wmj13

WorldMMeeddiiccaall JJoouurrnnaall
Vol. No.1,March200753
OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
G 20438
Contents
EEddiittoorriiaall 1
MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
Harmonization of Research Ethics
Committees – are there limits? 2
MMeeddiiccaall SScciieennccee
Better heart transplants
will quadruple lives saved 3
People in Pain Confused About Pain Relievers
and Missing Out On Effective Treatment 4
MMeeddiiccaall EEdduuccaattiioonn
Patients with Alzheimer’s disease may lack
the mental capacity to give informed consent 8
WHO/WFME strategic partnership
to improve medical education 8
New on-line TB training course to be launched
by WMA on World TB Day 9
The World Medical Association Statement
on Medical Education 9
FFrroomm tthhee SSeeccrreettaarryy GGeenneerraall
Health Professional Council of South Africa
announces amnesty on restoration fees 11
WWoorrlldd MMeeddiiccaall AAssssoocciiaattiioonn
Scientific Session “Health as an Investment:
Leadership and Advocacy” 12 October 2006 12
The Health Care System in Japan 15
The World Medical Association Statement on
HIV/AIDS and the Medical Profession 17
The World Medical Association Statement on
Assisted Reproductive Technologies 20
WWHHOO
Key Issues for future WHO work 23
International action needed
to increase health workforce 23
Africa Reports 24
New report shows improvements
in child survival in Africa for the first time
since the 1980s 25
WHO reports some promising results on avian
influenza vaccines 26
UN Global goal to reduce measles deaths in
children surpassed 27
World Leprosy Day 2007 28
Appeal to migrant physicians to return 28
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Website: https://www.wma.net
WMA Directory of National Member Medical Associations Officers and Council
Association and address/Officers
WMA OFFICERS
OF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
i see page ii
President-Elect President Immediate Past-President
Dr. J. Snaedal Dr. N. Arumagam Dr. Kgosi Letlape
Icelandic Medical Assn. Malaysian Medical Association The South African Medical Association
Hlidasmari 8 4th Floor MMA House P.O Box 74789
200 Kopavogur 124 Jalan Pahang Lynnwood Ridge 0040
Iceland 53000 Kuala Lumpur Pretoria 0153
Malaysia South Africa
Treasurer Chairman of Council Vice-Chairman of Council
Prof. Dr. Dr. h.c. J. D. Hoppe Dr. Y. Blachar Dr. K. Iwasa
Bundesärztekammer Israel Medical Association Japan Medical Association
Herbert-Lewin-Platz 1 2 Twin Towers 2-28-16 Honkomagome
10623 Berlin 35 Jabotinsky Street Bunkyo-ku
Germany P.O. Box 3566 Tokyo 113-8621
Ramat-Gan 52136 Japan
Israel
Secretary General
Dr. O. Kloiber
World Medical Association
BP 63
01212 Ferney-Voltaire Cedex
France
ANDORRA S
Col’legi Oficial de Metges
Edifici Plaza esc. B
Verge del Pilar 5,
4art. Despatx 11, Andorra La Vella
Tel: (376) 823 525/Fax: (376) 860 793
E-mail: coma@andorra.ad
Website: www.col-legidemetges.ad
ARGENTINA S
Confederación Médica Argentina
Av. Belgrano 1235
Buenos Aires 1093
Tel/Fax: (54-11) 4381-1548/4384-5036
E-mail:
comra@confederacionmedica.com.ar
Website: www.comra.health.org.ar
AUSTRALIA E
Australian Medical Association
P.O. Box 6090
Kingston, ACT 2604
Tel: (61-2) 6270-5460/Fax: -5499
Website: www.ama.com.au
E-mail: ama@ama.com.au
AUSTRIA E
Österreichische Ärztekammer
(Austrian Medical Chamber)
Weihburggasse 10-12 – P.O. Box 213
1010 Wien
Tel: (43-1) 51406-931/Fax: -933
E-mail: international@aek.or.at
REPUBLIC OF ARMENIA E
Armenian Medical Association
P.O. Box 143, Yerevan 375 010
Tel: (3741) 53 58-68
Fax: (3741) 53 48 79
E-mail:info@armeda.am
Website: www.armeda.am
AZERBAIJAN E
Azerbaijan Medical Association
5 Sona Velikham Str.
AZE 370001, Baku
Tel: (994 50) 328 1888
Fax: (994 12) 315 136
E-mail: Mahirs@lycos.com /
azerma@hotmail.com
BAHAMAS E
Medical Association of the Bahamas
Javon Medical Center
P.O. Box N999
Nassau
Tel: (1-242) 328 1857/Fax: 323 2980
E-mail: mabnassau@yahoo.com
BANGLADESH E
Bangladesh Medical Association
BMA Bhaban 5/2 Topkhana Road
Dhaka 1000
Tel: (880) 2-9568714/9562527
Fax: (880) 2-9566060/9568714
E-mail: bma@aitlbd.net
BELGIUM F
Association Belge des Syndicats
Médicaux
Chaussée de Boondael 6, bte 4
1050 Bruxelles
Tel: (32-2) 644-12 88/Fax: -1527
E-mail: absym.bras@euronet.be
Website: www.absym-bras.be
BOLIVIA S
Colegio Médico de Bolivia
Calle Ayacucho 630
Tarija
Fax: (591) 4663569
E-mail: colmed_tjo@hotmail.com
Website: colegiomedicodebolivia.org.bo
BRAZIL E
Associaçao Médica Brasileira
R. Sao Carlos do Pinhal 324 – Bela Vista
Sao Paulo SP – CEP 01333-903
Tel: (55-11) 317868-00/Fax: -31
E-mail: presidente@amb.org.br
Website: www.amb.org.br
BULGARIA E
Bulgarian Medical Association
15, Acad. Ivan Geshov Blvd.
1431 Sofia
Tel: (359-2) 954 -11 26/Fax:-1186
E-mail: usbls@inagency.com
Website: www.blsbg.com
CANADA E
Canadian Medical Association
P.O. Box 8650
1867 Alta Vista Drive
Ottawa, Ontario K1G 3Y6
Tel: (1-613) 731 8610/Fax: -1779
E-mail: monique.laframboise@cma.ca
Website: www.cma.ca
CHILE S
Colegio Médico de Chile
Esmeralda 678 – Casilla 639
Santiago
Tel: (56-2) 4277800
Fax: (56-2) 6330940 / 6336732
E-mail: rdelcastillo@colegiomedico.cl
Website: www.colegiomedico.cl
Title page: The National Hospital of Neurology, London (often referred to as “the National” or Queen’s Square”). Founded in 1859, the many distinguished physicians who have wor-
ked there include both J. Hughlings Jackson and C-E. Brown-Sequard, the hospital is internationally famed for its teaching and research. Now part of the UCL Hospital NHS Trust, it
is called The National Hospital for Neurology and Neurosurgery. This picture shows the early 20th century building now dwarfed by the much larger complex of buildings, one of
which is the Institute of Neurology next door (founded in 1950 and merged with University College, London 1997), with which it has retained links.
Below: New building of the German Medical Association (Bundesaerztekammer) in Berlin. After very many years situated in Cologne, following the movement of the givernment and many
of the ministries from Bonn to Berlin, following the decision by its General Assembly to relocate in Berlin, in 2004 the Bundesaerztekammer moved into this fine new building in Berlin.
U2–4_WMJ_01_07.qxd 30.04.2007 09:38 Seite U2
1
OFFICIAL JOURNAL OF
THE WORLD MEDICAL
ASSOCIATION
Hon. Editor in Chief
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suffolk IP14 3QT
UK
Co-Editors
Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte-Verlag
Dieselstr. 2
D–50859 Köln
Germany
Dr. Ivan M. Gillibrand
19 Wimblehurst Court
Ashleigh Road
Horsham
West Sussex RH12 2AQ
UK
Business Managers
J. Führer, D. Weber
50859 Köln
Dieselstraße 2
Germany
Publisher
THE WORLD MEDICAL
ASSOCIATION, INC.
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01212 Ferney-Voltaire Cedex, France
Publishing House
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Bank: Commerzbank Köln No. 1 500 057,
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At present rate-card No. 3 a is valid.
The magazine is published quarterly.
Subscriptions will be accepted by
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Medical Association.
Subscription fee € 22,80 per annum (incl. 7 %
MwSt.). For members of the World Medical
Association and for Associate members the
subscription fee is settled by the membership
or associate payment. Details of Associate
Membership may be found at the World
Medical Association website www.wma.net
Printed by
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ISSN: 0049-8122
Wherever one looks the medical profession it seems to be facing more and more problems
despite, or sometimes due to, advances in medical science and their introduction into med-
ical practice. They range from the global problems of human resources and health profes-
sionals including physicians, inequities in their distribution across the world, continuing
efforts to maintain standards for professional practice and ensuring maximum patient safe-
ty, the changing face of medical practice with increasing emphasis on prevention, huge
increases in the intrusion of management and administrative bureaucracy associated with
medical practice both in hospitals and the communities.
As these problems are addressed, it is vital that the profession in each country is seen to
have considered them and prepared its own position, rather than reacting to short term poli-
cies proposed by others which may be neither in the best interests of the community, of
individuals, or of the profession.
The contents of this issue of WMJ reflects the diversity of both the positive developments
in medicine, science and in disease control, strategic plans and health policy developments,
as well as some of the problems which still need to be solved.
It includes some further WMA policy statements, one of which, that on medical education, is
also the subject of a report on a new strategic partnership between the World Health
Organisation and the World Federation of Medical Education. There is also a report on the
first meeting of the Taskforce of the Global Health Workforce Alliance (GHWA) to seek prac-
tical solutions to the health workforce problems, including investment in education and train-
ing of all healthcare workers. The WMA Secretary General comments on one particular effort
seeking to persuade physicians who have emigrated to return to practice in their own country
where there is a grave shortage of physicians. Another article addresses the problems of med-
ical research ethics posing a question as to whether or not there are limits to the possible har-
monisation of activities of ethical research committees. Two papers given at the WMA scien-
tific meeting in South Africa address the important topic of “Health as an investment”
In the context of the problems of shortage of physicians it is interesting to note the results
of a ten year cohort study of 545 of doctors who graduated in one country in 1995*. Of
approximately 1400 of the final year students who expressed willingness to participate in
the survey, a sample of 600 were drawn and of these 545 participated in the questionnaire
which was sent to all participants each year for ten years. This was combined with focus
groups which were random sub-samples each year, where questions could be more deeply
examined. Apart from information on type of work, career choice and training, questions
were asked about working conditions and about participants’ attitudes to medicine as a
career, in the light of their experience year by year.
While all the results of this study are interesting, as will be those of the next ten year cohort
study, in the context of the debate on human health resources (particularly recruitment and
retention of physicians), it is interesting to note that in this study
• 2 in every 5 doctors in the cohort study (40%) found that the reality of a career in medi-
cine was very different from that envisaged on graduation in 1995;
• While three quarters (75%) of the cohort doctors ten years after graduating were satisfied
with practising medicine, a fifth (20%) reported a lukewarm desire to practice medicine.
• The rest (5%) had little or no desire to practise medicine. (3% of the cohort had left med-
icine during the 10 years of the study, the most common reason being dissatisfaction with
medicine as a career.
• 15% had changed their career choice during the study period, a key factor in this being
“hours of work and working conditions” followed by working/pay conditions.
While these findings are disturbing (20% having a weak desire to practice medicine after
10 years), when planning to educate more physicians to meet needs it is unfortunate that no
other countries have carried out comparable extensive cohort studies. If the profession is to
address its future in the light of the problems it faces, then such studies could contribute
valuable information in the formulation of such plans.
Alan Rowe
*BMA Cohort Study 10th
report 2005
Editorial
WMJ_1_01-28.qxd 30.04.2007 09:37 Seite 1
ing these this view it has served since the
age of Aristotle as a method of analysing
whether handling of human beings by
researchers is acceptable or not, as being
“good” or “bad”. The methods of this analy-
sis can be harmonized, such as the examina-
tion of the scientific merit of research pro-
jects or of their accordance with national or
international law. If there are positive
answers to these questions, then the deci-
sion on the ethical acceptability is based on
the question of “good” or “bad”. For the
terms “good” and “bad” there are no defin-
itions accepted worldwide. They are more-
over influenced by religion, tradition or
even different philosophical schools, which
may differ even within a country and of
course, within the different regions of the
world.
A recent example is the worldwide discus-
sion on the use of human embryonic stem
cells for research. Even in those countries
where the need for such type of research is
accepted, the ethical analysis, as mentioned
above, may lead to the view that it should not
be performed, as it is considered to be “bad”.
In the discussion on the ethical acceptabili-
ty of medical research, the expression
“medical ethics” is widespread, assuming
that in this way the diversity of ethics, as
marked e.g. by utilitarism or transcendental
ethics in the sense of Immanuel Kant, could
be overcome. This attempt needs considera-
tion as to whether the term “medical ethics”
is appropriate or not. The known general
ethical principles such as respect for the
human being, beneficence, non-malefi-
cence (“do no harm”) or justice, are basic
and leading guidelines for the whole life of
human beings in society. They may be, in an
appropriate way, applied to special fields
e.g. banking, or even medical research.
Everybody understands, that in financial
transactions the principles “do no harm” or
“justice” are obligatory to prevent any kind
of betrayal or deception of the person con-
Medical Ethics and Human Rights
2
Biomedical research involving human sub-
jects has to respect their autonomy, dignity,
identity, integrity and other rights and fun-
damental freedoms. Research ethics com-
mittees, initially established at the request
of national authorities such as the National
Institute of Health (NIH) in the late sixties
in the USA, the “Deutsche Forschungs-
gemeinschaft” (DFG) 1973 in Germany and
since 1975, part of the Declaration of
Helsinki, are universally charged with safe-
guarding these rights.
Biomedical research while initially per-
formed more on a national level is increas-
ingly spreading out on an international or
even intercontinental field.. For this reason
researchers and research institutions,
including the pharmaceutical industry (in
research a very important global player)
have for a long time stressed the need for
the harmonization of the decisions and the
procedures of research ethics committees.
The main argument concerns the suggestion
that there should be only one “medical
ethic” in a country, in a continent or around
the globe. On the basis of this assumption
all legal obstacles causing diversity of
ethics committees such as different compo-
sition, different kinds of financing, different
ways of decision making etc. should be
abandoned in favour of a “unique, harmo-
nized research ethics committees’ proce-
dure”. Are these arguments applicable; is
the diversity of ethics committees in differ-
ent countries or in unions of states justified,
or only superficial?
First of all it must be recalled that the main
task of an ethics committee is the multidis-
ciplinary assessment of the ethical accept-
ability of an envisaged research project.
This raises the question of the character of
ethics and its so often requested worldwide
uniformity.
Ethics is, at least in the circles of experts,
understood as a part of philosophy. Follow-
cerned! The adaptation to special sectors
may not deviate from the basic concept of
the relevant ethical principles.
The use of the term “ethics in medicine”,
used by preference in some circles rather
than “medical ethics” is more than a seman-
tic suggestion. It underlines this general
approach to ethics and is therefore much
more appropriate than “medical ethics”,
which can be misunderstood and should be
avoided, at least in multidisciplinary discus-
sions. It should be avoided, at least in a
multidisciplinary discussions. It follows
from these considerations that ethics in
medicine, so far as analytical methods are
considered, may be harmonized. The basis
of the decision to be taken by research
ethics committees – “good” or “bad” –, can-
not be standardized or harmonized. Any
other outcome would be surprising, imply-
ing the same definition for “good” and
“bad” around a world with differing reli-
gions, ethics, differing cultures/social pat-
terns etc.?
In contrast: by long tradition, discussions
on “good” and “bad” and conclusions on a
regional level are the basis for moral guide-
lines in any specific society. Professions
such as lawyers or physicians, are entitled
to contribute to these discussions and deci-
sion making for such an ethnic entity. But
no professional group has any right to pre-
scribe in isolation regulations for that enti-
ty. This is another argument against profes-
sional based ethics or morals as binding
provisions on all. Since in the work of pro-
fessions the rights of others have to be
respected, profession linked ethics are not
necessarily appropriate outside the profes-
sion.
Unavoidable diversity is the principal
obstacle to any kind of harmonization of
research ethics committees other than the
process leading to a decision, the decision
itself is not open to standardisation!
Harmonization of Research Ethics Committees – are there limits?
Prof. Elmar Doppelfeld MD Chair of the Permanent Working Party of
German Research Ethics Committees
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Medical Science
3
Research ethics committees are, at least by
tradition, embedded into a national frame-
work, which itself is influenced by religion,
history, tradition and the system of legisla-
tion of that country. In practice the protec-
tion of human rights and fundamental free-
doms (even when, as in most cases, it is
guaranteed by the constitution of the state)
may be influenced by juridical decisions of
courts competent for constitutional law in
different ways. There may exist on that
basis a diversity of interpretations of e.g.
“free informed consent” or conditions of its
expression such as “substitution” in place of
consent of persons not able to do so, of data
protection etc. Relevant decisions of the
courts and national legislation have to be
followed in the regulation of ethics commit-
tees and their work. These differences
appear even in regions of the world with
more or less common traditions.
In preparing the Directive 2001/20/EU, the
European Union tried to harmonize at least
the administrative part of ethics commit-
tees. These attempts failed, and everybody
knows the results: Member states are
obliged to establish a system of research
ethics committees which have to consider
the usual international principles of ethical
assessment and to make a decision within a
given time. Nothing is said, for example,
about conditions or interpretation of “free
informed consent” in the normal situation,
or in research in an emergency situation.
The diversity in ethics has been identified
as the main obstacle to any kind of harmon-
isation or standardisation of the work and
decision making of research ethics commit-
tees. The diversity in legal and administra-
tive provisions for these committees, them-
selves caused, at least in part by the ethical
diversity, constitute a second obstacle.
