WMJ 06 2010

vol. 56
MedicalWorld
Journal
Official Journal of the World Medical Association, Inc
G20438
Nr. 6, December 2010
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WMA President
Thai Health Professional Alliance
Against Tobacco (THPAAT)
Royal Golden Jubilee, 2 Soi
Soonvijai, New Petchburi Rd.
Bangkok,Thailand
WMA Vice-Chairman of Council
Japan Medical Assn
2-28-16 Honkomagome
Bunkyo-ku
Tokyo 113-8621
Japan
WMA Chairperson of the Finance
and Planning Committee
58 Victoria Street
Williamstown, VIC 3016
Australia
WMA Immediate Past-President
Fredericton Medical Clinic
1015 Regent Street Suite # 302,
Fredericton, NB, E3B 6H5
Canada
WMA Treasurer
Bundesärztekammer
Herbert-Lewin-Platz 1
10623 Berlin
Germany
WMA Chairperson of the Associate
Members
14 rue des Tiennes
1380 Lasne
Belgium
WMA President-Elect
WMA Chairperson of the Socio-
Medical-Affairs Committee
Associaçao Médica Brasileira
Rua Sao Carlos do Pinhal 324
Bela Vista, CEP 01333-903
Sao Paulo, SP
Brazil
WMA Chairperson of the Medical
Ethics Committee
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
Norway
WMA Treasurer Emeritus
Schubertstr. 58
28209 Bremen
Germany
WMA Chairperson of Council
American Medical Assn
515 North State Street
Chicago, ILL 60610
USA
WMA Secretary General
13 chemin du Levant
France 01212 Ferney-Voltaire
France
209
WMA News
Dr. Wonchat Subhachaturas
Dear Presidents and Ex. Com. of the
NMAs., Doctors, Colleagues and friends,
It has been a great honour given to me to
work for the WMA as President for the
year 2010-2011 at the WMA General As-
sembly in Vancouver, Canada, on 15th
. Oc-
tober 2010. It has been, as well, a great hon-
our to the Medical Association of Thailand
which occupies only 1 vote at the meeting
to receive a majority one single ballot. This
meant a lot to Thailand and Thai people.
Therefore, it is absolutely my responsibility,
as a doctor from a small country, in Asia,
to spend my all ability to shoulder this big
job at the global level. I do promise that I
will do my best to achieve the objectives and
goal of the WMA as stated. However, this
could not be a reality without good cooper-
ation and collaboration from all of you who
will carry on the most parts of our profes-
sional responsibility to make the people at
every corners of this world healthy at the
National level.
To achieve that goal, I propose that every
NMAs should break the barrier and fron-
tier between us. There must be no bound-
ary in Medicine. Every NMAs should be
responsible for sharing health data, health
problems and bring them to the meeting
and congress for discussion and find out the
best suitable solution. The solution that we
are making out of experience sharing may
not be an absolute one for everywhere but at
least it may be a principle standard or guide-
lines for our practices to fit the variable situ-
ation and environment in each country.
Health Information must be circulated to
all NMAs by means of various communica-
tions in order that we, at every part of the
world, can be aware and able to prevent the
spreading of the communicable diseases as
well as to learn from each other the best way
to prevent and cure the non communicable.
Case referring and sharing of the investiga-
tions using high cost technology and equip-
ments can be done through our NMAs with
the WMA Secretariat Office as a Centre of
communication and resource data bank.
It is always true that doctor’s rights and
responsibility come together and leads to
good relationship amongst the doctors and
patients. Medical Ethics is the most impor-
tant and standard of practices in Medical
Profession which will bring in the trustful-
ness to all of us.
One year of Presidency is not at all long, so
I invite and welcome all of your suggestions
and comments to improve and benefit our
WMA future development.
Thanks and looking forwards to our close
relationship.
Kind regards,
Wonchat Subhachaturas
MD, FRTCS, FICS,
Thailand
President of the World Medical
Association 2010-2011
210
WMA news
Paul-Émile Cloutier
The Canadian Medical Association (CMA)
is very proud to have been host for the re-
cently completed World Medical Associa-
tion (WMA) General Assembly meeting.
Although the meeting lasted only four days,
CMA staff had been busy planning and
preparing for it since 2006. Vancouver was
chosen as the host city,and I think most will
agree that this was a superb choice.
Staff from the CMA joined the WMA
secretariat in Vancouver a week before the
meetings began, and they were then joined
by delegates from 50 countries. Working
groups met Oct. 12, with the General As-
sembly itself beginning Oct. 13.
Over four days, delegates discussed and
debated important and topical issues of
concern to the physicians of the world,
including health and the environment,
the debate for which was led by Canada,
violence against women and children, and
the relationship between physicians and
pharmacists. Several new policies were ad-
opted, and are outlined elsewhere in this is-
sue of the World Medical Journal.
I think it is safe to say that a true feeling
of camaraderie and consensus-building
emerged during this meeting, particu-
larly with respect to the issue of prescrib-
ing rights. It was very gratifying for me, as
CEO of the host national medical associa-
tion, to witness this very effective collabora-
tion involving physicians from all parts of
the world.
The camaraderie was also
obvious at the numerous so-
cial events held during the
meetings, from the opening
reception at the Pan Pacific
hotel to the trip across the
Capilano suspension bridge
and the dinner atop Grouse
Mountain.
I would be remiss if I did not
express the pride felt by the
CMA as one of our own, Dr.
Dana Hanson, gave his vale-
dictory address at the end
of his very successful year as
WMA president. I would
also like to thank the CMA’s
outgoing WMA Council
representative, Dr. Ruth Col-
lins-Nakai, for all of her hard
work, and welcome our new
council member, Dr. Robert
Ouellet.
I would also like to give spe-
cial thanks to the people I
have the pleasure of working with every
day at CMA headquarters. Over the past
few years they have worked tirelessly to en-
sure that this meeting would be successful,
and I am sure you will agree that it was. In
particular, I would like to thank our execu-
tive director of international affairs, Dr. Jeff
Blackmer, and his team Karen Clark,
Jackie Chapman-Davis, Jay Remillard, Lu-
cie Boileau, Eve Elman, Dr. Maura Rick-
etts, Jill Skinner and Pat Rich.
Finally, I would like to thank you, the del-
egates from national medical associations
around the world, for your attendance at
the meeting in Vancouver. Because of your
preparation, participation and friendship,
this was a General Assembly to be remem-
bered.
Paul-Émile Cloutier,
Secretary General and Chief Executive Officer
Canadian Medical Association
Vancouver, British Columbia
October 13-16, 2010
211
WMA news
The 61st
annual General Assembly held at
The Fairmont Hotel in Vancouver, Canada,
from October 13th
to 16th
was attended by
representatives from almost 50 national
medical associations.
Speaking at the opening of the ceremonial
session on Friday October 15th
, His Hon-
our the Honourable Steven Point, Lieutenant
Governor of British Columbia, said that the
WMA had a global vision.He welcomed the
recent movement of looking back at indig-
enous medical knowledge and expressed his
opinion that it was absolutely crucial to try
to broaden our horizons and understanding.
The work of coming together was the ques-
tion of our time and we had to believe that
we could make a difference by doing so.
Following the Honourable Steven Point,
Dr. Jeff Turnbull, President of the Canadian
Medical Association, welcomed the WMA.
He said that since the WMA was founded,
the world had become not only a smaller
place but, unfortunately, a more fragile
one as well. He spoke about the remark-
able changes in health care and revealed
that the health status of Canada’s poor was
comparable to that of countries with a frac-
tion of its gross domestic product.The social
determinants of health still led to massive
unacceptable health inequities worldwide.
He remarked that these were challenges the
WMA had and must continue to address.
He spoke about the myriad challenges
Canada’s physicians faced and said that,
“We strive to provide the best care for our
patients. But we face the same issues as
medical professionals in other countries
stress, burnout and fatigue to name a few.”
He noted that the medical profession in
Canada was aging, with the average age of
the Canadian physician being older than
the average Canadian citizen.He concluded
by saying “We face having fewer physicians
to meet a growing need.I believe the WMA
must continue to speak out for the welfare
of its members as they continue to serve
their patients.”
Dr. Dana Hanson, the 60th
President of the
WMA, followed and in his valedictory ad-
dress, spoke about the three E’s Energize,
Engage, Educate. Energize the profession.
Engage the public and Educate govern-
ments. “In my travels, I clearly see physi-
cians who entered our profession for many
varied reasons but all of them, all of us, have
at least one common reason the vision to
reach out and help those around them. In
medical school we were bright, young and
altruistic. But what we often see today are
physicians who have stepped out of medical
school into a world financial crisis, severe
physician shortages, often a demanding,
critical public, the loss of the golden age of
antibiotics, and the erosion of self regula-
tion to name just a few problems. Physi-
cians are often tired and disillusioned.”
He said an area of personal interest to him
had been the resilient physician what
could be learned from those who continued
to function in situations where others could
not and, from that learning, help all of them
continue to serve.This is what he called en-
ergizing the profession.
Dr. Hanson called on physicians to engage
the public in the battle to improve health.
He said that financial crises often resulted
in slashed health budgets and he followed
with the question “But why is there no
Vancouver, British Columbia October 13-16, 2010
212
WMA news
outcry by the public that the disease burden
remains the same or greater?” He said that
during his year as President, the WMA had
highlighted health and the environment 
“something which, regardless of causes,
will touch untold millions of people in a
very real and concrete way when it comes
to their health.” But he asked why patients
were so surprised when physicians pointed
this out to them in clinics and hospitals.
These were just two examples of where the
WMA had a role, in partnership with na-
tional medical associations, in engaging
the public to realise that in order to ad-
dress their individual concerns they must
be partners with the medical profession and
other healthcare professionals. He said that
governments across the world had not been
educated by the right people when it came
to heath issues. He asked why the climate
change conference in Copenhagen last
year had no reference to health in its final
draft? Why were 80 percent of the observ-
ers ‘industry’ based while only a handful of
healthcare representatives and environmen-
talists were present?
He continued by asking why governments
always listen to the World Bank and the
International Monetary Fund about our
economic health, often to the detriment
of public and individual health? Why were
health systems seen as a cost centre when
they had been proven to be a positive eco-
nomic investment? And why, with a resur-
gence of infectious diseases and drug resis-
tance, were there common drug shortages
and a paucity of new drug innovation?
“Part of the answer to these vital questions
is that we, along with the public, have not
educated governments and industry. They
have only heard part of the story. Yet the
public and the medical profession together
represent a powerful force that no govern-
ment could oppose.The World Medical As-
sociation and national medical associations
have a vital role in society not just at the
bedside but indeed well beyond.”
Dr. Edward Hill, Chair of Council, then
brought to the Assembly a recommendation
from the Council that President-Elect, Dr.
Ketan Desai, who was not able to be present
in Vancouver to be installed as President, be
considered “disabled” and unable to carry
out his duties. He proposed that Dr. Desai’s
inauguration be suspended indefinitely.This
would then require an extraordinary elec-
tion to elect a President for 2010/11. The
recommendation was approved. In the elec-
tion that followed, three candidates were
nominated Dr. Eva Bågenholm from Swe-
den, Dr. Mikhail Perelman from Russia and
Dr. Wonchat Subhachaturas from Thailand.
All three candidates addressed the Assem-
bly and in the voting that followed,Dr. Sub-
hachaturas was elected on the first ballot.
Dr. Subhachaturas, President-Elect of the
Medical Association of Thailand, became
the first doctor from Thailand to hold the
post of WMA President. He is a neuro-
surgeon who did his medical training in
Bankok and worked for many years at the
city’s Central Hospital before moving to
Charoenkrung Hospital where he became
Director. He was Deputy Secretary of the
Bankok Metropolitan Administration and
currently works at the Thai Health Profes-
sional Alliance Against Tobacco.
Following his installation,Dr. Subhachaturas
spoke to the Assembly about how the medi-
cal profession needs to be united. He said
that even though physicians spoke different
languages they were all in the same boat
and rowing the same direction. With good
will, they could connect with one another,
with the health of the people of the world
as their target goal.
At the plenary session of the Assembly the
following day, Dr. José Gomes do Amaral,
President of the Brazilian Medical Associa-
tion, was elected unopposed as WMA Pres-
ident-Elect. He will become the third Bra-
zilian to become President when he takes
up the post at the Association’s annual As-
sembly in Montevideo, Uruguay next year.
213
WMA news
Dr. Gomes do Amaral is an anesthesiologist
and specialist in critical care in São Paulo,
where he works at Santa Helena Hospital.
He is also Chairman of Anesthesiology and
Critical Care Discipline at the Surgery De-
partment, at Sao Paulo Federal University.
The Assembly adopted the following policy
documents from the Socio-Medical Affairs
Committee:
The Resolution on Violence against Wom-
en and Girls warned that this issue had
become a worldwide institutionalised phe-
nomenon and a major public health crisis.
In its first policy Declaration on the issue,
the WMA urged physicians and their na-
tional medical associations to pay far greater
attention to the issues of female feticide, fe-
male genital mutilation, forced marriages
and honour killings and to condemn gang
rape as a weapon of war and a crime against
humanity.
Dr. Ruth Collins-Nakai, Canadian Medi-
cal Association, who headed the WMA’s
workgroup on the issue, said: “These forms
of violence reflect the persistence of gender
inequalities worldwide. Physicians can be
the agents of change and promote a shift of
mentality for the achievement of women’s
human rights, their dignity and integrity.”
(see full text p. 224)
The Statement on Environmental Degrada-
tion and Sound Management of Chemicals
warns that chemical contamination of the
environment continues to exert harmful ef-
fects on global public health. Dr. Hill said
“As we have seen from recent environmen-
tal disasters, the public continues to be at
great risk from chemical contamination.
Governments have the primary responsibil-
ity to protect the public’s health from these
hazards and our job as the World Medi-
cal Association, on behalf of the world’s
physicians, is to highlight the human health
risks and to recommend action.”
(see full text p. 220)
The Statement on Family Violence, which
revises previous WMA policy, offers pro-
posals for increasing awareness and involve-
ment among physicians, including the need
to oppose violent practices such as dowry
killings, honour killings and the practice of
child marriage
(see full text p. 222)
The Statement on Medical Care for Refu-
gees, including Asylum Seekers, Refused
Asylum Seekers and Undocumented Mi-
grants, and Internally Displaced Persons
was adopted.
(see full text p. 226)
A revised Statement on the Relation-
ship between Physicians and Pharmacists
in Medical Therapy was adopted after a
lengthy debate. At issue was a sentence in
the original document that “The right to
prescribe medicine should be solely the re-
sponsibility of the physician”.
Dr. Jon Snaedal, from the Iceland Medical
Association, proposed an amendment to
delete those words,arguing that it ran coun-
ter to the collaboration the WMA engaged
in with other health professionals who, in
many countries, also had a right to prescribe
under certain circumstances.
But Dr. Frank Montgomery from Germany
supported the original wording which he
said was the essence of the document. “We
as physicians want for ourselves the right
and the responsibility to prescribe”, he said.
Dr. Kgose Letlape from South Africa said
that if this wording was supported, in South
214
WMA news
Africa it would condemn more than four hundred thousand
people a year to HIV related deaths. South Africa had more than
two million people who could not access doctors and who were
dying unnecessarily from HIV and they were being treated by
prescribing nurses and other health professionals.
Dr. Ruth Collins-Nakai from Canada said the ability to prescribe
should be a competency-based decision, not an autonomy based
decision.If people had the appropriate training then they had the
responsibility and the obligation to prescribe.However Dr. Pedro
Nuñes from Portugal said that prescribing was the responsibility
of the doctor. It would be very strange if a medical association
would give up what physicians had achieved so far.
Dr. Arie Kruseman from the Royal Dutch Medical Association,
supporting the deletion of the sentence, said there was ample
evidence that specialist nurses, if properly trained, performed
equally, and in some situations, even better than doctors in their
treatment of certain chronic diseases. Dr. Peter Foley from New
Zealand said the WMA must not be seen to be just protecting
the physicians. They were here for their patients and healthcare
was a team delivery. Dr. Vivienne Nathanson from the British
Medical Association said that to deny access to healthcare to
many people in many countries was so retrogressive that the
WMA would look back in the future with great shame.The best
qualified person available should be able to prescribe to people
in dire need of treatment.
The Assembly eventually agreed to substitute the sentence “The
right to prescribe medicine should be solely the responsibility of
the physician” with “The right to prescribe medicine should be
competency based and ideally the responsibility of the physician”.
The revised Statement was adopted.(see full text p. 227)
A Resolution on Drug Prescription was then adopted setting out
principles on prescribing. (see full text p. 228)
The Assembly received an oral report from the Treasurer Prof.
Jörg-Dietrich Hoppe. It approved the Audited Financial State-
ment for 2009 and adopted the Budget for 2011.
Applications for membership from the Mozambique Medical
Association and the Serbian Medical Chamber were approved.
215
WMA news
The Assembly approved and adopted a consolidation and revision
of the WMA Bylaws, marking the end of a year-long task related to
updating and amending outdated and repetitive documents.
It was agreed that junior doctors and medical students should have
their membership fees for WMA Associate Membership waived for
the first five years after graduation instead of the present three years.
Dr.Hanson,who was instrumental in encouraging this change,said this
would give junior doctors an important platform within the WMA.
It was agreed that three documents Professional and Ethical Us-
age of Social Media, Ethical Principles for Medical Research on
Child Subjects and Physicians’ Ethical Responsibilities regarding
Bio Banks be r eferred to Council for discussion.
It was reported that a working group would be set up to examine
organ procurement, including the issues of transplantation from ex-
ecuted prisoners, the commercialisation of organ transplants, pre-
sumed and other systems of consent and related issues.
The Council’s detailed report to the Assembly about significant de-
velopments during the year referred to the WMA’s involvement in
the WHO global action plan on noncommunicable diseases and ac-
tivities to progress the WHO Framework Convention on Tobacco
Control.The Association had also been involved in the global strat-
egy to reduce the harmful use of alcohol.
On the multi drug resistant tuberculosis project, as part of the Lilly
MDR-TB partnership, the TB refresher course for physicians had
been launched during the General Assembly in 2009 in Delhi. The
purpose of the course was to set the baseline for basic knowledge on
the subject, with the existing Multi-Drug Resistant TB course pro-
viding more advanced knowledge.The TB refresher course had been
nominated by the United States Center of Disease Control as an edu-
cational highlight and had received an award.Over time,both courses
would be translated into different languages. The Georgian Medical
Association had offered to translate the TB refresher course for free.
