WMJ 04 2004

WMA General Assembly, Tokyo 2004
WorldMMeeddiiccaall JJoouurrnnaall
Vol. No.4,December200450
OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
G 20438
Contents
EEddiittoorriiaall 85
New WMA Secretary-General 85
Presidential address by Dr. Yank D. Coble,
Jr, MD to the world medical assembly, Tokyo 86
WMA has a new President 86
MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
Medical ethics and bereavement 89
The World Medical Association
statement concerning the relationship
between physicians and commercial enterprises 91
The World Medical Association
Regulations in times of armed conflict 92
The World Medical Association
Statement on health emergencies
communication and coordination 93
Note of clarification on paragraph 30
of the WMA Declaration of Helsinki 95
MMeeddiiccaall SScciieennccee,, PPrrooffeessssiioonnaall PPrraaccttiiccee
aanndd EEdduuccaattiioonn
Account by Dr. James Appleyard of
his Presidential year of office 2003–2004 95
The future of medical technology –
Implications for medical education and practice 97
Blame your genes for a restless
night’s sleep – new research revealed 99
WWHHOO
New tools and increased funds
will beat malaria, say global leaders 100
Skilled attendants vital to
saving lives of mothers and newborns 101
A globally effective HIV vaccine
requires greater participation of
women and adolescents in clinical trials 101
Landmark report could influence the
future of medicines in europe and the world 102
Who awards million dollar contract
for global treatment preparedness activities 105
WWMMAA SSeeccrreettaarryy GGeenneerraall
From the Secretary General’s Desk 106
WWMMAA
The Ceremonial session of the World Medical
Association General Assembly, Tokyo 2004 107
Meeting of the WMA General
Assembly, Tokyo, 9th October 2004 108
RReeggiioonnaall aanndd NNMMAA NNeewwss
Patients’ Access To Care At Risk With
America’s Broken Medical Liability System 110
Tobacco Control Capacity Building 112
The President addresses the Emperor and Empress
at the JMA reception
The new President addresses the WMA Ceremonial session
00_US_04_2004.qxd 17.02.2005 10:16 Seite 1
Website: https://www.wma.net
WMA Directory of National Member Medical Associations Officers and Council
Association and address/Officers
WMA OFFICERS
OF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
i see page ii
President-elect President Immediate Past-President
Dr K. Letlape Dr Y.D. Coble Dr J. Appleyard
South African Med. Assn. 102 Magnolia Street Thimble Hall
P.O. Box 74789 Neptune Beach, FL 32266 108 Blean Common
Lynnwood Ridge 0040 USA Blean, Nr Canterbury
Pretoria 0153 Kent, CT2 9JJ
South Africa Great Britain
Treasurer Chairman of Council Vice-Chairman of Council
Dr. K. Vilmar Dr. Y Blachar Dr. T.J. Moon
Schuberstr.58 Israel Medical Association Korean Medical Association
28209 Bremen 2 Twin Towers, 35 Jabotisky St. 302-75 Ichon1-dong,Yongsan-gu,
Germany 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
Fax (33) 4 50 40 59 37
E-mail: delon@wma.net
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
P.O. Box 143, Yerevan 375 010
Tel: (3741) 53 58-63
Fax: (3741) 53 48 79
E-mail:info@armeda.am
Website: www.armeda.am
AZERBAIJAN
Azerbaijan Medical Association
5 Sona Velikham Str.
AZE 370001, Baku
Tel: (994 50) 328 1888
Fax: (994 12) 315 136
E-mail: Mahirs@lycos.com /
azerma@hotmail.com
BAHAMAS
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
15/2 Topkhana Road,
Dhaka 1000
Tel: (880) 2-9568714/9562527
Fax: (880) 2-9566060/9568714
E-mail: bma@aitlbd.net
BELGIUM
Association Belge des Syndicats
Médicaux
Chaussée de Boondael 6, bte 4
1050 Bruxelles
Tel: (32-2) 644-12 88/Fax: -1527
E-mail: absym.bras@euronet.be
Website: www.absym-bras.be
BOLIVIA
Colegio Médico de Bolivia
Casilla 1088
Cochabamba
Tel/Fax: (591-04) 523658
E-mail: colmedbo_oru@hotmail.com
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) 317868 00
Fax: (55-11) 317868 31
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
CHILE
Colegio Médico de Chile
Esmeralda 678 – Casilla 639
Santiago
Tel: (56-2) 4277800
Fax: (56-2) 6330940 / 6336732
E-mail: sectecni@colegiomedico.c
Website: www.colegiomedico.cl
U2_4_WMJ_04_04.qxd 17.02.2005 10:17 Seite U2
Editorial
Those arriving in Tokyo for the Council, the Scientific meeting and the General Assembly
of the World Medical Association, might be forgiven if they felt a sense of forboding when
they were greeted with persistent and rather gloomy rain and mist. Indeed, this may well
have been enhanced by the not insignificant earthquake one night and the typhoon two
days later. However, the excellent scientific meeting, impeccable efficiency of the organi-
sation and the warm hospitality of the Japanese Medical Association, more than compen-
sated for the vagaries of the weather.
The meeting was further greatly honoured by the presence of the Emperor and Empress of
Japan at the Opening Reception, and the Chief Secretary of the Cabinet (the Prime Minister
being out of the country), the Minister of Health and the Governor of Tokyo at the
Ceremonial session (see report p. 107).
The scientific session was also a success, addressing the advantages and the problems of
advanced medical technology and also the subject of Continuing Medical Education and
Physicians’Autonomy (various papers appear in this issue).
The GeneralAssembly is reported on page 108.Among the decisions of theAssembly appears
a note of clarification on article 30 of the Declaration of Helsinki. While this will undoubted-
ly not be the last we shall hear on this subject, interested parties will no doubt take their time
to quietly consider and debate what appears to be the controversial issue of the rights of par-
ticipants in clinical trials, before returning to the subject at some point in the future.
Meanwhile, the world moves on and the unavoidable delay in publishing this issue (due to
illness), has meant that we have all experienced the terrible consequences of the “natural
disaster” in South-East Asia. The global response in terms of aid, both financial and other
resources, to this terrible event has been unprecedented. In all of this the medical profes-
sion, both through its national medical associations and other organisations geared to deal-
ing with major disasters, reacted quickly and responsibly both in terms of provision of
human resources and other forms of assistance. At the same time the profession and the
population in general must not neglect the continuing needs of populations threatened by
major scourges such as famine and other forms of deprivation, AIDS/HIV and Malaria. The
needs of the world are huge – part of which depends on medical care. This is not only the
responsibility of governments and administrations, but also a professional responsibility
for the medical profession thoughout the world.
Alan Rowe
Editorial
85
OFFICIAL JOURNAL OF
THE WORLD MEDICAL
ASSOCIATION
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New WMA Secretary-General
Dr. Otmar Kloiber has been appointed to be the next Secretary-Gene-
ral of the World Medical Association following Dr. Delon Human.
Dr. Kloiber is currently Deputy Secretary General of the Bundesärt-
zekammer (German Medical Association) where for many years he
was the Foreign Relations Advisor, and has extensive knowledge
both of WMA, and the affairs of many national medical associations
(particularly the problems in Central and Eastern Europe) and of
international organisations and NGO’s. Dr. Kloiber has also been a
member of the German Parliamentary Commission on Law and Ethics in Modern Medi-
cine.He had previously worked at the Max-Plank Institute in Cologne and was a Postdoc-
toral Fellow in the University of Minnesota USA from 1985-86. Dr. Kloiber will take up
his post on the 1st February 2005.
WMJ_04_2004.qxd 17.02.2005 09:50 Seite 85
Following his investiture as President of the
World Medical Association, Dr. Coble
opened his address expressing his gratitude
to those who elected him, to the retiring
President and his fellow officers, to the
Secretary-General, Dr. Delon Human, to
the American Medical Association and its
delegation at WMA, also to his WMA pre-
decessors from the USA.
Dr. Coble continued
“All of you have given me opportunities to
work hard for a worthy cause. To seek and
to strive for the best health care for the peo-
ple of the world, through the pursuit of the
highest standards of medical care, medical
education, medical ethics and medical sci-
ence.
These things form the intellectual founda-
tion and the creative spark of the art of
medicine. They are ingrained in the Charter
of the World Medical Association. They are
our mission and our charge –“Caring,
Ethics and Science” – the three fundamen-
tal, enduring traditions. Fulfilling this mis-
sion- living out these ideals- is what gives
us the power to be strong, effective advo-
cates for patients and for our profession the
world over. Through changes in govern-
ments, changes in policies, changes in eco-
nomic and in medical science and methods,
we will flourish.
At this moment of history, the wealth of
nations is not the most pressing issue; it is
rather, the health of nations.
Indeed, one of the most pressing issues fac-
ing nations, be they first world or third-
post-industrial or developing – is access to
care, how to deliver medical and health care
of high quality (including public health and
preventive medicine) to the greatest num-
ber of their citizens, with the maximum
possible efficiency. This at a time when the
quality of medical care and the good health
of our patients, face unprecedented chal-
lenges both locally and globally, natural
and man-made.
These challenges include AIDS, SARS,
resistant tuberculosis, Malaria, the threat of
bio-terrorism, bureaucratic meddling,
changing health policies, an unprecedented
number of ageing citizens, unprecedented
migration of physicians, and the need – in
many lands if not most – for health care
system reform. All of these things make
global co-operation essential if we as physi-
cians are to protect the public health. Our
increasingly open borders and our increas-
ingly mobile populations are creating a rich
environment for infectious agents, posing a
serious threat to human health and interna-
tional security. New infectious diseases
such as SARS can emerge and travel swift-
ly around the globe, mutating and infecting
less resilient hosts. These microbes respect
no international borders or the landscape’s
physical barriers.
Editorial
86
Presidential address by Dr. Yank D. Coble, Jr,
MD to the world medical assembly, Tokyo
WMA has a new President
Yank D. Coble, Jr., MD, MACP, MACE, became President
of the World Medical Association in Tokyo, Japan, in
October of 2004. Dr. Coble served as Chair of the WMA’s
2003-2004 Committee on Finance and Planning, has been a
Delegate to the WMA since 2002, and is Past President of
the American Medical Association.
A graduate of Duke Medical School, Dr. Coble also received
a degree in clinical medicine of the tropics from the London
School of Hygiene and Tropical Medicine. He is a clinical
professor of medicine at the University of Florida School of
Medicine and was formerly Professor of Medicine and
Family Medicine and Chair of the Department of Community Health and Family
Medicine. Dr. Coble is listed in “The Best Doctors in America” and in 2002 was select-
ed by Modern Healthcare as one of the “100 Most Powerful People in Healthcare.”
Under the auspices of the Office of International Research at the National Institutes of
Health (NIH), he cared for patients and conducted medical research in Egypt, Nigeria
and England from 1964 through 1969. During this time, he made site visits to more than
50 countries. Most recently, he served on the U.S. delegation to the WHO’s 2003 and
2004 World Health Assembly.
Among his many leadership roles, Dr. Coble has been a member of the Advisory
Committee to the Director of the NIH. He co-chaired both the 35th anniversary celebra-
tion of the NIH’s Office of International Medicine and the 50th anniversary celebration
of the Human Genome Project.
A distinguished leader in medicine, Dr. Coble is a Past President of the American Society
of Internal Medicine, American Association of Clinical Endocrinologists, and American
College of Endocrinology. He currently holds appointments on the boards of Research.
America, National Osteoporosis Foundation, Institute of Medicine Roundtable on
Environmental Health Sciences, Research and Medicine, Campaign for Public Health,
and Hospice of Northeast Florida. He has also served on the Board of Directors of the
National Quality Forum, the Joint Commission on the Accreditation of Healthcare
Organizations and the National Guideline Clearinghouse of the Agency for Healthcare
Research and Quality.
Dr. Coble and his wife Shereth reside in Neptune Beach, Florida and have five children
and ten grandchildren.
WMJ_04_2004.qxd 17.02.2005 09:50 Seite 86
Our weapons against these microbes are
becoming less effective as they develop
resistance to the drugs, which once kept
them at bay.
For medicine to survive these threats, it
must continue to push the boundaries of sci-
ence and technology. By so doing we make
longer, better lives available to all
humankind. From these challenges, from
adversity of all kinds we can learn as we
overcome. Learn because we overcome.
Recently, I was in a country where physi-
cians offered a candid admission – that their
government delayed the medical communi-
ty from releasing what they knew about
SARS when they knew it.
Because of this, valuable time was lost
addressing the epidemic and identifying the
disease. This country’s scientists knew the
structure of SARS, knew what it was and
how dangerous it was for two months
before it could be reported. Ultimately this
silence cost lives and cost the country $80
million.
But because of physician inspired public
pressure there has been a change.
Physicians and other scientists in the coun-
try can now freely report their findings.
This provided clear evidence of the value of
disclosure, of co-operation and the trans-
parency of science, not only for the health
of a country, but for its economy and its
wealth.
From adversity has come knowledge and
progress in the fight against contagion.
In an African nation, a physician was dis-
charged from his duties as a hospital super-
intendent in early 2002 for “insubordina-
tion”, because he allowed a public health
organisation to use space in his facility to
administer HIV prophylaxis to rape vic-
tims. At the time when he was fired, that
nation’s Health Ministry prohibited the use
of HIV drugs as a method of prevention and
treatment after HIV exposure. Because of
the international pressure brought to bear,
in part because of this physician’s case, this
government changed its policy on HIV
treatment.
Through the adversity suffered by these
brave physicians, medicine was advanced.
These are the types of obstacles we face as
a community, and which we must overcome
together.
The traditions of medicine are what enable
physicians to work together under difficult
conditions.
Consider the Addis Ababa Fistula Hospital
in Ethiopia, where in one of the world’s
most impoverished regions physicians treat
women suffering form obstetric fistula, a
debilitating childbirth injury still common
in the developing world. Or Dr. Paul
Farmer, who for 20 years has worked to
develop a community-based health network
in Haiti. He helped implement one of the
first AIDS treatment programmes in the
developing world and an innovative treat-
ment for patients with multi-drug-resistant
tuberculosis.
I have seen adversity and a common goal
unite physicians with my own eyes. In
Nigeria before the Biafran War, I helped
work on a nutrition survey of the entire
country – a co-operative effort with physi-
cians from America and Nigeria (Ibo,
Yoruba, Hausa and Faluni) all working
together.
At the London School of Tropical Medicine
at the time of the Six-day War in 1967, I
watched Christian, Jewish, Muslim and
Hindu physicians work side by side for the
betterment of all nations, all faiths and all
peoples.
Through adversity we find co-operation
and innovation. We learn from each other
and take inspiration from each other,
because we are all in this together. We must
delight in our diversity, but always remem-
ber the danger of discord. There is power
only in unity. With enthusiasm, hard work
and hope, we can take the challenges we
face in medicine and turn them into oppor-
tunities for better health. But only if we
remain responsible for out traditions of
ethics, caring and science. Only if we work
with our patients and others to topple the
barriers to quality medical care. Only if we
are active, united members of our profes-
sion.
Without science and its application, ethics
and caring alone are merely good inten-
tions, only well intentioned kindness.
It is our commitment to science and the life-
long process of learning that science, that
directs, expands and makes unique what we
do, as physicians. We must not permit oth-
ers to diminish our scientific standards.
Ethics is what compels us to put the inter-
ests of the patient first, or in some
instances, that of the public.
This is the heart of my message today – that
everything we do, we do for our patients –
The sick, the infirm, the elderly – those
most vulnerable among us throughout the
world, those who most need physicians, our
traditions, our advocacy and our autonomy.
Sir William Osler said, “Caring is the most
important thing – so do it first. For it is the
caring physician who most inspires hope
and trust”.
In that spirit, I would like the members of
the World Medical Association to be known
as “The Caring Physicians of the World”.
Toward that end, we are asking that each of
our national medical associations too nom-
inate one to three of their physician mem-
bers who best reflect the principles of car-
ing, ethics and science. We will select some
50 or 80 of these physicians and feature
them in a publication to be distributed at
our annual meeting in Santiago, Chile in
October 2005. We are grateful for the sup-
port of the Pfizer Medical Humanities
Initiative in this publication effort. The pub-
lication will be disseminated around the
world to national medical associations,
governments, foundations and other inter-
ested groups. This activity will also include
a dedicated website, a series of regional
meetings and bridges to other opportunities.
We seek the most caring physicians in the
world, and we want the world to know who
they are. We also want the world to know
who we are at the World Medical
Association- what we do, what we stand
for, and the values we embrace in the ser-
vice of our patients and the public health
Caring – Ethics – Science
Our Caring is evident in our everyday work
and the millions of hours of charity care we
provide in the four corners of the globe.
