WMJ 4 2016 WEB

COUNTRY
vol. 62
Medical
World
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 4, December 2016
Contents
Valedictory speech of WMA President Sir Michael Marmot October 2016 . . . . . . . . . . . . . . . 121
Inaugural speech of WMA President 2016–2017 Dr. Ketan Desai. . . . . . . . . . . . . . . . . . . . . . . 123
WMA 2016 General Assembly Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
WMA Statement on Ageing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
WMA Statement on Cyber-Attacks on Health and Other Critical Infrastructure . . . . . . . . . 145
WMA Statement on Divestment in Fossil Fuels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
WMA Statement on Ethical Considerations in Global Medical Electives. . . . . . . . . . . . . . . . 147
WMA Statement on Obesity in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
WMA Resolution on Occupational and Environmental Health and Safety. . . . . . . . . . . . . . . 149
WMA Resolution on Refugees and Migrants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
WMA Resolution on the Protection of Health Care Facilities and Personnel in Syria. . . . . . 152
WMA Resolution on Zika Virus Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Health Care Reform in the United States: Past, Present and Future Challenges . . . . . . . . . . . 153
Health System Sustainability with Regard to Global Migration
and Refugees: the Case of Germany. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
2nd
WVA/WMA Global Conference on One Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
The UN-2030 Sustainable Development Goals and the One Health Concept:
a Case for Synergistic CollaborationTowards‘a Common Cause’. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Health Negotiations at COP22 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Editor in Chief
Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@arstubiedriba.lv, editorin-chief@wma.net
Co-Editor
Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor
Maira Sudraba, Velta Pozņaka; lma@arstubiedriba.lv
Journal design and
cover design by
Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher
The Latvian Medical Association, “Latvijas Ārstu biedrība”,
Skolas street 3, Riga, Latvia.
ISSN: 2256-0580
Dr. Ketan DESAI
WMA President
Indian Medical Association
Indraprastha Marg
110 002 New Delhi
India
Dr. Donchun SHIN
WMA Chairperson of the Finance
and Planning Committee
Korean Medical Association
46-gil Ichon-ro
Yongsan-gu, Seoul 140-721
Korea
Prof. Dr. Frank Ulrich
MONTGOMERY
WMA Vice-Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Sir Michael MARMOT
WMA Immediate Past-President
British Medical Association
BMA House,Tavistock Square
London WC1H 9JP
United Kingdom
Dr. Joseph HEYMAN
WMA Chairperson
of the Associate Members
163 Middle Street
West Newbury, Massachusetts 01985
United States
Dr. Andrew DEARDEN
WMA Treasurer
British Medical Association
BMA House,Tavistock Square
London WC1H 9JP
United Kingdom
Dr. Yoshitake YOKOKURA
WMA President-Elect
2-28-16 Honkomagome
113-8621 Bunkyo-ku,
Tokyo, Japan
Dr. Heikki PÄLVE
WMA Chairperson of the Medical
Ethics Committee
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Finland
Dr. Miguel Roberto JORGE
WMA Chairperson of the Socio-
Medical Affairs Committee
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Ardis D. HOVEN
WMA Chairperson of Council
American Medical Association
AMA Plaza, 330 N. Wabash,
Suite 39300
60611-5885 Chicago, Illinois
United States
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
World Medical Association Officers, Chairpersons and Officials
Official Journal of The World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
121
WMA General Assembly
This year I have been ever more vigorous in
promoting my two key messages on health
equity: evidence based policy and the cen-
tral role of social justice. It seemed ever
more urgent given the rise of some rather
nasty political movements with scant regard
for the truth, which has led to the notion of
‘post-fact’ politics.
Martin Luther King said it rather bet-
ter than I: ‘I believe that unarmed truth
and unconditional love will have the final
word in reality’. This is why right, tempo-
rarily defeated, is stronger than evil tri-
umphant.
My mission as WMA President, stated
clearly from the outset, was to encourage
doctors’ involvement in social determi-
nants of health and health equity. ‘Encour-
aging doctors’ includes individual doctors,
National Medical Associations and other
bodies, and the World Medical Associa-
tion.
To support this mission,I set out three aims:
• WMA issue a statement on social deter-
minants of health and health equity; and
produce a supporting publication that
would answer the question: “what do we
do?”
• Support post-graduate education and
training.
• Promote regional networking on social
determinants of health
The WMA Statement and Publication,The
Declaration of Oslo, agreed at the Council
meeting in Oslo in April 2015, was passed
by the General Medical Assembly in Mos-
cow. It sets out the importance of social de-
terminants of health (SDH) and principles
of action for WMA, NMAs and individual
doctors.
A question commonly put, sometimes even
a cri de coeur, is of the form: “I am con-
vinced but what do you want me to do?”My
colleagues at the UCL Institute of Health
Equity have prepared a document, Doctors
for Health Equity, which seeks to answer
that question. We emphasise five domains
of activity:
• Education and training
• Seeing the patient in broader perspective
• The health service as employer and its im-
pact on the local community
• Working in Partnership
• Advocacy
In addition,there is the crucial issue of mea-
surement of health equity and key determi-
nants. The report is as a way of developing
communities of action, sharing knowledge
and a source of material for budding part-
nerships at local level. It is an opportunity
for the WMA to show by their actions what
they are doing. Sharing through the report
and the web site are good ways of helping
each other in each of our member’s coun-
tries. We see this publication as continuing
to develop with the addition of case stud-
ies. We have invited NMA’s to contribute
examples.
During the year the WMA put out state-
ments consistent with this SDH theme. In
particular,following the meeting in Istanbul
on War, Migration and Health, the WMA
issued a declaration.
Training
We run a Summer School at UCL in
London on social determinants of health.
In addition, we are planning one or more
workshops with the International Asso-
ciation of Academies of Medical Science
(IAMP). The first was in Trieste. We con-
ducted a regional workshop at the Uni-
versity of Brasilia in Brazil. With BMJ
Valedictory speech of WMA President Sir Michael Marmot
October 2016
Sir Michael Marmot
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122
WMA General Assembly
Publishing we have developed a MOOC,
Mass Online Open Course on Social De-
terminants of Health. It was launched in
October 2016, and is running at the same
time as the WMA General Medical As-
sembly.
Networking
My agenda for the year was clear, involving
doctors in social determinants of health and
health equity.It is part of my broader,­
longer
term mission promoting the importance of
social determinants of health in research,
training, policy and practice. Accordingly,
my choice for the year, was to attend those
meetings that had the prospect of advanc-
ing that agenda. And proudly wearing the
WMA hat while doing so. The networking
has taken three forms.
1. Country visits. These visits have includ-
ed: BMA House London; Livingston
Zambia; Helsinki; Alpbach Austria;
USA, various cities; Suriname; Taipei;
Sweden  – Commissions++; Kolkata;
Bangkok; Istanbul; Tashkent, Uzbeki-
stan; Montevideo; Buenos Aires; Ghent
and Brussels; Trinidad and Tobago;
Panama; Canada various cities; German
MA, Hamburg; Geneva; Tel Aviv; To-
kyo; Australia; Malta; Sri Lanka.I single
out Sweden from this list to make the
point that action on social determinants
of health and health equity can be at city
level as well as at country level. Sweden
has now set up a national commission
on social determinants of health. But
prior to that it had several city commis-
sions to plan city level action. Similarly
in the UK, we have had action at city
level which is very encouraging. We did
a report for the government of Taiwan
on health inequalities. We recommend-
ed cross government action on the social
determinants of health.
2. Networking with groups. My general
strategy has been to probe gently to see
where interest is to be found.I have spo-
ken at meetings of CONFEMEL, the
confederation of Latin American Medi-
cal Societies, CMAAO, confederation
of medical associations of Asia and
Oceania, the Commonwealth Medi-
cal Association, and the World Health
Professionals Alliance. I spoke at the
EFMA meeting in Uzbekistan, which
involved doctors from the Eastern part
of the WHO European Region. We
have a partnership which includes the
constituent countries of the UK – Eng-
land,Scotland,Wales and Northern Ire-
land – as well as the Republic of Ireland.
We held a side event with the Interna-
tional Committee of the Red Cross at
the World Health Assembly. We will
now be working with them to bring a
social determinants of health frame-
work to their work.
3. Commission on Equity and Health In-
equalities in the Americas. I have been
asked by the Pan American Health Or-
ganisation, PAHO, to lead a review of
social justice and health in the Ameri-
cas. It will focus on social determinants
of health putting equity and human
rights, gender and ethnic differences,
at the heart of social action to improve
health. I will seek to engage the active
cooperation of medical societies. We
have now had our second meeting of
Commissioners. We are due to report
in Spring 2018. Fourteen countries will
become active partners in this PAHO
Commission.
While in Washington DC, I came across
this quotation from President FD Roos-
evelt: In these days of difficulties, we Amer-
icans must and shall choose the path of so-
cial justice…the path of faith, the path of
hope,and the path of love toward our fellow
man. Inspiring words for our Commission
on Equity.
Fantasy Land?
I was in Australia giving lectures for the
ABC. On a Television programme I de-
scribed extreme inequalities in income.
I used the example that the top 25 hedge
fund managers in New York, with a com-
bined annual income of $25 billion, had the
same combined income as the 48 million
people of Tanzania. When I mused about
what a fairer distribution of income could
achieve, I was told I was in Fantasy Land.
In my lecture I responded. When Martin
Luther King rose in Washington to de-
clare: “I have a dream that on the red hills of
Georgia, the sons of former slaves and the
sons of former slave owners will be able to
sit down together at the table of brother-
hood”, what if he had said: “I’ve been told
I’m in Fantasy Land. We should accept the
status quo”, there would have been no civil
rights act.
Let me invite you to join me in my Fan-
tasy Land and let us seek a fairer world and
more socially just societies.
123
WMA General Assembly
Respected Chairperson of the Council,
Sir Michael Marmot, learned dignitaries,
ladies and gentlemen. It is a great honour
and privilege for me to be here in Taipei to
assume the prestigious Presidency of the
World Medical Association. For me it has
been a humble journey, which began with
WMA as a representative of Indian Medi-
cal Association, way back in the year 2000.
Ultimately this journey has shaped itself
one step at a time, bringing me to the as-
cendency of assuming charge as President
of this august body of great intellectuals/
medical scientists – the World Medical As-
sociation.
I offer my humble salutations to our Past
President, Sir Michael Marmot. His great
and incessant work over the past years in the
field of redefining social determinants of
health, has enormously contributed towards
brightening the image of the WMA across
the Globe, in an enviable manner.
Starting an online course on
social determination on health
I sincerely appreciate the efforts of WMA
for starting an online course on Social De-
termination on Health, prepared by the In-
stitute of Health Equity at the University
College of London – under the stewardship
of Sir Michael Marmot. Coupled with the
efforts of our beloved Vivienne Nathanson,
this online course will go a long way to fulfil
many objectives of WMA in the times to
come. Yet more needs to be done in con-
tinuation with such deserving efforts.
Increasing the membership
of WMA
It is an undeniable fact that as of now out of
197 countries,WMA has only 111 countries
as members in its fold. This reality brings to
the fore that the representation of the Gulf
countries needs to be increased. The ‘repre-
sentative character’ of the WMA must be
such, that it should be recognized as rep-
resenting the true and genuine voice of the
entire Globe. This can be achieved only by
our committed and collective efforts towards
increasing WMAs membership strength.
Raising the status of WMA
Is it not a hard fact that when any Gov-
ernment talks about formulation of health
policy in its wide and varied manifestations,
they invariably ask for inputs from WHO
or any other concerned UN organization.
Efforts need to be made to take the cred-
ibility of WMA to that very level, whereby
inputs from WMA are considered as inevi-
table imperatives by each and every Gov-
ernment when they seek to crystallize and
formulate health policies.
About myself
In the fitness of things, I deem it appropri-
ate to apprise this distinguished gathering,
in nutshell, about my passion and profes-
sion. I am a Urologist by profession but a
committed educational reformist by pas-
sion.When I took over,in my home country
India, as the Head of the regulator Medical
Council of India way back in 1996, I real-
ized that my country had needed tough yet
enforceable regulations in the context of
evoking desired doctors-pharma relation-
ships, introduction of soft skills in medical
curriculum and transparency in ‘Undergrad-
uate’ and ‘Post Graduate’ medical entrance
examination and imparting of quality based
medical education. It is a matter of record
that my tenure was instrumental in placing
various ‘regulations’ in place bringing phar-
ma-doctors Code of Ethics, introduction of
Common Medical Entrance Examination
and introduction of Soft Skills and Mental
Health in the medical education curricu-
lum.These have resulted in inducing desired
quality centricity towards fulfilment of the
set out objectives, in a measurable manner.
Internationally significant issues
In this context I would like to flag some of
the international issues of urgent impor-
tance and of significant consequence as well.
Global health, which is defined as “the area
of study, research and practice that places a
priority on improving health and achieving
equity in health for all people worldwide”
needs to be incorporated in the medical
education curriculum across the world as an
inclusion of unavoidable need.
The next pertinent issue is a material reality
to the effect that health care is in danger:
Physicians are under constant threat all over
the world. Realistically speaking they risk
their lives while treating their patients in a
committed manner. They legitimately need
protection from violence while at work,
whether in war or civil conflict situations.
While on one hand in some parts of the
Inaugural speech of WMA President 2016–2017 Dr. Ketan Desai
Ketan Desai
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124
world hospitals are bombarded, ambulances
hijacked, nurses and doctors kidnapped or
killed and physicians are pressured, threat-
ened and tortured, on the other hand in
other parts of the world especially Asian
Countries, doctors are assaulted and medi-
cal establishments attacked and damaged.
The Geneva Convention is practiced more
in ‘breach’than ‘observance’, invariably end-
ing up in flagrant violation of the inviolate
human rights. It is the core commitment of
‘Physicians’ as a part of their basic duty to
help patients by their professional knowl-
edge without any distinction or discrimina-
tion of any type and magnitude. To a phy-
sician a patient is neither a ‘friend’ nor an
‘enemy’but an opportunity rendered to him
by the Almighty God to cater to a humane
cause in the most diligent and devoted pro-
fessional manner. They legitimately need
protection from violence while at work,
whether in war or civil conflict situations.
Yet another arena of vital concern turns out
to be ‘Professional Autonomy’. In many
countries like Turkey, India, United King-
dom and others,there are continued political
attempts to undo or marginalize autonomy
and self-governance of the medical profes-
sion including mauling and trampling upon
the trinity of ‘Professional autonomy, Clini-
cal independence and Self-governance’.This
is an imperative, sine-quanon, for the pink
health of the profession. Frankly speaking,
professional autonomy is not limited to ask-
ing for the privilege to do what we want
to do. It is less about physicians and more
about patient’s rights.It is the assurance that
individual physicians have the freedom to
exercise their professional judgment in the
care and treatment of their patients without
undue influence of any type from any quar-
ter how so powerful and mighty they be.
Regulation of clinical practice, framing evi-
dence based standard treatment guidelines,
defining and checking professional mal-
practice and medical education all need vital
professional independence and a democratic
system based on meaningful participative
decision making.
The WMA has been, is and must continue
to be against the Government attempts to
usurp the professional independence through
bureaucrats and politicians and making the
same ‘subservient’, as a part of their calculat-
ed nefarious designs. In a democratic society,
self-governance is an element of horizontal
power sharing and an important pillar of civ-
il society and democracy itself. Doing away
with the vital concept of self-governance will
not only amount to subverting a valuable ele-
ment of democracy but end up in devouring
the very soul of it. Borne out from the vari-
ous ‘international charters’generally and vide
the constitutional mandate,‘Right to Health’
should be a humane priority not open to
any ‘concession, compromise or condona-
tion’ of any type. This must be espoused by
WMA and all NMAs should put in all their
might at their disposal to see that the same is
wholesomely reflected in the laws enacted by
the respective Governments in their health
policies.
We need to recognize the criticality of
diligence in the present era of living in a
‘digital world’. The medical profession has
to be concerned about the protection of our
patients’ personal and health data with the
introduction of ‘e-health and m-health’.
Good quality education is essential and vital
for generating ‘Competent, Confident, Con-
cerned and Compassionate’ trained health
manpower. The same needs to be promoted.
It is imperative that the desired goals need
to be achieved by ensuring that timely ef-
forts are made at the WMA level to shift
the focus of health care from ‘Disease’ to
‘Wellness’ and from ‘Human Health’ to
‘One Health’ towards achieving the real es-
sence of unitary unification.
The unchecked malady of the unqualified
people indulging in professional medical
practice has caused and continues to cause
endless harm to society.Keeping in mind the
cardinal scientific reality that modern scien-
tific medicine is not without ill effects,it can-
not be bestowed in the hands of unqualified
and unregulated people. This is in the inter-
est of men, mankind and for upholding the
‘ethos and morality’of the profession.
It has to be our collective uppermost con-
cern that ‘equality, justice and equity’ are
fundamental bioethic principles that need
to be upheld at all costs and consequences.
There is no denying the fact that sexual vio-
lence against children and women is a serious
concern in most countries. Sexual violence
against children, whether evident or suspect,
is a common, preventable and punishable
acute medico-legal emergency. Educators are
duty bound to address sexual violence against
children, which needs to be addressed with
‘timely,appropriate and effective’intervention.
We need to take note of the stark reality that
professional honesty and integrity is at stake
in many countries. The profession should
be practiced transparently. All referrals and
prescriptions should be transparent. Referral
by physicians to health care facilities, where
they do not engage in professional activities
but in which they have a pecuniary interest
is called ‘self-referral’.This practice can influ-
ence clinical decision-making and is not in
sync with the desired ethicality and moral-
ity. Kickbacks (or fee splitting) occur when a
physician receives financial consideration for
referring a patient to a specific center or for
a specific service for which a fee is charged.
This obviously is inconsistent with a desired
value system of the profession. As such, the
physician should not receive any financial or
other consideration for referring a patient to
labs, pharmacies or opticians etc.
One needs to decipher clearly that the in-
terests of the ‘clinician’ and the ‘researcher’
may not be the same. If the same individual
is assuming both the roles, the potential
conflict should be addressed by ensuring
that appropriate steps are put in place to
protect the patient, including disclosure of
the potential ‘conflict of interest’ to the pa-
tient and all concerned.
WMA General Assembly
125
Cross Boarder Terrorism anywhere and ev-
erywhere needs to be stopped at all costs.Be
it the 9/11 terrorist attack in the USA (twin
towers), Mumbai terror attack, traumatized
Brussels, victimized Paris, school children
massacred in Pakistan, bruised Uri or any
other attack globally disrupts the tranquil-
lity and harmony of the society in an irrepa-
rable manner. Terrorism by any name and
for any reason is terrorism and terrorism
alone. There is nothing like “good” or “bad”
terrorism. It is a slur on civilization of man-
kind and hence needs to be dealt with an
iron hand and commensurate political will
by all the countries in the world.
Along with the problem of malnutrition,
‘lack of safe drinking water and poor sani-
tation’ are among the major causes of child
illnesses and deaths. The incidence of diar-
rhoea can be reduced by nearly a quarter
and the number of deaths by close to two-
thirds through improvements in safe water
supply with sanitation and hygiene.
Non communicable diseases are on the rise
globally. The focus must change from ‘sick-
ness’ to ‘wellness’ and on common country
specific life style protocols. The same needs
to be advocated strongly.
As per WHO projections, there’s a global
shortage of 7.2 million doctors, nurses and
midwives. As we begin the first full year of
our new Sustainable Development Goals,
more countries will be working towards
‘Universal health coverage’ and to meet their
health-related targets through stronger, more
equitably distributed health workforces that
include ‘community health workers, wide-
spread access to technology and a health team’
approach for bringing care to those in need.
The relevant statistics brings out that around
3 in 10 deaths globally are caused by cardio-
vascular diseases. At least 80% of premature
deaths from cardiovascular diseases could
be prevented through a healthy diet, regular
physicalactivityandavoidingtheuseoftobac-
co, but then why the same remains wanting?
In the backdrop of deafening slogans of
gender equality,every day about 830 women
die due to complications of pregnancy and
childbirth. Maternal mortality is a health
indicator that shows very wide gaps between
rich and poor, both between countries and
within them. Should the pregnant mothers
be left to die or should it not be realistic hu-
man touch to reach them in a ‘handy, acces-
sible, timely and affordable’ manner, which
would be in the interest of mother, the child
and resultantly all humanity.
Mental health disorders such as depression
are among the 20 leading causes of disabil-
ity worldwide. Depression affects around
300 million people worldwide and this
number is projected to increase. This needs
to be addressed on priority.
Almost 10% of the world’s adult population
have diabetes. People with diabetes have in-
creased risk of heart disease and stroke. It
is imperative that timely action plans are
evolved for dealing with the problem in the
context of its magnitude, so that it does not
gain proportions that would turn out to be
difficult to tackle in times to come.
Around 70% of all HIV/AIDS deaths in
2012 occurred in sub-Saharan Africa. Glob-
ally,the number of people dying from AIDS-
related causes is steadily decreasing from a
peak of 2.3 million deaths in 2005 to an es-
timated 1.6 million in 2012. As such timely
policy interventions need to be evoked.
More extreme weather and rising sea levels,
temperatures,and carbon dioxide levels are ush-
ering a wide array of human health effects,from
asthma to chikungunya to mental illness. Con-
cern on these aspects should not remain a mat-
ter of ‘lip sympathy’, that is ‘cosmetic’in nature.
Yoga and meditation
Today, more than ever, the need for preven-
tive systems of medicine is being widely
realized. Sophisticated diagnostic tools,
prescriptive drugs that come in complicated
combinations and a high level of specializa-
tion are making medical care expensive. Ill-
nesses are on the rise.
This is where Yoga comes in. Meditation
is an integral part of Yoga. The mind is the
root of most physical problems, is brought
out and guidelines for healthy living are giv-
en. Shri Narendra Bhai Modi, the Hon’ble
Prime Minister of India and a Global leader
has also emphasized the need for connect-
ing more and more people not only in In-
dia but all over the world – with Yoga and
its adoption for the complete health of the
mankind. United Nations from 2015 has
also adopted 21st
June of every year as the
International Yoga Day.
As such,the core thought that WMA has to
evolve so as to gain credibility, whereby its
inputs are availed by all the Governments
all over in formulation of their policies. Per-
haps the time has come to seriously think
about the need to create a “World Health
Keeping Force” on the lines of “World
Peace Keeping Force”. By virtue of the fact
that National Medical Associations that
have substantial membership of health pro-
fessionals with them together can jointly
go in for creation of such an ‘international
health keeping force’ under the aegis of the
WMA. This requires diligent application
of mind and evolving necessary ‘blue print’
and a resultant ‘action plan’.
