WMJ 05 2012

COUNTRY
• WMA General Assembly, Bangkok
• World-leading Plain Packaging Laws
• Physicians on Strike
vol. 58
MedicalWorld
JournalJournal
Official Journal of the World Medical Association, INC
G20438
Nr. 5/6, November 2012
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Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
161
WMA news
Members of the General Assembly, col-
leagues, guests and our hosts the Medical
Association of Thailand.
I am honored to serve as President of the
World Medical Association.
I am committed to being a voice for the
WMA and our profession worldwide.
And as I think about working with the
incredibly dedicated members of this pro-
fession, this noble profession of medicine,
I am enthusiastic and optimistic about the
future. I am proud that the World Medi-
cal Association provides an important voice
and speaks for the medical profession on
health-related issues of worldwide signifi-
cance.
My pledge to you is that in speaking to
national medical associations and other or-
ganizations around the world I will use my
best efforts to enhance the reputation of the
World Medical Association.
As I work with colleagues around the globe,
I am reminded of the commitment we all
have to the profession of medicine.I am re-
minded of the similarity of the challenges
we face regardless of our country of origin.
Reminded, that there are different ways to
respond to those challenges – each of which
has its own value.
Most of us went to medical school because
of the desire to serve the allure of science
and, yes,the thrill of achievement, of doing
the difficult – the hard stuff, of running the
fastest mile, sinking the hole in one, pole-
vaulting higher than any other.
In my country its major league baseball’s
Josh Hamilton of the Texas Rangers hit-
ting four home runs in one game earlier
this summer. For you fans of real football,
it’s Great Britain and Manchester city scor-
ing twice in two minutes to win the English
soccer championship – a first for Manches-
ter City in 44 years.
For the future of the WMA and world
health my three nominees for the most sig-
nificant, the difficult, the hard stuff are:
1. The moral imperative of ethics in medi-
cine;
2. The challenge of non-communicable
diseases and
3. The threat of climate change.
For this audience of world medical leaders
what I am going to talk about may seem
a little like stating the obvious. However,
I support the rationale that it is important
to from time to time state the obvious be-
cause what should be obvious, if never stat-
ed, risks becoming not so obvious.
First ethics:
As physicians we must have moral author-
ity and speak and act with moral authority.
That means we must speak out on broad
public health issues. Doing that makes
our message more credible – and more ef-
fective – when we advocate on matters of
public policy. We are most credible when
we speak from a platform based on principle
and ethics.
Those physicians from around the world
who came together to form the World
Medical Association in 1947 recognized
this. They understood that an organization
was needed to become the authoritative
voice on global standards for medical ethics
and professional conduct,rather than focus-
ing solely on protecting the interests of the
profession.They recognized the importance
to the profession of providing guidance,
moral support and practical advice. They
recognized the importance of endeavoring
to achieve the highest possible standards of
medical care, ethics and health-related hu-
man rights for all people.
From the beginning this intent was codified
in our International Code of Medical Eth-
ics and the Declaration of Geneva  – also
known as the modern “Hippocratic oath”.
Other declarations have addressed issues
such as the patient safety, medical ethics
and advanced technology, end of life care,
access to care,protection of medical person-
nel in armed conflicts – and more recently
the use of social media.
The Future for Global Health Care
Cecil B. Wilson, MD, MACP
Inaugural Speech
President, World Medical Association
October 12, 2012
Cecil B. Wilson
162
WMA news
Today the WMA is bigger, stronger and
more active than ever before and it serves
as a voice recognized the world over. There
is perhaps no clearer example of that rec-
ognition than the Declaration of Helsinki
that advises physicians on doing medical re-
search on human subjects. The Declaration
of Helsinki is the loadstone; the North Star
if you will that guides physicians, govern-
ments and industry in this area.Next month
in Cape Town, South Africa the WMA is
convening distinguished ethicists, educa-
tors and government officials from around
the world to look at potential revisions of
the Declaration – not to change core princi-
ples – but to determine whether more guid-
ance is needed to deal with the complexities
of today’s world.
But ethical guidance by itself is not enough –
hence our additional goals of moral support
and practical advice.To that end the WMA
is active in making its voice heard:
most recently speaking out urging the gov-
ernment of Bahrain to overturn the crimi-
nal court verdict of doctors sentenced to
jail for providing care to the injured, and
calling on the government of Syria and
President Assad to protect health care fa-
cilities and their workers from interference,
intimidation or attack;speaking out in sup-
port of professional orders in West Africa,
and earlier this year, sending our presi-
dent Dr.  Do  Amaral and chair of coun-
cil Dr.  Haikerwal to Turkey where they
marched in solidarity with fellow physicians
in opposition to threats to professional au-
tonomy and self-regulation.
Now more than ever, this WMA, this bea-
con of principle and ethics is needed. The
WMA is not involved in health care per se,
but does have an important role in seeking
to influence the environment, the milieu in
which health care is delivered – the struc-
ture of health care systems.
Which leads to my second point  – the
challenge of non-communicable diseases.
Non-communicable Diseases (or NCDS)
are now the leading cause of death and dis-
ability worldwide. And that is true in the
developed and the developing world. These
diseases including cardiovascular and circu-
latory diseases, diabetes, cancer and chronic
lung disease are expected to increase in fre-
quency and are largely preventable.They are
not replacing the existing causes of illness
such as infectious disease and trauma, but
are adding to the disease burden. So that
developing countries face the triple burden
of infectious disease, trauma and chronic
disease. The causes of non-communicable
diseases are smoking, obesity, physical in-
activity and alcohol abuse  – all lifestyle
behaviours. The primary solution is disease
prevention. In a statement adopted at this
General Assembly in Uruguay last year
the World Medical Association called for
national policies that help people achieve
healthy lifestyles and behaviors; for pro-
grams to increase access to primary care; for
medical education systems to be socially ac-
countable; to direct their education,research
and service activities towards addressing the
priority health concerns of the community,
region or nation they serve; for strengthen-
ing the health care infrastructure to care
for the increasing numbers of people with
chronic disease. This includes: training the
primary health care team; improved health
care facilities such as hospitals and clinics;
chronic disease surveillance; public health
promotion campaigns; quality assurance;
assuring adequate numbers of well-trained
and motivated health care professionals.
This is a challenge that cannot be met solely
by the individual physician seeing a patient
in the office, important and essential as that
is. It is a job for all of society – world gov-
ernments, national medical associations,
medical schools, patients and yes  – indi-
vidual physicians working in their commu-
nities seeking to affect health policy. But,
lifestyle behaviours, smoking, obesity and
alcohol abuse are only part of the story of
NCDs.
To get there let me digress.
There is an old fable from this part of the
world about three princes who lived long
ago in the country of Serendippo – what
we now know as Sri Lanka. Their father,
the king, wanted them to have the best
possible education. But even though he
hired the very best teachers, he was not
convinced that his sons were getting the
training they needed to rule as king. So he
sent them abroad, away from the privileges
of the palace, to sharpen their wits and
broaden their horizons. And in the course
of their travels, by keeping their minds
open, more by accident than design, they
gained an education that afforded them
the wisdom and knowledge to rule. And
years later, the English writer Harold Wal-
pole coined the word “serendipity” based
on these stories. He noted that when the
princes travelled, they were always mak-
ing discoveries and developing the ability
to link together seemingly unrelated facts
to come to a valuable conclusion. Louis
Pasteur, the French chemist and microbi-
ologist, said it this way:”Chance favors the
prepared mind.”
Our consideration of the proximate causes
of non-communicable diseases – tobacco,
obesity, alcohol  – has led to the in some
ways serendipitous understanding that
there are equally important causes of the
causes  – root causes. These causes of the
causes are social determinants of health –
the conditions in which people are born,
grow, live, work and age, and the soci-
etal influences on these conditions. They
are major influences on both quality of
life, including good health, and length of
disability-free life. For example: in many
societies, unhealthy behaviors are higher
in people on the lower end of the social
gradient. The lower they are in the socio-
economic hierarchy, the more they smoke,
the worse their diet is and the less physi-
cal activity they engage in – thus, putting
them at increased risk of non-communica-
ble disease. Lower levels of education have
the same effect  – increased risk of non-
communicable disease. Another example
163
WMA news
is that price and availability are key driv-
ers of alcohol consumption and smoking.
The excellent scientific session we enjoyed
yesterday asked the question Megacity –
Megahealth?,illustrating another aspect of
social determinants of health. We are in-
debted to the work of the Council member
Sir Michael Marmot and his colleagues
for giving understanding and international
visibility to this important subject. For
governments, understanding this concept
means that all policies need to be evalu-
ated as to their effects on the health of its
citizens. Therefore, not just one designated
minister of health, all ministers are health
ministers. And the medical profession has
a valuable role to play in seeking action on
these social conditions, the causes of the
causes that have such important effects on
health.
My third point: global warming with its
accompanying climate change, and its ac-
companying extremes of weather is already
having and will continue to have signifi-
cant health effects. Although governments
and international organizations have the
main responsibility for creating regulations
and legislation to mitigate the effects of
climate change the WMA feels an obliga-
tion to highlight the health consequences
and suggest solutions. Over the past two
decades extreme heat events have killed
tens of thousands around the globe. Heat
waves are becoming more frequent, of lon-
ger duration and more intense. Heat waves
can cause illness and death from heart dis-
ease, diabetes, stroke, respiratory disease
and even accidents, homicide and suicide.
At the same time increased evaporation
arising from warming seas is generating
heavier downpours increasing flooding and
water-borne disease outbreaks when flood-
ing overwhelms sewer systems and con-
taminates drinking water. Warmer winters
favor insect migration. In the past decade
in the state of Maine in the US reports
of tick-borne Lyme disease not only rose
ten-fold but parts of the state experienced
Lyme for the first time. Worldwide the ef-
fect may be mixed for Malaria. In some re-
gions the geographical range will contract
and in others expand, and the transmis-
sion season may be changed. Worldwide
disruption of the food supply is predicted
to increase malnutrition and subsequent
disorders. Social and health inequalities
due to possible desertification, natural di-
sasters, changes in agriculture, feeding and
water policy will have consequences on
both human health and human resources
in health and disproportionately affect de-
veloping countries.
Physicians have a role to play to: encourage
advocacy for environmental protection, re-
duction of greenhouse gas production and
sustainable development of green adapta-
tion practices; work to improve the abil-
ity of patients to adapt to climate change
and catastrophic weather events;work
with others to educate the general pub-
lic about the important effects of climate
change on health and the need to mitigate
climate change and adapt to its effects;
work with others, including governments,
to address the gaps in research regarding
climate change and health. As individu-
als act to minimize their impact on the
environment and to call all upon govern-
ments to strengthen public health systems
in order to improve the capacity of com-
munities to adapt to climate change.All of
which brings to mind an ancient Chinese
proverb: “When is the best time to plant a
tree,” asks a young student, sitting in the
hot sun with his teacher. “Twenty years
ago,” replies the teacher. The young boy,
feeling a drop of sweat run down his cheek
asks,”Well, then when is the second best
time?” “Now!!” intoned the teacher. Now.
Now is the time.
Fifty years ago – doesn’t seem that long –
the US President John F. Kennedy gave
a speech at Rice University in Houston.
Kennedy spoke of the conquest not only
of physical and technological barriers, but
psychological ones. He said: “We choose to
go to the moon in this decade and do the
other things, not because they are easy, but
because they are hard.Because that goal will
serve to organize and measure the best of
our energies and skills. Because that chal-
lenge is one we are willing to accept, a chal-
lenge we are unwilling to postpone. And
one we intend to win.”
Ethics, non-communicable disease, climate
change. So, is the job difficult? Yes.
Is the path long and winding? Absolutely. Is
success assured? Absolutely not.
All the more reason to embrace it. And our
success or lack of success depends in the end
on our attitude.
The American industrialist Henry Ford
said: “If you think you can,if you think you
cannot,you are right.” From India, Ma-
hatma Gandhi said it this way: “Man often
becomes what he believes himself to be. If
I keep on saying to myself that I cannot do
a certain thing, it is possible that I may end
by really becoming incapable of doing it.
On the contrary, if I have the belief that I
can do it, I shall surely acquire the capac-
ity to do it even if I may not have it at the
beginning.”As physicians, we are joined by
our common contract with humanity. We
reach out to the sick, the disabled and the
chronically ill.
Suffering knows no language, and eas-
ing pain, finding treatments, developing
cures – know no borders. Working togeth-
er we can create the future of medicineTo-
gether, we can open new doors, share new
insights, find new cures, prevent disease
and help our patients the world over to live
healthier, happier, longer, more productive
lives.
I look forward to that.
Thank you.
164
WMA news
I will start by greeting and thanking you,
all delegates from the medical associa-
tions, who gave me the privilege and the
honor to represent the WMA. I thank the
WMA Officers: the immediate Past Presi-
dent, Wonchat Subhachaturas, and all our
former Presidents; the Chairman of the
Council, my dear friend Mukesh Haik-
erwal; the Vice-Chairman, Masami Ishi;
our treasurer, Frank-Ullrich Montgomery;
the Chairmen of our Standing Commit-
tees,Thorunn Jambu, Michael Marmot and
Leonid Eidelman. All the members of the
Council… Our always present Secretary
General, the bright counselor and friend,
Otmar Kloiber. 
The friends we have in the extraordinary
and competent WMA staff: Yoonsun “Sun-
ny” Park, Roderik Dennett, Lamine Smaali,
Clarice Delorme, Anne-Marie “Anna”
Delage, Julia Seyer, Adolph Hallmayr and
Annabel Seebohm; Pēteris Apinis and Ni-
gel Duncan.Also a very special warm greet-
ing to Joelle Balfe. Our dear interpreters:
thank you so much!
My dear Friends and Colleagues,
I will talk about a long journey from Mon-
tevideo on the Atlantic Ocean to Bangko,
on the Pacific Ocean.
Since Montevideo (Uruguay), October
2011, I have faced an extensive agenda,
which gave me the opportunity to experi-
ence the reality of medical practice, prob-
lems and accomplishments of many of the
present day more than one hundred Na-
tional Medical Associations that form our
World Medical Association. Just after tak-
ing over the Office, our first commitment
was to take part in the Social Determinants
of Health at the International Conference
in Rio de Janeiro (Brazil).
At that time, we talked about the impor-
tance of finding a solution for the social
inequalities seen in both wealthy and de-
veloping countries. Those inequalities are
the main factor responsible for the level
of health of our populations. They refer to
the conditions in which people are born
and grow up, the differences in education,
opportunities and working conditions, and
to the conditions how people are ageing.
There,we emphasized the importance of the
role of Physicians in this field. In addition
to assisting people in need, the profession
includes interventions in the factors that
cause poor health. In Chihuahua (Mexico),
last November, we offered solidarity to our
Mexican colleagues at the Assembly of the
Mexican Medical College, where the issue
was the response to violence against health
professionals related to the drug trafficking
war, particularly in the city of Juarez. There,
I could see the many aspects of insecurity
doctors face in many areas around the world.
Several National Medical Associations from
Latin-American Nations met on November
19 in Panama City (Panama). Among the
problems that threaten the quality of medi-
cal attention and, especially, Medicine, I ob-
served the repeated political interferences
in medical organizations, mainly in Bolivia
and Venezuela. In Bolivia, the government
tried to dismantle the medical profession
and to regulate it themselves. They also de-
cided on ethical issues and technical com-
petences that qualify different specialties.
The main goal of the Bolivian government
is to fully control the profession.
Still in November, in Porto (Portugal), we
met Portuguese medical students in order
to discuss the European economic crisis
viewed from the stand point of young doc-
tors in a continent that is going through
major challenges. This January and Febru-
ary, in São Paulo (Brazil), at the headquar-
ters of the Medical Association of the State
of São Paulo and in Rio de Janeiro (Brazil),
we subscribed and announced  the world-
wide campaign for 2012 – “Global Appeal”
against the discrimination faced by persons
affected by leprosy, a neglected disease that
still affects hundreds of thousands of people
in different regions of the world.
One year after the earthquake followed by
a tsunami and a nuclear accident in Japan,
on March 11, 2012, we were in Tokyo (Ja-
pan) to discuss with our colleagues from
the Japanese Medical Association about the
WMA “Montevideo Declaration”, which
deals with the role of the medical asso-
ciations and the physicians in response to
disaster situations. The successful mobili-
zation of Japanese physicians around that
key issue gives us a picture of the enormous
benefits of readiness in decreasing the im-
pacts of catastrophic events less and less in-
frequent in people’s lives.
In April this year, in Taipei (Taiwan), at
the opening of the 20th
International Con-
ference on Health Promoting Hospitals,
I addressed the role of hospitals and health
services in the promotion of health and in
tackling the social determinants of health.
During that same event, we actively partici-
Valedictory address
José Luiz Gomes do Amaral,
President of the World Medical Association
José Luiz Gomes do Amaral
165
WMA news
pated in the meeting “Health without Dan-
ger”,which was oriented to the management
processes in health institutions and to envi-
ronment preservation. More and more, the
environmental impact of modern hospitals
has been capturing the attention of society.
In Ankara and Istanbul (Turkey), also last
April, WMA was represented by the Presi-
dent and by the Chairman of the Council
for the mediation between physicians and
a parliamentary group in that country in
regard to a crisis caused by a decree which
brutally restricted the independency and the
authority of doctors for professional ethics
and technical self-regulation.  The increas-
ing animosity of the Turkish government
towards the medical profession created a
hostile environment for health profession-
als, generating serious situations: Physicians
were blamed for the consequences of the
erroneous public system, and the dissemi-
nation of false information on the lack of
doctors had been used as a justification to
“import” physicians from neighbouring
countries. The climax of the crisis was the
murder of a 30-year-old doctor, followed
by demonstrations all over the country. In
Istanbul, as the president of WMA, I par-
ticipated in a manifestation with more than
20 thousand doctors, bringing the city of
Istanbul into a halt and raising a popular
outcry as an extension of that tragedy.
On April 23rd
, in London (England), Presi-
dents of WMA and its Council took part
in the meeting “Health Care in Danger”, an
initiative that gathers organizations such as
World and British Medical Associations,
International Red Cross/Crescent and
Doctors without Borders on the growing
wave of violence against health profession-
als in civil and military conflicts in several
regions of the world such as Somalia, Libya,
Egypt, Bahrain, Syria, Iraq, Afghanistan,
Israel, Mexico, Colombia.  At that time, we
presented the WMA’s position in the field
of ethics and medical neutrality in situations
of conflict. Physicians and other medical
professionals have been arrested,kidnapped,
tortured and murdered in retaliation for as-
sisting people that eventually belonged to
an opposing group. Hospitals have been
bombed and invaded. Such incidents have
interrupted humanitarian actions, causing
the withdrawal of voluntary teams to whom
security cannot be provided, and leaving a
great amount of unassisted people behind.
At the end of April,more precisely from the
24th
to the 29th
, many of us were together
when the Council Meeting of the World
Medical Association took place in Prague,
the Czech Republic.  In addition to the
issues already mentioned before, other im-
portant ones such as the review of the Dec-
laration of Helsinki were addressed.
