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COUNTRY
• Council Session and General Assembly. South
Africa,Durban
• Anniversary of the Declaration of Helsinki
vol. 60
MedicalWorld
Journal
Official Journal of the World Medical Association, INC
G20438
Nr. 4, December 2014
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Dr. Xavier DEAU
WMA President
Conseil National de l’Ordre des
Médecins (CNOM)
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Dr. Leonid EIDELMAN
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and Planning Committee
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Dr. Masami ISHII
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Dr. Margaret MUNGHERERA
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Uganda Medical Association
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Joseph M.HEYMAN,MD,FACOG
WMA Chairperson
of the Associate Members
163 Middle Street
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Prof. Dr. Frank Ulrich
MONTGOMERY
WMA Treasurer
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Sir Michael MARMOT
WMA President-Elect
British Medical Association
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London WC1H 9JP
United Kingdom
Dr. Heikki PÄLVE
WMA Chairperson of the Medical
Ethics Committee
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Finland
Dr. Mukesh HAIKERWAL
WMA Chairperson of Council
2/174 Millers Road/PO Box 577
Altona North, VIC 3025
Australia
Dr. Otmar KLOIBER
Secretary General
World Medical Association
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01212 Ferney-Voltaire
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World Medical Association Officers, Chairpersons and Officials
Official Journal of the World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
121
WMA News
The Declaration of Helsinki (DoH) trans-
lates the willingness of the World Medical
Association and its Founding President,
Eugène Marquis, French Physician, to
bring the ethics of medical practice and
research at the highest level with a twofold
goal:
• to ensure a universality of ethics in re-
search on human beings as well as the
protection of people subjected to these
researches.
• to make definitely impossible the horrible
abuse of Medicine encountered during
the thirties and forties.
These ethical principles are often translated
into the codes of Ethics of each country
or laid down in the resolutions of interna-
tional organisms which are usual partners
of the Word Medical Association (WHO,
UNESCO, UNITED NATIONS, ICRC..)
And Governments felt encouraged to include the DoH principles
into their legislation.
This Declaration conciles with pragmatism and wisdom “primacy
of the individual” dear to and the “societal primacy”. This raises
awareness of the physician to the fundamental importance of the
informed consent and information of the
patient, the secrecy of personal and espe-
cially patient data, and the value of the pro-
fessional autonomy of the physician., Under
the aegis of independent research commit-
tees, the DoH rigorously codifies the scien-
tific studies and trials, and in particular, the
protection of the research subjects against
dangerous experiments and exploitation.
The declaration commands the application
of the necessary scientific rigor, including
the usage of placebos when necessary.
The sustainability of the DoH is a shining
example of universality of medical ethics.
Even if its drafting seemed to be labori-
ous, our Declaration of Helsinki has the
merit to be a historical and yet modern
document, compiling the cultures of more
than 100 medical associations.Thus, it is an
authentic factor of peace and union between medical professions
around the world in full respect for the patients for who we care.
The DoH ensures a rigorous application of sciens as well as the eth-
ics on the grounds of a genuine respect for the patient and human
rights we are caring for.
Dr. Xavier DEAU
WMA President
Editorial
Xavier Deau
122
WMA News
Wednesday October 8
At the invitation of the South African
Medical Association,delegates from 46 Na-
tional Medical Associations met at the In-
ternational Convention Centre in Durban,
South Africa from October 8–11.
Council
Dr. Mukesh Haikerwal AO, Chair of the
WMA, opened the 198th
Council session.
The Secretary General, Dr. Otmar Kloiber,
welcomed a new member of the Council,
Dr. Steven J. Stack (American Medical
Association) and gave apologies from del-
egates from Austria and Brazil, welcoming
their replacements, Dr. Reiner Bretten-
thaler (Austria) and Dr. Miguel R. Jorge
(Brazil).
President’s report
The President, Dr. Margaret Mungherera,
reported on her activities since April, vis-
iting many national medical associations.
She said she had attended several mental
health meetings and many countries did
not have mental health policies or laws.
In addition no mention had been made of
mental health in the post 2015 sustainable
development goals. On the African de-
velopment initiative, she said the findings
from a survey carried out among African
NMAs justified the need for a capacity
building programme. She spoke about the
importance of strengthening NMA activi-
ties and continuing professional develop-
ment and the need for training. There was
also a need to work on universal health
coverage and the social determinants of
health.
She said there were now twinning arrange-
ments between the New Zealand Medical
Association and Tanzania, the Danish and
Rwanda, and Japan and Malawi.
Finally, she referred to the fact that there
were 33 African NMAs that were not
members of the WMA. The plan was that
every year at least four NMAs joined and
this year four had applied to join – Zambia,
Kenyan, Rwanda and Lesotho.
Influenza
Dr. Julia Tainijoki-Seyer, WMA medical
adviser, updated the meeting about the next
stage of the WMA’s influenza campaign,
which was to be launched the following day.
This was based on encouraging physicians
to become role models and to meet their
ethical obligations to protect their patients.
The evidence was that if physicians got vac-
cinated they were more likely to ask their
patients to be vaccinated. She said a micro
site as part of the WMA website had been
developed to enable greater use of digital
and social media to get this message across.
The micro site was being launched the fol-
lowing day.
Chair’s report
Dr. Haikerwal reported briefly on his ac-
tivities over the past year, including the
successful Council meetings in Bali, Indo-
nesia and Fortaleza, Brazil. The year had
proceeded with the usual full, diverse and
intense agendas pursued with consider-
ation and in a timely way. He emphasised
three important thoughts – that health was
a core component of a successful fair and
just society, a wise investment bringing hu-
man, political and economic dividends and
that physicians were part of the solution
in health and healthcare research planning
implementation.
Resolution on Ebola Viral Disease
Professor Vivienne Nathanson (British
Medical Association) introduced an emer-
gency Resolution on Ebola. She said this
was a global problem, but some govern-
ments had been treating it as a local prob-
lem for a few countries in West Africa.
However, because of air travel every coun-
try was affected. At the moment Ebola was
disproportionately affecting countries with
the least money to deal with it and the
poorest infrastructures because of their rel-
ative poverty. She said that although some
countries had been doing a lot, there were
many countries who could do more to help.
There were also many health staff who were
trying to deal with this crisis who were not
being given the facilities to do this safely.
Nor did they have the contact tracing facil-
ities to help them shut this epidemic down.
She said the WMA should be supporting
their colleagues in Sierra Leona, Guinea
and Liberia and saying something to force
governments to recognise that this was a
global.
This led to a lengthy debate, with several
proposals being suggested for amending
the proposed Resolution. Dr. Ardis Hoven
(American Medical Association) suggested
an amendment urging all countries, es-
pecially those not yet affected, to educate
health care providers about the current case
definition. In addition they should be edu-
cated about strengthening infection control
methodologies and contact tracing to pre-
vent transmission in their countries. She
said it was important for everyone to ‘gird
up their borders’.Her proposed amendment
was accepted by the Council.
Dr. Ames Dhai (South Africa) suggested
including support for the use of unproven
interventions for the treatment of patients
with the Ebola virus. However, Dr. Na-
thanson said the proposed Resolution was
WMA 2014 General Assembly Report
Durban, South Africa, October 8–11
123
WMA News
about providing resources to manage the
epidemic. She was not sure that unproven
treatment should be part of the recommen-
dations. It was an extraordinarily complex
issue that required a much longer explana-
tion. Dr. Ajay Kumar (India) also opposed
introducing the issue of unproven treat-
ment, while Dr. Heikki Pälve (Finland)
agreed that it was outside the scope of the
resolution.
The amendment proposed by Dr. Dhai was
eventually withdrawn.
Dr. Pälve proposed an addition that nation-
al medical associations should urge their
governments to act on the WMA’s recom-
mendations in the Resolution. The Presi-
dent, Dr. Mungherera, said she would like
to see a recommendation that international
agencies work with the medical experts on
the ground. These experts and local physi-
cians felt they were being ignored, she said.
These suggestions were accepted.
Dr. Xaviour Walker, Past Chair of the Ju-
nior Doctors Network, wanted to see a ref-
erence in the Resolution to the special role
that junior physicians faced with inadequate
protection equipment and supervision.
However, this did not find support.
Dr. Juan Rodriguez Sendin (Spanish Med-
ical Association) reported on the situation
in Spain where a nurse had been infected
after being in contact with a patient suf-
fering from Ebola. Other speakers com-
plained about the inaccurate information
appearing on social media. Dr Yoshitake
Yokokura (Japan) reported on activities
in his country, while Dr. Mungherera sug-
gested that the issue of prevention and
health promotion should be considered.
She was particularly concerned that these
fevers were common in Africa and there
was a need for joint animal-human disease
surveillance.
Eventually, the emergency Resolution, as
amended, was approved.
Council was then suspended for the three
committee meetings
Socio Medical Affairs Committee
Sir Michael Marmot, Chair of the Com-
mittee, in his opening remarks, referred
to progress on the social determinants of
health. He reported that a joint letter had
been sent to UN Secretary General Ban Ki-
moon from the British Medical Associa-
tion, the NCD Alliance, the International
Planned Parenthood Federation and many
other concerned organisations drawing his
attention to the fact that most of the sus-
tainable goals impacted on health and that,
as a consequence, social determinants of
health should be fully mainstreamed in the
process. The WMA leadership had signed
the letter.
He also raised the opportunity of develop-
ing collaboration with the World Psychi-
atric Association with a view to making
mental health a public health issue. The
newly-elected President of the WPA, Dr.
Dinesh Bhugra, whom he met with recent-
ly, welcomed future such collaboration with
the WMA.
Finally, Sir Michael informed the commit-
tee that three WHO regional offices (Eu-
rope, PAHO and EMRO) had made health
equity a main objective within the frame-
work of their activities. As a consequence,
a process for health equity and social deter-
minants of health has been set up.
Dr. Kloiber, Secretary General, reported on
three items of interest to the committee.
The first was the trial of the Turkish Medi-
cal Association, which had begun the pre-
vious week in Turkey, following the health
care given by doctors during the Gezi Park
demonstrations. Dr. Kloiber said he had
attended the opening of trial on behalf of
the WMA. The Standing Committee of
European Doctors and Physicians for Hu-
man Rights were also present. But unfor-
tunately the court did not dismiss the case
as requested, but postponed the trial until
December 23.
The second item was that, on the initia-
tive of the government of Norway, a group
of countries had been working on a draft
resolution on the protection of health care
personnel in situations of armed conflicts
and other emergencies for submission to
the United Nations General Assembly. The
WMA had been consulted about this.
The final issue was the fruitful coopera-
tion with the World Veterinary Association
(WVA). The WMA was currently working
with the WVA on an international confer-
ence on zoonosis in Madrid in 2015.
Health Care in Danger
Dr. Nathanson (British Medical Associa-
tion), Chair of the Work Group on Health
Care in Danger, reported on the activities
of the group. Dr. Bruce Eshaya-Chauvin,
of the International Committee of the Red
Cross, had presented a detailed report on
the HCiD project. Members of the group
agreed to reflect further on how the WMA
and its members could bring forward issues
at the national level.
The group had also discussed the issue of
violence against health care workers out-
side of armed conflicts, in particular in the
area of mental health. It was now working
on a revision of the current WMA policy
on Ethical Issues Concerning Patients with
Mental Illness and planned to consult the
World Psychiatric Association.
Dr. Nathanson concluded by informing the
committee that she was working on the de-
velopment of a booklet for doctors in situa-
tions of violence.
Violence against Women & Girls
Sir Michael Marmot reported on the suc-
cessful seminar organized by the WMA
124
WMA News
and the International Federation of Medi-
cal Students Associations in Geneva dur-
ing the World Health Assembly last May.
The event was very well attended, reflecting
the strong interest of the health community
to engage further in this area. In terms of
follow-up, the Chair proposed convening
a small meeting of interested NMAs at
the BMA in London to consider how the
WMA could continue working on address-
ing violence against women. Medical as-
sociations from the Netherlands, India and
South Africa had expressed an interest in
attending.
Role of Physicians and NMAs, SDH and
Health Equity
The committee received a report of Dr.
Jeff Blackmer (Canadian Medical Asso-
ciation) on the international meeting on
social determinants of health which would
take place on March 24–25 at the British
Medical Association in London. Invita-
tions had been sent out and many medical
associations had already confirmed their
participation or expressed an interest. Dr.
André Bernard (Canadian Medical Asso-
ciation) underlined that this was expected
to be a high level meeting, providing a real
opportunity for NMAs to explore potential
actions in terms of SDH.
Medical Education
Dr. Andreas Rudkjoebing (Danish Medi-
cal Association) reported on the activities of
the Work Group on Medical Education on
providing guidance to the World Federa-
tion of Medical Education on their revision
of their global standards for post gradu-
ate medical education. He thanked group
members (South Africa, Netherlands and
JDN) for their useful input.
Role of Physicians in Preventing the Traffick-
ing with Minors and Illegal Adoptions
Dr. Fernando Rivas (Spain), Chair of the
Work Group, informed the committee that
a new draft of a Resolution on the Role of
Physicians in Preventing the Trafficking
with Minors would be submitted at the next
Council meeting in Oslo in April 2015.
Physicians’ Well-being
Dr. Robert Wah (American Medical As-
sociation), Chair of the Work Group on
Physicians’ Well-being, reported that the
group had been busy since being set up last
April. It had held a meeting the previous
day, during which it worked on a first draft
proposal. It hoped to have a final propos-
al ready for the next Council meeting in
Oslo.
Non-Commercialization of Human Repro-
ductive Material
The committee considered the proposed
revision of the WMA Resolution on the
Non-Commercialization of Human Repro-
ductive Material, which called on NMAs
to urge their governments to prohibit com-
mercial transactions in human ova, sperm
and embryos and any human material for
reproductive purpose. Following further
informal discussions the committee agreed
several amendments and recommended
that the document be sent to the Council
for adoption by the Assembly.
Aesthetic Treatments
The committee considered the proposed
WMA Statement on Aesthetic Treat-
ments, a document that combined draft
documents originally submitted by the
Israeli and Swedish medical associations.
The statement expressed concern that
in many countries aesthetic procedures
were not adequately regulated and it set
out new guidelines, primarily for physi-
cians, warning that many treatments in-
volved risks and might potentially harm
the health of patients. There was a brief
debate about prohibiting advertisements
showing patients before and after opera-
tions and it was agreed to strengthen the
document to read that ‘unrealistic or al-
tered photographs showing patients before
and after treatments must not be used in
advertising’. Suggestions were put forward
for stating that only ‘qualified’ physicians
should be allowed to carry out these treat-
ments. However, this was opposed and in-
stead it was agreed to amend the document
to read that ‘aesthetic treatments must only
be performed by practitioners with suffi-
cient knowledge, skills and experience of
the interventions performed’.
The committee recommended that the pro-
posed Statement, as amended, be approved
by the Council and forwarded to the Gen-
eral Assembly for approval and adoption.
Air Pollution
The proposed Statement on the Prevention
of Air Pollution Due to Vehicle Emissions
was submitted by the Austrian Medical
Chamber for discussion. This called for the
introduction of more stringent emission
standards for all new diesel vehicles to
limit the concentration of soot particles in
the air. After a brief debate it was agreed
to make it clear in the document that there
were also other ways of reducing the vol-
ume of harmful emissions. The committee
decided to recommend that, as amended,
the Statement be approved by the Council
and be forwarded to the General Assembly
for adoption.
Solitary Confinement
The committee considered the proposed
Statement on Solitary Confinement, in-
troduced by the Finnish Medical Associa-
tion. This urged those authorities respon-
sible for overseeing solitary confinement to
take account of an individual’s health and
stated that solitary confinement should not
be imposed when it would adversely af-
fected the medical condition of prisoners
with a mental illness. An amendment was
proposed by the British Medical Associa-
tion and accepted that doctors had a duty
125
WMA News
to consider the conditions in solitary con-
finement and to protest to the authorities
if they believed that they were unacceptable
or might amount to inhumane or degrad-
ing treatment. A further debate took place
on whether prolonged solitary confinement,
without the will of the prisoner, must be
avoided and the recommendation that phy-
sicians should never participate in any part
of the decision-making process resulting in
solitary confinement.
The committee agreed that as amended, the
Statement be approved by the Council and
forwarded to the General Assembly for ap-
proval and adoption.
Protection of Healthcare Workers
The German Medical Association put for-
ward a proposed Declaration on the Protec-
tion of Healthcare Workers in Situations
of Violence. This called on those in power
and all parties involved in violence to ensure
the protection of healthcare workers and
facilities and to respect their neutrality. It
was argued that this document was needed
to focus on the responsibilities of govern-
ments and others in positions of author-
ity to provide the necessary protection for
health care workers. Some speakers argued
about whether such a document was needed
or whether it replicated other WMA policy
documents.
After agreeing on several detailed amend-
ments, the committee recommended that
the Declaration be sent to the Council for
forwarding to the General Assembly for
adoption.
Street Children
A proposed Statement on Providing Health
Support to Street Children presented by
the Conseil National de l’Ordre des Mé-
decins was considered by the committee.
It was suggested that although good will
was often expressed about helping these
children it was not followed by action. Yet
thousands of children over 14 were com-
pelled to work, while thousands more were
subjected to trafficking and sexual abuse
or were involved in armed conflict. Several
speakers argued that the Statement was not
yet ready for adoption and that further work
was needed to incorporate comments from
members.
The committee recommended that the doc-
ument be re-circulated among constituent
members for comments.
Water and Health
The committee considered several minor
revisions to the WMA Statement on Water
and Health, adding the words that an ad-
equate supply of fresh water was ‘central to
living a life in dignity and upholding human
rights’and supporting ‘the promotion of the
universal access to clean and affordable wa-
ter as a human right and as a common good
of humanity’.
The committee agreed these and other
amendments and recommended that the
revised Statement be sent to the Council
for forwarding to the General Assembly for
adoption.
Chemical Weapons
A proposed Statement on Chemical Weap-
ons presented by the Turkish Medical As-
sociation was considered by the committee.
This recommended strongly to States to re-
frain from using riot control agents because
of the potential grave impact on the health
of those exposed.
The committee agreed to recommend that
the Statement be circulated among mem-
bers for comment.
Declaration on Alcohol
A draft International Declaration on Alco-
hol was proposed by the Australian Medi-
cal Association. The document outlined the
main objectives of alcohol harm-reduction,
and recommended priority measures to ad-
dress alcohol-related harm.
The committee decided to recommend to
Council that the document be circulated for
comment.
Mobile Health
The committee considered a proposed
Statement on Mobile Health proposed
by the German Medical Association. The
document drew attention to the oppor-
tunities and risks associated with mobile
health and called for appropriate regula-
tion to protect patient safety and user data.
Speakers from several NMAs welcomed
the document and said this had become a
very important issue.
The committee recommended that the
Statement be circulated among members
for comment.
World Day for Health Professionals
A proposal for a World Day of Combat-
ing Violence against Health Professionals
on April 17 was suggested by the Turk-
ish Medical Association. Its draft State-
ment said this would be in memory of the
young Turkish doctor Dr. Ersin Arslan
who was killed by a patient’s relative in
hospital. The idea was to increase public
awareness of what the medical associa-
tion said was a worldwide problem. An
amendment was agreed to change the title
of the document to ‘preventing’ violence
and the committee recommended that the
document should be circulated to mem-
bers for comment.
Migrant Workers’ Health in Qatar
The committee considered a proposed
Resolution on Migrant Workers’ Health in
Qatar. The Resolution, from Finland, de-
manded that FIFA as the responsible orga-
nization of the World Cup take immediate
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WMA News
action to secure the life, safety and free-
dom of movement of migrant workers in
the World Cup construction sites in Qatar
or change the venue as soon as possible.
During a debate that followed, it was said
that workers elsewhere were being simi-
larly treated. It was decided to strengthen
the Resolution by amending it to read that
FIFA should take immediate action and
change the venue.
The committee recommended that, as
amended, the Resolution be sent to the
Council for forwarding to the General As-
sembly for adoption.
Ethical Principles of Health Care in Times of
Armed Conflict and other Emergencies
The committee considered a document on
proposed Ethical Principles of Health Care
in Times of Armed Conflict and other
Emergencies. This was submitted within
the framework of the Health Care in Dan-
ger Project of the International Commit-
tee of the Red Cross. It was explained that
different organisations had different sets of
principles and the document was a common
denominator of ethical principles of health
care applicable in times of armed conflict
that has been agreed by the WMA, the In-
ternational Committee of Military Medi-
cine, the International Council of Nurses
and the International Pharmaceutical Fed-
eration.
The committee agreed to recommend that
the document be forwarded to the Council
for adoption by the Assembly.
Medical Ethics Committee
The committee met under the chairmanship
of Dr. Heikki Pälve.