This would be my endeavour of priority.
With reverence, committing myself to the
path by my illustrious predecessors who
have left their marks on the sands of time as
‘milestones’ to guide me, I sincerely commit
myself to the ‘Vedic’ ethos to the effect –
Om Sarve Bhavantu Sukhinah Sarve Santu
Nir-Aamayaah | Sarve Bhadraanni Pashy-
antu Maa Kashcid-Duhkha-Bhaag-Bhavet
The English version of the same means  –
“May all be prosperous, joyous and happy
May all be sickness free,all their way May all
gain spiritual ascendency May no one suffer,
in any way”Thank you one and all Jai Hind.
WMA General Assembly
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126
Wednesday October 19
At the invitation of the Taiwan Medical So-
ciety, delegates from more than 40 National
Medical Associations met at the Grand
Hyatt Taipei Hotel from October 19–22 for
the WMA’s 2016 General Assembly. It was
the first time the WMA had met in Taiwan
and the number of policy documents sub-
mitted for the meeting was the most ever
recorded.
Council
Dr. Ardis Hoven, Chair of the WMA,
opened the 204th
Council session, by wel-
coming the delegates and thanking the
Taiwan Medical Association for its hospi-
tality and great leadership. In particular, she
thanked Dr. Yung-Tung Wu, chairperson of
the Taipei organizing committee, as a men-
tor and great friend of the WMA.
Apologies
The Secretary General, Dr. Otmar Kloiber,
reported that apologies for absence had been
received from several Council members  –
Dr. Mark Porter from the British Medical
Association, Dr. Jorge Janez of Argentina,
who had been replaced by Dr. Ruben Tucci,
and Dr. Mzukisi Grootboom from South
Africa who had been replaced by Dr. Mark
Sonderup. There were new members of
Council, Dr Michael Gannon from Aus-
tralia, Dr. Mari Michinaga from Japan and
Dr. David Barbe from the American Medi-
cal Association.
Treasurer
In an election for Treasurer of the WMA,
Dr. Andrew Dearden,Treasurer of the Brit-
ish Medical Association, was elected unop-
posed. He succeeds Dr. Masami Ishii who
had left the leadership team of the Japan
Medical Association.
China
Dr. Kloiber responded to a question he
had been asked at the last Council meet-
ing about the use of organs from executed
prisoners in China. He had written to the
Chinese Medical Association to ask them if
the procedure was still going on. He had re-
ceived a reply from the Secretary General of
the Chinese Medical Association that read
as follows: ‘In 2007 the State Council of
WMA 2016 General Assembly Report
Taipei City,Taiwan, October 19–22
WMA General Assembly
127
China promulgated the Human Transplant
Regulation. In March 2013, the National
Health and Family Planning Commission
and the Red Cross Society of China jointly
formed the National Organ Donation and
Transplantation Committee (NODTC).
Under the leadership of the State Council
this committee is the highest policy making
body and accountable organisation for or-
gan donation and transplantation in China.
The Hangzhou Resolution fully showed the
determination of further improvement of
organ donation and transplantation system.
The NODTC made a public announce-
ment that China will fully cease the use
of the death penalty prisoners’ organ for
transplantation, with effective from January
2015. The community-based organ dona-
tion has become the only legitimate source
of transplantable organ in China since
then. The organ procurement from ‘Falun
Gong practitioners and members of other
religious and ethnic minority groups’ never
happened in China. We strongly protest
those who have ulterior motives assaulting
organ transplantation course in China, just
like the auscultation of politics and culture
in China. We sincerely hope that the organ
transplantation could benefit more patients
through efforts from different parties. And
we also hope our international peers could
learn about the reality in China and posi-
tively face the advances in China’s organ
transplantation.Therefore we firmly oppose
including this item into business item of
WMA session and abolish the 2006 policy
regarding organ procurement in China’.
Syria
A proposed emergency Resolution on the
protection of health care facilities and per-
sonnel in Syria was submitted by the Finn-
ish Medical Association and it was agreed
that this should be considered by the Socio-
Medical Affairs Committee.
Legal Adviser
The meeting approved the appointment of
a new legal adviser, Ms. Marie Colegrave-
Juge from France, who succeeds Ms. An-
nabel Seebohm. Ms. Seebohm had left to
become CEO of the Standing Committee
of European Doctors.
Finance and Planning Committee
Prof. Dong Chun Shin, Chair of the Com-
mittee, took the chair.
The Committee approved the report of the
previous meeting held in Buenos Aires.
Financial Statement
The newly elected Treasurer, Dr. Dearden,
gave a brief report on the healthy and stable
state of the Association’s finances for 2015.
The Committee agreed that the audited fi-
nancial statement for 2015 be approved by
the Council and be forwarded to the Gen-
eral Assembly for approval and adoption.
Membership Dues
The Committee received a report on mem-
bership dues payments for 2016 and on
dues categories for 2017 and agreed to for-
ward these to the General Assembly for in-
formation.
Budget
The Committee considered the proposed
Budget for 2017 and agreed that it be ap-
proved by the Council and forwarded to the
General Assembly for approval and adop-
tion.
Royal Dutch Medical Association
Dr. Kloiber reported that a request had
been received from the Royal Dutch Medi-
cal Association to abstain from voting in the
Council elections at the end of 2016 and to
obtain a council seat by increasing their de-
clared membership to 50,000 physicians.
Prof. Rutger J. van der Gaag from RDMA
said that the RDMA wished to have stron-
ger engagement with the WMA and sug-
gested this method in order to achieve this
goal.
The Committee agreed to the request and
recommended that the Council approve the
arangement.
Auditor
The Treasurer recommended the reappoint-
ment of KPMG as auditor for the 2016
WMA Financial Statement. The Commit-
tee agreed to this and recommended the
Council to approve the decision.
Strategic Plan
Dr. Kloiber reported on the WorkGroup’s
progress and indicated that a report would
be made next year.
Business Development Group
Dr.Dearden,Chair of the WorkGroup,pre-
sented a written report and gave an oral re-
port on three items – the issue of subscrip-
tions, possible forms of foundation support
Nigel Duncan
WMA General Assembly
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128
and potential sponsorship and the develop-
ment of a web-based platform for educa-
tional materials as a way of offering a new
service to members and as a possible addi-
tional source of income to the Association.
The Committee agreed to the WorkGroup’s
proposals.
WMA Meetings
The Committee considered planning and
arrangements for future WMA meetings.
It was reported that the Chinese Medical
Association had invited the WMA to hold
a meeting in Beijing for either the Council
session in 2020 or for the General Assem-
bly in 2021. The Chair said that the invita-
tion would be considered at the next meet-
ing along with any new invitations.
Dr. Jón Snædal (Iceland) informed the
Committee on the progress made for the
General Assembly in Reykjavik in 2018.
The UNESCO Chairs of Bioethics Con-
ference planned to have a three-day con-
ference, and the WMA Scientific Session
would be replaced by the third day of the
bioethics conference.
The Chair reminded the committee that the
meetings in 2017 would be held in Living-
stone, Zambia (Council) and Chicago (As-
sembly), and in 2018 in Riga (Council) and
Reykjavik (Assembly).
Dr. Kloiber reported on the first WVA-
WMA Global Conference on One Health
and said that the second conference would
be held in Fukuoka, Japan in November. He
also reported on the 12th
UNESCO World
Conference on Bioethics, Medical Ethics
and Health Law to be held in Limassol,
Cyprus, in March (21–23) 2017.
It was proposed to hold two sessions,one on
databases and biobanks and a second dis-
cussion on the Declaration of Geneva.
Governance Review
Prof. Dr Rutger J. van der Gaag, Chair of
the WorkGroup, reported on the four sub
groups that had been set up to consider
involvement, inclusiveness and represen-
tation; consistency, efficiency and quality;
transparency; and the value of associate
membership.Their work would be conclud-
ed next year.
He said the WorkGroup was consid-
ering how to involve the 80 countries
worldwide who were not members of the
WMA or not involved in the Associa-
tion’s activities.
A survey was being planned for early next
year on the issue of prioritizing goals and
increasing members’involvement.The results
would be reported to the Council meeting
in Livingstone, Zambia. The committee ac-
cepted the report and agreed to the survey.
Associate Members
The Committee received a written report on
the activities of the Associate Members.
Past Presidents’ and Chairs’ Network
The Committee received a report from
Dr. Kloiber of the Past Presidents and
Chairs of Council Network. Dr. Kloiber
thanked Drs Cecil Wilson, Yank Coble,
Yoram Blachar, Wonchat Subhachaturas
and Jón Snædal for their contributions.
Junior Doctors Network
The Committee received a report of the
Junior Doctors Network from Dr. Ahmet
Murt, and he thanked the NMAs and
WMA for the support provided to the JDN.
International Committee of Military Medicine
The Committee considered the Memo-
randum of Understanding with the Inter-
WMA General Assembly
129
national Committee of Military Medicine
(ICMM). Dr. Kloiber explained the long-
standing relationship with the International
Committee and the ICMM’s proposal to
have a formal memorandum.
It was agreed that the Memorandum be ap-
proved by the Council and be forwarded to
the General Assembly for approval.
Socio-Medical Affairs Committee
Dr. Miguel Roberto Jorge, Chair of the
Committee, took the chair.
The Committee approved the report of the pre-
vious meeting held in Buenos Aires, Argentina.
Doctors for Health Equity
The President, Sir Michael Marmot, re-
ported that this issue had been a key theme
of his Presidency for the year. He said that
he had been hugely encouraged by national
medical associations in all regions express-
ing enthusiasm for taking action on health
equity. He was hopeful that something tan-
gible would come out of this.
Health Care in Danger
Prof. Vivienne Nathanson (British Medi-
cal Association) reported on the activities
of the WorkGroup, which had met the day
before. The Group discussed its role in the
framework of the HCiD initiative, led by
the International Committee of the Red
Cross, which has been in progress for sev-
eral years. The initiative was now evolving
from a project to a community of concerns
with continuous active involvement of
various partners, including the WMA. She
called for an intense letter writing campaign
whenever attacks took place on hospitals,
patients and health care personnel, par-
ticularly physicians, and she urged NMAs,
when they write to their governments about
such attacks, to send copies of their letters
to the WMA.
The Group had agreed to conclude its ac-
tivities and disband.
Physicians’ Right to Information
The Committee considered a proposed Dec-
laration submitted by the Russian Medical
Society on Physicians’Right to Information
about the WMA and its Policies. The Rus-
sian delegate informed the Committee that
it wished to withdraw the document. This
was agreed by the Committee.
Role of Physicians in Preventing the Traf-
ficking with Minors and Illegal Adop-
tions
The Committee considered the proposed
Statement on the Role of Physicians in Pre-
venting Trafficking with Minors and Illegal
Adoptions which sets out guidelines for
increasing physicians’ awareness of the pos-
sible criminal activities related to trafficking
of children. During a brief debate, some op-
position was voiced about the way the issue
had been addressed in the document, and
it was suggested that further consideration
was needed.
The committee recommended that the
document be sent back to the WorkGroup
for further consideration and that a revised
version be circulated among members for
comment.
Armed Conflicts
The Committee considered the proposal
for a Statement on Armed Conflicts which
reminds governments of the human conse-
quence of warfare. The Chair of the Work-
Group, Dr. Shin, suggested that discussion
on this document be postponed until the
next meeting to allow further consideration
The Committee recommended that the
proposed Statement be sent back to the
WorkGroup for further consideration and
that a revised version be circulated among
members for comment.
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130
Occupational Health
The Committee considered the proposal
for a Resolution on Occupational and
Environmental and Safety as well as Gen-
der Aspects, setting out a package of mea-
sures to strengthen the role of physicians
in preventing, diagnosing, treating and re-
porting work accidents and occupational
diseases.
The Committee recommended that the
proposed Resolution be approved by the
Council and forwarded to the General As-
sembly for adoption.
Boxing
The Committee considered a proposed revi-
sion of the 2005 Statement on Boxing, sub-
mitted by the South African Medical Asso-
ciation.This suggests hardening the WMA’s
opposition to boxing.
After a brief debate about the proposal that
boxing should be regulated before it was
banned, the Committee agreed that the
proposed revision be revised by the South
Africans and then be re-circulated among
members for comment.
Obesity in Children
The Committee considered the proposed
Statement on Obesity in Children submit-
ted by the Israel Medical Association. This
set out a comprehensive programme to
prevent childhood obesity, including con-
sideration of a tax on non-nutritious foods
and sugary drinks. A brief debate followed,
when the committee agreed that there
should be a specific WMA policy document
on childhood obesity. It was agreed that the
proposed document should be amended to
include a sentence about the crucial role
that parents have in fostering physical ac-
tivity in their children.
The Committee recommended that the
document, as amended, be approved by the
Council and forwarded to the General As-
sembly for adoption.
Fossil Fuel Divestment
The Committee considered the proposed
Statement on Divestment in Fossil Fu-
els urging national medical associations
and other health organisations around the
world to transfer their investments from
energy companies relying on fossil fuels to
those generating energy from renewable
sources.
The Committee recommended that the
proposed Statement be approved by the
Council and forwarded to the General As-
sembly for adoption.
Cyber Attacks on Health and Other Critical
Infrastructures
The Committee considered the proposed
Statement on Cyber-Attacks on Health
and Other Critical Infrastructures submit-
ted by the German Medical Association.
The document warns that the spread of
electronic medical records and billing sys-
tems has made the healthcare sector vul-
nerable to cyber-attacks. It says the sector
is now a prime soft target for cyber crimi-
nals.The meeting heard that this was a very
big problem for health care, and hospitals
had been threatened and blackmailed by
cyber-attacks. The meeting amended the
document to refer specifically to the risk of
medical records being altered as a result of
cyber-attacks.
The Committee recommended that the
proposed Statement, as amended, be ap-
proved by the Council and forwarded to the
General Assembly for adoption.
Medical Tourism
The Committee considered a proposed
Statement on Medical Tourism submitted
by the Israel Medical Association, which
sets out protocols to protect the right of
foreign patients who receive medical treat-
ment abroad. In the debate that followed,
several delegates criticised the document,
and it was suggested that the WMA should
not approve policy that might be seen as
legitimising medical tourism. However, it
was argued that there were ethical issues in-
volved and it would be wrong to ignore the
topic. Medical tourism should be regulated
because medicine has been commercialised
whether they liked it not. Many people
were making profits out of medical tourism
and the WMA had a responsibility to the
profession and to the population to have a
policy.
After changes to the document, the Com-
mittee recommended that the proposed
Statement, as amended, be approved by the
Council and forwarded to the General As-
sembly for adoption.
Medical Cannabis
The South African Medical Association
Committee submitted a proposed State-
ment on Medical Cannabis saying that laws
governing the use of cannabis in research
should be modified to allow unhindered
scientific research. However, some delegates
argued that the document did not properly
separate the issues of medical and recre-
ational use of cannabis.
The Committee recommended that the
Statement be revised by the South African
Medical Association and then re-circulated
among members for comment.
The Committee then considered documents
that had been revised as part of the annual
policy review process.
It recommended that the following policies
with minor revisions be approved by the
Council and forwarded to the General As-
sembly for adoption.
• Statement on Traffic Injury
• Statement on Adolescent Suicide
• Statement on Alcohol and Road Safety
WMA General Assembly
131
• Statement on the Physician’s Role in
Obesity
• Statement on Physicians and Public
Health
• Statement on the Responsibilities of
Physicians in Preventing and Treating
Opiate and Psychotropic Drug Abuse
• Statement on Injury Control
The revised policy on adolescent suicide
was approved only after a lengthy debate on
whether or not to it should refer to specific
adolescent groups, such as first peoples in
some developed countries. The Committee
decided to amend the document to include
the sentence ‘The incidence of adolescent
suicide is observed to be greater in the “first
peoples” of some nations’.
The Committee also recommended that
the following policies that had undergone
major revision should be circulated among
members for comment.
• Resolution on Medical Assistance in Air
Travel
• Resolution on Tuberculosis
• Statement on Access to Health Care
• Professional Autonomy of Physicians
• Medical Education
• General policy on alcohol
The Committee recommended that three
new items that had been submitted should
also be circulated among members for com-
ment.These are
• Proposed Statement on Water and Health
• Proposed Statement on Cooperation of
National Medical Associations during or
in the Aftermath of Conflicts
• Proposed Statement on Epidemics/Pan-
demics
Sustainable Development
The Portuguese Medical Association pro-
posed that a WorkGroup be set up to de-
velop a WMA policy on sustainable devel-
opment and to define a proposed strategy
for sustainable development at international
and national level.
The proposal was agreed by the Committee
and it was decided to recommend this to the
Council.
Advocacy
Dr. André Bernard (Canadian Medical As-
sociation), Chair of the Advocacy Advisory
Group, reported on the activities of the
Group. He said they had discussed their re-
mit and the need to focus on advocacy and
communication. It was suggested that the
Group should report directly to the Coun-
cil and that new terms of reference should
be developed. He also reported that as this
was his last meeting at the WMA, Dr. Ste-
ven Stack (American Medical Association)
would serve as chair ad interim  until the
next meeting when a decision on the new
chair would be made.
Dr. Jorge thanked Dr. Bernard for his com-
mitted work in successfully leading the
Group.
Protection of Health Care Facilities and
Personnel in Syria
The Committee considered the proposed
emergency Resolution from the Finnish
Medical Association on the bombing that
had taken place in Syria and in particular
in Aleppo. The meeting heard that there
had been repeated and targeted bombings
of hospitals, healthcare facilities and people
working there, as well as patients being
treated. This was something totally new.
In past decades both sides agreed not to
attack hospitals and places where patients
were being treated. The new situation was
something the WMA should be especially
worried about.
The Committee approved the proposed
Resolution and recommended that it be
sent to the Council and be forwarded to the
General Assembly for adoption.
Medical Ethics Committee
Dr. Heikki Pälve (Finland Medical Asso-
ciation) took the chair.
The Committee approved the report of the
previous meeting held in Buenos Aires, Ar-
gentina.
Euthanasia and Physician Assisted Dying
The Committee received an oral report
from the Secretary General. He said the
Executive Committee planned to initiate
regional debates about this topic, particu-
larly with those medical associations they
had not heard from. Dr. Kloiber reported
that the first initiative has been taken by
the Brazilian Medical Association, which
had offered to host a workshop bringing
together the Latin-American medical as-
sociations to discuss end-of-life issues, in-
cluding euthanasia and physician-assisted
suicide.
He expressed the hope of the Executive
Committee that medical associations from
Africa and Asia would also organize region-
al debates and workshops.
Person Centered Medicine
Dr. Andrew Dearden, Chair of the Work-
Group, gave an oral report, saying that the
group would not be able to pursue this
issue at this time because members had
other commitments. He suggested that
the group should be disbanded and that
subsequent work on person centered med-
icine should be left to individual member
associations. He stressed that this did not
mean the topic should not be pursued,
but that a work group was unnecessary.
At any time, any NMA was welcome to
continue working on this topic again, us-
ing the existing definition paper and the
draft policy.
The Committee approved the oral report,
and recommended to the Council that the
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132
WorkGroup be disbanded for the time
­being.
Health Databases
The Committee received the newly pro-
posed Declaration on Ethical Consider-
ations regarding Health Databases and
Biobanks, which sets out ethical guidelines
for physicians involved in the collection and
use of identifiable health data and biological
material in health databases and biobanks.
Dr Jon Snædal, Chair of the WorkGroup,
gave an oral report on the extensive work
that had been undertaken to produce the
document. He proposed several amend-
ments to the document concerning the
compatibility between the proposed guide-
lines and national laws.This led to a lengthy
debate.
The Committee considered the revised
Statement and recommended that, as
amended, it be approved by Council and
forwarded to the General Assembly for
adoption.
It was also recommended that the State-
ment be called the Declaration of Taipei if
adopted by the Assembly.
Pre-natal Gender Selection
An oral report was received about a pro-
posed Resolution from the Swiss Medical
Association on the Participation of Physi-
cians in Pre-natal Gender Selection, which
stated that national medical associations
should recommend their governments to
adopt laws to prohibit the use of pre-natal
sex selection for reasons of gender preva-
lence. However, the document did not gain
widespread support. It was argued that
rather than approve a new policy, delegates
should be revising existing WMA policy
documents.
The Committee recommended that the
proposed Statement not be accepted.
Quality Assurance in Medical Education
The American Medical Association Com-
mittee submitted a Proposed Declaration
on Quality Assurance in Medical Educa-
tion.
The Committee recommended that the
document be circulated to members for
comment.
Declaration of Geneva
The Committee received oral reports from
Dr. Ramin Parsa-Parsi, Chair of the Work-
Group on revising the Declaration of Ge-
neva, and from the ethics expert on the
Group, Prof. Urban Wiesing. The meeting
was updated on the work of the group, in-
cluding a survey of NMAs on the use of the
Declaration. There was some discussion of
possible amendments to the Declaration
and information about holding a possible
session to present a new draft policy at the
12th
UNESCO World Conference on Bio-
ethics in March 2017, if accepted by the
conference organizer.
The Committee recommended to the
Council that the WorkGroup continue with
its work.
The Committee recommended that the
following agenda items be referred to the
Council.
Policies with minor revisions:
• Declaration of Sydney on the Determi-
nation of Death and the Recovery of Or-
gans
• Declaration of Therapeutic Abortion
Declaration of Tokyo with guidelines
for Medical Doctors concerning Torture
and other Cruel, Inhuman or Degrading
Treatment or Punishment in relation to
Detention and Imprisonment
• Statement on Child Abuse and Neglect
• Statement on Medical Ethics in the
Event of Disasters
• Statement on Weapons of Warfare and
Their Relation to Life and Health
Policies with major revisions:
• Declaration of Venice on Terminal Illness
• Declaration of Malta on Hunger Strikers
• Statement on Assisted Reproductive
Technologies
• Statement on HIV/AIDS and the Medi-
cal Profession
New items:
• Proposed Resolution on Forced Anal Ex-
aminations
• Proposed Statement on Bullying and Ha-
rassment within the Profession
Thursday October 20
Associates Members
Dr. Joseph Heyman, Chair of the Associ-
ated Members, took the chair.
The minutes of the previous Associate
Members Meeting, held in Moscow in Oc-
tober 2015 were approved.
Junior Doctors Network
The meeting received an oral report from
Dr. Caline Mattar (Lebanon), Junior Doc-
tors Network Chair-Elect, who presented
the JDN’s written report. This outlined the
work of the JDN, including its participa-
tion in a Caring Physicians of the World
course, organized in collaboration with the
Mayo Clinic in Jacksonville, Florida, and its
partnership with the Healthcare in Danger
project headed by the International Com-
mittee of the Red Cross. It detailed its work
at the World Health Assembly and reported
on its monthly teleconferences, which had
become one of the main ways JDN mem-
bers kept in touch with each other.