Editorial
87
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Our Ethics guide not only our practice of
medicine, but also the practice of interna-
tional physician organisations
Our medical science is evident in our grow-
ing success at treating and curing diseases
once thought to be fatal, in the miracles of
organ transplants, vaccines, chemotherapy,
medical genetics and advanced technology.
Caring, Ethics and Science, are the watch-
words of our profession. But everywhere I
go around the world, physicians are being
subjected to ever greater pressures.
Subjected to forces that make it more and
more difficult to live out the credo of our
calling. The elimination of patient choice
and the erosion of appropriate physician
autonomy, put the sacred patient – physi-
cian relationship in jeopardy.
So it falls to us, we who represent interna-
tional medicine to help restore pride, pas-
sion, enthusiasm and optimism among our
colleagues wherever they practice, wherev-
er they are challenged. The irony is that we
are small, but our power to do good and to
wield influence, is great.
We will reach out
– and encourage national medical associ-
ations to form where none exist today;
– to assist in the development of quality
care and to enhance safety;
– and focus attention on developing world
issues, HIV/AIDS, hunger and infec-
tious diseases; violence, terrorism and
torture; obesity, diabetes and cardiovas-
cular disease; with Regional meetings
of our WMA;
– in the houses of parliaments, the legisla-
tures, the board rooms, in partnership
with our brother and sister organisa-
tions.
And we will reach out with a strong,
authoritative voice, as a fierce guardian of
ethics and human rights on the internation-
al stage – because we remain the global
voice of medicine.
It is a voice I have constantly heard in the
years since I embarked on my course of
study in international research – a journey
that took me to Egypt, Nigeria and London.
Since then, I have visited health care, edu-
cation and research facilities in more than
60 countries. These travels have given me
unconditional respect for our global profes-
sion of medicine, and a deep sense of awe
at the remarkable trust and hope which our
calling commands and inspires.
I’ve witnessed the world of physicians like
you more extensively that I could have
imagined. I’ve seen your skill and caring
and compassion in settings from the most
advanced hospital to the most remote clin-
ic, and seen how you manage the expecta-
tions created by innovations in medicine.
In these forty years I have seen much suf-
fering – but I have also seen much relief of
suffering. I have seen how good health
leads to more literacy, more equality of
opportunity in political and economic mat-
ters and in environmental improvements.
When health improves, all other aspects of
life improve. While health experts and
economists may differ on how to go about
it, the goal is the same, and the rewards are
tremendous.
Politicians and governments like to to think
of medical care and research as a cost- an
expense. But we know that medical care
and research is an investment, a value – one
with tremendous return.
In some countries there is a need for basics
such as clean water, edible food and reliable
electricity. But in these places they still
know and respect their doctor. Our patients
value medial research and innovation. They
value medical care and they do not want
their care undermined or withheld.
We must make sure that our patients under-
stand how the problems we face as physi-
cians undermine our ability to deliver that
care. We need to communicate the value of
our work and its importance to our patients,
to the media and to our governments.
We need to continue to communicate the
value of our work to each other. Few things
are as central to the development of science
and medicine as the exchange of informa-
tion. By sharing information, either in jour-
nals or textbooks, or in international confer-
ences such as these, we reaffirm what we
understand about the art and science of
medicine and broaden our knowledge base.
These are gifts we bring back to our
patients and our communities – gifts we can
use to make medical practice in our respec-
tive nations better, stronger than ever
before.
Experiences such as this gathering are also
gifts to us as physicians. They present
opportunities for friendship, for greater
understanding, not only of science and
health policy, but also of culture and histo-
ry. They challenge us to see our profession
and ourselves from a new perspective, and
change us for the better.
No one better understands the obstacles to
quality health care than physicians and their
patients. That is why, as WMA President I
will take my cue from the people in the
frontlines and make your agenda – your
individual country’s health care agenda,
and your patients’ agenda – my agenda –
our agenda.
To fulfil this mission we have to be deter-
mined and stay that way – we can’t give up
or give in. This is a time of excitement and
anticipation – for me a time of wonder and
expectation. I look forward to working
together as we shepherd the spirit of inter-
national medicine into this 21st century. I
can only hope that my time as President
will strengthen the bonds that unite us all.
Bonds such as our shared commitment to
the best science – to caring and compassion
– and to excellence in every aspect of med-
icine – bonds such as our commitment to
professional integrity, and to the ethic that
requires us to put our patients first.
As physicians we can do much on our own,
but we can do even more together. The
WMA and its members are, and will contin-
ue to be an ethical beacon and a force of
endless possibilities.
So let us continue to build bridges among
our national associations and among the
individual physicians in this room, and con-
tinue to share our dreams of better health
for all. As I look ahead to the next year, it
occurs to me that there is no greater gift
than this “To see medicine’s traditions lived
to the fullest, and to work to protect those
traditions from harm”.
How can we not be enthusiastic and opti-
mistic about our profession with such
enduring traditions- about our opportunity
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88
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to be useful and of value every day- and
about the marvels of modern medicine?
There is an old Japanese proverb “The go-
between wears out a thousand sandals”.
We must be willing to wear out a thousand
sandals – or more – in our advocacy for our
patients and our profession.
Together, the family of medicine will bring
its agenda to the global stage. We will
encourage and lead patients and other part-
ners to stand beside us. We will tear down
the barriers that stand between our patients
and us, and between us and quality medical
care. We will be “The Caring Physicians of
the World”.
Medical Ethics and Human Rights
89
Medical Ethics and Human Rights
Medical ethics and bereavement
Although there have been a great many
publications and conference presentations
on ethical issues related to death and dying,
the ethical literature on the physician’s
responsibilities to bereaved persons is rela-
tively scant. In their interactions with the
bereaved, physicians can either provide
benefit or inflict harm, and so such interac-
tions require ethical analysis and guidance.
The bereaved are not the physician’s
patients, so the well-established principles
of the physician-patient relationship are
not necessarily applicable.
In this article I propose a set of ethical prin-
ciples for the interactions of physicians
with the bereaved, namely, respect, com-
passion and truthfulness. The application of
the principles will be illustrated by case
vignettes. Particular attention will be given
to the resolution of possible conflicts
between principles, for example, compas-
sion vs. truthfulness.
Ethical Responsibilities
The WMA Declaration of Geneva requires
of the physician that “The health of my
patient will be my first consideration”, and
the International Code of Medical Ethics
states, “A physician shall owe his patients
complete loyalty and all the resources of his
science”. However, the care of patients
often involves interactions with family
members, particularly when the patients are
unable to make decisions about their own
medical care. A considerable degree of con-
sensus has developed on the ethical and
legal principles for dealing with family
members in such situations, although the
application of these principles is often prob-
lematic.2 However, there has been very lit-
tle consideration to date of the responsibili-
ties of physicians to family members after
the patient’s death.
Some might argue that physicians have no
such responsibilities. Just as the physician-
patient relationship ends with the death of
the patient, so also do any professional rela-
tionships with the bereaved family mem-
bers. If they are in need of consolation or
some other type of care, they should seek it
from bereavement counsellors, clergy or
other specialists in the field.
A strong case can be made for an opposing
view, namely, that physicians should
address the needs of the bereaved.
Sometimes physicians are the only ones
who can fulfil these needs and their refusal
to do so can result in harm to the bereaved.
Examples of such situations are presented
below.
Ethical Principles
Some of the ethical principles that govern
the physician-patient relationship are equally
appropriate to the relationship of physicians
with the bereaved. Others, such as informed
consent and confidentiality, are not as appro-
priate. The shared principles are these:
• Compassion – have understanding and
empathy for those who are suffering.
• Respect for persons – acknowledge and
promote their dignity and their autono-
my.
• Truthfulness – do not lie, and be discreet
when disclosing unwelcome or unwant-
ed information.
Sometimes the application of these princi-
ples can be challenging, not least because
they can conflict with one another.
Moreover, the needs and wishes of the
bereaved may conflict with those of the
patient prior to death. It is, of course,
preferable to anticipate and prevent con-
flicts before they arise. But if this has not
been done, then a conflict-resolution
process is required.
Case 1 – Compassion vs.
truthfulness
Mr. A, a 30 year old single male, is
admitted to an emergency ward with
severe injuries resulting from an auto-
mobile accident and dies soon after-
wards. Medical tests administered upon
admission revealed the presence of
heroin, which may well have con-
tributed to the accident. When Mr. A’s
parents arrive at the hospital, they ask
the attending physician what caused the
death. The physician wonders whether
she should mention only the accident or
should reveal the possible contributing
factor as well. She fears that the family
might be devastated by this knowledge.
This case demonstrates a conflict between
the physician’s compassionate desire not to
harm the family members and her duty to
tell the truth. It is also about the limits of
confidentiality. Traditional medical ethics
was clear on this point, as is stated in the
WMA International Code of Medical
Ethics: “A physician shall preserve
absolute confidentiality on all he knows
about his patient even after the patient has
died.” However, current medical ethics rec-
ognizes some exceptions to this principle.
The British Medical Association advises
that the obligation of confidentiality after
the patient’s death “needs to be balanced
with other considerations, such as the inter-
ests of justice and of people close to the
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 89
deceased person”.3 And the American
Medical Association allows that, “When a
family or other decision maker has given
consent to an autopsy, physicians may dis-
close the results of the autopsy to the indi-
vidual(s) that granted consent to the proce-
dure”.4
In the case of Mr. A, it would be advisable
for the physician to enter into discussion
with the family to determine whether her
fear of harming them is justified. Perhaps
they already knew that their son was addict-
ed to heroin, and therefore they would not
be disturbed to know that this might have
been a factor in his death. But if, after dis-
cussion, her fear is confirmed, she could be
justified in withholding some information
both to respect patient confidentiality and
to avoid harming the family. Lying, howev-
er, is never permissible.5
Case 2 – Compassion and
respect in the face of blame
Mrs. B is an elderly patient in a critical
care unit for management of multiple
organ failure. The medical team are
agreed that there is no possibility of
arresting her decline and that henceforth
her care should be palliative only. The
patient is non-communicative so the
team turns to her family to seek agree-
ment with this plan. The family mem-
bers, perhaps hoping for a miracle, are
adamant that the team continue their
efforts to prolong the patient’s life. The
team agrees reluctantly to do so. After
five days of aggressive and apparently
uncomfortable treatment, Mrs. B dies.
The family members are angry and
accuse the team of not doing enough to
save their mother. Some of the team,
among themselves, blame the family for
Mrs. B’s unnecessary suffering and want
to confront them openly about this.
Others feel that compassion for the fam-
ily requires that they accept these unjus-
tified criticisms as part of the bereave-
ment process.
In retrospect, the medical team may have
wished that they had not acceded to the
family’s wishes to continue aggressive
treatment for Mrs. B.6 However, they now
have to make the best of a bad situation. It
seems clear to them that the family’s grief
at the death of the patient is compounded by
their anger that the treatment was not suc-
cessful and perhaps also by remorse for
contributing to Mrs. B.’s prolonged suffer-
ing and dying. Team members may share
this remorse, which is made worse by the
family’s unjust accusation.
In such a situation, the medical team may
well consider that they have no further
responsibility to the family. However, as in
the first case, the family members have
needs that only the medical team can meet,
and despite the obstacles, the team should
try to provide compassionate help to the
family in coping with their grief. This may
involve inviting the family members to dis-
cuss the case while reassuring them that
everybody had the best interests of Mrs. B.
in mind, even though the decision to contin-
ue treatment was, in retrospect, probably
not appropriate. Prior to encountering the
family, the team members should meet by
themselves and try to come to terms with
their own remorse and anger.
Case 3 – Patient’s Directive
vs. Survivors’ Needs
Mr. C. a 64-year-old man, has just died
of a cardiac arrest. In his last will, made
when he was 55, he stipulated that he did
not want any funeral or memorial ser-
vice. His surviving wife, four children
and eight grandchildren were very close
to him and are devastated by his death.
Upon learning of his directive regarding
no funeral or memorial service, they are
torn between their need to bring closure
to their grief at losing him and their
desire to respect his wishes. To help
resolve this conflict, they turn to his per-
sonal physician for advice.
Although the physician is not the decision
maker in this case, he has been asked for
advice because of his professional relation-
ship with the patient while alive. The physi-
cian is faced with a conflict between his
loyalty to his former patient and his com-
passion for the bereaved survivors. Here
again, the survivors’ grief at losing their
loved one is compounded by another factor,
in this case, his directive to have no funeral
or memorial service. Even if the physician
favours the survivors, he has to decide
whether they have the right to counteract
the express wishes of the deceased for their
own benefit.
On this latter point, the physician must con-
sider two opposing views. The first is that
individuals have the right to dispose of their
possessions after death, as expressed in
their last will and testament, and nobody
can change their decisions. Arguably this
can apply to how their corpse should be
treated, even though it is not considered
property. The second view is that overrid-
ing previously expressed wishes regarding
funeral arrangements cannot harm the
deceased person and therefore is permissi-
ble if it will benefit others. At present there
is no ethical consensus as to which of these
views should prevail, and hence physicians
have to decide for themselves which to
favour in specific situations.
Conclusion
Each of these cases illustrates a conflict
between important ethical principles.
Although it is preferable that all principles
be upheld, sometimes one must take priori-
ty over another. When such conflict arises,
discussion among all those involved is
important for reaching a decision that, if not
unanimous, at least reflects a compromise
that is tolerable to all. As medical authori-
ties, physicians have a special responsibili-
ty to initiate such discussions and to con-
tribute to their successful outcome.
John R. Williams
Readers’ comments on these cases are wel-
come and a selection will be published in
the next issue of the Journal. Please send
them to the Hon. Editor in Chief, Haughley
Grange, Stowmarket, Suffolk 1P14 3QT,
United Kingdom, email:
efmara@rowe110.fsnet.co.uk
1 An earlier version of this article was present-
ed at the 21st International Conference on
Death and Bereavement, Eilat, Israel, 23-25
Medical Ethics and Human Rights
90
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 90
March 2004. The views expressed here are
those of the author, not of the World Medical
Association.
2 WMA (2005) Medical Ethics Manual 47-50,
available at www.wma.net
3 BMA (2004) Medical Ethics Today: The
BMA’s handbook of ethics and law (2nd ed.),
London, BMJ Books, 439
4 AMA (2002) Confidentiality of Medical
Information Postmortem, available at www.
ama-assn.org/ama/pub/category/print/8354.html
5 Jackson, J (2001) Truth, Trust and Medicine,
London and New York, Routledge
6 WMA (2005) Medical Ethics Manual 46 and
92, available at www.wma.net
Medical Ethics and Human Rights
91
Approved by the WMA General
Assembly, Tokyo 2004
A. Preamble
1. In the treatment of their patients, physi-
cians use drugs, instruments, diagnostic
tools, equipment and materials developed
and produced by commercial enterprises.
Industry possesses resources to finance
expensive research and development pro-
grammes, for which the knowledge and
experience of physicians are essential.
Moreover, industry support enables the
furtherance of medical research, scientif-
ic conferences and continuing medical
education that can be of benefit to
patients and the entire health care system.
The combination of financial resources
and product knowledge contributed by
industry and the medical knowledge pos-
sessed by physicians enables the develop-
ment of new diagnostic procedures,
drugs, therapies, and treatments and can
lead to great advances in medicine.
2. However, conflicts of interest between
commercial enterprises and physicians
occur that can affect the care of patients
and the reputation of the medical pro-
fession. The duty of the physician is to
objectively evaluate what is best for the
patient, while commercial enterprises
are expected to bring profit to owners
by selling their own products and com-
peting for customers. Commercial con-
siderations can affect the physician’s
objectivity, especially if the physician is
in any way dependent on the enterprise.
3. Rather than forbidding any relationships
between physicians and industry, it is
preferable to establish guidelines for
such relationships. These guidelines
must incorporate the key principles of
disclosure, avoidance of obvious con-
flicts of interest and the physician’s
clinical autonomy to act in the best
interest of patients.
4. These guidelines should serve as the basis
for the review of existing guidelines and
the development of any future guidelines.
B. Medical Conferences
5. Physicians may attend medical confer-
ences sponsored in whole or in part by a
commercial entity if these conform to
the following principles:
5.1 The main purpose of the conference
is the exchange of professional or
scientific information.
5.2 Hospitality during the conference is
secondary to the professional
exchange of information and does
not exceed what is locally customary
and generally acceptable.
5.3 Physicians do not receive payment
dircetly from a commercial entity
to cover travelling expenses, room
and board at the conference or com-
pensation for their time unless
provided for by law and/or the pol-
icy of their National Medical
Association.
5.4 The name of a commercial entity
providing financial support is pub-
The World Medical Association statement
concerning the relationship between
physicians and commercial enterprises
licly disclosed in order to allow
the medical community and the
public to assess the information
presented in light of the source of
funding. In addition, conference
organizers and lecturers disclose
to conference participants any
financial affiliations they may
have with manufacturers of prod-
ucts mentioned at the event or
with manufacturers of competing
products.
