wmj11

WorldMMeeddiiccaall JJoouurrnnaall
Vol. No.3,September200652
OFFICIAL JOURNAL OF THE WORLD MEDICAL ASSOCIATION, INC.
G 20438
Contents
EEddiittoorriiaall
Sun City – A chance to influence change 59
First steps towards selecting a new
who Director General 60
MMeeddiiccaall EEtthhiiccss aanndd HHuummaann RRiigghhttss
Safeguarding Global Research on Human Subjects 60
A European Perspective on the Clinical Research
Ethical Review Procedure 63
8th
World Congress of Bioethics, Beijing, China 65
A Discussion Paper on the Future of Self Care and
its Implications for Physicians 66
WWHHOO
Medicines, money and motivated health workers
are key to universal access to hiv/aids prevention,
treatment care and support 72
G8 commitments to infectious disease can improve
global health security 74
Worldwide shortage of doctors, nurses and other
health workers 74
who hiv/aids Director Outlines Progress and
Obstacles to Achieving Universal Access
to aids Treatment 75
Top level push to tackle priorities in sexual
and reproductive health 76
who launches new plan to confront
hiv-related health worker shortages 78
Indonesia holds avian influenza
expert consultation 80
Viet Nam eliminates maternal and
neonatal tetanus 80
who and unicef tackle problem of lack of
essential medicines for children 79
MMeeddiiccaall SScciieennccee,, PPrrooffeessssiioonnaall PPrraaccttiiccee
aanndd EEdduuccaattiioonn
Improved formula for oral rehydration salts
to save children’s lives 81
Needleless immunisations possible in the future? 82
New AIDS and malaria medicines added to
prequalification list 82
Male circumcision update 82
RReeggiioonnaall aanndd NNMMAA NNeewwss 84
RReevviieewwss 86
00_US_03_2006.qxd 05.10.2006 17:27 Seite 1
Website: https://www.wma.net
WMA Directory of National Member Medical Associations Officers and Council
Association and address/Officers
WMA OFFICERS
OF NATIONAL MEMBER MEDICALASSOCIATIONS AND OFFICERS
i see page ii
President-Elect President Immediate Past-President
Dr N. Arumagam Dr. Kgosi Letlape Dr. Y. D. Coble
Malaysian Medical Association The South African Medical Association 102 Magnolia Street
4th Floor MMA House P.O Box 74789 Lynnwood Ridge Neptune Beach, FL 32266
124 Jalan Pahang 0040 Pretoria USA
53000 Kuala Lumpur South Africa
Malaysia
Treasurer Chairman of Council Vice-Chairman of Council
Prof. Dr. Dr. h.c. J. D. Hoppe Dr. Y. Blachar Dr. K. Iwasa
Bundesärztekammer Israel Medical Association Japan Medical Association
Herbert-Lewin-Platz 1 2 Twin Towers 2-28-16 Honkomagome
10623 Berlin 35 Jabotisky Street Bunkyo-ku
Germany P.O. Box 3566 Tokyo 113-8621
Ramat-Gan 52136 Japan
Israel
Secretary General
Dr. O. Kloiber
World Medical Association
BP 63
01212 Ferney-Voltaire Cedex
France
ANDORRA S
Col’legi Oficial de Metges
Edifici Plaza esc. B
Verge del Pilar 5,
4art. Despatx 11, Andorra La Vella
Tel: (376) 823 525/Fax: (376) 860 793
E-mail: coma@andorra.ad
Website: www.col-legidemetges.ad
ARGENTINA S
Confederación Médica Argentina
Av. Belgrano 1235
Buenos Aires 1093
Tel/Fax: (54-114) 383-8414/5511
E-mail: comra@sinectis.com.ar
Website: www.comra.health.org.ar
AUSTRALIA E
Australian Medical Association
P.O. Box 6090
Kingston, ACT 2604
Tel: (61-2) 6270-5460/Fax: -5499
Website: www.ama.com.au
E-mail: ama@ama.com.au
AUSTRIA E
Österreichische Ärztekammer
(Austrian Medical Chamber)
Weihburggasse 10-12 – P.O. Box 213
1010 Wien
Tel: (43-1) 51406-931
Fax: (43-1) 51406-933
E-mail: international@aek.or.at
REPUBLIC OF ARMENIA E
Armenian Medical Association
P.O. Box 143, Yerevan 375 010
Tel: (3741) 53 58-63
Fax: (3741) 53 48 79
E-mail:info@armeda.am
Website: www.armeda.am
AZERBAIJAN E
Azerbaijan Medical Association
5 Sona Velikham Str.
AZE 370001, Baku
Tel: (994 50) 328 1888
Fax: (994 12) 315 136
E-mail: Mahirs@lycos.com /
azerma@hotmail.com
BAHAMAS E
Medical Association of the Bahamas
Javon Medical Center
P.O. Box N999
Nassau
Tel: (1-242) 328 6802
Fax: (1-242) 323 2980
E-mail: mabnassau@yahoo.com
BANGLADESH E
Bangladesh Medical Association
B.M.A House
15/2 Topkhana Road,
Dhaka 1000
Tel: (880) 2-9568714/9562527
Fax: (880) 2-9566060/9568714
E-mail: bma@aitlbd.net
BELGIUM F
Association Belge des Syndicats
Médicaux
Chaussée de Boondael 6, bte 4
1050 Bruxelles
Tel: (32-2) 644-12 88/Fax: -1527
E-mail: absym.bras@euronet.be
Website: www.absym-bras.be
BOLIVIA S
Colegio Médico de Bolivia
Casilla 1088
Cochabamba
Tel/Fax: (591-04) 523658
E-mail: colmedbo_oru@hotmail.com
Website: www.colmedbo.org
BRAZIL E
Associaçao Médica Brasileira
R. Sao Carlos do Pinhal 324 – Bela Vista
Sao Paulo SP – CEP 01333-903
Tel: (55-11) 317868 00
Fax: (55-11) 317868 31
E-mail: presidente@amb.org.br
Website: www.amb.org.br
BULGARIA E
Bulgarian Medical Association
15, Acad. Ivan Geshov Blvd.
1431 Sofia
Tel: (359-2) 954 -11 26/Fax:-1186
E-mail: usbls@inagency.com
Website: www.blsbg.com
CANADA E
Canadian Medical Association
P.O. Box 8650
1867 Alta Vista Drive
Ottawa, Ontario K1G 3Y6
Tel: (1-613) 731 9331/Fax: -1779
E-mail: monique.laframboise@cma.ca
Website: www.cma.ca
CHILE S
Colegio Médico de Chile
Esmeralda 678 – Casilla 639
Santiago
Tel: (56-2) 4277800
Fax: (56-2) 6330940 / 6336732
E-mail: sectecni@colegiomedico.c
Website: www.colegiomedico.cl
Cover photos: World Health Headquarters Building,Geneva. Courtesy of WHO.
Copyirght WHO / P.Virot
1. and 2. Main building, 3. Entrance main building
U2–4_WMJ_03_06.qxd 05.10.2006 16:40 Seite U2
CHINA E
Chinese Medical Association
42 Dongsi Xidajie
Beijing 100710
Tel: (86-10) 6524 9989
Fax: (86-10) 6512 3754
E-mail: suyumu@cma.org.cn
Website: www.chinamed.com.cn
COLOMBIA S
Federación Médica Colombiana
Calle 72 – N° 6-44, Piso 11
Santafé de Bogotá, D.E.
Tel: (57-1) 211 0208
Tel/Fax: (57-1) 212 6082
E-mail: federacionmedicacol@
hotmail.com
DEMOCRATIC REP. OF CONGO F
Ordre des Médecins du Zaire
B.P. 4922
Kinshasa – Gombe
Tel: (242-12) 24589/
Fax (Présidente): (242) 8846574
COSTA RICA S
Unión Médica Nacional
Apartado 5920-1000
San José
Tel: (506) 290-5490
Fax: (506) 231 7373
E-mail: unmedica@sol.racsa.co.cr
CROATIA E
Croatian Medical Association
Subiceva 9
10000 Zagreb
Tel: (385-1) 46 93 300
Fax: (385-1) 46 55 066
E-mail: orlic@mamef.mef.hr
CZECH REPUBLIC E
Czech Medical Association .
J.E. Purkyne
Sokolská 31 – P.O. Box 88
120 26 Prague 2
Tel: (420-2) 242 66 201/202/203/204
Fax: (420-2) 242 66 212 / 96 18 18 69
E-mail: czma@cls.cz
Website: www.cls.cz
CUBA S
Colegio Médico Cubano Libre
P.O. Box 141016
717 Ponce de Leon Boulevard
Coral Gables, FL 33114-1016
United States
Tel: (1-305) 446 9902/445 1429
Fax: (1-305) 4459310
DENMARK E
Danish Medical Association
9 Trondhjemsgade
2100 Copenhagen 0
Tel: (45) 35 44 -82 29/Fax:-8505
E-mail: er@dadl.dk
Website: www.laegeforeningen.dk
DOMINICAN REPUBLIC S
Asociación Médica Dominicana
Calle Paseo de los Medicos
Esquina Modesto Diaz Zona
Universitaria
Santo Domingo
Tel: (1809) 533-4602/533-4686/
533-8700
Fax: (1809) 535 7337
E-mail: asoc.medica@codetel.net.do
ECUADOR S
Federación Médica Ecuatoriana
V.M. Rendón 923 – 2 do.Piso Of. 201
P.O. Box 09-01-9848
Guayaquil
Tel/Fax: (593) 4 562569
E-mail: fdmedec@andinanet.net
EGYPT E
Egyptian Medical Association
„Dar El Hekmah“
42, Kasr El-Eini Street
Cairo
Tel: (20-2) 3543406
EL SALVADOR, C.A S
Colegio Médico de El Salvador
Final Pasaje N° 10
Colonia Miramonte
San Salvador
Tel: (503) 260-1111, 260-1112
Fax: -0324
E-mail: comcolmed@telesal.net
marnuca@hotmail.com
ESTONIA E
Estonian Medical Association (EsMA)
Pepleri 32
51010 Tartu
Tel/Fax (372) 7420429
E-mail: eal@arstideliit.ee
Website: www.arstideliit.ee
ETHIOPIA E
Ethiopian Medical Association
P.O. Box 2179
Addis Ababa
Tel: (251-1) 158174
Fax: (251-1) 533742
E-mail: ema.emj@telecom.net.et /
ema@eth.healthnet.org
FIJI ISLANDS E
Fiji Medical Association
2nd Fl. Narsey’s Bldg, Renwick Road
G.P.O. Box 1116
Suva
Tel: (679) 315388
Fax: (679) 387671
E-mail: fijimedassoc@connect.com.fj
FINLAND E
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Tel: (358-9) 3930 826/Fax-794
Telex: 125336 sll sf
E-mail: fma@fimnet.fi
Website: www.medassoc.fi
FRANCE F
Association Médicale Française
180, Blvd. Haussmann
75389 Paris Cedex 08
Tel: (33) 1 53 89 32 41
Fax: (33) 1 53 89 33 44
E-mail: cnom-international@
cn.medecin.fr
GEORGIA E
Georgian Medical Association
7 Asatiani Street
380077 Tbilisi
Tel: (995 32) 398686 / Fax: -398083
E-mail: Gma@posta.ge
GERMANY E
Bundesärztekammer
(German Medical Association)
Herbert-Lewin-Platz 1
10623 Berlin
Tel: (49-30) 400-456 363/Fax: -384
E-mail: renate.vonhoff-winter@baek.de
Website: www.bundesaerztekammer.de
GHANA E
Ghana Medical Association
P.O. Box 1596
Accra
Tel: (233-21) 670-510/Fax: -511
E-mail: gma@ghana.com
HAITI, W.I. F
Association Médicale Haitienne
1ère
Av. du Travail #33 – Bois Verna
Port-au-Prince
Tel: (509) 245-2060
Fax: (509) 245-6323
E-mail: amh@amhhaiti.net
Website: www.amhhaiti.net
HONG KONG E
Hong Kong Medical Association, China
Duke of Windsor Building, 5th Floor
15 Hennessy Road
Tel: (852) 2527-8285
Fax: (852) 2865-0943
E-mail: hkma@hkma.org
Website: www.hkma.org
HUNGARY E
Association of Hungarian Medical
Societies (MOTESZ)
Nádor u. 36
1443 Budapest, PO.Box 145
Tel: (36-1) 312 3807 – 311 6687
Fax: (36-1) 383-7918
E-mail: motesz@motesz.hu
Website: www.motesz.hu
ICELAND E
Icelandic Medical Association
Hlidasmari 8
200 Kópavogur
Tel: (354) 8640478
Fax: (354) 5644106
E-mail: icemed@icemed.is
INDIA E
Indian Medical Association
Indraprastha Marg
New Delhi 110 002
Tel: (91-11) 337009/3378819/3378680
Fax: (91-11) 3379178/3379470
E-mail: inmedici@vsnl.com /
inmedici@ndb.vsnl.com
INDONESIA E
Indonesian Medical Association
Jalan Dr Sam Ratulangie N° 29
Jakarta 10350
Tel: (62-21) 3150679
Fax: (62-21) 390 0473/3154 091
E-mail: pbidi@idola.net.id
IRELAND E
Irish Medical Organisation
10 Fitzwilliam Place
Dublin 2
Tel: (353-1) 676-7273
Fax: (353-1) 6612758/6682168
Website: www.imo.ie
ISRAEL E
Israel Medical Association
2 Twin Towers, 35 Jabotinsky St.
P.O. Box 3566, Ramat-Gan 52136
Tel: (972-3) 6100444 / 424
Fax: (972-3) 5751616 / 5753303
E-mail: estish@ima.org.il
Website: www.ima.org.il
JAPAN E
Japan Medical Association
2-28-16 Honkomagome, Bunkyo-ku
Tokyo 113-8621
Tel: (81-3) 3946 2121/3942 6489
Fax: (81-3) 3946 6295
E-mail: jmaintl@po.med.or.jp
KAZAKHSTAN F
Association of Medical Doctors
of Kazakhstan
117/1 Kazybek bi St.,
Almaty
Tel: (3272) 62 -43 01 / -92 92
Fax: -3606
E-mail: sadykova-aizhan@yahoo.com
REP. OF KOREA E
Korean Medical Association
302-75 Ichon 1-dong, Yongsan-gu
Seoul 140-721
Tel: (82-2) 794 2474
Fax: (82-2) 793 9190
E-mail: intl@kma.org
Website: www.kma.org
KUWAIT E
Kuwait Medical Association
P.O. Box 1202
Safat 13013
Tel: (965) 5333278, 5317971
Fax: (965) 5333276
E-mail: aks.shatti@kma.org.kw
LATVIA E
Latvian Physicians Association
Skolas Str. 3
Riga
1010 Latvia
Tel: (371-7) 22 06 61; 22 06 57
Fax: (371-7) 22 06 57
E-mail: lab@parks.lv
LIECHTENSTEIN E
Liechtensteinischer Ärztekammer
Postfach 52
9490 Vaduz
Tel: (423) 231-1690
Fax: (423) 231-1691
E-mail: office@aerztekammer.li
Website: www.aerzte-net.li
LITHUANIA E
Lithuanian Medical Association
Liubarto Str. 2
2004 Vilnius
Tel/Fax: (370-5) 2731400
E-mail: lgs@takas.lt
LUXEMBOURG F
Association des Médecins et
Médecins Dentistes du Grand-
Duché de Luxembourg
29, rue de Vianden
2680 Luxembourg
Tel: (352) 44 40 331
Fax: (352) 45 83 49
E-mail: secretariat@ammd.lu
Website: www.ammd.lu
Association and address/Officers
ii
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Association and address/Officers
iii
MACEDONIA E
Macedonian Medical Association
Dame Gruev St. 3
P.O. Box 174
91000 Skopje
Tel/Fax: (389-91) 232577
MALAYSIA E
Malaysian Medical Association
4th Floor, MMA House
124 Jalan Pahang
53000 Kuala Lumpur
Tel: (60-3) 40418972/40411375
Fax: (60-3) 40418187/40434444
E-mail: mma@tm.net.my
Website: http://www.mma.org.my
MALTA E
Medical Association of Malta
The Professional Centre
Sliema Road, Gzira GZR 06
Tel: (356) 21312888
Fax: (356) 21331713
E-mail: mfpb@maltanet.net
Website: www.mam.org.mt
MEXICO S
Colegio Medico de Mexico
Fenacome
Hidalgo 1828 Pte. Cons. 410
Colonia Obispado C.P. 64060
Monterrey, Nuevo Léon
Tel/Fax: (52-8) 348-41-55
E-mail: fenacomemexico@usa.net
Website: www.fenacome.org
NEPAL E
Nepal Medical Association
Siddhi Sadan, Post Box 189
Exhibition Road
Katmandu
Tel: (977 1) 225860, 231825
Fax: (977 1) 225300
E-mail: nma@healthnet.org.np
NETHERLANDS E
Royal Dutch Medical Association
P.O. Box 20051
3502 LB Utrecht
Tel: (31-30) 28 23-267/Fax-318
E-mail: j.bouwman@fed.knmg.nl
Website: www.knmg.nl
NEW ZEALAND E
New Zealand Medical Association
P.O. Box 156
Wellington 1
Tel: (64-4) 472-4741
Fax: (64-4) 471 0838
E-mail: nzma@nzma.org.nz
Website: www.nzma.org.nz
NIGERIA E
Nigerian Medical Association
74, Adeniyi Jones Avenue Ikeja
P.O. Box 1108, Marina
Lagos
Tel: (234-1) 480 1569,
Fax: (234-1) 493 6854
E-mail: info@nigeriannma.org
Website: www.nigeriannma.org
NORWAY E
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
Tel: (47) 23 10 -90 00/Fax: -9010
E-mail: ellen.pettersen@
legeforeningen.no
Website: www.legeforeningen.no
PANAMA S
Asociación Médica Nacional
de la República de Panamá
Apartado Postal 2020
Panamá 1
Tel: (507) 263 7622 /263-7758
Fax: (507) 223 1462
Fax modem: (507) 223-5555
E-mail: amenalpa@sinfo.net
PERU S
Colegio Médico del Perú
Malecón Armendáriz N° 791
Miraflores, Lima
Tel: (51-1) 241 75 72
Fax: (51-1) 242 3917
E-mail: decano@colmedi.org.pe
Website: www.colmed.org.pe
PHILIPPINES E
Philippine Medical Association
PMA Bldg, North Avenue
Quezon City
Tel: (63-2) 929-63 66/Fax: -6951
E-mail: pmasec1@edsamail.com.ph
POLAND E
Polish Medical Association
Al. Ujazdowskie 24, 00-478 Warszawa
Tel/Fax: (48-22) 628 86 99
PORTUGAL E
Ordem dos Médicos
Av. Almirante Gago Coutinho, 151
1749-084 Lisbon
Tel: (351-21) 842 71 00/842 71 11
Fax: (351-21) 842 71 99
E-mail: ordemmedicos@mail.telepac.pt
/ intl.omcne@omsul.com
Website: www.ordemdosmedicos.pt
ROMANIA F
Romanian Medical Association
Str. Ionel Perlea, nr 10
Sect. 1, Bucarest, cod 70754
Tel: (40-1) 6141071
Fax: (40-1) 3121357
E-mail: AMR@itcnet.ro
Website: www.cdi.pub.ro/CDI/
Parteneri/AMR_main.htm
RUSSIA E
Russian Medical Society
Udaltsova Street 85
121099 Moscow
Tel: (7-095)932-83-02
E-mail: rusmed@rusmed.rmt.ru
info@russmed.com
SINGAPORE E
Singapore Medical Association
Alumni Medical Centre, Level 2
2 College Road, 169850 Singapore
Tel: (65) 6223 1264
Fax: (65) 6224 7827
E-Mail: sma@sma.org.sg
SLOVAK REPUBLIC E
Slovak Medical Association
Legionarska 4
81322 Bratislava
Tel: (421-2) 554 24 015
Fax: (421-2) 554 223 63
E-mail: secretarysma@ba.telecom.sk
SLOVENIA E
Slovenian Medical Association
Komenskega 4, 61001 Ljubljana
Tel: (386-61) 323 469
Fax: (386-61) 301 955
SOUTH AFRICA E
The South African Medical Association
P.O. Box 74789, Lynnwood Rydge
0040 Pretoria
Tel: (27-12) 481 2036/7
Fax: (27-12) 481 2058
E-mail: liliang@samedical.org
Website: www.samedical.org
SPAIN S
Consejo General de Colegios Médicos
Plaza de las Cortes 11, Madrid 28014
Tel: (34-91) 431 7780
Fax: (34-91) 431 9620
E-mail: internacional1@cgcom.es
SWEDEN E
Swedish Medical Association
(Villagatan 5)
P.O. Box 5610, SE – 114 86 Stockholm
Tel: (46-8) 790 33 00
Fax: (46-8) 20 57 18
E-mail: info@slf.se
Website: www.lakarforbundet.se
SWITZERLAND F
Fédération des Médecins Suisses
Elfenstrasse 18 – POB 293
3000 Berne 16
Tel: (41-31) 359 –1111/Fax: -1112
E-mail: fmh@hin.ch
Website: www.fmh.ch
TAIWAN E
Taiwan Medical Association
9F No 29 Sec1
An-Ho Road
Taipei
Deputy Secretary General
Tel: (886-2) 2752-7286
Fax: (886-2) 2771-8392
E-mail: intl@med-assn.org.tw
THAILAND E
Medical Association of Thailand
2 Soi Soonvijai
New Petchburi Road
Bangkok 10320
Tel: (66-2) 314 4333/318-8170
Fax: (66-2) 314 6305
E-mail: math@loxinfo.co.th
Website: http://www.medassocthai.org/
index.htm.