In Geneva (Switzerland), this last May, at
the WHO Assembly, we confirmed our
partnership with WHPA and we discussed
the economic crisis and health care. We
hosted the traditional “WMA Luncheon”,
which had the United States Secretary of
Health and Human Services,the Honorable
Kathleen Sybelius as a lecturer,and counting
on the presence of Health Ministers from
many countries. Last July, I took part in the
Symposium “Healthcare systems in times of
crisis _ Protect the Present – Build the Fu-
ture”: a debate in Lisbon (Portugal) with the
Portuguese health authorities and Michael
Porter from Harvard Business School about
the quality of care and the opportunities in
times of economic difficulties.
The value of a profession can be measured
not only through the reputation of its mem-
bers, the quality of the services they provide
to their people,and their many contributions
to Science, but also through their capacity to
organize and support other organizations. I
also had the privilege of attending the As-
semblies of the German Medical Associa-
tion, last May, in Nurnberg (Germany), the
American Medical Association, last June
in Chicago (United States), and, in Bour-
nemouth (England), the British Medical
Association Assembly.In each of those occa-
sions,I could express to them our deep grati-
tude on behalf of the millions of doctors in
the other 100 National Medical Associations
which integrate the World Medical Associa-
tion. In August, CONFEMEL gathered in
Lima (Peru). This meeting gave me another
opportunity to talk about the many reasons
why they should strengthen the participa-
tion of Latin-American countries in WMA.
In Madrid (Spain), last September, the main
subject under discussion was medical atten-
tion to immigrants and the different regula-
tions in several European countries. Finally,
last September in Tiberias (Israel) on the Sea
of Galilee, with Yoran Blachar and Leonid
Eidelman, we discussed the possibilities of
new partnerships with UNESCO in an edu-
cational program on medical ethics.
Dear Friends and Colleagues,
Before leaving, I would like to share with
you a Guarani (South American Indian
ethnic group) story: Nhanderuvuçu, the
Great Father, announced that the world
would perish because of men’s iniquity, and
ordered the sorcerer Guiraypoty to pray.The
Earth was then got out of the ties that hung
it in the sky and fire spread out, forcing
Guiraypoty and his tribe to flee toward the
East.They started a very long and hard jour-
ney, nowadays known as the Peabiru way, an
ancient Indian route that linked the Pacific
and the Atlantic Oceans, from Peru to São
Paulo.They finally reached, at heaven’s door,
the “yvy marã ei”,which means “a land with-
out evilness”, a land with no suffering where
people never get sick, old or die.
In 1947, just after the miseries of World
War II, the millions of doctors represented
herein started a long journey, crossing land
and ocean. We have completed our path, our
“Peabiru”, always praying for good standards
in medical care, standing for human rights
in health, and looking for a healthy land of
equal opportunities, solidarity and  justice.
Dear Cecil Wilson, now it is your turn to
lead us and light our way.
I am ready to follow you.
Thank you very much.
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WMA news
Wednesday October 10
Delegates from more than 50 national med-
ical associations met at the Centara Grand
Hotel Convention Centre, Bangkok, Thai-
land for the 63rd
annual General Assembly
of the World Medical Association from
October 10 to 13.
Council Session
The proceedings of the 192nd
Council ses-
sion were opened by Dr. Mukesh Haikerwal,
Chair of the WMA, and delegates were wel-
comed by Dr.Wonchat Subhachaturas,Pres-
ident of the Medical Association ofThailand.
Dr. Haikerwal reported on recent events he
had attended,including a meeting in Algiers
of the Maghreb group of medical associa-
tions, including Tunisia, Morocco and Al-
geria. He said it was an important meeting
to go to as the WMA had little presence
in North Africa or the Gulf. It was a good
meeting to start extending the spread of the
WMA to organisations that were not part of
the Association. The meeting also received
an oral report from the Vice Chair of Coun-
cil, Dr. Masami Ishii, who spoke about the
cholera alert in the Middle East and the ef-
fect of pilgrims going to Saudi Arabia.
The President, Dr. José Luiz Gomes do
Amaral, spoke about the many events he
had attended around the world during the
year, including the annual meetings of the
German, American and British Medical
Associations. At a meeting in Israel he had
discussed the possibilities of a new partner-
ship with UNESCO on an educational pro-
gramme on medical ethics.
Dr. Otmar Kloiber, Secretary General, sub-
mitted a detailed written report from the
secretariat to the Assembly about the general
activities of the Association. In his oral com-
ments to Council he said that the WMA
had been very successful in the last eight
years in increasing the amount of financ-
ing for projects through sponsorship, but in
the current financial crisis this was getting
tougher. Funds were being restricted and
more targeted. He thanked those organisa-
tions still sponsoring the Association, as well
as national medical associations (NMAs)
that had offered help to the WMA, either
through advice, staff support or other activi-
ties.He said that for the first time the WMA
had received sponsorship from the World
Health Organisation for transforming one of
the WMA’s educational programmes on TB
control into a more mobile device.
He also reported that grants were available
through the World Health Professions Al-
liance for the counterfeit medicines cam-
paign. Member organisations that com-
bined together from different countries and
different professions would be eligible to
apply for a grant.
Two emergency motions were then present-
ed to Council.
Minimum Unit Price for Alcohol
Dr. Vivienne Nathanson (British Medical
Association) said that several legislatures,
including Scotland, had either passed or
were considering passing a law to enable
them to set a minimum unit price for al-
cohol. It was believed this would make a
significant difference to drinking levels.
Unfortunately a number of governments,
particularly within Europe, were trying to
oppose the right of these governments to
set a unit minimum price,saying it was a re-
straint on trade. In many countries, includ-
ing the United Kingdom, there was a seri-
ous misuse of alcohol and the government
was trying to take an evidence based public
health approach and was being stopped by
other governments.
Council agreed that this was an urgent mat-
ter and should be considered by the Social
Medical Affairs Committee.
Cigarette Packaging
Dr. Nathanson also presented an emer-
gency motion on plain cigarette packaging
and said this was about to come into force
in Australia. But there were legal challenges
from the tobacco industry. Many govern-
ments around the world were watching
Australia and it was important that the pro-
fession showed that it supported all moves
to reduce the consumption of tobacco.
Council again agreed that this was an ur-
gent matter and should be considered by the
Social Medical Affairs Committee.
The Council meeting was then suspended
for the committee meetings to take place.
Medical Ethics Committee
The Medical Ethics Committee met with
Dr.Torunn Janbu in the Chair.
Declaration of Helsinki
Dr. Ramin Parsa-Parsi, chair of the Work-
group on revising the Declaration, reported
on progress. He spoke about preparations
for two expert conferences in Cape Town,
South Africa in December and in Tokyo,
Japan in February. After these, the Work-
group would meet to consider a first draft of
the revised Declaration to put to the Coun-
cil meeting in April 2013. This would be
followed by a public consultation until June.
Dr. Jeff Blackmer (Canada) summarised the
comments received from 21 organisations,
including eight NMAs,about what the main
themes of the revision should be. These co-
alesced around insurance compensation and
protection of research subjects,the use of un-
proven interventions, the issue of broad con-
sent and medical research involving children.
WMA General Assembly
63rd
World Medical Association General Assembly, Bangkok,Thailand, October 2012
167
WMA news
Dongchun ShinA. Hallmayr Torunn JanbuLeonid Eidelman Ramin Parsa-Parsi Vivienne Nathanson
Wonchat Subhachaturas
Frank Ulrich
MontgomeryMukesh Haikerwal Masami Ishii Sir Michael MarmotMargaret Mungherera
Anne-Marie DelageAnnabel SeebhomSunny Park Clarisse DelormeJeff Blackmer Nigel Duncan
The committee then received an oral report
from the WMA’s medical ethics adviser on
the Declaration, Professor Urban Wiesing
from the University of Tuebingen in Ger-
many, about a first possible draft of para-
graph 32 of the Declaration concerning the
use of placebo control. He gave a history of
previous changes to paragraph 32 and the
criticisms that each change had provoked.
He explained why the Workgroup was now
proposing a more systematic approach.
In a brief debate that followed Dr. Peter
Carmel (American Medical Association)
congratulated Prof. Wiesing on his presen-
tation. He said that the longer the Decla-
ration was the more involved the explana-
tions, the higher the number of exceptions
that were included and the loss of precision
that was the basis of a universal statement.
Dr. Jon Snaedal (Iceland) agreed that sat-
isfactory progress was being made and the
right balance was being struck.
Medical Ethics and Advanced Technology
Revisions to the Declaration on Medi-
cal Ethics and Advanced Technology were
debated and a discussion took place about
whether the document should refer to ‘pa-
tients’ or ‘persons’. It was decided to use the
word’persons’and to recommend forwarding
the document to the Assembly for adoption.
Safe Injections in Health Care
The committee considered a proposed revi-
sion of the 2002 WMA Statement on Safe
Injections in Health Care and after sev-
eral members proposed amendments it was
agreed that the document should be referred
back to undergo further minor revision.
Women’s Right to Care
Dr.Mark Sonderup (South Africa) reported
that the proposed Statement on Women‘s
Right to Health Care and How that Re-
lates to the Prevention of Mother-to-Child
HIV Infection was in the process of being
circulated to regional NMAs and a further
report would be made to the next Council
meeting in Bali in April 2013.
Person Centred Medicine
Dr. Snaedal introduced a proposed State-
ment on Person Centred Medicine. He said
NMAs had commented on the Statement,
one suggesting that it should be divided in
two, and another that the document was
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WMA news
too general in nature and needed to be more
specific. Dr. Kloiber said that progress on
this issue had been very interesting because
the WMA had achieved bridging together
two concepts, the patient centred approach
that most NMAs had fostered for curative
medicine and the more people centred ap-
proach of the WHO. The WHO had now
joined with the WMA and others in trying
to develop the debate and it was important
that the WMA continued to be involved.
The committee agreed that the Statement
needed further consideration before being
recirculated among NMAs.
Euthanasia
Dr. Janbu said that the WMA Resolution
on Euthanasia was now 10 years old and
should be reviewed. But there was also a
Declaration on Euthanasia which was not
subject to review at this time. The commit-
tee decided that the Resolution should un-
dergo a minor revision by the secretariat.
Death Penalty
Dr. Parsa-Parsi (Germany) presented a pro-
posed Statement, jointly submitted by the
German Medical Association, the Norwe-
gian Medical Association and the French
Conseil National de L’Ordre des Médecins,
that the WMA should support a United
Nations General Assembly Resolution call-
ing for a moratorium on the use of the death
penalty. He thanked the WMA Workgroup
which had been set up to consider the ethi-
cal issues of capital punishment and had
produced a paper. But it was not enough
to simply ask physicians not to participate
in capital punishment. The practice of the
death penalty itself needed to be addressed.
He acknowledged the different views and
beliefs prevalent in the countries of NMA
members, therefore the proposed Statement
did not ask for a complete abolition of the
death penalty, but rather a universal mora-
torium or a temporary suspension of the use
of the death penalty by all states.There were
many compelling reasons for supporting
a moratorium. There was, for instance, no
conclusive evidence that the death penalty
had any additional value as a deterrent. Also
a miscarriage of justice could never be com-
pletely ruled out.
But several delegates from the USA spoke
out against the proposal. Dr. Cecil Wilson,
Chair of the Workgroup on capital punish-
ment, said the group had already decided to
recommend to the Assembly that as citizens
physicians had the right to form their own
views on capital punishment. He said there
was a separation between what they did as
physicians and what they might decide as
non-physicians. Dr. Peter Carmel (Ameri-
can Medical Association) said it would be
premature to circulate the new proposed
Statement before the Assembly had con-
sidered the Statement from the Workgroup.
But Dr. Snaedal said that the moratorium
proposal should be circulated because it was
important that physicians addressed this is-
sue. Dr. Nathanson also thought the issue
should be circulated.
The committee agreed by 10 votes to four
with two abstentions to recommend to
Council that the proposal for a moratorium
be circulated to NMAs.
Human Rights
Clarisse Delorme, the WMA’s Advocacy
Advisor, reported on two current issues that
had arisen since the written report on human
rights had been submitted. The first related
to Professor Cyril Karabus, a South African
paediatrician, who was in jail in Abu Dhabi
following his arrest on a charge of man-
slaughter relating to the death of a child un-
der his care in the United Arab Emirates 10
years ago. The second concerned the health
professionals who had been convicted and
imprisoned in Bahrain on charges following a
public demonstration. She told the commit-
tee that on both cases the WMA had taken
action by writing to the respective authorities.
Dr. Mark Sonderup (South Africa) thanked
the WMA for its assistance on Professor
Karabus, and said the South African Medi-
cal Association would like to submit an
emergency motion later in the meeting.
Clinical trials
Professor André Herchuelz (Belgium)
raised the issue of a European Commission
draft regulation that had been published in
July regulating clinical trials in Europe.This
had omitted all reference to prior approval
by ethical committees which would have
the effect of reducing the protection of pa-
tients. Dr. Kloiber said that the WMA was
aware of the document, which he said was a
legal document, and it was planning to sub-
mit a response shortly.
Finance and Planning Committee
The Finance and Planning Committee met
with Dr. Leonid Eidelman in the chair.
He opened the proceedings by saying that
the WMA had had a sound financial year
and had been able to fulfil its goals and still
stay in a good financial position.
Financial Statement
The committee considered and approved
the audited financial statement for 2011
and agreed that it should be sent to Council
and the Assembly for adoption.
Budget for 2013
Mr Adi Hällmayr, the Financial Adviser,
presented the proposed budget for 2013 and
said the WMA had not had any exposure
to financially risky investments. The policy
was to protect the Association’s assets. He
explained the details of the Association’s in-
come and expenses.The Budget was adopted.
Membership Dues
The committee received the report on
membership dues payments for 2012 and
Mr Hällmayr reported on dues arrears.
Dr. Kloiber spoke about the task of stabilis-
ing the dues, the baselines for payments and
allowing some countries to pay by instal-
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ments. The committee received the report,
which was forwarded to the Assembly for
information.
Declaration of Helsinki 50th
Anniversary
Dr. Eidelman, in his capacity as Chair of
the Workgroup on the 50th
anniversary of
the Declaration of Helsinki, reported on
plans for celebrating the anniversary in
2014. He said the goal should be to in-
crease the visibility of the Declaration and
strengthen the ownership of the WMA of
the ethical principles on the experimenta-
tion on humans. Among the ideas being
considered were the holding of a major
event in Helsinki in 2014, simultaneous
national and regional events around the
world on World Medical Ethics Day in
September 2014, articles by NMAs for the
media, a survey of NMAs about the influ-
ence of the Declaration and a book on the
history of the document.
Strategic Plan 2013–2015
Dr.Robert Ouellet,Chair of the Workgroup
on the Strategic Plan, gave a progress report
on the strategic plan. He said the process
which had been going on for some years
had now reached its conclusion. NMAs had
commented on the draft plan. A list of 38
strategic initiatives had been agreed and
many were now being implemented.
Dr. Kloiber said that four themes of the
plan had been identified as of particular im-
portance – ethics, advocacy and representa-
tion; partnerships and collaboration; com-
munication and outreach; and operational
excellence. He detailed the plans for tack-
ling 20 initiatives that had been highlighted
for immediate action.
The committee agreed to forward the Plan
to Council to be adopted by the Assembly.
Business Development
Mr Tony Bourne,Chair of the Business De-
velopment Group, reported on progress in
developing a WMA roundtable of commer-
cial and non-commercial organisations who
wanted to develop a closer relationship with
the Association. He said this would not be
revenue producing,but it would be cost cov-
ering.The Group had developed draft terms
of reference to govern the roundtable and
had drawn up a short list of possible partici-
pants. These would be finalised and he said
a report would be given to the next Council
meeting in Bali in April 2013.
Disaster Preparedness and Medical
Response
Dr. Miguel Roberto Jorge, Chair of the
Workgroup, gave an oral report on disaster
preparedness, saying that a questionnaire
based on the Declaration of Montevideo
had been prepared for NMAs. This related
to what initiatives should be undertaken.
The summarised responses would be pre-
sented to the next Council meeting in Bali
for further discussion.
Future WMA Meetings
The committee considered arrangements
for future WMA meetings. Invitations
had been received from Argentina, Co-
lumbia, Taiwan and Russia to meet in
their countries in 2015 and the com-
mittee heard presentations from Argen-
tina, Taiwan and Russia. It recommended
postponing any decision until the Council
meeting in Bali.
Greening of Meetings
The committee received an oral report
from Dr. Mads Koch Hensen, Chair of the
Workgroup on Greening of WMA meet-
ings. He highlighted what had been done
since the Council meeting in Sydney by way
of reducing the use of paper at meetings,
opening a new green page on the WMA
website and assisting people to share airport
transportation.
Membership
A request was received from Romania for a
change in membership. The committee rec-
ommended to Council that the Romanian
Medical Association should be replaced by
the Romanian College of Physicians.
Relations with World Veterinary
Association
The committee received a report on a pro-
posed Memorandum of Understanding
with the World Veterinary Association. Dr.
Cecil Wilson said that one of the realities
of the world was that whether their pa-
tients walked on two legs or four legs phy-
sicians and veterinarians shared two-thirds
of all the world’s diseases. It was therefore
critical for the two professions to work to-
gether. The Memorandum of Understand
set out the principles under which the two
organisations would co-operate.
Socio-Medical Affairs Committee
The Socio-Medical Affairs Committee met
with Sir Michael Marmot in the chair.
Health and the Environment
Dr. Dongchun Shin (Korea) reported on a
meeting of the Environment caucus earlier
in the day. He said the meeting had discussed
the outcome of the UN Conference on Sus-
tainable Development and the outcome of the
third session of the International Conference
onChemicalsManagement.Inadditionithad
considered the promotion of green hospitals
and sustainable transport.He said the NMAs
were invited to share their experiences on
the environment page of the WMA website.
Social Determinants of Health
Sir Michael Marmot reported that the
WMA and the International Federation of
Medical Students had held a successful side
event at the World Health Assembly where
participants had discussed how physicians
and medical students could get engaged in
the issue of social determinants.Two NMAs,
from Britain and Canada, had produced
initiatives on this, preparing position state-
ments on how doctors could get involved.He
said it was planned to present a paper on this
issue to the next meeting of Council.
Health Care in Danger
Dr. Nathanson, Chair of the Workgroup
on Health Care in Danger, reported on
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how the group was supporting the cam-
paign of the International Committee
of the Red Cross on the issue of protect-
ing health care in areas of armed conflict.
The Workgroup had agreed to work on an
ethics toolkit to mirror an ICRC publica-
tion on ethics law for doctors working in
conflict situations. It would assist WMA
speakers with slides for use in presenta-
tions and NMAs with advocacy materials.
It had also agreed to work with the World
Psychiatric Association on examining ex-
isting evidence on reducing violence in the
health care workplace and it would moni-
tor the WHO’s activities.
