WMJ 03 0205

WorldMedical Journal
Vol. No.3,Septemer200551
OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
G 20438
Contents
Editorial
Backward to the future? 57
Cardiovascular Research Advances 58
Comprehensive cover for modern medics 61
Medical Ethics and Human Rights
Conference of experts on biological weapons 63
AMA position on Physician participation
in Guantanamo Interrogations 67
WMA
The Significance of the Scientific Session
of WMA General Assembly, Tokyo 2004 69
WMA Secretary General
The Bologna Process – not well done,
but well intented? 68
Medical Science, Professional Practice
and Education
Current Problems in Medical Education 71
Development of new vaccines 73
Robots on the Hospital Wards 75
Detection Of Faulty Genes In Breast Cancer 76
Building Capacity for Radiation Therapy
in Developing Countries 76
WHO
WHO declares TB an emergency in Africa 79
Models of Disease 79
Indonesia launches country’s largest-ever
immunization campaign to tackle expanding
polio epidemic 80
Partnerships Working for Health Forum 80
Concerted Action to Achieve The Millennium
Development Goals 81
New Bangkok charter for health promotion
adopted to address rapidly changing
global health issues 81
Regional and NMA News
EU Project Targets Killer Viruses 82
Developments in Kazakhstan 83
Family Medicine recruitment in Canada 83
TCRC receives WHO Certificate of Appreciation 84
Bomb explodes outside NMA building 84
Review
Information Products Catalogue 2003, 2004 84
Website: https://www.wma.net
WMA Directory of National Member Medical Associations Officers and Council
Association and address/Officers
WMA OFFICERS
OF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
i see page ii
President-Elect President Immediate Past-President
Dr K. Letlape Dr Y. D. Coble Dr J. Appleyard
South African Med. Assn. 102 Magnolia Street Thimble Hall
P.O. Box 74789 Neptune Beach, FL 32266 108 Blean Common
Lynnwood Ridge 0040 USA Blean, Nr Canterbury
Pretoria 0153 Kent, CT2 9JJ
South Africa Great Britain
Treasurer Chairman of Council Vice-Chairman of Council
Prof. Dr. Dr. h.c. J. D. Hoppe Dr Y. Blachar Dr N. Hashimoto
Bundesärztekammer Israel Medical Association Japan Medical Association
Herbert-Lewin-Platz 1 2 Twin Towers 2-28-16 Honkomagome
10623 Berlin 35 Jabotisky Street Bunkyo-ku
Germany P.O. Box 3566 Tokyo 113-8621
Ramat-Gan 52136 Japan
Israel
Secretary General
Dr O. Kloiber
World Medical Association
BP 63
France
ANDORRA S
Col’legi Oficial de Metges
Edifici Plaza esc. B
Verge del Pilar 5,
4art. Despatx 11, Andorra La Vella
Tel: (376) 823 525/Fax: (376) 860 793
E-mail: coma@andorra.ad
Website: www.col-legidemetges.ad
ARGENTINA S
Confederación Médica Argentina
Av. Belgrano 1235
Buenos Aires 1093
Tel/Fax: (54-114) 383-8414/5511
E-mail: comra@sinectis.com.ar
Website: www.comra.health.org.ar
AUSTRALIA E
Australian Medical Association
P.O. Box 6090
Kingston, ACT 2604
Tel: (61-2) 6270-5460/Fax: -5499
Website: www.ama.com.au
E-mail: ama@ama.com.au
AUSTRIA E
Österreichische Ärztekammer
(Austrian Medical Chamber)
Weihburggasse 10-12 – P.O. Box 213
1010 Wien
Tel: (43-1) 51406-931
Fax: (43-1) 51406-933
E-mail: international@aek.or.at
REPUBLIC OF ARMENIA E
Armenian Medical Association
P.O. Box 143, Yerevan 375 010
Tel: (3741) 53 58-63
Fax: (3741) 53 48 79
E-mail:info@armeda.am
Website: www.armeda.am
AZERBAIJAN E
Azerbaijan Medical Association
5 Sona Velikham Str.
AZE 370001, Baku
Tel: (994 50) 328 1888
Fax: (994 12) 315 136
E-mail: Mahirs@lycos.com /
azerma@hotmail.com
BAHAMAS E
Medical Association of the Bahamas
Javon Medical Center
P.O. Box N999
Nassau
Tel: (1-242) 328 6802
Fax: (1-242) 323 2980
E-mail: mabnassau@yahoo.com
BANGLADESH E
Bangladesh Medical Association
B.M.A House
15/2 Topkhana Road,
Dhaka 1000
Tel: (880) 2-9568714/9562527
Fax: (880) 2-9566060/9568714
E-mail: bma@aitlbd.net
BELGIUM F
Association Belge des Syndicats
Médicaux
Chaussée de Boondael 6, bte 4
1050 Bruxelles
Tel: (32-2) 644-12 88/Fax: -1527
E-mail: absym.bras@euronet.be
Website: www.absym-bras.be
BOLIVIA S
Colegio Médico de Bolivia
Casilla 1088
Cochabamba
Tel/Fax: (591-04) 523658
E-mail: colmedbo_oru@hotmail.com
Website: www.colmedbo.org
BRAZIL E
Associaçao Médica Brasileira
R. Sao Carlos do Pinhal 324 – Bela Vista
Sao Paulo SP – CEP 01333-903
Tel: (55-11) 317868 00
Fax: (55-11) 317868 31
E-mail: presidente@amb.org.br
Website: www.amb.org.br
BULGARIA E
Bulgarian Medical Association
15, Acad. Ivan Geshov Blvd.
1431 Sofia
Tel: (359-2) 954 -11 26/Fax:-1186
E-mail: usbls@inagency.com
Website: www.blsbg.com
CANADA E
Canadian Medical Association
P.O. Box 8650
1867 Alta Vista Drive
Ottawa, Ontario K1G 3Y6
Tel: (1-613) 731 9331/Fax: -1779
E-mail: monique.laframboise@cma.ca
Website: www.cma.ca
CHILE S
Colegio Médico de Chile
Esmeralda 678 – Casilla 639
Santiago
Tel: (56-2) 4277800
Fax: (56-2) 6330940 / 6336732
E-mail: sectecni@colegiomedico.c
Website: www.colegiomedico.cl
Titlepage: Great Ormond Street Hospital for Sick Children, London. This hospital was founded in 1852,
the first Children’s Hospital in Britain. From very modest beginnings it has developed into a world famous centre both for the
treatment of childrens’diseases and for teaching and research into paediatric diseases. The photograph shows the entrance to
the present main building. Photo by courtesy of GOS.
Editorial
Backward to the future?
WHO has not only warned about the potential danger of a global pandemic ofAvian Influen-
za but recently, in this connection, has also welcomed articles in Nature and in Science
reporting possible means of containment of pandemics following work based on two model
projections (1)(2)(3). These suggest both the use of the drug – Oseltamivir, and strict early
individual and area quarantine as a possible means of avoiding a major pandemic.(see p. 79).
Turning to another area of concern namely, Multi-Resistant Stqphylococcus Aureus
(MRSA), amongst the world wide activities to contain infections with MRSA, there has
been a renewed emphasis on the basic principles of strict cleanliness-, hand-washing and
scrubbing and non- touch techniques, as well as the use of detergents and bactericides. For
years now there have been repeated warnings to physicians about the dangers of the devel-
opment of antibiotic-resistance and the need to avoid over-prescribing of antibiotics, and
their overuse and misuse. While there is still unfortunately a need to remind some physi-
cians to discipline their use of antibiotics, the contributory factors of deregulation of antibi-
otics and their sale over the counter still exists in some jurisdictions, as well as the use of
drugs in cosmetics and to increase food production.
Perhaps the time has come when we should return to basics – to the principles upon which
our predecessors worked before the advent of antibiotics, a re-examination of the applica-
tion of fundamental precautions and techniques which were common in the late 1940-
1950s, became unfashionable in the present industrialised systems of healthcare, and have
been forgotten or neglected in a new age of wonder drugs, technology and commercial
pressures for rapid “through put” of patients in healthcare systems and public demands for
immediate cure. We also hear calls for the revision of medical training, from a system
geared to dealing with acute medicine to one capable of dealing with the huge increase of
chronic disease morbidity, exacerbated by the increased longevity of mankind.
None of this is suggesting that we should not welcome and utilise the remarkable develop-
ments in medical science technology, the ability to discover new treatments.
It is, rather, an emphasis on the need to respect the basic principles of medical care and
treatment, which include assessment of the need for sophisticated drugs when others will
also achieve a cure, and to use medications and new technology with respect.
Coupled with all of this, there are calls for the re-humanisation of medical care. Is there a
need to stress to those responsible for the administration and organisation of healthcare ser-
vices, that these services are for human beings, each having a unique persona and physical
needs? The healthcare services provided are provided to individual human beings – not
simply to machines requiring servicing or repair.
Have we really reached the stage when the qualities which each individual personally pos-
sesses can be repaired by standard “spare part” technology taken as a package off the shelf?
The opening paragraphs above address fundamental principles of medical care. Do we need
to add to these the basic principles of humanity and care for others? We hear of many exam-
ples of selfless activity amongst physicians, but are we also hearing cries of despair at
changing attitudes in physicians? Humanity and care for individuals are certainly qualities
which have for generations been basic to the practice of medicine. Is there nevertheless a
need today to re-emphasise this in basic medical training? Is there is a need to reject an en-
thusiastic unquestioning welcoming of the wonders of modern scientific and technological
development in medicine without pause for thought? While an evidence-based approach to
treatment deals with the tools available for treatment, is such a questioning approach ap-
plied to individual self analysis of each physicians’ activity?
Editorial
57
OFFICIAL JOURNAL OF
THE WORLD MEDICAL
ASSOCIATION
Hon. Editor in Chief
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suffolk IP14 3QT
UK
Co-Editors
Dr. Ivan M. Gillibrand
19 Wimblehurst Court
Ashleigh Road
Horsham
West Sussex RH12 2AQ
UK
Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte-Verlag
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We face a dilemma – how to deal with new
medical discoveries and technological ad-
vances at a rate which has led to a belief that
nothing is beyond the reach of a science to-
day, and that it should be available to every-
one immediately. Of course this is unrealis-
tic but should we be reconsidering the need
to go “back to basics”, both in our daily
practice and our approach to the wonders of
medical advances and how we apply them
in the 21st century?
There is a need for physicians to renew their
allegiance to Hippocratean principles, and
to the Geneva Declaration.
(1) WHO Statement 3rd August 2005
(2 Nature on-line: accessed 31.09.05.
(3) Science 2005, 309, 870.
Alan Rowe
Editorial
58
During embryonic development, the great
veins, atrial and ventricular chambers and
arterial trunks are formed, and the process
occurs by which the heart divides into its
two distinct halves. Following this, further
complexities kick in when the heart’s out-
flow vessels form. An understanding of the
way in which the heart normally develops
is essential both to fully comprehend the
nature and mechanisms which underlie
congenital malformations, such as holes in
the heart and transposition of the great
arteries (Fallot’s Tetralogy), and for subse-
quent corrective surgery to be successful.
We now know that much of the early
knowledge of embryonic heart develop-
ment was incorrect, and that patients were
dying following heart repair operations,
because surgeons put their stitches into
essential parts of the heart’s conduction
system of Purkinje fibres. In turn, in some
malformations, the electrical physiological
“wiring” is itself abnormal – so the ethical
dilemma of where it is safe to cut and stitch,
and avoid losing a life, becomes even more
complex. The importance of such work is
backed up by the falling death rates associ-
ated with heart repair. As many as one in
four patients used to die during or after
surgery 30 years ago, compared with about
one in 50 today. While this is in part due to
advances in cardiac diagnostics, surgery
and intensive care, increased anatomical
knowledge has undoubtedly contributed to
safer and more successful surgery.
Congenital malformations, which present
in a range of degrees of severity, affect as
many as 1% of live births. They are also the
prime cause of miscarriage in 2–3 times
this number of embryos. Clarifying the
structure of the congenitally malformed
heart now underpins much research and
several treatment approaches in this area
worldwide, as well as laying the founda-
tions for current research into sub-types of
malformations and how these arise. In
terms of refined diagnosis, three-dimen-
sional ultrasound, echocardiography and
computerised imaging methods are being
utilised to find out more about the efficien-
cy of heart valve function before and after
surgery. Cardiovascular physiology can be
investigated before, during and following
birth. There is a strong focus now on exer-
cise physiology in children with congenital
heart disease. Strategies are being devel-
oped to improve the outcome of surgical
repair of transposition of the great arteries.
Indeed, the long-term outcome of congeni-
tal heart disease in adults is being studied in
order to improve current management in
childhood, and to further anticipate prob-
lems in adulthood.
There is a greater emphasis now on inter-
ventional cardiology, such as introducing
stents, closing defects, and even inserting
valves through a catheter – in some
instances avoiding the need for open heart
surgery. Atrioventricular septal defects
(AVSDs) are a type of cardiac malforma-
tion, where the septum fails to develop
properly – leading to septal defects
between the chambers, with serious abnor-
malities of the atrioventricular valves.
Digital imaging technology is being
employed to improve the quality of surgi-
cal repair in this malformation. All of the
operations carried out by the surgeon are
filmed using a head camera. In a unbal-
anced AVSD in the child one ventricle is
smaller than the other. What would be the
best way to increase the size of the smaller
ventricle? It was discovered that in these
unbalanced ventricles there are often thick
muscular bundles that are amenable to sur-
gical division, which frees up the small
chamber. Three-dimensional functional
MRI reconstruction of these imbalanced
defects are performed in order to determine
the position of these muscular bundles
before the operation is carried out.
Dividing these muscle fibres means that the
size of the right ventricular cavity, and
hence efficient pumping action, can be sig-
nificantly increased.
Computational fluid dynamics is used to
improve the design of heart operations –
and studying cerebral blood flow together
with metabolic pathways during the course
of open heart surgery aims to reduce subse-
quent brain damage. Pulmonary hyperten-
sion is also coming under the spotlight:
severe pulmonary vascular disease pre-
vents the surgical repair of congenital heart
defects. Consequently more basic research
is needed on the pathogenesis of this condi-
tion combined with clinical research on
treatment strategies.
In adults with normally formed hearts, ath-
erosclerosis is a major cause of morbidity
and mortality, and reducing the burden of
coronary arterial disease is a priority. The
disease has its origins in childhood, and so
risk factors which lead to atherosclerosis
are being assessed with the intention of
evolving strategies to prevent its onset.
Heart attacks
Vascular smooth muscle cells and inflam-
matory cells comprise the atherosclerotic
plaque, where a rupture causes arterial
occlusion and heart attacks. Excessive
accumulation of vascular smooth muscle
Cardiovascular Research Advances
The developing human heart and its congenital malformations
cells also promotes re-narrowing of arteries
after re-vascularisation, such as intracoro-
nary stenting and bypass grafts. The prolif-
eration of such cells is therefore critical to
understanding myocardial infarction dis-
ease processes. A major focus of research
has been to identify the key regulatory path-
ways that control cell proliferation in ather-
osclerosis and re-stenosis. Why should cells
in advanced human atherosclerotic plaques
proliferate poorly, and therefore be unable
to repair minor damage? It has now been
determined how cells from in-stent narrow-
ings bypass conventional cell cycle control.
Similarly, how novel therapies such as
brachytherapy (radiation therapy) achieve
their effect is becoming increasingly clear.
These studies have led to the design of anti-
proliferative agents that are disease-specif-
ic, which are currently being tested. Genetic
profiling has identified new markers of dis-
ease, a prelude to rational drug design to
target diseased tissues.
New studies have recently been funded to
study the various processes of cell ageing, as
exemplified by atherosclerosis, and to iden-
tify mechanisms that either halt or reverse
the intrinsic biological cellular clock.
Vascular smooth muscle cell death promotes
instability of atherosclerotic plaques.
Advanced disease plaques have lost the abil-
ity to protect themselves from cell death,
being also particularly vulnerable to local
scavenging inflammatory cells. Cholesterol-
lowering drugs such as the statins have ben-
eficial effect on these disease states.
Mechanisms of immune
response triggered by
endothelium
Although the latest immunosuppressant
drugs have virtually eliminated the risk of
acute rejection of heart transplants, the risk
of chronic rejection in the form of a gradual
hardening of the arteries remains. It was
previously considered that graft rejection is
triggered by “passenger leukocytes”, donor
white blood cells present in the graft, which
migrate to the patient’s lymph nodes and
activate host T-cells that attack the graft and
lead to rejection. Graft endothelial cells
may be capable of activating host T-cells,
which would explain why chronic rejection
occurs long after the clearance of passenger
leucocytes. Differences between subsets of
CD4+
and CD8+
T-cells have been demon-
strated in their ability to be activated by
endothelial tissue. It may thus be possible
to develop target agents for therapeutic
intervention.
Myocardial stem cell biology
Until recently, the heart was believed to lack
regenerative capacity. However, there is
mounting evidence that a population of
progenitor cells within the heart is capable
of producing mature cardiac myocytes in
response to injury. The challenge is to
understand why this healing process is so
limited in the heart, which results in inade-
quate tissue response after large myocardial
infarcts or global insults to the heart such as
viral infection. What is the molecular basis
for differentiation of adult cardiac myocytes
derived from embryonic stem cells? The
processes which inhibit complete myocar-
dial regeneration need to be identified.
Indeed, several approaches are possible for
myocardial tissue engineering towards
potential therapeutic strategies in both con-
genital and acquired cardiac disease.
Tissue engineered vascular
conduits
In surgery, both coronary artery and periph-
eral artery bypass procedures depend on the
ready availability of adequate arteries or
veins. Many patients lack suitable blood
vessels for grafting, which limits their abil-
ity to benefit from surgical re-vascularisa-
tion. In collaboration with a biotechnology
company research will begin with clinical
trials utilising wholly autologous, engi-
neered vascular conduits. Engineered ves-
sels in the way will have no foreign proteins
and will be “grown” in the laboratory from
a small skin and vein biopsy donated by the
patient. If successful, this will revolutionise
vascular surgery and will provide proof in
principle that similar engineering approach-
es for other tissues will be possible.