TUNISIA F
Conseil National de l’Ordre
des Médecins de Tunisie
16, rue de Touraine
1082 Tunis Cité Jardins
Tel: (216-71) 792 736/799 041
Fax: (216-71) 788 729
E-mail: ordremed.na@planet.tn
TURKEY E
Turkish Medical Association
GMK Bulvary,.
Pehit Danip Tunalygil Sok. N° 2 Kat 4
Maltepe
Ankara
Tel: (90-312) 231 –3179/Fax: -1952
E-mail: Ttb@ttb.org.tr
UGANDA E
Uganda Medical Association
Plot 8, 41-43 circular rd.
P.O. Box 29874
Kampala
Tel: (256) 41 32 1795
Fax: (256) 41 34 5597
E-mail: myers28@hotmail.com
UNITED KINGDOM E
British Medical Association
BMA House, Tavistock Square
London WC1H 9JP
Tel: (44-207) 387-4499
Fax: (44- 207) 383-6710
E-mail: vivn@bma.org.uk
Website: www.bma.org.uk
UNITED STATES OF AMERICA E
American Medical Association
515 North State Street
Chicago, Illinois 60610
Tel: (1-312) 464 5040
Fax: (1-312) 464 5973
Website: http://www.ama-assn.org
URUGUAY S
Sindicato Médico del Uruguay
Bulevar Artigas 1515
CP 11200 Montevideo
Tel: (598-2) 401 47 01
Fax: (598-2) 409 16 03
E-mail: secretaria@smu.org.uy
VATICAN STATE F
Associazione Medica del Vaticano
Stato della Citta del Vaticano 00120
Tel: (39-06) 6983552
Fax: (39-06) 69885364
E-mail: servizi.sanitari@scv.va
VENEZUELA S
Federacion Médica Venezolana
Avenida Orinoco
Torre Federacion Médica Venezolana
Urbanizacion Las Mercedes
Caracas
Tel: (58-2) 9934547
Fax: (58-2) 9932890
Website: www.saludfmv.org
E-mail: info@saludgmv.org
VIETNAM E
Vietnam General Association
of Medicine and Pharmacy (VGAMP)
68A Ba Trieu-Street
Hoau Kiem district
Hanoi
Tel: (84) 4 943 9323
Fax: (84) 4 943 9323
ZIMBABWE E
Zimbabwe Medical Association
P.O. Box 3671
Harare
Tel: (263-4) 791/553
Fax: (263-4) 791561
E-mail: zima@healthnet.zw
U2–4_WMJ_03_06.qxd 05.10.2006 16:40 Seite U4
59
OFFICIAL JOURNAL OF
THE WORLD MEDICAL
ASSOCIATION
Hon. Editor in Chief
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suffolk IP14 3QT
UK
Co-Editors
Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte-Verlag
Dieselstr. 2
D–50859 Köln
Germany
Dr. Ivan M. Gillibrand
19 Wimblehurst Court
Ashleigh Road
Horsham
West Sussex RH12 2AQ
UK
Business Managers
J. Führer, D. Weber
50859 Köln
Dieselstraße 2
Germany
Publisher
THE WORLD MEDICAL
ASSOCIATION, INC.
BP 63
01212 Ferney-Voltaire Cedex, France
Publishing House
Deutscher Ärzte-Verlag GmbH,
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The General Assembly of the World Medical Association takes place in South Africa in
October. At a time when the continuing burden of disease, AIDS/HIV, Malaria,
Tuberculosis etc., inadequate resources and under-funding of need is so great (despite the
international response so far), it is thus appropriate that the Assembly is meeting in the
African continent.
Although the agenda of the General Assembly will be much occupied with the necessary
updating of WMA policy statements, including the International Code of Medical Ethics
(see Council meeting report in WMJ 52(2)) and possibly adopting statements on other
issues such as Obesity, Pandemic Influenza etc., no doubt other matters relating to major
health issues including those of the African continent will be raised during the meeting.
The Scientific session will be devoted to “Health as an Investment” and “Advocacy”, pro-
viding an opportunity to examine aspects of these topics as diverse as Investment in Human
Resources, Medical Research, Public-funded healthcare planning – not to mention the eco-
nomic aspects of the topic. The presentation will consider the obligations of governments
in the provision of basic health care, move on to aspects of Advocacy and finally address
the Role of National Medical Associations in the topics addressed.
Looking round the world today, it is clear that health care is a major topic of discussion not
only in developing countries. Developed countries, with health care – often long estab-
lished and well developed – are also experiencing major problems although not to the same
degree. It is not without significance that in considering the economics of health, both its
promotion and care, governments are now trying to assess the value of investment in health
and how the best value for this type of investment can achieved. This situation is not with-
out its effect on physicians, as can be seen in the notes on news from the regions and nation-
al medical associations (p. 82). Disquiet is with lack of resources both financial and
human, due not only to problems associated with the economy or productivity in both
developing and developed countries. In developing countries it can be due to emergence of
new diseases or inadequate control of old ones, or by armed conflict or social unrest.
In developed countries as well, governmental and healthcare system’s suggested or
imposed changes, or dissatisfaction with the working conditions of health professionals,
are increasingly provoking not only disquiet and demonstrations but, in some countries,
even strikes.
In todays world of rapid change it is not to be unexpected that change will affect the med-
ical profession. Indeed we have addressed this problem previously in these columns.
However, it would appear that in some quarters the rapidity of change or the perceived
inequity of conditions, are producing considerable reactions. Not infrequently the views
being expressed are reflections of concern that proposed or imposed changes are not in the
interest of the relevant population in general and patients in particular.
Faced with these trends, it is to be hoped that the discussions in South Africa will shine
some light on the best ways in which National Medical Associations can act themselves and
advise their members, both in there interest and that of the health of the people.
Alan Rowe
Editorial
Sun City – A chance to influence change
WMJ_2_59-86.qxd 05.10.2006 14:05 Seite 59
Medical Ethics and Human Rights
60
Principles of Medical Research involving
Human subjects from its origin in 1964 has
provided the source of guidance set for
Physicians worldwide. The 2000 version of
the Declaration states that ‘it is the duty of
the physician to promote and safeguard the
health of the people. The physician’s
knowledge and conscience are dedicated to
the fulfillment of this duty”. The
Declaration also recognizes that medical
progress is based on research which ulti-
mately must rest in part on experimentation
involving human subjects, but that consid-
erations related to the well being of the
human subject should take precedence over
the interests of science and society.
These duties and responsibilities of physi-
cians to their patients cannot be subsumed
by a research ethics committee or research
team.
Physicians by themselves or as members of
national medical associations are unable to
provide full protection to their patients and
populations. They work as members of
research teams in an increasingly complex
environment. They should not work in an
environment which breaches their ethical
duties and obligations.
Awareness of these ethical issues had been
heightened by Claude Bernard in France in
the mid-nineteen century. Personal, institu-
tional and national codes of practice
emerged over the next hundred years.
An expert group, bringing together the
research community, industry and regula-
tors was set up by the International
Conference on the Harmonisation of
Technical Requirements for the
Registration of Pharmaceuticals for Human
use. (ICH) Their consolidated “guidance”
on Good Clinical Practice in 1996 was
gleaned from their participants. This has
provided a uniform standard for the
European Union (EU), Japan and the
United States for designing, conducting,
recording and reporting clinical trials on
human subjects. (ICH.GCP) In the intro-
duction, the Guidance states that
“Compliance with this standard provides
public assurance that their rights, safety and
wellbeing of trial subjects are protected
consistent with the principles that have their
Following the tragic death of Dr. Lee Jong-
wook, the WHO Executive decided to has-
ten the process of electing a successor.
Nomination by Member States closed on
5th
September and the list of thirteen nomi-
nations were announced and appear below.
Amongst the formidable list of candidates
are members and former members of WHO
staff, and a former member of the WHO
Executive committee
It also should be noted that Dr. Lee Jong-
wook had only completed 3 of his 5 years of
office. While this might be thought to influ-
ence the decision in favour of an Asian can-
didate and normally other UN elections
such as that of the UN Secretary General do
not influence proposals, it may be that the
possibility in the UN Security Council that
the next UN Secretary General will be
Asian may prove significant.
The 34 members of the Executive commit-
tee meeting in a special session on 6-8
November and make a nomination from a
short list to the World Health Assembly on
9th
November, who will take the final deci-
sion and appoint the new Director General.
The list of candidates and the proposing
Member State are:
Dr. Kazem Behbehani (Kuwait)
Dr Margaret Chan (China)
Fr. Julio Frenck (Mexico)
Mr David A. Gunnarsson (Iceland)
Dr. Nay Htun (Myanmar)
Dr. Karam Karam (Syrian Arab Republic)
Dr. Bernard Kouschner (France)
Dr. Pascoal Manuel Mocumbi (Mozambique)
Dr. Shigaru Omi (Japan)
Dr. Alfredo Palacio Gonzalez (Ecuador)
Professor Pekka Puska (Finland)
Ms Elena Saigado Médez (Spain)
Professor Dr. Tomris Türmen (Turkey)
First steps towards selecting a new
WHO Director General
WHO announces list of candidates
Dr. James Appleyard, FRCP, Past
President of the World Medical
Association.
The majority of research on human subjects
is now being undertaken in the ‘developing’
nations. This change from the established
centres of clinical research in the United
States, Europe and Japan has been acceler-
ating in the recent years because of relative-
ly low costs and the increased availability
of human subjects in the poorer countries.
Medical Ethics and Human Rights
Safeguarding Global Research
on Human Subjects
Concerns have been raised about the vul-
nerability of local populations in the devel-
oping world and whether there are suffi-
cient safeguards to protect them. Instances
of alleged abuse have been highlighted in
the medical literature as well as the World’s
Press.
Physicians have a clear duty to look after
the best interests of those who entrust them-
selves to their care. The WMA’s
Declaration of Helsinki on the Ethical
WMJ_2_59-86.qxd 05.10.2006 14:05 Seite 60
Medical Ethics and Human Rights
61
receiving research support from the NIH
did most of the research community appear
to respect the basic underlying ethical prin-
ciples of the Belmont Report, those of
Respect for Persons, beneficence and jus-
tice. The first Director of OHRP Dr. Greg
Koski emphasized the requirement for
“shared goals and shared responsibilities“
and the need to move from “a culture of
compliance to a culture of conscience in
human research”. His view underscores the
need for the research community to inter-
nalize the principles of the Declaration of
Helsinki and the Belmont Report into their
“conscience” Dr. Melody Lin, the Deputy
Director, emphasizes that the work of the
OHRP depends on Trust ( that is individual
and institutional ‘conscience’), Education
and Regulatory oversight – it is indeed get-
ting this balance right that is the major chal-
lenge for Governments and the professions
and the research community.
The challenge is not only to promote these
principles world wide but to ensure that
there is a robust ethical research committee
infrastructure globally to support the
increase in research in developing countries
necessary to correct the global imbalance of
research. The WHO has estimated that 90%
of the resources devoted to research and
development on medical problems are
applied to diseases causing less than 10% of
the global suffering.
The WHO published Operational
Guidelines for Ethics Committees review-
ing Biomedical Research following an ini-
tiative by the Research and Training in
Tropical Diseases (TDR), the World Bank
and the United Nations DP in 2000. The
Secretary General of WMA assisted in this
development in the International Working
Party, which was chaired by Francis P.
Crawley from Belgium.
A strategic Initiative for Developing
Capacity in Ethical review (SIDCER) was
launched under the aegis of UNICEF /
UNDP / World Bank / WHO TDR in 2001.
This is a network of independently estab-
lished regional forums for Ethical Review
committees, health researchers and invited
partner organisations including the WMA.
It was designed to address the principle
gaps and challenges in ethics encountered
origin in the Declaration of Helsinki and
that the Clinical Data are credible”.
Revelations that financial relationships and
conflicts of interest had become ‘pervasive’
and were undermining public trust in the
integrity of Science resulted in the call for
greater transparency (honesty) within the
US regulatory framework. The Office for
Human Research Protections (OHRP) was
set up in 2000 from the former Office for
Protection from Research Risk (OPRR). It
reports to the Assistant Secretary of Health
and Human services.
The National Institutes of Health [NIH] is
by far the largest human research funding
agency worldwide. To carry out its research
mission, nearly 10,000 universities, hospi-
tals and other Research Institutions in the
United States and internationally have for-
mal assurances with OHRP to comply with
the US regulations related to human subject
protection.
Only when the NIH required documentation
of some training in research ethics and
human subject protection as a condition of
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Medical Ethics and Human Rights
62
in global health research. In Dr. Vichai
Chokevivat (Thailand), its Chairman’s
words “ the network of regional forums cre-
ate unique opportunities for professional
development and learning with innovative
approaches to cross cultural, cross national
and cross regional understanding and mutu-
al support”. Funding from different sources
including the OHRP was channeled through
the WHO/TDR. The regional fora are
known by their acronyms – FERCAP
(Forum for Ethical Review Committees in
Asia and Western Pacific), the first to be set
up; FLACEIS (For a Latino American de
Comits de Etica en Investigacion en Salud);
PABIN (Pan African Bioethics Initiative),
FECCIS (Forum for Ethical Committees in
the Confederation of Independent States
and FOCUS (Forum for Ethical Review
Boards/Institutional Review Boards in
Canada and the US.
The European Forum for Good Clinical
Practice (EFGCP) had previously been set
up under the pioneering guidance of
Professor Joseph Hoet and has contributed
to SIDCER’s work.
SIDCER’s vision was to establish systems
and infrastructure for the accreditation of
ethics in Health Research and develop a
register of resources and data bases of
ethics committees and institutional review
boards within the countries who are mem-
bers of the Regional Fora.
Members of the original WHO International
Working Party are still very active in the
Fora. Host governments to the Regional
meetings are interested “stakeholders”.