Ethical Implications of Physician Strikes
Leah Wapner (Israel) reported on the activ-
ities of the Workgroup on physician strikes.
The Israeli Medical Association had put
forward a proposed Statement on this issue
at the last Council meeting. She presented
a revised document, recognising that some
NMAs did not have responsibility for trade
union issues. But she said that at least half
the NMA members were involved with ne-
gotiations and every NMA was involved in
doctors’ working conditions in some way or
another. The proposed Statement had been
revised to focus on the ethical principles
that should be faced by NMAs and physi-
cians once they had decided to engage in
industrial action.
Dr. Janbu (Norway) thought the paper was
still an unfortunate mix of ethical consider-
ations and trade union issues.It also dealt with
matters that were regulated by national laws.
Dr. Jon Snaedal (Iceland) said this was a con-
troversial document which should now been
sent out for consideration by NMAs. But Dr.
Frank Ulrich Montgomery (Germany) asked
how a document such as this could be written
without mixing up ethical and trade union is-
sues. He thought this was a good document.
Dr. Konstanty Radzwill, President of the
Standing Committee of European Doctors,
also supported the Statement as a balanced
document, which on the one hand showed
the responsibility of the profession and on
the other hand reminded doctors to re-
member their patients when protesting.
Dr. Heikki Pälve (Finland) said doctors
should have the right to strike, but they
should not strike to achieve political goals.
Physicians should carry out protest actions
only to improve their working conditions
and should not strike about patient care
because that was for politicians to decide.
The committee decided to recommend to
Council that the document should be circu-
lated for further consideration.
Ms Wapner said this was a matter of ur-
gency because with so many NMAs taking
strike action it was inconceivable that the
WMA had no policy on the issue.
Forced Sterilisations
Dr. Nathanson presented a proposed State-
ment on Forced and Coerced Sterilisation
that had been submitted by the British
Medical Association and had been circulat-
ed for comments. Several friendly amend-
ments were suggested and agreed.The com-
mittee recommended that the Statement
should be forwarded to Council for adop-
tion by the Assembly.
Prioritisation of Vaccination
Dr.Claire Camilleri (Irish Medical Associa-
tion) presented a proposed Statement jointly
with the Icelandic Medical Association. She
said it was a reminder of the role of immuni-
sation in global health. Smallpox had been
eradicated and polio was on the verge of
being eradicated. This Statement presented
an opportunity to refocus attention onto the
priority of delivering vaccination and im-
munisation programmes around the world.
The committee recommended that the
Statement be forwarded to Council for
adoption by the Assembly.
Health Databases
Dr. Snaedal presented a proposed revision
of the Declaration on Ethical Consider-
ations regarding Health Databases. He pro-
posed that a Workgroup be established to
further discuss the document and this was
agreed by the committee.
Political Abuse of Psychiatry
Dr.Jeremy Lazarus (American Medical As-
sociation) presented a proposed revision of
the WMA Resolution on Political Abuse of
Psychiatry. The document had been revised
to add the use of psychiatric hospitals for
religious persecution. It was agreed that this
be forwarded to Council for adoption by the
Assembly.
Drugs and Methadone
A proposed Statement on drugs and metha-
done had been submitted by the National
Medical Association of Kazakstan. No-one
from the association was present and after
a brief debate, during which it was argued
that the paper was contrary to scientific evi-
dence and WMA policy, it was decided not
to approve the paper.
WMA Advocacy
Dr. Jeff Blackmer (Canada) reported on the
activities of the Advocacy Advisory Com-
mittee and a survey that had been under-
taken among NMAs.There had been a very
good response rate showing a strong de-
mand for training and workshops on advo-
cacy.The Group suggested organising train-
ing sessions during a General Assembly and
this topic could be the focus of a scientific
session.
Minimum Unit Price for Alcohol
The committee considered the emergency
Resolution proposed earlier in the day. Dr.
Nathanson said there was very clear evi-
dence that if a minimum unit price was set
as part of a strategy for dealing with alco-
hol abuse it influenced young people who
were beginning to drink as well as older
people with higher disposable incomes who
were heavy drinkers. It reduced the average
amount of alcohol consumed. Minimum
unit pricing was part of a strategy that
would include higher taxation and a ban on
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advertising. The evidence from the UK was
that a minimum unit price might reduce the
level of drinking by between 10 and 25 per
cent.But certain parts of the drinks industry
had persuaded some governments to back
them in opposing minimum unit pricing as
a restraint of trade.
The committee agreed to forward the Reso-
lution to Council for further discussion.
Plain Packaging of Cigarettes
The committee also considered the emer-
gency Resolution on plain packaging of cig-
arettes and it was agreed that this should be
forwarded to Council for further discussion.
Thursday October 11
Associates Members Meeting
The meeting opened with Dr. Guy Du-
mont in the Chair. Dr. Xaviour Walker
gave a report on the Junior Doctors Net-
work, which had met earlier in the week.
The Network had been busy during the
year, producing a white paper on social me-
dia and medicine. It was now working on
the issues of physician wellbeing and glob-
al health training and its ethical implica-
tions. Elections had been held at its meet-
ing and the new Chair of the Network was
Thorsten Hornung from Germany. It had
represented the WMA at many meetings
during the year.
Scientific Session
‘MegaCity – MegaHealth’
Dr. José Luiz Gomes do Amaral opened the
proceedings by saying that cities generated
between 30 and 50 per cent of the gross do-
mestic product for their respective countries.
But pollution, violence, traffic jams and traf-
fic accidents, floods and poor infrastructure
were common to most of them, affecting
people’s health. However big cities also con-
tained big ideas and this was what speakers at
the Scientific Session would be talking about.
Dr. Malinee Sukavejworakit, Deputy Gov-
ernor of Bangkok, spoke about the goals of
the Bangkok Metropolitan Administration
to improve the health of its population. She
said that with an inner city population of
5.7 million and an outer population of 10
million the city was faced with numerous
health problems, including traffic conges-
tion and accidents, poverty, social inclusion,
noise pollution, crime, violence and mental
health care. The goals were for Bangkok to
become a healthy city where its residents
had good health, good quality of life, hap-
piness, safety, secure income, a pleasant en-
vironment for living with good governance
and participation from all concerned. To
that end the city had developed a ‘Green
and Clean’ project that involved four devel-
opment strategies – on shelter supply, social
development and eradication of poverty,
on progressive economic development, on
good environmental management and on
good governance.
She spoke about the city’s response to last
year’s flood and the fact that no communi-
cable diseases resulted from the event. The
city was now putting in place measures to
strengthen the city’s flood defences.
Professor Yasuhide Nakamura, Professor of
International Collaboration at Osaka Uni-
versity, said Tokyo Metropolitan City had
a population of 13 million, 23 per cent of
whom were 65 years old and over. United
Nations statistics showed that the greater
Tokyo area, including its neighbouring pre-
fectures, was the biggest urban conglomera-
tion in the world with a total population of
37.2 million.
He referred to the decline in the infant
mortality rate in Tokyo and said that when
the rate was high, fighting against starva-
tion and infectious diseases were the main
counter measures.Nowadays,improving the
provision of psychosocial support for chil-
drearing was one of the most critical issues
because of the decrease in the number of
children being born. In the city there were
many programmes to improve maternal,
neonatal, and child health, with the empha-
sis on the importance of starting childcare
during pregnancy and continuing maternal
health care after delivery.
He said the elderly population had also in-
creased rapidly in the city, the majority be-
ing born in rural areas and moving to Tokyo
for work during Japan’s period of rapid eco-
nomic growth. Most had chosen to stay and
die in Tokyo, instead of returning to their
hometowns. The characteristics of the “no
return elderly” were very different from the
elderly who had remained in rural areas.The
“No return elderly” had relatively high lev-
els of education and had often had business
careers but they tended to lack social capital
due to relatively weak family and commu-
nity networks.
Finally, Professor Nakamura spoke about
the city’s disaster preparedness plans in the
light of the earthquake and tsunami of 2011
and the lessons that had been learned. Sev-
eral hundreds of the Japan Disaster Medical
Assistance Team had provided emergency
medical services just after the earthquake.
Then, the Japan Medical Association, the
Japanese Red Cross Society, and the Japan
Primary Care Association, as well as mu-
nicipalities and private hospitals gave their
support.
He said that megacities had big advantag-
es: a lot of human resources such as health
professionals, universities and institutes
conducting health research and highly ad-
vanced infrastructures. However, from the
viewpoint of human resources, both strong
leadership with regard to public protection
and the empowerment of local communi-
ties were essential. The roles of frontline
health workers became more important at
the interface of protection and empower-
ment.The final target of health for everyone
in a megacity was to entail a harmonious
society, where people felt secure growing
up, having children, working, growing old,
and dying.
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Dr. Bechara Choucair, Commissioner of
the Chicago Department of Public Health,
spoke about the Healthy Chicago public
health agenda developed in 2011, which
served as a framework for how the Chicago
Department of Public Health was improv-
ing the health and well-being of all residents
of the city. Healthy Chicago’s development
was guided by a commitment to implement
policies, systems, and environmental chang-
es to improve population health in partner-
ship with the community. He highlighted a
part of Chicago that many people did not
see – with crowded housing, poverty, poorer
education and health. Healthy Chicago
was about making a difference in people’s
health – by identifying public health priori-
ties, setting measurable targets for each of
the priorities, identifying specific strategies
around policy systems and environmental
change, and finally finding more meaning-
ful ways to engage community partners.
He gave a snapshot of various measures be-
ing taken. On tobacco he referred to the de-
velopment of smoke free zones in the city,
the prohibition of vending machines and
the increase in fines for illegal cigarette sales.
The city also faced a problem with obesity.
Sixty per cent of the population was obese
or overweight and 20 per cent of children
entering kindergarten were obese. So the
city was working with the public schools on
a number of measures to tackle the problem.
They were also providing neighbourhood
fresh produce carts selling fresh food and
vegetable. He spoke about the measures be-
ing taken on HIV Aids, leading to a signifi-
cant decrease in the number of new cases in
the city. He referred to disparities in breast
cancer death rates between black and white
women and about heart disease. Access to
health care was also one of their priorities
with half a million of the city’s population
having no access to health insurance.
The final speaker was Dr. José Bonamigo,
from Brazil, an internist and haematologist
practicing at the Albert Einstein Hospital
in São Paulo.
He spoke about the Brazilian health system,
particularly relating to São Paulo. He said
the population of the city was 11 million
people, with 20 million in the metro region.
It was a very rich city. The national health
system was mixed public and private created
in 1990. There were three levels – the fed-
eral government, state level and city level.
Seventy five per cent of the population de-
pended on the public system with private
health for those who had insurance. Sixty
per cent of health expenditure was private
and only 40 per cent public. In São Paulo
55 per cent of the population depended on
public health, while 45 per cent had private
insurance, much higher than the national
average. While the older population was
increasing, the younger population was
shrinking.
He said the challenges facing the city in-
cluded planning and managing demo-
graphic transition, improving access and
improving primary care, which was the
weakest part of the system. He also said
there was a need to implement information
technology projects so that health budgets
could be better used.
He spoke in support of Brazil’s public
private partnership on health which had
brought about an improvement in people’s
health. The old system was 100 per cent
public health with huge underfunding. Un-
der the new model, more money was being
spent for clinical work with market rates
being paid and the system was more trans-
parent. In São Paulo the demand for doc-
tors increased, as did the salaries.
Friday October 12
Council
Council met to consider the reports from
its three committees and agreed to for-
ward these to the Assembly for adoption.
Further debates were held on the follow-
ing:
Declaration of Helsinki
It was agreed to hold an event in Helsinki
to celebrate the 50th
anniversary of the Dec-
laration in 2014 and that a history of the
document be published.
Primary Health Care
Dr. Haikerwal reported on the idea of hold-
ing a global conference on primary health
care.The idea was to hear about best practice
models around the world and to discuss how
the WMA might promote the best use of
primary care physicians.It was proposed that
a conference be held in the early part of 2013.
Ethical Implications of Physician Strikes
Leah Wapner (Israel) proposed amend-
ments to the proposed Statement that had
already been discussed in the Socio-Medical
Affairs Committee, adding the words ‘Phy-
sicians carry out protest action and sanc-
tions in order to improve direct and indirect
working conditions which also may affect
patient care’. She said the document did not
state whether physicians should or should
not take industrial action. It was ethical ad-
vice for when physicians decided to strike.
Dr. Eidelman proposed that the document
should be forwarded to the Assembly for
adoption rather than recirculated for further
discussion.
But several delegates said that the Statement
conflicted with the legislation in their coun-
tries. Dr. Janbu said that although the inten-
tion was good, the paper was not ready to be
accepted as policy and she could not support it.
Dr. Lazarus said that it would be very haz-
ardous for doctors in the USA to go on
strike, but he thought the changed word-
ing had improved the document as an ethi-
cal statement and he supported the idea of
adoption. Dr. Montgomery said the fact
was that physicians did take industrial ac-
tion and the WMA had to give them ethi-
cal guidance. It was impossible to cover the
legal situation in all 102 different states and
he supported adopting the Statement.
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WMA news
Dr. Xaviour Walker said that junior doctors
around the world faced very bad conditions,
working with no employment contracts,
very short maternity leave and unsafe work-
ing conditions. He therefore supported the
Statement. Council agreed to recommend
to the Assembly that the Statement should
be adopted.
Drugs and Methadone
Dr. Aizhan Sadykova (Kazakstan) proposed
a Statement on drugs and methadone. She
said the doctors of Kasakstan were united in
the belief that drug addiction could not be
treated by narcotics. She urged the WMA
to support this position and to consider
instead therapy that included preventive
treatment, psychological and social reha-
bilitation of dependents.
Dr.Lazarus said the proposed Statement was
contrary to existing WMA policy and con-
trary to 30 years research in the use of meth-
adone as part of a treatment for addiction.
Council agreed with the Socio-Medical Af-
fairs Committee that the Statement should
not be adopted. Council then considered
the three emergency motions that had been
proposed.
Minimum Unit Price of Alcohol
Dr. Nathanson said this Resolution was
about the right of a state to set a public
health policy in place requiring legislation.
A minimum unit price for alcohol was es-
sential because countries like the UK,which
had the second highest tax for alcohol any-
where in the world, had a major problem
with alcohol. Simply increasing tax did not
work. Minimum unit price was a method
for saying that there was an amount below
which nobody could sell alcohol. The alco-
hol industry was pressing a number of gov-
ernments to support them in trying to stop
in this case Scotland from enacting public
health legislation. It seemed unacceptable
that governments of other countries should
be interfering with a public health measure
by a government of a country with a serious
public health crisis.
Dr. Lazarus proposed new wording that
‘The WMA supports states seeking to use
such innovative measures to combat the se-
rious public and individual health effects of
excessive and problem drinking.’
Council agreed to recommend the Resolu-
tion as amended to the Assembly for adop-
tion.
Plain Packaging of Cigarettes
Dr. Nathanson said the Australian legisla-
tion on plain packaging had passed but the
tobacco industry was challenging the legal
aspects of the changes. Several countries
had said they would introduce such legisla-
tion if the Australian Government won the
legal case. Doctors and the WMA should
be seen to be supporting them.
Dr. Steve Hambleton (Australia) said the
WMA should support the stand against to-
bacco companies.Big tobacco was now sup-
porting individuals to take this issue to the
World Trade Organisation. This emergency
Resolution would give the Australian Gov-
ernment encouragement that they could
make a stand.
Council agreed to recommend the Assem-
bly to adopt the Resolution.
Professor Cyril Karabus
Dr. Mark Sonderup (South Africa) pro-
posed an emergency Resolution on the
case of Professor Cyril Karabus. He said
Prof. Karabus, a 78-year-old retired pae-
diatric haematologist from South Africa,
was working in the United Arab Emirates
10 years ago for a six week period. While
there a child under his care died. Prof.
Karabus returned to South Africa and
unknown to him a charge was brought
against him and in his absence he was
found guilty of murder. This was never
communicated to him and in August
while he was travelling through Dubai
he was arrested and jailed in Abu Dhabi.
Despite six court appearances he was re-
fused bail. The original murder charge was
dropped and this week he was granted bail
to await his trial in November. Dr. Sond-
erup said they were extremely concerned
about a number of issues and they were
not convinced that Prof. Karabus would
get access to a fair trial.
Dr. Kloiber thanked those NMAs who had
raised this issue and urged other associations
to take action.Council agreed to recommend
the Assembly to adopt the Resolution.
Ceremonial Session
The official opening of the 63rd
General As-
sembly then took place. WMA President
Dr. José Luiz Gomes do Amaral called the
Assembly to order, before Dr. Kloiber in-
troduced the delegations from the national
medical associations and the observers of
international organisations.
Delegates were welcomed by the guest of
honour, Royal Privy Council, Prof. Dr. Kas-
em Wattanakul, and by Dr. Wonchat Sub-
hachaturas, President of the Medical Asso-
ciation of Thailand.
Dr. Haikerwal, Chair of Council, paid trib-
ute to the retiring President, Dr. Gomes do
Amaral, who delivered a valedictory ad-
dress.
Dr.Cecil Wilson was then installed as Pres-
ident of the WMA for 2012/13 and gave
his inaugural address.
Saturday October 13
Assembly Plenary Session
President Elect
Dr. Margaret Mungherera, President of the
Uganda Medical Association, was elected
unopposed as President-elect. Dr. Mung-
herera, a psychiatrist, will take up office
in October 2013 and will serve for a year,
becoming the first woman President of the
178
WMA news
WMA since 2002 and the first African
woman.
Dr. Mungherera thanked the Assembly for
their support and said she had been a doctor
for 30 years and a psychiatrist for 20 years
with forensic psychiatry as her special area
of interest. She had studied medicine at
Makerere University Medical School in
Kampala, Uganda, before taking a diploma
in tropical medicine at the London School
of Tropical Medicine and Hygiene. For the
past 10 years she had been senior consul-
tant psychiatrist at Mulago National Refer-
ral Hospital, Kampala. She was a founder
member of Uganda Women Medical Doc-
tors Association and was the first woman
in Uganda to be elected President of the
Uganda Medical Association in 1998 and
again in 2010. She was in the forefront of
bringing together the national medical as-
sociations in Eastern Africa (Kenya, Ugan-
da, Tanzania and Rwanda) long before the
revived East African Community started its
work.
She said that one of her dreams was to get
the poorer nations participating more in the
WMA. She said she would like to see regu-
lar regional meetings so that the poorer and
smaller member associations could gather
together to discuss the many policies ad-
opted by the WMA.
Council Report
The Assembly received the report of the
Council. Dr. Kloiber spoke about the year’s
activities and emphasised that the WMA
was there to support NMAs if needed. He
encouraged NMAs to consider applying for
a grant related to the counterfeit medicine
project and to consider nominating candi-
dates to attend the next leadership course in
January 2013.