Heart transplantation
The success of heart transplantation is pri-
marily limited by the availability of suitable
donors. Papworth Hospital, University of
Cambridge, has pioneered approaches to in
vivo donor organ resuscitation and evalua-
tion, which have become the recognised
“standard of care” both in the UK and
North America. A surgical device will be
tested which can perfuse explanted hearts
with substrate-enhanced, warm, oxygenat-
ed blood and thereby resuscitate the organ
outside the inflammatory milieu of the
brain-dead donor. Moreover, in developing
the resuscitation device, each heart will be
fully evaluated in terms of its physiological,
anatomical and biochemical performance,
so as to provide an evidence-based assess-
ment of transplant suitability.
Vascular smooth muscle cell
gene expression
At Addenbrooke’s Hospital, Cambridge, an
entirely novel gene has been identified and
sequenced which is expressed in both
smooth muscle and cardiac muscle. In
terms of its chromosomal location it may
turn out to be an important agent in excita-
tions-contraction coupling and the regula-
tion of myocardial contractility.
Also identified is a family of genes, con-
taining some novel members, that regulate
the transcription of smooth muscle specific
genes.
Vascular calcification
It has been established that vascular calcifi-
cation is a regulated process involving both
inhibitory and facilitative gene products.
Apoptotic cell death, under certain circum-
stances, may lead to the precipitation of cal-
cium salts and the initiation soft tissue cal-
cification. With respect to the gene coding
for matrix Gla protein, an important
inhibitory protein in calcification, there is
significant variability in the gene coding
which may predispose some individuals to
Editorial
59
develop either earlier or more pronounced
calcification.
By adopting novel approaches to imaging
the atherosclerotic process, pilot data sug-
gest that in patients with symptomatic vas-
cular disease, using functional MRI and
CAT scans, visualisation of localised
inflammatory activity may become feasi-
ble. The thin layer of cells which lines
blood vessels, particularly vulnerable to
build up of deposits at vessel junctions, is
crucially important in normalising raised
blood pressure. Dysfunction here is
believed to be a key factor in atherosclero-
sis, and so mechanisms are being investi-
gated and therapies evaluated aimed at
restoring endothelial function.
Arterial vessel wall injury
Early atheroma development in the arterial
wall covers the impact of key genetic,
inflammatory and dietary factors. The latter
include the role of partially oxidised lipids
and essential fatty acids. Such early mech-
anisms are linked with abnormalities in the
function of vascular endothelial cells and
with activation of fibrin and platelets trig-
gering thrombotic complications, as for
example in stroke and heart attacks. It is
possible to identify patients with threatened
myocardial infarction, to inhibit the throm-
bin and platelet aggregation mechanisms
with the “clot-buster” group of drugs, and
to diminish the risks of major cardiovascu-
lar complications, provided that the patient
is seen early enough by the doctor. This
now means that, in delivery of healthcare to
heart patients, myocardial infarction and
unstable anginal pain can be more accu-
rately assessed for their frequency and clin-
ical significance.
Cardiac specific gene
targeting
A research group at the Edinburgh New
Royal Infirmary under Dr. KAA Fox has
examined the molecular genetics of key
factors involved in hypertension. Important
steps have been identified in the control of
the renin-angiotensin cascade, regulating
Editorial
60
It is with great sadness that we report the death of Sir Richard Doll whose
seminal work on Smoking and Lung Cancer was reflected on its fiftieth
anniversary last year in his guest editorial in this journal (WMJ50 (3)).
William Richard Shaboe DOLL
d. 24 July 2005 aged 92
It is over fifty years since the young researcher who had served in a hospital
ship during the second world war and had lost a kidney to tuberculosis, first
demonstrated in collaboration with Austin Bradford Hill, the close link
between smoking and lung cancer (and so many other diseases, notably coro-
nary heart disease). Inevitably he was frustrated by the subsequent failure both
of governments and so many victims of their smoking habit to follow his
example and act on these findings, but, supported by a “powerful marriage“ to
Joan Faulkner, he devoted his painstaking epidemiological skills to an infinite
range of diseases related to environmental, occupational and lifestyle factors.
His exact and exacting scientific work, underpinned by a strong humanitari-
an drive, made him an example and an inspiration to those who followed him.
Showers of honours worldwide failed to spoil a truly modest man. Despite
increasing frailty and the loss of his wife in 2001, he continued to the end to
respond to requests for advice and support to those who shared his commit-
ment to the prevention of preventable disease and suffering.
blood pressure and arterial vascular tone,
and in gluccorticoid metabolism, covering
susceptibility to atheroma and accelerated
phase hypertension. It has been possible to
mark renal juxtaglomerular cells genetical-
ly, which are critically involvend in the dis-
ease process.
This group of doctors has the largest single-
centre experience in Europe of survivors
from out-of-hospital cardiac arrests. Specific
brain enzyme markers can predict the risk of
death and cognitive impairment amongst
those surviving initial resuscitation Using
MRI, the anatomical location and metabolic
substrate for defects in mental function and
memory loss have been defined. Related
work examines the risk of the patient devel-
oping further arrhythmias. Thus, specific
rehabilitation measures can now be targeted
as survivors of cardiac arrest.
Arrhythmias
According to Dr. AJ Cann, St. George’s
Hospital, fatal atrial fibrillation is a com-
mon rhythm disorder which requires inves-
tigation in a long series of studies. Examples
include design and testing of pacemaker
algorithms for control of atrial fibrillation
and the development of implantable defib-
rillators. New medications and medical reg-
imens are being discovered to treat paroxys-
mal, persistent and permanent atrial fibrilla-
tion. Mapping of atrial fibrillation at surgery
is being carried out in order to identify areas
which can be destroyed that will eliminate
rhythm disturbance, together with the use of
digital recordings to evaluate oscillatory
mechanisms initiating atrial fibrillation.
Heart muscle disorders, such as hypertrophic
obstructive cardiomyopathy (HOCM) and
dilated cardiomyopathy, generally occur in
families. These disorders and other genetic
cardiac conditions, which may cause sudden
unexpected cardiac death, are being studied:
the genetic basis and the phenotype-genotype
correlations in HOCM; dilated cardiomyopa-
thy genetics, arrhythmogenic dysplasia,
Marfan syndrome, long QT syndrome,
Brugada syndrome, sudden infant death syn-
drome (SIDS) and the conditions responsible
for sudden death in professional athletes.
The latest techniques which can assess the
cardiac electrical arrhythmogenic risk of
patients suffering from heart disease incor-
porate several risk of patients suffering
from heart disease incorporate several large
databases taken from multi-centre clinical
trials. Risk factors cover heart rate variabil-
ity – frequency, time and non-linear meth-
ods; a new approach known as heart rate
turbulence; and spatial and temporal vari-
ability of the QT interval (QT dispersion).
Outlook
Analysis of hospital records in Western
Europe and America by computer has
shown that many fatal diseases of Western
culture, particularly heart attacks and
strokes, can be brought on by a previous
infection. Clinical technology should there-
fore be harnessed to identify patients at risk
of cardiac disease progression, whether
from the genetic point of view of inherited
diseases associated with heart muscle and t
he conduction system, sudden death in the
young, HOCM, the ion channelopathies
and arrhythmogenic right ventricular car-
diomyopathy – or on the other hand the
environmental approach via the strength of
the immune reaction in fending off disease.
The recognition of such patients at risk is
important from an ethical point of view as
effective treatments are available.
Ivan M. Gillibrand
Further reading
Institute of Child Health &
Great Ormond Street Hospital for Children
NHS Trust:
“Leading The Way” Research Review
2003
British Heart Foundation 2003/04
Annual Report of the Medical Division
Medical Director: Professor Sir Charles
George
www.bhf.org.uk
Guest Editorial
61
This article explores the trends in indemni-
ty insurance worldwide, set against the UK
scene and draws conclusions about the
future arrangements for liability cover for
physicians and other healthcare workers.
The number of multi-million pound medical
negligence claims has been rising above the
rate of inflation for some years and stories
about such cases are a regular feature in the
newspapers. Despite this, some UK doctors
and dentists do not always know for certain
whether compensation for harm suffered
from proven clinical negligence will be avai-
lable. Contractual indemnity insurance is in
place throughout the United States, Austra-
lia and most of continental Europe but this
has not yet happened in the United Kingdom.
This article investigates whether there is
now irresistible momentum behind insur-
ance being made compulsory for healthcare
professionals
Medical negligence trends
Set against the staggering number of
National Health Service (NHS) consulta-
tions which take place in the UK – around
270 million every year1
– the number of
medical negligence claims is very small.
The NHS Litigation Authority (NHSLA),
which indemnifies NHS bodies, such as
hospitals, paid out £502.9million in claims
and legal costs in 2004-5, compared to
£422.5million in 2003-4. In contrast, the
number of clinical negligence claims
against the NHS in 2004-5 fell to 5,609,
compared with 6,251 in 2003-42
.
The Medical Defence Union (MDU) has
revealed that the costs of medical negligence
claims are rising well above the rate of infla-
tion, although the trend seems to be for fewer
claims to be made against members. Those
we do see are generally well thought out and
have a more realistic chance of succeeding.
Last year the MDU, which has over 165,000
members, including over 50 per cent of UK
doctors, paid seven patients more than £1mil-
lion each for claims and legal costs against
hospital doctor and GP members3
. Ten years
ago just one patient received more than £1mil-
lion. The high cost of these cases reflects the
severity of the injury and the amount of care
the patient needs for the rest of his or her life.
It is difficult to draw conclusions in com-
paring the claims statistics in different
countries because legal systems differ so
greatly that this would be misleading.
Suffice it to say that there is some evidence
that there has been an increase in medical
negligence claims in other countries. In the
United States, for example, a study by the
Joint Economic Committee of US Congress
reported in May 2003 that, between 1994
and 2001, the average medical malpractice
award increased 176 per cent to $1million4
.
Government action
Some governments, such as that in Australia,
have sought to tackle the high cost of clini-
cal negligence cases by imposing a cap on
the amount of damages that can be awarded.
In the United States too, President Bush has
stated his determination to reform the system
and reduce the number of lawsuits, including
a cap on non-economic damages.
Meanwhile, the UK Government is investi-
gating ways to regulate the claims system.
This may include an attempt to rein in so-
called “claims farmers” which offer to assist
in pursuing personally injury claims, usual-
ly in exchange for a share of any compensa-
tion recovered. In a speech to the Institute of
Comprehensive cover for modern medics
Dr Michael Saunders, Chief Executive of the Medical Defence Union
Public Policy and Research (IPPR) on 26
May 2005 Lord Falconer, the Secretary of
State for Constitutional Affairs and Lord
Chancellor said: “The growth of claims
farmers has fostered and encouraged the
attitude that if you are injured, you should
see if you can turn it into money. Our
Compensation Bill will help with that by
introducing regulation of claims farmers.”
In addition, in the 2005 Queen’s Speech at
the opening of parliament a NHS Redress
Bill was proposed with the aim of reducing
long delays in bringing cases and the high
legal costs in settling some claims.
Although the details of the scheme have yet
to be made available, it is likely to follow
the outline of the scheme outlined in the
Chief Medical Officer’s consultation paper
on reforming clinical negligence: ‘Making
Amends’ in 20035
. This also included a pro-
posal for a scheme of no fault compensa-
tion. In 2002, such cases accounted for 5
per cent of the cases on the NHS’s books
but 60 per cent of the money paid out by the
NHS to compensate patients.
Medical indemnity
With the costs of claims rising so rapidly, it
is vital that doctors are properly indemni-
fied against the cost of a claim which could
easily bankrupt them, while leaving a
patient uncompensated.
In the past, some doctors have relied on dis-
cretionary indemnity – that is, they have
paid a subscription to an organisation that
gives them the right to seek assistance from
that company and have that request fairly
considered, but not the contractual right to
receive help which comes with an insurance
policy. No Company providing discre-
tionary indemnity can give a guarantee that
they will assist with clinical negligence
claims. The decision to assist or not can
only be made at the time the practitioner
presents the indemnifier with the facts of
the case for which he is seeking help.
The alternative – contractual indemnity
insurance – is already a requirement for
practising doctors and dentists in most
developed countries in order to protect
patients, amongst them, the US, France,
Germany, Belgium, Holland and Spain.
Australia was the most recent country to con-
vert in 2003 following a crisis in the medical
indemnity market precipitated by the threat-
ened failure of one of the biggest organisa-
tions that had offered discretionary indemni-
ty, United Medical Protection (UMP). UMP
was forced into provisional liquidation in
2001 by a combination of factors identified
by the provisional liquidator (Deloitte)
including multi-million dollar court payouts,
and the collapse of its reinsurer HIH.
In the midst of the crisis, the Australian
Federal Government stepped in to rescue
UMP (which was allowed to resume trading
in 2003) and put in place a new medical
indemnity insurance framework, which
included direct financial support to ensure
that doctors in high-risk specialisms such as
obstetrics and gynaecology, could afford pre-
miums. The Government made it a require-
ment for all Australian doctors and dentists to
have professional indemnity insurance on a
claims-made basis, through an approved
provider. Doctors and dentists are also
required to buy a ‘run-off’ policy so that after
the claims made policy has expired (for exam-
ple because the insured has retired, is disabled
or has died), incidents that have occurred dur-
ing the term of the policy remain insured.
Launching the scheme the Australian gov-
ernment said the reason for the change was
to ensure that doctors and dentists “will have
access to contracts of insurance that are
legally enforceable rather than discretionary
arrangements that exist now which provide
no certainty that claims will be met.”
Indemnity in the UK
In the UK, concerns about discretionary
indemnity were expressed as far back as
1979 in a judgment of the then Vice-
Chancellor, Sir Robert Megarry:
‘… When a person insures, I think that
he is contracting for the certainty of pay-
ment in specified events, and not merely
for the certainty of proper consideration
being given to his claim that the discre-
tion to make a payment in those events
should be exercised in his favour. The
certainty must be direct, and not at one
remove.’ 6
Today, lawyers, architects and accountants
working in private practice in the UK have
to have professional indemnity insurance,
as do health professionals such as chiro-
practors and the majority of osteopaths, but
the same is not true of doctors and dentists.
However, recent events have renewed focus
on the insurance question.
In 2004, the Department of Health (DoH)
issued a consultation, which proposed to
make indemnity insurance compulsory for
dentists. However after the consultation had
closed, the DoH said there was a mistake in
the wording and that discretionary indemni-
ty would be equally acceptable. The Dentists
Act 1984 (Amendment) Order 2005 makes
“adequate and appropriate insurance” a
requirement for all registered dentists and
dental care professionals. However, in defin-
ing “adequate and appropriate insurance” the
order states that as well as a contract of
insurance, “an arrangement made for the
purpose of indemnifying a person…” is
acceptable. It is now up to the General
Dental Council (GDC) to draw up rules
specifying what type of insurance it consid-
ers will provide adequate and appropriate
safeguards for dentists and their patients.
In the debate surrounding the DoH consulta-
tion and the insurance versus discretion ques-
tion, discretionary-only providers suggest
that discretion is more flexible and that the
problem with insurance is the ‘small print’.
However, one of the major problems with
discretion is that there isn’t any print at all, no
contract, any enforceable right to assistance.
In contrast, an insurance policy should set
out, in plain English, what is covered and
what is excluded. If a healthcare professional
is refused assistance under their insurance
policy they may seek and be given a reason
for that decision. He or she also has recourse
to the Financial Ombudsman Service and the
civil courts for assistance in challenging the
decision. Doctors refused indemnity by a
discretionary provider have none of these
safeguards and only know if they will be
assisted when they make the claim.
The Consumers’ Association has said:
“…the provision of clinical indemnity
should be regulated to ensure that one only
Guest Editorial
62
practitioners are assured that they have
cover if something goes wrong, but also that
consumers will be able to achieve redress
and receive recompense in this event…”
Discretion only indemnifiers are unregulat-
ed. Only doctors who are insured have the
kind of consumer guarantees that one
would expect from a highly regulated
industry. Insurers are authorised and regu-
lated by the Financial Services Authority
(FSA) which oversees the financial man-
agement of insurance companies in order to
protect solvency margins, insure capital
adequacy and reduce the risk of capital
flight. It also sets standards for systems,
sales and policyholder communications,
claims handling and complaints procedures.
Both the UK General Dental Council and the
General Optical Council, which has also
been given the power to make rules specify-
ing their indemnity requirements, have
sought or will seek legal advice and no doubt
will wish to consider whether an indemnity
arrangement that gives healthcare profes-
sionals no contractual rights, and that is not
legally enforceable, provides adequate and
appropriate safeguards for healthcare profes-
sionals, and patients who sue for negligence.
The need for insurance
As professional accountability increases,
the likelihood also increases that non-med-
ical healthcare professionals will be sued
personally if a patient they are treating is
harmed. Given that discretionary indemnity
is no longer acceptable in Australia, in most
other EU countries and most states in the
USA, it is the MDU’s view that discre-
tionary indemnity does not provide the nec-
essary safeguards for UK healthcare profes-
sionals and their patients and that all health-
care professionals should be required to
hold professional indemnity insurance.
©
MDU Services 2005
Address for correspondence:
Dr. Michael Saunders,
The MDU,
302 Blackfriars Rd,
London SE1 8PT
The Medical Defence Union was founded in
1885 and was the first medical mutual pro-
fessional assurance organisation in the
world. It continued worldwide coverage for
its members who, at various stages, have
included members from other countries
practising in many parts of the world until
the year 2000, when only doctors and den-
tists practising in the UK and Ireland
became eligible for membership. ED
1 Office of Health Economics Compendium of
Health Statistics, London 2000, p36
2 NHSLA Report and Accounts 2005, London
2005
3 Medical Defence Union, London 2005
4 Liability For Medical Malpractice Issues And
Evidence, Joint Economic Committee United
States Congress, Washington 2003 (introduc-
tion)
5 Making amends: a consultation paper setting
out proposals for reforming the approach to
clinical negligence in the NHS – A report by
the Chief Medical Officer, London, July 2003
6 MDU Ltd v Department of Trade [1979] 2
WLR 686
Medical Ethics and Human Rights
63
The following presentation was given on
behalf of the WMA at the Conference of
Experts on Biological Weapons in Geneva
11th
June 2005.