It is understandable, that researchers and
research institutions or sponsors (such as the
pharmaceutical industry) are faced with that
situation and have a special interest in over-
coming it or at least living with it. In an
attempt to help in this situation, the
European Forum for Good Clinical Practice
(EFGCP) recently published an overview on
the “Procedure for the ethical review of pro-
tocols for clinical research projects in the
European Union” (International Journal of
Pharmaceutical Medicine, Vol. 21, No 1,
2007). This publication gives an excellent
overview of the ethics revue systems in 26
European countries plus Switzerland and
Norway. The report provides an excellent
overview showing the different interpreta-
tions of the directive 2001/20/EG by the
member states of the European Union. In
this way it assists researchers to prepare
multinational research projects within the
Union, while respecting national provisions.
Prof. Elmar Doppelfeld MD
Chair of the Permanent Working Party of
German Research Ethics Committees
Ottostraße 12
D-50859 Köln
Tel. 00492234993237
Fax 00492234993239
e-mail: med.ethik.komm@netcologne.de
Death of a valiant defender of human
rights of prisoners.
The death of Dr. Fusen Sayek, former
President of the Turkish Medical
Association, marks the loss of an out-
spoken opponent of torture and inhu-
mane conditions in prison.
In particular during the 90’s she put
up a fierce battle against the inhu-
mane treatment of people in custody
in Turkey. Dr. Sayek died after a long
struggle with cancer on 12th
February
2007.
Professor Bruce Rosengard, Papworth
Hospital, Cambridge, has perfected a
machine to pump sterile, oxygenated
blood, saline and nutrients through
organs for transplantation – especially
the heart. For the last 25 years, hearts for
transplant have been kept on ice, with
gradual deterioration, requiring an opera-
tion within 3-4 hours. Now using this
new technique, organs in sub-optional
condition can be resuscitated into action;
they can be transported much greater dis-
tances, such as for example across
Medical Technology
Better heart transplants will quadruple lives saved
American or Australia; and the time for
surgery extends to around 12 hours with-
out any significant deterioration. A heart
(or other organ) can be removed, for
instant at the scene as an accident, where
the patient has died, is brain-dead, but the
heart still beating. The heart for trans-
plant is connected to the machine via the
aorta and pulmonary artery with around 1
litre of blood which is recycled. The
organ for transplant arrives at the operat-
ing theatre in a better condition than
when it left in the donor.
Prospects for the heart
transplant surgery
According to Professor Sir Magdi Yacoub,
this technique will revolutionise the way
heart transplants are done in the future.
Cloning of hearts is not the answer although
stem cell regenerative therapy does have
this place alongside transplantation. These
methodologies do interact with one another
at the tissue and organ levels very well. It is
very significant that this innovative method
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Medical Science
4
will improve heart function for thousands of
patients when disease begins to set in. In
principle it could be used for every organ in
the body, and for the liver and lungs with
immediate effect.
The stages are:
(1) Assess heart function. Estimate the
chances of a heart attack in terms of
narrowing and blockages in the coro-
nary arteries.
(2) If the heart is impaired, how can be
improve it?
(3) More hearts will consequently become
available for transplant, estimates being
an increase by a factor of 3-4 times. Only
139 heart transplants were carried out in
the UK during the last year, because of an
acute shortage of donor organs.
(4) This enables more intricate surgical
work to be done on the heart which is
outside the patient. Currently 10% of
cardiac patients are dying at the waiting
list.
(5) The failure rates of tissue grafts in
surgery can be very high, and some
don’t start to function at all. Four inter-
national centres are now running clini-
cal trials to confirm the efficacy of the
technique.
At the present there is a huge shortage of
organs for transplantation, and the UK is
one of the lowest in Europe. Such a method-
ology would offer hope for the many
patients currently condemned to a ‘living
dead’ because of a lack of transplant
resources.
Ivan M. Gillibrand
Amsterdam, The Netherlands, 23 June
2006 – Up to 64% of people in pain,
including those with musculoskeletal pain,
are confused about which pain medication
they should and shouldn’t take, and many
do not know how to manage their pain
appropriately, according to the results of a
global patient and physician survey
announced by the Arthritis Action Group
(AAG).(1) The survey builds on previous
AAG research, the Arthritis Research
Survey, showing major inadequacies in the
management of pain,(2) and has compelled
the group to call for improved communica-
tion with patients so they don’t endure pain
unnecessarily.
“These are disturbing findings – large num-
bers of people in pain are confused about
treatment options and risks, and as a result
do not know how to manage their pain
properly,” said Professor Anthony Woolf,
Chairman of AAG. “Action is needed now
to clear this confusion for support patients
Pain relief
People in Pain Confused About Pain Relievers and Missing Out On
Effective Treatment
Experts Urge Clarity to Reduce the Debilitating Impact of Daily Pain
and physicians to manage pain effectively
to reduce its pervasive impact on daily life.”
The survey of 1204 people with pain, and
604 primary care physicians, was conduct-
ed by Harris Interactive, on behalf of AAG,
in six countries worldwide – United
Kingdom, Germany, Italy, France, Mexico
and Australia.
Pain severely impacts on the
quality of life
One in five people worldwide has moderate
to severe chronic pain, including 100 mil-
lion Europeans with musculoskeletal pain
and arthritis.(3,4) People in pain report that
it strongly impacts on their life, affecting
their ability to sleep and complete daily
tasks.(1) Not only does pain affect quality-
of-life, but previous studies show that it can
also predict increased mortality.(5)
People in pain are confused
and under-informed (1)
• Up to 64% of people feel that conflict-
ing information about pain medications
makes it confusing to know what to
take.
• Up to 78% of people feel they don’t
know enough about the benefits and
risks of pain medications (either pre-
scription medications, over-the-counter
medications, or both).
Pain is not being managed
appropriately (1)
Many people are putting themselves at risk
by using treatments inappropriately:
• If their pain medication doesn’t work
after 10 days of use, less than half of
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Medical Science
5
people taking prescription medication
and less than half taking non-prescrip-
tion medication will go to their doctor
for advice or treatment. To get better
pain relief, people are using strategies
such as taking more of the same type of
medication, taking a different type of
medication, or exercising.
• Up to 47% of people in pain don’t use
medication at all. Reasons include expe-
rience with or concern about side-
effects, a perception that they can man-
age without medication, their doctor
advised them to stop taking medication,
or because they’re worried following
stories in the news.
Information gap exposed
Despite patient confusion, detailed discus-
sions about different treatment options and
their specific benefits and risks are not tak-
ing place in consultation with their physi-
cian. Patients report that during their last
consultation: (1)
• Less than half discussed how effective
their current medication was (≤43%), or
treatment benefits (≤40%)
• Less than a third discussed potential
problems or medication side-effects
(≤30%)
Insufficient information sharing between
patients and physicians was attributed to the
following:
• Many physicians underestimate the
level of patient concern about treatment
risks. For example, up to 48% of
patients are very concerned about the
potential side-effects of non-prescrip-
tion NSAIDs (of those who are aware of
them), whereas only a small number of
physicians felt their patients were very,
or extremely concerned about this
(=14%). Most discussions are about the
benefits and risks of prescription med-
ications. (1,6)
• Up to 92% of physicians think patients
don’t have the expertise to evaluate the
relative benefits and risks of treatment.
(6)
• Up to 25% of physicians find it difficult
to communicate the benefits and risks
of prescription medications, and up to
24% for non-prescription pain medica-
tions. (6)
• Less than half of physicians are very
familiar with the recently updated
guidelines for pain medications
(=49%). (6)
• Up to 92% of physicians think their
elderly patients don’t want responsibility
for treatment decisions. (6)
• Up to 89% of physicians see consulta-
tion time constraints as a problem. (6)
“These survey results highlight the large
gap in understanding between patients and
physicians,” said Sandra Canadelo, Vice
Chair of the PARE Manifesto Steering
Group, and Chair of the EULAR Social
Leagues. “Chronic pain is hugely debilitat-
ing for patients, and severely impacts qual-
ity of life. Informed discussions are needed
to ensure pain is managed effectively, and
the best decisions are made to improve the
lives of patients.”
Background
About the survey
About a total of 1204 people with pain, and
604 primary care physicians were inter-
viewed. This included approximately 200
people with chronic pain and 100 general
practice patient-care physicians from each
of the following countries: United
Kingdom, Germany; Italy, France, Mexico
and Australia.
The research was conducted by Harris
Interactive on behalf of the Arthritis
Action Group between 22 December 2005
and 22 February 2006. The data were not
weighted to the patient and physician pop-
ulation proportions in each country and
therefore are not representative of those
populations.
About the Arthritis Action
Group (AAG)
Arthritis Action is an international, physi-
cian-led initiative dedicated to advance
awareness of rheumatic conditions and
management choices so that healthcare
providers, patients and carers can work in
the true partnership towards maximum
quality of life. It aims to help healthcare
providers, people with musculoskeletal
problems and they cares by:
• Raising awareness of unmet needs in the
management of musculoskeletal pain
• Improving timely access to the most
effective management options
• Promoting the “optimal practice” man-
agement of musculoskeletal pain
About the PARE Manifesto
PARE (people with Arthritis/ Rheumatism
in Europe) Manifesto is the campaigning
arm of the EULAR Social Leagues. It rep-
resents the parents’ voice in Europe and
seeks to ensure that the “European
Manifesto” ten calls to action in a single,
agreed document, developed by the
EULAR Social Leagues, Arthritis and
Rheumatism International and the
Organisation of Youth with Rheumatism
in 1999, is implemented in Europe where
more than 100 Million Europeans are
affected by arthritis/ rheumatism. For
more information visit www.paremani-
festo.org
About Harris Interactive®®
Harris Interactive is the 13th largest and
fastest-growing market research firm in the
world. The company provides research-dri-
ven insights and strategic advice to help its
clients make more confident decisions
which lead to measurable and enduring
improvements in performance. Harris
Interactive is widely known for The Harris
Poll®
, one of the longest running, indepen-
dent opinion polls and for pioneering
online market research methods. The com-
WMJ_1_01-28.qxd 30.04.2007 09:37 Seite 5
Medical Science
6
pany has built what could conceivably be
the world’s largest panel of survey respon-
dents, the Harris Poll Online. Harris
Interactive serves clients worldwide
through its United States, Europe and Asia
offices, its wholly-owned subsidiary
Novatris in France and through a global
network of independent market research
firms.
References
1. Insights into Pain Relief Patient Survey.
Arthritis Action Group.23 June 2006.
2. A Woolf, et. al. Musculoskeletal pain in
Europe: Its impact and a comparison of popu-
lation and medical perception of treatment in
eight European countries. Annals of the
Rheumatic Diseases. April 2004.
3. WHO press release accessed online 11 May
2006: www.painreliefhumanright.com/pdf/
press-reease.pdf .Statistics released by
International Association for the Study of Pain
and European Federation of IASP Chapters.
4. World Health Organisation. World Health
Report. Life in the 21th Century. A Vision for
all. 1998. pp47-48.
5. Sokka T, Pincus T, Pain as a Significant
Predictor of Premature Mortality over 5 Years
in the General Population, Independent of
Age, Sex and Acutely Life- Threatening
Diseases. Poster presented at the Annual
Scientific Meeting of the American College of
Rheumatology, November 12-17, 2005, San
Diego.
6. Insights into Pain Relief, Pain Relief
Physician Survey .Arthritis Action Group. 23
June 2006.
Pain Relief Survey
• The “Insights Into Pain Relief” global
survey was commissioned by the
Arthritis Action Group, an international
group of leading physicians and acade-
mics, to gauge the opinions and experi-
ences of people with pain, including
arthritis and musculoskeletal pain, and
the physicians who treat people with
pain.
• The survey was conducted among 1204
patients and 604 primary care physicians
across six individual countries – United
Kingdom, Germany, Italy, France,
Mexico and Australia.
• The research was conducted by Harris
Interactive, on behalf of AAG, between
22 December 2005 and 22 February
2006.
• This survey builds on AAG research
conducted in 2004, via the Arthritis
Research Survey, which revealed major
inadequacies in the management of pain
resulting from arthritis and other muscu-
loskeletal problems. It showed that one
in three people affected by muscu-
loskeletal pain never consults a physi-
cian about their pain.
Key Findings from the
“Insights into pain relief”
survey
Pain severely impacts quality of life
• Many people in pain report it impacts
their life, affecting their ability to sleep
(up to 42% pf patient) and conduct day-
to-day activities (up to 61% of patients).
• Physicians warn that a number of health-
related issues are likely to result if
chronic pain is not managed effectively,
including loss of normal day-to-day
activity (up to 92% of physicians),
impaired social function (up to 86% pf
physicians), depression (up to 85% of
physicians), weight gain (up to 81% pf
physicians).
• Back pain is the most common muscu-
loskeletal ailment suffered /up to 70% of
patients), followed by neck/shoulder
pain (up to 61% of patients) and
knee/ankle pain (up to 53% op patients).
Many people in pain are confused and
under-informed about pain relievers
• Up to 64% of people feel that conflicting
information about pain relievers makes it
confusing to know what to take.
• Up to 64% of people feel they don’t
know enough about the benefits and
risks of prescribed pain medications, and
up to 63% feel they don’t know enough
about the benefits and risks of non-pre-
scription pain medications.
Pain medications aren’t being used
appropriately
• If their pain medication didn’t work
after 10 days of use, less than 47% of
people taking prescription medication
went to their doctor for advice or treat-
ment, or to ask for a different medica-
tion. To get better pain relief, people are
using strategies such as taking more of
the same type of medication, taking a
different medication, exercise, massage
therapy, and pain relieving creams and
rubs.
• Up to 47% of people in pain don’t use
medication at all. Of those, up to 73%
say they feel they can manage without
medication, up to 25% say it’s because
they are worried about side effects, and
up to 22% say that their doctor advised
them to stop taking their medication.
Many people in pain find it difficult to
get information from their doctor
• Most people in pain (up to 89%) obtain
information about their condition and
treatment from their doctor, with up 78%
seeing their doctor as the most important
source of information.
• Over half of people in pain (up to 52%)
use their pharmacist to find out about
pain conditions and pain medications,
whilst only a small number of people in
pain see their pharmacist as the most
important source in information (≤10%)
• At their last consultation with their doc-
tor or nurse practitioner:
– Less than half a patients discussed how
effective their current medication was
(≤43%), or treatment benefits (≤40%)
– Less than a third of patients discussed
potential problems or medication side-
effects (≤30%)
Survey Methodology
Patients
• For inclusion in the study , patients had
to be age 18 or older and suffering from
at least one qualifying chronic pain con-
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Medical Science
7
dition (pain conditions included back
pain, neck shoulder pain, knee/ankle
pain, joint pain, arthritis, hip pain, morn-
ing stiffness, migraine pain, dental pain,
serve menstrual pain, sprains/strains,
bursitis/tendonitis, post-operative pain,
other body pain).
• Approximately 200 pain sufferers were
interviewed from each of the following
countries: United Kingdom, Germany,
Italy, France, Mexico and Australia.
• All respondents were sampled from list
generated by Random Digit Dialling
(RDD) in each country, screened by tele-
phone, and if qualified, invited to contin-
ue with a survey 15 minutes in length.
• The data were not weighted to the
patient population proportions in each
country and therefore are not representa-
tive of those populations.
Physicians
• For inclusion in this study, physicians
had to be Primary Care Physicians
(PCPs) involved in treatment decisions
of patients with pain conditions who
write 30 or more scripts for pain,
inflammation or arthritis per month.
• Approximately 100 general practice
patient-care physicians were interviewed
from each of the following countries:
United Kingdom, Germany, Italy,
France, Mexico and Australia.
• All respondents were sampled from
physician lists in each country, contacted
by phone, screened, and if qualified,
invited to continue with a survey 10 min-
utes in length.
• The data were not weighted to the
patient population proportions in each
country and therefore are not representa-
tive of those populations.
Arthritis Action Group
Arthritis Action is a physician-led initia-
tive, dedicated to advance awareness of
rheumatic conditions and management
choices so that healthcare providers,
patients and carers can work in the true
partnership towards maximum quality of
life. It aims to help healthcare providers,
people with musculoskeletal problems and
they cares by:
• Raising awareness of unmet needs in the
management of musculoskeletal pain
• Improving timely access to the most
effective management options
• Promoting the “optimal practice” man-
agement of musculoskeletal pain
Arthritis Action currently brings together
experts from eleven countries across the
world, eight of which are in Europe: France,
Germany, Ireland, Italy, Spain, Sweden,
Switzerland and the UK. Arthritis Action
has collaborative partnerships with a num-
ber of other organisations which have an
interest in musculoskeletal conditions, to
help raise musculoskeletal problems as a
priority on the European healthcare agenda,
for example Bone and Joint Decade and the
World Health Organisation.
In addition to participating in international
and European-wide activity, individual
countries involved in Arthritis Action have
their own National Action Groups, dedicat-
ed to adressing key national issues to mus-
coloskeletal conditions.
The Arthritis Action initiative is driven by
the AAG, a steering committee of 17 lead-
ing physicians and academics. The group
members specialise in the management of
musculoskeletal conditions and work with-
in a range of disciplines including: rheuma-
tology, epidemiology, gastroenterology,
geriatrics, clinical pharmacology,
orthopaedics and primary care.
AAG Research
In 2002 the group conducted The Arthritis
Research Survey, the largest survey of its
kind to be carried out in Europe. Published
in Annals of Rheumatic Diseases in 2004,
the survey remains the most up to date data
collected which quantifies the impact of
musculoskeletal pain on quality of life,
assesses the management of condition
across Europe and identifies the beliefs and
perceptions of treatment held by physicians
and people with musculoskeletal condi-
tions.
Key points from the survey findings
include:
• From the physician perspective it
appears that musculoskeletal pain is well
managed, from the population perspec-
tive the pasture is less optimistic
• There is lack of communication between
physicians and patients concerning mus-
culoskeletal pain and the benefits and
risk of medications
• Some people with musculoskeletal pain
may be receiving inadequate treatment
and therefore may be at risk for avoid-
able pain or side effects
• Barriers to diagnosis and optimum man-
agement of musculoskeletal pain may be
attitudinal and could be improved by
better communication between patients
and their physicians
Pan- European findings from the survey
were published in the Annals of the
Rheumatic Diseases (ARD), April 2004.
Currently underway is the Environmental
Factors Programme, which is aims to
identify the barriers and facilitators to the
best practice management of musculoskele-
tal conditions, using the WHO classified
contextual factors.