Person Centred Medicine
Dr. André Bernard (Canada), Chair of
the Work Group, informed the commit-
tee about the development of the group’s
work and highlighted discussions about the
meaning of the terms ‘person centred’ and
‘patient centred’ healthcare. The group did
not have a clear enough understanding of
these terms and further consensus building
was needed. He said the group would invite
advice from outside experts and would sub-
mit a further paper to the committee.
50th
Anniversary Celebration of the Declara-
tion of Helsinki
Dr. Leonid Eidelman (Israel), Chair of the
Work Group, reported on the event to be
held in Helsinki, on November 11 due to be
attended by the President of Finland.
Health Databases
The committee heard that NMA comments
had been received about the draft policy pa-
per circulated by the Work Group on da-
tabases. The recent Work Group meeting
in Copenhagen in August had focused on
the links between this document and the
Declaration of Helsinki, on broad consent,
anonymity, pseudo-anonymity, medical
transfer agreements and the recently ad-
opted CMAAO (Confederation of Medical
Associations in Asia and Oceania) policy on
health databases. The group had also dis-
cussed initiating an open consultation out-
side of NMAs, similar to that carried out
during the recent revision of the Declara-
tion of Helsinki.
The committee decided to recommend to
Council that the Workgroup be authorized
to continue drafting policy and that the Ex-
ecutive Committee be mandated to approve
the start of an open consultation as soon
as the Workgroup considered that it had a
draft version appropriate for sharing.
Human Rights
Clarisse Delorme, WMA Advocacy Advi-
sor, reported that the WMA had met the
newly appointed United Nations Special
Rapporteur on the right to health, Dr.
Dainius Pūras from Lithuania. Dr. Puras
was the first physician to hold this position.
The WMA was considering further col-
laboration with him.
Finance and Planning Committee
The committee met under the chairmanship
of Dr. Leonid Eidelman.
Financial Statement
The Audited Financial Statement for 2013
was considered and the committee recom-
mended that it be approved by Council and
forwarded to the Assembly for adoption.
Budget and Membership Dues Payments
The committee considered documentation
on the Budget for 2015 vs. Actual 2013 Ex-
penditures and membership dues payments
for 2014 and agreed that the documents be
sent to Council for approval and forwarding
to the Assembly for information.
Statutory Meetings
The committee considered arrangements
for future WMA meetings – the Council
Session in Oslo in April 2015, the 2015
General Assembly in Moscow, the April
2016 Council in Buenos Aires and the
2016 Assembly in Taipei, Taiwan. No in-
vitation had yet been received yet for the
Council meeting in 2017, but the commit-
tee recommended that the 2017 General
Assembly be held in Chicago from 11–14
October.
Special Meetings
The Chair of Council, Dr. Haikerwal, re-
ported on three meetings – the pre-G20
Health Summit in Melbourne in No-
vember, the One Health conference with
the World Association of Veterinarians
in Spain in cooperation with the Spanish
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WMA News
Medical Association and a possible confer-
ence on eHealth/Telehealth in Italy.
Membership
The committee considered applications
for membership from the Kenya Medical
Association, the Lesotho Medical Asso-
ciation, the Zambian Medical Association
and the Rwanda Medical Association and
agreed to forward these to the Assembly
for adoption.
Thursday October 9
Associate Members Meeting
Dr. Joseph Heyman (American Medical
Association), a gynaecologist from Mas-
sachusetts, was elected unopposed as Chair
for 2014–16. He succeeded Dr. Guy Du-
mont.
Junior Doctors Network
The meeting received an oral report from
Dr. Nivio Moreira, immediate past Chair
of the Junior Doctors Network, who spoke
about the Network’s activities. He said
that a meeting had been held at the begin-
ning of the week in Durban, attended by
23 junior doctors. Dr. Ahmet Murt from
Turkey had been elected JDN Chair for
2014–15.
Past Presidents and Chairs of Council Net-
work
A report was also received on the Past
Presidents and Chairs of Council Network.
Dr. Jon Snaedal said this new group would
have a vital role within the WMA in future.
Proposed Revision of WMA Statement on
Nuclear Weapons
Dr. Xaviour Walker, former Chair of the
Junior Doctors, said the JDN would like
to propose revisions to the Statement on
Nuclear Weapons on the basis that the
threat of a limited nuclear war was more
likely. The revisions included new advice to
all governments that even a limited nuclear
war would have catastrophic effects on the
world’s food supply and would put a sig-
nificant proportion of the world’s popula-
tion at risk from a nuclear famine. A fur-
ther amendment would urge NMAs to use
available educational resources to educate
the general public.
The meeting agreed to forward the amend-
ments to the Assembly for adoption.
Destruction of smallpox virus stockpiles
Dr. Walker also proposed a Statement on
the destruction of smallpox virus stockpiles.
This recommended that the World Health
Assembly pursue an international witnessed
destruction of the remaining stockpile of
smallpox virus, that the World Health Or-
ganization have access to adequate smallpox
vaccine and antiviral stockpiles and that
governments had appropriate emergency
pandemic planning for outbreak for small-
pox virus. It also encouraged the urgent
outlining of robust international laws and
guidelines to stop the use of recombinant
laboratory technology to recreate the small-
pox virus.
The proposed Statement attracted some
criticism that it needed more work and it
was agreed the document should be sent to
the Assembly with a suggestion that fur-
ther consideration should be given to the
issue.
Investments
A suggestion was made that future potential
investments of the WMA should exclude
fossil fuel based energy companies. The
Secretary General, Dr. Kloiber, said that the
Association did not have any investments in
stock shares,but the Chair promised that he
would present the suggestion to the Gen-
eral Assembly.
Scientific Session
“Health Determinants Beyond the MDGs”
The Chair of the first session, Dr. Mung-
herera, opened the proceedings by asking
what the priorities post 2015 would be. She
said physicians would have a role to play in
providing the professional leadership that
would be required. Their role was to moti-
vate others and to ensure communication
between with those they led.
Dr. Mzukisi Grootboom, Chair of the
South African Medical Association, said
it was 350 days before they started tak-
ing stock of what the nations of the world
had achieved on MDGs. These goals had
achieved universal support because they
were ambitious.But they now needed to ad-
dress the post-MDG agenda and the social
determinants of health.
The first speaker in the Scientific Session
was Sir Michael Marmot, Research Pro-
fessor of Epidemiology and Public Health
at the University College London. He
said doctors needed to concern themselves
with sustainable development and people
concerned with sustainable development
should bother about health. What hap-
pened with the draft Millennium Devel-
opment Goals post 2015 would have a
profound impact on health and the fair
distribution of health between countries
and within countries. Health and wellbe-
ing should be the outcome, the mission
and the overarching goal of sustainable
development. And doctors and the WMA
should be advocates of health and wellbe-
ing. Physicians were the advocates of the
poor.
Sir Michael spoke about the work going
on to draft new goals, but said there ap-
peared to be no focus on equity. He said
universal health coverage was required as
well as concerted action on the social de-
terminants of health. They were comple-
mentary.
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Measurement and monitoring could drive
equity and although many countries said
they did not have the systems, they had to
start with what was feasible.
He looked at what had been happening
with MDGs in eradicating poverty. In sub
Saharan Africa 48 per cent of people were
still in poverty, living on less than $1.25 a
day.Here there had been a colossal failure to
bring about a sufficient reduction.There had
been a decline in poverty in Southern Asia,
although the figure was still 30 per cent.
Less than a quarter of the world’s poor lived
in low income countries and half the world’s
poor lived in India and China.
He spoke about the importance of educa-
tion for women and said this was a health
issue. He said we had the resources to im-
prove global health but those resources were
so inequitably distributed that they were
making things very difficult.
Answering questions he said that health
was getting better and global poverty was
coming down.
The next speaker was Prof. Hoosen (Jerry)
Coovadia, a Director at MatCH Health
Systems (Maternal, Adolescent and Child
Health),with a speech entitled ‘Countdown
to 2015: the global situation’. He spoke
about progress in achieving the MDGs.
There had been monitoring of MDG goals
and many of them had been met. But peo-
ple had not analysed whether the MDGs
from 2000 had made a substantial differ-
ence. The problem was that the difference
made by MDGs could not be easily mea-
sured. Throwing money at things it might
not always make a difference.
Malebona Precious Matsoso,Director Gen-
eral of the South African National Depart-
ment of Health, spoke about South Africa
and the MDGs.She said that in 2008,eight
years after the MDGs were adopted the
world faced three crises – a financial crisis, a
food crisis and a fuel crisis, the three Fs. But
over and above these crises, in some parts
of the world they had conflict which was
still continuing. Lately they had seen what
happened in post-conflict countries when
systems had failed,when countries were un-
able to thrive and when health systems were
fragile. West Africa was a reminder to all of
them that post-conflict, if they failed to de-
velop countries, they could not talk about
development.
She said there were some countries that
had shown progress. There was a wide-
spread feeling among policy makers that
progress against hunger, poverty and dis-
ease was notable and that MDGs had
played a role in a world that had been un-
dergoing the three Fs. Referring to South
Africa’s achievements she said that the
proportion of the population living below
$1 a day in 2000 was 11.3 per cent and in
2011 was down to four per cent. But even
that four per cent was not acceptable.There
had also been an improvement in educa-
tion. However one survey undertaken had
shown that in early school entrants about
89,000 of the children had learning dis-
abilities, such as sight problems. Others
had serious hearing problems and others
were suspected TB cases.
She went on to say that investments in
South Africa required that they dealt with
social determinants of health and also pro-
moted inter-sectoral collaboration. It was
not enough to say they had a ministry of
water affairs or a ministry dealing with
sanitation because where other sectors had
failed health had to serve as a safety net. If
the water ministry did not do its work there
would be problems with diarrhoea. If the
ministry of trade did not create employ-
ment they would have to ensure they had
got psychologists and psychiatrists to look
after people with depression because they
could not look after their families. So they
were setting up inter-ministerial and so-
cial clusters that could specifically look at
the social determinants of health. She was
pleased to say that with the interventions
they had made they were seeing an increas-
ing life expectancy, improvements in under
five mortality and in infant mortality rates.
But these improvements would not be sus-
tainable if they did not address the social
determinants of health. As the countdown
to post 2015 MDGs continued, they had
identified 15 interventions that could help
them save 10,000 more lives between now
and 2015. She would like to see this unfin-
ished business continue.
In the next session, entitled ‘Is Univer-
sal Access and National Health Insurance
the same concept?’ Professor Diane Mc-
Intyre, Professor of Health Economics in
the School of Public Health and Family
Medicine at the University of Cape Town,
said the simple answer to the question in
the title of her presentation was ‘No!’ She
said that often the concept of universal ac-
cess was equated with health insurance. But
the misconception that universal coverage
might equal health insurance was quite dan-
gerous and allowed government to abrogate
its responsibility. Speaking about terminol-
ogy – universal health coverage, universal
coverage or access – she said she preferred
universal health system. This definition
drew on the most common definition put
forward by the World Health Organisation
which had said it was about everyone hav-
ing access to needed care, of sufficient qual-
ity to be effective as well as financial protec-
tion from the costs of using health services.
A universal health system realised the right
and entitlement.
She spoke about the key things needed
from the health care financial perspective,
including funds coming from mandatory
pre-payment sources. People should be
paying in advance,but government revenue
was also a form of pre-payment through
taxes. She drew on international data to
illustrate the importance of this and the
importance of large quantities of govern-
ment revenue going towards health. There
was an onus on governments to make suf-
ficient revenue available. If they were going
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to pursue a universal health system they
could not do it without adequate govern-
ment revenue.
Some people asked how much was enough.
The Chatham House health care financ-
ing discussions, recently published, looked
at the relationship between government
spending on health as a percentage to
GDP and the conclusion was that govern-
ment spending on health should be at least
five per cent of GDP. Some people might
ask why it should be as a percentage of
GDP and not 15 per cent of government
expenditure.The answer was that the target
of 15 per cent was nothing if government
expenditure was small. If it was expressed
as a percentage of GDP pressure was ap-
plied on government to raise revenue and
to how much it spent. From the social de-
terminants perspective high levels of gov-
ernment spending was needed in all social
sectors. One of the discussions happening
internationally was a growing call that
governments should be seeking to generate
revenue and have expenditure in the region
of 35 per cent of GDP in order to achieve
the sustainable development goals.
Prof. McIntyre went on to talk about the
pools of funds in South Africa and frag-
mentation within the pools and the issue
of strategic or active purchasing.They were
not going to have universal access un-
less they started getting purchasing right.
South Africa had said it intended to in-
troduce a national health insurance fund.
But would this proposed NHI and the
way it was being rolled out actually pro-
mote progress to a universal health sys-
tem? They were in the preliminary phases
of these reforms and these reforms focused
on the service delivery and management
side. She said the current reforms would
create the conditions for efficient and eq-
uitable provision of quality services within
the public sector. There had been a lot of
debate around the National Health Insur-
ance Fund and a lot of confusion. A lot of
people thought that it would be just a big
insurance scheme. But her understanding
was that it would be fully tax funded. Al-
though it was called the National Health
Insurance Fund it was not going to be on
a contributory basis where only those who
contributed would benefit from it. It was
going to be universal and would create a
universal entitlement to services and would
be tax funded. So why were they going to
create the national health insurance fund?
Her understanding was that the primary
role of that institution would be to under-
take strategic purchasing. If they created a
good institution that was a strategic pur-
chaser it would take them an enormous
distance towards a universal health system.
In conclusion she said that the proposed
reforms had the potential to move them
towards a universal health system. The in-
tention was that the majority of health care
funding would be from mandatory pre-pay-
ment tax funding. There would be reduced
fragmentation in the funding pools. The
majority of funds would be in a single pool
and lastly they would strive to get strategic
purchasing through an independent public
institution.
The final speaker, Professor Olive Shisana,
Chief Executive Officer of the Human
Sciences Research Council, spoke about
South Africa’s journey to National Health
Insurance and traced the history of its de-
velopment. She compared the proposals
first made in 1935 with the 2011 green
paper. For almost 50 years from 1944 and
1994 there was no action. In 1994 the
ANC took the decision to have a NHI
review. The green paper now in the pub-
lic domain had several principles, one of
which was the right to access to health
care and the transformation of the health
care system in such a way that it would be
evidence based.
She compared the differences between the
proposals from the past and today’s green
paper. Previously it was planned to include
employers and employees only and the pro-
posals would cover only the urban working
population.Those that were poor or lived in
rural areas would not be included. In other
words, it was a racially based system. In
2011 the plan envisaged was for a compre-
hensive universal entitlement programme in
which everyone would be included except
migrants not resident in South Africa.
Quality control under past proposals lay
with the doctors. Now it was proposed than
an independent body would be responsible
for compliance.
There were now many key stakeholders
who were not involved years ago. While
many of the health professionals and po-
litical parties were ambivalent towards
NHI, the public said they supported the
proposed reforms.
She said there had been missed opportuni-
ties since the 2011 green paper had been
published. A wide consultation had taken
place with further proposals being made.
But she said that the system of NHI was
not being piloted. What was now needed
was strong stewardship. Consultation must
continue with stakeholders and there would
have to be more changes. It was also impor-
tant that pilots took place.
The session ended with a panel discussion
involving Prof. Yosuf Veriava and Prof. Alex
van der Heever, both from the University
of the Witwatersrand, and Dr. Jonathan
Broomberg (Discovery Health).
In the afternoon there was a session on ad-
vocacy entitled ‘Can Physicians be activists
for change?’
The first speaker, Dr. Nivio Moreira (Bra-
zil), Past Chair of Junior Doctors Network,
spoke about the role of the junior doctors
within the WMA and the way they could
become more active within the Association.
He stressed the way in which the JDN used
social media, through the use of twitter and
Facebook.
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Dr. Jeff Blackmer, Director of Ethics at
the Canadian Medical Association spoke
about physicians as activists for change and
explained why physicians should become
activists. He posed the question – was this
an option or an ethical obligation? He gave
several examples from Canada of where
doctors had become involved actively on
behalf of their patients and said doctors had
the power individually and collectively to
act on their social conscience.They had cer-
tain rights, but along with these came cer-
tain responsibilities. Putting patients above
all else was one of these. Another was to ad-
vocate on behalf of patients. Doctors were
in a unique situation to influence policies,
particularly health policies and WMA pol-
icy made it clear that doctors had an ethical
obligation to undertake advocacy activities.
The final three speakers gave examples of
how effective advocacy could be. Dr. Cecil
Wilson (American Medical Association),
Past President of the WMA, and Dr. An-
dré Bernard (Canada), Chair of the WMA’s
Advocacy Advisory Group, spoke about the
advocacy activities of the WMA, giving
recent examples of successful media cam-
paigns. Dr. Bernard said that advocacy was
key to everything the WMA did and had
to be mainstreamed into all NMA activities.
And Bruce Eshaya-Chauvin, Medical Ad-
visor with the International Committee of
the Red Cross, and head of the Health Care
in Danger Project, spoke about the way the
project had been developed.
Friday October 10
Council
The Council resumed under the Chair
Dr. Haikerwal to consider reports from the
three committees.
Medical Ethics Committee
The report from the committee was ap-
proved. The report from the Finance and
Planning Committee was approved after
Dr. Haikerwal reported on plans to hold
a pre G20 meeting in November in Mel-
bourne on health as an investment.
The Council also agreed to recommend to
the Assembly that four new members be
admitted from the national medical as-
sociations of Kenya, Lesotho, Zambia and
Rwanda.
Socio Medical Affairs Committee
Environment
An oral report was received about a meet-
ing of the Environment Caucus.The caucus
meeting had heard about the greening of
hospitals and clinics and the issue of disin-
vesting from fossil fuel.
Street Children
The French Medical Association raised
again the issue of the UNESCO Interna-
tional Day for Street Children on Novem-
ber 26 and said it hoped that the WMA
would support the day. Meanwhile the
Conseil National de l’Ordre des Médecins
would continue to fine tune its document
on proposals for assisting street children
around the world.
Alcohol
The Australian Medical Association ex-
plained further how its International Dec-
laration on Alcohol had emerged. A similar
document had been pursued in Australia.
Alcohol was a scourge and the harmful ef-
fects of alcohol killed about two and a half
million people every year, almost four per
cent of all the deaths worldwide.
It was significant burden of disease. The
Australian Medical Association had worked
with a strong coalition in Australia to de-
velop this statement. They accepted that it
would be a long campaign, and it was one
that should not be joined by the alcohol in-
dustry which did not have the best interests
of patients at heart. The Council approved
the Socio Medical Committee report.
Assembly Ceremonial Session
Prof. Ames Dhai, President of the South
African Medical Association, officially wel-
comed delegates to the 65th
General Assem-
bly.She said it had been an honour for South
Africa to host the WMA Assembly for the
second time since 2006. She said that one of
the most important issues which the WMA
was in an excellent position to address was
the importance of strong national medi-
cal associations. At a time when healthcare
was under so much pressure from a number
of conflicting interests NMAs had to take
up the role as the conscience of the medical
profession. It was also important to maintain
the unity of medical professionals at both
national and international levels. Keeping
a united front was absolutely necessary as
it was the only way NMAs could have the
necessary positive impact to bring about the
changes needed to make the world a better
place. NMAs were particularly important as
vital components of national health systems.
The current Ebola crisis had demonstrated
again what they had known in advance that
badly managed and poorly supported health
systems lead inevitably to disaster. If they
compared the current Ebola outbreak to the
SARS outbreak a few years ago it became
apparent how much of a difference adequate
health systems made.
Dr. Haikerwal then paid tribute to the
retiring WMA President, Dr. Margaret
Mungherera. He said she had been a very
powerful leader who led from the front and
had travelled widely during her Presidency.
Dr. Mungherera delivered her valedictory
speech and was given a standing ovation.
Dr.Xavier Deau,a general practitioner from
France and President of the European and
International Delegation of the French
Medical Council speech, was then installed
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WMA News
as the 65th
President of the WMA to serve
in 2014/15.
He took the oath of office as President
and delivered his inaugural speech, speak-
ing partly in French, partly in Spanish and
partly in English.
The ceremonial session ended with a presen-
tation from Bruce Eshaya-Chauvin, Medical
Advisor with the International Committee of
the Red Cross, and head of the Health Care
in Danger Project ICRC, who spoke about
plans to launch an e learning module on the
project. This would be a simple tool explain-
ing physicians’rights and responsibilities.
Saturday October 11
Plenary Assembly Session
President 2015/16
Professor Sir Michael Marmot, Research
Professor of Epidemiology and Public
Health at University College London, was
elected unopposed as President for 2015/16
after the only other candidate, Dr. Osahon
Enabulele (Nigerian Medical Association)
withdrew his nomination.
Thanking the Assembly Sir Michael said he
was on a mission to promote health equity
in the world through action on the social
determinants of health.
