education
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 48
This is not an exhaustive list and serves
simply to illustrate the potential offered by
this invention.
Technical field
The invention is based on a novel use of a
horseradish peroxidase substrate, ABTS, as
a mediator in an electrochemical enzyme
electrode.
Preparation of Biologically-
Active Molecules by Template
Polymerization
This invention provides an innovative
method for the synthesis of biologically-
active molecules (e.g. drugs, effectors,
modulators, inhibitors), providing a power-
ful tool for many applications in analytical
chemistry. The synthetic molecules have a
structure that is complementary to that of
the original template, i.e. it is a replica that
resembles the drug molecule. However,
compared to the conventional methods for
producing biologically-active molecules
this approach is quicker, easier and hence
low-cost.
Advantages
Previous efforts in drug design have typi-
cally been based on the cumbersome inves-
tigation into the structure-activity relation-
ships of a large number of chemical struc-
tures. This invention provides a much more
simple and direct method to design biolog-
ically-active substances.
Applicability
This invention can be adapted to provide
biologically-active molecules, derived from
a wide range of receptors including:
• Enzymes and nucleic acids
• Cells, prions and viruses
• Tissue samples and drugs
Hence, once prepared these molecules have
a wide range of applications, e.g. used as
drugs for pharmacology and medicine, as
receptor-specific ligands in analytical
chemistry (sensors, assays) and for separa-
tions in the biotechnology and pharmaceu-
tical industries.
Technical field
The biologically-active molecules are syn-
thesised using the following sequence of
events: 1) polymerisation of functional
monomers in the presence of a biological
receptor, 2) separation of the complex
formed, 3) removal of the template mole-
cule, and 4) solubilisation of the synthesised
replica. Synthesised using this method, the
target molecules (dimers, oligomers, poly-
mers, or a mixture of these compounds) can
rebind either in vitro and/or in vivo.
A Novel Building Block
Approach for Designing
Affinity Ligands for
Glycosylated Haemoglobin
The exponential increase in the number of
structures available in the Brookhaven
Protein Databank has led to a growing inter-
est in the direct approach to drug design.
Based on the development, this invention
exploits the tools developed and used by
pharmaceutical companies to aid the devel-
opment of synthetic receptors.This inven-
tion provides the novel concept of using a
“building blocks” approach for designing
affinity ligands; significantly enhancing the
potential for constructing specific sensor
systems that, hitherto, would have proved to
be extremely difficult.
Advantages
Using this technology it is possible to char-
acterise the target protein molecule efficient-
ly, estimate the interactions between individ-
ual combinatorial “building blocks” and any
proposed binding site, rationally designing
new peptide sequences and also to investi-
gate the interaction between lead ligands and
the binding site. Hence, the invention pro-
vides a highly efficient and effective method
for the design of “bespoke” synthetic recep-
tors. This is a distinct advantage when it is
desirable to either replace a less robust, bio-
logically derived, receptor or to designing a
ligand for a particular sensor system when
no such (biological) element exists.
Applicability
This invention can be used for a number of
applications including:
• The rational design of new peptide
sequences
• The rational design of synthetic recep-
tors that could be used in conjunction
with a wide range of sensor systems,
e.g. amperometric, potentiometric, opti-
cal, magnetic and gravimetric based
transducers
Technical field
This invention relates to the generation of
synthetic affinity ligands. It is based on a
three-domain approach that can be general-
ly applied to the design of artificial ligands,
intended for analytical purposes. These
domains are comprised of recognition,
affinity, and flexible components, each
domain fulfilling a specific function. The
design of each is obtained through a virtual
screening of chemical databases.
An Intelligent Volatile Pattern
Analyser for Diagnosis of Uri-
nary Tract Infections in vivo
Urinary tract infections (UTI) are a signifi-
cant cause of morbidity with around 3 mil-
lion UTI cases each in the USA alone.
Thirty-one percent of nosocomial infec-
tions in medical intensive care units are
attributable to UTI. Current diagnostic
techniques require 24-48 hours to identify
pathogenic species in urine midstream
specimens. Despite the introduction of mol-
ecular tests, culture remains the gold stan-
dard in everyday clinical practice. This
invention greatly reduces the time required
to carry out a diagnostic test. Based on the
use of an intelligent diagnostic model,
detection and recognition of UTIs can be
accomplished within 5 hours of the receipt
of specimens in the laboratory.
Advantages
The application of this novel technique,
combining sensor technology with artifical
intelligence, offers the opportunity for rapid
and accurate discriminating between differ-
ent infective organisms in fresh samples of
urine. Based on this invention, future devel-
opments could lead to a new generation of
diagnostic instruments capable of providing
rapid detection of infectious agents in vitro
49
Medical Science, Professional Practice and Education
00_WMJ_02_2004.qxd 23.07.2004 12:11 Seite 49
50
The Commission on Intellectual Property
Rights, Innovation and Public Health held
its first meeting on 5-6 April at the World
Health Organization (WHO) in Geneva.
The Commission was established as a result
of a World Health Assembly Resolution in
2003 which called for WHO to establish a
time-limited body to “produce an analysis
of intellectual property rights, innovation,
and public health, including the question of
appropriate funding and incentive mecha-
nisms for the creation of new medicines and
other products against diseases that dispro-
portionately affect developing countries.”
Welcoming the members of the
Commission, Dr. LEE Jong-wook,
Director-General of WHO, said: “Making
treatments available for diseases associated
with poverty has been a major priority for
WHO ever since the organization came into
existence. These diseases confront us with
highly urgent needs that are usually
extremely difficult to meet. Bold and inno-
vative thinking is required – not only to find
technical solutions but to find economic,
social and political ones as well.”
The Commission held discussions with
senior officials from WHO, representatives
from international organizations (UNC-
TAD, UNAIDS, WIPO, WTO), from the
research-based pharmaceutical industry and
from civil society.
In her opening remarks, the chairperson of
the Commission, Ms Ruth Dreifuss, said:
“The advance of medical science is of the
utmost importance in attacking these prob-
lems. The issue we are asked to address is
that medical science tends to focus dispro-
portionately on diseases and ailments of the
developed world.”
The Commission agreed on a policy of
openness in consulting the many different
stakeholders with an interest in its work,
and in drawing on the expertise they have to
offer in supporting the work of the
Commission. It requested the Secretariat to
compile a register of stakeholders and indi-
viduals with expertise to offer. Its publica-
tions, and submissions received by the
Commission, will be placed on the
Commission website.
World Health Report
2004 and the World
Health Assembly
The World Health Report 2004 has as its
main theme the problem of the pandemic of
HIV/AIDS and concentrates on the call for
a comprehensive strategy linking preven-
tion, treatment, care and long-term support.
It stresses the need for international organi-
sations, national governments, the private
sector and communities to combine their
strengths to tackle HIV/AIDS and in parall-
el, strengthen their health systems, which
will also benefit whole communities. The
World Health Assembly itself reflected both
the immediacy of the HIV/AIDS crisis and
the importance of improving public health
in the resolutions it adopted. This was
summed up by the comment of Dr. LEE
Jong-wook, WHO Director-General, that
“This World Health Assembly clearly
raised the bar for improving public health
of all people”.