5.5 Presentation of material by a
physician is scientifically accu-
rate, gives a balanced review of
possible treatment options, and is
not influenced by the sponsoring
organization.
5.6 A conference can be recognised
for purposes of continuing med-
ical education/continuing profes-
sional development (CME/CPD)
only if it conforms to the follow-
ing principles:
5.6.1 The commercial entities acting
as sponsors, such as pharmaceu-
tical companies, have no influ-
ence on the content, presenta-
tion, choice of lecturers, or pub-
lication of results.
5.6.2 Funding for the conference is
accepted only as a contribution to
the general costs of the meeting.
C. Gifts
6. Physicians may not receive gifts from a
commercial entity unless this is permit-
ted by law and/or by the policy of their
National Medical Association and it
conforms to the following conditions:
6.1 The gift is only of nominal value.
6.2 The gift is not in cash.
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 91
6.3 The gift, even one of nominal
value, is not connected to any stip-
ulation that the physician pre-
scribes a certain medication, uses
certain instruments or materials or
refers patients to a certain facility.
D. Research
7. Aphysician may carry out research fund-
ed by a commercial entity, whether indi-
vidually or in an institutional setting, if it
conforms to the following principles:
7.1 The physician is subject only to the
law, the ethical principles and guide-
lines of the Declaration of Helsinki,
and clinical judgmenet in performing
research and does not allow himself
or herself to be subject to external
pressure regarding the results of his
or her research or their publication.
7.2 If possible, a physician or institution
wishing to undertake research
approaches more than one company
to request funding for the research.
7.3 Identifiable information about
research patients or voluntary par-
ticipants is not passed to the spon-
soring company without the con-
sent of the individuals concerned.
7.4 A physician’s compensation for
research is based on his or her time
and effort and such compensation
is in no way connected to the
results of the research.
7.5 The results of research are made
public with the name of the spon-
soring entity disclosed, along with
a statement disclosing who request-
ed the research. This applies
whether the sponsorship is direct or
indirect, full or patial.
7.6 Commercial entities do not suppress
the publication of research results. If
results of research are not made pub-
lic, especially if they are negative,
the research may be repeated unne-
cessarily and thereby expose future
participants to potential harm.
E. Affiliations with
Commercial Entities
8. A physician may not enter into an affil-
iation with a commercial entity such as
consulting or membership on an advi-
sory board unless the affiliation con-
forms to the following prinicples:
8.1 The affiliation does not compro-
mise the physician’s integrity.
8.2 The affiliation does not conflict
with the physician’s obligations to
his or her patients.
8.3 Affiliations and/or other relationships
with commercial entities are fully
disclosed in all relevant situations
such as lecturers, articles and reports.
9.10.2004
Medical Ethics and Human Rights
92
1. Medical ethics in times of armed con-
flict is identical to medical ethics in
times of peace, as established in the
International Code of Medical Ethics
of the World Medical Association. The
primary obligation of physicians is to
their patients; in performing their pro-
fessional duty, their conscience should
be their guide.
2. The primary task of the medical pro-
fession is to preserve health and save
life. Hence it is deemed unethical for
physicians to:
a. Give advice or perform prophylac-
tic, diagnostic or therapeutic proce-
dures that are not justifiable for the
patient’s health care.
b. Weaken the physical or mental
strength of a human being without
therapeutic justification.
c. Employ scientific knowledge to
imperil health or destroy life.
3. During times of armed conflict, stan-
dard ethical norms apply, not only in
regard to treatment but also to all other
interventions, such as research. Research
involving experimentation on human
subjects is strictly forbidden on all per-
sons deprived of their liberty, especially
civilian and military prisoners and the
population of occupied countries.
4. The medical duty to treat people with
humanity and respect applies to all
patients. The physician must always
give the required care impartially and
without discrimination on the basis of
age, disease or disability, creed, ethnic
origin, gender, nationality, political
affiliation, race, sexual orientation, or
social standing or any other similar
criterion.
5. Governments, armed forces and others
in positions of power should comply
with the Geneva Conventions to
ensure that physicians and other health
care professionals can provide care to
everyone in need in situations of armed
conflict. This obligation includes a
requirement to protect health care per-
sonnel.
6. As in peacetime, medical confidential-
ity must be preserved by the physician.
Also as in peacetime, however, there
may be circumstances in which a
patient poses a significant risk to other
people and physicians will need to
weigh their obligation to the patient
against their obligation to other indi-
viduals threatened.
The World Medical Association
Regulations in times of armed conflict
Adopted by the 10th World Medical Assembly, Havana, Cuba, October 1956,
Edited by the 11th World Medical Assembly, Istanbul, Turkey, October 1957, and
Amended by the 35th World Medical Assembly, Venice, Italy, October 1983 and
The WMA General Assembly, Tokyo 2004
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 92
7. Privileges and facilities afforded to
physicians and other health care pro-
fessionals in times of armed conflict
must never be used for other than
health care purposes.
8. Physicians have a clear duty to care for
the sick and injured. Provision of such
care should not be impeded or regard-
ed as any kind of offence. Physicians
must never be prosecuted or punished
for complying with any of their ethical
obligations.
9. Physicians have a duty to press gov-
ernments and other authorities for the
provision of the infrastructure that is
a prerequisite to health, including
potable water, adequate food and
shelter.
10. Where conflict appears to be imminent
and inevitable, physicians should, as
far as they are able, ensure that author-
ities are planning for the repair of the
public health infrastructure in the
immediate post-conflict period.
11. In emergencies, physicians are
required to render immediate attention
to the best of their ability. Whether
civilian or combatant, the sick and
wounded must receive promptly the
care they need. No distinction shall be
made between patients except those
based upon clinical need.
12. Physicians must be granted access to
patients, medical facilities and equip-
ment and the protection needed to
carry out their professional activities
freely. Necessary assistance, includ-
ing unimpeded passage and complete
professional independence, must be
granted.
13. In fulfilling their duties, physicians
and other health care professionals
shall usually be identified by interna-
tionally recognized symbols such as
the Red Cross and Red Crescent.
14. Hospitals and health care facilities sit-
uated in war regions must be respected
by combatants and media personnel.
Health care given to the sick and
wounded, civilians or combatants,
cannot be used for morbid publicity or
propaganda. The privacy of the sick,
wounded and dead must always be
respected.
Initiated February 2004
Approved by the WMA General
Assembly, Tokyo 2004
A. INTRODUCTION
1. In late 2002, an outbreak of a new
severe acute respiratory syndrome
(SARS) began in southern China. The
disease, which was caused by the
SARS coronavirus, spread internation-
ally in late February 2003. The most
severely affected countries were
China, Canada, Singapore and
Vietnam, all of which experienced out-
breaks before the issue of global alerts
by the World Health Organization
(WHO). According to WHO data, alto-
gether 8422 cases occurred in 29 coun-
tries; in the four afore-mentioned
countries, 908 cases were fatal.
2. SARS was an especially difficult new
disease to diagnose and treat – it passed
readily from person to person, required
no vector, had no particular geograph-
ic affinity, mimicked the symptoms of
many other diseases, took its heaviest
toll on hospital staff, and spread inter-
nationally with alarming ease. The
spread of SARS along the routes of
international air travel emphasizes the
fact that pathogens know no bound-
aries and reinforces the critical need
for global public health strategies.
3. The main outbreaks of SARS occurred
in areas with well-developed health
systems. If SARS had become estab-
lished in areas with weak health infra-
structure, it is unlikely that contain-
ment would have been achieved so
quickly. But even in well-developed
health care systems, certain very sig-
nificant flaws were demonstrated dur-
ing this epidemic:
• Lack of effective real-time, two-way
communication channels to front-
line physicians;
• Lack of adequate resources, stock-
piles of medication and supplies to
deal with this type of catastrophe;
• Lack of surge capacity within acute
care and public health systems.
4. A gap between public health authori-
ties (national and international) and
clinical medicine was demonstrated
during this episode. At its September
2003 General Assembly, the WMA
adopted a Resolution on SARS that:
„strongly encouraged the World
Health Organization to enhance its
emergency response protocol to pro-
vide for the early, ongoing and mean-
ingful engagement and involvement of
the medical community globally.…“
B. BASIC PRINCIPLES
5. The international community must be
constantly alert to the threat of emerg-
ing disease outbreaks and ready to
respond with a global strategy. The
Global Outbreak Alert and Response
Network (GOARN) of WHO has a sig-
nificant role to play in global health
security by:
• combating the international spread of
outbreaks;
• ensuring that appropriate technical
assistance reaches affected states
rapidly; and
The World Medical Association Statement on
health emergencies communication and
coordination
Medical Ethics and Human Rights
93
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 93
• contributing to long-term epidemic
preparedness and capacity-building.
The WMA has been actively
involved in GOARN, where appro-
priate. The role of GOARN must,
however, be acknowledged and
actively promoted within the med-
ical profession.
6. Sovereign states have a responsibility
to address the health needs within their
borders. Today, however, many urgent
health security risks are not confined
by national boundaries. Early detec-
tion, through effective national sur-
veillance systems, of unusual disease
events that threaten public health, and
international cooperation between
WHO, its member states, and non-
governmental partners like the WMA,
are required to effectively respond to
public health emergencies of interna-
tional concern. A strengthening of the
International Health Regulations to
broaden their scope to include new
and future health emergencies and
enable WHO to actively assist States
in responding to international health
security threats will provide additional
tools for global epidemic control.
7. Effective communication between
WHO and the WMA, the WMA and its
member National Medical Associations
(NMAs), and NMAs and physicians
can strengthen the information
exchange between WHO and its
Member States during public health
emergencies.
8. Physicians are often the first point of
contact with the emergence of new
diseases; therefore they are in a posi-
tion to aid in all elements of diagnosis,
treatment and reporting of affected
patients and prevention of disease.
Physicians with key expertise must be
incorporated into the health emer-
gency decision-making process so that
the impact of national and internation-
al directives on clinical settings and
patient care is understood.
9. WHO and its Member States must work
with the WMA and NMAs to proactive-
ly address the safety of patients and of
health professionals involved in caring
for the sick during outbreaks of new dis-
eases. Delays in identifying and distrib-
uting supplies of protective equipment to
health professionals and their patients
exacerbate anxiety and risk of spread of
infectious disease. National and interna-
tional systems that stockpile relevant
and adequate supplies and rapidly move
them to affected areas should be created
or enhanced. All the principles employed
in the safeguarding of patient safety
should be respected and followed in
emergencies such as SARS.
C. RECOMMENDATIONS
10. That the WMA and member NMAs
should work closely with WHO,
national governments, and other pro-
fessional groups to jointly promote the
elements of this Statement.
11. That the WMA urge physicians to a) be
alert to the occurrence of unexplained
illnesses and deaths in the community,
b) be knowledgeable of disease sur-
veillance and control capabilities for
responding to unusual clusters of dis-
eases, symptoms and presentations,
and assiduous in the timely reporting
of suspicious cases of illness to appro-
priate authorities; c) utilize appropriate
procedures to prevent exposure of
infectious pathogens to themselves and
others; d) understand the principles of
risk communication so that they can
communicate clearly and non-threaten-
ingly with patients, their families, and
the media about issues such as expo-
sure risks and potential preventive
measures (e.g., vaccinations); and e)
understand the roles of the public
health, emergency medical services,
emergency management, and incident
management systems in response to a
health crisis and the individual health
professional’s role in these systems.
12. That the WMA encourage physicians,
NMAs, and other medical societies to
participate with local, national, and
international health authorities in devel-
oping and implementing disaster pre-
paredness and response protocols for
natural infectious disease outbreaks.
These protocols should be used as the
basis for physician and public education.
13.That the WMA call on NMAs to pro-
mote and support WHO’s GOARN as
a control coordinating entity in com-
bating global health security threats.
14.That the WMA call for the establish-
ment of a strategic partnership agree-
ment with WHO, so that in case of
epidemics, health communication can
be stepped up considerably and two-
way flow of information ensured.
15.That WHO should coordinate the
development of an inventory based
on existing stockpiles of supplies, so
that such supplies can be rapidly
deployed and accessed by physicians
involved in the care of victims.
16.That WHO should strengthen the
International Health Regulations to
broaden their scope to include report-
ing of new and future health emer-
gencies, and to enable WHO to
actively assist States in responding to
international health security threats.
17. That international agreements should
be proactively explored to facilitate
the movement of health professionals
who are involved in the management
of epidemics.
18. 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.
19. That education and training of physi-
cians should be modified 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 health care worker safe-
ty when managing patients with acute
infectious diseases.
20. That physicians everywhere in the world,
including those in Taiwan, have unlimit-
ed access to WHO programs and infor-
mation concerning health emergencies.
Medical Ethics and Human Rights
94
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 94
Note of clarification on paragraph 30 of the
WMA Declaration of Helsinki
“The WMA hereby reaffirms its position that it is necessary during the study planning
process to identify post-trial access by study participants to prophylactic, diagnostic and
therapeutic procedures identified as beneficial in the study or access to other appropri-
ate care. Post-trial access arrangements or other care must be described in the study pro-
tocol so the ethical review committee may consider such arrangements during its review.”
Medical Science, Professional Practice and Education
Account by Dr. James Appleyard of his
Presidential year of office 2003–2004
It has been a great honour and privilege to
have represented the World Medical
Association over the last twelve months as
your President. My enduring memory has
been the warm, friendly and respectful wel-
come from physicians worldwide. This was
a the reaffirmation of our Declaration of
Geneva that „my colleagues will be my
brothers and my sisters“. We all share a
common professionalism underpinned by
our core values.
My main theme has been the Right of a
Child to Health Care advocating our
Declaration of Ottawa, highlighting the
gap between the rich and poor both between
and within the nations of the World, seeking
to raise awareness and encouraging profes-
sional links particularly in education and
research. I was able to spread the message
from Africa (at the Ugandan Medical
Association and in South Africa), to
America (in Miami at the Academy of
Pharmaceutical Physicians, New York, at
the Hispanic Development Foundation,
Portland Oregon to the medical students
during their Global Health Week) and in
Malta, where the theme was taken up in a
four minute television feature augmented
by their own archives.
Emphasizing that Violence is a leading pub-
lic health problem particularly impacting on
the lives and wellbeing of children, it was
possible to stress the message of the
Helsinki WMA statement on Violence at
meetings in the UK, Dominica, and notably
at the annual meeting of the International
Federation of Medical Student Associations
(IFMSA) in Ohrid, Macedonia where the
major theme was “Violence and Health”.
Finally I addressed the Symposium on
“The application of Children’s Rights” at
the 24th International Congress of
Pediatrics in Mexico. At the Congress, Ms.
Carol Bellamy from UNICEF emphasized
that six out of the eight Millennium Goals
were Child focused and that these were the
goals of each government of the nations of
the World. (UNICEF is publishing a Report
on “Progress for Children” this autumn),
Joy Phumaphi from WHO stressed the
“unfinished agenda” of the “Alive at Five”
initiative also pointing out that 11 million
children are dying each year from pre-
ventable and treatable conditions. Thus
children are bearing 1/3 rd of the world’s
burden of disease, 9/10ths of which was
affecting the poorer countries who had the
least resources to cope with it. She said that
the conference knew who was at risk, where
they were, what must be done and how to
do it. There are several concomitant initia-
tives such as the “Child Survival
Partnership” with UNICEF, WHO and the
World Bank that WMA, as the Association
of the Worlds’ Physicians needs to join and
there are also two effective pilot projects
“Child Watch Africa” and the Save the
Children’s “Saving New Born Lives”,
which are physician driven.
I have contacted all our national medical
association members about the need to
develop the WMA Declaration of Ottawa
further, and am currently collating the
replies.
There were two other areas for which, as
President, I sought your support. Firstly,
action to stop the increasing health prob-
lems of sub-Saharan Africa and to try and
include more African National Medical
Associations in our work; and secondly, the
importance of medical education in this
mission. My first engagement was to attend
the “Strategies for Survival” Conference of
the South African Medical Association
under the inspired leadership of Dr. Kgosi
Letlape. In the very challenging times
ahead, all the members of the profession in
South Africa are united both in the ethical
values that underpin medical practice and
in their quest for improved health services
for the underserved. At the Annual Meeting
of the Ugandan Medical Association, there
was an opportunity to meet the Presidents
of the Kenyan and Tanzanian Medical
Associations in conjunction with the World
Health Organization who were discussing
the setting up of an East African Medical
and Dental Association.