‘I chaired the WHO Commission on Social
Determinants of Health. When we pub-
lished, one government as a form of criti-
cism said our report was ideology with evi-
dence. That was meant as a criticism I took
it as praise. I do have an ideology. Health
inequalities that are avoidable are wrong,
unjust, unfair.That is an ideology.’
He said what he brought to the debate was
a deep respect for the evidence. Good in-
tentions were not enough.Since that WHO
report he had been talking to governments
making the case that there needed to be ac-
tion right across government on social de-
terminants of health. He said he would like
to represent the voice of the world’s doctors
in those discussions.
‘Who cares more about health than we do.
We should be the voice for health. We want
action from the whole of government. The
doctors are absolutely key. Of course, the
WMA represents the interests of doctors and
that’s absolutely right.But we have a key eth-
ical role to play in representing the interests
of our patients and indeed of populations.’
He said he had been asked what advice he
would give to young doctors considering
working the field of social determinants of
health. ‘What I would say to young doctors
is what a privilege it is every day to know
that your work is trying to improve the
health of the most disadvantaged.’
Committee Reports
The Assembly adopted the following policy
documents:
• Declaration on the Protection of Health-
care Workers in Situations of Violence
• Statement on Aesthetic Treatment
• Statement on the Ethical Guidelines for
the International Migration of Health
Workers (Revised)
• Statement on the Prevention of Air Pol-
lution and Vehicle Emissions
• Statement on Solitary Confinement
• Statement on Water and Health (Revised)
• Resolution on Ebola Viral Disease
• Resolution on Unproven Therapy and the
Ebola Virus
• Resolution on the Non-Commercializa-
tion of Human Reproductive Material
(Revised)
• Resolution on Migrant Workers› Health
and Safety in Qatar
Financial Report
The Treasurer, Prof. Dr. Frank Ulrich Mont-
gomery, gave an oral report on the past two
years,thanking NMAs for their prompt pay-
ment of their dues. He also spoke about the
budget for 2015 and said the positive finan-
cial development he could report on was due
to the frugal use of budgetary means,efficient
cost control and a risk free investment poli-
cy. The Assembly approved the Financial
Statement for 2013 and the 2015 Budget.
Meetings
The Assembly agreed that the 2017 General
Assembly be held in Chicago, USA (Oct
11–14) and that the 2018 Assembly be held
in Reykjavic, Iceland.
New Members
The Assembly approved an application for
constituent membership from the Ordre
National des Medicins de Guinée and ap-
proved four new members from the nation-
al medical associations of Kenya, Lesotho,
Zambia and Rwanda.
Ebola
Dr.Haikerwal reported that the Council had
approved an emergency Resolution on Ebola
on Wednesday and he asked the Assembly
to adopt this. Dr. Mark Sonderup (South
Africa) suggested amending the Resolution
to give more emphasis to honouring those
working in dealing with the Ebola crisis. He
also wanted to see a paragraph inserted on
the use of untested therapies. The WMA
was the author of the Declaration of Hel-
sinki and given the debate around the use of
therapies and untested therapies which was
referred to in the Declaration he believed the
WMA should re-emphasise this.
The Assembly voted in favour of amending
the Council Resolution by re-ordering the
recommendations to give more priority to
honouring those fighting the Ebola crisis.
But Prof. Nathanson opposed putting the
issue of untested therapies into the Council
Resolution. The use of unproven therapies
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WMA News
was extraordinarily complicated. She said
the WHO had got this issue right and had
referred to Declaration of Helsinki. To in-
sert something on untested therapies in the
Council Resolution would require a great
deal of information and it would distort
the Resolution which was about supporting
people in West Africa with the resources
they needed to safely care for patients with
Ebola.She suggested the issue should be in-
cluded in a separate statement.
Prof. Montgomery (Germany) also argued
against changing the Council Resolution,as
this had already been publicised and would
cause confusion. He agreed that a second
statement could be issued.
Dr. Grootboom (South Africa) said all that
was being proposed was an addition to the
Resolution. But Dr. Deardon (British Medi-
cal Association) believed changing the Res-
olution would dilute its effectiveness. Dr.
Mungherera supported leaving the Resolu-
tion unamended and said the most important
thing was to try to engage with the commu-
nities affected by Ebola. She said the differ-
ence between the Nigerian response and that
of others was community engagement.
Dr. Sonderup said he had heard the objec-
tions to his proposal and still wanted to add
to the Resolution. He proposed inserting
the words ‘The WMA draws attention to
the ethical principle that given that proven
interventions currently do not exist and that
the case fatality rate for EVD is high, the
WMA supports the use of unproven inter-
ventions if in the physician’s judgment it
offers reasonable hope of saving life as ex-
pressed in the Declaration of Helsinki’.
Dr. Kayode Obembe (Nigeria) said the
experience of Nigeria was very important
because they had controlled and contained
Ebola completely. Other countries had a lot
to learn from Nigeria in terms of mobili-
zation, quick response, community epide-
miologists and all other aspects. This was
a disease that was global and must be con-
tained. He said if they prevented other in-
terventions which had not been proven they
would open their practice to the possibility
that may occur in the future. He said the
Resolution should be left as it was but they
should emphasise that physicians’judgment
should be taken into consideration.
Dr. Joyce Banda (Zambia) urged caution.
What they had been standing for all along
was the Declaration of Helsinki where they
said they should not use unproven interven-
tions. Now what were they saying? Were
they going back on that?
Prof. Montgomery suggested that the
Council Resolution should not be amended
but that a second emergency Resolution
should be considered.He proposed that this
would read: ‘In the case of Ebola the WMA
strongly supports the intentions of Article
37 of the newly revised Declaration of Hel-
sinki which reads “Unproven interventions
in clinical practice: In the treatment of an
individual patient, where proven interven-
tions do not exist or other known interven-
tions have been ineffective, the physician,
after seeking expert advice, with informed
consent from the patient or a legally autho-
rized representative, may use an unproven
intervention if in the physician’s judgment
it offers hope of saving life, re-establishing
health or alleviating suffering. This inter-
vention should subsequently be made the
object of research, designed to evaluate its
safety and efficacy. In all cases, new infor-
mation must be recorded and, where appro-
priate, made publicly available”.
Dr. Sonderup said the suggested Resolution
would be acceptable.
Prof. Montgomery’s proposed emergency
Resolution, slightly amended, was adopted
by the Assembly .
Associate Members
Dr. Joseph Heyman, newly elected Chair of
the Associate Members, reported on their
meeting and brought two recommendations
for consideration by the Assembly, one on
nuclear weapons and the other on smallpox.
Nuclear Weapons
The first,the proposed Revision of the WMA
Statement on Nuclear Weapons, was intro-
duced by Dr. Xaviour Walker. He explained
that the Junior Doctors Network wanted to
update the statement to highlight the effect
that even a limited nuclear war would have on
the world’s food supply. He also wanted the
Statement amended to focus on how NMAs
could educate their physicians and the gen-
eral public about this threat and he wanted
the WMA to join a coalition urging govern-
ments to advocate a ban on nuclear weapons.
Prof. Montgomery said this was a paper of
high importance and he suggested that it
should be circulated to NMAs for further
consideration.
Dr. Walker said he wanted to see the pro-
posed revision adopted by the meeting. But
the Assembly decided that the proposal be
sent to Council for further consideration.
Smallpox
Dr. Walker also proposed a Statement on
the destruction of smallpox virus stockpiles.
He said smallpox was eradicated in 1980
but live samples were still retained in the
United States and in the Russian Federa-
tion. He said he would like a proposal for
the destruction of the remaining stockpile
to be sent to the Council for further consid-
eration.This was agreed.
Bioethics
Dr. Yoram Blachar (Israel) delivered a pre-
sentation on the new curriculum for medi-
cal ethics to be taught at medical schools
and the annual conference to be held by the
UNESCO Chair in Bioethics in Jerusalem
in January 6–8 2015, sponsored jointly by
WMA and others.
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WMA News
Ebola
The Assembly then heard an address from
Dr. Andrew Medina-Marino, an epidemi-
ologist with Medecin sans Frontieres,on his
recent experiences dealing with the Ebola
outbreak in Liberia. Dr. Medina-Marino,
Head of the research unit of the disease
surveillance and laboratory systems, Foun-
dation for Professional Development, said
that the virus was first identified in Zaire
in 1976 and until recently all previous out-
breaks had occurred in east and central Af-
rica.
The current outbreak was unprecedented
and was already 20 times greater than any
previous outbreak. Ebola was a zoonotic
disease and one of its reservoirs was bats.
He spoke about how the infection spread.
Currently in West Africa many individuals
had been exposed due to certain types of
burial traditions. This was not specific to
one religion. But unfortunately, at least in
Liberia, there were particular communities
that had found it difficult to break with
certain burial traditions. The current out-
break in West Africa was first identified in
the south east region of Guinea in March
this year. It was inevitable that this disease
would be transmitted across borders and
by late March cases had been reported in
Liberia. The first wave started in March
and ended around mid-April, or so people
thought. Local and national governments
took their foot off the pedal and did not
continue to provide the extensive contact
tracing and isolation of individuals. So a
second wave flared up, starting at the be-
ginning of May, and this was the current
outbreak. He explained how MSF had re-
sponded by sending additional support to
the affected countries. But their resources
had become very strained and in mid-June
MSF urged the international community
to mobilise resources. Unfortunately this
did not materialise and certain interna-
tional organisations were well behind the
curve in identifying this as an international
emergency.
He then spoke about his own personal
experiences in Liberia. When he arrived
there were 231 cases against a background
of a recent conflict and hostilities. It was a
degrading situation, with significant resis-
tance to the government entering commu-
nities because of the recent civil war. As a
result MSF personnel were often attacked
either because of fear and ignorance. The
government was overwhelmed during
this period. Civil war had decimated the
leadership and the health structure in the
country. The Ministry of Health was un-
able to cope with the situation which was
not surprising and this was coupled with
a lack of international response. This re-
sponse was still lagging.The World Health
Organisation had a mandate to co-ordi-
nate activities but unfortunately at this
stage it had not stepped up to the plate.
There was an extreme impact on healthcare
workers and to date there had been more
than 200 healthcare workers in Liberia
alone who had become infected, of whom
more than 94 had died. This included
11–12 doctors who had died, 10 per cent
of the country’s total number of medical
doctors. By the time he left Liberia in Au-
gust there were 768 cases, a tripling over a
period of a month. And between the time
he left the country and that moment there
were nearly 4,000 cases alone in Liberia.
The situation was still quite dire.
He said the international community’s slow
response had been quite deadly. Support
had often not materialised and donations
without proper co-ordination had gone un-
utilised. He challenged the WMA to ask
their members to urge their national gov-
ernments to provide an organised response
to the West Africa crisis.
Moscow General Assembly
The Russian Ambassador to South Africa,
His Excellency Mikhail Petrakov, then for-
mally invited delegates to the next WMA
General Assembly in Moscow in October
2015.
Nuclear War
Dr. Ira Helfand, Co-President of the In-
ternational Physicians for the Prevention
of Nuclear War, spoke about the threat of
nuclear war. Such a possibility was loom-
ing so large that it should demand people’s
attention as much as Ebola as the medical
consequences would be catastrophic. There
were more than 16,000 nuclear warheads
held by nine countries, the vast major-
ity by the United States and the Russian
Federation. The use of even only a small
percentage of these warheads would be a
global catastrophe. He described the hor-
rific consequences of nuclear warfare, even
limited nuclear warfare, and set out what
he thought the medical profession could do
to prevent this eventuality. Physicians were
not speaking out at the moment, but he said
they should speak out to terminate these
weapons. He asked Assembly delegates to
engage with their national medical associa-
tion to take action.
Polio
Dr. Kenneth Collins AM, former Director
of Rotary International from Western Aus-
tralia, talked about Rotary’s involvement in
the global partnership to eradicate polio.
He charted the start of the project in the
Philippines and its spread to other parts of
the world. The eventual worldwide cam-
paign led Rotary to raise sufficient funding
for 606 million children to be vaccinated.
A total of $1.3billion had been raised dur-
ing this period. National governments and
the Gates Foundation joined the campaign
and in 1991 national immunization days
were started. He spoke about the campaign
in India and said there were now just three
endemic countries, Pakistan, Afghanistan
and Nigeria. Pakistan was the only country
where the number of cases was escalating.
As a result of the global polio eradication
initiative 10 million polio cases and 1.5 mil-
lion deaths had been averted. He urged the
WMA and its members to do what they
could to help the campaign.
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WMA News
Open Session
During this session NMAs had the op-
portunity to present any profession-specific
problem they believed the WMA should
know about. Several delegates took the op-
portunity to address the Assembly.
Costa Rica
Dr. Alexis Castillo Guttierez (Union Med-
ica Nacional Costa Rica) spoke about what
he called ‘the dearth of medical services in
Latin America’.He spoke particularly about
the importation of Cuban medical man-
power which was affecting Brazil, Venezu-
ela and other countries and was leading to
a health crisis. He said he was speaking on
behalf not only of Costa Rica but also of the
Latin American Confederation of medical
colleges, of Uruguay, Argentina and Brazil
and supported by Spain and Portugal who
were partly responsible for the training of
millions of their colleagues.
He said his Peruvian colleagues could not
attend because of their very fragile situa-
tion. He appealed to the WMA on behalf
of Peruvian physicians in their conflict with
their Government. They had been taking
strike action since May 2014. The Peruvian
Medical Association had not found a way
out of the difficulties despite a great num-
ber of consultations with the Government.
In May the Latin American Forum issued a
statement supporting the Peruvian Medical
Association. Several appeals had been made
to the Government and to the President
of Peru, but with no positive outcome. In
September a new statement was made re-
garding the right to strike and non-violence
due to acts of violence perpetrated by the
Peruvian police against doctors. Dr. Gut-
tierez said they had brought evidence of
this violence to the WMA Assembly and
he urged the WMA to get involved in this
conflict, by denouncing the violent treat-
ment against physicians and requesting the
Peruvian Government to find a solution to
the conflict.
Dr. Kloiber responded by saying that the
WMA would certainly support the Peru-
vian physicians.
India
Dr. Narendra Kumar Saini (Indian Medi-
cal Association) talked about the emergency
declared by WHO on MDR tuberculosis.
There were 9.3 million cases every year
and 1.8 million deaths. Of the nine million
cases, one million were multi drug resistant
tuberculosis. He said that according to the
WHO there were three million missing
cases. One undetected case gave rise to be-
tween ten and 15 more cases. So this was a
very grave statistic. He said 70 per cent of
affected patients went to the private sector
for treatment. Unfortunately many coun-
tries did not have the capacity to diagnose
cases. Airborne transmission was very high
and people often did not complete their
course of treatment. He said this was a very
grave situation and as grave as Ebola and
he urged NMAs to help detect these three
million cases.
Turkey
Dr. Bayazit Ilhan (Turkish Medical Asso-
ciation) raised the issue of problems follow-
ing the Gezi Park Demonstrations. Thou-
sands of people had been injured as a result
of police force and tear gas. There were dif-
ficulties in accessing health care services.
The Turkish Ministry of Health had failed
to organize health services and did nothing
to stop the violence. Injured people being
treated were asked to give their personal
details. As a result many people were afraid
to go to hospital. Physicians ran to help the
injured. But the Ministry of Health then
began inquiring about those healthcare
workers who were involved.
He said the Turkish Medical Association
reconfirmed its commitment to give first aid
care to all without any distinction. It gath-
ered information about the health status of
demonstrators and it had conducted a web
based scientific study of health problems
experienced by people exposed to tear gas.
It had also issued a statement on the use of
riot control agents.
The Ministry of Health had since appealed
to the court for the dismissal of members
of the Ankara Chamber of Medicine saying
they gave unauthorized and unsupervised
medical care. There was a pre-trial hearing
in September, attended by the WMA Sec-
retary General, but the judge had refused
to dismiss the case, but postponed it until
December 23.
There had also been trials against individual
physicians. Now new legislation had been
introduced about delivering unauthorised
health services, a new type of offence with
sanctions of one to three year prison sen-
tences and fines of up to $900,000 dollars.
USA
Dr. Cecil Wilson, Past President of the
WMA, gave a report on a meeting he had
held with the US Defense Health Subcom-
mittee on the subject of “medical profes-
sional practice policies and guidelines”. The
purpose was to have the Defense Health
Board deal with the challenges faced by
military medical professions in their dual-
hatted positions as a military officer and a
medical provider.
Dr. Wilson said the Board had asked two
questions – how could military professionals
most appropriately balance their obligations
to their patients against their obligations as
military officers to help commanders main-
tain military readiness? And how much lati-
tude should military medical professionals
be given to refuse participation in medical
procedures or request excusal from military
operations with which they had ethical res-
ervations or disagreement?
He said the Defense Health Board was a
civilian-appointed body responsible for
providing guidance on ethics to the De-
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WMA News
partment of Defense under Secretary of
Defense Chuck Hagel and the current
president of the Board was Nancy Dickey,
Past President of the American Medical
Association.
Dr. Wilson said that to the question as to
whether the issues for the military related
to dual responsibility were increasing the
response was, perhaps. However in 98 to 99
per cent of cases the situations were worked
through without problem. However in the
cases that did involve a conflict meant that
for that one individual professional the
consequences for his or her life’s work were
catastrophic.
He gave two examples. One concerned a
young female primary care physician de-
ployed in Afghanistan who was directed to
perform physicals on male detainees prior
to their interrogations.
Female physical exams performed on male
Muslims were considered highly embarrass-
ing. She refused and was threatened with
a court martial. She subsequently did the
physicals, fearing the risk of a court martial
and serving a two-jail term.This doctor had
a young daughter and did not want to miss
time with her daughter.
The second example related to a team phy-
sician for critical care transport stationed
outside the US who was directed to trans-
port four critically ill civilians to another
hospital. The team physician on boarding
the plane determined that the facilities of
the newer hospital were not able to pro-
vide care and the civilians would die. He
directed the aircraft pilot to return the
plane. The pilot refused – he had differ-
ent orders. There was potentially a court
martial.
Dr. Wilson said he had also discussed the
WMA’s Tokyo Declaration and the issue of
forced feeding as there was interest in how
the WMA representing physicians saw the
problems with forced feeding worldwide.
He said the discussions for the day had
gone well and he was hopeful that problems
were being assessed.
Cote d’Ivoire
The meeting also heard an appeal from the
Ivory Coast medical profession for physi-
cians to do more to protect themselves from
Ebola. Some simple medical practices were
not being abided by and routine measures
were not being applied. Physicians were not
washing their hands regularly after attend-
ing patients. They were not wearing gowns
or gloves when examining patients. In the
case of confirmed cases the request was for
all physicians to incinerate all the materials
and equipment used.
Germany
Dr. Armin Ehl (Germany), Executive Di-
rector of Marburger Bund, the trade union
of employed doctors in Germany, invited
delegates to attend the first congress of
medical trade unions to be held in Berlin in
June 2016. The conference would deal with
physicians’working conditions and with the
migration of doctors.
Council
The WMA Council briefly reconvened to
consider the two motions sent to it by the
Assembly on nuclear war and smallpox.
It was agreed that both motions should be
sent to the Socio Medical Committee for
consideration.
Mr. Nigel Duncan,
Public Relations Consultant,
WMA
136
WMA News
The Guest of Honour, the Chair of the
World Medical Association Council,
Dr.  Mukesh Haikerwal. The Immediate
Past President, Dr. Cecil Wilson.The Presi-
dent Elect, Dr.  Xavier Deau. The Secre-
tary General, Dr. Otmar Kloiber. Council
Members, delegates, observers, ladies and
gentlemen,
I want to begin by again thanking our
hosts, the South African Medical Asso-
ciation for having accorded us such warm
hospitality.
Then I want to pay tribute to those physi-
cians and other health workers who are on
ground working very hard to overcome the
Ebola outbreaks in Sierra Leone, Guinea,
Liberia and until recently, Nigeria.
As is the African culture,I ask for a moment
of silence to remember all those physicians
who have succumbed to the Ebola haemor-
rhagic fever since the outbreaks started in
West Africa.
Over the last one year I have listened care-
fully to physicians, speak of their work
and the issues that confront them. What
strikes me is that the challenges of physi-
cians working in high income countries are
the same as those of physicians working in
poorer countries. The only difference is the
scale. Physicians everywhere are concerned
about the increasing burden of chronic
diseases and the need for something to be
done about the lifestyles of people. Physi-
cians everywhere are faced with an increas-
ing plethora of stakeholders inside and out-
side the health sector and the challenge of
finding ways of engaging more effectively
with them. Everywhere you go, physicians
are concerned about the increasing work
load, the wider scope of work, the bureau-
cracy and fears of litigation. Physicians all
over the world have recognized the need to
strengthen inter- professional collaboration
and team work.