(A full comment will appear in the next
issue of WMJ-Ed.)
WHO
and in vivo, with enormous implications for
future clinical practice.
Applicabilitiy
This apparatus will be ideally suited for use
in a hospital laboratory environment, where
the rapid (and hence more economical)
determination of UTIs can be achieved.
Technical field
The apparatus comprises a vapour or gas
generating system which, by interaction
with a urine sample, produces volatile
chemicals that are characteristic of infec-
tion. The product of this interaction is then
delivered to a detection system in a precise
and reproducible way. This detection sys-
tem comprises an array of sensors, each
having a different sensitivity to potential
components of the gas stream. An electrical
output signal is generated in response to
these components. A data processing sys-
tem then analyses this output signal, pro-
viding a profile of the urine sample – high-
lighting any UTIs.
Cranfield University
Silsoe
Institute of Bioscience and Technology
Bedfordshire MK45 4DT
England
Tel.: +44 (0) 1525 863000
Fax: +44 (0) 1525 863001
Website: www.silsoe.cranfield.ac.uk
WHO
Commission on Intellectual Property Rights,
Innovation and Public Health
WORLD HEALTH
ASSEMBLY
RESOLUTIONS 2004
WHO Global strategy on Diet, Physical
activity and Health
Health Promotion and healthy lifestyles
Reproductive health
Resolution on the family and reproductive
health
Response to HIV/AIDS
Global effort to eradicate Polio
Guinea-worm disease
Buruli ulcer
Human African Trypanosomiasis
Reducing Measles deaths
Human organ and tissue transplantation
International migration of Health Per-
sonnel
Framework Convention on Tobacco control
00_WMJ_02_2004.qxd 23.07.2004 12:12 Seite 50
Asian and African Countries Move to
Improve the Quality of their Medicines
Geneva – The World Health Organization
has launched an action plan against sub-
standard and counterfeit medicines with six
countries from the Greater Mekong sub-
region. The plan follows similar initiatives
in Africa and will continue to expand in
response to countries’ increasing call for
assistance to improve the quality of their
medicines.
Counterfeit and substandard medicines are
frequently detected in Cambodia, China,
the Lao People’s Democratic Republic, My-
anmar, Thailand and Viet Nam and the pro-
blem seems to be increasing. Products most
commonly counterfeited in this region in-
clude antibiotics and those used in the treat-
ment of tuberculosis, malaria and
HIV/AIDS. The use of poor-quality or
counterfeit medicines has little or no thera-
peutic effect and in poor settings often leads
to death.
“Combating low quality or illegal medici-
nes is now more important than ever. Ex-
panding access to safe, effective treatment
for AIDS and other illnesses is no longer an
option, it is an imperative,” says Dr LEE
Jong-wook, WHO Director-General.
At a meeting from 11-13 November 2003 in
Hanoi, Viet Nam, WHO and the six coun-
tries kick-started joint activities directed at
key decision-makers, health professionals
and the general public to strengthen inspec-
tion and post-marketing surveillance.
Substandard medicines are thought to
account for 8.5% of medicines on the mar-
ket in Thailand. Eight per cent of randomly
collected samples in Viet Nam and 16% in
Myanmar failed laboratory testing for qual-
ity assessment. From these batches,
Rifampicin (used to treat tuberculosis)
showed the highest failure rate at 26% fol-
lowed by Cotrimoxazole (an antibiotic used
mostly for children) at 24%.
In 2001 it was estimated there were 2,800
illegal medicine sellers in Cambodia and
1000 unregistered medicines on the market.
In the Lao People’s Democratic Republic
2,100 illegal drug sellers are said to exist.
With more complex combination medicines
now being recommended for drug-resistant
malaria, there is a strong possibility that
more substandard and counterfeit medi-
cines will enter the market in malaria-
endemic countries. Even in terms of older,
more traditional antimalarials, the quality
of the medicines is often poor.
A recent WHO survey of the quality of anti-
malarials in seven African countries (sam-
ples from Gabon, Ghana, Kenya, Mali,
Mozambique, Sudan, and Zimbabwe)
revealed that between 20% and 90% of the
products failed quality testing. The anti-
malarials in question were chloroquine-
based syrup and tablets, whose failure rate
ranged from 23% to 38%; and sulphadox-
ine/pyrimethamine tablets, up to 90 % of
which were found to be below standard.
The medicines were a mixture of locally
produced and imported products.
The reason why many of the antimaterials
tested were substandard seems to stem from
pervasive poverty. Poorly equipped labora-
tories, under-funded regulatory authorities,
and poor handling and manufacturing prac-
tices mostly contributed to the results of the
tests.
“Many tools exist to improve medicines’
quality control and supply systems,”
explains Dr Vladimir Lepakhin, Head of
Health Technology and Pharmaceuticals at
WHO. “The problem is one of resources.
Most of the countries with the lowest qual-
ity pharmaceuticals are also the ones with
the highest disease burden and the poorest
economies.”
The findings of the report have provided a
basis from which to address potential prob-
lems in the transition to the combination
artesimin-based medicines for drug-resis-
tant malaria and have given impetus to the
fight against poor quality and counterfeit
medicines in Africa.WHO is now running a
series of training workshops in several
African countries assisting manufacturers
to upgrade their standards, and regulatory
authorities (the national bodies meant to
assure the quality and safety of medicines)
to improve their practices in the screening
and testing of local and imported products.
51
WHO
Quality control
Action Against Substandard and Counterfeit
Medicines
In political circles, the term VISIBILITY
means a great deal. If a politician or organi-
zation has visibility, it has a better chance of
convincing the electorate or general public of
new directions or policies which should be
followed, or the importance of maintaining a
current position. Translated into our world of
health care, the World Medical Association
(WMA) can only act effectively as a strong
advocate for the profession and the patients it
serves, if it is VISIBLE on the global stage
of leadership in health care. The question is
therefore how visible the WMA is today, par-
ticularly in relation to its collaboration with
the World Health Organization (WHO) and
its impact on the members of WHO (the gov-
ernments of the world).
Currently, the global leadership in health
care is represented by a curious mix of
players, including governmental, intergov-
ernmental, non-governmental, and private
groups, as well as some public-private part-
nerships. Because these groups have to get
their message communicated and heard in a
globalizing and highly information-driven
world, there is tremendous competition to
be the one to actually set or influence the
WMA Secretary General
From the Secretary General’s Desk, May 2004
00_WMJ_02_2004.qxd 23.07.2004 12:12 Seite 51
52
global health agenda. This battle often takes
place during the WHO’s annual meeting,
the World Health Assembly (WHA), which
happened to follow the WMA Council
meeting in May 2004. During the WHA,
governmental delegations from all countries
of the world gather to discuss and set policy.
As with all political meetings, the most
important actions and political deal-making
often take place in the corridors. It is there-
fore understandable that one would find in
these corridors representatives of health
professions’ associations, non-governmen-
tal organisations and private industry, all
trying to influence the decision-makers in a
way which would be of benefit to the groups
they represent. One of the most effective
health professional groups in terms of lob-
bying has been the International Council of
Nurses (ICN). During the WHA, they have
a team advocating on behalf of nursing and
make several interventions on matters
which might have an impact on nursing and
its future. Reflecting on how the WMA has
performed in this regard, one must unfortu-
nately concede that until the year 1999, the
WMAvoice had been largely absent. In fact,
for several years, the WMA was not even in
official relations with WHO.