Advanced Technology
Dr. Haikerwal said that when there was a
discussion on this topic earlier in the meet-
ing it became clear there was little consid-
eration of the positive role of health profes-
sionals in relation to the use of technology
in the health care sector. As a result a paper
would be drafted by Dr. Hambleton (Aus-
tralia) for presentation at the next meeting.
Ethical Implications of Collective Action
by Physicians
A further lengthy debate took place about
the wording of the document after Dr. Son-
derup proposed an amendment to make it
clear that ‘Physicians may take part in in-
dividual acts or collective actions provided
a minimum level of health care service is
maintained.’ This led to a discussion about
the meaning of the word ‘minimum’, with
delegates arguing that this could not be pre-
cisely defined. After several interventions,
Dr. Hambleton said the document should
simply read ‘Physicians may carry out pro-
test action.’This was eventually supported.
Several speakers then opposed the idea of
opening the document with a negative sen-
tence about physicians’ dissatisfaction with
their working conditions. This prompted a
wider debate about whether the document
should be recirculated among NMAs or ad-
opted by the Assembly. On a vote, it was
overwhelmingly decided against recirculat-
ing the document.
The meeting then voted to retain the open-
ing sentence about physicians’working con-
ditions, but agreed to amend it to read ‘In
recent years, in countries where physicians’
satisfaction with their working conditions
has decreased, collective action by physi-
cians has become increasingly common.’
Dr.  Hambleton said it was important for
the WMA to be seen to be providing lead-
ership on this issue.
The amended Statement was finally adopt-
ed as WMA policy.
Adopted Statements and Resolutions
The Assembly also adopted the following
documents:
• Resolution on a Minimum Price for Al-
cohol
• Resolution on Plain Packaging of Ciga-
rettes
• Resolution in Support of Professor Cyril
Karabus
• Revised Declaration on Medical Ethics
and Advanced Technology
• Statement on Organ Tissue and Dona-
tion
• Resolution on Physician Participation in
Capital Punishment
• Revised Regulations in Times of Armed
Conflict and Other Situations of Vio-
lence
• Statement on Electronic Cigarettes and
Other Nicotine Delivery Systems
• Statement on Violence in the Health
Sector by Patients and Those Close to
Them
• Statement on Forced and Coerced Ster-
ilisation
• Statement on the Prioritisation of Vac-
cination
• Resolution on the Abuse of Psychiatry
Report of the Treasurer
Dr. Frank Ulrich Montgomery, the Trea-
surer, reported that net income had
strengthened over recent years, although
there had been a decrease in membership
dues. He hoped that associations would pay
their dues each year. He assured the As-
sembly that the money of the Association
was safely invested and that the positive
financial trend started in 2005 had been
maintained.
The Assembly adopted the Financial State-
ment for the year ended 2011 and the Bud-
get for 2013.
Membership
The Assembly agreed that the Myanmar
Medical Association and the Sri Lanka
Medical Association be admitted into
WMA membership, bringing the total
number of NMA members to 102.
It was also agreed that the French Medical
Association be replaced by the Conseil Na-
tional de l’Ordre des Medecins and that the
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WMA news
Romanian Medical Association be replaced
by the Romanian College of Physicians.
Strategic Plan
The Strategic Plan 2013–15 was adopted.
WMA Meetings
It was agreed that the 2014 Assembly take
place in Durban, South Africa and that
the decision about a venue for the 2015
meetings should be taken by the Executive
Committee.
World Dental Federation
In a presentation to the Assembly, Dr. Tin
Chun Wong, President elect of the World
Dental Federation, said that the FDI and
the WMA had been working closely to-
gether through joint membership of World
Health Professions Alliance. They had
worked together on producing the toolkit
for prevention of NCDs, first in paper form
and now online. Both organisations should
take immense pride in developing one of
the few practical tools available on the mar-
ket.
She then spoke about the FDI’s new stra-
tegic plan, Vision 2020, which she de-
scribed as a road map for the future of the
dental profession. Its aim was to focus on
emerging issues likely to impact the den-
tal profession, such as areas of regulation,
legislation and advocacy, and she added
that if they did not do this other bod-
ies would, notably politicians. The docu-
ment provided a sketch of how oral health
might look in 2020 and paved the way for
a new model of oral health care. Vision
2020 was of extreme importance to den-
tal profession and also to the partners of
the WHPA. Dr. Wong said she trusted it
would generate collaboration with other
professions.
The document laid bare a number of is-
sues, such as unequal access to oral health
care around the world. In some parts of
Europe there was one dentist for every
560 people and in some parts of the un-
der developed world that figure was 1 per
1.2 million. Even in a wealthy area such as
California some two million people, eight
per cent of the population, were missing
hours of work and school because of den-
tal diseases.
Dr. Wong said the document focused on a
new model for oral health care which called
for a move to a preventive approach.
World Veterinary Association
A short ceremony was held for the WMA
and the World Veterinary Association to
sign a Memorandum of Understanding.
Dr. Cecil Wilson, President of the WMA,
said the two professions shared much in
common, whether on drug research, ag-
riculture or nutrition. The interaction be-
tween the two professions was critical in
treating and diagnosing.The Memorandum
committed both organisations to the inter-
national movement, One Health Initiative,
with the opportunity for continuing col-
laboration.
Dr. Faouzi Kechrid, President of the WVA,
welcomed this new mutually beneficial re-
lationship, which would allow both organ-
isations to collaborate on improving global
health and working on surveillance to pre-
vent zoonotic disease.
Associate Members
Dr. Xaviour Walker, outgoing Chair of the
Junior Doctors Network, reported on the
progress that the network had made over
the past year. The Network was a platform
for experience sharing and resource devel-
opment and worked closely with the NMAs
and with the International Federation of
Medical Students Associations. The Net-
work had held three meetings and he said
it was important to keep contributing to
WMA policies.The Network had produced
the Social Media white paper, and were
currently working on a review of physician
wellbeing and global health training.
Open Forum
An Open Meeting was then held, when
NMAs and observers were invited to talk
about any issue.
Organ Transplants
Hernan Reyes, from the International
Committee of the Red Cross, who said he
had spent 22 years working with the WMA,
congratulated the Assembly on adopting its
document on organs transplants. But he
said that there was no mention about living
donors and the hidden issue of economic
pressure where people felt under pressure
to sell their kidneys for an iPad or a car.
Although this was not allowed, there was a
‘don’t ask don’t tell’tendency and some doc-
tors were discreetly making a lot of money
selling organs from so called relatives. He
urged NMAs to be alert to these pressures
and to ensure their physicians knew they
should not accept organs unless they knew
where they came from.
Bahrain
Dr. Rudolph Henke (Germany), a delegate
in the German Parliament, reported on his
visit to Bahrain with a delegation from the
German Parliament. They had met official
representatives of the Royal Family, hu-
man rights activists and with four people
who had received prison sentences. Those
who had been jailed said that a number of
doctors and nurses had been detained and
abused, stripped of their clothes made to
dance naked in front of their guards, beaten
and subjected to other ill treatment. Other
colleagues from academia and scientific cir-
cles had also been detained and some had
been stripped of their licence and could no
longer work. He said that after the dem-
onstrations in the country the Royal Fam-
ily had appointed a committee to examine
these accusations. A 500-page report had
now been published, answering the accusa-
tions levelled at government. Health pro-
fessionals who had been jailed were more
or less pardoned or reprieved. But recently
there had been more arrests, trials and con-
victions. Some of these sentences, ranging
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WMA news
Dr. Otmar Kloiber, Secretary General,
presented the annual report of Council to
the General Assembly, combined with his
report from the secretariat. Among the sig-
nificant activities during the year were:
Non-Communicable Diseases
This was one of the most important top-
ics on the public health agenda.The WMA
had concerns from the beginning about
the WHO’s identification of four specific
NCDs-namely, cardiovascular disease,
cancer, lung and respiratory disease, and
diabetes-as a focus of the NCD initiative.
The risk of selecting particular diseases as
a focus was a return to a silo-based ap-
proach to public health, similar to that of
previous years when the focus was largely
concentrated on HIV/AIDS, tuberculosis,
malaria, and river blindness. The WMA
advocated a comprehensive approach that
linked individual risk factors with social
and economic determinants of health, con-
ditions in which people were born, grew up,
lived, worked and aged, and the influences
of society. The WMA emphasised the need
to take a holistic approach, and suggested
targets should address the elimination of
inequalities in health care. The WHO was
currently developing a 2013–2020 Global
Action Plan for the Prevention and Con-
trol of NCDs.
Together with the partners at the World
Health Professions Alliance (WHPA), the
WMA participated in the development of
the NCD toolkit to assess the risk level in
life style behaviours and bio measures in the
form of NCD indicators. It was also setting
up an independent project together with Sir
Michael Marmot (British Medical Asso-
ciation) and his team to develop a common
set of Social Determinants of Health and
NCD indicators.
Multi Drug Resistant
Tuberculosis Project
In March, the WMA launched the revised
MDR-TB online course. There was now a
complete set of TB and MDR-TB cours-
es as online versions, printed formats and
CDs.The printed courses had been translat-
ed into Azeri, Chinese, French, Georgian,
from imprisonment for a few months to
several years, were still on appeal.
Dr. Henke said that those health profes-
sionals he had met were very grateful for
the WMA support. He said he and his col-
leagues were planning to return next year to
assess the situation and review progress.
South East European Medical Forum
Dr. Andrey Kehayov, from the South East
European Medical Forum, reported on the
organisation’s progress. It now had more
than 15 members and was anxious to work
closely with the WMA.
Independence of Medical Associations
Dr. Konstanty Radzwill, from the Standing
Committee of European Doctors, warned
that they were facing in Europe attempts
to standardise medicine and healthcare
from outside the profession. This was a real
danger for physicians’ autonomy and their
patients. He said that with some support
from parts of the medical profession there
were bodies in Europe that were trying to
standardise what doctors did. The Standing
Committee was of the opinion that these is-
sues should be done only by the profession
and not by anyone outside.
Dr. Haikerwal referred to the independence
of medical associations and problems that
had occurred in Bolivia, Mexico, Slova-
kia, Poland and other countries, where the
WMA had offered its support. He said he
was particularly impressed at how the Turk-
ish Medical Association had confronted
their problems and had involved the WMA
in helping them. He said this was an ex-
ample that should be used as a template by
other NMAs.
Dr. Ozdemir Aktar (Turkey) thanked the
WMA for its help with the problems fac-
ing the Turkish Medical Association. The
issues were still unresolved and were await-
ing a decision of the Supreme Court. Last
week a new report on Turkey was pub-
lished, strongly criticising the country’s
record on freedom of speech, the number
of people in jail and the pressure on cer-
tain organisations and unions, including
the Turkish Medical Association. He said
they were now faced with another prob-
lem, with 13 medical students who were in
jail.These students had been in jail for four
months, but did not know what they were
accused of.
Dr. Kloiber said that the secretariat was in
discussions with the Turkish Medical Asso-
ciation about future action.
Secretary General’s Report
Otmar Kloiber
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WMA news
Russian Spanish and other languages may
follow. All courses could be accessed free of
charge via the WMA webpage.The printed
TB refresher course and the new MDR-
TB course were nominated by the United
States Centre for Disease Control (CDC)
as an educational highlight and received an
award.
The WMA was collaborating with the
WHO to develop the MDR-TB course as
an application for tablet computers, espe-
cially for low-cost 10-inch devices running
on Android which were increasingly used
in low-income countries. The app would be
accessible from the WMA and WHO web-
sites and, once downloaded, would be self-
contained and able to run offline without an
internet connection.
Tobacco Project
The WMA was involved in the implemen-
tation process of the WHO Framework
Convention on Tobacco Control and was
co-operating with the public private part-
nership “QuitNowTXT program” to de-
velop an evidence-based diffusion of health
information for tobacco cessation via mo-
bile phones to reach people at risk from pre-
ventable NCDs.
Alcohol
The WMA was monitoring progress on the
Global Strategy to Reduce the Harmful
Use of Alcohol and was involved in confer-
ences on the issues.
Counterfeit Medical Products
The WMA and the members of the
WHPA had stepped up their activities on
counterfeit medical issues and developed
an Anti-Counterfeit campaign with an
educational grant from Pfizer Inc. and Eli
Lilly.The basis of the campaign was the ‘Be
Aware’ toolkit for health professionals and
patients to increase awareness of this topic
and provide practical advice for action to
take in case of a suspected counterfeit med-
ical product. A  grant application process
for all national members was due to start
from mid-October. All national members
and national student organisations could
apply for a grant of 2,500–5,000 US$ for a
half year project where at least two different
health professional groups were involved.
The deadline for applications was 30 No-
vember 2012.
Health and the environment
Climate change
The WMA had been involved in the UN
Climate Change Conference in Durban in
December 2011, and in an informal con-
sultation group set up by the WHO which
brought together civil society actors work-
ing on health and environmental issues.
The WMA agreed to be a partner for the
Global Climate and Health Summit and
Prof. Dong Chun Shin (Korean Medi-
cal Association), represented the WMA
at the Summit and presented the WMA
Delhi Declaration on Health and Climate
Change.
Mercury
The WMA had been a member of the
UNEP Global Mercury Partnership since
December 2008 in order to contribute to
the goal of protecting human health and
the global environment from the release
of mercury and its compounds. This en-
gagement was based on the WMA State-
ment on Reducing the Global Burden of
Mercury (Seoul, 2008). Together with the
representatives of the Mercury Partner-
ship, the WHO and other relevant health
professionals, the WMA Secretariat was
exploring the possibility of developing joint
actions in this area.
Chemicals
Since December 2009, the WMA had been
engaged in the Strategic Approach to In-
ternational Chemicals Management of the
Chemicals Branch of the United Nations
Environment Programme, which aimed to
develop a strategy for strengthening the en-
gagement of the health sector in the imple-
mentation of the Strategic Approach. In
consultation with the WHO,Prof.Shin had
represented the WMA at several meetings.
In September 2012, the WMA,  togeth-
er with the World Federation of Public
Health Associations, the Government of
Slovenia and the WHO, organised a side
event focussing on strengthening of the
role of the health sector in international
chemicals management. This event took
place in the context of the third session of
the International Conference on Chemi-
cals Management, held in Nairobi in Sept.
2012. Participants looked at strategies while
presenting examples of some recent innova-
tions in multi-stakeholder engagement that
promise a healthy outcome for all.
Social Determinants of Health
The WMA attended as observer at the
WHO World Conference on Social Deter-
minants of Health in Rio de Janeiro in Oc-
tober 2011, which adopted a Declaration,
emphasizing the role of the health sector
in reducing health inequities. The WMA
and the International Federation of Medi-
cal Students Associations held a side-event
during the World Health Assembly in Ge-
neva to discuss ways for health care provid-
ers to implement the Rio Declaration and
engage in reducing health inequities.
Health Care Systems
The World Economic Forum had organized
a working group to develop and define the
principles of a Global Charter on Health
Data and the WMA represented the phy-
sicians’ perspective in this group and had
demanded the anonymity and aggregation
of data, as well as patient ownership rights
to the data. As the position of the WMA
relating to patient advocacy had not been
properly incorporated into this Charter, the
WMA Executive Committee had not yet
recommended signing it.
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WMA news
In June, the first ever Asia Pacific Influenza
Summit took place in Bangkok, Thailand.
Dr. Wonchat Subhachaturas was invited as
past president of WMA to present a paper
on the effect of influenza on health care
workers. The aim of the conference was to
increase awareness of the burden of influ-
enza on public health in the Asia-Pacific
region.
Person Centred Medicine
Together with the World Psychiatric Asso-
ciation, the World Organization of Family
Doctors, the World Health Organization,
the International Association of Patient
Organizations and many other partners,
the WMA held the 4th
Conference on Per-
son Centered Medicine in Geneva in May
2012.The partners were currently preparing
for the 5th
Conference to be held from April
28-May 1 2013. Dr. Jon Snaedal represent-
ed the WMA.
Positive Practice Environment
Campaign
The WMA continued its close involvement
with this campaign,spearheaded by WHPA
members together with the International
Hospital Federation, which aimed to ensure
high-quality health workplaces for qual-
ity care. Activities on a country level con-
tinued in Uganda, Morocco and Zambia,
which were among the fifty-seven countries
worldwide suffering from a critical shortage
of health care workers. The PPE Partners
were working with national health profes-
sional and hospital organisations in these
three countries to develop country projects
and improve their practice environments.
Migration & Retention
The WHO had developed the Guidelines
on Retention Strategies for Health Profes-
sionals in Rural Areas, with the WMA tak-
ing part in the drafting process. The guide-
lines were based on three pillars: educational
and regulatory incentives, monetary incen-
tives and management, and environment
and social support.
Workplace Violence in
the Health Sector
The 3rd
Conference on Workplace Violence
in the Health Sector was due take place
from 24–26 October 2012 in Vancouver.
This was supported by the International La-
bour Organisation,the International Coun-
cil of Nurses, Public Services International,
the WHO and other health organizations.
The WMA was a member of the planning
committee.
Education & Research
The World Federation for Medical Educa-
tion had started a discussion process on the
future role of the physician, involving the
WMA, and international and regional or-
ganizations for medical education
The WMA had also participated as a mem-
ber of steering groups in two projects com-
missioned by the European Union on the
Mobility and Migration of Health Profes-
sionals.
Patient Safety
The WHO had stepped up its commitment
to patient safety and had revised the exist-
ing Patient Safety Curriculum Guide for
medical schools and transformed it into a
Multi-professional Patient Safety Cur-
riculum Guide. The WMA was a member
of the reviewing committee for the multi-
professional guidelines
Caring Physicians of the
World Initiative
The fourth leadership course, organized by
the INSEAD, was held at the INSEAD
campus in Singapore from November 20–25
2011.The courses were made possible by an
unrestricted educational grant provided by
Pfizer, Inc. This work, including the prepa-
ration and evaluation of the course, was
supported by the WMA cooperating centre,
the Center for Global Health and Medi-
cal Diplomacy at the University of North
Florida.The fifth course was planned, again
at the INSEAD campus in Singapore, for
early 2013.
Health Politics
At the beginning of the year the, WMA
intervened three times on health politics
matters at the request of member associa-
tions:
In Slovakia,the government declared a state
of emergency in hospitals in order to stop
protests and industrial action by physicians
fighting for better working conditions and
against the privatisation of public hospitals.
In consultation with the Slovak Medical
Association, the WMA wrote to the Prime
Minister and the President of the Republic
to call for proper working conditions and
fair payment.
In Poland, physicians were made liable for
managing the reimbursement entitlements
of the insured. Everyone in Poland was in-
sured under a state insurance scheme which
gave various entitlements for reimburse-
ment. These different entitlements were at
least in part non-transparent to the physi-
cians, who should not be held liable for
wrongly assigning reimbursement statuses
for drugs on prescription.Together with the
Polish Chamber of Physicians and Dentist,
the WMA protested against this measure,
which later was revoked.