Concerning medical education, my aim
was to raise awareness of international
issues in a sustainable way by encouraging
all medical students to do a month’s elec-
tive in a developing country and to suggest
“exchanges” during residency training pro-
grammes, with the support and encourage-
ment of joint research initiatives. I visited
the International Department of Cornell
Medical School where 40% of the students
already have international assignments,
met the Dean of New York College of
Medicine and joined an inspired core of
dedicated medical students who had
arranged a Global Health Week at Oregon
Health and Sciences University in
Portland, Oregon. The energy and enthusi-
asm apparent at the International
Federation of Medical Students
Associations (IFMSA) in Ohrid,
Macedonia, where I participated in the
impressive opening ceremony held in the
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Roman Amphitheatre, bodes well for the
future. Members of the IFMSA are given
free associate membership of the WMA
after they graduate and have to move on
from their own association. I hope as many
of these young and dedicated physicians
will attend our meetings and continue to
help shape the future.
Our continuing work with other interna-
tional professional associations is essential
if we are to get our important messages
across to the wider world community. I
attended the excellent International
Federation of Dentist’s (FDI) first Regional
Conference on Oral Health of the African
Region, where the importance of including
the major oral health problems within the
collaborative general health programs was
stressed in the presence of the Ministers of
Health, WHO, representatives from
Academia and dental practitioners. This
was an inclusive conference dealing with
the particular problems of the Region and
one which we should be emulated in other
Regions. The European Forum for Good
Clinical Practice held a Conference on
Clinical Research involving Academia,
Industry, Medical Organizations, NGOs.,
seeking to influence current European leg-
islation The European Platform for Patient
Organizations also expressed a concern to
rescue reliable, ethical research
initiatives on children.
The World Health Professions Alliance
Conference held in Geneva after our
Council Meeting in Divonne was a major
innovation for the WMA. It is essential that
we use such forums to join with other
health professional colleagues to help tack-
le the global problems such as AIDS in a
coordinated way. We must rise above the
unnecessary turf battles that have belittled
us all. The combined energy should be used
to advocate our own shared policies so that
together we can have much greater impact.
We are also a Founder Member of Oxford
Vision 2020 dedicated to the prevention of
the forecast pandemic growth of largely
preventable chronic diseases in the low and
middle income countries and the poorer
segments of society in the developed world.
The forum includes academia, industry,
professional and other non governmental
organization, patient groups and young
people. It focuses on three risk factors
tobacco, diet and lack of exercise, and four
chronic diseases, diabetes, cardiovascular
disease, chronic lung disease and some can-
cers, which lead to 50% of deaths globally.
Our profession should set an example and
follow the lead of our American colleagues
with regard to diet, smoking, and exercise
and reduce our own BMI’s!
During a meeting of the Maltese Medical
Association, I had the opportunity to
encourage policy development to imple-
ment the Framework convention on
Tobacco Control in a meeting with the
Minister of Health. Some progress has been
made with regard to the hazards of passive
smoking on the island. Increasingly other
countries are following the example of the
Republic of Ireland. I wrote to the Prime
Minister in the UK but he has so far failed
to respond to the lead of his own Chief
Medical Officer.
As the global representative body of some 7
million physicians we have a duty to sup-
port our “brothers and sisters” in times of
great difficulty. In conjunction with our
Human Rights Unit I tried through contacts
to help free Dr. Biscet who is still languish-
ing in a Cuban Jail as a result of his endeav-
ors to promote human rights.
Some 10.000 doctors were on strike when
I visited the Dominican Republic. Their
concerns were the deteriorating situation in
Government Hospitals, and the catastrophic
effects of the fall in the value on the peso on
basic maintenance of hospitals and on their
own salaries. With the President of the
Colegio Medico Dominicano I visited the
Hospital General Materno Infantil and met
the faculty, residents and the administra-
tion. The acute services budget was running
at 15% of the hospitals needs. Hospital
blackouts could last up to 13 hours, and
sometimes the only available light during
emergency operations had been from the
LCD display of a mobile phone.
The collapse of the health system in
Zimbabwe, whose government has ratified
with the other African Countries the
WHO’s “Right to Health”, is a humanitari-
an disaster with an additional 20.000 chil-
dren dying each year in the year 2002 than
would have died ten years previously.
Cuban doctors have been imported to try
and reverse the effects of the loss of physi-
cians from the country but they are unable
to provide a proper primary care service
because of language difficulties, and have
settled in the cities. I met a dynamic group
of non governmental organizations includ-
ing the Amani Trust, Amnesty
International, Zimbabwe Association and
ZADHR to be informed about the current
culture of repressive violence and torture in
Zimbabwe which is being reinforced by the
“War Veterans” and Youth Militia.
At the BMA Annual Representative Body
in Llandudno, I met Dr Raj Doolabh, who
then was Treasurer of the Zimbabwe
Medical Association, one of our member
associations. He did not expect significant
change in Zimbabwe until Mr. Mugabe
retired. Members of the opposition were
being denied treatment for HIV/Aids. By-
elections caused by their deaths allowed
their replacement by ZANU members. Raj
Doolabh suggested that the main help
physicians from outside Zimbabwe could
give their colleagues in Zimbabwe was
through Continuing Medical Education,
which is now mandatory in the Country. It
was hoped that it would be possible to
arrange a meeting with the ZIMA executive
during a conference on AIDS which Dr.
Letlape was organising in September but
unfortunately this has not been possible.
Physicians in Iraq have started to develop
links with the WMA following the atten-
dance of Dr. Brennan on their behalf at the
Council Meeting in May. At a recent Iraqi
Medical Specialty Forum in Washington I
met some Iraqi physicians from Baghdad
and several others who had emigrated to the
US. The security situation for physicians
was very serious. Dr Khalili, a
Neurosurgeon, who had been kidnapped
himself, said the main problems were secu-
rity, a regular supply of electricity and
water and the maintenance of medical sup-
plies and provisions for Government
Hospitals. On the other hand the budget for
Health had been increased from $16 million
in Saddam Hussein’s time to $905 million.
600 extra medical facilities for essential
care had been developed with 110 primary
health care centers. Certain areas of the
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Medical Science, Professional Practice and Education
97
country such as Kurdistan were peaceful
and safe. It was suggested that a conference
including all interested national medical
associations in the region might be held to
look how the health problems in the Region
and in particular how those in Iraq could be
addressed. This is a contribution that the
WMA might make with the WHO subject
to funding which I gather could be raised.
My last visit before handing over the badge
of office to the President-elect, Dr. Yank
Coble, was to talk about “Professionalism”
at the annual meeting of the Icelandic
Medical Association, a subject already
taken up by the Editor of the WMJ. Here it
was emphasized that we need to guard our
professional autonomy by ensuring the
highest standards of education, care and
ethics.
This last visit had a timely topic for reflec-
tion and illustrates the importance of the
WMA continuing to support the work of
physicians worldwide.
“Wherever the Art of Medicine is loved,
there is also the love of humanity”
Hippocrates 400 BC
James Appleyard MA (Oxon), MD (Kent),
FRCP (Lon), FRCPCH (UK)
President of the World Medical Association
2003–2004
The future of medical technology –
Implications for medical education and practice
Address to the World Medical Associa-
tion (Tokyo, Japan)
Henry Haddad, MD, FRCPC
Past President
Canadian Medical Association
Thank you very much for asking me to
speak to you today. It is indeed a great hon-
our, and I would like to express my gratitude
to our Japanese hosts for having invited me
to address this distinguished gathering.
As many of you know, medical technology
has revolutionized both medical education
and the clinical practice of medicine in most
parts of the world. Some people may still
view advances in the field as a relatively
recent development, and medical technolo-
gy as a modern phenomenon.
However, medical technology as we under-
stand it has been developing over many
years, from the discovery of medical appli-
cations of radioactivity by Roentgen to the
isolation of insulin by our own Canadian
researchers Banting and Best. More recent
developments have included implantable
medical devices such as pacemakers and
artificial valves, and the refinement of
organ transplantation techniques and antire-
jection drug regimens.
Although medical technology is not new, its
development has certainly accelerated sig-
nificantly, and keeping up with these
changes has become a difficult challenge
for many medical practitioners.
Before expanding on the concept of medical
technology, it may be useful to take a step
back and consider human achievements
which are in today’s terms decidedly “low-
tech”. Some of our most prominent medical
practitioners, such as Pasteur, Burkett,
Osler and Freud worked without the benefit
of high technology.
It was in 1950 that Dicke suggested, in a
landmark study, that certain dietary cereal
grains were harmful to children with a
coeliac sprue – a malabsorbtion disorder
that is potentially fatal. He acutely observed
that the incidence of coeliac sprue in chil-
dren in Holland during World War II was
markedly reduced and that previously diag-
nosed coeliac patients improved during the
war years. During this period, grain produc-
tion such as wheat and rye flour, were in
short supply in Holland. When cereal grains
again became plentiful after the war, the
incidence of coeliac sprue rapidly returned
to previous levels. It was subsequentely
demonstrated that the gluten moiety of wheat
was the offending agent. This simple obser-
vation has improved the quality of life of
many thousands of people, including some of
my relations.
There are also other factors of determants
of health that have had a tremendous
impact on global health, these include
patient education, improved diet and recog-
nition of environmental factors. Inventions
not directly related to medicine have also
played an important role. For example, the
invention of refrigeration may have saved
more human lives than any other. Having
said this, most people would still probably
agree that, on balance, medical technology
has had a positive impact on patient health
and well-being. Life expectancy in most
countries around the world has increased
significantly and other markers of health,
such as neonatal and maternal mortality,
have also improved.
In general, medical technology has enhanced
diagnostic accuracy and efficiency.
This has allowed physicians to see, diag-
nose and treat more patients in a shorter
period of time, an important development
in those many places with insufficient med-
ical human resources. Patients live longer
and have higher quality of life because of
developments such as insulin pumps, pros-
thetic heart valves and artificial joints.
However, in many parts of the world
including my own country, great advances
in medical technology have not generally
translated into the large leaps in productiv-
ity as witnessed in other industries.
It would now appear that what we once
referred to as the “future” of medical tech-
nology is nearly upon us.
Advances previously thought to be in the
realm of science fiction are fast approach-
ing reality. Among the numerous examples
of medical technology, the most widely dis-
cussed is the genetic/genomic revolution.
Following the unravelling of the human
genome, we have been witness to wide-
spread and diverse predictions regarding
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 97
future applications of this new knowledge.
The genomic revolution has raised many
questions:
• Is the development of designer drugs
based on a person’s genetic makeup far
off?
• Is gene therapy for currently untreatable
conditions on the horizon or will the
potential roadblocks prove insurmount-
able?
And what of stem cell transplantation?
• Is it truly the answer we have been seek-
ing to help cure diabetes, Parkinson’s
Disease and spinal cord injury?
Along with these questions, which tend to
provoke much excitement and optimism
amongst medical practitioners and their
patients, are other, potentially more trou-
bling ones, which also deserve some atten-
tion and discussion.
Who will have access to these new tech-
nologies?
Access to care remains a major concern in
many parts of the globe.
Access to care based on need rather than
ability to pay, is still a pipe dream for most.
It is certainly possible that as medical tech-
nology advances further, inequities in
access to care will become more rather than
less apparent and profound.
Wealthier nations who are able to fund the
development of technologies will move fur-
ther ahead, while those without the
resources to compete will fall further
behind.
This also has to do with the broader issues
of resource allocation and priority setting.
Hi-tech interventions tend to be relatively
more expensive, both in terms of initial
capital outlay and recurrent expenditures.
We need to ask ourselves how far we
should go in allocating scarce resources to
meeting increasing patient demands for
these more costly interventions, when the
end result may be decreased availability of
simpler, but often equally effective, treat-
ments. For example, many countries,
including Canada, devote inadequate
resources to caring for the terminally ill. It
is difficult to compare results seen from the
use of medical technology to the benefits of
compassionate care at the end of life. But
decisions about where to allocate our pre-
cious resources must be made, and we must
grapple with the issue of what kind of
rationing in health care is morally acceptable.
Will predictive genetic testing disadvantage
those with a genetic susceptibility to dis-
eases for which there is no cure? For exam-
ple, the development of a test could deter-
mine with certainty that a person would
develop incapacitating and untreatable can-
cer or a neurological disorder at a young age
would be likely to affect their insurability
and employability if insurers and employers
were able to gain access to this information.
Currently the insurance industry is lobbying
for exactly this type of access.
This threatens to have a detrimental impact
on the doctor-patient relationship.
Presently in Canada it is known that in
approximately 11% of medical encounters,
the patient withholds relevant medical
information because of concerns about who
will have access to this data (including
employers, banks and insurance compa-
nies). In the United States this percentage
appears to be about 15% of patients. This
problem is likely to become worse over
time, with the advent of predictive genetic
testing and the use of electronic health
records, which could be accessed by other
parties. If more medical information is
withheld, and many experts estimate that
the figure will rise to 20% of patients, the
doctor-patient relationship will be further
compromised, and there can be little doubt
that patient care will suffer.
And what about the psychological impact of
this type of information on these patients?
Just because we have the ability to uncover
certain medical information, does that mean
we should, especially when treatment or
cures do not exist?
Does the benefit of planning for the future
outweigh the potential burden of knowing
when this future will end? Experts in this
important field are currently considering
these questions and others.
Will those who bear the burden of medical
research ultimately reap the rewards of dis-
covery? There are many examples of stud-
ies done in populations which ultimately do
not derive the primary benefits from their
results. There is no reason to believe that
technological research might be any differ-
ent, and as physicians we must do whatev-
er we can to guard against this, and to
ensure that the burdens and benefits of
medical research are equitably distributed,
– a major concern of the WMA:
Where is the line drawn between innovative
medical practice and medical research? If a
surgeon is perfecting a new procedure such
as implantation of a new mechanical pump,
does this qualify as standard medical prac-
tice or as research? The distinction can be a
critical one. If it is research, it would
require review by a duly constituted resarch
ethics board and would be subject to a dif-
ferent standard of informed consent.
Oversight and monitoring of the procedure
would also be more stringent in many parts
of the world if it were considered to be
research rather than standard treatment.
Does the advance of medical technology
further skew the balance between art and
science in the practice of bedside medicine
towards science, and what impact will this
have on the education and development of
future physicians?
Over many centuries, medical practitioniers
relied on the art of medicine to help relieve
suffering. This was true for both diagnosis
and treatment. As a very famous Canadian
physician, Sir William Osler, once said:
“Always listen to the patient, they will tell
you the diagnosis.” The point is that test-
ing should never be used as a substitute
for a good history. The emphasis is today
– and I see this every day at my University
Hospital – on scan and blood test. Keep
repeating to your students that there is noth-
ing more satisfying or more informative
than sitting down with the patient and real-
ly considering what they are saying. Sir
William Osler was right – “Technology is
there to complete the art of medicine – it is
not a substitute”!
However, in modern times, the thorough
bedside medical examination has often
given way to the full-body or MRI scan.The
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99
long and emotional discussion about the
impact of a person’s physical illness on
their psychological well-being has been
replaced by the prescription for the newest
anti-depressant, often one the patient has
seen advertised on TV. These changes have
altered the physician-patient relationship,
and usually not for the better.
Medical students today train in an environ-
ment with a bias towards specialization of
care, often driven by rapid advances in
technology.
Physicians cannot be expected to keep up
with every new development when the
body of medical knowledge is, by some
estimates, doubling every year. These fac-
tors have led to increasing subspecializa-
tion and the gradual erosion of the role of
the primary care practitioner, which is so
crucial to the maintenance of overall
patient health and well being.
Students are also often attracted to the more
glamorous and higher paying specialities,
which not coincidentally, are often those
which make the most use of technology.
Unless we are able to swing the pendulum
back towards the art of medicine, and
demonstrate to a greater number of stu-
dents the merits and rewards of primary
practice, we will see a further decline of the
doctor-patient relationship and a further
dehumanization of the practice of medi-
cine. This is not in the best interest of either
the physicians or their patients.
As we have focused more attention on
acute care and life-saving technologies,
have we neglected areas such as public
health and health promotion? Certainly
much of the attention and publicity tends to
be focused on those medical interventions
that save individual lives – the coronary
bypass, the new cancer treatment, the kid-
ney transplant. And while this attention
(and, not coincidentally, much of the fund-
ing) has been focused on acute care and the
impact of new advances, the public health
and promotion infrastructure has been
slowly deteriorating.
We need look no further than SARS for an
example. Billions of dollars world-wide are
currently being poured into the develop-
ment of medical databases so that, for
example, emergency physicians can access
patient information and test results at the
touch of a button. This we would all agree
is a positive development-improving health
care and eventually hopefully reducing
cost. In the meantime, public health care
workers in Toronto were faced with a com-
pletely outdated and inadequate computer
system to try and track new cases of SARS
and their contacts during the height of the
epidemic. In many offices, sticky notes were
used instead of computer databases to keep
track of new developments. While we may
have learned a lesson from this example,
whether or not we can apply it in a meaning-
ful and ongoing way remains to be seen.