Fortunately, this was rectified in 1996 when
official relations were re-established.
However, even after the “re-unification”, it
was distressing to find at that time a quite
palpable “anti-physician” sentiment in
WHO. In response to this undesirable situa-
tion, and in an effort to make the WMA
more visible, the WMA leadership estab-
lished a clear strategy in 1998 to improve
relations with WHO and other international
stakeholders. Almost immediately, the strat-
egy bore fruit. In 1999, the WMA was
requested by WHO to chair a planning com-
mittee of all the health professional associa-
tions for the development of a global pro-
gram supporting World No Tobacco Day
1999. Subsequently, relations have been
greatly strengthened, with many tangible
results to confirm this increased visibility
and political effectiveness, as for example:
– the WMA participated in all the negoti-
ations and debates leading up to the
adoption of the Framework Convention
on Tobacco Control;
– the inclusion of the WMA in the WHO
Global Alert and Response Network to
combat communicable diseases. This
has been updated to deal more effective-
ly with new epidemics such as SARS;
– the development of policy on safe injec-
tions, with the Safe Injection Global
Network (SIGN);
– the development of policy on “Violence
and Health”, and participation in the
WHO launch of this project;
– the management of human resources for
health.
Another important part of the WMA’s “vis-
ibility” strategy was to encourage its mem-
bers to work to become regular advisers to
the governmental delegations participating
in the World Health Assembly. In this
regard, the May 2004 event had unprece-
dented levels of visibility for the WMA:
– 9 Governmental delegations to the
WHA included representatives from the
WMA leadership;
– 10 members of Council stayed on to
attend part of the WHA;
– during the WHA, several interventions
were made on behalf of the WMA;
– the WMA arranged a leadership sympo-
sium, in partnership with the
International Council of Nurses and the
International Pharmaceutical Federation,
which was attended by the Councils of
the three groups and WHO. This historic
event was sponsored, in part, by WHO
(another first) and the WHO Director-
General was the keynote speaker;
– the WMA had two further receptions for
Ministers of Health during the
Assembly, each time drawing more than
40 Ministers of Health with their dele-
gations. At one of the receptions, the
WMA chose the theme of HIV/ AIDS,
and it was remarkable that the three
most prominent groups involved in this
area all accepted invitations to speak –
the Executive Director of UNAIDS, Dr.
Peter Piot, the WHO Assistant Director-
General, Dr. Jack Chow, and the Chair
of the Global Fund to Fight AIDS,
Tuberculosis and Malaria, Secretary
Tommy Thompson of the USA.
Quite a remarkable turnaround in relations
and visibility! In fact, it can be argued that
the WMA has never been more VISIBLE
on both the WHO and international stage of
health leadership than it has been over the
last month. This has required tremendous
time and effort from all the leadership and
staff of the WMA, but for a cause well
worth it – our profession and our patients.
Needless to say, this was only the introduc-
tion to greater visibility and effectiveness in
a never-ending quest for relevance and
influence. In fact, Churchill’s words ring
true when we reflect on our “visibility”
strategy and its first fruits:
“This was neither the beginning nor the
end, rather, it was the end of the beginning.”
Regional & NMA News
Regional & NMA News
BANGLADESH
The Bangladesh Medical Association, with
the collaboration of the Ministry of health
and Family Welfare, the Ministry of LGRD
and Co-operation has launched a Health
Sector Strengthening Programme for capa-
city building of doctors and other staff
fighting Arsenicosis and published a Trai-
ning Manual for Trainers on the Early
Diagnosis and Management of Arsenicosis,
a major public health problem in this coun-
try. Whilst referring to the first case of large
scale health problems caused by naturally
occurring arsenic being in Taiwan in 1968,
to its existence in many other countries and
heavy dependence on groundwater for pu-
blic drinking water supply, it is stated that
problems in groundwater from the alluvial
and deltaic aquifers of Bangladesh repre-
sent the most serious occurrences identified
globally. In one survey across the country,
46% of wells less than 150m deep excee-
ded the WHO guideline of 10 µg/l. Dr.
M.A. Hadi, President of the Bangladesh
Medical Association, writes:
“One of the most serious public health pro-
blems that we are facing in Bangladesh isAr-
senicosis. The majority of our people are ex-
posed to this health hazard and a large num-
ber are also suffering from complications.”
00_WMJ_02_2004.qxd 23.07.2004 12:12 Seite 52
UN, World Bank and Global Fund call on
European Ministers to scale up HIV pre-
vention and treatment programmes
Dublin – AIDS is rapidly spreading in
Eastern Europe and is on the rise again in
Western Europe because integrated preven-
tion and treatment programmes have not
been sustained or do not exist. Countries in
Eastern Europe, home to the fastest-grow-
ing epidemic in the world, will be in
Europe’s borders following the European
Union’s enlargement on 1 May 2004. The
Baltic States, which will be part ot the EU,
are also experiencing a rapid rise in HIV
infections.
Leading UN agencies, the Global Fund to
Fight AIDS, Tuberculosis and Malaria and
the World Bank are calling on European
Ministers to urgently take decisive action to
prevent the further spread of AIDS across
Europe and to treat those in need. They warn
that young people and other groups, such as
sex workers, men who have sex with men
and injecting drug users, are particularly at
risk of HIV infection. The agencies partici-
pated in a Ministerial Conference hosted by
the Irish EU Presidency, “Breaking the bar-
riers – Partnership to fight HIV/AIDS in
Europe and Central Asia”, in Dublin.
“Europe and Central Asia are the centre of
the fastest-growing HIV epidemic in the
world. There is no time to waste – European
Ministers must urgently scale up and roll
out effective HIV prevention and treatment
programmes,” said Dr Peter Piot, UNAIDS
Executive Director. “Given that the EU will
form the biggest trading bloc in the world,
covering more than 500 million people, it is
in the EU’s best interest to prevent the
AIDS epidemic from crippling Europe’s
social and economic development.”
Although most people in Western Europe
now have access to free treatment through
national health systems, many governments
have not focused as much on prevention as
they did in the 1990s. Infection rates are
once again on the increase. Integrated pre-
vention and treatment programmes are also
urgently needed to ensure that life-prolong-
ing treatment is not seen as a cure and to
ensure that people living with HIV/AIDS
continue to protect themselves and their
partners.
Over 1.5 million people are living with HIV
in Eastern Europe and Central Asia, com-
pared to only 30,000 in 1995. Young peo-
ple, who make up 40% of the population in
the region, account for the majority of HIV
infections among injecting drug users. A
large number of them also engage in unsafe
sex, increasing the risk of HIV. There is
also evidence that people are having sex at
a much younger age without protection.
The percentage of people reporting premar-
ital sexual relations more than doubled
between 1993 and 1999, from 9% to 22%.
Only 10% of girls in Tajikistan have ever
heard of HIV/AIDS.
