wmj1

G 20438
Editorial – The World Medical Journal 1954 – 2004 –
yesterday, today and tomorrow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
A Rational Approach To Drug Design . . . . . . . . . . . . . . . . . . . . . . . 2
Medical Ethics and Human Rights – Medicine, the Law and
Medical Ethics in a Changing Society . . . . . . . . . . . . . . . . . . . . . . . 5
Helsinki and the Declaration of Helsinki . . . . . . . . . . . . . . . . . . . . . 9
Linking moral progress to medical progress:
New opportunities for the Declaration of Helsinki . . . . . . . . . . . . 11
WMA – « Getting it Right for our Children » . . . . . . . . . . . . . . . . . 13
Medical Science, Professional Practice and Education –
Orthopaedic Surgeons Are Failing To Prevent
Osteoporotic Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Relationship Based Health Care in Six Countries . . . . . . . . . . . . . 18
WHO – More Research, More Resources Needed To
Control Expanding Global Diseases . . . . . . . . . . . . . . . . . . . . . . . . 19
Health And Finance Ministers Address Need For
World-wide Increase In Health Investment . . . . . . . . . . . . . . . . . . 20
WHO welcomes new initiative to cut the price
of Aids medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Maternal Deaths Disproportionately
High In Developing Countries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
WMA – Secretary General: From the Secretary
General’s Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Regional and NMA News – Social Security is a
National Security Issue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Health Reform in Germany
« sustaining or diluting social insurance? » . . . . . . . . . . . . . . . . . . . 24
The South African Medical
Association’s work on the HIV/Aids front . . . . . . . . . . . . . . . . . . . 25
Norwegian Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
U.K.: New report details the impact of smoking
on sexual, reproductive and child health . . . . . . . . . . . . . . . . . . . . 27
Fiji and India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Book Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
World Medical Journal 1954 – 2004
Law and Medical Ethics in a
changing society
“Getting it right for our children”
News from the Regions
O F F I C I A L J O U R N A L O F
T H E W O R L D M E D I C A L A S S O C I A T I O N
VOL. 50 NO 1, March 2004
50
Photo:Prof.Dr.Dr.M.Putscher
HIPPOKRATES
ANDORRA
Col’legi Oficial de Metges
Edifici Plaza esc. B
Verge del Pilar 5,
4art. Despatx 11, Andorra La Vella
Tel: (376) 823 525 Fax: (376) 860 793
E-mail: coma@andorra.ad
Website: www.col-legidemetges.ad
ARGENTINA
Confederación Médica Argentina
Av. Belgrano 1235
Buenos Aires 1093
Tel/Fax: (54-114) 383-8414/5511
E-mail: comra@sinectis.com.ar
Website: www.comra.health.org.ar
AUSTRALIA
Australian Medical Association
P.O. Box 6090
Kingston, ACT 2604
Tel: (61-2) 6270-5460/Fax: -5499
Website: www.ama.com.au
E-mail: ama@ama.com.au
AUSTRIA
Österreichische Ärztekammer
(Austrian Medical Chamber)
Weihburggasse 10-12 – P.O. Box 213
1010 Wien
Tel: (43-1) 51406-931
Fax: (43-1) 51406-933
E-mail: international@aek.or.at
REPUBLIC OF ARMENIA
Armenian Medical Association
Yerevan 375 010
Tel: (3741) 53 48-63
E-mail: armainter@hotmail.com
AZERBAIJAN
Azerbaijan Medical Association
AZE 370001, Baku
Tel: (994 50) 328 1888
Fax: (994 12) 315 136
E-mail: Mahirs@lycos.com /
azerma@hotmail.com
BAHAMAS
Medical Association of the Bahamas
Javon Medical Center
P.O. Box N999
Nassau
Tel: (1-242) 328 6802
Fax: (1-242) 323 2980
E-mail: mabnassau@yahoo.com
Bangladesh
Bangladesh Medical Association
Dhaka 1000
Tel: (880) 2-9568714/9562527
Fax: (880) 2 9566060/9562527
E-mail: bma@aitlbd.net.com
BELGIUM
Association Belge des Syndicats
Médicaux
Chaussée de Boondael 6, bte 4
1050 Bruxelles
Tel: (32-2) 644 -12 88/Fax: -1527
BOLIVIA
Colegio Médico de Bolivia
Casilla 1088
Cochabamba
Tel/Fax: (591-04) 523658
E-mail: colmedbo@supernet.com.bo
Website: www.colmedbo.org
BRAZIL
Associaçao Médica Brasileira
R. Sao Carlos do Pinhal 324 – Bela Vista
Sao Paulo SP – CEP 01333-903
Tel: (55-11) 3266 9391
Fax: (55-11) 3266 6631
E-mail: presidente@amb.org.br
Website: www.amb.org.br
BULGARIA
Bulgarian Medical Association
15, Acad. Ivan Geshov
1431 Sofia
Tel: (359-2) 954 -11 69/Fax:-1186
E-mail: usbls@inagency.com
Website: www.blsbg.com
CANADA
Canadian Medical Association
P.O. Box 8650
1867 Alta Vista Drive
Ottawa, Ontario K1G 3Y6
Tel: (1-613) 731 9331/Fax: -1779
E-mail: monique.laframboise@cma.ca
Website: www.cma.ca
Website: https://www.wma.net
WMA Directory of National Member Medical Associations Officers, Council
Association and address/Officers
WMA OFFICERS
OF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
Vice-President President Immediate Past-President
Dr. J.D.Coble Dr. J. Appleyard Dr. K. Millymaki
American Medical Association British Medical Association Finnish Medical Association
515 North State St. BMA House,Tavistock Square P.O. Box 49
Chicago, Illinois 60610, USA London WC1H 9JP, UK 00501 Helsinki, Finland
Treasurer Chairman of Council Vice-Chairman of Council
Dr. K. Vilmar Dr. Y Blachar Dr. T.J. Moon
German Medical Association Israel Medical Association Korean Medical Association
Herbert-Lewin Strasse 1 2 Twin Towers, 35 Jabotisky St. 302-75 Ichon1-dong,Yongsan-gu,
50931 Köln P.O. Box 3566, Ramat-Gan 52136 Seoul 140-721
Secretary General
Dr. D. Human
World Medical Association
BP63, 01212 Ferney-Voltaire Cedex
France
Tel (33) 4 50 40 75 75
E-mail: delon@wma.net
Fax (33) 4 50 40 59 37
i see page ii
OFFICIAL JOURNAL OF
THE WORLD MEDICAL
ASSOCIATION
Dr. Alan J Rowe
Haughley Grange Stowmarket
Suffolk IP 14 3 QT
UK
Executive Editor
Dr. Ivan M. Gillibrand
19 Wimblehurst Court
Ashleigh Road
Horsham
West Sussex RH12 2AQ
UK
Co-Editor
Prof. Dr. med. Elmar Doppelfeld
Ottostr. 12
D-50859 Köln
Germany
Business Managers
H. Dinse, D. Weber
50859 Köln
Dieselstraße 2
Germany
Publisher
THE WORLD MEDICAL
ASSOCIATION, INC.
BP 63
01212 Ferney-Voltaire, Ledex France
Publishing House
Deutscher Ärzte-Verlag GmbH, Die-
selstr. 2, P. O. Box 400265, 50832 Köln/
Germany, Phone (02234) 7011-0,
FAX (02234) 7011-255, Postal Cheque
Account: Köln 19250-506, Bank: Com-
merzbank Köln No. 1500057, Deutsche
Apotheker- und Ärztebank,
50670 Köln, No. 01513330.
At present rate-card No. 3a is valid.
The magazine is published quarterly.
Subscriptions will be accepted by
Deutscher Ärzte-Verlag or the World
Medical Association.
Subscription fee $ 28.— per annum
(incl. 7% MwSt.). For members of the
World Medical Association and for As-
sociate members the subscription fee is
settled by the membership or associate
payment Details of Associate Members-
hip may be found at the World Medical
Association website www.wma@wma.net
Printed by
Deutscher Ärzte-Verlag
Köln — Germany
ISSN: 0049-8122
The World Medical Journal 1954 – 2004
– yesterday, today and tomorrow
The issue is the first of the fiftieth volume of the World Medical Journal, which we celebrate
with the appearance of a new style quarterly journal. Readers may not be aware that this
journal was not the first ”house publication” of the WMA. Following the early meetings
starting in 1945 which led to the setting up to the World Medical Association in 1947, a reg-
ular publication entitled ”The World Medical Association Bulletin” made its first appear-
ance in 1950. It was printed in three languages, English, French and Spanish and appeared
quarterly. The Bulletin of October 1953 was the last, being replaced by World Medical Jour-
nal in January 1954. According to the editorial of the first issue, it was renamed ”because it
has become more important and deserves such a name. It also reduces the possibility
of confusion with other bulletins, particularly those published by other international
societies”. The editorial also comments that as ”an official organ for a medical organ-
isation, (it) must reproduce the actions of that organisation”. With the new style journal
we intend to enlarge on this by reinstating the views from the desk of the Secretary Gener-
al, including reporting on the activities of the Chief Officers. There will also be informative
background articles on topical issues, some of which may be under consideration by Coun-
cil and its committees.
Information about major problems and initiatives of National MedicalAssociations (NMAs)
are not only of general interest to members but may also identify issues relevant to the med-
ical profession in other parts of the world and facilitate exchange of experiences. Therefore
a new section ”Regional and N M A News” will in future appear as a separate section of the
Journal. It is appropiate that this new section opens with a contribution from Japan, provid-
ing an informative and thoughtful background for the Tokyo WMA General Assembly later
this year.
Articles will be grouped in sections devoted to ”Medical Ethics & Human Rights”, and
”Medical Science, professional practice and education”. In these sections it is our aim not to
duplicate the plethora of material already available in the journals dealing with scientific and
technical matters for individual medical disciplines, but to address issues which relate to the
aims of the WMA. At the same time we will try to reflect the comment in WMJ 1(1) ”While
doctors are always interested in medical economic and social problems, they also want
additional items, and these must be offered to arouse and maintain interest and sup-
port”. This will of course not preclude useful reference to, and comment on, important epi-
demiological, preventive and therapeutic innovations and other issues, including WHO and
other relevant international agencies’ initiatives and policies.
With the current trends in globalisation impacting on all parts of society, this cannot be dis-
regarded by the medical profession, and increasingly individual physicians are recognising
that these developments affect them directly or indirectly, both personally and in their indi-
vidual medical practice. As a non-governmental organisation comprising a membership of
national medical associations, the World Medical Association is in a unique position to in-
fluence international opinion, both in the interests of the medical profession and of society
whom it serves. The WMJ therefore aims to inform the profession and hopefully engage its
support for these WMA activities on its behalf.
We hope that these changes will enhance the value and interest of the Journal as it moves
into its sixth decade and beyond. Meanwhile, during this year we will include some com-
mentaries on the remarkable scientific and other changes which have taken place over the
past 50 years. In this connection it is interesting to note that in 1954 the first issue of the Jour-
nal reported that the Council has discussed ”Ethical problems of Bacteriological warfare and
1
Editorial
Hon. Editor in Chief
experiments on humans”, ”preparation of the programme for the First World Congress on
Medical education”, ”recommendations to WHO on the International Pharmacopoeia”, and
”seeking information from NMAs on Social Security”. It also reported the WHO aid to six
countries to produce antibiotics and insecticides – with special reference to the problem of
malaria, and WHO’s call for enhanced services to control Tuberculosis. Looking at the
medical scene today one may well comment ”plus ça change, plus c’est la même chose!”
Alan Rowe
2
Editorial
A Rational Approach To Drug Design
”Essentially, health is another name for human harmony, harmony not only among our sev-
eral parts, but also between ourselves and our environments.”
Earle P. Scarlett
The future for delivery of healthcare
Technological advances, increased expectations for medicine, an ageing population and le-
gal, ethical and economic factors coupled with a move towards ”evidence-based” medicine
are all driving the rapid change in the delivery of healthcare at the start of the new millenni-
um.
In a fast-changing world, where increasing healthcare regulation co-exists with globalisation
of business, we encounter on a daily basis, more diversity and more uncertainty.
At no other time in global history has healthcare, its benefits, its risks and its structure been
so frequently and so widely discussed. From the man in the street through the pressure
groups and governments, everyone is talking ”healthcare”. The language may vary, but the
topics remain the same.
Both as producers and consumers as doctors, patients and healthcare providers, we face
higher demands and higher expectations in targeted drug treatment.
Over the years, the pharmaceutical sector has had some notable successes. Antibiotics and
vaccines mean that many infections our parents and grandparents feared are now little more
than medical curiosities. Antihypertensives, cholesterol lowering agents and other cardio-
vascular drugs are making considerable in-roads into the morbidity and mortality arising
from the epidemic of heart disease. In the area of osteoporosis, which often leaves sufferers
disabled and debilitated, bisphosphonates are tackling the increasing problem of osteoporo-
sis.
However, pharmacologists cannot rest on their laurels. There is a continuing need for new
medicines. But, finding innovative, more effective and safer drugs is not easy. A recent edi-
torial in Nature noted that some 99.9 % of drugs either fail during development in the labo-
ratory or during clinical trials. This attrition rate means that the cost of bringing a drug to
market is around US$ 800 million (Nature 2002). This wastage delays the launch of drugs
that could potentially reduce the morbidity and mortality associated with cancers, heart dis-
ease, osteoporosis and other common conditions.
So for the last few years, pharmacologists advocated ”rational drug discovery” and ”ratio-
nal drug design” as ways to reduce the attrition rate, lower development costs and advance
drugs to market more rapidly. ”Rational
drugs discovery is a systematic process
based on screening for a particular biologi-
cal effect,” explains Professor Philippe Van
der Auwera, Lifecycle Leader Roche Basel.
”Rational drug design uses our intimate
knowledge of the target’s molecular shape
and structure to develop specific medi-
cines.” Both approaches offer powerful
methods for discover of new medicines.
Track record
In some ways, of course, drug discovery has
always been rational – at least within the
prevailing intellectual culture. In the mid-
eighteenth century, for example, the Rev-
erend Edward Stone of Chipping Norton in
Oxfordshire, England developed a new
treatment for fever. As he explained later,
the idea was a rational extrapolation of the
prevailing scientific view that ”remedies lie
not far from their causes”. Swamps and
marshes, doctors believed, caused fevers
and agues. Willow grows near swamps and
marshes. Ergo, willow should cure fevers.
The discovery that willow bark was an ef-
fective treatment for fever led, ultimately, to
aspirin’s development (Vane 2000) Al-
though scientists no longer accept the logic,
Stone’s discovery was an example of ratio-
nal drug discovery within the intellectual
framework of the time.
Probably the first drug to emerge from a
modern rational drug design programme
was the angiotensin converting enzyme
(ACE) inhibitor captopril. ACE is an en-
zyme that cleaves an inactive precursor to
produce the protein angiotensin II. This con-
trols blood pressure by action of the heart,
blood vessels and kidneys. In the 1950s,
Sergio Farreira, in Sao Paulo, found that the
Brazilian pit viper’s venom contains pep-
tides that inhibit an enzyme that degrades
another protein called bradykinin. Eventual-
ly, researchers recognised that ACE and the
enzyme that degraded bradykinin were
identical. One of the venom’s peptides –
teprotide – lowered blood pressure when
given to humans. Researchers from Squibb
identified teprotide’s active site and devel-
oped specific inhibitors. Captopril was the
first of the ACE inhibitors to reach the mar-
ket (Landau 1999 p 186–187).
On the other hand, for scientists to recognise
that an idea is ”rational”, it must link logi-
cally to other aspects of the current knowl-
edge base. If not, scientists tend to dismiss
or ignore the idea – however rational it
seems in retrospect. For instance, DNA was
first discovered as a constituent of the nu-
cleus of living cells by the Swiss biochemist
Frederick Miescher in 1869, but not until
1953 was its true nature as the unique sub-
stance of heredity identified. But the intel-
lectual framework was not in place for other
biologists to appreciate its importance be-
fore the pioneering work of James Watson,
Francis Crick and Maurice Wilkins was
awarded the Nobel Prize in 1962. This was
based on their model building of the con-
stituent DNA base pairs and Rosalind
Franklin’s X-ray diffraction patterns of the
DNA double helix. Even today the proper-
ties of the genes remain elusive, despite our
knowledge of the complete sequence of the
human genome, in terms of embryonic
growth, organ development and the phased
switching on and off for gene sequences in
human development.
Mendel’s work lay unread for years, partly
because his findings about inherited charac-
teristics did not fit in the prevailing intellec-
tual paradigms4
(Sacks 1997 p. 158). More-
over the now well-accepted idea that viruses
caused some cancers proved so controver-
sial that one of the concept’s pioneers was
virtually ostracised by some of his col-
leagues5
(Kevles 1997 p. 82–3).
Such examples are relatively rare, however.
Rational drug discovery and computer-aid-
ed design are emerging as valuable means to
develop new medicines. The explosion in
the number of possible drug targets arising
from, in part, genomics, gave the move to-
wards rational drug discovery and design
extra impetus.
Around 1,000 disease genes might be rele-
vant for therapeutic development by big
business. Not all these offer direct therapeu-
tic targets. However, many disease genes are
linked to between 5 and 10 physiological or
pathological proteins that might offer alter-
native targets. Thus, the total number of
possible drug targets might lie between
5,000 and 10,000. Drugs available in 1996
targeted just 483. In other words, there are at
least 10 times as many molecular targets
than the pharmaceutical sector currently ex-
ploits6
(Drews 2000). Screening all these us-
ing conventional drug discovery techniques
would prove impossible.
Fortunately, rational drug discovery through
molecular biology offers powerful means to
develop, prioritise and test medicines aimed
at these targets. For example, during rational
drug discovery, researchers systematically
screen compounds against the target. The
screening test depends on the disease and
target. So researchers could use the strength
of the drugs’ binding to a particular receptor
involved in blood pressure control for an an-
tihypertensive, or an ability to inhibit osteo-
clasts when screening for a drug for osteo-
porosis. However, all screens need to be
very sensitive – so that researchers do not
miss a potential drug – and also specific, to
avoid false leads.
Traditionally, screening was time consum-
ing, especially when using biological
screening systems such as cells or even ani-
mals. In some cases, researchers had no al-
ternative but to test every possible drug on
animals. However, recent technological ad-
vances, in particular, high throughput
screening (HTS) and laboratory robotics
dramatically increase productivity. Auto-
mated HTS can test some 10,000 possible
drugs against the target each day, without
using animals. Increasingly sophisticated
computer programs can prioritise the hits
for further development.
”At first, there is a disease and a ‘dream’,
such as inhibiting osteoclasts to alleviate os-
teoporosis,” says Professor Van der Auwera.
”We then identify a potential molecular tar-
get, such as a receptor or enzyme, based on
literature and pathophysiological research.
If the target can be isolated, we clone it us-
ing genetic engineering. This allows us to
build a specific and sensitive screening as-
say. But in many cases we don’t know the
target. So, we have to identify the gene’s
function and, if applicable, the gene prod-
uct, the latter using so-called proteomic ap-
proaches. However, identifying what the
product does in the body – a procedure
called functional genomics – can be a real
nightmare. But ultimately we are usually
able to identify a target that we can produce
in large quantities for high-throughput
screening assays.”