At the end of last year, the Turkish Gov-
ernment removed key functions such as the
supervision of physicians and the regulation
of post-graduate education from the Turk-
ish Medical Association and other self-
governing institutions. Together with the
Turkish Medical Association, the WMA
staged public events in Ankara and Istanbul
in April to fight for retaining these critical
rights of physician self-governance.
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WMA news
Social Media
The WMA Junior Doctors Network had
developed a White Paper on Social Media
and Medicine, helping to facilitate under-
standing of the mechanisms of social media,
and giving guidance on the potential uses
and risks of social media in medicine.
Physicians and Patients in
Distress Worldwide
Bahrain
Since February 2011, the WMA had been
monitoring the situation in Bahrain where
assaults on health professionals by security
forces had been reported by Amnesty In-
ternational. Several appeals were sent to the
Bahrain authorities expressing deep concern
about access to appropriate healthcare for
victims, as well as regarding the indepen-
dence of health professionals. The WMA
highlighted more specifically the case of
20 Bahraini health professionals who were
sentenced by a military court last Septem-
ber to between five and 15 years in prison in
connection with popular anti-government
protests in February and March.
Last June, following the verdict of the High
Criminal Court of Appeal regarding the 20
health professionals, the Secretariat sent
another letter expressing concern for the
4 doctors Ali ‘Esa Mansoor al-‘Ekri, Ebra-
him ‘Abdullah Ebrahim, Ghassan Ahmed
‘Ali Dhaif and Sa’eed Mothaher Habib Al
Samahij for whom the court issued arrest
orders.
Egypt
In June,the WMA sent letters to the Egyp-
tian authorities regarding the case of Mah-
moud Mohamed Amin arrested by military
forces near Al-Nour Mosque, Cairo in May
2012 because he had participated in a dem-
onstration alongside hundreds of others to
protest against military rule. He was then
referred to the military prosecutor. Accord-
ing to Amnesty International, he already
had a medical condition caused by military
forces and during his arrest was assaulted
and injured and did not receive adequate
medical care.
The WMA called upon the Egyptian au-
thorities to allow Mahmoud Mohamed
Amin to receive adequate medical care for
his medical condition, and for his immedi-
ate and unconditional release.
Iran
The Secretariat had acted in support of the
Iranian blogger Hossein Ronaghi Maleki
who was sentenced to 15 years in prison
after a trial in 2010 for being a member of
an illegal internet group, for spreading pro-
paganda against the system and for insult-
ing the leader and the President.The WMA
called on the Iranian authorities to ensure
that Mr Meleki received all necessary medi-
cal attention, including post-operative care
as called for by his doctors and the Medical
Examiner.
Syria
The Association had issued press releases
urging the Syrian authorities to call an im-
mediate ceasefire to allow the sick and the
wounded to be properly treated. The prin-
ciple of neutrality was reiterated along with
the Declaration of Tokyo, which clearly set
out guidelines prohibiting physicians from
participating in, or even being present dur-
ing the practice of torture or other forms of
cruel, inhuman or degrading procedures.
Romania
In July 2012, the WMA responded at the
request of the Romanian College of Phy-
sicians to interference by Romanian law
enforcement agencies apparently violating
the confidentiality of medical communica-
tion between physicians and their patients
and relatives respectively. Following the
attempted arrest of the previous president
of Romania, who tried to commit suicide
during the arrest and injured himself in
the process, doctors where accused of being
complicit in preventing the arrest by hos-
pitalizing the injured person. The WMA
President wrote to the Romanian authori-
ties demanding that they respect the con-
fidentiality of medical communication and
respect the rights of every patient, regard-
less of his or her civil status. The Romanian
government responded with assurances of
correct treatment.
WHO Role in Humanitarian
Emergencies
The growing threats to health personnel in
armed conflicts areas and other situations of
violence had been the subject of increasing
global debate and action over the last year.
In January 2012, the WHO Executive
Board discussed the role of the WHO
as the health cluster lead  in meeting  the
growing demands of health in humanitar-
ian emergencies with a draft resolution for
the Board’s consideration.The Safeguarding
Health in Conflict Coalition (composed of
NGOs active in the field of health and/or
humanitarian issues, including the WMA
as an observer) sent an open letter for the
attention of Member States in support of
the draft resolution. The resolution was en-
dorsed by the WHO Board, which recom-
mended its adoption by the World Health
Assembly in May.
Further to this resolution,the WHO organ-
ised a technical meeting in March, attended
by the WMA, to discuss the methods for
systematic collection and dissemination of
data on attacks on health facilities, health
workers, health transports, and patients in
complex humanitarian emergencies.
The resolution was finally adopted by the
World Health Assembly in May.  With
the resolution, Member States called on
WHO  Director General: “to provide lead-
ership at the global level in developing meth-
ods for systematic collection and dissemination
of data on attacks on health facilities,  health
workers, health transports, and patients in
complex humanitarian emergencies, in coor-
dination with other relevant United Nations
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WMA news
bodies, other relevant actors, and intergovern-
mental and nongovernmental organizations,
avoiding duplication of efforts;”
ICRC Campaign “Health
Care in Danger”
The WMA jointly organised a symposium
entitled “The security and delivery of effec-
tive and impartial health care in armed con-
flict and other situations of violence” which
took place in London in April 2012.Partici-
pants examined how to improve security and
delivery of effective and impartial health
care in armed conflict and other situations
of violence, and provided  the health  com-
munity and other important stakeholders
with an opportunity for greater engagement
with this global humanitarian issue. Dr. José
Luiz Gomes Do Amaral presented WMA
policies related to this area.
Cooperation with the
International Rehabilitation
Council for Torture Victims
As an elected member of the Executive
Committee of the IRCT, Clarisse Delorme
attended the meetings which took place in
London last November,and in Copenhagen
in September. Issues discussed included the
preparations for the upcoming General As-
sembly (November 2012, Budapest), as well
as the activities of the UN Subcommittee
on Prevention of Torture and more gener-
ally the Human Rights Council.
Detention
The WMA had been involved in the possi-
ble revision of the UN Standard Minimum
Rules for the Treatment of Prisoners by the
UN Office on Drugs and Crime, drawing
the UN Office’s attention to several relevant
WMA policies on the conditions of prison-
ers from a medical ethics and human rights
perspective.
In June, the WMA was invited by the UN
Subcommittee on Prevention of Torture to
participate in a roundtable discussion with
NGOs on mental health issues in places of
deprivation of liberty. The aim of the event
was to enhance the Committee’s skills and
efficiency in preventing torture and ill-
treatment in mental health institutions and
to improve the situation of the mentally ill
and the disabled by raising human rights
standards and legal safeguards for this pop-
ulation.
Women and Children,
and Health
During the World Health Assembly, the
WMA organised a reception for Ministers
of Health and Heads of Delegations of the
Assembly. The Honorable Kathleen Sebel-
ius, the U.S. Secretary of Health and Hu-
man Services, was the key note speaker on
the topic of Women’s, Maternal and Girls’
Health – Their Futures in Our Hands.
The WMA was an observer of the advocacy
group of the mission of the Every Woman
Every Child initiative, spearheaded by UN
Secretary-General Ban Ki-moon, set up
to mobilize and intensify global action to
improve the health of women and children
around the world.
The WMA had been involved in aiming
to increase the health status of children, by
developing with the German Development
Aid Agency GIZ and the South East Asian
Ministers of Education Organisation the
‘Fit for School course’. This was designed
to promote and facilitate effective school
health programmes worldwide through
building conceptual, implementation, and
management capacity along with govern-
ments, international organisations and
NGOs in low and middle-income coun-
tries. The course would be developed in a
comprehensive yet modular way, enabling it
to be adapted to different target audiences
and national settings.
The Declaration of Helsinki
In October 2011, the WMA Council de-
cided to embark on a new process of re-
vising the Declaration. A workgroup was
formed with the mandate to present a re-
vised wording of the Declaration to the
Ethics Committee.The revision process was
accompanied by a series of expert confer-
ences to provide a platform for the inter-
national biomedical ethics community to
air diverse viewpoints on the Declaration.
The first conference was to be hosted by
the South African Medical Association in
Cape Town from 5–7 December 2012.This
would be followed by a second conference
hosted by the Japan Medical Association in
Tokyo from February 28–March 1 2013.
The Workgroup aimed to gather as much
input as possible from WMA members,
the international expert community and
relevant international organisations. A call
for comments had been sent to all WMA
members, and selected international organ-
isations had been invited to submit their
suggestions for topics requiring revision. A
public consultation on the revision process
was envisioned for spring 2013.
World Health Professions Alliance
In May 2012, the fifth WHPA leader-
ship forum discussed collaborative practice
among health professionals and the impli-
cations of the financial crisis for national
and international associations. As an out-
come of the forum, the WHPA was devel-
oping a policy statement on collaborative
practice focusing on the principle of collab-
orative practice with a global and universal
approach.
WMA Newsletter
The Secretariat has started a bi-monthly
newsletter for its members.The first two is-
sues were in July and September.
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WMA news
WMA Declaration on Medical
Ethics and Advanced Medical
Technology
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA,
October 2002 and revised by the 63rd
WMA General Assembly, Bangkok,
Thailand, October 2012
It is essential to balance the benefits and risks for persons inherent
in the development and application of advanced medical technology.
Maintaining this balance is entrusted to the judgment of the physician.
Therefore:
Medical technology should be used to promote health. Patient safe-
ty should be fully considered by the physician in the development
and application of medical technology.
In order to foster physicians› ability to provide appropriate medical
care and having sufficient knowledge of medical technology efforts
must be made to ensure the provision of comprehensive medical
education focusing on the safe and effective use and development
of medical technology.
WMA Statement on Electronic
Cigarettes and Other Electronic
Nicotine Delivery Systems
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand,
October 2012
INTRODUCTION
electronic cigarettes (e-cigarettes) are products designed to deliver
nicotine to a user in the form of a vapor.They are usually composed
of a rechargeable battery-operated heating element, a replaceable
cartridge that contains nicotine and/or other chemicals, and an at-
omizer that, when heated, turns the contents of the cartridge into
a vapor (not smoke). This vapor is then inhaled by the user. These
products are often made to look like other tobacco-derived products
like cigarettes, cigars, and pipes. They can also be made to look like
everyday items such as pens and USB memory sticks.
No standard definition of e-cigarettes exists and different manufac-
turers use different designs and different ingredients. Quality control
processes used to manufacture these products are substandard or non-
existent. Few studies have been done to analyze the level of nicotine
delivered to the user and the composition of the vapor produced.
Manufacturers and marketers of e-cigarettes often claim that use
of their products is a safe alternative to smoking, particularly since
they do not produce carcinogenic smoke. However, no studies have
been conducted to determine that the vapor is not carcinogenic, and
there are other potential risks associated with these devices: Appeal
to children, especially when flavors like strawberry or chocolate are
added to the cartridges. E-cigarettes can increase nicotine addiction
among young people and their use may lead to experimenting with
other tobacco products.
Manufacturers and distributors mislead people into believing these
devices are acceptable alternatives to scientifically proven cessation
techniques, thus delaying actual smoking cessation. E-cigarettes are
not comparable to scientifically-proven methods of smoking cessa-
tion. Their dosage, manufacture, and ingredients are not consistent
or clearly labelled. Brand stretching by using known cigarette logos
is to be deplored.
Unknown amounts of nicotine are delivered to the user, and the
level of absorption is unclear, leading to potentially toxic levels of
nicotine in the system.These products may also contain other ingre-
dients toxic to humans.
High potential of toxic exposure to nicotine by children, either by
ingestion or dermal absorption, because the nicotine cartridges and
refill liquid are readily available over the Internet and are not sold in
child resistant packaging.
Due to the lack of rigorous chemical and animal studies, as well as
clinical trials on commercially available e-cigarettes, neither their
value as therapeutic aids for smoking cessation nor their safety as
cigarette replacements is established. Lack of product testing does
not permit the conclusion that e-cigarettes do not produce any
harmful products even if they produce fewer dangerous substances
than conventional cigarettes.
Clinical testing, large population studies and full analyses of e-ciga-
rette ingredients and manufacturing processes need to be conducted
before their safety, viability and impacts can be determined as either
clinical tools or as widely available effective alternatives to tobacco
use.
RECOMMENDATIONS
That the manufacture and sale of e-cigarettes and other electronic
nicotine delivery systems be subject to national regulatory bodies
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WMA news
prior approval based on testing and research as either a new form of
tobacco product or as a drug delivery device.
That the marketing of e-cigarettes and other electronic nicotine
delivery systems as a valid method for smoking cessation must be
based on evidence and must be approved by appropriate regulatory
bodies based on safety and efficacy data.
That e-cigarettes and other electronic nicotine delivery systems be
included in smoke free laws.
Physicians should inform their patients of the risks of using e-ciga-
rettes even if regulatory authorities have not taken a position on the
efficacy and safety of these products.
WMA Statement on the Ethical
Implications of Collective Action
by Physicians
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand,
October 2012
PREAMBLE
In recent years, in countries where physicians’satisfaction with their
working conditions has decreased, collective action by physicians
has become increasingly common.
Physicians may carry out protest action and sanctions in order to
improve direct and indirect working conditions that also may affect
patient care. Physicians must consider not only their duty to indi-
vidual patients, but also their responsibility to improve the system
such that it meets the requirements of accessibility and quality.
In addition to their professional obligations, physicians are often also
employees.There may be tension between physicians’duty not to cause
harm, and their rights as employees. Therefore, physicians’ strikes or
other forms of collective action often give rise to public debate on ethi-
cal and moral issues. This statement attempts to address these issues.
RECOMMENDATIONS
The World Medical Association recommends that National Medi-
cal Associations (NMAs) adopt the following guidelines for physi-
cians with regard to collective action:
Physicians who take part in collective action are not exempt from
their ethical or professional obligations to patients.
Even when the action taken is not organized by or associated with
the National Medical Association,the NMA should ensure that the
individual physician is aware of and abides by his or her ethical ob-
ligations.
Whenever possible, physicians should press for reforms through
non-violent public demonstrations, lobbying and publicity or infor-
mational campaigns or negotiation or mediation.
If involved in collective action, NMAs should act to minimize the
harm to the public and ensure that essential and emergency health
services,and the continuity of care,are provided throughout a strike.
Further, NMAs should advocate for measures to review exceptional
cases.If involved in collective action, NMAs should provide contin-
uous and up-to-date information to their patients and the general
public with regard to the demands of the conflict and the actions
being undertaken. The general public must be kept informed in a
timely manner about any strike actions and the restrictions they
may have on health care.
WMA Statement on Forced and
Coerced Sterilisation
Adopted by the 63rd
WMA General Assembly, Bangkok , Thailand,
October 2012
The WMA recognises that no person, regardless of gender, ethnic-
ity, socio-economic status, medical condition or disability, should be
subjected to forced or coerced permanent sterilisation.
A full range of contraceptive services, including sterilisation, should
be accessible and affordable to every individual. The state may have
a role to play in ensuring that such services are available, along with
private, charitable and third sector organisations. The decision to
undergo contraception, including sterilisation, must be the sole de-
cision of the individual concerned.
As with all other medical treatments,sterilisation should only be per-
formed on a competent patient after an informed choice has been
made and the free and valid consent of the individual has been ob-
tained. Where a patient is incompetent, a valid decision about treat-
ment must be made in accordance with relevant legal requirements
and the ethical standards of the WMA before the procedure is carried
out. Sterilization of those unable to give consent would be extremely
rare and done only with the consent of the surrogate decision maker.
Such consent should be obtained when the patient is not facing a
medical emergency, or other major stressor.
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WMA news
The WMA condemns practices where a state or any other actor at-
tempts to bypass ethical requirements necessary for obtaining free
and valid consent.
Consent to sterilisation should be free from material or social in-
centives which might distort freedom of choice and should not be
a condition of other medical care (including safe abortion), social,
insurance, institutional or other benefits.
The WMA calls on national medical associations to advocate against
forced and coerced sterilisation in their own countries and globally.
WMA Regulations in Times
of Armed Conflict and Other
Situations of Violence
Adopted by the 10th
World Medical Assembly, Havana, Cuba, October
1956, and edited by the 11th
World Medical Assembly, Istanbul, Turkey,
October 1957, revised by the 35th
World Medical Assembly, Venice, Italy,
October 1983, the 55th
WMA General Assembly, Tokyo, Japan, October
2004, editorially revised by the 173rd
WMA Council Session, Divonne-
les-Bains, France, May 2006, and revised by the 63rd
WMA General
Assembly, Bangkok, Thailand, October 2012
General guidelines
Medical ethics in times of armed conflict is identical to medical eth-
ics in times of peace, as stated in the International Code of Medi-
cal Ethics of the WMA. If, in performing their professional duty,
physicians have conflicting loyalties, their primary obligation is to
their patients; in all their professional activities, physicians should
adhere to international conventions on human rights, international
humanitarian law and WMA declarations on medical ethics.
The primary task of the medical profession is to preserve health and
save life. Hence it is deemed unethical for physicians to:
• Give advice or perform prophylactic, diagnostic or therapeutic
procedures that are not justifiable for the patient’s health care;
• Weaken the physical or mental strength of a human being with-
out therapeutic justification;
• Employ scientific knowledge to imperil health or destroy life;
• Employ personal health information to facilitate interrogation;
• Condone, facilitate or participate in the practice of torture or any
form of cruel, inhuman or degrading treatment.
During times of armed conflict and other situations of violence,
standard 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 prison-
ers and the population of occupied countries.
The medical duty to treat people with humanity and respect applies
to all patients. The physician must always give the necessary care
impartially and without discrimination on the basis of age, disease
or disability, creed, ethnic origin, gender, nationality, political affilia-
tion, race, sexual orientation, or social standing or any other similar
criterion.
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 and other situations of violence.This
obligation includes a requirement to protect health care personnel
and facilities.
Whatever the context, medical confidentiality must be preserved
by the physician. However, in armed conflict or other situations of
violence, and in peacetime, 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 individuals threatened.
Privileges and facilities afforded to physicians and other health care
professionals in times of armed conflict and other situations of vio-
lence must never be used other than for health care purposes.
Physicians have a clear duty to care for the sick and injured.Physicians
should recognise the special vulnerability of some groups, including
women and children. Provision of such care should not be impeded
or regarded as any kind of offence. Physicians must never be prose-
cuted or punished for complying with any of their ethical obligations.
Physicians have a duty to press governments and other authorities
for the provision of the infrastructure that is a prerequisite to health,
including potable water, adequate food and shelter.
Where conflict appears to be imminent and inevitable, physicians
should, as far as they are able, ensure that authorities are planning
for the protection of the public health infrastructure and for any
necessary repair in the immediate post-conflict period.
In emergencies, physicians are required to render immediate atten-
tion 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.
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WMA news
Physicians must be granted access to patients, medical facilities and
equipment and the protection needed to carry out their professional
activities freely. Such access must include patients in detention cen-
tres and prisons.Necessary assistance,including unimpeded passage
and complete professional independence, must be granted.