To increase the outreach of itsTB and MDRTB educational activities,
the WMA had held a train-the-trainer course in TB and MDR-TB
216
WMA news
in China, based on the existing training ma-
terials from the courses held in South Africa
and India. In April 2010, the WMA and
the Chinese Medical Association organised
a third workshop in Hangshuang with the
help of the Chinese Thoracic Society. Thirty
leaders of TB hospitals from all over China
took part in the training.The government and
the provincial health department honoured
the activities of the WMA and the Chinese
Medical Association.
The WHO had developed a policy on ethics
in the TB Setting, and launched the policy
during a conference and workshop in Ath-
ens in May this year.The WMA was invited
to address the issues related to health pro-
fessionals in the policy and Dr. Jeff Blackmer
from the Canadian Medical Association of-
fered to draft this part of the policy, which
addressed the duty to treat and the risks and
obligations to patients.The WMA, together
with the International Council of Nurses,
International Hospital Federation and Inter-
national Committee of the Red Cross,and in
close cooperation with the WHO, organised
an inter-professional workshop on Health
Care Worker Safety and Infection Control
in the Context of Drug Resistant TB in Be-
nin in September. Forty-eight physicians,
nurses, managers and laboratory technicians
from Benin,Burkina Faso,Mali,Ivory Coast,
Guinea and Senegal discussed the infection
control measures in their hospitals and the
challenges to improve the situation and de-
veloped ten recommendations for their TB
hospitals.
On counterfeit medical products, the
WMA and the members of the World
Health Professions Alliance had developed
the “Be Aware” toolkit for health profes-
sionals and patients to increase awareness of
this topic and provide practical advice for
actions to take in case of a suspected coun-
terfeit medical products. Workshops were
being organized.
A WMA workgroup on health and the en-
vironment, established in 2008, had been
involved in the global United Nations
Framework Convention on Climate Change
and the Association had been involved in ac-
tion to reduce the global burden of mercury
and the management of chemicals.
The WMA had continued its close involve-
ment in the Positive Practice Environment
Campaign, a global five-year campaign
spearheaded by the World Health Profes-
sions Alliance that aimed to ensure high-
quality health workplaces for quality care.
The first activities on a country level started
in Uganda, Morocco and Zambia. National
researchers conducted studies about the
working conditions of health profession-
als in these countries and during two-day
workshops, national and local health pro-
fessionals, governments and researchers
developed an action plan to improve the
working conditions of health professionals.
The Association had also been involved
with the UN Millennium Development
Goals, in workplace violence in the health
sector, patient safety and with the Inter-
national Rehabilitation Council for Tor-
ture Victims. It had also participated as a
member of steering groups in two projects
commissioned by the European Union on
the mobility and migration of health pro-
fessionals.
The Caring Physicians of the World proj-
ect had continued with further leadership
courses organised by the INSEAD Business
School. The courses had been made possible
by an unrestricted educational grant provid-
ed by Pfizer, Inc. During the year, Books of
Hope, with the support of Pfizer, the Chi-
nese Center of Disease Control, the Chinese
Medical Doctors Association, the Chinese
Association on Tobacco Control and the
WMA presented a speaking book on the
dangers of smoking.It targeted a low literacy
community that had experienced significant
increases in smoking rates over the last de-
cades,yet could not benefit from much of the
written informational products on tobacco
cessation and the dangers of smoking.
217
WMA news
The WMA had campaigned on behalf of
physicians in distress worldwide.
It had sent an appeal to the President of Su-
dan for the release of six Sudanese doctors
arrested and detained without charge for
their activities as members of the Doctors’
Strike Committee calling for better pay and
working conditions for doctors in Sudan.
WMA members were invited to act in sup-
port of these doctors, for their immediate
release and the assurance that they were not
being tortured. The six doctors were subse-
quently released.
The WMA also wrote to the Iranian au-
thorities concerning the cases of Dr. Arash
Alaei and Dr. Kamiar Alaei who were sen-
tenced to six and three years’ imprisonment
respectively, for ‘cooperating with an enemy
government’. But despite strong calls from
the international medical and scientific
community, the brothers remained in jail,
more than two years after their arrest. The
WMA considers them prisoners of con-
science, as they appear to have been impris-
oned solely in relation to their work with
international and specifically US insti-
tutions in the field of HIV and AIDS pre-
vention and treatment.
The WPHA had celebrated its 10th anni-
versary during the year and the four main
health professions-physicians, nurses, phar-
macists and dentists had now been joined
by the World Confederation for Physical
Therapy. Together they had shown that
working in collaboration instead of along
parallel tracks, benefited both patients and
health care systems. The WHPA amplified
the policy and advocacy messages of mem-
ber organisations and facilitated coherence
and synergy among the messages of nation-
al member organisations.
The WHPA had established an expert
working group on collaborative practice to
search for best practice models of collabora-
tive practice in different health care settings
and different regions, to advocate for these
examples among WHPA members, and to
encourage national or regional organiza-
tions to replicate these models.
In the session set aside for representatives to
report on any issue of interest to the Assem-
bly, Dr. Cecil Wilson, President of the Ameri-
can Medical Association, spoke about health
care reform in the US. He said that not since
the creation of Medicare providing insur-
ance for senior citizens in 1965 had America
witnessed such sweeping legislation.The Af-
fordable Care Act set out to boldly reform
the American healthcare system to increase
access for millions,reform insurance industry
practices and place new emphasis on qual-
ity and prevention, all while reducing cost.
It remained to be seen whether all the items
could be achieved. But it was already clear
that the right goals were in place and over the
coming months and years the AMA would
remain involved every step of the way. They
would push to correct those items the law got
wrong, improve those it got right and tackle
those it failed to address.
Dr. Rudolf Henke, a member of the Medi-
cal Council in Germany, talked about phy-
sicians’ employment contracts in Germany
and serious concerns relating to interference
in physicians’ union representation.
Dr. Douglas Leon Natera from the Venezu-
ela reported on the freezing of doctors’con-
tracts in his country. This had led to 45 per
cent of doctors leaving their hospitals, 25
percent going into private practice and 15
percent to other health care professions.
Now thousands of new “community doc-
tors” were being educated with lower stan-
dards, which would create huge problems
not only for the profession but for patients.
Earlier in the week the scientific session
was held on the theme of “Health and the
218
WMA news
Environment” and the keynote speaker was
Professor Sir Michael Marmot, professor of
Epidemiology and Public Health at Uni-
versity College, London. He spoke about
the 40 year difference in life expectancy
between different countries and between
different regions in the same country. Envi-
ronment was one reason, but social and eco-
nomic factors were another. He compared
the 28 year difference in the life expectancy
for men living in Glasgow, Scotland with
the life expectancy of men in India which
is eight years longer than the life expectancy
of men in the poorest parts of Glasgow.
Explaining why he was an evidence based
optimist about the future, he said that be-
ing rich was not a necessity for a country to
improve life expectancy. Costa Rica had a
relatively low income but remarkably good
health. It had abolished its military in 1948
and put the money into education, social
protection, clean water and health care.
Now life expectancy there was the same as
in the United Kingdom, yet their gross na-
tional income was one third of that in the
UK.
His conclusion was: “If we put fairness at
the heart of all decision-making, health
would improve and health inequities would
diminish”.
Dr. Diego Bassani, an epidemiologist from
the University of Toronto, spoke about the
huge problem of indoor air quality in de-
veloping countries. He presented data on
the effect of using solid fuels inside houses
and said people did not realise how low the
quality of air was inside the homes of most
people in the world.
Dr. Dongchun Shin,chair of the Department
of Preventive Medicine at Yonsei Univer-
sity College of Medicine in Seoul, Korea,
spoke about the strategic approach to in-
ternational chemical management and said
that environmental toxic chemical exposure
was now ubiquitous in our everyday life.
He warned that the world was facing a big
environmental disaster which he referred to
as chemical warfare. Dr. Peter Orris, Chief
of the Occupational and Environmental
Medicine Clinical Service at the Univer-
sity of Illinois at Chicago Medical Center,
spoke about the current status of knowledge
on mercury toxicity and its phasing out in
health care.
Dr. Alan Abelsohn, a family physician in
Toronto, addressed the meeting about the
health impact of climate change. He talked
about the science of climate change, and the
direct health effects from extreme weather
events which would become more evident.
The indirect effects would include more air
pollution, air allergens and an increase in
vector borne diseases. He said that rather
than bringing new diseases, climate change
would change the distribution of diseases.
Dr. Lawrence Frank, Bombardier Chair-
holder in Sustainable Transportation at
the University of British Columbia, spoke
about the health impact of community de-
sign,focused around travel patterns.Dr. Ray
Copes, Director of Environmental and Oc-
cupational Health at the Ontario Agency
for Health Protection and Promotion in
Toronto, spoke about adaptive measures
at local and regional levels to mitigate the
health impact of climate change
The last two speakers were Dr. Kue Young,
Professor and TransCanada Pipelines
Chair in the Dalla Lana School of Public
Health at the University of Toronto, who
spoke about Health and Environment in
Circumpolar Indigenous Peoples, and Dr.
Robin Walker, Vice-President, Medicine at
the IWK Health Centre in Halifax, Nova
Scotia and a Professor of Paediatrics at Dal-
housie University, who spoke about Child
health and the environment.
The 2011 WMA General Assembly will be
held in Montevideo, Uruguay from October
12 to 15.
219
WMA news
Earlier in the week, a number of issues
were raised during the committee meetings,
which included:
Medical Ethics Committee
Dr. Torunn Janbu, Chair of the Medical
Ethics Committee, reported that a docu-
ment on end-of-life palliative care was be-
ing prepared by a working group for con-
sideration at the next meeting in Sydney,
Australia.
Dr. Ramin Parsa-Parsi, from Germany, re-
ported on the workgroup’s progress on de-
veloping a proposal for revising paragraph
32 of the Declaration of Helsinki. At the
expert conference in Sao Paulo earlier in
the year, the question arose regarding pla-
cebo research use in resource poor settings.
Dr. Parsa-Parsi said another international
expert conference led by the WMA would
be required to resolve this and to develop
a proposal for a new wording of paragraph
32. He recommended holding a conference
in the summer of 2011, which Council later
approved.
An oral report was received from the
workgroup considering guidance to na-
tional medical associations on how best to
use the Declaration of Tokyo, which ad-
dresses physician participation in torture.
Dr. Vivienne Nathanson from the British
Medical Association said this was one of
the WMA’s Declarations that was cited
internationally and it was important for
national medical associations to have guid-
ance on how to respond to allegations of
violations of patients’ health rights and
physicians’ professional ethics in custo-
dial settings. A draft document would be
circulated to NMAs for consideration at
the next meeting.
Socio-Medical Affairs Committee
It was agreed to circulate for comment revi-
sions to the WMA Declaration on Prison
Conditions and the Spread of Tuberculosis
and Other Communicable Diseases.
It was agreed to circulate for comment a state-
ment on the Global Burden of Chronic Dis-
ease for consideration at the next meeting.
The Israel Medical Association presented a
draft statement on Violence in the Health
Workplace, arguing that it was a big prob-
lem in many countries and yet the WMA
had no policy on the subject. It was agreed
to circulate the document to NMAs for
comment and consideration at the next
meeting.
The committee recommended that a work-
group be set up to consider the social de-
terminants of health. Sir Michael Marmot,
President of the British Medical Associa-
tion, presented a draft paper arguing that
the inequalities of the health of the public
should be a core con-
cern of the medical
profession and of the
WMA.The recommen-
dation was approved by
the Council.
Mr. Nigel Duncan,
Public Relations
Consultant, WMA
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WMA news
This Statement focuses on one important aspect of environmental
degradation, which is environmental contamination by harmful do-
mestic and industrial substances. It emphasizes the harmful chemi-
cal contribution to environmental degradation and physicians’ role
in promoting sound management of chemicals as part of sustainable
development, especially in the healthcare environment.
Most chemicals to which humans are exposed come from indus-
trial sources and include, food additives, household consumer and
cosmetic products, agrochemicals, and other substances (drugs;
dietary supplements) used for therapeutic purposes.  Recently, at-
tention has been concentrated on the effects of human engineered
(or synthetic) chemicals on the environment, including specific
industrial or agrochemicals and on new patterns of distribution of
natural substances due to human activity.  As the number of such
compounds has multiplied, governments and international orga-
nizations have begun to develop a more comprehensive approach
to their safe regulation.
While governments have the primary responsibility for establishing
a framework to protect the public’s health from chemical hazards,
the World Medical Association, on behalf of its members, empha-
sizes the need to highlight the human health risks and make recom-
mendations for further action.
During the last half-century, the use of chemical pesticides and
fertilizers dominated agricultural practice and manufacturing in-
dustries rapidly expanded their use of synthetic chemicals in the
production of consumer and industrial goods.1
    The greatest con-
cern relates to chemicals,which persist in the environment,have low
rates of degradation, bio-accumulate in human and animal tissue
(concentrating as they move up the food chain), and which have
significant harmful impacts on human health and the environment
(particularly at low concentrations).2
Some naturally occurring met-
als including lead, mercury, and cadmium have industrial sources
and are also of concern.   Advances in environmental health research
including environmental and human sampling and measuring
techniques, and better information about the potential of low dose
human health effects have helped to underscore emerging concerns.
Health effects from chemical emissions can be direct (occurring as
an immediate effect of the emission) or indirect. Indirect health ef-
fects are caused by the emissions’effects on water, air and food qual-
ity as well as the alterations in regional and global systems, such as
red tide in many oceans, and the ozone layer and the climate, to
which the emissions may contribute.
The model of regulation of chemicals varies widely both within and
between countries, from voluntary controls to statutory legislation.  
It is important that all countries move to a coherent, standardized
national legislated approach to regulatory control.  Furthermore,
international regulations must be coherent such that developing
countries will not be forced by economic circumstances to circum-
vent potentially weak national regulations.  An example of a leg-
islative framework can be found at http://ec.europa.eu/environment/
chemicals/index.htm.
Synthetic chemicals include all substances that are produced by, or
result from, human activities including industrial and household
chemicals, fertilizers, pesticides, chemicals contained in products
and in wastes, prescription  and over-the-counter drug products
and dietary supplements, and unintentionally produced byproducts
of industrial processes or incineration, like dioxins.  Furthermore,
nanomaterials, in some circumstances, can be regulated by synthetic
chemicals regulations but in other cases, may need explicit regula-
tion.
Several notable agreements on chemicals exist.These were prompt-
ed by the first United Nations Conference on the Human Envi-
ronment declaration in 1972 (Stockholm) on the discharge of toxic
substances into the environment.3
These agreements include the
1989 Basel Convention to control/prevent trans-boundary move-
ments of hazardous wastes, the 1992 Rio Declaration on Envi-
ronment and Development, the 1998 Rotterdam Convention on
informed consent and shipment of hazardous substances, and the
2001 Stockholm Convention on Persistent Organic Pollutants.4 5 6
It should be noted that little information is available on the efficacy
of the controls.
Worldwide hazardous environmental contamination persists de-
spite these agreements, making a more comprehensive approach
221
WMA news
to chemicals essential. Reasons for ongoing contamination include
persistence of companies, absolute lack of controls in some coun-
tries, lack of awareness of the potential hazards, inability to apply
the precautionary principle, non-adherence to the various conven-
tions and treaties and lack of political will.  The Strategic Approach
to International Chemicals Management (SAICM) was adopted in
Dubai, on February 6, 2006 by delegates from over 100 govern-
ments and representatives of civil society.  This is a voluntary global
plan of action designed to assure the sound management of chemi-
cals throughout their life cycle so that, by 2020, chemicals are used
and produced in ways that minimize significant adverse effects on
human health and the environment.  The SAICM addresses both
agricultural and industrial chemicals, covers all stages of the chemi-
cal life cycle of manufacture, use and disposal, and includes chemi-
cals in products and in wastes.7
Despite these national and international initiatives, chemical con-
tamination of the environment due to inadequately controlled
chemical production and usage continues to exert harmful effects
on global public health.  Evidence linking some chemicals to some
health issues is strong,but there is not evidence for all chemicals,es-
pecially newer or nano materials, particularly at low doses over long
periods of time.  Physicians and the healthcare sector are frequently
required to make decisions concerning individual patient and the
public as a whole based on existing data.  Physicians therefore cau-
tion that they, too, have a significant role to play in closing the gap
between policy formation and chemicals management and in reduc-
ing risks to human health.
National Medical Associations (NMAs) advocate for legisla-
tion that reduces chemical pollution, reduces human exposure
to chemicals, detects and monitors harmful chemicals in both
humans and the environment, and mitigates the health effects
of toxic exposures with special attention to vulnerability during
pregnancy and early childhood.
NMAs urge their governments to support international efforts
to restrict chemical pollution through safe management, or phase
out and safer substitution when unmanageable (e.g. asbestos),
with particular attention to developed countries aiding develop-
ing countries to achieve a safe environment and good health for
all.
NMAs facilitate better communication between government
ministries/departments responsible for the environment and pub-
lic health.
Physicians and their medical associations advocate for environ-
mental protection, disclosure of product constituents, sustainable
development, and green chemistry within their communities,
countries and regions.
Physicians and their medical associations should support the
phase out of mercury and persistent bioaccumulative and toxic
chemicals in health care devices and products.
Physicians and their medical associations should support legisla-
tion to require an environmental and health impact assessment
prior to the introduction of a new chemical or a new industrial
facility.
Physicians should encourage the publication of evidence of the
effects of different chemicals and dosages on human health and
the environment.  These publications should be accessible inter-
nationally and readily available to media, non-governmental or-
ganizations (NGOs) and concerned citizens locally.
Physicians and their medical associations advocate for the de-
velopment of effective and safe systems to collect and dispose of
pharmaceuticals that are not consumed.
Physicians and their medical associations should support efforts
to rehabilitate or clean areas of environmental degradation based
on a “polluter pays” and precautionary principles and ensure that
moving forward, such principles are built into legislation.
The WMA, NMAs and physicians should urge governments to
collaborate within and between departments to ensure coherent
regulations are developed.