For example, researchers developed iban-
dronate using a rat model that induced hy-
percalcemia (raised calcium levels in the
blood) using retinoids. This example of ra-
tional drug discovery uses the rise in serum
calcium levels as a marker for increased os-
teoclast activity. In this model, bisphospho-
nates and other drugs targeting the osteo-
clasts lead to lower calcium levels compared
to controls. Recently, the target of a drug
like ibandronate has been identified and
could be used to better understand the inter-
action between the enzyme [fiarnesyl dis-
phosphate (FPP) synthase] and its specific
inhibitor. The enzyme activates essential in-
tracellular signalling proteins (”intracellular
hormones”) which regulate a variety of cell
processes important for osteoclast function.
When these signalling proteins are no
longer activated, the osteoclast triggers its
apoptosis (programmed cell death).
Gene expression
Rational drug design takes a different ap-
proach. A gene encodes a protein. But this
protein is rarely the final biologically active
form. Often the ”first generation” gene
product undergoes considerable modifica-
tion in the cell’s cytoplasm. Enzymes in the
cell may, for example, cleave the active pro-
tein from the precursor – as ACE does to
form angiotensin II. In other cases, the cell
adds sugars to the protein backbone. More-
over the allostery between the amino acids
in the protein means that the protein folds
into a complex three-dimensional shape, to
achieve its biological effect.
Even a single acid change can dramatically
alter the protein’s three-dimensional shape
and function. That is one reason why muta-
tions and polymorphisms, which often sub-
tly change the amino acid sequence, can so
dramatically influence the risk of develop-
ing a particular disease.
So genetically encoded differences in the vi-
tamin D receptor seem to influence patients’
risk of developing osteoporosis7
(for exam-
3
Editorial
ple, Tofteng 2002). The mutation alters vita-
min D’s ability to bind to its receptor. As vi-
tamin D contributes to bone mineral density,
the reduced binding ultimately weakens the
skeleton.
Researchers can grow crystals of these pro-
teins. By examining the way in which the
crystal scatters X-rays, biologists can gain an
insight into the protein’s structure. A comput-
er can integrate these X-ray results with the
protein sequence to show the shape of, for
example, a receptor or an enzyme. This al-
lows researchers to home in on the active site
and design drugs that fit specifically into the
site-rather like a lock and key mechanism.
Nevertheless, validating targets can prove dif-
ficult, especially when the lead comes from
genomic rather than clinical studies. ”Tradi-
tionally, we associate the target and the dis-
ease from clinical studies. So we knew from
clinical and pathophysiological studies that,
in comparison to osteoclasts (bone forming
cells), overactive osteoclasts contribute to
low bone mass,” Professor Van der Auwera
comments. ”However, genomic studies link a
gene to the disease. Discovering what the
gene’s product does can be difficult. Knock-
out animals, which are genetically engineered
not to express the gene, are fashionable and in
many cases allow us to better understand the
link with the disease. Nevertheless, we often
have to go to phase II or even phase III clini-
cal studies to validate the target – which has
an enormous failure rate! Nevertheless, as we
hone our understanding of the gene’s func-
tion, our failure rate is declining.”
Drug discovery
Against this background, the next generation
of drugs for osteoporosis is likely, Professor
Van der Auwera believes, to emerge from ra-
tional drug design and discovery. ”Molecular
biology and genomics identified many targets
that either reduce resorption or increase bone
formation,” he says. ”However, ibandronate
and the other anti-resorptive agents are now
just about as effective as they can be. Any ad-
vances in anti-resorptive agents are likely to
be relatively minor, such as enhancing safety,
tolerability and convenience. The key objec-
tive today is finding a drug to stimulate an-
abolism, the formation for new bone.”
For example, Professor Van der Auwera notes
that up to half the patients using current oral
bisphosphonates may stop taking the treat-
ment within a year, which precludes any re-
duction in the risk of sustaining a fracture.
”Treatment schedules such as a once a month
tablet, instead of weekly (52 tablets) or daily
(365 tablets) can make a huge difference to
compliance”, he comments. ”Likewise for
patients already taking lots of oral medica-
tion, a quarterly intravenous injection can al-
low them to benefit from a very effective
medicine that they would not otherwise take.”
Professor Van der Auwera adds that in addi-
tion to optimising anti-resorptive agents, an-
other key objective for researchers is to find
drugs that stimulate the formation of new
bone (anabolism). ”It is predictable that, at
least for patients with the most severe bone
loss, combination or sequential therapy with
an anabolic drug, probably for a short period
such as 6 months, and an anti-resorptive agent
will become the rule. So we need ‘smart’
treatment schedules allowing the patients to
improve their quality of life without the con-
stant reminder of their disease.”
In many ways, drug discovery has always
been rational. But biologist’s limited under-
standing of the body’s complexities hindered
attempts to develop targeted drugs.And tradi-
tionally time-consuming screening slowed
the development of much needed medicines.
Today, the genomics revolution has massive-
ly increased biologists’ understanding of the
nature of common diseases and identified a
plethora of possible targets. Fortunately, ra-
tional drug design and development give re-
searchers the power to identify and develop
specific and selective drugs that target a sin-
gle cell type or even a single gene product.
The possibilities for new medicines tackling
some of the commonest diseases seem end-
less.8
Modern pharmacological
advances
Epilepsy
Around 30 % of patients diagnosed with
epilepsy fail to respond to prescribed
antiepileptic drugs and continue to have
seizures. These refractory seizures are asso-
ciated with increased mortality and psy-
chosocial morbidity and pose an enormous
human and financial burden. Notwithstand-
ing the seriousness of the problem, remark-
ably little attention has been paid to the bio-
logical basis of refractory epilepsy. Workers
in the field of epilepsy-those concerned with
the basic science of resistance and the
blood-brain barrier, and those with clinical
experience of drug resistance in cancer are
collaborating with a view to exploring par-
allels between the fields and suggesting fur-
ther potentially profitable avenues for ex-
ploration on drug resistance in epilepsy.
Ageing
Social and medical developments during the
past century have led to a dramatic increase
in life expectancy. The study and under-
standing of the endocrine organismic
changes associated with ageing are there-
fore matters of urgency. Basic scientific
facets and clinical aspects relevant to age-re-
lated changes in the multiple endocrine sys-
tems have been discussed. The implications
of therapeutic reconstitution with hormones
in the elderly, could be very important in the
future.
Mucus hypersecretion in respiratory disease
A number of chronic respiratory diseases in-
cluding chronic bronchitis, asthma, cystic
fibrosis and bronchiectasis are characterised
by mucus hypersecretion and this excessive
mucus production can lead to a pathological
state with increased risk of infection, hospi-
talisation and morbidity. Despite a high and
increasing prevalence and cost to healthcare
services and society, this phenomenon has
received little attention until recently, prob-
ably because of the difficulties inherent in
studying its pathology. Basic scientists and
clinicians need to discuss recent advances
and their implications for the development
of novel, rational therapies, particularly as a
potential cure for CF is on the horizon.
Autism as a spectrum
Twin and family data convincingly indicate
that the heritability for the underlying liabil-
ity to autism exceeds 90 % and these studies
point to a multi-factorial causation involv-
ing an interaction among a relatively small
number of susceptibility genes. New tech-
niques are now available for examining the
4
Editorial
neurobiology of autism and imaging studies
have been used to explore the contributions
of different brain regions. The most impor-
tant practical question facing medical and
psychological practitioners is how to help
children with autism. Data on possible psy-
chological or psychiatric interventions for
rehabilitation of children with autism need
to be thoroughly investigated in child pa-
tients in order to prove the link between
MMR injections, inflammatory bowel dis-
ease and autism.
Design of new drugs
Biological modelling and oscillatory prop-
erties represent fundamental approaches to
collating data on gene structure and func-
tion. Since cell signalling systems form a
particularly complicated aspect of all cellu-
lar function and are extremely important
both in the understanding of basic cellular
processes and in the practical problems of
selecting targets for drugs, much work has
been devoted to integrating data on cell sig-
nalling into computer models. Building on
these approaches, computerised models of
intact cells and ultimately of whole organs
can be developed. Not only do computer
models aid understanding of the basic na-
ture of biological systems, but they also
help in the design of new drugs for specific
diseases.
The intrinsic measurement of time in
biological systems
The primary hallmark of biological clocks is
their ability to entrain to environmental stim-
uli and the dominant, and therefore physio-
logically most important, entraining stimu-
lus comes from environmental light cues.
The classical view of the circadian system
describes it as diverse physiological rhythms
regulated by a centralised clock structure.
Data coming from both vertebrate and inver-
tebrate systems have challenged this view,
demonstrating that the circadian timing sys-
tem is dispersed throughout the animal and
that possibly every cell contains a functional
circadian clock. The mechanism of light sig-
nalling to the vertebrate clock, the connec-
tions between central and peripheral clocks,
the genetics of the clock and clock proteins
remain to be evaluated at the molecular lev-
el, for example pairs of enzymes working in
harmony across membrane.
5
Calcium ion flux in smooth muscle
Ion channels play a crucial role in regulating
diverse cell functions in both electrically ex-
citable and non-excitable cells, and have
been found in organisms ranging from
viruses and bacteria to plants and mammals.
An increasing number of diseases (”chan-
nellopathies”) are associated with dysfunc-
tion of ion channels. Control of calcium ion
flux and compartmentalisation in terms of
theoretical biology would be illuminated by
G the structure of channels and pores,
G computer simulations of channel func-
tion, and
G detailed data on potassium channels,
chloride and calcium channels and lig-
and-gated ion channels.
Smooth muscle contraction is crucial to
health as in, for example, blood vessels, the
uterus, airways and bladder and its malfunc-
tion can lead to serious pathological condi-
tions such as hypertension and pre-term
labour. The calcium ion plays a central role
in its function, increasing in concentration
for contraction and decreasing for relax-
ation. The source of calcium is through entry
across the surface membrane and release
from the sarcoplasmic reticulum (SR). How-
ever, recent data have challenged the view
that the SR is simply a source and sink of
calcium ions. Indeed the SR probably also
acts to limit contraction, via ion channel-
based feedback mechanisms. There is a
most important relationship between calci-
um release and inhibition and/or promotion
of contraction, the control and modulation
of the SR in smooth muscle, the extent to
which the SR may vary between smooth
muscles and therefore potential therapeutic
implications.
References
1. Editorial “Bigger isn’t always better“ Nature
2002; 418: 353.
2. Vane JR The fight against rheumatism: from
willow bark to COX-1 sparing drugs. J Physiol
Pharmacol 2000; 51: 573–86.
3. Landau R, Achilladelis B and Scriabine A eds
Pharmaceutical Innovation Chemical Heritage
Press 1999.
4. Sacks O Scotoma: Forgetting and neglect in sci-
ence in Silvers RB (ed) Hidden histories of sci-
ence Granta 1997.
5. Kevles DJ Pursing the unpopular in Silvers RB
(ed) Hiddeen histories of science Granta 1997.
6. Drews J Drug discovery: A historical perspec-
tive Science 2000; 287: 1960–4.
7. Tofteng CL, Jensen JE, Abrahamsen B, et al.
Two polymorphisms in the vitamin D receptor
gene-association with bone mass and 5-year
change in bone mass with or without hormone-
replacement therapy in postmenopausal women:
the Danish Osteoporosis Prevention Study. J
Bone Miner Res 2002; 17: 1535–44.
8. Osteoporosis Care Club e-bulletin, Issue 4, pp
8–12, October 2002,
Ivan M. Gillibrand
Paula Kokkonen, LL.M., Director Gener-
al, National Authority for Medico-legal
Affairs, Finland
Address given at the Ceremonial Session of
theWorld Medical Association, Helsinki 2003
First of all I wish to express my great plea-
sure for this opportunity to address such an
influential audience as represented by this
WMA General Assembly. You represent a
profession which in well organised coun-
tries issues both birth and death certificates,
Medical Ethics & Human Rights
Medicine, the Law and Medical Ethics in a
Changing Society
Medical Ethics & Human Rights
thus controlling human life not only when
people are patients, but also at the beginning
of life and at its end. This fact leads to dis-
cussion of power, responsibility, liability,
ethics, trust and control.
The medical profession has for a long time
been in the forefront of discussions on Med-
ical Ethics. You all know very well the his-
tory of the WMA, established in Paris in
1947 due to the acts that had been revealed
during the Nuremberg trials.
Although I usually present myself as a
lawyer who has sacrificed her life for medi-
cine, I have tried to bridge the two disci-
plines – Law and Medicine – both at home
and also « globally ». Thus I thought that it
may be worth while drawing your attention
to the existence of the World Association for
Medical Law. The purposes of this associa-
tion are
– to encourage the study and discussion of
problems concerning Medical Law and
their possible solutions, in ways that are
beneficial to humanity,
– to promote the study and discussion of
new developments in medicine and re-
lated sciences,
– to address any matters that involve is-
sues of Health Law.
The Association was founded in Gent, Bel-
gium in 1967, that is twenty years later than
the WMA. This is a very concrete sign that
the Law usually follows behind the ethics. I
hope that the gap will be less than twenty
years today.
At the time when the Association was
founded, « Medical Law » was the term used.
The question as to whether we should use
the term « Health Law » instead has recently
been raised. This discussion reflects very
well the developments in the health-care
field. Modern health-care is a very complex
teamwork of many actors and disciplines.
This is also reflected in the legislation.
The development of science has created a
world where we live much longer than did
our ancestors. Many of us who live in the so-
called developed countries have a curricu-
lum of diseases each of which would have
killed our ancestors. There are many actors
interfering in the doctor-patient relation-
ship. One of them is society, which often
bears the major part, if not all of the costs of
health care. In Democracies, the modern
way to organise relationships between indi-
viduals and between citizens and society is
to use legislation as well as agreements.
Earlier, Medical Law was very much in-
volved in questions like setting limits for
« the profession » (i. e. medical doctors),
drafting legislation concerning patients with
contagious diseases, involuntary care of the
mentally ill etc. Then came the discussion of
medical negligence, and slowly after that, of
patients’ rights. Patients were not any more
considered as material, but they were indi-
viduals who had a say in their own treat-
ment. By this time the scientific develop-
ments in medicine had been enormous. Pa-
tients could in many cases be offered the
choice of their own preferred treatment from
amongst a few alternatives. This again in-
creased the demand for more information in
order to allow patients to really make an in-
formed choice.
The result of this, we can recognise in pa-
tient insurance schemes and legislation, and
also legislation on patients’ rights. The Pa-
tients’ Rights movement can be seen as an
reflection of the modern discussions
strengthening human rights and consumer
rights.
From Ethics to Law and Law
to Ethics
In « western societies », a Law passed in Par-
liament reflects the stage of common agree-
ment. Legislation thus consists of the ethical
minimum.
The values documented and instructions
commonly and voluntarily accepted by the
members of a given association or profession
are called ethical rules. The most well-known
of them is, as this audience knows, the Hip-
pocratic Oath, which focussed on the rela-
tions between doctors and doctors vis-a-vis
their patients.
Ethical rules drafted lately by the WMA have,
to my mind, approached legislation. They aim
at giving concrete directives in anticipation of
foreseeable conflicts. Like legislation, ethical
rules are based on facts and values. Values are
culturally bound and thus stand in relation to
a given society and time. Ethical rules are of-
ten compromises that lie on sound ethical
grounds but to which reservations can be
made, and from which it is possible to deviate
under special circumstances.
Ethical discussions in medicine focused first
(with the Hippocratic Oath) on the character-
istics of the doctor, and the point of departure
was that a good doctors performs good deeds.
Wider ethical discussion in medicine dates
back to the Nuremberg trials and the event in
Hiroshima. It was realised that ethical discus-
sion in medicine and in medical research can-
not be limited to the medical profession, but
that society at large has the right to a dia-
logue.
Human dignity, autonomy and the right to
self-determination have been the focus of the
discussion since the Nuremberg trials. The
above mentioned values have also been docu-
mented in many human rights texts such as
the Universal Declaration of Human Rights
(1948), International Covenants on Econom-
ic, Social and Cultural Rights and on Civil
Rights (1966) and the European Convention
on Human Rights (1959), as well as the Con-
vention on Bioethics of the Council of Eu-
rope, which is the latest of them and entered
into force on December 1st 1999.
The values expressed in the Human Rights
documents mentioned above are appropriate
for legislation as well. In fact they are includ-
ed in many Constitutions – not to mention oth-
er legislation.
Why doesn’t the system work in a satisfacto-
ry way although there are so many rules? One
of the reasons is probably the fact that the
good principles cannot easily be found from
the sources mentioned earlier. Or if they are
found they need interpretation, which is not
very easy even for lawyers, not to speak of
lay-people.
Medical Ethics or health-care
ethics draws a great deal of
attention
Most of the topics discussed in the sphere of
medical ethics have been discussed during
decades. To these topics belong the begin-
ning of life as well as the end of it. We have
6
Medical Ethics & Human Rights
been able to witness how insemination has
been developed into assisted reproduction
and surrogate motherhood. Mercy killing is
not any more offered as a topic for scientific
meetings, but euthanasia and terminal care,
as well as assisted suicide are. Dialysis has
been changed into transplantation, which has
brought about a new type of scarcity discus-
sion. This Discussion has escaped the cabi-
nets where doctors used to take difficult de-
cisions as to who was to get dialysis and live,
and who was not. International declarations,
as well as many Constitutions secure the
right to health care. What does this mean in
the era of priorities?
The Transplantation debate has reached the
level where many countries have already for-
bidden the selling of human organs. Interna-
tional Declarations and Conventions also
condemn buying and selling of organs. Yet
there are actors who advocate in favour of
commercial activities in this field, arguing
that a poor person should not be denied the
right to improve his/her standard of living by
selling organs to those in need. The argu-
mentation is that this would just be using fi-
nancial incentives and commercial consider-
ations to save lives.
Human cloning can be used for the develop-
ment of tissue for transplantation, but
« cloning » can also refer to a wide range of
activities, from bringing into existence ge-
netically identical individuals to pre-implan-
tation diagnostics. Distinctions between var-
ious techniques need to be drawn, and their
acceptability has to be discussed thoroughly.
When discussing ethics and legislation, it is
useful to keep in mind that theoretical dis-
cussion may widen our perspectives and give
new ideas. It may thus enrich our thinking
and decision making, and will help us to
recognise at least our own motives.
Lay-people very often think that legislation
is an open process of fundamental thinking
and great elegance, as the ideal would de-
mand. The common truth is very different.
Open, profound discussion is often either ab-
sent or takes place in very small circles.
Health-care is an area of great common in-
terest. There has been, still is, and may be
even a growing tendency to try to increase
the sphere of health-care. There is a tenden-
cy to try to medicalise social problems and
ask doctors to testify more and more in mat-
ters that are not medical, or to ask them to
isolate people for reasons other than med-
ical. In our society we are to discuss for
whom we are designing health-care services,
and what are the values of the population.
Pressure, routine generally accepted behav-
iour, and the atmosphere, may be used as an
excuse to deviate even from the ethical prin-
ciples accepted by ourselves. The most com-
mon excuse is, of course, that the patient
does not really understand his/her own best
interest. But this way of thinking brings us to
a weak soil, both ethically and legally.
In health-care we need both legislation and
ethical rules. The aim of both is to promote
co-operation and minimise conflicts.As time
passes our values may change, and the leg-
islative process is often rather slow. In the
meantime ethics may guide us and cast a
light for the developing legislation. An ex-
ample of ethical discussion leading to legis-
lation is The Finnish Law on the Status
and Rights of a Patient.
Finnish Law
Following a long-almost twenty years de-
bate, the Law on the Status and Rights of a
Patient was finally passed in the Finnish Par-
liament in 1992 and it entered into force on
1st March 1993, ten years ago.
In all legislative work, the history and cul-
tural tradition of a country, as well as previ-
ously existing legislation and administrative
systems and structures, have to be taken into
consideration. Legislation may be described
as a safety net. If you are going to mend the
net, you have to know where the holes are.