Arthritis Action Mission
Advancing awareness of rheumatic con-
ditions and management choices so that
healthcare providers, patients and carers
can work in true partnership towards
maximum quality of life
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Medical Education
8
numbers of mentally incapacitated patients
may be being significantly underestimated.
Professor Matthew Hotopf and colleagues
at the Institute of Psychiatry, Preston and
Yale tested the degree of cognitive impair-
ment of patients admitted to a London hos-
pital. Some 31 per cent of inpatients were
considered to lack mental capacity.
However, when clinical teams interviewed
inpatients, they rated just 8 per cent as lack-
ing mental capacity.1
Most patients probably rely on doctors to
make the most appropriate decision for
them. A need to assess mental capacity in a
medically pressing situation could present
Patients should consent to medical treat-
ment. But an inability to give reasoned
consent may be more common than doctors
appreciate.
The consent to medical treatment, patients
should be making voluntary and informed
choices, and have the mental capacity to
make a decision. Patients lack mental
capacity when they cannot understand the
information being given to them, or use it to
decide on a course of action, or are unable
to communicate their decision. Usually,
mental capacity is taken as read unless the
patient’s difficulties are very obvious.
However, recent research suggests that the
Informed Consent
Patients with Alzheimer’s disease may lack the mental capacity
to give informed consent
significant difficulties to the medical pro-
fession. On the other hand, there is clearly
also a need to protect vulnerable patients,
particularly when major – and irreversible –
medical decisions are being made.
These kinds of issues are being considered
in the UK’s draft Mental Capacity Bill. The
researchers suggest that, even if legislation
is seen as too heavy handed, the issue of
patients’ mental capacity should be given
more attention by doctors.
1 Raymont V et al. Prevalence of mental inca-
pacity in medical inpatients and associated risk
factors: cross-sectional study. Lancet 2004; 364
(9443): 1421-7.
WHO and the World Federation for Medical
Education (WFME) propose a strategic
partnership to pursue a long-term work plan
– open to participation by all medical
schools and other educational providers –
intended to have a decisive impact on med-
ical education in particular and ultimately
on health professions education in general.
The WHO/WFME work plan will benefit
from the accumulated experience and assets
of each partner and will result in:
– A shared database that will include up-to-
date experience in implementing quality-
improvement processes in medical
schools
– Access, via the database, to information
on specific schools and in particular to a
WHO/WFME strategic partnership
to improve medical education
description of their approach to quality
improvement
– Promoting twinning between schools and
other institutions in processes to foster
innovative education
– Means to update the management of med-
ical schools
– Identification and analysis, by WHO
regions, of innovations in medical educa-
tion in order to help define appropriate
lines of work for each region
– Assistance to institutions or national/
regional organizations and agencies in
developing and implementing reform pro-
grammes or establishing recognition/
accreditation systems
– A review of good practices in medical
education that can serve as examples and
as a source for further innovation.
The strategic partnership will also address
other crucial questions that medical schools
now face, such as improving their leader-
ship function. Through a systematic dia-
logue, the partners will pursue the work
plan and provide useful information to med-
ical schools worldwide.
The strategic partnership is another out-
growth of WHO’s strong commitment to
supporting Member States’ efforts to attain
the Millennium Development Goals
(MDGs) (http://www.who.int/mdg/en/),
adopted at the Millennium Summit of the
United Nations in September 2000. A major
thrust of the MDGs is improved health sta-
WMJ_1_01-28.qxd 30.04.2007 09:37 Seite 8
Medical Education
9
tus, towards which human resources for
health will make a crucial contribution. But
in order to contribute optimally, the health
workforce must receive the best possible
educational preparation.
Planning and providing high-quality human
resources education demands the active par-
ticipation of medical schools and other
providers of medical education and training,
since physicians are important to any model
of a health team for developing and developed
countries alike. WHO and the WFME have
been working together since 1972 towards
improving medical education worldwide.
There is no single path towards improving
the quality of medical education. Each
region and country features different
approaches that must be acknowledged,
explored and brought to wider use. But to
achieve significant and lasting results, insti-
tutions must be committed to an ongoing
process of quality development. The
WHO/WFME strategic partnership aims to
foster this commitment.
On World TB Day (March 24th
), WMA will
launch a new on-line course to improve
earlier diagnosis, prevention and treatment
of multi-drug resistant tuberculosis
(MDRTb).
This course has been in development with
the Foundation for Professional Develop-
ment of the South African Medical
Association and the Norwegian Medical
Association is coordinated by the German
Medical Association.
Based on the WHO guidelines on the man-
agement of MDRTb, it will allow physician
to train on-line at their own pace. The web-
based course will be available in several
New on-line TB training course to be launched
by WMA on World TB Day
languages and participating physicians may
able to receive credits as part of their con-
tinuing medical education. It will be avail-
able in several languages.
The course will be piloted first amongst
physicians in South Africa, extended to
physicians in Estonia and the Philippines in
the summer and then be available globally.
It has been made possible by an education-
al grant from Eli Lilly.
This new course follows the successful
web-based course already developed and
run by WMA and the Norwegian Medical
Association for Prison Doctors on Human
Rights and Ethics.
Adopted by the WMA General Assembly,
Pilanesberg, South Africa, October 2006
Preamble
1. The practice of medicine is dynamic
and continues to evolve. Medical edu-
cation represents a continuum of learn-
ing that commences with undergraduate
medical school and endures until a
physician retires from active practice.
Its goal is to prepare practitioners of
medicine to apply the latest scientific
knowledge for the promotion of health
and the prevention and cure of human
diseases and the mitigation of symp-
toms of presently incurable diseases.
Medical education also comprises the
The World Medical Association Statement on Medical Education
ethical standards governing the thought
and behaviour of physicians. All physi-
cians have a responsibility to them-
selves, the profession and their patients
to maintain a high standard for their
medical education.
Basic Principles of Medical
Education
2. Medical education consists of basic
medical education, postgraduate med-
ical education, and continuing profes-
sional development. The profession, the
faculties and educational institutions,
and the government share the responsi-
bility for guaranteeing that medical
education meets a high quality standard
throughout this continuum. The aim of
medical education is to develop compe-
tent and ethical physicians that deliver
high quality healthcare to the public.
Basic Medical Education
3. The goal of basic medical education is
to instruct students in the practice of the
profession, and to supply the public
with well-qualified physicians. The first
professional degree should represent
the completion of a curriculum that
qualifies the student for a spectrum of
career choices, including, but not limit-
ed to, patient care, public health, clini-
WMJ_1_01-28.qxd 30.04.2007 09:37 Seite 9
Medical Education
10
cal or basic research, or medical educa-
tion. Each of these choices will require
additional education beyond the first
professional degree.
Selection of Students
4. A general liberal education is beneficial
for anyone embarking on the study of
medicine. A broad cultural education in
the arts, humanities, and social sci-
ences, as well as biological and physical
sciences, is advantageous. Students
should be chosen for the study of medi-
cine on the basis of their intellectual
ability, motivation, previous experi-
ences, and character and integrity. The
numbers admitted for training must
meet the needs of the population and be
matched by appropriate resources.
Selection of students should not be
influenced by age, sex, race, creed,
political persuasion or national origin,
although the mix of students should
reflect the population.
Faculty
5. Basic medical education must be taught
by a structured faculty. The faculty must
possess the appropriate qualifications
that can only be achieved through for-
mal training and experience. The selec-
tion should not be based on age, race,
creed, political affiliation, or national
origin.
6. The faculty must foster an academic
environment in which learning and
inquiry are encouraged and can thrive.
As such, active research to advance the
body of medical knowledge and the
quality of care must take place in acad-
emic settings that promote the highest
medical standards. The goals, content,
format and evaluation of the education
provided are the responsibility of the
faculty. Medical schools should ensure
continued growth of the teaching skills
of the faculty.
7. The faculty is accountable for providing
its own basic curriculum in an academ-
ic environment that allows learning to
flourish. The faculty should review the
curriculum frequently, allowing for the
needs of the community and for input
from practising physicians.
Furthermore, the faculty is responsible
for regularly evaluating the quality of
each educational experience and for
reviewing each other.
8. In addition to competent faculty, the
institution must require that library
resources, research laboratories, clinical
facilities, and study areas be available
in sufficient quantity to meet the needs
of all learners. Moreover, a proper
administrative structure, including but
not limited to academic records, must
be maintained in order to provide the
most comprehensive education.
Content of Basic Medical
Education
9. The educational content should equip
the student with a broad base of general
knowledge in the whole field of medi-
cine. This includes a study of the bio-
logical and behavioural sciences as well
as the socio-economics of health care.
These sciences are basic to an under-
standing of clinical medicine. Critical
thinking and self-directed learning
should also be required, as should firm
grounding in the ethical principles upon
which the physicians will function and
in the principles of human rights. The
student should also be introduced to
medical research and its methodology
at this stage.
Clinical Education
10. The clinical component of medical edu-
cation must be centered on the super-
vised study of patients and must involve
direct experiences in the diagnosis and
treatment of disease. The clinical com-
ponent should include personal diag-
nostic and therapeutic experiences with
a gradual increase in responsibilities.
An appropriate balance among the
patient base, trainees and teachers must
be observed.
11. Before beginning independent practice,
every physician should complete a for-
mal program of supervised clinical edu-
cation. This clinical experience should
range from primary to tertiary care in a
variety of inpatient and outpatient set-
tings, such as university hospitals, com-
munity hospitals and other health care
facilities.
12. The faculty and medical schools have
the responsibility to ensure that students
who have graduated and received the
first professional degree have acquired
a basic understanding of clinical medi-
cine and the basic skills needed to eval-
uate clinical problems and take appro-
priate action independently, and exhibit
the attitude and character to be an ethi-
cal physician.
Postgraduate Medical
Education
13. It is highly desirable, and in many juris-
dictions it is already a requirement, that
a graduate from a basic medical educa-
tion institution participate in a postgrad-
uate training program prior to obtaining
a license. Postgraduate medical educa-
tion, the second phase of medical edu-
cation, prepares physicians for practice
in a medical specialty. Postgraduate
medical education focuses on the devel-
opment of clinical skills and general
and professional competencies and on
the acquisition of detailed factual
knowledge in a medical specialty. This
learning process prepares the physician
for the independent practice of medi-
cine in that specialty.
14. The programs are based in communi-
ties, clinics, hospitals or other health
care institutions and should, in most
specialties, utilize both inpatient and
ambulatory settings, reflecting the
importance of care for adequate num-
bers of patients in the postgraduate
medical education experience.
Postgraduate medical education pro-
grams, including Transitional Year pro-
grams, are usually called residency pro-
grams, and the physicians being educat-
WMJ_1_01-28.qxd 30.04.2007 09:37 Seite 10
From the Secretary General
11
ed in them, residents. A resident takes
on progressively greater responsibility
throughout the course of a residency,
consistent with individual growth in
clinical experience, knowledge, and
skill.
15. The education of resident physicians
relies on an integration of didactic activ-
ity in a structured curriculum with diag-
nosis and management of patients under
appropriate levels of supervision and
scholarly activity aimed at developing
and maintaining life-long learning
skills. The quality of this experience is
directly related to the quality of patient
care, which is always the highest priori-
ty. Educational quality and patient care
quality are interdependent and must be
pursued in such a manner that they
enhance one another. A proper balance
must be maintained so that a program of
postgraduate medical education does
not rely on residents to meet service
needs at the expense of educational
objectives. A resident is prepared to
undertake independent medical practice
within a chosen specialty on the satis-
factory completion of a residency.
Professional Development of
Physicians
16. Continuing professional development*
is defined as the educational activities
that serve to maintain, develop, or
increase the knowledge, skills, and pro-
fessional performance and relationships
a physician uses to provide services for
patients, the public, or the profession.
Physicians should strive to further their
medical education throughout their
careers. These educational experiences
are essential to the physician’s continu-
ing professional development: to keep
abreast of developments in clinical
medicine and the health care delivery
environment, and to maintain the
knowledge and skills necessary to pro-
vide high quality care. The goal of con-
tinuing professional development is to
sustain and enhance the competent physi-
cian. Medical schools, hospitals and pro-
fessional societies all share a responsibil-
ity for developing and making available
to all physicians effective opportunities
for continuing professional development.
17. The demand for physicians to provide
medical care, prevent disease, and give
advice in health matters calls for the
highest standards of basic, postgradu-
ate, and continuing professional devel-
opment.
* Note on terminology: There are different uses
of the term ‘Continuing Professional
Development’ (CPD). One way to describe it is
all those activities that contribute to the profes-
sional development of a physician including
involvement in organized medicine, committee
work in hospitals or group practices, teaching,
mentoring and reading, to name just a few. One
of the components of CPD should be Continuing
Medical Education, which in many jurisdictions
is specially defined and possibly required for
licensure.
South Africa has lost a significant part of its
physician work force to other countries dur-
ing recent years. WHO’s World Health
Report 2006 estimates that more than
12.000 doctors who have originally been
trained in South Africa now work in 8
OECD countries (Australia, Canada,
Finland, France, Germany, Portugal, United
Kingdom and the United States of America).
This amounts to nearly 37% of the South
African physician work force and is only the
number for these selected 8 countries.
Of course these countries may be the most
attractive and certainly physicians did not
turn their back to South Africa because it
offered them good working conditions, a
healthy motivated population and excellent
From the Secretary General
Health Professional Council of South Africa announces amnesty
on restoration fees
An Amnesty difficult to understand
salaries. South Africa has some of the most
difficult problems in the world. It has a high
burden of HIV/AIDS cases and during last
fall the occurrence of the so-called
“Extended Drug Resistant Tuberculosis”
(XDR-TB) became a nightmare for TB
patients and their care givers.
Although South Africa is a country rich in
resources, the majority of its population is
still very poor and what Europeans would
describe as a regular access to health care,
for many of the South Africans is far out of
reach. This country badly needs physicians.
There are a lot of South African physicians
in this world who have left their country.
Wouldn’t it be good, if some of them
returned?
Earlier this year the South African Medical
Association (SAMA) reached out to their
lost colleagues to bring them news from the
South African Medical Council: In a “Call
on South African doctors to return home“
they told the South African Physicians that
“the Health Professions Council of South
Africa has agreed to a once-off waiver of
penalties for those practitioners, both local
and abroad, who failed to pay their annual
registration fees on time, or who had
allowed their registration to lapse without
informing Council.” And while the SAMA
sees this as a win, the foreign observer still
may find this strange.
It is even more difficult to understand when
on a further look the amnesty is not really an
WMJ_1_01-28.qxd 30.04.2007 09:37 Seite 11
WMA
12
amnesty, as the Council expects “all health
care practitioners who take advantage of this
amnesty period to render professional ser-
vices to any public sector institution of their
choice. We expect them to work for 100
hours in service to public health within six
months of their restoration.”
It is certainly without question that physi-
cian have to be subject to supervision. The
supervision is a public service. If it is done
by self-governance there is good reason to
pay it by contributions from the physicians.
Otherwise it should be paid by the state. To
avoid supervision is not acceptable.
However, if physicians who have left the
country they are simply out of this supervi-
sion, and there is absolutely no reason to
expect money from them.
To make this clear once more: South Africa is
one of the countries with the sharpest loss of
health professionals in this world, South
Africa is one of the countries with the highest
demand for physicians and yet – as this publi-
cized amnesty reveals – it is threatening pun-
ishment to physicians who have not paid fees
to the SA Council while they were abroad.
Yes, some may have forgotten to de-regis-
ter. I did so, when I left my country for the
first time. My chamber sent me a letter
(after locating me abroad) and told me that,
since I had left the country they would
strike me off the register. They also told me
that I had to reregister as soon as I wanted
to come back. I did so. No penalty, no
amnesty, no fuss. Even professional matters
can be dealt with professionally.
South Africa should embrace every physi-
cian who wants to come back wholeheart-
edly. Instead it threatens them with punish-
ments or an amnesty, which in fact is noth-
ing else than a punishment-in-kind.
We will have to learn how many have
accepted the amnesty that ended April
30th. If the number of physicians is small,
the Council may have to consider that an
amnesty which includes a punishment
may not really be perceived as an amnesty.
If the number of physicians is significant,
the South Africans must consider to waive
the penalties and fees for physicians
abroad all together, because in that case
they would have given proof that their
regulation is part of the cause for the
health professional shortage. But maybe
that is what the Council fears finding out
and why there is no real amnesty in the
first place.
I wonder what else South Africa does to
make the everyday-life of a physician a lit-
tle bit harder than necessary.
Otmar Kloiber
Further informations:
http://www.hpcsa.co.za/
(See also page 28)
Speech by Dr. Thami D. Mseleku,
Director National Department of Health,
South Africa to the WMA Scientific
Session, Pilanesberg.
Let me start by thanking you for extending
an invitation to the Minister of Health, Dr.
Manto Tshabalala-Msimang, to this gather-
ing of eminent medical professionals.
Unfortunately she is unable to be here due
to ill health. As we gather here this morn-
ing, the South African medical fraternity is
also gathering elsewhere to pay tribute to
one of the sons of our country, Professor
Sam Mhlongo who was known by many,
and dared to push the boundaries of medical
science. May his soul rest in piece.
It is of great significance that the World
Medical Association consciously took a
decision more than five years ago to hold its
General Assembly in our country, barely
General Assembly, Pilanesberg South Africa „Continued“
Scientific Session “Health as an Investment:
Leadership and Advocacy” 12 October 2006
five years after an earlier one in Somerset
West in 1996. That assembly was attended
at a very high level by our government in
the form of the then Minister of Health and
current Minister of Foreign Affairs Dr.
Nkosazana Dlamini-Zuma and the then
Deputy President and now President of the
country Mr. Thabo Mbeki. When you visit-
ed our country in 1996, this country’s med-
ical associations were many. There was a lot
of resistance to unifying into a single
national association. It is without doubt that
holding the 48th WMA General Assembly
on our shores in 1996 gave some impetus to
the unity talks of the medical profession
because almost two years later on 21 June
1998, a new medical association was
launched.