Supports the goals of the Strategic Approach to International
Chemicals Management (SAICM), which promotes best prac-
tices in the handling of chemicals by utilizing safer substitution,
waste reduction, sustainable non-toxic building, recycling, as well
as safe and sustainable waste handling in the health care sector. 
Cautions that these chemical practices must be coordinated with
efforts to reduce green house gas emissions from health care to
mitigate its contribution to global warming.
Urges physicians, medical associations and countries to work
collaboratively to develop systems for event alerts to ensure that
health care systems and physicians are aware of high-risk indus-
trial accidents as they occur, and receive timely accurate informa-
tion regarding the management of these emergencies.
Urges local, national and international organizations to focus on
sustainable production, safer substitution, green safe jobs, and
consultation with the health care community to ensure that dam-
aging health impacts of development are anticipated and mini-
mized.
Emphasizes the importance of the safe disposal of pharmaceuti-
cals as one aspect of health care’s responsibility and the need for
222
WMA news
collaborative work in developing best practice models to reduce
this part of the chemical waste problem.
Encourages environmental classification of pharmaceuticals in
order to stimulate prescription of environmentally less harmful
pharmaceuticals.
Encourages ongoing outcomes research on the impact of regu-
lations and monitoring of chemicals on human health and the
environment.
Work to reduce toxic medical waste and exposures within their
professional settings as part of the World Health Professional Al-
liance’s campaign for Positive Practice Environments.
Work to provide information on the health impacts associated
with exposure to toxic chemicals, how to reduce patient exposure
to specific agents and encourage behaviours that improve overall
health.
Inform patients about the importance of safe disposal of pharma-
ceuticals that are not consumed.
Work with others to help address the gaps in research regarding
the environment and health (i.e., patterns and burden of disease
attributed to environmental degradation; community and house-
hold impacts of industrial chemicals; the most vulnerable popula-
tions and protections for such populations).
Physicians and their professional associations assist in building
professional and public awareness of the importance of the envi-
ronment and global chemical pollutants on personal health.
National Medical Associations (NMAs) and physician profes-
sional associations develop tools for physicians to help assess their
patients’ risk from chemical exposures.
Physicians and their professional associations develop locally
appropriate continuing medical education on the clinical signs,
diagnosis and treatment of diseases that are introduced into com-
munities as a result of chemical pollution and exacerbated by cli-
mate change.
Environmental health and occupational medicine should become
a core theme in medical education.  Medical schools should en-
courage in the training of sufficient specialists in environmental
health and occupational medicine.
1. Wiser G, Center for International Environmental Law, UNEP Forum,
Sept. 2005
2. http://www.unep.org/hazardoussubstances/Introduction/tabid/258/lan-
guage/en-US/Default.aspx
3. http://www.unep.org/Documents.Multilingual/Default.asp?DocumentID
=97&ArticleID=1503&l=en
4. http://www.unep.org/Documents.Multilingual/Default.asp?DocumentID
=78&ArticleID=1163
5. Wiser G, Center for International Environmental Law, UNEP Forum,
Sept. 2005
6. http://chm.pops.int/Convention/tabid/54/language/en-US/Default.aspx
7. http://www.chem.unep.ch/saicm/SAICM%20texts/SAICM%20docu-
ments.htm
Adopted by the 48th
General Assembly Somerset West, Republic of
South Africa, October 1996, editorially revised at the 174th
Council
Session, Pilanesberg, South Africa, October 2006 and amended by
the WMA General Assembly, Vancouver, Canada, October 2010
Recalling the World Medical Association Declaration of Hong
Kong on the Abuse of the Elderly and the World Medical Associa-
tion Statement on Child Abuse and Neglect, and profoundly con-
cerned with violence as a public health issue, the World Medical
Association calls upon National Medical Associations to intensify
and broaden their efforts to address the universal problem of family
violence.
Family violence is a term applied to physical and/or emotional
mistreatment of a person by someone in an intimate relationship
with the victim. The term includes domestic violence (sometimes
referred to as partner,spouse,or wife battering),child physical abuse
and neglect, child sexual abuse, maltreatment of older people, and
many cases of sexual assault. Family violence can be found in every
country in the world, cutting across gender and all racial, ethnic,
religious and socio-economic lines. Although case definitions vary
from culture to culture, family violence represents a major public
health problem by virtue of the many deaths, injuries, and adverse
psychological consequences that it causes. The physical and emo-
tional harm may represent chronic or even lifetime disabilities for
many victims. Family violence is associated with increased risk of
depression, anxiety, substance abuse, and self-injurious behaviour,
including suicide.Victims often become perpetrators or become in-
volved in violent relationships later on. Although the focus of this
document is the welfare of the victim, the needs of the perpetrator
should not be overlooked.
Although the causes of family violence are complex, a number of
contributing factors are known. These include poverty, unemploy-
ment, other exogenous stresses, attitudes of acceptance of violence
for dispute resolution, substance abuse (particularly alcohol),
rigid gender roles, poor parenting skills, ambiguous family roles,
223
WMA news
unrealistic expectations of other family members, interpersonal
conflicts within the family, actual or perceived physical or psycho-
logical vulnerability of victims by perpetrators, perpetrator pre-
occupation with power and control, and familial social isolation,
among others.
There is a growing awareness of the need to think about and take
action against family violence in a unified way, rather than focusing
on the particular type of victim or community affected. In many
families where partner battering occurs, for example, there may be
abuse of children and/or of older people as well, often carried out by
a single perpetrator. In addition, there is substantial evidence that
children who are victimized or who witness violence against oth-
ers in the family are later at increased risk as adolescents or adults
of being re-victimized and/or becoming perpetrators of violence
themselves. Finally, more recent data suggest that victims of family
violence are more likely to become perpetrators of violence against
non-intimates as well. All of this suggests that each instance of
family violence may have implications not only for further family
violence, but also for the broader spread of violence throughout a
society.
Physicians and NMAs should oppose violent practices such as dow-
ry killings and honour killings.
Physicians and NMAs should oppose the practice of child marriage.
Physicians have important roles to play in the prevention and treat-
ment of family violence. Of course they will manage injuries, ill-
nesses,and psychiatric problems deriving from the abuse.The thera-
peutic relationships physicians have with patients may allow victims
to confide in them about current or past victimization. Physicians
should inquire about violence routinely, as well as when they see
particular clinical presentations that may be associated with abuse.
They can help patients to find methods of achieving safety and ac-
cess to community resources that will allow protection and/or inter-
vention in the abusive relationship.They can educate patients about
the progression and adverse consequences of family violence, stress
management and availability of relevant mental health treatment,
and parenting skills as ways of preventing the violence before it oc-
curs. Finally, physicians as citizens and as community leaders and
medical experts can become involved in local and national activities
designed to decrease family violence.
Physicians recognise that victims of violence may find it difficult
to trust their physician at first. Physicians must be prepared to de-
velop a trusting relationship with their patient over time until s/he
is ready to accept advice, help and intervention.
The World Medical Association recommends that National Medi-
cal Associations adopt the following guidelines for physicians:
All physicians should receive adequate training in the medical,
sociological, psychological and preventive aspects of all types of
family violence. This would include medical school training in
the general principles, specialty-specific information during post-
graduate training, and continuing medical education about family
violence.Trainees must receive adequate instruction in the role of
gender, power and other issues of family dynamics in contribut-
ing to family violence. The training should also include adequate
collecting of evidence, documentation and reporting in cases of
abuse.
Physicians should know how to take an appropriate and culturally
sensitive history of current and past victimization.
Physicians should routinely consider and be sensitive to signs in-
dicating the need for further evaluations about current or past
victimization as part of their general health screen or in response
to suggestive clinical findings.
Physicians should be encouraged to provide pocket cards, book-
lets, videotapes, and/or other educational materials in reception
rooms and emergency departments to offer patients general in-
formation about family violence as well as to inform them about
local help and services.
Physicians should be aware of social, community and other ser-
vices of use to victims of violence, and refer to and use these rou-
tinely.
Physicians have the obligation to consider reporting to appro-
priate protection services suspected violence against children and
other family members without legal capacity.
Physicians should be acutely aware of the need for maintaining
confidentiality in cases of family violence.
Physicians should be encouraged to participate in coordinated
community activities that seek to reduce the amount and impact
of family violence.
Physicians should be encouraged to develop non-judgemental
attitudes toward those involved in family violence so their
ability to influence victims, survivors and perpetrators is en-
hanced. For example, the behaviour should be judged but not
the person.
National Medical Associations should encourage and facili-
tate coordination of action against family violence between and
among components of the health care system,criminal justice sys-
tems, law enforcement authorities, family and juvenile courts, and
victims’ services organizations. They should also support public
awareness and community education.
National Medical Associations should encourage and facilitate
research to understand the prevalence, risk factors, outcomes and
optimal care for victims of family violence.
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WMA news
Violence is a worldwide, institutionalised phenomenon, and a com-
plex issue, which includes many manifestations.  The nature of the
violence experienced by victims is at least partly dependent upon
the social, cultural, political and economic contexts within which
the victims and their abusers live.  Some violence is deliberate, sys-
tematic and widespread while others will experience it in covert cir-
cumstances; this is especially true of domestic violence in settings
where women enjoy legislated equal and protected rights to those of
men but culturally still have an increased likelihood of experiencing
life-threatening domestic violence.
There is clear evidence in most countries that men can be and are
often the victims of violence, including intimate partner violence. 
They are also statistically far more likely to be the victims of random
violence on the streets.  Research shows that while men frequently
experience such events, they are not associated with systemic abuse
in terms of denial of rights, which makes the experience of women
so much worse in many cultures.Nothing in this paper suggests that
violence against men including boys should be condoned.  Actions
to protect women and girls are likely to reduce everyone’s experience
of violence.
Definitions of violence vary (see footnote), but it is essential that the
various forms violence may take are recognised by policy makers. 
Violence against women and girls includes violence within the family,
within the community and violence perpetrated by (or condoned by)
the state.  Many excuses are given for violence generally and spe-
cifically; in cultural and societal terms these include tradition, beliefs,
customs, values and religion. Although rarely cited the traditional
power differential between men and women is also a major cause.
Within the family and domestic settings violence includes the de-
nial of rights and freedoms enjoyed by boys and men.  This includes
female feticide and infanticide, systematic and deliberate neglect of
girls, including poor nutrition and denial of educational opportuni-
ties1
as well as direct physical, psychological and sexual violence. 
Specific cultural practices that harm women, including female
genital mutilation, forced marriages, dowry attacks and so-called
“honour” killings are all practices that may occur within the family
setting.
Within society, attitudes towards rape, sexual abuse and harass-
ment,intimidation at work or in education,modern slavery,traffick-
ing and forced prostitution, are all forms of violence condoned by
some societies. One extreme form of such violence is sexual violence
used as a weapon of war. In several recent conflicts (e.g. the Balkans,
Rwanda) rape was both associated with ethnic cleansing and spe-
cifically, in some cases, used to introduce widespread AIDS into a
community. The ICRC has examined this issue, and recognises that
sexual violence of this sort may be commonly perpetrated against
women and girls.2
  
Sexual violence or the threat of it can also be used against men, but
culturally, women are more vulnerable and more likely to be targeted. 
Current conflicts are not based upon battles fought in far away places,
but are increasingly concentrated around dense centres of population
increasing the exposure of women to soldiers and armed groups. In
war and in immediate post-conflict situations, societal fabric can col-
lapse, making women increasingly vulnerable to group attacks.
Lack of economic independence, and of basic education, also mean
that women who survive abuse are more likely to be or to become
more dependent upon the state or society and less able to support
themselves and contribute to that society. Biologically and behav-
iourally, women are likely to outlive men; denial of the opportu-
nity to be economically independent leaves society with a cohort of
older, economically dependent women.
All these forms of violence may be condoned by the state, or it may
remain silent on them, refusing to condemn or act against them. 
In some cases the state may legislate to allow violent practices (for
example rape within marriage) and itself become a perpetrator.
All human beings enjoy certain fundamental human rights; the
examples listed above of violence against women and girls involve
denial of many of those rights, and each abuse can be examined
against the UN convention on human rights  (and for children the
Convention on the Rights of the Child).3
 
In health terms, the denial of rights and the violence itself have
health consequences to the girls and women and to the society of
which they are a part.  In addition to the specific and direct physical
and health consequences, the general way in which girls and women
are treated can lead to an excess of mental health problems; suicide
is the second leading cause of premature death in women.
The direct health consequence of the violence depends upon the na-
ture of the act. Female genital mutilation for example may kill the
woman at the time of infliction, may lead to difficulty in voiding the
body of waste products including those of menses,and will give rise to
difficulties in childbearing. It also reinforces the ideological concept
of women as the possessions of men (on its own,a form of abuse) who
225
WMA news
control their sexuality. Gang rape or other forms of sexual violence
may result in long-term gynaecological, urological and intestinal
difficulties including the development of fistulae and incontinence,
which further diminishes societal support for the abused female.
The short and long term mental health consequences of violence
may severely influence later wellbeing, enjoyment of life, function in
society and the ability to provide appropriate care for dependants.
Gathering evidence is an important role for doctors.  Currently
many countries do not have mandatory registration of all births,
making evidence about infanticide or the effects of neglect difficult
to document.  Equally, some countries allow marriage at any age,
exposing girls to the high risks associated with childbearing before
their own bodies are fully mature, let alone the mental health risks
involved.  The health consequences of such policies and their rela-
tionship to other health costs must be better documented.
Denial of good nutritional opportunities leads to generations of
women with poorer health, poorer growth and development leading
to women who are less fit to survive pregnancy and childbirth or to
rear their families.  Denial of educational opportunities leads to poor-
er health for all the family members; good education is a major factor
in the mother providing optimal care for all her family. In addition to
being wrong in and of itself, violence against women is also socially
and economically damaging to the family and to society.  There are
direct and indirect economic consequences to violence against women
that are far greater than the direct health sector costs.
The costs and consequences of violence, including neglect, against
women have been reported in many fora including by WHO4
.The
health consequences to the women, their children and thus to soci-
ety are clear and need to be made explicit to policy makers.
The WMA has a number of policies on violence including the
WMA Statement on Violence and Health and the WMA State-
ment on Family Violence. This current (Statement/resolution/ dec-
laration) brings some of these policies together with a coordinated
set of action points for the WMA,NMAs and individual physicians.
As most human beings look first for the advantages to themselves,their
families and their societies in enabling change, making the benefits of
change obvious from the beginning creates a “win:win”solution. Con-
centrating first on the health aspects,for women,their children,and the
broad family is therefore a useful way to enter the debate.
Doctors have a unique insight into the combined effects upon well-
being of social, cultural, economic and political environments.  If all
persons are to achieve health and wellbeing, all these factors need
to operate positively.  The holistic view from doctors can be used to
influence society and politicians. Gaining societal support for im-
proving the rights, freedom and status of women is essential.
Asserts that violence is not only about physical, psychological and
sexual violence but includes abuses such as harmful cultural and
traditional practices, and actions such as complicity in trafficking
of women, and is a major public health crisis.
Recognizes the linkage between better education and other rights
for women with family and societal health and wellbeing and
emphasizes that equality in civil liberties and human rights is a
health issue.
Will prepare briefing and advocacy materials for NMAs to use
with national governments and intergovernmental groups ad-
dressing the health and wellbeing implications of discrimination
against women and girls, including adolescents.This material will
include relevant references about the impact of violence on family
wellbeing and on societal financial sustainability
Will work with others to prepare and distribute to physicians and
other health workers briefing and advocacy materials dealing with
harmful traditional and cultural practices, including female geni-
tal mutilation, dowry, and honour killings, and emphasizing the
health impact as well as the violations of human rights.
Prepare practical examples of the impact of violence and strate-
gies for reducing it, such as consensus guidelines that are based
upon the best available evidence.
Will advocate at WHO, other UN agencies and elsewhere for
ending discrimination and violence against women.
Will work with others to prepare templates of educational ma-
terials for use by individual practitioners for documenting and
reporting individual cases of abuse.
Encourages others to develop free educational materials online to
provide guidance to front line health care workers on abuse and
its effects, and on prevention strategies.
Encourage legislation that classifies gang rape used as a weapon
of war as a crime against humanity that is eligible for litigation
through the jurisdiction of the International Criminal Court sys-
tem.
Use and promote the available materials on preventing and treat-
ing the consequences of violence against women and girls and act
as advocates within their own country.
Seek to ensure that those devising and delivering education to
doctors and other health care workers are aware of the likelihood
of exposure to violence, its consequences, and the evidence on
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WMA news
preventative strategies that work, and place appropriate emphasis
on this in undergraduate, graduate and continuing education of
health care workers.
Recognise the importance of more complete reporting of the
sequelae of violence and encourage the development of training
that emphasises violence awareness and prevention, in addition to
using better reporting and research into incidence, prevalence and
health impact of all forms of violence.
Encourage medical journals to publish more of the research on
the complex interactions in this area, thus keeping it in the pro-
fessions’awareness and contributing to the development of a solid
research base and ongoing documentation of types and incidence
of violence.
Encourage medical journals to consider publishing theme issues
on violence including neglect of women and girls.
Advocate for universal registration of births, and a higher age
limit for marriage.
Advocate for effective implementation of universal human rights.
Advocate for parental education and support on the care, nurtur-
ing, development, education and protection of children, especially
girls.
Advocate for the monitoring of statistics on children, including
both positive and negative indicators of health and well-being,
and social determinants of health.
Advocate for legislation against specific harmful practices includ-
ing female feticide, female genital mutilation, forced marriage,
and corporal punishment.
Advocate for the criminalisation of rape in all circumstances in-
cluding within marriage.
Condemn the use of gang rape as a weapon of war and work with
others to document and report it.
Advocate for the development of research data on the impact of
violence and neglect upon primary and secondary victims and
upon society, and for increased funding for such research.
Advocate for the protection of those who speak out against abuse,
including physicians and other health workers.
Use the material developed for their education to better inform
themselves about the effects of abuse and the successful strategies
for prevention.
Provide health care and protection to children, (especially in
times of crisis) and document and report all cases of violence
against children, taking care to safeguard the patient’s privacy as
much as possible.
Treat and reverse, where possible, the complications and adverse
effects of female genital mutilation and refer the patient for social
support services.
Oppose the publication or broadcast of victims’ names, addresses
or likenesses without the explicit permission of the victim.