Finally, the Network reported on its new
collaboration with the World Federation
WMA General Assembly
133
for Medical Education. The JDN had been
invited to the WFME Executive Council
meetings and would in future be the voice
for junior doctors at the WFME.
Past Presidents and Chairs of Council
Network
The Associate Members received a report of
the Past Presidents and Chairs of Council
Network.
Declaration on Health and Climate Change
The meeting considered a proposed Dec-
laration on Health and Climate Change
calling for urgent action to ensure that the
mitigation and adaptation measures agreed
at the climate change summit in Paris are
followed through. The document was pre-
sented by Dr. Yassen Tcholakov, the JDN
representative on the Socio-Medical Affairs
Committee. He said the wording had been
updated to take account of the progress that
had been made on the issue.
The meeting agreed that the proposed Dec-
laration be considered by the General As-
sembly.
End-of-Life Conversations
The meeting considered a proposed State-
ment on End of Life Conversations, which
sets out principles for physicians involved in
end of life care.
The meeting agreed that the document
should be forwarded to the General As-
sembly for consideration.
Destruction of Smallpox Virus Stockpiles
A proposed Statement on Destruction of
Smallpox Virus Stockpiles was presented
by Dr. Caline Mattar, JDN Chair-Elect, on
behalf of the JDN.The proposed policy says
that remaining stockpiles of the smallpox
virus should be destroyed because of the
unacceptable risk they pose to the world’s
population
The meeting agreed that the document be
considered by the General Assembly.
Scientific Meeting
“Healthcare System Sustainability”
WMA President, Sir Michael Marmot
opened the day-long meeting by saying that
there were major challenges, threats and
opportunities and their job was to rise to
the challenges and to turn the threats into
opportunities. Digitisation and the digital
world could be a threat, but it is a potential
opportunity.Mass migration could be major
threat but it was also a challenge to which
they must rise.
People talked about the ageing of the popu-
lation as a problem. But they should see this
as something to be welcomed. After all, it
was at least in part a triumph because of the
control of major killing diseases and im-
provement in social conditions.
He said that while the global north grew
rich before it grew old, the global south was
growing old before it grew rich. Japan and
India were both facing a rapid growth of
their elderly population and India was hav-
ing to deal with this at the same time as it
dealt with the major medical problems of
poverty and deprivation.
Sir Michael ended by praising Taiwan’s re-
cord in improving health through a com-
bination of improved economic and social
conditions that had guaranteed better living
conditions for its whole population and at-
tending to the health needs of the popula-
tion with universal health coverage.
Dr.Tzou-Yien Lin,Minister of Health and
Welfare, Taiwan, was the first speaker with
a talk entitled ‘The Roadmap for Better
Healthcare in Taiwan’.He talked about Tai-
wan’s development of universal health cov-
erage and the country’s compulsory health
insurance system. Ninety-three per cent of
health care providers had contracts with the
system.He talked about the development of
long term care in Taiwan and the network
that supported it. Statistics for life expec-
tancy, infant mortality and cancer survival
were similar to OECD average rates, dem-
onstrating the high quality of medical care
in the country.
Prof. Dr. Frank Ulrich Montgomery,
President of the German Medical Associa-
tion and Vice-Chair of the WMA, spoke
about how the German healthcare system
had coped with the influx of migrants and
refugees. The healthcare system had been
confronted with a major challenge of hav-
ing to integrate more than one million
refugees into the outpatient and inpatient
sectors as quickly as possible. The burden
of providing medical care had been borne
primarily by volunteer doctors, psychother-
apists and nursing staff.The system in place
was a patchwork as reflected in the incon-
sistent policies regarding access to health-
care services, billing procedures and benefit
eligibility, which varied not only from state
to state, but also from municipality to mu-
nicipality.
There were no uniform and reliable nation-
wide structures for administering healthcare
to asylum seekers in Germany, which had
made the situation challenging. However,
constructive discussions about these issues
had also given rise to potential solutions
for improving the system and eliminating
bureaucratic hurdles. For example, in order
to streamline procedures and ultimately re-
duce administrative costs, German physi-
cians had supported the idea of introducing
a health card providing access to the full
range of services available in the statutory
health insurance system starting on the date
of registration. It could also prevent redun-
dant examinations and delays in medical
WMA General Assembly
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134
treatment resulting from the complicated
process of applying for treatment vouchers.
In addition, the system could benefit from
the reinforcement of financial and human
resources in the public health sector at both
the state and municipal level.
Prof. Kenji Shibuya, Chair of the De-
partment of Global Health Policy at the
Graduate School of Medicine, University
of Tokyo, spoke about The Sustainability of
Health Care in Aging Societies: A Global
Perspective.
He said Japan had achieved universal health
coverage in 1961 at the time of rapid eco-
nomic development, while the country was
still relatively poor. It had achieved one of
the best population health outcomes at rela-
tively low cost with equity over the next half
century. However, Japan was now facing a
huge demographic and fiscal challenge to
the sustainability of its health systems. He
reviewed the historical context for Japan’s
health system development, examined cur-
rent challenges to its sustainability, and ex-
amined ongoing efforts to reform Japan’s
health system. He said the major objective
was to share important lessons in the cur-
rent debates on global health policy from
Japan’s experiences.
Dr. Andrew Dearden, newly elected Trea-
surer of the WMA and Treasurer of the
British Medical Association, spoke about
the general practice system in the United
Kingdom and the gate keeper role it played.
The central principles underpinning the
National Health Service, which was found-
ed in 1948, were clear: that the health ser-
vice would be available to all and financed
entirely from taxation, which meant that
people paid into it according to their
means. There had been some changes since
1948 to the way the service was accessed
and how people contributed to its fund-
ing – for example prescription charges were
introduced in 1952, abolished in 1965 and
reintroduced in 1968.
The NHS today had one of the lowest
spends per capita in the industrial world.
According to a study produced by the
Commonwealth Fund in 2014 the NHS
spent £3,405 per capita, compared to the
USA $8,508, Germany $4,495 and Austra-
lia $3,800. Yet this same study placed the
NHS in first place compared to 10 other
health services in the quality, effective,
­
co-ordinated, safety, and patient centred
care.The NHS also ranked first place in pa-
tients accessing care and the efficient use of
resources.It was ranked 2nd
in equity of care
and 3rd
in timeliness of care.
Yet it had a comparatively low number of
beds per capita at 2.8 per 1000 of the popu-
lation and a low number of physicians per
capita too, at 2.8 per 1000.
This efficient and effective use of resources
in providing healthcare had been credited
in the main to the well-developed and
comprehensive primary care services pro-
vided by the general practitioner in the
United Kingdom and their extended pri-
mary care teams acting as gate keepers to
secondary care investigations, assessment
and referrals.
While no healthcare system was perfect
or perfectly cared for the needs of its pop-
ulation the NHS did demonstrate how
comprehensive primary care and general
practice could help a health care system
use its limited resources to the best for its
people.
Dr. Steven J. Stack, immediate past Presi-
dent of the American Medical Association,
spoke about health care reform in the Unit-
ed States.He discussed the history of health
insurance reform in the United States, the
rationale for reform, and the current state
of implementation of the Affordable Care
Act. He talked about the AMA’s involve-
ment in reform efforts and the challenges
physicians – as well as the next U.S. Presi-
dent and Congress – were likely to face in
the near-term future.
He said that the enactment of the Afford-
able Care Act in 2010 was the culmination
of a long and contentious battle in Con-
gress to address shortcomings in the health
care system that left millions of Americans
uninsured. While the Act had achieved no-
table success in expanding health insurance
coverage for millions of people,and in mak-
ing improvements to quality and efficiency,
significant challenges remained. Political
resistance to the Act continued, millions
remained uninsured or underinsured, and
many people still could not afford health
coverage. Recent reforms to health care
payment and delivery systems also posed
significant challenges.
He concluded that only time would tell
whether the Act was truly transformative or
a failed experiment.
Prof. Ju Han Kim, Professor and Founding
Chair, of the Division of Biomedical Infor-
matics at Seoul National University College
of Medicine in Korea, entitled his talk ‘Per-
sonal and Private Big Data: Genomes and
Health Records’.
He said that a flood of multi-modal high
throughput clinical genomic data and per-
sonal health records meant that many of
the challenges in biomedical research and
healthcare were now challenges in integra-
tive and computational sciences for their
bidirectional translations. The  ability to
‘connecting the dots’in the wealth biomedi-
cal big data would bring the ‘big picture’ in
a mass of genes, drugs, diseases, and diag-
nostic, therapeutic and prognostic markers.
Precision medicine attempted to determine
individual solutions based on the genomic
and clinical profiles of each individual, pro-
viding opportunity to incorporate individu-
al molecular data into patient care. While a
plethora of genomic signatures had success-
fully demonstrated their predictive power,
they were merely statistically-significant
differences between dichotomized pheno-
types that were in fact severely heteroge-
neous. Despite many translational barriers,
WMA General Assembly
135
connecting the molecular world to the clini-
cal world and vice versa would undoubtedly
benefit human health in the near future.
He concluded with the words:‘Better health
is not a science problem, it’s an information
problem’.
Prof. Yu-Chuan (Jack) Li, Professor in
Biomedical Informatics and Dean of the
College of Medical Science and Technol-
ogy at Taipei Medical University, spoke
about ‘Conquering Medical Errors with
Artificial Intelligence’. He said that care
was complex and unco-ordinated and in-
formation was often not available to those
who needed it when they needed it. As a
result, they often did not get the care they
needed or got the care they did not need.
He talked about the reasons for poor quality
care in relation to lack of information and
went on to discuss AI in relation to medical
errors. Medical errors were a leading cause
of death, more common than they thought
and were a costly system problem. And
more than 50 per cent of errors were pre-
ventable. He talked about the current prob-
lems with health informational technology
and the challenges it faced.
Prof. Chun-Ying Wu, Professor of Medi-
cine at Taiwan’s National Yang-Ming Uni-
versity, talked about Big Data Approach in
Health Care Assessment.
He said that big data approach in health
care outcome assessment was an important
trend. Precision medicine initiatives pro-
posed by President Obama were actually an
ultimate big data project. Curing either rare
diseases or common cancers did not just
require more trials, but also needed linking
all the data the researchers or physicians al-
ready had. Nationwide cohort studies based
on big data had several advantages com-
pared with traditional cohort studies and
randomized clinical trials.
He used previous big data research expe-
rience based on Taiwan’s National Health
Insurance Research Database (NHIRD)
as examples to introduce the feasibility of
big data approach in health care outcome
assessment. Based on big data research, they
had found early Helicobacter pylori eradi-
cation and regular use of non-steroidal anti-
inflammatory drugs (NSAIDs) associated
with reduced risk of gastric cancer.They had
also reported that antiviral therapy reduced
hepatocellular carcinoma (HCC) risk in
patients with hepatitis B. Antiviral therapy
also reduced HCC recurrence in patients
with HBV and HCV-related HCC after
liver resection or radiofrequency ablation
(RFA).
Finally, he said that big data approach could
be used to conduct novel clinical studies, to
assess effectiveness in real world, to make
health policies, and to achieve precision
medicine. Big data approach in health care
outcome assessment was feasible and useful.
And he concluded by quoting Winston
Churchill: ‘Now this is not the end. It is not
even the beginning of the end. But it is per-
haps the end of the beginning’.
Dr. Florentino Cardoso, President of the
Brazilian Medical Association, entitled his
talk ‘Health IT:The Essential Infrastructure
for Universal Coverage’.
He said that as in other areas, information
technology played a key role in the devel-
opment and optimization of health service.
New possibilities in care and management
became available thanks to democratiza-
tions of information between medicine key
players and the society. Some developed
countries had expertise in offering services
related to remote health care, such as tele-
medicine, in regions where distance was a
critical factor, which had improved in ac-
cess.
He said that telecommunication enhanced
emergency medical services by helping ex-
pedite urgent patient transfer, provided
remote consultation and supervision of
paramedics and nurses, avoiding treatment
delay, reducing mortality and improving
quality of life. Furthermore, I.T. was also
inserted in teaching and research.
Continuing online education to the phy-
sician training, even in places of difficult
access and/or poor educational structure.
Electronic Health Records systems al-
lowed advances in medical research, access
to clinical guidelines, and also utilization
of data for epidemiological and statistical
purpose.
Dr. Robert M. Wah, former President of
the American Medical Association, from
the National Institutes of Health and
Walter Reed Military Center at Bethesda
Maryland, USA, spoke about ‘Transform-
ing Healthcare with Information Technol-
ogy’.
He said that as the conversion from paper to
digital format progressed across healthcare,
the opportunity to use information tech-
nology to improve and transform health-
care grew larger. It was important to keep
in mind that technology was a tool to help
take better care of patients.There were three
waves to the change; conversion to digital
from paper; networking the digital infor-
mation together; and then analysing the
digital, networked information in new and
powerful ways to help population health
and personalized medicine.This would pro-
vide better information for better decisions
in healthcare.
He talked about cumbersome electronic
health records and the burden of regulations
and what was required to improve their us-
ability. Better information was required for
better health care decisions.
Dr. Mark Sonderup, Vice Chairman of
the South African Medical Association,
talked about the problems and pitfalls of e
Health. He said that eHealth encompassed
information and communication technolo-
gies that had the potential to enhance the
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136
­
rendering of healthcare, particularly in un-
der-resourced and remote regions.
The case for e health included improved
efficiency, improved governance, improved
quality of health care, increased value for
money and increased access to health care.
Several challenges however posed prob-
lems and included technical, financing and
political issues. For example, work was re-
quired to ensure the seamlessness between
existing systems and platforms. However,
the cost of developing such platforms might
be prohibitive and new funding models and
commitments from stakeholders such as
government and corporates were needed.
Furthermore, any eHealth system must be
integrated into the existing health systems
and physicians might require additional
training to ensure that eHealth systems
were optimally utilized. Concerning, and a
potential pitfall, was that eHealth systems
must take into account the legislated pro-
tections on the processing and transfer of
confidential medical information.
Dr. Andreas Rudkjøbing, President of
the Danish Medical Association, talked
about how eHealth could support citizens
and healthcare services, using the exam-
ple of e-health in Denmark. He said that
20 years ago the Danish Ministry of Health
launched a strategy for the public hospitals
to implement EHRs  – Electronic Health
Records. This initiative coupled with a
strategy for improving the electronic health
data connection was the starting point of
the digitalized Danish health care sector. In
2016 all public hospitals in Denmark had
an EHR. The strategy had been to imple-
ment not only one EHR-system, but to
ensure key information was collected and
might be transferred between health care
providers.
In 2016 every citizen in Denmark had ac-
cess to his own personal health record
through the site “Sundhed.dk”. When
logged on it was possible for the citizen to
read part of the patient record and see his
own medication data and laboratory test
results. GPs had electronic patient records
too – and referrals, prescriptions etc. were
sent by standardized electronic communica-
tion between the GP, the hospital and the
municipality.
He talked about the expectations and obsta-
cles relating to the design and implementa-
tion of the Danish e-health infrastructure,
and about what he saw as the main chal-
lenges for health professionals in the Dan-
ish e-health care sector in the years to come.
These included the sharing of patient re-
cords across sectors, their usability, unstable
systems and the interaction between pa-
tients and doctors.
Throughout the day, panel discussions and
questions from the floor, led to lively and
informative debates.
Friday October 21
Council
Dr. Ardis Hoven took the chair for the re-
convened Council meeting.
Finance and Planning Committee Report
Financial Statement 2015
The Council approved the Audited Fi-
nancial Statement for 2015 and agreed to
forward it to the General Assembly for ap-
proval and adoption.
Budget and Membership Dues Payments
The Council approved the proposed Bud-
get for 2017 and agreed to forward it to the
General Assembly for approval and adop-
tion.
Membership Dues Payments for 2016
The Council approved the report on WMA
Dues Categories 2017 and agreed that it be
forwarded to the General Assembly for ap-
proval and adoption.
Royal Dutch Medical Association
The Council approved the arrangement
requested by the RDMA, under which
the RDMA would abstain from voting in
2016 and obtain a council seat by declaring
50,000 physicians in 2017.
Auditor
The Council agreed to the appointment of
KPMG as auditor of the 2016 WMA Fi-
nancial Statement.
Business Development
The Council agreed to allow the new Trea-
surer to ask NMAs to review their number
of declared members and to make sure they
are consistent with the number of members
in their association.
Governance Review
TheCouncilapprovedthereportoftheGov-
ernance Review WorkGroup and agreed to
the proposal for a survey of NMAs and As-
sociate Members to prioritize the goals of
the Association and increase members’ in-
volvement.
International Committee of Military Medicine
The Council agreed the Memorandum of Un-
derstanding with the International Commit-
tee of Military Medicine and forwarded the
item to the General Assembly for approval.
Socio-Medical Affairs
Committee Report
Role of Physicians in Preventing the Traf-
ficking with Minors and Illegal Adoptions
The Council agreed that the proposed
Statement be sent back to the WorkGroup
WMA General Assembly
137
for further consideration and that a revised
version be circulated among members for
comments.
Armed Conflict
The Council agreed that the proposed
Statement be sent back to the WorkGroup
for further consideration and that a revised
version be circulated among members for
comments.
Occupational Health
The Council approved the proposed Reso-
lution on Occupational and Environmental
and Safety and agreed to forward it to the
General Assembly for adoption.
Boxing
The Council agreed that the proposed revi-
sion of the Statement on Boxing be further
revised by the author and then re-circulated
among members for comments.
Fossil Fuel Divestment
The Council agreed that the Statement on
Divestment in Fossil Fuels be approved
and sent to the General Assembly for
adoption.
Cyber Attacks on Health and Other Critical
Infrastructures
The Council approved the proposed State-
ment and agreed to forward it to the Gen-
eral Assembly for adoption.
Medical Tourism
The Council approved the proposed State-
ment and agreed to forward it to the Gen-
eral Assembly for adoption.
Medical Cannabis
The Council agreed that the proposed
Statement be revised by the author and
then re-circulated among members for
comments.
Medical Assistance in Air Travel
The Council recommended that the pro-
posed Resolution be circulated among
members for comments.
Tuberculosis
The Council recommended that the pro-
posed revised Resolution be circulated
among members for comments.
Access to Health Care
The Council recommended that the pro-
posed Statement be circulated among
members for comments.
Injury Control
The Council approved the revised State-
ment and forwarded it to the General As-
sembly for adoption.
Traffic Injury
The Committee approved the revised State-
ment and agreed to forward it to the Gen-
eral Assembly for adoption.
Adolescent Suicide
The Council approved the revised State-
ment and agreed to forward it to the Gen-
eral Assembly for adoption.
Alcohol & Road Safety
The Council approved the revised State-
ment and agreed to forward it to the Gen-
eral Assembly for adoption.
Physicians and Public Health
The Council approved the revised State-
ment and agreed to forward it to the Gen-
eral Assembly for adoption.
Professional Autonomy of Physicians
The Council agreed that the proposed revi-
sions to the Declarations of Seoul and Madrid
be circulated among members for comments.
Medical Education
The Council agreed that the proposed re-
vised Statement be circulated among mem-
bers for comments.
Physician’s Role in Obesity
The Council approved the revised State-
ment and agreed it should be forwarded to
the General Assembly for adoption.
Responsibilities of Physicians in Preventing and
Treating Opiate and Psychotropic Drug Abuse
The Council approved the revised State-
ment and agreed it should be forwarded to
the General Assembly for adoption.
Review of WMA general policy on Alcohol
The Council agreed that the proposed re-
vised Declaration should be circulated
among members for comments.
Water and Health
The Council agreed that the proposed
Statement be circulated among members
for comments.
Cooperation of National Medical Associations
during or in the Aftermath of Conflicts
The Council agreed that the proposed
Statement be circulated among members
for comments.
Epidemics
The Council agreed that the proposed
WMA Statement on Epidemics/Pandem-
ics be circulated amongst members for
comments.
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138
Sustainable Development
The Council recommended to the General
Assembly that a workgroup on sustainable
development be established
Protection of Health Care Facilities and Per-
sonnel in Syria
The Council approved the proposed
emergency Resolution and agreed it be
forwarded to the General Assembly for
adoption.
Medical Ethics Committee
Person Centered Medicine
The Council agreed that the Person Cen-
tered Medicine Workgroup be disbanded
for the time being.
Health Databases
The Council approved the proposed State-
ment on Health Databases and Biobanks
and recommended that it be forwarded to
the General Assembly for adoption. It also
agreed that the Statement be called the
Declaration of Taipei if adopted by the
General Assembly.
Participation of Physicians in Pre-natal
Gender Selection
The Council agreed that the proposed revi-
sion of the Statement be not be accepted.
Quality Assurance in Medical Education
The Council agreed that the proposed
Declaration be re-circulated to constituent
members for comments.
Declaration of Geneva
The Council agreed that the WorkGroup
should continue its work as proposed.
The Council agreed that the following poli-
cies with minor revisions be forwarded to
the General Assembly for adoption:
• Declaration of Sydney on the Determi-
nation of Death and the Recovery of Or-
gans
• Declaration of Tokyo with guidelines
for Medical Doctors concerning Torture
and other Cruel, Inhuman or Degrading
Treatment or Punishment in relation to
Detention and Imprisonment
• Statement on Child Abuse and Neglect
• Statement on Weapons of Warfare and
Their Relation to Life and Health
The Council agreed that the following poli-
cies with major revisions should to be sent
out for comment
• Declaration of Malta on Hunger Strikers
• Statement on Assisted Reproductive
Technologies
• Statement on HIV/AIDS and the Medi-
cal Profession
• Declaration of Therapeutic Abortion
• Statement on Medical Ethics in the
Event of Disasters
Declaration of Venice on Terminal Illness
The Council agreed that proposed revisions
to this Declaration be postponed until the
wider debate on euthanasia and physician
assisted dying.
The Council agreed that two new items be
sent out for comment:
• Proposed Resolution on Forced Anal Ex-
aminations
• Proposed Statement on Bullying and Ha-
rassment within the Profession
Ceremonial Session of the
General Assembly
Sir Michael Marmot, the outgoing Presi-
dent of the WMA, welcomed the President
of Taiwan and other guests to the official
opening of the Assembly at the Ceremonial
Session. The event was attended by hun-
dreds of WMA delegates, including more
than one hundred visiting physicians from
India.
The event began with a traditional Taiwan-
ese drum performance, followed by the re-
lease of several large sky lanterns.