You have come again to South Africa just
two years before the South African Medical
Association celebrates its first ten years of
existence. An evaluation of SAMA activi-
ties will certainly take into consideration
internal, national and international perfor-
mance in line with the goals the association
set itself and the promise the association
made to the country at its inception. This
congress will have some influence in shap-
ing such an evaluation.
Internationalism in the world of medical
politics is an important element in the
development of health systems. Like all
international instruments it must be based
on sound principles and have clear focused
goals and objectives. Your theme: ‘Health
as an Investment: Leadership and
Advocacy’ is in my view an appropriate
one to adopt as the world is facing serious
challenges on the health front. Over the past
two decades the world has seen and experi-
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WMA
13
enced increasing burden of diseases (both
communicable and non-communicable)
requiring global, national and local collabo-
ration on a scale never envisaged before.
One can immediately bring to mind a num-
ber of public health incidents that have
required intensive investments in scientific
research to avoid them becoming emergen-
cies. The emergence of HIV and its progres-
sion over the years should be taken as a les-
son by all of us that innovative research
must be prioritized in our countries, and
trans-nationally. It is of course a fact that
the size of investment, who really does the
investment and the purposes of the invest-
ment, are critical factors in determining
social and economic outcomes of the health
investment. As a country, we have been
committed to investing in this area and pro-
vided funding to bodies like the Medical
Research Council and the South African
AIDS Vaccine Initiative to ensure that we
confront HIV challenges from all health
issue fronts. Severe Acute Respiratory
Syndrome is another, which recently served
to remind the scientific community that our
efforts should always be to prioritise public
health. It took the eminent scientists to
rapidly come up with measures to curb what
seemed a very serious threat to humankind.
These reminders emphasise the absolute
need to invest in scientific research in antic-
ipation of new diseases that will certainly
challenge and push the boundaries of what
health systems should provide. Medical
research brings together many stakeholders
including communities and individuals.
With many facets of research spanning
diverse areas, it is critical that the guide-
lines are clear and mechanisms are put in
place to monitor how it is conducted.
Increasingly the nature of the public health
pressures faced by countries, particularly
developing countries, will necessarily
involve research by allied professionals in
multidisciplinary research teams which
focus on health issues, as well as health
researchers and academics. Costing of
interventions and public health strategies
increasingly features in research work on
managing public health crises for example.
Similarly we cannot say we are investing in
health if we continue to marginalize indige-
nous knowledge systems, in particular the
knowledge that lies in African traditional
medical practices. Those African practices
continue to be denigrated and called unsci-
entific when they have sustained our people
for many years.
As far back as the 1980’s the progressive
health forces in our country led by the
National Medical and Dental Associations,
waged endless protests against apartheid
health, calling for not only an end to
apartheid health but also increased invest-
ment in the national health system. This was
informed by the tireless work of the health
professionals who had gained a lot of expe-
rience serving the poor and marginalized of
this country. International experiences and
lessons shared, played a major role. It was
therefore no coincidence that our health
system was initially modeled on UK’s
National Health Service. The foundation of
the role of the medical organizations in pol-
icy advocacy was therefore laid and it is our
expectation that SAMA should be in a posi-
tion to continue on that trajectory, ensuring
that it becomes a partner in developing a
sustainable health system to serve the poor,
so that the distribution of quality health pro-
vision becomes more equitable in our sys-
tem.
South Africa inherited serious challenges on
attainment of its freedom in 1994. The
extent of social, educational, health and
other challenges we inherited is often
underestimated. There was therefore a con-
scious decision to waste no time in trans-
forming the services, choosing the primary
health care route as the preferred mecha-
nism to bring and provide health services
nearer to our people. We built on the work
already done by various non-governmental
bodies like NAMDA and the National
Progressive Primary Health Care Network
which had paved the way for developing a
health system that should be responsive to
the needs of ordinary South Africans.
SAMA, as a successor to previous doctor
formations, was expected to ensure that
those values are not lost. It is however not
an issue of prescription of one to another
but one of ensuring that our health services,
whilst trying to compete with the best in the
world in some respects as driven by profes-
sionals, remain rooted in prioritizing provi-
sion for the poor. Focusing and contextual-
izing this is critical for ensuring appropri-
ateness of health care.
It is no mistake that South Africa invests
just under 4% of GDP in the health services
if one considers the serious socio-econom-
ic challenges it faces. In our opinion,
investing in health care is fundamental and
there should be no disagreement on that.
The debate should be on what it is that
must be prioritized in doing such invest-
ment. The preamble to a resolution adopted
by the 50th World Medical Assembly in
Ottawa in October 1998 notes WMA’s con-
cern ‘about health care systems in all coun-
tries not having adequate resources to meet
the basic needs of their populations’. In
adopting that resolution WMA reconfirmed
the guidelines on access to health care,
which were adopted at the 1988 Assembly
in Vienna. That resolution had emphasized
equity in access irrespective of economic
factors, cost financing and transportation.
This is just but two of your own resolutions
that indicate the need to invest better in
health care. Almost all health systems,
almost ten years on from 1998, are battling
even more trying to improve health care
investment.
However, health care investment must be
viewed from a variety of perspectives. Let
us start with the most critical aspect – the
health workforce. Many health system plan-
ners fail to adequately deal with this aspect
even in the well-resourced health systems
of the West. It is without doubt that certain
professional categories were however prior-
itized, probably by default, such that even
limited resources would be poured to their
education and training. The medical profes-
sion has certainly benefited immensely
from that approach. The nursing profession,
even though forming the majority of health
professionals in all countries and on whose
shoulders health care services rest, has not
necessarily enjoyed the kind of resource
allocation invested in the medical profes-
sion. The breakthrough was only achieved
to some extent with the adoption of the
Alma Ata Declaration in 1984, which
emphasized a primary health care approach
to providing health services as being the
most preferred vehicle. This still did not
mean that countries started investing better
in health.
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14
Our government has prioritized the health
human resource element by developing a
comprehensive human resource plan for
health to address the serious challenges we
are facing specifically with the health work-
force. These range from planning, develop-
ment, to management. Our efforts now are
focused on how each of the sub-sectors
engages and implements aspects of the plan
that affect their core business. We are inter-
acting and collaborating with the Health
Professions Council of South Africa, South
African Nursing Council and the South
African Pharmacy Council in developing
sub-sector specific human resource plans to
inform the country’s investment in produc-
ing the skills that our health system needs
now and in the future. This work is very
critical to directing investment appropriate-
ly so that we can derive better value.
Directed investment in education and train-
ing of health professionals is just a single
element. Economic development and its
impact on health care is a recognized factor.
The better the economic prospects of a
country the more tension arises within its
health system. The presence of a strong pri-
vate health sector always retards the
strengthening of the public health sector. A
strong private health sector serves as a
major attraction for health professionals
because of the economic prosperity that it
offers. Several formations within health
care have been discussing and debating
these issues for some time now, culminating
in the World Health Organisation setting up
a Commission on Macro-Economics in
Health. This was driven by a realization that
the country’s economic development status
and the economic opportunities that ordi-
nary citizens have or do not have, have a
direct impact on the health status of a
nation. A similar scenario exists in the
migration phenomenon, with highly skilled
health professionals being attracted more to
the better-resourced health systems of west-
ern countries. This only perpetuates
inequity in the world health care systems.
Although the private health sector is largely
a recipient of public goods it has not con-
tributed to developing, there is little evi-
dence of a willingness to invest massively
in strengthening the public health sector.
Many individual practitioners are doing a
sterling job in providing health care ser-
vices at State institutions, some at no cost at
all. This is highly appreciated; however, it is
always the collective efforts that bring real-
izable benefits on a national scale. This is
the case in all countries of the world.
On the infrastructure investment side, our
government took a strategic decision
through its 1994 policy declaration that
health services would be transformed. This
meant amalgamating 14 separate depart-
ments into a single national health system
with nine provincial departments responsi-
ble for health service provision and one
national department responsible for policy
formulation. There had to be a massive
infrastructure development – building many
new primary care clinics and revamping
and/or constructing new hospitals. Our hos-
pital revitalization project has been a phe-
nomenal success in improving infrastruc-
ture. Where possible we have partnered
with the private health sector in erecting
new facilities e.g. Inkosi Albert Luthuli
Academic Hospital in Durban.
All the issues that I have raised above need
good quality leadership. As you may know,
leadership also has to be taken into context
with the political landscape integral to that.
A leadership confronted by serious fiscal
constraints in a developing world situation
will respond differently to the same stimu-
lus when compared to leadership that has
little constraints in financial and human
capital terms. That is why for many years it
has been easier for western countries to
freely recruit doctors and nurses from poor
countries and difficult for poor countries to
put in place monetary incentives to retain
their expensively trained human assets. The
lack of proper planning by rich countries
has a lot to do with this. Health is a complex
and very diverse sector. It is comprised of
disparate sections of health professionals
that are not necessarily driven by the same
values. One may not refer to the centuries
old fight between doctors and pharmacists
over dispensing of medicines!
The essence of this is that as policy planners
and decisions makers, we have to always
balance the aspirations of the health profes-
sions with the needs of citizens who depend
entirely on public health facilities to receive
health care. So whilst your Vienna resolu-
tion called for improved investment in
health care, resource availability has
remained a serious constraint globally.
Certainly the policies of some international
finance institutions have not necessarily
assisted despite the efforts. In our situation
we are confronted with challenges that
require government to drastically improve
the quality of life of ordinary South
Africans. This means providing households
with running tap water, providing sanitation
Death of Erwin Odenbach, long time
physician leader.
Dr. Paul Erwin Odenbach, former
Secretary General of the German
Medical Association has been a long
term adviser to the WMA Council and
Associate Members. As a physician,
teacher, leader, and friend Erwin has
been tirelessly engaged for his
patients, society and our work. Being
engaged in medical education, regula-
tion, humanitarian action and med-
ical ethics his attitude was always dri-
ven by values. It made him an out-
standing example for our profession.
His leadership career started with his
involvement in the medical students’
organization in Germany soon after
World War II. He surfaced interna-
tionally as the second president of the
International Federation of Medical
Students Association (IFMSA) and
since then has been a leader in orga-
nized medicine on the national and
international level.
He first encountered the World
Medical Association in 1954, address-
ing the General Assembly in Rome as
the IFMSA representative. He contin-
ued to be actively engaged with WMA
until recently. His last policy piece, a
Resolution on Medical Assistance in
Air Travel, was adopted by the WMA
at its General Assembly in
Pilanesberg in October 2006.
On Saturday, February 10th
, 2007 Dr.
Paul Erwin Odenbach, passed away in
peace surrounded by his loved family.
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WMA
15
services and habitable housing, while con-
centrating on growing the economy. We
have a government that has a mandate to
improve social welfare, provide access to
education, promote access to individual eco-
nomic development through providing the
young people of the country with opportuni-
ties to be productive citizens and ensure that
South Africa continues to play its role with
others in developing the African continent.
Leadership and advocacy in our context
therefore have to be seen through that prism.
The leadership of the professions has a duty
to advocate for improved patient care, not
over-emphasise its own self-interest in
rationing of health care resources. Advocacy
must not be concentrated and limited to pub-
lic platforms that serve to highlight only the
perceived failings of interventions without
engaging robustly with government agen-
cies responsible for health. Advocacy in our
context must also be a broad health profes-
sional focus, guided by the desire to propa-
gate the good professional values that are
inherent in each. It must go beyond the pub-
lic health sector and must influence the cul-
ture of the private health sector. Without
such intensified focus, your resolutions on
improving investment in health care will fall
short. In many instances the private health
industry has massive resources that should
be used for public good without compromis-
ing the drivers of that sector – profit making.
Your leadership as a profession must be able
to go beyond advocating for political rea-
sons. It must be guided and be rooted in
ensuring delivery of good quality health care
to the most poor of society. It must engage
professionally and robustly to advance the
pro-poor agenda. South Africa invests a lot
of resources to educating and training health
professionals who form part of our intellec-
tual base as a country. It is only through
working hard at establishing and nurturing
good relations that we can influence each
other.
I therefore hope that SAMA will, after this
assembly, engage with my department on
the resolutions that you will have adopted.
Mr. Thami D. Mseleku
Director General
National Department of Health –
South Africa
hygienic conditions was the supply of run-
ning water and maintenance of water quali-
ty. The improvement of these secured the
supply of pure water for drinking and other
domestic uses, enabling the supply and con-
sumption of hygienic food and clean cloth-
ing. By 1956, Japan was no longer regarded
as being “postwar”, and the average life
expectancy had grown to 63.6 for men and
67.75 for women. The country entered a
period of economic expansion that saw busi-
ness boom. Housing improved, and at the
same time as the use of electrical appliances
such as refrigerators, washing machines,
and television sets became widespread, so
too did the use of medical equipment such as
X-ray, electrocardiographic, and endoscopic
equipment spread rapidly amongst medical
institutions, with medical technology also
advancing rapidly. Throughout the country
everyday living became hygienic and con-
sideration to the environment improved with
the installation of sewage systems and treat-
ment of waste water, and these develop-
ments in particular contributed significantly
to the enterprise of the people.
However, as industry expanded, atmospher-
ic pollution was caused by smoke and other
pollution was caused by industrial waste
water; environmental pollution became a
serious concern in some situations and
efforts were made to rectify these. Against
this background, health management mea-
sures to prevent over-consumption of salt
and ensure the adequate consumption of
protein were spreading. At the same time
that medical examinations became com-
monly carried out as a means of preventing
diseases. Group examinations were held for
stomach cancer and businesses implement-
ed health check-ups for their employees.
Consequently, the early diagnosis of fre-
quently occurring diseases and preventative
examinations expanded on a national scale,
producing highly significant results. Thus
since about 30 years ago, people’s nutrition
has improved and the incidence of infec-
Dr. Yoichi Hozumi,Vice President, Japan
Medical Association
(presentation given during the Scientific
Session “Investment in Health”, Palens-
berg)
A general overview of health care in Japan,
with particular mention of health care as an
investment.
Overview
Approximately 60 years ago, Japan had just
begun postwar reconstruction. Food was
inadequate and nutritional and hygienic
conditions for the general public were
extremely bad. The incidence of infectious
and other diseases was high in both urban
and rural areas, and life expectancy in 1947
was 50 for Japanese men and 54 for women.
Health care in these circumstances was
completely inadequate.
Japan lost approximately 1.85 million people
in the Second World War; most cities were
razed and the national wealth lost. The post-
war reconstruction of Japan’s social security
system proceeded with the establishment of
a new National Constitution under the pow-
erful supervision of the occupational forces
GHQ. The new Japanese Constitution guar-
anteed fundamental human rights for citizens
in Article 11 and based on this, guaranteed
citizens’ right to live in Article 25, establish-
ing the State’s social responsibility in
Paragraph 2, which states that “In all spheres
of life, the State shall use its endeavors for
the promotion and extension of social wel-
fare and security, and of public health.”
Amidst the harsh conditions imposed by the
devastation left by the war, Japan began to
rebuild, and through the many efforts of its
citizens the society’s productive, economic,
and educational conditions began to gradual-
ly and steadily improve.
Little by little, everyday living conditions
also improved. The greatest issue for
The Health Care System in Japan:
Current Situation and Future Perspectives
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WMA
16
tious diseases has decreased; in 2002 the
average life expectancy for men was 78,
and for women was 85, making Japan the
world’s top country for longevity.
Japan is an island nation with little flat land;
90% of the country is forest-covered moun-
tains. Not only is Japan a volcanic country
that faces the constant threat of massive and
epicentral earthquakes, but it also faces
wind and water damage every typhoon sea-
son. Since plentiful rainfall is beneficial for
tree growth, Japan has many fast-flowing
rivers. Compared with continents, rivers
flow only short distances from their well-
springs to the ocean. These plentiful, clear
rivers play an important role in rice cultiva-
tion, in hydroelectric power generation, and
in many other functions in which water has
been innovatively utilized. Japan cannot
produce oil or natural gas as energy sources
and its mineral resources are also small.
Consequently, national production in Japan
tends towards importing raw materials from
overseas, then manufacturing products using
various original processing technologies;
promotion of high intelligent added value in
industrial production and high computeriza-
tion, Industrial structuring in areas such as
finance, distribution, and services increasing
more and more, invigorating the economy.
Many innovations have been made to pro-
duction methods for traditional rice, fruit,
and vegetable crops; developments in pro-
duction technology are not only used in
domestic production but are also spread
overseas, with the export of production tech-
nology now becoming an important industry
that also contributes internationally. Deep-
sea and coastal fishing are two other impor-
tant industries; the development and promo-
tion of innovative fish farming technology is
becoming increasingly important as a means
of securing resources. The international
export of seafood is a small industry in
Japan, but it also contributes greatly to the
development and diffusion of technology.
Since the industrial revolution, Japan’s basic
policy has been to enhance the education
system; citizens make efforts to promote
intelligent industry, understanding that we
receive praise and great benefits from other
countries through the development of sci-
ence and technology and our contributions
to the international community.
The development of transportation facilities
in Japan has enabled many people and goods
to be transported anywhere within the coun-
try within half a day, and information can be
transmitted instantly throughout the country.
This was a huge leap forward for emer-
gency and disaster medicine in Japan. With
these developments, from the 1950s on-
wards the basic components necessary for
providing health care – hospitals, clinics,
doctors, and nurses – all of which had been
inadequate, gradually increased and health
care in regional areas expanded. A health
insurance system which operated indepen-
dently for each health field continued to
exist, but there continued to be a large num-
ber of people who had not paid their insur-
ance. The Japan Medical Association re-
commended that the individual insurance
systems be integrated and the entire system
expanded. Eventually, in 1961, the total
health insurance was expanded and a uni-
versal health care system available to all cit-
izens was introduced. Through the process
of establishing this system, medical fields
were classified broadly into four groups.
All citizens were required to join one of four
insurance plans depending on their occupa-
tion and position: government-managed
health insurance administered by medium
and small businesses; association-managed
health insurance administered by the majori-
ty of large businesses; National Health
Insurance administered by local government
authorities; and National Health Cooperative
Insurance, also administered by the same
kind of businesses on a local level. The estab-
lishment of this system enabled citizens to
receive health care equally and fairly any-
where in Japan, at any time and for whatever
reason, for a minimal self-payment and with-
out having to undergo screening simply by
showing their insurance card to prove they
were insured. Under this system, the medical
institution providing treatment receives the
portion of payment covered by public funds
under a reimbursement system known as a
fee-for-service system. The system operates
smoothly due to the efficient functioning of a
medical fee payment fund that carefully
checks the details of medical treatment.