Thus I do not offer our law as a global solu-
tion applicable to all societies and problems
a patient may ever experience in the field of
health-care.
Our law regulates, inter alia, the patients’
right to good health care, to medical care
and related treatment when needed; the right
of access to treatment, to be informed and of
self-determination; the status of minor pa-
tients; emergency treatment; powers of the
representatives of the patient in certain situ-
ations, and a new complaint procedure.
It also establishes a Patient Ombudsman in-
stitution.
Right to care
Every person who stays in Finland perma-
nently is entitled, without discrimination, to
the health and medical care required by
his/her state of health, within the limits of
resources available to health care at the time
in question.
This provision has drawn much attention
now that the discussion concerning the divi-
sion of scarce resources has once again sur-
faced. It was originally designed with the
notion in mind that society has the right to
limit how much and what kind of care it pro-
vides for its citizens. (There had at that time
been cases of Finnish citizens demanding
that they be sent abroad at society’s expense
for treatment which was not available in
Finland.)
The care has to be of good quality, the pa-
tients’ dignity must not be violated and
her/his individual needs and culture have to
be taken into account as far as possible.
These provisions sound perhaps like mere
declarations, but they are still important.
They can be especially important in cases
where psychiatric care is required, since
mental patients and their relatives are, at
least according to our Finnish experience,
very often not capable of defending their
own rights.
Patient’s right to be informed
The right to information is closely connect-
ed to the right of self-determination, be-
cause the latter cannot be exercised without
the former.
How much information and in which form it
is given to patients, seems to vary between
countries. The right to information has dur-
ing the last quarter of the century, been in-
creasingly emphasised in Finland.Yet, judg-
ing from the patients’ complaints the situa-
tion is far from satisfactory. The law speci-
fies that various alternative methods of treat-
ment and their effects have to be explained
to the patient. It is noteworthy that the law
7
Medical Ethics & Human Rights
also gives the patient the right not to know,
and the « therapeutic exception » – the with-
holding of information from the patient in
certain cases. The information to be given
should be tailored to the individual patient
and interpreters should be used if needed.
Patients’ right to self-determi-
nation
With the provision of health care, a mutual
understanding between patient and care-
giver must exist. If the patient refuses a cer-
tain treatment or measure s/he has to be
treated according to the possibilities provid-
ed by another medically acceptable way, in
mutual understanding. There had been cas-
es in which, for example, a terminal cancer
patient had refused radiation because of
side effects. This led to a discussion in
which the patient was threatened with de-
portation.
There are also provisions in the law accord-
ing to which a legal representative etc. can
interpret the patient’s will. It is, however, to
be emphasised that it is the patient’s will
which is decisive and not the representa-
tives. If the patient’s will cannot be assessed,
that patient has to be given the treatment that
can be considered to be in accordance with
his/her personal interests.
Emergency treatment
A patient has to be given treatment necessary
to ward off a hazard imperilling her/his life
or health even if it is not possible to assess
the patient’s will because of unconsciousness
or other reason. However, if the patient has
previously steadfastly and competently ex-
pressed her/his will concerning the treatment
given to her/him, s/he must not be given
treatment that is against her/his will.
The latter part of this section is aimed at
guaranteeing the patient’s right to self-de-
termination. For instance, the patient’s
right to draft a valid „living will“ is based
on this provision, as is the right of an adult
Jehovah’s Witness to refuse a blood trans-
fusion even after losing consciousness –
both are topics constantly debated in
health care.
Complaints
A patient who is not satisfied with the health
care or medical care and related treatment
received by her/him, has the right to make a
complaint on the matter to the director re-
sponsible for the health care unit in ques-
tion. A decision on the complaint must be
given within a reasonable time after the
making of a complaint.
Making a complaint does not restrict the
right of a patient to appeal to the authorities
controlling health care or related treatment
received by her/him.
If, once the complaint has been dealt with it
becomes obvious that the care or treatment
of the patient my cause liability for patient
injury, indemnification liability, taking legal
action, cancelling or restricting the right of
vocational practice of health care staff, or
taking disciplinary proceedings, the patient
shall be advised as to how the matter can be
initiated through a competent authority or
organ.
When investigating a complaint, special at-
tention is paid to patient safety, the equality
of citizens, and good service to consumers
of health services.
Patient Ombudsman
A Patient Ombudsman, who may also be
common for two or more units, has to be ap-
pointed for health care units. The tasks are to
advise patients on issues concerning the ap-
plication of the Law on Patients’ rights, to
help patients in complaints and liability
questions, to inform patients of their rights,
and to act also for the promotion and imple-
mentation of patients’ rights.
There are hundreds of Patient Ombudsmen
in Finland. The National Authority of
Medico-legal affairs has organised sym-
posia for them at the State level, and the
Provincial Boards at the provincial level.
Ethics and Law
The Law on Patients’ Rights is our attempt
in Finnish society to try to clarify and to
strengthen a few of those rights of patients
which in everyday clinical practice, seem to
have caused insecurity, and have resulted in
varying interpretations and complaints to
supervising authorities. We have tried to
keep in mind that the rights of the health-
care personnel and the patients ought not to
conflict but should be seen as complemen-
tary.
It is obvious that we need both Ethical Rules
and Law. Nowadays they seem to be in in-
teraction. Health care professionals are very
conscious about the situation. Professional
organisations, both domestic and interna-
tional, draft Ethical Rules with the aim of
improving quality control of the work of
their members. Yet society also drafts legis-
lation, as it wants to control the professions
and the work of professionals, and to guide
them.
The training and curricula of health care
professions are under reflection. I want to
inform you that there is a world-wide pro-
ject under the UNESCO Chair of Medical
Ethics, Professor Amnon Carmi, to draft a
universal curriculum for teaching medical
ethics. The project involves more than 50
universities in different parts of the world
and 124 professors. The aim is to collect
some 20-30 booklets dealing with living
cases, offering from two to three ethical so-
lutions. The approach is multicultural and
aims at showing that ethics cannot be taught
by just giving information. Students have to
be involved in discussions and trained in de-
cision making.
New challenges are ethics, behavioural sci-
ences, genetics and information technology.
The two latter disciplines offer powerful
tools to be used in health care for the bene-
fit of humanity, but they also carry risks if
they are used irresponsibly. A more compre-
hensive approach than today’s strictly bio-
medical one towards patients is a « must » for
health care professionals in the future, if
they want to be trustworthy. It is clear from
statements made in public speeches that
ethics is widely being introduced into the
curricula. In addition to the ethical and the
biological, other aspects of human life are
also being discussed. This will no doubt
bring « added value » to the well being of the
people.
8
Medical Ethics & Human Rights
The 55th
General Assembly of the WMA1
took place in Helsinki on September 2003,
a long-waited meeting which it was hoped
would have allowed the controversies that
arose from the latest version of the Decla-
ration of Helsinki to settle. A final agree-
ment in the town where the Declaration
had been established for the first time in
1964 would give a symbolical value to the
event. This paper sets out a personal view
of the twists and turns of the ethical dis-
cussion concerning the most recent ver-
sion.
The 6th
edition of the Declaration of
Helsinki2
was adopted in Edinburgh on Oc-
tober 7, 2000. During the debates, several
delegates had asked that the adoption of
this new version be postponed. They were
expecting many criticism from researchers
and sponsors, but their warnings were soon
swept away, it being said that the credibili-
ty of the WMA would be compromised if
the revision (already announced for a long
time) would be delayed after so many
years of preparatory work.
Nevertheless those who had argued for a
time of further reflection had been right:
suddenly some members of the WMA
raised serious objections to the previous
unanimously adopted version. The United
States especially had rebukes from their
rearguard – read the FDA3
. The sources of
irritation were paragraphs 29 and 30, re-
spectively concerning the use of placebo,
and the participants’ right of access to the
best-proven treatment identified by the
study.
The opponents of paragraph 29 considered
that studies controlled by placebo were es-
sential for a reliable statistical assessment
of the results of the trial. This is moreover
the reason why the FDA recommends sys-
tematic control, because the methodology
of the scientific study is otherwise worth-
less, and if worthless, the research projects
do not receive subsidies. By following
paragraph 29, institutions, including uni-
versities, have taken the risk of a negative
response from their Institutional Review
Board4
, from the NIH5
and obviously
from the FDA. Therefore several scientific
projects involving human subjects have
been interrupted and others not even start-
ed. In the circumstances the protests are
understandable.
The opponents of paragraph 30 empha-
sised the very poor functioning of the
healthcare systems in poorly resourced na-
tions where most experimentation involv-
ing human beings is carried out. This para-
graph would oblige the pharmaceutical
companies to provide the participants with
the best-proven treatment identified at the
end of the study. From the drug industry’s
point of view this cannot be afforded.
The academic authorities and spokesper-
sons of the pharmaceutical industry insist-
ed very firmly that the Declaration of
Helsinki should be amended. They would
otherwise seriously be thinking of not re-
ferring anymore to the strong mandatory
character of the Declaration of Helsinki.
Such a boycott would mean a loss of pres-
tige for the WMA whose Declaration of
Helsinki is its pride. Basically nobody in-
tended to undermine the moral leadership
of the WMA regarding research, and cer-
tainly not the developing countries.
In order to avert an imminent crisis the
WMA organised a conference in Pretoria
on March 2001, in collaboration with the
EFGCP6
and the University of Pretoria
School of Health Systems and Public
Health, which had the appearance of an
emergency sitting. Representatives of the
pharmaceutical industry, of the FDA and of
the NIH were numerous. In contrast the at-
tendance of developing countries was on
the other hand very sparse, possibly be-
cause they were financially too weak to be
represented.
The only agreement that could be reached
in Pretoria was that the Declaration of
Helsinki had to remain the most important
guideline in the field of research. The few
countries which could hardly accept the
paragraphs 29 and 30 would just have to
come to terms with it. However these
« few » countries were clearly the richer
countries who persisted in protesting and
asking for revision. A revision of the dec-
laration hardly a few months after its adop-
tion was politically not feasible, as it would
have undoubtedly led to the view that the
WMA had bowed to the financial interests
of the rich countries.
To get out of the deadlock, the Council of
the WMA has simply attributed this impor-
tant difference of opinion to difficulties in
interpretation of the controversial para-
graphs, which could be easily resolved by
adding notes of clarification and through
amendments if necessary. The United
States agreed with the proposal that the de-
claration would not be rewritten, but para-
graphs 29 and 30 would be examined
closely. The situation was defused!
A working group would examine whether
paragraph 29 was really an obstacle to reli-
able scientific research and also consider
the financial implications of paragraph 30.
It was felt advisable to involve in the dis-
cussions external representatives respected
for their moral authority and expertise.
Thus the CIOMS7
took part in the debates
despite engaging in rewriting its own « eth-
ical guidelines for biomedical research »8
.
The working group decided to add a note of
clarification to paragraph 29 rather than
rewrite it. The note of clarification was
adopted by the 160th the Council of the
WMA, October 7, 2001, and is now an inte-
gral part of the Declaration of Helsinki.
The unchanged paragraph 29 and its added
note of clarification read as follows:
« Paragraph 29:
The benefits, risks, burdens and effective-
ness of a new method should be tested
against those of the best current prophylac-
9
Medical Ethics & Human Rights
Helsinki and the Declaration of Helsinki
P. G. DE ROY
Member of the Belgian National Council of the Order of Physicians
tic, diagnostic and therapeutic methods.
This doesn’t exclude the use of placebo, or
no treatment, in studies where no proven
prophylactic, diagnostic or therapeutic
method exists. »
« Note of clarification on paragraph 29 of
the WMA Declaration of Helsinki
The WMA hereby reaffirms its position that
extreme care must be taken in making use of
a placebo-controlled trial and that in gener-
al this methodology should only be used in
the absence of existing proven therapy.
However, a placebo-controlled trial may be
ethically acceptable, even if proved therapy
is available, under the following circum-
stances:
– Where for compelling and scientifically
sound methodological reasons its use is
necessary to determine the efficacy or
safety of a prophylactic, diagnostic or
therapeutic method; or
– Where a prophylactic, diagnostic or
therapeutic method is being investigated
for a minor condition and the patients
who receive placebo will not be subject
to any additional risk of serious or irre-
versible harm.
All other provisions of the Declaration of
Helsinki must be adhered to, especially the
need for appropriate ethical and scientific
review. »
Commentators judged that rather than throw
light on the paragraph, this note of clarifica-
tion by reintroducing the use of placebo,
certainly on well-defined conditions, made
it meaningless. Some claim that this would
finally be of benefit to scientific research;
while others considered that the ethical im-
plications for poor countries didn’t get
enough attention.
Paragraph 30:
« At the conclusion of the study, every pa-
tient entered into the study should be as-
sured of access to the best proven prophy-
lactic, diagnostic and therapeutic methods
identified by the study. »
This paragraph needs to be read with para-
graph 19.
Paragraph 19:
„Medical research is only justified if there is
a reasonable likelihood that the populations
in which the research is carried out stand to
benefit from the results of the research.“
Both paragraphs deal with the sensitive sub-
ject of experimentation on human beings in
developing countries. Without these para-
graphs, the protection of participants is vir-
tually non-existent.
The supporters of an unchanged paragraph
30 recalled that the Declaration of Helsinki
adopted in 1964 was directly inspired by the
Nuremberg Code. This Code refers to the
mandatory safeguard of participants’ rights,
especially for the most vulnerable. Other in-
ternational authorities such as the CIOMS
and the EGE9-10
also favoured the protection
of population groups involved in clinical re-
search.
The dispute about paragraph 30 showed a
gap between North and South, between
wealthy nations and poor nations. The re-
source-poor nations consider that they have
a right to the best-proven treatment identi-
fied by the study. In practice however, the
experimental treatments usual cease at the
end of the study. The group in question for
whom the only available treatment is that in
the investigation, is then left on its own, with
no-one concerned about them.11
The devel-
oping countries invoke paragraph 30 specif-
ically to prevent conduct which, in their
view, is unethical. Paragraph 30 is their last
defence.
The resource-rich countries say that these
people would not anyway have access to
some treatments. The pharmaceutical com-
panies are not inclined in these conditions to
engage in heavy financial commitments.
Companies are not humanitarian aid organi-
sations, but are, fully prepared to sustain re-
search knowing that they will profit from
some of it allthough they don’t intent to set
up and pay the cost of effective healthcare
systems for under-resourced countries. The
companies are not satisfied with paragraphs
19 and 30, taking a less absolute approach to
the right of participants to the best treatment
and its cost. An ethical declaration is not a
law and it is ultimately only mandatory to do
one’s best to observe it. Often the researcher
is not able to decide which is the best treat-
ment at the end of the research, the results of
which must be compared with others before
knowing which treatment is best; it can take
decades before a medicine becomes avail-
able on the market.
Those who have ever heard the plea of rep-
resentatives of developing countries recall
how distressing their message is. With dig-
nity, they make a distinction between their
frustrations and the harm done to them with-
out anger, but resigned to the misfortune of
having to cope with a poor health care sys-
tem and a cruel lack of technology, pharma-
ceuticals and basic welfare. For many this
means utmost poverty and reliance on char-
ity to survive. They don’t have Social Secu-
rity (= the Heath Service) based on solidari-
ty as in the wealthier countries and fre-
quently mentioned in the WMA.
Virtually everyone is convinced that these
well founded concerns are justified and that
many things need to be done for developing
countries, but by whom it is to be done ap-
pears much less clear. For the rich countries,
this large-scale problem can’t be solved by
the Declaration of Helsinki but by the local
authorities. But the response is that this is
another debate (in which the term « corrup-
tion » often appears), and in which the eco-
nomically weak are reduced to silence. It
rests with the poorer countries to interpret
paragraph 30 correctly. Its aim is not to make
drugs available to the population of the Third
World but to protect that population from
possible exploitation in clinical trials.
In this period of growing commercialisation
and globalisation, the poorer countries won-
der anxiously, what will be left of paragraph
30, their only glimmer of hope, after its clas-
sification by the wealthy countries.
The General Assembly promised to contin-
ue working on the problem meanwhile leav-
ing the paragraph unchanged – hopefully for
not too long, think those countries which re-
member well where they buried the hatchet
in May 2001. Certainly the debate will con-
tinue …
No-one questions the Declaration of
Helsinki as being an authoritative reference
document. Its implications are ethically
binding on everyone involved in scientific
10
Medical Ethics & Human Rights
clinical research, including both the inves-
tigator as sponsor on the study, and the
members of ethic committees. It is there-
fore satisfying that the Declaration of
Helsinki is often referred to in both Euro-
pean and national law. In March 2001 in
Pretoria, the draft European directive
2001/20/EC on « the approximation of the
laws, regulations and administrative provi-
sions of the Members States relating to the
implementation of good clinical practice in
the conduct of clinical trials on medicinal
products for human use » was presented.
The Assembly was very keen that the direc-
tive should refer to the Declaration of
Helsinki which would give it the force of
law, at least in the Members States of the
European Union.
The Directive was published on May 1,
200112
, and refers to the Declaration of
Helsinki in its preamble. But one is amazed
to discover that it refers to the obsolete ver-
sion of 1996 and not to that of 2000. Thus
the last revised version with its hindering
prescriptions regarding to drug industry is
considerably weakened.
The Member States of the European Union
have to transpose the directive into their na-
tional legislation for May 1, 2004. Although
the directive refers to the version of the De-
claration of Helsinki of 1996, we hope that
national legislators will take into account
the last stance of the WMA thus avoiding
(by way of parody!) that someone consults
an invalidated version of the Highway Code
to determine his way of driving! The time
has come both for WMA and for the phar-
maceutical industry to decide on driving ei-
ther on the left or on the right, in other
words, to choose in favour of the rich or the
poor.
References:
1. World Medical Association
2. https://www.wma.net/e/policy/17_e.html
3. Food and Drug Administration
4. Similar to the committees of ethics in Belgium
5. National Institutes of Health
6. European Forum on Good Clinical Practice
7. Council of International Organisations of Med-
ical Sciences, www.cioms.ch
8. CIOMS Revised ethical guidelines for biomed-
ical research involving human subjects. August
2002; ISBN 92-9036-075-5. Text available
online
9. European Group on Ethics in Science and New
Technologies;
http://europa.eu.int/comm/european_group_eth
ics
10. Advice of February 17, 2003: Ethical aspects of
clinical research in developing countries; text
available online
11. To be perfectly honest, a few remarkable excep-
tions must be noticed
12. Official Journal of the European Communities L
121/34 1.5.2001
Editorial note:
Following the September 2003 Council
meeting in Helsinki (see WMJ 49 (5/6), 71),
the working group on the Helsinki Declara-
tion has continued its work and following
the many comments, discussions and con-
sultations, and will present a report to the
WMA Council meeting in May 2004.
11
Medical Ethics & Human Rights
Introduction
The Declaration of Helsinki has played a
seminal role in promoting protection of re-
search subjects from abuse and exploitation.
However, as medical advances have benefit-
ed only a small proportion of the world’s
population it cannot be claimed that moral
progress has matched scientific progress.
Given the limited value of progress for hu-
mankind as a whole if its benefits are not
widely shared, it is essential that scientific
progress be coupled to moral progress in re-
search and in access to health care. We have
previously argued that moral progress will
require more than new or refashioned decla-
rations, as it is people with the will and the
capacity to implement the content of decla-
rations that are the key factor. The recent fo-
cus on the future of the Declaration of
Helsinki at the 2003 World Medical Associ-
ation (WMA) General Assembly scientific
meeting provides an opportunity to consider
the potential for making moral progress
through visionary modifications to this Dec-
laration.