Progress has been made in influencing
some of the governments in the newly inde-
pendent states to adopt legislation respect-
ing human rights and human dignity upon
which the ethical principles in medical
research on human subjects depend.
Reports from the different participating
countries are presented, shared and dis-
cussed at the Fora Training courses are also
arranged.
When President of the WMA I was invited
to give the Joseph Hoet Lecture at the
EFGCP, to attend FECCIS and have since
had the opportunity to participate in three of
the five regional fora. Such conferences are
both stimulating and enjoyable for the par-
ticipants. Often there is a feeling of
achievement when new recommendations
are made to the constituent members.
However only three Medical Research insti-
tutions have been accredited by SIDCER in
5 years – two of these in Taiwan. The
research community in Taiwan have taken
the ethical issues very seriously and have
established their own Forum for
Independent Review System in Taiwan –
FIRST. National medical associations are
not directly involved in the regional confer-
ences and the most senior researchers from
the countries are not invited regularly. The
fora are therefore not always connected
with those that influence and implement
policy locally. Some training may ‘trickle
down’ but there must be more effective
ways to promote and support education in
Research Ethics locally.
In addition to the WMA setting the ethical
standards through the Declaration of
Helsinki, the Association needs to support
measures to implement it globally.
The Declaration itself has been the subject a
comprehensive study by Carlson, Boyd and
Webb from Edinburgh University. They
comment: “there is no doubt that the
Declaration of Helsinki – still less than
2000 words in length – is one of the most
succinct documents encapsulating the prin-
ciples guiding research ethics in existence”
The World Medical Association can only be
effective in its promotion locally through its
constituent national medical associations,
who are the local custodians of the princi-
ples in the Declaration of Helsinki. The tra-
ditional ethical base within the national
medical associations in the ‘developing’
countries needs to be strengthened and sup-
ported so they can contribute more actively
to the development of research within their
domain and the infrastructure of research
ethics committees. This could be achieved
through educational materials which can be
easily accessed. The WMA has initiated two
web based courses over the last three years
on other topics; these on-line courses allow
greater access. This can be complemented
by materials available on CDs, as in the
more remote areas access to the internet is
at present difficult and disproportionately
expensive.
A number of courses are already available
in the USA and Europe. It would be possi-
ble for the WMA to develop with suitable
partners web-based courses which could be
integrated with Regional and National
strategies. One potential partner could be
the Collaborative Institutional Training
Initiative (CITI) together with international
funding agencies involved in planning
research in the developing world, such as
the Gates Foundation, the Welcome Trust,
the pharmaceutical industry, non-govern-
mental organizations, and national
Governments themselves.
CITI was formed by a small group of physi-
cians, bio-ethicists, institutional review
board chairs and scientists from nine inde-
pendent academic institutions in the USA,
including the university of Miami,
Dartmouth College, the University of
Washington and the Children’s Hospital,
Boston. The universities pooled their
resources to meet the requirements of the
US Department of Health and Human
Services (DHHS) that all investigators and
key personal in human subject research
must complete training in human subject
protection by October 1st
2000. The CITI
programme has been devised by the multi-
disciplinary research community itself and
is independent of any US National
Regulatory Body.
Courses have been developed covering
Biomedical Research including Good
Clinical Practice and Social and
Behavioural Research with quality controls.
An International Group has been formed
within CITI which includes input from the
Caribbean, SE Asia and the Middle East.
Though the underlying ethical principles
need to be the same worldwide, the local
context and culture are important.
International Courses are being developed
on a pilot basis for individual countries.
Research institutions in the poorer nations
are already finding even the current more
US-centric CITI courses helpful.
Such a collaborative approach would allow
the creation of sound international educa-
tional materials leading to accreditation and
continuing professional development with
quality standards shared with those in the
US, Europe and Japan. In short a truly glob-
WMJ_2_59-86.qxd 05.10.2006 14:05 Seite 62
Medical Ethics and Human Rights
63
al research ethics network. Enhanced train-
ing will give more confidence to those
funding and sponsoring clinical research.
Professions are the rightful custodians of
their body of knowledge. In medicine this
means a continuing duty to expand that
knowledge base in the interest of patients
with new therapies and new procedures and
ensuring that the best evidence is available
for effective management of disease and
disorders internationally. A sound research
ethics infrastructure should encourage a
greater increase in the clinical research in
the developing world necessary to reduce
the overwhelming burden of disease due to
AIDS, Malaria, and Tuberculosis in the
poorer nations.
The WMA with other key stakeholders
could build on their recognized standards of
medical research ethics to influence their
practical implementation and to reduce the
serious research ‘gap’ between the rich and
the poor nations. The resultant improve-
ment in the health of the nations from qual-
ity research will have major economic ben-
efits by enabling nations to prosper, rather
than perpetuate their cycles of poverty and
malnutrition.
It will be a long, hard and continuing
process but one that could well make a
major contribution to protection of patients
in research worldwide.
James Appleyard, Thimble Hall, Blean, 109
Blean Common,Canterbury, CT2 9JJ, UK
References
1. Declaration of Helsinki 2000 World Medical
Association
2. International Conference on Harmonisation of
Technical Requirements for the Registration
of Pharmaceuticals for Human use (ICH) Note
for Guidance on Good Clinical Practice
(CPMP/ICH/135)
3. Koski G Research, Regulations and
Responsibility. Emory Law Journal 52 403-
416 2003
4. Forum for Institutional Review
Boards/Research Ethics Boards in Canada and
the United States October 2003
5. Operational Guidelines for Ethics Committees
that review Biomedical Research W.H.O.
Geneva 2000 TDR/PRD/ETHICS/2000al
6. Chokevival V. A Global Strategy to promote
Ethical Health Research. Strategic Initiative
for Developing Capacity in Ethical Review.
Scince and Development Network 2004
www.scidevnet/ms/sidcer
7.Global Forum for Health Research 10/90
Report 2003-2004 P.O. Box 2100 Geneva
8. Carlson, Boyd and Webb Brit J Clin
Pharmacology 2004 57.6 695)
9. Braunschweiger P and Hansen K
Collaborative Institutional Training Initiative
Report of Developers Meeting April 2006
cal (research) practice where they had not
already done so and, particularly, to estab-
lish research ethics committees. For some
member states these had, in practice, been
in operation for many years, but in others
the ethical review procedure for clinical tri-
als was vestigial and, for them, the imple-
mentation of this Directive presented a
number of problems.
The European Forum for Good Clinical
Practice (EFGCP) is a not-for-profit organ-
isation, based in Brussels, which exists to
promote, in its widest sense, and across the
board, uniformly high standards for the
conduct of clinical research. It is a confus-
ing convention that, throughout the clinical
research community, the word ‘research’
has been dropped from the phrase ‘good
clinical research practice’, but that is what
‘good clinical practice’ (GCP) means, cer-
tainly in the context of this article.
One of the key features of the strategy of
the European Forum for Good Clinical
Practice (EFGCP) has always been to pro-
mote European values and principles in
ethics across the EU member states and in
international research. The standards
against which this should be achieved were,
by general agreement, set out by the
Declaration of Helsinki of the World
Medical Association2
, the International
Conference on Harmonisation (ICH)
process as it applied to good clinical prac-
tice (GCP)3
and, as far as Europe is con-
cerned, were included within the Clinical
Trials Directive1. All these important policy
documents included reference to the struc-
ture and function of independent ethics
committees established to provide the ethi-
cal review of all clinical trial protocols.
EFGCP operates through conferences,
workshops and working parties and it was
the EFGCP Ethics Working Party that felt
that the advent of the Clinical Trials
Directive presented a golden opportunity to
ascertain exactly how this extremely impor-
tant Directive, which was drafted to ensure
that clinical trials throughout Europe were
all conducted to the same high standard
having been subjected to a proper ethical
review, had in practice been interpreted in
each of the 25 member states. We felt that
A major challenge that exists for each of
the, now 25, member states in the European
Union is how to adopt a Directive whilst
still retaining all the national characteristics
within the particular field that is to be cov-
ered by that Directive*. On the other hand,
the adoption of a European Directive can
provide a good opportunity to alter, or even
A European Perspective on the Clinical
Research Ethical Review Procedure
Dr. Frank Wells, Co-chairman of EFGPC Ethics Working Party
abandon, national characteristics that have
become outdated or are inappropriate or
irrelevant.
One such Directive, known as the Clinical
Trials Directive, was introduced in 2001
(20/2001/EC)1
, which required member
states to adopt the principles of good clini-
WMJ_2_59-86.qxd 05.10.2006 14:05 Seite 63
Medical Ethics and Human Rights
64
reporting on the structure and function of
research ethics committees in every mem-
ber state was important, given that such a
review had not been conducted previously
by anyone else and that nobody seemed to
know what was happening outside their
own country in this regard.
We were particularly mindful that one of
the functions of EFGCP is to observe the
methods by which member states fulfil the
various Directives of the European
Commission that affect the conduct of clin-
ical research to GCP standards. Thus it was
in early 2005 that the EFGCP Ethics
Working Party recognised that the ethical
review processes in the various member
states varied widely and that, in the context
of multi-national research, it was not easy
to be sure that ethical review had been con-
sistent across the whole of Europe. The
Working Party even wondered whether the
differences between operational policies in
the various member states might interfere
with the aims of the Directives.
Furthermore, whereas a sponsor could be
reasonably confident that it understood the
ethical review process that operated in the
member states in which it regularly con-
ducted research, it was sometimes difficult
to gain access to the ethical review process
in other member states in which it might
wish to conduct research in the future.
A subgroup of the EFGCP Ethics Working
Party was established, specifically to ascer-
tain in detail exactly what were the struc-
tures and functions of research ethics com-
mittees across the 25 member states of the
EU. The nine members of the subgroup
came from eight different member states,
which made it easy for us to share the work
that had to be done. In practice, we
acknowledged that Luxembourg relied
wholly on Belgian legislation in this regard,
and, because much clinical research
emanates from, or is conducted within,
Switzerland and Norway, we took a prag-
matic decision to add these two countries to
our project.
The differences we discovered were wide-
spread. For example, roughly half the mem-
ber states specify that an application should
be made to an ethics committee by the
sponsor, whereas the other half specify that
it should be made by the chief investigator.
Another example revealed the different
methods by which a single opinion is
obtained for a multi-site application within
any given member state: some countries
designate which committee out of several,
whereas others only have one committee for
the whole country anyway. The most strik-
ing differences arose in the areas of training
for members of research ethics committees
and of quality assurance, assessment and
accreditation of such committees.
We were particularly interested in the inde-
pendence of research ethics committees
(RECs). For some time there has been con-
cern within the research ethics community
that the equivalent bodies to RECs in the
USA are institutional review boards (IRBs)
which, by definition, cannot be truly inde-
pendent as they are based on specific, usu-
ally academic, institutions. In general, we
found that RECs in Europe are constituted
in such a way as to ensure that the indepen-
dence of committees and of individual
members is safeguarded, but there were
some member sates that clearly followed
the institution-based model. However,
where appropriate safeguards are in place,
even institutional review boards can
demonstrate that they operate independent-
ly; but such safeguards are not always there.
It is therefore important that bodies such as
the WMA and EFGCP strive to ensure that
any committee conducting ethical reviews
of research projects involving human sub-
jects is truly independent in its constitution
and in its decision-making processes.
EFGCP hopes that this report4
, which will
be published in January 2007, will be of
practical use to sponsors, investigators, reg-
ulators and those that have responsibility
for setting research ethics committees up
and subsequently approving them. The
report could not have been produced with-
out the invaluable help and co-operation
provided by the many persons within the
member states who have provided informa-
tion that has been gathered together.
Finally, the development of the research
ethical review process in Europe is
inevitably in a state of flux. Recent entrants
into the EU have clearly striven to achieve
the requirements of the Directive and of its
recent companion on GCP (2005/28/EC)5
.
New candidates for EU membership,
notably Bulgaria and Romania, have yet to
demonstrate their adoption of these
Directives but no doubt they will. Even
within well-established member states we
found that the detail of how ethical review
was actually being conducted was constant-
ly changing. However, by referring to the
relevant websites for the various countries,
readers will be able to check for themselves
the exact situation pertaining at any given
time. The challenge of safeguarding
research subjects is a highly responsible one
for research ethics committees throughout
the world. Our awareness of the importance
of this challenge should go some way
towards ensuring that the highest possible
standards of clinical research practice are
attained.
References
1. European Commission. Clinical Trials
Directive (2001/20/EC) Brussels, 2001.
2. World Medical Association. Declaration of
Helsinki. Haughley, 2004
3. International Conference on Harmonisation.
Good Clinical Practice (E6). IFPMA, Geneva,
1996.
4. EFGCP. Structure and Function of Research
Ethics Committees. Intl Jl Pharm Med, 2007
(in print).
5. European Commission. GCP Directive
(2005/28/EC) Brussels, 2005.
* A Directive is a form of European Legislative
instrument which is binding as to the effect to
be achieved but permits the Member State to
choose the form and method of legislative
implementation.
Frank Wells
Correspondence to:
Old Hadleigh, London Rd., Capel St.
Mary, Suffolk IP9 2JJ,U
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Medical Ethics and Human Rights
65
tions and relatively little opportunity for
discussion. The presentations dealt with
the following aspects of the topic: an
update onAIDS vaccine research, which is
not very promising; design issues in
HIV/AIDS clinical trials, including stan-
dards of care (para. 30 of the Declaration
of Helsinki was cited favourably);
informed consent: from theory to practice
(it was noted that the practice in China is
far from adequate); risks and benefits to
participants and communities; meaningful
stakeholder consultation and community
advisory boards; and vulnerable groups.
The three other pre-conference workshops
dealt with public health ethics and control
of emerging contagious diseases, stem-cell
research, and human enhancement (physi-
cal, cognitive, life-extending, etc.).
The opening Plenary session featured the
following presentations:
• The British philosopher, Onora O’Neill,
spoke on informed consent, the topic of
her forthcoming book. She contended that
the requirement that consent be explicit
and specific, which is found in the Decla-
ration of Helsinki and many laws and reg-
ulations, is impossible to fulfil. Her justifi-
cation of consent procedures would see
them not as securing individual autonomy,
but as a way by which research subjects
can waive standard obligations – such as
obligations not to injure, coerce or deceive
– in limited ways in particular circum-
stances
• In his response, Dan Wikler of Harvard
criticized her position and pointed out that
the Nuremberg Declaration was developed
in the context of the Cold War, when West-
erners considered it necessary to promote
respect for the individual over against the
collective. He contended that research
abuses have usually been the result of
racism, not of the subordination of the
individual to the collective.
• Sang-yong Song of the Korean Academy
of Science and Technology gave a detailed
account of the Korean stem cell research
scandal involving Hwang Woo-suk,
including the cultural and commercial fac-
tors that prepared the ground for such mis-
conduct and the failure of the political
authorities and the media to learn from the
disaster. He noted that there had been ear-
ly and consistent ethical opposition to
Hwang Woo-suk’s research in Korea. In
his response, Chingli Hu from Shanghai
noted that there are similar problems in
China but that the Chinese have become
more vigilant.
• Florencia Luna of Argentina spoke about
vulnerability, powerlessness and exclusion
in research, particularly regarding women.
In discussing the problematic status of
reproductive rights in her country, she
posed the question, how can bioethics be
context sensitive when context seems
insensitive? She criticized a recent tenden-
cy in bioethics to downplay the concept of
‘vulnerability’.
Other plenary sessions dealt with health
care reform in China, ethical lessons from
Unit 731’s human experiments, access to
life-saving drugs, and experiences and
lessons in emergent public health issues:
from SARS to avian flu.
Most of the conference timetable was
devoted to 64 concurrent sessions on a wide
variety of topics which, amongst others,
included the following:
• “Medical professionalism” – this consist-
ed of four short presentations on why pro-
fessionalism cannot be assessed, profes-
sionalism in psychiatry, enhancing profes-
sionalism in Taiwan following the SARS
outbreak, and fostering patient autonomy.
• “Sex ratio at birth imbalance” – this
focussed on China but included compar-
isons with other countries where there is
no such imbalance, the question being
whether the ethics of pre-natal sex selec-
tion are universal or country-specific.
• “Ethical issues in pandemic avian influen-
za” – this included presentations on Chi-
This biennial conference of the Internatio-
nal Association of Bioethics attracted
approximately 600 participants, including
over 200 Chinese scholars and students. It
was held concurrently with the 6th
Interna-
tional Congress on Feminist Approaches to
Bioethics and consisted of two days of pre-
conference workshops and four days of ple-
nary and simultaneous sessions.
There were five preconference
workshops of which I was
able to attend two which were
all day sessions:
“Bioethics and Human Rights: Working
Together for Global Health” – this was
organized by three Harvard University
units. Their premise was that there has been
relatively little communication or other
interaction between these two academic and
organizational fields and that this should be
changed. The main presenter, Steven Marks,
a human rights specialist at Harvard and
editor of a recent book, Health and Human
Rights: Basic International Documents
(which includes 6 WMA statements). He
described in some detail the similarities and
differences between bioethics and human
rights: both cover many of the same issues
but human rights tends to be more general
while bioethics deals with specific details of
the implementation of rights. Both combine
aspirations and current realities. The rest of
the workshop was devoted to a free-ranging
discussion of the topic from many points of
view and ended with reactions to a proposed
Harvard graduate programme on bioethics
and human rights.
• “Ethical Issues in AIDS Vaccine
Research” – This was a tightly structured
session with numerous formal presenta-
Conference Report
8th
World Congress of Bioethics,
4-9 August 2006, Beijing, China
John R. Williams, Ph. D, Head of Ethics Department, WMA
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66
na’s planning, the WHO’s project, and dif-
ferent scenarios for distributing scarce
resources such as Tamiflu. Dan Wikler
made an interesting observation that dur-
ing the 1918-19 influenza pandemic, the
annual number of deaths from TB in the
U.S.A. decreased by almost the same
amount as the increase in deaths from the
‘flu.