Dr. Pi-Sheng Wang, Secretary General of
the Taiwan Medical Association, explained
that the sky lantern had a long history since
the first century and was still a symbol of
good luck.
‘Every year, at the beginning of the spring
season, people would release sky lanterns
into the air as a prayer for the coming year.
The lanterns are the reflected lives and hopes
of the people as the sky lanterns slowly rose
aloft. Today, we are here together to make
prayer and vows of the brighter future of
the medical system and the sustainability of
healthcare’.
Dr.Kloiber then introduced the various del-
egations from member associations and ob-
servers of international organizations with
the traditional roll call.
Dr.Tai-Yuan Chiu, President of the Taiwan
Medical Association, welcomed delegates
to the Assembly and paid special thanks
to all the national medical associations for
supporting the Taiwan Medical Associa-
tion.
The Assembly was then addressed by
President Ing-Wen Tsai. She said that the
Taiwan Medical Association was one of
the most important NGOs for medical af-
fairs in Taiwan. It played a crucial role in
liaising with physicians on a national ba-
sis, promoting the advancement of medical
technology and common interests and co-
ordinating medical development. She said
she was grateful for their long-term sup-
port, assistance and advice on the Govern-
ment’s medical policies. It was also thanks
WMA General Assembly
139
to their members that Taiwan had estab-
lished an excellent reputation for medical
academic research, for innovative technol-
ogy and medical industry development.
She said the WMA played a pivotal role
in co-operation between the World Health
Organisation and international medical
groups.
She went on: ‘In the past with the WMA’s
support Taiwan attended the World Health
Assembly as an observer. The WMA also
supported Taiwan’s quest to join the WHO
and the international health regulations net-
work so we can contribute to global health
issues. When it comes to health epidemic
control or health care there are no borders.
Health is a fundamental human right and
a universal value. We hope the WMA will
continue to support our WHO member-
ship efforts so that we can better contribute
to global health matters’.
President Tsai said that in recent years Tai-
wan’s physicians had capably managed the
SARS epidemic, the H1N1 swine flu and
hundreds of burnt patients from a major
dust explosion.This outstanding conduct in
a crisis had won international recognition
and showed that Taiwan’s medical services
were second to none. But like many coun-
tries,they had an ageing population and this
had led to rising medical costs and increased
demand on the health system. Because the
government believed it had a responsibil-
ity to build a comprehensive health system
it had proposed a policy to reach several
goals. These included a reasonable increase
in medical expenses, building a community
care system and strengthening the medical
disputes mechanism to avoid unnecessary
litigation.
She said the government strongly support-
ed legislation to improve physicians’ labour
conditions and to simplify hospital accredi-
tation and increased government scholar-
ships. In response to the ageing society it
was implementing an extended long term
care plan. They hoped to build a high qual-
ity, affordable and universal long term care
system.
Dr. Ardis Hoven, Chair of the WMA, paid
tribute to the retiring WMA President, Sir
Michael Marmot,who,she said,had presid-
ed with great distinction over the WMA’s
affairs.
Sir Michael Marmot then delivered his
valedictory address.
After presenting Sir Michael with a Past
President’s medal, Dr. Hoven invited
Dr.  Ketan Desai (Indian Medical Asso-
ciation) to the rostrum, where she installed
him as the WMA’s 67th
President for
2016/17. After taking the oath of office of
the President, Dr. Desai gave his inaugural
address.
The Ceremonial Session then closed.
Saturday October 22
The final day began with a new session to
inform new delegates about the procedure
of the General Assembly and to allow them
to question WMA officers. This was in re-
sponse to comments that some people were
not sure what was going on or the agenda
was happening too quickly.
General Assembly
Dr. Ardis Hoven took the Chair at the ple-
nary session of the General Assembly.
President Elect
The election took place for President elect.
Four nominations were initially submitted.
However,two were withdrawn,one of them,
Dr. Osahon Enabulele (Nigeria Medical
Association) announcing that he would
stand in October 2017.
In a two-way contest, Dr. Yoshitake Yo-
kokura, President of the Japan Medi-
cal Association, was elected in a contest
against Dr. Adriana Vince (Croatian
Medical Association). He will take office
in a year’s time to serve in 2017/18. Dr.
Yokokura, a surgeon, has been a WMA
Council member since 2010 and Presi-
dent of the JMA since 2012 and Presi-
dent of Yokokura Hospital since 1990. In
his submission for election, Dr. Yokokura
said that the world was in a state of un-
certainty and the WMA had to address
urgent global issues, including health care
in danger, climate change and the social
determinants of health.
Council Reports
The Assembly considered the reports
from Council and took the following de-
cisions.
Medical Ethics Committee
Declaration on Health Databases and Bio-
banks
Dr. Jon Snædal said the document, one
of the WMA’s most important policies,
was the result of a long process of internal
and external consultation. He proposed an
amendment to the document relating to
the section which stated that no national
or international ethical, legal or regulatory
requirement should reduce or eliminate
any of the protections for individuals and
populations set out in the Declaration. He
proposed an amendment to the related sen-
tence which originally stated that ‘When
authorized by a national law adopted
through a democratic process in respect of
human rights, an opt-out process or other
procedures could be adopted to protect the
dignity, autonomy and privacy of the indi-
viduals’. He proposed deleting the words ‘an
opt out process or’.The amendment reflect-
ed the fact that NMAs had different view-
points on this issue.He said the Declaration
was a living document and would probably
WMA General Assembly
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140
come up for revision in two or three years’
time.
The Assembly agreed the amendment and
then approved for adoption the whole doc-
ument and agreed to name it the Declara-
tion of Taipei.
The Assembly approved for adoption the
following documents from the Medical
Ethics Committee:
• Revision of the Declaration of Sydney on
the Determination of Death and the Re-
covery of Organs
• Revision of the Declaration ofTokyo with
guidelines for Medical Doctors concern-
ing Torture and other Cruel, Inhuman or
Degrading Treatment or Punishment in
relation to Detention and Imprisonment
• Revision of the Statement on Child
Abuse and Neglect
• Revision of the Statement on Weapons of
Warfare and Their Relation to Life and
Health
Socio-Medical Affairs Committee
The Assembly approved for adoption the
following documents from the Socio-Med-
ical Affairs Committee:
• Statement on Ageing (see p. 143)
• Revised Resolution on the Implementa-
tion of the WHO Framework Conven-
tion on Tobacco Control
• Revised Statement on Female Genital
Mutilation
• Revised Statement on Body Searches of
Prisoners
• Statement on Ethical Considerations in
Global Medical Electives (see p. 147)
• Resolution on Zika virus Infection (see
p. 152)
• Resolution on Refugees and Migrants
(see p. 151)
• Resolution on Occupational and Envi-
ronmental and Safety (see p. 149)
• Statement on Obesity in Children (see
p. 148)
• Statement on Divestment in Fossil Fuels
(see p. 146)
• Statement on Cyber-Attacks on Health
and Other Critical Infrastructures (see
p. 145)
• Revised Statement on Injury Control
• Revised Statement on Traffic Injury
• Revised Statement on Adolescent Sui-
cide
• Revised Statement on Alcohol and Road
Safety
• Revised Statement on Physicians and
Public Health
• Revised Statement on the Physician’s
Role in Obesity
• Revised Statement on the Responsi-
bilities of Physicians in Preventing and
Treating Opiate and Psychotropic Drug
Abuse
• Resolution on the Protection of Health-
care Facilities and Personnel in Syria (see
p. 152)
Proposed Statement on Medical Tourism
Mr Bjorn Hoftvedt (Norwegian Medical
Association) proposed that this document
should be referred back to Council for fur-
ther consideration. He said it missed the
clear distinction between patients seeking
health care abroad paid for by the state,
which was possible within the European
Union, and patients who went abroad for
health care paid for by themselves. The
problem was the second group who paid
themselves because their home state could
not offer that kind of health care, such as
surrogate pregnancy or a new organ. The
shortage of organs and trafficking of organs
was an international problem and patients
seeking health care abroad for a new organ
could stimulate the increased use of illegal
organs. Medical tourism not properly or-
ganised could spread infections. And not
everybody could afford to seek health care
abroad.This kind of medical tourism aimed
at rich people could widen the gap between
wealthy and not wealthy people. And he
argued that the WMA had adopted several
policies which could be perceived as being
inconsistent with this document on medical
tourism.
The proposal to refer back was supported by
many speakers, and the Israel Medical Asso-
ciation,which submitted the proposed State-
ment agreed to reconsider the document.
The Assembly agreed to refer the proposed
Statement back to Council.
Finance and Planning
The Treasurer, Dr. Andrew Dearden, gave
an oral report on the Association’s finances.
He said the Association had a safe financial
basis and its investment strategy was stable.
As a result, the Association’s finances were
in a very positive position.
The Assembly approved and adopted the
Audited Financial Statement for the year
ending 31 December 2015 and the pro-
posed WMA Budget for 2017.
WMA Meetings
The Assembly agreed that the 209th
Coun-
cil Session be held in Riga, Latvia on 26-28
April 2018, that the date of the 69th
General
Assembly in Reykjavik, Iceland be 3-6 Oc-
tober 2018. It agreed that the Turkish Medi-
cal Association in Istanbul be the venue for
the General Assembly in 2019 and that the
Georgian Medical Association in Tbilisi be
the venue for the General Assembly in 2020.
The Assembly agreed that the topic of the
Scientific Session at the Assembly in 2017
be “Assuring Quality in Undergraduate
Medical Education”.
International Committee of Military
Medicine
The Assembly agreed that the Memoran-
dum of Understanding with the Interna-
tional Committee of Military Medicine be
approved and adopted.
The remainder of the Finance and Plan-
ning Committee report from Council was
accepted.
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141
Associate Members
Dr. Joe Heyman, Chair of the Associate
Members, reported on the group’s activities
and submitted three items for consider-
ation – the proposed Declaration on Health
and Climate Change, the proposed State-
ment on End of Life Conversations and
the proposed Statement on Destruction of
Smallpox Virus Stockpiles.
The Assembly agreed that the three docu-
ments be sent to Council for consideration.
Open Session
Several speakers took the opportunity of the
open session to talk about issues relating to
their association.
Cote d’Ivoire
Dr. Gabriel Faye (Ordre National Des Mé-
decins De La Côte D’Ivoire) addressed the
Assembly on the buruli ulcer disease which
was rampant in his country and in many
other African countries. He said the dire
consequences were fatal for many patients
and he urged national medical associations
to support the Rotary Club appeal which
had been launched to combat this scourge.
Venezuela
Dr. Ruben Tucci(Argentina), spoke of the
concern about the state of health in Venezu-
ela He urged the WMA to intervene with
the Venezuelan Government to draw their
attention to the state of health of their popu-
lation. He also urged other organisations
and national medical associations to assist
the Venezuelan organisation of physicians
to take action and such measures as they
deemed fit to resolve their current problems.
Kuwait
Dr. Loujain Alkodmani, from the Kuwait
Medical Association, said it had been a
pleasure to attend the Council meeting and
to be part of the discussion. Unfortunately,
the Kuwait Medical Association was the
only medical association from the region to
be involved at the meeting. She said it was
important that different views from differ-
ent cultures were presented at these meet-
ings and the Kuwait association was com-
mitted to try to recruit other NMAs from
the region. It was essential that the WMA
was and continued to be open to all cultures.
Investment in Health
Dr. Kloiber gave a report on the Commis-
sion report on Health Employment and
Economic Growth that had reported to
the United Nations Secretary General on
investment in the health work force. It was
headed by the Presidents of South Africa
and France and was important for the fact
that for the first time it put the emphasis
not only on investment in health but also
on investment in the health work force.
He said that report showed that the health
care sector in the world was a very sizeable
part of the economy.The size of the world’s
health sector was more than $5.8 trillion a
year. In the OECD countries, the employ-
ment in health and social work had grown
by 48 per cent between 2000 and 2014,
while jobs in industry and agriculture had
declined.
Dr. Kloiber said estimates suggested that
globally each health worker was supported
by another 1-2 people working. In the low
and middle income countries one quarter of
economic growth between 2000 and 2011
had resulted from the value of improve-
ments in health. The report to the UN
had estimated that the return on invest-
ment in health was probably nine to one.
This showed that the money that went into
health was not simply an expense. It was a
return on investment.
He said that the health care systems could
lead to six pathways to economic growth –
health production, economic output, in-
crease in social protection, social cohesion
in a society, innovation and diversification,
and health security.
Dr Kloiber invited all national medical
associations to be part of the process by
following the development and implemen-
tation of this report. The World Health
Organisation and the UN would stage a
number of events in the coming month to
promote the report and the WMA would
be part of this by reminding the UN that it
had a specific focus on the social determi-
nants of health.
Dr. Xavier Deau
Dr. Deau, delivered a brief speech of
thanks, marking the end of his time as
an immediate past President. He said he
would continue to seek to build while oth-
ers destroyed, he would keep searching for
peace in the midst of war, keep crying out
while others preferred to keep silent and
he would continue to love even while some
distilled hatred. Independence, freedom
and solidarity were the three key words of
his inaugural address. He said he would
continue to promote human rights and he
thanked all of those who welcomed him
during his Presidency.
Chicago Assembly
Dr. David Barbe, President elect of the
American Medical Association, invited all
those present to the next General Assembly
to be held in Chicago in October 2017.
Taiwan
The Assembly closed with a brief speech
of thanks from Dr. Wu, chair the Taiwan
Medical Association organising committee
for the meeting. He said this had been the
first time Taipei had hosted the WMA. He
thanked the WMA for an excellent meet-
ing and said the Taiwan Medical Associa-
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142
tion would continue to play an active part
in the WMA.
The meeting thanked Dr. Wu and the Tai-
wan Medical Association for hosting the
meeting.
African Initiative
WMA Past President Dr.Margaret Mung-
herera spoke about the need for the WMA
to continue work on the African continent
and on the African medical initiative she
had started during her presidency. African
national medical associations needed to be
strengthened and supported. She remind-
ed delegates about a meeting to be held on
the social determinants of health in Febru-
ary next year in South Africa. And she em-
phasised the importance of the mentoring
project under which stronger associations
were twinned with smaller associations to
assist them.
Thanks
The Assembly ended with Dr. Kloiber
thanking all those who had helped to orga-
nise the meeting.
Council
The week ended with a brief meeting of
Council, convened to consider items sub-
mitted to it by the Assembly.
Medical Tourism
The Council decided to circulate the pro-
posed Statement on Medical Tourism to
NMAs for comment.
End-of-Life Conversations
The Council considered the proposed State-
ment on End of Life Conversations, which
sets out principles for physicians involved in
end of life care.
This led to a debate about what to do with
the paper. The Council eventually agreed to
a proposal to postpone consideration of the
document indefinitely.
The Council agreed to circulate the pro-
posed Statements on Climate Change and
Smallpox to NMAs for comment.
Mr. Nigel Duncan
Public Relation Consultant,
WMA
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143
WMA Statement on Ageing
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October
2016
Preamble
The world is undergoing a longevity extension at an unprecedented-
ly rapid pace. Over the last century, some 30 years have been added
to global average Life Expectancy at Birth (LEB) – with more gains
expected in the future. By 2050, LEB is projected to reach 74 years
with an ever-increasing number of countries reaching 80 years and
beyond. In 1950 the total number of people aged 80+ was 14 mil-
lion – by 2050 the estimated number is 384 million, a 26-fold in-
crease.The proportion of elderly will more than double from 10% in
2015 to 22% of the total population in 2050. These improvements
are very variable; many of the poorest communities in all countries
and a larger percentage of the population in the poorest countries
have gained little in terms of life expectancy over this period of time.
The increase in longevity has been paired with a decreasing num-
ber of children, adolescents and younger adults as more and more
countries experience Total Fertility Rates below replacement level,
raising the average age in these countries.
The challenges of aging in developing countries are complicated
by the fact that basic infrastructure is not always in place. In some
cases, populations in developing countries are aging more quickly
than infrastructure is being developed.
Longevity is arguably the greatest societal achievement of the 20th
century but it could turn into a major problem during the 21st
century. The World Health Organization (WHO) defines Active
Ageing as “the process of optimizing opportunities for Health,
Lifelong learning, Participation and Security in order of enhanc-
ing quality of life as individuals age”. This definition presupposes
a life course perspective as the determinants that influence active
ageing operates throughout the life course of an individual. These
are social determinants of health and include behavioral determi-
nants (life-styles), personal determinants (not only hereditary fac-
tors which are, overall, responsible for no more than 25% of the
chances of ageing well but also psychological characteristics), the
physical environment where one lives as well as broad social and
economic determinants. All of these act individually on the pros-
pects of active ageing but also interact among themselves: the more
they interact and overlap, the higher the chance of an individual
ageing actively. Gender and culture are crosscutting determinants,
influencing all the others.
General principles
Medical Expenses
There is strong evidence that chronic diseases increase the use (and
costs) of health services rather than age per se.
However, chronic conditions and disabilities become more preva-
lent with advancing age – therefore health care use and spending
rise in tandem with age.
In many countries health care spending for older persons has
increased over the years as more interventions and new tech-
nologies have become available for problems common in older
age.
Effect of Ageing on Health Systems
Health care systems face two major challenges in the longevity
revolution: preventing chronic disease and disability and deliver-
ing high quality and cost-effective care that is appropriate for in-
dividuals regardless of age.
In less developed regions the disease burden in old age is higher
than in more developed regions.
Special Health Care Considerations
The leading diseases contributing to disability in all regions are
cardiovascular diseases, cancers, chronic respiratory diseases,
musculoskeletal disorders, and neurological and mental diseases,
including the dementias. Some common conditions in older age
are especially disabling and require early detection and manage-
ment.
Chronic diseases common among older people include diseases
preventable through healthy behaviors and/or lifestyle interven-
tions and effective preventive health services – typically cardio-
vascular disease, diabetes, chronic obstructive pulmonary disease
and many types of cancer. Other diseases are more closely linked
to ageing processes and are not understood well enough to prevent
them – such as dementia, depression and some musculoskeletal
and neurological disorders.
While research may eventually lead to effective disability preven-
tion or treatment, early management is key to controlling disabil-
ity and/or maintaining quality of life.
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Older persons may be more vulnerable to the effects of accidents
within and outside the home.This will include risks when operating
machinery such as road vehicles, but also risks from handling other
potentially dangerous equipment. As older people continue to work
these risks must be assessed and managed.Those who suffer injuries
may have their recovery complicated by other medical vulnerabili-
ties and comorbidities.
Considerations for Health Care Professionals
Health care for elderly people usually requires a variety of profes-
sionals working as an articulated team.
Education and training of health professionals to treat and manage
the conditions common in the elderly are generally not sufficiently
emphasized in undergraduate curricula.
Reducing Impact on Health Care
A comprehensive continuum of health services needs to be adopted
urgently as population age.
It should include health promotion, disease prevention, curative
treatments, rehabilitation, management and prevention of decline,
and palliative care.
Different types of health care providers offer these services, from
self and family/informal care – sometimes in a voluntary capacity –
to community-based providers and institutions.
Establishing Optimal Health Care Systems
Universal Health Care coverage ideally should be provided to all,
including elderly people. The vast majority of health problems can
and should be dealt with at the community level.In order to provide
optimal community care and ensure care coordination over time it is
critical to strengthen Primary Health Care (PHC) services.
In order to strengthen PHC to promote active ageing, WHO ad-
vanced evidence-based principles for age-friendly PHC in three
areas which should be considered: information/education/com-
munication/training, health management systems and the physical
environment.
The health sector should encourage health systems to support all
such dimensions of care provided to individuals as they age given
the importance of health to ensure quality of life.
Specificities of Health Care
Many formal systems of health care have been developed with an
emphasis on “acute or catastrophic care” of a much younger popu-
lation, often focused on communicable diseases and/or injuries.
Health systems should emphasize other needs, especially chronic
diseases management and cognitive decline, when treating the el-
derly.
While acute care services are essential for people of all ages, but
they are not focused on keeping people healthy or providing the
ongoing support and care required to manage chronic conditions. A
paradigm shift is needed to avoid treating chronic diseases as if they
were acute conditions.
Medical conditions in older age often occur simultaneously with
social problems and both need to be considered by health profes-
sionals when providing health care. Doctors, particularly specialists,
should bear in mind that elderly patients may have other concurrent
chronic diseases or comorbidities that interact with each other and
that their treatment should not lead to inadvertent and preventable
induction of complications.
When initiating a pharmacologic treatment for chronic disease in
an elderly patient, prescribers should generally start low (doses) and
go slow (increasing the doses) to accommodate the specific needs
of the patient.
If the patient cannot decide for him/herself, due to the high preva-
lence of memory and cognitive problems in old age, physicians
treating elderly patients should actively communicate with the fam-
ily, and frequently with the formal caretaker, to better educate them
about the patient’s health condition and about medication adminis-
tration, in order to avoid complications.
When considering different therapeutic options, physicians should
always seek to find out the wishes of the patient and recognize that
for some patients quality of life will be more important than the
potential results of more aggressive treatment options.
Education and Training for Physicians
All physicians should be appropriately trained to diagnose and treat
the health problems of older people, which means mainstreaming
ageing in the medical curriculum.
Secondary health care for the elderly should be provided as neces-
sary. It should be holistic, including taking into consideration psy-
chosocial as well as environmental aspects. Physicians should also
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145
be aware of the risks of elder abuse and measures to be taken when
abuse is identified or suspected. (See the WMA Declaration of
Hong Kong on the Abuse of the Elderly.)
Every doctor, particularly general practitioners, should have access
to information and undergo training to identify and prevent poly-
pharmacy and adverse drugs interactions that may be more common
in elderly patients.
Continuing medical education on topics relevant to the ageing pa-
tient should be emphasized in order to help physicians adequately
diagnose, treat, and manage the complexities of caring for an ageing
population.
WMA Statement on
Cyber-Attacks on Health and
Other Critical Infrastructure
Adopted by the 67th
World Medical Assembly, Taipei, Taiwan, October
2016
Preamble
Advancements in modern information technology (IT) pave the
way for improvements in healthcare delivery and help streamline
physician workflow, from medical record keeping to patient care. At
the same time, implementing new and more sophisticated IT in-
frastructure is not without its challenges and risks, including cyber-
attacks and data breaches.
Cyber security threats are an unfortunate reality in an age of digital
information and communication. Attacks on critical infrastructure
and vital assets of public interest, including those used in the fields
of energy, food and water supply, telecommunications, transporta-
tion and healthcare, are on the rise and pose a serious threat to the
health and well-being of the general public.
With the proliferation of electronic medical records and billing
systems, the healthcare sector is especially susceptible to cyber in-
trusions and has become a prime soft target for cyber criminals.