Improvement of medical institution facilities
and the implementation of this medical insur-
ance system have enabled huge advances in
regional health care systems and provided the
tremendous benefit of care being available
equally and fairly to all citizens.
Because of differences in the history of their
establishment and composition of member
businesses and organizations, each of the
heath insurance plans has difference insurance
rates. The government-managed health insur-
ance plan is the largest in scale and imposes
public benefits in addition to the insurance
burden on employers and members.
Against this background the Japan Medical
Association, as a pillar supporting the
health care of citizens, proactively promot-
ed the establishment and maintenance of
this system, and with the cooperation of
medical institutions nationwide, the
National Health System has made a huge
contribution to the health system in Japan.
With the development of the economy and
industry in Japan, already outlined, the
emergency medicine infrastructure and
treatment of chronic illness improved
through the continued improvement of
hygienic conditions, better nutrition, and
the creation of infrastructure for the univer-
sal and fair provision of health care.
In 2000 and 2004, the World Health
Organization named Japan as a country with
one of the highest longevity rates in the
world, recognizing the excellence of Japan’s
health system. Japan ranks Number 1 in the
world in a comparison of health achievement;
in 2002 longevity was again the highest in the
world, with the average life expectancy for
men being 78.4 and for women 85.3; and
Japan also has one of the lowest infant mor-
tality rates in the world. Japan’s excellent
National Health Insurance system is the most
effective health insurance system of all the
developed countries. Since the 1970s, Japan’s
GNP has skyrocketed. With citizens’growing
health consciousness and medical care
awareness as well as improvements in medi-
cine and medical technology, the total cost of
medical treatment in Japan is gradually grow-
ing and management of the health insurance
system has been revised repeatedly.
Since 1980, the total fertility rate has
dropped below 2.0 for a variety of reasons,
and in 2005 dropped to a marked low of
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WMA
17
1.25. In a world rapidly ageing, Japan has
hurtled fastest into an aging society with
fewer children.
As I have explained, medical expenses in
Japan are not high compared with other
developed countries. Total health expenses
are 7.9% of GDP, a low rank of 17 amongst
the developing countries. However, in 2000
Japan established a national Long-term Care
Insurance system, administered on a munic-
ipal basis, aimed at elderly citizens requiring
nursing care as a means of lightening the
continuously increasing cost of health care
for the elderly. The degree of nursing care
required is determined through screening
and nursing care services appropriate for the
elderly person’s needs are provided.
“Health as an Investment”
Considering the population dynamics of
Japan, despite the difficulty of boosting the
productive-age population, it could be possi-
ble to secure a potential working population
by improving the health of senior citizens.
Increased numbers of elderly people capable
of working would be an enormous opportu-
nity, creating fresh consumer activity and
invigorating the economy. In other words,
proactive health care to restore, maintain, or
increase health – such as avoiding the risk of
disease occurring through preventative med-
icine and the promotion of social rehabilita-
tion and independence through early diag-
nosis and treatment – has ample potential to
increase the health investment of each indi-
vidual, thereby increasing the population of
potential workers, bringing about an
increase in productivity, GDP, and revenue
from tax, and thus more stable employment
and fresh economic activity. Furthermore,
health care is a labor-intensive industry, so a
stable supply of workers for medical institu-
tions will facilitate more stable health care.
Moreover, the construction of the necessary
medical facilities could also create a wave
effect in the economy. In this way, there are
certainly investment aspects in health care,
and it is vital that this is recognized widely
by members of the general public. The JMA
is currently seeking the understanding of the
government headed by Prime Minister Abe,
newly formed in September this year, of the
necessity of promoting basic policies such
as this.
The JMA is proactively pursuing the fol-
lowing items as comprehensive and central
policies for health reform, including the
views just mentioned.
1. Creation of a society able to truly rejoice
at longevity through enhanced health
care and welfare for the elderly.
2. Creation of a society where one can give
birth with peace of mind through the
expansion of obstetrical care and mater-
nal and child health.
3. Creation of a society where children can
thrive and grow healthily through
enhanced pediatric care and school
health.
4. Creation of a society where people can
work healthily and enthusiastically
through enhanced industrial health and
workers’ compensation insurance.
5. Creation of a society with as little occur-
rence of disease as possible through the
promotion of healthy lifestyle and
lifestyle disease countermeasures and
anti-smoking campaigns.
6. Creation of a society able to provide
high quality medical care for those who
are sick, through the guarantee and
enhancement of community health care
and health insurance.
7. Creation of a society that provides an
excellent health care system through the
enhancement of community heath care
centred on primary care doctors and the
promotion of cooperation between
health services.
8. Creation of a society able to put medical
advances into practice in health care
through the establishment of lifetime edu-
cation and a medical specialist system.
Finally, with regard to approaches to gov-
ernment agencies concerning issues such as
these, the JMA is campaigning to prevent
corruption of the medical care system,
including financially motivated proposals
for medical system reform, mainly through
petitions and the endorsement of Diet mem-
bers who represent the position of the JMA
in the government.
The JMA intends to continue to promote the
construction of a foundation for communi-
ty health care, working with the general
public to formulate and propose strategies
for realizing the establishment of a health
care framework that people trust, in order to
create a durable social insurance system
that safeguards the heath and welfare of
Japan’s citizens.
Adopted by the WMA General Assembly,
Pilanesberg, South Africa, October 2006
Introduction
1. HIV/AIDS is a global pandemic that
has created unprecedented challenges
for physicians and health infrastruc-
tures. In addition to representing a stag-
gering public health crisis, HIV/AIDS
is also fundamentally a human rights
issue. Many factors drive the spread of
The World Medical Association Statement on
HIV/AIDS and the Medical Profession
the disease, such as poverty, homeless-
ness, illiteracy, prostitution, human traf-
ficking, stigma, discrimination and gen-
der-based inequality. Efforts to tackle
the disease are constrained by the lack
of human and financial resources avail-
able in health care systems. These
social, economic, legal and human
rights factors affect not only the public
health dimension of HIV/AIDS but also
individual physicians/health workers
and patients, their decisions and rela-
tionships.
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18
Discrimination
2. Unfair discrimination against
HIV/AIDS patients by physicians must
be eliminated completely from the prac-
tice of medicine.
a. All persons infected or affected by
HIV/AIDS are entitled to adequate
prevention, support, treatment and
care with compassion and respect for
human dignity.
b. A physician may not ethically refuse
to treat a patient whose condition is
within his or her current realm of
competence, solely because the
patient is seropositive.
c. National Medical Associations
should work with governments,
patient groups and relevant national
and international organizations to
ensure that national health policies
clearly and explicitly prohibit dis-
crimination against people infected
with or affected by HIV/AIDS.
Appropriate / Competent
Medical Care
3. Patients with HIV/AIDS must be pro-
vided with competent and appropriate
medical care at all stages of the disease.
4. A physician who is not able to provide
the care and services required by
patients with HIV/AIDS should make
an appropriate referral to those physi-
cians or facilities that are equipped to
provide such services. Unless or until
the referral can be accomplished, the
physician must care for the patient to
the best of his or her ability.
5. Physicians and other appropriate bodies
should ensure that patients have accu-
rate information regarding means of
transmission of HIV/AIDS and strate-
gies to protect themselves against infec-
tion. Proactive measures should be
taken to ensure that all members of the
population, and at-risk groups in partic-
ular, are educated to this effect.
6. With reference to those patients who are
found to be seropositive, physicians
must be able to effectively counsel them
regarding: (a) responsible behaviour to
prevent the spread of the disease; (b)
strategies for their own health protec-
tion; and (c) the necessity of alerting
sexual and needle-sharing contacts, past
and present, as well as other relevant
contacts (such as medical and dental
personnel) regarding their possible
infection.
7. Physicians must recognize that many
people still believe HIV/AIDS to be an
automatic and immediate death sentence
and therefore will not seek testing.
Physicians must ensure that patients
have accurate information regarding the
treatment options available to them.
Patients should understand the potential
of antiretroviral treatment (ART) to
improve not only their medical condi-
tion but also the quality of their lives.
Effective ART can greatly extend the
period of time that patients are able to
lead healthy productive lives, function-
ing socially and in the workplace and
maintaining their independence.
HIV/AIDS is increasingly looked upon
as a manageable chronic condition.
8. While strongly advocating ART as the
best course of action for HIV/AIDS
patients, physicians must also ensure
that their patients are fully and accurate-
ly informed about all aspects of ART,
including potential toxicity and side
effects. Physicians must also counsel
patients honestly about the possibility
of failure of first line ART, and the sub-
sequent options should failure occur.
The importance of adhering to the regi-
mens and thereby reducing the risk of
failure should be emphasized.
9. Physicians should be aware that misin-
formation regarding the negative
aspects of ART has created resistance
toward treatment by patients in some
areas. Where misinformation is being
spread about ART, physicians and med-
ical associations must make it an imme-
diate priority to publicly challenge the
source of the misinformation and to
work with the HIV/AIDS community to
counteract the negative effects of the
misinformation.
10. Physicians should encourage the
involvement of support networks to
assist patients in adhering to ART regi-
mens. With the patient’s consent, coun-
selling and training should be available
to family members to assist them in pro-
viding family based care. Physicians
must recognize families and other sup-
port networks as crucial partners in
adherence strategies and, in many
places, the only means to adequately
expand the care system so that patients
receive the required attention.
11. Physicians must be aware of the discrim-
inatory attitudes toward HIV/AIDS that
are prevalent in society and local culture.
Because physicians are the first, and
sometimes the only, people who are
informed of their patients’ HIV status,
physicians should be able to counsel
them about their basic social and legal
rights and responsibilities or should refer
them to counsellors who specialize in the
rights of persons living with HIV/AIDS.
Testing
12. Mandatory testing for HIV must be
required of: donated blood and blood
fractions collected for donation or to be
used in the manufacture of blood prod-
ucts; organs and other tissues intended
for transplantation; and semen or ova
collected for assisted reproduction pro-
cedures.
13. Mandatory HIV testing of an individual
against his or her will is a violation of
medical ethics and human rights.
Exceptions to this rule may be made
only in the most extreme cases and
should be subject to review by an ethics
panel or to judicial review.
14. Physicians must clearly explain the pur-
pose of an HIV test, the reasons it is rec-
ommended and the implications of a pos-
itive test result. Before a test is adminis-
tered, the physician should have an
action plan in place in case of a positive
test result. Informed consent must be
obtained from the patient prior to testing.
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19
15. While certain groups are labelled „high
risk“, anyone who has had unprotected
sex should be considered at some risk.
Physicians must become increasingly
proactive about recommending testing to
patients, based on a mutual understand-
ing of the level of risk and the potential
to benefit from testing. Pregnant women
should routinely be offered testing.
16. Counselling and voluntary anonymous
testing for HIV should be available to all
persons who request it, along with ade-
quate post-testing support mechanisms.
Protection from HIV in the
Health Care Environment
17. Physicians and all health care workers
have the right to a safe work environ-
ment. Especially in developing coun-
tries, the problem of occupational expo-
sure to HIV has contributed to high
attrition rates of the health labour force.
In some cases, employees become
infected with HIV, and in other cases
fear of infection causes health care
workers to leave their jobs voluntarily.
Fear of infection among health workers
can also lead to refusal to treat
HIV/AIDS patients. Likewise, patients
have the right to be protected to the
greatest degree possible from transmis-
sion of HIV from health professionals
and in health care institutions.
a. Proper infection control procedures
and universal precautions consistent
with the most current national or
international standards, as appropri-
ate, should be implemented in all
health care facilities. This includes
procedures for the use of preventive
ART for health professionals who
have been exposed to HIV.
b. If the appropriate safeguards for pro-
tecting physicians or patients against
infection are not in place, physicians
and National Medical Associations
should take action to correct the situ-
ation.
c. Physicians who are infected with HIV
should not engage in any activity that
creates a risk of transmission of the dis-
ease to others. In the context of possi-
ble exposure to HIV, the activity in
which the physician wishes to engage
will be the determining factor. Whether
or not an activity is acceptable should
be determined by a panel or committee
of health care workers with specific
expertise in infectious diseases.
d. In the provision of medical care, if a
risk of transmission of an infectious
disease from a physician to a patient
exists, disclosure of that risk to patients
is not enough; patients are entitled to
expect that their physicians will not
increase their exposure to the risk of
contracting an infectious disease.
e. If no risk exists, disclosure of the
physician’s medical condition to his
or her patients will serve no rational
purpose.
Protecting Patient Privacy
and Issues Related to
Notification
18. Fear of stigma and discrimination is a
driving force behind the spread of
HIV/AIDS. The social and economic
repercussions of being identified as
infected can be devastating and can
include violence, rejection by family and
community members, loss of housing
and loss of employment, to name only a
few. Normalizing the presence of
HIV/AIDS in society through public
education is the only way to reduce dis-
criminatory attitudes and practices. Until
that can be universally achieved, or a
cure is developed, potentially infected
individuals will refuse testing to avoid
these consequences. The result of indi-
viduals not knowing their HIV status is
not only disastrous on a personal level in
terms of not receiving treatment, but
may also lead to high rates of avoidable
transmission of the disease. Fear of
unauthorized disclosure of information
also provides a disincentive to partici-
pate in HIV/AIDS research and general-
ly thwarts the efficacy of prevention pro-
grams. Lack of confidence in protection
of personal medical information regard-
ing HIV status is a threat to public health
globally and a core factor in the contin-
ued spread of HIV/AIDS. At the same
time, in certain circumstances, the right
to privacy must be balanced with the
right of partners (sexual and injection
drug) of persons with HIV/AIDS to be
informed of their potential infection.
Failure to inform partners not only vio-
lates their rights but also leads to the
same health problems of avoidable
transmission and delay in treatment.
19. All standard ethical principles and
duties related to confidentiality and pro-
tection of patients’ health information,
as articulated in the WMA Declaration
of Lisbon on the Rights of the Patient,
apply equally in the context of
HIV/AIDS. In addition, National
Medical Associations and physicians
should take note of the special circum-
stances and obligations (outlined
below) associated with the treatment of
HIV/AIDS patients.
a. National Medical Associations and
physicians must, as a matter of prior-
ity, ensure that HIV/AIDS public
education, prevention and coun-
selling programs contain explicit
information related to protection of
patient information as a matter not
only of medical ethics but of their
human right to privacy.
b. Special safeguards are required when
HIV/AIDS care involves a physically
dispersed care team that includes
home-based service providers, family
members, counsellors, case workers
or others who require medical infor-
mation to provide comprehensive
care and assist in adherence to treat-
ment regimens. In addition to imple-
menting protection mechanisms
regarding transfer of information,
ethics training regarding patient pri-
vacy should be given to all team
members.
c. Physicians must make all efforts to
convince HIV/AIDS patients to take
action to notify all partners (sexual
and/or injection drug) about their
exposure and potential infection.
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20
Physicians must be competent to
counsel patients about the options for
notifying partners. These options
should include:
1. notification of the partner(s) by the
patient. In this case, the patient
should receive counselling regard-
ing the information that must be
provided to the partner and strate-
gies for delivering it with sensitivi-
ty and in a manner that is easily
understood. A timetable for notifi-
cation should be established and
the physician should follow-up
with the patient to ensure that noti-
fication has occurred.
2. notification of the partner(s) by a
third party. In this case, the third
party must make every effort to
protect the identity of the patient.
d. When all strategies to convince the
patient to take such action have been
exhausted, and if the physician knows
the identity of the patient’s partner(s),
the physician is compelled, either by
law or by moral obligation, to take
action to notify the partner(s) of their
potential infection. Depending on the
system in place, the physician will
either notify directly the person at risk
or report the information to a desig-
nated authority responsible for notifi-
cation. In cases where a physician
must disclose the information regard-
ing exposure, the physician must:
1. inform the patient of his or her
intentions,
2. to the extent possible, ensure that
the identity of the patient is pro-
tected,
3. take the appropriate measures to pro-
tect the safety of the patient, espe-
cially in the case of a female patient
vulnerable to domestic violence.
e. Regardless of whether it is the
patient, the physician or a third party
who undertakes notification, the per-
son learning of his or her potential
infection should be offered support
and assistance in order to access test-
ing and treatment.
f. National Medical Associations should
develop guidelines to assist physi-
cians in decision-making related to
notification. These guidelines should
help physicians understand the legal
requirements and consequences of
notification decisions as well as the
medical, psychological, social and
ethical considerations.
g. National Medical Associations
should work with governments to
ensure that physicians who carry out
their ethical obligation to notify indi-
viduals at risk, and who take precau-
tions to protect the identity of their
patient, are afforded adequate legal
protection.
Medical Education
20. National Medical Associations should
assist in ensuring that there is training
and education of physicians in the most
current prevention strategies and med-
ical treatments available for all stages of
HIV/AIDS, including prevention and
support.
21. National Medical Associations should
insist upon and assist with, when possi-
ble, the education of physicians in the
relevant psychological, legal, cultural
and social dimensions of HIV/AIDS.
22. National Medical Associations should
fully support the efforts of physicians
wishing to concentrate their expertise in
HIV/AIDS care, even where HIV/AIDS
is not recognized as an official specialty
or sub-specialty within the medical edu-
cation system.
23. The WMA encourages its National
Medical Associations to promote the
inclusion of designated, comprehensive
courses on HIV/AIDS in undergraduate
and postgraduate medical education
programs, as well as continuing medical
education.
Adopted by the WMA General Assembly,
Pilanesberg, South Africa, October 2006
Preamble
1. Assisted reproductive technology
encompasses a wide range of tech-
niques designed primarily to aid cou-
ples unable to conceive without medical
assistance. Since the birth of the first
so-called ‘test-tube baby’ in 1978, more
than 1.5 million children worldwide
have been born following IVF treat-
ment.