The World Medical Association was set up
following the Nuremburg trials to deal with
the issue, amongst others, of abuse of med-
ical expertise. (Box 1) In the concept of the
current conference it could even be shown
that some of the abuses were dual use of
medicine. The WMA was also set up
because doctors’ recognised a need for
international standards which were codified
and formalised. Such standards offer bene-
fits to individuals, and help them to resist
imprecations to become involved in ethical-
ly unacceptable practices.
When we consider common medical stan-
dards, it is important to look at issues such
as the core values that bind doctors together.
These values are what being a doctor is all
about and include concepts such as compas-
sion, caring and commitment (box 2).
Medicine has also had the advantage of
having ethical codes for over two and a half
thousand years which most doctors regard
as being binding.
As a profession we are also regulated. For
many doctors, this regulation which
includes consideration of the concept of
self-development, learning and working to
Medical Ethics and Human Rights
Conference of experts on biological weapons
Professor Vivienne Nathansen
Director of Professional Activities, British Medical Association
Box 1 What is the WMA?
• Established in 1948
• An association of associations
• National Medical Associations
• Independent and representative
• Members from all parts of the world (but not all countries)
• Bound by common standards
externally agreed standards, will be wholly
by other members of their profession, that
is a peer group. Increasingly such regula-
tion is only partly self-regulation and
includes input from lawyers, parliamentari-
ans, patients and many others.
Being a professional includes a commitment
to common standards, but also includes the
concept of regulation or licensing.
For most doctors throughout the modern
world, being employed depends upon hav-
ing a licence, and that licence itself is likely
to be in part dependent upon understanding
educational achievement and in part upon
adherence to ethical and other norms and
observation of ethical standards is therefore
a routine part of medical practice. (Box 3)
Ethical codes have been established to raise
the standards of medical practice to a high
common norm. Whilst they do not guaran-
tee the end of abuse by individuals, or
indeed of observance of ethical principles
by individuals, we believe they have con-
tributed significantly to a decrease in the
incidence of such abuse.
There are, of course, many ethical codes sur-
rounding medicine. While the Hippocratic
Oath has been around for more than two and
a half thousand years, there are many other
codes established by the World Medical
Association. These include the Declaration
of Geneva and the International Code of
Medical Ethics, established in 1948 effec-
tively as a modern re-statement of the princi-
ples in the Hippocratic Oath. Other codes
include the Declaration of Tokyo on the
treatment of prisoners, the Declaration of
Helsinki on Research Ethics, and the
Declaration of Washington on Biological
Weapons. The key to all of these codes and
many others is that the World Medical
Association has significant experience in
crafting codes and promoting those to doctor
members of its member associations around
the world.
Where do these codes fit in the network of
guidance available doctors? As set out in
box 4. there are many different areas of
control of medical practice and these laws
vary from country to country. However,
ethical codes and professional guidance can
effectively become customary law within a
country because the majority of practition-
ers will practice according to those codes
and guidance. Courts do not accept igno-
rance of the Geneva code as an excuse for
breaching well accepted principles.
How does the World Medical Association
go about writing a code? The first thing to
say is that although historically these were
written by doctors for doctors with little
external advice, based upon Judaeo-
Christian ethics and setting doctors apart
from other professionals, this is gradually
being changed. Increasingly they are writ-
ten with a medical view but as codes by
health professionals for all health profes-
sionals and with input from many stake-
holders, including patients. This has partic-
ularly been the case in relation to the revi-
sion of the Declaration of Helsinki on
research ethics, where patients and research
subjects had a major role to play in inform-
ing the debate.
Because ethical codes are about the frame-
work of limits set by society with the pro-
fessions that serve it, it is important to
recognise that there has to be multi-cultur-
al, multi-professional input, but the key to
the code being useful remains getting “buy-
in” from those will have to follow it.
Why then did the World MedicalAssociation
write a Declaration on Biological Weapons
(box 5). The simple answer was that a num-
ber of different associations had been doing
work on biological weapons and related
issues for some time. The British Medical
WMA
64
Box 2 Common medical standards
• Core values
• Binding ethical codes
• Professional regualtion – partly or wholly self regulation
• Continuing education/professional development
Box 3 Ethical codes
• Post Nuremberg
• Code by doctors for doctors
• General adherence even if not formally sworn
• Set of principles
• Interpretation required
Box 4 Control of Medical Practice
• Statute Law
• Judicial Decisions
• Customary Law
• Ethical Codes
• Professional guidance
WMA
65
A. Introduction
1. The World Medical Association recogni-
zes the growing threat that biological wea-
pons might be used to cause devastating
epidemics that could spread international-
ly.All countries are potentially at risk. The
release of organisms causing smallpox,
plague, anthrax or other diseases could
prove catastrophic in terms of the resul-
ting illnesses and deaths compounded by
the panic such outbreaks would generate.
At the same time, there is a growing po-
tential for production of new microbial
agents, as expertise in biotechnology
grows and methods for genetic manipula-
tion of organisms become simpler. These
developments are of special concern to
medical and public health professionals
because it is they who best know the po-
tential human suffering caused by epide-
mic disease and it is they who will bear
primary responsibility for dealing with the
victims of biological weapons. Thus, the
World Medical Association believes that
medical associations and all who are con-
cerned with health care bear a special re-
sponsibility to lead in educating the public
and policy makers about the implications
of biological weapons and to mobilize
universal support for condemning rese-
arch, development, or use of such wea-
pons as morally and ethically unaccepta-
ble.
2. Unlike the use of nuclear, chemical, and
conventional weapons, the consequences
of a biological attack are likely to be insi-
dious. Their impact might continue with
secondary and tertiary transmission of the
agent, weeks or months after the initial
epidemic. The consequences of a success-
ful biological attack, especially if the in-
fection were readily communicable, could
far exceed those of a chemical or even a
nuclear event. Given the ease of travel and
increasing globalization, an outbreak an-
ywhere in the world could be a threat to all
nations.
3. A great many severe, acute illnesses oc-
curring over a short span of time would al-
most certainly overwhelm the capacities
of most health systems in both the develo-
ping and industrialized world. Health ser-
vices throughout the world are struggling
to meet the demands created by
HIV/AIDS and antimicrobial-resistant or-
ganisms, the problems created by civil
strife, refugees and crowded, unsanitary
urban environments as well as the increa-
sed health needs of aging populations. Co-
ping over a short period of time with large
numbers of desperately ill persons could
overwhelm entire health systems.
4. Actions can be taken to diminish the risk
of biological weapons as well as the po-
tentially harmful consequences of serious
epidemics whatever their origin. Interna-
tional collaboration is needed to build a
universal consensus that condemns the de-
velopment, production, or use of biologi-
cal weapons. Programs of surveillance are
needed in all countries for the early detec-
tion, identification, and response to se-
rious epidemic disease; health education
and training is needed for professionals,
civic leaders, and the public alike; and
collaborative programs of research are
needed to improve disease diagnosis, pre-
vention, and treatment.
5. The proliferation of technology and scien-
tific progress in biochemistry, biotechno-
logy, and the life sciences provides the op-
portunity to create novel pathogens and
diseases and simplified production me-
thods for bioweapons. The technology is
relatively inexpensive and, because pro-
duction is similar to that used in biological
facilities such as vaccine manufacturing, it
is easy to obtain. Capacity to produce and
effectively disperse biological weapons
exists globally, allowing extremists (ac-
ting collectively or individually) to threa-
ten governments and endanger peoples
around the world. Nonproliferation and
arms control measures can diminish but
cannot completely eliminate the threat of
biological weapons. Thus, there is a need
for the creation of and adherence to a glo-
bally accepted ethos that rejects the deve-
lopment and use of biological weapons.
B. Strengthening public
health and disease surveillan-
ceCE systems
6. A critical component in dealing with epi-
demic disease is a strong public health in-
frastructure. Investment in public health
systems will enhance capacity to detect
and to contain expeditiously, rare or un-
usual disease outbreaks, whether delibera-
tely induced or naturally occurring. Core
public health functions (disease surveil-
lance and supporting laboratory services)
are needed as a foundation for detection,
investigation, and response to all epidemic
threats. A more effective global surveil-
lance program will improve response to
naturally occurring infectious diseases
and will permit earlier detection and cha-
racterization of new or emerging diseases.
7. It is especially important that physicians
be alert to the occurrence of cases or clu-
sters of unusual infectious diseases, to
seek help from infectious disease specia-
lists in diagnosis, and to report cases
promptly to public health authorities. Be-
cause any physician may see only one or a
few cases and may not recognize that an
outbreak is occurring, cooperation bet-
ween primary care physicians and public
health authorities is especially important.
8. Public health officials, dealing with an
epidemic, will require the cooperation of
emergency management agencies, law en-
forcement officials, healthcare facilities,
and a variety of community service orga-
nizations. For these different groups to
work together effectively, advance plan-
ning will be important. In addition to de-
veloping surveillance activities for early
detection and reporting, public health eff-
orts should be directed toward educating
primary caregivers and public health staff
about potential agents that might be used,
building laboratory capacity for rapid
identification of biological agents, provi-
Box 5: The WMA Declaration of Washington
on biological weapons
WMA
66
ding medical and hospital services as well
as vaccines and drugs to control the epide-
mic.
C. Enhancement of medical
preparedness and response
capacity
9. The first indication that a biological wea-
pon may have been disseminated is likely
to be the appearance of patients in the of-
fices of practicing physicians, especially
those in acute care settings. Physicians
thus play a critical role in early detection
of an outbreak and must be prepared to
recognize and deal with diseases resul-
ting from the use of biological weapons
as well as other infectious disease agents
and to promptly report suspicious illnes-
ses and diseases to public health officials.
10. In the course of an epidemic, physicians
will be directly involved with mass pa-
tient care, with mass immunization and
antibiotic prophylaxis, with providing in-
formation to the public, and in a variety
of hospital and community efforts to con-
trol the epidemic. Thus, physicians
should participate with local and national
health authorities to develop and imple-
ment disaster preparedness and response
plans for intentional and natural infec-
tious disease outbreaks.
D. Bioweapons research and
medical ethics
11. Rapid advances in microbiology, mole-
cular biology, and genetic engineering
have created extraordinary opportunities
for biomedical research and hold great
promise for improving human health and
the quality of life. Better and more rapid
diagnostic tools, novel vaccines, and the-
rapeutic drugs can be foreseen. At the
same time, there is concern about the
possible misuse of research for the deve-
lopment of more potent biological wea-
pons and the spread of new infectious di-
seases. It may be difficult to distinguish
legitimate biomedical research from re-
search by unscrupulous scientists with
the malign purpose of producing more
effective biological weapons.
12. All who participate in biomedical rese-
arch have a moral and ethical obligation
to consider the implications of possible
malicious use of their findings. Through
deliberate or inadvertent means, genetic
modification of microorganisms could
create organisms that are more virulent,
are antibiotic-resistant, or have greater
stability in the environment. Genetic
modification of microorganisms could
alter their immunogenicity, allowing
them to evade natural- and vaccine-indu-
ced immunity. Advances in genetic engi-
neering and gene therapy may allow mo-
dification of the immune response sy-
stem of the target population to increase
or decrease susceptibility to a pathogen
or disrupt the functioning of normal host
genes.
13. Research specifically for the purposes of
creating biological weapons is to be con-
demned. As scientists and humanitari-
ans, physicians have a societal responsi-
bility to decry scientific research for the
development and use of biological wea-
pons and to express abhorrence for the
use of biotechnology and information
technologies for potentially harmful pur-
poses.
14. Physicians and medical organizations
have important societal roles in deman-
ding a global prohibition on biological
weapons and stigmatizing their use,
guarding against unethical and illicit re-
search, and mitigating civilian harm
from use of biological weapons.
E. Recommendations
15. That the World Medical Association and
National Medical Associations worldwi-
de take an active role in promoting an
international ethos condemning the deve-
lopment, production, or use of toxins and
biological agents that have no justifica-
tion for prophylactic, protective, or other
peaceful purposes.
16. That the World Medical Association, Na-
tional Medical Associations and health-
care workers worldwide promote, with
the World Health Organization, the Uni-
ted Nations, and other appropriate ent-
ities, the establishment of an internatio-
nal consortium of medical and public he-
alth leaders to monitor the threat of biolo-
gical weapons, to identify actions likely
to prevent bioweapons proliferation, and
to develop a coordinated plan for monito-
ring the worldwide emergence of infec-
tious diseases. This plan should address:
(a) international monitoring and repor-
ting systems so as to enhance the surveil-
lance and control of infectious disease
outbreaks throughout the world; (b) the
development of an effective verification
protocol under the UN Biological and
Toxin Weapons Convention; (c) educa-
tion of physicians and public health wor-
kers about emerging infectious diseases
and potential biological weapons; (d) la-
boratory capacity to identify biological
pathogens; (e) availability of appropriate
vaccines and pharmaceuticals; and (f) fi-
nancial, technical, and research needs to
reduce the risk of use of biological wea-
pons and other major infectious disease
threats.
17. That the World Medical Association urge
physicians to be alert to the occurrence of
unexplained illnesses and deaths in the
community and knowledgeable of disea-
se surveillance and control capabilities
for responding to unusual clusters of di-
seases, symptoms, or presentations.
18. That the World Medical Association en-
courage physicians, National Medical
Associations and other medical societies
to participate with local, national, and
international health authorities in develo-
ping and implementing disaster prepa-
redness and response protocols for acts
of bioterrorism and natural infectious di-
sease outbreaks. These protocols should
be used as the basis for physician and pu-
blic education.
19. That the World Medical Association urge
all who participate in biomedical rese-
arch to consider the implications and
possible applications of their work and to
weigh carefully in the balance the pursuit
of scientific knowledge with their ethical
responsibilities to society.
Association for example wrote book length
reports in 1999 and 2004, but first published
on weapons control issues in the 1890s. The
American Medical Association had started
the drafting work on the Washington
Declaration before the Anthrax attacks, and
followed it up by organising the scientific
session at the 2002 General Assembly on
Natural and Deliberately Inflicted
Biological Events.
The key is that doctors see disease and are
engaged in trying to control, manage and
reduce the impact of epidemics. In terms of
biological weapons doctors would like to
see principles of public health applied,
including both primary and secondary pre-
vention, to decrease the likely incidence or
prevalence of such biological attacks and
also to manage the seriousness of such
attacks including reducing the spread of
disease.
If codes have something to offer, then the
question is what makes them effective? The
World Medical Association believes that
making codes work needs to follow a sim-
ple set of rules. These include making them
relevant, simple and clear. Similarly ensur-
ing that the code is taught and understood
by those who will have to follow it and
ensuring that you engage those who must
use it or follow its principle so that they
understand, are aware of and are compliant
with that code on a voluntary basis
The key to effectiveness is getting those
who should be bound to it, to understand,
value and internalise it as well as getting
society itself to recognise the important
place that the code plays.
In terms of this Conference of Experts on
Biological Weapons and the concept of
codes, there are a number of questions to
ask which raise problems in writing these
codes. The first of these is “what is a scien-
tist?“. The answer is that there are many
types of scientist, including life scientists,
natural scientists, pure scientists, biolo-
gists, physics, chemists and so on who are
key players in reducing the risk of bio-war-
fare and bio-terrorism. This makes the sci-
ences more difficult to regulate than medi-
cine which has the advantage of being a
relatively cohesive profession wherever
you are in the world.
WMA
67
The second problem is that regulation and
licensing of scientists is at a much earlier
stage than it is in medicine, where regula-
tion has existed for one and a half centuries
in many countries. The question that has to
be addressed is whether licensing and regu-
lation will be of different groups of scien-
tists separately and apart, or whether there
will be a cohesive all-scientist programme.
The third point is whether employment
standards are adequate as an alternative to a
code. The World Medical Association
believes that employment standards are
useful, but those employment standards
work best when they embody concepts such
as adherence to a code of ethics as a pre-
requisite for continuing employment.
There are already a plethora of codes of
conduct and practice around the world
which can in their own way undermine the
development of a new code unless it is seen
as being over arching and having real pro-
fessional value and support.
The final problem that we see is the absence
of a single international body representing
scientists. There is a plethora of representa-
tive bodies, both national and international,
within the sciences. The key factor here is to
create a new international body which can
over arch in all these areas and get input and
“buy-in” to an emerging code from all spe-
cialities and subspecialties.
Finally – what can the World Medical
Association do to help in this process? The
first simple answer is that we can help write
a code based upon our significant expertise
in doing just that. The second way in which
the World Medical Association can and will
help, is to publicise and engage with med-
ical researchers and their colleagues to
spread the message and achieve engage-
ment from the scientific community.
The third thing that the World Medical
Association can do is use its links with
other professional groups such as the World
Health Professionals Alliance to get further
publicity for, and “buy in” to, an emerging
code.
The final thing that the World Medical
Association can do is to offer reassurance
to scientists. Codes are far from being the
end of freedom. They are a part of the
responsibility that scientists have to the
society which they serve. They are a frame-
work which helps to ensure that scientists
keep within the limits that society would
wish and expect to have in place and they
will contribute to all of our overall safety.
The WMA looks forward to continuing the
debate.
AMA position on Physician participation in
Guantanamo Interrogations
Dr J. Edward Hill, President of the American
Medical Association, speaking at the BMA
Annual Representative Meeting made the fol-
lowing points concerning the position of the
AMA on allegations of physician participa-
tion in Guantanamo Interrogations e.g arti-
cles in the New England Journal of Medicine
(7 July) New York Times (June 24) and earli-
er report in the Press etc.
The American Medical Association Code of
Medical Ethics clearly prohibits any form
of physician participation in torture. Any
physician involvement in torture compro-
mises te integrity of the medical profession.
The AMA defines torture as the use of
“cruel, inhumane and degrading treatments
or punishments during imprisonment or
detainment”. The AMA CODE specifies that
“participation in torture includes, but is not
limited to, providing, or with-holding any
services, substances or knowledge, to facili-
tate the practice of torture”. “Physicians
should provide support for victims of torture
and whenever possible, strive to change sit-
uations in which torture is practised or the
potential for torture is great.”
The confidentiality of medical records and
patient-physician communications should
be protected, when that confidentiality is
violated, trust in undermined and patients
may not provide full and accurate informa-
tion to their physicians (AMA Policy E-5
05). This applies even to patients who are
prisoners or detainees.