Finally, will the emphasis currently placed
on technological research and its transla-
tional application detract both attention and
funding from equally important basic sci-
ence research?
Just as medical students are more likely to
be attracted to the more glamorous spe-
cialities, so too will scientists in training
often follow their mentors as they pursue
the dollars and glory promised by the next
technological miracle. Let me conclude by
saying that, overall, we have been well
served by advances in medical technology,
and our patients in general are living
longer and healthier lives because of these
developments.
However, we must not push ahead blindly
or unquestioningly.
I have tried to raise several questions,
which I think require further thought and
discussion. Until we can answer these ques-
tions, and others, the future of medical tech-
nology is likely to remain uncertain at best
and troubling at worst.
Twin Studies
Blame your genes for a restless night’s sleep –
new research revealed
New research carried out by doctors in the
Twin Research Unit at St. Thomas’
Hospital, London, U.K. indicates that
genetic factors make a “substantial contri-
bution” to common sleep disorders.
Professor Tim Spector, Director of the Unit,
has revealed the results of a new study of
almost 2,000 pairs of female twins during a
press briefing at the Science Media Centre.
1,937 pairs of identical and non-identical
twins from the Twin Research Unit data-
base were asked questions on sleep disor-
ders such as obstructive sleep apnoea
(OSA) and restless legs syndrome (RLS).
Dr. Adrian Williams, a co-author of the
research study and Consultant in the Sleep
Disorders Centre at St. Thomas’ Hospital,
says: “Sleep disorders are surprisingly com-
mon and it is increasingly recognised that
they can have a devasting impact on suffer-
ers’ everyday lives.”
“For example, OSA affects approximately
24% of men and 9% of women aged 30 to 60.
It even contributes to road traffic accidents
when sufferers fall asleep at the wheel.”
Twins were asked, in connection with OSA,
if they ever snored and, if so, how often
their snoring disturbed others or caused
them to wake up – they were also asked if
they experienced daytime sleepiness.
In relation to RLS, twins were asked if they
ever experienced an urge to move their legs
during the night to relieve tingling or numb-
ness and also if they ever found their legs
jerked involuntarily during the night.
Key findings of the research study include:
• Genes contribute significantly to sleep
disorders – approximately 50% of the
variance in liability to these symptoms is
due to genetic factors.
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World Health Organization
100
• Heritability was estimated to be 42%
(disruptive snoring), 45% (daytime
sleepiness), 54% (restless legs) and 60%
(legs jerking).
• An important strength of the research
study is that these heritability estimates
have been corrected to take into account
other influences on the symptoms of
snoring and daytime sleepiness such as
sufferers being overweight or heavy
smokers.
Professor Spector says: “These results sug-
gest a substantial genetic contribution to the
symptoms of both obstructive sleep apnoea
and restless legs syndrome and that could
be good news for people who suffer from
these conditions if the genes responsible
can be identified.
“One reason the genes for disruptive sleep
may have persisted is that poor sleep pat-
terns make people gain weight and retain
fat. These genes may have helped our
ancestors through periods of famine and the
Ice Age.”
The Twin Research Unit was originally set
up at St. Thomas’ Hospital (London U.K.)
in 1992 to look at the role that genes play
in the development of rheumatic diseases
in older women and has now expanded to
look at most common diseases, behaviours
and traits.
World Health Organization
New tools and increased funds will
beat malaria, say global leaders
Arusha, Tanzania – New technologies for
malaria prevention and treatment, com-
bined with an increase in available funding,
are fuelling optimism in the fight against
malaria. Global leaders gathered in Arusha
for the launch of the Olyset® Net at A to Z
Textile Mills – the first factory in Africa to
produce this long-lasting insecticidal mos-
quito net – agreed that conditions were right
for a massive scale-up in the battle against
the disease, which claims more than a mil-
lion lives each year and hampers develop-
ment, especially in Africa.
The President of the United Republic of
Tanzania, Benjamin W. Mkapa, delivered a
message of hope to a group of dignitaries
including US Secretary of Health and
Human Services Tommy Thompson, Roll
Back Malaria Partnership Executive
Secretary Awa Marie Coll-Seck, and Global
Fund to Fight AIDS, Tuberculosis and
Malaria Executive Director Richard
Feachem, as well as representatives of the
Roll Back Malaria partners who had made
the A to Z technology transfer possible.
“Long-lasting insecticidal nets are Africa’s
best hope for preventing malaria, and we
are very proud that Tanzania is the home of
Africa’s first manufacturer of these nets,”
said President Mkapa. “We hope that this
shining example of technology transfer and
strengthening of local industry will serve as
a model for similar efforts, making the nets
more affordable and available to the mil-
lions of Africans who need them.”
The technology for long-lasting insecticidal
nets, which embed insecticide within the
net’s very fibres and therefore retain their
efficacy for up to five years without retreat-
ment, was transferred to Tanzania last year
in a groundbreaking collaboration between
private and public sector players including
the Acumen Fund, Sumitomo Chemical, the
World Health Organization, UNICEF,
ExxonMobil, and Population Services
International. A to Z Textiles now produces
nearly half a million of these new nets each
year and hopes to ramp up production to
pass the one-million mark in 2005.
The latest generation of highly effective
malaria treatments known as artemisinin-
based combination therapy (ACT) offer a
cure that so far has met only minimal resis-
tance from the malaria parasite. Derived
from the Artemisia annua (sweet worm-
wood) plant traditionally used to treat
malaria in China, these medicines have
become the drug of choice for more than 40
countries (20 of them in Africa), and
demand for them has increased rapidly.
The factory visit took place in the context
of th 9th
board meeting of the Global Fund,
which was held in Arusha from 17–19
November. “The Global Fund has commit-
ted nearly US$ 1 billion over the coming
two years and expects to scale up malaria
funding substantially,” said Global Fund
Executive Director Feachem. “These funds
will be used by countries to purchase both
preventive and curative tools – including
long-lasting nets, artemisinin-based combi-
nation therapy, and insecticide spraying
where suitable – for maximum impact
against malaria.” The Global Fund is also
working with Roll Back Malaria partners to
provide the financial incentives that will
bring a new malaria vaccine to the market.
“This is a new era for malaria control,”
declared the Roll Back Malaria
Partnership’s Executive Secretary Coll-
Seck. “Demand for this latest generation of
effective malaria-control tools is increasing
rapidly, and so is funding. If we can repli-
cate the success of A to Z to ensure an ade-
quate supply of long-lasting insecticidal
nets, and work with pharmaceutical com-
panies to ensure ACT supplies, we will
demonstrate the true power of public-pri-
vate partnerships by dramatically reducing
malaria deaths.”
Background
To provide a coordinated global approach
to fighting malaria, the Roll Back Malaria
Partnership was launched in 1998 by the
World Health Oarganization, the United
Nations Children’s Fund (UNICEF), the
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World Health Organization
101
United Nations development Programme
(UNDP) and the World Bank. The
Partnership’s goal is to halve the global
burden of malaria by 2010.
The Partnership now includes malaria-
endemic countries, their bilateral and multi-
lateral development partners, the private sec-
tor, non-governmental and community-based
organizations, foundations, and research and
academic institutions and has succeeded in
raising global awareness of malaria, generat-
ing increased resources and achieving con-
sensus on the tools and priority interventions
required to control the disease.
Midwives/Gynaecologists
Skilled attendants vital to saving lives
of mothers and newborns
Geneva – The number of skilled attendants in
developing countries needs to be increased by
at least 333,000 if the international communi-
ty is to meet the Millennium Development
Goal (MDG) of reducing maternal deaths by
two thirds by 2015, according to a joint state-
ment* issued by the World Health
Organization, the International Federation of
Gynaecologists (FIGO) and the International
Confederation of Midwives (ICM).
A skilled attendant is a health professional
with the competencies for care during nor-
mal birth and the capacity to recognize,
manage and refer complications in the
woman and newborn. Skilled attendants
play a pivotal role in reducing maternal and
newborn mortality and morbidity, says the
joint statement of WHO, ICM and FIGO.
The statement calls for better monitoring
and reporting on progress in achieving the
MDG target of increasing the proportion of
births attended by a skilled attendant to
90% by 2015.
The shortfall is most acute in the developing
world. In developed countries and countries
in transition, the average rate is above 90%.
The lowest levels are in Eastern Africa
(33.6%), South-Central Asia (37.5%) and
Western Africa (39.6%), with much higher
levels in South America (84.8%). Globally,
only 61% of all childbirths are attended by a
skilled birth attendant.
“Life-threatening complications occur in
15% of all births,” says Joy Phumaphi,
Assistant Director-General of Family and
Community Health at WHO. “For a moth-
er and her newborn, a skilled birth atten-
dant can make the difference between life
and death. Not only can they recognize and
prevent medical crises on the spot, but they
can refer women for life-saving care when
complications arise.”
The joint statement defines a skilled atten-
dant, sets out what skills they should have,
and the training and support they need. In
their statement, WHO, ICM and FIGO
jointly urge the international community,
professional associations and donors to
make skilled care for all pregnant women
and their newborns a priority – focusing on
increasing the number of skilled birth
attendants, strengthening their capacity and
increasing the resources available to them.
Aids
A globally effective HIV vaccine requires
greater participation of women and
adolescents in clinical trials
Geneva – Greater participation of women
and adolescents is needed in HIV vaccine
clinical trials, according to a group of inter-
national experts, who attended a consulta-
tion on HIV vaccine trials in Lausanne,
Switzerland.
The meeting, organized by the World
Health Organization and the Joint United
nations Programme on HIV/AIDS
(UNAIDS), brought together for the first
time 40 experts from around the world to
address the issues of gender and age in par-
ticular, as well as race in HIV vaccine-
related research and clinical trials.
“We have identified measures aimed at recti-
fying the injustice stemming from the fre-
quent exclusion or low participation of
women and adolescents in HIV vaccine clin-
ical trials. Clinical trial enrolment needs to be
more inclusive, so the benefits of research
are more fairly distributed,” said Dr. Ruth
Macklin, co-Chair of the meeting and a
bioethics professor at the Albert Einstein
College of Medicine in New York City.
Studies show that women, when exposed to
HIV, are at least twice as likely to become
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World Health Organization
102
of VaxGen’s AIDSVAX, the only candidate
vaccine so far to reach Phase III efficacy
testing in large numbers of people, found
that although the vaccine was not effective
overall, non-whites and women possibly
had some degree of protection. This finding
merits further investigation.
More than 30 promising, new candidate
HIV vaccines are currently being tested in
human clinical trials, the majority of which
began in the past four years. The number of
AIDS vaccine candidates in small-scale
human trials has doubled since 2000. The
trials are taking place in 19 countries. A
safe, effective and affordable vaccine
against HIV would be a powerful arm
against the AIDS epidemic which continues
to infect five million adults and children
and kill three million people every year.
The international HIV vaccine research
mission is to develop HIV vaccines that are
licensed, acceptable, available and accessi-
ble by all populations regardless of their
gender, age, socio-economic status, race,
ethnicity or country, and that are effective
across the board. Special attention must be
paid to ensure that vulnerable groups, par-
ticularly women and girls, benefit from an
HIV vaccine.
Recommendations – covering ethics, poli-
cy, advocacy, community participation,
clinical trial design and research gaps –
issued at the consultation will form the
basis of a policy document that will help
guide those designing and conducting HIV
vaccine clinical trials. An important sug-
gestion for future work was to study HIV
clinical trial sites with enrolments that
include appropriate numbers of people
from different sub-groups, and to try to bet-
ter understand the barriers that have pre-
vented wider participation.
The challenges to the creation of an HIV
vaccine are mainly and economic, primari-
ly due to the lack of incentive by the private
sector to engage in product development.
However, new momentum has been gener-
ated in the field of HIV vaccine research. In
June 2004, the G8 countries endorsed a
Global HIV Vaccine Enterprise to acceler-
ate efforts to develop an HIV vaccine
through an expanded capacity to test and
manufacture vaccines, the establishment of
vaccine development centres around the
world and the development of an integrated
global clinical trials system allowing labo-
ratories to easily share data.
Represented at the consultation, co-spon-
sored by WHO and UNAIDS, were govern-
mental public health research institutions in
developing and industrialized countries,
medical schools, industry, foundations and
non-governmental organizations.
infected with HIV as their male counter-
parts. In parts of sub-Saharan Africa, girls
and young women are up to six times more
likely to be infected than their male peers.
Girls and young women aged 15-24 make
up 62% of the young people in developing
countries living with HIV or AIDS.
“Women and girls are particularly vulnera-
ble to HIV infection for biological, social
and economic reasons,” said Dr. Catherine
Hankins, Chief Scientific Advisor at
UNAIDS, who spoke at the opening of the
meeting.
Youth and young adults are also at high risk
for HIV: about half of new HIV infections
in the developing world occur among 15 to
24 year olds.
“In spite of the epidemiological reality,
women and adolescents, especially girls,
have often had minimal involvement in
clinical trials of HIV vaccines, as compared
to men. This is in spite of the fact that they
would be major beneficiaries of a future
HIV vaccine,” said Dr. Saladin Osmanov,
Acting Coordinator, WHO-UNAIDS HIV
Vaccine Initiative, WHO. The Initiative
promotes the development of an HIV vac-
cine, including through the facilitation of
clinical trials.
Reasons for the lack of participation of
women and young people in HIV vaccine
trials to date are numerous and include:
lack of empowerment, independent deci-
sion-making and education in some set-
tings; social isolation; discrimination; preg-
nancy and the potential effects of a candi-
date vaccine on a foetus; stigma associated
with high-risk behaviour; trial enrolment
criteria; and issues concerning confidential-
ity and informed consent. For instance, the
participation of a minor in a clinical trial
would require the parents’ or guardian’s
consent, and youth must fully understand
what receiving a candidate HIV vaccine
does or does not mean for their health.
Experts agreed that these obstacles could
and should be overcome because HIV vac-
cines need to be tested in a heterogeneous
population, particularly in those most in
need of vaccine. Vaccines for several infec-
tious diseases have shown varying levels of
efficacy in different gender, age and radical
or ethnic sub-groups. The 1998-2003 trial
Priority Medicines
Landmark report could influence the future
of medicines in europe and the world
Gaps in pharmaceutical research and innovation can be closed, says WHO report
Geneva – The World Health Organization
has released a groundbreaking report which
recommends ways in which pharmaceutical
research and innovation can best address
health needs and emerging threats in
Europe and the world.
Priority Medicines for Europe and the World,
commissioned by the Dutch Government as
current president of the European Union
(EU), identifies a priority list of medicines
for Europe and the rest of the world, taking
into account Europe’s ageing population,
the increasing burden of non-communica-
bel illness in developing countries and dis-
eases which persist in spite of the availibil-
ity of effective treatments. The report looks
at the gaps in research and innovation for
these medicines and provides specific poli-
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 102
cy recommendations on creating incentives
and closing those gaps.
At present, pharmaceutical research and
development are based on a market-driven
incentive system relying primarily on
patents and protected pricing as a prime
financing mechanism. As a result, a number
of health needs are left unaddressed.
The report identifies gaps for diseases for
which treatments do not exist, are inade-
quate or are not reaching patients. Threats
to public health such as antibacterial resis-
tance or pandemic influenza, for which pre-
sent treatments or preventive measures are
unlikely to be effective in the future, also
require immediate action.
“This report identifies health gaps and
potential solutions. It is particularly timely
for a continent where an ageing population
faces increasing health problems, and for a
world where old and new threats no longer
respect national borders,” said Dr. LEE
Jong-wook, Director-General of WHO
from the Ministerial Summit on Health
Research, taking place in Mexico.
In addition, the report addresses obstacles
where effective medicines could be better
delivered to the patient. It emphasizes fixed
dose combination medicines (medicines
which include more than one active ingre-
dient in one pill) as worthy of further
research and development. Finally, it looks
at particular groups such as children,
women and the elderly, who have frequent-
ly been neglected in the scientific or medi-
cine development process.
The 17 priority conditions identified by the
report are:
Future public health threats: infections
due to antibacterial resistance; pandemic
influenza;
Diseases for which better formulations
are required: cardiovascular disease (sec-
ondary prevention); diabetes; postpartum
haemorrhage, paediatric HIV/AIDS,
depression in the elderly and adolescents;
Diseases for which biomarkers are
absent: Alzheimer disease; osteoarthritis;
Neglected diseases or areas: tuberculosis;
malaria and other tropical infectious dis-
eases such as trypanosomiasis, leishmania-
sis and Buruli ulcer, HIV vaccine;
Diseases for which prevention is particu-
larly effective: chronic obstructive pul-
monary disease including smoking cessa-
tion; alcohol use disorders; alcoholic liver
diseases and alcohol dependency.