Healthcare institutions and business partners, from the smallest
of private practices to the largest of hospitals, are vulnerable not
only to the theft, alteration and manipulation of patients’ electronic
medical and financial records, but also to increasingly sophisticated
system breaches that could jeopardise their ability to provide care
for patients and respond to health emergencies. Especially discon-
certing is the threat posed to a patient’s fundamental right to data
privacy and safety. In addition, repairing the damage caused by suc-
cessful cyber-attacks can entail significant costs.
Patient data also demands protection because it often contains sen-
sitive personal information that can be used by criminals to access
bank accounts, steal identities, or obtain prescriptions illegally. For
this reason, it is worth far more on the black market than credit
card information alone. Alterations to or abuse of patient data in
the case of a breach can be detrimental to the health, safety and
material situation of patients. In some cases, breaches can even have
life-threatening consequences.
Current security procedures and strategies in the healthcare sector
have generally not kept pace with the volume and magnitude of
cyber-attacks. If not adequately protected, hospital information sys-
tems, practice management systems or control systems for medical
devices can become gateways for cybercriminals.Radiology imaging
software, video conferencing systems, surveillance cameras, mobile
devices, printers, routers and digital video systems used for online
health monitoring and remote procedures are just some of the many
IT structures at risk of being compromised.
Despite this danger, many healthcare organisations and institutions
lack the financial resources (or the will to provide them) and the ad-
ministrative or technical skills and personnel required to detect and
prevent cyber-attacks. They may also fail to adequately communi-
cate the seriousness of cyber threats both internally and to patients
and external business partners.
Recommendations
1. The WMA recognises that cyber-attacks on healthcare systems
and other critical infrastructure represent a cross-border issue
and a threat to public health. It therefore calls upon govern-
ments, policy makers and operators of health and other vital in-
frastructure throughout the world to work with the competent
authorities for cyber security in their respective countries and
to collaborate internationally in order to anticipate and defend
against such attacks.
2. The WMA urges national medical associations to raise aware-
ness among their members, health care institutions and other
industry stakeholders about the threat of cyber-attacks and to
support an effective, consistent healthcare IT strategy to pro-
tect sensitive medical data and to assure patient privacy and
safety.
3. The WMA underscores the heightened risk of cyber intrusions
and other data breaches faced by the healthcare sector and urges
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medical institutions to implement and maintain comprehensive
systems for preventing security breaches, including but not lim-
ited to providing training to ensure employee compliance with
optimal data handling practices and to maintain security of
computing devices.
4. In the event of a data security breach, healthcare institutions
should have proven response systems in place,including but not
limited to notifying and offering protection services to victims
and implementing processes to correct errors in medical records
that result from malicious use of stolen data. Data breach insur-
ance policies could be considered as a precautionary measure
for defraying the costs associated with a potential cyber intru-
sion.
5. The WMA calls upon physicians, as guardians of patient safety
and data confidentiality, to remain aware of the unique chal-
lenge cyber-attacks could pose to their ability to practice their
profession and to take all necessary measures that have been
shown to safeguard patient data, patient safety and other vital
information.
6. The WMA recommends that undergraduate and postgraduate
medical education curricula include comprehensive information
on how physicians can use modern IT and electronic communi-
cations systems to full advantage, while still ensuring data pro-
tection and maintaining the highest standards of professional
conduct.
7. The WMA acknowledges that physicians and healthcare pro-
viders may not always have access to the resources (including
financial), infrastructure and expertise required to establish fail-
safe defence systems and stresses the need for the appropriate
public as well as private bodies to support them in overcoming
these limitations.
WMA Statement on Divestment
in Fossil Fuels
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October
2016
Preamble
As noted by the 65th
World Medical Assembly in Durban in 2014,
physicians around the world are aware that fossil fuel air pollution
reduces quality of life for millions of people worldwide, causing a
substantial burden of disease,economic loss,and costs to health care
systems.
According to World Health Organization data, in 2012, approxi-
mately “7 million people died, one in eight of total global deaths, as
a result of air pollution” (WHO, 2014).
The United Nations’ Intergovernmental Panel on Climate Change
(IPCC) notes that global economic and population growth, relying
on an increased use of coal, continues to be the most important
driver of increases in Carbon Dioxide emissions. These emissions
are the major component of an accelerating the amount of human
fossil fuel Greenhouse Gas (GHG) emissions despite the adoption
of climate change mitigation policies (IPCC, 2014).
The burden of disease arising from Climate Change will be dif-
ferentially distributed across the globe and, while it will affect ev-
eryone, the most marginal populations will be the most vulnerable
to the impacts of climate change and have the least capacity for
adaptation.
Background
In many densely settled populated cities around the world, the fine
dust measurable in the air is up to 50 times higher than the WHO
recommendations. A high volume of transport, power generated
from coal, and pollution caused by construction equipment are
among the contributing factors (WMA, SMAC 197, Air Pollution
WMA Statement on the Prevention of Air pollution due to Vehicle
Emissions 2014).
Evidence from around the world shows that the effects of climate
change and its extreme weather are having significant and sometimes
devastating impacts on human health. Fourteen of the 15 warmest
years on record have occurred in the first 15 years of this century
(World Meteorological Organization 2014).The vulnerable among
us including children,older adults,people with heart or lung disease,
and people living in poverty are most at risk from these changes.
The WMA notes the Lancet Commission’s description of Climate
Change as “the greatest threat to human health of the 21st
centu-
ry”, and that the Paris agreement at COP21 on Climate calls upon
governments “when taking action on climate change” to “respect,
promote and consider their respective obligations on human rights
(and) the right to health”.
As the WMA states in its Delhi Declaration on Health and Cli-
mate Change, “Although governments and international organiza-
tions have the main responsibility for creating regulations and leg-
islation to mitigate the effects of climate change and to help their
populations adapt to it, the World Medical Association, on behalf
of (…) its physician members, feels an obligation to highlight the
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147
health consequences of climate change and to suggest solutions.
(…) The WMA and NMAs should develop concrete actionable
plans/practical steps” to both mitigate and adapt to climate change
(WMA 2009).
Recommendations
The WMA recommends that its national medical associations and
all health organizations:
1. Continue to educate health scientists, businesses, civil society,
and governments concerning the benefits to health of reducing
greenhouse gas emissions and advocate for the incorporation of
health impact assessments into economic policy.
2. Encourage governments to adopt strategies that emphasize
strict environmental regulations and standards that encourage
energy companies to move toward renewable fuel sources.
3. Begin a process of transferring their investments, when feasible
without damage, from energy companies whose primary busi-
ness relies upon extraction of, or energy generation from, fossil
fuels to those generating energy from renewable energy sources.
4. Strive to invest in companies upholding the environmental
principles consistent with the United Nations Global Compact
(www.unglobalcompact.org), and refrain from investing in com-
panies that do not adhere to applicable legislation and conven-
tions regarding environmental responsibility.
WMA Statement on Ethical
Considerations in Global
Medical Electives
Adopted by the 67th
General Assembly of the World Medical Association,
Taipei, Taiwan, October 2016
Preamble
Medical trainees are increasingly participating in global educa-
tional and service experiences, commonly referred to as ‘interna-
tional medical electives’ (IMEs). These experiences are normally
short term, i.e., less than 12 months, and are often undertaken in
resource-limited settings in low-and middle-income countries.
Although IMEs can provide valuable learning experience, this must
be weighed against the potential risks to the host community, the
sponsor organization and the visiting trainee. Successful placements
help to ensure that there are mutual benefits for all parties and are
built upon an agreed understanding of concepts including non-ma-
leficence and justice.
Published ethical guidelines, such as the Ethics and Best Prac-
tice Guidelines for Training Experiences in Global Health by the
Working Group on Ethics Guidelines for Global Health Train-
ing (WEIGHT), call on sponsor institutions (i.e., universities and
organizations facilitating electives) to commit to sustainable part-
nerships with host institutions and local communities. All parties
are also called upon to work collaboratively in creating professional
guidelines and standards for medical electives.
In turn, trainees undertaking IMEs must adhere to relevant ethi-
cal principles outlined in WMA ethical documents, including the
WMA’s Declaration of Geneva, the WMA International Code of
Medical Ethics and the WMA Statement on the Professional and
Ethical Use of Social Media.
Recommendations
Therefore the WMA recommends that:
1. Sponsor institutions work closely with host institutions and lo-
cal communities to create professional and ethical guidelines on
best practices for international medical electives. Both institu-
tions should be actively engaged in guideline development. The
sponsor organization should evaluate the proposed elective us-
ing such standards prior to approval.
2. Guidelines should be appropriate to local context and endorse
the development of sustainable, mutually-beneficial and just
partnerships between institutions and the patients and the local
community, with their health as the first consideration. These
must take account of best practice guidelines, already available
in many countries.
3. Guidelines must hold patient and community safety as para-
mount, and outline processes to ensure informed consent, pa-
tient confidentiality, privacy, and continuity of care as outlined
in the WMA International Code of Medical Ethics.
4. Guidelines should also outline processes to protect the safety
and health of the trainee, and highlight the obligations of the
sponsor and host institutions to ensure adequate supervision of
the trainee at all times. Institutions should consider means of
addressing possible natural disasters, political instability, and ex-
posure to disease. Emergency care should be available.
5. Sponsor and host institutions have a responsibility to ensure
that IMEs are well planned, including, at a minimum, appro-
priate pre-departure briefings, which should include training in
culture and language competency and explicit avoidance of any
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activity which could be exploitative, provision of language ser-
vices as required,and sufficient introduction and guidance at the
host institution. Post-departure debriefing should be planned
on return of the trainee, including reviewing ethical situations
encountered and providing appropriate emotional and medical
support needed.
6. It is expected that the trainee will receive feedback and assess-
ment for the experience so that he/she can receive academic
credit. The trainee should have the opportunity to evaluate the
quality and utility of the experience.
7. Trainees must be fully informed of their responsibility to follow
instructions given by local supervisors, and to treat local host
staff and patients with respect.
8. These guidelines and processes should be reviewed and updated
on a regular basis as sponsor and host institutions develop more
experience with one another.
9. National Medical Associations should develop best practices for
international medical electives, and encourage their adoption as
standards by national or regional accrediting bodies, as feasible,
and their implementation by sponsor and host institutions.
WMA Statement
on Obesity in Children
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October
2016
Preamble
Childhood obesity is a serious medical condition and a major
public health concern affecting many children. Childhood obe-
sity is emerging as a growing epidemic and is a challenge in both
developed and developing countries. Due to its increasing preva-
lence and its immediate and long-term impact on health, includ-
ing predisposition to diabetes and cardiovascular abnormalities,
childhood obesity should be viewed as a serious concern for pub-
lic health. The increase in childhood obesity may be attributed to
many factors:
Recent studies show that marketing targeted at children has a
wide influence on the shopping trends and food preferences of
households all over the world. Special offers, short-term price
reductions and other price promotions and advertising on social
as well as traditional media all play a role in increasing product
demand.
Many advertisements are in conflict with nutritional recommenda-
tions of medical and scientific bodies. TV advertisements for food
and drink products with little or no nutritional value are often
scheduled for broadcast hours with a large concentration of child
viewers and are intended to promote the desire to consume these
products regardless of hunger. Advertisements increase children’s
emotional response to food and exploit their trust. These methods
and techniques are also used in non-traditional media,such as social
networks, video games and websites aimed at children.
Unhealthy dietary patterns, together with a sedentary lifestyle and
lack of exercise, contribute to childhood obesity. The sedentary
lifestyle is the most predominant one in the developed world to-
day. Many children typically spend more time than ever in front of
screens, rarely engaging in physical activities.
International corporations and conglomerates that manufacture
foods and beverages are not always subject to regional regulations that
govern food labeling. Concern for profits may come at the expense of
corporate responsibility for environmental and public health issues.
Products containing large amounts of added sugar, fat, and salt can
be addictive, especially when combined with flavor enhancers. In
some countries, not all ingredients are required to be listed on food
labels and manufacturers often refuse to release data on methods
employed to maximize consumption of their products. Govern-
ments should require that all ingredients in food and beverages be
clearly labeled, including those proprietary ingredients intended to
increase consumption of the product.
Socioeconomic disparities also correlate with increasing rates of
childhood obesity. The link between living in poverty and early
childhood obesity continues to negatively affect health in adult
life [1].Exposure to environmental contaminants, sporadic medical
checkups,insufficient access to nutritious foods and limited physical
activity lead to obesity and other chronic illnesses that are all more
prevalent among children living in poverty.
Recommendations
1. A comprehensive program is needed to prevent and address
obesity in all segments of the population, with a specific focus
on children. The approach must include initiatives on price and
availability of nutritious foods, access to education, advertising
and marketing, information, labeling and other areas specific to
regions and countries. An approach similar to that on tobacco
in the WHO Framework Convention on Tobacco Control is
advocated.
2. International studies stress the importance of adopting an inte-
grated approach to education and health promotion.Investment
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149
in education is key to minimizing poverty,improving health and
providing economic benefits.
3. Quality education offered in formal settings to children aged 2
to 3 years, combined with enrichment activities for parents, and
sufficient supply of nutritious food and beverages may help to
reduce the rate of adolescent obesity and reduce its health im-
plications throughout the life course. Developing early healthy
eating practices and experiencing flavors of healthy food when
very young appear to be positive factors in prevention of child-
hood obesity.
4. Governments should invest in education related to menu
design, food shopping including budget setting, storage and
preparation so that people are better equipped to plan their
food intake.
5. Governments should seek to regulate the availability of food and
beverages of poor nutritional value, by a range of methods in-
cluding price. Attention should be paid to the availability close
to schools of establishments selling products of poor nutritional
quality. Governments should seek to persuade manufacturers to
reformulate products to reduce their obesogenic effects. Where
possible government and local authorities should seek to man-
age the density of such establishments in the area.
6. Governments should consider imposing a tax on non-nutritious
foods and sugary drinks and use the additional revenue to fund
research and epidemiological studies aimed at preventing child-
hood obesity and reducing the resulting disease risk.
7. Ministries of health and education should regulate food and
beverages that are sold and served at educational and healthcare
facilities.
8. Given the scientifically proven link between the extent of media
consumption and adverse effects on body weight in children,
the WMA recommends that the advertising of non-nutritious
products be restricted during television programming and other
forms of media that appeal to children. Regulators should be
aware that children access television programs designed for
adults and ensure that legislation and regulation also limits mar-
keting associated with such programs.
9. Governments should work with independent health experts to
produce sound guidance on food and nutrition,with no involve-
ment of the food and drink industry.
10. Governments and local authorities should subsidize and en-
courage activities that promote good health among their resi-
dents, including providing safe spaces for walking, bike riding
and other forms of physical activity.
11. Parents have a crucial role in fostering physical activity in their
children. Schools should incorporate daily physical activity into
their daily routine. Participation in sport activities should be
possible for everyone regardless of their economic situation.
12. National Medical Associations should support or develop
guidelines and recommendations to ensure that they reflect
current knowledge of prevention and treatment of childhood
obesity.
13. National Medical Associations should work to raise public
awareness on the issue of childhood obesity and highlight the
need to tackle the rising prevalence of obesity and its health and
economic burden.
14. Clinics and Health Maintenance Organizations should employ
appropriately trained professionals to offer classes and consulta-
tion in selecting appropriate amounts of nutritious foods and
beverages and attaining optimal levels of physical activity for
children. They should also ensure that their premises are exem-
plars in the provision of healthy food options.
15. Educational facilities should employ appropriately trained pro-
fessionals who educate for healthy lifestyles from an early age
and allow all children, whatever their social environment, to
practice regular physical activities.
16. Physicians should guide parents and children in how to live
healthy lives and emphasize the importance of doing so, and
must identify as soon as possible obesity in their patients, par-
ticularly children. They should direct patients suffering from
obesity to the appropriate services at the earliest possible stage,
and conduct regular follow-ups.
17. Physicians and health professionals should be educated in nutri-
tion assessment, obesity prevention and treatment. This could
be accomplished by strengthening CME activities focused on
nutritional medicine.
1.
WHO Commission on Social Determinants of Health (Closing the Gap in
a Generation) 2008.
WMA Resolution on
Occupational and Environmental
Health and Safety
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October
2016
Preamble
Occupational and environmental health and safety (OEHS) is an
integral part of public health, and the primary health care (PHC)
system in particular, since it is often the first level of contact of
individuals, the family and the community with a health system,
bringing health care as close as possible to where people live and
work [1].
WMA General Assembly
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150
Workers represent at least half of the world’s population and are the
backbone of many economies, but may have inadequate access to
occupational and environmental health services [2]. Decent work
sums up the aspirations of people in their working lives. It involves
opportunities for work that is productive and delivers a fair income,
security in the workplace and social protection for families, better
prospects for personal development and social integration, freedom
for people to express their concerns, organize and participate in
the decisions that affect their lives and equality of opportunity and
treatment for all women and men (ILO).
Every 15 seconds,a worker dies from a work-related accident or dis-
ease [3], and each year there are 160 million cases of work-related/
occupational diseases; 313 million work accidents occur annually
and over 2.3 million people die as a result of work accidents and
occupational diseases [4].
Despite this,the proportion of work accidents and occupational dis-
eases that are recorded and reported is incredibly extremely small.
It estimated that only less than 1% of occupational diseases are re-
corded [5].
The United Nations Development Programme’s Sustainable Devel-
opment Goals 3, 5, 8 and 13 call for action in health promotion for
all people of all ages, gender equality, decent work and management
of the impact of climate change; OEHS is well positioned to impact
positively within the work place on all the above mentioned sustain-
able development goals.
Physicians have a critical role in preventing and protecting from,
diagnosing, treating and reporting work accidents and occupation-
al diseases. Information, skills and functions of physicians form
the basis of service models that vary by countries and constitute
key elements in addressing OEHS. In addition, physicians should
strive for inclusive working life so that even employees with dis-
abilities are given opportunities to stay integrated in decent work-
ing life.
Despite many governments and employers’ and workers’ organiza-
tions place greater emphasis on the prevention of occupational dis-
eases. Prevention is not receiving the priority warranted by the scale
and severity of the occupational disease epidemic.
Physicians and National Medical Associations can contribute to
the identification of problems, development of national report-
ing systems and formulation of relevant policies in the field of
OEHS.
Unsatisfactory and unsafe working conditions play a significant role
in the development of occupational diseases and injuries, which
are, in their turn, a cause of mortality among working population.
Women bear the brunt of the work-related burden which often
makes them a more vulnerable group in working life.
Recommendations
1. Physicians should play a pivotal role in the development of a
workforce that is trained in the social determinants of health,
and raise workplace awareness about the social determinants of
health.
2. The field of OEHS should be accorded the necessary impor-
tance in both graduate and post-graduate medical studies.
3. All workers should have access to risk based OEHS services
from the first day of work, and extending beyond the last day
at work in order to account for occupational diseases with a
long latency period. Service content should be standardized and
the role of physicians in the planning and implementation of
OEHS systems that are essentially preventive/protective must
be recognized.
4. National Medical Associations should act proactively and en-
courage the expansion of the scope of OEHS services, prevent
and reduce occupational diseases, and injuries, reproductive
health and protect the environment. They should also promote
workplace gender equality, and improve recording and report-
ing systems. In addition, they should focus on capacity building,
teaching and training, collaborative research and improving the
qualifications of their members in this field.
5. National Medical Associations, together with governments,
should take an active role, where appropriate, in the formula-
tion and development of national systems that facilitate OEHS
prevention, and recording and reporting occupational diseases
in their respective countries and lead their member physicians
in efforts to be made in this area.
6. Occupational diseases and injuries are often addressed in the
context of insurance and compensation. Where these mecha-
nisms are not in place, national medical associations should ad-
vocate for the protection of workers through by means of insur-
ance or social security.
7. NMAs should engage in establishing “medical causality” in the
context of reporting accidents and diseases,and inform the pub-
lic that the health impacts of hazards and risk factors inherent
to working life can be established and recorded only through a
well-developed reporting system.
8. As part of medical care, physicians who are evaluating workers’
compensation patients should be accredited in occupational and
environmental medicine. The first contact may be with the pa-
tient’s regular physician who should routinely obtain history on
patient’s occupation and environmental exposures. If the physi-
cian establishes a relationship between the diagnosis and these
exposures, he/she must report it to the relevant authority and
WMA General Assembly
151
ideally refer the patient for an evaluation by a accredited occu-
pational and environmental medicine physician.
9. National Medical Associations should consider forming an in-
ternal body for addressing the problems of physicians working
in this area and encourage them to contribute to related scien-
tific studies
10. National Medical Associations should promote opportuni-
ties for physicians to benefit, in their daily professional prac-
tice, from systems identifying environmental/occupational risks
and hazards having an impact on workers’, including pregnant
workers, health and safety. In this context, apart from the lists
of WHO International Classification of Diseases and the In-
ternational Labour Organisation (ILO), they should promote
an easy-to-use system for “exploring, recording and reporting
environmental risks and factors” that physicians can use easily.
11. Governments should collaborate in setting up an international
system to assess occupational hazards and develop strategies to
protect the health of workers.
12. Governments should establish legislative frameworks that pro-
tect the rights and health of workers, including reproductive
health and health effects of work at home.
13. The active participation of employers’and workers’organizations
is essential for the development of national policies and pro-
grammes for the prevention of occupational diseases.
14. Employers should provide a safe working environment, recog-
nising and addressing the impact of adverse working conditions
on individuals and society.
15. When rendering services for an employer, physicians should ad-
vocate that employers fulfil minimum requirements set in the
International Labour Organization’s (ILO) occupational stan-
dards, especially when such requirements are not set by national
legislation. Physicians must maintain their autonomy and inde-
pendence from employer.
1. World Health Organization. Declaration of Alma-Ata: International Con-
ference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978.
2. World Health Organization. Workers’ health: Global plan of action. WHA
60.26.
3. International Labour Organization [internet]. Safety and health at work.
ILO; [updated 2016; cited 2016 January 19]. Available from: http://www.ilo.
org/global/topics/safety-and-health-at-work/lang–en/index.htm
4. Safety and health at work, ILO The Prevention of Occupational Diseases.
World Day for safety and health at work 28 April 2013.
5. The Prevention of Occupational Diseases. World Day for safety and health
at work 28 April 2013.
6. National System for Recording and Notification of Occupational Diseases
Practical guide
7. International Statistical Classification of Diseases and Related Health Prob-
lems (ICD-10) In Occupational Health. World Health Organization Ge-
neva 1999.
8. Improving Workers› Health Worldwide: Implementing the WHO Global Plan
of Action on Workers’ Health.GOHNET NEWSLETTER NO. 22. Novem-
ber 2013 Edition.