As the leading voice of the American
Medical Profession, the AMA calls on all
physicians to stand together in opposing
torture, physician participation in torture,
and breaches of patient confidentiality.
Dr. Hill also referred to AMA meetings with
the US Department of Defence to express
concern over published reports alleging
physician participation in coercive interro-
gations in Guantanamo Prison Camp. DOD
officials assured the AMA that aggressive
investigation of these complaints was taking
place but disputed whether military physi-
cians were involved in any unethical mis-
conduct. Further conversations with DOD
Officials had subsequently taken place,
detailing AMA concerns about the allega-
tions. In June 2005 a document outlining the
ethical principles for all health personnel of
the Armed Forces was sent to the AMA.
At the June meeting of the House of
Delegates of the AMA, the house reaf-
firmed its support of the ethical medical
treatment of prisoners of war and said it
would “encourage medical schools to
include ethics training on the issue of med-
ical treatment of prisoners of war and
detainees”.
The AMA is working with colleagues from
the British, Icelandic, French and Danish
Medical associations to study the
Declarations of Geneva and Tokyo to deter-
mine whether additional provisions are nec-
essary to provide guidance to physicians
and address violations by physicians in
conflict settings.
The AMA policy that “physician participa-
tion in torture and/or abuse of prisoners is
unethical and unacceptable has been com-
municated to the media, public and the
Pentagon itself, and the AMA will continue
both to monitor the situation and to advo-
cate that all physicians honour these ethical
principles.
WMA
68
In the Middle Ages studying was a fairly
international activity. Many of the universi-
ties were in southern Europe and persons
seeking education had to travel a long way
to find their teachers. However, the power
of the titles academicians earned at that
time was not questioned. Once bestowed
the title remained with the person.
Nowadays students may travel much faster,
but to take their degrees and credits from
one country to another takes not only longer
than any journey across Europe in the
Middle Ages, it is also very cumbersome
and sometimes even very expensive.
Universities, claiming their independence,
often do not care about the interests of their
migrating students, and governments find it
difficult to compare degrees and to proper-
ly recognize them.
Moreover, many students feel unprepared
for university studies and many drop out
early without acquiring a degree.
One of the most unknown international
mega-projects is the so-called Bologna
Process. In 1999, twentynine European
Ministers of Education meeting in Bologna,
agreed to install a uniform system of
University degrees and credits with two
major aims:
• To facilitate migration by awarding easily
understandable and comparable credits
and degrees and
• To provide two study cycles for all disci-
plines/fields, each ending with a degree
giving access to the labour market.
This step was unprecedented: The Ministers
of Education met and decided to take com-
mon action to provide easier migration
across Europe, not only in the European
Union, which had at that time 15 member
states. And of course, such changes had to
be mandatory for all studies, all disciplines/
fields, all Universities and Colleges. In the
future there should be two degrees a
European Bachelor to be reached after 3 or
4 years of undergraduate education, and a
European master to be reached after anoth-
er 1 to 2 years of graduate studies. (The
doctorate degree was later added to this sys-
tem as an additional third degree.)
However the Ministers of Education took
this decision on their own: Experts from the
different disciplines were obviously not
involved, students and representatives of
the professions were not heard. In conse-
quence, the result is a reform which looks
nice on first sight, but which raises many
doubts on further examination.
Interestingly, in medicine the Bologna
process was widely ignored and this for a
good reason. For the last thirty years many
efforts have been made to unify the tradi-
tionally bi-phasic medical undergraduate
education. The formerly separated basic
and clinical sciences were combined into
one study cycle in order to expose the stu-
dent to a medical setting from the very
beginning of medical education. Of course,
this cycle has precisely one end product, the
physician. There is no half-way product –
this was never intended nor would it have
From the Secretary General’s Desk
The Bologna Process – not well done,
but well intended?
been meaningful. Splitting this up again
just doesn’t make sense!
Confusion in the medical field is complete.
Some countries decided to split the medical
studies in accordance with the Bologna
process, so that the Bachelor degree defines
more or less only the theoretically educated
physician, and the Masters degree the com-
pletion of internship. Other countries want
to introduce just a mock Bachelor – an inter-
mediate degree without any meaning and
without any use. Most countries have not
decided what to do with medicine, while
other countries are certain that they will not
include medicine in the Bologna process.
One thing is clear: better comparability of
equal and qualifying degrees remains far
away, the new situation actually appears to
be more difficult than before the Bologna
process.
Academic studies at public universities in
many of the European countries are offered
more or less free of tuition fees. This is a
huge burden for governments, most of
which are in financial troubles. But the
promise always is repeated: “Education
will remain free“. However, the small print
in the political programmes reads rather
differently. A closer look reveals that in the
future, studies may be free only up to the
first professional degree, and thanks to
Bologna, in all countries this will now be
after three to four years instead of four to
six years as it was previously.
WMA
69
WMA
The Significance of the Scientific Session of
WMA General Assembly, Tokyo 2004
Nobuya Hashimoto, MD Vice-Chairperson, WMA Council
Executive Board Member, JMA
The Scientific Session of the WMA General
Assembly Tokyo held from October 6 to 9,
2004 gave direction to resolving a variety of
issues that directly confront global health
care today. As a person involved in planning
this session from the JMA side and as an
executive board member from the host
NMA responsible for this event, I wish to
review the significance of the Scientific
Session (and WMA General Assembly), and
make a few suggestions.
The Scientific Session provided a forum
through which the overall state of medical
and health care in the 21st
century was
reviewed through two themes – “Advanced
Medical Technology and Medical Ethics”
(Theme I) and “Progress in Information
Technology and Health Care” (Theme II).
Progress made in science and technology has
greatly changed the environment around us
today and has also affected medical and
health care. Subsequently, it has also pro-
duced a variety of unforeseen problems that
inevitably accompany the progress made by
humanity and which are unavoidable. Thus, I
believe a consensus was reached on how the
issues that were discussed at the Scientific
Session should be addressed. In summary,
we, physicians, should secure the patient’s
safety based on a relationship of physician-
patient trust and do our utmost best to pro-
vide high quality medical care. The themes
that were addressed at the Scientific Session
dealt with problems that health care related
personnel have never had to face in the past.
Therefore, there are no exemplar models that
may provide the answers. However, the out-
come of the day and a half of active discus-
sions, was a shared recognition of the need
for a code of behaviour for our profession by
the participants from 42 countries. Thus, I
hope that what was discussed at the Scientific
Session will contribute to more effective dis-
cussions at the WMA.
The essential points of the Scientific
Session were summarised as follows. The
achievements of advanced medical tech-
nology and information technology (IT)
based on the knowledge of past generations
are indeed wonderful, and no one will deny
this fact. But these achievements are not
shared at large within the global communi-
ty. As pointed out by Dr. Takaku, we must
not forget the view that the benefits that are
derived from this new technology should
be shared equally and globally. In the
advanced countries, concern regarding
advanced medical technology and progress
in IT has been increasing. As emphasized
by JMA president, Dr. Uematsu, society as
a whole must recognise that advanced med-
ical technology should guarantee the safety
and happiness of humanity, and that a sys-
tem which enables only a handful of people
to benefit from costly advanced medical
technology should be reformed. As Dr.
Sakurai has explained, in Japan the JMA
has lobbied the Japanese government to
enable medical insurance to cover
advanced medical technology under the
guidance of the JMA. This is, of course,
related to national financial issues, but it is
the duty of medical associations to protect
the public health by lobbying the govern-
ment to prevent fiscal initiatives from dom-
inating medical and health care issues. To
achieve this, physicians must have the abil-
ity to foresee future developments in med-
ical technology.
As Dr. Haddad has pointed out, we should
constantly bear in mind that future devel-
opments in science and technology should
supplement the knowledge and experience
that physicians have accumulated through
traditional methods and they should not
replace them. If we lose sight of this basic
concept, then physicians become merely
the subcontractors of electronic engineers.
The need for common ethical guidelines for
advanced medical technology was pointed
out; and at the 2002 WMA General
Assembly in Washington the Japanese
Medical Association’s draft proposal on
Medical Ethics and Advanced Medical
Technology was adopted as a WMA
Declaration. This declaration is a general
statement on advanced medical technology
and medical ethics, and there is a continued
need to review this issue from many differ-
ent perspectives. For example, Japan has
achieved the world’s highest life expectancy
with low health costs. But to sustain this
feat, it has become essential to secure finan-
cial resources. In advanced countries,
improving the financial foundations needed
to secure the health level of its population
has become a major problem, and there is
wide scope for discussion.
In the area of medical technology and
advanced IT, Dr. Kim pointed out the
inevitable transformation of health care due
to IT and genomics. But, as Dr. Uematsu
has advocated, the goals that we physicians
should aim for are to practice holistic med-
icine and to provide safe and high quality
medical care. It is to be expected that med-
ical costs will rise when quality medical
care is provided. But, its quality should not
be lowered as a means of containing health
costs. However, financial resources for
medical and health care are limited.
Therefore, how these resources are allocat-
ed is a major issue which should be
reviewed by the WMA.
Certainly, as Dr. Groth has pointed out,
more than 90 percent of advanced technol-
ogy is currently developed by less than 10
percent of the countries in the world
(advanced countries). Of course, it is a fact
that the social and financial foundations of
advanced and developing countries differ
greatly. However, it is also a fact that physi-
cians in developing countries should do
their ultimate best within the respective
environment of the country.
Progress in IT technology will continue to
influence developments in medical care. As
noted by Dr. Kaihara, obtaining correct
information will promote physician-patient
relations and will help realize better med-
ical care. Thus, balancing IT and medical
care is one of the goals before us to attain.
But, again, as stated by attorney, Dr.
Higuchi, medical information must ulti-
mately function under the principle that it
will be used to provide the best treatment
for patients and allow society at large to
benefit from it. As pointed out by Dr.
Takaku, that is the difficulty of resolving
specific issues such as the need to protect
individual gene related data. By whom, and
how such issues will be resolved should be
carefully addressed with the co-operation
of physicians on a global scale through the
WMA General Assembly meetings, rather
than under the leadership of individual
country governments and their financial
concerns. Therefore, the WMA should be
willing to provide a forum to discuss these
issues as needed. As Dr. Haddad has indi-
cated, WMA is also duty bound to alert
each country about the responsibility not to
leave our future generations with the bur-
den of dealing with the destruction of the
natural environment and environmental
pollution caused by national greed.
These are my personal views on the impor-
tant issues of CME and professional auton-
omy that are being debated in Japan today,
based on the discussions that took place at
the Scientific Session. Against a back-
ground of extensive mass media coverage
about medical errors and publicity about
distrust of medical care, CME for physi-
cians is a vital issue that must be addressed
to enable physicians to provide high quality
medical care. Moreover, physicians volun-
tarily undertake CME, and this is where
professional autonomy becomes important.
Therefore, I would like to emphasise the
need for voluntary discipline by physicians
through reaffirmation of the WMA
Declaration of Madrid on Professional
Autonomy and Self-Regulation.
The following observations and proposals
are made in the light of the opportunities
which were presented at the Tokyo General
Assembly.
In the past, many prominent declarations
and statements have been drafted and
adopted by the WMA Council and General
Assembly, which have been used as guide-
lines by NMAs in resolving different
issues, and I pay sincere homage to the
efforts of the WMA to produce these
invaluable statements.
In particular, the Declaration of Geneva,
Declaration of Helsinki, Declaration of
Madrid on Professional Autonomy and
Self-Regulation are some of the many very
distinguished statements that have been
produced so far. They have served as the
golden rule for physicians throughout the
world during both under and postgraduate
education. Their principles remain
immutable in both the East and the West.
Despite this fact, the WMA has repeatedly
revised these historical declarations begin-
ning with the Declaration of Helsinki. The
Physician’s Oath in the Declaration of
Geneva embodied the Hippocratic Oath, the
Declaration of Helsinki had incidently the
effect of applying some of the principles of
the Nuremburg Code to the ethical princi-
ples for medical research involving human
subjects, and the Declaration of Madrid
provided the principles governing the com-
plex physician-patient relationship and
defined the attitude of the physician about
professional autonomy and self-regulation.
WMA
70
WORLD MEDICAL ASSOCIATION
The General Assembly and Scientific Meeting of the World Medical
Association will take place in the Hyatt Regency Hotel, Santiago,
Chile, on the 12–15 October 2005.
The Scientific Meeting on “Health System Reform and Access to
Medicine“ will be held on Thursday 13th October, preceded an
Associates meeting.
The General Assembly Ceremonial Session will be on the morning
of the Friday 14th October and the rest of the General Assembly will
take place on Saturday, the 15th October;
The basic principles that are inherent in
these declarations are important and they
represent WMA’s recognition of their sig-
nificance in adopting them at that time.
Therefore, they are also invaluable histori-
cal assets. To revise them unnecessarily
may be to ignore the intent of those who
originally drafted them. Moreover, it may
also obliterate their significance as histori-
cal assets of the time. There is also concern
that the original text will eventually disap-
pear with repeated revisions.
The revisions of WMA declarations have
hitherto been limited to unavoidable cir-
cumstances. But I would like to propose that
in future, when there is a need for a declara-
tion to reflect present-day medical and
health care issues, a new and separate decla-
ration be proposed, discussed, and adopted.
I would like to see the WMA Council spend
its valuable time discussing current and
important issues rather than revising past
documents. There is a backlog of many sig-
nificant issues that we must discuss.
Disclosure of medical information and pro-
tection of personal information, the spread
of advanced medicine and soaring medical
expenses, policies to control medical costs
and improve quality of medical care, and
the specialist and the general practitioner
are just some of the many issues at hand
that the WMA should address.
As a global professional organisation for
physicians, the WMA must contribute to
providing high quality medical care, based
on professional medical ethics against a
background of changing social conditions
and public awareness. Therefore, it must be
vigilant in its efforts to resolve the many
issues at hand.
In conclusion, I look forward to WMA’s
further growth and development.
Medical Science, Professional Practice and Education
71
A prerequisite for progress towards the
United Nations (UN) Millennium
Development Goals (MDG), relevant for
the health care sector, will be adjustments
in the capacity of the professional health
workforce worldwide1
. This requirement
will have considerable implications for
medical education and education and train-
ing of other health professions in many
parts of the world. The World Health
Organisation (WHO) decision to launch a
decade dedicated to human resources for
health (HRH), starting with the World
Health Day and the World Health Report in
2006, is a clear indication of the fact that
we are challenged by tremendous problems
of ensuring the necessary HRH basis for
sustainability and efficiency of health care
systems. HRH is the central asset of health
systems’ development.
A new Strategic Partnership to Improve
Medical Education and ultimately health
professions education in general, formed
jointly in 2004 by the World Health
Organization and the World Federation for
Medical Education2
, is based on the rather
simple concept (unfortunately not always
recognised by all stakeholders) that quality
medical education is of fundamental signi-
ficance for quality health care.
The actual situation is that medical educa-
tion is facing huge quantitative and qualita-
tive problems worldwide. They are to a cer-
tain extent interrelated. The former are
foremost determined by insufficient plan-
ning of production and distribution of med-
ical doctors and their uncontrolled migra-
tion; the latter by insufficient leadership,
conservatism and lack of incentives at the
institutional level. For both, lack of or not
using proper priorities of resources is a crit-
ical factor.
Focus is presently put on negative effects
of migration of doctors. What from ancient
times has traditionally been considered an
advantage for the medical profession has
now become a threat to health care systems
in the developing world. In earlier periods,
mobility was mostly a temporary phenom-
enon resulting in the achievement or deliv-
ery of expertise, whereas the present trend
is a (unfortunately unclosed) circular
movement in a chain reaction with the end
result of the developing world being
deprived of medical doctors. The mecha-
nisms behind this traffic are, on one side,
insufficient capacity of the educational sys-
tem in some rich countries, the major sin-
ners (USA, Canada and UK) benefiting
from brain-gain without providing the nec-
essary investments in health professionals
education. On the other side, insufficient
postgraduate training possibilities and the
unattractive working and remunerative
conditions for medical doctors in the poor
countries, lead to external brain-drain and
subsequently to increased in-country
migration from rural areas to the big cities.
Evidently, this pattern has catastrophic
consequences for the health care systems,
especially in Sub-Saharan Africa. The den-
sity of doctors in some parts of Africa is
below 1 per 100,000 compared to 160–350
(in a few countries up to 550) per 100,000
in the Western world.
The existence of a vicious circle is under-
pinned by the fact that the underdeveloped
countries are loosing some of the best qual-
ified doctors and thereby part of the foun-
dation for their training institutions.
The problem of migration, which is in fact
even more complicated by the existence of
active recruitment by some countries, and
also by deliberate brain-export by other
countries, have already been discussed
extensively. In 2004, a World Health
Assembly resolution3
emphasised the criti-
cal situation and follow-up is planned, e.g.
at the upcoming UN General Assembly
Special Session (UNGASS) on migration.
Some initiatives to remedy the critical situ-
ation have been taken, but the fundamental
Medical Science, Professional Practice and Education
Current Problems in Medical Education
Hans Karle
President World Federation of Medical Education (WFME)
causes have so far not been tackled. A recent
proposal to obtain solutions points to the
need for internationally adopted standards
or norms for numbers of doctors in the
developed part of the world and also for
effective compensation to the developing
countries4
. Discussion at high political lev-
els like the G8 Forum has included the HRH
area in their considerations for support. It is
generally agreed that capacity building
regarding HRH is needed in many countries
in Sub-Saharan Africa. This will require bet-
ter data on the situation country-wise, eval-
uation of the existing training capacity and
the needed conditions for expansion, and
probably the establishment of new institu-
tions in some countries as well as direct sup-
port from institutions in other Regions. The
latter could include twinning arrangements
between universities and hospitals and tele-
education programmes.
Facing the present HRH capacity problems,
many authorities seem to be looking for a
reduction of the training programmes in
medical schools below the present norm of
5–7 years for graduate and 3.5–4 years for
postgraduate medical curricula, which
would enable higher production rates. The
medical profession should resist such a
development without thorough analysis of
consequences. A curriculum programme
below 5 years is generally not compatible
with production of a medical doctor. Health
workers coming out of such programmes
must have other designations than “medical
doctor”, and instead of shortening the cur-
riculum, a more realistic approach would be
to consider the role of medical doctors and
their relationship to the function and educa-
tion of other health professions, including
perhaps new cadres.