Assess for risk of family violence in the context of taking a routine
social history.
Be alert to the association between current alcohol or drug depen-
dence among women and a history of abuse.
Support colleagues who become personally involved in work to
end abuse.
Work to establish the necessary relationship of trust with abused
women and children including respect for confidentiality.
Support global and local action to better understand the health con-
sequences both of abuse and of the denial of rights, and advocate for
increased services for victims.
References
1. At first glance neglect does not seem to equate with violence.  But the accept-
ance of neglect and the lesser rights given to women and girls are major factors
in reinforcing an acceptance of causal and systematic violence. In that it denies
basic rights,many would classify neglect as a form of violence in and of itself.
2. Rape is considered to be a method of warfare when armed forces or groups
use it to torture, injure, extract information, degrade, displace, intimidate,
punish or simply to destroy the fabric of the community, The mere threat
of sexual violence can cause entire communities to flee their homes.  from
Women and War, ICRC 2008
3. Women’s Health and Human Rights: the Promotion and Protection of
Women’s Health through International Human Rights Law.  Rebecca
Cook.  Presented at the 1999 Adapting to Change Core Course
4. Women and Health: Today’s Evidence, Tomorrow’s Agenda. WHO No-
vember 2009. ISBN 978 92 4 156385 7
Adopted by the 50th
World Medical Assembly Ottawa, Canada,
October 1998, reaffirmed by the WMA General Assembly, Seoul,
Korea, October 2008 and amended by the WMA General Assem-
bly, Vancouver, Canada, October 2010
International and civil conflicts as well as poverty and hunger re-
sult in large numbers of refugees, including asylum seekers, refused
asylum seekers and undocumented migrants, as well as internally
displaced persons (IDPs) in all regions.These persons are among the
most vulnerable in society.
International codes of human rights and medical ethics, includ-
ing the WMA Declaration of Lisbon on the Rights of the Patient,
227
WMA news
declare that all people are entitled without discrimination to appro-
priate medical care. However, national legislation varies and is often
not in accordance with this important principle.
Physicians have a duty to provide appropriate medical care regard-
less of the civil or political status of the patient, and governments
should not deny patients the right to receive such care, nor should
they interfere with physicians’obligation to administer treatment on
the basis of clinical need alone.
Physicians cannot be compelled to participate in any punitive or
judicial action involving refugees, including asylum seekers, refused
asylum seekers and undocumented migrants, or IDPs or to admin-
ister any non-medically justified diagnostic measure or treatment,
such as sedatives to facilitate easy deportation from the country or
relocation.
Physicians must be allowed adequate time and sufficient resources
to assess the physical and psychological condition of refugees who
are seeking asylum.
National Medical Associations and physicians should actively sup-
port and promote the right of all people to receive medical care on
the basis of clinical need alone and speak out against legislation and
practices that are in opposition to this fundamental right.
Adopted by the 51st
World Medical Assembly Tel Aviv, Israel, Oc-
tober 1999 and amended by the WMA General Assembly,Vancou-
ver, Canada, October 2010
The goal of pharmacological treatment is to improve patients’health
and quality of life. Optimal pharmacological treatment should be
safe, effective and efficient. There should be equity of access to this
kind of treatment and an accurate and up-to-date information base
that meets the needs of patients and practitioners.
Pharmacological treatment has become increasingly complex, often
requiring the input of a multi-disciplinary team to administer and
monitor the chosen therapy. In the hospital setting the inclusion of
a clinical pharmacist in such a team is increasingly common and
helpful. The right to prescribe medicine should be competency
based and ideally the responsibility of the physician.
Physicians and pharmacists have complementary and supportive
responsibilities in achieving the goal of providing optimal pharma-
cological treatment.This requires communication, respect, trust and
mutual recognition of each other’s professional competence. Access
by both physicians and pharmacists to the same accurate and up-to-
date information base is important to avoid providing patients with
conflicting information.
Physicians and pharmacists must provide quality service to their
patients and ensure safe use of drugs. Therefore collaboration be-
tween these professions is imperative, including with respect to the
development of training and in terms of information sharing with
one another and with patients. It is necessary to keep an open and
continued dialogue between physicians’ and pharmacists’ represen-
tative organizations in order to define each profession’s respective
functions and promote the optimal use of drugs within a framework
of transparency and cooperation, all in the best interests of patients.
Diagnosing diseases on the basis of the physician’s education and
specialized skills and competence.
Assessing the need for pharmacological treatment and prescribing
the corresponding medicines in consultation with patients, pharma-
cists and other health care professionals, when appropriate.
Providing information to patients about diagnosis, indications and
treatment goals, as well as action, benefits, risks and potential side ef-
fects of pharmacological treatment.In the case of off-label prescriptions
the patient must be informed about the character of the prescription.
Monitoring and assessing response to pharmacological treatment,
progress toward therapeutic goals, and, as necessary, revising the
therapeutic plan in collaboration with pharmacists, other health
professionals and, when appropriate, caregivers.
Providing and sharing information in relation to pharmacological
treatment with other health care practitioners.
Leading the multi-disciplinary team of health professionals respon-
sible for managing complex pharmacological treatment.
Maintaining adequate records for each patient, according to the
need for therapy and in compliance with legislation respecting con-
fidentiality and protecting the patient’s data.
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WMA news
Where practically possible, actively participating in establishing
electronic drug delivery systems within their workplace and sup-
porting those systems with their professional knowledge.
Maintaining a high level of knowledge of pharmacological treat-
ment through continuing professional development.
Ensuring safe procurement and storage of medicines that the physi-
cian is required to supply or permitted to dispense.
Reviewing prescription orders to identify interactions, allergic reac-
tions, contra-indications and therapeutic duplications.
Reporting adverse reactions to medicines to health authorities, in
accordance with national legislation.
Monitoring and limiting, where appropriate, prescriptions of medi-
cations that may have addictive properties.
Documenting adverse reactions to medicines in the patient’s medi-
cal record.
Ensuring safe procurement, adequate storage and dispensing of
medicines in compliance with the relevant regulations.
Providing information to patients, which may include the informa-
tion leaflet, name of the medicine, its purpose, potential interactions
and side effects, as well as correct usage and storage.
Reviewing prescription orders to identify interactions, allergic re-
actions, contra-indications and therapeutic duplications. Concerns
should be discussed with the prescribing physician but the phar-
macist should not change the prescription without consulting the
prescriber.
Discussing medicine-related problems or concerns with regard to
the prescribed medicines when appropriate and when requested by
the patient.
Advising patients, when appropriate, on the selection and the use of
non-prescription medicines and the patient’s management of minor
symptoms or ailments. Where self-medication is not appropriate,
advising patients to consult their physician for diagnosis and treat-
ment.
Participating in multi-disciplinary teams concerning complex phar-
macological treatment in collaboration with physicians and other
health care providers, typically in a hospital setting.
Reporting adverse reactions to medicines to the prescribing physi-
cian and to health authorities in accordance with national legisla-
tion.
Providing and sharing general as well as specific medicine-related in-
formation and advice with the public and health care practitioners.
Maintaining a high level of knowledge of pharmacological treat-
ment through continuing professional development.
The patient will best be served when pharmacists and physicians
collaborate, recognizing and respecting each other’s roles, to ensure
that medicines are used safely and appropriately to achieve the best
outcome for the patient’s health.
Adopted by the WMA General Assembly, Vancouver, Canada, Oc-
tober 2010
From the beginning of their studies and throughout their profes-
sional careers, doctors acquire the knowledge, training and compe-
tence required to treat their patients with the utmost skill and care.
Physicians determine the most accurate diagnosis and the most ef-
fective treatment to cure illness, or alleviate its effects, taking into
consideration the overall condition of the patient.
Pharmaceutical products are often an essential part of the treatment
approach.  In order to make the right decisions in accordance with
the ethical and professional principles of medical practice, the doc-
tor must have a thorough knowledge and understanding of the prin-
ciples of pharmacology and possible interactions among different
drugs and their effects on the health of the patient.
The prescribing of medication is a significant clinical intervention,
which should be preceded by multiple, integrated processes to as-
sess the patient and determine the correct clinical diagnosis. These
processes include:
Taking a history of the current condition and past medical his-
tory;
The ability to make differential diagnosis;
Understanding any multiple chronic and complex illnesses in-
volved;
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WMA news
Taking a history of the medications currently being administered
successfully or previously withdrawn and also being aware of pos-
sible interactions.
Inappropriate drug prescription without proper knowledge and accu-
rate diagnosis may cause serious adverse effects on the patient’s health.
In view of the possible serious consequences that may result from an
inappropriate therapeutic decision, the WMA affirms the following
principles on high quality treatment and ensuring patient safety:
Prescription of drugs should be based on a correct diagnosis of the
patient’s condition and should be performed by those who have suc-
cessfully completed a curriculum on disease mechanisms, diagnostic
methods and medical treatment of the condition in question.
Prescriptions issued by physicians are vital for ensuring patient safe-
ty, which in turn is critical for maintaining the relationship of trust
between patients and their physicians.
Although nurses and other healthcare workers cooperate in the
overall treatment of patients, the physician is the best qualified in-
dividuals to prescribe independently. In some countries, laws may
allow for other professionals to prescribe drugs under specific cir-
cumstances, generally with extra training and education and most
often under medical supervision. In all cases, the responsibility for
the patient’s treatment must remain with the physician. Each coun-
try’s medical system should ensure the protection of public interest
and safety in the diagnosis and treatment of patients. If a system
fails to comply with this basic framework due to social, economical
or other compelling reasons, it should make every effort to improve
the situation and to protect the safety of the patients.
The World Medical Association added its
support to worldwide calls for an immedi-
ate inquiry into allegations that more than
700 women, men and children were raped
when Angola recently expelled thousands
of people back to the Democratic Republic
of Congo. These atrocities add to the wide-
spread and systematic nature of rape and
other human rights violations in the Congo
by rebels. More than 8,000 women were
raped during fighting in 2009, the UN says.
In a statement to mark the international day
fortheeliminationofviolenceagainstwomen
(http://ndcommunications.hosted.phplist.com/
lists/lt.php?id=N0RSBk8BBkgMU1Q%3D,
the WMA”s chair Dr. Edward Hill said:
„The appalling allegations of rape in the
Congo are a grim reminder that violence
against women has become a systematic
weapon of war. This is only the latest in a
catalogue of similar atrocities in various
parts of the world. As the WMA declared
in its Statement last month this is a major
public health issue and one on which physi-
cians are calling for absolute zero tolerance.
„Today we are calling in the strongest possi-
ble terms for the perpetrators of these rapes
to be prosecuted for their crimes. We urge
all national medical associations to remind
their members to pay far greater attention
to these unacceptable violations of the most
basic women”s human rights.
„Physicians are in a position to document
and report all cases of violence against
women that come to their attention and I
would urge them to do so. We must also
seek to protect those who speak out against
abuse,including physicians and other health
professionals.”
Dr. Nkelani Matondo Norine, from the
Order of Physicians of the Democratic
Republic of Congo, said that the situation
of abused women in the Congo was criti-
cal and required urgent attention from the
international community and all organiza-
tions working for peace and human rights.
Mass rape had become a weapon of destruc-
tion, much used by the enemy and many
physicians were now working for women
victims in the area, including Dr. Denis
Mukwege of the Panzi Hospital in Bukavu/
South Kivu, specializing in the reconstitu-
tion of vaginas, which has already operated
on more than mutilated 20,000 women.
She added: „In my political struggle
against violence towards women, I al-
ways explain the disastrous consequences
of sexual assault. It can cause lesions that
can have grave consequences in the long
run, such as frigidity and sterility. Sexually
transmissible diseases, such as HIV, and
unwanted pregnancies are other common
consequences.
„Psychologically, women feel diminished
and humiliated and without proper support
from a psychology specialist, they fall into
a deep depression. Socially, many women
are abandoned by their husbands because of
rape. Towards their children, they feel hu-
miliated, in particular those violated in the
presence of her children”.
Dr. Nkelani said: “the WMA and its mem-
bers should put pressure on the UN to take
appropriate action towards the Congolese
authorities.”
230
WMA news
Cancun The “Cancun Climate and
Health Statement” launched 6th
December,
2010, Health Day at COP 16 [1], calls on
negotiators to consider the “real costs” of
climate change and the benefits of strong
action by taking the human health dimen-
sion into account.
Endorsed by the World Medical Associa-
tion [2], the International Council of Nurs-
es and other global health organizations
representing millions of health profession-
als worldwide [3], the Cancun Climate and
Health Statement calls on the negotiators
to “take into account the significant hu-
man health dimensions of the climate crisis
along with the health benefits of climate
change mitigation and adaptation policies.”
Dr. Michael Wilks from the Standing
Committee of European Doctors (CPME)
[4] in announcing the Statement during a
meeting of the World Health Organization
[5] says: “Overwhelming evidence exists
that reducing greenhouse gases benefits not
just health but countries’ economies. These
“co-benefits” provide all those attending
Cancun with a powerful and unifying new
narrative – reducing greenhouse gases is
good for your health, and for your budget.”
One regional example of these co-benefits
is recent research published by the Health
and Environment Alliance and Health Care
Without Harm Europe. It shows that up to
an additional 30.5 billion Euros of public
health benefits could be achieved each year by
2020 if the European Union adopted a policy
of 30% domestic cuts in greenhouse gas emis-
sions (instead of the current 20% target) [6].
But negotiators in Cancun are barely men-
tioning this health dividend to the climate
talks. “Negotiations seem focused on fi-
nancial rather than human costs of climate
change,” says Professor Hugh Montgom-
ery, University College London. “We want
them to take into account the fact that,
quite aside from any benefits from avert-
ing climate change, strong data show that
low-carbon living brings with it enormous
benefits to health (less cancer, heart and
respiratory disease, dementia, diabetes, de-
pressive illness) and with that comes huge
savings in healthcare costs. These health
gains could substantially offset the costs
of mitigation and urgently need to be fac-
tored in” [7].
“Monetary estimates of public health sav-
ings do not just apply to Europe: a re-
cent independent scientific report shows
that such health and financial gains apply
worldwide, and especially to countries such
as India and China” [8]. “We want the even
greater benefits for health in countries and
regions other than Europe to be taken into
account by governments and acted upon. It
is high time for governments to realize that
reducing greenhouse gas emissions will im-
prove human health and save them money.
Today – Health Day at COP 16 – we plan to
take this message to delegates,” says Pendo
Maro, Senior Climate Change and Energy
Policy Advisor,Health Care Without Harm
Europe (HCWH Europe) and Health and
Environment Alliance (HEAL).
Dr. Pendo Maro, Health Care With-
out Harm Europe (HCWH Europe)
and Health and Environment Alliance
(HEAL), pendo.maro@hcwh.org  or pen-
do@env-health.org. Mobile phone: + 32
495 281 494(in Cancun)
Dr. Michael Wilks, Standing Committee
of European Doctors, MWilks@bma.org.
uk. Mobile phone: + 44 7870 674490(in
Cancun)
Prof. Hugh Montgomery, University
College London, h.montgomery@ucl.
ac.uk  Mobile phone: +44 7981 654 009
1. Health Day at COP 16 has been organized
to bring the health community together to
highlight the benefits for public health of
strong climate change to delegates. Doctors
and health experts believe that this is a crucial
argument for why we need to work towards a
global agreement.
2. The World Medical Association is a credited
observer at the UNFCCC talks. The Decem-
ber issue of its Journal will feature climate
change. See WMA website.
3. The Cancun Climate and Health Statement
is signed by ten organizations: Climate and
Health Council, International Federation of
Medical Students’ Associations, Health and
Environment Alliance, Health Care Without
Harm, International Council of Nurses, In-
ternational Society of Doctors for the Envi-
ronment, Physicians for Social Responsibility,
Standing Committee of European Doctors,
World Federation of Public Health Associa-
tions, and World Medical Association. It has
also been endorsed by Richard Horton,Editor,
The Lancet, and Fiona Godlee, Editor, Brit-
ish Medical Journal. It is available in English,
French and Spanish.
4. Dr. Michael Wilks, Climate Advisor and
Immediate Past President of the Standing
Committee of European Doctors (CPME)
is part of the Health and Environment Al-
liance/Health Care Without Harm Europe
delegation in Cancun. CPME represents 27
medical associations with approximately 1.5
million members in Europe. Other mem-
bers are Pendo Maro (see above), Prof Hugh
Montgomery, University College Lon-
don, UK and Walter Vernon (HCWH US
Board), San Francisco, USA. More about
them at HEAL website and at HCWH
website. The delegation is working closely
with other groups in Cancun including In-
ternational Federation of Medical Students’
Associations (IFMSA) and Nurses Across
the Borders (Nigeria).
5. The Cancun Climate and Health Statement
will be announced by Dr Wilks at a World
Health Organization and World Food
Programme “side event” called “Improv-
ing resilience to protect human health and
welfare from the adverse affects of climate
Source: http://www.noharm.org/global/news_hcwh/2010/dec/hcwh2010-12-06a.php  
231
Medical and socio-medical affairs
change” to be held on Monday, 6 December
from 13.20 to 14.40 (Mexico time, minus
6  GMT).
6. “Acting Now for better health, A 30% reduc-
tion target for EU climate policy”, HEAL and
HCWH Europe, Brussels, September 2010.
7. Prof. Montgomery was one of the lead authors
involved in The Lancet Series, Health and
Climate Change, November 2009. One study
showed that lower carbon policies in Lon-
don and New Delhi associated more “active
transport” (walking and cycling), more public
transport and reduced use of private cars could
produce measurable benefits for heart disease,
cerebro-vascular disease, dementia, breast can-
cer,lung cancer,colon cancer,diabetes,and de-
pression. It was called “Public health benefits
of strategies to reduce greenhouse gas emis-
sions: urban land transport.”
8. Inter Academy Medical Panel, 2010, State-
ment on the health co-benefits of policies to
tackle Climate Change (from Haines A, et al.
(2009). Public health benefits of strategies to
reduce greenhouse-gas emissions: overview
and implications for policy makers. The Lan-
cet. doi:10.1016/S0140-6736(09)61759-1.)
Achieving final agreement on the draft Di-
rective on Patients’ Rights in Cross-Border
Healthcare in the next few months will
be an important step forward in codify-
ing patients’ rights in European law. While
the draft Directive as it stands today is not
perfect with some remaining gaps and de-
tails that need to be worked out in its key
aspects the recommendation of the Euro-
pean Parliament has the broad support of
patients and the health community.