The World Medical Association Statement on
Assisted Reproductive Technologies
2. The term ‘assisted reproductive tech-
nology’ includes techniques such as
in-vitro fertilisation (IVF) and intra-
cytoplasmic sperm injection (ICSI). It
can be defined as including all treat-
ments that include medical and scien-
tific manipulation of human gametes
and embryos in order to produce a
term pregnancy. Although some legis-
latures have considered artificial
insemination, whether using donor
semen or semen from the patient’s
partner, as different, many of the
issues about regulation in relation to
obtaining, storing, using and dispos-
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WMA
21
ing of gametes and embryos are close-
ly interlinked. In this statement treat-
ments such as artificial insemination
are excluded.
3. Assisted reproductive technologies
raise profound moral issues. Views
and beliefs about the moral status of
the embryo, which are central to much
of the debate in this area, vary both
within and among countries. Assisted
conception is also regulated different-
ly in various countries. Whilst consen-
sus can be reached on some issues,
there remain fundamental differences
of opinion that cannot be resolved.
This statement identifies areas of
agreement and also highlights those
matters on which agreement cannot be
reached. Physicians faced with such
situations should comply with applic-
able laws and regulations as well as
the ethical requirements and profes-
sional standards established by their
National Medical Association and
other appropriate organisations in the
community.
4. Physicians involved in providing assist-
ed reproductive technologies should
always consider their ethical responsi-
bilities towards any child who may be
born as a result of the treatment. If there
is evidence that a future child would be
exposed to serious harm, treatment
should not be provided.
5. As with all other medical procedures,
physicians also have an ethical obliga-
tion to limit their practice to areas in
which they have relevant expertise and
experience and to respect the rights of
patients. These rights include that of
personal bodily integrity and freedom
from coercion. In practice this means
that valid or real consent is required as
with other medical procedures; the
validity of such consent is dependent
upon the adequacy of the information
offered to the patient and their freedom
to make a decision, including freedom
from coercion or other pressures to
decide in a particular way.
6. Assisted conception differs from the
treatment of illness in that the inability
to become a parent without medical
intervention is not always regarded as
an illness. While it may have profound
psychosocial, and thus medical, conse-
quences, it is not in itself life limiting. It
is, however, a significant cause of major
psychological illness and its treatment
is clearly medical.
7. Obtaining informed consent from those
considering undertaking treatment must
include consideration of the alterna-
tives, including accepting childlessness
or pursuing adoption, the risks associat-
ed with the various techniques, and the
possibility of failure. In many jurisdic-
tions the process of obtaining consent
must follow a process of information
giving and the offer of counselling and
might also include a formal assessment
of the patient in terms of the welfare of
the potential child.
8. Patients seeking assisted reproductive
technologies are entitled to the same
level of confidentiality and privacy as
for any other medical treatment.
9. Assisted reproductive technology
always involves handling and manipu-
lation of human gametes and embryos.
Different individuals regard this with
different levels of concern but there is
general agreement that these special
concerns should be met by specific
safeguards to protect from abuse. In
some jurisdictions all centres handling
such materials require a licence and
must demonstrate compliance with high
normative standards.
Success of the
techniques
10. The success of different techniques
may differ widely from centre to cen-
tre. Physicians have an obligation to
give realistic information about success
rates to potential patients. If their suc-
cess rates are widely different from the
current norm they should disclose this
fact to patients. They also have an
obligation to consider the reasons for
this as they might relate to poor prac-
tice, and if so, to correct their deficien-
cies.
Multiple pregnancies
11. Replacement of more than one embryo
may raise the likelihood of at least one
embryo implanting. This is offset by
the increased risk, especially of prema-
ture labour, in multiple pregnancies.
The risk of twin pregnancies, while
higher than that of singleton pregnan-
cies, is considered acceptable by most
people. Practitioners should follow pro-
fessional guidance on the maximum
number of embryos to be transferred
per treatment cycle. If multiple preg-
nancies occur, selective termination
might be considered on medical
grounds to increase the chances of the
pregnancy proceeding to term where
this is compatible with the national law
and code of ethics.
Donation
12. Some patients are unable to produce
usable gametes. They require ova or
sperm from donors. Donation should
follow counselling and be carefully
controlled to avoid abuses, including
coercion of potential donors. It is inap-
propriate to offer money or benefits in
kind (for example free or lower cost
treatment cycles) to encourage donation
but donors may be reimbursed for rea-
sonable expenses.
13. Where a child is born following dona-
tion, families should be encouraged to
be open with him/her about this, irre-
spective of whether domestic law enti-
tles the child to information about the
donor. Keeping secrets within families
is difficult and can be harmful to chil-
dren if information about donor concep-
tion is disclosed inadvertently and with-
out appropriate support.
Pre-implantation Genetic
Diagnosis (PGD)
14. Pre-implantation genetic diagnosis
(PGD) may be performed on early
embryos to search for the presence of
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WMA
22
genetic or chromosomal abnormalities,
especially those associated with severe
illness and very premature death and
for other reasons, including identifying
those embryos most likely to implant
successfully in women who have had
multiple spontaneous abortions.
Embryos carrying the abnormality are
discarded; only embryos with apparent-
ly normal genetic and chromosomal
complements are implanted.
15. Neither this powerful technique nor
simpler means should be used for triv-
ial reasons such as sex selection for rea-
sons of gender preference. The WMA
holds that physicians should only be
involved with sex selection where it is
used to avoid a serious sex-chromo-
some related condition such as
Duchenne’s Muscular Dystrophy.
16. PGD can also be combined with HLA
matching to select embryos on the basis
that stem cells from the resulting
child’s umbilical cord blood could be
used to treat a seriously ill sibling.
Views on the acceptability of this prac-
tice vary and physicians should follow
national laws and local ethical and pro-
fessional standards if confronted with
such requests.
Use of spare gametes
and embryos and disposal
of unused gametes and
embryos
17. In most cases, assisted conception
results in the production of gametes and
embryos that will not be used to treat
those from whom they are procured.
Such so-called spare gametes and
embryos may be stored, cryo-preserved
for future use, donated to other patients
or disposed of. One alternative to dis-
posal, in countries that permit embryo
research, is donation to a research facil-
ity. The available options must be
explained clearly and precisely to indi-
viduals before donations are made or
retrievals performed.
Surrogacy
18. Where a woman is unable, for medical
reasons, to carry a child to term, surro-
gacy may be used to overcome child-
lessness, unless prohibited by national
law or the ethical rules of the National
Medical Association or other relevant
organisation. Where surrogacy is prac-
tised, great care must be taken to protect
the interests of all parties involved.
Research
19. Physicians should promote the impor-
tance of research using tissues
obtained during assisted conception
procedures. Because of the special sta-
tus of the material being used, research
on human gametes and especially on
human embryos is, in many jurisdic-
tions, specifically regulated.
Physicians have an ethical duty to
comply with such regulation and to
help inform public debate and under-
standing of the issues.
20. Due to the special nature of human
embryos, research should be carefully
controlled and should be limited to
areas in which the use of alternative
materials will not provide an adequate
alternative.
21. Views, and legislation, differ on
whether embryos may be created
specifically for, or in the course of,
research. Physicians should act in
accordance with national legislation and
local ethical advice.
Cell Nuclear Replacement
22. The WMA opposes the use of cell
nuclear replacement with the aim of
cloning human beings.
23. Cell nuclear replacement may also be
used to develop embryonic stem cells
for research and ultimately, it is hoped,
for therapy for many serious diseases.
Views on the acceptability of such
research differ and physicians wishing
to participate in such research should
ensure that they are acting in accor-
dance with national laws and local ethi-
cal guidance.
Recommendations
24. Assisted reproductive technology is a
dynamic, rapidly developing field of
medical practice. Developments should
be subject to careful ethical considera-
tion alongside the scientific monitoring.
25. Human gametes and embryos are
accorded a special status. Their use,
including for research, donation to oth-
ers and disposal, should be carefully
explained to potential donors and sub-
ject to local regulation.
26. Embryo research should only be carried
out if local law and ethical standards
permit it and should be limited to areas
where the use of alternative materials or
computer modelling does not provide
an adequate alternative.
27. Physicians should follow professional
guidance on the maximum number of
embryos to transfer in any treatment
cycle.
28. It is inappropriate to offer money or
benefits in kind (for example free or
lower cost treatment cycles) to encour-
age donation but donors may be reim-
bursed for reasonable expenses
29. Families using donated embryos or
gametes should be encouraged and sup-
ported to be open with the child about
this.
30. Sex selection should only be carried out
to avoid serious, including life threaten-
ing, medical conditions.
31. Physicians have an important role in
ensuring that public debate about the
possibilities of assisted conception, and
the limits to be applied to its practice, is
informed.
32. Physicians should comply with national
legislation and should demonstrate
compliance with high normative stan-
dards.
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WHO
23
nations and their populations interact inter-
nationally. Referring to SARS as an exam-
ple of how vulnerability to health threats
had changed in a mobile and interconnected
world, she referred to the impact on health
of emerging infective diseases, natural dis-
asters or environmental change.
In 2008, the 60th
anniversary of WHO and the
30th
of Alma- Ata, the focus of the World
Health report would be on primary health care
and its role in strengthening health systems.
Dr. Chan spoke of the unprecedented
growth in numbers of partnerships, initia-
tives and funding agencies devoted to pub-
lic health in terms of avoiding duplication
and fragmentation of efforts. One way for-
ward to integrated service delivery such as
malaria and neglected tropical diseases was
to use an integrated primary health care
approach. Stress was also laid on health sys-
tems, evidence for measuring impact, and
access to essential care.
Dr. Chan concluded by commenting on
avian influenza and the “need not to let
down our guard”, Commenting on this she
observed that the new International Health
Regulations come into effect in June, which
should help to reinforce the preparations of
the past three years.
In her first address to the Executive
Committee of WHO as Director General,
Dr. Margaret Chan identified six issues to
guide the approach to future work. Two
addressed fundamental needs – health
development and health security. Two
referred to strengthening health systems and
acquiring better evidence to measure and
shape results, and the last two concern oper-
ation reliance on partners and good perfor-
mance of WHO as an organisation.
Addressing health development, Dr. Chan
referred to her earlier indication that the mea-
sure of WHO’s work should be its impact on
two groups, women in particular, and the peo-
ple ofAfrica, which would require more to be
done in some areas of work. In developing
these issues particularly in relation to Africa
and Women stress was laid on the high atten-
tion already taking place to achieve the mille-
nium goals and the importance of the links
between poverty and health. The measles
reduction success in Africa was an indication
of the real potential for health improvement.
There was need for the capacities of African
people to be released. Turning to the
immense suffering due to Malaria in many
parts of the world, she stressed that in Africa,
where there was no malaria season as trans-
mission occurs throughout the year, in terms
of economic impact 25 % of household
incomes were consumed by malaria.
However the progress in scaling up interven-
tions on Malaria was good news.
She also referred both to neglected tropical
diseases and also to the impact of chronic
diseases, especially their impact on low and
middle income countries. The demands and
costs of chronic care challenge health sys-
tems across the world and for this preven-
tion is the best option .WHO must continue
to convince health leaders that chronic dis-
ease is part of the development agenda.
Health and Security, the topic for World
Health Day, would be the topic for this
year’s World Health Report ( and for World
Health Day) would focus on risks and dan-
gers to health from the ways in which
World Health Organisation
Key Issues for future WHO work
GENEVA March 2007 – A new internation-
al Task Force was launched and has met to
tackle the global shortage of health work-
ers. With a shortfall of 4.3 million health
workers worldwide, including more than 1
million in Africa alone, there is an urgent
need to increase the number of doctors,
nurses, health managers and other health
care workers needed to face immediate
health crises.
Dr. Margaret Chan, Director-General of the
World Health Organization (WHO), wel-
comed the new Task Force: “The simple
fact is that the world needs many more
health workers. The world faces global as
well as local threats to health. Infectious
diseases have staged a dramatic comeback,
and chronic diseases are on the rise. We
cannot improve people’s health without
staff to deliver health care.”
The new global Task Force, chaired by Lord
Nigel Crisp, former Chief Executive of the
National Health Service in England, and
Bience Gawanas, the African Union
Commissioner for Social Affairs, has been
set up under the auspices of the Global
International action needed
to increase health workforce
Health Workforce Alliance (GHWA). It
includes two African Ministers of Health –
Dr. Stephen Mallinga of Uganda and
Marjorie Ngaunje of Malawi – and senior
health policy makers from across the globe,
from public and private sectors, and both
developing and developed countries.
Together these leaders in health and educa-
tion will champion the need for significant-
ly increased investment in the education
and training of health workers in develop-
ing countries, and will build international
commitment to practical action.
The Joint Learning Initiative (2004) and the
World Health Report 2006 have brought this
shortage of health workers to the world’s
attention, and the World Health Assembly
has called for urgent action. Fifty-seven
countries have critical shortages of health
workers of which 36 are in sub-Saharan
Africa. If the crisis is not tackled, these
countries will not be able to provide their
populations with basic health care.
“HIV/AIDS, malaria and TB, and maternal
and child mortality – which together kill
many millions of people annually across the
WMJ_1_01-28.qxd 30.04.2007 09:37 Seite 23
WHO
24
world, will not be significantly reduced
unless the crisis in health workers is tack-
led,” said Lord Crisp. “There is an urgent
need for a massive international effort to
train more health care workers, including
doctors, nurses, managers and community
health workers.”
The Task Force will focus on practical
solutions, also considering the need and
scope for international financial and tech-
nical support, links between training insti-
tutions and universities in the developed
and developing world, and innovative use
of distance-learning technology. Already
some countries are beginning to address
the problem with programmes of education
and training. Some countries such as
Ethiopia, India and Malawi are beginning
to address the problem, rapidly increasing
the production of health workers through
education and training in various ways.
The Task Force will look at the impact of
such programmes and assess the scope to
replicate these and the resources needed to
do so.
The Task Force GHWA Executive Director
Dr. Francis Omaswa, welcomed the Task
Force. “GHWA has identified a need for
some type of ‘fast-track’ training initiative
to address the health worker shortage. This
new GHWA Task Force will make practical
recommendations for action. The Task
Force will also work closely with other pro-
grammes which address issues such as
health worker migration, health financing,
and access to HIV/AIDS treatment, preven-
tion and care.“
The Task Force is due to present its initial
recommendations to the GHWA Forum in
Autumn 2007.
The Task Force members are
• Lord Nigel Crisp (co-chair)
• Bience Gawanas (co-chair,African Union
Commission)
• Hon. Stephen Mallinga (Health Minister
Uganda)
• Hon. Marjorie Ngaunje (Health Minister
Malawi)
• Prof. Srinath Reddy (Director, Public
Health Foundation of India)
• Peter Loescher (President Global Human
Health Merck and Co)/Jeff Sturchio (Vice
President External Affairs, Merck and Co).
• Dr. Joy Phumaphi (Vice-President and
Head Human Health Development
Network/Alexander Prekker (Lead Eco-
nomist, Health, Nutrition and Population,
World Bank)
• Judith Oulton (CEO, International
Council of Nurses)
• Kathy Cahill (Gates Foundation)
• Sarita Bhatla (CIDA,DG Governance and
Social Directorate)/Jeea Sarawati (CIDA,
Health Specialist African Branch)
Further information:
P. Ben Fouquet, Communications Officer,
GHWA, WHO Geneva tel+41 22 791 3554
e-mail fouquetp@who.int
Africa is developing solutions for fighting
disease and improving health, a new WHO
report finds
20 NOVEMBER 2006 | ADDIS
ABABA/GENEVA/LONDON – The signs
are everywhere, across the continent: Africa
is finding African approaches to solving its
health problems.
In Uganda, 50 percent of all HIV/AIDS
patients have been reached with life-saving
antiretroviral medicine through an innova-
tive programme that trains nurses to do
some of the work traditionally done by doc-
tors and community health workers to take
on some of the work of nurses.
In Mali, community cost-sharing schemes
have provided 35 of the country’s 57 com-
munity health centres with staff trained to
deliver babies and perform emergency cae-
sarian sections, making skilled obstetric
care available to thousands of women who
could not previously afford it.
In Rwanda, a police-led road safety cam-
paign, which has included introduction of
fines for failure to wear seatbelts or hel-
mets, resulted in a drop of nearly one quar-
ter in the number of deaths from road traffic
injuries in a single year.
And in South Africa, a health-care train rou-
tinely transports young doctors and final-
year medical students to isolated farming
areas that would otherwise have no access
to basic medical services. To date the train
Africa Reports
African Regional Health Report
has provided health care to half a million
people and health screening and education
to an additional 800000.
These steps forward and others chronicled
in The African Regional Health Report:
The Health of the People – the first report
to focus on the health of the 738 million
people living in the African Region of the
World Health Organization – offer hope that
over time the Region can address the mas-
sive health challenges it faces, given suffi-
cient international support.
“Africa confronts the world’s most dramatic
public health crisis, but this report shows
there are public health solutions that work
in the African setting. These can be exten-
ded to all Africans in need, if governments
build on lessons learnt from successful
interventions while seeking better coordina-
tion with the efforts of international part-
ners”, said Alpha Oumar Konaré, Chairman
of the Commission of the African Union.
The Report provides a comprehensive
analysis of key public health issues and
progress made on them in the Africa
Region.
• HIV/AIDS continues to devastate the
WHO Africa Region, which has 11% of
the world’s population but 60% of the
people living with HIV. Although
HIV/AIDS remains the leading cause of
death for adults, more and more people
are receiving life-saving treatment. The
WMJ_1_01-28.qxd 30.04.2007 09:37 Seite 24
WHO
25
number of HIV-positive people on anti-
retroviral medicines increased eight-fold,
to 810 000 in December 2005 from
100000 in December 2003.
• More than 90% of the estimated 300–500
million malaria cases that occur worldwide
every year are in Africans, mainly in chil-
dren under five years of age, but most coun-
tries are moving towards better treatment
policies. Of the 42 malaria-endemic coun-
tries in the African Region, 33 have adopt-
ed artemisinin-based combination therapy –
the most effective antimalarial medicines
available today – as first-line treatment.