“Schools are the best defence against HIV
infection,” said Carol Bellamy, Executive
Director of UNICEF. “They offer the best
mechanism to deliver HIV prevention
information, as well as the long-term edu-
cational and social skills that protect
against infection. With knowledge so criti-
cal in the fight against HIV/AIDS, the best
defence against the epidemic is keeping
vulnerable young people, especially girls,
in school.”
In Eastern Europe and Central Asia, only
7000 people receive antiretroviral therapy
for HIV, which is 9% of those in need in the
region. For many, the treatment is too
expensive or simply not available. To
address this imbalance, the World Health
Organization and UNAIDS have launched
an ambitious challenge to get three million
people on antiretrovirals by 2005 in devel-
oping countries and emerging economies.
Dr LEE Jong-wook, WHO Director-
General, said: “Treatment saves lives.
Without treatment, the millions of people
living with HIV will die prematurely.
Prevention must go hand in hand with treat-
ment. Europe cannot divide over the issue
of AIDS treatment, and only provide treat-
ment in the richer countries. Treatment
should be a right for all, including for sex
workers and injecting drug users.”
In many countries of Western Europe, there
are increasing rates of sexually transmitted
infections, indicating resurgence in unsafe
sex, primarily among young heterosexuals.
In 2003 alone, between 30,000 and 40,000
people became infected with HIV, raising
the number of people living with HIV to
between 520,000 and 680,000. “The
enlarged EU and its neighbours could
rapidly be faced with a more vigorous
phase of the epidemic unless political lead-
ers transform their verbal commitments
into concrete action on the ground,” said
Lars Kallings, the UN Secretary-General’s
Special Envoy for HIV/AIDS in Eastern
Europe, speaking at the conference.
53
Reviews
GERMANY
At the 107th
meeting of the Deutscher
Ärztetag (Annual Meeting of the German
Medical Association) in Bremen, adherence
to the provisions of the Helsinki Declaration
was reinserted into the professional Ethical
Regulations. At this meeting Dame Cicely
Saunders, the pioneer of palliative medicine,
was honoured by the award of the
Paracelsus Medal, the highest award which
the German Medical profession can bestow.
Due to Dame Cicely’s indisposition, the pre-
sentation was made in the U.K. by the
President of the Bundesärztekammer,
Professor Jörg-Dietrich Hoppe.
EU Enlargement
The enlargement of the European Union to 25 Member States means that the EU will
constitute almost half of the WHO European Region (51 Member States).
TB Resistance and Aids Threat Growing
Throughout Europe
00_WMJ_02_2004.qxd 23.07.2004 12:12 Seite 53
54
Humans in the service of medical science
in the twentieth century
Jordan Goodman, Anthony McEllgott, and
Lara Marks, Des.
Johns Hopkins University Press, 2003,
£31, pp. 217
ISBN 0 8018 7342 8
This multi-disciplinary volume is based on
contributions to a workshop on Human
Experimentation at the Wellcome Institute
for the History of Medicine in London in
1998.
In a comprehensive introductory chapter
“Making Human Bodies Useful”, the edi-
tors set out their aim of presenting an his-
torical review of medical experimentation
in the 20th century based “not around the
familiar doctor-patient or scientist-subject
axis, … but on the role of the state as actor,
legitimator and provider.” They aver that
“the concept of usefulness is the point of
contact between human experimentation,
knowledge, and the state. “With reference
to the “horrible uniqueness” of medical
experimentation in Nazi Germany and the
consequential Nuremberg Code, they claim
– with melancholy justification – that abu-
sive practices flourished in medical practice
in situations where the state was not so
coercive as in Germany. They argue that
‘medical science has become a constitutive
force in the creation of a knowledge soci-
ety’, and they show that the hallowed con-
cept of ‘informed consent’ which has dom-
inated ethical discussion since Nuremberg
is seriously flawed; even when it has been
obtained, human experiments “may still
violate the patient’s autonomity”. Examples
abound of the experimental dilemma in
which they are torn between the conflicting
imperatives of obtaining information and
preserving their ethical integrity. Subjects
are too often unwitting if not unwilling.
The following seven chapters range widely
throughout the world and the century, with
reference to earlier ethical codes from Hip-
pocrates, through Thomas Percival, to Clau-
de Bernard, reviewing and discussing expe-
riments on healthy individuals, groups of
patients, military service personnel, and
whole populations. Readers may be familiar
with some of the examples, such as the in-
vestigations during and after the Second
World War aimed at elaborating the com-
plexities of viral hepatitis, and the exposure
of 35,000 service personnel and 2,000 civi-
lians to atomic blasts in Australia and on
Christmas Island. Other examples may
come as a shock, notably the germ warfare
tests in the UK after World War II in which
great swathes of the country were sprayed
(without the knowledge or consent of the
population, needless to say) with ‘simu-
lants’which post-hoc evaluation fortunately
adjudged to be innocuous, and – at the other
extreme of the spectrum of harm – the injec-
tion of comatose patients with uranium. The
outstanding feature of every chapter is a
cornucopia of notes (extended references
and explanatory comments) which are a tre-
asure for researchers. Conversely, an index
was evidently considered redundant.
Although the authors address particularly
the role of the state in influencing medical
experimentation either directly as in the
“euthanasia” of “lives unworthy of life”
(lebensunwertes Leben) in pursuit of the de-
mented “eugenic” policy of the Herrenvolk,
or indirectly sponsoring selective experi-
ments in its own interests as in the exposure
of thousands of people to nuclear radiation,
the compelling challenge of this book is to
the medical experimenter. That challenge is
to resist the temptation to rationalise, e.g.
that the subjects are in a situation where it is
assumed that they will become infected
sooner or later, as in the case of the mentally
retarded children in the Willowbrook State
School on Staten Island who were admini-
stered infected material from patients with
hepatitis. Arguably, it may be thought even
less defensible to inflict potentially dange-
rous and traumatic experiments on “use-
less” patients suffering from, eg. an uncura-
ble brain tumour or neurosyphilis, on the
pretext that they can be rendered useful to
medical science and its future beneficiaries.
Ultimately the challenge is to the integrity
and the conscience of researchers and their
ability to resist the blandishments of
finance, fame and fortune.
A. W. Macara
Reviews
“Data from the region unambigously points
to the socio-economic and governance
dimensions of the epidemic. Members of at-
risk groups are often subject to social exclu-
sion, poverty, stigmatisation, or incarcera-
tion – factors which actually heighten the
spread of the disease,” said Kalman Mizsei,
Assistant UNDP Administrator and
Regional Director for Europe and the CIS.
In addition to increased AIDS funding from
national governments, the World Bank and
the European Union, the Global Fund to
Fight AIDS, Tuberculosis and Malaria has
approved over US$ 400 million in funding
over five years for 22 programmes in 16
countries in Eastern Europe and Central
Asia. Most of these funds are earmarked for
HIV prevention and treatment programmes,
along with programmes to control tubercu-
losis, the biggest killer of people living with
HIV. Dr Richard Feachem, Executive
Director of the Global Fund, said: “Swift
implementation of programmes is possible,
as our experience in Estonia has shown,
moving from grant signing to first disburse-
ment to implementation of targeted preven-
tion and treatment programmes in just 12
weeks. Urgent action is needed throughout
the region to turn the tide of the disease.”
“Effective HIV/AIDS prevention and care
programmes will require that funding from
all sources increase to about US$ 1.5 billion
by 2007. But money alone is not the issue.