On the qualitative side, the problems are
closely related to the mushrooming of new
medical schools. Over the last decade, there
has been an increase in number of about 100
per year. At the moment, there are no clear
data regarding the overall number of medical
schools. It is also becoming an issue of con-
cern that this question depends on how we
define a medical school. In this respect,
some of the new schools have been estab-
lished without adequate resources and often
without sufficient clinical training facilities.
A transition from a situation with largely
public financed medical schools to an
increasing private enterprise (in some cases
even with for-profit purposes), adds to the
problem of ensuring quality. Medical educa-
tion like other types of higher education has
now become a trade commodity which not
only invites the establishment of diploma
mills without proper training activities, but
which also has led to off-shore satellites
from some highly estimated medical
schools, looking for opportunities to stabilise
their economy by attracting affluent students
more than thinking about quality education.
However, on the qualitative side of the coin
there are also positive trends. Medical edu-
cation is gradually being directed into an
evidence-based educational activity with
many valuable innovations as far as curric-
ular design, teaching- and learning methods
and assessment are concerned. More focus
on social accountability, introduction of
integrated curricula and community orien-
tation as well as more reliable examination
systems are examples of this development.
With respect to mutual integration of basic
sciences and integration between basic and
clinical sciences in education and assess-
ments, medical education is now threatened
by the European Bologna Declaration and
Process, which tends to influence higher
education principles also beyond Europe.
This process, which otherwise includes
important and valuable qualitative elements,
requires a two-cycle model of independent
bachelor- and master-degrees. Although
several stakeholders5
have criticised such a
development in medicine, arguing that cur-
rent attempts to create integrated curricula
will be invalidated, there is still major con-
cern in many countries and institutions.
On the positive side could be added broad
international consensus about the use of
standards in medical education and the
attention to quality assurance and accredita-
tion of medical education institutions and
programmes. The WFME Global Standards
Programme for Quality Improvement,
which received broad international
endorsement at the World Conference on
Medical Education in 20036
is now being
implemented in all Regions of the world.
The Trilogy of WFME Standards7
are being
used in institutional self-evaluation and
peer reviews as basis for reforms (in the
near future to be supported by a new
WFME Advisor function) and are also
being incorporated in National and
Regional standards and accreditation proce-
dures of both well-established and new
accreditation systems. In most parts of the
world there is a growing awareness of the
need for effective, but transparent accredi-
tation systems. Recently, the WHO/WFME
Partnership has developed Guidelines for
accreditation8
. This development will most
likely result in a Register of accredited
medical schools based on quality indica-
tors. The plans for developments of the
WHO Directory of Medical Schools9
are in
accordance with this.
The ongoing focus on outcome-based cur-
ricular design might be seen as a germ to
the creation of new problems. While every-
body would agree that attempts to use out-
come definition is a valuable lighthouse in
curricular planning, too narrow and short-
termed specification of the outcome of the
educational process (which already seems
to be the case in some medical schools),
will have the risk of spoiling the fundamen-
tals of academic medicine. Medical educa-
tion should not only be determined by the
endeavour to achieve a number of concrete
practical competencies, but should fore-
most foster understanding and methodolog-
ical capabilities.
References
1. Mercer, H., Dal Poz, M., Adams, O., Stilwell,
B., Buchan, J., Dreesch, N., Zurn, P. and
Beaglehole, R. Human Resources for Health:
Developing Policy Options for Change. In:
Towards a Global Health Workforce Strategy.
Eds.: Paulo Ferrinho and Mario Dal Poz.
Studies in Health Services Organisation &
Policy, 21, 2003.
2. WHO/WFME Strategic Partnership to
Improve Medical Education. Geneva/Copen-
hagen 2004. www.who.int & www.wfme.org
3. World Health Assembly Resolution:
International Migration of Health Personnel:
A Challenge for Health Systems in
Developing Countries. WHA 57.19, 2004.
4. Eastwood, J.B., Conroy, R.E., Naicker, S.,
West, P.A., Tutt, R.C. and Plange-Rhule, J.
Loss of Health Professionals from Sub-
Saharan Africa: The Pivotal Role of the UK.
Medical Science, Professional Practice and Education
72
5. World Federation for Medical Education and
the Association for Medical Education in
Europe: Statement on the Bologna Process
and Medical Education. 2005. www.wfme.org.
6. van Niekerk JP de V. WFME Global
Standards Receive Ringing Endorsement.
Commentary. Medical Education 2003, 37,
585-86
7. WFME Global Standards for Quality
Improvement: (a) Basic Medical Education;
(b) Postgraduate Medical Education; (c)
Continuing Professional Development (CPD).
Copenhagen 2003. www.wfme.org
8. WHO/WFME Guidelines for Accreditation of
Basic Medical Education. Geneva/Copen-
hagen 2005. www.wfme.org
9. World Directory of Medical Schools. Seventh
Edition. World Health Organization, Geneva,
2000 and www.who.int.
Correspondence to:
Dr. Hans Karle
WFME Office
University of Copenhagen
Faculty of Health Sciences
The Panum Institute
Blegdamsvej 3
DK-2200 Copenhagen N
Denmark
Medical Science, Professional Practice and Education
73
A number of new vaccines with major
potential for controlling infectious diseases
are at advanced stages of development.
Among the illnesses targeted are rotavirus
diarrhoea, pneumococcal disease, and cer-
vical cancer (as caused by human papillo-
mavirus), which together kill more than a
million people each year, most of them in
developing countries. In addition to these
efforts against diseases of global impor-
tance, progress is being made on a vaccine
for the regional menace posed by meningo-
coccal meningitis serogroup A, which caus-
es frequent epidemics and high rates of
death and disability in African countries
south of the Sahara.
These advanced candidate vaccines are the
focus of the information provided below.
However, it should be noted that continu-
ing, intensive efforts are under way to
develop effective vaccines for AIDS,
malaria, dengue, leishmaniasis, and shigel-
la dysentery, among others.
Vaccine development proceeds through dis-
covery, process engineering, toxicology
and animal studies to human Phase I, II,
and III trials. The process can take more
than 10 years, depending on the disease.
The human trials focus initially on safety,
involving small groups of people (I); then
progress to moderate-sized “target” popula-
tions (persons close to the age and other
characteristics for whom the vaccine is
intended) to determine both safety and the
stimulation of immune response (II); and
finally to large target populations to estab-
lish whether a vaccine actually prevents a
disease as intended (efficacy) (III).
The current situation of a number of new
vaccines in development:
Rotavirus
Acute diarrhoea is responsible for nearly 1.9
million deaths per year in children under age
five. Rotavirus is responsible for as much as
one quarter of these casualties, almost all of
which occur in developing countries.
Status of vaccine development:
RotaRix, a vaccine developed by
GlaxoSmithKline (GSK), showed an effica-
cy rate against severe rotavirus diarrhoea of
87% in a clinical study of 1986 infants in
Venezuela, Brazil, and Mexico, and is now
licensed in Mexico, the Dominican Republic,
and Kuwait, although currently used only in
the private market.APhase III trial of over 60
000 infants was carried out in Latin America
in 2003–2004, and efficacy results are
expected soon. Phase III trials also are under
way in South Africa and Bangladesh.
RotaTeq, a vaccine developed by Merck,
protected more than 95% of recipients from
severe rotavirus diarrhoea in a clinical trial
of 1,946 infants in Finland. A Phase III trial
of more than 70,000 infants in the United
States and European countries has been
carried out to investigate safety, and a sub-
set of that group was followed to determine
efficacy. The results of these studies are
expected by mid 2005. Trials in Asia and
Africa – where different strains of the virus
may predominate – are likely to start this
year but may not be completed for several
years.
Rotavirus vaccines in earlier stages of
development include two vaccines spon-
sored by the United States National
Institutes of Health; a neonatal vaccine
developed by an Indian-US consortium;
and an Australian neonatal vaccine.
Challenges: A vaccine must be effective
against numerous rotavirus strains
(serotypes), including those prominent in
developing countries. Large, stringent safe-
ty trials are necessary because an earlier,
unrelated rotavirus vaccine appeared to
cause, in rare cases, a serious complication.
Candidate vaccines, since they are live,
oral vaccines, must be shown not to inter-
fere with oral polio vaccine; and must be
shown to be safe in HIV-infected children.
Price is also likely to be an issue.
Prospects: Rotavirus vaccines will be
ready for use in some additional countries
by 2006, but information on their effective-
ness in Africa and Asia will not be avail-
able until 2008. They are expected to be
ready for widespread use in immunization
programmes in Africa and Asia by 2009.
Pneumococcal disease
Acute lower respiratory infections are
responsible for two million deaths per year
and a large proportion of these are pneumo-
coccal disease. A recent study (Cutts F. et
al., The Lancet 2005) in The Gambia indi-
cates that more than one third of these
deaths might be caused by the bacterium
Streptococcus pneumoniae. Most victims
are children in developing countries.
Development of new vaccines
Pneumonia deaths far outnumber deaths
from meningitis. Nonetheless, in non-epi-
demic situations, Streptococcus pneumoniae
is the main cause of meningitis fatalities in
sub-Saharan Africa; of those who develop
pneumococcal meningitis, 40–75% either
die or are permanently disabled. Children
infected with HIV/AIDS are 20–40 times
more likely to contract pneumococcal dis-
ease than children without HIV/AIDS.
Status of vaccine development: A seven-
valent conjugate vaccine called Prevnar is
designed to act against seven strains of
pneumococcal disease. It has been devel-
oped by Wyeth and is licensed in the United
States and several other countries, but does
not include two serotypes (types 1 and 5)
that cause a high percentage of pneumococ-
cal illness in developing countries.
(Conjugate vaccines, which have proved to
be highly effective, are made by linking
purified polysaccharides – complex sugars
– from the coat of a disease-causing bacteri-
um to a protein “carrier.”) In the United
States, use of this vaccine has led to a dra-
matic decline in rates of pneumococcal dis-
ease, not only in immunized children, but
also in the un-immunized population
through reduced transmission. Wyeth has
now completed evaluation of a nine-valent
conjugate vaccine, including serotypes 1
and 5. A Phase III trial of the vaccine
involving 40,000 people was completed in
South Africa in 2002, and a Phase III trial
with 17,437 subjects was concluded in the
Gambia in 2004. In the South African trial,
the vaccine offered a rate of protection
against invasive disease caused by the rele-
vant serotypes of 83% in HIV-uninfected
children and 65% in HIV-infected children.
Results just released from The Gambia trial
show the vaccine was 77% effective in pre-
venting infections caused by the relevant
serotypes; that it resulted in 37% fewer
cases of pneumonia (as confirmed by chest
X-ray) as compared with a control group;
and that recipients experienced a 16%
reduction in overall mortality. A vaccine
containing these nine serotypes with or
without additional serotypes is expected to
be submitted for licensure within the next
three to four years.
In addition, two 11-valent vaccines for
pneumococcal disease – developed by two
different pharmaceutical firms – are under-
going evaluation.
Challenges: It can be difficult to establish
the extent of pneumococcal disease as
developing countries often lack the clinical
and laboratory facilities, the expertise, and
the resources to do so. As a result, public
health decision-makers are often unaware
of the prevalence of the disease and of the
toll it exacts in death and disability.
Because of the scarcity of data from devel-
oping countries, there is concern over
whether the seven- and nine-valent vac-
cines contain the serotypes appropriate for
all countries. Concerns remain – although
results to date are encouraging – that pre-
vention of some serotypes of pneumococcal
disease may lead to increased incidence of
other serotypes. The price of the vaccine,
although still to be set for developing coun-
tries, may be too high for them to afford
without special financing arrangements.
Prospects: A vaccine providing effective
protection against pneumococcal disease
for young children in developing countries
may be ready for use in 2008–2009, and
could be introduced in such countries pro-
vided adequate supply and financial help
are arranged.
Human Papillomavirus (HPV)
Sexually transmitted HPV is the major
cause of cervical cancer, the most common
cause of cancer deaths among women in
developing countries. About 500,000 cases
occur each year, 80% of them in developing
countries. Cervical cancer kills some
240,000 women annually.
Status of vaccine development: Phase III tri-
als are under way of two commercial vac-
cines, each given in three doses. One, devel-
oped by Merck, covers four types of HPV,
including the cancer-causing types 16 and
18 and types 6 and 11 for non-cancerous
genital warts. The multi-year Merck trial,
with an enrolment of over 25 000 women, is
expected to conclude this year. The second
vaccine, developed by GSK, covers HPV
types 16 and 18 alone. The GSK trial began
in 2004, has an enrolment of about 30000
women, and is still under way.
Results of a Phase II trial on a monovalent
type 16 vaccine were published by Merck
in 2002. GSK published Phase II results of
its bivalent type 16 and 18 vaccine in 2004.
Both studies indicate that the candidate
vaccines are well-tolerated; that they are
highly immunogenic (produce antibodies);
that they are greater than 90% effective in
protecting against the relevant viral infec-
tions; and that they offer virtually complete
protection against persistent infections by
the target viruses.
Challenges: HPV types 16 and 18 cause
70% of HPV cervical cancers, but the vac-
cines in development will not cover the
30% of cancers attributed to other HPV
types. Because these other types are numer-
ous, significantly expanding vaccine cover-
age against them may present technical
challenges for manufacturers. The duration
of the immunity conferred by the vaccines
is not yet known, but studies are planned
that will look at this question. Because
HPV is spread by sexual contact, and the
high-risk years for infection are roughly
from ages 18 to 25, the best subjects for
vaccination will likely be pre-adolescents
or adolescents, unlike for traditional vacci-
nation programmes, which are aimed most-
ly at infants and pregnant women. Access to
the vaccines is likely to be an issue in
developing countries due to limited
resources for the implementation of vacci-
nation programmes.
Prospects: Both vaccines may be licensed
within one or two years in the United
States and Europe. Discussions are ongo-
ing about collecting the necessary data for
introducing the vaccines into developing
countries. Their systematic use in develop-
ing countries may well depend on local
epidemiology, acceptability, financial
resources, and the feasibility of vaccinating
adolescents.
Meningococcal meningitis A (Men A)
The African “meningitis belt” – which
includes all or part of 21 countries stretch-
ing south of the Sahara desert from Senegal
to Ethiopia – is the site of frequent epi-
demics, usually caused by serogroup A
meningitis. Over the past decade more than
700,000 cases have been reported. Roughly
10–20% of persons infected die, and one
out of five survivors is likely to suffer from
a permanent disability such as hearing loss,
Medical Science, Professional Practice and Education
74
mental retardation, or paralysis. The rate of
meningitis epidemics in the region has
increased in recent years.
Status of vaccine development: Polysaccha-
ride vaccines (vaccines made from complex
sugars taken from the outer coats of the
Men bacterium) are currently in use, but are
not very effective at protecting young chil-
dren, do not create long-lasting immunity,
and do not confer a “herd effect” – that is,
do not prevent spread of the disease in non-
vaccinated people through reduction of the
carriage of the infectious agent by vaccinat-
ed people during epidemics. Because of
these shortcomings, immunization with
polysaccharide vaccines is usually under-
taken only after the onset of an epidemic.
To provide greater and more efficient pro-
tection, a public-private effort called the
Meningitis Vaccine Project (MVP) is
developing a Men A conjugate vaccine.
This vaccine is intended to have long-last-
ing effect, to create immunity in infants,
and to allow protection to be conferred in
advance through mass immunization pro-
grammes. Toxicology studies and animal
studies have been successfully completed,
and the animal studies suggest the conju-
gate vaccine is highly immunogenic – that
is, stimulates high levels of antibodies
against Men A infection. Phase I trials will
begin in May 2005 in India.
Other conjugate vaccines, including a
tetravalent vaccine covering serogroups A,
C, Y, and W135, are being developed by
the private sector; and a tetravalent vaccine
has recently been licensed by Sanofi-
Pasteur in the United States.
Challenges: Clinical development of the
Men A conjugate vaccine must still be car-
ried out – it must be shown to be safe and
effective in humans in Phase I, II, and III
trials. In addition, other meningococcal
meningitis strains are circulating in Africa
which will not be controlled by a vaccine
for serogroup A. One strain, referred to as
W135, has recently caused epidemics in
Burkina Faso and has become more preva-
lent, although its long-term potential as an
epidemic agent is not known.
Prospects: A low-priced conjugate vac-
cine for Men A may be ready for wide-
Medical Science, Professional Practice and Education
75
spread use in the African meningitis belt
by 2008 or 2009, thanks to an innovative
arrangement for development and produc-
tion. The vaccine was designed by the
Center for Biological Evaluation and
Research of the United States Food and
Drug Administration. The technology was
then transferred without intellectual prop-
erty charges to the Serum Institute of
India, which carries out production at the
lower costs prevailing in a developing
country. The Serum Institute uses raw
materials (group A polysaccharides) sup-
plied by SynCo Bio Partners of the
Netherlands. The arrangement is expected
to keep costs as low as US$ 0.40 per dose,
making the vaccine affordable for low-
income countries. Much of this vaccine-
development project was underwritten by
a US$ 70 million grant from the Bill &
Melinda Gates Foundation.
WHO Initiative for Vaccine Research
(IVR)
The WHO Initiative for Vaccine Research
was established in 2001 to streamline the
various vaccine research and development
projects being carried out by different
departments of WHO (including the
Special Programme for Research and
Training in Tropical Diseases: TDR) and
UNAIDS. IVR also provides leadership,
priority setting, and coordination among
efforts worldwide to develop vaccines
against neglected diseases, particularly dis-
eases endemic in developing countries. In
addition to collaboration within WHO, IVR
works in close association with internation-
al organizations, philanthropic organiza-
tions, academic medical institutions, and
private- and public-sector partners active in
the research and development of vaccines.
Robots on the Hospital Wards
In a pilot scheme Remote Presence (RP6)
Robots are being tried out in a trial con-
ducted in a General Surgery Ward and
Accident and Emergency Department in St.
Mary’s Hospital, London and for training
purposes, in the Academic and Clinical
Skills Unit at Imperial College, London.