• River blindness has been eliminated as a
public health problem, and guinea worm
control efforts have resulted in a 97 %
reduction in cases since 1986. Leprosy is
close to elimination – defined as less than
one case per 10 000 people in the Region.
• Most countries are making good progress
on preventable childhood illness. Polio is
close to eradication, and 37 countries are
reaching 60% or more of their children
with measles immunization. Overall
measles deaths have declined by more than
50% since 1999. In 2005 alone 75 million
children received measles vaccines.
While drawing the world’s attention to
recent successes, the Report offers a candid
appraisal of major hurdles such as the high
rate of maternal and newborn mortality
overall in the Region. Of the 20 countries
with the highest maternal mortality ratios
worldwide, 19 are in Africa; and the Region
has the highest neonatal death rate in the
world. There is the strain on African health
systems imposed by the high burden of life-
threatening communicable diseases coupled
with increasing rates of noncommunicable
diseases. Basic sanitation needs remain
unmet for many: only 58% of people living
in Sub-Saharan Africa have access to safe
water supplies. Noncommunicable dis-
eases, such as hypertension, heart disease
and diabetes are on the rise; and injuries
remain among the top causes of death in the
Region.
“We know what the challenges are, and we
know how to address them – but we also
recognize that Africa’s fragile health sys-
tems represent an enormous barrier to wider
application of the solutions highlighted in
this report. If we are to continue moving
forward, African governments and their
partners must make a major commitment
and invest more funds to strengthen health
systems,“ said Dr. Luis Gomes Sambo,
Regional Director of the WHO Regional
Office for Africa.
22 NOVEMBER 2006 | JOHANNES-
BURG/GENEVA – Sub-Saharan Africa
remains the most dangerous region in the
world for a baby to be born – with 1.16 mil-
lion babies dying each year in the first 28
days of life – but six low-income African
countries, Burkina Faso, Eritrea, Madagascar,
Malawi, Uganda and the United Republic of
Tanzania, have made significant progress in
reducing deaths among newborn babies,
according to a report.
The report, “Opportunities for Africa’s
newborns“, brings together new data and
analysis from a team of 60 authors and nine
international organizations from the
Partnership for Maternal, Newborn and
Child Health, (PMNCH). The Partnership
represents developing and donor countries,
non-governmental agencies, foundations
and multi-lateral organizations, including
the World Health Organization.*
“Good news does come out of Africa“, said
Dr. Joy Lawn, co-editor of the report, who
New report shows improvements in child survival in Africa
for the first time since the 1980s
works in Africa for Saving Newborn
Lives/Save the Children-US. “Whilst the sur-
vival of the African child has shown almost
no improvement since the 1980s, the fact that
during 2006 several large African countries
have reported a dramatic reduction in the risk
of child deaths gives us new hope of more
rapid progress to save Africa’s children.”
Although no measurable progress has been
made in reducing newborn mortality rates
for babies during the first month of life in
Africa at regional level, a turnaround has
been seen in the six countries highlighted in
the report, with an average reduction of
29% over the last 10 years. Across the six
countries, the reduction ranges from 20% in
Tanzania and Malawi to 39% in Burkina
Faso and 47% in Eritrea.* The authors iden-
tified factors that contributed to this
progress. For example:
• In Malawi, there is presidential-level
commitment to maternal newborn and
child health and increased investment by
partners to address the lack of human
resources.
• United Republic of Tanzania has recorded
a 30% reduction in child mortality and a
20% fall in newborn deaths over the last 5
years. District health managers set local
budget priorities based on deaths in each
district and this has meant increased gov-
ernment spending on essential maternal
and child healthcare.
• In Uganda, the performance of district
health services is ranked each year and
published in the national newspaper.
• Eritrea has made consistent progress over
20 years in reducing child and newborn
deaths with an average annual reduction of
around 4% over the last decade through a
focus on reaching high coverage of basic
public health services, including to the poor.
• Burkina Faso ensures that poor women do
not pay for the catastrophic cost of an
WMJ_1_01-28.qxd 30.04.2007 09:37 Seite 25
WHO
26
emergency caesarean section – often more
than an average family income for the
year.
Up to half a million African babies die on
the day they are born – most at home and
uncounted. According to the report, Liberia
has the world’s highest newborn mortality
rate at 66 deaths per 1,000 births compared
to less than 2 deaths per 1,000 births in
Japan and 6 deaths per 1,000 births in
Latvia. Half of Africa’s 1.16 million new-
born deaths occur in just five countries –
Nigeria, Democratic Republic of the
Congo, Ethiopia, United Republic of
Tanzania and Uganda. Nigeria alone has
over 255,000 newborn deaths each year.
“The health of newborn babies has fallen
between the cracks – Africa’s un-named, and
uncounted, lost children,“ said Dr. Francisco
Songane, Director of the Partnership. “We
must count newborn deaths and make them
count, instead of accepting these deaths as
inevitable. The progress of these six African
countries demonstrates that even the world’s
poorest countries can look after their new-
borns, their most vulnerable citizens. They
have shown the way – we must seize the
opportunity.”
The President of the Pan-African
Parliament, Hon. Amb. Gertrude Mongella,
is spearheading action in maternal, newborn
and child health through the African Union
and the Pan African Parliament in
Johannesburg. “Reaching every woman,
baby and child in Africa with essential care
will depend on us, the users of this publica-
tion. We all have a role to play as govern-
ments to lead, as policymakers to guarantee
essential interventions and equity, as part-
ners and donors to support programmes,“
she said.
The authors warn that opportunities to save
newborn lives within existing programmes
are often missed. For example two-thirds of
women in Africa attend antenatal care yet
only 10% receive preventive treatment for
malaria and a mere 1 % of mothers with
HIV receive the recommended treatment to
prevent mother to child transmission of
HIV/AIDS.
The report found that two-thirds of newborn
deaths in sub-Saharan Africa – up to 800000
babies a year – could be saved if 90% of
women and babies received feasible, low-
cost health interventions. These include
immunizing women against tetanus, provid-
ing a skilled attendant at birth, treating new-
born infections promptly and educating
mothers about hygiene, warmth and breast-
feeding for infants. Saving these lives would
take only an estimated US $ 1.39 per capita
– or US $1 billion per year. According to the
report, this cost would benefit others, in par-
ticular the one million stillborns and 250
000 mothers who also die each year.
Quotations from other
Partnership members
Professor E. Oluwole Akande, chair of
the African Regional Maternal Newborn
and Child Health Task Force
“Policy frameworks such as the Roadmap
for Maternal and Newborn Survival are
now in place in many African countries to
reach every mother and baby with essential
care. The gap remains between policy and
action,” said Professor E. Oluwole Akande.
“This publication helps to bridge this gap
and will be an invaluable toolkit for action.“
Kate Kerber, co-editor of the publication
“We identified the ABCD of progress by
examining the six low income countries that
are progressing”, said Kate Kerber.
“Accountable leadership, Bringing national
policy into district-level action, Community
ownership, and Demonstrated focus on
reaching all mothers, newborn and children
with essential life-saving care.”
Dr. Doyin Oluwole, Director of Africa
2010 (one of the authors of the report)
“Maternal, newborn and child health care is
the backbone of a healthy health system.”
states Doyin Oluwole. “African decision
makers are finding that systematically
addressing newborn health benefits existing
maternal and child health care and promotes
integration with other programmes.
Integration saves lives and money.”
* The Partnership Maternal, Maternal, Newborn
& Child Health (PMNCH)
GENEVA – At a two day meeting at the
World Health Organization (WHO) on
advances in pandemic influenza vaccine
development, experts reported encouraging
progress.
Sixteen manufacturers from 10 countries
are developing prototype pandemic influen-
za vaccines against H5N1 avian influenza
virus. Five of them are also involved in the
development of vaccines against other
avian viruses (H9N2, H5N2, and H5N3).
At present, more then 40 clinical trials have
been completed or are ongoing. Most of them
have focused on healthy adults. Some compa-
nies, after completing safety analyses in
adults, have initiated clinical trials in the
elderly and in children.All vaccines were safe
and well tolerated in all age groups tested.
WHO reports some promising results on avian
influenza vaccines but also concerned by glob-
al vaccine production capacity
For the first time, results presented at the
meeting have convincingly demonstrated
that vaccination with newly developed
avian influenza vaccines can bring about a
potentially protective immune response
against strains of H5N1 virus found in a
variety of geographical locations. Some of
the vaccines work with low doses of anti-
gen, which means that significantly more
vaccine doses can be available in case of a
pandemic.
These developments were discussed at the
WHO meeting on the evaluation of pan-
demic influenza prototype vaccines in clini-
cal trials which took place in Geneva,
Switzerland, on 15-16 February 2007. It
was a third such meeting in two years the
objectives to review progress in the devel-
opment of candidate vaccines against pan-
WMJ_1_01-28.qxd 30.04.2007 09:37 Seite 26
WHO
27
demic influenza viruses and to reach con-
sensus on future priority activities.
More than 100 influenza vaccine experts –
from academia, national and regional public
health institutions, the pharmaceutical
industry and regulatory bodies throughout
the world – attended the meeting convened
by the WHO Initiative for Vaccine Research
and the WHO Global Influenza Program-
me. Information on more than 20 projects
was presented and discussed. Most manu-
facturers are using reference vaccine strains
corresponding to H5N1 viruses provided
from by WHO Collaborating Centres.
In spite of the encouraging progress noted
at the WHO meeting, WHO stresses that the
world still lacks the manufacturing capacity
to meet potential global pandemic influenza
vaccine demand as current capacity is esti-
mated at less than 400 million doses per
year of trivalent seasonal influenza vaccine.
In response to this challenge, WHO
launched in 2006 the Global pandemic
influenza action plan (GAP) to increase
vaccine supply, a US$10 billion effort over
10 years. One of its aims is to enable devel-
oping countries to establish their own
influenza vaccine production facilities
through transfer of technology, providing
them with the most sustainable and reliable
response to the threat of pandemic influen-
za. WHO is currently working with several
vaccine producers, mainly in developing
countries affected by H5N1, to facilitate
establishment of in-country influenza vac-
cine production.
Information contact:
Melinda Henry
Communications officer
WHO Department of Immunization, Vaccines
and Biologicals
Telephone: +41 22 791 2535
Mobile phone: +41 79 477 1738
E-mail: henrym@who.int
routine dose increased from 71% to 77%
and through immunisation campaigns more
than 360 million aged 9 months to 15 years
received the vaccine.
The measles vaccination campaigns have
also contributed both to the development of
a global public health laboratory network
and provided a channel for the delivery of
other life saving interventions, such as bed
nets providing protection against malaria,
de-worming medicines and vitamin A sup-
plements. Such activities, combining
measles intervention with other health inter-
ventions is a contribution to the achieve-
ment of MDG 4, – a 2/3 reduction in child
deaths between 1990 and 2015.
UNICEF Executive Director Ann M.
Veneman said “Immunising children is
clearly saving lives and contributing to the
achievement of the Millennium Develop-
ment Goals. We must urgently build on this
momentum with integrated community-
based health programmes to help save the
lives of more than 10 million children who
die of preventable causes every year”.
Of the estimated 345,000 measles deaths in
2005, 90% were among children under the
age of five, many deaths resulting from the
complications related to severe diarrhoea,
pneumonia and encephalitis.
The challenge now is to reach a new global
goal – the reduction of global measles
deaths by 90% by 2010, compared with
2000 levels. This calls for the sustaining of
the gains made in countries that have imple-
mented accelerated measles control strate-
gies and for similar strategies to be imple-
mented in countries with high numbers of
measles deaths, such as India and Pakistan.
In a joint news release the partners in the
Measles Initiative, WHO, UNICEF, ARC,
CDC and UNF, announced earlier this year
that Measles deaths worldwide have fallen
by 60% since 1999, exceeding the United
Nations goal “to halve measles deaths
between 1999 and 2005”.
According to new data from WHO, global
measles deaths fell from an estimated
873,000 deaths in 1999 to 345,000 in 2006.
The progress was even greater in Africa
where measles deaths fell by 75% from an
estimated 506,000 to 126,000. (see Wolfson
L.J. et al., Lancet 2007, 369, 191-200).
Dr. Margaret Chan, WHO Director-General,
is reported as saying “This is an historic vic-
tory for global public health, for the power
of partnership and for commitment by coun-
tries to fight a terrible disease. Our promise
to cut measles deaths by half and save hun-
dreds of thousands of lives has not only been
fulfilled, it has been surpassed in just six
years with Africa leading the way”.
The strategy to reduce measles, comprising
four components, has been the key to ensur-
ing the massive decrease in measles deaths
called for:
• the provision of one dose of measles
vaccine for all infants via routine
health services,
• a second opportunity for measles
immunisation for all children, generally
through mass vaccination campaigns,
• effective surveillance for measles, and
• enhanced care, including the provision
of supplemental vitamin A.
In consequence, between 1999 and 2005
global immunisation coverage with the first
UN Global goal to reduce measles deaths
in children surpassed
World Leprosy Day 2007
InternationalAppeal to end stigma and ostraci-
sation of leprosy sufferers and their families.
While the availability of multi-drug therapy
(MDT) since the 1980s has revolutionised
the treatment of leprosy and resulted in the
cure of over 15 million people, the age-old
stigma and discrimination attached to lep-
rosy continues to add to the suffering of
those now cured of the disease and their
families.
Following World Leprosy Day, a second
Global Appeal signed by amongst others, Dr.
WMJ_1_01-28.qxd 30.04.2007 09:37 Seite 27
Regional and NMA News
28
Mr Sasakawi said “Considering the long
history of discrimination against people
with leprosy and their families, action to
resolve this issue is long overdue. An
important step toward eradicating this dis-
PK Gopal, President of the National Forum,
India (an organisation of people affected by
leprosy) and Hilarion M Guia the first Mayor
of Culion an island municipality which was
once the worlds largest leprosy colony, was
launched by Mr Yohei Sasakawa, WHO
Goodwill Ambassador for the elimination of
leprosy, on 29th January 2007.
This year the appeal, organised by Ateneo de
Manila University, the Department of Health
of the Philippines, WHO, the Nippon
Foundation and Sasakawa Memorial Health
Foundation, was led by leaders of people
affected by leprosy standing beside Mr.
Sasakawa at the launch. It builds on the First
Appeal in New Delhi 2006 which “called on
people all over the word to change their per-
ception and foster an environment in which
leprosy patients ,cured persons and their fami-
lies can lead normal lives free from stigma and
discrimination” This was signed by 11 World
Leaders including former Presidents of Brazil,
Costa Rica, India, Nigeria, the USA, by the
Dalai Lama and Archbishop Desmond Tutu.
Since 1995 WHO has supplied MDT free to
all identified leprosy patients. Initially this
was with funding from the Nippon
Foundation and subsequently through MDT
donated by Novartis and the Novartis
Foundation for Sustainable Development.
Despite the initial appeal and the fact that such
therapy produces a cure the discrimination
and stigma. Associated with leprosy, (active
and cured) persist largely due to lack of edu-
cation. According to John Sasakawa“ leprosy
and the mystery surrounding its transmission
have always given rise to fear- and fear has
generated discrimination – not just to those
with the disease but their families as well”.
Johei Sasakawa, who for more than 30
years has supported efforts to tackle leprosy
“as a medical problem” approached the UN
Sub-commission on the Promotion and
Protection of Human Rights on this issue in
2005 and 2006. They unanimously adopted
resolutions recommending that govern-
ments take action to redress the issue of
stigma and discrimination associated with
leprosy. A report is currently being prepared
on this issue by a Special Rapporteur which
will go to the Human Rights Council (suc-
cessor to UNCHR) and hopefully lead to
full UN support.
NMA news
Appeal to migrant physicians to return
crimination is to educate society about the
disease”. He also commented “I have come
to appreciate that no one who has had lep-
rosy will be truly free of the disease so long
as discrimination remains”
The subject of the World Health Report 2006
was Human Resources for Health. Over the
past few years there has been increasing con-
cern, debate and pronouncements on this topic
which, following the WHA decision last year,
will be a topic for active consideration and
action over the next decade. In consequence
there appears to a move towards openness both
in the declarations of countries who are net
consumers of migrant health professionals’
services and also of the realities of the internal
effects of emigration on countries who are net
losers of health care professionals.
Recently the Health Professions Council of
South Africa, expressly in the context of the
health care need in that country, has written
to all South African physicians currently
practising in other countries, seeking to
encourage their return to practice in their
own country. As an incentive, a one off
„amnesty“ until 30th April 2007 is being
offered to those professionals willing to
return to practice in South Africa. For those
returning, the current punitive financial
requirements for those wishing to reregister
to practice in their own country, will be
waived. In a letter, the Head of corporate
communications of the Health Professions
Council writes „In the interest of encourag-
ing our doctors to return to SA, where they
are desperately needed ,we will waive the
penalty fees for doctors whose names have
been erased from the register“. The only
condition required is an undertaking to prac-
tice in the public health care system for 100
hours within six months. Whilst previously
some countries have appealed to nationals to
return to practice in their own country, such
an open appeal with incentives to return
must be considered as an index of the seri-
ousness of the shortage in South Africa.
In a commentary on the relevance of both the
numbers of African doctors practising in
Canada and its dependence on migrant physi-
cians, the Canadian Medical Association
comments that South Africa’s medical dias-
pora involves more than 1500 physicians
now practising in Canada and thousands
more who have moved to the UK ,Australia,
New Zealand and the USA. In CMA news(1)
setting out the background to Canadian and
International concerns about this problem
,attention is also drawn to a report issued by
the Canadian Policy Research Networks in
1st February (2) quoting a remark which,
while it is made with reference to Canada, is
highly relevant to the realities of addressing
this problem both from the point of view of
developed and developing countries „The
ethics of international recruitment has to be
dealt with in the overall context of domestic
health human resource planning“ While this
report considers the options for Canada in
dealing with the ethical problems associated
with planning its own domestic health human
resources, it also presents a valuable exten-
sive overview not only of the ethical prob-
lems relating to international recruitment, but
also of national and international statements,
codes of practice of international bodies both
intergovernmental and non-governmental,
and of national governments who have
addressed this issue in the past 3-4 years.