It is crucial to improve the information base
for programmes, to support what works
against HIV/AIDS, and to break down the
policy and social barriers to effective
actions across the region,” said Shigeo
Katsu, World Bank Regional Vice President
for Europe and Central Asia.
Reviews
USEFUL BODIES
00_WMJ_02_2004.qxd 23.07.2004 12:12 Seite 54
Roy Porter and David Wright,Eds.,
Cambridge University Press 2003,
£59, pp 371, ISBN 0521802067, Hardback
Samuel Johnson defined ‘to enlighten’ as
‘to illuminate, to supply with light, to in-
struct, to furnish with increase of knowled-
ge, to cheer, to exhilarate, to gladden, to
supply with sight, to quicken the faculty of
vision’. So we are informed in Roy Porter’s
brilliant book ‘Enlightenment’ (2000). In
all senses of the word, Roy Porter himself
enlightened the history of medicine, inclu-
ding psychiatry, in his own writings and in
his exhilarating teaching of a host of glad-
dened and quickened students at the Well-
come Institute for the History of Medicine.
Many of these have contributed to this vo-
lume, which is dedicated to him. He died –
much too early – in March 2002, but not
before contributing a characteristically li-
vely and generous Introduction, summari-
sing all the contributions and reviewing
some of the conflicting interpretations of
the chequered history of psychiatry. He re-
lished the clash of views, and the opportu-
nies to challenge all of them in turn,
through careful research.
The sub-title ‘International Perspectives’ is
fully justified, as every continent gets atten-
tion – Switzerland, Germany, France,
England and Ireland in Europe; Nigeria and
the Cape (Robben Island) in Africa;
Victoria in Australia; Canada, USA,
Mexico and Argentina in America; India
and Japan in Asia. All the contributions
make interesting reading.
The dates are not so precise as suggested, a
few accounts beginning before 1800 and
several going up to the end of the last cen-
tury. The print is clear, but some of the fig-
ures, a murky patchwork of grey stippling,
are rather difficult to make out.
A simplistic narrative of British psychiatry
begins in the late 18th century, when some
leading local benefactors decided to build
handsome hospitals, each with a classical
portico, which would care for unfortunate
lunatics in a humane and up-to-date fashion
and return them to their homes or other
accommodation in due course. But these
patients did not all recover, nor did they die,
but survived as an increasing burden – a
space-occupying lesion which required the
gradual enlargement of the hospital. The
result was a degraded and deteriorating
environment, with the portico dwarfed by
the ramparts of later building, and the disil-
lusionment of staff patients and their fami-
lies; and a fall in income. One of the found-
ing notions had been that the better-off
patients would pay for better accommoda-
tion. But these now stayed away, and their
contributions, always smaller than expect-
ed, became insignificant. The occasional
scandal led to management changes and
some transient improvement. Meanwhile,
all this did not deter a considerable invest-
ment of public money in the construction
and staffing of local mental hospitals
throughout the 19th century.
In his lifetime, Roy Porter encouraged a
different approach of ‘history from below’,
based on, the people and processes
involved in the system and their networks.
There are several examples of this approach
in the book, as well as others on more tradi-
tional lines.
For instance, in Argentina, a country with a
stormy political history, the first asylum to
be opened, in an old convent in Buenos
Aires in 1854, admitted only women. The
men’s asylum opened 9 years later. There
were only 200 beds in each, to serve not
just the capital but the whole country,
whose welfare system was focussed on the
needs of working people in various indus-
tries rather than on the indigent poor. The
Ministry in charge was that of ‘Foreign
Relations and Religion’ (the Health
Ministry only took responsibilty reluctant-
ly, and under intense pressure, in 1947).
Both hospitals were soon in trouble with,
among other things, a serious shortage of
nurses. The women’s hospital had a tradi-
tion of recruiting its staff from female
immigrants as they arrived at the dockside.
(In Ontario, by contrast, recently arrived
and homeless female immigrants, mostly
from Ireland, made a considerable contribu-
tion to the hospital – as patients.) Argentina
passed its first mental health act in 1983.
In Mexico (1910 – 1930), the opening of the
General Insane Asylum in 1910, in a village
just outside the city boundary, had been
preceded by nearly 20 years of planning
and consultation, including advice from
Baron Haussmann, the transformer of Paris.
(The administrative building had an impos-
ing classical facade.) The paying patients
had bedrooms and the others were housed
in wards. This hospital could accommodate
1,330 patients – some 500 more than the
two which had preceded it. But the social
upheavals of the long Mexican revolution
led to greatly increased demands and short-
age of funds. The hospital was destitute by
1920, starved of food, shelter and staff. Yet
it remained open, serving particularly the
homeless and indigent, and providing 24
hours’shelter for drying out a drunken man,
or 24 years for someone with a chronic
mental illness. Cristina Rivera-Garza
emphasises the important role which the
families played in initiating admissions –
those on a State Order as well as ‘volun-
tary’ – and in remaining in touch with the
patients and liaising with staff concerning
their progress.
Continuing the view from below, Patricia
Prestwich reports on a development in Paris,
where in 1876 the psychiatrists at St Anne,
the city asylum, negotiated a system of ‘vol-
untary admisssion’, in which the patient was
admitted at the request of the family, who
retained control of the decision for dis-
charge. The current police proceedings had
been fiercely criticised as heavy-handed and
intimidating. The psychiatrists wanted more
acute and curable patients and a better image
– and also a financial contribution from the
families, some of whom paid for separate
rooms and better food. The new system was
a success, and was extended to some other
asylums. Dangerousness was not a neces-
55
Reviews
The Confinement
of the Insane:
International Perspectives 1800-1965
00_WMJ_02_2004.qxd 23.07.2004 12:12 Seite 55
sary criterion for admisssion, as it was for
the ‘official’ patients, so people could be
admitted before they had frightened their
families irrevocably. Nearly 40% were
admitted by their spouses, husbands and
wives in equal proportions. Compared with
the ‘official’ patients, they were more likely
to be released – too early, the psychiatrists
complained – but they were transferred to
other asylums less frequently, and after
much longer stays, often more than two
years, at St Anne. In general, the relatives
were not waiting for a complete recovery but
for a tolerable level of behaviour, with a
capacity to provide support either at work or
at household tasks. The prolonged absence
of a wife could result in children being sent
away to relatives and the husband left to
fend for himself. Although in hospital, the
patient retained the important support of
remaining involved in his or her rôle in the
family.
The scenario in Paris in the late 19th centu-
ry may seem fairly familiar to most readers
of the World Medical Journal. But Akihito
Suzuki’s contribution on ’The state, the
family and the insane in Japan 1900 – 1945’
takes them to a different society, where
home care meant confinement in a cage, in
or near the family house, and where
lunatics, beggars (and also Koreans, social-
ists and those suffering from infectious dis-
eases) were ‘swept’off the streets into some
sort of confinement on the days preceding
and during a Royal visit or ceremony – a
practice which also occurred in the Soviet
Union on certain public holidays.