The report suggests that Europe can and
should play a global leadership role in pub-
lic health, as reflected by its history of
social services provision and social safety
nets for all citiziens. In many developing
countries, the poor are increasingly affected
by the chronic diseases that are widespread
in Europe, including cardiovascular dis-
ease, diabetes, tobacco-related diseases and
mental illnesses such as depression.
Moreover, the ten countries that joint the
EU in 2004 have additional public health
challenges.
For all number of diseases that effect peo-
ple in all members of the EU, no effective
and safe medicinal treatment is yet avail-
able (e.g. Alzheimer diseases and several
cancers). For some diseases, potentially
large markets exist for medicines (e.g.
breast cancer) and associated pharmaceuti-
cal research is likely to be intensive for cer-
tain therapeutic classes. For other cate-
gories of medicines, the number of patients
is low (e.g. cystic fibrosis) or the market-
driven pharmaceutical industry has failed to
pursue research and development (e.g. new
medicines for tuberculosis).
Innovative solutions
The report suggests that efforts to shorten
the medicine development process without
compromising patient safety would greatly
assist in promoting pharmaceutical innova-
tion. For instance, the EU could create and
support a broad research agenda through
which the European Agency for Evaluating
Medicines (EMEA), national regulatory
authorities, scientists, industry and the pub-
lic would critically review the regulatory
requirements within the medicine develop-
ment process for their relevance, costing,
and predictive value.
Health authorities are responsible for medi-
cines reimbursement decisions that aim to
ensure safe and effective treatment for all
patients, while reconciling this with bud-
getary constraints. Health and reimburse-
ment authorities and manufacturers should
agree on general principles for the evalua-
tion of future medicines. For example, the
EU Commission and national authorities
should support a research agenda on the
various methods of rewarding clinical per-
formance and linking prices to national
income levels. The report authors believe
that these measure will help encourage
industry to invest in the discovery of inno-
vative medicines that address priority
health care needs.
The report maintains that where the market
is strong and the problem is poor under-
standing of the basic biology of the disease,
investment in basic research and in faciliat-
ing innovation by the pharmaceutical
industry will be needed. Where the biology
is well understood but the market is weak,
public support for breaching the gap
between basic and clinical research – possi-
bly through public-private partnerships and
other not-for-profit development initiatives
– will be the preferred solution. Where the
biology is not well understood and there is
also a weak market, then biological
research can be supported while market
incentives are created for the pharmaceuti-
cal industry, through reducing barriers to
innovation and through improving reim-
bursement rewards.
The report points out that major pharma-
ceutical gaps have been closed in the past.
For example, until 1975 the main treatment
for severe peptic ulcer – a common ailment
– was surgery. Following a long period of
focused research in biological mechanisms
underlying ulcer disease, effective medical
treatments werde discovered. These break-
through discoveries, combined with the dis-
covery that most ulceration was caused by a
bacteria treatable with antibiotics, made
surgery unnecessary.
The recommendations contained in the
report could have a significant impact on
research innovation and policy, with sup-
port from Europan leaders. The report was
discussed further at a High Level Meeting
in the Hague on November 18th 2004.
World Health Organization
103
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Geneva – The first international standard
for a human genetic test has been approved
by the World Health Organization. Use of
the standard will help to improve the accu-
racy and quality of laboratory results world-
wide from a frequently used genetic test.
This test identifies a genetic predisposition
to thrombosis – a potentially life-threaten-
ing blood condition – and could therefore
enable people to take preventive measures.
“Establishment of the first international
standard for a genetic test is an important
milestone. Genetic testing procedures are
playing a vital and growing part in clinical
medicine. This new standard will help to
ensure that the tests are giving accurate
results worldwide,” said Dr. Davie Wood,
Coordinator of Quality Assurance and
Safety of Biologicals at WHO.
The newly established standard, formally
called an international Reference Panel,
relates to the testing of patients for a partic-
ular genetic mutation known as Factor V
Leiden. Discovered in 1994, this mutation
is one of the most common genetic risk fac-
tors for venous thrombosis (blood clot), and
is involved in 20–40% of all cases. Factor V
Leiden induces a defect in the natural anti-
coagulation system.
The test for Factor V Leiden is one of the
most frequent genetic tests carried out in
clinical laboratories. It determines the pres-
ence or absence of the mutation, which has
been shown to result in a seven-fold to 80-
fold higher risk of thrombosis depending on
whether the individual carries one or two
copies of the gene respectively.
The new standard was agreed at the 55th
session of one of WHO’s longest-standing
committees, the WHO Expert Committee on
Biological Standardization (WHO ECBS)
which met from 15 to 18 November in
Geneva. It is composed of ten global experts
from academia, industry and national regu-
latory authorities, as well as 25 advisors.
One of WHO’s key functions, specified in
its Constitution, is to develop, establish and
promote international standards with
respect to biological and other products.
WHO is the world authority on biological
standards, and has established more than
300 standards covering vaccines; blood
products; therapeutic biological products,
such as insulin; and diagnostic tests, such as
those that detect HIV in a blood product.
Researchers are currently investigating
whether or not there is a link between air
travel and deep vein thrombosis. This is one
example of a condition which may be more
likely as a result of the Factor V Leiden
mutation. Having information about their
genetic make-up could allow travellers at
risk to take additional precautions.
The standard for Factor V Leiden was devel-
oped by WHO partner and the leading inter-
national laboratory for biological standards,
the National Institute for Biological Standards
and Control (NIBSC) in the United Kingdom,
in collaboration with colleagues from the clin-
ical National Quality Assessment schemes
for Blood Coagulation and the Royal
Hallamshire Hospital in Sheffield, UK.
“This is an important step in genetic medi-
cine. I am delighted that the NIBSC has
taken the international lead in developing the
first WHO standard for a genetic test. This
will provide information on susceptibility to
venous thrombosis, and ultimately will
deliver clinical benefits for people at
increased risk of developing thrombosis,”
said Professor Gordon Duff, Chairman of the
NIBSC Board. NIBSC is currently develop-
ing several other new reference standards to
support testing for a range of other clinically
important genetic characteristics.
DNA-based genetic testing offers enor-
mous promise for improved disease man-
agement by giving doctors better informa-
tion about patients on which to base diagno-
sis and decisions about treatment or coun-
selling. It also offers the potential for better
targeting of therapies and drugs to those
patients most likely to benefit. Hundreds of
different genetic tests are currently available.
A recent study estimated that in the European
Union alone more than 700,000 genetic tests
were performed in 2002; and found that at
least 700 laboratories and 900 clinical centres
in Europe were carrying out genetic tests.1
Though the exact number is unknown, it is
likely that millions of genetic tests are being
carried out worldwide each year.
Setting standards is particularly critical as
genetic testing has expanded to more and
more laboratories throughout the world.
Genetic testing must be done consistently
in all laboratories around the world and to
high standards in order to give confidence
in the results.
A standard for a biological product is essen-
tially a yardstick (either on paper or in an
ampoule, in which there is a specially pre-
pared reference material) which enables
laboratories around the world to compare
results. The work of the WHO Expert
Committee on Biological Standardization
contributes to global public health in a fun-
damental way since the written guidance
and reference preparations established on
its recommendations define international
technical specifications for the quality and
safety of biological medicines and in vitro
diagnostic procedures.
Once a WHO collaborating laboratory
physically creates a standard, it is typically
evaluated by 15 other top laboratories. The
WHO ECBS reviews all the laboratory data
and decides to approve or not the proposed
standard for international use. The rigorous
assessment of the standard for the Factor V
Leiden genetic test was carried out by an
international panel of investigators in con-
junction with the International Society on
Thrombosis and Hemostasis (ISTH).
The announcement of the first international
standard for the genetic diagnosis of the
Factor V Leiden mutation is a significant
step forward in the assurance of high quali-
ty genetic testing. In the future, the WHO
ECBS will likely approve standards for
other genetic tests, the increasing use of
which will enable prevention and early
treatment of genetic disorders, improving
quality of life.
1 Ibarreta, D., Elles, R., Cassisman, J-J.,
Rodriguez-Cerezo, E., and Dequeker, E.
Towards quality assurance and harmoniza-
tion of genetic testing services in the
European Union. Nature Biotechnology, 22,
1230–1235 (October 2004).
Common Genetic Test
First standard adopted by WHO
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World Health Organization
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Geneva – The World Health Organization
is awarding a US$ 1 million contract to a
global consortium of people living with
HIV/AIDS and treatment activists to help
prepare people living with HIV/AIDS
(PLWHA) for antiretroviral (ART).
Following a competitive process, the
Collaborative Fund for HIV Treatment
Preparedness consortium – a programme
created in 2003 to channel funds for com-
munity-based education, managed by the
US-based organization Tides Foundation –
was awarded the contract through WHO’s
‘Preparing for Treatment’ programme.
The WHO initiative supports community-
based treatment preparedness activities as
part of the drive to increase access to treat-
ment and prevention in line the “3 by 5”
target to get three million people living
with AIDS on antiretroviral treatment by
the end of 2005.
“People living with HIV/AIDS need to
know about antiretroviral medicines. Those
who currently have access to treatment need
this knowledge to be informed about their
treatment and to ensure they know how and
when to take their medicines. Those without
access need this knowledge in order to
become active in advocating for scale up in
their countries,” said Dr. LEE Jong-wook,
WHO Director-General.
In implementing the million dollar grant,
Tides Foundation-Collaborative Fund is
supporting more than 30 networks of
PLWHA around the world in treatment pre-
paredness activities, including treatment lit-
eracy projects and civil society advocacy
initiatives.
The Collaborative Fund distributes funding
to regional networks of people living with
HIV/AIDS who then establish grants initia-
tives and tendering processes at the commu-
nity level. In each of these regions, work-
shops are already under way to help devel-
op the treatment preparedness agenda.
Supporting the ‘Preparing for Treatment
Programme’, UNAIDS has contributed
over US$ 100,000 over the past year to
these regional meetings and will be provid-
ing a ‘best practices’ document based on
experiences of programmes in late 2005.
“UNAIDS is pleased to support WHO in
this innovative movement to expand treat-
ment access. Providing people living with
HIV with the necessary tools to access
treatment is vital to improving their quality
of life and engaging them in expanding
access to treatment and care,” said Dr. Peter
Piot, UNAIDS Executive Dirctor.
“This proposal ensures the participation of
people living with HIV/AIDS in all aspects of
the programme and at all levels of decision-
making and activity,” said Dr. Jim Yong Kim,
Director of the HIV Department at WHO.
Treatment preparedness activities aim to give
people on or in need of antiretroviral treat-
ment easy-to-understand information about
issues such as how HIV works in the body,
HIV testing, opportunistic infections, the dif-
ferent treatment types available and how they
work, how to take treatment correctly and the
support services that are available.
This information can be conveyed in many
ways, including through workshops, publica-
tions and other activities designed to educate
communities about obstacles to accessing
treatment and enable them to contribute to
local treatment policy development and
advocacy efforts. All treatment preparedness
activities aim to ensure the meaningful
involvement of people living with AIDS and
their communities in decisions regarding
their care, including the distribution of
resources.
“This is perhaps one of the greatest UN-led
examples of implementation of the GIPA
(Greater Involvement of People with AIDS)
principle [established in 1994]. The con-
tract award shows a commitment to a com-
munity-driven model, relying on the exper-
tise of people living with AIDS and com-
munity-based groups to developing projects
they need to do. It also acknowledges that
treatment preparedness is as important a
component of the “3 by 5” success as is
receiving the drugs”, said David Barr,
Senior Philanthropic Advisor for Tides
Foundation.
In addition to WHO, the Collaborative Fund
is supported by a growing number of donors
from around the world including Rockefeller
Foundation, Ford Foundation, Open Society
Institute, the Stephen Lewis Foundation, and
AIDS Fonds Netherlands. To date, US$ 3.4
million has been raised to support activities
through the end of 2005 and fundraising for
continued activities is on-going.
The concept of treatment preparedness was
defined at the international treatment pre-
paredness summit, held in Cape Town,
South Africa in March 2003 and was based
originally on examples of activists prepar-
ing for their own treatment. The summit led
to the creation of the Collaborative Fund to
generate funding for such activities.
WHO’s ‘Preparing for Treatment
Programme’ was initiated in July 2004 when
WHO called for applicants with global reach
and local capacity in the world’s most affect-
ed countries to submit tenders to design and
operate programmes. With over 140
enquiries, some 30 tenders were reviewed by
a WHO panel before the award of the contract
to Tides Foundation-Collaborative Fund.
“Making this happen has been a dream for
WHO and underlines the recognition that
the future of health belongs as much in the
hands of those affected as those who care
for them. Treatment preparedness is key to
“3 by 5” and a first instalment towards
reaching universal access for all who need
it,” said Dr. Kim.
The million dollar contract is the first of
what WHO hopes will be an ongoing
process within the Preparing for Treatment
Programme with the aim of supporting addi-
tional community-based treatment prepared-
ness activities as funding becomes available.
The Tides Foundation has a long history of
administering community-based grant pro-
Aids
Who awards million dollar contract
for global treatment preparedness activities
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 105
WMA Secretary General
106
grammes in countries worldwide including
Brazil, Afghanistan, Sierra Leone, Peru,
Russia, Ukraine and Croatia, as well as
across the United States.The Foundation
manages over 300 donor advised funds and
over the past decade has administered more
than $235 million in grants to not-for-profit
organizations. To help countries achieve this
goal, WHO provides normative guidance
and direct technical support in country.
The World Health Organization aims to
help people attain the highest possible level
of health by providing leadership on nor-
mative issues and technical assistance to its
192 Member States. In 2003, WHO joined
UNAIDS in declaring the lack of
HIV/AIDS treatment to be a global public
health emergency and jointly launched the
“3 by 5” target to get 3 million people on
treatment by 2005. To help countries
achieve this goal, WHO provides norma-
tive guidance and direct technical support
in country.
During February 2005 I will leave the office
of WMA Secretary General. After eights
years of service to the WMA and the med-
ical profession, I can only say that it was a
tremendous privilege and an outstanding
experience. May I use this opportunity to
thank you all from the bottom of my heart
for your support and care during my tenure.
At the same time I would like to express
my sincere congratulations to my succes-
sor, Dr. Otmar Kloiber from Germany.
Otmar has a wealth of experience and the
WMA is fortunate to have such a champion
of medical ethics and sound health care
policy join our team.
The last four months have been a particular-
ly impressive period in the existence of the
WMA, and I would like to mention three
reasons why:
WMA General Assembly
in Tokyo, Japan
Medical leaders from around fifty countries
of the world gathered, during October 2004,
in the Imperial Hotel, Tokyo for our annual
Assembly. Most fittingly, it was the
Emperor and Empress of Japan themselves
who wished to welcome the leaders to this
historic occasion. Having started the meet-
ing in such an auspicious way, the rest of
the meeting followed suit with high quality
discussions and content. The Japan Medical
Association excelled in developing a world-
class scientific session on the relationship
between advanced medical technology and
medicine. Dr. Yank Coble was inaugurated
as the new WMA President and had the
opportunity to officially launch the “Caring
Physicians of the World” project (www.car-
ingphysicians.info). This is the most ambi-
tious Presidential project to date, with the
development of a book on examples of
physicians from around the world who
vividly display the traditional values of
medicine – science, ethics and care. In addi-
tion, he will be visiting most of the WMA
Member Associatons during regional meet-
ings planned for 2005.
World Ocean Forum
in New York, USA
The WMA identified the important link
between water and health as one of the pri-
ority areas for the organization some 3
years ago. It was decided to develop a more
comprehensive policy on this subject,
which was completed when the WMA
General Assembly in Tokyo adopted the
WMA Statement on Water and Health
(www.wma.net – see “Policy”). In addi-
tion, a two-day symposium was planned
with the World Ocean Observatory to fur-
From the Secretary General’s Desk
ther investigate and debate some of the
more pressing water and ocean issues such
as sanitation, ocean preservation, the bio-
medical potential of the oceans and access
to water. Several high- level leaders attend-
ed the event, including the Executive
Director of the World Health Organization
tasked with Environmental Health, Dr.
Kerstin Leitner. It is tragic and prophetic
that this event preceded the tsunami disas-
ter. In the aftermath of the tragedy, all the
water- and ocean-related issues discussed
during the meeting came into play in the
most dramatic fashion. Please read the full
report on the symposium, including slides
and speeches, at www.worldoceanfo-
rum.org.
Launch of the WMA Ethics
Manual
It is incredible to think that despite the fact
that medical ethics is more than 2000 years
old, there is no one universally used train-
ing manual for the teaching of medical
ethics. The WMA had adopted a Statement
on the Inclusion of Medical Ethics and
Human Rights in the Curriculum of
Medical Schools Worldwide (www.
wma.net – see “Policy”) during 1999, and
it was therefore quite fitting that the WMA
develop a simple and concise ethics train-
ing manual for use by medical students and
physicians. The WMA Director of Ethics,
Dr. John Williams, did a splendid job in
putting this manual together along with a
committed team of advisors. At a launch
event in January 2005, the first edition of
the manual was released to the press and
some partner organizations. The launch
was a huge success, as we are confident the
distribution and use of the manual will be.