The robots are controlled with a joystick
from a remote site and, via the machine and
using wireless technology, permit the doc-
tor to see the patient, ask questions and read
patient notes, view x-rays and test results
from the console. The patient can see the
doctor’s image on the robot’s face.
Parv Sains, Surgical Specialist registrar and
Research Fellow, who leads the project,
said benefits include allowing patients
direct access (for consultation) to experts
worldwide and to the doctor who per-
formed their surgery even if they cannot be
physically at the patient’s bedside.
Dr. Sains said:
“Our robots certainly would never replace
all doctors on ward rounds, but they are a
communication tool with allows doctors to
have direct contact with their patient if they
are unable to get to them.”
The RP6 was developed by In Touch
Health, a US robotics company. Trials of
the robots are taking also place in the UAA
(3) and in Strassbourg (1).
The robot runs on a wireless system with
the doctor at another location. It is con-
trolled by a secure internet connection, the
doctor (controller) and patient are able to
have a real time two way audiovisual inter-
action, with the controller in full command
of the robot’s movements.
This first trial in the United Kingdom is the
latest strand in pioneering integration of
robots into healthcare Professor Sir Ara sur-
geon at St. Mary’s Hospital, who is the
head of Imperial’s Division of Surgery,
Anaesthetics and Intensive care.
Professor Darzi added “This revolutionary
concept which opens new avenues for
telemedicine research an integrates technol-
ogy with healthcare at the grass roots level,
increasing the interface between patients,
clinicians and teaching staff.”
Four genes on chromosome 8 have been
discovered by Professor Caldas and his
researchers at Cambridge University which
appear in breast cancer tumours but not in
normal tissue. During the 1990s defects in
the breast cancer tumour suppressor genes
were established as the major cause of
hereditary or familial breast cancer. Now
mutations of genes within tumours have
been discovered linking cancer to the envi-
ronmental and non-hereditary forms of
breast cancer. Nevertheless scientists are
still puzzling over why these genes are so
rarely mutated in sporadic forms of the dis-
ease, which represent the vast majority of
cases.
Aggressive tumours
Why should breast cancer, in terms of its
metastasis, be so aggressive in its attack on
other organs when its cells are transported
round the body? The disease is known to be
triggered by faulty genes, and now we have
the technology to isolate rogue gene muta-
tions in tumours from hundreds of other
genes which are also present. Making mul-
tiple copies of gene sequences could lead
ultimately to sensitive diagnostic tests for
cancer and treatments that work far more
effectively.
According to Professor Tony Kouzarides of
Cancer Research UK, a protein binding on
the BRCA2 breast cancer gene, in a region
deleted in cancer, might itself be involved
in the cancer process. Such a gene, known
as EMSY, has been mapped to a large
region on chromosome 11, at q13.5, which
is amplified in many breast cancers. An
antibody has been raised against EMSY
which could mean further diagnostic
progress, but to date the gene hasn’t been
persuaded to over-express itself or been
knocked out by a new technique known as
RNA interference. However it has been
shown to be involved in DNA repair and in
transcriptional control. A search of
BRCA2’s lengthy DNA sequence could
reveal similarities to other known genes,
Medical Science, Professional Practice and Education
76
Detection Of Faulty Genes In Breast Cancer
which would provide clues as to its func-
tion. It turned out that there was a similari-
ty between a small region of BRCA2 and a
transcription factor. Such a finding is clini-
cally important, because it is known that
this sequence in BRCA2 is deleted in
patients with familial breast cancer.
Mapping studies confirmed that the func-
tion of the EMSY gene lay in the binding of
methylated chromatin in the chromosome,
which links EMSY to specific signals
recognised by the nuclear transcription
machinery.
EMSY as a cancer gene
Professor David Huntsman’s group in
Vancouver have analysed very large num-
bers of tumour samples. EMSY was ampli-
fied in 13% of breast cancers and 17% of
ovarian cancers – another particularly
aggressive tumour – with a clinical profile
that perfectly mirrored deletions of BRCA2
in hereditary cancers. It was found that
breasts cancer patients, in whose tumours
EMSY was amplified, lived on average for
a further 6.4 years, compared with 14 years
otherwise, which suggests that EMSY has
the potential when cloned up to be a very
useful prognostic marker.
Ivan M. Gillibrand
IAEA Programme of Action for Cancer Therapy (PACT)
Building Capacity for Radiation Therapy in
Developing Countries
Werner Burkart, G. Gellert, M.D. Rosenthal, Massoud Samiei, Susan Snyder
and Bhadrasain Vikram
Abstract
World Health Organization (WHO) data
predict a growing cancer epidemic, espe-
cially in the developing world. In 2003,
WHO issued a global call to action to
address increasing cancer needs. The
International Atomic Energy Agency
(IAEA) answered this call in June, 2004,
and established the Programme of Action
for Cancer Therapy (PACT). The IAEA has
long standing experience in developing
countries with the delivery of technical
assistance related to cancer detection and
treatment through nuclear technologies.
PACT is designed to respond to the needs of
developing countries by addressing the
technical, human resource, legal, and regu-
latory needs to establish, improve, or
expand radiotherapy programs in the con-
text of sound national cancer control
strategies. PACT invites organisations
sharing this interest in advancing cancer
control in developing nations to partner
with the IAEA and others in a global effort
to respond immediately and effectively to
the WHO call to action.
Cancer in the Developing
World
Cancer is a global problem today, and its
prevalence will increase dramatically over
the next decade, especially in the developing
world. According to the World Health
Organization (WHO), 12.5% of all deaths
world-wide are currently caused by cancer, a
greater percentage than caused by
HIV/AIDS, tuberculosis, and malaria com-
bined. (1) And while cancer is often viewed
as primarily a disease affecting the advanced
industrialized states, where it is already the
second leading cause of death, it is among
the three leading causes of death for adults in
the developing world. (1)
Based on recent incidence and mortality
data, in 2000, there were 10.1 million new
cancer cases, 6.2 million deaths and 22.4
million persons living with cancer. (2) This
represents an increase of 19% in incidence
and 18% in mortality since 1990. The
International Agency for Research on
Cancer (IARC) data predict that cancer rates
could further increase by 50% from 10 mil-
lion new cases in 2000 to 15 million new
cases by 2020. (1) The largest rates of
increase of new cases are foreseen to occur
in developing countries, where governments
are least prepared to address the growing
cancer burden. (1) This dramatic increase
will result, in part, from changing demo-
graphics with steadily aging populations in
developing countries, as well as current
trends in smoking prevalence and the grow-
ing adoption of unhealthy lifestyles and
behaviours. (2)
Cancer varies between developing and
developed nations in both incidence and site.
Cancers associated with infectious agents,
including cancers of the stomach, uterine
cervix, and liver, impact more heavily on
populations in developing countries. (2) The
developed world has a higher incidence of
colorectal and prostate cancers. The differ-
ences are attributable to many factors,
including tobacco use and diet. (2) Up to 25
percent of malignancies in the developing
world are caused by infectious agents, while
in developed countries these malignancies
account for only about 8 percent. (2) This
difference is especially large for cervical
cancer. In developed countries, early detec-
tion has led to impressive cure rates, to such
that among cancer deaths, the death rate
from cervical cancer is more than 4 times
higher in the developing world than it is in
developed countries.
Tobacco use, a leading cause of cancer,
stroke, chronic lung, and cardiovascular
disease, is also on the increase in the devel-
oping world. In the 20th
century, approxi-
mately 100 million people died from tobac-
co-related diseases, including cancer. (3)
Almost half of all men in developing coun-
tries now smoke, and the tendency of youth
around the world to start smoking at
younger and younger ages is alarming. (4)
The data are unequivocal: a cancer epidem-
ic is emerging in the developing world.
Action to stem the increase, manage the
growing burden of morbidity, and reduce
the suffering caused by cancer in the devel-
oping world should begin immediately.
Indeed, the World Health Organization has
called for action from all sectors, public and
private, in a global effort against cancer.
The International Atomic Energy
Agency and Promotion of Human Health
and Development
The International Atomic Energy Agency
(IAEA) is highly regarded for its successful
long-term effort in safeguarding nuclear
material and preventing nuclear prolifera-
tion. The IAEA is less well known for
advancing development in the areas of agri-
culture, nutrition, water, and health. Since its
inception, the IAEA has had a dual mandate:
containing the spread of nuclear weapons
while advancing the peaceful application of
nuclear sciences and technology. Over the
past five decades, nuclear applications have
expanded to become an almost ubiquitous
factor in daily life, especially in the devel-
oped world. Around the globe, nuclear tech-
nologies are used widely to support industri-
al applications and to combat disease, pover-
ty, hunger and a shortage of drinking water.
Radiation medicine, including the diagnosis
and treatment of cancer, is an area where
the IAEA has excelled in the past 50 years.
The IAEA is the only international organi-
sation with the specific mandate to “accel-
erate and enlarge” (5) the use of nuclear and
radiation techniques for the prevention,
diagnosis, and treatment of health prob-
lems. Nuclear techniques play a major role
in modern medicine. They are important
tools for the diagnosis and treatment of
many diseases and are indispensable in
fighting cancer, where radiation therapy
plays a fundamental role. Alone or in com-
bination with surgery and/or chemotherapy,
radiation therapy is recommended for the
majority of cancer patients, although this
can vary by country or region.
The IAEA has solid technical and manage-
rial experience in working in developing
countries over the past 30 years to develop
and deploy essential elements of sound can-
cer management programmes. Since 1980,
the IAEA has delivered to developing coun-
tries some $150 million worth of cancer-
related assistance under its Technical
Cooperation programme. This assistance
has involved over a 100 countries and has
enabled many of them to establish for the
first time safe and effective radiotherapy
capabilities. (Figure 1 – World Map show-
ing IAEA assistance in RT transfer)
However, in order to meet the ever growing
needs placed on developing countries by
the burgeoning cancer epidemic, much
more needs to be done. More staff needs to
be trained, diagnostic and treatment tech-
nology needs to be in place, and at least
hundreds of millions of additional dollars
need to be raised over the next 10 years.
Although it is anticipated that the IAEA’s
support for cancer programmes will remain
significant, at about $15 million per year,
the resources available to the IAEA fall
well short of what is needed to meet the
growing needs of developing countries.
Programme of Action for Cancer
Therapy (PACT)
In the light of rapidly increasing rates of
cancer in the developing world, in June,
2004, the IAEA launched a Programme of
Action for Cancer Therapy (PACT). This
new programme offers a crucial element in
the global response to the growing cancer
burden. Radiotherapy is a mature, robust
and cost-effective technology that can,
depending on stage of presentation, cure
many cancer patients and relieve many oth-
ers’ suffering. Currently, radiotherapy is not
available to most cancer patients in the
developing world.
PACT is designed to respond to the needs of
developing countries by addressing the
technical, human resource, legal, and regu-
latory needs to establish, improve, or
expand radiotherapy programmes in the
context of sound national cancer control
strategies. PACT will develop a systematic,
global, sustainable and accountable pro-
gramme to prevent and treat cancer and
Medical Science, Professional Practice and Education
77
relieve the pain and suffering of cancer
patients throughout the developing world.
Specifically PACT will: (a) build an inter-
national, public-private coalition of inter-
ested parties committed to addressing the
challenge of cancer in developing countries
in all of its aspects; and (b) mobilize
resources from foundations, charitable
trusts, industry and others in the public and
private sectors for the benefit of cancer
patients. PACT will build partnerships
among countries, with other UN institutions
such as WHO and IARC, and other interna-
tional stakeholders. In addition to securing
resources for radiotherapy centres, PACT
will respond to the most frequent problems
encountered by developing countries in
building effective cancer control infrastruc-
ture. In order to assist countries in the
analysis of options and to put in place can-
cer therapy programmes appropriate to
their needs: PACT will:
• Increase capacity within ministries of
health and other health sector institutions,
to formulate policies and set priorities for
investments in radiotherapy. According to
WHO, “many policy makers do not
attach enough importance to the provi-
sion of good radiotherapy.Although it has
a strong clinical background, its role has
not been understood as well as other can-
cer treatment modalities such as surgery
and chemotherapy.”(6)
• Provide training, management skills and
other resources that will help institutions
leverage the initial investments in trained
staff and equipment towards safe, effec-
tive, and sustainable operations.
• Promote the development and imple-
mentation of effective, well balanced
national strategies for cancer control,
including generation of surveillance data
to ascertain local cancer disease bur-
dens, care needs, and outcomes.
• Enhance technical, legal and administra-
tive capabilities to establish and imple-
ment regulatory systems, including
those appropriate for radiation protec-
tion, safety and security.
Specifically, PACT will meet the needs of
developing countries because it will:
• Strengthen national programmes for
cancer control.
• Enable health sector institutions to
design and support the implementation
of policies and projects for the sound
application of radiation therapy.
• Establish radiotherapy centres in each
developing country appropriate to its
needs and national cancer control strate-
gy, taking into account economic and
demographic factors.
• Establish centres of excellence for radia-
tion therapy that will serve as training
sites for regions served by PACT.
• Review the status of radiation protection,
safety, and security arrangements at
national and local levels, and, as needed,
help nations put in place the technical,
legal, and regulatory capacities appropriate
to take best advantage of radiation therapy.
• Promote strategic partnerships between
countries in cancer therapy and in their
national research, education, and regula-
tory systems at the sub-regional and
regional levels; between national and
international organizations; and between
the public and private sectors that are
both South-South as well as North-South.
Most importantly, the investment of signif-
icant resources to advance cancer preven-
tion and therapy in developing countries
will save untold lives and relieve suffering.
Call To Collaboration
PACT invites organisations sharing this
interest in advancing cancer care in develop-
ing nations to partner with the IAEAand oth-
ers in a global effort to respond immediately
and effectively to the WHO call to action.
PACT seeks organisations with pertinent
developing world experience and capability
in cancer control, including, but not limited
to radiation oncology, cancer screening and
diagnosis, cancer prevention programmes,
fundraising, programme impact evaluation
and outcomes research. Interested parties
should contact PACT at PACT@iaea.org to
learn more, or volunteer support.
References
1. Global Action Against Cancer, World
Health Organisation, International Union
Against Cancer (2005)
2. World Cancer Report, World Health
Organization, International Agency for
Research on Cancer (2003)
Medical Science, Professional Practice and Education
78
3. World Health Organization, Press
Release, Geneva, 3 April 2003 “Global
Cancer Rates Could Increase by 50% to 15
Million by 2020”
4. Sener, Stephen F., “Disease Without
Borders,” CA A Cancer Journal for
Clinicians (2005) Vol. 55
5. IAEA Statute, Article 2, “The Agency
shall seek to accelerate and enlarge the con-
tribution of atomic energy to peace, health
and prosperity throughout the world.”
A Global Strategy for Radiotherapy: A
WHO Consultation, Clinical Oncology
WHO
79
The World Health Organization (WHO)
Regional Committee for Africa comprising
health ministers from 46 Member States
has declared tuberculosis an emergency in
the African region – a response to an epi-
demic that has more than quadrupled the
annual number of new TB cases in most
African countries since 1990 and is contin-
uing to rise across the continent, killing
more than half a million people every year.
The declaration was made in a resolution
adopted today at the end of the Committee’s
fifty-fifth session in Maputo, Mozambique.
The resolution urges Member States in the
African Region to commit more human and
financial resources to strengthen DOTS pro-
grammes and scale up collaborative inter-
ventions to fight the co-epidemic of TB and
HIV. These and other measures recom-
mended by the Committee encompass those
laid out in a “blueprint” developed by the
global Stop TB Partnership, which calls for
US $2.2 billion in new funding for TB con-
trol in Africa during 2006-2007.
“Despite commendable efforts by countries
and partners to control tuberculosis, impact
on incidence has not been significant and
the epidemic has now reached unprecedent-
ed proportions,” said WHO Regional
Director for Africa, Dr. Luis Gomes
Sambo. “Urgent and extraordinary actions
must be taken, or else the situation will only
get worse and the TB targets in the Abuja
Declaration and the Millennium
Development Goals will not be achieved.”
In the late 1970s and early 1980s, African
countries like Tanzania, Mozambique and
Malawi were among the first to apply what
became the global TB control strategy now
known as DOTS. But in the past 15 years,
TB incidence rates have soared in the
region – to as high as four-fold in Malawi
and five-fold in Kenya, to cite some typical
examples -due largely to the link with
HIV/AIDS, poverty and weak health sys-
tems. Although countries have made efforts
to treat the rising tide of TB cases, they are
still being outpaced by the epidemic.
“It is tragic that this disease has not been
brought under control, because I am living
proof that TB can be effectively treated and
cured,” said Nobel laureate Archbishop
Desmond Tutu, who along with former
South African President Nelson Mandela is
a survivor of the disease. “The problem is
huge and medical authorities cannot over-
come it alone, they need help. A full course
of TB drugs that costs 15 dollars will save
the lives of TB patients – and in the case of
people who are co-infected with HIV,
extend their lives by precious years until
ARVs become more widely available in
Africa.”
Among the constraints to fighting the epi-
demic cited in the Maputo meeting is the
inadequate financial support currently
available for TB control. A large majority
of African countries that provided financial
data to WHO in 2003 reported funding
gaps, including eight of the nine countries
with the highest TB burden.
But more financial resources alone will not
solve the TB problem. Dedicated efforts
must also be made to strengthen health sys-
tems and respond to the crisis of health
workforce attrition in the region. The specif-
ic actions called for by the Regional
Committee to address the TB emergency are:
• improve the quantity and quality of staff
involved in TB control;
• rapidly improve TB case detection and
treatment success rates with expanded
DOTS coverage at national and district
levels;
• reduce the combined TB patient default
and transfer out rates to 10% or less;
• scale up interventions to manage TB and
HIV together, including increased access
to anti-retroviral therapy for TB patients
who are co-infected with HIV, and to
chemoprophylaxis against TB for people
with HIV;
• expand national TB partnerships, public-
private collaboration and community
participation in TB control activities.
In the other four WHO regions of the world,
TB trends are either stable or in decline and
are on track to reach the MDG targets of
halving TB prevalence and deaths by 2015.