In fulfilling their duties and where they have the legal right, physi-
cians and other health care professionals shall be identified and pro-
tected by internationally recognized symbols such as the Red Cross,
Red Crescent or Red Crystal.
Hospitals and health care facilities situated in areas where there
is either armed conflict or other situations of violence must be re-
spected by all combatants and media personnel. Health care given
to the sick and wounded, civilians or combatants, cannot be used
for publicity or propaganda. The privacy of the sick, wounded and
dead must always be respected. This includes visits from important
political figures for media purposes and also when important politi-
cal figures are among the wounded and the sick.
Physicians must be aware that, during armed conflict or other situ-
ations of violence, health care becomes increasingly susceptible to
unscrupulous practice and the distribution of poor quality/counter-
feit materials and medicines, and attempt to take action on such
practices.
The WMA supports the collection and dissemination of data relat-
ed to assaults on physicians, other health care personnel and medi-
cal facilities, by an international body. Such data are important to
understand the nature of such attacks and to set up mechanisms to
prevent them. Assaults against medical personnel must be investi-
gated and those responsible must be brought to justice.
Code of conduct: duties of physicians working in armed conflict
and other situations of violence
Physicians must in all circumstances:
• Neither commit nor assist violations of international law (inter-
national humanitarian law or human rights law);
• Not abandon the wounded and sick;
• Not take part in any act of hostility;
• Remind authorities of their obligation to search for the wounded
and sick and to ensure access to health care without unfair dis-
crimination;
• Advocate and provide effective and impartial care to the wounded
and sick (without reference to any ground of unfair discrimina-
tion, including whether they are the “enemy”;);
• Recognise that security of individuals, patients and institutions
are a major constraint to ethical behaviour and not take undue
risk in the discharge of their duties;
• Respect the individual wounded or sick person, his/her will, con-
fidence and his/her dignity;
• Not take advantage of the situation and the vulnerability of the
wounded and sick for personal financial gain;
• Not undertake any kind of experimentation on the wounded and
sick without their real and valid consent and never where they are
deprived of liberty;
• Give special consideration to the greater vulnerability of women
and children in armed conflict and other situations of violence
and to their specific health-care needs;
• Respect the right of a family to know the fate and whereabouts
of a missing family member whether or not that person is dead or
receiving health care;
• Provide health care for anyone taken prisoner;
• Advocate for regular visits to prisons and prisoners by physicians,
if such a mechanism is not already in place;
• Denounce and act,where possible,to put an end to any unscrupu-
lous practices or distribution of poor quality/counterfeit materials
and medicines;
• Encourage authorities to recognise their obligations under in-
ternational humanitarian law and other pertinent bodies of in-
ternational law with respect to protection of health care person-
nel and infrastructure in armed conflict and other situations of
violence;
• Be aware of the legal obligations to report to authorities the out-
break of any notifiable disease or trauma;
• Do anything within their power to prevent reprisals against the
wounded and sick or health care;
• Recognise that there are other situations where health care might
be compromised but in which there are dilemmas.
Physicians should to the degree possible:
• Refuse to obey an illegal or unethical order;
• Give careful consideration to any dual loyalties that the physician
may be bound by and discuss these dual loyalties with colleagues
and anyone in authority;
• As an exception to professional confidentiality, and in line with
WMA Resolution on the Responsibility of Physicians in the
Documentation and Denunciation of Acts of Torture or Cruel or
Inhuman or Degrading Treatment and the Istanbul Protocol1
,de-
nounce acts of torture or cruel, inhuman or degrading treatment
of which physicians are aware, where possible with the subject’s
consent, but in certain circumstances where the victim is unable
to express him/herself freely, without explicit consent;
• Listen to and respect the opinions of colleagues;
• Reflect on and try to improve the standards of care appropriate
to the situation;
1 Manual on Effective Investigation and Documentation of Torture and Other
Cruel, Inhuman or Degrading Treatment or Punishment, OHCHR, 1999
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WMA news
• Report unethical behaviour of a colleague to the appropriate su-
perior;
• Keep adequate health care records;
• Support sustainability of civilian health care disrupted by the
context;
• Report to a commander or to other appropriate authorities if
health care needs are not met;
• Give consideration to how health care personnel might shorten
or mitigate the effects of the violence in question, for example by
reacting to violations of international humanitarian law or human
rights law.
WMA Statement on Organ and
Tissue Donation
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand,
October 2012
PREAMBLE
Advances in medical sciences, especially surgical techniques, tis-
sue typing and immuno-suppressive drugs, have made possible
a significant increase in the rates of successful transplantation of
human organs and tissue. Yet, in all countries, a shortage of organ
donors results in potentially avoidable loss of life. National medi-
cal associations should support attempts to maximise the num-
ber of donor organs available in their countries and to ensure that
the highest ethical standards are maintained. The World Medical
Association has developed this policy to assist medical associa-
tions, physicians, other health care providers and policy makers to
achieve this.
• This policy is based on a number of core principles: altruism, au-
tonomy, beneficence, equity and justice. These principles should
guide those developing local policies and those operating within
it, both in relation to organ procurement and to the distribution
and transplantation of donor organs. All systems and processes
should be transparent and open to scrutiny.
• This statement applies to organ and tissue donation from both
deceased and living donors. It does not apply to blood donation.
Raising public awareness
It is important that individuals are aware of the option of dona-
tion and have the opportunity to choose whether or not to do-
nate organs and/or tissue after their death. Awareness and choice
should be facilitated in a coordinated multi-faceted approach
by a variety of stakeholders and means, including media aware-
ness and public campaigns. In designing such campaigns account
needs to be taken of any religious or cultural sensitivities of the
target audience.
Through awareness raising campaigns, individuals should be in-
formed of the benefits of transplantation, the impact on the lives
of those who are waiting for a transplant and the shortage of do-
nors available.They should be encouraged to think about their own
wishes about donation, to discuss their wishes with their family and
friends and to use established mechanisms to formally record them
by opting into, or out of, donation.
The WMA advocates informed donor choice. National medical as-
sociations in countries that have adopted or are considering a policy
of “presumed consent” (or opt-out), in which there is an assump-
tion that the individual wishes to donate unless there is evidence to
the contrary, or “mandated choice”, in which all persons would be
required to declare whether they wish to donate, should make every
effort to ensure that these policies have been adequately publicised
and do not diminish informed donor choice, including the patient’s
right not to donate.
Consideration should be given to the establishment of national do-
nor registries to collect and maintain a list of citizens who have cho-
sen either to donate or not to donate their organs and/or tissue. Any
such registry must protect individual privacy and the individual’s
ability to control the collection, use, disclosure of, and access to, his
or her health information for other purposes. Provisions must be in
place to ensure that the decision to sign up to a register is adequately
informed and that registrants can withdraw from the registry easily
and quickly and without prejudice.
Living organ donation is becoming an increasingly important
component of transplantation programmes in many countries.
Most living donation is between related or emotionally close in-
dividuals but small but increasing numbers are donating to people
they do not know. Given that there are health risks associated
with living organ donation, proper controls and safeguards are
essential. Information aimed at informing people about the pos-
sibility of donating organs as a living donor should be carefully
designed so as not to put pressure on them to donate. Potential
donors should know where to obtain detailed information about
what is involved, should be informed of the inherent risks and
should know that there are safeguard in place to protect those
offering to donate.
Protocols for organ and tissue donation from deceased donors
The WMA encourages its members to support the development of
comprehensive, coordinated national protocols for deceased (also
referred to as cadaveric) organ and tissue procurement in consulta-
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tion and cooperation with all relevant stakeholders. Ethical, cultural
and societal issues arising in connection with donation and trans-
plantation should be resolved, wherever possible, in an open process
involving public debate informed by sound evidence.
National and local protocols should provide detailed information
about the identification, referral and management of potential do-
nors as well as communication with those close to people who have
died. They should encourage the procurement of organs and tissues
consistent with this statement. Protocols should uphold the follow-
ing key principles:
• Decisions to withhold or withdraw life-prolonging treatment
should be based on an assessment of whether the treatment is
able to benefit the patient. Such decisions must be, and must be
seen to be,completely separate from any decisions about donation
• The diagnosis of death should be made according to national
guidelines and as outlined in the WMA’s Declaration of Sydney
on the Determination of Death and Recovery of Organs.
• There should be a clear separation between the treating team and
the transplant team. In particular, the physician who declares or
certifies the death of a potential donor should not be involved in
the transplantation procedure. Nor should he/she be responsible
for the care of the organ recipient.
• Countries that carry out donation following circulatory death
should have specific and detailed protocols for this practice.
• Where an individual has expressed a clear and voluntary wish to
donate organs and/or tissue after death, steps should be taken to
facilitate that wish wherever possible. This is part of the treating
team’s responsibility to the dying patient.
• The WMA considers that the potential donor’s wishes are para-
mount.Relatives and those close to the patient should be strongly
encouraged to support a deceased person’s previously expressed
wish to donate organs and/or tissues.
• Those charged with approaching the patient, family members or
other designated decision maker about organ and tissue donation
should possess the appropriate combination of knowledge, skill
and sensitivity for engaging in such discussions. Medical students
and practising physicians should seek the necessary training for
this task, and the appropriate authorities should provide the re-
sources necessary to secure that training.
• Donation should be unconditional. In exceptional cases, requests
by potential donors, or their substitute decision makers, for the
organ or tissue to be given to a particular recipient may be consid-
ered if permitted by national law. Donors seeking to apply condi-
tions that could be seen as discriminatory against certain groups,
however, should be declined.
Hospitals and other institutions where donation occurs should en-
sure that donation protocols are publicised amongst those likely to
use them and that adequate resources are available for their imple-
mentation. They should also foster a pro-donation culture within
the institution in which consideration of donation is the norm,
rather than the exception, when a patient dies.
The role of transplant coordination is critical to organ donation.
Those performing coordination act as the key point of contact be-
tween the bereaved family and the donation team and usually also
undertake the complex logistical arrangements to make donation
happen.Their role should be recognised and supported.
Deceased organ donation must be based on the notion of a gift,
freely and voluntarily given. It should involve the voluntary and un-
pressured consent of the individual provided before death (by opt-
ing in or opting out of donation depending upon the jurisdiction) or
the voluntary authorisation of those close to the deceased patient if
that person’s wishes are unknown.The WMA is strongly opposed to
the commercialisation of donation and transplantation.
Prospective donors or their substitute health care decision makers1
should have access to accurate and relevant information, including
through their general practitioners. Normally, this will include in-
formation about:
• the procedures and definitions involved in the determination of
death,
• the testing that is undertaken to determine the suitability of the
organs and/or tissue for transplantation and that this may reveal
previously unsuspected health risks in prospective donors and
their families,
• measures that may be required to preserve organ function until
death is determined and transplantation can occur,
• what will happen to the body once death has been declared,
• what organs and tissues can be donated,
• the protocol that will be followed in the event that the family
objects to donation, and
• the possibility of withdrawing consent.
Prospective donors or their substitute health care decision makers
should be given the opportunity to ask questions about donation
and should have their questions answered sensitively and intelligibly.
Where both organs and tissues are to be donated, information
should be provided,and consent obtained,for both together in order
to minimise distress and disruption to those close to the deceased.
In some parts of the world a contribution towards funeral costs is
given to the family of those who donate.This can be viewed either
1 The term “substitute health care decision maker” is intended to refer to any
person properly designated to make health care related decisions on behalf
of the patient.
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as appropriate recognition of their altruistic act or as a payment
that compromises the voluntariness of the choice and the altruistic
basis for donation. The interpretation may depend, in part, on the
way it is set up and managed. When considering the introduction
of such a system, care needs to be taken to ensure that the core
principles of altruism, autonomy, beneficence, equity and justice
are met.
Free and informed decision making requires not only the provision
of information but also the absence of coercion.Any concerns about
pressure or coercion should be resolved before the decision to do-
nate organs or tissue is made.
Prisoners and other people who are effectively detained in institu-
tions should be eligible to donate after death only in exceptional
circumstances where:
• there is evidence that this represents their long-standing and con-
sidered wish and safeguards are in place to confirm this; and
• their death is from natural causes; and
• the organs are donated to a first or second degree relative either
directly or through a properly regulated pool.
In jurisdictions where the death penalty is practised, executed pris-
oners must not be considered as organ and/or tissue donors. While
there may be individual cases where prisoners are acting voluntar-
ily and free from pressure, it is impossible to put in place adequate
safeguards to protect against coercion in all cases.
Allocation of organs from deceased donors
The WMA considers there should be explicit policies, open to pub-
lic scrutiny, governing all aspects of organ and tissue donation and
transplantation, including the management of waiting lists for or-
gans to ensure fair and appropriate access.
Policies governing the management of waiting lists should ensure
efficiency and fairness.Criteria that should be considered in allocat-
ing organs or tissue include:
• severity and urgency of medical need
• length of time on the waiting list
• medical probability of success measured by such factors as age,
type of disease, likely improvements in quality of life, other com-
plications, and histocompatibility.
There should be no discrimination based on social status, lifestyle or
behaviour. Non-medical criteria should not be considered.
Living donation is becoming increasingly common as a way to over-
come the shortage of organs from deceased donors. In most cases
donors provide organs to relatives or people to whom they are emo-
tionally close. A small number of individuals choose to donate an
organ altruistically to a stranger. Another scenario is where one or
more donor and recipient pairs are incompatible with each other but
donate in the form of a cross-over or pooled donation system (for
example, donor A donates to recipient B, donor B donates to recipi-
ent C and donor C donates to recipient A).
All potential donors should be given accurate and up to date in-
formation about the procedure and the risks of donation and have
the opportunity to discuss the issue privately with a member of the
healthcare team or a counsellor. Normally this information will in-
clude:
• the risks of becoming a living donor,
• the tests that are undertaken to assess suitability for donation and
that this may reveal previously unsuspected health problems,
• what will happen before, during and after donation takes place,
and
• in the case of solid organs, the long-term implications of living
without the donated organ.
Prospective donors should be given the opportunity to ask ques-
tions about donation and should have their questions answered sen-
sitively and intelligibly.
Procedures should be in place to ensure that living donors are act-
ing voluntarily and free from pressure or coercion. In order to avoid
donors being paid and then posing as a known donor, independent
checks should also be undertaken to verify the claimed relationship
and, where this cannot be proven, the donation should not proceed.
Such checks should be independent of the transplant team and
those who are caring for the potential recipient.
Additional safeguards should be in place for vulnerable donors, in-
cluding but not only, people who are dependent in some way (such
as competent minors donating to a parent or sibling).
Prisoners should be eligible to be living donors only in exceptional
circumstances, to first or second degree family members; evidence
should be provided of any claimed relationship before the donation
may proceed.Where prisoners are to be considered as living donors,
extra safeguards are required to ensure they are acting voluntarily
and are not subject to coercion.
Those who lack the capacity to consent should not be considered
as living organ donors because of their inability to understand and
decide voluntarily. Exceptions may be made in very limited circum-
stances, following legal and ethical review.
Donors should not lose out financially as a result of their donation
and so should be reimbursed for general and medical expenses and
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any loss of earnings incurred. In some parts of the world individuals
are paid for donating a kidney, although in virtually all countries
the sale of organs is unlawful. The WMA is opposed to a market
in organs.
Protocols for free and informed decision making should be followed
in the case of recipients of organs or tissue. Normally, this will in-
clude providing information about:
• the risks of the procedure,
• the likely short, medium and long-term survival, morbidity, and
quality-of-life prospects,
• alternatives to transplantation, and
• how organs and tissues are obtained.
Organs or tissue suspected to have been obtained through unlawful
means must not be accepted for transplantation
Organs and tissues must not be sold for profit. In calculating the
cost of transplantation, charges related to the organ or tissue itself
should be restricted to those costs directly associated with its re-
trieval, storage, allocation and transplantation.
Transplant surgeons should seek to ensure that the organs and tis-
sues they transplant have been obtained in accordance with the pro-
visions of this policy and should refrain from transplanting organs
and tissues that they know, or suspect, have not been procured in a
legal and ethical manner.
In the case of a delayed diagnosis for infection, disease or malig-
nancy in the donor, there should be a strong presumption that the
recipient will be informed of any risk to which they may have been
exposed. Individual decisions about disclosure need to take account
of the particular circumstances, including the level and severity of
risk. In most cases disclosure will be appropriate and should be
managed carefully and sensitively.
FUTURE OPTIONS
Public health measures to reduce the demand for donated organs
should be seen as a priority, alongside moves to increase the effec-
tiveness and success of organ donation systems.
New developments and possibilities, such as xenotransplan-
tation and the use of stem cell technology to repair damaged
organs, should be monitored. Before their introduction into
clinical practice such technologies should be subject to scien-
tific review and robust safety checks as well as ethical review.
Where, as with xenotransplantation, there are potential risks
that go beyond individual recipients, this process should also
involve public debate.
WMA Statement on
the Prioritisation of
Immunisation
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand,
October 2012
PREAMBLE
Vaccination use to prevent against disease was first done successfully
by Jenner in 1796 when he used cowpox material for vaccination
against smallpox. Since then, vaccination and immunisation have
been acknowledged as an effective preventive strategy for several
communicable diseases and are now being developed for the control
of some non-communicable diseases.
Vaccine development and administration are some of the most sig-
nificant interventions to influence global health in modern times.
It is estimated that immunisation currently prevents approximately
2.5 million deaths every year, saving lives from diseases such as
diphtheria, tetanus, whooping cough (pertussis) and measles. Ap-
proximately 109 million children under the age of one are fully
vaccinated with the diphtheria-tetanus-pertussis (DTP3) vaccine
alone.
Mostly the ultimate goal of immunisation is the total eradication
of a communicable disease. This was achieved for smallpox in 1980
and there is a realistic goal for the eradication of polio within the
next few years.
The Global Immunisation Vision Strategy (GIVS) 2006–2015 was
developed by the WHO and UNICEF in the hope of reaching tar-
get populations who currently do not have immunisation services or
who do not have an adequate level of coverage.
The four strategies promoted in this vision are:
• Protecting more people in a changing world
• Introducing new vaccines and technologies
• Integrating immunisation, other linked health interventions and
• Surveillance in the health systems context
• Immunizing in the context of global interdependence1
1 World Health Organization and United Nations Children’s Fund. Global
Immunisation Vision and Strategy, 2006–2015. Geneva, Switzerland:
World Health Organization and United Nations Children’s Fund; 2005.
Available at: http://www.who.int/immunisation/givs/related_docs/en/in-
dex.html
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Vaccine research is constantly revealing new possibilities to protect
populations from serious health threats. Additionally, new strains
of diseases emerge requiring the adaptation of vaccines in order to
offer protection.
The process of immunisation requires an environment that is re-
sourced with appropriate materials and health workers to ensure the
safe and effective administration of vaccines. Administration of vac-
cines often requires injections, and safety procedures for injections
must always be followed.
Immunisation schedules can vary according to the type of vaccine,
with some requiring multiple administrations to be effective. It is
vitally important that the full schedule is followed otherwise the
effectiveness of the vaccine may be compromised.