This was the strong message from stake-
holders the High-Level Roundtable organ-
ised by the European Patients’Forum under
the patronage of the Belgian EU Presi-
dency, ahead of the Council’s debate on the
draft Directive on 6 December 2010, and
in anticipation of the draft Directive’s Sec-
ond Reading in the European Parliament
in mid-January 2011. Indeed, some of the
participants were involved in the trialogue
meeting that was to take place on the eve-
ning of 1 December.
In the words of , Commis-
sioner for Health and Consumers, the mo-
mentum achieved so far in the negotiations
means that “time is of the essence”, and
flexibility is needed to reach agreement.
However, Mr Dalli reiterated that his guid-
ing principle is “patients first”, so while the
Belgian Presidency and the EP can count
on the European Commission’s support in
finding acceptable compromise solutions,
“we should not lose sight of the proposed
Directive’s original purpose: to clarify pa-
tients’ rights to access safe and good quality
treatment across borders,and be reimbursed
for it.”
In the course of the day, most of the high-
level participants at the Roundtable con-
tributed their views as stakeholders. In ad-
dition to the Health Commissioner, they
included members of the European Parlia-
ment, Commission officials, representatives
of the Belgian Presidency and the Perma-
nent Representations of Sweden, Denmark,
Romania plus the Swiss negotiating team,
as well as leaders of stakeholder organisa-
tions (nurses, doctors, community phar-
macists, hospital, health managers, medical
specialists, the pharmaceutical industry and
medical devices industry).
, Head of the Belgian Na-
tional Institute Health & Disability Insur-
ance (NIHDI) stressed that the Belgian
Presidency’s approach to the Directive was
not a simple application of the EU’s internal
market rules, but a sector-specific approach
on the basis of high quality, equity and
universality in healthcare. “The Directive
will create a momentum beneficial to all
patients, not just the one or two percent of
patients that would need to travel abroad”,
he said. He also emphasised that the de-
bate is not just about general principles, but
about practical issues that affect patients’
lives and which therefore require solutions
to be found.
, the Rap-
porteur on the draft Directive, said that
MEPs want to reassure the Council that the
purpose of the Directive is not to promote
health tourism or facilitate cross-border ac-
tivity by healthcare providers what is vi-
tally important is that it offers patients the
opportunity to access healthcare that is not
available to them in their own countries. In
this context,she regretted the “lack of ambi-
tion”shown by some Member States, which
seem willing to accept a continuation of the
current system of patients seeking recourse
to the courts in defence of their rights.
addressed
the wider topic of health inequalities. She
stressed the importance of addressing the
existing health inequalities across the Euro-
pean Union, and linked the Directive to the
ongoing work by the Commission and the
Parliament, including the health inequali-
ties report now being discussed within the
ENVI Committee. It is crucial to uphold
the right of all patients to access good qual-
ity healthcare in their own countries, par-
ticularly in the context of the current eco-
nomic climate. She finally highlighted that
the Directive should be seen as a first step,
which should later serve to promote a wider
approach of public health initiatives at EU
level.
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Medical and socio-medical affairs
Manchester, UK – Bioanalysis announced
that Stephen Holman (Michael Barber
Centre for Mass Spectrometry Manches-
ter Interdisciplinary Biocentre (MIB), The
University of Manchester) has been award-
ed the Young Investigator of the Year title
by the international editorial board of the
monthly journal Bioanalysis.
Over the course of 2009/2010, the profiles
of 8 international bioanalysts were featured
in the journal, nominated by their supervi-
sors. Each Young Investigators was given the
opportunity to highlight their bioanalytical
work to date, discuss their future career aspi-
rations and give their thoughts on the future
revolution of the field of bioanalysis.
The Young Investigator of the Year award
has been awarded by the international edi-
torial advisory board of Bioanalysis in rec-
ognition of the achievements of a young
bioanalysts at an early stage of their career.
At the end of the year, votes were cast by
the international editorial advisory panel to
select the winner.
Brian Booth, US FDA, Senior Editor
said: “When we launched Bioanalysis, we
thought of beginning a regular Young In-
vestigator segment to highlight the devel-
opment and talents of the youngest genera-
tion in this field. They represent the future
of this science, and there are very few ven-
ues to demonstrate their skills and potential.
The purpose of this award is to stimulate
these young people and provide some small
Other key issues identified by various con-
tributors included the following:
The importance of safety and quality of
healthcare is recognised by all. There ap-
pears to be agreement in principle on
Member State cooperation in this area,
although there is disagreement about the
exact mechanisms to ensure safety and
improve quality.Mr Dalli said: “I am con-
fident that once adopted, this Directive
will pave the way towards a convergence
of standards in this area.”
From the patients’perspective,upfront pay-
ment, reimbursement and prior authorisation
remain crucial. In order to ensure equity,
and to prevent new inequalities emerg-
ing, a workable system must be found to
avoid individual patients having to shoul-
der the financial burden of cross-border
healthcare. Mrs Grossetête emphasised
that “money must not be a form of dis-
crimination”.There is strong support from
patients’ organisations echoed among
MEPs for developing a system to handle
cross-border payments directly. Establish-
ing national channels for accessible, clear
and reliable information for patients is a
crucial component of the process.
From the perspective of patients with rare
diseases, obtaining an accurate, timely diag-
nosis is pivotal point in the delivery of care.
A compromise that enables cross- border
solutions for rare diseases patients to access
to diagnosis in the first instance, will be an
acceptable starting point. It is also crucial
that prior authorization be given by special-
ist physicians familiar with rare diseases and
their complexities.A clear procedure should
be established for such cases.
The importance of eHealth to patient safety
and continuity of care, and its role in the
future sustainability of health systems was
mentioned by several contributors, while
the challenges of achieving interoperabil-
ity and working cross-border prescrip-
tions were also acknowledged. Speakers
felt that those Member States with the
most advanced systems should promote
the sharing of information and best prac-
tices. However, as the area is still contro-
versial, any eventual compromise is likely
to be a partial solution, on which further
cooperation may be built in future.
The role of health professionals, and the
sharing of practitioner information across
Member States to improve patient safety
were touched upon, as were the practical
implications of cross-border healthcare
for other actors, such as health managers
and administrators.
Once the Directive comes into force, there
will be much work involved in its imple-
mentation and its eventual review. The
real-life impact of the Directive on patients
and all the other parties will only become
clear as it is implemented across the EU.
The involvement of all relevant stakeholders,
including patients’ organisations, in this
process will be key to its success.
In his summing up at the end of the day,
, EPF President
stressed the importance of keeping the
principles of equity and solidarity at the
centre of the draft Directive: “At heart, the
Directive is, after all, about people the pa-
tients, who need equitable access to good
quality healthcare. We as EPF, and through
our member organisations and allies all over
Europe, are committed to playing the part
of a proactive and constructive partner in
this ongoing process, and we look forward
to working together with the Institutions,
and with all stakeholders to make the Di-
rective the best it can be.”
A full report of the High-Level Roundtable
will be prepared and disseminated to all par-
ticipants and stakeholders in the next days.
For more information please contact:
Kaisa Immonen-Charalambous
Policy Officer
European Patients’ Forum 65, rue
Belliard, 1040 Brussels Tel:+3222802334
Fax: +3222311447
Website: www.eu-patient.eu
Nicola Bedlington, Director
233
NMA news
Marija Vavlukis
From September 30th
through October 2nd
,
the Macedonian Medical Chamber hosted
the 17th
Symposium of Medical Cham-
bers of the Central and Eastern European
Countries – ZEVA.
The central theme of the meeting was “pa-
tient safety and quality in medicine”. Issues
concerning self-governance and self-regula-
tion in medicine were also main topics. The
Symposium was attended by 39 participants
from delegations of 17 European countries.
Members of the Assembly, the Executive
Board and members of bodies of the Medi-
cal Chamber of Macedonia, as well as rep-
resentatives of the Macedonian Medical
Association, the Ministry of Health and
various NGOs were in attendance.
The meeting began on September 30th
with a reception organized by the Medical
Chamber. Opening ceremonies were prop-
erly commenced with opening remarks by
the President of the Macedonian Medical
Chamber – Vladimir Borozanov. He wished
a warm welcome to all guests and partici-
pants. Welcome and wishes for successful
work on behalf of The Ministry of Health
were delivered by Deputy Minister, Vladi-
mir Popovski.
The meeting was enriched by lectures and
discussions,especially on topics discussed by
Dr. Dana Hanson, President of the World
Medical Association, Dr. Otmar Kloiber,
Secretary General of the World Medical
Association, and Dr. Konstanty Radzivill
President of the Standing Committee of
reward for their efforts. Stephen Holman
was selected this year (among some very
stiff competition) because of his involve-
ment in some innovative research, and we
anticipate much more from him in the fu-
ture. Congratulations Stephen!”*
Stephen Holman commented; “I was very
surprised, but also very honoured and hum-
bled, to be bestowed the award of Young In-
vestigator of the Year 2010.” He went on to
say,“The award will provide a significant boost
to my CV given that it is a truly international
prize; the list of nominees spanned several
continents, as did the selection committee
who decided upon the eventual awardee. The
journal is quickly becoming established in the
field of Bioanalysis, and to be associated with
it as the first recipient of the Young Investiga-
tor award is a great privilege.”
In addition, Stephen’s original profile/
nomination can be found here: http://
www.future-science.com/doi/abs/10.4155/
bio.09.45
Stephen was nominated for the award by
Dr Pat Wright (Pfizer UK) whilst studying
for his PhD at the University of Southamp-
ton. Pat said: “Stephen has shown himself
to be an exceptional advocate for bioanalysis
and an outstanding researcher. He quickly
adapted his skills to the requirements of his
PhD project, acquiring an understanding of
mass spectrometry to which even more ex-
perienced practitioners would aspire. With-
in 18 months, he published his first paper,
with a second being recently accepted for
publication, and he has presented his work
at a number of meetings. In September
2008, he received the Michael Barber award
for the best student oral presentation at the
British Mass Spectrometry Society confer-
ence in York, which attests to his enthusi-
astic delivery as well as the high standard
of his science. His outstanding work and
position in his peer group was further rec-
ognized when he won the poster prize com-
petition, held at the end of the second year
of PhD study at the School of Chemistry,
University of Southampton. Stephen has
expanded his project to a self-initiated and
exciting area that is not only of extreme rel-
evance to metabolite identification, but also
increases fundamental knowledge of gas-
phase ion chemistry within the collision cell
of a mass spectrometer.”
Stephen receives a complementary 1-year
print and online subscription to Bioanalysis
and the next paper he submits to Bioanaly-
sis will be highlighted as “Young Investiga-
tor of the Year 2010”and made free-to-view
permanently, which we hope will further
boost his research career.
Bioanalysis is now accepting nominations
for Young Investigator 2011. They should
be under the age of 30, including Masters
and Doctorate students, Post doctorate re-
searchers and those working in industry. If
you wish to nominate a Young Investigator,
please contact the Commissioning Editor at:
r.devooght-johnson@future-science.com.
* The views expressed are those of the author and do not
reflect official policy of the FDA. No official endorse-
ment by the FDA is intended or should be inferred.
234
NMA news
European Doctors.Rich and interesting de-
bate sparked wide interest among the par-
ticipants, who stressed that the meeting in
Skopje opened new horizons in the opera-
tion of medical associations.
, gave
his speech about medical regulation and
self-government At the beginning of his
speech he spoke about self-regulation and
self -governance in professional organiza-
tions and associations. He remarked that
self-regulation in an association is a bal-
ance between professional and public func-
tions. If the activities of the association are
dominated by public offices, membership
in such associations is compulsory, but if
dominated by professional functions, mem-
bership is optional. He pointed out that, in
democratic societies, self-regulation means
a healthy distribution of power, protecting
the freedom of vulnerable groups and those
who serve them. It was noted that the chal-
lenges of these organizations are:
Competence,
Quality,
Behavior (without the involvement of
criminal activities), and
Providing high quality health care for all.
In regard to patients and patient relation-
ships, it is important to remember that
patients are not customers or consumers
and healthcare professionals are not only
providers of healthcare services. Self-man-
agement in healthcare is much more than
self-regulation; it involves a contract with
society, and often represents more effort
than a privilege. Self-regulation is a factor
that provides quality care for all.
spoke
about the system to ensure patient safety
from the German perspective. Elaborating
on the German experience, she concluded
that patient safety must be an integral part
of all institutions involved in healthcare,
through good communication and coop-
eration, measures that to some degree have
been implemented in daily routine practice.
These measures should, in the future, be
available to every healthcare professional
and be emphasized as the role of experts
and boards of arbitration in terms of pre-
vention of adverse incidents and promotion
of increased professionalism. Identification
and implementation of quality indicators to
ensure the safety of procedures and patient
safety must be based on scientific research,
by which an authoritarian system will be re-
placed by a system of learning from errors.
, shared Austrian ex-
periences on the measures and activities un-
dertaken by Austrian institutional systems
to improve patient safety. The focus was on
the experiences of utilizing an electronic
database for patients, particularly in relation
to the prescribing of drugs by doctors and
pharmacists, and the possibility of interac-
tions especially in select patient subgroups,
such as the elderly and patients with mul-
tiple diseases. He underlined that improv-
ing care for patients must be accompanied
by appropriate legislation. Dr. Bretenhaler
also explained the Medical CIRS project
for anonymous reporting of critical inci-
dents, and the learning system based on this
by health professionals with the support of
health authorities.
Prof. Borozanov- President of Macedonian
Medical Chamber and host of the meeting,
gave his introductory lecture about actual
situations in the area of patient safety and
quality in healthcare in Macedonia. At the
beginning he stressed the necessity of con-
sistent terminology in the area of medical
235
NMA news
error. It was reemphasized that despite
well-documented cases of unsafe care in de-
veloped countries, we are lacking the load-
bearing unsafe medical care in countries in
transition and developing countries, where
limited resources, technology and infra-
structure contribute to increase this burden.
In our field, we need considerable political
will and cooperation from all stakeholders in
the to improve the education of health pro-
fessionals in the field of patient safety, and
to stimulate research projects in this area,
which ultimately will result in improved
quality of treatment. Required related sys-
tems for documenting and disseminating at
the national level will result in linking the
institutions of the system horizontally and
vertically, including the private and public
sectors, based on the principle of fairness
and impartiality. What is now a reality in
our country is that we have established ev-
idence-based standards in patients’ medical
treatment beginning in 2006, but we lack
feedback on their implementation. A par-
ticularly prominent project is the introduc-
tion of the electronic medical card, however,
we cannot yet speak on the effectiveness of
an integrated medical information system.
Patient safety depends on many elements.
Doctor-patient confrontations are absolute-
ly an undesirable situation. The improve-
ment of the working environment of medi-
cal professionals is critical to providing a
healthy work environment.That way we will
minimize the role of the human factor as a
cause of medical errors. In order to improve
patient safety by 2008, a law was introduced
to protect patients rights and manuals dis-
tributed to facilitate its implementation.
Despite numerous systems for reporting
cases of unsafe treatment, available data
is insufficient. There were less than 100
reported cases in the last eighteen months
to state authorities, primarily to the Insti-
tute of Public Health and state inspection.
This practice shows that patients, or their
families, often complain or report cases of
unsafe care, not in the system, but at less
appropriate places (in the electronic media,
to the Minister of Health in person, to the
directors of health facilities, and rarely in
the Medical Chamber). Work is needed in
this area to ensure one comprehensive sys-
tem for reporting medical errors.
During the meeting, representatives of med-
ical associations presented their experiences
in their work and the problems they face in
realizing the goals and tasks through their
national reports. Six national reports were
presented from five countries from the re-
gion (Serbia,Slovakia,Croatia,Romania and
Canton Sarajevo – Bosnia and Herzegovina).
Speaking on the experiences of the Serbian
Chamber, the President of the Medical As-
sociation of Serbia presented the legisla-
tion on which it operates, including some
of their problems . Prominence in the re-
port was given to the policy for prescription
drugs. It was emphasized that it prescribing
is restricted only to general practitioners,
and specialists can only prescribe drugs in
rare, specific cases. However, despite this
absurd situation Serbian doctors do not for-
get their ethical principles. In the second
part of the report, the president addressed
the status of medical professionals. It was
noted that only 37.6% of physicians are sat-
isfied with the availability and equipment
at work, only 19.2% are satisfied with their
earnings,and over 60% are satisfied with the
choice of profession.
The report from the Medical Association in
Slovakia largely concerned the identifica-
tion of general common interests in relation
to:
Improvement of medical care;
Increased patient safety;
Greater satisfaction of all stakeholders in
the system.
Measures that can achieve these objectives
are: improving the relationship in the re-
lational triangle of doctors-patients-health
institutions,improving relations with health
insurance funds, the quality of medical care
and ways of payment for medical care pro-
vided, and the intellectual efforts and op-
portunities for the public.
The Romanian delegation presented two
national reports. In the first report atten-
tion was given to the relationship between
the historical evolution and current situ-
ation in order to present the situation in
their country and organization, as well as
difficulties in the initiation and continua-
tion of reforms. Significant observations in
the report were:
The medical profession in Romania is not
treated as a craft but as a liberal profes-
sion;
The healthcare system focuses on each
patient individually;
Restrictions on the role of the legisla-
tor in establishing general conditions in
healthcare policies is recommended, as
well as limiting the misuse of the medi-
cal profession. It was pointed out that se-
curity and protection of the patient as an
individual is not only the responsibility of
health authorities.
identified two central
guidelines aimed toward the Chamber:
The Chamber represents a guarantee for
high standard of medical profession and
ethics.
For physicians, the Chamber is an insti-
tution through which they are represent-
ed in society, administration and politics.
The Chamber has a legal background and
a multitude of functions including: the de-
velopment of professional ethics and super-
vision of the profession, the supervision of
postgraduate education, continuing medical
education, licenses and registration, arbitra-
tion, and quality assurance of healthcare
236
NMA news
services.The Chamber defends the econom-
ic interests of doctors at all levels, including
working conditions,represents medical pro-
fessionals to the media and political enti-
ties, and, although often in limited capacity,
can participate if called upon in legal proj-
ects and other regulatory matters, providing
its expert opinion if asked in court or parlia-
mentary bodies.