The responsibility for confining lunatics,
generally regarded as dangerous, rested
with the family. In one village during the
late 19th century, when a lunatic son
escaped from his father’s house, killing two
villagers and then himself, half of the
father’s property was confiscated and he
was expelled from his village. Such family
confinement could be and was abused. The
first Mental Patients’ Custody Act was
passed by the Westernising regime in 1900.
This codified home confinement and crimi-
nalised its unjust use. A ‘competent custodi-
an’ would be appointed. and the imposition
of custody and release from it required the
approval of a ‘local senior administrator. In
fact all real responsibility rested locally,
with the family and the village chief. No
central authority was involved. Hospital
confinement was also legal, but at that time
there was only one hospital, in Tokyo.
The pressure for expansion was increased
by the Mental Hospitals Act of 1919. At this
date, while England and Wales with a pop-
ulation of 35 million had 100,000 hospital
beds, Japan with a population of 55 million
had 4,000, of which only 450 were in the
single public hospital in Tokyo. The rest
were in 57 private hospitals. By 1940 there
were 7 public and 160 private hospitals
with a median length of stay of 717 days
and 44 days respectively. The number of
home custody cases continued to grow
slowly until the late 1930s and remained a
crucial part of psychiatric provision; but the
hospitalisation rate grew much faster –
mainly in the private sector which looked
after a considerable number of long-stay
patients who brought in a stable income
from the public purse. At the same time
they were competing (successfully) for the
acute patients and touting for trade at the
entrance to the Tokyo Metropolitan
Asylum, where the private Tokyo Brain
Asylum advertised an ‘inpatients’ informa-
tion office’ on a large billboard. Suzuki
comments that ‘the mutual stimulation
between the public and private sector seems
to have been the main engine behind the
increased institutionalisation of the insane’.
(He might have added ‘and remains so
today, in Japan.’)
One question which many contributors
address is ‘Did the Great Confinement as
proclaimed by Michel Foucault in his
“Madness and Civilisation” really exist?’
The answer seems to be No, in so far as the
population of those being admitted was
quite representative of the population as a
whole, with rather more ‘unsupported’
groups – single men and the poor – but not
specifically deviant. And the numbers ‘con-
fined’, at least at first, were quite small, not
great in epidemiological terms; and at least
50% would be discharged. But there was a
‘great accumulation’ which required expan-
sion, and made the hospitals look and feel
like factories or warehouses. Elaine
Murphy in her chapter on ‘Insanity in
England 1800-1870’ makes the important
point that in London large asylums replaced
the large network of private asylums, pau-
per houses and farms which provided the
refuge for ‘dull-witted, incompetent and
dependent paupers’ which was adminis-
tered by the Poor Law Commissioners. The
attraction of the new asylums was their
lower charges: eight shillings and
ninepence a week at Hanwell compared to
eleven shillings for the private asylums.
However, Hanwell’s low cost depended on
its high occupancy. Foucault’s insistence on
the Great Confinement may be wide of the
mark, but Andrew Scull’s economic inter-
pretation remains closer to the truth. Lord
Shaftesbury, the reforming Chairman of the
Lunacy Commisssion, would have support-
ed it. In 1859 he commented that:
When I look into the whole matter I see that
the principle of profit vitiates the whole
thing. It is at the bottom of all these move-
ments that we are obliged to counteract by
complicated legislation, and if we could but
remove that principle of making a profit we
should confer an inestimable blessing upon
the middle classes, getting rid of half the le-
gislation and securing an admirable, sound
and efficient system of treatment of lunacy.
Doctors are taught that ‘taking a careful his-
tory’ is an essential skill for clinical compe-
tence. In psychiatry this is of particular
importance. Over the past ten years there has
been a huge expansion of studies of its his-
tory. This volume is one of them; and its
world perspective makes it particularly help-
ful in diagnosing and treating our current
local problems. lt is indeed enlightening.
Porter R. (2000) Enlightenment. Britain
and the Creation of the Modem World.
London.
Foucault M. (1965) Madness and
Civilisation. A History of Insanity in the
Age of Reason. New York.
Scull A. (1979) Museums of Madness. The
Social Organisation of Insanity in
Nineteenth Century England. London
Jim Birley
56
Web-based course on Human Rights for Prison Doctors
The web-based accredited course for Prison Doctors on
Human Rights and Ethical Dilemmas announced in the
World Medical Journal (WMJ 50 (1), 27) has been
finalised and is now accessible via the WMA website at
www.wma.net. No course fee is charged.
00_WMJ_02_2004.qxd 23.07.2004 12:12 Seite 56
CHILE
Colegio Médico de Chile
Esmeralda 678 – Casilla 639
Santiago
Tel: (56-2) 4277800
Fax: (56-2) 6330940 / 6336732
E-mail: sectecni@colegiomedico.cl
Website: www.colegiomedico.cl
Vicepresidente
CHINA
Chinese Medical Association
42 Dongsi Xidajie
Beijing 100710
Tel: (86-10) 6513 4885
Fax: (86-10) 6512 3754
E-mail: cmafrd@public3.bta.net.cn
COLOMBIA
Federación Médica Colombiana
Calle 72 – N° 6-44, Piso 11
Santafé de Bogotá, D.E.
Tel: (57-1) 211 0208
Tel/Fax: (57-1) 212 6082
E-mail: federacionmedicacol@
hotmail.com
DEMOCRATIC REP. OF CONGO
Ordre des Médecins du Zaire
B.P. 4922
Kinshasa – Gombe
Tel: (242-12) 24589/
Fax (secr.Gen): (242) 8846574
COSTA RICA
Unión Médica Nacional
Apartado 5920-1000
San José
Tel: (506) 290-5490
Fax: (506) 231 7373
E-mail: unmedica@sol.racsa.co.cr
CROATIA
Croatian Medical Association
Subiceva 9
10000 Zagreb
Tel: (385-1) 46 93 300
Fax: (385-1) 46 55 066
E-mail: orlic@mamef.mef.hr
CZECH REPUBLIC
Czech Medical Association .