The benefits of immunisation have had a profound effect on popula-
tions,not only in terms of preventing ill health but also in permitting
resources previously required to treat the diseases to be redirected to
other health priorities. Healthier populations are economically ben-
eficial and can contribute more to society.
Reducing child mortality is the fourth of the United Nation’s Mil-
lennium Development Goals, with immunisation of children hav-
ing a significant impact on mortality rates on children aged under
five. According to the WHO, there are still more than 19 million
children who have not received the DTP3 vaccine.In addition,basic
health care services for maternal health with qualified health care
personnel must be established.
Immunisation of adults for diseases such as influenza and pneu-
mococcal infections has been shown to be effective, not only in
decreasing the number of cases amongst those that have received
immunisation but also in decreasing the disease burden in soci-
ety.
The medical profession denounce any claims that are unfounded
and inaccurate with respect to the possible dangers of vaccine ad-
ministration. Claims such as these have resulted in diminished im-
munisation rates in some countries.The result is that the incidences
of the diseases to be prevented have increased with serious conse-
quences for a number of persons.
Countries differ in immunisation priorities, with the prevalence
and risk of diseases varying among populations. Not all countries
have the same coverage rates, nor do they have the resources to
acquire, coordinate, distribute or effectively administer vaccines to
their populations, often relying on non-governmental organizations
to support immunisation programmes. These organizations in turn
often rely on external funding that may not be secure. In times of
global financial crisis, funding for such programmes is under con-
siderable pressure.
The risk of health complications from vaccine-preventable diseases
is greatest in those who experience barriers in accessing immunisa-
tion services.These barriers could be cost,location,lack of awareness
of immunisation services and their health benefits or other limiting
factors.
Those with chronic diseases, underlying health issues or other risk
factors such as age are at particular risk of major complications due
to vaccine-preventable diseases and therefore should be targeted to
ensure adequate immunisation.
Supply chains can be difficult to secure,particularly in countries that
lack coordination or support of their immunisation programmes.
Securing the appropriate resources, such as qualified health profes-
sionals, equipment and administrative support can present signifi-
cant challenges.
Data collection on vaccine administration rates, side effects of
vaccines and disease surveillance can often be difficult to achieve,
particularly in isolated and under-resourced areas. Nevertheless, re-
porting incidents and monitoring disease spread are vital tools in
combating global health threats.
RECOMMENDATIONS
The WMA supports the recommendations of the Global Immuni-
sation Vision Strategy (GIVS) 2006–2015, and calls on the inter-
national community to:
• Encourage governments to commit resources to immunisation
programmes targeted to meet country specific needs.
• Recognise the importance of vaccination/immunisation through
the continued support and adoption of measures to achieve global
vaccination targets and to meet the Millennium Development
Goals, especially four (reduce child mortality), five (improve ma-
ternal health) and six (combat HIV/AIDS, malaria and other
diseases).
• Recognise the global responsibility of immunisation against pre-
ventable diseases and support work in countries that have difficul-
ties in meeting the 2012 targets in the Global Polio Eradication
Initiative1
.
• Support national governments with vulnerable populations at risk
of vaccine-preventable diseases, and the local agencies that work
1 World Health Organization. Global Polio Eradication Initiative: Strategic
Plan 2010–2012. Geneva, Switzerland: World Health Organization; 2010.
Available at:http://www.polioeradication.org/Portals/0/Document/Strategic-
Plan/StratPlan2010_2012_ENG.pdf
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to deliver immunisation services and to work with them to allevi-
ate retrictions in accessing services.
• Support vaccine research and development and ensure commit-
ment through the adequate funding of vital vaccine research.
• Promote vaccination and the benefits of immunisation, particu-
larly targeting those at-risk and those who are difficult to reach.
Comply with monitoring activities undertaken by WHO and
other health authorities.Promote high standards in the research,
development and administration of vaccines to ensure patient
safety. Vaccines need to be thoroughly tested before implemented
on a large scale and subsequently monitored in order to identify
possible complications and untoward side effects. In order to be
successful, immunisation programmes need public trust which
depends on safety.
In delivering vaccination programmes, the WMA recommends
that:
• The full immunisation schedule is delivered to provide optimum
coverage. Where possible, the schedule should be managed and
monitored by suitably trained individuals to ensure consistent de-
livery and prompt appropriate management of adverse reactions
to vaccines.
• Strategies are employed to reach populations that may be isolated
because of location, race, religion, economic status, social margin-
alization, gender and/or age.
• Ensure that qualified health professionals receive comprehensive
training to safely deliver vaccinations and immunisations, and
that vaccination/immunisations are targeted to those whose need
is greatest.
• Educate people on the benefits of immunisation and how to ac-
cess immunisation services.
• Maintain accurate medical records to ensure that valid data on
vaccine administration and coverage rates are available, enabling
immunisation policies to be based upon sound and reliable evi-
dence.
• Healthcare professionals should be seen as a priority population
for the receipt of immunisation services due to their exposure to
patients and to diseases.
The WMA calls upon its members to advocate the following:
• To increase awareness of national immunisation schedules and
of their own (and their dependents) personal immunisation his-
tory.
• To work with national and local governments to ensure that im-
munisation programmes are resourced and implemented.
• To ensure that health personnel delivering vaccines and immuni-
sation services receive proper education and training.
• To promote the evidence base and increase awareness about
the benefits of immunisation amongst physicians and the pub-
lic.
WMA Statement on Violence in
the Health Sector by Patients and
Those Close to Them
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand,
October 2012
PREAMBLE
All persons have the right to work in a safe environment without
the threat of violence. Workplace violence includes both physical
and non-physical (psychological) violence. Given that non-physical
abuse, such as harassment and threats, can have severe psychologi-
cal consequences, a broad definition of workplace violence should
be used. For the purposes of this statement we will use the widely
accepted definition of workplace violence, as used by the WHO:
“The intentional use of power, threatened or actual, against another
person or against a group, in work-related circumstances, that either
results in or has a high degree of likelihood of resulting in injury,
death, psychological harm, mal-development, or deprivation”.
Violence, apart from the numerous health effects it can have on
its victims, also has potentially destructive social effects. Violence
against health workers, including physicians, not only affects the
individuals directly involved, but also impacts the entire healthcare
system and its delivery. Such acts of violence affect the quality of
the working environment, which has the potential to detrimentally
impact the quality of patient care. Further, violence can affect the
availability of care, particularly in impoverished areas.
While workplace violence is indisputably a global issue, various cul-
tural differences among countries must be taken into consideration in
order to accurately understand the concept of violence on a universal
level. Significant differences exist in terms of what constitutes vio-
lence and what specific forms of workplace violence are most likely
to occur.Threats and other forms of psychological violence are widely
recognized to be more prevalent than physical violence. Reasons and
causes of violence in the healthcare setting are extremely complex.
Several studies have identified common triggers for acts of violence
in the health sector to be delays in receiving treatment and dissatis-
faction with the treatment provided.1
Moreover,patients may act ag-
1 Carmi-Iluz T, Peleg R, Freud T, Shvartzman P. Verbal and physical violence
towards hospital- and community- based physicians in the Negev: an observa-
tional study BMC Health Service Research 2005, 5:54. Derazon H, Nissimian
S, Yosefy C, Peled R, Hay E. Violence in the emergency department (Article
in Hebrew) Harefuah. 1999 Aug;137(3-4):95-101, 175. Landua S F. Violence
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WMA news
gressively as a result of their medical condition, the medication they
take or the use of alcohol and other drugs.Another important exam-
ple is that individuals may threaten or perpetrate physical violence
against healthcare workers because they oppose, on the basis of their
social, political or religious beliefs, a specific area of medical practice.
A multi-faceted approach encompassing the areas of legislation, se-
curity, data collection, training, environmental factors, public aware-
ness and financial incentives is required in order to successfully ad-
dress the issue of violence in the health sector.
In addition, collaboration among various stakeholders (including
governments, National Medical Associations (NMAs), hospitals,
general health services, management, insurance companies, trainers,
preceptors,researchers,police and legal authorities) is more effective
than the individual efforts of any one party.As the representatives of
physicians, NMAs should take an active role in combating violence
in the health sector and also encourage other key stakeholders to act,
thus further protecting the quality of the working environment for
healthcare employees and the quality of patient care.
This collaborative approach to addressing violence in the health sec-
tor must be promoted throughout the world.
RECOMMENDATIONS
The WMA encourages National Medical Associations (NMAs) to
act in the following areas:
Strategy – NMAs should encourage healthcare institutions to de-
velop and implement a protocol to deal with acts of violence. The
protocol should include the following:
• A zero-tolerance policy towards workplace violence.
• A universal definition of workplace violence.
• A predetermined plan for maintaining security in the workplace.
• A designated plan of action for healthcare professionals to take
when violence takes place.
• A system for reporting and recording acts of violence, which may
include reporting to legal and/or police authorities.
• A means to ensure that employees who report violence do not
face reprisals.
In order for this protocol to be effective, it is necessary for the man-
agement and administration of healthcare institutions to commu-
nicate and take the necessary steps to ensure that all staff are aware
of the strategy.
against medical and non-medical personnel in hospital emergency wards in
Israel Research Report, Submitted to the Israel National Institute for Health
Policyand Health Services Research, December 2004
Policymaking – In order to help increase patient satisfaction, na-
tional priorities and limitations on medical care should be clearly
addressed by government institutions.
The state has obligations to ensure the safety and security of patients,
physicians, and other healthcare workers. This includes providing
an appropriate physical environment. Hence, healthcare systems
should be designed to promote the safety of healthcare staff and
patients. An institution which has experienced an act of violence by
a patient may require the provision of extra security,as all healthcare
workers have the right to be protected in their work place.
In some jurisdictions, physicians might have the right to refuse to
treat a violent patient. In such cases, they must ensure that adequate
alternative arrangements are made by the relevant authorities in or-
der to safeguard the patient›s health and treatment.
Patients with acute, chronic or illness-induced mental health dis-
turbances may act violently toward caregivers; those offering care to
these patients must be adequately protected.
Training – A well-trained and vigilant staff supported by manage-
ment can be a key deterrent of violent acts. NMAs should work
with undergraduate and postgraduate education providers to ensure
that healthcare professionals are trained in the following: com-
munication skills and recognising and handling potentially violent
persons and high risk situations in order to prevent incidents of
violence.The cultivation of physician-patient relationships based on
respect and mutual trust will not only improve the quality of patient
care, but will also foster feelings of security resulting in a reduced
risk of violence.
Communication – NMAs should work with other key stakehold-
ers to increase awareness of violence in the health sector. When
appropriate, they should inform healthcare workers and the public
when acts of violence occur and encourage physicians to report acts
of violence through the appropriate channels.
Further,once an act of violence has taken place,the victim should be
informed about the procedures undertaken thereafter.
Support to victims – Medical, psychological and legal counselling
and support should be provided to staff members who have been the
victims of threats and/or acts of violence while at work.
Data Collection – NMAs should lobby their governments and/or
hospital boards to establish appropriate reporting systems enabling
all healthcare workers to report anonymously and without reprisal,
any threats or incidents of violence. Such a system should assess
in terms of number, type and severity, incidents of violence within
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WMA news
an institution and resulting injuries. The system should be used to
analyse the effectiveness of preventative strategies. Aggregated data
and analyses should be made available to NMAs.
Investigation – In all cases of violence there should be some form of
investigation to better understand the causes and to aid in preven-
tion of future violence. In some cases, the investigation may lead to
prosecution under civil or criminal codes. The procedure should be,
as much as possible, authoritative-led and uncomplicated for the
victim.
Security – NMAs should work to ensure that appropriate security
measures are in place in all healthcare institutions and that acts of
violence in the healthcare sector are given a high priority by law-
enforcement institutions. A routine violence risk audit should be
implemented in order to identify which jobs and locations are at
highest risk for violence.Examples of high risk areas include general
practice premises, mental health treatment facilities and high traffic
areas of hospitals including the emergency department.
The risk of violence may be ameliorated by a variety of means which
could include placing security guards in these high risk areas and at
the entrance of buildings, by the installation of security cameras and
alarm devices for use by health professionals, and by maintaining
sufficient lighting in work areas, contributing to an environment
conducive to vigilance and safety.
Financial – NMAs should encourage their governments to allocate
appropriate funds in order to effectively tackle violence in the health
sector.
WMA Resolution on the Abuse
of Psychiatry
Adopted by the 53rd
WMA General Assembly, Washington, DC, USA,
October 2002 and revised by the WMA General Assembly, Bangkok
2012
The World Medical Association (WMA) notes with concern evi-
dence from a number of countries that political dissidents, practi-
tioners of various religions and social activists have been detained
in psychiatric institutions and subjected to unnecessary psychiatric
treatment as a punishment and not to treat a substantiated psychi-
atric illness.
The WMA:
• Declares that such detention and unwarranted treatment is abu-
sive, unethical and unacceptable;
• Calls on physicians and psychiatrists to resist involvement in
these abusive practices;
• Calls on member NMAs to support their physician members
who resist involvement in these abuses, and
• Calls on governments to stop abusing medicine and psychiatry
in this manner, and on non-governmental organizations and the
World Health Organization to work to end these abuses; and
• Calls on governments to uphold the United Nations Interna-
tional Covenant on Civil and Political Rights, which states that
“all persons are equal before the law and are entitled without any
discrimination to the equal protection of the law.”
WMA Resolution to Reaffirm the
WMA’s Prohibition of Physician
Participation in Capital
Punishment
Adopted by the 63rd
General Assembly of the World Medical Association,
Bangkok, Thailand, October 2012
There is universal agreement that physicians must not participate
in executions because such participation is incompatible with the
physician›s role as healer. The use of a physician›s knowledge and
clinical skill for purposes other than promoting health, wellbeing
and welfare undermines a basic ethical foundation of medicine –
first, do no harm.
The WMA Declaration of Geneva states: “I will maintain the ut-
most respect for human life”; and,“I will not use my medical knowl-
edge to violate human rights and civil liberties, even under threat.”
As citizens, physicians have the right to form views about capital
punishment based on their individual moral beliefs. As members
of the medical profession, they must uphold the prohibition against
participation in capital punishment.
Therefore, be it RESOLVED that:
• Physicians will not facilitate the importation or prescription of
drugs for execution.
• The WMA reaffirms:“that it is unethical for physicians to partici-
pate in capital punishment, in any way, or during any step of the
execution process, including its planning and the instruction and/
or training of persons to perform executions”, and
• The WMA reaffirms: that physicians “will maintain the utmost
respect for human life and will not use [my] medical knowledge
to violate human rights and civil liberties, even under threat.”
197
WMA news
WMA Resolution on a Minimum
Unit Price for Alcohol
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand,
October 2012
Evidence from epidemiological and other research demonstrates a
clear link between the price of alcohol and levels of consumption,
especially amongst young drinkers and those who are heavy alcohol
users.
Setting a minimum unit price at a level that will reduce alcohol
consumption is a strong public health measure, which will both re-
duce average alcohol consumption throughout the population and
be especially effective in heavy drinkers and young drinkers.
Some states are intending to set a minimum unit price in order to
reduce the medical and social effects of excessive alcohol consump-
tion.
The WMA supports states seeking to use such innovative measures
to combat the serious public and individual health effects of exces-
sive and problem drinking.
WMA Resolution on Plain
Packaging of Cigarettes
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand,
October 2012
The WMA recognises that:
• Cigarettes offer a serious threat to the life and health of indi-
viduals that use them, and a considerable cost to the health care
services of every country;
• Those who smoke predominantly start to do so while adolescents;
• There is a proven link between brand recognition and likelihood
of starting to smoke;
• Brand recognition is strongly linked to cigarette packaging;
• Plain packaging reduces the impact of branding, promotion and
marketing of cigarettes.
The WMA encourages national governments to support moves
to introduce plain packaging of cigarettes, initially by the Federal
Government of Australia, to break the brand recognition/smoking
cycle and commends adoption of this policy to other national gov-
ernments and deplores the legal moves being taken by the tobacco
industry to oppose this policy.
WMA Resolution in Support of
Professor Cyril Karabus
Adopted by the 63rd
WMA General Assembly, Bangkok, Thailand,
October 2012
The WMA welcomes the bail granted on the 11th
of October to the
retired South African paediatric haematologist, 78-year-old Profes-
sor Cyril Karabus, as a positive step given his state of health; he has
cardiac disease. Dr. Karabus had been detained in an Abu Dhabi,
UAE prison since August 18th
2012. He was arrested in Dubai,
whilst in transit to South Africa, owing to alleged charges emanat-
ing from a brief period that he worked in the UAE in 2002.
Professor Karabus was neither informed of the charges leveled
against him nor the subsequent trial that was held in absentia relat-
ing to the unfortunate death of a child with acute leukemia under
his care during his tenure in the UAE in 2002. His defense lawyer
has also been unable to access any documents or files relating to the
case that may assist in providing a fair defense.
Therefore,
The WMA General Assembly urgently calls on the authorities of
the United Arab Emirates to ensure that Professor Karabus:
• Is guaranteed a fair trial according to international standards;
• Has access to the relevant documents or information he may re-
quire to prepare his defense.
198
WMA news
Preamble
Acknowledging that the World Veteri-
nary Association [hereinafter referred to as
WVA] is the recogn ized global professional
veterinary organisation, founded in 1863, as
an Association of 100 national veterinary
medical associations supporting the global
public good, including in animal health
and veterinary public health internationally,
food safety and the management of zoo-
notic diseases, animal welfare and disease
monitoring based on veterinary education
and evidence based science, representing
the veterinarians by promoting their health
and well-being.
Acknowledging that the World Medi-
cal Association [hereinafter referred to as
WMA] is an international professional
organisation representing physicians,
founded in 1947, and is an independent
confederation of 100 national medical as-
sociations whose purpose is to serve hu-
manity by endeavouring to achieve the
highest international standards in medical
education, medical science, medical art and
medical ethics and health care for all people
in the world.
Bearing in mind that collaboration with
the World Health Organisation [WHO]
is a key focus of WMA’s external relations
because the WMA’s core mission is to pro-
mote health and well-being of physicians
and patients. Therefore the WMA com-
mits itself to actively collaborating with
the WHO in the areas of medicine with
a strong focus on health systems develop-
ment and strengthening public health pro-
grams.
Bearing in mind also that WVA has a
longstanding collaborative agreement with
WHO based on mutually agreed objectives
that outlines activities for three-year periods.
Main areas of involvement include lowering
the burden of zoonotic diseases, increasing
food safety and improving the global health
status [healthy animals = healthy people];
raising the quality of teaching of veterinar-
ians in food safety issues and zoonosis; ad-
dressing food safety; and responsible use of
antimicrobials.
Recognizing that the World Animal
Health Organisation [OIE] is the formal-
ly mandated international animal health
standard setting body recognized by the
World Trade Organisation [WTO] and
that a long term collaborative agreement
between WVA and OIE exists. That WVA
has a Memorandum of Understanding with
the Food and Agriculture Organisation of
the United Nations [FAO] to support in-
ternational [animal] health capacity build-
ing, that extends to public health and food
safety-food security.