(1) “South Africa Licensing body issues“
amnesty“, begs MDs to return home“
http://www.cma.ca/index.cfm?ci_id=100376
23&1a_id=1 consulted 19.02.07
(2) McIntosh T.,Torgeson R,,Klassen N.“Ethical
Recruitment of Internationally Educated
Health Professionals from abroad and
Options for Canada“ Research Report H/11,
Canadian Policy Research Network, Ottawa.
WMJ_1_01-28.qxd 30.04.2007 09:37 Seite 28
CHINA E
Chinese Medical Association
42 Dongsi Xidajie
Beijing 100710
Tel: (86-10) 6524 9989
Fax: (86-10) 6512 3754
E-mail: suyumu@cma.org.cn
Website: www.chinamed.com.cn
COLOMBIA S
Federación Médica Colombiana
Carrera 7 N° 82-66, Oficinas 218/219
Santafé de Bogotá, D.E.
Tel/Fax: (57-1) 256 8050/256 8010
E-mail: federacionmedicacol@
sky.net.co
DEMOCRATIC REP. OF CONGO F
Ordre des Médecins du Zaire
B.P. 4922
Kinshasa – Gombe
Tel: (243-12) 24589
Fax (Présidente): (242) 8846574
COSTA RICA S
Unión Médica Nacional
Apartado 5920-1000
San José
Tel: (506) 290-5490
Fax: (506) 231 7373
E-mail: unmedica@sol.racsa.co.cr
CROATIA E
Croatian Medical Association
Subiceva 9
10000 Zagreb
Tel: (385-1) 46 93 300
Fax: (385-1) 46 55 066
E-mail: hlz@email.htnet.hr
Website: www.hlk.hr/default.asp
CZECH REPUBLIC E
Czech Medical Association
J.E. Purkyne
Sokolská 31 – P.O. Box 88
120 26 Prague 2
Tel: (420-2) 242 66 201-4
Fax: (420-2) 242 66 212 / 96 18 18 69
E-mail: czma@cls.cz
Website: www.cls.cz
CUBA S
Colegio Médico Cubano Libre
P.O. Box 141016
717 Ponce de Leon Boulevard
Coral Gables, FL 33114-1016
United States
Tel: (1-305) 446 9902/445 1429
Fax: (1-305) 4459310
DENMARK E
Danish Medical Association
9 Trondhjemsgade
2100 Copenhagen 0
Tel: (45) 35 44 -82 29/Fax:-8505
E-mail: er@dadl.dk
Website: www.laegeforeningen.dk
DOMINICAN REPUBLIC S
Asociación Médica Dominicana
Calle Paseo de los Medicos
Esquina Modesto Diaz Zona
Universitaria
Santo Domingo
Tel: (1809) 533-4602/533-4686/
533-8700
Fax: (1809) 535 7337
E-mail: asoc.medica@codetel.net.do
ECUADOR S
Federación Médica Ecuatoriana
V.M. Rendón 923 – 2 do.Piso Of. 201
P.O. Box 09-01-9848
Guayaquil
Tel/Fax: (593) 4 562569
E-mail: fdmedec@andinanet.net
EGYPT E
Egyptian Medical Association
„Dar El Hekmah“
42, Kasr El-Eini Street
Cairo
Tel: (20-2) 3543406
EL SALVADOR, C.A S
Colegio Médico de El Salvador
Final Pasaje N° 10
Colonia Miramonte
San Salvador
Tel: (503) 260-1111, 260-1112
Fax: -0324
E-mail: comcolmed@telesal.net
marnuca@hotmail.com
ESTONIA E
Estonian Medical Association
(EsMA)Pepleri 32
51010 Tartu
Tel/Fax (372) 7420429
E-mail: eal@arstideliit.ee
Website: www.arstideliit.ee
ETHIOPIA E
Ethiopian Medical Association
P.O. Box 2179
Addis Ababa
Tel: (251-1) 158174
Fax: (251-1) 533742
E-mail: ema.emj@telecom.net.et /
ema@eth.healthnet.org
FIJI ISLANDS E
Fiji Medical Association
2nd Fl. Narsey’s Bldg, Renwick Road
G.P.O. Box 1116
Suva
Tel: (679) 315388/Fax: (679) 387671
E-mail: fijimedassoc@connect.com.fj
FINLAND E
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Tel: (358-9) 3930 91/Fax-794
E-mail: fma@fimnet.fi
Website: www.medassoc.fi
FRANCE F
Association Médicale Française
180, Blvd. Haussmann
75389 Paris Cedex 08
Tel/Fax: (33) 1 45 25 22 68
GEORGIA E
Georgian Medical Association
7 Asatiani Street
380077 Tbilisi
Tel: (995 32) 398686 / Fax: -398083
E-mail: Gma@posta.ge
GERMANY E
Bundesärztekammer
(German Medical Association)
Herbert-Lewin-Platz 1
10623 Berlin
Tel: (49-30) 400-456 369/Fax: -387
E-mail: renate.vonhoff-winter@baek.de
Website: www.bundesaerztekammer.de
GHANA E
Ghana Medical Association
P.O. Box 1596
Accra
Tel: (233-21) 670-510/Fax: -511
E-mail: gma@ghana.com
HAITI, W.I. F
Association Médicale Haitienne
1ère
Av. du Travail #33 – Bois Verna
Port-au-Prince
Tel: (509) 245-2060
Fax: (509) 245-6323
E-mail: amh@amhhaiti.net
Website: www.amhhaiti.net
HONG KONG E
Hong Kong Medical Association, Chi-
naDuke of Windsor Building, 5th Floor
15 Hennessy Road
Tel: (852) 2527-8285
Fax: (852) 2865-0943
E-mail: hkma@hkma.org
Website: www.hkma.org
HUNGARY E
Association of Hungarian Medical
Societies (MOTESZ)
Nádor u. 36 – PO.Box 145
1443 Budapest
Tel: (36-1) 312 3807 – 311 6687
Fax: (36-1) 383-7918
E-mail: motesz@motesz.hu
Website: www.motesz.hu
ICELAND E
Icelandic Medical Association
Hlidasmari 8
200 Kópavogur
Tel: (354) 8640478
Fax: (354) 5644106
E-mail: icemed@icemed.is
INDIA E
Indian Medical Association
Indraprastha Marg
New Delhi 110 002
Tel: (91-11) 23370009/23378819/
23378680
Fax: (91-11) 23379178/23379470
E-mail: inmedici@vsnl.com
INDONESIA E
Indonesian Medical Association
Jalan Dr Sam Ratulangie N° 29
Jakarta 10350
Tel: (62-21) 3150679
Fax: (62-21) 390 0473/3154 091
E-mail: pbidi@idola.net.id
IRELAND E
Irish Medical Organisation
10 Fitzwilliam Place
Dublin 2
Tel: (353-1) 676-7273Fax: (353-1)
6612758/6682168
Website: www.imo.ie
ISRAEL E
Israel Medical Association
2 Twin Towers, 35 Jabotinsky St.
P.O. Box 3566, Ramat-Gan 52136
Tel: (972-3) 6100444 / 424
Fax: (972-3) 5751616 / 5753303
E-mail: doritb@ima.org.il
Website: www.ima.org.il
JAPAN E
Japan Medical Association
2-28-16 Honkomagome, Bunkyo-ku
Tokyo 113-8621
Tel: (81-3) 3946 2121/3942 6489
Fax: (81-3) 3946 6295
E-mail: jmaintl@po.med.or.jp
KAZAKHSTAN F
Association of Medical Doctors
of Kazakhstan
117/1 Kazybek bi St.,
Almaty
Tel: (3272) 62 -43 01 / -92 92
Fax: -3606
E-mail: sadykova-aizhan@yahoo.com
REP. OF KOREA E
Korean Medical Association
302-75 Ichon 1-dong, Yongsan-gu
Seoul 140-721
Tel: (82-2) 794 2474
Fax: (82-2) 793 9190
E-mail: intl@kma.org
Website: www.kma.org
KUWAIT E
Kuwait Medical Association
P.O. Box 1202
Safat 13013
Tel: (965) 5333278, 5317971
Fax: (965) 5333276
E-mail: aks.shatti@kma.org.kw
LATVIA E
Latvian Physicians Association
Skolas Str. 3
Riga
1010 Latvia
Tel: (371-7) 22 06 61; 22 06 57
Fax: (371-7) 22 06 57
E-mail: lab@parks.lv
LIECHTENSTEIN E
Liechtensteinischer Ärztekammer
Postfach 52
9490 Vaduz
Tel: (423) 231-1690
Fax: (423) 231-1691
E-mail: office@aerztekammer.li
Website: www.aerzte-net.li
LITHUANIA E
Lithuanian Medical Association
Liubarto Str. 2
2004 Vilnius
Tel/Fax: (370-5) 2731400
E-mail: lgs@takas.lt
Website: www.lgs.lt
LUXEMBOURG F
Association des Médecins et
Médecins Dentistes du Grand-
Duché de Luxembourg
29, rue de Vianden
2680 Luxembourg
Tel: (352) 44 40 331
Fax: (352) 45 83 49
E-mail: secretariat@ammd.lu
Website: www.ammd.lu
MACEDONIA E
Macedonian Medical Association
Dame Gruev St. 3
P.O. Box 174
91000 Skopje
Tel/Fax: (389-91) 232577
E-mail: mld@unet.com.mk
MALAYSIA E
Malaysian Medical Association
4th Floor, MMA House
124 Jalan Pahang
53000 Kuala Lumpur
Tel: (60-3) 40413740/40411375
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Association and address/Officers
iii
Fax: (60-3) 40418187/40434444
E-mail: mma@tm.net.my
Website: http://www.mma.org.my
MALTA E
Medical Association of Malta
The Professional Centre
Sliema Road, Gzira GZR 06
Tel: (356) 21312888
Fax: (356) 21331713
E-mail: mfpb@maltanet.net
Website: www.mam.org.mt
MEXICO S
Colegio Medico de Mexico
Fenacome
Hidalgo 1828 Pte. D-107
Colonia Deportivo Obispado
Monterrey, Nuevo Léon
Tel/Fax: (52-8) 348-41-55
E-mail: rcantum@doctor.com
Website: www.cmm-fenacome.org
NAMIBIA E
Medical Association of Namibia
403 Maerua Park – POB 3369
Windhoek
Tel: (264) 61 22 44 55/Fax: -48 26
E-mail: man.office@iway.na
NEPAL E
Nepal Medical Association
Siddhi Sadan, Post Box 189
Exhibition Road
Katmandu
Tel: (977 1) 4225860, 231825
Fax: (977 1) 4225300
E-mail: nma@healthnet.org.np
NETHERLANDS E
Royal Dutch Medical Association
P.O. Box 20051
3502 LB Utrecht
Tel: (31-30) 28 23-267/Fax-318
E-mail: j.bouwman@fed.knmg.nl
Website: www.knmg.nl
NEW ZEALAND E
New Zealand Medical Association
P.O. Box 156
Wellington 1
Tel: (64-4) 472-4741
Fax: (64-4) 471 0838
E-mail: nzma@nzma.org.nz
Website: www.nzma.org.nz
NIGERIA E
Nigerian Medical Association
74, Adeniyi Jones Avenue Ikeja
P.O. Box 1108, Marina
Lagos
Tel: (234-1) 480 1569,
Fax: (234-1) 492 4179
E-mail: info@nigeriannma.org
Website: www.nigeriannma.org
NORWAY E
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
Tel: (47) 23 10 -90 00/Fax: -9010
E-mail: ellen.pettersen@
legeforeningen.no
Website: www.legeforeningen.no
PANAMA S
Asociación Médica Nacional
de la República de Panamá
Apartado Postal 2020
Panamá 1
Tel: (507) 263 7622 /263-7758
Fax: (507) 223 1462
Fax modem: (507) 223-5555
E-mail: amenalpa@cwpanama.net
PERU S
Colegio Médico del Perú
Malecón Armendáriz N° 791
Miraflores, Lima
Tel: (51-1) 241 75 72
Fax: (51-1) 242 3917
E-mail: decano@cmp.org.pe
Website: www.cmp.org.pe
PHILIPPINES E
Philippine Medical Association
PMA Bldg, North Avenue
Quezon City
Tel: (63-2) 929-63 66/Fax: -6951
E-mail: medical@pma.com.ph
Website: www.pma.com.ph
POLAND E
Polish Medical Association
Al. Ujazdowskie 24, 00-478 Warszawa
Tel/Fax: (48-22) 628 86 99
PORTUGAL E
Ordem dos Médicos
Av. Almirante Gago Coutinho, 151
1749-084 Lisbon
Tel: (351-21) 842 71 00/842 71 11
Fax: (351-21) 842 71 99
E-mail: intl@omcne.pt
Website: www.ordemdosmedicos.pt
ROMANIA F
Romanian Medical Association
Str. Ionel Perlea, nr 10
Sect. 1, Bucarest
Tel: (40-1) 460 08 30
Fax: (40-1) 312 13 57
E-mail: AMR@itcnet.ro
Website: ong.ro/ong/amr
RUSSIA E
Russian Medical Society
Udaltsova Street 85
119607 Moscow
Tel: (7-095)932-83-02
E-mail: info@rusmed.ru
Website: www.russmed.ru
SAMOA E
Samoa Medical Association
Tupua Tamasese Meaole Hospital
Private Bag – National Health Services
Apia
Tel: (685) 778 5858
E-mail: vialil_lameko@yahoo.com
SINGAPORE E
Singapore Medical Association
Alumni Medical Centre, Level 2
2 College Road, 169850 Singapore
Tel: (65) 6223 1264
Fax: (65) 6224 7827
E-Mail: sma@sma.org.sg
www.sma.org.sg
SLOVAK REPUBLIC E
Slovak Medical Association
Legionarska 4
81322 Bratislava
Tel: (421-2) 554 24 015
Fax: (421-2) 554 223 63
E-mail: secretarysma@ba.telecom.sk
SLOVENIA E
Slovenian Medical Association
Komenskega 4, 61001 Ljubljana
Tel: (386-61) 323 469
Fax: (386-61) 301 955
SOMALIA E
Somali Medical Association
14 Wardigley Road – POB 199
Mogadishu
Tel: (252-1) 595 599
Fax: (252-1) 225 858
E-mail: drdalmar@yahoo.co.uk
SOUTH AFRICA E
The South African Medical Associa-
tionP.O. Box 74789, Lynnwood Rydge
0040 Pretoria
Tel: (27-12) 481 2036/2063
Fax: (27-12) 481 2100/2058
E-mail: sginterim@samedical.org
Website: www.samedical.org
SPAIN S
Consejo General de Colegios Médicos
Plaza de las Cortes 11, Madrid 28014
Tel: (34-91) 431 7780
Fax: (34-91) 431 9620
E-mail: internacional1@cgcom.es
SWEDEN E
Swedish Medical Association
(Villagatan 5)
P.O. Box 5610, SE – 114 86 Stockholm
Tel: (46-8) 790 33 00
Fax: (46-8) 20 57 18
E-mail: info@slf.se
Website: www.lakarforbundet.se
SWITZERLAND F
Fédération des Médecins Suisses
Elfenstrasse 18 – C.P. 170
3000 Berne 15
Tel: (41-31) 359 –1111/Fax: -1112
E-mail: fmh@hin.ch
Website: www.fmh.ch
TAIWAN E
Taiwan Medical Association
9F No 29 Sec1
An-Ho Road
Taipei
Tel: (886-2) 2752-7286
Fax: (886-2) 2771-8392
E-mail: intl@med-assn.org.tw
Website: www.med.assn.org.tw
THAILAND E
Medical Association of Thailand
2 Soi Soonvijai
New Petchburi Road
Bangkok 10320
Tel: (66-2) 314 4333/318-8170
Fax: (66-2) 314 6305
E-mail: math@loxinfo.co.th
Website: www.medassocthai.org
TUNISIA F
Conseil National de l’Ordre
des Médecins de Tunisie
16, rue de Touraine
1002 Tunis
Tel: (216-71) 792 736/799 041
Fax: (216-71) 788 729
E-mail: ordremed.na@planet.tn
TURKEY E
Turkish Medical Association
GMK Bulvary
Sehit Danis Tunaligil Sok. N° 2 Kat 4
Maltepe 06570
Ankara
Tel: (90-312) 231 –3179/Fax: -1952
E-mail: Ttb@ttb.org.tr
Website: www.ttb.org.tr
UGANDA E
Uganda Medical Association
Plot 8, 41-43 circular rd.
P.O. Box 29874
Kampala
Tel: (256) 41 32 1795
Fax: (256) 41 34 5597
E-mail: myers28@hotmail.com
UNITED KINGDOM E
British Medical Association
BMA House, Tavistock Square
London WC1H 9JP
Tel: (44-207) 387-4499
Fax: (44- 207) 383-6710
E-mail: vivn@bma.org.uk
Website: www.bma.org.uk
UNITED STATES OF AMERICA E
American Medical Association
515 North State Street
Chicago, Illinois 60610
Tel: (1-312) 464 5040
Fax: (1-312) 464 5973
Website: http://www.ama-assn.org
URUGUAY S
Sindicato Médico del Uruguay
Bulevar Artigas 1515
CP 11200 Montevideo
Tel: (598-2) 401 47 01
Fax: (598-2) 409 16 03
E-mail: secretaria@smu.org.uy
VATICAN STATE F
Associazione Medica del Vaticano
Stato della Città del Vaticano
00120 Città del Vaticano
Tel: (39-06) 69879300
Fax: (39-06) 69883328
E-mail: servizi.sanitari@scv.va
VENEZUELA S
Federacion Médica Venezolana
Avenida Orinoco
Torre Federacion Médica Venezolana
Urbanizacion Las Mercedes
Caracas
Tel: (58-2) 9934547
Fax: (58-2) 9932890
Website: www.saludfmv.org
E-mail: info@saludgmv.org
VIETNAM E
Vietnam Medical Association
(VGAMP)68A Ba Trieu-Street
Hoau Kiem District
Hanoi
Tel/Fax: (84) 4 943 9323
ZIMBABWE E
Zimbabwe Medical Association
P.O. Box 3671
Harare
Tel: (263-4) 791553
Fax: (263-4) 791561
E-mail: zima@zol.co.zw
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