• “Ethical Lessons from Unit 731’s Human
Experiments” – Takashi Tsuchiya from
Osaka gave a detailed account of the
Japanese biological weapons programme
in Manchuria and elsewhere. He noted that
following W.W. II the U.S. did not investi-
gate medical crimes of the Japanese but
sought the data to use against the U.S.S.R.
The Soviets did conduct some trials but
both the Japanese and the Americans cov-
ered up the atrocities. The first Japanese
exposé was in 1981 but only in the 1990s
did the crimes become known outside
Japan. The Japanese medical profession
considers the subject taboo.
• Another session on “Professionalism in
Medicine” was chaired by David Rothman
of Columbia University. He dealt with the
current challenges to professionalism,
including conflicts of interest, weak self-
regulation, medical errors, lack of civic
engagement, patient use of the Internet
and overwork. There were two presenta-
tions of surveys of American physicians’
attitudes towards professional and ethical
issues and one on professionalism among
Chinese physicians.
• “From SARS to Avian Flu in China” – a
presentation by Guang Zeng, Chief Epi-
demiologist, Center for Disease Preven-
tion and Control. SARS caused Chinese
politicians to become concerned with pub-
lic health for the first time and to begin to
overcome the tradition of secrecy and cov-
er-up with regard to health-related prob-
lems. There is a better surveillance and
reporting system now, although decentral-
ization poses obstacles.
• “Bioethics Without Borders” – this con-
sisted of presentations on the ethics activi-
ties of the WMA, WHO, UNESCO and
the European Commission.
Several other concurrent sessions focussed
on China, including a Germany-China
Forum on ethical and legal issues in end-of-
life care, emerging health and environmen-
tal issues facing China, a France-China
Forum on stem cell research, a Japan-China
Forum on “Is human dignity or human right
principle sustainable for a future Asian soci-
ety?”, ethical issues in new rural coopera-
tive medical care programs of Mainland
China, and Confucianism and bioethics.
None of the presentation abstracts men-
tioned the retrieval of organs from executed
prisoners for transplantation although three
of them discussed the sale of organs and
compensation of donors.
The next World Congress of Bioethics will
take place in Croatia in 2008.
(Clearly the selfcare aspect of healthcare,
both in the context of self management of
minor illness and the selfcare aspect of col-
laborative care by the affected individual in
partnership with caring health profession-
als such as doctors and nurses etc., is
important to both patient and health profes-
sionals. The following discussion paper is
particularly timely also in the context of the
global shortage of healthcare professionals,
which is currently the focus of WHO’s
decade of action. Comments on this will be
welcomed in these columns – edit)
This discussion paper is the first product of
a project that has been initiated by represen-
tatives of the World Medical Association
(WMA) and the World Self-Medication
Industry (WSMI), although it does not nec-
essarily reflect the official policy of either
organization. Its goal is to identify the
potential impacts and implications for
physicians of the increasing prevalence of
self care. Following on from this, there will
be an opportunity to consider ‘tools’ by
which physicians may be better equipped to
support and deal with patient self care.
The discussion paper is structured as fol-
lows:
• Introduction – purpose, scope, defini-
tions;
• Section 1 – Current trends regarding self
care (social, economic, technological,
etc.);
• Section 2 – Implications for physicians;
• Conclusion;
• Select bibliography.
Introduction
The topic of this project is very broad.
Moreover, there has been relatively little
attention paid to it by health professionals,
policy makers, academics and industry.
Although it would benefit from a well-fund-
ed, large-scale study, the scope of this pro-
ject is much more modest. It will review
some of the recent developments on the
subject of self care and identify the major
factors that are likely to have an impact on
physicians. The general approach of the
project is deliberately towards a broader,
over-arching view that will be useful in
guiding future activities, rather than an
expert focused study.
The basic methodology of the project will
be to pull together and synthesise available
information rather than undertake original
research. Since it is likely that ‘gaps’ in
FROM PATIENT TO SELF CARER:
A Discussion Paper on the Future of Self Care
and its Implications for Physicians
David E. Webber Ph.D., General Secretaery Self Medication
Industry. John R. Williams Ph.D., Head of Ethics Department,
World Medical Association
WMJ_2_59-86.qxd 05.10.2006 14:05 Seite 66
Discussion Paper
67
knowledge will be identified that will lead
to the possibility of commissioning
research; such opportunities will be consid-
ered as they arise.
The following working definitions of key
terms are proposed for the purposes of the
project:
Health – An indicator of physical, mental,
emotional and/or spiritual well-being, char-
acterized in part by an absence of illness (a
subjective experience) and disease (a patho-
logical abnormality) that enable one to pur-
sue major life goals and to function in per-
sonal, social and work contexts.
Wellness – Another term for health that
emphasizes measures, such as a healthy
diet, exercise and self-care decisions, that
promote health and prevent illness. This
includes reducing the risk of chronic dis-
ease, preventing injuries, banishing envi-
ronmental and safety hazards from home
and workplace, and eliminating unneces-
sary trips to the hospital.
Health care – Any activity that has as its
primary objective the improvement, main-
tenance or support of physical, mental,
emotional and spiritual well-being, as char-
acterized by the absence of illness and dis-
ease.
Self care – The care taken by individuals
towards their own health and well being,
including the care extended to their family
members and others.
In practice self care includes the actions
people take to stay fit and maintain good
physical and mental health; meet social and
psychological needs; prevent illness or acci-
dents; avoid unnecessary risks; care and self
medicate for minor ailments and long-term
conditions; and maintain health and well
being after an acute illness or discharge
from hospital.
Patient – The traditional term for a person
receiving health care. Although the term has
evolved away from the passivity that is its
root meaning towards a more active role for
the person in decisions concerning his or
her health care, it probably does not fully
express the emphasis on self care that is the
focus of this report.
The future – The horizon for this report is
3-10 years. Further than that it becomes
extremely difficult to predict and plan,
given the rapid pace of technological and
social change.
Section 1 – Current trends
regarding self care
• What is self care?
Self care is the care taken by individuals
towards their own health and well being,
including the care extended to their family
members and others.
In practice, self care includes the actions
people take to stay fit and maintain good
physical and mental health; meet social and
psychological needs; prevent illness or acci-
dents; avoid unnecessary risks; care and self
medicate for minor ailments and long-term
conditions; and maintain health and well
being after an acute illness or discharge
from hospital.
This is a substantial and broad set of activi-
ties that may be further detailed; today’s
understanding of self care involves:
• Healthy choices that encourage the
maintenance of health and the preven-
tion of illness, including good nutrition
and appropriate levels of physical activi-
ty;
• Avoidance of risk factors such as unsafe
sex, tobacco smoking and environmental
hazards;
• Self recognition of symptoms, screening
and assessing these in partnership with a
healthcare professional, when necessary;
• Self management that includes being
able to handle the symptoms of disease
either alone or in partnership with
healthcare professionals or other people
with the same condition;
• Self treatment involving responsible use
of medication, both OTC and prescrip-
tion (but specifically excluding ‘self pre-
scription’).
In practice, the definition and understand-
ing of self care have evolved significantly
over the last 25 years and are likely to
evolve still further. An early narrow defini-
tion of self care was simply the lay behav-
ioural response to illness, in contrast to pro-
fessional care (Dean 1989). Until 1980 self
care and self medication were not high pri-
ority issues in country health policies or for
the World Health Organisation (WHO)
(Levin 1990). During the early 1980s self
care was conceptualised as a part of
lifestyle, with WHO being the initial cata-
lyst for this perspective. By 1990 self care
was already being identified as one of the
megatrends in the health care sector
(Bezold 1990). Self care started to be seen
more broadly as actions that people do to
improve their health and well-being within
the context of everyday life. Thus in 1998
WHO stated:
Self care is what people do for themselves to
establish and maintain health, prevent and
deal with illness. It is a broad concept
encompassing hygiene (general and per-
sonal), nutrition (type and quality of food
eaten), lifestyle (sporting activities, leisure
etc), environmental factors (living condi-
tions, social habits etc), socioeconomic fac-
tors (income level, cultural beliefs etc) and
self-medication. (WHO 1998)
More recently this definition has been
expanded to include a focus on risk factors
and risk factor avoidance (WHO 2002) and
a more explicit and better defined expres-
sion of the role of physical activity (beyond
‘sporting activity, leisure, etc.’) in maintain-
ing health.
Another important understanding today is
that self care may be exercised alone (e.g.
treating a mild headache) or in collabora-
tion with professional care. In other words,
self care presents an important opportunity
for the healthcare professional in a support-
ing role, guiding and advising the self care
manager. For the present discussion this
role (sometimes called ‘collaborative care’)
should be underlined: self care should not
mean absence of healthcare professional
involvement.
Of course, seeking professional care can
also be the result of a self-determined self
care decision-making process. In effect the
role of the patient in symptom recognition
and even minor ailment diagnosis is also
expanding. In future, self care may more
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Discussion Paper
68
explicitly involve family and friends, as
well as community-level activities.
• The self care continuum
The fact that the majority of symptoms and
complaints are treated by self care has been
described as an “iceberg” (Verbrugge &
Ascione 1987). The small part of the ice-
berg that is above the water represents the
cases seen by health professionals and the
large unseen part under the water represents
cases treated via different self care prac-
tices. Overall, an estimated 70% to 95% of
all illnesses are managed without the inter-
vention of a physician (Dean 1981, Coons
& McGhan 1988, Segal & Goldstein 1989,
Vulcovic & Nichter 1997).
In terms of episodes and hours, most health
care in daily life is self-evidently self care.
If, for illustrative purposes, a person has 3
hours contact with a healthcare profession-
al each year, they in reality undertake self
care for the remaining 8757 hours of the
year. They do this by using the advice given
by professionals during the 3 hours contact,
or by using knowledge and skills gained
from a variety of sources. There are many
opportunities to improve on this self care,
and physicians can play a leading role in
supporting and encouraging more appropri-
ate self care across the whole spectrum of
care, to the advantage of healthcare profes-
sionals and particularly to people them-
selves.
An alternative visualisation is of health care
on a continuum (see Fig. 1) ranging from
100% self care (e.g. brushing teeth regular-
ly) to 100% professional care (e.g. neuro-
surgery). In between these two extremes is
shared care where individuals or families
partner with practitioners in the care of the
individual; practitioners include physicians,
nurses, allied health professionals, social
workers and pharmacists. This is a more
useful image than the iceberg since it shows
that supporting self care has always been
part of good practice, especially for allied
health professionals, nurses and pharma-
cists. Further, it shows that the dividing
lines between self care, collaborative care
and professional care are not necessarily
fixed, but can depend on a variety of indi-
vidual and social factors.
• The (re)-emergence of self care
At a simplistic level it is a fact that through-
out most of human history, self care was the
norm and the only available form of health
care for the majority of the population. With
the industrialisation of societies and the
increase in knowledge and specialisation of
the last 300 years has come the develop-
ment of – and wider access to – medical
professional help. But fundamentally, self
care is not a new invention so much as the
previous norm.
Today self care is being positively driven by
a number of powerful forces and trends.
These include the following:
• Many developing countries are starting
to experience the disease transitions that
come with improved economic perfor-
mance. This includes a shift away from
communicable diseases such as TB and
malaria to non-communicable diseases.
Today’s reality is that, globally, the
greatest causes of avoidable death in the
world are not HIV/AIDS or TB but car-
diovascular disease, cancer and respira-
tory diseases. If disease burden is con-
sidered, neuropsychiatric disorders and
injuries should be added to this list.
(World Health Report 2005). The epi-
demiological shift in disease patterns
from acute to chronic morbidity results
in the need to move from ‘curative’ to
‘chronic’ care. Self care is particularly
important for patients living with chron-
ic diseases and the term ‘self manage-
ment’ is sometimes used here.
• Improved scientific and medical under-
standing of the causes of health and ill-
ness shows where self care can most
appropriately be deployed (WHO 2002).
Increased knowledge about the effects of
lifestyles on health is playing a part. As
expressed by one set of authors: “It is
estimated that by 2020 two-thirds of the
global burden of disease will be attribut-
able to chronic non-communicable dis-
eases, most of them strongly associated
with diet. The nutrition transition
towards refined foods, foods of animal
origin and increased fats plays a major
role in the current global epidemics of
obesity, diabetes and cardiovascular dis-
eases, among other non-communicable
conditions. Sedentary lifestyles and the
use of tobacco are also significant risk
factors” (Chopra et al 2002).
• Putting this another way, increasingly
the fundamental causes of disease are
being understood and it is seen that
many represent a failure of prevention
rather than an inevitability of life.
Figure 1. The healthcare continuum
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69
Although controversial, there is now a
good body of evidence to show that per-
sons with better health habits survive
longer, and in such persons, disability is
postponed and compressed into fewer
years at the end of life (Vita et al 1998).
With ageing populations this has sub-
stantial implications on the design of
health care systems of the future, and for
the self care sector. A new balance
between disease prevention + wellness
management vs. downstream disease
treatment needs to be struck.
• Society is ever-changing. People around
the world are better educated and want
more information, choice and control
over their lives and this is no different
for health. The public’s attitude to look-
ing after their own health is beginning to
change. There is a shift towards indepen-
dence and a range of personalised
options for provider agencies. Surveys in
many countries consistently indicate that
many patients and the public have the
increasing sense that health, and health-
care in general, is something with rights
attached to it and want more support for
self care.
• There is an increasing amount of infor-
mation available to people on all aspects
of self care and self medication, in print-
ed form in books and articles, and
through the Internet. Some of this is of
high quality; some of lesser quality.
• As part of the consumer movement,
groups representing patients have
become more prominent in recent years.
For example, the International Alliance
of Patient’s Organisations (IAPO) has
been formed and has expanded rapidly.
IAPO has produced a ‘Declaration on
Patient-Centred Healthcare’ that
includes patient information and
involvement in health policy as key prin-
ciples (IAPO 2006). Patient-focused
organisations such as the Picker Institute
are publishing studies on topics such as
‘patient-centred medical professional-
ism’ (Askham & Chisholm 2006).
• Economic constraints, always a major
consideration in much of the world, are
increasingly a key factor in the most
developed countries as the cost of tech-
nologies (medicines and other high-tech
interventions) continues to rise.
Governments and payers are looking
afresh at all means of containing health
care costs. Encouraging people to take
more responsibility for their own health
through self care is seen as an important
potential opportunity to achieve a double
effect of better health at lower cost.
In summary, a complex mix of drivers has
combined to give impetus to the movement
for self care. At the same time, there are
substantial hurdles or barriers to be over-
come before self care can make its full con-
tribution to human health.
• The case for encouraging self care
The potential opportunity in self care is well
expressed in the UK Department of Health’s
publication: “Self Care – A Real Choice”
(2005):
Research shows that supporting self care
can improve health outcomes, increase
patient satisfaction and help in deploying
the biggest collaborative resource available
to the NHS [National Health Service] and
social care – patients and the public.
Helping people self care represents an
exciting opportunity and challenge for the
NHS and social care services to empower
patients to take more control over their
lives.
Many individual peer-reviewed studies
have shown that there are a variety of
potential benefits that can be achieved by
encouraging self care. Some examples are
as follows:
• Reduction in general practitioner consul-
tations. Professors Blenkinsopp and
Noyce from Keele and Manchester
Universities in the UK collected data on
GP consultations for 12 ailments: consti-
pation, cough, diarrhoea, dyspepsia, ear-
ache, hay fever, headache, head lice,
nasal symptoms, sore throat, temperature
and vaginal thrush. The proportion of GP
consultations for these ailments was
8.9% representing about 11 consulta-
tions per GP per week. Almost 40% of
consultations for these ailments were
transferred to pharmacy management,
with the implication that future recur-
rence could be similarly managed with-
out the need for further consultation
(Blenkinsopp & Noyce 2002).
• Dr. Martin Lipsky of Northwestern
University Medical School in Chicago
and colleagues showed in a study that
availability of over-the-counter clotrima-
zole for the treatment of candidal vagini-
tis led to a 15% decline in the number of
vaginitis visits. The decrease in physi-
cian visits resulted in approximately $45
million in direct cost savings and anoth-
er $18.75 million in indirect savings by
reducing time lost from work (Lipsky et
al 2000).
• In Canada, a study by Mullet showed
that people’s intent to use emergency
services decreased from 30.5% to 13.4%
after advice from a health support line.
Compliance with self care advice was
84%. Some patients still visited doctors
for reassurance that they had done the
right thing but self-reported doctor visits
were reduced (Mullet 2000).
• In Shanghai China, Fu et al. evaluated
the effectiveness of a chronic disease
self-management programme in the form
of a lay-lead teaching course and guide-
book. The study found that, compared
with controls, patients who received this
had significant improvement in amount
of exercise undertaken, cognitive symp-
tom management, self-efficacy in symp-
tom management, and self-efficacy in
disease management (Fu et al. 2003).
• In the UK, emergency hormonal contra-
ception (EHC) became available over
the counter from pharmacies in 2001 for
women aged 16 and over. This change
was welcomed by emergency physicians
and there were anecdotal reports of
fewer requests for EHC at accident and
emergency departments. Kerins et al
(2004) undertook a study to see if these
anecdotal reports were true, reviewing
patient records from two emergency
departments. They showed a 52% reduc-
tion in the number of women attending
for EHC between 2000 and 2001.
• In a project commencing in 1995,
Healthwise, a US based non-profit orga-
nization, initiated the Healthwise
Communities Project: distributing
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70
143,000 copies of a handbook on 180
common ailments and how to care for
them, plus a telephone nurse advice
helpline. Three years after the pro-
gramme launch, an estimated $7.5 to
21.5 million was saved in unnecessary
health care costs. More recently a similar
initiative reported a reduction in unnec-
essary visits to the doctor of 23% and of
15% in unnecessary visits to emergency
room services, and 16% of employees
saving a sick day from work (see
http://www.healthwise.org/a_communi-
ties.aspx).