J.E. Purkyne
Sokolská 31 – P.O. Box 88
120 26 Prague 2
Tel: (420-2) 242 66 201/202/203/204
Fax: (420-2) 242 66 212 / 96 18 18 69
E-mail: czma@cls.cz
Website: www.cls.cz
UNITED STATES
Colegio Médico Cubano Libre
P.O. Box 141016
Coral Gables, FL 33114-1016
Tel: (1-305) 446 9902/445 1429
Fax: (1-305) 4459310
DENMARK
Danish Medical Association
9 Trondhjemsgade
2100 Copenhagen 0
Tel: (45) 35 44 -82 29/Fax:-8505
E-mail: dadl@dadl.dk
Website: www.laegeforeningen.dk
DOMINICAN REPUBLIC
Asociación Médica Dominicana
Calle Paseo de los Medicos
Esquina Modesto Diaz Zona
Universitaria
Santo Domingo
Tel: (1809) 533-4602/533-4686
/533-8700
Fax: (1809) 535 7337
E-mail: asoc.medica@codetel.net.do
ECUADOR
Federación Médica Ecuatoriana
V.M. Rendón 923 – 2 do.Piso Of. 201
P.O. Box 09-01-9848
Guayaquil
Tel/Fax: (593) 4 562569
E-mail: fedmedec@andinanet.net
EGYPT
Egyptian Medical Association
„Dar El Hekmah“
42, Kasr El-Eini Street
Cairo
Tel: (20-2) 3543406
EL SALVADOR, C.A
Colegio Médico de El Salvador
Final Pasaje N° 10
Colonia Miramonte
San Salvador
Tel: (503) 260-1111, 260-1112/
Fax: -0324
E-mail: comcolmed@telesal.net
ETHIOPIA
Ethiopian Medical Association
P.O. Box 2179
Addis Ababa
Tel: (251-1) 158174
Fax: (251-1) 533742
E-mail: ema.emj@telecom.net.et /
ema@eth.healthnet.org
FIJI ISLANDS
Fiji Medical Association
2nd Fl. Narsey’s Bldg, Renwick Road
G.P.O. Box 1116
Suva
Tel: (679) –315388
Fax: (679) 387671
E-mail: fijimedassoc@connect.com.fi
FINLAND
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Tel: (358-9) 3930 826/Fax-794
Telex: 125336 sll sf
E-mail: fma@fimnet.fi
Website: www.medassoc.fi
FRANCE
Association Médicale Française
180, Blvd. Haussmann
75389 Paris Cedex 08
Tel: (33) 1 53 89 32 41
Fax: (33) 1 53 89 33 44
E-mail: cnom-international@
cn.medecin.fr
GEORGIA
Georgian Medical Association
7 Asatiani Street
380077 Tbilisi
Tel: (995 32) 39868 / Fax: -398083
E-mail: Gma@posta.ge
GERMANY
Bundesärztekammer
(German Medical Association)
Herbert-Lewin-Strasse 1
50931 Köln
Tel: (49-221) 400-4360/Fax: -4384
Teletex: 2211315 – BAK
E-mail:auslandsdienst@baek.de
Website: www.bundesaerztekammer.de
GHANA
Ghana Medical Association
P.O. Box 1596
Accra
Tel: (233-21) 670-510/Fax: -511
E-mail: gma@ghana.com
HAITI, W.I.
Association Médicale Haitienne
1ère
Av. du Travail #33 – Bois Verna
Port-au-Prince
Tel: (509) 245-2060/511-0253
Fax: (509) 223-9885
E-mail: amh@acn2..net
Website: www.amhhaiti.org
HONG KONG
Hong Kong Medical Association, China
Duke of Windsor Building, 5th Floor
15 Hennessy Road
Tel: (852) 2527-8285
Fax: (852) 2865-0943
E-mail: hkma@hkma.org
Website: www.hkma.org
HUNGARY
Association of Hungarian Medical
Societies (MOTESZ)
Nádor u. 36
1443 Budapest, PO.Box 145
General Director
Tel: (36-1) 312 3807 – 311 6687
Fax: (36-1) 383-7918
E-mail: motesz@motesz.hu
Website: www.motesz.hu
ICELAND
Icelandic Medical Association
Hlidasmari 8
200 Kópavogur
Tel: (354) 5 864 0478
Fax: (354) 5 644106
E-mail: icemed@icemed.is
INDIA
Indian Medical Association
Indraprastha Marg
New Delhi 110 002
Tel: (91-11) 337009/3378819/3378680
Fax: (91-11) 3379178/3379470
E-mail: inmedici@vsnl.com /
inmedici@ndb.vsnl.com
INDONESIA
Indonesian Medical Association
Jalan Dr Sam Ratulangie N° 29
Jakarta 10350
Tel: (62-21) 3150679
Fax: (62-21) 390 0473/3154 091
E-mail: pbidi@idola.net.id
IRELAND
Irish Medical Organisation
10 Fitzwilliam Place
Dublin 2
Tel: (353-1) 676-7273
Fax: (353-1) 6612758/6682168
Website: www.imo.ie
ISRAEL
Israel Medical Association
2 Twin Towers, 35 Jabotinsky St.
P.O. Box 3566, Ramat-Gan 52136
Tel: (972-3) 6100444 / 424
Fax: (972-3) 5751616 / 5753303
E-mail: estish@ima.org.il
Website: www.ima.org.il
JAPAN
Japan Medical Association
2-28-16 Honkomagome, Bunkyo-ku
Tokyo 113-8621
Tel: (81-3) 3946 2121/3942 6489
Fax: (81-3) 3946 6295
E-mail: jmaintl@po.med.or.jp
KAZAKHSTAN
Association of Medical Doctors
of Kazakhstan
117/1 Kazybek bi St.,
Almaty
Tel: (3272) 62 -43 01 / -92 92
Fax: -3606
E-mail: sadykova-aizhan@yahoo.com
REP. OF KOREA
Korean Medical Association
302-75 Ichon 1-dong, Yongsan-gu
Seoul 140-721
Tel: (82-2) 794 2474
Fax: (82-2) 793 9190
E-mail: intl@kma.org
Website: www.kma.org
KUWAIT
Kuwait Medical Association
P.O. Box 1202
Safat 13013
Tel: (965) 5333278, 5317971
Fax: (965) 5333276
E-mail: aks.shatti@kma.org.kw
LATVIA
Latvian Physicians Association
Skolas Str. 3
Riga
1010 Latvia
Tel: (371-7) 22 06 61; 22 06 57
Fax: (371-7) 22 06 57
E-mail: lab@parks.lv
LIECHTENSTEIN
Liechtensteinischer Ärzteverein
Postfach 52
9490 Vaduz
Tel: (423) 232 -3440
Fax: (423) 232 3455
Website: www.aerzte-net.li
LITHUANIA
Lithuanian Medical Association
Liubarto 2
2004 Vilnius
Tel/Fax: (370-5) 2731400
E-mail: lgs@takas.lt
LUXEMBOURG
Association des Médecins et
Médecins Dentistes du Grand-
Association and address/Officers
ii
U2_4_02.2004.QXD 01.07.2004 13:31 Seite U3
Association and address/Officers
Duché de Luxembourg
29, rue de Vianden
2680 Luxembourg
Tel: (352) 44 40 331
Fax: (352) 45 83 49
E-mail: secretariat@ammd.lu
Website: www.ammd.lu
MACEDONIA
Macedonian Medical Association
Dame Gruev St. 3
P.O. Box 174
91000 Skopje
Tel/Fax: (389-91) 232577
MALAYSIA
Malaysian Medical Association
4th Floor, MMA House
124 Jalan Pahang
53000 Kuala Lumpur
Tel: (60-3) 40418972/40411375
Fax: (60-3) 40418187/40434444
E-mail: mma@tm.net.my
Website: http://www.mma.org.my
MALTA