WHO
WHO declares TB an emergency in Africa and
Calls for “urgent and extraordinary actions”
to halt worsening epidemic
Models of Disease
Geneva 3 August 2005 – Statement
The World Health Organization welcomes
the pandemic influenza response modelling
papers published in the journals Science
and Nature 3rd
August 2005. This is work
done by expert scientists using two differ-
ent sets of assumptions. The models pro-
vide additonal information which will help
WHO and public health officials in our
Member States to improve pandemic
influenza preparedness planning.
Both papers suggest that a combination of
early, targeted use of antiviral medicines and
social distancing (measures such as can-
celling mass gatherings and closing schools)
can stop a pandemic, or at least slow its
spread. There would be significant practical
challenges to implementing such measures,
but the enormous social trauma and human
suffering that an influenza pandemic could
inflict creates an obligation to thoroughly
explore all proposals to limit this damage.
Several countries have already purchased
stockpiles of antiviral drugs and WHO has
taken steps to establish an international stock-
pile. National and international stockpiles of
antiviral drugs may be an essential compo-
nent of comprehensive international pandem-
ic preparedness, that also includes vaccine
development and disease surveillance.
If we have a chance to reduce the scale of a
pandemic with antivirals and other public
health measures, the success of these inter-
ventions will depend on effective disease
surveillance and early reporting in risk-
prone countries. Before any stockpile can
be used effectively, both must be strength-
ened.
WHO
80
To combat Indonesia’s largest recorded
polio epidemic, which now threatens a
broad swath of countries across Asia, on 30
August, 24 million children were to be
immunized during the country’s largest-
ever mass immunization campaign.
Since March, 225 children have been paral-
ysed, due to a poliovirus imported into the
country earlier this year. Initially restricted
to two provinces on Java island (Banten
and West Java provinces), the outbreak is
geographically expanding, recently infect-
ing the country’s capital Jakarta, as well as
Sumatra and Central Java.
“In addition to paralysing children through-
out Java and southern Sumatra, the outbreak
continues to expand, and there is great risk
that it could spread into neighbouring coun-
tries,” confirmed Dr David Heymann,
Representative for Polio Eradication at the
World Health Organization (WHO), who
recently returned from Jakarta. “As with
other infectious diseases, the poliovirus does
not respect borders. The Government of
Indonesia has assured the polio partners that
it is fully engaged and committed to stop-
ping this outbreak, and to doing everything
it can to prevent further international spread
of the virus.”
The polio eradication partnership is urgent-
ly scaling-up both technical and financial
assistance to the Indonesia authorities.
Leading the civil society sector charge is
Rotary International, which has raised
more than US$600 million for polio eradi-
cation since 1985.
“We are more than ever committed to the
attainment of a polio-free world,” com-
mented Frank J Devlyn, Chairman, The
Rotary Foundation. “Concerned Rotarians
are mobilising across Asia. Rotarians from
Malaysia, Thailand and Singapore are join-
ing their fellow Rotary members in
Indonesia in supporting these important
activities.”
“Reaching every, single child requires a
massive communication effort, in high-
lighting to parents the dangers of the cur-
rent polio outbreak and of the need to
immunize every child,” said Alan Court,
Director of UNICEF’s Programme
Division. “This is our best chance to pro-
tect Indonesia’s children, safeguard vulner-
able children across the region, and keep a
polio-free world within our sight.”
The campaign on 30 August will be fol-
lowed by additional immunization rounds
on 27 September and early November.
Indonesia launches country’s largest-ever
immunization campaign to tackle expanding
polio epidemic
Partnerships Working for Health Forum
In announcing a WHO Forum on
Partnership, WHO states that the proposed
theme will be “Making Partnerships work
for Health”, with subsidiary illustrative
themes of “Preventing Chronic Diseases”,
“Human Resources for Health” and
“Making every mother and child count” –
the theme of this year’s World Health report
and World Health Day.
“Human resources for Health” is the sub-
ject of the World Health report and World
Health Day in 2006, which will also mark
the beginning of a decade of action on this
theme. The WHO, which, for the first time
has offered open consultation encouraging
broad participation on the 2006 World
Health report theme via e-mails and the
web, stresses that the WHO workforce is
crucial to scaling up health interventions to
meet the MDG health goals. Pointing out
that a common problem is overall health
workforce shortage, it says that this is
aggravated by in-balanced distribution
between urban and rural areas. This all
leads to low productivity and is made worse
by inadequate investment and pre-service
training, work overload, inadequate remu-
neration and negative working conditions.
An interim working group has already been
formed to explore workforce problems fac-
ing leaders, which call for long term strate-
gies and high level commitment.
The Forum, to be held on 26-28 October,
will involve UN organisations, NGO’s, pro-
fessional and research institutions, as well
as private sector entities.
Geneva – The World Health Organization
has joined the United Nations in supporting
the mean message of the Millennium
Development Goals Report 2005: Despite
uneven progress towards achieving the
global development goals, they are still
achievable with determination, renewed
commitment and immediate concerted
action from global leaders.
Progress on the health-related Millennium
Development Goals (MDGs) is mixed and
if current trends continue, most poor coun-
tries will not meet these goals. However,
investing in proven solutions can still turn
the tide and help to achieve the goals.
“We have the means to achieve those goals.
We have the technology. What we need are
the resources and the political will”, said Dr
LEE Jong-wook, WHO Director-General.
“We cannot wait any longer to do what we
have promised to achieve in the coming
decade.”
No region of the developing world is cur-
rently on track to meet the child mortality
target of reducing by two-thirds the mortal-
ity rate of children under the age of five.
For maternal mortality, evidence indicates
that declines have been limited to countries
with lower levels of mortality; countries
with high maternal mortality are experienc-
ing stagnation or even reversals.
Data on coverage of some health interven-
tions are more hopeful. For example, the
proportion of women who have a skilled
medical person with them during delivery
has increased rapidly in some regions –
especially in Asia, albeit from a low base-
line; use of insecticide-treated bednets has
risen; and coverage of effective tuberculo-
sis treatment has expanded.
In June 2005, WHO launched its own MDG
report, Health in the Millennium
Development Goals, which looks beyond
the target-by-target information and identi-
fies trends, successes and failures which are
currently affecting the health sector as a
whole.
In September 2000, 189 world leaders
signed the Millennium Declaration, and
made a commitment to achieve the
Millennium Development Goals by 2015.
Three of the eight goals relate directly to
health: to reduce maternal mortality by
three-quarters, child mortality by two-thirds
and combat HIV/AIDS, malaria and other
diseases. Health is an essential component
of three further targets: to halve the propor-
tion of people who suffer from hunger,
improve access to safe drinking water and
sanitation and ensure affordable, safe
access to essential drugs.
WHO
81
Concerted Action to Achieve The Millennium
Development Goals
The 6th
Global Conference on Health
Promotion. Thailand, 7-11 August, adopted
a new Bangkok Charter for Health
Promotion. It identifies major challenges,
actions and the commitments needed to
address the determinants of health in a
globalized world by engaging the many
actors and stakeholders critical to achieving
health for all.
The Charter highlights the changing con-
text of global health and the challenges
faced in achieving its aims, including the
growing double burden of communicable
and chronic diseases which include heart
disease, stroke, cancer and diabetes. There
is also the need to address and harness the
health effects of globalization such as
widening inequities, rapid urbanization and
the degradation of environments.
The Bangkok Charter gives new direction
to Health Promotion by calling for policy
coherence, investment and partnering
across governments, international organiza-
tions, civil society and the private sector to
work towards four key commitments.
These include ensuring that health promo-
tion is central to the global development
agenda, that it is a core responsibility of all
governments and part of good corporate
practice, as well as a focus of community
and civil society initiatives.
“The Bangkok Charter for Health
Promotion will be the product of many
organizations, networks, groups and indi-
viduals in many countries. It will urge all
stakeholders to work together in a world-
wide partnership to fulfill its commitments
and carry out its strategies,” said Dr. LEE
Jong-wook, Director-General of the World
Health Organization in his opening address
to the conference. “The action you take in
the light of this Charter can radically
New Bangkok charter for health promotion adopted to address rapidly
changing global health issues
A new project targeting the increasing
resistance of some viruses to drugs is being
funded with the help of nine million euros
under the Life Sciences, Genomics and
Biotechnology for Health area of the EU’s
Framework Programme.
The VIRGIL (Vigilance against Viral
Resistance) project brings together experts
from 55 organisations in 12 European
countries to examine the problems being
faced in treating certain diseases. Many of
these problems have been caused by heavy
use of antivirals in treating viruses and this
is resulting in a growing number of muta-
tions in viruses that are becoming increas-
ingly resistant to drugs.
VIRGIL draws on the experience of the top
academic researchers within Europe as well
as the pharmaceutical industry, clinicians
and public health authorities to help save
lives by overcoming the problems associat-
ed with viral drug resistance.
“Acute and chronic viral infections repre-
sent a major public health problem in
Europe and are responsible for a major
socio-economical burden”, says Howard
Thomas, Professor of Medicine at Imperial
College. “The development of new antivi-
ral drugs and new diagnostic tools in the
past decade has played a major role in the
improvement of patient care and treatment
of viral diseases to extend the quality and
duration of human life. However, their
increased use – and sometimes misuse – in
medicine have brought about viral drug
resistance. This has led to treatment failure
and increased costs for health care and soci-
ety.”
improve the prospects for health in com-
munities and countries around the world.”
The Charter was developed through an
open consultation process involving partic-
ipants from a wide range of groups and
organizations around the globe. The discus-
sion was concluded at the conference this
week, attended by 700 participants from
more than 100 countries including leading
Health Promotion experts, government pol-
icy makers, non-governmental organiza-
tions, health specialists and representatives
from the private sector.
The Ottawa Charter of 1986 established the
core principles of Health Promotion which
seek to identify and positively affect the
root causes, or determinants, of health.
These are social and economic factors that
determine health status such as income,
education, profession, working conditions,
mental status, which in turn can affect risk
factors such as smoking, alcohol consump-
tion, eating habits and physical inactivity.
Health Promotion works to enable people
to increase control over their health and its
determinants by developing personal skills,
embracing community action, and foster-
ing appropriate public policies, health ser-
vices and supportive environments. Health
Promotion is currently guiding global,
national and community health policies,
thereby contributing to reducing health
risks. The WHO Framework Convention
on Tobacco Control and The WHO Global
Strategy on Diet, Physical Activity and
Health represent just two examples of such
activity.
Nevertheless major inequities persist glob-
ally, particularly in the developing world.
Speaking at the Bangkok conference,
Professor Sir Michael Marmot, Chair of
WHO’s Commission on the Social
Determinants of Health, identified a funda-
mental concern: “It is not inevitable that
there should be a spread of life expectancy
of 48 years among countries and 20 years
or more within countries. A burgeoning
volume of research identifies social factors
at the root of much of these inequalities in
health.” The challenge of the Bangkok
Charter has been to determine how best to
respond to the many global changes and
trends that are critically affecting health
Regional and NMA News
82
and well-being and how to evolve Health
Promotion strategies to address these
inequalities and to be more relevant to the
demands of the new millennium.
The conference has also examined many
issues pertaining to these challenges.
Discussion ranged from trade agreements
and public health to the regulation of prod-
ucts harmful to health, and from the health
experience of marginalized groups to the
role of private sector foundations. The con-
ference proved a valuable forum for dis-
seminating results and lessons learnt of the
effectiveness of Health Promotion and how
to evolve these to better address ongoing
inequalities.
Speaking at the opening ceremony of the
conference, the Prime Minister of Thailand,
H. E. Pol. Lt. Col. Dr. Thaksin Shinawatra,
noted, “It is clear that good health is a key
to progress. In those societies where people
are healthy, such communities are sure to
progress in many ways. Building health has
thus become a priority on national and
global agendas.”
Information contact:
Mike Shaw
Conference Communications Coordinator,
Telephone: + 66 9 534 5177
Jane McElligott
Communications Officer,
Telephone: +41 22 791 3353
Email: mcelligottj@who.int
Regional and NMA News
EU Project Targets Killer Viruses
83
Regional and NMA News
“As there is no global programme to devel-
op strategies for the surveillance and con-
tainment of viral resistance to antiviral
agents, there is a clear need to implement a
European programme to optimise patients
care and to minimise emergence and spread
of antiviral drug resistance. The overall
objective of the VIRGIL Network of
Excellence is to set up the first-ever
European Vigilance Network capable of
addressing current and emerging antiviral
drug resistance developments that will
allow for the management of this critical
problem in Europe.”
Initially, VIRGIL will be looking into drug
resistance in the treatment of three major
diseases – hepatitis B and C and influenza.
Research shows that more than 520 million
people around the world are chronically
infected by hepatitis viruses (B or C). In
addition, new strains of influenza cause up
to 500,000 deaths every year worldwide.
However, it is intended to broaden the viral
scope later in the project, to treat further
diseases VIRGIL is being built around
seven “research and technological plat-
forms” all centred around the patients. Two
of them will test and monitor antiviral drug
resistance in patients with the aim of
improving and standardising the manage-
ment of viral resistance on a global level.
Other platforms will look to find the rea-
sons for the increasing drug resistance with
particular focus on patient-related factors.
The project will also investigate how drugs,
pharmacology, innovation and technology
can be brought together to anticipate ways
which will beat drug resistance.
“Viral resistance is becoming a major
health problem”, says Claire Horton,
FP6UK’s National Contact Point for Life
Sciences, Genomics and Biotechnology for
Health. “The VIRGIL project complements
a 30 million Euro EU research investment
into antimicrobial drug resistance over the
past two years to address this growing prob-
lem.”
information on the VIRGIL project visit
http://www.virgil-net.org.
The Canadian Medical Association reports
that after a period during which there has
been a fall – off in the number of new grad-
uates choosing Family Medicine as a career
choice, the latest figures indicate some
increase. In the first quarter of this year the
residency match indicated that 28% of
graduating students from English language
medical schools made family medicine
their first choice in 2005. Whilst this is far
from the 35% level achieved in 1997 it is
an improvement. It shows an improvement
on the low of 24% two years ago. Dr.
Gutkin Chief Executive of the College of
Family Physicians of Canada said “Public
survey after public survey reinforces the
fact that patients value having a family
doctor very highly and that Canadians see
the shortage of FPs as one of the nation’s
main health system problems”.
Recent polls indicate that more than three
million Canadians do not have a family
physician.
Family Medicine
recruitment in
Canada
Developments in Kazakhstan (Kazakhstan
Medical Association)
The Kazakhstan Medical Association
(KzMA) established in 1990, continues
its development not only by its represen-
tation on relevant governmental commis-
sions, influencing draft health legislation,
state programmes and projects in health
and other professional activities, but also
by its strong interest and action in the
ethics of biomedical research. It partici-
pated in the Central and Independent
States (CIS) Ethics Commission in 2001,
suggesting the need for a Forum for
Ethics Committees in the CIS which was
subsequently adopted, and holding an
international conference on “Qualitative
Ethical Practice in Biomedical Research”
in 2002. This led to a further initiative,
the Second International Conference in
2005 on “Bioethical Problems in Health
in the Twenty-first century”. The out-
come of this conference was a Resolution
recommending that the Kazakhstan gov-
ernment and other relevant institutions
should institute the development of edu-
cational programmes on ethics and the
establishment of an Ethics and Bioethics
committees. It further considered it nec-
essary to support cooperation on issues
relating to the ethics of science and
bioethics with international organisations
such as the UNESCO, World Health
Organization, the Council of Europe and
other Non-governmental organisations
such as the World Medical Association
and European Forum of Good Clinical
Practice etc. The KzMA has developed a
draft Regulation on National Committees
for Bioethics, which has been submitted
to the government.
84
The Tobacco Control Resource Centre
(TCRC) run by the British Medical
Association and supported by the European
Community and the World Health
Organisation has been awarded a Certificate
of Appreciation by the World Health
Organisation, in recognition of its outstand-
ing contribution to Tobacco Control.
The TCRC is well known not only to NMAs
in the European Region but to NMAs
worldwide, both for its assistance to NMAs
individually and its international seminars
lectures and research. TCRC has produced a
range of important publications, in particu-
lar “Doctors and Tobacco – medicine’s big
challenge” (now translated into nine lan-
guages) and “Doctors and Tobacco: The
Masterclass” which includes the reports
“Smoking and reproductive life”, “Smoke
free World: doctors’notes on clean air laws”
and “Towards smoke-free public places”.
The TCRC is based in the BMA Office in
Edinburgh e-mail: tcrc@bma.org.uk
Regional and NMA News
TCRC receives WHO Certificate of Appreciation
It is unique in these columns to review a
catalogue, but on this occasion the contents
could be so useful to those working in any
field of Healthcare provision, no matter in
which part of the world, that this review is
particularly justified.
The second publication by the WHO
European Regional Office of the second
Information Products Catalogue is a
remarkable document which could easily
be overlooked by those who could benefit
from it. It provides bibliographic data,
including descriptions of the material avail-
able, categorised to reflect the WHO global
database for 130 publications issued in
2003/2004. But even more commendably,
the full text of each publication is available
in the CD ROM which is attached to the
catalogue.
The scatter of topics is vast. The ready
availability of the full material of papers or
books in fields as variable as Chronic
Disease control, Communicable Diseases
and their control, Environmental and Public
Health, Epidemiology and Statistics, Health
Manpower and Planning, Mental Health,
Parasitic Diseases and their control,
Smoking and Health (to mention but a few
of the diverse topics covered by the 18
broad categories under which the 130
reports and books are classified) is indica-
tive of their potential value.
Anyone with an interest in any one of these
areas would be well advised to look at this
catalogue and, if they so wish, access
immediately any relevant documents
whose full text is available in the CD ROM
provided with the Catalogue.
Review
Information Products Catalogue 2003, 2004
(WHO Regional Office for Europe, Copenhagen p. 47 + CD ROM)
Walter Burkart
It is with great regret that we report the
death of Walter Burkart who was for many
years the Co-Editor of the World Medical
Journal.Amulti-linguist, his comments on
the international scene were clear and pen-
etrating. In his activities he was particular-
ly interested in psychiatry and in the pro-
vision of further medical education. The
earlier part of his career was as Editor and
Bonn correspondent of The Hamburg Ad-
vertiser and later among many other activ-
ities Publisher of the Social Press Service
„Bonn Social Politics“ Later he joined the
editorial staff in the scientific division – of
the German Medical Journal (Deutsches
Ärzteblatt) He was a good friend and
colleague to all who knew and worked
with him.