• A workplace health education pro-
gramme aimed at reducing unnecessary
outpatient visits was designed by Lorig
et al. A total of 5,200 employees attend-
ed a presentation, received self-help
books, and completed self-administered
questionnaires. The study found that a
minimal cost, self-care workplace inter-
vention can reduce outpatient visits by
important magnitudes – up to 17% or 2.0
visits per household per year (Lorig et al
1985).
Based on these and other studies the poten-
tial benefits may be summarised as:
• Reducing time spent in seeing a general
practice physician for minor or trivial
ailments, giving physicians more time
for more important cases.
• Reduction in the number of unnecessary
visits to accident and emergency depart-
ments, again saving the time of these
hard-pressed services.
• Increased motivation for patients and for
healthy people in maintaining or improv-
ing their well being.
It is important to emphasise that none of
these examples excludes healthcare profes-
sionals; indeed their full involvement helps
ensure the success of self care schemes. An
important point must, however, be made. In
many poor countries the reality is of oblig-
atory self care due to the absence of basic
healthcare facilities. Obligatory self care is
prevalent in the least developed countries
and can be most unfortunate when it is a
forced substitute for essential medical inter-
ventions. On the other hand, in many devel-
oped countries, the reverse is true – insuffi-
cient self care and over-dependency on the
health care system gives a major opportuni-
ty to encourage self care in these countries.
In both situations there are significant ques-
tions about the appropriate levels of self
care for a country, given the particular cir-
cumstances, and around approaches for
integrating self care into the mainstream
health care systems.
Section 2 – Implications for
physicians
Every person has the right to health educa-
tion that will assist him/her in making
informed choices about personal health and
about the available health services. The
education should include information about
healthy lifestyles and about methods of pre-
vention and early detection of illnesses. The
personal responsibility of everybody for
his/her own health should be stressed.
Physicians have an obligation to partici-
pate actively in educational efforts (WMA
Declaration of Lisbon on the Rights of the
Patient).
As described above, self care is already
widely practised in many parts of the world
and this is likely to increase.
Physicians and medical associations may be
sceptical of some of the claims of self care
advocates, especially regarding the finan-
cial savings that can result from the expan-
sion of self care (e.g., the reduction in hos-
pital admissions). For one thing, these
advocates may underestimate the role of
uncertainty in symptom analysis, especially
when the analysis is performed by someone
with no medical training. It is often only
after an examination by a physician that it is
evident that the patient’s condition is self-
limiting and can be dealt with by self care.
Conversely, attempts to provide self care
for some conditions can result in serious,
and costly, complications because a physi-
cian was not consulted in time.
Nevertheless, physicians and medical asso-
ciations should welcome the self care
movement. There are both ethical and prac-
tical reasons for this:
• Physician support of appropriate self
care is in keeping with the shift to shared
decision making in the patient-physician
relationship that has been occurring in
many parts of the world during the past
half-century. This shift is reflected in the
policy statements of the World Medical
Association. For example, the
Declaration of Lisbon on the Rights of
the Patient states, “The patient has the
right to self-determination, to make free
decisions regarding himself/herself. The
physician will inform the patient of the
consequences of his/her decisions.”
• Although self care deprives physicians
of certain functions that they are accus-
tomed to perform, it also frees them from
routine, relatively unskilled, tasks and
allows them to focus on more interesting
and challenging ones. This is especially
appropriate in areas where there is a
shortage of physicians.
Physician involvement in self care is noth-
ing new. They have always encouraged
patients to adopt practices that are con-
ducive to good health, e.g., a balanced diet,
moderate exercise and, more recently, absti-
nence from tobacco, and most of the med-
ications prescribed by physicians are
administered by the patients themselves or
their family members. The current self care
movement requires an evolution, rather
than a revolution, in the role of the physi-
cian. The principal elements of this evolv-
ing role are the following:
• Learning about self care – Just as physi-
cians have to maintain their clinical
knowledge and skills, so also do they
need to be aware of developments in
patient expectations and requirements
for self care, as well as the resources
available for this purpose. Whereas at
one time physicians had a virtual
monopoly on medical knowledge, now
there are many other sources – the
Internet, the media (articles and adver-
tisements), WHO, governments, patient
organizations, pharmacies, health food
stores, etc. Much valuable information is
available from these sources, but there is
a great deal of misinformation as well.
Physicians need to have some familiari-
ty with these sources in order to direct
WMJ_2_59-86.qxd 05.10.2006 14:06 Seite 70
Discussion Paper
71
patients towards those that are reputable
and away from the others.
• Listening to patients – Patients differ
greatly in their understanding of and
capacity for self care. Some will ask for
a physician’s help in learning how to care
for themselves while others will expect
the physician to take care of them. Only
by careful questioning and listening to
their answers can the physician know the
extent to which they are able to exercise
self care.
• Encouraging and teaching patients how
to care for themselves and when to seek
expert advice – Self care is vastly more
complex than it was a few decades ago
when its main form was taking medica-
tion as prescribed by a physician.
Nowadays there are multiple regimes of
pharmaceutical products, medical
devices, monitors and exercises avail-
able for a great variety of conditions,
both acute and chronic. The choice of the
most appropriate regime for a particular
patient and instruction for its use can be
a significant task for a physician, espe-
cially when there are intellectual, lin-
guistic or cultural barriers. Self-medica-
tion is an important aspect of self care.
The World Medical Association
Statement on Self-Medication (www.
wma.net/e/policy/s7.htm) provides guid-
ance to physicians and patients on the
following topics: the distinction between
prescription and non-prescription med-
ication and potential interactions
between the two; the roles and responsi-
bilities of patients, physicians, drug
manufacturers, pharmacists and govern-
ments; and the promotion and marketing
of self-medication products.
• Monitoring patient self care – In order to
provide optimal care, physicians need to
know what self care measures, such as
non-prescription medication and health
foods, are being used by the patient. If
they are inappropriate, the physician
should so inform the patient.
• Developing and maintaining skill in
motivating behaviour change in patients
– Many self care measures, for example,
smoking cessation and dieting, require
significant will power on the part of
patients to overcome long-established
habits or addictions. There is a large
body of evidence-based literature on
how physicians can best assist such
behaviour changes (www.tcsg.org/tobac-
co/cessation/biblio/medical_01.pdf), and
familiarity with this literature is an
important step in developing the skill
required to help patients with this aspect
of self care. Also important for patient
motivation is physician role modelling
of healthy behaviour.
• Collaborating with other health profes-
sionals (nurses, pharmacists, social
workers, etc.) – Just as self care requires
collaboration between patients and
physicians, so too are other health pro-
fessionals involved. For various reasons,
patients receive more education in self
care from these others than they do from
physicians, but physicians need to know
what patients are being told and whether
they are following the advice they
receive from these sources. Ideally self
care will be part of collaborative care
involving good communication among
all those who deal with the patient.
For self care to enter the mainstream of
medical practice, certain system changes
are required:
• As noted above, education and advice
regarding self care can be very time con-
suming, and many physician remunera-
tion plans do not provide adequate com-
pensation for this work, even though it
can provide significant cost savings to
health care systems. Medical associa-
tions should develop evidence-based
arguments to convince the appropriate
funding authorities to correct this imbal-
ance.
• Medical school curricula need to prepare
future physicians to deal with self care,
which will include instruction in the
knowledge and skills listed above.
Continuing medical education pro-
grammes on this subject should also be
developed.
• Medical associations should collaborate
with patient self help and support groups
to develop programs and resources that
promote a proper balance between self
care and professional care.
Conclusion
As stated at the beginning of this document,
its purpose is to identify the potential
impacts and implications for physicians of
the increasing prevalence of self care. The
WMA and WSMI welcome comments on
this paper, including suggestions for next
steps. Please send your comments by email
to Dr. David Webber, Director-General,
WSMI, dwebber@wsmi.org and Dr. John
Williams, Director of Ethics, WMA,
williams@wma.net.
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18 AUGUST 2006 | TORONTO – Dr.
Anders Nordström, Acting Director-
General of the World Health Organization
told delegates at the XVIth International
AIDS Conference that “drastic measures”
were required to ensure there are enough
health workers available to deliver univer-
sal access to HIV/AIDS prevention, treat-
ment, care and support by 2010. He also
welcoming the broad consensus at the con-
ference that a comprehensive response to
HIV/AIDS was essential. Speaking at the
closing session, Dr Nordström stressed that
“money, medicines and a motivated, skilled
workforce” were key to delivering universal
access.
He underscored that the funds available for
HIV/AIDS globally were growing, but, so
were the needs. “Worldwide, resources for
HIV/AIDS have increased to over US$
8 billion a year, but estimated need in low-
and middle-income countries is US$ 15 bil-
lion this year, and that will grow to US$ 22
billion in 2008. “That widening gap must be
filled, and commitment sustained. It calls
WHO
Medicines, money and motivated health work-
ers are key to universal access to HIV/AIDS
prevention, treatment care and support
A “borderless society for health” necessary to make greater
inroads: WHO Acting Director-General
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WHO
73
enced the HIV/AIDS landscape. He paid
tribute to Dr Lee Jong-Wook, WHO’s for-
mer Director-General, and his role in forc-
ing a shift in approach and attitude to access
to treatment. “This is demonstrated through
a ten-fold increase in people on treatment in
sub-Saharan Africa,” he said. “But the chal-
lenges in that region also illustrate what still
needs to be done. Seventy per cent of the
global unmet need for treatment is in
Africa.”
He stressed that drug pricing was still an
issue – to ensure that both first-line and sec-
ond-line treatments were affordable. “There
is growing momentum for innovation,
research and addressing intellectual proper-
ty issues to ensure maximum access to new
products that save lives.
“We need ideas to turn into new drugs and
diagnostics that strengthen our ability to
safely treat infants and children as well as
adults. We also need a vaccine and a micro-
bicide.”
“Universal access must include access to a
skilled and motivated health worker,” said
Dr Nordström. “No improvement in financ-
ing or medical products can make a lasting
difference in people’s lives until the crisis in
the health workforce is solved.”
for more than traditional international
development assistance.”
Dr Nordström praised recent initiatives
aimed at providing sustainable financing
mechanisms, such as the UNITAID initia-
tive of France, Brazil, Chile, Norway and
the United Kingdom, which uses a levy on
airline taxes to channel new money to HIV
work. He also noted that new potential
mechanisms – such as advance market com-
mitments – could provide incentives for
research and development into new medi-
cines and vaccines. He stressed that devel-
oped countries, including the G8, must live
up to their financial and political HIV/AIDS
commitments, and that national govern-
ments must also spend more on health
domestically, and make HIV/AIDS a fund-
ing priority.
Medicines – access to drugs
remains critical
Dr Nordström noted that “3 by 5” – the
WHO and UNAIDS initiative to expand
access to antiretroviral treatment to 3 mil-
lion people in low- and middle-income
countries by the end of 2005 – had influ-
Without health workers, uni-
versal access not possible
He called for “drastic measures” to urgent-
ly strengthen the workforce. WHO’s new
‘Treat, Train, Retain’ plan, launched at the
conference, (see below) also demonstrates
how ensuring prevention and treatment for
health workers in a supportive work envi-
ronment can help improve working condi-
tions, and critically, keep staff healthy and
motivated.
A health system also depends on stronger
information and surveillance systems,
logistics and distribution systems – all areas
that WHO is helping national governments
to address, he said.
Dr Nordström asked delegates to make uni-
versal access possible through “a borderless
society for health. One that embraces all
who can make a difference, from political
leaders, scientists, health workers to young
people, persons living with HIV, the poor,
sex workers, injection drug users, people in
prisons.”
Strengthening prevention
Dr. Nordström also stressed the need for a
strong gender perspective to ensure that
both women and men have equal opportuni-
ties.
Finally, Dr. Nordström told delegates that,
along with treatment, care and support,
renewed attention must be paid to the pre-
vention of HIV.
“Too many resources – time, energy and
money – have been wasted on the debate
over whether prevention or treatment
should be the priority. At this conference we
have come to a clearer understanding that it
is not a case of doing one or the other.
Millions have died through lack of both.”
WHO’s contribution to achieving universal
access to HIV prevention, treatment, care
and support focuses on five strategic direc-
tions: scaling up HIV testing and coun-
selling; maximizing the health sector’s role
in prevention; scaling up treatment, care
and support; strengthening health systems
and investing in strategic information.
WMJ_2_59-86.qxd 05.10.2006 14:06 Seite 73
WHO
74
Immunization Financing Facility, and
the France/Chile/Brazil/Norway plan to
fund HIV/TB and malaria drugs through
airline ticket taxes are very promising.
The 12-page health outcome document
includes G8 country’s commitments to:
strengthen the global network for surveil-
lance and monitoring; increase global pre-
paredness for a human influenza pandemic;
combat HIV/AIDS, tuberculosis and malar-
ia; eradicate polio; make progress on
measles and other vaccine-preventable dis-
eases; ensure access to prevention, treat-
ment and care including through research,
the use of Trade-Related Aspects of
Intellectual Property Rights (TRIPS) flexi-
bilities and also strengthened health sys-
tems; and to address the health conse-
quences of natural and man-made disasters.
The Russian Federation carried on the G8
tradition of supporting polio eradication and
made a specific funding pledge for polio
eradication, committing US$18 million to
the programme, as did the United Kingdom
in Gleneagles in 2005.
ST PETERSBURG – At their July meeting
Group of Eight vowed to improve the ways
in which the world cooperates on surveil-
lance for infectious diseases, including
improving transparency by all countries in
sharing information. The G8 also commit-
ted to continued support to fight
HIV/AIDS, tuberculosis, malaria, and to
eradication of polio. Dr. Anders Nordström,
acting Director-General of the WHO said
„Today the G8 spoke together on the essen-
tial need to tackle infectious diseases,
because of their health, social, security and
economic impacts”, „The commitments are
detailed and specific, and represent another
step forward in G8 leadership on public
health.”
Dr. Nordström led a senior WHO team at
the Summit to contribute to discussions on
infectious disease and he addressed G8
leaders, in the presence of the Heads of
State or Governments of Brazil, China,
Congo, Finland, India, Kazakhstan, Mexico
South Africa and invited UN leaders. He
underscored priorities for infectious dis-
ease, including the need to:
• Sustain the political and financial
momentum for scaling up against the
major infectious diseases and basic
health services: HIV, tuberculosis,
malaria, polio and immunization.
• Manage new disease outbreaks and
threats – including a potential pandemic
influenza outbreak.
• Improve access to existing and new
drugs and vaccines though expanded
markets and increased affordability.
• Ensure there are enough motivated
health workers in health centres and hos-
pitals and address the current four-mil-
lion health worker shortage. The biggest
shortages are in the poorest countries
where the need is greatest.
• Invest in innovative financing. The
United Kingdom’s support for the
G8 commitments to infectious disease can
improve global health security
Geneva – A new global partnership that
will strive to address the worldwide short-
age of nurses, doctors, midwives and other
health workers has been launched. The
Global Health Workforce Alliance will
draw together and mobilize key stakehold-
ers engaged in global health to help coun-
tries improve the way they plan for, educate
and employ health workers. Its secretariat
will be hosted by the World Health
Organization.
Responding to the call by African Heads of
State, the G-8 and the World Health
Assembly for urgent solutions to the health
workforce crisis, the Alliance will seek
practical approaches to urgent problems
such as improving working conditions for
health professionals and reaching more
effective agreements to manage their migra-
tion. It will also serve as an international
information hub and monitoring body.
The Alliance will start an ambitious pro-
gramme – the Fast Track Training Initiative
– aimed at achieving a rapid increase in the
number of qualified health workers in coun-
tries experiencing shortages. The initiative
will work towards that goal through five
strategies:
• Mobilizing direct financial support for
health training institutions, through a
model similar to that of the Education for
All Fast Track Initiative – a global part-
nership between donor and developing
countries to ensure accelerated progress
towards the Millennium Development
Goal of universal primary education;
• Training partnerships between schools in
industrialized and developing countries
involving exchanges of faculty and stu-
dents, with the aim of improving the edu-
cation of doctors, nurses, midwives and
paraprofessional health workers, and
training more of them now;
• Nurturing a new generation of academic
leaders in developing countries with the
support of experts in the clinical, public
health and managerial sciences from
around the world;
• Developing innovative approaches to
teaching in developing countries with
state-of-the art teaching materials and
continuing education through information
and communications technology;
• Assistance with the creation of planning
teams in each country facing health work-
Global Health
Worldwide shortage of doctors, nurses and
other health workers
WMJ_2_59-86.qxd 05.10.2006 14:06 Seite 74
WHO
75
er shortages, drawing on the top leader-
ship of the major schools, whose task will
be to develop a comprehensive national
health workforce strategy.
Fifty-seven countries, 36 of which are in
sub-Saharan Africa, have severe shortages
of health workers. More than four million
additional doctors, nurses, midwives, man-
agers and public health workers are urgent-
ly needed to fill this gap. An adequate
health workforce is defined by WHO as at
least 2.3 well-trained health care providers
available per 1000 people and balanced in
such a way as to reach 80% of the popula-
tion or more with skilled birth attendance
and childhood immunization.
“The inadequacy of the health workforce in
many developing countries is a major obsta-
cle to providing essential life-saving health
services to millions of people who lack
access now,” said Dr Timothy Evans, WHO
Assistant Director-General. “Coordinated
action to address this crisis at the global
level, in regions and within countries must
begin now.”
The Alliance will seek to spur country
action implementing the ten-year health
workforce plan set forth in The world health
report 2006: Working together for health.
The Report calls for national leadership to
urgently formulate and implement country
strategies for the health workforce, with
backing by international assistance.