There are other, social functions of the
Chamber as well, for example, an initiative
for additional pension insurance intended
solely for the medical profession so that
they can provide welfare to members in
need.
Dr. Kulenovik gave a comprehensive de-
scription of the Medical Chamber of Bos-
nia and Herzegovina, and the problems
faced by the chambers within the country.
The assertion of his speech was that the
quality of medical care also depends on
the condition of medical professionals.
The conclusion was that efforts should be
directed towards activities to improve the
material and financial wellbeing of medical
professionals.To achieve these goals, cham-
bers have to act together with the unions in
a measure of solidarity when approaching
government institutions. Government in-
stitutions should bear in mind that the best
way to express respect for the medical pro-
fession is through material rewards and a
more dignified presentation of the medical
profession in society.
The title of the report of the Croatian
Medical Chamber was “between doc-
tors and objective needs and real op-
portunities as a result of organization-
al, legal and technological resources”.
The first part of the report was the presen-
tation of the historical development of the
Chamber’s organization in Croatia from
1913 until today. The report followed with
the presentation of current activities, such
as preparing and maintaining the Register
of doctors, the process of licensing, supervi-
sion and oversight of the work of doctors,
the determination of basic working condi-
tions and prices of services of private doc-
tors.. Among other things discussed was the
prominent cooperation with educational
institutions in the country and the super-
vision and evaluation of continuing profes-
sional training of doctors in Croatia. The
Croatian Chamber has the prominent role
in cooperation with the Croatian Health
Insurance Institute in proposing the basics
of the health network as well as suggestions,
opinions and expert opinions in this area.
The President of the Chamber is a member
of the Croatian parliamentary Committee
on Health and the Board of Directors of
the Agency for quality and accreditation.
Regarding patients’ rights, this body un-
conditionally supports their needs, guaran-
teeing quality and accessibility to healthcare
institutions, protecting their rights before
the decisions of healthcare administrations,
and sanctioning doctors.
Dr. Radziwill spoke about current EU poli-
cies and activities of this the CPME.This is
an organization of 27 European countries
and other specialized European medical
associations. The purpose of this organiza-
tion is to promote high standards in medi-
cal practice for all residents of Europe. He
stressed the need for further development
of electronic databases in healthcare sys-
tems and for their availability and a stan-
dardization of communication. In terms
of patient safety, he noted that the CPME
contributes actively in order to complete the
project EUNetPaS, especially in the field of
education, training and manuals. He also
cited other problems in healthcare policy
related to the field of patient safety.
Dr. Vurhe shared the German experience
on the evaluation of postgraduate education
of residents. Analysis of evaluation that spe-
cializing doctors made about the quality of
their education is the basis for recommen-
dations provided by the German Associa-
tion, and refers to postgraduate education.
Namely, it is recommended that reports of
any specialist training center be analyzed by
specialists and residents together.Individual
results should be published if necessary, and
positive and negative impacts on specialist
training should be clearly stated. Emphasis
on the importance of clear feedback should
be made which would motivate participants
to be involved in projects of this kind in
future. According to the findings that Dr.
Vurhe presented for this project, it is evi-
dent that residents exhibit little interest in
participating in the evaluation of educators
and training programs in such a manner
(electronic).Those who expressed interest in
participating in the project have expressed
their dissatisfaction with the workload in-
volved in their practice, bureaucratic proce-
dures, and time pressure and overtime work.
Precisely because of these considerations, a
clear need for open discussion about these
problems was expressed,in order to improve
operational models.
Dr. Georgievska-Ismail addressed the pro-
cess of continuing medical education or-
ganized within the activities of the Mace-
donian Medical Chamber. CME is a tool
that covers the gap between current and
237
Climate change
optimal medical care. She stays current
with healthcare law according to which
doctors are bound by CME. Successfully
performed, CME is the basis for renewal
of medical licenses, an activity that has
been legitimately transferred to the Medi-
cal Chamber. The current organization
of CME is based on global principles for
its performance, but the observations are
that its impact on professional practice
is moderate. This is important because of
the introduction of the process of moving
from CME to CPD. Continuous profes-
sional development is a range of educa-
tional activities through which healthcare
professionals maintain and develop their
capacity to practice safely, effectively and
legally within their practice. In her speech,
Dr. Georgievska-Ismail stressed the dif-
ferences between CME and CPD, and
suggested ways to implement CPD. Her
main suggestion: There should be a process
of learning based on practical work (prac-
tice), which can be implemented through
four major levels of CPD: identifying areas
of improvement, engaged learning, apply-
ing new knowledge and skills in practice
and control of improvement. She then
she addressed the major obstacles in the
implementation of CPD: lack of knowl-
edge about the usefulness of education,
lack of time, resources and opportunities,
the wrong timing and type of educational
activities, lack of wider choice of learning
and professional conservatism. What is
expected as a benefit of regular CPD is
well-designed educational activities, phy-
sician satisfaction, change in knowledge
and behavior and improved medical care
to patients.
The main conclusions and recommenda-
tions from this ZEVA meeting will be
merged into one declaration mainly de-
signed for countries and governments
from the ZEVA region. The main idea: it
is necessary to change the widely accepted
perception of unsafe medical care as a doc-
tor’s (medical personnel) error.  It is of es-
sential importance to identify patient safety
incidents as a result of a system-wide error.
The declaration will soon be distributed to
all professional associations of the member
states of the ZEVA region. The host of the
next – XVIII ZEVA Symposium in Sep-
tember next year will be the Polish Cham-
ber of Physicians and Dentists.
Marija Vavlukis MD, PhD
University Clinic for Cardiology, Macedonia
e-mail: marija.vavlukis@gmail.com
It is high time for doctors everywhere to
stand up and be counted on the impact of
climate change on health.
The phenomenon of human-induced global
climate change can no longer be refuted [1].
Without any doubt, climate change will hit
public health and health services very hard.
Last year, the world’s foremost medi-
cal journal, the Lancet described climate
change as the greatest potential threat to
public health in the 21st
century. It said that
climate change will have devastating effects
on human health as a result of changing
patterns of disease, heat waves, reduced wa-
ter and food security, and because extreme
weather events, such as hurricanes, cyclones
and storm surges, will result in flooding and
direct injury [2].
With catastrophes like Haiti or Pakistan in
the news, no-one finds it difficult to imag-
ine the pressure on medical staff from ex-
treme weather, especially in an era of ever
tightening health budgets.
The Standing Committee of European
Doctors, Health and Environment Alliance
Michael Wilks Genon Jensen Anja Leetz
238
Climate change
(HEAL) and Health Care Without Harm
(HCWH) are currently in Cancun, Mexico
where the latest round of climate change ne-
gotiations is taking place. We are convinced
that the leadership of health professionals
– with its high moral standing – is vital to
persuade governments about the urgency of
strong climate change policy. Acting now
will save lives and reduce health care and
other costs for governments.
Fortunately, we have a positive message
to help us convince governments in Can-
cun. Research shows that stronger climate
change policy would bring almost immedi-
ate public health benefits. This is because
some policies aimed at mitigating climate
change have the effect of reducing air pollu-
tion and therefore improving health.
The so-called “co-benefits” of climate
change are entirely separate from the poten-
tial health benefits associated with combat-
ing global warming.The co-benefits, or side
effects of climate change policy, take place
because as falls in greenhouse gases occur
so do air pollutants such as fine particles,
nitrogen oxides and sulphur dioxide. Since
exposure to air pollutants is associated with
many deaths and substantial morbidity, re-
ducing greenhouse gases as part of climate
change policy has the effect of improving
public health.
A recent report published by the Health
and Environment Alliance and Health Care
Without Harm
Europe quantifies
these benefits for
countries of the
European Union.
It estimates that up
to 30.5 billion Eu-
ros of public health
benefits could be
achieved within
the EU per year by
2020 if the Euro-
pean Union adopt-
ed a policy of 30%
cuts in greenhouse
gas emissions[3].
The health benefits associated with stronger
climate change policy in EU countries are
mainly due to a reduction in the number
of anticipated respiratory and cardiac cases
associated with exposure to air pollution.
These benefits begin almost immediately
the policies are introduced. By 2020 for a
30% domestic cut in greenhouse gas emis-
sions, 140,385 fewer years of life would be
lost and 13 million fewer days of restricted
activity could be avoided for those with re-
spiratory problems.In addition,there would
be 1.2 million fewer days when people
would need to use respiratory medication
and 142,000 fewer consultations for upper
respiratory problems and asthma during the
year 2020 [3].
In countries with severely polluted major
cities, the benefits for health are likely to
even greater. For example, a study in air-
polluted Mexico City shows that reducing
both ozone and PM10 (a type of Particu-
late Matter that contributes to air pollution)
by just 10% would result in 33,287 fewer
emergency room visits in 2010, 4,188 fewer
hospital admissions for respiratory distress
and 266 fewer infant deaths a year due to
cleaner air.This is estimated to result in po-
tential savings of US $760 million a year [4].
Similar health co-benefits from cli-
mate change policy occur when carbon
emissions from private vehicles are the
target. Studies from New Delhi and Lon-
don published in the Lancet medical jour-
nal have shown how lower carbon policies
associated with more public transport,
less use of private cars and more “active
transport” (walking and cycling) would
benefit health. Measurable benefits were
recorded for ischaemic heart disease,
cerebro-vascular disease, dementia, breast
cancer, lung cancer, colon cancer, diabetes,
and depression [5].
The World Medical Association has al-
ready urged doctors to help steer political
thinking on climate change. In his valedic-
tory speech as President at the WMA’s an-
nual assembly in Vancouver in October, Dr
Dana Hanson voiced his conviction that
the  World Medical Association, national
medical associations and the public should
begin educating governments and indus-
try on the vital issue of health and climate
change [6].
Both WMA and the Standing Committee
of European Doctors have position state-
ments for members to use in writing and
speaking to politicians and policy makers
[7], and WMA has recently sent a letter to
all members urging them to write to their
environment ministers.Floods in Venice
Copenhagen, December 2009
239
Health financing
National medical association around the
world should join these efforts if the worst
perils of climate change are to be avoided.
When doctors speak up publicly, govern-
ments listen. The moral standing of doctors
within society creates a powerful force. We
urge you to turn your attention to treating
our ailing planet earth.
For more information – and to let us know
about your efforts – please contact Dr Pendo
Maro, Health Care Without Harm Europe
(HCWH Europe) and Health and Envi-
ronment Alliance (HEAL) at pendo@env-
health.org or pendo.maro@hcwh.org
1. Climate Change 2007: synthesis report. Sum-
mary for policy makers. Intergovernmental
Panel on Climate Change (IPCC-AR-4), p.2.
2. Managing the health effects of climate change,
The Lancet Series, Health and Climate
Change, November 2009.
3. “Act Now for better health, A 30% reduction
target for EU climate policy”, HEAL and
HCWHE, Brussels, September 2010.
4. Taking Control of Air Pollution in Mexico
City, http://www.idrc.ca/en/ev-31594-201-1-
DO_TOPIC.html.
5. The Lancet Series, Health and Climate
Change, November 2009, “Public health ben-
efits of strategies to reduce greenhouse gas
emissions: urban land transport.
6. WMA press release, October 2010.
7. “Global Warming and Health” (CPME
2009/021 EN/FR final).
Dr. Michael Wilks, Climate Advisor and
Executive Committee member, Standing
Committee of European Doctors;
Genon Jensen, Executive Director, Health
and Environment Alliance (HEAL);
Anja Leetz, Executive Director,
Health Care Without Harm
Markus Schneider
Several countries have made serious cuts in
public health expenditures during the current
period and expect more in the near future to
cope with budget deficits and increased pub-
lic debts caused by the current world financial
crises. Sustainability serves in this context as
a general principle to guide fiscal policy, how-
ever “sustainability” is a buzzword defined
differently around the world and,perhaps,has
been universally accepted and used simply be-
cause it seems to be immediately understand-
able. Subsequent to the Brundtland Report
(1987) at least the following definition is gen-
erally agreed: Sustainable development meets
the needs of the present without compromis-
ing the ability of future generations to meet
their own needs[1]. A sustainable health sys-
tem is one in which the scale and the structure
of the state’s activities are such that the health
needs of the current generation for high qual-
ity effective health services may be met with-
out compromising the ability of future gen-
erations to meet their needs. No wonder that
sustainability compilation is the domain of
generational accounts, focusing on fiscal gaps
in the long-run [2]. But the long-term view
is not suited to deal with the tremendous fis-
cal imbalances in the short-term and will not
provide the appropriate remedy for healthcare
system development in the short-term.
Short-term and long-term fiscal gaps of
the general government have to be dis-
tinguished from the financial sustainabil-
ity of the healthcare system as part of the
economy. Fiscal stability in the short-term
relates to the need for public revenue and
public expenditure on healthcare to be in
equilibrium within an economic cycle (say
five years). Financial sustainability is a
broader concept embracing the idea that to-
tal (public and private) income and expen-
diture on the healthcare system should be
in equilibrium in the mid-term (say twenty
years).Several instruments have been devel-
oped to deal with the long-term stability of
social and private insurance programs these
instruments are not appropriate to manage
the immediate burden of fiscal shocks that
can overwhelm the financial capacity of a
country, (e.g. in the cases of Greece and
Latvia).
Obviously, concepts and measurements are
critical to sustainability. Sustainability rep-
resents a process rather than a static quality.
Indicators of sustainability must therefore
capture this movement over time, or capac-
ity for continuity. But how do we measure
sustainability? By definition a fiscal im-
balance exists if government expenditures
exceed tax revenues in a particular period.
This fiscal imbalance of a particular period
is called the budget deficit. Since the bud-
get deficit adds to the national debt, the
budget deficit represents the increase in the
Presentation given at the WMA conference of “Financial crisis and its implications for
health care”, Riga, September, 10-11th
2010
240
Health financing
public debt from one year to the next. In
the same way the deficit of health insurance
adds to health insurance debts.
What is the problem with deficits? It is the
related interest payment. The increased
debt raises the government’s interest spend-
ing and decreases the government’s ability
to spend the revenues for other purposes.
For example, suppose the total public deficit
was 100% of the GDP, with an interest rate
of 5%. If the governments ratio of the GDP
was 30%, then the government would have
to spend one sixth of its budget on interest
payments alone. That is above the financial
capabilities of the public health expendi-
tures for Latvia and several other countries.
Any increase in public debt would further
raise interest payments, thereby reducing
the government’s available funds for health-
care,education,security,and other purposes.
Obviously, such a policy is not sustainable
in the long-run. So, the question remains,
what to do in the short-run?
The assessment of both short-term and
long-term sustainability of public finances
is a multifaceted issue and there is not a
unique indicator that provides a clear re-
sponse to what extent a country’s public
finances are sustainable in the long-term.
Hence, the European Commission and the
Council assess long-term sustainability of
public finances by using both quantitative
indicators and qualitative information so
that the determinants affecting the long-
run state of public finances in the Member
States are reflected [3].
Focusing on the inter-temporal balance of
the public budget, the S1 indicator shows
the durable adjustment required to reach
a target debt below 60% of GDP in 2060,
as defined in the European Stability and
Growth Pact for EU public finance. The
S2 indicator shows the durable adjustment
required to fulfil the infinite horizon inter-
temporal budget constraints, which states
that the present value of government pur-
chases and net debts cannot be larger than
the present net value of government reve-
nues. In the EU as a whole and in the Euro
area, the sustainability gap is estimated
about 2% of GDP according to the S1 in-
dicator and about 3% of GDP according to
the S2 indicator [4]. Unsurprisingly, there
are large variations by countries, strongly
depending on the current debt position.The
contribution of health and long-term care
to this stability gap is roughly the same as
the additional liabilities of the pension sys-
tems [5].
While constraints and indexation rules for
public pension systems policies are imple-
mented in many countries, the rules for
healthcare are rather opaque. As a result,
governments can more easily cut healthcare
expenditures than public pensions if reve-
nues are falling. Following the experience of
the Great Depression, governments should
counter-balance sudden drops in private
demand. In fact, pro-cyclical cuts of public
expenditure, especially health care, have a
tendency to aggravate the economic crisis
instead of alleviat it [6].
Counter-cyclical fiscal policy should be a
short-term economic policy. A short-term
indicator of financial need of the health
sector is Medicare’s sustainable growth
rate mechanism, which limits payments for
physicians’ services. Cumulative Medicare
spending on physicians’ services is sup-
posed to follow a target path that depends
on the rates of growth in physicians’ costs,
Medicare enrolment, and real GDP per
person. That system is currently projected
to reduce the growth of payments to phy-
sicians. However, growth rates of public
health care will be positive and not nega-
tive, as discussed in Latvia and other Cen-
tral and Eastern European countries. Even
in the long-run, in the United States, the
Congressional Budget Office (CBO) has
anticipated in its last projection that, de-
spite financial crises, spending for Medicare
will expand faster than the economy. As a
result, by the end of the decade, outlays for
Medicare are projected to total $929 billion
(4.0 percent of GDP), compared with $519
billion (3.5 percent of GDP) this year [7].
The conclusion is that there are similarities,
but also different views on the concept of
sustainability and its measurement. While
demographic impacts are generally consid-
ered rather low, institutional structures and
deficit spending are assessed differently by
countries, experts, and politicians. Under
the perspective of public finance,many poli-
ticians see health care rather as a cost factor
than as an investment in human capital and
consequently a factor of economic growth.
It is worth the effort to analyse the argu-
ment for budget cuts in healthcare in great-
er detail, as the projections neither consider
developments in the past nor health re-
forms in the future. Clearly, the pressure
on healthcare expenditure will be reduced
by the compression of morbidity and de-
creasing prevalence in rates of acute and
chronic diseases (decline in chronic diseas-
es) [8]. On the other hand, the pressure on
healthcare expenditure will be increased by
relatively higher labour intensity and lower
productivity growth in the service economy,
which leads to relative health care prices
above GDP prices or the so-called “Bau-
mol’s cost disease” [9]. Further pressure
comes from the medical-technical devel-
opment and consumer behaviour. But, the
expenditure side is only one component of
the government’s accounts. What happens
on the revenue side? The prerequisite of a
healthy labour workforce is a healthy popu-
lation which is therefore crucial to sustain-
able revenue development. Independence of
healthcare financing from the general bud-
get and willingness to pay are other factors
of sustainable revenue development. Insti-
tutional factors that affect financial stability
of health financing are the mode of revenue
collection income-independent premiums,
income related contributions, and taxes,
the allocation of risks to public and private
schemes, the organisation of purchasing of
241
Health financing
providers (single versus multi-pipes), and
the contracting and payment of provider
(framework versus selective contracts, capi-
tation versus fee-for-service) [10]. Premi-
ums for health insurance have an advantage
because they are not directly related to fluc-
tuation, but they do need to be counterbal-
anced by equity measures. The need to bal-
ance increasing needs for healthcare and
scarce public resources is present among
economic and healthcare policy makers in
all countries. Many instruments have been
developed to assess the benefits and costs
of medical technologies at the micro-level,
however, at the macro-level comprehensible
models to guide policy for the governance
of the health care budget do not exist.