And In Low and Middle Income countries
in Asia, South America and Africa, physi-
cians are particularly concerned about the
massive brain drain resulting in a human
resource for health crisis and unsatisfied
with the response of governments and the
lack of priority given to health especially
when allocating funding. In many areas of
the world, physicians are confronted with
harassment and their right to clinical in-
dependence is threatened by governments
which should be protecting them. Unfor-
tunately, in many places, these incidences
do not get reported because the physicians
themselves fear the repercussions of report-
ing or have nowhere to report.
What is encouraging however is the resolve,
the commitment and the passion with
which physicians all over the world regard-
less of the challenges they face, continue to
do their work. It is for instance inspiring
when you hear of the courage shown by the
Turkish Medical Society in protecting their
physicians.
One important challenge facing physicians
is the Information Age. Physicians indeed
need to play their part in contributing to
the global movement to build what is re-
ferred to as the Information Society. WMA
should be at the forefront of advocacy for
instance in Africa against the negative
perceptions policy makers have towards
ICT and especially social media and lobby
strongly for the cost of ICT infrastructure
to come down. These are among the major
causes of the lack of or underdevelopment
of e-health approaches that you find in Low
and Middle Income countries.
The Information Age, global security and
the global economy are among the key chal-
lenges for global health in the 21st
Century.
The physicians of the 21st
century therefore
are likely to face challenges that are very
different from those that were faced by the
physicians of the 20th
Century. Physicians
of the 21st
Century will be required to be
more effective change agents, stronger hu-
man rights advocates, patients’ advocates,
more effective communicators with patients
and communities they serve. They will also
increasingly be expected to play a larger role
in convincing governments and other stake-
holders, as to why it makes economic and
development sense to invest more in health.
NMAs of the 21st
Century therefore must
play different roles from the NMAs of the
20th
Century.NMAs must speak out against
violence and other injustices their physi-
cians face. They must be at the forefront of
civil society advocacy campaigns. And they
must advocate more strongly for the right to
health of the communities they serve.
The WMA will continue to provide oppor-
tunities for NMAs to develop their leader-
ship capacity by providing guidelines, train-
ing modules, networking opportunities and
the leadership development course at the
INSEAD in Singapore. NMAs must make
an effort to access these resources and use
them to build the capacity of their physi-
cians so they are able to do the action and
advocacy required
The WMA must be more proactive in
reaching out especially to those NMAs in
poor countries. In response to requests by
the membership, WMA has embarked on a
process to strengthen the advocacy capacity
of NMAs.
Over the last one year, I  have played my
role and represented WMA at a total of 15
global meetings, speaking about the role of
WMA and the potential roles for NMAs in
addressing issues of brain drain, regulation,
medical education, access to quality health
care for patients and protection of health
workers in armed conflict and other emer-
gencies, the Social Determinants of Health,
Mental Health, Violence against Women,
Violence in the Health care setting, Pa-
Valedictory address
Dr. Margaret Mungherera,
President of the World Medical Association 2013-2014
137
WMA News
tient Safety, ethical issues around health
care, post 2015 priorities and health sys-
tem challenges in Low and Middle Income
countries. And as a Rotarian, I am eager to
see that WMA works closely with Rotary
International and that NMAs participate
actively in the campaign to eradicate polio
from this planet.
What has made a big impression on me
however, are the discussions we have had
during my interaction with many of you.
Many NMAs have extended to me an in-
vitation to visit them and as a result, I have
spoken at a total of 10 annual general
meetings in a period of only 12 months
and have visited a total of 20 countries
in 6 continents, some of them more than
once. I  have also had the pleasure to be
invited by several of you to participate in
your NMA activities – like the Medical
Mission in Benin City in Nigeria, where
I looked at the expressions of relief on the
faces of mothers of ill children which made
me even more convinced that this is what
NMAs are supposed to do. The reception I
received at the studios of Radio New Zea-
land further convinced me that the media
can be an effective partner for NMAs in
promoting health.
The WMA is making an effort to address
many of these issues in the working groups
and through collaboration with other orga-
nizations. The WMA of the 21st
Century
however cannot be the same as the WMA of
the 20th
Century. The roles are different and
so are the expectations of the NMAs, physi-
cians and other stakeholders.This requires the
WMA to review its institutions with a view
to strengthen them based on the needs. The
Council has introduced the idea of Round
Table conferences as a means of fundraising.
However,these efforts must be improved.
Two groups of people will be useful in pro-
pelling NMAs to cope with the new chal-
lenges of the 21st
Century. These are junior
doctors and medical students.They are truly
the future of the profession, the NMAs and
the WMA. And through my own interac-
tion this year with the Junior Doctors Net-
work and the International Federation of
Medical Students Associations, I have be-
come more and more convinced that these
2 groups are ready to take on the mantle of
leadership. As NMAs therefore, let us open
our doors, provide them space to participate
effectively in the NMAs and invite them to
get involved in the leadership.
As far as Leadership is concerned, in 2015
the world celebrates 20 years since the Bei-
jing Conference on Women. We shall be
celebrating the achievements of the world
in terms of empowerment of women in
many areas including leadership. The very
first speech I made after my election as
WMA President was the keynote speech at
the Congress of the Medical Women Inter-
national Association last year in Seoul, Ko-
rea. I spoke at great length about the roles
that women physicians can and should play
in influencing the health agendas in their
countries and in strengthening the roles
of their national medical associations. As
I move around the world, I have been im-
pressed by the work women physicians do
in their national medical associations.
There are several NMAs that do not have
or have very few women in their leadership.
Yet there are benefits of allowing women to
participate in the NMA leadership. I have
met and interacted with vibrant and com-
mitted women NMA Presidents in the
US, in UK, in Ethiopia, in Sweden and in
Rwanda and in South Africa. Having a
woman as the NMA President is a good
thing but what is even better is to have
more women and achieve a gender balance
within the leadership of the NMA. We are
encouraging NMAs to involve themselves
more in issues around women’s health and
Violence against Women. Women leaders
can more easily become actively involved in
such programs because they are more likely
to appreciate the related socio-cultural is-
sues. It also encourages more women to join
the profession and more importantly more
women will be encouraged to take up po-
sitions of leadership within the profession.
Our NMAs must therefore reflect what we
would like to see in other public and private
institutions and in society as a whole. Good
examples of NMAs where I found gender
balance in the governance structure were
the Philippines Medical Association and
the Ethiopian Medical Association. Maybe
WMA should consider taking up the re-
sponsibility of leading the way and setting
an example for NMAs.
Every WMA President gets to choose a
theme around which he or she will do their
advocacy work. I chose Africa as my theme.
I set out to increase the focus of WMA on
the African continent and particularly on
the African NMAs. The reason contrary to
what some people may think is not because
I am an African. It is because Africa is part
of the world and in fact, 11% of the world’s
population lives on the African continent.
Africa’s health therefore impacts on global
health. And as has now finally been realized
with the Ebola outbreaks, the world’s sur-
vival depends on Africa’s survival.
The African continent is the continent with
the largest disease burden, one that is dis-
proportionate to its population. For instance,
with 11% of the world›s population, Africa
has 45% of the world›s women dying from
childbirth related complications and 62% of
the world›s HIV patients. This huge disease
burden can be attributed to natural disasters,
wars, political instabilities etc. But the most
significant causative factor is the weak health
systems that African countries have especial-
ly those that are in the Sub Saharan region.
It is however, unfortunate that it has taken
the recent Ebola outbreaks for the world to
realize that it is the weak health systems of
Africa that are the biggest threat to global
health. Millions have been dying from Ma-
laria and other diseases as a result of these
weak health systems. And yet there is little
done to strengthen these systems. In fact,
the main problems that are making over-
coming the Ebola outbreaks difficult is not
lack of hospital beds or health workers but
the lack of disease surveillance systems,
138
WMA News
epidemic preparedness and an effective epi-
demic response.
African Governments have responded to
the challenge of weak health systems by
ratifying several international and regional
declarations with several countries further
developing national policies and health sec-
tor strategic plans and incorporating them
into national development plans. Subse-
quently, massive amounts of funds from do-
nor and foreign sources have been pumped
into African health sectors for the purpose
of implementing these policies. It is how-
ever estimated that 20-40% of these funds
are wasted largely due to massive corruption
and due to implementation that is not in line
with the policies.The major cause of Africa›s
weak health systems therefore is not a short-
age of policies or road maps or funding. It is
effective leadership to implement the policies
and road maps. Let us hope however that it
will not need many more Africans and oth-
ers to die before the world realizes that the
key solution to strengthening these systems
lies in effective leadership from within Africa
rather than from outside the continent.
A good leader has followers. A Malawian
proverb says “A leader without followers is
simply taking a walk”. Africa has too many
leaders without followers, leaders simply
taking a walk. A common example is the
delay in the local response to the Ebola
outbreaks by the governments affected, the
African Union and others on the continent,
clearly showing a lack of effective leader-
ship. Developing leadership capacity should
therefore be the main emphasis of any effort
aimed at to strengthening health systems
and reducing Africa’s disease burden.
The solutions for Africa’s health problems
lie within the African continent. The inter-
national community must allow Africa to
take charge of their health sector by helping
Africa to develop its professional leadership.
So during my term as WMA President,
I have spearheaded the WMA Africa Medi-
cal Initiative. The Initiative set out to assess
the strength of African NMAs. A capacity
needs assessment has been carried out this
year consisting of 4 regional consultative
meetings held in Kenya, Nigeria, Tunisia
and South Africa and as a result 8 key the-
matic areas have been identified. These are
Organizational Strengthening, Migration
and Retention, promoting quality Medi-
cal Education, improving physicians’ access
to Continuing Professional Development,
Social Determinants of Health, Universal
Health Coverage, Research and Publication.
Over a period of 5 years, African NMAs ir-
respective of whether they are members or
not) will be offered capacity building op-
portunities to enable them more effectively
influence their health systems. We have in-
troduced the WMA Initiative to the Afri-
can Union, the African Development Bank
and to 44 African Ministers of Health who
I spoke to explaining the potential role of
their NMAs in strengthening their health
systems in their countries.
The next stage is for the identified Lead Fa-
cilitators to design the Program basing on
the findings and then work with resource
persons who have been identified from
among NMAs outside Africa and from
among African physicians in the diaspora
in the UK. And anyone or NMA interested
is welcome to participate.
The Program will involve online discussions,
skills training workshops and conferences.
Twinning is also being encouraged between
strong NMAs outside the African conti-
nent and African NMAs. I want to there-
fore appreciate those NMAs outside the
Africa region who have offered to twin with
African NMAs- the New Zealand Medical
Association, h will twin with Medical As-
sociation of Tanzania, the Japan Medical
Association with the Malawi Medical As-
sociation and the Danish Medical Associa-
tion with the Rwanda Medical Association.
African NMAs that have not yet joined the
WMA have been invited to join. Our target
is to see that at least 4 new African NMAs
join WMA every year. This target has been
met this year with NMAs of Kenya, Zam-
bia, Rwanda and Lesotho applying to join.
However, we still have 29 of the 54 coun-
tries in Africa which are not represented in
the WMA. This is half, so we have a long
way to go.
At this juncture I wish to thank the Dan-
ish Medical Association for offering to sup-
port the Chair of the Kenya Medical As-
sociation and the President of the Rwanda
Medical Association to attend this meeting
as observers. We shall need more of such
support from other NMAs.
We again look forward to many more of you
participating in this important initiative be-
cause again I say when the health of Africa
is threatened, global health and survival is
also threatened.
This flight of WMA 2014-15 took off on
the 19th
October 2013 in Fortaleza, Brazil.
Some of you looked uneasy seeing an Afri-
can woman from one of the poorest nations
in the world taking charge and yes,the flight
did experience some turbulence from time
to time. Generally, it was a smooth flight.
And as I was assured from the beginning
by my good friends Vivienne and Ardis and
Mzukisi, I  have had tremendous support.
I have had an excellent co-pilot,Mukesh you
have taught me a lot, and Otmar, you have
been an excellent flight engineer, and the
crew, Julia, Clarisse, Sunny, Anna, Lamine,
Annabel and the volunteers, Salma and
Stintje have been very supportive, and more
importantly the passengers, that is you the
constituent members have been exceptional.
Well now, a new Captain takes over. Xavier
mon ami, I wish you all the best in this im-
portant and prestigious position. I pledge
my support to you. I am very confident that
with your commitment, and you being calm
and clear headed you will take the WMA to
greater heights.
I want to end by expressing sincere appre-
ciation to my husband Richard and the rest
of my family for their patience and unwav-
ering support.
To all of you again, I say, thank you for this
wonderful opportunity to serve. It has in-
deed been a wonderful year and thank you
all for listening to me.
139
WMA News
It is a great honour and pleasure for me to
be here in Durban to take on the Presidency
of the World Medical Association in front
of all of you and to represent the 106 Medi-
cal Associations of our Association.I’m sure
you will understand that it is with some
emotion that I address you today.
Allow me first to pay tribute to our Past
President,Dr Margaret Mungherera,whose
great amount of work over the past year
has contributed to promoting the ethical
standards of our Association at the highest
level, particularly on the African continent
through the African Forum project.
Let me introduce myself:
I am a medical specialist in general medi-
cine, and since 1976 I have been working
in Epinal (in the Eastern part of France) in
a multi-professional medical practice locat-
ed in a socially disadvantaged area (which
includes a re-housing centre, a children’s
home and social housing…). I founded this
multi-professional and multidisciplinary
medical practice in order to optimize the
quality of healthcare and answer the spe-
cific needs of a precarious population in a
coordinated manner.
Having lived in Lorraine, 20 meters from
the German border, for the first 25 years
of my life, I have always been sensitive to
multiculturalism, to the importance of re-
specting difference, and to the construction
of a Europe in the spirit of peace and un-
derstanding so dear to Robert Schuman,the
founder of the European Union who was
born in the same region. Therefore, I have
always held within me great faith in a world
of peace, fraternity and joy.
This spirit of peace,respect and understand-
ing has led me to take on professional re-
sponsibilities within the French Medical
Council as an Elected Representative, first
at Departmental level, then at National
level as Vice-President, then as President of
the European and International Relations
Delegation, and lastly as Secretary General
of the European Council of Medical Or-
ders and of the Francophone Conference of
Medical Orders gathering of 22 countries,
including 15 from the African continent.
I would like to express my gratitude to the
French Medical Council for making all
these commitments possible.
During my studies, I was fortunate enough
to get to know Doctor Bernard Kouchner
and Doctor Xavier Emmanuelli, found-
ers of Doctors without Borders and of the
SAMU Social International, who have been
outstanding examples of the universality of
medical ethics for me.
Lastly, I could never forget my daily source
of energy: the affection of my wife who is
here with us today, as well as my 5 children
and 12 grandchildren, who are not physi-
cally present, but who are in my heart and
soul.
Therefore, you will understand that, as
is true for each of us, my path has been
marked by my own family and my own cul-
tural determinants. I would like to thank
all of those who have helped me to be here
with you today.
All your actions within the World Medical
Association have allowed me to continue
along this path.
The question I am now asking myself is
probably the same one that you have in
mind:
Why did I accept the role of the Presidency
of the WMA?
I would first like to call to mind one of the
fathers of the WMA, the French doctor
Eugène Marquis, who, following the atroci-
ties of the last World War, showed along
with many of his colleagues a very strong
willingness to work for peace by raising the
ethical standards of medical practice to the
highest level through the foundation of the
WMA.
Since its creation in 1947, the WMA has
been constantly affirming loud and clear
through its declarations and statements the
universality of essential ethical values for
practicing our profession.
I want to maintain continuity with my pre-
decessors; it is with humility that I will head
our Association.
Therefore, throughout the coming year
I will endeavour to enhance our ethical val-
ues even further because, beyond the deon-
tology proper to the legislation in each of
our countries, these ethical values should
sway the mind of each and every doctor,
regardless of his or her culture, religion or
skin colour.
Along with you, I will seek to protect and
further develop:
The independence of the medical profes-
sion, which should be duly respected by
political, administrative, military as well as
religious authorities. The independence of
doctors’ decision-making forms the basis
of the trust indispensable to the doctor–pa-
tient relationship.
Professional secrecy: in all circumstances,
including during armed conflicts, profes-
sional secrecy must be respected along
with all information on patients and their
consent to the health care proposed to
them.
A high-level, good quality education is the
cornerstone of the competence of doctors,
and it is essential that the WMA be one of
the effective players in this field, especially
through the development of the worldwide
junior doctors network. The JDN has dem-
onstrated its role within the WMA. The
WMA should remain at the service of the
education of the doctors of tomorrow.
Let us not forget the protection of our
patients’ personal data at this time of new
technologies, e-health and m-health. The
protection of these sensitive data should be
enhanced as rigorously as possible without
Inaugural speech
Dr. Xavier Deau,
President of the World Medical Association 2014-2015
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WMA News
jeopardizing the evolution of our medical
science.
At the same time, in a world where every-
thing tends to have a monetary value, we
should remain very watchful of all poten-
tial conflicts of interest. Human values must
always prevail over financial considerations,
bearing in mind that the well-being of hu-
mans cannot be dissociated from financial
contingencies.The WMA has to participate
in finding a balance between the “primacy
of the individual” and “societal primacy”.
All of these ethical values have been under-
lined in the latest version of the Declaration
of Helsinki, which is a shining example of
the universality of medical ethics. Even if
its drafting seemed laborious at times, our
Declaration of Helsinki has the merit of
compiling the cultures of 106 medical as-
sociations, and thus is an authentic factor
in promoting peace and the union between
medical professions around the world in full
respect for patients and their care.
Nonetheless, these ethical values cannot ex-
ist without a structured and organized soci-
ety, taking into account the social determi-
nants of health in order to optimize health
equity.
This coordination should include all the dif-
ferent players around patients, both in care
and prevention, as well as in health educa-
tion, in one single, all-encompassing and
dynamic vision within a given territory.
The WMA should contribute to a genuine
revolution in primary care by promoting
holistic and personalized medicine, coordi-
nated between the different health profes-
sions.
In this respect, I would particularly like to
praise the work of Sir Michael Marmot for
his contribution towards this goal, both in
his own country and worldwide.
Taking account of our cultural differences
necessarily raises the level of care require-
ments, particularly at a time when viruses
like Ebola have no more borders and require
a maximum level of coordination from all
health care professionals and politicians. In
this regard, the role of the WMA becomes
indispensable. We must all mobilize our-
selves.
Working through their constant perspec-
tive of multiculturalism, I would like to pay
tribute to the efforts of our WMA lead-
ers: our Chairman of the Board, Mukesh
Haikerwal, our Secretary General, Otmar
Kloiber, as well as the rigorous and care-
ful vigilance of our Treasurer, Frank Ulrich
Montgomery, not forgetting our legal advi-
sor, Annabel Seebohm and ethical advisor
Jeff Blackmer. I would also like to thank
all the members of the WMA’s Executive
Committee, not forgetting the efficiency of
the entire Secretariat and those who sup-
port their work (Sunny,Clarisse,Anne-Ma-
rie, Roderic, Rosie, Julia and Lamine, and
of course…Nigel,always looking out for the
latest news).
I am French and my country, France, is not
only a country with a strong human rights
record, but also a republic which has been
based on the triptych: liberty, equality, fra-
ternity since 1789 (and the French Revolu-
tion).
I will therefore strive during this mandate
to promote healthcare equity for every hu-
man being regardless of his or her language,
culture or religion.
To conclude, I  have one final wish: our
world is currently going through a dramatic
increase in armed conflicts,which are seeing
the values of our Association permanently
violated. Impartiality remains an inescap-
able ethical value, as much in our schools
as in our administrations and our hospitals.
This impartiality guarantees a deep respect
for all cultural differences and the rejection
of all forms of fundamentalism.
That is why I am asking everyone to act as
peacemakers by strictly observing these val-
ues within your Associations, towards your
governments and also with respect to each
of your patients.
Today marks the 12th
World Day Against
the Death Penalty, and I would like to
stress the importance of this issue for the
WMA. This gives me an opportunity to
pay tribute to the work of our association
in this field through its policies aimed at
supporting doctors working in prisons to
promote human rights and ethics. I refer
in this regard to the Declaration of Tokyo,
which provides Guidelines for Physicians
Concerning Torture and Other Cruel, In-
human or Degrading Treatment or Pun-
ishment in Relation to Detention and
Imprisonment, the Declaration of Malta
on Hunger Strikers and the Declaration of
Edinburgh on Prison Conditions and the
Spread of Tuberculosis and Other Com-
municable Diseases.
On this special day of my election, I would
also like to underline the crucial action of
two South African Nobel Peace Prize Lau-
reates, Nelson Mandela and Archbishop
Desmond Tutu. These two men have man-
aged to be drivers for peace and impartiality
beyond the borders of South Africa.