“The Global Health Workforce Alliance
will bring together all the stakeholders
needed to move forward on this plan with a
view to sharing evidence-based practices
countries can follow to expand their work-
forces and make them more effective,” said
Dr Lincoln Chen, WHO Special Envoy for
Human Resources for Health and Chair of
the Alliance’s Board.
The initial partners of the Alliance include
the Bill & Melinda Gates Foundation, the
Canadian International Development
Agency, the European Commission, the
Global Alliance for Vaccines and
Immunization, the Global Equity Initiative
at Harvard University, the International
Council of Nurses, the New Partnership for
Africa’s Development, the Norwegian
Agency for Development Cooperation, the
Ministry of Public Health, Thailand,
Physicians for Human Rights, the World
Bank and WHO. Its executive director, Dr
Francis Omaswa, is the former Director
General of Health Services of Uganda.
The Government of Norway has donated
US$ 3.5 million towards the Alliance’s
operations during its first year. Seed money
for its start-up was donated by the govern-
ments of Canada, Ireland and Sweden.
16 AUGUST 2006 | TORONTO –
Addressing a plenary session of the XVI
International AIDS Conference, WHO
HIV/AIDS Director Dr Kevin De Cock
reported that the number of people receiv-
ing HIV antiretroviral therapy in sub-
Saharan Africa has surpassed 1 million for
the first time, a ten-fold increase in treat-
ment access in the region since December
2003.
In low- and middle-income countries, just
over 1.6 million persons were receiving
antiretroviral therapy at the end of June
2006, a 24 percent increase over the 1.3
million who had access to the drugs in
December 2005, and four times the 400,000
people receiving treatment in these coun-
tries in December 2003. Ninety-five percent
of people living with HIV/AIDS today live
in the developing world.
While WHO and UNAIDS reported signifi-
cant increases in treatment access in several
regions of the world, Dr De Cock empha-
sized that there is considerable work ahead
to reach the G-8 and UN-endorsed goal of
providing as close as possible to universal
access to HIV prevention programmes,
treatment, care and support by 2010. In his
remarks today. He also laid out WHO’s
vision for continuing to expand HIV treat-
ment access, calling for new action to over-
come barriers that, if unaddressed, will slow
the rate of expansion in access to HIV treat-
ment in the future.
“The combined efforts of donors, affected
nations, UN agencies and public health
authorities are providing substantial, ongo-
ing increases in access to lifesaving HIV
treatment,” commented Dr De Cock. “Yet,
in many ways we are still at the beginning
of this effort. We have reached just one-
quarter of the people in need in low and
middle-income countries, and the number
of those who need treatment will continue
to grow. Our efforts to overcome the obsta-
cles to treatment access must grow even
faster.”
Of the 38.6 million persons living with HIV
globally, approximately 6.8 million people
living in low- and middle-income countries
require antiretroviral therapy now, meaning
that about 24 percent of people in need
worldwide were receiving antiretroviral
therapy by end-June 2006. Coverage by
region varied, from five percent in North
Africa and the Middle East and 13 percent
in Eastern Europe and Central Asia to 75
per cent in Latin America and the
Caribbean. Sixty-three percent of persons
on antiretroviral therapy in low- and mid-
WHO Reports from XVI International Aids Conference
WHO HIV/AIDS Director Outlines Progress
and Obstacles to Achieving Universal Access
to AIDS Treatment
HIV treatment access reaches over 1 million in sub-Saharan
Africa, WHO reports
WMJ_2_59-86.qxd 05.10.2006 14:06 Seite 75
GENEVA – Leaders of the World Health
Organization (WHO) and UNFPA, the
United Nations Population Fund, are coor-
dinating action to reverse the global trend of
deteriorating levels of sexual and reproduc-
tive health and reduce the adverse impact on
mothers, babies and young people.
WHO
76
dle-income countries today are African,
compared with 25 percent in late 2003.
Although sub-Saharan Africa has the great-
est number of people on treatment, and the
second-highest rate of treatment coverage
among those who need it, the region still
accounts for 70 percent of the global unmet
treatment need.
In addition to expenditures by countries
themselves, treatment scale-up has been
funded through the U.S. President’s
Emergency Plan for AIDS Relief; the
Global Fund to Fight AIDS, Tuberculosis,
and Malaria; the World Bank; other bilater-
al donors, and pharmaceutical companies
through contributions such as the
Accelerating Access Initiative. In general,
progress has been greatest in countries
receiving specific assistance from these ini-
tiatives.
Increasing Equitable Access
Speaking on efforts to ensure equitable
access to treatment among all people who
need it, Dr De Cock reported that current
data do not indicate any systematic bias
against women in treatment access, with the
proportion of female ART recipients corre-
sponding closely to, and in some cases
exceeding, the proportion of people infect-
ed.
However, other inequities are clear. While
an estimated 800,000 children below the
age of 15 require antiretroviral therapy,
only about 60,000 to 100,000 are estimated
to be receiving it. One in 7 people dying of
HIV-related illness worldwide is a child
under 15 years of age, a fact that is largely
due to the failure to scale up programmes
for the prevention of mother-to-child trans-
mission of HIV and to prevent HIV infec-
tion in young women, noted Dr De Cock.
Despite the successes of such countries as
Brazil, Thailand, and Botswana, only about
six percent of HIV-positive pregnant
women globally are currently benefiting
from antiretroviral prophylaxis to help pre-
vent HIV transmission in childbirth. In con-
trast, pediatric HIV disease has been virtu-
ally eliminated in the industrialized world.
People who contracted HIV through inject-
ing drug use are also not receiving equitable
access to treatment. In Eastern Europe and
Central Asia, injecting drug users, a major-
ity of them men, account for over 70 per
cent of HIV-infected persons, but only
about a quarter of treatment recipients.
Dr De Cock encouraged delegates at the
meeting to evaluate treatment efforts not
only based on the number of patients
receiving care, but on the quality of treat-
ment outcomes as well. Noting that most
patients in developing country treatment
programmes present with late-stage disease,
he emphasized that improving treatment
outcomes will require both diagnosing HIV
and starting treatment earlier.
“A three-and-a half times higher death rate
after one year of therapy in HIV-infected
citizens of resource-poor countries com-
pared with Europeans and North Americans
should not be viewed as acceptable, and we
must commit to change it,” said Dr De
Cock. “These priorities are not radical new
insights but they do require altered commit-
ment to saving human life.”
Moving Towards Universal
Access
Looking forward, Dr De Cock outlined five
strategic directions, each of which repre-
sents a critical area where the health sector
must lead if countries are to make progress
towards achieving universal access, and on
which WHO will focus its technical assis-
tance. These include:
• expanding HIV testing and counselling;
• maximizing prevention opportunities in
health care settings;
• increasing access to treatment and care;
• strengthening health systems; and
• investing in strategic information.
While stressing that prevention, treatment
and care are inextricably linked, Dr. De
Cock called for an increased emphasis on
prevention efforts where HIV transmission
is most intense. He also emphasized the
need to be guided by science when deter-
mining the effectiveness of prevention
interventions.
Reviewing lessons learned from the “3 by
5” effort to rapidly scale up access to HIV
treatment, Dr. De Cock cited the frailty
of health systems – including human
resources, physical infrastructure, laborato-
ry capacity, procurement and supply sys-
tems, and fiscal management – as the key
obstacle to widescale provision of HIV ser-
vices, and called for the elevation of health
systems strengthening among global politi-
cal priorities. Dr. De Cock also cited the
reliability and availability of strategic infor-
mation, including epidemiology and sur-
veillance, monitoring and evaluation, and
operational research as essential in monitor-
ing progress towards universal access.
Noting that only about 10 percent of people
living with HIV in sub-Saharan Africa
know their HIV status, Dr. De Cock added
that WHO is working with UNAIDS to
evaluate how countries are implementing
HIV testing and counseling. A consultative
process is under way to develop operational
guidelines to help countries expand access
to provider-initiated testing and counseling
in health care settings, with a view to
increasing uptake of treatment and preven-
tion particularly in high prevalence coun-
tries. The guidelines will be issued later this
year.
Top level push to tackle priorities in sexual and
reproductive health
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77
improving maternal health and reducing
perinatal death. Yet, in developing countries
and those in transition, an estimated 200
million women lack access to family plan-
ning.”
In addition, in some cultures, three million
girls and young women are subjected each
year to genital mutilation/cutting which, in
recent studies by WHO, has been shown to
significantly increase the risk of death and
serious injury for newborn babies and their
mothers around childbirth.
Following a high-level meeting on Friday,
the leaders agreed the agencies will coordi-
nate action in countries to ensure pro-
grammes are more effective and account-
able for results.The aim is to scale-up work
to put a number of global proposals and ini-
tiatives into action in countries: The Global
Reproductive Health Strategy, endorsed by
the World Health Assembly, a 2005
Resolution on achieving internationally
agreed health-related development goals,
including those contained in the
Millennium Declaration, another on work-
ing towards universal coverage of maternal,
newborn and child health interventions, and
this year’s World Health Assembly
Resolution agreeing to the Global Strategy
to tackle sexually transmitted infections.
A communiqué issued at the end of the
meeting identified a number of priority
areas including:
• A coordinated action plan to implement
the Global STI Prevention and Control
Strategy;
• Support to countries to increase skilled
health attendants in target countries;
• Coordinated workplans on improving
reproductive, maternal, newborn and ado-
lescent health;
• “One framework” plans for the 16 African
countries covered by the strategic frame-
work just completed by the UN agencies;
• Advocacy for inclusion of sexual and
reproductive health in national economic
planning such as Poverty Reduction
Strategies (PRSPs);
• Strengthening the linkages between HIV
and sexual and reproductive health
through coordinated action in HIV pre-
vention, care and treatment;
• Joint training of country teams on the
process for planning and working together
at country level and joint competency
reviews;
• Coordinated work in countries addressing:
• Female genital mutilation/cutting
• Obstetric fistula
• Violence against women, including in
emergencies
• A pilot programme in two countries to
introduce the Human Papilloma Virus
(HPV) vaccine
• Human resources for health.
• The key is to make practical plans in order
to implement these strategies,” says Ms
Obaid. “We are faced with an urgent need
to increase investment in sexual and
reproductive health to ensure access to
quality reproductive health services,
including youth-friendly services, and to
link HIV/AIDS and STI prevention with
reproductive health services and vice
versa.”
• Country support and advocacy are going
to be vital elements for any successful
attempt to reduce the impact of poor sex-
ual and reproductive health,” says Dr
Nordström. “Evidence shows that invest-
ments in and access to sexual and repro-
ductive health, including family planning,
are essential to breaking the cycle of
poverty. This then frees national and
household resources for investments in
health, nutrition, and education, promot-
ing economic growth with tangible
returns.”
For further information please contact:
Christopher Powell, WHO
Telephone: +41 791 2888
Mobile: +41 79 217 3425
Email:powellc@who.int
Omar Gharzeddine, UNFPA
Telephone: +1 212 297 5028
Email:gharzeddine@unfpa.org
Globally, inadequate sexual and reproduc-
tive health services have resulted in mater-
nal deaths and rising numbers of sexually
transmitted infections (STIs), particularly in
developing countries. WHO estimates that
340 million new cases of sexually transmit-
ted bacterial infections, such as chlamydia
and gonorrhoea occur annually in people
aged 15 – 49, many untreated because of
lack of access to services. In addition, mil-
lions of cases of viral infection, including
HIV, occur every year. The sexually trans-
mitted human papilloma virus (HPV) infec-
tion is closely associated with cervical can-
cer, which is diagnosed in more than 490
000 women and causes 240 000 deaths
every year. Around eight million women
who become pregnant each year suffer life-
threatening complications as a result of
STI’s and poor sexual health. Annually, an
estimated 529 000 women, almost all in
developing countries, die during pregnancy
and childbirth from largely preventable
causes.
“There is a really worrying rise in the num-
ber and severity of sexually transmitted
infections,” says Dr Anders Nordström,
Acting Director-General, WHO. “But the
consequences of poor sexual and reproduc-
tive health go well beyond Sexually
Transmissible Infections. They lead directly
to completely preventable illness and death.
It is unacceptable today for a woman to die
in childbirth, or for a person to become HIV
positive for lack of information and
resources.”
Young people are particularly vulnerable.
More than 100 million curable sexually
transmitted infections occur each year and a
significant proportion of the 4.1 million
new HIV infections occur among 15-to-24
year olds. In sexually active adolescents
(aged 10-19 years), sexual and reproductive
health problems include early pregnancy,
unsafe abortion, STIs including HIV, and
sexual coercion and violence. “It is clear
that the Millennium Development Goals 5
and 4 to reduce mother and child deaths by
2015 cannot be achieved without investing
in sexual and reproductive health,” says Ms
Thoraya Ahmed Obaid, Executive Director,
UNFPA. “For example, averting unintended
pregnancy and reducing unmet need for
family planning are key interventions in
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78
leading to a lack of health workers trained
to prevent and treat AIDS. In addition,
many health workers trained in developing
world health systems leave their jobs (or
countries) for better-paying jobs in wealthy
countries, in bigger cities, or in non-govern-
mental organizations (NGOs).
“WHO has a unique role to play in helping
countries mount an effective, comprehen-
sive and sustainable response to the AIDS
epidemic,” said Dr. Anarfi Asamoa-Baah,
Assistant Director-General of WHO. “The
shortage of health workers is devastating
public health systems, particularly in the
developing world, and it is one of the most
significant challenges we face in preventing
and treating HIV. WHO is launching ‘Treat,
Train, Retain’ to confront this crisis.”
Dr Sigrun Mogedal, the Norwegian govern-
ment’s Ambassador for HIV/AIDS said
“WHO’s ‘Treat, Train, Retain’ plan pro-
vides a much-needed boost to national
health systems that will have an impact far
beyond HIV/AIDS. By increasing the num-
ber of well-trained, healthy and motivated
health workers, the plan will provide signif-
icant benefit to health systems generally.”
The ‘Treat, Train, Retain’ plan will be
implemented under the umbrella of the
Global Health Workforce Alliance, hosted
by WHO, which was established in May
2006 and is a partnership of governments,
aid agencies, civil society groups and mul-
tilateral organizations.
“’Treat, Train, Retain’ draws on the growing
body of evidence and experience of what
works in improving the performance of the
health workforce,” said Dr Francis
Omaswa, Executive Director of the Global
Health Workforce Alliance. “It will acceler-
ate the adoption of best practices on critical
issues like the increased roles and responsi-
bilities of community health workers in
combating HIV/AIDS and promoting better
health at household and community level.”
‘Treat, Train, Retain’ will focus on those
countries most severely affected by
HIV/AIDS, and incorporates a menu of
options that countries can adapt to their spe-
cific needs. WHO estimates that it will cost
a minimum of US$7.2 billion over the next
five years to implement the plan in the 60
countries with the highest HIV burden, and
it could cost substantially more – up to
US$14 billion. This corresponds to an annu-
al per capita cost of approximately US$0.60
in the countries concerned, or between two
and five percent of the levels of health
expenditure typically found in low-income
countries.
‘Treat’
Although health workers are at the frontline
of national HIV/AIDS programmes, they
often do not have adequate access to
HIV/AIDS services themselves. The ‘Treat’
component of the plan represents a full
package of HIV/AIDS prevention, treat-
ment and care services that should be made
available to health workers on a priority
basis and tailored specifically to their
needs. These include:
• Specially designed awareness and anti-
stigma and discrimination campaigns
• Testing and counselling services
• Priority access to antiretroviral treatment
for health workers and their families
• Protection from HIV transmission in the
health care environment, including
access to post-exposure prophylaxis
‘Train’
The ‘Train’ aspect involves strategies for
countries to expand the numbers of new
health workers and maximize the efficiency
of the existing workforce. These include:
• Recruiting and training additional health
workers
• Shifting tasks from more- to less-spe-
cialised health workers (e.g., from spe-
cialists to physicians, physicians to nurs-
es, and nurses to community health
workers and lay providers including peo-
ple living with HIV)
TORONTO – The World Health
Organization (WHO), in collaboration with
the International Labour Organization and
the International Organization for
Migration, announced the launch of a coor-
dinated global plan to address a major and
often overlooked barrier to preventing and
treating HIV/AIDS namely the severe
shortage of health workers, particularly in
developing nations.
Called ‘Treat, Train, Retain’, the plan is an
important component of WHO’s overall
efforts to strengthen human resources for
health and to promote comprehensive
national strategies for human resource
development across different disease pro-
grammes. The plan is also part of WHO’s
work to promote universal access to
HIV/AIDS services. Through its HIV/AIDS
Programme, WHO is playing a central role
in making the goal of universal access a
reality.
Fifty-seven countries, mostly in sub-
Saharan Africa and Asia (particularly
Bangladesh, India, and Indonesia) face crip-
pling shortages of health workers. WHO
estimates that more than four million health
workers are needed to fill the gap. Sub-
Saharan Africa faces the greatest chal-
lenges. With 11 percent of the world’s pop-
ulation and almost 64 percent of all people
living with HIV, the region has only 3 per-
cent of the world’s health workers. Globally,
health workers are also concentrated in
urban areas, leaving shortages in rural
areas.
In sub-Saharan Africa and elsewhere, the
HIV/AIDS epidemic is contributing to
health worker shortages. HIV/AIDS is an
emerging source of mortality, loss of pro-
ductivity and demoralisation among health
workers. HIV/AIDS has also changed the
way young people view health work, mak-
ing it a less desirable career choice and
WHO launches new plan to confront
HIV-related health worker shortages
Crisis in human resources for health poses significant obstacle to
global HIV/AIDS prevention and treatment
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79
• Increasing the number of graduates by
improving and expanding pre-service
training in medical and nursing schools,
and incorporating AIDS-specific training
• Providing in-service training to health
workers already in the health system to
empower and better equip them with the
skills needed to more effectively care for
patients living with HIV/AIDS
‘Retain’
‘Retain’ relates to a set of interventions to
help ensure that countries are able to keep
existing workers employed in the health
system. These include:
• Instituting policy changes, codes of prac-
tice and ethical guidelines to minimize
migration of health workers from low-
income countries to developed countries.