The manual can be downloaded from the
WMA website at www.wma.net.
Looking at the huge strides the WMA has
made over the last quarter, it bodes well for
the future growth and expansion of the
WMA and the profession. It gives me great
joy to see this happen as I leave the WMA
stage. Thank you and au revoir.
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 106
WMA Secretary General
107
The meeting was opened by the President,
Dr. James Appleyard, who welcomed the
Mr. Assodo Chief Secretary of the Cabinet
(representing the Prime Minister who was
abroad), the Minster of Health and the
Governor of Tokyo.
The Secretary General, Dr. Delon Human
introduced the delegations of the National
Association Members of the WMA, and the
official observers from other international
organisations.
Dr. Uematsu, President of the Japanese
Medical Association expressed his pleasure
at being able to welcome the members of the
WMA to Tokyo once again after 29 years.
He was delighted to see 500 people present
during the Assembly and considered that
there had been very valuable exchanges of
information at the Scientific Sessions during
which various aspects of Advanced Medical
Technology had been discussed, including
Medical Ethics, IT and Healthcare. There
was much valuable information which
would contribute to the advance of World
Peace. The JAMA looked forward to suc-
cessful conclusions at the end of the
Assembly. Referring to the earthquake the
previous day and to the tornado to be
expected later, he expressed the view that,
no doubt, these were part of the global
weather changes.
The President then thanked Dr. Uematsu
and the Japanese Medical Association for
their excellent organisation and hospital
during the Assembly. He then introduced
Mr. Assodo who extended the good wishes
of the Prime Minister who had planned to
be present but had had to travel to Vietnam.
He informed the assembly that the
approaching Typhoon was unusually large
and warned delegates not to leave the hotel.
However, he then cheered them with news
of expected good weather the next day.
Japan had been challenged by new
infections such as SARS and AIDS.
Expectations of the population were rising.
On the other hand, after referring to the
increasing role of the Japanese Medical
Association, he drew attention to the rise in
life expectancy between 1997 and 2003
from 76,68 to 85. Infant mortality had fall-
en from 1 to 3 per 10.000. All of these were
due to the efforts of the nation and of the
doctors. Health Care reform was a universal
challenge, notably with the increase in the
elderly population and the diminishing birth
rate, also the economic and environmental
environments. Safety is a key to health care.
The discussions of the Assembly on
Medical Healthcare Technology an Medical
Ethics was particularly timely. The
Japanese were trying to introduce safety of
health technology into health care. He
hoped that the outcome of the meeting
would enlarge the understanding of these
issues. He felt that the World Medical
Association is an organisation which con-
tributes to the world’s good future.
Mr. Ossuchio the Minister of Health, congrat-
ulated the Assembly. WMA had a fifty year
history of engagement in major problems
affecting health care globally. The WMA
works with the World Health Organisation
and other international organisations to
enhance the health of the peoples of the
world.
In Japan, Healthcare Services and advanced
technology have improved the health of the
people. The major challenges were Safety,
Quality, and higher efficiency in Health Care,
he looked forward to benefiting from the con-
clusions of the discussions on Health Care
Technology. Finally he also expressed his
thanks to the Japanese Medical Association
for their work in organising this meeting.
The governor of Tokyo Mr. Ishiharo pointed
out that medicine in Japan was referred to as
Western Medicine. However there was also a
school of Oriental Medicine which, contrary
to belief, was a schematic system of care.
Recently there had been an evaluation of this
type of medicine by members of the
Japanese Medical Association and now
Acupuncture had been included in the
Japanese Healthcare system. He personally
values the work of experts in acupuncture
which, he noted, was appreciated also in the
USA. He quoted various examples of natur-
opathy applied successfully to various condi-
tions ranging from obstetric complications to
diseases of the liver and of the kidney. He
specifically referred to CHI and to
Chiropractic and stressed that they were not
Sharmatic. It was important that there should
be co-operation between both systems of
medicine. He urged physicians to be gener-
ous in their approach to oriental medicine
and closed by referring to the fact that the
Japanese enjoyed the greatest longevity in
the world.
Dr. Blachar, Chairman of Council,
expressed the appreciation of the Assembly
to the three high representatives of govern-
ment and authority in Japan for kindly
attending and addressing the Assembly. He
then paid tribute to Dr. James Appleyard, the
retiring 54th President who had served the
Assocation with great distinction. Dr.
Appleyard had many accomplishments.
Personally Dr. Blachar had enjoyed the
association with a fellow paediatrician who
also had three children. Dr. Appleyard had
brought to fruition the Declaration if Ottawa
on the Rights of the Child and had consis-
tently lobbied for childrens’ rights to health
and for child health services. In addition he
had promoted Oral health and had supported
the ICRC project on notification of torture
and the treatment of torture victims. He had
been chairman of the Ethics committee
1995-99, and oversaw the Declaration of
Helsinki changes, speaking in New York,
The Ceremonial session of the World Medical
Association General Assembly was held in
The Imperial Hotel, Tokyo 9th October 2004
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 107
World Medical Association
108
Japan, Malta, Uganda and many other
places.
Dr. Appleyard had enhanced the image of
WMA. He had been most a helpful person
to work with and had greatly assisted the
Chairman in promoting the changes within
the organisation. Dr. Blachar looked for-
ward to his playing a further role in the
future.
Dr Appleyard in response expressed his
enjoyment of the work in his past year as
President. —-(see text of speech page 95) Dr.
Blachar then presented Dr. Appleyard with
the Past President’s medal and conferred on
him lifelong membership of the WMA.
The Secretary General then invited the
incoming President Dr. Coble, to take the
Presidential Oath, following which he was
invested as President and delivered his
Presidential address (see page 86).
Dr. Moon, retiring Vice Chair of Council
then briefly addressed the Assembly
expressing his pleasure at being invited to
make some closing remarks. The WMA was
founded in 1947 by a group of idealistic
physicians, to build something better out of
the ashes of World War II. WMA has done
this by issuing declarations over the years
and helping to define Medical Ethics and
standards in a changing world. It had worked
to promote idealistic ideas and continue the
ethical tradition of the medical profession.
WMA now includes 84 National Medical
Associations and millions of doctors. Huge
strides have been made in health care and in
human rights. For all. Tokyo is very memo-
rable because Advanced Medical
Technology and related issues promise
together with IT to improve global health.
He could think of no better way to address
the agenda of global health care and Health
for All. He expressed his appreciation of Dr.
Uematsu and the leaders of JAMA for the
hospitality enjoyed by all during the
Assembly. Thanks to this he had been able to
witness the Tokyo Assembly as a great occa-
sion. He gave a special tribute to the work of
Dr. Tsuboi for his leadership over many
years to millions of doctors. Finally he paid
a tribute to Dr. Delon Human for his work
over the past seven years, for his tolerance
and patience and devotion to the WMA. He
thanked him and expressed the best wishes
of everyone his future. The audience rose
and endorsed this appreciation.
Dr. Coble thanked Dr. Moon for his address
and closed the meeting.
Dr. Begenholm reported that the Credential’s
Committee had verified that there were 35
Members present who were in good stand-
ing. This amounted to a total of 87 votes, and
that 65 would be necessary to adopt any pro-
posal relating to Medical Ethics.
After the Annual Report of Council and the
Standing Orders had been adopted, Dr.
Letlape (South Africa) was unanimously
elected President-elect.
Dr. Letlape expressing his appreciation of
the responsibility of this office and thanking
the Assembly, said this was the time of the
new President and his remarks would be
brief. He referred first to the very few
Junior doctors present and speculated that if
the age of the President was linked to life
expectancy, for South Africa the age would
be 39. He intended to carry forward the
work of Drs. Millymakki, Appleyard and
Coble, not only in advocating “patients
first” but also “patients’ rights”. This would
fit the theme of “Access to Medical Care”
in Chile 2005 and would be most appropri-
ate. There was inequality in South Africa,
where, with finite resources, privatisation
was a key issue.
Dr. Otmar Kloiber, Secretary General-
elect, then addressed the Assembly, thank-
ing Council and those who supported him
for the trust they had placed in him. He
Meeting of the WMA General Assembly,
Tokyo, 9th October 2004
referred to earlier remarks about the
meaning of service, namely “helping doc-
tors doing a good job and to save our
patients”. He thanked Dr. Delon Human
for his work in restructuring the secretari-
at, and opening new networks and new
avenues to explore. He was proud to be
here also as a successor to Dr. Andre
Wynen who had been designated
Secretary General 29 years ago in Tokyo.
For Dr. Kloiber the commitment of the
representative members of the Assembly
was most important and gives power to
the WMA. National Medical
Associations’ commitment is what counts.
If the members did not carry this out,
WMA would be nothing. His primary job
was to ask for this and to service their
commitment. The first priority was the
Dues, and the second was to participate
and work in the WMA. Continuing the
reconstruction was dependant on mem-
bers’ support and participation leading to a
strong, visible organisation for the future.
The Assembly then adopted the following:
• A note of clarification on paragraph 30
of the Helsinki Declaration (see 95)
• A Statement on Physicians and
Commercial Enterprises (see 91)
• A statement on Water and Health
• Amendment to the Regulations in times
of Armed Conflict (see 92)
• A statement on the World Federation of
Medical Education
• A statement on Health Emergencies
Communication and Co-ordination (see 93)
An Addition to Section M of the WMA
Schedule of Functions and Operation
Policies also was adopted.
Applications from the Vietnamese Medical
Association and the Estonian Medical
Association were unanimously approved
with acclamation.
The Assembly also approved the themes of
the 2005 Santiago General Assembly scien-
tific meeting “Health Care system reform”
and “Access to Medicine”.
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 108
Approval was also given for the meeting in
2008 to take place in Seoul, in the anniver-
sary year of the Seoul Medical Association.
Following the Treasurer’s report, the
Financial Statement for the year 2003 and
the budget were adopted.
The report of the Associates meeting, which
included their resolution concerning Enfor-
ced Sterilisation, was approved.
The Assembly then proceeded
to an open session
The first speaker from the Frauenarzte-
Verlag (Germany), referring to the lack of
representation of women both in the
Assembly and on the platform, pleaded for
the enlistment of more women doctors who
care about the medical profession and
patients. It should be possible for the organ-
isations of women doctors and the WMA to
work together.
Dr. Arumugam (Malaya) was concerned
that the topic of “Oriental medicine” had
been raised during the formal ceremonial
session of the Assembly and asked whether
WMA had any policy on this. Ministers did
not know whether or not medically-quali-
fied doctors should be involved in this. He
referred to “over the counter” sales and tra-
ditional medicine treatments now compris-
ing 50% more than Western medical activi-
ty in the East. Dr. Blachar responding
asked whether this was controllable. He felt
that WMA should have a policy and hoped
that an NMA would produce a background
paper for discussion. Dr. Human, the
Secretary General, hoped that the Malay
Medical Association would send a consul-
tation paper. He commented that WMA had
a position on this. There were no controls
on this type of medicine. He would send a
paper to the MMA. Then Dr. Haikerwal
(Australia) informed the meeting that legis-
lation governing this issue in Victoria,
Australia was the first in the world.
Dr. Adu-Gyanfi (Ghana) spoke about the
importance of student exchanges and also,
in relation to human resources, mentioned
that while in 1969 there were 5500 doctors
for a population of 7 million, now there were
only 6500 for a population of 20 million.
Dr. Millymakki (Past President) drew
attention to the absence of delegates from
Turkey, although they sent their greetings.
Recently there had been three strikes by
Turkish doctors, respectively of one, one,
and two days duration, during which doc-
tors saw all emergencies and any sick chil-
dren. The strike related to the need for more
financing of health care. She also reported
that 85 doctors were in court, including
members of the doctors’ Chamber. Doctors,
who were classified as civil servants, had
the right to be members of a Union, but not
the right to strike. NMAs should be in touch
with the Turkish Medical Association to
assist their colleagues. Dr. Human reported
that he had spoken to the Vice-President of
the Turkish Medical Association to give
support to their leaders. He had written to
the Ministers of Health, of Justice and of
Foreign Affairs concerning the unfair trial of
85 doctors, including their leaders. There
was a conference of the Turkish doctors dur-
ing this week. The WMA would try to send
a WMA leader to be present at the trial.
Dr. Montgomery (Germany) referring to
the comments from Ghana, said that doc-
tors’ workload in much of the world was
rising to such an extent that some could
work no more. There was a problem con-
cerning the Worktime Directive in the EU,
and in the USA doctors were working 90
hours a week. WMA could define a safe-
guard mechanism when the workload was
too great. The Secretary General said this
suggestion was useful and asked the BAK to
produce paper on physician “burn-out” etc.
In response to a question from Dr. Masson
concerning the doctor and other health
workers condemned to death in Libya, Dr.
Human reported that the WMA and ICN
had met the Libyan delegation during the
World Health Assembly. They received a
poor reception from the delegates who
despite offering to send them a reply, had not
responded so far despite three reminders. As
an NGO, WMA would continue to seek dis-
cussions with the government.
Dr. Chan Yee Shing (Hong Kong)
observed that Chinese Medicine is not
alternative medicine, it is mainstream.
There is a need to deal with question of its
recognition and registration. There is a
problem concerning the difficulties with
standardisation. There were major medico-
legal problems. For example in the case of
coronary heart disease treated under both
western and eastern medicine, when there is
a lawsuit how can the court rules on the
problem. In the scientific discussion of the
previous day the medical profession
seemed to be moving in the direction of
Medical Technology. Physicians were
working as members of a team. If the two
professions were to be treated equally this
was very difficult as there was no scientific
basis for Traditional Medicine. He won-
dered whether WMA could help.
Dr. Appleyard (the President), referring to
the problem raised by Ghana mentioned the
importance of links with Medical
Institutions in the West to help developing
countries. He cited as an example a Surgeon
from Germany who went for three months
to work in a hospital in which there was no
surgeon. Such a three months period could
not only provide much needed assistance
but also a valuable experience. Other alter-
natives were Fellowships linked with
Medical Academic Institutions, or for indi-
vidual doctors just to go and assist. He urged
National Medical Associations to take this
message back to their own countries and
stressed the importance of such links being
established as between equal partners.
Dr. Harma from the International
Rehabilitation Council for Torture Victims,
referred to the real problem for doctors who
have been treating victims of torture in
Turkey. The work of the WMA both in con-
nection with the Tokyo declaration and
more recently with the new initiative on
training doctors in connection with the
Istanbul Protocol was very valuable. He
also referred to the recent Lancet article on
World Medical Association
109
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 109
Regional & NMA News
110
possible involvement of physicians in
Middle Eastern prisons and the Norwegian
Medical Association/WMA programme of
training for prison doctors and others in
Human Rights. IRCT sought a WMA part-
nership.
Dr. Blachar (chairman of Council) spoke
of the visits to Morocco, Uganda and
Georgia in connection with the
Istanbul/EU project of training in how to
recognise victims of torture.
Dr Grewin, (President of CPME), had
written to the relevant EU Commissioner
concerning the Turkish situation.
Dr. Letlape (South Africa) informed the
Assembly that in South Africa legislation
recognising traditional medicine is produc-
ing problems, as there is competition for
limited resources, which were already in
great difficulty. One part of traditional med-
icine is spiritual – there was a family tradi-
tion of training its members who were initi-
ated into healing. If patients don’t recover
the blame lay with their ancestors!
A speaker from the Thai delegation report-
ed that they had 30,000 doctors for a popu-
lation of 63 million people. Herbal medi-
cine has been known for 200 years and does
work in a limited context. Currently the
Ministry of Health and the University were
conducting a trial under the Professor of
Medicine from Hong Kong. He pointed out
that because of the very few physicians in
rural areas the population has to use
Traditional Medicine.
The Vietnamese delegation commented that
the discussion was really about oriental
medicine. There was a need for a careful
look at the evidence. If the evidence is pos-
itive we should accept it.
Dr. Blachar, summing up, welcomed the
discussion. There was clearly a need to look
into the problems and he welcomed the
Malayan lead.
After a presentation by the Chilean delega-
tion in preparation for next year’s
Assembly, Dr. Blachar thanked the
Japanese Medical Association for their
great organisation and hospitality in the
organisation of the Assembly, and extend-
ed his thanks to the Council, the Secretary
General and to the staff of WMA.
By Donald J. Palmisano, MD, JD
Immediate Past President,
American Medical Association
The United States is not alone in con-
fronting the deleterious effects of overzeal-
ous personal injury lawyers who seek mil-
lion-dollar awards and settlements that
result in scores of physicians restricting their
services and patients losing access to care.