Both parties assist global efforts to redress
pathogen emergence and re-emergence
at the animal-human-ecosystems inter-
face. WVA is an observer in the Codex
Alimentarius Commission. Therefore it is
important to have a Memorandum of Un-
derstanding between WVA and WMA as
well.
Conscious of the prospects of a mutually
beneficial relationship and the need to es-
tablish working arrangements within a
framework of their respective rules, regula-
tions and bylaws:
The WVA and the WMA [hereinafter re-
ferred to as “The Parties”] agree to the fol-
lowing:
Section 1.Global Development Objective
The Parties will collaborate in The One-
Health concept, which is a unified approach
to veterinary and human medicine [veteri-
narians and physicians] in order to improve
Global Health.
Section 2. Scope of Cooperation
The scope of cooperation proposed by this
Memorandum of Understanding will in-
clude
2.1 Support the concept of joint educational
efforts between human medical and vet-
erinary medical schools;
2.2 Support cross species disease surveil-
lance and control efforts in order to pre-
vent zoonotic diseases
2.3 Collaborate in the responsible use of
antimicrobials with respect to critical
antimicrobial lists for humans and ani-
mals.
2.4 Enhance collaboration between hu-
man and veterinary medical profes-
sions in medical education, clinical
care, and public health and biomedical
research.
Section 3. Use of Logos
The use of the WVA-logo is specifically
prohibited without prior written approval
from WVA. The use of the WMA-logo is
specifically prohibited without prior written
approval from WMA.
Section 4. Final Provisions
This Memorandum of Understanding re-
flects the professional collaboration be-
tween WVA and WMA on a basis of
good-fellowship and shall represent the un-
derstanding of the Parties upon its signing
by the WVA and the WMA.
Memorandum of Understanding between
the World Veterinary Association and
the World Medical Association
199
Tobacco HazardsAUSTRALIA
Australian smokers will soon be plucking
their cigarettes, cigars and other tobacco
products from drab olive brown packets
emblazoned with graphic health images and
warnings, as the world’s first tobacco plain
packaging laws come into effect.
In a measure that has drawn widespread in-
ternational interest, the Australian Govern-
ment has successfully enacted laws virtually
eliminating the ability of tobacco compa-
nies to market their products through their
packaging.
From 1 December all tobacco products sold
in Australia must be in plain packaging,car-
rying large and explicit health images and
warnings covering at least 75 per cent of the
packet. Any product branding will be lim-
ited to words in small areas at the bottom
and sides of packs.
The tough measures, strongly backed by
public health organisations, came into effect
after the High Court of Australia rejected a
legal challenge mounted by the world’s major
tobacco companies. The Australian Medical
Association has been a strong advocate for
plain packaging, which it sees as an effec-
tive tool for combating the glamorisation of
smoking, particularly to young people.
In their challenge, British American Tobac-
co Australia, Japan Tobacco International,
Philip Morris and Imperial Tobacco Aus-
tralia, argued the new measures amounted
to the acquisition of their brands and logos
by the Government without just compensa-
tion, and should be ruled unconstitutional.
But the High Court found in favour of the
counter argument from the Government
that although the laws required the removal
of trademarks from all cigarette packets,
they did not weaken the companies’ exclu-
sive ownership of their trademarks.
“Although the Act regulated the plaintiffs’
intellectual property rights and imposed
controls on the packaging and presenta-
tion of tobacco products, it did not confer a
proprietary benefit or interest on the Com-
monwealth,”the High Court said in a sum-
mary of its judgement.
The Government has insisted that the laws
were aimed solely at reducing the incidence
of smoking.
“Research shows that industry branding
and packaging design on tobacco products
can mislead consumers about the harms of
smoking, make smoking more appealing –
particularly among young people – and re-
duce the effectiveness of health warnings
on tobacco products,” the Department of
Health and Ageing said.
Attorney-General Nicola Roxon, who in-
troduced the plain packaging legislation as
Health Minister, and her successor Tanya
Plibersek, said the High Court decision was
“a victory for all those families who have
lost someone to a tobacco-related illness
[and] a relief for every parent who worries
about their child picking up this deadly and
addictive habit”.
“Plain packaging is a vital preventative pub-
lic health measure, which removes the last
way for big tobacco to promote its deadly
products,” the Ministers said in a joint
statement. “Over the past two decades,
more than 24 different studies have backed
plain packaging, and now it will finally be-
come a reality.”But the tobacco industry has
not given up the fight completely.
In addition to the High Court challenge, it
has also backed action being taken by sev-
eral countries against the legislation under
trade laws.
The Dominican Republic has joined
Ukraine and Honduras in complaining that
the laws unfairly restrict trade and should
be scrapped.
While the Caribbean nation is a tiny trade
partner, exporting just $20 million worth
of goods to Australia in 2011, it is a major
producer of cigars, and has lodged a formal
complaint about the plain packaging laws
with the global trade umpire, the World
Trade Organisation.
The Dominican Republic Government
formally notified of a trade dispute by re-
questing consultations with Australia “on
certain measures concerning trademarks,
geographical indications and other plain
packaging requirements applicable to to-
bacco products and packaging” through the
auspices of the WTO.
Both Honduras and Ukraine, both tobacco-
exporting nations, are already well advanced
in the preliminary steps that need to be tak-
en before the matter proceeds to the WTO
adjudication, having requested consulta-
tions with Australia over the measure.
World-leading Plain Packaging Laws
Squeeze Big Tobacco
Steve Hambleton
200
Regional and NMA news ESTONIA
Under the WTO rules, if the matter cannot
be resolved by negotiation within 60 days,
the complainant can ask the WTO to set up
a panel to adjudicate the case.
The issue has drawn significant internation-
al interest, with a large number of countries
acting as third-party observers in the case.
The plain packaging laws are among a range
of measures being taken by Australian
governments at all levels to curb smoking,
which is estimated to cost the nation $31.5
billion a year in health expenses.
In its May Budget,the Federal Government
slashed the duty-free allowance for travel-
lers bringing tobacco products into the
country from 250 cigarettes or 250 grams
of tobacco to 50 cigarettes or 50 grams of
tobacco, and two years ago it raised the to-
bacco excise by 25 per cent.
The range and appearance of health warn-
ings on tobacco products has been in-
creased, restrictions have been imposed on
advertising tobacco products on the internet
in Australia, and access to nicotine replace-
ment therapies and other aids to quitting
smoking is subsidised.
These more recent measures follow a long-
standing nationwide ban on tobacco ad-
vertising and sponsorships, particularly of
sporting events, and the progressive in-
troduction of laws prohibiting smoking at
workplaces, sporting and entertainment
venues and enclosed public places.
Official figures show the incidence of smok-
ing among adults, particularly men, has
been steadily decreasing in recent decades.
According to the Australian Bureau of Sta-
tistics, the proportion of men who smoke
dropped from more than 27 per cent in
2001 to 23 per cent in 2008, while among
women there was a more modest reduction
from 21.2 to 19 per cent over the same pe-
riod.
The AMA has been a long-standing advo-
cate for plain packaging laws.
In mid-2009 it lobbied federal politicians to
support the Plain Tobacco Packaging Bill
introduced by independent Senator Steve
Fielding, and eight months later threw its
public support behind a decision by the
Rudd Government to introduce plain pack-
aging laws in 2012.
A year later, in July 2011, the Association
made a submission to a Parliamentary in-
quiry in which it strongly backed the Gov-
ernment’s Tobacco Plain Packaging Bill,
and AMA officials were prominent advo-
cates for the measure in the media.
Despite the breakthrough plain packaging
laws, the Australian Government is under
pressure to do more to combat smoking.
The AMA is among health groups critical
of recent investments made by a public fund
in tobacco companies.
The Government’s $73 billion Future Fund,
set up to offset future public servant su-
perannuation liabilities, invested almost
$38 million in tobacco company shares be-
tween December 2010 and February 2012.
The AMA believes it is simply irrational to
have the good work that the Federal Govern-
ment has done in tobacco plain packaging
and tax measures undermined by Future Fund
investments that help the tobacco industry to
profit from selling a lethal substance.
The Future Fund has a responsibility to in-
vest taxpayer money in a way that was con-
sistent with the interests of the country and
its people.
But the Government has so far firmly re-
sisted pressure to dictate to the Future
Fund how it should invest the money it
manages.
Dr. Steve Hambleton,
President of Australian
Medical Association
Estonian Medical Association and the
Trade Union Association of Health Offi-
cers of Estonia organised a strike to fight
for better working conditions (workload!!!
1 doctor does 2,5 “places”) to medical staff,
their salary and emigration policy!
First week of the strike – 1–7 october – in
two biggest towns in Estonia (Tartu and
Tallinn) strike was in action in ambula-
tory clinic – only children, oncological and
pregnant patients were seen during elec-
tive hours. All emergency departments and
ICU’s of course were working.
Second week of the strike – 8–14 october –
in Tartu and Tallinn  – strike affects also
stationary care (about 50% of the elective
operations are postponed and those patients
coming to hospital for evaluation/investiga-
tions are cancelled.) + ambulatory stop in
smaller hospitals in Estonia. Third week –
15-smaller hospitals also stop/inhibit their
stationary care.
Still going on…
After two weeks of strike no compromise
has been made.
During strike, government and major poli-
tic forces have gone really cheap – the me-
dia is publishing extreme numbers of doc-
tors’salaries to show people that doctors are
Estonian Physician on Strike
III
Regional and NMA newsESTONIA
just a “bunch of greedy and dumb people
who do not want to work”. Fortunately the
nurses and orderlies are not attacked, the
doctors’ take all the blame.
The demands of the strike are:
• changes in health care system in gen-
eral (more money to health sector out of
GDP, currently 6,3% )
• raising salaries for nurses, orderlies and
doctors!
• Workload management!
• To stop people leaving Estonia
Negotiations about raising salaries of medi-
cal workers which started as much as 3 years
ago, are still in progress.The salaries are still
staying the same due to the fact that no of-
ficial meetings have been successful.
The counter-act from the political side
seems to be affecting media in producing
unbelievable stories about over-paid doc-
tors who don’t know how to treat people
and only take their money out of pure
greed.
The picture the media is painting of Esto-
nian doctors right now is in really dark and
gloomy colors and we have a hard time do-
ing our jobs because there’s a lot of people
lacking trust towards us.
(Currently minimum gross wages per hour
are for doctors and dentists 7,16 € (resident
have usually 0,8 place),nurses and midwives
3,83 € and caregivers 2,11 €. Minimum sal-
ary suggestions are respectively for year
2012 8,6/5,5/3 €, 2013 10/6,6/3,35 € and
2014 12/7,7/4,2 € per hour, for assistant
doctors 60% of minimum doctors wages.
For the residents a normal 40 hours work-
week (at the moment it is paid for 32 hours
per week).
Emigrating healthcare professionals
(Doctors and nurses migration to the
abroad have been increased, partly due to
adverse environmental healthcare situa-
tion, low salaries and high workload. This
applies in particular to young doctors, for
example, 28 (26%) of this year MD gradu-
ates did not even apply to residency, most
of them went to work or study abroad.
Healthcare workers leaving: year ‘04 439,
’05 279, ’06 196, ’07 182, ’08 188, ’09 254,
’10 398. From 2010 it costs 200€ to have
certificate to work abroad as a doctor and
it is valid for 3 month. Nurses leave have
been doubled in a year (200 versus 100).
In Estonia are approximately 2 nurses per
1 doctor, for 1000 inhabitant are 7,1 nurs-
es, which is low in Europe.
Further, new doctors’ addition is not
enough. Annual retirement age exceeds
residency graduates from year 2014 (until
2027), for example, in 2023 is estimated to
have at least 100 doctor less. In 2010 there
was 4510 working doctors, 81 new doctors
graduated residency but in same time went
to abroad 146 and retired 126.)
*Campaign “I believe in the
future of Estonian Medicine”
In association with Estonian Medical
Students Association we have launched a
campaign saying “ I believe in the future of
Estonian Medicine” to promote discussion
among medical workers of what’s good in
our system and what’s bad, and to show
patients that there are still some doctors
who want to stay here and treat our own
people. The campaign t-shirts where sent
to important people in Estonia and in all
the hospitals, they were sold during the Es-
tonian Doctors Days and one can order it
on our webpage. Also little pins with the
same slogan were handed out and those
who wanted had the possibility to order
fleeces with the same slogan. The idea was
to promote discussion and that has worked
out fine – people are talking to each other
trying to figure out the weak spots in our
system and finding solutions to make situ-
ation better. We have had quite many doc-
tors and associations telling us that we’re on
the right track.
Next step of the campaign is a meeting be-
tween all different parties  – the Ministry,
the employers, employees, nurses, students,
doctors etc. For the meeting all those who
are joining in are asked to think of 3 goals
that should be fulfilled by the year of 2020
(without thinking of any restrictions  –
money ie).The main idea is to make clear if
we’re all aiming the same target or our ideas
are totally different.
• the campaign is still in action but a bit
less from our part.
• Now the minister of Social affaires has
overtaken the idea about “chatroom” –
what should we change by the time 2020.
Raili Ermel
Estonian Junior Doctors Association
16th
October 2012
Update on strike of Estoniana
doctors and nurses
A preliminary agreement was approved on Oc-
tober 25th
by Estonian Medical Assoication and
Estonian Union of Hospitals and Minister of
Social Affairs. The strike was stopped with the
agreement. Agreement encompasses: Work in-
tensity of doctors will be decreased by 20% in
outpatient clinics and 16% in case of inpatient
work. Trainees will be paid for longer hours
(from 32 hours per week currently to 40 hours
per week). Minimum salary of specialst doctors
will be increased by 11% and |that of nurses
by 17,5%.
IV
Contents
My first English Christmas, on 25 Decem-
ber 1964, was a white Christmas, in a true
sense. I was born in India, medically quali-
fied in Pakistan and started work in Whipps
Cross Hospital, East London. Those were
happy days. I saw for the first time in my
life that:
• The ground, cars, trees, rose bushes and
buildings were covered with snow.
• The patients, other doctors, the matron,
nurses, some nuns who were nurses, para-
medics, porters and all other staff includ-
ing cleaners were white.
• There were some male nurses. This was
new for me. A charge nurse was called
“Mr Rowbottom.” He was a cockney,
born in east London within sounds of
Bow bells.
• Pearly kings and queens came to hospi-
tal, sang carols and danced. I saw western
dancing for the first time. England was
peaceful, no war. Everyone looked happy
and praised the Lord. I thought it was
akin to what,I had been told,is in heaven.
• The ward sisters waited for a male consul-
tant to cut the turkey,for Christmas lunch.
He was wearing a Father Christmas cos-
tume.The atmosphere was magical.
• On the Christmas day ward round, as a
houseman, I was pushing a trolley, full
of bottles of wines and spirits. The con-
sultant poured every patient’s choice in
a glass and the ward sister, with a rare
smile, offered it to each patient, includ-
ing the one with alcoholic cirrhosis, with
a greeting “Merry Christmas & a Happy
New Year.”
• I joined the nurses in carol singing, with-
out opening my lips. I did not know car-
ols and the singing tone, but I joined in.
Since then, I am skilled in team working.
• Traditionally, some ward nurses, called
“sisters” were very powerful under the
Matron’s rule. They even influenced con-
sultants in decision making. Ironically,
I observed that one in three ward sisters
were unkind to house doctors,especially to
female doctors. However, their staff nurses
were extremely nice.They were all nicer at
Christmas time. Fortunately, I was alright,
as I am cheerful, careful and tactful.
• Charge nurses were merrier at Christmas.
I was amused, bemused and confused.
What a new white world. As a child,
I learnt that angles were white, made of
light.
• Mr Rowbottom, a Charge nurse, advised
me on my first night ward round on the
Christmas eve “Doctor, write a laxative
for each patient and the night nurse can
choose to give it without waking you up
to write for it.”Then he winked at me and
said “If you keep their bowels open they
would keep their mouths shut!”
• I was taken aback as I knew that winking,
by a male or a female, is a sexual gesture in
the East! I was startled to see that a Charge
nurse was winking at me, a strictly hetero-
sexual soul. I learnt later on that “winking”
is a benign friendly gesture in the West.
No Easterner needs to worry.This was the
beginning of my strong interest in pio-
neering new disciplines of “Transcultural
Medicine”and “Transcultural Litigation”.
That Christmas, I had thick black hair, a
moustache turning upward, slim figure, and
no sense of humour. I was a typical East-
erner. Some nurses thought that I was very
handsome. As a result of my age and west-
ernisation over last 48 years, I shall not need
a comb this Christmas and I am not be a
slim guy anymore, but I have acquired the
British sense of humour, including satire.
I  enjoy western music and dancing. I do
my best to help people, as a caring doctor
and I  issue all prescriptions or certificates
carefully. Yesterday was history, tomorrow
is mystery, I enjoy today. I hope to remain
a jolly good fellow for many more Christ-
mases. As a jolly good fellow, I wish readers
Merry Christmas and Happy New Year.
Dr. Bashir Qureshi
E-mail: drbashirqureshi@hotmail.com
Happy Christmas 2012 – My First Christmas
in 1964 was a truly White Christmas in London
The Future for Global Health Care . . . . . . . . . . . . . . . . . . 161
Valedictory address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
WMA General Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Secretary General’s Report . . . . . . . . . . . . . . . . . . . . . . . . . 180
WMA Declaration on Medical Ethics
and Advanced Medical Technology . . . . . . . . . . . . . . . . . . 185
WMA Statement on Electronic Cigarettes
and Other Electronic Nicotine Delivery Systems . . . . . . . . 185
WMA Statement on the Ethical Implications
of Collective Action by Physicians . . . . . . . . . . . . . . . . . . . 186
WMA Statement on Forced and Coerced Sterilisation . . . 186
WMA Regulations in Times of Armed Conflict
and Other Situations of Violence . . . . . . . . . . . . . . . . . . . . 187
WMA Statement on Organ and Tissue Donation . . . . . . . 189
WMA Statement on the Prioritisation of Immunisation . . 192
WMA Statement on Violence in the Health Sector
by Patients and Those Close to Them . . . . . . . . . . . . . . . . . 194
WMA Resolution on the Abuse of Psychiatry . . . . . . . . . . 196
WMA Resolution to Reaffirm the WMA’s Prohibition
of Physician Participation in Capital Punishment . . . . . . . 196
WMA Resolution on a Minimum Unit Price
for Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
WMA Resolution on Plain Packaging of Cigarettes . . . . . 197
WMA Resolution in Support of Professor
Cyril Karabus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Memorandum of Understanding between
the World Veterinary Association and
the World Medical Association . . . . . . . . . . . . . . . . . . . . . 198
World-leading Plain Packaging Laws Squeeze
Big Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Estonian Physician on Strike . . . . . . . . . . . . . . . . . . . . . . . 200