• Diminishing the draw of private-sector
and NGO HIV/AIDS programmes on
workers in public health systems.
• Improving the quality of the workplace
environment, including establishing
occupational health and safety proce-
dures, reducing the risk of contracting
HIV and other blood-borne diseases and
addressing workplace issues such as
stress and burnout.
• Supporting staff and families with HIV
by guaranteeing job security, prohibiting
discrimination, providing social benefits
and adjusting work demands.
• Providing financial incentives, as well as
non-financial incentives such as career
and training opportunities, transport and
HIV treatment access for family mem-
bers.
WHO’s Priority Action Steps
To ensure the success of ‘Treat, Train,
Retain’, WHO has identified the following
priority action steps:
• Establish a special steering committee
that will advocate for the ‘Treat, Train,
Retain’ plan, guide the implementation
of its activities, and monitor progress.
• Provide guidance and technical assis-
tance to national governments for the
implementation of the activities outlined
in the ‘Treat, Train, Retain’ plan.
• Promote global recognition of the health
workforce as a ‘vulnerable group’, with
campaigns targeted specifically to the
well-being of health workers within the
context of the HIV epidemic.
• Design and facilitate the implementation
of a global agenda on task shifting to
expedite the world’s response to the
human resource crisis.
• Advocate for financial incentives to
retain health workers and research
potential options for non-financial incen-
tives.
The first international Expert Consultation
on Paediatric Essential Medicines, jointly
held by the World Health Organization
(WHO) and the United Nation’s Children’s
Fund (UNICEF), has delivered a plan to
boost access to essential medicines for chil-
dren.
Dr Howard Zucker, Assistant-Director
General at WHO said “Children are often
hailed as the hope and future of humanity,
but they don’t benefit enough from pharma-
ceutical research and technologyToo often,
the right medicines for children, in the right
dosages and formulations are missing from
the spectrum of available treatment options.
WHO and UNICEF will work quickly with
partners to change this.”
Ten million children die every year, many
of them from diarrhoea, HIV/AIDS, malar-
ia, respiratory tract infection or pneumonia.
Effective interventions – classified on
WHO’s list of essential medicines – exist for
these illnesses but there’s a lack of knowl-
edge of how best to use these medicines in
children, and a lack of paediatric formula-
tions of them.
During two days of intensive discussion
held 9-10 August at WHO’s headquarters in
Geneva, a mix of more than 20 developed
and developing countries, NGO’s including
Médecins Sans Frontières, regulatory agen-
cies, UNICEF and WHO staff prioritized a
long-needed approach to overall paediatric
care.
A top priority resulting from the meeting is
to dramatically expand access to much
needed child-focused formulations such as
fixed dose combinations (several pills in
one), crucial for children’s correct use of
medicines and treatment adherence. The
plan also calls for the improvement of med-
icines and prescribing guidelines address-
ing the entire range of infant and child care
needs. Priorities include respiratory infec-
tions, neonatal care, palliative care for end
stage AIDS, for HIV/TB co-infection and
for other opportunistic infections, and
improved electronic access to the latest
WHO drug information.
The WHO Expert Consultation warned that
without a model of best practice guidelines
and paediatric formulations, and a buy-in at
national levels right down to local care cen-
tres, then children – who in many countries
make up half of the population – will contin-
ue to be considered as therapeutic orphans.
“For example, it is worrying to see so very
few medicines suitable for children in
resource-poor settings where there is enor-
mous need. For these children, we must
address cost issues and ensure the right
medicine formulations exist”, said Dr Hans
Hogerzeil, WHO’s Director for Medicines
Policy and Standards. “The expert consulta-
tion was unanimous in its support for
urgent, specific actions, which will signifi-
cantly improve the chances for children to
access the right medicines.”
WHO and UNICEF tackle problem of lack of
essential medicines for children
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80
According to Hanne Bak Pedersen, Senior
Adviser Pharmaceutical Policy, UNICEF
Supply Division, “UNICEF is concerned
that children’s access to medicines is very
low in many resource limited settings.
Furthermore, there is a lack of availability
of several paediatric formulations. Based on
the work of this new project and WHO clin-
ical recommendations, UNICEF Supply
Division will strengthen and expand the
dialogue with industry on paediatric formu-
lations for HIV/AIDS to promote the devel-
opment of the missing medicines for chil-
dren.”
High priority will be placed on ensuring a
holistic approach to child care and treat-
ment, including addressing quality of life
issues such as producing painless remedies
over injections, better tasting medications
and investigating new mini tablet presenta-
tions.
Emphasis will also be placed on consider-
ing the climate zone requirements linked to
distribution and use whenever new product
formulations are made. For example, chew-
able or soluble powders are preferred over
syrups as they do not require refrigeration
and are less bulky to transport.
The plan will immediately be sent to coun-
tries for feedback on how best to implement
the recommendations at the local level. In
addition, WHO will consider several chil-
dren’s medicines for inclusion in the WHO
Essential Medicines List in March 2007.
For more information contact:
Dr Suzanne Hill
Medical Officer
WHO
Telephone: +41 22 791 35 22
Mobile phone: +41 79 815 79 21
E-mail: hills@who.int
Persahabatan Hospital, U.S. Centers for
Diseases Control and Prevention, France’s
Epicentre, Hong Kong University,
NAMRU-2 laboratory and Japan’s National
Institute for Infectious Diseases.
Indonesia became the focus of international
attention last month when the largest cluster
of human H5N1 cases was identified. The
outbreak involved eight members of a sin-
gle family in Kubu Sembelang village,
Karo District, of North Sumatra. Samples
confirmed the presence of the virus in seven
members of the family, and it is presumed
that the initial case was also infected with
H5N1. Seven of the eight family members
died. The outbreak was considered con-
trolled on June 12, three weeks after the
death of the last case with no new cases
reported.
The H5N1 virus is considered firmly
entrenched in poultry throughout much of
Indonesia, and this widespread presence of
the virus has resulted in a significant num-
ber of human cases. This year alone,
Indonesia has reported more than 33 cases
with 27 deaths. Unless this situation is
urgently addressed, sporadic human cases
are likely and human-to-human transmis-
sion is possible.
Results from the expert consultation were
provided to Komnas FBPI on Friday, 23
June.
“Indonesia’s Ministry of Health has already
demonstrated a great degree of transparency
and collaboration since the first case
appeared last year,” said Dr. Paul Gully, a
senior advisor for communicable diseases at
the World Health Organization. “Indonesia
has quickly acknowledged all cases pub-
licly, teamed up with WHO for rapid field
investigations, and provided virus isolates
to the WHO H5 Reference Laboratory
Network to enable monitoring of the evolu-
tion of the H5N1 virus. With this consulta-
tion, Indonesia is taking another step to
assess how best to protect the health of its
people. The results will certainly be of great
importance to all worldwide, who are eye-
ing the risk of the next pandemic.”
This consultation brought together experts
from Indonesia’s Ministries of Health and
of Agriculture, with those from the World
Health Organization, the Food and
Agriculture Organization, UNICEF and
experts from Airlangga University
Surabaya, Udayana University Bali,
June 2006 – The continuing avian influenza
outbreak in Indonesia, involving both
humans and animals, was the focus of a
three-day international consultation starting
in Jakarta.
On 13 June, Indonesia’s National
Committee for Avian Influenza Control and
Pandemic Influenza Preparedness, known
as Komnas FBPI, asked the World Health
Organization and other UN agencies to
“urgently convene” an international consul-
tation of experts to:
• Review the status of the H5N1 virus in
humans and animals
• Provide recommendations to control the
virus in both animals and humans
• Review lessons learned for rapid response
and containment, and
• Provide an authoritative risk assessment
of avian influenza in Indonesia in both
human and animals.
H5N1 Virus
Indonesia holds avian influenza expert
consultation
Hanoi/Manila/Bankok/Geneva – Viet
Nam has eliminated maternal and neonatal
tetanus as a public health problem. The dis-
ease, that kills tens of thousands of newborn
each year, most of them in developing
countries, is often called the “silent killer”
because many newborn affected by it die at
Viet Nam eliminates
maternal and
neonatal tetanus
In a joint news release the Ministry of
Health of the Socialist Republic of Viet
Nam, the World Health Organization
and the United Nations Children’s
Fund (UNICEF) announced that.
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Medical Science, Professional Practice and Education
81
home in very remote and poor communities
where both the births and the deaths go
unreported.
« We congratulate the Government of Viet
Nam on achieving this critical goal for chil-
dren and women. This accomplishment
demonstrates that life-saving vaccines can
be delivered to even the poorest and most
marginalized communities,” said Anupama
Rao Singh, Regional Director of UNICEF
for East Asia and the Pacific. « UNICEF
remains committed to working with all part-
ners to target and invest more in maternal
and child health services to reach the most
vulnerable. »
A survey conducted by UNICEF, WHO and
the Government of Viet Nam in three of
Vietnam’s disadvantaged districts — Bao
Yen and Bao Thang in Lao Cai Province,
and Phuoc Long in Binh Phuoc Province —
showed less than one neonatal tetanus death
per 1000 live births. If neonatal tetanus is
shown to be eliminated in the most under-
served and poorest performing areas, it is
considered as having been eliminated in
better performing areas.
« These excellent results mark a major
achievement by a country that used to have
a high incidence of neonatal tetanus. All
countries in the WHO Western Pacific
Region have made progress towards neona-
tal tetanus elimination. Viet Nam has shown
that government commitment, hard work
and partnerships lead to results. We are
hopeful that several other countries in the
region will soon follow Viet Nam’s exam-
ple, » said Dr Shigeru Omi, WHO Regional
Director for the Western Pacific. Five coun-
tries in the Western Pacific have yet to reach
the elimination goal of one case per 1000
live births at district level.
« More than ten years of accelerated immu-
nization activities targeting women in high-
risk districts of the country and pregnant
women, are paying off and we will make
every effort to sustain this progress against
a disease that kills but which can be pre-
vented, » said Professor Tran Thi Trung
Chien, Minister of Health, Viet Nam.
In the 1980s, in Vietnam there were approx-
imately ten neonatal deaths due to tetanus
per 1000 live births. Some 20,000 Viet-
namese babies died annually of tetanus
before the age of one month. Since 1991,
TT vaccine has been routinely given to
pregnant women throughout Viet Nam
through its Expanded Programme on
Immunization resulting in a high vaccina-
tion coverage rate; accelerated activities
began in 1993.
In 2000, 58 countries in the world had yet to
eliminate maternal and neonatal tetanus.
Vietnam is the ninth country and first East
Asian country within the priority country
group that has been assessed and validated
as having eliminated these diseases. The
other eight are Eritrea, Malawi, Namibia,
Nepal, Rwanda,South Africa, Togo and
Zimbabwe. Major contributors of financial
and technical support to maternal and
neonatal elimination efforts in Viet Nam
include: the Bill & Melinda Gates
Foundation, Beckton & Dickinson (a med-
ical technology company), the government
of Japan, AusAid, US Fund for UNICEF,
UNICEF and WHO.
The next Communication from the
WMA Secretary General will appear in
the December issue, which will contain
a report on the WMA General Assembly
in South Africa.
The World Health Organization (WHO) and
UNICEF today announced a new formula
for the manufacture of Oral Rehydration
Salts (ORS). The new formula will better
combat acute diarrhoeal disease and
advance the Millennium Development Goal
of reducing child mortality by two-thirds
before 2015.
Diarrhoea is currently the second leading
cause of child deaths and kills 1.9 million
young children every year, mostly from
dehydration.
The latest improved ORS formula contains
less glucose and sodium (245 mOsm/l com-
pared with the previous 311 mOsm/l). The
lower concentration of the new formula
allows for quicker absorption of fluids,
reducing the need for intravenous fluids and
making it easier to treat children with acute
non-cholera diarrhoea without hospitaliza-
tion.
ORS use is the simplest, most effective and
cheapest way to keep children alive during
severe episodes of diarrhoea. The ORS
solution is absorbed in the small intestine,
thus replacing the water and electrolytes
lost. WHO provides the only updated inter-
national quality specifications for this for-
mula and UNICEF is a leading supplier of
ORS to poor countries. WHO and UNICEF
have jointly issued guidance for the produc-
tion of the new ORS.
WHO and UNICEF recommend that coun-
tries manufacture and use the new ORS in
place of the previous formula. WHO and
UNICEF will help national authorities
develop manufacturing guidelines and pro-
cedures for the new formula. Establishing
the local production of ORS will be a key
step to ensure countries can meet their own
needs in controlling diarrhoeal disease.
According to UNICEF and WHO, oral
rehydration therapy should be combined
with guidance on appropriate feeding prac-
tices. Provision of zinc supplements (20 mg
of zinc per day for 10 to 14 days) and con-
tinued breastfeeding during acute episodes
of diarrhoea protect against dehydration and
reduces protein and calorie consumption to
have the greatest impact on reducing diar-
rhoea and malnutrition in children.
Medical Science, Professional Practice and Education
Improved formula for oral rehydration salts
to save children’s lives
Improved formula means better treatment for life-threatening
diarrhoeal dehydration
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Medical Science, Professional Practice and Education
82
The revised monograph for the new ORS
formula will be published in the fourth edi-
tion of The International Pharmacopoeia. It
is also available on the WHO website.
Additional information on diarrhoea can be
found on UNICEF’s Facts for Life website
and on the WHO Child and Adolescent
Health web site: http://www.who.int/medi-
cines/publications/pharmacopoeia/ors
Detailed recommendations concerning the
provision and production of ORS are pro-
vided in a revised joint WHO/UNICEF
publication, ‘Oral Rehydration Salts:
Production of the New ORS’:
http://www.who.int/child-adolescent-
health/publications/CHILD_HEALTH/WH
O_FCH_CAH_06.1.htm
The antimalarial, artemotil, manufactured
by ARTECEF BV, is a parenteral (non-oral)
artemisinin preparation intended for the
treatment of severe malaria, such as cere-
bral malaria, which may cause a lowered
degree of consciousness and thus preclude
oral intake of medicines. Malaria leads to
more than one million deaths yearly, of
which over 75% occur in African children
under 5 years of age infected with the cere-
bral form of the illness.
Products newly listed:
• Efavirenz, 50mg Hard Capsule, Merck
Sharp & Dohme BV, The Netherlands
• Efavirenz, 200mg Hard Capsule, Merck
Sharp & Dohme BV, The Netherlands
• Tenofovir, 300mg Tablets, Gilead
Sciences, Inc., United States
• Artemotil, 50mg/ml solution for injection,
ARTECEF BV, Germany
• Artemotil, 150mg/ml solution for injec-
tion, ARTECEF BV, Germany
Three new antiretrovirals and two anti-
malarials have been added to the World
Health Organization’s list of prequalified
medicines. Tenofovir and efavirenz (in two
different strengths) and artemotil (also in
two different strengths) are crucial products
for the treatment of HIV/AIDS and malaria
respectively and will considerably boost the
choice of therapy in resource-poor coun-
tries.
Tenofovir, produced by Gilead Sciences,
Inc. was recommended in WHO’s 2003
AIDS treatment guidelines mainly as an
option for the second-line treatment of
AIDS. In 2006, its use will be expanded to
first-line treatment.
The second antiretroviral is efavirenz, man-
ufactured by Merck Sharp and Dohme BV.
This product is one of the medicines recom-
mended by WHO for first-line treatment
and is a preferential drug in treatment pro-
grammes for patients with HIV/tuberculosis
co-infection.
New AIDS and malaria medicines added to
prequalification list
Needleless immuni-
sations possible in
the future?
A new approach to
an old problem.
Reuter. A press release from a British
Pharmaceutical Conference in Man-
chester reports research carried out at the
School of Pharmacy at University of
London has found a means of applying
low-frequency ultrasound to the skin
coupled with a product which makes the
skin more permeable. Vaccines then
applied to the skin in liquid form are then
easily absorbed. Researchers tested the
tetanus vaccines on mice and rats and
will now proceed to trials on human skin.
The leader of the research, Afendi
Dahian, commenting on the potential for
removing the problems associated with
needle delivery is reported as saying
“Needle usage can spread blood-borne
diseases if someone is accidently pricked
with a needle or if a needle is reused.
Also you need a doctor or trained nurse
to administer a vaccine using a needle.”
He hoped that a hand-held,low frequency
ultrasound could be developed for use in
hospitals and clinics.
Male circumcision update: Ongoing clinical
trials are key to validating the link between
male circumcision and protection against HIV
infection
As trials continue, UN agencies work to ensure that current male
circumcision practices are safe
17 AUGUST 2006 | TORONTO – In June
2006, the US National Institutes of Health
announced that, following an interim
review, two ongoing trials in Uganda and
Kenya examining the link between male
circumcision and the risk of acquisition of
HIV infection in men should be continued.
The trials are scheduled to end in July 2007
and September 2007 respectively. Data
from these studies will be important in val-
WMJ_2_59-86.qxd 05.10.2006 14:06 Seite 82
Medical Science, Professional Practice and Education
83
idating findings reported in July 2005 from
the Orange Farm Intervention Trial in South
Africa, funded by the French Agence
Nationale de Recherches sur le SIDA
(ANRS), which showed a reduction of 60%
or more in the risk of acquiring HIV infec-
tion among circumcised men.