Linking moral progress to medical progress:
New opportunities for the Declaration
of Helsinki1
Solomon R Benatar MBChB, FRCP, Professor of Medicine, University of Cape Town
Summary
G Progress in science and medicine is
essential for human advancement.
G Ethical values are essential in direct-
ing the application of scientific and
medical advances.
G Moral progress requires that the bene-
fits of progress be shared more wide-
ly and more equitably throughout the
world.
G Scientific and medical progress
should be inextricably linked to moral
progress.
1 Based on a presentation at the WMA General
Assembly in Helsinki in September 2003
Discussion
Moral progress in research on human sub-
jects since the infamous Nazi human exper-
iments, is evident in many activities. These
include the development of many codes,
guidelines and procedures for research
ethics that aim to protect research subjects
from harm and exploitation, and the increas-
ing attention being paid by scientists and
others to the requirements for ethical re-
search. Expansion of international collabo-
rative research has prompted generous fund-
ing from the US National Institutes of
Health’s Fogarty International Centre for
promotion of capacity building in research
ethics in developing countries.1
However, there is a wide gap between scien-
tific/medical progress and moral progress in
medical research and practice. This is stark-
ly evident from widening disparities in
health, longevity and health care and in the
expenditure on medical research. Indeed
questions must be raised about the moral
credibility of a medical research endeavour
in which 90 % of US$ 73 billion is spent on
diseases that cause 10 % global burden of
disease (10 : 90 gap),ii
and only 16 of the
1393 new drugs marketed from 1975-1999
were for tropical diseases or tuberculosis.iii
Dealing with such moral challenges requires
that in addition to preserving and enhancing
commitment to long-standing values in re-
search ethics (Box 2), several new values be
built into the research endeavour (Box 3).
In evaluating the research enterprise and
possible future changes to the Declaration of
Helsinki from a moral perspective, a critical
question that could be asked is what the pri-
orities of the World Medical Association
(WMA) and its Declaration should be. That
is, whose agenda should the WMA be ad-
dressing through the Declaration? Choices
include the pharmaceutical industry; med-
ical associations in North America and Eu-
rope; the US Federal Drug Administration;
researchers in privileged countries; the
health of those who already have the
prospect of long lives; the health of those dy-
ing prematurely from preventable diseases,
or the health of all people at a global level.
Given the widening disparities in health
globally,iv
and the presumption that the
health of all people globally is the concern of
the WMA, it is suggested that incorporation
of new ethical values in research (Box 3) into
the Declaration of Helsinki could enhance
the « moral capital » of the Declaration. This
in turn may lead to reduction in disparities in
health and medical research.
Suggested Changes to the
Declaration of Helsinki
An appropriate preamble to the declaration
could sensitise research workers to imbalance
in the research agenda.
« Spectacular developments in science, tech-
nology and medical practice have transformed
health care and improved the lives of many.
Despite such progress millions of people live
in degrading poverty with little access to
health care and are denied even basic medical
treatments. Because improving the potential
for good health for a greater proportion of the
world’s population is one of the most pressing
moral problems of our time, research should
increasingly be directed towards diseases that
afflict poor and marginalised people. Those
undertaking research in developing countries
should also have some understanding of and
be sensitive to the social, economic and politi-
cal milieu that frames the context in which
such research is undertaken. Lessons learned
from research should be made more equitably
available world wide and used to improve re-
lationships between host and sponsoring
countries, as part of the endeavour to improve
health globally. »
The declaration states that medical research
involving human subjects must conform to
generally accepted scientific principles, and
be based on a thorough knowledge of the
scientific literature. An accompanying state-
ment should indicate that all such research
should conform to accepted ethical princi-
ples, be based on a thorough knowledge of
the research ethics literature, and that med-
ical research involving human subjects
should be conducted by scientifically quali-
fied persons with knowledge of research
ethics.
It should also be explicitly stated that exploita-
tion of subjects, or their use as means to the
ends of others, must be avoided by ensuring
that the research is of relevance to the individ-
uals participating in the research as well as to
their communities. The balance of benefits and
burdens of research should be fairly distrib-
uted with due consideration of the benefits that
could accrue to sponsors in the long term, and
to ensuring that studies are not done with the
intention of spending as little as possible on
care of research subjects and the communities
12
Medical Ethics & Human Rights
Box 2. Long-standing
ethical values in research
ethics
G Do not harm
G Minimisation of risk
G Protection of the vulnerable
G Respect for dignity of patients/sub-
jects
G Informed consent
G Protection of confidentiality
G Freedom to withdraw
G Justice
G Compensation for injury
G Appropriate remuneration for
participation
Box 3. Newer ethical values
in research ethics
G Justice
G Fair access to participation in re-
search studies
G Fairness in distribution of harms/ben-
efits – long term as well as short-term
G Non-Exploitation of the vulnerable
G Coupling the research endeavour to
improvements in health care through
partnerships and improves overall
standards of care in research
G Relevance of research to local needs
– the importance of context
G Narrowing the 10 : 90 gap by re-
shaping the research agenda
G Cultural and linguistic sensitivity
in obtaining informed consent
G Solidarity and interdependence –
acknowledging and facing global
threats
G Addressing deteriorating global
health
G Focusing on re-emerging and new
infectious diseases
G Global health information equity
in which they live, when large profits may re-
sult from the research.
Care should be taken that research does not in-
appropriately deflect local human or material
resources away from the health care system in
the host country towards research projects,
thus more deeply entrenching existing dispari-
ties. Priors evaluation by a local committee or
governing body should include consideration
of whether study findings can, and will be in-
corporated into the local health care system.
Informed consent should be obtained in the
language spoken by the research subject and
with insight into, and respect for the subject’s
culture.
At the conclusion of the study, every patient
should receive interventions identified as ben-
eficial by the study, or access to other appro-
priate care. This is particularly important for
patients with serious conditions for whom ces-
sation of the study intervention could have se-
vere consequences. Research in developing
countries should be linked to a broader notion
of standard of care, to capacity building in
health care, and to economic and educational
empowerment that could benefit delivery of
health care specifically, and progress general-
ly, in the host country. Some of these issues are
being addressed in an expanding discourse on
research ethics and much remains to be
done.v vi vii viii ix
Conclusions
Disparities in global health pose the greatest
potential security risk to the lives of all people
in the world.x
We are challenged to recognise
this risk and to take appropriate action. To
paraphrase Virchow « health is political and
population health is politics writ large ». Re-
search is also political and it does not take
place in a vacuum.
Scientific progress must be coupled to moral
progress, and in particular in relation to social
justice. The Helsinki Declaration has the po-
tential to stimulate moral progress in research.
Such progress, if made, will be reflected in re-
ductions in health inequity, and in improve-
ments in population health.
Acknowledgement. I thank Peter Singer for construc-
tive comments.
13
WMA
World Medical Association
Presidential Address of Dr. James Apple-
yard to the General Assembly of the World
Medical Association, Helsinki, September
2004
”The level of civilisation attained by any so-
ciety will be determined by the attention it
has paid to the welfare of its children.” Pro-
fessor Billy Andrews (1964)
The continuing challenge facing the World
Medical Association is to maintain and pro-
mote the professional values that underpin
medical practice world-wide. At the 90th
birthday celebrations of our hosts the
Finnish Medical Association entitled ”pro
humanitate”, the Emeritus Archbishop of
Helsinki encouraged physicians to reaffirm
our shared values so that they became ”in-
ternalised” as our professional conscience.
Our conscience should become our compass
in the everyday practice of medicine and for
our role as leaders and teachers in the field
of healthcare.
The Hippocratic tradition recognises our re-
sponsibility to respect the individual
”rights” of those who entrust themselves to
our care. This respect for our patients, nur-
tured by our profession in the patient/physi-
cian relationship, is fundamental for the sur-
vival and development of communities and
nations.
The standards we set in our WMA Declara-
tions are important safeguards for our pa-
tients. The Declarations of Geneva(1),
Helsinki (2) and Tokyo (3) in particular re-
established ourselves as a trustworthy ethi-
cal profession after the horrors of World
War 2. More recently we have established
essential standards for the care of children
world-wide in the Declaration of Ottawa on
the ”Right of a Child to healthcare”(4)
Children are a country’s most valuable re-
source. Poverty and the denial of children’s
rights have devastating effects on our chil-
drens’survival. The World Health Organisa-
References
i Singer PA, Benatar S R. Beyond Helsinki: a vision
for global health ethics. Brit. Med. J. 2001; 322:
747-8
ii Commission on Health Research for Development.
Health Research: Essential link to equity in devel-
opment. OUP. Oxford. 1990.
iii Trouiller P, Olliaro P, Torreele E, Orbinski J, Laing
R, Ford N. Drug development for neglected dis-
eases: a deficient market and a public health fail-
ure. Lancet. 2002; 359: 2188-94 4
iv Benatar S R. Some reflections and recommenda-
tions on research ethics in developing countries.
Social Science & Medicine. 2002; 54 : 1131-41
&1147-48
v Benatar S R, Singer P A. A new look at interna-
tional research ethics. Brit Med J 2000; 321: 824-
26
vi Lo B, Bayer R. Establishing ethical trials for treat-
ment and prevention of AIDS in developing coun-
tries. Brit Med J 2003; 327: 337-9
vii Berkley S. Thorny issues in the ethics ofAIDS vac-
cine trials. Lancet 2003; 362: 992.
viii Fitzgerald D, Pape J W, Wasserheit J N, Counts G
W, Corey L. Provision of treatment in HIV-1 vac-
cine trials in developing countries. Lancet 2003;
362: 993-4
ix Tucker T, Slack C. Not if but how? Caring for HIV-
1 vaccine trial participants in South Africa. Lancet
2003; 362: 995.
x Benatar S R. The coming catastrophe in interna-
tional health: an analogy with lung cancer. Interna-
tional Journ 2001; LV1 (4)611-631
Address for correspondence
Bioethics Centre,
Department of Medicine
University of Cape Town
J Floor, Old Main Building
Groote Schuur Hospital
Observatory
7925 Cape
South Africa
Tel +27 +21 406 6115
Fax +27 +21 448 6815
Email sbenatar@uctgshl.uct.ac.za
”Getting it Right for our Children”
tion’s Commission on Macro-economics
and Health has recognised that substantially
improved health outcomes are a pre-requi-
site if developing countries are to break out
of the cycle of poverty.(5) Healthy children
become healthy, more productive adults and
remain healthier in their old age.
A study of the ”Value of Children” was con-
ducted in nine countries comparing parents’
motivation for child bearing.(6) It was found
that in less developed countries where chil-
dren were conceived to be ”used” for eco-
nomic reasons, there was a relatively high
fertility rate. In more affluent countries
where children were conceived as loved in-
dividuals in what was termed their ”psycho-
logical value”, there was a lower fertility
rate. With improvement in health and educa-
tion, less children will die and less
children will be conceived.
UNICEF publish international com-
parative tables of the under five mor-
tality rate per 1,000 births.(7) This is
a remarkably sensitive indicator of
how individual nations ”value” their
children. Top of the list with the low-
est mortality rate is Sweden, which
has only around 3 children dying un-
der five year of age per 1,000 births
(Table 1). Bottom of the world list is
Sierra Leone with 316 children per
1,000 dying under the age of five
years (Table 2). That country is ”sac-
rificing” nearly one third of its
young children. The difference be-
tween the top and bottom nations is
100 fold. This differential reflects
that widening gap between the
”rich” and ”poor” nations which is
unsustainable for clear humanitari-
an, health and economic reasons.
Just how sensitive this ”index” is to
the ”political” factors of a nation can
be seen in table 3. With a very simi-
lar birth rate and gross national in-
come per capita to Tanzania, Uganda
has ”saved” the lives of some
50,000 children under five in 2001
as compared to the rate in 1990.
Neighbouring Tanzania however
made no real progress. Likewise
over the same ten year period, the devastat-
ing deterioration in the survival of children
under five in Iraq contrasts dramatically
with neighbouring Iran. The additional
loss of around 20,000 children under five
in Zimbabwe as compared to ten years ago
will have very serious consequences for
the future of that country.
Though the difference in the Gross Nation-
al Income per capita in US$ between the
top and bottom ten nations in the UNICEF
list is enormous, the correlation between
how rich a country is and how much it in-
vests in its children is variable. For in-
stance Cuba has had half the gross nation-
al income per capita of Iraq but they are
ranked 42nd, whereas Iraq has fallen to
162nd of the 195 nations in the world
which are recognised by the WHO
(Table 4). Slovenia (6th) has an under five
mortality rate of only 5 with a GNI of
9,780 US$, which is significantly above
the United Kingdom (31st) with a GNI of
well over twice as much!
The major causes of the under 5 mortality
world-wide are diarrhoea, malnutrition,
malaria, measles, HIV/AIDS and Pul-
monary Tuberculosis. Each of these condi-
tions is easily preventable and treated. In-
deed the World Bank has estimated that if
the burden of infectious disease were lifted
from the developing world, the gap be-
tween the richest 20 and poorest 20 nations
would largely be bridged.(17)
So what action can national medical asso-
ciations take to effect change? Their mem-
bers are involved in and affected by all as-
pects of these problems. There needs to be
both the central political will to make
changes as well as an effective local infra-
14
WMA
Country Value Rank Gross National
Income per capita
US$
Sweden 3 1 25,400
Singapore 4 2 24,740
Norway 4 35,530
Iceland 4 28,880
Denmark 4 31,090
Slovenia 5 6 9,780
Monaco n/a
Malta 9,120
Luxembourg 5 41,770
Korea 5 9,4000
Table 1 – Under 5-year mortality – Top 10
Country Value Gross National
Income per capita
US$
Sierra Leone 316 140
Niger 265 170
Angola 260 500
Afghanistan 257 250
Liberia 235 490
Mali 231 210
Somalia 225 120
Ginea Bissan 211 160
Congo 205 700
Zambia 202 320
Table 2 – Under 5-year mortality – 10 na-
tions with highest rates per 1,000 births
Country Value Rank Gross National
Income per capita
US$
Japan 5 11 35,990
Greece 5 11,780
Germany 5 23,700
Finland 5 23,940
Czech 5 5,270
Austria 5 23,940
Switzerland 5 36,970
Spain 5 14,860
San Marino 6 19 n/a
Portugal 6 10.670
Country Value Rank Gross National
Income per capita
US$
Israel 6 24 16,710
United Kingdom 7 31 24,230
United States 8 34 34,870
Cuba 9 42 1,170
Kuwait 10 43 18,070
Occ. Palestine 24 80 1,350
China 39 110 890
Iran 42 114 1,750
Zimbabwe 123 156 480
Iraq 133 162 2,170
Table 3 – Selected countries – under 5-year
Mortality ranking and GNI
structure in which changes can be made.
This requires advocacy with professional
and allied partners, and the setting of prior-
ities for action.
Water and Sanitation
About 1,2 billion people world-wide lack
access to safe drinking water and 2,4 billion
lack adequate sanitation, giving rise to dis-
eases such as diarrhoea, cholera and tra-
choma. In poor countries it has been esti-
mated that at any one time, about half the ur-
ban population is suffering from one or
more of the diseases associated with the lack
of water and proper sanitation.(8) The inci-
dence of diarrhoea can be reduced by near-
ly a quarter and the number of deaths by
close to 2/3rds, through improvements in
safe water supply with sanitation and hy-
giene. The cost of realising universal access
to health, water sanitation and education,
was estimated by the United Nations and the
World Bank in 1995 to be an additional
70–80 billion dollars per year. The World
leaders can and must afford this. The Ugan-
dan Medical Association has made ”sanita-
tion” their theme for the coming year.(9)
The Japan Medical Association is leading
the WMA’s current initiative on key issues
concerning water world-wide.
Malnutrition
More than half the deaths of children in the
world under the age of five are associated
with malnutrition. The number of malnour-
ished children in sub-Saharan Africa has in-
creased over the last ten years. Malnutrition
is a cause as well as a consequence of pover-
ty. Despite the high profile and the work of
a large number of non-governmental organ-
isations, the essential infrastructure has not
been properly developed to relieve this to-
tally preventable burden.
Armed Conflict
More children have suffered from armed
conflicts and violence in the last ten years
than in any other comparable period in his-
tory.(8) Ethnic conflicts and civil wars have
come in the wake of the ”cold war”. Con-
flicts killed 2 million children in the ‘90s.
They left large numbers of children disabled
and psychologically scarred. Violence
breeds violence! Children have been dis-
placed, placed in unsanitary conditions with
poor or absent social infrastructure, and
with no system of justice. There are 35 mil-
lion displaced persons and refugees world-
wide, 80 % are women and children. This is
a severe indictment on the responsibilities of
some nations’ leaders and the ineffective-
ness of the United Nations to resolve inter-
national conflicts.
Abuse, Neglect and
Exploitation
In the wake of armed conflict, poverty and a
culture of violence, children are increasing-
ly becoming victims of abuse, neglect and
exploitation. It has been estimated that there
may be as many as 35 million child victims
of child prostitution, sex tourism and child
”slavery”. One form of gross breach of hu-
man rights affecting young girls is female
genital mutilation. The WMA believe that
this practice is completely unethical.(18)Yet
in the UK where the practice is outlawed, it
is widely alleged that FGM continues to be
practised in private hospitals.(10) Girls are
also being sent abroad to those countries
where the operation is allowed. Physicians
have a duty to do all in their power to expose
unethical practice and try and prevent all
forms of child abuse.
Smoking
More than five million children alive today
will die prematurely of smoking related dis-
eases.(11) Recent studies have revealed that
in Bangladesh as a result of marketing by
the tobacco industry, family members are
spending money on cigarettes rather than on
food for their children, even to the extent of
causing malnutrition.(12) It is crucial that
the tobacco ”epidemic” that has swept the
western world causing such a toll of respira-
tory, cardio-vascular and neurological dis-
ease, is not inflicted on the poor nations al-
ready bearing an intolerable and financially
overwhelming burden of disease by the mar-
keting practices of a selfish and unscrupu-
lous tobacco industry. Cigarette Companies
spend more then US$ 11,22 billion on pro-
moting their products. It is well known that
15
WMA
Table 4 – Rate of progress
Country Gross Under 5 Under 5 Annual Change
National mortality mortality births
Income per 1,000 per 1,000 1000’s in
per capita births births 2001
US$ 1990 2001
Tanzania 270 163 165 1,393 2,786 +
Uganda 280 165 124 1,222 50,000 +
Zimbabwe 480 80 123 459 20,000 –
South Africa 2,900 60 71 1,105 12,155 –
Iran 1,750 72 42 1592 47,600 +
Iraq 2170 50 133 823 66,840 –
Occ. Palestine 1350 40 24 132 2,112 +
Israel 16,710 12 6 126 756 +
Afghanistan 250 260 257 1,078 3,234 +
Rwanda 220 178 183 320 1,600 –
Russian
Federation 1,750 21 21 1,230 – 0 –
Romania 1,170 32 21 233 2,330 +
children are more susceptible to cigarette ad-
vertising than adults. To quote Philip Morris:
”Today’s teenager is tomorrows regular cus-
tomer, and the overwhelming majority of
smokers first begin to smoke in their teens.
The smoking pattern of teenagers is particu-
larly important to Philip Morris.” National
medical associations need to advocate in the
strongest possible terms for their country to
sign up to the UN Framework Convention on
Tobacco Control (13) which will provide
their fellow citizens with some protection
from the predicted tobacco epidemic.