Bomb explodes
outside NMA
building
During the bomb incidents in London in
July, a bomb exploded in a bus immediate-
ly outside the headquarters building of the
British Medical Association, killing 13
people and injuring many more. Hospital
doctors and GPs who were in the building,
led by the Deputy Chairman of Council and
the Deputy Chairman of the General
Practice Committee, converted the building
into an effective and efficient casualty unit
for emergency care. Staff and doctors
joined together to comfort the injured, cre-
ate makeshift stretchers and move the dead
and injured to the safety of the building.
The Chairman of Council who is also
member of WMA Council, commented
“I want to pay a huge tribute to BMA staff
and doctors, who pulled together to help
the victims of this atrocious terrorist act. I
believe that without the skills of our doc-
tors on the scene the death rate would have
been significantly higher.
It is also a tribute to the organisation which
I am honoured to lead, that within a day
plans were made to keep services to mem-
bers functioning even though only a hand-
ful of BMA staff and members were able to
get into our HQ for the next ten days”.
CHINA E
Chinese Medical Association
42 Dongsi Xidajie
Beijing 100710
Tel: (86-10) 6524 9989
Fax: (86-10) 6512 3754
E-mail: suyumu@cma.org.cn
Website: www.chinamed.com.cn
COLOMBIA S
Federación Médica Colombiana
Calle 72 – N° 6-44, Piso 11
Santafé de Bogotá, D.E.
Tel: (57-1) 211 0208
Tel/Fax: (57-1) 212 6082
E-mail: federacionmedicacol@
hotmail.com
DEMOCRATIC REP. OF CONGO F
Ordre des Médecins du Zaire
B.P. 4922
Kinshasa – Gombe
Tel: (242-12) 24589/
Fax (Présidente): (242) 8846574
COSTA RICA S
Unión Médica Nacional
Apartado 5920-1000
San José
Tel: (506) 290-5490
Fax: (506) 231 7373
E-mail: unmedica@sol.racsa.co.cr
CROATIA E
Croatian Medical Association
Subiceva 9
10000 Zagreb
Tel: (385-1) 46 93 300
Fax: (385-1) 46 55 066
E-mail: orlic@mamef.mef.hr
CZECH REPUBLIC E
Czech Medical Association .
J.E. Purkyne
Sokolská 31 – P.O. Box 88
120 26 Prague 2
Tel: (420-2) 242 66 201/202/203/204
Fax: (420-2) 242 66 212 / 96 18 18 69
E-mail: czma@cls.cz
Website: www.cls.cz
CUBA S
Colegio Médico Cubano Libre
P.O. Box 141016
717 Ponce de Leon Boulevard
Coral Gables, FL 33114-1016
United States
Tel: (1-305) 446 9902/445 1429
Fax: (1-305) 4459310
DENMARK E
Danish Medical Association
9 Trondhjemsgade
2100 Copenhagen 0
Tel: (45) 35 44 -82 29/Fax:-8505
E-mail: er@dadl.dk
Website: www.laegeforeningen.dk
DOMINICAN REPUBLIC S
Asociación Médica Dominicana
Calle Paseo de los Medicos
Esquina Modesto Diaz Zona
Universitaria
Santo Domingo
Tel: (1809) 533-4602/533-4686/
533-8700
Fax: (1809) 535 7337
E-mail: asoc.medica@codetel.net.do
ECUADOR S
Federación Médica Ecuatoriana
V.M. Rendón 923 – 2 do.Piso Of. 201
P.O. Box 09-01-9848
Guayaquil
Tel/Fax: (593) 4 562569
E-mail: fdmedec@andinanet.net
EGYPT E
Egyptian Medical Association
„Dar El Hekmah“
42, Kasr El-Eini Street
Cairo
Tel: (20-2) 3543406
EL SALVADOR, C.A S
Colegio Médico de El Salvador
Final Pasaje N° 10
Colonia Miramonte
San Salvador
Tel: (503) 260-1111, 260-1112
Fax: -0324
E-mail: comcolmed@telesal.net
marnuca@hotmail.com
ESTONIA E
Estonian Medical Association (EsMA)
Pepleri 32
51010 Tartu
Tel/Fax (372) 7420429
E-mail: eal@arstideliit.ee
Website: www.arstideliit.ee
ETHIOPIA E
Ethiopian Medical Association
P.O. Box 2179
Addis Ababa
Tel: (251-1) 158174
Fax: (251-1) 533742
E-mail: ema.emj@telecom.net.et /
ema@eth.healthnet.org
FIJI ISLANDS E
Fiji Medical Association
2nd Fl. Narsey’s Bldg, Renwick Road
G.P.O. Box 1116
Suva
Tel: (679) 315388
Fax: (679) 387671
E-mail: fijimedassoc@connect.com.fj
FINLAND E
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Tel: (358-9) 3930 826/Fax-794
Telex: 125336 sll sf
E-mail: fma@fimnet.fi
Website: www.medassoc.fi
FRANCE F
Association Médicale Française
180, Blvd. Haussmann
75389 Paris Cedex 08
Tel: (33) 1 53 89 32 41
Fax: (33) 1 53 89 33 44
E-mail: cnom-international@
cn.medecin.fr
GEORGIA E
Georgian Medical Association
7 Asatiani Street
380077 Tbilisi
Tel: (995 32) 398686 / Fax: -398083
E-mail: Gma@posta.ge
GERMANY E
Bundesärztekammer
(German Medical Association)
Herbert-Lewin-Platz 1
10623 Berlin
Tel: (49-30) 400-456 363/Fax: -384
E-mail: renate.vonhoff-winter@baek.de
Website: www.bundesaerztekammer.de
GHANA E
Ghana Medical Association
P.O. Box 1596
Accra
Tel: (233-21) 670-510/Fax: -511
E-mail: gma@ghana.com
HAITI, W.I. F
Association Médicale Haitienne
1ère
Av. du Travail #33 – Bois Verna
Port-au-Prince
Tel: (509) 245-2060
Fax: (509) 245-6323
E-mail: amh@amhhaiti.net
Website: www.amhhaiti.net
HONG KONG E
Hong Kong Medical Association, China
Duke of Windsor Building, 5th Floor
15 Hennessy Road
Tel: (852) 2527-8285
Fax: (852) 2865-0943
E-mail: hkma@hkma.org
Website: www.hkma.org
HUNGARY E
Association of Hungarian Medical
Societies (MOTESZ)
Nádor u. 36
1443 Budapest, PO.Box 145
Tel: (36-1) 312 3807 – 311 6687
Fax: (36-1) 383-7918
E-mail: motesz@motesz.hu
Website: www.motesz.hu
ICELAND E
Icelandic Medical Association
Hlidasmari 8
200 Kópavogur
Tel: (354) 8640478
Fax: (354) 5644106
E-mail: icemed@icemed.is
INDIA E
Indian Medical Association
Indraprastha Marg
New Delhi 110 002
Tel: (91-11) 337009/3378819/3378680
Fax: (91-11) 3379178/3379470
E-mail: inmedici@vsnl.com /
inmedici@ndb.vsnl.com
INDONESIA E
Indonesian Medical Association
Jalan Dr Sam Ratulangie N° 29
Jakarta 10350
Tel: (62-21) 3150679
Fax: (62-21) 390 0473/3154 091
E-mail: pbidi@idola.net.id
IRELAND E
Irish Medical Organisation
10 Fitzwilliam Place
Dublin 2
Tel: (353-1) 676-7273
Fax: (353-1) 6612758/6682168
Website: www.imo.ie
ISRAEL E
Israel Medical Association
2 Twin Towers, 35 Jabotinsky St.
P.O. Box 3566, Ramat-Gan 52136
Tel: (972-3) 6100444 / 424
Fax: (972-3) 5751616 / 5753303
E-mail: estish@ima.org.il
Website: www.ima.org.il
JAPAN E
Japan Medical Association
2-28-16 Honkomagome, Bunkyo-ku
Tokyo 113-8621
Tel: (81-3) 3946 2121/3942 6489
Fax: (81-3) 3946 6295
E-mail: jmaintl@po.med.or.jp
KAZAKHSTAN F
Association of Medical Doctors
of Kazakhstan
117/1 Kazybek bi St.,
Almaty
Tel: (3272) 62 -43 01 / -92 92
Fax: -3606
E-mail: sadykova-aizhan@yahoo.com
REP. OF KOREA E
Korean Medical Association
302-75 Ichon 1-dong, Yongsan-gu
Seoul 140-721
Tel: (82-2) 794 2474
Fax: (82-2) 793 9190
E-mail: intl@kma.org
Website: www.kma.org
KUWAIT E
Kuwait Medical Association
P.O. Box 1202
Safat 13013
Tel: (965) 5333278, 5317971
Fax: (965) 5333276
E-mail: aks.shatti@kma.org.kw
LATVIA E
Latvian Physicians Association
Skolas Str. 3
Riga
1010 Latvia
Tel: (371-7) 22 06 61; 22 06 57
Fax: (371-7) 22 06 57
E-mail: lab@parks.lv
LIECHTENSTEIN E
Liechtensteinischer Ärztekammer
Postfach 52
9490 Vaduz
Tel: (423) 231-1690
Fax: (423) 231-1691
E-mail: office@aerztekammer.li
Website: www.aerzte-net.li
LITHUANIA E
Lithuanian Medical Association
Liubarto Str. 2
2004 Vilnius
Tel/Fax: (370-5) 2731400
E-mail: lgs@takas.lt
LUXEMBOURG F
Association des Médecins et
Médecins Dentistes du Grand-
Duché de Luxembourg
29, rue de Vianden
2680 Luxembourg
Tel: (352) 44 40 331
Fax: (352) 45 83 49
E-mail: secretariat@ammd.lu
Website: www.ammd.lu
Association and address/Officers
ii
Association and address/Officers
iii
MACEDONIA E
Macedonian Medical Association
Dame Gruev St. 3
P.O. Box 174
91000 Skopje
Tel/Fax: (389-91) 232577
MALAYSIA E
Malaysian Medical Association
4th Floor, MMA House
124 Jalan Pahang
53000 Kuala Lumpur
Tel: (60-3) 40418972/40411375
Fax: (60-3) 40418187/40434444
E-mail: mma@tm.net.my
Website: http://www.mma.org.my
MALTA E
Medical Association of Malta
The Professional Centre
Sliema Road, Gzira GZR 06
Tel: (356) 21312888
Fax: (356) 21331713
E-mail: mfpb@maltanet.net
Website: www.mam.org.mt
MEXICO S
Colegio Medico de Mexico
Fenacome
Hidalgo 1828 Pte. Cons. 410
Colonia Obispado C.P. 64060
Monterrey, Nuevo Léon
Tel/Fax: (52-8) 348-41-55
E-mail: fenacomemexico@usa.net
Website: www.fenacome.org
NEPAL E
Nepal Medical Association
Siddhi Sadan, Post Box 189
Exhibition Road
Katmandu
Tel: (977 1) 225860, 231825
Fax: (977 1) 225300
E-mail: nma@healthnet.org.np
NETHERLANDS E
Royal Dutch Medical Association
P.O. Box 20051
3502 LB Utrecht
Tel: (31-30) 28 23-267/Fax-318
E-mail: j.bouwman@fed.knmg.nl
Website: www.knmg.nl
NEW ZEALAND E
New Zealand Medical Association
P.O. Box 156
Wellington 1
Tel: (64-4) 472-4741
Fax: (64-4) 471 0838
E-mail: nzma@nzma.org.nz
Website: www.nzma.org.nz
NIGERIA E
Nigerian Medical Association
74, Adeniyi Jones Avenue Ikeja
P.O. Box 1108, Marina
Lagos
Tel: (234-1) 480 1569,
Fax: (234-1) 493 6854
E-mail: info@nigeriannma.org
Website: www.nigeriannma.org
NORWAY E
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
Tel: (47) 23 10 -90 00/Fax: -9010
E-mail: ellen.pettersen@
legeforeningen.no
Website: www.legeforeningen.no
PANAMA S
Asociación Médica Nacional
de la República de Panamá
Apartado Postal 2020
Panamá 1
Tel: (507) 263 7622 /263-7758
Fax: (507) 223 1462
Fax modem: (507) 223-5555
E-mail: amenalpa@sinfo.net
PERU S
Colegio Médico del Perú
Malecón Armendáriz N° 791
Miraflores
Lima
Tel: (51-1) 241 75 72
Fax: (51-1) 242 3917
E-mail: decano@colmedi.org.pe
Website: www.colmed.org.pe
PHILIPPINES E
Philippine Medical Association
PMA Bldg, North Avenue
Quezon City
Tel: (63-2) 929-63 66/Fax: -6951
E-mail: pmasec1@edsamail.com.ph
POLAND E
Polish Medical Association
Al. Ujazdowskie 24
00-478 Warszawa
Tel/Fax: (48-22) 628 86 99
PORTUGAL E
Ordem dos Médicos
Av. Almirante Gago Coutinho, 151
1749-084 Lisbon
Tel: (351-21) 842 71 00/842 71 11
Fax: (351-21) 842 71 99
E-mail: ordemmedicos@mail.telepac.pt
/ intl.omcne@omsul.com
Website: www.ordemdosmedicos.pt
ROMANIA F
Romanian Medical Association
Str. Ionel Perlea, nr 10
Sect. 1, Bucarest, cod 70754
Tel: (40-1) 6141071
Fax: (40-1) 3121357
E-mail: AMR@itcnet.ro
Website: www.cdi.pub.ro/CDI/
Parteneri/AMR_main.htm
RUSSIA E
Russian Medical Society
Udaltsova Street 85
121099 Moscow
Tel: (7-095)932-83-02
E-mail: rusmed@rusmed.rmt.ru
info@russmed.com
SLOVAK REPUBLIC E
Slovak Medical Association
Legionarska 4
81322 Bratislava
Tel: (421-2) 554 24 015
Fax: (421-2) 554 223 63
E-mail: secretarysma@ba.telecom.sk
SLOVENIA E
Slovenian Medical Association
Komenskega 4
61001 Ljubljana
Tel: (386-61) 323 469
Fax: (386-61) 301 955
SOUTH AFRICA E
The South African Medical Association
P.O. Box 74789, Lynnwood Rydge
0040 Pretoria
Tel: (27-12) 481 2036/7
Fax: (27-12) 481 2058
E-mail: liliang@samedical.org
Website: www.samedical.org
SPAIN S
Consejo General de Colegios Médicos
Plaza de las Cortes 11
Madrid 28014
Tel: (34-91) 431 7780
Fax: (34-91) 431 9620
E-mail: internacional1@cgcom.es
SWEDEN E
Swedish Medical Association
(Villagatan 5)
P.O. Box 5610
SE – 114 86 Stockholm
Tel: (46-8) 790 33 00
Fax: (46-8) 20 57 18
E-mail: info@slf.se
Website: www.lakarforbundet.se
SWITZERLAND F
Fédération des Médecins Suisses
Elfenstrasse 18 – POB 293
3000 Berne 16
Tel: (41-31) 359 –1111/Fax: -1112
E-mail: fmh@hin.ch
Website: www.fmh.ch
TAIWAN E
Taiwan Medical Association
9F No 29 Sec1
An-Ho Road
Taipei
Deputy Secretary General
Tel: (886-2) 2752-7286
Fax: (886-2) 2771-8392
E-mail: intl@med-assn.org.tw
THAILAND E
Medical Association of Thailand
2 Soi Soonvijai
New Petchburi Road
Bangkok 10320
Tel: (66-2) 314 4333/318-8170
Fax: (66-2) 314 6305
E-mail: math@loxinfo.co.th
Website: http://www.medassocthai.org/
index.htm.
TUNISIA F
Conseil National de l’Ordre
des Médecins de Tunisie
16, rue de Touraine
1082 Tunis Cité Jardins
Tel: (216-71) 792 736/799 041
Fax: (216-71) 788 729
E-mail: ordremed.na@planet.tn
TURKEY E
Turkish Medical Association
GMK Bulvary,.
Pehit Danip Tunalygil Sok. N° 2 Kat 4
Maltepe
Ankara
Tel: (90-312) 231 –3179/Fax: -1952
E-mail: Ttb@ttb.org.tr
UGANDA E
Uganda Medical Association
Plot 8, 41-43 circular rd.
P.O. Box 29874
Kampala
Tel: (256) 41 32 1795
Fax: (256) 41 34 5597
E-mail: myers28@hotmail.com
UNITED KINGDOM E
British Medical Association
BMA House, Tavistock Square
London WC1H 9JP
Tel: (44-207) 387-4499
Fax: (44- 207) 383-6710
E-mail: vivn@bma.org.uk
Website: www.bma.org.uk
UNITED STATES OF AMERICA E
American Medical Association
515 North State Street
Chicago, Illinois 60610
Tel: (1-312) 464 5040
Fax: (1-312) 464 5973
Website: http://www.ama-assn.org
URUGUAY S
Sindicato Médico del Uruguay
Bulevar Artigas 1515
CP 11200 Montevideo
Tel: (598-2) 401 47 01
Fax: (598-2) 409 16 03
E-mail: secretaria@smu.org.uy
VATICAN STATE F
Associazione Medica del Vaticano
Stato della Citta del Vaticano 00120
Tel: (39-06) 6983552
Fax: (39-06) 69885364
E-mail: servizi.sanitari@scv.va
VENEZUELA S
Federacion Médica Venezolana
Avenida Orinoco
Torre Federacion Médica Venezolana
Urbanizacion Las Mercedes
Caracas
Tel: (58-2) 9934547
Fax: (58-2) 9932890
Website: www.saludfmv.org
E-mail: info@saludgmv.org
VIETNAM E
Vietnam General Association
of Medicine and Pharmacy (VGAMP)
68A Ba Trieu-Street
Hoau Kiem district
Hanoi
Tel: (84) 4 943 9323
Fax: (84) 4 943 9323
ZIMBABWE E
Zimbabwe Medical Association
P.O. Box 3671
Harare
Tel: (263-4) 791/553
Fax: (263-4) 791561
E-mail: zima@healthnet.zw