WMA Resolution
on Refugees and Migrants
Adopted by the 67th
World Medical Assembly,Taipei,Taiwan, October 2016
Preamble
Currently, a very large number of people are seeking refuge and/
or asylum; some are fleeing war zones or other conflicts, others are
fleeing from desperate poverty, violence, and other injustices and
abuses with potentially very harmful effects to mental and physical
health.
The global community has been ill prepared for handling the refu-
gee crisis, including addressing the health needs of those seeking
refuge.
The WMA recognizes that mass migration will continue unless
people are content to stay in their birth countries because they see
opportunities to live their lives in relative peace and security and
to offer themselves and their families the ability to live lives with
opportunities for fulfilment of various sorts, including economic
improvement. The global community has a responsibility to seek to
improve the lot of all populations, including those in countries cur-
rently with the poorest economies and other key factors. Sustain-
able development will give all populations improved security, and
economic options.
The WMA recognizes that warfare and other armed conflict, in-
cluding continuous civil strife, unrest and violence, will inevitably
lead to people movement.The worse the conflict the higher the per-
centage of people who will want to leave the conflict zone. There
is a responsibility for the global community, especially its political
leaders, to seek to support peace making and conflict resolution.
The WMA recognizes and condemns the phenomenon of forced mi-
gration, which is inhumane and must be stopped. Such cases should
be considered for referral to the International Criminal Court.
Principles
1. The WMA reiterates the WMA Statement on Medical Care for
Refugees originally adopted in Ottawa, Canada in 1998 which
states:
–
– Physicians have a duty to provide appropriate medical care re-
gardless of the civil or political status of the patient, and gov-
ernments should not deny patients the right to receive such
WMA General Assembly
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WMA General Assembly
care, nor should they interfere with physicians’ obligation to
administer treatment on the basis of clinical need alone.
–
– Physicians cannot be compelled to participate in any punitive
or judicial action involving refugees, including asylum seekers,
refused asylum seekers and undocumented migrants, or Inter-
nally Displaced Persons or to administer any non-medically
justified diagnostic measure or treatment, such as sedatives to
facilitate easy deportation from the country or relocation.
–
– Physicians must be allowed adequate time and sufficient re-
sources to assess the physical and psychological condition of
refugees who are seeking asylum.
–
– National Medical Associations and physicians should actively
support and promote the right of all people to receive medical
care on the basis of clinical need alone and speak out against
legislation and practices that are in opposition to this funda-
mental right.
2. WMA urges governments and local authorities to ensure access
to adequate healthcare as well as safe and adequate living condi-
tions for all regardless of their legal status.
WMA Resolution
on the Protection of Health Care
Facilities and Personnel in Syria
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan, October
2016
The World Medical Association (WMA) notes with great concern
the recent and repeated attacks on health care facilities, health care
workers and patients in Syria, especially in Aleppo. These attacks
have killed and injured civilian people, and the most vulnerable
among them, children and patients. Since the beginning of the war
in Syria in 2011, an estimated 270 health care facilities have been
attacked and 760 health care workers have been killed.The WMA is
profoundly concerned by this development, as health care facilities
and personnel should, according to the international law, be pro-
tected by the parties of the conflict.
Therefore the WMA
• Deeply regrets and condemns the recent and recurring bombings
of the hospitals in Aleppo, considering these as a violation of hu-
man rights;
• Reaffirms its statements on “Healthcare in Danger”and demands
all countries to ensure the safety of healthcare personnel and pa-
tients in conflict situations;
• Calls on all countries to fully implement the UN Resolution 2286
(2016) which demands all parties to armed conflicts to fully com-
ply with their obligations under international law, to ensure the
respect and protection of all medical personnel and humanitarian
personnel exclusively engaged in medical duties, of their means of
transport and equipment, as well as hospitals and other medical
facilities;
• Demands an immediate and impartial enquiry into the attacks
against health care facilities and personnel, and actions taken
against those responsible in accordance with domestic and inter-
national law.
WMA Resolution
on Zika Virus Infection
Adopted by the 67th
WMA General Assembly, Taipei, Taiwan
Recognizing that the WHO has designated the Zika virus infec-
tion a global health emergency, the WMA provides the following
recommendations:
• WHO should work with ECDC, CDC and other disease control
organisations to better understand the natural history and current
epidemiology of Zika virus infection.
• Information should be disseminated widely to advise and protect
all women and men who live in or must travel to Zika-affected
areas and who are considering becoming parents. Advice should
also include recommendations for women who are already preg-
nant who may have been directly exposed to the Zika virus or
whose partners live in or have travelled to Zika-affected areas.
• Relevant agencies, including WHO, should gather data on the
efficacy of different mosquito control methodologies, including
the potentially harmful or teratogenic effects of the use of various
insecticides.
• Work on diagnostic tests, antivirals, and vaccines should continue
with an emphasis on producing a product that is safe for use in
pregnant women and public funding should be assured for this
research. When such products are developed states should ensure
that they are available to, and affordable by, those most at risk.
• States which have witnessed the delivery of a number of babies
with microcephaly and other fetal brain abnormalities must en-
sure that these infants are properly followed up by health and oth-
er services, and provide support to families seeking to cope with
a child with developmental abnormalities. Wherever possible re-
search on the consequences of microcephaly should be published,
to better inform future parents, and to allow the development of
optimal service provision.
153
UNITED STATES OF AMERICA Health Care
Enactment of the Affordable Care Act
(ACA) in 2010 was the culmination of a
long and contentious battle in the United
States Congress to create a more sustainable
health care system by addressing shortcom-
ings that left millions of Americans unin-
sured. Six years later, the ACA has achieved
notable success in expanding health insur-
ance coverage for millions of people, and in
making improvements to quality and effi-
ciency.
However, significant challenges remain.
Many people still cannot afford insurance,
costs continue to rise significantly in cer-
tain sectors, and health insurers are drop-
ping out of unprofitable markets. Compli-
cating matters, the political environment
in the United States remains uncertain,
with the incoming president having run on
a platform of repealing and replacing the
law.
A closer look at the past, present and fu-
ture challenges of health care reform  –
specifically, the Affordable Care Act – in the
United States may be helpful for world
observers during this time of uncertainty
and change.
Why reform was needed
Perhaps the best way to describe the im-
petus behind the ACA  – also known as
Obamacare, as it was strongly endorsed by
our current president, Barack Obama – is
through a story. My specialty is emergency
medicine and I am in active practice in
Lexington, Kentucky. I ask you to imag-
ine that it is the year 2009  – seven years
ago. The year before the Affordable Care Act
passed.
A typical patient who I may have seen at
that time is “Delores”. Delores is 60 years
old, eighty pounds overweight, and dia-
betic. She does not have health insurance.
She has trouble managing her diabetes,
and comes to the Emergency Depart-
ment when her blood sugar spikes. Delores
epitomizes much of what was unsustain-
able about the American health care sys-
tem a few years ago, and the reason health
reform was necessary. She is aging, she
has a chronic condition, and she is unin-
sured. Because she is uninsured, she does
not have a regular source of health care or
the medications she needs. She waits until
she is truly ill before she seeks care. And
because she waits, her care is unnecessarily
expensive, irregular and without primary
care follow up.
This pattern of care was far more expen-
sive than it would have been had she been
able to prevent her blood sugar from spik-
ing through regular use of medications and
regular visits to the doctor.
If you multiply Delores’s story by millions
of others, you see some of the primary rea-
sons why the United States’health care sys-
tem was unsustainable.
Estimates at the time the ACA was debat-
ed showed that nearly 50 million Ameri-
cans were uninsured; health care costs were
soaring; and an epidemic of chronic condi-
tions was sweeping the nation, to the point
that nearly half of American adults had a
chronic condition such as heart disease or
diabetes. It was clear that major changes
were needed to reduce the impact of chron-
ic disease, of skyrocketing costs, and of hu-
man misery.
Political division and
health reform
The Affordable Care Act debate was pre-
ceded by numerous other attempts to ex-
pand health insurance coverage in the last
century. Beginning in 1912 and continuing
throughout the 20th
century, many Ameri-
can presidents from Theodore Roosevelt
to Bill Clinton tried, and largely failed,
to implement a national health insurance
program. There are a few notable excep-
tions. During the 1960s, President Lyndon
Johnson and Congress successfully enacted
a health insurance system for older Ameri-
cans and the disabled, called Medicare, and
an insurance program for the poor, called
Medicaid. In 1997, Congress passed and
the President signed legislation called the
State Children’s Health Insurance Pro-
gram, or S-CHIP, which provides insur-
ance for children in families with mod-
est means. And then, in 2003, Congress
expanded prescription drug coverage for
seniors through what became Part D of
the Medicare program. Other than those
examples, there has been a clear pattern of
failure.
International observers may wonder why
the U.S. does not simply adopt a single-
payer system like other countries. One
Steven J. Stack
Health Care Reform in the United States:
Past, Present and Future Challenges
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154
Health Care UNITED STATES OF AMERICA
­
answer, for good and for bad, is capitalism.
But, I think a more salient factor is Amer-
icans’ long history of self-reliance, and a
fear of too much intrusion by government
into our lives. During the debates over
the Affordable Care Act, for example, one
side saw the legislation as a government
takeover of health care, the slippery slope,
they said, to socialism. The other side saw
it as a step towards making health care a
universal right – available to all, regardless
of their ability to pay. Each side felt this
was a moral imperative – to refrain or to
reform.
Viewed this way, the debate over health
reform is more about individualism ver-
sus collectivism than Republican ver-
sus Democrat. It is a disagreement that
reflects deep-seated views on the roles
and responsibilities of both individu-
als and the government in society. It’s
an argument that continues to this day.
The ACA, debated from 2008 – 2010, is
considered to be one of the most contro-
versial and divisive pieces of legislation
in recent American history. Not a single
Republican in the House of Representa-
tives or the Senate voted for the final bill.
Political careers have been launched  –
and ended – solely on the basis of a can-
didate’s position on this one issue. And
even though the bill became law, the de-
bate is not over.
Opposition to the Affordable Care Act con-
tinues. Consider that the Republican-con-
trolled House of Representatives has tried
to repeal or defund the ACA more than
60 times! So far, however, attempts to re-
peal the legislation or to invalidate major
provisions in the courts have been mostly
unsuccessful. Similarly, efforts to refine the
law, not at all uncommon in an undertaking
this enormous, have also been unsuccess-
ful. Politics keeps us from both repealing
the legislation, and improving it. The sta-
tus quo could change, though, as a result of
America’s recent federal elections, as I will
describe later.
The American Medical
Association and the
Affordable Care Act
The debate over the 2010 Affordable Care
Act was extremely contentious within the
American Medical Association (AMA) as
well as the nation as a whole. But behind
the AMA Board of Trustee’s decision to
support the legislation was the recognition
of a number of things:
First, the status quo was no longer an op-
tion. As I illustrated through the example
of Delores, America’s health care sys-
tem was simply unsustainable. It was too
costly, and too many people with treatable
medical problems were falling through the
cracks.
Second, if we took the politics out of the
issue,it would be impossible to justify deny-
ing meaningful health care to tens of mil-
lions of patients. In fact, access to health
care is one of the primary founding prin-
ciples of the AMA. We knew that people
without access to insurance were living sick-
er and dying younger – something to which
physicians are professionally, personally and
morally opposed.
And third,achieving real,substantive health
system reform would take time. Lasting
change often comes slowly. And that has
certainly been the case with health care re-
form.
Ultimately, after a long and passionate in-
ternal debate, the AMA decided to support
the legislation – not because it was perfect –
but because many of its major provisions
were consistent with AMA principles and
policies:
• Expanding health insurance coverage for
the uninsured;
• Making health coverage more affordable;
• Preventing denials of care and coverage,
including those for pre-existing health
conditions;
• Investments in prevention and wellness
initiatives.
Supporting the ACA gave the AMA an-
other advantage: the ability to be construc-
tively engaged throughout the process. In-
stead of sitting on the sidelines, we were
actively involved in shaping the legislation.
We worked with lawmakers from both par-
ties and key members of the Administration
to get as much AMA policy reflected in the
legislation as possible, and to exclude those
items we opposed. After a protracted po-
litical battle, Congress passed the ­
Affordable
Care Act in March of 2010. President
Obama signed the legislation on March 23,
2010.
Major elements of reform
So what provisions are in the Affordable
Care Act? What does the legislation do?
Perhaps most important, the ACA made
substantial reforms in the private health
insurance markets. In an effort to reduce
the number of uninsured Americans, new
health insurance exchanges, or market-
places, were created for consumers to shop
for and purchase health insurance plans.
Subsidies were offered for individuals with
qualifying incomes so they could afford
to purchase coverage. For the first time,
all Americans were required to purchase
health insurance. Known as the “individ-
ual mandate,” this provision was included
to ensure that enough young and healthy
patients would purchase insurance to offset
older patients whose care is more expen-
sive, as well as ensure that individuals could
not forego coverage until they become ill or
injured. The law also stopped insurers from
denying coverage to people who had pre-
existing conditions, and eliminated a prac-
tice where insurance companies would pay
only up to a certain limit for each individ-
ual.These insurance practices were particu-
larly problematic if the person had a serious
disease such as cancer, or a traumatic injury
involving lengthy hospitalizations. And, it
155
allowed young adults to stay on their par-
ents’ health insurance until age 26.
Other major elements of health reform
contained in the Affordable Care Act include
an emphasis on prevention. Private insurers
are now required to cover a range of recom-
mended preventive health services includ-
ing immunizations, well visits and con-
traceptives without requiring any patient
cost-sharing. The Medicaid program was
expanded, to provide coverage to individu-
als earning less than 133 percent of poverty-
level income. This provision was challenged
in the courts, however, and because of a
Supreme Court decision, individual states
are able to decide whether or not to provide
that level of coverage.
The ACA also set up several demonstra-
tion programs to test and evaluate a variety
of new payment models. For example, the
legislation established a Center for Medi-
care & Medicaid Innovation at the Centers
for Medicare and Medicaid Services to test
care models to improve quality and slow
the rate of growth in Medicare costs, and
a National Bundling Pilot Program to im-
prove coordination, quality and efficiency of
services when patients are hospitalized. We
recognized that it is not enough to expect to
control costs solely by insuring more indi-
viduals. Physicians and hospitals must also
improve the quality and delivery of care to
reduce costs.
Results of the Affordable Care
Act
Six years have passed since the Affordable
Care Act became law.Implementation of the
bill has come in phases, with the legislation
not fully implemented until 2014. However,
we can draw some important conclusions
from the data that is now available.
First, it is undeniable that the ACA has in-
creased access to health care for tens of mil-
lions of men, women and children:
• 20 million people have gained coverage
because of the ACA;
• 6.1 million young adults have gained cov-
erage;
• 137 million patients have private insur-
ance coverage of preventive services with
no cost-sharing;
• 12.7 million patients have signed up on
exchanges; and
• 15.7 million additional people have en-
rolled in the Medicaid and CHIP pro-
grams. This includes people who were al-
ready eligible for Medicaid, but who had
not previously enrolled.
Next, there have been significant declines
in the percentage of racial and ethnic mi-
norities who are uninsured.The percentage
of African Americans who were uninsured
dropped from nearly 16 percent in 2013
to 11 percent in 2015. The percentage of
Hispanics who were uninsured dropped
from more than 24 percent to 16 percent
during the same period. (See Chart 1)
African Americans, Hispanic Americans
and Asian Americans have traditionally
had higher rates of uninsured than non-
Hispanic whites, so we are pleased to see
significant gains for these underserved
populations. There have also been signifi-
cant declines in the percentage of unin-
sured in every age group and income level.
(See Charts 2, 3)
Finally, for health reform to truly be suc-
cessful, not only must more people have ac-
cess to care, but costs must also be sustain-
able.Right now we spend about $3 trillion a
year on health costs – a staggering amount.
While it is unlikely we will ever spend less
on health care from year to year, the evi-
dence suggests that the rate of increase in
health care costs is going down. According
to a 2016 report of the Robert Wood John-
son Foundation published by the Urban
Institute, the United States is on track to
spend $2.6 trillion less on health care be-
tween 2014 and 2019, compared to initial
projections made right after passage of the
ACA in 2010.
Future challenges and
opportunities
For American physicians, the ACA is one
of a number of developments that have
ushered in seismic changes in health care.
Other factors are rapid advancements in
technology, especially health information
Chart 1. Decline in Percent Uninsured by Race and Ethnicity
UNITED STATES OF AMERICA Health Care
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156
technology, a shift in demographics and
changing patient expectations. For Ameri-
can physicians, a key question is “How can
we best adapt to change?” The American
Medical Association has decided that it is
critically important for physicians to lead,
and to help shape the future, rather than
simply being affected by it. The AMA is
actively involved on the state and federal
levels, with legislators and regulators, try-
ing to address some of the challenges cre-
ated by the ACA. For example, some peo-
ple still cannot afford to purchase health
insurance, even with subsidies. Or, they are
purchasing insurance with low premiums,
but with such high deductibles that their
level of out-of-pocket costs is unaffordable.
That’s why the AMA is supporting efforts
to make the cost-sharing obligations under
the exchange plans with high deductibles
more affordable, and to allow low-to-
moderate-income families who only have
access to unaffordable employer-sponsored
coverage to receive financial assistance to
purchase health coverage through the ex-
changes. In another example, prescription
drug spending continues to rise faster than
overall health spending. That’s why the
AMA is supporting market-driven initia-
tives to control pharmaceutical costs, as
well as improvements to ensure that the
pharmaceutical marketplace operates effi-
ciently and effectively.
A third issue is that health insurance mar-
ketplaces are failing to attract enough
younger, healthier people who would offset
the cost of coverage for older, less healthy
people. This is a contributing ­
factor to
insurers­­
trying to maintain profitability
through health insurance mergers, restrict-
ing physician and hospital networks, or
discontinuing their participation in the
marketplaces. The AMA is very actively in-
volved in opposing mergers that would limit
access to care or increase the cost of care.
But we know insurers are important part-
ners in keeping the system alive, so we work
to ensure that our policies are fair and data
driven.
Presidential and
Congressional elections
The future of the Affordable Care Act is un-
certain in the wake of America’s recent fed-
eral elections. Businessman Donald Trump
was elected president.Republicans still hold
majorities in both chambers of Congress,
although their margins were reduced slight-
ly. The incoming president and Republican
leaders in Congress are expected to attempt
to repeal much of the ACA and replace its
provisions with alternate private sector op-
tions. Shortly after the election, president-
elect Trump indicated he was open to
keeping some key provisions of the ACA
intact, including the prohibition on denying
coverage to individuals with pre-existing
Chart 2. Decline in Percent Uninsured by Age
Chart 3. Decline in Percent Uninsured by Income
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157
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GERMANY
conditions, and provisions allowing young
adults to remain on their parents’ insurance
until age 26. So, while the ACA may not be
completely dismantled, at the very least it
appears there will be substantial modifica-
tions.
AMA core principles
regarding health care
reform
As a mission-oriented organization, dedi-
cated to improving the health of the nation,
the AMA’s policy objectives do not change
as a result of elections. Shortly after the
election, the AMA’s House of Delegates
reaffirmed its commitment to health care
reform that improves access to care for all
patients, and signaled its intent to actively
engage the incoming Trump Administra-
tion and Congress in discussions about the
future of health care reform.The AMA will
be steadfast in advocating for the core prin-
ciples and priorities that we have long stood
for when it comes to reform:
• Coverage for all Americans;
• Pluralism;
• Freedom of choice;
• Freedom of practice
• Universal access for patients.
We have made clear that any new reform
proposals should not cause individuals cur-
rently covered as a result of ACA provisions
to become uninsured. The AMA also sup-
ports reform efforts focused on improving
delivery of care, professional satisfaction,
and physician practice sustainability. And
finally, the AMA also supports more effi-
cient and effective use of the $3 trillion cur-
rently spent on health care.
Final thoughts
The Affordable Care Act was an attempt to
create a more sustainable health care system
in the United States. What is undeniable
is that the ACA has allowed more people
like Delores, the patient I told you about
earlier, to become insured. That, combined
with the law’s emphasis on prevention,
should mean that more patients receive care
earlier and more reliably. We hope this will
lead to better health outcomes and will also
reduce costs. Only time will tell if history
will judge the Affordable Care Act to be truly
transformative, or as a failed experiment.
The AMA will fight for the principles I laid
out earlier, regardless of what our political
leaders may or may not do. As physicians,
we know what needs to be done to create
sustainable health care for our patients, for
our communities, and for our countries. It
is up to us to do all we can to support plans
and programs that embody those principles
and to work together to convince our lead-
ers to do so as well.
Steven J. Stack, MD
Immediate Past President
American Medical Association
E-mail: AMA.President@ama-assn.org
Health System Sustainability with Regard to Global Migration
and Refugees: the Case of Germany
Introduction
Healthcare systems are regularly faced with
new challenges. In 2015, the arrival of large
numbers of refugees in countries across Eu-
rope had considerable impact on the health-
care situation in these countries.
By the end of 2015, around 1,000,000
people had crossed the German borders as
refugees, approximately 477,000 of whom
submitted formal applications for asylum.
We only count the people coming in – no
one keeps track of those leaving the country.
Some moved on to other European coun-
tries like Sweden or Norway. Some never
registered but stayed on, and quite a few
have even gone back home. Europe didn’t
easily fulfil their dreams and proved a disap-
pointment. Therefore it is difficult to deter-
mine how many undocumented people have
remained in Germany either because they
have been denied asylum or simply because
they chose not to register. We estimate the
number of the “undocumented” or “illegals”
to be between 140,000 and 330,000 indi-
viduals.
The German healthcare system was con-
fronted with the major challenge of having
to integrate these individuals as quickly as
possible. The German Medical Association
at all times made it clear that every patient
we see comes to us as a patient,a sick person
seeking help and relief and not primarily
as a refugee, an asylum seeker, an undocu-
mented person or even an illegal person.
We heavily defend the position that there
is no such thing as an “illegal” person in the
health care system.
However: The legal system in place is a
patchwork of sometimes inconsistent poli-
cies regarding access to healthcare services,
billing procedures and benefits eligibility,
as this varies not only from state to state,
but also from municipality to municipal-
ity. Therefore we could not rely on regional
or local governments provisions alone.
As the number of arrivals peaked, medi-
cal volunteers played an important role in
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complementing the official healthcare sys-
tem. It was our duty as a profession to or-
ganize help for those in need. And we are
proud to say we managed.
Our Chancleress Angela Merkel was heav-
ily criticised for her words “Wir schaffen
das” – we can manage…. It was the same
spirit we heard from American President
Barak Obama when he said “Yes, we can”.