HIV/AIDS
The HIV/AIDS pandemic is a global disas-
ter. There are 10.4 AIDS orphans, 95 % of
whom live in Sub-Saharan Africa. In chil-
dren under five years, it has been predicted
that the virus will cause 2/3rds of deaths in
Botswana and half the deaths in Zimbabwe
and South Africa. In Uganda of the
100,000 people suitable for anti-retroviral
therapy, only 10,000 can be afforded the
treatment.(14)
Medicines, Resources and
Responsibilities
The affordability of medications is a key issue
in the battle against infectious diseases in
poor nations. The development of life saving
drugs is however largely subject to market
forces. Those nations with the highest burden
of disease have the smallest financial market.
Indeed only 10 % of the global health re-
search is devoted to conditions that account
for 90 % of the global disease burden – the so
called 10/90 dis-equilibrium. Of the 1393
new chemical entities developed between
1975 and 1999, only 1/3rd were truly ”break-
through” drugs and only 16 were for tropical
diseases, TB and AIDS. All these 16 drugs
were developed with ”public sector” sup-
port.(15)
There are seriously disabling and life threat-
ening diseases, mainly affecting the poor in
developing countries, that may be considered
as ”neglected diseases”, where treatment op-
tions are inadequate or simply do not exist.
These include Malaria – causing over a mil-
lion deaths – and Tuberculosis, over 2 million
deaths each year, HIV/AIDS which result in
some 3 million deaths each year, and visceral
Leishmaniasis which affects some 12 million
people world-wide. InAfrica,Asia andAmer-
ica 146 million are affected by Trachoma and
in 6 million this has caused blindness. Like-
wise Onchocercosis affects 18 million with
nearly a third of a million blinded. The agen-
cies active in the field of drugs for the ”ne-
glected diseases” include the WHO/World
Bank’s Tropical Disease Research Unit, the
Global Alliances for ”TB” and ”Vaccines and
Immunisations”, Medicines for Malaria and
the International AIDS Vaccine Initiative. But
all these entities with the few others involved
only have a combined budget of around
100 million dollars a year.(15) It is only a
fraction of the reported cost of up to US$
800 million that it takes the pharmaceutical
industry to develop a single new drug. In or-
der to restore a proper balance to the current
10/90 dis-equilibrium, it is essential that Gov-
ernments of all nations, global industries,
academia, universities and the non-govern-
ment organisations involved, urgently start
focusing on these neglected diseases. Nation-
al medical associations need to encourage
and foster academic partnerships between
universities and academic centres in the rich
and poor countries which could provide a
valuable research network world-wide.(16)
The modern pestilences due to HIV, Ebola
Virus and more recently SARS have arisen
in the aftermath of conflict and/or in areas of
great poverty. When faced with a greater
risk of dying and the serious financial con-
sequences of the SARS epidemic, it was re-
markable that in the ”rich” world the com-
bined resourcefulness of humans and human
resources were mobilised, commercial com-
petition set aside and the causative organism
of SARS, its genetic sequence, likely mode
of transmission and some possible therapeu-
tic agents identified within a very short time.
If the same energy could be sustained to re-
solve the burden of infectious diseases in the
poor countries, great strides would be made
in relieving the widening inequalities in the
health and wealth of nations.
Future Progress
There are clear and well trodden paths to
progress. These require children to be at the
centre of each nation’s thoughts for their fu-
ture, and governments need to examine the
impact of all their policies on the health of
children. The World Medical Association has
built on the foundations of the UN Declaration
of the Rights of the Child in the WMA Decla-
ration of Ottawa on the Right of a Child to
Healthcare.(4) National Medical Associations
with others need to use these standards as a
measurement of progress to achieve improved
healthcare for, and the health of children.
The World Summit for Children’s ”Plan of
Action” in 1990 called on Government to
prepare their own national programmes, in
order to implement their World Summit com-
mitments on children. It is the will to incor-
porate the needs of children into each nation’s
mainstream developmental thinking together
with a robust local infrastructure that will
produce results. Local communities often
struggle to meet the needs of children without
a fair share of the country’s resources. In the
1990s, the World Health Organisation’s 20/20
initiative was based on the premise that an av-
erage of 20 % of the national budget in devel-
oping countries and 20 % of the Official De-
velopmental Assistance (ODA), would be
sufficient to achieve universal access to basic
social and health services. Most countries
continue to seriously under invest in these ba-
sic social and health services for children,
with only 12–14 % of the national budget and
only 11 % of the ODA being allocated to
these basic services.
Developing countries spent on average more
on defence than on either basic education or
basic healthcare.(8) Levels of defence spend-
ing by developed countries were about
10 times the level of spending allocated to in-
ternational development. Yet the increasing
gap between the rich and poor nations has
been shown to foster violence and terrorism
and to promote conflict. This vicious circle
can and must be broken.(17)
Physicians individually and collectively
through their national medical associations,
are strong advocates for the health needs of
their local communities and nations. Medical
students and young doctors in the rich coun-
tries need to experience the health facilities of
the ”poor” countries first hand as an elective
and as part of their postgraduate training.
Such experience will change their lives. In
turn their work and their advocacy will
change the lives of those currently over-
16
WMA
whelmed by the burden of disease. The final
thought I leave with them is a quote from Nel-
son Mandella and Graca Machel:
”We cannot waste our precious children.
Not another one. Not another day. It is long
past the time for us to act on their behalf.”
References
1. Declaration of Geneva 1948 World MedicalAsso-
ciation.
2. Declaration of Helsinki 1964 Recommendations
guiding physicians in biomedical research involv-
ing human subjects. (Revised 2000) World Med-
ical Association.
3. Declaration of Tokyo 1975 Guidelines for med-
ical doctors concerning Torture. World Medical
Association.
4. Declaration of Ottawa 1998 The Right of a Child
to Health Care.
5. WHO 2001 Report of the Commission on Macro-
economics and Health WHO Geneva.
6. Kagitcibasi Cigdem The Value of Children. Inter-
national Child Health Vol. 9 1 Jan 1998.
7. The State of the 3 Worlds Children 2003
UNICEF.
8. We the Children: End of decade review of the fol-
low up to the World Summit for children. Report
of Secretary General 2001 United Nations Gener-
al Assembly.
9. Margaret Mungherera Presidential Address
Uganda Medical Association Scientific Meeting
Kabale Uganda 2003.
10. Joint Committee on Human Rights 10th Report to
the Houses of Lords and Commons. UK 2002.
11. National Centre for Tobacco Free Kids 2002.
12. GM Leung, L-M Ho, T-H Lam “The economic
burden of environmental tobacco smoke in the
first year of life” Arch Dis Child Vol. 88 9 Sept
2003.
13. United Nations Framework Convention on Tobac-
co Control WHO 2003.
14. Okongo Bernard “Development of Resistance to
ARVs” Ugandan Medical Association Scientific
Meeting, Kabale 2003.
15. Patrice Trouiller et al. “Drug Development for
Neglected Diseases”. Lancet Vol. 359 June 22,
2002.
16. Weatherall David Leading Article BMJ 2003
Vol. 327 20th Dec. 1415–1416.
17. Poverty and Health OECD World Health Organi-
sation 2003.
18. Statement on Condemnation of Female genital
Mutilation. Budapest 1993 World Medical Asso-
ciation.
17
Medical Science, Professional Practice and Education
A multinational study of orthopaedic surge-
ons has found that in as much as 95 % of ca-
ses, orthopaedists fail to investigate osteo-
porosis as a cause of the fracture and are in-
consistent in offering specific treatment or
referrals.
Full results of the study co-sponsored by the
Bone and Joint Decade and the International
Osteoporosis Foundation (IOF), were pre-
sented by Dr Karsten Dreinhöfer, Ulm Uni-
versity Hospital, Germany on October 15th
during the first global 24-hour eLecture con-
ference on musculoskeletal disorders, orga-
nised by the Bone and Joint Decade for the
medical community and in recognition of
World Osteoporosis Day, October 20th.
Until recently, the only fractures considered
to be osteoporotic in nature were spinal
wedge, hip and wrist fractures as these cau-
sed the majority of problems for patients
and hospitals. ”However, it is now clear that
fractures of the pelvis, ankle, knee and
shoulder, as well as fractures of the clavicle
should all be treated as osteoporotic fractu-
res,” said Dr Karsten Dreinhöfer.
”All orthopaedic surgeons who treat midd-
le-aged and elderly patients with fractures
have a duty to consider and institute mecha-
nisms for preventing future fractures. This
can be done by instituting protocols for the
screening, identification and treatment of
those who have sustained a fracture”, he
said.
Studies show that 50 % of women and 30 %
of men will experience an osteoporotic frac-
ture in their lifetime and a prior fracture in-
creases the risk of subsequent fracture as
much as five-fold. Osteoporotic fractures
are associated with increased morbidity and
mortality: 50 % of hip fracture patients will
have long-term disability, and 25 % will re-
quire long-time nursing home care. With the
population ageing world-wide, the number
of fragility fractures is expected to increase
dramatically over the next few years.
A multinational survey involving 3,500 or-
thopaedic surgeons from France, Germany,
Italy, Spain, the UK and New Zealand was
conducted earlier in 2003 to determine the
scope of the problem and areas for improve-
ment. The results revealed striking examples
of ineffective care of osteoporosis:
G Fifty percent of orthopaedic surgeons
practising today received little or no
training in osteoporosis.
G Only roughly one in four orthopaedic
surgeons in France and the UK feel
knowledgeable about managing the dis-
ease in their patients.
G Only in Germany are the majority of
fracture patients referred for a bone den-
sity test; in the UK, this figure is as low
as 16 %.
G Only half of the orthopaedic surgeons in
Southern Europe know about the impor-
tance of external risk factors for hip frac-
tures (cataracts, poor lighting, pathway
obstacles, poor balance).
G In four of the countries surveyed, more
than half of the surgeons have not heard
about their national osteoporosis patient
society.
”Since orthopaedic surgeons are often the
first and only physicians to see fracture pa-
tients, they are in a unique position to iden-
tify untreated cases of osteoporosis, and as
such reduce the risk of subsequent fracture,”
said Professor Olof Johnell, International
Osteoporosis Foundation, who led the de-
velopment of guidelines for orthopaedic
surgeons to identify and treat osteoporosis.
He cautioned, ”It is important to act at the
time of fracture. It is the responsibility of or-
thopaedic surgeons to investigate whether
osteoporosis is the underlying cause.”
Osteoporosis is a condition that affects peo-
ple of all ethnic and cultural groups from
around the world. Although there is no cure
for osteoporosis, there are treatments and
lifestyle changes such as regular exercise that
can stop further bone loss and reduce the risk
Medical Science, Professional Practice and Education
Orthopaedic Surgeons Are Failing To Prevent
Osteoporotic Fractures
of fractures. For example, a recent study in
China by Professor Kai Ming Chan, shows
that regular tai chi chuan exercises can delay
bone loss in postmenopausal women.
Background
The Bone and Joint Action Week,
October 12–20th 2003
As a highlight of the Bone and Joint Decade
Action Week, leading authorities in the mus-
culoskeletal field presented a 24-hour series
of eLectures via webcast. Subjects ranged
from prevention, to state-of-the-art treatment
and from how to best teach musculoskeletal
disorders to the best biological approaches.
The Action Week was a major driving force
for prevention and advocacy and included:
World Arthritis Day (Oct 12th), World Spine
Day (Oct 16th), World Trauma Day (Oct 17th)
and World Osteoporosis Day (Oct 20th).
Launched in January 2000, the Bone and
Joint Decade is an NGO, headquartered in
Sweden. Its mission is to advance under-
standing of musculoskeletal disorders
world-wide through research, and to im-
prove the quality of life for those affected by
these disorders. The Bone and Joint Decade
is supported by National Action Networks,
professional medical societies, patient advo-
cacy groups, governments, industry and re-
searchers who are to effect change. The
Bone and Joint Decade is delighted to have
the personal and active support of Kofi An-
nan, Secretary-General of the UN, the WHO
and the World Bank.
The Bone and Joint Decade encompasses
diseases associated with musculoskeletal
disorders such as joint diseases, osteoporo-
sis, osteoarthritis, rheumatoid arthritis, low
back pain, spinal disorders, severe trauma to
the extremities, crippling diseases and defor-
mities in children.
For more information and a copy of the os-
teoporosis guidelines, see: The Bone & Joint
Decade: http://www.boneandjointdecade.org
and: International Osteoporosis Foundation:
http://www.osteofound.org.
18
Medical Science, Professional Practice and Education
A comparative study of patient and
physicians’ perceptions world-wide
The following is an abstract summary of
this study carried out and presented at
the Helsinki General Assembly, Septem-
ber 2003 by Dr. Mike Mcgee, WMA, Fel-
low in Humanities 2003 The full text can
be obtained from the author*
Context of study
A number of forces have transformed the
practice of medicine in the past two decades.
Evidence suggests that these forces are im-
pacting on both patients and physicians and
on their relationship with each other.
Objectives
To simultaneously survey patients’ and
physicians’ perceptions of their relationship
with each other in six countries on four
continents.
Design and Setting
Patients and physicians were simultaneous-
ly studied in six countries using nationally
representative telephone surveys between
July 22, 2002 and October 13, 2002. 2506
interviews were conducted on patients (63
% response rate) and 1201 interviews were
conducted on physicians (58 % response
rate) using a random digit dialing (RDD)
methodology.
Participants
Patients had to be at least 21 years of age.
Physicians had to be general practitioners
and in practice for five or more years.
Main Outcome Measures
Relative importance of patient-physician re-
lationships compared to other critical rela-
tionships in society. Type of relationship as
defined by patients and physicians. Levels
of patient empowerment and self-manage-
ment of care. Actual and ideal performance
ratings in 5 dimensions in the humanistic
domain (compassion, trust, understanding,
patience, listening) and 5 dimensions in the
access domain (access to physician, time
with physician, appointment scheduling,
choice of treatment, choice of specialists).
Results
The patient-physician relationship ranked
second in importance only to family rela-
tionships in all countries studied. Physicians
were the leading source of health informa-
tion, the most trusted source, and the source
most likely to instigate positive behavioural
change in patients in all countries studied.
All countries agree that authoritarian pater-
nalistic relationships between physicians
and patients are relatively uncommon today.
These relationships are being replaced by
mutual partnerships or advisor models. Pa-
tients and physicians in all countries foresee
future movement toward partnership and
team based models. Compared to 10 years
ago, most patients in all countries believe
they ask more questions, make more choic-
es, actively evaluate benefit and risk, and
take better care of their own health. Patients’
confidence in managing their own health is
very high in all countries except Japan.
Physician confidence in patients self-man-
agement is lower than patients scoring in
five of the six countries. In general, all co-
horts rate physician humanistic perfor-
mance higher than access performance.
Physicians in all countries rate their ideal
humanistic performance higher than do pa-
tients. In contrast, physicians in the United
Kingdom and Germany rate their ideal ac-
cess performance lower than the patients’
expectation for ideal access performance. In
actual performance both in humanistic and
access domains, physicians score them-
selves higher than do patients in 8 of the 10
dimensions. Patients and physicians scoring
of opportunities for improvement is relative-
ly well aligned in five of the six countries
studied. The greatest variance in opportuni-
Relationship Based Health Care in Six Countries
ty scores between patient and physician ex-
ists in the United Kingdom in both humanis-
tic domain (17 % difference) and access do-
main (26 % difference) and in Germany ac-
cess domain (19 % difference), with patients
seeing more opportunity than do physicians.
Conclusions
The findings indicate a fundamental shift in
the patient-physician relationship away
from an authoritarian and paternalistic mod-
el and toward partnership and team based
approaches. Patients are significantly more
confident and empowered than they were
ten years ago. Physician confidence in pa-
tient self-management is more modest. Pa-
tients possess high confidence in physicians
but also demonstrate higher expectations for
ideal physician performance and higher ex-
pectations for improvement along five di-
mensions of humanistic care and five di-
mensions of access to care. The ability to
align expectations of patients and physi-
cians, and meet commonly held objectives,
will be increasingly important in assuring
the future health of this critically important
societal relationship.
* Mike Magee, Pfizer Medical Humanities
Initiative, 235 East 42nd
St, New York NY
10017
19
World Health Organisation
World Health Organisation
More Research, More Resources Needed To
Control Expanding Global Diseases
Dr. Lee Jong-wook, WHO Director General
in his introduction to the World Health Re-
port 2003, writes „Today’s global health sit-
uation raises urgent questions about justice.
In some parts of the world there is a contin-
ued expectation of longer and more com-
fortable life, while in many others there is
despair over the failure to control disease al-
though the means to do so exist.
This contrast is starkly evident in lack of ac-
cess to HIV/AIDS treatment, which led me,
earlier this year, to declare a global health
emergency. WHO decided to take this rare
measure after evaluating the global situation
and finding that only 5 % of those in the de-
veloping world who require antiretrovirals
(ARVs) are getting them. In sub-Saharan
Africa, only 50,000 of the 4 million people
in need have access toARVs. This spells cat-
astrophe, not only for the societies hardest
hit but for the world as a whole. Our first
step to respond to this crisis must be to reach
”3 by 5” – 3 million people in developing
countries on antiretrovirals by 2005. Major
disparities also exist in areas such as child
mortality. Of the more than 10 million chil-
dren under 5 years old who die every year,
almost all are in developing countries.
A world marked by such inequities is in very
serious trouble. We have to find ways to
unite our strengths as a global community to
shape a healthier future. This report on the
world’s health, my first since taking office,
gives some initial indications of how to do it.
The message (running through the report) is
that progress in health, including rapid and
sustainable expansion of emergency treat-
ments, depends on viable national and local
health systems. Scaling up ARV therapy in
resource-poor settings has to be done in such
a way as to strengthen health systems based
on primary health care. In most countries,
there will be only small and short-lived ad-
vances towards acceptable standards of
health without the development of health
care systems which are strong enough to re-
spond the current challenges.
To lend impetus to this process WHO is now
making results in countries its main objec-
tive. Effective action to improve population
health is possible in every country but it
takes local knowledge and strength to turn
that possibility into reality. We have learnt
this through successes such as controlling
the SARS epidemic and major advances in
the polio eradication campaign, and we have
learnt it through setbacks as well, such as
continuing rise of AIDS, TB and malaria.
All of these lessons have prepared us for the
task ahead.
Twenty-five years ago, the Declaration of
Alma-Ata challenged the world to embrace
the principles of primary health care as the
way to overcome gross health inequalities
between and within countries. ”Health for
all” became the slogan for a movement. It
was not just an ideal but an organizing prin-
ciple: everybody needs and is entitled to the
highest possible standard of health. The
principles defined at that time remain indis-
pensable for a coherent vision of global
health. Turning that vision into reality calls
for clarity both on the possibilities and on
the obstacles that have slowed and in some
cases reversed progress towards meeting the
health needs of all people. This entails work-
ing with countries – especially those most in
need – not only to confront health crises, but
to construct sustainable and equitable health
systems.
I urge the global health community to set its
sights on bold objectives. All countries of the
world have pledged to reach the Millenium
Development Goals set at the United Nations
Summit in 2000. These include ambitious tar-
gets for nutrition, maternal and child health,
infectious disease control, and access to essen-
tial medicines. With this support we have a real
opportunity now to make progress that will
mean longer, healthier lives for millions for
people, turn despair into realistic hope, and lay
the foundations for improved health for gener-
ations to come.
To reach our goals, increased resource
commitments and intensified collabora-
tion among partners will be required. The
[…] report describes the challenges we
face and points the way for a united re-
sponse from WHO and the global health
community.“
Geneva
October 2003
WHO welcomes new
initiative to cut the
price of AIDS
medicines
20
World Health Organisation
Poverty
Health And Finance Ministers Address Need
For World-wide Increase In Health Investment
Geneva – Ministers of Health, Finance and
Planning from 40 developing countries
came together with development partners at
WHO headquarters from 29 to 30 October
to address the need to significantly increase
investments in health. This is the first time
that the World Health Organisation has host-
ed a meeting so widely attended by non-
health officials, underlining the urgency of
building national capacity to absorb in-
creased health funding.