Let us be the actors and also the builders of
a healthier, fairer and more equitable soci-
ety, in which human rights, but also liberty,
equality and fraternity, as well as high qual-
ity health care, enable each person to grow
and live in peace.
Let us be doctors acting towards peace in
the name of the universality of the ethics of
our Medical Association…!
Seamos médicos actores de paz en nombre de
la universalidad de la ética de nuestra aso-
ciación… !
I thank you all.
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WMA News
WMA Declaration on the
Protection of Health Care
Workers in situation of Violence
Adopted by the 65th
WMA General Assembly, Durban, South Africa,
October 2014
Preamble
The right to health is a fundamental element of human rights which
does not change in situations of conflict and violence. Access to
medical assistance for the sick and wounded, whether they have
been engaged in active combat or not,is guaranteed through various
international agreements, including the Geneva Convention and
the Basic Principles on the Use of Force and Firearms by Law En-
forcement Officials of the United Nations.
The primary obligation of physicians is always to their patients, and
physicians have the same ethical responsibilities to preserve health
and save life in situations of violence or armed conflicts as in peace-
time. These are as set out in the WMA Regulations in Times of
Armed Conflict and Other Situations of Violence.
It is essential to ensure the safety and personal security of healthcare
workers in order to enable the provision of the highest standard of
care to patients. If healthcare workers are not safe, they might not
be able to provide care, and patients will suffer.
In situations of violence,the delivery of healthcare is frequently obstruct-
ed and the sick and wounded deprived of essential treatment through:
1. Medical workers being prevented from attending to the injured;
2. Interference by the state or others in positions of power through
intimidation, detention or other legal measures;
3. Patients being denied access to medical facilities;
4. Targeted attacks upon medical facilities and medical transport;
5. Targeted attacks upon medical personnel,including kidnapping;
6. Non-targeted violent acts which result in the damage to or
destruction of facilities or vehicles, or cause injury or death to
medical personnel.
Such actions have serious humanitarian implications and violate interna-
tional standards of medical neutrality as set out in the provisions of inter-
national human rights and humanitarian law and codes of medical ethics.
Attacks on the fundamental ethical principles of the medical pro-
fession, such as attempts to coerce medical professionals into pro-
viding details regarding those under their care, can undermine the
confidence of patients and discourage injured people from seeking
necessary treatment.
Recommendations
The WMA calls upon governments and all parties involved in situ-
ations of violence to:
1. Ensure the safety,independence and personal security of health-
care personnel at all times, including during armed conflicts and
other situations of violence, in accordance with the Geneva
Conventions and their additional protocols;
2. Enable healthcare personnel to attend to injured and sick patients,
regardless of their role in a conflict,and to carry out their medical
duties freely, independently and in accordance with the principles
of their profession without fear of punishment or intimidation;
3. Safe access to adequate medical facilities for the injured and
others in need of medical aid should not be unduly impeded;
4. Protect medical facilities, medical transport and the people
being treated in them and provide the safest possible working
environment for healthcare workers and protect them from in-
terference and attack;
5. Respect and promote the principles of international humanitar-
ian and human rights law which safeguard medical neutrality in
situations of conflict;
6. Establish reporting mechanisms to document violence against
medical personnel and facilities as set out in the WMA State-
ment on the Protection and Integrity of Medical Personnel in
Armed Conflicts and Other Situations of Violence.
7. Raise awareness of international norms on the protection of
healthcare workers and cooperate with different actors to identify
strategies to tackle threats to healthcare.The collaboration between
the WMA and the International Committee of the Red Cross on
the Health Care in Danger project provides one example of this.
WMA Resolution on Ebola Viral
Disease
Adopted by the 65th
WMA General Assembly, Durban, South Africa,
October 2014
Backgound
A number of viral diseases have caused occasional health emergen-
cies in parts of Africa, with local or wider spread epidemics. These
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WMA News
include Lassa, Marburg and Ebola Viral Diseases (EVD). The
2013–14 outbreak of EVD in West Africa has proven far more dif-
ficult to control than previous epidemics and is now present in Si-
erra Leone, Liberia and Guinea with more than 2000 deaths. This
epidemic appears to have a case related mortality of approximately
55% against a range for EVD of 50–95%.
Following infection, patients remain asymptomatic for a period of
2–21 days, and during this time tests for the virus will be nega-
tive, and patients are not infectious, posing no public health risk.
Once the patient becomes symptomatic, EVD is spread through
contact with body fluids including blood. Symptoms include diar-
rhoea, vomiting and bleeding, and all these body fluids are poten-
tially sources of infection.
Management is primarily through infection control, the use of per-
sonal protective equipment (PPE) by health care workers and those
disposing of body fluids and of bodies, and supportive care for sick
patients including using IV fluids and inotropes. Contact tracing is
also important but may be difficult in many of the communities cur-
rently affected. Vaccines are in development as are some antivirals,
but they will arrive late in this epidemic if they are proven successful.
Evidence from those treating patients in affected communities is
that a shortage of resources,including health care workers and PPE,
as well as poor infection control training of health care workers,
caregivers and others at risk are making epidemic control difficult.
Some governments have indicated that they will build new treat-
ment centres in affected areas as a matter of urgency, while others
are directly providing personal protective equipment and other sup-
plies.
Recommendations
The WMA honours those working in these exceptional circumstanc-
es, and strongly recommends that national governments and inter-
national agencies work with health care providers on the ground and
offer stakeholders training and support to reduce the risks that they
face in treating patients and in seeking to control the epidemic.
The WMA commends those countries that have committed re-
sources for the urgent establishment of new treatment and isola-
tion centres in the most heavily burdened countries and regions.
The WMA calls upon all nations to commit enhanced support for
combatting the EVD epidemic.
The WMA calls on the international community, acting through
the United Nations and its agencies as well as aid agencies, to im-
mediately provide the necessary supplies of PPE to protect health
care workers and ancillary staff and reduce the risk of cross infec-
tion. This must include adequate supplies of gloves, masks and
gowns, and distribution must include treatment centres at all levels.
The WMA calls on all those managing the epidemic,including local
and national governments and agencies such as WHO, to commit
to adequate training in infection control measures, including PPE
for all staff and caregivers who might come into contact with infec-
tive materials.
The WMA calls on national and local governments to increase pub-
lic communication about basic infection control practices.
The WMA calls upon WHO to facilitate research into the timeli-
ness and effectiveness of international interventions, so that plan-
ning and interventions in future health emergencies can be better
informed.
The WMA strongly urges all countries, especially those not yet af-
fected, to educate health care providers about the current case defi-
nition in addition to strengthening infection control methodologies
and contact tracing in order to prevent transmission within their
countries.
The WMA calls for NMAs to contact their national governments
to act as described in this document.
WMA Resolution on Migrant
Workers’ Health and Safety in
Qatar
Adopted by the 65th
WMA General Assembly, Durban, South Africa,
October 2014
Preamble
Reliable reports indicate that migrant workers in Qatar suffer from
exploitation and violation of their rights. Workers basic needs, e.g.
access to sufficient water and food, are not met. Less than half of
the workers are entitled to health care. Hundreds of workers have
already died in the construction sites since 2010 as the country pre-
pares to host the 2022 FIFA [1] World Cup. Workers are not free
to leave when they see their situation hopeless or health endangered
since their passports are confiscated.
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WMA News
Despite the pleas of international labour and human rights organi-
zations, such as ITUC (International Trade Union Confederation)
and Amnesty International, the response of the Qatar government
to solve the situation has not been adequate. FIFA has been inef-
ficient and has not taken the full responsibility to facilitate the im-
provements to the worker´s living and working conditions.
The World Medical Association reminds that health is a human
right that should be safeguarded in all situations.
The World Medical Association is concerned that migrant workers
are continuously put at risk in construction sites in Qatar, and their
right to freedom of movement and right to health care and safe
working conditions are not respected.
Recommendations
The WMA calls upon the Qatar government and construction
companies to ensure the health and safety of migrant workers.
The WMA demands the FIFA as the responsible organization of
the World Cup to take immediate action by changing the venue as
soon as possible.
The WMA calls upon its members to approach local governments
in order to facilitate international cooperation with the aim of en-
suring the health and safety of migrant workers in Qatar.
[1] Fédération Internationale de Football Association
WMA Resolution on the Non-
Commercialisation of Human
Reproductive Material
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, Sep-
tember 2003 and revised by 65th
WMA General Assembly, Durban,
South Africa 2014
Preamble
The rapid advances in biomedical technologies have led to growth
of the reproductive assistance industry, which tends to be poorly
regulated. Despite the fact that many governments have laws pro-
hibiting commercial transactions of reproductive material, most
have not been successful in universally preventing the sale of human
ova, sperm and embryos on the internet and elsewhere. The market
value of human material, including cells, tissues, and cellular tissue
can be lucrative, creating a potential conflict for physicians and oth-
ers between economic interests and professional ethical obligations.
For the purposes of this resolution human reproductive material is
defined as human gametes and embryos.
According to the WHO, transplant commercialism “is a policy or
practice in which cells, tissues or organs are treated as a commodity,
including by being bought or sold or used for material gain.” [1]
The principle that the “human body and its parts shall not, as such,
give rise to financial gain”[2] is laid down in numerous international
declarations and recommendations.[3] The 2006 WMA Statement
on Human Organ Donation and Transplantation and the 2012
WMA Statement on Organ and Tissue Donation call for the pro-
hibition of the sale of organs and tissues for transplantation. The
WMA Statement on Assisted Reproductive Technologies (2006)
also states that it is inappropriate to offer financial benefits to en-
courage donation of human reproductive material.
The same principles should be in place for the use of human repro-
ductive material in the area of medical research. The International
Bioethics Committee of the United Nations Educational, Scientific
and Cultural Organization (UNESCO IBC) in its report on the
ethical aspects of human embryonic stem cell research states that
the transfer of human embryos must not be a commercial transac-
tion and that measures should be taken to discourage any financial
incentive.
It is important to distinguish between the sale of clinical assisted re-
productive services, which is legal, and the sale of the human repro-
ductive materials, which is usually illegal. Due to the special nature
of human embryos, the commercialization of gametes is unlike that
of other cells and tissues as sperm and eggs may develop into a child
if fertilization is successful.
Before human reproductive material is donated,the donor must give
informed consent that is free of duress. This requires that the indi-
vidual donor is deemed fully competent and has been given all the
available information regarding the procedure and its outcome. If
research is to be conducted on the material,it is subject to a separate
consent process that must be consistent with the provisions in the
WMA›s Declaration of Helsinki. There must not be any induce-
ment or other undue pressure to donate or offers of compensation.
Monetary compensation given to individuals for economic losses,
expenses or inconveniences associated with the retrieval of donated
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WMA News
reproductive materials should be distinguished from payment for
the purchase of reproductive materials.
Recommendations
National Medical Associations (NMAs) should urge their govern-
ments to prohibit commercial transactions in human ova,sperm and
embryos and any human material for reproductive purpose.
Physicians involved in the procurement and use of human ova,
sperm, and embryos should implement protocol to ensure that ma-
terials have been acquired appropriately with the consent and au-
thorization of the source individuals. In doing so, they can uphold
the ethical principle of non-commercialization of human reproduc-
tive material.
Physicians should consult with potential donors prior to donation
in order to ensure free and informed consent.
Physicians should adhere to the WMA Statement on Conflict of
Interest when treating patients who seek reproductive services.
[1] Global Glossary of Terms and Definitions on Donation and
Transplantation, WHO, November 2009
[2] European convention of human rights and biomedicine – Ar-
ticle 21 – Prohibition of financial gain
[3] Declaration of Istanbul guiding principle 5
WMA Resolution on Unproven
Therapy and the Ebola Virus
Adopted by the 65th
WMA General Assembly, Durban, South Africa,
October 2014
In the case of Ebola virus, the WMA strongly supports the inten-
tion of Paragraph 37 of the 2013 revision of the Declaration of Hel-
sinki, which reads:
In the treatment of an individual patient, where proven interventions
do not exist or other known interventions have been ineffective, the
physician, after seeking expert advice, with informed consent from
the patient or a legally authorized representative, may use an unprov-
en intervention if in the physician’s judgement it offers hope of sav-
ing life, re-establishing health or alleviating suffering. This interven-
tion should subsequently be made the object of research, designed to
evaluate its safety and efficacy. In all cases, new information must be
recorded and, where appropriate, made publicly available.
WMA Statement on Aesthetic
Treatment
Adopted by the 65th
World Medical Assembly, Durban, South Africa, Oc-
tober 2014
Preamble
Aesthetic treatments have become increasingly common in recent
years as society appears to have become more preoccupied with
physical appearance. These treatments are performed by practitio-
ners with widely differing clinical and educational backgrounds.
For the purpose of this statement, aesthetic treatment is defined as
an intervention that is performed not to treat an injury, a disease or
a deformity, but for non-therapeutic reasons, with the sole purpose
of enhancing or changing the physical appearance of the individual
concerned. In this statement, the individual undergoing treatment
is referred to as the patient.The treatments available include a great
variety of interventions, ranging from surgical procedures to injec-
tions and different kinds of skin treatments. This statement focuses
on interventions that are methodologically similar to those per-
formed in conventional health care. Tattooing, scarring and similar
interventions are therefore not considered in this statement. Body
image affects a person’s self-esteem and mental health and is an
integral part of a person’s overall health and well-being. However,
media images of “perfect bodies” have become the norm, causing
some people, to develop unrealistic and unhealthy body images.
Many aesthetic treatments involve risks and may potentially harm the
health of the patient. Minors [1] are particularly vulnerable, as their
bodies are often not fully developed. In order to protect persons con-
sidering or undergoing aesthetic treatment the WMA has developed
the following basic principles regarding aesthetic treatments.
Reaffirming the medical ethics principles laid out in the WMA Dec-
laration of Geneva, the WMA Declaration of Lisbon on the Rights
of the Patient and the WMA International Code of Medical Ethics,
and consistent with the mandate of the WMA, this statement is ad-
dressed primarily to physicians. However, the WMA encourages other
practitioners performing aesthetic treatments to adopt these principles.
Principles
1. The patient´s dignity, integrity and confidentiality must always
be respected.
2. Physicians have a role in helping to identify unhealthy body im-
ages and to address and treat disorders when these exist.
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WMA News
3. Aesthetic treatments must only be performed by practitioners
with sufficient knowledge, skills and experience of the interven-
tions performed.
4. All practitioners providing aesthetic treatments must be regis-
tered with and/or licensed by the appropriate regulatory author-
ity. Ideally, the practitioner should also be authorized by this
authority to provide these specific aesthetic treatments.
5. All aesthetic treatments must be preceded by a thorough exami-
nation of the patient. The practitioner should consider all circum-
stances,physical and psychological,that may cause an increased risk
of harm for the individual patient and should refuse to perform the
treatment if the risk is unacceptable. This is especially true in the
case of minors.Practitioners should always choose the most appro-
priate treatment option,rather than the most lucrative one.
6. Minors may need or benefit from plastic medical treatments but
pure aesthetic procedures should not be performed on minors. If,
in exceptional cases,aesthetic treatment is performed on a minors,
it should only be done with special care and consideration and
only if the aim of the treatment is to avoid negative attention
rather than gain positive attention. All relevant medical factors,
such as whether the minor is still growing or whether the treat-
ment will need to be repeated at a later date, must be considered.
7. The patient must consent explicitly to any aesthetic treatment,
preferably in writing. Before seeking consent the practitioner
should inform the patient of all relevant aspects of the treat-
ment, including how the procedure is performed, possible risks
and the fact that many of these treatments may be irreversible.
The patient should be given sufficient time to consider the infor-
mation before the treatment starts. Where the patient request-
ing the treatment is a minor, the informed consent of his or her
parents or legally authorized representative should be obtained.
8. All aesthetic treatments performed should be carefully documented
by the practitioner. The documentation should include a detailed
description of the treatment performed, information on medica-
tions used,if any,and all other relevant aspects of the treatment.
9. Aesthetic treatments must only be performed under strictly hy-
gienic and medically safe conditions on premises that are adequately
staffed and equipped.This must include equipment for treating life-
threatening allergic reactions and other potential complications.
10. Advertising and marketing of aesthetic treatments should be re-
sponsible and should not foster unrealistic expectations of treat-
ment results. Unrealistic or altered photographs showing patients
before and after treatments must not be used in advertising.
11. Advertising and marketing of aesthetic treatments should never
be targeted to minors.
12. Practitioners should never offer or promote financial loans as a
means of paying for aesthetic treatment.
[1] For the purpose of this statement minor is defined as a person
who, according to applicable national legislation, is not an adult.
WMA Statement on Ethical
Guidelines for the International
Migration of Health Workers
Adopted by the 54th
WMA General Assembly, Helsinki, Finland, Sep-
tember 2003 and revised by the 65th
WMA General Assembly, Durban,
South Africa, October 2014
Preamble
The WMA acknowledges that temporary stays of physicians in
other countries help both the receiving and the sending countries
to exchange medical knowledge, skills and attitudes. The exchange
of medical professionals is therefore beneficial for the development
of medicine and healthcare systems and in general deserves the sup-
port of national medical associations as well as governments.
The WMA Statement on Medical Manpower – 1 (1983, 1986)
called upon all National Medical Associations to work with their
governments towards solutions to the emerging problems related to
the medical workforce.
The WMA Resolution on the Medical Workforce (1998) identified
the major components of the medical workforce situation that need
to be taken into account when developing a national workforce policy.
For several decades many governments, employers and medical as-
sociations have misinterpreted demographical data regarding the
number of physicians that are required. Young people seeing em-
ployment as physicians have often been seriously affected by poor
medical workforce planning.
In many countries, including the wealthiest ones, there is a short-
age of physicians. A major reason for the shortage is a failure to
educate enough physicians to meet the needs of the country. Other
reasons for the net loss of physicians are the recruitment of physi-
cians to other professions, early retirement and emigration, and the
problems of combining professional and family responsibilities, all
of which are often due to poor working conditions for physicians.
Some countries have traditionally solved their need for physicians
by recruiting medical graduates from other countries. This practice
continues today.
The flow of international migration of physicians is generally from
poorer to wealthier countries.The poorer countries bear the expense
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WMA News
of educating the migrating physicians and receive no recompense
when they enter other countries.The receiving countries gain a valu-
able resource without paying for it, and in the process they save the
cost of educating their own physicians.
Physicians do have valid reasons for migrating, for example, to seek
better career opportunities and to escape poor working and living
conditions,which may include the pursuit of more political and per-
sonal freedoms and other benefits.
Recommendations
National medical associations, governments and employers should
exercise utmost care in utilizing demographic data to make projec-
tions about future requirements for physicians and in communicat-
ing these projections to young people contemplating a medical career.
Every country should do its utmost to educate an adequate number
of physicians,taking into account its needs and resources.A country
should not rely on immigration from other countries to meet its
need for physicians.
Every country should do its utmost to retain its physicians in the
profession as well as in the country by providing them with the sup-
port they need to meet their personal and professional goals, taking
into account the country’s needs and resources.
Countries that wish to recruit physicians from another country should
only do so in terms of and in accordance with the provisions of a
Memorandum of Understanding entered into between the countries.
Physicians should not be prevented from leaving their home or ad-
opted country to pursue career opportunities in another country.
Countries that recruit physicians from other countries should en-
sure that recruiters provide full and accurate information to poten-
tial recruits on the nature and requirements of the position to be
filled, on immigration, administrative and contractual requirements,
and on the legal and regulatory conditions for the practice of medi-
cine in the recruiting country, including language skills.
Physicians who are working, either permanently or temporarily, in
a country other than their home country should be treated fairly
in relation to other physicians in that country (for example, equal
opportunity career options and equal payment for the same work).
Nothing should prevent countries from entering into bilateral
agreements and agreements of understanding, as provided for in
international law and with due cognizance of international human
rights law, so as to effect meaningful co-operation on health care
delivery, including the exchange of physicians.
The WHO Global Code of Practice on the International Recruit-
ment of Health Personnel (May 2010) was established to promote
voluntary principles and practices for the ethical international re-
cruitment of health professionals and to facilitate the strengthening
of health systems. The Code takes into account the rights, obliga-
tions and expectations of source countries and migrant health pro-
fessionals.The WMA was involved in the drafting of the Code and
supports its implementation.
The WHO Code states that international recruitment should be “con-
ducted in accordance with the principles of transparency, fairness and
promotion of sustainability of health systems in developing countries.”
The monitoring and information-sharing system established by
the WHO should be robustly supported with the goal of interna-
tional cooperation. Stakeholders should regularly collate and share
data, which should be monitored and analysed by the WHO. The
WHO should provide substantive critical feedback to governments.