Medical Association of Malta
The Professional Centre
Sliema Road, Gzira GZR 06
Tel: (356) 21312888
Fax: (356) 21331713
E-mail: mfpb@maltanet.net
Website: www.mam.org.mt
MEXICO
Colegio Medico de Mexico
Fenacome
Hidalgo 1828 Pte. Cons. 410
Colonia Obispado C.P. 64060
Monterrey, Nuevo Léon
Tel/Fax: (52-8) 348-41-55
E-mail: fenacomemexico@usa.net
Website: www.fenacome.org
NEPAL
Nepal Medical Association
Siddhi Sadan, Post Box 189
Exhibition Road
Katmandu
Tel: (977 1) 225860, 231825
Fax: (977 1) 225300
E-mail: nma@healthnet.org.np
NETHERLANDS
Royal Dutch Medical Association
P.O. Box 20051
3502 LB Utrecht
Tel: (31-30) 28 23-267/Fax-318
E-mail: j.bouwman@fed.knmg.nl
Website: http://www.knmg.nl
NEW ZEALAND
New Zealand Medical Association
P.O. Box 156
Wellington 1
Tel: (64-4) 472 –4741/ Fax-0838
Fax: (64-4) 471 0838
E-mail: nzma@nzma.org.nz
Website: www.nzma.org.nz
NIGERIA
Nigerian Medical Association
74, Adeniyi Jones Avenue Ikeja
P.O. Box 1108, Marina
Lagos
Tel: (234-1) 497 7262,
Fax: (234-1) 585 1432 (ext 2197)
E-mail: nigeriannma@hotmail.com
NORWAY
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
Tel: (47) 23 10 -90 00/Fax: -9010
E-mail: ellen.pettersen@
legeforeningen.no
Website: www.legeforeningen.no
PANAMA
Asociación Médica Nacional
de la República de Panamá
Apartado Postal 2020
Panamá 1
Tel: (507) 263 7622 /263-7758
Fax: (507) 223 1462
Fax modem: (507) 223-5555
E-mail: amenalpa@sinfo.net
PERU
Colegio Médico del Perú
Malecón Armendáriz N° 791
Miraflores
Lima
Tel: (51-1) 241 75 72
Fax: (51-1) 242 3917
E-mail: decano@colmedi.org.pe
Website: www.colmed.org.pe
PHILIPPINES
Philippine Medical Association
PMA Bldg, North Avenue
Quezon City
Tel: (63-2) 929-63 66/Fax: -6951
E-mail: pmasec1@edsamail.com.ph
POLAND
Polish Medical Association
Al. Ujazdowskie 24
00-478 Warszawa
Tel: (48-22) 628 86 99
Fax: (48-22) 628 86 99
PORTUGAL
Ordem dos Médicos
Av. Almirante Gago Coutinho, 151
1749-084 Lisbon
Tel: (351-21) 842 71 00/842 71 11
Fax: (351-21) 842 71 99
E-mail: ordemmedicos@mail.telepac.pt
/ intl.omcne@netcabo.pt
Website: www.ordemdosmedicos.pt
ROMANIA
Romanian Medical Association
Str. Progresului 10
Sect. 1, Bucarest, cod 70754
Tel: (40-1) 6141071
Fax: (40-1) 3121357
E-mail: amr@amr.sfos.ro
Website: www.cdi.pub.ro/CDI/
Parteneri/AMR_main.htm
RUSSIA
Russian Medical Society
34, Build. 1, Novy Arbat
121099 Moscow
Tel: (7-095)205-7371
Fax: (7-095) 205-3293
E-mail: rusmed@rusmed.rmt.ru
SLOVAK REPUBLIC
Slovak Medical Association
Legionarska 4
81322 Bratislavia
Tel: (421-2) 554 24 015
Fax: (421-2) 554 223 63
E-mail: secretarysma@ba.telecom.sk
SLOVENIA
Slovenian Medical Association
Komenskega 4
61001 Ljubljana
Tel: (386-61) 323 469
Fax: (386-61) 301 955
SOUTH AFRICA
The South African Medical Association
P.O. Box 74789, Lynnwood Rydge
0040 Pretoria
Tel: (27-12) 481 2036/7
Fax: (27-12) 481 2058
E-mail: liliang@samedical.org
Website: www.samedical.org
SPAIN
Consejo General de Colegios
Oficiales de Médicos
Villanueva 11
Madrid 28001
Tel: (34-91) 4317780
Fax: (34-91) 5764388
E-mail: internacional1@cgcom.org
SWEDEN
Swedish Medical Association
(Villagatan 5)
P.O. Box 5610
SE – 114 86 Stockholm
Tel: (46-8) 790 33 00
Fax: (46-8) 20 57 18
E-mail: info@slf.se
Website: www.lakarforbundet.se
SWITZERLAND
Fédération des Médecins Suisses
Elfenstrasse 18 – POB 293
3000 Berne 16
Tel: (41-31) 359 –1111/Fax: -1112
E-mail: fmh@hin.ch
Website: www.fmh.ch/ww/fr/pub/fmh/
histoire_fmh.htm
TAIWAN
Chinese Medical Association – Taipei
201, Shih-pai Rd., Sec. 2
P.O. Box 3043
Taipei 11217
Tel: (886-2) 2871-2121, ext 7358
Fax: (886-2) 28741097
E-mail: cma@vghtpe.gov.tw
THAILAND
Medical Association of Thailand
2 Soi Soonvijai
New Petchburi Road
Bangkok 10320
Tel: (66-2) 314 4333/318-8170
Fax: (66-2) 314 6305
E-mail: math@loxinfo.co.th
Website: http://www.medassocthai.org/
index.htm.
TUNISIA
Conseil National de l’Ordre
des Médecins de Tunisie
16, rue de Touraine
1082 Tunis Cité Jardins
Tel: (216-1) 792 736/799 041
Fax: (216-1) 788 729
E-mail: ordremed.na@planet.tn
TURKEY
Turkish Medical Association
GMK Bulvary,.
Pehit Danip Tunalygil Sok. N° 2 Kat 4
Maltepe
Ankara
Tel: (90-312) 231 –3179/Fax: -1952
E-mail: Ttb@ttb.org.tr
UGANDA
Uganda Medical Association
Plot 8, 41-43 circular rd.
P.O. Box 29874
Kampala
Tel: (256) 41 32 1795
Fax: (256) 41 34 5597
E-mail: myers28@hotmail.com
UNITED KINGDOM
British Medical Association
BMA House, Tavistock Square
London WC1H 9JP
Tel: (44-207) 387-4499
Fax: (44- 207) 383-6711
E-mail: vivn@bma.org.uk
Website: www.bma.org.uk
UNITED STATES OF AMERICA
American Medical Association
515 North State Street
Chicago, Illinois 60610
Tel: (1-312) 464 5040
Fax: (1-312) 464 5973
Website: http://www.ama-assn.org
URUGUAY
Sindicato Médico del Uruguay
Bulevar Artigas 1515
CP 11200 Montevideo
Tel: (598-2) 401 47 01
Fax: (598-2) 409 16 03
E-mail: secretaria@smu.org.uy
VATICAN STATE
Associazione Medica del Vaticano
Stato della Citta del Vaticano 00120
Tel: (39-06) 6983552
Fax: (39-06) 69885364
VENEZUELA
Federacion Médica Venezolana
Avenida Orinoco
Torre Federacion Médica Venezolana
Urbanizacion Las Mercedes
Caracas
Tel: (58-2) 9934547
Fax: (58-2) 9932890
Website: www.saludfmv.org and
info@saludgmv.org
ZIMBABWE
Zimbabwe Medical Association
P.O. Box 3671
Harare
Tel: (263-4) 791/553
Fax: (263-4) 791561
E-mail: zima@healthnet.zw
iii
U2_4_02.2004.QXD 01.07.2004 13:31 Seite U4