”This meeting signifies real political commit-
ment from the highest levels of government
and donor representatives. Let us capitalize on
this unique opportunity to regognize health as
a critical investment and together develop a
common understanding of how countries and
their partners can transform these commit-
ments into immediate actions. We must
choose to make equitable and efficient health
investments a reality,” said WHO Director-
General Dr Lee Jong-wook.
This meeting comes nearly two years after
the launch of the 2001 Report of the Com-
mission on Macroeconomics and Health
(CMH), which recommends that by 2007,
donors should increase assistance for health
to US$ 27 billion. The Commission also
calls for more budgetary resources for pub-
lic health from both developed and develop-
ing countries, and more political and organ-
isational effort than has been seen in the past
decades to achieve real improvements in
health.
Two years on, the world still has not shown
determination in increase investment in
health to the levels needed to measurably
impact major diseases that affect the world’s
poor. A recent study* has shown that the to-
tal development assistance for health from
major selected sources increased by US$
1.6 billion, from an average of US$ 6.1 bil-
lion (1997–1999) to US$ 7.7 billion (2001).
Most of the increase in funding was allocat-
ed to fighting HIV/AIDS in sub-Saharan
Africa. Although these recent increases in
assistance for health are encouraging, they
still fall short of meeting real needs.
”On taking office, I declared the target of
‘3 by 5’ – to have 3 million people with AIDS
in developing countries on treatment with an-
tiretrovirals by the end of 2005. Only 300,000
are on treatment at the moment. To achieve
‘3 by 5’ and other health priorities we need
considerably more funds than those currently
available. If we don’t increase resources for
health and target these resources to activities
that will have the greatest impact, we stand to
lose millions of men, women and children to
disease. This also means trapping individuals
and families in poverty and disillusionment,”
said Dr Lee.
During the meeting, the combined work of
countries, WHO and partners was to devel-
op concrete plans for increased health in-
vestment in countries. Continued global
leadership and follow-up from the develop-
ment community, combined with inter-min-
isterial collaboration is needed: first, to in-
crease resources for health from domestic
resources, debt relief and development as-
sistance for health, and second to eliminate
health system and institutional constraints,
enabling greater absorption of increased re-
sources. This will be critical for pursuing
country action to reach the ‘3 by 5’ and oth-
er health targets.
”We need country-specific blueprints for
making real increases in health investment.
Developing countries and their partners
need to collectively and quickly do much
more, for health and global stability. This
meeting can identify ways to make this hap-
pen,” added Dr Lee.
National Macroeconomics and Health activ-
ities are ongoing in the countries participat-
ing in the Consultation: From Africa: Ango-
la, Botswana, Congo, Ethiopia, Ghana,
Kenya, Malawi, Mozambique, Nigeria,
Rwanda, Senegal, South Africa, Uganda,
United Republic of Tanzania. From the
Americans: Argentina, Brazil, Mexico,
Nicaragua, Peru and the Caribbean Com-
munity including Haiti. From the Eastern
Mediterranean: Djibouti, Iran (Islamic Re-
public of), Jordan, Pakistan, Sudan, Yemen.
From Europe: Azerbaijan and Estonia.
From South East Asia: Bangladesh, Bhutan,
India, Indonesia, Myanmar, Nepal, Sri Lan-
ka and Thailand. From the Western Pacific:
Cambodia, China, Philippines and Viet
Nam.
* Development
Assistance for health (DAH): Recent Trends and
resource Allocation Dr. Catherine Michaud, Senior
Reserach Associate, Harvard Center for Population
and Development Studies
Geneva – The World Health Organisation
has welcomed a new initiative to further cut
the price of AIDS medicines in developing
countries. WHO also underlined the impor-
tance of speedy delivery and distribution, as
well as effective treatment and care to en-
sure equitable access to treatment around
the world.
In New York, the William J. Clinton Foun-
dation announced that it had reached agree-
ment with some manufacturers to cut the
price of AIDS medicines in half.
”Providing AIDS treatment to those who
most urgently need it in poor countries is the
most urgent health challenge the world
faces,” said the WHO Director-General, Dr
LEE Jong-wook. ”WHO welcomes this
Clinton Foundation initiative and all private
and public sector efforts that will both re-
duce the price of AIDS medicines and en-
sure their availability to the people who
most urgently need them.”
WHO and its partners are fully committed
to delivering antiretroviral therapy to three
21
World Health Organisation
million people in developing countries by
the end of 2005, the ”3 by 5” target. To do
this, WHO is leading emergency response
teams to assist developing countries in in-
creasing the availability of treatment for
people with AIDS, developing simplified
treatment guidelines, building an AIDS
drugs and diagnostics facility, and ensuring
the widespread availability of training for
health staff and volunteers.
”Further price reductions are vital for coun-
tries to be able to provide treatment to those
who need it,” said Dr Paulo Teixeira, Direc-
tor of the HIV/AIDS Department at WHO.
”But lower price medicines alone will not
deliver treatment. Improving the ability of
countries to deliver the medicines, building
stronger health systems and training more
health workers are also vital if we are to
reach the ‘3 by 5’ target.”
Maternal mortality
Maternal Deaths Disproportionately High In
Developing Countries
African women are 175 times more likely to
die in childbirth than women in developed
regions of the world
Geneva – New findings on maternal mortal-
ity by WHO, UNICEF and UNFPA show
that a woman living in Sub-Saharan Africa
has a 1 in 16 chance of dying in pregnancy
or childbirth. This compares with a 1 in
2,800 risk for a woman from a developed re-
gion. These findings are contained in a new
global report on maternal mortality released
online by the three agencies at.
www.who.int/……..
Of the estimated 529,000 maternal deaths in
2000, 95 % occurred in Africa and Asia,
while only 4 % (22,000) occurred in Latin
America and the Caribbean, and less than
one percent (2,500) in the more developed
regions of the world.
Experience from successful maternal health
programs let show that much of this death
and suffering could be avoided if all women
had the assistance of a skilled health worker
during pregnancy and delivery, and access to
emergency medical care when complica-
tions arise.
”Many women deliver their children alone
or with family members or other untrained
attendants who lack the skills to deal with
complications during delivery,” said Dr LEE
Jong-wook, Director-General of WHO.
”Skilled attendants are vital because they
can recognise and prevent medical crises
and provide or refer for life-saving care
when complications arise. They also provide
mothers with basic information about care
for themselves and their children before and
after giving birth.”
Reducing maternal mortality is a key factor
in ensuring that all children, especially in
the world’s poorest countries, survive and
thrive through adolescence.
”These new estimates indicate an unaccept-
ably high number of women dying in child-
birth and an urgent need for increased access
to emergency obstetric care, especially in sub-
Saharan Africa,” said UNICEF Executive Di-
rector Carol Bellamy. ”The widespread provi-
sion of emergency obstetric care is essential if
we want to reduce maternal deaths.”
The maternal mortality ratio, was estimated
to be 400 per 100,000 live births globally in
2000. By region, it was highest in Africa
(830), followed by Asia – excluding Japan
(330), Oceania – excluding Australia and
New Zealand (240), Latin America and the
Caribbean (190) and the developed countries
(20).
Worldwide, 13 developing countries ac-
counted for 70 % of all maternal deaths. The
highest number occurred in India where
136,000 women died, followed by Nigeria
where there were 37,000 deaths.
In 2000, world leaders agreed to reduce ma-
ternal mortality by three-quarters by 2015,
as part of the Millenium Development Goals
(MDGs). Tracking progress remains diffi-
cult, except where comprehensive registra-
tion of deaths, including causes of death, ex-
ists. For this reason, the use of indicators
such as the proportion of women who have a
skilled attendant at delivery is essential to
track change.
The use of skilled attendants at delivery in
developing countries increased between
WHO/UNICEF/UNFPA Estimates of number of maternal
deaths, lifetime risk and maternal mortality ratio,
by MDG regions, for the year 2000
Number of Lifetime risk of Maternal
maternal deaths* maternal deaths: mortality ratio
1 in: (maternal deaths
per 100,000 livebirths)MDG region
World 529,000 74 400
Developed regions ² 2,500 2,800 20
Europe 1,700 2,400 24
Developing regions 527,000 61 440
Africa 251,000 20 830
Northern Africa 4,600 210 130
Sub-Saharan Africa 247,000 16 920
Latin America and the Caribbean 22,000 160 190
Asia 253,000 94 330
Eastern Asia 11,000 840 55
South-central Asia 207,000 46 520
South-eastern Asia 25,000 140 210
Western Asia 9,800 120 19
Oceania 530 83 240
* includes Canada, United States of America, Japan, Australia and New Zealand.
22
WMA Secretary General
1990 and 2000 from 42 to 52 %, suggesting
a potential decrease in maternal deaths.
Findings show the greatest improvements in
South East Asia and Northern Africa and the
slowest change in sub-SaharanAfrica, which
went from 40 % in 1990 to 43 % in 2000.
Most maternal deaths and disability occur as
the result of one or more of three delays: a
delay in recognising complications; a delay
in reaching a medical facility; or a delay in
receiving good quality care. Efforts to ad-
dress these delays are essential in order to
save the lives of mothers and babies.
Education on family planning and the provi-
sion of family planning services of high
quality can also make a difference.
As the focal agencies within the United Na-
tions systems for the health of women and
children, WHO, UNICEF and UNFPA
pledge to enhance – both individually and
jointly in collaboration with their partners –
their efforts in assisting countries strengthen
their maternal health programs.
For further information contact: Chris Powell, Com-
munications Advisor; Family and Community
Health, WHO, Geneva, Email: powelle @who.int
WMA Secretary General
From the Secretary General’s Desk
It is fascinating to look back on the history
of the World Medical Association (WMA)
in this historic 50th edition of the World Me-
dical Journal (WMJ). The roots of the WMA
are described in an article of the British Me-
dical Journal on October 5, 1946, where it
was reported that physician’s leaders had
met to discuss the establishment of the
World Medical Association (WMA). This
Association would ”promote closer ties bet-
ween National Medical Associations, study
the problems which confront the medical
profession throughout the world, organise
the exchange of information and establish
relations with the World Health Organisati-
on and present the views of the profession”.
Subsequently the WMA was formally esta-
blished on September 18, 1947, and has gro-
wn into a formidable organisation. What I
find most appealing of the work of National
Medical Associations and the WMA is its
dual purpose – serving the profession, but
always making sure that the best interest of
the patient remains our first consideration.
This is one reason why medical leaders are
often, as it should be, gifted social leaders.
As the WMJ turns a new page and embarks
on a new style, format and list of contents,
we stand on the shoulders of these medical
and social giants of the past and present to
build an even greater WMA, the global re-
presentative body for physicians. We con-
gratulate and wish Dr. Alan Rowe, our new
WMJ Editor-in-Chief and his team all of the
very best in this worthy endeavour.
Much has been done to promote the medical
profession since the WMA General Assem-
bly last met in Helsinki during September
2003:
Working against torture
The WMA, in partnership with the Interna-
tional Council for the Rehabilitation of Tor-
ture Victims (IRCT), has developed a suc-
cessful project to help train physicians in the
detection, documentation and treatment of
torture victims, using the so-called ”Istanbul
Protocol”. Funded by the European Union,
the partnership has now completed the first
phase of establishing links and building trai-
ning centres in five pilot countries (Georgia,
Morocco, Mexico, Uganda and Sri Lanka).
One of the highlights over the last few
months has been the determined efforts by
Dr. Yoram Blachar, WMA Chair of Council
(and President of the Israel Medical Asso-
ciation) to help establish these centres as he
undertook the trip to Sri Lanka on behalf of
the WMA;
Fight against SARS
The Canadian Medical Association was par-
ticularly effective in helping their members
understand and combat the SARS virus
when it hit that country during 2003. Buil-
ding on the CMA example and following a
resolution by the WMA General Assembly,
the CMA and WMA are now preparing a
new policy on NMA preparedness for epide-
mics. The WMA has been negotiating with
WHO to develop a more effective communi-
cation channel and network to provide in-
formation and resources to NMAs and their
members in times of epidemics such as
SARS or the current Avian Flu;
Russian Medical Society
(RMS) comes of age
It took the WMA four years of persistent
and often difficult negotiations to identify
and help develop a National Medical Asso-
ciation in Russia. When the Russian Medi-
cal Society was admitted as member to the
WMA in 2002, it was a historic moment,
long overdue. In this process, Dr Leonid
Mikhailov, RMS Secretary General, deser-
ves credit for his committed efforts to forge
together medical groups in Russia and build
links with the international community.
Russia has such vast intellectual riches that
a world body simply cannot afford to grow
without the Russian medical leadership. Du-
ring February 2004, this was strengthened
even more when one of the fathers of Russi-
an medicine, Prof. Valerie Pokrovsky, was
elected as President of the RMS for the next
year. Prof. Pokrovsky is also the President of
the prestigiousAcademy of Russian Medici-
ne and is thus in a very good position to fur-
ther strengthen the uniting role of the RMS
in the Russian medical profession;
Advocacy at the WHO
Never before in the history of the WMA have
there been a stronger links and more colla-
borative work between the WMA and WHO.
During the annual meetings of WHO, WMA
leaders regularly present the views of the
profession in a concise and forthright man-
ner. Most recently the Chair of Council, Dr
Blachar represented the WMA views on
health promotion and healthy lifestyles at the
WHO Executive Board Meeting during Ja-
nuary 2004. Other examples of collaboration
over the last 6 years include:
23
Regional and NMA News
G The WMA has been a forceful partner
and supporter of the Framework Conven-
tion on Tobacco Control
G Leadership of health professional groups
in the World No Tobacco Day 1999
G Development of a policy on safe injec-
tions as part of the Safe Injection Global
Network
G Development of a policy on Violence and
Health
G Survey on Human Resources for Health
G Inclusion of the WMA in the GlobalAlert
and Response Network for the combat of
communicable diseases and now the de-
velopment of a more comprehensive net-
work to respond more rapidly and effec-
tively against diseases such as SARS.
Even though it is reassuring that progress
has been made, much still needs to be done.
The WMA has as one of its stated objectives
that every nation in the world should be re-
presented in its membership. This ideal has
not yet been achieved. Furthermore, the
WMA Council has set some priorities for
action over the next few years. The organi-
sation will focus on medical ethics, health
related human rights, the development of a
database of physician and NMA informati-
on, and to be the foremost central advocate
for the medical profession, especially at the
level of WHO and other United Nations
agencies. At the Secretariat, we are very ex-
cited about this growth of enthusiasm and
energy in the organisation, and hope that all
physicians and NMAs will unite and help
build the WMA into a truly world class as-
sociation. We owe this to our dual constitu-
encies, our patients and our colleagues in the
medical profession, the noblest profession
on earth.
Regional and NMA News
Social Security is a National Security Issue
Eitaka Tsuboi, MD President, Japan Medical Association
The time for government intervention is
when the national security of its citizens is
threatened. That is why the national popula-
ce pays taxes to enable their national leaders
to deal with national crises. If the Japanese
government does not adequately address na-
tional security or the social security of its
people, our country may undergo the expe-
rience of total national dysfunction.
To rescue Japan from this kind of crisis situa-
tion, it is vitally important for the government
to pursue a national policy that will provide
Japanese citizens with a sense of security. Fo-
stering a national sense of security, removes
apprehensions about the future and creates an
atmosphere of social pace. A sense of securi-
ty must be restored, in other words, national
security must be definitely promised.
This must be regarded as a national task that is
a segment of the overall national security stra-
tegy without diminishing social security as a
safety net. The ultimate goal of social securi-
ty is employment, i. e., the ability of individu-
al citizens to contribute confidently to buil-
ding society and the economy in good mental
and physical health through gainful employm-
ent. What supports employment is health care,
long-term care, education, pension, employm-
ent insurance and livelihood protection –
components of the social security system.
The ability to work is developed through edu-
cation, while national securityprotects our
lives through health care. Employment insur-
ance provides assistance in the unfortunate
event we become unemployed. Livelihood in-
surance provides assistance when we experi-
ence permanent unemployment. Pension is re-
muneration for yielding our job to a younger
person. Pensions help us maintain our liveli-
hood in our twilight years as we prepare for
death. Long-term care helps us through our fi-
nal stage of life. The social security system is
our common social capital that supports the
cycle of transitions in our lives. The govern-
ment has an obligation to permanently en-
hance this common social capital.
Social security is a dynamic system that is
constantly evolving to enable us to live and
work in prosperity. In terms of the health
care sector, social security has evolved in
tandem with the era of infectious diseases in
the aftermath of the war, followed by the era
of lifestyle related diseases, the current era
of medical care for the elderly and the fu-
ture era of preventive medical care. Japan
has become a nation with the world’s
longest life expectancy and the lowest in-
fant mortality rate. Although individual is-
sues remain, the fact that the entire nation
functions quietly on a system that guaran-
tees these living standards for its people has
raised Japan’s national worth and has con-
tributed to high quality human resources.
This social security system is a paramount
task that maintains and strengthens national
stability. As common social capital, social
security must be strategically invested to
achieve the combined components of health
care, long-term care, pension, education,
employment and others. Based on this fun-
damental recognition of the social security
system, those of us who have been entrust-
ed with the country’s health care must fulfil
the following three responsibilities.
1) Recognise that the universal national
health insurance is national security.
Strongly demand that the government
substantiate, improve and strengthen the
national health insurance system.
2) Secure that individual rights of citizens
to have access to physicians at all time
and in all areas throughout the country,
in order to guarantee the equality of life.
3) Individual payments of medical expens-
es are required under the prevent sys-
tem. However they should be limited to
a 20 % maximum of the medical cost. In
future, individual payments should be
completely abolished.
Physicians should continue to advocate
this responsibility while enduring the criti-
cism and disapproval of market principle
supporters.
Substantiating, improving and strengthen-
ing health care is a welcome means of main-
taining and increasing the health of the na-
tional populace. But as we pursue the bene-
fits that are derived from this process and
those stemming from the introduction of ad-
24
Regional and NMA News
vanced medical technology, there is always
the risk that medical ethics will be aban-
doned.
At the time of my inauguration as the 52nd
president of the WMA in Edinburgh, 2000,
I discussed the subject of ”channelling the
abundant benefits of advanced medical
technology”. The JMA submitted a pro-
posed declaration on this issue, and ”the
WMA Declaration on Medical Ethics and
Advanced Medical Technology” was adopt-
ed by the WMA General Assembly, Wash-
ington 2002.
A scientific session on the theme, ”Advanced
Medical Technology and Medical Ethics” and
”The Internet and Health Care”, is planned for
the WMA General Assembly, Tokyo 2004,
and many successful developments are antici-
pated. It is hoped that the medical profession,
which has been entrusted with the control of
advanced medical technology and cutting-
edge information technology in the 21st cen-
tury, will raise its awareness about its respon-
sibility of overseeing humanity’s health based
on a code of medical ethics that is the essence
of all medical practice.
I look forward to the contribution of your
wisdom and the participation of all WMA
member associations of the WMA Tokyo
General Assembly.
The German Health Care System (social in-
surance system) has been financed on the
basis of contributions linked to wages and
salaries. For many years now Co-payments
have also been a feature of the system but
these were only set at a symbolic level.
In a major reform act the government coali-
tion with support of the opposition Christian
Democrats have introduced multiple
changes in the Statutory Health Insurance
(Gesetzliche Krankenversicherung). The
changes are of considerable concern to Ger-
man doctors but will be of interest to others
whose health care systems are based on this
type of social insurance.