In many countries the healthcare economy
is the largest industry. There is a paradigm
shift from healthcare as cost factor toward
health as growth factor. The impact of the
health economy on the general economy
and public finance system can be simu-
lated by healthcare satellite accounts inte-
grated into the national accounts. A sat-
ellite account captures all of the economic
activities of the health economy. A study
of Germany’s health economy has shown
a considerable export surplus, a large share
of the overall economy’s total workforce, a
marked predominance of service industry, a
high share of value added, and significant
spillover effects into other industries. The
Health-Input-Output-Table makes it pos-
sible to exhibit the supply for health com-
modities in consistent differentiation from
the supply of the overall economy. The
above mentioned study for the German
Ministry of Economics and Technology
confirms the strong link between the health
economy and overall economy [11].
One particular question of cost contain-
ment measures is the impact on final de-
mand in healthcare and the economy as a
whole. How do cuts of public healthcare
expenditures affect economic growth. The
compilation of production multipliers by
the so-called “Leontief Inverse” shows
variations of these multipliers for different
branches of the health economy between
1.47 and 2.38. On average, a reduction of
public health expenditures by 1% will lead
to further indirect and induced reductions
of the output by in total 1.8%. As a result
negative consequence can be expected from
cuts of public health expenditures, not only
for patients and health professionals, but
also for the economy as a whole.
Health expenditures contribute in manifold
ways to economic development. Health
impacts of economic growth take place over
several channels [12]:
The labour force becomes more produc-
tive and can generate higher income
thanks to improved health;
Improved health gives people a longer
working life an imperative in our aging
and childless society;
Fewer days are lost to ill health/disability
and early retirement;
Improved health and a longer working
life increase the return on investing more
in education and helps raise productivity;
Improved health extends people’s
healthy-life expectancy.This fuels a high-
er savings rate and thus creates funds for
further investment.
Finally, a stable health sector contributes to
the stabilization of the whole business cycle
and contributes to the functioning of the
labour markets.
Many studies have confirmed the positive cor-
relation between health and growth. Suhrke et
al. 2005 examined 65 studies about the con-
nection of health in the most diverse develop-
ments and their economic effects. The review
confirmed that the health of the population
is a crucial factor for personal income and the
economic growth. In economic growth mod-
els,economic growth rises with the productiv-
ity of both health generation and the human
capital accumulation process. Furthermore,
improvements in health raise longevity,which
will increase savings (for retirement) and
hence facilitate investment, and the occur-
rence of a demographic dividend that creates
an increase in the population of working age
[14]. There is also an indirect link, similar to
the impact of education,on economic growth.
Investments in health, together with invest-
ments in education, determine the number of
effective labour-services relative to the physi-
cal units of labour available that represent po-
tential labour services.
Certainly,there are limits of the contribution
of the subsidised health economy to econom-
ic growth and productivity across the whole
economy [15]. Oversupply and over-medi-
calisation may harm both economic growth
and the health of the population. Taking into
consideration the overall development of the
health economy and its impact on society,
reliable indicators about the performance of
health economy are crucial for both health-
care and economic policy. The contribution
of the health economy to gross value added,
employment, and economic growth can be
verified in the framework of health satellite
accounts. Additionally, both the contribu-
tion to growth and the labour force in the
health economy can be compared to other
branches of the overall economy. Moreover,
the limits of the national accounts regarding
the welfare of the nation (beyond GDP) are
taken into account.
The direction of sustainable development
is based on the sector view, viewed across
Health impacts
Source: BASYS, adapted from WHO 2008. [13]
242
Health financing
sectors,and fiscal feedback. From the sector
perspective, the increase of efficiency within
the healthcare system, fiscal discipline, and
revenue raising (e.g. via complementary in-
surance) contribute to sustainable develop-
ment. Across sectors, economies of scope
by a holistic approach can contribute to
sustainable development. Links between
medical care and the extended health sec-
tor (e.g. health tourism, sport, and wellness)
and reduction of risk factors have to be
considered in the assessment of the health
economy. Health risks can be reduced by
primary prevention and human capital
as growth factors can be strengthened by
health education. The inclusion of coverage
for the whole population and equity issues
are essential in considering such a broad
perspective.
From the view point of fiscal stability, the
fiscal feed back of cuts or expansions of
healthcare expenditures are of particular
interest. In most countries healthcare is
heavily subsidised. Therefore, the indirect
and induced effects on the overall economy
and public finance and the feedback have to
be compiled to make a proper assessment
of healthcare expenditure cuts. More-
over, self-financing of the health economy
and independence from the public budget
should be checked by both social and pri-
vate health insurance systems and private fi-
nancing mechanisms while at the same time
balancing access to care.
Securing the safety net of the healthcare
system is an imperative in the short-run. It
takes generations to develop a healthcare
system, train and educate health profession-
als and implement governance and contract
structures. Therefore, avoid pro-cyclical
cuts of public health system expenditures
because of large impacts on employment
and value added; governments should sus-
tain healthcare expenditures despite finan-
cial crisis; Avoid healthcare bubbles – prices
of health insurance policies or health infra-
structure investments rising to a level that
appears to be unsustainable and well above
the assets’ value as determined by economic
fundamentals.
Reforms of the healthcare system within a
country are always embedded in a specific
institutional environment and value system
which has been developed over several gener-
ations. Although constraints differ by coun-
tries’ productivity, development is a must for
healthcare, independent of the system, and a
prerequisite for sustainable financing. Strat-
egies for productivity development might
build on the experience of the industrial side
of the health economy and on the results of
healthcare system comparisons. If the crises
of public finance continue, further measures
should be taken under consideration of the
impact on the supply side and health of the
population. Independently, tradeoffs be-
tween different types of investments in hu-
man capital have to be considered:
The well-being of future generations will
depend not only upon how much stock of
exhaustible resources we leave to them but
also how much we devote to the constitu-
tion of human capital, essentially through
expenditure on education, research, and
health.
All industrial countries invest a substantial
proportion of national income in human
capital development. Taking into account
both public and private sources of funds,
OECD countries had spent 16.8% of their
Gross Domestic Product, on average in
2006, on human capital. In many Central
and eastern European Countries, as well as
in less advanced countries, the investment
in human capital is far below this level.
The following conclusions of sustainable
health financing have been drawn:
In the short-term, governments should sus-
tain healthcare expenditures despite finan-
cial crises (public deficit financing) because
of the strong economic impact of the health
economy on the whole economy and em-
ployment;
Cutting resources of healthcare systems is
not a likely solution for financial sustain-
ability, rather the focus should be on effi-
ciency and equity;
Understand healthcare as an investment
in human capital: long-term fiscal policies
have to optimize both health and human
capital development (education, R&D, and
health expenditures);
Develop international consensus about rel-
evant indicators of financial sustainability of
public healthcare expenditures and policies;
install an international learning process about
best practises in economic and financial crisis.
1. Brundtland G.H. Our Common Future, Re-
port of the World Commission on Environ-
ment and Development. Published as Annex
to General Assembly document A/42/427.
Development and International Co-opera-
tion: Environment August 2. 1987. Retrieved,
2007.11.14.
2. Auerbach H., Gokhale J., Kotlikoff L.J. Gen-
erational Accounting: A Meaningful Way to
Evaluate Fiscal Policy. Journal of Economic
Perspectives, vol. 8, 1994: 73-94.
3. European Commission. Public Finances in
EMU, European Economy 4/2010, Economic
and Financial Affairs, Brussels, 2010.
4. European Commission. Sustainability Report
2009. EUROPEAN ECONOMY 9/2009,
Brussels
5. European Commission.The 2009 Ageing Re-
port: economic and budgetary projections for
the EU-27 Member States (2008-2060). Joint
Report prepared by the European Commis-
sion (DG ECFIN) and the Economic Policy
Committee (AWG).
6. Weisbrot, Mark, Rebecca Ray, Jake Johnston,
Jose Antonio Cordero and Juan Antonio
Montecino. IMF-Supported Macroeconomic
Policies and the World Recession: A Look at
Forty-One Borrowing Countries. Center for
Economic and Policy Research Briefing Pa-
per, October. http://www.cepr.net/documents/
publications/imf-2009-10.pdf.
7. Congressional Budget Office.The Budget and
Economic Outlook: An update, The Congress
of the United States, August 2010: p.20.
243
NMA news
8. Fogel R.W. Forecasting the cost of U.S.
Health Care in 2040. NBER Working Paper
No. 14361. September 2008. JEL No. I11.
9. Baumol W. J. Productivity policy and the ser-
vice sector. Inman R. P. (ed.): Managing the
Service Economy: Prospects and Problems.
Cambridge University Press. Cambridge
1985: 301-317.
10. Henke K.-D., Schreyögg J. Towards sustain-
able health care systems: Strategies in health
insurance schemes in France, Germany, Japan
and the Netherlands A comparative study
Technical University of Berlin, Department
for Public Finance and Health Economics and
Department for Health Care Management,
Working paper, 23. March 2004.
11. Ministry of Economics and Technology
(BMWi). Towards a German Health Sat-
ellite Account. November 2009. http://
www.bmwi.de/BMWi/Navigation/Service/
publikationen,did=320754.html and BASYS.
Foundations, methodology, and selected re-
sults of a Satellite Account for the German
health economy, 2005. Working paper. June
2010. http://www.basys.de/aktuelles/gsk-en.
pdf.
12. 12 Suhrke, M. et al. The Contribution of
Health to the Economy in the European Un-
ion, European Commission, Health & Con-
sumer Protection Directorate-General. 2005.
13. 13 WHO (2008). The contribution of regions
to health and wealth. Technical report for the
WHO European Ministerial Conference on
Health Systems: “Health Systems, Health and
Wealth”, Tallinn, Estonia, 2527 June 2008,
Regions for Health Network in Europe.
14. 14 Bloom D.E, Canning D. and J. Sevilla.The
Demographic Dividend: A New Perspective
on the Economic Consequences of Population
Change. Santa Monica. 2003.
15. 15 Zon van A.H., Muysken J. Health as a
Principal Determinant of Economic Growth.
MERIT-Infonomics Research Memorandum
series, 2003-021, Maastricht University.
Markus Schneider, BASYS,
Consulting Company for
Applied Systems Research
e-mail: ms@basys.de
Cecil B. Wilson
My thanks to the House of Delegates, my
colleagues, my friends, and my family for
what is truly the greatest honor of my life
in medicine.
Some of you know my story of growing
up in South Georgia, the son of a Meth-
odist minister. And in the tradition of the
itinerant ministry, moving every few years 
from town to town and church to church
throughout the state. And I recall how,
when my brothers and I would head out the
door to go to school,our fathert he Rev.Dr.
Wilsonw ould admonish us: “Remember,
you represent the whole family. Act accord-
ingly.” That simple statement of purpose
has guided me through college, medical
school, my service in the U.S. Navy as a
flight surgeon, and my professional career
and personal life in Florida.
It guides me today, and it will continue to
guide me tomorrow, when I head out the
door to tour this country on behalf of the
American Medical Association.
My commitment to you is that now as in
the past I will remember that I represent
the whole family of medicine. And I will act
accordingly.
Life is about opportunities and responsibili-
ties.And nowhere are these found in greater
measure than in the calling we have chosen
the profession of medicine. As physicians
we have the opportunity to heal, and the re-
sponsibility to do no harm.We have the op-
portunity to care for those who are ill, and
the responsibility to deliver the best care
possible. And at this historic time, we have
the opportunity to assure that our country’s
healthcare system bears the imprimatur of
physicians, and we have the responsibility
to bring to that task a voice that is clear,firm
and constructive.
In thinking about what I was going to say
this evening, I turned to my love of sailing
an attraction to the sea and ships sealed
during my service in the Navy.
Among the joys of living in Florida are
the proximity to the ocean and access to
sailboats preferably, someone else’s. I’ve
learned that off the coast, the waters are
sometimes shallow and the winds variable.
Running aground, being whipped by gales,
or becoming becalmed are all part of the
experience. I recall one sailing trip from St.
Petersburg across Florida Bay toward Key
West. In early evening, we strayed from the
channel and ran aground in the middle of
the bay an 850-square mile body of water.
To get off the reef,we tried hoisting our sails
and lowering them; we cranked the auxil-
iary engine; we put out an anchor and tried
to winch ourselves off. Nothing worked.We
244
NMA news
even tried to rock the boat off the entire
crew running from one side to the other
from port to starboard and back, and from
bow to stern and back. By the way, did I say
the crew was all doctors? Fortunately, this
was in the days before You Tube or else we
may have gone “viral.”
During this exercise in futility we dislodged
the dingy, which then drifted away. One of
the crew dove in, swam to it, and climbed
in only to discover there were no oars. The
dingy, with him in it, was being blown out
to sea. Another member of the crew dove
in carrying oars and swam to the drifting
dingy. Two hours later, two very exhausted
sailors came back. Six hours later a rising
tide helped free us from the reef, and we
could continue our trip.
This reminds me a bit of our journey toward
health system reform. Embarked upon with
a plan of action, at times diverted off course,
at times becalmed but ultimately the
country reached its destination. In talking
with AMA members around the country, I
found most physicians did not dispute the
core principles of health system reform.
Rather, physicians disagreed on the in-
terpretation of those principles and the
strategy and tactics used to advance re-
form. Some did not like how we plotted our
course, unfurled our sails and set our speed.
Others sought a different destination. All
were sincere in their views.
To me,these reforms are a long overdue first
step a first step toward a better health
care system in this country. This legislation
is not perfect, but it makes medical care
more accessible and coverage more reliable
for millions. It makes insurance companies
more accountable. It strengthens wellness
and prevention. These are no small things.
But it’s easy to lose sight of what’s good
amid the finger-pointing, partisanship and
just plain anger that marked this debate.
It’s been said that: “Honest criticism is hard
to take especially when it comes from a
relative, a friend, a colleague, an acquain-
tance or a stranger. Did I leave anyone out?”
I know too well that there are fences to
mend, assurances to make, and wounds to
heal.I am also well aware that if we dwell on
the past, we risk running aground.
Our energies are better spent making health
system reform the best it can be for physi-
cians and patients. Now more than ever we
need to focus on what’s best for our profes-
sion and act accordingly. Of course that’s
easier said than done. This is a complicated
system, with many stakeholders involved.
And it’s also complex work that we do every
day. Sometimes we forget that.
Think about it:
Physicians must choose from among more
than 60,000 diagnoses; 11,000 surgical pro-
cedures; and at least 4,000 different drugs.
The pressures on physicians are intense.
And we welcome that responsibility. But we
also have to recognize that we can do even
better. All of us can do betterfr om govern-
ment officials, to insurers to patients. Well
Tonight, the doctor is in. That’s me. And
I would like to offer some prescriptions for
our ailing health care system.
Let me start with four of the biggest chal-
lenges we face to make health system re-
form a success:
medical liability,
skyrocketing costs,
inefficiencies in health care delivery, and
Medicare underpayment.
First, medical liability.
Studies tell us that today 75 per cent of
American physicians are forced to prac-
tice defensive medicine to order tests or
procedures more out of a need to protect
against possible litigation, than to improve
patient care.This drains as much as 126 bil-
lion dollars out of the health care system an-
nually. The health system reform legislation
acknowledges this problem but it does not
go far enough to solve it.Ultimately,caps on
non-economic damages are the gold stan-
dard for successful medical liability reform.
They’ve worked for more than a generation
in California, and they are also working to-
day in Texas, Louisiana and other states.
My prescription: Caps. Caps are AMA pol-
icy. Caps are the only prescription proven
to work.
In addition, we need to explore alternative
reforms, such as health courts, administra-
tive compensation systems, early offer mod-
els and “safe harbors” for physicians who
follow best practices.
Next, cost.
If nothing changes, by 2020 America will
spend 4.4 trillion dollars a year on health
care. Let me put this in perspective. That
means a family of four that makes 80 thou-
sand a year would spend a fourth of their
income on health care. That’s not sustain-
able.
My prescription:
We need a comprehensive plan for contain-
ing costs and getting the most out of our
health care dollars. If we don’t, reform will
fail.
The AMA has identified four broad strate-
gies to contain costs:
reduce the burden of preventable disease;
make the delivery of care more efficient;
reduce nonclinical costs that don’t con-
tribute to patient care; and
promote value-based decision-making
at all levels.
Let me next focus for a moment on one of
the accomplices of soaring costs inefficient
delivery of care.
From fragmentation of care to a lack of
available comparative effective research
245
NMA news
data, the current system is plagued by inef-
ficiencies. Some services are over-utilized,
others are under-underutilized.
My prescription: Focus on making sure pa-
tients get the right care at the right time, at
the right place.
This means:
improving coordination of care;
using more services that address cost and
prevention; and
making available more research to help
physicians make the best decisions pos-
sible.
Another challenge is all too familiar
the Medicare reimbursement crisis. Be-
cause of the senseless payment formula,
the SGR, physicians are threatened with
cuts. Year after year. And year after year,
the costs of providing care and running an
office continue to rise. The disparity be-
tween actual expenses and what Medicare
pays are, to use an expression familiar in
Florida, like the open jaws of an alligator.
And they’re ready to snap shut on access
for our seniors.
My prescription: Scrap the SGR. Toss it
overboard. Feed it to that gator, instead.
Replace it with a payment structure that re-
flects the true costs of providing care in the
21st
century. We also need new approaches
to physician payment that are rooted in the
reality of how medical care is provided. For
example, Medicare should encourage better
disease management, which is especially im-
portant for seniors in need of chronic care.