Today we can say: we managed, and we
could….
The German health care
system
In order to put these challenges into some
context, I would like to take a few moments
to point out some features of the German
healthcare system:
Germany has a population of around
81  million. Total expenditure in the
healthcare system amounts to € 328 billion
($  427  billion PPP) per annum (2015),
which equates to €4,050 ($ 5,300 PPP)
in spending per capita and an 11 per cent
share of GDP.
We are among the richest countries of
the world. We have access of virtually all
inhabitants to nearly all health services.
There is no medically indigent person in
Germany.
Our system is characterised by the so-
called Bismarck model, which provides
comprehensive health insurance financed
by contributions from the employers and
the employees and a smaller subsidy by the
federal Government. These contributions
are all collected into a healthcare fund and
then distributed to the insurers. As a result,
90 per cent of our population is insured in
the statutory health insurance system in just
over 100 insurances. The remaining 10 per
cent of the population – civil servants and
the self-employed in particular – is privately
insured in approx. 50 companies. The fed-
eral level primarily provides the framework
and defines the structure of the statutory
health insurance system. But as mentioned
before – Germany is a federal country with
16 federal states. These states are respon-
sible for the provision of public healthcare,
for planning hospital capacities and for cov-
ering the investment costs of hospitals. And
we have rich states and poor states and we
have different political parties and all sorts
of coalitions ruling the states. And that’s
where the problems start. I will go into
more detail later on.
Outpatient care is carried out in the pri-
vate practices of around 150,000 practice-
based physicians. These physicians then
refer patients to hospitals in cases where
inpatient treatment is necessary. In to-
tal, Germany has 485,800 doctors who
are all compulsory members of our State
Chambers of Physicians. You see: we don’t
seem to have an overall shortage of physi-
cians. In fact the physician per capita ratio
of Germany is one of the highest in the
world.
We see approximately 20 Mio. cases each
year in hospital and perform close to 18
Mio. operations. We have over 500 Mio.
consultations in private practices. All in all
almost 7% of the German workforce work
in the health care sector – that is more than
four million people.
The medical treatment of
refugees in Germany
But how do refugees fit into this picture?
And which legal provisions govern the
medical treatment of refugees in Germa-
ny?
In Germany, anyone who is politically
persecuted has the constitutional right to
asylum  – and this persecution does not
necessarily have to originate from the gov-
ernment of his home state.It may also be re-
ligious persecution, persecution on grounds
of sexual behavior, tribal disputes or sheer
unbearable violence.
Asylum seekers are individuals whose ac-
cess to healthcare is regulated by federal
law and the scope of medical services of-
fered to asylum seekers depends upon the
duration of their stay and their administra-
tive status:
The federal law in question grants asylum
seekers for the first 15 months access to
treatment only in cases of acute illness
and pain and emergency. Women who are
pregnant or who have recently given birth
are eligible to receive medical and nursing
care, as well as access to midwives, medi-
cation and surgical dressings. The law also
covers officially recommended vaccina-
tions and a compulsory preventive medi-
cal examination. We – the GMA – have
always and persistently contested this
federal bill as it did not cover chronic dis-
ease and access to preventive medicine in
general. It is a shame that we as physicians
see chronic disease and are not allowed to
treat it!
But things are even worse. In practical
terms, the 16 federal states shape policy
details with their municipalities. Refugees
Frank Ulrich Montgomery
159
are placed in different states on the basis
of a special distribution key. It is sheer luck
whether you end up in Berlin, Munich or
somewhere in the lowlands of rural Germa-
ny. And it is sheer luck, what sort of service
you get.
The extremes are: In some states the asy-
lum seekers have to request treatment
vouchers – valid 24 hours – from the mu-
nicipal social security offices.This is an ad-
ministrative act determined at the discre-
tion of officials who are not physicians and
who do not have a medical background.
And in some states sick persons had to
queue for hours to obtain these vouchers.
Other states hand out electronic health ac-
cess cards which offer access to physicians.
However – the range of services is limited
to the catalogue of acute diseases I men-
tioned earlier on.
The decision to give shelter to hundreds of
thousands of refugees has impacted each
German municipality differently. Public
health services, volunteer physicians, nurses,
psychotherapists and many other volunteers
from the general public form the backbone
of every early refugee medical care.
Several larger cities were dramatically
overburdened  – like Berlin in 2015, for
example, where new arrivals often had to
wait for days before getting registered –
and/or treatment vouchers. There are,
however, also accounts of stable condi-
tions in larger reception centres, for ex-
ample in Munich, where the medical
care of refugees, asylum seekers and their
children is coordinated by an volunteer
medical organisation called Refudocs, in
conjunction with the relevant state au-
thorities, with the ultimate goal of reduc-
ing bureaucratic hurdles.
In other federal states or cities, newly ar-
rived refugees are examined by doctors from
the local health authority immediately upon
admission. Depending on the size of the
city, further on-site care was then carried
out by practice-based physicians through
decentralised accommodations.
After fifteen months asylum seekers are
transferred into the general statutory health
care system. They are eligible to the same
services as all Germans.
Generally speaking, transferring asylum
seekers into the general social benefits sys-
tem immediately upon their arrival would
be, in the eyes of the German Medical As-
sociation, a humane and unbureaucratic
solution and avoid a complicated parallel
system.
This could prevent administrative costs re-
sulting from the streamlining of procedures,
delayed medical examinations resulting
from the cumbersome process of applying
for treatment vouchers, and even redundant
examinations. In fact, an expert commission
established by the Robert Bosch Founda-
tion last year came to the conclusion that
the most cost-effective solution is to fully
integrate asylum seekers into the estab-
lished health insurance system from the first
day on. And that for the last twenty years
has also been the position of the GMA!
Despite these and other efforts to allevi-
ate the administrative burden of providing
asylum seekers with access to medical care,
there is still more work to be done.
Psychotherapy,
undocumented refugees and
unaccompanied minors
One aspect of refugee healthcare that has
not yet been dealt with sufficiently is ac-
cess to psychotherapeutic care. Studies have
shown that approx. 40% of refugees are suf-
fering from post-traumatic stress disorder,
but the services available for traumatised
refugees are not yet able to meet the de-
mand for care, resulting in long waits for
appointments.
Psychotherapy is an essential treatment
method for those suffering from PTSD.
Only independent and qualified evalua-
tors can recognise whether a refugee re-
quires psychotherapeutic treatment, and
all too often, these challenges are ampli-
fied by a shortage of qualified interpreters
and fear on the part of medical profes-
sionals that their own expertise is inad-
equate for treating extremely traumatised
individuals.
And, of course, there is a social aspect to
this issue as well. The process of being
granted asylum can take years and even
then asylum may be limited to a number of
years. These refugees simply lack the most
basic securities in life. How can they inte-
grate into the strange and foreign society
they live in? They feel like cliff-hangers
without a stable perspective in their life.
We as physicians have to point out, that all
psychotherapy and all psychologic treat-
ments are completely futile if we don’t of-
fer the refugees stable perspectives in their
lives!
Let me briefly mention another group of
refugees: illegal and undocumented indi-
viduals. Due to fear of deportation, these
are often very hesitant to seek out medical
treatment and therefore wait until a physi-
cian has to be called. Children of parents
without legal residence status are some-
times totally cut off from medical services.
Some patients wait until their disease has
progressed so far that they virtually “carry
their head under the armpit” as a German
proverb says, before they see a nurse or a
doctor.
If you allow me now a short intermediate
résumé: we encountered a wave of refugees
in 2015 that confronted us with an adminis-
trative but no real medical problem. 70% of
the refugees were young males between 17
and 30 years of age. They suffered from the
typical conditions of lack of food and sleep,
starvation, unbelievable hygienic conditions
and accidents. A few cases of tuberculosis,
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160
hepatitis and HIV  – nothing really chal-
lenging.
Health care capacities where there, physi-
cians and other professionals quickly volun-
teered to cover temporary lacks in services
and by integrating the refugees into our
society we will overcome even the remain-
ing problems of culture and language that
do still exist.
Refugees are requested to integrate into
their host society. This is correct. But we
must never forget. Integration is a process –
not a prerequisite for asylum seekers. You
have to learn a new language and under-
stand a new culture. It takes time and ef-
fort and needs help by professionals and by
society as a whole!
Actually we have experience with similar
numbers of refugees. Between 1986 and
1992 more than six million “Russian Ger-
mans” immigrated into Germany. They
were descendants of Germans that had mi-
grated into western parts of Russia in the
18th
century, had been relocated to Siberia
and Kazakhstan in the Stalin era and now
returned to the homelands of their grand-
fathers. 3.6 million stayed in Germany and
still live – mostly integrated – amongst us.
They never posed a threat to our health-care
system. No one was afraid of a lack of ca-
pacities. No one ever contested their rights
and privileges.
Their most valuable privilege was: they were
allowed to work from the first day on. Apart
from giving them something to do and pre-
venting tribal Ghetto structures – under the
Bismarck idea of equal contributions from
employers and employees they immediately
contributed to their own social insurances
and they paid taxes.That is what integration
means.
What do we learn from this experience?
Give refugees a fast and low-threshold ap-
proach to the labour market and they will
integrate automatically and quickly.
Keep them out of work and you will en-
counter the typical criminal problems of
young underprivileged youths.
Integration is a two way process of give and
take. If I ask someone to integrate, I also
have to move a little bit.
Let’s now finally talk about the sustain-
ability of healthcare systems under these
circumstances.
Outlook
The German healthcare system is facing
extensive challenges. These are primarily
demography, the translation of scientific
progress into everyday service and the edu-
cation of physicians and other health care
professionals. Mass migration into Europe
of people searching for peace and relief has
pushed public services to their limits in
some German municipalities. Of course,
in comparison to the situation in Syria’s
neighbouring countries and along the Bal-
kan route this was not really critical. Vol-
unteers  – especially volunteer healthcare
workers – helped to solve the biggest bot-
tlenecks we were facing in Germany. This
experience has reiterated the importance
of healthcare planning in terms of meet-
ing medical needs and anticipating surges
in capacity.
Refugee healthcare was also a key point of
discussion at this year’s German Medical
Assembly in Hamburg. These and other
discussions within the German medi-
cal profession have brought to light some
of the practical and administrative chal-
lenges of providing care within Germany’s
federal system. In order to create reliable
and sustainable healthcare conditions, it
is important that we devise and imple-
ment national solutions which lower the
threshold for healthcare access for refu-
gees, minimise red tape, expand human
and financial resources in the public health
sector, and clarify medical, administrative,
financial and legal accountability among
public authorities. This requires a consis-
tent approach at the federal, state and mu-
nicipal levels. And it is also imperative that
we address the transparency of distributing
refugees and funding  – including at the
European Union level.
The “Take Home Messages” of my speech
should be:
1. Don’t be afraid of refugees.
2. Give them medical services, stability
and security and give them work.
3. To obtain this, work with the profes-
sional organizations and not against
them.
For more than 2000 years, the Hippocratic
Oath has embodied the physician’s obliga-
tion to help patients regardless of their ori-
gin, nationality, ethnic affiliation or social
status. For medical care is a basic human
right, not an act of charity.
Allow me to close with a quote from a
colleagu. Dr Jenny de la Torre, a Berlin-
based physician originally from Peru, who
is known in Germany as the “Angel of the
Homeless” for her treatment of home-
less persons in Berlin. She expresses what
it means to be a physician in the following
words:
“I am not an angel, nor am I Mother Teresa.
I am just a doctor.”
Prof. Dr. Frank Ulrich Montgomery
E-mail: monti@montgomery.de
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One Health
2nd
WVA/WMA Global Conference on One Health
Moving forward from One Health Concept to One Health Approach
10–11th
November 2016
Kitakyushu City, Fukuoka Prefecture, Japan
Summary
On 10 and 11th
of November 2016, in
Kitakyushu City, Fukuoka Prefecture, Ja-
pan, the World Veterinary Association
(WVA) and the World Medical Associa-
tion (WMA) in collaboration with Japan
Medical (JMA) and Veterinary (JVMA)
Associations held the 2nd
Global Con-
ference on ‘One Health’ with the theme:
Moving forward from One Health Concept
to One Health Approach”.
The conference was attended by more than
600 participants from 44 countries around
the world with approximately 30 lectures
covering different One Health issues.
The aim of the 2GCOH was to strength the
links and communications and to achieve
closer collaboration between Physicians,
Veterinarians and all appropriate stake-
holders to improve the different aspects of
health and welfare of humans, animals and
the environment.
The Opening Ceremony of the 2GCOH
was opened with the remarkable presence
of their Imperial Highnesses, Prince and
Princess Akishino. In his address to the
2GCOH delegates, Prince Akishino high-
lighted the importance of the One Health
approach to address public and animal
health challenges.
After short welcome speeches session by
the representatives of WVA, WMA, JMA,
JVMA, the FAO/OIE/WHO Tripartite,
Japan Ministries of Health and Agriculture
and from the directors of Fukuoka region
and Kitakyushu City, the conference started
with different sessions on the One Health
Concept, Zoonotic diseases, Antimicrobial
resistance, Veterinary Education of One
Health Concept and other aspects One
Health.
Summarizing the two full days of lectures
and presentations, the WVA and WMA
emphasised the need for:
• More advocacy for sustained political
attention in particular at national level,
on One Health issues to ensure health
(human, animal, and environment) is the
priority when developing policy.
• To ensure a focus on environmental
health is included in One Health discus-
sions moving forward (e.g. antimicrobial
contamination from aquaculture, agricul-
tural uses, contamination resulting from
human uses).
• To encourage further development of
educational and experiential training
programs in One Health that are multi-
disciplinary in nature and bring together
students of human and veterinary medi-
cine.
• To support more cross disciplinary con-
tinuing professional development pro-
grams for human and animal medical
practitioners that address One Health.
• To encourage additional resources for
research in preventative strategies to
enhance One Health concept and ap-
proach.
The 2GCOH resulted in the historic sig-
nature on the Memorandum of Fukuoka by
WVA,WMA,JMA and JMVA.The 4 asso-
ciations agreed to move from the validation
and recognition stage of the “One Health
Concept”, to the practical implementation
stage:
1. Physicians and veterinarians shall
promote the exchange of information
aimed at preventing zoonotic dis-
eases and strengthening cooperative
relationships, as well as to undertake
further collaboration and cooperation
aimed at creating a system for zoono-
sis research.
2. Physicians and veterinarians shall
strengthen their cooperative relation-
ships to ensure the responsible use of
important antimicrobials in human and
animal healthcare.
3. Physicians and veterinarians shall sup-
port activities for developing and im-
proving human and veterinary medical
education, including understanding the
One Health concept and approach to
One Health challenges.
4. Physicians and veterinarians shall pro-
mote mutual exchange and strengthen
their cooperative relationships in order
to resolve all issues related to the cre-
ation of a healthy and safe society.
Following the successful 2GCOH, the
WVA and WMA received a number of
proposals from Veterinary and Medical
Associations to hold the 3rd
Global Con-
ference on One Health in their countries
showing their great interest to enhance the
collaborations between the veterinarians
and physicians to work together on One
Health issues.
To be continued at the 3rd
GCOH…
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162
One Health UNITED KINGDOM
Introduction and
global challenges
The early decades of the 21st
century have re-
minded us of the pressing need to find ways
forward for a world that seems to be facing,
what some have called, an ‘ingenuity gap.’
That is, as highlighted in my new book on
global population health and well-being [1],
we are facing complex and unprecedented
socioeconomic, environmental and geopo-
litical problems for which there appear to
be no ‘ready-made’ solutions. Conventional
20th
century reductionist thinking  – un-
derstand, predict, control, provide  – is no
longer adequate in an interconnected and
uncertain world faced with confronting
climate change, armed conflicts, economic
volatility, urbanisation, social intolerances,
ideological extremism, humanitarian crises,
pandemics, famine and migration, to name
but a few intractable global issues.
On many fronts we seem to be living in a
dichotomous world, where ‘the gap widens
between right and reality’ [2]. To illustrate,
2 billion out of 7.4 billion people – most in
Africa – do not have access to surgical pro-
cedures of any kind [3],and close to a billion
people are undernourished. Paradoxically,
the number of people who are overweight
or obese has increased to over a billion “in
countries from Columbia to Kazakhstan,”
leading to “diabetes, heart disease, and high
blood pressure’[4]. And, while there are ex-
amples of decreasing global hardships, for
example, ‘people living on less than $1.25 a
day having declined from a high of 1.9 bil-
lion in 1981 to a low of 1.4 billion in 2005,’
dropping ‘ from 52.0 to 25.7 per cent during
this period’ [5], huge discrepancies remain.
It is becoming increasingly clear that as we
head into this century most people – over
5.5 billion out of around 7.4 billion – live in
the global South and East – while resources
and services – including most medical and
nursing schools  – remain largely in the
North and West.
This imbalance is brought into sharp focus
in Africa where the population now exceeds
1.2 billion people with an estimate of 9 bil-
lion by the end of this century. Similar to
other nations in southeast Asia,‘Africa faces
a quadruple burden not only must it tackle
communicable diseases (e.g. HIV/AIDS,
malaria, tuberculosis, and most recently
Ebola), it must also confront an increas-
ing number of non-communicable diseases,
many of which can be traced to problems
of modernity, where there appears to be
considerable incongruence between our
lifestyle today and our genetic make-up
evolved over millions of years. In addition,
poverty illnesses (e.g. perinatal/maternal),
violence and injury continue to undermine
health and well-being and quality of life in
general.The continent has 24% of the world
disease burden but only 3% of the world
resources and 1% of the doctors. Doctor to
people ratios are as high as 50,000:1 in sev-
eral African countries and over 20,000:1 in
several nations, such as Bhutan and Papua
New Guinea. In effect, for many in these
nations “health systems,” as we define them
in the literature, are non-existent. In the
North and West the doctor-inhabitant ratio
is about 300:1’ [6].
And, although globalisation has the poten-
tial of benefiting everyone,the facts indicate
that ‘the gap between those who enjoy the
fruits of wealth and those who rely on the
wage packet for their income’ is growing
each year [2], and that, as the latest Ipsos
MORI Social Research study has con-
cluded, ‘the majority (61%) of populations
of 25 nations1
think their countries are ‘off
on the wrong track’ and that re-direction is
required [7]. Given recent events in the UK
and the US there can be little doubt that
‘people are desperate for big change, and
most desperate are the poorer, working class
and industrial communities that have borne
the brunt of the technological changes and
spending cuts of the globalisation era’[8, 9].
The UN 2030 sustainable
development goals (SDGs)
On 25 September 2015,193 Member States
of the United Nations General Assembly
ratified the UN 2030 Sustainable Devel-
opment Goals (SDGs) or Global Goals,
as they are also called [10]. The 17 SDGs
1 
Argentina, Australia, Belgium, Brazil, Canada,
China, France, Britain, Germany, Hungary, India,
Israel, Italy, Japan, Mexico, Poland, Peru, Russia,
Saudi Arabia, South Africa, South Korea, Spain,
Sweden,Turkey and the United States.
George Lueddeke
The UN-2030 Sustainable Development Goals and the One Health
Concept:a Case for Synergistic CollaborationTowards‘a Common Cause’
163
One Health
UNITED KINGDOM
and 169 targets superseded the 2000-2015
UN Millennium Development Goals [11],
which, while raising the profile and funding
of global health and making variable prog-
ress on the eight agreed goals, failed to fully
address the broader concept of economic,
social and environmental development and,
in particular, according to UN Secretary-
General Ban Ki-moon, tackling root causes.
Extending the nature and scope of the
MDGs dramatically, the SDGs, as shown
in Figure 1, are ‘a universal call to action to
end poverty, protect the planet and ensure
that all people enjoy peace and prosper-
ity [10].They are intended to be ‘integrated
and indivisible, global in nature and univer-
sally applicable’ while ‘respecting national
policies and priorities.’
According to Johan Rockström, Direc-
tor of the Stockholm Resilience Center,
‘the SDGs are maybe the biggest decision
in history…a much more complex agenda,
which requires humans to reconnect with
their planet’ [12].
The SDGs provide a synthesis of major
global issues and place collaborative part-
nerships (#17) at the centre of strategic
implementation strategies. Their consider-
ation cannot come too soon as, according
to Marco Lambertini, Director General of
WWF International, observes in the intro-
duction to the WWF Living Planet Report
2014 (Summary):
In less than two human generations, popula-
tion sizes of vertebrate species have dropped by
half….These are the living forms that consti-
tute the fabric of the ecosystems which sustain
life on Earth – and the barometer of what we
are doing to our own planet, our only home. We
ignore their decline at our peril [13].
In his plea for transformative change the Di-
rector General challenges global leaders to
respond to three main questions: ‘What kind
of future are we heading toward?…What
kind of future do we want?’ [and], ‘Can we
justify eroding our natural capital and allo-
cating nature’s resources so inequitably?’
His concerns go beyond the immediate UN
-2030 global goals and demand finding,first
and foremost, a lasting ‘unity around a com-
mon cause.’ His message is intended for the
public, private and civil society sectors and
implores these stakeholders to be proactive,
to “pull together in a bold and coordinated
effort,” for “Heads of State” to think glob-
ally; businesses and consumers, ‘to stop be-
having as if live in a limitless world’ – before
facing inevitable and potentially disastrous
consequences [13].
Making a fundamental
mindshift in this century
The WWF Director-General’s core argu-
ment also reflects a recurring theme that
runs through my current publication [1]. In
short, to sustain the planet and its people in
the long term requires making a fundamen-
tal mind – or paradigm shift this century:
moving away from a stance held by many
stakeholders, such as Governments and Big
Business, that see, as Pope Francis laments,
‘the world as a means to an end’ [14], and
‘a place made especially for humans and a
place without limits’[15] to one that rec-
ognises that the survival of the planet and
people depends on evolving a future that is
‘compatible with our needs as human beings
but also an outer world that is compatible
with the needs of our ecosystem’ [15]. The
overarching goal – the common denomina-
tor to pull us together regardless of ‘race,
colour, religion, sex, or national origin’-
must surely be creating ‘healthy people on a
healthy planet’ [16].