The major aim is the reduction of expendi-
ture. As the financing of the SHI is based on
contributions linked to wages and salaries,
increasing cost for health insurance is being
seen as an economic burden to the export
orientated German industry. The following
note indicates some of the major concerns
about the changes in the SHI.
Co-payments
Co-payments have existed for many years
but only on a symbolic level. Now they have
been raised significantly and can in some in-
stances reach 100 %, including prescribed
”Over-the-Counter”-Drugs (OTC), trans-
portation costs, and many remedies includ-
ing glasses. For hospital stays the co-pay-
ment has been raised from 9 Euros for a
maximum of 14 days per year, to 10 Euros
for 28 days per year. A 10 Euro co-payment
is required for the first consultation with a
physician in each quarter. If another physi-
cian is consulted without referral by a Gen-
eral practitioner, an additional co-payment
is applied. It is thought that this will reduce
the common ”doctor hopping” in Germany.
A limit of 2 % of annual income has been set
on the yearly sum of co-payments for which
participants are responsible. If co-payments
exceed this value the excess is covered. For
serious chronically ill patients (needing at
least one physician consultation per quarter)
the capping operates a 1 % of income. Cer-
tain exceptions much more rigid than in the
past may however be set in the future.
Whilst in the past Pharmacists income de-
pended in part on a percentage payment based
on the cost of drugs, this has been replaced by
a fixed pharmacy charge of 8.10 Euro. Where-
as this has resulted in an increase in price for
low-cost prescribed drugs, it has reduced the
cost of the higher priced ones.
The introduction of these co-payments is
highly criticised by consumer organisations
and unions. Due to unclear wording in the
law and lack of regulations at the time of im-
plementation, many problems and argu-
ments occurred.
Sick funds may provide some relief to their
members by offering the use of internet
pharmacies, which was previously prohibit-
ed, or of enrolment in a primary care model
in which the insured would agree always to
consult a GP first.
Definition of Basket
A common body of the sick funds, physi-
cians and hospitals, will define the services
and treatment that can be rendered under
SHI. In the past this covered only ambulato-
ry treatment, but now also includes the hos-
pital sector. The decisions have to be based
on evidence, thus giving Health Technology
Assessment and EBM a strong boost. In ad-
dition a patients’ representative has been in-
stalled (Bundesbeand is to be heard before
decisions will be taken). Furthermore the
self-government of sick funds and providers
has to introduce a new institute for quality
matters. (The initial plan to copy the British
National Institute for Clinical Excellence
was not followed.)
Selective contracting – new provider types
While until now contracts between the sick
funds and the ambulatory physicians only ex-
isted as group contracts negotiated between
the ”umbrella” organisations of the sick funds
and the association of the office based physi-
cians (Kassenärztliche Vereinigung – KV) (a
statutory body with obligatory membership),
sick funds are now permitted to make con-
tracts with physicians and groups of physi-
cians directly on a limited basis. One percent
of the budget for ambulatory treatment is to
be set aside for such new types of contracts,
whose number is planned to be increased in
the future. At the same time new types of am-
bulatory institutions owned by third parties
will be eligible to provide ambulatory treat-
ments. Hospital emergency rooms, which in
the past have been strictly limited to use for
Health Reform in Germany ”sustaining or
diluting social insurance?”
Dr. Otmar Kloiber, German Medical Association
The South African Medical Association
(SAMA) has for years been the association
taking doctors forward and into the future.
As an Association with many social res-
ponsibilities, we have dedicated ourselves
to fighting the HIV/Aids scourge.
In July 2001, SAMA criticised the govern-
ment for their lack of direction in rolling
out an HIV programme, and called on go-
vernment to provide antiretroviral treat-
ment (ART) to SouthAfricans in the public
sector. SAMA Chairperson, Dr Kgosi Let-
lape, said South Africa was the only coun-
try in the world where there was no policy
for the treatment of HIV.
A year later SAMA praised government
for the provision of Nevirapine for the pre-
vention of mother-to-child transmission of
HIV. Dr Anant Chetty, then Chairperson of
SAMA’s Human Rights, Law and Ethics
Committee, emphasising that doctors need
not be afraid to prescribe HIV/Aids drugs,
said ”Doctor’s ethical and moral rights are
protected in our constitution, their clinical
independence is fully supported by the
Health Professions Council of SA and in-
ternationally by world health organisati-
ons.”
Yet, still adamant that a treatment pro-
gramme was necessary, SAMA met with
the Minister of Health in August 2002. In
discussions with the Minister, Dr Manto
Tshabalala-Msimang, SAMA re-cemented
its views that an HIV/Aids treatment po-
licy that includes the provision ofART was
essential to slow down the impact of
HIV/Aids in South Africa. Following the
unsuccessful meeting with the Department
of Health, SAMA continued to persevere
in its efforts to facilitate treatment for peo-
ple living with Aids, irrespective of the go-
vernment’s position of not providing ART.
After the meeting Letlape stated, ”We have
not changed our position, and neither has
the Department of Health. But both parties
are committed to further dialogue, and we
will continue urging the department to re-
view its stance on makingART available in
the public sector. Unfortunately time is not
on our side. We would like to see the im-
plementation of pilot projects for
25
Regional and NMA News
emergency cases, will also be eligible to pro-
vide ambulatory services.
Commentary:
The reform brings back some of the birth
defects of the SHI, namely the high burden
for the sick and a market (financial interest)
driven system for the relations between sick
funds and physicians.
In the beginning of the SHI, the sick funds
only paid compensation for lost income.
Over time it became more and more evident
that it is better to care for the medical treat-
ment in a comprehensive way, including fi-
nancial protection. Access to care is limited
by high co-payments. However, while one
might correctly argue that contributing an
extra 1 or 2 % of income is not very much,
it hits especially the seriously ill patients.
Often they already have only a very small
income because of their disease or handi-
cap. 1 or 2 % percent may be above what
they can afford – just the money they can’t
decide about. Taking this away may have ef-
fects on compliance.
In the beginning of the SHI it took more
than 30 years to understand that selective
contracting of physicians leads to a suppres-
sion of the provider side by powerful sick
funds. Finally after years of strikes and
fights the situation was resolved, as it was
ordered by government and later by law, that
contracts could only be made with the trade
union of ambulatory physicians. The union
was later transformed into a statutory body
with obligatory membership for all physici-
ans who wished to treat patients insured un-
der SHI in ambulatory settings. Also, in or-
der to avoid Sick Funds circumventing this
mutual bargaining, they were not permitted
to have their own establishment for ambula-
tory treatment or to contract with third par-
ties. This gave enormous stability and pre-
vented competition for prices.
The new regulation shifts the provision of
ambulatory care towards a commodity bu-
siness, as it will put financial considerations
before medical ones. The same is true for
permitting third parties e. g. commercial
entities, to open ambulatory treatment faci-
lities competing with established specialists
and GPs.
Although there have never been formally
mandated patient representatives in Ger-
many, the patient’s voice has always been
effective. If not, public movements resulted
in change, and the courts decided very often
in favour of patients and continuously ex-
tended benefits for patients. The underlying
notion was that neither sick funds nor provi-
ders in their contractual relationship should
be able to deprive patients of benefits. Now,
with a formally installed patient representa-
tive included in the procedures, the argu-
ment that decisions were taken without par-
ticipation of patients may no longer be ap-
plicable. This may lead to more effective li-
mitation of the basket than in the past. In-
deed the introduction of a patient represen-
tative may in the end do just this: limiting
patient claims. In the context of the overall
aim of the reform, namely limiting health
care expenditure, this of course would be a
success but at what cost to be principle of
equity in providing for the needs of the sick
The South African Medical Association’s work
on the HIV/Aids front
26
Regional and NMA News
HIV/Aids treatment in all provinces as a
matter of urgency, and will pursue all possi-
bilities towards facilitating treatment
through efforts with other organisations.”
Meanwhile, SAMA joined forces with the
Treatment Action Campaign and the Nelson
Mandela Foundation to strengthen its positi-
on in the fight against the disease.
SAMA has over the years used all means ne-
cessary to inform its members, and patients,
on the right to treatment of HIV. SAMA has
reiterated the profession’s commitment to
the alleviation of the HIV pandemic by all
means possible, and affirmed its strong sup-
port for the fundamental rights of medical
practitioners to clinical independence and
autonomy. This includes the right to treat
patients without undue influence, pressure
or victimisation from employers or govern-
ment institutions.
The Association then adopted a set of guide-
lines, ”HIV Human Rights and Ethical Gui-
delines” which informed members how to
deal with the management of HIV. Members
were kept informed of rulings by the Labour
Court regarding HIV through our Human
Rights, Law and Ethics Unit, and adopted a
document on ”Doctors’ and Patients’ Rights
and Responsibilities”. What makes this do-
cument unique, is that it translates the hu-
man rights found in the South African Con-
stitution into real-life situations affecting
doctors and patients. A second distinctive
feature is the inclusion of responsibilities or
duties. For example, every doctor has the
right to life, which includes the right not to
be placed in disproportional life-threatening
situations. But every doctor has the duty to
protect life, within the confines of patient
autonomy and decision-making power. On
the other hand, patients have the right to
have their lives protected by means of the
benefits of medicine when available, and
when they so wish. However, patients also
have the duty to ensure that their illness or
incapacity does not endanger the lives of
others.
SAMA has always stressed the fact that its
members were fighting the pandemic in
their everyday work. ”Medical practitioners
are under an ethical duty to act in the best in-
terest of their patients, who form an excep-
tionally vulnerable group in South Africa
society,” said Dr Chetty.
Doctors’ clinical independence came under
fire with the von Mollendorff case. Dr Thys
von Mollendorff was dismissed for treating
HIV-positive patients. SAMA worked close-
ly with the Greater Nelspruit Intervention
Programme (GRIP) and the Aids Law Pro-
ject to see that the case was concluded for
the positive. Letlape referred to the dismis-
sal of Dr von Mollendorff as an example in
which doctors’ responsibility to their pati-
ents was severely disrupted, which was in
direct contrast with the rights of individuals
which are entrenched in the constitution. He
emphasised that urgent discussion with go-
vernment was needed to look at the principle
of interference in the profession’s obligati-
ons and duties on a broad scale. ”We need
guidelines and rules to stimulate and nurtu-
re private public interface,” Letlape said.
SAMA continued to reiterate the profes-
sion’s right to clinical independence and au-
tonomy. Letlape referred to the 38th World
Medical Assembly (WMA) in 1986 when
the WMA unambiguously denounced politi-
cal interference in health care delivery.
”Physicians must have the professional fre-
edom to care for their patients without inter-
ference. The exercise of the physician’s pro-
fessional judgement and discretion in ma-
king clinical and ethical decisions in the
care and treatment of patients must be pre-
served and protected.” The Association
made it clear that it would continue to assist
and support doctors who acted in the best in-
terest of patients and their rights to access to
health care.
Later Amnesty International (A.I.) urged the
Minister of Health to put a stop to the haras-
sment of health care professionals and other
service providers in Mpumalanga Province,
to end discrimination against women in
need and to uphold professional ethics.
A.I.’s involvement in this issue started in
November 2001 when renewed action was
taken against Dr von Mollendorff for his in-
volvement in GRIP, which offered counsel-
ling and treatment to rape survivors. Accor-
ding to A.I., its correspondence with the re-
levant authorities requesting information on
the issue remained unanswered.
As part of awareness campaigns the Junior
Doctors’Association of SA (Judasa), an af-
filiate group of SAMA, created the Black
Armband Campaign to show solidarity with
HIV/Aids victims. Judasa emphasised that
their campaign was not an attack on govern-
ment, but rather an offer to assist in any go-
vernment action aimed at fighting the
HIV/Aids pandemic. As part of the cam-
paign, junior doctors intended to keep
thorough records of patients they saw dying
of HIV. The records would then be sent to
the relevant authorities, to share with gover-
nment what junior doctors’ experienced in
dealing with the HIV/Aids pandemic every
day.
Awareness campaigns continued with
SAMA closely watching the development of
the country’s HIV/Aids programme.
On December 1, 2002 SAMA launched the
Tshepang Treatment Programme, named af-
ter baby Tshepang who had been savagely
raped and was put back together by caring
doctors.
Nearly a year later the Association’s dream
came true – supplying ART to people living
with HIV. On December 1, 2003, World
Aids Day, SAMA launched an ART treat-
ment programme at the GF Jooste Hospital
in the Western Cape. The Association plans
to gather more financial support from the
role-players in the industry, and eventually
have two treatment sites in every province.
SAMA’s Foundation for Professional Deve-
lopment (FPD), the educational arm of
SAMA, has developed an HIV management
course for doctors and other health person-
nel. To date they have trained 3,500 health
care professionals in South Africa, and also
train health workers in Africa.
SAMA’s motto is ”Uniting doctors for the
health of the nation,” and we plan to do just
so. KL/TS
27
Regional and NMA News
Health care for prisoners: human rights
and ethical dilemmas for doctors working
in prison – a web-based course for health
care personnel working in prison
In 2001 the Norwegian Medical Association
took the initiative to develop a web-based
course on Human rights and ethics for prison
doctors. Various associations and organisa-
tions have contributed to this course, and
World Medical Association will be the main
provider.
Doctors working in prisons face problems
that are different from the problems encoun-
tered by doctors working with the ordinary
population. Prison doctors must be able to
provide adequate health care in the special
environments to be found in prisons, and en-
sure that this practice does not conflict with
international human rights and ethical stan-
dards.
In many countries education of prison doc-
tors is a priority area. Many doctors do not
even have access to international conventions
and rules regulating the health care service
for prisoners. We are aware that many doctors
know about human rights violations, but do
not know how to deal with them in an ade-
quate way. We hope this course will con-
tribute to meeting some of the needs for more
knowledge and skills in human rights and
medical ethics felt by many prison doctors.
The objectives of the course are to present
relevant international statements regulating
medical treatment of prisoners, and to raise
prison doctor’s awareness of their role in var-
ious areas of conflicting interests between the
prisoner (patient) and the prison administra-
tion, e. g. during hunger strikes; the patient’s
right to confidentiality; certifying prisoners
for special punishment etc.
The course will be accessible to everyone with
an Internet connection. Doctors and other
health personnel working in prison can take the
course at their own pace and whenever they
want. Participants do not have to complete the
whole course in one go. The course is divided
into lessons and the system remembers which
lessons the participant has completed.
No course fee will be charged for those who
wish to complete the course. When it is fin-
ished we will apply for approval at European
Accreditation Council for CME.
This course is sponsored by The Norwegian
Ministry of Foreign Affairs. The authors and
editors have contributed without receiving
any fees.
A preliminary version of the course is acces-
sible at http://www.lupin-nma.net/b.m.
A new report from the British Medical Asso-
ciation presents a disturbing picture of the ef-
fects of smoking on sexual, reproductive and
child health – and demands national and inter-
national action to tackle the issue. Smoking
and Reproductive Life, a joint publication of
the BMA board of Science and Education and
the BMA-funded Tobacco Control Resource
Centre, is the first focused overview of its
kind.
The picture that emerges is disturbing. Smo-
king harms sexual and reproductive health in
both men and women. Its damaging effects
are seen throughout reproductive life – from
puberty, through young adulthood and into
middle age. Smoking can compromise the ca-
pacity to have a family, and parental smoking
can have long-term and serious consequences
for child health. Exposure to second-hand
smoke is a risk during pregnancy, and harms
infants and children.
The peer-reviewed report draws together ma-
terial from more than 200 reference sources,
including expert evaluations by the US Sur-
geon General and the World Health Organi-
sation, as well as more recent original rese-
arch. Among the effects linked to active smo-
king are impotence, sperm damage, delayed
conception, infertility. increased risk of ecto-
pic pregnancy and miscarriage. damage to
the foetus, low birthweight, placental compli-
cations, premature birth. Smoking is also a
cause of early menopause, and increases the
risk of malignant cervical cancer up to three
fold.
The effects of passive smoking are also high-
lighted. Non-smoking women exposed to
other people’s tobacco smoke during preg-
nancy have lighter babies. and are at increa-
sed risk of having a low birth-weight baby.
Even relatively low-level exposure has a sig-
nificant effect. In children, secondhand smo-
ke is a cause of cot death, and increases the
risk of respiratory illness and middle ear in-
fection. It can cause asthma, and exacerbates
attacks in those already affected.
The good news is that giving up smoking re-
duces or eliminates many of the risks to re-
productive life and health. In contrast to much
of the excess risk of death associated with
smoking, much of the bürden of smoking on
reproductive life falls in younger adults, befo-
re age 40. In coming years. this bürden looks
set to increase: smoking rates look set to triple
among women in the next generation, and
more than half the world’s children are expo-
sed to secondhand smoke.
The report frames smoking as an important
consideration in sexual, reproductive and
child health. It makes recommendations to re-
duce the burden of sexual, reproductive and
childhood ill health caused by tobacco. inclu-
ding recommendations for research, healthca-
re professionals and public policy.
The full report is available from the Tobacco
Control Resource Centre website:
http://www.tobacco-control.org. For further
information, contact: tcrc@bma.org.uk.
Norwegian Medical Association
U.K.
New report details the impact of smoking on
sexual, reproductive and child health
28
Reviews
The WHO Bulletin WHO Bull. 82/2 reports
concern that legislative delays are slowing
down the progress of continuing medical ed-
ucation in India. ”The Medical Council has
been campaigning for CME to be made
compulsory” and has ”proposed a draft
amendment to a law that would standardise
medical practice across the country while
making sure that it is up to date with the lat-
est medical developments”.
The Fiji MedicalAssociation is seeking re-
vision of the Medical Act and is also en-
countering problems in generating politi-
cal will to provide legislative time. The
key issues are to bring the licensing re-
quirements into line with global trends in
2004, to introduce obligatory CME as a
condition for renewal of registration and to
update professional disciplinary proce-
dures. The Fiji Medical Association has
also joined the Fiji Human Rights Com-
mission to become actively involved in as-
sessment of treatment of persons in cus-
tody.
Fiji and India
Licensing and Regulation
Book Review
Medical Ethics Today: The BMA’s handbook
of ethics and law (2nd
edition). British Med-
ical Association Ethics Department. Pp. xxv,
882, London, BMJ Books, 2004, £ 60.00
In 1993 the BMA published Medical Ethics
Today: Its Practice and Philosophy, which
was the fifth in a series of handbooks on
ethics dating back to 1980. Now, a decade
later, a revised version of the 1993 edition
has appeared. Its greatly increased bulk,
more than twice that of its predecessor, is
largely due to the addition of legal issues that
were formerly treated in a separate BMA
publication, Rights and Responsibilities of
Doctors. Indeed, the title of the present vol-
ume is somewhat inaccurate, since the law
receives at least as much consideration as
does ethics.
Unlike the 1993 edition, the authorship and
status of this book is unclear. The front cov-
er assigns authorship to the BMA Ethics De-
partment whereas on p. xxiii the book is re-
ferred to as a publication from the BMA’s
Medical Ethics Committee. The text fre-
quently speaks in the name of the BMA (”In
the BMA’s view …,”, ”the BMA believes
…,”, ”BMA advice is that …,” etc.) but it is
seldom evident what type of approval any
particular statement has received within the
BMA.
The book comprises an introduction and
21 chapters on topics ranging from the doc-
tor-patient relationship to public health and
from assisted reproduction to responsibilities
after a patient’s death. Each chapter includes
a statement of relevant principles, detailed
treatments of the chapter subtopics with
summaries of the main points, abstracts of
pertinent legal cases, and extensive endnotes.