Now, improving our system is not just about
tackling the important issues. It’s also about
fulfilling our responsibilities as stakeholders.
It’s been said that Socrates was a teacher
who went around giving everyone advice
so they poisoned him.
So despite this great personal risk, and well
aware of the aphorism that “fools rush in
where angels fear to tread” I would now
like to offer some prescriptions to each of
the major stakeholders in our health care
system.
Starting with the private sector.
To America’s health plans, insurance com-
panies, pharmaceuticals and device manu-
facturers:
You have a special responsibility to the
health care system. Your products and ser-
vices, like ours, directly affect patients’ lives
and health. This isn’t as simple as offering a
choice of toothpaste or cell phone.
My prescription: Always remember you are
more than just businesses. Keep your business
practices transparent and keep the needs
of your customers our patients foremost
when you develop products and policy. To
our leaders in government, especially those
in elected offices such as Congress.
We are ill-served by partisan bickering
amid a toxic atmosphere that poisons efforts
to work together.Turning every policy deci-
sion even suggestion into a 30-second
attack ad damages our democracy.
The prescription: Develop legislation that
serves us well. Move beyond the partisan
fight. Seek accommodation or at least un-
derstanding across political divides. Tol-
erate differences of opinion. Do the job for
which you were elected!
Above all remember that you represent the
interests of the nation. Act accordingly.
To my fellow physicians: This has been a
challenging year, and on an issue as complex
as health system reform it is inevitable that
differences of opinion will arise. Remember,
the common ground we share is vast what
divides us is not.
Thomas Jefferson once said: “Not every dif-
ference of opinion is a difference of principle.”
My prescription:
Support the AMA, support all your medi-
cal associations they are the only way to
focus light on the goals of our profession,
the challenges we face, and our efforts to
better serve our patients. Do not let others
divide us.
Get involved. Make a difference.
To our medical students and residents
those who are now learning what this call-
ing entails You are embarking on your
careers at an historic time.
Remember: the issues we face are not just
challenges they also are opportunities.
Remember too that the system itself may
need fixing, the tradition of excellence in
this country is as strong as ever. American
physicians are world leaders in medical
knowledge, technical skills and cutting-
edge care. And most important, remember
that the profession you have chosen is in-
credibly rewarding. To heal, to comfort, to
relieve pain to be trusted with this most
sensitive part of your patients’ lives is a
great privilege. And after more than 30
years of practice, I can honestly say that the
sense of gratification I get from helping pa-
tients now is just as strong as it was when
I first started out some years ago.
My prescription for you:
Listen to your patients; they will tell you
their problems. And sometimes their di-
agnoses as well. And join the AMA. Join
organized medicine. Influence the policies
that affect your education and how to pay
for it. Influence the policies that affect your
future profession. Add your voice.
To businesses remember that investing in
the health of your employees today, can lead
to significant savings in the long run. And
it’s not just a matter of offering insurance.It’s
also a matter of fostering healthier lifestyles.
246
NMA news
My prescription: Take an interest in the
health of your employees. If they smoke,
help them quit. Provide a gym membership
or better yet, a gym. Replace some of the
candy bars and snacks in the vending ma-
chine with healthier options.
The rewards aren’t just physical.They’re also
financial.Healthier employees mean less in-
cidence of obesity, diabetes, cancer, and the
costly chronic care that goes with it.
And this brings me to patients. To them
to you:
My prescription: Take responsibility for the
kind of care you receive. Empower and edu-
cate yourself as a patient.
Make important health decisions now
such as insuring your family, choosing a
personal physician, and documenting your
wishes about end-of-life care.
Most common diseases are preventable.Chal-
lenge yourself to adopt healthier behaviors.
Your well-being is your biggest asset. Don’t
waste it.Your loved ones will thank you.
Now I’m going to break a cardinal rule of
medicine and issue one final prescription
for myself.
As president of the American Medical As-
sociation, I promise to do what I can to
mend the divisions within our ranks. Isaac
Newton observed: “We build too many
walls and not enough bridges.” I plan to
heed those words a nd act accordingly.
One way I plan to do this is through regular
conference calls or other means to speak with
AMA members. The goal will be in part to
update you on the latest developments, but
primarily, to hear from you your thoughts,
suggestions, questions and concerns.
This will be interactive. A two-way conver-
sation to openly and honestly communicate
with each other.
I’m not just going to talk – I’m going to lis-
ten.
We will let you know the details soon.
These communications will be a way to ad-
dress the here and now.
Ultimately, history will judge whether the
decisions made during this historic and tur-
bulent time were the right ones.
But I can assure you that these decisions
were rooted in principle, not expedience.
For a better health care system not a bro-
ken status quo. In the interests of our pa-
tients not just ourselves.
We did not control events. But neither did
events control us. We plotted a course, un-
furled our sails, and journeyed on, tempest
tossed but hands on the wheel. We helped
determine our own fate.The alternative was
to have it determined for us.
Earlier, I spoke of a lesson learned on the
sea and from it. Let me offer a second,
about a race from Daytona Beach to Ber-
muda. The third day out featured sunny,
cloudless skies, moderate temperature,
a strong breeze blue water sailing at
its best. We were making 16 knots on a
downwind tack with all sails flying. Crest-
ing large waves, then plowing into troughs
as water broke across the bow. Even as we
reveled in perfect conditions, the captain
noted that the breeze had picked up and
that we should take in some of the sails.
But among the crew, there was much sec-
ond-guessing. We were, after all, “experi-
enced”sailors.We’d taken the Coast Guard
courses. We’d learned celestial navigation.
We’d sailed around Florida on a serious
recreational basis. We knew better. By the
way did I say the crew was all doctors?
This “discussion” was interrupted by a loud
pow!! blasting from the bow. We looked up
to find that a sail had blown out, shredded
by the strong winds.
Lessons learned.
A cruise to Bermuda that reminds us that
even when the sailing is smooth and the sun
is shining, prudence dictates we check the
wind, check the sea, check our sails, expect
changes and prepare for them. And maybe
maybe it tells us that no single one of us
has all the answers. If we fail to plan if we
let outside forces plot our course and set our
speed, we will ultimately drift, powerless
without direction or purpose.
That is why the AMA kept our hand on the
wheel during the storms of the reform de-
bate. Now, we face a defining moment for
organized medicine and the AMA. This is
not just a challenge, but a tremendous op-
portunity. Let’s work together to bridge the
legitimate differences that exist between us.
And let’s keep in mind that we’re in this
boat together.
The poet Ella Wilcox wrote:
One ship sails East,
And another West,
By the self-same winds that blow,
Tis the set of the sails
And not the gales,
That tell the way we go.
Like the winds of the sea
Are the waves of time,
As we journey along through life,
Tis the set of the soul,
That determines the goal,
And not the calm or the strife.
Tis the set of the soul. We are the family
of medicine. We represent our patients. We
must set our souls and the course together.
Because together we are stronger.Thank you.
Cecil B. Wilson, MD, American
Medical Association, President
247
NMA news, Education
Armin Ehl
Currently the employed doctors in Ger-
many and their trade union, the Marburger
Bund,face a very serious problem.The Mar-
burger Bund is the association of the em-
ployed doctors in Germany and their trade
union as well. It was founded in 1947 and
organizes 108,000 doctors. In 2006 the first
collective agreements especially for doctors
were signed after a strike period of 14 weeks
at the university hospitals and another 7
weeks at the communal hospitals.
In July 2010 the Federal Labour Court
ruled that the working conditions in one
enterprise can be defined by multiple col-
lective agreements covering different groups
of workers (nurses, auxiliary staff, doctors).
With this judgement the Federal Labour
Court changed its previous interpretation
and confirmed the lawfulness of general
practice in Germany.
Soon afterwards the German Federation
of Employer Associations (BDA) together
with the Confederation of German Trade
Unions (DGB) started to lobby the Ger-
man Government in order to change the
existing law. In their opinion the collective
agreement of the trade union with most
members in the enterprise should have pre-
cedence over all other collective agreements.
They argue that otherwise the enterprises
would face too many strikes (they talk about
“Englische Verhältnisse”) and as a result the
economy in general would suffer. The los-
ers would be the employees which decided
to organise their interests in specialist trade
unions (doctors, pilots, train drivers, air-
traffic controllers). Among other things
specialist trade unions would be at risk to
forfeit their right to strike.
The Marburger Bund points out that an
alteration of the labour law as pursued by
the BDA and the DGB will not only be
undemocratic but also violates the Basic
(Constitutional) Law of the Federal Re-
public of Germany (Article 9 (3): Freedom
of Association).We do everything we can to
convince the government to respect the lat-
est judgement of the Federal Labour Court
and leave the law unchanged.Together with
other specialist trade unions the Marburger
Bund started the campaign “Save the Free-
dom of Association” (www.rettet-die-ko-
alitionsfreiheit.de). With this campaign we
want to make the general public aware of
the problem. We also asked our members to
write to the members of the Parliament and
let them know their opinion.
Armin Ehl,
Marburger Bund Bundesverband
The International Federation of Medical
Students’Associations (IFMSA), one of the
largest international student organizations
in the global medical community, aims to
serve medical students all over the world.
Currently, the IFMSA represents 1.2 mil-
lion medical students through its 102 na-
tional member organizations.
The IFMSA is an independent, non-polit-
ical organization, founded in 1951, and is
officially recognized as a Non Governmental
Organization (NGO) within the United Na-
tions’ and recognized by the World Health
Organization as the International Forum for
medical students. The IFMSA aims to offer
medical students a comprehensive introduc-
tion to global health issues. This is done by
our exchanges with more than 11.000 ex-
changes taking place per year. It is the largest
student-run exchange program in the world,
and operates through our work in the fields
of medical education, reproductive health,
human rights and public health.
The IFMSA’s Standing Committee on
Medical Education strives to improve medi-
cal education worldwide.In order to achieve
this goal, members from all national orga-
nizations share their experiences and train
each other, organize projects and advocate
for the improvement of their curricula.
Twice a year, 800 IFMSA members come
together to educate one another on issues
regarding global health.During these meet-
ings, specific sessions focusing on medical
education are organized for members of the
Standing Committee on Medical Educa-
tion. Also, workshops called the Medical
248
Education
Education Development International
Kit Training (MEDIK-T) are organized
to give students the necessary knowledge
and skills to work with their faculties to re-
structure and improve their own education.
These peer-to-peer trainings utilize various
teaching methods on a wide range of topics
(e.g. adult learning theory and curriculum
development), with additional support from
expert teachers.
In between meetings, students make use of
a Wiki-based online platform[1]
and mail-
ing lists to stay in touch, follow-up on work
done during meetings and share ideas for
further improvement and new projects.
The IFMSA organizes projects on local, na-
tional and international levels. The aim of
the projects of our Standing Committee are
to provide medical students with additional
information concerning global health and to
make them aware of the role they can play in
their own education. Examples include elec-
tive courses on tropical medicine and inter-
national health[2
]and online databases where
information about curricula and residency
systems of many countries can be found [3]
.
Another important aspect of our work is
advocacy. The IFMSA aims to empower
medical students and improve participa-
tion in their medical education either as
student-teachers or student-representatives.
With our work we emphasize the important
role medical students play in the improve-
ment of their education.
In 2004, medical students were the first
stakeholders to issue a statement on The
Bologna Process; the effort to harmonize
European higher education. This state-
ment[4]
was the result of a series of meet-
ings organized by medical student repre-
sentatives. Over the years that followed, we
have evaluated the implementation of The
Bologna Process in Medicine and consid-
ered constructive approaches to European
policy. In our work, we emphasized the stu-
dent’s role and responsibility as an impor-
tant stakeholder of The Bologna Process in
Medicine [5, 6]
.
We have written an outcome-based core
curriculum identifying nine domains with
76 learning outcomes for graduates of Eu-
ropean medical schools. The “European
Core Curriculum the Students’ Perspective”
expresses the medical students’ opinion on
which abilities, knowledge and attitudes
students of medical schools in Europe
should have gained upon graduation. This
core curriculum has served as a framework
in numerous countries, and can be adjusted
for specific national and local needs[6]
.
Our statements are used for lobbying uni-
versity leadership, national professional
bodies or governments and relevant inter-
national organizations. Representatives of
IFMSA are members of the executive board
of the World Federation for Medical Edu-
cation (WFME) and AMEE. They pres-
ent outcomes of our work during executive
meetings and raise awareness of the student
point of view. In addition, our members
aim to present our views at scientific con-
ferences and in peer-reviewed journals [7, 8]
.
The work of the Standing Committee on
Medical Education of IFMSA aims to im-
prove medical education worldwide. We
enable students to share their experiences
and empower them to train each other. We
organize projects in 102 countries world-
wide and advocate for the improvement of
medical education through our network of
students.The outcomes of our work are dis-
seminated through our professional partner
organizations, and by presenting at confer-
ences and meetings. We also intend to pub-
lish our work in journals, such as the World
Medical Journal, to broaden our sphere of
influence.
1. www.ifmsa.org/scome/wiki
2. Duvivier RJ, Brouwer EE, Weggemans M.
Medical Education in Global Health: Stu-
dent Initiatives in the Netherlands. Med
Educ.2010;44(5):528-9.
3. http://residency-database.helmsic.gr/
4. Onur O, Westbye HJ, Kovac K. The Bologna
declaration and medical education: a policy
statement for the medical students of Europe.
Med Teach. 2005;27(1):83-5.
Margot Weggemans Robbert Duvivier
249
The mobility of health professionals is of
crucial importance from the point of view
of the sustainability of health care sys-
tems in member states of the EU. One of
the recommendations of the Green Paper
on the migration of the health workforce
is to establish an EU-wide data collection
system to monitor flow of health workers.
Monitoring and analysis of the changes and
trends can only be based on valid, reliable
and comparable data. One of the objectives
of the Prometheus project (Health Profes-
sionals’ Mobility in the EU Study) was to
collect valid and reliable data on health
professionals’ migration particularly of Eu-
ropean countries, but also of countries out-
side Europe. International data collection
has never been done before. Comparative
analysis was carried out using a set of stan-
dardized health workforce indicators.
The main aim of the Health Prometheus
Project was to prepare the establishment
of an EU-wide health professionals’ migra-
tion monitoring system (observatory) to
support both EU and national decision-
making in this area. The project aimed to
obtain an overview about the current situ-
ation and the changes, which took place in
the last decade, in Europe. Moreover, it was
based on the available routine data, various
reports and grey literature from a network
of participating countries and provides an
initial mapping of the scale and nature of
mobility for all EU countries by different
professional cadres.The Prometheus Project
also included and differentiated mobility of
health professionals from 3rd
(i.e. non EU)
countries. The findings and experiences re-
garding the sources, the quality and
the comparability of the available data,
gathered together in the frame of this
project is used to assess the feasibility
of a sustainable data collection system
on the migration of health profession-
als, as the future target.
The Health Prometheus Project is
an FP7 supported research project
(the research leading to these results
has received funding from the Euro-
pean Community’s Seventh Frame-
work Programme ([FP7/2007-2013]
[FP7/2007-2011]) under grant agreement
n° [223383]) led by the European Health
Management Association and the WHO
European Observatory on Health Systems
and Policies. There
were eleven partner
institutions from eight
countries. Semmel-
weis University, Health
Services Management
Training Centre, Hun-
gary was responsible
for data collection and
analyses.
The next figure shows
the participating
countries in the Pro-
metheus Project.There
were project partners (conceptual contribu-
tion, data collection and case study), coun-
try correspondents (data collection and case
study) and country informants (only data
collection). Regarding Australia, Canada,
New Zealand, Norway and the USA we
have collected the data from country experts
or online-access websites.
Members of Semmelweis
Team: Miklós Szócska MD,
Péter  Gaál  MD, Edmond Girasek,
Eszter Kovács, Edit Eke MD
Medical and socio-medical affairs
5. Duvivier RJ Hilgers J, Davaris N, Rodriguez
Muñoz D. Implementation of the Bologna
Two-Cycle System in Medical Education
the Student’s View. Med Teach. 2009;31:376-
7.
6. Duvivier RJ, Weggemans M. Joint issue
TMO/ZMA: Reply from International
Medical Students. GMS Z Med Ausbild.
2010;27(3):Doc40.
7. IFMSA, EMSA, Hilgers J, De Roos P. Eu-
ropean Core Curriculum The students’ per-
spective. Med Teach. 2006;29:270-5.
8. Duvivier RJ, Mansouri M, Iemmi D, Ru-
kavina S. Migrants and the Rigth to
Health: The Students’ Perspective. Lancet
2010;375(9712):376.
Margot Weggemans, Liaison Officer for
Medical Education issues 2010-2011
Robbert Duvivier, Liaison Officer for
Medical Education issues 2008-2010
250
WMA news
Message from the President
of the World Medical Association . . . . . . . . . . . . . . . . . . . . . . 209
The World Medical Association General Assembly. . . . . . . . . 210
The World Medical Association General Assembly. . . . . . . . . 211
Statement on Environmental Degradation
and Sound Management of Chemicals . . . . . . . . . . . . . . . . . . 220
Statement on Family Violence . . . . . . . . . . . . . . . . . . . . . . . . . 222
Statement on the Relationship between
Physicians and Pharmacists in Medicinal Therapy . . . . . . . . . . 227
Resolution on Drug Prescription . . . . . . . . . . . . . . . . . . . . . . . 228
World Physicians Call for Inquiry into Congo Rapes . . . . . . . 229
Health Day at COP16 – Doctors Say:
Don’t Forget the Health Dividend . . . . . . . . . . . . . . . . . . . . . . 230
Time is of the Essence to Achieve
a Solution on Patients’ Rights. . . . . . . . . . . . . . . . . . . . . . . . . . 231
Stephen Holman awarded Bioanalysis:
Young Investigator 2010. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
Patient Safety and Quality in Medicine
Permanent Obligation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Climate Change: Governments Need to
Hear from Medical Professionals . . . . . . . . . . . . . . . . . . . . . . . 237
Sustainable Health Financing . . . . . . . . . . . . . . . . . . . . . . . . . 239
A Prescription for America’s Health Care System . . . . . . . . . . 243
Freedom of Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Students Striving to Improve Medical Education
Experiences from International Perspective . . . . . . . . . . . . . . . 247
Health Professionals’ Mobility
Presentation of a Research Project . . . . . . . . . . . . . . . . . . . . . . 249