Reports from the United Kingdom state
how negligence claims against physicians
are rising1 as are the expected payouts –
E150m by 20102. In Australia, increased
concern has led to “several of the country’s
states and territories taking action to limit
damages for non-economic loss and cap
economic loss,”3 among other measures.
And in New Zealand, health officials are
alarmed by the large increases in payouts.
In Wales, for example, claims have
remained relatively steady, but payouts
have seen from £63.3 million to £117.8 mil-
lion from 1999-2000 to 2002-20034.
In the United States, the costs are even more
severe. Medical liability tort costs have
increased from $9.5 billion in 1991 to more
than $21 billion by 20015. But rather than
the money going to compensate injured par-
ties, the U.S. tort system is so grossly inef-
Regional & NMA News
Patients’Access To Care At Risk With
America’s Broken Medical Liability System
ficient that only 22 cents in the dollar actu-
ally goes toward compensating those
injured for economic losses, and 24 cents
goes toward non-economic damages6.
Consider, too, that in most jurisdictions,
personal injury lawyers can receive as
much as 50 percent of a jury award, and it
becomes more clear why personal injury
lawyers fight tooth-and-nail to defeat rea-
sonable measures at limiting non-economic
damages in state legislatures and the U.S.
Congress. The U.S. medical liability tort sys-
tem is the personal injury lawyers’ cash cow.
The bitterness of the dispute can be traced
directly to personal injury lawyers’ desire
to maintain the status quo of a civil justice
system where multimillion-dollar jury
awards benefit a very few, but have nega-
tive ripple effects that affect many.
Blockbuster medical liability cases in 2003
in the United States have included verdicts
and settlements of $112 million, $70 mil-
lion, $50 million, $40.4 million and 10 that
were $20 million or more7.
The broken system becomes obvious when
you consider that 70 percent of all cases
filed against physicians are closed without
any payment8. As a surgeon, I don’t operate
on demand. There must be valid indica-
tions. And surgeons get instant peer review.
Every appendix I remove for the preopera-
tive diagnosis of appendicitis is examined
by a pathologist. If it was found that 70
percent of my operations were on normal
appendices, I would not be allowed to oper-
ate. Shouldn’t attorneys also be subject to
peer review for the cases they file? Why is
that personal injury attorneys are not held
to a similar standard? Why is that these
attorneys rarely – if ever – sanctioned for
filing a suit without merit?
This lack of accountability is very expen-
sive. Even though 70 percent of claims are
dropped or dismissed, they still incur legal
costs that average $16,743. Expense costs
for settled claims average $39,891 and
claims in which the defendant wins at trial,
$85,718.9 Now consider that on any given
day, there are 125,000 suits active in the
U.S. court system, and the costs grow
exponentially.
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 110
Snapshot of a Crisis
There are 20 states which the AMA believes
are in a full-blown medical liability crisis10.
We define this crisis after careful analysis
of several key factors, including:
• The magnitude of patients losing access
to health care.
• What type of medical liability reform
legislation currently exists in a state – and
for how long the reforms have been in
place.
• The actions of a state court system to
uphold or overturn medical liability
reforms.
• The affordability and availability of pro-
fessional liability insurance.
• The actions of a state’s legal community,
particularly the trend of increasing fre-
quency and severity of jury awards.
Medical liability reform has been the
AMA’s top legislative priority for several
years. Our fight has been on two simultane-
ous fronts: namely the U.S. Congress and
the state legislatures throughout the coun-
try. We also have supported state medical
societies in their efforts to protect existing
reforms before state supreme courts11.
Unfortunately, the U.S. Congress and state
legislatures have become the battlegrounds
for deciding whether patients will have
access to care. Because of a runaway legal
systems, patients have suffered as physi-
cians have been forced to relocate, retire
early, or restrict their services – such as
delivering babies or performing trauma
surgery12.
In my travels across the United States, I
have personally spoken with scores of
physicians who have given up part of their
practice because of excessive lawsuits and
skyrocketing liability insurance premiums.
It is distressing to hear a young paediatric
specialist tell the story of how he moved to
the Mississippi Delta as part of “a calling”
to treat rural patients, but he was forced to
leave the state after being sued by patients
who did not even realize they were suing
him. One patient who hoped to earn a few
thousand dollars said “I’m kind of upset. I
do not want him leaving because of all the
suits. If we run off all the doctors, what are
the people gonna do?”13
It is even more distressing to be speaking to
a group of America’s top surgeons about
this crisis and learn from a young surgeon
that he “understood the crisis all too well
because he recently lost his son because
there was no neurosurgeon available.”
Mississippi surgeon John Lucas, III, MD,
told me that his son was in a car accident
and needed immediate neurosurgical inter-
vention, but the area’s neurosurgeons had
already either quit doing head trauma cases
or had moved away. His son had a cor-
rectible problem if immediate attention by a
neurosurgeon could be given. Dr. Lucas did
everything he could to expedite the transfer
and find a neurosurgeon. Unfortunately his
son John Lucas IV died despite the subse-
quent transfer.
A Solution Exists
Experience tells us that there are a few
states that have had long-term medical lia-
bility reforms: California, Colorado,
Indiana, Louisiana, New Mexico and
Wisconsin. They all have in common a rea-
sonable limit on damages. California, in
particular, places a $250,000 limit on non-
economic damages, and there is no limit for
economic damages. If a patient is harmed
by negligence, the AMA strongly believes
that the patient should be able to receive
fair and quick compensation. The model
the AMA has advocated for the United
States Congress to pass into law is the
California model which gives all medical
expenses, lost wages and benefits, future
wages and benefits, child care costs and
more, but limits non-economic damages to
$250,000. Without a proven performer such
as the California $250,000 limit on non-
economic damages, the system breaks
down. The majority of individuals in the
United States House of Representatives and
the Senate as well as President Bush favor
such a law but a minority of Senators fili-
buster it and currently there are not the nec-
essary 60 votes to overcome the filibuster.
California’s reasonable reforms also
include limits on attorney contingency fees,
allocating responsibility for damages fairly,
providing for periodic payment of damages
over time, and more. California’s law – for-
mally known as the Medical Injury
Compensation and Reform Act (MICRA) –
was enacted in 1975. Between 1976 and
2002, medical liability insurance rates have
increased in the United States by 750 per-
cent. In California, they only have
increased 245 percent. MICRA is the rea-
son why an obstetrician pays about $69,000
per year for professional liability insurance
while the same physician would pay more
than $277,000 per year in Southern Florida,
which does not have MICRA-style reforms.
MICRA provides the predictability and sta-
bility for the liability insurance market that
moderates physicians’ insurance rates and
protects patients’ access to care.14
Recent State Actions Cause
for Optimism
In the recent November elections, four
states had constitutional ballot measures
regarding different medical liability
reforms. In each case, the AMA stood side-
by-side with our state medical societies to
present the facts. In each case, our opposi-
tion tried to suggest that there was no need
for reform, that the status quo worked just
fine to protect patients.
In Florida, where women have been forced
to wait as long as six months for a mammo-
gram because radiologists are scared to read
them, the physicians won a great victory.
Despite personal injury lawyers and their
supporters spending an estimated $24 mil-
lion, voters enacted new limits on contin-
gency fees. Now, patients will be assured to
receive at least 70 percent of the first
$250,000 of a jury award; and 90 percent of
any amount more than $250,000.
In Nevada, where Jim Lawson died in cir-
cumstances similar to Dr. Lucas’ son, and
scores of women searched for months to
find a doctor to deliver their babies, the
medical community also had a great victo-
ry when voters amended the state constitu-
tion to eliminate all exceptions to the state’s
$350,000 limit on non-economic damages.
Previously, a crafty personal injury lawyer
Regional & NMA News
111
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 111
could use rhetorical arguments to circum-
vent the cap.
In Oregon – despite the fact that more than 40
percent of the state’s neurosurgeons and near-
ly one quarter of its obstetricians have
already stopped providing certain services or
will soon do so – voters narrowly defeated
(50.7 percent to 49.3 percent) a measure that
would have restored a $500,000 limit on non-
economic damages. The AMA is deeply con-
cerned Oregon’s crisis will become worse.
And in Wyoming, where rural health care is
the norm, the loss of even one physician can
have negative consequences. But despite
widespread examples of physicians restricting
their practices and patients being forced to
drive an hour or more to find care, voters nar-
rowly defeated a measure designed to allow
the legislature to enact a limit on non-eco-
nomic damages. However, voters did approve
a measure that could lead to legislation enact-
ing medical review panels to weed out the
frivolous cases currently choking the system.
Clearly, these results are mixed, but they
show forward momentum, building on the
outstanding win in Texas in 2003 where the
legislature passed reforms and the citizens
voted to change the state constitution to be
certain the new law would allow caps on
non-economic damages. Since enactment of
the Texas law, the largest insurer of physi-
cians in Texas lowered the medical liability
premiums 17%. The AMA plans on carrying
that momentum into 2005. We will continue
to work with our champions in Washington,
D.C., as well as in the halls of state legisla-
tures across the country. We stand ready to
support our international colleagues in their
efforts as well, including the efforts to enact
patient safety legislation akin to the success-
ful Aviation Safety Reporting System of
voluntary confidential reporting of errors or
“near-misses” for review by experts, with
feedback for a system change to enhance
safety and then communicate the lesson
learned to all in a “no shame, no blame” de-
identified manner. Such a proposed law,
entitled the Patient Safety and Quality
Improvement Act, has passed both the
House and Senate in the United States
Congress but it is questionable whether it
will get out of the conference committee
during the few days left in the 2003-2004
Congress. We also continue to support the
National Patient Safety Foundation (NPSF)
that we founded with others. To date we
have contributed $7.3 million to it and are
very proud of its extensive patient safety
bibliography and teaching modules.15
In my 40+ years as a physician, I have wit-
nessed the miracles of organ transplants, vac-
cines, chemotherapy, and more. Today, we
can treat birth defects with the baby still in the
mother’s womb. We can perform microsurg-
eries on the brain. We can re-attach severed
limbs. Tomorrow holds great promise here in
the United States and abroad, but we must
safeguard our future. The rising threat of
unchecked lawsuits and out-of-control costs
threatens us all, which is why we must share
the commitment to be relentless in the fight to
enact reasonable reforms that protect patients’
access to the courtrooms without sacrificing
our patients’ access to medical care.
1. “Hospital awards bill to cost E400m,”
The Sunday Tribune, Dec. 7, 2003.
2. Ibid
3. “Liability insurance: a global concern,”
Insurance Day, Sept. 9, 2003.
4. “Claims now cost NHS trust more,”
South Wales Evening Post, Sept. 2, 2003.
5. U.S. Tort Costs: 2002 Update. Trends and
Findings on the Costs of the U.S. Tort
System. Tillinghast-Towers Perrin.
Appendix 5.
6. Id at 17.
7. VerdictSerach:
http://www.verdictsearch.com/news/top100/
(note: page last accessed June 8, 2004)
8. Physician Insurers Association of America,
PIAA Claim Trend Analysis: 2002 edition
(2003), exhibit 1-2.
9. Physician Insurers Association of America
(PIAA) testimony United States House of
Representatives Committee on Energy and
Commerce Subcommittee on Health,
February 23, 2003
10. For an extensive look at America’s medical
liability crisis, please visit
www.ama-assn.org/go/crisismap
11. The AMA filed amicus briefs in support of
existing medical liability reforms in
Wisconsin and West Virginia in 2004.
12. Several patient-specific examples of the loss
of care can be found in the
November/December 2004 issue of the
Saturday Evening Post. See: Open Forum:
“Why Your Doctor Might Quit,” by Donald
J. Palmisano, M.D.
13. Clarion-Ledger, July 29, 2002
14. To ensure an accurate and extensive discus-
sion of MICRA and other types of reforms,
including action in the U.S. Congress and
state legislatures, the AMA has prepared a
research compendium, Medical Liability
Reform – Now!, which is regularly updated.
See www.ama-assn.org/go/mlrnow for the
most recent version.
15. Visit the NPSF at www.npsf.org
Regional & NMA News
112
Tobacco Control Capacity Building
At the British Medical Asociation’s TCRC* meeting, held in Edinburgh during the 50th
anniversary year of the 1954 paper by Doll, participants heard a keynote address by its
author. Sir Richard Doll, after outlining the latest evidence of the health effects of tobac-
co stressed that the important messages were that in Europe half of all smokers are killed
by their smoking, a quarter of whom are killed by middle age, stopping smoking extends
lifespan, and that doctors must become involved. He suggested that the choices open to
doctors were to make a commitment to reduce smoking rates, or to do nothing and see
tobacco related illnesses increase! Presentations were also made by Sir Richard Peto and
Dr. Carolyn Dressler, Head of Tobacco Control at WHO’s IARC and many others.
Participants each outlined their individual priorities for action and in a joint resolution
agreed to make every effort to persuade member states to ratify the WHO Framework
Convention of Tobacco control and also welcomed the WHO Code of Practice for
Health professionals’ organisations
*The Tobacco Control Resource Centre (TCRC) the global first such institution – was founded in
1998 by the British Medical Association, WHO Europe ,and supported by the European
Commission Commission.
WMJ_04_2004.qxd 17.02.2005 09:51 Seite 112
CHINA
Chinese Medical Association
42 Dongsi Xidajie
Beijing 100710
Tel: (86-10) 6524 9989
Fax: (86-10) 6512 3754
E-mail: suyumu@cma.org.cn
Website: www.chinamed.com.cn
COLOMBIA
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 (Présidente): (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
717 Ponce de Leon Boulevard
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: er@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: fdmedec@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
marnuca@hotmail.com
ESTONIA
Estonian Medical Association (EsMA)
Pepleri 32
51010 Tartu
Tel/Fax (372) 7420429
E-mail: eal@arstideliit.ee
Website: www.arstideliit.ee
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.fj
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) 398686 / Fax: -398083
E-mail: Gma@posta.ge
GERMANY
Bundesärztekammer
(German Medical Association)
Herbert-Lewin-Platz 1
10623 Berlin
Tel: (49-30) 400-456 363/Fax: -384
E-mail: renate.vonhoff-winter@baek.de
Website: www.bundesaerztekammer.de
GHANA
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
Fax: (509) 245-6323
E-mail: amh@amhhaiti.net
Website: www.amhhaiti.net
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
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) 8640478
Fax: (354) 5644106
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 Ärztekammer
Postfach 52
9490 Vaduz
Tel: (423) 231-1690
Fax: (423) 231-1691
E-mail: office@aerztekammer.li
Website: www.aerzte-net.li
LITHUANIA
Lithuanian Medical Association
Liubarto Str. 2
2004 Vilnius
Tel/Fax: (370-5) 2731400
E-mail: lgs@takas.lt
LUXEMBOURG
Association des Médecins et
Médecins Dentistes du Grand-
Duché de Luxembourg
29, rue de Vianden
2680 Luxembourg
Tel: (352) 44 40 331
Fax: (352) 45 83 49
E-mail: secretariat@ammd.lu
Website: www.ammd.lu
Association and address/Officers
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Association and address/Officers
iii
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: www.knmg.nl
NEW ZEALAND
New Zealand Medical Association
P.O. Box 156
Wellington 1
Tel: (64-4) 472-4741
Fax: (64-4) 471 0838
E-mail: nzma@nzma.org.nz
Website: www.nzma.org.nz
NIGERIA
Nigerian Medical Association
74, Adeniyi Jones Avenue Ikeja
P.O. Box 1108, Marina
Lagos
Tel: (234-1) 480 1569,
Fax: (234-1) 493 6854
E-mail: info@nigeriannma.org
Website: www.nigeriannma.org
NORWAY
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/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@omsul.com
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
Udaltsova Street 85
121099 Moscow
Tel: (7-095)932-83-02
E-mail: rusmed@rusmed.rmt.ru
info@russmed.com
SLOVAK REPUBLIC
Slovak Medical Association
Legionarska 4
81322 Bratislava
Tel: (421-2) 554 24 015
Fax: (421-2) 554 223 63
E-mail: secretarysma@ba.telecom.sk
SLOVENIA
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 Médicos
Plaza de las Cortes 11
Madrid 28014
Tel: (34-91) 431 7780
Fax: (34-91) 431 9620
E-mail: internacional1@cgcom.es
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
TAIWAN
Medical Association
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) 383-6710
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
E-mail: servizi.sanitari@scv.va
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
E-mail: info@saludgmv.org
VIETNAM
Vietnam General Association
of Medicine and Pharmacy (VGAMP)
68A Ba Trieu-Street
Hoau Kiem district
Hanoi
Tel: (84) 4 943 9323
Fax: (84) 4 943 9323
ZIMBABWE
Zimbabwe Medical Association
P.O. Box 3671
Harare
Tel: (263-4) 791/553
Fax: (263-4) 791561
E-mail: zima@healthnet.zw
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