The chapters are generally quite comprehen-
sive in their treatment of the issues, as least
insofar as they affect doctors in the UK.
There are very few citations of publications
from other countries.
Like the 1993 edition, the aim of this book is
to produce a working tool for doctors rather
than a philosophical treatise: ”Since doctors
tend to need a quick and workable solution
for an immediate case, the guidance focuses
on practical responses to these common
questions, but this process inevitably brings
in reference to philosophy and law” (p. 2).
For many issues the practical response is rel-
atively unproblematic, since the legislators,
the courts or the General Medical Council
have already reached a conclusion and the
book states categorically that ”it is … neces-
sary to ensure that the action proposed is not
contrary to law or to guidance issued by the
GMC” (p. 10).
Other issues are not so clear-cut because the
law and the GMC are silent or inconclusive.
However, as with the unproblematic issues,
the book encourages doctors to look for ex-
ternal advice rather than deciding on their
own how to deal with the situation. The guid-
ance provided by the book on these issues is
derived from previous BMA statements, re-
ports from various organisations, the ethics
and legal literature, and especially standards
of good clinical practice. Indeed, much of the
guidance is neither ethical nor legal but
rather descriptive of social and organisation-
al factors that doctors need to take into ac-
count in their everyday practice. And when
the guidance is specifically ethical, it is
sometimes formulated in prescriptive terms
without any ethical reasoning, for example,
”doctors with a conscientious objection to
providing contraceptive advice or treatment
have an ethical duty to refer their patients
promptly to another practitioner or family
planning service” (p. 233).
Where ethical dilemmas occur for which
there is no explicit legal or regulatory re-
quirement, the book recommends that the
BMA Ethics Department and/or the medical
indemnity bodies be consulted. However, in
these circumstances the book frequently also
recommends that doctors seek legal advice.
The reader is entitled to question the value of
this approach, since legal opinions can and
do differ greatly, especially when the law is
unclear, and seeking such advice is both
time-consuming and costly. Clinical ethics
committees, which in other countries have
proved useful for dealing with ethical dilem-
mas, are mentioned only in connection with
assisted reproduction.
Despite the book’s massive size, there are
several topics that would have merited more
extensive treatment. These include alloca-
tion/rationing of health care resources, par-
ticularly the role of the individual doctor; the
participation of doctors in medical research,
including their qualifications, compensation
and responsibility for ethical committee re-
view; the relationship of doctors and com-
mercial organisations, especially pharmaceu-
tical companies; multicultural health care;
and ethics education in medical schools.
Doctors in the UK will find this book to be a
useful reference for a great variety of clinical,
professional and public policy issues. Since
so much of the book is devoted to British law,
however, it has limited applicability in other
countries.
A CD-ROM version of the book, with a
handy search feature, is included at no extra
cost or can be purchased separately. Updates
on the issues covered in the book are to be
provided on the BMA Ethics web site.
John R. Williams
Director of Ethics
World Medical Association
Ferney-Voltaire, France
CHILE
Colegio Médico de Chile
Esmeralda 678 – Casilla 639
Santiago
Tel: (56-2) 4277800
Fax: (56-2) 6330940 / 6336732
E-mail: sectecni@colegiomedico.cl
Website: www.colegiomedico.cl
Vicepresidente
CHINA
Chinese Medical Association
42 Dongsi Xidajie
Beijing 100710
Tel: (86-10) 6513 4885
Fax: (86-10) 6512 3754
E-mail: cmafrd@public3.bta.net.cn
COLOMBIA
Federación Médica Colombiana
Calle 72 – N° 6-44, Piso 11
Santafé de Bogotá, D.E.
Tel: (57-1) 211 0208
Tel/Fax: (57-1) 212 6082
E-mail: federacionmedicacol@
hotmail.com
DEMOCRATIC REP. OF CONGO
Ordre des Médecins du Zaire
B.P. 4922
Kinshasa – Gombe
Tel: (242-12) 24589/
Fax (secr.Gen): (242) 8846574
COSTA RICA
Unión Médica Nacional
Apartado 5920-1000
San José
Tel: (506) 290-5490
Fax: (506) 231 7373
E-mail: unmedica@sol.racsa.co.cr
CROATIA
Croatian Medical Association
Subiceva 9
10000 Zagreb
Tel: (385-1) 46 93 300
Fax: (385-1) 46 55 066
E-mail: orlic@mamef.mef.hr
CZECH REPUBLIC
Czech Medical Association .
J.E. Purkyne
Sokolská 31 – P.O. Box 88
120 26 Prague 2
Tel: (420-2) 242 66 201/202/203/204
Fax: (420-2) 242 66 212 / 96 18 18 69
E-mail: czma@cls.cz
Website: www.cls.cz
UNITED STATES
Colegio Médico Cubano Libre
P.O. Box 141016
Coral Gables, FL 33114-1016
Tel: (1-305) 446 9902/445 1429
Fax: (1-305) 4459310
DENMARK
Danish Medical Association
9 Trondhjemsgade
2100 Copenhagen 0
Tel: (45) 35 44 -82 29/Fax:-8505
E-mail: dadl@dadl.dk
Website: www.laegeforeningen.dk
DOMINICAN REPUBLIC
Asociación Médica Dominicana
Calle Paseo de los Medicos
Esquina Modesto Diaz Zona
Universitaria
Santo Domingo
Tel: (1809) 533-4602/533-4686
/533-8700
Fax: (1809) 535 7337
E-mail: asoc.medica@codetel.net.do
ECUADOR
Federación Médica Ecuatoriana
V.M. Rendón 923 – 2 do.Piso Of. 201
P.O. Box 09-01-9848
Guayaquil
Tel/Fax: (593) 4 562569
E-mail: fedmedec@andinanet.net
EGYPT
Egyptian Medical Association
„Dar El Hekmah“
42, Kasr El-Eini Street
Cairo
Tel: (20-2) 3543406
EL SALVADOR, C.A
Colegio Médico de El Salvador
Final Pasaje N° 10
Colonia Miramonte
San Salvador
Tel: (503) 260-1111, 260-1112/
Fax: -0324
E-mail: comcolmed@telesal.net
ETHIOPIA
Ethiopian Medical Association
P.O. Box 2179
Addis Ababa
Tel: (251-1) 158174
Fax: (251-1) 533742
E-mail: ema.emj@telecom.net.et /
ema@eth.healthnet.org
FIJI ISLANDS
Fiji Medical Association
2nd Fl. Narsey’s Bldg, Renwick Road
G.P.O. Box 1116
Suva
Tel: (679) –315388
Fax: (679) 387671
E-mail: fijimedassoc@connect.com.fi
FINLAND
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Tel: (358-9) 3930 826/Fax-794
Telex: 125336 sll sf
E-mail: fma@fimnet.fi
Website: www.medassoc.fi
FRANCE
Association Médicale Française
180, Blvd. Haussmann
75389 Paris Cedex 08
Tel: (33) 1 53 89 32 41
Fax: (33) 1 53 89 33 44
E-mail: cnom-international@
cn.medecin.fr
GEORGIA
Georgian Medical Association
7 Asatiani Street
380077 Tbilisi
Tel: (995 32) 39868 / Fax: -398083
E-mail: Gma@posta.ge
GERMANY
Bundesärztekammer
(German Medical Association)
Herbert-Lewin-Strasse 1
50931 Köln
Tel: (49-221) 400-4360/Fax: -4384
Teletex: 2211315 – BAK
E-mail:auslandsdienst@baek.de
Website: www.bundesaerztekammer.de
GHANA
Ghana Medical Association
P.O. Box 1596
Accra
Tel: (233-21) 670-510/Fax: -511
E-mail: gma@ghana.com
HAITI, W.I.
Association Médicale Haitienne
1ère
Av. du Travail #33 – Bois Verna
Port-au-Prince
Tel: (509) 245-2060/511-0253
Fax: (509) 223-9885
E-mail: amh@acn2..net
Website: www.amhhaiti.org
HONG KONG
Hong Kong Medical Association, China
Duke of Windsor Building, 5th Floor
15 Hennessy Road
Tel: (852) 2527-8285
Fax: (852) 2865-0943
E-mail: hkma@hkma.org
Website: www.hkma.org
HUNGARY
Association of Hungarian Medical
Societies (MOTESZ)
Nádor u. 36
1443 Budapest, PO.Box 145
General Director
Tel: (36-1) 312 3807 – 311 6687
Fax: (36-1) 383-7918
E-mail: motesz@motesz.hu
Website: www.motesz.hu
ICELAND
Icelandic Medical Association
Hlidasmari 8
200 Kópavogur
Tel: (354) 5 864 0478
Fax: (354) 5 644106
E-mail: icemed@icemed.is
INDIA
Indian Medical Association
Indraprastha Marg
New Delhi 110 002
Tel: (91-11) 337009/3378819/3378680
Fax: (91-11) 3379178/3379470
E-mail: inmedici@vsnl.com /
inmedici@ndb.vsnl.com
INDONESIA
Indonesian Medical Association
Jalan Dr Sam Ratulangie N° 29
Jakarta 10350
Tel: (62-21) 3150679
Fax: (62-21) 390 0473/3154 091
E-mail: pbidi@idola.net.id
IRELAND
Irish Medical Organisation
10 Fitzwilliam Place
Dublin 2
Tel: (353-1) 676-7273
Fax: (353-1) 6612758/6682168
Website: www.imo.ie
ISRAEL
Israel Medical Association
2 Twin Towers, 35 Jabotinsky St.
P.O. Box 3566, Ramat-Gan 52136
Tel: (972-3) 6100444 / 424
Fax: (972-3) 5751616 / 5753303
E-mail: estish@ima.org.il
Website: www.ima.org.il
JAPAN
Japan Medical Association
2-28-16 Honkomagome, Bunkyo-ku
Tokyo 113-8621
Tel: (81-3) 3946 2121/3942 6489
Fax: (81-3) 3946 6295
E-mail: jmaintl@po.med.or.jp
KAZAKHSTAN
Association of Medical Doctors
of Kazakhstan
117/1 Kazybek bi St.,
Almaty
Tel: (3272) 62 -43 01 / -92 92
Fax: -3606
E-mail: sadykova-aizhan@yahoo.com
REP. OF KOREA
Korean Medical Association
302-75 Ichon 1-dong, Yongsan-gu
Seoul 140-721
Tel: (82-2) 794 2474
Fax: (82-2) 793 9190
E-mail: intl@kma.org
Website: www.kma.org
KUWAIT
Kuwait Medical Association
P.O. Box 1202
Safat 13013
Tel: (965) 5333278, 5317971
Fax: (965) 5333276
E-mail: aks.shatti@kma.org.kw
LATVIA
Latvian Physicians Association
Skolas Str. 3
Riga
1010 Latvia
Tel: (371-7) 22 06 61; 22 06 57
Fax: (371-7) 22 06 57
E-mail: lab@parks.lv
LIECHTENSTEIN
Liechtensteinischer Ärzteverein
Postfach 52
9490 Vaduz
Tel: (423) 232 -3440
Fax: (423) 232 3455
Website: www.aerzte-net.li
LITHUANIA
Lithuanian Medical Association
Liubarto 2
2004 Vilnius
Tel/Fax: (370-5) 2731400
E-mail: lgs@takas.lt
LUXEMBOURG
Association des Médecins et
Médecins Dentistes du Grand-
Association and address/Officers
ii
Association and address/Officers
Duché de Luxembourg
29, rue de Vianden
2680 Luxembourg
Tel: (352) 44 40 331
Fax: (352) 45 83 49
E-mail: secretariat@ammd.lu
Website: www.ammd.lu
MACEDONIA
Macedonian Medical Association
Dame Gruev St. 3
P.O. Box 174
91000 Skopje
Tel/Fax: (389-91) 232577
MALAYSIA
Malaysian Medical Association
4th Floor, MMA House
124 Jalan Pahang
53000 Kuala Lumpur
Tel: (60-3) 40418972/40411375
Fax: (60-3) 40418187/40434444
E-mail: mma@tm.net.my
Website: http://www.mma.org.my
MALTA
Medical Association of Malta
The Professional Centre
Sliema Road, Gzira GZR 06
Tel: (356) 21312888
Fax: (356) 21331713
E-mail: mfpb@maltanet.net
Website: www.mam.org.mt
MEXICO
Colegio Medico de Mexico
Fenacome
Hidalgo 1828 Pte. Cons. 410
Colonia Obispado C.P. 64060
Monterrey, Nuevo Léon
Tel/Fax: (52-8) 348-41-55
E-mail: fenacomemexico@usa.net
Website: www.fenacome.org
NEPAL
Nepal Medical Association
Siddhi Sadan, Post Box 189
Exhibition Road
Katmandu
Tel: (977 1) 225860, 231825
Fax: (977 1) 225300
E-mail: nma@healthnet.org.np
NETHERLANDS
Royal Dutch Medical Association
P.O. Box 20051
3502 LB Utrecht
Tel: (31-30) 28 23-267/Fax-318
E-mail: j.bouwman@fed.knmg.nl
Website: http://www.knmg.nl
NEW ZEALAND
New Zealand Medical Association
P.O. Box 156
Wellington 1
Tel: (64-4) 472 –4741/ Fax-0838
Fax: (64-4) 471 0838
E-mail: nzma@nzma.org.nz
Website: www.nzma.org.nz
NIGERIA
Nigerian Medical Association
74, Adeniyi Jones Avenue Ikeja
P.O. Box 1108, Marina
Lagos
Tel: (234-1) 497 7262,
Fax: (234-1) 585 1432 (ext 2197)
E-mail: nigeriannma@hotmail.com
NORWAY
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
Tel: (47) 23 10 -90 00/Fax: -9010
E-mail: ellen.pettersen@
legeforeningen.no
Website: www.legeforeningen.no
PANAMA
Asociación Médica Nacional
de la República de Panamá
Apartado Postal 2020
Panamá 1
Tel: (507) 263 7622 /263-7758
Fax: (507) 223 1462
Fax modem: (507) 223-5555
E-mail: amenalpa@sinfo.net
PERU
Colegio Médico del Perú
Malecón Armendáriz N° 791
Miraflores
Lima
Tel: (51-1) 241 75 72
Fax: (51-1) 242 3917
E-mail: decano@colmedi.org.pe
Website: www.colmed.org.pe
PHILIPPINES
Philippine Medical Association
PMA Bldg, North Avenue
Quezon City
Tel: (63-2) 929-63 66/Fax: -6951
E-mail: pmasec1@edsamail.com.ph
POLAND
Polish Medical Association
Al. Ujazdowskie 24
00-478 Warszawa
Tel: (48-22) 628 86 99
Fax: (48-22) 628 86 99
PORTUGAL
Ordem dos Médicos
Av. Almirante Gago Coutinho, 151
1749-084 Lisbon
Tel: (351-21) 842 71 00/842 71 11
Fax: (351-21) 842 71 99
E-mail: ordemmedicos@mail.telepac.pt
/ intl.omcne@netcabo.pt
Website: www.ordemdosmedicos.pt
ROMANIA
Romanian Medical Association
Str. Progresului 10
Sect. 1, Bucarest, cod 70754
Tel: (40-1) 6141071
Fax: (40-1) 3121357
E-mail: amr@amr.sfos.ro
Website: www.cdi.pub.ro/CDI/
Parteneri/AMR_main.htm
RUSSIA
Russian Medical Society
34, Build. 1, Novy Arbat
121099 Moscow
Tel: (7-095)205-7371
Fax: (7-095) 205-3293
E-mail: rusmed@rusmed.rmt.ru
SLOVAK REPUBLIC
Slovak Medical Association
Legionarska 4
81322 Bratislavia
Tel: (421-2) 554 24 015
Fax: (421-2) 554 223 63
E-mail: secretarysma@ba.telecom.sk
SLOVENIA
Slovenian Medical Association
Komenskega 4
61001 Ljubljana
Tel: (386-61) 323 469
Fax: (386-61) 301 955
SOUTH AFRICA
The South African Medical Association
P.O. Box 74789, Lynnwood Rydge
0040 Pretoria
Tel: (27-12) 481 2036/7
Fax: (27-12) 481 2058
E-mail: liliang@samedical.org
Website: www.samedical.org
SPAIN
Consejo General de Colegios
Oficiales de Médicos
Villanueva 11
Madrid 28001
Tel: (34-91) 4317780
Fax: (34-91) 5764388
E-mail: internacional1@cgcom.org
SWEDEN
Swedish Medical Association
(Villagatan 5)
P.O. Box 5610
SE – 114 86 Stockholm
Tel: (46-8) 790 33 00
Fax: (46-8) 20 57 18
E-mail: info@slf.se
Website: www.lakarforbundet.se
SWITZERLAND
Fédération des Médecins Suisses
Elfenstrasse 18 – POB 293
3000 Berne 16
Tel: (41-31) 359 –1111/Fax: -1112
E-mail: fmh@hin.ch
Website: www.fmh.ch/ww/fr/pub/fmh/
histoire_fmh.htm
TAIWAN
Chinese Medical Association – Taipei
201, Shih-pai Rd., Sec. 2
P.O. Box 3043
Taipei 11217
Tel: (886-2) 2871-2121, ext 7358
Fax: (886-2) 28741097
E-mail: cma@vghtpe.gov.tw
THAILAND
Medical Association of Thailand
2 Soi Soonvijai
New Petchburi Road
Bangkok 10320
Tel: (66-2) 314 4333/318-8170
Fax: (66-2) 314 6305
E-mail: math@loxinfo.co.th
Website: http://www.medassocthai.org/
index.htm.
TUNISIA
Conseil National de l’Ordre
des Médecins de Tunisie
16, rue de Touraine
1082 Tunis Cité Jardins
Tel: (216-1) 792 736/799 041
Fax: (216-1) 788 729
E-mail: ordremed.na@planet.tn
TURKEY
Turkish Medical Association
GMK Bulvary,.
Pehit Danip Tunalygil Sok. N° 2 Kat 4
Maltepe
Ankara
Tel: (90-312) 231 –3179/Fax: -1952
E-mail: Ttb@ttb.org.tr
UGANDA
Uganda Medical Association
Plot 8, 41-43 circular rd.
P.O. Box 29874
Kampala
Tel: (256) 41 32 1795
Fax: (256) 41 34 5597
E-mail: myers28@hotmail.com
UNITED KINGDOM
British Medical Association
BMA House, Tavistock Square
London WC1H 9JP
Tel: (44-207) 387-4499
Fax: (44- 207) 383-6711
E-mail: vivn@bma.org.uk
Website: www.bma.org.uk
UNITED STATES OF AMERICA
American Medical Association
515 North State Street
Chicago, Illinois 60610
Tel: (1-312) 464 5040
Fax: (1-312) 464 5973
Website: http://www.ama-assn.org
URUGUAY
Sindicato Médico del Uruguay
Bulevar Artigas 1515
CP 11200 Montevideo
Tel: (598-2) 401 47 01
Fax: (598-2) 409 16 03
E-mail: secretaria@smu.org.uy
VATICAN STATE
Associazione Medica del Vaticano
Stato della Citta del Vaticano 00120
Tel: (39-06) 6983552
Fax: (39-06) 69885364
VENEZUELA
Federacion Médica Venezolana
Avenida Orinoco
Torre Federacion Médica Venezolana
Urbanizacion Las Mercedes
Caracas
Tel: (58-2) 9934547
Fax: (58-2) 9932890
Website: www.saludfmv.org and
info@saludgmv.org
ZIMBABWE
Zimbabwe Medical Association
P.O. Box 3671
Harare
Tel: (263-4) 791/553
Fax: (263-4) 791561
E-mail: zima@healthnet.zw
iii