Information should be shared about how to overcome challenges
encountered.
WMA Statement on Solitary
Confinement
Adopted by the 65th
WMA General Assembly, Durban, South Africa,
October 2014
Preamble
In many countries substantial numbers of prisoners are held at times
in solitary confinement. Prisoners are typically kept in isolation for
most of the day,and are allowed out of their cells only a short period
of time of solitary exercise. Meaningful contact with other people
(prisoners, prison staff, outside world) is kept to a minimum. Some
countries have strict provisions on how long and how often prison-
ers can be kept in solitary confinement, but many countries lack
clear rules on this.
The reasons for the use of solitary confinement vary in different ju-
risdictions. It may be used as a disciplinary measure when a prisoner
does not respond to other sanctions intended to address his or her
behaviour,for example,in response to seriously disruptive behaviour,
threats of violence or suspected acts of violence.
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WMA News
The legal authorities in some nations allow individuals to be held in
solitary confinement during an on-going criminal investigation or to
be sentenced to solitary confinement, even when the individual poses
no threat to others. Individuals with mental illness may be kept in
high-security or super-maximum security (supermax) units or prisons.
Solitary confinement can be imposed for hours to days or even years.
Reliable data on the use of solitary confinement are lacking. Various
studies estimate that tens of thousands or even hundreds of thousands
of prisoners are currently held in solitary confinement worldwide.
People react to isolation in different ways. For a significant number
of prisoners, solitary confinement has been documented to cause
serious psychological, psychiatric, and sometimes physiological ef-
fects, including insomnia, confusion, hallucinations and psychosis.
Solitary confinement is also associated with a high rate of suicidal
behaviour. Negative health effects can occur after only a few days,
and may in some cases persist when isolation ends.
Certain populations are particularly vulnerable to the negative
health effects of solitary confinement. For example, persons with
psychotic disorders, major depression, or post-traumatic stress dis-
order or people with severe personality disorders may find isolation
unbearable and suffer health harms.Solitary confinement may com-
plicate treating such individuals and their associated health prob-
lems successfully later in the prison environment or when they are
released back into the community.
Human rights conventions prohibit the use of torture,cruel,inhuman
or degrading treatment or punishment. The use of pronged solitary
confinement against a prisoner´s own will or the use of solitary con-
finement during pre-trial detention or against minors can be regarded
as a breach of international human rights law, and must be avoided.
Recommendations
The WMA urges National Medical Associations and governments
to promote the following principles:
1. Solitary confinement should be imposed only as a last resort
whether to protect others or the individual prisoner, and only
for the shortest period of time possible. The human dignity of
prisoners confined in isolation must always be respected.
2. Authorities responsible for overseeing solitary confinement
should take account of the individual’s health and medical con-
dition and regularly re-evaluate and document the individual’s
status. Adverse health consequences should lead to the immedi-
ate cessation of solitary confinement.
3. All decisions on solitary confinement must be transparent and
regulated by law. The use of solitary confinement should be
time-limited by law. Prisoners subject to solitary confinement
should have a right of appeal.
4. Prolonged solitary confinement, against the will of the prisoner,
must be avoided. Where prisoners seek prolonged solitary con-
finement, for whatever reason, they should be medically and
psychologically assessed to ensure it is unlikely to lead to harm.
5. Solitary confinement should not be imposed when it would ad-
versely affect the medical condition of prisoners with a mental
illness. If it is essential to provide safety for the prisoner or other
prisoners then especially careful and frequent monitoring must
occur, and an alternative found as soon as possible.
6. Prisoners in isolation should be allowed a reasonable amount of
regular human contact. As with all prisoners, they must not be
subjected to extreme physical and mentally taxing conditions.
7. The health of prisoners in solitary confinement must be moni-
tored regularly by a qualified physician. For this purpose, a phy-
sician should be allowed to check both the documentation of
solitary confinement decisions in the institution and the actual
health of the confined prisoners on a regular basis.
8. Prisoners who have been in solitary confinement should have
an adjustment period before they are released from prison. This
must never extend their period of incarceration.
9. Physician´s role is to protect, advocate for, and improve pris-
oners´ physical and mental health, not to inflict punishment.
Therefore, physicians should never participate in any part of the
decision-making process resulting in solitary confinement.
10. Doctors have a duty to consider the conditions in solitary con-
finement and to protest to the authorities if they believe that
they are unacceptable or might amount to inhumane or degrad-
ing treatment.
WMA Statement on the
Prevention of Air pollution due
to Vehicle Emissions
Adopted by the 65th
World Medical Assembly, Durban, South Africa, Oc-
tober 2014
Preamble
There are a number of ways in which the volume of harmful emis-
sions can be reduced. These include encouraging fewer road traf-
fic journeys, active transport for individuals undertaking relatively
short journeys, the use of mass public transit in preference to indi-
vidual vehicles, and alternative energy sources for vehicles, includ-
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WMA News
ing electric and hybrid technologies. Where vehicle use is essential,
means of reducing harmful emissions should be used.
Physicians around the world are aware of air pollution. It impacts
the quality of life for hundreds of millions of people worldwide,
causing both, a large burden of disease as well as economic losses
and increased health care costs. According to WHO estimates, in
2012, urban outdoor air pollution was responsible for 3.7 million
annual deaths, representing 6.7% of the total deaths (WHO, 2014).
Especially, diesel soot is acknowledged as a proven carcinogen
(IARC,07/2012).Furthermore,it has many other toxic effects,most
prominently in the cardiovascular (Brook et al.,2010) and respirato-
ry systems (ERS,2010).Moreover,in the context of global warming,
soot,along with methane,is identified as the second most important
greenhouse driving force substance after CO2 (Kerr, 2013).
Despite the fact that new vehicles will have to comply with stricter
emission standards which take into account most harmful ultra fine
particles too, a high-polluting in-use fleet, including off-road vehi-
cles such as construction engines and ships, will continue polluting
for many more years.
Background
In many densely populated cities around the world, fine dust concen-
trations measurable as aerosols exceed up to 50 times the maximum
WHO recommendation. High volumes of transport, power gener-
ated from coal, and pollution caused by construction machinery are
among the contributing factors.People living and working near major
(high density volume traffic) streets are most affected by pollutants.
For fighting the health risks mentioned above, there exist a variety
of highly efficient and reliable filter systems on the market (Best
Available Technology (BAT) filters[1]). They are applicable to all
internal combustion engines and they reduce even most harmful
ultra-fine particles by a factor of over one hundred.
As soon as 90% of heavy duty vehicles, both, new and upgraded
ones, satisfy this standard, health problems attributable to emissions
of heavy duty traffic will be greatly reduced, and no further tight-
ening of emission standards will be possible or even needed at all
because of an almost total elimination of the pollutant as such.
In a variety of countries on different continents and under varying
conditions retrofit or upgrading programs have been successfully
performed. The UN’s Working Party on Pollution Prevention and
Energy in Geneva has just proposed a technical standard for regula-
tion in their member states, which will be applicable worldwide.
The WMA supports these efforts and calls on policy makers in
all countries, especially in urban regions, to introduce regula-
tory restrictions of access for vehicles without filter, and/or to
provide financial assistance to support the retrofitting of in-use
vehicles.
Recommendations
The WMA therefore recommends that all NMAs should encourage
their respective governments to:
• Introduce BAT standards for all new diesel vehicles (on road and
off-road)
• Incentivise retrofitting with BAT filters for all in-use engines
• Monitor and limit the concentration of nanosize soot particles in
the urban breathing air
• Conduct epidemiological studies detecting and differentiating
the health effects of ultrafine particles
• Build professional and public awareness of the importance of die-
sel soot and the existing methods of eliminating the particles
• Contribute to developing strategies to protect people from soot
particles in aircraft passenger cabins, trains, homes and in the
general environment.These strategies should include plans to de-
velop and increase use of public transportation systems.
Abbreviations:
• EPA: Environmental Protection Agency (US)
• ERS: European Respiratory Society
• IARC: International Agency for Research of Cancer
• BAT Standards: Emission standards for passenger cars, heavy-
duty vehicles and off-road machinery, based on count of ultrafine
particles rather than mass and aimed at the protection of human
health from the most hazardous soot particles, the lung and even
cell membrane penetrating ultra-fines.
References:
• Brook, Robert D. et al. (2010): AHA Scientific Statement: Par-
ticulate Matter Air Pollution and Cardiovascular Disease. An
Update to the Scientific Statement from the American Heart As-
sociation. Circulation 121: 2331-2378.
• ERS (2010): The ERS report on air pollution and public health.
European Respiratory Society, Lausanne, Switzerland. ISBN:
978-1-84984-008-8
• IARC (2012): “IARC: Diesel Engine Exhaust Carcinogenic”.
Press Release No. 213.http://www.iarc.fr/en/media-centre/
pr/2012/pdfs/pr213_E.pdf. (access: 14/02/14)
• Kerr, Richard R. (2013): “Soot is Warming the World Even More
Than Thought”. In: Science 339(6118), p. 382.
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WMA News
• WHO (2014): “Burden of disease from Ambient Air Pollution for
2012.”http://www.who.int/phe/health_topics/outdoorair/databas-
es/AAP_BoD_results_March2014.pdf?ua=1 (access: 26/08/14)
[1] Euro 6/VI, US/EPA/CARB, Chinese and equivalent standards.
WMA Statement on Water and
Health
Approved by the 55th
WMA General Assembly, Tokyo, Japan, October
2004 and revised by the 65th
WMA General Assembly, Durban, South
Africa 2014
Preamble
An adequate supply of fresh (i.e. clean and uncontaminated) water
is essential for individual and public health. It is central to living a
life in dignity and upholding human rights. Unfortunately, over half
of the world’s population does not have access to such a supply, and
even in those places where there is an abundance of fresh water, it is
threatened by pollution and other negative forces.
In keeping with its mission to serve humanity by endeavouring to
achieve the highest international standards in health care for all
people in the world, the World Medical Association has devel-
oped this statement to encourage all those responsible for health
to consider the importance of water for individual and public
health.
Considerations
Water-borne diseases account for a large proportion of mortality
and morbidity, especially in developing countries. These problems
are accentuated in times of disasters such as wars, nuclear and man-
made accidents with oil and/or chemicals, earthquakes, epidemics,
droughts and floods.
Anthropogenic changes to ecosystems, lowered retention by the
earth’s surface, and the limitation of the inherent capacity of nature
to filter dirt from the water are causing increasing damage to the
natural environment, especially the water environment.
The commodification of water, whereby it is provided for profit
rather than as a public service, has implications for access to an ad-
equate supply of drinking water.
The development of sustainable infrastructure for the provision of
safe water contributes greatly to sound public health and national
well-being. Curtailing infectious diseases and other ailments that
are caused by unsafe water alleviates the burden of health care costs
and improves productivity. This creates a positive ripple effect on
national economies.
Water as a vital and necessary resource for life has become scarce
in many parts of the world and therefore has to be used reasonably
and with care. Water is an asset that is shared by humanity and the
earth.Thus, water-related issues should be addressed collaboratively
by the global community.
Recommendations
Physicians, National Medical Associations and health authorities
are encouraged to support the following measures related to water
and health:
• International and national programmes to provide access to safe
drinking water at low cost to every human on the planet and to
prevent the pollution of water supplies. International, national
and regional programmes to provide access to sanitation and to
prevent the degradation of water resources. Research on the re-
lationship between water supply systems, including waste-water
treatment, and health.
• The development of plans for providing potable water and proper
wastewater disposal during emergencies.These will vary according to
the nature of the emergency,but may include on-site water disinfec-
tion, identifying sources of water, and back-up power to run pumps.
• Preventive measures to secure safe water for health care institu-
tions after the occurrence of natural disasters, especially earth-
quakes. Such measures should include the development of infra-
structure and training programs to help health care institutions
cope with such crises. The implementation of continued emer-
gency water supply programs should be done in conjunction with
regional authorities and with community involvement.
• More efficient use of water resources by each nation. The WMA
especially urges hospitals and health institutions to examine their
impact on sustainable water resources. Preventive measures and
emergency preparedness to save water from pollution. The pro-
motion of the universal access to clean and affordable water as a
human right [1] and as a common good of humanity.
[1] In 2010, the United Nations General Assembly and the Human
Rights Council explicitly recognized the human right to water and
sanitation,derived from the right to an adequate standard of living
as stipulated in article 11 of the International Covenant on Eco-
nomic, Social and Cultural Rights and other international human
rights treaties. Hence, it is part of international human rights law.
150
Declaration of Helsinki
The 50th
anniversary of the signing of the
Declaration of Helsinki in 1964 was cel-
ebrated in style at a day-long seminar in
Helsinki on November 11. The event, at-
tended by around 200 people, was held in
the magnificent Pörssitalo building in the
city and hosted by the Finnish Medical As-
sociation (FMA).
The audience was welcomed by Dr. Tuula
Rajaniemi, President of the FMA, and the
morning session was entitled “The Dec-
laration of Helsinki in a real world – The
Implementation of the Declaration”.
The first speaker was Dr. Ramin Parsa-
Parsi, from the German Medical Associa-
tion, who chaired the WMA workgroup on
revising the Declaration in 2013. He said it
was in Helsinki that, 50 years ago, the 18th
General Assembly of the WMA adopted
the very first Declaration of Helsinki set-
ting out “recommendations guiding doctors
in clinical research”. It was therefore fitting
that they should return to Helsinki five de-
cades later to celebrate the anniversary of
its adoption and to reflect on its abiding
role in providing the highest ethical stan-
dards for medical research involving hu-
man subjects.
He went on: “Many changes have taken
place in medical science since the prom-
ulgation of the first version of the Decla-
ration in 1964, and it has been repeatedly
revised to take account of these. The most
recent revision lasted two years and was the
most comprehensive and inclusive revision
process yet undertaken.
During the revision process,national medi-
cal associations, international organisations
and other key stakeholders were invited to
provide their input at expert conferences on
four continents, as well as during an inter-
national online public consultation, which
attracted responses from 36 countries and
regions of the world. It was the task of the
workgroup members to examine all of the
arguments put forward and to evaluate
their merits. Our shared goal was to revise
the document in such a way as to promote
good quality clinical research, while at the
same time ensuring the utmost protection
for research subjects. The workgroup was
very pleased that it could be completed in
time for this anniversary year.
“The current, eighth version of the Decla-
ration of Helsinki, was adopted by a large
majority at the WMA General Assembly
in Fortaleza in October 2013. The result
was an altogether more comprehensive,
methodical and usable document. Despite
the new structure of the revised Declara-
tion, five decades after its original promul-
gation it still retains its unique character as
a concise set of ethical principles drawn up
by physicians for physicians. This is a tes-
timony to the strength of the Declaration
and to the dedication of the World Medical
Association as its guardian.
“The importance of having an internation-
ally recognised global ethical standard for
physicians has again been underlined dur-
ing the current Ebola crisis. For example,
when concerns were raised about the ethical
acceptability of using unproven interven-
tions to treat Ebola patients, the WMA was
able to react immediately by referring to
Paragraph 37, which permits the use of an
unproven intervention with the informed
consent of the patient, where no proven
intervention exists and if it offers hope of
saving life. The WMA General Assembly
referred to this in an emergency resolution
this October.”
He concluded by saying: “I am sure that
these anniversary celebrations will raise
further awareness of the importance of this
guideline and the ethical responsibilities
of physicians and researchers to promote
progress in medical science without com-
promising the health, well-being and rights
of research subjects.”
Jeff Blackmer
He was followed by Dr. Jeff Blackmer,
Director of Ethics at the Canadian Medi-
cal Association and medical ethics adviser
to the WMA, who spoke about the imple-
Anniversary of the Signing
of the Declaration of Helsinki
11 november 2014
Ramin Parsa-Parsi
151
Declaration of Helsinki
mentation of the Declaration in North and
South America.
Dr. Jeff Blackmer, said the Declaration was
not a legally binding document under inter-
national laws. However, it exerted authority
through the extent to which it had directly
and indirectly influenced national and in-
ternational legislation and regulations. In
some cases, it had been codified into those
laws and regulations. It was important to
always keep in mind, however, that the
Declaration was morally binding on physi-
cians, and that this obligation was generally
considered to override any national or local
laws or regulations.
Among international documents, the DoH
was relatively unique in that it represented
a set of ethical principles combined with
some degree of proscriptive detail, while
many of the other documents were more
technical in nature. However, their pres-
ence had meant that a number of national
regulatory bodies had decided to make
reference primarily to one particular docu-
ment or standard.
For some, this has meant “choosing” be-
tween using the DoH as a standard versus
another more static and/or technical docu-
ment.He went on to consider how the Dec-
laration was viewed in the United States
and in Latin America.
In April 2006, the United States Food
and Drug Administration (FDA) had
published a regulatory change ending the
need for clinical trials conducted outside of
the US to comply with the Declaration of
Helsinki.
Previous to this, the FDA had already re-
jected the 2000 version of the DoH and all
subsequent revisions, recognizing only the
1989 version in its regulations. These deci-
sions were made largely over the question
of whether placebos should be allowed in
clinical trials in resource-poor settings (and
to a lesser extent on the issue of post-trial
access). Representatives from the FDA had
actively engaged on the placebo issue with
the WMA, including during the DoH revi-
sion processes and as part of the placebo-
control meetings held in Sao Paulo.
He said that what the FDA said was: “We
didn”t think the World Medical Associa-
tion understood you really do need pla-
cebos to learn something in a lot of cases.
Fundamentally, in a lot of symptomatic
conditions, it”s common for studies that
compare a new drug with placebo to fail. If
doing the right design, or doing an infor-
mative design would mean denying some-
body a therapy that would really save their
lives, then you just can”t do the study at all.
Everybody agrees on that. But if it”s just
a matter of symptoms, having a headache
a little longer, being depressed for a few
more days, I would say most people and
certainly we believe that you could ask a
person to participate in a study [using pla-
cebos]. But it”s not unethical to do a trial
like that.”
Dr. Blackmer also outlined the concerns in
the pharmaceutical industry and fears that
the new obligations, to use a comparator
other than placebo, would make it harder to
prove the efficacy of a new drug and would
drive up the costs of development. He re-
ferred to one observation that pharmaceuti-
cal companies ultimately looked to see what
were the regulations and laws they must
comply with in whatever countries they
were going to seek approval to market a
particular product.To the extent that it was
easier and perhaps less costly to conduct
their research in settings that appeared to
have looser standards or less rigorous ethical
processes, then we”ve seen a trend in which
they had been moving more towards doing
research in that setting.
He said that the FDA”s adoption of less
morally stringent guidelines could encour-
age pharmaceutical companies to take ethi-
cal short cuts. It could also have practical
consequences for trial ethics in developing
countries, especially where research ethics
committees might not be promoting high
standards of protection for participants in
clinical trials, due to lack of financial and
human resources. Pharmaceutical compa-
nies might also pressurise research ethics
committees to relax guidelines and legisla-
tion, in order to facilitate future clinical tri-
als in developing and emerging countries
that lack the resources to conduct their own
clinical research on epidemics such as HIV/
AIDS, which have devastating effects on
their populations.
Turning to the position in South America,
Dr.Blackmer said that in Uruguay the Dec-
laration was used as the main research eth-
ics guideline by which all researchers must
abide. National legislation had incorpo-
rated the 2000 revised version of the docu-
ment. But later modifications on the use
of placebo were not part of the legislation.
In Brazil, following the 2008 revision, the
position adopted by the WMA concern-
ing the use of placebo in research involving
human beings was immediately contested.
According to the position advocated offi-
cially by the Brazilian government, through
a Resolution from its National Health
Board, “the benefits, risks, difficulties and
effectiveness of a new method should be
tested by comparing them with the best
present methods”.
He said there remained in some parts of
South America a concern about a “double
standard” for research that they felt was
not fully addressed by the DoH. Subjects
in resource-poor settings might be exposed
to placebo controls or to controls that are
less than standard of care in more developed
countries. Research might not be responsive
to the needs of the community in which it
is conducted. While revisions of the DoH
had attempted to address some of these
concerns, they had not done so to the satis-
faction of all of those involved.
Finally Dr. Blackmer referred to the Decla-
ration of Cordoba.He said that in November
152
2008, the Congress of the Latin-Ameri-
can and Caribbean Bioethics Network of
UNESCO (Redbioetica) had approved the
Declaration of Cordoba on Ethics in Research
with Human Beings. This document pro-
posed that Latin American countries, gov-
ernments and organisations should refuse
to follow 2008 version of the Declaration
of Helsinki, which was approved in Seoul,
South Korea. It recommended instead as
an ethical and normative frame of reference
the principles of the Universal Declaration
on Bioethics and Human Rights, proclaimed
in October 2005 at the UNESCO General
Conference.