The interim data from the ongoing Uganda
and Kenya trials were reviewed in June
2006 by the Data and Safety Monitoring
Board (DSMB), which recommended that
the studies continue on the grounds that
there were not yet enough data to draw firm
conclusions. The DSMB further proposed
that an additional interim analysis of data
from the two studies take place within the
next year. “The results of the two ongoing
trials will help clarify the relationship
between male circumcision and risk of HIV
in differing contexts, which is key to deter-
mining the reproducibility and application
of the Orange Farm findings,” noted Dr
Kevin De Cock, Director, WHO HIV/AIDS
Department. “While we await these impor-
tant results, UN partners and others are
working to provide coordinated guidance
and support to countries to help improve the
safety of current male circumcision prac-
tices.”
An additional trial assessing the impact of
male circumcision on the risk of HIV trans-
mission to female partners, led by
researchers at Johns Hopkins University, is
currently under way in Uganda with results
expected in late 2007. The effect of male
circumcision on reducing the risk of HIV
transmission among men who have sex with
men has been studied but has not been the
subject of a trial.
GUIDANCE AND SUPPORT
EFFORTS NOW UNDER-
WAY
WHO, UNFPA, UNICEF and the UNAIDS
Secretariat emphasize that their current pol-
icy position has not changed and that they
do not currently recommend the promotion
of male circumcision for HIV prevention
purposes. However, the UN recognizes the
importance of anticipating and preparing
for possible increased demand for circumci-
sion if the current trials confirm the protec-
tive effect of the practice. Recent mathe-
matical modelling based on an assumed
reduction of HIV transmission of 60% in
circumcised men suggests that, if this level
of protection is indeed confirmed and if
male circumcision were widely practised,
the number of HIV-related infections and
deaths could be considerably reduced over a
twenty-year period in sub-Saharan Africa.
Countries currently considering how to
improve the safety of current services will
need to ensure that male circumcision is
implemented by appropriately trained prac-
titioners with adequate equipment in
hygienic settings, and with close follow-up
and post-operative care. Countries should
ensure that the procedure is being per-
formed under conditions of informed con-
sent, confidentiality, and counselling tai-
lored to the individual, emphasizing the
continuing need for multiple HIV preven-
tion measures.
“Even if further trials show a lower risk of
HIV infection in circumcised men, male cir-
cumcision will not provide complete pro-
tection against HIV infection,” said
Catherine Hankins, Chief Scientific
Adviser, UNAIDS. “Circumcised men can
still contract HIV and pass it to their part-
ners. If male circumcision is proven to be
effective, it must be considered as just one
element of a comprehensive HIV preven-
tion package that includes correct and con-
sistent use of condoms, reductions in the
number of sexual partners, delaying onset
of sexual relations, and voluntary and con-
fidential counselling and HIV testing to
know one’s HIV serostatus. Just as combi-
nation treatment is more effective than sin-
gle drug therapy for people with HIV, com-
bination prevention is more effective than
reliance on a single HIV prevention
method.”
Since the reporting of the Orange Farm
study findings, the UNAIDS Secretariat,
WHO, UNFPA, UNICEF, the World Bank
and other partners have been working
together to develop a range of guidance
documents and practical materials for coun-
tries or institutions that choose to improve
the safety of and/or scale up male circumci-
sion services, now or in the future.
The UN Work Plan on Male Circumcision,
which was developed with financial support
from the US National Institutes of Health,
the UNAIDS Secretariat, the ANRS and the
Bill & Melinda Gates Foundation, includes
the development of technical guidance as
well as survey methodologies that can help
countries to determine their needs and
capacity to enhance services, and help track
implementation and changes in sexual
behaviour. As part of the UN plan, a number
of country stakeholder meetings are also
being organized to help countries assess the
current status of male circumcision includ-
ing human rights, ethical and cultural
aspects, evaluate clinical capacity, and
define knowledge gaps.
While this programme and policy work is
ongoing, some high HIV prevalence coun-
tries are already working to improve the
safety of current male circumcision prac-
tices and some are considering whether and
how to offer male circumcision in an HIV
prevention context. UN agencies emphasize
that the final results of the ongoing trials
will be essential to determining the efficacy
of circumcision in preventing HIV infection
in men in differing social and cultural set-
tings. Once the findings of these trials have
been announced and reviewed in 2007,
WHO, the UNAIDS Secretariat and their
partners will define specific policy and pro-
gramming recommendations.
For more information contact:
WHO
Anne Winter
Telephone: +41 79 440 6011
E-mail: wintera@who.int
Cathy Bartley
Telephone: +44 7958 561 671
E-mail: cathy.bartley@ukonline.co.uk
Iqbal Nandra
Telephone: +41 22 791 5589
Mobile Phone: +41 79 509 0622
E-mail: nandrai@who.int
Tunga Namjilsuren
Telephone: +41 22 791 1073
E-mail: namjilsurent@who.int
UNAIDS
Sophie Barton-Knott
Telephone: +41 22 791 1697
WMJ_2_59-86.qxd 05.10.2006 14:06 Seite 83
Regional and NMA News
84
Mobile Phone: +41 79 472 7917
E-mail: bartonknotts@unaids.org
UNICEF
Gerrit Beger
Telephone: +1 212 326 7116
Mobile Phone: +1 646 764 0200
E-mail: gbeger@unicef.org
UNFPA
Patricia Leidl
Telephone: +1 212 297 5088
Mobile Phone: +1 917 535 9508
E-mail: leidl@unfpa.org
resource issues in the health field remain a
key CMA priority.
(see CMAJ Sept,2006-175(6))
Germany
There have been a series of demonstrations
and strikes in the hospital sector over the
past few months. These have recently been
settled and a report on these actions will
appear in the next issue of WMJ
The Exopharm newsletter (www.exophar-
mde/newsletter) also reports concern about
an initial draft proposal in the context of
health reform in Germany. It proposes radi-
cal changes in the provision of medication
under the health insurance system.
France
INPADHUE (trade union of practitioners
qualified outside the European Union),fol-
lowing two strikes of emergency care
physicians earlier this year which sought to
further their demand for the same working
conditions and remuneration as their French
colleagues, further demonstrations in Paris
have now taken place in Paris.. They are
seeking a re-opening of negotiations on the
legislation governing doctors with foreign
qualifications working in France and have
threatened further actions if their request is
not met. According to the report these
actions have been going on for two years.
America
Subsequent to the Annual Meeting of the
American Medical Association, AMA News
reports that delegates voted to press Congress
to make it quicker and easier for foreign doc-
tors to obtain visas to work and stay in the
USA,. Also reported is the adoption of new
ethical policy placing an obligation on physi-
cians to disclose all relevant information to
their patients, making “ therapeutic privilege
” no longer acceptable, as it creates a conflict
between the physician’s obligation to pro-
mote patients’well-being and respect for their
autonomy by communicating truthfully”. The
opinion states that if patients ask to be not
The following report gives some indication
of activities or problems exercising the
medical professional organisations or issues
addressed in NMA publications since the
last Regional and NMA news.
General
Differing problems of migrant physicians
continue to exercise both groups of
migrants and members of the profession in
the host country. Apart from the global con-
cern about shortage of physicians as part of
the growing shortage of healthcare workers
generally and the moral problem of recruit-
ing from countries already undersupplied
with physicians, there are dilemmas arising
from political decisions by governments to
solve this problem. In certain countries of
both North and South America there have
been actions- in one case to the advantage
to the migrant if not to his country of origin.
In the particular host country express con-
cern is about tolerance of unlicensed prac-
tice by migrant physicians from a specific
country the nature of whose training cannot
be challenged. In another country a court
has pronounced illegal immigration regula-
tions concerned with the period of service
in a deprived area recognised as qualifying
for a “national interest” waiver in respect of
obtaining a permanent visa approval.
In the European Union, professional con-
cerns of migrant physicians qualified out-
side the European Union about inequity in
working conditions between medically
qualified EU nationals and Non-EU migrant
physicians, has not only led to demonstra-
tions but also to the threat of strikes.
Demonstrations have also taken place in
one war- torn country in the Middle East
where physicians have not been paid for six
months
Canada
Much of Canadian Medical Association’s
Annual meeting was dominated by the rela-
tionship between public and private medi-
cine. Delegates voted on more than 20
motions concerning the relationship
between the public and private sectors,
approving a motion to request the govern-
ment to remove bans preventing physicians
practising in both sectors but in addition
requested the CMA to develop a code of
conduct for doctors who do this, which
would balance professional autonomy with
social responsibility The meeting voted
against the establishing of health insurance
services which would lead to a parallel pri-
vate system. The Retiring President Ruth
Collins-Nakai left no doubt that Canadian
MDs “continue to support the principle that
access to care mist be based on need, not
ability to pay”. The new President, Dr.
Colin McMillan made clear that human
Regional and NMA News
The medical profession: the scene across
the world
WMJ_2_59-86.qxd 05.10.2006 14:06 Seite 84
Review
85
informed or a proxy told this should be
respected. Other adopted policy includes that
stating that the public soliciting of organs
from living donors is ethically acceptable
under certain conditions including the provi-
so that it does not unreasonably disadvantage
others on the organ waiting list. The policy
adopted is intended to help guide doctors
through the issues study of which will contin-
ue. (see http:/ww.ama-assn.org/ama/pub/cat-
egory/16450.html).
AMA news also reports the formation of a
Council on Physician and Nurse supply.
This is part of the Consortium for
Workforce Research Policy, a joint pro-
gramme of Pennsylvania’s School of
Medicine, School of Nursing and the
Leonard Davis Institute of Health
Economics and will monitor and address
the problems of what many say is a growing
shortage of physicians and nurses across the
USA. Interestingly there is also a report
that following a five year study by a work-
force of the Massachusetts Medical Society
there is a shortage of primary care physi-
cians in Massachusetts .The report “2006
Physician Workforce Study” also refers to
severe to critical shortages of specialists in
some other disciplines.
United Kingdom
Following a debate and resolution at the
Annual Meeting of the BMA (ARM), the
Association is engaged in formulating
views on the future of health service pro-
vision in the UK. In addition it is consulting
its members in preparing its response to the
proposals of the Report “Good Doctors:
Safer Patients – proposals to strengthen the
system to assure and improve the perfor-
mance of doctors and to protect the safety
of patients”. This report by the Chief
Medical Officer contains radical proposals
concerning the regulation of the profession
and changes in the functions of the General
Medical Council, the regulating body, some
of which have caused grave concern to the
medical profession. In particular, the pro-
posals to remove responsibility for the
overview of medical education and are
thought to be a retrograde step. Following
the ARM a well attended meeting entitled
“Improving health in the developing world:
what can national medical associations
do?”, was attended by a number of repre-
sentatives of National Medical
Associations and many others from bodies
with an interest with these problems. The
conference was held under the BMA’s
Strategic Grant Agreement with the
Department for International Development.
Speakers in the opening session included
Professor Paul Hunt, UN Special
Rapporteur on the Right to Health and in
the afternoon Mr Gareth Thomas, UK
Parliamentary Under-Secretary of State for
International Development The final ses-
sion was opened by Dr Kgnosi Letlape,
President of the WMA, followed by formal
presentations from two NMA speakers.
There were very lively discussions after
each session, and Dr. Edwin Borman,
Chairman of the BMA International
Committee, summing up and suggesting an
agenda for co-operation, emphasised the
key challenge for NMAs to develop
Advocacy; that the Right to Health and
other principles of human rights provided a
good basis for dialogue with governments;
and the importance above all of
Partnerships with others to achieve policies
to improve the health of the poor and the
associated social problems.
Speaking of Public Health he referred to the
challenges and problems of population
groups and Public Health, also to the need
for healthcare systems to be fit for purpose
if, for example, the health-related MDGs
were to be achieved in relation to specific
populations and the burdens imposed by
“neglected diseases” addressed. He finally
stressed the importance of Collaboration, a
pure form of which was the Links move-
ment, a system enabling health profession-
als in developed and developing countries
to work together to regenerate health sys-
tems.
In the glorious setting of Cape Town, South
Africa, at the recently-opened Institute of
Infectious Disease and Molecular Medicine
of the University’s Faculty of Health
Sciences, the Novartis Foundation held a
symposium on the highly-relevant topic of
Innate immunity to pulmonary infection.
Lung infection is a major cause of morbidi-
ty and death in developing, as well as devel-
oped countries. In South Africa, there is an
explosive combined epidemic of Tuber-
culosis and HIV, but also a great deal of
infection in adults and children by other
micro organisms, including pyogenic bacte-
ria such as S. pneumoniae and H. influen-
zae, viruses such as influenza and respirato-
ry syncytial virus (RSV) and fungal agents
such as Pneumocvstis carinii and
Cryptococcus, (nosocomial, 2 immunodefi-
ciency and primary). In addition, there is an
increasing incidence of asthma, associated
with urbanization. All of this occurs against
an historical background of occupational
lung disease in miners (silico-anthracosis
and asbestosis) and environmental factors
associated with a rural lifestyle. While TB
and AIDS are receiving increasing attention
and attracting international research effort,
scientific studies of other aspects of lung
infection, many treatable or preventable, are
relatively neglected
The subject of innate immunity has moved
towards the centre of immunology and is
key to the pathogenesis of and vaccination
strategies for infectious diseases. Whilst
much has been learnt with regard to cellular
and molecular mechanisms of innate resis-
tance to infection, this has still received lit-
tle application to human diseases The lung
Book review
Innate Immunity to Pulmonary Infection
Chair; Siamon Gordon, Sir William Dunn
School of Pathology, University of Oxford, UK
WMJ_2_59-86.qxd 05.10.2006 14:06 Seite 85
Review
86
is a key target for environmental pathogens,
as well as for opportunistic infection, and
could be a fertile source of cells and clini-
cal/pathological materials to investigate dis-
ease in a genetically varied population.
Genetic as well as environmental factors
which determine the outcome of infection
are still poorly understood.
Autumn meetings
AMA-CMA International Conference
on Physician Health, Ottawa, Ontario,
Canada 30 November – 2 December,
2006
Further information: cma.ca/physician-
health
The Institute of Medical Law,
International Conference “Global Safety
and Rights in Healthcare” Hospital
Phuket, Bangkok, Thailand, 13 -15
December 2006.
Further information: ww.imrab.se/phuket
Devolution: a map of divergence in the
NHS -Smith T. & Babbington E in BMA
Health Policy Review Summer 2006 BMA.
ISSN 1750-0885
In this article, it is interesting to note that
the Devolution of powers to Scotland,
Wales and (eventually) to Northern Ireland
shows signs of divergence in the way in
which national policies are developing,
which raise questions as to whether the
National Health Service in the United
Kingdom hitherto regarded by some as
monolithic, can be so described in the
future. As this article in the summer issue of
Health Policy Review from the British
Medical Association’s Health Policy and
Economic Research Unit comments, while
superficially it could be argued that the
aims in England are the same as those in
Scotland and not dissimilar to those in
Wales and Northern Ireland (all wishing to
streamline the acute sector and provide
more care in the community and broad
commonalities in broad policy objectives
across the UK), these aims are being pur-
sued within different political and contexts
and political communities.
This is succinctly illustrated in the reference
to a note by Scott Greer (1). Commenting
on Scottish policy direction, and referring
to its broad tone of professionalism, trust in
professionals running the system and lack
NHS Healthcare system in UK shows divergence
following Devolution in the Four Kingdoms
need for them to position themselves in
relation to the four different strategic direc-
tion in which policies are moving. Finally
in a section entitled “Different working
environments for doctors” in the context of
the strategic directions and organisational
context, they address the question “to what
extent does the NHS remain a national
health service?” and consider the implica-
tions for doctors in the four countries.
This fascinating article will be of consider-
able interest to both policy makers and
physicians in both developing and devel-
oped countries who are in the process of, or
considering, health policy change. It will
prove an eye-opener to those who have
hitherto observed the huge organisation of
the UK National Health Service and its rel-
atively uniform policy direction with both
admiration and scepticism. Reading about
these trends following devolution in the UK
is well worth the effort and to be widely
commended.
Other articles in this issue of the review
include the problems of management of
long-term conditions in a system under
reform, the reality of choice in the political
context of health and the role of quality in
NHS productivity, providing a most valu-
able thought provoking resource.
(1) Greer S (2004) The politics of health-policy
divergence in Adams J & Scheumueker K
Devolution in practice in 2006: public policy dif-
ferences in the UK. Newcastle upon Tyne: Ippr
North.
W.M.A. MEDICAL ETHICS MANUAL
The Bulgarian Medical Association have
recently translated the Medical Ethics Manual
into Bulgarian and it will be made available to
all first year medical students in Bulgaria. The
Ethics Manual is now available in 13 lan-
guages. Further information about availability
wma@wma.net
of trust in, “or even antipathy towards the
markets and managers – who have been
called in, in increasing numbers, to reform
the English NHS” he continues – “under the
slogan partnership, Scotland has restored its
planning capacity and sharply reduced the
role of managers while eliminating the pur-
chaser-provider divide and the market
manipulating policies that English policy
makers use to try and create competition”.
It is further illustrated by Smith and
Babbingtons’comment on Wales (where the
Health and Social Care (Wales) Act 2003
provided powers to take forward policies in
NHS healthcare etc.) – “much more so than
in England or Scotland, policy is concerned
with health rather than healthcare and there
is a greater emphasis on public health.
Political rhetoric has been directed against
the causes of ill-health in society with less
attention played to the management of the
system”.
In this article in BMA Health Policy and
Economic Research Review published by
the BMA (but not necessarily reflecting
BMA policy), in a section entitled
“Strategic direction”, Scott Greer (1) is
quoted as having given labels to three dis-
tinct approaches: England characterised by
markets and management: the Scotland by
new professionalism – focused on clinical
management: Wales as being primarily
“localist”: Northern Ireland is labelled
Uneventful management” but the authors
comment that while this is beginning to
change it is the least changed of the four
countries.
After concentrating on the political, philo-
sophical and policy divergences behind the
divergences in the NHS, the authors analyse
some of the implications for doctors work-
ing in the United Kingdom, dealing with the
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