One Health historical
perspectives and linking
the UN global goals to
One Health values
The present focus on One Health builds
on historical roots going as far back as
ancient Greece and Hippocrates (c.500
BCE) [1], and well-known reformers in
the 19th
century, such as Dr. Rudolph Vir-
chow (1821-1902),German physician-pa-
thologist, who coined the term “zoonosis,”
and Canadian physician Sir William Os-
ler (1849-1919), father of modern medi-
cine [17].In the 20th
century Sir John McFa-
dyean (1853-1941), a UK veterinarian and
physician, considered the ‘founder of mod-
ern veterinary research, ‘built bridges across
human veterinary fields in infectious disease
and comparative medicine,’ while in the US
veterinarian Dr. Calvin Schwabe, consid-
ered the ‘father of veterinary epidemiology,’
Figure 1. The UN-2030 Sustainable Development Goals
BACK TO CONTENTS
164
framed the concept and coined the term
One Medicine [17]. Dr. James Steele (1913-
2013), called the “father of veterinary public
health,”founder of the US Centers for Dis-
ease Control and Prevention’s (CDC) vet-
erinary division in 1947, co-authored Con-
fronting zoonoses through closer collaboration
between medicine and veterinary medicine
[18] and advocated the One Health concept
(then referred to as “One Medicine”) dur-
ing much of the 20th
century, long before it
became fashionable.
In the past few decades One Health has
been championed by individuals, such as
veterinarian Dr. Roger Mahr, former presi-
dent of the American Veterinary Medi-
cal Association (AVMA), who along with
physician Dr. Ronald Davis, then presi-
dent of the American Medical Association
(AMA), passed a One Health resolution
in 2007. In the intervening years physi-
cian Dr. Laura Kahn, veterinarian Dr. Bruce
Kaplan, and physician Dr. Thomas Mon-
ath, as co-founders, spearheaded the es-
tablishment of the One Health Initiative
(OHI) [19], while veterinarians Drs. Cher-
yl Stroud and Joann Lindenmayer have been
leading developments for the One Health
Commission (OHC)  [20]. These organ-
isations complement those in the World
Veterinary Association (WVA)  [21], rep-
resenting over 500,000 veterinarians across
the world on six continents, and the World
Medical Association (WMA) [22] with
112 Constituent Members and 1013 As-
sociate Members, presently headed by
Presidents’ Dr. René Carlson, a veterinarian
and Dr. Desai Ketan, a physician, respec-
tively. It appears that for all these inspira-
tional and committed leaders One Health
is unquestionably the core concept that
represents global ‘unity around a common
cause’ – bringing together human, animal,
environmental health and well-being – to
which the world needs to aspire and also
advocated strongly earlier by the WWF
Director General [13].
Inherent in the concept is the need to
adopt ethical responsibilities that are root-
ed in interdependencies and the sanctity
of life [23], which were also at the root of
UNESCO Director-General Irena Bo-
kova’s appeal, envisioned a few years ago,
for ‘a new humanism that reconciles the
global and the local, and teaches us anew
how to build the world’  [24]. Moving in
these directions may yet offer us the best
chance to “free the human race from the
tyranny of poverty and want and to heal
and secure our planet,’ espoused in the
UN direction-setting report, ‘Transform-
ing our world: the 2030 Agenda for Sus-
tainable Development’ [10]. It is for these
underlying reasons that governments and
organisations, such as the United Nations
(e.g., Office for Sustainable Development,
the UN High-level Political Forum), the
World Health Organisation, the World
Bank and the Commonwealth, are en-
couraged to consider adoption of the One
Health triad, as shown below (Figure 2) as
an integral structural component of fram-
ing policy and enabling action plans, shift-
ing from a mantra of ‘Health in All Poli-
cies,’ to ‘One Health in All Policies’ [1]. As
a filter for decision-making – or as the late
Nobel laureate, Douglass North, defined
the purpose of institutions as ‘the humanly
devised constraints that structure political,
economic and social interaction’ [25], – the
guiding or principled question ‘to what ex-
tent does the policy initiative/action impact
on the sustainability of life on this planet?’
seems vital to embedding a critical global
common good. Following this path might
lead not only to creating ‘social benefit’ but
also ‘sustainable economic development
and job creation’ or long-term prosperity in
the long run [26].
One Health and well-being:
implications for preparing
health professionals
In Educating for a Sustainable Future:
A  Transdisciplinary Vision for Concerted
Action  [28], UNESCO highlighted that
‘education is the most effective means that
society possesses for confronting the chal-
lenges of the future.’The significance of this
resolve was also captured in the UN’s Earth
Charter, which emphasises the importance
of integrating into ‘education and life-long
learning the knowledge, values, and skills
needed for a sustainable way of life (Prin-
ciple 9)’ [23].
More recently, the UN 2030-Sustainable
Development Goals (SDGs) reinforce this
principle, declaring that by 2030
All learners acquire knowledge and skills need-
ed to promote sustainable development, includ-
ing among others through education for sus-
tainable development and sustainable lifestyles,
human rights, gender equality, promotion of a
culture of peace and non-violence, global citi-
zenship, and appreciation of cultural diversity
and of culture’s contribution to sustainable de-
velopment (SDG 4) [10].
SUSTAINABLE DEVELOPMENT GOALS IMPLEMENTATION
Figure 2. Linking UN-2030 Global Goals to One Health and Well-Being [27]
One Health UNITED KINGDOM
165
While the rhetoric is certainly going in the
right directions, the impetus for taking for-
ward the means for our survival as a species,
which depends on sustaining the health and
well-being of the planet and people, has
regrettably not yet been taken forward in
health education generally,including veteri-
nary and human medicine.
Despite the reality that most human ill-
nesses in history are caused by zoonotic dis-
eases and that of the 1,415 microbes that
are known to infect humans, more than
70% come from animals [29], few contem-
porary health curricula reflect causes, pos-
sible consequences, prevention and treat-
ment. In addition, in many schools scant
attention is given to environmental factors
that may affect human and animal health
through contamination, pollution and poor
conditions that may lead to new infectious
agents.Taken as a whole, it is becoming ap-
parent and urgent that we need to go be-
yond teaching not only ‘a relatively simple
animal–human dyad, but also take the ‘the
root causes of human well-being (and ill
health) in the dynamics of complex eco-
logical systems’ much more seriously [30].
According to the authors of ‘Integrating
a One Health Approach in Education to
Address Global Health and Sustainability
Challenges [31,1],‘less than 3% of the total
veterinary curriculum in the U.S. is devoted
to public health issues, resulting in fewer
than 2% of current veterinarians working
in public health.’ With regard to medical
education, the authors also observe that,
given the “anthropocentrism” of traditional
medical curricula and medical education,
‘medical training maintains a strict focus on
human health.’
Moreover, while adopting a ‘bottoms-up’
change model approach, the post-graduate
students, who at the time were studying at
Duke University Oxford University, UNC
Gillings School of Public Health,and North
Carolina State University,asserted that ‘One
Health educational programs could benefit
significantly from the creation of ‘Centers of
One Health Excellence [COHE]),’possibly
with “seed” funding provided by a number
of organizations (e.g.,WHO, CDC, United
States Agency for International Develop-
ment [USAID], the UN’s environmental
program, foundations) [1].These could col-
laborate with national, regional, and global
and educational institutions, government
agencies, and public–private partnerships,
develop blended curricula, advance multi-
disciplinary research, and inform ‘plans that
acknowledge the balance of the environ-
ment and health in achieving sustainable
development’ [31,1].
The World Veterinary
Association(WVA) and the
World Medical Association
(WMA) 2nd
global conference
on One Health
A significant step in ‘building capacity for
a healthier world’ was recently taken by
the WVA-WMA in association with the
Japan Veterinary Association and the Ja-
pan Medical Association at the 2nd
Global
Conference on One Health (GCOH)  –
Moving forward from One Health Con-
cept to One Health Approach, held 10-11
November in Kitakyushu City, Fukuoka
Prefecture in Japan [32]. With more than
600 participants from 44 countries, the
conference focused on four main themes:
Zoonotic and Foodborne Diseases, An-
timicrobial Resistance, Environmental
Hazards -exposure to humans and ani-
mals, and The Future of the One Health
Concept. The resultant Memorandum of
Fukuoka underscores the importance of
preventing zoonotic diseases, collabora-
tion and cooperation aimed at creating a
system for zoonosis research and giving
priority to support activities for develop-
ing and improving human and veterinary
medical education, including applying the
One Health concept and approach to One
Health challenges along with the ‘creation
of a health and safe society.’
Creating the world we need
through One Health
education
In a post WVA-WMA conference sum-
mary document, Dr Chiang Johnson, WVA
president-elect, emphasised the need for
political action in progressing One Health
policies, focusing on environmental health,
and advocating the development of multi-
disciplinary One Health human and veteri-
nary education and training programmes,
including continuing professional devel-
opment (CPD). It may be noteworthy to
mention that WVA-WMA support for
additional resources for research in preven-
tive strategies to enhance One Health also
parallels the recommendations of the post-
graduate student authors arguing for ‘Cen-
tres of One Health Excellence,’ discussed
previously [31,1].
Key resolutions reached at the WVA-WMA
2nd
Global Conference on One Health
(GCOH) underpin current One Health
Commission (OHC) [20] in association
with One Health Initiative [19] efforts, an-
nounced in a previous OHC-OHI Press
Release [32], to give the younger generation
‘a better deal’ for helping to shape a sus-
tainable world. A basic assumption behind
the Commission’s funding proposal, sum-
marised in a concept paper,‘Preparing Soci-
ety to Create the World We Want through
One Health Education’[34], is that the best
opportunity to achieve meaningful societal
change and prepare future leaders to create
a healthier world must be seized early on
in children’s lives as they form fundamental
views of their places on the planet and carry
those views forward into adulthood.’
In a recent conference/webinar, The World
We Need [35], the One Health Education
Task Force shared findings of a global One
Health education survey and highlighted
developments to date with regard to the
proposed funding initiative supporting
learning K-12+ learning opportunities that
One Health
UNITED KINGDOM
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166
focus through team-building on the forma-
tion of:
• basic values and responsibilities with re-
spect to “the community of life” [32];
• knowledge with respect to the intercon-
nectedness of life on our planet;
• real world application skills underpinned
by interdisciplinary teamwork, creativity
and group problem-solving; and
• a global network of One Health educa-
tion providers who are committed to
supporting learners and teachers in their
quest to realize a more sustainable world.
A possible side-benefit of the One Health
education initiative with a view to future
generations and the creation of closer re-
lationships with the natural world – espe-
cially ‘in our technology-dependent age’ – is
that it may address a phenomenon, coined
by American writer Richard Louv, as ‘na-
ture deficit disorder,’or ‘a diminished ability
to find meaning in the life that surrounds
us’ [36]. Reconnecting with the natural en-
vironment may raise awareness of ‘how im-
portant nature is for children’s development,
affecting “everything from a positive effect
on the attention span, to stress reduction,
to cognitive development and their sense of
wonder and connection to the earth…”
At more advanced post-secondary or high-
er education levels, for example, the early
years of undergraduate human and veteri-
nary medicine, recent articles such as ‘One
Health training, research, and outreach in
North America’  [37], appearing in Infec-
tion Ecology & Epidemiology  – the One
Health Journal, and initiatives proposed by
the Planetary Health Alliance [38] should
prove informative for those planning de-
velopment opportunities. In terms of inter-
disciplinary education, more consideration
might also be given to shared topics using
cross-cutting problem-based learning activ-
ities that are high on the global SDG/One
Health agenda [39], including
• Global health and well-being challenges
• SDGs and the One Health concept and
approach
• zoonotic diseases
• antibiotic resistance
• food safety and security
• ecosystem and environmental health
• land degradation and urban development
• agriculture and sustainability
• health impact of water
• energy usage
• biodiversity…
Concluding comments
By means of summary, in a chapter contrib-
uting to Jekel’s Epidemiology, Biostatistics,
Preventive Medicine, and Public Health [40],
Dr. Meredith Barrett and Dr. Steven Os-
ofsky compellingly affirm that ‘Issues of
global environmental change, global health,
emerging disease, and sustainability present
some of the most complex and far-reaching
challenges of the 21st
century.’
Furthermore, given the enormity of the
universal transformation required in the
decades ahead and along with a growing
voice representing public health and related
health professionals [41], the authors stress
that ‘individual disciplines cannot address
these issues in isolation.’ The best way for-
ward is to tackle ‘the fundamental causes of
global health and environmental threats.’
For these researchers ‘One Health offers
a logical path forward by recognising not
only the interconnected nature of human,
animal, and ecosystem health but also by
acknowledging the potential to fundamen-
tally ‘inform health and environmental pol-
icy, expand scientific knowledge, improve
healthcare training and delivery, improve
conservation outcomes, identify Upstream
solutions, and address sustainability chal-
lenges.’
As we continue to strive toward a new ‘life-
sustaining’ world order in this decade and
beyond, there can be little doubt about the
vital importance of linking the UN-2030
Global Goals to the holistic One Health
concept. Adopting a One Health in All Poli-
cies [1] approach may not only be an ‘idea
whose time has come’but also, as evidenced
at the PAHO/WHO 17th
Inter American
Ministerial Meeting on Health and Agri-
culture in July 2016 [42], a progressive step
in the right direction.
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George Lueddeke, Med, PhD
Chair, One Health Education Task
Force, One Health Commission
Consultant in Higher and Medical Education
Southampton, United Kingdom
E-mail: glueddeke@aol.com
One Health
UNITED KINGDOM
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168
Climate Change
Overview
The twenty-second session of the Confer-
ence of the Parties (COP 22) in Marrakech,
labelled as the “African COP”and the “COP
of Action”followed the adoption of the Paris
Agreement (PA) in 2015 and brought about
many commitments and climate actions with
respect to the implementation of the PA and
hosted multiple important health events.
Furthermore, numerous items important
for health in relation to adaptation, loss and
damage and multi-stakeholder engagement
were negotiated.
Moving from ADP to APA
The Ad Hoc Working Group on the Dur-
ban Platform for Enhanced Action (ADP)
was established in December 2011 to de-
velop a legal instrument that is applicable to
all Parties through two main work streams:
the 2015 agreement and pre-2020 ambi-
tion. The ADP concluded its work in Paris
in December 2015, right before COP21,
and submitted a draft agreement text and
conclusion addressing various issues such as
capacity building, technology development
and transfer, loss and damage and finance,
to be considered by COP21. After the clo-
sure of the ADP and the adoption of the
Paris Agreement, the Ad Hoc Working
Group on the Paris Agreement (APA) was
established to prepare the agreement for en-
tering into force.The APA was requested to
develop guidance to nationally determined
contributions (NDC), create modalities for
the transparency framework for action and
support, and global stocktake, and facilitate
and promote compliance.
In Marrakech, the negotiations were going a
bit slower than expected with the developed
countries calling for urgent efforts while the
developing Parties, in particular the African
Group, demanding the developed countries
to show leadership and provide guidance. On
November 14,at the closing plenary,the APA
mandated the Parties to submit their Nation-
ally Determined Contributions (NDCs) to
climate action under the Paris Agreement by
April 1,2017 in addition to submissions in re-
lation to adaptation communication,transpar-
ency framework and compliance and imple-
mentation of the Paris Agreement. The APA
will convene again in Bonn in May 2017.
Health had a high profile at COP 22
Health had quite a high profile at COP 22,
hosting the Action Agenda “Health Day”on
Friday, November 11. It provided several ex-
amples of how the public health community
can support action towards the implemen-
tation of the Paris Agreement. Namely, the
new divestment from fossil fuels policy ad-
opted by the WMA at its most recent Gen-
eral Assembly was presented. Additionally, a
high level ministerial meeting was also or-
ganized during COP by WHO, UNEP and
the Moroccan Government on November
15. It aimed at bringing together Ministers
of Health and Ministers of Environment to
launch a global initiative on health, environ-
ment and climate change, to promote better
management of climate risks to health, and
low carbon, climate resilient, sustainable and
inclusive development aimed at ensuring
good health and well-being, with the help of
WHO,UNEP,WMO,UNFCCC and other
interested Parties.
UNFCCC, in collaboration with WHO
and WMO, held the 10th
Forum of Nai-
robi Work Program (NWP) on health and
adaptation that addressed changes in geo-
graphical distribution of disease, new and
emerging diseases, and their impacts on so-
cial and economic structures, issues of mal-
nutrition, waterborne disease, vector-borne
disease and disaster impacts and the effects
of climate change on health and productiv-
ity in the workplace. A synthesis report will
be presented and adopted by the Parties in
Bonn, in May 2017.
Other health events that were held include
the following:
1. Climate Change, Human Migration
and Health on November 9 by USPC,
Charité – Universitätsmedizine Berlin,
Université de Genève, Université Inter-
nationale de Rabat, Université de Liège,
and the Lancet Countdown on Health and
Climate Change. It focused on enhanc-
ing the health of climate migrants and
possible indicators for migration, health
and climate change;
2. Conference on Climate and Health
Care on November 14 by Health Care
Without Harm and the Mohammed VI
University Hospital of Marrakech. It dis-
cussed the vital role of health care sector
to mitigate climate change impacts and
develop low-carbon models of care;
3. Lancet Countdown: Tracking Prog-
ress on Health and Climate Change on
November 14 by Lancet and UNFCCC.
This press conference marked the official
launch of international and multi-disci-
plinary collaboration between researchers,
health practitioners and policy-makers;
4. Interministerial Meeting on Health,
Environment and Climate Change on
November 15, by the Ministry of Envi-
ronment and the Ministry of Health of
Morocco,in partnership with the World
Health Organization and the UN En-
vironment Programme. It brought to-
gether over two dozen Ministers and
high level officials from both the health
and environment sectors who signed the
Declaration for Health, Environment
and Climate Change;
5. UN High Level Side Event on Climate
Change and Health – SDG3: good health
and wellbeing,on November 15.It empha-
sized the importance of a sustained country
progress in achieving SDG3 and SDG13
through sustainable low carbon policies.
Despite the various well-structured side
events and forums by the health sector to
address health as an important vital aspect
to implement and achieve the Paris Agree-
ment, COP22 ended with few decisions
taken on important elements for health:
Health Negotiations at COP22, 7–18 November 2016
III
Climate Change
most elements were forwarded for a deci-
sion to be taken at a later point in time in
the coming years. At the closing plenary,
the Parties adopted the Marrakech Action
Proclamation that expressed the irreversible
momentum on climate. Poverty, food secu-
rity and agriculture were addressed but with
no mention to health or its co-benefits.
COP22 launched a set of climate actions,
called Marrakech Partnership for Global Cli-
mate Action,to be implemented by the Parties
and other stakeholders.Health was mentioned
as part of the suggested thematic approach for
multi-stakeholder engagement in addition to
gender,education,and decent work.
Divestment from fossil fuels
COP22 hosted a historic breakthrough
when 48 climate vulnerable countries com-
mitted to 100% renewable energy by mid-
century. It was announced during the Cli-
mate Vulnerable Forum (CVF) chaired by
Ethiopia. The CVF vowed to end energy
poverty and protect water and food secu-
rity through committing to renewables and
adopt de-carbonization plans. Members
of the CVF pledged to help each other to
ensure support is given in terms of capacity
building, finance and technology.
The participating Parties also committed
to advocate for an international collabora-
tive system to provide adequate support to
climate change adaptation and mitigation
action to developing countries through
engaging all countries, the United Nations
system, international financial institutions
and other global governance structures
with a particular initial focus on protecting
food production and other domains such as
health and human rights.
Furthermore,the work of the WMA on fossil
fuel divestment was shared during the Health
Action Day and other participants from
healthcare organizations were encouraged to
follow suit and adopt divestment policies.
Adaptation to climate change impacts
There has been good progress on the work
of the Nairobi Work Programme (NWP)
on impacts, vulnerability and adaptation to
climate change as many submissions by the
Parties were reviewed at COP 22. Further-
more, it is important to note that many of
those highlighted the importance of health.
Additionally, while financing for adapta-
tion was a contentious issue in the discus-
sions during COP 22, clear commitments
to financing for adaptation were expressed
by many Parties and a clear way forward in
determining the best mechanism for such
financial flows has now been established
and we may expect the outcomes of future
work in this area.
Loss and Damage
While the Paris Agreement set the tone for
action in the coming years,details around the
implementation of loss and damage still re-
main unclear. One of the most contentious
issues, that of financing for loss and damage,
has been pushed to future discussions. Nev-
ertheless, at this past COP 22, there has been
good progress: namely through the comple-
tion of the first review of the work of the
Executive Committee of the Warsaw Inter-
national Mechanism (WIM) on Loss and
Damage that is now set on developing its five
year workplan. Additionally, the newly start-
ed work aiming to bring together technical
expertise on the topic of non-economic losses
will be crucial for how health is addressed
by the WIM and, thus, will be followed by
health actors in the years to come.The WMA
remains committed to contribute technical
expertise on health and climate change, in-
cluding on non-economic loss and damage.
Way forward
Given the progress at COP 22, there are
many new areas that the health sector may
contribute to in the coming years. Firstly, on
a national level, medical organisations are
encouraged to continue work in line with
the recently adopted WMA Statement on
Divestment from Fossil Fuels, namely, by
encouraging “governments to adopt strate-
gies that emphasize strict environmental
regulations and standards that encourage
energy companies to move toward renewable
fuel sources” and by beginning “a process of
transferring their investments, when feasible
without damage, from energy companies
whose primary business relies upon extrac-
tion of,or energy generation from,fossil fuels
to those generating energy from renewable
energy sources.”1
Additionally, as the Parties
continue working on their national adapta-
tion plans, the health sector can ensure ad-
equate consideration of public health using
health in all policies methods. As the Par-
ties confirm their NDCs at the beginning
of 2017, this also remains a potential area to
address through national level advocacy to
ensure that commitments acknowledge the
true level of impact on health and that mea-
sures are taken to minimize their negative
consequences. Secondly, on the international
level, the UNFCCC has now set an agenda
of work for many elements directly originat-
ing from the adoption of the Paris Agree-
ment that will need to be addressed, namely,
the Expert Group on non-economic losses,
created under the WIM, will need to find
ways of accounting and addressing health
losses from climate change impacts, financial
flows towards the health sector will need to
be established from mechanisms under the
convention and under the Paris Agreement.
Finally, on all levels, the health sector actors
involved in climate change have a responsi-
bility of contributing to capacity building in
this sector so that clinicians can take into ac-
count the expected health outcomes, policy-
maker can develop the necessary safeguards
to protect people from health impacts of cli-
mate change and to reduce the contribution
of the health sector to climate change.
Lujain Al-Qodmani, MD, Kuwait
E-mail: lujainalq@gmail.com
Diogo Martins,MD, Public Health Resident,
Portugal, MSc Public Health LSHTM, UK
E-mail: diogo.correiamartins.md@gmail.com
Yassen Tcholakov, MD, MIH, Public Health
Resident, McGill University, Canada
E-mail: yassentch@gmail.com
1 WMA Statement on Divestment from Fossil
Fuels, World Medical Association. http://www.
wma.net/en/30publications/10policies/f13/
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IV
Wishing you, your family and your medical
association a Happy New Year!