He concluded by saying that the use and
implementation of the DoH in the Amer-
icas was, to say the least, inconsistent
and controversial. In the United States,
the FDA did not endorse the document,
and only referenced the 1989 version. In
South American countries, there remained
a concern that the DoH did not contain
sufficient safeguards when it came to the
issues of placebo controls and post-trial
access.
Dominique Sprumont
The next speaker, Professor Dominique
Sprumont, a health lawyer from the Uni-
versity of Neuchatel, Switzerland, said that
the original Declaration was not meant to
reinforce the Nuremberg Code, but had
rather been adopted in opposition to the
Code. To a large extent, the Nuremberg
Code was not well accepted within the
research community and was often dis-
regarded by the same countries that con-
tributed to its promulgation. The Helsinki
Declaration was originally drafted to allow
the medical profession to maintain its con-
trol of the conduct of biomedical research.
The main purpose was not so much the
protection of human participants but an at-
tempt to accelerate research involving hu-
man participants.
He went on: “The medical profession was
facing a number of challenges. There was
not only a proposal from a human rights
lawyers” organization to develop an inter-
national treaty on biomedical research, but
some countries such as the US were con-
sidering adopting legislation in the field.
The DoH was an attempt to prevent such
a move toward the end of research self-
regulation. It was also supported by the in-
dustry that looked for a more user-friendly
regulation than the Nuremberg Code and
what was planned by the US and EU drug
authorities. Ironically, it is worth mention-
ing that WMA was suffering from certain
financial difficulties in 1964 and the support
from the industry seems to have been wel-
come. This may also explain why the docu-
ment adopted in Helsinki in 1964 did not
contain the same level of protection for re-
search participants than earlier draft docu-
ments such as the one from 1962”.
Prof. Sprumont added that the drafting of
the DoH coincided with the emergence of
bioethics as new discipline of applied eth-
ics. At that time society was going through
important changes. The years after WWII
were characterized by unprecedented eco-
nomic growth, but people were becoming
more aware of the negative consequences
for society and the environment. In the 60s
people started to question that model.
The medical profession did not escape this
reality. It was also under pressure to change
its paternalistic attitude. This resulted in
the development of a more equal relation
between doctors and patients based on the
rule of informed consent. The right of self-
determination became the rule in society in
general and in medical practice in particular.
The medical profession realized the need to
be more receptive to the patients” wishes.
Ethics gained a new role in medical edu-
cation and practice. This “moralization” of
medicine also served the previous objective,
namely to avoid unnecessary intervention
from the State to regulate the profession.
The DoH was the product of this move-
ment.
“Today, as we are celebrating the DoH
50th
anniversary, we can only be impressed
by how the WMA managed to develop
this document, one among many others
to become what is often coined the “con-
stitution of research ethics”. The fact that
the DoH is playing such a central role in
research ethics, promoting high ethical
principles in the field seems partially in
contradiction with the fact the DoH has
been revised seven times (or even nine if
one includes the two notes of clarifica-
tion concerning the placebo rule). A closer
look at those revisions shows that the core
elements of the DoH were never altered,
but that the main changes were adapta-
tions to the law and also improvement in
the structure and the formulation of some
provisions.”
He said the DoH had evolved in parallel
with legislation and the fact that it managed
to stay in line with the legal framework at a
time when many countries adopted legisla-
tion in favour of the protection of research
participants could explain its success. The
WMA changed its original attitude that
was primarily to facilitate research. Since
the late 90s, the DoH clearly focused on
the protection of the participants, their dig-
nity, rights and welfare. Another important
element was that until the late 1990s, laws
and regulation of biomedical research were
mostly limited to developed countries. To-
Declaration of Helsinki
153
day, the situation had changed as a grow-
ing number of countries in the South and
in the North had recently adopted new laws
and regulation in the field. On one hand,
this had modified the status of the DoH as
today researchers would primarily refer to
their national laws on biomedical research
in the conduct of research, but on the other
hand, the DoH was often cited in the laws
and regulation as the main source of inspi-
ration concerning the principles of research
ethics.
Prof. Sprumont went on to ask why there
was a need to formulate rules on fundamen-
tal freedoms and human rights, and said it
was because the rules were violated. “It may
seem a contradiction but if everyone would
act according to the highest ethical and le-
gal standards, there would be no need to
specify them. For instance, if doctors would
always spontaneously inform their patients
before asking their consent, there would be
no need to specify the rule of informed con-
sent.”
He went on: “It is a fact that the DoH is
limited to ethical principles or, in other
words, ethical norms of the highest rank
that makes it a universal document that
can be used and applied in all regions and
cultures of the world. There is a famous
statement from Confucius “seeking har-
mony within difference” that describes
well what the DoH is all about. The DoH
allows differences in its implementation
while defending a universal and harmoni-
ous understanding of the highest ethical
principles in the protection of research
participants”.
He said that the DoH was not merely an
academic document. It was the product of
history, lobbying from various stakeholders,
of the development strategy of the WMA,
its adaptation to the laws, etc. Its present
structure and content was the expression of
a carefully built consensus within the medi-
cal profession and also the research commu-
nity, the RECs and the competent authori-
ties worldwide. In fact, they should salute
the last two revisions as a true attempt from
WMA to conduct broad consultations and
seek consensus on difficult issues related to
research ethics worldwide. During the last
decade,the ethics and regulation of research
involving human participants had expe-
rienced some important changes, moving
from broad principles to detailed regula-
tion, from self-regulation to legislation and
to the bureaucratization of research. For the
WMA, this meant both challenges and op-
portunities. The DoH was bound to remain
an essential document in the field as it of-
fered a clear statement of the accepted and
applicable principles in the field.
He concluded: “The WMA should main-
tain the DoH as it stands: a document of
principles focusing on the protection of hu-
man participants. If people have a clear un-
derstanding of their responsibilities in view
of the ethical principles, there is less need
for specific regulation. This is an essential
barrier against the present bureaucratiza-
tion of research ethics. The system should
be able to rely more on responsible actors
able to interpret and implement fundamen-
tal principles of research ethics, rather than
on technicians applying check lists”.
Lasse Lehtonen
The next speaker, Prof. Lasse Lehtonen
from the University of Helsinki, spoke
about the impact of the Declaration on
European human rights development. He
said that from a purely legal perspective,
the authority of the Declaration was lim-
ited. It was a professional recommenda-
tion in nature. The original wording stated
that the standards set by the Declaration
were only a guide to physicians all over
the world. Doctors were not relieved from
criminal, civil and ethical responsibilities
under the laws of their own country. Even
the current version of the Declaration
stated that it was addressed primarily to
physicians. However, the WMA encour-
aged others who were involved in medical
research involving human subjects to adopt
these principles.
Prof. Lehtonen went on to compare the
Declaration with the Conventions of Eu-
ropean Council and with European Union
regulation on clinical trials, which had re-
cently been approved and which was ap-
plied in all Member States of the European
Union from May 2016 onwards. In Europe
the postwar development in the field of hu-
man rights had most notably been guided
by the Council of Europe and the European
Convention on Human Rights. In 1992
the Council of Europe had set up a specific
Steering Committee on Bioethics which
had led to the Convention on Human
Rights in Biomedicine and in this way the
ethical principles set out by the Declaration
of Helsinki had found their way into bind-
ing European Human Rights regulations.
The standards created by the Council of
Europe and the Court had had a major im-
pact on the legislation of European Union.
He went on to compare some of the recom-
mendations set by the DoH to the regula-
tions in European Conventions and in the
European Union law.
He referred at first to the general principle
that the interests of the subject must always
prevail over the interests of science and
compared that to the totalitarian ideolo-
gies of the 1930s when it was common to
claim that the interests of society overrode
Declaration of Helsinki
154
the interest of an individual also in relation
of research. It could be concluded that more
or less the principle of primacy of the hu-
man being as presented in the Declaration
in 1975 had been adopted by both the Bio-
medicine Convention and by the EU regu-
lation on clinical trials.
He discussed the fact that the requirement
for an independent review before an ex-
periment could start was a safe-guarding
procedure that had truly been invented by
the WMA in its Declaration.There was no
mention of that in the Nuremberg code
or in any preceding ethical document. The
1975 revision of the Declaration also fur-
ther emphasized the oversight of research
protocols by an independent committee
and the transparency and independence
of these committees. He compared the
informed consent requirements of the dif-
ferent documents.The requirement for vol-
untary consent for human subject research
was a key part of the Nuremberg code, but
the DoH put much more emphasis on the
necessary information that was given the
research subject prior to the study. In its
current form the Declaration required that
each potential subject must be adequately
informed of the aims, methods, sources of
funding, any possible conflicts of interest,
institutional affiliations of the researcher,
the anticipated benefits and potential risks
of the study and the discomfort it might
entail, post-study provisions and any other
relevant aspects of the study. Furthermore,
the potential subject must be informed
of the right to refuse to participate in the
study or to withdraw consent to participate
at any time without reprisal. The Declara-
tion also supported the requirement of
consent for research with identifiable hu-
man material or data and the consent re-
quirements for research in the Convention
on Biomedicine were more or less identical
to those in the Declaration.
Finally, Prof. Lehtonen made some com-
parisons about the status of incapacitated
subjects and minors. One of the recom-
mendations of the original Helsinki Dec-
laration was to substitute the consent of the
research subject with the consent of the le-
gal guardian in cases of legal incompetence.
The Nuremberg code did not have this op-
tion and it mandated that medical research
could only be carried out with a legally com-
petent subject. This would have would pre-
vented valid research, such as in the field of
paediatrics.The Convention of Biomedicine
found research in subjects not able to con-
sent possible. However, it could be carried
out only for his or her direct benefit. The
requirements in the Convention were thus
clearly stricter than in the current Decla-
ration. Paragraph 20 of the Declaration,
however, stated that medical research with
a vulnerable group was only justified if the
research was responsive to the health needs
or priorities of this group and the research
could not be carried out in a non-vulnerable
group. In addition, this group should stand
to benefit from the knowledge, practices or
interventions that result from the research.
The EU clinical trials regulation, on the
other hand,set even more stringent rules for
trials in incapacitated subjects or in minors.
For incapacitated subjects, the trial should
bring direct benefit for the research subject
in comparison to risks or at least some ben-
efit for the population represented by the
incapacitated subject concerned, if the trial
related to a life-threatening or debilitat-
ing medical condition. Similar rule applied
for trials in minors. Furthermore, the trial
might impose only minimal burden on the
research subject concerned in comparison
with the standard treatment of the condi-
tion.
In conclusion, he said that the influence of
the Declaration had been far-reaching for
the development of national and interna-
tional guidelines and regulations. The prin-
ciples of the Declaration had more or less
directly been implemented to the Conven-
tion on Biomedicine of the Council of Eu-
rope and many principles of the Declaration
could be found also in the regulation con-
cerning clinical trials in European Union.
However, information technology made
it easy to gather information on patients
without their consent and there might be
new problems arising with the availability
of whole genome-sequencing both in re-
search and in the treatment of patients. It
was noteworthy that the science community
was very committed to follow the principles
of the Declaration, but it was by no means
that clear that the business community de-
veloping new technologies was that well ac-
quainted with these principles.
“Thus far the Declaration has followed
the development of science and is likely
to be updated, when times and conditions
change. It is, however, important that the
compliance of the research practices with
the principles is actively monitored not
only by physicians, but by the society as a
whole.”
Ames Dhai
Professor Ames Dhai, immediate Past-
President of the South African Medical
Association, and Director of the Steve
Biko Centre for Bioethics at the Uni-
versity of the Witwatersrand in Johan-
nesburg, spoke about the DoH from the
perspective of the developing world. She
said the moral authority of DoH was in-
tricately linked with respecting the hu-
man dignity of participants in research.
The principles of the DoH accentuated
Declaration of Helsinki
155
that research participants were not to be
treated as a means to answer a hypoth-
esis posed or as mere things, and every
wrong done to them infringed their hu-
man dignity. Respecting dignity was both
implicit and pervasive in the Declaration.
She illustrated from a developing world
perspective how this respect for dignity
translated to safeguards in particular for
participants with vulnerabilities. In Afri-
ca there were large numbers of vulnerable
populations and individuals, little or no
health care, failing and failed health sys-
tems, low levels of literacy or no literacy,
and an acceptance of authority without
question.
She referred to the references in the DoH
that appropriate compensation and treat-
ment for subjects who were harmed as a
result of participating in research must
be ensured, as well as the issue of un-
proven interventions in clinical practice.
In South Africa sponsors for clinical tri-
als ranged from pharmaceutical companies
to research organisations, such as the US
National Institutes of Health (NIH) and
Centers for Disease Control and Preven-
tion (CDC). A typical statement from an
informed consent document for an NIH-
sponsored clinical trial read “If you are
injured as a result of being in this study,
you will be given immediate treatment for
your injuries. The cost of this treatment
will be provided by the Department of
Health in a referral hospital or your in-
surance company. There is no program for
compensation either through this institu-
tion or the National Institutes of Health.
The investigators will provide you with
reasonable medical care as is available at
the. . . hospital”.
“At first glance this statement seems fair,
but human research ethics committees in
South Africa do not agree. The consent
statement is such that the overburdened
and under-resourced health system that is
trying to provide care to poor vulnerable
populations without medical insurance will
have to cover for research injuries caused by
research sponsored by a wealthy developed-
country institution.
Naturally, research ethics committees
have questioned this practice. The NIH
response is that US federal regulations do
not allow payment for treatment of re-
search injuries, nor do they allow inclusion
in NIH grants of funds sufficient for local
researchers to take out suitable insurance
or pay for suitable care. Indeed no agency
within the US federal health system has
a formal compensation policy for research
injuries”.
“Vulnerability” was now understood as ex-
tending beyond an inability to consent or
to protect one”s own interests. In addition,
using “wrong” recognised that participants
who were harmed as a result of their in-
volvement in research were not necessarily
always wronged. “Wrong” denoted greater
moral burden and significance as compared
to “harm”. It indicated a moral transgres-
sion. The strength of the DoH was that it
considered vulnerable individuals as well as
groups. Vulnerability could differ between
individuals. For instance, in South Africa a
white Constitutional Court Judge from an
advantaged background with HIV infection
had far less of a chance of being wronged as
compared to a black, illiterate woman from
a township or rural setting who had HIV
infection. With her, wrongs ranged from
physical, social, psychological, consent, to
justice.
Finally, Prof. Dhai referred to the relevance
of the Helsinki Declaration to the out-
break of the Ebola virus. There were several
paragraphs within the DoH that were ap-
plicable to the outbreak, in particular the
provision that the duty of the physician was
to promote and safeguard the health, well-
being and rights of patients,including those
involved in medical research, that research
should be conducted only by individuals
with appropriate ethics, and scientific edu-
cation, training and qualifications and the
issue of unproven interventions in clinical
practice.
“Because no cure or vaccine exists for the
disease, the WHO on the 11th
August con-
vened a special consultation to assess the
ethical implications of the use of unregis-
tered interventions which existed in the
laboratory in small quantities at that time
and a day later put out a statement that in
the face of the EVD threat, it was ethical
to offer unproven interventions with as yet
unknown efficacy and adverse effects as po-
tential treatment or prevention. The ethical
criteria to guide the provision of such in-
terventions should include transparency re-
garding all aspects of care,ensuring freedom
of choice and informed consent, respecting
confidentiality, human dignity and involv-
ing the community.
“The WHO decision is in line with the
Declaration of Helsinki which in section
37, on “Unproven Interventions in Clini-
cal Practice” states: “In the treatment of an
individual patient, where proven interven-
tions do not exist or other known interven-
tions have been ineffective, the physician,
after seeking expert advice, with informed
consent from the patient or a legally autho-
rised representative, may use an unproven
intervention if in the physician”s judgement
it offers hope of saving life, re-establishing
health or alleviating suffering. This inter-
vention should subsequently be made the
object of research, designed to evaluate its
safety and efficacy. In all cases, new infor-
mation must be recorded and, where appro-
priate, made publicly available.”
She said the Ebola virus continued to spiral
and external sources had now come forward
to assist the affected countries.However,for
as long as governments in these countries
did not commit to strengthen their health-
care systems and improve the underlying
social determinants of health attempts at
combatting the Ebola crisis and other crises
that followed could end up being ineffec-
tive.
Declaration of Helsinki
156
During the afternoon session, speakers fo-
cused on “Ethics as a Foundation of Re-
search”.
The session was opened by Dr. Xavier
Deau, President of the WMA. He said the
Declaration of Helsinki had translated the
willingness of the WMA and its Found-
ing President, Eugène Marquis, a French
physician, to bring the ethics of medical
practice and research to the highest level
with a twofold goal – to ensure a universal-
ity of ethics in research on human beings
as well as the protection of people subject-
ed to this research and to make definitely
impossible the horrible abuse of medicine
encountered during the thirties and for-
ties. These ethical principles were now
translated into the codes of ethics of many
countries or laid down in the resolutions
of international organisations, such as the
WHO, UNESCO, United Nations and
the ICRC. Governments also felt encour-
aged to include the DoH principles into
their legislation.
He continued: “This Declaration combines
pragmatism and wisdom with the “primacy
of the individual”. This raises awareness of
the physician to the fundamental impor-
tance of informed consent and information
of the patient, the secrecy of personal and
especially patient data, and the value of the
professional autonomy of the physician.
Under the aegis of independent research
committees, the DoH rigorously codifies
the scientific studies and trials, and in par-
ticular, the protection of the research sub-
jects against dangerous experiments and
exploitation. The Declaration commands
the application of the necessary scientific
rigour, including the use of placebos when
necessary. The sustainability of the DoH is
a shining example of universality of medi-
cal ethics. Even if its drafting seemed to be
laborious, our Declaration of Helsinki has
the merit to be a historical and yet modern
document, combing the cultures of more
than one hundred medical associations.
Thus, it is an authentic factor of peace and
union between medical professions around
the world in full respect for the patients
for whom we care. The DoH ensures a rig-
orous application of science as well as the
ethics on the grounds of a genuine respect
for the patient and human rights we are
caring for”.
Urban Wiesing
Professor Urban Wiesing, ethics adviser
to the WMA on the Helsinki Declaration
and Director of the Institute for Ethics
and History of Medicine at the University
of Tübingen, was the next speaker. He said
that delegates attending the WMA Assem-
bly 50 years ago could hardly have imagined
the historical significance of their decision
to adopt the Declaration of Helsinki. “One
tiny step had been taken by the delegates
that would later turn out to be a giant leap”.
But the road to the Declaration was neither
straight nor smooth. The work took more
than a decade, with discussions starting fol-
lowing the Nuremberg Code.
“The Nuremberg code was meant to pre-
vent crimes like those committed by Nazi
doctors in the concentration camps.There-
fore it demanded to obtain participants”
voluntary consent without any exception.
ln addition, the code set a limit on rea-
sonable risks and demanded that subjects
have the right to leave the experiment at
any time. However, the code attracted little
interest at first. How could it? lt served
to justify the judgment of an American
military court. It was a secret document
in some countries. What authority could
such a Code claim to have? This was a dif-
ficult question to answer. The Nuremberg
Code was an important document, but it
did not serve as an influential answer to the
demanding situation in medical research.
Another answer was needed.”
He said it was in 1953 that a first proposal
for a position paper was submitted to the
Medical Ethics Committee of the WMA,
published a year later as the “Resolution
on Human Experimentation”. Seven years
later, in 1961, the Medical Ethics Commit-
tee presented the first draft of the Declara-
tion. Three additional years of intense and
controversial debates had to pass until it was
adopted.
“The Declaration is what it is because it
gives an answer, an answer to a question
that is desperately needed to be answered in
modern medicine; an answer to the funda-
mental ethical question of research involv-
ing human subjects, an answer to a dilem-
ma. What is the dilemma modern medicine
is confronted with? On the one hand, mod-
ern medicine knows that precise knowl-
edge concerning the “efficacy and safety
of interventions can only be gained from
research involving human subjects. Animal
or laboratory experimentation is necessary
and a prerequisite to clinical research. On
the other hand, research involving human
subjects is fraught with ethical conflicts that
cannot be completely prevented. lf one con-
ducts research on human subjects, there will
always be the risk of harming them. Expos-
ing the patients to such risks is inconsistent
with the medical professional”s obliga-
tions, especially with the old Hippocratic
principle primum nil nocere, do no harm.
However, harmful effects are inevitable in
research.lf the researcher knows beforehand
that the patient will not be exposed to any
risks because the intervention is effective
and does not inflict any harm, then no fur-
Declaration of Helsinki
157
ther research is needed. Research involving
human subjects is controversial because of
the risks.”
But abstaining from conducting research
to avoid ethical conflicts would mean treat-
ing future patients with previously untest-
ed drugs. This would significantly lessen
the quality of medical practice. Yet clini-
cal research was ethically critical because
it violated the principle “do no harm”. The
Declaration stressed the protection of the
participants on the one hand and medicine”s
need for research on the other.
“After the adoption of the Declaration the
inevitable happened. The Declaration was
debated. It was classified from the very
beginning as too permissive by some com-
mentators and as too restrictive by others.
The debate on whether the Declaration is
too “research-friendly” or too restrictive
persists up to the present day. But if a docu-
ment is criticized to be too liberal and also
criticized to be too restrictive it may very
well be a balanced compromise.”
He said the Declaration was now a living
document that had been adapted to a chang-
ing environment and improved. Thanks to
the Declaration and others this research no
longer had an exclusively negative image.
The Declaration not only limited research
on human beings, but it also legitimized
it. The Declaration not only protected the
participants but the researchers as well.This
not only stabilized the medical profession
but gave the system of research hope that
the people would accept it.
And he added: “The Declaration was cre-
ated and adopted by an organization of
physicians for physicians, thus creating a
close relationship to the profession and the
professionals. The Declaration remains an
expression of professional self-reflection. lt
is living proof that a profession can regulate
not only scientific but also ethical aspects
responsibly.The adoption and the successful
efforts of the World Medical Association
for self-imposed regulations confirm the
fundamental willingness and ability to learn
as a professional self-organization.Thus,the
Declaration is an expression of responsibil-
ity”.
Looking to the future scientific and tech-
nological development of modern medicine,
Prof. Wiesing said: “They will confront us
with new challenges. I only have to remind
you of some of the latest medical projects
like individualized medicine, system medi-
cine, new developments in genetics or bio-
banks. And I am sure there are more to
come and are already coming.I am speaking
in particular of the Ebola crisis. In the case
of Ebola, we can see how adequate the ethi-
cal principles of the Declaration are. We do
not need a new ethics in the case of Ebola.
However, we do need to make new deci-
sions in the face of such a global crisis, but
these decisions must be made on the basis of
existing ethical principles. The ethical prin-
ciples laid down in the Declaration remain
valid. They are applicable to the current sit-
uation and indeed helpful. The Declaration
stresses the importance of protecting par-
ticipants on the one hand and medicine”s
need for research on the other. Both must
be balanced. This holds true when it comes
to Ebola as well. A balance between expos-
ing current patients to potential risks for
their own benefit as well as the benefit of
future patients is absolutely crucial in order
to prevent a pandemic”.
The Declaration allowed the “treatment of
an individual patient, where proven inter-
ventions do not exist” under certain con-
ditions”. The case of Ebola illustrated just
how appropriate the ethical principles of
the Declaration were.
The main question now was not how often
the Declaration should be revised. It was
how the Declaration could keep providing
the ethical principles for research involving
human subjects in the face of rapid devel-
opments in science and society. While the
frequency of revisions should be low, they
should also be appropriate to keep up with
scientific and ethical progress”.
“As long as the Declaration remains the
most important answer to one of the fun-
damental challenges of modern medicine
I have no doubt that there will be good rea-
sons to meet again in 10, 25, in 50 years for
the next anniversaries. And where should a
meeting take place? There is no doubt- in
the city, where it started, in Helsinki, where
else?”
Sauli Niinistö
An official greeting was then given by the
President of Finland,His Excellency Sau-
li Niinistö, who said the Declaration had
been described as the most widely accepted
guidance worldwide on medical research in-
volving human subjects.
“During the past 50 years theory has turned
into practice. Guidelines and principles
contained in the Declaration have been en-
shrined in national and international law
and conventions regulating medical research
today. For instance, in Finland ethical com-
mittees have been statutory since the late
1990s. Regardless of their field of study, re-
searchers have a great thirst for new knowl-
edge. However, the pursuit of knowledge is
never without risk. But we will have no new
knowledge without active research. Clinical
medicine has made immense progress in the
Declaration of Helsinki
158
last 50 years.This would not have been pos-
sible without countless studies.
“In general, ethical principles do not adapt
in step with the opportunities offered by
medicine to examine and treat patients.
Modern methods for the management and
analysis of information are at a completely
different level than in the 1960s.These days,
we place a particular emphasis on the right
of individuals to control personal informa-
tion. Despite the speed of development in
medical science, the World Medical Asso-
ciation has managed to keep the Declara-
tion up-to-date. And the Association has
found a well-functioning compromise both
in terms of manner and pace of updating.
The Declaration provides a valuable guide
for all parties involved in research”.
He said that continuous, open discussion
on the ethics of medicine and its basis in
research was necessary to ensure the sus-
tainable well-being of societies and people.
The Declaration had proved to be a well-
functioning cure, but they had to continue
with this treatment. He hoped the Declara-
tion would continue to play a key role in en-
abling medical advances of a high standard
in the years to come.
Laura Räty
The final speaker was Dr.Laura Räty,Finn-
ish Minister for Health and Social Affairs.
As a politician and a physician, she asked
whether there was room for physician”s eth-
ics in political decision-making. She said
there were six main principles in medical
and care ethics: respect for life, respect for
human dignity, self-determination (autono-
my), caring, justice (fairness) and maximiz-
ing of benefit. She addressed each of these
principles and said they could be reflected
against the political decision-making that
had been and was being carried out in Fin-
land, on one hand, at local government level
and, on the other hand, in central govern-
ment policy.
In addition there was the essential principle
in the work of a physician of confidential-
ity. The basic condition for a good doctor-
patient relationship was that the patient
could be confident that his or her informa-
tion could not be accessed by others than
the health care professionals that participate
in the care of the patient.
Returning to the title of her address “Is
there room for physician´s ethics in political
decision-making?” her answer was “There is
and there must be”.
She concluded: “We in Finland are aware
that all those conditions where people are
born, grow up, live, work and age contrib-
ute to wellbeing and health. Therefore we
consider that the different sectors of soci-
ety must in their decision-making evaluate
the impact of their decisions on wellbeing
and health. Health in all policies has been
on the agendas of international forums at
Finland”s initiative for about ten years, and
in spring this year the World Health Or-
ganization (WHO) adopted a resolution on
the issue. Integrating health and wellbeing
extensively into societal decision-making
can bring concrete benefits to citizens. For
instance the systematic and consistent to-
bacco policy conducted in Finland has re-
duced smoking, and the nutrition policy
has improved the composition of nutrition
among the population. The cardiovascular
disease mortality in working-age men has
fallen by 80 per cent in 40 years. The im-
proved level of education and working con-
ditions and the improved living conditions
in general have had a favourable impact on
the population”s health.
“When treating patients as a physician
I have been well aware of the responsibility
I have for the health of an individual. As a
politician I have a broader responsibility to
influence the population”s health and well-
being. I see this responsibility not only as
a political but also as an ethical issue. We
must all act ethically so that the citizens”
interests are taken into account.
The slogan of the Finnish Medical Asso-
ciation – my own association – is: “For the
patient”s best with physician”s skills.” I am
convinced also on the basis of my own ex-
perience that a physician can help a patient
even in the field of politics – and a poli-
tician can help a patient without having
medical education. Health in all policies
is our – physicians” and politicians” – joint
ethics.
Yes – there is room for physician”s ethics in
political decision-making”.
Dr. Mukesh Haikerwal, Chair of the
WMA, concluded the day”s proceedings
with a vote of thanks to the speakers and all
the participants.
Mr. Nigel Duncan,
Public Relations Consultant, WMA
Declaration of Helsinki
159
NMA News
Melbourne Health Summit
Memoranda
Health Care in Danger
The H20 Health (Melbourne 2014) Summit urges the Worlds’
Leaders, including those at the G20 Australia, to be aware of the
mortal danger of those providing and receiving health care across
the world and the resulting effects on peoples’ health.
We commend the efforts of the International Committee of the
Red Cross to secure safe access to Healthcare and call on Govern-
ments to legislate and not tolerate infringements against health fa-
cilities and personnel.
https://www.icrc.org/eng/resources/documents/event/2014/violence-
against-aid-workers-future-of-humanitarianism-overseas-develop-
ment-institute-htm.htm
Climate And Health
The H20 Health (Melbourne 2014) Summit urges the Worlds’
Leaders, including those at the G20 Australia, to prioritise action
on the Climate as a matter of urgency in the interest of the Health
of the Public.
Human influence on the climate system is clear,and recent anthropo-
genic emissions of greenhouse gases are the highest in history.Recent
climate changes have had widespread impacts on human and natural
systems. http://www.ipcc.ch/news_and_events/docs/ar5/ar5_syr_head-
lines_en.pdf
The environment influences human health in many ways — through
exposures to physical, chemical and biological risk factors, and
through related changes in behaviour in response to those factors.
According to the WHO, 13 million deaths annually are due to pre-
ventable environmental causes.Mitigating environmental risk could
save as many as four million lives a year in children alone, mostly in
developing countries.https://www.wma.net/en/20activities/30publich
ealth/30healthenvironment/10climate/
Health is a Wise Investment
The H20 Health – Health People,Successful Economy (Melbourne
2014) – Summit wishes to emphasise to the Worlds’ Leaders, in-
cluding those at the G20 Australia, that health and health care are
core components of a fair, just and successful economy.
We urge that there be meaningful dialogue with the Health Sector
to progress better health outcomes across Nations.
We note that:
• Concerns about health costs exist in all nations.
• Health of Nations is a core component of the Wealth of Nations.
• Good health systems are a marker of a fair and just society.
• The Health Sector employs significant numbers of people.
• A productive society depends on a healthy, engaged and
• Confident workforce.
• People participating and contributing in the economy continue
to do so if kept healthy. “Health is the greatest social capital a
nation can have”.
Non-Communicable Diseases
The H20 Health (Melbourne 2014) Summit urges the Worlds’
Leaders, including those at the G20 Australia, to work con-
structively and meaningfully with the Health Sector to address
the catastrophic effects of unresolved “Non-Communicable Di-
seases”.
WMA asserts all NCDs need to be addressed and in a systematic,
coordinated and sustainable way: the work is more urgent now.http://
www.wma.net/en/20activities/30publichealth/10noncommunicabledise
ases/
The spread of non-communicable diseases remains a socio-econom-
ic and development challenge of “epidemic proportions.” Govern-
ments in 2011 pledged to work with the United Nations to adopt
before the end of 2012 targets to combat heart disease, cancers,
diabetes and lung disease and to devise voluntary policies that cut
smoking and slashed the high salt, sugar and fat content in foods
that caused them. http://www.un.org/press/en/2011/ga11138.doc.
htm
Social Determinants of Health
The H20 Health (Melbourne 2014) Summit has resolved that ad-
dressing the Social Determinants of Health is a core strategy for a
fair and just Society. We stand prepared to work with the Worlds’
Leaders, including those at the G20 Australia, to act on and address
the Social Determinants of Health and request that the G20 Aus-
tralia secretariat progress this.
“The Social Determinants of Health, Health inequality among
people between and within countries is significant and consti-
tutes an urgent issue of social justice. It is clear that these health
inequalities are the result of differences in living conditions; the
environment in which a person is born, grows, lives, works, ages,
and dies.The International community including the health sector,
must redouble our efforts to address these and reach a more fair
and just society.” https://www.wma.net/en/20activities/30publicheal
th/80socialdeterminants/
160
NMA News
Hungarian Medical Chamber
Office Bearers (2011–2015)
President: Dr. István Éger
1st Vice President: Prof. Dr. János Banai
2nd Vice President: Dr. János Gerle
3rd Vice President: Dr. Attila Kováts
Secretary General: Dr. Ferenc Nagy
1st Secratary: Dr. Gábor Hollós
2nd Secretary: Dr. János Lengyel
3rd Secretary: Dr. Zsolt Pataki
4th Secretary: Dr. Péter Takács
Membership
Any medical doctor from all States of Hungary can join the
Hungarian Medical Chamber as a regular member. Since 1994
the Hungarian law says all medical doctor, who is practicing
have to join the Hungarian Medical Chamber. Between 2007
and 2011 the membership temporarily was voluntary. In 2011
the law have been reconstructed and since then the membership
is mandatory.
Services Provided
The Hungarian Medical Chamber is an independent, democratic
body which preserve professional, moral and substantial interest
of doctors. Functionally it is a public body as a representative de-
mocracy. With an open structure and influence it serves people and
people’s health.
Activities
• With Members: A monthly newspaper with scientific and
health publications for all member of the Hungarian Medical
Chamber.
• With the Public:Serves people’s health with the principle of “sal-
vation of patient is the primary law”.
• With the Governments:Law proposal and estimate, lobby at the
Ministry of Health for better medical basic services.
• With the Media: Press releases and interviews to health issues of
public interest and promotion of debates related to health poli-
cies.
• With Strategic Partners: Collaboration with Chamber of Nurs-
es, Chamber of Pharmacies health insurance companies and pro-
motion of public health.
Szondi street 100., Budapest 1068, Hungary
Phone: +36-1/302-0065
E-mail: elnok@mok.hu
www.mok.hu
Somali Medical Association
(SMA)
Office Bearers (2014-2016):
President: Prof. Mohamed Yusuf Hassan
Vice-President: Dr.Shafii Mohamed Jamale
General Secretary: Dr.Hassan Mohamed Habibullah
Finance Secretary: Dr.Mohamed Mohamud Omar
Public & International relations Secretary: Dr.Nor Abdullahi
Karshe
Social & Emergency Secretary: Dr. Lul Mohamud Mohamed
CPD & Research Secretary: Dr.Mohamed Abdulrahman Jama
Membership: Any registered medical or dental practitioner in So-
malia is eligible to join SMA.
Services provided: The main services provided by SMA to their
members are: Continued professional development (finding schol-
arships for junior doctors), Welfare services, and representation of
their interests locally and internationally.
Activities:
• With Members: Support for newly qualified doctors, Continued
professional development Programs including scholarships, wel-
fare,
• With the Public: Emergency relief programs for displaced peo-
ple, Mobile clinics for areas where low socioeconomic people live,
Education of the public on the prevention of infectious and Non
Communicable Chronic diseases with the help of MOH.
• With the Government:develop protocols and guidelines for hos-
pitals and district hospitals with Ministry of Health. Advise the
ministry of Higher education for improving the quality existing
medical schools.
• With the Media: press releases related to health issues of public
interest,promotion of debates related to health policies,education
on health related issues.
• With Strategic Partners: on the process of establishing relations
with worldwide medical associations to get assistance of contin-
ued professional development. Also on the process of creating ac-
cess to E-Libraries with the help of WHO to provide free access
to scientific publications to the Somali doctors.
KPP, Wadnaha Street,
Hodon district, Mogadishu-Somalia
Phone: +2521652641
E-mail: Intl@sma.org.so , Info@sma.org.so
www.sma.org.so
III
NMA News
Trinidad & Tobago Medical
Association (T&TMA)
Motto: Teach, Treat, Mentor, Advocate (TTMA)
Origin: Originally formed as a branch of the British Medical Associa-
tion 1891. Formally created by an act of Parliament in 1974.
Office Bearers: (2014)
President: Liane Conyette
1st
Vice President: Muhammad Rahman
Secretary: Stacey Chamely
Treasurer: Edmund Chamely
Public Relations Officer: Austin Trinidade
International Liaison Officer: Solaiman Juman
Membership: All medical doctors registered with the Medical
Board of Trinidad and Tobago to practice medicine in the country
are eligible to be members of T&TMA
Services Provided:
• The T&TMA is the official agent of the Medical Protection. So-
ciety (MPS) of the United Kingdom.
• The Caribbean Medical Journal (CMJ) – a peer reviewed journal
continuously printed since 1938 – is distributed to all our mem-
bers.
• We are the biggest provider of Continuous Professional. Devel-
opment (CPD) activities for doctors in the country.
• We have been approved by the American Academy of Continu-
ing Medical Education (AACME) to provide AACME credits
for eligible activities in the Country
• The T&TMA does regular outreach clinics and activities to un-
derserved areas.
Affiiations
• University of the West Indies (UWI).We work closely with UWI
(the largest Medical School in the Caribbean) to provide high
quality CME activities.
• Medical Board of Trinidad & Tobago (MBTT). We are working
in an ongoing project with the MBTT to ensure and facilitate the
implementation of mandatory CME requirements for all doctors
to obtain annual registration.
• Ministry of Health (MOH). There is ongoing discussion and
communication with the MOH
• International Associations. We are active members of the World
Medical Association and the Commonwealth Medical Associa-
tion
• Other Professional Medical Organizations and Societies. We
are developing links with other medical bodies to strengthen the
medical lobby in our country.
#1 Sixth Ave.,
Xavier Street Ext., Gardens,
Chaguanas, Trinidad
Tel: (1-868) 671-7378
Tel/fax: (1-868) 671-5160
E-mail: medassoc@tntmedical.com
Website: www.tntmedical.com
German Medical Association
Office Bearers:
President: Prof. Dr. Frank Ulrich Montgomery (Hamburg)
Vice-President: Dr. Martina Wenker (Lower Saxony)
Vice-President: Dr. Max Kaplan (Bavaria)
The German Medical Association (Bundesärztekammer), based in
Berlin, is the umbrella organisation in the system of physicians’
self-governance in Germany. As the joint association of the 17 state
chambers of physicians (Landesärztekammer), it represents the pro-
fessional interests of the 470,000 physicians in Germany at the na-
tional, European and international level.
The structure of physicians’self-governance in Germany reflects the
federal nature of the German healthcare system, which is adminis-
tered at the State (Land) rather than the national level.The GMA’s
Executive Board is comprised of the presidents of all state cham-
bers of physicians and two further physician representatives. Its
president and two vice-presidents are elected every four years by the
250 delegates of the annual German Medical Assembly (Deutscher
Ärztetag). Individual physicians are only indirectly members of the
GMA via compulsory membership of the state chamber of physi-
cians in the State where they work.
In addition to its politically representative function,the GMA also pro-
motes the exchange of experiences and coordinates the activities of the
state chambers of physicians. Among other things, it draws up model
guidelines intended to facilitate uniformity in medical regulation across
the country. Once adopted by the German Medical Assembly, it is up
to the boards of the individual state chambers to determine the extent
to which these guidelines will be implemented at the state level. The
GMA also hosts numerous expert committees and advisory boards,
which provide the medical profession with information and advice re-
lating to specific areas of medical science, ethics and healthcare policy.
IV
Contents
The GMA arose from the Working Group of West German Medi-
cal Associations, which was founded in 1947. Following the reuni-
fication of Germany in 1990, the system of physicians’ self-gover-
nance was extended to the former East German states, where state
chambers of physicians were also established.As corporations under
public law, the state chambers of physicians have responsibility for
the following main areas:
• Physician registration
• Organisation and regulation of specialty training and continuing
medical education (CME)
• Upholding professional ethics and monitoring adherence to their
Professional Code
• Maintaining ethics committees to assess clinical research proj-
ects
• Establishing expert commissions and/or arbitration boards to
promote the out of court settlement of conflicts between physi-
cians and patients over malpractice claims
• Representing the interests of the medical profession in the politi-
cal and public sphere, including in the media.
The GMA has been representing the physicians of Germany as an
active member of the World Medical Association since 1951. The
maintenance of close relations with the international medical com-
munity has always been an important aspect of the GMA’s work,
and is listed as one of its functions in its statutes.
Bundesärztekammer/German Medical Association
Herbert-Lewin-Platz 1
10623 Berlin, Germany
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
WMA 2014 General Assembly Report . . . . . . . . . . . . . . . 122
Valedictory address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Inaugural speech . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
WMA Declaration on the Protection of Health Care
Workers in situation of Violence . . . . . . . . . . . . . . . . . . . . 141
WMA Resolution on Ebola Viral Disease . . . . . . . . . . . . . 141
WMA Resolution on Migrant Workers’ Health and Safety
in Qatar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
WMA Resolution on the Non-Commercialisation of
Human Reproductive Material . . . . . . . . . . . . . . . . . . . . . . 143
WMA Resolution on Unproven Therapy and the Ebola
Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
WMA Statement on Aesthetic Treatment . . . . . . . . . . . . . 144
WMA Statement on Ethical Guidelines for the International
Migration of Health Workers . . . . . . . . . . . . . . . . . . . . . . . 145
WMA Statement on Solitary Confinement . . . . . . . . . . . . 146
WMA Statement on the Prevention of Air pollution due
to Vehicle Emissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
WMA Statement on Water and Health . . . . . . . . . . . . . . . 149
Anniversary of the Signing of the Declaration of Helsinki . . . 150
Melbourne Health Summit Memoranda . . . . . . . . . . . . . . 159
Hungarian Medical Chamber . . . . . . . . . . . . . . . . . . . . . . 160
Somali Medical Association (SMA) . . . . . . . . . . . . . . . . . . 160
Trinidad & Tobago Medical Association (T&TMA) . . . . III
German Medical Association . . . . . . . . . . . . . . . . . . . . . . . III